**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the Facility failed to ensure residents were supervised to prevent accidents for 1 of 3 residents (R2) reviewed for falls in the sample of 5. This failure resulted in R2 being left unsupervised in bed in the high position on a low airloss mattress causing R2 to fall from the bed sustaining multiple fractures to both legs.Findings include: R2's July 2025 Physician Order Sheet (POS) document a displaced comminuted fracture of shaft of left fibula subsequent encounter for closed fracture with routine healing (dated 7/28/2025); osteomyelitis of vertebra, sacral and sacrococcygeal region, type 2 diabetes mellitus without complications, unspecified fracture of lower end of left tibia, subsequent encounter for closed fracture with routine healing (start date 7/28/2025), unspecified fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing (start date 7/28/2025); displaced fracture of second metatarsal bone right foot, subsequent encounter for fracture with routine healing (start date7/28/2025); muscle wasting and atrophy; abnormalities of gait and mobility; other lack of coordination; Fournier gangrene; cutaneous abscess of back; local infection of the skin and subcutaneous tissue; unspecified fracture of right calcaneus sequela, renal osteodystrophy; end stage renal disease; and weakness. R2's Minimum Data Set (MDS) dated [DATE] document R2 was cognitively intact for decision making of activities of daily living. R2's MDS documents R2 has impairments on both sides, uses a wheelchair, and is dependent on staff for most Activities of daily living and has two stage 3 pressure ulcers. R2's MDS documents for him to roll from left to right he is dependent on staff; helper does all of the work. R2‘s Care Plan with a Target Date of 10/26/2025 does not address falls.R2's Follow Up Occurrence Note dated 7/11/2025 at 9:00 AM, Note Text: Incident Note: Resident on floor. Says he rolled out of bed. Denies hitting head. Neuro check WNL (within normal limits). VSS (vital signs stable). Says he has pain to rt (right) elbow and rt (right) and lt (left) ankles. No new skin issues. ROM (Range of motion) present to all extremities as per resident normal. Resident moved rt arm bending at elbow and both ankles rotated per resident. Nurse Practitioner here and saw resident post fall. Extra Norco ordered to be given for c/of (complaint of) of pain. Nurse Practitioner also said to send an extra Norco to Dialysis with resident per his usual request when going to Dialysis. Resident gotten up off floor with mechanical lift per staff. R2's Investigation does not address the root cause of his fall (lack of supervision).R2's Progress Notes dated 7/11/2025 at 4:32 PM, Note Text: Resident called facility driver to tell him he is in the ER (emergency room) and was sent from dialysis. Writer called ED (emergency department) who confirmed resident was there and was sent over for L (left) ankle pain. They confirmed that there was a L (left) tibia fracture and that they are awaiting ortho to consult to determine if they will admit or splint and send back tonight. PCP (primary care physician) and wife made aware.R2's Progress Notes dated 7/11/2025 at 6:49 PM, Note Text: Writer called for update- res (resident) will be admitted for fx (fracture). They don't know if he will need surgery yet or not.R2's Verification of Incident Report date of incident 7/11/2025 at 9:00 AM, Resident rolled out of bed at 9 AM. Resident sent to ER (emergency room) there. ER was called for a status updated and was made aware of fractures. Immediate Action: Nurse Practitioner in building and assessed. Extra dose of Norco provided for pain management. Bolsters added to resident mattress. POA (Power of Attorney), IDPH and Ombudsman notified. Summary of investigation: Resident had a fall after rolling out of bed. Resident was seen by the wound nurse and wound NP prior to rolling out of bed. Resident was ready to get up for the day, wound nurse notified CNA (Certified Nurse's Assistant) that resident was ready to get up. When aide entered room, resident was observed on the floor. CNA notified nurse who immediately assessed. No altered skin integrity noted. Does complaint of pain to right elbow and right ankle. Resident was able to move all extremities himself with no issues, rotated ankles and moved his arms and bending them at the elbows, resident denies hitting his head. Wife was present in the room at the time of the incident and states he did not hit his head. Resident was assisted up off the floor with (mechanical lift). Placed in bed, aid got him ready for dialysis then assisted to wheelchair via (mechanical lift). Primary care NP (Nurse Practitioner) was making rounds, who also assessed resident. NP ordered an extra dose of Norco to be given and ordered for one to be sent with resident to dialysis. Resident lays on a low loss mattress, and when he rolled over, the air in the mattress went to the opposite side, causing him to roll out of bed. Bolsters were placed on air mattress for boundary awareness and as a safety intervention. CP (Care Plan) updated. Transportation driver reported that the resident had no complaints on the ride to dialysis. Once at the dialysis, resident complained of pain to BLE (bilateral lower extremities), dialysis then sent resident to the ED (emergency department). Nurse called the ED for status update, and they confirmed resident did have a fracture of the left and right distal tibia as well as the 2nd metatarsal. Resident was admitted to the (hospital) for further evaluation.R2's Hospital Records dated 7/11/2025 R2 had a mechanical fall and suffered from an acute left distal tibial diaphysis fracture; Acute left distal fibular fracture; Acute fracture of the distal right tibial diaphysis and acute fracture of the neck of the 2nd metatarsal of the right foot and was admitted to the ortho bed and neurology was consulted for management. R2's Progress Notes dated 7/25/2025 at 7:04 PM, Note Text: Resident returned from Hospital. Resident asked to lay dawn. Resident was (mechanical lift) into bed with assist of 2. Resident became very agitated and yelled hey watch my legs! Don't move them! Resident is in the sling appropriately, staff guided him into bed. Was provided by reassurance in a calming voice by nurse in room and let resident know that he is safe and ok. Resident hollered no it's not ok!On 7/29/2025 at 4:00 PM, R2 stated, I use to be at another facility and at that facility I developed wounds on my back and buttocks. When I got here, two staff members, I am not sure of their names came into my room to change my dressings. They had me roll to the side and slide down so they can get to the wounds better. They pulled me towards the end of the bed and had me roll to my left side. After the nurse was done, she left the room. The other staff (not sure of her name) she was changing the linen because of the drainage from the wound, and I was still laying on my left side and the bed was high up in the air because they just finished doing the treatment. The girl changing the sheets said she needed a draw sheet because it was dirty from the wound draining on it. She said she would be right back. I was holding on to the bar and was on my left side waiting. The staff left the room, but I waited as long as I could, and I just could not hold on any longer