Based on interview and record review the facility failed to ensure a resident was safely transferred using a mechanical sit to stand lift for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 being assisted to the ground and sustaining a proximal tibia and fibula fracture of her right leg. The findings include: R1's Nursing Notes dated 6/28/25 shows that at 1:00 PM, the Certified Nursing Assistant said that R1 passed out while providing care to R1 after having an extra large bowel movement while using a sit to stand lift and R1 was assisted to the floor with two person assist. R1's Right Tibia/Fibula X-ray dated 6/28/25 shows, There is a fracture involving proximal tibia and fibula (bones of the upper shin) with minimal displacement. On 7/2/25 at 10:12 AM, V3, Certified Nursing Assistant (CNA) said that on 6/28/25 after lunch, she was assisting R1 to use the toilet. V3 said that she placed R1 on the toilet from her wheelchair using the mechanical sit to stand lift. V3 said that once R1 was done using the bathroom, she lifted her up from the toilet with the lift and moved her to the side so she could clean her up. V3 said R1 then had another bowel movement all over herself and the floor. V3 said that as she was cleaning her up, R1 slumped over and her hands went down from holding onto the lift and would not respond to her. V3 said that she immediately started calling for V4 (CNA) and the nurse. V3 said that R1 was brought out of the bathroom and into her room area. V3 said that she tried to lower her to her wheelchair but the lift was not lowering and the emergency release button was not working as well. V3 said that V5, Registered Nurse (RN) and V6 Licensed Practical Nurse (LPN) Supervisor showed up and said to put her on the ground. V3 said that her and V4 both grabbed under R1's arms and lowered her to the ground while the nurse used the control to lower the machine. V3 stated, I guess the nurse was able to get the machine to work to be able to lower her as we were lowering her. On 7/2/25 at 10:34 AM, V4 (CNA) said that she was by the shower room waiting for her resident to get done going to the bathroom when V3 came to the door of R1's room and said to call the nurse. V4 said that she immediately went into R1's room and R1 was hooked up to the sit to stand lift and was located outside of the bathroom door. V4 said that R1 was unresponsive and her right leg was off of the platform of the lift and her foot was turned inward. V4 said that the leg strap was not around R1's legs. V4 said that they were not able to sit her into her wheelchair because her leg was in the way and they did not want to twist it anymore. V4 said that V3 told her that they were going to have to put her onto the floor. V4 said that she was worried about putting her onto the floor because of the way her leg was positioned. V4 stated, I was worried that putting her on the floor would break her leg based on how it was already positioned. V4 said that they proceed to slowly lower her to the floor by holding under her arms. On 7/2/25 at 10:51 AM, V5 (RN) said that she heard V4 yelling for help. V5 said that she went into R1's room and saw R1 hanging from the sit to stand lift and unresponsive. V5 said that she did not pay attention to the positioning of R1, she was more worried about her being unresponsive. V5 said that she immediately called V6 (LPN Supervisor) to help. V5 said that she then exited the room and went and got R1's code status and oxygen. V5 said that when she returned, R1 was on the floor. V5 said that she did an assessment and found R1 to have a bruise with an abrasion on her right shin area. On 7/2/25 at 11:08 AM, V6 said that V5 called her while she was on the elevator. V6 said that she immediately went to R1's room and saw R1 still harnessed into the sit to stand lift. V6 said that R1 was unresponsive, her left arm was hanging down and her right arm was elevated above her head due to the harness slipping up and pushing her arm up. V6 said that she tried to put the wheelchair under her but she had slipped down too far so was unable to get the wheelchair under her. V6 said that they then lowered her to the ground. V6 said that during the transfer, her right leg was bent and turned but they were unable to straighten it so when she was lowered to the ground, her right lower leg was bent and under her. On 7/2/25 at 11:40 AM, V3 said that when R1 was taken out of the bathroom, her right leg came off of the platform. V3 said that the leg strap was on but it was loose. V3 said that she removed the strap to try and get R1's right leg back onto the platform but she was unable to. On 7/2/25 at 11:49 AM, V4 said that when they got R1's bottom to the floor, her left leg was straight out and her right lower leg was under her and to the side. V4 said that V3 moved her leg to a straight position and then they laid her flat on the floor. On 7/2/25 at 1:27 PM, V9 (R1's Physician) said that she saw R1 immediately after the fall. V9 said that R1 had some bruising and swelling of her lower leg right below her knee which is where the fracture was found. V9 said that R1's leg must have twisted during the fall. V9 said that the fracture is directly related to the fall. On 7/2/25 at 1:45 PM, V8 (Restorative Aide) said that residents should be secured appropriately in the sit to stand lift before performing any transfers. V8 said that a harness is applied to the torso and secured with a strap. The strap should be snug. V8 said that the feet should be placed flat on the platform and their knees should be up against the knee pad. V8 said that once the resident's legs are in proper position, the leg strap should be applied snuggly. V8 said that the resident should be lifted a little bit and the torso harness strap should be tightened more. V8 said that resident's should only be moved short distances with the sit to stand lift. V8 said that if a resident becomes unresponsive during a transfer, the staff should immediately lower the resident back to a seated position on whatever surface is closest to the resident. V8 said that if a resident is secured correctly on the sit to stand lift, the torso should not be able to slip from the harness and the feet would not be able to fall off of the platform. V8 said that it could be very dangerous if a resident was transferred with a sit to stand lift and not secured appropriately. On 7/2/25 at 2:22 PM, V2 (Director of Nursing) said that when using a sit to stand lift, the resident should have the harness strap secured tightly around their waist and should have the leg strap secured tightly around their lower legs. V2 said that if the leg strap is on securely, a resident's foot would not be able to come off of the platform. The facility's Mechanical Lift Policy dated 5/23/24 shows, The purpose of this policy is to establish the general principles and procedure of safe lifting using mechanical lifting devices Position the top of the harness around the upper body of the resident (approximately 4-5 inches below the underarm). Securely fasten the harness safety strap around the resident's chest . Position the unit in front of the resident and have the resident place their feet on the foot plate and position their shins into the shin pad Secure the shin straps around the resident legs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate pain control for a resident with a history of cancer and compression fracture. This failure resulted in R1 experiencing increased pain from 4/21/2025 to 4/24/2025. This applies to 1 of 3 (R1) residents reviewed for pain in the sample of 3. The findings include: R1's current admission Record shows R1 is an [AGE] year-old female resident with a history of lung cancer and compression fracture who was admitted on [DATE]. On 4/30/2025 at 10:00AM, R1 was observed lying in bed resting comfortably and showing a slight grimace with movement. On 4/30/2025 at 10:00AM & 10:18AM, R1 said her pain was 4 out of 10 and a 4 was acceptable. R1 said her pain is more controlled now. R1 said she doesn't like using the numbers to describe the pain. R1 said she had increased pain when she came into the facility because the facility had trouble getting her medication. On 4/30/2025 at 11:04PM, V5 Nurse Practitioner (NP) said she saw [R1] on 4/24/024 for the first time and she had reported increased pain in the previous days but stated her pain was better controlled now after she got a dose of medication this morning. On 4/30/2025 at 1:30PM, V3 Licensed Practical Nurse (LPN) said [R1] was admitted on [DATE] and [R1] complained of 