**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that proper number of staff were used in transferring one of four residents (R1) to prevent accidental hazard in the sample who requires two persons assist in transfers from chair to bed or bed to chair. This failure affected R1 who was transferred from chair to bed by one staff instead of two. As a result, R1 sustained laceration of left lower leg, was sent to the hospital and the laceration required eighteen (18) sutures to be repaired. This has a potential to affect all 70-residents residing at the facility. Findings include: R1's medical record admission Record showed that R1 was originally admitted to the facility on [DATE] and the latest admission date was 08/26/24 with a diagnosis list that includes but not limited to Unspecified intracapsular fracture of the left femur, subsequent encounter for closed fracture with routine healing, aftercare following joint replacement surgery, syncope and collapse, unspecified atrial fibrillation, mixed hyperlipidemia, ataxic gait, muscle weakness(generalized), muscle wasting and atrophy, major depressive disorder, single episode unspecified, Unspecified Dementia unspecified severity without behavioral disturbance and anxiety. R1 was sent to the hospital on [DATE] and was treated for diagnoses that includes laceration of lower leg initial encounter and cellulitis of left lower extremity. R1 was discharged from the facility on 10/11/2024. According to facility incident report, on 10/02/24 R1 was assisted from chair to the bed by V5 CNA (Certified Nurse's aide) not following the plan of care of using two persons assist and, in the process, R1 sustained skin tear (referring to laceration to left lateral lower leg that required 18 (eighteen) sutures from the local hospital. R1's medical record PT (Physical Therapy) Evaluation and Treatment notes with certification period 8/16/2024 to 10/14/2024 showed documentation that transfers from chair/bed-to chair transfer = dependent indicating that R1 is dependent on staff in performing this task, maximum of two person assist. R1 progress notes, V6 RN (Registered Nurse) describe the injury site as skin tear to LLE (Left Lower Extremity), hollow area noted adipose tissue exposed. On 02/06/2025 at 10:20am, V2 DON (Director of Nurse's) stated that the incident occurred during the evening shift and was reported 10/03/25. V2 stated that the CNA incorrectly transferred the resident (referring to R1). On 2/06/25 at 12:06pm, V8 CNA (Certified Nurse's aide) stated that she was usually assigned R1 in the morning shift when on duty. V8 stated that R1 needs two staff (persons) assistance when transferring from bed to wheelchair. V8 stated that the PT (Physical therapy) /OT (Occupational Therapy)/ Restorative department staffs are usually on the floor walking residents, and they will help with routine care of the residents as needed. In additional will bring R1 for meals and therapy. On 02/06/2025 at 12:09am, V9 (Restorative Nurse) stated that R1 is clinically compromised with ADL's (Activity of Daily Living) not wanting to get up. R1 had hip surgery and due to the surgery R1 was dependent on staff and not functionable. We educated the nursing staff including the CNAs that R1 was on hip precaution due to the hip surgery and R1 requires two persons assistant with transfers. All the residents have the green card or/and yellow card in their rooms that showed what kind of assistance needed and there is a 24-hour report on the computer that the CNAs can access to show the plan of care in assistant level. At 1:06pm V19 OT (Occupational Therapist) stated I worked with R1 and R1 needs two persons assist the day R1 was admitted to the day R1 was discharged . Staff must not transfer R1 by themselves, R1 becomes anxious, fearful due to fall history because R1 used to be very independent and now must depend on others. Multiple training was given to the family and staff before discharge from the (facility). V19 stated the PT/OT notes showed that R1 needs 2-person assistant with transfer and that for the incident on 10/02/2024, (V5) transferred R1 incorrectly by self and according to what was reported R1 got injured from (V5)'s action. At 1:16pm, V18 PT (Physical Therapist) stated that she is familiar with R1. V18 stated that R1 needs two (2) persons assistance with transfers. V18 stated that both herself and V19 do evaluation of the residents together to decide whether the resident needs a mechanical lift or sit to stand assistance. V18 stated that with R1, R1 needs 2 persons assistance with lateral transfer. V18 stated that R1 should not be transferred with a mechanical lift device because with any hip surgery and hemiarthroplasty that R1 had; it will force R1's hip to flexion greater that 90 degrees and this is contraindicated. The surveyor asks whether it is appropriate to transfer R1 with one person assist, V18 stated that transferring R1 alone is wrong. V18 stated that the staff must follow the green sheet in residents' room