**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to respond to residents' requests for assistance in a timely manner to promote dignity and respect for 1 (R1) of 4 residents reviewed for call light response in the sample of 4. This failure resulted in R1 having to urinate on herself, causing her feelings of discomfort, anxiety, humiliation, and embarrassment.Findings Include: R1's admission Record documented an admission date of 4/27/25 and included diagnoses of morbid (severe) obesity due to excess calories, spinal stenosis, need for assistance with personal care, presence of right artificial hip joint, pain in right hip, presence of artificial knee joint, bilateral, essential tremor, anxiety, and muscle weakness. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. This MDS also documents under Functional Abilities and Goals, R1 is dependent for toileting hygiene, shower/bathe self, upper body dressing, and putting on/taking off footwear. R1's current Care Plan included a focus area of I currently have an alteration to my ability to care for self and need assistance d/t (due to) Anxiety, Cognitive impairment, Weakness initiated on 1/31/25. Corresponding interventions include: encourage resident to participate to the fullest extent possible with each interaction, encourage resident to use bell to call for assistance, praise all efforts at self care, PT (physical therapy), OT (occupational therapy) and ST (speech therapy) evaluation and treatment. R1 also has a focus area of I am currently able to perform mobility with 2 assist, gait belt and walker initiated on 5/7/25 with corresponding interventions of: encourage (R1) to use bell to call for assistance if needed and monitor/document ability to perform ADLs (activities of daily living).Facility Resident Council meeting minutes dated 7/18/25 document under 4. New Business: (R1) says only one CNA (Certified Nurse Assistant) at night needs more. A facility Resident/Family Concern/Grievance Form dated 07/18/2025 documented Resident Council by the Resident Name. Under Section 1, the Nature of Concern documented Resident states not enough CNA's on the floor at night. Says she needs things like ice water and there is no one to get it. In Section 2 under Review and Action Taken, V2 (Director of Nursing/DON) documented Nurse managers come in to assist as needed, assured resident council that there is always at least 3 CNAs overnight. Staff more assist b/t (between) 6 - 10p and 4-6a to help during busy X's (times). Facility Resident Council meeting minutes dated 8/15/25 under #4, New Business documented Still not enough CNAs at night.On 08/29/2025 at 10:53 AM, R1 stated she sometimes has trouble getting her call light answered. R1 stated on night shift, there is one CNA per hall. R1 stated that she has been told staff have been hired but she has yet to see any new faces. R1 stated that she has peed on herself waiting for her call light to be answered. R1 stated she knows of three times that this has happened and added that this has only occurred on weekends. R1 stated it's embarrassing when she's in the hall and has to pee on herself. R1 said she does not like that she had to pee on herself, but she had to wait too long. R1 stated there isn't a problem on day shift, that shift always has plenty staff. R1 said on weekends the staff number is much lower than during the week. R1 stated she has complained about staffing in resident council meetings and has even sent a text message to V7 (Assistant Director of Nursing/Licensed Practical Nurse - ADON/LPN) on 08/22/2025 and told her that she has had her call light on for over an hour. R1 stated the staff that work here are really good, there just isn't always enough staff to take care of all the residents. On 08/29/2025 at 11:09 AM, V3 (Family Member) stated that R1 called him about 6 weeks to 2 months ago crying and upset. V3 couldn't recall the exact date, but stated R1 told him her call light had been on for 2 hours and no one was answering. V3 stated he told R1 that if she had an accident that was ok, she couldn't help that no one was answering. V3 said he told R1 if you go in the hallway and have pee on yourself then maybe they will help you. V3 stated he hated to tell R1 that, but he did not know what else to do. V3 stated that he was furious, so he called the facility and sternly told them to go take care of R1. V3 stated the nurse who answered the phone told him if you think you can do it better then you need to come here and help. V3 stated he then got on social media and found V7 (ADON/LPN) and explained to her what happened. V3 stated V7 said she would take care of the problem. V3 stated he had no issues with this until last weekend 08/23/2025 and 08/24/2025. V3 stated on 08/23/2025 around 8:00 PM, R1 called because her call light had been on since she came back from the dining room after supper. V3 stated R1 said she told the staff member pushing her that she needed to use the restroom but R1 ended up having to relieve herself and was incontinent. V3 said R1 didn't say who the staff member was. V3 stated he checked with R1 on 08/24/2025 and R1 had no complaints at that time, but R1 called V3 later that night on 08/24/2025 around 8:30 PM and told V3 that R1's call light had been on for over an hour, and no one had answered it. V3 stated that R1 is very proper and that it