**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #2) of 6 residents reviewed for quality of care. The facility failed to identify and treat a wound to Resident #2's left great toe, prior to his visit to a local hospital on [DATE], where Resident #2 was found to have wound to his left great toe with osteomyelitis . Resident #2's left great toe was amputated on 06/18/24. An Immediate Jeopardy (IJ) situation was identified on 08/09/24. While the IJ was removed on 08/10/24, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. This failure could place residents at risk for delay in needed treatment and diminished quality of care. The findings included: Record review of Resident #2's face sheet, printed on 08/10/24, reflected a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of cerebrovascular disease (conditions that affect blood flow to the brain), Partial traumatic amputation of left great toe, Osteomyelitis (bone infection), End stage renal disease (the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), Essential hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause), and Type 2 diabetes mellitus(high blood glucose). Record review of Resident #2's quarterly MDS assessment, dated 05/24/24 reflected Resident #2 had a BIMS score of 03, which indicated a severe cognitive impairment. Section GG - Functional Abilities and Goals of the assessment indicated Resident #2 required substantial or maximal assistance with ADLs of Toileting, personal hygiene, bathing, and lower body dressing. Record review of Resident #2's care plan, dated 05/31/24, reflected the following: - Problem start date: 03/05/24 - I am a diabetic and is at risk for complications from disease process., with approaches to include Approach Start Date: 03/05/2024 - MONITOR SKIN FOR CHANGES--REDNESS, CIRCULATORY PROBLEMS, BREAKDOWN, REPORT TO M.D., R.P. and Approach Start Date: 03/05/2024 WEEKLY SKIN ASSESSMENTS. Record review of the progress notes tab of Resident #2's electronic health record reflected the following notes: - Documented by RN B on 06/13/24 at 2:55 p.m., Resident went to the dialysis, dialysis nurse called to me said he has a pus like drainage from the cvc catheter and he is confusion little bit he need to go to hospital for checkup, talked to the NP, AND DON, and try to make him ready, he said after lunch, and he refuse again, give handover to the incoming nurse . continue on plan of care. - Documented by RN B on 06/13/24 at 3:18 p.m., Resident went hospital with facility transport at 3pm. - Documented by LVN C on 06/22/24 at 7:25 p.m., Resident was readmitted to [facility] at around [5:30 p.m.] from [hospital]. Patient was brought in via stretcher and placed in room [number]. Resident is alert and verbally responsive to care. Respirations are even and unlabored. No SOB noted or s/sx of respiratory distress. Vitals are stable. BP:121/67, 83, 97.5, o2 sat 98% @ RA. Afebrile. Resident will continue to be under the care of [PCP]. All orders clarified with [PCP]. Covid test done, negative results. Current weight is 75.7 kg and height 170.2 cm. Upon head-to-toe assessment, this nurse noted patient to have a laceration on his right groin. Scabs on left knee and left thigh. Discoloration on left thigh was noted as well. A pustule noted on on left lateral thigh. Bruising on left elbow and low abdomen. Black hard tissue on right ankle was also noted. Upon report via telephone per [hospital RN], she stated that doctor from [hospital] ordered to not remove dressing on left great toe until 6/28/24 due to his amputation . Record review of the Plan of Care History, Skin tab of Resident #2's electronic health record, dated 06/01/24 through 06/13/24 and documented by CNAs C, D, E, F, G, and H reflected Resident #2's skin was clear and free of any skin problems. Record review of Resident #2's skin assessment documentation, documented by RN I on 05/27/24 at 11:39 a.m., on 06/03/24 at 12:15 p.m., and on 6/11/24 at 1:39 p.m., reflected Resident #2's skin was warm, dry, normal in color and no alteration to the skin was observed. Record review of Resident #2's local hospital records, service date of 06/13/24 reflected the following: - Documented by hospitalist on 06/13/24 at 7:23 p.m., Assessment & Plan . Leukocytosis, Left great toe wound POA . Will do Xray, wound cultures, wound care consulted; - Wound Evaluation Note documented by hospital physician on 06/14/24 at 8:11a.m., 06/14 Evaluation and Assessment: Pt presents with a chronic necrotic ulcer present at the tip of the L great toe wound. Wound initially covered with lifting dry necrotic tissue. Performed selective sharp excisional debridement with scissors to remove lifted non adherent necrotic tissue to level of necrotic tissue. After initial debridement, bone became palpable differed any further debridement. After sharp debridement, the wound measures 1.5cmx3.0cm with unknown depth. Toe nail is separating from the nail bed as well. With palpation of the wound and surrounding area able to express thick purulent drainage as well as mild foul odor present. Peri wound is dry and slightly dusky. Tissue composition is dark purple with yellow necrotic tissue, overall viability of wound is questionable. Treatment: Wound cleansed with normal saline, patted dry with sterile gauze. Applied xeroform double layer to the wound bed to assist with maintaining appropriate level of moisture and antimicrobial properties. Covered with dry gauze and secured with tape. Provided education about wound clinical presentation and plan of care while patient is admitted . Continued skilled PT wound care services are indicated for dressing changes, selective debridement as needed, management of drainage/edema, patient education and to assess progression of advanced wound products. Messaged attending MD due to clinical presentation of purulence, bone palpable and necrotic tissue present. At time of documentation, Xray suggestive of OM. MRI and podiatry consult pending. PT wound to continue monitor plan of care and assist with dressing management as appropriate. - Documented by hospitalist on 06/21/24 at 12:05 p.m., Assessment & Plan: Acute Problems: . Acute osteomyelitis of left foot . Resolved problems: *no resolved hospital problems. * Leukocytosis: Left great toe wound POA . Xray/MRI foot positive for great tie osteomyelitis . angiogram followed by left great toe amputation by podiatry on 06/18. Follow biopsy results for final determination for antibiotics. Podiatry recommends dressings to stay intact till next evaluation in 1 week to 10 days. In a telephone interview on 08/08/24 at 12:37 p.m., Resident #2's primary care physician stated he became Resident #2's facility physician on 07/02/24, which was after the amputation of his toe. The physician stated he ordered an arterial of the lower extremities on 08/02/24 and found ischemia and Peripheral Vascular Disease, which affected the blood circulation to Resident #2's foot. The physician stated without proper circulation and oxygen to the area, the wound would never heal. The physician stated he was not aware of any change of condition or skin issues prior to Resident #2's amputation, but he would have to double check the records provided to him by Resident #2's previous physician. In an interview on 08/08/24 at 2:01 p.m. with WCN J and the IDON when WCN J stated she was the facility's wound care nurse since February of 2024. WCN J stated Resident #2 had two amputations after being sent to a local hospital in June and July. WCN J stated After Resident #2's amputation of his left great toe, he had to be sent to the hospital because his surgical wound had dehisced (a surgical complication that occurs when a wound incision reopens after being stitched or stapled closed) after the sutures were removed. WCN J stated Resident #2 returned to the facility on or around 7/30/24 with the remainder of his toes amputated. WCN J stated the resident returned to the facility with what appeared to be necrotic tissue around the wound. She stated the wound was monitored, per physician orders and the resident was sent back to the hospital on [DATE], when the surgical wound declined. WCN J stated she was not aware of any skin integrity issues or wounds to Resident #2 left great toe prior to his amputations. In an interview on 08/08/24 at 4:02 p.m., Resident #2 stated he was well, but he did not want to go back to the facility. Resident #2 stated he had a wound on his toe before it was amputation and that he had told facility staff about his toe, but he could not recall how long the wound was there or who he reported his toe to. Resident #2 was unable to verbalize what happened to his foot. Resident #2 was seen and interviewed in his room at a local hospital. Telephone interviews were attempted on 08/09/24 from 9:12 a.m. through 9:22 a.m., with Resident #2's podiatrist, previous primary care physician, and wound care physician but were unsuccessful. In a telephone interview on 08/09/24 at 9:50 a.m., CNA G stated she was Resident #2's aide prior to the amputation of his toe. CNA G stated she checked Resident #2 every two hours and provided care as needed. CNA G stated she could not recall ever noticing a wound or skin issue to Resident #2's left toes or foot. CNA G state Resident #2 liked to keep his socks on, so she had never changed his socks and focused more on his brief. A telephone interview was attempted on 08/09/24 at 11:06 a.m. with LVN L, who was Resident #2's weekend nurse prior to the amputation of his toe but was unsuccessful. In a telephone interview on 08/09/24 at 11:20 a.m., RN K stated she was Resident #2's weekend nurse from February 2024 until June 2024. RN K stated she did not recall Resident #2 having a wound or skin integrity issue to his feet and she could not recall an aide reporting an issue to her. RN K stated if a skin integrity issue or wound it report by an aide, nurses were to assess the resident, provide first aide as needed, notify the resident physician and responsible party and carry out any orders provided. RN K stated skin assessments were to be documented as a skin progress note and they are to make a skin event if issues are noted. In an interview on 08/09/24 at 11:36 a.m., CNA C stated she was Resident #2's first shift aide in June 2024. CNA C stated Resident #2 received total care from facility staff. CNA C stated she could not recall if Resident #2 had a wound to his left great toe. CNA C stated if she had saw a wound to his toe, she would have reported to a nurse for evaluation. In an interview on 08/09/24 at 11:54 a.m., CNA E stated he was Resident #2's aide briefly when he first started to work for the facility, which was roughly 2 months ago. CNA E stated he did not recall seeing a wound to Resident #2's toes but would have reported to a charge nurse if he did. Telephone interviews were attempted on 08/09/24 at 11:56 a.m. with RN B and at 11:59 a.m. with RN I, who were Resident #2's first and second shift nurses prior to the amputation of his toe, but attempts were unsuccessful. In a telephone interview on 08/09/24 at 12:05 p.m., CNA D stated she was Resident #2's aide prior to his first amputation. CNA D stated Resident #1 was a total assist resident but could transfer himself. CNA D stated she gave the resident bed baths instead of showers and had not observed any skin integrity issues to his toes. In a interview on 08/09/24 at 12:23 p.m., the IDON stated to her knowledge Resident #2 was sent to a local hospital on [DATE], after returning from dialysis with pus like discharge coming from his dialysis port. The IDON stated she believed Resident #2's left great toe was black or something and it was amputated prior to his return to the facility on [DATE]. The IDON stated Resident # 2 had to be sent to the hospital two additional times due to wound complications on 07/15/24 and 08/06/24. The IDON stated she had no knowledge of Resident #2 having skin integrity issues to his left foot. The IDON stated she would have to check Resident #2's records to see if his physician was following Resident #2's foot prior to is amputation. The IDON stated if a skin integrity issue or wound is observed on a resident the aide was expected to report to a nurse. She stated the nurse was expected to assess the resident, report to the resident's physician, responsible parties, facility leadership and to carry out any orders given by the physician. The IDON stated Resident #2 had not reported any issues with his feet to her. In an interview on 08/09/24 at 12:39 p.m., the ADMIN stated she was not aware of a wound to Resident #2's left great toe prior to his hospital visit on 06/13/24. The ADMIN stated she normally communicate with hospital staff to check on the residents and no one let her know Resident #2 arrived at the facility with a wound to his left great toe. The ADMIN stated she spoke with Resident #2's primary care physician who ordered a doppler and confirmed the resident had Peripheral Vascular Disease, which was contributed to the healing process of Resident #2's surgical wounds. The ADMIN stated if a nurse identifies a skin issue they should create and event in the electronic health record, report the issue to the resident's physician and carry out treatment orders until the wound care physician could visit with the resident. The ADMIN stated all residents were to have weekly skin assessments completed and are also completed by aides during showers. The ADMIN stated this information is documented in the resident's electronic health record. The ADMIN stated it was expected for all skin integrity issues to be identified and reported to the appropriate parties, as not doing so could create a delay in needed care. The ADMIN stated she would begin to in-service staff on skin assessments and documentation to ensure all skin integrity issues were addressed as needed. Review of the facility's policy entitled Pressure Injury Risk Assessment, revised in March of 2024, read in part: The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries (PIs) . Conduct a comprehensive skin assessment with every risk assessment. a. When conducting a skin assessment, provide for the resident's privacy. b. Once inspection of skin is completed document the findings on a facility-approved skin assessment tool. c. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin . Notify attending MD if new skin alteration noted. 4. Notify family, guardian or resident update if new skin alteration noted . The identified failure was determined to be an Immediate Jeopardy (IJ) on 08/09/24 at 3:38 p.m. The Administrator and the IDON were notified. The Administrator was provided with the IJ template on 08/09/24 at 3:45 p.m. In a telephone interview on 08/09/24 at 4:42 p.m., the local hospital charge nurse stated the POA reviewed on Resident #2's hospital records, dated 6/13/24, meant present on arrival or admission. The charge nurse stated if the hospital staff wanted to document the power of attorney was notified, they use 'MPOA', as in Medical Power of Attorney. The following Plan of Removal submitted by the facility was accepted on 08/10/24 at 11:08 a.m.: On 8/9/2024 At 4:40pm Surveyor reported to the Administrator that the facility failed to identify and treat a wound to Resident #1's great toe, which lead to osteomyelitis and amputation of the toe on 6/18/2024. At 4:45pm Nurse Managers started a skin sweep of all residents; any findings will be corrected by notification to PCP for recommendation of wound orders. A referral to Wound Physician will be made. There were no negative findings. - Completion Date: 8/9/2024 On 8/9/2024 At 5:15pm In-service started for Licensed Nurses by DON/ADONS on completing Hospital Transfer Form to include if wound is present and documentation of wound. - Completion Date: 8/10/2024 On 8/09/2024 5:36pm DON/ADON's started an in-service with all Licensed Nurses, Med aides and CNA's regarding skin/wound documentation and notification in their documentation in the [electronic health record system]. Documentation will be monitored daily by DON/ADON's/Weekend Supervisor to ensure all skin issues identified were reported to the physician and treatment ordered. - Completion Date: 8/10/2024 On 8/9/2024 at 5:30pm We have added to our current system the ADON's will complete skin sweeps 3X weekly to ensure all wound/skin issues are documented. This will be monitored by the DON/Designee 3X weekly to ensure skin sweeps are completed and all negative findings corrected. Any negative findings will be corrected immediately. - Completion Date: 8/9/2024 Monitoring of the facility's implementation of the Plan of Removal revealed the following: Record review of skin assessment sheets dated 08/09/24 and 08/10/24, reflected all facility's residents, 94 in total, received a skin assessment and new skin integrity issues were reported to the resident's physician. Record review of in-services dated 08/09/24, regarding Hospital Transfer Form completion, wound documentation and skin assessment completion and documentation, reflected all facility nursing staff were in serviced in person or by phone. Interviews conducted on 08/10/24 from 12:30 p.m. through 4:26 p.m., with the ADMIN, the DON, the IDON, ADON A, ADON M, 10 CNAs, 4 MAs, 4 LVNs, and 4 RNs from various shifts revealed all interviewed staff were in serviced in person or by phone and phone in serviced staff would have to be in serviced again before their next shift. During the interviews staff could explain the facility's skin assessment and documentation and notification policies in their own words. In interviews with facility nursing leadership all staff were aware of the expectation of monitoring for skin sweeps three times a week to ensure all skin integrity issues were identified and treated, as needed in the future. The Administrator was informed the Immediate Jeopardy was removed on 08/10/24 at 5:00 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for 2 of 8 residents (Resident #1) reviewed for Quality of Care. Cumulative effects of LVN A's and MA V's individual failures to provide oversight of care delivery on 03/25/24, Resident #1 had an unwitnessed fall and sustained bruising, swelling, and an abrasion to the frontal scalp. The facility failed to implement interventions for Resident #1 identified as a fall risk on 12/05/22 to observe frequently and place in supervised area when out of bed (Start date 12/23/22). Resident #1 sustained unwitnessed falls in the dining room from the wheelchair on 03/14/24, 03/23/24, 03/28/24 and 04/03/24; a fall on 04/01/24 was documented as witnessed. Resident #1 had 46 documented falls since 12/05/22. The facility failed to ensure residents were protected from physical and psychosocial harm during abuse or neglect investigations. Resident #1 had an unwitnessed fall on 03/28/24 and a witnessed wall on 04/01/24. Resident #2 had an unwitnessed fall on 03/28/24. An Immediate Jeopardy (IJ) was identified on 04/01/24. The IJ template was provided to the facility on [DATE] at 4:30 PM. While the IJ was lowered on 04/04/24, the facility remained out of compliance at a scope of Pattern and severity level of No actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. The facility failed to oversee the implementation of resident care policies. LVN M failed to assess, evaluate, and obtain vital signs after Resident #1 fell on [DATE] per the facility's policy and procedure, Assessing Falls and Their Causes, revised March 2018. The facility failed to oversee the implementation of resident care policies. LVN A failed to initiate and document investigation of the accident on 03/28/24, when Resident #2 sustained an unwitnessed fall from her wheelchair in the Dining Area, per the facility's policy and procedure, Accidents and Incidents - Investigating and Reporting, revised July 2017. These deficient practices placed residents at considerable risk of serious injury, harm, impairment, developing complications, or death by not receiving services necessary, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Record review of the nursing schedule dated 03/25/24 revealed LVN L, CNA T, CNA J, and CNA U worked the 6A - 2P shift; MA V worked 7A - 7P. CNA W had Unpaid Time Off and CNA X was a No call, No Show; LVN A, CNA P, and CNA Q worked the 2P - 10P shift. CNA S had an excused call off. Resident #1 Record review of Resident #1's Continuity of Care Document, created 03/30/24, reflected a 94 y.o. male, who admitted to the facility on [DATE] from a long-term care facility. The latest return to the facility was on 03/04/23 after a short-term acute care hospital inpatient stay with the diagnosis of Displaced fracture of base of neck of left femur. Resident #1 had a history of Repeated falls (effective date: 03/04/23); Localized swelling, mass and lump, head (effective date 03/25/24); Anxiety; COPD; unsteadiness on feet; other abnormalities of gait and mobility; dementia; and other lack of coordination. Record review of Resident #1's Annual MDS review assessment, dated 01/10/24, revealed Resident #1 had a severe cognitive impairment per staff assessment because a BIMS interview was not conducted. Resident #1's functional status required one-person extensive assistance with ADLs and a wheelchair for mobility. Record review of Resident #1's Comprehensive Care Plan, date initiated 05/31/23, reflected: Resident #1 had Frequent falls due to unsteady gait, family not allowing wheelchair, in a geri-chair, he slides from the geri-chair, and he tries to walk by self . The intervention(s) included Try and put to bed (Start date 02/19/24); involve in activities (Start date 01/16/24, 11/27/23, and 11/06/23); recline wheelchair (Start date 10/30/23); Replace Dycem in the wheelchair (start date 10/24/23); will have leg rests replaced on the wheelchair (Start date 10/15/23; will be provided a Scoop mattress on bed (Start date 10/09/23); will be provided a fall mat at bed side while in bed (Start date 09/25/23); and bed will be kept in the lowest position while in bed (Start date 09/25/23). The long-term goal indicated Resident #1 will not have no injuries from falls that require hospitalization in next 90 days (Target date: 05/04/24). Resident #1 had Potential risk for injury due to poor safety awareness. The intervention(s) included Dycem added to wheelchair (start date 01/12/23); Encourage [Resident #1] to request needed assistance in all transfers, keep call light in reach, wedge cushion to wheelchair. (Start date 01/11/23); and [Resident #1] to call for assistance with all transfers (Start date 01/11/23). The long-term goal indicated Resident #1 will be free from injury and will have safe transfers (Target date: 05/04/24). Resident #1 experienced a fall. 12/31/22. had two additional falls. 02/28/23 Injury fall. unwitnessed fall 03/15/23 . The intervention(s) included bed in lowest position to prevent falls (Start date 03/15/23); hipsters added to both hips due to frequent falls also anti-roll back brakes (Start date 01/03/23); Keep call light in reach at all times (Start date 12/23/22);and Observe frequently and place in supervised area when out of bed (Start date 12/23/22); and Provide an environment free of clutter (Start date 12/23/22). The long-term goal reflected Refer to Therapy for evaluation for treatable causes of the fall such as poor balance, muscle weakness, and poor safety awareness. (Target date: 05/04/24). Record review on 03/30/24 at 4:08 PM of Resident #1's Orders History (01/01/24 - 03/30/24) reflected: - Start date 03/06/23: Admit to hospice for Dx: Senile Degeneration of the brain on 03/04/23. - Start date 02/24/24: Resident requires secured unit due to unsafe wandering and exit seeking on 02/21/24. - Start date 03/14/24: Fall: Cleanse skin tear on right palm with NS and apply steri-strips dressing. Every Shift. - Start date 03/18/24: OT to evaluate and treat as indicated. - Start date 03/23/24: Cleanse skin tear on left arm palm with NS and apply dry dressing. Monitor for s/s of infection and dc when resolved. - Start date 03/25/24: Triple Antibiotic ointment (TAO). Apply a small amount on the affected area for 7 days. Twice A Day (7:00 AM - 10:00 AM; 5:00 PM - 7:00 PM) - Start date 03/26/24: Other Test: (Skull series due to fall with head injury). STAT.' - Start date 03/28/24: Skin Tear: Apply antibiotic ointment, cover with dressing if needed to minor cuts or skin tears until healed. Once a Day PRN. - Start date 03/28/24: 'Suspected head trauma neuro checks. Q15mins (x4); Q1H (x2); Q2H (x2); Q4H (x2); then, every shift (x3). [Previous orders were written on 03/14/24, 03/23/24, and 03/25/24] - Start date 03/30/24: 'Wound care: Forehead - Cleanse with wound cleanser and pat dry with gauze. Apply Calcium Alginate and cover with border dressing. Once a Day. 06:00 AM - 02:00 PM.' Record review of Resident #1's active Orders on 04/04/24 at 4:13 PM reflected: - Start date 04/01/24: Fall Interventions: Call light .; Encourage and assist resident for frequent rest periods .; Locate resident when up near station .; Toilet at regular intervals . Every Shift. - Start date 04/02/24: PT to evaluate and treat as indicated. LATE ENTRY effective 04/02/24 - Start date 04/03/24: Place Dycem (multipurpose non-slip material) in wheelchair to prevent resident from sliding out. Every Shift. - Start date 04/04/24: Suspected head trauma neuro checks. Q4H (x2 - 1:30 AM, 5:30 AM); then, every shift Days, Evenings, Nights (x3 - End Date 04/06/24).' Record review of Resident #1's progress notes indicated: - 03/14/24 at 12:37 PM, written by LVN L, reflected, [Resident #1] had an unwitnessed fall at 12:15 PM, was found by CNA sitting on the floor in one of the female patient's room. [Resident #1] was on a wheelchair at the time of fall. [Resident #1] unable to explain what happened . skin tear at the palm of the right hand . given Morphine 20 mg/5 mL for mild pain (PRN). Intervention includes redirecting patients, patient had non-skid socks on. - 03/28/24 at 12:48 PM, written by ADON, reflected, [ADON] noted [Resident #1] forehead, frontal aspect with fluid filled hematoma with open abrasion to center of hematoma at this time. called and spoke with [hospice services RN] and informed of area to [Resident #1's] head with visual documents provided for review. MD aware as well with zero new orders noted. attempted to reach hospice nurse to confirm that orders had not been given to her at this time. - 03/28/24 at 4:03 PM, written by ADON, reflected, [ADON] noted zero response to medically