**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure two (#2 and #1) of three residents were kept free from abuse out of three sample residents. Specifically, the facility failed to ensure Resident #2 was free from physical abuse by certified nurse aide (CNA) #1. On 1/21/25, CNA #1 entered Resident #2's room to provide care. CNA #1 roughly repositioned Resident #2 with pillows and forcefully pushed Resident #2 toward the wall, causing a loud thud. Resident #2 cried out in pain multiple times, asking CNA #1 to stop being rough with her. The facility failed to initiate an abuse investigation and make a report to the state agency after Resident #2's family reported CNA #1 was rough toward Resident #2 when providing care. The rough care provided by CNA #1 toward Resident #2 caused Resident #2 physical pain and mental anguish as evidenced by her crying out and asking CNA #1 repeatedly to stop and not treat her that way. Additionally, the facility failed to protect Resident #1 from abuse from licensed practical nurse (LPN) #1. Findings include: I. Facility policy and procedure The Abuse Prevention policy and procedure, undated, was provided by the nursing home administrator (NHA) on 3/6/25 at 1:55 p.m. It read in pertinent part, Our residents have the right to be free from abuse, neglect, exploitation, misappropriation of resident property, mistreatment, corporal punishment and involuntary seclusion. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individuals. The Abuse Investigations policy and procedure, undated, was provided by the NHA on 3/6/25 at 1:55 p.m. It read in pertinent part, All reports of alleged or suspected abuse, neglect, exploitation, misappropriation of resident property, mistreatment of residents and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the administrator, or his/her designee, will investigate the alleged incident. The individuals conducting the investigation will, as a minimum: review the completed documentation forms; review the resident's medical record to determine events leading up to the incident, as well as the resident's cognitive function and medical condition; interview the person (s) reporting the incident; interview any witnesses to the incident; interview the resident (as medical appropriate); interviews the resident's attending physician as needed; interview staff members who have had contact with the resident during the period of the alleged incident; interview the resident's roommate two other residents on their hall, family members, and visitors; if the accused is an employee, interview other residents to whom the accused employee provides care or services; if the accused is another resident, interview residents who have contact with the accused resident; if the accused is a visitor, or family member, interview staff and residents who have contact with them; and review all events leading up to the alleged incident. Employees of this facility who have been accused of resident abuse will be suspended from duty until the results of the investigation have been reviewed by the administrator. The administrator or designee will provide a written report as indicated to the [State Agency] as mandated. II. Resident #2 Resident #2, age greater than 65, was admitted on [DATE] and discharged to the hospital on 2/2/25. According to the February 2025 computerized physician orders (CPO), diagnoses included dementia with severe agitation. The 11/14/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of five out of 15. She required partial to moderate assistance with bed mobility, toileting, dressing and personal hygiene and was dependent upon staff for transfers. It indicated the resident did not experience any hallucinations, delusions nor exhibit any behavioral symptoms. A. Resident #2's representative interview The resident's representative was interviewed on 3/4/25 at 4:50 p.m. She said Resident #2 had a recent decline since November 2024 and December 2024. She said her family members felt the facility had broken a lot of trust over the course of her stay at the facility and they were concerned with how staff were treating Resident #2, so they installed a hidden camera in Resident #2's room and recorded the care conferences. She said one of the nurses said during a care conference that Resident #2 would often misbehave and that comment was concerning for the resident's family members. The resident's representative said the facility would constantly complain to the family members that Resident #2 was attempting to get out of bed unassisted. The resident's representative said the camera was placed facing the head of the bed. The resident's representative said, during the second care conference which was held on 1/23/25, the family members expressed several staff members treat her [Resident #2] as a job, not as a human and I find that absolutely deplorable. She said she informed the facility staff that there was a caregiver on the night shift on 1/21/25 that was pretty rough turning the resident, with the resident saying phrases like, don' t touch me like that, you are hurting me and please don' t push my leg. The resident's representative said their family felt they had to be a babysitter to ensure Resident #2 would be well treated and treated with kindness. The resident's representative was interviewed again on 3/5/25 at 3:15 p.m. She said during the care conference on 1/23/25, she showed the facility staff, specifically the director of nursing (DON) a picture of a CNA that was rough with Resident #2. She said she took the picture