is degrading that the facility does not have enough help to the point R1 is having to urinate on herself. V3 stated he told R1 that he will notify the proper people and will get this handled. V3 stated on the weekends, the staffing is much lower than during the week. V3 stated if it is happening to R1 who is alert and with it, it is happening to other residents who cannot speak. On 08/29/2025 at 11:35 AM, V7 (ADON/LPN) stated she was contacted by V3 (Family Member) months ago about an issue and it was addressed. V7 stated that R1 sent her a text and told her R1's call light had been on for over an hour, and no one was answering it. V7 stated that it was between 6:00 and 7:00 PM and that time frame is very busy for the staff. V7 stated as soon as staff was available, they went in the room and took care of R1. V7 stated they try to keep a staff member on the hall during meals, but it is hard to meet all the needs after supper. V7 stated they try to schedule enough staff and sometimes if a call in occurs, it doesn't pan out. On 08/29/2025 at 11:39 AM, V2 (DON) stated when R1 was incontinent a couple months ago, she couldn't remember exactly when but she was aware of it as she was working as a CNA that night. V2 stated she went and toileted/cleaned R1, changed her clothes, and placed her in bed. V2 stated they educate the staff all the time about answering call lights promptly. V2 stated she was not aware of any issues that occurred over the weekend with R1. V2 stated call lights should be answered within 10-15 minutes. V2 stated for the weekend of 08/23/2025 and 08/24/2025, there were 3 or 4 CNA's scheduled to work. V2 stated she thinks that one called in and was not replaced. V2 stated in those situations, they try to have a CNA stay late until around 10 PM and then have a day shift person come in around 2:00 - 04:00 A.M. V2 stated they must have not found someone to come in. V2 stated that ideally, she would like to have 4 CNA's every night, but it does not matter what she thinks staffing should be. V2 stated there are two nurses on night shift. V2 stated there are 35 residents in the facility that require two staff assist. V2 stated that on evening/nights, the toughest time is from 6:00 PM to 10:00 PM. V2 stated they attempt to cover when needed but it doesn't always happen. V2 stated they are attempting to hire more staff and get them trained.On 08/29/2025 at 11:44 AM, V1 (Administrator) stated she was not made aware of the call light concerns regarding R1 on the weekend of 08/23/2025 and 08/24/2025 until now. V1 stated the call light does not have a report that can be viewed to see how long the call light was going off. V1 stated she has never been made aware of any resident complaining about call lights going off for an hour. On 08/29/2025 at 2:04 PM, V12 (CNA) stated at times I feel like we are understaffed. V12 stated it is hard to get to call lights on night shift because there are not a lot of staff working. V12 stated there are a lot of times there are only three CNA's in the building for the entire night. V12 stated lately when there are 4 scheduled and someone calls in, they are not replaced on the schedule. V12 stated she gets the bare basics done for the residents, but there are too many that require two-person assist and they have to wait for up to an hour.On 08/29/2025 at 3:21 PM, V11 (CNA) stated R1 had incontinent episodes over the weekend of 08/23/2025 - 08/24/2024. V11 stated that it is not typical for R1 to be incontinent. V11 stated we cannot get to all the residents after supper in a timely manner. V11 stated it happens more often than not. V11 stated a lot of residents have to wait when they shouldn't. V11 stated the staff try to get everyone out of the dining room, residents changed who are wet, the ones who want laid down, laid down and answer the call lights. V11 stated management is aware of the issues as the night shift staff have complained. V11 stated they are told to ask the other CNA's or the nurse for help. V11 stated that all the staff are busy including the nurses and it is hard to get the call lights answered. V11 stated the staff issues are mostly on the weekends. V11 stated she does not do as well as she could because it is impossible. V11 stated if I would have been able to get to R1 in time she would not have been incontinent. V11 stated if a resident is a two assist, they have to wait until there are two staff available and it can easily take an hour. V11 also stated that the weekend laundry staff recently quit so they have to do the laundry on night shift too.On 09/02/2025 at 2:21 PM, V15 (LPN) stated she was working and was R1's nurse the weekend of 8/23-8/24/25 when R1 had an incontinent episode. V15 stated R1 is normally continent, and she thought it was odd that this happened. V15 stated it wasn't until later in the shift, R1 told her that she was incontinent because the call light was on for over an hour. V15 stated that one nurse and one certified nurse assistant is not enough for the 30 residents that reside on R1's hall. V15 stated this last Saturday 08/30/2025 a CNA called in and the nurse on call (V7) did not find any coverage and did not come in to help. V15 stated it seems every weekend they are short staffed. V15 stated all the residents cannot receive the care they need with the current staffing they have.A facility