**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow a provider order for a STAT (immediately) x-ray to be completed for a resident after a fall. This failure applied to one (R1) of three residents reviewed for accidents and resulted in R1 having a delay in being transferred to the hospital for evaluation and treatment of a fractured hip, which required surgical intervention. Findings include: R1 is a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses that include: right femur fracture; unspecified dementia, moderate, w/out behavioral disturbance, psychotic disturbance, psychotic disturbance, mood disturbance, and anxiety; and mild cognitive impairment. Fall Report dated 1/24/25 3:34pm written by V8 (Licensed Practical Nurse / LPN) reads: Incident Description: Writer heard residents in the dining room yelling. When writer got to the dining room to assess what was going on the patient (R1) was noted laying on the floor on her right side while other resident (R2) was standing over her. Floor was noted dry and free of clutter. Noted walker was next to resident at the time of the incident. Immediate Action Taken: Patient was assessed from head to toe and was given pain medication and helped back to her room. NP (V9-Nurse Practitioner) assessed resident and ordered right hip x-ray and bilateral shoulder x-ray .Patient reported having pain in her right hip. There was no bruising or shortening of her legs . Mobility: Ambulatory with assistance Nursing progress notes read the following: 1/24/2025 3:58pm Nurses Note written by V8 (LPN) reads: Note Text: Writer heard residents in the dining room yelling at each other. When writer got to the dining room to assess what was going on the patient (R1) was noted laying on the floor on her right side while other resident (R2) was standing over her. Writer checked residents vitals and is as follow; bp (blood pressure) 126/86, rr (respiratory rate) 18, p (pulse) 71, o2 (oxygen saturation) 98%. Pupils equal and reactive and same size and no weakness bilateral, Patient reported having pain in her right hip. There was no bruising or shortening of her legs. Resident was assisted back to her room and given pain medication. The administrator was informed and the (V9) NP was informed. (V9) NP assessed patient and asked writer to order right hip x-ray and bilateral shoulder x-ray. All orders carried out. Administrator informed writer that she would contact family. Patient was assisted into bed and made comfortable. HOB (head of bed) raised and call light within reach. 2/08/2025 at 6:08PM V10 (Registered Nurse/RN) said, I have worked here almost a year. On 1/24/25 I worked 3-11pm. During that time, the morning nurse endorsed to me that there was an incident that another resident pushed R1 and that's why she fell. They ordered an x-ray. The morning nurse ordered the x-ray. Surveyor asked V10 if the x-ray company was called to find out the status. V10 responded, yes and they said that they would come but I don't remember them giving me a time frame. If an x-ray is ordered STAT (immediately) it should be ordered within 30 minutes to one hour. Since they said they would come, I endorsed it to the next nurse for them to follow-up again. Surveyor asked if it was expected that the x-ray company would not come within the timeframe of the eight hour shift that V10 worked. V10 said, no, I know it should have been done sooner. I don't remember what time I followed up with them. When asked if anything should have been done differently, V10 said, maybe I would have followed up again and informed the supervisor and then maybe we could have sent the patient to the hospital. During my assessment with her she was sleeping at first. Towards the end of the shift, I checked her again, I touched her left and right back and you could notice that she was in pain. The first thing I did was put the Lidocaine patch and give Tylenol since those pain orders were already in the system. V10 affirmed that she did not call the doctor to notify them that R1 was having pain but did endorse it to the oncoming nurse; because it was towards the end of V10's shift already. V10 added, I did assess her lower extremities and I didn't see any swelling or shortening of the leg. She (R1) was quiet, but she had facial grimacing when I touched her back. I applied the Lidocaine patch to her back. V10 said, sometimes when I call (x-ray company) they give a rough estimate but not an exact time. They may say we'll be there in the morning or evening but not an exact time. 2/8/25 at 6:20PM V11 (LPN) said, I have worked at the facility about 14-15 years. I normally work the overnight shift. I remember that the 3-11 nurse told me that R1 had a fall and that we were waiting for the x-ray company to come and take the x-ray. I made rounds and she was in bed sleeping so I did not touch her. When I made rounds again, she had her eyes open, and I asked her if she was in pain. She is hard of hearing, so I checked her leg. When I moved her leg, she made a noise and verbalized ow. I noticed the swelling and I called V2 (Director of Nursing/DON) and the doctor right away to tell them that I had to send her to the hospital. I called the x-ray company and they said they were on their way but with the swelling and the little bit of external rotation I did not want to wait for the x-ray company. I left a message with the doctor, called her POA (Power of Attorney), and notified V2 (DON) that I had to send R1 out. I called the ambulance, and they were here within 10 minutes. For x-rays that are ordered STAT, I don't really encounter that problem (with delays) because I work night shift so there are not a lot of incidents because the residents are sleeping. My expectation as a nurse is that if it's a STAT x-ray they come soon. I don't think that I would wait eight hours for a STAT x-ray; so, they should come right away. I would follow up again and see if they are really coming to do the x-ray and if they still are not coming and it's a fall, I would have to use my judgment as a nurse. If I notice something unusual, I will call the doctor, Director of Nursing, and POA right away to send the patient to the ER. I did my part as the nurse on duty. I know the assessment is very important as a nurse, especially when the patient has had a fall. I always make sure that I check them right away and do frequent rounds because they might not have a visible injury right away, but you never know. You might think there is nothing wrong and then later on you see something. I always ask the CNA (Certified Nurses Assistant) for help because if they are sleepy, they may hit you or something because it is a dementia unit. 2/08/2025 at 5:06PM V2 (DON) said, since R1 hasn't had a fall for years she can be independent. The reason we have her as supervision (on MDS) is more for incontinence because she needs assistance to the bathroom. Again, she hasn't had any falls. When she doesn't have an infection, her ambulation is quite good. For us, the concern was because of the UTI (urinary tract infection) and the COVID with this fall. She walks around in the morning and in the afternoon but it's not realistic for us to have a one to one. Someone is always there. There is always staff monitoring them. Someone always has to be visible in the hallway, but they can't just be sitting in the dining room. It has to be something that's going to work for all residents. I can't restrain her. She is safe to walk around with the walker. If we order a STAT x-ray, it should be done within a 4-6-hour window and we do call that in after we call the nurse practitioner. We noticed there was swelling in the right leg, and we notified the doctor. At 10:38pm it was the left right back where she was having pain. No mention of swelling. If the x-ray isn't done within 6 hours, we call the doctor to send them out to the hospital. If it's not STAT, then waiting 24 hours is okay. 2/8/25 at 3:20PM V9 (NP) said, I wasn't a witness to the incident. I just remember that it was unclear circumstances. She fell and broke her hip and required an ORIF (Open Reduction and Internal Fixation - (ORIF) is a type of surgery used to stabilize and heal a broken bone). Typically, those x-rays are ordered STAT (immediately) but I'm not sure what time the x-ray was done. V9 was asked if she would expect the facility to wait 12 hours for a STAT x-ray to be done. V9 said, if the patient was not feeling well, I would have expected it a lot sooner or the patient sent out. The nurses told me she was pain free and I didn't think she had broken that hip based on how she looked really. But if the nurses assessed and she was not in pain I could understand why she wasn't sent out sooner. When I saw her (immediately after the fall), she was stable, and I asked if she had any pain and she said no. It could have been pain from the fall and if they knew the x-ray department wasn't coming in time then of course they should not wait. As much as I wish they would come sooner, we are at their (x-ray company) mercy. For a STAT x-ray, I would ideally like it done within the hour but at least 3-5 hours. Review of R1's hospital record documents that R1 was admitted on [DATE] for a right, closed, hip fracture. Physical exam documents that R1's right hip was externally rotated, pulses intact and pain with movement of the hip. Hospital x-ray confirmed partially impacted right femoral neck fracture; mild to moderate displaced fracture of the right superior and inferior pubic rami. Hospital record also documents that R1 had sepsis, urinary tract infection, pneumonia, COVID-19, and leukocytosis present on admission, in addition to the fracture. Facility policy titled, Physician Notification of Laboratory/ Radiology/Diagnostic Results (last revised 7/8/24) reads: Purpose: To assure physician ordered diagnostic test are performed, and to assure test results are reported to the ordering physician so that prompt, appropriate action may be taken if indicated for the resident's care. Guidelines: A licensed nurse is responsible for assuring the laboratory is notified of physician's orders for testing. A requisition is to be completed and lab to be drawn on next scheduled lab draw day UNLESS Stat or Same Day order is received. oCollect and label specimen, name, date, time and name of test. Place in plastic transport bag - note stat. oCall for transport service. STAT or Same Day orders will be called to the laboratory service by the nurse who transcribes the order. A nurse is responsible for monitoring the receipt of test results. Laboratory and/or diagnostic company will contact assigned licensed nursing staff with any abnormal or critical results that require prompt attention. Test results should be reported to the primary care physician or other ordering practitioner pursuant §483.50 Laboratory, radiology, and other diagnostic services guidelines. Guidelines for Reporting Abnormal Results: o All Critical laboratory values - also called Alert or Panic values o X-ray or other diagnostic tests reveal suspected findings which may require immediate intervention including but not limited to: o Pneumonia o New fracture In the event a physician does not respond promptly to attempts to convey critical laboratory results, the alternate physician or Medical Director will be notified. Promptly may be defined based on the clinical condition of the resident and the judgement of the nurse in each individual situation. For example, some conditions may require immediate 911 intervention, others may be delayed 4 or more hours if the condition of the resident is stable. Should the alternate physician or Medical Director not respond, the Director of Nursing will be notified. The Director of Nursing interventions should include: o Assessment of the resident's clinical condition (in person or by phone) o Further attempt to contact the Physician, Alternate Physician or Medical Director o Emergency transfer based on clinical judgement .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide supervision/touching assistance for a resident when moving from a seated to standing position, per the residents plan of care and assessments, in order to prevent a fall. This failure applied to one (R1) of three residents reviewed for accidents and resulted in R1 having a fall causing a fractured hip that required surgical intervention. Findings include: R1 is a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses that include: right femur fracture; unspecified dementia, moderate, w/out behavioral disturbance, psychotic disturbance, psychotic disturbance, mood disturbance, and anxiety; and mild cognitive impairment. R1's Minimum Data Set (MDS) assessments document the following: 1/4/25 Section GG Functional Abilities codes R1 as requiring supervision or touching assistance during sit to stand (ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed); walk 10 feet (once standing, the ability to walk at least 10 feet in a room, corridor, or similar space); walk 50 feet with two turns (once standing, the ability to walk at least 50 feet and make two turns); walk 150 feet (once standing, the ability to walk at least 150 feet in a corridor or similar space). Fall Report dated 1/24/25 3:34PM written by V8 (Licensed Practical Nurse / LPN) reads: Incident Description: Writer heard residents in the dining room yelling. When writer got to the dining room to assess what was going on the patient (R1) was noted laying on the floor on her right side while other resident (R2) was standing over her. Floor was noted dry and free of clutter. Noted walker was next to resident at the time of the incident. Immediate Action Taken: Patient was assessed from head to toe and was given pain medication and helped back to her room. NP (Nurse Practitioner) assessed resident and ordered right hip x-ray and bilateral shoulder x-ray .Patient reported having pain in her right hip. There was no bruising or shortening of her legs . Mobility: Ambulatory with assistance Nursing progress notes read the following: 1/24/2025 3:58PM Nurses Note written by V8 (LPN) reads: Note Text: Writer heard residents in the dining room yelling at each other. When writer got to the dining room to assess what was going on the patient (R1) was noted laying on the floor on her right side while other resident (R2) was standing over her. Writer checked residents vitals and is as follow; bp (blood pressure) 126/86, rr (respiratory rate) 18, p (pulse) 71, o2 (oxygen saturation) 98%. Pupils equal and reactive and same size and no weakness bilateral, Patient reported having pain in her right hip. There was no bruising or shortening of her legs. Resident was assisted back to her room and given pain medication. The administrator was informed, and the NP was informed. NP assessed patient and asked writer to order right hip x-ray and bilateral shoulder x-ray. All orders carried out. Administrator informed writer that she would contact family. Patient was assisted into bed and made comfortable. HOB (head of bed) raised and call light within reach. 2/7/25 at 3:38PM V7 (Certified Nursing Assistant / CNA) said, I was standing by room [ROOM NUMBER]; not in the dining room. I was supervising the unit. R1 and R2 were having a verbal disagreement. I saw R1 put her hand on the walker to get up and the walker tipped over and she fell on the right side. At no point did I see R2 hit R1 or R1 hit R2. The nurse then came, and the other CNA came to help. No issues with either of them being aggressive with other residents. There were no other residents in the dining room at that time. 2/8/25 at 1:13PM V8 (LPN) said, I have worked here since May 2024. I normally work on the second floor but recently I have been floating around. Regarding the incident with R1 and R2, I was at the nurses station charting and I heard a commotion. I went to the dining room and R1 was on the floor. R2 was in the room, right next to her or over her. I don't remember exactly. The dining room is not in view of the nurses' station. I think they were right when you first go into the dining room. I don't recall any other residents being in there are the time. When I got there the CNA (V7) was there. I don't remember her name because I don't work with her that often, but it wasn't CNA (V4) because I know her, so yes it was V7 and then V4 came in after. R1 was hysterical and saying, I fell. I was asking her what happened, but she was just saying that her leg hurt. I just examined her, and we helped her get up and I called V1 (Administrator). R1's walker was in there with her. I usually see her getting up independently and she walks over to the dining room with her walker, sometimes I'll see her by the nurses station. Surveyor asked V8 if she would have expected someone to be in the dining room monitoring R1 and R2. V8 responded, there is usually someone in there monitoring. I know that around that time of day, a lot of them like to walk around. Right before the shift ends there are rounds and I am usually charting getting ready to go home. I don't know if the CNA was in there the entire time. She didn't report anything specific to me. I had to open my charting, call V1 (Administrator) and the Nurse Practitioner (NP). When I did go to get a statement from V7, I couldn't find her. I assumed she had left for the day. The NP ordered the x-ray. We helped R1 to her room and then right after that, the NP came to the floor and assessed her as well. Surveyor asked, what type of supervision is expected for a resident who has an MDS code of (4) Supervision / Touching Assistance. V8 said, I would say that you have to guide them and be there when they are getting up so if they look weak you may have to provide them with more assistance than usual. A lot of times they get up on their own, but you have to watch them. I would expect for someone to be around them when they are getting up from the bed or chair. I would probably say staff should be within eye length distance; within your view. I have never seen R1 get aggressive. I have heard about R2 getting aggressive, but I have never witnessed it; he may touch things or move things around; or he can get close to you. Again, I haven't experienced that with him. 2/7/25 at 2:03PM, V3 (LPN) said she was not present during the incident with R1 and R2. V3 said that the residents must always be monitored because this is a dementia unit. Some people can be more agitated, and we have to monitor them closely and they can fall. Safety is the priority. V3 added that she has not witnessed any abuse between R1 and R2 but that R1 can get mad at times, and she is hard of hearing so she can get frustrated. 