**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was positioned in a safe manner for one of three residents (R1) reviewed for safety in the sample of three. This failure resulted in R1 experiencing a fall which required sutures and resulted in R1 obtaining a small subdural hematoma. The findings include: R1's Face Sheet shows he was admitted to the facility on [DATE], with diagnoses including alcohol abuse, fall from bed, mood disorder, vascular dementia, generalized anxiety disorder, Parkinson's disease, and malnutrition. R1's Fall Risk assessment dated [DATE], shows that R1 is at risk for falls. R1's Significant Change in Status Minimum Data Set, dated [DATE], shows R1 is not cognitively intact, has an impairment on both upper and lower extremities, is dependent (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity) on staff for toileting, personal hygiene, putting on/taking off footwear, sit to lying, and lying to sitting on the side of the bed. R1's Progress Notes dated August 10, 2024; shows he was transferred to the local emergency room after a fall. R1's Progress Notes dated September 4, 2024; shows he experienced another fall while ambulating. R1's Care Plan initiated February 26, 2024, shows R1 is resistant to ADL (Activities of Daily Living) care such as dressing and changing. He is also combative, hitting, pushing, holding onto and punching staff during care. This generally occurred almost daily. He has a diagnosis of dementia. Work in pairs when providing care if necessary for safety of resident or staff. R1's Care Plan initiated February 26, 2024, and revised September 9, 2024, shows R1 is at risk for falls related to confusion, incontinence, poor communication/comprehension. Falls were noted on April 29, 2024, May 20, 2024, June 16, 2024, August 2, 7, and 10, 2024, September 4, 2024, and September 7, 2024. The facility's Facility Reported Incident shows that on September 7, 2024, at approximately 9:00 AM, [R1] fell from the edge of his bed while in a seated position. R1 returned from the local emergency room. CT (computed tomography) of the brain showed a possible tiny subdural hemorrhage. The emergency room physician spoke to the power of attorney (POA) and discussed goals of care. The POA declined treatment and wanted the resident transferred back to the facility. The resident has sutures in place on the left side of his forehead with order to remove in seven days. Conclusion: The CNA was next to the resident and was reaching for his shoes when the resident fell forward and sustained the fall but was unable to stop the fall. On September 10, 2024, at 10:11 AM, V5 CNA (Certified Nursing Assistant) stated she was the CNA taking care of R1 when he fell on September 7, 2024. V5 stated R1 was sitting on the side of the bed with his left hand holding the side rail. V5 stated R1 fell face first to the floor when V5 went to the foot of R1's bed to grab R1's shoes. V5 stated that R1 hit his head on the ground. V5 stated that when R1 wants to do something he will. V5 stated that R1 is impulsive. V5 stated that R1 tries to get out of the wheelchair by himself. V5 stated that prior to R1's recent fall, R1 was able to ambulate on his own. V5 stated that in the last month or so, R1 would cross his legs when he tried to stand up. V5 stated that R1's legs would get tangled. V5 stated that R1 has not really walked since his fall. V5 stated that when R1 fell forward from the bed, she immediately called for R1's nurse. V5 stated that R1 is pretty much nonverbal, but when R1 fell, he was moaning. V5 stated that R1 had a little blood coming from his forehead when he fell. V5 stated that R1 went to the hospital via 911. On September 10, 2024, at 10:29 AM, R1 was sitting in a high back wheelchair at the nurses' station. R1 had 5-6 sutures to his left forehead with fading bruising. R1 was nonverbal. On September 10, 2024, at 9:40 AM, V2 DON (Director of Nursing) stated that it was Saturday when R1 fell. V2 stated that R1 was sitting on the edge of the bed when V5 turned around to pick something up. V2 stated that R1 has been declining. V2 stated that R1 has agitative behaviors and is very cognitively not intact. At 11:34 AM, V4 RN (Registered Nurse) stated she was the nurse taking care of R1 the day he fell. V4 stated that R1 was on the floor when she came into R1's room. V4 stated that R1 had a bump on his head and there was a small amount of blood. V4 stated that R1 has severe dementia. V4 also stated that R1 is able to ambulate