provided census sheet documented there are 27 residents that reside on R1's hall. Of those 27 residents, V2 indicated by placing a dot beside resident names that there were 15 residents who require the assist of two staff for transfers and care, with R1 being one of those residents. V2 indicated by yellow highlight that 10 residents on that hall require the assist of one staff member for transfers and care. Facility policy titled Facility Resident Rights Policy and Procedure with no date documents under section V. Respect and dignity. Every resident has a right to be treated with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement progressive person centered interventions for fall prevention for 1 (R1) of 3 residents reviewed for falls in the sample of 3. This failure resulted in R1 experiencing 4 falls between 2/20/24 and 3/3/24 which required emergency room evaluation and/or treatment for injuries that included skin tears to right arm, a right orbital fracture, head lacerations, and baseball size hematoma to the head. Findings Include: R1's admission Record documented an initial admission date to the facility as 9/22/23. R1 is documented on this same record as being [AGE] years old with diagnoses including but not limited to: Unspecified Dementia, unspecified severity, with agitation; Type 2 Diabetes Mellitus; Major Depressive Disorder; Insomnia; Muscle Weakness; and Cognitive Communication Deficit. V9 (Physician) is documented as being R1's Primary Care Physician. R1 was observed as being alert to person only during this survey. Review of R1's Progress Notes in her Electronic Health Record documented falls most recently occurred on 2/20/24, 2/23/24, 2/29/24, 3/3/24, 3/13/23, and 3/27/24. R1's Electronic Health Record included the following documentation in relation to these falls: 1. A Nursing Progress Note documented on 2/20/24 at 11:02 AM that at 6:00 AM that day, R1 was found in her room lying on the floor following an apparent fall. Resident was lying flat on her back and clearly had a laceration to her right orbital. The fall was not witnessed and resident was not able to provide any information otherthan (sic) she had fallen. Pressure was applied to the laceration until EMS (Emergency Service Personnel) arrived, resident was encouraged to stay in place The local hospital Discharge Instructions dated 2/20/24 documented the diagnosis of Blow-out fracture of orbital floor; Facial laceration. A Nursing Progress Note documented on 2/20/24 at 7:24 PM, that R1 returned to the facility from the local hospital with x-ray's to R1's right wrist and shoulder being normal, but a CT (Computed Tomography) of her head revealing a FX (fracture) to right orbital. 4 sutures are documented as being in place to right orbital laceration. R1's current Plan of Care documented a focus area of being at high risk for falls, initiated on 9/26/23. Interventions listed following this fall include: hipsters with a date initiated of 2/21/24, and Therapy to screen with a date initiated of 2/20/24. On 3/27/24 at 10:13 AM, V1 (Administrator) confirmed the accuracy of the documented interventions. 2. A Nursing Progress Note documented on 2/23/24 at 8:23 PM that R1 experienced unwitnessed fall. States hit their head. Has two skin tears 2 in. (inches) in length and 0.5 in. diameter to the right forearm. C/o (complains of) shoulder and arm pain. No visible injuries to the head V9 (Physician) is documented as being notified with orders to send to ER (Emergency Room) for evaluation and treatment. The local hospital Discharge Instructions dated 2/23/24 documented the diagnosis of, Carotid artery calcification; Closed head injury; fall. Major Tests and Procedures documented as being completed on this same form include a CT of head or brain without contrast and CT of spine cervical without contrast. No findings of significance were discovered in relation to the fall. Review of R1's current Plan of Care documented no new interventions were implemented following this fall. On 3/27/24 at 10:13 AM, V1 confirmed R1's Plan of Care was reviewed, and no new interventions were implemented following this fall as she stated new interventions had just been implemented following her previous fall and not had time to show their effectiveness yet. 3. A Nursing Progress Note dated 2/29/24 at 9:38 AM documented R1, Found on the floor, yelling help. Unwitnessed fall. Resident states they hit their head trying to walk. Notable laceration to the R (right) temple. R (right) temple bleeding. Resident denies hitting any other part of body. Alert to person only. Resident follows commands, and eyes can track movement. V9 is documented as being notified with orders to send to the ER for head trauma. 