**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow fall policy related to prevention of falls and implementation of resident-centered fall interventions on a resident with cognitive impairment. This failure affected one (R1) of five residents reviewed for accidents and supervision and resulted in R1 falling while walking without staff assistance and sustaining a right intertrochanteric hip fracture with associated intramuscular hemorrhage.Findings include:R1 is a [AGE] year-old, male, originally admitted in the facility on 08/20/25 with diagnoses of End Stage Renal Disease; Unsteadiness on Feet; Other Abnormalities of Gait and Mobility; Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris.According to R1's census report, R1 was admitted in the facility on 08/20/25 and was discharged on 08/22/25. On 09/10/25, he came back in the facility and was considered new admission.MDS (Minimum Data Set) dated 09/19/25 documented R1 has memory problem and his cognitive skills for daily decision making is severely impaired. His functional abilities recorded that he needs supervision or touching assistance when walking 10 feet; and partial/moderate assistance when walking 50 feet with two turns. MDS also indicated that he uses a manual wheelchair.Fall risk assessment dated [DATE] categorized R1 as high risk with a score of 15.R1's admit/readmit evaluation dated 09/11/25 documented:E. Neurological: Comments - confusionM. Mobility/Safety:a. walk in room: self-performance - supervisionb. walk in corridor: self-performance - activity did not occurg. wheelchairi. gait disturbance/unsteady gait Facility's incident report dated 09/19/25 recorded: R1 had an unwitnessed fall in the hallway. R1 was observed laying on the floor on his back with his walker on the side of him. Staff did full body assessment and R1 was complaining of pain. Pain medication was offered and given. Family and on call doctor were notified and order was given to send R1 out for further evaluation. Upon checking on R1's hospital status nurse on duty spoke with emergency room nurse and was informed that R1 was being admitted for a right hip fracture.R1's hospital records dated 09/19/25 documented: Xray of hip 2 views right and pelvis: Final result - Impression: Acute comminuted displaced and angulated right intertrochanteric fracture. CT (Computed Tomography) chest abdomen pelvis without contrast: Findings: Right intertrochanteric hip fracture with associated intramuscular hemorrhage. R1 was diagnosed with closed trochanteric fracture of right femur with nonunion and acute traumatic injury of cervical spine.On 09/24/25 at 2:18 PM, V10 (Certified Nurse Assistant, CNA) stated, On 09/19/25 at 1:30 AM, I was by the nurses' station and just heard a sound like something dropped on the floor. Immediately, I stood up and went to the direction of the sound and saw him (R1) on the floor by his room. I called nurse immediately, who was at the other side of the hallway, on the east side. Nurse came immediately. R1 said he wants to walk around. He complained of pain on his hip, right side. The time he fell, he was walking out from his room. I didn't see if he was using his walker at that time. I don't remember. I didn't hear any alarm. When I did my rounds around 12ish he was sleeping on bed. That time it happened; I was the only staff on that side (west wing) where R1 was. That time it was only me and the nurse worked on the west wing. Normally, he (R1) ambulates with a walker. there's no assistance needed because he can do it by himself. He can walk around by himself. He doesn't need assistance to walk around. He has no chair or bed alarm, not that I know of.On 09/24/25 at 2:53 PM, V11 (Licensed Practical Nurse, LPN) said, That time of incident on 09/19/25, I was on 1 East, because one nurse left at 1 AM and I was the only nurse on the first floor. I had two CNAs - one in west and one in east. CNA was sitting at the nurses' station. I heard CNA called me, I went there, and I saw R1 on the floor. I did assessment. I asked him (R1) and said he was walking. I asked him about pain and showed me his right hip. I gave him PRN (when needed) pain pill. I called physician he was sent out as ordered. V11 said, He is alert, oriented to self, time and place, able to verbalize needs. he never uses call light; always sitting in his room. His room is somehow close to nurse station. At night, sometimes, he was awake and will call nurse, nurse. He usually sits in bed and will call nurse, nurse. When we go to his room, he doesn't say anything. If you tell him to sleep, he will lie in bed. I don't know if he is a fall risk, it was the second time I took care of him. I've never seen him walking with a walker, only time he had was when he had the fall.R1's room was observed across nurses' station (1West). R1's door is on the side across nurses' station.On 09/25/25 at 10:25, V12 (Registered Nurse, RN) stated, R1 is very much confused; he talks nonsense. Not able to use call light. He is very much a fall risk patient. His room was just across the station. We always monitor and check on him at least every two hours. CNAs do their rounds also. RNs and CNAs do monitor at least every two hours. I always tell my CNAs to monitor him. I do my rounds then CNAs, so more or less he is monitored and checked every hour. He gets up, he has a rollator. He is able to use rollator with supervision from staff. He uses his rollator with reminders but if not, he won't use it. His legs are weak and has unsteady gait. He needs monitoring/supervision frequently and make sure he uses the rollator when he walks.On 09/25/25 at 10:52AM, V14 (CNA)verbalized, R1 is alert but confused. Able to verbalize needs. He is not able to use call light, he uses a rollator. He is supposed to use a wheelchair. We always redirect him. He always wanted to use the rollator. He is a fall risk. We have to monitor and check on him pretty often, at least every 2 hours and when we do rounds, we check on him. He has no alarms. bed should be lowered. He has a behavior of getting up and walk, needs redirection. He needs to be reminded to use the wheelchair not rollator.On 09/25/25 at 11:14 AM, V5 (LPN/Restorative Coordinator replied, On 09/19/25 at 1:30 AM, he got up from bed, attempted to self-transfer. Did not tell nurse where he was going. The CNA heard him fall, the CNA said she was doing patient care in another patient's room. When the CNA heard it, she went to the room and found him lying on his right side, the walker was next to him. The nurse came and assessed him, he was in pain to his right hip. The nurse called the doctor and R1 was sent out to the hospital. Cause of the fall - R1 was getting up and due to unsteady gait, he fell. Staff should have done rounding/monitoring at the time to ask if he needs something. Rounding/monitoring should be every hour like nurse simultaneous with CNA doing rounds; he might need to go to the bathroom at the time because it was around 1:30 AM but no one was around, cognitively he forgot to use the call light, and he did not know his limits and walked. He gets up when he wants to and walk. He uses a walker with staff assistance. R1 definitely has confusion. Somebody has to monitor and do an hour rounding on him. R1's care plans documented the following:1. Requires restorative walking program due to his limitation in walking related to weakness (dated 09/12/25):Interventions:Discuss ambulation program with resident and responsible party.Provide staff assist with ambulation at level resident requires (e.g. set up, oversight, encouragement, cueing, physical assistance).Remind resident to not ambulate without assistance.2. Resident is high risk for falls (dated 09/11/25):Interventions:Anticipate and meet the res needs.Be sure the resident (R1) call light is within reach and encourage the resident (R1) to use it for assistance as needed. The resident (R1) needs prompt response to all requests for assistance.Educate the resident (R1)/family/caregivers about safety reminders and what to do if a fall occurs.Follow facility fall protocol.The resident (R1) uses (specify: chair/bed) electronic alarm. Ensure the device is in place as needed. R1's care plan interventions focused on his (R1) education, reminders and use of call light when assistance is needed. However, R1 is confused and forgetful. R1's Progress notes dated 09/11/25 documented in part but not limited to the following: R1 was observed up in chair, in no acute distress, eating breakfast, denies pain currently, alert and oriented to self, with noted confusion, requiring redirection per staff. On 09/25/25 at 1:19 PM, V2 (Director of Nursing) stated, He is a fall risk. He came from the hospital because of a fall. He is alert, in and out, able to hold a conversation with you. He can tell you his needs and wants but detailed conversation and remembering things, not really. He needs to be redirected. He had a fall early in the morning, like at 1:30 AM, he got up and walked. His legs gave out when he was walking using the walker. It was unwitnessed fall, so he could not be redirected.Per admit evaluation note dated 09/11/25, R1 uses a wheelchair due to gait disturbance and unsteady gait. Per care plan, R1 uses electronic alarm, but was not implemented.On 09/25/25 at 10:46 AM, V13 (Nurse Practitioner) stated, R1 is confused with place and time, he has dementia, able to verbalize needs. He sits in the wheelchair. I have not seen him walk. He is a fall risk. Rounds/monitoring should be done; making sure bed is locked; wheelchair locked; wearing non-skid socks; and follow the facility fall protocol. Facility's policy titled, Falls Guideline, dated 8/2024 documented in part but not limited to the following:Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization-wide ownership for fall prevention to:To achieve each resident's maximum potential of physical functioning.To prevent or reduce injuries related to falls.To enhance residents' dignity and self-worth.The intent of this guideline is to ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following process:I. Identification of hazards and risksII. EvaluationIII. ImplementationIV. MonitoringV. AnalysisFall risk evaluation: a fall evaluation is used to identify individuals who have predicting factors for falls. This evaluation is completed upon admission, quarterly, annually and with a significant change in condition. Residents evaluated as at risk for falls will be identified and individualized fall precautions developed for each resident. Preventative measures shall be taken to decrease the number of falls whenever possible.Purpose:1. To consistently identify and evaluate residents who fall and to treat or refer for treatment appropriately.3. To prevent or reduce injuries related to falls.6. Individualize interventions for each resident.Evaluation may include: Residents with recent surgery or new admission; fall history; cognitive status1. If the evaluation finds the resident at risk, implement resident specific interventions/precautions.7. All residents identified as at risk for falls will be reviewed for individualized interventions.Fall Prevention is achieved through an IDT (interdisciplinary team) approach of managing predicting factors and implementing appropriate interventions to reduce risk for falls. Facility staff across all departments together with resident representatives and residents provide resourceful information with individualizing care and approaches.Understanding contributing and predicting factors that present will assist with determining individualized care approaches.Systems approach - Tips for Compliance:Involve interdisciplinary team (IDT) on: Individualized assessment for safety; identification of hazards; Development and implementation of interventions to reduce accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to monitor and prevent a high risk cognitively impaired resident from sustaining a preventable fall, failed to provide fall preventative devices, failed to develop/implement a plan of care for residents at high risk for falls, and failed to educate staff on identifying and protecting residents from accidental falls. This failure affects 1 (R57) of 1 residents reviewed for falls in the sample of 28. R57 was admitted to the hospital with a left comminuted (multiple bone breaks) femur fracture with surgical intervention as a result of this failure. Findings include: R57 is a cognitively impaired resident with diagnoses including but not limited to End Stage Renal Disease, Major Depressive Disorder, Dependence on Renal Dialysis, Other Abnormalities of Gait and Mobility, Lack of Coordination, Long Term (Current) Use of Anticoagulants, Reduced Mobility, and Weakness. R57's MDS Minimum Data Set (Comprehensive Assessment) dated 05/24/24 documents a brief interview for mental status (BIMS) score of 4 out of 15. A score of 0-7 indicates severe cognitive impairment. All 3 consecutive MDS assessments dated 05/24/24, 02/27/24, and 12/06/23 maintain R57's cognitive decision making to be severely impaired with the latest MDS assessment showing a significant change post-fall incident. Four consecutive fall risk assessments dated 12/1/2023, 4/15/2024, 5/20/2024, and 7/17/20204 all assess R57 at High Risk for Falls. On 9/23/24 at 11:15 AM, R57 was observed in bed asleep. One fall mat on the floor next to the right side of the bed. No other fall precautions were in place. On 09/25/24 at 10:51 AM, interview with V16 Maintenance Technician regarding R57's fall on 07/17/2024. V16 said, I got a work order for the room. I knocked on the door and asked if I could come in. I was there for bed B by the bathroom because the TV wasn't working. When I saw R57 she was in bed A she was sitting in the middle of the bed facing the door. I came and went in the middle of both beds. I started to set up the TV remote for bed B. I heard a loud thud noise like something dropped. I turned my face and saw (R57) on the floor. I said just a minute to R57, and I went to the nurse's station. V8 RN was in the hall, and I said somebody in the room was on the floor. She went into the room first. I didn't go back into the room. As soon as I knew what happened V1 Administrator and V5 Restorative Nurse came and talked to me. They said I had to make a report and I wrote it down. This surveyor showed V16 Maintenance the written statement provided by V1 Administrator and asked if he saw her fall. V16 said, That's mine. I didn't see her fall; I saw the privacy curtain move after she fell. On 09/25/24 at 11 :24 AM, V8 RN inquired of R57's fall incident on 07/17/2024. V8 said, V16 Maintenance came to me I was in the hallway passing medication. He told me someone had fallen in the room. I went into the room and R57 was on the floor by the side of the bed. I told V16 Maintenance to call for help to get her off the floor. While I was assessing her, I asked her if she had pain. I checked her extremities and skin. She said she had pain on both thighs. She said the pain was about 3 out of 10. She was able to move her extremities at her baseline, able to move everything. I asked if she hit her head on the floor and she said no. I asked her how she fell. She said she was trying to get out of the bed. She didn't say where she was going. The other staff came in and helped me get her off the floor. V21 CNA, another restorative person, V18 RN, and I lifted R57 and put her back in bed. R57 didn't show any pain. R57 has confusion sometimes. They helped me put her back in bed and we turned her, and I checked her skin if she had any bruises. I asked her to move her arms and legs and she was able to move as much as she can. Surveyor asked to clarify how she assessed and interviewed