**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to prevent abuse for 6 out of 8 residents, (R1, R2, R3, R5, R6, R7) reviewed for abuse in a sample of 8. This failure resulted in R2 being hit in the face resulting in a bruised chin, feeling uncomfortable and R5 feeling unsafe in the facility. Findings include: 1. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact, that he has delusions, verbal behavioral symptoms directed towards others occurring daily, rejection of care occurred daily, and wandering occurred daily. R1's MDS continued to document that R1's current behavior status has worsened. R1's Care Plan dated 4/9/25 documented R1 has potential to be physically aggressive related to anger and poor impulse control with interventions placed on 4/9/25 to administer medications as ordered, monitor/document for side effects and effectiveness, analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, assess and address for contributing sensory deficits, assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, and encourage seeking out of staff member when agitated. On 4/9/25 R1 was care planned for having the potential to be verbally aggressive related to poor impulse control with interventions placed on 2/3/25 to give the R1 as many choices as possible about care and activities, when the R1 becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. R2's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, idiopathic peripheral autonomic neuropathy, major depressive disorder, and atrial fibrillation. R2's MDS dated [DATE] documented he is cognitively intact with no behavioral concerns. R2's Care Plan dated 4/10/25 documented no plan for risk of abuse. R1's face sheet documented he was admitted to the facility on [DATE] with diagnoses of, in part, severe protein calorie malnutrition, schizophrenia and cataract. On 6/23/25 at 10:50 AM, a bruise approximately 3 centimeters in diameter was noted on R2's left lower chin. On 6/23/25 at 11:25 AM, V1, Administrator, and V2, Director of nursing (DON) played a recording of the hallway where the incident on 6/21/25 took place with R2 present. In the video, R2 walked up to the men's restroom door but it was in use, so he walked away, then R1 wheeled up to the restroom and tried to get in. R2 saw R1 at the restroom and walked up to him, bent down with his hands in his pockets, told R1 something and then R1 hit R2's face with a small light colored object grasped in R1's hand approximately the size of his hand, and then again seconds after with a cup of water, the cup making contact with R2's face. The material of the cup could not be identified due to the video quality. After R1 hit R2 twice in the face, V6 (LPN) watched the incident then walked up to the residents and they backed away from each other. On 6/23/25 at 12:30 PM, video footage showed R1 throwing a chair down while R4 was nearby in the room on 6/21/25. The facility's initial report for the abuse investigation dated 6/21/25 documented at approximately 5:00 PM, R1 was in the west unit restroom. When he exited the restroom, he threw a cup with water in it at R2. Residents immediately separated. R1 placed on 1:1. Residents do not reside on the same unit. R2 was noted to have an abrasion to his mouth. MD (medical doctor) notified. ED (executive director) and DON (director of nursing) notified. Residents will remain separated. A full investigation to follow. On 6/23/25 at 10:50 AM, R2 stated he has to use the community men's restroom because he doesn't have one in his room. On Saturday evening, R2 went to use it but someone was in there, so he had to wait. R2 stated he saw R1 try to go in the restroom while the other resident was still in there, so he went up to him and told him not to go in because it was being used and that he had a restroom in his own room if he needed to go. R2 stated R1 then struck him in the face with a metal water bottle and water spilled everywhere. R2 stated he called the local police department and made a report about it. R2 stated he is the resident council president and has gotten many complaints on R1 over the past year. R2 stated the staff assessed him after the incident and offered to send him to the hospital but he said there was no need. R2 stated he has to avoid R1 anywhere he goes in the facility and feels uncomfortable with him here. R2 stated R1 has made verbal threats to him in the past but could not remember details. R2 stated he reported everything to the social worker. On 6/25/25 at 10:36 AM, R2 stated R1 injured his chin, how else would I have this as he pointed to a bruise on his left lower chin. R2 stated R1 threatened him by hitting him in the face. R2 stated, This should be a safe place, I shouldn't have gotten hit. On 6/23/25 at 1:36 PM, R1 stated he has never had any issues with any of the other residents and he gets along with everyone. R1 stated he has never gotten in an argument with anyone here. On 6/23/25 at 2:42 PM, V6 (LPN) stated she was working at the time of the incident with R1 and R2 on 6/21/25. V6 stated she was in the middle of medication pass she thinks and didn't hear anything but turned around and saw R1 hit R2. V6 stated she was on orientation, and it was just her third shift. V6 didn't have the other nurse next to her at the time and was shocked. V6 stated she told R1 not to hit R2 and tried to separate them. V6 stated R1 hit R2 with a Styrofoam cup and the cup broke. V6 stated R1 was put on 1:1 when she first started and was newly off it when the incident occurred. V6 stated at first R1 didn't seem to have a lot of behaviors but she's only worked three days and doesn't know if he was provoked by R2, she couldn't hear anything that was being said. V6 stated it looked like R1 and R2 were waiting for the restroom when it happened. On 6/23/25 at 3:26 PM, V5 (LPN) stated she was in another room when the incident happened with R1 and R2 on 6/21/25. V5 stated R2 told the police that he bent down and told R1 he wasn't supposed to use that restroom. V5 stated there was a red spot on R2's left lower chin he claimed was from R1 hitting him. V5 stated R1 doesn't always start stuff, some residents provoke him, and she doesn't think R1 has the capability of restraining himself in response. 