**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure residents' right to be free from neglect for 1 of 9 (Resident #10) sampled residents reviewed for allegations of abuse. Resident #10 was severely cognitively impaired, bedridden and totally dependent on staff for all needs. On 4/5/2024 staff noted Resident #10's left arm swollen with nonpitting edema. On 4/8/2024 the practitioner was notified and orders obtained for x-rays. On 4/9/2024 an x-ray revealed a comminuted (A broken bone that has shattered into 3 or more pieces. This type of fracture is usually caused by a serious trauma) humeral fracture to the left arm of unknown source. The facility's failure to provide timely services to address Resident #10's left arm swelling resulted in Actual Harm. The findings include: 1. Review of the facility's policy titled ABUSE Prevention Policy, dated 11/2021, revealed .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .also includes the depravation [deprivation] by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being .Neglect means failure to provide goods and services necessary to avoid physical harm .Injury of Unknown source means source was not observed by another person or injury could not be explained by the resident. Injury is suspicious because of the extent of the injury, location of injury (e.g. injury is located in an area not generally vulnerable to trauma such as facial injuries, bruising of inner thighs, wrap around bruises of arms, legs or torso, skin tears, on sites other than arms/legs) or the number of injuries observed at one point in time or the incidence of injuries over time . Review of the facility's policy titled, INCIDENT REPORT - DOCUMENTATION, INVESTIGATING, AND REPORTING, dated November 2022, revealed .The Charge Nurse at the time of the incident is responsible for documenting the incident in the resident's medical record. The nurses note should contain the following documentation .Clear, objective facts about what occurred .A thorough assessment of the resident's condition at the time of the accident/incident. (This assessment should include a description of the resident, vital signs, and any other physical characteristics apparent as a result of the accident/incident) .Any treatment provided .Any contacts made or attempted with the resident's physician, family .The Administrator/Director of Nursing should obtain signed and dated written statements, from all witnesses with knowledge of the event .Indicate .the follow up interventions put into place to prevent reoccurrences . 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure with Hypoxia (An absence of enough oxygen in the tissues to sustain bodily functions), Tracheostomy (a surgical opening to help air and oxygen into the trachea to provide an alternate airway), Gastrostomy Status (a surgical procedure to insert a tube through the abdomen and into the stomach to provide nutritional support), Functional Quadriplegia (complete immobility due to severe disability or frailty from medical condition without injury to the brain or spinal cord), Dementia, Cerebral Infarction (Stroke), and Contracture Left Hand. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 had severe cognitive impairment and was totally dependent on staff for all activities of daily living (ADLs). Review of the Progress Note dated 4/5/2024 at 2:32 PM by Licensed Practical Nurse (LPN) A, revealed .left arm swollen nonpitting edema, placed in MD [medical doctor] book . LPN A noted the left arm swelling in the MD book to notify the MD on the next onsite facility visit and failed to immediately notify the MD or practitioner. Review of the Situation, Background, Assessment and Recommendation (SBAR) note dated 4/8/2024 at 10:10, revealed .Recommendations: resident noted with nonpitting edema to left upper extremity. Extremity repositioned and elevated with pillow. PRN [as needed] Acetaminophen [another name for Tylenol, for pain] administered, New orders obtained for Left Shoulder, Humerus, Elbow and Forearm X-ray and Doppler . The MD/practitioner was not notified of Resident #10's left arm swelling until 3 days after the swelling was initially noted on 4/5/2024. Review of the Incident Report dated 4/9/2124, revealed No Injuries observed at time of incident .No Injuries Observed Post Incident .Notes 4/9/2024, Educate staff on transfers and use of Hoyer lifts . The facility was unable to provide documentation the staff education was provided. The facility X-Rays were obtained on 4/9/2024 and resulted in a comminuted left humerus fracture. Review of the Care Plan dated 4/9/2024, revealed The resident [#10] has left arm Fracture and is at risk for complications .Monitor limb for swelling and skin changes . On 4/10/2024 Resident #10 was sent out to the hospital per family request. Resident #10 was admitted to the hospital on [DATE] - 4/15/2024. Review of the [Named Hospital Progress Note] dated 4/15/2024, by Doctor M revealed .Left humeral fracture - occurred at NH [Nursing Home]. Ortho [Orthopedics] consulted and evaluated the patient. Not a surgical candidate with underlying hemiplegia from CVA [Cerebrovascular Accident] Sling, non-weightbearing in LUE [Left Upper Extremity]. Hx [history] of CVA s/p [status post] trach [tracheostomy], PEG [percutaneous endoscopic gastrostomy tube], nonverbal - Pt [patient] is bed bound; will refer to SW [Social Worker] for APS [Adult Protective Services] referral .Social Determinants of Health that impact treatment or disposition: non-verbal patient with unknown POA [Power of Attorney]. Need to discuss with SW about referral to APS to investigate further nature of this patient's injuries (non-verbal, bedridden patient develops left humeral fracture-how?). Review of the quarterly MDS dated [DATE], revealed Resident #10 had severe cognitive impairment. During an interview on 8/15/2024 at 1:59 PM, LPN A was asked about the injury of unknown origin for Resident #10. LPN A stated, The shower aide [Certified Nursing Assistant (CNA) N], came and got