necessary orders due to [Resident #1] radiology report or area to [Resident #1] head at this time. [ADON] sent message to hospice nurse and MD requesting a return call at this time. - 03/29/24 at 11:04 AM, written by NP, reflected, [Resident #1] seen and examined per nursing staff request for report of a fall yesterday. Noted large hematoma to mid-frontal scalp area with ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising). denies any pain or headache but overall stays stable . - 04/01/24 at 8:21 PM, written by LVN A, reflected, Skull x-ray ordered for [Resident #1] r/t unwitnessed fall. Call to RP did not go through and unable to leave a voice message. - 04/02/24 at 7:28 AM, written by RN N, reflected, [Resident #1] refused to do skull series, notified MD, Administrator and [Resident #1] daughter aware. - 04/02/24 at 7:36 AM, written by RN N, reflected, [Resident #1] fell yesterday, continue on neuro checks, no delayed injuries seen. Continue to be monitored. - 04/03/24 at 7:51 PM, written by LVN A, reflected, At around 6:30 PM was notified by Speech Pathologist that [Resident #1] was on the floor in the dining room. Went to the dining area and found resident on the floor next to his wheelchair. Assessed resident, then put back to wheelchair with 2 persons assist. noticed [Resident #1] was able to unlock the armrest on the wheelchair and push it down, and probably slipped from the side . Record review of Fall Event, dated 03/23/24, linked SBAR Communication Tool (dated 03/27/24) and Resident #1's following progress notes: - 03/25/24 at 6:09 PM, written by LVN A, reflected, [Resident #1] had a fall at around 5:50 PM in the dining area, and hit his head on the floor . assessed and put back on wheelchair . [Resident #1] has a bump in the front of his head and is c/o pain on his head. MD notified via text message with a picture of the injured area and replied, Apply TAO bid for seven days. Hospice called and said they are sending a nurse at the facility to assess [Resident #1] . Neuro checks initiated. - 03/25/24 at 10:07 PM, written by LVN A, reflected, Hospice nurse did not show up . TAO applied on resident bump per MD Order, morphine 0.25 ML provided for pain. [Resident #1] currently resting on bed . in lowest position and mat on the floor. Neuro checks ongoing. - 03/26/24 at 12:52 PM, written by LVN L, reflected, [Resident #1] BP 96/50, HR 77 . rechecked at 12:50 PM, BP 117/70, HR 90 . on bedrest in supine position with legs elevated 8 - 12 inches until BP returns to baseline . - 03/26/24 at 6:45 PM, written by LVN A, reflected, Skull x-ray done at around 6:15 PM. Result pending. - 03/27/24 at 6:31 AM, written by RN O, reflected, Post fall day 2/3. [Resident #1] has a decreased in his blood pressure reading. legs were elevated 8 inches and offered fluids . Fall preventive measure implemented. - 03/27/24 at 9:13 AM, written by LVN L, reflected, [Resident #1's] x-ray results . significant findings and head CT suggested . sent to MD and hospice nurse. [Resident #1] sent to hospital accompanied by facility driver at 9:00 AM. Record review of the Fall Event dated 03/25/24, LVN A indicated the fall was NOT witnessed. [Resident #1] complained of pain 3 out of 10 [4 out of 10 = Moderate Pain - Distressing, Miserable] (to his head). Injury to the head was a bump . Resident has a bump in the front of his head and is c/o pain on his head. MD notified via text message with a picture of the injured area and replied Apply TAO (an ointment that prevent infection and aids in healing of minor cuts, scrapes, and burns) BID (twice daily) for seven days. The following progress notes were linked to the Fall Event: - 03/19/24 at 12:56 PM, written by PCP, reflected, GDR ordered to change Ambien to PRN for 14 days, Ativan changed to AM and HS (at bedtime) per pharmacist recommendation. - 03/28/24 at 12:44 PM, written by ADON, reflected, [ADON] noted [Resident #1's] CT Scan results . notified PCP of available results with impressions that indicated Advance chronic microvascular ischemic changes (brain condition cause problems with thinking, walking and mood after an injury) and moderate generalized volume loss (associated with major neurological diseases, such as a large stroke or progressive dementia) noted. Ventriculomegaly (a condition in which the brain ventricles, or fluid-filled cavities, are enlarged due to build up of cerebrospinal fluid [CSF] found with moderate or severe traumatic brain injury) . hospice requested results fax . [ADON] sent fax . Record review of video surveillance dated 03/25/24, provided by the NFA, revealed the Dining Area. A Med Aide was against the wall standing behind the medication cart approximately 5 - 6 feet in front and to the right of Resident #1 in his high back wheelchair. The Med Aid did not have a direct line of sight of Resident #1. LVN A was approximately 15 - 20 feet away, assisting a resident with eating. Resident #1 was in LVN A's direct line of sight. Resident #1 was scooting in his wheelchair, but unable to move forward past a table and chair. It appeared that there was an object that prevented him from moving forward. Resident #1 reached towards the table on his left side to try and propel forward but could only turn left. Resident #1 turned to the left twice. Resident #1's back was to the camera when it was noted that he fell forward out of the chair hitting his face/head on the floor. The Med Aide and LVN A looked up from what they were doing 4 - 5 seconds after Resident #1 fell. LVN A walked towards Resident #1 and the MA left from behind the medication cart and headed towards the hall away from the Dining Area, where the nurses' station was located. The video clip ended. Record review of Fall Event dated 03/28/24 indicated Resident #1 had an unwitnessed fall at 8:16 PM in the Dining Room. The event details stated Resident #1 went to Station 5 just prior to the fall. Resident #1's following progress notes were linked to the Fall Event: - 03/28/24 at 8:27 PM, written by LVN A, reflected, [Resident #1] found on the floor at around 7:35 PM, in the dining room. Resident was assessed and put back on wheelchair with 3-person assist. skin tear observed on [Resident #1] right hand and behind the right ear. Record review of Fall Event dated 04/01/24 indicated Resident #1 had a witnessed fall in the Dining Room. The following progress notes were linked to the Fall Event: - 04/01/24 at 11:43 AM, written by LVN M, reflected, [Resident #1] fall in the dining room with witness during Chaplain. immediately went to the dining room, observed resident sitting down on the floor by wheelchair. Assessment done and 2-person assist resident back in chair. - 04/01/24 at 2:26 PM, written by NFA, reflected, Administrator spoke with Director of Hospice Services to discuss plan of care for [Resident #1] related to falls. Administrator explained that per our Rehab Manager we requested Therapy services to be given to [Resident #1] to assist in reducing falls. Director agreed. She will schedule with their therapy department to schedule therapy services to be provided to [Resident #1] She will provide [NFA] an updated plan of care for [Resident #1] and we will continue to be aware of any further changes. - 04/01/24 at 2:42 PM, written by NFA, reflected, Update: Spoke with Director of Hospice Services, we will have our Therapy Department to treat resident to assist in reducing [Resident #1] falls. Once that is completed we will update Plan of Care. Record review of Fall Event dated 04/03/24 indicated Resident #1 had an unwitnessed fall from his wheelchair in the Dining Room at 7:21 PM. Neuro checks were initiated. A record review of hospital medical records for 03/27/24 reflected [Resident #1] arrived at the emergency department (ED) in a wheelchair on 03/27/24 at 09:04 AM. ED triage notes indicated [Resident #1] presented to the ED after a fall and need for imaging. [SNF staff] stated [Resident #1] fell the other day and got an x-ray yesterday (03/26/24) that showed possible right temporal bone nondisplaced fracture. [Resident #1] denied pain. A review of the ED physician physical exam on 03/27/24 at 10:06 AM revealed Large ecchymosis to the frontal parietal bone with an abrasion but no active bleeding . Review of medical assessment and plan dated 03/27/24 at 11:00 AM indicated final diagnoses Head Trauma. CT Scan without Contrast resulted Advance chronic microvascular ischemic changes (brain condition cause problems with thinking, walking and mood after an injury) and moderate generalized volume loss (associated with major neurological diseases, such as a large stroke or progressive dementia) noted. Ventriculomegaly (a condition in which the brain ventricles, or fluid-filled cavities, are enlarged due to build up of cerebrospinal fluid [CSF] found with moderate or severe traumatic brain injury). A review of the ED provider note entered on 03/27/24 at 12:15 PM reflected Blood pressure has been low, however [Resident #1's daughter] stated that it has been low since Monday (03/25/24) . [Resident #1] is on hospice at the nursing home. She [Resident #1's daughter] does not want [hospice] revoked and does not want further testing at this time . nursing home had a plan, and they are following it . [Resident #1] was discharged from the ED on 03/27/24 at 12:16 PM. Record review of video surveillance dated 04/01/24, revealed Resident #1 in the Dining Area propelling in his wheelchair toward the vending machine. There was a Medication Aide with back against the wall standing at a medication cart preparing and crushing medications (approximately 20 feet away from where Resident #1 fell). 7 - 8 other residents noted in the Dining Area participated in an activity (with the Chaplain) in the center of the Dining Area. There was a pressure relief pad in the seat of [Resident #1's] wheelchair and a balled-up sheet between Resident #1 and the left arm of the wheelchair. Resident #1 scooted forward to the edge of the seat, placed his right hand on the vending machine and tried to stand. A Dycem non-slip mat was not in place [reflected as an intervention in the care plan]. Resident #1 could not stand, his knees lowered to the floor, and when tried to sit back in the wheelchair, it rolled backwards. Resident #1 fell sideways on his right side, rolled over onto his back, reached out, grabbed, and pulled the wheelchair forward. Resident #1's right foot was in the gap between the left wheel and the body of the wheelchair. Resident #1 rolled over to the right side, slowly raised his upper body, and rolled back over to his right side. The Medication Aide looked up and walked towards Resident #1. LVN M was seen stepping into the Dining Area from the hall. LVN M did not assess or evaluate Resident #1's vital signs, range of motion, or inspect for any injury before the Resident #1 was assisted back into the wheelchair by the Medication Aide and LVN M. The video clip ended. Record review of video surveillance dated 04/03/24, revealed Resident #1 sitting at a table in the Dining Area. There was no staff present. A staff in light blue scrubs was observed coming from out the hallway into the Dining Area, approached Resident #1 and then walked away. Resident #1 attempted to stand up. Resident #1 fell backwards onto his back. An individual entered from the secured doors, noted Resident #1 on the floor and headed towards the hall where the nurses' station was located. The video clip ended. During an observation on 03/30/24 between 2:00 PM - 3:00 PM, Resident #1 was observed resting quietly in a right lateral laying position in bed. Bed in the lowest position, flushed to wall with scoop mattress (edges are raised higher than the mattress center). A fall mat was noticed on the opposite side of the room away from bed. Call light on floor under the foot of the bed. There was one nurse and one CNA observed in the secured unit. During an interview on 03/30/24 at 3:00 PM, RN D stated he was the assigned nurse for Resident #1. RN D stated that he worked weekends double shifts (6A - 2P and 2P - 10P). RN D stated he placed Resident #1 to bed. RN D said that he pulled the fall mat away from the bed to assist Resident #1 to bed from the wheelchair (high back wheelchair next to the bed, pressure-relieving pad in place, no Dycem mat noted) and did not place the fall mat next to the bed. RN D picked the call light up from under the foot of the bed and placed within Resident #1's reach. RN D said that there were two nurses and three CNAs assigned to the secured unit, however he and one CNA were the only staff currently in the secured unit while the other nurse and two CNAs attended an in-service. RN D said that a resident is at risk for harm if care plan interventions were not implemented appropriately or timely. RN D said that interventions in place for Resident #1 to prevent falls included bed in lowest position, to use the call light for help, to place call light within reach, and to place the fall mat at the bedside when Resident #1 was in bed. RN D said he was not present when Resident #1 sustained a fall on 03/25/24. RN D said that Resident #1 had multiple falls and tried to keep [Resident #1] within line of sight or interact during activities to prevent falls. RN D said that