2/7/25 at 2:17PM, V4 (CNA) said, I was here during the incident with R1 and R2, but I was in the room with another resident. R2 was out for a few months but he is calm now and seems to have gotten better actually. Someone is in the dining room at all times; the residents can fall. If activities is in the dining room, they will monitor them too. 2/7/25 at 2:34PM V2 (Director of Nursing) reviewed facility fall report with surveyor. V2 added that they were not aware that R1 had COVID at the time of the fall, until the hospital called to report it to them. There are cameras in the dining room, but you can ask V1 (Administrator) to see it. All of the progress notes and assessments are in the chart. 2/7/25 at 2:45PM V1 (Administrator) said there is no video to see currently because the cameras loop every 48 hours. V1 added, I didn't get a chance to look at the video. I had left early that day because I had just gotten back from vacation. This was our only incident for January. I unsubstantiated the abuse. I initially reported it as abuse because the nurse (V8) said she didn't know what happened but assumed R2 pushed R1. During my investigation though, V7 (CNA) said she saw when R1 fell and that R2 had not pushed her. V7 said she was walking towards the dining room and could not get to R1 before she fell. When I tried to interview R1, she said she couldn't hear me, and she was confused. The combination of COVID and UTI (urinary tract infection) explain a lot about why she fell. V1 added that R1 is normally very careful when getting up but that having the infections contributed to the fall. It had been a while since R1 had any falls or infection. 2/08/2025 at 5:06PM V2 (Director of Nursing) was interviewed, and surveyor asked if R1 should have been supervised when getting up from the chair or had supervision while in the dining room since her MDS has her coded as requiring supervision and/or touching assistance. V2 said, since R1 hasn't had a fall for years she can be independent. The reason we have her as supervision is more for incontinence because she needs assistance to the bathroom. Again, she hasn't had any falls. When she doesn't have an infection, her ambulation is quite good. For us, the concern was because of the UTI and the COVID with this fall. She walks around in the morning and in the afternoon but it's not realistic for us to have a one to one. Someone is always there. There is always staff monitoring them. Someone always has to be visible in the hallway, but they can't just be sitting in the dining room. It has to be something that's going to work for all residents. I can't restrain her. She is safe to walk around with the walker. 2/8/25 at 7:10PM V1 (Administrator) said, V7 (CNA) was standing in front of room [ROOM NUMBER] and if she had been in the dining room, she would not necessarily have been any closer to the resident. We will send you a picture of the distance from the room to the dining room entrance where the residents were at the time of the fall. She was about 5 feet from the resident at the time of the fall. Review of R1's care plans include: High Risk for Falls, Initiated: 2/18/21, Revised: 2/7/25 Interventions: Needs activities that minimize the potential for falls while providing diversion and distraction (Initiated: 2/18/21); Be sure call light is within reach and encourage (R1) to use it for assistance as needed (Initiated: 2/18/21) (R1) presents with a functional deficit in ambulation due to: generalized weakness, Initiated and Revised: 4/5/21 Interventions: Staff to assist as needed (Initiated: 4/5/21); Observe for signs/symptoms of fatigue, SOB (shortness of breath), pain, discomfort, or intolerance (Initiated: 4/5/21) (R1) has an ADL Self Care Performance Deficit related to Dementia and dx of HL, HTN (hypertension), and h/o (history of) UTI, Initiated and Revised: 2/18/21 Interventions: Encourage (R1) to use bell to call for assistance (Initiated: 2/18/21). R1's restorative observation - quarterly review, dated 11/12/24 documents that R1 has Maintained ability to ambulate 100-200 feet using rolling walker with staff supervision .Resident AO (Alert and Oriented) x1-2, able to express needs, able to feed self, able to follow simple command, continent of bowel, occasionally incontinent of bladder, ambulatory with supervision touching assist using rolling walker .Resident with ADL (Activities of Daily Living) Self Care Performance Deficit related to generalized weakness, unsteady gait and poor safety awareness. Resident requires supervision to partial assist to safely complete ADLs . R1's fall risk assessment dated [DATE], documents that R1 is high risk for falling, with a weak gait and mental status limitation of overestimates or forgets limits. 2/8/25 at 3:20PM V9 (Nurse Practitioner) said, I wasn't a witness to the incident. I just remember that it was unclear circumstances. She fell and broke her hip and required an ORIF (open reduction and internal fixation (ORIF) is a type of surgery used to stabilize and heal a broken bone). Review of R1's hospital record documents that R1 was admitted on [DATE] for a right, closed, hip fracture. Physical exam documents that R1's right hip was externally rotated, pulses intact and pain with movement of the hip. Hospital x-ray confirmed partially impacted right femoral neck fracture; mild to moderate displaced fracture of the right superior and inferior pubic rami. Hospital record also documents that R1 had sepsis, urinary tract infection, pneumonia, COVID-19, and leukocytosis present on admission, in addition to the fracture.

Based on observations, interviews, and record reviews, the facility failed to consistently monitor resident's skin every shift, turn and reposition every two hours, carry out wound treatment orders as prescribed, and implement pressure relieving interventions to prevent a facility acquired pressure ulcer from recurring for one resident. This affected one of three residents (R3) reviewed for pressure sore prevention. This failure resulted in R3's sacral/right buttock stage 3 pressure ulcer re-opening and new wound treatment orders to be obtained. Findings include: On 12/13/23 at 10:40am, this surveyor observed V12 CNA (certified nurse aide) perform incontinence care for R3. R3 was observed to have a small blue brief tucked within large yellow brief. There was a disposable incontinence pad also under R3. V12 removed the briefs, provided care, and placed two new briefs on R3. Barrier cream was not applied to R3. On 12/13/23 at 11:00am, this surveyor observed V3 (wound care nurse) perform wound care treatments for R3. R3's sacrum to right buttock stage 3 pressure ulcer was cleaned with normal saline, then medihoney, adaptic, and calcium alginate were applied to wound and covered with a bordered gauze dressing. On 12/13/23 at 12:43pm, V3 stated that R3' sacrum to right buttock wound opened again. V3 stated that V3 observed wound open during wound treatment today. V3 stated that he will notify the physician that wound has re-opened and obtain treatment orders. V3 stated that there should be a single flat sheet and one brief when a resident is on a low air loss mattress. V3 stated that a disposable incontinence pad and double briefing resident is not recommended. V3 stated that the low air loss mattress manufacturer's instructions recommend only a flat sheet under resident. V3 stated that he was not aware that V10 (wound care physician) changed R3's treatment order for R3's sacrum/right buttock wound on 12/6/23. V3 acknowledged R3's sacrum/right buttock treatment should have been changed on 12/6 per V10's order. V3 stated that low air loss mattress are designed to allow air flow to pass through and prevent moisture build up. On 12/13/23 at 2:00pm, V3 was observed performing wound care treatment for R3. R3's wound measures 2.5cm x 1cm. V3 stated that the wound is superficial, shallow open wound. On 12/13/23 at 3:15pm, V10 (wound care physician) stated that V10 was not aware staff have been placing two incontinence briefs on R3 when providing care. V10 stated that using two incontinence briefs could affect wound healing and should not be used. V10 stated that there is no literature in medical journals on what effect the incontinence pad would have on wound development or deterioration. V10 stated that it is common sense not to use two briefs and an incontinence pad under resident on low air loss mattress. V10 stated that he spoke with V3 (wound care nurse) and gave new treatment orders for R3's sacrum/right buttock wound. On 12/13/23 at 3:35pm, V11 (nurse) stated that when the order is written in the resident's EMR (electronic medical record), it is also entered on the resident's TAR (treatment administration record). V11 stated that all scheduled treatments will pop up when due when in the resident's EMR. V11 stated that if a treatment is scheduled for day shift, evening shift, and night shift, it will continue to pop up until it is marked as completed by the nurse on that shift. V11 stated that skin checks are completed every shift for all residents. V11 stated that if the scheduled treatment time on the TAR is blank then the treatment was not done. V11 stated that the nurse should make sure all scheduled treatments for his/her shift are completed. R3's medical record notes R3 with diagnoses including, but not limited to, left buttock stage 4 pressure ulcer, right buttock stage 3 pressure ulcer, chronic respiratory failure, tracheostomy, ventilator dependent, functional quadriplegia, gastrostomy, and anoxic brain damage. R3's MDS (minimum data set), dated 11/2/23, notes R3 with severely impaired cognition and total dependence on staff for all ADLs. R3's braden score, dated 12/8/23, notes resident is at very high risk for skin breakdown. R3's POS (physician order sheet), dated 11/10/23, notes an order for a low air loss mattress. There is an order, dated 11/15, for heel protector at all times or offload with pillows. On 12/2, skin checks every shift. On 12/11, turn and reposition every two hours and as needed. R3's ADL care plan, revised 10/21/22, notes R3 has an ADL self-care performance deficit related to activity intolerance, impaired mobility, and poor cognition. R3 is totally dependent and requires two person physical assistance with bed mobility. R3 is at risk for skin breakdown/pressure ulcer development related to impaired mobility, bladder/bowel incontinence, co-morbidities. On 10/21/23, R3's sacrum to right buttock stage 3 pressure ulcer re-opened. Interventions identified, but not limited to, apply moisture barrier ointment after each incontinent episode, heel protectors at all times or offload with pillows, low air loss mattress, and turn and reposition every 2 hours and as needed. V10 (wound care physician) note, dated 12/6/23, notes R3's musculoskeletal functional status is total care. R3's upper and lower extremities-contractures stiff. Sacrum to right buttock stage 3 pressure ulcer, re-opened on 10/21/23. Wound measures 2.5cm (centimeters) x 5cm, 50% epithelialization and 50% maroon. Treatment changed on 12/6 to clean with normal saline, apply zinc oxide, and cover with bordered gauze. R3's TAR (treatment administration record), dated December 2023, notes R3's skin was not checked on the evening shift or night shift on 12/10, the evening shift on 12/11, or the evening shift on 12/12. It also notes R3 was not turned or repositioned from 12:00pm until midnight on 12/12 or 8:00am and 10:00am on 12/13. The low air loss mattress manufacturer's instructions note the low air loss mattress is designed to prevent and treat pressure ulcers. Residents can directly lie on the mattress or cover with a sheet and tuck loosely to increase the comfort of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to include documentation in the residents medical record of assessment and monitoring of tracheotomy status and cares provided. This failure affected one (R7) of one resident reviewed for tracheotomy care and resulted in R7 being found unresponsive, with tracheotomy tube not in place and the facility was not able to identify how long the resident was without the trache tube in place; R7 expired of respiratory distress. Findings include: R7 is a [AGE] year-old female, admitted in the facility on [DATE] with diagnoses of Chronic Respiratory Failure, Unspecified, Unspecified Whether with Hypoxia or Hypercapnia and Encounter for Attention to Tracheotomy. Nurse Practitioner progress notes dated [DATE] recorded that R7 was alert and oriented to time, place, person and event. She was able to write and mouth out words as a way of communication. She had a tracheotomy tube in placed to oxygen source. According to progress notes dated [DATE] time stamped 8:30 AM, V6 (Respiratory Therapist, RT) documented that around 7:25 AM, she was called to come to R7's room. As she entered the room, R7 appeared to be dusty and unresponsive. Code blue was called, and CPR (cardiopulmonary resuscitation) began. V6 observed in R7's left hand her trache. Another RT (V24) entered the room and replaced the trache and started ambu bagging the resident (R7). CPR was continued until paramedics entered and took over. Progress notes dated [DATE] time stamped 9:00 AM, R7 expired at 8:20 AM. On [DATE] at 11:17 AM, V6 was asked regarding R7. V6 stated, I remember she had her trache in her hand. I did start CPR immediately and chest compressions. I don't know how the entire trache got to her hand. When I started CPR, V24 (Respiratory Therapist) inserted the same trache to get an airway. The trache ties were there, one part is open and the other part still has the tie. I might say that she pulled it and it came out, not sure. She was alert and oriented. She had anxiety. She could have been redirected or notify nurse that she is anxious so PRN (as needed) medication for anxiety could be administered. V6 was also asked on what could be the cause of her (R7) death. V6 verbalized, Because she did need oxygen and she removed it, then it could be the cause of her death, which is due to lack of oxygen. On [DATE] at 12:24 PM, V24 (Respiratory Therapist) was interviewed regarding R7 but denied any knowledge regarding R7 and incident. However, in progress notes dated [DATE] time stamped 12:03 PM, V24 documented R7 was found unresponsive, CPR was done for 50 minutes. V5 (Licensed Practical Nurse, LPN) was also asked regarding R7. V5 replied, That time, I already saw her lying down, unresponsive. We tried to talk to her but she was not responding. We started CPR. After paramedics arrived, they checked her. And after one to two hours, they said she (R7) expired. Respiratory Therapist does trache care and changing of trache. They don't have a specific time, they do it as needed. As a nurse, I monitor resident's trache when doing rounds in the morning, when I started my shift, and during med pass. I checked trache every two hours or less. When I came that morning, I saw her unresponsive already. I was morning shift that time. Usually, after night shift gave report around 7 AM, I do my rounds. R7 was found unresponsive around 7:25 AM as