**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure 2 (R1 & R3) of 3 residents received adequate supervision and assistance devices to prevent accidents.*R1 was admitted to the facility on [DATE] with a history of falls. R1 fell on 8/11/25 while attempting to self transfer. The facility did not thoroughly investigate this fall and was aware of R1's multiple attempts to self transfer but did not address R1's self transferring behaviors. On 8/19/25 R1 fell, was transferred to the hospital and diagnosed with a pelvic fracture. R1 returned to the facility on 8/28/25. On 8/31/25 R1 fell. The facility did not thoroughly investigate this fall.*R3's falls on 6/26/25, 7/7/25, 7/13/25, 7/29/25, 8/2/25, 8/20/25, & 8/26/25 were not thoroughly investigated. On 9/4/25 R3 received the incorrect diet for lunch., putting R3 at risk for choking. On 9/8/25 during morning cares, R3 bed was not lowered according to R3's falls plan of care when CNA-L went into the bathroom and/or left R3's room.Findings include:The facility's policy titled, Falls and last reviewed 5/8/25 documents under Policy Prevention measures are put in place to reduce the occurrence of falls and risk of injury from falls. Under Procedure documents .2. Procedure of Fall Event and Implementation of Intervention: a. Licensed nurse completes electronic documentation of the Fall Incident Report. b. The care plan will be updated with an identified intervention. c. Registered Nurse reviews and completes the fall assessment and interventions. d. Fall follow-up assessments completed as indicated. 3. Administrative Review: a. The Interdisciplinary Team (IDT) will review Fall Incident report and utilize root cause analysis to make further recommendations. b. Director of Nursing (or designee) and Executive Director to review and sign Fall Incident Report. c. Quality Assurance and Process Improvement Committee reviews facility fall incidents and trends.On 9/4/25, at 12:01 p.m., Surveyor asked Registered Nurse (RN)-G to explain the process when a resident has a fall. RN-G informed Surveyor that after a fall, an RN will assess the resident from head to toe, obtains vital signs, contact the provider and POA if the resident has one have one. RN-G indicated an incident report, pain assessment, progress note, and fall assessment are completed. RN-G informed Surveyor usually the unit manager will let them know what new fall intervention was initiated. RN-G informed Surveyor if the fall was witnessed she will get witness statements and give these to the manager. If the fall is unwitnessed she will usually ask the CNAs questions such as who last saw the resident, if their bed was in a low position. RN-G informed Surveyor that the statements are then given to the unit manager.On 9/4/25, at 2:12 p.m., Surveyor asked Licensed Practical Nurse/Unit Manager (LPN/UM)-I to explain the process when a resident falls. LPN/UM-I informed Surveyor when a resident falls staff will let her know and if she is at the facility she will put in a new fall intervention. If she is not at the facility when she will comes back she will put in an intervention. LN/UM-I explained all assessment have been completed, she will do an investigation, the IDT (interdisciplinary team) will do a root cause and an intervention. Surveyor asked if LPN/UM-I if during the investigation she gets staff statements or are staff interviewed. LPN/UM-I informed Surveyor the nurse usually gets statements and puts them under her door. Surveyor asked what happens with staff statements. LPN/UM-I informed Surveyor they would be with the packet that is given to DON-B. Surveyor asked LPN/UM-I what she provides to DON-B. LPN/UM-I informed Surveyor the the investigation summary which includes what happened, diagnoses, IDT met discussed incident with root cause and care plan intervention. All assessments are printed out which include risk management, nurses note, fall risk assessment, pain assessment, and e-interact change of condition which is like an SBAR, and copy of the care plan with interventions. LPN/UM-I informed Surveyor she will put a new Kardex in the resident's room with the new intervention. Surveyor asked LPN/UM-I if DON-B would have staff statements. LPN/UM-I replied yes if there were statements given to me.1.) R1 was originally admitted to the facility on [DATE] with diagnoses which includes cardiogenic shock (inadequate blood flow to the body's organs due to dysfunction of the heart), diabetes mellitus (high blood sugar), atrial fibrillation (irregular and rapid heart beat), atrial fibrillation (irregular and rapid heartbeat), chronic kidney disease (kidneys are damaged and cannot filter blood and waste effectively), and heart failure (chronic condition in which the heart doesn't pump blood as well as it should). R1's hospital Discharge summary dated [DATE] for reason for hospitalization is falls.R1's fall risk evaluation dated 7/25/25 has a score of 4. A total score of 10 or greater is high risk for falls.R1's at risk for falls care plan initiated 7/25/25 & revised 8/31/25 documents the following interventions: Anticipate and meet the resident's needs, initiated 7/25/25. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, initiated 7/25/25. Follow facility fall protocol, initiated 7/25/25. PT/OT (physical therapy/occupational therapy) evaluate and treat as ordered or PRN (as needed), initiated 7/25/25. Ensure that the resident is wearing appropriate footwear when ambulating, transferring or mobilizing in w/c (wheelchair), initiated 8/11/25 & revised 8/13/25. Call before you fall sign placed in bathroom, initiated 8/19/25. Offer resident assistance with using the toilet with every interaction, initiated 8/31/25. R1's admission MDS (minimum data set) with an assessment reference date of 8/1/25 has a BIMS (brief interview mental status) score of 12 which indicates moderate cognitive impairment. R1 is assessed as being dependent for toileting hygiene, supervision or touching assistance for rolling left and right & chair/bed to chair transfer and partial/moderate assistance for toilet transfer. R1 is frequently in continent of urine and always continent of bowel. R1 has fallen in the last month prior to admission and has not had any falls since admission.R1's functional abilities (self care and mobility) CAA (care area assessment) dated 8/4/25 under analysis of findings for nature of the problem/condition is blank. Under care plan conditions for describe impact of this problem/need on the resident and your rational for care plan decision documents CAA triggered due to resident requires extensive assist of 1 people for bed mobility, toileting and transfer. Extensive assist of 1 for dressing and personal hygiene. Dependent on staff for locomotion. Ambulating short distance with walker and CGA (contact guard assistance). Resident recently admitted from hospital where he had been for cariogenic shock. Lived with son prior to hospitalization. Currently resident has had a decline in mood related to situation. Isolates self in room. Goal is to return home. Resident has decondition. Is at risk for further decline in ADL's (activities daily living), falls, contractures, further isolation, complications of immobility: further pressure ulcers, muscle atrophy, incontinence and contractures. Referred to and is receiving PT/OT (physical therapy/occupational therapy) 5x/week (five times per week). Referred to MD (medical doctor) for evaluation of mood/depression and pain med (medication) management. Will proceed to care plan to prevent/minimize risks; work with resident to return to prior level of independent functioning.R1's falls CAA dated 8/4/25 under analysis of findings for nature of the problem/condition is blank. Under care plan considerations for describe impact of this problem/need on the resident and your rationale for care plan decision documents CAA triggered for falls due to risk factors resulting from Balance problems: Not steady, only able to stabilize with human assistance for moving from seated to standing position, moving on and off toilet and surface-to-surface transfer; Resident admitted to facility with fall history. Resident has had no falls during this assessment period, refer to DQI documentation. Nursing staff assists resident with ADLs (activities daily living) as needed according to facility policy. Resident is at risk for fall related injury. Resident receives physician ordered Physical and Occupational Therapy services. No referrals at this time, will proceed to care plan with goal to have no fall related injuries.R1's nurses note dated 8/11/25, at 17:35 (5:35 p.m.) written by Licensed Practical Nurse/Unit Manager (LPN/UM)-I documents: Writer entered resident's room to take his blood sugar and found him sitting on his bottom on the floor between the head of the bed and night stand. Resident had both legs straight out in front of him, one gripper sock on his left foot and his right foot was bare. Resident's wheelchair was across from him about 3 feet away from where he was sitting at the foot of the bed facing him, parallel to the bed, the wheels were not locked. Writer had last seen resident about 10 minutes prior, he was on the toilet, resident asked writer to come back and take his blood sugar. Writer had reminded resident to use the call light to ask for help to get off the toilet when he was done. Writer checked with CNA (Certified Nursing Assistant) and resident had not called for help to get on or off the toilet. Resident joked that he decided to just sit on the floor for a little bit. Resident then stated he was attempting to get into bed he stated he stood up and went to pivot into the bed when his knees gave out causing him to fall landing on his bottom. Resident assessed for injury, none noted, resident denied pain or discomfort, skin check done no injuries noted, neuro checks started, were negative, vitals WNL (within normal limits); BS (blood sugar) 93. Resident assisted up off the floor and into bed by the writer and CNA. POA (power of attorney) [Name] updated, [Name] NP (Nurse Practitioner) updated, writer is on call manager so no notification to on call manager made. Resident placed on 24 hour board for monitoring, Risk Management started.Surveyor reviewed the facility's fall investigation which included an investigative report for date of incident of 8/11/25 prepared by RN/UM-H. The summary of alleged incident documents Writer entered resident's room to take his blood sugar and found him sitting on his bottom on the floor between the head of the bed and night stand. Resident had both legs straight out in front of him, one gripper sock on his left foot and his right foot was bare. Resident's wheelchair was across from him about 3 feet away from where he was sitting at the foot of the bed facing him, parallel to the bed, the wheels were not locked. Writer had last seen resident about 10 minutes prior, he was on the toilet, resident asked writer to come back and take his blood sugar. Resident joked that he decided to just sit on the floor for a little bit. Resident then stated he was attempting to get into bed he stated he stood up and went to pivot into the bed when his knees gave out causing him to fall landing on his bottom. Writer had reminded resident to use the call light to ask for help to get off the toilet when he was done. Writer checked with CNA and resident had not called for help to get on or off the toilet. Resident assessed for injury, none noted, resident denied pain or discomfort, skin check done no injuries noted, neuro checks started, were negative, vitals WNL; BS 93. Resident