**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 52 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease with dyskinesia, dementia, insomnia, monoplegia of upper limb, dysphagia, myalgia, and muscle spasms. Resident 52's medical record was reviewed on 1/6/25 through 1/9/25. A care plan Focus initiated on 7/31/19, documented [Resident 52] is High risk for falls r/t Parkinson's disease, poor safety awareness, impaired balance, impaired mobility, impulsiveness frequently taking all of his clothing out of the closet and drawers and throwing them on the floor. The Focus was revised and canceled on 12/27/23. No new fall interventions were implemented in 2023. An annual MDS assessment dated [DATE], revealed resident 52 had a BIMS score of 3, indicating significant cognitive impairment. The assessment also revealed resident 52 required one person extensive assistance for transfers, walking, and locomotion in the facility, and toileting. A fall risk assessment dated [DATE], determined that resident 52 was a high fall risk. On 2/10/23 at 6:44 PM, a Nurses note revealed, Note text: The patient is impulsive and has poor safety awareness, attempts to walk without assistance and forgets to use a wheelchair. [Resident 52] is monitored continuously for safety due to his hx [history] of falls resulting in trauma. Pt is continent of bowel and bladder. However, due to Parkinson's has accidents when he cannot move. [Resident 52] is learning safe transferring techniques and maintaining ROM [range of motion]. On 7/27/23 at 6:22 AM, a Nurses note revealed, Note text: Pt was up majority of the night attempting to rearrange his rooms furniture. Pt was very energetic and impulsive, in [sic] was unable to reason with the patient to lie down and rest. Pt was checked on throughout the night and was found moving his bed and climbing in and out of his closet. On 8/14/23 at 4:30 AM, a fall note revealed, Note text: Found patient trying to get into his closet with his pillows and blankets during pill pass at 0430 [4:30 AM]. Patient had dry blood around his right eye. Has bump to right side of right eyebrow with dry blood. Ask patient what happened? He replied, 'riding a horse.' I questioned- Horse? He replied, 'yes, I fell off the horse.' Patient had minimal swelling noted to right top of hand. Started Neuro checks and VS. Cleansed and left open to air. On 8/14/23 at 10:07 AM, a nurses note revealed, Note text: Dr. [name redacted] here this am to see resident due to unwitnessed fall during night. new order for x-ray of right hand. On 8/15/23 at 6:23 PM, a nurses note revealed, Note text: Results from XR [x-ray] right hand received. MD [Medical Director] notified at 1000 [10:00 AM]. No new orders at this time. Patient has had no c/o [complaints of] pain this shift. Patient was using right hand to feed himself during meals. On 9/14/23 at 6:02 PM, a nurses note revealed, Note text: Small laceration noted to pt L [left] eyebrow. Pt stated he had hit his head yesterday, but was unable to say where. Neuro assessment revealed no deficits. Site cleaned and left open. MD notified. Will continue to monitor. On 9/30/23 at 12:01 AM, a fall note revealed, Note text: I and another nurse were in another resident's room across the hall when an aide yelled that [resident 52] had fallen and she needed help. I went into the room and [resident 52] was lying on the floor with his arm stuck in-between where the bed meets the frame. We immediately started calling out [resident 52's] name to see if he was conscious which he responded to his name by grunting. The aide lifted his body and I dislodged his arm from the frame and where the bed meet. We sat him on the bed and I asked the aide to get the vital cart and I looked at his arm to check for injuries. I asked him if he had hit his head and he stated, 'yes.' We began neuro checks q [every] 15 mins [minutes] and I inspected his head for injuries which I did not notice any bruising on his arms or his head at that time. He had equal hand grasps, [NAME] [Pupils equal, round, reactive to light and accommodation] was not reactive to light and his pupils were pinpoint. He was able to move all extremities. His arm was red and an indentation was noticeable from where his arm was struck. On 10/4/23 at 9:28 PM, a nurses note revealed, Note text: patient was found on the floor, face down in his room approx [approximately] 2000 [8:00 PM]. He appeared to have hit his head on the corner of the dresser in his room. There was some fairly fresh bleeding. He was helped up onto the bed and when I asked how long he had been on the floor he very quietly said 'a while.' Neuro checks and VS were started immediately. He was not out of normal limits. He was put in his WC and taken into the dining room so he could safely eat his snack. The small wound on his forehead was cleaned and antibiotic ointment was placed on the wound with a band-aid. He did deny pain. He denies LOC [loss of consciousness]. An event/alert was created. The patient was seat belted into his WC due to him constantly getting up and attempting to walk. On 10/5/23 at 10:26 PM, an event/alert charting note revealed, Type of event: Unwitnessed fall. Assessment/Observations: Vital signs and neuros are stable. Patient was up walking around without wheelchair and fought staff when we tried to