progress note documented. There was no other documentation noted pertaining to R7's condition prior to 7:25 AM, unable to determine how long she (R7) was unresponsive. On [DATE] at 1:14 PM V16 (Respiratory Therapy Director) was interviewed regarding trache monitoring. V16 verbalized, Residents can remove their own trache. If it is a resident who continuously remove the trache or tubing, Nursing Department is informed so mittens could be used on those residents. Trache removal usually happens on residents who are very anxious, having periods of restlessness; when they have anxiety episode, they can remove the trache. Staff has to do frequent monitoring, if staff observed a resident having anxiety, let nurses know so PRN medication can be administered. If a resident is alert and conscious, staff has to redirect them and reeducate on the importance of trache in breathing process. Further review of R7's progress notes showed no documentation related to any anxiety episodes. Her (R7) face sheet listed Anxiety Disorder, Unspecified as one of the diagnoses. POS (Physician Order Sheet) dated [DATE] indicated that R7 had an order of Alprazolam tab 0.25mg (milligrams) - give 1 tablet via Gtube (gastrostomy tube) every 12 hours as needed for anxiety. MAR (Medication Administration Record) recorded that Alprazolam was administered to R7 on [DATE] and [DATE] only. R7's care plan on tracheotomy documented: Intervention ([DATE]) - Monitor for s/s (signs and symptoms) of respiratory distress (restlessness, agitation, confusion, increased heart rate (tachycardia), air hunger and / or bradycardia. On [DATE] at 2:10 PM, V10 (Nurse Practitioner, NP) was interviewed regarding R7. V10 stated, She was alert, oriented to time, place, person and event; very pleasant lady. She was diagnosed with acute hypoxemic and hypercapnia respiratory failure. When she was at the facility, she needed a trache collar to oxygen source. She felt anxious on and off. When I saw her last [DATE], she felt that she was having slow progression in mobility and she wanted to get disconnected from trache and oxygen. She wanted to get back to normal life. V10 was also asked about the importance of trache in R7's condition. V10 stated, If she cannot breathe and not getting adequate oxygenation, she would clearly not do well and need a trache. R7's Death Certificate dated [DATE] documented: date of death : [DATE] Causes: Respiratory Failure On [DATE] at 9:37 AM, V20 (NP/Pulmonology) was asked regarding tracheotomy care and respiratory failure. V20 stated, Residents with respiratory failure is not able to breathe on their own, they have tracheotomy placed on them to assist with breathing. It is a system that helps residents breathe on their own. The lungs cannot get enough oxygen in the blood, and not able to breathe out their carbon dioxide which is a waste gas. If trache is removed and no oxygen, you don't breathe, you die. Staff needs to make sure trache is in place, make sure the resident is alive and breathing. Staff needs to monitor residents for breathing and tracheotomy placement. Residents can still remove the trache when they are confused, or accidentally remove the trache when they scratch the neck. If residents are anxious, it is possible that they can also remove their trache. Facility's policy titled Tracheostomy Care, undated, does not specifically address procedures or guidelines on trache monitoring and management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have effective interventions in place to prevent a resident, admitted with intact skin, from developing a Stage III pressure injury while in the facility. This failure applied to one (R4) of one resident reviewed for pressure ulcers. Findings include: R4 is a [AGE] year old female admitted to the facility 8/7/23 with diagnosis that include enterocolitis due to C-Diff, Acute and Chronic Respiratory Failure with Hypoxia, Tracheostomy, Dependence on Respirator (Ventilator), Chronic Kidney Disease Stage 5, Dependence on Renal Dialysis and Dementia. According to R4's electronic health record, she was admitted requiring total assistance for all activities of daily living including turning, repositioning and incontinence care. According to admission notes and assessments, R4 admitted to the facility with intact skin, and no skin conditions. R4 was transferred to the hospital 10/8/23, admitted for abdominal distention and is currently hospitalized during this investigation. The facility identified MASD (Moisture Associated Skin Dermatitis) 8/28/23 on the perineum and buttock. On 9/13/23 the facility identified a Stage 3 pressure ulcer to the sacrum. Treatment administration records reviewed from August to October identified treatments were put and place at the time of assessment and carried out as ordered. Wound assessment dated [DATE] identified wound to the sacrum as healed. On 10/18/23 at 10:19AM V21 Wound care NP said R4 developed MASD due to incontinence. The pressure injury likely developed due to infrequent repositioning in addition to incontinence, but it is hard to determine the exact cause because this patient has other health concerns that can contribute to skin break down. It is the goal however that any resident coming to the facility with in-tact skin will maintain intact skin unless the factors were unavoidable. I determined the stage of the wound to the sacrum as III because there was some slough that developed. At that time, I also recommended a low air loss mattress to help alternate pressure since R4 was bed bound. The air mattress does not take precedence over the staff providing manual assistance, but it is a helpful measurement. Since the wound was not very deep, we were able to heal it quickly using daily treatments. Policy titled Pressure Ulcer Prevention revised 1/15/18 states in part: Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: 3. Change bed linen per schedule and whenever soiled with urine, feces or other material. 4. Keep bottom sheet dry and tightly stretched and free of wrinkles; 5. Turn dependent resident approximately every two hours or as needed and position resident with pillow pr pads protecting bony prominences as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to follow their policy and procedures for fall prevention by not identifying and implementing personalized care plan interventions on admission and not providing adequate supervision for a resident at high risk for falls; they also failed to adequately supervise or remove a safety hazard when identified, for a resident at high risk for falls. These failures applied to two of three residents (R5 and R6) reviewed for falls and resulted in R5 sustaining a head injury requiring sutures. Findings include: R5 is an [AGE] year-old male with a diagnoses history of Prostate Cancer, Bone Cancer, Mild Cognitive Impairment, Major Depressive Disorder, Anxiety Disorder, and Cognitive Communication Deficit who was admitted to the facility 08/09/2023. R5's Hospital Record dated 08/09/2023 and included in the facilities electronic medical record documents he is a high fall risk with interventions implemented including: place of bed locked in lowest position, bed alarm set, side rails up times three, and frequent rounds maintained. R5's Fall Risk assessment dated [DATE] documents he was at moderate risk for falls. R5's current care plan initiated 08/10/2023 documents he is at high risk for falls related to confusion, being unaware of safety needs, hearing problems, and history of falls with interventions including: Review information on past falls and attempt to determine cause of fall, record possible root causes, alter remove any potential causes as possible, educate resident/family/ caregivers/ interdisciplinary team as to causes; effective 9/1/23 anticipate resident's needs, offer toileting before bedtime or during night shift when awake, encourage resident to use assistive device, therapy to screen; physical therapy to evaluate and treat as ordered or as needed; does not include low bed as an intervention. R5's current care plan initiated 08/18/2023 documents he displays socially inappropriate and maladaptive behavior as manifested by wandering aimlessly and leaving room Disrobed; These symptoms are related to mild cognitive impairment with interventions initiated 10/06/23 including: Use frequent reassuring phrases to help minimize feelings of fear and anxiety. Statements such as You are safe with me, You are okay, You are in good hands, and You and I are old friends will help instill a feeling of security and, in turn, should minimize incidents of maladaptive behavior. R5's current care plan initiated 10/06/2023 documents he exhibits movement behavior that may be interpreted as aimlessly roaming, wandering his unit, and wandering into peers rooms; behaviors are related to the diagnoses of Mild Cognitive Impairment of Uncertain or Unknown Etiology, poor safety awareness, and problems understanding the immediate environment with interventions including: Make rounds/room checks to minimize chance of unauthorized leave. R5's Nurse Practitioner progress note dated 8/9/2023 5:24 PM documents history of present illness (obtained from previous medical records and patient) patient is an [AGE] year-old male with past medical history of metastatic to bone prostate cancer, cognitive impairment, depression, anxiety, and delirium, who was admitted to the hospital on [DATE] with agitation/aggressive/erratic behavior and required soft restraints; was subsequently transferred to nursing facility for skilled nursing and rehab. R5's progress note dated 9/1/2023 03:13 AM documents: Heard a noise from patients room, CNA (Certified Nursing Assistant) went to check and call the nurse on duty. Patient was observed sitting by his bed bleeding at the back of his head, patient is alert and verbally responsive. 911 called. left message to V10 (Nurse Practitioner). R5's progress note dated 9/6/2023 3:44 PM documents: Removed three sutures. Facility Reported Incident Final Investigation Report dated 09/07/2023 documents on 09/01/2023 at 2:15 AM R5 had an unwitnessed mechanical fall inside his room; Assigned nurse observed R5 sitting on the floor by the edge of his bed; Observed with bleeding from the back of his head; When asked what happened, R5 stated he wanted to go to the bathroom to urinate, ambulated without using his walker, lost his balance and fell; R5 sustained a head injury, was sent to Lutheran General Hospital emergency room for further evaluation of head injury and staples to his head wound and was readmitted back to the facility at 10:59 AM; The facility concludes that the root cause of R5's fall included unsteady gait, impulsiveness related to cognitive impairment and poor safety awareness prompting him to overestimate his ambulatory ability; R5 returned to the facility from the emergency room with three staples which will be removed in one week. Care plan was reviewed to include nursing interventions of prompted toileting, anticipate his needs, remind to use assistive device, physician, and family aware of investigation; R5 is interviewable and alert and oriented times two. R5's progress note dated 10/2/2023 08:49 AM documents Patient seen and examined in room. Patient currently walking around room comfortably putting on his clothes. Patient has shown improved ambulation and strength but just limited by poor cognition and safety awareness. Facility Reported Incident Final Investigation Report dated 10/12/2023 documents on 10/06/2023 the facility received a complaint from R5's family claiming he was neglected, V9 (Family Member) reported he observed R5 in the bed with no sheets or clothes on during a weekend visit but could not specify when; multiple interviews with staff who worked with R5 from 10/02/2023 - 10/04/2023 included reports of him often attempting to get out of bed and in doing so hitting his elbows on the side rails, attempting to use the bathroom without calling for assistance, attempts to walk on his own and being redirected, and having a continual behavior of taking off his clothes and incontinence brief with staff constantly having to redress him; On 10/04/2023 V10 (Nurse Practitioner) noted in his progress notes: R5 had been hospitalized [DATE] for agitation, aggressive/erratic behavior and required soft restraints and was transferred to the facility for skilled nursing rehab; on 09/01/2023 R5 had a fall, hit the back of his head, lacerated his scalp, was sent to the hospital emergency room and returned the same day to the facility with staples to the back of his head; was being seen on 10/04/2023 for follow up and was observed to be more confused than usual, agitated, requires assistance with transfers and overall observed with weakness and confusion, was observed with scratch marks/skin abrasions that are self-inflicted when he hits side rails, table, etc; R5's care plan was reviewed and documents he displays socially inappropriate and maladaptive behavior as manifested by wandering aimlessly and leaving room disrobed and these symptoms are related to mild cognitive impairment. R6 is a [AGE] year-old male with a diagnoses history of Seizure, Traumatic Subdural Hemorrhage, Dementia without Behavioral Disturbance, History of Falling, Unsteadiness on Feet, Lack of Coordination, Abnormalities of Gait and Mobility, and Abnormal Posture who was admitted to the facility 02/12/2021. Observed R6 in his room lying down in his bed fully clothed with his bed in low position, observed a falling leaf next to his name outside his room. R6 stated he had a fall but didn't have to have any stitches or anything and had no scratches or scrapes from it. Observed a walker and wheelchair in the corner of R6's room. R6 stated the wheelchair and walker are not his and he has neither. R6's current care plan initiated 02/13/2021 documents he is at high risk for fall, is alert with periods of confusion, was admitted related to post Fall with Subdural Hematoma and multiple fractures and other Medical diagnoses of hypertension, depression, stroke, Senile Dementia; R6 is able to ambulate but with unsteady gait and resident is on medication Anti-seizure, Antidepressant and Anti-Hypertensive with interventions including: Evaluate fall risk on admission and as needed. R6's Quarterly Fall assessment dated [DATE] documents he does not use any ambulatory aids and is at high risk for falls. R6's progress note dated 8/23/2023 7:37 PM documents: At 4:25 pm, staff reported to writer that resident had a witnessed fall incident in the unit. Investigation initiated. On interview staff reported that they noticed resident standing by the nurses station with his cane. Staff noted the resident took several steps back and lost balance. Head to toe assessment done, bleeding noted on back of head, area cleansed with and covered with gauze. Resident could not explain what prompted him to step backwards. Resident was transferred via 911 to hospital emergency room for further evaluation; at 8:58 PM Called hospital for follow up, resident will be admitted with diagnosis of Head Bleed. Facility Reported Incident Final Investigation Report dated 08/24/2023 documents on 08/23/2023 at 4:25 PM staff reported to V2 (Director of Nursing /Registered Nurse) that R6 had a witnessed fall on the unit; Interviewed staff reported they noticed R6 standing by the nurses station and observed he took several steps back and lost his balance; R6 could not explain what prompted him to step backwards. Upon further review staff reported R6 was observed holding a cane which was not appropriate and was not included in the plan of care; [NAME] was removed from R6's room; R6 was readmitted from hospital, care plan was reviewed and revised with new interventions including screening and evaluation for physical therapy and occupational therapy. R6's progress note created by V10 (Nurse Practitioner) dated 8/29/2023 11:38 AM documents: Patient seen and examined today post readmission; on 8/23/23 patient was sent to the hospital after a fall, patient struck the back of his head and sustained a traumatic subdural hematoma, he was closely monitored and treated. Patients back of head small skin alteration is clean, dry, and intact. On 10/18/2023 at 11:01 AM V2 (Director of Nursing) stated R5's strength improved before he left the facility and was able to dress himself. V2 stated R5 was a high fall risk. V2 stated any review of past falls and root cause analysis information would be included in a fall risk management report. V2 agreed the purpose of reviewing past falls and developing a root cause analysis is to identify any personalized interventions that may be needed for a resident. V2 stated she uses the Morse fall evaluation and the nurse fall observation to assess if a resident is high risk for falls. V2 agreed an admitting residents hospital records are reviewed for fall