Resident #1 required frequent redirection and attention to prevent falls. During an interview on 03/30/24 at 4:55 PM, the NFA stated she was still investigating the incident when Resident #1 fell on [DATE]. The NFA stated that staff must notify her immediately of any incident or accident. The NFA said if an unusual incident (possible resident abuse, neglect, mistreatment and/or unwitnessed injuries) was reported, she immediately reviewed the surveillance cameras to gather information about individuals involved and determine if staff followed protocol when reacted to an accident or incident. The NFA stated that she first learned on 03/27/24 about Resident #1's head injury sustained from a fall (on 03/25/24) and completed a facility incident self-report on-line. The NFA indicated that she did not see staff or another resident push or cause Resident #1 to fall and neglect was not identified. During an interview on 03/30/24 at 5:47 PM, the ADON indicated Resident #1 . still wants to be independent . will not ask for help. The ADON stated Resident #1 was wheelchair bound and should remain within the staff line of sight in the Dining Area to prevent falls. The ADON said there were signs posted for Resident #1 to use the call light for assistance and the wheelchair and bed lowered to prevent falls. The ADON said that Resident #1 had a fall on Monday (03/25/24) evening. The ADON said she had already left for the day when LVN A called to notify that Resident #1 had a fall and reported that he did not complain of pain and there was no injury. LVN A reported to the ADON that Resident #1 was sitting at the nurses' station and the hospice on-call nurse was notified to come assess Resident #1. The ADON said that she assessed and evaluated Resident #1 the next day (03/26/24) when she returned to work. The ADON said that she discovered a raised bump on Resident #1 forehead with an abrasion that appeared shiny where a generous amount of ointment was applied. The ADON said that she asked LVN A about the injury and what actions were taken. LVN A told the ADON that she [LVN A] texted the PCP about the fall and applied the ointment [TAO] as ordered, then notified the hospice on-call nurse, but she never showed. The ADON said that she explained to LVN A that the facility was Resident #1's primary caregiver and immediate actions should be taken when a resident sustained an apparent head injury. The ADON said that she immediately called the PCP and requested orders for a skull x-ray and labs. The ADON said she implemented the orders right away. The ADON said that she reviewed the Skull x-ray results the next morning (03/27/24). The results suggested a CT scan because a skull fracture could not be ruled out by the images. ADON said that Resident #1 was sent to the hospital accompanied by the facility van driver via the facility van. The ADON stated that she expected nurses to conduct rounds minimally every two hours and as needed, or more frequent for residents who were a high fall risk. The ADON indicated keeping residents within the line of sight and not alone in their rooms if the resident tried to act beyond their level of function. Additionally, the ADON stated that nurses should check that fall precautions were in place, residents are wearing non-slip socks or appropriate slippers/shoes, positioning, if the resident is in pain, or assist to the restroom during rounds. Record review of the text communication sent to the MD from LVN A when Resident #1 fell on [DATE] and hit his head indicated, . Resident #1 had a fall in the Dining Area and hit his head on the floor . complaining of pain on his head. He is alert. Hospice notified. LVN A attached a picture of Resident #1's head injury to the communication that revealed a raised area on the frontal region of [Resident #1's] scalp. A light purplish-blue discoloration surrounded the raised area. There was a redden scraped area at the middle of the raised area. The reply from the MD stated, Apply TAO BID for seven days. During an observation on 04/01/24 at 1:29 PM, Resident #1 was observed in a high back wheelchair propelling with his feet only, grabbing and pushing chairs out of the pathway. Resident #1 leaned forward trying to reach a sandwich from under a chair. Dycem material was not observed under Resident #1 on the seat of the wheelchair. The ADON observed Resident #1 leaning forward and went to his side to assist upright in wheelchair. When the ADON walked away, Resident #1 tried to stand up. The ADON came back over to Resident #1, assisted and repositioned Resident #1 back into an appropriate upright position in wheelchair. The ADON gave verbal reminders not to stand up or try to transfer from the wheelchair without assistance. The ADON asked a CNA to frequently observe and supervise Resident #1 while in the Dining Area. The ADON rearranged the chairs back to the tables and cleared a pathway around the tables in the Dining Area. A conversation was overheard between a nurse and the NFA that Resident #1 had a fall in the morning (04/01/24). During an interview on 04/01/24 at 4:40 PM, LVN A indicated that she worked on 03/25/24, 03/28/24, and 04/03/24, 2P - 10P shift. LVN A stated that she was assigned to Resident #1. LVN A stated that Resident #1 had unwitnessed falls on those days that she worked. LVN A stated that Resident #1 needed one-to-one supervision to prevent falls and that was not possible with 5 staff and 30 or more residents that were fall risks, required incontinent care, or demonstrated behaviors that may harm another resident. LVN A stated that she notified the MD by text about Resident #1's fall (on 03/25/24). LVN A said that she texted the MD that Resident #1 hit his head on the floor, complained of pain, that he [Resident #1] was alert, and attached a picture of Resident #1's head injury to the text. LVN A said that alert indicated that Resident #1 did not lose consciousness. LVN A said that the MD replied by text to apply TAO to the abrasion. LVN A stated that she would assess and evaluate a resident by checking vital signs, range of motion of extremities (by asking the resident to move their extremities and then moving the resident extremity), asked about pain, and look for any bruises or injuries. LVN A said that she was not sure if Resident #1 had a fall in the morning, she was not present. LVN A said that she was supposed to initiate a Fall Event report for every accident or incident. LVN A said that it was her responsibility to check on residents every two hours alternating with the CNAs to ensure resident safety, interventions were in place, and acknowledge whereabouts. During an observation and interview on 04/01/24 at 4:45 PM, the OT assisted Resident #1 from the high back wheelchair to a smaller blue wheelchair. The OT assessed and evaluated Resident #1's comfort in the chair. The OT pushed Resident #1 in the wheelchair to the Dining Area and tilted the wheelchair back enough to raise Resident #1's feet off the floor. The OT conducted a visual observation of Resident #1 in the wheelchair. During an interview, the OT stated that occupational therapy was consulted on 04/01/24 to assess and evaluate Resident #1 after multiple falls. The OT indicated that the blue wheelchair was called a [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 2 of 8 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure adequate supervision for residents identified as a fall risk. Resident #1 sustained a skin tear to the right inner wrist on 03/14/24, a skin tear on the left inner wrist on 03/23/24, and sustained head trauma from an unwitnessed fall on 03/25/24. Resident #2 sustained blunt head trauma and a laceration above the left eyebrow from an unwitnessed fall on 03/09/24. The facility failed to implement effective care plan interventions for residents identified as a fall risk. An Immediate Jeopardy (IJ) was identified on 04/01/24. The IJ template was provided to the facility on [DATE] at 4:30 PM. While the IJ was lowered on 04/04/24, the facility remained out of compliance at a scope of Pattern and severity level of No actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. The facility failed to oversee the implementation of resident care policies. LVN M failed to assess, evaluate, and obtain vital signs after Resident #1 fell on [DATE] per the facility's policy and procedure, Assessing Falls and Their Causes, revised March 2018. The facility failed to oversee the implementation of resident care policies. LVN A failed to initiate and document investigation of the accident on 03/28/24, when Resident #2 sustained an unwitnessed fall from her wheelchair in the Dining Area, per the facility's policy and procedure, Accidents and Incidents - Investigating and Reporting, revised July 2017. These deficient practices placed residents at considerable risk of serious injury, harm, impairment, developing complications, or death by not receiving services necessary, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Resident #1 Record review of Resident #1's Continuity of Care Document, created 03/30/24, reflected a 94 y.o. male, who admitted to the facility on [DATE] from a long-term care facility. The latest return to the facility was on 03/04/23 after a short-term acute care hospital inpatient stay with the diagnosis of Displaced fracture of base of neck of left femur. Resident #1 had a history of Repeated falls (effective date: 03/04/23); Localized swelling, mass and lump, head (effective date 03/25/24); Anxiety; COPD; unsteadiness on feet; other abnormalities of gait and mobility; dementia; and other lack of coordination. Record review of Resident #1's Annual MDS review assessment, dated 01/10/24, revealed Resident #1 had a severe cognitive impairment per staff assessment because a BIMS interview was not conducted. Resident #1's functional status required one-person extensive assistance with ADLs and a wheelchair for mobility. Record review of Resident #1's Comprehensive Care Plan, date initiated 05/31/23, reflected: Resident #1 had Frequent falls due to unsteady gait, family not allowing wheelchair, in a geri-chair, he slides from the geri-chair, and he tries to walk by self . The intervention(s) included Try and put to bed (Start date 02/19/24); involve in activities (Start date 01/16/24, 11/27/23, and 11/06/23); recline wheelchair (Start date 10/30/23); Replace Dycem in the wheelchair (start date 10/24/23); will have leg rests replaced on the wheelchair (Start date 10/15/23; will be provided a Scoop mattress on bed (Start date 10/09/23); will be provided a fall mat at bed side while in bed (Start date 09/25/23); and bed will be kept in the lowest position while in bed (Start date 09/25/23). The long-term goal indicated Resident #1 will not have no injuries from falls that require hospitalization in next 90 days (Target date: 05/04/24). Resident #1 had Potential risk for injury due to poor safety awareness. The intervention(s) included Dycem added to wheelchair (start date 01/12/23); Encourage [Resident #1] to request needed assistance in all transfers, keep call light in reach, wedge cushion to wheelchair. (Start date 01/11/23); and [Resident #1] to call for assistance with all transfers (Start date 01/11/23). The long-term goal indicated Resident #1 will be free from injury and will have safe transfers (Target date: 05/04/24). Resident #1 experienced a fall. 12/31/22. had two additional falls. 