redirect him back to his wheelchair. Interventions: assisted patient into wheelchair and put the seatbelt on to help with decrease the occurrence of falls. Resident reaction to interventions: noncompliant. Improvement/Decline: stable. On 10/26/23 at 2:15 PM, a Skin/Wound note revealed, Note text: CNA approaches this nurse to report resident standing in room with a 'bloody gash' to his face. Upon inspection, injury is approximately 3 cm [centimeters] in length located at the distal end of L eyebrow. Area is cleaned, TAO [Troleandomycin] and bandage applied. Denies pain at site. Resident is questioned in regards to how injury occurred; points toward sink and cabinets only. VS WNL; 134/72, P 82, RR [respiratory rate] 17, T 98.2. Bed remains in low and locked position. Frequent rounding by staff continues. On 11/2/23 at 11:02 PM, a fall note revealed, Note text: CNA found patient on floor of room, with his door closed and it appeared that he had fallen from his wheelchair and hit his head on the door knob. He was alert and oriented, did nod yes when asked if he was in pain. His pupils are PERRLA motor function WNL for patient but he does have Parkinson's. Will begin neuro checks and VS protocol. On 8/14/23, a physician progress note revealed, . HPI [History and Physical Information]: [AGE] year-old nursing home resident who fell today and has pain and swelling in his right hand. He also had a small laceration on the side of his eyebrow.Physical exam: Patient appeared unchanged except for, very small laceration on the side of his eyebrow. Patient's right had had some mild swelling. The skin was intact. There was no ecchymosis . Assessment/plan: 1. Injury of hand- Right-patient will have an x-ray of the right hand will follow-up with results. It should be noted that fall interventions were not implemented after each fall. On 1/8/25 at 12:50 PM, an interview was conducted with the DON who stated every resident was evaluated for fall risk during the admission assessment. The DON did not know the frequency that residents were evaluated for falls. The DON stated falls were documented in the care plan. The DON stated after a resident fall, an IDT meeting would be held and the staff would go through the risk management process and try to figure out what the cause of the fall was. Interventions would be changed and documented in the resident's care plan. The DON stated staff checked on the residents at least every two hours. The DON stated recently staff had been checking hourly due to so many residents having falls. The DON stated during the night when resident doors were closed, the CNA would still peek into the room to check on the resident. On 1/8/25 at 2:39 PM, an interview was conducted with the Admin who stated if a resident had an unwitnessed fall it would be reported because staff did not know what happened. The Admin stated fall risk assessments were conducted on admission, post fall, and quarterly. The Admin stated after a resident sustained a fall, they would be monitored for several days afterwards. On 1/9/25 at 8:02 AM, an additional interview was conducted with the DON who stated resident 52 had bad Parkinson's and often got frozen. The DON stated resident 52 wanted to do everything by himself including feeding himself even though it was messy. The DON stated resident 52 was non-verbal, and could not walk although he thought he could. The DON stated resident 52 was in a wheelchair about 99% of the time. The DON stated resident 52 would sit on the side of his bed while in his room. The DON stated she thought resident 52 was an old bronco rider. The DON stated resident 52 was a fall risk in the sense that he had really bad Parkinson's. The DON stated she never saw resident 52 fall, but also was not in the facility much at the time resident 52 was a resident. The DON stated resident 52's bed was in the lowest position and at one point the staff moved all the furniture away from the bed. The DON stated resident 52 had a fall mat next to his bed. The DON stated staff padded everything with corners on it in his room to prevent resident 52 from bumping and injuring his head. The DON stated staff watched resident 52 like a hawk. The DON stated resident 52 was also moved close to the nurses station so he could be checked on more frequently. The DON stated both staff and residents checked on resident 52 frequently as resident 52 became increasingly impulsive and stubborn. The DON stated she was not included in the IDT meetings when resident 52 was in the facility. The DON stated she never looked at care plans, but staff would get text messages when new interventions were put into a resident's care plan. The DON stated she did not remember monitoring resident 52 for his behaviors and if resident 52 was freezing up more often, she would tell the ADON or the administrator. On 1/9/25 at 8:20 AM, an additional interview was conducted with the Admin who stated resident 52, at one time, had knee pads and a helmet to prevent injuries when he fell. The Admin stated after a while, resident 52 refused to wear the helmet. The Admin stated resident 52 slept most of the night, and staff would give him snacks during the day to keep him busy. The Admin stated resident 52 could not toilet independently, but tried occasionally. The Admin stated resident 52 was