me, they were in the shower on 4/8/2024, to look at her left arm. The whole left side shoulder to her hand were [was] swollen. I assessed her arm it was swollen I let the [Named Medical Director] know and he came to the facility later that day. He advised me to get an x-ray. Got x-ray the next day on 4/9/2024. I'm not sure if results came back that evening or the next day 4/10/2024. It was on 4/10/2024, a Wednesday, when got results, it [was] fractured. They had gotten an appointment with [named Orthopedic Clinic], but the daughter came in that day and insisted she go to ER [Emergency Room]. She came back a couple days later with a hard brace on the upper left shoulder area. She had the brace until she went to the ortho appointment [and] came back without the brace. LPN A did not report or act on the findings when she noticed the left arm swelling on 4/5/2024, 3 days prior to notifying the facility's Medical Director. During an interview on 8/15/2024 at 2:11 PM, CNA N, confirmed she took Resident #10 to the shower on a shower bed and noticed her left arm was swollen. She said she finished her shower because she could not leave her alone. Then she got the Nurse, LNP A, to come and look at her arm. It was swollen. We used the lift and put her back in the bed. LPN A said she would notify the doctor. During an interview on 8/15/2024 at 4:04 PM, CNA O, working 2nd shift, was asked about the injury of unknown origin for Resident #10. CNA O stated, .She is a heavy wetter, so I do her early. When I pulled the cover back [to do perineal care in Resident #10's room on 4/8/2024] it looked like Popeye's arm, Left [arm] was so swollen and Right [arm] was normal. I went to get the nurse on the 3 to 11 shift. [CNA O didn't remember which nurse] She looked at her arm and said she may need to go out to the ER. She called the doctor. I moved on to another resident. We had to write statements. CNAs do not give report to oncoming shift . During an interview on 8/16/2024 at 12:28 PM, the DON was asked, should an injury of unknown origin be investigated. The DON stated, Yes. The DON stated, . X ray was ordered 4/9/2024 and received results on 4/9 [2024] but I know we didn't get them on 4/9/24 [2024], it was later. The DON was asked, do you have documentation where you interviewed other staff. The DON stated, No, I don't . The DON was asked, why did it take so long to send her out to the hospital. The DON stated, .out to hospital on 4/10/2024. They didn't have an order to send her out sooner. No one knew anything about her arm being injured .First time noted swelling was in shower on 4/9/24 [4/8/2024]. No reason for the fracture. We did not find the reason or cause of fracture. The DON confirmed there was no monitoring for Resident #10 on 4/16/2024 one day after she was readmitted and there should have been. During a telephone interview on 8/29/2024 at 10:55 AM, after the survey team had exited the facility, Medical Doctor M returned the surveyor's call after several attempts were made to contact the doctor during the survey. Medical Doctor M was asked about Resident #10's humeral fracture. Medical Doctor M was asked, would it take a hard force or hit to cause a comminuted humeral fracture. Medical Doctor M stated, .a fall could do that. Medical Doctor M was asked, could transferring the resident by a lift with a lift pad cause that type fracture. Medical Doctor M stated, I don't think so. In summary, the swelling was first noted in Resident #10's left arm on 4/5/2024 per the note documented by LPN A, the MD/practitioner wasn't notified until 4/8/2024. The x-rays were obtained on 4/9/2024 and the resident was sent to the hospital on 4/10/2024. The hospital admitted Resident #10 from 4/10/2024 - 4/15/2024. The facility's failure to provide timely services to address Resident #10's left arm swelling resulted in Actual Harm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to thoroughly investigate an injury of unknown source/origin for 1 of 9 (Resident #10) residents reviewed for abuse. The facility failed to thoroughly investigate an injury of unknown origin when Resident #10, a severely cognitively impaired, bedridden resident sustained a comminuted (A broken bone that has shattered into 3 or more pieces. This type of fracture is usually caused by a serious trauma) humeral fracture. This resulted in Actual Harm for Resident #10. The findings include: 1. Review of the facility's policy titled, ABUSE PREVENTION POLICY, dated 11/1/2021, revealed .Injury of unknown source means source of injury was not observed by another person or injury could not be explained by the resident. Injury is suspicious because of the extent of the injury, location of injury .injury is located in an area not generally vulnerable to trauma such as facial injuries, bruising of inner thighs, wrap around bruises of arms, legs, or torso, skin tears .When suspicion or reports of abuse, neglect or exploitation occur, as investigation is immediately warranted .Components of the investigation may include .Interview .staff members in the area .Document the entire investigation chronologically .including injuries of unknown source .are reported immediately, but not later than 2 hours after the allegation is made .The Administrator should follow up with the governmental agencies during business hours to confirm the report was received and to report the results of the investigation when final, as required by state agencies .Administrator will review investigational findings to determine appropriate corrective, remedial, or disciplinary actions to occur with accordance with applicable local, state or federal law . Review of the facility's policy titled, INCIDENT REPORT - DOCUMENTATION, INVESTIGATING, AND REPORTING, dated November 2022, revealed .The Charge Nurse at the time of the incident is responsible for documenting the incident in the resident's medical record. The nurses note should contain the following documentation .Clear, objective facts about what occurred .A thorough assessment of the resident's condition at the time of the accident/incident. (This assessment should include a description of the resident, vital signs, and any other physical characteristics apparent as a result of the accident/incident) .Any treatment provided .Any contacts made or attempted with the resident's physician, family .The Administrator/Director of Nursing should obtain signed and dated written statements, from all witnesses with knowledge of the event .Indicate .the follow up interventions put into place to prevent reoccurrences . 