assisted up off the floor and into bed by the writer and CNA with hoyer lift. POA [Name] updated; [Name] NP updated. POA, [Name] made aware. Pertinent diagnoses included weakness, AFIB (atrial fibrillation), DM2 (diabetes mellitus two), Metabolic encephalopathy and unsteadiness on feet. IDT (interdisciplinary team) discussed fall, determined root cause to be resident not having proper footwear on. Care plan updated to have proper footwear on at all times. Also included in the fall investigation is an incident report dated 8/11/25, pain tool dated 8/11/25, fall risk evaluation dated 8/11/25, and SBAR (situation, background, appearance, review and notify) dated 8/11/25, neurological flow sheet started on 8/11/25 at 1710 (5:10 p.m.) a written statement dated 8/11/25 under statement documents was on ground sitted sic (sitting) up when walked in. The employee name is blank and this statement is not signed. The nurses note dated 8/11/25 at 17:35 (5:35 p.m.) and R1's at risk for falls care plan initiated 7/25/25 & revised 7/28/25.Surveyor noted the facility did not conduct a thorough investigation as the facility did not investigate what prior interventions were in place at the time of R1's fall and whether these interventions continue to be effective. Additionally, the facility did not address R1 self transferring and none of R1's care plans address R1 self transferring.R1's fall risk evaluation dated 8/11/25 has a score of 9. A total score of 10 or greater is high risk for falls.R1's nurses note dated 8/19/25, at 11:04 a.m., documents Resident found on floor on his buttock in front of the toilet. Resident tried to self transfer to the toilet. Vitals 79/52, 121, 97.6%, 98.9, 16. Resident able to move all extremities and denies any new pain. Resident was sent to [Name] Hospital due to several low b/p (blood pressure), increased confusion and weakness.Surveyor reviewed the facility's fall investigation which included an investigative report for date of incident of 8/19/25 prepared by RN/UM-H. The summary of alleged incident documents Resident found on floor on his buttock in front of the toilet. Resident tried to self transfer to the toilet. Vitals 79/52 121, 976% sic (97%), 98.9, 16. Resident hypotensive. Resident able to move all extremities and denies any new pain. Neuro check performed. Resident assisted back into bed via hoyer lift. [Name] NP notified. Resident's POA, [Name] notified. Resident to be sent to [hospital initials] per NP for further evaluation. Pertinent diagnoses include weakness, AFib, DM2, Metabolic encephalopathy and unsteadiness on feet. IDT discussed fall, determined root cause to be resident not calling for assistance. Care plan updated to have call before you fall sign placed in bathroom. Also included in the facility's fall investigation is an incident report dated 8/19/25, fall risk evaluation dated 8/19/25, SBAR communication form dated 8/19/25, pain tool dated 8/19/25, neurological flow sheet starting on 8/19/25 at 0800 (8:00 a.m.), R1's progress notes 8/19/25 at 10:07 a.m. through 8/21/25 at 14:23 (2:23 p.m.), and R1's at risk for falls care plan initiated 7/25/25 & revised 7/28/25. The facility reported R1's fall on 8/19/25 with a fracture to the State agency. Included in the facility's investigation included staff interviews for the following questions: Resident was admitted to the hospital with a pelvic fracture. What can you tell us about this? What is the care routine like for [R1's first name]? Does [R1's first name] use his call light to make needs known? Is there anything else you would like to share with us regarding [R1's first name]? Surveyor noted 8 of 10 staff statements indicate R1's self transfers.Surveyor noted the facility did not conduct a thorough investigation as the facility did not investigate who last observed R1, what was R1 doing, when was R1 last toileted, were prior interventions in place at the time of R1's fall and whether these interventions continue to be effective. In addition the facility did not address R1 self transferring and none of R1's care plans address R1 self transferring. R1's fall risk evaluation dated 8/19/25 has a score of 16. A total score of 10 or greater is high risk for falls.R1's nurses note dated 8/20/25, at 8:46 a.m., written by Registered Nurse/Unit Manager (RN/UM)-H documents Contacted [hospital initials] and spoke to [Name] RN. Dx (diagnosis): Pelvic facture. R1 was readmitted to the facility on [DATE].R1's hospital discharge summary for date of discharge 8/28/25 for Reason for hospitalization documents Unwitnessed fall. Under Discharge diagnoses includes documentation of L (left) ischiopubic ramus facture 2/2 (secondary to) fall and LC 1 injury to left hemipelvis 2/2 fall.R1's nurses note dated 8/31/25, at 01:13 (1:13 a.m.) written by LPN-F documents At 0025 (12:25 a.m.) writer and CNA heard the room door of [room number] close loudly. CNA went to check immediately and found resident laying on his back in the bathroom doorway. Resident had pulled his brief off prior to going to bathroom and urine was noted on the floor in center of room. Resident has used w/c to navigate to the bathroom door. W/C was outside the bathroom, facing into his room. Resident was barefoot. RN was called to assess resident. ROM (range of motion) WNL (within normal limits). Neuro check negative. No bumps or bruises noted. Resident alert. Forgetful. Did not put call light on. Urinal was in reach of bed as call light was also in reach on bed. Vitals taken at 0025 150/90 98.0 - 101 - 18 94%. Resident was hoyered into bed with 3 assist. Reminded to call for assistance or use urinal or to get up. Will continue neuro checks as facility protocol.Surveyor reviewed the facility's fall investigation which included an investigative report for date of incident of 8/31/25 prepared by Director of Nursing (DON)-B. The summary of alleged incident documents A door was heard slamming in resident's room. CNA went to room and found resident on the floor, laying on his back in the doorway of his bathroom. Resident stated he slipped and fell. Resident had removed his brief, and urine was on the floor. Call light was not in use. RN assessed resident. ROM (range of motion) WNL (within normal limits). Neuro check negative. Vitals stable. Resident assisted off the floor via hoyer lift. [Name] PA (physician assistant) updated via HUCU. Resident's POA [name] updated. Diagnoses include cerebral infarction, DM2, metabolic encephalopathy, fracture of L (left) pubis, syncope, falls, anemia, and CKD (chronic kidney disease). IDT discussed fall. Root cause determined resident self-transferring to bathroom without calling for assistance, related to cognitive deficits. New intervention to offer toileting with every interaction. Also included in the facility's fall investigation is an incident report dated 8/31/25, fall risk evaluation dated 8/31/25, e-interact change in condition evaluation dated 8/31/25, pain tool dated 8/31/25, R1's progress notes dated 8/31/25 at 01:13 (1:13 a.m.) and 01:18 (1:18 a.m.) and R1's at risk for falls care plan initiated 7/25/25 & revised 8/31/25.Surveyor noted the facility did not conduct a thorough investigation as the facility did not investigate who last observed R1, what was R1 doing, when was R1 last toileted, and were prior interventions in place at the time of R1's fall and whether these interventions continue to be effective. There are no staff statements or evidence staff was interviewed regarding R1's fall. In addition the facility did not address R1 self transferring and none of R1's care plans address R1 self transferring. R1's fall risk evaluation dated 8/31/25 has a score of 11. A total score of 10 or greater is high risk for falls.On 9/3/25, at 3:32 p.m., Surveyor observed R1 sitting on the edge of the bed. Surveyor observed R1 is not wearing gripper socks and has bare feet. Surveyor observed Certified Nursing Assistant (CNA)-J enter R1's room and ask R1 about a shower. Surveyor observed CNA-J did not offer toileting to R1 according to R1's plan of care. On 9/3/25, at 3:35 p.m., Surveyor asked CNA-J about R1's toileting and if they ask R1 if he needs to use the bathroom. CNA-J replied no and explained R1 will call staff. CNA-J informed Surveyor R1 has an urinal at his bed so will only call when he has to have a BM (bowel movement).On 9/4/25, at 8:19 a.m., Surveyor observed R1's Visual/Bedside Kardex report as of 8/22/25 located inside R1's closet. Surveyor noted this kardex does not include the fall intervention to offer resident assistance with using the toilet with every interaction which was initiated on 8/31/25.On 9/4/25, at 12:08 p.m., Surveyor asked CNA-E when she goes in R1's room does she have to offer to toilet R1 or does he ask. CNA-E informed Surveyor this is the first day working with R1. CNA-E informed Surveyor R1 is incontinent but will say when he wants to be on the toilet.On 9/4/25, at 2:19 p.m., Surveyor met with LPN/UM-I to discuss R1's falls. LPN/UM-I informed Surveyor R1's first two falls occurred while R1 resided on the rehab unit. Surveyor inquired who Surveyor should speak with. LPN/UM-I replied name of RN/UM-H. Surveyor asked LPN/UM-I if she investigated R1's fall on 8/31/25. LPN/UM-I informed Surveyor name of DON-B investigated this fall.On 9/4/25, at 3:20 p.m., Surveyor interviewed RN/UM-H. RN/UM-H explained when a resident falls the nurse on the unit will check for injury, neuro checks are done, notify the provider, notify the family if there is a POA or if the resident is their own person will ask if they want the family contacted. The resident is transferred to bed with a hoyer. There is on going monitoring, vital signs, pain assessment and the care plan is updated with the latest intervention. Surveyor asked RN/UM-H if there is a fall investigation. RN/UM-H replied I do that. RN/UM-H explained she asked staff what happened, what was the resident doing, did they call for help. RN/UM-H informed Surveyor they try to figure out what happened and add an intervention. Surveyor asked RN/UM-H if their investigation includes staff statements. RN/UM-H replied we do, a lot of falls have statements. RN/UM-H informed Surveyor night shift is pretty good as she's not here. Surveyor asked RN/UM-H what happens to the staff statements. RN/UM-H informed Surveyor they are added to the incident report. Surveyor asked RN/UM-H what happens with her fall investigation. RN/UM-H informed Surveyor she gives the information to DON-B and DON-B and Nursing Home Administrator (NHA)-A review it. Surveyor asked RN/UM-H regarding R1's fall on 8/11/25. RN/UM-H informed Surveyor R1 was getting up frequently without calling staff. RN/UM-H informed Surveyor it looks like R1 didn't have the proper footwear on at the time R1 was attempting to get into bed. Surveyor informed RN/UM-H the investigation does not include who last saw R1 what was R1 doing and if prior interventions were in place. Surveyor informed RN/UM-H staff was aware R1 had self transferred onto the toilet but there is no evidence R1's self transferring was addressed. Surveyor inquired regarding R1's fall on 8/19/25. RN/UM-H informed Surveyor they were concerned with R1's mobility and stated we just knew something was wrong. Surveyor asked RN/UM-H after R1 was transferred to the hospital asked if there were any staff statements or was staff interviewed. RN/UM-H replied I don't believe for that one. Surveyor informed RN/UM-H Surveyor has the same concerns as R1's fall on 8/11/25. Surveyor informed RN/UM-H there is no evidence staff was spoken to as to what was R1 doing prior to the fall, when was R1 last observed, when was R1 last toileted so R1 wouldn't attempt to self transfer. Surveyor informed RN/UM-H the facility still had not addressed R1's self transferring.On 9/8/25, at 9:54 a.m., Surveyor met with DON-B. Surveyor inquired about staff statements. DON-B informed Surveyor they do not obtain staff statements. Surveyor asked DON-B if there is ever a time they would get staff statements or interview staff regarding a resident's fall. DON-B informed Surveyor if there is an unknown or vague documentation they would get staff statements. DON-B informed Surveyor for R1's fall with fracture on 8/19/25 they obtained staff statements. Surveyor informed DON-B the fall investigation she completed for R1's fall on 8/31/25 does not address who last saw R1, what was R1 doing, when was R1 last toileted, were prior intervention in place and were these interventions effective. Surveyor informed DON-B the facility did not address R1's self transferring and R1's care plans do not address self transferring. DON-B informed Surveyor she has never addressed self transferring in a care plan. Surveyor asked DON-B if there is anything Surveyor should review. DON-B replied nope.No additional information was provided. 