**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent resident verbal and physical abuse for 1 of 8 residents (R2) reviewed of abuse in a sample of 8. This failure resulted in an Immediate Jeopardy on 12/19/24, when V6, R2's brother, who was known to have a history of abusing R2, was allowed to have unsupervised visits with R2 and verbally abused her. Subsequently, on 12/29/24, V6 verbally and physically abused R2. Using a reasonable person concept, this would have caused psychosocial harm resulting in feelings of being unsafe, sadness, fear, and humiliation. The Immediate Jeopardy began on 12/19/24, when the facility failed to prevent V6 from verbally abusing R2 and implement interventions to prevent future abuse. On 12/29/24, V6 again verbally and physically abused R2. On 1/7/25, at 11:00 AM, V2, Assistant Administrator, and V3, Director of Nursing (DON), were notified of the Immediate Jeopardy. The surveyors confirmed by interview and record review, the Immediate Jeopardy was removed on 1/9/25, but remains at a level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R2's Face Sheet, undated, documents she has diagnoses of metabolic encephalopathy, severe protein-calories malnutrition, diabetes, dementia, schizoaffective bipolar disorder, severe intellectual disabilities, Down syndrome, and vascular dementia. R2's Minimum Data Set, (MDS), dated [DATE], documents resident is severely cognitively impaired with minimal hearing deficit. R2's MDS documents she requires substantial assistance with eating, and is dependent on staff for all other activities of daily living, (ADL's). R2's Care Plan, dated 12/21/24, documented R2 is at risk for abuse and neglect due to cognitive impairment and use of psychotropic medications. Care plan interventions include assuring resident is in a safe and secure environment. The goal is that staff will monitor well-being of others and R2 will have zero episodes of abuse and neglect throughout next review. On 4/19/24, the care plan documented V6 visitation is to occur only with window visits and phone visits supervised by staff. Also assess R2 for abuse and neglect upon admission and quarterly, assure resident that she is in a safe and secure environment with caring professionals, assure resident she is in a safe and secure environment with caring professionals, assure resident staff members are available to help, continue to in-service the staff about abuse and neglect, identify areas that put resident at risk, immediately report any episodes of unknown injury, abuse or change in R2's behavior for immediate intervention and review, monitor for any changes in behavior during and following V6 visits, observe the resident for signs of fear and insecurity during delivery of care. No further interventions regarding visits are documented in the care plan. Facility's initial report phoned to the state hotline documented, On 12/29/24 at 1 pm, (V6), (R2's) brother, came into the facility and beat (R2). (V6) put his hands on (R2's) face and said, 'hold your head up or I will break your f****** neck.' (V1, Administrator), called police and police stopped (V6). (V6) was suspended and cannot come into the building until the investigation is complete. V6 was previously banned, and this appears to be an ongoing issue was also documented on the intake investigation. R2's Progress Notes, dated 12/29/24 2:40 PM, documented by V8, Licensed Practical Nurse (LPN), stated it was reported to her by V7, LPN, that V5, Certified Nurse's Aide (CNA) had reported to her that V6 was feeding her lunch and yelled I will break your f****** neck. When V5 went into check on R2, V5 stated V6 had shoved R2's head. The note documented V1 and V3 were notified. R2's Progress Note on 12/29/24 at 2:47 PM, documented V5 reported to V8 that V6 was feeding R2 and yelled using profanity, and stated he would break her neck, and when V5 entered the room she stated she saw V6 shove her head. V5 then told V7. On 12/29/2024, a written witness statement was provided by V5, which documented on 12/29/24, around noon, she was sitting at the nurse's station across from the main dining room. V5 documented she overheard V6 yelling very angrily and aggressively. V5 heard V6 him say, I will break your f***** neck. V5 decided to check on R2, and as she walked into the doorway of R2's room, V6 had shoved R2's head up, leaving her hair ruffled. V5 asked R2 and V6 if everything was okay, and V6 said yes. V5 asked R2 and stated she did not respond. V5 told V6 that R2 had ate all her breakfast. V6 told V5 he had asked two