911 was called for transport. This note also documents Chair next to residents bed knocked over. The local hospital ED (Emergency Department) Note - Physician dated 2/29/24, documented a chief complaint of, Fell this am, 3rd fall in 1 week, opened old wounds to right eye brow. 1 3 cm (centimeter) laceration and 1 1 cm to right eye brow. History of Present Illness includes the following notation, Differential includes intercranial hemorrhage, skull fracture, laceration. CT scan obtained and independently interpreted by myself. Is negative for internal injuries Given that the wound is old and now reopened, there is no indication to close it. This will have to heal by secondary intent . R1's current Plan of Care documented a focus area of being at high risk for falls. Therapy screenings were documented as being completed on 2/27/24, with services now being provided. The plan documented a new intervention of Resident to wear soft helmet for head protection 2/29/2024. If resident takes off or refuses to wear. Staff is to chart behavior. Soft helmet use following this fall with date of initiation documented as 2/29/24. On 3/27/24 at 10:13 AM, V1 confirmed the accuracy of R1's documented interventions and confirmed the soft helmet use was to be implemented at all times, removed only for bathing. 4. A Nursing Progress Note dated 3/3/24 at 9:26 AM documented .CNA (Certified Nurse Assistant) called for help. This nurse went to resident's room. Resident was laying on her back. She was next to the sink. Her walker was turned over and laying above her head. An additional note made on 3/3/24 at 9:27 AM documented, .Resident did c/o (complain of) head pain. Nurse assessed a significant size hematoma to the parietal area on the back of the head .MD notified. NO (new order) to send to ER for eval and treat . The local hospital ED Note - Physician dated 3/3/24 documented a chief complaint of, .unwitnessed fall this am. Per report from (V2's name-Registered Nurse/ RN), patient has frequent falls and old laceration and bruising above right eye and old fx (fracture) to right wrist. Today, baseball size hematoma to right occipital area . A CT scan of R1's head is documented as being obtained, demonstrating a scalp hematoma. R1's current Plan of Care documented no new interventions implemented after this fall. The care plan documents Continue with therapy for balance and strengthening with a date initiated of 3/3/2024. In addition, therapy services are documented as being continued for balance and strengthening on the Intervention Timeline 2024 provided by V1. On 3/27/24 at 10:13 AM, V1 confirmed the accuracy of R1's documented interventions. On 3/26/24 at 1:32 PM, V2 (RN) stated that R1's normal status is confused and forgetful. V2 stated that staff are to document if R1 refused to utilize equipment such as her helmet. V2 stated she cannot recall who the CNA (Certified Nurse Assistant) was that called for help during R1's fall on 3/3/24. V2 stated that she recalled R1 was lying in front of the sink on the floor, in her room. V2 stated R1's helmet was not in place at the time of the fall. V2 stated the fall occurred in the morning and she had not yet seen R1 yet that day. V2 stated R1 had a large knot to the back part of her head. V2 stated that if R1 is refusing to comply with fall interventions, such as wearing her helmet, staff should re-approach later to offer interventions and document the refusal if that is still the case after later failed attempts. On 3/27/24 at 9:13 AM, V14 (CNA) stated she was the staff member working on 3/3/24 when she observed R1 lying on her back in front of the sink in her room. V14 stated she had heard something, and when she went to check, found R1 on the floor. V14 stated R1 didn't have her helmet on and isn't sure if it had even been implemented yet at the time of this fall. V14 stated once the helmet was implemented, it was to be worn at all times. V14 stated she doesn't know if R1 can remove the helmet herself. V14 stated R1 seems to leave the helmet on as far as she knows and has observed, at the times she's worked with R1. V14 stated at the time of R1's fall, R1 was complaining of her head hurting. V14 stated that R1 is not supposed to walk by herself but is very confused and does. R1's Electronic Health Record documented no refusal notation regarding R1's soft helmet on 3/3/24. An Orders - Administration Note dated 3/3/24 at 8:55 AM, entered by V2 (RN) stated Note Text as, Ensure frequent rounding is being done by staff and ensure soft helmet and hipsters are in place. Chart any non-compliance. Every shift for MONITORING. Resident non-compliant with soft helmet. On 3/27/24 at 11:35 AM, V16 (Director of Nursing/DON) stated that she does recognize R1's Clinical Record lacks documentation regarding any refusal of services R1 has had or different interventions the facility staff may have attempted in an effort for fall prevention. V16 stated that she would expect staff to document any refusal of care or interventions such as the helmet in her record. V16 stated that R1 was not always compliant with wearing her helmet and did have some refusals at the start of its initiation, but is doing better now. In reference to the Administration Note documented above, V16 stated she views non-compliant and refusal as having two separate meanings. V16 stated non-compliant would mean that redirection is needed to fulfill the intended task. Such as if R1 would allow her helmet to be on, but needed frequent reminders to leave it in place, or re-apply the helmet .the desired outcome could be reached with the task being re-attempted, etc. V16 stated refusal of a service would be that despite redirection and interventions, R1 would not allow the service or intervention to be provided. V16 stated there is no official program or direction in place to deal with R1 being non-compliant or refusals. V16 stated if R1 was refusing to wear her helmet, there was no alternative intervention in place to implement. V16 