**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices based on the comprehensive assessment of resident for 1 (CR#1) of 18 residents reviewed for anticoagulants. -The facility delayed sending CR #1 to a higher level of care on 11/21/2024 when CR #1 experienced an unwitnessed fall with a head injury (swelling to right cheek). CR #1 was receiving the medication Eliquis (blood thinner). -CR #1 was diagnosed with an Acute Subdural Hematoma with mass effect An Immediate Jeopardy (IJ) was identified on 11/23/2024 at 4:24PM. While the IJ was removed on 11/25/2024, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility need to evaluate the effectiveness of the corrected system. This failure has the potential to place residents at risk for hospitalization and death. Findings: Record review of CR #1's face sheet dated 11/22/24 revealed a [AGE] year-old female admitted to the NF originally on 05/11/2024 and readmitted on [DATE]. CR #1's diagnoses included the following: muscle weakness, unsteadiness on feet, vascular dementia (memory loss), end stage renal disease (kidney disease), and osteoporosis (bones become weak and brittle). Record review of CR#1's MDS assessment dated [DATE] revealed a BIMS score of 7 indicating the resident's cognition was severely impaired. Record review of CR #1's Comprehensive Care Plan dated 11/04/2024 reflected that the resident was being care planned for anticoagulants that reflected the following: -Give meds per order -Monitor for increase bruising, bleeding, etc. -Notify MD if bleeding is not stopped with pressure Record review of CR #1's Physician Orders for the month of November 2024 reflected the following orders: -Dated 05/16/24 Eliquis 5mg give one capsule by mouth q 12 hours related to atherosclerosis (build-up of fats, cholesterol, and other substances in and around the artery {a vessel that carry blood away from the heart to the entire body}) walls. -Dated 05/14/24 Acetaminophen Tablet 325mg give 2 tablets by mouth every 6 hours for general discomfort. Record review of CR #1's MAR for the month of November 2024 reflected that RN A medication administered on 11/21/24 to CR #1 included: -Tylenol (325 mg 2 tablets administered by mouth) with a pain level documented as 0. Further review of CR #1's MAR dated November 2024 reflected that Medication Aide RR administered the medication Eliquis 5mg po prior to resident being transported to the hospital on [DATE]. Further review revealed that CR #1 was receiving the medication Eliquis twice a day as ordered by the physician. Record review of CR #1's Nursing Progress Notes dated 11/21/24 at 5:50 AM revealed CR #1 was found in her room sitting on the floor by RN A. RN A assessed resident and documented that resident had swelling to her right cheek. Further record review revealed that CR #1 was transferred to the hospital on [DATE] at 7:40 AM. Record review of CR #1's Progress Notes documented by RN A dated 11/21/24 reflected the following: .CR #1 was assessed, V/S were evaluated to be stable and WNL. Swelling / hematoma was noted to the Right cheek. No distress is noted at this time. CR #1 denies any pain or discomfort at this time. Fall precaution is in place. Neuro assessment is initiated and ongoing. CR #1 educated to call for assistance whenever she needed help, CR #1 verbalized understanding. Bed is put in the lowest position with call bell and personal belonging within her reach. MD was notified. DON and RP were also notified. This nurse called report to hospital. CR #1 is awaiting transfer to the hospital . Record review of CR#1's SBAR dated 11/21/2024 documented by RN A reflected the following: -Form Summary: SBAR (Change of Condition) - Fall Event Date/Time of Fall: 11/21/2024 5:50 AM Location of the Fall: Resident's room Classification of the Fall: Unwitnessed What was the resident doing prior to the fall: Resident states I was trying to turn and I rolled over. Initial Vital Signs Post Fall Event: Blood Pressure-124/71 Pulse-78 Temperature-97.6 Respirations-17 02 Saturation-99% Medication Reviewed with the Physician: Yes Notifications Physician/Physician Extender: PCP; 11/21/2024 5:54 AM Resident/Responsible Party: 11/21/2024 5:55 AM Observation on 11/23/2024 at 11:30AM revealed CR# 1in the ICU unresponive, resting in the hospital bed connected to a ventilator, and a neck collar. The top and left side of CR #1's head was bald with dressing on top of her head. There was a small plastic bulb that appeared to be connected to CR #1's head with red fluids draining inside of bulb. CR #1 was receiving the medication Cardene (used to treat high blood pressure and control chest pain) IV 40 mg in 200 ml of fluid at 75 ml/hr. Resident was receiving gastrostomy feedings Nova Source that read on pump 20 ml/hr. Record review of CR #1's hospital records revealed that CR #1 admitting diagnoses was Acute Subdural Hematoma (a pool of blood between the brainand its outermost coverin) with mass and a left craniotomy ( surgical procedure that involves removing a section of the skull to access the brain) evacuation. In an interview on 11/22/24 at 10:12 AM with the NF Administrator, and the DON present, the Administrator said CR #1 was residing on the Memory Care Unit and on 11/21/24 around 5:30 AM, the staff (RN A and CN B) had gotten CR #1 up for dialysis. The Administrator said from her understanding, the staff placed CR #1 near the nurse station in her wheelchair. The Administrator said the staff began to round on other residents in the MCU at 5:40 AM. The Administrator said CNA B said shortly after, she saw CR #1 laying on her bed. The Administrator said, at 5:50 AM, the Charge Nurse heard a noise coming from CR #1's room and went to see what was going on. The Administrator said when RN A arrived to CR #1's room, she found CR #1 sitting on the floor in between the 2 beds. The Administrator said CR #1 could walk. The DON interjected and said that CR #1 could walk, but had an unsteady gait. The surveyor requested copies from the Administrator of everything that the NF had done (investigation/in-services, etc.) regarding CR #1's fall on 11/21/2024. The Administrator said she had not completed her investigation, but would email so far what the facility had completed. Interview on 11/22/24 at 1:58 PM with a family member of CR #1 said CR #1 was still at the hospital in a coma and her condition was not looking good because CR #1 had a lot of bleeding on the brain. The family member said the NF called her on 11/21/24 around 6:40 AM telling her that CR #1 had a fall, and they were preparing to send CR #1 to the hospital for further evaluation. The family member said she spoke with CR #1 prior to leaving the NF and CR #1's speech was slurred. The family member said the nurse, who name she did not recall, told her it was probably CR #1's medications causing the slurring of speech. The family member said when the nurse called her to report that CR #1 had a fall, the nurse told her that she had called transportation instead of 911. Interview on 11/22/24 at 2:34 PM, RN A said she worked the 6:00 PM- 6:00 AM shift, and worked on 11/20/24. RN A said herself and CNA B had gotten CR #1 out of bed at 5:30 AM to dress CR #1 and placed in her wheelchair for dialysis. RN A said CR #1 was taken to the common area across from the nurse station. RN A said the CNA that was assigned to CR #1 was CNA C, but CNA B assisted with getting CR #1 out of bed for dialysis. RN A said CNA B was in the common area as well but later began to make rounds with CNA C getting the other residents out of bed and taking some to the common area as well, but still checking on CR #1. RN A said she began to pass medications on the other residents while keeping an eye on CR #1. RN A said she could see CR #1 because of the way her cart was positioned on the hallway. RN A said when she came out of a resident room, she did not see CR #1. RN A said she rushed to CR #1's room where she found CR #1 sitting on the floor. RN A said she never heard a noise coming from CR #1's room. RN A said she called CNA C to come and assist her with CR #1. RN A said after she finished assessing CR #1, herself and CNA C placed CR #1 back in bed. RN A said CR #1 had some swelling to the right side of face but was not complaining of pain. RN A said CR #1 vital signs were stable and she initiated neurological checks on CR #1 which were within normal limits. RN A said she called the doctor, resident family member as well as the Administrator. RN A said CR #1's family member wanted to speak to CR #1. Therefore, she took the phone to CR #1's room so she could speak to the family member. RN A said when she initially called the doctor, he did not answer. RN A said CR #1's PCP came to the facility later. RN A said because CR #1 appeared stable, she used her own judgment to send CR #1 to the hospital via regular EMS and not 911. RN A said she was aware that CR #1 was receiving the medication Eliquis and reiterated that she used her own judgement. RN A said the facility policy on unwitnessed falls with head injuries receiving anticoagulants was to send to hospital via 911. RN A said if a resident experienced an unwitnessed fall with a head injury and on blood thinners, they should be sent to the hospital via 911. RN A said if this was not done, the resident could die. Interview via phone on 11/22/24 at 3:05 PM, CNA B said she worked the night shift from 10 PM - 6 AM and worked on 11/20/24 on the MCU. CNA B said she was not the CNA assigned to CR #1. CNA B said she never provided any type of care for CR #1 including assisting with placing CR #1 in the wheelchair on 11/21/2024 at 5:30AM. Interview on 11/22/24 at 3:13 PM, the Administrator said RN A initially called regular transportation to transport CR #1 to the hospital. The Administrator said she asked RN A why she called regular transportation instead of 911. The Administrator said RN A said because CR #1 appeared to be stable. The Administrator said according to CR #1's Nursing Progress Notes, RN A sent CR #1 to the hospital via regular EMS at 7:40AM. Interview on 11/22/24 at 3:26 PM, the DON, with the Administrator present, said the NF did not have a policy on unwitnessed falls with head injury receiving anticoagulants. The DON said prior to reviewing CR #1's chart on 11/21/24, she was not aware that CR #1 was on the medication Eliquis. The DON said she was not aware what time CR #1 left the NF to go to the hospital until she reviewed the Nursing Progress Notes. The DON said if the nurse felt that it was okay to send CR #1 to the hospital via regular EMS, she would have to trust RN A's judgement because she was not present at the time of the incident. The DON said if she was present when CR #1 experienced the unwitnessed fall with head injury, she could not say what she would have done. The DON said she in-serviced the staff on falls on 11/21/24. Interview on 11/22/24 at 3:40 PM with the Administrator and the DON being present, the Administrator said she informed the Medical Director about CR #1's fall on 11/21/24. The Administrator said the Medical Director told her she would have to review CR #1's medical records to see if there were concerns about resident's fall with a head injury. The Administrator said she spoke with the Medical Director on 11/22/24 asking the MD about how the resident was transferred to the hospital via regular EMS instead of 911 after an unwitnessed fall with head injury and receiving the medication Eliquis. The Administrator said the MD told her after reviewing CR #1's medical records that the situation regarding CR #1's unwitnessed fall with head injury was tricky. The Administrator did not elaborate further what the MD meant by tricky. The Administrator said after herself and the DON discussed CR #1's incident further, they decided moving forward that any resident that experienced a fall with a head injury witnessed or unwitnessed needed to be transported to the hospital via 911 transport even if the resident was not on blood thinners. The Administrator said this should be done because of the gray areas and one could not see what may be happening to the resident internally. The Administrator said the NF could not perform CT scans (type of x-ray). Therefore, the resident should be sent to the hospital for further evaluation. Interview on 11/22/24 at 4:13 PM the Administrator provided a copy of more in-service, she said, had been conducted by the DON that entailed falls, anticoagulant, and visible head injury. The Aministrator said this in-service was in a book with other in-services the DON had done. Attempted an interview via phone on 11/22/24 at 3:52 PM with the Medical Director. There was no answer, and the mailbox was full. Interview on 11/22/24 at 4:45 PM via phone with the NP revealed the NF notified her of CR #1's fall on 11/21/24 and resident went to the hospital. The NP said the PCP made rounds at the facility on 11/21/24. The surveyor asked the NP if a resident experienced an unwitnessed fall with head injury receiving an anticoagulant medication, should the resident be sent out via regular EMS or 911. The NP said she could not really answer the question and that the surveyor would need to speak with CR #1's PCP. Attempted an interview via phone on 11/22/24 at 4:55 PM with CR #1's PCP. There was no answer; left voicemail. Interview on 11/23/24 at 11:35 AM, the hospital nurse said CR #1 would be taken off the ventilator on 11/23/24, and the family wanted comfort measures (treatments that focus on relieving the pain and distress for a dying person) after taking CR #1 off the ventilator. Interview on 11/24/24/ at 7:26 PM via phone, CNA C said she worked the 10 PM-6 AM shift. CNA C said on 11/20/24, she was CR #1's CNA on the Memory Care Unit. CNA C said the nurse helped her in getting the resident ready for dialysis. CNA C said after her and the nurse got CR #1 ready for dialysis at 5:30 AM, CR #1 was taken to the common area in her wheelchair across from the nurse station. CNA C said she went to check on the other residents. CNA C said the nurse was on another hallway passing medications. CNA C said CNA B was making rounds on the residents. CNA C said the last time she saw CR #1, prior to the fall, was at 5:40 AM in her room laying on her bed. CNA C said shortly after, she heard RN A calling her to come to CR #1's room. CNA C said when she arrived to CR #1's room, she saw CR #1 sitting on the floor. CNA C said RN A assessed CR #1, and afterwards, she assisted RN A in placing CR #1 back in bed. CNA C said CR #1 denied any pain. CNA C said RN A was preparing to send CR #1 to the hospital. CNA C said after assisting RN A, she went to check on the other residents. CNA C said she left the facility at 6 AM. Interview on 11/25/24 at 12:38 PM, the Administrator said the reason she provided the surveyor more in-services via email on 11/22/24 at 4:13 PM, regarding falls and anticoagulants, was due to the surveyor asking about polices. The Administrator said it prompted her to tell the DON to get the rest of the training the NF had done with the staff. Interview on 11/25/24 via phone at 12:50PM with CR #1's PCP said if CR #1's speech was slurred, CR #1 should have been sent to the hospital via 911. The PCP said a good rule of thumb, was if a resident with dementia experienced an unwitnessed fall with head injury, the resident should be sent to the hospital via 911 because the resident might be experiencing bleeding on the brain. The doctor said that he never received a call from the NF because it was not in his call log. Interview on 11/25/24 at 3:25PM via phone, at 3:25PM RN A said on the morning of CR #1's fall, 11/21/24, she administered CR #1 Tylenol because the family asked her to. A follow up interview via phone on 11/26/24 at 9:31am with CR #1's family member revealed CR #1 was on hospice. The family member said, on 11/21/24, the NF called to tell her that CR #1 fell, but she was okay. The family member said she wanted to talk to CR #1, but when CR #1 was talking back, she was slurring her words. The family member said the only thing the NF told her was that CR #1 had a small hematoma in her cheek. The family member said when she went to see CR #1 , CR #1's left side of the face and nose looked broken and bent to the side. CR #1's face had a lot of swelling and discoloration. The family member said the hospital had to do an emergency surgery on her brain to stop the bleeding. The family member said CR #1 wasn't waking up and she got another CT scan and it showed there was still internal bleeding in the brain and that the second surgery would have been too risky, and the chances of survival were low. Interview on 11/27/24 at 2:15 PM, Medication Aide RR said she worked on the MCU on 11/21/24. The medication aide said when she arrived at the facility on the MCU, the time was between 6:30 AM. Medication Aide RR said CR #1 was sitting up in a wheelchair at the nurse station. Medication Aide RR said CR #1 did not appear to be in any pain. Medication Aide RR said she was told that CR #1 had fallen. Medication Aide RR said CR #1 had some swelling to her face. Medication Aide RR said she asked RN D if it was okay to administer CR #1 her medications before CR #1 went to the hospital, and RN D said that it was okay. RN D said that she administered CR #1's morning medications including the medication Eliquis. Interview on 11/27/24 at 4:02 PM via phone, the Medical Director said she was aware of CR #1's fall on 11/21/24. The Medical Director said if a resident was clinically stable, without doctor's orders, the nurse could not hold a medication. The Medical Director said giving it or not giving Eliquis, it wouldn't have changed any outcome in CR #1's case. The Medical Director said it would not have mattered even with CR #1's face being swollen. The Medical Director said CR #1's vitals were stable before and after the fall. The Medical Director said Medication Aide RR did their job. The Medical Director said she did not have any concerns about the facility administering the medicine Eliquis after the resident had an unwitnessed fall with head injury. Record review of the NF's policy on Change in Condition Communication revised January 2024 reflected in part: . To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition .If the physician does not respond within an acceptable time frame, the Medical Director and Director of Nursing will be notified. The Medical Director will provide medical orders as necessary to treat the patient's/resident's condition . Record review of the NF's policy on Fall Management revised 07/2024 reflected in part: .The facility will provide a safe environment for all residents by implementing a fall management program. This program includes fall risk assessment, individualized care plans, staff education, and post fall evaluations .The charge nurse will notify the Physician/Physician extender of the fall, provide assessment findings and medications review, and receive orders as indicated .If the resident's condition warrants, the charge nurse will arrange for appropriate emergency services or hospital transfer in collaboration with the physician/Physician Extender . The Administrator and DON were notified on 11/23/2024 at 4:24 PM that an Immediate Jeopardy situation (IJ) was identified due to the above failures. The Administrator was provided the IJ template on 11/23/2024 at 4:30 PM and a Plan or Removal (POR) was requested. The facility's POR was accepted on 11/24/2024 at 12:40 PM and indicated: PLAN OF REMOVAL F684 Name of facility: [facility]: 11/24/2024 Immediate Action POR F684 CR #1 was transferred to hospital on [DATE]. The Administrator, Director of Nursing, and Medical Director held an ADHOC QAPI meeting on 11/23/24 to review the IJ template and Plan of Removal. RN A was suspended pending investigation on 11/21/24. On 11/22/24 and 11/23/24 the Director of Nursing and Assistant Director of Nursing assessed residents who had unwitnessed fall in the last 10 days for any signs or symptoms of headache, vomiting, or abnormal findings to the scalp/head with no adverse findings. The Director of Nursing initiated an in-service on 11/21/24 with licensed nurses. Topics included: Fall Procedures, specifically on activating the emergency response system (911) for any residents who has a fall with a visible head injury. 911 should be activated upon identification and notification to Physician and the DON would be secondary. Licensed nurses will be educated before starting their next shift. Education will be included in orientation. Education will be completed on 11/23/24. The Director of Nursing provided 1:1 education with RN A on 11/22/24. Education included Fall Procedures and activating the emergency response system (911) for any resident who has a fall with a visible head injury. 911 should be activated upon identification of the abnormal findings and notification to Physician and DON would be secondary; and completing through assessments post-fall with consideration for residents on anticoagulants. The Regional Nurse Consultant provided 1:1 education with the DON on 11/22/24. Education included Fall Procedures and activating the emergency response system (911) for any resident who has a fall with a visible head injury ' 911 should be activated upon identification and notification to Physician and DON secondary; and completing through assessments post-fall with considerations for resident on anticoagulants. Fall documentation will be reviewed each weekday in morning meeting on weekends, holidays, and after hours by DON/designee to ensure completed and appropriate actions are taken and documented. The Administrator and DON reviewed the policy on Fall Management and Changes of Condition no changes noted. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview on 11/24/24 at 12:50 PM, RN D, on the Memory Care Unit (6AM-6PM), said she had been in-serviced on abuse and neglect as well as falls. RN D said if a resident experienced a fall with head injury witnessed or unwitnessed to prepare to send the resident to the hospital 911, notify the Physician, DON, and the resident's RP. RN D said she was in-serviced to assess the resident for pain, skin assessment, check their vital signs, and began neurological checks per facility protocol. RN D said if the resident was in pain to medicate the resident. RN D said even if the resident was not complaining of pain to give something for pain due to residents in the MCU decrease in cognition, the resident may not be able to express that they were in pain. RN D said she was also in-serviced to document all actions taken in the facility's electronic medical records system. Interview on 11/24/24 at 1:03 PM, RN E said she was the weekend supervisor and worked from 6AM-6PM. RN E said she had been in-serviced on falls witnessed and un-witnessed with head injury and anticoagulants. RN E said a resident that had fallen and developed a head injury, she would have to send to the hospital right away via 911 services. RN E said an assessment had to be done on the resident that included neurological assessment, vital signs, checking for bleeding. RN E said she would also notify the physician, family, DON and document all necessary actions taken in PCC. Interview on 11/24/24 at 1:10 PM, RN F said she was a new grad in orientation. RN F said she had received in-services on fall precautions witnessed or unwitnessed with head injuries receiving blood thinners. RN F said the resident should be sent to the hospital via 911. RN F said, at the time of the fall, neurological checks should be done on the resident and the resident should assessed for pain. RN F said the vital signs were taken and the doctor should be notified as well as the RP and the DON. RN F said documentation had to be done as well. Interview on 11/24/24 at 1:30 PM, LVN G said she worked from 6AM-6PM shift PRN. LVN G said she had been in-serviced on the following: abuse and neglect, resident falls, being sure to round on the residents regularly to see if they needed anything, making sure that personal belongings were in reach to prevent falls, answering their call lights in a timely manner. LVN G said she had been in-serviced on falls with injuries, particularly falls, with head injuries along with resident receiving blood thinners. LVN G said a resident with a head injury had to be sent to the hospital right away via 911 services. LVN G said when a resident had a fall, the resident had to be assessed by the nurse along with initiating neurological checks, vital signs, notifying the physician, DON, and responsible party. LVN G said she was in-serviced to also document all actions taken. Interview on 11/24/2/4 at 1:40 PM, RN H said she worked the 6AM-6PM shift. RN H said she had been in-serviced on falls witnessed and unwitnessed with head injuries to send to the hospital 911 services. RN H said she had been in-serviced on residents receiving blood thinners, notifying the physician of falls with injuries and the resident receiving blood thinners, how to assess a resident that had a fall being sure to initiate neurological checks per facility protocol, assessing the resident for pain, taking the residents vital signs, documentation and to notify the family and the DON of the incident. Interview on 11/24/24 at 7:11 PM, LVN I said she worked at the NF PRN on the 6PM-6AM. LVN I said she received in-services on falls, witnessed and unwitnessed with head injuries, to send the resident to the hospital via 911 because the resident's life depended on it. LVN I said the physician needed to be notified right away along with the RP and the DON. LVN I said she was in-serviced on blood thinners and documentation. Interview on 11/24/24 7:40 PM via phone at LVN J said she worked 6PM-6AM shift. LVN J said she was in-serviced on falls with head injuries, blood thinners, notifying the doctor of any changes in a resident condition as well as the DON and RP, documentation, and sending resident out to the hospital 911 if they had fallen and hit their head. Interview on 11/25/24 at 11:58 AM with LVN M 6AM-6PM said she use to work at the facility full time but worked on a PRN basis at that time. LVN M said she had received in-services on the following: witnesses and unwitnessed falls with head injuries to send the resident to hospital 911, call the doctor, family, and the DON. LVN M said she was in-serviced on documentation, assessments, and blood thinners. Interview on 11/25/24 at 12:05 PM, the DON said if a resident experienced a fall with a head injury and speech was slurred, there could be something going on neurologically such as a stroke or bleeding on the brain. The DON said it could only be determined by a test. The DON said she had been in-serviced on falls witnessed and unwitnessed with head injury to notify the physician, sending resident to hospital via 9ll. Interview on 11/25/24 at 12:19 PM, LVN N said she worked full time 6AM-6PM and had been in-serviced on falls witnessed and unwitnessed. LVN N said a fall with a head injury, 911 services and the doctor should be called right away. LVN N said if they were unable to reach the doctor or NP, they were supposed to call the Medical Director, DON, and document. LVN N said if a resident was on blood thinners need to monitor the resident for bleeding. Interview on 11/25/24 at 3:25 PM via phone, RN A said she had been in-serviced on falls witnessed and unwitnessed with head injuries, blood thinners, sending the resident out via 911, notifying the physician, DON, and family. On 11/25/2024 at 4:56 p.m., the Administrator was informed that the IJ was removed, however, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility need to evaluate the effectiveness of the corrected system. Medication Eliquis Reference www.fda.gov/dragsatfda reference ID: 3237516: .Call your doctor or get medical help right away if expereince unexpected pain .swelling .