02/28/23 Injury fall. unwitnessed fall 03/15/23 . The intervention(s) included bed in lowest position to prevent falls (Start date 03/15/23); hipsters added to both hips due to frequent falls also anti-roll back brakes (Start date 01/03/23); Keep call light in reach at all times (Start date 12/23/22);and Observe frequently and place in supervised area when out of bed (Start date 12/23/22); and Provide an environment free of clutter (Start date 12/23/22). The long-term goal reflected Refer to Therapy for evaluation for treatable causes of the fall such as poor balance, muscle weakness, and poor safety awareness. (Target date: 05/04/24). Record review on 03/30/24 at 4:08 PM of Resident #1's Orders History (01/01/24 - 03/30/24) reflected: - Start date 03/06/23: Admit to hospice for Dx: Senile Degeneration of the brain on 03/04/23. - Start date 02/24/24: Resident requires secured unit due to unsafe wandering and exit seeking on 02/21/24. - Start date 03/14/24: Fall: Cleanse skin tear on right palm with NS and apply steri-strips dressing. Every Shift. - Start date 03/18/24: OT to evaluate and treat as indicated. - Start date 03/23/24: Cleanse skin tear on left arm palm with NS and apply dry dressing. Monitor for s/s of infection and dc when resolved. - Start date 03/25/24: Triple Antibiotic ointment (TAO). Apply a small amount on the affected area for 7 days. Twice A Day (7:00 AM - 10:00 AM; 5:00 PM - 7:00 PM) - Start date 03/26/24: Other Test: (Skull series due to fall with head injury). STAT.' - Start date 03/28/24: Skin Tear: Apply antibiotic ointment, cover with dressing if needed to minor cuts or skin tears until healed. Once a Day PRN. - Start date 03/28/24: 'Suspected head trauma neuro checks. Q15mins (x4); Q1H (x2); Q2H (x2); Q4H (x2); then, every shift (x3). [Previous orders were written on 03/14/24, 03/23/24, and 03/25/24] - Start date 03/30/24: 'Wound care: Forehead - Cleanse with wound cleanser and pat dry with gauze. Apply Calcium Alginate and cover with border dressing. Once a Day. 06:00 AM - 02:00 PM.' Record review of Resident #1's active Orders on 04/04/24 at 4:13 PM reflected: - Start date 04/01/24: Fall Interventions: Call light .; Encourage and assist resident for frequent rest periods .; Locate resident when up near station .; Toilet at regular intervals . Every Shift. - Start date 04/02/24: PT to evaluate and treat as indicated. LATE ENTRY effective 04/02/24 - Start date 04/03/24: Place Dycem (multipurpose non-slip material) in wheelchair to prevent resident from sliding out. Every Shift. - Start date 04/04/24: Suspected head trauma neuro checks. Q4H (x2 - 1:30 AM, 5:30 AM); then, every shift Days, Evenings, Nights (x3 - End Date 04/06/24).' Record review of Resident #1's progress notes indicated: - 03/14/24 at 12:37 PM, written by LVN L, reflected, [Resident #1] had an unwitnessed fall at 12:15 PM, was found by CNA sitting on the floor in one of the female patient's room. [Resident #1] was on a wheelchair at the time of fall. [Resident #1] unable to explain what happened . skin tear at the palm of the right hand . given Morphine 20 mg/5 mL for mild pain (PRN). Intervention includes redirecting patients, patient had non-skid socks on. - 03/28/24 at 12:48 PM, written by ADON, reflected, [ADON] noted [Resident #1] forehead, frontal aspect with fluid filled hematoma with open abrasion to center of hematoma at this time. called and spoke with [hospice services RN] and informed of area to [Resident #1's] head with visual documents provided for review. MD aware as well with zero new orders noted. attempted to reach hospice nurse to confirm that orders had not been given to her at this time. - 03/28/24 at 4:03 PM, written by ADON, reflected, [ADON] noted zero response to medically necessary orders due to [Resident #1] radiology report or area to [Resident #1] head at this time. [ADON] sent message to hospice nurse and MD requesting a return call at this time. - 03/29/24 at 11:04 AM, written by NP, reflected, [Resident #1] seen and examined per nursing staff request for report of a fall yesterday. Noted large hematoma to mid-frontal scalp area with ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising). denies any pain or headache but overall stays stable . - 04/01/24 at 8:21 PM, written by LVN A, reflected, Skull x-ray ordered for [Resident #1] r/t unwitnessed fall. Call to RP did not go through and unable to leave a voice message. - 04/02/24 at 7:28 AM, written by RN N, reflected, [Resident #1] refused to do skull series, notified MD, Administrator and [Resident #1] daughter aware. - 04/02/24 at 7:36 AM, written by RN N, reflected, [Resident #1] fell yesterday, continue on neuro checks, no delayed injuries seen. Continue to be monitored. - 04/03/24 at 7:51 PM, written by LVN A, reflected, At around 6:30 PM was notified by Speech Pathologist that [Resident #1] was on the floor in the dining room. Went to the dining area and found resident on the floor next to his wheelchair. Assessed resident, then put back to wheelchair with 2 persons assist. noticed [Resident #1] was able to unlock the armrest on the wheelchair and push it down, and probably slipped from the side . Record review of Fall Event, dated 03/23/24, linked SBAR Communication Tool (dated 03/27/24) and Resident #1's following progress notes: - 03/25/24 at 6:09 PM, written by LVN A, reflected, [Resident #1] had a fall at around 5:50 PM in the dining area, and hit his head on the floor . assessed and put back on wheelchair . [Resident #1] has a bump in the front of his head and is c/o pain on his head. MD notified via text message with a picture of the injured area and replied, Apply TAO bid for seven days. Hospice called and said they are sending a nurse at the facility to assess [Resident #1] . Neuro checks initiated. - 03/25/24 at 10:07 PM, written by LVN A, reflected, Hospice nurse did not show up . TAO applied on resident bump per MD Order, morphine 0.25 ML provided for pain. [Resident #1] currently resting on bed . in lowest position and mat on the floor. Neuro checks ongoing. - 03/26/24 at 12:52 PM, written by LVN L, reflected, [Resident #1] BP 96/50, HR 77 . rechecked at 12:50 PM, BP 117/70, HR 90 . on bedrest in supine position with legs elevated 8 - 12 inches until BP returns to baseline . - 03/26/24 at 6:45 PM, written by LVN A, reflected, Skull x-ray done at around 6:15 PM. Result pending. - 03/27/24 at 6:31 AM, written by RN O, reflected, Post fall day 2/3. [Resident #1] has a decreased in his blood pressure reading. legs were elevated 8 inches and offered fluids . Fall preventive measure implemented. - 03/27/24 at 9:13 AM, written by LVN L, reflected, [Resident #1's] x-ray results . significant findings and head CT suggested . sent to MD and hospice nurse. [Resident #1] sent to hospital accompanied by facility driver at 9:00 AM. Record review of the Fall Event dated 03/25/24, LVN A indicated the fall was NOT witnessed. [Resident #1] complained of pain 3 out of 10 [4 out of 10 = Moderate Pain - Distressing, Miserable] (to his head). Injury to the head was a bump . Resident has a bump in the front of his head and is c/o pain on his head. MD notified via text message with a picture of the injured area and replied Apply TAO (an ointment that prevent infection and aids in healing of minor cuts, scrapes, and burns) BID (twice daily) for seven days. The following progress notes were linked to the Fall Event: - 03/19/24 at 12:56 PM, written by PCP, reflected, GDR ordered to change Ambien to PRN for 14 days, Ativan changed to AM and HS (at bedtime) per pharmacist recommendation. - 03/28/24 at 12:44 PM, written by ADON, reflected, [ADON] noted [Resident #1's] CT Scan results . notified PCP of available results with impressions that indicated Advance chronic microvascular ischemic changes (brain condition cause problems with thinking, walking and mood after an injury) and moderate generalized volume loss (associated with major neurological diseases, such as a large stroke or progressive dementia) noted. Ventriculomegaly (a condition in which the brain ventricles, or fluid-filled cavities, are enlarged due to build up of cerebrospinal fluid [CSF] found with moderate or severe traumatic brain injury) . hospice requested results fax . [ADON] sent fax . Record review of video surveillance dated 03/25/24, provided by the NFA, revealed the Dining Area. A Med Aide was against the wall standing behind the medication cart approximately 5 - 6 feet in front and to the right of Resident #1 in his high back wheelchair. The Med Aid did not have a direct line of sight of Resident #1. LVN A was approximately 15 - 20 feet away, assisting a resident with eating. Resident #1 was in LVN A's direct line of sight. Resident #1 was scooting in his wheelchair, but unable to move forward past a table and chair. It appeared that there was an object that prevented him from moving forward. Resident #1 reached towards the table on his left side to try and propel forward but could only turn left. Resident #1 turned to the left twice. Resident #1's back was to the camera when it was noted that he fell forward out of the chair hitting his face/head on the floor. The Med Aide and LVN A looked up from what they were doing 4 - 5 seconds after Resident #1 fell. LVN A walked towards Resident #1 and the MA left from behind the medication cart and headed towards the hall away from the Dining Area, where the nurses' station was located. The video clip ended. Record review of Fall Event dated 03/28/24 indicated Resident #1 had an unwitnessed fall at 8:16 PM in the Dining Room. The event details stated Resident #1 went to Station 5 just prior to the fall. Resident #1's following progress notes were linked to the Fall Event: - 03/28/24 at 8:27 PM, written by LVN A, reflected, [Resident #1] found on the floor at around 7:35 PM, in the dining room. Resident was assessed and put back on wheelchair with 3-person assist. skin tear observed on [Resident #1] right hand and behind the right ear. Record review of Fall Event dated 04/01/24 indicated Resident #1 had a witnessed fall in the Dining Room. The following progress notes were linked to the Fall Event: - 04/01/24 at 11:43 AM, written by LVN M, reflected, [Resident #1] fall in the dining room with witness during Chaplain. immediately went to the dining room, observed resident sitting down on the floor by wheelchair. Assessment done and 2-person assist resident back in chair. - 04/01/24 at 2:26 PM, written by NFA, reflected, Administrator spoke with Director of Hospice Services to discuss plan of care for [Resident #1] related to falls. Administrator explained that per our Rehab Manager we requested Therapy services to be given to [Resident #1] to assist in reducing falls. Director agreed. She will schedule with their therapy department to schedule therapy services to be provided to [Resident #1] She will provide [NFA] an updated plan of care for [Resident #1] and we will continue to be aware of any further changes. - 04/01/24 at 2:42 PM, written by NFA, reflected, Update: Spoke with Director of Hospice Services, we will have our Therapy Department to treat resident to assist in reducing [Resident #1] falls. Once that is completed we will update Plan of Care. Record review of Fall Event dated 04/03/24 indicated Resident #1 had an unwitnessed fall from his wheelchair in the Dining Room at 7:21 PM. Neuro checks were initiated. A record review of hospital medical records for 03/27/24 reflected [Resident #1] arrived at the emergency department (ED) in a wheelchair on 03/27/24 at 09:04 AM. ED triage notes indicated [Resident #1] presented to the ED after a fall and need for imaging. [SNF staff] stated [Resident #1] fell the other day and got an x-ray yesterday (03/26/24) that showed possible right temporal bone nondisplaced fracture. [Resident #1] denied pain. A review of the ED physician physical exam on 03/27/24 at 10:06 AM revealed Large ecchymosis to the frontal parietal bone with an abrasion but no active bleeding . Review of medical assessment and plan dated 03/27/24 at 11:00 AM indicated final diagnoses Head Trauma. CT Scan without Contrast resulted Advance chronic microvascular ischemic changes (brain condition cause problems with thinking, walking and mood after an injury) and moderate generalized volume loss (associated with major neurological diseases, such as a large stroke or progressive dementia) noted. Ventriculomegaly (a condition in which the brain ventricles, or fluid-filled cavities, are enlarged due to build up of cerebrospinal fluid [CSF] found with moderate or severe traumatic brain injury). A review of the ED provider note entered on 03/27/24 at 12:15 PM reflected Blood pressure has been low, however [Resident #1's daughter] stated that it has been low since Monday (03/25/24) . [Resident #1] is on hospice at the nursing home. She [Resident #1's daughter] does not want [hospice] revoked and does not want further testing at this time . nursing home had a plan, and they are following it . [Resident #1] was discharged from the ED on 03/27/24 at 12:16 PM. Record review of video surveillance dated 04/01/24, revealed Resident #1 in the Dining Area propelling in his wheelchair toward the vending machine. There was a Medication Aide with back against the wall standing at a medication cart preparing and crushing medications (approximately 20 feet away from where Resident #1 fell). 