**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R93's Face sheet dated 9/24/24, shows R93 has diagnoses including (but not limited to) Parkinson's disease, dementia, and epilepsy. R93's Morse Fall Scale dated 3/7/24 shows R93 has a score of 55 which denotes R93 is at high risk of falling. This document also shows R93 has a history of falling, has an impaired gait, and overestimates or forgets her own limits. R93's un-witnessed fall report dated 3/7/24 shows R93 had an unwitnessed fall in the dining room with no injuries. R93's un-witnessed fall report dated 6/6/24 shows R93 had an unwitnessed fall in her room with no injuries. R93's Care Plan dated 9/24/24 shows R93 has a care plan focus created on 1/22/2023 that states, The resident is a risk for falls r/t (related to) Parkinson's Disease, confusion, psychotropic medication use, vision. This care plan and all interventions were last revised on 1/8/2024. No revisions were made after the un-witnessed fall on 3/7/24 or 6/6/24. Facility Accidents and Supervision policy reviewed on 6/2024 states, . 4. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: a. Ensuring that interventions are implemented correctly and consistently. b. Evaluating the effectiveness of interventions. c. Modifying or replacing interventions as needed. d. Evaluating the effectiveness of new interventions. 2. On 09/24/24 at 11:38AM, R23 was sitting in the dining room. R23 with a 3.5-centimeter by 1.5-centimeter irregular shaped scabbed wound on the center of the forehead. On 09/25/2024 at 9:30AM, V1 Administrator said, V11 CNA-Certified Nursing Assistant was with R23 when she fell on [DATE]. R23's fall on 09/13/2024 caused the wound to R23's forehead. On 09/25/2024 at 9:56AM, V11 CNA said, I was with R23 when she fell. I transferred her, as I was situating her in the chair, it was like she threw herself forward. I transferred R23 with a full body mechanical sling lift; I transferred her by myself. Normally a mechanical sling lift is supposed to be performed by two staff members. On 09/25/2024 at 11:29AM, V2 DON-Director of Nursing said, there should be two staff members present when transferring a resident with a mechanical sling lift. R23's Progress Notes dated 9/15/2024 at 5:53PM, shows, Incident Note, Note Text: Notified by CNA that upon transferring resident out of bed onto wheelchair, resident leaned forward and fell to the ground onto her side. R23's Fall Risk assessment dated [DATE] shows, High Risk for Falls. The facility's undated Mechanical Lift policy shows, two staff members must be present when using any mechanical lift. One staff member directs mechanical lift towards the receiving surface while the other staff member gently guides resident. Based on observation, interview, and record review the facility failed to supervise a resident with a history of falls, failed to ensure a safe transfer was performed, and failed to review/revise fall interventions post fall for 3 of 24 residents (R114, R23, R93) reviewed for safety in the sample of 24. This failure resulting in R114 sustaining a right hip fracture and R23 sustaining a head wound. The findings include: 1. On 09/23/24 at 10:54 AM, R114 was sitting in his wheelchair, in the activity room by nurses station. R114 was unable to answer any questions. The facility's Reporting to IDPH worksheet dated 6/25/24 shows fall with injury-R114 was sent to hospital for evaluation and treatment of bruising to right groin. Notified that R114 had a femur fracture and would be admitted for treatment. On 09/25/24 at 10:02 AM, V1 Administrator said V17 CNA came and told V2 Director of Nursing that something was wrong with R114, he was not walking right. V1 said upon assessment, R114 had some discoloration in his right groin area. V1 said they spoke with the doctor and got an order for an x-ray. V2 said the x-ray company wasn't coming soon enough, so they sent R114 to the hospital. V2 said she interviewed staff and R114 had no out of the normal behavior, no documented incident, no falls and no signs of pain, but something happened to his hip. R114's Progress Note dated 6/24/24 at 10:25 PM, shows writer called and followed up with hospital, per emergency room Nurse, R114 is being admitted due to closed fracture of right hip. R114's hospital x-ray report dated 6/24/24 shows comminuted intertrochanteric right hip fracture (bone broken in at least two places, caused by severe trauma- fall, car accident). On 09/25/24 at 11:07 AM, V17 Certified Nursing Assistant (CNA) said she got R114 up in the morning (6/24/24) and took him to breakfast. V17 said R114 sat up fine and had no complaints of pain. V17 said later when she was putting him back to bed (after therapy), R114 had a hard time standing up, and