**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R2) of 1 resident reviewed for pressure injuries. * R2 was admitted to the facility 1/20/25 without any pressure injuries. Upon admission R2 was identified as being at high risk for pressure injury development. The facility did not develop a potential for skin integrity care plan and R2's care plans do not address repositioning or offloading R2's feet/heels. The endocrine system care plan initiated 1/24/25 includes an intervention of: inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness. This intervention was not implemented as diabetic orders were not ordered for R2. On 2/28/25, R2 was identified with unstageable pressure injuries on the right lateral ankle and right heel and suspected deep tissue injury on the right inner ankle and top of the right foot. Treatments for these pressure injuries were not ordered until 3/2/25, two days later, and R2's March TAR (Treatment Administration Record) is not checked and initialed as being completed on 3/2/25 and 3/3/25. During the survey, observations were made of R2 not wearing Prevalon boots and/or R2's heels were not being offloaded. The facility's failure to provide care to prevent the development of pressure injuries and promote the healing of pressure injuries and the failure to develop and/or update resident's pressure injury care plans created a finding of Immediate Jeopardy (IJ) that began on 1/20/25. Surveyor notified Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, [NAME] President of Success (VPS)-C, and Unit Manager (UM)-D of the immediate jeopardy on 3/13/25 at 2:23 p.m. The immediate jeopardy was removed on 3/13/25. The deficient practice continues at a scope and severity of D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's policy titled, Pressure Injuries and Non pressure Injuries and reviewed/revised 7/20/22 documents under policy: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. The following protocols should guide prevention and treatment efforts, unless specified by a physician otherwise. Documented under Policy Explanation and Compliance Guidelines: c. Initiate the baseline plan of care related to current skin status and skin risk level. (The comprehensive care plan will be developed within seven days of the completion of the comprehensive assessment - see below for additional information related to the comprehensive care plan). When determining skin risk status and appropriate interventions, consider the following: i. Braden Scale Score. ii. Co-morbid conditions, such as end stage renal disease, thyroid disease, or diabetes mellitus; iii. Drugs such as steroids that may affect healing; iv. Impaired diffuse or localized blood flow, for example, generalized atherosclerosis or lower extremity arterial insufficiency; v. Resident declination of some aspects of care and treatment; vi. Cognitive impairment; vii. Use of splints/braces or presence of a cast; viii. Presence of a medical device(s) such as an indwelling catheter, trach, nasal cannula, or CPAP (Continuous Positive Airway Pressure)/BiPAP (Bilevel Positive Airway Pressure) mask; ix. The need or request to elevate the HOB (head of bed); x. Exposure of skin to urinary and fecal incontinence; xi. Under nutrition, malnutrition, and hydration deficits; and xii. The presence of a previously healed PU (Pressure Ulcer)/PI (Pressure Injury). The history of any healed PU/PI, its origin, treatment, its stages [if known] is important assessment information since areas of healed Stage 3 or 4 PU/PIs are more likely to have recurrent breakdown. Documented under Care Planning: A Comprehensive Skin Integrity Care Plan is based on resident history, review of Skin Assessment, Braden Scale Scoring, Nutritional Assessments, resident and family interviews, and staff observations. Consider the areas of risk, as well as overall risk assessment score of the Braden Scale. Communicate identified risk factors and interventions to direct care staff . 2. Develop interventions based on individual Risk Factors including, but not limited to, weight, presence of edema, overall health status/comorbidities, use of medical devices, presence of acute infection, end of life/hospice, resident choice/preferences, or medications that may impact healing. R2 was admitted to the facility on [DATE] with diagnoses to include fracture of right femur, Diabetes Mellitus, Chronic Kidney Disease Stage 5, Peripheral Vascular Disease, Depressive Disorder, Anxiety Disorder, and Restless Leg Syndrome. R2's Power of Attorney for healthcare was activated on 1/29/25. Staff communicate with R2 by writing their question or what they are going to do on a whiteboard. R2's Braden assessment dated [DATE] has a score of 12. A score of 10 to 12 is high risk for development of a pressure injury. R2 was admitted with a right leg immobilizer with orders dated 1/21/25 of Immobilizer to right lower extremity at all times, may remove for skin checks Q (every) shift and PRN (as needed). R2's care plan documents endocrine system related to DM (diabetes mellitus) 2 initiated and revised on 1/24/25 includes an intervention of: Inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness. Initiated 1/24/25. Surveyor reviewed R2's January 2025, February 2025, and March 2025 MAR/TAR (Medication Administration Record/Treatment Administration Record). There is no evidence staff were inspecting R2's feet daily for open areas, sores, pressure areas, blisters, edema, or redness on these MARs/TARs. The facility did not develop a potential for skin integrity care plan upon admission. A potential for skin integrity care plan was not developed until 3/10/25, after R2 developed multiple pressure injuries. R2's ADL (Activities Daily Living) self-care deficit initiated 1/20/25 and revised 1/21/25 does not include an intervention for repositioning. R2's admission MDS (Minimum Data Set) with an assessment reference date of 1/26/25 has a BIMS (Brief Interview for Mental Status) score of 11 which indicates moderate cognitive impairment. R2 is assessed as requiring supervision or touching assistance for eating, substantial/maximum assistance to roll left and right, and is dependent for toileting hygiene, chair/bed to chair transfer, and toilet transfer. R2 is always incontinent of urine and occasionally incontinent of bowel. R2 is at risk for pressure injury development and is assessed as not having any pressure injuries. R2's pressure ulcer/injury CAA (care area assessment) dated 1/29/25 documents under analysis of findings for nature of the problem/condition: Pressure Ulcers CAA triggered secondary to potential for pressure ulcers. Contributing factors include ADL/functional/mobility impairment and incontinence. Risk factors include pain, development of PU/skin condition, and fluid deficit risk. A licensed nurse assesses skin each week and puts proper interventions in place to prevent skin breakdown. Skin is also assessed by caregivers with each bath and each time the resident is dressed. The physician is to be notified of any abnormal findings and treatment orders are obtained. The dietitian is monitoring her food and fluid intake, and implementing dietary interventions, as necessary. Caregivers assist with repositioning at least every two hours and as needed for comfort. Care plan will be initiated or reviewed to improve or maintain current ADL status and functional ability, maintain continence status, prevent pain, and decrease pressure ulcer/fluid deficit risk. Location of documentation: see NN (nurses notes)/Braden/TAR for the look back period. Resident has increased risk for skin impairment related to increased need for help with ADL such as bed mobility which can decrease blood flow and increase pressure leading to wounds. Documented under care plan considerations for describe impact of this problem/need on the resident and your rationale for care plan decision is the same wording as under analysis of findings for nature of the problem/condition. R2's Braden assessment dated [DATE] has a score of 14 which indicates moderate risk for the development of pressure injuries. R2's physical medicine and rehabilitation note dated 2/7/25 under history of present illness documents: Patient seen and examined. History provided partially via nursing staff and pt (patient) family. Has some improvement of appetite today. No pain today. She has been intermittent up in her chair participating in therapy. Daughter is concerned her brace on her R (right) leg is too long and irritating her skin both proximally and distally - padding has helped some. I did then reach put [sic] (out) to the orthopedic clinic and they recommend that she come out and visit for them to assess her splint and decide her weight bearing status. Her family and primary team were informed. R2's Braden assessment dated [DATE] has a score of 15 which indicates at risk for the development of pressure injuries. On 2/24/25, R2 went to an orthopedic appointment and R2's immobilizer was discontinued. R2's nurses note dated 2/28/25, at 11:38 a.m., and written by Unit Manager (UM)-D documents: Writer was called to resident's room by floor nurse. Daughter reported an area on resident's R (right) ankle. RN (Registered Nurse) and writer went in to assess. Found 4 DTIs (deep tissue injury). Resident has no description d/t (due to) cognition. Daughter stated she thought it was from the immobilizer but that was discontinued 2/24/25 and wound NP (nurse practitioner) saw resident on 2/25/25 and assessed R (right) hip incision OA (open area), assessed feet and circulation, no wounds were present. Writer and RN measured and assessed wound. NP here and aware. New treatment orders ordered and performed. POA (Power of Attorney) in agreement for wound NP to follow wounds. Prevalon boots when in bed ordered and put on Resident today. Pressure Injury #1 R2's pressure injury weekly tracker dated 2/28/25 for pressure injury, acquired in house is indicated. Under location for site documents: 47) Right ankle (outer), type is pressure, under units of measure: centimeters for length is 1.9, width 1.5, and depth 0.1. Stage is documented as Unstageable. Tissue type is 100% necrotic. Drainage is none. Documented under additional interventions/plans: Prevalon boots when in bed order obtained, applied today during assessment and treatment. NP notified and treatment ordered. POA aware. Air mattress ordered. R2's physician order with an order date of 3/2/25 documents wound care: Betadine R outer ankle and R heel, cover with Mepilex QD (every day) and PRN (as needed). Surveyor notes this order is 2 days after R2's pressure injury was identified, and the treatment is not checked and initialed as being completed on 3/2/25 and 3/3/25. On 2/28/25, the resident has a Stage IV (4) pressure ulcer to R outer ankle. Care plan