**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure resident safety by failure to provide 2 persons assist when transferring resident using a mechanical lift. This affected one resident (R1) of three residents reviewed for falls. This failure resulted in resident (R1) falling from mechanical lift and sustaining a left displaced femoral neck fracture. Findings include: R1 was admitted on [DATE] with diagnosis listed in part but not limited to Displaced fracture of base of neck of left femur, unspecified osteoarthritis, encounter for other specified surgical aftercare, hypothyroidism, hemiplegia, unspecified affecting left nondominant side, unspecified dementia, unspecified severity without behavioral disturbance, difficulty in walking, unspecified fall, subsequent encounter. Admission/Baseline care plan dated 2/14/23 indicated at risk for falls with interventions monitor residents' position when changing in bed, falling star program. ADL care plan dated 2/17/22 indicates requires assistance partial to substantial assist with Activities of Daily Living due to decreased strength and endurance, decrease balance, decrease mobility, unsteady gait, h/o Left sided weakness, CVA's, Dementia interventions include transfer with mechanical lift and 2 persons assist. admission functional mobility assessment dated [DATE] indicated that he needs Dependent assistance with chair/bed-to-chair transfer, sit to stand, toilet transfer. On 6/11/25 at 12:35 PM, R1 observed in dining room, in wheelchair, proper footwear in place, R1 said he does not recall what happened when he fell on 5/23/25. On 6/11/25 at 12:42PM, V8 (Certified Nurse Aide) said she was the certified nurse aide assigned to R1 and was transferring him to bed using the mechanical lift. V8 said she noticed that R1's left foot was not on the base of mechanical lift, and she bent over to place it on the base when R1 let go from the grab bar with his right hand and slid off to the floor. V8 said she assisted R1 back to the bed. V8 said she was the only certified nurse aide in the room with R1. V8 said she is aware that R1 is a two person assist and that when using any mechanical lift two-person assist is also required. V8 said that the other staff were busy and could not get any help. On 6/11/25 at 1:09PM, V9 (Registered Nurse) said he saw call light on and went to R1's room and saw R1 in bed already. V9 asked V8 if she needed any help because the call light was on and V8 said that R1 was a little restless and had assisted R1 to bed. V9 said he assessed R1, and no injuries noted. R1 denied any pain. V9 said V8 was the only certified nurse aide in the room. On 6/11/25 at 1:49PM, V10 (Restorative Nurse) said she is familiar with R1 and R1 is a two person assist with activities of daily living and transfers. When using any Mechanical lift machine for transfers staff should be a two person assist. V10 said it is the facility policy when using a mechanical lift that two-person assist is implemented. V10 said all staff gets training prior to working the floor with residents upon hire and agency staff is trained as well. On 6/11/25 at 3:07PM, V11 (Evening Registered Nurse Supervisor) said V9 had called him to assess R1 after R1 falling. V11 said, When I entered the room, R1 was already in bed and no injuries were observed. R1 denied pain. R1 is somewhat confused. V11 said V8 told him R1 had slid off the mechanical lift and had assisted him back to bed, V8 was the only one transferring R1. V11 said when transferring with a mechanical lift the staff are supposed to have a two person assist. On 6/11/25 at 3:15PM, V2 (Director of Nursing) said her expectations of staff are to follow the residents care plan for fall interventions. V2 said that when using a mechanical lift, the standard of care should be a two person assist. The staff is trained during orientation prior to start of working the floor. The interventions are in the resident's profile the CNAs and nurses can access them. They also have the Kardex at the nurse's station for the transfer status. On 6/11/25 at 3:20PM, V1 (Administrator) said her expectations when staff is using a mechanical lift should always be a two person assist per facility policy. V1 said she was unaware that only one certified nurse aide was transferring R1, V1 said she knew about the fall incident. R1's fall incident documented by V11 (Evening Registered Nurse Supervisor) on 5/23/25 at 9:30PM indicated: V8 (Agency Certified Nurse Aide) reported to the nurse that the resident was assisted to bed and at that time V8 instructed the resident to use the grab bar to help him ease himself down to the bed. V8 observed the residents' left foot was on the floor. V8 was unable to give support to put the resident back into bed. Assessment at the time of the fall indicated no injury. The staff monitored resident post-fall for any injuries. No signs of injury and no complaints of any pain until 5/24/25, when resident complained of pain to his left hip. X-ray to hip and pelvis showed a fracture to the left femoral neck. Resident was transferred to the hospital for further evaluation. His vital signs at the time of discharge were observed as follows: BP 160/78 mmHg, pulse 72 bpm, temp 97.5 F, RR 18 breaths/min, and O2 sat rate at 94% on room air. R1 fall incident initial report was sent to IDPH on 5/25/25 at 5:19PM. Final report was submitted to IDPH on 5/30/25 at 3:33PM indicated: On 5/23/2025 a CNA reported to the nurse that R1 was put to bed, and at that time the CNA instructed the resident to use the grab bar to help him ease himself down to the bed. The CNA observed R1's right hand had let go of the grab bar, which caused the resident to slide off of the bed. The CNA observed his left foot was on the floor. CNA was able to give support to put the resident back into bed. Assessment at the time of the fall indicated no injury. The staff monitored the resident post-fall for any signs of injuries. No signs of injury and no complaint of any pain until 05/24-/2025, when R1 complained of pain to his left hip. X-ray to hip and pelvis showed a fracture to the left femoral neck. R1 was transferred to the hospital for further evaluation. His vital signs at the time of discharge were as follows: BP 160/78 mmHG, pulse 72bpm, temperature 97.5F. respiratory rate 18 breaths/min, and oxygen saturation rate 94% on room air. R1's hospital emergency department records dated 5/25/25 to 5/30/25 discharge summary indicated: Left femoral neck fracture, surgical intervention on 5/27/25, no weight bearing to lower left extremity. Patient had called his wife and said that he was dropped into his bed and then after that was complaining of hip pain. Due to dementia, he is a poor historian. Per wife patient has been non ambulatory at the nursing home, they use a mechanical lift for mobility in and out of bed. Patient was discharged to nursing home facility on 5/30/25 for skilled therapy. Facility Policy on Mechanical Lifts revised 1/2024. Policy Statement- It is the policy of Ascension Living to use mechanical lift(s) according to current standards of practice and keeping with manufacturer's guidelines. B. The use of the mechanical equipment is considered either as a full body lift or sit to stand lift that aids the resident and associate in transfer and/or care procedures. G. Education shall be provided on the proper use of the assistive mechanical lifting equipment prior to the use. Facility Policy on Falls revised 1/2024. Purpose-To prevent and/or reduce the number of falls by providing an individualized, person-centered care approach with Communities managing fall risk through the process of assessment, planning, implementation, and evaluation (APIE). B. Residents who are at risk for falls will have an individualized care plan developed which identifies interventions to reduce fall risk. Facility Policy on Fall Prevention revised 7/2023. Policy Statement- The intent of this policy is to provide an environment that is free from accidents hazards, over which there is control, and provide supervision and intervention to residents to prevent avoidable accidents.

Based on interview and record review, the facility failed to protect a resident from allegedly being roughly handled, threatened, punched, and intimidated by an agency staff person; failed to assess resident of any injuries; and failed to train staff on screening, abuse prevention and investigation. This failure affected 1 (R1) of 3 residents reviewed for abuse from the sample of 3 and resulted in R1 abruptly ending her rehabilitation to discharge home due to the resident feeling unsafe and distressed for fear of agency staff's return. Findings include: R1 is an alert and cognitively intact resident with diagnoses listed in part with chronic kidney disease, spinal stenosis, hypertension and hyperlipidemia. On 4/4/25 at 11:25 AM, R1 stated upon interview, It was about 4 AM and I had to go to the bathroom, so I did it myself because it seemed there was no one around. No one was at the nursing station when I peeked outside my door plus the hallway was dark and a lot of the lights were turned off. I couldn't get my diaper back on so I put a clean diaper on the bed to lay it down. I went to sit on it but couldn't put it on. I put my call light on so I could get help and a woman (with a winter hat and coat on) came barging in without a word, and just takes my diaper that I was sitting on and angrily rips it into shreds and then walks out of the room and then came back in with another diaper. She pushed me and took her fist and punched me twice in my back. I told her to stop, and I tried to grab the rail because I almost fell. I screamed because I was afraid of what this person was going to do to me. She said to me scream all I want but that that nobody was around. I tried to get her name, but she would not tell me, and I said please don't do that again and she told me to turn around and kept punching me while she tried to get my diaper on me. I said stop punching me or I'm going to call somebody. She said go ahead nobody is here. I was scared to death, and I didn't yell again because I did not see anyone anyway and I was afraid if I did scream again, she may have punched me harder again or even pull out a knife. When this nurse V4 (RN) finally came in it was around 6 in the morning, I was crying, my back hurt where she punched me, and I told him what happened. He said he'd take care of it, and he called in another nurse V5 (LPN supervisor) because he was in charge of the building, and he said that the woman isn't coming back. I didn't understand what that meant and was frustrated that they weren't around all night and now they tell me that woman is gone now, so their words were not assuring to me. That was the reason I left because I was scared and didn't know if she would retaliate against me for telling on her. A written statement by R1 provided to V1 (Administrator) dated 3/7/25 at 3:45 AM, reads in part, I got myself up and went to the bathroom and had bowel movement and took off my pull-ups as it was soiled and I cleaned myself up and came out and got a new diaper to put on, but I could not, so I laid it on the bed and sat on it. I pressed call button at 4:15 (AM) and a woman came in with her winter coat on and was yawning and I told her about my diaper and told me to sit on it again. She started pulling and ripped it to shreds. She left and came back with another one and said turn over and she put her fist and pushed me so hard I said stop you're going to push me on the floor. Then she turned me to the other side and pushed me again and I said stop and take blanket off me and then she left. I asked her name 3 times, and she would not tell me. So, 10 minutes later I put call button and said I want someone else here. She says no and I said I want to tell them you're about to push me off the bed. She says you're still on the bed, I said, oh you're now getting smart with