2. R3's face sheet he was admitted to the facility on [DATE] with diagnosis of, in part, spinal stenosis, idiopathic peripheral autonomic neuropathy, and major depressive disorder. R3's MDS dated [DATE] documented he is cognitively intact, with verbal behavioral symptoms occurring 4 to 6 days. R3's Care Plan dated 3/26/25 documented diagnosis of insomnia, MDD (major depressive disorder) with use of psychotropic medication. R3 has a history of becoming verbally abusive to staff and other residents. Becomes irritated easily with interventions to evaluate effectiveness and side effects of psychotropic drugs for possible decrease in dosage/elimination of drug, administer medications as ordered, observe for change in mood/behaviors, refer to psychiatry as needed, observe for changes in cognitive status, notify MD as needed, educate regarding appropriate behavior within the facility, encourage resident to talk about his emotions to avoid any verbal/physical aggression toward others dated 1/11/2025. The facility's abuse investigation involving R1 and R3 dated 2/1/25 documented R3 propelled his wheelchair up to R1 and told him to move out of the way. R1 did not move and R3 began yelling, screaming, and cursing at R1 stating you better f*****g move. R3 screamed and put his face within inches of R1's face. R1 responded by tossing a cup of ice at R3. R3 grabbed R1's arm and raised his hand and made a fist putting it in front of R1's face. The nurse jumped in and separated R1 and R3. R1 was propelling himself to another unit and R3 went after him and stated, I'm going to get you. Staff intervened and redirected R3. The conclusion of the facility's investigation documented on 2/1/25 there was a resident-to-resident altercation between R3 and R1 with no injuries. The residents were separated with no other incidents occurring. Both residents state they feel safe in the facility. On 6/23/25 at 9:55 AM, R3 stated R1 has hit him in the forehead before and he has thrown water and cold coffee at him too. 3. R5's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, hemiplegia and hemiparesis following cerebral infarction, chronic obstructive pulmonary disease, and heart failure. R5's MDS dated [DATE] documented he is severely cognitively impaired and has no behavioral concerns. R5 answers questions appropriately. R5's Care Plan dated 4/18/25 does not document any risk for abuse. The facility's abuse investigation involving R1 and R5 dated 4/28/25 documented at approximately 3:30 AM, R1 was being very disruptive in the common area and hallway on the East Unit. As witnessed by a nurse, R1 was repeatedly going to the fire extinguisher on the wall and opening the door to it. Staff repeatedly attempted to redirect R1 unsuccessfully. R1 began to yell and curse loudly to himself and staff. R1 propelled his wheelchair down the hallway and began to open resident's doors while yell and cursing. Staff attempts at redirection were unsuccessful. R1 went to his room and after a few minutes R1's roommate R5 came out to the nurse's station. R5 stated, I got up out of bed and he threw cold coffee on me and my bed sheets. I think he was mad because I wouldn't talked to him. Nurse separated R1 and R5. The facility's investigation conclusion documented R1 was physically aggressive toward R5 as evidenced by R1 throwing cold coffee on R5. No injury occurred. On 6/24/25 at 12:33 PM, R5 stated R1 used to be his roommate and it was horrible. R5 stated R1 is a ticking time bomb. R5 stated he remembers R1 throwing cold coffee on him while he was sleeping in the middle of the night, and he would take my things all the time and call me offensive names. R5 stated he doesn't trust R1 and thinks R1 is capable of hurting other residents at the facility. R5 stated he didn't feel safe in the same room with R1 ever. R5 stated R1 would creep the halls every night yelling. 4. R6's MDS dated [DATE] documented he is cognitively intact with no behavioral concerns. R6's Care Plan dated 5/12/25 does not document him to be at risk for abuse. R7's face sheet documented she was admitted to the facility on [DATE] and discharged on 5/21/25 with diagnosis of, in part, idiopathic peripheral autonomic neuropathy, type two diabetes mellitus, and generalized anxiety disorder. R7's MDS date 4/28/25 documented she was cognitively intact with no behavioral concerns. R7's Care Plan documented an onset of problem with history of yelling/shouting at other when frustrated with interventions for behavior tracking as needed, refer to psychiatry as needed and group therapy, social services to provide 1:1 with R7 when behaviors are inappropriate last reviewed May 2025. The facility's abuse investigation involving R1, R6 and R7 dated 3/24/25 documented that at approximately 6:00 PM there were two residents (male and female) having a verbal altercation in the dining room. R6 inserted himself into the conversation and stated he was sticking up for the lady. R6 told R1 to quit yelling at the lady. R1 began using racial slurs toward R6. The verbal altercation escalated between R1 and R6 and both were threatening to kick the others a**. Staff immediately separated the two and R6 went to the common area. R1 went to his room and then wheeled himself back up the hall with a butter knife in his hand waving it in the air. This was witnessed by a visitor who told V5 licensed practical nurse (LPN) who followed R1 to the activity room where she saw R1 place the butter knife under the popcorn machine. V5 retrieved the knife. R6 had no other contact with R1. R6 stated, I just heard him (R1) being loud with her, so I said something to him. I told him to get out of here and to quit yelling at her. Then R1 just started yelling at me and calling me a n****r. Then I said I'll kick you're a**. He said the same to me. Then V5 came and took him away. I went to the lobby. I didn't talk to him anymore after that. The interview with R7 documented, I backed into him. I apologized. It was my fault. I wanted to back up and he wouldn't move, so I backed up. He yelled at me, so I called him a mother f****r. The interview with R1 documented, she (R7) backed into me. Then she called me a mother f****r. I called her a b***h. Then R6 came over and we argued. I called him a n***r. We both threatened to kick each other's a****s. I went and got a knife. I wasn't going to do anything with it. It was a butter knife. The facility's investigation conclusion documented there was a verbal altercation between R7 and R1. There was a verbal altercation between R6 and R1. R1 was seen with a butter knife. It is not known what his intentions were. R1 did not attempt to harm anyone with the knife, and it was immediately retrieved. Since that time, they have had no further incidents. R1 and R6 are getting along with no issues. All residents involved stated they are comfortable and safe living in the facility. On 6/25/25 at 9:58 AM, V1 stated she expects all residents to be free from abuse and that the facility is responsible to keep the residents free from abuse. The facility's Abuse policy dated 1/25 documented the facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteer, and staff agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. The policy documented it is the responsibility of all staff to provide a safe environment for the residents. The facility's Resident Rights policy review 1/15 documented facility residents shall have the right to be free from mental and physical abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to notify the nurse of a resident having a change in condition to ensure timely assessment for 1 of 4 residents (R3) reviewed for quality of care in the sample of 5. This failure resulted in R3 not having timely assessment and subsequently having a Hypoxic/Unresponsive episode, with Cardiopulmonary Resuscitation (CPR) started, and was hospitalized . The Findings Include: R3's admission Record, dated [DATE], documents R3 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. R3's diagnoses includes Chronic Obstructive Pulmonary Disease (COPD), Arteriosclerotic Heart Disease (ASHD), Cardiomyopathy, Myocardial Infarction (MI), Morbid Obesity, Hyperlipidemia, Anemia, Sleep Apnea, Hypertension (HTN), and a Coronary Artery Bypass Graft (CABG). R3's Baseline Care Plan, dated [DATE], documents R3 was alert cognitively, is a fall risk, and the receives special treatment: Oxygen. R3's Minimum Date Set (MDS), dated [DATE], documents R3 was cognitively intact and dependent on staff for toileting, dressing, and transfers, substantial/moderate assistance with showers and partial/moderate assistance for all other Activities of Daily Living (ADLs). R3's Physician Order, dated [DATE], documents, Oxygen: Oxygen at 2 L (liters) per NC (nasal cannula), as needed for SOB (shortness of breath). On [DATE] at 1:46 PM, V4, Licensed Practical Nurse (LPN), stated, I took care of (R3), and she was always on O2 (oxygen). Even though she had an order for PRN (as needed) oxygen, if you tried to lower her dose, or take it off, she would have a hard time breathing and her sats would drop, so I kept her on 3 L/NC. If I would find her with her Oxygen off, she would always look pale and be slightly lethargic and would have to put her Oxygen back on her. On [DATE] at 9:33 AM, R3 stated, That morning ([DATE]) I was assisted up to my wheelchair and then to breakfast. After breakfast, I had to go to therapy and then I asked the CNA (Certified Nursing Assistant/V6) to put me back to bed because I was tired and didn't feel good but wanted to get up later for activities. When (V6) came back and got me up to my wheelchair, I told her I wasn't feeling good and she put the nasal cannula in my nose and pushed me to the nurse's desk and told me to wait there because my oxygen tank was empty, and the nurse had to fill it. When I told her I did not feel anything coming out of my cannula, she told me I told you it was empty and needed to be filled. When I got to the desk, there was no one around and (V6) left. I started to feel funny and the next thing I know, I woke up with people doing CPR on me. Then the ambulance guys came and took me to the hospital. On [DATE] at 2:15 PM during revisit interview, R3 stated, I was assisted to my wheelchair by the CNA, and she put the cannula in my nose and hooked it up to a portable oxygen tank. I told her I was not feeling good. I just didn't feel right and felt tired. I told her that I did not feel any oxygen coming out of the cannula and she told me it was because the oxygen tank is empty. She told me to go to the nurse's desk and sit there until I see a nurse and tell her that I didn't feel good and that I needed oxygen. It seemed to be around 30 minutes without seeing the nurse. The next thing I knew, I woke up with someone doing CPR on me and the EMTs taking me away. I did have my caregiver come visit me that morning, but she did not bring me lunch or give me anything for pain. I was not in any pain and did not receive anything for pain that day. On [DATE] at 1:13 PM, V6, CNA, stated, I had already gotten (R3) up for breakfast and after breakfast, she said she wasn't feeling well and wanted to go back to bed, so we helped her back to bed to rest. She wanted back up before bingo, so later I asked a therapist (V5) for help in getting her up, but the therapist was busy, so I just grabbed someone else, and we got her up to her wheelchair. I put her oxygen on the portable tank and pushed her to the nurse's desk because she wanted to talk to the nurse because she was not feeling well. I couldn't see the nurse so had (R3) sit there while I went and answered another resident's call light. (R3) was awake and talking when I left her at the desk. When asked why she did not tell the nurse that R3 was not feeling well, V6 stated, I hadn't seen the nurse around to let her know, so just went and answered the call light. On [DATE] at 10:08 AM during revisit interview, V6 stated, (R3) was not feeling well and wanted back to bed, so I put her back to bed. Shortly after that, she had two visitors, a male and a female who brought her lunch. When they were visiting, (R3) seemed very happy, perky, smiling, and cheery while she at lunch with them. (R3) was complaining that her head and stomach was hurting that morning. I told the nurse (V7, Licensed Practical Nurse/LPN) that morning that (R3) needed her oxygen tank filled because she went to therapy and used most of it. That is why I parked her at the nurse's desk, so she could tell the nurse she wasn't feeling good and to get more oxygen. I went and answered another resident's call light down the hall from (R3's) room and he is hard to get out what he needs, so I was in there for a while, I'm guessing around 10 minutes but less than 30 minutes. When I came out of his room, that's when they were all over (R3). On [DATE] at 11:53 AM, V6 stated, I did tell the nurse that (R3's) O2 was running empty. It was not in the red yet but was low. I put (R3) on that portable tank to take her to the desk because when I hooked her up, it hissed like it still had air in it. I do regret not looking at the tank to make sure it had oxygen. On [DATE] at 12:30 PM, V5, Director of Therapy Service (DTS), stated, I had a CNA (V3) come ask me for help getting (R3) out of bed and I told her I would be there as soon as I could. When I was on my way, I noticed that (R3) was already up and sitting by the nurse's desk. I said Good Morning (R3) and she did not answer me, which was unusual, so I started talking to her and she was not responding. The Nurse, who was on the floor, must have been with another resident, so I went to the DON's (Director of Nursing) office and got her to come help. On [DATE] at 11:25 AM during revisit interview, V5 stated, (V6, CNA) asked me to help get (R3) out of bed to go to bingo, and when I went to (R3's) room, (V6) told me that (R3) had to get cleaned up first because she was soiled. I left and went back to therapy department and waited for maybe 30 minutes to an hour, and when heading back to help out, that is when I found (R3) at the desk. On [DATE] at 1:24 PM, V7, LPN, stated, I was at lunch and when I came back from lunch, the DON was doing CPR on (R3). I assessed (R3) in the morning when I gave her medications, and she did not have any complaints at that time. When I am at lunch, the other nurse covers for me. I told everyone that day that I was going to lunch. (R3) was always on an oxygen concentrator while in her room and a portable tank when she was up in her wheelchair. On [DATE] at 10:59 AM during revisit interview, V7 stated, I don't remember what time I went to lunch that day. I do know that I let the CNAs know I was going to lunch, and I reported off to the DON. I was probably gone around 30 to 35 minutes. (R3) had no complaints of feeling bad that day. I don't recall seeing any visitors with (R3) that day. The CNA on the floor did not tell me anything about (R3's) oxygen tank needing filled. On [DATE] at 12:20 PM, V2 stated, I was in my office when (V5), came in and got me and said that (R3) needed checked out because she doesn't look good. I immediately went to check on her and she was unresponsive, gray, and was not breathing. I do recall seeing an oxygen tank on her wheelchair but could not tell you how much O2 was in there. (R3) did have a nasal cannula on as well. We then got about four of us and took her to her room and laid her on the floor and could