**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect two cognitively impaired residents (R1, R8) who were at risk for abuse; and failed to prevent resident to resident physical abuse by two cognitively impaired residents (R2, R9). This failure affected 4 of 4 residents (R1, R2, R8 & R9) reviewed for abuse in a sample of 9. The failure resulted in R2 placing both of his hands around R1's neck and forcefully squeezing into R1's neck; and resulted in R8 being physically punched in the face with a closed fist by R9. Findings include: The final abuse investigation report provided by V1 (Administrator) documented an incident date of 04/27/2025 and indicated, resident was noted to have his peer put his hands around his neck. Report documented that R1 placed his hands around the neck of R2, however, during staff interviews, it was determined that R2 was the aggressor and R1 was the victim. 1. R1's electronic record documented last admission date of 07/20/2022 with a past medical history not limited to Alzheimer's disease, dementia, and major depressive disorder. Brief interview for Mental Status (BIMS) assessment dated [DATE] indicated severe cognitive impairment. R1's care plan report provided by facility on 05/14/2025 reads in part: impaired cognitive function/dementia or impaired thought processes related to Alzheimer's, dementia, impaired decision making, psychotropic drug use and is at a medium risk for abuse/neglect as noted from abuse screening related to diagnosis of Alzheimer's, dementia, and major depressive disorder. Report also indicated that R1 has a terminal condition and is receiving hospice services that was initiated on 11/25/2024. R1's hospice note dated 04/27/2025 at 03:11 PM documented that resident is alert with usual confusion, and has been fine since incident this morning. R1's abuse/neglect screen dated 04/28/2025 indicated that R1 is at moderate risk for abuse and/or neglect. R1's psychosocial assessments dated 04/28, 04/29, and 04/30/2025 documented R1 was unable to recall any details related to a resident to resident physical altercation. On 05/13/2025 at 09:45 AM and 05/14/2025 at 08:44 AM, R1 was observed resting in a wheelchair on the memory care unit in front of the nurse's station. R1 was alert to self and was not interviewable. R2's electronic record documented admission date of 01/16/2025 with a past medical history not limited to vascular dementia, mood [affective] disorder, anxiety disorder and convulsions. Brief interview for Mental Status (BIMS) assessment dated [DATE] indicated severe cognitive impairment. Behavior note dated 03/26/2025 at 02:11 PM documented R2 was punching nurse during medication administration. Behavior note dated 03/27/2025 at 11:43 PM documented R2 would be aggressive to staff when trying to help resident sit down. Behavior note dated 04/06/2025 at 10:38 PM documented R2 can be resistive to care and can be combative at times. Behavior note dated 04/09/2025 at 02:43 PM documented R2 is aggressive with staff and was hitting, scratching, cussing. R1 was uncooperative and shoving with hospice staff at facility to shower resident. Behavior note dated 04/13/2025 at 06:02 PM documented R2 was pacing prior to supper then suddenly became agitated and refused nursing care. Behavior/Mood Charting dated 04/27/2025 at 12:03 PM documented R2 had agitation and was exit seeking. Physical aggression incident happened at 9:45 am with another male peer. no injuries noted. Intervention included as needed lorazepam administered at 11:30 AM. Hospice aware of both hospice residents involved and indicated could administer R2 a second lorazepam in 2hours if needed. Behavior note dated 04/28/2025 at 04:51 PM documented R2 struck nurse's hand when trying to administer medications to resident. R2's psychosocial assessments dated 04/28/2025 documented R2 was unable to recall any details related to a resident to resident physical altercation. R2's aggressive behavior assessment dated [DATE] documented resident does not have a history or recent episode of aggressive/agitated behavior and/or non-compliance with medications, treatments, regimen or resisting care with no known triggers. Behavior note dated 04/30/2025 at 12:46 AM documented R2 will usually follow directions but can become aggressive to staff and other residents. R2's psychiatry note dated 04/30/2025 indicated resident was seen per staff request because R2 had an altercation with another resident. Appearance/Behaviors displayed were exit seeking and pleasantly confused. Plan of action indicated R2's diagnosis of dementia is worsening and unstable at visit with new orders to start haloperidol (antipsychotic) 5 milligrams (mg) intramuscularly every eight hours as needed for dementia and agitation, increase divalproex (mood stabilizer) 500mg to three times daily. R2's medication list includes sertraline 100mg daily for anxiety symptoms, trazadone 75mg nightly for sleep disturbance and lorazepam 0.5mg nightly for anxiety symptoms. Most recent gradual dose reduction on 04/30/2025 for sertraline, trazodone and lorazepam was contraindicated due to increased risk for worsening of anxiety and/or insomnia. (Review of active orders showed medication orders as indicated). Behavior note dated 05/07/2025 at 02:51 PM documented R2 was administered as needed lorazepam due to being restless, resistive with cares, punching staff, saying negative statements to staff, and wandering. Medication Administration Note dated 05/08/2025 at 04:29 PM documented R2 was administered haloperidol 5 mg due to agitation, cursing, walking