CENTRE AVENUE HEALTH AND REHAB LLC

A revisit survey was completed on 6/21/23 for all previous deficiencies cited on 4/18/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 6/21/23 for all previous deficiencies cited on 4/18/23. The facility is in compliance with all regulations surveyed.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is two story, Type II (111), construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 2000 and is license for 90 beds. This re-certification survey conducted on May 11, 2023 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey. The Administrator reported the daily census to be 78 residents on May 11, 2023.

STANDARD is not met as evidenced by: Based review of the records and discussion during the survey, it was determined the facility failed to inspect and test the fire alarm system per NFPA 101, Chapter 9 (Section 9.6 Paragraph 9.6.1.4) and NFPA 72, (Chapter 7, Paragraph 7-1.2.2). Failure to maintain and test the fire alarm system has the potential to harm all occupants, staff and visitor in the build if the fire alarm system failed to operate if a fire was to occur. During the review of the records, with the Administrator, documentation was not available to verify the sensitivity testing of the smoke detectors per NFPA 101 2012 Edition 19.3.4.1, 9.6.1.3, NFPA 72 7-3 and 7-3.2.1. The Administrator acknowledged the condition of testing the fire alarm system during the record review.

STANDARD is not met as evidenced by: Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3. This deficient practice could affect all residents within the smoke compartments should the egress become untenable, due to smoke and heat transfer via the non-latching corridor doors. This was evidenced by the following: Corridor doors were not maintained to close and positively latch, as required. Door opening in the cross-corridor 2nd floor Library to dining would not latch and close completely into the door frames creating a rated barrier. The Director of Maintenance acknowledge the corridor door condition during the facility tour. The Life Safety Code Section 19.3.6.3.2 requires that corridor doors be provided with the means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. Doors must be unobstructed from closing and positively latching into the door frame. Section 19.3.6.3.1, Exception #2 requires that corridor doors installed within sprinklered protected smoke compartments be constructed to resist the passage of smoke.

Based on observation and staff interview during the course of the survey conducted on March 1, 2018, it was determined the facility failed to maintain the building services for gas equipment in accordance with NFPA 101, 19.5, 19.5.1.1, 9.1.1, including NFPA 54, National Fuel Gas Code. The following evidenced this:During the walk through of the facility with the Maintenance Director;The Dryer vents had been assembled using screws:NFPA 54 10.4.4.2 Ducts for exhausting clothes dryers shall not be assembled with screws or other fastening means that extend into the duct and that would catch lint and reduce the efficiency of the exhaust system.

A licensure survey was completed on 4/12/23 to 4/18/23. One deficiency was cited.

Based on interviews and record review, the facility failed to ensure three (#53, #16 and #33) of eight residents reviewed for accidents out of 32 sample residents received adequate supervision to prevent an accident/hazard. Resident #53 was known to be at risk for falls on admission as he had fallen at home. The facility failed to implement effective interventions. The resident fell two times on 2/17/23, with the first fall resulting in a head wound with active bleeding where the resident was sent to the emergency department for treatment and the head wound was glued. Observations revealed fall interventions were not consistently implemented. In addition, the facility failed to:-Implement effective fall interventions for Resident #16; and, -Implement interventions when Resident #33 obtained a skin tear during a transfer to prevent it from occurring again. Findings include:I. Resident #53A. Facility policy and procedure The Skilled Nursing Facility Fall Management policy and procedure, revised on 2/8/23, was received from the nursing home administrator (NHA) on 4/13/23 at 4:52 p.m. It read in pertinent part: "Residents have a right to a safe environment, while maximizing their independence. Fall prevention seeks to balance resident's safety from falls while respecting individual rights and preservation of dignity. It is the facility's goal to reduce falls and injury related falls. "Admitting Nurse will complete the Fall Risk Observation upon admission. Individualized interventions will be implemented to minimize potential fall occurrence dependent upon the resident's risk. "Additional interventions for residents identified to be at greater risk: anticipate needs by observing normal routines and times of increased risk, obtain consults as appropriate, encourage adequate rest periods to prevent over tiring, and increase staff observation and avoid self isolation. Encourage inclusion in activities and social interaction." The Fall Prevention Philosophy, dated 2/1/23, was received by the clinical nurse consultant on 4/18/23 at 11:00 a.m. It read in pertinent part:"Call lights: We strive to meet each resident's needs prior to them having to use their call light. If a call light is used, it will be answered promptly and courteously by the first available staff person. "Purposeful rounding is rounding routinely to meet the resident's needs before they ask, is proactive rather than reactive, prevents falls and other injuries, takes less time than answering call lights, and is done by all nursing department staff."With each round offer toileting/check incontinence products, reposition for comfort, offer, encourage, and assist with fluids, ask about pain or discomfort, ask if there are any personal items they need or an activity they would like to participate in. Look at the environment: ensure call lights are in reach, ensure water is available and in reach, and ensure the room is free of clutter and a neat appearance."B. Resident statusResident #53, age 87, was admitted on 10/8/22. According to the April 2023 computerized physician order (CPO), the diagnoses included atrial fibrillation, muscle weakness, repeated falls, unspecified dementia, traumatic subdural hemorrhage (bleeding inside the skull) with loss of consciousness, attention and concentration deficit, cognitive communication deficit and frontal lobe and executive function deficit. The 4/3/23 facility assessment revealed the resident's cognition was severely impaired with a brief interview for mental status score (BIMS) of three out of 15. He required extensive assistance of two persons for dressing and toileting, extensive assistance of two persons with bed mobility and transfers, and extensive assistance of one for personal hygiene and the supervision of one person for eating. The resident was also identified to be at high risk for falls. C. Resident representative interviewThe resident was not interviewable due to his cognitive communication deficit. The resident's spouse was interviewed on 4/12/23 at 11:34 a.m. She said she was with the resident all the time because she was responsible for all choices/decisions regarding the resident's care. She stated the resident had problems understanding things. She said he fell at home in the bathroom and hit his head that caused his brain to bleed. She said after she was admitted to the facility. She said the resident had been different ever since the fall, he had a poor memory and could not carry a conversation. She said she encouraged the resident to press the call light but he did not remember and the call light was always within his reach when he was sitting in the wheelchair. She said she had concerns the resident had fallen out of his wheelchair during the night. She said the staff were not consistent with rounding, it depended who was working and varied everyday. D. ObservationsOn 4/12/23 at 2:49 p.m. the resident was in his wheelchair in his room without the call light within reach. The resident was not wearing his prescribed glasses. The resident had heel protectors on his feet that were resting on foot rests with no non-skid footwear. On 4/13/23 at approximately 9:00 a.m. to 10:05 a.m. the resident was observed in his room sitting in a wheelchair, he was dozing and abruptly woke up and cried out for his wife to take him home. No staff member entered the resident's room during that time period. The resident was not wearing his prescribed glasses, or non-skid footwear on both feet. The call light was hanging over the right armrest of the wheelchair resting on the floor. On 4/18/23 at 8:22 a.m. to 8:32 a.m. the resident was not wearing his prescribed glasses. At 9:29 a.m. the resident was yelling for help. A certified nurse assistant (CNA) arrived and attempted to calm the resident. The resident was not wearing his prescribed glasses. The call light was on his bed and the CNA tucked the call light between the gel seat cushion and left side of the wheelchair before exiting the room. At 12:42 p.m. the resident was sitting in the wheelchair in his room without a call light within reach.