able to use the call light, but it was not always in line with when he needed care. The Admin stated their current DON did not participate in resident 52's care planning because she was not the DON at that time. The Admin stated the IDT meeting staff tried to put common sense interventions in place for resident 52. On 1/9/25 at 8:25 AM, an interview was conducted with the MDS Coordinator who stated she had been the coordinator for 12 years. The MDS Coordinator stated when changes were made to the care plan she was the person who put the information into the care plan. The MDS Coordinator stated when a resident had a fall, the fall would be discussed in the IDT meeting the following morning. The MDS Coordinator stated the IDT tried to put new interventions into the care plan every time a resident fell. The MDS Coordinator stated for resident 52, it was hard to find new things that could be put into place. The MDS Coordinator stated it was difficult adding actual falls each time, putting interventions in, and resolving the intervention. The MDS Coordinator stated the nurse on the floor would do the risk management documentation at the time of a fall and she would look each morning to see if there had been any events for the IDT meeting. The MDS Coordinator stated the DON was responsible for writing the note about the incident, and then the incident note would be scanned into the resident's medical record. The MDS Coordinator stated resident 52 was a high fall risk. The MDS Coordinator stated they were always trying to put new things into resident 52's care plan and put every thing they could think of. The MDS Coordinator stated the only CNA's that would remember resident 52 would be working at night. On 1/9/25 at 8:55 AM, an interview was conducted with CNA 5 who stated if she came upon a resident who had sustained an unwitnessed fall, she would ask the resident if they knew how they fell, how long they had been down, and if they hit their head. CNA 5 also stated she would contact a nurse to have the resident evaluated. CNA 5 stated she would ensure the resident's bed was lowered to the floor so they did not fall again, and put a protective padding down so if another fall was sustained, the resident would have a soft landing area. CNA 5 stated she would check the resident's vital signs after the nurse had assessed the resident. CNA 5 stated she found out how much assistance the resident needed by looking in the area of the resident's chart where nurses were able to leave notes for them. On 1/9/25 at 9:07 AM, an interview was conducted with the Medical Records (MR) staff who stated resident 52 had Parkinson's and dementia. The MR stated resident 52 would get up and walk, and then his legs would freeze up on him and he would fall to his knees, then get back up and went. The MR stated resident 52 had hallucinations quite a bit, and would fall a lot. The MR stated resident 52 was very impulsive and would jump up and start walking. The MR stated resident 52 was more confused at night. The MR stated the IDT and the MDS Coordinator were the staff who would work on the care plans and create the interventions. The MR stated resident 52 could not understand explanations or redirection. The MR stated all you could do was watch resident 52 and help him when needed. The MR stated resident 52 often fell by his chest of drawers where he would hit his head, or he would rummage through his closet. On 1/9/25 at 9:46 AM, an interview was conducted with CNA 2 who stated if she observed a resident who had fallen, she would get the nurse so the resident could be assessed and do vital signs on the resident. CNA 2 stated the nurse usually would tell her what to do. CNA 2 stated after she assisted a resident who had fallen, she would fill out a report and give to the nurse providing the information around the circumstances of the resident's fall if she knew. CNA 2 stated the report asked questions about the the observations that were made when the resident was found. CNA 2 stated she would also ask the resident if they knew what happened. CNA 2 stated this information was to help prevent the resident from falling again. CNA 2 stated every time the CNAs pass a resident room they were supposed to look to see that the call light was within reach, and have eyes on the resident. CNA 2 stated she checked on residents every time she passed the resident's room. On 1/9/25 at 10:16 AM, an interview was conducted with LPN 3 who stated if she found a resident that had fallen, she would try to figure out what happened, and if the resident was injured and needed to be sent to the hospital, she would call the family and the doctor. LPN 3 stated she would put a progress note in the resident's chart and an alert so the resident would be monitored more closely. LPN 3 stated she always made sure the resident was not injured before moving them to their bed. LPN 3 stated she would ask the resident if they knew what happened and document their response. LPN 3 stated there was a binder at the nurse's station with step by step instructions for caring for a resident who had sustained a fall. LPN 3 stated she would communicate what happened to the oncoming nurse for continuity or care. 3. Resident 19 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, severe dementia with psychotic