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure with Hypoxia (when the body's tissue don't have enough oxygen), Tracheostomy (a surgically created hole in the windpipe to provide an alternate airway), Gastrostomy Status (a surgical procedure to insert a tube through the abdomen and into the stomach), Functional Quadriplegia (complete immobility due to severe disability or frailty from medical condition without injury to the brain or spinal cord), Dementia, Cerebral Infarction (stroke), and Contracture Left Hand. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 had severe cognitive impairment. The facility was unable to obtain a Brief Interview for Mental Status (BIMS) score as the resident was unable to participate in the test. Review of the Progress Note dated 4/5/2024 at 2:32 PM by Licensed Practical Nurse (LPN) A, documented swelling with nonpitting edema to Resident #10's left arm and placed a note regarding the swelling in the Medical Doctors (MD) book. LPN A failed to notify the practitioner for immediate action and failed to ensure an investigation was immediately started. Review of the Situation, Background, Assessment and Recommendation (SBAR) note dated 4/8/2024 at 10:10, revealed .Recommendations: resident [#10] noted with nonpitting edema to left upper extremity . New orders obtained for Left Shoulder, Humerus, Elbow and Forearm X-ray and Doppler . The facility's investigation consisted of 3 staff interviews with LPN A, certified Nursing Assistant (CNA) N, and CNA O obtained on 4/9/2024, but dated 4/8/2024. The facility's investigation failed to interview staff who cared for Resident #10 back to and before 4/5/2024, when LPN A first documented the swelling in the Resident's left arm. Review of the Care Plan dated 4/9/2024, revealed The resident [#10] has left arm Fracture and is at risk for complications .Monitor limb for swelling and skin changes . The facility X-Rays were obtained on 4/9/2024 and resulted in a comminuted humerus fracture. On 4/10/2024 Resident #10 was sent out to the hospital per family request. Resident #10 was admitted to the hospital from [DATE] - 4/15/2024. Review of the [Named Hospital Progress Note] dated 4/15/2024, by Doctor M revealed .Left humeral fracture - occurred at NH [Nursing Home]. Ortho [Orthopedics] consulted and evaluated the patient. Not a surgical candidate with underlying hemiplegia from CVA [Cerebrovascular Accident] Sling, non-weightbearing in LUE [Left Upper Extremity]. Hx [history] of CVA s/p [status post] trach [tracheostomy], PEG [percutaneous endoscopic gastrostomy tube], nonverbal - Pt [patient] is bed bound; will refer to SW [Social Worker] for APS [Adult Protective Services] referral .Social Determinants of Health that impact treatment or disposition: non-verbal patient with unknown POA [Power of Attorney]. Need to discuss with SW about referral to APS to investigate further nature of this patient's injuries (non-verbal, bedridden patient develops left humeral fracture- how?). Review of the quarterly MDS dated [DATE], revealed Resident #10 had severe cognitive impairment. During an interview on 8/15/2024 at 1:59 PM, LPN A was asked about the injury of unknown origin for Resident #10. LPN A stated, The shower aide [Certified Nursing Assistant (CNA) N], came and got me, they were in the shower on 4/8/2024, to look at her left arm. The whole left side shoulder to her hand were [was] swollen .I let the [Named Medical Director] know and he came to the facility later that day. He advised me to get an x-ray. Got x-ray the next day on 4/9/2024. I'm not sure if results came back that evening or the next day 4/10/2024. It was on 4/10/2024, a Wednesday when got results, it [was] fractured . During an interview on 8/16/2024 at 12:28 PM, the DON was asked should an injury of unknown origin be investigated. The DON stated, Yes. The DON was asked what the process was for injuries of unknown origin. The DON stated, . Receive statements from staff, assess the resident and talk with the resident [if able]. After being re-admitted we do initial assessment, and regular body audits. [Named Medical Director] was called by LPN A when swelling was noted. Communicate by report and 24- hour report. Nurses do a huddle with oncoming staff. The DON was asked, do you consider the 3 staff statements were a thorough investigation. The DON stated, All the other staff there had no knowledge of what had happened. X ray was ordered 4/9/2024 and received results on 4/9 [4/9/2024] but I know we didn't get them on 4/9/24 [2024] it was later. The DON was asked, do you have documentation where you interviewed other staff. The DON stated, No, I don't . The DON was asked, why did it take so long to send her out to the hospital. The DON stated, .out to hospital on 4/10/2024. They didn't have an order to send her out sooner. No one knew anything about her arm being injured .First time noted swelling was in shower on 4/9/24. No reason for the fracture. We did not find the reason or cause of fracture. The DON confirmed there was no 72 hour post incident monitoring for Resident #10 on 4/16/2024 one day after she was readmitted and there should have been. During a telephone interview on 8/19/2024 at 1:44 PM, the Medical Director was asked about the humerus fracture of Resident #10. The Medical Director stated, I remember her now, they called me for left arm swelling. She does not move. I ordered a doppler and an x-ray. The x-ray result was a fracture. I got an appointment with Ortho [Orthopedics] but the family was upset and wanted her to go to the hospital. They sent her right back. She is bedridden and it [a comminuted humerus fracture] could happen at any time. Review of the hospital records revealed Resident # 10 was not sent dight back to the nursing home but was admitted to the hospital from [DATE] - 4/15/2024. The facility was unable to provide staff interviews from staff that completed resident care the day prior to finding the swollen arm on 4/5/2024 and 4/8/2024. There was no interview for the staff member who completed the injury of unknown cause report. Resident #10 was an immobile, bedridden resident, who was totally dependent on staff for all her activities of daily living, that sustained a comminuted humerus fracture. Refer to F600.