**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy and procedures, staff and resident interviews, the facility failed to protect the resident's right to be free from physical, and verbal abuse for 1(Resident #999) of 3 residents reviewed for abuse.The findings included: Review of the facility policy N-1265 Abuse, Neglect, Exploitation and Misappropriation effective 11/30/14 (revised 11/16/22) documented It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse . Employees of the center are charged with a continuing obligation to treat residents so they are free from abuse . No employee may at any time commit an act of physical, psychological, or emotional abuse . against any resident . Acts of abuse directed against residents are absolutely prohibited. Any action that may cause or causes actual physical, psychological or emotional harm which is not caused by simple negligence, constitutes abuse . All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights. Review of the clinical record revealed Resident #999 was a [AGE] year-old, Spanish speaking female with an admission date of 5/10/25. Diagnoses included displaced fracture of fifth cervical (neck) vertebra, peg tube (a tube inserted into the stomach to provide nutrition and hydration) placement, type 2 diabetes mellitus, hypothyroidism, and pain. Review of the Medicare 5 day Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 6/22/25 documented Resident #999 was dependent to go from sitting to standing and for transfers. The MDS noted Resident #999 scored 06 on the Brief Interview for Mental Status, indicating the resident's cognitive skills for daily decision making were severely impaired.On 7/7/25 at 9:09 a.m., Resident #999 was interviewed with the assistance of Registered Nurse (RN) Staff E translating in Spanish. The resident said a male therapist came to her room and yelled at her because she had pain in her back. He was very angry for no reason. She said he pulled her from the wheelchair (w/c) and forcibly put her into bed. She did not know why he did not take her to the therapy room. She does not speak English, did not understand him and did not offer her a translator. The resident said the therapist was fine when he came in but got angry with her, because she did not understand the instructions he gave her. When he put her in bed, she hurt her cervical area, she had a fracture there and had recently had surgery. She said she told the therapist he had hurt her, he smiled at her. Resident #999 said the therapist used a gait belt to lift her up out of the wheelchair and he threw her into bed. The resident said there was no other person in the room when the male therapist was providing care. She said she was yelling and crying. A female therapist and the nurse came into her room when they heard her yelling.She said when she started to yell and cry, the therapist left her room; he was very angry. He did not say anything to me. He told her about the therapy, and she did not understand him.Resident #999 said after it happened, she was anxious and fearful, she did not expect that to happen to her. She was screaming and crying because he had hurt her.Review of the facility's incident investigations revealed on 6/13/25 the facility initiated a physical and verbal abuse investigation for Resident #999.Review of the investigation revealed:On 6/13/25 at 3:30 p.m., Physical Therapy Assistant (PTA) Staff A and Occupational Therapist (OT) Staff D were assisting Resident #999 to transfer from her bed to the wheelchair. During the transfer PTA Staff A grabbed the resident's arms and started to yell at her and shake her for not following his directions for the transfer.Registered Nurse (RN) Staff C in her statement said on 6/13/25 at approximately 3:25 p.m., she was one room down the hallway and heard Resident #999 screaming out. She went to the resident's room and saw a male therapist with his hands on both of the resident's arms yelling and shaking her and he stated very loudly I told you not to do this. This is why you keep getting hurt. The resident was crying and stated that he hurt her and was pointing to her peg tube area.RN Staff C had a certified nursing assistant stay with the resident while she went to report the abuse.PTA Staff A said in his written statement that around 3:00 p.m., when he arrived in Resident #999's room, the resident was upset and started to complain in rapid Spanish which he didn't understand. The PTA gave her detailed instructions on how to transfer from the bed to the wheelchair and how to place her hands. After detailed instructions, the resident grabbed the wrong armrest and started to twist her arm and gave out a loud scream. PTA Staff A asked why, in a loud voice, she grabbed the wrong armrest despite all instructions given. That's when RN Staff C came into the room and witnessed the PTA's question to the resident and said, This is patient abuse.OT Staff D in