**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to apply a vehicle safety restraint during transportation in the facility van for one of three (R1) residents reviewed for falls on the sample list of three. This failure resulted in R1's wheelchair flipping backwards in the facility van during transport and R1 sustained a left side rib fracture. Findings Include: The Motor Vehicle Safety Program dated January 2025 documents seat belts and shoulder harnesses (occupant restraint systems) must be worn or used whenever the vehicle is in operation. The vehicle may not move until all passengers have fastened their restraints. R1's Fall Follow-up Note dated 5/15/25 documents R1 fell from his wheelchair while in the facility van. R1 was being transported back to the facility and his wheelchair was not properly secured. The root cause of the fall was determined to be the wheelchair was not properly secured. R1's Incident Note dated 5/12/25 documents R1 sustained a fall at 6:20 PM in the facility van. R1 is alert and orientated to person, place, time, and situation. R1 is rating new onset pain at a 5/10. R1's Progress Note dated 5/13/25 documents V5 Nurse Practitioner was called to evaluate R1 due to accident the day before. R1 was sitting at the nurses' station in his wheelchair complaining of pain in the neck and upper back radiating to the rib area. R1 stated the pain was not controlled by Acetaminophen. V5 requested R1 to be sent to the emergency room for evaluation. R1's Progress Notes document multiple requests for pain medication due to rib pain after the accident on 5/12/25. R1's Progress Note written by V5 Nurse Practitioner dated 5/13/25 documents V5 assessed R1 after a fall with a head strike. R1 complained of neck pain, headache, bilateral eye redness, and rib/chest wall pain. R1 was alert and orientated. R1 indicated when he fell backwards in the van in his wheelchair, he struck his head and blacked out. R1 reported having to deal with a headache and neck pain since the accident. R1 described the pain as bad and throbbing. V5 sent R1 to the emergency room. R1's emergency room documentation dated 5/13/25 documents R1 had a fall in his wheelchair which resulted in a closed head injury and closed left side rib fracture. On 5/12/25 R1 was loaded into the facility van in his wheelchair for transport. The facility driver did not strap in R1's wheelchair. When the driver hit the gas R1's wheelchair flipped backwards causing him to fall from his wheelchair. R1 woke up on 5/13/25 with continued chest wall pain and head and neck pain. The documented clinical assessment documents chest wall tenderness is present which correlates with the radiology report. R1's Radiology Report of the Chest dated 5/13/25 documents R1 sustained a possible non-displaced acute fracture of the left lateral rib number six and clinical correlation is advised. R1's Medical Diagnoses list dated May 2025 documents R1 is diagnosed with Dementia, Major Depression, and Obesity. R1's Minimum Data Set, dated [DATE] documents R1 is mildly cognitively impaired, requires supervision/touching assistance from staff to safely transfer from a seated position, and requires the use of a manual wheelchair for mobility. R1's Medication Administration Records for May 2025 documents prior to the accident on 5/12/25, R1 did not request any as needed pain medication. After R1's wheelchair flipped backwards in the van when being transported, R1 requested pain medication (Tylenol) daily. A new as needed pain medication (Tramadol 50 milligrams) was also added for R1's rib pain on 5/14/25 and then the frequency was increased from every six hours to every eight hours on 5/20/25. R1 has been taking pain medication regularly since the accident. On 5/24/25 at 12:55 PM R1 stated two staff members (V7 Certified Nurse's Assistant) and (V8 Licensed Practical Nurse) came to pick him up from the hospital. R1 stated V7 loaded him in his wheelchair into the facility van. R1 stated she did not provide him with a seatbelt or strap his wheelchair in with the van safety strap system. R1 stated they began to drive and stopped at a stop light. R1 stated as R1 took off from the red light, R1's wheelchair flipped backwards, and he fell back and hit his head. R1 stated the fall hurt his head, neck, and he felt it all through his body. R1 stated he has been having pain ever since the accident and for the first two days it was hard for him to get out of bed. R1 stated he has had chest wall pain on both sides, but it often hurts more on the right side. R1 stated he was sent to the emergency room the day after the accident, and they told him he had a fractured rib. R1 stated before the accident he rarely had pain but since the accident he has had pain every day mostly in his chest when he breaths more deeply. R1 stated he went from not taking any pain medication to taking pain medication every day. On 5/24/25 at 1:04 PM V8 Licensed Practical Nurse stated she went with V7 Certified Nurses Assistant (CNA) in the facility van to go pick up R1 from the hospital. V8 stated when V7 started driving after stopping at a red light, R1's wheelchair flipped backwards and R1 was on his back. V8 stated her and V7 helped get R1 back in his wheelchair in the van and they took him back to the facility. V8 stated R1 complained of a headache at the time. V8 stated she was never trained on how to properly secure a resident in the van for transport. On 5/24/25 at 1:31 PM V7 Certified Nurses Assistant (CNA) stated she was asked to pick up R1 from the hospital on 5/12/25. V7 stated she had transported residents before however V7 stated she had never been trained on how to properly secure residents in wheelchairs in the facility van. V7 stated as she drove back to the facility, R1's wheelchair flipped backwards, and he was on his back on the floor of the van. V7 stated she went back to check on R1 and he stated he felt like he was having a heart attack, his neck, head, and chest hurt. V8 helped get R1 back into the wheelchair and they returned to the facility. V7 stated the accident happened about 6:20 PM and R1 continued to complain of chest wall, head, and neck pain for the rest of her shift which ended at 10:00 PM. On 5/24/25 at 3:45 PM V2 Director of Nurses (DON) confirmed V7 and V8 failed to properly secure R1 in the wheelchair during transport in the facility van on 5/12/25. V2 confirmed this caused R1's wheelchair to flip backwards during transport. V2 confirmed R1 has had pain on his chest wall since the accident and the radiology scan completed on 5/13/25 documents R1 sustained a possibly acute left sixth rib fracture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R8's undated Medical Diagnosis List documents R8's medical diagnoses of Dementia, Delusional Disorders and Heart Failure. R8's Minimum Data Set (MDS) dated [DATE] documents R8 as severely cognitively impaired. This same MDS documents R8 requires maximum assistance with toileting, bathing, lower body dressing and moderate assistance with personal hygiene. R8's Care Plan interventions dated 8/17/23 document R8 requires one person assistance with personal hygiene, toileting, dressing and bathing. On 3/24/24 at 9:35 AM R8 was sitting in his wheelchair with bedside table in front of him. R8's breakfast plate, personal items and can of shaving cream was sitting on R8's bedside table. R8's hands, bedside table and breakfast plate were all covered with small mounds of smeared shaving cream. The lid to the can of shaving cream was sitting on the floor. R8's incontinence brief completely saturated hanging down exposing the front of R8's perineal area. R8 was not wearing pants. R8 stated 'I wanted to wear pants but they (staff) were too busy. I'm a mess and I am cold. Can you put those pants on me?'. On 3/24/24 at 9:40 AM V6 Licensed Practical Nurse (LPN) stated R8 should not be left with shaving cream. V13 stated (R8) always makes a mess with it. (R8) doesn't shave himself so he really doesn't need that shaving cream anyway. I will make sure he gets cleaned up before he eats any of it. B. Based on interview and record review the facility failed to maintain the dignity for three residents (R11, R33, R55) affected negatively by another resident's (R289) yelling and cussing outbursts. This failure affects four (R11, R33, R55, R289) residents out of six residents reviewed for dignity in a sample list of 39 residents. Findings include: 1.) R11's Minimum Data Set (MDS) dated [DATE] documents R11 as cognitively intact. R11's Care Plan intervention dated 9/14/22 instructs staff to provide a safe and secure environment for R11. On 3/24/24 at 1:05 PM R11 stated (R289) needs to move somewhere else. (R289) yells and hollers out all kinds of curse words right in front of me. I told (V1) about it last week but nothing gets done. (R289) was out of control last night (3/23/24) at supper. (R289) was yelling the 'f' (expletive) word and calling people names. I couldn't tell if (R289) was yelling at staff or residents but he was yelling loud enough everyone in the dining room could hear and the dining room was full. I was getting ready to call the cops on (R289) because he scared me because he was so out of control. The staff walked him (R289) to his room but then he came right back and started yelling again. I don't know why (R289) gets so mad but they ought to do something to control him before he hurts someone. (R289's) face gets so red and he yells so loud. You can tell (R289) is about to explode. That is why I wanted to call the cops. 2.) R33's Minimum Data Set (MDS) dated [DATE] documents R33 as cognitively intact. R33's Care Plan intervention dated 12/27/23 documents R33 as a moderate risk for abuse. On 3/24/24 at 1:10 PM R33 stated (R289) yells and cusses in front of everyone. (R289) was in the hallway this morning at 5:00 AM yelling at the staff to get their 'head out of their a** (expletive)'. I heard every word of it. The whole hall could hear (R289) yelling. I don't like it at all. I don't talk to people like that and I don't like it when people talk to me like that. 3.) R55's Minimum Data Set (MDS) dated [DATE] documents R55 as moderately cognitively impaired. R55's Care Plan initiated 1/7/24 documents R55 is at moderate risk of being abused. On 3/25/24 at 1:30 PM R55 stated (R289) yells and cusses all the time. (R289) screams out the 'f' (expletive) word and so much worse in the halls, the dining room during meal time, during the day, during the night. (R289) woke me up the other morning when he was screaming obscenities in the hall. I told the nurse to make him be quiet. I was afraid (R289) would come into my room. (R289's) room is not too far away. (R289) rolls around here (facility) scaring people and they (facility) won't do anything about him. (R289) is so intimidating because of his size and how he gets so angry when he yells. R289's undated Face Sheet documents R289 admitted to facility on 3/15/24. R289's Electronic Medical Record (EMR) documents R289's medical diagnoses as Developmental Delay, Bipolar Disorder, Major Depressive Disorder, Chronic Obstructive Pulmonary Disorder (COPD) and Heart Failure. R289's Brief Interview for Mental Status (BIMS) dated 3/19/24 documents R289 as cognitively intact. R289's Care Plan does not include a focus area, goal nor interventions for behaviors. R289's Nurse Progress Note dated 3/19/24 at 4:59 PM documents Kitchen staff notified (V6) Licensed Practical Nurse (LPN) that (R289) was in the dining room yelling at other staff members and residents. (R289) has been noted to have this behavior continuously. (R289) was removed from dining room and escorted to his room to prevent any further altercations. On 3/24/24 at 12:55 PM V4 [NAME] stated (R289) acts up all the time in the dining room during mealtime. (R289) was yelling you are a f******* (expletive) b**** (expletive)' and 'get your f****** (expletive) a** (expletive) over here'. (R289) yells things like that all the time. (R289) was doing it last night during supper. There are a lot of other residents around. On 3/24/24 at 1:00 PM V5 Dietary Aide stated (R289) is out of control in the dining room. At lunch today (R289) was yelling at the staff 'you f****** (expletive) b**** (expletive)' and 'this food s**** (expletive)' and 'you f****** (expletive) stupid b**** (expletive)'. I went over to talk to (R289) and he just kept yelling so loud. (R289) does that about every meal. I don't know why they (facility) doesn't control that somehow. Other residents don't like it at all. On 3/25/24 at 11:50 AM R289 stated I get angry sometimes. I yell and scream at other residents when they say mean things to me. The other night one lady (unknown resident) told me to 'Shut up' and it made me mad so I yelled at her back. Yesterday (3/24/24) I yelled really loud in the dining room. There were a lot of people in there but I don't care. Somebody told me to shut up because I was mad at one of the kitchen staff so I yelled at all of them. They can't tell me what to do. Then they made me go to my room but I was so mad I went back to the dining room. On 3/26/24 at 8:00 AM V1 Administrator stated R289's careplan was entered on 3/24/24. V1 stated R289 did not have a behavioral careplan prior to 3/24/24. V1 Administrator stated R289 yells out in the dining room during mealtime all the time. V1 Administrator stated On 3/19/24 during supper time (R289) was yelling in the dining room. (R289) was yelling 'you f****** (expletive) b**** (expletive) ' and 'f****** (expletive) stupid b******* (expletive)' at the staff in front of a dining room full of people. V1 Administrator stated other residents are upset by (R289's) behaviors and outbursts. V1 stated We (facility) are working on a behavioral plan for (R289) to make it a better environment for everyone. The facility policy titled 'Dignity' effective March 2024 documents the facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The facility shall consider the resident's lifestyle and personal choices identified through the assessment processes to obtain a picture of his/her individual needs and preferences. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. Maintaining a resident's dignity should include promoting resident independence and dignity while dining, protecting resident's private space, including residents in conversations during activities or when care is provided and refraining from practices demeaning to residents. Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to promote residents' dignity by failing to care for and treat them with respect and in a manner that promotes their quality of life and individualized needs. This failure affects two of six residents (R8, R52) reviewed for dignity in the sample list of 39. This failure resulted in emotional distress and a significant increase in anxiety for one resident (R52). Findings Include: The facility policy titled 'Dignity' effective March 2024 documents the facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The facility shall consider the resident's lifestyle and personal choices identified through the assessment processes to obtain a picture of his/her individual needs and preferences. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. Maintaining a resident's dignity should include promoting resident independence and dignity while dining, protecting resident's private space, including residents in conversations during activities or when care is provided and refraining from practices demeaning to residents. 1.) R52's Diagnoses List dated March 2024 documents R52 is diagnosed with Dependency on Renal Dialysis, Anxiety, Depression, Legal Blindness, Homelessness, and Bipolar Disorder. R52's Minimum Data Set (MDS) dated [DATE] documents R52 is cognitively intact. R52's Care Plan dated 12/27/23 documents R52 requires assistance bathing, transfers, mobility, and eating. R52 has issues with anxiety and depression and takes psychotropic medications. R52 has had episodes of suicidal ideations and suicidal attempts due to his current level of care and mental health diagnoses. R52 is at risk for abuse and neglect. R52 has impaired vision and is legally blind. R52 requires staff to verbalize things when they are taking care of him. Staff need to verbalize when they are approaching R52 and inform him of who they are and their role. Staff need to inform R52 of where they are places items he needs and and be consistent. On 3/24/24 at 10:30 AM R52 stated often staff enter his room without knocking or introducing themselves. R52 stated staff will wait until they are right beside his bed to say anything and because he is blind, this startles him and causes him anxiety. R52 stated staff also often bring in his food tray and set it on his bedside table without making sure he knows it is there. By the time he realizes it is there, the food is cold and he does not even know what food is on his tray. R52 states he feels staff should be telling him they are bringing his food tray and letting him know what is on the plate for him to eat and assisting him in setting up his meals if needed. On 3/25/24 at 1:45 PM R52 stated the Transportation Driver (V23) often comes up behind him and wraps his arm around R52 (upper chest, shoulder neck area) and startles him. R52 stated V23 also sneaks into his room and shake his bed and yells his name to startle him. R52 also stated V23 has tipped his wheelchair backward as if he was falling during times V23 has transported R52. R52 stated V23 has caused him a significant increase in anxiety and emotional stress which is something he struggles with already. R52 stated he has repeatedly asked V23 to stop and he just keeps on doing these things. R52 stated he has told other residents and some staff members about V23's behavior but it continues. R52 stated he is fed up with it and he doesn't want to be around V23 Transportation Driver. On 3/25/24 at 3:30 PM V20 Activity Aide confirmed R52 has mentioned V23 makes him uncomfortable with the way he treats him and the disregard for his (R52) vulnerabilities (blindness). On 3/25/24 at 3:00 PM V1 Administrator confirmed it would be inappropriate and unprofessional for any staff member to try to startle or scare R52 in any way, and staff need to be cognizant of R52's vulnerabilities (blindness) and individualize his care accordingly. V23 was away from the facility and unable to be reached during this time. On 3/25/24 at 4:08 PM V22 Certified Nurses Assistant stated R52 has complained to her on multiple occasions about staff not introducing themselves when they enter his room, about staff not telling him they are delivering his food tray or informing him what is on the tray, and about V23 Driver making R52 feel uncomfortable by purposefully scaring him and startling him even after R52 has asked him to stop. On 3/27/24 at 10:15 AM V2 Director of Nurses confirmed staff need to be sensitive to R52's medical conditions, specifically being blind. Staff need to knock upon entry to his room and announce who they are and what their role is. They need to tell him what they are going to be doing and if they deliver food, they need to make sure R52 knows what he has on his tray to eat. V2 stated V23 Driver should not be purposefully startling or scaring R52 and his actions are inappropriate and unprofessional. V2 confirmed if R52 had asked V23 to stop and he continued to startle and do things to scare R52, it is understandable that R52's anxiety would increase.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement fall interventions, provide supervision to prevent a fall, provide safe transfer assistance, and thoroughly investigate falls to identify root cause and develop post fall interventions for three (R1, R2, R3) of three residents reviewed for falls in the sample list of nine. These failures resulted in R1 falling and sustaining a subdural hematoma and R3 falling and sustaining a scalp laceration that required sutures. Findings include: 1.) R1's Minimum Data Set (MDS) 10/16/23 documents R1 has moderate cognitive impairment, has upper/lower extremity range of motion impairment, and requires substantial/maximal assistance for chair/bed transfers. R1's Care Plan revised on 5/1/23 documents R1 transfers with extensive assistance of two staff. R1's Care Plan revised on 5/4/23 documents R1 has decreased ability to self transfer due to Parkinson's Disease and spastic movements/tremors. R1's Care Plan revised 11/28/23 documents R1 is at risk for falls and continues to self transfer even after being educated to call for assistance and includes an intervention dated 6/12/23 to offer to lay R1 down after meals. R1's November 2023 Medication Administration Record documents R1 receives Plavix (antiplatelet, blood thinning medication) 75 milligrams by mouth daily. The facility's Report to IDPH (Illinois Department of Public Health) Regional Office dated 11/29/23 documents R1 fell on [DATE] at 6:21 PM while attempting to self transfer from the wheelchair to the bed and R1's head hit the floor. R1 was found on the floor with a laceration and hematoma (bruising/swelling) to the right side of R1's head. R1 was transferred to the local emergency room and was diagnosed with a subdural hemorrhage (brain bleed). R1's Fall Investigation for 11/22/23 6:21 PM fall, provided by V2 Director of Nursing, documents V3 Licensed Practical Nurse's (LPN) incident description that R1 self propelled R1 to R1's room, attempted to self transfer into the low bed, and R1 fell to the floor hitting R1's head which caused a laceration and hematoma. V5 Certified Nursing Assistant (CNA) interview is the only documented interview as part of this investigation. V5's statement dated 11/22/23 documents V5 walked past R1's room and found R1 partway on the low bed and partway on the floor. R1's call light had not been activated, R1 was wearing nonskid socks, and R1's wheelchair lap cushion had been in place when V5 last saw R1 at 6:15 PM in the hallway. There is no documented interviews with staff to determine when staff last observed R1 prior to the fall, what R1 was doing at that time, if any staff had offered to lay R1 down after supper, or if R1 had requested to lay down prior to the fall. R1's Hospital Emergency Department Notes dated 11/22/23 at 6:58 PM, recorded by V6 Advanced Practice Registered Nurse, documents R1 presented to the emergency room for complaints of a fall and R1 hitting R1's head. This note documents R1 has a hematoma to the right scalp, R1 takes Plavix, and a head CT (computed tomography ) was ordered. R1's Head CT without Intravenous Contrast dated 11/22/23 at 7:17 PM documents the indication for this test was fall- on Plavix and there was a small left anterior frontal subdural hemorrhage with a depth of up to 7 millimeters. R1 was transferred to another hospital for further treatment. R1's Hospital Emergency Department Note dated 11/22/23 at 10:33 PM document R1 had an unwitnessed ground level fall with the following injuries - right frontal subdural hemorrhage, right scalp laceration, and hematoma. R1 was admitted with principal diagnoses of Trauma and Subdural Hemorrhage. On 12/11/23 at 10:37 AM R1 was next to the dining room sitting in a wheelchair. R1 had bruising to R1's right forehead. R1 stated R1 recalls falling recently and R1 was hurt bad. R1 was unable to recall any additional details of R1's fall. On 12/7/23 at 12:14 PM V7 LPN stated V7 was not assigned to R1's care the day R1 fell. V7 stated it was R1's norm to go back to R1's room and lie down after supper, R1 had not asked to lay down, and R1's call light was not on when R1 fell. V7 stated R1 doesn't always call for help and R1 is very impulsive with transfers. On 12/11/23 at 10:48 AM V3 LPN stated V3 last saw R1 in the dining room prior to R1's fall, R1 had finished eating and had made R1's way to R1's room. V3 stated that's (R1's) norm. V3 stated R1 did not mention that R1 wanted to lay down and V3 did not offer to lay R1 down after supper. V3 stated R1 does not have a routine bedtime. V3 stated R1 was found partway on the floor and partway on the bed with a bleeding head laceration. V3 stated V3 was unsure what R1 hit R1's head on as R1 has a lot of items in R1's room including totes and an overbed table. V3 stated R1 told V3 that R1 was trying to go to bed and attempted to self transfer from the wheelchair to the bed. V3 stated R1 usually tells staff when R1 wants to lay down. On 12/11/23 at 10:57 AM V5 CNA stated V5 was R1's assigned CNA on the evening of 11/22/23. V5 stated V5 did not witness R1's fall and V5 was walking past R1's room and found R1 with R1's upper body on the bed in low position and R1's legs on the floor. R1 had a bump and a bleeding cut to R1's right forehead. V5 stated V5 last saw R1 around 6:15 PM when V5 washed R1's face as R1 was leaving the dining room. V5 stated V5 did not recall if V5 offered to lay R1 down that day, after R1 was finished with supper. V5 stated R1 does not have a routine bed time and R1 attempts to self transfer at times. On 12/7/23 at 10:43 AM V2 Director of Nursing (DON) stated R1's fall investigation includes interviews that were conducted, and V3 LPN and V5 CNAs were the only staff interviewed as part of the investigation. On 12/11/23 at 12:17 PM V2 stated R1 doesn't like to stay put and we are unable to restrain R1. V2 stated V2 was told R1 removed R1's wheelchair lap cushion and attempted to self transfer for R1's fall on 11/22/23. V2 stated we try to keep R1 in the hallway to keep eyes on R1. V2 stated V1 Administrator, V2 