and when I let go, I fell from the bed being up high in the air to the floor. I just couldn't hold on any longer. I think the staff forgot about me. They came back and put me on one of those (mechanical lifts) and put me back into the bed. I was in a lot of pain. My wife shared a room with me, and she saw the whole thing too. I was in the hospital for two weeks and had 2 breaks in the right leg and one break in the left leg. Both of my legs were broken. I get dialysis on Mondays, Wednesday and Friday. I feel like they should not have left me like that and should have sent me to the hospital right away. They gave me some pain medicine but when I got to dialysis it was so bad they sent me out to the hospital and that is when I found out I had broken both of my legs. On 7/29/2025 at 4:12 PM, R4, wife and roommate of R2, stated I was in the room at the time they were treating (R2), and he fell out of bed. The nurse left the room as soon as (R2's) treatment was done. They were changing (R2's dressing). When the nurse was done, she left the room. The other girl was changing the sheets. (R2) was on his side and was holding on to the bar. The girl left the room, and she said she would be right back but (R2) waited and waited and he could not hold on any longer and the bed was up really high, and he fell and broke both of his legs with one leg have two fractures. After he fell, they came in and used that machine to put him back into bed and then later the Nurse Practitioner came and looked at him and gave him pain medication.On 7/30/2025 at 10:42 AM, V8, Hospital Social Service Worker stated, (R2) was admitted to the hospital on [DATE] and he had an extended admission and was not discharged until 7/25/2025. So, he was here for a while. I was the consultant towards the end of this visit and (V9, Palliative Care Social Worker) was with him when he was first admitted . (R2) told me he had a pressure ulcer on his back and buttocks and was receiving care from the wound Nurse and they had his bed high in the air. (R2) stated he was rolled to his side, and he grabs onto the side rails. The lower rail was missing on the bed. The Nurse member left the room because she was done with the treatment. The agency staff told him she would be right back because she was changing the sheets and needed a drawsheet and left the room with him on his side, no lower bed rail and she did not reposition him. He said he waited and waited but she did not come back, and he could no longer hold on and he fell from the bed in the high position to the floor.On 7/30/2025 at 11:01 AM, V9, Hospital Palliative Social Worker stated, When I first saw (R2) at the hospital he told me they were doing a dressing change on him, and he had rolled to his side and was holding on to the side rail. The bed was in the high position because of the treatment. The bottom side rail was missing on the bed. He said the nurse had finished the wound treatment and the agency CNA was cleaning up the sheets and she did not put him back on his back, and she told him she would be right back and left the room because she wanted to get a drawsheet. His wife was in the room with him. The CNA did not come back and (R2) said he became weak and could not hold on any longer and he fell off the bed between the bed and wall. Staff then came in and checked on him and even the NP came in to see him. They asked him if he was hurt and put him in a (mechanical Lift) and transferred him to his wheelchair, gave him some pain medicine and eagerly rushed him off to dialysis. (R2) said he was in shock and when he got to dialysis the nurse there said his color was off and asked if he was feeling okay and he said he was in a lot of pain and had fallen and they sent him to the hospital where he was admitted . (R2) had two broken legs, 2 breaks in the left leg, and one break in the left leg.On 7/30/2025 at 11:48 AM, V2, Director of Nursing stated, (V7, Registered Nurse, RN) was the person responsible for (R2's) fall report. She wrote it up and investigated. I know we asked (R4, wife and roommate) if (R2) had hit his head and she said no. I was not present at the time of the fall. I know the Nurse Practitioner (V18) was here and she went and put eyes on (R2) so we could do an intervention, and we put boosters on his bed. That is all I know you will have to talk to (V7). If staff are doing treatment and put the bed up, I would expect staff to put the bed down after the treatment is finished. I would expect staff to never leave any resident unattended or left laying on their side. I would expect staff to reposition the resident, so they are safe, go and get what they needed and then return. I would not expect staff to leave a resident with the bed up, laying on their side. This is the first I am learning of it.On 7/30/2025 at 11:47 AM, Dialysis center called back and read V10's, Dialysis Center's Registered Nurse, RN, notes from that day. The notes document, Patient arrived to dialysis with complaints for pain to BLLE (bilateral lower extremities). Patient stated he fell out of bed prior to coming to the facility and the bed was elevated. Pain too high to do treatment. EMS (emergency medical services) called to transport. 911 was called. On 7/30/2025 at 2:13 PM, V10, Dialysis RN stated, We got a call from the (Facility) telling us (R2) had fall and that he was still going to make his appointment. When (R2) arrived, he was grimacing, and I could tell he was in a lot of pain, so I called 911 just to be safe.On 7/30/2025 at 12:56 PM V7, Registered Nurse, RN/Floor Nurse stated I am the one that made the incident report for (R2's) fall. I did ask (R2) and (R4) because they share a room if (R2) hit his head and they said no. I did not get any statements from them. It's all in the report. I remember the CNA came and got me and told me (R2) was on the floor and she said he had rolled out of bed. I went and assessed him, and he said he was having pain in his arm and ankle. I got another CNA, and he said he could move his ankles. We used the (mechanical lift) and put him back into his wheelchair. I asked him if he was hurting anywhere else and he said he was alright. He then said he didn't feel like going to dialysis and I told him it was important not to miss any days. We then sent him out to dialysis, and I found later he had injured himself. Nobody ever told me anything else. I didn't get any written statements from anybody. I just thought he fell out of bed.On 7/30/2025 at 1:26 PM, V4, Agency Certified Nurse's Aide, CNA, stated, We were passing out breakfast trays. The Wound nurse was in (R2's) room providing treatment and then she walked out. I grabbed the breakfast tray and asked the Wound Nurse if they were done. I asked her if she could give (R2) his food. I looked in the room a little later and no staff was in the room. The resident was laying on his left side and the bed was not down and was high up and even then, I knew he was a fall risk. The Wound Nurse was not in the room, and he was in up high, and I went to try and find the Wound Nurse and she was on her phone on the other hall. Then I heard a loud help, help and help. I saw the wound nurse and asked why she would leave the bed all the way up and he fell, and he was yelling. The Wound nurse left the bed all the way up, and the other nurse and I said why would she do that. The Wound Nurse was the last