that showed the individual care needed which is updated as to resident needs. At 4:08pm, V5 CNA (Certified Nurse's Aide) stated that on that day (referring to 10/02/2024), I had given R1 a shower. Pulled R1 to the side of the bed for dinner. R1 tried to get out the wheelchair and R1 said I can do this, I (V5) put the gait belt around R1 and asked for R1 to reach for the bed side rails to turn into the bed easily and I picked up R1's legs and put it on the bed. That was when I noticed that R1 got a skin tear on the leg, I can't remember which leg. I left out of the room and called the nurse (referring to V6) who decided to send R1 to the hospital. When the surveyor asked V5 how many staff are needed and whether there is any transfer device used in transferring R1, V5 stated that in R1's case the needs were changing rapidly and by now I cannot remember what it was that day. V5 stated one person assistance means transfer must be done with one staff and use of gait belt, two persons assistance means two people with use of gait belt. The surveyor then asked if a resident is marked for two people assist and one staff did the transfer task, whether that is appropriate. V5 stated that will not be appropriate because the resident can fall, can have skin tear and staff can also injure self. On 2/10/2025 at 11:15am, V17 (Physician) stated that he cannot remember seeing the resident. V17 stated that the facility staff has reminded him of what happened with the incident (referring to 10/02/24 incident resulting in injury). V17 stated that skin tear can be managed with compression, dressing and we (referring to the facility) can keep the resident. If the resident must receive sutures, it is laceration, the resident must be sent out, it means they (facility) cannot take care of it there (facility). R1's Hospital report presented dated 10/2/2024 showed instructions documented that R1 was seen and evaluated after an injury that resulted in a laceration. In addition, R1 was treated for soft tissue infection. Facility Job Description for CNA (Certified Nursing Assistant) documented that the purpose of this position is to work under the direction of the charge nurse. Provides assists with all areas of ADL's. Assists in observing and reporting changes in resident's condition. Accountabilities and job duties listed includes but not limited to always understanding and adherence to resident rights. Ensures proper positioning of all residents while in bed or wheelchair, making sure that all mattresses and positioning device are in place, and carries out restorative programs. The facility job description for RN (Registered Nurse) documented that RN purpose is to be responsible for all nursing care administered to residents, including but not limited to overall supervision of the nursing assistants. Accountabilities and job duties listed includes but not limited to always understanding and adherence to resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the bed frame is locked to the size of the mattress for the safety of one resident (R1) reviewed for injury. As a result, R1's left lower leg made contact with the loose bed frame during transfer into bed causing a laceration. R1 was sent to the hospital and the laceration was repaired with 18 sutures. This has the potential to affect all 70 residents residing in the facility. Findings include: R1's medical record admission Record showed that R1 was originally admitted to the facility on [DATE] and latest admission date was 08/26/24 with diagnosis list that includes but not limited to Unspecified intracapsular fracture of the left femur, subsequent encounter for closed fracture with routine healing, aftercare following joint replacement surgery, syncope and collapse, unspecified atrial fibrillation, mixed hyperlipidemia, ataxic gait, muscle weakness(generalized), muscle wasting and atrophy, major depressive disorder, single episode unspecified, Unspecified Dementia unspecified severity without behavioral disturbance and anxiety. R1 was sent to the hospital on [DATE] and was treated for diagnoses that includes laceration of lower leg initial encounter and cellulitis of left lower extremity. R1 was discharged from the facility on 10/11/2024. According to facility incident report on 10/02/24, R1 was assisted from chair to the bed by V5 CNA (Certified Nurse's aide) not following the plan of care requiring use of two persons assist and, in the process, R1 sustain skin tear (referring to laceration to left lateral lower leg that required 18 (eighteen) sutures from the local hospital. On 02/10/25 at 4:29pm, V23 (Case Manager) was asked why V5 was written up for the incident on 10/02/2024? V23 stated that the write-up was for (V5) improperly transferring the resident (referring to R1). V23 stated that R1 was transferred with one-person assistance instead of 2-person assistance. V5 transferred R1 from wheelchair to bed and in the process R1 bumped the leg on the bedframe and caused the skin to open. Having 2-person would