aides if R2 had eaten. V5 told V6 she was on the hall, and he must have asked the wrong aide. V5 then walked away, and stated she reported it to the first nurse she saw, which was V8. On 12/31/24, at 2:45 PM, V5 stated she was sitting at the nurse's station, and she heard V6 yelling angrily about her f******* neck. V5 got up to see what was going on, and as she approached the doorway, V5 witnessed V6's hand coming off R2's head and R2's body coming back from the momentum, with her hair raised up from the physical placement of his hand. V5 stated V6 was pushing R2's head up very abruptly. V5 stated when she approached the doorway, V6 looked at her and didn't say anything. V5 stated V5 immediately went into de-escalation mode. V5 told V6 that R2 had eaten all her breakfast this morning, and it had taken her a long time to do so. V5 added R2 didn't finish breakfast until 9:30 am or so. Since it was around 12:00 pm, V5 explained to V6 it hadn't been that long since R2 had eaten, and that she might not be hungry. V6 replied he had already asked two nursing assistants how she had eaten, and that they did not know. V5 stated she told V6 he had asked the wrong CNAs, since she was the CNA assigned to R2. V5 did not notice any redness on her head, but she did state it was an aggressive shove. V5 added no one should be talking to any resident like this. V5 stated V6 always yells when he talks to her, but this time his tone was out of his norm. V5 stated after this occurred, V6 stayed about an additional 20 - 30 minutes. V6 returned after he had initially left because he had left behind his phone on R2's table. V5 stated the next thing she knew, she was talking to the police officer. V5 stated she has also heard V6 talk derogatory to some of the nurses. About 3-4 months ago, V5 was walking out of the facility and V6 had said to his dog, see that white woman there - get her. V5 stated V6 is known for saying out of line things. V5 stated V1, Administrator, has not contacted her. V5 stated she did write out a statement of the incident like she was asked. V5 stated she has not spoken with any of the management directly. On 12/30/24 at 12:55 PM, V1, Administrator, stated she called the Illinois Department of Public Health (IDPH) hotline and reported the allegation of abuse against R2 by her brother, V6. V1 stated she is still investigating the allegation, and has banned V6 from the facility pending the investigation results. V1 presented a written statement by V5 dated 12/29/24. On 12/30/24 at 1:15 PM, R1 was asked if he ever heard yelling coming from R2's room. He stated R2 yells all night. When R1 was asked if he had ever heard any male voices yelling, he stated that her brother, (V6), yells all the time. R1 stated V6 will yell at R2 to take a bite and to shut the f*** up. R1 stated V6 usually visits R2 at least daily around a mealtime. R1's room is located next to R2's room, on the same side of the hallway. On 12/30/24 at 3:00 PM, V9, CNA, stated V6 has been visiting in the facility without restrictions for at least the past 3 months. V9 stated she has heard V6 yell and curse at R2 in the past, even prior to the abuse that was reported by the paramedic in April of this year. V9 stated she has not worked R2's hall for several months, so she has not recently witnessed V6 interacting with R2. V9 stated she has not issues getting R2 to eat, and she verbally cues R2 to keep her head up, and R2 complies. On 12/30/24 at 3:00 PM, V11, LPN, stated, The facility kept (V6) out of the facility for about 3-4 weeks back in the spring, when the ambulance people witnessed him abusing her, then the facility implemented supervised visits for a while. V11 stated she does not know what interventions have been in place to keep R2 safe when V6 visits, since the supervised visits stopped, and he was allowed to be anywhere throughout the building. On 12/20/24 at 3:21 PM, V4, MDS Coordinator, stated she has worked for the facility for about 2.5 years. V4 stated V6 is allowed to visit anywhere in the facility. V4 added there have been so many incidents with (V6). She receives reports on how V6 talks to R2 and to the staff. V6 is also known to make racial and sexual remarks to staff. V4 stated R2 has spoken with V1, facility owner, and facility lawyers. V4 stated there are no interventions in place to keep R2 safe. V4 stated the previous Administrator had left in August or September. V4 stated R2's current care plan does document the interventions that were put into place in April of this year, after R2's brother, V6, did abuse R2. These