appeared to be in pain so she told the nurse. On 09/25/24 at 10:17 AM, V18 Physical Therapist said she got R114 from the dining room that morning and took him to therapy. V18 said R114 was hardly able to stand up, which was not his norm so she brought him back to his room. V18 said she thought maybe R114 was just tired. V18 said R114 normally wants to stand up and has to be close to the nurses station for supervision. On 09/25/24 at 11:12 AM, V16 Licensed Practical Nurse said she was the evening nurse from 6:00 PM to 6:00 AM over the weekend (6/21/24-6/23/24) and she had no issues with R114. V16 said R114 has behaviors of trying to get up out of the chair, and can be antsy. V16 said she would keep him in eyesight for supervision due to history of trying to get up. On 09/25/24 at 11:39 AM, V14 CNA said she worked the evening shift (6/23/24) and she didn't see R114 out of bed after she put him to bed, but R114 can swing his legs over and try to get up. On 09/25/24 at 12:01 PM, V15 Registered Nurse said she worked with R114 all weekend (during the day) and nothing out of the ordinary occurred. V15 said R114 was antsy and was up and down all weekend and not sleeping. On 09/25/24 at 12:20 PM, V13 (R114's Power of Attorney) said he got a call from the facility that R114 had a fall in evening trying to get up. V13 said they sent R114 to hospital. V13 said he was upset that this happened, R114 needed hip surgery and needed screws. V13 said R114 had a fall before this with bruising to his face. V13 said since R114 had a stroke, he has trouble with balance and walking. V13 said R114 needs to be monitored more. On 09/25/24 at 11:34 AM, V20 Orthopedic Doctor (performed hip surgery at hospital for R114) was phoned and a message was left with the nurse for the doctor to call back. V20 did not return this surveyor's call. R114's Morse Fall Scale dated 6/2/24 shows R114 is at moderate risk for falling due to medical diagnoses, impaired gait, and overestimates or forgets his limits. R114's Care Plan shows R114 has diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, aphasia, history of transient ischemic attack, dementia and restlessness and agitation. The same Care Plan shows R114 has moderately impaired cognitive function requiring cues and supervision in daily decision making. R114 will attempt to get up on own and has been observed crawling on bedroom floor. Resident is not verbal for the most part and has difficulty communicating. Resident is at risk for falling. The intervention for risk for falling of mattress to be placed on floor next to bed at all times. Resident crawls from bed at times, was added on 9/25/24. This same Care Plan does not include interventions of close supervision.

Based on interview, and record review the facility failed to ensure a nurse reported a potential injury promptly to another nurse or physician. This applies to 1 of 3 (R1) residents reviewed for quality of care in the sample of 10. This failure resulted in R1 experiencing a delay in care/assessment and experiencing increased pain. The findings include: On 2/20/2024 at 10:56AM, V5 Registered Nurse (RN) said on 1/27/2024 she could see [R1's] right foot stuck behind the front wheel of the wheelchair. V5 said [R1] did say oww while her foot was stuck behind the wheel. V5 said [R1] did complain of pain upon palpation of the leg. V5 said she did not see any swelling at that time. V5 said she moved [R1] down to the nurse's station she was working at to watch the patient. V5 said she was not the primary nurse for [R1] that day. V5 said she did not report the information to [R1's] primary nurse. V5 said she told V8 Certified Nursing Assistant (CNA) about the incident when (V8) came to get (R1) approximately 30 minutes after the incident occurred. V5 said she should have told [R1's] primary nurse about the incident and the resident's complaint of pain. On 2/20/2024 at 11:12AM, V7 CNA said [R1] was sitting at the nurse's station for approximately 20-30 minutes before V8 came to get [R1] and take her back to her unit. On 2/20/2024 at 1:09PM, V6 Licensed Practical Nurse (LPN) said around 3:00-3:30PM she could see [R1] sitting down by the other nursing station. V6 said she asked V8 to bring [R1] back down the hallway to keep an eye on her. V6 said V8 reported the resident was complaining of pain. V8 said [R1] had right knee swelling that was clearly visible and appeared twisted. V8 said she went to find V5 and ask her what happened. V8 said V5 told her [R1's] foot had got stuck behind the front wheel of the wheelchair. V8 said she notified V2 Director of Nursing right away and an order for an x-ray was obtained. V8 said the stat x-ray was taking a long time, up to 45 minutes. V8 said [R1] was placed back in bed via (mechanical) lift from the wheelchair and further assessed [R1's] leg. V8 said the swelling appeared to be worse after removing [R's] pants. V8 said she contacted V2 again and [R1] was sent out after calling 911 via EMS (emergency medical) transport. V6 said [R1] didn't complain of much pain while sitting in her wheelchair. On 2/20/2024 at 11:43AM, V2 said if anything changes with the resident or seems wrong there should be an assessment completed. V2 said oww would indicate a resident is hurt or something is wrong. V2 said following the assessment if any swelling or pain is noted the physician should be notified for further orders, tests, or to send the resident out of the facility. R1's progress notes dated 1/27/2024 states around 3:15PM the resident was brought back to the unit by CNA. CNA informed nurse of the resident's complaint of pain. X-ray order was obtained, and PRN Tylenol was administered per order. Resident continued to scream out in pain whenever resident is moved. Resident was placed back in bed with (mechanical) lift x3 staff. Upon removing pants, residents' right knee was visibly swollen and blue/purple. Resident was in tears and crying out for help. DON was informed again. Resident was sent out to [a local area hospital]. On 2/20/2024 at 12:36PM, V4 Doctor said the resident was admitted to [a local area hospital] on 1/27/2024 and found to have a fractured femur. V4 stated the x-ray report read a commuted displaced fracture of the distal femur shaft. V4 said it was a nasty break. V4 said the type of fracture [R1] sustained was not pathological and there would need to be some type of mechanical force to create it. V4 said [R1] needed surgery to repair her broken femur.

Based on interview and record review the facility staff failed to safely transport a resident in a wheelchair for 1 of 3 (R1) residents in the sample of 10 reviewed for accidents/incidents. This failure resulted in R1 experiencing a femur fracture. The findings include: On 2/20/2024 at 11:12AM, V7 Certified Nursing Assistant (CNA) said on 1/27/2024 she was in a resident's room when she heard the door alarm going off. V7 said she left the residents room and saw [R1] trying to leave the facility out the back door. V7 said she approached [R1] to prevent her from going outside because it was cold and icy that day. V7 said [R1] became agitated and began hitting her. V7 said she was able to turn around [R1's] wheelchair and started pushing her down the hallway. V7 said there were no foot pedals on [R1's] chair because she self-propels down the hallway on her own using her feet. V7 said [R1] began trying to put her feet on the floor to stop the wheelchair from going and putting her feet behind the front wheel of the wheelchair. V7 said she tried to redirect [R1] from putting her feet down but she kept putting her feet down. V7 said [R1] tried to throw herself out of the wheelchair. V7 said she put her arm around [R1] to prevent her from falling. V7 said she couldn't see the angle of [R1's] foot because she was behind the resident. On 2/20/2024 at 10:56AM, V5 Registered Nurse (RN) said on 1/27/2024 she saw [R1] trying to get out of the back door. V5 said she came up to [V7] pushing [R1] down the hallway in the wheelchair. V5 said [V7] caught [R1] from falling forward in the wheelchair by putting her arm around her. V5 said she could see [R1's] right foot stuck behind the front wheel of the wheelchair. V5 said [R1] did say oww while her foot was stuck behind the wheel. On 2/20/2024 at 12:36PM, V4 Doctor said the resident was admitted to [a local area hospital] on 1/27/2024 and found to have a fractured femur. V4 stated the x-ray report read a commuted displaced fracture of the distal femur shaft. V4 said it was a nasty break. V4 said the type of fracture [R1] sustained was not pathological and there would need to be some type of mechanical force to create it. V4 said [R1] needed surgery to repair her broken femur. On 2/20/2024 at 11:43AM, V2 Director of Nursing (DON) said if a resident was becoming combative and putting their feet down on the ground while pushing their wheelchair staff should stop and get help. V2 said the resident is at risk of catapulting out of the chair and staff should get additional help. V2 said stopping and getting additional help would be done to keep the resident safe. R1's progress notes dated 1/27/2024 stated Resident admitted for closed fracture to distal end of right femur. R1's Care Plan dated 1/29/2024 states [R1] has thrown herself out of her wheelchair when agitated. [R1] is able to slowly self propel in wheelchair throughout the facility. [R1] is a CNA safe lift transfer x2 assist for all transfers. The facility's Policy for preventing