but does not have good balance. R1's Hospital Records dated September 7, 2024, shows, Impression: New small right temporal subdural hematoma likely subacute in nature. Patient's laceration was repaired using sutures. The facility's Fall Prevention Program policy revised on November 21, 2017, shows, The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Safety interventions will be implemented for each resident identified at risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure pressure reducing interventions were in place for residents with pressure injuries for 2 of 8 residents (R106, R183) reviewed for pressure injuries in the sample of 28. This failure resulted in R106's coccyx excoriation progressing to an unstageable pressure injury and R183's Stage 3 coccyx pressure injury advancing to an unstageable pressure injury. The findings include: 1. On 07/24/23 at 10:34 AM, R106 was in her room, sitting up in her wheelchair on a flattened pillow. R106 said she has a dressing on the sore on her bottom. R106 said the wound doctor comes, but her wound is not getting better. R106 said the wound doctor did a procedure the last time and her bottom is very inflamed and burns. R106 did not have a pressure reducing cushion in her wheelchair or a pressure reducing air mattress on her bed. On 07/24/23 at 12:57 PM, R106 was sitting in her wheelchair in the dining room on a flattened pillow. R106's Most Recent Skin assessment dated [DATE] shows pressure ulcer coccyx, Stage: Unstageable, Length:3.5 cm Width: 3 cm, Appearance: moist, color: gray, Drainage amount: small, Exudate: Purulent. On 07/25/23 at 9:40 AM, V5 Wound Registered Nurse said wound assessments are done weekly and include measuring the wounds, assesses the treatment orders to determine whether to continue or change them, and looking at the pressure reducing interventions in place. V5 said pressure reducing intervention used are turn/reposition every 2 hours, low air loss pressure reducing mattress, protein supplements, and wheelchair cushions or roho cushions. V5 stated any resident comes in with a pressure wound should have an air mattress. They should have some sort of pressure reducing cushion on their wheelchair. R106 has an unstageable pressure to her coccyx, it started out as just excoriation. R106 should have an air mattress and a wheelchair cushion. On 07/26/23 at 11:15 AM, V13 Wound Doctor stated R106 has an unstageable pressure wound to her coccyx. I just debrided it last week; it was the first time seeing her and it was at unstageable. R106 should have low air loss mattress, nutritional supplements, and a wheelchair cushion in place. I believe I ordered one. The low air loss mattress and wheelchair cushion helps wounds from deteriorating by reducing the pressure by redistributing the pressure off the wound. R106's Physician Orders do not contain orders for a pressure reducing wheelchair cushion or air mattress. R106's Care Plan shows R106 was re-admitted on [DATE] with excoriation on the buttocks and is at risk for impaired skin integrity with interventions: pressure reduction support surface in bed and pressure reduction sitting/wheelchair surface. The same Care Plan was updated 7/12/23 and shows resident has actual open area: unstageable coccyx due to worsened excoriation. R106's Skin assessment dated [DATE] shows excoriation/blistering to both buttocks. R106's Skin assessment dated [DATE] shows Moisture Associated Skin Damage (MASD) Excoriation on bilateral buttocks and coccyx with increased skin redness. R106's Skin Assessments on 6/27/23 and 7/4/23 shows worsening MASD excoriation. R106's Progress Note from V13 dated 6/28/23 shows discussed care and course of treatment and obtained general consent to evaluate and treat. Patient not seen, up in chair. R106's Skin Assessment on 7/12/23 shows pressure ulcer, site: coccyx, Stage: unstageable, Length 6 cm, Width 6 cm, Appearance: slough, Color: yellow. R106's Progress Note from V13 dated 7/19/23 shows unstageable pressure injury sacrum, 3.5 cm Length x 3 cm width. 100% slough. Post Debridement Wound Bed 3.5 cm length x 2.5 cm width x 1/1 cm depth. Removed some slough today, able to better determine depth but still 100% slough left on wound bed. Treatment Order: Preventative Wound Recommendations: Low air loss mattress recommended. The facility's View Delivery Order Form dated 7/25/23 shows a low air loss mattress was ordered for R106 on 7/25/23. 