**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the 2 persons assistance while turning one dependent resident (R1) in bed. This failure affected one resident of three reviewed for accidents. This failure resulted in R1 falling to the floor and sustaining a frontal hematoma and laceration requiring glue to close. The findings include: R1 has diagnoses of Paraplegia, Complete, Dementia, Major Depressive Disorder, Mononeuropathy of Bilateral Lower Limbs, Cataract, Hemiplegia and Hemiparesis Following Cerebral Infarction, Contracture, and Immobility Syndrome (Paraplegic). Progress Note, dated 2/15/24, documents R1 is a 2 person assist with bed mobility. R1's MDS (Minimum Data Set), dated 8/7/24, notes a BIMS (Brief Interview for Mental Status) score of 3, impaired. R1 is noted to have no physical or verbal behavioral symptoms. R1 is noted to have Functional Limitation in Range of Motion to her lower extremity on both sides. Section GG notes R1 is dependent on staff for toileting hygiene, sit to lying or lying to sitting on side of the bed and transfers. R1 requires substantial/maximal assistance with the helper does more than half the effort for rolling left to right. R1 had 0 falls since the prior assessment. R1's fall risk assessment score is 14, dated 8/5/24. R1's Restorative Observations, dated 8/5/24, notes right and left lower extremity paralysis/paresis. Existing contracture or limited range of motion. R1's care plan designates requires assistance with bed mobility related to weakness. Intervention include provide assist of 1-2 staff as needed. R1's Fall Initial, dated 10/24/24, noted R1 noted on floor by CNA (Certified Nursing Assistant) upon during rounds. Unwitnessed fall, precipitating and contributing factors: R1 confused, forgets to use call light and incontinent. New injuries observed raised area/ swelling/discoloration noted to right forehead. 911 called. R1's IDT Fall Committee Meeting Note: resident was observed on the floor and stated she wanted to reposition herself and rolled over to the floor. Review of V4 incident statement documents R1 observed on the floor. 911 called and transported resident to hospital for evaluation. V8's statement, as I was doing rounds at about 4:00 AM I walked into (R1's) room to do a safety check and (R1) was on the floor. (R1) stated she rolled out of bed and hit her head. Both statements are dated 10/24/24. No statement from V13 was provided. Fire Department record, dated 10/24/24, documents, dispatched for the fall victim. Upon arrival crew located the patient laying supine on the floor. Alert and oriented times three. Patient's nurse stated the patient was being changed and cleaned in bed when she was rolled out. Patient hit her head on the floor when she fell. Staff had already performed general wound care to the patient's forehead. Patient's history and meds was obtained from staff on scene. Call received at 3:43AM and ambulance on scene at 3:50AM. Hospital records, dated 10/24/24, presents with mechanical fall out of bed, (R1) states nurses were changing her diaper and rolled her over and she kept rolling and fell to the ground. (R1) head strike with frontal hematoma. Additionally pain in knee with a hematoma just below the right knee. Contracture and external rotation of right hip. Pain in right knee with hematoma over right tibial tuberosity. Mental status: Alert and oriented to person, place, and time. Neurological: positive for headaches. Imaging results for bilateral hips, pelvis, knees, right tibia and femur listed as results pending. Emergency Department Course: 10/24/24 agreeable to return to nursing home after irrigation and skin glue repair of laceration. On 11/19/24 at 10:01AM, R1 was observed in bed with a bump on the right side of her forehead, scabbed over in the center, pink skin, and dry without drainage. R1 was asleep. On 11/19/24 at 11:45AM, V4 said, The CNA (Certified Nursing Assistant) called me to the room. I went to the resident room; after assessing (R1), I called 911 because the physician told me to send her to the hospital. At baseline, (R1) is alert and oriented x 2, and she is very responsive and has periods of confusion. (R1) is a 2 person assist for transfers and she typically sleeps throughout the night. (R1) had been checked not long before the fall. Whatever I wrote is what happened. V4 said she didn't remember more than what was written. On 11/19/24 at 1:57PM, V8, CNA, said, I don't know who (R1) is. I don't remember someone falling and getting a goose egg or large bump on their head. I have had people fall but I don't know their names. Some people are 2 person assists because they are combative. On 11/20/24 at 12:54PM, V13, CNA, said, On 10/24/24, there was only 2 CNAs that night. V13 I was coming to east hall (opposite R1 hall) and the nurse called me and said they had a fall. I went in the room and (R1) was on the floor next to the bed. V13 said she was trying to change her diaper and she fell. The surveyor who is she? V13 said V8 by name. V13 said, (V8) told me she was trying to change (R1's) diaper in bed. I did not help in turning or changing R1 before the fall, I was on the East hall. They called 911 and I came back to my hall. On 11/20/24 at 11:50AM, R1 was in bed alert and oriented place and self, confused about time. The surveyor asked R1 what happened to her head? R1 she had a raised area, size and shape of an egg, with a scab in the center. R1 said her head and ankle hurt. R1 said, You should have seen it before; it was bigger and ugly. The girl was turning me and was pushing me, and I kept saying stop, you're going to push me out. The girl kept pushing, and next thing I knew, I fell to the floor. V15, Director of Nursing, was brought to the room, and R1 repeated the incident that the girl pushed her out of bed. R1 said, It hurt my shoulder and my head. R1 was on air mattress. R1's right leg was contracted, with knee bent, and foot towards R1's torso. R1's left leg extended out in front of her. On 11/19/24 at 12:11PM V5, CNA, said, (R1) needs 2 persons to turn her. (R1) can't help with positioning and is heavy, and 2 people are needed to turn her. We don't have a rail for (R1). I have not seen R1 kick, fidget, or try to get of the bed. (R1's) cognition goes in and out; she does get confused. On 11/19/24 at 12:49PM V7, CNA, said, (R1) is 2 persons assist for cares. (R1) never tries to get up or out of bed. (R1) can't roll out of the bed, and she can't help to turn. (R1) is cooperative. (R1) had a fall; when I came back to work R1's face was swollen, all on the right