2.) R3 was admitted to the facility on [DATE] with diagnoses which include hemiplegia (paralysis on one side of the body) and hemiparesis (weakness one one side) following cerebral infarction (type of stroke) affecting right dominate side, diabetes mellitus (high blood sugar), chronic kidney disease (kidneys are damaged and cannot filter blood and waste effectively), , aphasia (language disorder that affects a persons ability to communicate), and dysphagia (difficulty swallowing). R3's power of attorney for healthcare was activated on 5/6/25.R3's hospital Discharge summary dated [DATE] under admission diagnoses documents fall.R3's at risk for falls care plan initiated 6/12/25 and revised 8/26/25 documents the following interventions: Anticipate and meet the resident's needs, initiated 6/12/25. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, initiated 6/12/25. Follow facility fall protocol, initiated 6/12/25. PT/OT (physical therapy/occupational therapy) evaluate and treat as ordered or PRN (as needed), initiated 6/12/25. Soft touch call light in place, initiated 6/26/25. Offer resident to eat meals by the nurses station per her preference, initiated 7/7/25 & revised 8/18/25. Offer the resident assistance to go to bed after dinner, initiated 7/14/25. Encourage resident to participate in activities and spend time in common areas while up in her wheelchair, initiated 8/2/25. Bed in lowest position while resident is in it, initiated 8/4/25. Encourage resident to rest in bed or take a nap after lunch, initiated 8/21/25. Dycem in wheelchair, initiated 8/26/25.R3's admission MDS (minimum data set) with an assessment reference date of 6/18/25 has a BIMS (brief interview mental status) score of 0 which indicates severe cognitive impairment. R3 is assessed as being dependent for toileting hygiene, chair/bed to chair transfer, and toilet transfer. R3 is assessed as requiring substantial/maximal assistance for rolling left and right. R3 is frequently incontinent of urine and always incontinent of bowel. R3 fell one month prior to admission and has not fallen since admission. R3's Fall CAA dated 6/23/25 under analysis of finding for nature of the problem/condition is blank. Under care plan considerations for describe impact of this problem/need on the resident and your rationale for care plan decision documents CAA triggered for falls due to risk factors resulting from Balance problems: Not steady, only able to stabilize with human assistance for moving from seated to standing position, moving on and off toilet and surface-to-surface transfer; [R3's first name] has had a CVA (cerebrovascular accident) with right side flaccid. Resident admitted to facility with fall history. Resident has had no falls during this assessment period, refer to DQI documentation. Nursing staff assists resident with ADLs (activities daily living) as needed according to facility policy. Resident is at risk for fall related injury, Resident receives physician ordered physical and occupational therapy services. No referrals at this time, will proceed to care plan with goal to have no fall related injuries.R3's fall risk evaluation dated 6/11/25 & 6/30/25 has a score of 9. A total score of 10 or greater, the resident should be considered high risk.R3's nurses note date 6/26/25 at 7:49 a.m. created on 7/1/25 at 9:50 a.m. written by Registered Nurse/Unit Manager (RN/UM)-H documents: Patient found laying on floor next to bed by CNA (Certified Nursing Assistant) and called writer to room. Resident stated I crawled out of bed to go to the bathroom. Patient assessed, no injury noted, VSS (vital signs stable), no c/o (complaint of) pain/discomfort, patient transferred back into bed with hoyer lift. Neuro checks performed. [Name] NP (Nurse Practitioner) notified. Resident's POA (power of attorney) [Name] notified.Surveyor reviewed the facility's fall investigation which included an investigative report for date of incident of 6/26/25 prepared by RN/UM-H. The summary of alleged incident documents Patient found laying on floor next to bed by CNA and called writer to room. Resident stated I crawled out of bed to go to the bathroom. Patient assessed, no injury noted, VSS, no c/o pain/discomfort, patient transferred back into bed with hoyer lift. Neuro checks performed. [Name] NP notified. Resident's POA, [Name] notified. Pertinent diagnoses include weakness, DM, unsteadiness on feet, repeated falls and history of CVA. IDT (interdisciplinary team) discussed fall, determined root cause to be resident not calling for assistance. Care plan updated to have soft touch call light in place. Also included in the facility's fall investigation is an incident report dated 6/26/25, SBAR (situation, background, appearance, review and notify) dated 6/26/25, pain tool dated 6/26/25, fall risk evaluation dated 6/26/25, neurological flow sheet starting on 6/26/25 at 0715 (7:15 a.m.), R3's progress notes dated 6/26/25 at 07:15 (7:15 a.m.), 07:49 (7:49 a.m.) & 7:26 p.m., and R3's at risk for falls care plan initiated & revised 6/12/25.Surveyor noted the facility did not conduct a thorough investigation as the facility did not investigate who last observed R3, what was R3 doing, how was R3 positioned in bed, when was R3 last toileted, and were prior interventions in place at the time of R3's fall and whether these interventions continue to be effective.R3's nurses note dated 7/7/25 at 18:30 (6:30 p.m.) created on 8/21/25 by Licensed Practical Nurse/Unit Manager (LPN/UM)-I documents Resident had an unwitnessed fall in the dining room after dinner, discovered by housekeeping. She sustained a minor forehead laceration and bruising near the right eye but denied hitting her head. No other injuries noted; vitals and neuro checks were WNL (within normal limits). EMS (emergency medical services) transported resident to [Name] Hospital. POA (power of attorney), on call NP, and Unit Manager notified. Care plan updated for meals with nurses station per resident preference.Surveyor reviewed the facility's fall investigation which included an investigative report for date of incident of 7/7/25 prepared by LPN/UM-I The summary of alleged incident documents Resident experienced an unwitnessed fall in the dining room following dinner. She was discovered on the floor by housekeeping staff. On assessment, resident had a minor laceration to the right forehead and mild bruising with minimal bleeding noted at the corner of her right eye. Resident reported, I was trying to pick up my hearing aide and I was sliding, then I fell. She denied striking her head. Further assessment revealed no additional injuries to the head or body. Vital signs were obtained and neurological checks were initiated, all within normal limits. EMS was contacted and the resident was transferred to [Name] Hospital for further evaluation. The POA, on-call NP, and Unit Manager were notified. Pertinent diagnoses include: Hemiplegia and Hemiparesis following cerebral infarction affecting right dominate side, muscle weakness (generalized); polyarthritis, unspecified; repeated falls; spondylosis without myelopathy, lumbar region; strain of unspecified muscle; fascia and tendon at shoulder and upper arm level, right arm; type 2 diabetes mellitus; unspecified fall; unsteadiness on feet; vitamin D deficiency. The IDT reviewed the incident and determined that the fall occurred when the resident attempted to reach down to retrieve her hearing aid, causing her to slip from her wheelchair. The care plan was updated with: meals near nurses' station per resident preference. Also included in the facility's fall investigation is an in[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 2 (R1 and R2) residents reviewed for accidents. R1 was care planned to transfer with a sit to stand mechanical lift and assist of 2 staff. CNA's transferred the resident with 2-person pivot. R1 sustained a leg fracture.R2 was care planned to transfer with a sit to stand mechanical lift and assist of 2 staff. The CNA transferred the resident alone. R2 sustained a fall from the sit to stand resulting in a head laceration requiring staples.Findings include:R1 admitted to the facility on [DATE] and entered onto Hospice [DATE]. Diagnoses included Atrial Fibrillation, Heart Failure, Peripheral Vascular Disease, Dementia, anxiety, Osteoporosis and Pulmonary Hypertension. R1 passed away at the facility on [DATE].R1's Care Plan documented: The resident has an ADL (Activity of Daily Living) self-care performance deficit r/t (related to) activity intolerance, limited mobility - initiated [DATE]. Interventions include: Transfer: The resident requires Mechanical Lift sit to stand with 2 staff assist for transfers, May use Hoyer lift as needed when resident not tolerating the sit to stand lift - initiated [DATE] revised [DATE]. The facility does not have a policy and procedure specific to mechanical lifts. Surveyor was provided the facility policy and procedure with the subject Safe Individual Handling Program which documents (in part) A. Transfer assessment1. Individuals will be assessed according to ability per transfer and movement objective criteria. Nursing will perform this assessment in collaboration with therapy as applicable.2. Once the assessment is completed, the appropriate transfer status will be determined.B. Care Plan1. Individual-specific transfer status will be addressed on the Care Plan to include specific equipment type if applicable.2. All staff to transfer according to the Care Plan unless it is determined by the Registered Nurse (RN)/Licensed Practical Nurse (LPN)/Certified Nursing Assistant (CNA) at the time that the transfer is not a safe transfer for either the individual or the staff member. On [DATE] at 9:42 PM, R1's progress notes included an Einteract change in condition (CIC) form completed by Licensed Practical Nurse (LPN)-G which documented: New or Worsening Pain. Nursing observations, evaluation, and recommendations are: When resident being transferred to bed. She stated that she was having pain in her left ankle from the transfer. Residents' bilateral ankles and feet are swollen 4+ pitting edema. No redness or bruising noted to the left ankle. On [DATE] at 12:06 AM, LPN-H documented: C/O (complained of) increased pain to left ankle / foot. Left ankle, foot appears swollen red pain to touch. Resident requested to go to the hospital. PRN (as needed) Morphine