developed and revised on 3/4/25 with documented interventions all initiated on 2/28/25 of: Administer medication as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/position requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. If the resident refuses treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x width x depth), stage. Obtain and monitor lab/diagnostic as ordered. Report results to MD and follow up as indicated. Prevalon boots on when in bed. On 3/5/25, an intervention of: the resident requires Air Mattress: Check function and setting every shift. Settings are 150, was initiated. Pressure Injury #2 R2's pressure injury weekly tracker dated 2/28/25 for pressure injury acquired in house with date acquired documents 2/28/25. Under location for site documents: 49) Right heel, type is Pressure, and units of measure: centimeters for length is 4.5, width 1.5. Stage is Unstageable. Tissue type is 100% necrotic. Drainage is none. Under additional interventions/plans documents: Prevalon boots when in bed order obtained, applied today during assessment and treatment. NP notified and treatment ordered. POA aware. Air mattress ordered. R2's physician order with an order date of 3/2/24 documents wound care: Betadine R outer ankle and R heel, cover with Mepilex QD (every day) and PRN (as needed). This order is 2 days after R2's pressure injury was identified, and the treatment is not checked and initialed as being completed on 3/2/25 and 3/3/25. On 2/28/25, the resident has an unstageable pressure ulcer to R heel care plan developed and revised on 3/4/25 with documented interventions all initiated on 2/28/25 of: Administer medication as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/position requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. If the resident refuses treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Inform the resident/family/caregivers of any new area of skin breakdown. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x width x depth), stage. Obtain and monitor lab/diagnostic as ordered. Report results to MD and follow up as indicated. Pressure Injury #3 R2's pressure injury weekly tracker dated 2/28/25 for pressure injury acquired in house with date acquired documents 2/28/25. Under location for site documents: 45) Right ankle (inner), type is Pressure and units of measure: centimeters for length 0.7 and width 0.8. Under Stage documents Suspected Deep Tissue Injury. Skin is 100% purple. Drainage is none. Under additional interventions/plans documents: Prevalon boots when in bed order obtained, applied today during assessment and treatment. NP notified and treatment ordered. POA aware. Air mattress ordered. R2's physician order with an order date of 3/2/25 documents: Skin prep to R inner ankle and top of R foot QD (every day) at bedtime. This order is 2 days after R2's pressure injury was identified, and the treatment is not checked and initialed as being completed on 3/2/25 and 3/3/25. On 2/28/25, the resident has a DTI R inner ankle care plan developed and revised on 3/4/25 with documented interventions all initiated on 2/28/25 of: Administer medication as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. If the resident refuses treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Inform the resident/family/caregivers of any new area of skin breakdown. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection wound size (length x width x depth), stage. Obtain and monitor lab/diagnostic as ordered. Report results to MD and follow up as indicated. Pressure Injury #4 R2's pressure injury weekly tracker dated 2/28/25 for pressure injury acquired in house is indicated with date acquired 2/28/25. Under location for site documents: Other (specify) Top of R foot, type is Pressure, and units of measure: centimeters for length 1.0 and width 0.5. Stage documents Suspected Deep Tissue Injury. Drainage is none. Under additional interventions/plans documents: Prevalon boots when in bed order obtained, applied today during assessment and treatment. NP notified and treatment ordered. POA aware. Air mattress ordered. R2's physician order with an order date of 3/2/25 documents: Skin prep to R inner ankle and top of R foot QD (every day) at bedtime. This order is 2 days after R2's pressure injury was identified, and the treatment is not checked and initialed as being completed on 3/2/25 and 3/3/25. On 2/28/25, the resident has a DTI top of R foot care plan developed with documented interventions all initiated on 2/28/25 of: Administer medication as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. If the resident refuses treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Inform the resident/family/caregivers of any new area of skin breakdown. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Pressure Injury #5 R2's nurses notes dated 3/4/25 at 12:11 p.m. and written by Unit Manager (UM)-D documents: During wound rounds with wound NP found new Unstageable DTI of the right toe. Wound NP measured and assessed. Treatment ordered and in place. POA aware. In house NP aware. Prevalon boots in place in bed. Wound NP-Q's assessment dated [DATE] for Stage 4 pressure wound of the right lateral ankle for wound size documents: 2.4 x 1.8 x not measurable cm (centimeters). Thick adherent black necrotic tissue (eschar) 80% and Slough 20%. Under additional note documents: Post-debridement assessment of this previously unstageable necrotic wound has revealed the underlying deep tissue at the muscle/fascia level, which had been obscured by necrosis prior to this point. This wound has now revealed itself to be a Stage 4 pressure injury. This is not a wound deterioration. Wound NP-Q's assessment dated [DATE] for Unstageable DTI of the right heel for wound size documents: 4.4 x 4.1 x not measurable. Skin is intact with purple/maroon discoloration. Wound NP-Q's assessment dated [DATE] for Unstageable DTI of right medial ankle for wound size documents: 1.0 x 0.9 x not measurable. Skin is intact with purple/maroon discoloration. Wound NP-Q's assessment dated [DATE] for Unstageable DTI of right dorsal foot for wound size documents: 2.2 x 1.4 x not measurable. Skin is intact with purple/maroon discoloration. Wound NP-Q's assessment dated [DATE] for Unstageable DTI of right toe for wound size documents: 0.4 x 0.8 x not measurable. Skin is intact with purple/maroon discoloration. On 3/4/25, the facility developed and revised the resident's DTI pressure ulcer R toe care plan with all interventions initiated on 3/4/25 of: Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Frequent repositioning. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate. The facility's pressure injury weekly tracker dated 3/4/25 assessment of R2's right ankle (outer), right ankle (inner), top of R foot, and right toe document the same stage, measurements and description of wound bed as Wound NP-Q's assessment. The assessment of R2's right heel has the same measurements, but the stage and tissue type are different than Wound NP-Q. The facility's assessment documents the stage as Unstageable and tissue type 100% necrotic tissue. R2's nurses note dated 3/11/25 at 13:45 (1:45 p.m.) and written by UM-D documents: Wound rounds done with wound NP, exposed hardware from a previous surgery to R ankle exposed. MD updated. [First name] POA updated talked about referral to orthopedics per POA family decided on comfort care for resident and keeping her comfortable. Will be pursuing Hospice at home. MD aware. On 3/10/25 at 9:49 a.m., Surveyor observed R2 in bed on her back with the head of the bed elevated and R2's breakfast tray on the over bed table. Surveyor observed R2 has eaten 100% of her breakfast which was on the plate. Surveyor observed R2 has bare feet and R2's heels are resting directly on the mattress. R2's heels are not being offloaded and R2 is not wearing Prevalon boots according to R2's plan of care. On 3/10/25 at 10:01 a.m., Surveyor observed Certified Nursing Assistant (CNA)-R enter R2's room. CNA-R covered R2 with a sheet and blanket and then left R2's room. During this observation Surveyor noted CNA-R did not offer to put on R2's Prevalon boots and did not offload R2's heels. On 3/10/25 at 10:19 a.m., Surveyor observed R2's POA in the room. R2 continues to be in bed on her back with her heels not offloaded and R2 is not wearing Prevalon boots. During conversation with R2's POA, Surveyor was informed they aren't here 24/7 but she is at the facility during the week from around 9:00 a.m. to about 6:00 p.m. and after she leaves other family members come, and they also come on the weekend. Surveyor inquired how often staff changes R2. R2's POA informed Surveyor they are supposed to every two hours but if we are here we change her, sometimes we are here all morning and they, (referring to staff,) aren't in. At 10:34 a.m., R2's POA checked R2's incontinence product stating, she's pretty wet. At 10:37 a.m., R2's POA put the call light on, and CNA-R responded. From 10:39 a.m. to 10:48 a.m. Surveyor observed CNA-R wash R2 and provide continence cares to R2. During this observation at 10:46 a.m., CNA-R placed a pillow under R2's lower right leg, then removed and folded the pillow in half and placed under R2's right leg. Surveyor observed the right heel is being offloaded but the left heel is resting directly on the mattress. On 3/10/25 at 2:11 p.m., Surveyor observed R2 in bed on her back with the head of the bed elevated sleeping with R2's POA at the bedside. Surveyor observed R2 is not wearing Prevalon boots. R2's heels are resting directly on the mattress; the right foot is bare and the left foot has a slipper/sock on. On 3/10/25 at 3:21 p.m., Surveyor observed R2 continues to be in bed on her back with the head of the bed elevated and R2's POA at the bedside. R2 is still not wearing the Prevalon boots and R2's heels are resting directly on the mattress. On 3/11/25 at 7:49 a.m., Surveyor observed R2 in bed on her back with the head of the bed elevated. Surveyor observed R2 is not wearing the Prevalon boots as they are in the chair. R2's heels are not being offloaded. On 3/11/25 at 7:50 a.m., Surveyor observed CNA-R enter R2's room. CNA-R wrote on the white board asking R2 if she was ready to get washed up. CNA-R raised the height of the bed. Surveyor asked CNA-R if Surveyor could see R2's feet. Surveyor observed R2 has bare feet and R2's heels are resting directly on the mattress. CNA-R then placed a pillow under R2's lower legs but R2's heels are resting directly on the pillow and are not being offloaded. CNA-R did not offer to place R2's Prevalon boots on. CNA-R wrote on the white board can I get you up. R2 responded no. CNA-R lowered the height of the bed and left R2's room. On 3/11/25 at 8:00 a.m., Surveyor asked Licensed Practical Nurse (LPN)-G if she is doing treatments today. LPN-G replied, I don't have to do them today, its wound care day, the wound nurse will do them. Surveyor asked LPN-G how R2 developed the pressure injuries. LPN-G informed Surveyor she didn't know and explained she's not over here, (referring to R2's unit,) often. On 3/11/25 at 9:09 a.m., Surveyor observed CNA-R enter R2's room with her breakfast tray, which CNA-R placed on the over bed table and left R2's room. R2 is in bed with the head of the bed elevated and a family member in the room. R2's heels are not being offloaded and R2 is not wearing the Prevalon boots. On 3/11/25 at 9:12 a.m., Surveyor asked CNA-R if she has to assist R2 with eating. CNA-R replied, she can eat herself. Surveyor asked CNA-R if R2 has any pain. CNA-R replied in the right leg, she won't let you put anything on her leg. On 3/11/25 at 10:17 a.m., Surveyor spoke with CNA-U on the telephone regarding R2. CNA-U informed Surveyor she takes care of R2 daily along with CNA-R. Surveyor asked CNA-U if she has observed any pressure injuries on R2's feet. CNA-U stated, I'm the one that discovered the sore on the bottom of her foot when I took socks off. Surveyor asked CNA-U if she remembers when this was. CNA-U replied, last week or the week before, can't remember the exact date. Surveyor asked if she reported this to anyone. CNA-U informed Surveyor she believes [first name of RN-I] was on the floor and UM-D was there. CNA-U informed Surveyor she told UM-D first as RN-I was talking to someone. Surveyor asked CNA-U before the pressure injury had developed did she take off R2's socks when doing cares. CNA-U replied we try to, but she screams out, there could be days when we did not remove the socks because she was in too much pain. Surveyor asked when R2 was in pain did she report this to the nurse. CNA-U informed Surveyor she reported each time to the nurse. CNA-U informed Surveyor R2 did start to wear the boots after the area developed. On 3/11/25 at 10:56 a.m., Surveyor observed R2 in bed on her back with the head of the bed elevated. There is a pillow under R2's right leg, length wise and R2's right heel on the pillow. R2's left heel is on the mattress. Surveyor observed R2's heels are not being offloaded and R2 is not wearing Prevalon boots. On 3/11/25 at 11:18 a.m., Surveyor observed wound rounds for R2 with Wound NP-Q and UM-D. Surveyor observed R2's wound supplies are on the over bed table. Wound NP-Q removed the dressing from R2's right knee (surgical) and right ankle. Wound NP-Q then measured R2's wounds, stating the measurements out loud. Surveyor noted the following measurements: The right knee (surgical) 1.8 x 1.2, right outer ankle 2.4 x 1.7 with hardware exposed. Surveyor observed Wound NP-Q did not measure the depth of the right outer ankle. Right heel 2 x 3.7, right medial ankle 1.8 and right dorsal foot blanching 2.5 x 1.5. During this observation, Wound NP-Q did not measure R2's right toe and did not describe the wound bed of any R2's pressure injuries. After measuring, Wound NP-Q left R2's room to document and UM-D did the treatment to R2's surgical wound and R2's pressure injuries according to physician orders. During this observation at 11:32 a.m., UM-D informed Surveyor she was going to skin prep the right heel. Surveyor asked UM-D if R2's right heel pressure injury is 100% necrotic. UM-D replied yes. At 11:38 a.m. after UM-D completed the treatment for all R2's pressure injuries, UM-D stated, I know the daughter took the boots off, but I need to find them. UM-D removed her gloves and cleansed her hands. Surveyor noted as of this time, R2's daughter has not been at the facility. UM-D located R2's Prevalon boots and placed them on R2. Surveyor asked UM-D how staff know R2 is supposed to be wearing the boots. UM-D replied, it's on the Kardex. UM-D lowered R2's bed down low, placed the call light in reach, and left R2's room. On 3/11/25 at 1:41 p.m., Surveyor observed R2 in bed on her back, wearing Prevalon boots, and a family friend is sitting next to R2's bed in a chair. On 3/11/25 at 2:27 p.m., Surveyor interviewed Wound NP-Q regarding R2. Wound NP-Q informed Surveyor 2/25/25 was her first consult with R2 as she was a new orthopedic patient. Surveyor asked Wound NP-Q when she saw R2 on 2/25/25 did she assess R2's feet. Wound NP-Q replied yes, the lower leg and feet. Surveyor asked Wound NP-Q if she observed any skin impairment areas. Wound NP-Q replied on the dorsal foot, 1st and 2nd toe had little area and believes this was all that was noted at the time. Surveyor asked Wound NP-Q how a treatment is ordered if she is not at the facility. Wound NP-Q informed Surveyor they notify her via phone, she will give a treatment order and then will assess the next week. Surveyor asked Wound NP-Q today during wound rounds why didn't she measure the depth for the right outer ankle. Wound NP-Q informed Surveyor it looked exactly the same, so she left it at the same depth. Surveyor inquired about description of the wound bed. Wound NP-Q informed Surveyor she charts them in her computer and after wound rounds she manually synchs and uploads into PCC (pointclickcare). Surveyor asked Wound NP-Q how she thought R2 developed these pressure injuries. Wound NP-Q informed Surveyor it's probably a mix of pressure, in so much pain, not willing to have cares done, repositioning, and stated to Surveyor you saw today when you touch her leg. Wound NP-Q also informed Surveyor R2 was not eating well. Wound NP-Q informed Surveyor they did order Prevalon boots after they developed. After Surveyor met with Wound NP-Q, Surveyor reviewed Wound NP-Q's initial wound evaluation dated 2/25/25. For examination of right lower extremities documents foot warm, no edema. Wound present. See focused wound exam below. There is no documentation regarding this wound, on Wound NP-Q's evaluation. On 3/12/25 at 9:09 a.m., Surveyor observed R2 eating breakfast in bed on her back with the head of the bed elevated. R2 has yellow gripper socks on her feet, R2's heels are resting directly on the mattress, and R2 is not wearing Prevalon boots. Surveyor observed the Prevalon boots are in a chair. On 3/12/25 at 9:11 a.m., Surveyor observed CNA-S enter R2's room, CNA-S informed Surveyor she usually works upstairs and was floated down. CNA-S asked R2 if she was done eating. R2 yelled I can't hear you. Surveyor informed CNA-S she has to write on the white board as R2 can't hear her. CNA-S stated they didn't even tell me that. CNA-S then wrote on the communication board if she was done eating and then if she needed anything. CNA-S removed the over bed table, which was across R2, lowered the leg portion and the head of bed and lowered the height of the bed. CNA-S then wrote on the communication board can I put a pillow on your side. CNA-S lowered the head of the bed down so the bed was flat, raised the height of the bed, and assisted R2 with rolling on her right side. CNA-S placed a pillow under R2's left side, covered R2, raised the head of the bed and lowered the bed back down. Surveyor observed R2's heels are not being offloaded and CNA-S did not offer to place R2's Prevalon boots on. On 3/12/25 at 9:23 a.m., Surveyor asked CNA-S if she has provided incontinence cares to R2 this morning. CNA-S informed Surveyor R2 was one of the first residents she washed up and changed. Surveyor asked CNA-S why R2 was not wearing Prevalon boots according to her care plan. CNA-S informed Surveyor R2 takes them off and then stated, I don't know if she is supposed to wear them. On 3/12/25 at 9:26 a.m., Surveyor interviewed UM-D regarding R2. Surveyor asked UM-D how R2's pressure injuries developed. UM-D replied, honestly they developed very quickly in a couple days. UM-D explained couple days prior R2 was

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure 1(R2) of 1 Resident was as free of accident hazards as is possible and that R2 received adequate supervision and assistance devices to prevent accidents, resulting in a fall from bed *On [DATE] at approximately 1:07 PM, R2 was found on the floor next to R2's bed on the right side unresponsive and with no pulse. The medical examiner's (ME) preliminary autopsy report dated [DATE] documents that R2 suffered possible positional asphyxia, small epidural hemorrhage of spinal cord and hemorrhage of posterior right neck soft tissue which resulted in R2's death. The report documents that R2 was found lying prone on the floor of R2's room upon first observation of the ME. R2's head was tucked under R2's chest and was bent at an extreme angle. The weight of R2's upper body was on R2's head. R2's [NAME] and comprehensive care plan documented that R2 required to be in a low bed due to being a fall risk. Based on interviews and police body camera images, R2's bed was not in the low position and the head of the bed was elevated at 30-45 degrees or more at the time of the incident. Surveyor notes that several staff members knew R2 leaned to the right when in bed. Surveyor was informed that R2 had no trunk support so if leaning to the right, R2 would have been unable to re-position R2's self or stop from rolling. Surveyor notes that there were no interventions put into place to create a barrier so R2 would be less likely to roll out of bed. Staff were aware that R2 was to be in a low bed, but needed it elevated to watch television which R2 liked to do. Surveyor notes there was no environmental adjustments with positioning and level of R2's television so R2 could safely watch television. Failure to follow the care plan and to provide an environment that was free of accident hazards based on R2's positioning needs created a finding of Immediate Jeopardy (IJ), which began on [DATE]. NHA (Nursing Home Administrator)-A , DON (Director of Nursing)-B were notified of the immediate jeopardy on [DATE] at 12:55 P.M. The immediate jeopardy was removed on [DATE]. However, the deficient practice continues at a severity/scope level of an E as the facility continues to implement their action plan. Findings Include: Surveyor reviewed the facility's Fall Prevention and Management Guidelines reviewed/revised [DATE] policy and procedure provided on [DATE] at 1:48 PM and notes the following applicable: Policy: Each Resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls to reduce the possibility/severity of injury. Policy Explanation and Compliance Guidelines: 1. The facility utilizes a standardized risk assessment for determining a Resident's fall risk. 2. Upon admission, the nurse will complete a fall risk assessment. a. Review the Resident's medical record for any diagnosis that may contribute to an increase in fall risk. The list of common diagnosis applicable to R2 include Dementia, Atrial Fibrillation, Cerebrovascular Accident (CVA) 3. The nurse will initiate interventions to help prevent falls on the Resident's baseline care plan. 4. Suggested standard interventions may include: a. Implement universal environmental interventions that decrease the risk of Resident falling, including, but not limited to: a. Implement universal environmental interventions that decrease the risk of Resident falling, including, but not limited to: i. A clear pathway to the bathroom and bedroom doors. ii. Bed is locked and lowered to a level that allows the Resident's feet to be flat on the floor when the Resident is sitting on the edge of the bed. iii. Call light and frequently used items are within reach. iv. Adequate lighting. v. Wheelchairs and assistive devices are in good repair. b. Implement routine rounding schedule. c. Monitor for changes in Resident's cognition, gait, ability to rise/sit, and balance. d. Encourage Residents to wear shoes or slippers with non-slip soles when ambulating. e. Ensure eyeglasses, if applicable, are clean and the Resident wears them when ambulating. f. Monitor vital signs in accordance with facility policy. g. Complete a fall risk assessment quarterly, post-fall, and as with a significant change of condition. 