not feel a pulse, so I started CPR. After about three compressions, (R3) began to move and CPR was stopped. We had the Ambu-bag attached to the O2 concentrator and was assisting her breathing. When the EMTs (Emergency Medical Technicians) arrived, (R3) was talking to them before she left the facility. (R3) had an oxygen concentrator in her room and if she felt short of breath, she should have been put on that and the nurse notified instead of taken to the nurse's desk. On [DATE] at 1:55 PM, V2 stated, I would expect the CNAs to get a nurse anytime a resident state they don't feel good and not to leave them alone at the nurse's desk while waiting on the nurse. I would expect anyone putting a resident on O2 to check the tank to make sure there is Oxygen in it. On [DATE] at 11:22 AM during revisit interview, V2, Director of Nursing, DON, stated, EMS (Emergency Medical Service) was called at 2:23 PM, and (V7), was at lunch and returned when the EMS was already here and taking care of (R3). When one nurse goes to lunch, the other nurse covers, or the nurse manager will cover. (V7) did tell me she was going to lunch that day, and she usually takes her lunch after the resident's lunch is over. On [DATE] at 8:30 AM, V10, CNA, stated, If a resident tells me they are not feeling well and wants to see the nurse, I will tell the nurse immediately, and the nurse will go check that resident out and do vital signs. I would not park the resident by the nurse's station to wait for the nurse, I would leave that resident in their room and go get the nurse to go to the resident. On [DATE] at 1:00 PM, V12, Physician, stated, I was not made aware of the incident until last evening ([DATE]) when the facility called me and was asking me about a resident who was sent to the hospital and was found to have Fentanyl in her system. I was not even sure who the resident was. I can tell you that this has happened to other residents at different facilities before with the hospital finding Fentanyl in a resident's urine when they were not on Fentanyl. The facility does not even use Fentanyl. I would expect the CNA to go get a nurse right away anytime a resident states they are not feeling well and needs assistance. On [DATE] at 10:32 AM, V14, Lab Supervisor at (Local Hospital), stated, Our Fentanyl cut off limit is 1 NG (nanogram)/ML (milliliter) and usually once it's positive, it's rare to have a false positive. There are proteins and mouse antibodies that can be found in urine that have been known to give a false positive, however, they usually trigger several false positives and not just one. I remember we had one nursing home resident who tested positive for several things and that was her reason. If the ER (Emergency Room) would have called us, we could have double checked it, but we got rid of that urine and no longer have it to do anything with it. I don't see very many false positives with Fentanyl. We do a QC (quality control) every day and it was done on that day as well. On [DATE] at 11:20 AM, V1 stated, We went and talked to (R3), and she has no idea if or how she may have received Fentanyl. The physician ordered for a hair sample from (R3) to be tested for Fentanyl and that was done and sent off and we are waiting for the results. On [DATE] at 11:29 AM, V15, Lab Employee, stated, We did receive about six hairs from (R3) to run a Fentanyl test, but we could not run the test because it takes 120 hairs to get the results. The facility only collected six hairs and put them in a urine cup, and it was not packaged properly. I spoke to the facility and gave them the correct way to collect the sample, and they are supposed to be resending them the correct way. It normally takes between five to seven days, once they receive the sample, to get the results. R3's Nursing Note, dated [DATE] at 8:23 AM, documents, Resident up in wheelchair in the dining room at this time. Resident receives skilled therapy r/t (related to) generalized weakness. VS (vital signs) 107/47, 69, 99.7, 95% @ (at) 3LNC (liters per nasal cannula). When O2 placed at 2 L (liters), resident's O2 sats drop to 90%. Lung sounds clear to auscultation. Bowel sounds present in all 4 quadrants. Skin warm, dry, and intact. Able to make needs known. Plan of care continues. Monitoring ongoing. R3's Nursing Note, dated [DATE] at 2:49 PM, documents, 2:26 PM (V5) came to DON office asking for help. DON followed (V5) to [NAME] nurse's station to find resident (R3) up in wc (wheelchair). (R3) was nonresponsive to verbal and tactile stimuli, eyes rolled back, skin grey in pallor, no respirations noted, faint pulse noted. 911 called. Crash cart obtained. Res (Resident) pushed to her room, transferred to floor via 4-person lift. CPR initiated. 3 rounds of CPR compressions and ventilation via Ambu bag provided. 4th round of CPR initiated when res became responsive, res squeezed finger of nurse providing compressions. Rising and falling of chest noted. Res verbally responded by moaning. O2 94% on 2L /NC (nasal cannula), P-65. EMTs arrived at this time. Res began verbalizing to EMT's at this time. EMT's exited facility at approximately 2:45 pm transport to (local hospital). R3's Hospital Record/Discharge summary, dated [DATE], documents in part: Date of Discharge [DATE]. C-Diff (Clostridium Difficile) Positive. She refused to go back to the same nursing home. Patient accepted to (another local facility). Plan: Syncopal episode probably multifactorial in origin, including possibly Fentanyl, she tested positive for Fentanyl in the urine which is not a nursing home medication. She also said that her oxygen tank was empty, and she could have passed because of hypoxia. Acute hypoxic respiratory failure present on admission she was saturating at 81% on room air, blood pressure was 80 she had hypovolemic shock on admission both resolved. Fentanyl in her urine - I spoke with the nursing home and that was not a nursing home medication. Patient was transferred to (current facility) from this facility on [DATE]. She was noted to get some Morphine while she was here, but no Fentanyl was given. Had a Cardiac Cath on [DATE] at (local hospital). R3's Cardiac Cath Hospital Records, page 27, dated [DATE], documents R3 had a Left Heart Catheterization on [DATE] with 2 MG (milligram) of Versed and 75 MCG (microgram) of Fentanyl for the procedure. R3 also had another Cardiac Catheterization from a different hospital on [DATE]. Those hospital records were not available for review. The Facility's Notification of a Change in a Resident's Status, dated 11/2017, documents, The attending physician/physician extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations. 