**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, and records reviewed the facility failed to identify and evaluate interventions for one (R70) of 13 residents reviewed for nutrition in sample of 54. This failure resulted in R70 having an unplanned significant weight loss of 28% over 7 months. The findings include: R70's diagnosis include but are not limited to Hypertension, Gastro Esophageal Reflux Disease, Incontinence, Muscle Weakness, Chronic Pain, Anxiety, Dysphagia, Facial Weakness following Cerebral Infarction, Hemiplegia and Hemiparesis, Major Depressive Disorder, Muscle Wasting and Atrophy, Non Pressure Chronic Ulcer of Foot (Bunions), Chronic Pain, Recurrent Depressive Disorder, Pneumonia, and Osteoarthritis. On 3/20/25 at 12:35PM V24, CNA, said R70 has contracted hands but she can participate with feeding. V24 said R1 needs assistance, it changes with her sometimes she feeds herself. On 3/20/25 at 12:40PM R70 in her room, in bed, lunch of chopped meat and potatoes and gravy with spoon in it. R70 said I didn't touch it. On 3/20/25 at 12:45PM V12, RN said R70 appetite is poor, she feeds herself. V12 said she refuses what we do. V12 said she is supposed to go to the gastric doctor. V12 said R70 don't eat, we did a calorie count. On 03/20/25 at 10:22 AM V9, Registered Dietician, said I asked about the MDS for R70. V9 said R70 definitely had 10% loss in 6 months and 4.2% loss for 1 month. V9 said R70's weight in July 2024 was 146 pounds, she had a 28% loss of weight. V9 said in January 2025 R70's weight was 113.2 pounds and her current weight is 111 pounds. On 03/20/25 at 11:04 AM V6, MDS Nurse, said I do section K (Swallowing/Nutritional Status) of the MDS, I gather information from the Registered Dietician. V6 said I then enter the information into the assessment. On follow up interview at11:34 AM V6 said R70 had a significant weight loss x 1 month and 6 months. V6 said I made a correction for the 1/9/25 MDS. V6 said R70 was 146 pounds 6 months ago. V6 said I am not part of the weight meeting. At 12:05PM V6 said I updated the care plan and notified the nurse. On 3/21/25 at 11:12AM V20, Nurse Practitioner, said R70's weight loss started in October 2024. V20 said sometimes R70 will eat and other times not at all. V20 said the CNAs told us that R70 was not eating at all even though R70 told us she ate. V20 intervention include trying to get her into a GI doctor, encourage her to eat, we provided supplements, and appetite stimulants. V20 said for the calorie counts we see she may eat breakfast and no lunch or dinner. V20 said we discussed hospice with the progression of her Rheumatoid Arthritis, and I increased her pain medication. V20 said R70 said she doesn't want a feeding tube. She went recent to GI, I called the office, we are questioning her cognitive ability. V20 said R70's agrees to eat but then she does not do it. V20 said we are going based on what the CNAs tell us. V20 said the staff were supposed to do weekly weights based on my conversation with the Dietician. V20 said of course R70 is someone we would be concerned for weight. V20 said R70 is a slow feed, since her hands are arthritic she needs a lot of time. On 3/21/25 at 12:53PM V9, said the extent of the calorie count is all they do with it. There is not a section with the calorie calculation, not for this facility. On 3/20/25 the surveyor requested from V1 evidence of Weight Committee procedures #2, 3, 4 and 5 for R70. Information was not provided by 3:30PM On 3/21/25 11:05AM requested from V1 documentation for weight committee, at 1:27PM the documentation has not been provided. 3/21/25 1:25PM V14, Regional Nurse Consultant, said we are still working on getting the progress notes. Review of Progress notes for R70 written by V9 include 12/10/24; 12/11/24 and 2/17/25 No documented evaluation of calorie count. Review of Progress Notes written by V20 include notes on 11/6/24 and 2/5/25, there is no evaluation of calorie count. Nurse progress notes include 12/9; 12/16; 24; 1/3/25; 1/4/25; 1/9/25; and 1/10/25. No evaluation of calorie count. On 3/21/25 at 2:02PM the facility provided the progress notes for R70. R70 MDS dated [DATE] section K0300 states 0 for weight loss. Current weight is 113 pounds The corrected MDS V6 presented on 3/20/25 notes Weight loss 2- yes, not on prescribed weight loss regimen. Three day Calorie Count reviewed for R70 dated 12/10/25 at 10:45AM and 6:23PM and 12/12/25 at 9:38PM. No total of calorie count, protein count, or total intake percentage. Care Plan reviewed for R70 nutritional support. Interventions include meal monitoring and recording, monitor labs. Review of R70's Order Summary Report includes Check Weight weekly x 4 ordered 1/8/25 and end date 2/5/25. Review of R70's January Medication Administration Record includes 1/8/25; 1/15/25; and 1/29/25 with weight NA. 1/22/25 weight is 113.2. Monthly Weight Report for R70 includes weights December 2024 118.8 pounds; January 116.0 pounds; 109.0 February; and March 111.3 pounds. (V9 said R70's weight in July 2024 was 146 pounds, she had a 28% loss of weight since. Policy for Weight Committee dated 2023 states the purpose to reduce the risk of altered nutritional status. Committee will discuss residents with significant weight change, root cause for weight loss and intervention. The committee will also identify individual with insidious weight loss, gradual weight loss, and develop plan of care. The weigh committee will meet weekly to discuss residents with weekly weights. The committee will evaluate the nutritional status of the resident, identify root cause and develop interventions. Information discussed in Weight Committee to be documented via progress note and care plan as needed. The Weight Committee meeting will be obtained via PCC exception reports. Policy for Weights dated 9/2020 states residents will be weighted to establish a baseline weights and identify trends of weight loss and weight gain. Report any weight loss or gain greater than 5% within one month, 7.5% within three months or 10% within 6 months. Policy for Calorie Count dated 9/20 states a calorie count is to monitor adequacy of resident's calorie intake. 5. If a resident refuses a meal or does not eat any of the items, document the reason why the meal was missed and indicate amount consumed with a zero. (See calorie count, this is not documented.) 6. Dietary services will evaluate and document results and will make appropriate recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician of one resident's change in condition which included new onset of pain, changes in mobility, skin changes to lower left extremities and refusal of doppler study for over 6 days. This affected one of one (R1) residents reviewed for notification of change. This failure resulted in R1 being found to have an acute displaced fracture of distal tibia from an unknown origin, osteomyelitis and skin necrosis that requiring a left through the knee amputation of the lower extremity. Findings include: R1 had the diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominate side, peripheral vascular disease, personal history of (healed) traumatic fracture and history of falls. Minimal data set section C (cognitive pattern) brief interview for mental status (BIMS) dated 8/28/24 documents a score of fourteen which indicated cognitively intact. Section GG (functional abilities and goals) documents: impairment on one side for upper/lower extremity (shoulder, elbow, wrist, hand, hip, knee, ankle, foot). R1 required substantial/maximal assistance- help does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort for roll left to right, sit to lying, lying to sitting on side of bed. Sit to stand not attempted due to medical condition or safety concerns. On 10/17/24 at 4:12PM, V27 (Medical doctor) is unable to recall if she was notified of the refusal of the doppler on 9/26/24. If she was notified of the refusal, she would of ordered another treatment or x-ray. V27 said facility staff and/or her nurse practitioner did not notify her of any changes in pain or condition for R1. R1's progress notes dated 9/26/24 by V9(Nurse): X-ray company came to do doppler on R1 , she refused. Tried to convince her, she was upset and said no. Facility Witness interviews dated 10/3/24 documents: V9(Nurse) received report that R1 was scheduled for a doppler, but she refused. I did not assess her leg. When I asked her to assess her and she refused. I did not notify per primary care provider she refused the doppler study on 9/26/24. The last time R1 was due for a refill of her pain medication, V27(MD) stated there would need to be a review of her pain management because she is using pain medication too often. On 10/17/24 at 9:39am, V17 (CNA) said, R1 started complaining of pain at the end of August to her left contracted leg. R1 always complained of pain. R1 reported she fell while attempting to self-transfer. R1 complained of pain being worse, most severe than her normal pain level after her self-reported transfer/fall. V17 said, R1 was dependent with transfers. R1 was able to stand and pivot on her non-contracted leg with one-person physical assistance. V17 said, she reported the incident to the nurse, agency nurse and all the nurse managers every day during stand-up report. V17 said, stand-up report is where the nurse and managers get reports about resident from the cnas. V17 (CNA) witness statement undated documents: When was the last time you provide care for R1? Not sure, sometimes this week, V17 was not her c.n.a but V17 did assist V24 (CNA). How was R1 transferred? With a mechanical lift. Did she complain about pain? Yes, she did. Who did you notify? V17 notified V9 (nurse) and agency nurse and during stand up. R1 has been complaining for about a month. Two weeks ago, V17 was providing showers and when V17 asked her to take a shower R1 stated no because her leg was hurting. Did you notice anything wrong with her leg? V17 did not notice anything wrong with R1 leg due to R1's leg being contracted. R1 stated that, she was in pain more than usual. V17 notify the nurse about her refusal of shower and leg pain. Did she tell you she was in pain that day? Yes, V17 informed the nurse and stand up. Anything else you would like to add? V17 know they came to so x-ray twice and R1 refused once. On 10/17/24 at 10:08am, V24 (CNA) said, R1 always transferred with a one-person physical assist while she stood and pivoted. V24 said, R1 reported she could not take the pain of standing up to transfer anymore. R1 started to use the mechanical lift for transfers. V24 said, she reported the nurses and nurse managers in stand-up about R1's complaint of pain, change in transfer status and the appearance of R1's leg for about a week to a week in the half prior to R1 being sent to the hospital on [DATE]. V24 said, she reported R1's change in condition every day. V24 said, R1's left lower leg was redden at first and she reported that. Next R1's leg started to swell and she reported that. Then R1's leg turned dark purple in color and she reported that in stand-up because it did not look right. V24 said, towards the end before R1 went to the hospital, when she was putting on R1's shoes, R1's leg felt broken. V24 said, R1 leg was loose near the ankle. R1's leg was dangling. On 10/17/24 at 10:17am, V23 (CNA) said, she started working for the facility on 9/9/24. R1 was a pivot with transfers. V23 said, R1 always had a bandage on her left ankle and foot. V23 said, R1 used to ask her to wrap her left leg up in the blanket in-order to apply pressure. V23 said, R1 complained of pain when she was rolled from right to left during care. During stand-up report, the question was asked if there was any change in resident's condition. V23 said, she did not report anything because all the nurse managers were aware of R1's condition. On 10/16/24 at 1:20pm, V16 (CNA) said, R1 had a darken discoloration area on the left ankle the size of palm. V16 said, the discoloration looked like gangrene which she had seen before on another resident in the past. V16 said, she reported to V4 (unit manager). V16's witness statement dated 10/2/24 documents: On the 25th, V16 saw R1 and she had dark color by her ankle. R1 was in pain. V16 reported to V4. V16 had not seen this dark color on R1 in days prior. V16 asked R1 what happen, she said she didn't know. We transferred R1 with a mechanical lift because we didn't want R1 to stand. V16 asked the nurse what was going on with her foot and she said they were doing an x-ray. V16 texted on 9/25 at 9:17am about the dark ankle. On 10/18/24 at 9:51AM, V3(ADON) said all clinical management participates in stand-up meeting to include herself, V2(DON), unit managers, nurses and CNA's. Clinical management staff would be responsible for following up with any medical concerns that are brought up during stand-up meeting. V3 said V2(DON) was responsible for concerns related to R1 and unable to recall any further details related to R1. V3 said if a resident is experiencing a change in condition, nurses should report to clinical management, report to the physician and documents any orders. All this information should be documented in the progress notes. R1's Clinical and Order alert listing report dated 9/25/24 documents: Pain-new or worsening; Participate less in activities. R1's medical record does not document any notifications to the physician or nurse practitioner of R1 reports of increased pain, changes to skin and changes in mobility/transfer status. Radiology Results examination dated 10/01/24 at 20:45 (8:45pm) reported at 00:30 (12:30am) document: X-ray exam of lower leg. Findings: acute displaced fracture of distal tibia noted. On 10/16/24 at 6:39pm, V18 (hospital staff nurse) said, R1 presented to the emergency department with edema to the left lower extremity and no pedal pulse. The hospital did a work up and found a left tibia fracture. R1 had osteomyelitis and skin necrosis. R1's left limb was not salvageable. R1 had a through the knee amputation of left lower extremity on 10/16/24. Facility medication and treatment refusal policy dated 9/2020 documents: Patient refusal of mediation and or treatment must be recorded in the resident medical record. Under procedure: The date and time the physician was notified as well as the physician response. Facility change of condition policy dated 9/20 documents: To ensure that the resident's physician/physician on call/Nurse practitioner and responsible party is kept informed regarding the residents change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility neglected to assess R1 who was observed with a change in condition, new onset of worsening pain, redness, swollen, dark purple bruised discoloration to the left lower extremity for over four weeks . This affected one of three residents (R1) reviewed for nursing assessments and change of conditon. This failure resulted in R1 be found to have an acute displaced fracture of distal tibia from an unknown origin, osteomyelitis and skin necrosis that requiring a left through the knee amputation of the lower extremity. Findings include: R1 had the diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominate side, peripheral vascular