have made the transfer of R1 safe. After the facility administrative investigation of the cause of the skin tear (referring to the lower leg extremity laceration) we found out that the bed frame was larger than the bed mattress at the time of the transfer. The bed frame needed to be adjusted by pulling the lever (part of the bedframe) to adjust it, so it is stable. It was corrected after the incident. The surveyor asked who is responsible for making sure the bedframe is not larger than the mattress. V23 stated that the maintenance department are supposed to do that. On 2/11/25 at 9:02am, V25 Assistant Maintenance Manager EVS (Environment Services) stated that the bed frames maximum width is 42 inches, the facility standard mattress is 42, but the bedframe can be extended to about 80 inches. V25 stated that the bed frame can be adjusted down to 39 inches and if the mattress is narrower then it becomes a safety issue. The maintenance staff is responsible for making sure the bed frames are properly secured it's a safety issue. At 9:21am, V2 (DON) demonstrated on the bed frame with V25 and V26 present on how it was loose when the administration investigated the incident and what went wrong with the bed frame causing R1's injury laceration to lower left leg. V2 stated that the middle part of the bed frame was wider that the bed mattress causing R1's leg to make contact with the bed frame and resulted in the skin tear (Laceration). V2 stated that at the time of incident the bed frame was wider than the bed mattress and that's what caused the injury when the resident (R1) leg made contact (Bump) with the bed frame and that is what we reported (referring to IDPH (Illinois Department of Public Health)). On 2/11/25 at 9:22am, V26 EVSD (Environment Services Director) stated that we do not check on bed frames to check whether they are locked or loose. There is no reason for the bed frame to be out of place. V26 stated that all the facility beds should be at a 42 inches setting 100% of the time. The surveyor asked what measures have been put in place since the incident of 10/02/2024 to make sure this does not repeat itself. V2 who was present at the time stated that we (Facility) will have to put in a work order for the maintenance staff to come and check the bed frame. At 9:36am, the surveyor asked how they are monitoring the safety of the beds, V2 stated that a system must be put in place for checking the bed frames. As at 4:20pm on 2/11/25 the facility was unable to provide any work order or documentation that shows that a process has been put in place to ensure safety and prevention of such incident. The facility in-service instruction on Bed frame size, how and when to adjust the size, mattress sizes indicated that as a safety precaution the staff should make sure the bedframes are adjusted to match the mattress size correctly. Regular mattress size 42 inches wide, APM 42 inches wide, and Bariatric APM 48 inches wide. Bed frames can extend in length to 84 inches if needed. The facility policy on Safe and Home Environment with implementing date of 2/10/23 documented in part that in accordance with residents' rights, the facility will provide safe, clean, comfortable, and homelike environment which includes but not limited to ensuring that the resident can receive care and services safely and does not pose a safety risk. The facility Job description for job title Director of Facility management documented that the purpose of this position primary responsibilities includes but not limited to oversight of building and grounds maintenance, and to daily management of the facility operations and direct supervision of staff involved in these operations. Accountabilities and job duties listed includes but not limited to always understanding and adherence to resident rights, ensuring that the (facility) residents are always safe and secure. Listed primary job duties includes but not limited to ensures compliance with health safety and environment regulations. Making regular rounds.

Based upon observation, interview and record review the facility failed to address R3's (4/18/23) injury of unknown origin, failed to obtain physician orders for weekly skin assessments, failed to conduct bi-weekly showers/skin assessments (as scheduled) for four of four residents (R1, R2, R3, R4) in the sample, failed to document (R1) skin integrity impairments, and failed to timely notify the physician of (R1's) change in skin condition. These failures resulted in (R1) sustaining a keratotic papule on the chest measuring 1.6 cm (centimeters) which required surgical intervention due to neoplasm of uncertain behavior vs. keratoacanthoma. Findings include: On 4/5/23, IDPH (Illinois Department of Public Health) received allegations that the facility is not doing proper skin checks on residents. A resident wound was present, and staff were unaware. R1's diagnoses include dementia and malignant melanoma of skin. R1's (undated) BIMS (Brief Interview Mental Status) determined a score