from the video taken on the night of 1/21/25. She said she asked the DON to ensure that CNA (CNA #1) never cared for Resident #2 again. She said the DON and nurse educator (NE) told her they would identify the CNA and provide her with education. The resident's representative said she did not show the video which was taken on 1/21/25 to the facility staff because they did not want them to know there was a camera set up in Resident #2's room, to ensure Resident #2's protection. The resident's representative was interviewed a third time on 3/6/25 at 11:13 a.m. She said there was a video taken on 1/21/25 at 7:32 p.m. of a care interaction between a CNA and Resident #2. She said the video was one minute and twenty seconds long. The resident's representative described the video, the camera is sitting behind the top of [the resident's] bed looking at her head and body from the top of the bed. We see a CNA enter the frame on the left side with pillows in her hands. She is moving quickly and being quite brusque. She picks up a pillow, folds it in half and begins touching near the end of the bed where [the resident's] legs are. [The resident] says something unclear and then or are you going to touch me again? The CNA says, nope, I' m going to touch you again. The resident's representative continued to describe the video by saying The CNA then roughly pushes something near [the resident's] legs (presumably the pillow but it is not seen) and [the resident] cries out, Ow, I don' t want to be touched like that! It hurts! The CNA picks up another pillow and folds it in half. The CNA says, Well, we need you to stay in bed, so you don' t fall. The CNA forcefully pushed [the resident] over on to her right side, towards the wall, a loud thud is heard and [the resident] screams out in pain Ooooowwweee! The resident's representative said the video continued and she said While the CNA is forcefully pushing the pillows under her, [the resident] says I hate it, I don' t want that to happen again. Is that clear?! The CNA moves to the top of the bed and again forcefully pushes [the resident] towards the wall. [The resident] says Oh, that hurts me then rolls back on her back and screams AHHH, Stop it! The CNA pulls on the pillow under [the resident's] head and [the resident] asks Why are you being rough on me? The CNA answers sharply, Because I need you to stay in bed! You then see [the resident] trying to fix her blankets and says, You shouldn' t do that to me, you shouldn' t be here. The CNA is observed pushing the recliner chair directly up against the resident's bed. And the video ends. Cross reference F604 for failure to prevent physical restraints. B. Record review The delusion care plan, initiated on 12/30/24, documented Resident #2 was easily confused at baseline and would make delusional statements to staff. The delusions caused different levels of distress. Resident #2 had intermittent periods of agitation where she tried to get out of bed or her wheelchair. The cognition care plan, initiated on 7/19/24, documented Resident #2 was easily confused and experienced impaired decision making, memory loss and disorientation. The interventions included adjusting questioning according to the resident's current cognitive status, communicating with the family and caregivers regarding the resident's capabilities, engaging the resident in simple and structured activities, keeping the resident's routine consistent and trying to provide consistent caregivers as much as possible in order to decrease confusion. The 1/22/25 nursing progress note documented at 5:17 a.m., revealed Resident #2 showed signs of agitation throughout the shift and refused medications at 7:00 p.m., saying Get that out of my face, while waiving her hands back and forth in fighting motions after multiple attempts. Her family arrived at 11:10 p.m. to sit with the resident. The 1/23/25 care conference progress note documented the family had concerns regarding customer service, professionalism or being made uncomfortable by staff. -Review of Resident #2's electronic medical record (EMR) did not reveal any further documentation regarding Resident #2's family concern of rough treatment of the resident by CNA #1. Staffing documentation for the night shift on 1/21/25 was reviewed on 3/5/25 at 3:00 p.m. CNA #1 was documented as the only CNA working the hallway where Resident #2 resided during the incident on 1/21/25 at 7:32 p.m. C. Staff interviews The clinical consultant (CC) and the NHA were interviewed together on 3/5/25 at 3:09 p.m. The CC said there were staff call offs on 1/21/25 on the hallway where Resident #2 resided. He said CNA #1 was a floating CNA and was pulled to work that hallway due to the staff call offs. The NHA confirmed CNA #1 worked on Resident #2's hallway on 1/21/25. The NHA, the DON, social worker (SW) #1, SW #2 and the NE were interviewed together on 3/6/25 at 11:41 a.m. They all said they were not aware they were being recorded during Resident #2's care conferences. SW #1 said she was aware some residents at the facility had cameras in their resident rooms. The DON said Resident #2's family brought up concerns regarding a specific staff member and asked that the staff member not care for Resident #2 any longer. She said she remembered the resident's family showing her a picture of the CNA, but said she did not know who it was. She said she did not look at the staffing schedule, nor personnel file to determine who the CNA was. The DON said she did not conduct an investigation, nor report to the State Agency