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accident for 1 (CR #1) of 18 residents reviewed for accidents in that: - The facility failed to provide CR#1, who was on an anticoagulant medication, adequate supervision and interventions to prevent falls on 11/13/24, 11/14/24, 11/17/24, and 11/21/24 causing head injury and hospitalization. -The falls were unwitnessed, CR #1 had dementia and did not remember to use their call light when they needed assistance. Cr #1 was admitted to the hospital with diagnosis of Acute Subdural Hematoma with mass effect left craniotomy evacuation. An IJ was identified on 11/25/2024. While the IJ was removed on 11/27/2024, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility need to evaluate the effectiveness of the corrected system. This failure could place residents at risk for unwanted hospitalizations and death. Findings included: Record review of CR #1's face sheet dated 11/22/24 revealed a [AGE] year-old female admitted to the NF originally on 05/11/2024 and again on 11/02/2024. CR #1 diagnoses included the following: muscle weakness, unsteadiness on feet, vascular dementia (memory loss), end stage renal disease (kidney disease), and osteoporosis (bones become weak and brittle). Record review of CR#1's MDS dated [DATE] revealed a BIMS score of 7 indicating that resident cognition was severely impaired. Further review section GG-Functional Abilities and Goals reflected that CR #1 required supervision with transfer. Record review of CR #1's Comprehensive Care Plan dated 11/04/2024 reflected that resident was being care planned for risk for falls and injuries due to a hx of falls prior to admission. Further review reflected that CR #1 experienced falls on the following days for the month of November 2024 (11/13/24 unwitnessed fall in room no apparent injuries, 11/14/24 unwitnessed fall in room, 11/17/24 unwitnessed fall in room no injury, and 11/21/24 unwitnessed fall in room). The interventions included the following: -Anticipate needs- provide prompt assistance -Assure lighting is adequate and areas are free of clutter -Encourage resident to ask for assistance of staff -(Revised on 11/21/24) CR #1 will be reeducated to call for assistance from staff for all transfers, she continued to try to be independent, staff would make frequent rounds for closer monitoring, bed in lowest position, and call light in reach. Record review of CR #1's Physician Orders for the month of November 2024 reflected the following order: -Dated 05/16/24 Eliquis 5mg give one capsule by mouth q 12 hrs related to atherosclerosis (build-up of fats, cholesterol, and other substances in and around the artery {a vessel that carry blood away from the heart to the entire body}) walls. Record review of CR #1's MAR for the month of November 2024 reflected that the NF was administering the medication Eliquis as ordered by the physician. Record review of CR #1's fall incidents: -11/13/24 4:26 pm on the facility's incident report list -11/14/24 4:55 pm on the facility's incident report list -11/17/24 5:50 am on CR #1's change in condition assessment -11/21/24 5:50 am on CR #1's change in condition assessment Record review of CR #1's fall risk assessments, CR #1 had the following fall assessments with scores: -11/14/24 - high risk 25.0 -11/17/24 - high risk 19.0 -11/21/24 - high risk 19.0 Record review of CR #1's fall incident reports: -11/13/24: resident found sitting on bottom beside bed in bedroom. No witness. Resident unable to give description. -11/14/24 incident report- patient found on floor in bedroom, unbothered, patient confused no question answered. No witness. Resident unable to give description. Record review of CR #1's fall incident reports: -11/13/24: resident found sitting on bottom beside bed in bedroom. No witness. Resident unable to give description. -11/14/24 incident report- patient found on floor in bedroom, unbothered, patient confused no question answered. No witness. Resident unable to give description. Record review of CR #1's Nursing Progress Notes: -11/15/2024 17:02: S/P: Day 1 of 3. Fall occurrence on 1/14/2024. No complaint of pain or distress at this time. resident is moving around in her wheelchair in the common area interacting with other residents. Vitals are WNL. will continue with plan of care. Record review of CR #1's Nursing Progress Notes dated 11/21/24 at 5:50 AM CR #1 was found in room sitting on floor by RN A. RN A assessed resident and documented that resident had swelling to her right cheek. Further record review revealed that resident was transferred to the hospital on [DATE] at 7:40AM. Further record review CR #1's Nursing Progress Notes documented by RN A dated 11/21/24 reflected the following: . CR #1 was assessed, V/S were evaluated to be stable and WNL. Swelling / hematoma was noted to the Right cheeks. No distress is noted at this time. CR #1 denies any pain or discomfort at this time. Fall precaution is in place. Neuro assessment is initiated and ongoing. CR #1 educated to call for assistance whenever she needed help, CR #1 verbalized understanding. Bed is put in the lowest position with call bell and personal belonging within her reach. MD was notified. DON and RP were also notified. This nurse called report to hospital. CR #1 is awaiting transfer to the hospital . Further Record review of SBAR documented by RN A reflected the following: -Form Summary: SBAR (Change of Condition) - Fall Event Date/Time of Fall: 11/21/2024 5:50 AM Location of the Fall: Resident's room Classification of the Fall: Unwitnessed What was the resident doing prior to the fall: Resident states I was trying to turn and I rolled over. Initial Vital Signs Post Fall Event: Blood Pressure-124/71 Pulse-78 Temperature-97.6 Respirations-17 02 Saturation-99% Medication Reviewed with the Physician: Yes Notifications Physician/Physician Extender: PCP; 11/21/2024 5:54 AM Resident/Responsible Party: 11/21/2024 5:55 AM Interview on 11/22/24 at 10:12AM with the NF Administrator and the DON present, the Administrator said CR #1 was residing on the Memory Care Unit and on 11/21/24 around 5:30AM the staff (RN A and CN B) had gotten CR #1 up for dialysis. The Administrator said from her understanding the staff placed CR #1 near the nurse station in wheelchair. The Administrator said the staff began to round on other residents in the MCU at 5:40AM. The Administrator said CNA B said shortly after she saw CR #1 laying on her bed. The Administrator said at 5:50AM the Charge Nurse heard a noise coming from CR #1's room and went to see what was going on. The Administrator said when RN A arrived to CR #1' room, she found CR #1 sitting on the floor in between the 2 beds. The Administrator said CR #1 could walk. The DON interjected and said that CR #1 could walk but had an unsteady gait. Interview on 11/22/24 at 1:58PM with family member of CR #1 said CR #1 was still at the hospital in a coma and her condition was not looking good because CR #1 had a lot of bleeding on the brain. The family member said the NF called her on 11/21/24 around 6:40AM telling her that CR #1 had a fall, and they were preparing to send CR #1 to the hospital for further evaluation. The family member said she spoke with CR #1 prior to leaving the NF and CR #1's speech was slurred. Interview on 11/22/24 at 2:34PM RN A said she worked the 6:00 PM - 6:00 AM shift and worked on 11/20/24. RN A said herself and CNA B had gotten CR #1 out of bed at 5:30AM to dress CR #1 and placed in wheelchair for dialysis. RN A said CR #1 was taken to the common area across from the nurse station. RN A said the CNA that was assigned to CR #1 CNA C, but CNA B assisted with getting CR #1 out of bed for dialysis. RN A said CNA B was in the common area as well but later began to make rounds with the other CNA C getting the other residents out of bed and taking some to the common area as well but still checking on CR #1. RN A said she began to pass medications on the other residents while keeping an eye on CR #1. RN A said she could see CR #1 because of the way her cart was positioned on the hallway. RN A said when she came out of a resident room, she did not see CR #1. RN A said she rushed to CR #1's room where she found CR #1 sitting on the floor. RN A said she never heard a noise coming from CR #1's room. RN A said she called CNA C to come and assist her with CR #1. RN A said after she finished assessing CR #1, herself and CNA C placed CR #1 back in bed. RN A said CR #1 had some swelling to the right side of face but was not complaining of pain. RN A said CR #1 vital signs were stable and she initiated neurological checks on CR #1 which were within normal limits. RN A said she called the doctor, resident family member as well as the Administrator. Interview on 11/22/24 via phone at 3:05PM CNA B said she worked the night shift from 10PM-6AM. CNA B said she was not the CNA assigned to CR #1. CNA B said she never provided any type of care for CR #1 including assisting with placing resident in wheelchair on 11/21/2024 at 5:30AM. Observation on 11/23/24 at 11:30AM CR #1 in the ICU resting in hospital bed connected to ventilator unresponsive wearing a neck collar. Further observation on the top and left side of CR #1's head was bald with dressing on the top of head. There was a small plastic bulb what appeared to be connected to CR #1's head with red fluids draining inside of bulb. CR #1 was receiving the medication Cardene (used to treat high blood pressure and control chest pain) IV 40mg in 200ml of fluid at 75ml/hr. Resident was receiving gastrostomy feedings Nova Source that read on pump 20ml/hr. Record review of CR #1's Admitting diagnoses revealed that CR #1 was admitted to the hospital for Acute Subdural Hematoma with mass effect left craniotomy evacuation. Interview on 11/23/24 at 11:35AM the hospital nurse said CR #1 would be taken off the ventilator 11/23/24 and the family wanted comfort measures (treatments that focus on relieving pain and distress for a dying person) after taking CR #1 off the ventilator. Interview on 11/24/24/ at 7:26PM via phone CNA C said she worked the 10PM-6AM shift. CNA C said on 11/20/24 she was CR #1's CNA on the Memory Care Unit. CNA C said the nurse helped her in getting resident ready for dialysis. CNA C said after her and the nurse got CR #1 ready for dialysis at 5:30AM CR #1 was taken to the common area in her wheelchair across from the nurse station. CNA C said she went to check on the other residents. CNA C said the nurse was on another hallway passing medications. CNA C said CNA B was making rounds on the residents. CNA C said the last time she saw CR #1 prior to the fall was at 5:40AM in her room laying on her bed. CNA C said shortly after, she heard RN A calling her to come to CR #1's room. CNA C said when she arrived too CR #1's room, she saw CR #1 sitting on the floor. CNA C said RN A assessed CR #1 and afterwards, she assisted RN A in placing CR #1 back in bed. CNA C said CR #1 denied any pain. CNA C said RN A was preparing to send CR #1 to the hospital. Interview on 11/25/24 at 1:00 PM, the MDS Coordinator said the ways the facility tried to prevent CR #1 from falling was by keeping CR #1 in the common area across from the nurse station as much as possible, but CR #1 moved freely in her wheelchair in the MCU. The MDS Coordinator said the NF also tried to keep CR #1 engaged in activities. The MDS Coordinator said the interventions that were in place for CR #1 were sufficient in preventing continuous falls for CR #1. The MDS Coordinator said due to CR #1 being mobile in her wheelchair, the only other intervention was to place resident maybe on 1 on 1 supervision. Interview on 11/25/24 at 1:25 PM, the DON said, regarding falls. she started working at the NF on 10/21/2024. The DON said she was aware of how often CR #1was falling because it was discussed in the morning meetings. The DON said the NF tried to put interventions in place to prevent CR #1 from falling. The DON said because of CR #1's resident disease process, regarding her dementia it made it difficult to prevent CR #1 from falling. The DON said the NF did not have the staff to place resident on 1 on 1 supervision. The DON said the interventions that the NF put in place for CR #1 was the best the facility could do to prevent resident from falling. The DON said she could not say if the NF could have done anything different to keep resident from falling. Interview on 11/25/24 at 2:08 PM, the Administrator said CR #1's falls were discussed in the morning meetings. The Administrator said she was aware of CR #1's continuous falls in the month of November, but would have to review her notes to see what was discussed about resident falls. The Administrator never provided any notes about CR #1's falls during the morning meeting. Interview on 11/26/24 at 8:54AM the Rehab Director said she participated in the morning meetings. The Director said she was familiar with CR #1. The Director said CR #1 was pretty much independent prior to hip fracture which took place at the facility about a month and a half ago. The Director said prior to CR #1 hip fracture she was transferring independently but after, she required assistance with transfers. The Director said CR #1's falls on 13, 14, 17, and 21st of November 2024 were discussed in morning meetings and the interventions included all that were in CR #1's care plan. The Director said the problem was due to CR #1's dementia, she would not remember about safety. The Director said she did not meet with the family regarding CR #1's repeated falls. The Director said CR #1 was receiving therapy but cognitively, CR #1 thought she could do what she was doing before. The Director said the NF were trying to keep CR #1 in the common area as much as possible. The Director said she remember coming to pick up another resident and remembered seeing CR #1 trying to walk back to her room. The Director said she had to redirect CR #1 back to the common area. The Director said CR #1 would go to her room and self-transfer. The Director said in some cases during morning meetings they discussed medications and fall. The Director said she could not say if CR #1's medications were discussed, but they should have discussed it. The Director said she was not working at the NF on the 15th and 18th of November. The Director said an intervention would be to ask the psychiatrist to review medications, do labs for UTI maybe, but that was done on an individual basis. The Director said she did not recall if the NF talked about medications and labs regarding CR #1. The Director said the interventions that the facility had in place regarding falls for CR #1 were sufficient. The Director said the NF could not do 1-on-1 supervision. The Director said after reviewing the interventions, the NF implemented their suggestions one being getting CR #1 up earlier so she would not get up on her own. Interview on 11/26/2024 at 9:31am via phone with CR #1's family member/RP said she never attended a meeting regarding CR #1's falls with the NF. The RP said the NF would sometimes call regarding a fall, and other times would wait until CR #1's family member visited the facility, to tell them CR #1 had a fall. The RP said that on 11/21/2024 the facility called the RP to say that CR #1 fell but that she was okay and that she only had a small hematoma on her cheek. CR #1 speech was slurred on the phone. When the RP went to see CR #1, see saw the entire left side of CR #1's face was swollen and that her nose appeared broken and bent to the side and there was a lot of swelling and discoloration. The RP said that CR #1 had successfully completed emergency brain surgery to stop the bleed, but that CR #1 did not wake up afterward. The hospital informed the RP that another CT scan showed there was still internal bleeding in the brain but that a second surgery would have been too risky, and the chance of survival was low. CR #1 was currently on hospice at that time. Interview on 11/26/2024 at 12:57 PM, the Regional Nurse she said that after a resident fell, the unit manager should conduct a fall risk assessment and that would trigger an incident report. The Regional Nurse said based on that information a skin, pain, or change in condition assessment would be triggered. Those forms could be completed by either the unit manager or charge nurse. The Regional Nurse said from what she was told, a lot of CR #1's falls would be a staff member finding her on the floor, but she was comfortable and unbothered. The Regional Nurse said she was aware of the fall on 11/21/2024 and that the Administrator told her the family called the facility to inform that CR #1 was transferred to another hospital. The Regional Nurse said she was aware that an intervention the NF came up with was placing CR #1 in a common area, but CR #1 would wheel herself around the unit. The Regional Nurse said CR #1 had the right to go into her room or the dining room. The Regional Nurse said the NF notified the family of all CR #1's falls and updated them on lab work, etc. The Regional Nurse said there were no specific meetings regarding the falls. Record review of the NF's policy on Fall Management revised 07/2024 reflected in part: .The facility will provide a safe environment for all residents by implementing a fall management program. This program includes fall risk assessment, individualized care plans, staff education, and post fall evaluations .The charge nurse will notify the Physician/Physician extender of the fall, provide assessment findings and medications review, and receive orders as indicated .If the resident's condition warrants, the charge nurse will arrange for appropriate emergency services or hospital transfer in collaboration with the physician/Physician Extender . The Administrator and Regional Nurse was notified on 11/25/2024 at 3:58 PM an Immediate Jeopardy situation (IJ) was identified due to the above failure. The Administrator was provided the IJ template on 11/25/2024 at 3:58 PM and a Plan or Removal (POR) was requested. The facility POR was accepted on 11/26/2024 4:45PM. PLAN OF REMOVAL F689 Name of facility: 11/25/2024 Immediate Action According to the IJ template: The facility failed to provide CR#1, who is on an anticoagulant medication, adequate supervision and interventions to prevent falls after multiple falls which lead to an unwitnessed fall on 11/21/24 resulting in a hematoma to the right cheek requiring hospitalization due brain bleed and placed on ventilator. CR #1 was transferred to the hospital on [DATE]. The Administrator, Director of Nursing, and Medical Director held an ADHOC QAPI meeting on 11/25/24 to review the IJ template and Plan of Removal. CR #1 had a fall on 11/13/24. On 11/13/24 the resident's careplan was reviewed and fall interventions updated by MDS Coordinator to include: Neuro vital signs in place- lab work ordered to rule out infection. Neuros were initiated and completed with no adverse findings. CR #1 had a fall on 11/14/24. On 11/14/24 the resident's careplan was reviewed and fall interventions updated by MDS Coordinator to include: Staff will redirect/offer her to attend activities of choice in the common area. CR #1 had a fall on 11/17/24. On 11/17/24 the resident's careplan was reviewed and fall interventions updated by MDS Coordinator to include: staff will offer to get her up early in the morning is she chooses and she can sit in common area and watch tv/or visit with staff On 11/21/24 the MDS coordinator reviewed residents who had a fall for the last 60 days to ensure adequate interventions are in place, with no adverse findings. The Regional Nurse did 1:1 in-service with MDS on 11/21/24. Topics included: Fall management: to include developing an individualized fall prevention plan for each resident identified at risk and updating the care plan with each fall event to ensure new interventions are implemented according to the resident's risk. Residents who experience a fall event are reviewed during the daily clinical morning meeting, which includes members of the Interdisciplinary Team (IDT). During this meeting, the IDT evaluates the fall event, reviewing documentation in the medical record (progress notes) and the incident report. The MDS Coordinator/Designee updates the resident's care plan to reflect the agreed-upon fall prevention interventions that are individualized and aimed at preventing further falls. The facility will identify residents who are on anticoagulants by Physician Orders, Anticoagulant Care Plans, and side effect monitoring on the EMAR. Residents are assessed for risk for falls by the charge nurse on admission, quarterly, with significant change and fall events. Residents noted at risk for falls careplans are updated to identify the fall risk and appropriate interventions. The ADON conducted an audit on 11/26/24 with no adverse findings. The Director of Nursing initiated an in-service on 11/21/24 with licensed nurses. Topics included: Fall management, change of condition, Kardex; Education was completed on 11/23/24. Licensed nurses will receive education before their next shift, with new hires receiving training during orientation. The Director of Nursing provided education with staff members that provide direct care to residents on 11/21/24. Education included: Reviewing the Kardex for resident-specific fall prevention measures. Staff will receive education before their next shift, with new hires receiving training during orientation. Completion date 11/23/24. The Regional Nurse Consultant provided 1:1 education with the DON on 11/21/24. Education included Fall management to include Developing an individualized fall prevention plan for each resident identified at risk and updating the care plan with each fall event to ensure that any new risks or necessary interventions are addressed. On 11/25/24, the Regional Nurse discussed with CR#1's Nurse Practitioner (NP) the interventions implemented by the facility in response to the falls on 11/13, 11/14, and 11/17. It was determined that the interventions were appropriate for the resident's plan of care and aligned with clinical guidelines. There was no indication or order for 1:1 observation at the time. However, while the interventions were appropriate, the resident remains at high risk for falls. The Administrator and DON reviewed the policy on Fall Management on 11/21/24 with no changes required. Fall trends are brought to QAPI and reviewed monthly with the Medical Director. The Administrator reviewed the facility assessment, staffing on the memory care unit (supervision), and residents who are at risk for falls on 11/21/24 with no adverse findings identified. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview on 11/26/2024 at 10:07 am via phone, RN A said she received in-services from the DON on 11/22/2024 around 4:00 pm by phone after checking her phone log. RN A said the in-services were on falls regarding residents with physical or head injuries to be sent out by calling 911, notifying the doctor/ NP, RP and DON by phone calls and not through text messaging. RN A also said that she received an in-service on residents taking blood thinners. Interview on 11/26/24 at 10:50 PM via phone, LVN K 6PM-6AM said she had been in-serviced on falls with head injury, anticoagulants, fall prevention (making rounds on the resident anticipating their needs, making sure call light in reach and responding to the resident light in a timely manner, keeping bed locked and in low position, reviewing the resident Kardex on how to care for the resident looking at interventions for resident, make sure resident wearing non-slip socks or shoes) when to call 911 to transport resident to a higher level of care, notifying the doctor, family, DON when there was a change in a resident condition, and documentation. Interview on 11/26/24 at 11:15 PM, CNA B said she worked the 10PM-6AM shift. CNA B said she had received the following in-services: if a resident experienced a fall prevention and falls to report to the nurse immediately so that the nurse could assess the resident, reviewing resident Kardex that was found in POC on how to care for each resident, abuse and neglect, and resident rights. Interview on 11/26/24 at 11:27 PM, CNA O said she worked the 10PM-6AM shift. CNA O said she received in-service on falls and the prevention of falls, how to access the Kardex in POC to review resident plan of care that included if the resident was a fall risk. CNA O said when a resident experienced a fall, she was in-serviced to send for the nurse immediately, notifying the nurse if notice a change in a resident condition. Interview on 11/26/24 at 11:37 PM, CNA BB on the 10PM-6AM shift said she was in-serviced on resident rights, fall preventions (making sure bed was in the low, locked position, fall mats on the floor, checking the resident frequently every 2 hours or sooner, call light in reach, room free of clutter with call light in reach, answering the call lights in a timely manner, and making sure residents had a on non-slip socks or shoes), reviewing resident Kardex that instructed her on how to care for the resident, notifying the nurse if the resident had a change in condition. Interview on 11/26/24 at 11:39 PM, CNA C 10PM-6AM said she had received in-service on looking at the Kardex to see how to better care for the resident, fall preventions, and abuse/neglect. Interview on 11/26/24 at 11:43 PM, CNA P 10PM-6AM said she received in-service on fall preventions, how to access the Kardex in POC to show how her to care for the resident, and to notify the nurse of any changes in the resident condition. Interview on 11/26/24 at 12:00 AM, CNA Q said she worked the 2PM-10PM and 10PM-6AM shifts. said she had been in-serviced on how to access the resident Kardex in POC to review the resident care, fall preventions, resident rights, and abuse and neglect. Interview on 11/26/24 at 7:35 AM, LVN J said she worked the 6PM-6AM shift and had been in-serviced on fall prevention and supervision of the residents, responding to resident call lights in a timely manner, leaving the resident bed locked and in low position, fall mats in position on the floor for residents on fall risk, keeping the call light in reach along with their personal belongings, keeping the resident room free of clutter and providing adequate lighting, rounding on the residents at least every 2 hours or sooner pending on what was going on with resident, utilizing the Kardex because it provided guidance on how to care for the resident, documenting changes in a resident condition, along with notifying the doctor, family, and DON, falls witnessed and unwitnessed, assessments, blood thinners, and when to send a resident out via 911 services. Interview on 11/27/24 at 7:45AM, LVN R said she worked the 6PM-6AM shift and was in-serviced on fall preventions, falls witnessed and unwitnessed with head injury, blood thinners, sending the resident out 911, calling the doctor, family, and Administration, know what residents that were on blood thinners, utilizing the Kardex to care for the resident, and documentation. Interview on 11/27/24 at 8:00 AM, RN L said she worked the 6PM-6AM shift and was in-serviced on the following: when to send a resident to the hospital via 911 services, falls witnessed and unwitnessed with injuries, blood thinners, the use of the Kardex, abuse and neglect, and resident rights. Interview on 11/27/24 at 10:30 AM, CNA S said she worked the 6AM-2PM shift and the 2PM-10PM shift. CNA S said she had been in-serviced on where to find the Kardex in POC to review the care for a resident, fall prevention and falls witnessed and unwitnessed not moving the resident but alerting the nurse immediately, making sure residents who were fall risk, had their fall mats on the floor at the bedside, keeping call light in reach, answering the call lights, keeping the resident room organized, making sure the resident was wearing non-slip socks or shoes to prevent any falls, and constantly monitoring the residents because she worked on the Memory Care Unit. Interview on 11/27/24 at 10:35 AM, CNA T 6AM-2PM shift been in-serviced on falls, fall prevention, abuse and neglect, keeping resident room free of clutter, importance of using the Kardex to care for the resident, keeping resident bed in low position and locked, fall mats, and the use of grip socks to prevent residents from slipping and falling. Interview on 11/27/24 at 10:40 AM, LVN G 6AM-6PM in-serviced on falls and fall prevention falls with head injury, sending a resident to the hospital via 911, notifying the doctor, family member, and DON, blood thinners, Kardex, assessments, documentation, and PICC line care. Interview on 11/27/24 at 10:44 AM, CNA U 6AM-2PM on the Memory Care said she had received in-services on abuse and neglect, resident rights, usage of the Kardex regarding resident care, fall prevention, and rounding on the residents frequently. Interview on 11/27/24 at 10:48 AM, the MDS Coordinator said she had been in-serviced on fall prevention, head injuries, how to transport a resident to a higher level of care via 911 services, anticoagulants, being more resident specific to meet each resident needs when discussed in the morning meetings, and the IDT meetings. Interview on 11/27/24 at 10:50AM, the Certified Occupational Therapist Assistant said she had received in-service on fall preventions, making sure a resident on fall precautions mats were on the floor at the bedside, leaving calling light in reach, and making sure the resident wore grip socks to prevent falls. Interview on 11/27/24 at 10:54 AM, the Activity Director said she had received in-services on fall prevention and 1 on 1 supervision when needed, keeping residents engaged, and grip socks. Interview on 11/27/24 at 10:58 AM, the Unit Manager for the weekend said she had received in-services on abuse and neglect, anticoagulants, fall prevention (bed in low position, making sure fall matts on floor at the bedside, resident wearing non-slip shoes or socks, answering call lights in a timely manner, call light in reach, where to find resident Kardex in the computer. The Unit Manager said the Kardex would alert the staff if the resident was a fall risk, etc, and basically how to provide care for the resident). The Unit Manager said she had also been in-service on head injuries and to send the resident to the hospital via 911 and informing the physician, responsible party, and administration. Interview on 11/27/24 at 11:06 AM, CNA V 6AM-2PM shift said she worked at the NF PRN and had received