of 6 (severe cognitive impairment). R1's (undated) functional assessment affirms (1 person) physical assist is required for dressing and personal hygiene. R1's care plan states (4/9/23) resident requires full hands-on assistance with ADL's (Activities of Daily Living). Monitor skin for redness/breakdown when changing and report to Nurse/Medical Doctor. Resident is at risk for alteration in skin integrity related to history of melanoma. Intervention: weekly skin assessment On 4/19/23 at 9:15am, surveyor inquired about concerns with R1's care at the facility V3 (Family) stated, They (staff) have to bathe her (R1) twice a week and dress her because she's incapable of doing it herself. I (V3) came to visit R1 and, she (R1) said can you take a look at this and showed me her chest. She (R1) said she told the Nurse, and the Nurse said it could be skin cancer. They (staff) called the wound care nurse to see if it (lesion) was annotated and it was not. She (R1) needed to see a doctor to get a biopsy. He (V12/Dermatologist) thought it was a squamous spot, were awaiting the test results. He (V12) said squamous cells can grow quickly but this (lesion) has probably been there for at least 2 weeks. It's just neglect, they (staff) had to have seen it (lesion). On 4/19/23 at 9:45am, surveyor inquired about R1's alleged skin integrity impairment. V5 (CNA/Certified Nursing Assistant) stated, When they found out about what she (R1) had on her skin, that was my first time working with her (R1). Surveyor inquired how V5 found out about R1's skin integrity impairment. V5 responded, When I walked in the room (after breakfast) I was about to change her (R1), the sister (V3) was in the room. That's when she (R1) was telling the sister (V3) look at this, I've been having this for a long time and affirmed the Nurse (V6) was made aware. On 4/19/23 at 9:52am, surveyor inquired about resident skin assessments. V6 (Registered Nurse) stated, Usually, the CNA's will hit the light (call light) in the shower. We (Nurses) check their (residents) skin for any redness, bruising, skin tears or any new changes. Surveyor inquired about R1's skin integrity impairment. V6 responded, She complained that she had something like a lesion on her chest. It (lesion) was something that was raised, irregular and different shades of dark colors. Surveyor inquired when R1's lesion was identified. V6 replied, I think 3 weeks ago already. The sister (V3) was upset, she (V3) wanted to talk to someone. I went to see if there was anything on her chart, it said that she (R1) has a history of melanoma, but I really couldn't find much, there was nothing under wounds. I looked at her admission assessment also since there was nothing there. She (V3) spoke to (V4/Director of Clinical Operations). We (V4 & V6) did a thorough skin assessment then called the attending and wound doctor. Surveyor inquired if V6 was aware of R1's lesion prior to (V3) requesting to speak with someone. V6 stated, Her (R1's) showers are in the evening so I never did a skin assessment on her (R1) before. Surveyor inquired about R1's current location. V6 responded, She's in the hospital. R1's (March/April 2023) progress notes include (4/5/23) resident skin assessment was completed (entered by V4) observed with dry, flaky skin all over, dry brown, irregular shaped moles on her arms, legs upper back, dry healing scabs to bilateral shins, some redness to buttocks, dry patch nickel size to back of head. To the left chest area, a quarter sized elevated lesion hard to touch middle noted with whiteness and brown, area surrounding noted with dry, scaly redness. Doctor made aware order for dermatology consult given [there were no prior skin integrity impairments documented]. R1's (4/6/23) skin/pressure ulcer assessment states resident was assessed today by wound care nurse. Resident was noted to have a dry patch in the back of her head. Dry skin and lesions throughout her face, back and upper anterior body. Left upper chest there is a raised lesion brown in color, quarter size, hard to touch, no redness, no temp, no complaint of pain to area. Right shin skin tear present dressing applied, scabs on bilateral shins, red spots on bilateral lower extremities. Left arm skin lesions present. Dryness under breasts. Dry scaly skin throughout the body. Floor Nurse gave her shower today. R1's (4/9/23) physician progress notes state patient was seen and examined. She is complaining of skin lesion/mass on her left chest. Skin: left chest skin mass. Skin mass on the left side of the chest most likely skin cancer. R1's (4/10/23) dermatology consult states patient seen for an evaluation of a skin lesion that has been present for at least 2 weeks and increasing in size. Pertinent history: melanoma unspecified, removed and squamous cell skin cancer. Additional visit reasons: evaluation for suspicious growths. An examination was performed including the chest and back. Diagnoses include neoplasm of uncertain behavior vs. keratoacanthoma 1.6 cm (centimeters). A