10/10 pain in the evening at 10:30PM. V3 said she gave [R1] Tylenol for her pain because she didn't have the morphine order from pharmacy yet. V3 said she would normally give a narcotic for that type of pain. V3 said she did get the morphine tablets that night and gave [R1] her morphine pills at 2:00AM on 4/22/2025. V3 said she never received the PRN (as needed) morphine from pharmacy that night. V3 said she couldn't get into the controlled substance box because her morphine order wasn't the right concentration and needed to be clarified. V3 said she did not contact the doctor to get a different as needed medication. V3 said [R1's] pain was an 8/10 when she gave her the morphine tablet and the resident was resting comfortably in bed with her eyes closed. On 4/30/2025 at 12:54PM, V4 Physician said Tylenol is not adequate for a patient complaining of 10/10 pain because Tylenol is a very mild analgesic. The facility provided Electronic Shipping Manifest shows the Morphine Sulfate 100mg/5mL was delivered on 4/24/2025 at 12:51AM and the Morphine Sulfate ER 15mg tablet was delivered on 4/22/2025 at 1:28AM. On 4/30/2025 at 9:52AM & 10:10AM, V6 LPN said he normally works the unit [R1] is on and has seen her since she came. V6 said [R1's] pain is more controlled now compared to where she was when she first came. V6 said [R1] is still working with therapy and pain medication is given prior to receiving therapy services. R1's Progress Notes dated 4/22/2025 at 11:22AM states the resident declined to get out of bed, complaining of back pain. R1's Weights and Vitals Summary dated 4/30/2025 shows the following pain scores 4/21/2025 10:32PM score of 10, 4/22/2025 [2:00AM verified by V3] score of 8 and 6:37AM score of 2. R1's Medication Administration Record dated 4/1/2025 to 4/30/2025 showed R1 received Morphine Sulfate Oral Tablet 15mg was scheduled on 4/21/2025 at 9:00PM but didn't receive the medication until 4/22/2025 at 2:00AM.

Based on observation, interview, and record review the facility failed to communicate and effectively treat a resident's pain; and failed to verify and obtain a resident's ordered pain medication in a timely manner for 1 of 1 resident (R425) reviewed for pain in the sample of 35. These failures resulted in R425 experiencing continued pain and emotional anguish. The findings include: On 11/19/24 at 11:46 AM, R425 was lying in bed, on his left side. R425 had a catheter drainage bag on each side of the bed frame. R425 said he's been sick since March and was in the hospital. R425 said the hospital found out that he had urine draining into his right upper leg area (fistula - an abnormal opening in the urinary tract). R425 said that caused him to develop an abscess in his right upper leg. R425 said they had to drain out the fluid from his leg and now he has a catheter in his penis to protect the fistula and a suprapubic catheter (directly through the abdominal wall, into the bladder) to empty most of his urine. R425 said his pain seemed to be getting worse. R425 said in the hospital he was getting 2 Norcos (opiate pain medication), but when he was transferred to the facility it was changed to 1 Norco. R425 started crying and plead, I'm just so miserable and I can't get anyone to listen to me. R425 shook his head then became irritable. R425 stated, I just don't feel like anyone communicates with each other. I'm tired of being in pain. I tell them and no one listens. This position (left side lying) is the only position that is even the slightest bit comfortable for me. Any movement of my right leg is excruciating. I can't do therapy because my right leg hurts so bad when it's moved. I'm so f****** frustrated! I'm sorry I'm cussing, but that's how I feel. (R425 began crying again). Most days I just lay here, grip the side rail and cry. This pain is awful, and no one is doing anything about it. V20 (R425's spouse) was seated in a chair at the bedside. V20 said the facility wasn't managing his pain, but they had a tele-visit with R425's pain doctor at 1:30 PM today. V20 reminded R425 of the appointment and attempted to reassure him. On 11/20/24 at 12:47 PM, R425 was sitting up in the wheelchair in his room. R425 and V20 (R425's spouse) were discussing nutritional supplements with V15 (RN - Registered Nurse). After V15 left the room, the surveyor asked R425 how he was feeling today. R425 reported, I'm miserable! (and began crying). R425 became agitated and said they had the tele-visit with V22 (Pain Nurse Practitioner) at 1:30 PM yesterday. R425 said about an hour later V22 called V20 (R425's spouse) to provide an order for Fentanyl patch 12 mcg. R425 said he was supposed to continue the Norco scheduled every 4 hours and start the Fentanyl patch. R425 said V22 (Pain NP) would follow-up with them in a few days to see if his pain was improving. R425 yelled, I still don't have the damn patch! I guess they don't have the order or something like that! How can that be, it's almost been 24 hours! See what I mean. The communication sucks! R425 was becoming agitated and crying. V20 (R425's spouse) rubbed his shoulders and tried to calm him. V20 said when V22 (Pain NP) called with the order for Fentanyl, she couldn't find the nurse. V20 said she went to the desk; the nurse wasn't there. V20 said the receptionist was there and said she would make sure the order was put in right away. V20 said she's not sure what the receptionist's credentials were, but she trusted that the information would be communicated. V20 said the receptionist provided the facility's pharmacy information to her. V20 said she provided the pharmacy information to V22 (Pain NP), and she said that she would send the Fentanyl patch prescription directly to the pharmacy. V20 said the nurse did not come in the room to discuss it with her later. V20 stated, I expected the pain patch to be delivered by this morning (at the latest), but it's still not here. They don't even have an order for it here. R425 stated, I'm so disgusted, miserable, and frustrated! They need to communicate and control my pain. R425 started crying and placed his face into his hands. At 12:55 PM, V16 (NP) entered the room. V16 asked R425 how are you? R425 replied, Don't even ask! R425 reported his frustrations to V16. V16 stated, This is my first time seeing you. I'll have to take a look at your notes. There is no Fentanyl order in the computer at this time. The surveyor walked to the nurses' station where V15 (RN) was on the phone with pharmacy. V15 said there was a prescription for a Fentanyl patch sent yesterday and the family is asking me about it. V15 said he reviewed the chart and R425 did not have an order for Fentanyl and there were no progress notes. V15 said the pharmacy said they received a prescription from V22 (Pain NP), but the prescription was for 30 patches, and they will not accept it. V15 stated, I don't know why the pharmacy didn't call [V22 - Pain NP] to verify the order. They are the ones that gave the phone number for [V22]. V16 (NP) walked up to V15 sand stated, I'll give you a one-time order (for Fentanyl patch) now, so the resident can get it right away. He's in pain. Then we can make follow-up appointments to get an order (for ongoing treatment). Don't even bother to call this office [V22]. I'll give the Fentanyl order and [V23 - Pain MD] will follow-up. V16 asked V15 to call the nursing supervisor and see if they can get the Fentanyl patch from the emergency box, so he (R425) doesn't have to wait any longer. V15 said R425's Fentanyl patch prescription was sent directly to the pharmacy, but they didn't call the doctor's office to get the quantity changed. V15 stated, They should have done that. They gave me the number. Why didn't they call? I'm putting the orders in now. Hopefully they can get the Fentanyl patch from the emergency box. This is the first time I've experienced Pharmacy not liking a quantity. They (Pharmacy) didn't call us to check. The previous nurse would have told me that. The pharmacy should have sent at least 1 Fentanyl patch to get the resident's pain controlled, then got the clarification. It's important to control the resident's pain. That's why I was surprised someone came to me and said he was asking for his pain medication. I didn't know anything about the Fentanyl. I checked the orders and progress notes and there wasn't anything. It's true that there was a communication break down and I'm sorry this happened to them. V15 said R425 has prostate cancer and had pain to his lower back and right hip area. V15 said R425 had therapy in the gym and that may have