history information and this information would be applied to the resident's care planned fall interventions. V2 stated V27 (Family Member) visited with R5 frequently and the facility does not rely on family to supervise residents. V2 stated R5's behaviors do put him at risk for falls. V2 stated the facility cannot provide one on one supervision daily because it is not sustainable. V2 stated rounds are conducted every two hours and as needed. V2 stated as needed indicates when staff is done working with another patient, they can go back to R5 even if it was sooner than two hours. V2 stated R5 may not necessarily need one on one supervision but does require increased supervision which is not currently part of his care plan. V2 stated most of the time R5 wore a gown and did not wear a robe. V2 stated the term disrobing in R5's care plan indicates removal of any clothing the resident is wearing. V2 stated R5's history of needing soft restraints while in the hospital prior to admitting to the facility indicates he could be restless or impulsive. V2 stated she cannot explain what specific interventions could have been in place to prevent R5's unwitnessed fall 09/01/2023. V2 stated R5's decision making limitations, and overestimation of his abilities related to his cognitive impairment contributed to his fall on 09/01/2023. V2 stated although R5 was receiving rehabilitative therapy he still required the use of an assistive device to ambulate. V2 stated a low bed might have minimized the risk of R5's fall. Observed V2 read R5's care plan and confirmed it did not include low bed as an intervention. V2 stated impulsiveness does include getting up an attempting to ambulate without asking for assistance as it was documented when he fell on [DATE]. V2 stated when R6 fell in August staff were present. V2 stated if staff observed R6 using a cane and was not approved to use one they should have taken it from him. V2 confirmed due to it not being appropriate for R6 to use a cane, him using one did contribute to his fall. The facility did not provide a risk management report for R5 and R5's medical records did not include a nurse fall observation. The facility's Fall Prevention Program Policy reviewed 10/18/2023 states: The purpose of the policy is To assure the safety of all residents in the facility, when possible. The program will include implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The Fall Prevention Program includes the following components: Methods to identify risk factors, Use and implementation of professional standards of practice. Care Plan incorporates: Identification of all risk/issue, preventative measures. Safety interventions will be implemented for each resident identified at risk. The admitting nurse and assigned CNA (Certified Nursing Assistant) are responsible for initiating safety precautions at the time of admission. All assigned nursing personnel are responsible fore ensuring ongoing precautions are put in place and consistently maintained. The bed will be maintained in a position appropriate for resident transfers. The frequency of safety monitoring will be determined by the resident's risk factors and the plan of care.

Based on observation interview and record review the facility failed to ensure that one residents (R313) wound was assessed properly and worsening wound was identified, and doctor was notified for one resident R313 of 3 residents reviewed for wounds in a sample of 33. Findings include: On 7/20/23 at 1:16 PM with V11 (Wound Care Coordinator) reviewing pictures and documentation of R313 sacral wound. All of the sacral wound assessment each week documents the wound to be 5x7/0 CM, area to be 35 centimeters, and the tissue to be bright pink or red=100%. 4/19/23 picture V11 states that there is some slough on the sacral wound and that V41 (Wound care nurse) assessment is incorrect but the treatment ordered is correct. Wound size documented 5x7x0 and 100% pink tissue. 4/26/2023 picture V11 states slough is more of non-adherent slough. There is a new/wider wound on the left buttock next to/attached to original sacral wound. V11 states there is more dead tissue and the measurement that V41 put is incorrect and yes these findings would signify a change in condition. 5/1/2023 picture measurement not correct some necrotic tissue. 5/8/2023 V11 states measurement incorrect and some necrotic tissue. V11 states she would say that this wound is unstageable with 90-95% slough and 5% pink viable tissue again what V41 documented is incorrect. 5/16/2023 picture V11 states the wound is unstageable and 95% slough. On 7/20/23 at 2:52 PM V2 (DON) states V2 states she expect if there is a change in condition or worsening wound that the staff will notify family and doctor and measure wound and chart what they see. Documentation should be in the resident's electronic medical record in the progress notes or wound rounds. V2 states she assumes within 24 hours of a change of condition the doctor and family should be notified. On 7/21/2023 at 1:45 PM V28 (Nurse Practitioner ) states they defer to wound care doctor to assess as soon as possible during next wound round. The facility should notify nurse practitioner and wound care doctor if worsening. V28 states a stage 4 wound should be consulted right away . V28 states Nothing should be delayed when it comes to wounds. Review of R313's progress notes did not show any documentation that family or doctor were notified of the 4/26/2023 change and worsening in wound condition. R313 progress note dated 5/20/23 documents a change in condition and with shortness of breath that is different than usual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 07/18/2023 at 11:20AM during observation, R100's bed was observed with plugged in power strip on the side of his bed leaning against the side rail with two chargers plugged on it and the cord coiled on the side rail. At 11:56AM, the above-mentioned was observed with V47 (Maintenance Assistant) and at 12:00PM, it was also observed with V15 (Maintenance Director). On 07/18/2023 at 11:56AM, V47 stated that he has always seen R100's extension cord like that. On 07/18/2023 at 12:00PM, V15 said that it should not be on the bed because it is not safe for the R100. R100's order summary report dated 7/21/2023 indicated admission date of 01/14/2021 and diagnoses including anxiety disorder due to known physiological condition and major depressive disorder, recurrent, mild. Facility Policy: Title: Electrical Equipment Review Date: 11/2022 Power Strips: The following are the circumstances where power strips are allowed in the facility: 4. Power strips are prohibited in patient care vicinity and may not be utilized for other devices, such as: personal electronics. Based on interview and record review the facility failed to provide safety by not following the mechanical lift manufacturer instruction. This failure resulted in R36 falling from a Mechanical lift while under staff direct care sustaining multicompartmental intracerebral hemorrhage (ICH). The facility also failed to follow its policy in reporting, investigating and monitoring of resident who has unwitnessed fall, and ensure resident's environment is free of accident hazards. This affected 3 of 5 residents (R36, R88, R100) reviewed for safety. Findings include: On 7/19/2023 at 12:09 PM, V25 (RN) said V32 (CNA) asked if she could help her transfer R36 into a dialysis chair with a Mechanical lift. V25 and V32 went to the resident room. V25 said that V32 was positioned on the resident right side and V25 was positioned on the resident left side. V25 said that V32 asked V25 to hook the purple loop onto the Mechanical lift hook. V25 said that she confirmed with V32 that all the purple loops are on all four sides of the Mechanical lift hooks. V25 said that the dialysis chair was positioned at the foot of the bed. V25 said that V32 elevated R36 up with the remote control. V25 said that once R36 was up, V25 went to the right side of R36 to guide her into the dialysis chair. V25 said that R36 was about 30 degrees above bed and was being moved towards the dialysis chair when R36 fell. V25 said that R36 body hit the floor first, and then R36 hit her head on the foot of the Mechanical lift. V25 said that V25 immediately assessed R36, called V11 (Wound Care Nurse) and V3 (Assistant Director of Nursing) ADON, and V11 and V3 also assessed R36. V25 said that V11 applied pressure on R36 head. V25 said that V3 and Wound Care Nurse stayed with R36 while V25 went and called 911. V25 said that V11 and V3 continued to stay with R36 and assessing her until 911 came and took R36 to the local hospital. V25 said that is possible that the resident slipped out of the sling because the loops were intact. Mechanical lift manufacturer instruction that stipulates when patient is elevated a few inches off the surface of the stationary object (wheelchair, commode or bed) and before moving the patient, check again to make sure that the sling is properly secured. On 7/19/2023 at 12:41 PM, V3 (ADON) said that she was called to room by V25 (RN) and upon entering the room, V3 noticed that R36 was on the floor. V3 said that R36 was noted with laceration at the back of her head. V3 said that V7 (Wound Nurse) was also present, so V7 applied pressure to the back of her head. 911 took R36 to local hospital. R36 was diagnosed with multicompartmental intracerebral hemorrhage (ICH), including: Left frontal intraparenchymal hemorrhage (IPH), with surrounding edema and subdural hematoma (SDH), L temporal SDH and subarachnoid hemorrhage (SAH), Left parafalcine SDH. On 7/20/2023 at 12:30 PM, V32 (CNA) said that V32 and V25 were transferring R36 to a dialysis chair using a Mechanical lift. V32 said that V32 and V25 confirmed all 4 purple loops were attached to the Mechanical lift hooks. V32 said that R36 fell from the sling while being transferred to the dialysis chair. V32 said that after the fall, she noticed that only 3 of the purple loops were intact. V32 said that she couldn't identify what caused the fall until the fire marshal came and inspected the Mechanical lift, then V32 said that V32 noticed that one of the metal lash was missing. V32 said that if she had noticed that a metal lash was missing prior to operating the Mechanical lift, she would have not used it and would have told V25 that they need to use another Mechanical lift. 07/20/2023 at 2:12 PM, V11 (Wound Care Coordinator) said that she was on second floor rounding when the floor nurse called V3 (Assistance Director of Nursing) and V11 into R36 room. V11 said that when she came to the room, R36 was on the floor with small amount of bleeding coming from back of R36 head and V11 applied pressure to the area where R36 is bleeding from until 911 arrived. 07/20/2023 at 2:24 PM, V2 said during her investigation, V25 (RN) and V32 (CNA) both said that used proper technique when transferring R36 with a Mechanical lift from her bed to dialysis chair. V2 confirmed that if the loops were properly secured, it might not gotten loose during the transfer. V2 said that the facility had an in-service in May which included all transfers. V2 said that right after the incident all clinical staff were in-serviced with return demonstration. V2 said that moving forward that all agency staff will be in-serviced to ensure that they are competent in transfer using Mechanical lift with return demonstrations and will be on-going. R36 is a [AGE] year old female admitted on [DATE] with a diagnosis not limited to acute and chronic respiratory failure, dependence on respirator (Ventilator) status, dependence on renal dialysis, and hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease. Facility Fall Prevention Program Effective Date: 11-28-12 Department: Nursing, Therapy, Administration Revisions: 11-21-17 Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Guidelines: The Fall Prevention Program includes the following components: Adherence to manufacturer's recommendation in use of alarm and medical devices and special care equipment. Battery Powered Patient Lift Manufacturer Instruction Lifting Patient WARNING When elevated a few inches off the surface of the stationary object (wheelchair, commode, or bed) and before moving the patient, check again to make sure that sling is properly connected to the hooks of the hanger bar. If any attachments are not properly in place, lower the patient back onto the stationary object (wheelchair, commode, or bed) and correct this problem. On 7/18/23 at 12:20pm Observed R88 lying on scoop mattress. V19 LPN said that R88 is at high risk for fall and just fell recently. On 7/19/23 at 9:58am, V7 Restorative Nurse (RN) said that she does the formulation and updating fall care plan. V2 DON does the initial investigation and root cause analysis after each fall. The floor nurse will do the fall incident documentation and report the incident. Review R88's medical record with V7 RN. V7 said that R88 is admitted on [DATE] with diagnosis listed in part but not limited to history of falling, Laceration to part of head due to fall, Vascular dementia. V7 said that admission fall assessment done on 1/5/23 indicated that R88 is at high risk for fall. V7 said that R88 has several incidents of unwitnessed fall namely: 2/1/23 - Unwitnessed fall. R88 observed sitting on the floor in his room. 5/15/23- Unwitnessed fall. R88 observed on prone position on the floor, bleeding on the left forehead. R88 was sent to hospital for suturing of laceration on left forehead. 7/14/23- Unwitnessed fall, R88 observed in supine position on the floor in his room. Informed V7 that on 7/11/23 at 4:54am documented by V30 RN on R88's progress notes indicated: Observed R88 sitting on the floor in his room. R88 denies any pain or headache, able to move all extremities and no shortening of his legs. R88's physician order dated 7/11/23 indicated: May send 911 to hospital emergency room due to fall. V29 Night shift Nursing supervisor documented that R88 strongly refused to go to the hospital. 911 paramedic staff and V29 spoke with R88's family member and refused R88 to be sent to the hospital. V7 said that she is not aware and was not notified that R88 had a fall incident on 7/11/23. V7 said that there is no fall investigation done regarding possible cause of R88's fall incident and fall care plan is not updated. V7 said that there is no fall incident done by V30 RN on 7/11/23. On 7/20/23 at 7:21am, V29 Night shift Nursing Supervisor said that on 7/11/23 R88 had unwitnessed fall, he was found sitting on the floor in his room. R88's fall incident report is completed by V30 RN on 7/11/23. V29 said that she reported to V2 DON about R88's fall incident. On 7/20/23 at 9:40am, V2 DON gave the fall incident report dated 7/11/23 done by V30 RN. V2 said that she was not notified of the incident report not until 7/19/23. V2 said that she did not complete the fall investigation and update the care plan not until she just learned about it yesterday. V2 said that V30 RN did not put R88's fall incident report in the risk management so she did not see it. On 7/20/23 at 11:30am, V7 Restorative Nurse said that she probably overlooks R88's fall incident report completed by V30 RN on 7/11/23. Facility's policy on Incident and Accident indicates: Policy: The incident/accident report is completed for all unexplained bruises or abrasions, all accidents, or incidents where there is injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitors, or other and resident-to-resident altercations. Procedures: An incident/accident report will be completed for: 1. All serious accidents or incidents of residents 3. All unusual occurrences 1. An incident/accident report is to be completed by RN or LPN and is to include: a. Date and time of an incident/accident b. Full written statement and possible cause of incident, physical assessment, injuries noted, vital signs, treatment rendered and notification of appropriate parties. 4. Documentation on nurse's notes is to include: a. a description of the occurrence, the extent of injury, the assessment of the resident, vital signs, treatment rendered, and parties notified. b. A minimum of 72 hours of documentation by all three shifts on resident status after the incident. Vital signs, mental and physical state follow up, test, procedures, and findings are to be documented. 5. All incident/accident reports are reviewed, signed, and investigated by: a. Administrator b. DON or ADON Facility's policy on Fall prevention program indicates: Purpose: To assure safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Program will monitor the program to assure ongoing effectiveness. Guidelines: *Care plan incorporates: Addresses each fall, interventions are changed with each fall, Standards: *Accident/incident reports involving falls will be reviewed by the interdisciplinary team to ensure appropriate care and services were provided and determine possible safety interventions