biopsy by shave method to the level of the dermis was performed using a dermablade on the left lateral superior chest. Patient will be notified of biopsy result. The shower assignment sheet affirms R1's showers are scheduled Mondays and Thursdays (PM shift). On 4/19/23 at 10:33am, surveyor inquired about requirements for resident showers. V7 (CNA) stated, We got a shower list Monday through Saturday, they're scheduled 2 times (a week) on days or evening shift. We document the shower and have the Nurse sign off on the skin check. R1's (March 2023) skin monitoring: CNA shower reviews include the following: (3/6/23) Stated she personally bathed herself [R1 has dementia & requires assistance]. (3/9/23) Visual assessment excludes any abnormalities (bruising, skin tears, rashes, dryness, lesions, wound, blisters, scratches, abnormal color, abnormal skin). (3/27/23) Refused. (3/30/23) Visual assessment excludes any abnormalities. [3/2, 3/13, 3/16, 3/20, 3/23 assessments were not documented as scheduled]. R1's (4/6/23) skin monitoring: CNA shower review includes left chest lesion, right shin skin tear and dry skin from the neck down endorsed by the CNA and Nurse however dry skin lesions throughout the face, red spots on bilateral lower extremities and scabs on bilateral shins (documented 4/6/23 by the wound care nurse in the progress notes) were excluded. R1's Physician Orders were updated (4/20/23) with skin assessment twice weekly on shower days [2 weeks after R1's lesion was identified]. On 4/19/23 at approximately 12:15pm, surveyor relayed concerns with resident showers and/or skin assessments not documented twice a week. V1 (Administrator) affirmed the facility identified the concern and presented a (4/7/23) memo which states In doing bath sheet audits, it has been discovered that residents are not getting their baths as scheduled. In addition, it appears that Nurses are not doing body check each time a bath sheet has been filled out. This does not meet the standards for good care. R3's diagnoses include dementia, muscle wasting and atrophy. R3's care plan states resident is at risk for impaired skin related to impaired mobility, fragile skin, incontinence, and muscle wasting. Intervention: bi-weekly skin assessment on shower days to monitor for any alterations in skin integrity (goal date 7/15/23). R3's POS excludes bi-weekly skin assessments. The shower assignment sheet affirms R3's showers are scheduled every Wednesday and Saturday (AM shift). R3's (April 2023) Skin Monitoring: CNA shower sheets were documented (Monday) 4/3, (Thursday) 4/6, 4/12, 4/15, and 4/19 (not as scheduled). R3's (4/18/23) progress notes state resident noted with bruise to lateral side of right knee however cause of the bruise was excluded. On 4/19/23 at 11:10am, a large (dark purple) bruise was observed on R3's right (lateral) leg below the knee. On 4/20/23 at 10:31am, surveyor requested R3's (4/18/23) incident report. At 11:23am, V2 (Director of Nursing) stated, we don't have anything in particular for that bruise because we attributed that to her (R3) fall on March 23rd (4 weeks ago). Surveyor inquired how an old bruise appears. V2 responded, It's actually pink, yellow and green depending on what stage it is. Surveyor inquired how R3's (dark purple) bruise was therefore considered old. V2 replied, I'm not a wound doctor so I don't know. Surveyor inquired if R3 has weekly skin checks ordered. V2 stated, Your concern with the weekly skin checks is our concern as well, so we're currently doing house-wide assessments on everyone's skin. She (R3) has orders for skin protectors cause she's high skin risk so it's not like we don't have interventions in place for her (R3). Surveyor inquired again if R3's physician orders include skin checks. V2 responded, I think everyone should have twice a week skin checks during showers, it's not an order though. On 4/20/23 at 1:14pm, surveyor inquired about potential harm to a resident (with history of malignant melanoma) that develops a new lesion that is not addressed. V13 (Medical Director) stated, They do assessment of the patients there. I know what you are calling me about, it was addressed. Surveyor advised that R1's lesion was not addressed by the facility until (V3) reported it to staff. V13 responded, This lady (R1) complained and said look at what I have. I said this looks like cancer, we need to send you to a dermatologist and do a biopsy. I talked to the lady (R1) and said it's not an infection it looks like cancer. Surveyor inquired if R1's (1.6cm) lesion may have developed within less than a week because R1's (3/30/23) skin assessment excluded skin integrity impairment. V13 replied, No, it's like a week or more. Surveyor inquired about potential for harm to a resident with a large bruise (of unknown origin) that is not addressed. V13 stated, Bone fracture if somebody falls, and it's a bruise. They (staff) have to pay attention to that part. Anything is possible, it may be in a shower she (resident) was handled a