in-services about the Kardex, fall preventions, keeping residents' bed locked and in low position, call light in reach, answering the call lights as quickly as possible, if a resident fell not to move the resident, and to notify the nurse immediately. Interview on 11/27/24 at 11:10 AM, RN H, on the 6AM-6PM shift, said she had received in-service regarding resident Kardex, fall preventions, falls with head injury, anticoagulants, and PICC Lines. Interview on 11/27/24 at 11:11 AM, CNA W 6AM-6PM shift said she received in-services on answering call lights, keeping call light within resident reach, Kardex, rounding on the residents every 2 hours and as needed, keeping the resident room clutter free, bed locked and in low position, fall mats to prevent falls. CNA W said if the resident had a fall, she would not move the resident but call for the nurse to assess the resident. Interview on 11/27/24 at 11:18 AM, RN X, on the 6AM-6PM shift, said she had been in-serviced on falls with head injury and [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #37) residents reviewed for intravenous fluids. - The facility failed to ensure Resident #37 had physician orders and care plan in place for monitoring and dressing change of Resident #37's PICC line (Peripherally Inserted Central Catheter, a tube inserted through a vein in the arm which passes to the larger veins near the heart and used to deliver medications, liquid nutrition or other treatments) from when Resident #37 was readmitted from the hospital with a PICC line on 9/09/2024 to 10/2/2024 when the NP put in an order for the PICC line to be discontinued. -The facility failed to ensure Resident #37 's PICC line was removed after completion of IV antibiotics which ended on 09/19/24. -The facility failed to ensure Resident #37 's dry dressing was changed every 5 to 7 days per facility policies and procedures, including orders for monitoring the site. An IJ was identified on 10/04/2024. The IJ template was provided to the facility on [DATE] 12:47pm. While the IJ was removed on 10/06/2024 at 11:47am, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility need to evaluate the effectiveness of the corrected system. This deficient practice could place residents at risk of serious harm, injury or death by leaving the PICC line in longer than necessary and exposing residents to infections in the blood stream and serious illness. Findings included: Record review of Resident #37's face sheet dated 10/03/2024 revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of acute cystitis with hematuria (a bladder infection that may cause blood in the urine), anemia(low red blood cell count), hypotension (abnormally low blood pressure), colostomy (a surgical opening for the colon in the abdomen which provides an alternative channel for feces to leave the body), intestinal obstruction, and schizophrenia (a serious mental health condition which may include hallucinations, delusions and disorganized thinking and behavior) . Record review of Resident #37's hospital discharge records dated 9/9/24 revealed Resident #37's midline placement (a catheter placed in a vein used to deliver medications and other treatments quickly to the body) date was 09/05/24. Further review revealed Resident #37 was ordered meropenem (MERREM) 500 mg intravenously every 8 hours for 9 days with a start date of 9/10/2024 and a stop date of 9/19/2024. He had a transfer diagnosis of hematuria (blood in urine). Record review of Resident #37's September MAR revealed he received the medication every shift as ordered starting 09/10/2024 at 11:00pm to 09/19/2024 at 3:00pm. Record review of Resident #37's physician's orders last updated 10/03/2024 and care plan last revised 09/11/2024 revealed no documented orders or instructions for maintenance of midline and dry bandage. Record review of Resident #37's physician's progress notes dated 9/11/24 revealed, Patient is being seen today to follow up on hospitalization. Patient is on IV abx (antibiotics) for 9 days for sepsis . Observation on 10/1/24 at 5:10 p.m., revealed Resident #37 lying in bed and , had a PICC line in his left arm, double lumen (a catheter which splits into two tubes, with each tube being used to take or give blood products and the other used for medication or IV fluids) with two tape dressings cover it one on the other. The first dressing was dated 9/5/24 which was when Resident #37 was in the hospital and the second dressing on top was used to secure the first dressing and was not dated. Both dressings and tape were brownish in color. Resident #37 was not interview-able and had a representative at bedside. Interview with the DON on 10/2/2024 at 2:54pm, nurses should ensure residents with PICC line have physician orders for it. PICC line dressings should be changed every 5 to 7 days and that nurses should observe the PICC line site every shift to ensure no redness, drainiage, not be hot to the touch. Interview with the MDS Coordinator A on 10/3/24 at12:28p.m., she was not aware of Resident #37's PICC line. She always assessed a resident with PICC on admission, documenting how the PICC line site is and checking for infection. She said currently the facility had 2 residents with a PICC. Interview with LVN B on 10/03/2024 at 11:52am, she stated that nurses were to follow physician's orders for residents with PICC llines. LVN B stated that dressing changes should be done every 5 to 7 days and as needed and that nurses should inform the doctor when a resident's antibiotic therapy was completed. LVN B said sometimes a PICC Line was not removed immediately after antibiotic therapy completion because the resident's physician ordered more labs before discontinuing the PICC Line, but that she would continue to monitor and flush the PICC line every shift until it is discontinued. She said she never worked with Resident #37. Interview with LVN C on 10/03/2024 at 12:00pm, he stated that when a resident is admitted to the facility with a PICC Line, they should already have physician's orders for it, including dressing changes. LVN C stated that after a resident completes antibiotic therapy, the physician should be notified. Interview with LVN A on 10/03/2024 at 3:00 pm, LVN A stated when a resident was admitted the nurse was supposed to call the physician do all the paperwork such as verifying and entering medications and treatments into the MAR. Interview with NP A on 10/3/2024 at 4:32pm, she stated that when a resident is admitted from the hospital the NP will review medications that day and review the resident's clinical notes the next on-site visit. NP A stated she did not put any orders for the resident's PICC line to be discontinued nor for dressing changes it, but that it was her fault that the orders were not put in Resident #37's MAR and it was her responsibility to do that when her residents were admitted with a PICC line. She stated that nurses are to update her if there is changes in condition and to questions her orders, but that they did not do so. NP A stated that PICC lines would be discontinued after the treatment is completed and after all labs are done to confirm it can be removed. She stated the facility called her on 10/2/24 to get the PICC line discontinued. NP A said that risks for a resident not having their dressing changed per physician's orders or standard practice is that it could cause infection and sepsis. Interview on 10/3/24 at 5:04pm with the ADON and Administrator, the ADON said that the PICC line and dressing change should be administered according to physician's orders and that nurses were expected to let the doctor know when the antibiotics were completed. The ADON said that when a resident completed their antibiotics, the nurse should call the physician to see if the order should be discontinued, if labs needed to be drawn or if the antibiotics need to be continued. The Administrator said that staff should have followed physician's orders. The ADON said that having the dressing on since 9/5/24 would be an infection control concern and it could pose a risk of bacteria with a dressing on that long without being changed and cleaned. The Administrator said the risk due to leaving the bandage on for that amount of time is related to infection control . An IJ was identified on 10/04/2024. The facility was notified of the IJ on 10/04/2024 at 12:47pm with the Interim Administrator, RNC and DON present. The IJ template was provided to the facility on [DATE] 12:47pm and a POR was requested by email to the Interim Administrator, RNC and DON. The following Plan of Removal was submitted by the facility and accepted on 10/04/2024 at 5:45pm. Allegation F694: [Facility Name] - IJ Plan of Removal F694 10/4/2024 The facility failed to ensure a peripherally inserted central catheter (PICC) (a thin, flexible tube that is inserted into a vein in the upper arm and ends in a large vein near the heart) used to administer parenteral fluids and antibiotics had an order how to cleaned and discontinued consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. On October 2, 2024, Resident #37's PICC line was assessed by the Director of Nursing (DON), with no adverse effects or signs or symptoms of infection noted. A physician's order was obtained for the removal of the PICC line, and PICC line was discontinued without adverse effects. The Physician ordered lab work on 10/3/24 and results were noted with no adverse findings. On October 2, 2024, all other residents with central lines were assessed by the Director of Nursing to ensure an up-to-date dressing, active order sets to include monitoring, flushes, dressing changes, orders to obtain central lines after IV therapy is completed, and central line specific care plans. No adverse findings were noted. The Administrator and DON informed the Medical Director of the Immediate Jeopardy situation on October 4, 2024, through an AD Hoc QAPI meeting. The Regional Nurse Consultant provided 1:1 education with the DON on 10/2/24 on providing oversight with residents with central lines and ensuring compliance with central line policies and procedures to include active orders for monitoring central line site, flushing the central line, central line dressing changes, and obtaining orders to remove central lines after IV therapy is completed. The Director of Nursing initiated in-services with licensed nurses on 10/2/24 on and ensuring compliance with central line policies and procedures to include active orders for monitoring central line site, flushing the central line, central line dressing changes, and obtaining orders to remove central lines after IV therapy is completed. Education will be completed on 10/4/24. Licensed Nurses will be educated prior to their next shift: including PRN employees or new hires. After the IJ was called out on 10/4/24, the Director of Nursing conducted 100% rounds on residents with central lines and compliance was noted with policies and procedures. The Administrator reviewed the Central Line Policies and Procedures on 10/4/24 and no changes were required. The charge nurse will input and complete orders for residents who obtain or admit with a central line and will be validated in clinical morning meeting by nurse leadership. The clinical morning meeting will include reviewing high risk residents to include residents with central lines and ensuring compliance with central line policies and procedures (orders and care plans). DON Inservice nurse leadership on 10/4 on the above process; The charge nurse will input and complete orders for residents who obtain or admit with a central line. Completion date 10/4. Record review of Physician Order policy last reviewed January 2024 revealed that all physician orders must be verified by the receiving nurse for accuracy and upon receipt the nurse will enter the order into the electronic health record. Nursing staff will review physician orders and follow up on any discrepancies or unclear orders with the prescribing physician. Record review of the facility's Nurses' Infusion Manual for Long Term Care Facilities last updated 05/16/2022 revealed a dressing changing must be done every 7 days or sooner if compromised adn be monitored for signs and symptoms of compllications from infection like swelling, redness or pain. Record review of the facility's Central Line policy last revised January 2024 revealed that nursing staff are not obtain physician orders to remove the central line once IV therapy is completed. [Signed by Interim Administrator, 10/4/2024] Monitoring the Plan of Removal for Effectiveness as follows: Observation on 10/05/2024 at 12:45pm of Resident #10 revealed the resident had a left peripheral IVF hep-lock single lumen (a single catheter line placed in a vein on a resident's left side of the body that contains a medication called heparin used to prevent blood clotting), the site was cleaned with no redness, dressing infiltration, odors, or warmth. The dressing on the site was dated 10/03/24. Observations and record review of other residents with a PICC line revealed: Record review of Resident #7's orders revealed nurses were to monitor the PICC line site every shift, midline dressing change every 5 days and as needed, a midline flush 10 millilters of Normal Saline every shift. Observation of the resident on 10/05/2024 revealed Resident #7 was sitting in the dining area eating lunch with their PICC line to their left upper arm intact. Resident #7 had a left upper arm IVF hep-lock double lumen, the site was clean with no redness, dressing infiltration, odors, or warmth. Dressing on the PICC line site was dated 10/02/24. Record review of Resident #155's orders revealed nurses were to monitor the midline every shift, midline dressing changes every 5 days and as needed, a midline flush of 10 milliliters of Normal Saline every shift. Observation of Resident #155 on 10/05/2024 revealed the resident was sitting in the dining area eating lunch with the PICC line to their upper arm intact. Resident #115 had left upper arm IVF hep-lock double lumen line, the site was clean with no redness, dressing infiltration, odors, or warmth. Dressing on the PICC line site was dated 10/02/24. Interview with LVN I on 10/04/2024 at 4:30pm, she said she only took care of Resident #37 when he was admitted . LVN I said she was supposed to document in the TAR that Resident #37 is to have his PICC line inititaed but that she forgot. LVN I said that any nurse, including the nurse on the next shift could have obtained orders and entered them in Resident #37's chart. LVN I said she had not worked at the facility since that day when she admitted Resident #37. Interview with RN G on 10/05/2024 at 1:15pm, she said that she received in-services a few days ago for PICC line. RN G said she was educated on making sure residents with a PICC line had orders from their physician for monitoring, maintaining the dressing, which should be changed every 5-7 days depending on the physician orders , and to notify the physician when the residents get to the facility and when antibiotics were completed so that the nurse could place an order to discontinue the PICC line. Interview with RN A on 10/05/2024 at 1:30 pm, she said that she received in-services a few days ago for PICC line. RN A said she was educated on making sure residents with a PICC line had orders from their physician for monitoring, maintaining dressing which should be changed every 5-7 days depending on the physician orders, and that she should notify the physician when the residents get to the facility and when antibiotics are completed so that the nurse can place an order to discontinue the PICC line. Interview with the DON on 10/05/2024 at 2:00pm, the DON said the nurses were not doing what they should have, which included the documenting residents with PICC line and to check the line every shift and flush the line, ensure the site is clean, and getting Physician Orders for removal of PICC line after antibiotics are completed. The DON said she immediately started in-services on PICC line for the nurses. Interview with RN E on 10/05/2024 at 8:30pm, she stated she worked every other weekend as a weekend supervisor. RN E said she had in-services and also conducted in-services for other nurses, which included making sure staff get physician orders for residents with PICC lines including monitoring the line site and maintenance of the line, notifying the physician when antibiotics are completed, contacting the physician with labs and when to discontinue the PICC line. RN E stated that staff are to notify the resident's physician if they do not see PICC line orders. RN E also said that all care provided to a resident for their PICC line should be documented in their MAR. Interview with LVN B on 10/05/2024 at 8:42pm, she said that she received in-services a few days ago for PICC line. LVN E said she was educated on making sure residents with a PICC line have orders from their physician for monitoring and changing the resident's dressing every 5 to 7 days depending on the physician orders, and to notify the physician when the residents get to the facility and when antibiotics are completed so that the nurse can place an order to discontinue the PICC line. Interview with LVN D on 10/05/2024 at 9:47pm, she stated that she had been at the facility for a year and works night shifts. She stated she received educations on PICC and IV lines, making sure residents have orders after having a PICC line placed, calling the physician and verifying that residents have orders for the PICC line, monitoring for signs and symptoms of infection, and dressing changes which are every 5 days. LVN D said she also received education on informing the physician when the antibiotics are completed and make sure that orders are put in for PICC line to be discontinued. LVN D said that after treatment is completed and before being discontinued, nurses should still observe for any changes in the PICC line site and to flush the line every shift and to document anything done for the PICC line in the resident's chart. Interview with RN D on 10/05/20234 at 9:54pm, she stated that she had been with the facility for more than a year and works night shifts. She stated that she received in-services on PICC line on 10/04/2024, which included making sure residents with a PICC line have orders for dressing changes every 5-7 days depending on the physician orders, flushing before and after medication and every shift, monitoring the PICC site for signs of infection and reporting any changes to the physician, and to inform the physician when the resident's antibiotics are completed and to get an order to discontinue the PICC line per physician orders. RN D stated that after a resident is admitted , nurses are to verify PICC line orders with the resident's physician, the nurse then assess the PICC line site to see where and when the line was placed, make sure there are orders for signs of infection, dressing changes, how often to flush the line, checking fluids through the lines, and documenting PICC line care in the resident's MAR. An IJ was identified on 10/04/2024. The IJ template was provided to the facility on [DATE] 12:47pm. While the IJ was removed on 10/06/2024 at 11:47am, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility need to evaluate the effectiveness of the corrected system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) for 1 (CR#8) of 9 residents reviewed for advanced directives. - The facility failed to ensure that CR#8 received CPR in accordance with professional standards of practice on [DATE]. -The facility failed to immediately initiate CPR on [DATE] at 4:19 a.m. when CR#8 was found unresponsive. -The facility failed to immediately contact Emergency Services on [DATE] at 4:19 a.m. when CR#8 was found unresponsive. EMS was contacted on [DATE] at 4:34 a.m. (15-minute delay). An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 2:34 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not an Immediate Jeopardy because all staff had not been effectively trained on CPR, calling the code, and immediately contacting Emergency Medical Services and evaluate the effectiveness of the corrective systems. These failures could place residents who are a full code-status (everything that is done to keep a person alive) at risk of death. Findings include: Record review of CR#8's face sheet dated [DATE] revealed CR #8 was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with dementia, unspecified severity, with other behavioral disturbance, osteoarthritis, hypertension, benign prostatic hyperplasia (prostate gland enlarged, but not cancerous) with lower urinary tract symptoms, insomnia, cachexia (wasting syndrome), overactive bladder, major depressive disorder, recurrent, severe with psychotic symptoms and hallucinations. Record review of CR#8's Care Plan dated [DATE] revealed, CR#8 had delusions and was at risk for injury with interventions to report delusions in the clinical record, notify MD of changes in behavior, psychiatric consult as needed. CR#8 resident in Memory Care Unit for impaired cognition secondary to diagnosis of dementia, elopement risk, wandering with interventions to call resident by name when giving care, explain procedures, keep environment free of possible hazards .He also took psychotropic medication and was at risk for adverse reactions and episodes of driven behavior as evidenced by taking anti-psychotic with interventions to give medication as ordered, monitor each behavioral episode for frequency, intensity, duration and document in the clinical record .He was at risk for falls and injuries as evidenced by unsteady gait, confusion with interventions to anticipate needs, provide prompt assistance, assure lighting is adequate and areas are free of clutter, ensure call light is in reach and answer promptly, keep frequently used items at resident bedside, monitor for incontinent episodes-provide peri care as indicated and therapy to screen resident. Evaluate/treat per order. Self care deficits was identified with interventions to anticipate needs-provide prompt assistance, ensure light is within reach and answer in a timely manner, provide (extensive) assistance of (1-2 support persons for bed mobility, provide extensive assistance of (1-2 support persons) for transfers and provide (Supervision/Set up) assistance of (1-2 support persons for eating and staff to monitor for tolerance of intake, provide total assistance of (1 support persons) for toileting/incontinent care and provide privacy and maintain dignity. CR#8 was identified for being at risk for wandering as evidenced by dementia/Alzheimer's and was full code. Record review of CR#8's MDS assessment dated [DATE] revealed a BIMS Summary score of 3 indicating severe cognitive impairment, no behaviors exhibited, verbal behavior, the functional status revealed bed mobility, transfer, locomotion off the unit, dressing, toilet use and personal hygiene were extensive assistance with one person physical assist and limited assistance for walking in room and corridor, and locomotion on unit. Record review of CR#8's physician orders revealed CR#8 did not have a DNR. Observation: Behaviors, target behaviors (Hallucinations, Aggression, Wandering, Depressive Feature) every shift Monitor resident for presence of behaviors. Document yes or no to whether behaviors were observed? Notify MD as needed for behaviors. Started on [DATE]. Observation: Pain-observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate. Document in the PN's. every shift. Started on [DATE]. Amlodipine Besylate oral tablet 5 mg (Amlodipine Besylate) give 5 mg by mouth one time a day related to essential (primary) hypertension (110) Hold for sbp <110, dbp <60, pulse <60. Started on [DATE]. Aricept Oral tablet 10 mg (Donepezil Hydrocholoride) Give 0.5 tablet by mouth one time a day for dementia started on [DATE]. Gemtesa Oral tablet 75 mg (vibegron) give 1 tablet by mouth one time a day related to overactive bladder started on [DATE]. Megestrol Acetate oral suspension 400 mg/10ml (Megestrol Acetate) give 10 ml by mouth two times a day for loss of appetite started on [DATE]. Memantine HCl oral tablet 10 mg (Memantine HCl) give 10 mg by mouth two times a day for dementia started on [DATE]. ProAir HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 1 inhalation inhale orally every 6 hours as needed for COPD started on [DATE]. ProMod Oral Liquid (Nutritional Supplements) give 30 ml by mouth three times a day related to unspecified protein-calorie malnutrition started on [DATE]. Tylenol Oral tablet 325 mg (Acetaminophen) give 2 tablets by mouth every 6 hours as needed for OA related to unspecified osteoarthritis started on [DATE]. Record review of CR#8's Physical Therapy PT Evaluation & Plan of Treatment started on [DATE] revealed: Patient will have increase strength of trunk rotators and abdominals to [DATE] to be able to do all bed mobility with CGA x 1 (Target [DATE]) Baseline strength of trunk rotators and abdominals 3/5, able to do all bed mobility with minimum assistance of staff. Assessment Summary Clinical impressions: Patient presents with clinical impairments consisting of decreased strength of trunk rotators, abdominal and both LE, pain on both knees and thighs, decreased endurance, impaired dynamic standing balance. Reason for Skilled Services Skilled Patient services are warranted to analyze gait pattern, analyze/instruct in home exercise program, assess functional abilities, decrease complaints of pain, develop and instruct in restorative nursing program, enhance fall recovery abilities, enhance rehab potential, establish and instruct in compensatory strategies, facilitate anticipatory reactions .gait, increase LE ROM and strength, minimize falls, promote safety awareness . Record review of CR#8's Facility Provider Investigation Report dated [DATE] and reported to the State on [DATE] at 1:50 p.m. revealed Incident Category Death on [DATE] at 6 a.m. in resident's room. CR#8 functional assistance was total assistance in Memory Care. CR#8 was independently ambulatory, not interviewable, no capacity to make informed decisions and not wearing a wander guard at time of incident. Description of the allegations: Allegedly while the CNA was making her rounds she observed the resident lying on the floor in his room unresponsive. The assessment was on [DATE] at 6 a.m. Name and title of person who completed assessment was LVN E, with the description of assessment: Description of assessment including extent of injuries. Provide details of any physical harm, pain, or mental anguish including serious bodily injury, other injuries including but not limited to measurements, location, color of bruises, scratches, lacerations, fractures, changes in resident's behavior that is different from the normal baseline. LVN E immediately assessed the resident (CR#8) noting bleeding from the right side of the forehead, resident unresponsive CPR initiated and 911 was called. The incident was reported to the police and CPR initiated, notification to DON, Administrator, staff in-service initiated on rounds, supervision, fall prevention. Investigation Summary: Based on the information provided this investigation, while making AM rounds the CNA observed the resident lying on the floor in his room unresponsive. Per the CNA, she started her rounds at 10:00 p.m. the resident was in bed resting. Rounds were made again at 12:00 a.m. and then at 2 am, resident was resting in bed. When the CNA made rounds at 4 AM she noted the resident lying on the floor. She went into the room, called his name but did not get a response. The CNA immediately notified the Charge Nurse of her findings. The Charge Nurse immediately assessed the resident noting blood on the right side of his forehead and resident unresponsive. CPR was initiated and 911 was called. Resident continued to be unresponsive and was pronounced by the EMS. As a result of the incident, the facility could not rule out a cardiac or neurological event prior to falling. The family and physician were notified. The investigation findings were inconclusive. Record review of Fall assessment dated [DATE] at 5:53 a.m. with incident description: The CNA made her regular round at 10:25pm, 2 am. Then started her morning job at 4 am. When she went in there and found the resident on the floor unresponsive. Immediate Action Taken: She run and called me. I came in and observed resident on the floor by the bed side. Resident was bleeding from the head and was unresponsive. CPR initiated. 