side was swollen. (R1) said they were trying to roll her over and she fell. (R1) told me that. It can be possibly true. (R1) can't sit up in the bed and she can't stand or doesn't try to walk. On 11/20/24 at 10:25AM, V11, MDS (Minimum Data Set) Nurse, said, When the fall was discussed with the team, we were told the fire department picked (R1) off the floor after the fall. Per the documentation, (R1) rolled off the bed. At 10:43AM, V11 presented Functional Ability assessment, dated 8/7/24. V11 said, (R1's) bed mobility is dependent. (R1) needs 2 person assistance. In the facility when someone is dependent, we use 2 people or more. (R1) has no behaviors that would mean she needs 2 persons for assistance. For turning and repositioning in bed, (R1) needs 2 people. (R1) has no strength in arms and legs. (R1) does not have the strength to turn herself in bed. I have no idea how she rolled out of bed. When they talked about the fall, I wondered too. Vased on our assessment, (R1) is dependent and can't roll herself. The binder at the nurses' station tells how many people can help. The staff gets trained to use 2 people. The staff is told if they use 2 people for the transfer, then they need to use 2 for bed mobility and changing briefs. On 11/20/24 at 11:07AM, V10, Restorative Nurse, said, Anyone with a fall risk score below a 9 are at risk. (R1) was not part of the falling leaf program when she fell, and she is not now. Based on assessments, (R1) needs extensive assistance with care; she needs a lot of help. (R1) cannot get up, she can assist with slight movement, but staff would need to do the turning. (R1) can be between 1 to 2 person assist with bed mobility, it depends on staff. I can do (R1) by myself. It is in the [NAME] in computer chart; you can see how much staff (R1) needs for care. V10 read from [NAME] and documented BED MOBILITY with assistance. V10 said, There is no direction if she needs 1 or 2 person, it depends on the person. Observation record will show if she has contractures. (R1) was not able to walk before the fall. I went over the fall. (R1) is on a bed mobility restorative program. The program says (R1) will practice repositioning in bed, and she does not use rails for program. On 11/20/24 at 12:03PM, V12, Restorative Aid, said, For (R1's) bed mobility, I go in and I turn her side to side, with another person at all times. I move her contracted leg as much as she can bear. (R1's) right leg is contracted and her left leg she does not bend. The CNA and I are doing all the work to turn her, she is dependent on staff. I have never seen her turn or try to roll. In all the time I have worked with (R1), she has never tried to roll or initiate the roll in bed. On 11/20/24 at 12:28PM, V15, Director of Nursing, said, I started last week. Paraplegia affects the ability to use legs. Facility fall prevention program, dated 11/21/2017, states the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The fall prevention program includes the following components: use and implementation of professional standards of practice. Care plan incorporates: Preventative measures. Safety interventions will be implemented for each resident identified at risk. Direct care staff will be oriented and trained in the Fall Prevention Program. Residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or chair and provide care as assigned in accordance with the plan of care.

Based on interview and record review, the facility failed to prevent a fall by providing a two person assist with bed mobility during ADL (Activity of Daily Living) care. This affected one of three (R2) residents reviewed for safety during direct care. This resulted in rolling of the bed during direct care and sustaining a head injury requiring 9 sutures. Findings include: Facility final report to the department, dated 9/19/24, denotes thorough investigation completed, including staff and resident interviews. On 9/13/2024 resident was observed on the floor in his room. Head to toe assessment completed. Minimal bleeding noted to right forehead. First aid rendered, and pressure applied to area. Neuro checks initiated and completed. NO change in LOC (level of consciousness). ROM (range of motion) at baseline. Resident denied pain. MD (Medical Doctor) gave orders to send resident to ER (Emergency Room). Staff Interviews revealed staff was present at the time of the fall. Based on the investigation, the root cause of the fall was resident stated he was attempting to reposition himself in his bed, lost his balance, rolled over the side of the bed onto the edge of the floor mat. Staff could not reach him in time to break the fall. Resident returned from ER with sutures to the right forehead. CT (Computed Tomography) scans negative. Care plans were reviewed and updated. Facility incident report, dated 9/13/2024 for witness fall, location (room #) room, The CNA (Certified Nursing Assistant) verbalized that she was doing ADL (Activities of Daily Living) care in the morning, the resident abruptly turned on his side, lost his balance and rolled over. The CNA tried to grab the resident but was unsuccessful and the resident landed at the edge of the floormat. The resident verbalized that he rolled over and landed at the edge of the floor mat. Physical assessment done, vital signs taken and are all within normal limits, wound dressing done. Pain medication administered. Sent to (hospital name) for further evaluation. Injury type: face. Oriented to place, person, and situation. Predisposing environmental factors- there was already a safety intervention in place. Predisposing physiological factors- gait imbalance. R2 hospital records, dated 9/13/24, denotes chief complaint-fall, physical exam- 4 cm (centimeters) laceration overlying his forehead, simple. clinical impression head injury, forehead laceration. Laceration repair- location: forehead, length: 4 cm, number of sutures: 9 sutures. R2 MDS (Minimum Data Set), dated 07/29/24, denotes in section GG for functional abilities and goals denotes roll left and right: the ability to roll from lying on back to left and right side, and return to lying on back on the bed, 02 is noted, 02 substantial/maximal assistance- helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. On 9/19/24 at 10:59am, R2 was observed alert to person, place, time, and situation, R2 observed sitting in a high back wheelchair. R2 said he was being washed up in bed, the girl told him to roll over, and he rolled too far and fell out of bed. R2 said he hit his head on the floor. R2 said it was one girl that was