little bit roughly, they are frail, they are old if you put the hand, they (residents) may have a bruise. If there's anything suspicious, they tell the nurse they have to do that. R2's diagnoses include weakness, chronic kidney disease, urinary incontinence, muscle wasting and atrophy. R2's care plan states resident is at risk for skin breakdown related to impaired mobility, fragile skin, incontinence, muscle wasting and atrophy. Intervention: bi-weekly skin assessment on shower days (goal date 5/6/23). R2's POS (Physician Order Sheets) exclude bi-weekly skin assessments. The shower assignment sheet affirms R2's showers are scheduled every Wednesday and Saturday (AM shift). R2's (April 2023) Skin Monitoring: CNA Shower sheets were documented 4/1, 4/5, 4/12, 4/15 and 4/19 however 4/8 was not documented. 4/1 & 4/15 showers were refused therefore skin assessments were not documented for over 1 week. R4's diagnoses include encephalopathy. R4's care plan states resident is at risk for skin breakdown related to impaired mobility, fragile skin, incontinence, muscle weakness and dementia. Interventions exclude skin assessment. R4's POS excludes skin checks. The shower assignment sheet affirms R4's showers are scheduled every Tuesday and Friday (PM shift). R4's (April 2023) Skin Monitoring: CNA shower sheets were documented 4/7 (refused). 4/11 and 4/14 (denied shower/bed bath) however 4/4 and 4/18 were not documented. The skin audits by Nursing Assistants policy (revised 3/31/23) states Nursing Assistants shall inspect all skin surfaces during bath/shower and report any concern to the resident's Nurse immediately after the task. Nursing assistants shall also report changes in skin condition that are noted during any care procedure. Notification shall be made to the Nurse verbally and in writing via shower sheet. The (2/10/23) abuse/neglect policy states the facility will identify events, occurrences, patterns and trends that may constitute neglect: failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. [Injuries of unknown origin is inclusive].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to supervise three cognitively impaired residents (R11, R53, and R62) who are at high risk for falls and have a history of falls from having repeated falls and failed to implement fall prevention interventions as care planned for two residents (R11 and R53) in a total sample of 29 residents. As a result, R11 fell and sustained a 2-centimeter laceration to the left posterior head that required four staples and bruising to the right hand. Findings include: R11's Face Sheet documents an admission date of 11/1/22 and diagnoses including but not limited to intracranial injury w/o (without) loss of consciousness, anxiety disorder, dementia, osteoarthritis, abnormalities of gait and mobility, muscle weakness and history of falling. R11's 11/14/22 BIMS (Brief Interview for Mental Status) determined a score of 3, indicating that R11's cognition is severely impaired. R11's 11/2/22 admission Fall Risk Assessment documents, in part, Overall score of 10 or above represents HIGH RISK. Calculated overall score: 10. The facility fall report reviewed from July-December 2022 documents that R11 sustained a fall on 11/2/22 at 7:15 AM with no injury and on 11/11/22 at 7:15 pm with injury and sent to hospital. R11's 11/3/22 care plan documents, in part, Problems: (R11) is at risk for injury related to fall risk. (R11) is admitted to skilled rehab from independent living. She (R11) experienced a fall while a resident in independent living that resulted in a subdural hematoma. Falls in skilled rehab then listed on 11/2/22 and 11/11/22. Interventions include but are not limited to, Keep (R11) in public area as much as possible for increased supervision; Continue to increase frequent rounds and monitoring for the resident; Communication boards/signs in Italian placed in resident room. On 12/05/22 at 9:50 AM, V1 (Executive Director) provided the surveyor with the Initial and Final Facility Reported Incidents reports that were sent to the state agency for the alleged incident that occurred on 11/11/2022. The Final Investigation report documents, in part, She (R11) is one person assist with transfers, speaks Italian, and needs cueing and redirection. On the evening of November 11, 2022, around 7 pm, resident was toileted and assisted to bed and then at approximately 7:30 PM, the Nurse on duty reported she was making rounds and observed resident on floor next to her (R11) bed and soiled. The nurse assessed resident and then assisted resident to bathroom and incontinence care provided. During her assessment, the nurse used hand gestures to determine any signs of pain or discomfort. The resident pointed to the lateral side of her hand and expressed pain. The nurse continued to further assess resident and noted a small laceration to her head .Resident returned from ER (Emergency Room) with results of no right-hand fracture, negative CT (Computed Tomography scan), and staples to the laceration