triggered more pain again. V15 said V23 (Pain MD) is at the facility 1-2 times per week and will see R425 tomorrow. On 11/20/24 at 1:23 PM, V17 (RN - Registered Nurse/Unit Manager) said she is not sure what happened with R425's Fentanyl. V17 said she called V18 (LPN - Licensed Practical Nurse) because she was R425's nurse yesterday (11/19/24). V17 said V18 didn't know anything about a Fentanyl order sent to the pharmacy. V17 states if an outside physician order's medication, then the facility needs to get approval from an in-house provider and enter an order. V17 said R425 did not have a Fentanyl order entered into the EMR (electronic medical record) yesterday. V17 said the emergency box does not contain Fentanyl patches. V17 said pharmacy was called and a STAT order was placed. V17 said the pain patch should be here in 2-4 hours. On 11/20/24 at 1:34 PM, V19 (Guest Services Associate) said she works at the reception desk on R425's floor. V19 said she works 8 AM to 4 PM. V19 said she answers the phones, assists with scheduling appointments, and orders equipment and supplies for the unit. V19 said she was working 11/19/24 and spoke with V20 (R425's spouse). V19 said the nurse was busy and V20 was asking what pharmacy we used and what their phone number was. V19 said she gave V20 the information because the nurses were busy. V19 said she didn't ask V20 why she needed the pharmacy number. On 11/21/24 at 9:08 AM, V18 (LPN) said she worked 11/19/24 and took care of R425. V18 said she was not aware that R425 had a tele-visit with a pain NP. V18 said V19 (Guest Services Associate) did tell me that V20 (R425's spouse) was asking for the pharmacy we use and for the number. The surveyor asked why V20 would be asking about the pharmacy information. V18 replied, I'm not sure why she would be asking for the pharmacy information. That's a good question. V18 said she didn't follow-up with R425 or V20 regarding their request for the pharmacy information. V18 said she worked until 7 PM on 11/19/24. V18 said they didn't mention they were waiting for a pain patch. V18 said if she knew, then she would have checked to see if there was an order in the EMR. V18 said if there wasn't an order, then she would call the facility provider to obtain an order, enter it into the EMR, and notify pharmacy. V18 said there should have been follow-up to V20's request for the pharmacy information. V18 said she didn't speak to the pharmacy about R425's Fentanyl patch because she didn't know anything about it. On 11/21/24 at 9:26 AM, V21 (Pharmacist) said an electronic order for Fentanyl patch 12 mcg was sent on 11/19/24 at 7:43 PM by V22 (Pain NP). V21 said it looks like there was a discrepancy on the quantity. I see documentation that the pharmacy attempted to contact the facility at 9:11 PM and was not get in contact with facility staff. There was a note in the system that the Fentanyl patch was pending clarification. V21 said there is no further documentation, and he is unsure if the pharmacist made contact with someone at the facility. V21 said on 11/20/24 at 1:13 PM, V16 (NP) entered an order for 1 Fentanyl patch for R425. V21 said the delivery left the pharmacy at 2 PM and arrived at the facility a few hours later. V21 said the pharmacy director will follow-up with more details on 11/22/24. On 11/21/24 at 9:59 AM, V24 and V25 (Restorative Aides) were donning gowns and gloves to provide R425 incontinence care and get him up to the wheelchair. R425 looked up and started crying and motioned for the surveyor to come talk. R425 stated, This is a f****** mess! The system is broken down. I tell every f****** person that comes in that I'm in pain. I lay here in unbearable pain. One time I laid here crying for what seemed like 5 hours, but only 1 f****** hour had passed. I don't feel like I'm moving forward with pain control. I had that tele-visit on Tuesday at 1:30 PM (11/19/24) with [V22 (Pain NP)]. [V22] called back within an hour to give an order. It took damn near 24 hours to get the pain patch (Fentanyl patch). When I finally got the patch, they started messing with my Norco. I don't like taking narcotics. It scares the s*** out of me, but I need them! I don't like it, but I NEED them. (R425 was lying on his back in bed, speaking loudly, cursing frequently, and his eyes welled up with tears.) I've never not been in pain. I can't even say if this pain patch is working because they quit giving my Norco last night. [V22 - Pain NP] knew I was on Norco every 4 hours and said it wasn't effective and added the Fentanyl patch. They were NOT supposed to stop my Norco! I got a couple doses of my scheduled Norco with the Fentanyl patch, but then the nurse last night said she I couldn't have them both together. I told her I was in pain and needed them. (R425 began crying). Why do they keep messing with stuff. I can hardly take this and their poor communication. See what I mean? They don't communicate! It's beyond frustrating and I'm still in pain. V24 and V25 came in the room to assist R425. They provided incontinence care and dressed R425, rolling him side to side. Each time R425 was rolled onto his right side, or his right leg was touched, he groaned in pain and grimaced. R425 told V24 and V25 that it hurt whenever his right leg was moved. They assisted R425 to roll up on his right side to sit up on the edge of bed. R425's right side was on the bed, and he started crying, It hurts, lying on this side hurts. I'm lying on my sore spot. V24 and V25 assisted off his right side and to a sitting position on the edge of the bed. On 11/21/24 at 11:17 AM, V20 (R425's Spouse) said the facility's pain doctor (V23) just left R425's room. V20 said they are going to allow him to take his scheduled Norco every 4 hours and the Fentanyl patch to see if it works. If that doesn't work, then they will come up with a different plan. V20 said R425 seemed to be in better spirits after the visit and he feels like they are finally starting to listen to him. V20 said R425 had been in so much pain every day, so they decided to call his pain doctor because he needed some relief. V20 said she told the receptionist (V19) why she needed the pharmacy number because the nurse wasn't around. V20 said she doesn't know what happened after that because she went back to R425's room. V20 stated, All I know is when I came back yesterday (11/20/24) he still didn't have his pain patch and he was very upset about it. It didn't come until around 4 PM. R425's Facesheet dated 11/20/24 showed he had diagnoses to include, but not limited to: urinary tract infection; sepsis; cutaneous abscess of right lower limb; diabetes; prostate cancer; obstructive and reflux uropathy; other injury of the ureter; chronic kidney disease; and benign prostatic hyperplasia with lower urinary tract symptoms. R425's Brief Interview for Mental Status (BIMS) Evaluation dated 11/17/24 showed he was cognitively intact. R425's Physician Order Sheet dated 11/20/24 showed Norco 5-325 mg - Give 1 tablet by mouth every 4 hours for pain was started on 11/15/24. On 11/20/24 an order for Fentanyl 12 mcg transdermally every 72 hours for pain was entered. (The facility did not have an order in the EMR prior to 11/20/24. V20 (R425's spouse) requested the facility's pharmacy information at approximately 2:30 PM. The nurse did not follow-up with V20 and R425 regarding their request for the pharmacy information). R425's November 2024 MAR (Medication Administration Record) showed he received the Fentanyl patch at 4:09 PM on 11/20/24. This document showed that R425's Norco tablet scheduled for midnight on 11/21/24 was held. The code 5 was documented. This form showed 5 means hold, see progress notes. R425's Progress Notes did not contain an entry explaining why this dose was held. R425's NP Progress Note dated 11/20/24 showed the patient is upset he has not received his Fentanyl patch. The wife relayed it was ordered by his pain MD. Spoke to RN and gave order for Fentanyl patch and V23 (Pain MD) to follow-up with patient for pain control. The patient is complaining of right thigh pain. R425's Nursing Note dated 11/20/24 at 12:50 PM showed, Resident and family asking about the order for Fentanyl patch as from pain MD office. As nurse writer verified today (11/20/24). Pharmacy received order/prescription directly from Pain MD office on 11/19/24 for Fentanyl 12 mcg every 72 hours; but it was not delivered due to questions regarding the prescription. [The pharmacy] did not call [the unit] for verification of order. Upon knowledge, nurse immediately contacted primary attending NP to inform resident circumstance of investigation and approved orders for Fentanyl by outside MD, with current med order on Norco given at 12 PM for pain 8/10 (rated at 8 on 1-10 scale, 10 being worst pain ever experienced) . 