2. On 07/24/23 at 9:41 AM, R183 was in bed (on a regular mattress) with V7 (R183's husband) at bedside. V7 stated R183 has a sore on her bottom that causes her pain, she cries like a baby. They have not been changing the dressing. They didn't change it on Friday, Saturday, or Sunday. I'm here from 8 AM to 8 PM and they say they will take care of it, but they don't. They change it when they remember. On 07/24/23 at 9:41 AM, V8 Certified Nursing Assistant (CNA) lowered R183's saturated brief and R183's dressing to her right buttock was undated, saturated with yellow/tinged with pink drainage, and was rolled up (not on wound) in the brief. R183 had a large golf ball size wound with immeasurable depth on her coccyx. R183's brief was completely saturated with urine. R183 had an open excoriated area on her left buttock. R183 winced when moved during incontinence care. V8 said she had checked R183's brief at 8 AM and she saw a dressing in the brief but did not change R183 at that time. On 07/24/23 at 11:45 AM, R183 was up in the wheelchair at bedside with V7. V7 said R183 was crying like a little girl, she is in so much pain from her bottom. V7 said he was there when V8 came in and checked R183 earlier, but V7 only looked at R183's brief and didn't check the dressing at all. On 07/25/23 at 9:27 AM, R183 was in bed on her back. There was no air mattress on the bed. On 07/25/23 at 1:30 PM, R183 was up in the wheelchair at the bedside with V7. There was an air mattress on the bed. V7 stated they just put that mattress on the bed now. I've been asking for a month for that bed! She had one like that in the hospital. R183's Physician Orders shows R183 was admitted on [DATE]. R183's Skin assessment dated [DATE] shows sacrum: stage 3, length: 4.5 cm, width: 2.5 cm, depth: 0.5 cm, Appearance: dry, pink, no drainage or exudate. R183's Skin assessment dated [DATE] shows sacrum: unstageable, Appearance: necrotic, Color: gray, Drainage: moderate, Exudate: sanguineous. R183's Physician Progress Note by V13 dated 7/19/23 shows Unstageable Coccyx pressure injury. Post Debridement Wound Measurement 3 cm length x 3 cm width x 0.8 cm depth with 50% slough remaining. Treatment Order: Every Day and as needed cleanse wound with normal saline, santyl nickel thick layer, cover with moist gauze. On 07/26/23 at 11:15 AM, V13 Wound Doctor stated R183 has an unstageable on her coccyx. She should have an air mattress. It off loads to decrease the pressure on the wound to help heal. In general, all pressure wounds that are stage 2 or greater should have air mattress and wheelchair cushions to reduce pressure. On 07/25/23 at 9:40 AM, V5 Wound Registered Nurse said wound assessments are done weekly and include measuring the wounds, assesses the treatment orders to determine whether to continue or change them, and looking at the pressure reducing interventions in place. V5 said pressure reducing intervention used are turn/reposition every 2 hours, low air loss pressure reducing mattress, protein supplements, wheelchair cushion or roho cushion. V5 stated any resident comes in with a pressure wound should have an air mattress. They should have some sort of pressure reducing cushion on their wheelchair. I thought R183 had an air mattress, I'll have to double check. If a dressing is rolled or not in place it should be changed right away. R183's Care Plan dated 6/26/23 shows R183 has an alteration in skin integrity and lists pressure reduction support surface in bed. R183's Physician Orders shows R183 was admitted on [DATE] and contains no order for a low air moss mattress. The facility's Prevention of Pressure Ulcers/Injuries Policy dated 9/2021 shows review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Conduct a comprehensive skin assessment including areas of impaired circulation due to pressure from positioning. Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body weight, and overall risk factors. Review the interventions and strategies for effectiveness on an ongoing basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents are free from significant medication errors for 1 of 3 residents (R1) reviewed for medications in the sample of 6. This failure resulted in R1 having a hypoglycemic episode with stroke like symptoms, requiring hospitalization for 6 days. The findings include: On 7/19/23 at 10:15 AM, R1 was sitting in his room, talking on his phone. R1 was alert and orient and able to answer questions appropriately. R1 stated I've been back here for a few days now; I was in the hospital a couple times. The last time, they sent