5. Suggested interventions for Residents determined to be at higher risk for falls may include: a. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. b. Provide additional interventions as directed by the Resident's assessment and based on input from the Resident or family members, including but not limited to: i. Assistive devices ii. Increased frequency of rounds iii. Increased supervision, if indicated iv. Medication regiment review v. Low bed vi. Alternate call system access vii. Scheduled ambulation or toileting assistance viii. Family/caregiver or Resident education ix. Therapy services referral x. Scheduled rest periods xi. Environmental modifications(s) including furniture, e.g. recliners. 6. Each Resident's risk factors and environmental hazards will be evaluated when developing the Resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed and should be communicated to the staff, Resident, and Resident's family/responsible party. R2 was admitted to the facility on [DATE] with diagnoses of Hypertensive Heart Disease, Type 2 Diabetes Mellitus, Anemia, Chronic Atrial Fibrillation, and Vascular Dementia, Moderate with Mood Disturbance. R2 was her own person while at the facility. On [DATE], R2 discharged to the hospital with a UTI (urinary tract infection). R2 returned to the facility on [DATE] with a diagnosis of Sepsis. A Brief Interview for Mental Status (BIMS) was completed on [DATE] upon return from the hospital. R2 scored an 8 indicating R2 demonstrated moderately impaired skills for daily decision making. Surveyor reviewed R2's most recent quarterly Minimum Data Set (MDS) dated [DATE]. R2's BIMS was a 3 indicating R2 was demonstrating severely impaired skills for daily decision making. R2's MDS documented no behaviors. The following is documented for R2's level of physical assistance: Upper dressing-substantial/maximum assist Lower dressing-dependent Left to Right roll in bed-substantial/maximum assist Lying to sitting-dependent Transfers-dependent R2's Usual/Customary Functional IDT Summary-Discharge assessment dated [DATE] documents that R2 required the following physical assistance: Mobility- Substantial/Maximum Assist Sit to lying-Dependent Transfers-dependent Eating-set-up R2's readmission Evaluation assessment dated [DATE] documents that R2 now required the following physical assistance: Bed Mobility-Total assist of 2-staff uses muscle-R2 does not help Transfers-total assist of 2- staff uses muscle-resident does not help Eating-extensive assist of 1-staff uses muscle-resident helps Ability to change and control body position-completely immobile-does not make even slight changes in body or extremity position but unable to make frequent or significant changes independently. R2's [NAME] dated [DATE] documents that R2 was an assist of 1. R2 required a hoyer lift for transfers. The [NAME] documents bed in low position and was a fall risk. R2 required assist of 1 for personal hygiene and to turn and reposition R2 every2-3 hours when in bed. R2 was assist of 2 for bathing/showering and was assist of 1 for toileting. R2 was set up for eating. R2's comprehensive care plan had the following focused problems: 1. At risk for falls due to decreased mobility-Initiated [DATE] Interventions all on [DATE] -bed in low position -encourage to transfer and change positions slowly -fall risk -have commonly used articles within easy reach -reinforce need to call for assistance 2. ADL self-care deficit as evidenced by: weakness related to:CVA-Initiated [DATE] Interventions all on [DATE] -ambulation/locomotion: with device wheelchair -bathing showering: assist of 2 -bed mobility: assist of 1 -personal hygiene-assist of 1 -toileting: assist of 1 -transfer: mechanical lift xlarge sling 3. At risk for loss of range of motion due to prior CVA-Initiated [DATE] Interventions established on [DATE]: -administer analgesia per physician's orders -therapy evaluation and treatment as ordered. Surveyor notes that R2 had an alternating pressure reducing mattress. Surveyor notes that physician orders dated [DATE] upon return from hospital document R2 was to have an evaluation and treat as indicated for physical therapy, occupational therapy, and speech therapy. This evaluation did not occur. Surveyor reviewed the initial (Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report) facility reported incident dated [DATE] at 2:50 PM and the Misconduct Incident Report dated [DATE] at 3:38 P.M for R2 falling out of bed. The facility documents R2 was found on [DATE] at approximately 1:07 PM unresponsive and no pulse. The facility indicates the alternating air mattress was functioning correctly, there were no siderails or repositioning bars on the bed, and bed was in low position. The facility provided a timeline of events leading up to R2's death on [DATE]. The following is documentation of the timeline, and interviews obtained by Surveyor during the survey process. At 7:15 AM, Housekeeper (House-C) entered R2's room and observed R2 sleeping in bed per facility documentation. On [DATE] at 11:00 AM, Surveyor interviewed House-C over the phone. House-C stated House-C was in R2's room cleaning for about 15 minutes. House-C stated that R2 was in the middle of the bed, on R2's back like always. House-C stated R2 was in a low bed like usual and was sound asleep. Between 7-8 AM, Certified Nursing Assistant (CNA-D) per facility documentation, entered the room and noted R2 seemed to be confused and was making statements about being robbed and waiting two hours for the police. CNA-D provided reassurance to R2 and reported R2's confusion to Licensed Practical Nurse (LPN-E). LPN-E received orders to obtain a UA, CBC, and BMP. On [DATE] at 11:35 AM, Surveyor interviewed CNA-D. CNA-D described R2 as quiet and a little stand offish. CNA-D stated that R2 did not move much. CNA-D stated R2 was a full assist with cares and mobility requiring 2 person assist. CNA-D informed Surveyor that R2 would frequently lean to the right side and would need to be repositioned. CNA-D stated that R2 never got out of bed per R2's choice and was alert to R2's needs. CNA-D stated that R2 had no bars on the bed and no mat on the floor next to the bed. CNA-D stated R2's bed was to be in the low position at all times. CNA-D stated the morning of [DATE], R2 was confused saying someone had robbed R2 and kept looking at the wall. CNA-D stated R2 appeared to be more confused than usual. CNA-D helped R2's roommate and told LPN-E about R2's confusion. CNA-D stated R2 was in a low bed and lying flat at this time. CNA-D confirmed that CNA-D responded to R2's incident. CNA-D observed R2 on the floor, R2's head was under R2's body. CNA-D stated the bed was at an angle and does not recall if the head of the bed was elevated. At 9:00 AM, LPN-E collected urine from R2's clean foley catheter bag and was noted to be sleeping in bed per facility documentation. At 11:00 AM, LPN-E and lab tech entered R2's room to obtain the blood samples for the labs that were ordered per facility documentation. On [DATE] at 9:17 AM, Surveyor interviewed LPN-E. LPN-E stated that R2 was confused and seeing things. Made delusional statements that men were chasing R2. LPN-E notified the physician on call and was instructed to get labs. LPN-E went to change the foley catheter bag to get clean urine. Collected the urine and gave R2 morning medications. About 1/2 hour later the lab came. The lab technician stated that R2 was not able to identify who R2 was so requested LPN-E go to the room with LPN-E to identify R2. LPN-E informed Surveyor that LPN-E verified it was R2 and left the room, not staying with the lab technician. LPN-E stated that after R2 was deceased , towards the end of LPN-E's shift is when LPN-E learned that the lab technician was not able to obtain the labs. LPN-E stated the lab technician alleges they told LPN-E but LPN-E does not remember this. LPN-E states LPN-E realized when another lab technician showed up later to obtain the labs. LPN-E stated that LPN-E observed R2 in bed, R2's right leg was hanging off of the bed. LPN-E stated that R2 would consistently lean to the right always. LPN-E stated that R2 was to be in a low bed and remembers R2's bed was elevated on [DATE]. LPN-E stated that R2 was confused that day, and who knows why R2 fell out of bed. At 11:00 AM, Activities Aide (ACT-G) entered the room to invite R2's roommate to church per facility documentation. On [DATE] at 1:20 PM, Surveyor interviewed ACT-G. ACT-G talked to R2's roommate and invited R2's roommate(R6) to church. ACT-G stated R2 was observed in bed flat, sleeping. ACT-G stated that R2's head of bed was not elevated and R2's bed was in a regular position, not a low bed. ACT-G thought the bed was parallel to the wall. ACT-G states ACT-G was in the room at 10:45 AM because church started at 11:00 AM. Surveyor notes that there is probability that the time of lab draw may not be accurate. At 12:30 PM, R2's roommate(R6) left the room to go to the dining room. A CNA had overheard R6 complaining about R2's behaviors and the CNA informed LPN-E. Staff were instructed to keep an eye on both. On [DATE] at 3:27 PM, Surveyor interviewed R2's roommate(R6). R6 stated R2's bed was against the wall and that R2 would always lean over to the right side. R6 stated R6 would always get help to reposition R2. R6 stated that R2 never moved. R6 stated R2 and R6 got along well. R6 stated the call light was never within reach of R2 so R6 would frequently get things for R2. R6 stated on [DATE], R6 recalls R2's bed being elevated but nothing else. Surveyor notes that R6's [DATE] quarterly MDS documents R6's