washing him up at the bedside. R2 observed with 2-inch laceration to the forehead with multiple sutures in place. R2 had purplish discoloration around the right eye and purplish discoloration under the left eye. R2 said he feels safe at the facility. On 9/19/24 at 11:37am, V1 (CNA-Certified Nursing Aide) said, I was giving (R2) a bed bath, I was washing (R2's) back, (R2) was laying on his left side, his back was facing me. (R2) turned a little more and fell out of bed. The air in the air mattress was increased on my side, and that contributed to pushing (R2) out of the bed. V1 said she did bring R2 closer to her before the turn, and R2 had room on the side of the bed for the turn. V1 said, The air in the air mattress always does that. V1 admitted to putting the air mattress on static mode when providing R2 care. V1 said, (R2) fell on the floor, he landed on the floor mat, but his head landed on the corner of the floor mat. V1 said she observed blood on R2's forehead. V1 said she went and got the nurse right away. V1 said she was on the opposite side of where R2 fell, and she could not catch R2 before he fell. V1 said R2 was not resisting to care. V1 said R2 is one assist with turning, repositioning, and bed mobility. V1 said the plan for R2 is to move his bed to the wall. V1 admitted the current plan of 2-persons assist with bed mobility for R2. V1 admitted the current plan of 2-person assist with turning and repositioning R2. On 9/19/24 at 1:50pm, V2 (Director of Nursing) said the facility does not put the air mattress on static mode during care / ADL care. V2 said after R2's fall, the facility plan is to use two people for turning and repositioning all residents that use an air mattress, regardless of body weight, V2 said this is for safety, it will prevent resident from rolling out of bed. On 9/19/24 at 2:42pm V4 (Restorative aide) said R2 need substantial to max assist with bed mobility, tuning from side to side. V4 said R2 needs two-person assist with bed mobility. V4 said R2 required two-persons assist prior to the fall. V4 said R2 sometimes does not want two people assisting him. On 9/20/24 at 10:13am V6 (Physical therapy manager) said R2 has weakness on his left side. R2 can roll to his left side but he will not stay in that position too long. V6 said she was not there when the fall occurred, she knows sometimes those air mattresses are slippery. R2's most current plan of care was presented by V2. R2's plan of care does not address the use of 2 person assist with bed mobility, does not address the use of two person assist with turning and repositioning while in use of air mattress. The operator's manual for R2's bed denotes, in static mode, the mattress provides a firm surface that makes it easier for the patient to transfer or position. The static mode will help ensure the patient does not bottom out when in a sitting position. Facility policy titled Fall prevention program, last revision date 11/21/2027, denotes to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate intervention to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Program will monitor the program to assure ongoing effectiveness. Guidelines: methods to identify risk factors, methods to identify residents at risk, assessments time frames, use and implementation of professional standards of practice, communication with direct care staff. Safety interventions will be implemented for each resident identified at risk. The admitting nurse and assigned CNA are responsible for initiating safety precautions at the time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Facility Comprehensive care plan policy, with revision date of 11/17/17, denotes to develop a comprehensive care plan that directs the care team and incorporate the residents' goals, preference, and services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, assess, and implement interventions in preventing the development of pressure ulcer for one (R19) of three residents in the sample of 37 reviewed for pressure ulcer. This failure resulted in R19 developing an unstageable pressure ulcer on the sacral area. Findings include: R19 is an [AGE] year old, female, initially admitted in the facility on 06/14/22, with diagnoses of Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Right Dominant Side; Parkinson's Disease without Dyskinesia, Without Mention of Fluctuations; and Neurocognitive Disorder with Lewy Bodies. R19's MDS (Minimum Data Set), dated 07/02/24, recorded: Section C, BIMS (Brief Interview for Mental Status) score of 99, which means R19 was unable to complete the interview; and Section M0150 Risk of Pressure Ulcers/Injuries - R19 is at risk of developing pressure ulcers/injuries. R19's Care plan on potential for alteration in nutrition, dated 09/06/23, documented: Intervention - Assess for changes in elimination, changes in skin integrity (04/02/24). Braden Observation, dated 01/03/24, documented a score of 16.0, which means R19 is at risk for development of pressure ulcers. Weekly Skin Observation, dated 08/05/24, documented R19 had intact skin. Her progress notes, dated 08/05/24, also documented intact skin. R19's shower sheets, dated July 2024, recorded normal skin. Shower sheet, dated 08/06/24, documented an open area on R19's sacrum. There was no documentation in the progress notes/wound notes, dated 08/06/24, addressing R19's open area on the sacrum. R19's Wound Assessment Details, dated 08/09/24, recorded an Unstageable Facility Acquired Pressure Ulcer on the sacrum with measurements: 2.7cm length x 2.4 width x depth unknown. R19's POS (Physician Order Sheet), dated 08/09/24, documented: Cleanse sacrum with wound cleanser then apply calcium alginate with silver then cover with foam dressing daily and PRN (when needed) one time a day for wound. On 08/12/24 at 11:40 AM, R19 was observed in the dining room attending activities. She was sitting in her wheelchair. R19 was awakeand alert, but did not respond when greeted. On 8/12/2024 at 1:10 PM, V24 (Wound Care Nurse) was observed performing wound care on R19. R19 was in bed, on a low air loss mattress, turned to left side, with a pressure ulcer on the sacral area. The sacral pressure ulcer had 30% slough, 70% granulation tissue, with clean wound edges. There was no discharge noted on the wound. Current measurements were taken as 2.7 cm (centimeters) x 2.4 cm. According to V24, R19's sacral wound is an unstageable pressure ulcer, facility acquired. V24 added, She had an old pressure ulcer healed on the sacrum, it reopened. She is nutritionally compromised and also