interventions document V6 can only visit through R2's window or on the phone with staff supervision. On 12/30/24 at 3:30 PM, V2, Assistant Administrator, stated the facility owner had talked to V6. V2 was unable to remember which of the owners it was. V2 stated V6 had supervised visits with R2 in the conference room, but she would have to ask an owner when these visits started and stopped. V2 stated after there had been no behaviors from V6 during the supervised visits, it was agreed to let him visit in R2's room unsupervised sometime after August. V2 was unaware the previous abuse claim from April 2024 was substantiated. On 12/30/24 at 3:40 PM, V1 was asked when V6 was allowed back in the facility. V1 stated she wasn't sure, but she thought there was a reassessment done due to R2 declining. V1 stated R2 would call out for her bubba. V1 added she would have expected the change in visit status would have been entered on the care plan. On 12/31/24 at 8:17 AM, V13, CNA stated V6 is very aggressive with R2, and he bangs his hands on R2's table. V13 stated V6 curses all the time at R2, and she heard V6 tell R2 to shut the f*** up a couple of weeks ago, and her partner V17, CNA, said she was reporting the incident to management. V13 stated she has no issues getting R2 to eat, she verbally cues her to hold her head up, and sometimes with help her lift her chin. On 12/31/24 at 9:15 PM, V14, police officer, returned call. He stated there are no reports generated from the 12/29/24 police visit to the facility. V14 checked the CAD (computer aided dispatch) program, and stated on 12/29/24 at 1:40 PM, they received a call from V1, and the reason was described as a welfare check. V14 reviewed the visiting officers' notes, which stated no crime appeared to have occurred. There were no witnesses beside the CNA, who reported the incident, and she did not observe any physical contact. The officer observed R2 while V5 was present, and did not see any signs of injur,y and attempted to talk with R2 to the best that her baseline status allowed. V14 added they had dealt with V6 in the past when he had trespassed in the facility. V1 had told police officer V6 was only allowed to drop off food at the nurse's station. V6 received a trespass warning, which involves that he is not permitted to return to the facility, or he will receive criminal charges. V14 stated he reviewed V6's record and found no criminal charges within the county, other than a few traffic citations. V14 stated V6 is hot headed and has an opinion that he will let you know about. V14 stated there was an incident on 5/4/23, which was a domestic report when he pushed the Administrator, and on 5/19/24, a battery report that V6 slapped R2's arm. States Attorney declined to file charges. On 12/31/24 at 9:47 AM, V2, Assistant Administrator/former facility Administrator, stated she went through her emails and texts last night, and she created a timeline of events regarding R2 and V6's issues. V2 stated the facility does not have any interdisciplinary team (IDT) notes, nor documentation in R2's chart. V2 stated she put together a soft file, with a timeline from her texts and emails, regarding enhanced visitation for R2 and V6. This documented that on 8/2/24, V6 had been calling up to the facility asking when he is allowed to come in and see his sister. Corporate team agreed to supervised visits. On 8/4/24, V6 was in the parking lot with a police officer, and it was decided V6 could have supervised visits for 2 weeks in the conference room, with V2 present for breakfast and lunch and reassess in 2 weeks. On 8/19/24, it was decided there were no issues with the supervised visits, and V6 could come back into the facility to assist R2 with feeding all meals. On 8/20/24, visits were permitted in R2's private room. On 12/31/24 at 9:53 AM, V1 stated the maintenance people came to her a couple of weeks ago and reported they witnessed V6 tell R2 to shut the f*** up. V1 stated that she did not report it. V1 just went and talked to R2 about it, and asked her how she was feeling. On 12/31/24 at 10:15 AM V15, Maintenance, stated on 12/19/24 around 1 PM, V15 and V16, maintenance, heard someone yelling very loudly. We saw (V6) was in (R2's) face screaming and telling her to 'shut the f*** up.' V15 reported this to V1. V15 stated became very clear to him that the proper steps were not going to be taken. V15 added, There are people that do their job, and those that don't. (V1) had a very laid-back attitude. I immediately told (V1), and she did not report it to the state. We care for the residents. I pulled (V6) out of (R2's) room, and took (V6) to the conference room, and told him that if I heard that again he would never come in the facility again. V15 stated he has heard V6 saying sexual and vulgar comments to staff. V15 added, (V6) makes our staff feel very uncomfortable. V16 agreed with all the statements provided by V15. On 12/31/24 at 10:37 AM, V1 reported to surveyors she was suspended, and any further questions should be directed toward V2. V1 stated she is leaving because she has been suspended for not reporting the allegation of abuse the maintenance men reported to her a couple of weeks ago about V6 verbally abusing R2. 