me and she leaves and on her way out she says Do not put call button on, so I did anyway because I thought maybe someone else was on duty but she did not come back for 1/2 hours . On 4/4/25 at 11:00 AM, V10 (family member) stated that she never received a call pertaining to the incident involving the CNA V8 but rather was only informed to come in to the facility to sign papers about her mom receiving continued therapy and to obtain payer information. V10 stated when she came in to the facility around 1:30 PM on 3/7/25 her mom started crying to her and informed her that some staff person pushed her while in bed, punched her in the back, and then threatened her to not use the call light. V10 said she immediately went to tell the nurse to call the police and that was when V1 administrator came in to talk to her about the incident. V10 said she was upset that no one told her about what had happened to her mother until she came in to visit and that V1 appeared very nonchalant and indicated she would handle the situation after she had her lunch. V10 said, My mom said she wanted to go home because she didn't feel safe and that no one was around all night to protect her, so I took her home. On 4/4/25 at 12:30 PM, V4 (RN) stated upon telephone interview, What happened was I was drawing blood for the whole house when I received (R1) she was in her chair next to her bed. She looked very distraught and was crying. It was about 5 or 6 in the morning because I was drawing every body's blood and I started around that time. The resident was trying to explain to me what happened, and she looked very guarded, almost as if she was in shock. She explained that V8 CNA on duty told her she should not ring the bell until the end of her shift or until she left. The resident is very alert, so she came across very credible, so I let the charge nurse V5 know when I saw him walk by and told him that we have a situation here and told him to come into the room. I told him because he was the supervisor at night. I have never seen this agency CNA before as there's been so much Agency staff lately. (R1) identified the CNA and I saw her just sitting by the couch near the nurses station. She had her stuff with her already like bags, notebooks and she had her winter coat on. We actually asked her to leave about 20 minutes to 7 AM after we called the administrator. Initially (V1-Administrator) didn't pick up but then she eventually called the facility back and said to write a statement later and so I did that and left. Surveyor asked if V4 did anything else with the resident to determine if she had any visible injuries or felt safe. V4 said, I don't recall and I'm not familiar with the policy in that facility because I'm mostly PRN (as needed) and I don't get involved in the whole thing like this. Surveyor asked if V4 called the police. V4 said, No I didn't call the police because I'm not familiar with their policies here. I just called the nurse in charge, and he called the administrator. Surveyor asked if V4 assessed the resident for any injuries. V4 stated, I don't know, everything went so fast, and I probably should have but no I didn't. A written statement signed by V4 dated 3/7/25 reads, This morning when arrived to (R1) room, I noticed she (R1) was in tears and when I asked her why, she stated that she was scared. I asked her why she was scared. She (R1) responded that the CNA threatened her to not pull the call light. She also mentioned that she almost fell because the CNA was pushing her. She described what the CNA looked like, and it matched what she described. Supervisor (V5) informed and reassured her the event will be handled. Kept her safe. Signed by V4. (Absent from this statement is any physical assessment of any injuries or psychosocial assessment of the resident's well-being) There was no written statement taken by V1 (Administrator and abuse prohibition coordinator) for V5 (LPN night supervisor) who was directly involved during R1's initial reporting of allegation of abuse. Surveyor however was able to interview V5. On 4/4/25 at 12:40 PM, telephone interview with V5 (LPN night supervisor) said, There was an incident where an agency CNA was assisting a patient (R1). The nurse on duty (V4) called my attention to R1's room about a concern that the patient was scared about an Agency CNA. R1 described the CNA as African American, tall, wearing coat. I asked V4 what happened, and he described what the patient told him. What I can get from the nurse was that when the patient was being changed, she had a feeling she was going to fall from the bed during a diaper change. I guess she was being pushed too far at end of the bed and she was scared of the CNA and while being changed was pushed or hit by the CNA. When this all happened, I guess I was basically on 2nd floor doing rounds. I've been here since 2005 and this is the first time this has ever happened. The patient is very alert and is not confused at all. She was here for rehab. When I saw R1, she appeared very frightened and shaken up by the whole thing I could tell. Surveyor asked V5 if there was any assessment conducted. V5 said, No I don't recall doing that. We got so busy getting information from her and we called the administrator and left a message for her and by the time she called back, it was may have been about a quarter to 7 and the CNA (V8) was going home soon anyway but yes, I should have made sure V4 assessed her to see she was uninjured. Surveyor clarified if there was any nursing assessment conducted as V1's abuse incident report indicated that there was one done. V5 stated, No I don't recall that. Surveyor asked if the physician or family was notified of the incident. V5 said, No I didn't call the family or doctor, we just called the administrator. I'm just supposed to call the administrator and I haven't encountered this situation before, so I didn't know what to do. On 4/4/25 at 10:40 AM, V9 (Human resource director) said, I don't handle agency staff paper work or trainings, just our own. We don't screen agency staff; they do the screening for us. Surveyor asked if agency staff screenings were reviewed by her, V9 said, No I don't review any of their staff that they send, I didn't know I had to. Surveyor requested to have V8's hire records and trainings provided to her by her agency, but no records were provided during the investigation. V8 (agency CNA) could not be reached for interview during this investigation after several attempts were made. V12 (NP) and V13 (Doctor) could not be reached for interviews during this investigation after several attempts were made. Facility interdisciplinary notes showed no assessments were conducted on R1 to determine any injuries after alleged incident and no efforts were made or documented to reach family, physician or medical director. Policy dated 9/27/24 titled Abuse Investigation and Reporting reads in part, All reports of resident abuse, neglect, mistreatment shall be promptly reported to local, state and federal agencies and thoroughly investigated. Conclusions of investigations will also be reported, as defined by the facility policy. The individual conducting the investigation will, at a minimum: Review the completed documentation forms; Review the resident's medical record to determine events leading up to the incident; Interview the person (s) reporting the incident; Interview any witnesses to the incident; Interview the resident (as medically appropriate); Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; Interview associates members (on all shifts) who have had contact with the resident during the period of the alleged incident; Interview other residents to whom the accused employee provides care or services; Review events leading up to the alleged incident. Witness reports will be obtained in writing, either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. Examine the alleged victim for any sign of injury, including physical examination and/or psychosocial assessment, if needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and a review of records, the facility failed to follow its weight monitoring policy to prevent or reduce the risk of residents experiencing unplanned significant weight loss. This failure affected three of ten residents (R17, R28, and R61) who were reviewed for weight monitoring and weight loss as part of a sample of 40 residents. As a result, R17 experienced an unplanned weight loss of 6.15% over a 30-day period, R28 experienced a 15.3% weight loss over six months, and R61 experienced an 11.2% weight loss during a six-month period. Findings include: 1) On 3/11/25 at 10:15 AM, R17 was observed to be on a pureed diet with nectar thick liquids. R17 was observed attempting to self-feed breakfast. R17 was observed to have only consumed 20% of breakfast. Staff were not observed assisting R17 with meal or encouraging R17 to eat. On 3/12/25 12:27 PM, Staff were not observed assisting R17 with meal or encouraging R17 to eat. On 3/12/25 at 10:45 AM, V8 RD (registered dietitian) reviewed R17's documented weights. R17 had an 8.8-pound weight loss in one month. V8 stated residents on a pureed diet should be eating in the dining room so staff can monitor them. V8 stated there is no re-weight documented. V8 stated that residents with a weight change of 5 pounds or more in one month should be re-weighed to verify the accuracy of the weight. V8 stated R17 will be re-weighed today. V8 stated V8 was not made aware of R17's weight loss. On 3/12/25 at 11:30 AM, V8 RD stated that V8 spoke with R17 and discussed food preferences. V8 stated V8 also spoke with staff to ensure R17 is in dining room for all meals so R17 can be monitored for amount eaten. As of 3/12/25 at 4:00 PM, R17 had not been re-weighed. R17's medical record notes on 3/6/25, R17's weight was 134.2 pounds. On 2/5/25, R17's weight was 143 pounds. R17 had a 6.15% weight loss in one month. There is no documentation found in R17's medical record noting R17's physician was notified of R17's weight loss. This facility's weight monitoring policy, revised 01/2023, notes residents with a weight change of five pounds or greater shall be re-weighed to determine an accurate weight. The registered dietitian should make recommendations for nutritional interventions. A nursing or nutrition associate should notify the health care provider of any significant weight change. This facility's weighing and measuring the resident policy, revised 09/2022, notes report significant weight loss to the nurse supervisor. The threshold for significant unplanned and undesired weight loss will be based on 1 month - 5% weight loss is significant; greater than 5% is severe. 