incontinent. On 08/14/24 at 11:05 AM, V23 (Wound Nurse Practitioner) stated, I was contacted a week ago regarding sacral wound; it is a facility acquired. The last time I saw her was last January 2024, she had a wound on the sacrum and was healed. It reopened 08/09/24 as Unstageable. I was first notified on 08/09/24, and I gave orders for calcium alginate. Facility has to follow its skin protocol. With fragile scar tissue, it can open in a matter of hours. On 08/14/24 at 11:10 AM, V24, Wound Care Nurse, stated, I am not here every day. When I came back on 08/09/24, I was informed that she has a wound on the sacrum. When I assessed it, it was Unstageable. I notified (V23) right away. If I am not here, nurses should notify Director of Nursing (DON), and she notifies (V23). On 08/14/24 at 11:15 AM, V6 (Registered Nurse, RN) stated, The CNAs (Certified Nurse Assistants) usually check residents' skin during shower and incontinence care. If there are any skin issues per CNA, I do the assessment myself and I tell DON. I also sent a message to the Wound Care Nurse. On 08/14/24 at 11:55 AM, V20, Certified Nursing Assistant/CNA stated skin assessments on residents are done during morning care and changing. If skin issues are noted, the CNAs notify the nurse on duty. On 08/14/24 at 12:23 PM, V2, Director of Nursing, stated, (V24) is the Wound Care Nurse, and she is not here every day. She works Mondays, Wednesdays, Fridays, and PRN (as needed). Floor nurses do wound care. The nurses and CNAs do the skin assessment. CNAs assess skin during ADL (activities of daily living) care. If there are skin issues, CNAs notify nurses. Nurses will do the assessment, and if there are open areas or redness, the nurse will call the Primary Physician and ask for orders or treatment orders. On (R19), the wound on the sacrum was identified by (V24) on 08/09/24 as Unstageable. I was not here that time. They just told me over the phone that she (R19) had an open area on the sacrum. I told (V24) to do the assessment and implement interventions and notify (V23). In the shower sheet, on 08/06/24, there was an open area. I believe (V22, CNA) reported it to the nurse. The nurse will document under wound observation note. Staff has to assess the body of residents on a daily basis. If they found any redness, they have to inform the nurse, and the nurse will check/assess and inform the doctor and put all the necessary interventions. There is a weekly skin assessment completed by treatment nurse. CNAs do the skin assessment and it is recorded on a daily basis via plan of care. The nurse who identified the skin issue will do the first treatment. V2 was asked to present documentation from the plan of care, dated 08/06/24, relative to R19's open area to the sacrum, but nothing was presented during the course of this survey. On 08/14/24 at 1:34 PM, V25 (Medical Director) stated, If a resident is not mobile, they have to move the resident every two hours or so, feed resident properly; change resident on time; and if there are skin issues, contact wound care team immediately. Facility's Policy titled, Pressure Ulcer Prevention, dated 1/15/18, documented the following: Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: 2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. May use lotion on dry skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one dependent resident (R21) was safely transported in a wheelchair. This failure affected one (R21) of two residents reviewed for falls in a sample of 37. This failure resulted in R21 falling forward out of a wheelchair while being pushed by staff, hitting R21's head, and sustaining a contusion to right forehead, requiring transfer to a local hospital for emergent care. Findings include: R21 is an [AGE] year-old resident admitted to the facility on [DATE], with diagnoses including but not limited to generalized anxiety disorder, moderate intellectual disabilities, muscle wasting and atrophy, and history of falling. Minimum Data Set (MDS), dated [DATE], documents R21's Brief Interview for Mental Status (BIMS) score as 00, which indicates severe cognitive impairment. MDS, dated [DATE], also documents R21 is dependent on staff for wheelchair mobility and toileting hygiene; needs substantial/maximal assistance for oral hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear; needs partial/moderate assistance is needed for upper body dressing and personal hygiene; and needs supervision or touching assistance for eating. Fall risk assessments completed on R21 document the following: 11/20/2023 - Fall risk score =18; At risk for falls 02/19/2024 - Fall risk score = 14; At risk for falls 04/29/2024 - Fall risk score = 14; At risk for falls 07/12/2024 - Fall risk score = 16; At risk for falls 07/29/2024 - Fall risk score = 14; At risk for falls Care plan for R21, dated 11/21/2023, documents: Focus: I am at risk for falls and injury related to falls. I have history of fall. Risk factors: Requiring assistance with activities of daily living (ADL's), possible medication side effects, cataract, right leg cast in place. Goal: I will have interventions in place and reviewed as needed to address risk for falls and injury related to fall through next review. Interventions: All essential/personal items placed closer to bed and within resident's reach. Send to hospital for evaluation. Neurochecks as ordered. Bump to Forehead: assess for pain, provided pain interventions as appropriate. Assess for altered cognition, decline in safety awareness. Assess for side effects of medications. Assist with ADLs, anticipate and meet resident's needs. Assist with toileting upon awakening, before and after meals, during rounds and before bedtime. Progress note, dated 07/12/2024, documents: While (V31) Certified Nursing Assistant (CNA) was wheeling (R21) back to his room; (R21) abruptly became agitated and noted to slide his body down landing on the floor and bumping his head. Certified Nursing Assistant unable to prevent fall in a timely manner due to resident's abrupt agitated behavior. Upon staff interview of incident, (R21) stated, 'I wanted her (referring to V31) to wheel me faster back to my room.' (R21) assisted safely back to wheelchair. Vital signs taken. Body assessment completed with discoloration/redness noted to the right side of forehead. Pain assessment completed with no complaints of pain made. Range of motion assessed and within resident's baseline. Level of consciousness within resident's normal range. First aid rendered to affected site per medical doctor (MD) orders. Neuro checks