and V8 Assistant DON conducted R1's fall investigation. V2 confirmed R1's head hematoma and laceration were injuries from R1's fall. V2 stated the root cause of the fall was R1's attempt to self transfer after removing the lap cushion. V2 stated V2 inquired with V1 for the post fall intervention, and was told the intervention was that R1 was sent to the emergency room. V2 confirmed staff interviews for R1's fall investigation do not document what R1 was last observed doing, if staff had offered to lay R1 down, or if R1 had requested to lay down prior to the fall. V2 stated V2 expects staff to follow the interventions listed on the resident's care plan. 2.) R3's MDS dated [DATE] documents R3 has short/long term memory loss and requires extensive assistance of two staff for transfers/ambulation. R3's cumulative diagnoses list documents R3 has Alzheimer's Disease and Severe Dementia with Agitation. R3 has impaired balance with standing/walking/transfers and requires staff assistance to stabilize balance. R3's Care Plan revised 9/21/23 documents R3 requires extensive assistance of two or more staff for transfers/walking. R3's Care Plan dated 10/14/22 documents R3 is at risk for falls related to gait/balance problems, history of falls, poor safety awareness, and wandering. This care plan includes interventions to follow up with hospice that R3 is still not resting during the night (11/28/23), review information on past falls to attempt to determine the cause and educate R3/family/caregivers/interdisciplinary team as to cause as needed. R3's Report to IDPH Regional Office dated 11/21/23 documents R3 was found lying on the floor of another unidentified resident room on 11/13/23. R3 had moderate bleeding from the back of R3's head, R3 was transferred to the emergency room and received staple closure of the laceration. This report documents R3's medications were reviewed by hospice and adjustments were made to ensure better sleep to avoid daytime exhaustion/weakness. R3's Fall Investigation, provided by V2, documents R3 had an unwitnessed fall on 11/13/23 at 10:15 AM. V10's (LPN) incident description documents a CNA (V11) reported that R3 was on the floor and V10 found R3 lying on the floor on R3's right side with a head laceration and blood noted on the floor near. R3 was not able to explain what happened. This investigation does not contain interviews with V11, V10, or any other staff to determine when R3 was last observed prior to the fall and what R3 was doing when R3 was last observed. R3's Hospital After Visit Summary dated 11/13/23 documents fall as R3's reason for hospital visit, R3 was diagnosed with a scalp laceration, and R3 required laceration repair. This summary documents to remove R3's staples in 7-10 days. R3's Nursing Note dated 11/13/2023 at 4:31 PM documents R3 returned from the emergency room with two staples to the back of R3's head. R3's Fall Investigation, provided by V2, documents R3 had an unwitnessed fall on 11/25/23 at 7:57 AM. V12 Registered Nurse (RN) incident description documents R3 was found lying on R3's right side in the common bathroom/shower room. R3 was unable to give a description of the fall. R3's Fall Follow Up Note dated 11/28/23 at 10:01 AM documents the interdisciplinary team reviewed R3's fall, R3 wandering the unit was the root cause, and a code lock for the shower room door was the intervention. There are no documented interviews conducted with staff in regards to this fall. This fall investigation does not identify the last time R3 was observed prior to R3's fall and what R3 was doing at that time. R3's Fall Investigation, provided by V2, documents R3 had an unwitnessed fall on 11/28/23 at 5:40 AM. V13 LPN incident description documents R3 was walking back and forth in the hallway, became unsteady, and fell. R3 was then assisted to R3's reclining geriatric chair. V14's (CNA) interview is the only documented interview in this investigation. V14's interview dated 11/28/23 documents V14 was assisting other residents with morning cares, R3 was wandering in the hallway, and many attempts were made to have R3 sit in a chair. This note documents R3 got R3's self up and began wandering the hallway, and as V14 left an unidentified resident room V14 found R3 lying on the floor. R3's Fall Follow up Note dated 11/28/23 at 10:17 AM documents the interdisciplinary team reviewed R3's fall, R3 was observed walking in the hallway after early morning medication pass, and R3 fell. This note documents the root cause as R3 fell in the hallway and the intervention was for hospice to review medications to ensure sleep at night and prevent drowsiness during the day. There is no documentation in R3's medical record that hospice reviewed R3's medications or that any new medication changes were made after R3's fall on 11/28/23. On 12/7/23 at 2:22 PM V11 CNA stated V11, V15, and V16 were the CNAs on R3's unit (on 11/21/23), V16 had went on break, leaving V11 and V15 on the unit. V11 stated V15 was in another resident's room. V11 stated V11 was in another resident's room when R9 came to report that R3 had fallen in R9's room. V11 stated V11 had just observed R3 walking in the hallway a few minutes prior to the fall, R3 was able to walk independently, staff did not have to provide walking assistance just monitor R3 and direct R3 out of other resident rooms. V11 stated V11 had to leave the hallway where R3 was walking, to assist another resident who was up by herself and was a high fall risk. On 12/11/23 at 10:19 AM V3 LPN stated R3 has not been a walker and one day R3 just got up and started walking. V3 stated R3 is very hard to re-direct when R3 is up walking so staff will walk with R3. On 12/11/23 at 12:17 PM V2 DON stated R3 ambulates/wanders constantly, R3 can get R3's self up, R3 needs staff assistance to safely transfer. V2 stated once R3 is up, R3 can ambulate on R3's own with visual supervision/monitoring of staff. V2 stated staff should redirect R3 out of other resident rooms. V2 stated R3 had an unwitnessed fall on 11/13/23, R3 was wandering, and R3 was found on the floor of another resident's room. V2 stated staff applied a towel to the back of R3's head to stop bleeding from the laceration that was believed to be caused by hitting the base of the bedside table. V2 stated V10 and V11 were interviewed, they were in the next room, and they heard R3 fall. V3 stated the root cause of the fall was R3's confusion and weakness due to lack of sleep. V2 confirmed the fall investigation does not document staff were interviewed to determined when R3 was last observed prior to the fall and what R3 was doing at that time. V2 stated R3 had an unwitnessed fall on 11/25/23 where R3 fell in the shower room and a code lock was then installed on the shower room door. V2 confirmed there are no documented staff interviews as part of this fall investigation to determine when R3 was last observed prior to the fall. V2 stated R3 had an unwitnessed fall in the hallway on 11/28/23. V2 stated V2 viewed video surveillance that showed the nurse V13 was administering medications while R3 was walking in the hallway, there were no other staff present in the hallway, V13 went into another resident room, and R3 just fell down. V2 confirmed the investigation documents the CNAs were in resident rooms providing care at the time of R3's fall. V2 stated R3 almost needs a buddy to walk with R3 at all times and during the mornings R3 just wants to walk. V2 stated the root cause of the fall was that R3 fell in the hallway and the intervention was a medication review by hospice requesting medication to help R3 sleep through the night. V2 stated Trazodone was ordered by hospice following R3's fall, and on 12/4/23 or 12/5/23 an unidentified hospice nurse reported the Trazodone order to V2. V2 stated hospice verbally gives orders to the floor nurses and V2 did not implement this order. V2 stated V2 thought hospice enters their own orders into the resident's electronic medical record. V2 confirmed R3's current orders do not include Trazodone. At 2:33 PM V2 stated V2 was unable to locate documentation of R3's Trazodone order and hospice visit note/medication review. V2 stated hospice provides a form after their visit that includes new orders, and V2 is awaiting a call back from hospice to request this documentation. 3.) R2's MDS dated [DATE] documents R2 is cognitively intact, R2 uses a walker and wheelchair, and R2 requires substantial/maximal assistance of staff for transfers. R2's Care Plan dated 10/25/22 documents an intervention with a revised date of 9/20/23 for extensive physical assistance of one staff person for transfers. R2's Fall Investigation, provided by V2, documents R2 fell on [DATE] at 12:00 PM while V9 CNA assisted R2 in transferring. R2 lost R2's balance and fell face first onto the floor. R2 stated R2 lost balance and fell forward. R2 had a small laceration under the left eye, bleeding bleeding skin tear to middle and fourth right finger knuckles, and bruising to the right middle finger. R2 was transferred to the emergency room for evaluation. This investigation documents interviews were conducted with V17 LPN and V9 CNA. V17's interview dated 11/29/23 documents V9 was transferring R2 and R2 was not wearing any footwear. V9's interview dated 11/29/23 documents V9 was transferring R2, R2 lost balance, R2 fell forward, and V9 was unable to stop R2 from falling. This interview does not document if R9 was wearing footwear. These interviews do not document whether a walker and gait belt were used for R2's transfer. The Fall Follow Up note dated 11/30/23 documents at 12:49 PM the interdisciplinary team reviewed R2's fall, R2 was not wearing appropriate footwear and the intervention was to apply nonskid socks for transfers. On 12/7/23 at 11:57 AM R2 was sitting in a wheelchair in R2's room. R2 had faded bruising below R2's left eye. R2 stated R2 fell about a week ago while V9 CNA transferred R2 from the wheelchair to the bed. R2 stated staff do not use a gait belt for R2's transfers and one was not used that day. R2 stated V9 applied nonskid socks prior to R2's transfer. R2 stated I think my leg just gave out and that has happened before. R2 stated R2 had hit R2's eye on the bottom of the overbed table during the fall and the whole right side of R2's head had turned purple/bruised. At 2:11 PM R2's wheeled walker was folded beside R2's dresser. On 12/7/23 at 12:06 PM V9 stated V9 had applied R2's gripper socks prior to R2's transfer on 11/29/23 and R2 got dizzy when R2 stood causing R2 to fall forward. V9 stated R2 tried to grab R2's incontinence brief during the fall, and a gait belt was not used during the transfer. V9 stated R2 hit R2's eye on either the overbed table or dresser, and R2 was transferred to the emergency room. V9 stated R2 had been in bed bad with COVID-19 for a few days prior to R2's fall. At 2:09 PM V9 stated a walker was not used during R2's transfer and R2 has never used a walker. On 12/7/23 at 2:01 PM V18 Physical Therapy Assistant stated R2 has been on therapy prior to R2's fall, R2 had COVID-19 about a week prior to R2's fall, and R2 transferred with a wheeled walker and standby/contact guard assist. V18 stated R2 has had balance issues. R2 has a history of R2's legs giving out, and R2 doesn't have good standing tolerance. V18 stated staff should be using a gait belt and R2's wheeled walker for R2's transfers. V18 stated the walker would have helped stabilize R2's upper body during the transfer. On 12/7/23 at 12:17 PM V2 DON stated R2 fell while transferring from the bed to wheelchair and R2 is a stand/pivot transfer. V2 stated V9 reported that R2 lost balance and fell forward during R2's transfer, the root cause was that R2 was not wearing nonskid socks during the transfer, and nonskid socks were provided as the intervention. V2 stated V2 just went by what the nurse had reported, that R2 did not have on nonskid socks. V2 confirmed V9's interview does not document if R2's footwear at the time of the fall and R2 was not interviewed about R2's footwear. V2 stated staff should use a gait belt for residents who require extensive assistance for transfers and ambulation. V2 stated V2 was not aware that a walker and gait belt was not used during R2's transfer. The facility's Fall Prevention Program revised May 2022 documents nursing personnel are responsible for ensuring the ongoing use of fall precautions, the interdisciplinary team reviews the falls to determine possible safety interventions, and the Director of Nursing/Designee is responsible for monitoring the Fall Prevention Program and providing further staff education. This policy documents fall interventions are documented on the resident's care plan, and fall interventions may include using assistive devices and transferring residents in accordance with their plan of care and monitor resident's gait for balance and fatigue. The facility's Transfers-Manual Gait Belt and Mechanical Lifts dated as revised August 2023 documents resident transfer needs are designated into categories including using a gait belt for a one person transfer that requires 25% or less assistance from the caregiver, and the use of a gait belt is mandatory in all physical assist transfers, and failure to comply with lifting guidelines may result in disciplinary action. This policy documents the resident's transfer needs are documented on the resident's care plan.