R57 given her severe cognitive impairment, V8 said, I didn't ask her to show me where her pain was. I just checked her skin and asked her to move. I talked to V16 Maintenance, and he said he didn't actually see her fall, he just heard her fall. I called the V20 NP Nurse Practitioner on the phone about the pain she had, and she ordered an x-ray. V20 NP Nurse Practitioner was in the building. She said to give her Tylenol. We have a protocol for 72 hour neurological checks and follow up fall monitoring. I gave her Tylenol after the incident because she had an order. I went back in thirty minutes, and she wasn't having pain. R57 speaks English and I understood her clearly. She didn't have any changes to her condition. I called for an x-ray for her hips and pelvis, left femur and left elbow. I didn't say anything about R57's left side, it's just what the V20 NP ordered. I ordered the x-ray stat (immediately). They didn't say when they'd come. I work 7AM to 7PM. They didn't do the x-ray before I left so I gave report to the oncoming nurse. I said the x-ray hadn't been done yet. I didn't tell anyone else that the x-ray wasn't done yet. V8 was asked if she completed the fall event form for R57 and why certain areas were left blank. V8 said, Yes, I did it. Was R57 ambulatory? Why was the ambulatory status and extremities section left blank? V8 was asked, did you check her range of motion and position of her extremities? V8 RN said, No, she wasn't. She was a one person assist to a wheelchair. She could bear her weight and transfer to a wheelchair. I accidently left it blank; she didn't have any deformities. V8 was asked, was R57 a fall risk? How would you know if she was a fall risk? If so, what interventions were previously in place? V8 said, I'm not sure if she was. It would have been in her profile. This was the first time I worked with her. There's a folder on the unit with the fall risks. I'm not sure I checked. I could have checked her care plan, but I didn't. A nursing note written by V8 RN reads in part, On 7/17/24 at 11:30 AM, a staff member from maintenance notified NOD (nurse on duty) that resident was on the floor. Upon arrival in resident's room, NOD noted resident sitting on the side of the bed. Resident stated I was trying to sit on the side of the bed and lost my balance while trying to get up. Head to toe assessment done, no injury noted, able to move all extremities at baseline, VS (vital signs) taken and recorded, resident with complaint of pain on both thighs, Tylenol 650 mg PRN (as needed) administered. Resident denies hitting head at this time. V20 NP Nurse Practitioner notified with order for Xray of bilateral hip and pelvis, left femur, and left elbow order confirmed and carried out. Notified POA (Power of Attorney) via voicemail as cell phone wasn't picked up. Ongoing Neurological check and 72 hour post monitoring initiated. R57's progress notes reflect the x-ray was not performed by the portable x-ray company until 07/18/24. On 09/25/24 at 12:29 PM, V21 CNA Certified Nurse Assistant said, R57 is alert and knows where she is and what she wants. I was in her room after she was done with her restorative. I warmed up her milk and set up her tray while she was in bed. She was eating and I went back to the nurse's station. V16 Maintenance came and told me someone was on the floor. When I went to the room V8 RN, another nurse and V16 Maintenance were in the room. R57 was sitting on the floor next to the bed. I asked her what happened. She's not confused. R57 said I thought I could walk by myself. V8 RN assessed her and R57 said she was fine and didn't hurt herself. The nurses and I helped lift her up and we put her sling underneath her. We hooked it up to the mechanical lift and placed her on the bed. She didn't show any pain. The nurses checked her body, we repositioned her. She was wearing a house dress. They didn't take her dress off, they just lifted it up. I just checked on her after that, she didn't say anything hurt. V21 CNA said, R57 wasn't a fall risk because she never tried to get up. If she was a fall risk, we'd have a low bed and use little mattresses on the floor both sides of the bed. She only had the low bed. How would you find out if R57 was a fall risk? V21 CNA said, The restorative nurse educates the nurses and aides. On 09/25/24 at 1:00 PM, two surveyors visited R57 and observed the resident laying in the bed. There was one fall mat beside the resident's bed and another that was folded up and leaning in the corner of the room not being utilized. A call light was wrapped multiple times around R57's side rail and with the call light button tucked under R57's pillow away from R57's reach. V8 (RN) was asked to affirm what the surveyor's observed. V8 said, The call light is under her so she can't reach it. She needs repositioning. She has a mat on the floor and the other is in the corner. It's supposed to be on the other side on the floor. There's a sign hanging on the wall, but I don't know what it means. V8 was asked if she has had any training on fall risk precautions and fall risk residents? V8 said, It was last month with V5 Restorative Nurse. The CNA or nurse should make sure the fall precautions are in place. I'll tell her CNA to put the other mat down and to give her the call light. V8 RN attempted to speak to R57 asking, How are you feeling? Do you know where you are? R57 did not respond. V8 said, She wasn't able to answer. V8 was asked if this a change in her mental status? V8 said, Yes, she usually answers. On 09/25/24 at 01:27 PM, interview with V18 RN regarding R57's fall incident from 07/17/24. V18 RN said, I didn't witness her fall, I was on the other end. One of the CNA's came and got me. I got to the room, and they were asking for help to transfer back to bed. She was sitting on the floor next to the bed on the right side. I helped them. They had a mechanical lift pad or sheet underneath her, and just helped them get her in the bed. We repositioned her and I left. R57 shook her head no when asked if in pain. On 09/25/24 at 01:33 PM, V5 Restorative Director was interviewed regarding R57's fall incident on 07/17/24. V5 said, I was aware she fell on Wednesday the 17th; V8 RN reported it to me. I wasn't there during the assessment. I saw her after when she was in bed just to look at her to see what interventions we could place. R57 was sleeping, she wasn't able to answer me. I talked to her between Thursday and Friday. I asked R57 before she went out and she told me she was sitting on the side of the bed and was trying to get up, that's what she said. She had x-rays ordered on Wednesday; we got the results on Thursday night close to midnight. It said signs of old fracture healed in the results. On Friday the nurse had the report in hand, and I called the V20 NP Nurse Practitioner. When I told her she said to send R57 out to the hospital. I called the family, her POA, and told him we received the x-rays, and he was grateful. When she went to the hospital I called to see if they were admitting her. I did the interdisciplinary note. She was a high fall risk. She scored a 10 or higher on all her fall risk assessments done upon admission, quarterly, and annual. V5 said, We do 50% or more of the effort so we put a gait belt on her and a walker and follow with a wheelchair for resting periods. V5 was asked, what interventions were in place when she fell? V5 said, I would have to check, we didn't have the landing mats at that time. We only place interventions when there's a fall. This was her first fall with me. If anyone scores high, we don't place any interventions until they fall. She didn't have any interventions at that time. The only thing was to keep her bed in a low position. We do purposeful rounds, the four P's everyone does them. Position, check a resident. Potty, if they're soiled, clean them. Possessions, place items and call light within reach, before leaving ask if there's anything they need. I can't remember the last P. R57's fall was due to lack of coordination and weakness. V5 said, Yes, she was able to use it (call light). She was alert and oriented x 1 (person) to 2 (place) with bouts of confusion, but she's able to verbalize needs and follow simple instructions. V5 was asked, what are her current fall interventions? V5 said, She has landing mats bilaterally and while in bed. Regarding knowing if resident is a high fall risk, V5 said, We started training staff to use a cared file system, it's on the residents profile. It's new about a month ago. It would say high fall risk and if they have fallen it's shows what interventions are there. V5 said, Between me, nurses, CNAs, and RNAs (restorative nurse assistant). Once a resident falls and has interventions in place we tell them the interventions. I started the training of the card file on Tuesday the 24th. I have fall binders in the nurse's station, one per floor. At that time, this was the other way to know if they were a fall risk. They could also check the care plan. The card file system is in the electronic chart record. On 09/26/24 at 12:34 PM, interview with V20 NP Nurse Practitioner regarding R57's fall on 07/17/24. V20 NP said, Nursing staff called me on 7/17 the day of the fall, I'm not sure if I was in house. R57 is in bed most of the day, a dialysis patient. She is forgetful but could voice her needs and use her call light. Alert and oriented x 2 (to person and place) maybe. She was in the bed. She wasn't in any pain or distress. She said she was attempting to sit at the edge of the bed and slid off is what was told to me by the nurse. Nursing said staff found her sitting on the floor. My note is from 7/18/24. I did a full assessment. She was complaining of pain with movement of the left leg but appeared to be comfortable. She wasn't in any distress. There was no deformity from my clinical judgement. Sometimes a fracture can't be seen. She was in some pain. I ordered x-rays bilateral hip and pelvis, left femur and elbow. In this situation I ordered them stat, so it should be done as soon as possible. I ordered blood work to make sure nothing was underlying. After I saw the x-ray from (the x-ray company), I ordered R57 to be sent to the hospital for further evaluation. The x-ray doesn't say it's acute, it says healed or healing pubic fracture and Osteopenia. Due to this and her having a fall I ordered her to be sent for further evaluation. V20 was asked, were you informed the x-ray wasn't completed until 07/18/24? V20 NP said, I don't remember when the x-ray was done. I usually ask when I come in the next day. If not, I ask them to call the x-ray company. I don't remember if the nurse told me when it was done. It's been more difficult with this company. It's a common thing that a nurse should report that. When the x-ray company comes, they don't even tell the nurses when they are there and when it (the x-ray) was done. It's expected to be done as soon as possible the same day. R57 has an order for Tylenol 650mg by mouth every 6 hours as needed. I can't remember if V8 RN told me about how well she tolerated it. The nurses usually document the pain assessment and let me know if any additional orders are needed. Review of R57's POS (Physician Order Sheet) states in part she was prescribed Heparin 5,000 units/ml (milliliter) injectable solution. Inject 1ml (milliliter) into the skin every 12 hours. Heparin is in a class of anticoagulant medications used to prevent and treat blood clots. It works by decreasing the clotting ability of the blood (blood thinner). Falls can cause bone fractures which can be more serious for patients taking blood thinners due to the risk of severe bleeding. R57's 05/20/2024 care plan indicates R57 is at risk for falls related to vomiting, generalized weakness and multiple chronic disease conditions. Dx: HTN (Hypertension), COPD (Chronic Obstructive Pulmonary Disease), CKD-4 (chronic kidney disease), Anemia diagnosis of End Stage Renal Disease, COPD, Anemia, muscle weakness, difficulty walking, reduced mobility. Interventions: educate resident to use call light for assistance. Encourage resident to ask staff to help her put her sweater on. Keep furniture in locked position. Keep needed items, water, etc. in reach. Maintain a clear pathway, free of obstacles. Avoid repositioning furniture. Provide visual prompts to ask for help. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes as possible. Educate resident/family/caregivers/interdisciplinary team as to causes. Educate R57/family/caregivers about safety reminders and what to do if a fall occurs. R57 Needs activities that minimize the potential for falls while providing diversion and distraction. Encourage R57 to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that R57 is wearing appropriate footwear when mobilizing in wheelchair. R57 is on Anticoagulant therapy (Heparin injection) for clot prevention. R57 is at risk for bleeding and complications. Interventions: Daily skin inspection. Report abnormalities to the nurse. R57/family/caregiver teaching to include the following: take/give medication at the same time each day, use soft toothbrush, use electric razor, avoid activities that could result in injury, take precautions to avoid falls, signs/symptoms of bleeding, avoid foods high in Vitamin K. These include greens such as spinach and turnips, asparagus, broccoli, cabbage, brussels sprouts, milk, and cheese. Labs as ordered. Report abnormal lab results to the MD. Monitor/document/report to MD (medical doctor) PRN (as needed) signs/ symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, , diarrhea, muscle joint pain, lethargy, bruising , blurred vision, SOB (shortness of breath), loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Review medication list for adverse interactions. R57'S 05/24/24 MDS Minimum Data Set (Comprehensive Assessment) Section GG Mobility states in part C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed and with no back support. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. The portable x-ray company's date of service for R57 states in part 07/18/2024 x-ray of the pelvis and bilateral hips, five views. Impression: 1. Impacted left subcapital femoral neck fracture deformity, of unknown age. 2. Healed or healing left inferior pubic ramus fracture. The portable x-ray company's date of service for R57 states in part 07/18/2024 x-ray of the left femur, AP (anterior to posterior) and lateral. Impression: 1. Subcapital left femoral neck fracture deformity, of unknown age. 2. Osteopenia. R57 was hospitalized on [DATE] through 07/31/2024 with a diagnosis of closed fracture of the left hip. The physical exam for musculoskeletal indicates left hip restriction of range of motion due to pain. The 07/19/2024 hospital (CT) Computed Tomography Scan of the pelvis without contrast indicates final result 1. Comminuted (a bone breaks into more than two pieces), mild to moderately displaced left sacral ala fracture, extending to the left sacroiliac joint. Additional comminuted. mildly displaced fracture of the left posterior superior iliac spine, also extending to the sacroiliac joint. Suspected mild left sacroiliac joint diastases. 2. Comminuted, mildly displaced fractures of both superior and inferior pubic rami. Additional mildly displaced fractures of both acetabular and anterior columns. 3. Mildly displaced and impacted fracture of the left femoral neck, possibly Basi-cervical. 