**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and facility documentation, and during the course of an investigation the facility staff failed to ensure Residents are free from accidents and hazards for 2 Residents (#21 & #58) in a survey sample of 32 Residents resulting in harm for Resident #21. The findings included: 1. For Resident #21 the facility staff failed to transfer the Resident using the required number of staff as indicated on the MDS and the care plan, subsequently she sustained a skin tear requiring sutures, which became infected; this is harm. On 3/9/22 a review of the clinical record revealed that Resident #21 sustained an injury to her right leg while transferring from wheel chair to bed on 2/7/22. The Resident was transferred by one staff member. The most recent MDS with an ARD of 1/24/22 revealed that Section G coded the Resident as #3 -Extensive Assistance of #3 -2 or more persons Physical Assistance. Resident #21 was coded with moderate cognitive impairment. The care plan read as follows: Approach start date 1/17/22 - I need extensive assistance with transfers. I need 2 person staff support with transfers. Resident #21 was taken to the emergency room and required sutures to close the 7 cm x 6 cm x 0.1 cm skin tear. The Resident was sent back to the facility with instructions for wound care. Excerpts from the hospital ER Record are as follows: 2/7/22 at 11:01 PM - Well-appearing [age and gender redacted] coming to us from facility with skin tear/ laceration to the right lateral mid shin. Is quite extensive tear and goes fairly deep. There is some oozing from the wound as well. The muscle been a skin avulsion [sic] as well as the wound does not entirely come together. The wound is been repaired by the physician assistant. Please see her note for the procedure. The skin is quite think in this area and I do feel that it is possible that the wound will not heal well. I think there is a chance that there could be dehiscence or even wound degradation and so therefore of counseled the family that she needs very close follow-up with the wound care team. They state they have one at the facility where she is staying. Have also counseled them follow-up with [Hospital name redacted] in the next couple of days to make sure that this wound is healing well. Family is comfortable with plan for discharge home knows to return to the ER sooner if there are any new or worsening symptoms. Will give prescription for antibiotics as well.The Resident returned to the facility. However on 2/17/22, the wound physician noted signs of infection and wrote new orders. Excerpts from the RN note written on 2/17/22 at 2:08 PM read as follows: Right lateral shin 9 cm x 7 cm x 3 cm with light purulent drainage and 100% necrosis. New order to cleanse area with Dakin's solution, pat dry, pack with Dakin's solution-soaked gauze and cover with and ABD and wrap with Kerlix and ace wrap daily. New order for Rocefin [sic] IV ABT daily. New orders transcribed and emergency contact acknowledged via telephone. Excerpts from the Nurse Practitioner note entered on 2/17/22 at 3:20 PM read: Patient seen and examined, her right shin wound was observed with notable signs of infection, suture line skin is partially loosened & necrotic with underlying hematoma. She was seen by wound team and hematoma was evacuated, sutures removed. exacerbated with wound care. On 3/9/21 at approximately 3:00 PM an interview was conducted with the DON who stated that the injury was sustained with a staffing agency CNA who was providing care and transferred her without assistance of a second person. The DON stated the resident has fragile skin and has a history of injuring her legs during transfer. On 3/10/22 at approximately 11:15 AM an interview was conducted with LPN B who was asked where the CNAs get information on how each Resident needs to be transferred. LPN B stated that the CNA's look in the care plan. On the afternoon of 3/9/22 an interview was conducted with CNA C who stated that on 2/7/22 he asked the Resident if she could help with the transfer and she stated that she could. He stated that he used extreme care however when he transferred her to the bed he noticed she had a skin tear to her right leg. He stated he immediately notified the LPN. On the afternoon of 3/9/22 an interview was conducted with CNA D who stated that she found the skin tear on 3/22/22 when she was undressing the resident for bed. She stated the wound had dried blood on it when she discovered it. She denied having knowledge of how the wound occurred. On 3/10/21 at approximately 11:00 AM an interview was conducted with CNA B who was asked how a CNA knows each Resident needs to be transferred. CNA B stated that she will ask the Resident or ask another CNA or nurse. On 3/10/22 at approximately 10:45 AM an interview with Resident #21 was conducted and she stated As far as I can remember I hit my leg on the wheel chair On 3/10/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 2. For Resident #58 the facility staff failed to provide adequate supervision (hourly checks as stated in care plan) to ensure Resident safety after initial fall on 2/22/22. On 3/9/22 a review of the clinical record revealed that Resident #58 had 2 falls since his admission on [DATE]. The first fall occurred on 2/22/22 at 4:45 AM, the progress note read: 2/22/22 at 5:20 AM - Writer was sitting at nurse's station at 0445. Heard a small voice yelling out, Help Help. As I got up from behind nurses station