disease, personal history of (healed) traumatic fracture and history of falls. Minimal data set section C (cognitive pattern) brief interview for mental status (BIMS) dated 8/28/24 documents a score of fourteen which indicated cognitively intact. Section GG (functional abilities and goals) documents: impairment on one side for upper/lower extremity (shoulder, elbow, wrist, hand, hip, knee, ankle, foot). R1 required substantial/maximal assistance- help does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort for roll left to right, sit to lying, lying to sitting on side of bed. Sit to stand not attempted due to medical condition or safety concerns. On 10/15/24 at 12:24pm, R1 who was assessed to be alert and oriented to person, place and time, said the facility reported she was trying to get in bed by herself. R1 said, that was a lie. R1 said, she had a stroke with left side numbness. R1 said, her left side was dead and she does not have any feeling or control on her left side. R1 said, she uses a motorized wheelchair and can't stand or walk. R1 said, her electric wheelchair has a metal plate foot rest that she can't lift in order to self-transfer. R1 said, she wanted to go to bed, two black female staff members assisted her out of her motorized wheelchair to the bed and dropped her. R1 said, the mechanical lift was broken. R1 did not recall the staff's names or the exact date she was dropped. R1 said, the incident happen about three weeks prior to her being hospitalized . R1 said, she requested to go the hospital and was denied. R1 said, was in pain for three weeks. R1 said, she has to have her leg cut off because it leg got infected due to the bone sticking through the skin. R1 said, she had to have her leg cut off or die. On 10/15/24 at 2:05pm, V9 (nurse) said, during stand-up report she was alerted that R1 had hip pain. R1 had an ultra sound schedule. The tech came to do the ultra sound and said, he could not do the ultra sound because R1's leg looked fractured. V9 said, she assessed R1 left lower leg at that time. R1's leg had a black area with dry skin. V9 said, she did not see a break/opening in R1's skin. V9 said, she was informed R1 had a history of a fracture. V9 said, V2 (don) ordered a stat x-ray. V19 (x-ray tech) incident report dated 10/01/2024 at 4:01pm documents: `When V19 arrived at the facility, the patient (R1) was not in the room, so V19 asked the nurse to inquire with the aide and have R1 placed in bed. When the patient arrived, two CNAs helped R1 into bed using a machine. Once R1 was settled, V19 entered the room and noticed that R1 appeared upset about lying down. V19 explained the procedure and assured R1 that V19 would do it as quickly as possible. Upon examining R1's leg, V19 noticed that R1's foot and lower leg were misaligned, it look's displaced and foot dangling. It was swollen and discolored around the distal lower leg. V19 asked R1 if she had received an X-ray of her left leg or ankle, but she could not remember. Concerned about moving her leg, V19 asked the nurse if an X-ray had been ordered, but she said none had been ordered but wanted to be sure, so she called the Director of Nursing (DON) and the Administrator. The Nurse and DON checked the leg and informed me that the patient had suffered a fracture a long time ago. They advised me to proceed with the Doppler procedure and assured me that an X-ray would be ordered. They even asked V19 to perform the X-ray, but V19 explained that we have different techs and machine for that purpose. V19 suggested they call the office. Radiology Results examination dated 10/01/24 at 17:12 (5:12pm) reported at 19:36 (7:36pm) documents: Bilateral lower extremity arterial Doppler ultrasound Left ABI was not attempted due to possible fracture. Wound in left lower distal leg. Discoloration in left foot. On 10/16/24 at 12:36PM, V1 (administrator) said, she was informed by the team that R1 had some pain, tenderness and refused to have an ultra sound on 9/25/24. V1 said, she was informed, prior to that R1 was trying to self-transfer. R1 use to stand and pivot but R1 had to be transferred with the mechanical lift. V1 said, V10 (treatment nurse) said, R1 had a history vascular diseases so she ordered a Doppler. V1 said, she is not aware of who completed a pain assessment or body assessment for R1 on 9/25/24 when she was informed about R1 pain and tenderness. V1 said, she was not a nurse. V1 said, she went to speak to R1 by herself after stand-up. R1 reported no one harm her. R1 denied attempting to get up. R1 was alert and oriented times three. We found out that R1 had a fracture on 10/1/24. On 10/16/24 at 1:20pm, V16 (cna) said, R1 had a darken discoloration area on the left ankle the size of palm. V16 said, the discoloration looked like gangrene which she had seen before on another resident in the past. V16 said, she reported to V4 (unit manager). V16's witness statement dated 10/2/24 documents: on the 25th, V16 saw R1 and she had dark color by her ankle. R1 was in pain. V16 reported to V4. V16 had not seen this dark color on R1 in days prior. V16 asked R1 what happen, she said she didn't know. We transferred R1 with a mechanical lift because we didn't want R1 to stand. V16 asked the nurse what was going on with her foot and she said they were doing an x-ray. V16 texted on 9/25 at 9:17am about the dark ankle. On 10/16/24 at 1:30PM, V10 (treatment nurse) said, she was informed that R1 had a bruise on her lower leg. V10 said, based on R1's history of Peripheral Vascular Disease she notified the doctor, got an order for a Doppler. V10 said, she did not conduct any type of body assessment. V10 said, the body assessment should have been done by the nurse. V10 said, she does not treat bruises. On 10/16/24 at 6:00pm, V20 (complainant) said, R1 came to the emergency room with thick wool socks and heavy shoes on. R1 complained of pain at an eleven out of ten (11/10). R1's lower left leg wound did not have a dressing in place. The nurse reported, R1 had a fracture and a part of R1's leg bone was showing. R1 reported, she was transferred by staff and dropped. R1 reported, she complained of pain but the facility didn't do anything. On 10/16/24 at 6:39pm, V18 (hospital staff nurse) said, R1 presented to the emergency department with edema to the left lower extremity and no pedal pulse. The hospital did a work up and found a left tibia fracture. R1 had osteomyelitis and skin necrosis. R1's left limb was not salvageable. R1 had a through the knee amputation of left lower extremity on 10/16/24. On 10/17/24 at 9:39am, V17 (cna) said, R1 started complaining of pain at the end of August to her left contracted leg. R1 always complained of pain. R1 reported she fell while attempting to self-transfer. R1 complained of pain being worst, most severe than her normal pain level after her self-reported transfer/fall. V17 said, R1 was able to get herself up off the floor and back into the wheelchair. V17 said she did not witness R1's fall or the self-transfer. V17 said, R1 was dependent with transfers. R1 was able to stand and pivot on her non-contracted leg with one person physical assistance. V17 said, she reported the incident to the nurse, agency nurse and all the nurse managers every day during stand up report. V17 said, stand-up report is where the nurse and managers get reports about resident from the cnas. V17 (cna) witness statement undated documents: When was the last time you provide care for R1? Not sure, sometimes this week, V17 was not her c.n.a but V17 did assist V24 (cna). How was R1 transferred? With a mechanical lift. Did she complain about pain? Yes, she did. Who did you notify? V17 notified V9 (nurse) and agency nurse and during stand up. R1 has been complaining for about a month. Two weeks ago, V17 was providing showers and when V17 asked her to take a shower R1 stated no because her leg was hurting. Did you notice anything wrong with her leg? V17 did not notice anything wrong with R1 leg due to R1's leg being contracted. R1 stated that, she was in pain more than usual. V17 notify the nurse about her refusal of shower and leg pain. Did she mentioned to you at any time that someone dropped her or injured her? She mentioned that night cna dropped her and couldn't tell me who, but V17 don't remember when. Who did you notify? The nurse (not sure who) and at stand up. About a month ago R1 was on her wheelchair and when asked how she got on the chair she told V17 she transferred herself and fell so she can go smoke. Did she tell you she was in pain that day? Yes, V17 informed the nurse and stand up. Anything else you would like to add? V17 know they came to so x-ray twice and R1 refused once. On 10/17/24 at 10:08am, V24 (cna) said, R1 always transferred with a one person physical assist while she stood and pivoted. V24 said, R1 reported she could not take the pain of standing up to transfer anymore. R1 started to use the mechanical lift for transfers. V24 said, she reported the nurses and nurse managers in stand-up about R1's complaint of pain, change in transfer status and the appearance of R1's leg for about a week to a week in the half prior to R1 being sent to the hospital on [DATE]. V24 said, she reported R1's change in condition every day. V24 said, R1's left lower leg was redden at first and she reported that. Next R1's leg started to swell and she reported that. Then R1's leg turned dark purple in color and she reported that in stand-up because it did not look right. V24 said, she asked R1 what happen. R1 reported two variations of what happened. R1 said, she attempted to self- transfer and fell. V24 said, she asked R1 as her leg got worst what happen again. R1 replied, she was dropped by agency cnas. V24 said, the facility did not use agency cnas. V24 said, towards the end before R1 went to the hospital, when she was putting on R1's shoes, R1's leg felt broken. V24 said, R1 leg was loose near the ankle. R1's leg was dangling. On 10/17/24 at 10:17am, V23 (cna) said, she started working for the facility on 9/9/24. R1 was a pivot with transfers. V23 said, R1 always had a bandage on her left ankle and foot. V23 said, R1 used to ask her to wrap her left leg up in the blanket in-order to apply pressure. V23 said, R1 complained of pain when she was rolled from right to left during care. During stand-up report, the question was asked if there was any change in resident's condition. V23 said, she did not report anything because all the nurse managers were aware of R1's condition. On 10/17/24 at 2:32pm, V25 (nurse practitioner) said, if a resident is having a new onset of pain she would expect the nurse to completed a body assessment to determine the location of the pain. On 10/17/24 at 2:59pm, V27 (medial doctor) said, she was aware of R1 having chronic PVD.R1 had a history of refusing care. R1 was alert and responsible for herself. V27 said, she would expect the nurse to complete an body assessment for any new or worsening pain. V27 said, a distal tibia fracture can result from a fall, trauma of the c.n.a putting too much pressure on a resident's limb, V23 (cna) witness statement undated documents on the 27th or 28th, R1 pivots with my assistance. R1 complained about the leg with a bandage on it. R1's Clinical and Order alert listing report dated 9/25/24 documents: Pain-new or worsening; Participate less in activities. Radiology Results examination dated 10/01/24 at 20:45 (8:45pm) reported at 00:30 (12:30am) document: X-ray exam of lower leg. Findings: acute displaced fracture of distal tibia noted. Nursing Note dated 10/2/2024 document: Observed R1 at 7:30 am, she was roaming around in her wheel chair getting ready for breakfast. Looked over R1's X-ray results of the leg and it was reported she had a fracture. Nurse asked R1 could she perform a full body assessment R1 declined. Communicated results to doctor who stated to send R1 out to the hospital. Nurse went to R1 and told R1 we would be sending her to the hospital because she has a fracture. R1 was very upset and didn't want to go the hospital because she didn't want to miss her smoke breaks. Offered R1 pain medication and she declined because wanted her oxycodone but nurse informed R1 it was too early because it had not been 6 hours since the last time she received it. R1 refused any other pain medication. V12 (cna) witness statement dated 10/3/24 documents: V12 stated a few weeks ago on a Saturday, she noticed R1 transferred herself to the chair, she stated R1 told the nurse that she was in pain. She stated nurse instructed the c.n.a's to left R1 out to go smoke. V12 stated, she notified V2 (don) in regards to R1 complaining of pain, V12 stated that R1 has always been a time one person assist in transfers until just recently on 9/25/24. V22 (R1's nurse on 9/25/24) witness statement dated 10/3/24 documents: What type of care does the resident require? I/(V22) am not certain of the type of care she (R1) required. V22 did not have access to the computer system because there was a delay in getting her login information and V22 was not familiar with the computer system. 