Based on interview and record review, the facility failed to notify a physician of a change in condition, failed to implement physician's orders timely and failed to document a thorough assessment for multiple days after a resident's fall, for one of three residents (R1) reviewed for falls on the sample of five. These failures resulted in R1's left leg/hip pain progressively worsening with R1's range of motion declining to the left leg and R1's decline in bed mobility, transfers and ambulation. These failures also caused a delay in repair of R1's left femoral/hip fracture. Findings include: The fall investigation for R1's fall on 2/15/23 at 4:45 AM documents a final report to the State Survey Agency dated 2/23/23 with a summary as follows: On 2/15/23 R1 was observed on the floor of R1's room per witness statement. R1 was assessed with no changes noted. Later assessment reveals increased signs and symptoms of pain and that V9 (R1's Physician) was notified with a new order received to get a STAT x-ray of the left hip and leg. This report states the portable in-house x-ray documented an Acute Non-displaced Left Intertrochanteric Femoral/Hip Fracture with mild varus angulation of the fracture site. V9 (Physician) was made aware of the results and R1 was sent to the emergency room and admitted to the hospital for surgical intervention to the left hip. R1's Progress Notes dated as follows document: 2/15/23 at 4:48am - R1 has a new skin concern, a Hematoma, located to R1's rear Left Iliac Crest. Monitor R1's Hematoma to the left iliac crest and R1 complains of pain. There is no documentation of a description/details of circumstances of R1's Fall on 2/15/23 in R1's Progress Notes. 2/15/23 at 7:54am - R1's follow up assessment post-fall. This note documents R1 is alert and oriented. No changes in Range of Motion (ROM), No pain. 2/16/23 at 4:36pm - R1 is alert and oriented, intermittent confusion, with rating pain 4/10 to R1's left hip. This note documents swelling observed at site. Reddish-purple bruising noted. There is no documentation V9 (R1's Physician) was notified of these observations. 2/17/23 at 8:22am - Follow up assessment of Hematoma. R1 is alert and disoriented per usual baseline. R1 having pain at a 3/10 on the pain scale and not of new onset. This note documents no changes in range of motion and that R1 has swelling and deep purple bruising to the site. 2/17/23 at 1:03pm - Follow up assessment post-fall. Follow-up assessment of Hematoma. This note documents new injury noted on assessment, Hematoma on left hip with pain 3/10 on the pain scale and that V9 (R1's Physician) notified of new pain onset. This note documents R1 also has a new onset of limitation in ROM. There is no documentation of the location of limitation of ROM or that V9 was notified of R1's limitation in ROM. This note documents swelling was observed with deep purple bruising noted. There are no Progress Notes from 2/17/23 at 1:03pm until 2/19/23 at 7:03am documenting at 9:00pm (on 2/18/23), an unidentified Certified Nursing Assistant (CNA) reported change in condition advising that R1 has been in bed unable to walk or move for three days. This note documents on assessment, R1 unable to perform baseline ROM, with 2+ edema noted to the left distal ankle with grimacing noted. This note also documents, Per (V9), stat X-ray processed. There is no documentation of when the facility's Mobile X-ray company was notified of the STAT X-ray order for R1. R1's Medication Administration Record dated February 2023 documents R1's administration of Acetaminophen 650mg by mouth twice daily scheduled with a pain level as follows: 2/15/23 evening/dinnertime 4/10 2/16/23 day/breakfast and evening/dinner time 0 2/17/23 day/breakfast 0 and evening/dinner time 2/10 2/18/23 day/breakfast and evening/dinner time both 3/10 2/19/23 day/breakfast NA (not applicable) and evening/dinnertime 4/10. This record also documents R1's pain on 2/17/23 at 8:47pm as pain rating of 10/10 and on 2/18/23 at 8:08pm as pain rating of 5/10 with Acetaminophen (Analgesic) 650mg administered. R1's Progress Notes dated as follows document: 2/19/23 at 1:07pm the facility's Mobile Radiology company arrived at 12:00pm and completed X-ray to R1's hip, leg and ankle. 2/19/23 1:09pm, R1 with increased pain in the left hip, waiting on X-ray results, called V9 about stronger pain medication. There is no documentation of a response, orders received from V9 or a follow-up with V9 related to the request for stronger pain medication for R1's increased left hip pain. 2/19/23 at 2:34pm, R1 skin concern bruising to the left trochanter (hip) with swelling and slight bruising. R1 complains of pain, has facial grimacing with complaints of pain in left hip with difficulty with changing positions. 2/19/23 at 2:51pm documents V2 (Director of Nursing/DON) notified of R1's X-ray results of fractured hip. 2/19/23 at 3:55pm, R1 sent to the local emergency room for evaluation and treatment due to left hip fracture. R1's Radiology Results Report dated 2/19/23 documents R1's Left Hip and Pelvis X-ray was performed on 2/19/23 at 12:31pm and reported date of 2/19/23 at 1:58pm. This report documents R1 has an Acute Non-displaced Left Intertrochanteric Femoral/Hip Fracture with mild varus angulation of the fracture site. R1's hospital History and Physical (H&P) dated 2/19/23 documents R1 with likely memory difficulty/undiagnosed Dementia, presented to the local emergency room for left hip pain and reportedly suffered from a fall 3 days ago, had X-rays done, notable for left hip fracture and (R1) was subsequently sent to ED (Emergency Department). This H&P documents R1 has a history of Alcohol Abuse and Peripheral Vascular Disease (PVD) and that R1 has been taking Enteric Coated Aspirin 81mg (milligrams) (Antiplatelet Agent), one tablet by mouth daily and Clopidogrel (Antiplatelet Agent) 75 mg, one tablet by mouth daily. This H&P also documents R1's physical assessment at the hospital including R1 had tenderness (left hip/groin) with left leg externally rotated and shortened. R1's H&P documents R1's results of X-rays of the pelvis and left femur performed at the hospital as a Comminuted Displaced Left Intertrochanteric Fracture. On 3/20/23 at 1:57pm, V12 (Certified Nursing Assistant/CNA) stated on 2/18/23, R1 was in quite a bit of pain and V12 told V14 (Licensed Practical Nurse/LPN) because V14 had come to the unit to check in. V12 (CNA) stated V13 (CNA) and V12 told V14 that something was wrong/different with R1. V12 stated R1 had stayed in bed all day, which is not normal for R1. V12 stated R1 is usually independent for transferring, ambulation and toileting. V12 stated earlier in the day on 2/18/23, V12 mentioned to V15 (LPN) that something was going on with R1 and that R1 was not R1's self. V12 stated it wasn't until V14 was notified of R1's pain and not getting out of bed that the facility got orders for testing. V12 stated R1 just progressively worsened until R1 was sent out on 2/19/23 after receiving the results from R1's X-ray that R1 had a hip fracture. V12 stated after R1's fall, V12 noticed someone had given R1 a urinal and R1 was using that instead of independently ambulating to use the restroom. V12 stated R1 having a urinal threw (V12) off because R1 had never used one before. R1 did not get out of bed on 2/18/23 during V12's shift. V12 stated R1 was in a lot of pain, making sounds and grimacing in pain when staff would assist R1 with bed mobility/cares. On 3/22/23 at 11:45am, V11 (R1's family) stated V11 was notified of R1's fall on 2/15/23 but was told (R1) was okay. V11 stated the facility did not notify V11 of R1's hematoma/bruising to the left hip nor that R1 was having pain. V11 stated the facility should have never let R1 sit in pain and with the swelling and bruising of R1's left hip area for over three days before getting an order to x-ray the hip. V11 stated the facility told V11 that R1 had been assessed when they initially reported the fall and V11 was not notified of the additional details of injury nor that an x-ray to assess the hip had not been done. V11 stated V11 assumed an X-ray would have been done to assess to make sure there were no injuries after the fall or at least with the signs of the injury to the left hip. V11 stated the facility should have identified there were problems/potential internal injuries and if they would have assessed R1 thoroughly, the facility would have found the fracture sooner and R1 would not have had to lay in bed in pain and declining. V11 stated V11 came to the facility on 2/19/23 and R1 could not get out of bed and was complaining of pain to the left hip area. V11 stated R1 has a history of drug abuse and does not want narcotics so many times does not notify the facility of pain unless R1 is asked. In the morning of 2/19/23, the facility called V11 to notify V11 that R1 was not getting out of bed and was concerned for injury, so the facility was going to obtain x-rays. On 3/23/23 at 1:34pm, V2 (DON) stated on 2/15/23 at 4:45am when R1 fell, V2 was the nurse on hall. R1 was found sitting on R1's buttocks with R1's right side against the wall by R1's closet. V2 stated at that time, R1 was not complaining of pain. The facility assisted R1 back into bed. R1 had no facial grimacing or signs of pain. When asked about R1's range of motion (ROM), V2 stated R1 was asked to pick leg up and out and could but this is not documented in R1's progress notes. V2 stated R1's skin to R1's thigh area was raised but not discolored, and R1 stated R1's left hip/thigh hurts when it is pushed on and stated ouch, but nothing indicating severe pain. V2 stated V2 would not have expected the facility to notify V9 (R1's Physician) of the new bruising because there was already injury so bruising would be expected. V2 stated the facility was not measuring the raised area or bruising and there is no documentation of measurements of the raised area or size of the bruising. V2 stated V2 would have assumed V15 (LPN) would have told V9 R1 had new findings of limitation of range of motion. V2 stated V2 expects an X-ray ordered STAT should be completed within 4 hours. V2 stated if there is a delay, the facility should call the physician and follow up for further orders if X-ray cannot get here timely to complete testing as ordered. The facility's Physician-Family Notification-Change in Condition policy dated November 2018 documents the purpose of the policy is to ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient and effective manner. This policy documents the facility will inform the resident, consult with the physician and if known, notify the residents legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention, a significant change in the resident's physical, mental or psychosocial status, or a need to alter a treatment significantly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete and document thorough investigations to determine root cause of falls and failed to maintain a wheelchair in safe condition for two of three residents (R1, R4) reviewed for falls on the sample of five. Failing to maintain R4's wheelchair resulted in R4 sustaining a puncture/laceration wound to the right thigh requiring six sutures when R4 fell onto an uncovered wheelchair hand break while attempting to self-transfer from the bed to the wheelchair. Findings include: The facility's Fall Prevention Program dated May 2022 documents the Fall Prevention Program includes methods to identify risk factors, methods to identify residents at risk for falls, assessment time frames, use and implementation of professional standards of practice, notification of physician, communication with direct care staff members, documentation requirements, care plan incorporates identification of fall risk, addresses each fall, and preventative measures. This policy documents a fall risk assessment will be performed on admission, quarterly and with each significant change in mental or functional status and after any fall incident. Accident/Incident reports involving falls will be reviewed by the Interdisciplinary team to ensure appropriate care and services were provided and determine possible safety interventions. The facility's Incident and Accidents policy dated May 2022 documents an incident/accident report is to be completed by a licensed nurse and is to include the date and time of the incident/accident, a full written statement and possible cause of incident, physical assessment, injuries noted, treatment rendered and notification of appropriate parties. Documentation in nurses' notes is to include a description of the occurrence, the extent of injury (if any), assessment of the resident including vital signs, treatment rendered and parties notified. Mental and physical state, follow-up, tests, procedures, and findings are to be documented. 