disturbance, tremor, restlessness, and agitation. Resident 19's medical record was reviewed on 1/6/24 through 1/9/24. Exhibit 358 was reviewed and revealed on 10/3/24, Aide reported that while changing resident's brief he rolled resident on side, away from him, in order to provide peri care. Aide reached for wipe with right hand while left hand remained on resident. Aide states that resident flinched/jerked causing him to lunge slightly forward and fell of the side of the bed. Aide attended to patient and then went and got nurse. Nurse did assessment and call the ambulance for transport to ED [emergency department]. A care plan Focus initiated on 7/20/21, documented [Resident 19] had an ADL self-care performance deficit and is dependent on staff care for all ADL's R/t activity Intolerance, severe Alzheimer's, dementia, impaired balance. With interventions which included: BED MOBILITY: The resident used 1/2 side rails to maximize independence with turning and repositioning in bed. The resident requires substantial/dependent assistance) by 1-2 staff to turn and reposition in bed. TOILET USE: The resident is totally dependent on 1-2 staff as needed for brief changes. A MDS assessment dated [DATE], documented that resident 19 was dependent on staff for assistance, where staff did all of the effort or the assistance of two or more staff were required for the resident to complete the activity, in the areas of bed mobility, transfers, toilet use and personal hygiene. The MDS assessment documented that resident 19 had a BIMS score that suggested severe cognitive impairment. A Nurses note dated 8/30/24, documented, Resident is WC bound and requires mechanical lift for WC. Resident is dependent for all ADL's from staff . A Nurses note dated 9/5/24, documented, Resident is WC/bedbound. He is dependent on staff for all ADL's. He requires mechanical lift to get into his WC . A Nurses note dated 10/3/24, documented, 1705 [5:05 PM]-Aide came to nurse to report witnessed fall. Aide was changing patient's brief. Housekeeping one hand on patient, aide attempted to reach for some wipes while pt was turned on his side. Patient slid off the bed, face and upper body first. Bleeding noted to forehead. Pressure applied to laceration on forehead until bleeding slowed and then pressure dressing was applied. Small laceration also noted on bridge of nose. Pupils are equal and reactive. Patient did not lose consciousness. Did not attempt to move patient. 911 was called at 1716 [5:16 PM]. Assisted EMT's [Emergency Medical Technicians] with transferring pt to stretcher. Patient left facility with EMS at about 1735 [5:35 PM]. ER was notified at about 1735 [5:35 PM]. Nurses noted dated 10/3/24 at 7:08 PM, documented, Aide educated on use of siderails for pt safety. An ER note dated 10/3/24 at 6:11 PM, documented, [AGE] year-old male brought in by EMS after witnessed fall up at the nursing here in town sustaining head and nose laceration . Nasal bridge laceration, possible fracture on palpation . Significant left forehead laceration, laceration over the bridge of the forehead . Laceration does not extend down to the calvarium. A CT dated 10/3/24, documented that resident 19 had a fracture of the outer wall of the left frontal sinus. Minimal depression (1-2 mm of the outer skull fragment overlying scalp soft tissue injury, left frontal region. Comminuted nasal bone fractures, mild rightward deviation. On 1/8/25 at 11:17 AM, and interview was conducted with LPN 2. LPN 2 stated she was the nurse on duty when resident 19 fell out of bed. LPN 2 stated that CNA 4 came up to her and told her that he was changing resident 19's brief and as he went more wipes resident 19 had spasm and jerked off the bed. LPN 2 stated resident 19 was bleeding a lot from his forehead, they held pressure on the wound and took vital signs. LPN 2 stated they called for ambulance transport and they took him to the hospital. LPN 2 stated she told the DON and ADON when the incident occurred. LPN 2 stated resident 19 was not a two person when doing a brief change but the side rails should always be in place. On 1/8/25 at 4:30 PM, an interview was conducted with CNA 4. CNA 4 stated, that was basically a bad day. CNA 4 stated he was changing resident 19's brief, the resident was on his side, the resident twitched, and he fell off of the side of the bed. CNA 4 stated he usually would change resident 19 by himself and since that day he made sure the side rails were up. CNA 4 stated the side rails were not up on the day resident 19 fell out of bed. CNA 4 stated he was taught after that happened to keep the side rails up and to have another staff member with him when doing cares. CNA 4 stated he could do cares on resident 19 by himself and usually did not have another staff member with him. Observations were made during the recertification survey on 1/6/25 and 1/7/25, of CNA 4 using the Hoyer lift while performing cares on resident 19 without another staff member present. On 1/8/25 at 4:44 PM, an interview was conducted with the Admin who was the DON at the time of the fall. The Admin stated she was told CNA 4 had one hand on resident 19, reached to get wipes, resident 19 had a spasm, and he fell out of the bed. The Admin stated the side rails were not up. The Admin stated they did a one on one inservice with