911 called. Injury type: laceration, Injury location: top of scalp, mobility: wheelchair bound. Record review of police body camera dated [DATE] at 4:58 a.m. revealed Paramedic stated the facility staff said they last saw CR#8 at 2 a.m. and he was okay and at 4:34 a.m. they were rounding and found CR#8. Observation of CR#8's room did not reveal a crash cart, nothing on the floor, no [NAME] bag observed. The police stated you can still see the blood right there. The Paramedic stated some facilities have a bed alarm. Police asked did the resident pee and pointed to something on the floor and EMS said they have no idea what that was on the floor. The paramedic stated he did not know what the facility policy was. Police officer was heard asking the facility for CR#8's paperwork and observation revealed LVN E was still trying to get the face sheet. LVN E stated at 2 a.m. CR#8 was still in bed and at around 4 am. LVN E stated they decided to start their morning job. The Police officer was observed asking LVN E did they have something for when residents fell out the bed, and LVN E stated the facility did not have anything. Observation revealed the Nurses station and there were no other nurses assisting LVN E at this time printing paperwork. Observation of CR#8's room in the video did not reveal a crash cart out or an ambu bag at the nurses station. LVN E was observed printing all CR#8's paperwork for the paramedic and the police. LVN E stated all the facility had was the call light that the resident may use when they need help. LVN E stated the CNA found CR#8 and CR#8 was diagnosed with dementia. LVN E was observed printing out the face sheet for the police officer. LVN E stated there was no DNR on record for CR#8 and he was full code. LVN E stated the full code was the first thing he checked. LVN E told the police officer that nursing homes did not allow bedrails. LVN E stated bedrails were considered a restraint. The police was heard asking for the paperwork and saying the facility smelled like urine. Observation revealed the police was saying something and they muted the body camera. LVN E stated CR#8 raised the bed and CR#8 fell out of the bed. The police stated CR#8 bled for a minute and the police said they probably could have saved him [CR#8]. Police was heard asking LVN E if anybody walked down that aisle and LVN E said no body walked down that aisle. The police asked if LVN E called his boss. LVN E said he would call his boss at 5:07 a.m. to tell his boss. The police officer stated he did not know what the cause of death would be because CR#8 fell. LVN E could be heard stating that 911 was at the facility and they were working with CR#8 and police was heard asking what did LVN E's boss say. LVN E stated the paramedics called the death at 4:46 a.m. LVN E was heard calling the family at 5:12 a.m. The police asked was CR#8's family member's coming to the facility and if they stayed far. The police officer asked where the family member's were coming from and she said she was not too far. Police asked how long it would take to get here and if they had a funeral home in mind. She said they need to get all the paperwork and call the funeral home. Police said the funeral home could not get the body yet because he needed to call the Medical Examiner. The family member said they would come after they get the paperwork for the funeral home. LVN E was heard telling the family member to wait until she got to the facility to call the funeral home. LVN E told the police he just spoke with the Director but said it was the DON. LVN E stated CR#8's doctor does not sign the death certificate in a situation like this. The police asked for the doctor information. The police said CR#8's room smells. The police asked LVN E to call for CNA C. LVN E was heard calling for CNA C to come. The police asked CNA C what happened and she stated the first time she rounded to see the residents was around 10 p.m. CNA C stated they check the resident's every 2 hours and her next round was around 2 a.m. and he was laying in bed face up. CNA C stated at 2 a.m. CR#8 had been in the room fumbling around and picking stuff of the floor. CNA C stated after 4 a.m. she saw CR#8 on the floor and ran back out the room. CNA C stated she kind of touched CR#8 and said LVN E went into the room and she saw CR#8's blood. She stated when she saw CR#8, he was facing on the side downward. She said the bed was not high when she went into the room. She grabbed LVN E and LVN E touched CR#8. On [DATE] at 5:26 a.m. CR#8's family member spoke with the police and he told her they could not call the funeral home now because he had to call the medical examiner. He said the funeral home will have to get the body from the medical examiner. She said she had the mortuary for the funeral home. The Police asked what time they were coming to the facility. Police said they could start heading towards the facility. He said he was sorry for their loss. The police continued with CNA C and she stated CR#8 was cold to the touch and that CR#8 got hit on the left side of the temple and that was where the blood was coming from. LVN E heard that the iron tire on the bed was where CR#8 hit. Before he hit the ground he hit a metal piece that was attached to the bed. Police called the medical examiner at 5:36 a.m. LVN E stated he just spoke with CR#8's family member. LVN E told the police CR#8 was a full code. Police stated the facility staff did not hear CR#8 fall. Police was observed asking LVN E to print CR#8's physician orders. Observation did not reveal any other nurses printing any paperwork or assisting LVN E with anything. Observation revealed the police had the SILK test and the police said he would give it to the medical examiner. Case number (deidentified). Record review of Police body camera on [DATE] at 6:02 a.m. Resident observed laying on his back with both arms across his chest. Observation revealed blood at the head of roommates bed. Police observed walking down the hallway towards the Nurse Station. LVN E stated the roommate was walking in the hallway right now. The police stated the room and CR#8's body needed to be cleaned and he said the room smelled. They have to clean that room and they are going to come get the body. Police stated CR#8 peed in the bed. Police asked LVN E to call the family member at 6:05 a.m. CNA C was heard saying that CR#8 continued to raise the bed up and mess with the bed remote. The police said the family member could not come look at the body like that. The police spoke with the family member and said the body will be transported and they will not be able to see the body right now and the family member was already in the car right now. He said he could not let them see the body like this. (Deidentified) for Medical Examiner and the number is (deidentified). Police instructed them to say case in regards to her father and the medical examiner is (deidentified )The police said he could not let them see the body like this. They will pick the body up in the next 30 minutes. Record review of police body camera video dated [DATE] at 6:26 a.m. revealed 911 Police instructing LVN E tell to write specifics on the report stating CR#8 had a hole in the right temple of the head at 6:26 a.m. Police officer was heard asking how was CR#8's body was so close to the other bed (roommates bed) in the room. LVN E stated the foot of CR#8's bed was always up. LVN E was heard saying the bed was all the way up when he found CR#8. LVN E stated when he went into the room LVN E put the bed down low. CR#8 was found on his side. The black thing on the edge of the bed is metal and this is where CR #8's head was found. LVN E stated CR#8 liked to move his bed and his bed was moved all the way by the roommates bed. Observation revealed Police said he had the staff to remove roommate out of the room. CR #8 body's was observed on the floor with both of his arms across his chest. Observation of CR#8's room on the video did not reveal a crash cart, [NAME] bag and no other staff assisting LVN E. Observation of the body camera video revealed Police was heard asking how he can lift the bed up and he was heard asking for CR#8's bed remote. Observation revealed blood on the floor by roommates bed. Record review of County EMS date of Service [DATE] with primary role: Medic Transport, Paramedic, Ambulance Response Info: Nature of Call: Cardiac Arrest/Death, Patient found: On floor, Initial Patient Acuity: Dead without Resuscitation Efforts (Black) .(means dead without resuscitation efforts) Disposition: Type of Service 911 Response (Scene) Outcome: Dead at Scene- No Resuscitation Attempted- No Transport Barriers to Care: None noted Scene Delay: None/No Delay Times: Injury: 4:19 a.m. on [DATE] PSAP (Public Safety Answering Point): 4:34 a.m. on [DATE] Dispatch Notify: 4:34 a.m. [DATE] Received: 4:34 a.m. [DATE] Dispatch: 4:36 a.m. [DATE] En route: 4:37 a.m. [DATE] At scene: 4:42 a.m. [DATE] At Patient: 4:46 a.m. [DATE] In service: 5:09 a.m. [DATE] [DATE] 4:46 a.m. Body Area: Assessments and Comments: Body Area: Assessments and comments Airway Patent Breathing Absent Circulation Pulses-Carotid-Absent (0) Blood/Fluid loss 100-500 ml Pulses-Femoral-Absent Head Laceration External/Skin Cold: Dry Mental Status Unresponsive Neurological Not done Primary Impression: Death Secondary Impressions: Cardiac Arrest Cardiac Arrest Cardiac Arrest: Yes, Prior to EMS Arrival Arrest Etiology: Cardiac (Presumed) Resuscitation Attempted: Not Attempted-Considered Futile Arrest Witnessed by: Not witnessed Discontinued Reason: Obvious signs of death Patient Dead on Arrival: yes Pronounced Dead By: First Responder (Fire, Law, EMS) Time of Cardiac Arrest [DATE] 4:34 a.m. End of Cardiac Arrest Event: Expired in the field [DATE] at 4:48 a.m. Medic responded emergent for a 911 request for a cardiac arrest. Medic responded without delay from the station. Medic arrived on scene to find a [AGE] year-old male lying supine on the floor with signs of rigor mortis. The patient is apneic and pulseless. The nursing staff stated that they last saw the patient normal was around 2:00 a.m. The nursing staff stated that they found the patient on the floor and immediately called 911. The patient skin is cold and dry. The patient's jaw is stiff and unable to be moved. The patient's pupils are fixed and unreactive. The 4-lead (shows electrical activity of the heart) was applied to the patient. The patient was in asystole (heart stopped beating). The patient is DOA per protocol at 4:45 a.m. Scene was left with [PD]. Medic returned back in service. Record review of City Police Department Event Report dated [DATE] at 4:34 a.m. revealed, Call received [DATE] at 4:34 a.m. Call routed [DATE] at 4:34 a.m. Call take finished [DATE] 4:34 a.m. 1st Dispatch [DATE] 4:36 a.m. 1st En-Route [DATE] 4:36 a.m. 1st Arrive [DATE] 4:53 a.m. Last Clear [DATE] 7:14 a.m. Record review of Police Department Incident/Investigation Report dated [DATE] at 4:34 a.m., time reported [DATE] at 4:34 a.m. revealed: Crime Incident(s) Dead On Arrival Narrative: On [Wednesday] [DATE], at approximately 4:34 a.m., .Officers were dispatched to [facility]. A death investigation and a report was completed. On [Wednesday] [DATE], at approximately 0434 hours [4:34 a.m.], .a Police Officer for the City .was dispatched to [facility]. Upon arrival, I made contact with the on duty nurse who was identified as LVN E, The deceased male was identified as [CR#8], [ethnicity, gender, date of birth ], .The CNA who was taking care of the deceased male was identified as [CNA C][ethnicity, gender, date of birth ]. [CNA C], stated she went to [CR#8's], Room on [DATE] at approximately 10pm to check on him and she noticed he was doing fine. [CNA C], stated when she went to go check back on [CR#8], on [DATE], at approximately 2AM, she noticed he was alive. [CNA C], stated she left the room and returned at approximately 4AM on [DATE] and that`s when she noticed that [CR#8] had fallen out of his bed and struck the right side of his forehead on the ground. [CNA C] stated when she noticed [CR#8] was on the ground, She asked [LVN E] to come help her lift him up off the ground. [CNA C] stated when they touched [CR#8], he was already cold to the touch .medic 6:08 a.m. arrived on location and called the time of death on [DATE] at 4:46 AM. I asked [CNA C] how often they are supposed to check on their patient and she stated every two hours. I was advised by [LVN E] that [CR#8], was not on hospice. [LVN E] provided me with [CR#8's] doctor information, but he did not make contact with him while I was on location. While in the room, I did not notice any foul play. [CR#8`s] body was cold to the touch. There was blood on the right side of his bed. I observed [CR#8] to have a knot on the right side of his forehead. Photos of the room were taken of his body and the injury. [CR#8] was diagnose with the following, unspecified dementia, unspecified osteoarthritis, hypertension, benign prostatic, insomnia, constipation, cachexia, overactive bladder, major depression, and hallucination. The next of kin [CR#8's family member] [ethnicity, gender, date of birth ], was notified of the death and was also advised that [CR#8's] body`s will be transported to the .Medical Examiner`s. Body car arrived on location on [DATE] at approximately 06:39 a.m. hours to transport the body to the .County Medical Examiner`s Office .Medical examiner ., provided me with their case number [case number] and took custody of [CR#8`s] body. The body bag zip tie sealed number was [number]. While on scene, audio and video was recorded on my Utility body camera and in car camera in unit 2522. Record review of 911 call made by LVN E he stated the address to the facility and that they find a patient by the bedside it looks like he has fallen from the bed he is unresponsive. He is in [room number, side of room letter]. He is not breathing. He is [AGE] years old, he is not breathing I checked. Record review of 29 photographs taken on [DATE] of CR#8 and CR#8's room by First Responders revealed a large amount of blood on the floor and bed wheel of the (resident's) roommate. The blood was both smeared and puddled. CR#8 was observed laying at the end of his own bed with his feet towards the door. His arms were resting on his chest. HE was wearing socks and a gown. A puddle of blood was on the floor by his head. CR#8's eyes were open, mouth was closed. CR#8 was observed with a wound (appeared to be a hole) to right side of his head above his eye. The bed was observed to have 3 stacked pillows at the head of the bed. The pictures revealed the head of CR#8's bed was lower than the foot of the bed. One photograph revealed the bed was in a low lying position, head of bed lower than the foot of bed. A separate photo of the bed revealed the bed was in a raised position, the head of bed was lower than the foot of bed. Call light was attached to CR#8's) and roommates bed. Observation revealed there was a small amount of blood on the roommates call light cord. There was no blood visible on CR#8's bed. Record review of National Library of Medicine, Methods of Estimation of Time Since Death written by Rijen Shrestha; Tanuj Kanchan; Kewal [NAME] dated [DATE] reveaeld, Rigor mortis is the post-mortem stiffening of muscles caused by the depletion of adenosine triphosphate (ATP) from the muscles, which is necessary for the breakdown of actin-myosin filaments in the muscle fibers. Actin and myosin are components of the muscle fiber and form a bond during contraction. The cessation of oxygen supply causes the stoppage of aerobic respiration in the cells and leads to a lack of ATP production. Rigor mortis starts immediately after death and is usually seen in a sequence known as the march of rigor and Nysten's Law. While rigor mortis develops simultaneously in all muscle tissue in the body, voluntary and involuntary, the size of the muscle determines the perceptibility of changes by the examiner. Smaller muscles over the face - around the eyes, around the mouth, etc. are the muscles where rigor mortis first appears, followed by rigor mortis of the muscles in the hands and upper limbs, and finally appears in the large muscles of the lower limbs. Rigor mortis appears approximately 2 hours after death in the muscles of the face, progresses to the limbs over the next few hours, completing between 6 to 8 hours after death.[10] Rigor mortis then stays for another 12 hours (till 24 hours after death) and then disappears. In a telephone interview on [DATE] at 1:25 p.m. with CNA C she stated she worked the night shift in the Memory Care Unit from 10pm-6am and had been working on the unit for a year. CNA C said when she arrived to work on [DATE] at 10:00pm she made rounds on the residents and that CR#8 was sleeping in bed with the bed in low position with no concerns identified. She said she made rounds on the residents every 2 hours going in the resident's room making sure they were breathing and doing okay. CNA C said she made rounds again at 12:00am and 2:00am with CR#8 continuing to rest quietly in bed with bed in low position and bed had not been moved. She said when she went to check on CR#8 again at 4:00a.m., she found CR#8 on the floor in his room with his head somewhat under his roommate's bed and thought resident was resting on his left side but was not certain but resident (CR#8) was not responding when she started calling his name. CNA C said resident bed was still in the low position and the bed had not been moved. She said she did not see any blood at that time and ran out of the room to get the nurse. CNA C said when the nurse got to the room and turned resident on his back, she could see a lot of blood coming from his head and was not sure which side it was coming from. CNA C said LVN E went and called 911 while she stayed with CR#8 and after LVN E called 911, he came back and began CPR on CR#8. She said CR#8 could walk and dress himself always rearranging stuff in his room such as his table. CNA C said CR#8 did have the behavior of liking to play with the bed remote a lot raising the bed in the highest position or raising the head or foot of bed putting in different positions. CNA C said CR#8 did not like his roommate always saying get him out of here, but never witnessed him and the roommate getting in any physical altercations. CNA C said she had heard that on the day shift they may have had words at one time but that was here say. She said CR#8's roommate could walk but at the time of the incident, CR#8's roommate slept through the whole incident. In an interview on [DATE] at 11 a.m. with LVN F she stated she came in on [DATE] and walked in on the situation with CR#8 and allowed LVN E and EMS to take care of his passing. LVN F stated CR#8 passed on the night shift and when she walked in CR#8 was laying with his head toward his roommate's bed in the middle aisle between the bed and the chest of drawers. She stated the police officer was standing here and there was a lot of chaos on the floor and she was late due to traffic. LVN F stated the officer asked her if she knew anything. She stated when she came into CR#8's room, the bed was to the floor and the resident was laying on the floor. In an interview on [DATE] at 10:37 a.m. with the DON she stated she spoke with LVN E when he called her and said CNA C on night shift was making rounds and went to assess CR#8 she noticed CR#8 was unresponsive. The DON stated LVN E said he started CPR, called 911 and 911 worked on CR#8 and 911 pronounced CR#8 deceased . The DON stated CR#8 would try to walk but use the wheelchair sometime. In an interview on [DATE] on 11:29 a.m. with CNA E she stated she assisted CR#8 with showers and he was sometimes confused. She stated CR#8 would say things that were not true and he was always on the wheelchair. She stated sometimes CR#8 would just lay on the bed and on the day of his shower, she gave CR#8 limited assistance to transfer to the wheelchair and take him to the shower. CNA E stated sometimes CR#8 tried to stand up from the wheelchair and she assisted him to sit. In an interview on [DATE] at 10:49 a.m. with CNA C she stated she found CR#8 and she let the LVN E know. CNA C stated she called CR#8's name and he was laying on his side on the floor halfway by his roommate's bed. CNA C stated she did not touch CR#8. She stated there was blood when the LVN E moved CR#8. She stated there was no fall mat and the bed was at the lowest level. She stated she saw CR#8 at 10 p.m., 12 a.m., 2 a.m. and 4 a.m. She stated she saw CR#8 at 2 a.m. sleeping, and she did not have to change him. CNA C stated she called LVN E and he came into the room and called CR#8's name. She stated LVN E touched CR#8 and moved him and that is when they saw the blood on CR#8's head. She stated she did not remember if LVN E stated CR#8 was cold or warm and LVN E touched CR#8's chest. CNA C stated LVN E called 911 with crash cart (carries instruments for CPR) and started performing CPR. She stated LVN E did chest compressions and the [NAME] bag (used to deliver positive pressure ventilation for respiratory support in CPR) and the CNA D came and CNA C let 911 in. CNA C stated she did not go back in the room. CNA C stated she could not explain the CPR process LVN E carried out. CNA C stated CR#8's roommate was in the room in bed and she did not pay attention to him when she found CR#8. CNA C stated at 2 a.m. CR#8's roommate was sleeping. She stated she saw LVN E with the [NAME] bag but not what he was doing with it because she ran to the front. She stated she saw chest compressions. In an interview and Record review on [DATE] at 11:54 a.m. with the DON of CR#8's clinical records revealed CNA C did rounds at 1:11 a.m. on [DATE] and CNA C went to do her other rounds at 4 a.m. and that is when CNA C found the resident (CR#8). The DON stated CNA C said 911 found CR#8 and worked on him for a good while. The DON stated LVN E called her when 911 was at the facility and said what happened. She stated LVN E called her back with bad news 35 minutes later and said 911 said they could not stabilize CR#8. The DON stated she could not answer whether CR#8 should be cold or warm when a resident died as far as time. The DON stated she coul[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to ensure residents received treatment and care in accordance with professional standards of practice for Seven (7) residents (CR #1, CR#2, Residents #3, #4, #5, #6, and #7) of seven (7) residents reviewed for quality of care. 1. The facility failed to provide weekly skin assessment for CR #1 who was non- ambulatory and bed bound. 2. The facility failed to identify onset of CR #1's three large unstageable pressure ulcer and initiate intervention. 3. Facility failed to follow physician orders and treat pressure wound for CR #1, #2 and Residents #3, #4, #5, #6, #7, for multiple days. 4. The facility failed to provide education to their nurses regarding wound care and documentation, and nurses responsibility to do wound care when the treatment nurse was not in the facility. 5. Facility failed to obtain physician order before applying wound care treatment (Santyl and betadine) on CR #2 An Immediate Jeopardy (IJ) was identified on 07/28/2023. The IJ template was provided to the facility on [DATE] at 5:25pm. While the IJ was removed on 08/05/2023 at 3:50pm, the facility remained out of compliance at a severity of isolated actual harm that is not immediate jeopardy with a scope of pattern due to failure occurred to multiple residents over multiple days and the facility's need to evaluate the effectiveness of the corrective systems. These deficiencies could expose residents to low quality of care, wound deterioration, worsening of condition, infection, sepsis, and hospitalization. Findings included: CR #1 Review of face sheet revealed CR #1 was [AGE] years old female admitted to the facility on [DATE]. Her diagnoses were malignant neoplasm of rectosigmoid junction, fistula of vagina to large intestine, chronic pain, UTI (Urinary Tract Infection), fracture of lumbosacral spine and pelvis, and Hypertension, muscle wasting, lack of coordination, anxiety disorder, peripheral autonomic neuropathy, and encephalopathy. Review of skin assessment during admission on [DATE] reveal CR #1 only had redness under her bilateral breast. Record review of facility weekly skin assessment for the month of February and March 2023 revealed there were no skin assessments done for CR #1 in the months of February and March 2023. Further review revealed there were no weekly skin assessment for CR#1 in the month of April 2023, until April 24th when three wounds were first identified. The skin assessment on 04/24/2023 revealed the following: - Wound #1 was acquired in the facility, first observation, size was (length x width x height) 7.5cm x 5.3cm x 0.0cm. Wound #1 was identified as pressure wound at the right buttock, necrotic tissue present, dry, thick adherent devitalized necrotic tissue 70%, moderate drainage, no odor, peri-wound tissue was described to have redness and wound edges well defined. Stage of the wound was not documented, - Wound #2 acquired in the facility, first observation, size was (length x width x height) 5.5cm x 2.5cm x 0.0cm. wound #2 was identified as pressure wound at the left buttock, necrotic tissue present, dry, thick adherent devitalized necrotic tissue 70%, moderate drainage and no odor, peri-wound tissue was described having redness and wound edges well defined. Stage of the wound was not documented, - Wound #3 acquired in the facility, first observation, size was (length x width x height) 9.0cm x 0.8cm x 0.0cm. wound #3 was identified as pressure wound at the right ischium, necrotic tissue present, dry, thick adherent devitalized necrotic tissue 70%, no drainage and odor, peri-wound tissue was described as normal and wound edges well defined. Stage of the wound was not documented, Record review of progress note revealed CR #1 refused to be weighed on 02/06/2023. CR #1refused vital signs and medications multiple times, she also refused feeding and diaper change in the month of March and April 2023. However, there was no documentation of CR#1 or family member refusing skin assessment prior to 04/24/2023. Review of MDS dated [DATE] revealed CR #1 was identified as a resident who was at risk for pressure ulcers/injuries. Review of MDS dated [DATE] section M0300 revealed CR #1 had pressure ulcers. Review of care plan with close date 07/26/2023 revealed CR #1 had pressure wound. stage 4 buttock and DTI (Deep Tissue Injury) to the right ischium. Review of physician order dated 04/24/2023 revealed the following: - Left Buttocks Unstageable: Cleanse with normal saline, pat dry, apply Santyl + Calcium Alginate cover with gauze + island dressing daily. - Right buttocks Unstageable: Cleanse with normal saline, pat dry, apply Santyl + Calcium Alginate cover with gauze + island dressing daily. - Right Ischium Unstageable DTI: Cleanse with normal saline, pat dry, apply house barrier cream daily. Review of Wound Care Doctor's initial evaluation note dated 04/24/2023 revealed: - Site 1 was documented as unstageable (due to necrosis) of the right buttock full thickness. Wound size (L x W x D): 7.5cm x 5.3 x not measurable. - Site 2 was documented as unstageable (due to necrosis) of the left buttock full thickness. Wound size (L x W x D): 5.5cm x 2.5 x not measurable. - Site 3 was documented as unstageable DTI of the right buttock partial thickness. Wound size (L x W x D): 9cm x 0.8 x not measurable. Review of Treatment Administration Record for the month of April and May 2023 revealed there were no documentation of wound care provided to CR#1 on the following dates: 4/25/23, 4/26/23, 4/30/23, 5/5/23, 5/7/23, 5/14/23. Review of Wound Care Doctor's note dated 05/12/2023 revealed CR #1's wound Site 1 Stage 4 pressure wound of the right buttock full thickness became coalesced (merged) with Left buttock wound to form one large wound with new wound size. Wound Size (L x W x D): 12 x 18.5 x 1.5 cm; Surface Area: 222.00 cm²; Exudate: Light Serous; Thick adherent devitalized necrotic tissue: 60 % Granulation tissue: 30 %; Other viable tissues: 10 % (Dermis, Bone, Fascia) Wound progress: Deteriorated On 7/26/23 at 11:10am in an interview with the Wound Care Nurse she sated the assigned nurse or whoever was taking care of CR #1 identified that CR #1 had 3 pressure sore areas. She stated the wounds were unstageable to right buttock measuring 7.5cm x 3.5cm, unstageable left buttock and it was 5.5cm x 2.5cm and the third site was an unstageable DTI on the right buttocks 9.0cm x 0.8cm. She stated the Wound Care Doctor saw CR #1 on 4/24/2023. She stated the wounds were debrided by the Wound Care Doctor. The Wound Care Nurse stated before CR #1 passed away at the facility due to her end-of-life condition. She stated the wounds merged and became one as CR #1's condition worsened. She also stated she always did wound care for all residents when she (Wound Care Nurse) came to the building. She said she always had a lot to do, but sometimes she got someone to help her so she could catch up with her documentations. She stated she might have missed to document for some days, but she was not sure. On 7/27/2023 at 2:48pm during interview with CNA F, she stated CR #1 was in room [ROOM NUMBER], she stated she did not take care of CR #1 often because they rotated shift and assignment, she stated sometimes she might not have CR #1 assigned to her. CNA F stated the last time she took care of CR #1 had been a while and she did not see any skin breakdown on CR #1. CNA F stated that CR #1's sister was not allowing them to do many things for CR #1. She stated the sister would say CR #1 was hurting and the sister would change CR #1 by herself most of the time. CNA F said sometimes the sister would