her statement said she was in the room assisting PTA Staff A with Resident #999's transfer. The resident was positioned properly and educated numerous times by PTA Staff A on safe transfer techniques. The resident grabbed the wrong armrest, would not let go, started screaming and was very fearful. PTA Staff A became very loud and upset at Resident #999 stating she needed to listen to him so that she doesn't get hurt.The investigation noted on June 13, 2025, at approximately 3:45 p.m., the Administrator interviewed PTA Staff A and asked the PTA what happened with Resident #999. PTA Staff A replied, You can fire me now. I lost my cool and was rough with the patient and yelled at the patient. He went on to describe and show how he was attempting to get Resident #999 to transfer from the bed to the wheelchair.The facility verified the allegation of abuse.On 7/7/25 at 11:39 a.m., in a telephone interview OT Staff D said she had provided treatment to Resident #999 for a couple weeks. OT Staff D said she was standing nearby when PTA Staff A went to transfer Resident #999. Once the resident had transferred to the wheelchair, PTA Staff A yelled at her loudly that she needed to listen to him. She left the room when he was yelling. OT Staff D said PTA Staff A raised his voice because Resident #999 did not understand and did not listen. PTA Staff A spoke with the resident in some Spanish. OT Staff D said Resident #999 understands English way better then she pretends. She said they had done the transfer many times before. The resident gets very scared, he explained the procedure. PTA Staff A was frustrated because Resident #999 was screaming. OT Staff D said after the resident got into the wheelchair, I decided I did not need to be there. The door was open, and I left. The nurse came after the fact, she was not there to see anything, I don't know what she saw. I left the room to document the therapy provided. I was involved with the initial transfer into the wheelchair. I was not there when he transferred her to bed.On 7/7/25 at 12:32 p.m., in a telephone interview, RN Staff C said she was working on 6/13/25 and was administering medications. RN Staff C said, [Resident #999] yelled out and I thought they were probably moving her. The resident yelled again, extremely loud and I walked to her room. I was two doors away. When I entered the room I saw [PTA Staff A] had both hands on the resident's arms and he was shaking her. I asked him what the hell are you doing? The resident was yelling and crying. He said, this is what we have to do with her. I saw [OT Staff D] standing across the hall, looking in the room. I went to her and I asked her, are you going to let him do that to her? She put a piece of paper in front of her face and said, I see nothing, and I hear nothing. I went to the Administrator right away and I told him, and we went together to the resident's room. The resident was in her bed. The Administrator had a Spanish speaking staff member to translate, and the resident said, He threw me in the bed.RN Staff C said she did not witness PTA Staff A put the resident in bed. She said, I witnessed the therapist shaking her and yelling at her, he was very angry. The resident was crying. The resident was in the wheelchair when he was shaking her. He was shaking her, and he was so angry with her. I left the room and went to the Administrator. I did not see him put her into bed.RN Staff C said, I notified the resident's son. He came to the facility and wanted her sent to the emergency room. We did what he asked.On 7/7/25 at 1:20 p.m., in a telephone interview PTA Staff A said, I think I want to give a background first. I worked with the resident for 8 or 9 sessions, and I was very aware of her function and abilities and how she communicates. I think we had good communication and relationship. I had her up and taking 3-4 steps the day before. Her goal was to walk 30 to 40 feet with a walker and assistance. Her right leg and arm are pretty strong; her left leg is weaker. She was able to stand the day before. The resident was in bed supine (on her back). I greeted her and I said let's go and she said yes. I gave her maximum assistance to sit on the edge of the bed. I placed my gait belt around her under her buttocks because of the peg tube. She was very willing to transfer. I placed the wheelchair on her right side. I asked her to place her hand on the far side not the near side, it was very important that she placed her hand on the far side. I gave her a 1,2,3 count, and maximum assistance. She grabbed onto the near side of the arm rest and she started to scream. I thought she was very uncomfortable, it made me nervous because I never heard her screaming like that. She was screaming at the top of her lungs. I thought she was hurting. I kind of shook her hand a little to see if she had pain, and she said no. A nurse came into the room because she heard the resident