BIMS to be a 15, indicating R6 is cognitively intact for decision making. The facility's timeline documents at 1:07 PM, CNA-F was passing meal trays and entered R2's room. CNA-F found R2 on the floor and immediately called for help. LPN-E responded first and called 911. R2 was noted to have apparent head/neck injury and was pulseless. Registered Nurse (RN-K) also responded. RN-K confirmed R2 was breathless and pulseless. On [DATE] at 12:48 PM, Surveyor interviewed CNA-F. CNA-F stated CNA-F did not take care of R2 on a regular basis but knew R2 was immobile and rarely moved. CNA-F stated that R2 never got out of bed. R2 would move R2's arms only and would feed R2's self. CNA-F stated that R2 was in a low bed with no bars. CNA-F stated that R2 did not use the bed remote and would like to lay flat. CNA-F stated the morning of [DATE], R2 did not appear to be in any distress. CNA-F provided cares about 10:00 AM on [DATE]. CNA-F stated CNA-F provided cares and did not have the assistance of any other caregivers. CNA-F was informed of the alleged roommate problem. CNA-F stated CNA-F went to give R2, R2's lunch tray and found R2 on the floor on the right side of the bed. CNA-F stated CNA-F could not find R2's head, looked like it was lost. CNA-F stated the bed at this time was not in low position and the head of the bed was elevated. CNA-F confirmed the air mattress was working. CNA-F informed Surveyor, I don't understand how this happened, especially if R2 doesn't move. CNA-F stated, never seen anything like this. The facility's summary provided by the facility only concludes there was no misconduct but does not give information that may establish what happened or why. Surveyor notes the interviews provided in the facility self report do not ask important questions like, exactly what did you do for R2, what did R2 say, what was the height of the bed when you saw R2, was the head of the bed elevated, was the call light within reach, were R2's items within reach. On [DATE] at 3:05 PM, the survey team met with Administrator (NHA-A) and Director of Nursing (DON-B). DON-B stated that caregivers would heighten a low bed to do cares. DON-B described a low bed as being close to the ground. NHA-A informed Surveyor that the facility cameras have not been working for about a month. Surveyor obtained other pertinent interviews in regard to R2's incident. On [DATE] at 1:50 PM, Unit Manager (UM-H) stated that R2 liked to lay in bed and watch TV. R2's bed was angled in the room. R2 could not sit up on own or move head. R2 could not move self in bed. UM-H stated that R2 was in a low bed meaning the bed should be lowest to the ground. UM-H stated R2 would lean more to the right side. UM-H indicated that R2's bed would be elevated to 30-45 degree angle when eating meals. UM-H stated that if R2 was flat R2 would not be able to see the television which R2 liked to do. UM-H stated that after R2's hospitalization from [DATE]-[DATE], R2 was more tired. UM-H was in shock to hear that R2 had rolled out of bed, On [DATE] at 7:45 AM, physical therapist (PT-I) stated that R2 had no range of motion (ROM) in both lower extremities. PI-I stated that R2's legs were stuck in a straight position. PT-I stated that R2 could not tolerate sitting. PT-I stated R2 had difficulty rolling side to side. PT-I talked about pillows and relied on R2 to educate the staff in regard to pillows. PT-I stated R2 was a fall risk due to lack of mobility. PT-I confirmed R2 had the potential to lean to 1 side or the other, most likely due to being weak. PT-I stated R2 was a heavy log roll and had no activation in legs. PT-I described R2 to be very rigid and stiff and very little activation in arms. PT-I stated would typically have 2 people if helping with changing R2. PT-I informed Surveyor that R2 was a potential for fall risk if elevated in bed because of no strength. PT-I confirmed that therapy did not evaluate or screen R2 upon return from hospital on [DATE] despite having physician orders to be evaluated and treated as indicated for physical, occupational, and speech therapy. On [DATE] at 8:25 AM, Surveyor interviewed LPN-J who is familiar with R2. LPN-J stated R2 barely got out bed and needed a lot of assistance. LPN-J stated, for some, 2 would assist with cares for R2. LPN- J stated R2 would frequently lean to the right side often. LPN-J stated R2's bed should be at low level. LPN-J stated, It was a surprise that R2 fell out bed. LPN-J stated maybe R2 rolled out of bed because the head of the bed was elevated and R2 didn't have upper body strength. On [DATE] at 9:56 AM, Surveyor interviewed RN-K who responded to the incident of R2 on [DATE]. RN-K stated R2 was in the corner between the wall and the bed. RN-K stated R2's bed was at a slant. When RN-K responded, RN-K observed R2's bed was at regular height and elevated 30-45 degrees. RN-K stated R2's head was tucked under R2's body. RN-K stated, Never want to see that again. It was very unnatural looking, freaky. R2's neck was clearly broken. Surveyor had RN-K set up R2's room as RN-K observed it on [DATE]. R2's bed was at an angle and the head of the bed was in the corner where the 2 walls meet. R2's TV was high on a armoire stand across from the bed. The bedside dresser was on the left of the bed. Surveyor notes that in all the interviews obtained, nobody was able to recall where the over bedside table was. Surveyor reviewed the documented police report dated [DATE]. Surveyor was also able to obtain the police body camera images. Surveyor viewed these images on [DATE] and notes the most remarkable images: -The first image is audio and you can hear someone say, oh shit, now I see it as the sheet is pulled off of R2. To the left of the screen, you can see the height of the bed which is clearly not in a low position and the head of the bed is elevated. -The 2nd, 3rd, and 6th image you can see the height of the bed and that it is elevated at the head, and not in a low position. -7th image- You can't see R2's head, R2 is close up against the wall, right arm at side, palm up. -8th image-You can't see R2's head. -11th image-You can see the space between the bed and the height of the bed. On [DATE] at 10:22 AM, Surveyor spoke to the Medical Examiner (ME-L) over the phone. ME-L stated an autopsy was completed and the final report is pending toxicology results. ME-L informed Surveyor that R2 died from positional asphyxiation, small epidural hemorrhage of spinal cord, and hemorrhage of posterior right neck. Surveyor received the ME documented report on [DATE]. The report documents the following: R2 was found lying prone on the floor of R2's room upon first observation of the ME. R2's head was tucked under R2's chest and was bent at an extreme angle. The weight of R2's upper body was on R2's head. Contusions were noted to R2's anterior left arm near the antecubital fossa. Faint blanching purple-colored lividity was noted to R2's shoulders and forehead. R2's left eye was injected. The report also documents that the headboard of the bed was flush with the walls that formed the corner of the bedroom. R2 was lying on the floor parallel to the edge of the bed. R2's bed was measured to be 30 inches off the ground. Surveyor notes that several staff members knew R2 leaned to the right when in bed. Surveyor was informed that R2 had no trunk support so if leaning to the right, R2 would have been unable to re-position R2's self or stop from rolling. Surveyor notes that there were no interventions put into place to create a barrier so R2 would be less likely to roll out of bed. Staff were aware that R2 was to be in a low bed, but needed it elevated to watch television which R2 liked to do. Surveyor notes there was no environmental adjustments with positioning and level of R2's television so R2 could safely watch television. Surveyor also notes that R2 was being provided cares by 1 or 2 caregivers but was not consistently either way. DON-B stated the safest way to provide cares to R2 was a 2 person assist. On [DATE] at 9:07 AM, Surveyor asked CNA-M to demonstrate what a bed would like if a Resident's [NAME] read low bed. CNA-M stated if there is a mat listed, the bed is put to the lowest to the floor. If a Resident does not need a mat, then CNA-M raised the bed. CNA-M demonstrated the level of the bed. Surveyor measured about 7 inches from the ground. On [DATE] at 10:10 AM, Surveyor had CNA-D demonstrate for Surveyor where a low bed should be. CNA-D stated for a low bed it goes all the way down to the ground right before the wheels touch the ground and demonstrated this for Surveyor. When the wheels drop the bed rolls easily. Surveyor asked CNA-D if everyone knows how to put a bed in low position. CNA-D stated, I assume if they are a CNA. On [DATE] at 2:27 PM, Surveyor had DON-B show Surveyor an alternating pressure mattress like what R2 had. Surveyor observed the bed the mattress was on and asked DON-B if this was what DON-B would consider a low bed. DON-B confirmed the bed was in a low position. Surveyor measured approximately 11 inches from ground. Surveyor notes that the facility does not have a standard practice for what level from the ground is considered a low bed. Surveyor was shown from approximately 7 to 11 inches from ground for a low bed. Surveyor notes ME-L's written report documents the bed was measured at 30 inches. On [DATE] at 2:06 PM, Surveyor shared the serious concern of R2 falling out of bed which resulted in death with NHA-A and DON-B. Surveyor interviewed DON-B and asked what type of assistance did R2 require. DON-B stated that the CNAs would usually do 2 assist due to R2's weight. DON-B stated that would be the safest way to provide cares to R2. DON-B confirmed that R2 required a low bed. Surveyor shared the concern that the facility investigation summary did not indicate specific aspects of the bed as it looked on [DATE]. DON-B shared that R2 had to have the bed in a certain position to watch television. The facility stated they don't know what caused R2 to roll out of bed, but maybe it was R2's urinary tract infection or some other medical issue. No further information was provided by the facility at this time. Facility failure to address the positioning needs of R2 given that R2 would often lean to the right and given that R2 could not see the TV if lying flat and its failure to ensure that R2's bed was in the low position on [DATE] created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when the facility implemented the following: Nursing staff will receive re-education on the Fall prevention and Management Guideline Policy. Education will include but is not limited to: - Each resident's risk factors will be evaluated when developing an individualized plan of care - Interventions will be monitored for effectiveness - Monitoring changes