call for help to change CR #1. CNA F stated whenever she changed resident or reposition resident, she always assessed residents' skin. On 7/27/2023 at 3:01pm in an interview with CNA G, she stated she never had the opportunity to take care of CR #1 because she was always assigned to the other side of the hall. CNA G stated she assessed residents every time she saw them or when she changed /clean them, and she would tell the nurse if she saw anything like new wound or changes to existing wounds. On 07/27/2023 at 3:23pm in an interview with LVN A, she stated she knew CR #1, she stated at the time CR #1 was in the facility the sister to CR #1 was always at the bedside and the sister she was always preventing the staffs from taking care of the resident. LVN A stated CR #1's sister would tell them not to disturb CR #1 because the sister stated CR#1 was in a lot of pain. She stated CR #1 had a lot going on with her, LVN A said CR #1 had cancer and hospice was recommended for CR#1, but CR #1 was not able to get on hospice because of CR#1's insurance. On 07/28/2023 at 11:54am in an interview with LVN B she said she worked night shift, she said by the time she arrived on shift, the wound care nurse must have done the dressing. She said if the dressing comes off, she would re-do the dressing. She said most of the time resident's sister was at bed side and refusing care for CR #1. She stated they did weekly skin assessment on all residents; however, the sister was not allowing care for CR #1. On 08/06/2023 at 2:47pm in an interview with CR#1's family member she stated she came to the facility every day, and she would text what was happening every day to other family members. CR#1's family member stated CR#1 would call her crying saying she was burning because they would not change her brief. She stated when she got there, CR#1 was still dirty many times. She stated the staff would come in and say they were going to get someone to help them, and they would not come back. She stated on 4/24/23 that was the first time she saw the wound nurse. She stated she asked the Wound Care Nurse for an air mattress, and maybe 2 or 3 days later they still had not provided the air mattress. She stated CR#1 did not get the air mattress the day the Wound Care Nurse found the wound. CR#1's family member stated the next day on 4/25/23, they brought the air mattress to CR#1's room and it sat on the floor for 2 days not aired up. CR#1's family member stated the Wound Care Nurse took pictures, measured the wounds, and put gauze on it. CR #2 Review of face sheet revealed CR #2 was [AGE] years old male admitted to the facility on [DATE] with diagnoses of pressure ulcers, osteomyelitis of sacral pressure ulcer, multiple fractures ribs, end stage renal disease, type 2 diabetes mellitus, functional quadriplegia, metabolic encephalopathy, acquired absence of the left leg below the knee, and peripheral vascular disease. Review of admission assessment dated [DATE] revealed CR #2 was admitted with multiple wounds identified as pressure injury at the sacrum and right heel, wound at the left stump, scrotum, right lower extremity, groin, and redness at the chest. Review of CR #2's baseline care plan dated 07/21/2023 reveal there was no intervention initiated for wounds. Review of physician orders dated 07/23/2023 revealed CR #2 had the following pressure wound care orders: - Right Ischium Unstageable: Cleanse with normal saline, pat dry, apply Santyl + Vashe moist gauze sponge cover with gauze island dressing daily. - Sacrum Unstageable: Cleanse with normal saline, pat dry, apply Santyl + Dakins moist gauze sponge cover with gauze island dressing daily. - Bilateral Buttocks maceration: Cleanse with normal saline, pat dry apply maceration cover with gauze + island dressing daily. Review of Treatment Administration Record dated 07/23/2023 revealed a documentation of wound care for CR#2. Further review revealed there were no other documentation of wound care for CR#2 for 7/21/2023, 7/22/2023 at the time of his admission to the facility on [DATE]. On 07/26/2023 at 11:19am during interview with the Wound Care Nurse, she stated she assessed CR #2 and performed wound care for CR #2 on Friday 07/21/2023. Wound Care Nurse stated CR #2 was admitted on Thursday 07/20/2023, but Friday 07/21/2023 was the first day she saw CR #2, and at that time she was trying to reach out to the wound care company to give them a doctor who would cover for their Wound Care Doctor, because the Wound Care Doctor was on vacation. She stated but she did not hear back from the company on that Friday. She stated she also called the PCP (Primary Care Provider) for CR #2 but she could not get hold of anyone. The Wound Care Nurse said she did not want to leave the wound undone, and she did not want to leave the patient without dressing the wound. She said she took care of the wound, she cleaned the wound at the sacrum and applied Santyl to it because it had a slough, she stated the wound at the knee had necrotic tissue and she applied betadine to it. She stated CR#2's bottom had maceration and she put zinc oxide and cover all the wounds. The Wound Care Nurse stated she applied the same care, the same thing in the wound order. Surveyor asked how she could have used same wound supply in the order, because there was no wound care order given at that time. The wound Care Nurse responded that, based on her experience as a nurse, and based on the preference of the Wound Care Doctor, she knew that the Wound Care Doctor would use exactly what she used for the patient. She said she did not come to work on Saturday, but on Sunday when she came to work, she was able to reach out to the patient's primary care doctors Nurse Practitioner who gave order for the wound care. She stated that she (Wound Care Nurse) was the one who suggested the specifics of the wound care order for the nurse practitioner of which the nurse practitioner agreed. She said, I reached out to her, described everything and I said this will be a good order for the sacrum, and if you approve it, if you don't, you can give me something different. She stated the Nurse Practitioner agreed with the order. She stated she used Santyl for the sacrum and vashe moist, said she used Santyl because the sacrum wound had 90% slough. She said the stump and heel, had necrotic tissue and she used betadine on it. She stated the wound at the ischium had hard slough and she put Santyl on it with calcium alginate and covered it up. The Wound Care Nurse said CR #2 had maceration all around his bottom all the way to his anus, the Wound Care Nurse stated she put zinc oxide on the wound and covered them up. The Wound Care Nurse stated on the Friday she used those wound care supplies based on her experience with the Wound Care Doctor. She stated some other Doctors might use Medi-honey, but the wound Care Doctor never used Medi-honey, she said the Wound Care Doctor would use Santyl instead of Medi-Honey, and that was why she used it. She stated CR #2 was sent to hospital on Monday 07/24/2023 upon request by the family. On 07/26/2023 at 2:02pm, in an interview with LVN G. She stated she remembered the patient was brought in at her closing time and she only received the patient into the room and did a quick note on the resident. She stated the oncoming night nurse was the one who did the admission assessment on the patient. She stated she did not know anything regarding CR #2. On 07/26/2023 at 4:01pm in an interview with the Wound Care Nurse. She stated she was wrong by using the treatment (Santyl, betadine, Calcium alginate, and Zinc oxide) on CR #2's wound without Doctor's order. She stated she could have done the basic treatment of cleaning the wound with normal saline and covering it up. She stated she felt passion for the resident (CR #2) because the resident had multiple wounds and she did not want to leave his wound uncared for. On 07/26/2023 at 4:29pm, in an interview with LVN K, she said she started working at the facility about three weeks ago. She said she remembered CR #2 had wound in multiple locations including sacrum, because she saw it during the admission assessment. She stated she did not do anything to the wounds because the dressing was intact and did not require dressing change or reinforcement. She stated all the wounds were wrapped. She stated, honestly I did not see any order for wound care and it did not come to her mind to call the physician for wound care order. She stated she probably did not remember to call because she did not need to do the wound care that night. She said maybe if she had needed to do the wound care, she would have remembered to call for the order. She stated if there was no wound order and patient would not get timely wound care, and it might not be safe for the patient because of risk for infection. Resident #3 Review of face sheet revealed Resident #3 was a 54- year- old male initially admitted to the facility on [DATE]. Current admission date was 6/12/2023 with diagnoses of cerebral infarction, traumatic hemorrhage of cerebrum, quadriplegia, contracture, hypokalemia, Atherosclerotic heart disease, metabolic encephalopathy. Review of care plan dated 08/07/2023 revealed Resident #3 has multiple pressure wounds. Sites of the wounds were identified at sacrum, right plantar foot, left ischium, right Ischium, right calf, right and left posterior shoulder, and right lateral ankle. Review of MDS dated [DATE] section M0300 revealed Resident #3 has multiple pressure wounds. Review of physician order revealed the following orders: - Sacrum Stage 4: Cleanse with normal saline, pat dry, apply Vashe moist gauze sponge cover with gauze + island dressing daily. Order Date: 5/19/2023. - Left Ischium Stage 4: Cleanse with normal saline, pat dry, apply Vashe moist gauze sponge cover with gauze + island dressing daily. Order date: On 5/15/2023 - Right Ischium Stage 4: Cleanse with normal saline, pat dry, apply Vashe moist gauze sponge cover with gauze + island dressing daily. Order Date: 5/15/2023 - Left Posterior Shoulder Stage 4: Cleanse with normal saline, pat dry, apply Vashe moist gauze sponge cover with gauze + island dressing daily. Order date: 5/19/2023 - Right Posterior Shoulder Stage 4: Cleanse with normal saline, pat dry, apply Vashe moist gauze sponge cover with gauze + island dressing daily. Order Date: 5/15/2023. - Right Plantar Foot Stage 4: Cleanse with normal saline, pat dry, apply Collagen Powder + Calcium Alginate cover with gauze + island dressing daily. Order Date: 05/15/2023 - Right Calf Stage 4: Cleanse with normal saline, pat dry, apply Collagen Powder + Calcium Alginate cover with gauze + island dressing daily. Order Date: 5/15/2023 - Right Lateral Ankle Stage 3: Cleanse with normal saline, pat dry apply Calcium Alginate cover with gauze + Island dressing daily. Order Date: 7/14/2023. Review of Treatment Administration Record (TAR) for the months of April through July 2023 revealed there were no wound care documented in the TAR for Resident #3 on the following days: 7/2/23, 7/16/23, 7/22/23, 6/17/23, 6/18/23, 6/19/23, 6/25/23, 6/30/23 5/27/23, 5/29/23, 5/31/23, 4/15/23, 4/16/23, and 4/23/23. Review of progress notes revealed no documentation of wound care provided to Resident #3 on these dates: 7/2/23, 7/16/23, 7/22/23, 6/17/23, 6/18/23, 6/19/23, 6/25/23, 6/30/23 5/27/23, 5/29/23, 5/31/23, 4/15/23, 4/16/23, and 4/23/23. Review of Wound Care Doctor's note dated 07/20/2023 revealed the following on Resident #3's wound: - Stage 4 pressure wound sacrum full thickness Wound Size (L x W x D): 6 x 5.5 x 0.5 cm; Surface Area: 33.00 cm² Exudate: Moderate Serous; Slough: 20 %; Granulation tissue: 80 % Wound progress: Not Improved - Stage 4 pressure wound of the right, plantar foot full thickness. Wound Size (L x W x D): 1 x 0.5 x 0.3 cm; Surface Area: 0.50 cm²; Exudate: Moderate Serous, Slough: 20 %; Granulation tissue: 80 % Wound progress: Not Improved - Stage 4 pressure wound of the right ischium full thickness Wound Size (L x W x D): 6.5 x 7 x 1.5 cm; Surface Area: 45.50 cm² Exudate: Moderate Serous; Slough: 20 %; Granulation tissue: 80 % Wound progress: Not Improved - Stage 4 pressure wound of the left, posterior shoulder full thickness Wound Size (L x W x D): 7 x 8 x 0.5 cm; Surface Area: 56.00 cm² Exudate: Moderate Serous; Slough: 20 %; Granulation tissue: 80 % Wound progress: Not Improved - Stage 3 pressure wound of the right, lateral ankle full thickness Wound Size (L x W x D): 3 x 2 x 0.2 cm; Surface Area: 6.00 cm² Exudate: Moderate Serous; Granulation tissue: 100 % Wound progress: Not Improved On 07/25/2023 at 1:23pm, surveyor observed and interviewed Resident #3, he said he got wound care daily most of the time, and he got wound care yesterday (07/24/2023) by the treatment nurse, but he stated he had not gotten wound care today (07/25/2023), he said he probably would not get any treatment today because he thought the Wound Care Nurse was not in the building. He said whenever he did not get wound care, he would know that the Wound Care Nurse was not in the building that day. When asked about the specific days in the past that he did not get wound care as a result of the wound care nurse not in the building, Resident #3 could not recall specifically. However, he stated he knew if he had not seen the wound care nurse by this time of the day, he would know that the wound care nurse was not in the building. Resident #4 Review of face sheet revealed Resident #4 was a [AGE] year old male who was initially admitted to the facility on [DATE]. His current admission was on 07/16/2023. His diagnoses included cerebral infarction, Hemiplegia and hemiparesis, heart failure, dysphagia, acute respiratory failure, and pulmonary hypertension. Review of care plan dated 07/17/2023 revealed Resident #4 had multiple pressure wound identified as Left heel, Right heel, left ankle, and left lateral foot. Review of MDS dated [DATE] section M0300 revealed Resident #4 had pressure wounds. Section C revealed resident had significant cognitive impairment. Review of physician order revealed the following: - Sacrum Stage 4: Cleanse with normal saline, pat dry, pack with Dakins moist gauze roll(kerlix) cover with gauze + island dressing daily. Order Date: 05/30/2023. - Left Heel DTI: Cleanse with normal saline, pat dry, apply Skin Prep Daily. Order Date: 4/01/2023 - Leg Medial leg Stage 3: Cleanse with normal saline, pat dry, apply Calcium Alginate cover with gauze + island dressing daily. Order Date: 4/19/2023. Review of Treatment Administration Record revealed there were no documentation of wound care provided for Resident #4 on the following days: 7/22/23, 7/24/23, 6/3/23, 6/4/23, 5/4/23, 5/5/23, 5/10/23, 5/14/23, and 4/16/23. Review of progress note revealed there were no documentation of wound care provided to Resident #4 on the following dates: 7/22/23, 7/24/23, 6/3/23, 6/4/23, 5/4/23, 5/5/23, 5/10/23, 5/14/23, and 4/16/23. Resident #5 Review of face sheet revealed Resident #5 was a [AGE] years old male who was initially admitted to the facility on [DATE] with the diagnoses of intellectual disabilities, Acute respiratory failure, pneumonia, constipation, and developmental disorders of speech. Review of care plan dated 06/29/2023 revealed Resident #5 has pressure wounds and at risk for further skin break down, infection, worsening of existing pressure wounds, and developing new pressure wound formation. Review of MDS dated [DATE] section M0300 revealed Resident #5 has pressure wounds. Section C revealed resident had significant cognitive impairment. Review of physician order dated 05/12/2023 revealed the following: - Left Hip Stage: Cleanse with normal Saline, pat dry apply Collagen Powder + Vashe moist gauze sponge sterile cover with gauze + island dressing daily. - Right Hip Stage: Cleanse with normal Saline, pat dry apply Collagen Powder + Vashe moist gauze sponge sterile cover with gauze + island dressing daily. Review of TAR revealed there were no documentation of wound care performed for Resident #5 on the following days: 7/16/23, 7/22/23, 6/3/23, 6/16/23, 6/17/23, 6/18/23, 6/25/23, 5/7/23, 5/13/23, 5/17/23, 5/29/23, 4/16/23, 4/17/23. Review of progress note revealed there were no wound care provided for Resident #5 on 7/16/23, 7/22/23, 6/3/23, 6/16/23, 6/17/23, 6/18/23, 6/25/23, 5/7/23, 5/13/23, 5/17/23, 5/29/23, 4/16/23, and 4/17/23. Resident #6 Review of face sheet revealed Resident #6 was an [AGE] years old female admitted to the facility on [DATE] with diagnosis of multiple Sclerosis, Chronic kidney disease, cataract, essential hypertension. Review of care plan dated revealed Resident #6 had pressure wound Review of MDS dated [DATE] revealed Resident #6 had pressure wound. Review of Treatment Administration record revealed there was no documentation of wound care for Resident #6 on the following days: 7/2/23, 7/16/23, 7/22/23, 6/16/23, 6/17/23, 6/18/23, 6/25/23. Review of Physician order dated 06/06/2023 revealed Sacrum Unstageable: cleanse with normal saline, pat dry, apply Santyl + Calcium Alginate cover with gauze + island dressing daily. Review of progress note revealed there were no wound care provided for Resident #6 on 7/2/23, 7/16/23, 7/22/23, 6/16/23, 6/17/23, 6/18/23, and 6/25/23. Resident #7 Review of face sheet revealed Resident #7 was a [AGE] year old female who was admitted to the facility on [DATE]. Her diagnoses included Hemiplegia and Hemiparesis, cerebral infarction, pressure ulcers, metabolic encephalopathy, neuro muscular dysfunction of bladder, immunodeficiency, and essential primary hypertension. Review of MDS dated [DATE] revealed Resident #7 had pressure wounds. Section C revealed resident had significant cognitive impairment. Review of care plan dated 06/01/2023 revealed Resident #7 had pressure wounds Review of physician order dated 05/19/2023 revealed order Sacrum Stage 4: Cleanse with normal saline, pat dry, apply Collagen Powder + Calcium Alginate cover with gauze + island dressing daily. Review of Treatment Administration Record revealed there were no documentation of wound care for Resident #7 on the following dates: 7/22/23, 6/17/23, 6/18/23, 6/19/23, 5/5/23, 5/7/23, 5/14/23, 5/18/23. On 07/25/2023 at 12:08pm in an interview with Charge Nurse A on the hallway at 300 hall, Charge Nurse A was observed standing by the medication cart. She stated that the wound Care Nurse was at the other side of the building, in the 400 hall. On 07/25/2023 at 12:12 pm, in an interview with LVN G in the 400 hall, she said the wound care nurse had not been to that side of the building. She said the Wound Care Nurse should be in the 300 hall because the Wound Care Nurse had never been to the 400 hall that day and she had not seen the Wound Care Nurse today (7/25/2023). Surveyor asked who would be responsible for wound care if the Wound Care Nurse was not in the building. LVN G said she thought the Wound Care Nurse was at the other side in the 300 hall. She said she was new and did not know the practice in the facility when the Wound Care Nurse was not in the building, she said she did not know what the process was, and she did not know who was responsible to do the wound care if the wound care nurse was not in the building. LVN G said as far as she knew, the facility always has someone to do the wound every day. She said since the time she started working at the facility she never did wound care. Surveyor asked what she would do if she had a new admission with wound when the treatment nurse was not in the building. She said she was new in the facility, she said she just started working about three weeks ago and she had never had many resident admissions and she never had to deal with a wound on admission either. LVN G said at the time she was hired about three weeks ago, she was made to understand that the facility would always have somebody to take care of wounds, and that she would not have to worry about doing wound care. She also said she was not trained or receive in-service yet about wound care at the facility. On 07/25/2023 at 12:40pm in an interview with Charge Nurse A, surveyor asked about the wound Care Nurse. When the Surveyor told her that they wound care nurse was not at the other side of the building, she said well let me go and ask. Then she said she was not aware that the wound care nurse was not in the building today. She stated that if the Wound Care Nurse was not in the building, the nurses on the floor would be responsible to do the wound care. Surveyor asked how they (floor Nurses) would know when the wound care nurse was not in the building, then she said they (Unit Managers, DON) would tell them anytime the treatment nurse not in the building, she stated but today she had not heard if the treatment nurse was not in the building, and she said she had not seen the treatment nurse yes. She said, let me go and find out and she walked away. On 07/26/2023 at 2:07pm, in an interview with LVN G, she said yesterday (07/25/2023) the DON trained her in an in-service about the expectation that the nurses were responsible to perform wound care if the wound care nurse was not in the building. She stated prior to yesterday (7/25/2023) nobody had ever told her, but she said, I know it now from yesterday when the DON told me. On 07/26/2023 at 3:17pm in an interview with LVN J, she stated she was the nurse who took care of CR #2, Resident #5 and #6 on Saturday 07/22/2023, she said she started working at the facility around May 2023. She said she did not work at the facility very often, but she remembered taking care of CR #2 on Saturday 7/22/2023 but she did not remember if CR #2 had any wound. She stated she did not usually do wound care, she said only if wound dressing came off during diaper change, she would do the dressing. She said usually she did not deal with wound care, and she would not know if any resident had any wound unless she was told - she said if she admitted any resident, she would do skin assessment and that way she would see if the resident had any wound. She said if the CNAs noticed anything like new skin breakdown, they would notify her. She said she worked night shift, and at night she generally did not do wound assessment. She stated she was not aware if wound care was performed for CR #2 or not. She stated her understanding was that the wound care nurse during the day would always take care of all residents' wounds. She said they[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (CR#1) of 9 residents reviewed for accidents, hazards, and supervision. -The facility failed to safely transfer CR #1 when the Wound Care Nurse used a Hoyer lift and left her in the air unattended for about 45 minutes until CR #1's family member alerted LVN A. -The facility failed to adequately supervise CR #1 who was cognitively impaired when the Wound Care Nurse positioned her on her side and left her unattended after wound care resulting in an unwitnessed fall. -The facility failed to thoroughly document 3-day neuro checks to monitor CR #1 after her fall. -The facility failed to adequately document and notify the physician of CR#1's fall. -The facility failed to complete an Incident Report and investigation on the fall. An Immediate Jeopardy (IJ) was identified on 07/28/23. The IJ template was provided to the facility on 7/28/23 at 5:25 p.m. While the IJ was removed on 08/5/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not an Immediate Jeopardy because all staff had not been trained on accidents and supervision, neglect, safe transfer, fall prevention, and adequate monitoring. These failures placed residents at risk for accidents and supervision, risk for falls, unsafe transfers, no safety interventions, improper use Hoyer lifts, no fall prevention measures causing pain, lower quality of life, falls with unknown harm and death. Findings included: CR #1 CR #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. She was diagnosed with malignant neoplasm of rectosigmoid junction (cancer between the sigmoid colon and rectum), fistula of vagina to large intestine (feces coming through the vagina), chronic pain syndrome, muscle weakness, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), anxiety disorder, idiopathic peripheral autonomic neuropathy, encephalopathy (damage to the peripheral nerves), hypertension, bacteremia (bacteria in the blood), fracture of fifth lumbar vertebra, and fracture of lumbosacral spine and pelvis. Record review of CR #1's Care Plan dated 2/22/23 revealed CR#1 has a diagnosis of cancer and was at risk of increased weakness, weight loss, pain, depression, tiredness, death as evidenced by, receiving anticoagulant therapy and was at risk for increased bleeding, bruising, etc., bowel and bladder incontinence and was at risk for skin breakdown as evidenced by cognitive impairment, ADL self-care deficits and was at risk for further decline in ADL functioning and injury as evidenced by disease process with interventions being provide extensive assistance of (#2 support persons) for bed mobility, toileting/incontinent care and transfers. CR#1 complained of increased pain and was at risk for further episodes of increased pain/discomfort and injury with interventions/tasks to give pain medication, treatments, relaxation modalities, provide pressure reducing and positioning devices as needed. CR#1 was at risk for falls and injuries with goal to be free from falls and injuries over the next 90 days dated/revised on 2/22/23, risk for pressure wounds with interventions/tasks to assist with incontinent care, perform weekly skin checks, provide pressure reducing device for bed and wheelchair . Record review of Resident #1's Quarterly MDS dated [DATE] revealed Cognitive Pattern BIMS Summary Score was 00 indicating severe impairment. CR#1's functional status revealed walk in room and corridor, locomotion on/off unit did not occur, bed mobility, dressing, personal hygiene was extensive assistance with 2- person assisting, transfer was activity occurred once or twice with 2-person assisting and bathing, and she was totally dependent for bathing with 2-person assist. Record review of CR#1's family members text message to CR#1's family member dated April 27, 2023, at 5:16 p.m. revealed, Painful [CR#1] was suspended by a lift to keep her off the bed while they put blow up mattress on her bed to help with bed sores. I was trying to hold her head up the whole time by bracing my leg up on the metal part of the bed and stacking pillows on to my knee to it touched [CR#1's] head. Awful but not torture. Her legs were dangling and that was hurting so once the Nurse left, I stacked pillows until they reached under her leg. The Nurse came back and argued with me that the bed wouldn't fill with air with the pillows, and I said the man said the bed would inflate regardless and she said, he didn't say that and then said, well if you want it (air mattress) to never inflate and her stay dangling forever and walked out. The mattress filled with air just fine and I'm so thankful I was here. They would have left her neck/head with no support just dangling like, her legs, if I hadn't had been here. I do thank God for that. I can't even begin to understand what she would have gone through. I talked to the Dr. today and he did up one of her pain patch meds. I told him she's still not on Hospice because she is Medicaid pending but with Palliative Care, we're trying to keep her comfortable and she isn't comfortable. So at least a little more pain meds but it still isn't enough. Record review of CR#1 family member text message to CR#1's family member dated 4/27/23 at 7:06 p.m. revealed, I forgot to tell you they forgot [CR#1] and left her dangling .I was told the mattress would take 20 min to fill so after 30 min the mattress felt full and read normal. I waited another 15 minutes then headed to the Nurse Station. Finally, the Nurse came and lowered the sling on to the bed. She could have been there for hours. Record review of CR#1's progress notes dated 4/27/23 revealed no facility notes (documentation) regarding CR#1 being left dangling on a Hoyer lift without staff present. Record review of LVN A's text message to NP dated 5/10/23 at 1:33 p.m. revealed, Good morning just letting you know that [CR#1] fell from her bed, no injuries vital signs ok, she stated that she was trying to sit on the wheelchair and NP response revealed Ok thanks. Record review of CR#1 progress notes dated 5/10/23 at 1:34 p.m. by LVN A revealed, Resident fell from the bed, no injuries, vital sign ok, RP, NP all notified, Neuro check in progress. Record review of CR#1's Neurological Evaluation Flow Sheet dated 5/10/23 revealed: Eyes Open to: Spontaneously, to Speech, To Pain, None was not documented on 5/10/23 at 1:30 p.m., 1:45 p.m., 2 p.m., 2:15 p.m., 2:30 p.m., 2:45 p.m., 3 p.m. 4 p.m., 5 p.m., 6 p.m. 5/10/23 documented once during the shift 6 p.m. to 6 a.m. level 2 pain, 5/11/23 was not documented for pain at all. 5/12/23 at 2 p.m. and 8 p.m. documented 4 for spontaneously. 