fast up and down the hallway reaching out at staff. Behavior note dated 05/10/2025 at 02:06 PM documented that R2 was combative with staff while trying to record his vitals and was administered an as needed lorazepam for agitation. R2's care plan report reviewed at facility on 05/13/2025 documented that resident has impaired cognitive function, is/has the potential to be physically aggressive, the potential to be verbally aggressive at times, and is resistive to personal care at times related to dementia and is receiving anti-psychotic medications related to behavior management that was initiated on 05/13/2025 which is after the date of incident with R1. Care plan's focus for trauma informed care indicated that resident had a traumatic event, and circumstances occur and R2 is triggered by loud noises. On 05/13/2025 at 09:46 AM V4 (Licensed Practical Nurse) said R2 was anxious and resistive with cares this morning. At 09:59 AM, V4 indicated that R2 is aggressive at times with staff but not to his peers. On 05/13/2025 at 10:02 AM, V5 (Alzheimer Coordinator/Aide) said R2 was the aggressor in the incident between R1 and R2 on 04/27/2025. On 05/13/2025 at 10:06 AM, observed R2 was lying in bed and was not interviewable at this time. At 10:06 AM, V5 said R2 is very confused and can be combative at times. On 05/13/2025 at 12:00 PM, V1 (Administrator) said in the incident between R1 and R2, R2 was the aggressor and R1 was the victim. V1 then said both residents were sitting down at different tables on the memory unit not close to each other when something triggered R2 and he put his hands around R1's neck. V7 (Certified Nursing Assistant) ran over to the residents and had to wedge her hands under R2's hands and R1's neck to separate them. V1 added that R1 had no signs of injuries, R1 was monitored frequently, R2 was placed on 1:1 monitoring for the remainder of the shift (12 hours) and both residents were seen by a psych physician. On 05/13/2025 at 12:52 PM, V6 (Licensed Practical Nurse) said on 04/27/2025 at approximately 9:45 AM she was seated in the dining area on the memory (E) unit administering medications to another resident when V7 (Certified Nursing Assistant) rushed across the room. V6 couldn't see what was going on but V7 informed her that R2 had both his hands, one in front, and one to the back of R1's neck. V7 was trying to separate R2's hands from his neck. V6 said after R1 and R2 were separated, she assessed R1, but didn't see any markings on his neck. R1 complained that his neck hurt. V6 then said she administered an as needed lorazepam to R2 because he was pacing and wandering. R2 was placed on 1:1 monitoring, and staff performed frequent safety checks on R1. V6 said that R2 can be combative with staff, has behaviors, and is resistive with cares at times. She added a few days prior, R2 was hitting an aide that was trying to get his vital signs. On 05/13/2025 at 1:52 PM, V7 (Certified Nursing Assistant) said at 09:45 AM, she was clearing breakfast trays in the memory care unit. She added that R1 was seated at the table facing the nurse's station and R2 was wandering around the dining room then towards the nurse's station. V7 then said she heard R1 yell out, ouch stop it and when she looked over towards R1, V7 said she saw R2's right hand to the front of R1's throat and his left hand was to the back of R1's neck. V7 added that R2's fingers were digging into R1's neck and he looked mad. V7 then said she wedged her fingers in between R2's fingers which he was still squeezing around R1's neck and while also trying to push her away. V7 added that she yelled out for the other aide (V11) who was seated on other side of room feeding another resident to assist. V7 said she was able to pry R2's hands from R1's neck by the time V11 arrived and after they were separated, V7 and V11 both took R2 to his room and tried to calm him down. V7 said she made other reports on R2 to V1 (Administrator) about R2 grabbing her wrists and pulling her around the dining room who then followed her around after she got away from him. On 05/13/2025 at 2:05 PM, V7 said not too long after this incident, R1 was at the table with his walker next to him when R2 walked towards R1 and grabbed his walker then started walking away. V7 said when she attempted to get the walker from R2, he got agitated and shook the walker at her with a mean and irritated look to his face. V7 added that R2 tried to push her away with the walker but couldn't, so he let go of the walker then reached over and hit her in the stomach. V7 said the nurse gave him anxiety medication but he was still up walking around and was agitated so the nurse had to give him more medication. V7 also said that R2 has good days and bad days, and on his bad days, it is very bad. At times, R2 is resistive and combative and can't be redirected. On 05/14/2025 at 12:38 PM, V11 (Certified Nursing Assistant) said R2 is moody and will swing punches at staff for no reason, curse at us, etc. V11 then said on day of incident, she saw R2's hands around R1's neck and he was squeezing his hands. She added that V7 was trying to pry his fingers away from R1's neck and after they were separated, R1 had red marks to his neck that looked like finger marks. V7 added that the nurse (V6) said she didn't see any redness but she and V7 both saw them on R1's neck. She also said on the morning of this incident, R2 had grabbed her arm in which she had to pry his hands off and finally got away form R2, but he then started walking after V11. She added that R2 had punched V7 on the same day of incident. 2. Review of R8's abuse investigation report documented on 05/01/2025 (per V1 date is 5/11) at 05:40 PM, staff reported that a physical altercation occurred between R8 and a male resident. This report documented R8's diagnosis and mental status includes dementia, Brief Interview of Mental Status (BIMS) score of 01/15 which indicates severe cognitive impairment. R8's electronic record documented admission date of 10/10/2022 with a past medical history not limited to dementia, mood [affective] disorder, anxiety disorder and depression. Brief interview for Mental Status (BIMS) assessment dated [DATE] indicated severe cognitive impairment. R8's incident note dated 05/11/2025 at 07:24 PM documented another resident (R9) was walking very fast toward R8 and was witnessed by staff striking R8 on the right side of her face. R8 then complained of pain. R9 called R8 Mary and when he was informed by staff that R8 was not Mary, R9 said he was sorry. R8's abuse/neglect screen dated 05/12/2025 indicated resident is at moderate risk. On 05/13/2025 at 10:00 AM, R8 was seated at a table in dining area on memory care unit. R8 was alert to self and was not interviewable. R8's care plan report reviewed at facility on 05/13/2025 documented that resident has impaired cognitive function/dementia or impaired thought processes related to dementia; is at a medium risk for abuse/neglect as noted from abuse screening related to dementia and mental health diagnosis. On 05/13/2025 at 11:52 AM, V1 (Administrator) said R8's incident occurred approximately at 5:40 PM, a male dementia resident (R9) hit R8 in the face. V1 added that R9 thought R8 was his daughter named Mary and after staff intervened and explained she was not, R9 apologized. V1 said that R8's face was red with no indication to send out emergently. R9 was added on the list to be seen by psych. On 05/13/2025 at 12:50 PM, V6 (Licensed Practical Nurse) said around 5:40 PM on 5/11/2025, she was finishing her med pass in the dining area on memory unit. She added that the aides were either still feeding residents or cleaning up from dinner; V10 (CNA) was in dining room and V9 (CNA) was down the hall. V6 then said R8 was sitting at the table being quiet when she noticed R9 get up fast and started walking fast to R8's table so she followed him. V6 said that R9 went right up to R8, called her Mary, then hit her in the face with a closed fist. R8's right cheek looked red. On 05/13/2025 at 02:54 PM, V10 (Certified Nursing Assistant) said R9 had walked past him in the memory care dining room then he heard R8 scream out; prior to she was sitting quietly eating her dinner. V10 said when he turned, he heard R8 verbally reacting to what R9 did but V10 did not see any physical contact. He added that V6 (LPN) was by them and had it under control. V10 added that he did not see any injuries, but V6 said R8 had a mark on her face. R8's psychosocial assessments dated 05/14/2025 documented resident to resident physical altercation, resident hit R8 in the face. R8 is unable to recall incident. R9's electronic record documented admission date of 04/25/2025 with a past medical history not limited to dementia and history of falling. Brief interview for Mental Status (BIMS) assessment dated [DATE] indicated moderate cognitive impairment. R9's aggressive behavior assessment dated [DATE] documented resident has a history or recent episode of aggressive/agitated behavior and/or non-compliance with medications, treatments, regimen or resisting care including non-compliance with medications, resisting cares, and may be agitated at times. Incident Note dated 05/11/2025 at 06:33 PM documented that R9 was walking very fast toward R8 and was witnessed by staff striking R8 on the right side of her face. R8 then complained of pain. R9 called R8 Mary and when he was informed by staff that R8 was not Mary, R9 said he was sorry. Incident Follow Up note dated 05/12/2025 at 10:58 AM indicated R9 had a witnessed altercation with another resident, root cause determined to be dementia. New intervention is to have a medication review done by psych. R9's care plan report reviewed at facility on 05/13/2025 documented that resident has a behavior problem; is resistive to cares related to dementia; resident is/has potential to be physically aggressive related to dementia (05/12/2025); has impaired cognitive function. On 05/13/2025 at 10:15 AM, observed R9 seated at table in dining area on memory care unit. R9 was alert to self and not interviewable. On 05/14/2025 at 02:00 PM, V1 (Administrator) said the abuse incidents between R1, R2, R8, and R9 can be substantiated but could not be prevented due to the population and their unpredictable behaviors. Abuse policy effective 09/2024 reads in part: this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents.

