**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to a.) ensure (R3's) fall risk assessment was accurate b.) failed to implement fall prevention interventions and failed to provide supervision for two ( R2, R3) of four residents reviewed for falls. These failures resulted in the following: R2 fell on [DATE] and on 7/06/24. R3 fell on [DATE] (fall without injury) and R3 also fell on 7/04/24 (7 days later) and sustained a subdural hemorrhage (bleeding inside the head). Findings include: R2's face sheet dated 09/15/2024 documents that R2 is a [AGE] year-old resident with diagnoses not limited to: mild cognitive impairment of uncertain or unknown etiology, anxiety disorder, unspecified, unspecified fracture of t9-t10 vertebra, subsequent encounter for fracture with routine healing, metabolic encephalopathy, acute on chronic systolic (congestive) heart failure, insomnia, unspecified, type 2 diabetes mellitus with hyperglycemia, age-related osteoporosis. R2's MDS section GG dated 8/20/2024 documents R2's interim assessment affirms R2 requires partial/moderate assistance with transfers form bed to chair, toilet transfers, and to walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. The facility fall log affirms R2 fell on [DATE] (fall without injury) and on 7/06/24 (fall without injury). R2's fall risk evaluation dated 06/20/2024 documents R2 just had a fall and that R2 is a high fall risk. R2's fall risk evaluation dated 06/29/2024 documents R2 just had a fall and that R2 is a high fall risk. R2's care plan documents in part that R2 is at risk for falls related to weakness, fibromyalgia, chronic T8 com fracture, right shoulder pain, debility. Interventions: chair Alarm in place to alert staff when R2 reattempt to standup unassisted. Educated R2 the importance of calling staff if she needs assistance in anyway. Date Initiated: 02/15/2023. 09/15/2024 11:30 AM V4 (Registered Nurse) provided surveyor with a copy of the fall risk prevention list. Facility document dated 09/14/2024 titled Fall Risk Prevention List documents in part that R2 is marked for bed alarm, chair alarm, and floor mats; R4 is marked for bed alarm and chair alarm. 09/15/2024 11:51 AM observed R2 in her room, sitting on a recliner chair with two pillows behind her, observed bedside table in front of R2, observed R2 wearing her own clothes and gym shoes on. Observed R2 wearing glasses. Observed carpet flooring. Observed bed alarm, and observed chair alarm on a wheelchair that was against R2 ' s room wall. No observation of a chair alarm under R2 or around the recliner chair that R2 was sitting on. R2 states that she has had falls here. R2 states that she last fell out of her bed, R2 states now there is pad on the floor when she is in bed. R2 states that she has had 3 episodes that they have taken her to the hospital because R2 states that she has been sick. R2 states she honestly cannot remember what happened. R2 states that another fall she had, R2 states that it was pure accident, R2 states that her leg just buckled. 09/15/2024 12:16 PM surveyor questioned V3 (Director of Nursing) which CNA was assigned to care for R2. Observed V3 review the assignment sheet. V3 states that V6 is assigned to R2. 09/15/2024 12:20 PM V8 (Certified Nursing Assistant/CNA) states that if an alarm is not placed under a resident that is supposed to have bed or chair alarm, V8 states that the resident could have a fall. V8 states that it is a split second that a fall can happen. V8 states that the bed and chair alarms do not prevent a fall, but it is just alerting staff that the resident is moving out of the chair, V8 states or they are probably uncomfortable in the chair, V8 states they could probably need to go to the bathroom, V8 states or they can be reaching for something, want water. V8 states that staff can switch the chair alarm to the recliner. V8 states that the chair alarm is connected to a pad that will be triggered with movement. 9/15/2024 12:55 PM V6 (CNA) states that she is not sure which CNA has R2. V6 states that she thinks it was V7 (CNA) who was assigned to R2. V6 states that V7 walked out of the facility. V6 states that V7 said it was too much work and walked out of the facility. V6 states that the supervisors are aware. V7 states that she is not familiar with R2's care. V6 states that she would have to go to the nurse's station to review R2's care plan and V6 states to find out how R2 transfers, if R2 is a fall risk. V6 states that the chair alarm and bed alarm are pads and are motion sensor. V6 states that the pads should be under the resident. V6 states that the chair alarms are not built in the wheelchairs. V6 states that the chair alarm should be placed under any type of seating that the resident is sitting on. V6 states that she has never worked with R1 and R3 before. 09/15/2024 12:58 PM V6 states that the change in assignment must have just happened. V6 states that she has not seen R2 today. V6 states that she was not made aware that she was just assigned to R2. R3's face sheet dated 09/15/2024 documents that R3 is a [AGE] year-old resident with diagnoses not limited to: disorder of brain, unspecified, traumatic subdural hemorrhage without loss of consciousness, subsequent encounter, unspecified fall, subsequent encounter, Parkinson's disease without dyskinesia, orthostatic hypotension, primary generalized (osteo)arthritis, benign prostatic hyperplasia with lower urinary tract symptoms, anxiety disorder, unspecified. R3's MDS/Minimum Data Set, dated [DATE] documents that R3 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R3 is cognitively intact. R3's MDS/Minimum Data Set, dated [DATE] (post R3's falls) documents that R3 has a BIMS/Brief Interview for Mental Status score of 10/15, indicating that R3 is moderately cognitively impaired. R3's MDS section GG dated 4/24/2024 documents R3's annual assessment affirms R3 requires partial/moderate assistance with transfers form bed to chair, toilet transfers, and to walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. The facility fall log affirms R3 fell on [DATE] (documents fall without injury) and on 7/04/24 (documents fall without injury). R3's fall risk evaluation dated 06/27/2024 documents R3 did not have a fall and that R3 is a high fall risk. R3's fall risk evaluation dated 07/04/2024 documents R3 just had a fall and that R3 is a high fall risk. R3's care plan documents in part that R3 is at risk for falls related to Parkinson disease, orthostatic hypotension, past fall, lack of coordination and abnormalities of gait. Interventions: staff should anticipate and frequently round. Date initiated 04/14/2023. 