9/25/24 was the first time V22 took care of R1. V22 was at the facility from 7:30AM-10:30AM then sent home. V22 was not aware of any occurrence that may have occurred with R1. R1 was screaming in pain wanting her oxycodone. R1 was not scheduled to get her oxycodone until 11:50AM but R1 would stop screaming if she could get it at 11AM.What actions, if any did you take in response to the allegation? None because V22 was not aware of any allegations of abuse. If you're familiar with the alleged victim, have you noticed any change in alleged victim's behavior because of the alleged abuse? V22 was not familiar with R1's normal behavior. Facility abuse policy dated 9/20: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. Neglect is the failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, pain mental anguish or emotional distress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviewed the facility failed to provide supervision for one high fall risk resident who was restless and attempting to ambulate unassisted, and failed to provide clinical staff assistance to promote a safe sitting position for a high fall risk resident who was seen leaning in her wheelchair. These failures affect two of three residents (R1, R2) reviewed for supervsion and safety. These failures resulted in R1 sustaining an acute nondisplaced right femoral neck fracture and R2 sustaining a closed nondisplaced fracture of the fourth cervical vertebrae. Findings include: 1. According to the facility incident report dated 6/13/24 R1 tried to stand from a sitting position and sat on the floor. R1 is cognitive impaired according to his assessment dated [DATE], score of 3. R1's diagnosis include but are not limited to Vascular Dementia, Chronic Kidney Disease, Other Lack of Coordination, Weakness, Alcohol Dependency, Rheumatoid Arthritis, Osteoarthritis, and Spondylosis. On 7/17/24 at 12:10PM V6, Certified Nursing Assistant (CNA), said R1 was ambulatory, he was walking around most of the shift. V6 said since V6 came at 11:00PM R1 was awake and walking around in the halls. V6 said around 2:00AM and 3:00AM R3 stood up in the hall and he was walking. V6 said R1 was in the hallway the entire night. V6 said R1 said he was waiting for a taxi. V6 said she last saw R1 when he was sitting in a chair near the medication room. V6 said she was in the hallway doing rounds. V6 said V6 heard him, and when V6 saw him, he was on the floor. V6 said V8, CNA, was next to R1 and was helping him at his side. V6 said we had snacks available, but V6 did not give R1 any that night. V6 said V6 did not take R1 to the bathroom that night. V6 said usually, R1 may use the bathroom or be incontinent. On 7/17/24 at 12:32PM V8, CNA, said R1 was walking and then sitting down. V8 said V8 had asked R1 to sit and he did, but then he started walking and he fell. V8 said R1 had been sitting near the nurses station. V8 said to reach R1 when he was sitting, V8 would need to walk out and around of the nurses station. V8 said that was the first time V8 had seen R1 during the shift. V8 said V8 doesn't know if R1 slept during that shift, I did not offer him a snack or assist him to use then bathroom that shift. V8 said when R1 fell, he fell forward, when I saw him he was flat on his belly, his legs straight out, he was not on his face. V8 said V8 was at the desk doing V8's assignment, V8 was not monitoring R1. On 7/17/24 at 5:26PM V15, Registered Nurse said on 6/13/24, R1 was placed at nurses station to monitor him. V15 said when V15 put him there, V15 was at the nurses station doing paper work. V15 said V15 doesn't know if the CNA was there. V15 said R1 was sitting in a chair. V15 said R3 was awake during the night and not wanting to sleep. So we put him a chair. V15 said they did not tell V15 that R3 was a high fall risk. V15 said V15 did not assign anyone to monitor R1 when V15 went to the restroom. V15 said V15 was not informed if he was taken to the bathroom during the shift. V15 said R1 needed assistance with ambulation. V15 said V15 was in the bathroom when R1 fell. V15 said he did not see R1 on the floor because R1 was standing up already when he returned to the unit. On 7/17/24 at 2:37PM V13, Restorative Nurse, said R1 fell related to confusion and unsteady gait and he sustained an injury. V13 said V13 is not aware of interventions the staff had offered him prior to his fall. V13 said R1 may have been placed close to the nurses station. V13 said R1 could walk, but not independently, it was not safe for him. V13 said if R1 was having behaviors we would do 1 person assist for safety or if he was agitated he would need 2 persons. V13 said R1 had a hip fracture from the fall. R1's Functional Abilities assessment dated [DATE] documents R1 is dependent on staff to come to a standing position from sitting in a chair and walking was not attempted, no score at the time of the assessment. R1 was documented to be dependent on staff to use a motorized wheelchair. R1's Bladder and Bowel assessment dated [DATE] documents he was frequently incontinent of both bowel and bladder. Health Conditions assessment dated [DATE] indicates R1 had a fall in the last month and up to 6 months prior to admission. R1's Physical Therapy Notes from 6/9/24 - 6/12/24 notes R1 was able to ambulate with the use of a rolling walker and 1 therapist assistance. On 6/10/24 R1 required manual guidance and Max assistance while ambulating. R1's care plan initiated 6/8/24 states R1 is a HIGH RISK for falls. R1's x-ray dated 6/13/24 impression: acute nondisplaced right femoral neck fracture. The Facility Reported Incident report states following the fall on 6/13/24 R1 was sent to the hospital for further evaluation. According to progress notes, R1 returned to the facility on 6/18/24 after having surgery for a right hip fracture and 7 stitches. 2. R2's diagnosis include but are not limited to Dementia, Bilateral Cataract, and Dependency on Wheelchair. R1's cognitive assessment dated [DATE] indicates she is severely cognitively impaired with a score of 3. Progress notes dated 3/19/24 document R2 utilizes a reclining (brand name) chair for mobility. On 5/24/24 R2 was seen leaning forward in her wheelchair and falling forward. R2 sustained closed fracture of cervical vertebrae. R2's care plan initiated on 10/12/17 documents R2 is at risk for falls related to poor safety awareness secondary to Dementia and history of falls. R2's Functional Abilities assessment dated [DATE] indicate she is dependent on staff for all activities of daily living. Facility Reported Incident Report dated 5/24/24 notes R2 was leaning and fell forward onto the floor. R2 was sent to the hospital for evaluation. Facility was notified R2 was admitted with diagnosis of closed fracture of cervical vertebrae. Progress notes dated 5/28/24 document R2 returned to the facility on 5/28/24 with diagnosis of closed nondisplaced fracture of the fourth cervical vertebrae and right shoulder AC joint separation. On 7/16/24 at 1:56PM V2, Licensed Practical Nurse, said R2 leaned forward and hit the ground. V2 said R2 hit her shoulder and the left side of her forehead. V2 said V2 saw R2 first and the activity aide. V2 said V2 became aware that R2 fell because V2 heard the sound and then V2 looked. V2 said V2 had seen R2 in the TV room before the fall, but was not sure if she was awake. V2 said V2 remembers R2 was in a wheelchair. V2 said the wheelchair stayed in the upright position when R2 fell. V2 said V2 assessed R2 first, did vitals, looked at the bruising on her head and saw redness to her arm. V2 said V2 was sending R2 out because she hit her head, she went out 911. V2 said normally R2 was quiet and non verbal, needs assistance feeding, sits in the chair, does not do activity, she can watch TV. V2 said R2 is assisted by staff and requires total care. V2 said R2 is not able to stand with staff assistance. V2 said R2 was not reaching, she may have gotten tired. V2 said V2 saw her lean in her chair in the past. V2 said the activity staff was in the room when R2 fell, but she was assisting someone else on the opposite side of the room. V2 said R2 was a fall risk. V2 said R2 was at risk because she was not mobile, falls asleep in the chair, and her transfer status is dependent. V2 said R2 was found to have a fractured vertebrae and fracture to right shoulder, and upon readmission to the facility had neck brace and sling. V2 said R2 had a reclining chair as part of R2's fall prevention interventions, and V2 doesn't know if it was reclined when she fell. V2 said it should have been reclined. V2 said the reclining chair was ordered for R2. On 7/16/24 at 2:44PM V3, Certified Nursing Assistant (CNA), said V3 heard R2 fall, V3 went to the TV room to see what happened. V3 said it was a big sound, like something had fallen. V3 said V3 heard it while V3 was standing by the elevator. V3 said when V3 arrived to the TV room, V3 saw R2 on the floor. V3 said R2 had fallen from a tall wheelchair, it had an extended back, to lean back. V3 said for fall precautions we would recline her back in the chair. V3 said V3 think R2's fall was like a dead weight fall. V3 said I don't remember what position the chair was in when R2 fell. V3 said V3 was not assigned to R2, V3 did not get her up that day. On 7/17/24 at 10:29AM V4, Activity Aide stated V4 was in the room giving exercise classes to the resident. V4 said V4 noticed R2 was leaning and V4 adjusted her in her chair. V4 said V4 moved her so she would sit up and not be leaning. V4 said then R2 was leaning again and V4 could not get to her. V4 said R2 fell forward, it happened like in a second. V4 said V4 doesn't know what kind of chair R2 was in, it was some sort of wheelchair. V4 said it was new for her to be leaning like that. On 7/17/24 at 1:49PM V12, Memory Care Director, said activity staff can not reposition residents. V12 said the activity staff would not use devices or recline residents in the chairs. V12 said the activity staff are not clinical. V12 said the activity staff needs to ask for assistance from a nurse or CNA if the resident needs to repositioned. V12 said none of my activity staff are CNAs. On 7/17/24 at 2:37PM V13, Restorative Nurse, said the nurse said R2 fell from the chair. V13 said R2 leaned forward from the chair. V13 said R2 had a high back wheel chair with a taller back and can be reclined. V13 said V13 doesn't know if the chair was reclined when she fell. V13 said R2 used the reclining chair because she had poor trunk control. V13 said when she needs repositioning in the chair, staff should come and redirect her. V13 said CNA's or nurses, no one else, can recline the chair, the clinical team. V13 said V13 had seen her lean before. V13 said if other staff see R2 leaning, they should call a CNA and say that she is leaning. V13 said V13 had done a physical assessment in the past, to determine if the reclining chair was appropriate for her. V13 said V13 felt it was appropriate for her. V13 said V13 did not document that assessment. V13 said when completing fall investigations the restorative team is responsible for the root cause analysis. V13 said we were not documenting the root cause analysis at the time R2 had her fall. The facility activity aide job description was reviewed. Job description does not indicate responsibility for repositioning of residents. The facility policy management on falls dated August 2020 states the facility will assess hazard and risk develop a plan of care to address hazards and risk implement appropriate resident interventions and revise the residents plan of care in order to minimize the risk for fall incidents and or injuries to the resident. Develop a plan of care to include goals and intervention transfers. Provide this probability as appropriate for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R17 is a [AGE] year-old female with a diagnoses history of Fracture of Left Femur, Partial Paralysis due to Cerebrovascular Disease Affecting Left Non-Dominant Side, History of Falling, Generalized Anxiety Disorder, and Nicotine Dependence who was admitted to the facility 05/13/2019. On 02/06/24 at 11:25 AM R17 stated she fell 2 to 3 months ago but has no memory of the fall. R17 stated she was on blood thinners, and her head filled up with fluid, so she was afraid touch it. R17 stated she also fell 6 months ago because she couldn't get any help when she needed it. R17 stated she broke her femur during the last fall. R17 stated she had a metal rod in her leg and broke it because she fell so hard. R17 stated the doctors told her they had never seen anything like that. R17 stated she's a sleepwalker and wonders if she was trying to walk when she fell and broke her leg. R17 stated last night they put something on the right side of her bed so she couldn't move because she keeps leaning towards that side. R17 stated she's been in a lot of pain since her fall. R17's current care plan initiated 05/23/2019 documents she has an ADL (Activities of Daily Living) Self Care Performance Deficit secondary to weakness, history of CVA (Coronary Vascular Accident) with left hemiplegia/limitation in range of motion, wheelchair being primary mode of locomotion, COPD/shortness of breath (continues to smoke), impaired balance, history of falls, occasionally incontinent, chronic pain and anxiety; has behaviors of not asking for help although she requires it, and often refuses help; her ADL's tend to fluctuate related to this behavior with interventions including: Encourage palm protector to left hand; Allow enough time for completion of ADL tasks. Do not rush the resident; Assist with ADL tasks as needed; Assist with personal hygiene as needed; Assist with toileting needs as necessary; Encourage resident to participate as able in ADL's, Encourage to participate to the fullest extent possible with each interaction; Nurse encourage use of call light for assistance when needed; Monitor for any signs and symptoms of pain/discomfort during ADLs; Offer as needed analgesics prior to ADL activities and/or rehab if indicated; Palm protector to left hand, encourage resident daily to allow staff to apply; Provide needed level of assistance and support to complete Activities of Daily; Physical/Occupational Therapy evaluation and treatment as per physician orders. R17's current care plan initiated 05/23/2019 documents she is at risk for falls secondary to history of falls, incontinence, left partial paralysis, anxiety, pain, use of opiates, use of psychotropic medication and hypertension., R17 is impulsive, does not always wait for assistance for transfers, noted with impulsive behaviors, continued poor safety awareness and judgement with interventions including: Add Call Don't fall Posters in several areas of room for reminders to ask for assist; Encourage appropriate use of wheelchair; Encourage R17 to ask for assist with all transfers including toileting; Encourage resident to Call, don't fall; encourage resident to report falls as they happen; Encourage R17 to be aware of her surroundings; Encourage the use of a reacher for hard to reach places; Encourage/Remind R17 to wait for assist and if she feels it's taking a bit longer than she expects, call reception to let them know you are waiting for assist rather than doing on her own; Ensure resident is positioned in middle of bed; Evaluate multiple falls to determine commonalities or patterns; Promote placement of call light within reach; Provide 1:1 supportive counseling, reiterating the importance of becoming/remaining treatment plan compliant, especially as it relates to R17's safety; Provide an environment clear of clutter; Provide proper, well maintained footwear; Staff to ensure resident removes her shoes before bed and place in wheelchair for her; Supply a clock resident can see during night time hours; Will review care plan on return from Hospital (Date Initiated: 09/05/2023). R17's physician progress note dated 9/1/2023 at 09:42 AM documents Pain assessment interview was conducted for R17 today; she states frequent Left Hip and neck pain in the last 5 days. R17 describes the pain as stabbing and crushing that make it hard to sleep at night. Incident Report dated 09/02/2023 states at approximately 10 AM R17 self-reported a fall, no visible signs of injury noted, when she was interviewed, she was not really able to state how fall occurred. R17 complained of pain in right hip area, and x ray was ordered, and results were negative for a fracture. However, she continued to complain of pain in left lower extremity on 09/04/2023, an x-ray was ordered and results were positive for a fracture of left femur. Physician was notified with orders received to send her to the emergency room for further evaluation. R17 uses a low bed and floor mats and was not able to state exactly what happened. Per staff R17 was last observed in her bed at 10PM. Predisposing factors include gait imbalance, poor safety awareness, and weakness. R17's X Ray results dated 09/04/2023 documents a positive result for fracture of left distal femur. R17's progress note dated 9/5/2023 2:14 PM documents: This writer was made aware the resident has a fracture on her left distal femur and received order from physician to send her to the emergency room for further evaluation and treatment. R17 verbalized pain to her left hip and had been administered an opioid at 6 AM. R17 refuses to go to hospital