**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to assess, monitor, and provide treatments as ordered and notify a provider of maggots for 2 of 3 residents (R1, R2) reviewed for quality of care in the sample of 3. This failure resulted in maggots in R1's foot wound. that R1 described as giving her the heeby jeebies. Using a reasonable person concept, maggots in a wound would cause a person to feel shame, embarrassment, anxiety, and uncleanliness for this profound, disturbing experience of parasites in a wound.1-R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including paraplegia, acquired absence of right leg above the knee, and pressure ulcer of left heel.R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact, ambulated via wheelchair, and had three stage 3 pressure ulcers that were present on admission.R1's Care Plan initiated 6/30/24 documents R1 has a wound.R1's Specialized Wound Management Note dated 7/14/25 documents R1 has left dorsal foot pressure ulcer (no stage listed) measuring 3.0 cm (centimeters) x 5.5 cm x 0.3 cm.R1's Progress Note by V5, Licensed Practical Nurse (LPN) on 7/19/25 at 2:05 AM documents, this nurse was completing wound dressing change, when maggots were noticed. maggots removed with normal saline and hydrogen peroxide was applied to wounds. wound were dried and wound dressings applied. (V6), PA (Physician Assistant) was notified and NNO (no new orders) were received.On 8/29/25 at 2:15 PM and 9/3/25 at 11:55 AM, V5 was unavailable by phone.On 8/29/25 at 2:05 PM, V6 was unavailable by phone.On 9/3/25 at 10:55 AM, R1 stated, I've had maggots in my wounds twice here. That (V5) didn't know how to do a dressing (correctly). I told her to cover up my toes good, but she didn't, and that's what happened. They were all over my foot and moving around. I told her to get them out of there. It gave me the heeby jeebies. R1 stated V5 removed the maggots, but did not send her to the hospital. On 9/3/25 at 9:35 AM, V7, Wound Nurse Practitioner (NP), stated she was not aware of R1 having maggots in her wound and would have expected the Facility to notify her, if that were the case. She stated R1 goes out to smoke frequently, and dressing changes can prevent maggots. The general procedure is to remove the maggots and send the resident to the hospital.2-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including quadriplegia, contracture of upper arm muscle, and acquired absence of right and left legs above the knee.R2's MDS dated [DATE] documented R2 was cognitively intact, ambulated by wheelchair, and had one stage two pressure ulcer and one stage three pressure ulcer that were present on admission.R2's Care Plan initiated 6/3/25 documents R2 was admitted with pressure ulcers. The interventions included treatments as ordered by physician.R2's Wound Assessment Report dated 8/25/25 documents R2 has a stage 2 left buttock pressure ulcer measuring 2.0 cm x 2.0 cm wide x 0.2 cm deep.R2's Physician Order dated 6/17/25 documents cleanse left buttock with normal saline or wound cleanser, apply Dakin's Solution 0.5%, then Hydrocortisone cream, then collagen, then calcium alginate, and cover with bordered foam dressing every day shift. R2's Treatment Administration Record (TAR) does not document this treatment was completed on 6/26/25, 6/27/25, 7/2/25, 7/23/25-7/26/25, 8/1/25, 8/2/25, or 8/6/25.R2's Wound Assessment Report dated 8/25/25 documents R2 has a stage 3 left posterior thigh pressure ulcer measuring 12.0 cm x 12.0 cm x 0.3 cm.R2's Physician Order dated 6/17/25 documents cleanse left posterior thigh with normal saline or wound cleanser, apply Dakin's Solution 0.5%, then Hydrocortisone cream, then collagen, then calcium alginate. Cover with bordered foam dressing every day shift. R2's TAR does not document this treatment was completed on 6/26/25, 6/27/25, 7/2/25, 7/23/25-6/26/25, 8/1/25, 8/2/25, 8/6/25.R2's Wound Assessment Report dated 8/25/25 documents R2 has a stage 3 right posterior thigh pressure ulcer measuring 12.0 cm x 15.0 cm x 0.3 cm.R2's Physician Order dated 6/17/25 documents cleanse right posterior thigh with normal saline or wound cleanser apply Dakin's Solution 0.5%, then Hydrocortisone cream, then collagen, then calcium alginate. Cover with bordered foam dressing every day shift. R2's TAR does not document this treatment was completed on 6/26/25, 6/27/25, 7/2/25, 7/23/25-7/26/25, 8/1/25, 8/2/25, 8/6/25.On 9/3/25 at 9:46 AM, V2, Director of Nursing (DON), stated wound treatments should be given as ordered and documented in the TAR, when given. The Facility's Wound Care Policy and Procedure revised 11/9/19 documents, Document treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to order a abdominal ultrasound, urinalysis/culture and sensitivity in a timely manner for 1 (R4) of 3 residents reviewed for timeliness of care in the sample of 3. This failure resulted in a nonverbal resident (R4) being transferred to the emergency room and diagnosed with a impacted stool in the intestine that was digitally removed from her rectum, enema, IV hydration and intramuscular shot for the urinary tract infection and put on oral antibiotics. Using the reasonable person approach, this failure caused pain, discomfort and invasive interventions during a hospital visit. Findings include: R4's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with diagnoses including cerebral palsy, constipation and GERD.R4's Care Plan, dated 3/31/2025 documents focus bowel and bladder incontinence. Interventions: record bowel movements, frequency, and consistency. Assess any signs of discomfort, burning or itching around anus, loss of appetite, etc. No documentation of R4's diagnosis of constipation was addressed/documented on her care plan. Another focus: R4 has a communication problem, she is nonverbal. Goal: R4 will feel heard and understood, as reflected in her body language and facial expressions. Interventions: encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense or respond to the feeling resident is trying to express. Monitor/document for physical/nonverbal indicators of discomfort or distress and follow-up as needed. R4's Annual Minimum Data Set, dated [DATE] documents she is severely cognitively impaired, no constipation present, both sides functional impairment in range of motion, wheelchair for mobility device, doesn't ambulate, dependent on staff for toileting, incontinent of bowel and bladder. R4's Physician's Order Sheet (POS), dated 12/2/2021 MiraLAX 17 grams by mouth every day for constipation. 12/2/2021 Senokot S 8.6 milligrams/50 mg two times a day for constipation and 1/27/2025 Bisacodyl 1 suppository rectally at bedtime every other night for constipation. R4's Medication Administration Record (MAR) dated 8/2025 staff documented physician prescribed medications to treat constipation were administered as ordered. R4's POS, dated 8/4/2025, documents a urinalysis and reflex culture (no reason for order) and an ultrasound abdomen and pelvis indication: mass in lower left quadrant.R4's Bowel and Bladder document, dated 8/3/2025 through 8/14/2025 staff documented R4 had a small bowel movement on 8/3/2025, large bowel movement on 8/9/2025 and 8/11/2025 and a small bowel movement on 8/12/2025. R4's Nursing Progress dated 8/4/2025 through 8/7/2025 no documentation as to why a urinalysis and reflex culture was ordered and no documentation if either test was collected/completed. R4's Nursing Progress Note, dated 8/7/2025 at 1:33 AM, documents attempted to get urine per sterile technique without success. No documentation if the ultrasound abdomen and pelvis was completed. R4's Physician's Progress Note, dated 8/8/2025 at 7:00 AM documents urinalysis and reflex culture sent. R4's Medical Record dated 8/8/2025 through 8/11/2025 showed no urinalysis and reflex culture, or ultrasound abdomen and pelvis results were not uploaded in R4's Medical Record. R4's Physician's Progress Note, dated 8/11/2025 at 7:00 AM, documents the patient is a poor historian due to cerebral palsy and aphasia. The patient history is taken from her family and nursing staff. The patient has been restless and agitation for the past week. There was possible grimacing and complaint of pain witness by her family. Anxiety versus GI/GU (genitourinary/gastrointestinal) symptoms, continuing to await US (ultrasound) and UA (urinalysis)/UC (urine culture.) R4's Medical Record was reviewed for the UA/UC and abdominal/pelvic ultrasound on 8/12/2025 at 12:00 PM. The results were not uploaded in R4's electronic medical record at that time. On 8/12/2025 at 12:10 PM V1, Administrator and V2, Interim Director of Nursing stated he noted a day or so ago that R4's UA/UC was not collected yet and the abdominal/pelvic ultrasound was not completed yet and he had been on the phone with the ultrasound company all morning trying to figure out why it wasn't done yet. V2 stated the ultrasound company informed him that the physician's order verbiage was not correct, and it needed the word limited to be added to it so the ultrasound would be covered by insurance. V2 stated he didn't know why the physician ordered a UA/UC other than to rule out a UTI and the ultrasound abdomen/pelvis was ordered because R4's physician felt a mass in her abdomen. V2 wasn't aware the laboratory and ultrasound tests were not completed until the surveyor requested the test results, that's when he started making calls to see why the tests were not completed. V1 stated when a physician orders a lab test and/or an ultrasound she expects the UA to be collected and sent off to the lab the next day and if it was attempted to be collected and unsuccessful, the nurse should report that to the oncoming nurse and that nurse should attempt to collect the specimen. If there are any issues getting a specimen i.e. urine collected and/or issues with getting an ultrasound completed nurses should notify the resident's physician within 24 hours and update them on why the tests were not done. V1 stated it was a breakdown of communication between nurses as to why these tests were not completed in a timely manner. R4's Nursing Progress Note, dated 8/12/2025 at 2:16 PM staff documented company here to do abd (abdominal) x ray for a mass to left quad. At 2:50 PM, staff documented, attempted to obtain UA sample via straight cath per sterile technique. Attempt was unsuccessful. Evening shift nurse notified that sample is needing to be collected, verbally understood. At 9:21 PM, staff documented x ray results received and faxed to MD (physician.) At 9:34 PM staff documented, urine obtained & in fridge in med room. Lab req filled out & faxed to lab. Lab to p/u (pick up) urine in the AM (morning.)R4's Laboratory Report, dated 8/12/2025 documents urine specimen collected on 8/12/2025. UA results: pending. UC results: Escherichila Coli (E-Coli.) R4's Ultrasound Patient Report, dated 8/14/2025 documents pelvis ultrasound findings: images of the bladder are unremarkable. Left lower quadrant images are unremarkable as well. There is no evidence of mass, cyst or fluid collection. Impression: unremarkable examination. R4's Ultrasound Patient Report, dated 8/14/2025 documents abdomen ultrasound findings: trace amount of ascites is noted in the left lower abdomen/pelvis. Peristalsing bowel loops are noted in the left lower abdomen early in the exam, measuring up to 2.3 centimeters in diameter. No discrete mass is identified. Impression: slightly dilated peristalsing bowel loops in the lower left abdomen. Correlate for enteritis versus small bowel obstruction. R4's After Visit emergency room Summary, dated 8/15/2025 documents, reason for visit: abdominal pain. Diagnoses: impacted stool in intestine, UTI and constipation. Instructions: Evaluated in the emergency department today with primary concern of possible constipation. Your workup was concerning for UTI as well. Fecal disimpactation at bedside. Medications administered: Rocephin 1 gram injection (treatment of UTI), saline enema, sodium chloride 0.9% (intravenous fluid for hydration) and Iodamide. R4's POS, dated 8/15/2025, documents a new physician's order Cephalexin 500 mg twice a day for 7 days to treat UTI. On 8/19/2025 at 10:00 AM V1, Administrator and V2, DON stated R4 is a total care, she is incontinent of bowel and bladder and is dependent with all care and is nonverbal. V2 stated staff are expected to document when a resident has a bowel movement in the electronic medical record so they can ensure residents are not constipated. Staff documented R4 had a small bowel movement on 8/12/2025. R4 was transferred to the emergency room after R4's physician reviewed the abdominal ultrasound results on 8/15/2025 as she wanted to rule out a small bowel obstruction. The emergency room discharge paperwork documents she was impacted, and emergency room staff digitally removed the impaction at bedside. After an enema was administrated R4 had a large bowel movement, and she had another large bowel movement when she was readmitted to the facility. V2 stated R4 was also diagnosed a UTI and was administered an intramuscular shot of antibiotics in the emergency room and is continuing by mouth antibiotics at the facility to treat the UTI. V2 stated R4 didn't have a bowel obstruction and the constipation was resolved immediately after the enema was administered in the emergency room. On 8/19/2025 at 10:40 AM V19, R4's physician stated she ordered the abdominal ultrasound on 8/42025 due to feeling a mass in her abdomen but she was more concerned with her having a UTI at that time. R4 is nonverbal and therefore she can't voice pain but when she assessed her on 8/42025 V19 felt R4 was either in pain or experiencing anxiety so she ordered a UA/C&S and an abdominal ultrasound for the mass felt in her abdomen that day. V19 stated the tests were not done in a timely fashion and stated she comes to the facility on Mondays and Fridays and she expected to have both test results back that Friday, 8/8/2025 but she spoke to the floor nurses who were agency staff and they told her the tests were completed but the results weren't in R4's electronic medical record and the medical records employee was on vacation at that