12/31/24 10:52 AM, V2 stated she started back here in July. V2 stated V6 called nonstop, wanting to visit R2. The nurses stated R2 was not eating and crying out all the time. V2 called her boss, and her boss stated they would discuss supervise visits. In the meantime, V6 came to the facility on a Sunday (she is not sure of date but sometime in August) with a police officer demanding to come in. V2 stated she called her bosses and told them what was happening. V2 stated her bosses said to allow (V6) to visit Monday - Friday, with administration present. (V6) came to feed R2 breakfast and lunch, and was well behaved for those two weeks. (V6) then requested to visit in (R2's) room. The bosses stated to go ahead and allow him back in her room. This occurred around August 20th. No precautions were put into place other than staff were told to keep an eye on (V6 )with R2 from the hallway when they passed by. On 12/31/24 at 11:00 AM, V3, Director of Nursing, stated V6 can be a problem for other people. She added staff don't like him. V3 stated at a previous survey with federal surveyors, V6 yelled and cussed when V3 had to cut the belt off R2's wheelchair tray so it would not be considered a restraint. V3 has not witnessed V6 speaking abusively to R2, but she has witnessed him talk inappropriately to the staff. On 12/31/24 at 11:23 AM, V17, CNA, stated she did witness V6 tell R2 to shut the f**k up a couple of weeks ago. V17 stated she did not remember the exact date. V17 stated she reported it to an agency nurse, whose name she does not recall her. This agency nurse replied that V6 does this all the time. V17 stated she has witnessed V6 cursing and yelling at R2 ongoing for a long time, and management is aware, but nothing is ever done about it. On 1/2/25 at 2:05 PM, V2 stated there has not been any investigation started regarding the verbal abuse allegations against V6 in the middle of December reported by two CNAs, V13 and V17. Abuse Policy and prevention program, dated 10/2022, documented the facility affirms the right of the residents to be free from abuse and neglect. To do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse and neglect. As part of the resident's life history on the admission assessment, comprehensive care plan and MDS assessments, staff will identify residents with increased vulnerability for abuse and neglect who have needs that might lead to conflict. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary. Employees are required to report any incident, allegation, or suspicion of potential abuse, or neglect they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator. The nursing staff is responsible for reporting the appearance of suspicious bruises as soon as it is discovered. The report is to be documented on a facility incident report and provided to the nursing supervisor or designated individual. Following the discovery of any suspicious bruises, the nurse shall complete a full of the resident for other bruises. Accused individuals not employed by the facility will be denied unsupervised access to the residents while the investigation. If classified as an injury of unknown source, the person gathering facts will document the injury the location and time it was observed, any treatment given and notification of the resident's physician, responsible party. The Department of Public Health will be notified. The investigator will report the conclusions of the investigation in writing to the administrator within five working days of the reported incident. The final investigation report shall contain the resident information, the original allegation, the alleged perpetrator, witnesses to the occurrence, circumstances surrounding the occurrence, facts determined during the process of the investigation, review of medical record and interview of witnesses, conclusion of the investigation based on known facts. The Immediate