me out, I couldn't talk. I was in the hospital a few days because they gave me the wrong medication. The hospital found out I was given diabetes medication, I'm not diabetic. It was very scary. I could have had a stroke! On 7/19/23 at 10:50 AM, V6 Nurse Practitioner said R1 went to the hospital for a hypoglycemic episode and was there for a few days. V6 stated R1 is not diabetic and is not on any diabetic medications. V6 said if a diabetic medication is given to a non-diabetic patient hypoglycemia can occur. V6 said she gave orders to check R1's blood sugar twice a day to monitor R1's blood sugars for hypoglycemia since he came back. On 7/19/23 at 12:22 PM, V2 Director of Nursing said V7 Registered Nurse (RN) was the nurse on duty 7/2/23 for R1 and V7 was currently on vacation in the Philippines and not available. V2 was not aware of any medication errors reported to her and had not been told about R1's hospital test results showing R1 had been given a wrong medication. On 7/19/23 at 12:24 PM, V7's phone was not accepting calls at this time. On 7/19/23 at 12:25 PM, V8 RN Supervisor said he was the supervisor on duty when R1 was sent to the hospital. V8 said V7 RN came to him and asked him to check on R1 because V10 (R1's wife) said R1 was not acting himself and insisted something was wrong. V8 said he looked at R1 and new R1 was not himself. V8 said R1 could not talk to him and was unable to follow commands. V8 said he activated 911 and R1 was sent to the hospital. On 7/19/23 at 12:37 PM, V6 said if R1's sulfonylurea blood test (done in the hospital) is positive that would indicate that R1 was given a medication containing sulfonylurea which is found in diabetic medications. V6 said the test results would be helpful to know how to move forward in treating R1 and figuring out why R1 had a hypoglycemic event. On 7/19/23 at 1:35 PM, R1 said the hospital called his wife (V10) at home and told her the test results showed he had been given the wrong medications. On 7/19/23 at 1:47 PM, V11 Hospital Critical Care Doctor was paged and did not return the call. On 7/19/23 at 2:35 PM, V9 Social Service at Hospital said her coworker called in the complaint as a mandated reporter. V9 said R1's blood test for sulfonylurea came back positive for glimepiride. V9 said R1 is not a diabetic and had not been prescribed that drug so they reported it. V9 said they called R1's wife and spoke with her about the test result and what it meant. On 7/20/23 at 8:44 AM, V10 said she was at the facility the evening R1 was sent to the hospital. V10 said V7 brought in medications for R1 and poured all of them in R1's mouth at the same time. V10 said R1 couldn't swallow the pills or move his mouth or lips at all. V10 said she told V7 something was wrong and V7 kept trying to get R1 to swallow pills giving him Glucerna and pudding. V10 said she told V7 again that something was wrong, R1 was not himself, he couldn't move his lips at all, and his eyes were huge. V10 said two other nurses came into the room and V8 said to call 911. V10 said R1's face was drooping like he was having a stroke. V10 stated I was so scared; I rode in the ambulance with him. I thought he was having a stroke! V10 said when they arrived in the hospital R1's blood sugar was 17 in the emergency room and they were telling her that something was wrong, R1's sugar shouldn't be that low. V10 said R1 was admitted to the Intensive Care Unit where she stayed with him for several days while R1 received intravenous fluids with sugar in them. V10 said R1 was discharged back to the facility after his sugars were better. V10 said she received a call from the hospital a few days ago and they told her that the test results show R1 got medication for diabetes. V10 said the hospital was going to let the facility know what happened. On 7/20/23 at 9:06 AM, V2 Director of Nursing said she did receive the test results from the hospital for the sulfonylurea test and the results shows glimepiride positive with a result of 16. V2 said she was able to pull pharmacy records and there were residents in that hallway that were diabetic and had that prescribed medication. V2 said the resident's medications come in packets, sometimes with multiple drugs in each packet. V2 said the nurses are supposed to verify the resident name on the packet and check the medication order in the Medication Administration Record, verifying the medication and dosage before giving to the resident. V2 stated this is a disturbing mess! The nurse