Based on interviews, record review, and facility policy review, the facility failed to implement the baseline care plan interventions related to the equipment required for ambulating a resident and the assistance required for toileting for one (1) of four (4) residents care plans reviewed. Resident #1. Findings Include: A record review of the facility's Baseline Care Plan policy, dated 2/16/23, revealed, .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .Policy Explanation and Compliance Guidelines .2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders .b. interventions shall be initiated that address the resident's current needs including i. Any health and safety concerns to prevent .injury, such as .fall . A record review of the Baseline Care Plan, dated 8/11/23, revealed Resident #1 required the assistance of one staff member for walking and toileting and indicated the equipment to be used as a wheelchair or Front Wheeled [NAME] (FWW). A record review of the PT (Physical Therapy) & Plan of Treatment, dated 8/11/23, revealed, .Prior Equipment Prior to Onset: Cane, rollator, tub chair and grab bars .Functional Mobility Assessment .Resident uses a wheelchair? = Yes . During an interview, on 8/31/23 at 11:40 AM, CNA #1 confirmed that on 8/13/23 she assisted Resident #1 to the restroom and did not use a walker or wheelchair. She explained that he ambulated himself but held on to her arm for stability and he had a slow, unsteady gait while walking to the toilet. She stated that she gave him the call bell and advised him to call when he needed assistance back to bed. She then closed the bathroom door for privacy and left the resident's room. CNA #1 explained that after approximately five (5) minutes, his call light came on and she returned to the resident's room. She opened the bathroom door and Resident #1 was sitting on the toilet. He stated that he had fallen off the toilet and had gotten himself back onto the toilet without assistance. He complained of left leg pain at that time. CNA #1 said that the staff reviewed the baseline care plan on the kiosk to determine how much assistance is required to safely ambulate and toilet residents. She confirmed that she did not review the kiosk because a night shift CNA had reported to her that the resident could ambulate without a walker or wheelchair. Record review of Departmental Notes, Category Nurses Notes dated 8/13/23 at 9:41 AM, revealed .Resident was sent out to (Proper Name of Local Emergency Room) (ER) via (Proper Name of Ambulance Service) .ER nurse called back at 09:40 stating resident's hip was out of place . During an interview on 8/31/23 at 12:57 PM, with the Physical Therapist (PT), he stated Resident #1 needed the assistance of one staff member for toileting, transferring and ambulating and recommended the use of a wheelchair or walker for safety. He confirmed that he expected the facility staff to follow his recommendations. During an interview on 8/31/23 at 1:06 PM, with the Physical Therapy Assistant (PTA), she confirmed that she reviewed the Occupational Therapy and Physical Therapy recommendations and completed the base care plan to indicate the level of assistance required with ambulation, transfers, and mobility. The PTA recommended that Resident #1 have assistance from one person with either a walker or wheelchair for ambulation. She confirmed she expected that if a wheelchair or walker was recommended, then the staff should follow the care plan for the resident's safety. On 8/31/23 at 1:23 PM, an interview with the Director of Nurses (DON) revealed that it was her expectation that the nursing staff follow the care plans of all residents because the care plans provided a detailed and effective personalized outline of the care for the residents. On 8/31/23 at 2:21 PM, an interview with the Care Plan Nurse confirmed that staff should follow the care plans for residents' dignity, integrity, and safety. He reported that care plans were developed for individualized care and to ensure consistency in the nursing care of the resident, which helped improve services. He added that he expected all nursing staff in the facility to follow care plans for the residents. A record review of the Face Sheet revealed the facility admitted Resident #1 on 8/11/23 with diagnoses including Left Femur Fracture, Presence of Left Artificial Hip Joint, Hemiplegia following Cerebral Infarction affecting Left Side, and History of Falling.