4 PM Resident comfortable in bed, left side lying; received from pharmacy and applied Fentanyl patch 12 mcg on right upper chest . 6 PM Resident comfortable in bed, with some relief of pain observed. On 11/21/24 at 11:29 AM, V3 (ADON - Assistant Director of Nursing) said if the pharmacy has questions regarding a medication order, then they usually call the floor nurse of the 24/7 supervisor. V3 said the staff receiving the call should address the clarifications as soon as possible. V3 said the pharmacy makes three scheduled deliveries per day and can make STAT deliveries in between. V3 said STAT deliveries usually arrive to the facility in 2 hours. V3 said if a resident is complaining of pain, then the staff should believe it. The nurse should perform a pain assessment and determine the level of pain. If the resident is already receiving pain medications, then the nurse will need to notify the physician of continued pain. V3 said the resident may need additional pain medications or a different approach to pain control. V3 said as soon a resident is complaining of pain, then the nurse should start working on obtaining orders for pain control. V3 said the R425, and his family shouldn't have felt they needed to call an outside pain clinic. V3 said V23 (Pain MD) rounds at the facility 1-2 times per week and is available for consults when residents complain of pain. V3 said she expects her staff to communicate a resident's complaints of pain to each other and continuity of care should be maintained. V3 said if R425's wife was asking for pharmacy information, then the staff should have followed-up with her. I don't know why the nurse didn't follow up. There isn't a progress note that showed the nurse was aware of the request for pharmacy information. V3 said pain control is important to a resident's healing, rehab, overall health, and resident comfort. V3 said she was not aware that R425 was unhappy and experiencing such pain. The surveyor asked why R425's scheduled Norco was held at midnight 11/21/24. V3 said she didn't know, but 5 stands for hold, see progress notes. The surveyor asked V3 to review R425's progress notes for an entry for the held 11/21/24 midnight dose of Norco. V3 reviewed R425's chart and said there isn't a note, but there should be one. V3 stated, I'm not sure everyone is aware that he is in pain. It's expected that we would do our best to control the resident's pain. We must listen to them. I can't say what happened because the nurse didn't chart anything to explain why the Norco was held. She should have. On 11/22/24 at 12 PM, V33 (Director of Pharmacy) said he followed up regarding my questions for R425's Fentanyl patch. V33 said the electronic order was received from pharmacy at 7:43 PM on 11/19/24. V33 said there were errors with the prescription regarding the quantity and duration. V33 said the order was not entered as a STAT, so the pharmacist reviewed the orders later in the evening. V33 said pharmacy sent an email to V34 and V35 (Supervisors) regarding the need for order clarifications. V33 said it's the facility's procedure to email V34 and V35. V33 said a new order was entered for Fentanyl on 11/20/24 by V16 (NP) and it was filled STAT. V33 said he would expect the facility staff to communicate effectively to address any pharmacy concerns or resident complaints with pain. The facility's Pain Assessment and Management Policy reviewed 11/27/24 showed, A comprehensive and effective pain management program is provided to residents who require such services to ensure comfort, facilitate independence, and preserve dignity. The purpose of this policy is to provide guidelines for the assessment and identification of the resident's pain with underlying causes, and the development of pain management interventions consistent with professional standards of practice, person-centered care plan, and the resident's goals and preferences. Guidelines: 1. The pain management program is based on professional standards of practice and the resident's preferences related to pain management. 2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessments and recognition of pain. b. Identifying the underlying causes and characteristics of pain; c. Developing and implementing a treatment/pain management plan; d. Monitoring for effectiveness and modifying interventions; and 3. Documentation and reporting . Documentation and Reporting: 1. The following information shall be documented and reported to the physician/medical provider immediately: a. Significant changes in the level of the resident's pain . d. Prolonged, unrelieved pain despite care plan interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions to prevent pressure ulcers and failed to identify a pressure ulcer for 2 of 3 residents, R1 and R3, reviewed for pressure injuries in the sample of 3. These failures resulted in R1 developing a Stage 3 sacral pressure wound which later became an infected Stage 4 pressure ulcer and R3's pressure wound not receiving wound care treatment until it was an unstageable pressure injury. The findings include: On 11/6/24 at 10:42 AM, V4, Wound Care Nurse, V7, Registered Nurse, and V8, Certified Nursing Assistant transferred R1 from her chair to her bed to provide wound care. R1 had a half dollar coin sized wound to her sacrum. R1's admission Record dated 11/7/24 shows R1 was admitted to the facility on [DATE]. R1's Braden Scale for Predicting Pressure Ulcer Risk Evaluation shows R1 was At Risk on 10/20/23, was a High Risk on 11/3/23, a Moderate Risk on 12/13/23 and 1/4/24, High Risk again on 1/15/24 and Moderate Risk on 4/18/24. R1's Care Plan initiated on 10/20/23 shows R1 has an ADL (activities of daily living) self-care performance and functional mobility deficit related to confusion, dementia, and impaired balance. On 11/1/23, R1's care plan identifies she is incontinent of bowel and bladder. R1's care plan does not identify that she is at risk to develop pressure injuries with corresponding prevention interventions. R1 is totally dependent on staff for toilet use. R1's Full Body Skin Assessment effective 10/20/23 shows R1 has no wounds. R1's Wound Evaluation dated 5/8/24 shows R1 has a new, facility acquired, Stage 2 pressure wound of her butt crack. R1's Wound Evaluated dated 5/9/24 which was completed by V4, shows R1 has a Stage 3 facility acquired pressure wound of her sacrum. R1's Wound Evaluation & Management Summary completed by the Wound Care Physician, V5, on 5/9/24, shows the visit is an initial evaluation of R1's sacral wound and confirms R1's sacral wound is a Stage 3 Pressure Wound. R1's Wound Evaluation & Management Summary dated 7/18/24 shows R1's Stage 3 sacral Pressure Wound merged with a non-pressure wound of her right upper medial buttock and became a Stage 4 sacral pressure wound with odor, heavy serosanguinous exudate, and 100 percent necrotic tissue. R1's sacral wound culture collected 7/25/24 shows the wound has become infected by Escherichia coli (E-coli), and Morganella morganii. R1's Order Recap Report dated 11/7/24 shows R1 was prescribed an antibiotic on 7/30/24 for eight days related to her wound culture. R3's admission Record dated 11/7/24 shows he was admitted to the facility on [DATE]. R3's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 4/11/24 shows he was a Very High Risk. R3's Skin/Wound Note dated 4/12/24 at 3:17 PM shows R3's sacrum is clear. R3's Skin/Wound Note dated 5/23/24 at 5:31 PM shows R3 has MASD (moisture associated skin damage) to sacrum/coccyx, dry healing, also present upon admission, but much improved, this is not a pressure injury. R3's Skin/Wound Note dated 6/21/24 at 3:17 PM shows R3 has an unstageable sacral wound with a 3 centimeter (cm) by 3 cm area of slough surrounded by a 10 cm by 7 cm area of redness. It does not note the etiology of the wound. R3's Initial Wound Evaluation & Management Summary dated 6/28/24 shows an unstageable (due to necrosis) sacral pressure wound measuring 11.6 cm by 10 cm by 0.2 cm with heavy sero sanguinous exudate and 70 percent necrotic tissue. On 11/6/24 at 3:18 PM, V5 ( Wound Care Doctor) said (wound) infection is never normal. V5 said he would expect a wound to be identified before it is the size R3's sacral pressure wound was when it was found. V5 said R3 had a pretty horrific (pressure) ulcer. On 11/7/24 at 9:45 