administered resident appears anxious update PRN Lorazepam administered. (Hospice) called at midnight requesting X-ray to left ankle left arm. Awaiting call back. On [DATE] at 12:19 AM, Hospice nurse out to evaluate resident.On [DATE] at 2:52 AM, Hospice Registered Nurse (RN)-I documented: Received a call stating that (LPN-H) called to report that pt (patient) is calling out in pain. States that pt said that she was pivot transferred into bed and her ankle hurts. Call placed to (LPN-H) who states per pt was pivot transferred to bed and is complaining of L (left) ankle pain and pt want to go to the hospital. (LPN-H) is requesting an X-ray. Writer will visit and assess pain. Arrived to pt room, pt moaning. Writer, I talked with pt and asked pt where her pain was and she stated, all over. Pt has L shoulder pain which is chronic. Upon assessment pt LLE (left lower extremity) swollenness 4+ pitting edema Knee to foot. L ankle pain when touched. L calf to ankle red hot to touch. Pt with 4+ pitting edema LLE. RLE (right lower extremity) 2+ pitting edema. Slight redness noted to inner side of calf near ankle. Pictures sent to (Physician). Orders received for Cephalexin 500 mg (milligrams) BID (twice daily) x 7 days. Pt was given morphine 10 mg x 2 and lorazepam 0.5 mg x1. Pt comfortable and sleeping at end of visit.On [DATE] at 10:59 AM, Surveyor spoke with Hospice Nurse-I who reported she spoke to the Physician and sent pictures. Hospice Nurse-I stated, It appeared to look like cellulitis, so he ordered an antibiotic. Surveyor confirmed with Hospice Nurse-I that she was aware the resident was pivot transferred into bed and complained of pain after. Surveyor asked if she notified the Physician. Hospice RN-I stated she did not recall if she notified the Physician that R1 was transferred incorrectly by pivot instead of the sit to stand and was complaining of pain after. Surveyor located no evidence the Physician was notified. On [DATE] at 7:51 AM, progress notes document: Resident has c/o pain to the left leg and foot, rating it 10/10. Slightly relived by MSO4 (Morphine). Resident screaming upon staff gently moving her leg. Writer placed a call to (Hospice) and received orders for a X-ray. On [DATE] at 8:46, Biotech here to do X-rays. On [DATE] at 9:40 AM, RN Hospice here to see this resident. Resident continues to c/o pain, stating that it is not cellulitis pain it is something different and more painful. MSO4 given at 9:05 AM and resident currently resting. RN is alerting family.On [DATE] at 10:31 AM, X-ray reveal acute distal tibia fracture. Ortho evaluation recommended. RN will contact (family) to see if she would like this resident to be hospitalized . Resident currently sleeping and appears comfortable. The Radiology Results Report dated [DATE] documents (in part) Clinical information: Pain in foot and leg. Was transfer by standing and not stood in 3-4 years. Test procedure: Left tibia and Fibula, Two views. Findings/Discussion: Acute spiral nondisplaced distal tibial fracture is identified. R1 was transferred to the hospital and returned the same day. R1 declined surgical intervention and returned with a splint on left lower extremity. On [DATE] at 10:50 AM, Surveyor spoke with Family Member-M who reported the prior Thursday ([DATE]) R1 was having wheelchair races with her roommate and by Sunday ([DATE]) she was in crisis pain because I was told she was transferred using a pivot instead of the stand-up lift.Surveyor review of progress notes prior to the incident were uneventful, no adverse events were documented. R1's meal consumption from 5/27-[DATE] documented R1 consumed 75-100% of all meals. On [DATE] (the day after the incident/when the fracture was identified) R1 had significant decline. She refused meals on [DATE], ate 0-25% x 2, and 25-50% x 1 on [DATE], refused all meals on 6/3 and 6/4, and passed away on [DATE]. Surveyor reviewed the Facility Self Report investigation. The investigation summary documents Resident care plan was reviewed, and all assigned interventions were in place. The facility cannot reasonably conclude how the fracture happened. Possible sources are old age of 98, resident transfer, self-propelling and repositioning. Surveyor noted the investigation was not thorough. The investigation included no information regarding staff using pivot transfer versus the stand-up lift as care planned. LPN-G's statement obtained by Nursing Home Administrator (NHA)-A documented: I worked PM 5/31. Don't remember any issues during the shift although Surveyor noted LPN-G completed the CIC form on [DATE] after the incident. CNA-F's statement obtained by Nursing Home Administrator (NHA)-A documented: We transferred her together on PM's. Nothing else to share. We are new and normally work upstairs so we don't know the resident as well as the regular staff.On [DATE] Surveyor spoke with NHA-A and asked if he was aware that staff did not follow the care plan and transferred R1 using a pivot, versus the stand-up lift resulting in R1's leg fracture. NHA-A stated, I don't know if it was ever actually determined to be the case. Surveyor asked NHA-A when he interviewed the CNA's involved, did he ask them how the resident was transferred. NHA-A stated, I don't recall that I specifically asked that question. Surveyor advised NHA-A of progress notes documenting R1 was transferred via pivot, complained of pain immediately after and X-ray results confirmed a spiral fracture of her tibia. Surveyor asked if he investigated the fact that staff did not follow the care plan and R1 was improperly transferred. NHA-A stated, Again, I don't recall specifically asking that question.On [DATE] at 12:25 PM, Surveyor spoke with Hospice RN-J. Hospice RN-J reported she was aware R1 was transferred with pivot versus the stand-up lift. Hospice RN-J stated, Staff at the facility were talking about it and I heard them. Hospice RN-J was unable to provide names of staff but heard many staff talking about how they broke her leg because they transferred her with pivot instead of the EZ stand. Surveyor asked if she felt the fracture contributed to R1's decline. Hospice RN-J stated, Absolutely. She was doing really well before, eating, wheeling around, very happy. Literally, the next day she declined, was confused, not eating, and died a few days later. On [DATE] at 3:40 PM, Surveyor spoke with CNA-F (staff member involved in incident) who reported she went in to see if R1 was ready for bed. CNA-F stated, I did look at her care card and I know it said 2-person transfer, but I don't recall if it specifically said stand up lift. CNA-F reported R1 was not ready for bed, so she answered other call lights. When I went back, I remember asking her (R1) how she transferred, she said with 2 people - so we put a gait belt on her and pivoted her to bed. CNA-F reported R1's leg buckled and when we got her into bed R1 said I can't do that again. CNA-F stated R1 was complaining of leg pain, so she got the nurse. On [DATE] at 11:00 AM Surveyor spoke with LPN-G (the nurse working [DATE] PM shift at the time of the incident). LPN-G confirmed the CNA reported R1 had pain after transferring her into bed. LPN-G stated, The aides (they were new) said R1 started to complain of pain after they put her to bed with a 2-person transfer, because that's what R1 told them. LPN-G said she told the CNA's R1 was a stand-up lift and confirmed with the CNA's that they transferred her with 2 people. LPN-G reported CNA-F said yes, we pivoted her. LPN-G reported she completed the einteract CIC form and notified Hospice and the on-call supervisor, RN-D. Surveyor asked LPN-G if she notified RN-D that R1 was transferred incorrectly using a pivot and was complaining of pain. LPN-G stated Yes. Surveyor asked about her statement obtained by NHA-A on 6/2 that documented, I worked PM 5/31. Don't remember any issues during the shift. LPN-G informed Surveyor she did not provide any statements to NHA-A or anyone else and that no-one talked to her about the incident after it happened. On [DATE] at 11:27 AM, Surveyor spoke with RN-D who confirmed she did receive a call on [DATE] that R1 was complaining of pain after being transferred to bed and she told the nurse to call Hospice. RN-D reported she did not recall if the nurse told her R1 was transferred with pivot and not the stand-up lift as care planned. Surveyor reviewed the staff sign in sheet titled Safe resident transfers dated [DATE] which was included in the facility investigation packet. Surveyor noted only 13 of 72 CNA's names on the sign in sheet as having received the training. On [DATE] at 10:17 AM, Surveyor spoke with Deputy Medical Examiner (ME)-L. Deputy MD-L stated, I got a call from the hospice nurse, and she told me about her death and the spiral fracture that occurred after she was improperly transferred and went quickly downhill after that. Surveyor asked what does the death certificate list as cause of death: Complications of spiral fracture of left tibia. Manner of death: Accident. Injury Description: Staff-assisted pivot transfer into bed. On [DATE] at approximately 3:00 PM, the facility was notified of concern that R1's care plan was not followed. R1's care plan indicated she was to transfer with stand-up lift and 2 staff assist. On [DATE], PM CNAs assisted R1 to bed using a 2-person pivot transfer. R1's leg buckled, and she immediately complained of pain. X-ray results were positive for a spiral tibia fracture. The facility investigation was not thorough, as there was no information or documentation related to the improper transfer and not following the care plan. R1 significantly declined following the incident and passed away 4 days later. The facility provided no additional information. 2) R2 was admitted to the facility on [DATE] with diagnoses that include, Alzheimer's disease, dementia, arthritis, spinal stenosis, osteoporosis, muscle weakness, paraplegia and anxiety disorder. R2's annual Minimum Data Set (MDS) assessment, dated [DATE], documents R2 has a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. A Patient Health Questionnaire (PHQ-9) score of 0, indicating no depressive symptoms, and no indicators of psychosis including no hallucinations or delusions. R2 is assessed to require substantial/maximal assistance for transfers from chair to bed. R2's Care Area Assessment (CAA) documents, R2 is triggered for falls due to use of antidepressants. Risk factors: incontinence, paraplegia, visual, hearing, cognition, and anxiety. R2's Care Plan, date initiated [DATE], documents, Focus: R2 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) weakness, pain, dementia. Interventions include, R2 requires sit to stand lift with 2 staff assistance for transfers; date revised [DATE]. R2's CNA (Certified Nursing Assistant) Kardex dated [DATE], documents, Transfer: requires sit to stand lift with 2 staff assistance for transfers. R2's Progress Note, dated [DATE] at 19:13 (7:13 PM), documents, Note Text: The CNA reported to the floor nurse that the resident fell while using the sit to stand lift, striking the back of her head and briefly losing consciousness. Due to active bleeding, 911 was called, and the resident was transferred to [Hospital]. The POA (Power of Attorney], on-call manager, DON (Director of Nursing) and [On call Physician Group] were all notified. R2's Progress Note, dated [DATE] at 21:17 (9:17 PM), documents, NP (Nurse Practitioner) notified, pt (patient) sent to hospital post fall. Patient POA (Power of Attorney) notified of pt post fall. R2's Hospital emergency room summary, dated [DATE], documents, .Scalp: 