in residents condition including balance and positioning Re-education was initiated 4-24-2024 and will continue prior to employees next shift to work. Staff will receive re-education on definition of low bed and bed in low position On 4-24-2024 the ED, DON, and VPS reviewed the Fall Prevention and Management Guidelines policy and determined the policy identifies the compliance guidelines to provide services to minimize the likelihood of falls or reduce the possibility/severity of injury. No changes were required. Nursing management will re-evaluate residents with a care plan for bed in low position to determine if intervention is appropriate. Care plans will be updated based on the findings of the evaluations. DON and/or designee will complete audits on new admissions 5x weekly for 4 weeks and then 3x weekly for 4 weeks to ensure resident's at risk for falls have plans of care that are individualized and implemented by staff. DON and/or Designee will review 24 Hour Nursing Report/EMR Clinical Alerts 5x weekly for 4 weeks and then 3x weekly for 4 weeks to identify residents with a change of condition resulting in the need to re-evaluate fall risk and interventions. DON and/or Designee will audit 5 Residents per week to determine if fall interventions are in place as per plan of care for 4 weeks and then 3 Residents per week for 4 weeks Results of the audits will be brought to QAPI for further review and recommendations. ADHOC QAPI held with IDT and Medical Director telephonically on 4-24-24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility did not provide appropriate treatment and services for 1 (R1) of 1 resident with a diagnosis of dementia with behavioral symptoms to allow them to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. R1 has a diagnosis of Alzheimer's Disease and dementia. The December 2023, January 2024, February 2024, & March 2024 MAR (medication administration record) for daily behavior monitoring per shift does not document any behavior. On 4/4/24 R1's behaviors began & escalated. There was no comprehensive assessment with individualized interventions of R1's behaviors, the Facility did not assess the behavior change to identify the cause of R1's behavior, and the care plan was not revised until after R1 chased another Resident down the hall & ran over this resident's foot with her wheelchair. The Facility does not conduct dementia or trauma assessments. Failure to comprehensively assess R1's behavior and to conduct dementia & trauma assessments created a finding of Immediate Jeopardy (IJ), which began on 4/4/24. NHA (Nursing Home Administrator)-A , DON (Director of Nursing)-B, VP (Vice President) of Success-AA, and Operations-BB were notified of the immediate jeopardy on 4/24/24 at 12:55 p.m. The immediate jeopardy was removed on 4/25/24. However, the deficient practice continues at a severity/scope level of E (potential for harm/pattern) as the facility continues to implement its removal plan. Findings include: Although NHA-A informed Surveyor on 4/23/24 at 12:24 p.m. the Facility does not have a dementia care policy, on 4/24/24 at 1:48 p.m. NHA-A provided Surveyor with a dementia care policy. The Dementia Care policy dated 4/23/24 under policy documents It is the policy of this facility to provide the appropriate treatment and services for residents who display signs of, or are diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. Under Policy Explanation and Compliance Guidelines documents: 1. The Facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative, to the extent possible. 2. The care plan goals will be achievable, and the facility will provide resources necessary for the resident to be successful in meeting their goals. 3. The care plan interventions will be related to each resident's individual symptomology. 4. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. 5. Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being. 6. If needed, the environment will be modified to accommodate individual resident care needs. 7. The care plan goals and interventions will be monitored on an ongoing basis for effectiveness and will be reviewed/revised as necessary. 8. Appropriate referrals will be made if current interventions are ineffective or resident shows a decline in psychosocial, mood, or behavioral status (i.e. physician, mental health provider, licensed counselor, pharmacist, social worker). 9. Staff will be trained on dementia and dementia care practices upon hire, annually, and as needed to ensure they have the appropriate competencies and skill sets to ensure residents' safety and help residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. R1's diagnoses includes Alzheimer's disease, depression, anxiety disorder, and dementia. R1's power of attorney for healthcare was activated on 4/27/22. R1's care plan documents cognitive loss as evidence by (specify) r/t (related to): Alzheimer's disease/dementia initiated & revised on 3/30/21 documents the following interventions: * Allow adequate time to respond. Do not rush or supply words. Initiated 3/30/21. * Approach/speak in a calm, positive/reassuring manner. Initiated 3/30/21 & revised 4/27/21. * Encourage low stress activities such as music, small group activities. Initiated 3/20/21. * Invite to participate in activities such as trivia, reminiscence, current events/newspapers. Initiated 3/30/21. * Repeat communication using more than one method (words, gestures, facial expressions). Initiated 3/30/21. * Use resident's name when addressing. Initiated 3/30/21. R1's care plan documents at risk for behavior symptoms r/t: (specify) Alzheimer's disease/dementia and depression. Resident can become angry with no provocation Swear at staff, Throw items at staff, Insult other Residents, Grab other residents clothing, Will use wheelchair to get to other residents and staff to antagonize care plan initiated 9/8/23 & revised on 4/7/24 documents the following interventions: * Administer medications per physician order. Initiated 9/8/23. * Attempt psychotropic drug reduction per physicians orders. Initiated 9/8/23. * Do not seat near Resident [first name of resident with last name's initial]. Initiated 9/8/23. * Re approach resident at a later time if she becomes verbally or physically aggressive towards staff. Initiated 1/6/24. * Use consistent approaches when giving care. Initiated 1/6/24. * When Resident experiences an episode of anger ensure surrounding residents maintain an appropriate distance from Resident. Initiated 1/6/24. * Resident can become easily triggered by other residents with dementia-please monitor environment when she is amongst peers. Initiated 3/7/24. * Room change on 3/1/24 for a quieter space. Initiated 3/7/24. * Staff to not allow res (resident) by [first name of resident with last name's initial]. Initiated 4/6/24. * When res in bed-staff to attempt to pad the bed with pillows to create border to protect from hard surfaces if res. allows. Initiated 4/7/24. R1's MAR (medication administration record) documents the following: Behaviors Monitor for the following: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cursing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. If any new behavior observed document in progress notes every shift for depression/medication. Surveyor noted during the months of December 2023, January 2024, February 2024, and March 2024 there are no behaviors documented. The annual MDS (minimum data set) with an assessment reference date of 2/7/24 has a BIMS (brief interview mental status) score of 7 which indicates severe impairment. R1 is assessed as not having any behaviors including refusal of care. R1 is assessed as being independent for eating and rolling left to right, and requires supervision or touching assistance for toileting, & chair/bed to chair transfer. Yes is checked for does the resident use a wheelchair or scooter and is assessed as being independent with wheeling the wheelchair. R1 is assessed as being frequently incontinent of urine and always incontinent of bowel. The cognitive loss/dementia CAA (care area assessment) dated 2/9/24 under nature of the problem/condition is blank. Under care plan considerations documents cognitive loss will be addressed on the care plan. Resident has a dx (diagnosis) of dementia. Interventions in place. The nurses note dated 3/1/24, at 22:29 (10:29 a.m.), created 3/2/24 at 00:32 (12:32 a.m.), document Res was found standing over roommate grasping roommate's gown by her neck. Roommate was screaming for help as 2 CNAs (Certified Nursing Assistant) came to separate the two residents. Res was taken out of room and monitored at nurses station for behaviors. Room to be changed when res to lay down. At this time res calm and sitting at nurses station. Roommate in room and asking for snacks. Res in good spirits at this time. The psychosocial assessment dated [DATE] for Section B Mental Cognitive Status yes is answered for the question any psychosocial symptoms related to cognitive status. Under additional comments documents depression. Section C. Mood and Behavior Status for mood or behavior concerns since last assessment documents Res (Resident) acted out in physical aggression towards roommate. No is answered for is resident on any psychotropic medications and for mental health services Psychologist/other counselor involvement is checked. Under additional comments documents Res sees in house psych IPC (independent psychiatric consultant). Under Section D Psychosocial Status Check all those that apply: 1. Difficulty accepting placement and circumstances. 2. Difficulty with roommate. 3. Concerns with other Residents. 4. Concerns with Staff members. 5. Participates in Living Center Programs. 6. Pursues Independent Activities. 7. Maintains Supportive Relationships. 