time so she had issues getting the test results. After the abdominal ultrasound was completed, she reviewed the results the next day and stated she sent R4 to the emergency room to rule out a small bowel obstruction and stated she reviewed the emergency room records and it was determined R4 had impacted stool near the rectum which was digitally removed at bedside in the emergency room and R4 received an enema in the emergency room where she had 2 large stools right after. V19 stated it was determined that R4 has a UTI and she received an intramuscular shot of antibiotics in the emergency room and she is on a by mouth antibiotic at the facility to treat that. V19 stated she expected the facility to follow the policies and procedures to ensure physician ordered tests are completed in a timely fashion. On 8/19/2025 at 3:00 PM, V2 stated the facility doesn't have a policy or procedure that documents when a lab or ultrasound timeframe should be done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to administer prescribed opioid medications, muscle relaxants, and anticonvulsants prescribed for pain control to two of three residents (R1 and R2) reviewed for pain in the sample of three. This failure resulted in R2, who suffers from spinal muscular atrophy, restless leg syndrome, neuralgia and neuritis, and muscular dystrophy described experienced, symptoms of medication withdrawal, pain described as being ongoing, uncontrolled, excruciating, and unbearable to her head, neck, back and both lower legs, which resulted in an emergency room treatment for pain relief. This failure also resulted in R1 who suffers from cervical spinal cord injury, disorder of right wrist tendon and chronic pain syndrome too described experiencing ongoing, uncontrolled, severe pain, rated 9 on pain scale (1 to 10) to left side of his body. Findings include: 1. R1's admission Record, print date 5/14/2025, documents that R1 was admitted [DATE] and lists cervical spinal cord injury, disorder of right wrist tendon and chronic pain syndrome as diagnosis. R1's Care Plan dated, 1/28/2025, documents that the resident has pain. Interventions include Administer analgesia (specify medication) as per orders. Give 1/2 hour before treatments or care. Evaluate the effectiveness of pain interventions (FREQ). Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. R1's Minimum Data Set, (MDS), dated [DATE], documents that R1 is cognitively intact, dependent on staff for ADLs (activity of daily living). It also documents that R1 experience pain almost constantly that frequently interferes with day-to-day activities. It also documents that R1 receives pain medication routinely and as needed and has experienced pain at level of 7. R1's Progress Note, dated 4/9/2025 to 4/24/2025, documents that Orders -Administration Note, Note Text: Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG Give 1 capsule by mouth two times a day for Pain not in stock. R1's Controlled Substances Proof of Use, dated 3/25/2025, documents last dose of Xtampza ER 18mg was administered 4/8/2025 at 4 PM. R1's Controlled Substances Proof of Use, dispense date 4/24/2025, documents the first dose of Xtampza ER 18mg administered 4/26/2025 at 10 AM. R1's Progress Note, dated 4/21/2025, 4/22/2025, documents that Orders -Administration Note, Note Text: oxycodone HCl Oral Tablet 15 MG Give 15 mg by mouth six times a day for pain give 15mg PO q 4 hours routine for pain med out of stock(OOS). R1's Controlled Substances Proof of Use, dispense date 4/22/2025, documents that the first dose of Oxycodone HCL 15mg tab was administered on 4/23/2025 at 12 AM. R1's Progress Note, dated 4/28/2025 at 7:27 PM, documents that Orders -Administration Note, Note Text: Lyrica Oral Capsule 100 MG Give 100 mg by mouth every 12 hours for pain take 100 mg PO q12 hours med out of stock. R1's Medication Administration Record, dated April 2025, documents 10/10/2024 Baclofen 20mg tablet 3 times a day. It also documents blank 4/1 at 4 PM, 4/8 at 12 PM, 4/18 at 8AM, 12PM, and 4 PM. 4/19 at 12 PM and 4 PM, 4/20 at 8AM, 12 PM and 4 PM. R1's Progress Note, dated 5/6/2025, 5/8/2025, 5/9/2025 documents that Orders -Administration Note Note Text: Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG Give 1 capsule by mouth two times a day for Pain OOS. R1's Controlled Substances Proof of Use, dispense date 4/24/2025, documents that the last dose of Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG was administered on 5/5/2025 at 4PM. R1's Controlled Substances Proof of Use, dispense date 5/6/2025, documents that the first dose of Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG was administered on 5/7/2025 at 4AM and last dose administered 5/7/2025 at 4 PM. R1's Medication Administration Record, dated May 2025, documents 10/10/2024 Baclofen 20mg tablet 3 times a day. It also documents blank on 5/3 and 5/4 at 8AM, and 12PM. On 5/13/2025 at 11:50 AM R1 stated that when he doesn't have his pain medication his pain is ongoing, uncontrolled, and severe. R1 stated that his pain, is rated 9 on pain scale (1 to 10) to left side of his body. R1 stated that the pain gets so high that when he finally gets his medication it takes a while for the pain to lower. R1 stated that they don't do anything different for him he just waits till the medication comes in. R1 stated that he goes out of the facility but that can be difficult because of the pain. 2. R2's admission Record, print date 4/14/2025, documents that R2 was admitted [DATE]. It lists R2, who suffers from spinal muscular atrophy, restless leg syndrome, neuralgia and neuritis, and muscular dystrophy as diagnosis. R2's Care Plan, dated 4/10/2024, documents [NAME] has potential impairment to skin integrity. It also documents Administer Morphine and Hydrocodone as per orders. R2's MDS, dated [DATE], documents that R2 is cognitively intact. It also documents that R2 experience pain almost constantly that rates a 10 (1-10) on pain scale and receives routine and as needed pain medication. R2's Progress Note, dated 3/27/2025 and 3/28/2025, documents that Orders -Administration Note, Note Text: Morphine Sulfate ER Oral Tablet Extended Release 60 MG Give 1 tablet by mouth every 12 hours for pain HOLD IF PATIENT IS NODDING OR SHOWING S/S of BEING OVER-MEDICATED med out of stock, insurance issue, pharmacy notified. R2's Progress Note, dated 3/29/2025, documents that new order for liquid morphine given. Morphine Sulfate ER Oral Tablet Extended Release 60 MG discontinued. Morphine Sulfate(Concentrate) Solution 20 MG/ML Give 5 mg by mouth every 4 hours for pain med out of stock, pharmacy notified. R2's Progress Note, dated 3/30/2025 at 3:15 AM, documents that Health Status, Note Note Text: Resident c/o uncontrollable pain requesting to be sent to ER (emergency room). Call placed to 911 at this time. 0330 Resident leaving facility with (local) Ambulance service at this time. Report giving to (local hospital). At 1:07 PM Health Status Note Note Text: Resident returned to facility via ambulance at 11:15am after being sent out r/t back pain. Hospital treated pain with medications this morning. No new dx or medication orders at this time. Resident is currently in her room sitting up. R2's Progress Note, dated 4/7/202508:50 Orders -Administration Note, Note Text: Gabapentin Oral Tablet 800MG Give 1 tablet by mouth four times a day for neuropathy MEDICATION CURRENTLY UNAVAILABLE R2's progress Note, dated 4/12/2025 12:25 PM, documents that Health Status Note, Note Text: Resident was able to find local pharmacy that had previous Morphine script in stock wanted to know if it would be possible to change Morphine script back to Morphine 60mg: 1 tablet by mouth every 12 hours for pain scheduled at 8AM & 8PM. Spoke with (V19's) office asked if she could notify the provider of this and asked if they did approve change if they could send over Morphine ER 60mg to (local pharmacy). (V19's) Morphine 60mg 1 tab every 12 hours was approved and sent to (Local pharmacy) Will update prescription changes in EMR (electronic medical record). R2's Progress Note, dated 5/11/2025, 5/12/2025, 5/13/2025, and 5/14/2025 documents that Orders -Administration Note, Note Text: Morphine Sulfate ER Oral Tablet Extended Release 60 MG Give 1 tablet by mouth every 12 hours for pain med unavailable. R2's Resident Controlled Substance Record, not dated, documents the last dose of Morphine ER 60mg was administered 5/11/2025 at 8AM. R2's MAR, dated April 2025, documents blank for Baclofen 10mg on 4/1, 4/14, 4/18, 4/19, 4/20 Baclofen 20mg 4/6 at 6AM, 4/19 at 2Pm and 8 PM, 4/20 at 6AM and 8 pm. Gabapentin 800mg 4/1 at 4pm and 8 pm, 4/14 at 4 8 pm 4/18, 4/19, 4/20 at 4PM and 8 PM. R2's MAR, dated May 2025, documents Baclofen 10mg at bedtime and 20mg 5/10 blank. Gabapentin 800mg 5/3 and 5/4 at 8AM and 12 PM. 5/10 at 8PM blank. On 5/12/2025 at 2:30 PM V3, LPN, stated that they have had some issues with medication. V3 stated that more on the other halls. V3 stated that they had a recent change in pharmacy and causes some delays with the change. V3 stated that when there is a blank in a routine medication the system highlights that and it alerts her to verify if the medication was given because at that time it would look as it was not. On 5/12/2025 at 3:00 PM V2, Director of Nursing, stated that the facility is chaotic. V2 stated that she has been at the facility for about 3 months. V2 stated that prior to the changeover it was difficult to get medications from the pharmacy. Communication was horrible. V2 stated that the medication would be ordered and not delivered. V2 stated that they would have to call the pharmacy and then they were told it was an issue with the script or insurance. V2 stated that the previous pharmacy had emergency boxes in the medication room, but it was no good if you can't access it. V2 stated that it was difficult to care for the residents. V2 stated that then the changeover happened and again there were some challenges with getting medication. V2 stated that there were delays with getting medication. V2 stated that she feels its getting better. V2 stated that she is aware of medications not being delivered. V2 stated that when the medications are administered, they are signed off. V2 stated that the medication being blank would indicate that it wasn't given. V2 stated that she expects the staff to administer medication as ordered. V2 stated that she was aware of R1's medication being out and difficulty with getting the medications. V2 stated that R1 has a lot of pain and withdrawals from not receiving his pain. V2 stated that R1 goes out of the facility and when this happened the medication are to have documentation there shouldn't be an empty space on the MAR. The system is set up to make you document. V2 stated that if it's not documented it's not given. V2 stated that R2 medication is out currently, and they are trying to get it. V2 stated that R2 takes a lot of medication for pain and needs her medication. V2 stated that she likes to stay in her room, but she is different and lays in the bed more. V2 stated that due to R2's pain and the amount of pain medication she takes to manage it when the medication is not administered her pain is horrible and she has withdrawals depending on the length of time she is without. V2 stated r1 and R2 did not received their medication as ordered and did not receive medication from emergency kit or pixis. On 5/12/2025 at approximately 3:30 PM R2 stated that the pain scale did not cover her pain, the pain is excruciating and continuous. R2 stated that she went to the emergency room for pain relief. R2 stated that she stays in bed due to the pain, it hurts to breathe. R2 stated that due to her diagnosis of spinal muscular atrophy her muscles in her head and face are continuously being pulled downward. The pain is already horrible but without the pain medication it is horrid. R2 stated that she smokes cigarettes but not as much. R2 stated that smoking cigarettes helps with her anxiety which is elevated due to pain, and she doesn't go out to smoke as much because of it. R2 stated that she feels forgotten and the pain gets so bad she wants to die. R2 stated that this is not the first time. R2 stated that she has experienced withdrawal symptoms as well. R2 stated that she is always nauseated and has anxiety but it is more its extreme and she can't stand it. On 5/14/2025 at 2:16 PM, V17, Pharmacist, stated that the pharmacy took over April 1st. V17 stated that R2's Xtampza is a medication that is not in the pyxis and not available in the facility. V17 stated that 2 doses were sent on 5/6/2025 and then 5/9/2025 a 2 week dosage was sent. V17 stated as soon as they received the request and script the medication was sent out. V17 stated that the were notified of refill needed for R2's Morphine on 5/8/2025. V17 stated that the script was written by a physician that was not Medicaid eligible. V17 stated that the facility was notified about this. V17 stated that they were awaiting a script from another physician. V17 stated that at this time the medication has not been filled. V17 stated that the medications are scheduled medications and would be a significant medication error. V17 stated that R2's medication was not taken from Pixis. On 5/14/2025 at 2:45 PM V1, Administrator, stated that she was made aware by the pharmacy that there was an issue with script from V20. V1 stated that V19 was notified and requested a script from him for the medication. V1 stated that the medication is now being filled at a local pharmacy and awaiting call from pharmacy for pick up. On 5/14/2025 at 3:47 PM, V16, CNA, stated that R2 is having pain. Appetite has decreased. V16 stated that R2 usually sits up in her chair and has not been doing that as much. On 5/13/2025 at 4:00 PM V18, LPN, stated that she gave R2 the last dose. V18 stated that she ordered the morphine at that time. V18 stated that she has been off and today was her first day back. On 5/15/2025 at 9:40 AM V20, Nurse Practitioner, stated that she was aware that the facility recently went through and change and new pharmacy. V20 stated that there were some problems with getting medication when that transition occurred. V20 stated that she was made aware when a resident is getting low on the medication, and she will get the medication. V20 stated that R1 and R2 not receiving their schedule meds this is a significant medication error. V20 stated that obviously R1 and R2 would experience some discomfort related to not receiving the pain medication. V20 stated that it's obvious if they don't get the medication. V20 stated that she would expect the patients to get there medications as prescribed. V20 stated that she would expect the staff to address the pain with alternate interventions. V20 stated that she has ordered pain management in the past. On 5/15/2025 at 10:43 AM, V15, Medical Director, stated that he is usually notified of need for refills. V15 stated that he expects medication to be administered as prescribed. V15 stated that it is unfortunate that the medications were not available and administered to the patient as ordered. As of 5/15/2025 at 4:00 PM observed R2 outside leaning against wall crying. R2 stated that she is in so much pain that she didn't want to live like this and wanted to die. R2 stated that it hurts to sit and hurts to stand. R2 stated that it was miserable. R2 stated that her pain medication has not been delivered and she has not received her medication. The Administering Medication policy dated October 15, 2023, documents 3. Medications shall be administered according to physician written/verbal orders upon verification the right medication, dose, route, time and positive verification of resident identity when no contraindications are identified, and the medication is labeled according to accepted standards. 