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, facility investigation, and interview, the facility failed to ensure a safe environment, adequate supervision/monitoring related to falls, illegal substance use, and elopement for 5 of 9 (Residents #44, #85, #89, #102, and #119) sampled residents reviewed for a safe environment. On 5/27/2024 Resident #44 had a fall, and the facility failed to monitor the resident post fall. On 5/31/2024, 4 days after the fall, Resident #44 complained of rib cage pain and an x-ray revealed a fractured rib, the facility failed to monitor the resident. The Nurse Practitioner was unaware of the resident's fall and fractured rib until 6/3/2024, the resident complained of chest pain on breathing. The facility's failures resulted in Actual Harm for Resident #44. The findings include: 1. Review of the facility's policy titled, Fall Risk-Fall Prevention ., dated 11/28/2017, revealed .Fall refers to unintentionally coming to a rest on the ground floor .when resident is found on the floor, a fall is considered to have occurred .4. After an incident of a fall .complete the Post Fall Risk Assessment .Notify MD [Medical Doctor] and Resident Representative, complete pain assessment after the fall .Fall placed on 24-hour report . Review of the facility's policy titled, Incident Report-Documentation, Investigating, and Reporting . dated 11/2022, revealed .All accidents or incidents involving residents .occurring on our premises shall be investigated and reported to the Administrator .the Charge Nurse at the time of the incident is responsible for documenting the incident in the resident's medical record .The nurses note should contain the following documentation .a. Clear, objective facts that occurred .a thorough assessment of the resident's condition at the time of the accident/incident .all quotes by the resident and/or witness involved or present at the time .any contacts made .resident's physician, family .outcome .Nurse's signature, date and time of charting .All incidents .should be reported to the Administrator .The Administrator/Director of Nursing should obtain signed and dated written statements from all witnesses with knowledge of the event . Review of the facility's policy titled, Unsafe Wandering-Elopement Risk Policy, dated 11/30/2021, revealed .Every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for elopement .If an elopement occurs, a monitoring schedule will be implemented to ensure resident safety . Review of the facility's policy titled, Resident Rights Policy, dated 10/20/2022, revealed .The facility strives to protect the rights of residents, including .The resident has the right to reside and receives services in the facility with reasonable accommodation of needs .The resident has a right to a safe .environment, including .supports for daily living safely . 2. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE], with diagnoses including Orthopedic Aftercare following Surgical Amputation, Fracture of Rib on Right Side, Pressure Ulcer, and Heart Disease. Review of admission Minimum Data Set (MDS) dated [DATE], revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 14, indicating he was cognitively intact, had impaired mobility to his lower extremity, received set up help for eating, and partial/moderate assist with Activities of Daily Living (ADLs). Review of a Fall Risk Assessment sheet dated 5/27/2024, revealed an effective of date 5/27/2024 and a score of 12, indicating Resident #44 was at high risk for falls. The 5/27/2024 Fall Risk Assessment report was not signed until 8/13/2024. Review of an Incident Report dated 5/27/2024 at 2:20 PM, revealed Resident #44 sustained an unwitnessed fall and was noted to be on the restroom floor beside the toilet, and assisted back onto the toilet. Resident #44 was noted to have no injuries. The Incident Report dated 5/27/2024 was not completed by the Director of Nursing (DON) until 5/31/2024. Record review revealed there were no other progress notes related to Resident #44's fall on 5/27/2024. Review of a Progress Note dated 5/31/2024, revealed, .Resident [#44] c/o [complained of] pain to right rib cage .New order obtained for x-ray . Review of a Radiology Results report dated 5/31/2024, revealed Reviewed by [named person] Nurse Practitioner on 6/3/2024 .CHEST PAIN ON BREATHING .FINDINGS: The bilateral ribs demonstrate an acute right lateral sixth rib fracture . Review of a Physician Progress Note dated 6/3/2024 at 3:08 PM, revealed .He [Resident #44] is being seen for skilled follow up visit. Xray reviewed RIBS Bi-LAT [bilateral sides] .PA [Posteroanterior] CHEST MIN [Minimum] 4V [Views] with acute right lateral sixth, rib fracture. He stated he had a fall last week and he does not have complaints of significant pain . Review of a Progress Note dated 6/3/2024, revealed Resident #44 was transported via stretcher to the emergency room for evaluation due to an abnormal x-ray. Review of the Hospital emergency room Documentation dated 6/3/2024-6/4/2024, revealed .Basic Information .