1. Guideline for notification of physician/responsible party (not all inclusive): a. Significant change in/or unstable vital signs (temperature, BP (blood pressure), Pulse, Respiration). d. Any accident or incident (per Federal and State Regulations). f. Abnormal lab findings. i. Change in level of consciousness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent pressure ulcers for 1 of 4 residents (R62) reviewed for pressure ulcers in a sample of 36. This failure resulted in R62 sustaining an pressure ulcer on his left BKA. Findings include: R62's Care Plan dated 4/1/2021 documents problem: at increased risk for skin issues related to impaired mobility diagnoses right AKA, left BKA (below the knee amputation), ESRD (end stage renal disease) with dialysis, diabetes (DM), CHF (chronic heart failure) with edema. Goal: no break in skin integrity through next review 12/2022. Approaches: observe skin daily with cares, perform weekly skin assessments, notify physician of any abnormal findings. Pressure relieving mattress on bed and cushion in w/c as tolerated. Staff to assist with repositioning, perform a skin risk assessment quarterly and PRN, treatment as ordered. 5/2/2022 staff handwritten note treatment as ordered, prosthetic ortho looking at leg 5/9/2022. 6/20/2022 staff handwritten stage 3 pressure to left BK and left distal BKA admitted with from hospital. 6/20/2022 treatment as ordered; wound specialist ordered. 8/27/2022 handwritten left BKA Pressure wound stage 3. R62's Undated Face Sheet documents he was initially admitted to the facility on [DATE]. R62's Evaluation of Pressure Ulcer Risk, dated 4/8/2022 documents bed mobility problem: no. Bedfast: no. Bowel incontinence: no. Peripheral Vascular Disease (PVD): no. Previous ulcer: no. Skin desensitized to pain or pressure: no. Daily trunk restraint: no. It was determined R62 was not at risk of pressure ulcers. R62's Nursing Notes dated 5/2/2022 at 3:20 AM V6, Wound Nurse documented observed resident this shift, noted open area to left BKA related to ill-fitting prosthetic. Treatment applied as ordered. Prosthetic company coming 5/9/2022 to re-fill few new prosthetics. Physician and responsible representative aware of current situation. No assessment of the pressure ulcer was documented. R62's Physician's Order Sheet (POS) dated 5/2022 documents a physician's order dated 5/2/2022 cleanse left leg amputation site with wound cleanser, apply Medihoney, calcium alginate and cover with a dry dressing every day and PRN, (when necessary.) 5/31/2022 wound specialist consult and treat. R62's Medical Record dated 5/2022 no documentation the prosthetic company assessed his left leg prosthetic. R62's quarterly Minimum Data Set, (MDS), dated [DATE] documents he is alert, and needs is independent for bed mobility, transfers, locomotion on and off unit, eating and toilet use. Supervision with setup only for dressing and personal hygiene. Determination of pressure ulcer risk: resident has a pressure ulcer, formal assessment instrument tool and clinical assessment, resident at risk for developing pressure ulcers, 1 stage 2 pressure ulcer. Skin and ulcer treatments included pressure reducing device for chair and bed and pressure ulcer care. Mobility device: wheelchair. R62's Initial Wound Specialist Nurse Practitioner Note, dated 6/7/2022 HPI (history of present illness): initial consult of this [AGE] year-old male, who was noted on 5/2/2022 to have a pressure ulcer secondary to his prosthesis. Currently treating with Medihoney. He was noted today to have a new distal lateral area of his left BKA as well, awaiting orders. Patient has history of left BKA, DM and ESRD. Initial assessment of left BKA noted on 5/2/2022 stage 3 pressure ulcer with 100% granulation which measured 2.9 cm x 2.5 cm x 0.3 cm. Left BKA lateral distal noted 6/7/2022 stage 3 pressure ulcer with 100% granulation which measured 0.7 cm x 0.9 cm x 0.3 cm. R62's 6/2022 POS, dated 6/7/2022 documents discontinue current treatment to left BKA. Cleanse left BKA with wound cleanser apply skin prep to peri wound area apply alginate cover with foam dressing every day and PRN. R62's POS dated 6/10/2022 documents send resident to hospital for evaluation. R62's POS, dated 6/16/2022 documents a physician's telephone order for new BKA prosthesis. R62's Evaluation of Pressure Ulcer Risk, dated 6/20/2022 documents bed mobility problem: no. Bedfast: no. Bowel incontinence: no. PVD: no. Previous ulcer: yes. Skin desensitized to pain or pressure: no. Daily trunk restraint: no. Staff circled diabetes on the form. It was determined R62 was at risk of pressure ulcers. R62's Medical Record documents no readmission skin assessment dated [DATE]. R62's POS, dated 6/21/2022 documents a physician's order cleanse left leg amputation site with wound cleanser apply Medihoney cover with dressing daily. R62's Wound Nurse Practitioner dated 6/21/2022 documents unstageable pressure ulcer on left BKA measured 3 cm x 2.5 cm x UTD (unable to determine.) Wound bed 10% granulation and 90% necrotic. Peri-wound area scarring dry and flakey. Moderate yellow drainage. R62's 7/2022 POS documents cleanse left BKA with wound cleanser, apply Medihoney, cover with dressing every day and PRN. R62's Wound Specialist Nurse Practitioner Note, dated 8/9/2022 HPI: [AGE] year-old male with a pressure ulcer of his left BKA secondary to his prosthesis. Currently treating with Medihoney and calcium alginate. He also has history of diabetes and ESRD. Assessment of Left BKA pressure ulcer stage 3 with 100% granulation which measured 2 cm x 1.5 cm x 0.3 cm. Peri wound scarring dry, flakey with moderate yellow exudate. R62's POS dated 8/2022 documents a physician's order dated 4/7/2021 weekly skin checks, and cleanse left BKA with wound cleanser, apply Medihoney, calcium alginate, cover with dry dressing every day and PRN (when needed.) R62's Evaluation of Pressure Ulcer Risk, dated 8/27/2022 documents bed mobility problem: no. Bedfast: no. Bowel incontinence: no. PVD: yes. Previous ulcer: no. Skin desensitized to pain or pressure: no. Daily trunk restraint: no. Staff circled diabetes on the form. It was determined R62 was at risk of pressure ulcers. R62's POS dated 9/2022 documents a physician's order dated 9/23/2022 cleanse left BKA wound cleanser, apply Prizma and cover with dressing every day and PRN. Weekly skin checks. R62's quarterly MDS, dated [DATE] documents he is alert, and needs extensive assistance of setup only for bed mobility, locomotion on and off unit, dressing, eating, and personal hygiene and extensive assistance with two-person physical assist for transfers and toilet use. Mobility device was a wheelchair and limb prosthesis. Determination of pressure ulcer risk: resident has a pressure ulcer, formal assessment instrument tool and clinical assessment, resident at risk for developing pressure ulcers, 1 stage 3 pressure ulcer. Skin and ulcer treatments included pressure reducing device for chair and bed and pressure ulcer care. On 10/4/2022 at 9:30 AM R62 was sitting in his wheelchair in his room with a left leg prosthetic on. On 10/5/2022 at 9:00 AM, R62 was sitting in his wheelchair in his room with a left leg prosthetic on. Observation on 10/6/2022 at 8:15 am V6, Wound Nurse provided wound care to R62's left BKA. V6 washed her hands and donned gloves she removed a dressing dated 10/5/2022 removed gloves, washed hands and donned gloves and cleansed the pressure ulcer with dermal wound cleanser. V6 applied Prizma and cover the pressure ulcer with a dry dressing. The pressure ulcer wound bed was 80% granulation tissue and 20% red. It measured 0.7 cm x 0.4 cm. The peri wound area (area surrounding pressure ulcer) was dry and there was a small amount of serosanguineous drainage. On 10/6/2022 at 8:20 AM