-The resident was not able to consistently use the call light (see family interview) and it was not placed properly for use, did not have his glasses on and often did not wear non-skid footwear. E. Record reviewThe resident was admitted to the hospital from 9/28/23 to 10/3/22 status post fall at home resulting in subdural hemorrhage (bleeding in the brain), an 8th left rib fracture, increase in impaired mobility and generalized weakness. Care planThe care plan, revised on 1/5/23, read in pertinent part: the resident was at risk for falls related to a history of falls, decreased mobility, decreased balance, advanced age, and weakness. Interventions start date 10/8/22 date included PT, OT consults, strength training, toning, positioning, transfer training, gait training, and mobility devices. The resident was not a candidate for rehabilitation service due to presenting symptoms and the resident's spouse opted for hospice care. The care plan dated 1/5/23 continued with: keep call light and personal items and frequently used items in reach. Provide the resident with an environment free of clutter. Orient resident when there has been new furniture placement or other changes in environment. If falls occur, analyze resident's falls to determine pattern/trend. Give resident verbal reminders not to ambulate/transfer without assistance, provide resident with proper well-maintained footwear. Encourage the resident to use environmental devices such as hand grips, handrails. Assure the floor is free of glare, liquids, and foreign objects. Assure the resident was wearing glasses and they were clean. Toileting program, 12/28/22, read as follows: assure the resident is sitting upright in his wheelchair. Interdisciplinary team to review medication regimen, padding to gap in bed and bed extenders, and included offer distraction measures updated on 1/31/23. Interdisciplinary team: ensure resident has proper footwear over heel protectors when up in wheelchair updated 2/21/23. Care plan after 2/21/23 included the interdisciplinary team (IDT) to complete root cause(s) of fall events and establish and recommend interventions. Falls Two fall events occurred on 2/17/23 at 7:15 p.m. and at 11:53 p.m. The fall at 7:15 p.m. was unwitnessed and occurred in the hallway as the resident stood upright from his unlocked wheelchair and fell backward hitting his posterior head against the floor. The resident reported he was trying to find his wife. The resident was last toileted at 5:30 p.m. and was incontinent of urine at the time of the fall. Neurological checks were completed on 2/17/23 from 7:15 p.m. through 9:00 p.m. The spouse and medical provider were notified of the fall. At approximately 9:55 p.m. the resident's head wound started to actively bleed and the provider ordered an emergency room evaluation and computed tomography (CT) scan which was negative. The head wound was glued closed and the resident was returned to the facility. The investigation of the fall revealed the resident was not wearing non-skid footwear. Purposeful rounding stopped at 6:45 p.m. (30 minutes before the first fall). Root cause per interdisciplinary team (IDT): Urine incontinence. Interventions: proper footwear, educate the resident on importance of using call light, rearrange room.-There was no documentation the second fall on 2/17/23 at 11:53 p.m. was investigated. A third unwitnessed fall occurred on 3/20/23 at 1:35 a.m. The resident was found on the floor at his bedside, stating he wanted to "go out." No injury noted. Neurological checks were completed immediately after the fall through 3/22/23 on the evening shift (time not documented). The resident was incontinent of urine at the time of the fall. Last toileting/brief changed at 12:30 a.m. The spouse, hospice, and the medical provider were notified. Root cause per IDT: No root cause documented. Interventions: Staff implemented fall protocol, rearrange room, place bed against wall. A fourth unwitnessed fall occurred on 4/2/23 at 8:45 p.m. The resident was found on the floor leaning against his wheelchair facing the television. No injury noted. Neurological checks were completed immediately after fall through 4/5/23 on the evening shift (time not documented). The resident was not incontinent of urine at the time of the fall. Last toileting brief change at 5:45 p.m. Wife and medical provider were notified. Root cause per IDT: Believed to be agitation. Interventions: Post Void Residual Volume (no progress note related to post void residual volume output). An assisted fall occurred on 4/4/23 at 7:00 a.m. as a certified nurse assistant (CNA) was assisting the resident with a transfer from bed to wheelchair and the resident's knees buckled. The CNA lowered the resident to the floor. No injury noted. The resident was not incontinent at the time of the assisted fall. Last toileting/brief change at 5:30 a.m. Root cause per IDT: increased weakness. Interventions: Collaborate with hospice to request physical therapy for strengthening related to comfort/fall prevention (no progress note to support collaborative practice with hospice/physical therapy). F. Staff interviewsCNA #2 was interviewed on 4/13/23 at 2:10 p.m. He said the toileting program was knowing the resident's bowel and bladder habits and taking the resident to the toilet before they were incontinent. He said he used the Kardex (an abbreviated directive) to make sure he knew when to toilet residents but said it was "way too much" when he was the only CNA on the unit. CNA #1 was interviewed on 4/18/23 at 9:46 a.m. She said purposeful rounding was checking on residents every two hours to make sure they were okay and respond to their needs in a timely manner. She further explained, she was assigned to 15 residents and many were dependent on her for transfers but if she could not find help then she could not always round. The NHA was interviewed on 4/18/23 at 10:15 a.m. The NHA said the toileting program was located on the Kardex. The Kardex was generated every morning/evening (if needed) for the CNAs to offer toileting to residents because continence was a priority. The clinical nurse consultant (CNC) was interviewed on 4/18/23 at 11:20 a.m. The CNC said purposeful rounding was focused on answering call lights. The CNC stated there was no mechanism in place to assure purposeful rounding was consistently done, and no documentation to support purposeful rounding was completed. The CNC said all nursing staff were educated on fall prevention and purposeful rounding on hire and annually. II. Resident #16A. Resident status Resident #16, age 61, was admitted on 3/11/23 and discharged on 3/28/23 to the hospital. According to the March 2023 CPO, the diagnoses include displaced fracture of left femur, subsequent closed fracture, unsteadiness on feet, pain in left hip and left knee, history of falling, end stage renal disease, dependence on renal dialysis, kidney transplant, history of infections of the central nervous system-cryptococcal meningitis, history of sepsis (infection) and bacteremia (bacteria in bloodstream), pseudomonas (infection), type two diabetes and encephalopathy (altered mental status). The 3/17/23 facility assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required one person assistance with transfer, dressing, toileting and personal hygiene. He used a walker and a wheelchair. It indicated that he had a fracture related to a fall within the last six months. B. Record review The fall risk care plan, revised on 3/28/23, documented the resident was at risk for falling related to history of falls, decreased mobility, decreased balance and a hip fracture. The interventions included assure resident is wearing eyeglasses, assure eyeglasses are clean and in good repair, assure the floor is free of glare, liquids and foreign objects, encourage resident to use environmental devices such as hand grips, hand rails,etc, keep call light and personal items within reach, occupy resident with meaningful distractions, provide assistance as needed for ADLs and mobility, provide toileting assistance/toileting plan. The initial social services progress note on 3/13/23 at 5:07 p.m. indicated that the resident was independent with all ADLs with no need of mobility. -There was no intervention in his fall risk care plan related to residents identified to be at greater risk. The activities of daily living (ADL) function status/rehabilitation potential care plan, initiated on 3/12/23, documented the resident will attain and maintain the highest practicable functional level and complications will be minimized. The interventions included providing an occupational and physical therapy evaluation, enforce weight bearing restrictions as ordered, instruct in use of assistive device and monitor for correct use, provide assistance for ADL's and mobility as needed, and teach safety measures and monitor resident's safety. The 3/13/23 fall assessment documented at 9:08 p.m. the resident told the nurse he tried to roll in the bed and fell down on the floor. The nurse's progress note on 3/13/23 at 10:11 p.m. documented "the CNA informed the nurse that they came in the patient's room to help him to bed. Patient told the CNA he can't sleep and he needs his wife or someone (sic) to sleep with (sic) him in the room. The nurse told the resident that no one can be (sic) in his room during the night. Later the resident pressed the call light many times and asked the CNA if she can stay with him. There was no documentation that the staff asked the resident if they should call his wife nor did they attempt to reach the resident's wife at nightime. The facility attempted to reach the wife on 3/14/23 at 8:55 a.m. to inform the wife of the fall at night. They were unsuccessful in reaching thewife. They notified the son about the fall and he said he would visit the morning of 3/14/23." -There were no additional interventions added to the actual fall care plan related to the resident's need for increased supervision. The nurse's progress note on 3/21/23 at 12:09 p.m. documented the resident was