initiated. (R21) assisted safely to bed. Activities of daily living (ADL) care rendered. Bed in lowest position with call light in reach. MD made aware and gave orders to send (R21) to hospital for further evaluation. MD orders carried out. (V32) Case worker made aware. Plan of care ongoing. Progress note, dated 07/12/2024, documents: (R21) is being transported via ambulance to hospital. Order summary with signed bed hold policy sent with (R21). Report called and given to emergency room nurse. MD made aware. (V32) made aware. All departments made aware. Local hospital emergency room note dated, 07/12/2024, reads: [AGE] year-old man with history of hypertension, hyperlipidemia, benign prostatic hypertrophy, failure to thrive, not on blood thinners here for evaluation of head injury. Patient coming from facility after falling out of wheelchair, hit head, sustained small contusion to right forehead. Fall initial occurrence note, dated 07/12/2024, documents description of occurrence: While CNA (V31) was wheeling resident back to his room; resident abruptly became agitated and noted to slide his body down landing on the floor and bumping his head. CNA (V31) unable to prevent fall in timely manner due to resident's abrupt agitated behavior. On 08/12/2024 at 10:04 AM, R21 was sitting at table in a wheelchair in the activity room. Bruise noted to forehead, purple in color, and slightly smaller than quarter sized. On 08/13/2024 at 9:54 AM, R21 was in a wheelchair in activity room. Bruise remained purple in color and remained slightly smaller than a quarter in size. On 08/13/24 at 10:07 AM, V6 (Registered Nurse) stated, The bruise on his forehead is from his fall last July. The bruise did not fade out. He has not had any falls since last one in July. He sometimes is a bit aggressive with movement, but not all the time. No aggressive attitude. Bruise has remained since fall last month. It was a little bigger, not much. When asked what interventions are in place to keep him safe, V6 stated he had fall mats and low bed in place. On 08/14/24 at 9:49 AM, (V2) Director of Nursing (DON), stated, The bruise on (R21's) forehead has been there since his fall on 07/12/2024. It doesn't heal. He keeps messing with his face. He has not had a fall since the one in July. On 08/14/24 at 3:39 PM V29, (Certified Nursing Assistant/CNA), stated, I have worked here about a month. I have worked with (R21). He is a fall risk. The interventions we have in place are place call light in reach, lower his bed, and floor mats. I can't think of anything else at the moment. He does not have any behaviors. I am not aware of any falls. On 08/14/24 at 12:43 PM, V27 (CNA stated, I have worked here 3-4 months. I have taken care of (R21) before. Sometimes he gets a little aggressive. Nothing too crazy. Sometimes when someone sits where (R21) wants to sit, he makes noises or will ball up his fists and shake them. I have not been here when he has had a fall. I know (R21) is a high fall risk. The interventions we have in place are that we get (R21) up so someone is watching him. Staff is always in the activity/dining room so we can watch (R21). I am not aware of any other interventions in place to keep him from falling. On 08/14/24 at 11:57 AM, (V2) Director of Nursing (DON), stated, (R21) is confused. He can't walk and does not want to go to another facility. He loves it here. He has a lot of pictures. He has behaviors sometimes. He is resistive with care or does not want to be put to bed. He sometimes become restless. He has had 2 falls. The first one he rolled over on his bed, and the last one, (V31) was wheeling (R21), and he became restless and leaned forward and ended up on the floor. We sent him out to the hospital. The family is very concerned about him. They want him to be sent out to hospital for any fall. He sustained bruising to the head. He hit is head when he hit the floor. Sometimes he is just restless once in a while. When he is in bed he just moves around once in a while. He sometimes looks for his pictures, and if they are on the floor, he will try to get them. CNAs know if his pictures on the floor, to pick up and give to him because he will look for it. When he gets restless like that, we give him time and talk to him. He started to move that time in the wheelchair, and he lost his balance in the chair. A lot of times he is in the dining area, and he is leaning on the table. We are careful with him because he is leaning a lot of time without a table in front of him. We have people all the time in the dining room to watch him. I tell them to always check on (R21). He is high risk for falls. Interventions when he is in bed his bed is in low, low position and we have a floor mat, and always redirect him. When he is restless, we give him space and redirect him. We listen to him. We tell him to always stay by the table. He is alert with confusion. He is total care. He is dependent with all ADLS. Eating is fine, but he is total assist for everything else. When a risk assessment is 14-18, that means high risk for falls. For (R21) is high risk. Care plan states he has poor safety awareness. He is not aware what he is doing. V2 was asked when V31 was pushing him did he have leg rests? V2 replied, I am not sure. (R21) was sent out to the hospital; we did not report because it was no injury. His hematoma to forehead is not serious so we did not report it When asked, what is your expectation for CNA's? How should they propel resident in wheelchair? V2 responded, They should make sure resident is safe and tell them what they are doing and make sure they are not moving. Yes, if he leans forward, the CNA will tell him to lean back. The expectation is for the CNA to transport safely, so the resident is safe and does not get harmed. V2 was sked, When he fell on July 12, what intervention did you add to prevent further falls? V2 replied, We make sure to ask for assistance, and to stop pushing the chair. On 08/14/2024, investigation was provided, conducted by V2 regarding R21's fall on 07/12/2024. Investigation includes statement from V31 as follows: While I was wheeling resident back to his room; all of a sudden he became agitated and slide his body down landing on the floor and bumping his head. It happened so fast and I couldn't get to him fast enough. I then made sure he was safe and called for the nurse to see him. On 08/14/24 at 4:16 PM, V25, Medical Director, stated. I have been Medical Director since about 2015. I am not by the computer, but I can try to log in. I remember most of my patients, but do not