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow their wound prevention policies and plan of care interventions to include use of low air loss mattress and conduct skin condition assessments and measurements weekly. This affected 2 of 3 residents (R6, R8) reviewed for pressure sore prevention. This failure resulted in R6 having a deteriorating wound requiring debridement revealing a stage 4 pressure sore. Findings include: 1. R6 face sheet shows diagnosis of hemiplegia and hemiparesis following cerebrovascular disease, vascular dementia without behavioral disturbance, hypertensive heart and chronic kidney disease, chronic systolic heart failure, atherosclerotic heart disease, encounter for attention to gastrostomy, chronic embolism and thrombosis of right femoral vein, chronic embolism and thrombosis of left popliteal vein, long tern use of anticoagulants, abdominal distension, alcohol abuse, blindness of right eye, latent tuberculosis, and dysphagia. R6 braden score (risk for skin breakdown) dated 5/31/2023 denotes score of 10 (high risk) for skin breakdown. R6 progress notes denotes R6 was sent to hospital on 5/12/23 and returned to facility on 5/17/23. On 6/6/23 at 12:00pm R6 was observed sleeping in bed, R6 open his eye to voice, R6 did not follow redirection at this time. R6 resting on mattress with no pump noted at foot of bed or head of bed or on the floor near the bed. R6 has gastric tube feeding running at 45ml/hr., water flush at 130ml every 4 hours. Tube feeding labeled and dated. R6 has bilateral heel boots. R6 observed with bilateral hand mitten. R6 hair is cut low, facial hair observed trimmed. No body odor noted, no mouth odors noted. R6 observed resting on mattress, no mattress pumps noted. At 12:17pm wound care and skin check observation conducted with V8 (wound care nurse) and V9 (wound care coordinator). R6 skin was intact to heels bilaterally, skin intact to peri area, skin intact to elbows, skin intact to back, skin intact to back of head, skin intact to ear lobes. R6 has wound the size of a grapefruit to the right buttocks that extends to the sacrum; wound has black tissue with tan tissue were the wound is open partially. R6 has open area to the left buttocks the size of a half dollar; wound bed is pink, moist, surrounding tissue is hyperpigmented. V8 said the wound to the right buttock has tunnelling, V8 said the wound doctor is planning to debride the wound when it opens. V8 said the wound has open edges now and he will notify the wound physician for an update. V9 said R6 was admitted to the facility with the wound. Pain medication given prior to wound care observation. After wound care R6 repositioned for comfort. V9 said R6 mattress is a low air loss mattress, when asked where's the pump for the low air loss mattress, V9 then said R6 was resting on a pressure redistributing mattress, the facility regular mattress are pressure redistributing. R6 mattress was firm when pressed. V9 said the wound doctor usually see residents on Tuesday, however the wound doctor had an emergency, and he would see residents on Wednesday. V9 said R6 should have in place a low air loss mattress. On 6/14/23 V9 said the mattress should have been in place upon readmission on [DATE] or 5/18/23. R6 plan of care dated 9/14/2022 denotes in-part R6 has high risk for further skin breakdown related to decreased mobility, incontinence, O2 (oxygen) dependent, Dx (diagnosis) hemiplegia, heart failure, vascular, dementia, and blindness to right eye and refusal of care, 1- coccyx initiated 9/14/22, R6 wound site will show signs of improvement through next review date, initiated 5/18/2023. Apply moisture barrier after each incontinent episode, evaluate ulcer characteristics, keep skin clean and well lubricated, low air loss mattress 9/14/22, low air loss mattress 10/25/22, monitor bony prominences for redness, monitor nutritional status, monitor ulcer for signs of progressions or declination, off load heels while in bed, provide skin care per facility guidelines and PRN as needed, provide wound care per treatment order, RD (register dietitian) consults, turn and reposition every 2 hours and as needed, wound Dr/ Np consults as needed. R6 wound assessment dated [DATE] denotes in-part wound-coccyx, pressure ulcer, present on admission, size- 4.50 centimeters by 3.00 centimeters, unknown depth, area 13.50 centimeters squared. R6 wound assessment dated [DATE] denotes in-part wound-coccyx, pressure ulcer, present on admission, size- 4.50 centimeters by 3.00 centimeters, unknown depth, area 13.50 centimeters squared. R6 wound assessment completed by V38 (wound doctor) dated 5/30/23 denotes in-part patient seen on the request of the PCP (primary care provider) for skin ulcers/lesions. Skin problem site- coccyx, wound #4 coccyx un-staged, there is no exudate, infection or inflammation is none, the wound is 12 days since first recorded. Assessment and plan abnormal posture- monitor skin PROM, muscle weakness-low air loss mattress, reposition every 2 hrs (hours) and PRN, offload heels, heel protectors to both feet. Pressure ulcer sacral region, unstageable, frequency of treatment- daily and PRN, site should be cleaned with with normal saline, primary dressing-Medi honey, adaptic, ZN (zinc) oxide around, secondary dressing - foam island dressing, secure with off load, additional notes- please call me when the edges open so that I can debride and get the consent for debridement. Plan of care #5 continue with skin ulcer prevention protocol of the facility including daily skin check. #7 dressing change and plan discussed with treatment nurse. Avoid bony prominences under pressure, provide stage appropriate mattress, off load with heel protectors or pillows, repositioning in the bed and w/chair as needed, or per facility protocol, if patient cannot do it, education of staff and nurse assistant about prevention and treatment and repositioning as needed. Comments seen with WCC (wound care coordinator) (V8). Page 4 wound #4, coccyx, un-staged, pressure, date reported 5/18/23, size 8x11x0, 100% necrotic, undefined margins, treatment done 5/30/23. R6 wound assessment completed by V38 (wound doctor) dated 6/9/23 denotes in-part patient seen on the request of the PCP (primary care provider) for skin ulcers/lesions. Removal of necrotic tissue, slough, and biofilm and reduced bioburden, to promote healing and prevent infection. Tissue debrided was necrotic subcutaneous, necrotic muscle, percentage area was debrided 51-75%, viable wound bed was exposed. Page 5 denotes MDS stage 4, pressure, post debridement size- 9x11x2.5. Post debridement volume 247.5 centimeters squared. Necrotic/ escar color 90%, intact 10%. Treatment done 6/9/23, topical application gentamicin, calcium alginate, ZN( zinc) . Treatment has been changed. On 6/9/23 at 12:37pm V38 (wound physician) said R6 was re-admitted to the facility with the wound on 5/17/23, V38 said R6 wound has deteriorated, V38 said R6 has deep tissue injury. V38 said when there's deep tissue injury it takes about 72 hours or 4 days for the injury to present on the skin (show up). V38 describe deep tissue injury happens when pressure from bony prominences cause tissue to die due to lack of oxygen. V38 said it takes about 4 days for the injury to show on the skin because the injury happens deep inside. R6 admission dates were reviewed with V38 of 5/17/23, when 4 days is added to 5/17/23 the date is now 5/21/23, R6 wound assessment and images dated 5/24/23 reviewed with V38, R6 wound to coccyx measured the same as the 5/18/23. V38 was asked should the deep tissue injury should have come to the surface by then. V38 said R6 had a deep tissue injury. V38 said R6 deteriorated wound was debrided today to reveal a stage 4 pressure ulcer. V38 said wound debriding removes the necrotic tissue. V38 said the low air loss mattress assist pressure prevention. V38 was made aware that during the observation on 6/6/23 at 12:37pm R6 did not have the low air loss mattress in place, V38 said oh no that not good. V38 said not having that low air loss mattress in place can contribute to R6 wound deteriorating. V38 said cultures were sent today and R6 wound treatment was changed from honey to gentamicin. V38 said R6 previous wound healed. Facility policy tilted pressure injury and skin condition assessment with last review date 1/17/2018 denotes in-part to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. The resident care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches, and goals for care. Physician ordered treatments shall be initiated by staff on the electronic treatment administration record after each administration. Other nursing measure not involving medications shall be documented in weekly wound assessment or nurse noted. Facility policy titled pressure ulcer prevention with last revision date 1/15/2018 denotes in-part to prevent and treat pressure sores/pressure injury. Pressure reducing (foam) mattress are used for all residents unless otherwise indicated. Specialty mattress such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattress are typically used for residents who have multiple stage 2 wounds or one or more stage 3 or stage 4 wounds. Facility policy titled comprehensive care plan dated 11/17/17 denotes in-part to develop a comprehensive care plan that directs the care team and incorporates the resident's goal, preferences, and services that are to be furnished to attain or maintain the residents highest practicable physical, mental psychosocial well-being. The facility will develop and implement a comprehensive person centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical nursing and mental and psychosocial needs that are identified in the comprehensive assessment. 2.R8 care plan denotes R8 has diagnosis of chronic respiratory failure, obesity, DVT, glaucoma, long term use of anticoagulants, pressure ulcer left elbow, anemia, chronic kidney disease, atherosclerotic heart disease, acute embolism, long term use of insulin, protein calorie deficits. R8 Braden assessments dated 4/27/23 denotes score of 9 (very high risk). On 6/7/23 at 11:30am R8 observed for wound care with V9 (wound care coordinator) and V8 (wound care nurse), V9 (wound care coordinator), R8 left elbow noted with granulated tissue covering the wound bed, V9 said R8 only had preventive measures in place for the right elbow. On 6/8/23 V9 presents R8 wound documents denoting R8 has pressure wound to the right elbow, and R8 MAR denotes preventive dressing to the right elbow. On 6/9/23 at 9:50am skin check/wound care observation conducted with V8 (wound nurse), R8 noted with open area to the right elbow, wound bed observed moist and redden, with little yellow tissue inside wound bed. V8 said R8 has a stage 3 to the right elbow. V8 said R8 right elbow wound is facility acquired. On 6/9/23 at 1:50pm V9 (wound care coordinator) said she was not aware that R8 had an open wound to the right elbow. Review of R8 wound assessment completed by V35 (wound physician) on 5/23/23 denotes in-part right elbow, un-staged, pressure date reported 3/24/23, size- length (2 centimeters) by width (2 centimeters) by depth (0.2 centimeters). Post debridement measurements (2 centimeters) in length by (2 centimeters) in width by 0.4 centimeters in (depth). 60% granulation, 10% necrotic, and 30% slough. Pressure ulcer of right elbow, frequency of treatment- daily and PRN (as needed), site should be cleaned with normal saline, primary dressing- iodosorb adapatic, secondary dressing-4x4, secure with loose kerlix, wound debrided 5/23/2023. Plan of care #5 continue with skin ulcer prevention protocol of the facility including daily skin check. #7 dressing change and plan discussed with treatment nurse. Comments seen with WCC (wound care coordinator) V9 and wound nurse (V8). Facility wound report presented by V9 on 6/9/23 dated 6/9/23 denotes in-part R8, right elbow, date identified 6/9/2023, facility acquired (yes), pressure/ulceration, last assessed 6/9/23, stage 4, Length 2.50, width 2.50, depth 2.00, epithelia (pale pink or red) 100%, erythema, scant exudate, serosanguineous. Facility failed to present weekly skin assessments following the week of 5/23/23 for R8 during this survey. On 6/9/23 at 3:15pm V8 said weekly wound assessments include measurements, descriptions, including restaging the wounds by the physician. V8 said wound changes would be documents weekly or as needed, V8 said wound changes are necrotic tissue, slough, infection, change wound bed, and if the wound is purple, pale, if there's concerns for flow to the wounds, V8 said all residents admitted to facility with wounds will be seen by the wound doctor regardless of the stage of the wound. V8 said this allows for them to contact the wound doctor when there is a change int the wound. V8 said the wound doctor sees all residents with sacral wounds, stage 3 and stage 4 wound weekly. V8 said he can stage wounds and the wound physician will follow up with staging the wound. Facility policy titled pressure injury and skin condition assessment with revision date of 1/17/18 denotes in-part the purpose to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. Pressure and other ulcers (diabetic, atrial, venous) will be assessed and measured at least every seven (7) days by licensed, and document in the resident's clinical record. A skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/readmission. The pressure ulcer risk assessment will be updated quarterly and as necessary. Resident identified will have a weekly skin assessment by licensed nurse. A wound assessment will be initiated and documented in the resident's chart when pressure and/or other ulcers are identified by licensed. A disposable measuring device (one time use) will be used to measure dimensions, and if necessary, a clean cotton tipped applicator to measure wound depth/ tunneling/ undermining. Pressure injuries and other ulcer (arterial, diabetic, venous) will be measured at least weekly and recorded in centimeters in the resident's clinical record. A wound assessment for each open area will be completed and will include: site location, size( length x width x depth), stage of pressure ulcer, odor, drainage, description, date and initials od each individual performing the measurements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, records reviewed the facility failed to develop and implement individualized and effective fall prevention interventions to prevent or reduce the incidents of falls with injury. This affected 2 of 3 residents reviewed for falls with injury. This failure resulted in R2 having an unwitnessed fall being transported to hospital with a change in condition post fall. R2 was admitted to the hospital for abnormal with a complex left cerebral subdural hematoma containing significant acute hemorrhage. R2 expired 14 days related to complication of the fall. This failure also resulted in R1 having an unwitnessed fall sustaining a comminuted right femoral intertrochanter fracture Findings include: 1.R2 was [AGE] years old with diagnosis including but not limited to Fibromyalgia, History of Falling (Onset [DATE]), and Weakness. Cognitive patterns dated [DATE] documents he has modified independence for daily decision making. On [DATE] at 11:54AM V22, Restorative Nurse, said the purpose of the CNA charting is to know how many people assist the residents and for the staff to know how much assistance the patient needs. V22 said CNAs are told to document every shift and every time they assist the residents. V22 said blanks in the charting means it (the care) did not happen. V22 said the residents should have bed mobility charted on all shifts. V22 said if the charting is not documented then it did not happen. V22 said a fall is a change in plane. V22 said unless I saw them fall then it is a fall. V22 said she updates the care plan after a fall but she does not document the root cause. V22 said the purpose of the root cause analysis is to know what caused the fall. On [DATE] at 1:32PM V18, Registered Nurse, said R2 usually did not try to get out of the bed. V18 said standard care included to round frequently and offer R2 help. V18 said R2 had a call light but I am not sure if he would use it. On [DATE] (morning) R2 was having normal behavior, he was non-verbal. V18 said R2 would sit up in the bed in the middle of the bed with his legs out. V18 said on [DATE] 9:00AM when I was rounding I saw him on the floor by his bed. V18 said I had seen R2 prior to the fall, R2 was sleeping. V18 said when I walked in the room R2 was laying on the floor on the mat. V18 said R2 was flat on his back. V18 said R2 could not stand but was able to pull himself up into a sitting position. V18 said I did not ask R2 what he was trying