AM, V4 (Wound Care Nurse) said R1 did not have any pressure wounds on admission, but R1 was at risk of developing a pressure ulcer. V4 said R1 was a 12 on the Braden scale which puts her at high risk of developing a pressure wound. V4 said they should develop a care plan to include pressure injury prevention measures such as frequent turning. V4 said R1's risk factors include limited mobility, need for assistance with ADLs (toileting and transferring), bowel and bladder incontinence, and dementia. V4 said R1 did develop a wound infection this past summer. Signs and symptoms of wound infection include increased redness, drainage, warm to touch, necrotic tissue, increased slough, purulent drainage, increased drainage, and odor. V4 said wound infections are not very common and should not occur as part of the normal wound healing process. V4 said they are still working on healing R1's sacral pressure wound. V4 said R3 was admitted to the facility on [DATE] with a history of pressure ulcers. V4 said R3 was at risk for developing pressure ulcers. V4 said R3's sacral pressure ulcer was first identified on 6/21/24 as an open, unstageable pressure ulcer with slough and V5 first saw R3 on 6/28/24 regarding the sacral pressure ulcer. V4 said she would expect to have been notified (about R3's pressure ulcer) when there was just redness, before it opened. V4 said she expects nursing to notify her about any change in skin, any alterations of the skin, especially in the pressure point areas such as the sacrum. V4 said it is obvious a wound would not start out at 10 centimeters, she should be notified long before it ever gets to a significant size so she can assess the wound, make sure there is wound treatment and get the wound care physician involved. The facility's Pressure Injury Prevention Policy (revised 1/10/24) shows the wound team will manage wound care, implement prevention interventions, and monitor compliance with documentation. If a wound is identified, a would assessment is done and should include the type of injury (pressure versus non-pressure related). Identified wounds are assessed and measured on a regular basis at least weekly and documented. Based on the Braden's Scale, any resident who is identified as high risk for developing pressure injuries will have interventions initiated to decrease risks. The IDT (interdisciplinary team) will review care plan ensuring that it includes measurable goals for prevention and management of pressure ulcers with appropriate interventions.

Based on interview and record review, the facility neglected to ensure contracted staff reported a fall with a head injury for 1 of 3 residents (R1) reviewed for abuse in the sample of 7. This failure resulted in resident (R1) not being monitored for an hour and a half after the fall occurred. R1 was later sent to a local emergency room and admitted to the intensive care unit. The findings include: The facility's Initial IDPH (Illinois Department of Public Health) Notification of Serious Incident, dated 1/29/23, showed R1 was noted to have a laceration with purplish discoloration to forehead while in bed during nursing rounds at 7:56 PM on 1/27/23. The notification showed 911 was activated and R1 was transferred to a hospital. R1's Progress Notes, printed by the facility on 1/31/23, showed she had diagnoses including pneumonitis due to inhalation of food and vomit, altered mental status, moderate protein-calorie malnutrition, dysphagia (difficulty swallowing), reduced mobility, weakness, and need for assistance with personal care. R1's Brief Interview For Mental Status Assessment (an assessment to determine cognitive status), dated 1/23/23, showed she was not able to complete the assessment due to Resident is rarely/never understood. The assessment also showed R1 had a short-term and long-term memory problem. R1's admission Baseline Care plan showed she needed one-person physical assist for eating, personal hygiene, and bed mobility. The care plan showed R1 required assistance of two staff persons for transfers. On 1/30/23 at 4:50 PM, V16 (R1's daughter) said the incident happened on 1/27/23. V16 said she was at the facility until 11:00-11:30 AM on 1/27/23. V16 said V3 (Licensed Practical Nurse-LPN) called her around 8:00 PM and said she found (R1) in the bed with an injury to her head. V16 said there is no way (R1) could have made that kind of injury on her head by herself. V16 said Something happened, either accidental or on purpose. V16 said there is no way (R1) could have fallen out of the bed and got herself back up on her own. V16 said something happened between 11:30 AM and 8:00 PM. V16 said when she went to the emergency room to be with R1, she had a laceration about the size of your hand on her head. V16 said R1 was wailing and sobbing and making noises like an animal would make. V16 said R1 was on the critical care unit and was moved to the hospice unit of the hospital on 1/30/23. On 1/31/23 at 9:02 AM, V1 (Administrator) said V5 (Registered Nurse-RN) started his shift at 7:00 PM on 1/27/23. V1 identified V3 (LPN-Agency) as R1's nurse from 7:00 AM-7:00 PM on 1/27/23. V1 said V18 (an RN that works for a company that specializes in vascular access and is contracted with the facility's pharmacy) was in the facility and left around 6:00ish (PM). V1 said she spoke with V18, and he said he noticed a bump on R1's head when he was starting the intravenous (IV) line. V1 said she asked V18 if he reported it to the nurse, and he said no. V1 was told by V3 (LPN) that V18 seemed to be in a rush when he was leaving. V1 said V6 (Certified Nursing Assistant-CNA) told her (V1) that about 6:00 PM, she was sitting at a computer and heard R1 yell out. V1 said V6 ran to the doorway of R1's room where she saw a man trying to put both of R1's legs in the bed, like she had her legs off the side of the bed, and he was trying to put them back up on the bed. V1 said V6 asked the man what was going on and he got out of the room quick. V1 said around 7:00 PM, V6 noticed blood on the sheet by R1's arm. V5 (RN) went into R1's room to check her IV line and that is when the bump on her head was discovered. V1 said V18 came into the facility around 5:00 PM on 1/27/23 and was in R1's room for about 45 minutes to an hour. V1 said during that time, no one went into R1's room to check and see how it was going. On 1/31/23 at 11:38 AM, V5 (RN) said he worked on 1/27/23. V5 said his shift started at 7:00 PM and he got the shift report from V3. V5 said V3 (LPN) mentioned during report that R1 had a PICC line (a Peripherally Inserted Central Catheter that goes into a vein in the upper arm). V5 said after getting report, he started his medication pass and rounds. V5 said he went into R1's room to check her PICC line and saw bleeding near the PICC line. V5 said he did not notice the injury to R1's head at that time because her hair covered the area and R1 was looking the other way. V5 said he went out and got V20 (Nurse) to come in with him to check R1's PICC line and that is when V20 noticed the bump on R1's head. V5 said V20 asked V5 if he saw the injury on R1's head. V5 said it was probably a little smaller than a golf ball, with blood that was dried and crusted on it. V5 said it was not fresh blood. V5 said he went back out and asked V3 about it and V3 said she did not know anything about it. V5 said V3 told him it must have happened earlier and no one reported it to her. V5 said V3 took over for R1 after that. On 1/31/23 at 11:56 AM, V6 (CNA) said she worked on 1/27/23. V6 said she was not assigned to R1. V6 said about 6:00 PM, she was on the computer doing her charting and she heard R1 scream. She ran to R1's room to check on her, and she saw a guy bending down to put R1's legs back on the bed. V6 said she asked what happened and the guy said just bring a couple of sheets, maybe she's cold, then he went out of R1's room. She took a couple of sheets to R1 and covered her up. After the guy left R1's room, he went into the dining room and sat at a table for at least 10 minutes doing something on his computer, maybe charting. V6 said about 7:00 PM she went in to take R1's blood pressure and saw blood on R1's right arm and sheet. She ran to inform V5, and he (V5) came back to R1's room with her. V6 said she left R1's room at that time. She went back in to do R1's vitals a little later and that is when she saw the bump on R1's head. V6 said she heard V5 just outside of R1's room telling someone on the phone that she had a bump on her head. On 1/31/23 at 12:34 PM, V9 (RN/Unit Manager) said he worked