one in the room. Why did she tell him to hold on to the bed? The Wound Nurse was the last person in that room. Me and the other CNA found him on the floor.On 7/30/2025 at 2:14 PM, V16, CNA stated, I was working the day (R2) fell. (R2) had just had his wounds done. The Wound Doctor and the ADON (Assistant Director of Nursing) were doing the treatments. His bed was up high, and he was on his side. His wife was in the room too. Me and (V4) found (R2) after he had fallen. The bed was still up high. (V7, Registered Nurse/Floor Nurse) came and assessed him and looked him over. We were told to use the (mechanical lift) and put him in his wheelchair. He said he was in a lot of pain. (R2) did not want to go to dialysis. The Nurse Practitioner told him how important dialysis was for him and send him some pain medicine to take with him because he said he didn't want to go and was hurting. She said he might have some bruising and would be sort and she sent him some pain medication. On 7/31/2025 at 9:50 AM, R2 was wearing plastic splints/boots with Velcro on the side that goes up to the knee on both legs.On 7/31/2025 at 3:32 PM, V6, Medical Director stated, I would expect staff to always lower residents' bed after raising the bed. I am not sure how (R2) landed but I know he did have some broken bones. No fall is ever good for any resident. The bed should always be lowered. On 7/31/2025 at 3:11 PM, R2's bed was placed in the high position with V17, Maintenance Director and the V3, Assistant Director of Nursing, ADON. The bed was measured from the high position to the floor and measured 36 inches. R2's bed has a low air mattress on it.On 7/31/2025 at 3:12 PM, R2 was asked if the (V3) was the staff that left him alone in the room with his bed high and said she would return and he replied no, he thinks it was the agency CNA (certified nursing assistant). He was not sure, but it was not (V3). On 7/31/2025 at 3:13 PM, V3, stated, (V4) was the person in the room with us when we were doing treatment. This is the first I am learning the bed was high and (R2) was left lying on his side waiting for staff to return and he was not able to hold and a fell. I would expect staff to always put the bed down. (R2) has a remote so he can move his bed up and down. I did not realize staff left (R2) unattended and left the room.On 7/31/2025 at 4:12 PM, R2 stated that he fell from this bed with the same mattress, but after his fall the (Facility) added the bolsters.The Fall Policy with a revision date of 9/7/2023 documents, To provide staff with guidelines for investigating reporting and recording, Accidents and Incidents. All accidents/incidents involving a resident shall require an incident report. The interdisciplinary team (IDT) will complete an investigation to determine root cause and implement appropriate interventions. The MDS nurse shall update the Care Plan with implemented interventions and communicate interventions with line staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to notify resident representative of a worsening condition to a coccyx wound for 1 (R2) out of sample of 3 and failed to consult with Physician and/or Physician's Assistant. This failure resulted in R2 being sent to the emergency room for treatment per family request. Findings include: 1.) R2's diagnosis include essential tremors, hypothyroidism, peptic ulcer, anxiety, and osteoporosis. R2's Minimum Data Set, (MDS), dated [DATE] documents, a mental status of 14 which indicates R2 is cognitively intact. MDS documents, that R2 requires supervision with eating, dressing, toileting, transfers, and personal hygiene. On 03/08/23 at 10:25am, V12, (R2's POA), states she nor her husband received notification about the burn on 02/28/2023. V12 states, she received notification on 03/04/23, when she called the facility. V12 states, she was told at that time that R2 had a small blister on her bottom. Staff were applying ointment to it, and it should be healed in a few days. V12 states, she was told that the Doctor saw the wound on 03/01/23. V12 states, she came to the facility on [DATE] to look at the wound herself. After looking at it, she demanded R2 be sent to the hospital for evaluation of what she called a burn. V12 states, that on 03/08/23, she was told by V11, LPN, (License Practical Nurse), that the area on her bottom was due to pressure. R2's Progress Noted dated, 03/06/23 at 9:30am documents, R2's sister-in-law was here and upset regarding res., (residents), bottom. She wanted res. sent to the burn unit at (Local Hospital), Local Ambulance here and took res to Hosp. R2's Progress Note dated, 02/28/23 17:34pm, documented by V6, (Registered Nurse), documents while in bedroom, bedside table was knocked over and hot coffee spilled onto residents back & buttocks. Redness is present with a slight blister to coccyx. No pain reported. No s/s, (signs and symptoms), of distress. DON, (Director of Nursing), MD, (Medical Doctor), & Administrator notified of incident. On 03/08/23 at 9:50am, V4, DON states, she expected V6 RN, (Registered Nurse), to notify the Doctor and family about R2's condition in skin change. She expected V6 to call Doctor not to send a fax. On 03/07/23 at 3:15pm, V6, RN states, V5, (Certified Nursing Assistant), came to her and told her that R2 had coffee spilled on her. V6, RN, observed a red area to R2's back side. V6 states, she observed the bottom area later in the evening, and R2 had a blister forming. V6 RN, states, she did not call the Doctor that night, but did fax him. V6 states, she attempted to call the family, but no one answered. Facility policy titled Accidents and Incidents, documents it is the responsibility of the charge nurse to complete the accident and incident in PCC, (Physician's Computer Company), and notify attending Physician and responsible parties and documents information accordingly. 2.) Facility document titled, Skin Inspection Assessment completed by V4, DON, dated 02/23/23, for R2 documents redness to coccyx, barrier cream applied. On 03/08/23 at 9:50am, V4 states, R2 had redness to her coccyx on 02/23/23, when she had assisted R2 to the bathroom. V4 stated, she completed the weekly skin checks and noted about the redness. V4 stated, she did not measure the redness on 02/23/23. V4 stated CNAs were to apply barrier cream. On 3/7/2023 at 3:15pm V6 (RN) stated, she did not call the Doctor on 02/28/23. Facility fax document dated 03/01/23 documents during dinner bedside table was knocked over and hot coffee was spilled onto R2's back/buttocks. Area red and starting to slightly blister V/S, (vital signs), stable-no pain reported. V9 (Doctor) signature notes on note and an order to monitor. R2's Treatment Administration Record dated 03/2023, documents Monitor bilateral buttock for proper healing and s/s of infection r/t, (related to), burn order date 03/01/23, start date of 03/02/23, with the following dates 03/02/23, 03/03/23, 03/04/23, 03/05/23 containing nurses' initials. On 03/07/23 at 3:30pm V7, CNA, stated, R2 had a red area and blistering on 03/01/23 on her coccyx that was starting to bleed. V7 stated, R2's skin was skin starting to peel and that she applied barrier cream. On 03/08/23 at 9:50am V4 stated she observed R2's coccyx on 03/01/23 and the skin was starting to peel. On 03/08/23 at 11:20am V11, LPN, stated, the first time he saw R2's wound, on her coccyx was on 