Based on observation, interview, and record review the facility failed to prevent staff physical abuse for one resident (R1) of three residents reviewed for abuse in the sample of four. Findings include: The facility's Abuse Prevention and Reporting policy and procedure, dated 9/2024, documents This facility affirms the right of our residents to be from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. This same policy documents Resident-to-Resident Abuse (of any type): A resident-to-resident altercation should be reviewed as a potential situation of abuse. Resident-to-resident altercations that include any willful action that results in physical injury, mental anguish, or pain must be reported in accordance with regulations. R1's medical record documents R1 with the following diagnoses: Dementia, Schizoaffective Disorder, Major Depressive Disorder, Anxiety disorder, and Generalized Idiopathic Epilepsy and Epileptic Syndromes. The Abuse/Neglect Screening for R1, dated 11/10/24, documents R1's risk measure for likelihood for a history of previous/recent mistreatment and/or potential future problems/symptoms related to mistreatment at a 6; Indicating high risk due to score greater than five. On 11/14/24 at 11:00 am, interview attempted with R1. R1 closed his eyes and when he opened his eyes, noted R1's eyes would roll up and only white sclera visible, then would lower eyes. R1 became tearful and began mumbling distorted words and not making sense. The initial Abuse Investigation for R1, dated 11/10/24 documents an allegation of physical abuse to R1 by V8 Agency CNA/Certified Nursing Assistant was reported to V1 Administrator on 11/10/24 at approximately 4:18 am by V7 Agency LPN/Licensed Practical Nurse. V7 Agency LPN reported that (V8 Agency CNA) was assisting (R1) when (R1) became combative during the transition, (V8 Agency CNA's) hand made contact with (R1's) head during assistance. (V8 Agency CNA) suspended immediately. Investigation initiated. Police notified and Responsible Parties notified. 5 day to follow. The Progress Note for R1, dated 11/10/24 at 4:03 am, documented by V7 Agency LPN documents (R1) found on floor by CNA, Nurse responded and attempted to perform assessment and vitals but unable to do so due to resident being combative. Nurse received help from CNA to get the resident off the floor, when attempting to do so (R1) became combative with a male CNA in return the CNA struck (R1) on the left side of face. CNA was instructed to leave the residents room and 911 was initiated. Sheriff department and EMS (emergency medical service) responded. Nurse gave sheriff department details of incident. (R1) sent out to (local hospital) via EMS for further evaluation. Administrator and POA (Power of Attorney) notified via telephone. The Alleged Victim Interview form for R1, dated 11/11/24, documents I was asleep, and they came into my room. they woke me up and tried to take my pants off. I wouldn't let them. They called the police. I was in a dead sleep. I thought I was having a dream. R1 stated the incident occurred about 3:30 at night in his room. R1 stated he can't remember the staff names that told him Take all your clothes off - Take his socks. R1 reported he did not suffer injuries. The Alleged Perpetrator Interview form for V8 Agency CNA, dated 11/11/24, documents The nurse asked for help in (R1's) room. I went in (R1's) room with the nurse and two other staff members. (R1) was out of his bed and on the floor. (R1) was kicking and cursing and throwing his slippers at us. We placed the wheelchair close to him, we proceeded to lift him up off the floor and put him in his wheelchair. As soon as (R1) was placed in his wheelchair he punched me closed fisted on the right side of my face. I had a reflex and I hit (R1) open handed on the top of his head. After I hit him, I apologized. (R1) hit me closed fisted two more times on my shoulder area. (R1) went out to into the hallways cursing and yelling. On 11/15/24 V17 SSA/Social Service Assistant stated she did all the staff and resident interviews for R1's physical abuse allegation. V17 SSA stated she called all the staff who worked during the time of the allegation and wrote word-for-word everything they said. V17 SSA stated she did talk to V8 Agency CNA who did say he hit R1 and that it was reflex only and hit him open handed on the head. On 11/15/24 at 10:45 am, V1 Administrator stated she was notified on 11/10/24 at approximately 4:15 am by V7 Agency LPN that there was an altercation between R1 and V8 Agency CNA. V7 Agency LPN sent V8 Agency CNA home, called the local police, and R1 was sent out to the local hospital for evaluation. V1 Administrator stated she called V8 Agency CNA and told him he was not allowed back into the facility pending investigation and notified the staffing agency of the allegation. V1 Administrator confirmed V8 Agency CNA admitted to hitting R1 and has been added to the facility's DNR (do not return) listing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement pressure relieving interventions once a resident was assessed as being at high risk of developing pressure ulcers, failed to assess a pressure ulcer's stage and size once identified, failed to perform daily skin checks as ordered by the physician, failed to perform physician ordered wound treatment, and failed to perform pressure ulcer risk assessments every week for four weeks after admission and quarterly thereafter, as instructed by the facility's policy, for one of three residents (R1) reviewed for pressure ulcers in the sample of five. These failures resulted in R1 developing a facility acquired stage three pressure ulcer to the right medial ankle. Findings include: The Pressure Sore Prevention Guidelines policy dated 3/16/23, documents Policy: It is the facility's policy to provide adequate interventions for the prevention of pressure ulcers for residents who are identified as HIGH or MODERATE risk for skin breakdown as determined by the Braden Scale. Responsibility: all nursing staff and the dietary manager. Interventions/Comments for High-Risk residents. Special Mattress/Specify type of mattress on the Care Plan. Daily Skin Checks/follow protocol for coding skin conditions. Interventions/Comments for High or Moderate Risk residents: Turn and reposition