V6, Wound Nurse stated R62 in May 2022 staff notified her he had skin breakdown on his left BKA. She assessed it and documented a stage 3 pressure ulcer on this left BKA. R62 is alert and told her it was caused by his leg prosthetic rubbing against his skin. He was transferred to the hospital a few months ago and when he was readmitted the left BKA pressure ulcer was a lot bigger, so she documented it as a non-facility acquired pressure ulcer. On 10/6/2022 at 2:00 PM V16, Director of Therapy stated R62 was admitted to the facility years ago and he brought his left leg prosthetic with him upon admission. When residents are admitted to the facility with a prosthesis therapy staff evaluate to ensure it fits them properly. The prosthetic evaluation wouldn't be in therapy notes because they document it on a template, and it is not printable. On 10/6/2022 at 1:00 PM V2, DON stated the pressure ulcer on R62's left BKA was assessed in May 2022 and the wound nurse practitioner assessed it weekly. R62 told V2 his left leg prosthetic was rubbing against his skin and caused it to open, it was a facility acquired pressure ulcer. She expected staff to assess and document resident's skin under a prosthesis every day and to document the assessment on the weekly skin assessment. R62's Weekly Skin Assessment, dated 4/2022 through 10/2022 no assessment of R62's skin under the prosthesis. On 10/6/2022 at 1:17 PM, V29 Wound Nurse Practitioner stated she initially assessed the pressure ulcer on R62's left BKA on 6/7/2022. Staff informed her the pressure ulcer was caused from an ill-fitting prosthesis on his left leg. V29 stated this was an avoidable pressure ulcer because staff should have been checking the prosthesis to ensure it fit R62's left BKA properly and assessing his skin under the prothesis as well. On 10/6/2022 at 2:00 PM R62 was sitting in his room with his left prosthetic on. R62 stated they amputated his left leg about 5 years ago and his right leg 8/2022. He has a lot of health issues including diabetes, PVD and he's on dialysis. He got a wound on his left BKA because his leg prosthetic rubbed against his skin. The prosthetic company came to the facility a while ago and replaced a part on his prosthesis he didn't know when the prosthetic company came out. On 10/7/2022 at 7:30 AM V1, Administrator stated R62 wasn't compliant with wearing his left leg prosthetic. On 10/7/2022 at 8:00 AM, R62 was sitting in his wheelchair outside the dining room with his leg prosthesis. On 10/7/2022 at 9:43 AM, V28 Vascular Physician stated R62 had a left BKA years ago due to DM, ESRD and severe PVD. If a pressure ulcer developed from an ill-fitting prosthesis is an avoidable pressure ulcer. He expected the facility staff to follow their pressure ulcer and skin policies and assess the skin under the prosthesis per facility protocols. R62's Physician's Telephone Order dated 10/7/2022 documents a new physician's order stating R62 may wear the prosthesis to left BKA. The facility's Pressure Ulcer/Injury & Skin Conditions Guide for Wound Evaluations Document Policy, dated 11/2017 policy: it is the practice of this facility to ensure residents with pressure ulcers receive necessary evaluation and treatment to promote healing, prevent infection and prevent new ulcers from developing. The assessment documentation includes length, width and depth measurements, tunneling/undermining, exudate (drainage), wound bed, peri-wound and pain, wound status: healing, no change, physician/family notifications, order changes and nutrition/hydration status. Upon identification of a pressure ulcer regardless, if developed in house or upon admission, the area is to be documented on the Wound Evaluation form or in electronic format. Contact physician, interdisciplinary team, family members, and significant others as indicated. Initiate appropriate treatment per treatment protocol and physician order. Evaluate further interventions that may be indicated to promote healing and prevent infection. Documentation of wound status will occur at least once a week. this weekly evaluation will be documented electronically or on the Wound Evaluation Form/Skin Condition Form as appropriate. The physician is to be notified if there is no improvement in area, signs and symptoms of infection or signs of deterioration. The Unit Manager/Charge Nurse are responsible to ensure pressure ulcer treatment plan is addressed on the resident's plan of care. The Guide for Wound Evaluation and Documentation (above) can be utilized as a reference tool for licensed nurses when completing this documentation. This guide can be kept in the front with the treatment sheet for the month if completed manually. This is placed in the medical record. The Director or Nursing and/or designated licensed nurses will make pressure ulcer rounds on a weekly basis. Documentation of the area will be address. Resident progress or lack of progress will be evaluated. Directives may be given for further interventions and changes in plan of care. The resident's current care plan will also be reviewed. When a pressure ulcer heals, a preventative plan of care should have initiated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to provide restorative or licensed therapy to prevent the decline in Range of Motion, (ROM), for 1 of 3 residents, (R4) reviewed for restorative programs in the sample of 36. This failure resulted in (R4's) physical decline not able to use his left arm, limited ROM in his right arm. Findings include: R4's Minimum Data Set, (MDS), dated [DATE], documents R4 is intact cognitive response for cognitive skills for decision making, requires extensive assistance with two person physical assist for bed mobility, requires extensive assistance with two person physical assist for transfers, requires extensive assistance with one person assist for dressing, requires extensive assistance extensive assistance with one person physical assist for eating, requires extensive assistance with one person physical assist for personal hygiene, special treatments, procedures, and Programs zero (0) documentation for physical therapy, speech therapy, occupational therapy, or restorative nursing programs. R4's Care Plan dated 06/21/2022, documents R4 is a short-term care resident to return home with family and home health services. Interventions dated 06/21/2022 encourage me to participate in all recommended therapies. Require assist with Activities of Daily Living (ADL's) r/t impaired mobility impaired cognition will often refuse care, meds, and therapy. Transfers with 2 assist and Hoyer Lift - bedrest at this time per residents/family request, provide assist with any and all ADLs as needed. Medical Diagnoses dated October 2022 on the Physician Order Sheet (POS) unspecified sequelae of cerebral infarction, old myocardial infarction. On, 10/04/2022 at 11:58 AM, V18 R4's mother said, R4 tries to feed himself with finger foods. I bring in chicken tenders most of the time. Break the chicken tenders apart then hand him the chicken he will put it in his mouth using his right arm. V18 said she brings food in for him to eat because they serve him food he doesn't like and won't eat, and he likes the chicken tenders. He needs