8. The individual administering the medication shall sign of the electronic Medication Administration Record date for the specific day before administering the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to have fall interventions in place and implement progressive interventions in 3 of 7 residents (R6, R19, R36), reviewed for falls in the sample of 24. This failure resulted in R36 sustaining a head injury, requiring emergency room evaluation and treatment including but not limited to glue and adhesive skin closure strips to the right temple area. Findings include: 1. On 9/17/24 at 9:05 AM, R36 was observed in her room in a low bed with a mat to left side of the bed, the call light was behind the bed, not within reach. R36 had bruising noted to the bilateral eyebrow areas with adhesive closure strips in place to the right eyebrow area. R36 stated she fell recently and that is how she got the bruising. R36 stated she has fallen 3-4 times and has gotten hurt each time. R36 stated she tries to get up on her own and falls, unsure of why she falls, she just does. R36 stated she uses her call button when she needs help and stated it's usually clipped here (reaching on the right side of the bed), but it's not here. Surveyor moved the call light within resident's reach and she pushed it. Staff came into the room to see what R36 needed and R36 stated she was just checking to make sure it worked. R36 stated she had a headache and would like something for it. R36's Face Sheet, undated, documents R36 has a diagnosis of Dementia, Tremors and Hypertension. R36's MDS (Minimum Data Set), dated 7/16/24, documents R36 has a BIMS (Brief Interview for Mental Status) score of 10, indicating R36 has moderate cognitive impairment, requires partial/moderate assist with toileting, requires substantial/maximal assist with sitting to standing, requires substantial assist with transfers and has a history of falls. R36's Care Plan, dated 5/23/24, documents R36 has actual/potential risks for falls with the following interventions: 5/23/24 be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; 8/24/24 continue to educate resident that she needs to be patient and wait for staff to be available to assist; 8/28/24 continue to educate resident to wait for staff to assist her and she will need to ask for assistance; 9/12/24 sent to the emergency room for evaluation and treatment, received 2 adhesive skin closure strips and glue to the right temple and then was sent back to the facility; 9/14/24 continue to educate resident on waiting for staff for transfer needs and encourage her as much as she will allow to stay in high traffic areas. The Care Plan goes on to document R36 has an ADL (Activities of Daily Living) self-care performance deficit with an intervention to encourage her to use the call light and she requires 1-2 staff to assist in all transfers using a mechanical lift. The care plan fails to identify progressive interventions to prevent falls but utilizing the same intervention for multiple falls. R36's Progress Note, dated 7/11/24 at 9:40 AM, documents the following: Writer called into residents room by CNA. Resident was attempting to transfer herself into bed unassisted, she stood up and slid down the front of her chair onto the fall mat on the floor. Skin assessment completed, no injury or wounds noted. Resident denies any pain or discomfort. Resident assisted up into bed and is now resting quietly in bed with HOB elevated and call light in reach. Fall mat in position and bed in low position, will continue to monitor. R36's Progress Note, dated 8/24/24 at 12:16 AM, documents the following: Resident roommate summoned this nurse to resident room. Upon entering room resident was found in a sitting position on floor near bed. No internal/external rotation noted. Fall unwitnessed neuro checks initiated at this time. Assisted off floor with the help of two and placed into bed. Resident able to [NAME] WNL. Denies pain or discomfort. R36's Progress Note, dated 8/29/24 at 9:56 AM, documents the following: Resident noted to be sitting on the floor in the hallway, in front of wheelchair. Resident noted with a 2 cm (centimeter) hematoma to the left side of the forehead. Resident stated I leaned forward to pick something up and fell out of w/c. R36's Progress Note, dated 9/12/24 at 4:35 PM, documents the following: Resident found on floor in room after this nurse was notified by resident's roommate. BP: 116/66, P: 76 Temp: 98.4, O2: 96, res complaining of head pain, 3 cm laceration noted to right temple, ecchymosis noted to left temple, no other injuries noted. MD and POA notified. EMS (Emergency Medical Services) transported resident to the hospital. report given to ER (Emergency Room) charge nurse. R36's Progress Note, dated 9/12/24 at 9:46 PM, documents the following: Resident returned to facility from the hospital via EMS. Resident was transferred into bed via 2 EMS attendants. 2 Steri-strips and Dermabond was applied to resident's right eyebrow in hospital. Resident had no complaints of pain or discomfort. R36's Progress Note, dated 9/14/24 at 9:30 AM, documents the following: This nurse was alerted to resident being on the floor by resident's roommate. I went into room, found resident laying on the floor next to bed, resident was assessed for injuries, no injuries were found, resident's neuro-check was normal & vitals were stable. Once assessment was completed, resident was transferred from the floor to the bed. Resident states she was trying to transfer self from wheelchair to bed & fell, denies any pain or discomfort at this time, will continue to monitor for changes. POA, MD & DON notified. R36's Hospital After Visit Summary, dated 9/12/24, documents a diagnosis of Fall and Laceration to the Right Eyebrow. 2. R19 Fall Risk Data Collection Form dated 8/24/24 documents R19 is high risk for falls. R19 Minimum Data Set, dated [DATE] documents for rolling right to left R19 is dependent and going from chair to bed R19 is dependent. R19's Care Plan dated 8/5/24 documents (R19) is at risk for falls 7/30/24 fall with no injury and 8/9/24 fall with no injury. The resident will be free of minor injury through review date. The resident (R19) will be free of minor injury through review date. Interventions: The resident (R19) will be free of minor injury through review date. Hospice nurse to review medications resident has a floor mat next to bed while in bed. Bed in lowest position. Resident is in a broda chair R19's Fall Investigation dated 12/2/23 documents resident fell out of wheelchair to floor and hit head. R19's Fall Investigation dated 1/17/24 documents notified by CNA (Certified Nursing Assistant) that the resident (R19) had fell. Upon entry to the room resident (R19) noted sitting on the floor next to her bed. Sitting on floor on bottom with legs extended forward resident moving all extremities CNA stated resident (R19) fell backward onto floor. R19's Fall Investigation dated 2/8/24documents resident (R19) found on the floor lying on her left side near the bed. The fall (was) unwitnessed, (and) neuro checks started at this time. The resident (R19) assisted off the floor. R19's Fall Investigation dated 2/25/24 documents resident (R19) found on the floor near her bed, in her room there was a small goose egg area near the top of her scalp. small amount of blood from a small skin tear. Pressure applied, dry dressing applied, seemed a bit restless PRN tramadol and Ativan was given. R19's Fall Investigation dated 3/6/24 documents resident (R19) found on floor by her bed. R19's Fall Investigation dated 6/6/24 found resident (R19) sitting on her buttocks in the doorway resident unable to explain what happen. R19's Fall investigation dated 6/20/24 resident (R19) noted by staff sliding out of bed onto the floor mat. med review completed floor mat. R19's Fall investigation dated 7/30/24 resident (R19) taken to room to see if resident needed to be changed. Resident note to be screaming louder resident was noted actively sliding out of bed. R19's Fall investigation dated 8/3/24 resident (R19) found lying on her left side in the dining room. R19's untitled Fall Intervention form dated 1/17/24 documents the fall intervention is med review completed continue with med A. R19's untitled Fall Intervention form dated 2/1/24 documents continue with skilled therapy services for safety transfers. R19's untitled Fall intervention Form dated 2/8/24 documents care plan meeting held 2/7/24 via phone with POA (power of attorney) discussed hospice for next level of care. R19's untitled Fall Intervention form dated 3/6/24 documents contacted hospice nurse to perform a med (medication review). R19's untitled Fall intervention form dated 6/6/24 documents hospice nurse updated and came out for a visit will review medications. R19's untitled Fall intervention form dated 6/20/24 documents floor mat. The untitled Fall Intervention form dated 7/30/24 documents hospice nurse to review medications due to increased anxiety. R19'sUntitled Fall Intervention form dated 8/5/24 documents spoke with hospice nurse to review different medication for anxiety regimen. R19's POS (Physician Order sheet) Dated 8/5/24 documents Alprazolam 1mg every four hours when ever needed for anxiety. R19's untitled Fall Intervention form dated 8/24/24 documents resident is in a Broda chair. 0n 9/18/24 at 4:20 PM V3 Minimum Data Set (MDS) coordinator stated, she has had a lot of falls, and we have to reuse some of the interventions. We resolve them and use them again. 3. R6's Face Sheet documents R6 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, muscle weakness, unsteadiness on feet, and need for assistance with personal care. R6's Minimum Data Set (MDS) dated [DATE] documented R6 was severely cognitively impaired, independent with bed mobility and transfer, and used wheelchair. R6's Care Plan initiated 8/3/19 documents R6 is at risk for falls related to history of falls, need for assistance with activities of daily living, incontinence of bowel and bladder, and diagnosis of dementia with poor safety awareness. R6's Care Plan Intervention initiated 8/3/19 documents R6 will have anti-tippers to wheelchair at all times. On 9/18/24 at 11:30 AM, R6 was sitting in her wheelchair in the dining room with other residents. There were no anti-tippers on the wheelchair. On 9/19/24 at 12:40 PM, R6 was sitting in her wheelchair in the dining room feeding herself lunch. There were no anti-tippers on the wheelchair. R6's Fall Risk assessment dated [DATE] documented R6 was at risk for falls. R6's Unwitnessed Fall Report dated 5/10/24 documents, CNA came to the nurse saying res (resident) had blood all over her & was all over the floor beside the bed. Upon entering room, this nurse noted res's (resident's) face to be covered with dried blood and blood droplets were noted on the floor beside the res's WC (wheelchair). As CNA was wiping the dried blood off the res, a 2cm (centimeter) x 1cm hematoma with a 1cm gash in the middle was noted over the res's L (left) eyebrow. Resident Unable to give Description. R6's After Visit Summary from (Local) emergency room documents R6 was seen for a fall with the diagnoses forehead cut, head injury, and laceration repair with glue. R6's Care Plan Intervention updated 5/10/24 documented, Resident educated to ensure w/c (wheelchair) brakes are locked. (R6's 4/11/24 MDS documented R6 was severely cognitively impaired.) R6's Unwitnessed Fall Report dated 6/3/24 documents resident was found on the floor in her room sitting on bedside mat, and R6 was unable to explain what she was trying to do. R6's Care Plan Intervention updated 6/3/24 documents, (R6) will continue to work with Med B therapy services on strengthening. No new interventions were added following R6's 6/3/24 fall. R6's Unwitnessed Fall Report dated 6/13/24 documents Resident Unable to give Description. There was no Nursing Description, and there were no details of the fall or potential causative factors. R6's 6/13/24 Care Plan Intervention documents, Continue with therapy services. No new interventions were added following R6's 6/13/24 fall. On 9/18/24 at 1:12 PM, V17, Certified Nursing Assistant (CNA), stated most of R6's falls happened because she would forget to put on her wheelchair brakes when she was self-transferring. On 9/18/24 at 2:40 PM, V19, CNA, stated R6 does not let staff know when she needs to transfer, so they often do not know she needs help until she is already done. On 9/18/24 at 3:17 