4. Focal angulation of the right femoral head-neck cortex may represent a nondisplaced fracture. The assessment and plan indicate left hip fracture: patient has been evaluated by orthopedics plan for surgical intervention today. The preoperative diagnosis states in part 1. Left displaced femoral neck fracture. On 07/23/24 R57 had Left Hip Arthroplasty (a surgery to restore the function of a joint. The joint is replaced, remodeled, or realigned.) The 02/13/24 Fall Prevention and Management Policy states in part: Policy Statement: The facility is committed to its duty of care to residents and patients in reducing risk, the number and consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained. Procedures: Fall Risk Screening a. Residents and patients will be screened to determine fall risk. b. Fall risk screening will be used on admission, readmission to the facility, following a fall, following a change in status, and quarterly. c. High risk residents will receive interventions as appropriate to risk factors. Fall Interventions a. Fall precautions will be implemented for residents as appropriate. b. The IDT (interdisciplinary team) will discuss interventions that may be added to the resident's care plan. c. Fall interventions may include, but not be limited to: assess the need for an assistive device for mobility and locomotion. Meaningful activities are encouraged. Keep hearing aids, glasses, dentures with the resident. Pharmacy may review medications for any potential side effects/drug interactions. Physical/Occupational evaluation as appropriate. Assess needs for toileting or incontinence care. Restorative may evaluate programs such as ambulation, transfers, and bed mobility. Room change near the nurses station if available. Development of Plan of Care a. An interim or basic care plan will be initiated for all new admissions or readmissions. b. A comprehensive falls care plan will be developed. c. A review of the current care plan will be conducted after the fall with the IDT.

Based on observation, interview and record review the facility failed to recognize, evaluate and manage pain for a 1 (R57) resident with severe cognitive impairment of 3 residents reviewed for pain management in the sample of 28 residents. This failure affected R57 receiving inadequate pain medication after an unwitnessed fall, and failure to thoroughly assess and monitor for further pain for over 48 hours until being emergently sent to the hospital for treatment of a femur fracture requiring surgical intervention. Findings include: R57 is a cognitively impaired resident with diagnoses including but not limited to End Stage Renal Disease, Major Depressive Disorder, Dependence on Renal Dialysis, Other Abnormalities of Gait and Mobility, Lack of Coordination, Long Term (Current) Use of Anticoagulants, Reduced Mobility, and Weakness On 09/25/24 at 02:25 PM, Surveyor inquired with V1 Administrator about R57's fall incident and report to IDPH Illinois Department of Public Health. V1 said, R57 fell during the daytime, and she complained of pain. X-ray was ordered, technician came the next day, and the results came at midnight. She fell on a Wednesday and the results came between Thursday night and Friday morning. Based on the results of the x-ray relayed to the V20 NP R57 was transferred to the hospital. I found out from V5 Restorative Nurse on Monday or Tuesday that R57 was going to have surgery for a hip fracture. R57 was sent to the hospital for further evaluation. It was a recommended procedure for R57 to have surgery. This is a fall with a serious injury. The hospital conducted its own evaluation and confirmed the fracture, that's why she had the surgery. A nursing note written by V8 RN reads in part, On 7/17/24 at 11:30 AM, a staff member from maintenance notified NOD (nurse on duty) that resident was on the floor. Upon arrival in resident's room, NOD noted resident sitting on the side of the bed. Resident stated, I was trying to sit on the side of the bed and lost my balance while trying to get up. Head to toe assessment done, no injury noted, able to move all extremities at baseline, VS (vital signs) taken and recorded, resident with complaint of pain on both thighs, Tylenol 650 mg PRN (as needed) administered. Resident denies hitting head at this time. V20 NP Nurse Practitioner notified with order for Xray of bilateral hip and pelvis, left femur, and left elbow order confirmed and carried out. Ongoing Neurological check and 72 hour post monitoring initiated. R57's progress notes reflect the x-ray was not performed by the portable x-ray company until 07/18/24 a day after R57 sustained a mechanical fall. There were also no pain assessments conducted or pain medications during the time period based on the medical records provided to surveyor. R57's MDS Minimum Data Set (Comprehensive Assessment) dated 05/24/24 documents a brief interview for mental status score of 4 out of 15. A score of 0-7 indicates severe cognitive impairment. Surveyor asked to clarify how she (V8-RN) assessed and interviewed R57 given her severe cognitive impairment. V8 said, I didn't ask her to show me where her pain was. I just checked her skin and asked her to move. I talked to V16 (maintenance man), and he said he didn't actually see her fall, he just heard her fall. I called the V20 NP Nurse Practitioner on the phone about the pain she had, and she ordered an x-ray. V20 NP Nurse Practitioner was in the building. She said just to give her Tylenol. We have a protocol for 72 hour neurological checks and follow up fall monitoring. I gave her Tylenol after the incident because she had an order. I went back in thirty minutes, and she wasn't having pain. R57 speaks English and I understood her clearly. She didn't have any changes to her condition. I called for an x-ray for her hips and pelvis, left femur and left elbow. I didn't say anything about R57's left side, it's just what the V20 NP ordered. I ordered the x-ray stat (immediately). They didn't say when they'd come. I work 7 AM to 7 PM. They didn't do the x-ray before I left so I gave report to the oncoming nurse. I said the x-ray hadn't been done yet. I didn't tell anyone else that the x-ray wasn't done yet. Surveyor asked if she provided any other pain medications other than the one dose of Tylenol, V8 indicated that she provided only one time. The July MAR (Medication Administration Record) showed on July 17th, 2024 on the day of the fall incident, R57 was administered two tablets of regular strength Tylenol for mild pain by V8 (RN). This same nurse assessed a severely cognitively impaired resident with a pain level of 3 for mild pain after an unwitnessed mechanical fall to the floor sustained by R57. There were no additional pain medications administered to R57 from the 1 dose throughout her discharge to the hospital on July 19, 2024. Further review of the July medication administration records showed no other pain assessments were conducted for the entire month of July 2024. On 7/17/24, there is one pain evaluation written by V8 post fall incident with incomplete information and assessment of R57's pain and interventions for the pain. V8 left blank on the pain assessment form the sight, onset of pain or duration of the residents pain. R57's quality of pain was an ache. Numerous blanks of the assessment including any non-verbal indicators of pain or pain exacerbating factors for a resident with severe cognitive impairment. There were no non-pharmacological interventions provided. V8 indicated that Tylenol 650 mg should have been provided every 4 hours and as needed but left blank whether the resident had any side effects from the pain medication or if there were any signs of sedation, nausea, constipation, indigestion or diarrhea or whether the resident was receiving any medications to alleviate side effects which again was left blank. On 09/26/24 at 12:34 PM, V20 NP Nurse Practitioner V20 NP said, Nursing staff called me on 7/17 the day of the fall, I'm not sure if I was in house. R57 is in bed most of the day, a dialysis patient. She is forgetful but could voice her needs and use her call light. Alert and oriented x 2 (to person and place) maybe. She was in the bed. Per V8, she wasn't in any pain or distress. The nurse said that the resident was attempting to sit at the edge of the bed and slid off is what was told to me by the nurse. Nursing said staff found her sitting on the floor. My note is from 7/18/24. I did a full assessment. She was complaining of pain with movement of the left leg but appeared to be comfortable. She wasn't in any distress. There was no deformity from my clinical judgement. Sometimes a fracture can't be seen. She was in some pain. I ordered x-rays bilateral hip and pelvis, left femur and elbow. In this situation I ordered them stat, so it should be done as soon as possible. I ordered blood work to make sure nothing was underlying. After I saw the x-ray from (the x-ray company), I ordered R57 to be sent to the hospital for further evaluation. The x-ray doesn't say it's acute, it says healed or healing pubic fracture and Osteopenia. Due to this and her having a fall I ordered her to be sent for further evaluation. V20 NP said, I don't remember when the x-ray was done. I usually ask when I come in the next day. If not, I ask them to call the x-ray company. I don't remember if the nurse told me when it was done. It's been more difficult with this company. It's a common thing that a nurse should report that. When the x-ray company comes, they don't even tell the nurses when they are there and when it (the x-ray) was done. It's expected to be done as soon as possible the same day. R57 has an order for Tylenol 650 mg by mouth every 6 hours as needed. I can't remember if V8 RN told me about how well she tolerated it. The nurses usually document the pain assessment and let me know if any additional orders are needed. Facility's policy dated 1/01/2021 titled Pain Management reads in part, The facility will provide adequate pain assessment and management to that residents attain or maintain the highest practicable physical mental, and psychosocial well-being. Procedure: Evaluate the resident for pain upon admission, during periodic scheduled assessments, and with change in condition or status (after a fall, etc.). Behavior signs and symptoms that may suggest the presence of pain include: change in gait, loss of function, decline in activity, resisting care, bracing, guarding or rubbing, fidgeting, facial expressions of grimacing, frowning, fear, grinding of teeth; change in behavior: depressed mood, decreased participation in usual activities of daily living, loss of appetite, sleeping poorly, sighing, groaning, crying, breathing heavily. Assessment and evaluation: Asking the patient to rate the intensity of his/her pain using a numerical scale or a verbal or visual descriptor that is appropriate and preferred by the resident. Review of the resident's diagnosis or conditions that may be causing or contributing to pain. Identifying key characteristics of the pain, obtaining descriptors of the pain, determining factors that make the pain better or worse, identifying recent exacerbations of pain, impact of pain on quality of life. Current prescribed pain medications, dosage and frequency. Non-pharmacological pain management interventions include adjusting room temperature, smoothing linens, turning and repositioning to a comfortable position.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to medically manage a brittle Type 1 diabetic by failing to follow physician orders in administering insulin orders and obtaining blood glucose levels; failed to administer anti-seizure medications for a resident with a history of seizure disorders; and failed to have a care plan in place for a resident with history of seizure disorders. This failure applies to 1 resident R1 of 3 residents reviewed for quality of care and resulted in the emergent transfer to the ER (emergency room) to receive immediate critical care for treatment and prevention of imminent life-threatening deterioration of dehydration, endocrine crisis, and metabolic crisis. Findings include: R1 is [AGE] years old admitted to the facility on [DATE] with diagnoses include but are not limited to Toxic Encephalopathy, Type 1 Diabetes Mellitus, Seizures, Chronic Respiratory Failure with Hypoxia, Tracheostomy, End Stage Renal Disease, Dependence on Renal Dialysis. On 07/30/24 at 11:28 AM, R1 appeared alert and oriented to person and place. R1 was observed sitting near the nurse's station in her wheelchair. Inspection of R1's room showed snacks of diabetic cookies and sunflower seeds on her over bed table. Surveyor asked R1 about her care on 6/9/24. R1 said, I went to the hospital. R1 was unable to recall the reason for her hospitalization. On 07/31/2024 at 11:20 AM, R1's room was observed again and with V13 LPN Licensed Practical Nurse inside the room. There was a 1/2 package of diabetic cookies and 12 ounce bottle of zero sugar electrolyte drink with 1/2 amount remaining on the bedside table. No other food items were found. R1 appeared to be compliant with her nutrition. On 07/31/24 at 11: 23 AM, V10 CNA Certified Nurse Assistant was asked of R1's snacks in her room. V10 said, R1 has some diabetic wafer cookies and sunflower seeds. She usually drinks coffee or water. That's all. On 07/31/24 at 2:14 PM, Interviewed V12 LPN regarding R1's June 8, 2024, 6 AM dose of Insulin Glargine 100 units/ml (milliliters); inject 3 units subcutaneously (applied under the skin) one time a day for high sugar. V12 said, I believe I checked her blood sugar, but I can't remember since it's not documented. I have no idea. A review of R1's medication administration record dated June 8, 2024 showed insulin was not administered as ordered. The physician order states 6 AM dose of Insulin Glargine 100 units/ml (milliliters); inject 3 units subcutaneously (applied under the skin) one time a day for high sugar. This was not administered. V12 was asked of R1's seizure and blood glucose level of 255 from June 9, 2024, prior to being hospitalized . V12 said, I was the assigned nurse, I worked overnight. I was leaving at 7AM. I entered the blood sugar number at the time I documented it. I was busy calling the family and doctor, but I took it when it was scheduled at 6AM. I gave the insulin by the order at 6AM. [R1] was walking around the room when I came to do her blood sugar. I was there before I started my medication pass. She was alert. [V14 CNA] went to change her because she was incontinent. Between 6 and 7AM, [V14] called me in the room. When I came in [R1] was in the chair and she was shaking; it wasn't her normal. I called my co nurse and she called the doctor and got orders to call 911. I was taking her vitals. I took care of her the whole time. I stepped out the room when EMS (Emergency Medical Service) got here; not sure if they checked her blood sugar. She was still having seizures when they got here. V12 was asked if R1 had anything to eat during the night. V12 said, During the night, R1 came out a few times so I sat her at the desk with me. She had a snack, juice and a graham cracker or a peanut butter and jelly sandwich. I can't remember which one. It was around 3 to 4 AM. I don't think she had anything else. On 07/31/24 at 3:02 PM, V16 LPN was asked about administering R1's June 7, 2024, 8 PM Dilantin medication. V16 said, I know we have it on hand. I don't know if it was since it wasn't documented, it may be an error. She doesn't refuse medicine from me. I'm good with her. I'm not sure what happened. Review of R1's June 7, 2024, at 14:50 military time (2:50 PM) physician order and medication administration record indicates Dilantin Oral Suspension 125mg/5ml (milligrams/milliliters) (Phenytoin). Give 10ml by mouth every 12 hours for seizures. The medication is not documented as being administered as per physician order for the 8 PM dose. R1's 6/7/24 lab report states