1. R4's admission Record dated 3/23/23 documents R4's diagnoses including Laceration of muscle, Fascia and Tendon of the Posterior Muscle Group on Right Thigh, Repeated Falls, Cerebral Infarction, Alzheimer's Disease and Anxiety. R4's Minimum Data Set (MDS) dated [DATE] documents R4 requires extensive assistance of staff for bed mobility, transfers, dressing, and toilet use. This MDS documents R4 is not steady, only able to stabilize with staff assistance when moving from seated to standing position, moving on and off toilet and surface to surface transfer. R4's Care Plans with a revision date of 2/28/23 document R4 has alteration in urinary elimination as evidenced by urinary incontinence/stress incontinence. Interventions for this plan of care include toilet upon rising, before and after meals, in the evening and as needed. R4's Progress Notes dated as follows documents: 2/18/23 at 4:07am document R4 has a new skin concern of a puncture wound to the right rear thigh. This note documents R4 complains of pain from injury, the physician was notified and R4's care plan was reviewed. This note does not document how R4 got the laceration. 2/18/23 at 11:07am - attempt to notify emergency contact and unable to reach by phone. There is no documentation of reason for attempting to notify R4's emergency contact or who that contact is. 2/18/23 at 12:33pm - R4 continues on fall vitals. There is no documentation in R4's Progress Notes dated 2/1/23-2/18/23 documenting R4 had a recent fall. 2/18/23 at 4:56pm - R4 returned from the local hospital on 2/18/23 at 1:50pm. R4 has a laceration to the right inner thigh with 6 sutures measuring 7cm (centimeters) long. R4's dressing to the thigh was noted to have a moderate amount of bloody drainage and was changed as well as pressure applied to the wound. R4's hospital After Visit Summary (AVS) dated 2/18/23 documents R4's diagnoses including laceration of the right thigh and Hematoma. This AVS documents there are 6 sutures that were placed to the laceration and that there is a hematoma in the area of the wound. The facility's Final Report to the State Survey Agency dated 2/23/23 documents R4 was observed on the floor of R4's bedroom with a laceration to the right inner leg on 2/18/23 at 3:30am. This report documents R4 was seen in the emergency room and received 6 sutures to the right inner leg laceration. This report documents R4 returned to the facility on 2/18/23 from the hospital. The facility's investigation for R4's fall on 2/18/23 documents witness statements including V18 (Certified Nursing Assistant/CNA) stated V18 was on another hall when R4's call light came on. V18 stated V18 answered the call light and observed R4 and V19 (Licensed Practical Nurse/LPN) sitting on the ground with blood present, due to R4's leg being cut. This statement documents R4 said (R4) slipped and cut it on the brake. This typed statement documents there were no jagged edges to brake but does not document what time V18 responded to the call light being on. This investigation also documents V19's (LPN) statement. V19's typed statement documents R4 was last seen laying in R4's bed around 2:00am and R4 was wearing a pajama top and pull up brief. This statement documents V19 observed R4 on the floor laying on R4's back between the bed and the wheelchair with R4's knees up but does not document what time V19 observed/found R4. R4 stated R4 was trying to go to the bathroom and had forgotten to put R4's shoes on. R4 was not wearing shoes at the time of this fall. This investigation does not document when R4 was last toileted/offered toileting assistance. This investigation does not document how long R4's call light was sounding or the position of R4's wheelchair in relation to R4's position on the floor at the time of the fall. There is no documentation in this investigation if R4 had been incontinent at the time of the fall. On 3/23/23 at 1:34pm, V2 (Director of Nursing/DON) stated R4 fell onto R4's wheelchair and received a laceration to R4's right medial/posterior thigh. The facility reported the fall to V2 and told V2 that R4's wheelchair had gone into R4's leg, making a puncture wound. V2 stated V2 had the staff remove R4's wheelchair and replace R4's wheelchair with a different one after noticing R4's wheelchair brake did not have the silicone cover over the brake. V2 stated the facility looked at R4's wheelchair wheels and wheelchair brakes. R4's wheelchair was missing the handle cover for the brake that punctured R4's thigh. V2 stated R4 stated R4 was trying to go to the bathroom and fell. V2 stated V2 knows V19 (LPN) saw R4 last at 2:00am and R4 was asleep at that time. V2 was unsure of which CNA was assigned to care for R4 on 2/18/23 at the time of R4's fall. V2 stated V2 did not talk to anyone else/other staff regarding R4's fall or cares provided on 2/18/23 prior to R4's fall. V2 stated V2 did not ask staff about when R4 was last assisted with toileting. V2 stated R4 did not have shoes on and R4 stated R4 forgot to put them on. V2 stated V2 does not recall asking about where R4's shoes were at the time of R4's fall on 2/18/23. V2 stated the root cause of R4's fall on 2/18/23 was that R4 slipped trying to get out of bed to use the toilet because R4 did not have shoes on. V2 stated R4 tries to toilet (R4's) self frequently and has a history of falling due to that reason. 2. The facility's investigation documents R1 sustained an unwitnessed fall on 2/15/23 at 4:45am. This investigation documents a final report to the State Survey Agency. This final report documents a summary as follows: On 2/15/23 R1 was observed on the floor of R1's room per witness statement. R1 was assessed with no changes noted. Later assessment reveals increased signs and symptoms of pain and that V9 (R1's Physician) was notified with a new order received to get a STAT x-ray of the left hip and leg. Portable in-house x-ray revealed acute non-displaced left intertrochanteric femoral/hip fracture with mild varus angulation of the fracture site. This investigation does not document a statement from the Certified Nursing Assistant caring for R1 at the time of this fall. R1's Progress Notes dated as follows document: 2/15/23 at 4:48am - R1 has a new skin concern, a Hematoma, located to R1's rear Left Iliac Crest. Monitor R1's Hematoma to the left iliac crest and R1 complains of pain. There is no documentation of a description/details of circumstances of R1's Fall on 2/15/23 in R1's Progress Notes. R1's Incident Report dated 3/13/23 at 9:22am documents V10 (LPN) was called to R1's room where R1 was noted to be lying on the floor next to R1's bed. R1 had been using the trash can for a toilet and lost R1's balance and was on the floor. This report documents R1 did not have any injuries observed. R1 was sent to the local emergency department for evaluation. This report does not document R1's mental status at the time of this fall. There is no documentation in the investigation of fall prevention interventions that were in place at the time of this fall. Pre-disposing Physiological factors, decline in cognitive skills is marked, but no additional details documented. This report documents predisposing situation factors including behavior symptoms. This report documents no witnesses found. There is no documentation of interviews with staff who were responsible for R1's care/supervision on 3/13/23. On 3/23/23 at 1:34pm, V2 (DON) stated V2 could not remember who the CNA was taking care of R1 at the time of R1's fall on 2/15/23. V2 stated the only witness statement obtained was from V8 (CNA) although V8 was not working at the time of R1's fall on 2/15/23. V2 stated all interventions would have been in place at the time of R1's fall on 3/13/23, but V2 did not detail what the fall interventions were for R1. V2 stated family requested toileting after meals. V2 stated V2 did not interview the CNA responsible for caring for R1 on 3/13/23. V2 stated V2 reviews the nurses notes and counts that as the nurse's statement.

Based on observation, interview and record review the facility failed to prevent episodes of physical aggressive behaviors resulting in R1 kicking R2 and R2 subsequently hitting R1 in the face, R4 grabbing R1's arm, R9 shoving R11 and R6 pushing over a bedside table towards R5, hitting R5 in the face causing lacerations to R5's right side facial area, resulting in an emergency room visit due to right sided periorbital edema resulting in a closed fracture of the nasal bone. These failures affect seven of 14 residents (R1, R2, R4, R5, R6, R9 and R11) reviewed for abuse on the total sample list of 14. Findings include: The facility's Abuse policy, with a revision date of April 2022, documents, Guidelines: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes: verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 1. On 1/24/23 at 11:55 AM, V8 (Licensed Practical Nurse/LPN) stated, On 1/9/23 I was down on another hallway with V23 (Certified Nursing Assistant/CNA). V23 thought she heard some yelling. We listened and saw R6 in the hallway, who was yelling 'you better get down here and get this (explicit language)' and R6 headed back to room. We headed down the hallway and heard shouting. I walked into the room and R5 and R6 were arguing over the TV (television) being on. R5 was lying in bed, R6 stood up and pushed the bedside table into R5's face. I took R5 to the nurses' station, applied compression to nose as it was bleeding and strips to lacerations. The nurse on the next shift sent R5 to be checked out, because eye was swelling. R5's medical record documents on 1/9/2023 at 3:29 AM Incident Note by V8 (LPN) reports V8 heard yelling and cursing coming from the Hall; upon further investigation as I was walking to room, I got to the doorway, and I noticed R6 was standing over R5, cursing at R5 telling R5 to shut the television off. R6 pushed bedside table into the R5 at which time I ran and got in between both residents to separate. R5 was noted to have blood coming from R5's face. R5's medical record documents on 1/9/2023, Resident has a new skin concern. Type of skin concern: Laceration. Located to Face - right side of face - Laceration, Other (specify) - Right eye lid - Laceration. Treatments include Cleansed lacerations and steri strips applied. Resident complains of pain, aching. R5's medical record documents, 1/9/2023 at 4:22 PM, Resident sent out to Emergency Department for evaluation and possible treatment. The facility's abuse investigation files note On 1/9/23 at 6:15 PM V22 (Licensed Practical Nurse) notified V1 (Administrator), (R5's) eye was almost completely swollen shut and needs to be assessed. V22 sent R5 to the emergency room for evaluation. R5's emergency room After Visit Summary dated 1/9/23 documents, Reason for visit: Facial Pain, Facial Swelling. Diagnosis: Closed fracture of nasal bone. CT of facial bones without contrast: Clinical Impression: Blunt Facial Trauma. Findings: there is soft tissue swelling in the infraorbital, perinasal and peri-maxillary regions. There is an acute appearing fracture at the base of the right nasal bone with slight depression. Nasal septum is deviated to the right inferiorly. Impression: 1- Acute Right Base Nasal Bone Fracture. On 1/24/23 at 2:00 PM, R5 had a maroon/dark purple discoloration to R5's right cheek bone area. There was mild edema to the bridge of R5's nose on the right side. R5 stated, I was watching TV that night in my bed. R6 woke up and told me I needed to turn the TV off. I didn't even have the volume on, it was on mute. We started having words about it and R6 shoved the table into my face. On 1/25/23 at 1:30 PM R6 stated, It was around 2 AM; I woke up to the sound of the television on. I told R5 to shut it off. I got up and turned off the television, laid back down in bed, and R5 turned it back on again. I told R5 again to turn it off. R5 said something smart to me, and I said something smart back. I turned on the light and went down the hallway yelling for someone to come down to the