2 cm (centimeter) laceration to the back of R2's head, bleeding was controlled prior to arrival. Significant amount of dried blood. Face: Abrasion to left temple, no bleeding. Left Upper Extremity: Multiple ecchymosis around the elbow.CT head: No acute findings or interval change intracranially. New small right posterolateral scalp, laceration/hematoma without skull fracture.Diagnosis: Laceration. Imaging of head and neck were negative for trauma. Laceration was repaired with 2 staples. R2's Physician orders, start date, [DATE], Laceration care to the right side of the skull, gently wash with NS (Normal Saline) to keep clean, end date [DATE]. R2's Physician orders, start date, [DATE], Monitor for S/S (Signs and Symptoms) of concussion: HA (headache) and the severity, change in mentation or behavioral changes. Chart in progress notes, end date, [DATE]. R2's Physician orders, start date, [DATE], may use ice pack to right back of head for pain relief, end date [DATE]. R2's Progress Note, dated [DATE] at 00:17 ( 12:17 AM) documents, Resident returned at approx (approximately) midnight. She had 2 staples placed to the laceration on the back of her head. AMS (Altered Mental Status) is at her baseline. Resident denies pain. Surveyor reviewed the facility's Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report, dated [DATE] and completed by Nursing Home Administrator (NHA)-A, which documents . Allegation Type: Injury of unknown source: Injury was not observed and is suspicious because of extent or location. Brief Summary: Resident is not her own person. Resident had a fall over the weekend and went to the hospital with a laceration to her head. Resident has now admitted back to the facility with 2 staples in her head as a treatment for the laceration. Full investigation underway. Self-reporting as a fall with major injury. The facility Misconduct Incident Report, dated [DATE], included a summary completed by NHA-A, which documents, .Certified Nursing Assistant (CNA)-R noted that during resident transfer, around 7:30 PM, resident slipped out of the sling and she fell to the ground. CNA-R then grabbed RN-S and CNA-E. R2 was transferred to the ER (Emergency Room) and returned to the facility with two stitches/staples. Aide was following care plan and process, no issues. This was an accident. Surveyor notes, care plan was not followed as the care plan documents, R2 requires sit to stand lift with 2 staff assistance for transfers and only 1 CNA was assisting R2 when she slid from the sit to stand mechanical lift. The facility Investigation Report dated [DATE], and completed by Licensed Practical Nurse (LPN) Supervisor-N, documents Summary of Alleged Incident: R2 witnessed fall on [DATE]. The resident's CNA (Certified Nursing Assistant) reported to the floor nurse that the resident experienced a fall while using the sit-to-stand lift during a transfer from a sitting to standing position. During the fall, the resident struck the back of her head on the ground and briefly lost consciousness but quickly regained awareness. Due to visible bleeding from the occipital area, staff made the decision not to move the resident and immediately called 9-1-1. The resident was unable to recall the incident. EMS (Emergency Medical Services) responded promptly, and the resident was transferred to [Hospital] for evaluation. The resident's family, on-call manager, Director of Nursing, and [on call physician group] were all notified and updated accordingly. Following her return from the Emergency Room, the resident was noted to have received two staples to the back of her head. She was placed on a 24-hour observation board with neuro (neurological) checks initiated per protocol. Pertinent diagnoses include age-related Osteoporosis; Alzheimer's Disease; Dementia in Other Diseases; Paraplegia, Spinal Stenosis. The IDT (Interdisciplinary Team) reviewed the fall and determined that the root cause was the resident losing her balance during a transfer, likely due to her underlying diagnosis. The care plan was updated with PT/OT (Physical Therapy/Occupational Therapy) to evaluate and treat for transfers. CNA-R completed a Written Statement dated [DATE], which documents, I went into R2's room to put her into bed around 7 PM 06/06. I put her on the sit to stand and was about to put her into bed but she slipped out of the sling. She hit the floor, I tried to call her name but I got no response. I went get a nurse and she called 911. I was not aware that I needed a second person with a sit to stand. On [DATE], Surveyor interviewed R2, who stated she just cannot remember what happened when she fell. R2 stated she feels safe at the facility, and no one has ever hurt her. On [DATE] at 11:12 AM, Surveyor interviewed DON-B, who stated, R2 was a sit to stand lift with assist of 2 prior to fall on [DATE]. DON-B stated, R2's fall occurred because her legs gave out and she slid out of the sling and out of lift. R2 was getting ready for bed with CNA-R. DON-B stated, Therapy reassessed R2 after the fall and determined R2 did not have the strength for a sit to stand lift and now uses a Hoyer lift. On [DATE] at 2:12 PM, Surveyor interviewed DON-B who when asked about how the CNA's know what sling size to use for each resident who uses a sit to stand and DON-B stated, there are charts on each unit by the linen carts that goes by weight of resident. Surveyor asked if sling sizes are on the Kardex for the CNA's and DON-B stated, no we have not put the sling sizes on the Kardex. Surveyor asked DON-B if the sling size is charted anywhere for the CNA's and DON-B stated, no. Surveyor asked DON-B what the expectation of a CNA before a resident is transferred and DON-B stated, Typically, there is a sling in each resident's room that uses a sit to stand lift. The slings are not labeled per resident, but each resident should have their own sling. DON-B stated, if there is not a sling in the resident's room, the CNA will check the weight chart for the appropriate size. Surveyor asked DON-B if there has been any training post fall on [DATE] regarding how to determine sling size, how to attach sling to sit to stand lift and resident safely and DON- B stated, no. On [DATE] at 2:22 PM, Surveyor interviewed CNA-E, who also works as the Scheduler and Transfer Mobility Coach. Surveyor asked CNA-E what she recalls from the evening of R2's fall on [DATE]. CNA-E stated that CNA-R was running past her office in a panic and CNA-E asked CNA-R what was going on. CNA-R told CNA-E, R2 fell, and she needed to find a nurse. CNA-E located both RN-S and RN-U and everyone went to R2's room. CNA-E stated, R2 was lying on the floor, face up. 911 was called and together, the RN-U and RN- S did a complete assessment. RN-S asked R2 what happened, and R2 could not recall. RN-S asked CNA-R what happened, and CNA-R, stated R2 slipped out of sit to stand lift and CNA-R was transferring R2 by herself. CNA-E stated, that with the sit to stand being used for R2, it can be an assist of 1. CNA-E stated, R2's Kardex indicates a sit to stand lift but CNA-E did not know if Kardex stated assist of 1 or 2. CNA-E stated she provided CNA-R with an additional 8 hours of orientation, training on mechanical lifts, and lift observations with CNA-R post R2's fall on [DATE]. On [DATE] at 2:35 PM, Surveyor interviewed CNA-R. Surveyor asked CNA-R what she recalls from the evening of R2's fall on [DATE]. CNA-R stated, R2 was being transferred in the sit to stand lift. CNA-R had sling around R2's waist and it was buckled in front. R2 had on non-skid socks on her feet. CNA-R stated, when R2 was in the standing position, R2 became weak and slipped out of the sling. R2's arms went up and the sling went over her head, and she slipped out. CNA-R stated she tried to catch R2 but it happened fast and R2 fell to the floor and hit her head. CNA-R stated she was alone when she did the transfer for R2. CNA-R stated she was aware the Kardex documented R2 required a sit to stand lift and did not remember if the transfer needed a 1 or 2 staff assist or what sling size was needed. On [DATE] at 2:45 PM, Surveyor interviewed CNA-T, who stated, she will generally find sling size on care plan, if not found on care plan, CNA-T goes to Kardex. Surveyor asked CNA-T if she could show an example of a sling size on a Kardex and CNA-T could not find any evidence of sling size on a Kardex. CNA-T stated, there are not slings in each resident's room for a sit to stand lift, only for Hoyer lifts. The slings are in the hallway by the linen carts. Surveyor asked CNA-T if she knew how to determine sling size and CNA-T stated, if she already does not know, she would then ask the nurse. On [DATE] at 9:12 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A, who stated on [DATE], the facility purchased all new sit to stand lifts. NHA-A stated, the manufacturer guidelines say that the new sit to stand lifts can either be an assist of 1 or 2 staff. NHA-A stated, on [DATE], following R1's fall, training occurred for staff that all sit to stand, and Hoyer lifts should be an assist of 2 staff. NHA-A stated, when R2's fall occurred on [DATE], the facility did an audit of each resident using a sit to stand lift to see each resident's care plan is an assist of 1 or 2 staff and if it matches what the CNA is doing. NHA-A stated, facility then determined if it still met the needs of each resident. Surveyor notes, NHA-A did not provide an audit for the completion of each resident using sit to stand and if it matches care plan after request to review all audits. The only audit provided, documents the review of 2 incident reports related to falls and if the care plan was followed. On [DATE], at 10:35 AM, Surveyor interviewed CNA-E (also Scheduler and Transfer Mobility Coach). Surveyor asked CNA-E what how she knows what sling size to use for each resident and CNA-E stated, there should be a sling in the room for each resident, if not, slings are found on each unit. Surveyor asked CNA-E how she know how much to tighten sling belt and CNA-E stated, adjust the sling belt so that the resident would not slip, the belt would hold up. Surveyor asked how CNA-E would determine if a sling would slip off and CNA-E stated, the sling would not be tight enough. CNA-E stated, it is her assumption this is what happened with the fall with R2 on [DATE]. On [DATE], Surveyor interviewed DON-B who stated R2's legs gave out and this is why she slipped out. If a resident lets go of on sit to stand lift, the arms can slouch right through sling. DON-B stated even if the belt is tightened to a resident's body, the resident can still easily slip out when arms are above head when falling. Surveyor notes, CNA-R was unavailable for interview for questioning on use of sling. On [DATE], at 11:20 AM, Surveyor interviewed NHA-A and asked how the facility determined the method of R2's transfer was done correctly on [DATE]. NHA-A stated, it is safe to say that we assumed it was just the care plan not being followed. Surveyor asked, did you investigate why R2 slipped out of the sit to stand, for example, was the correct sling size used or did the CNA know how to properly hook up and adjust the sling, or if there were two CNA's assisting? NHA-A stated, he did not investigate any of these potential factors. Surveyor notified NHA-A of concern regarding an incomplete investigation to determine the root cause of R2's fall. NHA-A acknowledges there were several other factors to investigate. Surveyor notified NHA-A of concerns regarding R2's care plan not being followed which documents assist of 2 and only 1 staff assisted with the sit to stand transfer. That transfer resulted in R2 slipping from the sit to stand, hitting their head and requiring 2 staples in the ER.