to do. V18 said I did not see him fall and the roommates said they did not see anything. The surveyor asked V18, did R2 hit his head and V18 said I don't know if he hit his head V18 said it is possible for the patient to have an injury without signs of injury. V18 said there was a night stand next to the bed on the side R2 fell. V18 said usual rounding is every 2 hours. V18 said I was checking R2 every 30 minutes. V18 said I reported to the oncoming nurse that R2 had a fall and had no signs of pain and the nurse practitioner saw him. V18 said when a resident falls we do a head to toe assessment and make sure there is no injury. V18 said we make sure they did not hit their head. On [DATE] at 1:53PM V10, Assistant Director of Nursing, said when a resident falls immediately the nurse develops a new intervention. V10 said the nurse communicates the intervention verbally to the next shift and then adds the new intervention to the careplan. During a phone interview on [DATE] at 11:08AM V28, Nurse, said on the evening shift [DATE] R2 fell and he was more anxious so she reported it to the doctor. V28 said R2's baseline is alert, but he can't talk or have conversations and can't communicate his needs. V28 said I don't know how R2 got on the floor on 3/8 (evening). V28 said at the start of her shift she was told R2 had a fall earlier. V28 said the intervention was to do more frequent rounding and keep an eye on him. V28 said we tried to check on R2 to make sure he was ok. V28 said she was notified R2 was on the floor by V34, Certified Nursing Assistant (CNA). V28 said on [DATE] she last saw R2 around dinner time, 5:00PM and could not recall if she saw R2 prior to the fall. On [DATE] at 10:19AM V13, Director of Nursing (DON), said V22 is the fall coordinator and she follows the falls in the building. V13 said V22 makes sure the interventions are in place. After V13 reviewed R2's incident report with the surveyor, V13 said on [DATE] at 9:00AM R2 was attempting to reach items from the floor. R2 said the intervention following R2's fall was to provide a reacher. V13 said when she interviews the staff following a fall she does not document it and she only documents the interviews if the incident is a reportable that goes to IDPH. V13 said the nurse's statement will be documented in the nurse's notes. The surveyor asked if the reacher was provided to R2 and V13 said I need to check with V22 if the reacher was provided. V13 said as a whole, R2 is difficult to redirect, very impulsive, and he does not ask for assistance. V13 said due to R2's cognitive status he is difficult to educate even with the use of an interpreter. The surveyor asked V13 how R2 was going to retain the information to use a reacher? V13 said R2 could do a return demonstration. V13 said R2 was told if you need assistance please call, but that was difficult for him to retain. V13 said there could have been more effective prevention interventions for R2. V13 said each resident fall should be addressed in the care plan or the care plan updated. V13 said I expect the interventions on the care plan to be carried out. At 11:26AM V13 said we did not do a monitoring sheet for R2 after his fall on [DATE] at 9:00AM, we did not do that intervention. On [DATE] at 2:58PM V22 said I don't know why there is a sign on R10's room (R2's former room mate) to keep the door closed. V22 said a person who has had previous falls should not have the room door closed. V22 said she discussed implementing the reacher with the staff but she did not physically provide it to R2. On [DATE] at 3:02PM V13 and V22 were asked together who is the fall coordinator for the facility. V12 said V22 is. V22 adamantly said I am not the fall coordinator. On a follow up in person interview on [DATE] at 3:28PM V28 said I could not tell if R2 hit his head, V28 said she was informed of R2's fall by the CNA who said the call light was on. V28 said I don't recall if the door to R2's room was closed. V28 said R2 does not usually wear shoes and I can't recall if he had socks on. V28 said I was not told anything about a reacher device to be used for R2. V28 said when she saw R2 he was on the floor, next to his bed, on a mattress and his head was near the footboard of his bed. V28 said I called the ambulance right away. On [DATE] at 3:15PM during in person interview V34, CNA, said I can't remember about R2's fall. V34 was unable to answer any of the surveyor's questions regarding R2 or his shift on [DATE]. V34 said he remembers entering R2's room because the call light was on and then saw R2 on the floor mattress but that was all he could remember. On [DATE] at 2:49PM The surveyor asked V39, LPN, about the sign on R10's door that reads keep door closed at all times. V39 said let me ask about the sign on the door and V39 approached R10. R10 (speaking in Korean to V39) said he does not recall his former room mates or anything else. R10 said he requested his door be kept closed since last fall because he feels a chill from the hall way. R10 told V39 who told the surveyor R10 requested the sign be put up on his door sometime last fall. R10 told V39 who told the surveyor the sign was put on his door by the Korean Manager. (Based on the interview is reasonable to conclude the door was closed when R2 fell.) On [DATE] at 11:53PM V40, Nurse Practitioner, said R2 was a fall risk because he as Dementia and he was not able to comprehend his safety needs. V40 said all fall precautions that could have been initiated, were initiated. V40 said I don't believe R2 could retain any information given to him by staff. V40 said the purpose of fall precautions is to prevent falls. V40 said if a patient's condition worsens, I expect the staff will check on the patient frequently. V40 said patients who are acute should be checked on more frequently. V40 said a significant hit on the head can cause a subdural hematoma. Incident Reports document R2 had a fall on [DATE] a fall on [DATE] at 9:00AM and a fall on [DATE] at 9:35PM. Behavior assessment dated [DATE] documents no behaviors related to psychosis, physical or verbal symptoms, or behaviors directed towards others. R2 had rejected care during 1-3 days of the assessment. R2's Functional Status assessment dated [DATE] documents he requires extensive assistance with bed mobility and transfers between surfaces. R2's Incident Report dated [DATE] documents R2 was sitting next to bed. Notes sections denotes encouraged R2 to ask for assistance and staff reminded to anticipate needs. R2's Incident Report dated [DATE] 9:00AM documents observed on the floor next to his bed. Root cause dated [DATE] notes R2 with history of falls, very impulsive, difficult to redirect. Attempting to reach items on floor/nightstand etc. R2's Incident Report dated [DATE] 9:35PM documents R2 had unwitnessed fall. Observed at the side of the bed. In supine position with head on the footboard side of the bed. R2's Behavioral Symptoms Code denotes 0 behaviors on [DATE] - [DATE]. R2's Documentation Survey Report dated [DATE] has no entry for day or evening shift. This includes Bed Mobility and Dressing. R2's Fall Scale Evaluation dated [DATE] notes R2 has a fall risk scale of 55. Scoring indicates high risk is a score of 45 and higher. Mental Status notes R2 overestimates or forgets limits. Careplan initiated on [DATE] documents R2 is a at risk for falls related to impaired cognition, limited mobility, weakness, incontinence, poor safety awareness, and history of fall. Intervention dated [DATE] denotes: staff to anticipate resident's needs. Encouraged to ask for assistance. Intervention dated [DATE] keep needed items water, etc. in reach. Assess ability to use and provide reacher. Intervention initiated on [DATE] denotes past falls and attempt to determine cause of falls. Record possible root cause. Careplan focus dated [DATE] denotes R2 has a right hip fracture related to a fall. R2's progress notes written by Nurse Practitioner dated [DATE] document fall precautions. R2's progress notes dated [DATE] at 10:53AM R2 had a recent fall. Progress notes at 11:12am written by nurse practitioner document status post fall follow up. Fall precautions to be maintained. On [DATE] at 9:52pm R2 had a fall. R2's progress notes dated [DATE] 3:06PM document R2 admitted for subdural hematoma. At 3:19AM R2 being admitted to the hospital with diagnosis of fall. R2's record including a head CT denotes result time [DATE] at 2:02AM examination is abnormal with a complex left cerebral subdural hematoma containing significant acute hemorrhage. R2's hospital record [DATE] at 10:45PM denotes R2 has known history of falls Hospital record on [DATE] documents R2 was intubated during operation and remains so. Post op drain and dressing indicated on R2's head. Procedures listed: cerebral angiogram for embolization, left die [NAME] holes with placement of drain, and intubation. R2's death certificate dated [DATE] documents cause of death 1. Complications of closed head injury 2. Fall. 2. R1 is [AGE] years old with a diagnosis including but not limited to Fracture of Right Femur ([DATE]), History of Falling ([DATE]), Long Term Use of Anticoagulant, Lack of Coordination, Abnormal Posture, and Difficulty in Walking. R1's Fall Scale Evaluation dated [DATE] notes R1 has a fall risk scale of 51. Scoring indicates high risk is a score of 45 and higher. On [DATE] at 12:26PM the surveyor observed R1 in his room, laying on his bed, no socks or shoes on his feet, and no floor mats in place. On [DATE] at 11:27AM R1 observed sitting in his room in his wheelchair. R1's floor being mopped and wet floor sign in the room. No floor mat observed in the room. On [DATE] at 11:40PM V13, DON, said R1 has only 1 fall incident report dated [DATE]. V13 said I did the investigation for this fall. V13 said R1 only complained of pain on [DATE] while in the facility. V13 said it was written in his hospital file that while in the hospital he reported that he fell in the facility. At 12:03PM V13 said the nurse at the hospital told me R1 fell and it is in the record. V13 said [DATE] is the only other fall R1 had. At 12:26PM V13 said I was verbally told when R1 went to the hospital he self reported the fall at the hospital. On [DATE] at 1:09PM V26, LPN, said when I started my medication pass on [DATE] I noticed R1 was not comfortable. V26 said I noticed R1's right leg with swelling at the hip and upper leg. V26 said R1's overbed table was at the foot of the bed and that was unusual because the table was usually next to him. V26 said there were no floor mats in the room when he was assessing R1. V26 said after the X-ray was completed I was notified R1 had a right leg fracture. V26 said R1 was not acting at his baseline. V26 said R1 was often self transferring without assistance from staff and often seen reaching under his bed. V26 said R1 would sometimes take himself to the bathroom. V26 said R1 would remind him and tell him to ask for help. V26 said R1 never used the call light. V26 said R1 needs at least supervision for transfers because he was unsteady before the fracture. V26 said he used an interpreter when talking to R1 about his pain. V26 said R1 said he did not know what happened to his leg. V26 said R1 was a fall risk before [DATE]. V26 said if a patient is on the floor it is a fall. On [DATE] at 1:33PM V27, Certified Nursing Assistant (CNA), said she spoke with R1 on [DATE] in Spanish and he only said he had pain in his leg and she told the nurse what R1 said. On [DATE] 3:15PM V32, CNA, was assigned to R1 on [DATE] evening shift. V32 said R1 tries to get out of bed. V32 said R1 thinks he can get up and assist the room mate, he sits up and tries to stand. V32 said R1 never fell on my shift. V32 said R1 tries to go from bed to wheelchair on his own and sometimes he is successful. V32 said if you see a resident on the floor it is a fall. V32 said if I saw a resident crawling around. I would report it as a fall, because I don't know how you (the person) got on the floor. On [DATE] at 10:19AM V13, DON, said via a phone conversation with the hospital staff I was told R1 said he fell in the facility. V13 provided a record from the hospital that reads I usually take steps in my wheelchair. The surveyor questioned the document because the document does not denote R1 said he fell. V13 said I used the wrong wording on the incident report. I worded it incorrectly. The surveyor reviewed R1's previous falls and incident reports with V13. V13 said I don't want to comment on R1's fall on [DATE]. V13 said I can't answer the root cause. V13 said a fall is a change in plane. V13 said we have some residents with behaviors that lower themselves to the floor. V13 said if it is a behavior there will a progress note and a careplan for the behavior. V13 said the plane is majority of the time the floor. On [DATE] at 10:12AM V14, Social Services Director, said behaviors are care planned. V14 said we document behaviors on a form in the record. V14 said crawling on the floor is a behavior that would be care planned. V14 said we would collaborate with the other departments and develop interventions. On [DATE] at 10:57AM V22 said the floor mat interventions for R1 was implemented. V22 said I don't know when we took the floor mats out. V22 said staff should be following the care plan. V22 said R1's episodes of crawling in the room should have been investigated. On [DATE] at 11:53PM V40, Nurse Practitioner, said R1's baseline is confused and he sometimes follows commands and his answers may or may not be appropriate. V40 said R1 was able to transfer himself prior to the fall. V40 said R1 did not understand the risk of his movements. V40 said it is an assumption that R1 fell because no fall was reported. V40 was asked if R1 was a fall risk and V40 responded of course, he was dementia and patient getting in and out if bed numerous times. V40 said everyone should be following the documented list of actions and precautions for the residents. V40 said The staff should be checking in on him constantly, make sure he is safe and in good condition. V40 said no staff saw what happened to R1, he was just complaining of pain. V40 said I can't recall if I was notified of the fall investigation results. R1's X-Ray dated [DATE] denotes X-Ray Right Hip, Unilateral Impression: acute moderately comminuted intertrochanteric fracture of the proximal right femur with deformity. R1's Incident Report dated [DATE] denotes observed lying on the floor. Notes: Sent to ER for further evaluation, Bilateral floor mats and low bed and continue therapy. R1's Incident Report dated [DATE] denotes R1 with complaints of pain to right leg. No witnesses found. (There is no mention this report is related to X-ray results from [DATE].) This incident was reported to IDPH. Final incident report denotes per hospital notes cause of injury related to unwitnessed fall, resident informed staff at hospital, I usually take steps to my wheelchair. The facility provided a document dated [DATE] (during R1's hospitalization period) Occupational Therapy I usually take steps to my wheelchair. Review of the facility Documentation Survey Reports dated [DATE]-[DATE] day shift have no documentation that assistance was provided with Activities of Daily Living (ADLs), including dressing and transferring. Review of the facility provided monthly fall Logs indicate R1 had a fall on [DATE] and on [DATE]. R1's progress notes dated [DATE] denotes R1 is a Very High Fall Risk due to impaired cognition and mobility. Review of R1's progress notes dated [DATE] denotes checked by the CNA patient is crawling on the floor R1's care plan denotes he is a high risk for falls. Interventions include on [DATE] review information on past falls and attempt to determine root cause of falls. The facility provided a 13 page care plan and there is no mention R1 has a behavior of crawling on the floor. R1's hospital record dated [DATE] denotes patient unable to provide meaningful history. Per EMS and nursing home report, patient had an unwitnessed fall today with persistent right hip pain. Hospital X-ray report dated [DATE] denotes x-ray hip 2 views right and pelvis impression: comminuted right femoral intertrochanter fracture. The facility Fall Prevention Policy effective date [DATE], in part denotes the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The fall prevention program, includes the following immediate change in in interventions, communication with direct care staff members, documentation requirements. Care plan incorporates: addresses each fall, interventions are changed with each fall, as appropriate, preventative measures. Accident/Incident reports involving falls will be reviewed by the team to ensure appropriate care and services were provided and determine possible safety interventions. Residents will be assigned approximately every 2 hours. The fall risk