09/15/2024 2:03pm V9 (Fall preventionist/RN) states that she has been working for the facility for almost 2 years. V9 states that she has been the fall coordinator for a year and 4 months. V9 states that she completes the residents' fall risk care plans. V9 states that she inputs the fall risk care plan interventions too. Surveyor inquired how V9 determines that the chair and bed alarm interventions should be put in place. V9 states that if the resident has had history of falls, diagnosis of dementia, pain, UTI, or upon admission assessment, V9 states that it determines if the residents need to have bed and/or chair alarm. V9 states that she completes assessments upon admission. V9 states that also if the residents have weakness. V9 states that the bed and chair alarm intervention can help prevent residents from falling, V9 states that the chair alarm should be placed on whatever chair the resident is sitting on. V9 states that R2 fell on June 20th, V9 states that R2 said that she wanted to get out of bed, V9 states that R2's bed was in a low position. V9 states that R2 was found at the side of her bed at 1:00 am. V9 states that R2 did not suffer any injuries. V9 states that this fall could have been prevented if R2 would have used her call light. V9 states that R2 had another fall on June 29th, in the morning shift. V9 states that R2 said that she was trying to ambulate to the washroom, V9 states that R2 said that she lost her balance and fell. V9 states that for this fall, she would have to say that the same still applies, V9 states that R2 is a retired nurse, and V9 states that she encouraged R2 to use the call light. V9 states that R2 can use her walker and V9 states that R2 can go by herself to the washroom unsupervised. Surveyor inquired as to why did R2 had a chair alarm and bed alarm if she is able to go by herself to the washroom unsupervised. V9 states that that she wanted to discuss the previous fall R2 had, V9 states that R2 had an infection when she had her first fall on June 20th, V9 states that to prevent R2 from falling, R2 and her family were ok with R2 having a bed and chair alarm. V9 states that R2 still wants to have the alarms in place. V9 states that she feels that it is safer for R2 to have the bed and chair alarm, V9 states because R2 has had multiple falls, and V9 states that the root cause of R2 falling is that R2 is not calling for her. V9 states that staff need to anticipate R2's needs. V9 states that staff need to make rounds and anticipate needs. V9 states that she does not do reportables. V9 states that her director does the reportables. V9 states that R3 was a long-term care resident, and V9 states that R3 was declining. V9 states that R3 fell on June 27th, V9 states that R3 didn't call for help. V9 states that R3 had refused to go to the hospital the first time that R3 fell. V9 states that after his fall on June 27th, V9 states that she revised R3's care plan and implemented chair alarm, and R3 was reeducated to call for help. V9 states that R3 did not suffer any injuries from his fall on 06/27/2024. V9 states that R3 did not have bed and chair alarms in place prior to his fall on 06/27/2024, V9 states because R3 became very strong, and it had resolved. V9 states that prior to R3 having a fall on 06/27/2024, V9 states that R3 wasn't much of a fall risk, V9 states that R3 could do things by himself, V9 states that R3 went out by himself, V9 states R3 was independent. V9 states that R3 was this way for 9 to 10 months. V9 states that she noticed a decline in R3. V9 states that R3 had lab work done and no new orders were given. V9 states And we continued neuro check in house after fall on 27th. Why did he fall on June 27th, he said he wanted to use the washroom, I usually have, and he tripped going past the bedside table, it was in his way, and then he fell. And he verbalized that he didn't hit his head, and didn't have any pain, and that was the fall that he refused to go to the hospital. V9 states that R3 fell again on 7/4/24. V9 states that the nursing assistant found R3 on the floor. V9 states that prior to this fall, staff saw R3 watching T.V. (television), sitting on his recliner chair. V9 states that R3 didn't call for help. V9 states that R3 fell in front of his recliner. V9 states that R3 wanted to get up. V9 states that at that time, R3 couldn't engage a lot in conversation, V9 states that R3 didn't say where he was going, V9 states that R3 had denied any pain and denied hitting his head. V9 states that she insisted that R3 needed to go to the hospital. V9 states that she was concerned that R3 was declining. V9 states that he didn't look too good. V9 states that when R3 returned to the facility from being in the hospital, V9 states I put back the floor mats, and low position, after that he returned under hospice. V9 states that she does in-services regarding fall precautions every day, V9 states that she encourages staff and reminds staff about fall precautions in place, to check that fall precautions are in place every day, V9 states that she also reminds staff to review and understand the fall precautions in place for the residents from the care book binder, V9 states that she also reminds staff to rounds and anticipate residents' needs while rounding. 