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that residents remain free of accident hazards and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (R12) reviewed for accidents. R12 sustained a significant injury to her leg which required surgical intervention. The facility did not complete a thorough investigation as to how the injury occurred. Findings include: R12 admitted to the facility on [DATE] and has diagnoses that include Chronic Kidney Disease, Anemia, Atherosclerotic Heart Disease, PVD (Peripheral Vascular Disease), Hypothyroidism, Vascular Dementia with anxiety, Osteoarthritis and Neuromuscular Dysfunction of bladder. R12's BIMS (Brief Interview For Mental Status) Evaluation dated [DATE] documents a score of 4, indicating severe cognitive impairment. R12's admission MDS (Minimum Data Set) dated [DATE] documents: Self-Care Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement - Dependent. Mobility: Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed - Dependent. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed - Dependent. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed and with no back support - Dependent. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed - Dependent. Toilet transfer: The ability to get on and off a toilet or commode - Dependent. R12's care plan documents: The resident has potential for impairment to skin integrity r/t (related to) weakness, incontinence, prediabetes, fragile skin, PVD. Actual skin impairment of hematoma that burst to left shin. Resident went out to hospital and received surgical intervention for hematoma - dated [DATE]. Interventions include: Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface - initiated [DATE]. Resident to wear tubi grips to BLE (Bilateral Lower Extremities) for protection - initiated [DATE]. The resident has an ADL (Activity of Daily Living) self-care performance deficit r/t weakness, dementia date initiated [DATE]. Interventions include: Bed mobility: Dependent, assist of 1. Toileting: Dependent, assist of 1. Transfer: Sit to stand lift and assist of 2. Dressing/personal hygiene: Dependent, assist of 1. Resident to wear slippers or gripper socks, not shoes. Encourage the resident to use bell to call for assistance. The resident is at risk for falls r/t weakness, dementia, vision impairment, potential medication side effects, incontinence. Interventions: Resident not to be put in room alone when in w/c (wheelchair) dated [DATE]. The resident has impaired cognitive function/dementia or impaired thought processes r/t Dementia initiated [DATE]. Interventions: Anticipate and meet needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Call before you fall sign placed in room to remind resident to use call light - initiated [DATE]. Posey grip placed under w/c (wheelchair) cushion to prevent slipping - initiated [DATE]. R12's Fall Risk Evaluation dated [DATE] documents a score of 12 - At Risk for falls. R12 sustained 2 prior falls: R12's medical record documents on [DATE], at 2:45 PM: Resident found on bathroom floor by CNA (Certified Nursing Assistant). Resident assessed by nurse. Neuro checks negative ROM (range of motion) WNL (within normal limits). No injuries noted. On [DATE], at 3:25 PM, R12's medical record documents: Called to room by CNA. Upon entering room, resident was observed sitting upright on her buttocks in front of her w/c (wheelchair) on the floor. Daughter of room [room number] was present in room visiting with her mother at time of incident per her statement to this writer. Visitor stated resident was sitting in her w/c in her room and was leaning forward in her w/c. Resident was attempting to self transfer herself into her recliner chair across from her w/c. Resident slid out of her w/c onto the floor landing on her buttocks. Resident did not hit her head. No injury noted. ROM WNL. Denies pain/discomfort. Posey grip placed on top of and underneath w/c cushion to help prevent slipping. On [DATE], at 11:19 AM, Surveyor observed R12 sitting in the common area with her son. R12 was well groomed, wearing socks and slippers and foot pedals were observed on the wheelchair. Surveyor spoke with R12's son who reported R12 bumped her left leg with therapy, adding It was an accident, I don't blame anyone for what happened. She was in the hospital for weeks for the wound on her leg, it took a long time to heal, I think it's pretty much healed now. Surveyor reviewed R12's progress notes entered by LPN (Licensed Practical Nurse)-J which documented: On [DATE], at 1:50 PM, Nurse's Note Text: Called to room by CNA (Certified Nursing Assistant). CNA reported to writer that resident hit her left shin on the sit to stand lift prior to transfer. Some bruising present. Ice applied. Skin is intact. No bleeding noted. On [DATE], at 2:30 PM, Nurse's Note Text: APNP (Advanced Practice Nurse Practitioner) in the building. Notified of resident left shin injury from sit to stand lift prior to transfer. APNP assessed resident. No new orders at this time. Monitor and administer PRN (as needed) Tylenol and Biofreeze as ordered. Call placed (son) POA-HC (Power of Attorney for Health Care). Notified of resident injury to left shin. On [DATE], at 3:55 PM, Nurse's Note Text: F/U (follow up) Left lower shin hematoma: Writer called to room by CNA. Hematoma had ruptured. Blood gushing. Large gash present to left lower shin. Left leg wrapped with towel and pressure applied. 911 emergency services called. On [DATE] APNP note: [R12's], . female with a history of multiple chronic conditions, was seen today in her usual social situation for a routine SNF (Skilled Nursing Facility) follow-up. She was found sitting up in her wheelchair, appearing comfortable without complaints of pain. She states she is doing well and reports her appetite as okay. She denies experiencing cough, shortness of breath, nausea, vomiting, diarrhea, or constipation. However, towards the end of the shift, nursing staff reported that the patient had an injury during a sit-to-stand transfer, resulting in a hematoma on the medial aspect of her left leg, causing significant pain. An ice pack was applied, and Tylenol was administered for pain relief. The nursing staff was instructed to hold Plavix for two days and to notify the patient's family. Subsequently, the hematoma ruptured, and the patient was sent out via 911 for further evaluation and treatment. The Hospital Discharge summary dated : [DATE] documented: admitted with left leg wound with traumatic laceration with bleeding and large hematoma. S/P (status post) excisional debridement of the left leg wound necrotic skin, subcutaneous fat and fascia 8 cm (centimeters) x 10 cm on [DATE]. Started on wound vac [DATE]. Acute blood loss anemia due to left leg hematoma on top of chronic anemia. She received 2 units PRBC (packed red blood cells) on this admission. The facility Skin & Wound Evaluation dated [DATE] documented the wound healed. Surveyor asked for the facility investigation involving the injury to R12's leg. Surveyor was provided the Facility Investigation Report dated [DATE] which documented: Summary of alleged incident: Injury of known cause [DATE], 1:50 PM. CNA alerted nurse that resident had hit her left shin on sit to stand lift and developed a bruise that then became a hematoma. RN (Registered Nurse) assessed resident and noted bruise at that time. Later developed to a hematoma to left shin. Resident c/o (complained of) pain. PRN Tylenol given and ice pack applied. APNP in house and aware. Resident's POA notified. Pertinent diagnoses include Peripheral Vascular Disease and Vascular Dementia with anxiety. IDT (Interdisciplinary Team) discussed. Determined root cause to be resident moved leg and bumped on sit to stand machine. Care plan updated to have resident wear tubi grips to BLE (bilateral lower extremities) for protection. Nursing description: CNA notified writer and floor nurse that resident had hit her left shin on the sit to stand lift prior to transfer and that there was a bruise. Bruise was originally noted to left shin. Ten minutes later a large hematoma was present to LLE (left lower extremity). Resident also stated that her leg bumped the sit to stand lift. CNA-O's statement on [DATE] documented only: Hit shin bone left on sit to stand. Nurse was notified. On [DATE], at 3:30 PM, during the daily exit meeting with the facility, Surveyor asked if the investigation report provided was the entire investigation completed. DON (Director of Nursing)-B stated, Yes, what I gave you is everything, the whole investigation. Surveyor noted the investigation was not thorough to determine how the accident happened. CNA-O's statement did not include details or information of how R12 hit her shin bone on the sit to stand. On [DATE], at 10:08 AM, Surveyor interviewed CNA-O and asked her to walk through what happened regarding R12's leg injury. CNA-O stated, We were getting her up (Surveyor asked who she meant by we) me and the other aide. She (R12) was sitting on the side of the bed and we got her hooked up to the stand up lift. She said she had to go to the bathroom, so we took her. Surveyor clarified; so (R12) had no injury at this time before you took her to the bathroom. CNA-O stated, No. Surveyor asked CNA-O if she could see R12's legs. CNA-O stated, Yes. She had her pants on at her ankles, but when she said she had to go to the bathroom, we took her. We didn't pull them up because she had to go to the bathroom. Surveyor asked if the leg leg strap was in place on the sit to stand. CNA-O stated, Yes. When we got her onto the toilet, the other aide left and she was on the toilet while I stayed in the room, making her bed, and stuff. Surveyor clarified; so (R12) was alone on the toilet. CNA-O stated, Yes. When I went back into the bathroom I saw that she had kicked her leg out to the left and she must've bumped it on the lift frame and it was bleeding, so I got the nurse. Surveyor asked how R12 bumped her leg on the lift frame if the leg strap was on. CNA-O stated, We had the leg strap on when we took her to the bathroom, but then I unhooked it when she was on the toilet because she likes to move her legs around when she's sitting on the toilet. Surveyor confirmed; so everything else was still hooked up while she was alone on the toilet, but you undid the leg strap. CNA-O stated. Yes. Surveyor asked CNA-O if she received any education after the incident. CNA-O stated, We were told that she (referring to R12) shouldn't be left alone when on the toilet and stand up lift anymore and that we need to watch her legs closely. Surveyor asked CNA-O if R12 was wearing tubigrips. CNA-O stated, No, those were for her swelling, but she doesn't have swelling anymore, so she hasn't worn the tubi grips for some time. Surveyor informed CNA-O R12's care plan indicates the tubi grips are to be worn for protection because of the incident. CNA-O stated, I don't know about that, but if they want them put on again, I have no problem cutting her some more. On [DATE], at 10:34 AM, Surveyor asked Nursing Home Administrator (NHA)-A for the facility policy and procedure for the use of the stand up lift. NHA-A stated, I know we don't have a policy specific to the stand up lift, because I remember a complaint awhile back and they (referring to Surveyors) asked for it and we don't have one. Surveyor asked what is the expectation for staff regarding use of the stand up lift. NHA-A stated, Two people