PM, V26, Occupational Therapist (OT), stated R6 has a tendency to do things herself and is unlikely to ask for help due to cognitive deficits, so they requested increased supervision by staff. On 9/19/24 at 12:10 PM, V16, Licensed Practical Nurse (LPN)/Wound Nurse, stated R6 forgets her limitations and can take herself to the bathroom, but sometimes she rushes, and that is the problem. She stated interventions have been put in place, but there have been no changes in her level of supervision. She was unsure if R6 ever had anti-tippers on her wheelchair. On 9/20/24 at 9:18 AM, V21, CNA, stated she does not think R6 has ever had anti-tippers on her wheelchair. On 9/19/24 at 1:44 PM, V1, Administrator, stated she will have to check into R6's anti-tippers. She stated she expects progressive interventions to be implemented after each fall and followed. The Facility's Fall Policy reviewed 9/2024 documents, The purpose of the Fall Management Program is to develop, implement, monitor and evaluate an interdisciplinary team falls prevention approach and manage strategies and interventions that foster resident independence and quality of life. The Fall Management Program promotes safety, prevention and education of both Staff and residents. The Facility shall ensure that a Fall Management Program will be maintained to reduce the incidence of falls and risk of injury to the resident and promote independence and safety. Following any falls, the facility staff completes an Occurrence Report. Details of the fall will be recorded and potential causal factors identified and investigated. Interventions will be implemented and Care Plan Updated. The Falls and Fall Risk, Managing Policy, dated 12/2007, documents the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents are free from significant medication errors for 1 of 3 residents (R3) reviewed for significant medication errors in the sample of 8. This failure resulted in R3 not receiving seizure medications, having seizures, and being admitted to the hospital. Finding includes: 1.R3's Physician's Order (PO) dated 01/05/23 documents Epilepsy, unspecified, not intractable, without status epilepticus. R3's PO dated 03/23/23 documents Unspecified convulsions. R3's February 2023 Medication Administration Record (MAR) documents that R3 is to receive Levetiracetam (Keppra) Oral Tablet, 750 milligrams (Mg) 1 tablet by mouth every morning and at bedtime for seizures for 30 days. The MAR documents R3 should receive Phenytoin Sodium Extended Oral Capsule, give 200 mg by mouth every morning and at bedtime for seizures for 30 days. The MAR does not document R3 was given Phenytoin for the 8:00 PM dose on 02/27/23 and not document that Phenytoin was given the 8:00 AM or the 8:00 PM dose on 02/28/23. The MAR does not document that Keppra was given the 8:00 PM dose on 02/27/23. Does not document that Keppra was given the 8:00 AM or the 8:00 PM dose on 02/28/23. R3's March 2023 MAR does not document that Phenytoin was given the 8:00 AM or the 12:00 PM or the 4:00 PM doses on 03/01/23, 03/02/23, 03/03/23, 03/04/23, 03/05/23, 03/06/23, 03/07/23, 03/08/23, 03/09/23, 03/10/23, 03/11/23, 03/12/23, 03/13/23, 03/14/23, 03/15/23, 03/16/23, 03/17/23, 03/18/23, 03/19/23, 03/20/23, 03/21/23, 03/22/23, 03/23/23, 03/24/23, 03/25/23, 04 03/26/23. R3's MAR dated March 2023 does not document that Levetiracetam was given the 8:00 AM or the 4:00 PM dose on 03/01/23, 03/02/23, 03/03/23, 03/04/23, 03/05/23, 03/06/23, 03/07/23, 03/08/23, 03/09/23, 03/10/23, 03/11/23. 03/12/23, 03/13/23, 03/14/23, 03/15/23, 03/16/23, 03/17/23, 03/18/23, 03/19/23, 03/20/23, 03/21/23, 03//22/23, 03/23/23, 03/24/23, 03/25/23, or 03/26/23. R3's PO, dated 3/24/23 documents Phenytoin Sodium Extended Capsule 100 MG (milligrams); Give 2 capsule by mouth three times a day related to epilepsy, unspecified, not intractable, without status epilepticus. R3's PO dated 03/24/23 documents levetiracetam Oral Tablet 750 MG (Levetiracetam); Give 1 tablet by mouth two times a day related to epilepsy, unspecified, not intractable, without status epilepticus. R3's Health Status Note dated 03/21/23 at 6:44 PM documents Resident sitting in dining room around 1800 when she got stiff and rigid. She began to twitch and began to seize. Resident continued to seize for the length of one full minute. She then began heavy breathing coming out of seizing for roughly 4-5 seconds then began to twitch and seize again This time she seized for 2 minutes and 38 seconds. With only a few seconds between resident began to seize again. EMS (Emergency Medical System) arrived. EMS administered medication to attempt to stop seizure. Resident continued to seize as EMS transfer out of building. Sent to (local hospital) hospital (local city) per POA (Power of Attorney,V18). R3's Health Status Note dated 03/21/23 at 10:30 PM documents Spoke with (Nurse) at (local hospital) resident admitted with the DX (diagnosis) of seizures. Meds secured in lock box and items secured in room. R3's Care Plan dated 01/10/23 documents The resident has Seizure Disorder. Intervention dated 01/05/23 - Give medications as ordered. Monitor/Document for effectiveness and side effects. R3's Minimum Data Set (MDS), dated [DATE] documents a BIMS (Brief Interview of Mental Status) score of 11 out of 15. The MDS documents R3 is moderately impaired, requires limited assistance of one-person for bed mobility, requires extensive assistance of one-person for transfer, dressing, toilet use, and personal hygiene, and is independent with setup help only locomotion on unit, locomotion off unit, and eating. The MDS documents R3 is not steady, only able to stabilize with staff assistance. R3's Initial Investigation undated documents At approximately 6:30 PM (R3) was noted to have seizure activity, followed by another seizure. Call placed to 911. EMS arrived and administered medications and seizure activity continued. Resident was transported to (local hospital) for further evaluation and was admitted for seizures. It was noted that residents' seizure medication was only ordered for 30 days when discharged from hospital on 1/5/2023. Investigation initiated to review for medication error. Final summary to follow. R3's Final Investigation R3's Final Summary undated documents (R3), [AGE] year-old female admitted on [DATE] with the diagnosis of cerebral palsy, epilepsy, HTN, and cognitive communication deficit with a BIMS score of 12, who is assist of one with a walker had a seizure on 3/21/23 resulting in hospitalization. At approximately 6:30 pm (R3) was noted to have seizure activity, followed by another seizure. Call placed to 911. EMS arrived and administered medications and seizure activity continued. Resident was transported to (local hospital for further evaluation and was admitted for seizures. It was noted that residents' seizure medication was only ordered for 30 days when discharged from hospital on 1/5/2023. Investigation initiated to review for medication error. Upon investigation it was noted that on admission 1/5/23 she was admitted with orders for her Keppra and Dilantin (seizure medications) x 30 days. On 1/10/23 she went to her neurologist who sent orders for her Dilantin and Keppra but had stop date of 2/27/23. On 2/23/23 (V16) LPN (Licensed Practical Nurse) sent a request via fax to continue Keppra to (V15) NP (Nurse Practitioner). (V15's) office stated that responded via fax to continue Keppra orders. That order was not received at the facility and therefore was not processed. A meeting was held on 3/23/23 with (V15) NP to discuss options to ensure orders are being received. An email was sent to the office manager for (V10), Physician and (V15). It was agreed that the office would also send orders via email to administrator to be able to verify orders have been received and processed. (V3) returned to the facility on 3/23/23. Prior to her return I (V1) spoke with the case manager requesting that they do not send only 30-day order for her seizure medications. Upon arrival orders were confirmed to be correct with no stop date. Follow up labs for Keppra and Dilantin levels schedule. Resident seen by (V10) on 3/29/23. Neuro appointment scheduled for 7/12/23. On 04/12/23 at 11:03 AM, V10, Physician stated that (R3) missing 2 weeks of seizure medication was significant and probably caused her seizures and hospitalization. On 04/13/23 at 8:04 AM, V1, Administrator stated that (R3) first came to the facility with an order from the hospital for her seizure medication for 30 days. She saw her neurologist a short time later and he increased one of medications and put a stop date on them. The order fell off after the stop date. A nurse sent an order to the NP (V15) to continue the medication. (V15's) office sent a fax to continue the medication but we never received it. We have a backup system in place now. They fax everything and email it to me. I double check all the orders to make sure we got them. On 04/13/23 at 9:31 AM, V16, Licensed Practical Nurse, LPN, stated that she received a call the pharmacy stating that R3's Dilantin was only for 30 days and that it was expiring. She stated that she contacted V15's office to let them know that R3's Dilantin need to be continued. She said she never received anything back from the doctors during her shift. On 04/13/23 at 11:04 AM, V2, Director of Nursing, DON, stated that she would expect medications to be given as ordered and mark off in the MAR. Facility's policy Physician's Orders revised 04/2021 documents A. All medications, including non-legend medications (cathartics, headache remedies, vitamins, etc.) shall be given only upon the written order of the physician. All such orders shall have handwritten or electronic signature of the physician. These shall be given as prescribed by the physician and at the designated time. B. When necessary, telephone orders may be taken by a Registered Nurse or Licensed Practical Nurse. All such orders shall be immediately written on the Physician Order Sheet or Electronic Medical Record (EMR) and a Telephone Order Form and signed by the physician within 10 working days. Facility's policy Administration of Medication revised 04/2021 documents B. Immediately after a drug is ingested, it should be recorded in the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a safe environment and safe interventions during transfers to prevent falls for 1 of 3 residents (R3) reviewed for falls in the sample of 6. This failure resulted in R3 falling and fracturing his right hip, requiring hospitalization and surgery. Findings include: The facility's Initial Report of Accident with Injury to IDPH (Illinois Department of Public Health) dated 10/29/22 documents, On 10/29/22 at 12:57 PM (R3), age [AGE], sustained a fall during a transfer in his bathroom. Resident complained of right hip pain during assessment by the nurse. MD (Medical Doctor) notified of fall and order received to obtain x-ray of right hip. POA (Power of Attorney) updated on fall and new order for x-ray. X-ray results show acute intertrochanteric hip fracture. MD notified at 5:00 PM of results and new order received to transfer to (local hospital) emergency room for evaluation and treatment. POA notified of results and new order to transfer resident. Administrator notified of fracture at 5:10 PM by (V12) Licensed Practical Nurse (LPN). Initial report. Final to follow. The facility's fall investigation dated 10/29/22 includes the following documentation: V11's, Certified Nursing Assistant (CNA), handwritten statement dated 10/29/22, included in R3's fall investigation provided by V1, Administrator, documents, I was assisting (R3) to the toilet; he grabbed the bars as usual (both hands). I asked did he have his balance, he answered yes. I went to make sure the chair was locked because in order for him to back up close enough to the toilet, he has to hold the bar and transfer one hand to his wheelchair because the bar isn't long enough. As I was quickly checking the chair, he then let one hand go too soon and fell to the left side. The nurse was notified immediately. The facility's document, Investigative Guideline Fall documents the root cause of R3's fall on 10/29/22 as, Resident let go of bar during transfer. No gait belt on resident. R3's Physical Therapy note dated 10/28/22 documents, PTA (physical therapy assistant) providing CNA with Inservice training on transfers with patient. PTA educates CNA on use of gait belt, allowing patient increased time, and vc (voice commands) in left ear for greater stability. The facility's document, Statement of Education for Employees dated 10/31/22 at 11:30 PM documents, Inservice training presented by V1, Administrator to V11, CNA: The following areas of instruction were covered: (R3) transfer status, policy and procedure for transfers, and following interventions. R3's hospital records document x-ray results dated 10/30/22 at 12:58 AM as, Impression: 1. Compression deformity of L2 (lumbar 2) vertebral body with a 50% height loss in the midportion is new from 3/8/22 exam. The hospital records document, under Assessment and Plan, Right intertrochanteric hip fracture. R3's hospital records also document the results of x-ray of right hip dated 10/29/22 as: Comminuted, predominantly oblique intertrochanteric fracture of right proximal femur that is essentially non-displaced. The hospital records further document, Reason for admission: Hip Fracture. History of Present illness (R3) is an [AGE] year-old male with past medical history significant for Atrial-fibrillation, hypertension, presents to ER following a ground level fall. Patient states he was in the bathroom and fell to his right hip. He had immediate pain and could not get up. He denied any head injury or loss of consciousness. X-rays showed right hip fracture. Orthopedics notified. He will need an intertrochanteric nailing of the right hip performed. His surgery will be scheduled for late Tuesday afternoon/evening. R3's Face Sheet documents his diagnoses include Nondisplaced Intertrochanteric Fracture of Right Femur, Aftercare Following Joint Replacement, Primary Osteoarthritis of Right and Left Hips, Muscle Weakness, Repeated Falls, and Heart Failure. R3's Minimum Data Set (MDS) dated [DATE], prior to his fall with a right hip fracture on 10/29/22, documents he was severely cognitively impaired and requires extensive assist of one staff for bed mobility and extensive assist of two staff for transfers and toileting. It documented he is always incontinent of bowel and bladder. R3's MDS dated [DATE], after his fractured hip, documents he is severely impaired cognitively, he requires extensive assist with bed mobility, and he is dependent on two staff for transfers and toileting. R3's Care Plan documents: The resident is at risk for falls: Gait/balance problems: 9/26/22 resident lost balance during transfer and fell. resident had on crocs with no back. 10/29/22: witnessed fall while being transferred off toilet. Resident let go of rail and fell resulting in fracture. 