CNA 4 on how to keep the side rails up and what to do if resident 19 had a spasm. The Admin stated she also educated CNA 4 on the need to have two people during brief changes from then on. 4. Resident 17 was admitted to the facility on [DATE] with diagnoses which included hemiplegia affecting right dominant side, traumatic brain injury, protein calorie malnutrition, dementia, unsteadiness on feet, foot drop of right foot, adult failure to thrive, sexual dysfunction, bilateral primary osteoarthritis of hip, and insomnia. Resident 17's medical record was reviewed on 1/6/25 through 1/9/25. A care plan Focus initiated on 5/21/24, documented [Resident 17] High risk for falls per standardized fall scale cognitive deficits, confusion, deconditioning, gait/balance problems, incontinence, unaware of safety needs, wandering, impulsive behavior. With the intervention of 1:1 supervision and verbal redirection as needed for safety put into place on 10/24/24. A MDS assessment dated [DATE], documented that resident 17 was dependent on staff for assistance, where staff did all of the effort or the assistance of two or more staff were required for the resident to complete the activity, in the areas of bed mobility, transfers, toilet use and personal hygiene. The MDS assessment documented that resident 17 had a BIMS score of 3. A BIMS score of 0 to 7 would suggest severe cognitive impairment. A Nurses note dated 10/29/24 at 2:17 PM, documented, Patient has been 1:1 [one one one] since October 24 . A Nurses note dated 11/5/24 at 3:00 PM, documented, About 1400 [2:00 PM] - Heard pt yelling out. When nurse entered room, pt was lying supine on the floor by the foot of the bed. No injuries were noted, pt was then assisted into his WC x [times] 2 person assist. Neuros and vitals started per fall protocol after patient was cleaned up. Pupils are reactive and vitals are WNL. Medicated for c/o pain to his right shoulder, no bruising or redness noted to site. When asked how he fell, pt states that he attempted to go to the bathroom and his left leg 'gave out' on him. Patient denies hitting his head. Patient has been encouraged to use call light for further assistance to the restroom. A Nurses note dated 11/9/24 at 4:37 PM, documented, Heard resident yelling and swearing in his room around 1500 [3:00 PM]. Entered room and resident was lying on his back with head resting on drawers across from bed. Blood smear noted on drawer face. Assisted to wheelchair x 3 staff members and assessed resident. There was 1/4 cm lac [laceration] to back of scalp and was no longer bleeding. Started frequent VS and neuro checks. 1:1 Fall Prevention Charting was reviewed for resident 17 and revealed that on 11/5/24, resident was noted to be observed napping from 2:00 PM to 4:00 PM and on 11/9/24, resident was noted to be observed sleeping from 3:00 PM to 4:00 PM. During both of these times resident 17 was documented to have experienced a fall, one resulting in a laceration to the back of his head. On 1/7/25 at 2:31 PM, an interview was conducted with CNA 4. CNA 4 stated when a resident was on 1:1 it meant that the staff were always with the resident. CNA 4 stated 1:1 meant you stayed with the resident even when they were sleeping and watched them so they did not get hurt. On 1/7/25 at 2:50 PM, an interview was conducted with the CNAC. The CNAC stated when they had a resident who was on a 1:1 someone always kept an eye on them. The CNAC stated that when a staff member was on 1:1 duty that was their sole responsibility and if they needed to leave for any reason the responsibility was passed to another staff member, the resident always had supervision. On 1/8/25 at 10:35 AM, an interview was conducted with the Admin. The Admin stated when a resident was on 1:1 the resident would have a buddy with them all of the time. The Admin stated that a resident should not have a fall when on a 1:1 but sometimes it might happen. Resident 17 was very impulsive and difficult to predict. On 1/9/25 at 8:07 AM, a telephone interview was conducted with LPN 2. LPN 2 stated she remembered resident 17 was yelling so she went to the room, LPN 2 stated that resident 17 did not use his call light he would just get up on his own. LPN 2 stated she found him lying on the floor. LPN 2 stated she did not remember any other staff members being in the room with the resident. On 1/9/25 at 8:42 AM, an interview was conducted with the DON. The DON stated resident 17 had been on a 1:1 from 10/24/24 through 11/29/24. The DON stated that when a resident was on a 1:1 they always had a staff member with them, and if they needed cares done then the staff member needed to be certified to perform those cares. The DON stated resident 17 was very impulsive and sometimes it was difficult to get to him fast enough to keep him from falling. The DON stated there also was some staff education that needed to happen to instruct them on where to sit so they could see the resident at all time. The DON stated she was unaware of the fall where resident 17 cut his head. The DON stated she did not know where the 1:1 staff was during the incident but they should have been with the resident. 