because she has not been able to smoke. The restorative RN spoke to R17. R17 was transferred from the first floor to the emergency room and left the facility at approximately 09:30 AM. The incident investigation paperwork provided by the facility did not include documentation of a thorough investigation. This paperwork includes two undated witness statements from V41 (Morning Shift Certified Nursing Assistant) stating R17 could not remember exactly when she fell but she remembered landing on her matt. She has a habit of forgetting to use the call light for assistance; and from V21 (Restorative Nurse) stating R17 can't recall exactly what day and time she fell but remembered landing on her floor mats. R17 forgot to call for assistance and just got herself up to bed. R17's Post Occurrence Documentation progress note dated 1/13/2024 04:40 PM documents: Resident was observed on the floor by her bedside in a right side lying position, R17 was transferred back to bed by two nursing staff. On 02/08/24 at 01:21 PM V5 (Restorative Nurse/LPN/Fall Coordinator) stated R17 refuses assistance and won't wait for assistance especially if trying to go out and smoke. V5 sated R17 might have been half asleep when she fell 09/02/2023. V5 stated R17 often falls asleep in her chair. V5 stated she has had many conversations with R17 about safety awareness and she will listen but will not always correct her behaviors. V5 stated sometimes R17 will be receptive to redirection and sometimes she will continue to do as she pleases. V5 stated normally R17 has a fall when transferring herself when going to smoke. V5 stated we've tried to have someone go out with R17 when she wants to smoke to accommodate her smoking times but often she won't wait for assistance. V5 stated in January it seems R17 missed the chair when getting ready to go smoke. V5 stated R17 likes to smoke before she eats. V5 stated revising R17's care plan interventions for falls may not be received well from R17. V5 stated R17's current fall interventions are sometimes effective in preventing her from falling. V5 stated besides assisting R17 when going to smoke she could not provide any additional personalized interventions to prevent her from falling. V5 stated educating R17 and constant monitoring when she wants to smoke are some possible interventions for preventing her from falling. 3. R109 is a [AGE] year-old female with a diagnoses history of Partial Paralysis due to Brain Hemorrhage, Epilepsy, and History of Falling who was admitted to the facility 10/21/2023. On 02/05/24 at 11:34 AM Observed R109 sitting on the edge of a geriatric chair leaning forward in the 2nd floor dining area unsupervised by staff for several minutes. V42 (Certified Nursing Assistant) stated R109 is not a fall risk. On 02/06/24 at 11:09 AM Observed R109 seemed uncomfortable & didn't look well. R109 reported she had a fall yesterday and a couple of days ago. R109 stated she has some pain on her right upper arm and the right side of her head. R109's current care plan initiated 11/20/2023 documents she is at risk for falls, she has an ADL (Activities of Daily Living) Functional, Performance Deficit; she is a confused [AGE] year-old female readmitting to the facility after being stabilized at hospital post a suspected internal hemorrhage; she experiences weakness and gait abnormality with the Diagnosis of: End Stage Renal Disease, partial paralysis following a brain hemorrhage, COPD, Diabetes Mellitus 2, Hypertension, bacteremia, epilepsy, GERD (Gastro Intestinal Reflux Disease, Non Rheumatic valve stenosis, anemia in chronic kidney disease, cataracts, dependence on renal dialysis, hyperlipidemia, and hypothyroidism; she requires substantial max assistance with most ADLs and is incontinent of both bowel and bladder; and she has a documented history of falls within the last 6 months with interventions including: assist with ADL tasks as needed., Cue resident to grasp side rail and pull herself up to a sitting position or to the side of bed, Monitor/document/report to Nurse any as needed changes in ADL ability, any potential for improvement, reasons for inability to perform ADLs, Provide needed level of assistance and support to complete Activities of Daily Living; Assure resident is wearing eyeglasses; Encourage appropriate use of walker; Promote placement of call light within reach; Provide an environment clear of clutter; Provide proper, well maintained footwear; psych consult for anxiety medication. R17's current care plan initiated 12/12/2023 documents she has potential for injury related to seizure disorder with interventions including: Keep call light within reach. R109's current care plan initiated 12/04/2023 documents she has anxiety symptoms, as evidenced by constantly putting herself on the floor next to her bed, delusions such as stating that a person she knows is present but not there, and false accusations with interventions including: Assure bilateral mats are next to bed. Incident Report/Post Occurrence Documentation 11/20/2023 at 10:30 AM documents at approximately 10:30 A.M. CNA (Certified Nursing Assistant) reported that resident was on the floor in her room. Nurse immediately went to resident's room and observed her on the floor on the left side of her bed lying on the floor mat with her upper body under the bed facing the window. Nurse and staff pulled her out from under the bed. Resident was wearing gown, clean and dry brief and one sock on her right foot. Both quarter side rails were up and in a locked position. Lighting was adequate and floor was dry. Resident was very restless. Resident was observed by nurse approximately 20 minutes prior to incident and was very restless and grabbing at left side rail. Resident was redirected and calmed. Predisposing factors include confusion, gait imbalance, poor safety awareness, recent change in medications, recent illness, weakness, and improper footwear. Fall was unwitnessed. Incident Report dated 01/27/2024 at 5:21 PM documents R109 reported she fell yesterday but didn't tell anyone. Fall was unwitnessed. Predisposing factors include recent change in cognition. R109 was last observed prior to incident by nurse at 3:45 PM. R109's Progress note dated 1/28/2024 at 06:58 AM documents local hospital was called, nurse stated resident admitted into hospital due to fall. R109's hospital report dated 01/28/2024 documents she was placed on high fall risk interventions while in the emergency room; she presented from nursing facility with chief complaint of shortness of breath, she also fell. Incident Report/Post Occurrence Documentation dated 2/3/2024 11:52 PM documents R109 was observed in a sitting position with wheelchair behind her in her room outside the washroom door. R109 stated she was trying to get up from her wheelchair to use the washroom and slid down to a sitting position on the floor. Assisted back to bed with another nursing staff. Was encouraged and educated on use of call light and waiting for assistance from staff, was educated as well on locking wheelchair, resident demonstrated proper locking of wheelchair and use of call light. Predisposing factors include noise, and poor safety awareness. R109 was last observed prior to incident at 10:15 PM. Fall was unwitnessed. R109's Progress note dated 2/4/2024 10:45 AM documents reminded patient to call for assistance. Do not get up without assistance. Patient did not follow instructions. Patient got into wheelchair minutes after I reinforced to use call light, which is close to her. She insisted to go bathroom and not wait. R109's Progress note dated 2/6/2024 10:53 PM documents Notified by CNA (Certified Nursing Assistant) that resident had unwitnessed fall last night and hit her head 1st then right shoulder on bed and slid to the floor. Some discomfort to right shoulder with range of motion. On 02/08/24 at 01:21 PM V5 (Restorative Nurse/LPN/Fall Coordinator) stated she understands R109's urgency in going to the bathroom because she is diabetic. V5 stated in addition to R109's medical acuity, many times she says she needs to use the bathroom and tries to transfer herself. V5 stated R109 is impulsive and has anxiety and requires constant education on safety awareness and using call light to let CNA's (Certified Nursing Assistants) know she needs assistance. V5 stated re-education has not prevented R109 from falling. V5 stated additional fall interventions for R109 may include educating the staff on anticipating her needs, and possibly having her moved closer to the nurses station with the family's approval. V5 stated R109 is one of the facility's falling stars residents. V5 stated falling stars are residents considered high fall risks and they are constantly being monitored by staff. V5 stated every morning during the standup meeting residents who are high fall risk and residents who require frequent monitoring are discussed. V5 stated when R109 is out of her room she should be in the presence of staff. V5 stated if residents are high fall risks and are up and, in their wheelchairs, they should be kept engaged in activities and out of their room. V5 stated most of R109's falls are unwitnessed, and she seems to have a pattern of falling in the evenings which is when she seems to be more active. V5 stated during those times R109 should possibly be monitored more frequently. V5 stated these interventions would be more personalized for R109. 4. R535's medical records indicated resident admitted to the facility on [DATE] and discharged on 01/19/2024. Resident had a past medical history not limited to: hypertension, tremors, anemia, syncope and collapse, psychotic disorder with delusions, vascular dementia, insomnia, palliative care, and Parkinson's disease. R535's care plan with closed date of 01/25/2024 reads in part: had an actual fall with minor injury of small laceration to left eyebrow due to unsteady gait, poor safety awareness and poor endurance and trunk control (11/12/2023) with interventions to continue interventions on the at-risk plan (11/13/2023), monitor/document/report as needed x 72 hours to physician for signs/symptoms of pain, bruises, change in mental status, or new onset of confusion, sleepiness, inability to maintain posture, agitation (11/13/2023); resident will be monitored and placed on high traffic areas for close monitoring and frequent monitoring (11/13/2023). Care plan also indicated that R535 was a high risk for falls secondary to altered elimination pattern, cardiovascular disease, cognitive deficits, history of fall(s), medications that could affect functional level, level of consciousness, gait, visual acuity or cognitive ability, muscle weakness, poor safety awareness, use of assistive devices, use of psychotropic medication and Parkinson's with tremors; notify family and physician of any new fall (04/29/2022). Care plan also indicated R535 had a potential for alteration in skin integrity due to history of laceration to the right eyebrow and multiple medical diagnoses. R535's Fall Risk assessment dated [DATE] indicated resident fall risk score at 11. Scoring guidelines per assessment indicated, for scores 0-11 at risk-implement general safety interventions. Facility presented fall incident list dated 02/05/2024 for date range of 09/05/2023 to 02/05/2024 that indicated R535 had fall incidents on 11/11/2023 at 08:30 PM and 11/23/2023 at 11:30 AM. Facility presented final report investigation completed by V2 (Director of Nursing) dated 11/17/2023 that indicated on 11/11/2023, R535 was observed with active bleeding to his left eyebrow, and was sent out emergently to a local hospital for further evaluation. R535 returned to facility with laceration to left forehead that was closed with skin glue. R535's Nurses Note dated 11/11/2023 20:55 indicated the same. Reviewed hospital after visit summary dated 11/11/2023 that indicated R535 was seen for a laceration that was repaired with skin glue. Facility investigation report indicated R535 was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4, and fall incident was unwitnessed yet concluded that R535 reported slipping and sliding while ambulating from bathroom, fell and then crawled to his bed where he had hit his forehead on the bedframe while pulling himself back into bed. Resident was discharged from facility during investigation and was not available for interview. On 02/07/2024, upon further record review, noted Hospice Note dated 11/12/2023 11:19 that indicated R535 had been increasingly weaker and had two falls with injury within 24 hours. Nurses Note dated 11/23/2023 11:12 indicated writer was informed by housekeeping that resident was on the floor, in another patient's room laying on the floor when found by the writer; patient will be transferred to local emergency department for further observations. Hospice Note dated 11/27/2023 22:37 indicated R535 had an unwitnessed fall in his room and was found between his roommate's bed and the wall and sustained a 2.5 centimeter (cm) x 0.3cm laceration to the right brow with active bleeding. First aid was provided and fall protocol was initiated. On 02/07/2024, requested complete fall incident investigations for the following fall incidents: second fall within 24 hours indicated in 11/12/2023 hospice note, and for fall incidents on 11/11/2023, 11/23/2023, and 11/27/2023. V1 (Administrator) only provided a typed, undated and unsigned statement by the nurse on duty at time of incident related to R535's 11/11/2023 fall incident. On 02/08/2024, facility presented hospice certification of terminal illness statement dated 01/03/2024 that indicated R535 had multiple falls over the last few moths and difficulty maintaining trunk strength signed by V28 (Medical Director). No other investigation reports were provided by facility for R535. Facility provided document titled, Management of Falls policy dated 08/2020 reads in part: Policy: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident ' s plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Procedure: 1. Complete a Fall Risk Assessment upon admission, re-admission, with significant change, post-fall, quarterly, and annually. 2. Orient resident to room, call light, unit and location of the nurse ' s station upon admission to the facility. 3. Develop a plan of care to include goals and interventions which address resident ' s risk factors. Risk factors may include but are not limited to the following: Contributing diagnoses/disorders/disease processes / active infections/other comorbidities, history of fall incidents, Incontinence, Medications (Narcotics, Anti-hypertensives, etc.), assistance required with ADL ' s, gait/transfer/balance issues, Behaviors, and/or cognitive status. 4. Provide assistive devices for mobility, hearing and vision as appropriate for the resident. 5. Assess appropriateness for resident to participate in skilled therapy or restorative programming in order to maintain or improve physical function of resident. 6. Assess and monitor resident ' s immediate environment to ensure appropriate management of potential hazards. 7. Monitor for changes in medical condition and notify physician as necessary to manage changes in status of the resident. 