1/1/23: resident rolled out of bed resulting in subdural hematoma Interventions for this care plan include: 1/1/23: bolsters to be added to bed when resident returns 10/29/22: Resident sent to ER for tx (treatment). Staff education. Therapy to eval and tx (treat) as ordered was resident returns from hospital. 9/26/22 ensure resident has on appropriate footwear for transfers Area around the recliner/lift chair will be free from clutter/hazards Assistive devices will be within reach of resident while they are in the recliner/lift chair Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed Do not leave resident in bathroom unattended Provide Reacher/Grabber device On 1/3/23 at 2:50 PM V11 went to R3's bathroom to demonstrate how he fell and fractured his hip on 10/29/22. V11 stated R3 was holding onto the grab bar in front of the toilet, and she went to move his wheelchair (w/c) out of the way so he could sit down on the toilet, and during those few seconds she was moving his w/c, he lost his balance and fell against the door to his neighbor's room, falling through the door, breaking the door frame and falling onto the floor in that room. When asked why she did not use a gait belt while transferring R3 onto the toilet, V11 stated, That was totally on me. I was just moving too fast. V11 stated before he broke his hip on 10/29/22, (R3) was a fairly easy transfer of one assist with a gait belt. On 1/4/23 at 10:25 AM V1, Administrator, stated she would expect staff to use a gait belt when transferring any resident who requires assist of one or two staff to transfer. V1 stated she is not sure how much assist R3 was requiring at the time of his fall on 10/29/22 when he fractured his hip because therapy was frequently changing his transfer status but did not communicate the changes to nursing. V1 stated now, if therapy changes the transfer status of a resident, they provide nursing with a document that states how that resident transfers and how many staff is required to assist that resident. V1 stated staff should use a gait belt any time a resident requires physical assist w/transfer The facility's undated policy, Safe Lifting and Movement of Residents, documents 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 3.Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, slide boards) and mechanical lifting devices. The facility's policy, Fall Policy revised 9/17/19 documents, Purpose: The purpose of the Fall Management Program is to develop, implement, monitor and evaluate an interdisciplinary team falls approach and manage strategies and interventions that foster resident independence and quality of life. The Fall Management Program promotes safety, prevention and education of both staff and residents. Policy: The facility shall ensure that a Fall Management Program will be maintained to reduce the incidence of falls and risk of injury to the residents and promote independence and safety.

Based on observation, interview and record review the facility failed to timely assess and unknown cause of pain delaying treatment for one of 5 residents (R41) reviewed for quality of care in the sample of 26. This failure resulted in R41 expressing pain on 12/27/21 in left groin and the facility not seeking medical treatment until 1/3/2, eight days later. R41 sustained a left femoral hip fracture. Findings include: R41's Physical Therapy (PT) Treatment Note, dated 12/27/2021 documents R41 ambulated 20 feet with a wheeled walker. No complaint of pain documented. R41's PT Treatment Note, dated 12/28/2021, documents R41 ambulated 50 feet. No complaint of pain was documented. R41's PT Treatment Note, dated 12/29/2021, documents during therapy the resident stated, My L (left) groin hurts. PTA (physical therapy assistant) asked what happened with R41 stating, It happened this morning. The Treatment Note documented PTA attempted to have R41 stand with walker and pull up from parallel bar for standing act this day. The Note documented R41 was unable to reach standing and R41 complained of left groin pain. There was no documentation in the PT note that R41 ambulated that day. The Note documented PTA consults nursing (V13, Registered Nurse/RN) regarding R41's pain in left groin and inability to utilize full Active Range of Motion or come to full standing. The Note documented nursing states will keep an eye on resident throughout the day to monitor. On 8/24/2022 at 10:45 AM V13 stated she doesn't recall a PTA reporting R41 had pain in her left groin on 12/29/2021. V13 stated when a resident has a change in condition, she assesses the resident and administers a PRN (when needed) pain medication, documents the assessment in the resident's medical record and notifies the resident's physician and POA (power of attorney). R41's PT Treatment Note, dated 12/30/2021, documents R41 attempted to stand this day however unable to rise fully from wheelchair with R41 stating pain in left groin as cause. There was no documentation in R41's PT Note that R41 ambulated this day. R41's PT Treatment Note, dated 12/31/2021, documents R41 stated pain in left groin as cause. There was no documentation R41 ambulated this day. R41's PT Treatment Note, dated 1/3/2022, documents R41 complained of pain/tightness in left lower extremity knee to groin. The Note documented PTA alerts nursing to R41's pain complaint. The Note documented nursing staff states she will call the nurse practitioner and request an X-ray to resident's left leg. R41's Medical Record dated 12/2021 and 1/2022 has no nursing progress notes including an assessment as to why R41 was complaining of left groin pain. R41's Physician's Order Sheet (POS), dated 1/3/2022 at 5:00 PM, documents a STAT (to be completed immediately) L (left) hip X-ray 2 views and STAT left femur X-ray 2 views. R41's Patient X-Ray Report, dated 1/3/2022 and electronically signed at 12:36 AM, findings: a left radiologic examination, femur. Impressions: femoral neck fracture. R41's Health Status Note, dated 1/4/2022 at 1:00 AM documented that R41's X-ray results documented a femoral neck fracture. The Note documented a call was placed to the POA to notify of x-ray results and need to transfer to hospital. The Note documented 911 was called at that time. R41's Situation, Background, Assessment and Recommendation (SBAR) Communication Form and Progress Note, dated 1/4/2022, documents fx. (fracture) left femur started on 1/3/2022. The Note documented Functional status changes: fall. Transfer to the hospital. On 8/24/2022 at 10:24 AM V1, the Administrator stated she expected staff to communicate when residents have a change in condition and the nurse should assess the resident immediately and document the assessment in the nurse's notes. V1 stated she expected staff to follow facility policies. On 8/23/2022 at 4:46 PM V26, R41's Physician, stated when R41 complained of pain to therapy staff, He expected therapy staff to report the new complaint of pain to the nurse and expected the nurse assess R41 and administer pain medication if available on R41's POS then notify him or the nurse practitioner of the change in condition. V26 stated the nurse should have documented the assessment in R41's progress notes. He expected staff to reassess R41 at least every shift and document the assessment in R41's progress notes. V26 stated he expected staff to follow physician's orders and facility policies. The facility's undated Significant Condition Change & Notification Policy, documents to ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as a significant change in the resident's physical status including abnormal, unusual or new complaints of pain. The Policy documents All significant changes will be recorded on the Communication Board in the electronic medical record and in the resident record. Charting will include an assessment of the resident's current status as it relates to the change in condition. Charting will be done each shift for 72 hours for residents with change of condition. Change of condition is reviewed by the DON (Director of Nurses) or designee for the continued need for additional documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to monitor, assess, and provide progressive interventions to prevent falls for 4 of 5 residents (R9, R30, R41, R146) reviewed for accidents in a sample of 26. This failure resulted in R41 falling and fracturing her left hip, dislocating her left hip, having an oblique fracture of the distal femur superior to the prosthesis with displacement, angulation and axial shortening and a comminuted fracture of her kneecap which required surgical interventions at the hospital. Findings include: 1. R41's Care Plan documents Resident is at risk for falls due to history of falls. She has a diagnosis of Parkinson's with tremors and neuropathy. The Care Plan Goal documents Resident will remain free from injuries d/t (due to) falls through the next review. R41's Fall Care Plan Interventions documented 12/15/2021: ensure resident's feet are off the floor prior to pushing wheelchair or provide foot pedals if unable to keep feet off the floor. Keep resident by nurse's station or in viewing distance when in wheelchair for safety. R41's Care Plan Intervention added on 2/11/202 documents staff educated to ensure resident water pitcher within reach at all times. R41's Care Plan Intervention added on 3/18/2022 documents Check resident to be checked often for positioning, incontinence, with all need. Bring to nurse's station for closer observation. R41's Fall Risk Data Collection, effective date 10/6/2021 documents she had a fall within the last 90 days. The Form documented Resident is orientated to person. The Form documents Gait observation: resident unable to independently come to a standing position and requires hands-on assistance to move from place to place and decrease in muscle coordination. Staff documented she was high risk for falls. R41's Quarterly Minimum Data Set (MDS), dated [DATE] documents R41 is severely cognitively impaired. The MDS documents R41 is not steady, only able to stabilize with staff assistance for surface-to-surface transfers. The MDS documents R41 requires transfers and bed mobility extensive assist 2+ person physical assist. The MDS documents R41's balance during transitions and walking: not steady, only able to stabilize with staff assistance. The MDS documents R41 has had no falls and uses a wheelchair. R41's Health Status Note, dated 10/25/2021 at 4:31 AM documents This nurse was called into room by CNA (certified nurse assistant), noted res (resident) on the floor mat beside bed. Res. was assessed for any displaced hip or injury with none noted. Res. was then helped into chair with assist x 2. Neuro checks started r/t (related to) non witnessed fall. NP (nurse practitioner) notified. POA (power of attorney) to be notified in AM. R41's Fall Incident Report, dated 10/25/2021 at 4:26 AM documents Res was called to room by CNA. Res was on the floor beside her bed in sitting position on top of mat. Res was alert and wheelchair bound. Resident was assessed for any displaced hip or injury with none noted. Res was then helped into her chair with assist x2. Resident orientated to person and place. Neuro (neurological) checks stated r/t non witnessed fall. Nurse Practitioner notified in AM. No predisposing environmental factors were documented. Predisposing phycological factors: incontinent, confused and gait imbalance. Predisposing situation factors: staff checked none. No additional information was documented. R41's Physician's Order Sheet (POS), dated 12/2021, documents diagnoses: chronic kidney disease, depression, peripheral neuropathy, hyperlipidemia, insomnia, low back pain, osteoarthritis, osteopenia, Parkinson's Disease, repeated falls, unsteadiness on feet and anxiety. R41's Health Status Note, dated at 12/13/2021 at 5:46 PM documents Res (resident) was attempting to stand up in common area. This nurse helped res. back into chair and was attempting to help res. propel down the hall to sit with nurse during med pass to monitor her. When pushing chair to hall res. foot got stuck under chair and res. slid from w/c (wheelchair) onto her knees. Skin tears noted to her right loser outer leg. Two 1.5 cm (centimeter) skin tears, areas cleaned, and dry dressing applied. R41's Fall Incident Report, dated at 12/13/2022 at 5:38 PM documents Res was attempting to stand up in common area. This nurse helped res back into chair was attempting to help res propel down the hall to sit with nurse during med pass to monitor her. When pushing chair to hall res foot got stuck under chair and res slid down w/c (wheelchair) onto her knees. Res stated, I fell. Resident alert and ambulatory with assistance. Orientated to person. Predisposing environmental factors: noise. Predisposing physiological factors: gait imbalance and impaired memory. Predisposing situation factors: using wheelchair. No additional information was documented. VS (vital signs) taken, and res assessed for any injuries. Noted two 1.5 cm skin tears to right lower outer leg. POA and MD (physician) notified. Area cleaned and dry dressing applied. R41's Fall Risk Data Collection, effective date 12/21/2021 documents R41 had a witnessed fall on 12/13/2021. The Data Collection documented 'The resident is orientated to person, she is incontinent. Gait observation: unable to independently come to a standing position. Staff documented she was a low risk for falls. R41's Health Status Note, dated 1/4/2022 at 2:36 PM documents a late entry note: 1/3/22 2:30 PM CNA reported that resident was c/o about pain regarding her left leg and left hip. Then therapy came to me and stated that she was standing and walking and now can't do that. Asked resident if she was in pain and she states yes on a scale of 1-10 she states the pain is a 10. Was put back in bed. Notified nurse practitioner for x-ray orders. Rec'd (received) new order for x-ray of Left femur/left hip (2 views) STAT (immediately.) Called X-ray company for STAT order. R41's Physician's Order Sheet (POS), dated 1/3/2022 at 5:00 PM, documents STAT L (left) hip X-ray 2 views and STAT left femur X-ray 2 views. R41's Health Status Note, dated 1/4/2022 at 2:45 PM documents a late entry note: 5:00 PM X-ray called stating that they are busy, and they might be 3-4 hours before they are here. Spoke to POA and let her know of new orders. X-ray tech here. Awaiting results. 