7 - 8 other residents noted in the Dining Area participated in an activity (with the Chaplain) in the center of the Dining Area. There was a pressure relief pad in the seat of [Resident #1's] wheelchair and a balled-up sheet between Resident #1 and the left arm of the wheelchair. Resident #1 scooted forward to the edge of the seat, placed his right hand on the vending machine and tried to stand. A Dycem non-slip mat was not in place [reflected as an intervention in the care plan]. Resident #1 could not stand, his knees lowered to the floor, and when tried to sit back in the wheelchair, it rolled backwards. Resident #1 fell sideways on his right side, rolled over onto his back, reached out, grabbed, and pulled the wheelchair forward. Resident #1's right foot was in the gap between the left wheel and the body of the wheelchair. Resident #1 rolled over to the right side, slowly raised his upper body, and rolled back over to his right side. The Medication Aide looked up and walked towards Resident #1. LVN M was seen stepping into the Dining Area from the hall. LVN M did not assess or evaluate Resident #1's vital signs, range of motion, or inspect for any injury before the Resident #1 was assisted back into the wheelchair by the Medication Aide and LVN M. The video clip ended. Record review of video surveillance dated 04/03/24, revealed Resident #1 sitting at a table in the Dining Area. There was no staff present. A staff in light blue scrubs was observed coming from out the hallway into the Dining Area, approached Resident #1 and then walked away. Resident #1 attempted to stand up. Resident #1 fell backwards onto his back. An individual entered from the secured doors, noted Resident #1 on the floor and headed towards the hall where the nurses' station was located. The video clip ended. During an observation on 03/30/24 between 2:00 PM - 3:00 PM, Resident #1 was observed resting quietly in a right lateral laying position in bed. Bed in the lowest position, flushed to wall with scoop mattress (edges are raised higher than the mattress center). A fall mat was noticed on the opposite side of the room away from bed. Call light on floor under the foot of the bed. There was one nurse and one CNA observed in the secured unit. During an interview on 03/30/24 at 3:00 PM, RN D stated he was the assigned nurse for Resident #1. RN D stated that he worked weekends double shifts (6A - 2P and 2P - 10P). RN D stated he placed Resident #1 to bed. RN D said that he pulled the fall mat away from the bed to assist Resident #1 to bed from the wheelchair (high back wheelchair next to the bed, pressure-relieving pad in place, no Dycem mat noted) and did not place the fall mat next to the bed. RN D picked the call light up from under the foot of the bed and placed within Resident #1's reach. RN D said that there were two nurses and three CNAs assigned to the secured unit, however he and one CNA were the only staff currently in the secured unit while the other nurse and two CNAs attended an in-service. RN D said that a resident is at risk for harm if care plan interventions were not implemented appropriately or timely. RN D said that interventions in place for Resident #1 to prevent falls included bed in lowest position, to use the call light for help, to place call light within reach, and to place the fall mat at the bedside when Resident #1 was in bed. RN D said he was not present when Resident #1 sustained a fall on 03/25/24. RN D said that Resident #1 had multiple falls and tried to keep [Resident #1] within line of sight or interact during activities to prevent falls. RN D said that Resident #1 required frequent redirection and attention to prevent falls. During an interview on 03/30/24 at 4:55 PM, the NFA stated she was still investigating the incident when Resident #1 fell on [DATE]. The NFA stated that staff must notify her immediately of any incident or accident. The NFA said if an unusual incident (possible resident abuse, neglect, mistreatment and/or unwitnessed injuries) was reported, she immediately reviewed the surveillance cameras to gather information about individuals involved and determine if staff followed protocol when reacted to an accident or incident. The NFA stated that she first learned on 03/27/24 about Resident #1's head injury sustained from a fall (on 03/25/24) and completed a facility incident self-report on-line. The NFA indicated that she did not see staff or another resident push or cause Resident #1 to fall and neglect was not identified. During an interview on 03/30/24 at 5:47 PM, the ADON indicated Resident #1 . still wants to be independent . will not ask for help. The ADON stated Resident #1 was wheelchair bound and should remain within the staff line of sight in the Dining Area to prevent falls. The ADON said there were signs posted for Resident #1 to use the call light for assistance and the wheelchair and bed lowered to prevent falls. The ADON said that Resident #1 had a fall on Monday (03/25/24) evening. The ADON said she had already left for the day when LVN A called to notify that Resident #1 had a fall and reported that he did not complain of pain and there was no injury. LVN A reported to the ADON that Resident #1 was sitting at the nurses' station and the hospice on-call nurse was notified to come assess Resident #1. The ADON said that she assessed and evaluated Resident #1 the next day (03/26/24) when she returned to work. The ADON said that she discovered a raised bump on Resident #1 forehead with an abrasion that appeared shiny where a generous amount of ointment was applied. The ADON said that she asked LVN A about the injury and what actions were taken. LVN A told the ADON that she [LVN A] texted the PCP about the fall and applied the ointment [TAO] as ordered, then notified the hospice on-call nurse, but she never showed. The ADON said that she explained to LVN A that the facility was Resident #1's primary caregiver and immediate actions should be taken when a resident sustained an apparent head injury. The ADON said that she immediately called the PCP and requested orders for a skull x-ray and labs. The ADON said she implemented the orders right away. The ADON said that she reviewed the Skull x-ray results the next morning (03/27/24). The results suggested a CT scan because a skull fracture could not be ruled out by the images. ADON said that Resident #1 was sent to the hospital accompanied by the facility van driver via the facility van. The ADON stated that she expected nurses to conduct rounds minimally every two hours and as needed, or more frequent for residents who were a high fall risk. The ADON indicated keeping residents within the line of sight and not alone in their rooms if the resident tried to act beyond their level of function. Additionally, the ADON stated that nurses should check that fall precautions were in place, residents are wearing non-slip socks or appropriate slippers/shoes, positioning, if the resident is in pain, or assist to the restroom during rounds. Record review of the text communication sent to the MD from LVN A when Resident #1 fell on [DATE] and hit his head indicated, . Resident #1 had a fall in the Dining Area and hit his head on the floor . complaining of pain on his head. He is alert. Hospice notified. LVN A attached a picture of Resident #1's head injury to the communication that revealed a raised area on the frontal region of [Resident #1's] scalp. A light purplish-blue discoloration surrounded the raised area. There was a redden scraped area at the middle of the raised area. The reply from the MD stated, Apply TAO BID for seven days. During an observation on 04/01/24 at 1:29 PM, Resident #1 was observed in a high back wheelchair propelling with his feet only, grabbing and pushing chairs out of the pathway. Resident #1 leaned forward trying to reach a sandwich from under a chair. Dycem material was not observed under Resident #1 on the seat of the wheelchair. The ADON observed Resident #1 leaning forward and went to his side to assist upright in wheelchair. When the ADON walked away, Resident #1 tried to stand up. The ADON came back over to Resident #1, assisted and repositioned Resident #1 back into an appropriate upright position in wheelchair. The ADON gave verbal reminders not to stand up or try to transfer from the wheelchair without assistance. The ADON asked a CNA to frequently observe and supervise Resident #1 while in the Dining Area. The ADON rearranged the chairs back to the tables and cleared a pathway around the tables in the Dining Area. A conversation was overheard between a nurse and the NFA that Resident #1 had a fall in the morning (04/01/24). During an interview on 04/01/24 at 4:40 PM, LVN A indicated that she worked on 03/25/24, 03/28/24, and 04/03/24, 2P - 10P shift. LVN A stated that she was assigned to Resident #1. LVN A stated that Resident #1 had unwitnessed falls on those days that she worked. LVN A stated that Resident #1 needed one-to-one supervision to prevent falls and that was not possible with 5 staff and 30 or more residents that were fall risks, required incontinent care, or demonstrated behaviors that may harm another resident. LVN A stated that she notified the MD by text about Resident #1's fall (on 03/25/24). LVN A said that she texted the MD that Resident #1 hit his head on the floor, complained of pain, that he [Resident #1] was alert, and attached a picture of Resident #1's head injury to the text. LVN A said that alert indicated that Resident #1 did not lose consciousness. LVN A said that the MD replied by text to apply TAO to the abrasion. LVN A stated that she would assess and evaluate a resident by checking vital signs, range of motion of extremities (by asking the resident to move their extremities and then moving the resident extremity), asked about pain, and look for any bruises or injuries. LVN A said that she was not sure if Resident #1 had a fall in the morning, she was not present. LVN A said that she was supposed to initiate a Fall Event report for every accident or incident. LVN A said that it was her responsibility to check on residents every two hours alternating with the CNAs to ensure resident safety, interventions were in place, and acknowledge whereabouts. During an observation and interview on 04/01/24 at 4:45 PM, the OT assisted Resident #1 from the high back wheelchair to a smaller blue wheelchair. The OT assessed and evaluated Resident #1's comfort in the chair. The OT pushed Resident #1 in the wheelchair to the Dining Area and tilted the wheelchair back enough to raise Resident #1's feet off the floor. The OT conducted a visual observation of Resident #1 in the wheelchair. During an interview, the OT stated that occupational therapy was consulted on 04/01/24 to assess and evaluate Resident #1 after multiple falls. The OT indicated that the blue wheelchair was called a tilt-in-space. The OT stated the purpose of the wheelchair was to easily reposition Resident #1 when sitting in the wheelchair to prevent falls and maintain posture when in the reclined position. The OT stated the tilt-in-space wheelchair could reduce falls; however, when in the reclined position Resident #1 could not freely propel and move about in the wheelchair. During an interview on 04/01/24 at 5:15 PM, the DOR indicated that Resident #1 was currently on service with occupational therapy after assessment and evaluation related to a fall Resident #1 had on 03/18/24. The DOR stated therapy was consulted [04/01/24] for reassessment of Resident #1 due to frequent falls. The DOR indicated supervised stand-by assistance would be an effective intervention for Resident #1 to prevent falls. Record review of an undated typed Incident Narrative&quo[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents 1 of 14 residents (Resident #1) were free from neglect. The facility failed to provide adequate wound care monitored by a physician for 30 days for Resident #1 with a Stage IV pressure sacral ulcer, skin tear of right knee, and pressure ulcer of left foot. The resident was sent to the hospital by the facility after with symptoms of lethargy, disoriented, anorexia and hypotensive. Resident was admitted to the hospital ICU as septic, had fluid overload with shortness of breath. The facility neglected Resident #1 daily wound care treatment and wound care management by physician services. These failures could place residents at risk for neglect due to facility not providing needed care and services. An Immediate Jeopardy (IJ) was identified on 3/20/2024. The ED was notified and provided with the IJ template on 3/20/2024 at 5:36 PM. While the Immediate Jeopardy was removed on 3/22/2024, the facility remained out of compliance at a scope of pattern and a severity level of actual harm with the potential for more than minimal harm, due to the facility's need to implement and monitor the effectiveness of its corrective systems. Findings included: Record review of resident's electronic medical record history and physical revealed Resident #1 is an [AGE] year-old, female with a history of hypertension, pressure ulcer of sacral region, chronic respiratory failure with hypoxia (Chronic Obstructive Pulmonary Disease), dysphagia (difficulty swallowing), and end stage renal disease (kidney failure/dialysis required for blood filtration). Record review of resident's Nurse 24-hour Report identified two small skin tears on sacrum on 1/4/2024. Record review of resident's Care Plan on dated 5/5/2023 states Resident #1 is at risk for skin breakdown/pressure ulcer/injury. Record review of Specialty Physician Wound Evaluation and Management Summary revealed Stage 3 sacrum pressure wound (resolved on 7/28/2023) for Resident #1. Electronically signed by Physician A on 7/28/2023. Record review of resident's Nurse 24-hour Report identified two small skin tears on sacrum on 1/4/2024. Record review of resident's wound management notes document a sacral pressure ulcer for 5/11/2023, 6/1/2023, and 2/1/2024. This revealed a lapse weekly documented skin checks for Resident #1 from 2/7/2024 to 3/4/2024. Record review of Nursing Administration History: 2/7/2024 to 3/4/2024 physicians orders for wound care administration for sacrum: (Cleanse with NS or wound cleanser, pat dry, apply alginate calcium and cover with dry dressing daily.) Notes documented by LVN A and RN E from 2/10/2024 to 3/2/2024 Not Administered: To be done by wound nurse. Record review of LVN A progress note dated 3/4/2024 stated wound size is 1.7 x 1.2 cm, edges black in color. In an interview with the facility ADON B on 3/19/2024 at 1:20 PM stated she was hired on 2/15/2024 and Resident #1 transitioned to my roster the same day I discharged her to the hospital due to her nurse notifying me of her change in condition on 3/5/2024. Her assigned nurse said her wound dressing was soiled and she changed it before EMS arrived on 3/5/2024. The investigator asked, where are the Bath