remember everything. I am logging in now. I recall the name (for R21), but I want to be sure. I get calls on everything that happens. I am sure I was called regarding his fall. He has anxiety and dementia no other psych diagnoses. The psychiatrist would be better to ask that question. When asked what is the expectation MD has of staff regarding falls, he stated, Obviously they need to be assessed and sent to the hospital, and they will do evaluation and testing. When asked if this fall could have been prevented? V25 stated, Obviously they could have held them from falling forward. Did you ask the CNA? If I am on the street and see someone falling, I will try and prevent it. I think everyone will try to do that. I have not seen behaviors whenever I have seen him. Fall Prevention Program Policy, dated 11/28/12, states: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Guidelines: The Fall Prevention Program includes the following components: Use and implementation of professional standards of practice. Standards: Safety interventions will be implemented for each resident identified at risk. Fall/safety interventions may include but are not limited to: Direct care staff will be oriented and trained in the Fall Prevention Program Transfer conveyances shall be used to transfer residents in accordance with the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R6's admission Record, (dated 3/8/24), shows she was admitted to the facility on [DATE], with a fracture of her left upper arm. R6's diagnoses include, but are not limited to, Alzheimer's disease, repeated falls, and syncope with collapse. R6's Order Summary Report (dated 3/8/24) shows and order from 1/18/24 whereby R6 is to keep a shoulder immobilizer in place. R6's Care Plan initiated on 1/18/24 shows R6 had an open reduction internal fixation (ORIF) (surgical repair) of her left upper arm bone (humerus) and should keep her shoulder immobilizer in place. R6's Fall-Initial Occurrence Note, dated 1/28/24, shows R6 had an unwitnessed fall in her room at 8:30 AM and was found lying on the floor. R6 reported pain to her right upper leg at a level of 7 on a 0 to 10 pain scale. R6 was sent to the hospital for evaluation and treatment. R6's Nurse's Note, dated 1/28/24 at 8:10 AM, shows R6 was found on the floor near her bedside with complaints of right leg pain. R6 was given pain medication, assisted back to bed, then the physician was notified and R6 was sent to the Emergency Department for evaluation. R6's Progress Note, dated 1/28/24 at 3:00 PM, shows R6 was admitted to the hospital with a diagnosis of closed, non-displaced fracture of her right femur. On 3/8/24 at 11:29 AM, V8, Registered Nurse (RN), said she was summoned to R6's room after the CNA (Certified Nursing Assistant) found R6 on the floor (on 1/28/24). V8 said she did an assessment of R6, and R6 complained of right hip pain. R6 said she and four staff members rolled a blanket under R6 and used it to lift R6 to her to bed. V8 said she then contacted the physician and was given orders to send R6 to the hospital. V8 said she called 911 and R6 was taken to the hospital by ambulance. V8 said she later contacted the hospital for an update on R6, and was told R6 had a hip fracture and would need surgery. On 3/8/24 at 12:04 PM, V2, Director of Nursing/DON, said if a resident is found on the floor, the nurse needs to assess the resident and if there is hip pain, they need to leave them on the floor. V2 said when the ambulance, (EMS) emergency medical services arrives, they need to immobilize the resident and transfer them. V2 said staff should not move them because it could add insult to injury. V2 also said staff should never use a blanket to transfer a patient off the floor; it's not safe and they could drop the person. The facility's Transfers-Manual Gait Belt and Mechanical Lifts Policy (revised 1/19/18) shows, .manual lifting is not permitted. Based on interview and record review, the facility failed to immediately transfer a resident to the emergency room after a fall that resulted in left hip pain and a fracture. This failure resulted in a surgical delay in treatment (more than 7 hour) for R5 who was experiencing left leg pain and had a fracture. The facility also failed to ensure a resident (R6) was not transferred from the floor after a fall and complaints of right upper leg pain prior to emergency medical services arriving. These failures apply to 2 of 4 residents (R5 and R6) reviewed for quality of care in the sample of 14. The findings include: 1. R5's Fall-Initial Occurrence Note, dated 12/29/23, shows R5 had a fall in the dining room at 1:46 PM and landed on the floor and her left side. R5's Progress Notes, dated 12/29/23 at 8:44 PM, shows, Left leg new onset of pain .MD (Medical Doctor) notified of new pain onset, new orders received. x-ray of left leg. R5's X-ray report shows a reported dated and time of 12/30/23 at 12:10 AM. The report shows R5 had an impacted intratrochanter fracture with varus deformity of the left hip. R5's Progress Notes, dated 12/30/23 at 7:30 AM, shows, Resident noted to have pain in left leg with grimaced face. MD made aware and ordered transfer out to hospital for evaluation. (more than 17 hours after R5's fall and 7 hours after receiving x-ray results showing a hip fracture) R5's Hospital Notes shows she had a left femur cephalomedullary nailing on 12/30/23. On 3/8/24 at 11:45 AM, V8 (Registered Nurse) said she did an assessment after R5 fell. V8 said R5 was not complaining of pain, but she also is not able to articulate very well if she is having pain. V8 said she called the physician and he ordered a STAT (Immediate) x-ray of her left leg to make sure there were no injuries. On 3/8/24 at 1:26 PM, V18 (Registered Nurse) said she works from 3:00 PM to 11:00 PM. V18 said on 12/29/23, it appeared R5 was having pain so she called the doctor and he ordered stat x-rays to be done. V18 said she was unsure if x-ray came during her shift. On 3/8/24 at 2:01 PM, V8, Registered Nurse, said when she came in on 12/30/23, she noticed R5 was in pain. R5 was grimacing. V8 said she looked up the x-ray results and it showed a fracture, so she called the physician and sent R5 out to the hospital. V8 said she is not sure when x-ray came, but the nurse should be looking for the results within three hours. V8 said sometimes the x-ray company calls to let the staff know of the results, but sometimes they just fax the report. V8 said it is the nurse's responsibility to follow up on any x-ray results. V8 said she is unsure why R5 was not sent out when the x-ray results were received. On 3/8/24 at 1:54 PM, V2 (Director of Nursing) said if a stat x-ray is ordered, the x-ray company will arrive within 3 hours and she thinks they have 4 hours to read the x-rays and send the report. V2 said typically the x-ray company calls if there is a fracture, but sometimes they just fax the report. V2 said she is not sure why it took so long for the nurse to review the report and send R5 out to the hospital. V2 said sometimes if a resident has had a fall and is having pain, they would not wait for x-ray results, they would just send the resident to the hospital for evaluation. The facility's Physician Notification of Laboratory/Radiology/Diagnostic Results Policy, revised on 3/14/18, shows, STAT or Same Day orders will be called to the laboratory service by the nurse who transcribes the order. 