scream, she said this was patient abuse. Maybe I was shaking her hands at that time, or checking the gait belt, or checking something. No one else was in the room with me, only the patient. I asked her if she was in pain and she said no. I raised my voice asking her why did you put your hand here. That is my one regret, I raised my voice with her. I never yelled at any patient. I shook her hand; I was checking her. If that is deemed shaking, I never shook her body. I was shaking her hand and arm to see if she was okay, to see did she have pain. She was crying, she was sitting in the wheelchair. I put her into bed after that, I thought she was okay. Her right side was stronger, and she was able to stand and get to the edge of the bed. She was losing her balance, and she was screaming again. No one was watching me at all. I think the resident got so scared and was very afraid. I think that is why she screamed. I did not ask her why she was screaming. They think I abused the resident, but I do not think from my point of view that I abused her.On 7/7/25 at 1:47 p.m., in an interview the Director of Nursing (DON) said she was not at the facility when it happened. The Administrator started the investigation. She said, The PTA was not here long and he had a short fuse I guess. The DON said, I do know the resident is not the easiest person to give directions to. She is timid, scared and hesitant to do tasks. The DON said something was going on with the PTA to cause him to have this reaction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure residents were free from abuse, including but not limited to physical restraint not required to treat the resident's medical symptoms for 1 (Resident #1) of 1 resident reviewed for physical restraint. The findings included: Facility policy titled Abuse, Neglect, Exploitation & Misappropriation Revision date 11/16/2022 indicated Abuse is the willful infliction of injury. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of the clinical record revealed Resident #1 was re-admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbance. The admission Minimum Data Set (MDS) assessment noted the resident's cognition was severely impaired with a Brief Interview for Mental Status score of 00. On 6/12/25, record review of Resident #1's chart revealed a progress note dated 6/11/25 reading: When I came back to the unit from B wing, I heard the resident yelling in the dining room. I went in to see what was going on and I saw one CNA holding the resident head and chest and the other by her arm trying to keep her in the chair. She would try to kick the other cna. They were trying to put her socks on. I told them to leave her alone and I assisted her to get out of the chair. It was noted that she had a bruise on her chest and on her Right arm and hand. On 6/12/25 at 10:14 a.m., Resident #1 was observed lying in bed with red and purple bruising noted to her chest approximately 3 inch x 2 inch, bruising to the left forearm and hand, and bruising to the right forearm and hand. On 6/12/25 at 10:40 a.m., Staff C Unit Manager said on 6/11/25 she came on shift and a different nurse told her that Staff D Registered Nurse (RN) walked in and found Resident #1 was screaming and she found one aide holding her with her palm on her forehead and her palm on her chest. There were 2 aides in the room at the time, Staff C said she went and checked Resident #1 as soon as she was told. She said Resident #1 now has a bruise on her chest. She said Staff D was still there charting and she had her write an incident, informed the Administrator and called the Director of Nursing (DON). On 6/12/25 at 10:54 a.m., in a telephone interview Staff D (RN) said she went in and 2 Certified Nurse Assistants (CNA) were holding Resident#1 in the chair. One CNA had her by the head and the chest, and the other CNA was holding her hand at first and then her feet. Resident #1 started kicking at the CNA and she let go. Staff D said Resident #1 was agitated and screaming. Staff D said she told the CNA's to leave her alone and don't touch her. Staff D said she has had abuse training and she didn't like the way the CNA's were holding her. She said Resident #1 sustained bruises. Staff D said they are not allowed to restrain residents, and they were restraining her. Staff D said she guessed they were trying to keep her in the chair because she was trying to get up. I walked in and the one CNA backed off, I said what are you doing? On 6/12/25 at 10:57 a.m., in a telephone interview Staff E (CNA) said Resident #1 didn't want to sit and she helped her to sit down and the other CNA called the nurse. Staff E said, We did nothing wrong. Trying to get her to sit, she don't want to, she try to get up, I help for her to sit down. Staff E said she has had abuse and has never done nothing like that. Review of the facility's incident investigations revealed on 6/11/25 Staff F (CNA) said