8. Conduct Care Plan Meetings with Resident, Responsible Party, and Facility Interdisciplinary Team quarterly and as needed. 9. Review and/or modify the resident ' s plan of care at least quarterly and as needed in order to minimize risk for fall incidents and/or injury. Facility provided document titled, Incident/Accident Reports policy dated 09/2020 reads in part: Policy: The Incident/Accident Report is completed for all unexplained bruises or abrasions, all accidents or incidents where there is injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitors or other, and resident-to-resident altercations. Procedure: An accident refers to any unexpected or unintentional incident, which may result in injury or illness to resident. This does not include adverse outcomes that are a direct consequence or treatment or care that is provided in accordance with current standards of practice (e.g., drug side effects or reaction). 1. All serious accidents or incidents of residents 2. All injuries of staff, families, and visitors 3. All unusual occurrences 4. All situations requiring the emergency services of a hospital, the police, fire department, or coroner 5. Any type of resident abuse 6. Resident to resident altercation 7. Suicide or attempted suicide 8. Any condition resulting from an incident requiring first aid, physician visit, or transfer to another health care facility 9. An incident/accident report is to be completed and shall complete and shall include: a. date and time of incident/accident b. description and possible cause of incident, physical assessment, injuries noted, vital signs, treatment rendered, and notification of appropriate parties. 10. The facility shall maintain a file of each incident and accident affecting a resident that is not expected outcome of a resident's condition or disease process. A descriptive summary of each incident or accident affecting a resident shall also be recorded in the progress notes or nurse's note of that resident. 12. The Director of Nursing, Assistant Director of Nursing or Nursing Supervisor must notify: a. The Illinois Department of Public Health (IDPH) of any serious incident or accident, Serious means any incident or accident that causes physical harm or injury to a resident. b. The facility shall, by fax or phone, notify the regional office within 24 hours after each reportable incident or accident. c. The facility shall send a narrative summary of each reportable accident or incident to the Department within seven (7) days after the occurrence. 13. e. A minimum of seventy-two (72) hours of documentation by all three shifts on resident status after the incident or accident, vital signs, mental and physical state, follow-up, tests, procedures, and findings are to be determined. 14. All incident/accident reports are reviewed, signed, and investigated by: a. the administrator; and b. the director of nursing or the assistant director of nursing 15. Facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Facility policy: Smoking Policy, dated 8.2023: Policy: The facility will assess hazards and risk factors associated with smoking, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care to minimize the risks of incidents/accidents associated with smoking. The facility's policy for Management of Falls reviewed 02/08/2024 states: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Develop a plan of care to include interventions which address resident's risk factors. Review and/or modify the resident's care plan as needed in order to minimize the risk for fall incidents and/or injury. Based on observation, interview, and record review, the facility failed to follow their policy and procedures for fall prevention by failing to implement personalized fall prevention interventions and failing to supervise a dependent resident with impulsive behaviors. These failures applied to three of 15 residents (R17, R73, R109, R535) reviewed for accidents/supervision and resulted in R17 sustaining a left femur fracture and R73 sustaining a subarachnoid hemorrhage. Findings include: R73 is a [AGE] year-old, male, admitted in the facility on 04/07/2017 with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side; Aphasia Following Cerebral Infarction; and History of Falling. Per MDS (Minimum Data Set) dated 09/08/23, R73 has BIMS (Brief Interview for Mental Status) score of 11, which means moderate impairment in cognition. According to incident report dated 11/19/23, V6 (Registered Nurse, RN) was notified that R73 had a fall in the smoking patio. V6 went to see R73 and was observed lying on the ground with his head pointed towards the left side of his motorized wheelchair. V7 (Activity Director) who was present at the time of incident stated that he started to tilt to the left and she (V7) tried to brace his fall but could not. Progress notes dated 11/19/23 indicated that he (R73) was not strapped in at the time of fall. On 02/06/24 at 11:05 AM, R73 was observed smoking on the outside patio. R73 is alert, oriented, with right hand contracture. He had right above knee amputation. He is unable to talk and carry a full conversation but able to say yes or no, nods head, moves left hand and left leg and can communicate with gestures. He (R73) is using a motorized wheelchair and had the safety belt fastened and secured. R73 was asked regarding fall incident last 11/19/23. R73 communicated via gestures, that he was at the smoking patio, in his motorized wheelchair. He was repositioning himself in the wheelchair and slid. He also communicated that there were staff on the patio, and he tried to ask for help by raising his left hand, but staff did not respond. On 02/06/24 12:05 PM, V7 (Activity Director) was interviewed regarding R73's fall last 11/19/23. V7 replied, That incident with R73, it was the 11 AM smoke. I was the designated staff to supervise. I was lighting cigarettes of other residents. I was on the other side of the table where he (R73) was sitting. I noticed that he was actively tilting. I went there and not able to catch him on time. He fell. He didn't call my attention. He is non-verbal but he can raise his right hand for assistance. Progress notes dated 11/19/23 documented that R73 was assessed and was transferred out to the emergency room for further evaluation and management. R73's Hospital records under Trauma Progress Notes dated 11/24/23 recorded: Diagnosis: Acute right subarachnoid hemorrhage. On 02/06/24 at 1:43 PM, V2 (Director of Nursing) was asked regarding R73. V2 stated, They called me when that incident happened. V7 was with them. She (V7) was distributing the smoking materials like bib, cigarettes when he (R73) was tilting from the wheelchair. She (V7) was about to stop the fall but was too late. When I investigated, the seatbelt was loose when he was smoking outside. The order was to release it during activities. Smoking is an activity, so she (V7) kept it loose. R73 has a safety belt in his wheelchair. He slid from the wheelchair on his left side. He has poor trunk control related to hemiplegia on his right dominant side. A follow-up interview with V2 was conducted on 02/08/24 at 1:12 PM. V2 was again asked if R73's seat belt was loose at the time of incident. V2 stated, His safety belt was totally released. It was totally not secured, it was released, it was not put on. V7 should be monitoring if his (R73) safety belt is on or secured and if he has a problem with repositioning. Designated staff during smoking should be closely monitoring residents, and should be in close contact to all the residents during activities or during smoking. R73's POS (Physician Order Sheet) dated 02/22/22 documented: Self release safety belt while up in wheelchair, check and release every two hours and PRN (when needed), during activities and during meals. V13 (Physician) was asked on 02/07/24 at 11:22 AM regarding R73. V13 verbalized, He uses an electric wheelchair. During smoking, his safety belt should still be secured, not off, not loose. The expectation is that the belt helps him from falling out of the wheelchair. It should be secured/fastened during smoking since he is up in his wheelchair. Care plan regarding at risk for falls dated 04/08/2017 documented interventions: R73 to be escorted to the patio and monitored while on the patio smoking. R73 has a care plan formulated related to the use of self-release safety belt for medical reasons while up in the electric wheelchair related to poor trunk control.

Based on observation, interview, and record review, the facility failed to follow their policy of obtaining resident weights, failed to document meal intake, and failed to update an individualized care plan for one of two residents who were reviewed for nutrition. This failure applied to one of one (R166) resident reviewed for weight loss and resulted in R166 demonstrating an unintended weight loss of 29% during the first two months of admission. Findings include: R166 was admitted to the facility 10/4/23 with diagnoses that included hypertension, pressure ulcers and dysphagia. During this survey R166 was observed to receive lunch meals in bed, and on 2/6/24 observed to eat 0% of the meal provided. When R166 was interviewed at 1:00PM and observed siting up in bed alert and conversive. R166's arms and face appeared thin, and R166 refused further assessment due to room temperature. R166 mentioned that R166 was not very hungry and didn't want the meal. According to hospital transfer records and the facility's electronic health record, R166 was admitted at a weight of 146 lbs (pounds). During the second week of admission, R166 recorded weight was 145 lbs and the next recorded weight thereafter was recorded to be 103.4 lbs for a total weight loss of 29.18%. On 2/8/24 at 12:00PM V2 DON (Director of Nursing) was interviewed regarding the weight loss of R166. V2 said that it was the policy of the facility that residents who were newly admitted to the facility should have be weighed at least once weekly for four weeks to establish a baseline and pattern for meal habits and intake. After the baseline is established, the resident should have weights recorded at least monthly or daily as appropriate to condition or diagnosis. V2 said this is especially important for residents with wounds because nutritional status greatly affects wound healing. V2 reviewed the recorded weights with the surveyor and noted that the Weight Report for R166 was missing weight results for the third and fourth week of October, and no weight was recorded for November. V2 said that although some nutritional supplements were ordered and in place for R166, it was expected that when the weight loss was identified, that the care plan for nutrition would be revised to provide a more individualized plan. While referring to the Weight Report, V2 said that since the weight loss was identified in December, it remains stable and has even increased with weights reported on 1/5/24 at 107.8 lbs and 2/1/24 106 lbs. R166's Care Plan initiated 10/5/23 states in part; {R166} requires nutritional support {related to} {diagnosis} of dysphagia and presence of pressure wounds; receiving general pureed, {protein supplement} and fortified cereal. Scored malnourished on mini nutrition assessment due to moderate decrease in food intake, bed bound, and BMI (Body Metabolic Index) above 23. Interventions of the care plan were also initiated 10/5/23 and did not indicate any revisions had taken place. Interventions included Monitor labs and wight for signs of effective disease management and Weekly weights. Facility policy titled Weights revised 9/2020 states in part; Policy: Residents will be weighed to establish baseline weights and identify trends of weight loss or weight gain. Procedure: 1. A baseline weight will be established upon admission. The resident will be weighed weekly for 4 weeks after admission and monthly thereafter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow their policy and procedures for abuse prevention by not ensuring agency staff caring for a resident who is at risk for abuse was thoroughly informed about the resident's care needs prior to initiating care and by not ensuring staff provided care consistent with standards of practice to prevent pain or injury. This failure applied to one (R1) of three residents reviewed for abuse and resulted in R1 sustaining a fracture which required surgery after being provided with care from staff. Findings include: R1 is a [AGE] year-old female with diagnoses history of Alzheimer's Disease, Dementia w/o Behavioral Disturbance, Vitamin D Deficiency, Bilateral Primary Osteoarthritis of Knee (effective 07/23/2021), Personal History of (Healed) Pathological Fracture (effective 08/02/2021), and Personal History of (Healed) Traumatic Fracture (effective 07/22/2021). R1's Quarterly Minimum Data Set, dated [DATE] and Significant Change Minimum Data Set, dated [DATE] documents she has a Brief Interview for Mental Status score of 03 (severe cognitive impairment). R1's most current care plans initiated 07/23/2021 document R1 is at risk for falls related to previous fall with fracture prior to admission, dementia, poor safety awareness, legally blind, R1 has a behavior of crawling out of bed and scooting on the floor with interventions including floor mats while in bed, use low bed; R1 has potential for pain related to Osteoarthritis of bilateral knees, impaired cognition, history of fracture, a-fib, Diabetes Mellitus and generalized pain with interventions including Assess pain every shift, Monitor for nonverbal indicators of pain daily with care tasks and activities, Administer pain strategies according to Medication Administration Record / Treatment Administration Record. R1's most current care plan initiated 07/28/21 documents she is at risk for abuse related to a diagnoses of severe mental illness and/or dementia with interventions including: at onset of behavior, calmly and firmly attempt to redirect to socially acceptable behaviors, check and assure physical comfort, maintain a calm soothing approach/environment and smile/pay compliments to promote feelings of belonging and importance with resident. R1's most current care plan initiated 11/23/22 documents R1 is receiving an antidepressant psychotropic medication, she is noted to have diagnosis of: generalized anxiety disorder and noted with behavior or mood issues of: anxiousness, depressive symptoms standing up from wheelchair and crawling out of bed, and yelling out with interventions including: avoid overstimulation or under stimulation; provide support/reassurance, engage in groups and activities participation as tolerated; document mood and behaviors as needed as they occur. R1's progress note dated 04/29/2023 6:30 PM documents: writer called R1's room by assistive personal, upon entering room R1 observed in bed with head of bed elevated, yelling and screaming loudly, Upon further as assessment, R1 right leg appear to be red, swollen and dislocated, R1 unable to verbalize what happened, as needed pain medication given, Physician called and orders given to transfer resident to the local hospital emergency room. [sic] R1's progress note dated 04/30/2023 03:22 AM documents: Writer called hospital and was notified that R1 was