accidents and incidents, not dated, states the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident was free from physical abuse. This failure resulted in R1 being punched in the face by staff and sustaining a right eye contusion and right eye laceration requiring stitches. This applies to 1 of 4 residents (R1) reviewed for abuse in the sample of 4. The findings include: The facility's undated Final Incident Investigation Report documents on 11/29/22 at approximately 7:50 PM, [V4 (Terminated CNA)] notified the nurse [V3 (LPN)] that he and [R1] had an altercation and [V4] struck [R1] in the face and he was bleeding. [V4] was attempting to assist [R1] to bed for the night. When [V4] attempted to remove his pants [R1] became verbally and physically aggressive towards [V4]. [R1] kicked [V4] in the groin and attempted to grab his arms. [V4] then struck [R1] in the face to stop him from grabbing him. [V4] was escorted out of the building and awaited the police arrival [V4] was arrested and [R1] was sent out to the local hospital. [V4] was terminated from the facility and [R1] returned to the facility and received two stitches to the right inner eye lid. On 12/5/22 at 9:09 AM, R1 was sitting in his wheelchair in the common area. Diffuse bruising was observed under his right eye and a laceration observed to his right inner eye. R1 was unable to answer any questions with no behaviors observed at this time. On 12/5/22 at 10:21 AM, V3 (LPN) said he was the nurse the day of the incident with R1. V4 (Terminated CNA) came up to him and said that R1 was bleeding from his face but did not say what happened. V3 went to R1's room and he was bleeding from the right side of his face/cheek. I touched his cheek and [R1] pulled away and put his hands in the air and said, 'don't hit me'. V3 said R1, was traumatized, he cowed away and could not tell me what happened. V3 said he left R1's room and saw V4 at the nurses' station. He asked V4 what happened. V4 mumbled something, then he asked him again what happened. [V4] said he punched [R1] in the face. Never should staff hit another resident. [R1] has a history of being physically aggressive towards staff, you get out of his way and re-approach him when he has behaviors. I've been hit by [R1], he's not that strong. On 12/5/22 at 10:32 AM, V6 (CNA) said she was working on 11/29/22 when the incident happened with R1. V6 said, [V3] said that [V4] punched a resident and I needed to take over his assignment. [R1] can be aggressive, but if you take care of him properly, he is calm. You should explain what you're doing and reapproach him if he gets combative and notify the nurse. You should never hit a resident. [V4] usually keeps to himself and doesn't interact with people too much. On 12/5/22 at 11:46 AM, V1 (Administrator) said she got a call on 11/29/22 and staff reported that V4 hit R1 in the face. She notified the police and called 911. The police were there, and they interviewed V4. V4 said he went to R1's room to put him to bed and R1 kept on saying things that were not true and that V4 was in the army. R1 kicked V4 in the groin and attempted to grab him then V4 struck R1 in the face. V1 said that V4 was arrested and is still in jail. R1 was sent out to the local hospital and had a right eye laceration and required two stitches. V4 never said he was sorry or showed remorse for his actions. V4 was very quiet and did his job. V1 said that R1 has verbal and physical behaviors and is not easy to care for. V1 said, If there is no reasoning with him staff should leave him alone and re-approach him when he has behaviors. R1's face sheet showed he was an [AGE] year-old male with diagnoses that included hearing loss, dementia, urine retention, hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side, and heart disease. R1's Minimum Data Set assessment, dated 10/11/22, showed he had severely impaired cognition and incidents of verbal and physical behaviors, and rejections of care. The facility's Compliance with Reporting Allegations of Abuse/Neglect/Exploitation Policy states, The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation and reporting of abuse. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. b. Abuse: The willful infliction of injury. with resulting in physical harm, pain or mental anguish, which can include staff to resident abuse. Physical Abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R3's face sheet shows she has diagnoses including: unspecified dementia with behavioral disturbances, schizoaffective disorder and a history of falling. R3's 6/27/2022 facility assessment shows she has an unsteady gait and requires extensive 2 person staff assistance with transfers and toileting. R3's active care plan shows she has a self-care deficit and requires extensive assistance for all transfers. R3's 6/27/2022 fall risk assessment shows she is at high risk for falls. On 7/11/2022 at 1:11 PM, V8 (CNA) entered R3's room to assist her to use the toilet. R3 had been incontinent of stool that had leaked out of her pants and onto the floor in her room. R3 was sitting in her wheelchair and V8 pushed R3 into the bathroom. V8 did not apply a gait belt on R3 and R3 began to stand up from her wheelchair. V8 left R3 in the bathroom and went to clean stool off the floor in the room. V8 then said she was going to get housekeeping to assist with the stool on the floor and left R3 alone in the bathroom. When V8 returned R3 was standing up between her wheelchair and the toilet. V8 assisted R3 to pull down her pants and sit on the toilet. At 1:19 PM, R3 was finished using the toilet. Without applying a gait belt V8 told R3 to push up using the arms of her wheelchair to stand up. V8 pulled up R3's pants and helped her turn and sit in the wheelchair. On 7/12/2022 at 12:28 PM, V6 (Licensed Practical Nurse/LPN) said gait belts should be used for all residents during transfers and a resident should never be left alone standing up in the bathroom for safety reasons. On 7/12/2022 at 12:30 PM, V7 (CNA) said gait belts are always supposed to be used during transfers and residents should not be left alone in the bathroom for safety reasons. The facility's Safe Resident Handling/Transfers policy dated 2021 states, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employee safe in accordance with the current standards and guidelines . 5. Handling aids may include gait belts, transfer boards and other devices. 13. Staff members are expected to maintain compliance with safe/handling transfer practices . Based on observation, interview, and record review the facility failed to safely transfer a resident to bed who has a history of falls. This failure resulted in R98 being left unattended at the foot of the bed losing his balance, falling backwards, hitting his head, and sustaining a open laceration requiring nine staples. The facility failed to supervise a resident during a transfer and use a gait belt. This applies to 2 of 22 residents (R98, R3) reviewed for safety in the sample of 22. The findings include: 1. R98's Physician Order Sheets dated through July 2022 shows he is a [AGE] year old male admitted on [DATE] with diagnoses including vertigo, abnormalities of gait/mobility, muscle weakness, history of falls and laceration of the scalp. R98's Fall Risk assessment dated [DATE] shows he is a HIGH risk for falls. R98's Minimum Data Set assessment dated [DATE] shows he is cognitively intact, requires extensive two person assist with transfers, bed mobility toileting, and requires extensive assist with walking. On 7/11/22 at 10:27 AM, R98 was sitting in his wheelchair. Purple bruises were observed to both hands and R98 had a laceration to the back of his head. R98 said he had a fall in his room. On 7/13/22 at 9:41 AM, V4 (CNA) said on 6/16/22 she toileted R98 and was assisted him back to bed. V4 said she left R98 unattended at the foot of the bed and she went to the head of the bed telling R98 to come closer to her, but R98 is very hard of hearing and he could not hear me. V4 said R98 took one step and he fell backwards hitting his head on the metal door hinge. V4 said she was too far away to grab R98 and she was not holding on to his gait belt. V4 states, it was horrible. On 7/11/22 at 12:21 PM, V3 (RN) said R98 was admitted to the facility last month with a history of falls from home and very hard of hearing. V3 said she was R98's nurse when he fell on 6/16/22. V3 said V4 (CNA) assisted R98 after toileting and she left him unattended and he lost his balance and fell hitting his head on the wall. V3 said R98 was bleeding from his head, he sent out to the local hospital and required staples to his head. V3 said R98 had a previous fall the same day and V4 should have held onto his gait belt and not left him unattended. On 7/12/22 at 12:48 PM, V5 (CNA) said R98 is a two person assist and he is not steady when walking. The nurse's note dated 6/16/22 documents (R98) was in the room with V4 (CNA) assisting him after using the bathroom. R98 was walking towards his bed, but lost his balance and fell backwards and hitting his head and acquiring a laceration. R98 was sent out to the local hospital R98 returned to the facility with nine staples to his head. The facility's Accident and Supervision Policy reviewed 6/2021 states, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazards and risks 2. Evaluating . 3. Implementing interventions . 4. Monitoring for effectiveness and modifying interventions when necessary .