[Resident #44] who presents to the ED [Emergency Department] .for right sixth rib fracture .9 days ago .patient has mild diffuse expiratory wheezing .will order duo-neb given his wheezing .Prescriptions .Azithromycin 5 day Dose Pack .Chest x ray .scattered nodules which may be infectious/inflammatory .will discharge back to rehab center [nursing home] with antibiotic coverage for possible pneumonia and close follow up .Impression and Plan Diagnosis Fall .Pneumonia . Review of the revised Care Plan dated 6/4/2024, revealed .Altercation in musculoskeletal status r/t [related to] fracture of the ribs and gout . Review of a Progress Note dated 6/4/2024, revealed Resident #44 returned to facility with a diagnosis of Pneumonia with antibiotic therapy. Review of a Physician's Order dated 6/4/2024, revealed .Azithromycin Oral Tablet 250 mg [milligrams] .2 tablets by mouth one time a day .and Azithromycin .250 mg 1 tab [tablet] by mouth daily for 4 days .related to MUSCLE WEAKNESS . Review of the revised Care Plan dated 8/13/2024, revealed The resident [#44] has had an actual fall with Poor communication/comprehension. Fall without injury 5/27/2024 .[Revised 8/13/2024] . During an interview on 8/14/2024 at 4:01 PM, the DON confirmed Resident #44 fell on 5/27/2024, however the incident report was not completed until 5/31/2024. The DON stated, .We didn't know he fell till a couple days later .when he complained of pain [on 5/31/2024] . The DON was asked should the nurse have put the incident report in that day (5/27/2024 the day Resident #44 fell). The DON stated, Yes .I can't tell you why she didn't . The DON was asked, when were you made aware he fell in the bathroom. The DON stated, .not until [Resident #44] complained of rib pain to the unit manager, and the Xray was ordered. The DON confirmed she started her investigation on 5/31/2024. The DON was asked do you know the nurse's name that knows about the fall. The DON stated, Yes, [named Registered Nurse (RN) F]. The DON was asked to look in her computer and show the surveyor where the fall was documented on the 24-hour report on 5/27/2024. The DON confirmed Resident #44 was not listed as having a fall on the 24-hour report on 5/27/2024. During an interview on 8/14/2024 at 4:57 PM, RN F confirmed she did not know Resident #44, and did not know of any fall concerning him. During a telephone interview on 8/15/2024 at 9:58 AM, the Nurse Practitioner (NP) confirmed Resident #44 complained of rib pain on 5/31/2024 and she ordered x-rays. The NP was asked did the facility notify you of the results of the x-ray on 5/31/2024. The NP stated, No. The NP confirmed that the facility did not call her when the facility received the x-ray report of the fractured rib on 5/31/2024. The NP confirmed she was not aware of the fracture until 6/3/2024. The NP confirmed the facility should have called her on 5/31/2024 with results of a fracture. The NP confirmed she assessed Resident #44 on 6/3/2024 and sent him to the emergency room. During an interview on 8/15/2024 at 12:58 PM, the NP was asked if she thought the rib fracture could have contributed to Resident #44's pneumonia. The NP stated.It would take a few days to be acute . The NP was asked if the fall was 7-9 days old could it have contributed to the pneumonia. The NP states, It would be hard to give a definitive answer on that. During an interview on 8/16/2024 at 11:26 AM, the DON confirmed the 5/27/2024 Fall Assessment should have been completed and signed the date of fall. The DON was asked when they were notified that Resident #44 fell. The DON stated, .I would say the day the resident got the x-ray. The DON was asked should the Incident Report have been dated 5/27/2024, when she had no information showing the fall occurred on that date. The DON stated, I don't know, I can't remember why I did that, all my information was 5/31/2024. The DON confirmed the physician and family would have been notified on 5/31/2024, not on 5/27/2024 as documented in the incident report. The DON was asked do you have witness statements. The DON stated, No, just summaries of what they said. The DON was asked was there a pain assessment completed. The DON stated, I cannot confirm or deny it wasn't done on that date. The DON confirmed when she realized Resident #44 had fallen on 5/31/2024, he should have been put on the 24-hour report to be monitored. The DON confirmed there was no documentation of injury following a fall on 5/27/2024 or 5/31/2024 after Resident #44 was diagnosed with a rib fracture. During an interview on 8/16/2024 at 3:05 PM, Licensed Practical Nurse (LPN) H confirmed she assisted Resident #44 from the floor when he fell in the bathroom. LPN H was unable to confirm the date the fall occurred or the names of the 2 Certified Nurses Aides (CNA) that assisted her. LPN H stated, I told his [Resident #44's] [RN F] about his fall, he was not my Resident . During an interview on 8/21/2024 at 11:26 AM, the Administrator was asked, are you aware of Resident #44's fall. The Administrator stated, Yes. The Administrator confirmed she was not made aware the Resident fell, and staff didn't complete an investigation until 5/31/2024. The Administrator confirmed the Incident report should have been completed the day [5/27/2024] of the fall. The Administrator confirmed that the NP or physician should have been notified of the x-ray results showing the rib fracture on 5/31/2024. The Administrator confirmed witness statements are needed for a complete investigation and should have been completed. The facility failed to monitor Resident #44 for injuries following the fall on 5/27/2024, failed to notify appropriate facility staff, and failed to document timely related to the fall. The facility failed to monitor Resident #44 after the fractured rib was identified on 5/31/2024 and failed to monitor the resident's complaints of pain. The Nurse Practitioner was not aware of the resident's fractured rib identified on 5/31/2024 until the NP saw the resident on 6/3/2024, at which time Resident #44 was sent to the hospital ER. These failures resulted in Actual Harm for Resident #44. 