in part: Dilantin 4.0 ug/ml (microgram/milliliter) L (low). Reference range 10.0 - 20.0. On 07/31/24 at 3:09 PM, V17 LPN was asked about administering R1's Insulin Lispro Injection 100 units/ml (milliliters); inject 4 units intramuscularly with meals for high sugar. V17 said, I gave the insulin, maybe I forgot to click it. I always give my insulin with the food. Her blood sugar was fine. There is no documentation of V17 LPN administering R1's 4 units of Lispro insulin on 6/7/24 at 1700 (5PM) in the electronic medication administration record. There is no documentation of R1's blood glucose checked at 1700 (5PM) on the blood sugar summary. On 08/1/24 at 10:16 AM, V15 Nurse Practitioner was asked about R1's elevated blood sugar of 573 and abnormal Dilantin lab result of 4.0. V15 was also asked what interventions were done when the facility relayed the negative lab results. V15 said, R1 was a new resident to me. The nurses called me on 6/7/24 because her blood sugar was 573 and her Dilantin level abnormal at 4.0. Surveyor asked if the current order was sufficient to manage her seizures and whether the Valproic Acid was the same medication, V15 NP said, I increased the Valproic Acid to 10ml BID (twice daily). I just changed it in my notes. It's not the same medication. It was just a typo; it was for Phenytoin. We can increase at certain times usually 4 weeks, but she went to the hospital. Surveyor asked how the facility managed R1 being a brittle diabetic and any interventions or orders given because of the recent labs and what orders. V15 said, For the blood sugar, she's fragile diabetic type 1. Her blood sugar goes into the 20's and has been hospitalized multiple times for that. I told the nurse to give her insulin per her MAR (medication administration record). I don't see it in my notes. She [R1] had sliding scale Lispro and that's what I asked the nurse to give. It was my first time seeing her and she has a history or hypoglycemia. She's very non-compliant about her food. They check her blood sugars three times a day with meals and at night. When I did her rounds, we try to help her with her meals. We have a dietician on board with her as well. I did talk to the doctor the day before. I'm not sure how she did overnight if she ate some sugary snacks for her blood sugar to be 1600 when she went to the hospital. There are concerns with R1 not being administered blood glucose monitoring and insulin for meals as prescribed. Surveyor asked what the expectations were for R1's care, V15 NP said, The nurses have to make sure to check the blood sugar as ordered and make sure she eats, and give the insulin as ordered. If the blood sugar is more the 400, they have to notify us. Surveyor asked if there was a concern with R1 not being administered Dilantin 10ml by mouth as prescribed for 6/7/24, V15 NP said, Seizure medication should be given on timely manner. They have a window of 1 hour before and after to give it. A Review of R1's 6/7/24 09:10 AM progress note by V15 NP Nurse Practitioner states in part: HPI (History of Present Illness). Seen today for BS (medical abbreviation for blood sugar) 573. Abnormal Dilantin level. Lab/Imaging results: Dilantin (Phenytoin) 4.0. Assessment/Plan: #BS 573. Increase Valproic Acid to 10ml (milliliters) BID (medical abbreviation for twice a day). Review of R1's 06/01/2024 to 06/30/2024 physician order summary does not list Valproic Acid being an active order for her. On 08/01/24 at 11:35 AM, interview with V2 DON Director of Nursing regarding R1's blood glucose monitoring not performed and documented and insulin and Dilantin medication not administered as prescribed. Additionally, R1 was not administered blood glucose monitoring and insulin for meals as prescribed. V2 DON said, The nurses should be following the physician's orders. It should be documented on the MAR (medication administration record). Surveyor asked about R1's Dilantin 10ml by mouth not given as prescribed for 6/7/24. V2 DON said, The nurse should administer the medication as ordered and make sure to document it on the MAR. Surveyor asked about R1 not having any care plan for her seizure disorder, V2 said, She should have a care plan in place for her seizure disorder, so staff know what the precautions are, and what care to provide and what makes her at risk for a seizures. Review of records showed no documented plan of care for R1's seizure diagnosis as listed per MDS (Minimum Data Set/Comprehensive Assessment) dated 06/10/2024 Section I Active Diagnoses. Further review showed R1 was not provided an order for blood glucose monitoring until 06/07/2024. R1's 06/01/2024 to 06/30/2024 physician order summary states in part- check blood glucose before each meal and at bedtime related to Type 1 Diabetes Mellitus start date 06/07/2024. A care plan dated 06/06/24 states in part- R1 is at risk for elevated blood sugar and complications. R1 is on insulin injection (see POS Physician Order Sheet/MAR Medication Administration Record). Goal- R1 will have no complications related to diabetes through the review date. Interventions- Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Educate R1/family/caregivers as to the correct protocol for glucose monitoring and insulin injections and obtain return demonstrations. Continue until comfort level with procedures is achieved. Monitor/document/report to MD (medical doctor) PRN (as needed) for s/sx (signs/symptoms) of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma. Monitor compliance with diet and document any problems. R1 has nutritional problem or potential nutritional problem r/t diagnosis of respiratory failure, DM (Diabetes Mellitus) 2, ESRD End Stage Renal Disease, CKD Chronic Kidney Disease, moderate protein calorie malnutrition. On clear liquids, SLP (speech language pathology) to follow. BMI (body mass index) 24.2 is WNL (within normal limit). Skin intact. 6/7/24: Diet change to Lib. renal, regular texture, thin liquids, Nepro once daily. Interventions- Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Provide and serve supplements as ordered. Provide, serve diet as ordered. Monitor intake and record every meal. RD Registered Dietitian to evaluate and make diet change recommendations PRN (as needed). Weigh at same time of day and record: weekly weight x weeks or per facility protocols. R1's 06/09/2024 hospitalization documentation reads in part- [AGE] year-old female trach vent at baseline presents with seizure from nursing home she does have a history of seizure disorder her Dilantin level is very low given a dose of Fosphenytoin (anti-seizure medication). Patient also with severe hyperglycemia (high blood sugar) likely causing hyperosmolar hyperglycemic disorder, her bicarb and anion gap are actually normal not an official DKA (diabetic ketoacidosis), but hyperosmolar state may have contributed to her seizure no further seizure activity in the emergency room. Given severe hyperglycemia and severe dehydration patient started on insulin drip and multiple lactated ringer boluses (intravenous fluids). Patient admit to ICU (intensive care unit) covered with broad-spectrum IV (intravenous) antibiotics. Patient also with elevated lactic acid and metabolic acidosis noted on VBG (venous blood gas) likely multifactorial from severe dehydration as well as acute seizure IV fluids. Ordered patient lactic acid improved from 4.3 to 2.6 she did get 30 cc/kg (cubic centimeter/kilogram) bolus. Multiple liters for severe dehydration doubt septic shock. I do not have a source at this time chest x-ray was negative. Clinical Impression ED Diagnosis 1. Hyperglycemia 2. Seizure (CMD) 3. Metabolic acidosis Admit 6/9/2024 8:26 AM R1's 06/09/24 hospital lab results state in part Glucose 0720 AM 1,669 (H) High. Reference Range 70-99 mg/dl (milligrams/deciliter). Dilantin 1.1 (L) Low. Reference Range 10.0 - 20.0 mcg/mL (micrograms/milliliter). R1 remained hospitalized from [DATE] until 06/22/2024. The 2/28/24 Physician Orders policy states in part- General: Medications are administered upon orders of the primary care physician/ practitioner. Consulting physicians, podiatrists, dentists, and optometrist may write orders, and these orders will be verified by the primary care physician/ practitioner. Responsible Party: RN (Registered Nurse), LPN (Licensed Practical Nurse). Guideline: 4. The RN/LPN will follow the physician/ practitioner orders as written per the resident's POS (Physician Order Sheet). The March 2023 Drug Administration General Guidelines states in part- Policy: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after sufficient information regarding the resident's condition and expected outcomes of medication therapy is known. The licensed nurse is aware of an indication for the resident receiving medication, usual dose, parameters, and routes, contraindications, allergies, precautions, and side effects. Procedure: 2. Medications are administered in accordance with written orders of the attending physician. 7. Only the licensed or legally authorized personnel who prepare medication may administer it. This individual records the administration on the resident's MAR (medication administration record) at the time the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ascertain that all necessary doses are were administered and all administered doses were documented. In no case should the individual who administered the medications report off duty without first recording the administration of any medications. 9. The resident's MAR is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose administration. Initials on each MAR are verified with a full signature in the space provided on the MAR or on a master signature sheet. The 2/28/24 Care Plan policy states in part- Policy statement: To meet the resident's physical, psychosocial, and functional needs facility will develop and implement a comprehensive, person centered care plan for each resident that includes measurable objectives and target goals. Procedure: 1. A care plan is initiated at the time of admission for each resident. 2. An interdisciplinary care plan is completed according to federal regulations and the RAI (Resident Assessment Instrument) process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to implement intervention in preventing the development and worsening of pressure ulcers on a resident with physical and cognitive impairment. This failure applied to one (R36) of three residents reviewed for skin breakdown and resulted in R36's intact skin developing an unstageable pressure ulcer on the right buttock and right ischium; and Stage 3 pressure ulcer on the left ischium worsened into Unstageable. Findings include: R36 is a [AGE] year-old, male, initially admitted in the facility on 12/31/21 with diagnoses of Acute and Chronic Respiratory Failure with Hypercapnia; Human Immunodeficiency Virus (HIV) Disease; Nontraumatic Intracerebral Hemorrhage, Unspecified; Metabolic Encephalopathy; Schizoaffective Disorder, Depressive Type; Anxiety Disorder, Unspecified; Contracture of Muscle, Right Upper Arm and Contracture of Muscle, Left Upper Arm. Per MDS (Minimum Data Set) dated 08/16/23, under Section C, R36 has long and short-term memory impairment. R36's cognitive skills for daily decision making are severely impaired. On 11/06/23 at 10:20 AM, R36 was observed in bed, asleep. He was using a low air loss mattress. R36 is nonverbal, does not respond to verbal stimuli but wakes up when repositioned. Facility's pressure ulcer list indicated that R36 has facility acquired pressure ulcers on the left ischium, right ischium, and right buttock/trochanter. On 11/07/23 at 11:30 AM, R36 was observed for wound care. The left ischium pressure ulcer had 95% (percent) granulation tissue with 2-5% slough present. The right ischium and right trochanter pressure ulcers' wound beds appeared beefy red; on negative pressure wound therapy at -125 mm Hg (millimeters mercury). R36 Physician Wound notes recorded the following, with corresponding measurements: 04/03/23: Stage 3 pressure wound of the left ischium was identified, duration of more than 1 day - 0.8cm (centimeters) x 0.5cm x 0.3cm 04/17/23: Unstageable (due to necrosis) of the left ischium - 2cm x 2cm x 0.1cm 04/24/23: Stage 3 pressure wound of the left ischium - 2.6cm x 2.5cm x 1cm 05/15/23: Stage 4 pressure wound of the left ischium - 4cm x 3.5cm x 3.5cm 05/22/23: Stage 4 pressure wound of the left ischium - 4cm x 3.3cm x 3.5cm; Unstageable DTI (deep tissue injury) of the right ischium was identified - 1cm x 1cm x not measurable cm 06/01/23: Stage 4 pressure wound of the left ischium - 4.4cm x 3.3cm x 3.5cm; Unstageable DTI of the right ischium - 1cm x 0.4cm x not measurable cm 06/05/23: Stage 4 pressure wound of the left ischium - 4.8cm x 3.9cm x 3.5cm; Stage 3 right ischium - 1cm x 1cm x 0.1cm 06/19/23: Stage 4 pressure wound pressure wound of the left ischium - 5.5cm x 4.2cm x 3.5cm; Unstageable (due to necrosis) of the right ischium - 3cm x 2.7cm x 0.1cm; Unstageable (due to necrosis) of the right buttock - 5.1cm x 4cm x 0.1cm 06/26/23: Stage 4 pressure wound of the left ischium - 5.5cm x 4.1cm x 3.5cm; Unstageable (due to necrosis) of the right ischium - 4cm x 3.8cm x 0.1cm; Unstageable (due to necrosis) of the right buttock - 5cm x 4.2cm x 0.1cm 11/03/23: Plan of Care - Preventive Measures in place, general: Avoid bony prominence under direct pressure; repositioning in the bed and wheelchair as needed, or per facility protocol, if patient cannot do it. R36's census reports indicated that there were no hospitalizations occurred from 04/14/23 to 09/01/23. On 11/07/23 at 12:35 PM, V16 (Wound Care Nurse) was asked regarding R36's pressure ulcers. V16 replied, His left ischium, right ischium and right trochanter or buttock are facility acquired pressure ulcers. He developed the wounds because of moisture and not repositioning. He has HIV and wound is compromised. On 11/08/23, random observation from 9:55 AM to 12:10 PM was conducted regarding R36's repositioning. The following were observed: From 9:55 AM to 11:31 AM, R36 was observed asleep in bed, lying on his back. The head of his bed was slightly elevated. From 11:55 AM to 12:10 PM, R36 was again observed in bed, asleep, head of bed slightly elevated, and was lying on his back. V27 (Wound Care Tech) was asked regarding repositioning. V27 stated, He (R36) needs to be repositioned every two hours. We have to position him to one side and stay in that position for two hours. Then we put pillow between his knees. It was also observed that a signage was posted on R36's bedside stating, Rock and Roll. Please turn and reposition every two hours. On 11/08/23 at 11:45 AM, V22 (Licensed Practical Nurse) and V23 (Agency Certified Nurse Assistant, CNA) both stated residents with pressure ulcers need to be turned and repositioned every one to two hours. V17 (Wound Care Coordinator) was interviewed on 11/08/23 at 12:15 PM regarding R36. V17 stated, Unfortunately, in my opinion, he is immunocompromised. He has low air loss mattress; heel protectors and he needs repositioning every two hours. V19 (Wound Physician) was also interviewed on 11/08/23 at 1:56 PM regarding R36's pressure ulcers. V19 verbalized, He has severe contractures on both legs. In preventing the development of pressure ulcers, incontinence care; use of low air loss mattress and turning and repositioning every two hours. Facility's policy titled Wound Prevention and Healing dated 06/01/2022 documented in part but not limited to the following: Policy Statement: To provide wound care treatment/services (using a multidisciplinary approach) based on evidence-based standards of care under the direction of a physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R124 is a [AGE] year-old male who originally was admitted to the facility on [DATE] and continues to reside in the facility. Facility reported incident dated 9/27/23 states in part but not limited to the following: R124 was utilizing the facility bus to tour another facility as part of their discharge planning. While on the way back to the facility, one of the strap harnesses securing R124's wheelchair loosened and caused R124's wheelchair to tilt when the bus was making a turn. R124 called for help and V12 (Transportation Scheduler) pulled the bus over to assist. V12 observed R124 to be tilted at a 45-degree angle while still secured in the harness straps. R124 said he felt some pain by his rib cage on the side where he fell into the armrest when the wheelchair was tilted. R124 arrived back to the facility and was assessed by nursing staff. X-ray was ordered. X-ray impression result dated 10/1/23 shows acute fractures of the seventh and eighth right rib. On 11/7/23 at 10:29AM, R124 was interviewed regarding incident on 9/27/23. R124 said. (V12) was transporting me back to the facility after touring another facility to potentially transfer to. On our way back to the facility, I was in a manual wheelchair and (V12) had made a left turn which caused me to fall on my right side. Either the strap that was strapping me in was not secure or my wheelchair brakes were not locked. I had hit my ribs on the armrest of the wheelchair and hit my head off something. They did an x-ray of my ribs where they said I fractured two of my ribs. I was in pain for about two weeks after the incident. On 11/8/23 at 10:03AM, V12 was interviewed regarding the incident on 9/27/23. V12 said, I had transported (R124) to another facility to tour. On our way back that day, I made a left turn and I heard (R124) yell for help. I immediately pulled over and assessed the situation. (R124) was strapped into the seatbelt and the floor straps but was leaning at a 45-degree angle. I adjusted his chair upright and asked him if I should call 911 which he refused. He wanted to go back to the facility however he was saying he was in pain in his rib area. At the time of the incident, it had looked as if one of the harnesses on the floor had come loose. I was able to tighten it and transport him back to the facility where he was evaluated by his nurse. V12 said, We are now required to complete a vehicle check off list before and after operating the vehicle. Prior to this we did not have this checklist in place. V12 said the floor straps on the bus were replaced due to normal use and wear and tear of the straps. It is to be noted that this surveyor requested a transportation policy involving the use of the facility bus. V1 (Administrator) did provide this surveyor a policy titled Appointments and Transportation with reviewed date of 5/19/23. At 12:37PM, V1 said this policy does not have any details regarding our facility bus or the safety checklist that was implemented after the incident. V1 said this policy needs to be reviewed in our next quality assurance meeting. Based on observation interview and record review, the facility failed to provide an individualized program for supervision to prevent recurring falls for a resident and prevent a resident who is NPO from eating and drinking by mouth (R12), failed to ensure a proper system was in place for safe and secure transfers and failed to safely transport one resident (R124) while riding on the facility bus. This failure affected two residents (R12 and R124) of seven residents reviewed for accidents. R12 have had four falls since admission, was sent to the hospital after the last fall and returned to the facility with four staples to the right top forehead. R12 has been drinking his G-tube feeding, stealing, and eating food and is currently receiving antibiotic treatment for possible aspiration on food. R124 sustained two fractures to two of the right ribs during transfer. Findings include: 1. R12 is a [AGE] year-old male admitted to the facility on [DATE], with past medical history of acute respiratory failure unspecified whether with hypoxia or hypercapnia, chronic obstructive pulmonary disease with acute exacerbation, bipolar disorder, muscle weakness, dysphagia oropharyngeal phase, schizophrenia, difficulty walking, shortness of breath etc. 11/5/2023 at 10:40AM during random observation in the unit, R12 was observed in his bed sleeping. R12 was on an air loss mattress, trach noted to the neck but was capped and not connected to the oxygen tank. R12's bed was not low to the ground. Review of progress noted showed a fall incident on 11/7/2023 documented as follows: Sent patient to hospital for witnessed fall with superficial scrape on top of right side of head. Staff, CNA was in room [ROOM NUMBER] to 15 min ago for diaper change. RT reportedly in the room [ROOM NUMBER] min ago, changing the dressing on trach due to patient removing and throwing it on the floor. Patient is awake, alert, responsive, AXO 2-3. Resident returned to the facility with 4 staples for laceration to right forehead. Review of facility fall log showed resident had a fall on 9/17/2023 (found on the floor in his room), 9/21/2023 (found on the floor at the nursing station),10/31/2023 and 11/8/2023 as documented in progress notes. Fall risk assessment dated [DATE] scored resident as 12, indicating high risk for falls. Minimum data set (MDS) assessment dated [DATE], showed section G (functional) coded R12 as requiring extensive assistance with two-person physical assist for transfer and bed mobility and extensive assistance to total dependence with one-to-two-person physical assist for all other ADLs. Care plan initiated 9/14/2023 indicated resident is at risk for falls, interventions include educate resident to use call light, frequently remind resident to use wheelchair for locomotion/long distance transfer, instruct resident to use his wheelchair for long distance transfer, etc. 11/8/2023 at 11:38AM, V4 (RN) said R12 was non-compliant with his diet, R12 is supposed to get nothing by mouth (NPO) and R12 was eating by mouth at one time. V4 stated, R12 fell at the nursing station on the third floor while carrying some ramen noodle cups. V4 asked R12 what happened but R12 could not explain. V4 said the incident happened in the evening, close to 6PM. V4 said V4 could not recall if R12 was NPO before the incident but that R12 needed assistance with ADLs including ambulation. Progress note dated 9/11/2023, documented R12 was admitted from the hospital and was supposed to have nothing by mouth (NPO). R12 has a G-tube and on Jevity 1.2, [NAME] stoma with oxygen 2 liters via nasal canula. Review of medical record showed several documentations of resident wanting to eat food by mouth, stealing food from trays and drinking his tube feeding formula. At 2:28PM, V28 (Dietary Manager) said R12 came to the facility on NPO status. R12 expressed wanting to eat. V28 spoke to R12 and explained to R12 what could happen if R12 ate by mouth. V28 said a mechanical soft diet was initiated, R12 was not tolerating diet so ENT was consulted. R12 was placed back on NPO status. On 11/8/2023 at 2:45PM V26 (ADON) said R12 came with an open stoma, R12 was supposed to be NPO but was insisting on eating. V26 said nursing staff spoke to the attending physician and he recommended to try giving resident something by mouth. However. speech therapy recommended NPO because resident could not tolerate PO feeding and was put back on NPO. V28 added resident was changed to bolus feeding to avoid R12 from drinking his tube feeding. V26 said R12's feeding should not be left in his room to avoid R12 from drinking it and possibly aspirating on it. On 9/29/2023, V33 (LPN) documented R12 was given a scheduled bolus feeding. A box of feeding was left in the room and when staff returned for the tube feeding it was gone. R12 stated he drank it. On11/9/2023 at 10:39AM, V33 (LPN) said R12 is supposed to be NPO. V33 was told R12 eats and drinks. V33 flushed the R12's tube and gave him scheduled bolus feeding. V33 said V33 left one box in a closed drawer for the next dose. Next morning V33 came to the room to give the bolus feeding and could not find it. V33 asked R12 who stated he drank the feeding. V33 said she placed the feeding in a drawer on the other side of the room. V33 said the feeding was supposed to be in the nursing station or nursing cart but she left it in the room because she was going to give it soon. V33 stated R12 could choke or get an infection from drinking his feeding. On 10/29/2023, V34 documented R12 was observed putting back G-tube feeding bottle on the pole after drinking from it. R12 was sent out to the hospital and was treated with antibiotics for possible aspiration on food. On 11/9/2023 at 10:26AM, V34 (LPN) said she did not see R12 drinking the feeding but saw R12 hanging the bottle back on the pole. R12 was on continuous feeding. R12 returned to the facility with an antibiotic prophylactic order. V34 added R12 pulls off his trach and oxygen tubing. V34 said R12 is supposed to be monitored frequently, between the nurse and the C.N.A, R12 should be monitored every 15 to 30 minutes. On 11/9/2023 at 9:55AM, V32 (Therapy Director) said she is familiar with R12. Therapy worked with R12 initially when he was first admitted . Physical therapy evaluated him on 9/13/2023 and speech evaluated him on 9/12/2023. Speech therapy declared resident not appropriate for eating by mouth due to resident having an open stoma. Diet order was NPO and recommended for R12 to follow up with ENT. R12 went to the ENT appointment and was put back on trach due to paralysis of the vocal cord. Therapy department never cleared resident to have something by mouth. V32 said she is aware R12 was eating something by mouth at one time but was a decision made by the nursing department and the attending physician that R12 did not tolerate the PO diet and was placed back on NPO. V32 said she doesn't believe R12 had a video swallow study. R12 failed the ones he had at the hospital according to the hospital record. R12 had not had another swallow study because the scheduler stated was trying to schedule in the R12, but R12 was going in and out of the hospital. Speech would not have upgraded R12 to an oral diet for risk of aspiration. 11/9/2023 at 2:11PM, V36 (Registered Dietician) said R12 was NPO and R12 failed speech therapy evaluation for diet upgrade. R12 was always hungry and always wanting to eat by mouth which was not appropriate for him. V36 said she was made aware R12 is always trying to steal food and was drinking his G-tube feeding. V36 recommended bolus feeding on 9/25/2023 but was not sure if and when R12 was changed back to continuous feeding. V36 said they increased R12's feeding and made sure he does not have any feeding or food in his room. V36 was not aware R12 was still drinking his feeding formula after he was changed to bolus. V36 added if this behavior is being documented all staff should have been aware and made sure R12 is being monitored. Fall policy revised 10/30/2023 states, facility is committed to its duty of care to residents and patients in reducing risk, the number and consequences of falls including those resulting in harm and ensuring a safe patient environment is maintained. Under procedure, the policy states in part, high risks residents and patients for falls will receive individualized interventions as appropriate to risk factors. Interventions b. High risks residents and patients for falls will receive individualized interventions as appropriate to risk factors, interventions may include meaningful and or scheduled rounds.

Based on interviews and record reviews, the facility failed to follow its physician notification policy and notify the physician immediately of acute changes in a resident's condition. This failure affected one resident (R7) out of three reviewed for physician notification. Findings include: On 9/21/23 at 10:05am, V21 (wound care coordinator) stated on 9/18/23 V21 saw R7 in the afternoon for wound care treatment. V21 stated R7 was lethargic. V21 stated R7 informed V21 he didn't feel like eating, he was not 'feeling great today'. V21 stated R7 was alert and oriented. V21 stated V21 explained the importance of eating for wound healing. V21 stated R7's skin was pale, fingertips were discolored, and skin felt cooler to touch. When questioned if V21 notified R7's physician of these changes, V21 responded no. On 9/21/23 at 1:30pm, V26 (nurse) stated on 9/18/23 R7's family was present in R7's room and V26 informed family of R7's condition. V26 stated R7's family informed V26 R7 is not eating as much as before. V26 stated V26 explained R7's decline to the family, V8 (social services), and V2 DON. When questioned to clarify R7's decline, V26 responded R7 was not eating much. V26 stated V26 asked V21 (wound care coordinator) and V2 DON to assess R7. When questioned why V26 asked other nurses to assess R7's medical status, V26 responded R7 wasn't eating much. When questioned why V26 discussed changing R7's full code status to DNR (do not resuscitate) with R7's family if R7 was stable, V26 did not respond. When questioned if V26 notified V40 (attending physician) of the change in R7's condition when V26 notified V40 of R7's abnormal laboratory results, V26 responded no. On 9/26/23 at 11:12am, V40 (attending physician) stated V26 (nurse) called V40 with R7's laboratory results. V40 denied being made aware of R7's change in condition - generalized weakness, slow speech, glazed eyes, lazy eyes, blue discoloration to fingertips, cool swollen hands, and poor appetite. V40 stated if V40 had been informed of R7's condition, V40 would have sent R7 to the hospital on 9/18/23 for further evaluation. V40 stated V40 can only work with the information the nurse provides. On 9/21/23 at 2:00pm, V2 DON (director of nursing) stated V2 assessed R7 on 9/18/23. V2 stated R7's hand was pale due to edema (swelling), head of bed was elevated 40 degrees. R7 was alert and oriented x 3. V2 stated R7's skin was dry. R7 felt warm but his left hand felt cool. When questioned if V2 compared the temperature in both hands, V2 responded V2 only felt R7's left hand, both hands were swollen. V2 stated R7 was re-admitted to this facility 8/26/23 with generalized edema. The NP's (nurse practitioner) progress note, dated 9/8/23, was reviewed with V2. The NP noted R7 with trace edema to right lower extremity. When questioned if R7's bilateral hand swelling would be a change in condition and if the physician should have been notified, V2 responded this could be considered a change in R7's condition based on the documentation. V2 stated V26 (nurse) notified V40 (attending physician) of the lab results and R7's medical condition. V26's progress note, dated 9/18/23 at 5:18pm, reviewed with V2. V26's documentation notes all labs informed to V40. There is no documentation noting V40 was informed of R7's current medical condition. V2 acknowledged if it's not documented, it wasn't done. V2 stated V26 should have documented R7's condition in detail and informed V40. On 9/22/23 at 2:08pm, V34 (nurse) stated V34 was assigned to provide care for R7 on 9/19/23. V34 stated R7 wasn't as interactive with V34 as he had been earlier in September. V34 stated R7 recently had an above the knee amputation and thought R7 was depressed. V34 stated V34 asked R7 if R7 was okay because V17 CNA informed V34 R7 had not eaten breakfast or lunch day. V34 stated R7 informed V34 R7 was not hungry. V34 stated V34 took a break from 2:00pm until 2:45pm. Upon returning to nursing unit, V34 stated V34 went to R7's room. V34 stated R7 informed