8. Has no Current Supportive Relationships. & 9. Grieving Loss of Loved One or Grieving Other Loss. Surveyor noted none of these are checked. Under Comments documents Res can often become agitated without warning. APNP (Advanced Practice Nurse Prescriber)-Z psych consult dated 3/6/24 under chief complaint documents f/u (follow up) Alzheimer's Dz (disease) Depression Dementia in other Dz classified elsewhere with Anxiety. Under narrative documents this is a f/u visit to assess pt meds and Dx as listed under Chief Complaint; Staff reports pt had aggressive encounter with peer - VPA (valproic acid) was started and pts (patients) separated to different rooms; At visit pt reports sleeps/eats good no pain why are you here-what do you want-am I in trouble-leave me alone. SSRI (selective serotonin reuptake inhibitor) recent GDR (gradual dose reduction). Under general appearance and manner documents pt up w/c - alert mild moody with mild anxiety - testy at visit. For thought process documents mod (moderate)-severe impoverished. Judgment and insight documents severe impairment. Mood and affect documents mild moody/mild anxiety. For major neurocognitive disorder Alzheimer's, moderate/severe, & without behavioral disturbances are circled. Under recommendations/plan of treatment documents Increase Lexapro back to 15mg (milligrams) q (every) day continue to monitor mood/anxiety - goal is to improve mood. The next nurses note Surveyor was able to locate regarding R1's behavior is dated 4/4/24. The nurses note dated 4/4/24, at 17:16 (5:16 p.m.), documents Describe Behavior/Mood: resident propelling self throughout hallway using profanity to all staff and residents. Unable to redirect, calling staff names, residents names. Was in the dining room for dinner and starting throwing meal and fluids. Refusing to take medications. Observed kicking and striking out at staff. Writer offered to call son and agreed, on the phone talking to son at this time. What was the resident doing prior to or at the time of behavior/mood: sitting in w/c (wheelchair) in common area. Interventions attempted: Redirected all shift, one on one with resident attempted but unsuccessful. Effectiveness of the interventions: Ineffective. This note was written by LPN (Licensed Practical Nurse)-T. The nurses note dated 4/4/24, at 21:23 (9:23 p.m.), documents Describe Behavior/Mood: Resident continues to use profanity at staff. Staff offered toileting, food and fluids. Resident declined all of above. Resident throwing items at peer, staff. Resident banging on windows in common area, bumping chair against wall, pushing empty w/c (wheelchair) towards staff. Unable to redirect. Resident propelling self in w/c taking items off of medication carts. Resident observed rolling in hallway B in and out of residents rooms and observed kicking door open after resident attempted to close door to keep resident out of their space. Following behind staff and calling staff names. Offered snack, but threw it at staff. What was the resident doing prior to or at the time of behavior/mood: sitting in w/c. Interventions attempted: Redirected resident not to throw items at staff or peers. Effectiveness of the interventions: Ineffective. This note was written by LPN-T. The nurses note dated 4/5/24, at 00:34 (12:34 a.m.), documents Res (Resident) remains up, belittling everyone she sees. Asked to speak to her son, so we called [Name] so she could talk to him. He will be in today. This note was written by LPN-S. The nurses note dated 4/5/24, at 05:38 (5:38 a.m.), documents Res has been up all night. Talking constantly!! Res is belligerent, condescending, sarcastic, downright nasty with her comments. She goes to each one of us, then to any other residents who are up. We are stupid, ugly, nasty, smell, etc., not worth her time. She is pushing carts around, chairs, throwing med (medication) cups on the floor and blaming us. Res refused morning Thyroid med, stating You don't know what you are doing, I wouldn't take anything from you!. This note was written by LPN-S. The nurses note dated 4/5/24, at 10:15 (10:15 a.m.), documents Late entry for 4/4/24, 0600-1400 (6:00 a.m.-2:00 p.m.) shift: resident refused to eat breakfast. Continued with verbal aggression: insulting staff and students calling to son of b_tch, ugly fat, liars etc. Also threatened to hit staff. Continues to wander up and down halls. This note was written by LPN-U. The nurses note dated 4/5/24, at 10:18 (10:18 a.m.), documents Resident continues to verbally abuse staff: called several staff members and students b__ches because staff tried redirecting her from leaving the unit. Resident scratch staff member on her arms during the redirecting process. Increase supervision provided Refused morning medications x (times) 3. Message left for [Name] NP (Nurse Practitioner). Per shift to shift report, resident son and MPOA (medical power of attorney) aware and will visit resident today. This note was written by LPN-U. The nurses note dated 4/5/24, at 12:37 (12:37 p.m.), documents Staff tried multiple times to administer medications. Son/NP aware resident continues to refuse medications. This note was written by LPN-U. The nurses note dated 4/6/24, at 20:36 (8:36 p.m.), documents Resident up calling staff names, using profanity, pushing over chairs, kicking medication cart. Resident rolling throughout hallway screaming, nobody is sleeping tonight. Resident kicked open door while male peer was undressed and getting washed up for bed. Resident threw shoe at staff, resident threw medications on floor. Resident offered snack and then threw on floor. Resident refused meal this shift, resident in w/c antagonizing staff. Resident observed pushing empty w/c towards staff. This note was written by LPN-T. The nurses note dated 4/6/24, at 21:38 (9:38 p.m.), documents Resident ran over right foot of peer while chasing peer down the hallway. Peer then observed hitting resident due to resident running over foot. Resident observed antagonizing peer. Resident continued to follow peer and call her names. Unable to redirect behavior. Resident continued to follow peer and propel self up and down hallway turning over chairs, pulling garbage out of medication cart and throw on the floor. Resident observed standing up several times this shift and turning around with no brief on and telling staff to kiss her _ss. Unable to assist resident with putting on undergarment due to behavior. Resident at this time banging on windows in common area. This note was written by LPN-T. The administration note dated 4/7/24, at 05:55 (5:55 a.m.), documents Restless, agitated cussing, psychotic, refusing care, condescending, spiteful, mean, belligerent, throwing things around, etc. This note was written by LPN-S. The nurses note dated 4/7/24, at 06:03 (6:03 a.m.), documents Res has been up all night in w/c. Res has been belligerent, sarcastic, mean, nasty, etc with the staff. She goes from one to the other and starts over again, non stop. We are all dumb, fat smelly, lazy b_tches. Res has been throwing things from the med carts, tearing up paper, pounding on the windows, throwing offered snacks and water on the floor. Res. going up and down halls, singing, wondering why no one was up. Needing to be removed from other rooms at times. Writer attempted to do pain assessment, but res uncooperative. Also uncooperative with skin assessment, although she did show me her _ss and stated I could kiss it. Res has red scratches on both buttocks, not new. Res nodded off about 20 minutes in w/c. Refused AM (morning) Synthroid med. This note was written by LPN-S. The nurses note dated 4/7/24, at 13:13 (1:13 p.m.), documents Resident is 15 min (minute) checks 2 shift she is very verbal name calling writer got order for CBC (complete blood count) UA/C&S (urinalysis/culture and sensitivity) urine (urine) picked up 4/7/24 at about 12:30. CBC will be drawn 4/8/24. This note was written by LPN-N. The nurses note dated 4/7/24, at 15:36 (3:36 p.m.), documents Resident hurt her elbow on the head board while failing her arms and hit her left elbow on heard sic (head) board while writer was attempting to straight cath (catheter) her while staff helped, she c/o (complained of) pain to the area writer called on call [medical group name] Doc (doctor) or nurse practitioner she stated give some resident Tylenol. This note was written by LPN-N. The nurses note dated 4/7/24, at 18:15 (6:15 p.m.), documents Resident continues to verbally abuse staff and residents. Resident continues to call staff fat _sses and b_tches. Resident continues to call other residents dumb_sses. Staff has attempted to redirect resident multiple times. Resident continues to harass residents and staff nonstop. This note was written by LPN-V. The psychosocial assessment dated [DATE] for Section B Mental Cognitive Status yes is answered for the question any psychosocial symptoms related to cognitive status. Under additional comments documents BIMS: 7 Resident diagnosed with Dementia and Alzheimer's Disease. Section C Mood and Behavior Status for 1. Mood or Behavior concerns since last assessment documents Resident sometimes acts out in physical aggression and swears at other residents and staff members. Resident can become agitated at times and confused. Resident recently had an altercation with another resident. For the question is resident on any psychotropic medications yes is answered. If yes to psychotropic medications, list psychotropic medications and target behaviors documents Escitalopram Oxalate Tablet Depakote Tablet Target Behavior 3: Depression/Sadness Intervention #1: Redirect as able. Intervention #2 One on one conversation. Intervention #3 Offer appropriate activities. For the statement if yes to psychotropic medication list resident non-pharmacological interventions utilized documents Non-pharm interventions for behaviors: 1. Address in a calm manner. 2. Attempt to orientate to place and time. 3. Allow resident to express feelings or frustrations and provide reassurance as needed. 4. Provide assistance as needed. 5. Family visits. 6. Offer activities of choice. 7. Provide emotional support to resident as needed. 8. Offer to close door and curtains to facilitate sleep. For mental health services Psychologist/other counselor involvement is checked. Under additional comments documents Resident is seen by psych in facility. Under Psychosocial Status the following are checked: 1. Difficulty accepting placement and circumstances. 3. Concerns with other residents. 4. Concerns with staff members. 5. Participates in Living Center Programs. 