Resident #1 had been screaming in her bed, left her bed and entered the hallway. Staff F said Resident #1 was screaming and she tried to get her to sit down but she got up again and was screaming so she called the nurse to come see her. On 6/12/25 at 12:23 p.m., the DON said was out of the building at the time of the incident, but if they were truly holding her, it would be considered a restraint. DON said it was all still in the investigation phase and she didn ' t have all the facts, a lot of pieces still haven't been completed, but it would not be right to hold someone physically down in a chair. On 6/12/25 at 2:26 p.m., the Administrator said they are considering the incident as abuse. He said the investigation was still in progress and is an ongoing process at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility's policy and procedure, staff, and family interview the facility failed to implement a systemic approach to identify risk factors and implement appropriate supervision and interventions to prevent avoidable falls with serious injuries for 3 (Resident #10, #69 and #30) of 5 residents sampled with falls or fall related injuries. The findings included: The facility policy N-1259 Fall Management documented Residents are evaluated for fall risk. Patient centered interventions are initiated based on resident risk. A fall refers to unintentionally coming to rest on the ground floor or other lower level but not as the result of an overwhelming external force (e.g. resident pushes another resident). An episode where a resident lost his or her balance and would have fallen if not for another person or if he or she had not caught him or herself is considered a fall unless there is evidence suggesting otherwise when a resident is found on the floor a fall is considered to occur. Purpose: Is to identify residents at risk for falls and establish or modify interventions to decrease the risk of a future fall and minimize the potential for a resulting injury. 1. Review of the clinical record revealed Resident #10 was admitted to the facility from an acute care hospital on 3/1/23 after a fall and fall related fractures to the nasal bones, right maxilla, facial bone and right radius (forearm) fracture. Admitting diagnoses included difficulty walking, dementia, anxiety, repeated falls and Alzheimer's disease. The Annual Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated 3/6/24 documented the resident ambulated independently. The MDS noted Resident #10's cognitive skills for daily decision making were severely impaired. The Fall Risk Evaluation dated 5/13/24 documented a score of 50 indicating the resident was at a low risk for falls. The care plan initiated 12/26/23 revised 4/18/24 identified Resident #10 was at risk for further falls and fall related injuries due to decreased physical mobility, poor communication/comprehension, unaware of safety needs, and dementia. The goal was to minimize risk of minor injury through next review. The interventions included anticipate and meet the resident's needs. Physical Therapy to evaluate and treat as ordered or as needed. Be sure call light is within reach and encourage the resident to use it. Bed in low position. Review of the nursing progress note dated 5/13/24 at 11:40 a.m., documented Resident #10 had a fall hitting the back of her head causing bleeding, Fell in the doorway of [room #]. She was transferred to the local emergency room for evaluation. Per emergency department fracture nose. A nursing progress note on 5/13/24 at 11:45 a.m., documented resident with swelling, bruising and bleeding to face. Rt [Resident] walked into [room #] to visit another resident. She was walking out and fell. She hit her face on the floor causing, bruising, swelling and bleeding. 911 was called and Rt transferred to the ER [Emergency Room]. Results of x ray showed fracture of the nose. Resident returned to facility on 5/13/23. The emergency room discharge paperwork documented diagnosis: closed fracture of nasal bone, contusion of chest wall and fall. The Fall Investigation Form dated 5/13/24 provided by the facility noted the unwitnessed fall happened during the 7:00 a.m., to 7:00 p.m. shift. Resident #10 was found laying face down in the hallway. The form did not list the time of the fall. The interview section of the form noted: Resident: Why they think the fall happened: Maybe I was pushed. First Responder: Location: Hallway; What happened: Fall; Why they think the fall happened: Resident slipped on items on floor. The form listed the root causes as lack of safety awareness, anxiety, walkway unclear. The updated intervention was to educate staff to ensure walkways are clear. Review of the only witness statement obtained from Licensed Practical Nurse (LPN) Staff C documented Resident #10 went into [Room #], the resident in [Room #] told her to get out of the room. She was walking out of the room and fell