and looked up both hallways, I observed resident lying-in the floor in prone position in front of [Room number redacted] doorway. He was alert and verbal. Aspen collar intact. Resident assessed and was able to assist with repositioning himself into supine position. Neck and upper extremities supported at all times. Resident observed lifting both legs high in the air and bending his knees w/o being instructed to. Tolerated AROM to all extremities w/o c/o pain or discomfort. Neuro checks done and all were WNL. PEARL, bilateral hand grasps equal in strength. v/s 96.9 75 20 148/72 O2 sats 96%. Resident assisted into a sitting position w/o complaints. Then into standing position. Transferred into a wheelchair and was assisted back into bed. Resident observed with 4 skin tears in total on complete head to toe assessment. Rt elbow ST measuring 3.2x3cm. A review of the care plan revealed that the facility initiated the following interventions after the first fall. Approach Start Date: 02/22/2022 -Round on resident Q1H for safety -Certified Nurse Aide (CNA), Nursing. The second fall the Resident sustained was one day later on 2/23/22 at approximately 4:34 AM the progress note read 2/23/22 at 4:34 AM - Writer was sitting at nurses station and heard someone yelling out Help Help. Writer immediately got up from nurses station and immediately went into [Room number redacted], turned the light on and observed resident kneeling at the side of his roommates' bed. Aspen collar on and resident was observed still connected to his IV. Neuro check done and all WNL. Resident asked by writer, Why are you on the floor, resident replied, I don't know, I'm crazy. Skin abrasion observed on RT mid back. Resident assisted back into bed by three staff. Bed kept in lowest position at all times. v/s 96.7 78 20132/76 O2 sats 97% [MD name redacted] was made aware and no new orders received. Call was placed to resident's son [name redacted] and message was left on voicemail to call facility when available. On 3/10/22 at 11:00 AM an interview was conducted with the DON who stated she could not find the records of the hourly checks being done. She stated in her opinion it was because it was not put in as Display on POC so it was not in the system for the CNA's and or Nurses to check off. When asked if this meant the checks were not being done she stated they were not. On 3/10/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure that 2 residents. (Resident #60) and (Resident #8) in the survey sample of 26 residents were free of accidents hazards. This resulted in harm for Resident #60. The Findings included: 1. For Resident #60, the facility staff failed to ensure that her call bell was placed within a safe reaching distance, resulting in her leaning to reach it, losing her balance, and pulling the call bell cord out of the wall as she fell forward. This resulted in a left arm fracture. This is harm. Resident #60 was a [AGE] year old. Resident #60's diagnoses included Aftercare following Joint Replacement surgery Right Shoulder, Primary Osteoarthritis-Right Shoulder, Bicipital tendonitis, Right Shoulder, Abnormalities of Gait and Mobility, Generalized Muscle Weakness, and Glaucoma. The admission Minimum Data Set, dated [DATE] was reviewed. Resident #60 had a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. Resident #60 was coded as requiring the physical assistance of 1 person for eating, transfers, dressing and ambulation. On 2/25/20 a review was conducted of facility documentation, revealing a Facility Reported Incident dated 1/30/20. An excerpt read, Acute, Non-displaced fracture of the proximal Humerus. Resident pushed her bedside table after breakfast & fell forward with the table. Staff heard her calling for help. She was found on the floor in a prone position. The Follow-up report was not submitted by the Administrator (Employee A) until 2/10/20. An excerpt read, Resident, age [AGE] is recuperating from the results of her fall, which occurred as she pushed away her bedside tray from her bed after breakfast. We do not believe there was anything unusual about this incident, and certainly no suspicion of abuse was considered. On 2/25/20 at 11:02 A.M., an interview was conducted of Resident #60 in her room. She stated that there was no staff person in her room to assist her with her meal on the morning of her fall. She said that her right shoulder was inoperable due to a recent surgery. She said that during breakfast a staff member put her wheelchair near the bottom left of her bed, with her right shoulder closest to the bed. After she was put into her wheelchair by a staff member, The call bell was never moved from it's position on the right side of the bed near the outer edge, halfway down the mattress. The call bell was approximately 3 feet away from her left hand, which was her only working hand. She had to reach across her body and [NAME] toward the call bell. As she grabbed it, she fell out of the wheelchair onto the floor, with a force that pulled the call bell cord out of the wall. Resident #60 said that she fell and broke her left arm, and experienced a high level of pain. Resident #60 stated that she was subsequently given a pad-type call bell, which was easier to use. She originally had a standard plunger-type of call bell. She stated that she was on the floor screaming for a couple of minutes before staff came in to assist her. She subsequently was hospital. On 2/26/20 the second day of the survey, the facility obtained a