Based on interviews, record reviews, and facility policy review, the facility failed to use the appropriate equipment during ambulation and provide adequate supervision to prevent an injury for one (1) of three (3) sampled residents, as evidenced by a resident who had a fall, sustained a left hip dislocation, and required hospitalization after he was ambulated without a walker or wheelchair and left unsupervised on the toilet. (Resident #1) Findings include: A review of the facility policy, Incidents and Accidents, dated 5/13/23, revealed .It is the policy of this facility for staff to report, investigate and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident . A record review of the facility-reported investigation, dated 8/16/23, revealed, .Summary: On 8/13/23 (Proper name of Resident #1) was assisted to the toilet by a CNA (Certified Nurse Aide). CNA left room and returned when his call light came on again. CNA went to his restroom where (Proper name of Resident #1) was seated on the toilet. (Proper name of Resident #1) stated that he fell off the toilet . A record review of the Resident Incident Report revealed the Incident Type as Fall/Unobserved and the Date/Time was listed as 8/13/23 08:00 AM. Further review revealed that the Narrative of incident and description of injuries indicated Resident stated after CNA put him on the toilet, he fell and had put himself back on the toilet before CNA returned to room. Resident Condition at Time of Incident revealed Mobility as WC (Wheelchair) - non-motorized. Medical risk factors indicated Fall History and Fracture/Amputee and Activity at time indicated To/frm (from) bathrm (bathroom)-alone . A record review of the Diagnostic Imaging report, dated 8/13/23, from a local acute care hospital revealed, History: Hip pain status post fall, with a history of recent surgery and Impression: Superior dislocation of a left hip arthroplasty, without discrete or displaced fracture . A record review of Departmental Notes, for Resident #1, dated 8/11/23 at 12:32 PM, revealed a Nurse Notes that indicated, .Weakness noted to BLE (Bilateral Lower Extremities) mobility via wheelchair . A record review of Departmental Notes, for Resident #1, dated 8/12/23 at 11:24 AM, revealed a Nurse Notes that indicated, .Transfer x 1. Needs assist with ADL's (Activities of Daily Living) . Record review of Departmental Notes, Category Nurses Notes dated 8/13/23 at 9:41 AM, revealed .Resident was sent out to (Proper Name of Local Emergency Room) (ER) via (Proper Name of Ambulance Service) .ER nurse called back at 09:40 stating resident's hip was out of place . A record review of the PT (Physical Therapy) & Plan of Treatment, dated 8/11/23, revealed, .Patient Referral and History Current Referral Reason for referral/current illness: Patient is a 90 yo (year old) male who suffered a fall in his garden on 7/23/23 resulting in a L (Left) displaced femoral fx(fracture) .Medical Factors Precautions: Falls risk .Fall Risk Assessment History of Falls Has Patient fallen in past year? = Yes How many times? = 6 .Steadiness Does Patient feel unsteady when standing? = Yes Does Patient feel unsteady when walking? = Yes .Does Patient worry about falling? = Yes .Functional Mobility Assessment .Resident uses a wheelchair? = Yes .Reason for Therapy Clinical Impressions/Reason for Skilled Services: Skilled services required to address deficits in strength, endurance and balance affecting safety with functional mobility . Record review of the Nurse Data Collection and Screening document for Resident #1, dated 8/11/23, revealed, Risk: Fall Risk Form .History of Falls 3 or more falls in past 3 months . On 8/31/23 at 11:40 AM, in an interview with CNA #1, she confirmed that on 8/13/23, before breakfast trays were delivered, she assisted Resident #1 without his walker to the restroom. She said that he ambulated himself but held on to her arm for stability and he had a slow, unsteady gait while walking to the toilet. She stated that she gave him the call bell and advised him to call when he needed assistance back to bed. She then closed the bathroom door for privacy and left the resident's room. CNA #1 explained that after approximately five (5) minutes, his call light came on and she returned to the resident's room. She opened the bathroom door and Resident #1 was sitting on the toilet. He stated that he had fallen off the toilet and had gotten himself back onto the toilet without assistance. He complained of left leg pain at that time. CNA #1 said that the staff is supposed to review the baseline care plan on the kiosk to determine how much assistance is required to safely ambulate and toilet residents. She confirmed that she did not review the kiosk because a night shift CNA had reported to her that the resident could ambulate without a walker or wheelchair. On 8/31/23 at 12:57 PM, an interview with the Physical Therapist (PT) revealed that Resident #1 needed the assistance of one staff member for toileting, transferring and ambulating. The PT also recommended the use of a wheelchair or walker for safety and confirmed that he expected the facility staff to follow his recommendations. On 8/31/23 at 1:06 PM, an interview with the Physical Therapy Assistant (PTA) confirmed that she reviewed the Occupational Therapy and Physical Therapy recommendations and completed the base care plan to indicate the level of assistance required with ambulation, transfers, and mobility. The PTA recommended that Resident #1 have