3. Review of the medical record revealed Resident #85 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction with Hemiplegia (a condition that causes partial or total paralysis of one side of the body), Sickle-Cell Trait (A genetic blood disorder that occurs when someone inherits one sickle cell gene and one normal gene), Hypertension, History of Falling, and Anxiety. Review of the annual MDS dated [DATE], revealed Resident #85 had a BIMS score of 15, which indicated he was cognitively intact, required moderate/maximum assistance with ADL's and had 2 or more falls. Review of an Incident Report dated 4/20/2024, revealed Resident #85 sustained a fall that was witnessed by another Resident. Review of a Nurse's Note dated 4/20/2024, revealed Resident #85 slid from his chair to the floor, he was placed back in the wheelchair and sat next to the nurse's station. Review of the medical record revealed Resident #85 was not assessed or monitored for injuries for 72 hours following his fall. Review of an Incident Report dated 7/26/2024, revealed Resident #85 was observed half out of the bed with his head on the floor, with no injuries noted. Review of a Nurse's Note dated 7/26/2024, revealed Resident #85 returned from the hospital post fall. During an interview on 8/16/2024 at 12:02 PM, the DON confirmed after a fall a resident should be monitored for 72 hours in his medical record. The DON was asked if Resident #85 was monitored on 4/20/2024 and 7/26/2025 after his falls. The DON stated, No, he was not. Review of the medical record revealed Resident #85 was not assessed or monitored for injuries for 72 hours following his fall, there was no progress note related to his transfer to the hospital, and no assessment or monitoring following the hospital return on 7/26/2024. 4. Review of the medical record revealed Resident #119 was admitted to the facility on [DATE], with diagnoses including Fracture of Thoracic (T) 11-T12 (compression fracture of the thoracic spine usually at the bottom part of the thoracic spine), Respiratory Failure, Urinary Retention, Diabetes, Atrial Fibrillation, and Dysphagia. Review of the Care Plan dated 7/5/2024, The resident [#119] has impaired cognitive function or impaired thought processes r/t [related to] impaired decision making/POISONING BY FENTANYL OR FENTANY . Review of the Fall Risk assessment dated [DATE], revealed Resident #119 scored a 12.0. A score of 10 or higher indicated a high risk for potential falls. Review of the Progress Note dated 7/22/2024 at 8:24 PM, revealed .resident [#119] had an unwitnessed fall outside of her room in the hallway. Resident got up out the bed and walked in the hallway where she fell and hit her head. Resident was assessed, nuerochecks [neuro checks] started and placed back in bed. Resident have [The resident had] no complaints of pain I contacted the NP [Nurse Practitioner] and the DON I attempted to call her RP [Responsible Party] but the phone is disconnected will continue to monitor. Review of the facility's Fall Investigation dated 7/22/2024, revealed Injury Type No injuries observed at time of incident .Injury Report Post Incident No injuries Observed Post Incident .7/23/2024 Assist to nurses station for close supervision .7/24/2024 Resident [#119] remain visible when agitated . Review of the Progress Note dated 7/23/2024 at 5:41 AM, revealed Resident [#119] in bed resting, Resp. [Respirations] even and unlabored, skin w/d [warm/dry] to the touch, no changes in LOC [level of consciousness] noted, neuro checks remain in progress post fall, Resident has swelling noted over right eye, no s/sx [signs/symptoms] of pain or discomfort noted, will continue to monitor . Review of the Progress Note dated 7/23/2024 at 11:15 AM, revealed .Resident [#119] was sent to the hospital due to an unwitnessed fall that occurred last night [7/22/2024]. Resident alert-oriented x [times] 1 . resident has cut on her forehead from the fall. Unable to answer any questions pertaining to the fall . Review of the Fall Risk assessment dated [DATE], revealed Resident #119 scored a 12.0, which indicated the resident was a high fall risk. Review of the Care Plan dated 7/23/2024, revealed The resident [#119] has had an actual fall with injury Poor Balance Unsteady gait 7/22/24 [2024] actual fall with minor injury .Assist to nurses [nurses'] station for close supervision-7/22/24 . Review of the Physician Order Review Report dated 7/15/2024 - 8/15/2024 revealed no order for x-rays for Resident #119. Review of the Care Plan dated 8/12/2024, revealed The resident has a communication problem r/t Expressive Aphasia . Review of the Care Plan dated 8/13/2024, revealed Alteration in musculoskeletal status r/t [related to] fracture of the T11-T12 vertebra [Resident admitted with the diagnosis of T11- T12 fractures] . The fall investigation for Resident #119's fall on 7/22/2024 fall revealed no injuries. The resident was placed back to bed, but she would not stay, so she was put in a wheelchair and placed at the nurses' station. On 7/23/2024, the Resident was noted to have swelling above her right eye. On 7/23/2024 at 11:15 AM, Resident #119 was sent to hospital for a cut on forehead. During an interview on 8/16/2024 at 12:28 PM, the DON was asked about the injury to the forehead for Resident #119. The DON was asked how many falls Resident #119 had. The DON stated, One .put her back to bed but she would not stay so we put her in a wheelchair at the nurses' station. The DON was asked why she went out 9 hours after the fall. The DON stated, Because of the swelling . The DON was asked did you all put her back to bed after the fall. The DON stated, Yes, she wouldn't stay we put [her] in wheelchair at [the] nurses' station. Policy to get neuro checks. 7/23/24 5:41 AM swelling over right eye. Yeah, same cut from fall on 7/22/24. The cut was from that [7/22/2024] fall. The DON was asked was there a fall investigation for the forehead injury, any other injuries, or staff or resident interviews/statements obtained. The DON stated, Yes she only had one fall .We did not have an order to send her out [but due to the cut and swelling noted on 7/23/2024, the resident was sent out on 7/23/2024] .She didn't need sutures . 