6. Pursues independent activities. and 7. Maintains supportive relationships. Under Comments documents Resident recently had altercation with peer. Resident observed by staff using foul language and calling staff/residents derogatory names. Staff attempted to redirect resident, but resident proceeded to approach peer which caused peer to become upset. Resident ran over peers toe with wheelchair and staff witnessed peer striking resident. Staff separated residents and continued to monitor. Writer followed up with resident today, who stated she has no concerns. DON (Director of Nursing), psych NP, and family notified. The change of condition note dated 4/8/24, at 00:33 (12:33 a.m.), documents Situation: Left elbow painful, shiny brown and swollen. Right foot, middle toe, purpose, painful when moved. Urinalysis positive, C&S pending. Background: Res with behavior issues since Thursday, Verbally abusive towards staff and residents, physical at times. Assessment (RN) (Registered Nurse)/Appearance (LPN): Res up again at start of night shift, belligerent, complaining. Finally stated she was tired. CNA (Certified Nursing Assistant) helped her to bed. Noted elbow, res crying, limited ROM (range of motion), brown in color, swollen. Tylenol given and ice applied. Further investigation, bruising on arms from holding for straight cathing, tender. Noted right foot middle toe is purple, pain with PROM (passive range of motion). Recommendations: 0030 (12:30 a.m.) On call for [medical group name], [Name] aware. New order for X-ray of elbow in AM (morning), cont (continue) to monitor toe, wait for C&S results. Response: [Medical group name] on call [Name] updated. Res calm at this time, remaining in bed. The nurses note dated 4/8/24, at 23:13 (11:13 p.m.), documents D/T (due to) res increased aggressive behaviors with dementia, [Name] Psych NP increased her Depakote to 250 mg (milligrams) BID (twice daily). Nursing to monitor. This note was written by DON (Director of Nursing)-B. The nurses note dated 4/9/24, at 10:08 (10:08 a.m.), documents Writer updated POA with X-ray results indicating there is a fracture of the proximal ulna. POA would like resident to have a follow up/consult with ortho but unsure at this time if wanting surgical intervention if indicated. NP also made aware of results and NOR (new order received) to set up a consult with ortho. Will continue to monitor. This note was written by RN/ADON (Registered Nurse/Assistant Director of Nursing)-O. The nurses note dated 4/10/24, at 02:40 (2:40 a.m.), documents Pt (patient) with fracture to proximal ulna. Pt propelling self about unit for a couple hours using both arms. No c/o pain or discomfort. Pt with sensitivity pending on urine culture. No c/o dysuria. Pt was verbally hostile towards staff calling staff, stupid and lazy. Multiple attempts to redirect pt to her bedroom. About 2am pt finally went to bed. This note was written by RN-Y. The nurses note dated 4/11/24, at 05:53 (5:53 a.m.), documents Res has remained in bed this night shift. She is still being verbally belligerent, stated to writer to leave, she does not have nor never has had a urinary infection. You don't know what you're talking about. Res did take abt (antibiotic) and thyroid med earlier this AM when half asleep. Left arm remains bruised, elbow area swollen. Grimaces with movement. Denied need for meds. No new issues. This note was written by LPN-S. The nurses note dated 4/11/24, at 22:36 (10:36 p.m.), documents Resident alert and responsive. Resident refused cares, meds, and vital signs this PM shift. Resident strike out at writer after attempting to assess vital signs. This note was written by LPN-X. The administration note dated 4/12/24, at 01:15 (1:15 a.m.), documents agitation. This note was written by LPN-S. The administration note dated 4/12/24, at 01:16 (1:16 a.m.), documents restless, cussing, slurs, psychosis, aggression, refusing cares. The nurses note dated 4/12/24, at 06:24 (6:24 a.m.), documents Res has remained up in w/c, at desk, the entire night shift. Res has been talking non-stop to staff, or no-one, or Buddy about whatever is on her mind. How incompetent we are, dumb, fat, smelly, anything derogatory she can think of, over and over again. Refused cares, finally take water. Does not live here so she would not go to bed or lie down. Wanted to speak with the police. She would scream if we asked her to go away from the desk or be quiet. Refused AM med and offered analgesic. This note was written by LPN-S. R1 was discharged to the hospital on 4/16/24 for altered mental status and returned during the afternoon on 4/23/24. The hospital Discharge summary dated [DATE] under the admission Information section documents Reason for admission: Closed Fracture of olecranon process of left ulna, initial encounter [S52.022A], Urinary tract infection without hematuria, site unspecified [N39.0] Dementia with agitation, unspecified dementia severity, unspecified dementia type (CMD) [F03.911]. Under hospital course documents [R1's name, sex and age] with past medical history significant for CAD (coronary artery disease), sinus bradycardia, hypothyroidism, depression, Alzheimer's dementia who is living in nursing home and noted having more encephalopathic/combative than her usual. In the outpatient setting the patient had fallen, however there are inconsistent reports of the nature of the fall. Recently urine sample consistent with infection/UTI (urinary tract infection) and combative per the staff/son which is not her usual, and out of concern for recent fall as well as the concern of not receiving the appropriate medication, son brought her to ED (emergency department) at [Hospital name] . On 4/22/24 at 10:56 a.m. Surveyor spoke with NP (Nurse Practitioner)-CC regarding R1. NP-CC informed Surveyor R1 was confused, refused cares & medication, had behavior problems with psych involved. NP-CC informed Surveyor she was trying to get R1 to take her medication. Surveyor inquired when she was informed of R1's behaviors. NP-CC informed Surveyor she didn't know when but was aware. Surveyor asked NP-CC if she was notified of R1 refusing her medication. NP-CC replied yes, I was notified. NP-CC explained nursing would call her or would let her know when she was in the facility. NP-CC informed Surveyor some nurses were able to give R1 her medication and some weren't. Surveyor inquired when the last time she was notified of R1's medication refusals. NP-CC was unable to provide Surveyor the last time she was notified. Surveyor asked NP-CC about R1's fracture. NP-CC informed Surveyor RN/ADON-O informed her they were trying to straight cath R1 and R1 hit her elbow. NP-CC indicated she can't remember if it was on the wall or headboard of the bed. NP-CC informed Surveyor they got an X-ray and had an ortho appointment which R1 refused to go to. Surveyor asked NP-CC when was the last time she saw R1. NP-CC informed Surveyor 4/15. Surveyor asked NP-CC if she examined R1. NP-CC informed Surveyor she kind of went in she was trying to get R1's antibiotic switched. On 4/22/24, at 11:08 a.m., Surveyor asked CNA (Certified Nursing Assistant)-P to tell Surveyor about R1. CNA-P informed Surveyor before R1 went to the hospital she was acting anxious, had behaviors, was feisty, screaming out, cursing, getting up out of her chair & walking around. Surveyor asked CNA-P if she could redirect R1. CNA-P replied no. Surveyor informed CNA-P Surveyor had noted R1 was straight cath on 4/7/24 and asked if she was there during this. CNA-P informed Surveyor she and another CNA (CNA-M) tried helping R1 in getting R1 into bed. CNA-P explained she let R1 know the nurse was going to straight cath her. Surveyor inquired who the nurse was. CNA-P informed Surveyor the first name of LPN (Licensed Practical Nurse)-N. Surveyor asked if R1 let them put her in bed. CNA-P informed Surveyor she was feisty at first then calmed down. Surveyor asked CNA-P what she meant by being feisty. CNA-P replied yelling & screaming. CNA-P explained they let R1 know it was for her own good. CNA-P explained LPN-N tried putting the catheter in but couldn't get it. We had to try to redirect R1 and after she calmed down she told us to hurry up. CNA-P informed Surveyor LPN-N tried again to get the urine, R1's arm swung, hit the head board it was like a loud boom. LPN-N asked R1 if she could move her arm which R1 was able to. CNA-P indicated LPN-N never got the urine, they cleaned R1 and took R1 to the toilet. CNA-P informed Surveyor there was a hat in the toilet and they were able to get the urine. Surveyor asked while LPN-N was trying to straight cath R1 where was she. CNA-P informed Surveyor she was on one side of R1 and CNA-M was on the other side and they both were holding R1's arms so she wouldn't swing, she was like fighting. Surveyor asked CNA-P why they had to hold R1's arms. CNA-P informed Surveyor R1 was fighting & swinging. Surveyor asked CNA-P if she was ever involved with R1 being straight cath before. CNA-P replied no and explained R1 wasn't on her side. Surveyor asked CNA-P if she knew why R1 was fighting them. CNA-P replied no cause she normally not like that, normally a sweet little lady. On 4/22/24, at 12:09 p.m., Surveyor spoke with LPN-N on the telephone. Surveyor asked LPN-N what he could tell Surveyor about R1. LPN-N informed Surveyor R1 was confused, in a wheelchair and would roll around, talk with other residents & staff sometimes would say bad stuff other times good never would know what R1 was going to say. R1 recently had a UTI, at one time was taking her medications and then didn't take them. LPN-N explained when he came back from work R1 was diagnosed with a UTI, had me wondering if had a UTI as sometimes act normal then R1 got worse and went to the hospital. Surveyor asked LPN-N if he straight cathed R1. LPN-N informed Surveyor the names of CNA-M, CNA-P and CNA-Q. LPN-N informed Surveyor he told R1 okay [first name of R1] going to straight cath you and told her he had to do the procedure. LPN-N informed Surveyor he attempted to straight cath her and R1 was saying a bunch of stuff. LPN-N informed Surveyor no one was really holding her down because that's how she hit her arm. LPN-N informed Surveyor they had to hold her legs open but couldn't get it. LPN-N informed Surveyor he said lets put her on the toilet. They put R1 on the toilet, turned on the water and R1 said going to put on the water so I can pee. LPN-N informed Surveyor they were able to get the urine sample. Surveyor asked LPN-N if the CNAs had their hands on R1's arms. LPN-N replied no they weren't forcing her, R1 knew what they were going to do. They weren't holding her down that's why she hit her elbow if they were holding her down she wouldn't have been able to hit her elbow. Sometimes during the procedure she wasn't cooperative and other times she was. Sometimes she was kicking her legs and saying all kinds of stuff. Surveyor asked LPN-N how many times he attempted to straight cath R1 before placing her on the toilet. LPN-N informed Surveyor 3 or 4 times and was surprised he couldn't get R1's urine. LPN-N informed Surveyor he called DON (Director of Nursing)-B and [name of medical group] after R1 hit her elbow. On 4/22/24, at 1:20 p.m., Surveyor spoke with CNA-Q regarding R1. CNA-Q informed Surveyor R1 was a very sweet lady, has moods, gets depressed & sad, looking for her husband and son. Surveyor inquired if R1 had any behaviors. CNA-Q replied not on everyday basis. CNA-Q explained R1 stopped taking her medication, was hitting & fighting. CNA-Q informed Surveyor she thought R1's behavior was happening more frequently and she spoke with the night nurse who told her R1 was not sleeping, not taking her medication, stopped eating, and thought they were trying to kill her. Surveyor asked CNA-Q when R1 was having her episodes of behavior could she redirect R1. CNA-Q replied no and explained would get worse and call her fat a_s. CNA-Q informed Surveyor she would ask R1 what was wrong, if she wanted to talk with her s[TRUNCATED]