following Resident #2's family report of rough treatment of facility staff toward Resident #2. The NHA was interviewed on 3/6/25 at 12:10 p.m. The NHA said the word rough reported by Resident #2's family should have triggered an investigation. She said that was considered an allegation of abuse and an investigation should have been initiated and reported to the state agency. She said today (3/6/25) she had started an investigation, suspended CNA #1 and called the police. She said angel rounds had been completed that morning and in the days that followed the 1/21/25 incident between Resident #1 and CNA #1. She said during the angel rounds they asked questions such as if residents were being treated with respect and dignity and if they felt they were harmed by a staff member or resident. She said the residents had not reported any mistreatment by staff. She said the facility staff who attended the care conference on 1/23/25 said they thought the family had more of a customer service complaint, but the word rough was an allegation of abuse and should have been investigated as such. III. Incident of physical abuse by LPN #1 towards Resident #1 A. Facility investigation The facility incident report, dated 4/12/24 at 11:15 p.m., was provided by the NHA on 3/5/25 at 3:25 p.m. The report revealed an allegation of physical abuse involving Resident #1 and LPN #1. LPN #1 was working on the secured unit and did not like that Resident #1 was reaching over to grab items off the nurse's medication cart. LPN #1 grabbed the items and attempted to remove Resident #1 from the area. LPN #1 grabbed Resident #1's arm. CNA #2 observed LPN #1 grab Resident #1's arm to remove the resident from a restricted area. Resident #1 was assessed by registered nurse (RN) #2 and bruising was noted on the resident's bilateral upper extremities in various areas. CNA #2 submitted a form on 4/12/24 that was completed by CNA #2 and dated 4/12/24. The report documented LPN #1 was blocking the entry to the nurse's office to all of the residents on the secured unit. LPN #1 grabbed Resident #1 by her forearm and twisted it, telling Resident #1 to go away while the resident was trying to enter the nurse's station. Resident #1 grabbed some items from the medication cart and threw them at LPN #1. LPN #1 got upset and yelled at Resident #1. LPN #1 did not let the resident go and was yelling at the resident to stop. Resident #1 was getting more aggressive and combative. CNA #2 said she asked LPN # 1 to let the resident go and LPN #1 said no. CNA #2 told LPN #1 that yelling and grabbing Resident #1 would not help the situation. Resident #1 started hitting CNA #2. CNA #2 took Resident #1 away from LPN #1 and Resident #1 calmed down. The investigation documented Resident #1 was cognitively impaired and did not recall the incident. The investigation documented LPN #1 was interviewed on 4/17/24 at 8:31 a.m. LPN #1 said when she arrived on the unit, the nurse's station had residents roaming around it. She said that after escorting the residents out of the nurse's station, she used the medication cart to block the door. LPN #1 said a CNA was assisting her. LPN #1 said Resident #1 was grabbing things off the cart which she was allowing to happen until she was going for the computer on the cart. LPN #1 said that was when she intervened and was attempting to stop Resident #1. LPN #1 said the altercation was short and that she was not even aware that this was an issue until being suspended. Pictures were included in the investigation that was provided by the NHA on 3/5/25. A picture taken on 4/13/24 revealed round bruising to Resident #1's left wrist. A picture taken on 4/15/24 revealed round bruising to the resident's left lower elbow. Another picture taken on 4/15/24 revealed round bruising on the resident's right arm below the elbow. The facility's investigation revealed that, although Resident #1 presented with bruising, she had a history of sundowning behaviors. The facility concluded they were unable to substantiate physical abuse due to the pattern of Resident #1's bruising that was not consistent with twisting. -However, abuse occurred as CNA #2 observed LPN #1 willfully grab Resident #1's arm. The investigation documented, to help prevent a recurrence, LPN #1, an agency employee, was removed from returning to the facility. B. Resident #1 1. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included mood disorder and dementia. The 1/2/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. She required supervision/touching assistance with eating and toileting. The assessment indicated Resident #1 did not exhibit any physical or verbal behavioral symptoms directed towards others. 2. Record review The mood care plan, initiated 9/14/22, documented Resident #1's short-term memory had continued to decline since she was admitted to the facility. Resident #1 was easily overstimulated and did not do well in loud environments. The care plan documented loud environments caused her agitation and delusions to increase which led to increased exit seeking and striking out at staff. The care plan documented her mood fluctuated from pleasant to angry in a short time. She could verbally and physically strike out during these episodes. Her delusions caused her to become angry and distressed. Interventions included encouraging Resident #1 to participate in activities that may be of interest to her, redirecting the resident if the activity appeared to be overstimulating or triggering to her, ensuring the resident was in a safe place when her