03/02/23, stated, it was pink/red and with some open blisters on the left side of coccyx. V11 states he saw the wound again on 03/02/23 and it was more red. On 03/08/23 at 11:40am, V10, CNA, stated, the first time she saw R2's coccyx was on 03/02/23 and she had two white bandages it. V10 stated, on 03/03/23 it was red and bleeding and had open areas. V10 stated, she told the nurse, that is looked horrible. V10 stated, she did not apply any barrier cream because, she thought the nurses had a treatment for it. On 03/09/23 at 2:20pm, V14, CNA stated, she took care for R2 on the dates of 03/03/23, 03/04/23 and 03/05/23 from 7pm-7am. V14 stated, R2's coccyx was red, and skin was peeling with bleeding and spots of discoloration on 03/03/23, V14 stated she notified the nurse, unknow which one. V14 stated on 03/04/23 and 03/05/23 it looked about the same. V14 stated, I did not put barrier cream on area because, I thought the nurses were treating it. R2's Treatment Administration record dated 03/23, documents, Silvadene External Cream 1%, (Silver Sulfadiazine). Apply to sacral/buttocks topically every shift for wound, for 5 Days. Active 03/04/23, started 03/05/23 end 03/10/23. R2's only entry on Treatment Administration Record was documented on 03/05/23 which includes a Nurse Note documenting, Silvadene External Cream 1% topically applied to Foot - Both feet. R2's Physicians Orders, dated 03/07/23, documents, wash lower back/sacrum every day with warm soapy water, ok to take baths. Apply Santyl to bum, cover with Xeroform gauze and ABD, (abdominal), pad dressing. Secure with tape or mesh underwear every evening shift. V8's, (Wound Doctor), initial wound evaluation, dated 03/08/23 documents, R2 had a coffee spill and there was question whether the area on her sacrum was caused by the burn of the coffee, to me the wound looks like a very typical pressure sore not a burn. Necrosis was very adherent and not ready to be removed. Deep tissue injury is still progressing, will let Santyl work and will reassess next week for possible debridement. Off load wound, reposition per facility protocol. Limit sitting to 60 minutes, twice per day, 2 hours max. chronic stable wound with insignificant amount of necrotic tissue with no signs of infection. Monitor closely for now. Wound measures at 11.5 X 15.5 with light serous drainage, 60% necrotic tissue, 30% devitalized necrotic tissue and 10% granulation tissue. On 03/07/23 at 9:00am V3, Physician's Assistant, (PA), stated, the last time he saw R2 was 01/17/23. V3 stated, he expects nursing staff to notify him and report any new concerns, with residents. V3 stated, he is in the facility at least every week and willing to see any residents if a needed. V3 stated, he expects the nurses to tell him if someone needs to be seen. On 03/09/23 at 12:45pm, V9, Physician, stated on 03/08/23 was the first time that he saw R2's wound on her coccyx. V9 stated, that he was not notified of a red area to R2's coccyx on 02/23/23. V9 stated, himself or V3, PA, are at the facility twice or more a week and that he expects staff to notify them when a resident needs to be seen by one of them. V9 stated, he relies on the nurses to keep him updated of changes and any needs of the residents. V9 stated, he relies on the nurse's judgement to determine that. Facility provided document titled Pressure Ulcer Prevention, Identification and Treatment documents the following: the Physician is to be notified when A) pressure ulcer develops B) when there is a noted lack of improvement after a reasonable amount of time C) and/or upon signs of deterioration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to provide treatment for for 1 of 3 (R2, R5, R6) residents reviewed for wounds. This failure resulted in R2 being sent to the emergency room for treatment per family request on 3/6/2023 and wound specialist consultation on 3/8/2023 with diagnosis of deep tissue injury measuring 11.5 x 15.5 with 60% necrotic tissue, 30% devitalized necrotic tissue. Findings include: R2's diagnosis include essential tremors, hypothyroidism, peptic ulcer, anxiety and osteoporosis. R2's Minimum Data Set, (MDS), dated [DATE] documents a brief interview of mental status of 14 which indicates R2 is cognitively intact. MDS documents that R2 requires supervision with eating, dressing, toileting, transfers and personal hygiene. Facility document, titled Skin Inspection Assessment, completed by V4, (Director of Nursing), dated 2/23/2023, R2 documents redness to coccyx, barrier cream applied. On 3/8/2023 at 9:50am V4, stated, R2 had a redness to her coccyx on 2/23/23, when V4, CNA, assisted her to the bathroom. V4 stated, she completed the weekly skin checks and noted the redness on the Skin Inspection Assessment. V4 stated, she did not measure the redness on 2/23/23. V4 stated, the CNAs were to apply barrier cream. R2's Progress Note, dated 2/28/2023, at 5:34pm documents, while in her room the bedside table was knocked over and hot coffee spilled onto R2's back & buttocks. Redness is present with a slight blister to coccyx. No pain reported. No s/s of distress. DON, MD & Administrator notified of incident. On 3/7/2023 at 3:15pm V6, (RN), stated, she did not call the Doctor, on 2/28/2023. Facility fax document dated 3/1/2023 documents, during dinner, (in room), bedside table was knocked over and hot coffee was spilled onto R2's back/buttocks. Area is red and starting to slightly blister V/S stable-no pain reported. V9, (Doctor), signature and order to monitor. On 3/8/2023 at 9:50am V4 stated, she expected V6 to notify Doctor and family about R2's condition changes. V4 stated, she expected V6 to call Doctor not to send a fax. R2's Treatment Administration Record, dated 3/2023 documents, monitor bilateral buttock for proper healing and s/s of infection r/t burn, Order Date 03/01/2023 start date of 3/2/2023 with the following dates 3/2/2023, 3/3/2023,3/4/2023, 3/5/2023 containing nurses' initials. On 3/7/2023 at 3;30pm V7, CNA stated, R2 had red area and blistering on 3/1/2023 to coccyx that was starting to bleed. V7 stated, R2's skin was starting to peel and that she applied barrier cream as told. On 3/8/2023 at 9:50am V4 stated, she observed R2's coccyx on 3/1/2023 and the skin was starting to peel but, she did not see any blisters. On 3/8/2023 at 11:20am V11, LPN, stated, the first time he saw R2's wound on her coccyx was on 3/2/2023, states it was pink/red and some an open blister on the left side of coccyx. V11 states, he saw the wound again on 3/2/2023 and it was more red. On 3/8/2023 at 11:40am V10, CNA, stated, the first time she saw R2's coccyx was on 3/2/2023 and she had two white bandages on her. V10 stated, on 3/3/2023 it was red and bleeding and had open areas. V10 stated, she told the nurse that is looked horrible. V10 stated, she did not apply any barrier cream because, she thought the nurses had a treatment for it. On 3/9/2023 at 2:20pm V14, CNA, stated, she cared for R2 on the dates of 3/3/2023, 3/4/2023 and 3/5/2023 from 7pm-7am. V14 stated, R2's coccyx was red, and skin was peeling, and it was bleeding with spots of discoloration on 3/3/2023, V14 stated, she notified the nurse. V14 stated, on 3/4/2023 and 3/5/2023 it looked about the same. V14 stated, I did not put barrier cream on her because, I thought the nurses were treating it. On 3/7/2023 at 9:00am V3, (Physician's Assistant), stated, the