09/16/24 4:01pm via telephone V12 (Nurse Practitioner) states that if a resident falls and hits their head, the resident can have Subdural hematoma, V12 states which is bleeding in the brain. V12 states that for older residents, if they have a fall, V12 states that they can potentially suffer many complications with a fall, V12 states they can break their bone, lacerations, fat embolism. Facility document dated 07/26/2024 titled Fall occurrence documents in part It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and records reviewed the facility failed to follow fall prevention interventions to include supervision/monitoring and use of assistive/safety devices to prevent the risk of falling. This affected three of three residents (R1-R3) reviewed for falls and fall prevention interventions. This failure resulted in R1 being involved in a fall incident sustaining a fracture of the L4 and L5, Lumbar Spine, and R3 being involved in a fall incident resulting in an Oblique Fracture of the Left Fifth Metatarsal and of the Neck of the Right Radius. Findings include: A.R3's diagnosis include but are not limited to Spinal Stenosis, Anemia, Dementia, Osteoarthritis, Difficulty in Walking, Age Relate Physical Debility, Altered Mental Status, Lumbago with Sciatica, Right Side, and Radiculopathy - Lumbar Region. R3's Cognitive assessment dated [DATE] indicates mildly impaired. On 10/29/23 at 2:49PM The surveyor observed a star on the door, near R3's name, door closed. V3, Restorative Aid, in the room with the roommate. V3 sitting a chair near roommate. R3 opened the door and greeted the surveyor. R3 walking in the room then to sink to finish washing. R3 hanging washcloth on towel rack and then stumbled while turning, but regained balance, loud squeaking sound from shoe, before sitting on his bed. R3 said yes, I fell I was up alone in my room. R3 said I did not call for help. R3 said I was ashamed and did not call for help. R3 said I don't call for help when I need to use the bathroom or get something. No alarms sounding with the resident in the room. On 10/29/23 at 3:15PM V3, Restorative Aid, said I was in R3's room working with R3's roommate. V3 said I work with R3 for range of motion. V3 said R3 can walk with a standby. V3 said R3 was using the washroom I was in the room. V3 said I did not see him stumble. V3 said I would not have gotten to R3 from where I was if he was falling. V3 said R3 does not have alarms on and he should. V3 said I did not [NAME] R3's alarms off when I went in the room. On 10/30/23 at 9:52AM V9, Fall Nurse, said R3 is a fall risk. R3's diagnosis include Spinal Stenosis, Arthritis, Debility, Lack of Coordination, and Altered Mental Status. V9 said R3 had one fall on 10/17/23. V9 said R3 should be supervision for ambulation. V9 said this means R3 should have a person in the room while ambulating. V9 said R3 is not stand by assist for ambulation. V9 said Staff should be standing when supervising residents. V9 said staff don't need to sit so they can move faster for staff. V9 said R3 complained about the alarms being too loud so I stopped them. V9 said R3 is alert and can call for assist with the call light. V9 said she was unsuccessful in reaching the night shift agency staff to interview about R3's fall. V9 said it is unknown if the alarm was answered or if the alarm was in place and on at the time of R3's fall. V9 said R3 sustained a fracture on right foot. On 10/30/23 at 11:30AM V11, Therapy Director, said R3 is currently supposed to be walking with a walker and supervision, including yesterday. V11 said prior to R3's fall on 10/17/23 R3 required supervision for ambulation. V11 said supervision means staff should be in eyesight during ambulation. R3's Fall Risk Evaluation dated 10/17/23 score is 13, high risk. R3's care plan dated 9/15/23 identifies R3 at risk for falls related to Spinal Stenosis with Radiculopathy, Right Hip, Osteoarthritis, Altered Mental Status, Dementia, Depression, and Debility. Interventions dated 9/15/23 include bed alarm and chair alarm. R3's care plan for Activity of Daily Living and Fall Risk do not address R3's ambulation ability/status. R3's Functional Status dated 9/21/23 indicates he needs staff assistance during transfers and was not ambulating at the time. Incident Report dated 10/17/23 documents R3 notified staff he fell during the night and did not report or call for help. Resident statement, in part, reads I was trying to use the rest room and fell. The facility Incident Report dated 10/18/23 documents after hospital evaluation R3 findings include Oblique Fracture of the Fifth Metatarsal and of the Neck of the Right Radius - initial encounter. R3's hospital record dated 10/17/23 states oblique fracture through the fifth metatarsal shaft. Closed non-displaced fracture of fifth metatarsal bone of left foot and closed non-displaced fracture of neck of right radius. B. R1's diagnosis include but are not limited to Fracture of Left Femur, Anemia, and Hypertension. On 10/29/23 at 1:27PM V2, Licensed Practical Nurse, said R1 fell because he had a Urinary Tract Infection and may have had a behavior change. V2 said R1 could not walk. V2 said I was called to the room and saw R1 on the floor. V2 said I don't know what CNA was assigned to him. V2 said I was not assigned to R1. On 10/29/23 at 2:08PM V12, Nurse Supervisor said on 9/11/23 when I went to R1's room I saw him on the floor. V12 said R1 either pulled the light or the alarm sounding. V12 said R1 did not know he was on the floor. V12 said when I asked R12 about the fall, he said oh, I'm on the floor. V12 said I am not sure of R1's his mental status at the time. V12 said R1 was on isolation at the time and his room door was closed. V12 said R1 was on his back. He was right next to the bed. V12 said R1 was not a fall risk. V12 said I did not see him fall and I do not know what he was trying to do. On 10/30/23 at 9:52AM V9, Fall Nurse, said V5,Nurse, and V13, CNA, were interviewed and said R1 tried to transfer without assistance. V13 said she did not see the fall, V13 said to V9 I was providing care to another resident. V9 said V5, Nurse, said V12, Nurse Supervisor, called me and said R1 was on the floor. V9 said she was told V12 was rounding and saw the call light on and when he entered the room R1 was on the floor. V9 said R1 is always in bed, he had not tried to get up. V9 said R1 was on antibiotic and could have been confused causing him to fall. V9 said R1's baseline was incontinent of urine. V9 said I don't know what R1 was trying to do when he fell. V9 said R1 required a mechanical lift for