**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Based on interviews and records reviewed, the facility failed to ensure fall prevention interventions were utilized to include nonskid footwear and other appropriate interventions for 1 resident (R3) and provide assistance to one resident (R2) during transfer from wheelchair to bed. R3 has a cognitive communication disorder, poor safety awareness, and impaired cognition. R2 has a history of alcohol abuse, gait disorder, and neuropathy. These failures affected two of three (R2, R3) residents reviewed for falls. These failures resulted in harm, with R2 sustaining a laceration requiring two sutures to the left eyebrow region, and R3 was admitted to the hospital for Subdural Hematoma and received 7 staples to the left occipital region. The findings include: 1. IDPH facility reported an incident for R3 states on [DATE]. The nurse on duty observed the resident standing by the bed and attempting to walk. Nurse attempted to get to the resident to prevent him from falling. Resident fell on the floor between the bed and night stand. The nurse noted a laceration of approximately half an inch on the left posterior head and minimal bleeding on the lower mouth. The resident was taken to the emergency room, and the facility notified that the resident was admitted with a diagnosis of Subdural Hematoma. On [DATE] at 1:37 PM, V6, Certified Nursing Assistant (CNA), said around 11:00 AM, I saw Physical Therapy bringing R3 to his room, and therapy put R3 back to bed; the nurse and I checked him. V6 said I did not see R3 fall but saw him on the floor. R3 was between the bed and the nightstand. V6 said R3 kept asking us to get him up, but we left him in the position on the floor, and he kept trying to get up. V6 said it was out of his behavior for him to get up unassisted. V6 said R3 did not use a walker with her. V6 said R3 had a regular wheelchair. V6 said I don't remember what kind of shoes R3 had. V6 said R3 fell between 11:00 AM and 12:00 PM. V6 said I don't remember getting R3 up that day. V6 said the night shift usually takes R3 to dialysis in the morning before she gets on the unit. V6 said I didn't put shoes or socks on R3. V6 said R3 did make some urine but had not used the urinal or been incontinent at the time of the fall. V6 said that generally, R3 was alert and oriented, but that day, R3 was out of his behavior. On [DATE] at 2:20 PM, V3, Licensed Practical Nurse, said [DATE] R3 went to dialysis that morning; he was already off the unit when V3 came in; dialysis starts at 6:00 AM. V3 said around 10:00 or 10:30 AM, R3 was in bed with the CNA, making him comfortable. V3 said I checked R3 and he said he was just tired. V3 said at 11:00 AM, when I passed R3's room, he was in bed sleeping. Then he called me and wanted to be changed about 11:00-11:30 AM, and the CNA went to change him. V3 said while V6 was changing R3, I was at the desk, then V6 went to take the next patient to dialysis, and I remained at the desk. V3 said at 12:00 PM, I went to do blood sugar checks. V3 said I saw R3 was standing out of the bed, already losing his balance. V3 said, I was too late. He fell. V3 said R3 was trying to reach for the chair in the room, but he still fell. V3 said R3 had blood in his left hand and bottom lip. I called 911 and left him on the floor with V6. V3 said there was blood on the pillowcase V6 had placed under R3's head. V3 said R3 was bleeding from the back of his head. V3 said I had not seen R3 get up on his own before. V3 said sometimes R3 will shoot us away if we help him. V3 said R3 had fallen Friday before [DATE]. V3 said when I came in for my shift, the night nurse said they found him on the foot of the bed on [DATE]. V3 said on [DATE], R3 had a gown on, and he was barefoot. V3 said R3 came to us because he had fallen in the past. V3 said R3 may have had a bowel movement and still makes urine. V3 said R3 was in a regular bed, and it did not go to the floor. V3 said R3 had no walker or cane, just a wheelchair. V3 said we did not have floor mats in place for R3. V3 said it was not like R3 to get up on his own. On [DATE] at 12:48 PM V2, Fall Coordinator, said R3's behavior he was non complaint with cares, he was new to dialysis, had depression, and he had multiple falls at home. V2 said on [DATE], R3 stood up to try to go to the bathroom; he is weak from hospitalization and dialysis. V2 said R3 did not call for help, he fell and intervention was to continue therapy. V2 said on 9/2 24, R3 was seen at 11:30 AM in bed resting; the nurse did not wake him. V2 said R3 had already had dialysis on [DATE]. V2 said the nurse went in to check R3's blood sugar at 12:10PM. V2 said R3 had taken a step from the bed and fell and hit his head. V2 said V3 witnessed the fall. V2 said R3 fell between the bed and nightstand and he hit his head on the nightstand. V2 said R3 said I was going to go sit in my wheelchair and he thought he could do it. V2 said R3 was noted bleeding and R3 remained on the floor until ambulance came for him. V2 said the hospital notified us that R3 had a Subdural Hematoma and was in the intensive care unit for care. V2 said R3 died in the hospital of cardiac arrest and aspiration pneumonia. On [DATE] at 2:36 PM, V4, Director of Rehab, said R3 was on caseload from [DATE] through [DATE]. V4 said R3 required moderate assistance for transfers. V4 said R3 was ambulating with minimal therapist assistance with a rolling walker. V4 said the CNA would need to use a gait belt, give cues, and some assist to get him to stand. V4 said barriers for therapy for R3 were poor motivation, behavior, and he was refusing to participate in therapy. V4 said R3's balance fluctuated and is not the best, especially after dialysis, and poor after treatment related to fatigue. V4 said for residents on case load we will tell the nurse the level of support the resident needs and if they are a high fall risk we encourage them to have their walker. V4 said for R3 staff should not be using the walker with him. On [DATE] at 3:00 PM, V5 Restorative Nurse said R3's orientation fluctuated; he was incontinent, but he was not producing urine. R3's diagnosis include but are not limited to End Stage Renal Disease, Dependency on Renal Dialysis, Adjustment disorder with Mixed Anxiety and Depressed Mood, Abnormalities of Gait and Mobility, Lack of Coordination, Abnormal Posture, Cognitive Communication Deficit, Anemia, Type 2 Diabetes Mellitus, Hypertension, Congestive Heart Failure, and Presence of Cardiac Pacemaker. R3 was admitted to the facility on [DATE] and discharged to an acute care hospital on [DATE]. Incident report dated [DATE] for R3 states around 4:45AM patient observed lying on his back on the floor next to bed. Patient stated