9:30 PM called X-ray company called and asked if they could fax the results. They will fax when ready. R41's Patient X-Ray Report, dated 1/3/2022 and electronically signed at 12:36 AM, documents Findings: a left radiologic examination, femur. Impressions: femoral neck fracture. R41's Health Status Note, dated 1/4/2022 at 1:00 AM documents the facility received X-ray results, results showed fractured neck femoral. The Note documented a call placed to POA at this time to inform of X-ray results and need to transfer to hospital and 911 was called. R41's Health Status Note, dated 1/4/2022 at 5:33 AM documents resident admitted to local hospital with the DX (diagnosis) of fractured Lt (left) femur. R41's Situation, Background, Assessment Recommendation (SBAR) Communication Form and Progress Note, dated 1/4/2022, documents fx (fracture) left femur started on 1/3/2022. Functional status changes: fall. Transfer to the hospital. R41's Hospital Inpatient Consult, dated 1/4/2022, documents history of present illness Resident is an [AGE] year-old female presents to hospital for evaluation of left hip pain. Patient is nonverbal on evaluation this morning. Per report, nursing home states that she fell approximately 2 weeks ago but did not complain of significant pain. She is complaining of left hip pain today and subsequently brought in ER (emergency room.) Radiographs (X-rays) demonstrated a displaced left femoral neck fracture. Assessment/plan: this is an unstable injury that is generally managed operatively. To help improve clinical outcomes would recommend left hip hemiarthroplasty. Plan for surgery once medically cleared. We will continue to follow. R41's Health Status Note, dated 1/5/2022 at 11:46 AM documents Family called with update: resident is to have surgery tomorrow. Will keep us updated. R41's Health Status Note, dated 1/12/2022 at 8:00 PM documents Resident was returned to facility 1/12/2022 at 6:00 PM by ambulance with 3 attendances and went to resident's room. Resident appeared lethargic with eyes closed. Left hip fx - incision looks good slight discharge 20 staples intact. Dry foam dsg (dressing) applied. C/O (complaint of) pain on a scale of 1-10 rates it a 7. Pain med given as ordered. Call light in reach and resting quietly. R41's Fall Risk Data Collection, effective date 1/12/2022 documents Resident had a fall within the last 90 days. The resident is orientated to person and incontinent. Gait observation: unable to assess was documented. Staff documented she was high risk for falls. R41's Quarterly Minimum Data Set, dated [DATE] documents severely cognitively impaired. The MDS documents R41 is not steady, only able to stabilize with staff assistance for surface-to-surface transfers. The MDS documents R41 required 2+ staff physical assistance total dependence for transfers and bed mobility. The MDS documents R41 had no falls fall but had major joint replacement: hip replacement. The MDS documented R41 uses a wheelchair and R41 was not walking. R41's Health Status Note, dated 1/21/2022 at 6:40 PM documents R41 was found on the floor in her room by the CNA at 6:10 PM. The Note documented CNA alerted this nurse. Upon entering the room, resident was found face down in front of her chair with her head next to the nightstand. Resident was on her left side. The residents Foley catheter was seen hanging over the side of her chair, which was still reclined back, with the balloon still intact. Nurse assessed the resident. Breathing was normal and nonlabored. Resident was alert with confusion which is her baseline. Resident c/o (complaint of) hip pain. Resident stated she hit her forehead on the ground. 911 was called at 6:13 PM. Resident was left in the position she was in until EMS arrived. NP was made aware. EMS arrived and transferred resident to the hospital. Resident's POA was contacted twice, a message was left but there has been no call back. R41's Hospitalist Discharge summary, dated [DATE] documents R41's left hip fracture repaired by orthopedic surgeon on 1/4/2022. She was transferred to hospital for hip dislocation. Patient reportedly fell out of her chair at NH (nursing home.) ED (emergency department) attempted to reduce x 2 unsuccessfully. Transferred here to be evaluated by orthopedic surgeon for reduction possibly under anesthesia. Patient underwent left hip closed reduction under anesthesia on 1/22/2022 with orthopedic surgeon. She was discharged back to SNF (skilled nursing facility). R41's Health Status Note, dated 1/24/2022 at 2:47 PM documents Resident arrived back at facility from the hospital from L (left) hip repair at 2:15pm via ambulance. Two paramedics assisted resident back into bed. Resident was moved to room [ROOM NUMBER]. Resident was alert and able to answer yes and no questions. DBS is being charged at this time. Resident has same medications minus new Iron and ASA orders, see POS. Resident has a leg abductor in place. It must be always on while in bed and in chair for 2 weeks. Foley catheter tubing in place draining yellow urine. Steri- strips intact to L hip. Slight redness noted around site, no drainage present. Scattered bruising noted to both upper extremities. Heels looked good, heel protectors on at this time. Per Administrator CNA must sit outside resident's room to be monitored. Weight baring as tolerated. Resident resting comfortably in bed currently. Bed in lowest position with call light in reach. Provider notified of re-admit. R41's Fall Risk Data Collection, effective date 1/24/2022 documents resident had a fall within the last 90 days. The resident is orientated to person and incontinent. Gait observation: unable to assess was documented. Staff documented she was high risk for falls. R41's Health Status Note, dated 3/13/2022 at 1:00 AM documents Res observed on the mat on the floor on the side of her bed on her left side, res states that she did not hit her head, but no witness noted, res able to Move all extremities WNL, res states she has a little pain but not from fall, PRN (when needed) Tylenol given @1P. Will start neuro checks & continue to mx (monitor). R41's Health Status Note, dated 3/14/2022 at 1:20 PM documents Resident complained of severe left hip pain. Nurse Practitioner notified and she ordered a 2 view X-ray of left hip and femur. R41's Patient X-Ray Report, dated 3/14/2022 and electronically signed at 8:46 PM documents left radiologic examination, femur findings: an oblique fracture is noted involving the distal femur. A patella (kneecap) fracture is also identified. Impressions: oblique fracture involving the distal femur and patella fracture. R41's Hospital Records, dated 3/15/2022 documents the resident had a dislocated left hip bipolar prosthesis. Oblique fracture of the distal femur superior to the prosthesis with displacement, angulation, and axial shortening. Comminuted fracture (a bone that is broken in at least two places. Comminuted fractures are caused by severe traumas like car accidents. You will need surgery to repair your bone, and recovery can take a year or longer.) of the superior patella with associated effusion and probable hemarthrosis. R41's Health Status Note, dated 3/14/2022 3:46 PM documents Wheelchair company called on this date and they will be delivering resident's new wheelchair on March 17 at 1:00 PM. R41's Health Status Note, dated 3/15/2022 at 8:43 AM documents X-rays results came back in POA notified. POA stated that she did not want resident sent out or to have any surgery until physician was notified. She wanted his opinion before anything further was decided. I called physician's office and talked with receptionist, and she stated she would leave physician's assistant a message to call facility back. R41's Health Status Note, dated 3/15/2022 at 2:24 PM documents POA was notified and wanted resident sent to hospital to be evaluated. I told her that physician does not treat her type of fx, she said she understands but this hospital is closer so she can be there and if need be, they can send her to specialty hospital. Ambulance was called, EMTS arrived at 2:20 PM and left with resident at 2:22 PM. R41's Health Status Note, dated 3/16/2022 at 1:00 AM documents resident returned to facility via ambulance. Placed into bed with the help of two. Cleaned and dried at this time. Immobilizer in place to left knee. No circulatory impairment noted. Ice placed on Lt knee for pain at this time and PRN Norco giving. Resting quietly currently. R41's POS, dated 3/16/2022 documents keep knee immobilizer on. Apply ice packs to left knee to help with pain and swelling every shift for fracture patella. R41's Fall Risk Data Collection, effective date 3/28/2022 documents resident had a fall within the last 90 days. The resident is orientated to person and incontinent. Gait observation: unable to independently come to a standing position and requires hands-on assistance to move from place to place. Staff documented she was high risk for falls. R41's Significant Change MDS, dated [DATE] documents the resident was severely cognitively impaired. The MDS documents R41 is totally dependent with 2+ persons physical assist for bed mobility and transfers. The MDS documents R41 was not walking. The MDS documents R41's balance during transitions and walking: activity did not occur. Surface-to-surface transfer: not steady, only able to stabilize with staff assistance. Mobility device: wheelchair. Falls: yes. Number of falls since admission or prior assessment- major injury: one. R41's Health Status Note, dated 4/5/2022 at 1:08 PM documents The resident's POA called this morning requesting follow up x-ray of Left femur and knee to see if fx (fracture) has gotten any better. Provider notified and gave okay for x-ray of left femur and knee. Order placed with X-ray company, stated a tech would call when they were on their way. R41's Health Status Note, dated 4/6/2022 at 9:05 AM documents X-ray results in- acute comminuted distal femoral fracture noted still. POA notified. R41's Health Status Note, dated 5/13/2022 at 11:07 AM documents Per POA's request she wants a follow up x-ray of left femur and knee. Also, she wants brace to be off at HS (night.) Nurse Practitioner aware and is okay with the brace being off at night and is okay with getting a follow up x-ray. R41's Health Status Note, dated 5/20/2022 at 8:40 AM documents nurse practitioner replied to X-ray with new order to continue NWB (no weight bearing) status and to repeat x-ray in one month to monitor progress. Cannot DC (discontinue) immobilizer D/T (due to) not being healed and would risk further harm and not healing. R41's POS, dated 5/20/2022 documents continue NWB status and repeat X-ray in one month to monitor progress. R41's Fall Risk Data Collection, effective date 6/27/2022 documents resident has no fall history. It documents R41 is orientated to person and incontinent. Gait observation: unable to independently come to a standing position. Staff documented she was low risk for falls. R41's Fall Risk Data Collection, effective date 8/2/2022 documents resident had a fall within the last 90 days. It documents R41 is orientated to person and incontinent. Gait observation: unable to assess was documented. Staff documented she was low risk for falls. On 8/21/2022 at 9:15 AM R41 was sitting up in a reclined position her a specialty wheelchair in her room alone. Signs above R41's bed read, No (full body mechanical lift) transfers, assist of 2 transfers. Floor mat on floor in front of bed. Resident didn't respond to IDPH surveyor's questions. On 8/24/2022 at 8:40 AM V24 R41's family, stated R41 broke bones in her hands and wrists prior to being admitted to the facility, she didn't have previous fractures in her lower extremities, including her hips or knees. On 8/23/2022 at 1:00 PM V2, Director of Nursing/DON stated when a resident falls, she expects staff to document a fall report and to document if the resident complained of pain, injuries sustained, environmental, footwear worn and a description of how the resident fell and what the nurse saw at the time of the fall. V2 stated the floor nurse is responsible for adding an immediate intervention so the resident doesn't fall again and then administration will add an intervention to the resident's care plan within 24 hours. On 8/23/2022 at 4:46 PM, V26, R41's physician, stated he was aware R41 fell a few times at the facility and had fractured her hip and knee cap. V26 stated he expected staff to document a thorough assessment of each fall and to add an intervention to R41's care plan after each fall to prevent the resident from falling again in the future. V26 stated he didn't know how R41 her hip in January 2022 but stated he thought she fell. V26 stated if the facility didn't know how she sustained the hip fracture they should have investigated and found out what occurred. V26 stated he was not certain if the fractures R41 sustained at the facility were pathological or not, he stated if they were pathological that would be documented on the X-ray report and/or in the resident's hospital medical records. V26 stated he expected staff to follow physician's orders and facility policies. 