5/13/23 at 6 (unknown a.m. or p.m.) documented 4 for spontaneously Record review of CR #1's SBAR (Change of Condition) dated 5/10/23 at 4:17 p.m. revealed, Resident fell out of bed, no injuries, position lying left arm .Resident fell out of bed with no injuries noted, vitals sign completed and correct, neuro check in progress .Recommendation monitor vital signs, x-ray/ultrasound/ekg, other . Record review of CR#1's family member text message to CR#1's family member dated 5/10/23 at 9:48 p.m. revealed, Poor [CR#1] fell off her bed today between 12 and 1 PM, right before I got there .The Nurse said they checked her out and she seemed to be ok. After talking to the Nurse, a while to try to see how it could have happened, I found out that the Wound Nurse had just changed her bandage and I'm sure left her on her stomach because she needed the aide to change the diaper, but they all know if can take up to hours for an Aide to show up. Also, she left the bed as high as it goes up and she claims the aide was coming. Anyway, I told the Nurse that it hurts [CR#1] to lay on her stomach and being close to the edge of the bed managed to try to turn over and went off the bed. I told the Nurse to tell the Wound Nurse not to leave [CR#1] close to the edge or on her stomach. [CR#1] seemed to be really scared of anyone coming up to her except me .She (CR#1) said my head hurts then my body hurts, etc. I told her I know she fell on the floor because the stupid Nurse and it won't happen again. She kept saying help me help me off and on for the whole time I was there .I felt so bad for her. After I got there, she said don't leave .I checked her head while I was lightly rubbing her face and head and didn't feel any lumps. Praying she didn't break anything. The Nurse said they would check her out every day for 3 days. Record review of CR#1's Physician note dated 5/18/23 revealed, Uncontrolled pain, Patient currently on palliative care services, responsible party does not want any aggressive care, patient has a history of probable metastatic cancer, is on multiple pain medications, patient reported to be in uncontrolled pain at times as per her responsible party. Patient is currently not able to swallow medications. Hospice services not available due to insurance issues. Review of systems general: unreliable due to patients lethargy .bedbound, ulcers on bilateral buttocks .Uncontrolled, patient is currently on palliative services, patient appropriate for hospice services, hospice services not available due to insurance issues., patient currently on scheduled fentanyl 50 mcg patch per hour, methadone 10 mg p.o. daily, also Norco scheduled, pain reported to be uncontrolled, patient not able to take medications by mouth, have ordered sublingual morphine, 10 mg every 4 hours as needed for pain .Lethargy Patient has not been eating for several days, patient's responsible party does not want aggressive measures, continue with palliative care, goals of care palliative. Decline in condition expected due to patients' severe comorbidities. Continue with palliative care and symptoms control as much as possible. Pharmacy Orders: Morphine concentrate 100 mg/5ml (20 mg/ml) oral solution- Take ½ ml under tongue every four hours as needed for pain . In an interview on 7/26/23 at 11:30 a.m. with LVN A she stated the CNA came and called her on 5/10/23 at around 12 p.m. and she found CR #1 on the floor. LVN A stated she assessed CR #1, and she was fine, and they checked on her for 3 days. She stated she notified the NP and CR #1's family member. LVN A explained CNA A was going to take care of CR #1's roommate and she found CR #1 on the floor. Record review of CR#1's clinical records and interview with LVN A revealed CR #1 did not have any x-rays or labs completed after CR#1's fall on 5/10/23. In an interview on 7/26/23 at 12:14 p.m. the Wound Care Nurse stated the wound care doctor started taking care of CR #1 for pressure sores on 4/24/23 when he saw CR #1 for the first time. The Wound Care Nurse stated she stated working at the facility in March 2023. The Wound Care Nurse stated CR #1 passed away while at the facility on May 31, 2023. The Wound Care nurse stated when CR #1 got the wounds she would tell the staff to get the air mattress. She stated CR #1 got the air mattress on 4/25/23 after seeing the wounds. She stated by the time she got back to see CR #1 the air mattress was already on. The Wound Care Nurse stated CNA A had CR #1 most of the time and the nurse over her was LVN A. The Wound Care Nurse stated she went back the next day and CR #1 was already on it. Wound Care Nurse stated she did not recall the details of the day CR #1 got the air mattress because they had to use the Hoyer lift and put CR #1 up and put the mattress on and the CNA stayed with her. The Wound Care Nurse stated it took about 10 minutes and she told the CNA once it pumps up a little, although it was not finished just put CR #1 on and it would be enough cushion. The Wound Care Nurse stated she left the CNA that had her for that day stayed with the resident and they used pillows to help to hold her feet up and put a pillow at her back. The Wound Care Nurse stated she told the CNA (unknown) that she did not need to wait that long, and she thinks CR #1's family member came into the room. The Wound Care Nurse stated she left CR #1's room and the CNA was there. The Wound Care Nurse stated she could not recall what day, she did not even document about it. The Wound Care Nurse stated she finished CR#1's wound care and she let the CNA know she needed to be cleaned up. She stated she went out to tell the CNA (CNA A) that CR#1 needed to be cleaned up and CR#1 had fallen out of her bed. The Wound Care Nurse stated CR#1 rolled out of the bed from being on her side. She stated the facility had little rails and CR#1 was laying on her side because she had stool and the Wound Care Nurse did not want to put her back in the stool and she put pillows behind CR#1's back and positioned her. The Wound Care Nurse stated she did not document CR#1's fall. The Wound Care Nurse did check CR#1's clinical record and she stated that she does not see any notes about CR#1's fall on 5/10/23. The Wound Care Nurse stated CR#1 did not have any injuries. The Wound Care Nurse stated she was told CR#1 had fallen but by the time she got into the room they had already picked her up. She stated CR#1 was found on her right side on the floor with her back on the bed. The Wound Care Nurse stated there was no blood, no wound, and the wound dressing was intact. The Wound Care Nurse stated CR #1's bed did not go all the way down but was the lowest that it could go. She stated she did not know if the facility reported the fall, she did not have injury and she thought they reported when there was injury. She stated normally they determine when a resident needs an air mattress when they have an injury anywhere from the back down. The Wound Care Nurse stated the back, the buttocks, or the back of legs even if it there were no pressure wounds and that was when they determine the resident can have an air mattress. In an interview on 7/26/23 at 3:31 p.m. CR#1's Family member stated everyday she showed up at the facility CR#1 was left wet all night long and they would change the resident once a shift. CR#1's Family member stated when the facility finally got around to giving CR#1 an air mattress, the Wound Care Nurse and maintenance came, and she was in the room. CR#1's Family member stated there was no CNA in the room when the air mattress was being installed. CR#1 stated the Wound Care Nurse hooked CR#1 to the Hoyer lift and lifted her up to wait for the air mattress to fill up. CR#1's family member stated the Wound Care Nurse and maintenance left her in the room and CR#1 was on the Hoyer Lift in pain and she tried to put pillows to help her. She stated it was the time right before the night shift and everybody was already gone. CR#1's Family member stated she asked LVN A to come look and LVN A said Oh, I can put that back down and she said she cannot believe they left her (CR#1) like that. CR#1's Family member stated she even made the comment I can't believe they left her like this. She stated the maintenance person put the mattress up and it was the Wound Care Nurse and maintenance who were in the room. CR#1's family member stated she made it to the facility while they were lifting her up out of the bed with the Hoyer Lift. She stated CR#1's head was not lifted up. CR#1's Family member stated LVN A was also the one that told her that CR#1 had fallen out the bed about an hour after she arrived at the facility. She stated LVN A told her the Wound Care Nurse left her (CR#1) on her side and the bed was all the way up which made it a harder fall. CR#1's Family member stated CR#1 was really hurting, especially the next day. She stated CR#1 could have easily broken something on the inside. She stated if the facility had not left CR#1 in urine and poop she would not have had a wound. She stated during the day she did change CR#1 because she always found CR#1 dirty. She stated she would go and ask for help and it take them hours to come to change CR#1. She stated, pee and poop burns, so she changed CR#1 herself, but that did not have anything to do with why the facility did not change her at night. She stated she pushed the call button, and no one came, and CR#1 would say get her out of here. In an interview on 7/26/23 at 4:05 p.m. the Maintenance Assistant stated he helped a lot of residents and did not remember helping with CR#1. The Maintenance Assistant stated he takes the air mattress in the resident's room and put it on the bed. He stated he straps the air mattress down and set up the pump. He stated the air mattress has 3 straps, and he secures it to the bed, turns the air pump on and plug it in and that was all he does. The Maintenance Assistant stated its takes about 30 minutes to an hour to air up the air mattress. He stated they should not put a resident down on an air mattress after 10 min because it is not fully inflated. He stated he does not stay in the room to wait for the air mattress to inflate. In an interview and Record review on 7/26/23 beginning at 4:20 p.m. LVN A stated CR#1's family member came and asked her to come look for a little bit, but she did not know it was so urgent. LVN A stated when she went to CR#1's room, she was in the Hoyer lift. She stated Maintenance was already gone. LVN A stated she was sorry she did not know it was something she could do because she thought it was a maintenance issue. She stated CR#1 was in the Hoyer lift and she was in the air, so she put CR#1 down into the bed and took the Hoyer lift. She stated she did not know who did that and put CR#1 in that position that day (4/27/23). She stated no one else was in the room. LVN A stated it was CR#1, her family member and her in the room. LVN A stated at the time CR#1's family member came to her and reported, it took about 10 to 15 minutes that CR#1's family member waited for her to come to the room. She stated before that she did not know how long CR#1 had been up in the Hoyer lift. LVN A stated the air mattress was fully inflated. LVN A stated she worked the 6 a.m. to 6 p.m. shift on 4/27/23. LVN A stated when CR#1 had her fall there were multiple pillows in her bed and she was dirty because the CNA was going to her room to change her. LVN A stated the bed was in normal position and they assessed CR#1 for 3 days with no injuries. LVN A reviewed CR#1's clinical record and she stated the Doctor did not order labs or x-rays. In an interview on 7/26/23 at 5:06 p.m. the DON stated there were different times when it is appropriate for an air mattress. She stated it was not necessary that the resident is bed bound that a resident receives an air mattress. The DON stated they have to look at the patient and the situation of the patient and they look at every individual case. The DON stated they normally do full body assessments upon admission and then weekly unless there is a new occurrence. The DON said she would have to know all the details about the resident to see why they have 3 pressure sores that big overnight. She stated the procedures for Hoyer lift transfer can be done by one person or two. She stated she does not believe that someone left the resident with a family member hooked to a Hoyer lift. She said she would hate to believe that would happen. In an interview on 7/27/23 at 12:15 p.m. the Wound Care Nurse stated CR#1 was being put on air mattress and CR#1 was positioned over the bed on Hoyer Lift a few inches above the bed. She stated she did CR#1's wound care and she left her on her side because she had stool. The Wound Care Nurse stated CR#1 had a brief on and the stool was in the brief, so she left to call the CNA. The Wound Care Nurse stated she called the CNA to come, and she went to see another patient. The Wound Care Nurse stated she was not aware that CR#1 was a 2 person assist. The Wound Care Nurse stated she was in bed, and she positioned CR#1 on her side to do the wound. In an interview on 7/28/23 at 12:03 p.m. the NP stated CR#1 had cancer, she was very sick, CR#1 was by CR#1's bed side, and CR#1 was unable to go to hospice. The NP stated she did not recall CR#1 having a fall and would have to look at the chart. The NP stated CR#1 had wounds that were being taken care of by wound care team. The NP stated she thought they did weekly skin assessments, and she gives wound care orders if she is notified. In an interview and Record review on 7/28/23 beginning at 12:21 p.m. the DON stated she was not working at the facility when CR#1 was at the facility. The DON stated she started working at the facility on July 3, 2023, and CR#1 has a fall on 5/10/23. The DON stated CR#1 had a fall out of bed no injuries, vital signs, neuro checks and the RP/NP were informed. The DON stated she did not see an assessment for CR#1. She stated the facility did a change of condition so that was considered an assessment and it said CR#1 fell out the bed. The DON stated the change in condition revealed the NP was informed and stated to start neuro checks and it did say x-ray. The DON completed a record review of CR#1's clinical records and she did not see the x-rays for 5/10/23. The DON stated the only circumstance a resident should be left alone on a Hoyer lift was in an extreme emergency when you go to the door and scream for a nurse. She stated CR#1 should not have been left alone when hooked up to a Hoyer lift unless it was a 911 emergency situation. The DON stated CR#1 should not have been left for 45 minutes. In an interview on 7/28/23 at 2:50 p.m. the Administrator stated she did not recall who CR#1 was. She stated they discuss all of their incidents in the morning meeting. She stated she did not make a report to the State because there was no injury. She stated the nurse should do an incident report. She stated if the unwitnessed fall required a transfer out of the facility, then she would begin her investigation. In a telephone interview on 8/1/23 at 1:18 p.m. the NP stated on 5/10/23 the nurse said there was no visible trauma and CR#1 was able to move her extremities, and there was no hematoma. She stated she did not remember what the nurse (LVN A) told her. The NP stated she only went by what was documented, and she saw a lot of patients. The NP stated if the nurse says the fall was unwitnessed then it was unwitnessed, then she would assess the patient and tell her that if the patient did not have injuries, then start neuro assessments. She stated if there was a change in condition within 72 hours, they would do something else. The NP stated the Doctor saw CR#1 on 5/9/23. She stated there was no definite time that they send patients out after a fall. The NP stated CR#1 could not tell her about her pain, but the nurses were taking care of CR#1. She stated the CNAs would pay attention and say CR#1 was grimacing more after a fall, then they would report. She stated if it was not documented then it did not occur when asked if the nurse informed her if there was a bruise on CR#1's head or body. The NP stated if it was not documented, there was an error of omission. The NP stated from her assessment and interview with the nurse (LVN A) she did not see an indication for diagnostics. She stated there was no change in condition and CR#1 had a terminal disease that CR#1's family member did not want treated. The NP stated Cr#1 was already on morphine; multiple pain meds, and a fentanyl patch and CR#1 was consistently being covered with pain meds. The NP stated death was imminent given her terminal disease and there was no increased pain. She stated the pain meds were efficient. The NP asked, Would an x-ray have made more of a difference than a neurological assessment that was being carried out. In an interview on 8/2/23 at 10:25 a.m. LVN C stated she had worked with CR#1. She stated she was not here when CR#1 fell, but she was total care and unable to move by herself. She stated when they have a resident that has an unwitnessed fall, she lets the resident stay in the position and she would let the nurse know. LVN C stated she would take CR#1's vital signs, carry out her neuro checks to do their assessments and observations, take vitals and assess for pain, try to carry out range of motion to rule out fracture. She would notify her supervisor, Unit manager, call the doctor and the family member. She stated they put the resident back in bed after and they continue to monitor. She stated she would have completed the SBAR for change in condition and the questions on the SBAR are what happened, her opinion, should the patient be sent out. Whatever action she would take is based on the Doctor's order and that they use to fill out the SBAR. She stated most of the time they send the patient for an x-ray order. LVN C stated the doctor's do not say no about an x-ray because they are their eyes of the doctor. She stated most of the time they get an x-ray stat order. LVN C stated the doctor sends them out sometimes, but the doctor's do not say no. LVN C stated CR#1 was alert and oriented x2 and was able to tell them she was in pain, up to a point and she was taking pain meds. She stated she was not lucid very much and was not able to communicate a lot, but she still made sense. LVN C stated before she does the SBAR, she would have spoken with the doctor already and that was the priority. She stated CR#1 was in a lot of pain because she had a big tumor on her neck. She stated as long as they left CR#1 alone in a state of rest she had no pain, but when they touched her, she had pain. If a resident is on anticoagulant, she would have sent the resident out of the building if they had an unwitnessed fall. LVN C stated CR#1 started morphine on 5/18/23 according to the Medication Administration Record. In an interview and record review on 8/2/23 at 10:56 a.m. Unit Manager A stated when there is an unwitnessed fall, she does an assessment to make sure the resident was ok and she does a quick assessment to make sure there are no injuries and no pain. Unit Manager A stated she does range of motion and a complete body assessment of all, checks for injuries, does neuro checks, SBAR, a risk assessment, nurse note, notify the doctor, family/RP, DON, and Administrator. She stated she documents the neuro checks on a neuro check list, does vitals on the neuro checks every 15 minutes for the first hour, every half an hour for the 2nd hour, every hour after the 2nd hour, every 4 hours after that, and then its every 8 hours and every day for 4 days. She stated if the patient does not have any injuries, they monitor them (the resident) and chart on them (the neuro checks) daily. Unit Manager A stated the Doctor, and the RP was notified. She stated she does the SBAR at the same time when she speaks with the Doctor/NP, and she likes to get the exact times. She stated the SBAR asks them some of the same questions, it asks the time you talk to the Doctor and the orders, and it asks the same question about when they speak with the RP and what their reaction was. Unit Manager A stated they document the SBAR with what they get from the Doctor and the nurse note will have the same information from the SBAR. She stated if the fall was unwitnessed, they are supposed to write it there because it asks them the question. She stated if the Doctor did not order an x-ray, you don't check that. She stated on the SBAR they put what the Doctor said to do, and they always follow what the Doctor says to do. She stated if x-ray was ordered then they call the x-ray company. She stated it was up to the Doctor to make the decision to send the resident out or not. Unit Manager A stated they offered CR#1 nourishment, and pain meds and sometimes she took it and sometimes she did not. She stated around 5/18/23 CR#1 started having more pain and that was when she started getting morphine. Unit Manager A stated she was not here when CR#1 had the fall. In an interview on 8/2/23 at 11:27 a.m. CNA A stated she took care of CR#1. She stated CR #1 was not really eating, she moaned a lot, so she tried to give her a sip to drink and food but every now and then she took a bite. CNA A stated she was here at the facility when CR#1 had her fall on 5/10/23. She stated she found CR#1 on the floor, and she told the nurse (LVN A) she needed help getting CR#1 back in the bed. CNA A stated when she found CR#1, she was on the side of the bed on her stomach. CNA A stated CR#1 was laying with her head on the floor on the side by the door. CNA A stated CR#1 did not have a fall mat. She stated she did not notice any blood. She stated CR#1 barely did say anything, she did not hardly talk. CNA A stated she would not have been able to tell if CR#1 had more pain at that time. She stated LVN A assessed CR#1. She said she could not remember noticing if CR#1 had any bruises or not. She stated the wound care nurse did not come to tell her that CR#1 was on her side or that she (CR#1) needed changing. CNA A stated she heard the Wound Care Nurse was looking for her, but it was too late then. CNA A stated CR#1 did not have any rails and she did not recall any pillows around CR#1. CNA A stated she was surprised CR#1 was on the floor because she was not able to move herself around the bed. She stated for CR#1 to be on the floor that means she was in a position she should not have been in because CR#1 could not move. CNA A stated when LVN A came she looked at her and checked to see if she was ok. She stated LVN A checked CR#1's head and looked at her whole body to make sure she was ok. CNA A stated she could not remember if LVN A moved CR#1 legs or not. CNA A stated in the position she was in; it was likely that CR#1 hit her head on the floor. CNA stated she did not remember CR#1 getting an air mattress. She stated she would never have left CR#1 on a Hoyer lift. CNA A stated it takes 2 staff to put a resident on Hoyer lift and CR#1 needed 2 people to help her with ADL's and bed mobility because she could not move. CNA A stated CR#1 just laid there in the bed like she did not want to be bothered. She stated sometimes CR#1 would moan when she (CNA A) moved her around in the bed and she did not want to be touched on. She stated when she started working with CR#1 she already had the pressure sores. CNA A stated she saw CR#1's wounds but she did not know how many there were because she just saw one (1) big one. In an interview on 8/2/23 at 12:44 p.m. the NP said she did not order x-rays and CR#1's Family member did not want anything done. She stated she ordered neuro checks, they looked at CR#1, did she become unresponsive at this time within 72 hours. The NP stated CR#1's family member did not want anything done. She stated CR#1 was on palliative care heading towards Hospice. She stated, We are talking about someone who is terminal illness who the POA did not want anything invasive. She stated there was no increased pain level, she was on fentanyl, the doctor increased the morphine out of compassion not because she fell. She said they assess the patient; she knew that she was on anticoagulants. She stated she did not recall if she was in the building on 5/12/23. In an interview on 8/3/23 at 10:16 a.m. LVN A stated when CNA A called her on 5/10/23, she was in another room taking care of another resident and when she got there, CR#1 was trying to grab with both hands holding the edge of the bed. She stated before that she never tried to get up out of the bed. She stated she did the SBAR, started a neuro check and she did not have to call the family member because the sister came to the facility that day. LVN A stated she let the NP know and he told her to keep checking on CR#1 for 20 min. She stated she sent a text to the NP, and she told NP she found CR#1 and she fell out of the bed with no injury, she completed vital signs its ok. LVN A said CR#1said she was trying to sit on the wheelchair, and she replied, ok thanks. LVN A stated the bed was not up and there were at least 4 or 5 pillows on the bed. She stated CR#1 should not have been left on her side. LVN A stated on the SBAR they fill out the vital sign, the report of what happened, who you notified, phy[TRUNCATED]

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's right to be free from neglect for 8 of residents (CR#1, CR#2, Residents #3, #4, #5, #6, #7 and CR#8) of 9 reviewed for neglect. The facility failed to oversee the implementation of resident care policies and failed to ensure residents received appropriate wound care and CPR and were free of accidents and injuries. The facility Administration failed to thoroughly and accurately investigate the incident of CR#8 being found unresponsive with a laceration, requiring emergency services, and passing away at the facility, therefore, not identifying and correcting the CPR failures. The facility failed to ensure the administration and nursing staff were educated on CPR. The facility failed to identify onset of CR #1's three large unstageable pressure ulcer and initiate intervention. The facility failed to follow physician orders and treat pressure wounds for CR #1, #2 and Residents #3, #4, #5, #6, #7, for multiple days. The facility failed to practice safe positioning for CR #1 when she was placed on her side, left alone and CR #1 had an unwitnessed fall. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:46 p.m. The IJ template was provided to the facility on [DATE] at 4:46 p.m. While the IJ was removed on [DATE] at 3:50 p.m., the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy, and a scope of pattern while the facility continued to monitor the implementation of effectiveness of their plan of removal. A second Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 2:34 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that was Immediate Jeopardy due to the facility's needs to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of neglect and not having their care needs met, receiving treatments, which could cause a decline in physical and psychosocial health or even death. Findings included: CR #1 CR #1 was a [AGE] year old female who was admitted to the facility on [DATE] and re admitted on [DATE]. She was diagnosed with malignant neoplasm of rectosigmoid junction (cancer between the sigmoid colon and rectum), fistula of vagina to large intestine (feces coming through the vagina), chronic pain syndrome, muscle weakness, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), anxiety disorder, idiopathic peripheral autonomic neuropathy, encephalopathy (damage to the peripheral nerves), hypertension, bacteremia (bacteria in the blood), fracture of fifth lumbar vertebra, and fracture of lumbosacral spine and pelvis. Record review of CR #1's Care Plan dated [DATE] revealed CR#1 has a diagnosis of cancer and was at risk of increased weakness, weight loss, pain, depression, tiredness, death as evidenced by, receiving anticoagulant therapy and is at risk for increased bleeding, bruising, etc., bowel and bladder incontinence and is at risk for skin breakdown as evidenced by cognitive impairment, ADL self care deficits and is at risk for further decline in ADL functioning and injury as evidenced by disease process with interventions being provide extensive assistance of (#2 support persons) for bed mobility, toileting/incontinent care and transfers. CR#1 complained of increased pain and was at risk for further episodes of increased pain/discomfort and injury with interventions/tasks to give pain medication, treatments, relaxation modalities, provide pressure reducing and positioning devices as needed. CR#1 was at risk for falls and injuries with goal to be free from falls and injuries over the next 90 days dated/revised on [DATE], risk for pressure wounds with interventions/tasks to assist with incontinent care, perform weekly skin checks, provide pressure reducing device for bed and wheelchair . Review of care plan with closed date [DATE] revealed CR #1 had pressure wound. stage 4 buttock and DTI (Deep Tissue Injury) to the right ischium. Record review of Resident #1's Quarterly MDS dated [DATE] revealed Cognitive Pattern BIMS Summary Score was 00 indicating severe impairment. CR#1's functional status revealed walk in room and corridor, locomotion on/off unit did not occur, bed mobility, dressing, personal hygiene were extensive assistance with 2 person assisting, transfer was activity occurred once or twice with 2 person assisting and bathing, and she was totally dependent for bathing with 2 person assist. Review of MDS dated [DATE] section revealed CR #1 was identified as at risk for pressure ulcers/injuries. Review of MDS dated [DATE] section M0300 revealed CR #1 had pressure ulcers. Review of Treatment Administration Record for the month of April and [DATE] revealed there were no documentation of wound care provided to CR#1 on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. Review of physician order dated [DATE] revealed the following: Left Buttocks Unstageable: Cleanse with normal saline, pat dry, apply Santyl + Calcium Alginate cover with gauze + island dressing daily. Right buttocks Unstageable: Cleanse with normal saline, pat dry, apply Santyl + Calcium Alginate cover with gauze + island dressing daily. Right Ischium Unstageable DTI: Cleanse with normal saline, pat dry, apply house barrier cream daily. Review of skin assessment during admission on [DATE] reveal CR #1 only had redness under her bilateral breast. Record review of facility weekly skin assessment for the month of February and [DATE] revealed there were no skin assessments done for CR #1 in the months of February and [DATE]. Further review revealed there were no weekly skin assessment for CR#1 in the month of [DATE], until [DATE]th when three wounds were first identified. The skin assessment on [DATE] revealed the following: Wound #1 was acquired in the facility, first observation, size was (length x width x height) 7.5cm x 5.3cm x 0.0cm. Wound #1 was identified as pressure wound at the right buttock, necrotic tissue present, dry, thick adherent devitalized necrotic tissue 70%, moderate drainage, no odor, peri wound tissue was described to have redness and wound edges well defined. Stage of the wound was not documented, Wound #2 acquired in the facility, first observation, size was (length x width x height) 5.5cm x 2.5cm x 0.0cm. wound #2 was identified as pressure wound at the left buttock, necrotic tissue present, dry, thick adherent devitalized necrotic tissue 70%, moderate drainage and no odor, peri wound tissue was described having redness and wound edges well defined. Stage of the wound was not documented, Wound #3 acquired in the facility, first observation, size was (length x width x height) 9.0cm x 0.8cm x 0.0cm. wound #3 was identified as pressure wound at the right ischium, necrotic tissue present, dry, thick adherent devitalized necrotic tissue 70%, no drainage and odor, peri wound tissue was described as normal and wound edges well defined. Stage of the wound was not documented, Record review of CR#1's progress notes dated [DATE] at 4:45 p.m. by The Wound Care Nurse revealed, Patients assigned nurse notified me of skin injury to patient. Skin &Wound assessment done with indications of pressure injuries to right & left buttocks and deep tissue injury to the right ischium. [Wound Care Doctor] notified and new orders given for wound treatment as indicated . Record review of CR#1's family members text message dated [DATE], at 5:16 p.m. revealed, Painful [CR#1] was suspended by a lift to keep her off the bed while they put blow up mattress on her bed to help with bed sores. I was trying to hold her head up the whole time by bracing my leg up on the metal part of the bed and stacking pillows on to my knee to it touched [CR#1's] head. Awful but not torture. Her legs were dangling and that was hurting so once the Nurse left, I stacked pillows until they reached under her leg. The Nurse came back and argued with me that the bed wouldn't fill with air with the pillows, and I said the man said the bed would inflate regardless and she said he didn't say that and said, well if you want it to never inflate and her stay dangling forever and walked out. The mattress filled with air just fine and I'm so thankful I was here. They would have left her neck/head with no support just dangling like her legs if I hadn't had been here. I do thank God for that. I can't even begin to understand what she would have gone through. I talked to the Dr. today and he did up one of her pain patch meds. I told him she's still not on Hospice because she is Medicaid pending but with Palliative Care, we're trying to keep her comfortable and she isn't comfortable. So at least a little more pain meds but it still isn't enough. Record review of CR#1 family member text message dated [DATE] at 7:06 p.m. revealed, I forgot to tell you they forgot [CR#1] and left her dangling .I was told the mattress would take 20 min to fill so after 30 min the mattress felt full and read normal. I waited another 15 minutes then headed to the Nurse Station. Finally, the Nurse came and lowered the sling on to the bed. She could have been there for hours. Record review of CR#1's progress notes dated [DATE] revealed no notes regarding CR#1 being left dangling on a Hoyer lift without staff present. Record review of LVN A's text message to NP dated [DATE] at 1:33 p.m. revealed, Good morning Just letting you know that [CR#1] fell from her bed, no injuries vital signs ok, she stated that she was trying to sit on the wheelchair and NP response revealed Ok thanks. Record review of CR#1 progress notes dated [DATE] at 1:34 p.m. by LVN A revealed, Resident fell from the bed, no injuries, vital sign ok, RP, NP all notified, Neuro check in progress. Record review of CR#1's Neurological Evaluation Flow Sheet dated [DATE] revealed: Eyes Open to: Spontaneously, to Speech, To Pain, None was not documented on [DATE] at 1:30 p.m., 1:45 p.m., 2 p.m., 2:15 p.m., 2:30 p.m., 2:45 p.m., 3 p.m. 4 p.m., 5 p.m., 6 p.m. [DATE] documented once during the shift 6 p.m. to 6 a.m. 2 to pain, [DATE] was not documented for pain at all. [DATE] at 2 p.m. and 8 p.m. documented 4 for spontaneously [DATE] at 6 (unknown a.m. or p.m.) documented 4 for spontaneously Record review of CR #1's SBAR (Change of Condition) dated [DATE] at 4:17 p.m. revealed, Resident fell out of bed, No injuries, position lying left arm .Resident fell out of bed with no injuries noted, vitals sign completed and correct, neuro check in progress .Recommendation monitor vital signs, x ray/ultrasound/ekg, other . Record review of CR#1's family member text message dated [DATE] at 9:48 p.m. revealed, Poor [CR#1] fell off her bed today between 12 and 1 PM, right before I got there .The Nurse said they checked her out and she seemed to be ok. After taking to the Nurse, a while to try to see how it could have happened, I found out that the Wound Nurse had just changed her bandage and I'm sure left her on her stomach because she needed the aide to change the diaper, but they all know if can take up to hours for an Aide to show up. Also, she left the bed as high as it goes up and she claims the aide was coming. Anyway, I told the Nurse that it hurts [CR#1] to lay on her stomach and being close to the edge of the bed managed to try to turn over and went off the bed. I told the Nurse to tell the Wound Nurse not to leave [CR#1] close to the edge or on her stomach. [CR#1] seemed to be really scared of anyone coming up to her except me .She (CR#1) said my head hurts then my body hurts, etc. I told her I know she fell on the floor because the stupid Nurse and it won't happen again. She kept saying help me help me off and on for the whole time I was there .I felt so bad for her. After I got there, she said don't leave .I checked her head while I was lightly rubbing her face and head and didn't feel any lumps. Praying she didn't break anything. The Nurse said they would check her out every day for 3 days. Record review of CR#1's Physician note dated [DATE] revealed, Uncontrolled pain, Patient currently on palliative care services, responsible party does not want any aggressive care, patient has a history of probable metastatic cancer, is on multiple pain medications, patient reported to be in uncontrolled pain at times as per her responsible party. Patient is currently not able to swallow medications. Hospice services not available due to insurance issues. Review of systems general: unreliable due to patients lethargy .bedbound, ulcers on bilateral buttocks .Uncontrolled, patient is currently on palliative services, patient appropriate for hospice services, hospice services not available due to insurance issues., patient currently on scheduled fentanyl 50 mcg patch per hour, methadone 10 mg p.o. daily, also Norco scheduled, pain reported to be uncontrolled, patient not able to take medications by mouth, have ordered sublingual morphine, 10 mg every 4 hours as needed for pain .Lethargy Patient has not been eating for several days, patient's responsible party does not want aggressive measures, continue with palliative care, goals of care palliative. Decline in condition expected due to patient's severe comorbidities. Continue with palliative care and symptoms control as much as possible. Pharmacy Orders: Morphine concentrate 100 mg/5ml (20 mg/ml) oral solution Take ½ ml under tongue every four hours as needed for pain . In an interview on [DATE] at 11:30 a.m. LVN A stated the CNA came and called her on [DATE] at around 12 p.m. and she found CR #1 on the floor. LVN A stated she assessed CR #1, and she was fine, and they checked on her for 3 days. She stated she notified the NP and CR #1's family member. LVN A explained CNA A was going to take care of CR #1's roommate and she found CR #1 on the floor. Record review and interview with LVN A did not reveal CR #1 had any x rays or labs completed. In an interview on [DATE] at 12:14 p.m. the Wound Care Nurse stated the wound care doctor started taking care of CR #1 for pressure sores on [DATE] when he saw CR #1 for the first time. The Wound Care Nurse stated she stated working at the facility in [DATE]. She stated the assigned nurse of whoever was taking care of CR #1 on 4/23 or 4/24 identified that CR #1 had 3 pressure sore areas and they were debrided, and they all kept getting worse at unstageable to right buttock 7.5 by 3.5, unstageable left buttock and it was 5.5 x 2.5 and the 3rd site was an unstageable DTI on the right buttocks 9 x 0.8. The Wound Care Nurse stated all the wounds became 1 before (all the wounds blended together and become 1 big wound) she passed away. The Wound Care Nurse stated CR #1 passed away while at the facility on [DATE]. The Wound Care Nurse stated on [DATE], CR #1's family member said she would not allow them to treat CR #1 without the lidocaine spray. The Wound Care nurse stated when CR #1 got the wounds she would tell the staff to get the air mattress. She stated CR #1 got the air mattress on [DATE] after seeing the wounds. She stated by the time she got back to see CR #1 the air mattress was already on. The Wound Care Nurse stated CNA A had CR #1 most of the time and the nurse over her was LVN A. The Wound Care Nurse stated she went back the next day and CR #1 was already on it. Wound Care Nurse stated she did not recall the details of the day CR #1 got the air mattress because they had to use the Hoyer lift and put CR #1 up and put the mattress on and the CNA stayed with her. The Wound Care Nurse stated it took about 10 minutes and she told the CNA once it pumps up a little, although it was not finished just put CR #1 on and it would be enough cushion. The Wound Care Nurse stated she left the CNA that had her for that day stayed with the resident and they used pillows to help to hold her feet up and put a pillow at her back. The Wound Care Nurse stated she told the CNA (unknown) that she did not need to wait that long, and she thinks CR #1's family member came into the room. The Wound Care Nurse stated she left CR #1's room and the CNA was there. The Wound Care Nurse stated she could not recall what day, she did not even document about it. The Wound Care Nurse stated she finished CR#1's wound care and she let the CNA know she needed to be cleaned up. She stated she went out to tell the CNA (CNA A) that CR#1 needed to be cleaned up and CR#1 had fallen out of her bed. The Wound Care Nurse stated CR#1 rolled out of the bed from being on her side. She stated the facility had little rails and CR#1 was laying on her side because she had stool and the Wound Care Nurse did not want to put her back in the stool and she put pillows behind CR#1's back and positioned her. The Wound Care Nurse stated she did not document CR#1's fall. The Wound Care Nurse did check CR#1's clinical record and she stated that she does not see any notes about CR#1's fall on [DATE]. The Wound Care Nurse stated CR#1 did not have any injuries. The Wound Care Nurse stated she was told CR#1 had fallen but by the time she got into the room they had already picked her up. She stated CR#1 was found on her right side on the floor with her back on the bed. The Wound Care Nurse stated there was no blood, no wound, and the wound dressing was intact. The Wound Care Nurse stated CR #1's bed did not go all the way down but was the lowest that it could go. She stated she did not know if the facility reported the fall, she did not have injury and she thought they reported when there was injury. She stated normally they determine when a resident needs an air mattress when they have an injury anywhere from the back down. The Wound Care Nurse stated the back, the buttocks, or the back of legs even if it there were no pressure wounds and that was when they determine the resident can have an air mattress. In an interview on [DATE] at 3:31 p.m. CR#1's Family member stated everyday she showed up at the facility CR#1 was left wet all night long and they would change the resident once a shift. CR#1's Family member stated when the facility finally got around to giving CR#1 an air mattress, the Wound Care Nurse and maintenance came, and she was in the room. CR#1's Family member stated there was no CNA in the room when the air mattress was being installed. CR#1 stated the Wound Care Nurse hooked CR#1 to the Hoyer lift and lifted her up to wait for the air mattress to fill up. CR#1's family member stated the Wound Care Nurse and maintenance left her in the room and CR#1 was on the Hoyer Lift in pain and she tried to put pillows to help her. She stated it was the time right before the night shift and everybody was already gone. CR#1's Family member stated she asked LVN A to come look and LVN A said Oh, I can put that back down and she said she cannot believe they left her (CR#1) like that. CR#1's Family member stated she even made the comment I can't believe they left her like this. She stated the maintenance person put the mattress up and it was the Wound Care Nurse and maintenance who were in the room. CR#1's family member stated she made it to the facility while they were lifting her up out of the bed with the Hoyer Lift. She stated CR#1's head was not lifted up. CR#1's Family member stated LVN A was also the one that told her that CR#1 had fallen out the bed about an hour after she arrived at the facility. She stated LVN A told her the Wound Care Nurse left her (CR#1) on her side and the bed was all the way up which made it a harder fall. CR#1's Family member stated CR#1 was really hurting, especially the next day. She stated CR#1 could have easily broken something on the inside. She stated if the facility had not left CR#1 in urine and poop she would not have had a wound. She stated during the day she did change CR#1 because she always found CR#1 dirty. She stated she would go and ask for help and it take them hours to come to change CR#1. She stated, pee and poop burns, so she changed CR#1 herself, but that did not have anything to do with why the facility did not change her at night. She stated she pushed the call button, and no one came, and CR#1 would say get her out of here. In an interview on [DATE] at 4:05 p.m. the Maintenance Assistant stated he helped a lot of residents and did not remember helping with CR#1. The Maintenance Assistant stated he takes the air mattress in the resident's room and put it on the bed. He stated he straps the air mattress down and set up the pump. He stated the air mattress has 3 straps, and he secures it to the bed, turns the air pump on and plug it in and that was all he does. The Maintenance Assistant stated its takes about 30 minutes to an hour to air up the air mattress. He stated they should not put a resident down on an air mattress after 10 min because it is not fully inflated. He stated he does not stay in the room to wait for the air mattress to inflate. In an interview and Record review on [DATE] beginning at 4:20 p.m. LVN A stated CR#1's family member came and asked her to come look for a little bit, but she did not know it was so urgent. LVN A stated when she went to CR#1's room, she was in the Hoyer lift. She stated Maintenance was already gone. LVN A stated she was sorry she did not know it was something she could do because she thought it was a maintenance issue. She stated CR#1 was in the Hoyer lift and she was in the air, so she put CR#1 down into the bed and took the Hoyer lift. She stated she did not know who did that and put CR#1 in that position that day ([DATE]). She stated no one else was in the room. LVN A stated it was CR#1, her family member and her in the room. LVN A stated at the time CR#1's family member came to her and reported, it took about 10 to 15 minutes that CR#1's family member waited for her to come to the room. She stated before that she did not know how long CR#1 had been up in the Hoyer lift. LVN A stated the air mattress was fully inflated. LVN A stated she worked the 6 a.m. to 6 p.m. shift on [DATE]. LVN A stated when CR#1 had her fall there were multiple pillows in her bed and she was dirty because the CNA was going to her room to change her. LVN A stated the bed was in normal position and they assessed CR#1 for 3 days with no injuries. LVN A reviewed CR#1's clinical record and she stated the Doctor did not order labs or x rays. In an interview on [DATE] at 5:06 p.m. the DON stated there were different times when it is appropriate for an air mattress. She stated it was not necessary that the resident is bed bound that a resident receives an air mattress. The DON stated they have to look at the patient and the situation of the patient and they look at every individual case. The DON stated they normally do full body assessments upon admission and then weekly unless there is a new occurrence. The DON said she would have to know all the details about the resident to see why they have 3 pressure sores that big overnight. She stated the procedures for Hoyer lift transfer can be done by one person or two. She stated she does not believe that someone left the resident with a family member hooked to a Hoyer lift. She said she would hate to believe that would happen. In an interview on [DATE] at 12:15 p.m. the Wound Care Nurse stated CR#1 was being put on air mattress and CR#1 was positioned over the bed on Hoyer Lift a few inches above the bed. She stated she did CR#1's wound care and she left her on her side because she had stool. The Wound Care Nurse stated CR#1 had a brief on and the stool was in the brief, so she left to call the CNA. The Wound Care Nurse stated she called the CNA to come, and she went to see another patient. The Wound Care Nurse stated she was not aware that CR#1 was a 2 person assist. The Wound Care Nurse stated she was in bed, and she positioned CR#1 on her side to do the wound. In an interview on [DATE] at 12:03 p.m. the NP stated CR#1 had cancer, she was very sick, CR#1 was by CR#1's bed side, and CR#1 was unable to go to hospice. The NP stated she did not recall CR#1 having a fall and would have to look at the chart. The NP stated CR#1 had wounds that were being taken care of by wound care team. The NP stated she thought they did weekly skin assessments, and she gives wound care orders if she is notified. In an interview and Record review on [DATE] beginning at 12:21 p.m. the DON stated she was not working at the facility when CR#1 was at the facility. The DON stated she started working at the facility on [DATE], and CR#1 has a fall on [DATE]. The DON stated CR#1 had a fall out of bed no injuries, vital signs, neuro checks and the RP/NP were informed. The DON stated she did not see an assessment for CR#1. She stated the facility did a change of condition so that was considered an assessment and it said CR#1 fell out the bed. The DON stated the change in condition revealed the NP was informed and stated to start neuro checks and it did say x ray. The DON completed a record review of CR#1's clinical records and she did not see the x rays for [DATE]. The DON stated the only circumstance a resident should be left alone on a Hoyer lift was in an extreme emergency when you go to the door and scream for a nurse. She stated CR#1 should not have been left alone when hooked up to a Hoyer lift unless it was a 911 emergency situation. The DON stated CR#1 should not have been left for 45 minutes. In an interview on [DATE] at 2:50 p.m. the Administrator stated she did not recall who CR#1 was. She stated they discuss all of their incidents in the morning meeting. She stated she did not make a report to the State because there was no injury. She stated the nurse should do an incident report. She stated if the unwitnessed fall required a transfer out of the facility, then she would begin her investigation. In a telephone interview on [DATE] at 1:18 p.m. the NP stated on [DATE] the nurse said there was no visible trauma and CR#1 was able to move her extremities, and there was no hematoma. She stated she did not remember what the nurse (LVN A) told her. The NP stated she only went by what was documented, and she saw a lot of patients. The NP stated if the nurse says the fall was unwitnessed then it was unwitnessed, then she would assess the patient and tell her that if the patient did not have injuries, then start neuro assessments. She stated if there was a change in condition within 72 hours, they would do something else. The NP stated the Doctor saw CR#1 on [DATE]. She stated there was no definite time that they send patients out after a fall. The NP stated CR#1 could not tell her about her pain, but the nurses were taking care of CR#1. She stated the CNAs would pay attention and say CR#1 was grimacing more after a fall, then they would report. She stated if it was not documented then it did not occur when asked if the nurse informed her if there was a bruise on CR#1's head or body. The NP stated if it was not documented, there was an error of omission. The NP stated from her assessment and interview with the nurse (LVN A) she did not see an indication for diagnostics. She stated there was no change in condition and CR#1 had a terminal disease that CR#1's family member did not want treated. The NP stated Cr#1 was already on morphine; multiple pain meds, and a fentanyl patch and CR#1 was consistently being covered with pain meds. The NP stated death was imminent given her terminal disease and there was no increased pain. She stated the pain meds were efficient. The NP asked, Would an x ray have made more of a difference than a neurological assessment that was being carried out. In an interview on [DATE] at 10:25 a.m. LVN C stated she had worked with CR#1. She stated she was not here when CR#1 fell, but she was total care and unable to move by herself. She stated when they have a resident that has an unwitnessed fall, she lets the resident stay in the position and she would let the nurse know. LVN C stated she would take CR#1's vital signs, carry out her neuro checks to do their assessments and observations, take vitals and assess for pain, try to carry out range of motion to rule out fracture. She would notify her supervisor, Unit manager, call the doctor and the family member. She stated they put the resident back in bed after and they continue to monitor. She stated she would have completed the SBAR for change in condition and the questions on the SBAR are what happened, her opinion, should the patient be sent out. Whatever action she would take is based on the Doctor's order and that they use to fill out the SBAR. She stated most of the time they send the patient for an x ray order. LVN C stated the doctor's do not say no about an x ray because they are their eyes of the doctor. She stated most of the time they get an x ray stat order. LVN C stated the doctor sends them out sometimes, but the doctor's do not say no. LVN C stated CR#1 was alert and oriented x2 and was able to tell them she was in pain, up to a point and she was taking pain meds. She stated she was not lucid very much and was not able to communicate a lot, but she still made sense. LVN C stated before she does the SBAR, she would have spoken with the doctor already and that was the priority. She stated CR#1 was in a lot of pain because she had a big tumor on her neck. She stated as long as they left CR#1 alone in a state of rest she had no pain, but when they touched her, she had pain. If a resident is on anticoagulant, she would have sent the resident out of the building if they had an unwitnessed fall. LVN C stated CR#1 started morphine on [DATE] according to the Medication Administration Record. In an interview and record review on [DATE] at 10:56 a.m. Unit Manager A stated when there is an unwitnessed fall, she does an assessment to make sure the resident was ok and she does a quick assessment to make sure there are no injuries and no pain. Unit Manager A stated she does range of motion and a complete body assessment of all, checks for injuries, does neuro checks, SBAR, a risk assessment, nurse note, notify the doctor, family/RP, DON, and Administrator. She stated she documents the neuro checks on a neuro check list, does vitals on the neuro checks every 15 minutes for the first hour, every half an hour for the 2nd hour, every hour after the 2nd hour, every 4 hours after that, and then its every 8 hours and every day for 4 days. She stated if the patient does not have any injuries, they monitor them (the resident) and chart on them (the neuro checks) daily. Unit Manager A stated the Doctor, and the RP was notified. She stated she does the SBAR at the same time when she speaks with the Doctor/NP, and she likes to get the exact times. She stated the SBAR asks them some of the same questions, it asks the time you talk to the Doctor and the orders, and it asks the same question about when they speak with the RP and what their reaction was. Unit Manager A stated they document the SBAR with what they get from the Doctor and the nurse note will have the same information from the SBAR. She stated if the fall was unwitnessed, they are supposed to write it there because it asks them the question. She stated if the Doctor did not order an x ray, you don't check that. She stated on the SBAR they put what the Doctor said to do, and they always follow what the Doctor says to do. She stated if x ray was ordered then they call the x ray company. She stated it was up to the Doctor to make the decision to send the resident out or not. Unit Manager A stated they offered CR#1 nourishment, and pain meds and sometimes she took it a[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment plan of care for 2 of 9 residents (CR#1 and CR#8) reviewed for comprehensive care plans in that The facility failed to implement CR #1's comprehensive person-centered Care Plan for pain to provide pressure reducing and positioning devices (air mattress) and CR#1 did develop 3 pressure sores on [DATE]. The facility failed to implement CR#1's comprehensive person-centered Care Plan for ADL self-care deficits as she required extensive assistance of 2 support persons for bed mobility, toileting/incontinent care and transfers. The facility failed to care plan for CR#8's behaviors such as playing with his bed remote and rearranging his furniture. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:25 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not an Immediate Jeopardy because all staff had not been trained on developing and implementing a person centered comprehensive care plans. These failures placed residents at risk of not having their care needs met, which could cause a decline in physical and psychosocial health or even death. Findings include: CR #1 Record review of CR #1's face sheet dated [DATE] revealed a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. She was diagnosed with malignant neoplasm of rectosigmoid junction (cancer between the sigmoid colon and rectum), fistula of vagina to large intestine (feces coming through the vagina), chronic pain syndrome, muscle weakness, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), anxiety disorder, idiopathic peripheral autonomic neuropathy, encephalopathy (damage to the peripheral nerves), hypertension, bacteremia (bacteria in the blood), fracture of fifth lumbar vertebra, and fracture of lumbosacral spine and pelvis. Record review of CR #1's Care Plan dated [DATE] revealed CR#1 has a diagnosis of cancer and was at risk of increased weakness, weight loss, pain, depression, tiredness, death as evidenced by, receiving anticoagulant therapy and is at risk for increased bleeding, bruising, etc., bowel and bladder incontinence and is at risk for skin breakdown as evidenced by cognitive impairment, ADL self care deficits and is at risk for further decline in ADL functioning and injury as evidenced by disease process with interventions being provide extensive assistance of (#2 support persons) for bed mobility, toileting/incontinent care and transfers. CR#1 complained of increased pain and was at risk for further episodes of increased pain/discomfort and injury with interventions/tasks to give pain medication, treatments, relaxation modalities, provide pressure reducing and positioning devices as needed. CR#1 was at risk for falls and injuries with goal to be free from falls and injuries over the next 90 days dated/revised on [DATE], risk for pressure wounds with interventions/tasks to assist with incontinent care, perform weekly skin checks, provide pressure reducing device for bed and wheelchair . Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Cognitive Pattern BIMS Summary Score was 00 indicating severe cognitive impairment. CR#1's functional status revealed walk in room and corridor, locomotion on/off unit did not occur, bed mobility, dressing, personal hygiene were extensive assistance with 2 person assisting, transfer was activity occurred once or twice with 2 person assisting and bathing, and she was totally dependent for bathing with 2 person assist. Record review of CR #1's Physician Orders dated [DATE] revealed: Fentanyl Patch 72 hour 75 mcg/HR apply 1 patch trans dermally dated [DATE] Lidocaine-Menthol (Spray) External Liquid 4- 1% Lidocaine-Menthol apply to wound topically dated [DATE] Right Buttocks Stage 4: Cleanse with Vashe, pat dry and packed with Vashe moist gauze sponge cover with ABD (used to absorb discharges) pad + island dressing PRN every 1 hour as needed dated [DATE] Morphine Sulfate (Concentrate) Solution 20 mg/ml give 0.5 ml sublingually every 4 hours as needed for pain dated [DATE] Lorazepam Tablet 0.5 mg give 1 tablet by mouth dated [DATE] Gemtesa Oral Tablet 75 mg (Vibegron) give 1 tablet by mouth one time a day for overactive bladder dated [DATE] Nystatin Powder (Nystatin Bulk) Apply to breast topically dated [DATE] Lidocaine External Patch 4% (Lidocaine) Apply to right shoulder dated [DATE] Hydrocodone-Acetaminophen 7.5-325 mg give 1 tablet by mouth every 8 hours as needed for pain level 6-10 dated [DATE] Turn and reposition every 2 hrs. Every shift [DATE] Wound consult No directions dated [DATE] Lidocaine External patch 4% (Lidocaine) Apply to both thigh topically dated [DATE] Hydrocodone Acetaminophen Tablet 7.5-325 mg give 1 tablet by mouth dated [DATE] Phenergan Injection Solution (Promethazine HCl) Inject 12.5 mg intramuscularly every 8 hours as needed for nausea dated [DATE] Palliative Care only, no labs, no diagnostic exams. May Administer pain and nausea medication only, hold PO medications if unable to swallow x 7 days then discontinue dated [DATE] O2 Sat. via nasal cannula, 2-4 liters/92% continuously Every shift for difficulty breathing dated [DATE] Record review of CR#1's progress notes dated [DATE] at 4:45 p.m. by The Wound Care Nurse revealed, Patients assigned nurse notified me of skin injury to patient. Skin &Wound assessment done with indications of pressure injuries to right & left buttocks and deep tissue injury to the right ischium. [Wound Care Doctor] notified and new orders given for wound treatment as indicated . In an interview on [DATE] at 12:14 p.m. with the Wound Care Nurse she stated the wound care doctor started taking care of CR #1 for pressure sores on [DATE] when he saw CR #1 for the first time. The Wound Care Nurse stated she started working at the facility in [DATE]. She stated the assigned nurse of whoever was taking care of CR #1 on 4/23 or 4/24 identified that CR #1 had 3 pressure sore areas and they were debrided and they all kept getting worse at unstageable to right buttock 7.5 by 3.5, unstageable left buttock and it was 5.5 x 2.5 and the 3rd site was an unstageable DTI on the right buttocks 9 x 0.8. The Wound Care nurse stated when CR #1 got the wounds she would tell the staff to get the air mattress. She stated CR #1 got the air mattress on [DATE] after seeing the wounds. She stated by the time she got back to see CR #1 the air mattress was already placed on the bed. The Wound Care Nurse stated she finished CR#1's wound care on [DATE] and she let the CNA know she needed to be cleaned up. She stated she went out to tell the CNA (CNA A) that CR#1 needed to be cleaned up and CR#1 had fallen out of her bed. The Wound Care Nurse stated CR#1 rolled out of the bed from being on her side. She stated the facility had little rails and CR#1 was laying on her side because she had stool and the Wound Care Nurse did not want to put her back in the stool and she put pillows behind CR#1's back and positioned her. She stated normally they determine when a resident needs an air mattress when they have an injury anywhere from the back down. The Wound Care Nurse stated the back, the buttocks or the back of legs even if it is non pressure wounds and that is when they determine the resident can have an air mattress. In an interview on [DATE] at 3:31 p.m. with CR#1's Family member she stated when the facility finally got around to giving CR#1 an air mattress, the Wound Care Nurse and maintenance came and she was in the room. CR#1's Family member stated there was no CNA in the room when the air mattress was being installed. CR#1's family stated the Wound Care Nurse hooked CR#1 to the Hoyer lift and lifted her up to wait for the air mattress to fill up. In an interview on [DATE] at 4:05 p.m. with the Maintenance Assistant he stated he helped a lot of residents and did not remember helping with CR#1. The Maintenance Assistant stated he takes the air mattress in the resident's room and put it on the bed. He stated he straps the air mattress down and set up the pump. He stated the air mattress has 3 straps, and he secures it to the bed, turns the air pump on and plug it in and that is all he does. In an interview on [DATE] at 5:06 p.m. with the DON she stated there were different times when it is appropriate for an air mattress. She stated it was not necessary that the resident is bed bound that a resident receives an air mattress. The DON stated they have to look at the patient and the situation of the patient and they look at every individual case. The DON stated they normally do full body assessments upon admission and then weekly unless there is a new occurrence. The DON said she would have to know all the details about the resident to see why they have 3 pressure sores that big overnight. She stated the procedures for Hoyer lift transfer can be done by one person or two. In an interview on [DATE] at 12:15 p.m. with the Wound Care Nurse she stated CR#1 was being put on the air mattress on [DATE]. She stated she did CR#1's wound care and she left her on her side because she had stool. The Wound Care Nurse stated CR#1 had a brief on and the stool was in the brief so she left to call the CNA. The Wound Care Nurse stated she called the CNA to come and she went to see another patient. The Wound Care Nurse stated she was not aware that CR#1 was a 2 person assist. The Wound Care Nurse stated she was in bed and she positioned CR#1 on her side on [DATE] to do the wound. In an interview on [DATE] at 10:25 a.m. with LVN C she stated she had worked with CR#1. She stated she was total care and unable to move by herself. In an interview on [DATE] at 11:27 a.m. with CNA A she stated she took care of CR#1. CNA A stated she was here at the facility when CR#1 had her fall on [DATE]. She stated the wound care nurse did not come to tell her that CR#1 was on her side or that she (CR#1) needed changing. CNA A stated she heard the Wound Care Nurse was looking for her but it was too late then. CNA A stated CR#1 did not have any rails and she did not recall any pillows around CR#1. CNA A stated she was surprised CR#1 was on the floor because she was not able to move herself around the bed. She stated for CR#1 to be on the floor that means she was in a position she should not have been in because CR#1 could not move. CNA A stated she did not remember CR#1 getting an air mattress. CNA A stated it takes 2 staff to put a resident on Hoyer lift and CR#1 needed 2 people to help her with ADL's and bed mobility because she could not move. CNA A stated CR#1 just laid there in the bed like she did not want to be bothered. She stated sometimes CR#1 would moan when she (CNA A) moved her around in the bed and she did not want to be touched on. In an interview on [DATE] at 10:16 a.m. with LVN A she stated when CNA A called her on [DATE], she was in another room taking care of another resident and when she got there CR#1 was trying to grab with both hands holding the edge of the bed. She stated CR#1 should not have been left on her side. In an interview on [DATE] at 11:12 a.m. with Charge Nurse A she stated the Hoyer Lift was a 2 person lift used for transfers and to do weights and it is not ok to transfer someone without assistance. She stated when installing an air mattress they can put the air mattress to the side of the bed and have maintenance to air it up on the side of the bed while the patient is still in the bed. She stated once the air mattress is aired up they get the patient up and put the resident in the bed. In an interview on [DATE] at 12:50 p.m. with the Wound Care Nurse she stated she should have had a 2nd person with her when she was going to do CR#1's wound care from the beginning. She stated she should have had 2 people because CR#1 was a 2 person assist. The Wound Care Nurse stated CR#1 was positioned comfortably on her side, she did not think anything was wrong with her positioning. In an interview on [DATE] at 1:29 p.m. with CNA A she stated she was in-serviced on Hoyer lift and she stated it took 2 people to transfer with the Hoyer lift. She stated there was never a time it is acceptable to only have 1 person with a Hoyer lift. She stated she never transferred CR#1 on Hoyer lift. CNA A stated she never saw the wound care nurse on [DATE], and nobody told her CR#1 needed to be changed. In an interview on [DATE] at 12:46 p.m. with the DON she stated she did not know why the wound care nurse did not have 2 staff present with her. The DON stated the Therapy department completed the in-service on Hoyer Lifts. They did in-service on 2 person assist and always have 2 people on Hoyer's. She stated the care plans should be updated and make sure they are patient specific. In an interview on [DATE] at 2:47 p.m. with CR#1's family member she stated she came to the facility everyday. She stated on [DATE] that was the first time she saw the wound nurse. She stated she asked the wound nurse for an air mattress and maybe 2 or 3 days later they still had not done the air mattress. She stated CR#1 fell off the bed on [DATE] because the wound nurse left CR#1 all the way to the side of the bed on the edge on her side. CR#1's family member stated she spoke with the Wound nurse and she said she guessed she left CR#1 on her side and left her too close to the edge, but she said she went to tell the aide CR#1 needed to be changed. She stated CR#1 did not get the air mattress the day the Wound Care Nurse found the wound. CR#1's family member stated the next day on [DATE], they brought the air mattress to CR#1's room and it sat on the floor for 2 days not aired up. CR #8 Record review of CR#8's face sheet dated [DATE] revealed CR #8 was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with dementia, unspecified severity, with other behavioral disturbance, osteoarthritis, hypertension, benign prostatic hyperplasia with lower urinary tract symptoms, insomnia, cachexia, overactive bladder, major depressive disorder, recurrent, severe with psychotic symptoms and hallucinations. Record review of CR#8's Care Plan dated [DATE] revealed, CR#8 had delusions and was at risk for injury with interventions to report delusions in the clinical record, notify MD of changes in behavior, psychiatric consult as needed. CR#8 resident in Memory Care Unit for impaired cognition secondary to diagnosis of dementia, elopement risk, wandering with interventions to call resident by name when giving care, explain procedures, keep environment free of possible hazards .He also took psychotropic medication and was at risk for adverse reactions and episodes of driven behavior as evidenced by taking anti-psychotic with interventions to give medication as ordered, monitor each behavioral episode for frequency, intensity, duration and document in the clinical record .He was at risk for falls and injuries as evidenced by unsteady gait, confusion with interventions to anticipate needs, provide prompt assistance, assure lighting is adequate and areas are free of clutter, ensure call light is in reach and answer promptly, keep frequently used items at resident bedside, monitor for incontinent episodes-provide peri care as indicated and therapy to screen resident. Evaluate/treat per order. Self care deficits was identified with interventions to anticipate needs-provide prompt assistance, ensure light is within reach and answer in a timely manner, provide (extensive) assistance of (1-2 support persons for bed mobility, provide extensive assistance of (1-2 support persons) for transfers and provide (Supervision/Set up) assistance of (1-2 support persons for eating and staff to monitor for tolerance of intake, provide total assistance of (1 support person) for toileting/incontinent care and provide privacy and maintain dignity. CR#8 was identified for being at risk for wandering as evidenced by dementia/Alzheimer's and he was full code. Record review of CR#8's Care Plan did not reveal he was care planned for behaviors such as playing with his bed remote or rearranging furniture. Record review of CR#8's MDS assessment dated [DATE] revealed a BIMS Summary score of 3 indicating severe cognitive impairment, no behaviors exhibited, verbal behavior occurred 4 to 6 times, the functional status revealed bed mobility, transfer, locomotion off the unit, dressing, toilet use and personal hygiene were extensive assistance with one person physical assist and limited assistance for walking in room and corridor, and locomotion on unit. Record review of CR#8's physician orders revealed: Observation: Behaviors, target behaviors (Hallucinations, Aggression, Wandering, Depressive Feature) every shift Monitor resident for presence of behaviors. Document yes or no to whether behaviors were observed? Notify MD as needed for behaviors. Started on [DATE] Observation: Pain-observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate. Document in the PN's. every shift. Started on [DATE]. Amlodipine Besylate oral tablet 5 mg (Amlodipine Besylate) give 5 mg by mouth one time a day related to essential (primary) hypertension (110) Hold for systolic blood pressure <110, diastolic blood pressure <60, pulse <60. Started on [DATE] Aricept Oral tablet 10 mg (Donepezil Hydrocholoride) Give 0.5 tablet by mouth one time a day for dementia started on [DATE] Gemtesa Oral tablet 75 mg (vibegron) give 1 tablet by mouth one time a day related to overactive bladder started on [DATE] Megestrol Acetate oral suspension 400 mg/10ml (Megestrol Acetate) give 10 ml by mouth two times a day for loss of appetite started on [DATE] Memantine HCl oral tablet 10 mg (Memantine HCl) give 10 mg by mouth two times a day for dementia started on [DATE]. ProAir HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 1 inhalation inhale orally every 6 hours as needed for COPD started on [DATE] ProMod Oral Liquid (Nutritional Supplements) give 30 ml by mouth three times a day related to unspecified protein-calorie malnutrition started on [DATE]. Tylenol Oral tablet 325 mg (Acetaminophen) give 2 tablets by mouth every 6 hours as needed for OA related to unspecified osteoarthritis started on [DATE]. Record review of CR#8's Facility Provider Investigation Report dated [DATE] and reported to the State on [DATE] at 1:50 p.m. revealed Incident Category Death on [DATE] at 6 a.m. in resident's room. CR#8 functional assistance was total assistance in Memory Care. CR#8 was independently ambulatory, not interviewable, no capacity to make informed decisions and not wearing a wander guard at time of incident. Description of the allegations: Allegedly while the CNA was making her rounds she observed the resident lying on the floor in his room unresponsive. LVN E immediately assessed the resident (CR#8) noting bleeding from the right side of the forehead, resident unresponsive. Staff in-service initiated on fall prevention. Investigation Summary: Based on the information provided this investigation, while making AM rounds the CNA observed the resident lying on the floor in his room unresponsive. Per the CNA, she started her rounds at 10:00 p.m. the resident was in bed resting. Rounds were made again at 12:00 a.m. and then at 2 am, resident was resting in bed. When the CNA made rounds at 4 AM she noted the resident lying on the floor. She went into the room, called his name but did not get a response. The CNA immediately notified the Charge Nurse of her findings. The Charge Nurse immediately assessed the resident noting blood on the right side of his forehead and resident unresponsive. Resident continued to be unresponsive and was pronounced by the EMS. Record review of County EMS date of Service [DATE] with primary role: Medic Transport, Paramedic, Ambulance Response Info: Nature of Call: Cardiac Arrest/Death, Patient found: On floor, Initial Patient Acuity: Dead without Resuscitation Efforts (Black) . Disposition: Type of Service 911 Response (Scene) Outcome: Dead at Scene- No Resuscitation Attempted- No Transport Record review of police body camera dated [DATE] at 4:58 a.m. revealed Paramedic stated the facility staff said they last saw CR#8 at 2 a.m. and he was okay and at 4:34 a.m. they were rounding and found CR#8. Observation of CR#8's room did not reveal a crash cart, nothing on the floor, no [NAME] bag observed. The police stated you can still see the blood right there. The Paramedic stated some facilities have a bed alarm. Police asked did the resident pee and pointed to something on the floor and EMS said they have no idea what that was on the floor. The paramedic stated he did not know what the facility policy was. Police officer was heard asking the facility for CR#8's paperwork and observation revealed LVN E was still trying to get the face sheet. LVN E stated at 2 a.m. CR#8 was still in bed and at around 4 am. LVN E stated they decided to start their morning job. The Police officer was observed asking LVN E did they have something for when residents fell out the bed, and LVN E stated the facility did not have anything. Observation revealed the Nurses station and there were no other nurses assisting LVN E at this time printing paperwork. LVN E was observed trying to Observation did not reveal a crash cart out or an [NAME] bag at the nurses station. LVN E was observed printing all CR#8's paperwork for the paramedic and the police. LVN E stated all the facility had was the call light that the resident may use when they need help. LVN E stated the CNA found CR#8 and CR#8 was diagnosed with dementia. LVN E was observed printing out the face sheet for the police officer. LVN E stated there was no DNR on record for CR#8 and he was full code. LVN E stated the full code was the first thing he checked. LVN E told the police officer that nursing homes did not allow bedrails. LVN E stated bedrails were considered a restraint. The police was heard asking for the paperwork and saying the facility smelled like urine. Observation revealed the police was saying something and they muted the body camera. LVN E stated CR#8 raised the bed and CR#8 fell out of the bed. The police stated CR#8 bled for a minute and the police said they probably could have saved him [CR#8]. Police was heard asking LVN E if anybody walked down that aisle and LVN E said no body walked down that aisle. The police asked if LVN E called his boss. LVN E said he would call his boss at 5:07 a.m. to tell his boss. The police officer stated he did not know what the cause of death would be because CR#8 fell. LVN E could be heard stating that 911 was at the facility and they were working with CR#8 and police was heard asking what did LVN E's boss say. LVN E stated the paramedics called the death at 4:46 a.m. LVN E was heard calling the family at 5:12 a.m. The police asked was CR#8's family member's coming to the facility and if they stayed far. The police officer asked where the family member's were coming from and she said she was not too far. Police asked how long it would take to get here and if they had a funeral home in mind. She said they need to get all the paperwork and call the funeral home. Police said the funeral home could not get the body yet because he needed to call the Medical Examiner. The family member said they would come after they get the paperwork for the funeral home. LVN E was heard telling the family member to wait until she got to the facility to call the funeral home. LVN E told the police he just spoke with the Director but said it was the DON. LVN E stated CR#8's doctor does not sign the death certificate in a situation like this. The police asked for the doctor information. The police said CR#8's room smells. The police asked LVN E to call for CNA C. LVN E was heard calling for CNA C to come. The police asked CNA C what happened and she stated the first time she rounded to see the residents was around 10 p.m. CNA C stated they check the resident's every 2 hours and her next round was around 2 a.m. and he was laying in bed face up. CNA C stated at 2 a.m. CR#8 had been in the room fumbling around and picking stuff of the floor. CNA C stated after 4 a.m. she saw CR#8 on the floor and ran back out the room. CNA C stated she kind of touched CR#8 and said LVN E went into the room and she saw CR#8's blood. She stated when she saw CR#8, he was facing on the side downward. She said the bed was not high when she went into the room. She grabbed LVN E and LVN E touched CR#8. On [DATE] at 5:26 a.m. CR#8's family member spoke with the police and he told her they could not call the funeral home now because he had to call the medical examiner. He said the funeral home will have to get the body from the medical examiner. She said she had the mortuary for the funeral home. The Police asked what time they were coming to the facility. Police said they could start heading towards the facility. He said he was sorry for their loss. The police continued with CNA C and she stated CR#8 was cold to the touch and that CR#8 got hit on the left side of the temple and that was where the blood was coming from. LVN E heard that the iron tire on the bed was where CR#8 hit. Before he hit the ground he hit a metal piece that was attached to the bed. Police called the medical examiner at 5:36 a.m. LVN E stated he just spoke with CR#8's family member. LVN E told the police CR#8 was a full code. Police stated the facility staff did not hear CR#8 fall. Police was observed asking LVN E to print CR#8's physician orders. Observation did not reveal any other nurses printing any paperwork or assisting LVN E with anything. Observation revealed the police had the SILK test and the police said he would give it to the medical examiner. Case number 2300-2156. Record review of Police body camera on [DATE] at 6:02 a.m. Resident observed laying on his back with both arms across his chest. Observation revealed blood at the head of roommates bed. Police observed walking down the hallway towards the Nurse Station. LVN E stated the roommate was walking in the hallway right now. The police stated the room and CR#8's body needed to be cleaned and he said the room smelled. They have to clean that room and they are going to come get the body. Police stated CR#8 peed in the bed. Police asked LVN E to call the family member at 6:05 a.m. CNA C was heard saying that CR#8 continued to raise the bed up and mess with the bed remote. The police said the family member could not come look at the body like that. The police spoke with the family member and said the body will be transported and they will not be able to see the body right now and the family member was already in the car right now. He said he could not let them see the body like this. 23-01665F for Medical Examiner and the number is [PHONE NUMBER]. Police instructed them to say case in regards to her father and the medical examiner is [NAME], [NAME]. The police said he could not let them see the body like this. They will pick the body up in the next 30 minutes. Record review of police body camera video dated [DATE] at 6:26 a.m. revealed 911 Police instructing LVN E tell to write specifics on the report stating CR#8 had a hole in the right temple of the head at 6:26 a.m. Police officer was heard asking how was CR#8's body was so close to the other bed (roommates bed) in the room. LVN E stated the foot of CR#8's bed was always up. LVN E was heard saying the bed was all the way up when he found CR#8. LVN E stated when he went into the room LVN E put the bed down low. CR#8 was found on his side. The black thing on the edge of the bed is metal and this is where CR #8's head was found. LVN E stated CR#8 liked to move his bed and his bed was moved all the way by the roommates bed. Observation revealed Police said he had the staff to remove roommate out of the room. CR #8 body's was observed on the floor with both of his arms across his chest. Observation of CR#8's room on the video did not reveal a crash cart, [NAME] bag and no other staff assisting LVN E. Observation of the body camera video revealed Police was heard asking how he can lift the bed up and he was heard asking for CR#8's bed remote. Observation revealed blood on the floor by roommates bed. Record review of 29 photographs taken on [DATE] of CR#8 and CR#8's room by First Responders revealed a large amount of blood on the floor and bed wheel of the (resident's) roommate. The blood was both smeared and puddled. CR#8 was observed laying at the end of his own bed with his feet towards the door. His arms were resting on his chest. HE was wearing socks and a gown. A puddle of blood was on the floor by his head. CR#8's eyes were open, mouth was closed. CR#8 was observed with a wound (appeared to be a hole) to right side of his head above his eye. The bed was observed to have 3 stacked pillows at the head of the bed. The pictures revealed the head of CR#8's bed was lower than the foot of the bed. One photograph revealed the bed was in a low lying position, head of bed lower than the foot of bed. A separate photo of the bed revealed the bed was in a raised position, the head of bed was lower than the foot of bed. Call light was attached to CR#8's) and roommates bed. Observation revealed there was a small amount of blood on the roommates call light cord. There was no blood visible on CR#8's bed. In a telephone interview on [DATE] at 1:25 p.m. with CNA C she stated she worked the night shift in the Memory Care Unit from 10pm-6am and had been working on the unit for a year. CNA C said when she arrived to work on [DATE] at 10:00pm she made rounds on the residents and that CR#8 was sleeping in bed with the bed in low position with no concerns identified. She said she made rounds on the residents every 2 hours going in the resident's room making sure they were breathing and doing okay. CNA C said she made rounds again at 12:00am and 2:00am with CR#8 continuing to rest quietly in bed with bed in low position and bed had not been moved. She said when she went to check on CR#8 again at 4:00a.m., she found CR#8 on the floor in his room with his head somewhat under his roommate's bed and thought resident was resting on his left side but was not certain but resident (CR#8) was not responding when she started calling his name. CNA C said resident bed was still in the low position and the bed had not been moved. She said CR#8 could walk and dress himself always rearranging stuff in his room such as his table. CNA C said CR#8 did have the behavior of liking to play with the bed remote a lot raising the bed in the highest position or raising the head or foot of bed putting in different positions. In an interview on [DATE] at 12:19 p.m. with LVN E he stated on [DATE] at first CR#8 was in bed the last time they saw him was 2 a.m. and around 4:15 a.m. LVN E stated he was giving meds and CNA C started changing the residents. He stated CNA C went to CR#8's room to change him and when she entered the room CNA C came out running and calling his name. LVN E stated he asked what was going on and CNA C said come, come, it looks like [CR#8] fell out of his bed and they found CR#8 between his bed and his roommate's bed because CR#8 pushed his bed close to his roommate's bed. LVN E stated CR#8's bed was able to move. CR#8 was lying on his right side and CR#8's forehead was against the head of his roommate's bed on the tire. LVN E stated CR#8's head came straight down on the tire. He stated since CR#8 was between the beds, LVN E tried to push the bed back but it was all the way up and the bed was not going down. LVN E