he was trying to go to the washroom when he lost his balance. Blood pressure 91 / 50 pulse 105. Mental status oriented to person and place, lack of safety awareness. Post-fall investigation states activity at the time of incident: attempting to stand or transfer to get out of bed. Mental status at the time of the incident: poor safety awareness. The factors that contributed to the incident: attempting to stand transfer without assistance. Resident at risk for falls: fall risk score 16, resident has a history of falls, multiple files prior to admission. Interventions used to bed in the lowest position, call light within reach, and education to use call light for assistance. Root cause analysis states that the resident recently started dialysis and was hospitalized due to multiple falls and episodes of dizziness. The resident is currently here for therapy for strengthening. Per resident he got up from his bed to go to the washroom and lost his balance. Per staff, the call light was next to the resident but was not activated. Resident fell because resident unsafely transferred himself without assist despite unsteady gait and balance. Resident has a BIMS (cognition assessment) score of 10, which indicates moderate cognitive impairment, so he forgets to use the call light at times. Interventions: continue with skilled therapy for strengthening. The incident report dated [DATE] states that the nurse went to the patient's room. Observed R3 standing by the bed and attempting to walk but began to lose balance. The nurse attempted to get to the resident to prevent him from falling, but the resident fell between the bed and the nightstand. The resident stated I was trying to go sit in the chair. I thought I could do it myself. R3 noted with a laceration approximately half inch on the left posterior head and mild bleeding of the lower mouth. Blood pressure 108/62 pulse 74. R3 remained on the floor until paramedics arrived. Injury observed: laceration back of the head. Mental status: alert with periods of forgetfulness. Post-fall investigation states resident injury: Subdural Hematoma. Activity at the time of incident: attempting to stand or transfer to get out of bed. Mental status: poor safety awareness. Environmental factors: attempting to stand transfer without assistance. Date of last fall: [DATE]. Interventions: bed in the lowest position, call light within reach, skilled therapy. R3 was sent to the hospital post-fall with injury via 911. R3 was admitted with a diagnosis of Subdural Hematoma. Root cause analysis: R3 has poor decision-making skills. He overestimated himself to perform tasks independently and unsafely transferred himself without assistance despite unsteady gait and balance, causing him to lose balance and fall. R3 has poor safety awareness and impulsive behavior. On [DATE] at 6:00 AM R3 went for dialysis. Increased weakness, fatigue, and dizziness are mild symptoms after dialysis treatment, which may have contributed further to his fall. R3's Cognitive assessment dated [DATE] notes a score of 10. R3's behavior assessment dated [DATE] notes he has verbal behavioral symptoms directed towards others (threatening, screaming, cursing). Behaviors put the resident at significant risk for physical illness or injury. Significantly interfere with care. No rejection of care was exhibited. Functional abilities notes toileting and personal hygiene R3 requires substantial/maximal assistance with helper doing more than half the effort. Standing, transfer from chair to bed, bed to chair, and toilet R3 was dependent on staff. R3's bowel and bladder assessment noted R3 was always incontinent of bowel and bladder. R3's appliances assessment notes he has an indwelling catheter, external catheter, ostomy, and intermittent catheterization. R3's admission assessment, dated [DATE], notes a fall risk evaluation of 4, low risk. The assessment notes that R3 is continent of bowel and bladder. The resident has a short-or long-term memory problem. The resident is able to walk with assistance or an assistive device. Gait is not applicable. The history of falls states no, and it is unknown if the resident has fallen in the past three months. R3's care plan dated [DATE] states at high risk for falls related to decline in functional status, impaired balance during transitions, impulsivity or poor safety awareness, multiple falls prior to admission and muscle weakness from recent hospitalizations. Goal states R3 will be free of falls through next review date. Interventions dated 8/16 include call light and reach and encourage to use for assistance. Staff to provide a safe environment. Therapy to evaluate and treat as ordered to increase strength and mobility and prevent further falls. Keep needed items within reach, such as urinal. Intervention dated [DATE] states continue with skilled therapy. The speech therapy evaluation and plan of treatment dated [DATE] state that memory and safety awareness have been declining recently. The patient is memory impaired. The reason for therapy is that the patient presents with moderate problem-solving and safety awareness skills. Barriers likely to impact discharge to the next level of exasperation of cognitive impairment include lack of insight into the condition and risk factors. The physical therapy evaluation and plan of treatment dated [DATE] states, Has the patient fallen in the past year? Yes, six times per patient. The patient feels unsteady when standing and worries about falling. R3's hospital record dated [DATE] notes he received 7 staples to the left occipital side. R3 was admitted to the intensive care unit (ICU) for the management of Subdural hematoma. R3 did not return to the facility. 2. IDPH facility reported incident for R2 states on [DATE] nurse heard resident calling for help. Nurse observed resident sitting on the floor in his room. Resident stated I was trying to transfer myself but missed the bed, I hit my face on the side of the wheelchair and landed on the floor. R2 sent to hospital for evaluation of laceration on the left eyebrow measuring 1.0 X 0.3 centimeter with bleeding. R2 returned after few hours with diagnosis of laceration of forehead. Observed with sutures on left eyebrow. On [DATE] at 12:03 PM V8, RN, said on [DATE] I was passing medications, I heard someone calling for help. V8 said when I saw R2 he was kneeling at the side of the bed. V8 said I saw blood on the left eyebrow. V8 said R2 said I want to transfer myself. V8 said R2 thinks he can do things by himself, but he refuses to use the call lights. V8 said R2's roommate said R2 transferred himself. V8 said R2 hit his eyebrow on the bedside table. V8 said R2's call light is always in his reach and we have to remind him to use it. V8 said supervision