Jeopardy that began on 12/19/24 was removed on 1/9/2025, when the facility took the following actions to remove the immediacy: 1. The affected resident corrective actions: Residents: A. The administrator initiated the abuse investigation. B. To ensure the safety and well-being of R2, the DON (Director of nursing) completed an assessment on 12/30/24. The result of the assessment was documented in the resident's EHR (electronic health records), and the attending physician will be notified. C. The following actions were taken to prevent alleged aggressor from perpetrating additional abusive behaviors. a. Visitor was banned from visitation pending investigation. b. Police were notified of incident. c. Interdisciplinary team (IDT) will review and revise R2's care plan and implement interventions to ensure R2's safety. d. The care plan review and revision were completed by the DON/MDS (minimum data set) Nurse on 1/2/25. D. All residents have the potential to be affected by the alleged deficiency. 2. Immediate Actions: Initiated on 1/7/2025. The facility took the following immediate actions to address the citations and prevent any additional residents from suffering an adverse outcome. A. Administrator and DON education. RNC/designee will provide training to administrator and DON. The training will include buy not limited to following: a. Abuse prevention. b. Allegation of abuse checklist c. Reporting abuse within required timeframe d. Completing investigation per policy and protocols e. Reporting and investigation injuries of unknown origin f. Immediate action to ensure all potential abuse allegations are identified, reported, and investigated as abuse to safeguard the residents' safety. g. Protection of residents from further abuse from alleged perpetrators. B. Staff Education - the administrator will provide training to all staff. The training will include but not limited to the following: a. Abuse prevention including identification of the Abuse Coordinator b. Reporting abuse allegations to the administrator c. Abuse investigation procedures and documentation process. d. Reporting and investigation of injuries of unknow origin e. Immediate action to ensure all potential abuse allegations are identified, reported to the administrator to safeguard the residents' safety. f. Protection of residents from further abuse from alleged perpetrator C. The training will be started on 1/2/2025. D. All staff who are not available and/or currently on vacation will also receive the same education upon their return to work. The administrator will provide the same training. E. The facility will provide similar training to the agency staff. F. Residents were interviewed to identify if they felt safe and/or if they have experience verbal or physical abuse while living in this facility. No concerns were identified. G. Care plan meetings. The IDT will review care plans at least quarterly and as needed. H. As part of monitoring, the Administrator will monitor through facility audit tools five staff members daily for one week and then weekly x4 weeks to ensure any allegations of abuse are reported to the abuse coordinator and investigated and reported to organizations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R11's Face Sheet documents R11 has diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle weakness (generalized), unsteadiness on feet, other abnormalities of gait and mobility, and other lack of coordination. R11's Minimum Data Set (MDS), dated [DATE], documents R11 is significantly cognitively impaired, requires extensive 1-plus person assistance with bed mobility, requires extensive 2-plus person assistance with transfer, and the activity of walking did not occur in the previous 7 days. R11's Fall Risk Assessment, dated 5/3/22, documents R11 is at high risk for falls. R11's Care Plan, dated 10/27/22, documents, (R11) is at risk for falls related to safety deficit with cognition deficit, assistance needs from staff, use of WC, (wheelchair), for locomotion, medication use. R11's Fall Report, dated 4/10/22, documents, NA, (Nurse Aid), noted resident on the floor next to her bed. Resident stated, I just rolled out of my bed, did not hurt myself. Immediate Action Taken: Notified POA, (Power of Attorney), DON, (Director of Nursing), and (V27), Nurse Practitioner, and hospice, VS, (Vital Signs), 102/60 63 18 98% rm, (room air), bolsters on bed applied for perimeter awareness. There was no documentation in the Notes section. R11's Fall Report, dated 9/25/22, documents, Noted resident on the floor next to her bed on her knees, no injuries, resident stated, I'm ok I just slid out of my bed, notified hospice and POA, will continue to monitor. Per resident, I'm ok. I just slid out of bed. Immediate Action Taken: Assessed resident and assisted back to bed. Notes: Staff to put mattress with bolsters to prevent further falls. On 11/17/22 at 2:35 PM, V2, Director of Nursing (DON), pointed to the Notes for the 9/25/22 fall and stated, This is the intervention. Staff to put mattress with bolsters to prevent further falls. This is the same intervention that was implemented for the 4/10/22 fall. On 11/17/22 at 2:11 PM, V1 stated, I would expect changes in the interventions to be added to the care plan the following business day. The Facility's Fall Prevention and Management Policy, with review date of 7/2022, documents, While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe and environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. Facility Guideline following a fall incident: Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence. 3. R74's Minimum Data Set, (MDS), dated [DATE], documents moderately cognitively impaired, extensive assistance of 2-plus persons physical assist for transfers, dressing, and toilet use. The resident does not walk. Extensive assistance of 1-person physical assist for personal hygiene. No falls. Diagnoses stroke, GERD, benign prostatic hyperplasia, atrial fibrillation, high cholesterol, arthritis, dementia and depression. R74's Care Plan, dated 12/2022, documents R74 is at risk for falls related to, assistance needs with activities of daily living, safety needs deficit and use of wheelchair for mobility. Also incontinent of bowel and bladder. Goal: will be free of falls through the next review. Interventions: 12/10/2021 toileting schedule to be in place, 12/20/2021 offer urinal at bedside, offer resident frequent toileting. R74's Fall Risk Assessment, dated 1/27/2022, documents a fall risk score of 16; over 10 is considered high risk for potential falls. R74's Nurse's Note, dated 1/27/2022 at 10:56 PM, documents, Resident was found sitting on the pad beside the bed. He states, he just slid out vs, (vital signs), wnl, (within normal limits), ROM, (range of motion), to all extremities normal. Offers no c/o, (complaint of), pain or discomfort. Nurse practitioner, (NP), notified, no apparent injury will cont, (continue), to monitor. R74's Nurse's Note, dated 6/2/2022 at 10:10 PM, documents CNA (Certified Nursing Assistant) noted resident (R74) on the floor, trying to get out of his w/c, (wheelchair), and fell and hit the right side of his head, redden in color, no c/o pain, notified NP, ordered to sent to ER, (emergency room), due to being on anticoagulant, (blood thinner), and hit his head, notified family and DON, (Director of Nurses), sent to (Local Hospital) for eval, (evaluation.) R74's Nurse's Note, dated 6/2/2022 at 11:59 PM, documents, Resident, (R74), returned from hospital via, (by), EMS, (emergency medical services), and was accompanied by 2-EMT's, (emergency medical technicians), to his room. No new orders received. Resident is in bed resting with call light in reach. Will continue to monitor. R74's Fall Risk Assessment, dated 8/2/2022, documents resident is unable to stand, no falls in last 180 days and not at risk for falls. R74 is total dependent of staff for ADL, (activities of daily living) and requires 2x for transfers. R74's Nurse's Note, dated 8/31/2022 at 12:23 PM, documents, Resident found sitting on floor in front recliner, resident was previous in recliner with feet up, resident attempted to self-transfer and go to bathroom per self, resident slid down front of recliner, no injuries noted, POA notified and NP. R74's Fall Care Plan, dated 8/31/2022, documents, fall intervention use (non-slip mat) in wheelchair was added to R74's care plan on 9/6/2022. R74's Nurse's Note, 9/9/2022 at 11:57 AM, documents, Resident was found on floor on mat, in his room sitting in an upright position, back facing chair. Examined resident no lacerations or bruising at this time. Resident claims to not have hit head. Notified resident NP of fall and condition, also contacted emergency contact and notified of fall and condition. Asked her would she like to patient be sent to hospital, she responded no. Started neuro checks on resident, will cont, (continue), to [NAME], (monitor.) R74's Nurse's Note, 9/19/2022 at 9:47 PM, documents CNA, (unknown) called this Nurse, (V33) to Resident's, (R74's), room. Upon entering, resident observed sitting on floor with his back against the CNA's, (certified nurse assistant's), legs. Resident stated that he did hit his head and c/o a headache. Resident observed with abrasion to right/crown area of head. Assessment performed. PERRLA, (pupils equal reactive to light). No other injuries observed. Family notified. NP notified. Resident transferred to hospital for eval and tx, (treatment.) R74's Nurse's Note, dated 9/20/2022 1:46 AM, documents, Resident returned to the facility from ED, transported by family, no new orders received. Hospital staff called to report that CT, (cat scan), was negative. Resident resting in bed with eyes closed at this time. Call light within reach, will continue to monitor for changes in condition. R74's Care Plan, dated 12/2021, shows no documentation of progressive interventions after the above falls. On 11/16/22 at 9:42 AM, V10 (daughter), stated, (R74) had a stroke prior to being admitted to the facility and has right side weakness in his arm and leg, he was unable to stand or walk. Staff left (R74) alone in his wheelchair and he fell 4 times in 9/2022. Staff weren't doing anything to prevent (R74) from falling. On 11/17/2022 at 11:30 AM, V16, CNA, stated she worked with R74 often. He transferred with assist of 2-staff, and he had multiple falls from his wheelchair. She didn't know how to prevent him from falling, she asked the nurses what to do, but they didn't provide any suggestions. V16 was concerned one of these days, R74 was going to fall and really hurt himself. On 11/17/18/2022 at 1:45 PM, V1, Interim Administrator, stated she is the Regional Director of Career Development, and she doesn't know the residents at all. She expected staff to update residents' care plans, after each fall with a progressive intervention to prevent further falls. V1 also expected the facility to follow the fall policy. 2. R3 had 23 falls, and 9 out 23 did not have progressive interventions. R3's Minimum Data Set (MDS), dated [DATE], documents R3's Brief Interview for Mental Status (BIMS) score of 10, indicating moderate impaired cognition. R3 requires extensive assist with all Activities of Daily Living (ADL's), except eating. When moving from seated to standing position and surface to surface transfer-not steady, only able to stabilize with staff assistance; R3's Physician Order Sheet (POS), undated, documented, Skilled Occupational Therapy, (OT), services 4x's/week, (4 times a week), for 4 weeks per current plan of treatment, (POT). R3's Care Plan, undated, reviewed 11/01/22, documents R3 is High Risk for falls related to, impaired cognition and decision making, vision impaired, self-care deficit and muscle weakness. The same Care Plan also documented R3's has a self -releasing seat belt on his wheelchair, he is able to unfasten it himself. It is used to stabilize R3 when he is in the wheelchair, Care Plan Interventions include Non-Skid Strips to floor next to bed, keep personal items within reach to limit reaching and staff to anticipate R3's need to lay down after meals. Staff to assist resident to bed after meals. R3's Fall Risk Assessment, dated 9/28/22, documents R3 is at Risk for Falls. R3's Fall report, dated 11/7/21, documents R3 was observed on bathroom floor, attempting to self-transfer to toilet from wheelchair, no injuries and denies any pain or discomfort. R3 stated he had to pee. No Interventions documented. R3's Fall report, dated 11/20/21 at 8:25 PM, documents a CNA observed R3 on the floor next to his bed on his back. R3 stated, I was trying to pick up my remote control. No Interventions documented. R3's Fall report, dated 11/20/21 at 8:44 PM, R3 observed laying on the floor on the left side of his bed with remote. R3 stated, I rolled out of bed picking up my remote. No Interventions documented. R3's Fall Report, dated 11/23/21, documents CNA reported that R3 was on the floor on his left side. R3 stated he was sitting up in bed while eating and fell to the ground from the bed. Also state he did not hit his head. No bruising or redness to skin. No open areas noted. R3 stated that he wasn't in any pain. Will continue to monitor. No Interventions documented. R3's Fall report, dated 3/21/22, documents Nurse called to R3's room per housekeeping. R3 was noted to be on the floor sitting on buttocks between chair and toilet. R3 attempted to transfer self from toilet to wheelchair. R3 stated, he was trying to get in his wheelchair. I transferred myself. No Interventions noted. R3's Fall report, dated 3/25/22, documents R3 was found on his back on floor in room, denies pain. Denies hitting head. R3 fell getting out of bed- when asked why he didn't call for help. R3 states, I can do it myself. No interventions noted. R3's Fall report, dated 4/18/22, documents Nurse was called to resident's room and noted R3 laying on the floor next to his bed. R3 stated he was trying to get back in bed. No interventions noted. R3's Fall report, dated 5/30/22, documents R3 found on the floor. No interventions noted. R3's Fall report, dated 6/28/22, documents Nurse notified R3 on bathroom floor, back to toilet in upright sitting position. R3 was transferring self from wheelchair to toilet without assistance, no interventions noted. On 11/15/22 at 8:45 AM, R3 states, Yeah, I fall I be trying to get to the bathroom or bed. R3 stated he did not need assistance right now. R3 did demonstrate he knows how to use the call light. On 11/15/22 at 9:00 AM, R3 was trying to get out his wheelchair without asking for assistance. V7, CNA, was checking her room assignments and interrupted his attempt without assistance. R3 did allow V7 to assist him into getting into bed. R3's Call light Ability Assessment, dated 9/28/22, documents R3 is able to use the Call light. On 11/17/22 at 1:30 PM V1, Administrator, stated, We have interventions in place for (R3). I can't speak on what the prior administrator addressed or not. We have interventions for our time in this facility. (R3) has been referred to OT, hopefully we can get him to the point he can safely transfer. On 11/17/22 at 10:20 AM, V9, LPN, states, I am familiar with (R3), he will not stay in bed, will not stay in his wheelchair and will not use his call light. Somedays he cooperates, but in other days he does not. We have utilized gripper socks and a seat belt for the wheelchair. On 11/17/22 at 1:14 PM, V16, CNA, states, (R3) will not listen. (R3) will wait until you leave his room and then try to get out of his wheelchair. We have told him over and over again. (R3) will get angry if you try to stay in his room. Based on interview, observation, and record review, the facility failed to implement fall interventions for 4 of 10 residents (R3, R11, R55, R74) reviewed for falls in the sample of 33. Findings Include: 1. R55's Fall Care Plan, dated 10/25/22 and 8/2/22, documents R55 is at risk for falls related to impaired cognition, activities of daily living deficit, weakness, and medication. The goal will remain free of falls causing hospitalizations related to injury through next review. On 8/19/22 (interventions include), visual reminder in room and bathroom to use the call light, evaluate cause of falls, gather and assess information on past falls, (review) medication ordered, staff to assist resident with activity (and) set up (the) television. This care plan did not document a fall intervention for the fall of 6/15/22. R55's Minimum Data Set, (MDS), dated [DATE], documents R55 is severely cognitively impaired. For transfer and bed mobility she is an extensive assist of one staff person. R55's MDS also documents R55's balance on moving from seated to standing, moving on and off the toilet, surface to surface, and walking is not steady and only able to stabilize with staff assistance. R55's Fall Risk Assessment, dated 5/9/22, documents R55 is high risk for falls. R55's Fall Risk Assessment, dated 8/2/22, documents R55 is high risk for falls. R55's Fall Investigation, dated 8/19/22, documents, (R55) was found on the bathroom floor. (R55) stated, I was trying to get off the toilet. No pain or injuries was noted, and she did not hit her head. INTERVENTION: educate the resident to use the call light and wait for someone to come and help. R55's Fall Investigation, dated 6/15/22, documents, (R55)was sitting on the floor facing the toilet. She (R55) stated, I hit my head a little, and she rubbed the back of her head. The resident (R55) was transferred to the ER (Emergency Room). The resident(R55) was reminded by staff to wait, so they can assist her, as they were with another resident at the time. INTERVENTION: the resident (R55) was educated on the importance of staff assisting with transfer. On 11/17/22 at 10:05 AM, V22, Certified Nursing Assistant (CNA), and V23, CNA, entered R55's room and asked her if she wanted to get up for church. V22 placed a gait belt around R55's waist and helped her to a standing position. R55 then pivoted into her locked wheelchair with no issues. On 11/18/22 at 1:45 PM, V2, Director of Nursing, stated, We have a fall meeting the next business day after the fall. We do a root cause analysis. We come up with an intervention and we put it on the care plan.