room. I laid back down and R5 turned it on again, but this time had it muted. I stood up out of the bed again to go towards the television and at the same time R5 must have been starting to sit up in bed. I pushed the over the bed table that was towards the end of the bed over towards R5's side of the room and it hit R5 in the face. On 1/25/23 at 2:15 PM, V1 (Administrator) stated, R5 and R6 had just got placed in same room on Friday (1-6-23). That night (1-9-23) R5 was watching tv on mute, woke R6 up, R6 asked R5 to turn off the tv, R5 had the remote and R6 kept turning it off at the television. They had a verbal exchange. R5 stayed in bed, continued going back and forth, then V8 (LPN) heard raised voices. V8 saw R6 in the hallway, then R6 went back into room. V8 saw R6 push the tray table towards the other side of the room (R5's area); it hit R5 in right cheek area. R5 had lacerations and bruising to the face. Next day later in the day, R5 was sent out to ER. R5 had a Nasal Bone Fracture. The Facility's Abuse Investigation File documents, Initial report: 1/9/23. Conclusion and Action taken: R5 and R6 shared a room, R5 and R6 had a disagreement regarding the television. R6 voices R6 was getting up to go to the nurse's station and pushed that tray table away from him, inadvertantly pushed the tray table hitting R5 in the face. R5 was sent to the emergency department for evaluation and returned with a diagnosis of closed fracture of the nasal bone. 2. R1's medical record documents, 12/31/2022 at 2:45 PM, V22 (LPN) reported an alleged physical altercation between R1 and another resident. R2's medical record documents, 12/31/2022 at 2:46 PM, V22 (LPN) reported an alleged physical altercation between R2 and another resident. The Facility's Abuse investigation file documents, Initial report: 12/31/22, Conclusion and Action taken: Based on the results of the investigation, the facility has determined R1 and R2 were involved in a physical altercation. On 1/24/23 at 2:10 PM V5 (CNA) stated, On 12/31/22 I was sitting on the hallway with another resident. R2 was walking towards the door to look out the window, because that is what R2 does. R1 was coming back down the hallway. R2 said something; I could not make it out to R1. R1 turned around and kicked R2 in the back of the leg, and R2 then smacked R1 in the face. On 1/25/23 at 2:15 PM V1 (Administrator) confirmed, On 12/31/22 R1 kicked R2 in the leg and then R2 smacked R1. 3. R4's medical record documents, 1/5/2023 Incident Note: V7 (Activities Director) reported an allegation of a physical altercation between R4 and another resident. R1's medical record documents, 1/5/2023 Incident Note: V7 (Activities Director) reported an allegation of a physical altercation between R1 and another resident. The Facility's Abuse Investigation file documents, Initial report: 1/5/23. Conclusion and Action taken: Staff report R1 took (R4's) soda and R4 held (R1's) arms to get the soda back. On 1/25/23 at 9:10 AM, V6 (CNA) stated, I was in the hallway, and I heard R4 say 'give that back you (explicit language).' R4 had a hold of R1's upper arm, trying to reach in and grab soda R1 had under R1's arm pit area. I got to them, and I told R4 I would get it. R4 stepped away. On 1/25/23 at 2:15 PM V1 (Administrator) stated, R1 went into R4's room and took R4's soda. R4 came out to hallway and tried to get soda back from R1. Staff didn't get to R1 soon enough and saw R4 reaching and grabbing R1's arm to get the soda back from R1. 4. R9's medical record documents, 1/17/23 Behavior, resident to resident altercation noted. R11's medical record documents, 1/17/23 V21 (LPN) reported an allegation of a physical altercation between R11 and another resident. The Facility's Abuse Investigation file documents, Initial Report: 1/17/23. Conclusion and Action taken: R9 and R14 share a room. R11 entered (R9 and R14's) room. R11 approached R14's bed and sat in R14's wheelchair. R9 called for assistance. R9 pushed R11 to the hall while R11 was sitting in R14's wheelchair. On 1/25/23 at 9:30 AM, V26 (CNA) stated, On 1/17/23 I had just came on shift, and I saw a call light on to R9's room. Then I heard yelling 'get this (explicit language) out of here.' I got down to the room. R11 was in R9's doorway. R9 tried to push R11 in the wheelchair out of the room and it didn't go out all the way. Then R9 pushed on R11's shoulders to get R11 and the wheelchair out of R9's room. On 1/25/23 at 2:15 PM, V1 (Administrator) stated, R11 had only been here a few days. R11 was a little more confused than when here for a prior stay. R9 and R14 were roommates. R14 said R11 had come in room. R11 had tried to sit on R14's bed. R14 told R11 that R11 wasn't supposed to be in there. R14 turned on the call light. R11sat in R14's wheelchair beside the bed. R14 yelled for help. R9 then went around to R14's side of the room and pushed R11 in R14's wheelchair out of the room. The CNA said she saw R9 push on R11's shoulders to get R11 out of the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficiency requires two deficient practice statements. A. Based on interview and record review the facility failed to obtain physician ordered laboratory values, failed to report critical level laboratory values to Physician and failed to report a change in condition timely to Physician for one (R2) resident out of three residents reviewed for change of condition on the sample of 17. These failures resulted in R2 experiencing poor fluid intake, delayed medical testing, experiencing critical labs then subsequently being hospitalized with lower leg cellulitis and pneumonia. B. Based on observation, interview and record review the facility failed to provide timely pain medication for a resident by not maintaining supply of R4's prescribed narcotic pain medication. This failure affects one (R4) resident out of three residents reviewed for change of condition on the sample of 17. R4 experienced severe unrelieved pain causing R4 to call for emergency services. Findings include: A. R2's Medical diagnoses include Right Lower Extremity (RLE) Cellulitis, Aspiration Pneumonia, Right Lower Leg (RLL) Deep Vein Thrombosis (DVT), COVID-19, Acute Lower Respiratory Infection, Cognitive Communication Deficit, Down Syndrome, Chronic Obstructive Pulmonary Disease (COPD), Morbid Obesity due to excess calories, Dysphagia and Difficulty Walking. R2's Minimum Data Set (MDS) dated [DATE] documents R2 was moderately cognitively impaired. This same MDS documents R2 required extensive assistance of one person for bed mobility, dressing, eating, extensive assistance of two people for transfers and total assistance of one person for toileting and personal hygiene. R2's Physician Order Sheet (POS) dated November 1-30, 2022 documents a physician order dated 11/23/22 of Please monitor over next 24 hours and encourage oral fluids at meals. If no improvement in oral fluid intake or increase in urinary output, please send to emergency department (ED) for further evaluation/treatment. This same POS documents a physician order dated 11/22/22 to obtain Complete Blood Count (CBC) with Differential (diff), Comprehensive Metabolic Panel (CMP) or D-Dimer on 11/22/22. One time only. This same POS does not document a physician order for lab work on 11/29/22. R2's Documentation Survey Report dated November 1-30, 2022 documents intakes of: -11/23/22 R2 refused all food and fluids for breakfast, refused all food and drank 50 milliliters (ml) for lunch and refused all food and drank 480 ml for supper. -11/24/22 R2 refused all food and fluids for breakfast and lunch and refused all food for supper and drank 760 ml fluids. -11/25/22 R2 refused all food and fluids for breakfast and lunch and there were no entries documented for supper meal. -11/26/22 R2 refused all food and fluids for breakfast, there were no entries for lunch meal and refused all food and drank 120 ml for supper meal. R2's Electronic Medical Record (EMR) does not document notification to (V20) physician of intakes from 11/23/22-11/26/22. R2's Physician Order Sheet (POS) dated December 1-31, 2022 documents a physician order dated 12/2/22 of Please get labs as previously ordered stat. CBC with diff, CMP, D-dimer STAT. R2's EMR documents R2's weight as 148.5 pounds (lbs) on 11/2/22 and 139.0 lbs on 12/2/22. R2's Electronic Medical Record (EMR) does not document laboratory results for physician ordered Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP) or D-Dimer for 11/22/22 or 11/29/22. R2's Electronic Medical Record (EMR) documents the same labs were ordered STAT (immediately) on 12/2/22. R2's laboratory requisition dated 12/2/22 documents can't get as results of labs not obtained. R2's Laboratory Report dated specimen was obtained on 12/5/22. This same report documents R2's Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP) and D-Dimer results as follows: White Blood Cell (WBC) count result of 25.56 (high) with reference range of 4.0-12.0 10(3) cubic milliliter (mcL) of blood. D-Dimer result as >=20.00 (high) with a reference range of 0.50 micrograms (mg)/milliliter (ml) Fibrinogen Equivalent Unit (FEU). Nurse Progress Notes document: -11/26/22 at 2:45 pm documents Impaired balance noted. Weakness noted. Decreased sensation noted. (R2) has shortness of breath with exertion. (R2) has shortness of breath or difficulty breathing when lying flat. -11/27/22 at 6:45 AM documents (R2) has evidence of an acute change in mental status from (R2's) baseline noted. Decreased sensation noted. -11/29/22 at 3:05 PM V8 (Nurse Practitioner/NP) documents NEXT LABS PENDING: Will reorder missing labs for 12/2/22 - CBC, CMP, D-dimer. -11/30/22 at 6:40 AM documents (R2) has shortness of breath with exertion. (R2) has shortness of breath or difficulty breathing when sitting or at rest. Shortness of breath or difficulty breathing when lying flat. (R2's) Lung sounds diminished. -12/1/22 at 11:07 AM documents (R2) has shortness of breath with exertion. (R2) has shortness of breath or difficulty breathing when lying flat. -12/2/22 at 9:05 AM document (R2) has shortness of breath with exertion. (R2) has shortness of breath or difficulty breathing when lying flat. -12/3/22 at 9:05 AM documents (R2) has shortness of breath with exertion. (R2) has shortness of breath or difficulty breathing when lying flat. (R2) lung sounds diminished. -12/4/22 at 9:05 AM documents (R2) has shortness of breath with exertion. (R2) has shortness of breath or difficulty breathing when lying flat. (R2) lung sounds diminished R2's Hospital Laboratory Report documents R2's 12/5/22 D-Dimer results were called, results acknowledged and read back. R2's EMR does not document receipt of abnormal lab values on 12/5/22 or 12/6/22. R2's Nurse Progress Note dated 12/7/22 at 1:45 PM documents Resident noted to have a WBC of 25.56. (V8) NP ordered resident out to emergency room (ER) for evaluation. R2's Nurse Progress Note dated 12/7/22 at 2:04 PM (V8) NP documents New Right Leg redness, swelling, post COVID-19. Onset-acute, first noticed one to two days ago, location Right Lower Extremity (RLE). (R2's) EMR shows nine pound weight loss within one month. Right Lower Leg edematous, erythematous, non-tender. Assessment/Plan: RLE redness, swelling; Leukocytosis, abnormal weight loss, send to emergency room for further evaluation to rule out Deep Vein Thrombosis (DVT), Leukocytosis. R2's hospital records dated 12/7/22 document admitting diagnoses as Right Lower Extremity (RLE) Cellulitis and Aspiration Pneumonia. R2's Ultrasound Right Duplex Lower Extremity Veins Result dated 12/8/22 documents Impression: Deep Vein Thrombosis (DVT) in the visualized Common Femoral, Femoral, Popliteal, Posterior Tibial and Peroneal Veins. R2's Chest X-Ray Report dated 12/7/22 documents Impression: Patchy opacity suspected at Left Lung base. R2's Ambulance Report dated 12/7/22 documents Staff wanted (R2) evaluated in emergency room due to elevated [NAME] Blood Cell (WBC) count. Assessment revealed with vitals as documented with (R2) having redness in Right Lower Leg. On 1/5/23 at 10:35 AM V2 (Director of Nursing/DON) stated the laboratory levels were never drawn on 11/22/22 or on 11/29/22. V2 stated the physician should have been notified but was not. The laboratory technician did come to facility on 12/2/22 but was unable to get blood collected due to R2 was not compliant. V2 stated the labs were finally obtained on 12/5/22 and physician was notified of the results on 12/7/22. V2 stated R2 was sent to the hospital on [DATE] for a decline in condition. On 1/6/23 at 11:00 AM V8 (previous NP) stated (R2) had a productive cough with thick green mucous and generally did not look like he felt well. V8 stated (R2) was not eating or drinking very well so on 11/23/22 