last time he saw R2 was 1/17/23. On 3/9/2023 at 12:45pm V9, (Physician), stated, 3/8/2023 is the first time that he saw R2's wound on her coccyx. R2's treatment administration record dated 3/2023 documents Silvadene External Cream 1 % (Silver Sulfadiazine) Apply to sacral/buttocks topically every shift for wound for 5 Days Active 03/04/2023 start 03/05/2023 end 03/10/2023. R2's only entry on Treatment Administration Record, (TAR), is for 3/5/2023 which includes nurse note documenting Silvadene External Cream 1 % topically applied to Foot - Both feet. R2's progress noted dated 3/6/2023 at 9:30am documents R2's sister-in-law was here and upset regarding res., (resident), bottom. She wanted res. sent to the burn unit at hospital. Ambulance here and took res. On 3/8/2023 at 10:25am V12 (R2's POA) stated, she came in on 3/6/2023 and saw wound on coccyx and demanded R2 be sent to the hospital for evaluation of her burn. V12 stated, that on 3/8/2023 she was told by V11 that the area on her bottom was due to pressure. R2's Physicians Orders dated 3/7/2023 documents Wash lower back/sacrum every day with warm soapy water. Ok to take baths. Apply Santyl to bum. Cover with Xeroform gauze and ABD, (Abdominal), pad dressing. Secure with tape or mesh underwear every evening shift. R2's Progress Notes dated 3/7/2023 from V3 documents, there is a large sacral wound, (see nursing measurements), symmetrical full thickness with erythema and no blanching dermas centrally. Perirectal area/vaginal area not included in wound. Dx sacral wound. ER referral to [NAME]. On 3/8/2023 at 9:00 am V8, (Wound Doctor) stated, wound looks like a deep tissue injury. V8's initial wound evaluation dated 3/8/2023 documents, R2 had a coffee spill and there was question whether the area on her sacrum was caused by the burn of the coffee, to me the wound looks like a very typical pressure sore not a burn. Necrosis was very adherent and not ready to be removed. Deep tissue injury is still progressing will let Santyl work and will reassess next week for possible debridement. Off load wound, reposition per facility protocol. Limit sitting to 60 minutes twice per day 2 hours max. chronic stable wound with insignificant amount of necrotic tissue an no signs of infection. Monitor closely for now. Wound measures at 11.5 X 15.5 with light serous drainage, 60% necrotic tissue, 30% devitalized necrotic tissue and 10% granulation tissue. On 3/7/2023 at 9:00am V3 stated, he expects nursing staff to notify him and report any new concerns with residents. V3 stated, he is in the facility at least every week and is willing to see any of residents if a need arises. V3 stated, he expects the nurses to tell him if someone needs to be seen. On 3/8/2023 at 9:50am V4 stated, that she expects her staff to notify Doctor of condition of wound. V4 stated, she was aware of the order from R2's primary Doctor to monitor wound and she expected her nurses to monitor the wound. 3/9/2023 12:45pm V9 stated, he defers the wound care to the Wound Doctor, that he agrees with deep tissue injury and the care that the Wound Doctor has ordered. V9 stated, that he was not notified of a red area to R2's coccyx on 2/23/2023. V9 stated, 3/8/2023 is the first time that he saw R2's wound on her coccyx. V9 stated, himself or V3 are at the facility twice or more a week and that he expects staff to notify them when a resident needs to be seen by one of them. V9 stated, he relies on the nurses to keep him updated of changes and any needs of the residents. V9 stated, he relies on the nurse's judgement to determine that. Facility provided pressure ulcer policy documents includes the following: it is the responsibility of the charge nurse/designee to care for pressure areas and provide treatments as ordered. It is the responsibility of the charge nurse/designee to measure and document on the pressure areas weekly. It is the responsibility of the charge nurse/designee to monitor for healing progress and ensure appropriate treatment are in use. It is recommended that DON/Designee make frequent pressure ulcer rounds with the charge nurse. It is the responsibility of the CNA to report any skin conditions to the charge nurse immediately upon identification. When a pressure ulcer is identified whether in house or upon a resident's admission the area will be assessed using the skin and wound assessment and initial treatment started per Physicians' Orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to provide treatment for a pressure ulcer for 1 of 3 (R2, R5, R6) residents reviewed for pressure ulcers. This failure resulted in R2 being sent to the emergency room for treatment per family request on 3/6/2023 and wound specialist consultation on 3/8/2023 with diagnosis of deep tissue injury measuring 11.5 x 15.5 with 60% necrotic tissue, 30% devitalized necrotic tissue. Findings include: R2's diagnosis include essential tremors, hypothyroidism, peptic ulcer, anxiety and osteoporosis. R2's Minimum Data Set, (MDS), dated [DATE] documents a brief interview of mental status of 14 which indicates R2 is cognitively intact. MDS documents that R2 requires supervision with eating, dressing, toileting, transfers and personal hygiene. Facility document, titled Skin Inspection Assessment, completed by V4, (Director of Nursing), dated 2/23/2023, R2 documents redness to coccyx, barrier cream applied. On 3/8/2023 at 9:50am V4, stated, R2 had a redness to her coccyx on 2/23/23, when V4, CNA, assisted her to the bathroom. V4 stated, she completed the weekly skin checks and noted the redness on the Skin Inspection Assessment. V4 stated, she did not measure the redness on 2/23/23. V4 stated, the CNAs were to apply barrier cream. R2's Progress Note, dated 2/28/2023, at 5:34pm documents, while in her room the bedside table was knocked over and hot coffee spilled onto R2's back & buttocks. Redness is present with a slight blister to coccyx. No pain reported. No s/s of distress. DON, MD & Administrator notified of incident. On 3/7/2023 at 3:15pm V6, (RN), stated, she did not call the Doctor, on 2/28/2023. Facility fax document dated 3/1/2023 documents, during dinner, (in room), bedside table was knocked over and hot coffee was spilled onto R2's back/buttocks. Area is red and starting to slightly blister V/S stable-no pain reported. V9, (Doctor), signature and order to monitor. On 3/8/2023 at 9:50am V4 stated, she expected V6 to notify Doctor and family about R2's condition changes. V4 stated, she expected V6 to call Doctor not to send a fax. R2's Treatment Administration Record, dated 3/2023 documents, monitor bilateral buttock for proper healing and s/s of infection r/t burn, Order Date 03/01/2023 start date of 3/2/2023 with the following dates 3/2/2023, 3/3/2023,3/4/2023, 3/5/2023 containing nurses' initials. On 3/7/2023 at 3;30pm V7, CNA stated, R2 had red area and blistering on 3/1/2023 to coccyx that was starting to bleed. V7 stated, R2's skin was starting to peel and that she applied barrier cream as told. On 3/8/2023 at 9:50am V4 stated, she observed R2's coccyx on 3/1/2023 and the skin was starting to peel but, she did not see any blisters. On 3/8/2023 at 11:20am V11, LPN, stated, the first time he saw R2's wound on her coccyx was on 3/2/2023, states it was pink/red and some an open blister on the left side of coccyx. V11 states, he saw the wound again on 3/2/2023 and