on 1/27/23. V9 said he and V10 (Licensed Practical Nurse-LPN/IV Certified) went in to R1's room between 2:30 - 3:00 PM to try to start an IV. They were unsuccessful in trying to start the IV for R1, so they put R1's bed back down to the floor (low position) and placed the fall mat next to R1's bed. V9 said he did not see any injuries to R1 at that time. V9 said he and V10 went out and informed V3 that they were not able to start the IV and to call and get an order for someone from (the company that specializes in vascular access and is contracted with the facility's pharmacy) to come in and start the IV. On 1/31/23 at 12:43 PM, V7 (Certified Nursing Assistant/CNA) said she was assigned to R1 on 1/27/23. V7 said she did not see any bump, bruising or bleeding on R1 during her shift. V7 said after the residents had lunch, she took her break and then put R1 into her bed. V7 said she put R1's bed in the low position and placed the mat on the floor next to her bed. V7 said she was moved to another floor at 2:57 PM because someone had to leave. On 1//31/23 at 12:55 PM, V8 (Physician's Assistant) said she saw R1 around 11:30 AM on 1/27/23. V8 said R1 did not have any injuries to her face at that time. On 1/31/23 at 1:08 PM, V10 (LPN) said between 2:30-3:00 PM on 1/27/23 she went in with V9 to try to get a peripheral IV started on R1. V10 said they were not able to get the IV started. V10 said R1 was in bed with a sweater and pants on. V10 said R1 did not have any bumps, bruising or bleeding on her forehead when she and V9 were attempting to start the IV. V10 said they let V3 (LPN) know they were unsuccessful and V3 called to get an order for someone from (company that specializes in vascular access and is contracted with the facility's pharmacy) to come in and start the IV. V10 said she (V10) is the one that called the company to have them come in. On 1/31/23 at 1:18 PM, V1 (Administrator) said she spoke with V18 (RN that works for a company that specializes in vascular access and is contracted with the facility's pharmacy) again and he told her that R1 had fallen out of bed while he was trying to start the IV. V1 said V18 panicked and thought it was something manageable. V1 said V18 told him he changed R1's clothes and placed a gown on her because there was blood on R1's clothes. V1 said V18 told her he did not tell the nurse about the fall, and he knew it was not the right thing to do. He panicked. On 1/31/23 at 1:29 PM, V3 (LPN) said she was R1's nurse on 1/27/23 from 7:00 AM-7:00 PM. V3 said between 5:00-6:00 PM she took the tech (RN that works for a company that specializes in vascular access and is contracted with the facility's pharmacy) to R1's room. V3 said when V18 went to leave the area, he was in a hurry and was not going to provide her with paperwork about the procedure. She had to flag V18 down to get the paperwork from him. V18 handed her the paperwork, said here, and then left the area. V3 said R1 had been fully dressed when she took V18 to R1's room. V3 said after the injury was discovered, R1 had a gown on. She does not know who put the gown on R1. V3 said it was about 7:20 PM when V5 told her there was blood around R1's IV. V3 said she and V5 were in R1's room a few times tending to the IV and did not notice the injury to R1 because they were focusing on the IV. V3 said she went back out to chart and V5 came up to her asking about the injury to R1. She went back in to assess R1 and then called 911 because it was a bruise that she did not know where it came from and had not been there earlier. On 2/1/23 at 11:26 AM, V3 said she had walked by R1's room some time between 5:00-6:00 PM and R1's door was still closed. V3 said she told another nurse that it seemed to be taking a long time to start the IV. V3 said she did not go in to see what was taking so long. V3 said the injury was discovered some time between 7:30-8:00 PM. On 1/31/23 at 5:26 PM, V18 said on 1/27/23 he went to the facility to start three IVs. V18 said V3 took him to R1's room. V18 said he saw the mattress on the floor by R1's bed. He introduced himself to R1 and explained why he was there. V18 said he moved the mattress out of the way that was on the floor and raised R1's bed up about six to eight inches. V18 said he lifted R1's sleeve and prepared his kit. He applied a tourniquet to her arm and gave R1 lidocaine. V18 said R1 became squirrely at that time and was reaching over with her left arm to where he was working with her right arm. He wanted to get R1 more comfortable, so he turned to get more lidocaine from his cart. V18 said he heard a thud. V18 said he turned around and R1's torso and face were on the floor, and her feet were still on the bed. V18 said he panicked and lifted R1 back up into the bed. He did not notice any injury at that time. He asked R1 if she was okay and R1 did not respond. V18 said R1 had not responded when he introduced himself to her either. V18 said he gave R1 more lidocaine and inserted the mid-line. V18 said then he noticed blood on the right side of R1's head. He cleaned up the wound and applied pressure for about five minutes until the bleeding stopped. V18 said he noticed blood on R1's clothes and pillow case, so he removed her clothes and put a gown on her. V18 said he felt comfortable with R1's wound, that it was not bleeding. He was stressed out about what had happened, and he had other jobs to do. V18 said he moved onto the other residents in the facility. V18 said he panicked. He understands he should have reported it. It was a bad, bad, bad decision not to tell the nurse. When asked why he told V1 when she interviewed him the first time about the incident, V18 said he was scared to say what happened. V18 said he panicked. He was scared not only for her (R1), but for himself-the consequences. V18 said he is beside himself and feels horrible. He had been a nurse for 23 years and had emergency department experience. V18 said it is important to inform the nurse when a resident has a fall because they could have a head injury, a concussion, possible brain-bleed, or broken bones. R1's notes from a local hospital show R1 was sent to the emergency department on 1/27/23 and was diagnosed with acute localized area of extra-axial hematoma overlying the lateral left frontal lobe (intracranial hemorrhage). The hospital notes showed R1 was transferred from the emergency department to the ICU unit and a critical care physician was consulted. The facility's Abuse and Neglect of a Resident policy, with a revision date of 12/20/22, defined Neglect as Failure of the facility, it's associates or service providers to provide goods and services to a resident, necessary to avoid physical harm, pain, mental anguish, or emotional distress. Medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living are necessary to avoid physical harm, mental anguish, or mental illness of a resident. Examples are but not limited to not acting on medical problems, prescribed treatment, or therapies, not calling a physician when necessary .

Based on interview and record review, the facility failed to ensure the safety of a resident during care for 1 of 3 residents (R1) reviewed for abuse in the sample of 7. This failure resulted in R1 falling out of bed, getting a head injury, being sent to a local hospital emergency room, and later to the intensive care unit of the hospital. The findings include: R1's Progress Notes, printed by the facility on 1/31/23 showed she had diagnoses including pneumonitis due to inhalation of food and vomit, altered mental status, moderate protein-calorie malnutrition, dysphagia (difficulty swallowing), reduced mobility, weakness and need for assistance with personal care. R1's Brief Interview for Mental Status assessment (an assessment to determine cognitive status) dated 1/23/23, showed she was not able to complete the assessment due to Resident is rarely/never understood. The assessment also showed R1 had a short-term and long-term memory problem. R1's admission Baseline Care plan showed she needed one-person physical assist for eating, personal hygiene and bed mobility. The care plan showed R1 required assistance of two staff persons for transfers. No observations were made of R1 as she is no longer a resident of the facility. R1 is now on the hospice unit of a local hospital. On 1/30/23 at 4:50 PM, V16 (R1's daughter) said she received a call from the facility informing her that R1 had been found in bed with an injury to her head. V16 said there is no way R1 could have caused that kind of injury to herself. V16 said if R1 had