hard on the floor. She landed on her face; her nose was bleeding. I called 911. The witness statement did not document how the information for the unwitnessed fall was obtained. There was no documentation the facility considered Resident #10's statement that maybe she was pushed as a possible cause of the fall. The care plan was updated on 5/14/24 after the fall with the new intervention, Inservice staff to keep hallways/walkways clear of clutter. Requests for the education provided to staff, resident nursing notes and fall assessments were not provided at the time the survey ended. On 8/21/24 at 12:07 p.m., in an interview LPN Staff C said she was the only one on the floor at the time of the resident's fall on 5/13/24. Staff C said Resident #10 went into (Room #) and she feel in the doorway. Resident #10 said the resident in the room pushed her but the resident she said pushed her was in the bathroom at that time. Staff C said there was a sheet on the floor and she thinks Resident #10 may have tripped on it. She said she spoke with the other resident who said she just told Resident #10 to get out of her room but denied pushing her. Staff C said, We have a lot of wandering residents on this unit and some of them go into other residents' rooms. She said Resident #10 is always saying someone pushed her but she has never seen that. On 8/21/24 at 12:39 p.m., in an interview the Director of Nursing (DON) said she was at the facility and completed the investigation when Resident #10 fell and broke her nose. She said Resident #10 said she was pushed but she always says she was pushed, regardless of what happens to her. She said she has never witnessed anyone pushing Resident #10. She likes to be by herself and is afraid other residents will take her things. She said Resident #10 always carries her things with her because she is afraid someone is going to take what's hers. The DON said, We do have residents who get into verbal yelling matches because it is a secured dementia unit. We do have wandering residents who like to take things from other resident rooms. When asked about the unwitnessed fall, the DON said, As for the fall, no one pushed her. There was something on the floor a blanket or sheet and she slid on it and fell. 2. Review of the clinical record revealed on 8/9/24 Resident #69 sustained a fall resulting in a right wrist fracture requiring surgical intervention. Resident #69 was readmitted to the facility on [DATE]. Diagnoses included vascular dementia, anxiety disorder, Alzheimer's disease, restlessness and agitation. The Quarterly MDS dated [DATE] documented the resident had daily wandering behavior. The MDS noted Resident #69's cognitive skills for daily decision making were severely impaired. The care plan initiated 11/26/21 and revised 11/29/23 identified the resident was at risk for falls due to incontinence, unaware of safety needs, wandering and attempts to stand unassisted. The goal for the resident was to minimize the risk of falls. The interventions specified, Anticipate and meet the resident's needs. Ensure that the resident is wearing appropriate foot ware/nonskid socks when ambulating or mobilizing in w/c (wheelchair). On 8/9/24 the care plan was updated with the interventions to, Perform medication review. Resident sent to ER for eval per MD (Physician) orders. The intervention were to be implemented upon readmission to facility. On 8/18/24 at 10:05 a.m., Resident #69 was observed in the dining room sitting at a table s holding her right hand with the left across her chest. Her right hand and wrist were noted to be very swollen and bruised. Resident #69 has an expression of discomfort on her face with furrowed brow and was rubbing the right hand. On 8/18/24 at 10:10 a.m., in an interview LPN Staff F said the resident fell approximately a week ago and fractured her arm. Staff F said she did not know exactly when or how the resident fell and sustained the fracture. Staff F said Resident #69 had an order for a splint to the right hand but she would not keep it on. On 8/18/24 at 10:14 a.m., Resident #69 was observed at a table in the dining room with grip sock on. Resident #69 stood up unassisted from the table and left the dining room unsupervised. Resident #69 was observed wandering the hallway without staff supervision or redirection. On 8/18/24 at 5:09 p.m., in a telephone interview Resident #69's family member said she did not understand why Resident #69 keeps falling. She said the resident had dementia and wanders. She said, She will wander and will walk until she is fatigued, but they just let them do whatever they want on that unit. They don't do activities. The residents just sit or they walk. No one pay attention. The family member said last year Resident #69 had broken fingers and sutures to her hand but no one could tell her how or why it happened. She said then last October Resident #69 had a broken hip and they did