asking for percocet for his pain. He has confusion at times. The 3/21/23 fall assessment documented at 8:08 p.m. the resident told the nurse that he slid out of his wheelchair and was lying on the floor at the end of the hall in front of the wheelchair. The care plan revealed the following intervention was added: encourage resident to become more involved in facility activities. The 3/22/23 fall assessment documented at 5:45 p.m. the resident told the nurse that he was trying to go to the bathroom. The CNA found the resident in between the toilet and the wall. The care plan revealed the following intervention was added: continue with PT/OT, social work to speak with family about changing room closer to nurse's station and explore post dialysis activities during peak time of confusion. The nurse's progress note on 3/22/23 at 5:30 p.m. documented the resident told the CNA that he saw a woman with a dog and was going after the dog. When asked by the nurse, resident said he was trying to go up a three to four run ladder. The nurse's progress note on 3/22/23 at 11:59 p.m. documented the resident complained of pain to whole body. The interventions used were low bed, appropriate footwear or grippy socks. The nurse's note on 3/23/23 at 2:03 p.m. documented the night shift night nurse reported that resident complained of right lower extremity pain overnight after his fall. The nurse's progress note on 3/23/23 at 2:46 a.m. documented the interventions used were purposeful rounding, appropriate footwear or grippy socks and toileting programs. The resident was educated to not stand up by himself. Resident was upset with nurse stating he was not in a concentration camp. The nurse reminded the resident that he was in rehabilitation for his broken hip and the facility has safety regulations. The nurse reminded him about his falls. The 3/27/23 fall assessment documented at 8:56 p.m. documented the resident told the nurse he was trying to get to the wheelchair from his bed. He was found on his knees in his room. The nurse's progress note on 3/27/23 at 9:55 p.m. documented the resident sustained a skin tear to the left outer forearm. The nurse's progress note on 3/28/23 at 7:00 a.m. documented "the resident was very confused throughout the night. He was alert and oriented to self only. Resident had three falls since 8:00 p.m. last evening. The resident vacillated from very agitated and lethargic. When awake and restless (sic) and agitated, he continues to take off his clothes and attempting to grab staff and get up. Temperature started at 99.8 degrees F and went up to 100.2 degrees F. Tylenol was provided. Resident assisted to chair and back to bed but has remained unsafe and closely monitory. Heart rate was tachycardia but regular. Provider was notified after first fall and again this morning with orders to send to emergency room to evaluate and treat." The nurse's progress note on 3/28/23 at 9:54 a.m. documented "called hospital emergency room for resident's disposition. Resident is being admitted for altered mental status, generalized abdominal pain, urinary retention, blood in urine, urinary tract infection, elevated white blood cells, elevated potassium of 7."-The care plan revealed the following interventions were added: sent to ER for evaluation on 3/28/23, room rearranged related to falls and purposeful rounding. -The facility failed to put effective interventions into place to prevent Resident #16 from continued falls. C. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 4/17/23 at 11:53 a.m. He said purposeful rounding was to go to the resident's door say hello and seeing if the resident needed anything. The nurse would see if the resident was in distress or pain. LPN #1 was unable to answer how often purposeful rounding should be completed. CNA #3 was interviewed on 4/17/23 at 11:48 a.m. She said purposeful rounding was to check on all residents every 60-90 minutes. She said she did not know what purposeful rounding was if a resident had an intervention. She stated the toileting program was to check on the resident every two hours to see if they needed incontinence assistance. A copy of the facility's purposeful rounding policy was requested on 4/17/23. The clinical services manager (CSM) #1 did not have a policy. She provided a presentation on purposeful rounding. -The presentation did not state what the frequency of rounding should be when ordered. Admission coordinator (AC) #1 was interviewed on 4/18/23 at 11:58 a.m. She said she notified the nurse and therapists when a new resident was a high fall risk. She stated new residents identified as a fall risk should have maximum assistance, have a sling in the room and be close to the nurse's station. The fall risk was communicated through email to all disciplines and the admission coordinator would give a report in person. III. Resident #33A. Resident observationsOn 4/12/23 at 1:24 p.m., the resident sat in a wheelchair in her room. She had a bandage on her left lower extremity (shin). The bandage was dated 4/12/23. B. Family interviewAn interview was conducted with the resident's daughter on 4/12/23 at 1:24 p.m. She said on 4/2/23, the resident hit her left shin on a metal part of her wheelchair while she was in the bathroom with a staff member. The resident received a skin tear to her left shin. C. Resident statusResident #33, age 92, was admitted on 1/17/23. According to the April 2023 computerized physician orders (CPO), diagnoses included need for assistance with personal care, muscle weakness, history of falling, lack of coordination, chronic kidney disease stage 3, malignant neoplasm (cancer) of the breast, history of sepsis, chronic obstructive pulmonary disease, lack of coordination, cognitive communication deficit, lack of coordination, frontal lobe and executive function deficit. The 1/23/23 facility assessment, revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15 with no behaviors. The resident required extensive staff assistance for bed mobility, transfers (two plus staff physical assist), dressing, eating, toileting (two plus staff physical assist), and personal hygiene. The resident had functional limitations in range of motion impairment on both sides of her lower extremities (hip, knee, ankle, or foot). The resident had occasional moderate pain that did limit her day to day activities. D. Record reviewCare plan for a skin tear was started on 2/23/23. The pertinent interventions included for staff to apply dressings according to physician and wound care team orders. Staff were to consult with the facility wound care team to follow and guide the resident's treatment. Staff were to report signs of cellulitis (localized pain, redness/swelling/tenderness/drainage, fever); sepsis (fever/malaise/change in mental status, tachycardia/hypotension, nausea/vomiting); osteomyelitis (pain/redness/swelling, muscle spasms, fever). Wound care would be managed by a hospital wound clinic, facility wound care team and the resident's family. Event report by licensed practical nurse (LPN) #1 dated 2/20/23 at 8:45 a.m., revealed to monitor a skin tear to the resident's left lower extremity (shin) related to contact with her wheelchair footplates upon transferring. The skin tear was vertical measuring 2 centimeters (cm) on the left lower shin. There was no pain associated with the skin tear and no signs or symptoms of infection. Staff were to monitor the skin tear daily for any change in condition. -The resident's physician and family representative were not notified. Wound note dated 2/23/23 at 8:30 a.m., by a registered nurse (RN)revealed skin tear/laceration to the left shin. The wound bed had granulated and epithelial tissue with heavy sanguineous (blood) exudate. The surrounding skin was bruised. Resident reported no pain to the area. Resident was at baseline for movement, strength, sensation, temperature and edema (water retention) for the extremity wound. Physician order dated 2/23/23 revealed a skin tear to the left middle shin. Wound care team to cleanse with saline or wound cleanser, pat dry, apply xeroform (cut to fit) followed by foam dressing every other day and as needed.-After the resident obtained the skin tear on 2/20/23, there was no subsequent education with staff or preventative measures put in place to prevent recurrence. E. Staff interviewsThe assistant director or nursing (ADON) was interviewed on 4/18/23 at 8:40 a.m. He said the resident's lower extremity wound occurred when her left was bumped on her wheelchair during a transfer by staff. The wound nurse (WN) was interviewed on 4/18/23 at 12:10 p.m. She said on 2/20/23 from a skin tear that occurred during a transfer with staff. She said a staff member was transferring the resident and her shin came into contact with the wheelchair pedals that were folded up and to the sides of the wheelchair. She said she felt this was an accident and the transfer was completed according to facility policy. She acknowledged that there was no evidence the resident's family nor her physician were notified of the incident on 2/20/23 and they should have been notified. LPN #1 was interviewed on 4/18/23 at 2:46 p.m. He said he was told by a certified nurse aide (CNA) that the resident had hit her shin on the wheelchair foot pedals. He said the food pedals were flipped up and she nicked her shin on the metal. He said it was a small skin tear and she did have some edema at the time. He said it was bleeding a little at the time. He said he could not remember if he notified the resident's family or physician. He said for changes of condition, falls, head injuries and unwitnessed falls the family and physician should be notified.