2) R61 was admitted to the facility on [DATE] with a diagnosis of muscle weakness, transient cerebral accident, dementia, hypertension, type II diabetes and heart disease. R61's weight documented on hospital transfer form dated 2/27/25 documents 59 kilograms which equals 124 pounds upon readmission. On 3/14/25 at 11:34Am, V21 (certified nursing aide, CNA) assisted R61 in her wheelchair that measured 38.8 pounds to the wheelchair scale. Scale was balanced to zero prior to weight taken and measured at 151.2 pounds. R61 weight was 112.4 pounds. R61's physician order dated 2/27/25 documents to weigh daily x3 days and weigh weekly x 4 weeks. Review of R61's medical record does not document any weights for R61. V19 (nursing supervisor) on 3/13/24 said there were no other weights recorded for R61 except for a written weight taken on 3/12/25 that documented 110 pounds that was just documented into the electronic record. R61's facility weight documents weight in October: 131. Pounds and November 124.4 pounds. There were no other weights presented for R61 for this survey. On 3/13/25 at 3;38PM, V8 (dietician) said she was made aware of R61 change in appetite on 3/5/24. There were no weights documented since November 2024. R61 had a significant weight loss of 11.2 % based on weights documented. V8 said weekly weights help to ensure weight is remaining stable, to monitor if any additional weight loss and if interventions are effective. R61's nutrition risk assessment dated [DATE] documents under type of assessment: significant change. Under anthropometric data documents: height 60 inches, current weight 110 pounds, usually body weight 124 pounds, body mass index (BMI) 21.5 which indicates underweight. Under comments: Resident had significant weight loss over the past 6 months 11.2%. R61 plan of care dated 3/4/25 documents poor PO intake with the following interventions: monitor weekly and monthly weights; monitor and record meal intakes, obtain food preferences, instruct family about dietary modifications for resident; praise resident attempts to follow diet, feed resident slowly. Weight Monitoring Policy dated 12/2016 documents: appropriate nutritional care shall be provided to resident who have a significate weight change. Each resident should be weighed daily for the first three days of admission, weekly for the first four week and monthly thereafter. Weighing and measuring the resident dated 12/2016 documents: The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria. 1 month -5% weight loss is significantly greater than 5% is severe ;3 months -7.5% weight loss is significantly greater than 7.5% is severe;6 months 10% weight loss is significantly greater than 10% is severe. 3) R28 was diagnosis with malignant neoplasm of endometrium. R28's care plan dated 1/11/25 documents: R28 has compromised nutritional status related to the diagnosis of sepsis, malignant neoplasm of endometrium, type one diabetes, hyperlipidemia and major depression; (2/27/25) significate weight change. Dietician note dated 2/27/25 documents: unintentional weight loss related to variable by mouth intakes as evidenced by resident with 17.3% weight loss times six months. Dietician note dated 11/29/24 documents: Unintentional weight loss related to variable by mouth intake as evidence by resident (R28) with 23 pound (lbs.) 15% weight loss in three months and 15lbs (10.3%) weight loss in one month. R28's significant weight change notification dated 11/29/24 documents: R28 had a significant weight loss of 15.3 % in three months. Plan of care: One carton of nutritional supplement once a day. Dietary recommendation/communication form dated 11/29/24 documents: reason for recommendation: significant weight loss. On 3/12/25 at 3:41PM, R28 who was alert and orient to person, place, said she was a picky eater. R28 said, she eats very little. On 3/13/25 at 12:36PM, R28 did not eat lunch. R28's family was at the bedside. R28's family put R28's uneaten tray on the dirty cart. R28's family said he brought food from home. V25 (CNA) said R28's family brings in food every day and feeds R28. On 3/13/25 at 2:48pm, V25 (CNA) said R28 only likes Polish food. R28 does not drink a nutritional supplement every day. On 3/13/25 at 4:02pm, V8 (dietitian) said, R28 had a 15.5% significant weight loss in six months. On 3/13/25 at 5:00pm, V3 (unit manager) said R28's nutritional supplement should be signed out on the medication administration record (MAR). V3 said R28's dietitian recommendation was not on the MAR. R28's family does not come every day to feed R28. On 3/14/25 at 10:17am, V2 (DON) said R28's recommendation for a nutritional supplement once daily was not implemented on 11/29/24 and it is not on the current MAR. V2 said the nutritional supplement should have been placed on the medication administration record. It was recommended to promote weight gain. On 3/14/25 at 11:34am, V20 (restorative nurse) said R28's nutritional supplement was added today. On 3/14/25 at 11:39am, V28 (nurse practitioner) said she was aware R28 was losing weight. R28 does not like the facility food. R28 has a history of malignant neoplasm of endometrium. R28 had surgery a few years ago and everything was removed. A nutritional supplement is a high calorie protein supplement that will aid in weight gain. V28 said she expected the dietitian recommendations to be implemented. R28's weight report documents: 3/13/25 - 122.2 pounds 2/5/25 - 124.8 pounds 1/8/25 - 126.8 pounds 11/7/24- 130.0 pounds 10/9/24- 145.0 pounds Weight Monitoring Policy dated 12/2016 documents: appropriate nutritional care shall be provided to resident who have a significate weight change. Weighing and measuring the resident dated 12/2016 documents: The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria. 1 month -5% weight loss is significantly greater than 5% is severe. 3 months -7.5% weight loss is significantly greater than 7.5% is severe. 6 months 10% weight loss is significantly greater than 10% is severe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff V3 (Certified nursing assistant, CNA) failed to report a fall to the nurse for one resident (R2). This failure resulted in R2 being transferred back into bed with no nurse assessment for over 10 hours. R2 was transferred to the hospital for a left ear laceration requiring eleven sutures and broken ribs for one of three residents reviewed for falls. Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of Covid 19, urinary tract infection, Parkinson's and overactive bladder. R2 Minimum Data Set, dated [DATE] documents R2 required substantial/maximal assistance (helper does more than half the effort) with sit to stand, chair to bed transfer, and toilet transfers. R2's fall risk assessment dated [DATE] documents: R2 is moderate risk for falls. On 12/26/24 at 3:37PM, V21(former unit manager) said R2 was alert and oriented with periods of confusion. V21 said she went to R2's room around 4:00pm per family's request and daughter showed her R2's ear which had a cut. V21 said she asked R2 what happened and R2 reported the same story 3 different times, that she fell in the middle of night around 1-2 AM. R2 said she was trying to get water and fell. R2 said she hit her head hard on something but unsure what. R2 said a male staff member picked her up and put her back in bed. R2 reported that same male staff told her she did not need a nurse. On 12/26/24 4:26PM, V2 (Director of nursing, DON) said family wanted to speak to V2 about a cut on R2's ear around 4:00PM on 12/11/24. R2 reported she was thirsty and wanted water that was on the bedside table around 1-2AM. R2 said she spilled the water, got up from bed and fell. R2 was unsure what she hit her head on, but R2 said a male staff picked her up and put her back to bed. R2 did not report fall to anyone. R2 may have been fearful. V2 said they found a towel on the floor in the bathroom with dried blood. V2 said staff must have used the towel because R2 needs assistance to get to bathroom and would not be able to get towel herself. V2 is unsure why no other staff observed the towel. V2 said staff should stay with a resident if they fall and get the nurse to assess the resident before moving the resident. On 12/26/24 at 5:02PM, V1 (Administrator) said through his investigation it was determined V3 did not follow facility protocol by not reporting a fall or change in condition to the nurse. V1 said V3's interview did not add up based on other interviews conducted and injuries observed. V1 said staff did not feel like R2 could get up unassisted and if a resident is found on the floor, staff should stay with resident and call for nurse. R2's hospital record dated 12/11/24 at 5:30PM: Under Emergency department physician note: R2 alert and oriented x3. R2 who presents with laceration on the back of the left ear. R2 reports that she fell last night around 2AM when she was attempting to pick up a fallen tray. She slipped and fell, an event that went unnoticed by staff. R2 denied any neck or back pain but reports pain in left clavicle, shoulder, and forearm, under physical exam. Ear left with transverse laceration through the superior third auricle through the lateral edge there is exposed cartilage but its intact. Lateral edge of wound is macerated. Laceration repair: length 6 centimeter (CM), depth 8 Millimeters (MM). eleven sutures placed. Under chest x-ray documents: possible six and seven posterior rib fractures. Correlate with point of tenderness. V3's employee file record documents: V3 terminated due to violation of code of conducts. Facility fall policy revised 7/23 documents if a resident sustains a fall or is found on the floor without a witness to the event, associates shall evaluate for possible injuries and provide first aide treatment as indicated. A licensed nurse shall observe clinical status for 72 hours after an observed or suspected fall and document findings in clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to adequately supervise one (R2) resident at risk for falls, a total assist resident and dependent on staff supervision/assistance with all ADL's (Activities of Daily Living); failed to provide assistive device of foot rests on a geriatric wheelchair to prevent sliding/falling; and failed to maintain functionality of bed in order to lower close to the ground. This failure affected one resident (R2) of 9 residents reviewed for accidents/hazards/supervision and resulted in R2 being transferred to the emergency department after a fall from a geriatric wheelchair and diagnosed with a right tibial fracture; and transferred again 11 days later to the emergency department after another fall from a malfunctioning bed. Findings include: R2 is a [AGE] year-old-male with diagnoses including but not limited to hemiplegia, diabetes, neoplasm of prostate, and epilepsy. On 6/11/24 at 10:30 AM, V2 (director of nursing) stated that on 5/23/24 at 2:00 PM, R2 was in the dining area attending an activity program when R2 slid down from his high-back geriatric chair and bent/twisted his right leg in the process. According to interview on 6/11/24 at 10:50 AM with V3 (activity aide), V3 did not see R2 slide down because V25 (CNA) in charge of monitoring R2, left the dining area at the time of the incident. V3 called for help and two CNAs (V4, V6) came to lift the resident back up from the geriatric chair. Per V4 (CNA) and V6 (CNA) R2 was supposed to have leg rests on his wheelchair which would have prevented the resident from sliding down, however there were no leg rests that were attached as they should have been. The nurse on duty at the time (V8-RN), assessed R2 but did not report the incident of a fall because at the time, V8 did not consider the incident a fall. The following day, V7 (CNA) reported to the nurse on duty that R2 had pain and swelling on the right knee so the resident was sent to the emergency department for evaluation where he was diagnosed with the tibial fracture. On 6/5/24, R2 was found on the floor beside his bed at 4:50 AM but was last observed in bed at 2:50 AM sleeping. On 6/12/24 at 11:50 AM, V2 (director of nursing) stated, (R2)'s second fall on 6/5/24 happened on the night shift when the nurse (V29) found him on the floor on kneeling position. According to the 3-11 shift CNA (V30), around 4:15 PM, V30 noticed the remote was not working on the bed so V30 could not lower the bed to the lowest position. V30 told the nurse (V29) but didn't do anything about it. The next day V29 was no call-no show and quit. Regarding the bed functioning properly, V2 stated, We're supposed to keep his (R2) bed in the lowest position to keep him safe and (V29) knew that. She (V29) should've informed someone that the bed was not working because otherwise (R2) may not have fallen from the bed. Interviews of staff are as follows: On 6/11/24 at 10:30 AM, V2 (director of nursing) stated, (R2) was in the dining room attending an activity when one of the residents alerted the activity aide (V3) that the resident was on the bottom of the reclining chair. He (R2) slid there but it is still considered a fall. On 5/23/24 at 2:00 PM was when the activity was going on. V8 (RN) was the nurse but did not report this as a