sheets? Because I did not see them documented in the EMR skin assessments. ADON stated, Look on my watch this will change. That is a problem we have been working on. We have started in-services at the beginning of March with CNAs documenting skin assessments during ADL care. Yes, we are really working on improving documentation and making sure CNAs documenting what they see. In a phone interview with the facility contracted wound care Physician A on 3/19/2024 at 1:30 PM he stated he approved the telephone orders for Resident #1's sacral pressure wound requested by ADON C on 2/7/2024 . Physician A stated, I go to the facility every Thursday. I don't recall seeing that patient because I don't have any notes or any evidence of her making it to the rounding list. Not sure why if it was forgotten or if she was out of the building. For some reason she never made it. I just approved the order through a call. I don't know why she was never on the list. When I go into the building, they give me a list of everyone, and I make sure I see everyone. If someone was supposed to be there that's not there, there's no way for me to just, out of the top of my mind, troubleshoot. Who is this person? Unless it's someone I've seen the week before, I would ask them did this person go home? Why are we not seeing this person, for whatever reason. She had told me that patient was supposed to be seen, but somehow, she was not on the list. The resident was never on the list. I'm not sure why. In a phone interview with the Responsible Party (RP) on 3/19/2024 at 4:30 PM she stated, Resident #1 would call me in the middle of the night in excruciating pain. She told the nurses continually that she was an excruciating pain. One would think the nurses communicated that to somebody so somebody would have taken care of this prior to her suffering for a month in excruciating pain. I don't understand how it went on that long. In a phone interview with Resident #1's facility Primary Care Physician B on 3/20/2024 at 10:19 AM he stated he was not aware of any of Resident #1's wounds. In an interview with the facility ADON B on 3/20/2024 at 12:10 PM she stated, After researching the issues in documentation in skin assessments and other areas, we are still in-servicing CNA's and those giving ADL care we educated them on using the skin note and the POC to identify issues, also to verbally communicate to the nurses. For nurses we initiated the Events feature in the EMR template to be sure and educated them how use this feature when they identify problem. Nurses open the event fill it out and leave it open so we (DON/ADON's/ED) can follow up and complete it and investigate to see you know what needs to be done. Nurses were educated that if they find a skin concern, they have to notify the doctor get an order notify the family, their doctor and ED. The investigator asked, what is your expectation when a resident has not been seen by the wound care doctor? We instructed them to speak up and they should be involving their primary care doctor here in the facility as well in case something happens, or you know if something doesn't get sent or doesn't get caught. You know both providers need to be involved in the care, so nothing is overlooked. Even if their primary care provider is not in the facility. If a resident has a wound, nurses need to say they have a resident with a wound and need a referral consult to a wound care provider. In an interview and EMR template review with the facility ED on 3/21/2024 at 2:18 PM she stated, I identified back on January 31, 2024 that we needed to set up a protocol with the nurses to do weekly skin assessments for residents due on Mondays during the 6:00 AM to 2:00 PM shift. So, when a nurse goes into their dashboard, they can see what skilled nursing is due in a residents' chart in the EMR platform. Nurses would add a skin assessment which was called the weekly body observation. Unfortunately, it was not setup in a way, so the nurse managers (DON and ADONs) were responsible for auditing for these skin assessments, to make sure the assessments were done. That audit feature has been corrected for the ADON's and will be ready for the new DON when she starts in February. In fact, we discovered skin assessments still weren't getting done because it came up in a compliance audit after you (Investigator) entered the facility for this investigation. So, we began in-servicing the nurses on skill charting and documenting skin assessments in their progress notes. Now we have created a template in the EMR platform that uses checkmarks, to describe the nurses' findings during skin assessments and it turns into progress note. Now when I log into the EMR and see my scheduled compliance reports; I can pull these skilled tasks dated from 3/20/2024 and on. Moving forward, I will address any incomplete tasks in the morning meetings. I now, can see exactly what is going on the clinical side. I have set a lot of our skilled scheduled assessments, referrals, and other tasks to alert me so I can see exactly what was not done and from there I can follow up the nurse managers and the nurse responsible. I can no longer solely depend on the DON and ADON's to monitor assessment audits. I want to monitor it too. I can look at referrals and see if everything has been done so that will the event will trigger the consult or put in order. I have access to all now, so I can just go in and see if referrals have been done or rather if a consult or referral has not been done. Referral consults must be submitted through the wound care physician consultants' website. That's a manual process. Eventually, we want to get where our EMR system does feed referrals to their system. Now in my dashboard I can look at the order and see what was done and not done daily. As soon as identify a referral was not made, I'm immediately on the phone with the consultants, saying you have wound care consult in house. This was determined to be an Immediate Jeopardy (IJ) on 3/20/2024 at 11:45 AM. The ED and ADONs were notified. The ED was provided with the IJ template on 3/20/2024 at 5:36 PM. The following Plan of Removal (POR) submitted by the facility was accepted on 3/21/2024 at 1:48 PM: Plan of Removal On 3/14/2024 ADON's completed an in-service for Change of Condition using our SBAR should be c ompleted on any change of condition. Progress Notes should be completed every shift for the next 3 days following SBAR. 3/20/2024 3/18/2024 Administrator started reviewing resident 1 records, in-services were started to include Abuse, Neglect and Reporting. On 3/19/2024 at 5:00pm ADON's started a skin sweep of all residents, any negative findings were corrected by orders added and referrals were made to Wound Physician. On 3/19/2024 4:40pm ADON's started an in-service with all Licensed Nurses, Med aides and C.N.A's regarding skin/wound documentation and notification in their documentation in the POC. 3/20/2024 On 3/20/2024 at 9:00am ADON assisted Administrator in reviewing the events our system has available. On 3/20/2024 the new form for Pressure Sore/Stasis Ulcer was updated in the system and added to the events for the nurses to start using. In-service was started with all Licensed Nurses to complete the event when a Pressure Sore/Stasis Ulcer is present. The Braden Scale for Predicting Pressure Sore risk will be completed X4 Weeks after admissions or re-admissions. Quarterly thereafter. 3/20/2024 The Administrator/DON will pull the Event reports daily to ensure all orders are in place and referral completed for Wound Physician to see on their next rounds. Administrator/DON will follow up after each round conducted by the physician to ensure resident was seen and orders carried out. Any negative finding will be corrected immediately. 3/20/2024 All Licensed Nurses will be checked off for wound care for ADON's. DON/ADON's will complete observation wound care weekly for each nurse to ensure they are completing it correctly. 3/21/2024 On 3/14/2024 ADON's completed an in-service for Change of Condition using our SBAR should be completed on any change of condition. Progress Notes should be completed every shift for the next 3 days following SBAR. 3/20/2024 3/18/2024 Administrator started reviewing resident 1 records, in-services were started to include Abuse, Neglect and Reporting. On 3/19/2024 at 5:00pm ADON's started a skin sweep of all residents, any negative findings were corrected by orders added and referrals were made to Wound Physician. On 3/19/2024 4:40pm ADON's started an in-service with all nursing staff regarding skin/wound documentation and notification in include documentation in POC. 3/20/2024 On 3/20/2024 at 9:00am ADON assisted Administrator in reviewing the events our system has available. On 3/20/2024 the new form for Pressure Sore/Stasis Ulcer was updated in the system and added to the events for the nurses to start using. In-service was started with all Licensed Nurses to complete the event when a Pressure Sore/Stasis Ulcer is present. The Braden Scale for Predicting Pressure Sore risk will be completed X 4 Weeks after admissions or re-admissions. Quarterly thereafter. 3/20/2024 On 3/20/2024 at 9:00am ADON assisted Administrator in reviewing the events our system has available. On 3/20/2024 the new form for Pressure Sore/Stasis Ulcer was updated in the system and added to the events for the nurses to start using. In-service was started with all Licensed Nurses to complete the event when a Pressure Sore/Stasis Ulcer is present. The Braden Scale for Predicting Pressure Sore risk will be completed X 4 Weeks after admissions or re-admissions. Quarterly thereafter. 3/20/2024 All Licensed Nurses will be checked off for wound care for ADON's. DON/ADON's will complete observation wound care weekly for each nurse to ensure they are completing it correctly. 3/21/2024 Record review of facility Change in a Resident's Condition or Status Policy Statement (Revised 2021): Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, ., resident rights, etc.). 2. A significant change of condition is a major decline or improvement in the resident's status that: c. requires interdisciplinary review and/or revision to the care plan. Record review of facility Resident Rights Policy Statement (Revised 2016): Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation; 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: f. communication with and access to people and services, both inside and outside the facility. Record review of facility policy (Revised 2017): Abuse, Neglect, and Reporting: Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy Interpretation and Implementation - Role of the Administrator: 5. The administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Reporting 2. An alleged violation of abuse, neglect, .will be reported immediately, but not later than: a. two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury. Monitoring of POR Record review of the facility's In-service dated 3/14/2024 completed by facility ADON's for Change of Condition using Situation, Background, Assessment, and Recommendation (SBAR). Record review of the facility's In-Service dated 3/19/2024 completed by ADON's regarding skin/wound documentation and notification in their documentation in the Point of Contact (POC). Record review of Plan of Correction (internal for facility) provided by ED The Administrator/DON will pull the Event reports daily to ensure all orders are in place and referral completed for Wound Physician to see on their next rounds. Administrator/DON will follow up after each round conducted by the physician to ensure resident was seen and orders carried out. Any negative finding will be corrected immediately. ADON assisted Administrator in reviewing the events our system has available. On 3/20/2024 the new form for Pressure Sore/Stasis Ulcer was updated in the system and added to the events for the nurses to start using. In-service was started with all Licensed Nurses to complete the event when a Pressure Sore/Stasis Ulcer is present. The Braden Scale for Predicting Pressure Sore risk will be completed X 4 Weeks after admissions or re-admissions. Quarterly thereafter. All Licensed Nurses will be checked off for wound care for ADON's. DON/ADON's will complete observation wound care weekly for each nurse to ensure they are completing it correctly. (signed by the ED) Record review of the facility's Change in Condition Policy (copied for evidence) - No concerns noted. Interviews were conducted on 3/21/2024 at various times to include staff from various shifts. Interviews with ED, CNA A, CNA B, CMA A, LVN B, RN A, RN B, RN C, RN D, ADON A, ADON B to verify the in-services were conducted and to validate the staffs understanding of the trainings for Abuse, Neglect , and Exploitation, the importance skin/wound documentation and notification in their documentation in the Point of Contact. No concerns were found regarding the understanding of the requirements, training materials or expectations. All interviewed staff were able to communicate their understanding and proficiency of the in-services. On 3/22/2024 at 12:50 PM Investigator notified ED the immediacy was removed and conducted the exit. Immediate Jeopardy (IJ) was