transfer, and he was not strong enough to stand. V9 said R1's door was closed for isolation. V9 said there was no other cnas involved in R1's care, V13 was the assigned CNA. V9 had no additional interviews for R1's fall. While reviewing R1's incident report/investigation with V9, she was unable to say when R1 was last turned, repositioned, or received incontinent care. V9 was unable to say who assisted in repositioning R1 during the shift. On 10/29/23 at 11:32AM V8, R1's wife, said R1 had fractures of the L4 and L5 in his back he did not have those before the fall. R1's care plan dated 2/18/2023 states R1 is at risk for falls related to left femur fracture status post surgery, anemia, abnormal gait and mobility. Interventions for R1 include bed alarm in place chair alarm in place, requires two staff participation to reposition and turn in bed. Incident report for R1 dated 9/11/2023 reads R1 verbalized pain to the right leg and facial grimacing was noted level of pain is 6 out of 10. Review of R1's medication administration record and physician orders for September 2023 do not include treatment of urinary tract infection. Physical therapy Discharge summary dated [DATE] documents R1 to require partial/moderate assistance with sitting to standing. Transfers from chair to bed require partial/moderate assistance. Substantial/Maximal assistance for toilet use and patient was unable to ambulate. The facility's incident report to IDPH on 9/11/23 reveals R1 was transferred to the hospital on 9/11/23. R1 was admitted to the hospital with lower back trauma. A CT of the spine revealed L4 and L5 compression deformities that are new compared to 9/25/2022 and represent acute fractures. C.R2's diagnosis include but are not limited to Fall, Compression Fracture of Vertebra, Anemia, Difficulty in Walking, Weakness, and Osteoporosis. On 10/29/23 at 10:33 AM R2 called for the nurse in the dining room and asked V2, LPN, to check his blood sugar. V2 said in 2 minutes I will be there. The surveyor remained monitoring R2 until 10:45AM and V2 did not return him. On 10/29/23 at 1:27PM V2, LPN, said R2 is very alert but we must help him. V2 said R2 requires 2 person assistance to get from wheelchair to the bed we use the mechanical lift. On 10/29/23 at 3:32PM V4, Registered Nurse, said R2 used the call light around 6:45AM. V4 said R2 said he wanted to get up and sit in the wheelchair. I asked him to wait for the CNA. V4 said R2 called again, he said I want to get up, I just need some help, he did not want to wait. V4 said on the third time R2 called I helped him to get up. V4 said I helped him lower his feet from the bed, I held his arms, he was helping, but then his feet were shaking, he got weak. V4 said I was about to fall. V4 said the safest thing to do was to put him on the floor. V4 said this was my first time working with the resident. The surveyor asked V4 how she knows the transfer status of the residents she is assigned to. V4 was unable to answer. V4 said R2 is 1 assist. V4 said R2 said he is going to help me, and he said he can help. On 10/30/23 at 9:52AM V9, Fall Nurse, said R2 is high risk for falls because he has fractures in the spine, lack of coordination weakness, and history of falls. V9 said R2 is a 2 person assist with a mechanical lift for transfers. V9 said to use the commode R2 is a 2 person assist. V9 said R2 has required 2 person since his admission. V9 said the cause of the fall on 10/12/23 was related to R2 asking to transfer out of bed. V9 said the Staff Care Binder is used to notify staff of resident transfer status. V9 said the V4 can look at the binder to know what care to provide. V9 said R2 is cooperative with the mechanical lift. Incident report dated 10/12/23 reads R2 requested to get out of bed and into his wheelchair. This writer, V4, told him to wait for his CNA. Report reads I still want to sit in my wheelchair. At 7:00AM writer attempted to transfer R2 from bed to wheelchair. R2's legs began to shake and R2 became unsteady. R2 assisted to the floor. Review of R2's Incident Reports identify falls on 9/16/23; 9/29/23; and 10/12/23. R2's care plan dated 9/18/23 states R2 require 2 staff participation with mechanical lift transfers to prevent fall. On 10/30/23 at 9:52 AM V9, Fall Nurse, said a resident's diagnosis can increase the risk for falls such as Hypertension, Diabetes, Parkinson's, Impaired Memory, Dementia, Alzheimer's, Weakness, Debility, Seizure, and Syncope. V9 said the Root Cause Analysis is what led to the fall. V9 said the plan is developed from the cause. On 10/30/23 at 2:32PM V15, MDS Coordinator, said the purpose of the care plan is so the nurses can find the intervention for the plan of care of the resident. V15 said I expect the nurses to follow the careplan. V15 said when an intervention is no longer needed we do review and update the care plan. V15 said we can add and remove interventions or resolve them. The facility fall prevention program guidelines dated December 5th 2022 states fall prevention program guidelines shall be implemented to promote safety of all residents in the facility. safety interventions shall be initiated and implemented for each resident identified at risk for fall. All assigned nursing personnel and facility staff shall be responsible for ensuring ongoing precautions are put into place and consistently maintained. All file incidents shall be monitored, analyzed, root causes identified. The facility Fall Occurrence policy dated 7/17/23 reads it is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. If a resident has fallen, the resident is automatically considered as high risk for falls. The falls coordinator will add the intervention in the residence care plan. The interventions will be reevaluated and revised as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent a facility acquired pressure ulcer from developing, failed to develop and implement a care plan with pressure relieving interventions to prevent a pressure ulcer from developing, failed to develop and implement a care plan with interventions to address a pressure ulcer once developed, and failed to do skin checks for one of three residents (R4) reviewed