transferred to another hospital. Writer was notified that R1 has a left thigh bone broken and is still in the hospital emergency room department. R1's April 2023 Medication Administration Record does not include any abnormal observations of her skin. R1's documented pain levels are primarily at zero daily including on 04/29/23 during the morning shift prior to being discharged ; pain levels documented as the following: 4/21/23 Level 1 during the evening 4/26/23 Level 4 during the day MAR does not document that any as needed pain medications were administered from 04/01/23 - 04/29/23. R1's point of care skin observation reports from 04/10/23 - 04/29/23 documents no new skin abnormalities were identified. R1's point of care reports from 04/22/23 - 04/29/23 for behavior of crawling out of bed documents she crawled out of bed once on 04/22/23 noted at 6:53 AM and no other time during those days leading up to 04/29/23. R1's point of care reports from 04/22/23 - 04/29/23 for depressive symptoms or anxiousness documents no occurrences of these behaviors. R1's progress note dated 4/29/2023 10:30 AM documents: Received resident alert and responsive, In stable condition, No signs or symptoms of distress/pain noted. [sic] R1's progress notes from 03/01/23 - 04/29/23 up until 6:30 PM do not document any behaviors of her exhibiting any concerning behaviors or yelling loudly, or showing any signs of pain or distress. R1's progress notes from 04/22/23 - 04/29/23 up until 6:30 PM did not document any falls or reports of pain, discomfort, or injury. Incident Report dated 05/03/23 documents while providing care a CNA (Certified Nursing Assistant) observed R1 to complain of pain in her right leg when being turned on her side for activities of daily living care, the CNA informed the nurse who then observed R1 in bed with her right leg in a bent position at the knee, R1 observed with no other signs of injury other than redness and swelling to the right leg, the physician was notified an ordered R1 to be sent to the hospital; V13 (Agency Certified Nursing Assistant) was interviewed and reported during the incident when he began providing incontinence care to R1 after having a very large bowel movement she began screaming out loud and he continued to clean her up, as she continued to scream he stopped providing care, he then reported it to a nurse who examined R1 and stated she believes R1 had a fracture, he reported it was the first time he ever worked at the facility, he is not sure who he talked to when he arrived to the facility and cannot recall who he spoke with when he initially arrived to the facility and was informed about his sets; V14 (Certified Nursing Assistant) was interviewed and reported R1 typically cries out and screams but was not exhibiting this behavior during the afternoon when providing care for her, R1 is able to assist when she's being changed and can turn herself and lift her legs; V15 (Memory Care Director) was interviewed and reported R1 can communicate if she is in pain, has days where she does not yell or scream, can minimally provide assistance if she is being put in bed or changed; V16 (Licensed Practical Nurse) was interviewed and reported on the day of the incident she was asked to examine R1 and upon arriving to her room V13 was there and stated he didn't know why R1 was yelling out because he didn't know her behavior and was just changing her. V16 reported she observed R1's leg to be swollen and appeared to be dislocated, R1 does crawl out of bed and she has walked in and observed R1 swing her legs over the bed rails a few times; V17 (Certified Nursing Assistant) was interviewed and stated R1 is cognitively still intact and can communicate if she is in pain, he noticed she was in pain, R1 can move some in her bed, she used to put herself on the floor and crawl but it has been a couple of months since he observed her doing that; V18 (Certified Nursing Assistant) was interviewed and reported R1 can move and reposition herself, she is able to assist with her incontinence care and is not a total assist, she usually has R1 place her hand on the rail and get her to turn her body, R1 does scream out the name of V37 (Family Member) if she has needs, R1 can communicate if she is hurt or in pain or if she has other needs; V19 (Licensed Practical Nurse) was interviewed and reported she was R1's nurse when she had to be sent out to the hospital, throughout the day R1 was happy and calm, R1 was speaking Spanish and chatting when she passed her medication, she completed passing medications at 6:15 PM and was called back to R1's room at 6:30 PM and heard R1 yelling out loudly, she observed R1's leg and it visibly looked misplaced and the skin was red and puffy, prior to this R1 was in great spirits; Transmittal page dated 05/03/23 documents 2 pages were submitted to the State Agency including Report Page dated 05/03/23 documenting full investigation initiated, final report to follow; Final Conclusion dated 05/09/23 states local law enforcement was notified of the occurrence, the facility is unable to make a definitive determination as to how R1's injury was sustained, R1 has exhibited behavior of crawling in and out of bed in which she has a care plan for, interventions in place to prevent injury including but not limited to low bed, floor mats, and room near nurse's station were in place prior to the occurrence of the injury, as an additional precautionary measure the facility continues to ensure that staff is oriented to the care needs of the residents for which they are assigned, and to the prevention of abuse. R1's Hospital Report dated 04/29/23 - 04/30/23 documents the facility's Director of Nursing called and reported R1's Registered Nurse at the facility provided care at 6:30 PM and was observed to be comfortable and in no distress and 15 minutes later a Certified Nursing Assistant reported to R1's nurse that she was screaming, with help of interpreter R1 complained of pain in her right leg and was observed with her right thigh swollen, while receiving care from a Certified Nursing Assistant incontinence she began to scream out in pain when turned on her left side; after contacting local family support services department to report suspected elderly abuse a referral was made to the contact the state agency; R1 complained of pain to her right leg and denied falling, when R1 was asked when the pain started she reported she was in her bed when a female moved her abruptly to turn her, R1 reported that she does not walk and uses a wheelchair to ambulate; per emergency medical services they were called to R1's facility because she had a fracture deformity to her right thigh bone, according to facility staff she was found that way, R1 although demented states a girl at nursing home did this to her and appears to be in excruciating pain; R1 arrived to the hospital emergency room with midshaft thigh fracture that needs stabilization regardless of her palliative/hospice status, as she is in excruciating pain; V38 (Orthopedic Physician) also shares V39 (emergency room Physician) concern that R1's injury is a nonaccidental trauma therefore nursing notified the Department of Aging. On 05/09/23 at 10:35 AM V1 (Administrator) stated V13 (Agency Certified Nursing Assistant) is suspended pending investigation for R1's injury. V1 stated the facility is still investigating R1's incident involving injury on 04/29/23. On 05/09/23 from 12:25 PM - 12:30 PM V17 (Certified Nursing Assistant) stated he has worked for the facility more than thirteen years. V17 stated he knows R1 well and she screams like a loud bird whenever she wants to go back to bed or to the bathroom. V17 stated R1 may do this maybe a couple of times a day and some days won't scream at all. V17 stated R1 may make this sound while calling out to one of her family members and sometimes she'll call out V37's (Family Member) name repeatedly really loud which may have been one of her family members who used to take care of her. V17 stated he's never observed R1 to be in pain. V17 stated R1 doesn't normally make those loud sounds while receiving care. On 05/09/23 at 1:45 PM V15 (Memory Care Director) stated she has worked for the facility for approximately 13 years. V15 stated R1 yells out a lot for V37 (Family Member) and yells out ah ah loudly. V15 stated R1 makes that noise sometimes when she wants to go back to bed and at other times for no particular reason. V15 stated some days R1 won't yell out and other days she will yell out off an on throughout a few times a day. V15 stated she has never observed R1 to be in pain and when she does yell out they ask how she's doing and if she's in pain and she never says she's in pain but just may say she just wants to go to bed. V15 stated she has heard that R1 crawls around on the floor but cannot recall any reports of her doing so in April but would have to check her documentation. V15 stated it is documented when R1 is yelling out or crawling around on the floor under the point of care task observations and would be care planned. V15 stated to her knowledge R1 did not have any broken bones or injuries prior to going to the hospital. On 05/09/23 from 2:34 PM - 2:40 PM V19 (Licensed Practical Nurse) stated R1 was the last person she had seen 04/29/23 for medication pass and 15 minutes later when she came back in R1's room R1 was screaming loudly. V19 stated when she pulled the covers back from R1 she observed her right leg and could see the bone through the skin was bent and turned and wasn't normally aligned. V19 stated she could see R1's bone protruding right underneath the skin but it did not breach the skin. V19 stated R1's skin on over the injury was warm and red and she was screaming out in pain really really loud. V19 stated R1 was not yelling out as part of her normal behavior and was instead continuously screaming nonstop in a loud and agonizing way. V19 stated she didn't see when the V13 (Agency Certified Nursing Assistant) went in R1's room to provide incontinence care but he was in her room when she arrived. V19 stated R1 only speaks Spanish and there was another male Spanish speaking CNA (Certified Nursing Assistant) present and he stated R1 could not communicate what happened to her. On 05/10/23 at 12:31 PM V38 (Orthopedic Physician) stated he never examined R1 when she arrived to the hospital emergency room but reviewed her x-rays and recommended transfer to another hospital for surgery. V38 stated the emergency room physician reported that the department of aging was contacted because it didn't make since that the type of fracture R1 sustained happened to a non-ambulatory resident and R1 reported a girl did this to her so he agreed that the department of aging should be notified based on this information. V38 stated the thigh bone fracture R1 sustained usually occurs from a fall that possibly no one witnessed and it is unlikely that it would occur from a patient just laying in bed. On 05/10/23 at 12:41 PM V37 (Family Member) stated R1 reported to her that when she was being changed someone twisted her leg. V37 stated R1 is blind so she could not inform who exactly hurt her. V37 stated R1 is completely blind and can maybe see shapes but cannot clearly see figures. V37 would always complain about the nursing home reporting that they would always mistreat her. V37 stated R1 has not provided specific details as to how they mistreat her but states they don't treat me right and I don't want to be here anymore. V37 stated when R1 was in the emergency room that the physician stated it wasn't an accident. V37 stated R1 is mentally capable of communicating her needs and experiences. On 05/10/23 at 3:09 PM V1 (Administrator) and V11 (Registered Nurse/Restorative Nurse) stated they had not received any reports that R1 had fallen, or been injured, or had been crawling around on the floor prior to her injury on 04/29/23. V11 stated she spoke with V16 (Licensed Practical Nurse) about R1's incident on 04/29/23 and she reported R1 was up in the geriatric chair most of the day for her meals and there was no complaints and she was her usual self. V1 stated V3 (Assistant Director of Nursing) attempted to speak with family after R1 was admitted to the hospital but was unsuccessful. V1 stated they were unable to conclude what happened to R1. V1 stated R1's injury was believed to be an injury of unknown origin at the time which should be reported to the state agency immediately as well as allegations of abuse. V1 stated when she heard that something happened with R1 she immediately suspended V13 (Agency Certified Nursing Assistant) because she knew something had happened with the resident he was working with. V1 stated this would fall into the category of an abuse investigation. V1 stated residents who are at risk for abuse are monitored for signs of abuse by observing a change in mood, change in behavior, verbalized allegations of abuse, observing how staff interact with residents. V1 stated residents are monitored for bruises of unknown origin, scratches, or any injuries that were not normally on their body. V1 stated certified nursing assistants normally report any changes during morning standup meetings. V1 stated the certified nursing assistants notify her immediately of any abnormal physical changes, and they also notify nurses. V1 stated residents are monitored daily for any physical signs of abuse. V1 and V11 stated prior to R1's injury there had been no abnormal physical observations for her nor any abnormal complaints of pain. V11 stated R1's bed was in low position during the time of her injury and she also has floor mats on both sides of the bed. On 05/11/23 from 9:07 AM - 10:02 AM V1 (Administrator) stated it is of the utmost importance that agency staff are informed about the residents they are being cared for. V1 stated V8 (CNA/Scheduler/Unit Manager) is responsible for orienting agency staff or new Certified Nursing Assistants (CNA) about their assigned residents during the morning shift until 3PM and V40 (Administrative Night Manager) is responsible for this orientation during the evening shift and follows up new and agency staff orientation after 3 PM. V1 stated she added V40's position to ensure that orientation and resident education was being implemented during the evening/night shifts. V1 stated stand up meetings including the nurses and CNA's were also added during the evening shift to discuss any pertinent information concerning residents. V1 stated during both times the facility spoke with V13 (Agency Certified Nursing Assistant) told us he couldn't remember who spoke with him about his assigned residents. V1 stated V13 was irritated about his suspension and financial situation and that did come across when interviewing him about the incident with R1. V1 stated V13 stated he can't tell you what lady spoke to him about the residents. V1 stated V13 reported someone told him about his assigned residents, but he couldn't confirm who. V1 stated she's not sure if she asked V13 what information he received about R1 because she was mainly concerned about ensuring he was informed about all of the residents he was assigned to. V1 stated she can't explain why V13 reported to V16 (Licensed