is what we do for R2. V8 said R2 said he wanted to get into the bed. V8 said R2's mental status is causing him to fall. V8 said sometimes he understands direction. V8 said R2's current roommate wants the door closed, so it gets closed. V8 said R2 will transfer himself on and off the toilet. On [DATE] at 12:37 AM V9, CNA, said R2 refuses when you help him. V9 said R2 will stand up, closes the door and he just keeps doing what he was doing. V9 said R2 transfers himself, he wants to be independent. V9 said R2 gets up to walk into the bathroom. V9 said I will try to open the door for R2, and he sometimes wants the door open. V9 said I don't know if R2 would use the urinal or commode. V9 said if R2 falls he will try to stand up by himself. On [DATE] at 2:02PM R2 interviewed in tv room, no staff observing the area, only as they walk past. R2 said I don't know why I keep falling. R2 said my knee, (points at left knee) hurts or gives out. R2 Speaks in low soft tone. On [DATE] at 12:28 PM V1, LPN said R2 was trying to go to the bathroom by himself on [DATE]. V1 said I had just talked to R2 in the hall. V1 said R2 did not ask for assistance, he never told me he had to use the washroom. V1 said I was doing medication pass when he went past me. V1 said then I heard something and I saw R2 on the floor in the room. V1 said I don't recall what he said. On [DATE] at 12:48 PM V2 Fall Coordinator, said R2 is very alert he knows when to call. V2 said R2 gets mad if you try to help him. V2 said I called the daughter to ask what we can do. V2 said I speak with R2 often to call for assistance, but he won't call. V2 said R2's leg is unstable and we have him working with physical therapy to work with safety. V2 said the plan for R2 is he needs frequent checking on even if he refuses. V2 said R2 is alert, he can press the call light, and we continue to remind him. V2 said R2's room is close to the nurses' station, to keep checking on him. V2 said R2 has fallen in the common areas and in his room. On [DATE] at 1:05 PM, V2 said that on the fall risk assessment, a score of 8 or more is high risk, 7 or below is low risk, and everyone is at risk. V2 said 10 is a high risk. V2 said a history of alcohol abuse places someone at risk for cognition or balance problems. V2 said I can use the BIMS to determine the resident's cognition. V2 said a new BIMS (cognition assessment) is not usually done with a fall, only for changes in behavior. On [DATE] at 2:36PM V4, Director of Rehab, said R2 has been seen with therapy. V4 said R2 was last seen [DATE] thru [DATE] and prior to that [DATE] to [DATE]. V4 said for [DATE] R2 had another fall and we recommend to see him again to educate on safety and body mechanics. V4 said R2 participates with interventions but he demonstrates poor safety awareness and poor insight to deficits. V4 said R2 required assist with ambulation for safety. V4 said R2's deficits include he is impulsive. V4 said at the time of discharge in [DATE] R2 has the ability to transfer with moderate assist and ambulate with moderate assist. V4 said R2 assistive devices include a wheelchair and rolling walker. V4 said R2 has poor carryover and is very challenging. V4 said the responsibility of activating the call light for help should not be on him. V4 said we anticipate him resisting and declining assistance. V4 said we have done extensive education and reminders for R2 to use the call light. V4 said when ambulating R2 leans back and we prefer staff just wheel him up to the toilet. On [DATE] at 3:00 PM V5, Restorative Nurse, said R2 can propel in the wheelchair by himself. V5 said R2 can stand by himself, but he needs supervision because of poor bilateral lower extremity strength. V5 said R2 is able to stand but not safe alone. V5 said R2 does not use a walker or a cane to ambulate, he can't walk. V5 said I can't remember if R2 is using a walker. V5 said the urinal could be helpful for R2. V5 said R2 was not offered a urinal. On [DATE] at 2:21 PM, V5 said R2 restorative programs include active range of motion, dressing, and grooming. V5 said R2 was not walking with nursing before last week. V5 said the the MDS is incorrect for [DATE], R2 was not walking with a walker at that time. V5 said his endurance was poor when R2 was walked last week; he has a crisscross gait pattern, and he needs cueing, hands-on assistance, and a wheelchair to follow. V5 said R2's posture is poor he looks down when walking. On [DATE] at 1:51 PM, V10, the Physician said R2's neuropathy could affect his ability to know where he is putting his feet to walk. R2's history of alcohol abuse may cause him to have some cognitive issues. Proprioception (perceiving location of movement) and cognition can be affected. R2 can be more impulsive due to the alcohol affects on his frontal lobes and cerebral effects. V10 said R2 can be alert and oriented and have less ability to compensate for balance. V10 said we can do a neuropsyche consult to see if there could be subtle issues affecting impulsivity and following instructions. R2 diagnosis include, but not limited to history of Maxillary Fracture ([DATE]), Zygomatic Fracture ([DATE]), Fall ([DATE]), Laceration ([DATE]), Alcohol Abuse, Hypertension, and Vitamin D Deficiency. R2 admitted to the facility on [DATE]. Progress notes dated [DATE] written by V10, Physician, documents R2 with history of gait disorder likely from alcohol abuse and neuropathy seen earlier today due to fall few days ago. R2's fall risk evaluation dated [DATE] indicates score of 10, high risk. Mobility the residents gate described as unsteady. On [DATE], R2's incident report states that the nurse was informed that the resident slid out of his chair and was on his bottom in the dining room. Mental status forgetful. On [DATE], R2's incident report states that at approximately 11:45 AM, the nurse heard a little commotion. The nurse went to the resident's room. The resident was sitting on their buttocks and fell unwitnessed. The resident stated I was trying to go to the bathroom. Mental status lack of safety awareness and forgetful. Post fall investigation states activity at the time of incident: attempting to stand or transfer. Mental status: poor safety awareness. Environmental factors: attempting to stand transfer without assistance. Fall risk: resident at risk for falls evaluation score 10. Resident has history of falls last fall [DATE]. Interventions bed in lowest position, call light within reach, education to use of call light. Root cause analysis: states resident with history of hypertension alcoholism was brought by family for continued weakness and falls at home. Patient has become increasingly difficult to care for self. Was a functional alcoholic. A cognition score of 15 indicates intact