interventions will be identified on the care plan. Foot wear will be monitored to ensure the resident has proper fitting shoes and/or footwear is non-skid. In addition to these of Standard Fall Precautions, the following interventions may be implemented for residents identified at risk. The frequency of safety monitoring will be determined by the risk factors and the plan of care. In the event safety monitoring is initiated for 15-30 minute periods, a documentation record will be used to validate observations. Safety monitoring will be discontinued when the risk factors requiring monitoring is no longer evident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R50 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Encephalopathy, Waldenstrom Macroglobulinemia, Chronic Diastolic Heart Failure, and Obstructive and Reflux Uropathy. According to MDS (Minimum Data Set) dated 02/15/2022 under section C, R50 has BIMS (Brief Interview of Mental status) score of 14 indicating intact cognition. On 05/09/22 at 12:17 PM surveyor interviewed R50 about an incident that happened on 05/06/2022, R50 stated upon an interview, Couple of days ago, around 10:00 PM, another resident came into my room and started calling me names, and then he started punching my right forearm. He also hurt other people before. Somebody came in and told him to leave. Then they looked at me and my arm, and I got an x-ray couple of days later, but nothing is wrong with my arm. I believe the perpetrator is still here. I talked to the V3 (DON) the same night, I told him what I just told you. On 05/11/2022 at 10:24 AM Surveyor interviewed V3 (DON - Director of Nursing) regarding an incident that happened on 05/06/2022 involving R50, V3 stated, I was told by the nurse that R171 came into R50's room and hit him. V32 (LPN - Licensed Practical Nurse) then evaluated R50, no injury was noted, and x-ray was ordered. Notified family and the medical director. R171 was sent to the hospital for further evaluation for increased confusion, which resulted in hitting R50. Neither of them are violent, R171 is easily redirectable and it was very unusual for him to hit someone, that's why he was sent for further evaluation. V3 further stated, That floor (four south - dementia unit) needs more supervision, residents are demented, we're trying to keep them occupied but two demented patients walking into each other sometimes results in an altercation. On 5/11/2022 at 12:10 PM surveyor asked V21 to characterize R50, V21 stated, R50 has been here for a while, he rarely leaves the room. He gets a lot of packages but never opens them. He has a Power of Attorney who's involved in his care. Surveyor asked V21 to characterize R171, V21 stated, R171 is a very sweet but he's a sundowner, he wanders into residents' rooms but is easily redirectable. On 5/11/2022 at 12:10 PM Surveyor asked V21 why are there several altercation incidents in the four-south unit, V21 stated, Four south is a locked unit. There are a lot of residents with dementia, and a lot of them are not easily redirectable, wandering into others' room, getting into others' belongings, or just their personal space. Four south has expansive activity program. Activities keep residents engaged, prevent altercations, falls, and keep residents in one area. That allows us to monitor and supervise them easily. Four south is usually staffed with one nurse, two CNAs and one activity staff. More activities would benefit the unit. Based on interviews and record reviews, the facility failed to keep residents free from physical and sexual abuse. This failure affected two (R50 and R187) of four residents reviewed for abuse and resulted in R50 being physically abused by another resident and R187 experiencing fear while being touched inappropriately by another resident. Findings include: R187 is a [AGE] year old female, admitted in the facility with diagnosis of Major Depressive Disorder, Single Episode, Unspecified. MDS (Minimum Data Set) dated 03/18/2022 under Section C indicated that R187 has BIMS (Brief Interview for Mental Status) score of 15 which means intact cognition. According to abuse report dated 04/24/2022, R143 admitted to inappropriate touching R187 above clothing and flashing without her (R187) consent. On 05/10/2022 at 11:40 AM, R187 was asked regarding incident with R143. R187 stated, It happened in my room. He went to my room and got into my bed, put his hand into my mouth so I couldn't scream. He started touching me, my breasts. I started crying and told him to stop. It was a little scary at that time. He stopped and left the room. I went to the nurse and report it right away. The nurse checked me. I don't have any injuries or anything. I am not scared of him. Final Investigation report dated 04/29/2022 read: R143 stated during interview: I sometimes go into her room and I want to touch her. I attempted to touch on top of her pants and her breasts, but she pulled away and told me to get out of the room. R187's Progress notes dated 04/26/2022 authored by V16 (Nurse Practitioner) documented: Assessment/Plan: 12. Incident with another resident: Patient (R187) was touched inappropriately by another male resident at night while she was sleeping; patient reports no health concerns resulted from above. V8 (Registered Nurse, RN) was interviewed on 05/11/2022 at 10:24 AM regarding R187 incident with R143. V8 verbalized, The incident happened on 04/24/2022, around noon. I was doing my medication pass, I saw him (R143) with her (R187) in her (R187) room. He was talking to her but I was not listening. I remember she was feeling uncomfortable, she was looking at me like she was asking for my help to tell him (R143) to leave the room. I escorted him out of the room. He has Schizoaffective disorder, sometimes he says intrusive thoughts out loud, or talks to himself. She is always calm, nice and cooperative. As a nurse, we don't allow male residents to come into female residents' rooms for safety precautions. Sexual advances may occur. We do rounds every hour to check, talk to residents and redirect them. R143 has a diagnosis of Schizoaffective Disorder, Depressive Type, per his face sheet. On 05/11/2022 at 11:32 AM, V21 (Director of Social Services) stated in an interview that R143 admitted that he went to her room and tried touching her (R186) private parts. V21 continued, I asked her (R187) about the incident and she told me that it happened earlier in the day. She said she was sleeping, she woke up and he was standing there and was trying to touch her private areas, the breasts and was trying to put his hand inside her pants. She was assessed, I told V1 (Administrator) everything. I called paramedics and local authorities also came. During interviews by local authorities, she stated that he (R143) had his genitalia out while he was trying to touch her which she did not tell me during the interview. She said she did not say anything to me or to the nurse because she is afraid that he would kill her if she said anything. It makes sense because she did not tell me everything until I asked her. I am not aware of any rules in the facility that male residents are not allowed in female residents' rooms. Residents have rights but there should be some kind of boundaries between male and female residents when male residents going into female residents' rooms. Activities, CNAs (Certified Nurse Assistants) rand nurses need to be inserviced of the boundaries of male entering female rooms and vice versa, privacy, redirection, supervision and monitoring from staff. CNAs are supposed to do rounds as often as necessary to ensure privacy and safety of other residents. Involuntary Petition dated 04/24/2022 documented in part but not limited to the following: R143 was displaying sexually inappropriate behaviors and language towards a female peer. R143 confessed to exposing his genitalia and attempting to touch peer's breast and vaginal area. R143 often displays sexually abusive language, sexually threatening language and explicit/inappropriate language towards female peers. R143 expressed having overthinking, and auditory hallucinations stating, voices in my head are telling me to do bad things. R143 is a danger to peers and requires immediate hospitalization. On 05/11/022 at 1:13 PM, V3 was asked regarding interventions in preventing sexual abuse among residents in the facility. V3 stated, We need to set boundaries on female residents being visited or male residents coming into room; inform residents regarding interaction in the room or with supervision. Staff needs to intervene, ask if it was an invitation, especially if there are other residents residing in the room. Staff needs to monitor residents every two hours or as needed to ensure residents' needs are met and for safety purposes. V3 also added, He (R143) has Schizoaffective disorder. We need to monitor behavior and management for Schizophrenia. We need to supervise him and monitor regardless if there is a behavior or not because of his mental illness, medical illness and for psychotic episodes. He is alert, oriented and easily redirectable and can understand instructions. Just need guidance and monitoring. V1 (Administrator) also mentioned during interview on 05/11/22 at 2:43 PM, We always have an adequate amount of staff supervising and monitoring residents to ensure patients' needs are met, male residents roaming around or going into female residents' rooms without permission. Staff is constantly doing rounds in a shift and they do redirect residents when needed. We need to monitor and supervise residents with mental illness and redirect them. We monitor all residents and supervise them as needed and as frequent as possible for safety and prevention of incidents and redirection as necessary. R187's Care Plan dated 04/12/22 documented: The resident may voice allegations of mistreatment or exploitation. Interventions: assess the resident that they are safe and secure. Assure them that their needs will be addressed by trained caregivers. Keep the resident's representative informed about the behavior and staff interventions strategies, as appropriate; Investigate statements/allegations. Facility's policy titled Abuse Prevention and Reporting - Illinois reviewed date 12/17/2021, documented in part but not limited to the following: Guidelines: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Establishing a Resident Sensitive Environment This facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: Resident Assessment: As part of the resident social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment or misappropriation of resident property, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 1.) prevent a resident (R98) from developing moisture associated skin dermatitis related to incontinence and 2.) failed to assess and treat a neck wound for a resident (R173) at the time of admission. These failures affected two out of 10 residents reviewed for pressure ulcers and resulted in R173 having a delay in treatment for a neck wound, which progressed to a Stage III pressure ulcer. Findings include: R98 is a [AGE] year-old female admitted to the facility 07/05/2017 with diagnoses that include, chronic respiratory failure, diabetes, weakness and hypertension. R98 is alert and oriented but is unable to make needs known to staff as noted during observation and interview attempts. On 05/09/22 at 12:18PM R98 was observed in bed, with bilateral lower leg contractions, and heels resting on the mattress. The right heel was red in color and had noticeable skin peeling. R98 had on a disposable brief and sheets were observed to be soiled from underneath. On 5/10/22 at approximately 10:50 AM V22 Wound Care Coordinator said, the nurses are supposed to look at the skin and document on days that the residents get showers. The Certified nursing assistant will put if there is a skin issue in the electronic record and the nurse is supposed to follow up and assess. They should be documenting weekly on skin observation forms in the electronic record. It would not be beneficial for an air mattress to be covered with a bath blanket on the air mattress or a towel in between the resident and the air mattress because it will impede the healing process of the mattress. It should only be covered with a flat sheet. 5/10/22 at 11:40 AM R98 was observed receiving incontinence care before conducting a skin assessment with V22 Wound Care Coordinator. V28 and V29 Certified Nursing Assistants were observed changing R98 and there was a foul odor coming from the sheets, the brief was saturated and the sheets were soaked in urine and feces. V28 said I last changed her at 8am today. While repositioning for care, a soiled bath towel was noted in between the mattress and the flat sheet. The air mattress was saturated as well. R98's skin was observed to be reddened in color with multiple areas of open skin in areas of the sacrum, coccyx and labia. V22 said, I would assess this as moisture associated skin dermatitis in the perianal and scattered open areas caused by incontinence. R98 being wet for an extended period of time will certainly have accelerated this skin breakdown. It could have been prevented with frequent changes and repositioning. R98's Care Plan for Wound Care documents that R98 is high risk for skin breakdown related to immobility; Bowel and Bladder Incontinence and use of anti-coagulation therapy. Facility did not present weekly skin assessment notes upon request. R173 is a [AGE] year-old woman admitted to the facility 03/04/22 with diagnoses that include; tracheostomy, multiple sclerosis and functional quadriplegia. R173 was admitted with a tracheostomy and required a ventilator for primary respiration. R173 was not able to be interviewed as she is not alert or oriented. She is unable to make her needs known to staff. Initial comprehensive nursing assessment dated [DATE] documents that R173 had 1 skin alteration, a Stage IV pressure ulcer to the sacrum. In an initial respiratory note written for the same day, 3/4/22, it was noted that R173 also had a wound on the neck, and that nursing would be advised of the wound. There was no further assessment by nursing or wound care noted until 3/17/22. On 3/17/22 at 11:47AM, a wound assessment and details report documents that R173 had a Stage III pressure ulcer of the back of neck bright pink or red in color with serous exudate measuring 3.0 x 1.50 x 0.20 cm^2 (length x width x depth). The assessment states that the wound was present on admission. Physician Order Sheet dated 3/17/22 included orders for cleansing, med honey and foam dressing to be changed daily and as needed for back of the neck wound. Care plan initiated 3/7/22 and revised 3/17/22 said that R173 required wound care due to pressure injury to sacrum and back of neck upon admission. On 05/12/22 10:27 AM V22 Wound Care Coordinator said, the nursing and wound care team did not assess the wound on the back of the neck until 3/17/22. Although the wound was noticed by the Respiratory Therapist, they are not able to assess a skin issue. The nurse is supposed to assess. Since there was no assessment, there is no way of determining what type of wound was present and therefore did not have any treatment orders in place. By the time the wound care team saw R173, the wound was a Stage III. 05/12/22 12:45 PM V31 Wound Care MD said, The back of the neck wounds, when they open up, the skin opens very fast. I have no idea how old the wound was. Once a wound was identified, the treatment should be placed with urgency. Moisture Associated Skin Dermatitis (MASD) cause is secondary to exposure of body fluids including feces and urine. This could certainly transform into a pressure ulcer without treatment. MASD could have open skin with undefined edges and any moisture causes the skin to swell and skin breaks down. Facility Pressure Ulcer Prevention policy revised 1/15/18 reviewed and states in part; Purpose: to prevent and treat pressure sores/pressure injury. 3. Change bed linen per schedule and whenever soiled with urine, feces or other material. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated. Facility policy titled Wound Care Program: Pressure injury and Skin Condition Assessment revised 11/29/20 states in part, 2. Residents identified will have a weekly skin assessment by a licensed nurse; 3. A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by licensed nurse; 4. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment; 6. Care givers are responsible for properly notifying the charge nurse of skin breakdown; 7. At the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R171 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Vascular Dementia, Essential Hypertension, Personal History of Transient Ischemic Attack, and Cerebral Infarction. According to MDS (Minimum Data Set) dated 04/18/2022 under section C, R171 has a BIMS (Brief Interview of Mental status) score of 3 indicating severe cognitive functioning. 