Practical Nurse) that he wasn't aware of R1's behaviors and maybe he wasn't aware of R1's behavior of screaming out. V1 stated she's not sure what information V13 may not have received about R1, however she just knows that he confirmed that he was oriented to his assigned residents. V1 stated if there is any important information left out of anything in life it can increase risks. V1 stated she cannot speak for sure about what information V13 received about R1 because she was not there when he was oriented however the facility's standard process of orientation includes providing all pertinent information about the residents being assigned to new and agency staff. V1 stated she doesn't believe R1 had a behavior of screaming during care prior to her incident but if it was a new behavior then V13 would not have been informed of this. V1 stated if R1 did exhibit screaming as a behavior during care it would make sense that V13 would stop and go find someone else to find out why she is screaming during care. V1 stated she is wondering if R1 was exhibiting a new behavior of screaming during care which V13 would not have been informed about. V1 stated hopefully V13 did discontinue providing care when he observed her screaming although in his statements, he did say he continued to provide care to R1 and when she continued screaming that's when he went to go and get someone. V41 (Licensed Practical Nurse/Minimum Data Set Coordinator) stated if a staff is providing incontinence care and a resident screams the staff should stop and assess the resident for anything that may be causing the resident any pain or causing them to scream. V41 stated if staff don't assess the cause of the residents yelling they may not be able to determine what may be harming the resident or may not notice something is causing the resident pain. V41 stated if a residents screams during care because they are injured if staff do not stop to assess what is going on first this could possibly further the injury or cause the resident more pain. V1 stated she did hear that the scream R1 exhibited when she was receiving care from V13 was different than her normal behavior of screaming and yelling. The facility's Abuse Policy reviewed 05/10/23 states: This facility affirms the right of our residents to be free from abuse. This facility therefore prohibits abuse of its residents and has attempted to establish a resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse of our residents. This facility is committed to protecting our residents from abuse by anyone. Abuse means any physical injury inflicted upon a resident other than by accidental means in a facility. Abuse is willful infliction of injury resulting in physical harm, pain, or mental anguish. Willful means the individual acted deliberately, not that the individual must have intended the injury or harm. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. Serious Bodily Injury is any injury involving extreme physical pain; involving protracted loss or impairment of the function of a bodily member; or requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor and treat urinary tract infections for one resident (R3) who was displaying signs and symptoms of UTI for over one month. This failure affected one of one (R3) resident reviewed for nursing care and resulted in R3 being hospitalized with a diagnosis of sepsis. Findings include: R3 is a [AGE] year old female who originally admitted to the facility on [DATE] and currently resides in the facility. R3 has multiple diagnoses including but not limited to the following: multiple sclerosis, hemiplegia, neuromuscular dysfunction of the bladder, depression, mild protein calorie malnutrition, dysphagia, hydronephrosis, and calculus of kidney. Per facility progress note dated 4/17/23, R3 was sent to the emergency room due to altered mental status. Facility progress note states in part but not limited to the following: At 9:50 AM, R3 was observed alert, nonverbal, only making mumbling and moaning noises when spoken to. Pupils are nonreactive, no direct eye contact, mouth is open, minimal drooling, no asymmetrical facial features, and bilateral arms are flaccid. Nephrostomy tube is draining tea colored, urine is cloudy and odorous. 911 called. A later progress note dated 4/17/23 states in part but not limited to the following: R3 will be admitted to the intensive care unit with diagnosis of sepsis. Per hospital records and Discharge summary dated [DATE] states in part but not limited to the following: R3 presented to the emergency department for complaints of altered mental status. R3 was hypotension refractory to fluids, a positive urinalysis, hypernatremia, and leukocytosis. She was admitted to the ICU for septic shock and pressor support. Discharge diagnoses show but are not limited to the following: urinary tract infection associated with nephrostomy catheter, hypernatremia, and septic shock. Facility progress notes dated 3/8/23-3/12/23 states in part but not limited to the following: notified by hospital that patient urine is cloudy, needs a urinalysis with culture and sensitivity. Result of urinalysis relayed, no new order. Per V12 (Physician), he will consult physician at hospital and return call regarding follow-up. Per urinalysis results dated 3/9/23 show R3 had abnormalities including cloudy urine, large leukocytes, protein: 100, large blood, white blood cells: 5-10, and red blood cells: 5-10. On 5/8/23 at 11:20AM, V26 (family member) was interviewed about R3's hospitalization on 4/17/23. V26 said the hospital told us that R3 was severely dehydrated and her kidneys were not functioning properly. They told us that she had an untreated UTI for a long time which caused her to go septic. On 5/9/23 at 11:05AM, V12 (Physician) was interviewed regarding R3's treatment and care. V12 said R3 has kidney issues and develops kidney stones very rapidly. The tubing gets crusted with calcium from the stones. R3 went to the hospital on 4/17/23 where she was treated for a UTI infection which had led to sepsis. She does not get UTI's often but she is at high risk for developing UTI's due to calcium deposits and the nephrostomy tube. I reviewed the urinalysis that was obtained on 3/9/23 and consulted with the radiologist at the hospital. Our plan was to not order anything but to monitor R3 for signs of symptoms such as altered mental status or possibly do a blood test. It is to be noted that no blood test was ordered/obtained and no documentation of monitoring for signs and symptoms were received. At 1:05PM, V32 (Medical Director) was interviewed regarding infection management within the facility. V32 said I would expect the staff to be taking vitals every shift, monitoring mentation status, looking for a fever, making sure the resident is not experiencing tachycardia to make sure the resident is not experiencing a UTI. However, if a urinalysis comes back positive, I would recommend putting the resident on an antibiotic right away. These residents are geriatric and have comorbidities. If we do not start antibiotics, there is a possibility the resident could end of up in the hospital with sepsis. R3's care plan with initiation date of 1/20/12 states in part but not limited to the following: Focus: R3 requires use of nephrostomy related to frequent renal calculi. Goal: Nephrostomy tube site will be free from signs of infection till next review. Interventions: Empty drainage bag every shift and as needed; notify MD for any change of condition of the resident. Focus: R3 is noted to have potential for dehydration due to lack of awareness to drink fluids and inability to reach for liquids. Goal: R3 will not exhibit signs of dehydration. Interventions: Encourage fluids unless contraindicated. Monitor for signs and symptoms of dehydration such as: change in mental status, fever, infection, electrolyte imbalance, and concentrated urine. Requested policy for preventing urinary tract infections, however did not receive any sort of policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have effective fall interventions in place and failed to provide adequate supervision to keep residents assessed to be at risk for falls, free from injury related to falls. These failures applied to two (R4 and R5) of four residents reviewed for accidents and supervision and resulted in R4 having a fall and sustaining a right hip fracture and resulted in R5 having a fall that required treatment with three sutures for a laceration to his lip. Findings include: R4 is a [AGE] year old male who originally admitted to the facility on [DATE] and later expired in the facility under hospice care on [DATE]. R4 has multiple diagnoses including but not limited to the following: CHF, palliative care, CAD, CKD IV, pulmonary edema, dementia, type II DM, depression, hyperlipidemia, GERD, and history of falling. Facility incident report dated [DATE] states in part but not limited to the following: Activity staff notified nurse on duty that the resident was on the floor. R4 was observed sitting on the floor with his reclining chair directly behind him. R4 was sitting on his buttocks, back is upward, and knees are flexed. His left arm is extended with his palm on the floor and his right arm is in his lap. The reclining chair was unlocked. R4 is alert and oriented to his name only and was unable to give any explanation of what happened. On [DATE] at 10:26AM, V11 (Restorative Nurse/Fall Coordinator) was interviewed regarding R4's fall on [DATE]. V11 said R4's family member came into the facility and took him back to his room. At some point after this she had left the facility and did not let the staff know she was leaving. No one saw her leave. A staff member saw R4 on the ground in his room. His room was set back in the hallway and not located in a high traffic or visible area. R4 is verbal but not understandable. He was not able to let us know what happened. The intervention we put in place was to educate the family to let us know when they are leaving. R4 needs increased supervision since he would constantly attempt to get up on his own. He should be in a common area and never left unsupervised in his room alone. On [DATE], the family member let us know he was having pain to his pelvis area. An x-ray was ordered which showed he had a fracture to his right hip. However, the family member told us that he had previously fractured his hip in this same area prior to him admitting to the facility. The family opted to not do surgery when this happened. V11 said the CNA is responsible to provide supervision and care for the resident whether the family is visiting or not. R5 is an [AGE] year old male who originally admitted to the facility on [DATE] and currently resides in the facility. R5 has multiple diagnoses including but not limited to the following: hypotension, syncope, dementia, legal blindness, SOB, HTN, insomnia, and hallucinations. Facility incident report dated [DATE] states in part but not limited to the following: Heard yelling from down the hall and when entered R5's room, he was observed to be on his hands and knees at the end of his roommate's bed. Fall mat was pushed against the wall and resident had pulled roommates television down and turned over oxygen concentrator in the room. Blood was noted on the floor and R5's body. Observed blood coming from R5's lower lip from a laceration. R5 states 'I fell and a board hit me.' Laceration noted to lower lip, abrasion noted to left side of chin and to great toe. R5 was sent to emergency room. emergency room report dated [DATE] stated in part but not limited to the following: patient arrived to emergency department complaints of unwitnessed, mechanical fall at nursing home. Patient fell and hit his face on the ground. Patient has cut on his lip and complains of body aches. MD at bedside stitching patients lip. On [DATE] at 2:00PM, V34 (licensed practical nurse) was interviewed regarding R5's fall on [DATE]. V34 said I was the nurse assigned to V34 when he fell on [DATE]. V34 said R5 is blind and needs increased supervision because he will try and get up unassisted. On this day, I heard yelling and went to his room. I observed him on his hands and knees on the ground. There was blood on him and on the floor. He speaks Spanish and I was unable to understand what had happened. From my understanding, he had attempted to get out of bed on his own and fell, pulling down his roommates television and oxygen concentrator. I received orders to send him out to the hospital and he came back with sutures. I would say he is a high fall risk since he does attempt to walk without any assistance. Facility progress note dated [DATE] states in part but not limited to the following: R5 on floor on his floor mat and heard calling out for help. R5 stated he was looking for us. Resident denies any pain or discomfort. No signs of injury. Will cont. to monitor. On [DATE] at 12:05PM, V33 (CNA) was interviewed regarding R5's fall on [DATE]. V33 said I was R5's CNA when he fell on [DATE]. I was doing rounds and walked past R5's room. I observed R5 on the ground on his fall mat. Another staff member, not sure who, helped assist me get him up into his wheelchair and brought him to the nursing station. Prior to this, R5 had not exhibited any sort of behaviors such as trying to get up unassisted or crawling on the floor or out of his bed. At 1:30PM, V11 was interviewed regarding R5's fall on [DATE]. V11 said I was never notified of this incident. If I had been notified, I would have completed a fall incident report. We did not investigate it as a fall. At 3:51PM, V1 (administrator) was interviewed regarding facility understanding of falls. V1 said this would be considered a fall since it is a change of plane. Asked V1 if a resident was found on the floor, with no documentation of any behaviors, and they are unable to let you know what happened, would this be considered a fall? V1 answered yes. It is to be noted that no incident report or interventions were put in place after R5 fell on [DATE]. Facility care plan for R5 dated [DATE] states in part but not limited to the following: R5 is at risk for falls r/t poor safety awareness, recent fall with injury, dementia, left extremity weakness, unsteady gait/impaired balance, use of walker and wheelchair, hypotension, hypertension, various medications, incontinence, decline in ADLs, and blindness. Goal: Will show no change to fall risk score through next review. Interventions: Encourage resident to keep room free of obstacles. Fall risk assessment quarterly and as needed. Provide an environment clear of clutter. Facility policy titled Management of Falls dated 8/2020 states in part but not limited to the following: Policy: the facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize risks for fall incidents and/or injuries to the resident. Procedure: 1. Complete a fall risk assessment upon admission, readmission, significant change, post-fall, quarterly, and annually. 3. Develop a plan of care to include goals and interventions which address resident's risk factors. 