fall because she thought because the resident did not hit the ground that it wasn't a fall. I in serviced her (V8) about falls after this. So, the 3-11 shift nurse was not aware of any bruising that day until the night shift CNA (V7) reported to the nurse the next morning that she saw swelling on the resident. The resident's (R2) leg was under his right leg, and it got bent or caught somewhere. If there was a foot rest that could have prevented him from sliding down. On 6/11/24 at 10:50 AM, V3 (activity aide) stated, (R2) is one of our residents that goes to activities, and he does not walk and only uses his left hand. He is on a recliner chair. He comes to activities by a CNA bringing him to the activity room. He is very friendly to staff and does not have any behaviors. He is slightly confused. He's Spanish speaking only. So, when he fell, I was doing activities and one of the residents called out to me and said that (R2) is sitting near the foot of his recliner chair and his right foot was angled like a figure four and it was under his left knee. The CNA that was supposed to be monitoring the residents left the room when R2 fell, and she was supposed to stay there or get someone else to watch if she had to leave. Surveyor asked how many residents were attending the activity at the time, V3 stated, It was around 25 residents. On 6/11/24 at 11:45 AM, V4 (CNA) stated, I came to the dining room where they were having activities and V6 (CNA) called me over to help get a resident back up from his recliner. She (V6) told me the patient (R2) was near the ground, so I helped boost him back up. His leg was twisted under his other leg and looked like it got caught under the chair and he didn't have a leg protector or leg rest on him form keeping him from sliding which he should have had. We told the nurse what happened, and she came and assessed the resident (R2). On 6/11/24 at 11:50 AM, V6 (CNA) stated, I was not (R2)'s aide that day, I was just the one helping (V4-CNA) pull the resident up. His leg was bent because he slid down to the bottom of this recliner chair. He didn't have a foot rest, so he slid down and he got his leg caught from under the chair. Surveyor asked V6 to accompany surveyor to R2's room to look at the chair used. V6 pointed to the recliner which appeared more like a high back wheelchair. V6 pointed to the foot rest now resting on top of the chair. V6 stated, That was not on the chair at the time we scooted him up from the bottom of the chair and it should have been put there otherwise he wouldn't have slid down and bent his leg. On 6/12/24 at 10:55 AM, V8 (RN) stated, (R2) was sitting in the dining room around after 1:00 PM but I was on my break when the activity aide (V4) came and told me that the resident slid down on his knees to the reclining chair with his right knee bent backward. I assessed the patient and checked for pain, redness or edema. (R2) nodded he was in pain, so I gave Tylenol. We took him with mechanical lift to bed, but I didn't notify anyone that it was a fall, but I know now it was because the DON (V2) told me. Later on, the morning time the night shift found edema on the resident so they called the doctor and so they sent the patient out to the hospital, and they found the right leg or ankle was fractured. He came back. he was non weight bearing. He was total assist, but he was a low fall risk. Surveyor asked what fall preventative measures were taken to keep R2 safe, V8 stated, We do the rounds, and we keep him in bed at the lowest position and checking on the patients' needs. He's incontinent and knows how to pull the call light. He's nonverbal and alert and oriented times two. (R2) came back from the hospital after 4 or 5 days in the hospital then he fell from the bed because the bed could not be lowered, I guess due to mechanical failure I was told. On 6/12/24 at 12:05 PM, V25 (CNA) stated, He's (R2) very quiet patient and he is a 2-person assist with a mechanical lift. He needs help with feeding and incontinence, and right sided paralysis. We get him up every day on recliner chair. I put him in the dining room, but he was not a fall risk. I was supposed to be in dining room watching the residents, but I had to help another CNA, so I left, but I should have asked somebody to come to sit and watch. Hospital record dated 5/24/24 12:53 PM, written by emergency room doctor (V26) reads in part, (R2) is a [AGE] year old male who is being seen for right leg pain. Per nurse, he is confused at baseline. He is Spanish speaking. He lives at nursing home and was brought here for evaluation of his right leg. It is currently in a post mold. Indication: trauma (fracture). Findings: Comminuted fractures of the proximal tibia and fibula are identified. Hospital record for the second fall and emergency room visit dated 6/5/24 reads in part, Patient is a [AGE] year old male presenting to the emergency department from a musing home after being found down. Per EMS patient is currently at his baseline. Patient mumbles, does not answer questions, does not follow commands. No acute intracranial process or significant interval change when compared to prior CT head dated 5/24/24 (previous admission). Stable subdural hematomas bilaterally, right greater than left. Policy revised on 7/2023 titled Fall Prevention reads in part, The intent of this policy is to provide an environment that is free form accident hazards, over which there is control, and provide supervision and intervention to residents to prevent avoidable accidents. Residents shall be evaluated by a licensed nurse during the admission process, routinely and as indicated to identify potential risk of fall. The interdisciplinary team shall identify individualized interventions to reduce the risk of falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to adequately supervise one (R73) resident who has a history of falls and required staff supervision/assistance with all Activities of Daily Living (ADLs). This failure affected one resident (R73) of seven residents reviewed for accidents and resulted in R73 being diagnosed with a displaced nasal bone fracture. Findings include: R73 is a [AGE] year-old- female who was admitted to the facility on [DATE]. Past medical history includes, but not limited to, progressive supranuclear, dystonia, hyperlipidemia, unsteadiness on feet, need for assistance with personal care, anxiety, essential primary hypertension, etc. R73 has had three falls since January 2024. On 1/16/2024, R73 had an unwitnessed fall while at the nursing station. On 2/16/2024, R73 was found face down while at the nursing station and sustained some injuries on both knees, fall was unwitnessed. On 3/10/2024, R73 was found on the floor in activities room, was sent to the hospital and was treated for a minimally displaced nasal bone fracture. On 4/29/2024, R73 was observed in her room, awake and alert, but unable to answer any questions. Bilateral floor mats noted in the room. Oxygen concentrator noted at bedside but not connected toR73. No broader chair or Geri-chair noted in the room. On 4/30/2024 at 9:50AM, R73 was observed again in bed on a concave mattrass. R73 was lying on her back with floor mats on the floor. There was no wheelchair, broader chair or Geri chair noted inR73's room. Fall care plan dated 3/26/2023 stated R73 is at risk for fall related to decreased safety awareness. Interventions include closely monitor when in room, offer her to sit in recliner after lunch (6/24/2023), try to keep near nurses' station and keep her involved in things she likes. Minimum data set assessment (MDS) section GG (functional status) indicated R73 requires partial/moderate assistance to substantial/ maximal assistance from staff for all ADL needs. MDS section C: 2/6/2024 BIMS - 10 indicating cognitive impairment. Facility reported incident dated 3/15/2024 documented R73 was found on the floor on 3/10/2024 at 2PM. Upon head-to-toe assessment, R73 was having nose bleeding, first aid was provided, andR73 was sent to the emergency room and returned to the facility with a diagnosis of nose fracture, facility started an investigation. CT facial bones without contrast from the hospital dated 3/10/2024 showed a minimally displaced nasal bone fracture. Review of all staff statements indicated that no one witnessed the fall except the activity aide. On 05/01/24 at 11:25 AM, surveyor observed R73 in bed with the assigned nurse and V12 (R73's POA) at the bedside. V12 stated, she is usually at the facility every day and has a lot of issues with the care the R73 is receiving. V12 (POA) said, R73 had so many falls because the facility always put her in the activities room or the nursing station. V12 said, R73 likes to stay in her room and watch TV, but facility stated they do not have enough staff to watch her, and they do not provide 1:1 supervision. V12 said, she has consistently asked the facility to put R73 in a broader chair when she is out of bed instead of a regular wheelchair. The facility provided a broader chair for a while, and it disappeared. V12 said, the last fall R73 had with a nose fracture happened because the staff in activities room did not want to watch R73 and told the nurse to take R73 with her. V12 said the facility stated R73 jumped out of her wheelchair but R73 has unsteady feet and weakness in her lower extremity and there is no way she can jump out of her chair. On 05/01/24 at 2:33 PM, V2 (DON) said she is familiar with R73. R73 is unsteady, a high fall risk and requires 24 hours seven days a week 1:1 supervision. V2 said, one of the interventions the facility has in place for R73 is for her to be monitored closely. R73 is always at the nursing station or activities, but for some reason, R73 always falls when the staff is not looking. V2 said The staff can turn around and the next thing, R73 is on the floor. V2 added, R73 is not able to jump out of her wheelchair but tries to slide out of her chair. On 5/2/2024 at 10:13AM, V19 (C.N.A) said that she is familiar with R73, she is calm and sometimes tries to crawl out of bed. V19 said R73 is a fall risk and requires constant supervision. V19 stated R73 had three different fall incidents on 3/10/2024. The first time she slid out of her wheelchair to the floor while in the hallway. The second time, an activity staff saw R73 slid out of her wheelchair to the floor while at the nursing station and the third time R73 was found in the floor face down in the dining room. V19 added R73 was in a regular wheelchair for all the three incidents. On 05/02/24 at 10:26AM, V16 (Activity aide) said, she was in the activity room on 3/10/2024 when R73 fell and sustained an injury. V16 was watching R73 in activity and told the nurse that V16 could not watch R73. V16 said the nurse was leaving the room, R73 followed the nurse in her wheelchair and before V16 could reach R73, she fell face down from her wheelchair. V16 added, there were 20 to 25 residents in the activities room, and V16 cannot watch all of them. Fall policy provided by V2 (DON) with a revision date of 01/2026 states in its policy statement that the purpose of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall. Under policy details, the document states in part that the fall risk assessment form (or similar fall risk evaluation) should be utilized to complete the evaluation of the resident's potential for falls during the admission process. A licensed nurse shall observe clinical status for 72 hours after an observed or suspected fall, and document findings in the resident's clinical record. The falls should be reviewed at the daily stand- up meeting following the fall for identification of additional individualized interventions to reduce the risk of falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for abuse prevention by not ensuring an agency staff received a thorough criminal background check, not identifying a resident's behaviors that increase their risk for