for pressure ulcers in the sample of five. These failures resulted in R4, who was admitted to the facility without pressure ulcers, developing a stage two pressure ulcer to the right heel that progressed to an unstageable infected pressure ulcer that required R4 to be hospitalized and treated with intravenous antibiotics. Findings include: The facility's Wound Care Program policy dated 7-1-22 documents, It is the policy of this facility to ensure that residents whose clinical conditions and medical diagnosis potentiate the risk for skin breakdown and development of pressure ulcers are properly identified, assessed, and managed according to current regulatory guidelines and standard of care. Procedures: 1. Timely identification of residents assessed to be at risk for skin breakdown. Each risk factor and potential causes identified with the Braden scale (wound risk assessment) should be reviewed individually and addressed into the resident's care plan. Facility shall develop a plan of care and implement interventions according to the resident's Braden score and/or identified individual risk factors. Prevention of skin breakdown: Inspection of the skin every shift with care for signs of breakdown. Activity, Mobility, and Positioning: Establish an individualized turning and repositioning schedule of the resident if immobile or with impaired physical functioning. The resident's care plan shall be evaluated and revised based on resident's response to treatment, treatment goals and outcomes. Pressure Ulcer Treatment: Initiate wound care treatment upon identification of the wound with physician's order. Develop a care plan with appropriate interventions. R4's admission Record documents R4 was admitted to the facility on [DATE] with the diagnoses of Spinal Stenosis, Need for Assistance with Personal Care, Weakness, Lack of Coordination, and Mild Intellectual Disabilities. R4's Progress Notes dated 9-28-22 document R4 was discharged to the hospital on 9-28-22 and did not return to the facility. R4's MDS (Minimum Data Set) assessment dated [DATE] documents R4 was a [AGE] year-old admitted to the facility on [DATE]. This same MDS documents R4 was moderately cognitively impaired, required extensive assistance of one staff for bed mobility, transfers, dressing, and toileting. R4's admission Skin Evaluation dated 8-19-22 documents R4 was admitted with normal, warm skin and had no pressure ulcers upon admission. This same evaluation documents R4 had a non-pressure skin condition to the right great toe, is assessed to be at risk for pressure sore development related to fragile skin, incontinence, and impaired mobility, and should have heels offloaded with pillow while in bed. R4's Wound Risk assessment dated [DATE] and 8-27-22 documents R4 is at risk for developing pressure ulcers. R4's Wound Summary and Wound Assessment Details Report dated 8-25-22 through 9-27-22 documents R4 developed a partial thickness pressure ulcer to the right heel on 8-25-22 that measured 5.0 cm (centimeters) by 3.0 cm by an unknown depth and had a scant amount of sero-sanguineous (clear pinkish) exudate (drainage). R4's Progress Notes dated 8-26-22 and signed by V31 (LPN/Licensed Practical Nurse) documents, Writer spoke to (V32/R4's Power of Attorney) to give them an update on resident's skin integrity and wound care consultant visit from 8-25-22. Writer also addressed right heel blister that was noted on 8-25-22. (V32) was made aware. Writer will continue to monitor resident. R4's Care Plan dated 8-19-22 through 9-8-22 (hospital admission) does not include a plan of care to address R4's pressure ulcer to the right heel identified on 8-25-22. This same Care Plan does not include pressure relieving interventions to prevent the development of a pressure ulcers before the development of R4's pressure ulcer to the right heel on 8-25-22. R4's Electronic Health Record does not include documentation of skin checks being performed every shift by the nurses or CNAs (Certified Nursing Assistants) as directed by the facility policy and does not include documentation of daily or weekly skin checks being performed by the nurses. R4's Physician's Order Sheet and Treatment Administration Records dated 8-19-22 (Admission) through 8-31-22 document R4 did not receive an order, or a treatment for the right heel until 8-27-22 (two days after discovery). R4's Physician's Order dated 8-27-22 documents, Right heel: Cleanse with normal saline, pat dry, apply bacitracin plus xeroform and cover with border gauze every day shift every Tuesday, Thursday, and Saturday. R4's Arterial Duplex Scan Radiology Results Report of the lower bilateral extremities dated 9-2-22 documents Clinical Information: Right lower extremity wound to the right heel. Impressions: No evidence of hemodynamically significant luminal stenosis (narrowing of the blood vessels) in visualized vessels. R4's Hospital History and Physical dated 9-9-22 and signed by V30 (R4's Hospital Physician) documents, (R4) is sent to the emergency room because of wound on the right foot with infection there. Leukocytosis (high white blood count) admitted with antibiotics for right lower extremity wound infection and wound care on consult. admitted for further evaluation and treatment. (R4) given IV (Intravenous Meropenem/Antibiotic) in the emergency department. Assessment and Plan: Unstageable pressure ulcer right heel. Recommend betadine dressing changes twice a day per nursing. In addition to foam offloading boots, would keep pillows under his calf to float the heel. On 6-16-23 at 12:15 PM V32 (R4's Power of Attorney) stated, (The facility) did nothing to prevent (R4's) pressure ulcer to the heel. Every time I would go to the facility, staff would not re-position (R4) or do anything for (R4). That is why I had (R4) move to a different facility and had (R4) sent to the hospital. When (R4) went to the facility he did not have any pressure ulcers. On 6-16-23 at 5:35 PM V14 (Nurse Consultant) stated, (R4's) pressure ulcer to the right heel was facility acquired. On 6-16-23 at 6:00 PM V2 (Director of Nursing) stated that CNAs are supposed to do skin checks every shift and document them on the