every two hours. Turning and positioning may be more often than every two hours for high risk, if indicated. Care Plan Entry/Skin risk and appropriate interventions are to be placed on the Care Plan. If despite interventions a pressure ulcer develops, the care plan must reflect updated interventions for healing of ulcers and additional interventions for further prevention of Pressure Ulcers. Interventions/Comments as needed for High or Moderate Risk residents. Positioning Devices/Devices while in chair or in bed as needed to maintain turning. Specify on Care Plan. Any resident scoring a High or Moderate risk for skin breakdown will have scheduled skin checks on the Treatment Record. Skin checks will be completed and documented by the nurse. The facility's Preventative Skin Care policy dated 01/2018 documents, Policy: It is the facility's policy to provide preventative skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, well-groomed, and free from pressure ulcers. Procedures: All residents will be assessed using the Braden Pressure Ulcer Scale at the time of admission and weekly times four then will be re-assessed at least quarterly and/or as needed. Any resident identified as being at high risk for potential skin breakdown shall be turned and repositioned at a minimum of every two hours. Pillows and/or bath blankets may be used between two skin surfaces to slightly elevate bony prominences/pressure areas off the mattress. Pressure relieving devices may be used to protect heels and elbows. Ensure proper fit of wheelchairs, splints, braces, prosthesis, and shoes. R1's admission Record documents R1 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Paraplegia, Arnold Chiari Syndrome with Spina Bifida, Abnormal Posture, and Wheelchair Dependence. R1's admission Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE] documents R1's risk score 16 indicating R1 was at a high risk of development of pressure ulcers. This same Braden Scale Risk Assessment documents R1 did not have any pressure ulcers or wounds upon admission to the facility. R1's Medical Record dated 6-22-23 through 6-15-24 does not include any further Braden Scale Pressure Ulcer Risk Assessments. R1's Baseline admission Care Plan dated 6-22-23 documents R1 was dependent upon two staff for bed mobility, toileting, and transfers. This same Baseline admission Care Plan does not include any identified pressure ulcer risks or pressure relieving interventions. R1's MDS (Minimum Data Set) Assessments dated 7-3-23 (admission), 12-28-23 (quarterly), and 3-25-24 (quarterly) document R1 is cognitively intact, requires assistance of staff for turning left to right in bed, is at risk for development of pressure ulcers, and does not have any pressure ulcers. R1's MDS dated [DATE] documents R1 is not on a turning and repositioning program. R1's Physician's Order dated 9-10-23 documents, Hydrofera Blue (antibacterial foam dressing) ready foam external pad apply to lower right ankle every Sunday. R1's Medical Record does not include documentation of an assessment of R1's pressure ulcer to the right ankle once identified on 9-10-23. R1's Progress Note dated 9-27-23 documents, (R1's Family Member/V7) called and wanted to make sure staff knew that (R1) needed to be repositioned around 12:30 in the morning and every two hours. She stated she spoke to (R1), and he stated he hadn't been repositioned since earlier in shift. R1's Wound Care Visit Summary Initial Encounter dated 1-16-24 documents, Wound of right ankle initial encounter. Cleanse with soap and water. Apply lotion to peri-wound. Apply hydro (water-filled) dressing blue ready transfer to wound bed. Wear tubigrip (elastic bandage). Change dressings every other day and as needed if dressings get wet or soiled. Skin checks must be done every shift to ensure no bunching of (elastic bandages). R1's Wound Care Visit Summary dated 6-6-24 documents, Today's Visit: Pressure injury of right ankle, stage three. Wound Care Dressing: Right Medial Ankle. 1. Wash wound with soap and water. 2. Apply Prisma (collagen dressing formulated with oxidized regenerated cellulose and silver) to open part of the ulcer. 3. Cover with bordered foam. 4. Compression stockings during the day and take off at night. 5. Change dressing three times weekly and as needed if dressings get wet or soiled. R1's Physician's Order dated 6-12-24 and signed by V4 (R1's Primary Physician) documents, Cleanse right medial ankle with soap and water, apply (collagen dressing formulated with oxidized regenerated cellulose and silver) to wound bed, cover with border foam every day shift (on) Mondays, Wednesdays, and Fridays for wound care. R1's Treatment Administration Records (TARs) dated 1-16-24 through 6-15-24 do not include documentation of evidence of skin checks being performed every shift as ordered on the Wound Care Visit Summary dated 1-16-24. These same TARs document R1 only received skin checks weekly during this timeframe. On 6-15-24 at 9:15 AM R1 was sitting in wheelchair in the dining room. R1 had only a sock covering his left foot and the left foot was placed on the left wheelchair foot pedal. R1 had a cotton cushioned boot to the right foot. R1 stated, The sore on my ankle (right ankle) was caused from rubbing on either my wheelchair or my bed. I am not sure because I have no feeling in my feet. On 6-15-24 at 10:40 AM R1 was lying in bed and V7 (R1's Family Member) was visiting (R1) at the bedside. V9 (LPN/Licensed Practical Nurse) removed a wound dressing to R1's right medial ankle. R1's right medial ankle wound