assistance from one person with either a walker or wheelchair for ambulation. On 9/1/23 at 11:28 AM, during an interview with the Director of Nurses (DON), she stated that Resident #1 was assisted without his walker to the bathroom by CNA #1 and he had been left alone in the bathroom. The resident reported that he had fallen and gotten himself back up to the toilet without any assistance. She revealed that according to CNA #1, the resident requested privacy and she felt she could leave him alone in the bathroom. The DON confirmed that CNA #1 should have used a walker or wheelchair as per the care plan to assist Resident #1 with walking to the restroom. On 9/1/23 at 11:48 AM, an interview with the Administrator revealed that on 8/13/23, Resident #1 was assisted to the toilet by CNA #1 and the resident stated that he had fallen and gotten back onto the toilet within approximately three (3) minutes. On 9/8/23 at 2:00 PM, in an interview with CNA #1, she confirmed that even though Resident #1 was a new admission, had a slow and unsteady gait, a history of falls, and a diagnosis of Hemiplegia, she thought that because he had asked for privacy and he was alert and oriented, she could leave him unsupervised while on the toilet, and walk away from the resident's room. CNA #1 also confirmed because Resident #1 reported that he had fallen and had left leg pain, she used a wheelchair and transferred the resident from the toilet to the wheelchair and assisted him to his bed. On 9/8/23 at 2:30 PM, an interview with the DON revealed that she expected new residents who required assistance with toileting to be supervised and not left alone. She confirmed that CNA #1 should not have left the resident in his bathroom alone and unsupervised. On 9/8/23 at 4:00 PM, during an interview with Registered Nurse (RN) #2 revealed, that on 8/13/23, LPN #1 informed her that Resident #1 had reported that he had fallen off the toilet, but that he put himself back on the toilet without any assistance. RN #2 said that Resident #1 was back in his bed at that time and complained of left hip pain. She described Resident #1 as weak and confused. RN #2 notified the Nurse Practitioner (NP) of the allegation of a fall and the resident's pain and the NP gave an order to send Resident #1 to the local Emergency Department (ED) for evaluation and treatment. A record review of the Face Sheet revealed the facility admitted Resident #1 on 8/11/23 with diagnoses including Left Femur Fracture, Presence of Left Artificial Hip Joint, Hemiplegia following Cerebral Infarction affecting Left Side, and History of Falling. A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/13/23 revealed Resident #1 was admitted by the facility on 8/11/23 from an inpatient rehabilitation facility. He was discharged to an acute hospital on 8/13/23, which was two (2) days after his admission to the facility.

Based on observation, staff interviews, record review and facility policy review, the facility failed to follow the Comprehensive Care Plan by not providing pain medication prior to wound care for one (1) of three (3) wound care plans reviewed, Resident #31. Findings Include: Review of the facility's policy, Care Plans - Comprehensive, revision date June 2021, revealed, An individualized comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .Policy Interpretation and Implementation: Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her familial representative (sponsor), develops and maintains a comprehensive care plan. The comprehensive care plan is based on an assessment that includes, but is not limited to, the Minimum Data Set (MDS). The comprehensive care plan must describe the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, and psychological well-being . A record review of Resident #31's Comprehensive Care Plan, dated 2/5/21, revealed he has an alteration in comfort related to mild pain, arthritis, a history of muscle spasms, and a history of wounds. The care plan goal is Resident #31 will express relief of pain after receiving pain relieving measures. The care plan interventions include: Pain assessment as needed, allow adequate time for pain medications to take effect prior to resuming care and/or treatment. Medications documented on the care plan include Tylenol and Baclofen and to document effectiveness of these pain medications as needed. On 8/4/21 at 11:05 AM, the SA observed wound care on Resident #31 by Registered Nurse #3 (RN). RN #3 was assisted by Certified Nursing Assistant #1(CNA). RN #3 did not assess Resident #31 for pain prior to beginning wound care. Resident #31 started to complain about pain during the wound care to his left hip. RN #3 continued with the wound care even though Resident #31 had complained of pain. Upon completing the wound care to the left hip, RN #3 began wound treatment to Resident #31's sacrum. Resident #31 had facial grimacing and stated repeatedly that his butt was hurting. RN #3 continued with the wound care to the sacrum and did not stop to offer pain medication to the resident. The SA asked RN #3 if Resident #31 had any pain medication and she replied that she knew he did not have any thing (pain medication) scheduled to take today. RN #3 continued with the dressing change to the sacrum after being asked by SA. RN #3 measured the wound with a ruler and used a cotton tipped applicator to check the depth of the wound. The wound measured 3.50 cm length x 2.50 cm width with depth of 0.2 cm. Resident #31 continued to repeat my