6. Assess and monitor resident's immediate environment to ensure appropriate management of potential hazards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent a resident who is incontinent of bowel and bladder and requires extensive assistance from staff for ADL (Activities of Daily Living) care, from developing a pressure ulcer. These failures affected one (R18) of four residents reviewed for pressure ulcers and resulted in (R18) developing a Stage 3 sacral wound after being admitted to the facility with skin intact. Findings include: R18 is an [AGE] year-old female who was admitted to the facility on [DATE], with past medical history including but not limited to chronic kidney disease stage 4, hypertensive heart disease, type 2 diabetes with Diabetic Peripheral Angiopathy, anemia, dementia, etc. 03/28/23 10:22 AM, resident was observed sleeping in bed with pressure relieving mattress activated, resident was unable to answer any questions. Braden scale assessment dated [DATE] document a score of 14 (moderate risk) for pressure ulcer. New admission skin assessment dated [DATE] documented old bruise to bilateral upper extremities, old scab to heels, skin intact, no concerns. Facility' pressure ulcer list received 03/27/23 documented that R18 has a facility acquired pressure ulcer. Physician order dated 1/4/2023 stated to conduct skin checks one time a day, every Thursday. Documentation of weekly skin checks not provided during the course of this survey. Minimum Data Set (MDS) assessment 3/15/2023 section G (functional status) coded resident as requiring extensive to total dependence on staff for all activities of daily living (ADL). Section H (Bowel and Bladder) of the same assessment coded resident as always incontinent for bowel and bladder. Care plan initiated 1/5/2023 documents the following: resident has potential for alteration in skin integrity CKD, DM, COPD, Osteoporosis, Dementia, Emphysema, Anemia, Long term use of Anticoagulants, depression, and hx of falls. Skin Observation completed old bruising to the bilateral upper extremities, Toenails thick yellow, heels firm, and dry/closed black scab to the LLE Interventions include Inspect skin daily with care, Pericare after incontinent episodes, Barrier cream to areas exposed to moisture/incontinence, etc. ADL care plan initiated 1/9/2023 documents: resident has an ADL Self Care Performance Deficit Decreased Functional Ability, Fluctuating ADLs, Poor coordination. Interventions include Assist with ADL tasks as needed, Check skin for changes during bathing etc. Review of facility concern/grievance log showed a documentation of concern from resident's daughter dated 1/29/2023, stating that the C.N.A for the morning shift did not change resident on that day (sent the previous day), she showed resident's wet clothing to the afternoon shift staff. Further review of medical record shows the following documentation: 2/15/2023 10:00 Skin / Wound Progress Note Per Nurse request: Resident observed with MASD to the Perineum area and Buttocks. Primary made aware. Daughter updated. Orders received and carried out. Preventive measures in place. WC will monitor/ follow. Further review of medical record shows the following progress note dated 2/15/2023: Daughter called and asked for writer to evaluate her mom's buttock Sacral area. writer completed a body assessment small opening noted to the resident sacral area. writer cleansed and barrier protection applied. resident changed and re positioned made as comfortable as possible. No pain verbalized or observed at this time. call light is within reach Will have wound care to follow up for treatment. 2/15/2023 11:12 Nurses Note, Note Text: wound care has evaluated the buttock sacral area. Writer awaiting orders. daughter of resident notified of the findings. She has no questions or concerns currently. plan of care will continue as ordered. Wound assessment dated [DATE] documented two wounds; Wound 1- perinium buttocks diaper dermatitis and Wound 2 - sacral 3, with light exudate measuring 3.5 x 2.0 x 0.1. Wound note assessment dated [DATE] documented a stage 3 pressure ulcer to the sacrum measuring 9.8 x 9.8 x 0.2 and volume of 19.21. 3/29/2023 at 12:00PM, V9 (LPN/wound care) said that the wound team picked up resident on 2/2/2023 for Moisture Associated Dermatitis (MASD) to the perinium. The MASD was caused by moisture and being wet, resident is incontinent of bowel and bladder. V9 added that on 3/7/2023, resident was seen by the wound doctor who categorized her wound as a stage 3 facility acquired pressure ulcer to the sacrum measuring 3.5 x 2.0 x 0.1. The current treatment is Medi honey adapted or calcium alginate and Metro Cream External Cream 0.75 % (Metronidazole (Topical)), apply as needed. V9 said that resident was admitted to the facility with intact skin. Some of the interventions to prevent the development of pressure ulcer include timely incontinent care, turning and repositioning and completion of skin checks. V9 added that she does not know what happened, she was not here all the time. Document presented by V4 (DON) titled, Prevention and Treatment of Pressure Injury (dated 3/02/2021), states in part, that it is the policy of the facility to identify residents at risk for developing pressure injuries, identify the presence of pressure injuries and other skin alterations, implement preventive measures and appropriate treatment .through individualized resident care plan. Under procedures, the policy states that at least daily, staff should remain alert for potential changes in the skin condition during resident care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have effective and resident-centered interventions in place to prevent falls for a resident with a history of falls. This failure applied to one (R5) of eight residents reviewed for falls and resulted in (R5) having five falls in under two months, two of which resulted in injuries, including an odontoid fracture and requiring three stitches to the left side of her head. Findings include: R5 is an [AGE] year old female originally admitting to the facility on 4/18/2018 with multiple diagnoses including but not limited to the following: fibromyalgia, polyosteoarthritis, AFib, dementia, hypothyroidism, depression, osteoporosis, psychosis, pain, CKD III, bipolar disorder, type II DM, HTN, and moderate protein calorie malnutrition. Facility falls incident reports show R5 has had unwitnessed falls on 1/2/23, 1/16/23, 1/22/23, 2/1/23, and 2/22/23. It is to be noted that the falls 2/1/23 and 2/22/23 resulted in injuries requiring R5 to be hospitalized . Facility incident report dated 2/1/23 states in part but not limited to the following: R5 stated that she fell on the floor and rolled out of the bed. R5 ambulated with her walker to the nurse's station. R5 has complained of headache, pain to back of neck and upper back pain. Complete body assessment done: swelling and a bump to right side of forehead right above eyebrow noted. Redness and bruising below right eye with minimal bleeding noted. R5 transferred to hospital for further evaluation. Hospital records dated 2/1/23-2/13/23 state in part but not limited to the following: Admitting diagnosis of closed type II fracture. Patient presented after unwitnessed fall at nursing home. Recommended no surgical intervention, C-Collar. Assessment/plan: Ground level fall, type II odontoid fracture, T11 subacute fracture, and chronic thoracic compression fracture. Reviewed imaging results from MRI cervical spine without contrast, CT thoracic spine without contrast, and lumbar spine 2D reformatted. Facility incident report dated 2/22/23 states in part but not limited to the following: R5 ambulated out of room pushing wheelchair and nurse noted lump and small laceration to forehead. R5 stated I was sitting on the toilet and I fell asleep. I fell off the toilet and hit my head. R5 stated she had a headache. Received order to send to emergency room for evaluation. R5 returned to facility with dry dressing and three sutures to forehead. Hospital records dated 2/22/23 states in part but not limited to the following: Diagnoses: fall with closed head injury and forehead laceration Facility progress note dated 2/22/23 states in part but not limited to the following: R5 will be returning to facility with 3 stitches to the left side of her forehead. On 3/27/23 at 10:15 AM, this surveyor observed R5 to be in room with door closed. R5 was observed sitting in chair in room wearing own clothes and shoes. No fall mats were noted on either side of resident bed at this time. On 3/28/23 at 11:00AM, R5 was observed to be in room with door closed. Upon entrance, resident was standing in bathroom brushing her hair by herself. 3/28/23 at 11:30AM, V16 (Agency Licensed Practical Nurse) was interviewed regarding the resident's she was assigned to. V16 said she currently has no residents who are a high fall risk. It is to be noted that R5 was assigned to V16. V16 says they are notified about residents who are high fall risk by the previous nurse on duty, by the certified nursing assistants (CNA's) on duty, or within a daily communication. V16 said she was not notified of any resident being a high fall risk. 3/28/23 at 12:00PM, it was noted that R5's bedroom door was still closed. V6 (Restorative RN/Fall Coordinator) was interviewed regarding R5. V6 said R5 is at a very high risk for falls. She says some of the interventions we have in place for her are we moved her room to the first floor with no roommates and close to the nursing station, her room is clutter free, the bed is in the lowest position or an appropriate position for her to transfer independently, all items are within close reach, she is provided with a wheelchair and rolling walker for mobility aid. We have tried fall mats when she was on the second floor but they decreased her ability to ambulate safely. At this time, R5 was shuffling through room making bed and organizing clothes. V6 said agency nurses are notified of residents who are at a high risk for falls through reports, meetings, and in their plan of care. On 3/29/23 at 9:55AM, V6 (Restorative RN/Fall Coordinator) said that all R5's falls have been unwitnessed. Said R5 would come out of her room and let the staff know that she had fallen. I updated the resident's plan of care to add interventions and discontinue interventions if they are not appropriate anymore. Facility most recent Minimum Data Set, dated [DATE] states in part but not limited to the following: R5 needs supervision defined as oversight, encouragement, and cueing with bed mobility, transfer, walking in room and corridor, locomotion on and off unit, and extensive assistance with personal hygiene. R5 needs supervision or touching assistance with rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed/bed to chair transfer, toilet transfer, and walking. R5's care plan originally initiated 4/27/2018 states in part but not limited to the following: Focus: R5 has an ADL self-care performance deficit secondary to activity intolerance, confusion, decreased motivation, and fatigue. ADLs noted to fluctuate from time to time due to dementia. Requires supervision/cues/encouragement. R5's care plan originally initiated 4/18/2018 states in part but not limited to the following: Focus: R5 is at risk for falls r/t impaired memory, judgement, and safety awareness, history of falls, osteoarthritis, AFib, dementia, presence of pacemaker, use of wheelchair, use of walker, and use of antidepressant medication. Interventions: Bilateral floor mats dated 2/14/23; Encourage R5 to report falls to staff as they happen dated 1/2/23; low bed dated 2/14/23; encourage appropriate use of assistive devices; keep items within reach; provide an environment clear of clutter. Facility policy dated 8/2020 states in part but not limited to the following: Policy: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Procedure: 3. Develop a plan of care to include goals and interventions which address resident's risk factors. Risk factors may include but are not limited to the following: contributing diagnoses and comorbidities, history of fall incidents, assistance required with ADL's, balance issues, behaviors, and/or cognitive status. 9. Review and/or modify the resident's plan of care at least quarterly and as needed in order to minimize risk for fall incidents and/or injury.

Based on interview and record review, the facility failed to prevent an incident of staff to resident sexual assault, the facility also allowed the same staff member to provide care to R1 after the abuse investigation was concluded.This failure affected 1 of 3 (R1) residents reviewed for abuse. This failure resulted in R1 having his penis grabbed, pulled and scratched by facility staff (V7), R1 also said he felt uncomfortable having V7 providing care for him after this incident. Findings Include: On 10/26/22 at 3:17pm, R1 who was assessed to be alert and oriented to person, place and time, said, V7 (C.N.A.) entered my room during normal rounds to check my adult brief. My brief was open. I had a foley at the time. V7 (C.N.A.) wrapped her hand around my penis and pulled it. I asked V7 what she was doing. V7 replied, I'm playing. I told V7, I don't play like that. I told V4 (Nurse). I felt uncomfortable. I didn't report the incident initially, because I was embarrassed. V7 scratched my penis. V7 still works with me which makes me uncomfortable. On 10/27/22 at 10:40am, V4 (nurse) said, R1 reported that on 8/11/22, V7 manhandled him and played with his penis, he did not describe how V7 manhandled him. I reported to V1 (administrator). R1 has never made a false allegation against staff. On 10/27/22 at 4:36pm, V1 (administrator) said, sexual abuse is physical contact that the residents perceived as inappropriate. On 10/28/22 at 12:18pm, V2 (Director of Nursing, D.O.N.) said, I would not have an employee accused of abusing resident working with that resident. On 10/28/22 at 12:59pm, V3 (Assistant D.O.N.) said, V7 worked with R1 after the allegation of abuse. V7 worked with R1 on 10/12/22, 10/14/22, 10/18/22, 10/19/22, 10/21/22, 10/24/22, 10/25/22 and 10/26/22. On 10/28/22 at 1:53pm, V1 said, V7 should not be working with R1. V7 should not be work with R1, if R1 reported he felt uncomfortable with V5 providing care. A staff member accused of abuse still working with any residents that made an allegation of abuse would be considered a form of mental abuse. I am not aware of R1 making false allegation againt staff. On 10/28/22 at 2:39pm, V7 (C.N.A.) said, I am in the room with staff when R1 is receiving care. I witness other staff providing R1 care. IDPH reportable dated 9/5/22 document: IL (R1) said, his usual cna (V7) touched him in a way that was inappropriate and uncomfortable. IL (R1) said the cna (V7) was playing with his penis, and in the event may have scratched. Abuse Policy dated 9/20 documents: The facility affirms the right of our residents to be fee from abuse. Sexual Abuse is non-consensual sexual contact of any type with a resident. This includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. Mental Abuse includes, but is not limit to, humiliation, harassment and threats of punishment or deprivation. Mental abuse may occur through either verbal or nonverbal contact which has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation.