**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to protect the resident's right to be free from neglect related to: 1) providing timely care and services to prevent physical/emotional discomfort for toileting assistance for one resident (#4) out of five residents sampled, and 2) protecting residents from unsympathetic/negative attitudes from staff for three residents (#6, #7, and #5) out of three residents sampled. These failures resulted in emotional/psychological distress and a fear of retaliation among residents. Findings included: 1. During a facility tour on 6/21/25 at 9:32 a.m., an observation was made of a call light signal on in Resident #4's room. There were no staff observed in the hallway responding the call light. On 6/21/25 at 9:40 a.m., an observation was made of a staff member at the nurse's station while the call light was displaying on above the nurse's station. The staff member, Staff H, Certified Nursing Assistant (CNA), said she was looking for something and could not answer a question on staffing assignments. She said, I don't mean to ignore you; I'm looking for something. Staff H walked away. Staff H did not respond to Resident #4's call light. On 6/21/25 at 9:44 a.m., the call light was still on in Resident #4's room. An interview was conducted with Resident #4 who was in her room, sitting in her wheelchair by her bedside. She stated she was waiting to be assisted with toileting. She said, I have been waiting to go to the bathroom. I need help. The resident stated the CNA (Certified Nursing Assistant) already came a half hour earlier and stated she was passing trays and would come and assist her later. The resident said, Don't call anyone else, she already said to wait . Please do not say anything . She will be mad if you ask her. The resident stated she waits for assistance all the time. When a surveyor suggested again going to get her help, the resident stated a third time, No, do not ask them. They get mad at me. I know they are busy. The CNA said to wait. Review of Resident #4's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses to include: acute respiratory failure with hypoxia, colostomy status, Bipolar Disorder, and depression. Review of a Minimum Data Set (MDS) for Resident #4, dated 5/30/2025, showed the resident had a Brief Interview of Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Section GG: Functional abilities showed, for lower body dressing: The ability to dress and undress below the waist, including fasteners, the resident needs substantial to maximal assistance (meaning helper does more than half the effort). Helper lifts or holds trunk or limbs and provides more than half the effort). C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy include wiping the opening but not managing equipment, the resident required supervision or touching assistance (meaning helper provides verbal cues and or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. Review of the comprehensive care plan for Resident #4, initiated on 4/1/2025, showed a focus area of ADL (Activities of Daily Living) self-care and/or mobility deficit - at risk for developing complications associated with decreased ADL's self-performance related to disease process condition. The goal indicated the resident will have all ADLs completed by staff as needed. Interventions included toileting assistance - Total assist x1. A second focus area revealed Resident #4 was at risk for alteration in skin integrity related to fragile skin, impaired mobility, use of blood thinning medication and morbid obesity with interventions to assist with toileting and peri-care as needed. Review of Resident #4's Kardex report (a document used by staff with specific instructions to a resident's care needs) showed for bladder/bowel: - Assist with toileting and peri-care as needed. - Provide ostomy care as ordered and prn (as needed). The report showed for transfers the resident required extensive assistance x1, for toileting - Total assist x1, for dressing, UB (upper body) limited assistance and LB (lower body) extensive assistance x1. On 6/21/25 at 9:56 a.m., an observation was made of the call light still on in Resident #4's room. Staff D, Registered Nurse (RN)/Weekend Supervisor (WS), was observed going to a storage closet in the same hallway, picking up some supplies, and speaking to Staff E, CNA, asking, Who has room [number]? The resident wants to go the bathroom. I can't do it myself. Staff E, CNA, stated another CNA [Staff B] had the room. Staff D, RN/WS, was observed walking to the resident's room and leaving immediately. She did not assist the resident. The call light remained on. On 6/21/25 at 10:19 a.m. Resident #4's call light was still on. Staff B, CNA, was observed in the hallway, not providing care at the time. On 6/21/25 at 10:23 a.m., Resident #4's call light was still on. An interview was conducted with the resident. She confirmed staff had not assisted her to the bathroom yet. She stated it had been a very long time, since breakfast time. The resident became teary-eyed and said, I need to be changed. Resident #4 said, You can get me help now. I can't wait anymore. The resident stated her colostomy bag needed to be changed as well. She said, The smell is embarrassing. An interview was conducted on 6/21/25 at 10:27 a.m. with Staff E, CNA. She stated she was not assigned the room. She stated another CNA has her [Resident #4]. Staff E, CNA, said, I saw the call light. The supervisor told me. It has been on, probably an hour. I told her CNA the resident was waiting. Staff E, CNA, stated the resident's assigned CNA [Staff B] was helping another resident. Staff E said, Anyone can assist the resident. I could have. Staff E stated they were expected to help each other. She stated the residents should not wait that long to receive assistance. She said, I will go and help her now. On 6/21/25 at 10:33 a.m., an interview was conducted with Staff B, CNA. She stated she dropped off the breakfast trays around 8 a.m. She said, I saw her around 8 a.m.; she asked for ice and a shake. She did not ask to go to the bathroom at the time. When I picked up the tray, around 8:30 a.m., she asked to go to the bathroom, and I told her I would be back. Staff B stated another CNA had turned off the light and told her [the resident] I would be back. She said, I told her 'let me finish your roommate.' I finished her roommate and then went to care for other residents. Staff B stated she had asked the resident to wait maybe about an hour ago. She stated, I will help her now. Staff B stated the resident was dependent on staff for toileting. Resident #4 waited to be assisted with toileting for over 1.5 hours. An interview with Staff D, RN/WS, on 6/21/25 at 11:59 a.m. revealed she was filling in for the weekend supervisor. She said, I went there (Resident #4's room) and answered the light. I spoke to the resident; she said she wanted help to go the bathroom. It was after breakfast. I said I would be back with help. I told her I could not do it myself. Staff D, RN/WS, stated she went looking for help and notified a CNA [Staff E]. Staff D stated Staff E, CNA, reported they would assist her. Staff D, RN/WS said, I should have confirmed. I don't know when it went on or how long it was on. I should have gone to help. Staff D stated she was helping with discharges. She stated she tries to get the lights herself and encourages the CNAs to follow her example. Staff D confirmed waiting over an hour and half to be toileted is too long. She said, I should have gone to help her. I was aware. An hour and half or an hour is too long to wait. Other CNAs should have stepped in. It is not acceptable. I am sorry for the resident. She stated no resident should feel like it was a bother to ask for help. 2. During a facility tour on 6/21/25 at 9:20 a.m., an interview was conducted with Resident #5 in her room. She stated she had a problem with a staff member, a CNA. The resident was hesitant to talk about the problem. She said, I would rather not say anything and I don't want to upset her. The resident stated recently about a week ago, a CNA [Staff C] was providing her care. She stated the CNA was on the phone. She was ordering food during care. The resident stated she asked the CNA why she was ordering food during care. The resident reported the CNA got snappy with me. She stated, Since the incident she has been rude. The resident said, I saw her today. I pray to God I don't have her today. She stated she had not reported the incident to anyone. She said, I don't want any trouble with the CNA. The resident stated when the staff member comes to her room, She is rushed, she makes you feel bad about yourself. She stated, That sort of behavior cannot be right. Review of the admission record revealed Resident #5 was admitted to the facility on [DATE]. Review of a quarterly MDS, dated [DATE], showed the resident had a BIMS score of 14, meaning intact cognition. Review of a Kardex for Resident #5 showed the resident required an assist of x2 for toileting and an assist of x1 for grooming. The resident required an extensive assistance x2 for bed mobility. 3. An interview was conducted with Resident #7 on 6/21/25 at 10:15 a.m. in her room. She stated she has one CNA who is rough with her. She stated the staff member's name was [Staff C]. Resident #7 said, She has a nasty temper. She is short and abrupt during care. She stated the CNA handles her roughly. She stated roughly meant She pulls and tugs on you like you are a rag doll. The resident stated she takes an anticoagulant which makes her skin sensitive, but after the staff member takes care of her, she stated she leaves marks on her skin. The resident stated she had not filed a grievance. She stated she had said something to a nurse. She does not know her name. She stated, I should not say this to you. I don't want to upset her. She is going to take it out on me. You should not tell anyone. The resident was observed with bruising on her arms, consistent with her description. She said, Look, these are worse when she is assigned to me. Review of the admission record for Resident #7 revealed an admission date of 6/18/24. Review of an annual MDS, dated [DATE], showed the resident had a BIMS score of 13, meaning intact cognition. The CNA Kardex showed for ADLs the resident required extensive assist of x1 for bed mobility, toileting dressing and bathing. 4. On 6/21/25 at 10:09 a.m. an interview was conducted with Resident #6. The resident stated, Some of the CNAs here have an attitude problem. She stated she did not know if it was the new CNAs but they seem to lack in bedside skills. She stated, One CNA [Staff C], she is very grumpy, borderline verbal abuse. She is short with people. Resident #6 stated another resident (Resident #7) has expressed fear of the CNA, stating, She is rough, and she leaves marks on her skin after care. She stated some nurses knew about her. She stated, I know some residents are fearful of the staff. The resident said, If you complain, they delay your care. The resident stated she had not spoken to the facility administration, but some staff knew there are a few bad apples. On 6/21/25 at 12:16 p.m. an interview was conducted with the Staff Development Coordinator (SDC/LPN). She stated in-services were on-going due to a couple issues, such as call lights not answered. She stated customer service in-services done all the time, most recently three weeks ago. The SDC/LPN stated they educated about being respectful to residents. She said, The younger generation, they don't act well. The residents get upset with them. It is an on-going issue. We teach them to handle things in a better way. The SDC/LPN stated she had to in-service two CNAs (Staff J and Staff K) 1:1 related to customer service. She stated the residents complained about their behavior. The SDC/LPN said, I would not call it abusive, maybe insensitive. On 6/21/25 at 11:35 a.m. an interview was conducted with Staff C, CNA. She stated this was her first real job. She stated she was learning from the environment. Staff C stated a resident had a care issue with her, [Resident #11]. Staff C said, She does not want me to care for her related to something someone did to her when she was 14. I don't know what I had to do with it. I was advised not to go there by myself. She will claim I did not give her water, or she was stating I was neglecting her, like not changing her and stuff. They investigated, they spoke with her to get her side of the story. The end result they advised me not to go in there. Staff C stated she had not received customer service education. She said, Not that I know of. I did online training when I was hired, but not anything to do with that. Staff C stated she had received Abuse and Neglect training, most recently two weeks ago. She stated the SDC/LPN did it. She stated, She came and said, 'sign this paper about what not to do and how to care for the residents.' Staff C stated there was no reason why the residents would express concerns about her caring for them. She said, If they tell me they have a problem with me, I tell them I'm new and I'm still learning. Staff C said, No, I have not reported anything. Yes, some residents say stuff. I can't name them now. On 6/21/25 at 2:54 p.m. an interview with the Risk Manager revealed the way she investigates a grievance. She said, First, when I receive the grievance, I go to the resident and ask them if they had been abused. If they say 'no,' then I do not pursue it further. She stated she did not interview the staff members named in the complaints because the residents did not explicitly say they were abused. She said, I see what you are saying, the resident does not have to use the word abuse. She agreed if the use words like rough or mean, she should look into it. She stated she did not consider the residents might have been fearful of staff when they say they were not abused or neglected. She stated she did not consider the psychological impact on the residents. She said, I did not consider the fear of retaliation. An interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 6/21/25 at 2:21 p.m. The NHA stated they take abuse and neglect allegations very seriously. He stated in the last 11 days, they had 11 reportables. He stated they have a lot of grievances documented, which indicates they are following their policy. He said some are related to customer services. He stated sometimes they will go to the resident, and the residents will immediately say there were no concerns or they're happy with care. He said, There needs to be a more robust investigation. He said, We need to have accountability. We are trying to change a culture. We have started a Gem program - for staff to immediately reward a resident or get them a special treat if they like. Review of a facility policy titled, Grievance Policy and Procedure, Revised March 2024, showed: Purpose: The center recognizes the guest/resident/legal representative/family has the right to voice grievances to the center without discrimination and without fear of reprisal. The center team members are responsible for making prompt efforts to resolve a grievance and to keep the guest/resident appropriately updated on the progress being made toward resolution. Definitions: Prompt effort to resolve includes the center's acknowledgment of a grievance and to actively work toward a documented resolution of that grievance. Policy: The Grievance Official and Social Services personnel will serve as guest/resident liaisons/advocates in the concern grievance procedure. 1. The center will support the right of the guests/residents to file a grievance anonymously. 2. The center will make information available on how to file a grievance to the guest/resident/legal representative/family. This can be done by providing the information directly to the guest/resident and/or by posting the procedure in prominent locations throughout the center. 3. The name and contact information (business address and email address and business phone number) for the Grievance Official will be posted in prominent locations throughout the center. The Grievance Official is the Social Service Director/designee of the center. 4. The guest/resident has the right to file a grievance orally or in written format. 5. The center will make a prompt effort to resolve any grievance received. Grievances will be reviewed, investigated, resolved and documented in five days. 6. The center team members will immediately report all alleged violations involving neglect, abuse, injury of unknown origin, and/or misappropriation of guest/resident property following the center abuse prohibition policy. 7. The center will review with the guest/resident/legal representative/family the final resolution of the grievance. 8. The guest/resident/legal representative/family have the right to obtain a written decision regarding the grievance. 9. The center will maintain the grievance and any supportive documentation for a period of not less than 3 years. Procedure: 5. a. The Grievance Official is responsible for the following items: 1. Overseeing the grievance process to include receiving and tracking grievances through to their conclusions to include the investigation, documentation of the summary and the follow-up. 2. Leading any necessary investigations. Review of a facility policy titled, Abuse/Neglect prohibition policy and procedure, effective March 2015, showed: Policy: The center recognizes each resident's right to be free from abuse, neglect, and exploitation (ANE), misappropriation of resident property and maltreatment, including, but not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. This includes the center's identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, observing for changes that would trigger abusive behavior, reassessment of the interventions on a regular basis. The center will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; have a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property or have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, misappropriation of property or mistreatment. This center reports suspicions of crimes committed against a resident of this center in accordance with section 1150B of the Social Security Act to at least one law enforcement agency and the State Survey Agency. Definitions: Psychological abuse is defined as: humiliation, harassment, malicious teasing, and threats of punishment or deprivation. Verbal abuse is defined as the use of oral, written, or gestured language. Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to; threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Mistreatment: Inappropriate treatment or exploitation of a resident. Procedure: 3. Employee Obligation: all employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating the resident's rights. Any employee who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source of origin and misappropriation of resident property, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury to the immediate supervisor, or the Director of Quality Assurance, or the Executive Director of the center. 5. Identification: Reporting of suspected maltreatment is required of all team members. All incidents will be reviewed by the center's QAPI Committee for detection of patterns and/or trends. Non-action, which results in emotional, psychological, or physical injury, is viewed in the same manner as that caused by improper or excessive action. All actions in which employees engage with residents must have as their legitimate goal, the healthful, proper, and humane care and treatment of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure three (#320, #62, #321) of four residents reviewed for falls out of a total sample of 53 residents received accurate evaluations of fall risks to ensure adequate supervision, assistance devices, and individualized interventions were implemented to prevent accidents with injuries. Findings included: 1. Review of the admission Record revealed Resident #321 was originally admitted to the facility on [DATE] with diagnoses to include: history of falling, difficulty in walking, pain in left hip, muscle weakness, unspecified dementia, cognitive communication deficit, essential hypertension, and history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. The resident had a recent hospital stay from 2/16/2024 to 2/24/20224 when she was readmitted back to the facility. The admission Record showed an additional diagnosis of traumatic subdural hemorrhage without loss of consciousness, subsequent encounter dated 2/24/2024 following the recent hospitalization. During an interview with Resident #321's family member on 2/27/2024 at 10:24 AM, they revealed Resident #321 had a fall shortly after being admitted to the facility on [DATE]. She stated the staff don't come quickly enough when the call bell is pushed. The family member reported that it could take 20 minutes for the staff to come when she has visited. The family member stated the staff only came after she went to the nurses' station to request assistance because staff were not responding to the call light. On 2/26/2024 at 11:47 AM Resident #321 was observed lying in bed on a scoop mattress with floor mats on both sides of the bed. Review of Resident #321's clinical record revealed an eINTERACT SBAR (Situation, Background, Appearance, and Review) Communication Form dated 2/16/2024. The form revealed the Situation/change in condition was falls, and it was unknown if this had occurred before. The Background section revealed the resident was in the facility for post-acute care with a history of dementia. The Appearance section documented the nurse called this writer (Licensed Practical Nurse [LPN], Staff F) to patient's room. Resident noted on floor bleeding from left side of head. Urinary catheter in place and attached to bed frame. The Review section revealed the primary care clinician ordered the resident to be sent to the hospital and the family member was notified. Review of the Skilled Nursing Facility (SNF) to Hospital Transfer Form revealed the resident was transferred to an acute care hospital on 2/16/24 at 12:00 AM from the facility's Rehab Unit. The resident's usual functional status before the acute change in condition showed the resident ambulated with an assistive device, was totally dependent on staff for bathing, dressing, and toileting and needed assistance with transfers. The resident's usual mental status before the acute change was alert, disoriented, but can follow simple instructions. Risk alerts was checked for high fall risk. A review of the hospital History and Physical, dated 2/16/2024, revealed Resident #321 had an assessment of status post closed head injury; left parafalcine traumatic subdural hemorrhage with no mass effect as well as a large left frontal scalp hematoma status post unwitnessed fall. Resident was evaluated by neurosurgery in the emergency room and recommended ICU (Intensive Care Unit) admission for close monitoring. Plan included no surgical intervention, patient cleared for discharge back to rehabilitation from neurosurgical viewpoint on 2/24/2024. A review of the 02/15/2024 admission Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The resident displayed inattentive behavior that fluctuated (comes and goes, changes in severity). The resident had a history of falls, and falls in the last 2-6 months prior to admission was marked unable to determine. The resident had lower extremity impairment on both sides and required substantial/maximum assistance with mobility, lower body dressing and toileting. Review of Resident #321's Care Plan showed a focus concern (initiated 2/13/2024 and revised 2/16/2024) for Risk for further falls related to: Decreased lower extremity strength, h/o [history of] fall, dementia with Poor safety awareness, Unsteady gait/balance, bowel incontinence, balance deficit, decreased activity intolerance. The Goal for the focus concern (initiated 2/13/2024 with a target date of 2/28/2024) was Will strive to have falls and/or injuries minimized thru management of risk factors while maintaining independence and quality of life through the review date. All interventions to meet the goal were initiated on 2/13/2024 and included: • Encourage appropriate foot wear • Place items used in easy reach i.e. water, telephone, call lights; • Physical Therapy (PT) and Occupation Therapy (OT) to screen prn (as needed); • Keep adaptive equipment within reach • Check for toileting needs • Encourage frequent rest periods Review of Resident #321's Medical Certification for Medicaid Long-Term Care Services and Patient Treatment Transfer Form, AHCA Form 5000-3008 dated 2/12/2024, showed resident to be at risk for falls. Resident #321's AHCA Form 5000-3008 dated 2/18/2024, showed resident to be at risk for falls. Review of Resident #321's Medication Administration Record (MAR) for February 2024 revealed she was receiving: Amlodipine (antihypertensive), Metoprolol (antihypertensive), Pravastatin (antihypertensive), Senna Lax (cathartic), Dulcolax (cathartic), GlycoLax Powder (cathartic), Milk of Magnesia(cathartic), Tramadol (narcotic), and other medications. Review of Resident #321's Fall Risk Evaluation dated 2/12/2024 showed the resident had 1-2 falls in past 3 months, was alert (oriented x 3), was chairbound/continent; and had no predisposing diseases. The sections for systolic blood pressure, gait/balance, and medications were not completed. Because these sections were not completed the fall risk score was not calculated accurately to indicate if the resident was at high risk of falls and no focus care areas, interventions or clinical suggestions were completed to assist in the prevention of falls. On 2/28/2024 at 1:10 PM, Resident #321 was observed sitting in the room lying in the bed. The resident stated, I fell. The resident had no other recollection of a fall and was not able to verbalize what happened. During an interview on 2/28/2024 at 1:15 PM Staff F, LPN reported Resident #321's fall occurred on 2/16/2024 very early in the morning. Staff F reported she was working another hall when the Cart 1 nurse called for me in response to Certified Nursing Assistant's (CNA) call that Resident #321 was on the floor. When I arrived to the room, Resident #321 was lying on her back near the bathroom door. Her head was bleeding, and she was complaining of pain. Staff F stated Resident #321 had a foley catheter, which was still intact, even though the bag was still attached to the bed frame. During an interview on 2/28/2024 at 1:36 PM Staff J, Registered Nurse (RN) stated she reviewed Resident #321's hospital records and family information to complete the evaluations. She reported Resident #321 has a low bed. Staff J, RN reviewed the CNA [NAME] and tasks and stated nothing is showing on the task/[NAME] that would indicated Resident #321 is a fall risk. Staff J stated the CNAs would know Resident #321 was a fall risk by verbal report to one another. During an interview on 2/28/2024 at 2:00 PM the Nursing Home Administrator (NHA) stated she does not know about the falls and to speak with Director of Nursing (DON). During an interview on 2/28/2024 at 2:05 PM the Director of Nursing (DON) stated the Risk Manager (RM) takes responsibility for fall investigations. During an interview on 2/28/2024 at 2:10 PM the RM stated she does not have any information regarding the fall for Resident #321 and would need to follow up. Follow up interview on 2/28/2024 at 4:19 PM with the RM revealed she was just finding out about the fall of Resident #321. The RM confirmed the medical record showed Resident #321 was admitted back to the facility on 2/24/2024 status post fall with a subdural hematoma. The RM continued to state the Fall Evaluation was not completed appropriately for the 2/12/2024 admission. The RM reported that the Fall Evaluation left off a number of factors that would have increased Resident #321's score. The RM validated that no Fall Evaluation had been completed upon Resident #321's return to the facility on 2/24/2024. The RM stated a Fall Evaluation should be completed for all admissions and after every fall. The RM confirmed Resident #321's care plan had not been updated after her most recent fall on 2/16/2024. 2. Review of the admission Record revealed Resident #62 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: Left hip artificial joint, after care following joint replacement, osteoarthritis, rheumatoid arthritis, spinal stenosis, lumbar region, anxiety disorder, depression, muscle weakness, and difficulty in walking. Upon readmission on [DATE] the following diagnosis was added: periprosthetic fracture around internal prosthetic left hip joint, subsequent encounter, incomplete rotator cuff tear or rupture of left and right shoulder traumatic subdural hemorrhage. Review of a MDS with an assessment reference date of 1/5/2024 for Resident #62 revealed a BIMS score of 4 indicating severe cognitive impairment. The resident displayed inattentive behavior that fluctuated (comes and goes, changes in severity). The resident had lower extremity impairment on one side and required partial/moderate assistance with mobility. Review of the Progress Notes for Resident #62 revealed Resident #62 was transferred to an acute care hospital on 1/7/2024 at 3:35 PM due to a fall. Resident #62 was readmitted on [DATE]. Review of Resident #62's Medical Certification for Medicaid Long-Term Care Services and Patient Treatment Transfer Form, AHCA Form 5000-3008 dated 12/31/2023, showed resident to be at risk for falls. Resident #62's AHCA Form 5000-3008 dated 1/9/2024, showed resident to be at risk for falls. Resident #62's AHCA Form 5000-3008 dated 1/15/2024, showed resident to be at risk for falls. Review of Resident #62's MAR for January 2024 revealed the resident was receiving: Buspirone HCl (psychotropic), Fluoxetine HCl (psychotropic), GlycoLax Powder (cathartic), Senna Lax (cathartic), Bupropion HCl (psychotropic), Dulcolax (cathartic), Milk of Magnesia (cathartic), Tramadol (narcotic), and other medications. Review of Resident #62's Fall Risk Evaluation dated 1/2/2024 showed the resident had 1-2 falls in past 3 months, was alert (oriented x 3), and had 1-2 predisposing diseases. The sections for ambulation/elimination status, gait/balance, and medications were not completed. Because these sections were not completed the fall risk score was not calculated accurately to indicate if the resident was at high risk of falls and no focus care areas, interventions or clinical suggestions were completed to assist in the prevention of subsequent falls. Review of Resident #62's Fall Risk Evaluation dated 1/10/2024 showed the evaluation was incomplete for the section of level of consciousness/mental status. Based on the completion of the other sections of the evaluation, the resident scored a 16 (Score 10 or higher indicated high risk of fall); however, the Risk for Falls focus, goals, interventions and clinical suggestions to prevent future falls was not completed. Review of Resident #62's Care Plan showed a focus concern of risk for falls related to: Unsteady gait/balance due to recent left hip replacement, antidepressant medication, and incontinency (created 1/2/2024, initiated 1/22/2024, and revised 1/26/2024). The Goal: will strive to have falls and or injuries minimized through management of risk factors while maintaining independence and quality of life through the review date (created 1/2/2024, initiated and revised 1/22/2024). Interventions to meet this goal created 1/2/2024 and initiated 1/22/2024 included: • Place items used in easy reach i.e. water, telephone, call lights • PT and OT to screen prn (as needed) • Keep adaptive equipment within reach • Check for toileting needs • Interventions dated 1/11/2024 showed: TTWB LLE (Toe Touch Weight Bearing Left Lower Extremity). During an interview on 2/28/2024 at 1:36 PM, Staff J, Registered Nurse (RN) reviewed Resident #62's Fall Evaluation and admission documentation and stated the Fall Evaluation was not accurate. Staff J reported the information missed would have resulted in a higher score and would have placed the resident at moderate risk for falls. Staff J, RN confirmed that the care plan was not individualized for Resident #62 and had not been updated after the fall that resulted in a fracture. 3. Review of the admission Record revealed Resident #320 was admitted to the facility on [DATE], with diagnoses to include: Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, Difficulty Walking, Anxiety Disorder, Diabetes Type 2, Anemia, and Monoplegia of upper limb following Cerebral Infarction. Review of Resident #320's Medical Certification for Medicaid Long-Term Care Services and Patient Treatment Transfer Form, AHCA Form 5000-3008 dated 1/5/2024, showed resident to be at risk for falls. Review of Resident #320's Physician Order Summary Report active as of 1/14/2024 revealed resident was receiving: Alprazolam (psychotropic), Diphenhydramine HCl (antihistamine), Bupropion HCl (psychotropic), Dicyclomine HCl (cathartic), Dulcolax (cathartic), GlycoLax Powder (cathartic), Guaifenesin ER (antihistamine), Labetalol HCl (antihypertensive), Lasix (diuretic), Linzess (cathartic), Milk of Magnesia(cathartic) , Oxycodone-Acetaminophen (narcotic), Sertraline HCl (psychotropic), and other medications. Review of Resident #320's Fall Risk Evaluation effective 1/6//2024 showed the sections for systolic blood pressure and predisposing disease were not completed. Because these sections were not completed the fall risk score was not calculated accurately to indicate if the resident was at high risk of falls and no focus care areas, interventions or clinical suggestions were completed to assist in the prevention of subsequent falls. Review of Resident #320's progress note dated 1/14/2024 at 10:40 AM showed CNA found resident on the floor. Nurse noted resident was lying face down on floor next to the bed. Resident had complaints of pain all over. Supervisor alerted, 911 called. Son and physician notified. Review of the Local County Emergency Medical Services Patient Care Report dated 1/14/2024 at 9:50 AM reveals Resident #320 was found by the Paramedics in bed with care staff at bedside. Patient Primary complaint of a headache. Patient is alert to person, place and event and reports she reached for nurse call button and fell out of bed. Complains of left sided head pain denies loss of consciousness. Review of Resident #320's Care Plan showed a focus concern of risk for further falls related to: daily use of Antidepressants, history of falls, Unsteady gait/balance, occasional bladder accidents (created 1/6/2024, revised 1/11/2024). The Goal for the focus concern was: will strive to have falls and/or injuries minimized through management of risk factors while maintaining independence and quality of life through the review date (created 1/6/2024). The interventions to assist in meeting the goal were Interventions dated 1/6/2024 included: • Place items used in easy reach i.e. water, telephone, call lights; • PT and OT to screen prn (as needed); • Keep adaptive equipment within reach • Check for toileting needs • Interventions dated 1/11/2024 included: Encourage appropriate foot wear and frequent rest periods. During an interview on 2/28/2024 at 1:36 PM, Staff J, Registered Nurse (RN) reviewed Resident #320's Fall Evaluation and admission documentation and stated the Fall Evaluation was not accurate. The information missed would have resulted in a higher score. The score would have placed the resident at high risk for falls. Staff J, RN confirmed that the care plan was not individualized for Resident #320. During an interview on 2/28/2024 at 10:05 AM Staff D, Certified Nursing Assistant (CNA) stated, I just know how to care for residents, I've been doing this a long time. Staff D, CNA continued to state they don't really have a way to know if a resident is a fall risk. Most of the residents on this unit (Rehab) are oriented. An interview was conducted with Staff FF, CNA on 2/28/2024 at 1:10 PM. Staff FF, CNA stated she just knows how to care for residents. There is not any documentation we need to refer to regarding care. Staff FF, CNA stated, we don't need to treat anyone differently. An interview was conducted with Staff F, Licensed Practical Nurse (LPN) on 2/28/2024 at 1:15 PM. Staff F, LPN stated when a resident is admitted the nurse reviews the hospital transfer form and any attached orders. The nurse receives a nurse to nurse report regarding the resident. This verbal report gives us a short description of the resident's diagnosis, health status, behavior, and any unusual events, falls and orientation status would be included in this report. With all of this information the nurse is able to complete the facility required documentation, including the Fall Risk Evaluation. We usually put the same interventions in place for all admits. During an interview on 2/28/2024 at 1:36 PM, Staff J, Registered Nurse (RN) stated the nurse reviews the orders from the hospital to include the hospital transfer form. This information will give us insight on how to complete the evaluations for admission. Sometimes, the family is present and will assist with some of the history if needed. We usually put the same interventions in for all new residents. The information entered in the evaluation assists with the resident's care plan. The care plan links to the CNA [NAME]. The [NAME] is the document the CNAs utilize to care for the resident. The CNAs also know by verbal report from the nurse at times, if there is nothing on the [NAME]. During an interview on 2/28/2024 at 5:18 PM with Staff U, LPN/Supervisor said on all admissions she double checks the evaluations to ensure nothing got missed. The baseline care plan is developed from the evaluations and given to the family. We tailor the care plan based on the evaluations and information is added as it is learned. An interview was conducted on 2/29/2024 at 9:06 AM with the Director of Nursing (DON). The DON stated the