residents. V2 stated R4 does not have skin checks documented every shift and did not have a plan of care for pressure relieving interventions developed or implemented prior to R4 developing the pressure ulcer to his right heel, and R4 did not have a care plan implemented with interventions to address and treat R4's pressure ulcer once developed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to use an appropriate mechanical lift sling per manufacturer's instructions during a transfer and failed to transfer a resident safely, as directed by the facility's policy, using a mechanical lift for one of three residents (R3) reviewed for falls in the sample of five. These failures resulted in a mechanical lift tipping over with R3 during a transfer from the bed to the wheelchair, resulting in the mechanical lift falling on R3's left arm, fracturing the left radial head (knobby area of the radius where it meets the elbow) of R3's left arm. Findings include: The facility's Mechanical Lift Transfers policy dated 1-14-13 documents, Procedures: 1. Follow manufacturer's guidelines on how to operate machine. 4. Use sling compatible with mechanical lift and appropriate size. 5. There will always be two staff to assist resident. One staff will control the lift as the other will guide resident and support back and neck to transfer surface. 11. Lift resident up from the chair using lift with one person operating the machine while the other staff removes the resident's wheelchair/recliner out of the way while resident is suspended in the air. For a brief second, the second staff won't be able to put hands on the sling as staff removes the wheelchair or recliner. 12. The second staff will guide resident and sling as resident is transferred and lowered back to bed. 14. When lifting resident from bed to chair, one staff will also operate the machine while one staff guides the sling. The (Manufacturer's) User Manual for the Mechanical Lift Model dated 10-1-18 documents, Ensure the legs of the lift with patient in the sling are in the open position. Press the legs open button until maximum open position. Do not use slings and patient lifts of different manufacturers. Slings are made specifically for use with mechancial lifts. Injury or damage may occur. Warning: When using an adjustable base lift, the legs must be in the maximum opened/locked position before lifting the resident. R3's MDS (Minimum Data Set) assessment dated [DATE] documents R3 is at [AGE] year-old that is cognitively intact. This same MDS also documents R3 requires extensive assistance of two plus physical assist of staff for bed mobility and requires total assistance of two plus staff for transfers. R3's Incident Note dated 1/24/2023 at 2:42 PM and signed by V3 (LPN/Licensed Practical Nurse) documents, Incident Summary: Prior to the incident 11:50 AM, resident (R3) was in bed. Around 1:50 PM two CNAs (Certified Nursing Assistants) were transferring (R3) from the bed to the wheelchair with Hoyer lift (mechanical lift). CNAs called for help and three other staff went in to assist in re-positioning (R3) upright in the wheelchair. (R3) alert and oriented times three. (R3) was asked what happened and resident stated the (mechanical) lift was toppling over and l hit my left arm to the (mechanical lift). Body assessment done. No apparent injuries noted. No swelling noted to the arm. Resident complained of mild pain to the left arm. Tylenol 650 mg (milligrams) given. No other complaints. V17 (Nurse Practitioner) was notified with an order for x-ray to left arm/hand. R3's Left Elbow X-Ray report dated 1-25-23 documents, Impression: Small left elbow effusion, Cortical step-off of radial head, concerning for non-displaced left radial head fracture. V21 and V20's (Agency CNAs) Statement Forms dated 1-24-23 document around 12:15 PM on 1-24-23 both V20 and V21 were transferring R3 from the bed to the wheelchair using the (mechanical lift). During the transfer the mechanical lift toppled over and V20 and V21 supported R3 to the wheelchair. R3 landed in the wheelchair leaning toward the left. On 6-16-23 at 9:45 AM R3 was lying in a bariatric bed. R3 was holding his left arm. R3 stated, On (1-24-23) two agency staff were transferring me from my wheelchair to the bed. The two staff did not know what they were doing and were moving the Hoyer (mechanical lift) to fast and was jerking the lift. The lift tipped over with me in it and I fell hard into my wheelchair. The (mechanical lift) fell on top of me, hitting my left arm and my head. The lift broke my left arm. It hurt for a little while. The staff tipped the lift over on me sometime last year also. The lift tipped forward while I was in the wheelchair and pinned me against the wall, scratching my face. On 6-16-23 at 10:30 AM V15 (CNA/Certified Nursing Assistant) and V16 (CNA) transferred R3 from the bed to the wheelchair using a bariatric mechanical lift and sling labeled with another manufacturer name. During the transfer V16 raised R3 off of the bed with the mechanical lift and transferred, R3 with the mechanical lift from the bed to the wheelchair that was located 10 feet from the bed. R3 was suspended in the air, without staff support behind his back, head, or neck during the transport from the bed to wheelchair. V15 was standing beside R3's wheelchair during the transfer from the bed to wheelchair. On 6-16-23 at 12:48 PM V3 (LPN) stated, The (mechanical lift) was toppling over and fell on (R3), hitting (R3) on the shoulder. Two CNAs were transferring (R3). I assessed (R3) and he had some pain in his left shoulder. We got an order for an x-ray, and they found (R3's) arm was fractured. On 6-16-23 at 12:56 PM V23 (Building Maintenance Director) stated, I have always ordered 'Drive' brand mechanical lift slings for the mechanical lifts. I thought 'Drive' slings were compatible to use with the lifts. On 6-16-23 at 1:55 PM V21 (Agency CNA) stated, On (1-24-23) me and V20 (Agency CNA) were transferring (R3) from the bed to the wheelchair. During the transfer, the (mechanical lift) started to tip over, and the back wheel came off of the floor. We had to hold (R3) up and get him into the