abuse, and not ensuring an abuse risk or behavior care plan was developed for a resident with a history of refusing care. This failure applied to one of one (R1) resident reviewed for abuse and resulted in R1 being physically and verbally abused and sustaining physical and psychosocial harm. Findings include: R2 is an [AGE] year-old female with a diagnoses history of Cerebral Infarction, Aphasia, Partial Paralysis due to Cerebral Infarction, Dysphagia, and Adult Failure to Thrive, and Major Depressive Disorder who was admitted to the facility 07/08/2020. On 02/26/2024 from 2:38 PM - 2:55 PM Observed R2 in her room sitting up in her bed with her head down in front of a meal tray laying on a bedside table over her bed. Observed R2 could not communicate verbally. Observed R2 to communicate through gestures, nods, and sounds. Observed R2 push her tray towards surveyor not wanting to eat it. Observed R2 to be agitated and nearly knocking her tray to the floor before surveyor caught it. Surveyor handed R2's tray to V25 (Agency Certified Nursing Assistant). V25 stated R2 is not interested in eating her meal. V25 stated R2 is highly agitated and is often that way. Observed R2 exhibit agitation in the form of pulling her call light button and bed remote aggressively towards her chest and gesturing and making sounds indicating refusal of V25's offers when attempting to adjust her bedside table and ask what her needs were. Observed V25 plug back in R2's call light. V25 stated R2 pulls out her call light. Observed R2 press her call light multiple times. Observed V10 (Unit Secretary) respond to R2's call light. Observed V10 redirect R2 not to try and get out of her bed. Observed R2 respond to V10 with head nods and pointing in an agitated manner when being redirected. V10 stated she had been to R2's room at least 8 times because she keeps pressing the call light. R2's social service progress note dated 10/13/2023 documents upon notification of immediate care concern social services contacted V29 (Family Member) regarding nature of concerns. V29 reports that V29 understands R2 does refuse care at times and can be a little tough to deal with since her stroke. R2's Full Care Plan does not include refusal of care or behaviors. R2's Care plan initiated 05/23/2023 documents R2 is experiencing new symptoms of depression without a description of what those new symptoms of depression are with interventions including observe R2 for changes in mood status. Incident Investigation report dated 10/13/2023 documents on 10/13/2023 two student CNA's (Certified Nursing Assistant) who were at the facility notified their instructor they witnessed a CNA being rude to R2 while giving her care. The instructor notified the DON (Director of Nursing) around 2:30 PM. The alleged CNA V19 (Agency CNA) was interviewed by the Director of Nursing and Administrator and denied hitting R2. During a head-to-toe assessment R2 was observed with a fading light purplish skin discoloration on the right wrist with a surrounding yellow hue, a dried scab was also noted on R2's right forearm. R2 is unable to communicate verbally, has right sided partial paralysis due to stroke. R2 is interviewable and through non-verbal communication indicated V19 hit her on the arm and began to cry. An order for x-ray of right wrist was given and was negative for fracture or dislocation. The two CNA students who witnessed the incident were interviewed by the administrator and the director of nursing along with the clinical instructor. V21 (Student Certified Nursing Assistant) reported he observed CNA strike R2 multiple times on R2's forearm and observed the CNA asking R2, why are you always like this. Do you want me to leave you?. V21 stated V21 observed the CNA laughing at the resident causing her to cry. V20 (Student Certified Nursing Assistant) reported he did not observe the CNA hitting R2. The CNA did not assist R2 with getting out of the toilet and used force to make her get up. Law enforcement was notified, and a report was made. It was concluded that based on R2's interview and witness interviews from V20 and V21, the facility can substantiate physical abuse by V19 and V19 is no longer working at the facility. Witness statement dated 10/13/2023 from V20 (Student Certified Nursing Assistant) documents he observed the CNA be very rude towards R2 including laughing at her when she struggled on the toilet, not helping her properly transfer from toilet, using force to make her get up, continuing to force her to get up while she screamed in pain. R2 was very upset after all that occurred. Witness statement dated 10/13/2023 from V21 (Student Certified Nursing Assistant) documents the CNA struck R2 multiple times on her forearm, insulted her stating, Why are you always like this?, and threatened R2 stating Do you want me to leave you? Serious Injury Incident Report dated 10/13/2023 documents R2 was the victim of alleged abuse, Agency Certified Nursing Assistant V19 was terminated. V19's (Agency CNA) Personnel file reviewed 02/28/2023 does not include IDOC (Illinois Department of Correction) criminal background check, or Fingerprinting background check. On 02/29/2024 at 9:44 AM V1 (Administrator) stated agencies complete background screens but not fingerprints for their staff. V1 stated the facility does not have a policy for screening agency staff. V1 stated the staffing coordinator reaches out to agencies for staffing and there is a coordination with leadership to bring in the right staffing to the building. V1 stated most of the agencies have a platform where you can find background information for all the staff who have been screened and credentialed. V1 stated all the screening information available from the agency for V19 was in his personnel file. On 02/29/2024 at 11:26 AM V1 (Administrator) stated social services handles completing abuse risk assessments for residents. V1 stated if a resident is determined to be at risk for abuse, they should be care planned for abuse risk. V22 (Director of Quality Control/Registered Nurse) stated the facility educates staff regarding abuse and neglect so he doesn't believe there is anything further that could have been done to prevent the abuse incident for R2. V22 and V3 (RN/Nurse Manager) stated they conducted a background check on V19 (Certified Nursing Assistant) and there is no way to tell if a staff member is going to be abusive to residents. On 02/29/2024 at 12:08 PM V26 (Social Services Director) stated there are no assessments to determine if residents are at risk for abuse. V26 stated if we determine a case of abuse took place on site social services would do a screening to determine if any other residents were at risk for abuse. V26 stated abuse risk assessments are performed as needed. V26 stated risk factors that would increase a resident's likelihood of being abused include a psychiatric history of being abused, history of substance use, any behaviors such as anxiety, anger, fear, withdrawn behavior. V26 stated all the social factors that involve a history of abuse would be the same social factors that would potentially increase a resident's risk of being abused especially if there are changes in a resident's behavior. V26 stated agitation would not necessarily be a risk factor of abuse. V26 stated if a resident has an indicator of agitation which is a comorbidity of mental illness that would not necessarily be a risk factor for abuse. V26 stated R2 has periods of refusing care, can be agitated at times, and has a diagnosis of major depressive disorder. V26 stated when R2 is agitated she refuses care at times, presents with a sad affect, exhibits anxiety all of which are part of her mental status and would not necessarily be an indicator or risk factor for abuse. V26 stated when R2 refuses care it presents as agitation, combativeness, not wanting to be bothered, pushing things away if you try to hand them out to her, sometimes she pretends to sleep. V26 stated these have been her personal observations of R2. V26 stated she doesn't want to believe that R2's behaviors could lead to abuse because that would be very concerning. V26 stated a behavior care plan is developed for resistance to care. V26 stated one instance of exhibiting these behaviors would not warrant a care plan, multiple observations would be required before it is care planned. V26 stated if there is a care plan missing regarding R2's refusal of care it would possibly be because she is still under observation for those behaviors, and we complete quarterly updates to care planning. V26 stated within that quarter there would need to be at least three observations of this behavior before it is care planned. V26 stated behavior observations can be communicated verbally or in writing. On 02/29/2024 at 2:06 PM V29 (Family Member) stated R2 had a stroke and has these seizures and there's times where she can be mean which is usually during the times seizures come. V29 stated R2's been this way a number of years. V29 stated R2 had a stroke 23 years ago. V29 stated the facility has reported to him periodically that R2 refuses care at times and one of the most recent reports of this was three or four months ago. V29 stated he would say R2's refused care a few times over the course of the years she's been there. V29 stated he used to be able to have some influence over this behavior and calm her down when he was able to visit her more consistently. V29 stated he would redirect R2 not to behave that way. The facility's Abuse Prevention Policy received/reviewed 02/28/2024 states: Our residents have the right to be free from abuse. The objective of the abuse policy is to comply with the seven step approach to abuse detection and prevention. The community's goal is to achieve and maintain an abuse-free environment. As part of the resident abuse prevention program, the administration will provide a safe resident environment and protect the residents from abuse by anyone including, but not limited to: community associates, associates from other agencies. It is the policy of this community to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background check. Will not knowingly employ or otherwise engage any individual who has: Been found guilty of abuse or mistreatment by a court of law; Had a finding entered into the State nurse aide registry concerning abuse or; Had a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse or mistreatment of residents. The community will provide training for associates at new hire orientation and through ongoing programs that include, but not limited to, such topics as: Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms, include, but are not limited to, the following: a. Aggressive reactions of residents; c. Resistance to care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer physician ordered pain medication consistent with professional standards of practice for a terminally ill resident (R1) of 3 residents reviewed for pain management. This failure resulted in R1 crying and yelling out in extreme pain. The facility also failed to administer pain medications after an unwitnessed fall after showing signs of pain (moaning) and led to adverse consequence of transfer to an acute hospice facility. Findings include: R1 is an [AGE] year-old hospice resident with diagnosis of acute cerebral hemorrhage, congestive heart failure, chronic obstructive pulmonary disease, and chronic back pain. On 1/19/24 at 11:50 AM, V2 (Director of Nursing) was asked for R1's care plans. A review of care plans received from V2 did not have a care plan specific to pain management. Surveyor verified with V2 whether all care plans were received as requested, V2 stated, Yes. I gave you everything. Surveyor asked if pain management was part of the facility's and/or hospice responsibilities, V2 indicated that hospice's goal was for palliative care and to keep residents as pain-free as possible. R1's Physician orders dated 1/11/24 shows in part, Admit to hospice. No hospitalization. Comfort care medications: 1. Tylenol every 4 hours PRN (as needed), Morphine 5 mg or 0.25 ML every hour as needed for pain. 2. Morphine 10 mg or 0.5 ML every hour as needed for increased pain. 3. Lorazepam 0.5 mg or 0.25 ML every 2 hours as needed for anxiety (sign of pain). 