stated that the Administration Note (referenced above) in R1's Progress Notes stems from entries staff have made in the Medication or Treatment Administration Record (MAR/TAR) that automatically transcribe over into the progress notes then. V16 stated that she had put entries on R1's Treatment Administration Record to remind staff of interventions in place for R1's falls. V16 confirmed for example, the Administration Note made in R1's record at 8:55 AM on 3/3/24 of R1 being non-compliant with her soft helmet, does not mean R1 was refusing to wear her helmet at that time, or was even being viewed at that time, but is a general entry statement for the shift that day. V16 stated if R1's status was to change where she was actually refusing, a progress note should have been made to document that status. On 3/27/24 at 11:57 AM, V2 stated she does not recall the circumstances that triggered the entry that R1 was being non-compliant with her soft helmet on 3/3/24, as she had not seen her that morning prior to her fall. V2 stated she does not recall anything being reported to her regarding any non-compliance or refusal of services with R1 that morning. V2 stated usually what she does, is if it is reported to her that a resident is refusing a service, she will make a progress note in the record. For entries on the TAR reminding staff to ensure interventions, she makes the TAR entry at the time she is initially viewing the resident for that shift. On 3/27/24 at 10:13 AM, V1 confirmed that R1 was to wear her helmet at all times. V1 stated that in the beginning of the helmet being implemented, R1 would refuse to wear it, and she would expect those refusals to be documented. V1 acknowledged R1's record contains a lack of documentation which would have reflected more frequent refusals of wearing the helmet, should they have existed. V1 acknowledges the need for revision of a residents person centered care plan and documentation of interventions being implemented to add in addition to or replace ineffective interventions for effective fall prevention. On 3/27/24 at 9:33 AM, V13 (Nurse Practitioner) stated that she has seen R1, but mainly just for continued evaluation for therapy progress. V13 stated she believes overall, R1 did pretty well with therapy, but just has a lot of confusion which results in behaviors and contributes to her falls. V13 stated V9 is R1's primary caregiver and would be the staff who receive the day to day calls of events. V13 stated she would expect the facility to revise a resident's Plan of Care to fit the resident needs for fall prevention. On 3/27/24 at 10:53 AM, V9 confirmed he is the Primary Care Provider for R1. V9 stated that R1's mental status has recently suffered a significant decline due to her progressing dementia. V9 stated that the facility does a good job of notifying him of any changes in a resident's status. V9 stated he would expect a resident's plan of care to be revised to fit their specific person centered needs and does acknowledge that should R1 have been wearing her helmet during a fall, it could potentially lessen or negate a head injury. V9 stated that R1 has sustained a facial fracture from a fall in the past, so protecting her head is important. 5. A Nursing Progress Note dated 3/13/24 at 9:51 AM documented, R1 observed on floor in doorway by this nurse. Stated she just fell down. No injuries . R1's current Plan of Care documented a focus area of being at high risk for falls. A new intervention following this fall with an initiation date of 3/13/24 is documented as Refer resident to (name of outside acute psychiatric care hospital) for increased behaviors 3/13/2024. Another intervention listed as being initiated on 3/21/24 documents Resident often leaves walker away from her and walks without it. Remind resident that she needs to have her walker with her and someone with her when ambulating. On 3/26/24 at 12:38 PM, V1 stated that the facility received no response from (name of outside acute psychiatric care hospital) following the referral made. On 3/27/24 at 10:13 AM, V1 confirmed the accuracy of R1's documented intervention of a (name of outside acute psychiatric care hospital) behavioral service referral following her 3/13/24 fall with no contact made with them as of 3/27/24. 6. A Nursing Progress Note dated 3/27/24 at 2:20 PM documented, This nurse was outside the dining room and heard a noise, resident observed on the floor with chair turned on its side. Resident wearing soft helmet, and hipsters. CNA in the dining room witnessed event. Resident was assessed, neuro checks initiated, ROM (range of motion) performed. Resident denied any pain or injuries. No visible injuries were noted R1's Fall Risk Assess. (Assessment) dated 9/24/23, documented a score of 12, indicating she was assessed as being at high risk for falls. The Fall Reduction Policy with a revision date of June 17, 2022 documented the purpose of the policy included, .To identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries. To promote a systematic approach and monitoring process for the care of residents who have fallen and/or those who are determined to be at risk. The same policy also documented under the section of Prevention and Treatment Guidelines, .12. The care plan should be reviewed after every fall and updated with a new intervention, when applicable.