wheelchair. (R3) had hit his arm on the (mechanical lift) when the (mechanical lift) started to topple over. I am not sure why the (mechanical lift) tipped. On 6-16-23 at 4:00 PM V24 (Mechanical Lift Manufacturer's Representative) stated, (The Manufacturer) cannot guarantee the safety of residents during a transfer with our (mechanical lift) model unless the facility uses our manufacturer's slings. Any other manufacturer's slings are not guaranteed to be safe. On 6-16-23 at 4:05 PM V2 (Director of Nursing) stated, Two staff should do a mechanical lift transfer. While the resident is suspended in the air and being transferred to the wheelchair from the bed, so one will control the lift and the other staff will support the resident behind the resident's head and neck until they get the resident close to the wheelchair. One staff will then lower the resident with the lift, while the other maneuvers the resident into the wheelchair. I know (R3) got fracture to the left arm from the (mechanical lift) tipping over on him.

Based on interview and record review, the facility failed to ensure a resident was properly seated in her wheelchair during wheelchair transport. This affected 1 of 3 residents R2 reviewed for safety while transporting in a wheelchair. This failure resulted in R2 falling forward while being pushed in the wheelchair by facility staff, this fall incident resulted in R2 falling onto R2's face sustaining a facial laceration a treated at the local hospital with stitches. Findings include: On 12-27-22 at 12:00 PM, surveyor observed R2 in dining room during lunch meal under staff supervision. R2 was seated in her reclining high-back wheelchair with leg rests and footboard in place. R2 is confused and unable to carry conversation with surveyor. R2 was noted with resolving discoloration below her left eye. R2 was not showing any attempts to get up by herself. On 12-27-22 at 1:43 PM,V2 (Director of Nursing) said R2 is a fall risk. R2 had dementia and confusion. R2 is not directable due to cognitive deficits. R2 has poor safety awareness due to dementia and confusion. When CNA was bringing R2 back to her room via wheelchair, CNA stated R2 leaned forward. CNA was unable to prevent R2 from falling forward and sustaining facial laceration requiring stitches. Fall coordinator in-serviced CNA on safely transporting wheelchair residents. On 12-27-22 at 3:37 PM, V13 (CNA) said R2 is confused and forgetful. R2 is unable to make her needs known. R2 has poor safety awareness and will lean forward in wheelchair. During a transport to R2's room via wheelchair, R2 leaned forward and fell from the wheelchair. V13 said R2 hit her head on the floor and V13 saw R2's blood on the floor. The nurse came immediately. Nurse cleaned the blood, placed towel under the head, and called 911. On 12-27-22 at 2:59 PM, V12 (LPN) said R2 is alert and oriented x1 with confusion and forgetfulness. R2 is unable to make her needs known. R2 has poor safety awareness because she is impulsive and tries to get up by herself. R2 has to be re-directed and monitored. R2 needs to be re-directed several times. V12 said after dinner (after 6:00 PM), V13 was transporting R2 to her room via wheelchair. V12 was at nursing station and heard a crash and chair alarm. In dining room, V12 saw R2 in the floor in front of the wheelchair. V12 saw blood on the floor. V12 left R2 on the floor to lessen any trauma and V12 called 911. V12 saw blood on the bridge of R2's nose on the side where R2 was laying. 911 came right away and transported to the hospital. R2 had no indication of pain. The hospital records indicated fracture to nose R2's nose was treated with steri-strips. R2 had 5-6 stitches on the side of her forehead. R2 returned to facility that same night. R2 is a fall risk. On 12-27-22 at 2:51 PM, V11 (RN) said R2 is alert, oriented x 1-2, and mostly unable to make her needs known. R2 is confused and forgetful. R2 has no safety awareness. R2 is impulsive, will try to get up by herself, and takes multiple times for re-direction. V11 has seen R2 leaning forward in her wheelchair during transport in the past. On 12-27-22 at 2:43 PM, V10 (CNA) said R2 is confused and forgetful. R2 is unable to make her needs known and carry conversation. R2 requires feeding assistance most of the time. R2 is a high falls risk. R2 has chair alarm, bed alarm, floor mat, reclining high back wheelchair, and foot board. R2 will attempt to get up by herself and R2 is not able to be re-directed. V10 said she sees R2 leaning forward in her wheelchair. V10 says she will ensure R2's back is upon the back of the wheelchair. CNA will not transport R2 unless her back is up on the back of the wheelchair. V10 will do this several times as needed. Initial State Reportable dated 12-1-22 documents: Description of what happened: On 11-30-22 prior to fall, resident was up in her wheelchair in dining area and around 6:12 PM, assigned nurse stated the CNA was wheeling resident to her room and resident tipped forward and landed on the floor with face down. No loss of consciousness. Neuro checks was done and no deficit. Resident was noted with scant bleeding from right forehead and sustained a cut to the right forehead and superficial skin tear was noted to the bridge of the nose. Range of motion to all extremities were within resident's baseline. Resident unable to relay the cause of the fall due to cognitive impairment. Vital signs were with resident's baseline. 