5. Review of the medical record revealed Resident #89 was admitted to the facility on [DATE], with diagnosis including Paraplegia, Neurogenic Bladder (urinary bladder problems due to disease or injury of the central nervous system .involved in the control of urination), Neurogenic Bowel (loss of normal bowel function) Major Depressive Disorder, Constipation, and Chronic Pain. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status score (BIMS) of 15, indicating intact cognition. Review of the Progress Note dated 7/5/2024 at 11:14 AM, revealed Resident [#89] left facility 7/4/24 [7/4/2024] LOA [Leave of Absence] with family. Family transported resident to hospital on 7/5/24 [7/5/2024] and resident was admitted to the hospital on [DATE] . Review of the undated [Named Hospital] Discharge Summary, revealed .ED [Emergency Department] to Hosp [Hospital] admission .7/5/2024 - 7/11/2024 .Urine drug screen positive for amphetamines and THC [Tetrahydrocannabinol (THC), the main psychoactive ingredient in the cannabis plant] . During an interview on 8/14/2024 at 10:18 AM, the DON confirmed she was aware of Resident #89 having a positive drug test during the 7/5/2024-7/11/2024 hospitalization. The DON stated, He called me from the hospital [unable to recall the date Resident #89 called] .he told me that he does smoke marijuana when he goes home .he said it must have been laced with something . The DON confirmed Resident #89 denied the use of amphetamines, but admitted he does use marijuana when he goes home. Review of the care plan revised on 8/14/2024, a month after the hospital discharge, revealed .Resident [#89] is at risk for substance abuse disorder r/t [related to] potential THC and opioid use Date Initiated: 8/14/2024 .Monitor for s/sx [signs and symptoms] of possible use .changes in resident behavior, increased unexplained drowsiness, lack of coordination, slurred speech, mood changes, and or loss of consciousness .Report any abnormal s/sx . During an interview on 8/14/2024 at 4:16 PM, the Administrator confirmed she was not aware of Resident #89's positive drug test at the time but he smells of marijuana at times. The Administrator confirmed the facility was initiating monitoring of Resident #89 for illegal drug use beginning 8/14/2024 and the monitoring would be documented on the Medication Administration Record (MAR). The Administrator confirmed Resident #89 had not been monitored for illegal drug use since his return from the hospital on 7/11/2024. Review of the [Named Facility] Order History Report dated 8/16/2024, revealed there was no order to monitor Resident #89 for substance abuse. During an interview on 8/16/2024 at 1:24 PM, the DON confirmed the monitoring for illegal substance use order had not been entered into the system as of that time. During an interview on 8/21/2024 at 10:21 AM, the Administrator confirmed Resident #89 should have been assessed and monitored for illegal drug use and interventions should have been put in place in July 2024, when the facility became aware of the drug use, but nothing was initiated until 8/14/2024. 6. Review of the medical record revealed Resident #102 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, Chronic Obstructive Pulmonary Disease, Blindness right eye, and Hypertension. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #102 had a BIMS score of 6, which indicated Resident #102 had severely impaired cognition, and had no wandering behaviors. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #102 had a BIMS score of 3, which indicated Resident #102 had severely impaired cognition, required supervision or touching assistance from staff for ambulation, and had no wandering behaviors. Revised of the revised Care Plan dated 5/11/2024, revealed Resident #102 was .an elopement risk/wanderer . with interventions including .Wanderguard bracelet to help prevent elopement . Review of the facility's Incident Investigation Witness Interview Form sheet dated 5/13/2024, revealed Resident #102 exited an East End Hall door alone on 5/11/2024. Review of the facility's Logbook Documentation .Door Security System/Delayed Egress . dated 5/2024, revealed there was no daily interval monitoring of the East End Hall exit door from 5/11/2024 until 5/23/2024. Review of the facility's Securitas Healthcare, invoice dated 5/23/24, revealed .Keypad .Egressable Mag [Magnetic] Lock .Reset Switch .Installation of Locks System . During an interview with the DON on 8/14/2024 at 1:50 PM, the DON was asked about the incident concerning Resident #102 on 5/11/2024. The DON stated, It was a Saturday morning, [Licensed Practical Nurse (LPN C)] called me and stated [Resident #102] got out of the building, he had been agitated all night and would not sleep. She had went [gone] in another resident's room to give medication and heard the back door alarm, looked at [the] nurse's station, and the resident was not there. She looked out the back door and he was outside the back door. He was right outside the back door. The DON was asked what was done for the prevention of the resident being able to exit the door again. The DON stated, I cannot remember, will have to look at computer. During an observation and interview on 8/14/2024 at 3:37 PM, LPN C was asked about Resident #102 exiting the door on the East End Hall. LPN C stated, It was the weekend and one of his behaviors was not going to bed. He was walking around. We sat him at the nurse desk to rest him and keep watch on him. The last time I saw him, before he got out, he was sitting in his wheelchair at the nurse station. I went in a resident [resident's] room to pass medication; he was in the wheelchair when I went into that room. I came out [of] the room, because I heard the alarm, it was coming from the back door alarm. I notice [noticed] he was not at the nurse's desk. I ran to the back door. LPN C was asked to confirm which door [Resident #102] exited. LPN C stated, The hall that room [ROOM NUMBER] is on, went to the door and could see [Resident #102] .