written statement from Resident #60. An excerpt read, I sat in the wheelchair by the left side of the bed for breakfast. I finished my breakfast and the tray was on the table that was in front of the wheelchair, then I tried to reach the call light on top of the bed that was far away from me. I lost my balance and fell onto my left side facing the wall. The table moved forward in front of me. The incident report signed by LPN-J was reviewed. An excerpt read, .she pushed away the bedside table that was in front of the chair and she went forward with the table. This writer went to the resident's room and observed resident in a prone position, the bedside table in front of her and the call light hanging by the left side of the bed close to her. LPN-J did not state in the report that the call light had been pulled out of the wall by Resident #60. On 2/27/20 at approximately 4:00 P.M., an interview was conducted with Licensed Practical Nurse J (LPN -J). LPN-J was the staff person who wrote the incident report, because she responded to Resident #60's call for help after the fall. LPN-J stated, The call light was on She was yelling. I was busy passing meds. I can't tell how long the call light was on, the yelling alerted me. When asked why there was no Certified Nursing Assistant assisting Resident #60, LPN-J said, They were all busy helping other residents who needed assistance. She told me I want the tray to be taken out. She told me at the time that the call bell was out of reach. The new one is much better, it is more sensitive to the touch. When asked why she didn't document Resident #60's statement about the call bell being far away from her, LPN-J did not state the reason. On 2/27/20 the call bell Zone Activity Report was reviewed. It documented that on 1/30/20 from 8:54:28 A.M., until over 2 minutes later at 8:57:54 the call bell experienced Circuit Trouble, indicating that it had been abruptly disconnected from the wall. This was at the time of the fall. Prior to the fall, the call bell was working and had been rung at 7:54:05 A.M. and responded to at 7:54:33 A.M. On 2/27 a review was conducted of Resident #60's clinical record, revealing a care plan. An excerpt read, ADL [Activities of Daily Living]. Resident needs assistance with daily ADL care .need setup with eating. At risk for impaired nutrition .Staff to provide cut-up assistance at meal times as needed .potential for falls . Keep personal items within reach. 1/31/20 Regular call bell was changed to easy touch call. The x-ray report dated 1/30/20 was reviewed. An excerpt read, Acute, Non-Displaced Fracture of the Proximal Left Humerus. Resident #60 was sent to the hospital, and returned that day with her arm in a sling. The physician order was reviewed. An excerpt read, Sling to left upper arm at all times except for hygiene or the routine ROM [Range of Motion]. The facility staff conducted an inservice during the survey on 2/26/20 -2/27/20 regarding placing the call bell within reach. On 2/27/20, a review of facility documentation was conducted, revealing a Call Light Answering policy dated November, 2018. An excerpt read, When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. On 2/27/20 at approximately 4:30 P.M., the Administrator (Employee A) was informed of the findings. No further information was submitted. 2. For Resident #8, the facility staff failed to ensure that his call bell was within reach for two consecutive days during the survey. Resident #8 was a [AGE] year old. Resident #8's diagnoses included Heart Failure, Wheezing, and Acute Bronchitis. The Quarterly Minimum Data Set, dated [DATE] was reviewed. Resident #8 had a Brief Interview of Mental Status Score of 14, indicating no cognitive impairment. Resident #8 was coded as requiring the extensive physical assistance of 1 person for toileting, transfers, Wheelchair locomotion, and toileting. In addition to also having impaired range of motion in the upper and lower extremities on both sides. On 2/25/20 at 11:29 A.M., an observation was conducted of Resident #8 in his wheelchair, sitting in his room. The Call bell was on the floor between his bed and the night stand. The resident stated that the call light is often on the floor, and he has to bend down while in his wheelchair to pick it up. On 2/26/20 at approximately 1:00 P.M., a second observation was made of Resident #8's call bell on the floor between the bed and the nightstand. It was in that same position on the first day of the survey. Licensed Practical Nurse I was immediately interviewed inside of Resident #8's room. She was asked where Resident #8's call bell was located. She stated, I don't see it. When asked about the importance of the call bell being within Resident #8's reach, LPN-I stated, So that when he's calling for help, the CNA [Certified Nursing Assistant] can come in quickly. On 2/26/20 a review was conducted of Resident #8's care plan. An excerpt read, ADL [Activities of Daily Living] Functional/Rehabilitation. Resident requires limited assistance from one person for upper body dressing, and extensive assistance from one person for personal hygiene, lower body dressing and transfers. On 2/27/20, a review of facility documentation was conducted, revealing a Call Light Answering policy dated November, 2018. An excerpt read, When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. On 2/27/20 at approximately 4:30 P.M., the Administrator (Employee A) was informed of the findings. No further information was submitted.