2.R30's Physician's Order (PO) dated 05/09/22 documents unspecified dementia with behavioral disturbance. R30's Fall Risk Data Collection dated 05/09/22 documents a score of 30.0, High Risk. R30's MDS, dated [DATE] documents that R30 has severe impaired cognition. R30's MDS documents that R30 requires extensive assistance of one-person for bed mobility, transfer, and toilet use. The MDS documents R30 requires limited assistance of one-person for walk in room, dressing, and personal hygiene. Resident is independent with setup help only for locomotion on unit, locomotion off unit, and eating. The MDS documents R30 needs physical help in part of bathing activity of one-person. The MDS documents R30 is not steady, only able to stabilize with staff assistance and uses walker and wheelchair for mobility. R30's Care Plan dated 08/18/22 documents The resident is at risk for falls R/T (related to) occasional Incontinence and confusion at times 7/7/22: slid out of bed trying to put pants on. (F/U (follow-up) til 8/4/22): Resolved 7/17/22: up without assistance in resident's room (F/U till 8/14/22), (resolved) 7/29/22: unwitnessed fall, self-transfer (FU till 8/26/22) 7/31/22: up without assistance (FU till 8/28/22). Interventions: -07/07/22: Encourage resident to call for assistance when needing to get dressed (resolved). -7/17/22: medication review Psych r/t behaviors. tearfulness:(resolved). -7/29/22 floor mat at bedside. -7/31/22: offer to lay down after breakfast. R30's interventions for fall on 07/07/22 is to encourage resident to call for assistance. Resident is confused and her cognition is severely impaired. The intervention for fall on 07/29/22 is floor mat at bedside. During this investigation, no floor mat was noted at bedside. R30's Health Status Note dated 05/09/22 at 7:35 AM documents Resident was found on the floor in her room. CNA (Certified Nurse Aide) stated that the resident was in the sitting position on the floor next to her bed. Resident had no pants or shoes on and was hanging a depend up on a hanger. Fall was unwitnessed but resident denies pain and no injury noted. Neuro assessments started. DON (Director of Nursing) and POA (Power of Attorney) made aware. R30's Health Status Note dated 06/29/22 at 1:51 AM documents CNA and this nurse responded to call light. Res. found sitting on the right side of her bed with socks on, light activated. no clutter on floor, and well lit. Res. states, 'I slid out of my bed, I didn't hit my head, I'm ok.' and giggled. 97.9 T (temperature) 76 P (pulse) 18 R (respirations) 134/82 BP (blood pressure) 97% (oxygen saturation on room air). Pain denied. limbs symmetrical. Neuro assessment WNL (within normal limits). PEERLA (pupils equal, round, reactive to light, accommodation). Hand grips equal. No apparent injury upon skin assessment. This nurse and CNA assisted her back to bed. MD (Medical Doctor) notified. POA to be notified in morning. Incident protocol initiated. Bed in low position with call light in reach. Will continue to monitor. R30's Health Status Note dated 07/07/22 at 2:15 PM documents Res observed on floor in upright position on the side of the bed. Res states that she was trying to put her pants on & slid out of bed. Resident assessed, no open areas or skin issues noted, res stated that her buttocks was a little sore, Res states that she did not hit her head & that she felt ok. Neuro checks initiated. Floor mat placed on the side of bed, call light within reach, Res brought out into dining room & received snacks & did activities. All parties notified. Will continue to monitor. R30's Fall Investigation dated 07/07/22 documents CNA called for a nurse to come down to resident's room, upon arrival resident was noted in a sitting position on the floor on the side of the bed. Resident states that she was trying to put her pants on and forgot to call for assistance, resident call light was in place. Resident assessed, no open areas or skin issues noted. States that she did not hit her head and that her bottom was just sore. VS (vital signs) initiated. BP-145/86, P-85, R-18, T-97.8, O2-97% RA, was start neuro checks and notify MD, POA, DON, Administrator. Resident educated on using call light for assistance, floor mat placed on the side of the bed. Resident brought into dining room for activities and snack. Will continue to monitor. Notes 07/08/22 - Resident slid out of bed trying to put her pants on. Encourage resident to call for assist to get dressed. R30's Health Status Note dated 07/17/22 at 11:02 AM documents CNA notified nurse that res was on the floor. Res noted sitting on floor in front of WC (wheelchair). Feet extended toward WC with back facing recliner. Res assessed and able to [NAME] (move all extremities) WNL. No internal or external rotation noted. When asked if she hit her head, res said, 'No.' When asked if she was trying to get into her recliner, res said, 'No.' This nurse asked res what happened, and she said, 'I was trying to get into bed.' Res assisted up & into wheelchair by 3 staff with gait belt. Res brought to the DR (dining room) for 1:1 monitoring. R30's Fall Investigation dated 07/17/22 documents CNA came to this nurse and said resident was on the floor. This nurse and coworker went with CNA back to resident's room. WC in middle of room. Resident noted sitting on the floor in front of WC facing it. Legs extended toward bathroom door. Back in front of recliner. Resident balancing self on R (right) hand. This nurse asked resident if she was trying to get into her recliner. Resident shook head, No. This nurse asked resident if she hit her head. Resident shook head, No. This nurse asked resident what she was doing. Resident said, 'I was trying to get in bed.' Resident able to move all extremties within normal limits. No internal or external rotation noted. No c/o pain or discomfort noted. Resident assisted up into wheelchair by 3 staff with gait belt. Resident brought to the dining room to keep visual of resident. Notes: 07/18/22 - Medication review and psych eval. R30's Fall Investigation dated 07/29/22 documents Resident unable to give description. Notes: 08/01/22 - Staff to encourage resident to stay out in high traffic areas for supervision. R30's Health Status Note dated 07/30/22 at 12:09 AM documents CNA summoned this nurse to resident room. Resident found on floor in a stretched-out position. Denies hitting head. Fall unwitnessed neuro checks initiated. No internal/external rotation noted. Assisted off the floor with the help of two and placed into bed. Call light within reach. Denies pain or discomfort. R30's Health Status Note dated 07/31/22 at 11:17 AM documents CNA came to the DR (dining room) & said res was on floor in her room. No call light sounding. This nurse went to the room and noted res lying on her R side with R arm under the bed. L hand was holding onto top of mattress. Legs were extended towards wall @ HOB (head of bed). No internal or external rotation of legs noted. When asked if she was trying to get in bed by herself, res shook her head yes. No injuries noted. Res assisted up and into bed by 2 staff members. DON, ADON (Assistant Director of Nursing), MDS & MD notified of resident's fall. On 08/21/22 at 2:50 PM, there were no floor mats noted in R30's or on floor. On 08/23/22 at 8:50 AM, R30 was sleeping in recliner. observation of no floor mats in room. On 08/23/22 at 9:00 AM, V7, CNA stated, She doesn't have a floor mat. On 08/23/22 at 1:02 PM, R30 was lying in bed. There were no floor mats in R30's room. On 8/23/2022 at 1:00 PM V2, the DON stated when a resident falls, she expects staff to document a fall report and to document if the resident complained of pain, injuries sustained, environmental, footwear worn and a description of how the resident fell and what the nurse saw at the time of the fall. The floor nurse is responsible for adding an immediate intervention so the resident doesn't fall again and then administration will add an intervention to the resident's care plan within 24 hours. Facility's policy revised February 2021 documents The S.A.F.E program promotes Safety, Assessment, Fall Prevention and Education of both staff and residents. The Policy documents 3. Residents found to be at high risk for falls are placed on the S.A.F.E. program, and specific interventions are implemented to meet individual need. Under Program heading 3. documents Following any falls, the facility staff completes an Occurrence Report. Details of the fall will be reported, and potential casual factors identified and investigated. Interventions will be immediately implemented following each fall and added to the resident's care. The staff will review the resident's Fall Risk Data Collection. An update or change to the data collection form would be made only if the resident had previously been identified as low risk. 3. R146's Physician Order Sheet dated August 2022 document diagnoses of Hydronephrosis with renal and ureteral calculus obstruction, chronic obstructive pulmonary disease, type 2 diabetes, and hypertension. R146's Progress Notes document R146 was admitted to the facility on [DATE] at 6:43 PM. R146's MDS dated [DATE] admission documents R146 was moderately impaired for cognition. R146's MDS also documents, R146 does not need help from staff oversight at any time for bed mobility, and transfer. R146's MDS documents R146 did not walk in her room during this assessment period. The MDS documented locomotion on unit and locomotion on unit was marked as independent. The MDS document R146 had a fall prior to admission/entry or reentry. R146's balance was not steady, but able to stabilize without staff assistance from moving from seated to standing and walking, moving to and from toilet. R146's MDS does not document R146 uses a walker. R146's Care Plan documents, The resident is at risk for falls related to unaware of safety needs. (Date initiated 8/19/2022). On 8/22/2022 at 11:55 AM, V4, MDS Coordinator, stated, (R146) when she came in was a stand and pivot only. She was in her wheelchair most of the time and could only stand and pivot only. She did not walk and or use a walker. R146's Progress Notes dated 8/1/2022 at 9:49 AM, documented When I was getting ready to start medication pass, I heard someone yelling down Oak hall. I followed the sound to (R146's) room where I found resident lying on the floor. Upon entering the room, I seen that the bed side table was flipped over and was lying on the ground. Resident denture cup and dentures were lying on the floor close to the floor. Water was spilled on the floor from the denture cup. Resident was lying on left side. Feet were towards her roommate bed. Roommate was fast asleep. Resident head was towards dresser that had TV on it. She had non-slip socks with grips on at the time. She was also incontinent at the time of the fall. Lights were on in her room, but bathroom light was on. Resident said she was unsure what happened. She said she thought she heard someone call her name. She said the only thing that hurt was her heel and that she did not hit her head. Call light was in reach on bed rail closest to the door. Another nurse and I assessed resident. No apparent injuries and Range of Motion Within Normal Limits. Neuro checks initiated. Resident assisted to bathroom and changed then brought to the dining room. Notified Power of Attorney, Medical Director, and Director of Nursing and Assistant Director of Nursing. R146's Progress Note dated 8/2/2022 at 11:29 AM, documented Bruise noted to right inner ankle from fall yesterday. No complaint of pain or discomfort. No swelling or tenderness notes. Able to move ankle without pain or difficulty. Range of Motion, within normal limits. R146's Incident Report [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent urinary retention by following physician's orders regarding indwelling catheter care for 1 of 3 (R10) reviewed for urinary retention in the sample of 26. This failure resulted in R7 experiencing unnecessary urinary retention and severe abdominal pain. Findings include: R10's Care Plan dated 4/14/2021, documents R10 has an indwelling catheter. R10's Care Plan Goal documents he will remain free from catheter-related trauma through review date, and he will show no signs or symptoms of urinary infection through review date. R10's Care Plan Interventions documents Catheter care every shift and PRN (when needed), 16 FR (French) indwelling catheter. Position catheter bag and tubing below level of the bladder and away from entrance room door. Monitor for s/s (signs and symptoms) of discomfort on urination and frequency, monitor/record/report to MD (physician) for signs/symptoms of UTI (urinary tract infections): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. R10's admission Minimum Data Set (MDS) dated [DATE] documents he was alert and had an indwelling catheter. R10's Urology Follow Up Noted, dated 7/5/2022 documents history and physical: Resident is here for a follow-up. Resident had significant urethral erosion from chronic indwelling catheter. He wants to remove the catheter because it is bothering him and causing his penile pain and ureteral erosion is worse. The assessment/plan documents resident is a [AGE] year-old male with hx (history) of non-obstructive prostate. I am still not sure he has urinary retention or if catheter was placed out of convenience. He has CHF (chronic heart failure), and bladder scan won't be reliable. My recommendation is to remove the catheter and managed with diaper or bedside urinal. We can consider clean intermittent catheterization if needed to be. Follow up in 6 months. R10's July 2022 Physician's Order Sheet (POS), documents a new order, dated 7/5/2022, to remove catheter due to penile urethral damage and recurrent UTIs (urinary tract infections.) Void (urinate) and occasional straight catheterize. Bladder scan not reliable d/t (due to) CHF and fluid retention. Can consider condom catheters or depends (incontinence briefs.) Call urologist with further questions. Another physician's order dated 7/5/2022 documents remove indwelling catheter one time only