it was more red. On 3/8/2023 at 11:40am V10, CNA, stated, the first time she saw R2's coccyx was on 3/2/2023 and she had two white bandages on her. V10 stated, on 3/3/2023 it was red and bleeding and had open areas. V10 stated, she told the nurse that is looked horrible. V10 stated, she did not apply any barrier cream because, she thought the nurses had a treatment for it. On 3/9/2023 at 2:20pm V14, CNA, stated, she cared for R2 on the dates of 3/3/2023, 3/4/2023 and 3/5/2023 from 7pm-7am. V14 stated, R2's coccyx was red, and skin was peeling, and it was bleeding with spots of discoloration on 3/3/2023, V14 stated, she notified the nurse. V14 stated, on 3/4/2023 and 3/5/2023 it looked about the same. V14 stated, I did not put barrier cream on her because, I thought the nurses were treating it. On 3/7/2023 at 9:00am V3, (Physician's Assistant), stated, the last time he saw R2 was 1/17/23. On 3/9/2023 at 12:45pm V9, (Physician), stated, 3/8/2023 is the first time that he saw R2's wound on her coccyx. R2's treatment administration record dated 3/2023 documents Silvadene External Cream 1 % (Silver Sulfadiazine) Apply to sacral/buttocks topically every shift for wound for 5 Days Active 03/04/2023 start 03/05/2023 end 03/10/2023. R2's only entry on Treatment Administration Record, (TAR), is for 3/5/2023 which includes nurse note documenting Silvadene External Cream 1 % topically applied to Foot - Both feet. R2's progress noted dated 3/6/2023 at 9:30am documents R2's sister-in-law was here and upset regarding res., (resident), bottom. She wanted res. sent to the burn unit at hospital. Ambulance here and took res. On 3/8/2023 at 10:25am V12 (R2's POA) stated, she came in on 3/6/2023 and saw wound on coccyx and demanded R2 be sent to the hospital for evaluation of her burn. V12 stated, that on 3/8/2023 she was told by V11 that the area on her bottom was due to pressure. R2's Physicians Orders dated 3/7/2023 documents Wash lower back/sacrum every day with warm soapy water. Ok to take baths. Apply Santyl to bum. Cover with Xeroform gauze and ABD, (Abdominal), pad dressing. Secure with tape or mesh underwear every evening shift. R2's Progress Notes dated 3/7/2023 from V3 documents, there is a large sacral wound, (see nursing measurements), symmetrical full thickness with erythema and no blanching dermas centrally. Perirectal area/vaginal area not included in wound. Dx sacral wound. ER referral to [NAME]. On 3/8/2023 at 9:00 am V8, (Wound Doctor) stated, wound looks like a deep tissue injury. V8's initial wound evaluation dated 3/8/2023 documents, R2 had a coffee spill and there was question whether the area on her sacrum was caused by the burn of the coffee, to me the wound looks like a very typical pressure sore not a burn. Necrosis was very adherent and not ready to be removed. Deep tissue injury is still progressing will let Santyl work and will reassess next week for possible debridement. Off load wound, reposition per facility protocol. Limit sitting to 60 minutes twice per day 2 hours max. chronic stable wound with insignificant amount of necrotic tissue an no signs of infection. Monitor closely for now. Wound measures at 11.5 X 15.5 with light serous drainage, 60% necrotic tissue, 30% devitalized necrotic tissue and 10% granulation tissue. On 3/7/2023 at 9:00am V3 stated, he expects nursing staff to notify him and report any new concerns with residents. V3 stated, he is in the facility at least every week and is willing to see any of residents if a need arises. V3 stated, he expects the nurses to tell him if someone needs to be seen. On 3/8/2023 at 9:50am V4 stated, that she expects her staff to notify Doctor of condition of wound. V4 stated, she was aware of the order from R2's primary Doctor to monitor wound and she expected her nurses to monitor the wound. 3/9/2023 12:45pm V9 stated, he defers the wound care to the Wound Doctor, that he agrees with deep tissue injury and the care that the Wound Doctor has ordered. V9 stated, that he was not notified of a red area to R2's coccyx on 2/23/2023. V9 stated, 3/8/2023 is the first time that he saw R2's wound on her coccyx. V9 stated, himself or V3 are at the facility twice or more a week and that he expects staff to notify them when a resident needs to be seen by one of them. V9 stated, he relies on the nurses to keep him updated of changes and any needs of the residents. V9 stated, he relies on the nurse's judgement to determine that. Facility provided pressure ulcer policy documents includes the following: it is the responsibility of the charge nurse/designee to care for pressure areas and provide treatments as ordered. It is the responsibility of the charge nurse/designee to measure and document on the pressure areas weekly. It is the responsibility of the charge nurse/designee to monitor for healing progress and ensure appropriate treatment are in use. It is recommended that DON/Designee make frequent pressure ulcer rounds with the charge nurse. It is the responsibility of the CNA to report any skin conditions to the charge nurse immediately upon identification. When a pressure ulcer is identified whether in house or upon a resident's admission the area will be assessed using the skin and wound assessment and initial treatment started per Physicians' Orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide adequate supervision, and implement progressive interventions to prevent further falls for 1 of 3 residents (R2) reviewed for accidents in the sample of 4. This failure resulted in multiple falls, 2 of which required Emergency Medical Services for evaluation for head injury with multiple bruises and lacerations to her face and head. Findings include: R2's Undated Face Sheet documents she was admitted to the facility on [DATE] Diagnoses included Alzheimer disease, anxiety disorder, rheumatoid arthritis, cerebral infarction, and urinary tract infection. R2's admission Fall Risk Assessment, dated 7/26/2022 documents she was a low risk for falls. R2's Minimum Data Set (MDS), dated [DATE] documents she has severely impaired cognition, requires extensive assistance of two for Transfers, Locomotion on unit, Toileting. R2's Balance during Transitions and Walking not steady only stable with staff assistance, and has history of falls. R2's Fall Incident Reports document dates of falls: 10/13/2022 no injury, 10/22/2022 no injury but sent to local hospital emergency room (ER) related to R2 hitting her head, 11/14/2022 no injuries, 11/28/2022 hematoma to back of head, hematoma to left side of face, laceration to face, 12/2/2022 no injuries, 12/7/2022 no injuries, 12/14/2022 bruise to right front of shoulder, 12/19/2022 no injuries, 12/20/2022 hematoma to back of head, 12/21/2022 unable to determine injury to face, 12/25/2022 bleeding hematoma to face, and 12/30/2022 no injuries. R2's Care Plan, dated 11/15/2022 documents no progressive fall interventions for the falls on 11/14/2022, 12/2/2022, 12/14/2022, 12/19/2022, 12/20/2022, 12/21/2022, and 12/25/2022. R2's Care Plan dated 12/2/2022 documents R2 has severely impaired cognition and /or wandering behavior related to diagnosis to Dementia. Interventions dated 10/13/2022 include provide ensure resident transfers into dining room chair for meals, Put sign above bed (R2's) bed so she knows which bed is hers, keep call light within reach, keep environment clutter free, PT (Physical