anger appeared to be escalating and providing oversight as able to ensure safety. The health status note, dated 4/7/24, documented staff were monitoring Resident #1's arms for redness and irritation. The resident had no redness or irritation noted, lotion was applied and the resident denied itching or pain. The health status note, dated 4/13/24, documented the manager on duty (MOD) was notified by the previous shift's nursing staff during shift change that there was an incident that had happened between Resident #1 and LPN #1. A skin assessment was completed and Resident #1 had bruising to her bilateral upper extremities (BUE), three bruises to her left arm that were 1 centimeter (cm) by 1cm on her wrist, 0.5 cm by 0.5 cm on her lower elbow and 1 cm by 1 cm on her upper elbow. She also had a 0.3 cm by 0.3 cm bruise to her right upper elbow. All other skin areas were clean, dry and intact. The health status note, dated 4/13/24, documented the NHA and the DON were notified of the bruising to the resident's right hand and left wrist/forearm. The NHA and the DON advised staff to call the police. The note documented the police were notified and arrived to investigate. The physician note, dated 4/15/24, documented Resident #1 had bruising on her bilateral arms but denied any pain. -A review of Resident #1's EMR did not reveal any documentation that indicated the resident had sustained the bruising prior to the incident on 4/12/24, where LPN #1 grabbed Resident #1's arm. 3. Staff interviews CNA #3 was interviewed on 3/5/25 at 3:56 p.m. CNA #3 said she was not working when the abuse incident happened on 4/12/24. She said she heard that a nurse was rough with a resident CNA #3 said if she saw abuse, it was her duty to report it right away. She said she would report the abuse to the NHA, the DON and the manager on duty (MOD). She said she would fill out an incident sheet. She said the incident binder was located at the nurse's station. She said she had never witnessed resident abuse. RN #1 was interviewed on 3/5/25 at 4:10 p.m. RN #1 said she received abuse and dementia training when she first started. She said residents on the secured unit required more redirection and cuing. RN #1 said de-escalation skills helped and she tried to incorporate calmness on the secured unit. RN #1 said getting the residents outside for fresh air and walking with them helped keep the residents calm. RN #1 said if she saw resident abuse she would ask that staff member to leave immediately. She said she would approach the resident and de-escalate the situation. She said she would report the abuse to the DON. She said she would document what she witnessed in the resident's EMR The DON was interviewed on 3/6/25 at 10:40 a.m. The DON said agency staff received a large packet of training information that contained abuse, reporting and risk management. She said before agency staff worked at the facility, they had to read and acknowledge the information received. The DON said the residents on the secured unit were not able to verbalize their needs and feelings. She said the unit served residents of all different needs. She said the staff on the unit were trained to anticipating the residents' needs. She said the staff made sure the residents had a good quality of life, dignity, care and felt safe. The DON said she was not sure why the abuse investigation from 4/12/24 was unsubstantiated. The NHA was interviewed on 3/6/25 at 10:54 a.m. The NHA said the abuse investigation was unsubstantiated because LPN #1 said she only grabbed Resident #1's hand and the bruising was on her arms. She said the bruises on Resident #1's arm were not fingerprints. She said the bruising looked old and did not look fresh. She said she did not know if LPN #1 was the one who actually caused the injuries on Resident #1's arms. -However, review of Resident #1's EMR did not reveal documentation that the bruising was present prior to the incident on 4/12/24. The NHA said she was not at the facility when the police officer and nurse spoke to Resident #1. She said the police officer thought the injuries were not from the nurse. She said the police officer said the way the bruising displayed did not match up. She said the bruising showed one finger and there would have been more fingerprints on her arm. She said the police officer made the determination to unsubstantiate the findings. -However, abuse occurred due to CNA #2 observing LPN #1 willfully grab Resident #1's arm to move Resident #1 out of the way (see facility investigation above).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** D. Resident #29 1. Resident status Resident #29, age [AGE], was admitted on [DATE]. According to the November 2022 CPOs Huntington's disease, abnormal weight loss, dysphagia and contractures. The 10/4/22 MDS revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. He required extensive assistance of two people with bed mobility, transfers, toileting, dressing and one assist with personal hygiene. It indicated the resident sustained one fall since the previous assessment with no sustained injury. 2. Record review The 9/15/22 nursing progress notes documented the restorative certified nursing assistant reported to licensed practical nurse (LPN) #3 that Resident #29 was eating breakfast when he slid out of his wheelchair and onto the ground. A review of the resident's medical record did not reveal documentation that a registered nurse (RN) completed an assessment of the resident prior to the resident being moved from the floor or following the fall from the wheelchair. 