A recertification survey was completed from 4/12/23 to 4/18/23. Three deficiencies were cited.

An Emergency Preparedness survey was conducted from 4/12/23 to 4/18/23. No deficiencies were cited.

Based on record review and interviews, the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his/her authority, the resident's representative when there was a change of condition for three (#33, #59 and #64) of eight residents out of 32 sample residents. Specifically, the facility failed to notify the resident's physician and/or the resident's legal representative related to:-Resident #33's skin tear to the left lower extremity;-Resident #59's falls on 1/26/23 and 2/27/23; and,-Resident #64's falls on 2/20/23 and 3/9/23. Findings include:I. Facility policy and proceduresThe Change of Condition with Resident policy, revised on 7/7/22, was provided by the clinical services manager (CSM) #1 on 4/18/23 at 12:42 p.m. The policy revealed a change of condition with a resident was a multi-disciplinary approach and might be observed by any member of the team. The interdisciplinary team (IDT) reviewed residents routinely and might identify a change of condition. The IDT should monitor residents on-going, for a change of condition/change in status. Upon identification of a change of condition, an event will be opened in (charting program) and interventions implemented immediately. The registered nurse (RN) or the licensed practical nurse (LPN) was responsible for notifying the provider and the resident's power of attorney (POA) of a significant change of condition. Documentation of notification should be made in the medical record. Except in a medical emergency, a resident should not be transferred or discharged, or his/her treatment radically altered without consultation with the resident/POA and the provider. II. Resident #64A. Resident statusResident #64, age 86, was admitted on 1/31/23. According to the April 2023 computerized physician orders (CPO), diagnoses included metabolic encephalopathy (altered mental status), cognitive communication deficit, history of falling, permanent atrial fibrillation, muscle weakness, presence of cardiac pacemaker, frontal lobe and executive function deficit. The 4/1/23 minimum data set (MDS) assessment, revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15 with no behaviors. The resident required extensive staff assistance for bed mobility and dressing. The resident required limited staff assistance for transfers, toileting and personal hygiene. B. Record reviewCare plan for falls related to the resident's history of falls, decreased mobility, decreased balance and lack of understanding of surroundings was initiated on 1/31/23. The pertinent interventions were staff to provide ongoing education to use call light for assistance prior to getting out of bed or off the toilet. Ensure the resident was wearing eyeglasses. Ensure the floor was free of glare, liquids, and foreign objects. Encourage the resident to use environmental devices such as hand grips and hand rails. Provide the resident verbal reminders not to ambulate/transfer without assistance and encourage the resident to assume a standing position slowly. Provide the resident with proper and well-maintained footwear. If falls occur, analyze the resident's falls to determine the pattern/trend. Ensure the call light, personal items and frequently used items were within reach. Provide the resident an environment free of clutter. Staff were to orient the resident when there has been new furniture placement or other changes in environment. Staff were to provide the resident with assistance as needed for activities of daily living and mobility. Staff were to provide toileting assistance. C. Fall on 2/20/23Event report revealed an unwitnessed fall on 2/20/23 at 6:00 p.m., in his room. The resident did not exhibit or complain of pain related to the fall. There were no signs of injury. The resident was able to perform ranges of motion on all extremities without limitations or pain. There was no observed rotation, deformity or shortening of extremities. The resident was alert and oriented at times two. The resident had a history of falls, movement problems or unsteady gait and an orthopedic condition. -The resident's physician and legal representative were not notified. The post fall investigation revealed the resident had a fall on 2/20/23 at 6:00 p.m. The resident was found lying on the floor in front of his recliner and said he was trying to go to bed. There were no observed injuries. The wound nurse (WN) was interviewed on 4/18/23 at 10:40 a.m. She acknowledged the resident's family nor physician were notified of the resident's fall on 2/20/23. She said they both should have been notified about the fall. E. Fall on 3/9/23The family interview was conducted on 4/12/23 at 2:23 p.m. The daughter of the resident said the resident fell while going to the bathroom during the night of 3/9/23 and the facility staff did not notify them. She said she learned about the fall from the resident's physician the next day on 3/10/23 at 9:30 a.m. She said the resident fell and hit his head on the corner of the in room sink. She said the resident had a contusion to the back of his head, a bruise on his forehead, a bruise on the back of his neck and his left knee was hurting. She said he was sent to the hospital emergency department according to their request. Event report dated 3/9/23 at 11:15 p.m., revealed the resident had an unwitnessed fall at 9:55 p.m., in his room. The resident did not exhibit or complain of pain related to the fall. The resident's ranges of motion for all extremities were without any limitations or pain. There was no rotation, deformity or shortening of the extremities. The resident was alert and oriented at times one. The resident had a history of falling. The safety measures at the time of the fall were to ensure the call light (paddle) was in reach, bed in lowest position, walker, wheelchair and non-slip socks. -The resident's physician and legal representative were not notified. Fall investigation revealed on 3/9/23 at 9:55 p.m., the resident had an unwitnessed fall. A certified nurse aide (CNA) heard the resident fall and found him on the floor in his room. The resident wore regular socks. The resident said he was leaving. The resident had a hematoma to the base of the skull, minor injury of a skin tear or major bruise depending on the hospital's evaluation. The resident was educated on the use of the all light. Nurse note dated 3/10/23 at 10:24 a.m., by a RN revealed the resident's physician was notified the resident had a fall overnight. The resident was unable to bear weight on his left knee and was walking yesterday. The resident had a hematoma to the base of his skull and was going to the hospital for evaluation. Hospital note dated 3/10/23 at 11:12 a.m., revealed no acute osseous abnormality or intracranial processes. There was ecchymosis (contusion or bruise) to the occiput. There was no discomfort elicited upon the range of motion of the left knee or hip. The resident reported tenderness on palpation to the proximal aspect of the left femur and the lateral aspect of the proximal portion of left tibia/fibula. The WN was interviewed on 4/18/23 at 10:40 a.m. She acknowledged the resident's family was not notified of the resident's fall on 3/9/23. She said the resident's family should have been notified immediately due to his head injury and subsequent delayed transportation to the hospital emergency department. She acknowledged the resident's physician was not notified until 3/10/23 at 10:24 a.m. She acknowledged the resident's physician should have been notified immediately due to the resident's head injury. III. Resident #33A. Resident statusResident #33, age 92, was admitted on 1/17/23. According to the April 2023 CPO, diagnoses included need for assistance with personal care, muscle weakness, history of falling, lack of coordination, chronic kidney disease stage 3, malignant neoplasm of the breast, history of sepsis (infection), chronic obstructive pulmonary disease, lack of coordination, cognitive communication deficit, lack of coordination, frontal lobe and executive function deficit. The 1/23/23 minimum data set (MDS) assessment, revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15 with no behaviors. The resident required extensive staff assistance for bed mobility, transfers (two plus staff physical assist), dressing, eating, toileting (two plus staff physical assist), and personal hygiene. The resident had functional limitations in range of motion impairment on both sides of her lower extremities (hip, knee, ankle, or foot). The resident had occasional moderate pain that did limit her day to day activities. B. Record reviewEvent report by licensed practical nurse (LPN) #1 dated 2/20/23 at 8:45 a.m., revealed to monitor a skin tear to the resident's left lower extremity (shin) related to contact with her wheelchair footplates upon transferring. The skin tear was vertical measuring 2 centimeters (cm) on the left lower shin. There was no pain associated with the skin tear and no signs or symptoms of infection. Staff were to monitor the skin tear daily for any change in condition. -The resident's physician and family representative were not notified. Care plan for a skin tear was started on 2/23/23. The pertinent interventions included for staff to apply dressings according to physician and wound care team orders. Staff were to consult with the facility wound care team to follow and guide the resident's treatment. Staff were to report signs of cellulitis (localized pain, redness/swelling/tenderness/drainage, fever); sepsis (fever/malaise/change in mental status, tachycardia/hypotension, nausea/vomiting); osteomyelitis (pain/redness/swelling, muscle spasms, fever). Wound care would be managed by a hospital wound clinic, facility wound care team and the resident's family. C. Staff interviewThe WN was interviewed on 4/18/23 at 12:15 p.m. She acknowledged the resident's family nor physician were notified of the skin tear to the resident's left lower extremity on 2/20/23. She said they both should have been notified about the skin tear. IV. Resident #59A. Resident statusResident #59, age 78, was admitted on 7/1/22. According to the April 2023 CPO, diagnoses included dementia, depression, lack of coordination, attention/concentration deficit, symbolic dysfunctions, history of falling, muscle weakness, frontal lobe and executive function deficit. The 2/16/23 minimum data set (MDS) assessment, revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15 with no behaviors. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. B. Record reviewCare Plan for falls related to the resident's history of falls, decreased mobility, decreased balance and poor decision making was revised on 2/20/23. The pertinent interventions were to ensure the resident wore the proper anti-slip footwear, educate the resident to call staff prior to getting up independently and for the maintenance staff to assess for anti-roll back mechanism on the wheel chair. Ensure the resident's bathroom was free of clutter, and the light in the bathroom was tested and worked appropriately. Keep the resident's bed in the lowest position. Ensure the resident was wearing glasses. Ensure the floor was free of glare, liquids, and foreign objects. Encourage the resident to use environmental devices such as hand grips, and handrails. Provide the resident with verbal reminders not to ambulate/transfer without assistance and encourage the resident to assume a standing position slowly. If falls occurred, analyze the resident's falls to determine pattern/trend. Ensure the call light, personal items and frequently used items were within reach. Staff were to provide the resident an environment free of clutter. Staff were to orient the resident when there has been new furniture placement or other changes in environment. Staff were to provide assistance as needed for activities of daily living and mobility. Staff were to provide toileting assistance. C. Fall on 1/6/23Event report revealed on 1/6/23 at 6:45 p.m., the resident had a witnessed fall in their room. The resident said "I fell backwards cause my legs got wobbly." The resident was being transferred with staff assistance. The resident was able to move all extremities without pain. There was no observed rotation, deformity of the extremities. The safety measures that were in use at time of fall were the resident's bed was in the lowest position, paddle call light in reach, gait belt, shoes, and wheelchair.-The resident's physician and family representative were not notified of the fall. The post fall investigation for the fall on 1/6/23 at 6:45 p.m., revealed the resident was assisted to the bathroom, the resident's legs became weak and gave out from under her. The fall was witnessed and the resident hit the back of her head during the fall. The resident had slight pain to the area, and no other injuries were noted. The WN was interviewed on 4/18/23 at 10:05 a.m. She acknowledged the resident's family nor physician were notified of the resident's fall on 1/6/23. She said they both should have been notified about the fall. D. Fall on 2/27/23Event report revealed on 2/27/23 at 5:40 p.m., the resident had an unwitnessed fall with no injuries in the resident's room. The resident said "I was trying to get in the wheelchair and slipped." Prior to fall, the resident was sleeping in bed. The resident did not exhibit or complain of pain related to the fall. The resident was able to move all extremities without pain. There was no observed rotation or deformity of the extremities. The resident had a history of falls. The safety measures that were in use at time of fall were the resident's bed was in the lowest position, paddle call light in reach, cane, gait belt, low bed, shoes, walker and wheelchair. -The resident's physician and family representative were not notified of the fall. The WN was interviewed on 4/18/23 at 10:05 a.m. She acknowledged the resident's family nor physician were notified of the resident's fall on 2/27/23. She said they both should have been notified about the fall. V. Administrative interviewCSM #1 was interviewed on 4/18/23 at 12:40 p.m. She said a resident's family and physician should be notified if a resident experienced a change of condition, falls or pressure ulcers.

Based on record review and interviews, the facility failed to ensure two (#18 and #16) residents out of 32 sample residents received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan. Specifically, the facility failed to ensure Resident #18 and Resident #16 were administered medications according to the physician's orders. Findings include:I. Facility policy The Medication and Treatment policy, revised 6/23/22, was provided by the clinical nurse consultant (CNC) #1 on 4/18/23 at 11:55 a.m. It revealed in pertinent part, "all medications and treatments will be administered with a provider order in a timely manner. If an order cannot be followed, the provider will be notified and the situation will be documented in the resident order."Timely administration of medications/treatments means the medication/treatment is administered as close to the scheduled time as possible. One hour before or after the schedule time or range is acceptable. Ideally, medications are administered at the time scheduled; if unable, reasoning will be documented."Residents have the right to refuse medications/treatments. If a resident refuses a medication/treatment, the following will occur. After the nurse's assessment of refusal, if it is determined that the medication/treatment being refused has the ability to cause a significant adverse event, the provider will be notified by midnight of the next calendar day.""If there is a pattern of refusal (three consecutive refusals) the provider and the responsible party shall be notified. The type and purpose of the medication/treatment shall be taken into consideration and nursing judgment shall be used." II. Resident #18 A. Resident status Resident #18, age 79, was admitted on 10/17/22. According to the April 2023 computerized physician order (CPO), the diagnoses include Alzheimer's, type two diabetes, hypertensive chronic kidney disease with stage 5 chronic kidney disease, dependence on renal dialysis, congestive heart failure and syncope. The 1023/223 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 10 out of 15. She required two person assistance with transfer, dressing, toileting and personal hygiene. B. Record review The April 2023 CPO physician orders revealed: - Cinacalcet 30mg (milgrams) once a day for hyperparathyroidism (parathyroid gland overactive) secondary to chronic renal failure with dialysis, start on 1/25/23. The November 2022 medication administration record (MAR) showed the following medications were not administered per physician orders:On 11/12/22 Cincalcet 30mg was not administered as resident refused. The December 2022 MAR showed the following medications were not administered per physician orders:On 12/17/22, 12/23/22 and 12/29/22, Cincalcet 30mg was not administered as resident refused. The January 2023 MAR showed the following medications were not administered per physician orders:On 1/2/23, 1/4/23, 1/6/23, 1/13/23 and 1/16/23, Cincalcet 30mg was not administered as resident refused. The February 2023 MAR showed the following medications were not administered per physician orders:On 2/1/23, 2/2/23, 2/8/23, 2/12/23, 2/20/23, 2/22/23 and 2/28/23 Cincalcet 30mg was not administered as resident refused. The March 2023 MAR showed the following medications were not administered per physician orders:On 3/8/23, 3/14/23, 3/15/23, 3/21/23, 3/24/23 and 3/31/23 Cincalcet 30mg was not administered as resident refused. The April 2023 MAR showed the following medications were not administered per physician orders:On 4/7/23, 4/8/23, 4/9/23 and 4/10/23 Cincalcet 30mg was not administered as resident refused. The progress notes revealed that on 4/7/23 the dialysis center notified the facility that there was a concern for intact parathyroid hormone levels. The resident's level was 2,819 with a goal range of 160 to 720. It documented the resident was on cinacalcet 30 mg. -The Cinacalcet medication was used to produce less parathyroid hormone. There was an event created on 4/11/23 to monitor for medication refusals, document interventions and effectiveness. There was no documentation under the notification section of the event that the provider was notified. III. Resident #16 A. Resident status Resident #16, age 61, was admitted on 3/11/23 and discharged on 3/28/23. According to the March 2023 CPO, the diagnoses include end stage renal disease, dependence on renal dialysis, kidney transplant, history of infections of the central nervous system-cryptococcal meningitis, history of sepsis (infection) and bacteremia (bacteria in bloodstream), pseudomonas (infection), type two diabetes and encephalopathy (altered mental status). The 3/17/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required one person assistance with transfer, dressing, toileting and personal hygiene. B. Record review The March 2023 CPO physician orders: -Eliquis 5mg twice a day for deep vein thrombosis, start on 3/11/23. -Insulin glargine solution 100 unit/mL 10 units twice a day for type two diabetes, start on 3/11/23.