I ordered the staff to monitor (R2's) fluid intake for 24 hours and send to the emergency room if not any better. They (staff) did not notify me of any changes in (R2's) condition including poor fluid intake, or I would have sent (R2) into the emergency room that day (11/24/22). V8 stated attempted to review the labs that were ordered on 11/22/22 but the labs had not been completed. V8 stated No one could tell me why the labs I ordered on 11/22/22 were not completed, but I was told that they would be completed and I would be notified of any abnormal values. I ordered the D-Dimer to rule out a possible Deep Vein Thrombosis (DVT) due to many patients I have seen with COVID-19 end up with DVTs. I saw (R2) again on 11/29/22 and realized then that the labs had not yet been drawn. I re-ordered them on 11/29/22. On 12/2/22 I ordered the labs to be drawn STAT due to the facility still had not obtained the labs that originally ordered on 11/22/22. (R2) refused to have blood drawn on 12/2/22 so I reordered them again for 12/5/22. On 12/7/22 I was able to review the lab results and saw that (R2) had a D-Dimer over 20 which is a critical level, and also the highest I have ever seen. (R2's) [NAME] Blood Cell (WBC) count was also at a critical level so at that point I gave the order to send (R2) to the emergency room. No one from the facility notified me of (R2's) critical lab values. On 1/6/23 at 2:15 PM V21 (Laboratory (lab) Resolution Specialist) stated R2's CBC with Differential, CMP and D-Dimer were collected, received and processed on 12/5/22. V21 stated it is the policy of the laboratory to call the critical laboratory values to the facility as soon as they are realized by the lab. V21 stated We (lab staff) called the abnormal values, especially the critical lab values such as in (R2's) case as soon as possible on 12/5/22. We (lab staff) call the lab values directly to the facility and ask for the nurse in charge of that patient. From there, I do not know what happens, but we (lab) call the labs to the patient's nurse, not the Physician. On 1/6/23 at 1:00 PM V20 (Medical Director) stated resident laboratory values should be reported to Nurse Practitioner (NP) or Physician (MD) when they are received. V20 stated critical labs should always be reported immediately. V20 stated In this case (R2) was hospitalized for something we could have treated more aggressively in the facility initially or have sent (R2) to the emergency room if applicable, but because the lab work was not done and then not reported (R2) subsequently ended up in the hospital. V20 stated V20 was made aware of R2's abnormal lab values on 1/6/23. The facility policy titled 'Physician Notification of Laboratory/Radiology/Diagnostic Results' revised November 2019 documents the following: Purpose: To assure physician ordered diagnostic tests are performed, and to assure test results are reported to the physician, so that prompt appropriate action may be taken if indicated for the resident's care. A requisition is to be completed and lab to be drawn on the next scheduled lab day unless STAT is ordered. A nurse is responsible for monitoring the receipt of test results. Test results should be reported to the physician or other practitioner who ordered them. All critical lab values unless other parameters are ordered by physician: [NAME] Blood Cell greater than 12000. The licensed nurse is responsible for documenting the results in the clinical record. B. R4's undated Face Sheet documents medical diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Dysphagia, Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypercapnia, Chronic Pain Syndrome, Dilated Cardiomyopathy, Congestive Heart Failure and Spondylosis Without Myopathy of Lumbar Region. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact. This same MDS documents R4 as requiring extensive assistance of two people for bed mobility, dressing, toileting, personal hygiene and total dependence of two people for transfers. R4's Physician Order Sheet (POS) dated January 1-31, 2023 documents a physician order for Hydrocodone-Acetaminophen (Norco) 10-325 mg one tablet every four hours as needed for pain starting 12/6/22 and Norco 5-325 mg two tablets every four hours as needed for back pain starting 1/2/23. R4's Medication Administration Record (MAR) dated January 1-31, 2023 documents Norco 10-325 mg was administered on 1/1/23 at 4:23 AM, 1/1/23 at 2:10 PM and 1/1/23 at 10:40 PM. This same MAR documents Norco 5-325 mg was administered on 1/2/23 at 2:31 PM. On 1/3/23 at 11:00 AM surveyor observed R4 laying in bed with tears in eyes. R4 stated They (facility) let me go hours without my pain medication. I had to just lay here in bed for hours in pain. I was crying it hurt so bad. I asked to go to the emergency room and was told I had to wait because they (staff) were trying to get my pain medication. I got tired of waiting in pain so I sent myself to the emergency room [DATE]) for pain because they (facility) would not send me. The emergency room gave me some pain medication and a new prescription, but the facility still did not give me any until later that day (1/2/23). On 1/3/23 at 1:30 PM V2 (Director of Nurses/DON) stated R4 is an established patient at the local pain clinic. V2 stated R4 does have back pain and that is why R4 sees the pain clinic. V2 stated R4 can be 'very demanding' and have 'unreasonable expectations' of staff. V2 stated the pain clinic will send a prescription electronically (e-scribe) to the facility, the facility enters the order and then the pharmacy will send the new prescription. V2 stated In the case of (R4), the pain clinic never sent the prescription. We (facility) should have followed up with that but did not. That is when we (facility) called the pain clinic and were told that they (pain clinic) never sent the prescription to our facility. So, that is why the pharmacy never sent any more Norco for (R4). (R4) asked me if we (facility) could send (R4) to the emergency room and I told him 'you have the right to go to the emergency room but we (facility) are working on getting you more pain medication. You just have to be patient.' I did not call 911 for (R4). (R4) could not wait for us (staff) to get his pain medication figured out so he called 911 himself. The hospital gave (R4) some pain medication and a new prescription for Norco 5-325 mg two tablets every four hours as needed. (R4) may have went a total of 8 or 10 hours without any pain medication. I did not know until today that the pain clinic sent (R4's) Norco prescription to a local chain pharmacy. On 1/3/23 at 2:45 PM V12 (Pain Clinic Nurse Practitioner/NP) stated R4 is an established patient at local pain clinic. V12 stated R4 was given a computer tablet to enter any updated information on when R4 arrived at pain clinic appointment on 12/9/22. V12 stated R4 is alert and oriented and independently chose an outside pharmacy so that is where the Norco prescription was sent. V12 (NP) stated The facility got (R4) to the appointment and we (pain clinic) got (R4) the medication needed. The facility should have asked (R4) about any new orders or called the pain clinic to inquire. I personally tried to call the facility multiple times because I knew (R4) lived in a long-term care setting and most of those use their own pharmacies. I could not get anyone to respond so we (pain clinic) sent the prescription to the local chain pharmacy that was listed in (R4's) chart. On 1/4/23 at 10:05 AM V10 (Licensed Practical Nurse/LPN) stated January 2, 2023 was the day we realized (R4) did not have any more Hydrocodone-Acetaminophen 10-325 milligrams (mg). I began calling the pharmacy. When I called the pharmacy, they said the order had been discontinued and would not be filled until a new prescription was obtained. So, that is when I called the pain clinic. I could not get ahold of them right away so (R4) decided to send himself to the hospital to get a new prescription. (R4) did not want to wait on us (facility). The facility policy titled 'Physician Orders-Entering and Processing' revised January 2018 documents the following: Purpose: To provide general guidelines when receiving, entering and confirming physician or prescriber's orders (a prescriber is noted as a physician, nurse practitioner, and a physician's assistant). Following a physician visit, a licensed nurse will check for any orders that require confirmation. The orders will be confirmed by the nurse and the instructions for the order will be completed.

Based on interview and record review, the facility failed to protect a resident by failing to prevent further abuse for one of three residents (R3) reviewed for abuse allegations on the sample of seven. The facility failed to remove staff who were observed physically restraining a resident by the hands/arms to prevent the resident from stopping staff from performing COVID testing which R3 had refused. This failure resulted in the staff continuing to work at the facility for the rest of their shift, coming in to contact with R3 a second time, causing a reaction by R3 with aggressive physical behaviors toward the staff resulting in R3 sustaining a laceration to R3's right hand forefinger. Findings include: The facility's Final Abuse Investigation Report dated 11/30/22 documents R3's diagnoses including Hemiplegia, Hemiparesis, Cognitive Communication Deficit and Vascular Dementia. On 11/22/22 at 7:55am, R3 reported V4, V5 and V6, CNA's and V7, Activity Director for physical abuse. R3 was assessed and noted to have an alteration in skin integrity to the right finger. R3 reported V4 and V5, CNA's were physically aggressive when performing COVID testing. R3 reported staff held R3's arms and tested R3. R3 also reported later that night, V4, CNA came in and took R3's white board from R3. When R3 took the whiteboard back it resulted in an alteration in skin integrity to R3's right finger. The investigation report documents V7 stated R3 refused testing and later approached R3 again with V5, CNA. V7 stated R3 was attempting to throw the remote control at staff, jerking/tossing R3's communication board and pushing the intravenous pole toward staff. V7 stated V7 and V5 attempted to hold R3's hands to keep him from hitting staff. The investigation documents R3 reported V4, V5 and V7 held R3's arms and made R3 take the COVID test. There is no documentation of the staff participating in/observing the physical restraint of R3 being immediately suspended. The Time Card Reports for the following staff document these staff involved in the physical restraint of R3 were not immediately suspended and allowed to work until the end of their shift on 11/21/22: V4, CNA worked from 1:58pm to 10:23pm V5, CNA worked from 2:03pm to 10:24pm V6, CNA worked from 1:51pm to 10:19pm On 12/19/22 at 2:00pm, V1, Administrator stated V4, V5 and V6 should have been sent home and would have if V1 was aware. V1 stated V4, V5, and V6 did not recognize the incidents as abuse so V1 was not notified and V4, V5 and V6 were not sent home/suspended until 11/22/22 after V1 spoke with R3. The facility's Abuse Policy dated April 2022 documents the resident has the right to be free from abuse including physical restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete post fall investigations to determine a root cause and failed to implement post fall interventions to prevent further falls. These failures affect three of three residents (R2, R5, R6) reviewed for falls on the sample of seven. These failures contributed to R5 going without a post-seizure/post fall neurology follow-up appointment for a month. R5 was found on the floor again exhibiting seizure like activity and sustaining a second head injury with laceration requiring sutures and being hospitalized and started on Anti-seizure medication. Findings include: 1. R5's Progress Notes dated as follows document: 10/8/22 at 2:59am, Certified Nursing Assistant (CNA) (unidentified) called for assistance to R5's room. 1st responding nurse (unidentified) observed R5 lying face down. R5 was placed on R5's side noted snoring with jerking movements. There was evidence of bleeding noted on the floor but unable to observe where it was coming from. R5 was transferred out to the local emergency room for evaluation. 