to transfer with stand up lift, that's my official statement. On [DATE], at 12:14 PM, Surveyor observed R12 sitting in her wheelchair in the dining room waiting for lunch to be served. R12 was wearing socks and slippers, no tubi grips. On [DATE], at 12:48 PM, Surveyor interviewed LPN (Licensed Practical Nurse)-J about the accident and injury involving R12. LPN-J reported she remembers the incident. LPN-J stated, The CNA came and told me the resident bumped her leg on the sit to stand. I think it was toward the end of the day, near change of shift, so I didn't look at it right away, but did go down shortly after. She was in her wheelchair in her room and she had a large bruise with swelling, so I elevated her leg and gave some ice for comfort. I remember her son was here in the room and he said this happened before and it burst open. He no sooner left, and like 15 minutes after he left the CNA told me it ruptured. So I immediately wrapped it, applied pressure and stayed in the room with her. 911 was called and she was sent out. Surveyor asked if, when the CNA first told her the resident bumped her leg on the stand up lift, did she give any other information of how it happened? LPN-J stated, No, I think it was when they were transferring her to the toilet, but I'm not sure. Surveyor asked, if leg straps are supposed to be used when transferring residents with a stand up lift, how did she think R12 bumped her leg? LPN-J reported she did not know. Surveyor asked LPN-J if she asked the CNA for details or inquired how it happened. LPN-J stated, No, I think it was close to shift change, she just told me she bumped it and then left I think. Surveyor noted CNA-O's interview of the incident and LPN-J's interview of the incident differ in significant details. CNA-O reported when she returned to the bathroom after leaving R12 alone on the toilet and removing the leg strap, she saw R12 had kicked her leg out to the left and she must've bumped it on the lift frame and it was bleeding. LPN-J reported the CNA reported the bruise, ice was applied and it later (approximately 2 hours per progress notes) burst open with bleeding. Surveyor notes LPN-J did not report any bleeding until the bruise burst open and CNA-O identified bleeding noted upon returning to the bathroom after R12 was left alone. R12's CNA care card dated [DATE] (on the door of R12's closet) includes no documentation regarding safety of the sit to stand/not to be left alone on the toilet, ensuring leg straps are in place or watching her legs closely when using the sit to stand or during transfers. R12's care plan included no interventions to prevent further incidents other than implementing tubi grips to protect her skin. On [DATE], at 3:10 PM, Surveyor asked CNA-M to walk me through how to perform a stand up lift transfer. CNA-M showed Surveyor the stand up lift used for R12. CNA-M demonstrated and stated, We hook them up with the straps, put the leg straps on and then raise them up. Surveyor noted blue padded knee area for legs to rest against during transfer. Surveyor noted there are no metal bars or metal areas on either side of the stand up lift. Surveyor asked CNA-M if he knew how R12 would have bumped her shin on stand up lift. CNA-M stated, I don't know how that would be possible, there's no metal bars to bump the leg on. She must have bumped it on something else. She does try to self transfer, which is why we try to keep her out in the open where we can see her. On [DATE], at 3:42 PM, Surveyor met with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor asked if a facility self report was completed regarding R12's leg injury. NHA-A stated, No. I believe what probably happened was the aide told the nurse what happened, that she bumped her leg on the lift and the nurse went with it. Surveyor notified NHA-A of the concern R12 sustained a significant injury to her leg, which required a hospital stay, surgical intervention and a wound vac and there was not a thorough investigation as to how the injury occurred. For example was the transfer completed correctly, was the leg strap in place, how/what did she bump her leg on (as Surveyor located no area on lift which correlates with CNA's interview). The CNA statement documents only that the resident hit her shin bone on the sit to stand but does not indicate how this occurred. In addition, R12 is at risk for falls, had 2 prior falls and was left alone on the toilet with the leg straps not attached. DON-B stated, I'm sure the nurse manager did more of an investigation, I can get a statement from her. Surveyor clarified; I was told this is the entirety of the investigation. DON-B reported she can see if the nurse manager did anything else and get a statement. Surveyor notified NHA-A and DON-B of the interview with CNA-O and how the injury occurred is different than progress note documentation . Surveyor read CNA-O's interview and progress note documentation and LPN-J's interview. Surveyor notified NHA-A and DON-B of concern it is not clear how the injury actually occurred and due to the extent of the injury a thorough investigation would expect to be completed. Surveyor notified NHA-A and DON-B the only intervention documented was to implement tubi grips to protect the skin, but no interventions were implemented to prevent further incident with the sit to stand, transfers or toileting assistance/supervision. Surveyor notified NHA-A and DON-B R12 was not observed wearing tubi grips during the time of survey. Surveyor asked if an assessment was completed upon R12's re-admission to determine if R12 is safe/appropriate for stand up lift use. NHA-A reported he did not know. Surveyor asked if education or audits were completed to ensure proper/safe transfer using the stand up lift. NHA-A stated, Probably not. I think what happed was the aide told the nurse the resident bumped her leg, so it was a known injury and there wasn't much to investigate. On [DATE], at 9:13 AM, DON-B reported she spoke to CNA-O and provided Surveyor a revised statement by CNA-O which documented: Addendum: Myself and another aide (no longer works here) sat (resident) up on side of bed and got her up with the sit to stand and put her on the toilet. We undid the leg straps once she was seated on the toilet. When we came back, she had shifted her legs off the lift and a bruise was noted to her left shin. (R12) said she bumped her leg on the lift. I notified the nurse of the bruise. Surveyor asked what did CNA-O report R12 bumped her leg on. DON-B stated, The blue knee rest padding, and I was reading her H&P (History and Physical) and the same thing happened the previous year, she bumped her leg on her wheelchair and needed surgical intervention for a hematoma, so she does have very fragile skin. Surveyor notified DON-B of the concern the addendum statement by CNA-O is different than the statement CNA-O provided to Surveyor earlier. Surveyor notified DON-B the concern remains that R12 sustained a significant injury and there was not a thorough investigation as to how the injury occurred and interventions were not put in place that address the root cause of the injury and to prevent future injury. Surveyor read R12's H&P which documented exactly 1 year previous, on [DATE] RLE (Right Lower Extremity) hematoma from trauma/wheelchair transfer. EMS (Emergency Medical Services) was called and she required CPR (Cardiopulmonary Resuscitation). She required surgical evacuation of the hematoma on [DATE]. Laceration was complicated by paper thin skin limiting ability for suture closure. On [DATE], at 9:30 AM, Surveyor spoke with Clinical Nurse Consultant-G. Surveyor was informed the facility does not have a policy and procedure for the stand up lift. Surveyor asked for evidence of education or training with the CNA's. Surveyor was provided evidence of the skills fair on [DATE] in which CNA's demonstrated competence. Surveyor reviewed the manufacturer recommendations for the stand up lift, no additional information was obtained. Surveyor notified Clinical Nurse Consultant-G of concerns R12 sustained a significant injury to her leg, requiring surgical intervention. There was not a thorough investigation as to how the injury happened. R12 is at risk for falls, sustained 2 prior falls and was left alone on the toilet with the leg strap not fastened. Clinical Nurse Consultant-G stated, I'm sorry, I don't know this person at all. I understand your concerns, with the severity of the injury there should have been more digging into what happened. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents were free of a significant medication error for 1 (R86) of 1 resident reviewed for medication errors. R86 did not receive omeprazole as ordered for four weeks resulting in a hospitalization for a gastrointestinal bleed. Findings include: The facility policy and procedure entitled Transcribing Physician's Orders dated 3/2021 states: I. Basic Entry of Physician Orders: A. At the implementation stage, three conditions must be met before a nurse may legally follow through on any medication or treatment order: 1. The medication or treatment order must be valid. 2. The physician and nurse obtaining the order must be licensed. 3. The nurse must know the purpose, actions, effects, major side effects and appropriate dose for all medication orders. B. A valid order is one that leaves no room for doubt as to the directive, treatment or medication prescribed. Medications ordered must have a dose and route, and dosing intervals. All orders must include the prescribers name and signature of the licensed nurse accepting the order. The drug must be appropriate for the resident; therefore, a reason or diagnosis must accompany every medication order. Since nurses are legally, morally and ethically responsible for their actions, they must assess the order for its preciseness, accuracy and appropriateness. C. A Licensed Nurse will initially enter all physician orders in EMR (Electronic Medical Record) in draft form. If available, a second Licensed Nurse (RN/LPN) will complete a verification to assess the order for its preciseness, accuracy and appropriateness; this nurse will activate the order and print any medication and treatment orders for pharmacy. D. Licensed Nurses are to monitor the EMR system for any New Orders that require activation. F. All orders must be entered and worded in such a way that is correct, complete, and clearly understandable. An appropriate diagnosis or indication of use must be included for every medication ordered. If not, clarification must be sought from the MD who gave/wrote order or the nurse who accepted and entered the order. R86 was admitted to the facility on [DATE] with diagnoses of gastroesophageal reflux disease, atrial fibrillation, and benign prostatic hyperplasia. Hospitalization prior to admission included a surgical hernia repair and a transurethral resection of the prostate (TURP). The admission Minimum Data Set (MDS) assessment, dated 5/27/2022, indicated R86 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and needed extensive assistance with activities of daily living. On 5/20/2022, on the Hospital Discharge Summary, the Physician Assistant documented R86's hospital course as R86 having a right inguinal hernia repair and a TURP with continuous bladder irrigation for 24 hours. The following medications were ordered on discharge: omeprazole 20 mg Delayed Release (E.C.) daily, aspirin 81 mg chewable table daily, and re-start Plavix (clopidogrel) in 5 days. (No dose for the Plavix was documented at that time.) Per