fallen out of the bed, there is no way she would be able to get up and get back in bed by herself. On 1/31/23 at 11:56 AM, V6 (Certified Nursing Assistant-CNA) said she worked on 1/27/23. V6 said about 6:00 PM, she was on the computer doing her charting and she heard R1 scream. V6 said she ran to R1's room to check on her, and she saw a guy bending down to put R1's legs back on the bed. V6 said she asked what happened and the guy said just bring a couple of sheets, maybe she's cold, then he went out of R1's room. V6 said she took a couple of sheets to R1 and covered her up. She did not notice any injury at that time because R1's hair was covering her forehead. V6 said about 7:00 PM she saw blood on R1's right arm and sheet. She informed V5(Registered Nurse/RN), and he went back to R1's room with her. V6 said she left R1's room at that time. V6 said she went back in to do R1's vitals a little later, and that is when she saw the bump on R1's head. V6 said she heard V5 just outside of R1's room telling someone on the phone that she had a bump on her head. On 1/31/23 at 1:29 PM, V3 (Licensed Practical Nurse/LPN) said she was R1's nurse on 1/27/23 from 7:00 AM-7:00 PM. V3 said between 5:00-6:00 PM she took the tech (V18- RN that works for a company that specializes in vascular access and is contracted with the facility's pharmacy) to R1's room. V3 said when V18 went to leave the area he was in a hurry. V3 said she had to flag V18 down to get the paperwork from him. R1 had been fully dressed when she took V18 to R1's room. V3 said after the injury was discovered, R1 had a gown on. V3 said she was out charting and V5 (RN) came up to her asking about the injury to R1. No one had reported an injury regarding R1 to her. V3 said she went back in to assess R1 and then called 911 because it was a bruise that she did not know where it came from and had not been there earlier. On 1/31/23 at 5:26 PM, V18 (an RN that works for a company that specializes in vascular access and is contracted with the facility's pharmacy) said on 1/27/23 he went to the facility to start three IVs (Intravenous access). V18 said V3 (LPN) took him to R1's room. He saw the mattress on the floor by R1's bed. V18 said he moved the mattress out of the way that was on the floor and raised R1's bed up about six to eight inches. R1 became squirrely and was reaching over with her left arm to where he was working with her right arm. V18 said he turned to get more lidocaine from his cart, and he heard a thud. He turned around and R1's torso and face were on the floor, and her feet were still on the bed. V18 said he panicked and lifted R1 back up into the bed. He did not notice any injury at that time. V18 said he gave R1 more lidocaine and finished the procedure. Then he noticed blood on the right side of R1's head. V18 said he cleaned up the wound and applied pressure for about five minutes until the bleeding stopped. V18 said he noticed blood on R1's clothes and pillow case, so he removed her clothes and put a gown on her. V18 said he felt comfortable with R1's wound, that it was not bleeding. V18 said he was stressed out about what had happened, and he had other jobs to do. He moved onto the other residents in the facility. V18 said he panicked. V18 said he understands he should have reported it. It was a bad, bad, bad decision not to tell the nurse. V18 said it is important to inform the nurse when a resident has a fall because they could have a head injury, a concussion, possible brain-bleed or broken bones. R1's progress note dated 1/27/23 at 7:56 PM, showed Writer noted resident with discoloration/dry blood to right forehead and lethargic. Writer assessed. Called 911. The progress note dated 1/27/23 at 8:20 PM, showed Resident via stretcher transported to (local ER) . R1's notes from a local hospital show R1 was sent to the emergency department on 1/27/23 and was diagnosed with acute localized area of extra-axial hematoma overlying the lateral left frontal lobe (intracranial hemorrhage). The hospital notes showed R1 was transferred from the emergency department to the ICU unit and a critical care physician was consulted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R600's Progress Note dated September 28, 2022, showed R600 sustained a C2 (second cervical (neck) vertebrae (spine) fracture) with severe cervical stenosis and (spinal) cord edema after a fall. R600's Restorative Progress note dated January 23, 2023, showed R600 wears Aspen collar (cervical collar) on at all times except for eating and bathing time for spinal precautions . R600's physician order dated January 23, 2023, showed, Precautions: Fall Risk, cervical collar on at all times except eating and drinking: spinal precautions. On January 23, 2023, at 9:22 AM, R600 was lying in bed with no cervical collar around her neck. A cervical collar was noted on R600's bedside table. At 9:40 AM, V6 (Certified Nursing Assistant/CNA) and V7 (Certified Nursing Assistant/CNA) transferred R600, from her bed to a chair, without a cervical collar in place. At 12:20 PM, R600 was seated in her room with no cervical collar on. On January 24, 2023, at 9:24 AM, R600 was alone in her room with no cervical collar on. On January 23, 2023, at 10:15 AM, V6 (CNA) stated, I don't know why exactly she (R600) needs to wear that collar. I know she doesn't wear it when she eats. She is a new resident to us. She just got admitted last week. On January 25, 2023, at 9:10 AM, V3 (Assistant Director of Nursing/ADON) stated, R600 is to have her cervical collar on at all times except when eating or drinking. She needs it to keep her cervical spine fracture stable. She is at risk for falls. If she were to fall again, without the collar on, it could make her spine fracture worse or cause another spinal fracture. 3. R188's current care plan showed R188 was at high risk for falls due to her diagnosis of dementia and problems with her balance/gait. The care plan showed R188 required the assistance of one staff, with the use of a gait belt and walker, for all transfers. On January 23, 2023, at 9:10 AM, V7 (CNA) transferred R188 from a wheelchair to a recliner without the use of a gait belt. V7 placed her hand on the waistband of R188's pants to assist her with the transfer. On January 24, 2023, at 11:20 AM, V3 (ADON) stated, A gait belt should be used for all transfers. R188 had a fall about a month ago so a gait belt should be used when transferring her. The facility's Gait Belt/Transfers policy dated May 10, 2021, showed, Gait belt must be used with any assisted transfer or ambulating procedure. 4. R452's electronic medical record (EMR) shows, she was admitted to the facility on [DATE]. On January 23, 2023, at 9:34 AM, R452 was lying in bed. Her breakfast tray was on her bedside table, pushed up against the wall. She was served a regular diet of french toast, breakfast sausage, oatmeal and regular thin orange juice. There were 4 cups of water on her bedside dresser. 2 of them were regular water and the other 2 were thickened water. She had not eaten breakfast yet. On January 23, 2023, at 10:56 AM, V49 (Occupational Therapist/OT) asked V29 (CNA) to please warm up R452's breakfast so she could eat breakfast. (lunch being served at 11:30 AM) On January 23, 2023, at 11:15, V33 (R452's sister) was at the facility visiting her. She stated, they served her a regular diet for breakfast that morning. She had a feeding tube until Thursday last week (January 19, 2023). She was on a special diet when she left the hospital on Friday (January 20, 2023). We told them that on Friday when she was admitted . She can't eat a regular diet. On January 23, 2023, at 11:50 AM, V29 (CNA) stated, she did not know what R452's diet order was. V29 did not have a meal ticket for R452. She had given her a regular diet this morning even though she didn't know what her diet was. She stated, she asked the nurse, but the nurse did not have time to look at R452's diet order. V29 felt she couldn't wait for the nurse to look so she served her a regular tray. On January 23, 2023, at 12:03 PM, V30 (Licensed Practical Nurse/LPN) stated, she didn't know what R452's dietary orders were because she didn't see anything in the computer. R452's order summary report provided on January 24, 2023 shows, no dietary orders were entered into the computer until Monday, January 23, 2023 (3 days after she was admitted to the facility). Regular diet, mechanical soft texture, nectar/mildly thick consistency, seen by ST (speech therapy). R452's ST daily treatment note provided on January 25, 2023, shows, Reason