3. Staff interview The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed on 11/3/22 at 3:35 p.m. The DON said she was aware RN's were not performing assessments of residents following falls. Based on observations, record revise and interviews, the facility failed to ensure four (#39, #90, #86 and #29) of six residents reviewed for accidents out of 43 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to develop and implement a person-centered care plan that identified Resident #39's fall risk and put effective interventions into place to reduce falls and prevent an injury. Resident #39 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease (disorder of the central nervous system that affects movement), dementia, abnormalities of gait and mobility and restlessness and agitation. On 6/29/22 and 10/11/22 Resident #39 sustained falls. The facility failed to put effective interventions into place and the resident had two more falls on 10/14/22, for which he sustained a laceration to his head requiring three staples on the second fall of the day. After the resident sustained a head laceration on 10/14/22, the resident sustained an additional two falls on 10/29/22 and 11/3/22. The facility failed to determine the root cause of the resident's continued falls and put effective, person-centered interventions into place. Additionally, the facility failed to: -Ensure a registered nurse (RN) assessment was completed and documented following sustained falls by Resident #39, Resident #90, Resident #86 and Resident #29. I. Facility policy and procedure The Fall Monitoring and Management policy, dated April 2019, was provided by the nursing home administrator (NHA) on 11/3/22 at 5:06 p.m. It revealed, in pertinent part, The licensed nurse is responsible for assessing and evaluating the resident's fall risk on admission, quarterly, and with a significant change in condition. For an individual who has fallen, the following interventions should include, but are not limited to; obtain vital signs, assess for head injury/change in level of consciousness, assess for change in normal range of motion/weight bearing, initiate neurological assessment on residents that have hit their head or unwitnessed fall (even if resident states they did not hit their head, because they may have hit their head and may not have a recollection that they hit their head), assess for pain, precipitating factors, details on how fall occurred, provide first aide, notify MD (physician) for further orders, notify responsible party, document details under risk management in electronic medical record, document neurological assessments on neurological assessment form, update plan of care to minimize risks for injury due tot falls, monitor/document daily for 72 hours and notify physician if sings/symptoms of complications and update plan of care. IDT (interdisciplinary team) will meet in morning meeting to discuss following: predisposing factors, injuries and interventions. IDT will place fall IDT note in computer with verification of interventions or new interventions. Recommended in the morning meeting would by DON (director of nursing)/designess, activities, social services, and therapy. II. Failure to implement effective person-centered intervention to prevent falls A. Resident #39 1. Resident status Resident #39, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included Parkinson's disease (disorder of the central nervous system that affects movement), dementia, abnormalities of gait and mobility and restlessness and agitation. The 10/3/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score of 14 out of 15. He required limited assistance of one person for med mobility, transfers, locomotion, dressing, toileting and personal hygiene. The resident was occasionally incontinent of bladder and always continent of bowel. The MDS indicated the resident had not had a fall within the review period. 2. Resident interview and observation Resident #39 was observed on 11/2/22 at 5:45 p.m. He was lying in his bed. His call light pad was lying on his reclining chair and was not within reach of the resident. Resident #39 said he had a couple falls, but was unsure what caused them. -There was not a sign in the resident's room reminding him to use the call light. Resident #39 was observed on 11/3/22 at 12:55 p.m. He was in his wheelchair without a shirt on. Resident #39 had a shared room. He resided in the back side of the room closest to the window. The residents roommate preferred to have his curtain shut at all times, which made it difficult to see to the back of the room where Resident #39's bed was. There was a neon green sign on the wall reminding the resident to use his call light (the sign was not in place during the 11/2/22 observation). The resident also had a reacher in his room that was on the ground underneath the window sill. 3. Record review The 6/27/22 admission fall risk assessment identified the resident as at a high risk for falls. The fall risk care plan, initiated on 6/29/22, revealed Resident #39 was at risk for injury from falls due to Parkinson's disease, dementia, poor safety awareness and history of frequent falls. The interventions included: anticipating and meeting the residents needs, placing the resident's call light within reach, ensuring the resident is wearing proper fitting shoes or non-slip footwear, keeping clutter off the floor, requesting a pharmacy review as needed and therapy to evaluate as needed. A review of Resident #39's [NAME] (staff directive) was completed