cognition. Resident fell on [DATE] because resident unsafely transferred himself to the bathroom without any assisted device and staff assistance call light was not utilized. Resident is non-compliant and overestimated self to perform task independently causing him to fall. Intervention resident will be provided with visual prompts to ask for help to help him communicate his needs. On [DATE] R2's incident report states nurse heard resident calling for help. Nurse observed resident sitting on the floor. Resident said that he transferred himself from wheelchair but unable to reach the bed and, hit his left eyebrow at the edge of the bedside table and sustained a small laceration with bleeding. Residents said I transferred from my wheelchair but missed the bed. Laceration on the left eyebrow measuring 1.0 by 0.3 centimeters with bleeding. Set to emergency room for evaluation and treatment via 911 Mental status alert with periods of forgetfulness lack of safety awareness. Post fall investigation states resident was last seen on his wheelchair he propelled himself to his room. Resident verbalized he is OK and does not need any further assistance. Nurse reminded resident to press call light when needed. Activity at the time of incident: attempting to stand or transfer. Mental status: poor safety awareness. Environmental factors attempting to stand transfer without assistance. Resident at risk for falls evaluation score 13. Fall interventions in place bed in lowest position, call light within reach, visual prompts provided. Resident was sent to hospital post fall and returned to the facility with stitches to left eyebrow. Root cause analysis: according to the resident, he was unable to reach the bed and hit his left eyebrow at the edge of the bedside table and sustained a laceration with bleeding. Resident was last seen sitting on his wheelchair. Resident is aware about the call light use but prefers to do task independently. He is assessed at high risk for falls and noted to be overestimating his capability at this time to perform task independently resulting in fall. R2's care plan dated [DATE] states he is at high risk for falls related to impaired balance during transitions, impulsivity or poor safety awareness, history of multiple falls and recent falls. Goal R2 will be free of falls through next review date. Interventions include I have periods of forgetfulness-staff to provide me a safe environment. Re-educate to use call light and remind to ask for assistance. R2's care plan, dated [DATE], states that the resident is noncompliant with the call light and transferring. I may not necessarily understand my physical limitations. I am noted to be non-compliant, omitting to use my call light or asking for assistance prior to transferring. I display poor decision-making and poor judgment. Interventions include anticipating resident needs. R2's cognitive assessment score on [DATE] is 15. No behaviors were exhibited on the behavior assessment dated [DATE]. The functional abilities assessment on [DATE] notes that R2 requires substantial to maximal assistance with hygiene and is dependent on staff for toileting. Our two mobility devices include a [NAME] and a wheelchair. The assessment on 10424 indicates that R2 ambulates with assistance. R2's quarterly restorative assessment dated 93024 indicates he requires assistance with ambulation and transfer and has a fear of falling. R2's resident education, dated [DATE], educated the resident regarding orientation to the call light. This is the last resident education documentation provided for R2. A list of R2's incidents include fall on [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; and [DATE]. R2's physical therapy Discharge summary dated [DATE] notes restorative program range of motion program active range of motion on both lower extremities as tolerated. R2's physical therapy Discharge summary dated [DATE] states a restorative program for ambulation and passive range of motion. Ambulation 150 feet using a rolling [NAME] with minimal assistance and close wheelchair follow for safety. R2's hospital record dated [DATE]: Laceration Repair on the left eyebrow with 2 sutures. The facility Fall Occurrence policy dated [DATE] states it is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Those identified as high risk for falls will be provided fall interventions. The interventions will be reevaluated and revised as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to follow a resident care plan related to use of helmet for one (R3) of five residents reviewed for falls and injuries. This failure resulted in R3 sustaining a right subdural hematoma after a fall incident. Findings include: R3 is a [AGE] year-old female, admitted in the facility on 02/16/23 with diagnoses of Traumatic Subdural Hemorrhage without Loss of Consciousness, Subsequent Encounter; Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Unspecified Fall Subsequent Encounter and Epidural Hemorrhage with Loss of Consciousness Status Unknown, Subsequent Encounter. According to MDS (Minimum Data Set) dated 11/10/23 under Section C, R3 has BIMS (Brief Interview of Mental Status) score of 3, which means severe cognitive impairment. R3's Fall risk evaluation notes dated 07/05/23, 07/27/23 and 01/30/24 recorded a score of 17 - 18 which means high risk for falls. According to incident report dated 01/30/24, at around 6:30 AM, V14 (Certified Nurse Assistant, CNA) came into R3's room with all the materials needed for her (R3) to be changed and observed her (R3) on the floor next to her bed lying on her back. V14 immediately called V13 (Licensed Practical Nurse, LPN) and responded immediately. R3 verbalized I don't know how it happened. I didn't hit the back of my head only my forehead. She (R3) complained of pain on forehead with a 3.0 cm (centimeters) laceration with bump, was given Tylenol for pain. Moderate bleeding was noted on the forehead. Pressure dressing and ice pack were administered to control the bleeding and was sent to the emergency room for further evaluation and management. On 03/05/24 at 3:35 PM, V14 was interviewed regarding R3's fall on 01/30/24. V14 replied, Around 5:45 AM to 6 AM, I went to her (R3's) room to change her (R3). She (R3) was still lying in bed. I told her (R3) that it is time to get changed. I went to grab some supplies in the cart. The cart was in front of her (R3's) room. While I was walking to grab the supplies, I heard her (R3) falling on the floor. I immediately came to her (R3) and saw her (R3) on the floor. It happened so fast. When I saw her (R3) on the floor, I noticed a laceration on her (R3's) forehead. She (R3) was not wearing the helmet. I put a pillow on her (R3's) head and left to go get V13. He (V13) came and did an assessment. V13 was also interviewed regarding R3. V13 stated, On 01/30/24, she (R3) had a fall. It happened early morning. V14 was to change R3. She (R3) was still in bed. She (V14) went out of the room and when she (V14) came back, she (R3) was already on the floor. She (V14) called me and I came into the room. She (R3) was on the floor. Her (R3's) forehead was bleeding. I put pressure on the forehead to stop the bleeding. When the bleeding stopped, I put a band aid, I applied cold pack. I asked if she (R3) has any pain, she (R3) said yes and I gave Tylenol. She (R3) was not wearing the helmet. I called paramedics as ordered and she (R3) was sent out. R3's Hospital Records dated 01/30/24 recorded: CT (Computerized Tomography) Head without contrast final result - Right Convexity Acute Subdural Hematoma measuring up to 6 mm (millimeters) in thickness. On 03/04/24 at 12:00 PM, R3 was observed in the small dining room attending activities, in her wheelchair. R3 was alert, and able to respond yes when called by name and stated she was doing fine. She was observed wearing a soft helmet. She (R3) is able to verbalize needs and wants. Per V11 (CNA), R3 always wear the helmet even when in bed and sleeping. R3 is also able to tell staff if she wanted to go to the bathroom. R3 was asked regarding fall incident on 01/30/24, stated she don't remember anything about the fall and refused to answer further questions. On 03/05/24 at 10:54 AM, she (R3) was again observed in the small dining room attending activities, sitting in her wheelchair with her soft helmet on. She (R3) stated she wants to go to the bathroom. V11 provided assistance. On 03/05/24 at 4:23 PM, V12 (Fall Coordinator) was asked regarding R3. V12 verbalized, She (R3) is alert, has impulsive behavior and has history of falls prior to coming to facility. That is why she (R3) wears the helmet 24 hours a day, even while sleeping. She (R3) has a behavior of removing the helmet. We have to always redirect her (R3) not to remove it. Staff has to make sure that the helmet is on. She (R3) has to be educated and reminded that she (R3) needs the helmet on at all times. On 01/30/24, she (R3) had a fall, early in the morning. I talked to V14, she (V14) said that she (V14) was doing rounds room to room and looked at R3. She (R3) was awake, and bed was at the lowest position, she (R3) was not in any distress. Her (R3) helmet was not on and was removed. Since she (R3) was in bed, she (V14) went outside to grab the supplies from the cart. The cart was outside the hallway by the door. When she (V14) went to grab the supplies, she (V14) turned and saw her (R3) on the floor. The cause of her (R3's) fall was she (R3) has this impulsive behavior. All staff were aware of her (R3) impulsiveness. Staff to make sure helmet is on at all times. On 03/06/24 at 3:08 PM, V10 (LPN) and V11 stated during interviews that R3 is alert, oriented to self and place but confused. V10 stated, She (R3) forgets things. She (R3) has a behavior of standing and walking to the bathroom without assistance. When she (R3) is in bed, she (R3) will yell for help, won't use the call light. Staff has to go there right away. If not, she (R3) is going to go by herself, right away. She (R3) is wearing the soft helmet. She (R3) came with the helmet, because she (R3) has previous history of head injuries. The helmet protects the head. V11 also added, She (R3) wears the helmet during my shift. Both also verbalized, If it happened that (R3) was not wearing the helmet, (R3) will look for it and ask for it. Even when (R3) sleeps, (R3) still must wear the helmet. During our shift, we have never seen (R3) removing the helmet. R3's care plans documented the following: (Date initiated 03/01/23) General behavior symptoms: Frequently removes helmet Interventions: Conduct a review of the behavioral symptoms to determine what strengths or abilities and needs are communicated via the behavior (example verbal behavior or verbal aggression often communicates a need to feel in control and assertive) Give psychoactive medication as ordered. Record behavioral symptoms (example, verbal/physical aggression, inappropriate behavior) and side effects (example, tardive dyskinesia, anticholinergic effects) Refer R3 to the consulting psychiatrist for a psychiatric evaluation, as warranted. (Date initiated 02/21/23) R3 admitted with soft helmet, on at all times for medical necessity. R3 can take it off upon command and put it back on Interventions: Staff to monitor any negative or adverse effects noted, including skin breakdown, signs and symptoms of delirium, fall/accidents/injuries, agitation, weakness. (Date initiated 06/13/23) At risk for falls related to cognitive impairment, decline in functional status, depression, impaired balance during transitions, impulsivity or poor safety awareness and recent fall Interventions: I have periods of forgetfulness, I would like staff to frequently reorient me to my surroundings. R3's hospital records dated 01/31/24 under History and Physical Note also documented that she has a history of left-sided stroke with craniotomy and subsequent cranioplasty back in 2010. On 03/06/24 at 3:26 PM, V15 (Nurse Practitioner) was asked regarding R3 and use of helmet during fall incidents. V15 replied, (R3) had a fall and had history of craniotomy, has neurocognitive issue. The soft helmet protects the head for injuries during falls. (R3) does not have normal protection of the head due to craniotomy. During fall incidents, the soft helmet can possibly protect (R3) from developing the subdural hematoma. The soft helmet reduces the risk of head injuries to happen during fall. Staff has to do a lot of redirections since (R3) has a behavior of removing it from time to time. (R3) must be redirected and monitored that she wears the helmet at all times. V2 (Director of Nursing) also verbalized during interview on 03/06/24 at 3:40 PM, (R3) has Dementia, and has behavior of impulsiveness. (R3) must wear the soft helmet at all times, even when sleeping. (R3) has a behavior of removing her helmet, so staff has to do redirection and monitor if she wears the helmet at all times. Back in 2010, she had a history of traumatic brain injury. admitted back to us in 2022 and had the helmet on. We continued the helmet. Wearing the helmet is part of the fall intervention due to history of brain injury which was caused by a previous fall. Her fall incident last 01/30/24, (R3) sustained laceration on the forehead and was diagnosed with right sided subdural hematoma. The CNA (V14) mentioned that she saw her (R3) that morning that (R3) was not wearing the helmet while in bed. She (V14) should redirect the resident to put the helmet back on at that time before she gets the supplies. Staff has to follow what is being care planned on R3. If the care plan states (R3) should be wearing the helmet, (R3) should be wearing the helmet at all times. If (R3) removes the helmet, staff has to redirect and asked her (R3) to put the helmet back on. Staff has to monitor her (R3) for any untoward behaviors. Facility's policy titled Fall Occurrence dated 07/17/23 stated in part but not limited to the following: Policy Statement: It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary.