V34 he was fine, but R7 was not his usual self. V34 stated just before dinner, at 4:00pm, V34 instructed V17 to round on the residents. V34 stated V17 came and informed V34 R7 was not looking well. V34 stated V34 went to R7's room to assess R7. V34 stated R7 had oxygen at 3 liters via nasal cannula; V34 increased R7's oxygen to 4 liters and exited R7's room and went to the nurses' station. V34 stated V34 notified V2 DON R7 was not looking well. V34 stated V34 also contacted V40 (attending physician) one time, but V40 did not respond. V34 did not attempt to contact V40 again. V34 stated V2 informed V34 if he thought R7 did not look well, V34 should send R7 to the hospital via EMS (emergency medical services) 911. V34 stated V34 called EMS 911. V34 stated V34 was printing the paperwork for EMS and hospital when another resident was complaining of increased pain. V34 stated V34 was in the other resident's room when EMS paramedics arrived at R7's bedside. V34 stated V34 exited room and observed the paramedics working on R7. This facility's physician notification policy, dated 07/2009, notes it is the policy of this facility a resident's attending physician will be notified of any significant changes in condition. Upon determination a significant change has occurred for a resident, the nurse on duty is to notify the attending physician with as complete information about the resident as is available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R2 was admitted on [DATE] with a diagnosis of hemiplegia following cerebral infarction affecting left side, end stage renal disease, type II diabetes, morbid obesity, atrial fibrillation, hypertension, heart disease, hyperlipidemia, dementia with behavioral disturbances, chronic kidney disease, extrarenal uremia, major depressive disorder, lack of coordination, muscle weakness, limitation of activities due to disability. R2's brief interview for mental status dated 7/18/23 documents: 05/15 which indicates severe cognitive impairment. R2's Minimum Data Set, dated [DATE] documents under functional status: transfer indicates 3-extensive assistance (resident involved in activity; staff provide weight -bearing support and 3- two persons physical assist; bed mobility documents 3-extensive assistance (resident involved in activity; staff provide weight -bearing support and 2 indicating one-person physical assist. Under balance during transitions and walking documents a score of 2 not ready, only able to stabilize with staff assistance for moving from seated to standing position, walking, turning around. Moving on and off toilet, surface to surface transfer. R2's incident report dated 7/12/23 documents: writer called by staff member that resident was on the floor. Resident observed sitting on the floor. Resident stated, I fell on the floor on my butt while trying to move to the side of the bed. R2's care plan Interventions created on 7/17/23 with initiated date of 7/13/23 documents fall 7/12/23 visual cue to be placed in the room to ask for assistance. Physical therapy to continue reinforce safety with patient. R2's incident report dated 7/24/23 documents: writer called by staff member that resident was on the floor. Resident observed lying on the floor. Resident stated, I was too close to the end of the bed and fell on the floor while trying to move to the side of the bed. R2's care plan Interventions created dated 7/24/23 document low bed and floor mats. Interventions created date 7/27/23 with an initiated date 7/25/23 documents fall 7/24/23 educate on proper transferring techniques. R2's incident report dated 8/1/23 documents: Patient was on the floor, sitting and leaning on the bedside, trying to get up. Resident stated he was trying to get to the door. R2's care plan Intervention created date 8/4/23 documents bed rest after dialysis and wheelchair for locomotion for fall 8/1/23. R2's dialysis treatment information dated 8/3/23 documents under nurse's notes: patient alert and conscious, a bit aggressive, slip on the floor while trying to transfer to wheelchair, complaints of pain in the hips afebrile. On 9/22/23 at 12:48PM, V2 (DON) said R2 had a short temper and did not like people telling him what to do. R2 had a wheelchair and sometimes he would follow direction and other times he would forget. V2 said she is unsure where they previous staff documented root cause of falls. On 9/26/23 at 3:36PM, V2 (DON) said a resident with a brief interview score of five is a lower score and has lower cognition. Fall interventions should be placed as soon as possible after a fall based on the cause of the fall. When asked how these interventions were effective in preventing R2's falls, V2 said that he had a behavior of trying to get up and leave the building. Staff would redirect resident as needed. On 9/22/23 at 12:06PM, V33 (restorative nurse) said she updated fall care plans but did not help with the development of interventions. Interventions would be placed after cause of fall determined. V33 said she only wrote in the care plan with whatever the new intervention was at the time. When asked if R2 would be able to remember and be educated on proper transferring techniques, V33 said she did not know and that previous staff had developed interventions. V33 verified the that the created date is when intervention was put into the care plan. R2's fall care plan created on 7/28/23 documents R2 is at risk for falls as evidenced by the following risk factors and potential contributing diagnosis: diabetes, end stage renal disease, generalized muscle weakness, atrial fibrillation, and hypertension. Interventions created on 12/7/22: I would like staff to review information on my past falls and attempt to determine the cause of my falls; Staff to provide me with a safe environment with floors free from spills and clutter, a working call light, be din lowest position at night, bed mobility positioning devices and transfer devices to support highest level being; complete fall risk assessment per facility fall. Interventions dated 12/8/22 document: Ensure I'm wearing proper footwear and check to ensure that bed brakes are locked prior to transferring. Interventions on 7/28/22 documents: Physical therapy and occupational therapy, anticipate needs, place call light in reach and encourage use, follow fall policy. Facility falls prevention and management policy reviewed 11/10/22 documents: facility is committed to its duty of care to residents and patients in reducing the risk, the number and consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained. Under fall risk screening: high risk residents and patient falls will receive individualized interventions as appropriate to risk factors. High risk precautions will be implemented to residents and patients who scores on resident/family notification fall risk screen shows high risk will be considered on this precaution. Universal fall precautions will be implemented in addition to high risk fall precaution interventions; pharmacy medication review; physical therapy and occupational therapy evaluations; restorative program; room near the nursing station. Procedure for post- fall management: post fall observation will be completed; perform verbal assessment to cause for fall and potential for injury; perform physical assessment including head to toe assessment, vital signs, range of motion and neurological assessment as indicated; notify the provider and family; document fall event under risk management; nurse with knowledge of the event will document pertinent facts in the medical record. Other staff will be interviewed and or written witness statements will be completed. Under fall response: evaluate and monitor resident for 72 hours after the fall; investigate fall circumstances; Under procedures for fall with potential head injury: falls where patients/residents may have sustained a head injury or on blood thinners will be assessed for neurological check. R2's fall risk review dated 7/24/23 documents high risk for falls. Based on interviews and record reviews, the facility failed to monitor/supervise a resident requiring assistance in the shower room and failed to ensure effective fall prevention interventions were in place to prevent fall incidents. This affected 2 of 4 residents (R19, R2) reviewed for falls and fall prevention. This failure resulted in R19 being in the shower room, unmonitored, experiencing an unwitnessed fall sustaining a cervical spine fracture requiring immediate surgery. This failure also resulted in R2 having four falls in three weeks. Findings include: On 10/6/23 at 12:24pm, V30 (Nurse) said she was passing medications and overheard R19 reporting to staff at the nursing station that R19 fell in the shower room and bumped her head. V30 was unable to identify staff by name (agency, female, African American) R19 was talking to at time. V30 said R19 said R19 hit her head. Physical assessment completed no visible injuries but when V30 touched the right side of R19's forehead, R19 had pain. R19 had left or right hip was painful also. V30 stated she told R19 to stay in the room but r19 insisted on walking to the church services. V30 stated she called V2 (DON) and was instructed to send R19 out 911. V30 stated R19 usually goes to the shower room herself. R19 will usually ask if she can shower. The shower room is not locked. Usually someone will supervise her while in the shower and unsure if anyone was with her at time. V30 stated R19's hair was wet and R19 had her walker but no oxygen at time. V30 stated R19 is alert and oriented x 3 and uses rolling walker. V30 stated R19 uses an oxygen concentrator in her room and will get a portable tank that hangs on her walker if she leaves the room. There was no portable oxygen in her room or with R19. V30 stated R19 went down to church without oxygen but V30 checked R19's oxygen saturation level and it was 93-94% on room air. EMS (emergency medical services) arrived. On 10/6/23 at 1:28pm, V2 DON (director of nursing) stated V30 (nurse) reported to V2, R19 had a fall in the shower. V2 stated R19 is a poor historian and can be delusional. V2 stated R19 had an unwitnessed fall in the shower on 10/1/23. V2 stated R19 walks by herself with a rolling walker. V2 stated residents must let staff know before he/she takes a shower so staff can make sure no other resident is in shower. V2 stated the restorative nurse does an assessment to determine if a resident is safe to shower independently. V2 stated the resident's care plan will have documentation if the resident can shower independently. R19's functional abilities assessment, dated 8/9/23, notes for shower/bathing, R19 requires partial/moderate assistance from staff. R19's care plan notes R19's memory is impaired, initiated 11/12/21. R19 has problems with decision-making, insight, logic, calculation, reasoning, planning, organization, sequencing, and judgement. R19's ADL (activities of daily living) care plan, initiated 12/2/22, notes R19 has a self-care deficit and requires assistance with ADLs to maintain the highest level of functioning. Intervention identified R19 requires assistance of one staff member for bathing. R19's falls care plan, initiated 12/2/22, notes R19 is at risk for falls as evidenced by the following risk factors and potential contributing diagnoses - decreased strength and endurance, cardiomyopathy, dementia. Interventions identified on 12/2/22 - nursing staff will complete a fall risk assessment per facility fall protocol and follow facility fall protocol. Review of R19's medical record notes R19 with diagnoses including, but not limited to, COPD (chronic obstructive pulmonary disease), heart failure, hypotension, cardiomyopathy, unsteadiness on feet, lack of coordination, and dependence on supplemental oxygen. Review of R19's POS (physician order sheet) notes an order for oxygen at 4 liters via nasal cannula continuous. Review of R19's hospital medical record, dated 10/1/23, notes after fall at this facility, R19 found to have severe flexion teardrop fracture of C5 (cervical spine, 5th vertebrae) vertebral body with subluxation ligamentous injury posteriorly, as well as concern for anterior longitudinal ligament rupture. R19 hesitant to move due to the pain. R19 was admitted to the neurological critical care unit after anterior cervical corpectomy C5-C6, anterior plate and cage C4-C7, and posterior fusion C2-T1 Review of R19's fall risk assessment, dated 9/28/23, notes R19 is at high risk for falls. R19's MDS (minimum data set), dated 8/9/23, notes R19's BIMS (brief interview of mental status) score is 5 out of 15, bathing requires extensive assistance of one staff member. R19's MDS, dated [DATE], 5/11/23, and 8/9/23, notes R19 has not exhibited any behaviors. This facility's incident report, dated 10/1/23, notes R19 is alert and oriented to person and place. Predisposing physiological factors: confused and gait imbalance. It notes R19 insists on privacy and independence and non-compliance with shower schedule. Review of R19's POC (point of care) charting for the past 30 days notes R19 required physical assistance of one staff member with showers on 9/8, 9/9, 9/13, 9/14, 9/17, 9/18, 9/20, 9/21, 9/23, 9/26, 9/29, and 9/30. R19 required supervision of one staff member with showers on 9/12, 9/22, and 9/24. R19 required physical assistance of one staff member for bed baths on 9/7, 9/11, 9/13, 9/16, 9/18, 9/19, 9/20, 9/23, and 9/30. Review of R19's medical record does not note any documentation R19 insists on privacy and independence and is non-compliant with shower schedule. This facility's fall prevention and management policy, dated 10/29/21, notes high risk residents for falls will receive individualized interventions. High-risk fall precautions will be implemented for residents whose scores on fall risk screen shows high risk. Staff will remain with the resident when assisted to the bathroom. Interventions will depend on identified and assessed risk factors, including root cause(s) after each fall.