5. Resident 23 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia with moderate anxiety and mood disturbance, morbid obesity, epilepsy, right ankle and foot osteoarthritis and encephalopathy. Resident medical record was reviewed on 1/6/25 through 1/9/25. On 1/6/25 at 4:21 PM, an observation was made of CNA 4. CNA 4 took the Hoyer lift into resident 23's room and stated, Hey [resident 23], you ready to get up? Resident 23 was observed to by lying in bed, CNA 4 then closed the door. At 4:32 PM CNA 4 exited resident 23's room, resident 23 was observed to be sitting in his wheelchair. CNA 4 was observed to be the only staff in the room. A MDS assessment dated [DATE], documented that resident 23 was dependent on staff for assistance, where staff did all of the effort or the assistance of two or more staff were required for the resident to complete the activity, in the areas of bed mobility, transfers, toilet use and personal hygiene. A care plan Focus initiated on 7/9/19, documented [Resident 23] has an ADL performance deficit r/t contracture of legs, non wt [weight] bearing on legs, impaired cognition. The interventions to include Hoyer lift for transfers and the resident required total assistance by two staff to transfer using Hoyer. On 1/7/25 at 11:24 AM, an observation was made of CNA 4. CNA 4 took the Hoyer lift into resident 23's room. Resident 23 was observed to by lying in bed prior to the door closing. At 11:32 AM, resident 23 was observed to be brought out of the room in a wheelchair. No other staff members were observed to enter resident 23's room to assist CNA 4 with moving resident 23 using the Hoyer lift. 6. Resident 29 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis affecting the left non-dominant side, muscle weakness, dysphagia, unspecified osteoarthritis and cramps and spasm. Resident 29's medical record was reviewed on 1/6/25 through 1/9/25. On 1/6/25 at 4:14 PM, an observation was made of CNA 4. CNA 4 took the Hoyer lift to resident 29's room. Resident 29 was observed to be lying in bed, CNA 4 closed resident 29's door. At 4:26 PM, resident 29 was observed to exit the room with CNA 4, resident 29 had been placed in wheelchair. No other staff members were observed to have entered resident 29's room to assist CNA 4 with moving resident 29 using the Hoyer lift. A quarterly MDS assessment dated [DATE], documented that resident 29 was dependent on staff for assistance, where staff did all of the effort or the assistance of two or more staff were required for the resident to complete the activity, in the areas of bed mobility, transfers, toilet use and personal hygiene. A care plan Focus initiated on 1/24/23, documented [Resident 29] has limited physical mobility R/t stroke, weakness. The interventions to include Hoyer lift for transfers. On 1/7/25 at 1:49 PM, an interview was conducted Nursing Assistant (NA) 2. NA 2 stated when the Hoyer lift was used there needed to always be two people. NA 2 stated it took two people so one person could guide the Hoyer and one could keep the resident safe. NA 2 stated the other CNA would help the resident sit correctly on the bed or in the wheelchair and the other would run the controls of the Hoyer. On 1/7/25 at 2:01 PM, CNA 4 was observed to take the Hoyer lift and the shower bed into resident 29's room. Resident 29 was observed to be sitting in his wheelchair. At 2:10 PM, CNA 4 was observed to exit the room with the resident 29 now lying on the shower bed. No other staff were observed to enter resident 29's room. On 1/7/25 at 2:41 PM, an interview was conducted with resident 29. Resident 29 stated to talk to that guy, resident 29 was observed to point at CNA 4 if there were questions about the Hoyer lift, he was the head nurse. Resident 29 stated CNA 4 was the only one who would be in the room when he was put in the Hoyer lift. On 1/7/25 at 2:43 PM, an interview was conducted with CNA 4. CNA 4 stated when a Hoyer lift was used two staff needed to be there. CNA 4 stated resident 23 and 29 both needed a Hoyer lift to be moved from their beds to wheelchairs. CNA 4 stated he did not have any other staff member help him because he could do it by himself usually. CNA 4 stated the facility had regular staff meetings and that they did go over the use of Hoyer lifts and how to use them correctly. On 1/7/25 at 2:50 PM, an interview was conducted with the CNAC. The CNAC stated the staff should always use two staff members when they use the Hoyer lift. The CNAC stated it was unsafe to only have one person use the Hoyer lift. Two people were needed so one could guide the resident and keep them safe and the other could manage the controls. On 1/8/24 at 4:45 PM, an interview was conducted with the DON. The DON stated the staff should use two people when they need to use the Hoyer lift. The DON stated it was for the residents safety, one staff member would guide the resident when they were in the Hoyer and the other would use the controls. The DON stated they had done education with the staff on how to use the Hoyer lifts, how many staff needed to be there to use the Hoyer lifts, and how [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI). Specifically, for 1 out of 23 sampled residents, facility staff did not: promptly respond with the resident presented with signs and symptoms of a UTI; ensure the resident received an antibiotic susceptible to organism causing the UTI; and, obtain antibiotic order clarification when a disparity existed. Resident