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 .x-ray or other diagnostic tests reveal suspected findings which may require immediate intervention including but not limited to: Pneumonia, New fracture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions in preventing the reopening of a healed pressure ulcer and worsening of an existing pressure ulcer for two (R18 and R29) of four residents in the sample of 27 reviewed for skin breakdown. This deficiency resulted in R18's healed pressure ulcer on the sacrum reopening and being identified as a facility acquired, Stage 3 wound. Findings include: 1. R18 is a [AGE] year-old, male, admitted in the facility on 07/24/23. with diagnosis of Multiple Sclerosis. According to Skin Wound Report. dated 07/24/23, he was admitted with Stage 2 pressure injury on the sacrum, measuring 1cm (centimeter) x 1cm x 0.1cm. R18's Care plan on pressure ulcer to sacrum related to immobility, dated 08/23/23, documented: Interventions: Avoid positioning the resident on sacrum; Encourage and assist with turning and repositioning at regular intervals as allowed and tolerated every shift and when requested for comfort; Facility follow policies/protocols for the prevention/treatment of skin breakdown. R18's NP (Nurse Practitioner) wound notes recorded the following: 08/30/23 - Integumentary: Wound status is healed. The wound is currently classified as a Category/Stage II wound with etiology of pressure ulcer and is located on the sacrum. The wound measures 0cm length x 0cm width x 0cm depth. 09/20/23 - Integumentary: Wound status is open. The date acquired was 09/20/23. The wound is currently classified as a Category/Stage III wound with etiology of pressure ulcer and is located on the sacrum. The wound measures 7cm length x 8cm width x 0.2cm depth. There is a small amount of serosanguineous drainage noted. There is large granulation within the wound bed. There is a small amount of necrotic tissue within the wound bed including adherent slough. The periwound skin appearance exhibited: scarring, maceration. R18's Wound Assessment Details Report, dated 10/18/23, documented: Sacral wound/Stage 3 pressure ulcer, date identified 09/20/23, facility acquired. Measurements: 3cm x 4cm x 0.10cm. On 10/22/23 at 10:00 AM, R18 was observed lying on his back, in bed, with head of bed slightly elevated, watching TV (television). R18 was asked if he has an active wound. R18 stated, I have a pressure ulcer in the lower back. At 12:10 PM, wound care was observed on R18. R18 has an indwelling urinary catheter and wears an incontinence brief. It was observed the brief was dry, but with scant amount of serosanguineous drainage. V4 (Registered Nurse, RN) stated during wound care, The discharge was coming from his sacral wound. Treatment is clean with soap and water and apply (ointment) and zinc, leave it open to air. It was noted R18's wound is open, with pinkish to reddish wound bed. It was also observed 10:00 AM to 12:10 PM, R18 was lying on his back in bed, watching TV. On 10/23/23, random observation every 15 to 30 minutes interval was conducted from 10:10 AM to 12:48 PM, which showed R18 was not repositioned, nor was his sacral wound offloaded. From 10:10 AM to 11:00 AM, R18 was observed in bed, lying on his back in a semi-sitting position. From 11:15 AM to 12:10 PM, he was observed in bed, lying on his back, with head of bed elevated to a 90 degree-angle. From 12:35 PM to 12:48 PM, he was lying on his back again in a semi-sitting position. At 1:50 PM, he was again observed lying on his back, in bed. R18 was asked if he is turned or repositioned while in bed. R18 stated, No, I am not turned. When I'm asleep, I sleep on my side. But when I am awake, no, they don't turn me. On 10/23/23 at 12:56 PM, V7 (Wound Care Nurse) stated, He is verbal; does not like to be in the wheelchair. He was admitted with Stage 2 pressure ulcer on the sacrum on 07/24/23, healed on 08/30/23. No hospitalizations since admission. It reopened on 09/20/23 as Stage 3, measuring 7cm x 8cm x 0.2cm. It reopened because he is noncompliant with repositioning. On 10/23/23 at 1:39 PM, V6 (Certified Nurse Assistant, CNA) stated, He cannot turn himself, but he is willing to be turned. He is compliant with turning, awake and asleep. We do turning and repositioning every two hours. V4, Registered Nurse/RN was also asked regarding R18 and repositioning. V4 mentioned, We do side turning every two hours. He is able and compliant. On 10/23/23 at 4:23 PM, V9, Wound Nurse Practitioner stated, His sacral wound was healed on 08/30/23. It reopened to Stage 3 on 9/20/23. I don't have anything documented for the opening. Scar tissues are very fragile for reopening. After a wound is healed, it is prone to reopen. To prevent sacral pressure ulcer from developing and worsening, in general - turning and repositioning per protocol, in general about 2-3 hours; nutrition; use of low air loss mattress. I expect staff for early identification of skin issues and implementation of preventative measures like use of low air loss mattress, following up of nutritional status, offloading, turning and repositioning. R18's NP Wound Notes, dated 10/25/23, recorded: Wound status is open. The wound is currently classified as a Category/Stage III wound with etiology of pressure ulcer and is located on the sacrum. The wound measures 6cm length x 9cm width x 0.1cm depth. There is a small amount of serosanguineous drainage noted. There is medium red, pink granulation within the wound bed. The periwound skin appearance exhibited: scarring, maceration, ecchymosis. 