-Prednisone 5mg once a day in the morning for kidney failure, start on 3/11/23. -Vancomycin 125 mg twice a day for c-difficile prophylaxis, start on 3/14/23. The March 2023 MAR showed the following medications were not administered per physician orders:-3/15/23 Eliquis 5mg was not administered as resident was unavailable. The progress note documented the resident was at dialysis.-3/17/23 Eliquis 5mg was not administered as resident was unavailable. The progress note documented the resident was at dialysis.-3/15/23 Insulin glargine solution 100 unit/mL was not administered as resident was unavailable. The progress note documented the resident was at dialysis.-3/17/23 Insulin glargine solution 100 unit/mL was not administered as resident was unavailable. The progress note documented the resident was at dialysis.-3/15/23 Prednisone 5mg was not administered as resident was unavailable. The progress note did not give any additional information. -3/17/23 Prednisone 5mg was not administered as resident was unavailable. The progress note documented the resident was at dialysis.- 3/15/23 Vancomycin 125mg was not administered as resident was unavailable. The progress note documented the resident was at dialysis. - 3/17/23 Vancomycin 125mg was not administered as resident was unavailable. The progress note did not give any additional information. -3/20/23 Vancomycin 125mg was not administered as resident was unavailable. The progress note did not give any additional information. -3/22/23 Vancomycin 125mg was not administered as resident was unavailable. the progress note documented the resident was at dialysis. -3/24/23 Vancomycin 125mg was not administered as resident was unavailable. The progress note did not give any additional information. -There was no documentation in the resident's medical record that indicates the physician was notified when the prescribed medications were not administered. IV. Interviews Licensed practical nurse (LPN) #1 for Resident #16 and #18 was interviewed on 4/18/223 at 10:35 a.m. He said that if a resident did not receive medication, the doctor should be notified. The charge nurse (CN) #2 was interviewed on 4/18/23 at 10:40 a.m. She stated that if a resident has dialysis, the time should be readjusted so the resident receives the medication before or after dialysis. If a resident refused, it was the resident's right to refuse. She would educate the resident and call the family. For Resident #18, she stated they would call the husband to help encourage the resident to take the medication and the charge nurse would review. The assistant director of nursing (ADON) was interviewed on 4/18/23 at 10:51 a.m. He said that if a medication was not administered, it should be noted in the chart and the charge nurse should be notified. If the resident was at dialysis, the timing should be readjusted so the resident gets the medication before leaving for dialysis. If the resident refused and there was a pattern, an event should be opened. When an event was opened, that would trigger notifying the provider.

Based on interviews and record review, the facility failed to ensure three (#53, #16 and #33) of eight residents reviewed for accidents out of 32 sample residents received adequate supervision to prevent an accident/hazard. Resident #53 was known to be at risk for falls on admission as he had fallen at home. The facility failed to implement effective interventions. The resident fell two times on 2/17/23, with the first fall resulting in a head wound with active bleeding where the resident was sent to the emergency department for treatment and the head wound was glued. Observations revealed fall interventions were not implemented. In addition, the facility failed to:-Implement effective fall interventions for Resident #16; and, -Implement interventions when Resident #33 obtained a skin tear during a transfer to prevent it from occurring again. Findings include:I. Resident #53A. Facility policy and procedure The Skilled Nursing Facility Fall Management policy and procedure, revised on 2/8/23, was received from the nursing home administrator (NHA) on 4/13/23 at 4:52 p.m. It read in pertinent part: "Residents have a right to a safe environment, while maximizing their independence. Fall prevention seeks to balance resident's safety from falls while respecting individual rights and preservation of dignity. It is the facility's goal to reduce falls and injury related falls. "Admitting Nurse will complete the Fall Risk Observation upon admission. Individualized interventions will be implemented to minimize potential fall occurrence dependent upon the resident's risk. "Additional interventions for residents identified to be at greater risk: anticipate needs by observing normal routines and times of increased risk, obtain consults as appropriate, encourage adequate rest periods to prevent over tiring, and increase staff observation and avoid self isolation. Encourage inclusion in activities and social interaction." The Fall Prevention Philosophy, dated 2/1/23, was received by the clinical nurse consultant on 4/18/23 at 11:00 a.m. It read in pertinent part:"Call lights: We strive to meet each resident's needs prior to them having to use their call light. If a call light is used, it will be answered promptly and courteously by the first available staff person. "Purposeful rounding is rounding routinely to meet the resident's needs before they ask, is proactive rather than reactive, prevents falls and other injuries, takes less time than answering call lights, and is done by all nursing department staff."With each round offer toileting/check incontinence products, reposition for comfort, offer, encourage, and assist with fluids, ask about pain or discomfort, ask if there are any personal items they need or an activity they would like to participate in. Look at the environment: ensure call lights are in reach, ensure water is available and in reach, and ensure the room is free of clutter and a neat appearance."B. Resident statusResident #53, age 87, was admitted on 10/8/22. According to the April 2023 computerized physician order (CPO), the diagnoses included atrial fibrillation, muscle weakness, repeated falls, unspecified dementia, traumatic subdural hemorrhage (bleeding inside the skull) with loss of consciousness, attention and concentration deficit, cognitive communication deficit and frontal lobe and executive function deficit. The 4/3/23 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired with a brief interview for mental status score (BIMS) of three out of 15. He required extensive assistance of two persons for dressing and toileting, extensive assistance of two persons with bed mobility and transfers, and extensive assistance of one for personal hygiene and the supervision of one person for eating. The resident was also identified to be at high risk for falls. C. Resident representative interviewThe resident was not interviewable due to his cognitive communication deficit. The resident's spouse was interviewed on 4/12/23 at 11:34 a.m. She said she was with the resident all the time because she was responsible for all choices/decisions regarding the resident's care. She stated the resident had problems understanding things. She said he fell at home in the bathroom and hit his head that caused his brain to bleed. She said after she was admitted to the facility. She said the resident had been different ever since the fall, he had a poor memory and could not carry a conversation. She said she encouraged the resident to press the call light but he did not remember and the call light was always within his reach when he was sitting in the wheelchair. She said she had concerns the resident had fallen out of his wheelchair during the night. She said the staff were not consistent with rounding, it depended who was working and varied everyday. D. ObservationsOn 4/12/23 at 2:49 p.m. the resident was in his wheelchair in his room without the call light within reach. The resident was not wearing his prescribed glasses. The resident had heel protectors on his feet that were resting on foot rests with no non-skid footwear. On 4/13/23 at approximately 9:00 a.m. to 10:05 a.m. the resident was observed in his room sitting in a wheelchair, he was dozing and abruptly woke up and cried out for his wife to take him home. No staff member entered the resident's room during that time period. The resident was not wearing his prescribed glasses, or non-skid footwear on both feet. The call light was hanging over the right armrest of the wheelchair resting on the floor. On 4/18/23 at 8:22 a.m. to 8:32 a.m. the resident was not wearing his prescribed glasses. At 9:29 a.m. the resident was yelling for help. A certified nurse assistant (CNA) arrived and attempted to calm the resident. The resident was not wearing his prescribed glasses. The call light was on his bed and the CNA tucked the call light between the gel seat cushion and left side of the wheelchair before exiting the room. At 12:42 p.m. the resident was sitting in the wheelchair in his room without a call light within reach.