for referral: Dysphagia (difficulty swallowing), The patient (R452) is a [AGE] year old female who was admitted to the facility following hospitalization with diagnosis of CVA (cerebral vascular accident). During hospitalization, patient with increased lethargy and recommendations of NPO (nothing by mouth) with NG tube (nasogastric tube) for immediate nutrition. Increased levels of alertness noted, and video swallow study completed on 1/19/23 with diet recommendations of NTL (nectar thick liquids)/mechanical soft solids. Upon admission to the facility, no diet orders were placed in patient's chart, with staff requesting immediate SLP (speech language pathologist) evaluation to determine safest least restrictive diet . ST was not requested to see patient until January 23, 2023 (3 days after admission and no diet orders). On January 25, 2023, at 10:25 AM, V31 (Speech Therapist) stated that there were no orders from the hospital, but they should have still verified what her diet order was. She definitely is recommending nectar thick liquids because she is a silent aspirator (swallows liquids into her lungs) which was shown on the video swallow study. There were no orders for speech therapy either. If they would have entered orders for ST, we would have seen her over the weekend. R452's hospital admission paperwork dated January 20, 2023, shows, SLP recommendations: Compensatory swallowing strategies: Upright 90 degrees for all oral intake; remain upright for 10-30 minutes after meals; eat/feed slowly; small bites/sips; alternate solids and liquids. Recommended form of medications with puree. SLP skilled therapy needed at next level of care, YES. No ST orders were placed until January 23, 2023 (3 days after admission). Based on observation interview and record review, the facility failed to ensure fall interventions were put in place after a resident (R11) at risk for falls fell. This failure resulted in R11 sustaining a right hip fracture requiring surgical intervention. The facility failed to ensure a cervical collar was applied during transfer, the facility failed to ensure a gait belt was used to transfer a resident safely, and the facility failed to ensure a resident received nectar-thick liquids as ordered. This applies to 4 of 35 residents (R11, R600, R188, R452) reviewed for falls and safety in the sample of 35. The findings include: 1. R11's Physician Order Sheet dated 8/22 show R11 has diagnoses that include seizure, hypothyroidism and bipolar disorder. R11's facility assessment dated [DATE] show R11 is moderately cognitively impaired and needs extensive assist of 2 person assist with all transfers. R11's Fall Risk assessment dated [DATE] show R11 was at risk for falls. A Facility Reported Incident (FRI) dated 12/13/22 sent to the state agency show as initial and final, 12/12/22 at 10:30 AM, resident called out and was attended to in the room. The resident was observed lying on the floor by the bed, with call light within easy not activated by resident. When asked by the nurse what happened, resident verbalized, I stood up trying to look for my mask and lost balance. Nurse immediately initiated assessment. Head to toe assessment performed, noted with skin tear to right elbow, resident denies hitting his head noted pain in right hip .MD notified of incident and resident c/o of pain, STAT X-ray of the right hip was ordered . Results came back with Acute displaced right femoral neck fracture. MD notified of results with order to send patient out to the hospital for evaluation and treatment . (R11) was transported to ER via 911. Resident admitted for right hip fracture. Surgery planned 12/14/22 .Injury acute displaced right femoral neck fracture. R11's Emergency notes (ER) dated 12/12/22, show 80 y/o sig (significant) for developmental delay, seizure disorder CAD s/p CABG bipolar hypothyroidism who presented to ED with complaints of mechanical fall unto his right side .He was in a wheelchair when he dropped his mask onto the floor. He bent down from the wheelchair to pick up his mask, lost his balance and fell onto his R side . R11's radiology report dated 12/12/22 show R11 sustained Fracture of the right femoral neck (Right hip fracture) R11's surgical consultation dated 12/13/22 show the patient presents with observed fall . living in nursing home .who has pain and dysfunction in his right hip region. He was seen in the ER .X-rays taken in the ER consistent with right femoral neck fracture .He has pain with movement of the right hip .the right hip is short and externally rotated. It was difficult to get the history, he has some developmental delay which have been life long. Plan: We will take the patient to the operating room where he was medically optimized. R11 underwent surgical procedure: hemiarthroplasty of right hip. On 1/23/23 at 1pm, R11 was sitting in his wheelchair in his room. When asked how he was doing, he said Ok. When asked about his recent fall, he said he did not remember falling. On 1/24/23 at 8:34 am, V12 (Registered Nurse/RN) said she was the nurse when R11 fell. V12 (RN) said on 12/12/22 she was at the nurses' station when she heard R11 screaming. V12 said she ran to R11's room and found R11 on the floor on his right side. V12 said R11 said he was reaching for his mask and fell. V12 said R11 had discomfort to his right hip. R11 was sent to the ER via 911. R11 fractured his right hip. V12 said R11 had surgery to fix R11's right hip. V12 said R11 has history of falling due to unassisted transfers. V12 said R11 tends to forget frequent reminders. R11 has poor safety awareness and does not ask for assistance. V12 said R11 needs frequent monitoring. V12 said R11's room is far from the nurses' station. On 1/24/23 at 8:38 AM, V13 (Certified Nursing Assistant/CNA) said he was one of the CNAs working on 12/12/22. V13 said he heard R11 yelling for help. V13 said he went to R11's room and saw R11 on the floor. R11 said he stood up and tried to reach for something on the floor and fell. V13 said R11 has history of getting up from wheelchair without asking for assistance. R11 does not remember reminders. V13 said staff tries to make sure R11 was not transferring himself without assistance. V13 said there was no device to alarm staff when R11 was attempting to transfer. On 1/24/23 at 8:47 am, V14 (Certified Nursing Assistant/CNA) said R11 fell trying to reach for his mask. R11 was sent to the hospital. V14 said R11 had done this in the past, trying to transfer himself without waiting for assistance. V14 said staff do their best to check and monitor R11, but staff gets busy. A fall incident dated 9/30/22 show per resident had a fall . his head and c/o of back pain. Resident description: I slid from the chair. A fall incident dated 8/7/22 show writer heard a call from resident's room, went to resident's room and noted resident lying on his left side on the floor. Resident description: Per resident he was trying to go to bed by himself lost balance and fell to the floor. R11's fall care plan did not show any fall interventions or necessary precautions after R11's previous falls of 9/30/22 and 8/7/22. R11's latest care plan with revision date of 12/28/22 (only updated after R11 already had the fall with injury.) show R11 has history of falls r/t poor balance, unsteady gait, recent fall with right hip fracture with intervention to include remind resident to call for help and not to get up unassisted. On 1/24/23 at 11:30 AM, V3 (Assistant Director of Nursing/ADON) said reminders do not work for R11 since R11 has developmental delay. V3 said R11 does not retain reminders. V3 (ADON) said R11 is a fall risk due to history of unassisted transfers. V3 said unfortunately R11's care plan did not show any new evaluation and new fall interventions after R11's repeated falls due to unassisted transfers. V3 said there should be interventions for each fall that works for R11. R11's room is not visible from the nurses' stations. V3 said R11 will be moved closer to the nurses' stations, and more effective intervention has to be put into place to prevent falls and falls with injury. R11's progress notes, dated 12/28/22, by V48 (R11's physician), confirms R11's diagnosis of having developmental delay. The facility policy entitled Fall Risk Assessment and Prevention with revised date of 10/11/22 shows, Purpose: to guide management of falls within (name of the facility) according to regulation and best practices for fall management to assist the IDT in reducing the risks of resident falls in the community as well as managing post fall interventions.