2. R29 is a [AGE] year old male, admitted in the facility on 07/13/23 with diagnoses of Hemiplegia, Unspecified Affecting Left Nondominant Side; Nontraumatic Acute Subdural Hemorrhage; Malignant Neoplasm of Prostate; Cerebral Infarction, Unspecified and Aphasia Following Cerebral Infarction. According to MDS (Minimum Data Set), dated 7/20/23, Section M, R29 was admitted with a Stage 3 pressure ulcer. R29's care plan, dated 09/06/23, regarding pressure ulcer on sacral buttocks documented: Interventions: Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent positioning; Follow facility policies/protocols for the prevention/treatment of skin breakdown; Minimize pressure over bony prominences R29's Skin Wound Report, dated 07/13/23, recorded: Stage 3 pressure injury on the sacrum, measurements of 1cm x 1cm x 0.1cm. R29's NP (Nurse Practitioner) notes documented the following: 07/26/23 - Integumentary: The wound is currently classified as a Category/Stage III wound with etiology of pressure ulcer and is located on the sacrum. The wound measures 2.5cm length x 2.5cm width x 0.1cm depth. 08/02/23 - Integumentary: The wound is currently classified as Unstageable/Unclassified wound with etiology of pressure ulcer and is located on the sacrum. The wound measures 4cm length x 4.5cm width. There is large pink granulation within the wound bed. There is a small amount of necrotic tissue within the wound bed including eschar and adherent slough. 08/09/23 - Integumentary: The wound is currently classified as Unstageable/Unclassified wound with etiology of pressure ulcer and is located on the sacrum. The wound measures 5cm length x 5cm width. There is a large amount of necrotic tissue within the wound bed including adherent slough. The periwound skin appearance exhibited: scarring, maceration. On 10/23/23 at 12:56 PM, V7, Wound Care Nurse, stated, He is nonverbal; he is alert; he has a sacral ulcer, admitted with 07/19/23 his sacral wound increased in size to 2.5, he had multiple comorbidities, he had a history of head trauma. He had sepsis and infections; been in and out of the hospital. He also had prostate cancer. There were no recorded hospitalizations on R29 from 07/13/23 to 08/09/23 per census report. On 10/24/23 at 12:34 PM, V4 stated, He is turned every two hours. We put him in the reclining chair during daytime and stays there for about five to six hours. On 10/25/23 at 8:19 AM, V9, Wound Care Nurse Practittioner, was asked regarding length of time should a resident with sacral pressure ulcer can sit in the wheelchair or reclining chair. V9 stated, Residents who have pressure ulcers on the sacrum can be up and be put in wheelchair or reclining chair in two to four hours. Putting pressure on the sacrum will not allow blood flow. Blood flow facilitates wound healing. Facility's policy titled Skin Condition Assessment and Monitoring - Pressure and Non Pressure dated 6-8-18 stated in part but not limited to the following: Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent or determine how an injury of unknown origin occurred. This affected one of three residents (R6) reviewed injury of unknown origin. This failure resulted in R6 sustaining an injury to the right knee receiving seven sutures at the local hospital. Findings Include: R6 is a [AGE] year old with the following diagnosis: chronic venous hypertension with ulcer of the left lower extremity, venous, insufficiency, chronic obstructive pulmonary disease, congestive heart failure, and Alzheimer's disease. R6's Care Plan, dated 8/23/23, documents R6 has a potential for impairment of skin integrity related to fragile skin, impaired mobility, and incontinence. The Change of Condition Evaluation, dated 8/27/23, documents R6 had a change in condition of a skin wound and this occurred in the afternoon. R6 had no changes in mental status observed. There were no other changes of condition documented besides a skin tear to the right knee. The Hospital Records, dated 8/27/23, documents R6 was sent to the hospital when staff noted a linear laceration to the right knee. R6 does not have any pain and does not recall how this occurred. Staff denied any falls or witnesses to the injury. R6 was alert and oriented times two. The laceration to the right knee was 2.5 cm horizontally. R6 received seven sutures to the right knee during a laceration repair. On 9/6/23 at 5:35PM, V9 (Wound Nurse Practitioner) stated the older a resident becomes the more fragile skin becomes. V9 endorsed if a resident has a disease related to lack of circulation then wounds can develop easier than residents who don't have circulation issues. V1 stated the facility should be monitoring residents as best as they can to prevent any wounds. On 9/7/23 at 1:48PM, V2 (Director of Nursing/DON) stated when V14 (CNA) got R6 in bed, a skin tear was found to R6's right knee. V2 endorsed R6 was not able to say what happened. V2 reported assuming R6 bumped R6's leg, but was not able to confidentially say how the wound occurred. V1 stated the skin tear was about one to two inches long. V2 reported R6 was sent the hospital because of the skin tear and increased confusion. Per the documentation, R6 did not have any changes in mental status. V2 stated seeing a blood stain on R6's pants once R6 was in bed but was not able to see the blood stain before due to R6 having dark pants. On 9/7/23 at 2:29PM, V14 stated V14 put R6 in the bed and started to undress R6. V14 endorsed when V14 pulled on R6's pants, a cut was found to the top of the right knee. V14 stated when V14 asked R6 what happened, R6 couldn't say. V14 denied any falls and denied R6 hitting any part of R6's body when getting into bed. On 9/8/23 at 12:42PM, V1 (Administrator) stated R6 was sent to the hospital after obtaining a new skin tear in the facility. When asked what an injury of unknown origin is, V1 replied, It's an injury that can't be explained how it happened by the resident or staff. V1 denied R6 being able to explain how the skin tear happened. The policy titled, Abuse, Neglect and Misappropriation of Resident Property, that has no date documents, .Purpose: This policy's purpose is to ensure that resident rights are protected by providing a method for investigation and reporting of allegations of mistreatment, neglect, abuse, including injuries of unknown source, unusual occurrences and misappropriation of resident property .Policy Interpretation and Implementation: . 8. The facility will ensure that all allegations of mistreatment, neglect or abuse, including injuries of unknown source, are reported immediately to the Administrator of the facility. The Administrator and/or other officials shall notify ISDH in accordance with ISDH Guidelines.