-The resident was not able to consistently use the call light (see family interview) and it was not placed properly for use, did not have his glasses on and often did not wear non-skid footwear. E. Record reviewThe resident was admitted to the hospital from 9/28/23 to 10/3/22 status post fall at home resulting in subdural hemorrhage (bleeding in the brain), an 8th left rib fracture, increase in impaired mobility and generalized weakness. Care planThe care plan, revised on 1/5/23, read in pertinent part: the resident was at risk for falls related to a history of falls, decreased mobility, decreased balance, advanced age, and weakness. Interventions start date 10/8/22 date included PT, OT consults, strength training, toning, positioning, transfer training, gait training, and mobility devices. The resident was not a candidate for rehabilitation service due to presenting symptoms and the resident's spouse opted for hospice care. The care plan dated 1/5/23 continued with: keep call light and personal items and frequently used items in reach. Provide the resident with an environment free of clutter. Orient resident when there has been new furniture placement or other changes in environment. If falls occur, analyze resident's falls to determine pattern/trend. Give resident verbal reminders not to ambulate/transfer without assistance, provide resident with proper well-maintained footwear. Encourage the resident to use environmental devices such as hand grips, handrails. Assure the floor is free of glare, liquids, and foreign objects. Assure the resident was wearing glasses and they were clean. Toileting program, 12/28/22, read as follows: assure the resident is sitting upright in his wheelchair. Interdisciplinary team to review medication regimen, padding to gap in bed and bed extenders, and included offer distraction measures updated on 1/31/23. Interdisciplinary team: ensure resident has proper footwear over heel protectors when up in wheelchair updated 2/21/23. Care plan after 2/21/23 included the interdisciplinary team (IDT) to complete root cause(s) of fall events and establish and recommend interventions. Falls Two fall events occurred on 2/17/23 at 7:15 p.m. and at 11:53 p.m. The fall at 7:15 p.m. was unwitnessed and occurred in the hallway as the resident stood upright from his unlocked wheelchair and fell backward hitting his posterior head against the floor. The resident reported he was trying to find his wife. The resident was last toileted at 5:30 p.m. and was incontinent of urine at the time of the fall. Neurological checks were completed on 2/17/23 from 7:15 p.m. through 9:00 p.m. The spouse and medical provider were notified of the fall. At approximately 9:55 p.m. the resident's head wound started to actively bleed and the provider ordered an emergency room evaluation and computed tomography (CT) scan which was negative. The head wound was glued closed and the resident was returned to the facility. The investigation of the fall revealed the resident was not wearing non-skid footwear. Purposeful rounding stopped at 6:45 p.m. (30 minutes before the first fall). Root cause per interdisciplinary team (IDT): Urine incontinence. Interventions: proper footwear, educate the resident on importance of using call light, rearrange room.-There was no documentation the second fall on 2/17/23 at 11:53 p.m. was investigated. A third unwitnessed fall occurred on 3/20/23 at 1:35 a.m. The resident was found on the floor at his bedside, stating he wanted to "go out." No injury noted. Neurological checks were completed immediately after the fall through 3/22/23 on the evening shift (time not documented). The resident was incontinent of urine at the time of the fall. Last toileting/brief changed at 12:30 a.m. The spouse, hospice, and the medical provider were notified. Root cause per IDT: No root cause documented. Interventions: Staff implemented fall protocol, rearrange room, place bed against wall. A fourth unwitnessed fall occurred on 4/2/23 at 8:45 p.m. The resident was found on the floor leaning against his wheelchair facing the television. No injury noted. Neurological checks were completed immediately after fall through 4/5/23 on the evening shift (time not documented). The resident was not incontinent of urine at the time of the fall. Last toileting brief change at 5:45 p.m. Wife and medical provider were notified. Root cause per IDT: Believed to be agitation. Interventions: Post Void Residual Volume (no progress note related to post void residual volume output). An assisted fall occurred on 4/4/23 at 7:00 a.m. as a certified nurse assistant (CNA) was assisting the resident with a transfer from bed to wheelchair and the resident's knees buckled. The CNA lowered the resident to the floor. No injury noted. The resident was not incontinent at the time of the assisted fall. Last toileting/brief change at 5:30 a.m. Root cause per IDT: increased weakness. Interventions: Collaborate with hospice to request physical therapy for strengthening related to comfort/fall prevention (no progress note to support collaborative practice with hospice/physical therapy). F. Staff interviewsCNA #2 was interviewed on 4/13/23 at 2:10 p.m. He said the toileting program was knowing the resident's bowel and bladder habits and taking the resident to the toilet before they were incontinent. He said he used the Kardex (an abbreviated directive) to make sure he knew when to toilet residents but said it was "way too much" when he was the only CNA on the unit. CNA #1 was interviewed on 4/18/23 at 9:46 a.m. She said purposeful rounding was checking on residents every two hours to make sure they were okay and respond to their needs in a timely manner. She further explained, she was assigned to 15 residents and many were dependent on her for transfers but if she could not find help then she couldnot always round. The NHA was interviewed on 4/18/23 at 10:15 a.m. The NHA said the toileting program was located on the Kardex. The Kardex was generated every morning/evening (if needed) for the CNAs to offer toileting to residents because continence was a priority. The clinical nurse consultant (CNC) was interviewed on 4/18/23 at 11:20 a.m. The CNC said purposeful rounding was focused on answering call lights. The CNC stated there was no mechanism in place to assure purposeful rounding was consistently done, and no documentation to support purposeful rounding was completed. The CNC said all nursing staff were educated on fall prevention and purposeful rounding on hire and annually. II. Resident #16A. Resident status Resident #16, age 61, was admitted on 3/11/23 and discharged on 3/28/23 to the hospital. According to the March 2023 CPO, the diagnoses include displaced fracture of left femur, subsequent closed fracture, unsteadiness on feet, pain in left hip and left knee, history of falling, end stage renal disease, dependence on renal dialysis, kidney transplant, history of infections of the central nervous system-cryptococcal meningitis, history of sepsis (infection) and bacteremia (bacteria in bloodstream), pseudomonas (infection), type two diabetes and encephalopathy (altered mental status). The 3/17/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required one person assistance with transfer, dressing, toileting and personal hygiene. He used a walker and a wheelchair. It indicated that he had a fracture related to a fall within the last six months. B. Record review The fall risk care plan, revised on 3/28/23, documented the resident was at risk for falling related to history of falls, decreased mobility, decreased balance and a hip fracture. The interventions included assure resident is wearing eyeglasses, assure eyeglasses are clean and in good repair, assure the floor is free of glare, liquids and foreign objects, encourage resident to use environmental devices such as hand grips, hand rails,etc, keep call light and personal items within reach, occupy resident with meaningful distractions, provide assistance as needed for ADLs and mobility, provide toileting assistance/toileting plan. The initial social services progress note on 3/13/23 at 5:07 p.m. indicated that the resident was independent with all ADLs with no need of mobility. -There was no intervention in his fall risk care plan related to residents identified to be at greater risk. The activities of daily living (ADL) function status/rehabilitation potential care plan, initiated on 3/12/23, documented the resident will attain and maintain the highest practicable functional level and complications will be minimized. The interventions included providing an occupational and physical therapy evaluation, enforce weight bearing restrictions as ordered, instruct in use of assistive device and monitor for correct use, provide assistance for ADL's and mobility as needed, and teach safety measures and monitor resident's safety. The 3/13/23 fall assessment documented at 9:08 p.m. the resident told the nurse he tried to roll in the bed and fell down on the floor. The nurse's progress note on 3/13/23 at 10:11 p.m. documented "the CNA informed the nurse that they came in the patient's room to help him to bed. Patient told the CNA he can't sleep and he needs his wife or someone (sic) to sleep with (sic) him in the room. The nurse told the resident that no one can be (sic) in his room during the night. Later the resident pressed the call light many times and asked the CNA if she can stay with him. There was no documentation that the staff asked the resident if they should call his wife nor did they attempt to reach the resident's wife at nightime. The facility attempted to reach the wife on 3/14/23 at 8:55 a.m. to inform the wife of the fall at night. They were unsuccessfulin reaching the wife. They notified the son about the fall and he said he would visit the morning of 3/14/23." -There were no additional interventions added to the actual fall care plan related to the resident's need for increased supervision. The nurse's progress note on 3/21/23 at 12:09 p.m. documented the resident was asking for percocet for his pain. He has confusion at