not know what happened. They just told said she had pain when she was ambulating. The family member said, I don't care if you have dementia, if you break a hip you are going to yell out in pain. She said now she broke her wrist, had to have surgery again and once again no one could tell me what happened. She said when Resident #69 returned from the hospital, she told the nurse it was very important to keep the stiches covered and the doctor said she needed to keep the brace on her arm. She said on 8/15/24 the nurse called and said the splint was missing and no one could locate it. She said the surgical incision also looked infected and they contacted the physician for an order for antibiotics. The family member said, I am very upset right now over all of this. It is a small unit for dementia residents. Who is supervising them? On 8/19/24 at 8:38 a.m., in an interview LPN Staff C said on the day Resident #69 broke her wrist I found her sitting on the floor in room [ROOM NUMBER] (not her room) yelling. I knew her arm was broken; I could tell right away. I called the physician and we sent her to the emergency room. She said she did not know where the resident's splint was. She said she was off for two days. When she came back to work on 8/15/24 the splint was missing. They searched for the splint and could not find it. Staff C said, she won't keep it on anyway. She takes it and the dressing off. On 8/19/24 at 8:40 a.m., Resident #69 was observed sitting at a table in the dining room. She had her right sleeve pulled up and was picking at the sutures on the right wrist. There was no dressing in place. The skin surrounding the wound was red and there was an area that was missing the top layer of skin. Staff in the dining room did not intervene or redirect the resident from picking at the sutures. Resident #69 got up and exited the dining room. On 8/19/24 at 10:09 a.m., Resident #69 was observed wandering unsupervised on the unit. Her gait was noted to be very unsteady. On 8/19/24 at 3:18 p.m., review of the incident log revealed 28 incidents of falls from 12/1/23 through 8/19/24 in the secured unit. On 8/19/24 at 4:21 p.m., a meeting was held with the Administrator, the DON, and the Regional Nurse Consultant to discuss Resident #69's fall and supervision necessary to prevent avoidable falls. Resident #69's care plan for falls revised on 11/29/23 noted the risk for falls was related to incontinence, unaware of safety needs, wandering, attempts to stand unassisted. The care plan noted at times the resident refused staff assistance with ambulation. The interventions listed included a medication review (8/9/24), anticipate the resident's needs (11/26/21), and ensure the resident is wearing appropriate footwear/non-skid socks when ambulating or mobilizing in wheelchair. The care plan did not include adequate supervision to prevent avoidable falls and fall related injuries. The Administrator, the DON, and the Regional Nurse Consultant verified the care plan did not include specific measures, including necessary supervision to prevent avoidable falls. On 8/20/24 at 12:22 p.m., in an interview Unit Manager LPN Staff G said she was the manager for B wing and C wing (Memory Care Unit). She said, I go to the memory care unit daily, but the majority of my time is spent on B wing because it is the skilled unit. There are two CNA's, and one nurse assigned for each shift on the secured unit. We don't do anything special for the wandering residents except to try and redirect them to activities but most of them don't sit. The Unit Manager said when she is not on the unit, the nurse is responsible to supervise the unit. On 8/20/24 at 12:49 p.m., in an interview CNA Staff E said when a resident is wandering, they just go, you can't always get them to sit. They get up and they walk, and you try and redirect them but most of them do not do anything, there is nothing back here for them to do. With Resident #69 you can sit her down and she will get right back up. On 8/20/24 at 1:00 p.m., in an interview the DON said Resident #69 does not keep the dressing or anything on the right wrist. She will not sit down and when she does it is only for short periods. She is up and down all the time. She does not sit for activities. On 8/20/24 at 4:48 p.m., in an interview the Regional Nurse Consultant said the facility had no policy to address the needs for the residents on the memory care unit and no policy indicating the requirements for placement on the unit. 3. Resident #30 was admitted [DATE] with diagnosis to include muscle wasting and atrophy, unspecified dementia, longstanding persistent atrial fibrillation, sick sinus syndrome, repeated falls and unsteadiness on feet. The care plan for falls initiated on 7/15/24 noted Resident #30 was at risk for falls related to confusion, incontinence, unaware of safety needs and wandering. The goals were to minimize risk for falls, minimize