05/11/2022 at 10:24 AM Surveyor interviewed V3 (DON - Director of Nursing) regarding an incident that happened on 05/06/2022 involving R50, V3 stated, I was told by the nurse that R171 came into R50's room and hit him. V32 (LPN - Licensed Practical Nurse) then evaluated R50, no injuries found, x-ray was ordered. Notified family and the medical director. R171 was sent to the hospital for further evaluation for increased confusion, which resulted in hitting R50. Neither of them are violent, R171 is easily redirectable and it was very unusual for him to hit someone, that's why he was sent for further evaluation. V3 further stated, That floor (four south - dementia unit) needs more supervision, residents are demented, we're trying to keep them occupied but two demented patients walking into each other sometimes results in an altercation. On 05/12/2022 at 1:35 PM attempted to interview V32 via phone, no answer. Care plan Wandering/Pacing/Roaming dated 04/18/2022 reads in part, R171 should be assessed for unauthorized departure risk; if staff see that resident is attempting to go into another resident room, gradually show him where his room is and ask him to show you a personal item from his room; and make rounds/room checks to minimize chance of unauthorize leave. R174 is [AGE] years old. Current diagnoses include but are not limited to: Cognitive Communication Deficit, Symptoms and Involving Cognitive Functions Following Unspecified Cerebrovascular Disease, Aphasia, Unsteadiness on feet, and Other Abnormalities of Gait and Mobility. The facility reported incident of 4/27/22 states: Resident (R174) observed crawling on floor by bedside with a laceration to the forehead. Resident (R174) unable to explain what happened. Sent to hospital and sutures applied to the laceration on the forehead. On 05/10/22 at 10:46 AM, Resident # 174 is in lying in bed awake, opening and closing eyes when spoken to. Noted a handrail on the right side of the bed and a half side rail on the left side of the bed. The call light is wrapped around the handrail hanging in front of Resident # 174 while in bed within his reach. R174 has a BIMS score of 3 which indicates cognitive impairment' may be unable to understand how to use the call light. No fall mat noted on either side of his bed. Resident # 174 is wearing yellow non-slip socks. Review of R174's care plan indicates: Resident # 174 is utilizing half side rails to serve as enabler during repositioning and bed mobility 8/4/2021 Ensure that the mattress is appropriately sized for the selected bed frame Evaluate resident level of independence in repositioning Show to resident or staff how to take full advantage of the side rail for positioning, turning and transfer Resident # 174 is high risk for falls d/t generalized weakness and cognitive impairment secondary to AMS, UTI, Global amnesia, history of CVA (Cardiovascular accident) CKD (Chronic Kidney Disease), HTN (Hypertension), BPH (Benign Prostatic Hyperplasia) and Depression. 10/26/21 Falling leaf provided. o 2/18/22 Continue PT and OT o 4/20/22 Sent out for evaluation. Fall evaluation at hospital. To resume screening from therapy upon return. o 5/1. Sent to ER for evaluation. o Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes as possible. Educate resident/family/caregivers/interdisciplinary team as to causes. o Be sure call light is within reach and encourage resident to use it for assistance as needed Shows on [NAME]. o Ensure that resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. There are no appropriate individualized interventions documented regarding R174's ability to use the call light. There is no documentation of need for frequent monitoring or supervision. R174's MDS Minimum Data Set, dated [DATE] documents a BIMS Interview for Mental Status score of 03 out of 15. A score of 0-7 indicates the resident has severe cognitive impairment. Resident # 174's Restorative Care plan states: Resident # 174 presents with a functional deficit in Ambulation, due to: Generalized weakness 8/10/2021. Interventions-Explain program goals and procedure to resident. Shows on [NAME]. o Ensure resident is wearing proper footwear. Shows on [NAME]. o Apply gait belt to resident's waist. Shows on [NAME]. o Resident to continue gait sequence to cover goal distance, as tolerated. o Allow for rest periods, as needed. o Observe for signs/symptoms of fatigue, SOB, pain, discomfort, or intolerance. o Resident to continue gait sequence, with rest periods as needed, until the dining room is reached. No updates were made after his fall on 4/22/22. Resident # 174 presents with a functional deficit in Transfers, related to: Generalized weakness 4/5/2022. Interventions- Review goal and procedure to resident o Apply gait belt to resident's waist. o Cue & assist resident to place hand(s) on wheelchair arms or edge of bed and place feet flat on the floor. o Cue & assist resident to scoot forward to edge of bed, wheelchair or toilet seat. o Cue resident to lean forward. o Cue resident to push up with hands and feet to come to a stand. Assist as needed. o Pivot on feet until back of knees touch edge of bed, wheelchair or toilet seat. o On standing, cue resident to take short steps toward stronger side to turn until back of knees touch edge of bed, wheelchair or toilet seat. o Staff to assist as needed. No updates were made to this care plan area after the fall on 4/22/22. Review of the risk assessment for fall completed by V3 DON Director of Nursing was reviewed, indicates no injuries noted. On 05/12/22 at 12:24 PM, interview with V3 DON Director of Nursing regarding Resident 174's fall incident facility reported 4/27/22. V3 stated, The restorative nurse is the fall coordinator, but I am over all the falls for the residents. R174's BIMS score is 3, he's only alert and oriented to himself. He is ambulatory, but his gait is not steady. He shuffles and has poor posture. The incident happened on 4/20, but I reported it on 4/27. He was sent out due to the fall and had a laceration to his forehead. His interventions are low bed, he was screened by PT (physical therapy) for gait mobility and strength. He is on the falling leaf program. He is monitored closely with frequent rounding around the clock by all staff. The rounding is not documented. His aide that night was V35 CNA Certified Nurse Assistant, and the nurse was V34 RN Registered Nurse. There was another aide on the floor. I have statements from all of them. What was determined to be the cause of the fall? V3 DON stated, It occurred in his room on the floor crawling by the V35 CNA and he went to get the V34 Nurse to see what was wrong with him. R174 had a laceration to his forehead. He got out of bed and fell. It was late at night; his gait was unsteady so I'm not sure the exact cause. He has dementia, his BIMS is 3 and he can only be redirected. He paces and wanders into other rooms. What are the possible interventions to prevent R174 from falling? V3 stated, Monitoring and supervision R174 every 2 hours. He has a behavior of wandering, unsteady gait. We did labs a urinalysis t check for possible urinary tract infection. His medications were reviewed, and he was referred to physical therapy for evaluation again. On 05/12/22 at 01:04 PM, interview with V33 Rehab Director regarding R174's fall. V33 stated, R174 was evaluated upon readmission. He went to the hospital on 4/20/22, we were seeing him before that. He was on therapy at that time when he fell. Right now, he's on restorative. His functional limits are decreased safety awareness, unsteady gait he's not able to follow therapy with using the walker because of his dementia. I wasn't able to educate him with the walker. Staff have to watch him. We provided a wheelchair, but he just gets up and walks. He doesn't know how to use the wheelchair. His bed mobility is contact guard. He can move himself, transfer in bed, get out of bed but with unsteady gait. He has a restorative program. We recommended a low bed, no floor mat because if he tries to stand up he is high risk for falls. He is close to the nursing station. To observe him when walking to give him handheld assistance. He needs monitoring due to decreased safety awareness and decreased cognition. At 2:29 PM V3 stated, The nurse did the assessment for R174, but I did the risk assessment for the fall. V3 was inquired if he was at the facility on the date and time of R174's fall incident. V3 stated, No, I wasn't here, I just wrote what the nurse told me happened. Upon review of the change in condition evaluation completed on 4/20/22 at 8:49 PM by V3 DON indicates he completed the assessment. The initial report sent to IDPH Illinois Department of Public Health states the facility reported incident took place on 4/27/22. V3 DON did not present the requested nurse assessment of R174 after his fall incident on 4/22/22. R174 does not have a medical diagnosis of Dementia documented. V3 DON did not provide any documentation regarding frequent every 2 hour rounding on R174. R174's 4/19/22 Fall Risk Evaluation indicates a score of 17: At Risk. The revised 11/21/17 Fall Prevention Program states: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines: The fall prevention program includes the following components: methods to identify risk factors, methods to identify residents at risk, assessment time frames, use and implementation of professional standards of practice, immediate change in interventions thaw were successful, notification of physician, family/legal representative, communication with direct care staff members, documentation requirements, adherence to manufacturer's recommendation in use of alarm and medical devices and special care equipment. Care plan incorporates identification of all risk/issue, addresses each fall, interventions are changed with each fall, as appropriate, preventative measures. In addition to the use of Standard Fall Precautions, the following interventions may be implemented for residents identified at risk: The resident will be checked approximately every two hours, or as according to the care plan, to assure they are in a safe position. The frequency of safety monitoring will be determined by the resident's risk factors and the plan of care. Fall/safety interventions may include but are not limited to: Residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or a chair and provide care as assigned in accordance with the plan of care. Based on interviews and record reviews, the facility failed to provide required supervision and monitoring of residents assessed to require staff supervision. This failure affected three of three (R143, R174, and R171) residents reviewed for accidents and supervision and resulted in one resident (R143) from going into another resident's room (R187) and touching her inappropriately without consent; the facility also failed to supervise and monitor a resident according to their plan of care and the resident subsequently had a fall which resulted in one resident (R174) having to be transferred to the hospital for a laceration to the forehead that required sutures; and the facility failed to provide supervision to keep one resident (R171) from physically abusing another resident. Findings include: R143 is a [AGE] year old male, admitted in the facility on 12/30/2021 with diagnosis of Schizoaffective Disorder, Depressive type. MDS (Minimum Data Set) dated 04/08/2022 under Section C documented that R143 has BIMS (Brief Interview for mental Status) score of 13 which means intact cognition. According to abuse report dated 04/24/2022, R143 admitted to inappropriate touching R187 above clothing and flashing without her (R187) consent. On 05/10/2022 at 11:40 AM, R187 was asked regarding incident with R143. R187 stated, It happened in my room. He went to my room and got into my bed, put his hand into my mouth so I couldn't scream. He started touching me, my breasts. I started crying and told him to stop. He stopped and left the room. I went to the nurse and report it right away. I was okay, the nurse checked me. I don't have any injuries or anything. I am not sacred of him. V8 (Registered Nurse, RN) was interviewed on 05/11/2022 at 10:24 AM regarding R187 incident with R143. V8 verbalized, The incident happened on 04/24/2022, around noon. I was doing my medication pass, I saw him (R143) with her (R187) in her (R187) room. He was talking to her but I was not listening. I remember she was feeling uncomfortable, she was looking at me like she was asking for my help to tell him (R143) to leave the room. I escorted him out of the room. He has Schizoaffective disorder, sometimes he says intrusive thoughts out loud, or talks to himself. She is always calm, nice and cooperative. As a nurse, we don't allow male residents to come into female residents' rooms for safety precautions. Sexual advances may occur. We do rounds every hour to check, talk to residents and redirect them. R143 has a diagnosis of Schizoaffective Disorder, Depressive Type, per his face sheet. On 05/11/2022 at 11:32 AM, V21 (Director of Social Services) was asked for interventions in preventing incidents of going into another resident's room without permission. V21 stated, I am not aware of any rules in the facility that male residents are not allowed in female residents' rooms. Residents have rights but there should be some kind of boundaries between male and female residents when male residents going into female residents' rooms. Activities, CNAs (Certified Nurse Assistants) and nurses need to be inserviced of the boundaries of male entering female rooms and vice versa, privacy, redirection, supervision and monitoring from staff. CNAs are supposed to do rounds as often as necessary to ensure privacy and safety of other residents. On 05/11/022 at 1:13 PM, V3 was asked regarding R143 and supervision among residents in the facility. V3 stated, We need to set boundaries on female residents being visited or male residents coming into room; inform residents regarding interaction in the room or with supervision. Staff needs to intervene, ask if it was an invitation, especially if there are other residents residing in the room. Staff needs to monitor residents every two hours or as needed to ensure residents' needs are met and for safety purposes. V3 also added, He (R143) has Schizoaffective disorder. We need to monitor behavior and management for Schizophrenia. We need to supervise him and monitor regardless if there is a behavior or not because of his mental illness, medical illness and for psychotic episodes. He is alert, oriented and easily redirectable and can understand instructions. Just need guidance and monitoring. V1 stated on 05/11/22 at 2:43 PM, We always have an adequate amount of staff supervising and monitoring residents to ensure patients' needs are met, male residents roaming around or going into female residents' rooms without permission. Staff is constantly doing rounds in a shift and they do redirect residents when needed. We need to monitor and supervise residents with mental illness and redirect them. We monitor all residents and supervise them as needed and as frequent as possible for safety and prevention of incidents and redirection as necessary. R143's care plans documented: Care plan 03/17/2022: R143 has diagnosis of Schizoaffective Disorder and Bipolar Disorder. He exhibit symptoms of auditory hallucinations, psychosis, major depression, feelings of helplessness/hopelessness, poor insight/logic/judgment and contact with reality. Interventions: As warranted, conduct, carry out daily monitoring and supervision of resident; room safety checks; personal wellness check; mouth check during medication pass; behavior monitoring of the resident, looking especially for any change; evaluation of mental status, mood state, and thought content. Care plan 03/01/2022: R143 has a diagnosis of and history of Severe Mental Illness. Interventions: Explain facility rules, resident behavioral expectations and resident rights. Facility's Contract Between Resident and Facility stated in part but not limited to the following: No resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the Constitution of the State of Illinois, or the Constitution of the United States solely on account of his or her status as a resident of the Community, nor shall a resident forfeit any of the following rights: 1. The right to live in an environment that promotes and supports each resident's dignity, individuality, independence, self-determination, privacy, and choice and to be treated with consideration and respect. Facility's policy titled, Incidents and Accidents dated 04/07/2019 does not specifically address any guidelines regarding residents' going to other residents' rooms without permission.