on 11/3/22 at 10:57 a.m. documented the following fall interventions: placing the resident's call light within reach, educating the resident on using the call light, answering the resident's call light promptly, a. Fall incident on 6/29/22 - unwitnessed The 6/29/22 fall risk assessment documented the resident was at a high risk for falls. The 6/30/22 nursing progress note documented by licensed practical nurse (LPN) #4 revealed Resident #39 was found on the floor sitting on his buttocks behind his wheelchair in front of the closed bathroom door after LPN #4 and an unidentified certified nurse aide (CNA) heard a loud noise. The note documented the resident reported he had to go to go to the bathroom and fell. The resident did not report pain, but sustained a 0.5 centimeter (cm) x 0.2 cm abrasion to his right elbow. The area was cleansed and foam dressing was applied. It said the charge RN was notified and assessed the resident. Neurological checks were initiated per facility policy and the residents representative and nurse practitioner were notified. The progress note documented the resident's call light was within reach at the time of the fall. -However, there was not an RN assessment documented in the resident's medical record. The 6/30/22 IDT progress note documented Resident #39 had an unwitnessed fall on 6/29/22. The resident had the sudden urge to use the restroom. Resident #39 sustained an abrasion to his right elbow. The care plan was reviewed and updated. The resident was on therapy caseload and physical therapy was to assess the residents environment to decrease the risk of falls. The 6/30/22 physical therapy progress note documented the resident had a toilet riser in his bathroom. The resident said he had not used a toilet riser in the past and it was difficult for him to use. Physical therapist (PT) #1 recommended removing the toilet riser from the resident's room (see interview below). b. Fall incident on 10/11/22 - unwitnessed The 10/11/22 nursing progress note documented by LPN #5 revealed Resident #39 was found on the floor by LPN #5 after she heard a loud noise from the resident's room. Resident #39's wheelchair was tipped over on its side next to the resident. The progress note documented Resident #39 said he was attempting to reach for the remote and fell out of his wheelchair. The progress note documented an RN assessed the resident after the fall. The progress note documented the resident's call light was placed within reach after the fall and the resident was educated to use his call light (see interviews below). -However, there was not an RN assessment documented in the resident's medical record. The 10/11/22 fall risk assessment documented the resident was at a high risk for falls. The 10/11/22 fall huddle and root cause analysis assessment documented the resident was sitting in his wheelchair prior to the fall. The resident reported he was trying to reach his television remote that was on the floor when he fell. The resident was on isolation precautions related to COVID-19 positive at the time of the fall. The assessment documented the resident was frustrated he was unable to leave his room. The late entry nursing progress note documented by the assistant director of nursing (ADON) on 11/3/22 at 10:11 a.m. for 10/12/22 revealed the IDT reviewed Resident #39's unwitnessed fall from 10/11/22. The resident was on isolation precautions related to COVID-19 positive. The intervention included providing the resident with a reacher for items on the floor. The care plan was reviewed and updated. -However, the residents care plan was not updated until the survey process (10/31/22 through 11/3/22) with the intervention the IDT put into place after the resident sustained a fall on 10/11/22. c. Fall incident on 10/14/22 at 2:45 p.m. - unwitnessed The 10/14/22 nursing progress note documented at 5:34 p.m. by LPN #6, revealed Resident #39 was found sitting upright on his bottom in the bathroom doorway facing the bed. Resident #39's wheelchair was leaning toward the resident on its front wheels. The progress note documented an RN assessed the resident. The resident denied hitting his head. Resident #39 was on isolation related to COVID-19 positive at the time of the fall. Resident #39 said he had gone to the bathroom and was trying to transfer back into his wheelchair when he fell. The resident did not sustain an injury from the fall. The DON, resident representative and the physician were notified of the fall. -There was not a documented RN assessment in the Resident's medical record. The 10/14/22 risk management form documented the intervention was to place a sign in the resident's room to remind him to use his call light (see observations above). The 10/14/22 fall risk assessment documented the resident was at a high risk for falls. The 10/14/22 fall huddle and root cause analysis assessment documented the resident was lying in bed prior to the fall. The resident was confused and was attempting to climb a ladder that did not exist at the time of the fall. The resident was positive for COVID-19, had increased confusion and generalized weakness at the time of the fall. The late entry nursing progress note documented by RN #3 on 11/3/22 at 11:18 a.m. for 10/15/22 revealed the IDT reviewed Resident #39's unwitnessed fall. The fall intervention was to place a sign in the resident's room to remind him to use the call light. -However, the residents care plan was not updated until the survey process (10/31/22 through 11/3/22) with the intervention the IDT put into place