4. Lorazepam 1 Mg or 0.5 ML for increased anxiety. 5. May give Lorazepam 0.5 mg or 0.25 ML for sleep as needed. 6. Screen for pain every shift and record using 0-10 scale; Monitor for occurrences of anxiety; Monitor for side effects of anti-anxiety every shift. On 1/19/24 at 2:45 PM, V6 Hospice RN stated, I'm the hospice nurse and when I accessed (R1) she was crying and yelling out and very agitated. I asked the nurse on duty at the time (V15) if she had given R1 anything for agitation or for pain, V15 indicated she had given R1 morphine in the morning around 10:30 but hadn't given it on an hourly basis as needed. V15 wasn't even aware the patient had an order for Lorazepam until I asked her to give it to the resident. From what V15 told me, they didn't seem to be giving the patient any anti-anxiety medications at all since R1 was admitted . I don't think they were even accessing her pain as ordered. Surveyor asked what the signs of pain were, V6 stated, Increased agitation would be a clear sign that the resident was in pain. Efforts to reach V15 were met with no return calls to speak with surveyor. Hospice clinical notes dated 1/14/24 at 4:36 PM authored by V6 (Hospice RN) shows in part, Received patient in highly agitated state. Patient yelling out and crying. Requested that staff administer Lorazepam and Morphine. Patient is confused continuously. Non-verbal. Son reports that patient has not been eating in more than eighteen days. Little fluid ingestion. Oxygen 2 liters by nasal cannula. Patient is combative during assessment. Pushing writer away. Writer unable to redirect patient. Contacted doctor for orders to transfer patient to the acute hospice facility for agitation exacerbation. Facility not administering medication as ordered. Patient was highly agitated this AM. Staff at facility reports that patient had an unwitnessed fall where she was found face down on the floor at the side of her bed. Staff is unaware how long the patient was in that position and did not notify hospice primary care triage that patient had fallen. Son reports that patient has been highly agitated for days. Staff at the facility was asking son what medications (R1) patient was to receive. Pain Assessment score 7/10. Lorazepam (for agitation): No administration today or yesterday. Morphine Sulfate 0.25 ml 1 time today and 1 time yesterday. On 1/19/24 at 1:15 PM, V16 (family) stated, I'm currently at my mom's funeral so I can't talk long. If you speak with the hospice nurse (V6), she can tell you the problems I had when I came to visit my mom. I was very upset with the home because no one seemed to be managing (R1) very well. She was very agitated and screaming out and no one seemed to notice or care. When I got there the first day, the nurse didn't seem to know what to do or what to give my mom. I called the hospice agency right away to get over there to ensure that home knew what they were doing. On 1/19/24 at 1:22 PM, interview with V3 (LPN) was asked about R1's fall incident and interventions. V3 stated, I work night shifts and I was passing my medications which I started at 5 in the morning, when I got to R1's room around 6:15 AM, I didn't see R1 in bed and I heard moaning so I went in the room and she was face down on the floor next to her bed. The last time I saw her was around midnight when I assisted the CNA (V4) to turn her so she could be changed. Surveyor asked if R1 was at risk for falls, R1 indicated she was not aware of her fall risk status. V3 stated, I just know that she is on a specialty air mattress for her skin, so I guess that could cause her to fall. Surveyor asked if she was considered a fall risk, what fall precautions the facility would use, V3 stated, I'm not sure, I didn't have her long. Surveyor asked if she was provided any specific instructions on how to care for R1, V3 stated, I didn't get special instructions, I just know that she is hospice. Surveyor asked V3 if she was certain she last saw R1 around midnight, V3 stated, Yes it was either 12 or near that time. Surveyor asked what the standard would be to monitor residents, V3 stated, Well it's every two hours but I'm the only nurse at night on the floor and I only have one CNA. Surveyor asked if she had given R1 anything for pain since R1 was found on the floor face down and moaning, V3 stated, No. I didn't give her anything. A review of R1's MAR (medication administration record) affirmed V3's statement and showed no pain medications or anti-anxiety medication were provided throughout V3's shift to the resident either before or after R1's fall. R1's medication administration records during her stay at the facility showed Lorazepam given once by V15 (RN) when the hospice nurse asked her to give it to the resident. Morphine pain medication was administered on the last day of R1's stay (1/14/24) and on the previous day (1/13/24) but given only once for the entire 24 hours. There were no other administration of pain medications including Tylenol being administered for R1 to keep the resident comfortable and pain free. Hospice policy dated 12/2017 titled Hospice Program reads in part, Hospice providers who contract with this community are held responsible for meeting the same professional standards and timeliness of service. When a resident participates in the hospice program, a coordinated plan of care between the community, hospice agency and resident/resident representative will be developed and shall include directives for managing pain and other uncomfortable symptoms. Pain Policy dated 12/17 titled Pain Assessment and Management reads in part, The purpose of this procedure is to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that addresses the underlying causes of pain. Pain management is a multidisciplinary care process that includes the following: Evaluating the potential pain; Effectively recognizing the presence of pain; Identifying the characteristics of pain; Addressing the underlying causes of the pain. Recognizing pain: Verbal expressions such as groaning, crying, screaming.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care and services in a timely manner for residents with suspected injuries, who had orders for x-rays and resulted in delay of treatment for injuries. This failure applied to two (R2, R3) of three residents reviewed for resident injury and resulted in R2 and R3 waiting over 24 hours after injury to be transferred to hospital for further evaluation and treatment of fractures. Findings include: 1. R2 was admitted to the facility with diagnoses that include: Parkinson ' s Disease, difficulty walking and gastrostomy tube. Facility provided incident report for incident on 7/28/23, which documented the following: (R2) is AxO (Alert and Oriented) x0. BIMS score of 99. On 7/28/23 around 12:15pm, the resident's daughter notified the nurse that her mother (R2) was yelling when she grabbed her right ankle. Nurse immediately assessed the resident's right ankle and notified the Nurse Practitioner who ordered an Xray of the right ankle. The X Ray results came back on 07/29/23 which showed acute right ankle fracture and marked osteopenia and DJD of the right ankle. Resident's PCP was notified, and he gave orders to send the patient to (local hospital) for further evaluation and treatment .Facility immediately started an investigation. R2 returned from hospital the same day with orders for CAM Boot to the right foot and recommendations for non-weight bearing of the right lower extremity, and to follow up with an orthopedic clinic in 1 week. As a part of the investigation, we interviewed staff and residents, and conducted a chart review. Staff interviews revealed no noticeable changes to patients' right ankle while providing care prior to 7/28/23. However, staff did note that R2 is impulsive and restless in bed all the time with multiple attempts to exit from the bed .Conclusion: Based on the patient's diagnosis of primary osteoarthritis of right ankle and foot, disorder of bone density and structure of right ankle and foot, X-ray results from 7/28/23 indicating marked osteopenia and DJD of right ankle, and calcium level of 8.2 on 7/19/23, (R2) is at a higher risk for pathological fractures. Based on the investigation, staff and resident interviews, the facility could not substantiate any type of abuse or neglect . Nursing Progress Notes document the following: 7/29/2023 7:55 PM Nursing Notes for R2: LATE ENTRTY 7/28/23: At 12:15pm Patient's daughter approached this charge nurse on duty at nursing station to say that patient is yelling when right ankle is grabbed. Ankle was assessed, at the time no redness, discoloration or swelling noted on ankle. Informed and NP ordered a STAT ray of the right ankle to be performed. Called (x-ray company) portable to put in new order for x ray. Relayed information to nurse taking care of patient and Manager on duty notified. 7/29/2023 10:03 PM Nursing Notes for R2: LATE ENTRY, at 7:45 am. X-ray technician came and did x ray to her (R2) right angle. Her vitals are stable (BP-123/78 MMHG, P 76B/M, R 18b/m, temp 98f. At 11am her son came and put her in the wheelchair with the help of the CNA. The POA went to the small dining room with her and fed her lunch . After two hours (R2) was put back to the bed. The x-ray result came through fax (approx. 1:00 pm 7/29/23). The supervisor paged doctor to inform of the X-ray result, but no response. After that, supervisor called the doctor's phone and informed her of result. Send to the ER for further evaluation. Informed the manager on call and DON by supervisor. Ambulance took her (R2) to (hospital). ER (according to the paramedic she has hypotension on the way to ER) informed the POA also regarding the hospital transfer. The writer gave the report to the ER doctor also. 7/29/2023 11:09 PM Nursing Notes for R2: At 6 pm the writer and supervisor assessed the resident's right ankle. There is no redness or swelling in the right ankle. Informed the on-call manager and DON also. 7/30/2023 1:47 PM Nursing Notes for R2: The resident came from (hospital) at 11.15 am via ambulance. Vitals checked (bp 135/80 mmhg, P 81b/m, R 20 b/m, TEM 98 F). Fed lunch, ate 70%. Gave due medication and started the feeding . She is sleeping in the bed. Boot on the right leg. She has a follow up appointment on 8/6/2023 with her orthopedic surgeon. X-ray report for R2 date of service 7/29/23 documents impression findings of closed acute fractures of the distal tibia and lateral malleolus and marked osteopenia and DJD of the ankle. 2. R3 was admitted to the facility with diagnoses that include: multiple sclerosis, obesity, overactive bladder, and insomnia. Facility provided incident report and investigation documenting that on 9/22/23, R3 was involved in an incident that resulted in a right ankle fracture. Per CNA (V15), that was involved in the incident, on 9/22/23 at approximately 8 PM, while assisting R3 transfer from toilet to wheelchair, the resident had to be lowered to the ground because she was too heavy for V15 to transfer alone and R3 was no longer able to sustain herself while standing. After being placed in bed, R3 notified V15 that she was experiencing pain to her right foot. When V18 (RN) assessed R3's foot, V18 identified pain and swelling. V18 notified the doctor, who ordered an x-ray to be taken. Facility investigation concluded that based on the investigation, it was noted that (R3) was eased to the floor while she was assisted during transferring from the toilet to the wheelchair. During the process of transfer, she may have twisted her ankle which may have resulted in the right ankle fracture. The facility couldn't substantiate any form of abuse or neglect. Nursing Progress Notes regarding R3 document the following: 9/23/2023 12:47 AM LATE ENTRY 9/22/23 9:30 PM Resident lying in bed complained of pain on right ankle. Resident states she might have twisted her ankle. No bruise, or redness, swelling is more than the left ankle. Doctor was paged with order to do x-ray of the right ankle and Tylenol 650mg po every 6 hours as needed for pain. 9/23/2023 7:28 AM 11PM- 7AM shift late entry: Patient noted with swelling and tenderness on the right ankle. She verbalized that it is painful when she moves it. No redness, skin intact. Pain/discomfort is alleviated with rest and keeping her leg still. X-ray of right ankle scheduled to be done today. Endorsed to oncoming nurse. 