butt hurts really bad. After RN #3 had completed the wound care, Licensed Practical Nurse (LPN) #1 entered the room with Ultram 50 milligram (mg) crushed in chocolate pudding for Resident #31. LPN #1 asked Resident #31 what his pain level was on a scale of one (1) to ten (10) and he replied it was a ten (10). Resident #31 took Ultram in the pudding. RN #3 and CNA #1 asked Resident #31 if they could change his brief after he received his pain medication, but he repeatedly declined and stated his butt was hurting. On 8/5/21 at 1:56 PM, in an interview with RN #3, she stated the Comprehensive Care Plan is used to see what kind of care we are going to provide to the resident. She stated she did not follow the care plan and confirmed that it is very important to follow the care plan. On 8/5/21 at 2:10 PM, in an interview with RN #4, she stated the care plan is used for communicating with the rest of the staff about resident care. She further explained the care plan tells the staff what they should be following and resident orders are on the care plan. RN #4 stated the care plan tells the staff everything that is going on with the resident. She confirmed RN #3 did not follow the care plan regarding wound care. She stated it is very important you follow the care plan. She also confirmed that an assessment for pain should be completed prior to wound care and it is important to follow up with the resident to ensure pain is relieved. On 8/5/21 at 2:24 PM, in an interview with the Assistant Director of Nursing (ADON), she stated the care plan is used for resident care and it tells you how to care for the resident and the goals for residents. She stated it is the process for taking care of the resident for their best interest. She confirmed RN #3 did not follow the care plan. On 8/5/21 at 2:35 PM, in an interview with the Director of Nursing (DON), she stated the care plan is used as a guide for the staff in the care of the resident. She confirmed RN #3 did not follow the care plan and stressed the importance of following the care plan.

Based on observation, interviews, record reviews and facility policy review the facility failed to medicate the resident prior to providing wound care for one (1) of three (3) wound care observations Resident #31. Findings Include: Review of the facility's policy, Pain Management , dated 2020, revealed, Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences . The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain .1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. b. Evaluate the resident for pain upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g., after a fall, change in behavior or mental status, new pain, or an exacerbation of pain) c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences .3. Facility staff will be aware of verbal descriptors a resident may use to report or describe their pain. Descriptors include but are not limited to: d. Hurting or aching .Pain Assessment: .2. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary teams (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate gathering the following information, as applicable to the resident: .b. Asking the patient to rate the intensity of his/her pain using a numerical scale, a verbal or visual descriptor that is appropriate and preferred by the resident. Review of Resident #31's Physician Orders, dated August 2021, revealed orders for the following, Acetaminophen 325 milligram (mg) tablet 650 MG by mouth every four (4) hours as needed for pain/ fever, dated 7/14/21; Pressure ulcer of sacral region, stage 2 to sacrum wound, cleanse with normal saline, pat dry, apply promogram to wound bed, cover with dry foam dressing, change every 72 hours; Pressure ulcer of left ankle, unstageable to left malleolus wound cleanse with normal saline pat dry, apply promogran to wound bed. Cover with dry foam dressing. Change every 72 hours, dated 7/30/21; Pressure ulcer of the left hip stage 2 Santyl ointment cleanse left hip wound with normal saline pat dry using 4X4 gauze, apply Santyl to wound bed daily and cover with dry dressing, dated 8/4/21. On 8/4/21 at 11:05 AM, the SA observed wound care on Resident #31 by Registered Nurse #3 (RN). RN #3 was assisted by Certified Nursing Assistant #1(CNA). RN #3 did not assess Resident #31 for pain prior to beginning wound care. Resident #31 started to complain about pain during the wound care to his left hip. RN #3 continued with the wound care even though Resident #31 had complained of pain. Upon completing the wound care to the left hip, RN #3 began wound treatment to Resident #31's sacrum. Resident #31 had facial grimacing and stated repeatedly that his butt was hurting. RN #3 continued with the wound care to the sacrum and did not stop to offer pain medication to the resident. The SA asked RN #3 if Resident #31 had any pain medication and she replied that she knew he did not have any thing (pain medication) scheduled to take today. RN #3 continued with the dressing change to the sacrum after being asked by SA. RN #3 measured the wound with a ruler and used a cotton tipped applicator to check the depth of the wound. The wound measured 3.50 cm length x 2.50 cm width with depth of 0.2 cm. Resident #31 continued to repeat my butt hurts really bad. After RN #3 had completed the wound care, Licensed Practical Nurse (LPN) #1 entered the room with Ultram 50 milligram (mg) crushed in chocolate pudding for Resident #31. LPN #1 asked Resident #31 what his pain level was