10/8/22 at 12:42pm, R5 returned from the hospital via ambulance at 1240pm. No new medication orders. Discharge instructions say to follow-up with primary Dr. and Neurologist. There is no documentation of a follow-up appointment with V22, Neurologist. R5's emergency room After Visit Summary (AVS) dated 10/8/22 documents R5 was seen for Seizures and an unwitnessed fall. This AVS documents R5 is to follow up with V22, Neurologist in 2 days. There is no documentation R5 was scheduled for the neurologist follow-up or that R5 followed up with V22 as per physician's orders upon discharge from the emergency room on [DATE]. The facility's October 2022 Fall Log does not document R5's fall on 10/8/22. The facility did not provide a fall investigation for R5's fall on 10/8/22. R5's Progress Notes dated as follows document: 10/10/22 at 7:15pm, R5 was seen on 10/8/22 after being found on floor lying face down and making jerking movements. R5's work-up was negative for acute pathology. R5's diagnosis was Seizure. (R5) is to follow-up with Neurologist. ASSESSMENT/PLAN: Seizure, ground level fall- Neurology consult. Continue facility fall precautions. R5's Fall Investigation documents an initial report documenting on 11/10/22 at 3:15pm, R5 was observed on the floor of R5's room displaying seizure like activity. R5 was found to have a laceration to the forehead and was sent to the emergency room. This sheet documents R5's hospital diagnosis of soft tissue contusion of the right forehead with a superficial laceration of the supra orbital ridge requiring sutures. This fall investigation is incomplete. There is no documentation of which Certified Nursing Assistant (CNA) was assigned to care for R5 at the time of the fall or when or where R5 was last observed. R5's Progress Notes dated as below document: 11/9/22 9:20am, History of fall with seizure. R5 was seen at the local hospital on [DATE] after being found on floor lying face down and making jerking movements. R5 is to follow-up with Neurologist. To date (R5) has not yet been seen by neurology. R5 has had no additional falls or suspected seizure activity. ASSESSMENT/PLAN: Seizures -New onset -Neurology consult pending. 11/10/22 at 3:15pm, R5 found lying on R5's right side on the floor in R5's room next to R5's bed. R5's head was towards the bathroom and legs towards wall. An unidentified nurse stated R5 was exhibiting seizure activity. Laceration was noted to R5's right eyebrow and pressure was applied to stop the bleeding. Resident was initially not responding to unidentified nurse. R5 was sent to the emergency room. 11/10/22 at 6:21pm, Call placed to the hospital and was notified sutures were placed to R5's laceration. R5 is being admitted to hospital due to seizure like activity and is to see neurology. 11/11/22 at 1:32pm, R5 readmitted to the facility from the hospital. 11/15/22 at 2:22pm, R5 was hospitalized [DATE]-[DATE], for seizure (convulsive epilepsy), initially presenting after fall with head injury while at the facility. Hospital stay complications include lactic acidosis 2/2 seizure, right eyebrow laceration from falling . R5 was started on Keppra (Anti-seizure) 500 mg (milligrams) twice daily. ASSESSMENT/PLAN: Seizures -Chronic. Apparently, R5 has had convulsive epilepsy since 5/18/2011 per hospital records, now on Levetiracetam which facility will continue. Will have nursing make follow-up appointment with Neurology that R5 seen in hospital (V22). Ground Level Fall with head injury, 2/2 convulsions and eyebrow laceration with sutures. There is no documentation in R5's medical records of attempts to make an appointment for R5 to see V22, Neurologist for a week until 11/17/22. 11/17/22 at 8:49am, Facility has reached out to V22's Neurology Doctors office multiple times, and sent a referral for a new (unidentified) doctor to look at. Waiting for a response from R5's doctor's office. 11/18/22 9:13pm, Followed up with V22's office today, 11/18/2022 and they've asked to re-fax it to another fax machine due to it having lines through the fax they received and not being able to read it due to a receiving issue on their end. There is no documentation of facility follow up or appointment after 11/18/22 at 9:13pm in R5's Progress Notes until 12/6/22 at 1:32pm. On 12/19/22 at 2:00pm, V2, Director of Nursing (DON) stated V2 thinks R5 was admitted for the seizure like activity not the fall or laceration on 11/10/22. V2 stated V2 would have been made aware of a fall for R5 if there would have been one on 10/8/22. V2 stated V2 was aware of R5's seizure on 10/8/22 but was not aware R5 was found on the floor and that a fall investigation was not completed for 10/8/22. V2 stated V2 believed the facility attempted to schedule an appointment with Neurology for R5 October 8th or later, but V2 does not make the appointments so V2 was unsure. V2 stated attempts to make an appointment and appointments that are scheduled would be documented in the progress notes. V2 stated V2 did not see documentation of an attempt to schedule an appointment or that an appointment had been scheduled for R5 with a Neurologist between 10/8/22 and 11/17/22. V2 was unsure of which staff were taking care of R5 on 11/10/22 at 3:15pm. R5 usually walks up and down halls all hours of the day so staff may not have known where R5 was just before the fall. 2. The facility's Fall Investigation documents a report dated 11/12/22 at 4:10pm documenting a 2nd shift CNA (unidentified) reported R2 was on the floor to V19, Licensed Practical Nurse (LPN). R2 was sitting up against the side of R2's bed. R2 told V19 that R2 was trying to get up to use the bathroom. R2 had a hematoma with blood to the back of R2's head. R2 was sent to the hospital for a head injury. R2 was educated on the use of R2's call light to transfer with assistance. This investigation does not document a completed/final investigation report. There is no documentation of interviews with additional staff who were working at the time of R2's fall. This investigation does not document when R2 had last been observed, what R2 was observed doing prior to R2's fall or when R2 had last been offered assistance with toileting. This investigation also documents R2 has a gait imbalance, depression, forgets to use call light and needed to go to the bathroom. This investigation is incomplete and does not document when and where R2 was last observed or when R2 had last been toileted. There is no documentation of interviews with additional staff working with R2 at the facility during this fall. There is no documentation of a root cause of R2's fall on 11/12/22 in this investigation. R2's Progress Notes document: R2's Fall Investigation report dated 11/13/22 documents V19, LPN was informed by an unidentified CNA that R2 had fallen from R2's bed to the floor on R2's knees trying to transfer R2's self in to R2's wheelchair on 11/13/22 at 10:00am. This report documents R2 stated R2 tried to get up. This report documents R2 was not having pain and non-skid socks were placed on R2 and put her on 1:1 for the day to prevent any future falls/injuries. This report documents fracture before fall and predisposing factors including recent change in cognition, improper footwear and increased agitation. This report documents R2 is non-compliant with using the call light/asking for help when transferring. There is no documentation of a witness statement from the CNA (unidentified) who found R2. There is no documentation of when R2 was last offered to be toileted or seen or where R2 was last observed. There is no documentation as to if R2's call light was within reach. There is no documentation of a root cause of this fall. R2's Progress Notes document: 11/14/2022 11:59am Fall Follow Up, IDT note: IDT team met regarding recent falls. On 11/12 resident fell transferring herself to the bathroom but does not document when R2 was last toileted or last observed. Intervention will be to re-educate to use the call light for assistance to the bathroom. On 11/13/22, R2 fell again transferring from the bed to the wheelchair. There is no documentation of why R2 was trying to get up when R2 transferred R2's self on 11/13/22. 11/14/22 at 5:05pm, R2's Knee immobilizer to the right lower extremity with weight bearing as tolerated for closed fracture of right fibula. R2 reports some continued discomfort in right leg starting from the knee down. R2 is currently in wheelchair and is weight bearing as tolerated (WBAT). R2's Fall investigation report documents R2 had a fall on 11/15/22 at 1:20pm. This report documents V13, LPN was called to R2's room by an unidentified CNA stating R2 had fallen. R2 was observed laying on R2's right side near the dresser/closet. R2 stated R2 hit R2's head. R2's immobilizer to the right lower extremity was in place. R2's wheelchair was near the window. R2 stated R2 was leaning over the chair and fell, hitting R2's head on the dresser. R2 then stated R2 hit R2's head on the floor. There is no documentation as to why R2 was leaning over the chair. This report documents sutures intact to laceration on posterior head from previous incident. Floor mat placed next to R2's bed. Re-educated to use call light for staff assistance. This report documents R2 has poor safety awareness and exhibits balance and impulsive behavior impairments. This report documents R2 forgets to use the call light and fracture before the fall and R2 requires frequent reminders to sit upright in the wheelchair. This report documents V23, CNA stated V23 had been in R2's room a few minutes prior to the fall but does not document why V23 was in R2's room nor when R2 was last offered/provided with toileting. V23 stated V23 was alerted by another resident (unidentified) that R2 was on the floor. There is no documentation of a root cause of R2's fall on 11/15/22. R2's Progress Notes document: 11/17/2022 11:28 Fall Follow Up: It was discussed with R2, R2's disbelief in requesting assistance of staff for transfers. R2 stated R2 wishes to continue as much independence as possible. R2 was informed that there were high risks to this decision including severe head trauma, increased risk for another fracture, and possible death. R2 verbalized understanding and continues to state R2's wishes. This note documents R2 is cognitively intact. There is no documentation of the facility's attempts to provide preventative oversight to check on R2 regarding toileting, etc. 12/6/2022 11:10am Appointment note, Facility has tried to schedule hospital follow up, will continue to call and try and schedule. There is no documentation of previous attempts to attempt to schedule hospital follow-up or with which physician this progress note refers to. On 12/19/22 at 2:00pm, V2 stated V2 is unsure of the unidentified staff for R2's fall investigations. V2 stated V2 was unsure of why R2 was leaning over R2's chair. V2 stated V2 was unsure of toileting offering for R2. 3. R6's Fall Investigation Report documents R6 had a fall on 11/22/22 at 9:00pm. This report documents R6 was found lying on the floor on R6's left side. At this time R6 stated R6 slipped out of R6's bed on to the floor because R6 was trying to get up. This investigation does not document R6's use of narcotic, anticoagulation, antihypertensive, Antipsychotic, antidepressant or diuretic medication use. This fall investigation report does not document a thorough investigation as to why R6 was attempting to get up, if call light was within reach or if the call light had been activated. There is not a statement from staff as to when R6 was last observed, was last provided with incontinence care or a root cause of R6's fall. R6's Progress Notes do not document R6's details on R6's fall on 11/22/22 at 9:00pm. R6's Progress Notes document: 11/23/2022 at 9:58am, the Interdisciplinary Team met to discuss recent fall. R6 has an acute infection, COVID 19, and has increased weakness. New intervention is to apply bolsters. Will reevaluate with resident returns to baseline strength. 11/23/22 at 4:02pm, Recent fall (2 days ago), no injury. Trying to get a cat. No cat in room according to staff. R6 does not recall this. R6 remembers climbing out of bed but denies seeing cat. Second bed placed up against R6's bed per staff to prevent falling out of bed. There is no documentation of an investigation with intervention of a second bed being placed or a fall with documentation of hallucinations. On 12/13/22 at 2:57pm, R6 stated R6 had a fall recently (unable to recall date/time) in the facility due to R6's bed being slippery. R6 stated R6 doesn't remember exactly what was happening, but R6 slipped off R6's bed on to the floor. R6 said if R6 wears pants/clothes in R6's bed, R6 slides all over because the mattress is slippery. R6 stated R6 was not hurt when the fall happened. On 12/19/22 at 2:00pm, V2 stated V2 did not complete the fall investigation for R6's fall on 11/22/22. V2 stated V2 did not see a root cause documented in the investigation for V2's fall on 11/22/22. On 12/19/22 at 3:00pm, the facility's policies and procedures regarding Falls/Fall Investigations/Prevention of Falls was requested from V2, Director of Nursing (DON). As of 12/19/22 at 5:52pm, this policy had not been provided by V2 or the facility.