911 was called. Nursing supervisor was notified. Resident was sent to ED for further evaluation and returned to facility same day with stitches to forehead and steri-strips to the bridge of the nose. Final State Reportable dated 12-6-22 documents: Final Investigation/Conclusion: Imaging done in ED as follows: CT Facial bone without contrast: Mildly comminuted fractures of the tip of the nasal bone without significant displacement. Resident Care Plan has been reviewed and updated upon returning to the facility. Hospital Record dated 11-30-22 documents: Reason For Exam: facial laceration/nasal bone contusion/ laceration. Impression: Mildly comminuted fractures of the tip of the nasal bone without significant displacement. Fall Risk Assessments (dated 1-10-22, 2-11-22, 5-12-22, 11-9-22, and 12-15-22) document: R2 is high fall risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement resident specific fall prevention interventions for a resident with severe cognitive impairment for 1 (R6) of 5 residents reviewed for falls in the sample of 42. This failure resulted in R6 being transferred to the hospital's emergency department where he was diagnosed with a hip fracture and had subsequent hip surgery. Findings include: R6 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Chronic Obstructive Pulmonary Disease, Unspecified Asthma, Hypertension, Alzheimer's Disease, Major Depressive Disorder, and Dementia. According to MDS (Minimum Data Set) dated 05/18/2022 under section C, R6 has BIMS (Brief Interview of Mental Status) score of 4 indicating severely impaired cognition. According to MDS (Minimum Data Set) dated 05/18/2022 under section G, all shows R6's functional status for transfers requires extensive assistance with one-person staff assist to transfer, walk in the room, and toilet use. Fall risk assessment dated [DATE] shows R6's fall risk evaluation score of 12, indicating very high risk for falls. On 12/12/22 at 01:17 PM Surveyor observed R6 in his room. Bed placed against the wall, fall mat present on the right side of the bed. Bed in the lowest position with upper side rails up. Call light within R6's reach. R6's speech unintelligible, surveyor unable to conduct interview. On 12/14/22 at 11:51 AM Surveyor interviewed V16 (Registered Nurse/ fall preventionist), V16 stated, One of the reasons why R6 suffered multiple falls withing this year (2022) is that R6 has gait imbalances and is very impulsive. R6 is often displaying unpredictable behaviors, like trying to remove his clothes while being assisted to the bathroom. R6 was evaluated for urinary tract infections several times; however, all came back with negative result. V16 stated, When R6 was on the initial unit, he was placed right across from the nursing station. Additionally, R6 was encouraged to participate in day-care program to keep him occupied with multiple activities throughout the day. V19 (Psychiatrist) and the family were also involved in R6's care. Evenings and nights appeared to be the culprit of R6's fall problem. R6 had 12 fall incidents from the beginning of 2022. The hip fracture was suffered during one of his episodes of impulsiveness on 06/14/2022. R6 was attempting to get up without assistance. V17 (Certified Nursing Assistant) just rounded on R6 and offered toileting; around 1:50am V17 (CNA) and V18 (Licensed practical Nurse) found him on the floor. V16 stated, R6 would ask at times to take him to the bathroom, and he used his call light, but it was inconsistent. V16 further indicated that R6 was transferred to secured memory care unit for more effective monitoring. On 12/14/22 at 12:54 PM Surveyor interviewed V14 (LPN/ secured memory care unit staff), V14 stated, R6 was transferred to the secured memory care unit about six months ago. R6 is on fall preventions that include bed in lowest position, fall mats, upper side rails up, frequent monitoring, at least every 2 hours but with him it's usually every 45 minutes to 1 hour, bed and chair alarm in place, and call light within reach. Additionally, R6 resides in the room right across from the nursing station. On 12/14/22 at 12:54 PM Surveyor interviewed V15 (Certified Nursing Assistant/ secured memory care unit staff), V15 stated, R6 is on fall precautions. I check on him every 10 min, the door to his room is almost always open, so we can look at him pretty much constantly. R6 has fall mat beside his bed and chair alarm and bed alarm are in place. Fall care plan dated 03/10/2020 reads in part, R6 is at risk for falls, with interventions: educate R6 of the importance of calling staff if he needs assistance, create signs with instruction reminding R6 to use call light for assistance, keep call light within reach, remind R6 to ask for assistance. Resisting Care care plan dated 09/16/2020 reads in part, R6 exhibits symptoms of resisting care which is manifested by: getting up to go to the bathroom, with interventions: educate and remind resident to utilize call light, remind resident to ask for assistance form staff. Per record review, R6 fell on [DATE], 02/18/2022, 03/10/2022, 03/14/2022. 04/28/2022, 05/07/2022, 05/13/2022, 06/10/2022, 06/14/2022 while in the initial unit. R6 suffered hip fracture during 06/14/2022 fall incident. Additionally, R6 fell on [DATE], 07/22/2022, and 10/10/2022 while in the secured memory care unit. Per record review, hospital records dated 06/14/2022 at 01:01 PM reads in part, [R6] sustained mechanical fall at nursing home earlier today resulting in left hip fracture. Orthopedic surgery has been consulted and plan is for operative repair later today. On 12/15/2022 at 09:49 AM, 10:54 AM, and 12:44 PM Surveyor attempted to interview V17 (Certified Nursing Assistant) via phone, no answer, voicemail left. On 12/15/2022 at 09:51 AM, 10:56 AM, and 12:46 PM Surveyor attempted to interview V18 (Licensed Practical Nurse) via phone, no answer, voicemail left. On 12/15/2022 at 09:53 AM Surveyor attempted to interview V19 (Psychiatrist), message left with receptionist, waiting for a call back. On 12/15/2022 at 10:16 AM Surveyor received call back from V19 (Psychiatrist), V19 stated, R6 is not cognitively appropriate to respond to fall preventions such as [but not limited to] educating of the importance of calling staff if he needs assistance, creating signs with instruction reminding to use call light for assistance, or reminding to ask for assistance. R6 is not cognitively aware and cannot retain information and process through what's appropriate and what's not. Legacy Healthcare Fall Occurrence Policy dated August 3, 2016, reads in part, It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Ultimately, the Falls Coordinator may change the interventions provided by the nurse if the Falls Coordinator's investigation identifies a more appropriate intervention for the individual fall. The interventions will be reevaluated and revised as necessary.