Therapy), OT (Occupational Therapy), ST (Speech Therapy) to eval (evaluate) and treat. R2's Progress Note, dated 10/13/2022 at 11:41 AM, documents resident had a fall and was on the floor. Upon entering the Dining room resident was observed sitting on her butt, back leaning against the wall with her leg stretched out in front of her. The floor was dry, she had gripper socks on feet, there was a empty wheelchair at the table and she was sitting on a soft collapsible floor sign. R2's Incident Report, dated 10/22/2022 at 6:50 AM, documents resident fell in another residents room and was on her left side. Incident report states Certified Nurse Aide (CNA) thinks resident hit her head. Order received to send resident to local Emergency Department (ED) for evaluation and treatment for fall. R2's Progress Note, dated 10/22/2022 2:32 PM, documents call received from local ER (Emergency Room) stating resident was ready to return to facility. Resident has Urinary Tract Infection (UTI) and was given IV (intravenous) antibiotic in the ER and will return to facility with orders for Cefelexin (oral antibiotic). R2's Incident Report, dated 11/14/2022 at 9:59 AM, documents resident sitting on her buttocks in front of dining room chair in activity room on the special care unit. R2's Fall Incident Report, dated 11/28/2022 at 7:34 PM, documents resident was sitting on the floor in front of the toilet leaning on her arm. Another resident was leaving the dining room and stated I think someone needs help. 911 was called. Hematoma to face, hematoma to back of head, laceration on her face. Resident was transferred to local ED. R2's Progress Note, dated 11/28/2022 at 11:50 PM, documents resident returned to facility via stretcher per Ambulance. Resident incontinent of urine. Hematoma to left side of head and bruising around left eye. Multiple small lacerations to left forehead and nasal area. R2's Fall Incident Report, dated 12/2/2022 at 12:15 PM, documents resident was sitting on her buttocks with legs stretched out in front of her asking staff to help her up. Resident was in the door way to the activity room with the door to her left side and facing the dining area. The food cart was directly behind resident in the doorway. Staff member was standing at the tables gathering up dishes and when the staff turned to take the dirty dishes to the food cart resident was standing directly behind the staff. That staff person bumped into resident and resident lost her balance and fell into the door. Resident hit her head on the door and slid to the floor. R2's Fall Incident Report, dated 12/7/2022 at 11:30 AM, documents resident was sitting on her buttocks on the floor in the dining room. Agency CNA witnessed the fall and stated she R2 hit her head on the right side. R2's Fall Incident Report, dated 12/14/2022 at 2:10 PM, documents resident was sitting on her butt next to the air conditioner in the activity room scooting towards the doorway. Resident was bleeding on the left side of her face. 911 was called for an ambulance. Bruise was forming on the top of her left shoulder. Previous hematoma had re-opened and was bleeding. R2's Fall Incident Report, dated 12/19/2022 at 6:00 PM, documents resident was on her left side on the hallway floor. There was blood on the floor next to resident. Resident had a bloody nose, and an old skin tear above the eye had re-opened. R2's Fall Incident Report, dated 12/20/2022 at 5:30 PM, documents resident was found lying on her back in another resident's room and she has a bump on the back of her head. R2's Fall Incident Report, dated 12/21/2022 at 8:33 PM, documents resident was on the floor sitting upright. Unable to determine injury to her face. R2's Fall Incident Report, dated 12/25/2022 at 1:30 PM, documents resident was observed lying flat in a prone position with her left arm under her head and right arm out in front of her body. Legs were straight. She was lying with her back against the bathroom door, head towards the hall door in another residents room. Resident did have visible blood coming from a previous hematoma on her forehead. Bleeding from hematoma from previous hematoma to her forehead. R2's Fall Incident Report, dated 12/30/2022 at 6:32 AM, documents resident was sitting on another resident's floor mat next to her bed. Her feet went towards the door, bottom on the floor. No injuries observed at time of incident. On 12/27/2022 at 12:04 PM, V4, MDS/Care Plan Coordinator, stated they talk about new interventions for falls in morning meetings that they typically have Monday thru Friday. V2, Director of Nursing (DON), and V5, Assistant Director of Nursing (ADON), does the investigations and sometimes has the root cause for the fall before the meeting, Sometimes the nurse on the floor making the fall report will document new interventions (progressive interventions) V4 stated she does not put a new intervention in place until its discussed in the meeting. Sometimes root cause analysis is discussed in morning meeting, sometimes not. On 12/27/22 at 12:43PM, V8, Special Care Coordinator/CNA, stated they have falls back there on the unit and have to redirect constantly. V8 stated R2 is constantly getting up and walking by herself. They try to redirect as much as they can. They are working with her on medications, with ativan she doesn't sleep well at night and she wanders, paces, and then she gets tired from pacing the hallway and will fall, she wanders in other residents' rooms too. On 12/27/22 at 1:03 PM, V8 was walking R2 in the hallway without a gait belt and holding R2's hand. R2 walked with tiny steps, shuffling gait, and wobbly at times, gait unsteady. V8 stated she wasn't really sure about the policy of using a gait belt. On 12/27/22 at 1:37 PM, V11, CNA, stated, We have (R2) that falls a lot and wants to walk the hallways and she paces at a fast walk. Those bruises on her face is from one of her falls and when she falls she seems to fall on her face. I try my best to keep an eye on her but she is so fast at getting up. We do not get any new interventions for (R2) to keep her from falling again. Nurse gives us report when resident falls but no report of any new interventions for falls. On, 12/27/2022 at 1:54 PM, V12, Licensed Practical Nurse (LPN), stated R2 has advanced dementia and has had frequent falls where she has gotten bruises, lacerations, and abrasions on her face. She has a history of exit seeking, and aggression with other residents. She is just so exhausted from up pacing the halls and going in and out of residents rooms. V12 stated he is at his wits end she falls, falls, falls. Don't know what to do with her and her falls. V12 stated, We can't strap her down. As far as interventions, the management team tells us if any new interventions, but we haven't been told of any new interventions with (R2) with her falls. On 12/27/22 1:57 PM, V1, Administrator, stated not really sure of R2's root cause of her falls. V1 stated, We sent her to psych (psychiatric) hospital for medication adjustment, she came back zonked, she was sleeping all the time. We called her MD (medical doctor) and weaned her back off the medications. V1 stated that R2 does not require assistance, she is independent with her walking. On 12/27/22 2:05 PM, V2, DON, stated, she agreed with V1's statement except V2 stated R2 requires extensive assistance and is not independent. On 