after the resident sustained a fall on 10/14/22. d. Fall incident on 10/14/22 at 9:45 p.m. - unwitnessed and sustained a major injury The 10/14/22 nursing progress note documented at 10:39 p.m. by LPN #7 revealed the LPN had just been in Resident #39's room obtained neurological checks from a previous fall and had assisted the resident to the bathroom. Shortly after, Resident #39 was found sitting on the floor in front of his reclining chair. The progress note documented the resident said he was attempting to climb a ladder and pointed to his television. The resident had a laceration to his left temple and had blood running down his face. The progress note documented the resident had increased confusion and was unaware of where he was and unable to recall his last name or date of birth . The physician was called and ordered for the resident to be sent to the emergency room for further evaluation. -There was not a documented RN assessment in the Resident's medical record. The 10/15/22 nursing progress note documented the resident returned to the facility at 6:10 a.m. on 10/15/22. The resident received three staples to his head laceration and was diagnosed with a urinary tract infection (UTI). The late entry nursing progress note documented by the ADON on 11/3/22 at 10:46 a.m. for 10/17/22 revealed the IDT reviewed Resident #39's unwitnessed fall. The resident did not sustain injury from the fall. The intervention was to place a sign in the resident's room to remind him to use his call light and wait for assistance. The care plan was reviewed. The 10/18/22 multidisciplinary therapy screen documented by physical therapist assistant (PTA) #1 revealed the resident was on isolation precautions related to being positive for COVID-19. PTA #1 recommended placing signs in the resident's room to remind him to use the call light and wait for assistance. -However, the residents care plan was not updated until the survey process (10/31/22 through 11/3/22) with the intervention the IDT put into place after the resident sustained a fall on 10/14/22. e. Fall incident on 10/29/22 - unwitnessed The 10/29/22 nursing progress note documented by LPN #7 revealed Resident #39 was found lying on his left side in front of the bathroom door. The progress note documented the resident's wheelchair was next to the bed with the wheels locked. The resident said he was going to the bathroom, which he did not need help with. The progress note documented the resident sustain a laceration to the top of his head on the left side that was 0.2 cm x 0.2 cm. There were no other visible injuries noted. The resident was assisted to the bathroom and then back to bed. The progress note documented the resident was educated on the call light and the resident said he will throw the call light at the wall (see interview below). The resident's representative, physician, DON and ADON were notified of the fall. The 10/29/22 fall huddle and root cause analysis documented the resident was lying in bed with his eyes closed prior to the fall. The resident reported he was attempting to use the bathroom at the time of the fall. The assessment documented the resident had been refusing to use his call light. The 11/3/22 therapy progress note documented the resident had an unwitnessed fall on 10/29/22. PTA #1 recommended placing the resident's call pad next to his hip, so when the resident attempted to get out of bed the resident would trigger the call light. The 10/29/22 fall risk assessment documented the resident was at a high risk for falls. f. Fall incident on 11/3/22 The 11/3/22 nursing progress note documented the resident was found sitting on the floor next to his bed. The right side of his body was against his bed. The resident was unable to explain what happened or what he was trying to do. The resident did not sustain an injury from the fall. The 11/3/22 fall huddle and root cause analysis assessment documented the resident was lying in bed prior to the fall. The resident was unable to explain what he was doing that led him to fall. The assessment documented the resident was recently started on antibiotics for a UTI. The 11/3/22 fall risk assessment documented the resident was at a high risk for falls. 4. Staff interviews CNA #3 was interviewed on 11/3/22 at 12:52 p.m. She said fall interventions for each resident were documented on each resident's [NAME] (staff directive). CNA #3 said the person centered fall intervention that was in place for Resident #39 were frequent checks. She said Resident #39 often forgot to use his call light related to his cognitive status. -However, frequent checks were not on the [NAME] (staff directive) or care plan. LPN #2 was interviewed on 11/3/22 at 1:00 p.m. She said when a resident sustained a fall an RN must assess the resident prior to moving the resident. She said an LPN was unable to assess a resident after a fall. She said it was not within an LPN's scope of practice to assess a resident after a fall. LPN #2 said neurological checks are initiated after a resident sustained a fall and hit their head or for any unwitnessed falls. LPN #2 said the physician, resident representative and the DON were notified after a resident had a fall. LPN #2 said fall interventions should be documented on the resident's plan of care and in their physician orders. LPN #2 said she was not aware of any fall interventions Resident #39 had and was unable to find any person centered fall interventions under the physician orders. LPN #2 said later in the interview she had received education from the