Based on interviews and record reviews, the facility failed to notify the physician of chest x-ray results for one resident (R7) out of three reviewed for diagnostic imaging. Findings include: On 9/26/23 at 3:30pm, V2 DON stated the outside diagnostic imaging company will fax results or upload results directly into this facility's computer system. V2 stated the nurse should communicate any pending x-ray results on the 24-hour shift report. V2 stated all the nurses should follow-up with pending results and notify the physician of the results when known. On 9/26/23 at 3:28pm, V46 (diagnostic imaging company representative) stated R7's chest x-ray result was faxed to this facility on 9/13/23 at 6:34pm. R7's chest x-ray results, dated 9/13/23, notes study limited by R7's suboptimal inspiration. Faint retrocardiac infiltrate could represent a small focus of pneumonitis. Correlate clinically. Follow-up chest radiographs recommended after medical management. Review of R7's POS (physician order sheet), dated 9/10/23, notes an order for a chest x-ray. There is no documentation found in R7's medical record noting R7's chest x-ray results were reviewed by the nurse and relayed to V40 (attending physician) at any time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent a vulnerable resident from being the subject of physical abuse by an employee. This failure affected one (R4) of three residents reviewed for abuse and resulted in (R4) being mistreated while being provided with personal care from staff member. Findings include: R4 is a [AGE] year-old female who was admitted to the facility 1/27/22 with diagnoses that included Respiratory Failure, Tracheostomy, seizures, and history of Cardiac Arrest. MDS (Minimum Data Set) dated 1/14/23 notes that R4 had severely impaired cognition and required maximal assistance with all activities of daily living, was incontinent of bowel and bladder. R4 had a tracheostomy and was receiving full ventilator support. R4's Care Plan was reviewed. Care Plan initiated 2/10/22 Focus: R4 presents with an alteration in ability to communicate related to: Impaired cognitive abilities, Impaired speech. R4 has a hx of Pulseless Electrical Activity, Acute Saddle Pulmonary Embolism, and Ischemic Encephalopathy which could be affecting her cognitive abilities. R4 is also a trach/respiratory patient which could also be affecting her ability to speak. Based on surveyor review, there was no care plan included to address R4's risk of abuse. V2 Director of Nursing was interviewed 2/23/23 at 11:38AM and said, R4 was non-verbal, not responsive, and not able to track with her eyes at baseline. I helped with the allegation investigation regarding R4 and V17 CNA. The family came to the facility and asked to speak to management. She showed us a video where V17 lifted R4's head grabbing with one hand. V17 finished changing the resident and left the room. V1 Administrator was interviewed on 2/23/23 at 11:38AM. V1 said, the family of R4 had a teddy camera in the room that we were not aware of. The daughter (Power of Attorney) for R4 brought it to our attention; a video that showed R4 getting care from V17 CNA. V17 explained that when making the attempt to lift the head, her hand slipped because she was only using one hand. We would have preferred for her to use two hands to lift the head from underneath but unfortunately, she didn't. I called the local police and added to the report, and they said that there was nothing for them to investigate because it didn't appear that there was anything criminal involved. Therefore, we didn't deem this as abuse. V17 was suspended immediately pending investigation and then we decided to terminate her for discourteous behavior. Report obtained from Sheriff Police Department - Incident Report dated 4/13/22 documents: V18 (Police Officer) responded to the above address for Assault service call later reclassified to Suspicious Circumstances. Upon arrival V18 spoke with V1 (Administrator), who stated that this morning his staff removed a video camera from patients (R4) room. At approximately 1130Hrs (R4) family members arrived at the (facility). (R4's daughter) showed him a video where Staff member (V17) lifted (R4) head approximately 4-5 inches, pulled the pillow and did not place (R4) head back on the bed gently. (V1) stated (V17) might scooped or grabbed (R4) hair twice, video was unclear. (V1) said that Patient (R4) is comatose and brain dead, staff members performed head to toe physical and din not observed any signs of abuse. [sic.] (V1) stated that (V17) was suspended pending internal investigation and Illinois Department of Public health was notified via IDPH website (facility reported incident). (V1) said that he had a long conversation with (R4's) family members and explained that (V17) will be suspended pending investigation. Unable to interview (R4) due to her medical condition. Unable interview (V17), (V17) due to her not being on scene (suspended). Unable to interview family member (V20 Family Member) or watch the video of the incident. Supplemental Police Report dated 14-APR-2022 1835, completed by V18 (Police Officer) documents: In summary, V18 (police officer) responded to I.S.P. (Illinois State Police) and spoke with (V20 Family Member) who showed V19 (surveyor) the video footage that was taken in her mother's room located at (facility). (V19) observed a female subject who was identified as (V17 CNA) adjusting (R4's) pillows and body positioning. While doing so she grabs the back of R4's head and raises her off the bed to a semi seated position then roughly slams her head back onto the pillow, (V17) does this same motion twice to (R4). (V20) stated she is willing to sign Criminal Complaints against (V17). (V19) advised (V20) to save any footage for further investigation. Nothing further. V20 (Family Member) provided surveyor with video footage of interaction between V17 (CNA) and R4, in question. Video was reviewed and surveyor confirms description provided in supplemental police report completed by V18 (Police Officer). Facility provided investigation of incident which was reviewed. V17's CNA personnel file was reviewed. Employee Disciplinary Action Form dated 4/13/22 noted V17 was suspended pending investigation of Policy Violation. Employee Disciplinary Action Form dated 4/13/22 noted, After a thorough investigation, it was confirmed that the employee violated a category I offense, specifically, #27 Discourtesy to resident, family, or fellow employee. Employee was discourteous to a resident on 4/13/22. Employee is terminated effective immediately. Facility provided Employee Standards of Conduct (No revision date) which states in part: This list is intended not be representative of the types of activities that may result in disciplinary action, up to and including termination- Rough handling or abuse of a resident. (Under heading) Disciplinary Action the document explains, Category 1 offenses are most serious and subject to the employee's immediate discharge without rehire privileges. The following are Category 1 offenses: 1. Resident abuse (verbal or physical), or neglect; 27. Discourtesy to the resident, families, or fellow employees. Facility Abuse Policy revised 1/2019, was reviewed and states in part; As part of the social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident was safely transferred using a mechanical lift device to 1 of 3 residents (R1) reviewed for safe transfers in the sample of 12. This failure resulted in a right scapula fracture to R1. The findings include: R1's electronic medical record accessed on 11/4/22 show R1 has diagnoses that include chronic respiratory failure with trach, morbid obesity and diabetes. R1's facility assessment dated [DATE] show R1 has no cognitive impairment. The same assessment show R1 is dependent to 2 staff for mechanical lift transfers. R1's Facility Reported Incident (FRI) dated 10/22/22 (incident happened 10/21/22) reported to the state agency on 10/22/22 as final report show, Resident was being transferred to her chair from her bed when the mechanical lift slightly tilted in the direction of the chair, touching residents face. Nurse practitioner conducted a head-to-toe assessment and resident indicated that she had some shoulder pain. R1 was transferred to hospital and was diagnosed with closed fracture right scapula. R1's radiology report dated 10/21/22 show, Three view of radiographic evaluation of the right shoulder. Final Result: Inferior scapular fracture. R1's Emergency Department (ED) Notes dated 10/21/22 show that R1 is a 63 y/o with diagnoses that include atrial fib on Eliquis, diabetes, chronic hypoxic respiratory failure on trach collar at 3 liters presenting to the emergency room. she was being transferred from bed to an armchair at her nursing facility she was already in the chair when the [mechanical lift] tipped and fell into her. She endorses a mechanical lift hit her head, right shoulder and landed on her abdomen. The same notes show that given her scapular fracture patient encouraged to have CT scan of the abdomen as well as head, however she declines. Main reason to pursue these tests (CT scan) was because patient is on Eliquis (anticoagulant). The same ED notes show for R1 to be referred to an Orthopedic MD. On 11/4/22 at 9:13 AM, R1 was alert in bed with her trach intact. R1 said when the incident happened, the 2 (Certified Nursing Assistant-CNA) were transferring her from the bed chair to her wheelchair. R1 said there were 2 CNAs- male and female. R1 said the male CNA was busy in his phone during the care and transfer. The female CNA was the one controlling the mechanical lift. R1 said as she was suspended in the air and was being lowered down to her wheelchair, R1 informed the 2 CNAs that she was tilted sideways and need to be positioned well. R1 said then the whole lift tipped over her and the bar (where the mechanical slings were attached) hit her face and right shoulder. R1 said she was sent to the hospital and was told she fractured her right shoulder. R1 said she always had pain n that shoulder but after the incident, the pain had gotten worst. R1 said when she moves her arm over head or when she tries to comb her hair, her pain was at a 6 (0 no pain, 10 worst pain). R1 said she was waiting for his Orthopedic appointment to be scheduled. On 11/4/22 at 9:20 AM, V8 (Registered Nurse-RN) said on 10/21/22 she was called to R1's room. V8 said R1 was sitting in her wheelchair complaining of right shoulder pain. V8 (RN) said R1 was being transferred by the 2 agency CNA (V6 and V7) using a mechanical lift. The mechanical lift tipped over hitting the right side of R1's face and right shoulder. V8 said R1 complained of pain to her right shoulder and R1 was sent to the emergency room. R1 was diagnosed with fractured right shoulder. V8 said the 2 staff (V6 and V7) that transferred R1 on 10/21/22 were both agency CNAs. Both have not been allowed to go back to the facility. On 11/4/22 at 9:32 AM, V9 (Nursing Supervisor) said he investigated the incident on 10/21/22 involving R1 and the 2 agency CNAs (V6 and V7). V9 said the investigations show that when R1 was being transferred, the lift device legs were not opened wide enough. V9 said the mechanical lift device is more stable when the legs are widened preventing the device from tipping over. V9 said the 2 agency CNAs involved were not to return to the facility. V9 said since the incident, the facility staff have been re trained and reeducated how to properly operate the mechanical device. On 11/4/22 at 11:30 AM this surveyor with V10 and V11 (both Restorative Aides) observed the mechanical lift device. Both said the legs of the mechanical lift device should remain wide throughout the transfer of the resident, this ensures the lift device does not tip over and it keeps the device stable. On 11/4/22 at 12:57 AM, V2 (Director of Nursing-DON) said she also investigated the incident on 10/21/22 involving R1 and the 2 agency CNAs (V6 and V7). V2 said (V6 and V7) were operating the mechanical lift device when the incident happened. Both (V6 and V7) were not allowed to go back and work at the facility. V2 said she expected that the 2 staff should have utilized the lift device correctly and would have prevented the incident. V2 said the mechanical lift device legs should have been opened wide enough to provide balance and stability to the mechanical lift. V2 said she was looking into R1's orthopedic referral at this time. The facility policy entitled Policy and Procedure for Mechanical Lift Transfer Usage show, 3. Widen the legs of the Mechanical Lift using the shift handle located in the back. Widening the legs is essential in order to get a stable base under the mechanical lift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to urgently seek advanced medical care for a resident who was assessed by Nurse Practitioners and Nursing staff to be actively bleeding and suffering from severe dehydration; the facility failed to communicate and obtain approval from a resident's power of attorney for hospital transfer for a resident with severe cognitive impairment related to diagnosis of dementia. This failure affected one (R245) of one resident reviewed for change in condition and resulted in R245 being transferred to local hospital more than a month after initial physician order for emergent transfer to local hospital; R245 expired one day after hospital transfer with death certificate listing primary cause of death as sepsis. Findings include: R245 was a [AGE] year-old female who was originally admitted to the facility [DATE] with diagnoses that include, Adult failure to Thrive, Ulcerative Colitis and Major Depressive Disorder. On [DATE], R245 was assessed for a new diagnosis of unspecified Dementia while residing in the facility. R245's MDS (Minimum Data Set assessment) dated [DATE] documents BIMs (Brief Interview for Mental Status) score of 08, which indicates cognitive impairment. Care plan last reviewed [DATE] states: R245 has problems with decision making, insight, logic, calculation, reasoning, planning, organization, sequencing social skills and/or judgment related to diagnosis of Major Neurocognitive Disorder. Medical record documents that R245 underwent several abdominal surgeries prior to admission and was actively being treated for an abdominal fistula, ileostomy, and colostomy. R245's records indicate that she was hospitalized twice since admission, with the most recent return to the facility on [DATE] after she was treated for Sepsis and Septic shock. R245's Nursing progress notes were reviewed from [DATE] to [DATE]. On [DATE] at 1:46PM, nursing staff noted reddish liquid coming out of the fistula and notified V40 Medical Doctor. Later that evening, V40 Medical Doctor assessed R245 at the bedside, and left recommendations for nursing to continue monitoring. On [DATE] at 11:26AM, a nurse documents, Noted bleeding from colostomy. Colostomy bag noted with blood drainage, V40 called and order received for STAT GI (gastrointestinal) consult. DON (Director of Nursing) notified, told to send resident to ER. At 12:24PM, note said that R245 refused to go to the hospital. The Healthcare POA (Power of Attorney) was aware, and the resident refused to speak to them. Social Services and DON were notified. On [DATE] at 10:02, nurse writes, Resident still have the blood coming out from the fistula. Resident refused to go to the hospital last night. On [DATE] at 02:30AM, Resident still have blood coming out from her fistula. V40 made aware. Pt. was screaming, complaining of pain. On [DATE] R245 was evaluated by a nurse practitioner who noted that the resident was alert to self and Hospice appropriate. Labs were reviewed with order to give 2 liters of fluid bolus and repeat labs a week later. On [DATE] a nurse noted: pt. has mucousy blood coming out from the rectal; nurse practitioner and infectious disease doctor notified, a urinalysis and culture were ordered. Progress Notes reviewed for [DATE], [DATE], and [DATE] indicate that urine was unable to be collected. No follow up or explanation documented/provided. On [DATE], R245 was seen by a Psychiatric Nurse Practitioner, who assessed the resident to be to oriented only to person and place, limitedly insightful and labile. R245 said to the NP, that she wanted to go home, but did not know where home was. On [DATE] NP assessed R245 and documented to monitor for bleeding, and included orders for a urinalysis and culture, labs, and a GI consult. Notes include: recently patient had some bloody drainage to colostomy. Patient refused to go to hospital. WBC elevated at 13.76. Resident was noted to be weak and confused alert and oriented x1 during assessment. [DATE] NP assessed R245 as alert and oriented x1, non-cooperative and not talkative. Laboratory results were reviewed and noted that BUN was elevated. On [DATE], BUN was 71, while on [DATE] BUN was 57. Nurse Practitioner ordered one liter of Intravenous fluids, repeat labs on [DATE] and a Gastrointestinal Consult. On [DATE], NP assessed R245 and reviewed lab results. WBC's- 13.43 (high), BUN 77 (high), creatinine 0.64 (normal). R245 completed antibiotic treatment for C-diff on [DATE]. Intravenous fluids were discontinued. R245 was seen on [DATE] by NP who documented, Dehydration noted on labs. Lying in bed with legs pulled up underneath her and arms crossed. Agitated with