[Resident #102] was not far from [the] door I could see [Resident #102]. LPN C pointed to area right out the door. Observation at the East End Hall door revealed a metal gate to the left of the door. LPN C confirmed Resident #102 had no injuries. LPN stated, No, he was standing, stated to me he was trying to get home. I walked him back in arm and arm. The staff heard the alarm, went and found Resident #102 just outside near the door. During an interview on 8/14/2024 at 5:45 PM, LPN D was asked about Resident #102 exiting the East End Door on 5/11/2024. LPN D stated, It was myself and [LPN C] on the East Hall .The last time I saw [Resident #102] he was at the nurse station sitting in a wheelchair .I went to the cart to get medicine and he was still at the nurse station .I went back in the resident's room to give [female resident] her the med and that is when the door alarm sounded. When I came out [of] the room, I saw [Resident #102] and [LPN C] walking back into the facility . During an interview on 8/16/2024 at 10:06 AM, the Maintenance Director was asked how Resident #102 got out of the facility on 5/11/2024. The Maintenance Director confirmed he did not recall the time of day he was called and thought it was a Saturday. The Maintenance Director confirmed it was the East End Hall door, at the end of the hall that contains room [ROOM NUMBER] and 118. The Maintenance Director stated, .the door had malfunction [malfunctioned] due to a power surge . The Maintenance Director was asked how he determined it was a power surge. The Maintenance Director stated, Because immediately the door opened when pushed in on the door handle. The Maintenance Director was asked when the last time, before the incident, had the East End Hall door been checked to see if properly functioning. The Maintenance Director stated, I did it that Friday [5/10/2024], it is part of daily preventive maintenance, make rounds to check all doors Monday thru Friday. The Maintenance Director confirmed the doors are not checked on the weekends to see if they are working properly. The Maintenance Director was asked how he fixed the East End Hall door. The Maintenance Director confirmed the door is a magnet (mag) lock door; he took the Mag Lock apart then to see if it had problems or damage and found nothing with the Mag Lock, then he reset the Mag Lock and the Mag Lock worked. The Maintenance Director confirmed he checked every door after he came in (on 5/11/2024) and found the East End Hall door was unlocked, and the East End Hall door was the only door he found to have malfunctioned. The Maintenance Director was asked to explain a power surge. The Maintenance Director stated, It is when the power may go out, for example, if someone in those apartments behind us hit a pole and the power goes out, and the generator has to kick in for the electricity to come back on. The Maintenance Director was asked if another power outage happens does the nurses know what to do about the doors, to check the doors for malfunction. The Maintenance Director stated, I told them to check the doors to make sure they are locked. The Maintenance Director was asked did the nurses get an in-service about checking the doors to see if they lock if a power surge occurs, and was it documented. The Maintenance Director stated, No, I told them, it was word of mouth on what to do. The Maintenance Director confirmed after he found out the East End Hall door had malfunctioned; he contacted a vendor to have them to check all doors on the East End Hall and the findings were to replace the Mag Lock. The Maintenance Director stated, .a power surge may have caused the door to malfunction . The Maintenance Director was asked if there was anything in place, so that when it happens to be another power surge, staff will check doors' locks to make sure they are working properly. The Maintenance Director stated, If we have a power outage they will, and I will check the doors. The Maintenance Director confirmed before he left on Saturday, it was word of mouth, no documented in-service that nurses were to check the East End Hall door to make sure it is not immediately opening. The Maintenance Director was asked to explain the East End Hall door's Mag Lock. The Maintenance Director stated, It has a 15 second delay, if you hold handle down for 3 seconds, it will beep and within 15 seconds the magnet will release, and the door will open. The Maintenance Director confirmed after Resident #102 exited the East End Hall Door alone on 5/11/2024, there was no documentation the door was monitored and the intervals that the door was monitored, in order to make sure the Mag Lock was working properly and to prevent another resident from being able to exit alone. During an interview on 8/16/2024 at 1:12 PM, the Administrator confirmed it was the East End Hall door that houses rooms [ROOM NUMBERS], that Resident #102 exited alone, and confirmed the Maintenance Director informed her the Mag Lock to that door had malfunctioned and needed to be replaced. The Administrator confirmed the Maintenance Director told her the door needed a new Mag Lock. The Administrator stated, I asked the Maintenance Director do we need someone sitting at the door at all times because of the Mag lock and he reassured me no, to focus on getting the Mag Lock replaced. The Administrator confirmed she was not for sure if there was any documentation of random checks of the East End Hall door for not immediately opening when you push in on the handle. During an interview on 8/19/2024 at 4:28 PM, the DON confirmed the East End Hall exit door is an egress [hold down 15 sec and it will release] door for emergency purposes. The DON confirmed she did not ask the nurses to do anything with the doors. The DON confirmed there are no documented daily checks on the door after the resident got out the East End Hall exit door on 5/11/2024 and until the new Mag Lock was installed.