was approximately 2 cm (centimeters) long by 1 cm wide by 0.2 cm deep, pink in color, with a small amount of clear drainage. V9 cleansed the right medial ankle wound with wound cleanser, applied collagen dressing to the wound and covered with a four-by-four bordered gauze. V9 stated, (R1) was supposed to get a (collagen dressing formulated with oxidized regenerated cellulose and silver) treatment to the right medial wound. The wound clinic ordered (collagen dressing formulated with oxidized regenerated cellulose and silver) on Wednesday (6-12-24) and I ordered it from pharmacy. I have not worked the last two days, so I do not know if anyone has followed up on trying to get the (collagen dressing formulated with oxidized regenerated cellulose and silver) in. I just used the collagen dressing for now. On 6-15-24 at 10:50 AM V7 (R1's Family Member) stated, (R1) got the wound to his right ankle because when (R1) got here the staff were not putting on boots (pressure relieving boots) to (R1's) feet and (R1's) feet were not lifted off the bed. (R1) cannot feel his feet and cannot lift them off the bed. Somebody should have let me know or the wound clinic know that (R1) needed Prisma so we could have gotten it for him. I would have gone to the wound clinic myself and picked up the (collagen dressing formulated with oxidized regenerated cellulose and silver) had I known the facility did not have it. On 6-15-24 at 11:50 AM V9 stated the nurses have only been doing R1's skin checks weekly. On 6-15-24 at 11:30 AM V1 (Administrator-In-Training) stated, We (the facility) do not have a Care Plan Coordinator or MDS Coordinator currently. (R1's) medical record does not include any Braden Scale Pressure Ulcer Risk assessments since (R1's) admission to the facility. V1 also verified R1 did not have a care plan developed with pressure relieving interventions once R1 was assessed as being at high risk for pressure ulcer development upon admission to the facility. On 6-15-24 at 3:20 PM V2 (Director of Nursing) I was not aware of (R1) having an order from the wound clinic to check (R1's) skin every shift. The only documentation I can find is that (R1's) pressure ulcer to the right ankle started on 9-16-23. I cannot find an assessment in (R1's) medical record that indicates what the pressure ulcer looked like, the stage, or what it measured when it was found. That is the first date that I see a physician's order for a treatment to the wound on (R1's) right ankle. (R1's) skin checks have only been done weekly. I did not know there was an order from the wound clinic to do the wound checks daily on every shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident's bed was kept in the lowest position, failed to keep resident personal items and call light within reach, failed to ensure a resident was secure while being transported in the facility van, failed to investigate a fall, failed to implement and revise fall interventions, and failed to update the fall care plan after a fall for one of three residents (R1) reviewed for falls with injuries in the sample of five. These failures resulted in R1 falling out of bed while reaching for his cell phone while his bed was in a high position, sustaining a left femur fracture, and R1 falling forward out of his wheelchair while being transported in the facility van causing R1 to experience neck and shoulder pain, fear, and emergency department treatment for pain. Findings include: The facility's Fall Prevention dated 11/10/2018 documents, Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Responsibility: All staff. All falls will be discussed in the morning quality assurance meeting and any new interventions will be written on the care plan. 5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. 6.The unit nurse will place documentation of the circumstances of a fall in the nurse's notes or in a A.I.M. (Acute Illness Management) for Wellness form along with any new fall interventions deemed to be appropriate at the time. 1. On 6/15/24 at 9:15 AM R1 was sitting in wheelchair in the dining room. R1 stated, When I rolled out of bed (on 7/19/23) I was reaching for my cell phone and could not reach it. My remote to my bed was hanging down and I could not reach it. The staff did not leave it on my table beside me. I fell to the floor and broke my leg. The staff had left my bed high, so I fell from really far up. I needed help forever. I called my mom to come and help me. (V7/R1's Family Member) showed up to help me before the staff even came in to help. On 6/15/24 at 10:20 AM R1 was lying in bed flat, with the bed in the highest position. (V7) was at (R1's) bedside. No staff were supervising R1 in the room during this time. V7 stated, The staff always leave (R1's) bed in the highest position when I visit. I do not know how many times I have told staff that (R1's) bed needs to be low. When (R1) rolled out of bed and fractured his femur (on 7/19/23) he called me while he was on the floor and asked me for help because no staff was responding to him. I got to the facility and found (R1) laying on the ground beside his bed. (R1) had bruising to his hip and his bed was in the high position when (R1) rolled out. (R1) said he was reaching for his cell phone because the staff did not leave his phone within his reach. (R1's) knee was swelling more every day after the fall on 7/19/23 so I insisted the facility get (R1) an x-ray and that is when they found (R1) had a fractured his femur. (R1) would not have fractured his femur if his bed was low and his cell phone was within reach. R1's admission Record documents R1 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Paraplegia, Arnold Chiari Syndrome with Spina Bifida, Abnormal Posture, and Wheelchair Dependence. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is cognitively intact. R1's A.I.M. for Wellness dated 7/19/23 and signed by V16 (RN/Registered Nurse) documents R1 had a change of plane (fall) while trying to reach for his cell phone and slight discoloration was noted to the right hip. R1's Investigation Report for Falls dated 7/19/23 and signed by V16 documents R1 stated he was tired of waiting and wanted out of bed, was incontinent when found on the floor, and R1's call light was not within reach. R1's Progress Notes dated 7/27/23 document R1 was at another medical facility receiving care and R1's left knee was swollen, so an x-ray was obtained. R1's X-Ray Left Knee Report dated 7/27/23 documents, Impression: Distal Lateral Femur concerns for acute mildly displaced fracture. R1's Hospital After Visit Summary dated 7/28/23 documents, Reason for visit: Knee injury. Diagnosis; Aftercare for healing traumatic fracture of left femur. Instructions: Leave knee brace intact until evaluated by orthopedics (8/1/23). R1's Orthopedic Progress Notes dated 8/1/23 and signed by V18 (Orthopedic Surgeon) document, (R1) fell while trying to lean over for cell phone and injured his femur. He has a lateral femoral condyle fracture. Non-operative care and follow-up in six weeks. 2. The facility's Van Usage Policy and Procedure (undated) documents, The purpose of this policy is to establish procedures by which employees formally acknowledge and accept responsibilities of operating a facility owned van on behalf of (the facility). Further, it establishes requirements for enforcement of operating procedures and safe driving practices. When employees operate a facility owned van, they have inherent responsibilities to care for the vehicle and the residents, obey all state and local traffic laws, and abide by established driver operating procedures. Employees must practice safe driving procedures and obey the rules of the road when operating a facility owned van. b. Secure seat belts anytime the vehicle is in motion and require all passengers to wear seatbelts. c. Ensure all residents and wheelchairs are safely secured. On 6/15/24 at 9:15 AM R1 was sitting in wheelchair in the dining room. R1 stated, (V10/Maintenance Assistant) was bringing me home from the wound clinic (on 4/25/24) in the facility van and slammed on the brakes. I fell forward out of my wheelchair and hit my head on the seat in front of me. My shoulders and neck were hurting from hitting them on the seat. I thought I was paralyzed. I was so scared since I am already paraplegic. (V10) did not seat belt me in right. It hurt my neck and shoulders and I was taken to the hospital to make sure I was okay. R1's Medical Record does not include documentation of R1 having a fall while in the van on 4/25/24 and does not include an investigation into the root cause of R1's fall or the implementation of new fall interventions to prevent further falls. R1's current Care Plan does not address R1's fall on 4/25/24. On 6-15-24 at 9:45AM V10 (Maintenance Assistant) stated, On (4/25/24) I had to take (R1) to the wound clinic and had never driven the van before. While on the interstate the stop light switched quickly to red, and I had to hit the brakes quick. I did not check to make sure the d-ring was clamped onto the back of (R1's) seat belt. The d-ring keeps (R1's) seat belt secured. R1 fell face first and hit his head on the back of the seat. (R1) said he could not move his arms or chest or anything. After we went a little farther (R1) could feel his hands again. I took R1 into the emergency room there (in the same town) and asked the nurses to get (R1) off the floor and assess him. (R1) did not have any injuries. (V7) asked me to take (R1) to her house for the night. This was the first time I transported a resident in the facility van. I was not trained prior to transporting (R1) in the van on how to properly buckle residents in wheelchairs in the van or use the d-rings or seat belts in the van. On 6/15/24 at 1:10 PM V1 (Administrator-In-Training) stated, I cannot find evidence of an investigation being completed after (R1's) fall on 4/25/24. I had (V10) pick (R1) up from the wound clinic on 4/25/24. I did not realize (R1) was not trained on securing the residents in the van.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to investigate unwitnessed falls and adequately supervise a resident (R65) with a known history of wandering to prevent them from entering another resident's room (R60) startling her and causing a fall for two of two residents (R60, R65) reviewed for falls in the sample of 34. This failure resulted in R60 obtaining a hemorrhagic pelvic fracture. Findings include: The facilities ELOPEMENT PREVENTION POLICY, dated 10/06, documents 5. The Interdisciplinary Team will initiate a plan of care for any resident determined high risk for elopement. Facility specific measures as well as resident specific measures will be included in each high-risk resident's plan of care to minimize risk factors. R65's Care plan, dated 4/24/23, documents, (R65) has behaviors that others may find disruptive/socially inappropriate. This same care plan also documents Behaviors noted of verbal aggression, seeking female peers' attention, refuses medication, is easily agitated during redirection, is socially inappropriate. (R65) has a diagnosis of late onset Alzheimer's, dementia with behavioral disturbance, bipolar d/o (disorder), and anxiety. (R65) ambulates without device with supervision, directional, and verbal cues. (R65) does wander. R65's Psychosocial History, dated 4/14/23, documents that R65 is an elopement risk. R65's Elopement Evaluation, dated 4/14/23 and 4/25/23, documents that R65 has an inability to identify safety needs, has altered perception of awareness leading to seeking exit/escape, his level of agitation has required supervision, and he wanders in the vicinity of exit doors. R60's PT (Physical Therapy) Daily Treatment Note, dated 5/4/23, documents (R60) ambulated within the facility on even and uneven surfaces such as carpet with FWW (front wheeled walker) at a supervision level. Completed all transfers with SBA (stand by assistance) using FWW. The PT Daily Treatment Note, dated 5/8/23, documents (R60) has continued to progress towards all established goals. (R60) has demonstrated improved endurance and ability to complete all daily tasks with less assist. R60's A.I.M. (Assesses, Intercommunicate, Manage) for WELLNESS, dated 5/20/23, documents, R60 was Noted on floor lying on her right side. Pain pill given c/o (complaints of) pain everywhere. Unable to ambulate. Neuro (neurological) checks WNL (within normal limits). Had 1 emesis during lunch. Sending her to ER (Emergency room) to eval (evaluate) and Tx (treat). She was startled by another resident (R65) in her bathtub in her bathroom. R60's Nurses Notes, dated 5/20/23 at 7:30 PM, documents Received update from (local hospital), patient has a fracture of pelvis in multiple places, it is hemorrhaging. Transferring to (a critical care hospital) ICU (Intensive Care Unit). R60's Discharge summary, dated [DATE], documents (R60) was initially evaluated in the trauma bay by the trauma team after a ground level fall at SNF (Skilled Nurse Facility). She was found to have: pubic rami fracture, bilateral sacral insufficiency fractures. Fracture dislocation of left glenohumeral joint. Ortho (Orthopedics) took her the OR (Operating Room). Was discharged back to SNF in stable condition on 5/25. On 9/26/23 at 10:00 AM, R60 stated After breakfast (on 5/20/23), I went back to my room and took a 2-hour nap. I heard some knocking, but I thought it was construction or somebody fixing something. I got up to use the bathroom and when I opened the door, a guy was laying in my bathtub. It startled me and I turned to head out the door and that's when I went down. I landed on my right side. I was taken to the hospital within 30 minutes. I know who he is. His name is (R65) and he has dementia. He's known around here for going into peoples' rooms. He must have been in the bathroom when I came back from breakfast. I was doing great with therapy. I was riding the bike for 20 minutes and walking fast. Then I had to start all over (with rehabilitation) after I fell. The facility's Final Report to the State Agency, dated 5/20/23, documents, Female resident noted on ground in room. Resident sent to ER for eval and treat. 5 day to follow. Resident was admitted to hospital due to fractured pelvis. Root cause determined the be loss of balance. Intervention resident educated to use walker during ambulation. Resident will return to facility with therapy services. Care plan and POA (Power of Attorney) updated. The report lacked documentation R65 was on elopement precautions; was a known wanderer and found in the bathroom which resulted in R60's fall. On 9/26/23 at 12:30 PM, V14 (Licensed Practical Nurse) stated (R65) was laying in the bathtub. It looked like he sat on the edge of the tub and fell back with a leg hanging over the side and his hands behind his head. He looked really comfortable. He didn't have any injuries. I did neuro checks and movement assessments He is very much so a wanderer. He required extreme supervision with activity's but does walk independently. If we have wanderers, we should be doing every 15-minute checks and try to keep them close to us. On 9/26/23 at 1:25 PM, V10 (LPN) stated Yes, I remember it (5/20 incident). That's not something you find every day. When I got into the room. (R60) was lying on the floor with her walker beside her. Other people were in there checking out R65. I was checking out (R60). I had to send her to the hospital because she was unable to ambulate. No one from higher up asked me any questions after the fact. On 9/28/23 at 10:00 AM, V11 (Certified Nursing Assistant) After breakfast, we were looking for (R65). I heard (R60) scream and found R65 in R60's bathtub. I think he fell backwards. He said he wanted to take a bath. We yelled up the hall for help. I was helping with (R65) and V12 (CNA) was assisting (R60). (R60) went that day to the hospital for complaints of hip pain. V11 denied being interviewed by the Director of Nursing (V2) or the Administrator (V1) regarding R60's fall. On 9/28/23 at 10:15 AM, V12 (CNA) stated I told V11 Let's go check on (R60). When we got there (R60's room), R65 was in the bathtub and R60 was on the floor. I don't know how long (R65) was in there. R60 told me she heard knocking but thought it was construction. (R60) complained of pain. After the nurse checked her out, we sat her up and put her in a chair. On 9/26/23 at 11:45 AM, V1 (Administrator) stated an investigation and interviews were not conducted related to (R60's) falls which were unwitnessed. V1 confirmed R60's root cause for the fall on 5/20/23 was not related to just the loss of balance but also from R65's wandering and an investigation was not conducted and should have been.