for 1 day d/t (due to) penile urethral damage. End order date 7/6/2022. R10's Health Status Note, dated 7/5/2022 and 7/6/2022 has no documentation if staff removed R7's indwelling catheter, if staff performed a straight Cath on him, if he was able to urinate in a urinal, wore incontinence briefs or if staff administered R7 a condom catheter. R10's Health Status Note, dated 7/7/2022 at 7:47 PM documents Res. straight cathed after c/o (complaint of) extreme lower abd (abdominal) pain. 800 cc urine out. This nurse left in foley catheter and attached to drainage bag and called MD (physician) exchange. Awaiting response. At 7:52 PM NP (Nurse Practitioner) ordered to leave in indwelling catheter d/t (due to) urinary retention and frequent straight cathing. Notify Urologist of urinary retention and catheter being put back in. 9:50 PM 400 CC out after indwelling catheter put in at 7:30 PM. 1950 cc out this entire shift. Urologist to be notified in morning. R10's Health Status Note, dated 7/8/2022 at 2:14 PM documents Urologist office notified of res having urinary retention and of indwelling catheter being left in place. R10's POS, dated 7/20/2022 documents a new physician's order: start date 7/7/2022 for catheter 16 F for urinary retention. One time only for urinary retention. Catheter care, check catheter anchor placement every shift and as needed and catheter output every shift: start date 3/18/2022 end date 7/6/2022. R10's Physician's Order Sheet (POS), dated 7/22/2022 documents order to remove catheter due to penile urethral damage and recurrent UTIs (urinary tract infections.) Void (urinate) and occasional straight catheterize. Bladder scan not reliable d/t (due to) CHF and fluid retention. Can consider condom catheters or depends (incontinence briefs.) Call urologist with further questions was discontinued on 7/22/2022. On 8/23/22 at 1:35 PM, V7, Certified Nurse's Assistant (CNA) and V18, CNA administered catheter care for R10. R10's penis was reddened, split on the right side, and sometimes bleeds according to R10 On 8/23/2022 at 9:20 AM R10 stated, I've had a catheter for a long time, and I don't want it anymore because my penis is fractured, and it hurts really bad to have the catheter in. My penis is split in half, and I have major penile damage to the hole on my penis due to the long-term catheter use. I went to the urologist in July and came back to the facility and my catheter was taken out, but I didn't urinate for 2 days, no staff straight cathed me or asked me if I had urinated, it wasn't until days later that I told staff I was having severe abdominal pain and they put the indwelling catheter back in. It hurts so bad to have the catheter in, but staff didn't straight Cath me those days and I could feel the urine building up in my body, who knows how long I would have gone without urinating if I wouldn't have told staff I was hurting. No staff have discussed the catheter with me since they put a new catheter in in July 2022. I haven't had any current UTIs, but I have had them in the past. On 8/23/2022 at 1:00 PM V2, the Director of Nurses (DON) stated R7 was assessed by his urologist on 7/5/2022 and he ordered to take R7's catheter out to see if he had urinary retention, it was a trial. V2 stated she expected staff to document when R7's catheter was removed and how he responded to it. V2 stated she expected staff to follow the physician's order and to straight Cath him PRN (when needed.) V2 stated staff reported to her that R7 was not urinating on his own so they reinserted the indwelling catheter and notified the facility's nurse practitioner. V2 stated she expected staff to document when they straight cathed R7 and to document the output so they would know how was doing without the indwelling catheter in. On 8/23/2022 at 9:38 AM V19, the Urologist stated he assessed R7 in his office on 7/5/2022 and instructed the facility to take his indwelling catheter out due to penile urethral erosion. V19 stated R7 complained the indwelling catheter hurt and he wanted it out. V19 stated in July V19 wrote a physician's order to have staff straight cath, use a urinal or wear Depends to allow the penis to heal. V19 stated he wanted to make sure R7 had true urinary retention and not having an indwelling catheter for staff convenience. V19 stated his nurse called the facility on 7/8/2022 and R7's nurse reported R7 wasn't able to urinate on his own, so he ordered the indwelling catheter for true urinary retention. V19 stated when he ordered the indwelling catheter to be discontinued on 7/5/2022 he expected staff to straight cath R7 every 6 hours and to document how much urine was removed and to continue assessing the resident R7 to ensure he could urinate so he could assess R7's ability to urinate on his own. V19 stated he expected staff to follow physician's orders and facility policies. On 8/24/2022 at 2:34 PM V1, Administrator stated the facility doesn't have a urinary retention policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to assess risks and monitor the appropriate use of side rails for 1 of 12 residents (R28) reviewed for bed rails/side rails the sample of 26. This failure resulted in R28's face being found on the side rail causing R28's nose to bleed, facial swelling, and an opened area to her nose. Finding include: On 8/23/2022 at 2:00 PM, R28 was not able to respond to any questions, was not moving in bed and laying on her back staring into straight ahead with no responses and or expressions. On 8/23/2022 at 10:39 AM, R28 was lying in bed with her head elevated at a 40-degree angle. The side rail towards the window was attached at the top of the mattress towards her head and there was no covering on it. On R28's opposite side of the bed towards the entrance door the side rail was staggered and started at her shoulder level. The side rail did not have any padding on it. The side rails were 15 inches in length and 5 inches wide in the largest opening towards the top of the siderail and there was no padding present on either side rail. (This exceeds the of 120 mm (4 ¾ inches) as the basis for its dimensional limit recommendation for side rails). R28's Minimum Data Set (MDS) dated [DATE] document R28 was severely impaired for cognition. R28's MDS documents R28 is total dependent on two plus staff for turning and reposition, bed mobility, and transfer, dressing and eating. R28's MDS documents R28 has an impairment on both her upper and lower extremities. R28's Restraint Evaluation dated 8/1/2022 document, side rails for bed positioning or transferring. No other, lesser restrictive restraints have been attempted. No restraint reduction been attempted since last review: used for bed positioning. Benefits of restraint use include prevention of injuries, reduced fall potential and functional enhancement. IDT (Interdisplinary team) recommendations continue with current restraint. No benefits versus risks were documented for the assessment/evaluation. R28's August 2022 Physician Order Sheet (POS) documents, Full padded side rails up times two at all times when in bed except during care to prevent possible injuries related to seizures every shift. R28's POS, dated 8/22/2022 documents a new order, resident had full bilateral side rails an assessment was completed and a reduction was made, and bilateral quarter side rails were applied to maintain safety while in bed. On 8/22/2022 at 12:40 PM, V22 Maintenance Director was in R28's room and stated he was changing R28's bed. The long side rails were on the floor and new side rails were on the resident's bed. V22 stated V2, Director of Nursing, told him to change R28's side rails because they aren't supposed to use those side rails. R28's Progress Notes dated 7/21/2022 at 10:30 PM, When rounding at 2 PM this nurse found resident laying with her lower face on the siderail and oxygen tubing off her face. Scan amount of blood in left nostril. Left cheek and jaw reddened from lying on side rail and a 0.25cm open area to bridge of nose. MDS Coordinator notified. The nurse was instructed to write a progress note and not an incident report. On 8/22/2022 at 2:20 PM, V9, Licensed Practical Nurse (LPN) stated, I remember finding (R28) laying on her left side, her face was against the left side rail and the side rail was in her mouth. I immediately repositioned the resident on her back and assessed the left side of her face. (R28's) face was red and swollen and she had a laceration on the bridge of her nose. Her oxygen via nasal cannula was off and her oxygen saturation was 90% on room air. At the time I felt this could be abuse and neglect because the resident must have been laying like this for long periods of time because her left side of her face was red and swollen. (R28) can't move on her own at all, both of her arms are contracted, and she is unable to remove the nasal cannula off on her own. I notified the MDS Coordinator about the incident and she told me not to write an incident report on it, but I progress note which I did. On 8/22/2022 at 2:40 PM V4, MDS Coordinator stated she recalled the nurse notified her that R28 was found with her head on the side rail and an abrasion on the top of her nose. She didn't know how it occurred because she wasn't here at the time. (V1), the Administrator told her to do a reassessment of R28's side rails today and when she did, she noted the side rails were not appropriate because the resident cannot turn/reposition herself and she needed to do a restraint reduction. The side rails went from full side rails to quarter length side rails. On 8/22/2022 at 2:58 PM V2 stated she didn't know about the regulation for side rails. V2 stated V1 Administrator told the maintenance man to change out the side rails because she thought they were too long for R28. V2 stated R28 can't move on her own, staff turn and reposition her every2 hours and as needed. V2 stated she didn't know why R28 had side rails. On 8/22/2022 at 3:02 PM V1 stated she went to look at R28's side rails when the State surveyor requested the side rails manufacture guidelines and she noted her side rails didn't look stable. V1 stated she will have to read the long-term care regulations to see if the side rails were within regulation. V1 had staff change the side rails from full side rails to quarter length side rails after lunch on 8/22/2022. V1 stated she wasn't at the facility when staff assessed R28 laying on the side rail so she can't say how it occurred. V1 stated she spoke to the V2 and V4 and they came to the conclusion that R28 slid down in bed due to gravity depending on or perhaps she wasn't positioned quit at the right angle. V1 stated she was told the laceration on R28's nose was from her hitting the side rail. V1 stated she expected the side rails to be addressed on R28's care plan and for V2 to educate staff to ensure R28 was positioned away from the side rails so this doesn't happen again. V1 stated she didn't know how long R28 the long side rails had, she's had them since she started as the administrator in December 2021 or why she had them because the resident doesn't move on her own at all so she wouldn't use them for mobility. On 8/23/2022 at 10:00 AM V15, Nurse Practitioner stated she doesn't know why R28 has full side rails, and she wasn't aware if R28 had a history of seizures or not. V15 stated R28 has bilateral upper contractors, and she doesn't move on her own, staff must turn and reposition her. V15 stated she would expect staff to notify her or the physician if they wanted to make changes to R28's side rails because it was a physician's order. V15 stated she wasn't aware staff changed R28's side rails from full side rails to quarter side rails on 8/22/2022 or why they did that. V15 stated she expected staff to assess R28's risks and benefits to the side rails quarterly and when there is a change in R28 she also expected staff to assess R28 for a reduction inside rails every quarter. V15 stated she was not aware R28 was found lying on her left side with her head on the side and a laceration on the bridge of her nose side rail in July 2022 she would expect staff to notify the provider so they can ensure R28 is safe with the side rails. V15 stated if the physician's order was for full padded side rails, then she would expect the side rails to be padded. V15 stated this may have prevented R28 from acquiring the laceration on her nose in July 2022. V15 expected staff to follow physician's order and facility policies. The Guidance Industry and Food and Drug Administration (FDA) Staff Hospital Bed System and Assessment Guidance to Reduce Entrapment dated 3/10/206 documents, To reduce the risk of head entrapment, openings in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped. Country-specific anthropometric data show that a 1st percentile female head breadth may be as small as 95 mm (3 ¾ inches). A dimension of 120 mm (4 ¾ inches) encompasses the 5th percentile female head breadth in all data sources used to develop these recommendations and includes 1st percentile female head breadth as reported in some data sources. FDA is therefore using a head breadth dimension of 120 mm (4 ¾ inches) as the basis for its dimensional limit recommendations. This dimension is consistent with the dimensions recommended by The Hospital Bed Safety Workgroup. On 8/24/2022 at 10:18 AM, V2, Director of Nursing stated, I expect all Physician Orders to be followed including side rails/padding. I am not sure what happened with (R28). On 8/24/2022 at 10:22 AM, V1 stated, I would expect physician orders to always be followed. I am not sure why (R28) did not have any paddings on her side rails, but I have already had the side rails removed. The Proper Use of Side Rails Policy with a revision dated of 2/2021 documents, Side rails are conserved a restrain when they are used to limit the resident's freedom of movement (prevent the residents from leaving his/her bed). (Note: The side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstance.) Side rails with padding may be used to prevent resident injury in situations of uncontrollable movement disorders but are still restraints if they meet the definition of a restraint.