must have given the wrong medications in the morning and R1 started having signs and symptoms later that day around supper time. On 7/20/23 at 10:42 AM, V12 Social Service at Hospital said when R1 was at the hospital, the doctors and pharmacist thought something was off that R1 was having this hypoglycemic episode since he was not a diabetic and his records showed no order for diabetic medications, so they ordered a drug panel. V12 said the results did not come back until after R1 was already discharged back to the facility. V12 said the drug panel came back positive for glimepiride and confirmed the result of 16 indicating the drug was given to R1. V12 said she spoke with V10 and then reported to IDPH as a mandated reporter. R1's Minimum Data Set, dated [DATE] shows R1 is cognitively intact with diagnoses of: anemia, atrial fibrillation, coronary artery disease, gastroesophageal reflux disease, septicemia, hyperlipidemia, arthritis, respiratory failure, aftercare following joint replacement surgery, presence of left artificial knee joint, osteoarthritis, partial intestinal obstruction, Crohn's disease, ileus, and chronic combined systolic and diastolic heart failure. R1's Physician Order Activity Report dated 7/19/23 shows from 6/18/23 to 7/19/23 there are no orders for glimepiride or any other diabetic medication. R1's Nursing Home to Hospital Transfer Form dated 7/2/23 shows R1 was transferred to the hospital for facial droop and altered mental status on 7/2/23 at 7:30 PM. R1's Hospital Discharge Instructions dated 7/8/23 shows R1 was in the hospital from [DATE] to 7/8/23. The same instructions show a pending lab of sulfonylurea screen blood sent out 7/3/23. R1's Hospital History and Physical dated 7/2/23 shows [AGE] year-old male with recent left total knee replacement. Today, he was in his usual state of health. He ate dinner, he was given his evening meds. Shortly after, he began having alerted mentation. He developed slurred speech, facial droop, and he was not following commands. Accucheck per Emergency Medical Services (EMS) was 75. Upon arrival here accucheck was 17 and 18 on recheck. He was given dextrose 50 and blood glucose level increase Neuro symptoms have resolved. He feels back to baseline. He has no history of diabetes and is taking no meds for diabetes. R1's CarePort-Printable Review Referral Paperwork dated 7/8/23 shows R1's blood glucose lab result of 49 LL on 7/2/23 at 8:41 PM (normal range 70-99). The same paperwork contains a Critical Care Physician Progress Note dated 7/3/23 at 1:15 AM shows He presented to hospital emergency room (ER) late on 7/2/23 with facial droop and aphasia. Per notes upon arrival blood glucose was 17 and 18 on initial checks and he was given intravenous dextrose 50 (D50) with rise in blood glucose and a normalization of neuroexam. Repeat blood glucose in ER again noted to be low at 18. Additional D50 given and placed on infusion and admitted to intensive care unit for continued care. He has no history of diabetes and takes no oral hypoglycemic medications and is not on insulin. Elevated insulin and c-peptide levels were noted and raise concern for inadvertent administration of sulfonylureas while at rehab. Check sulfonylurea levels. V11's Progress Note dated 7/3/23 at 1:55 PM shows Active Problem: hypoglycemia- no history of diabetes, not on antihyperglycemics, erroneous sulfonylurea administration at skilled nursing facility? Sulfonylurea lab pending. Acute metabolic encephalopathy secondary to hypoglycemia, present on admission-resolved, confusion and altered state was due to his low glucose, with normalization of glucose, his mentation has normalized. R1's sulfonylurea screen from the hospital dated 7/3/23 shows glimepiride-positive result of 16. The facility's Physician Order Activity Report dated 7/2/23 shows R6 had an order for glimepiride 4 mg. The facility's Census for 7/2/23 shows R1 was in room XXX and R6 was in room YYY. The facility's Schedule for 7/2/23 shows V7 was the nurse assigned to the wings (including both R1 and R6). The facility's Administering Medications Policy dated 9/2021 shows medications must be administered in accordance with the orders, including any required time frame. The individual administering medications must verify the resident's identity before giving the resident his/her medications. The individual administering the medications must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method(route) of administration before giving the medications.