on a scale of one (1) to ten (10) and he replied it was a ten (10). Resident #31 took the Ultram in the pudding. RN #3 and CNA #1 asked Resident #31 if they could change his brief after he received his pain medication, but he repeatedly declined and stated his butt was hurting. A review of the August 2021 Medication Administration Record (MAR) revealed Resident #31 did not receive any pain medication prior to wound care by RN #3 on 8/4/21. On 8/4/21 at 5:03 PM, in an interview with RN #3, the Wound Care Nurse, she admitted she should have asked Resident # 31 about his pain his level before she started wound care. She stated she does not know why she did not ask the resident. She stated, I don't if it was because I was nervous, and that she continued with wound care because she did not want to leave the wound open. She stated it is more important that the resident not be in pain during wound care than being concerned about the wound being uncovered. She stated she should have stopped the wound care and got the resident some pain medication immediately. She confirmed that pain can have a negative effect on the resident and she knew he did not have any scheduled or routine pain medications ordered by the physician. On 8/4/21 at 5:14 PM, in an interview with License Practical Nurse #1 (LPN), Admissions Coordinator, stated she contacted the Nurse Practitioner (NP) because she felt as if the resident needed something for pain and that is why she gave him the Ultram 50 mg. The Ultram 50 was a one time order. She stated she went back to check on the resident after giving him medication and he was fine. She stated RN#3 should have given him pain medication as soon as Resident #31 complained of pain. She stated she felt like the Tylenol that was ordered would not help with the pain and she believed something was hurting him since he said his pain level was a 10. She stated it is unusual for Resident #31 to yell out during wound care. She confirmed RN #3 should have stopped the care and gave the resident pain medication when he first complained of pain. She stated that during wound care when a resident is in pain, it can cause the resident to have mental changes. She stated the resident's wound cannot heal properly if he is in pain during care and may cause a resident to refuse wound care the next time. She stated when a resident refuses wound care that it can lead to an infection. On 8/4/21 at 5:43 PM, in an interview with RN#1, Director of Nursing (DON), stated she spoke with RN #3 regarding giving pain medication prior to wound treatments. She stated RN #3 told her she felt bad because she did not stop the wound care when Resident #31 was in pain. She stated RN #3 should have assessed the resident for pain before starting wound care. She stated when a nurse is doing wound care and the resident is in pain, the nurse should stop the wound care, and give pain medication, and then proceed after the resident has received medication. She stated the wound care nurse should have asked the resident's LPN to administer his pain medication and then let her know so that she may provide wound care. She stated by not administering pain medication before wound care., Resident #31 will probably refuse wound care. On 8/4/21 at 5:54 PM, in an interview with RN #2, the Assistant Director of Nursing (ADON), she stated if she was doing wound care on a resident and they complained of pain, she would stop and get an order for pain medication, and after she gave the pain medication, she would wait until the medication became effective before continuing wound care. She stated RN #3, should have stopped the wound care and called the NP. RN #2 stated she completed a wound care check off (competency) with RN #3 and confirmed that was trained to assess residents for pain prior to beginning wound care. RN #2 confirmed RN #3 should have assessed the resident for pain before beginning wound care. She stated doing wound care on a resident in pain can cause the resident to have emotional pain. Review of Resident #31's Face Sheet revealed an initial admission date of 2/2/21 and a readmission date of 7/14/21. Medical diagnoses include Pressure Ulcer of the left ankle, unstageable, Pressure Ulcer of the sacral region, stage 2, Muscle Spasms, Pressure induced deep tissue damage of the left hip and Anxiety Disorder. Review of Resident #31's Comprehensive Care Plan, dated 2/5/21, with a goal target date of 11/4/21, revealed he has an alteration in comfort related to mild pain, arthritis, a history of muscle spasms, and a history of wounds. The care plan goal is that the resident will express relief of pain after receiving pain reliving measures. The care plan interventions include pain assessment as needed, allow adequate time for pain medications to take effect prior to resuming care and/or treatment. Pain medications include: Tylenol and Baclofen and to document the effectiveness of pain medication as needed. Record review of Physician orders, dated 8/4/21, revealed Ultram 50mg PO (by mouth) q (every) 12 hours PRN (as needed) was ordered at 11:30 AM. A review of the facility's Emergency Drug Kit sign out slip reveals Ultram 50 mg was signed out on 8/4/21. Record review of the MAR revealed Ultram 50 mg was given at 11:30 AM. A Review of the significant change Minimum Data Set (MDS) with an Assessment Record Date (ARD)date of 7/20/21, revealed a Brief Interview of Mental Status (BIMS) score of seven (7). A BIMS of 7 indicates Moderately Cognitive Impaired.