WebMD, https://www.webmd.com/drugs/2/drug-3766-2250/omeprazole-oral/omeprazole-delayed-release-tablet-oral/details, Omeprazole is used to treat certain stomach and esophagus problems (such as acid reflux, ulcers). It works by decreasing the amount of acid your stomach makes. It relieves symptoms such as heartburn, difficulty swallowing, and cough. This medication helps heal acid damage to the stomach and esophagus, helps prevent ulcers, and may help prevent cancer of the esophagus. Omeprazole belongs to a class of drugs known as proton pump inhibitors (PPIs). Surveyor reviewed the facility orders for R86. On 5/20/2022, R86 had the following orders in the Medication Administration Record (MAR): -aspirin 81 mg chewable tablet daily. -omeprazole 20 mg tablet delayed release daily for one day. (The order should not have read for one day.) On 5/26/2022, clopidogrel 75 mg daily was started as ordered. Review of the MAR showed R86 received omeprazole on 5/21/2022 and no other doses while at the facility. On 6/1/2022 on the Medication Regimen Review, the pharmacist noted the omeprazole was discontinued. On 6/1/2022 on the Skilled Nursing Facility History and Physical report, the physician documented R86 was seen in the wheelchair resting comfortably. The physician documented R86 had issues with anemia secondary to bleeding and continued on Plavix and aspirin; iron tablets would be started given the high risk of iron deficiency anemia secondary to acute blood loss. The physical examination was unremarkable. The following labs were on the report: -5/23/2022: Hemoglobin 10.1g/dL, Hematocrit 30.7% -5/27/2022: Hemoglobin 9.1 g/dL, Hematocrit 28% -5/31/2022: Hemoglobin 8.7 g/dL, Hematocrit 27.3% The physician documented in the Assessment and Plan section for the diagnosis Gastro-esophageal reflux disease without esophagitis that R86 continued omeprazole and to monitor for breakthrough symptoms. (R86 was not taking omeprazole at that time.) The physician documented to follow up with urinary symptoms, abdominal concerns, blood pressures, volume overload, progress with therapies, and routine laboratory monitoring. On 6/2/2022, at 8:42 PM, nursing charted R86 was straight catheterized due to urinary retention and 400 ml of dark cloudy yellow urine was drained. No blood was noted in the urine. On 6/2/2022, at 11:21 PM, nursing charted R86 requested a suppository and abdomen was firm in all four quadrants with hypoactive bowel sounds. A rectal check was completed and positive for firm but not hard stool plugging the rectum. The physician was contacted to request an order for Miralax or Metamucil to help with bowel motility. On 6/3/2022, at 4:45 AM in the progress notes, nursing charted R86 was unable to urinate and was straight catheterized with clear, apricot colored urine returned. On 6/3/2022, at 9:22 AM in the progress notes, nursing charted R86 had a large bowel movement with no difficulty to pass. On 6/3/2022, at 9:53 AM in the progress notes, nursing charted a foley catheter was placed due to urinary retention. The urine was amber/straw colored. On 6/3/2022, at 9:19 PM, in the progress notes, nursing charted indwelling catheter was draining blood-colored urine. R86 asked for Miralax or prune juice even though R86 had a bowel movement that day. R86's abdomen was soft, non-tender, and non-distended. The urine culture came back positive, and an antibiotic was started for five days. Vital signs were stable and afebrile. On 6/4/2022, at 1:46 PM, in the progress notes, nursing charted R86 had hematuria due to the resection of the prostate. On 6/5/2022, at 5:55 PM, in the progress notes, nursing charted the indwelling catheter was patent draining yellow urine at times and at other times the urine turns back to bloody red hematuria with blood shreds. Vital signs were stable. On 6/6/2022, at 1:24 AM, in the progress notes, nursing charted the indwelling catheter was patent and intermittently draining straw-colored yellow, amber, and blood colored urine with mucous shreds. Vital signs were stable. On 6/7/2022, at 4:32 AM, in the progress notes, nursing charted the indwelling catheter was patent and draining clear yellow urine; no hematuria was noted. On 6/7/2022, at 10:37 AM, in the progress notes, nursing charted R86 had a soft, flat abdomen with active bowel sounds. The indwelling catheter was draining clear yellow urine. On 6/8/2022, on the Skilled Nursing Facility Progress Note, the Nurse Practitioner (NP) documented R86 had labs completed on 6/6/2022 with a decrease in hemoglobin. No rectal bleeding had been noted and orders were for a close follow up of hemoglobin. On 6/6/2022, the Hemoglobin was 7.7 g/dL and the Hematocrit was 24.2%. The NP documented in the Assessment and Plan section for the diagnosis Gastro-esophageal reflux disease without esophagitis that R86 continued omeprazole and to monitor for breakthrough symptoms. (R86 was not taking omeprazole at that time.) The NP documented to follow up with urinary symptoms, blood pressures, volume overload, progress with therapies, and routine laboratory monitoring. On 6/8/2022, at 12:39 PM, in the progress notes, nursing charted R86 requested to have nightly scotch as that is the normal routine for R86 at home. An order was obtained for R86 to have 1-2 ounces of scotch nightly. On 6/9/2022, at 11:03 AM, in the progress notes, nursing charted R86 was alert and oriented with forgetfulness at times with anxiety related to bowel movements. R86 frequently wants something for bowel management even if R86 had a bowel movement. Nursing had been doing frequent education regarding bowel management and going over medication list and as needed medications with R86. R86 was informed bowel movements are tracked for all residents daily. R86's abdomen was flat and soft with active bowel sounds. The indwelling catheter was draining clear yellow urine. On 6/11/2022, at 9:38 AM, in the progress notes, nursing charted R86's abdomen was soft and non-tender with active bowel sounds in all four quadrants. R86 denied nausea, vomiting, and diarrhea. R86 reported having a complete clean out of the bowels yesterday after having Milk of Magnesia, fiberstat and a suppository. The indwelling catheter was patent draining dark urine. On 6/12/2022, at 1:00 PM, in the progress notes, nursing charted R86's abdomen was soft and non-tender with active bowel sounds in all four quadrants. The indwelling catheter was patent draining dark urine. On 6/13/2022, on the Skilled Nursing Facility Progress Note, the NP documented R86 was doing well that morning and nursing reported R86 had no pain and tolerating acetaminophen for pain. R86's urinary catheter was draining golden yellow urine without hematuria (blood in the urine). R86 reported an excellent appetite stating 100% of the breakfast was eaten. Labs were reviewed and hemoglobin was 6.7, previously at 8.9 on 6/9/2022. No active signs of bleeding were noted, and orders were placed for follow up lab in the morning to trend. The NP documented R86 may require further evaluation if hemoglobin remains low or drops further. R86 had no fevers, upper respiratory symptoms, shortness of breath, cough, nausea, abdominal pain, urinary concerns, diarrhea, or constipation. The following labs were on the report: -6/9/2022: Hemoglobin 8.9 g/dL, Hematocrit 27.6% -6/13/2022: Hemoglobin 6.7 g/dL, Hematocrit 20.9% On 6/13/2022, at 5:36 PM, in the progress notes, nursing charted R86's indwelling catheter was draining straw-colored urine that was clouded with sediment. R86 had an order per R86's request to have a serving of scotch liquor every day at 2:00 PM. R86 complained this afternoon of gas pains/stomach discomfort. Scheduled Simethicone was given before dinner. On 6/14/2022, at 8:56 AM, in the progress notes, nursing charted R86 complained of nausea with dry heaves. An order for Zofran was obtained from the physician. On 6/14/2022, at 9:00 AM, in the progress notes, nursing charted R86's abdomen was soft and flat with hypoactive bowel sounds. R86 had an extremely large bowel movement that morning that was not difficult to pass. The indwelling catheter was draining clear straw/yellow colored urine. On 6/14/2022, on the Skilled Nursing Facility Progress Note, the NP documented R86 was seen on that date due to anemia. Labs that morning confirmed a decrease in hemoglobin at 6.1 and had noted fatigue that morning in addition to worsening weakness. R86 did not have shortness of breath or audible cough. R86 reported poor appetite this morning. The urinary catheter had golden yellow urine without hematuria or sediment. Nursing staff reported R86 had a large dark bowel movement this morning. Vital signs were reviewed with a noted low blood pressure at 90 systolic. R86 reported mild abdominal discomfort. Orders were placed to have R86 evaluated in the emergency department due to anemia. The following labs were on the report: -6/13/2022: Hemoglobin 6.7 g/dL, Hematocrit 20.9% -6/14/2022: Hemoglobin 6.1 g/dL, Hematocrit 18.3% The Assessment and Plan section of the Note stated Hemoglobin at 8.9 on 6/9/2022 and now confirmed at 6.1 on 6/14/2022 with dark stool led to R86 being sent to the emergency room for further evaluation. On 6/14/2022, at 11:01 AM, in the progress notes, nursing charted an order was received to send R86 out to the hospital due to the repeat lab draw this morning of the hemoglobin and hematocrit. On 6/15/2022, at 9:19 AM, in the progress notes, nursing charted R86 was admitted to the hospital with a diagnosis of gastrointestinal bleed. R86 did not return to the facility. R86 was discharged from the hospital to a different facility for skilled nursing services. Surveyor reviewed the facility grievance log. A grievance was filed by R86's family member on 6/17/2022 regarding a medication error. Surveyor requested to see the follow up of the grievance. On the Incident Report-Medication Error form dated 6/17/2022, the error occurred on 5/22/2022 with a discovery date of 6/17/2022. The error that was discovered was a transcription error. The details of the incident section of the form stated the incident was brought to the attention of the facility that R86 was not receiving omeprazole. Through investigation it was noted that the medication was placed in the computer but only for one day. R86 only received one dose of omeprazole. The summary stated the policy was reviewed with both individuals about medication transcription as it was noted that the order was put in wrong and verified wrong. Employee statements were obtained during the investigation. The statement by Licensed Practical Nurse (LPN) that entered the orders into the EMR stated that was the first time entering orders into the EMR since hire date of 4/8/2022 and the LPN stated there were multiple admissions with frequent interruptions while entering the medication orders. The LPN stated they will now take initiative when more that one admission is coming in on the day shift and will slow down and do what is to be done with all tasks. The statement by Registered Nurse Unit Manager (RNUM)-D that activated the medication orders stated the medication was ordered to start the next day but did not note that the medication was written for one dose only. RNUM-D stated they were going to quickly and will now slow down and check to see if an amount in days was scheduled. On 8/9/2022, at 3:04 PM, Surveyor met with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and RNUM-D. Surveyor shared the concern R86 did not receive omeprazole for four weeks on admission that resulted in hospitalization for a gastrointestinal bleed. No further information was provided at that time.