Based on interview and record review the facility failed to notify the physician of an opened surgical wound for treatment orders. This affected one of three residents (R1) reviewed for quality of care of a surgical site. This failure resulted in R1's wound becoming infected with live insect larva and being sent to the local hospital for evaluation and treatment. Findings include: R1 face sheet show diagnosis of encounter for orthopedic aftercare following surgical amputation. Acquired absence of other left toe. On 10.29.23 at 3:07PM V4 (wound care coordinator) said she was the wound care coordinator, V4 she does initial wound assesses with measurements for new admission and readmitted residents Monday through Friday. V4 said she does the rounds with the wound doctor, input initial orders and order changes, she develops initial care plans for wounds and update the wound care plan, she completes MDS assessment for wounds. V4 said R1 had a left 5th toe amputation surgical wound upon admission. V4 said R1 was followed by the ortho (orthopedic) surgeon for orders and recommendations for wound care treatments. R1 was receiving betadine to the 4th and 5th toe, and the wound was open to air (no treatment dressing applied). V4 said the facility did not notice R1 wound to be infected. V4 said she was made aware that R1 was being sent to hospital for infection by the ortho clinic on 9.22.23. V4 said she conducted a weekly wound assessment on R1 on 9.19.23 and R1 wound was clean and did not have signs of infection, which is drainage, swelling, redness, odor, and R1 did not complain of pain. V4 said R1 did not voice any concerns about his wounds that would indicate there was an infection. V4 said R1's daughter in-law informed her that the maggots were inside the scabs of the surgical wound, and they were not visible and that they would not have seen it. V4 said the clinic sent R1 to hospital evaluation. V4 said R1 did not return to facility after hospital stay. V4 said they provided wound care treatments as ordered by the ortho physician. V4 said she did not see the maggots in the wound she cannot speak to how that happened. Review of R1 weekly wound assessments documentation dated 9.19.23 with V4 in comparison to prior week wound assessment, V4 said on 9.19.23 the scab came off R1 wound and the proximal local (closet to the head). V4 said there was a small opening. V4 said she did not notify the ortho surgeon V11, she did not notify the medical doctor V6. V4 said she did not have any concerns to notify the providers about. V4 was asked did R1 have a surgical wound, and if that surgical wound needed a covering since it had opened. V4 restated that V11 wanted the wound to be open to air. V4 said the wound opened a little. Review of the wound assessment picture, there is an area where there is no dark scab, and the wound is open. On 10.30.23 at 10:17am V10 (Assistant working with ortho physician V11) said they were in clinic, but she can assist surveyor. V10 said the doctor wanted to be notified of all wound changes, V10 said the doctor should have been notified of all wound changes. V10 said the nursing home did not notify the ortho doctor when R1 surgical wound opened on 9.19.23. V10 said the doctor would have recommended to cover the surgical site with a dressing. On 10.30.23 at 10:43am V6 (Medical Doctor) said R1 was followed by the ortho physician, and she would have referred the nurse to the ortho for any changes in condition. R1 progress note dated 9.22.23 denotes in-part resident was scheduled today am for follow up appointment with V11 orthopedic Surgery. Resident left facility via wheelchair with assist and transportation in stable condition around 7:00 am. Around 10:00 am received call from V11 office and spoke with Registered Nurse V10. Received information that resident was sent to Hospital ER (Emergency Room) for evaluation and treatment due to wound infection on left foot. Around 10:10 am spoke with ER regarding resident status and received information that resident is admitted with (diagnosis): wound infection on left foot. V6 was informed. Wound nurse informed. Resident POA (power of attorney) notified. DON (director of nursing), ADON (assistant director of nursing) aware. R1 orthopedic post operative visit dated 9.22.23 denotes in-part focused examination of the left lower extremity, there are two open wounds along the prior incision line quarter size near the distal aspect of the toe, there are visible maggots within the distal wound, numerous , live, protruding, there is surrounding erythema, there is malodor in the base of the wound there is devitalized necrotic tissue, proximal incision wound dime size 2 maggots seen within the wound bed. R1 care plan dated 8.3.2023 denotes in-part apply R1 is at risk for additional skin breakdown, R/T (related/to) chronic A-fib (atrial fibrillation), gangrene, PVD (peripheral vascular disease) , HTN (hypertension), acute kidney failure, thrombocytopenia, R1 was admitted with left 5th toe amputee, left 4th toe necrotic diabetic wound, R1 will not develop signs and symptoms of infection on the wound site. wound treatment as ordered by the physician, check skin every shift, report abnormalities to the nurse. Keep skin clean and dry, use lotion on dry skin. Monitor document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to MD (medical doctor). Facility's change in condition policy titled change in condition/ physician notification with last revised date 7.28.23, denotes in-part the facility will provide care to residents and provide notification of resident change in status. The facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in §483.12(a).