risk of minor or serious injury and minimize the side effects of medication contributing to increasing residents fall risk. The interventions included to educate the resident/resident's representative/caregivers about safety reminders and what to do if a fall occurs, ensure that the resident is wearing appropriate footwear/nonskid socks when ambulating and physical therapy evaluate and treat as ordered or as needed. The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #30 had a severe cognitive impairment and MDS section E for behaviors indicated Resident #30 exhibited Wandering behavior daily. A change of condition progress note dated 8/3/24 at 8:38 p.m. indicated Resident #30 had a fall and was sent to the emergency room (ER) for evaluation. Review of the incident report created 8/3/24 at 10:15 p.m., indicated the Certified Nursing Assistant notified the nurse Resident #30 was lying on the floor. The Nurse arrived and observed resident sitting up against the wall. Injuries were noted to left eyebrow, left arm skin tear. The resident was limping on the left side when tried to walk. Review of the ER discharge paperwork for encounter date 8/3/24 located in the chart revealed she had received stitches to the injury on the left eyebrow. A progress note dated 8/4/24 at 07:10 am noted: while walking at the hallway resident lost her balance and fell, hitting her head. Resident was wearing nonskid sock. Head to toe assessment done, resident placed on neuro checks. Resident returned back to ed x 2 persons. MD and family notified. Review of the incident report created 8/4/24 at 7:10 a.m., had the same information as progress note and indicated Resident #30 sustained an abrasion to top of scalp, but was not taken to the hospital. A progress note dated 8/5/24 at 5:51 p.m. noted: Resident was walking in the hallway by the nurses. She turned around fast and lost her balance and fell. She hit the left side of her forehead on the floor causing a hematoma. She has no other signs of injury. Moves all extremities normally. Alert and oriented x 1 as is normal for this resident . Resident was transported to Hospital ER for evaluation. Review of the incident report created 8/5/24 at 5:35 p.m., indicated same information as progress note and indicated Resident #30 was sent to the hospital for evaluation of hematoma on left upper forehead. Review of the ER discharge paperwork for encounter date 8/5/24 located in the chart revealed she was discharged from the ER with a primary encounter diagnosis of Fall and closed head injury. A progress note dated 8/5/24 at 11:58 p.m. noted: While sitting at the nursing we heard a thump. Went into Resident #30's room saw resident face down on the floor on the L side of her bed. Blood was coming from the L side of her head. Resident was transferred to her bed from the floor and assessed for other injuries. None noted. Unable to obtain vitals as resident fighting . Received order to send resident to ER. 911 called. Review of the incident report created 8/5/24 at 11:10 p.m., indicated same information as progress note and indicated Resident #30 was taken to the hospital with a laceration to the top of her scalp. Review of the hospital paperwork for encounter date 8/6/24 located in chart revealed Resident #30 had been admitted to the hospital for critical care management of a subarachnoid hemorrhage. Resident #30 did not return to the facility. On 8/19/24 at 2 p.m., LPN Staff C said Resident #30 was very demented and had fallen several days in a row. Staff C explained Resident #30'stypical behavior was she could be resistant to care and liked to do things her way. She said Resident #30 could walk well, had nonslip socks and wandered a lot. On 8/19/24 at 2:05 p.m. Staff E Certified Nurse Assistant (CNA) said Resident #30 used to wander around a lot, room by room, and she would mess up everything in the other residents room. Staff E said when she did that they just told the nurse. Staff E said she wasn't aware of any interventions for falls for Resident #30, nor did she have bedside mats. On 8/19/24 at3:39 p.m., LPN Staff F said Resident #30 wandered all day, room to room digging in stuff, taking clothes from one room to another. She said sometimes Resident #30 would sit down for a few minutes but then she would get up and just go again. Staff F said Resident #30 did have fall mats or a scoop mattress. She said Resident #30 was not one to stay still, unless she was tired she would go lay down, but she was always active wandering around. On 8/19/24 12 p.m., the Director of Nursing (DON) said Resident #30 was identified as a fall risk/wandering in her care plan. DON said somehow it was a miss with implementing any interventions specific to Resident #30 for falls/wandering. DON said in their analysis of Resident #30's falls they identified part of the root cause was she had no fall interventions in place for her falls and wandering behavior.