identified on 3/20/2024. While the IJ was removed on 3/22/2024, the facility remained out of compliance at a lowered severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy and a scope of pattern as the facility continued to monitor the implementation and effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care according to professional standards of care and the care plan to prevent pressure ulcers or develop new ulcers for 1 of 14 residents (Resident #1) reviewed for pressure ulcers. The facility failed to provide adequate wound care monitored by a physician for 30 days for Resident #1 with a Stage IV pressure sacral ulcer, skin tear of right knee, and pressure ulcer of left foot. The resident was sent to the hospital by the facility after with symptoms of lethargy, disoriented, anorexia and hypotensive. Resident was admitted to the hospital ICU as septic, had fluid overload with shortness of breath. The facility failed to add the resident to wound care physicians list of patients for pressure ulcers. These failures could place residents at risk of development of additional pressure ulcers and further health decline. Findings included: Record review of resident's electronic medical record history and physical revealed Resident #1 is an [AGE] year-old, female with a history of hypertension, pressure ulcer of sacral region, chronic respiratory failure with hypoxia (Chronic Obstructive Pulmonary Disease), dysphagia (difficulty swallowing), and end stage renal disease (kidney failure/dialysis required for blood filtration). Record review of resident's Care Plan dated [DATE] states Resident #1 is at risk for skin breakdown/pressure ulcer/injury . On turning/repositioning program. Record review of Specialty Physician Wound Evaluation and Management Summary revealed Stage 3 sacrum pressure wound (resolved on [DATE]) for Resident #1. Electronically signed by Physician A on [DATE]. Record review of resident's Nurse 24-hour Report identified two small skin tears on sacrum on [DATE]. Record review of resident's wound management notes document a sacral pressure ulcer for [DATE], [DATE], and [DATE]. This revealed a lapse weekly documented skin checks for Resident #1 from [DATE] to [DATE]. Record review of Nursing Administration History: [DATE] to [DATE] physicians orders for wound care administration for sacrum: (Cleanse with NS or wound cleanser, pat dry, apply alginate calcium and cover with dry dressing daily.) Notes documented by LVN A and RN E from [DATE] to [DATE] Not Administered: To be done by wound nurse. Record review of LVN A progress note dated [DATE] stated wound size is 1.7 x 1.2 cm, edges black in color. In an interview with the facility ADON A on [DATE] at 12:56 PM she stated she was hired on [DATE] and was not assigned Resident #1, I am assigned to the 100 hall. I did round with the wound care doctor (Physician A), but I didn't see Resident #1 on the wound management log. The day that the wound was brought to my attention by ADON B it was a very flustering day . Because I was like, how could this be missed? The honest truth, I don't know. I saw wound care orders, but that's it. The terminated ADON C discovered the wound [DATE] and did not refer resident to physician monitored wound care services. In an interview with the facility ADON B on [DATE] at 1:20 PM stated she was hired on [DATE]. Resident #1 transitioned to my roster the same day I discharged her to the hospital due to her nurse notifying me of her change in condition on [DATE]. Her assigned nurse said her wound dressing was soiled and she changed it before EMS arrived on [DATE]. In a phone interview with the facility contracted wound care Physician A on [DATE] at 1:30 PM he stated he approved the telephone orders for Resident #1's sacral pressure wound requested by ADON C on [DATE] . Physician A stated, I go to the facility every Thursday. I don't recall seeing that patient because I don't have any notes or any evidence of her making it to the rounding list. Not sure why if it was forgotten or if she was out of the building. For some reason she never made it. I just approved the order through a call. I don't know why she was never on the list. When I go into the building, they give me a list of everyone, and I make sure I see everyone. If someone was supposed to be there that's not there, there's no way for me to just, out of the top of my mind, troubleshoot. Who is this person? Unless it's someone I've seen the week before, I would ask them did this person go home? Why are we not seeing this person, for whatever reason. She had told me that patient was supposed to be seen, but somehow, she was not on the list. The resident was never on the list. I'm not sure why. Record review of physician orders dated [DATE] revealed, Sacrum: cleans with Normal Saline or wound cleanser, pat dry, apply alginate calcium and cover with dry dressing daily. Electronically signed by Physician A on [DATE]. In a phone interview with the Responsible Party (RP) on [DATE] at 4:30 PM she stated, Resident #1 would call me in the middle of the night in excruciating pain. She told the nurses continually that she was an excruciating pain. One would think the nurses communicated that to somebody so somebody would have taken care of this prior to her suffering for a month in excruciating pain. I don't understand how it went on that long. In a phone interview with Resident #1's facility Primary Care Physician B on [DATE] at 10:19 AM he stated he was not aware of any of Resident #1's wounds . Record review of ER records revealed that the resident was septic, had fluid overload with shortness of breath and the resident as admitted to the ICU on [DATE] and continued to decline after discharge to hospice. The hospital advised the family not to readmit the resident back to the facility and assisted the family with finding home hospice care were the resident expired on [DATE]. In an interview with the facility with ED on [DATE] at 5:37 PM she stated that ADON C was terminated on [DATE] with License Referral and the DON was demoted to Care Plan Coordinator on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. The ED was notified and provided with the IJ template on [DATE] at 5:36 PM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm with the potential for more than minimal harm, due to the facility's need to implement and monitor the effectiveness of its corrective systems . The Plan of Removal (POR) was accepted on [DATE] at 1:48 PM, and indicated the following: Plan of Removal On [DATE] ADON's completed an in-service for Change of Condition using our SBAR should be completed on any change of condition. Progress Notes should be completed every shift for the next 3 days following SBAR. [DATE] [DATE] Administrator started reviewing resident 1 records, in-services were started to include Abuse, Neglect and Reporting. On [DATE] at 5:00pm ADON's started a skin sweep of all residents, any negative findings were corrected by orders added and referrals were made to Wound Physician. On [DATE] 4:40pm ADON's started an in-service with all Licensed Nurses, Med aides and C.N.A's regarding skin/wound documentation and notification in their documentation in the POC. [DATE] On [DATE] at 9:00am ADON assisted Administrator in reviewing the events our system has available. On [DATE] the new form for Pressure Sore/Stasis Ulcer was updated in the system and added to the events for the nurses to start using. In-service was started with all Licensed Nurses to complete the event when a Pressure Sore/Stasis Ulcer is present. The Braden Scale for Predicting Pressure Sore risk will be completed X4 Weeks after admissions or re-admissions. Quarterly thereafter. [DATE] The Administrator/DON will pull the Event reports daily to ensure all orders are in place and referral completed for Wound Physician to see on their next rounds. Administrator/DON will follow up after each round conducted by the physician to ensure resident was seen and orders carried out. Any negative finding will be corrected immediately. [DATE] All Licensed Nurses will be checked off for wound care for ADON's. DON/ADON's will complete observation wound care weekly for each nurse to ensure they are completing it correctly. [DATE] On [DATE] ADON's completed an in-service for Change of Condition using our SBAR should be completed on any change of condition. Progress Notes should be completed every shift for the next 3 days following SBAR. [DATE] [DATE] Administrator started reviewing resident 1 records, in-services were started to include Abuse, Neglect and Reporting. On [DATE] at 5:00pm ADON's started a skin sweep of all residents, any negative findings were corrected by orders added and referrals were made to Wound Physician. On [DATE] 4:40pm ADON's started an in-service with all nursing staff regarding skin/wound documentation and notification in include documentation in POC. [DATE] On [DATE] at 9:00am ADON assisted Administrator in reviewing the events our system has available. On [DATE] the new form for Pressure Sore/Stasis Ulcer was updated in the system and added to the events for the nurses to start using. In-service was started with all Licensed Nurses to complete the event when a Pressure Sore/Stasis Ulcer is present. The Braden Scale for Predicting Pressure Sore risk will be completed X 4 Weeks after admissions or re-admissions. Quarterly thereafter. [DATE] On [DATE] at 9:00am ADON assisted Administrator in reviewing the events our system has available. On [DATE] the new form for Pressure Sore/Stasis Ulcer was updated in the system and added to the events for the nurses to start using. In-service was started with all Licensed Nurses to complete the event when a Pressure Sore/Stasis Ulcer is present. The Braden Scale for Predicting Pressure Sore risk will be completed X 4 Weeks after admissions or re-admissions. Quarterly thereafter. [DATE] All Licensed Nurses will be checked off for wound care for ADON's. DON/ADON's will complete observation wound care weekly for each nurse to ensure they are completing it correctly. [DATE] Record review of facility Change in a Resident's Condition or Status Policy Statement (Revised 2021): Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, ., resident rights, etc.). 2. A significant change of condition is a major decline or improvement in the resident's status that: c. requires interdisciplinary review and/or revision to the care plan. Record review of facility Resident Rights Policy Statement (Revised 2016): Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation; 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: f. communication with and access to people and services, both inside and outside the facility. Monitoring of POR Record review of the facility's In-service dated [DATE] completed by facility ADON's for Change of Condition using Situation, Background, Assessment, and Recommendation (SBAR). Record review of the facility's In-Service dated [DATE] completed by ADON's regarding skin/wound documentation and notification in their documentation in the Point of Contact (POC). Record review of Plan of Correction (internal for facility) provided by ED, [NAME]- The Administrator/DON will pull the Event reports daily to ensure all orders are in place and referral completed for Wound Physician to see on their next rounds. Administrator/DON will follow up after each round conducted by the physician to ensure resident was seen and orders carried out. Any negative finding will be corrected immediately. ADON assisted Administrator in reviewing the events our system has available. On [DATE] the new form for Pressure Sore/Stasis Ulcer was updated in the system and added to the events for the nurses to start using. In-service was started with all Licensed Nurses to complete the event when a Pressure Sore/Stasis Ulcer is present. The Braden Scale for Predicting Pressure Sore risk will be completed X 4 Weeks after admissions or re-admissions. Quarterly thereafter. All Licensed Nurses will be checked off for wound care for ADON's. DON/ADON's will complete observation wound care weekly for each nurse to ensure they are completing it correctly. (Signed by the ED) Record review of the facility's Change in Condition Policy (copied for evidence) - No concerns noted. Interviews were conducted on [DATE] at various times to include staff from various shifts. Interviews with ED, CNA A, CNA B, CMA A, LVN B, RN A, RN B, RN C, RN D, ADON A, ADON B to verify the in-services were conducted and to validate the staffs understanding of the trainings for Abuse, Neglect , and Exploitation, the importance skin/wound documentation and notification in their documentation in the Point of Contact. No concerns were found regarding the understanding of the requirements, training materials or expectations. All interviewed staff were able to communicate their understanding and proficiency of the in-services. On [DATE] at 12:50 PM Investigator notified ED the immediacy was removed and conducted the exit. Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a lowered severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy and a scope of pattern as the facility continued to monitor the implementation and effectiveness of their plan of removal.