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide supervision to prevent a dependent resident from falling for 1 of 3 residents (R3) reviewed for safety and supervision in the sample of seven. This failure resulted in R3 falling on 7/9/23 in her bathroom and sustaining a displaced intertrochanteric fracture of her right femur which required surgical intervention. The findings include: R3's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include bipolar disorder, nontraumatic chronic subdural hemorrhage, anxiety disorder, unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, anemia, end stage renal disease and unspecified falls. R3's facility assessment 6/18/23 documents R3 has severe cognitive impairment, requires extensive assistance of 1-2 staff members for all cares, and has a history of falls. R3's care plan initiated 6/14/23 showed, [R3] has impaired cognitive function related to traumatic subdural hemorrhage . Interventions . Break tasks into one step at a time. Cue, orient, and supervise her as needed. R3's care plan initiated 6/13/23 documents, [R3] requires assistance with ADL's (activities of daily living) (bed mobility, transfers, dressing, walking, personal hygiene, eating, and toileting). admitted [R3] to this facility on 6/13/23 from [acute care hospital] status post fall with left frontal lobe subdural hematoma, had hematoma drained and presents with incision on left frontal lobe . period of forgetfulness, able to follow commands, pleasant and cooperative with care, needs cueing, demonstrations, and encouragement from staff for task . Resident needs extensive assist of 1 staff for ADLs . Interventions . Resident on trial for sensor pad alarm in bed to notify staff when there's an attempt to get out of bed without calling for staff assistance . R3's care plan initiated 6/14/23 documents, [R3] is high risk for falls related to anxiety disorder, decline in functional status, impaired balance during transitions, impulsivity, poor safety awareness, fall in the last month and recent fall . Interventions . I have period of forgetfulness. I would like staff to frequently reorient me to my surroundings . R3's fall investigation dated 7/9/23 documents, Around 8:20 AM, CNA went to the resident to serve resident breakfast tray. Resident asked CNA to take her to the bathroom to use the toilet. CNA assisted resident on the toilet and gave residents privacy by closing the door partially and placing call light within reach. While CNA was waiting on resident, CNA heard a noise and responded immediately. When the CNA opened the washroom door, CNA observed the resident laying on the floor on the right side facing the door. Nurse on duty was near resident room and also heard the noise and immediately responded . resident displays signs of pain when moving right left . R3's acute care hospital documentation operative notes showed R3 was admitted to the acute care hospital on 7/9/23 after she sustained a right hip fracture and underwent a surgical repair of her right hip on 7/10/23. R3's July 2023 Physician Order Sheet documents a 7/17/23 order for Right Hip- Cleanse with NSS (normal saline solution), pat dry, apply Betadine paint and cover with bordered gauze dressing daily and as needed. On 7/29/23 at 9:56 AM, R3 was lying in bed. R3 was agitated and tearful asking for her husband. On 7/29/23 at 12:59 PM, V10 CNA (Certified Nursing Assistant) said, If a resident with dementia and confusion needs to go to the bathroom we have to stay with them for their safety. On 7/29/23 at 1:11 PM, V9 CNA said, It was breakfast time, I took her tray into the room and she was trying to get up and go to the bathroom. She was assisted to the bathroom . she said she wanted privacy. I was in the bedroom, she started screaming like something was wrong. It happened so quick. She was on the toilet saying something in her language and the next she was on the floor. The nurse heard it too and came in. On 7/29/23 at 2:16 PM, V3 (Fall Coordinator) said, [R3] was admitted to use with a chronic subdural hemorrhage. I looked at the referral and she had lots of falls . very confused and impulsive. If she wants to get up she gets up. She is unsteady. She has poor safety awareness . The CNA took her to the toilet and she insisted on closing the door to the bathroom for privacy. The CNA didn't close the door all the way because she knew she was impulsive. She gave her the call light. [R3] can sometimes use the call light. The facility's policy and procedure revised 5/17/23 titled Fall Occurrence showed, . Policy Statement, It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary .

Based on observation, interview and record review the facility failed to follow its policy in using restraints and failed to prevent a physical restraint from being used for staff convenience for one resident (R140) in the sample of 31 residents reviewed for restraints. These failures resulted in psychosocial harm in that, a reasonable person would react to such physical restraint with feelings of agitation, anxiety, frustration, fearfulness, humiliation, and punishment. Findings include: On 3/28/23 at 4:43pm, Observed R140 sitting on chair with walker in front of her. The frame of the walker is tied together with the arm rest of the chair extending around the back of the chair with plastic rope. Call light is not within reach. Called V17 Agency CNA assigned to her. V17 said that she tied R140 to her walker and chair to prevent her from getting out of chair and to prevent falling. She cannot watch her because she has to give a shower to another resident. V17 added that R140's family requested it and has been doing it to prevent her from falling if no one can watch her. On 3/28/23 at 4:48pm, Called V18 Agency Nurse and showed observation made. V18 said that she is not aware of restraining R140 to her chair and walker with rope. She said, this is a restraint, this is not right and not acceptable. V18 called V3 DON and V5 Fall coordinator. On 3/28/23 at 4:52pm, Showed observation made to R140 to V3 DON and V5 Fall Coordinator. V3 and V5 said that they are not aware that R140 is being restrained to chair and walker. Both said that they don't allow restraints in the facility. Both said that V15 Family member did not to talk to them about wanting R140 to be restrained. On 3/29/23 at 12:40pm, V15 Family member said that no one called her to explain what new fall prevention interventions were implemented for R140 to prevent her from falling again. Review of R140's medical records did not indicate that V15 requested R140 to be restrained. Facility's policy on Restraints indicates: It is the facility's policy to ensure that each resident is not restrained for the purposes of discipline or convenience. The facility will utilize non-restraining interventions first before trying to restrain -type devices which will be considered as last resort. Physical restraint is defined as any manual method, physical or mechanical device equipment or material that meets all the following criteria: a. attached or adjacent to the resident's body b. that the individual cannot intentionally remove easily and c. restricts freedom of movement or normal access to one's body.