12/27/22 at 3:34 PM, R2 was sitting in her recliner trying to get up. Her recliner was near her bed. V13, CNA, and V14, CNA, applied gait belt around resident's waist to transfer from her recliner to ambulate her to the bathroom. Both CNA's had their hands on the gait belt during ambulation. R2 had an unsteady gait, wobbling, she walked with tiny steps and shuffling gait. On 12/28/22 at 8:00 AM, R2 was up ambulating by herself in the hallway carrying a glass of juice in her left hand (hand is noted to be shaking) R2's gait was unsteady, wobbly, and walks with tiny steps and shuffling gait. Two CNA's were in the dining room assisting other residents while R2 was walking the hallway unassisted. Another resident was in her wheelchair and this resident pushed her feet making her wheelchair roll backwards to the point it almost hit R2 while walking in the hallway alone. V16, CNA, saw what was happening and ran over to stop the other resident from running over R2. V12, LPN, was standing at the med cart passing medications and did not see what happened. On 12/28/22 at 8:09 AM, V17, CNA, took R2 by the hand and walked R2 down the hallway without a gait belt. Placed R2 in her recliner, V17 CNA lifted R2 underneath her arms to scoot resident back in the recliner. R2's gait is unsteady gait, wobbly, staggered, took tiny steps and shuffling gait while walking. On 12/28/22 at 8:11 AM, R2 got back up from her recliner unassisted. R2 walked into another resident's room continues with short steps, shuffling gait, wobbling with unsteady gait. No staff was watching over R2 at this time. On 12/28/22 at 8:17 AM, V10, CNA, saw R2 up and stated her gait is not steady, walked to R2 placed a gait belt on R2 and walked her in the hallway. R2's gait is unsteady, wobbly, she continues to take little steps and walks with shuffling gait. V10 took R2 to her room and requested that V12, LPN, help to assist R2 to bed and scoot R2 up in the bed. On 12/28/22 at 10:48 AM, V18, facility Beautician/ R2's daughter in law, stated she visits R2 in the evenings after she gets done with work at the facility. V18 stated she takes in food and drinks for R2 and sits one on one and feeds her supper at times. V18 stated this facility has zero interventions they put in place for R2. V18 stated they sit her down in the recliner, or lay her in the bed, her anxiety is high and always has been before she got dementia. V18 stated many times when she goes in the unit during the evening, R2 is up walking in the hallway and very unsteady on her gait, she wobbles a lot when she walks. V18 states she sees CNA's on their phones most of the time or talking to each other instead of watching or taking care of the residents. On 12/28/22 at 3:45 PM, V15, CNA, stated she works as a float throughout the facility and the unit at times. V15 stated she witnessed R2 fall on Tuesday and Wednesday evening. V15 stated on Tuesday, she was in the hallway and heard another resident yell out R2's on her back on the floor crying. R2 fell down and hit her head, R2 had a huge knot on the back of her head, no bleeding. R2 fell in another resident's room. V15 called V2, DON, back to the unit and they moved R2 to a wheelchair. R2 did not go to ER, family did not want her sent out. V15 stated on Wednesday, R2 fell again. R2 had been sleeping in her bed, woke up and was wobbling out of her room. V15 stated she was charting outside of R2's room in the hallway. R2 had walked down to the locked door and had been knocking on the doors, she turned around wobbling, fell forward and her face hit the floor, there was blood coming from her forehead, her nose was bleeding from inside of her nose. V15 stated she yelled for V14 to use the intercom to call a nurse stat (immediately) to the unit. They applied pressure on her nose. R2 did not go to ER. V14 CNA and V15 CNA both stated Management gives us no new interventions or communication for any new interventions do the best we can with what staff we have. Family will come in at times especially the daughter in law she works here and will sit and feed her in the evenings. We need staff here to help Activities is here at times till 5pm on the unit but not daily. On 12/29/22 at 10:09 AM, V7, Primary Physician, stated he was not aware that R2 had that many falls - he asked how many falls she had exactly because he was not aware. V7 then stated it upsets him that the facility did not put further interventions in place for R2 prior to giving her medications. V7 stated giving Ativan and Morphine increasingly puts R2 who has dementia at higher risk for falling. V7 stated he felt the facility should be doing more activities to keep R2's mind occupied, increase staffing in the unit, walking her with a gait belt, alarms. On 12/29/2022 at 11:06 AM, V19, Nurse Practitioner, for V27, Psychiatrist, stated she saw R2 on 12/9/22 at the facility for psychiatric evaluation. She had multiple medication changes per medical doctor orders and hospital visit without my knowledge. V19 stated, I did not get notification of all falls nor medication changes. By reviewing above doses with only one fall in all the 13 doses of Ativan administered, it is in my professional opinion that the Ativan is not a contributor to falls on 12/20/22 or 12/25/22. The use of Ativan with Morphine when used together may cause increased sedation affect fall rates. After reviewing the medical chart, it does not appear she was given these two medications at the same time. On 12/29/22 at 1:04 PM, V24, Physician Assistant (PA), for V7, Primary Physician, for R2, stated regarding R2's falls, he did not know that she had so many frequent falls. V24 stated he thought she had a few and was not of aware of all those falls. Went back to the clinic to discuss with V7 her falls and medications. But again neither one of us was aware of the number of falls she sustained. I did know she was placed on ativan for 14 days but again would not have given the ativan or morphine with her having dementia and all those falls. Ativan and Morphine puts R2 at a higher risk for falls with her dementia and falls. The facility's Fall Risk Assessment policy and procedure, dated March 2018, documents, The nursing staff in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident - centered falls prevention plan based on relevant assessment information. While many falls are isolated individual resident, some individuals fall repeatedly. Information and observation assist in identifying patterns and may illustrate underling case. After a first fall the staff (and physician, if possible) will refer the individual to therapy services to identify patterns of gait, balance, strength and other factors that may benefit from retraining, or strengthening. Therapy will make recommendation to the physician or staff about opportunities to reduce risk and improve safety. The interdisciplinary team, therapy team, nursing or physician will recommend specific interventions to reduce identified factors that increase risk for falling. The interdisciplinary team, nursing, physician will recommend specific interventions that may reduce the probability of serious injury in the event a fall does occur. Nursing is responsible for implementation these interventions. Nursing and MDS are responsible for assuring timely and accurate Care Planning to assure full assessment and interventions implementation.