finger foods so he can use that right arm to feed himself. At times I will feed him, or the staff will feed him the foods that are not finger foods. V18 said he lost the ability to feed himself or do anything because he hasn't had any kind of exercises or therapy on him for a while now. V18 said R4 had a heart attack and stroke, and he needs therapy and exercises. I've told them he needs to be exercised but was told by staff that management said he couldn't have therapy. V18 said at times R4 can push the TV remote button, and call light at times with his good hand. V18 said R4 has not walked since February 2022. She said his legs and arms are sore most of the time and know it's because he does not get exercised. V18 said they don't get him up in a chair, or ever give him a shower. Would like to see him get up for just a bit, I know he has sores on his bottom but would like him up for a little bit and have a shower, exercises, and some kind of therapy to help him. 10/04/2022 at 1:30 PM V7 Licensed Practical Nurse/Restorative Nurse (LPN/RN) said, R4 is not on any Restorative Programs, not sure why he isn't. 10/04/ 2022 at 1:42 PM V2 Director of Nursing (DON) said, R4 was in Hospice and family revoked him being on Hospice, not interested in Hospice - family not on board. V2 said R4 came off Hospice 8/19/2022. Not sure why R4 wasn't placed on restorative program and screened for therapy. On, 10/05/2022 at 1:50PM, V20 R4's dad stated, don't want Hospice again they told us he wasn't eating and needed Hospice. The facility finally put him on a pill to help with his appetite. His appetite is better since on the pill. V20 said he told V6 Licensed Practical Nurse/Wound Care Nurse (LPN/WCN) they wanted him to get up to a chair, shower, and evening sit on side of the bed to soak his feet. V20 said, the WCN said they can't get him up in a chair because my boss said he couldn't get up. V20 said he is losing his ability to do anything by not getting therapy. On, 10/05/2022 at 2:03PM, R4 stated, I haven't got up for a shower, no exercises, only a bed bath. I would like to have a shower and have some exercises. On, 10/05/2022 at 2:57PM, V23 Certified Nurse Aide (CNA) assisted V6 LPN/WCN with providing treatment to R4's wounds. R4 used his right hand and grabbed the handrail to help roll to his right side for treatment to be provided. On, 10/06/2022 at 10:35AM, V15 Occupational Therapists (OT) stated, I evaluated R4 yesterday and we are picking him up for OT for self-feeding, grooming, hygiene, fine motor coordination, and positioning five times per week for eight weeks. On, 10/06/2022 at 10:45AM, V16 Occupational Therapists (OT) Director of Therapy Services said, anytime a resident comes off skilled therapy an email is sent to V7 Restorative Nurse and V1 Administrator cc'd for recommendations. R4 was discharged off skilled therapy because he went on Hospice. V16 said, when he was discharged from Hospice not sure what happened to why he wasn't screened after his Hospice discharge. On, 10/06/2022 at 12:25PM, V18 R4's mom at bedside visiting with R4. R4's head of bed elevated, and R4 has his right arm behind his head watching TV and talking to his mom. On, 10/06/2022 at 12:46AM, V16 (OT) stated we have no documentation that R4 was screened again after his discharge from Hospice. On, 10/07/2022 at 10:02AM, V24 Certified Occupational Therapy Assistant (COTA) stated it is possible if a resident comes off skilled therapy could decline if not recommended for Restorative Programs. On, 10/07/2022 at 10:06AM, V15 Occupational Therapists (OT) said, a Functional Maintenance Program (FMP) recommends the Restorative Program so any resident being discharged off skilled therapy and staying here in the facility is recommended a restorative program to help maintain, or decline. R4's Departmental Notes, dated 8/24/2022 at 4:00PM, documents, (R4) has chosen to discharge from hospice services as of 09/19/2022. R4's Departmental Notes, dated 8/26/2022 at 2:51PM, document, Interdisciplinary Department Team (IDT) meeting held (R4's) chart reviewed, wound care discussed, no new orders, no recommendations received, (R4) has been taken off hospice care, wound care specialists, registered dietician, director of nursing, responsible representative, medical director, aware of status. R4's Physical Therapy PT Discharge summary dated [DATE] - 6/29/2022, documents, discharge recommendations you are discharged from physical therapy on 6/29/2022 due to no longer requiring the skills of a therapist. You are discharge to this skilled nursing facility with hospice. You will require full time nursing care. You did not achieve your personal goal for wanting to get up in a wheelchair. Restorative program established/trained equals not indicated at this time. Functional maintenance program established/trained equals not at this time. Prognosis to maintain Current Level of Function (CLOF) equals N/A, Factors Impacting Prognosis Equal Risk for change in medical condition. R4's Occupation Therapy Treatment Encounter Notes dated 10/07/2022, documents, precautions/contraindications fall risk, foley catheter and rectal tube. Patient provided with Estim PENS UE triphasic to right forearm to facilitate wrist Range of Motion (ROM)/strength needed for self-feeding and hygiene/grooming. Patient provided with Active Range of Motion (AROM) to left upper extremity (LUE) and educated on SROM to increase ROM and strength to facilitate bilateral upper extremity (BUE) movement with washing face. Patient completed self-feeding with finger foods eating two sandwiches with SBA. Patient completed hygiene/grooming washing face with SBA Subject: Nursing Rehabilitation/ Restorative Care Policy dated 10/09 Rehabilitative or restorative care refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as is possible. Focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. A restorative program should be started when a resident is admitted with restorative needs, but not a candidate for therapy, or when the need arises during a stay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to document, assess, monitor and implement safety measures for 1 of 10 residents (R32) reviewed for falls in the sample of 36. This failure resulted R32 falling from his wheelchair and sustaining a focal hemorrhagic confusion of cerebrum (brain bleed) and being hospitalized and admitted to the trauma intensive care unit. Findings include: The Incident Log provided by the facility documents R32 had a fall on 1/5/2022 at 6:45 PM and suffered an injury. The log also documents R32 fell in resident room on 6/30/2022 at 5:30 PM, R32 was found on floor. The Fall log does not document any other falls for R32. R32's Physician Order Sheet (POS) dated October 2022 documents a diagnosis of hemiplegia following cerebral infarction affecting right dominant side, epilepsy, other symptoms and signs with cognitive functions following non-traumatic intracranial hemorrhage. R32 also has an order for 50 milligrams (mg) of Zoloft by mouth daily. R32's Diagnosis History document a diagnosis of Aphasia following non-traumatic intracerebral hemorrhage dated 7/22/2022 and Aphasia following non-traumatic intracerebral hemorrhage dated 6/17/2022 and