9/24/2023 11:29 AM 1025AM: Followed-up with (x-ray company rep) for right ankle x-ray result. 1040AM: Right ankle X-ray result received with impression acute, displaced trimalleolar fractures with ankle malalignment. Orthopedic consultation is recommended. Relayed to Doctor with order to send to (local hospital) ED for further evaluation and treatment. 10:42AM: Informed resident and she is amenable to be sent to (hospital) ED. 10:47AM: Attempted to call daughter, but phone is not accepting any calls. 10:48AM: Called (ambulance services) - ETA between 20-30 minutes 11:10AM: Called local hospital ED c/o (staff name) - gave report. 11:30AM: EMS 2 persons arrived to pick up resident. 11:40AM: (R3) Left the unit. Addendum 9/24/23 2:16 PM 01415PM: Followed up with (hospital) ED c/o (staff name) - resident admitted with diagnosis of right trimalleolar fracture, closed. X-ray report for R3 has date of service as 9/23/23 and documents that R3 had an acute, displaced trimalleolar fracture with ankle malalignment of the right ankle; orthopedic consult was recommended. Notation on report reads, 9/24/23 @ 10:40am, Relayed MD send to (local hospital) for eval and treatment. Interview with V18 (RN) on 9/29/23 at 4:11PM, V18 re-affirmed what she documented in her statement and added that the CNA (V15) transferred the resident from the toilet to the wheelchair by herself and that she couldn't do it because the patient is heavy. V18 stated, There should be two CNA's; (R3) has MS (multiple sclerosis) and uses a wheelchair. (R3) was given pain medication. V18 was asked if x-ray was ordered STAT (immediately). V18 responded that she did ask the doctor to do the x-ray in the morning since it was late, but that it should be done in the morning since the resident was in pain. Surveyor asked if it was reasonable for the injury to have occurred on 9/22 but the resident not sent out to the hospital until 9/24. V18 said she only works weekends and doesn't know when the resident was finally x-rayed or sent out but that it is not practical to wait two days to get the x-ray and send the resident to the hospital. V18 stated, If the resident complains of pain and x-rays are not done yet, we can call the doctor and get the resident sent to the hospital. Interview with V2 (Nurse Manager) on 9/29/23 at 3:45 PM, V2 stated, Normally, if residents have symptoms, we will let the doctor know what is going on so they can order the x-ray STAT. If there is pain and swelling upon assessment, we usually get a STAT x-ray. Otherwise, I think it's two days to get the x-ray. Interview with V1 (Director of Nursing) on 9/30/23 at 2:40PM, V1 stated, My expectation is that a STAT x-ray should be done at least within four hours but (x-ray company that facility uses) has told us that their time frame for a STAT x-ray is 12 hours. I will call them first thing Monday morning and let them know that it is unacceptable. I will have to continue to educate my nurses and let them know that if a fracture is suspected that they cannot wait over four hours and will have to call the doctor back and request for the resident to be sent to the hospital. I'm not sure what the policy is but it is my expectation that the nurses would call the doctor and send the resident to the hospital if they need an x-ray. I will discuss this with Corporate as well. Interview with V16 (Medical Director) on 10/01/23 at 3:37PM, V16 stated he has not been made aware of any issues with the facility obtaining x-rays for residents and that he regularly attends quality assurance meetings with the facility. V16 added that since COVID there have been more delays, maybe because of lack of staff or something. Regarding x-rays, V16 said, In this setting I understand that we have to wait for someone to get to the facility and such, but I would expect it (STAT x-ray) to be done within about two to three hours. If the patient is having symptoms like pain and there is an obvious fall, we can send them to the ER if we think or know that there will be a delay in getting the x-ray. If the person is in extreme pain, then we would not wait and just send them to the ER. If this is a problem that is happening, then I will follow up with the Director of Nursing personally because this shouldn't be happening. Facility provided contract from x-ray company, which did not have any indication of the expected time frame for services. Facility provided policies: Fall Policy dated 07/2023 reads: Policy Statement/Overview The purposes of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall. Policy Detail 1. The [NAME] Fall Risk Assessment form (or similar fall risk evaluation) should be utilized to complete the evaluation of the residents' potential for falls during the admission process. The [NAME] Fall Risk Assessment form (or similar fall risk evaluation) should be completed quarterly, with significant change MDS Assessment and after every fall. 2. If a resident sustains a fall or is found on the floor without a witness to the event, associates shall evaluate for possible injuries and provide first aid or treatment as indicated. Direct care associates shall evaluate the area where the fall occurred for possible contributors. A Licensed Nurse shall notify the resident's Attending Physician and Resident Representative of the event. The Licensed Nurse shall document the fall in the resident's clinical record. The documentation of the identified interventions should be maintained in the resident clinical record and available to the direct care associates. A Licensed Nurse shall observe clinical status for 72 hours after an observed or suspected fall, and document findings in the resident clinical record. The falls should be reviewed at the Daily Stand - up Meeting following the fall for identification of any additional individualized interventions to reduce the risk of falls. An incident report shall be completed for resident falls by a Licensed Nurse after the fall occurs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow residents' plan of care by not monitoring a resident (R1) at all times and keeping the resident free from injury; and failed to conduct a proper resident transfer by utilizing only one staff member for a resident (R3) assessed to require two staff members for transfers. These failures applied to two (R1, R3) of three residents reviewed for resident injury and resulted in R1 having an unwitnessed fall in room and obtaining a left wrist fracture and R3 obtaining a right ankle fracture during improper transfer. Findings include: 1. R1 was admitted to the facility with diagnoses that include: cerebral infarction, heart failure, Parkinson's disease, difficulty in walking, and need for assistance. R1 is no longer in the facility and expired on [DATE]. R1's current care plan documents the following: Problem Onset: [DATE] - (R1) is at risk for falls due to decreased safety awareness, decreased strength and endurance, decreased mobility, impaired balance, unsteady gait, h/o CAD, HTN, CHF, DM, dyspepsia, hypocalcemia, carotid stenosis with hx of carotid endarterectomy, anemia, a-fib, GI bleed, CVA, Parkinson's, arthritis, thyroidectomy, s/p hosp for non-radiating left chest pain at rest, associated SOB Approaches include: Orient resident/significant other to environment and how to call for assistance, keep equipment within reach (i.e., call bell, phone, urinal, etc.), and educate resident and family regarding safety issues and risks for falls. Other care plan interventions include: assign staff to account for resident whereabouts at all times. On [DATE], R1 had a fall in the facility in her room. Facility submitted final incident report that reads: On [DATE] around 5:45 pm, the roommate of the resident (R1) alerted the nurse on duty (NOD) that (R1) was found on the floor. The NOD immediately rushed to the room and noted (R1) sitting on the floor in her room against the wall with her hands embracing her body. The NOD immediately performed a head-to-toe assessment and noted some swelling to her left wrist. (R1) agreed to having pain to her left wrist when palpated. No bruises or skin tears noted on the exam. First aid was provided and (R1) was transferred to her bed with 1 person assistance. (R1) was made comfortable, fall precautions maintained and care plan updated. MD notified with orders to send (R1) to the ER. Daughter made aware. (R1) was transferred to (local) hospital ER via ambulance transfer on [DATE] at 5:55pm. (R1) was discharged from the ER on [DATE] and was admitted back to the facility at around 9am on [DATE] with a diagnosis of left wrist closed fracture. (R1) has a posterior mold applied to her left wrist. Facility immediately started an investigation. Conclusion: Based on the investigation, chart review and staff interviews, it was determined that the fracture had resulted from the fall. Care plan was updated with new fall interventions in place. All staff were educated on fall prevention. The NOD on [DATE] was V10 (RN). (V10) was interviewed and per (V10), (R1's) son visited R1 on [DATE] around 4pm, left (R1) in her bedroom alone in a wheelchair and left the building without informing any staff. The last time (V10) saw (R1) prior to the incident was when R1 was with her son and (V10) thought (R1) was with her son. Incident witness statement dated [DATE], written by V10 (RN), reads: When I am passing the medication in the hallways, one of my residents called me to her room. When I went to her room, the resident was on the floor in a sitting position. Leg extended and her hand braced her body. I called other nurse to put her in the bed. Head to assessment done. Noticed left hand wrist swelling. Informed doctor. Sent to (local hospital). [sic] Root cause analysis for incident dated [DATE] at 5:45PM, completed by V10 (RN) documents, Resident (R1) was trying to stand from wheelchair and trying to walk to her room and fell near chair and was in wheelchair; intervention most appropriate is listed as close supervision. [DATE] at 9:50AM, V1 (DON) stated, I don't know too much about (R1), but I do know that she was a frequent faller. We tried to keep her near the nurses station and monitor her at all times. She should have been monitored every hour; we don't document that anywhere. There are assigned CNA's when they are in the dining room to keep an eye on the residents. In this instance, it does look like she fell by trying to get up from her wheelchair. Even if we would tell her not to stand up by herself, she would do it anyway. 