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide adequate supervision to residents who are at high risk for fall and has history of falls. This failure caused one resident ( R117) to be hospitalized for surgery due to a fracture. The facility also failed to implement fall preventive intervention care plan. This deficiency affects 2 (R48, R117) residents in a sample of 31 reviewed for Fall prevent management. Findings include: 1. On 3/28/23 at 4:59pm, R117 was lying in bed moaning and restless. R117 is admitted on [DATE] with diagnosis list in part but not limited to Aftercare following joint replacement surgery, Displaced fracture of base of neck of right femur, Alzheimer's disease, Epilepsy and epileptic syndromes with complex partial seizures, Parkinson's disease, Neurocognitive disorder with [NAME] bodies, old myocardial infarction. The Fall assessment dated [DATE] indicated he is at high risk for fall. Care plan indicated he is at high risk for falls related to Alzheimer's disease, cognitive impairment, fatigue, weakness, seizures disorder, use of hypnotics, non-compliant with using his walker when ambulating, history of falls and recent falls. He has impaired cognitive function due to dementia. He has ADL self-care performance deficit. Intervention: Transfer- requires staff supervision to limited x 1 staff. There were no interventions in place for ambulation/locomotion in care plan. R117's MDS quarterly assessment dated [DATE] indicated that he needs limited assistance in transfers, supervision in walking in the room and locomotion on the unit. R117's Incident Report documents that the resident had an unwitnessed fall on 9/13/22 where the resident was found lying on the floor in the hallway, and a witnessed fall on 3/3/23 where the resident tripped in the dining room and hit his head on the door. R117 was sent to the hospital and admitted with minimally displaced and angulated right femoral neck fracture. A post fall investigation was done and indicated R117 needs supervision from staff when ambulating due to an unsteady gait and muscle weakness. The care plan updated but it was not indicated in care plan that he needs supervision when ambulating and assistance in transfers. R117's hospital records dated 3/3/23 indicated: X-ray of the right femur reveal minimally displaced and angulated right femoral neck fracture, with angulation of the right hip. A right hip replacement was done on 3/6/23. On 3/29/23 at 2:31pm, Review R117's medical records with V5 Fall Coordinator. Informed concerns of inadequate supervision for both falls. R117's MDS quarterly assessment dated [DATE] indicated that he needs limited assistance in transfers, supervision in walking in room and locomotion in unit. No intervention in place for ambulation/locomotion on care plan. Both post fall investigations indicated that R117 needs supervision from staff in ambulation due to unsteady gait, muscle weakness, and poor safety awareness. 2. On 3/28/23 at 4:29pm, R48 was sleeping in bed and there was afolded floor mat on the side of the dresser. The bed was not in the lowest position. The bed was pushed against the wall. V26 Agency nurse was shown the observation of R48. V26 said that R48 does not use the floor mat, it was brought to the facility by the hospice staff. V26 said that R26 is a fall risk due to her morphine medication and she is on hospice care. Asked V26 if the bed is in the lowest position, she said no. V26 said that she has to check R48's chart to see if her bed needs to be in the lowest position. On 3/29/23 at 3:00pm, R48 was sitting in the wheelchair. V5 Fall Coordinator assisted R48 to stand up to check the placement of the non-skid mat on the seat of her wheelchair. There was no mat found. V5 said that she should have a non-skid mat in place as part of the fall prevention interventions. On 3/29/23 at 4:10pm, R48 was observed sleeping in bed with a folded floor mat on the side of the dresser. The bed is not in the lowest position. The bed is pushed against the wall. Called V7 Restorative Nurse and V23 RN was standing outside R48's room and was shown the observations made. Both staff members said that R48's bed should be in the lowest position and the floor mat should be on the floor when the resident is in bed. V7 adjusted the bed to the lowest position and placed the floor mat on the right side of the bed. R48 is admitted on [DATE] with diagnosis listed in part but not limited to Parkinson's disease, Restlessness and agitation, Dementia, Depression, Anxiety, Wedge compression fracture of the second lumbar vertebrae. Fall assessment dated [DATE] indicated that she is at high risk for fall. Care plan indicated: She is at high risk for fall related to anxiety disorder, depression, Parkinson's disease and recent falls. A non-skid mat is to be added to her wheelchair to minimize her risk for sliding. She demonstrates cognitive impairment related to dementia and Parkinson's. R48's Incident Report documents unwitnessed falls where the resident slid from the wheelchair on 5/12/22 and 7/29/22, and a witnessed fall from the wheelchair on 3/23/23. On 3/29/23 at 10:30am, V30 CNA and V24 RN were interviewed and V30 said she was fixing the new low air loss (LAL) mattress that was placed on R48's bed when she slid from the wheelchair when trying to pick up something. V30 said that she landed on the folded mattress. Both V30 and V24 said that R48 is not using a floor mat brought by hospice care. On 3/29/23 at 2:31pm, R48's medical records were reviewed with V5 Fall Coordinator. V5 was informed of concerns of inadequate supervision related to falls. On fall incident dated 5/12/22, the care plan was updated but not based on the root cause analysis of the fall. R48 slid from the wheelchair and forgot to unlock her wheelchair. V5 said that she was not the fall coordinator at the time of the incident. V5 said that she has not done the post fall investigation yet. V5 provided updated fall care plans for R48 pending completion of post fall investigation. New fall intervention implemented: Place the bed in the lowest position and floor mats. Facility's policy on Fall occurrence indicated: It is the policy of the facility to ensure that the resident are assessed for risk for falls, that interventions are put in place and interventions are re-evaluated and revised ad necessary. Procedure: 2. Those identified as high risk for falls will be provided fall interventions. 5. The Fall coordinator will review the incident report and may conduct her own fall investigation to determine the reasonable cause of fall. 6. The nurse may immediately start interventions to address falls in the unit, even prior to fall coordinator's investigation. 8. The fall coordinator will add the intervention in the resident's care plan. 10. The interventions will be re-evaluated and revised as necessary.