times. The 3/21/23 fall assessment documented at 8:08 p.m. the resident told the nurse that he slid out of his wheelchair and was lying on the floor at the end of the hall in front of the wheelchair. The care plan revealed the following intervention was added: encourage resident to become more involved in facility activities. The 3/22/23 fall assessment documented at 5:45 p.m. the resident told the nurse that he was trying to go to the bathroom. The CNA found the resident in between the toilet and the wall. The care plan revealed the following intervention was added: continue with PT/OT, social work to speak with family about changing room closer to nurse's station and explore post dialysis activities during peak time of confusion. The nurse's progress note on 3/22/23 at 5:30 p.m. documented the resident told the CNA that he saw a woman with a dog and was going after the dog. When asked by the nurse, resident said he was trying to go up a three to four run ladder. The nurse's progress note on 3/22/23 at 11:59 p.m. documented the resident complained of pain to whole body. The interventions used were low bed, appropriate footwear or grippy socks. The nurse's note on 3/23/23 at 2:03 p.m. documented the night shift night nurse reported that resident complained of right lower extremity pain overnight after his fall. The nurse's progress note on 3/23/23 at 2:46 a.m. documented the interventions used were purposeful rounding, appropriate footwear or grippy socks and toileting programs. The resident was educated to not stand up by himself. Resident was upset with nurse stating he was not in a concentration camp. The nurse reminded the resident that he was in rehabilitation for his broken hip and the facility has safety regulations. The nurse reminded him about his falls. The 3/27/23 fall assessment documented at 8:56 p.m. documented the resident told the nurse he was trying to get to the wheelchair from his bed. He was found on his knees in his room. The nurse's progress note on 3/27/23 at 9:55 p.m. documented the resident sustained a skin tear to the left outer forearm. The nurse's progress note on 3/28/23 at 7:00 a.m. documented "the resident was very confused throughout the night. He was alert and oriented to self only. Resident had three falls since 8:00 p.m. last evening. The resident vacillated from very agitated and lethargic. When awake and restless (sic) and agitated, he continues to take off his clothes and attempting to grab staff and get up. Temperature started at 99.8 degrees F and went up to 100.2 degrees F. Tylenol was provided. Resident assisted to chair and back to bed but has remained unsafe and closely monitory. Heart rate was tachycardia but regular. Provider was notified after first fall and again this morning with orders to send to emergency room to evaluate and treat." The nurse's progress note on 3/28/23 at 9:54 a.m. documented "called hospital emergency room for resident's disposition. Resident is being admitted for altered mental status, generalized abdominal pain, urinary retention, blood in urine, urinary tract infection, elevated white blood cells, elevated potassium of 7."-The care plan revealed the following interventions were added: sent to ER for evaluation on 3/28/23, room rearranged related to falls and purposeful rounding. -The facility failed to put effective interventions into place to prevent Resident #16 from continued falls. C. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 4/17/23 at 11:53 a.m. He said purposeful rounding was to go to the resident's door say hello and seeing if the resident needed anything. The nurse would see if the resident was in distress or pain. LPN #1 was unable to answer how often purposeful rounding should be completed. CNA #3 was interviewed on 4/17/23 at 11:48 a.m. She said purposeful rounding was to check on all residents every 60-90 minutes. She said she did not know what purposeful rounding was if a resident had an intervention. She stated the toileting program was to check on the resident every two hours to see if they needed incontinence assistance. A copy of the facility's purposeful rounding policy was requested on 4/17/23. The clinical services manager (CSM) #1 did not have a policy. She provided a presentation on purposeful rounding. -The presentation did not state what the frequency of rounding should be when ordered. Admission coordinator (AC) #1 was interviewed on 4/18/23 at 11:58 a.m. She said she notified the nurse and therapists when a new resident was a high fall risk. She stated new residents identified as a fall risk should have maximum assistance, have a sling in the room and be close to the nurse's station. The fall risk was communicated through email to all disciplines and the admission coordinator would give a report in person. III. Resident #33A. Resident observationsOn 4/12/23 at 1:24 p.m., the resident sat in a wheelchair in her room. She had a bandage on her left lower extremity (shin). The bandage was dated 4/12/23. B. Family interviewAn interview was conducted with the resident's daughter on 4/12/23 at 1:24 p.m. She said on 4/2/23, the resident hit her left shin on a metal part of her wheelchair while she was in the bathroom with a staff member. The resident received a skin tear to her left shin. C. Resident statusResident #33, age 92, was admitted on 1/17/23. According to the April 2023 computerized physician orders (CPO), diagnoses included need for assistance with personal care, muscle weakness, history of falling, lack of coordination, chronic kidney disease stage 3, malignant neoplasm (cancer) of the breast, history of sepsis, chronic obstructive pulmonary disease, lack of coordination, cognitive communication deficit, lack of coordination, frontal lobe and executive function deficit. The 1/23/23 minimum data set (MDS) assessment, revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15 with no behaviors. The resident required extensive staff assistance for bed mobility, transfers (two plus staff physical assist), dressing, eating, toileting (two plus staff physical assist), and personal hygiene. The resident had functional limitations in range of motion impairment on both sides of her lower extremities (hip, knee, ankle, or foot). The resident had occasional moderate pain that did limit her day to day activities. D. Record reviewCare plan for a skin tear was started on 2/23/23. The pertinent interventions included for staff to apply dressings according to physician and wound care team orders. Staff were to consult with the facility wound care team to follow and guide the resident's treatment. Staff were to report signs of cellulitis (localized pain, redness/swelling/tenderness/drainage, fever); sepsis (fever/malaise/change in mental status, tachycardia/hypotension, nausea/vomiting); osteomyelitis (pain/redness/swelling, muscle spasms, fever). Wound care would be managed by a hospital wound clinic, facility wound care team and the resident's family. Event report by licensed practical nurse (LPN) #1 dated 2/20/23 at 8:45 a.m., revealed to monitor a skin tear to the resident's left lower extremity (shin) related to contact with her wheelchair footplates upon transferring. The skin tear was vertical measuring 2 centimeters (cm) on the left lower shin. There was no pain associated with the skin tear and no signs or symptoms of infection. Staff were to monitor the skin tear daily for any change in condition. -The resident's physician and family representative were not notified (cross-reference F580). Wound note dated 2/23/23 at 8:30 a.m., by a registered nurse (RN) revealed skin tear/laceration to the left shin. The wound bed had granulated and epithelial tissue with heavy sanguineous (blood) exudate. The surrounding skin was bruised. Resident reported no pain to the area. Resident was at baseline for movement, strength, sensation, temperature and edema (water retention) for the extremity wound. Physician order dated 2/23/23 revealed a skin tear to the left middle shin. Wound care team to cleanse with saline or wound cleanser, pat dry, apply xeroform (cut to fit) followed by foam dressing every other day and as needed.-After the resident obtained the skin tear on 2/20/23, there was no subsequent education with staff or preventative measures put in place to prevent recurrence. E. Staff interviewsThe assistant director or nursing (ADON) was interviewed on 4/18/23 at 8:40 a.m. He said the resident's lower extremity wound occurred when her left was bumped on her wheelchair during a transfer by staff. The wound nurse (WN) was interviewed on 4/18/23 at 12:10 p.m. She said on 2/20/23 from a skin tear that occurred during a transfer with staff. She said a staff member was transferring the resident and her shin came into contact with the wheelchair pedals that were folded up and to the sides of the wheelchair. She said she felt this was an accident and the transfer was completed according to facility policy. She acknowledged that there was no evidence the resident's family nor her physician were notified of the incident on 2/20/23 and they should have been notified. LPN #1 was interviewed on 4/18/23 at 2:46 p.m. He said he was told by a certified nurse aide (CNA) that the resident had hit her shin on the wheelchair foot pedals. He said the food pedals were flipped up and she nicked her shin on the metal. He said it was a small skin tear and she did have some edema at the time. He said it was bleeding a little at the time. He said he could not remember if he notified the resident's family or physician. He said for changes of condition, falls, head injuries and unwitnessed falls the family and physician should be notified.