2. R3 was admitted to the facility with diagnoses that include: multiple sclerosis, obesity, overactive bladder, and insomnia. Per MDS dated [DATE] and [DATE], R3 requires extensive assistance, one-person physical assist. Interview with V14 (RN/Restorative) on [DATE] at 12:50 PM, confirmed the MDS was coded as one person assist in error. V14 provided copy of R3's care card (undated) that shows resident is two person assist for transfers and bed mobility; but since she fell, now she requires a mechanical lift. V14 added that moving forward the care cards should be dated. R3's current care plan documents the following: Problem Onset: [DATE] - (R3) requires extensive assist with ADL's, due to decreased strength and endurance, decreased balance, decreased mobility, unsteady gait, h/o overactive bladder, insomnia, MS, mood disorder, T12 and L3, compression fx, resident transferred to [NAME] from another SNF due to onset of progressive weakness secondary to MS. Approaches include: 5-7-23, 2 staff members to assist with transfers, and 5-19-23 educate patient 'to call, don't fall' (sign on the wall), and toilet patient before and after meal; offer to use toilet before going to bed. On [DATE], R3 had a fall in the facility in her room bathroom. Facility submitted final incident report that reads: (R3) complained of right ankle pain and swelling on [DATE]. MD was notified with orders for an X-ray of the right ankle. The X-ray was taken on [DATE] and the results were received on [DATE] which showed acute displaced trimalleolar fractures with ankle malalignment. MD was notified of X Ray results. MD gave orders to send (R3) to (local hospital) ER and the resident got admitted at the (hospital) on [DATE] with right trimalleolar fracture. Family was notified. The facility immediately started an investigation. Investigation: (R3) is alert and oriented X4. (R3) has multiple sclerosis and has right lower extremity weakness. As a part of the investigation, we conducted staff interviews and chart review. The CNA (V15) who took care of the resident on [DATE] was interviewed. Per (V15), the resident asked her to help her with changing and preparing her for bedtime around 8pm. (R3) indicated that she would like to use the restroom prior to going to her bed. (V15) assisted (R3) to transfer her to the toilet. After (R3) used the toilet, she informed (V15) that she was finished. (V15) assisted (R3) to get up from the toilet with (R3) holding on to the railing. (R3) informed (V15) that she was feeling fatigued and was not able to continue standing and needed to sit down. (V15) offered (R3) assistance to transfer her to the wheelchair that was placed next to her but (R3) remained immobile and verbalized her concerns of falling. (V15) immediately lowered (R3) to the floor in a sitting position and called for assistance. With the assistance of another CNA, (V15) safely transferred (R3) to the wheelchair and returned her back to her bed. (V15) immediately notified the nurse on duty (NOD) about what had happened. The NOD completed an assessment and (R3) complained of having right ankle pain and swelling. Upon interview, (R3) told the NOD I did not fall but I may have twisted my ankle when I moved, I am not sure. The NOD immediately provided first aid to (R3) and notified the MD. The MD gave orders for an Xray of the right ankle and pain management with Tylenol. The X Ray was taken on [DATE] and the results were received on [DATE] which showed acute displaced trimalleolar fracture with ankle misalignment. The MD was notified of X Ray results with orders to send (R3) to (local hospital) for further evaluation and treatment. Family was notified. (R3) got admitted at local hospital on [DATE] and had a right ankle open reduction and internal Fixation (ORIF) done on [DATE]. (R3) returned back to the facility on [DATE] with orders for non-weight bearing to the right foot. (R3) will follow up with MD (ortho surgeon) in 2 weeks on [DATE]. Conclusion: Based on the investigation, it was noted that (R3) was eased to the floor while she was assisted during transferring from the toilet to the wheelchair. During the process of transfer, she may have twisted her ankle which may have resulted in the right ankle fracture. The facility couldn't substantiate any form of abuse or neglect. Incident witness statement dated [DATE] written by V18 (RN) documented, V18 did not witness fall but that around 9:30PM CNA approached her that resident was complaining of right ankle pain. V18 documented, resident (R3) complained of pain to touch (ankle). Per CNA, resident was lowered to the floor during transfer because she was heavy, then CNA had to call for help. Incident witness statement dated [DATE], written by V15 (CNA) reads: On Friday, [DATE], during my 3-11 shift at Ascension Living Resurrection Place, I provided care to (R3) at approximately 8 PM. (R3) expressed her desire to retire to her room for the night. Consequently, I accompanied her to her room to assist with changing and preparing her for bedtime. Upon arriving in her room, (R3) indicated that she needed to use the restroom. In response to my inquiry, she affirmed her ability to stand for a brief period. I proceeded to assist her in transferring to the toilet, which involved helping her stand, lowering her pants, and seating her on the toilet. She spent approximately 2 minutes on the toilet before informing me that she was finished. I assisted her once again in rising from the toilet, providing support as she held onto the railing. It was at this point that (R3) expressed fatigue and an inability to continue standing, stating that she needed to sit down. In response, I suggested that we turn her toward her wheelchair so she could sit on it, reassuring her that I was holding her securely. However, (R3) remained immobile, reiterating her inability to support herself and her fear of falling. Despite my efforts, I was unable to lift her due to her weight. In light of the situation, I suggested that she sit on the restroom floor while I sought assistance from another CNA to aid in her return to the wheelchair. After carefully placing (R3) on the restroom floor, I promptly summoned the assistance of another CNA to facilitate her safe transfer back into the wheelchair. Once (R3) was comfortably seated in her wheelchair, I assisted her in returning to her bed. Before leaving her room, I inquired about her well-being, to which she responded in the affirmative. Subsequently, I provided her with the call light in the case she may require any further assistance. I subsequently reported the incident to the nurse responsible for the wing, who acknowledged the information. A few minutes later, (R3) utilized her call light to request assistance with her foot, which she stated was hurting. I inquired about the cause of the discomfort, and she mentioned that she believed she had twisted it. I promptly informed the nurse, who conducted an examination to assess (R3's) condition. [sic] Nursing Progress Notes document the following: [DATE] 12:47 AM LATE ENTRY [DATE] 9:30 PM Resident lying in bed complained of pain on right ankle. Resident states she might have twisted her ankle. No bruise, or redness, swelling is more than the left ankle. Doctor was paged with order to do x-ray of the right ankle. And Tylenol 650 mg po every 6 hours as needed for pain. [DATE] 7:28 AM 11PM- 7AM shift late entry: Patient noted with swelling and tenderness on the right ankle. She verbalized that it is painful when she moves it. No redness, skin intact. Pain/discomfort is alleviated with rest and keeping her leg still. x-ray of right ankle scheduled to be done today. Endorsed to oncoming nurse. [DATE] 11:29 AM 1025AM: Followed-up with (x-ray company rep) for right ankle x-ray result. 1040AM: Right ankle X-ray result received with impression acute, displaced trimalleolar fractures with ankle malalignment. Orthopedic consultation is recommended. Relayed to Doctor with order to send to (local hospital) ED for further evaluation and treatment. 10:42AM: Informed resident and she is amenable to be sent to (hospital) ED. 10:47AM: Attempted to call daughter, but phone is not accepting any calls. 10:48AM: Called (ambulance services) - ETA between 20-30 minutes 11:10AM: Called local hospital ED c/o (staff name) - gave report. 11:30AM: EMS 2 persons arrived to pick up resident. 11:40AM: Left the unit Addendum [DATE] 2:16 PM On [DATE] at 4:11PM, V18 (RN) re-affirmed what she documented in her statement and added that the CNA (V15) transferred the resident from the toilet to the wheelchair by herself and that she couldn't do it because the patient is heavy. There should be two CNA's; R3 has MS (multiple sclerosis) and uses a wheelchair. R3 was given pain medication. Review of x-ray report for R3 dated [DATE] documents R3 had an acute, displaced trimalleolar fracture with ankle malalignment of the right ankle; orthopedic consult was recommended. Facility provided policies: Fall Policy dated 07/2023 reads: Policy Statement/Overview The purposes of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall. Policy Detail 1. The [NAME] Fall Risk Assessment form (or similar fall risk evaluation) should be utilized to complete the evaluation of the residents' potential for falls during the admission process. The [NAME] Fall Risk Assessment form (or similar fall risk evaluation) should be completed quarterly, with significant change MDS Assessment and after every fall. 2. If a resident sustains a fall or is found on the floor without a witness to the event, associates shall evaluate for possible injuries and provide first aid or treatment as indicated. Direct care associates shall evaluate the area where the fall occurred for possible contributors. A Licensed Nurse shall notify the resident's Attending Physician and Resident Representative of the event. The Licensed Nurse shall document the fall in the resident's clinical record. The documentation of the identified interventions should be maintained in the resident clinical record and available to the direct care associates. A Licensed Nurse shall observe clinical status for 72 hours after an observed or suspected fall, and document findings in the resident clinical record. The falls should be reviewed at the Daily Stand - up Meeting following the fall for identification of any additional individualized interventions to reduce the risk of falls. An incident report shall be completed for resident falls by a Licensed Nurse after the fall occurs. Falls Prevention dated 07/2023 reads: Policy Statement The intent of this policy is to provide an environment that is free from accident hazards, over which there is control, and provide supervision and intervention to residents to prevent avoidable accidents. 1. Fall Risk Evaluation Residents shall be evaluated by a licensed nurse during the admission process, routinely and as indicated; to identify potential risk of fall. If the resident scores a higher risk for falls, the resident shall be placed on the Falling Star Program. II. Fall Risk Intervention the Interdisciplinary Team shall identify individualized interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the associates may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 1. Falling Star Program Residents identified as members of the Falling Star Program shall have: a. A star placed next to the nameplate outside the resident room. b. The documentation of the identified interventions should be maintained in the resident clinical record and available to the direct care associates. c. If falling recurs despite initial interventions, associate shall implement additional, different interventions, or indicate reason the current approach remains relevant. This documentation should be maintained in the clinical record. 2. Graduation from the Falling Star Program a. The interdisciplinary team may identify residents who previously scored at a higher fall risk to consider if there is a benefit of maintaining the resident on the Falling Star Program. To be considered for graduation: 1. The resident should not have a fall within 6 months of the evaluation or no change in Psychotropic Medications in past 90 days or no orthostatic hypotension within 6 months of evaluation. it. Previous indicators identified as High Risk for a fall may be resolved or identified interventions are effective. b. Interdisciplinary Team shall review residents current status and determine whether graduation from program is indicated c. Interdisciplinary Team shall review care plan interventions to be maintained post-graduation.