sustained from her (R11) fall. On 12/07/22 at 1:53 PM, V23 (LPN/Licensed Practical Nurse) who was the nurse on duty on 11/11/22 stated that she (V23) was rounding on her (V23) residents at the start of her (V23) shift around 7pm when she (V23) found R11 on the floor next to her (R11) bed. V23 stated that during the initial assessment R11 was pointing to her right hand and had pain upon palpation so the physician was contacted for an x-ray order. Per V23, a CNA (Certified Nursing Assistant) noted blood in R11's hair so when V23 inspected it, a laceration was found to R11's scalp and the resident was sent to the hospital for evaluation. The surveyor inquired what fall precautions are in place for R11. V23 replied, We do pretty much a one to one with her. We keep her with a staff member. If the CNAs were busy, I would keep her with me. If they were available to take her, they would take her to keep her in close visuality to make sure nothing happens. V23 stated that this was an intervention that was in place from the first day that R11 came to the facility. The surveyor inquired where the assigned CNA was at the time of the fall. According to V23, she (V23) did observe a CNA in the break room when she (V23) arrived for her (V23) shift but did not know which CNA was assigned to which patients at the time and proceeded to obtain report from the previous nurse and do her (V23) rounds. On 12/07/22 at 3:05 PM, V25 (CNA) stated that on 11/11/22, I happened to be at the charting desk outside of (R11's) room when the day shift CNA (V18 Restorative Aide) was giving him (V22 Agency CNA) report, so I heard (V18) tell him (V22) that (R11) is one to one. According to V25, (V18) told V22 that R11's caregiver leaves at 4:30pm so after that she (R11) needs to be closely monitored and he (V22) responded, Oh ok. V25 added that she (V25) has taken care of R11 in the past and we wouldn't leave her (R11) alone in the room because R11 was a high fall risk and in report V25 was instructed to not leave R11 unsupervised. V25 also reported that on 11/11/22 when she (V25) returned from her (V25) scheduled break around 7-7:30 pm, she (V25) observed V22 sitting in the break room on his (V22) personal laptop. On 12/07/22 and 12/08/22, the surveyor attempted to contact V22 (Agency CNA) multiple times but was unsuccessful. On 12/07/22 at 2:07 PM, the surveyor walked with V14 (Restorative Nurse) to R11's room and inquired if there were any signs in Italian. V14 replied, No. There should be because I made them myself. V14 added that staff should have brought the signs with R11 when R11 was transferred from the first to the second floor. On 12/08/22 at 10:26 AM, V18 (Restorative Aide) stated, I remember giving him (V22) a walk-through of the whole set. I told him (V22) that he (V22) has to keep a close eye on (R11) because she's (R11) a busy body; she (R11) likes to move around a lot and that she's (R11) a one-to-one assist. The surveyor inquired what V18 meant by one-to-one assist. V18 replied, Like somebody has to sit with her (R11). So, if you're giving care to somebody else, you have to make sure somebody else is sitting with her (R11). V18 added, I told him that she (R11) has a caregiver and the caregiver leaves between 4 and 4:30 PM. He said, 'Ok.' On 12/08/22 at 10:47 AM, the surveyor inquired what is the risk to a resident who has an unwitnessed fall. V29 (R11's Primary Physician) replied that any injury can occur depending on how hard the resident fell. V29 listed, Fracture, head trauma, bruises, concussion, laceration, intracranial bleed .anything. R11's 11/11/2022 Emergency Department APP (Advanced Practice Physician) Note authored by V26 (PAC/Physician Assistant-Certified) and cosigned by V27 (DO/Doctor of Osteopathic Medicine) documents, in part, History of Present Illness: (R11) . presents to the ED (Emergency Department) with son from nursing home unwitnessed fall PTA (Prior to Arrival) .Physical exam: Skin: 2 cm (centimeter) linear laceration to left posterior head . dried blood noted. Musculoskeletal: TTP (Tenderness to Palpation)-scant edema (swelling) and ecchymosis (bruising) overlying posterior right 4th and 5th metacarpals (hand bones) . Laceration repair: skin closure: staples. Number of sutures: 4. R53's Face sheet documents an admission date of 9/2/2022. R53's 10/14/22 BIMS, determined a score of 9, indicating R53's cognition is moderately impaired. R53's 09/02/22 admission Fall Risk Assessment documents, in part, Overall score of 10 or above represents HIGH RISK. Calculated overall score: 14. R53's 9/14/22 care plan documents, in part, (R35) is at risk for falls related to: impaired mobility, muscle wasting cervical disc disorder, OA (osteoarthritis), lumbar spondylosis, SOB (shortness of breath), pain, muscle weakness, incontinence, difficulty walking, gait abnormalities, poor safety awareness, DM (diabetes mellitus), HTN (hypertension), NSTEMI (non-ST Elevation Myocardial Infarction), atrial flutter, CAD (Coronary Artery Disease), CKD (Chronic