nurse admitting the resident completes the Fall Evaluation based on the information they have from the hospital and family. The nurse implements a generic care plan for falls. The supervisor for the shift will review the information for accuracy and update as needed. Therapy will see the resident the following day and assist with updating the care plan, as necessary. The Interdisciplinary Team meets with the family and reviews the baseline care plan with them within 48 hours of admission. We complete an Interdisciplinary Plan of Care Summary (IPOC). If the family is not available to meet in person we complete with them via the phone. The Care Plan Coordinators take over the updating of the care plans after this. During an interview on 2/28/2024 at 10:00 AM the Risk Manager (RM) stated the Fall Evaluation gives a score to alert the staff if the resident is at high risk of falls. This would alert them to ensure additional interventions are in place for the resident. During an interview on 2/29/2024 at 1:13 PM with the Medical Director. The Medical Director stated he is in the facility several times per week and attends the monthly Quality Assurance Meeting. During the meetings the committee discusses several quality related items, for example; response times of call lights, falls, vaccinations and infection rates to name a few. In relation to falls we discuss total numbers. The goal is to minimize injury and identify a resident at admission for fall risks as this would lead to implementation of appropriate measures to prevent a fall with injury. My expectation would be the nurses identify the resident at the time of admission for correct fall risk. The nurse should take the extra minute to review the documentation to determine the correct risk elements. Review of the facility policy titled, Nursing/Risk Management-Risk Evaluation for Falls dated July 2017. Purpose: to identify and address risk factors associated with resident falls, to determine the need for any special care, assistive device or equipment needs, assist with resident care planning needs and to confirm the continued accuracy of the evaluation Post admission within 24 hours of admission, a risk evaluation for falls will be completed to confirm the continued accuracy of the evaluation and to assist with resident care planning Post-Fall 1. Post fall a team meeting of all available should occur. The goal is to huddle, discuss and assess the area of the fall and surroundings prior to the end of shift. This meeting initiates the investigation process. The team should become comprised of the fall ambassador or therapist on duty that shift, nursing team members and housekeeping. The post fall evaluation should be completed by the nurse 2. Therapy should screen for every post fall event 3. Interdisciplinary team (IDT) note will be utilized for documentation of repeat fall review and new fall related interventions . Review of the facility policy titled nursing/risk management-documentation of resident fall dated June 2021. Nursing documentation-resident fall when a resident fall occurs, a detailed narrative description will be documented on the SBAR. Evaluation and documentation will continue each shift for 72 hours using the 72 eval in [the electronic medical record] this narrative nursing note should include: 1. Date, time, and place of accident 2. A witnessed fall: if the fall was witnessed, describe what you saw if witnessed by another, document reported that 3. Unwitnessed fall: if unwitnessed, describe the position and location of the resident 4. Resident statement: document what the resident said regarding the fall. The statements made at the time of the fall are often most accurate 5. Condition of resident: * note the residence mental status at the time of the fall. If there is no change, document no change * obtained vital signs and compare to usual vital signs. Initiate neurological check when head injury is possible or if the fall was unwitnessed * document complaints of pain, using pain scale or no complaints of pain * document any visual signs of injury and evaluate for usual range of motion 6. Where was resident moved -injury: if possible, head, hip, or back injury, evaluate whether residents should be moved to bed. Emergency transport to hospital? How was resident moved? Number of people, lift, etc.? 7. Where was resident moved-no injury: if no injury, documented resident went to bed, sat in chair, continued inactivity 8. Document all resulting actions/interventions to care for the resident 9. Notification-physician: document full conversations to the physician concerning your evaluation(s), your intervention(s), and orders or directives received 10. Notification-legal representative: document all notifications. Indicate time and name of person information was relayed to. Document responsive person identified 11. Review and revise the care plan with new intervention(s) Review of the facility Guideline for Person-centered Comprehensive Care Plan with Effective Date: October 2022 revealed: Guideline: it is the practice of the center to develop and implement a person-centered comprehensive care plan that includes measurable objectives and time frames to meet the preferences and goals, and address the guest/residents nursing, medical, physical, mental, and psychosocial needs The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments and with significant changes in the guest/resident's condition.