identifier: 10. Findings included: Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, senile degeneration of brain, dementia, atrial fibrillation, essential hypertension, insomnia, and cellulitis. Resident 10's medical record was reviewed on 3/14/23. A quarterly Minimum Data Set assessment dated [DATE], documented that resident 10 was occasionally incontinent of bladder and always continent of bowel. In addition, resident 10 required limited assistance of one person for toileting. A care plan Focus initiated on 2/11/23, documented 2/11/23: [Resident 10's name removed] is on antibiotic therapy Cefadroxil r/t [related to] infection UTI. Interventions included, but were not limited to, Report pertinent lab results to MD [Medical Doctor] Date Initiated: 02/13/2023. On 2/7/23 at 12:35 PM, a Nurses Note documented Note Text: CNA [Certified Nursing Assistant] notified LN [Licensed Nurse] that pt [patient] had blood in her urine this morning. LN assessed and found Gross Hematuria and reported it to MD [name removed]. Vitals are stable and pts behaviors are baseline normal. No new orders at this time. On 2/8/23 at 9:49 AM, a Nurses Note documented Note Text: U/A was collected and sent to [name removed]. [Note: A U/A was collected the day after resident 10 present with signs and symptoms of a UTI.] An MD note dated 2/8/23 at 11:35 AM, documented a chief complaint of possible UTI. Assessment/Plan Patient presents with symptoms of UTI. Results of dipstick were positive for UTI. Advised to drink clear fluids, Tylenol for pain and take prescribed medications as instructed. Patient encouraged to follow up within 1 week if not improving. 1. Acute urinary tract infection - patient had a urine culture submitted. Empiric cefadroxil. Nursing home staff continue to monitor. cefadroxil 500 mg [milligram] capsule - Take 1 capsule(s) twice a day by oral route. The February 2023 Medication Administration Record (MAR) documented: a. On 2/8/23, U/A one time only for Hematuria for 1 Day. b. On 2/11/23 at 7:15 PM, Cefadroxil Oral Capsule 500 MG (Cefadroxil) Give 1 capsule by mouth two times a day for uti until 02/17/2023 13:00 [1:00 PM]. [Note: The cefadroxil was started three days after the MD note dated 2/8/23.] c. On 2/11/23, Event/Alert Charting following Event, Document every shift until resolved: UTI ABX [antibiotics] cefadroxil 500 mg BID [twice a day] x 7 days every shift for uti for 10 Days. On 2/8/23 at 4:52 PM, a Nurses Note documented Note Text: U/A results received: Positive nitrite and other infection markers. MD [name removed] notified and no new orders at this time. A Urine Culture collected on 2/8/23 and reported on 2/13/23, documented that resident 10 had the organism Escherichia coli (E coli) in her urine. [Note: Cefadroxil was not listed on the sensitivity report. An additional antibiotic was not initiated to treat the organism.] A review of the February 2023 MAR documented that resident 10 received the last dose of cefadroxil on 2/17/23, during the morning flex administration. On 2/19/23 at 7:12 PM, an Event/Alert Charting note documented Type of Event: UTI ABX Assessment /Observation: Patient UTI resolved . Resident Reaction to Interventions: UTI resolved, no C/O [complaints of] Urinary pain Pain Management: PRN [as needed] Improvement/Decline: improvement . The Infection Report Form documented that resident 10 had a healthcare associated UTI with an onset date of 2/7/23. The UTI had a resolved date of 2/19/23. The signs and symptoms included blood in urine, abnormal labs, lethargic, agitation, confusion, and odor. No organism was documented. On 2/20/23 at 11:06 PM, an Event/Alert Charting note documented Type of Event: ABX for UTI Assessment /Observation: Patient completed ABX a few days ago. Aide [CNA] reports of urine with minimal pyuria and blood noted earlier today. Assessment put up for MD to further evaluating [sic] in the morning. Continue to encourage fluids. Call light in easy reach. Interventions: Observation. [sic] Resident Reaction to Interventions: Cooperative with care thus far. Pain Management: Denied any pain and discomfort this evening. Improvement/Decline: Decline. Notifications: n/a [not applicable]. A MD note dated 2/21/23 at 8:11 AM, documented a chief complaint of possible UTI. Assessment/Plan 1. Dysuria - patient will have urinalysis and CNS [culture and sensitivity] will be done if the nitrite is positive. Follow up with results . PAINFUL URINATION (DYSURIA): CARE INSTRUCTIONS. On 2/21/23 at 2:32 PM, a Nurses Note documented Note Text: U/A collected and sent to [name removed]. On 2/21/23 at 5:32 PM, a Nurses Note documented Note Text: Lab results: negative for nitrites; however, there was plus 4 bacteria, and the lab indicated it would be ideal for running culture and sensitivity even with nitrite negative. LN contacted MD and agreed to add it to the order. A review of the February 2023 MAR documented on 2/21/23, U/A one time only for Hematuria for 1 Day. On 2/27/23 at 6:43 AM, a Nurses Note documented Note Text: Aide reports to LN dark red blood noted in commode this morning. Blood was about 1/4 cup with foul smelling odor. A Urine Culture collected on 2/21/23 and reported on 2/27/23, documented that resident 10 had the organism E coli in her urine. On 2/28/23 at 8:30 AM, a Nurses Note documented Note Text: Culture and sensitivity report received, MD [name removed] notified and new order for Nitrofurantoin 100 mg BID for 10 days for UTI started. A MD note dated 2/28/23 at 8:48 AM, documented a chief complaint of possible UTI. HPI [history of present illness] Lower Urinary Tract Symptoms (LUTS) Reported by patient. Notes: [AGE] year-old female nursing home resident who has had lethargy as well as foul-smelling and off colored urine. Patient does not have a chronic indwelling Foley catheter. She has not had nausea vomiting or fever. Patient has had recurrent urinary tract infections that have been treated recently. On 2/28/23 at 9:34 AM, a Nurses Note documented Late Entry: Note Text: Pt vomited and [sic] hour after taking her new medication Macrobid. PT took medication with her breakfast, MD [name removed] notified no new orders at this time. On 3/1/23 at 7:28 PM, an Event/Alert Charting documented Type of Event: UTI Assessment/Observation: resident up for am meal took po [by mouth] antibiotic became ill and vomited. [Doctor name removed] was here and was notified stated to wait short while then repeat the po antibiotic no vomiting this time but refused to eat at noon meal has rested this afternoon. Interventions: ongoing monitoring Resident Reaction to Interventions: vomited this am but was able to take second dose Pain Management: no c/o pain voiced Improvement/Decline: stable Notifications: On 3/1/23 at 11:15 PM, an Event/Alert Charting documented Type of Event: UTI; ABX Assessment /Observation: Patient continue to have some discomfort during urination. Patient on ABX therapy. No a/e [adverse effects] noted from ABX therapy. Continue to encourage water. On 3/2/23 at 9:52 AM, a Nurses Note documented 'Note Text: Pt vomited approx [approximately] 1 hour after admin [administration] of Macrobid 100 mg after breakfast. MD notified no new orders at this time. On 3/3/23 at 1:00 PM, a Nurses Note documented Note Text: Aid reported resident vomited to LN. LN contacted MD and has received no new orders at this time. A MD note dated 3/4/23 at 11:49 AM, documented a chief complaint of a possible UTI. Assessment/Plan 1. Acute urinary tract infection - Urine culture was positive for E coli sensitive to Macrobid. continue Macrobid twice daily for 14 days. if patient continues to vomit or is not improving may need hospitalization for IV [intravenous] antibiotics. A review of the nursing progress notes revealed that resident 10 had no further episodes of vomiting after 3/4/23. The antibiotic, nitrofurantoin, based on documentation was stopped after the last dose on 3/9/23. The nitrofurantoin was initially ordered on 2/28/23, for 10 days. No documentation was located that the nursing staff obtained clarification from the MD note dated 3/4/23, regarding the continuation of the Macrobid (nitrofurantoin) for 14 days. On 3/14/23 at 1:25 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated the MD would call the facility with orders or the MD would check the resident assessments daily and write an order while at the facility. RN 1 stated if the MD wrote an order in the MD note the MD would write the order on a script. RN 1 stated that she would review the MD notes because she was unable to follow the MD for resident rounds. RN 1 stated the laboratory would fax the urine culture and sensitivity to the facility and if the staff did not see the report the staff would call the laboratory for the results. RN 1 stated the MD would start the resident on an emergency antibiotic until the culture and sensitivity was received. RN 1 stated when the culture and sensitivity was received the MD would change the antibiotic if necessary. On 3/15/23 at 11:52 AM, an interview was conducted with RN 2. RN 2 stated the Alert Event Charting was completed during every shift and was initiated so the staff were aware of what was happening with the resident. RN 2 stated the Alert Event Charting could be for a new medication or behaviors and the staff should also write a progress note. RN 2 stated the facility had an emergency medication system that they could pull medications from, so there would not be a reason for resident 10's antibiotic delay. RN 2 stated if there was a revision in the medication order, the revision would discontinue the prior order and there may be a delay in starting the medication. RN 2 was unable to locate an order for the cefadroxil prior to 2/11/23. RN 2 stated that Medical Records would receive the resident lab reports and would give the lab reports to the floor nurse. RN 2 stated the nurse would sign the lab indicating that it had been reviewed and the MD had been contacted. RN 2 stated the urine culture and sensitivity report for resident 10 received on 2/13/23, was not signed indicating the MD had not been contacted. On 3/15/23 at 12:04 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated there was a laboratory book to write the resident cultures in. The ADON stated Medical Records would call the laboratory to get the reports because the laboratory would not send the reports to the facility. The ADON stated there was a delay in resident 10's cefadroxil. The ADON stated that she missed the antibiotic for resident 10 and should have caught it since she was the staff member that tracked resident infections for the Monthly Infection Surveillance Log.