interaction. Unable to start peripheral IV for dehydration-RN instructed to get midline and start IVF, then repeat labs in am. GI consult pending for mucous/bloody rectal drainage noted earlier in the week. An order was placed [DATE] for urine collection, which was unable to be collected as noted by nursing staff. R245 was evaluated by NP on [DATE] and documented, Patient is seen today for leukocytosis and again blood is noted in colostomy. Given WBC trending up, urine sample was ordered. However unable to collect per nursing. Per nursing after (urinary catheter) insertion noted with frank blood. In the assessment/plan, the NP writes: DNR (Do Not Resuscitate) with ok for hospitalizations. Per report, family refusing hospice. Needs hospital send out or hospice. Awaiting (Primary Doctor) response, contacted x2. Review of medical record did not address any further contact with primary physician or Medical Director for additional guidance or interventions. Progress notes document that R245 continued to receive Heparin medication for clotting prevention after being assessed for acute bleeding. On [DATE] at 5:52AM, Nurse held heparin due to signs of bleeding from unknown source. On [DATE] at 6:17AM nurse wrote: signs of bleeding noted at the sacral area from unknown site, site assessed, no wound, no sign of bleeding from the vaginal, ostomy pouch intact. Withheld heparin, notified supervisor on duty, will continue to monitor. On [DATE] at 9:09AM, nurse wrote, seen by wound care team and noted bleeding to her right ostomy. Notified House NP, Director of Nursing and Assistant Director of Nursing. At 9:18AM, nurse writes: Bleeding noted from her ostomy site, NP made aware. Waiting for any orders. Resident refused to check her vital signs. On [DATE] at 10:05AM, nurse got order from NP to send to the emergency room for further evaluation. PoA made aware and agreed. Private ambulance called. Ambulance picked up R245 at 10:55AM. In the Emergency Room, R245 had labs collected at 11:25AM and was found to have multiple abnormal lab values. In the ER, R245 was assessed with red colored output from the ileostomy, and active maroon colored stool leaking from the rectum. R245 was alert to person and place, otherwise not responding to questioning. R245 was treated in the ER for abdominal infection and admitted for rectal bleeding. On [DATE] at 10:32PM R245 expired while in the hospital. Death certificate lists Causes of death as Sepsis and Gastrointestinal Bleed. [DATE] at 05:15 PM V43 Resident Representative said, in the beginning of November the Nurse Practitioner called to inform me that my mother was bleeding, but they said they weren't sending her because she was coherent and refusing to go. I told them that they should send her anyway because she was suffering from dementia. I didn't think she could have made that decision for herself. They even called my cousin who they had listed as the PoA, and she agreed to send her as well. They didn't send her until it was too late. [DATE] 11:15 AM V40 Medical Doctor said, I'm one of the primary physicians in the facility and I currently round. The facility has their own nurse practitioners who see the residents. I have requested for staff nurses to reach out to me directly about any issues about my patients. I just want to make sure I get the information and know everything that is going on about the patient. There has been an occasion where the patient is at the hospital and I didn't know about it, and I am not always informed. Sometimes there is a situation where there are orders written by the NP that I am not aware of. I always want to be informed, particularly if a resident is clinically assessed to have to go to the hospital or their clinical condition is acutely worsening. I would expect both the NP and the nurse to recognize a medical emergency and the nurse should inform the NP or myself. I vaguely recall R245. Reviewing the labs leading up to hospitalization, that suggests dehydration and an evolving infection. A cause of dehydration could have been more loss of fluid, such as bleeding or diarrhea. Infection can also cause dehydration. Based on the labs she was actively bleeding. In this case, the patient is bleeding, the staff knows, and the next step is to monitor the corresponding lab values. As I recall, the patient had a staff consult with the Gastrointestinal surgeon who was aware and continue monitoring of the CBC. I don't recall if I was notified. I would expect the nurse practitioners to recognize the signs of infection that can lead to sepsis which is life threatening. For a patient that has dementia and cognitive dysfunction, I would talk to the PoA about hospitalization because we're unable to rely on the patient to make the decision. If I was unavailable, I would expect for the staff to call 911 in an emergency or to contact the Medical Director for orders. [DATE] at 12:41 PM V41 In House Nurse Practitioner said, Reviewing these labs and not directly knowing the resident, it looks as if they were suffering from infection, dehydration, and reactive thrombosis. I would probably order more tests to determine source of infection if any. If the nurses were unable to obtain urine from the straight catheter despite giving IV fluids, the resident should have been sent out to the hospital. [DATE] at 10:03 AM V34 former Director of Nursing said, I was the DON March of 2021 and I left Early January of 2022. I vaguely recall R245 was suffering from a lot of complications. I expect that if there were a life-threatening situation, we would have called 911 and worried about notifying the doctor later. As a floor nurse I would be looking at the labs and advocating for what was best for the resident to the doctor or nurse practitioner. I'm not aware of what happened to R245 after transfer to the hospital. [DATE] at 11:47 AM V35 Former Social Services Director said, When R245 arrived at the facility she was fully alert and oriented. When she became sick and frail, we recommended hospice, but the POA refused. As she began to decline, she was not able to make her own healthcare decisions. In that condition, we would have done whatever interventions we could to preserve her life. She also had an order for Do Not Resuscitate, however but she could still get sent to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent a resident from developing pressure ulcers who was assessed to be at high risk by and, not assessing a resident's skin regularly while providing personal care; they failed to conduct weekly skin checks as ordered; they failed to follow a physician order to apply a daily foam dressing for protection of the skin; and they failed to use a low air loss mattress effectively. This failure applied to one (R64) of one resident reviewed for pressure ulcers and resulted in R64 developing a new facility acquired Stage II pressure ulcer to the coccyx. Findings include: R64 is a [AGE] year old woman admitted to the facility 12/01/21 with diagnoses that include, Chronic Respiratory Failure, Anoxic Brain Damage and Left side Hemiplegia, Hemiparesis following Cerebral infarction. R64 has a BIMs (Brief Interview of Mental Status) score of zero and is not alert or oriented. She has a respiratory status requiring a Tracheostomy and mechanical ventilation. Nutrition is provided through gastrostomy feeding tube. R64 has a colostomy and indwelling urinary catheter. R64 has a functional status requiring two person total assistance with personal hygiene, bed mobility and transferring. The facility treated sacral wounds for R64 from the time of admission and healed the sacral wound on 6/13/22. 08/08/22 at 12:40PM, R64 was observed in bed, non-responsive and breathing without any noticeable distress. V44 CNA (Certified Nursing Assistant) was noted to turn and reposition with the help of another CNA. R64 was wearing a disposable brief, lying on an low air loss mattress that was dressed with a flat sheet, a folded flat sheet used as a draw sheet and a disposable incontinence pad. V44 CNA said, this is how we always set R64, because sometimes the urine is leaking, or the colostomy will get too full before I can empty it and it will leak. 08/08/22 at 4:11PM V25 Nurse Wound Care Director was observed conducting a full body skin assessment for R64. V25 said, R64 should not need all of these sheets on the air mattress. She has a disposable brief on because sometimes I know the urinary catheter to leak. It should not be leaking but it does. Too many layers will cause the mattress not to be beneficial. R64 does not have any more wounds. We have finally healed a wound on the sacrum that she had for a long time. In order to heal a wound, we have to assess it for 3 weeks to make sure it does not re-open. Currently, the only treatment is a preventative foam dressing that should be changed by nursing daily. Because she is high risk, the wound care team will still follow and assess weekly. I am not sure when is the last time a skin assessment was done for her. During this observation, R64 had a foam dressing to the sacrum that was dated 8/2/22 (6 days prior). V25 said that the dressing should be changed every day or every other day by the nurses. This dressing has not been changed for several days. After removal of the dressing, R64 was noted to have a skin opening in the center fold of the buttocks and a reddened area surrounding the sacrum. V25 said, I would consider this to be Moisture Associated Dermatitis and a Stage II Pressure Wound of the coccyx. I was not aware of this new wound so there is no treatment for it. The CNA's and nursing staff should have notified me or someone on the wound care team when they saw early signs of skin breakdown. They should be checking the skin every time they turn and clean the resident. They are probably not turning or cleaning frequently because she has a colostomy and urinary catheter. 8/11/22 at 2:52PM V24 Medical Director said, the protocol for wound care prevention relies heavily on CNA frequency of turning and repositioning. Patients who are receiving ventilator assistance are more prone to skin breakdown, because they are bedridden and are very vulnerable to having pressure sores. I would expect that a resident who is on a ventilator to be turned and repositioned at least every two hours. I would expect for the skin to be checked and assessed at minimum daily. If there is a sign of breakdown, distinguished early enough, it may help to prevent advanced breakdown. A Stage II wound is already opened and now needs additional prevention to not only heal but also be free of infection. Requested skin care assessments and documentation for R64 for the week of 8/01/22 and it was not provided during the course of this survey. Weekly skin assessments reviewed for 7/11/22, 7/18/22, and 7/25/22 document that R64 did not have any new loss in skin integrity. Weekly Wound Evaluation dated 8/8/22 defines Stage II as partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. New wound was identified 8/8/22 categorized as an In-House Acquired Stage II of the coccyx with measurements: length-1cm, Width: 0.2cm, red in color with small amount of serous drainage and erythema surrounding tissue. Physician order sheet reviewed includes an active order for weekly skin checks for wound prevention dated 12/01/21. An order dated 4/27/22 includes to apply foam dressing for protection every day on the sacrum. (TAR) Treatment Administration Record for August 2022 were requested from the facility but during the course of this survey, the facility only provided TAR for July 2022. Facility policy titled, Change of Condition, documents: .a significant change in condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. If the resident's physician does not respond to calls of a resident condition status change, the facility Medical Director will be notified to obtain orders, and this will be documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide effective pain management for a resident who has a diagnosis of brain cancer and sciatica pain by failing to accurately assess resident for pain and failing to administer pain medication as ordered by the physician. This failure affected one (R129) of one resident reviewed for pain and resulted in R129 experiencing pain rated at a level 8 on a 1-10 scale. Findings include: R129 is an [AGE] year-old male who was originally admitted to the facility on [DATE], with medical diagnosis including, but not limited to other disorders of brain, generalized muscle weakness, Sciatica unspecified side, anxiety disorder, etc. 8/08/2022 at 11:31AM, resident was observed in his room lying in bed and moaning, resident is awake and alert with some confusion and stated that he is okay, floor mats were noted at both sides of the bed. Resident room is located across the hall from the dining room where the surveyors were during the survey process, and he was heard moaning throughout the day. 08/09/22 1:38 PM, R129 was again observed in his room, awake and was moaning, resident was asked if he was in pain, and he said yes. R129 rated his pain as an 8 on a scale of 1 to 10, he added that he did not receive any pain pill today and cannot remember the last time he had one. Physician orders dated July 26, 2022 shows the following orders: Tramadol HCl Tablet 50 MG *Controlled Drug*Give 1 tablet by mouth every 8 hours as needed for Pain ordered July 26, 2022. Acetaminophen Tablet Give 650 mg by mouth every 4 hours as needed for pain or fever. 08/09/22 02:05 PM Pharmacy. Resident also has an order to monitor and record pain scale based on a scale of 1 to 10. Review of MAR (Medication Administration Record) for R129 showed that he received one dose of Tylenol on 8/3/2022 and has not at any time received Tramadol as ordered. 08/09/22 1:40PM, V11 (RN/Agency) said that she is the assigned nurse for the resident, surveyor asked if she assessed resident to know why he was moaning and she said that she was told by the outgoing nurse that resident has that as a behavior, it is not pain related. V11 said that when she checked on the resident, he said he just wanted her to come into the room. Surveyor asked V11 to check and see if the resident had any Tramadol in stock, she looked in the narcotic box and said that there is none and she could not find any narcotic sheet for the resident in the narcotic count sheet. 08/09/22 1:59 PM, V2 (DON) said that R129 has cancer in the brain, he used to be alert and oriented x3 but has gone down to two or three. He gets pain medication as needed and is able to verbalize when he is in pain. V2 added that if a resident has an order for pain medication, it is supposed to be in stock, if the medication runs out, the nurses are supposed to get a new script from the doctor and reorder the medication. Care plan initiated 4/27/2022 states that resident has potential for pain related to diagnosis of Sciatica, goal is for resident to have acceptable level of pain of 0/10 based on a 0 to 10 scale. Interventions include to assess and document the frequency and intensity of pain on the pain flow sheet, identify physical and psychosomatic causes of pain, medications as ordered, if ineffective, notify the physician, etc. Facility pain management policy (undated) provided by V2 (DON) states in part that the mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The same document states that this will be achieved through promptly and accurately assessing and diagnosing pain. Under procedures, the policy states that nursing observation is an important part of pain assessment, especially in the non-verbal resident. Nursing will observe behaviors that may indicate pain in the non-verbal pr cognitively impaired residents.