physical therapy department the morning of 11/3/23 regarding placing the resident's call pad at hip level, so if the resident attempted to get out of bed the call light would be initiated. The DON and the ADON were interviewed on 11/3/22 at 2:03 p.m. The DON said after a resident had a fall the IDT team reviewed the fall in the morning meeting the following day. She said person-centered interventions were put into place after a resident sustained a fall. She said the interventions were placed on the resident's care plan and sometimes in the physician's orders. She said interventions such as fall mats were put in physician orders to have the licensed nurse ensure the interventions were in place each shift. The DON said the care plan should be updated timely to ensure staff were aware of the person-centered fall interventions. The DON and ADON said the resident sustained multiple falls since he was on isolation related to positive for COVID-19. The DON said Resident #39 had a difficult time adjusting to the facility as he was very independent prior to admission. The DON and ADON were interviewed again on 11/3/22 at 3:23 p.m. The DON said Resident #39 did not always remember to use the call light related to his cognitive status. She said the staff had to remind him constantly to utilize it. The DON said they had not determined the resident was frequently attempting to go to the bathroom when he fell and had not developed a toileting schedule to reduce the risk of falls. The DON said LPN's were not able to assess residents after falls. She said it was not within their scope of practice. The DON said they had noticed LPNs documenting RN assessments and conducted an in-service. -The facility did not provide a copy of the requested in-service on assessments after falls. PT #1 and PTA #1 were interviewed on 11/3/22 at 2:26 p.m. PT #1 said Resident #39 admitted to the facility on [DATE] for therapy services. PT #1 was scheduled to complete the initial physical therapy evaluation on 6/30/22. She said she was notified Resident #39 had a fall the previous night. PT #1 said when she was evaluating Resident #39 he reported he was uncomfortable with the toilet riser that was in his bathroom. PT #1 said she recommended removing the toilet riser. The NHA was interviewed on 11/3/22 at 3:50 p.m. He said all falls were reviewed in the IDT team meetings. He said fall interventions were implemented after the IDT review. III. Failure to ensure Residents #90, #86 and #29 were assessed by a registered nurse after a fall A. Professional reference Colorado Department of Regulatory Agencies, State Board of Nursing: Practice Act and Laws. 2022. https://dpo.colorado.gov/Nursing/Laws retrieved on 11/8/22 at 3:07 p.m. The practical nursing student is taught to identify normal from abnormal in each of the body systems and to identify changes in the patient's condition, which are then reported to the registered nurse (RN) or medical doctor (MD) for further or 'full' assessment. B. Resident #90 1. Resident status Resident #90, age [AGE], was admitted on [DATE]. According to the October computerized physician orders (CPO), the diagnoses included dementia, delirium, bipolar disorder, anxiety disorder, unspecified pain, and a tremor. The 10/23/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and was unable to conduct a brief interview for mental status (BIMS). She required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. She required total dependence on staff for eating. 2. Record review The comprehensive care plan revised on 9/27/22 revealed the resident was at risk for injury from falls due to diagnoses of dementia, chronic pain, and general weakness. The resident had limited mobility with lumbar degenerative disease. 3. Fall report The 5/28/22 risk management for witnessed fall report revealed the resident was assessed for a fall by a facility licensed practical nurse (LPN). The resident sat down on her buttocks with knees slightly bent in front of her. There was no registered nurse (RN) signature on the fall report. On 5/30/22 the interdisciplinary team (IDT) documented a follow-up to the fall in their meeting. However, there was no documentation provided that an RN assessed the resident after the fall on 5/28/22. C. Resident #86 1. Resident status Resident #86, age [AGE], was admitted on [DATE]. According to the October 2022 computerized physician orders (CPO), the diagnoses included dementia, hallucinations, wandering, restlessness and agitation, and a fracture of the left humerus (the bone that runs from the shoulder to the elbow). The 9/14/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of three out of 15. She required supervision with transfers, walking in the room and corridors, eating, toilet use, and personal hygiene. 2. Record review The comprehensive care plan revised on 10/5/22 revealed the resident was at risk for injury from falls due to poor safety awareness. 3. Fall report The 9/5/22 risk management for witnessed fall report revealed the resident was assessed for a fall by a facility licensed practical nurse (LPN) which revealed the resident crossed one foot over the other as getting up, no injuries were noted. The follow-up RN signature about the fall report was signed on 9/6/22 (24 hours later). Under both LPN and RN signatures was a handwritten note which revealed skin was scraped with an abrasion to the left elbow. The note did not reveal who wrote the abrasion note. However, there was no documentation provided that the resident was assessed by an RN after the fall on 9/5/22.