Kidney Disease), heart failure, hx (history) of falls, hx hip replacement. Interventions include but are not limited to: Keep call light within reach at all times and encourage (R53) to ask for assistance. The facility fall report reviewed from July-December 2022 documents that R53 had a fall on 9/4/22 at 10:20 PM with no injury; 10/9/22 at 2:15 AM with no injury; and 11/23/22 at 1:23 AM with min injury. Not sent to hospital. On 12/05/22 at 10:41 AM, R53 was observed sitting in a recliner next to the window in R53's room. R53's call light was noted on R53's bed, not within reach. At 10:43 AM, this observation was brought to the attention of V30 (Restorative CNA) who verified that the call light was on top of the bed and when the surveyor inquired if R53 was able to reach the call light from his (R53) position, V30 replied, No. I wouldn't have set it here. The surveyor inquired what the risk is of not having the call light within reach. V30 replied, He's (R53) not going to be able to call and he (R53) could get up and fall. The 3/3/22 Protocol for: Fall Prevention, Response and Management documents, in part, Policy: (Facility) is committed to minimizing resident falls and/or injury so as to maximize each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, it is this community's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment. All staff will be responsible in assisting with the implementation of the Facility's Fall Management Program to ensure the safety of all residents in the community .Standards and Practice Guidelines: . 3. An indicated score of high risk for falls, or history of falls will require the development of a care plan with interventions designed to reduce the risk and/or re-occurrences. 4. 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. Standard fall/safety precautions for all residents: All staff will be oriented and trained on the Fall Prevention Program upon hire, annually and as needed. At the time of admission, and in accordance with the plan of care the resident will be oriented to use the call nurse device. The nurse call device will be placed within the resident's reach at all times .In addition to the use of Standard Fall Safety Precautions, the following interventions will be implemented for resident identified at risk: 1. The resident will be checked frequently or as according to the care plan, to assure they are in a safe position/environment. The frequency of safety monitoring will be determined by each resident's risk factors and plan of care. The September 2017 Call Lights: Accessibility and Timely Response Policy documents, in part, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance .Policy Explanation and Compliance Guidelines: . 5. Staff will ensure the call light is within reach of resident and secured with each interaction in the residents' room or bathroom and as needed. On 12/5/22 and 12/6/22 during observation of residents on the nursing units, R62 was observed and interviewed. R62 could not respond to any questions regarding any of the fall incidents and could not use call lights to ask for staff assistance. R62's face sheet shows that R2 has multiple diagnoses which include but are not limited to Dementia, History of Falling, and Abnormalities of Gait and Mobility. R62's MDS (Minimum Data Set) dated 10/1/2020, section C states that R62 has a BIMS (Basic Interview for Mental Status) score of 5 out of 15 (severe mental impairment). R62's MDS dated [DATE], Section G (Functional Status) shows that R62 requires assistance to walk, to transfer from bed or from chair. R62's Fall Risk assessment dated [DATE] shows that R62 has a score of 18 (High Risk for Falls). On 12/06/22 at 2:10pm, V14 (Restorative Nurse) was interviewed regarding why R62 was not supervised closely and had 8 falls within 6 months. V14 stated that R62 was previously residing at the Assisted Living side of the facility and wanted to do things for herself. V14 later presented eight records of R62's falls within the past 6 months. The fall incident records are as follows: 8/1/22 at 1:30am - R62 fell in her room and was sent to the hospital and returned. 8/4/22 at 8:30am - R62 fell in the hallway with no injury. 8/31/22 at 8pm - R62 fell in the common area. 8/31/22 at 10:30pm - R62 fell in the common area. 10/1/22 at 2:40pm - R62 fell in his room with minimal injury. 10/27/22 at 8am - R62 fell in the common area. 11/4/22 at 12:30pm - R62 fell while trying to walk. 11/15/22 at 5:50pm - R62 fell in the Dining Room and was sent to the hospital and returned. R62's care plan initiated on 6/20/22 states that R62 is at risk for injuries related to falls related due to several medical diagnoses including but not limited to Dementia, Alzheimer's Disease, Muscle Weakness, history of falls, and Poor Safety Awareness. Facility's policy on Accidents and Supervision dated September 2015 with latest revision date of January 2022 states in part: Each resident will receive adequate supervision and assistive devices to prevent accidents.