history of falling. R32's Fall assessment dated [DATE] document R32 was a high risk for falls. On 10/11/2022 at 9:49 AM, V30, Licensed Practical Nurse, (LPN), stated, (R32) would have behaviors of screaming and yelling, but he was easily redirected. I did not have any issues with him personally. I know he was involved in one resident to resident altercation, and he got into it with another resident. Again, I did not have any issues with redirecting him. On 10/11/2022 at 10:03 AM, V31, Certified Nursing Assistant (CNA) stated, (R32) has a history of screaming and yelling. It was usually started with another a resident. I did not have any issues with any issues with redirecting him. (R32) had a stroke a few months ago and he yells a lot now. On 10/11/2022 at 10:15 AM, V7 stated, At times (R32) will yell out and if he is upset, he will cuss loudly. As long as he has his cigarettes, he is usually happy. I do not have any issues with redirecting him. (R32) had a stroke back in July and has issues with communicating things from his brain to his mouth. He yells out a lot. R32's Care Plan dated 10/2022 documents R32 requires assist with all activities of daily living related to impaired mobility, weakness, diagnosis CVA with right side hemiplegia. R32's Care Plan also documents he is at increased risk for falls related to impaired mobility/weakness, diagnosis of right-side hemiplegia, HTN, seizure disorder, depression with the use of psychotropic medication. R32's Progress Notes showed nothing documented in his medical records regarding his fall on 10/3/2022. R32's Progress Notes handwritten dated 10/4/2022 at 5:00 AM, written by V17, Licensed Practical Nurse shows, Resident presented to this nurse by facility staff after having a behavior causing him to topple his wheelchair backward and hit the ground around 7:20 PM on 10/3/2022 in the hallway. This fall was witnessed and reported to this nurse as intentional. This nurse called (V2, Director of Nursing) at 7:33 PM to make her aware. Spoke with Nurse Practitioner (V25) at 7:35 PM and received orders to send the resident out for evaluation related to large knot that had formed on the back of his neck, continued behaviors and blown pupils slow to react. Emergency Medical Services was called to make a transfer of the resident from facility to (Hospital) around 7:40 PM. Report called into Emergency Department at this time. Emergency Medical Services (EMS) arrived and resident extremely confused and combative while responding inappropriately. EMS informed this nurse they would be taking the resident to a different hospital instead for better plan of care. This resident has no contacts listed. R32's Resident Incident Report dated 10/3/2022 at 7:20 PM, Resident was noted to be yelling and rocking his wheelchair and tipped it backwards in the hallway. Nurse assessed resident. Range of Motion performed. Resident placed back in his wheelchair. DON and NP notified of fall. NP gave order to send to ER for evaluation. Knot/hematoma to back of head 2 x 2 centimeters. Additional Follow ups: Sent to emergency room for evaluation. admitted to hospital with altered mental status, subarachnoid hemorrhage stroke, will place anti roll backs on resident wheelchair upon his return. The Incident Report was not reported to the state until 10/6/2022. R32's Initial Report dated 10/6/2022 documents, (R32) fell at approximately 7:15 PM on 10/3/2022, (R34) was transferred to emergency room for a bump of his head. He was admitted to hospital with altered mental status and a subarachnoid hemorrhage per the Nurse on 10/5/2022 at approximately 5:30 PM. Final to follow. This report was not sent to the state until 10/6/2022. R32's Incident/Accident Report dated 10/3/2022 at 7:20 PM, documents, resident started yelling and attempted to tip wheelchair. Large hematoma to back of head. Resident sent to Emergency Room. On 10/7/2022 at 1:45 PM, V26, Registered Nurse (RN) stated, If a resident has a fall there is a neurological evaluation form in the drawer at the nurse's station that we are supposed to fill out and then place in the resident's chart. On 10/17/2022 at 2:22 PM, R32's chart was reviewed and does not have any Neurological Evaluation Flow Sheet present in his chart or Incident Report. No neuro checks were present in the R32's medical records. R32's Hospital Records dated 10/3/2022 at 808 PM, (R35) us a [AGE] year-old male with past medical history significant for hypertension, hyperlipidemia, type 2 diabetes mellitus, right branch vein occlusion, and chronic left cerebellar stroke who present with AMS (altered mental status) and vomiting of S/P (Status post) fall from wheelchair. The fall occurred at an unknown time. There was unknown LOC (loss of consciousness). They did not arrive on a backboard and continued to remove the c-collar. The patient is altered and unable to provide a history due to mental status. On arrival, patient was reported to be alert and orientated x 2 but not on exam now, patient is non-verbal and lethargic. R32's Hospital Records dated 10/4/2022 document, admitted to the Intensive Care Unit (ICU) overnight. Worsening head bleed on CT (Computed tomography), follow up ordered. Platelet dysfunction addressed. R32's Assessment documents focal hemorrhagic confusion of cerebrum. On 10/11/2022 at 10:33 AM, V1, Administrator stated, I did not view the incident on the camera because it happened in the lounge area right in front of the area where residents go outside to smoke. The camera did not catch the fall. On 10/11/2022 at 10:41 AM, V17, LPN, Agency nurse stated, I did not witness (R34's) fall. I do not what his behavior were occurring at the time because I was not there. I was told (R32) threw himself from his wheelchair and the CNA put him back into his wheelchair and brought him to me. The CNA had got him up and he was in his wheelchair when I saw him. I am agency so I cannot tell you who the CNA was. I had to run around trying to find his chart, and the physician's information. (R34's) pupils were blown and his pupils were large. I was scared he had a brain bleed. I did not document any neuro checks on him, but he was with me the whole time. On 10/11/2022 at 12:46 PM, V33, Medical Director stated, Any resident with a fall I would expect staff to follow protocol and assess the residents, do neuro checks on the residents and send the resident out to the hospital. If a resident was yelling out, I would expect staff to try and find out why they were yelling and what was going on with them. On 10/11/2022 at 11:42 AM V32, R32's hospital nurse stated (R32's) CAT scan (CT) documents, R32 has an acute subdural hemorrhage, an acute subarachnoid hemorrhage, and an acute intraventricular hemorrhage. V32 stated these are all documented as acute, so the head injuries were caused from R32 falling and hitting his head. The Interdisciplinary Fall Reduction/ Injury Prevention Protocol with a revision dated of 7/12 documents, An interdisciplinary approach at reducing falls, preventing injury and increasing safety awareness ultimately resulting in improved quality of care for our residents. Witnessed statements are to be obtained as soon as possible post fall, by all staff members working on that unit.