Based on observation, clinical record review, policy review, and staff interview, the facility failed to provide the correct diet for 2 of 5 residents reviewed for nutrition(Residents #11 and #226). The facility reported a census of 26 residents. Findings include: 1. The Care Plan, dated 10/31/24, revealed that Resident #226 has nutritional problem or potential for nutritional problem and required regular diet with pureed texture, and instructed staff to serve diet as ordered. Resident #226 diet order, dated 10/31/24, revealed order for regular, puree texture diet and thin liquids. Review of Nutritional Assessment, dated 11/04/24, informed that Resident #226 is at increased risk for altered nutrition due to co-morbidities, chewing and swallowing difficulty, and modified texture. The Discharge Summary from previous nursing home, dated 10/31/24, stated that resident needed supervision with eating and that resident should be served one food at a time with a small spoon . On 11/04/24 at 11:20 a.m., Staff A, [NAME] served Resident #226 a plate of regular consistency food. One minute later, staff A, cook came back and stated that he knew he was going to screw that up and proceeded to take the food away from Resident #226 after he had consumed several bites of food. At that time the resident had began excessively coughing with large amount of phlegm coming from mouth and nose. On 11/04/24 at 11:22 a.m., Resident #226 stopped coughing and drooling. On 11/04/24 at 11:24 a.m., Resident #226 was served the correct consistency and proceeded to cough with eating intermittently, but was able to eat some more food of the pureed consistency. On 11/04/24 at 11:30 a.m., the Director of Nursing (DON) was interviewed on what Resident#226 ' s diet is ordered as and she stated that it is puree texture with thin liquids and handle cups. She stated that she provided it to the kitchen herself prior to the resident ' s arrival. She was then queried on what would happen if Resident #226 would be provided with regular consistency food and she stated that he would most likely choke because he eats his food very fast. At this point in time, the State Agency (SA) notified the DON of the findings to allow for appropriate assessment and interventions for this resident. On 11/04/24 at 11:38 a.m., interview from Staff A, Cook, revealed that the dietary staff get the dietary information from the nurses. Staff A, cook, acknowledged that he provided the resident with regular consistency food and then noticed that his count was off for plates so he and went back to fix it. Staff A, cook, acknowledged that Resident #226 would probably choke if he ate regular consistency food. When queried about the location of the modified diet postings in the kitchen, staff A, cook stated that it is posted in the kitchen and that it is also in a book. Staff A, Cook, stated that he does not utilize the books because he has struggled with them. On 11/04/24 at 11:48 a.m., Resident #226 was found lying in his room alone. The Resident stated that he was fine and he did not feel short of breath. At that time, the resident was noted to still have an intermittent cough. The resident denied feeling like there was anything stuck in his throat 2. The Minimum Data Set(MDS) assessment tool, dated 8/28/24, listed diagnoses for Resident #11 which included non-Alzheimer's dementia, anxiety, and psychotic disorder. The MDS listed a Brief Interview for Mental Status(BIMS) score of 0 out of 15, indicating severely impaired cognition. On 11/6/24 at 11:23 a.m., Resident #11 ate cole slaw which contained shredded cabbage approximately a half inch long. An Order Details report listed a 5/30/24 order for a mechanical soft ground meat diet texture. The Week 1 Wednesday Menu directed staff to serve residents on a regular diet creamy coleslaw and residents on a mechanical soft diet steamed cabbage. On 11/6/24 at 12:42 p.m., the Certified Dietary Manager(CDM) stated she served Resident #11 cole slaw because she did not have extra cabbage(to boil). She stated she cut it down to a smaller size for her to eat. On 11/19/24 at 11:59 a.m. via phone, the Director of Nursing(DON) of a sister facility stated the facility should follow diet orders. The facility policy Therapeutic Diets, revised October 2017, stated diets would be determined in accordance with the resident's treatment goals and would include modifications in texture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure evaluation of a mobility device prior to resident use, failed to ensure gait belt utilized for transfer, failed to remain with a resident when a non-verbal resident suspected to have a seizure resulting in a fall, failed to ensure adequate supervision for resident with known history of falls when the resident was found multiple times post unwitnessed fall in the lobby of the facility, failed to ensure residents' feet were placed on wheelchair foot pedals when residents assisted via wheelchair, and failed to ensure residents remained free from environmental hazards when one resident ingested a [NAME] egg and another resident obtained access to a locked restroom without the knowledge of facility staff for six of ten residents reviewed for accidents (Resident #2, Resident #3, Resident #5, Resident #10, Resident #21, and Resident #22). This deficient practice resulted in the following injuries: Resident #2 sustained bruises and a head laceration on 6/22/24. Resident #22 sustained a laceration to the right orbit with surrounding bruising, pain, and multiple skin tears sustained from falls on 7/5/24, 8/22/24, and 9/3/24. Resident #5 sustained bruising to the right forehead, pain, and a shattered humerus related to a fall on 11/1/24 and was hospitalized . Findings include: 1. Review of the Annual Minimum Data Set (MDS) assessment for Resident #5 dated 9/18/24 revealed the resident scored 00 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. a. Review of Resident #5's Care Plan dated 4/2/21, revised 11/1/24, revealed the following: [Resident #5] is at risk for injury from falls r/t (related to) hx (history) of right (R) femur fx (fracture), dementia, diabetes, anemia, neurogenic bladder, muscle atrophy, hx of TIA/CVA (Transient ischemic attack/Cerebrovascular accident). Falls: 11/1/24 witnessed fall with injury. Interventions per the Care Plan included the following: a.(Initiated 2/15/24, revised 9/10/24): Gripper strips to bed. b. (Initiated 2/15/24, revised 9/10/24): Gripper strip toilet. c. (Imitated 11/1/24): Send to ER (emergency room) for evaluation d. (Initiated 2/15/24, revised 9/10/24): Toilet rails Review of the Therapy Communication Form dated 1/26/24 revealed, in part, pt. (patient) is functional independent with 4 ww (wheeled walker) gait in hallway & common spaces after assist with stance WBAT (weight bearing as tolerated). Review of the Late Entry Nursing Note dated 10/30/24 at 11:00 AM revealed, Maintenance gave three wheel walker to resident after being notified by Maintenance manager that this is the only walker that he has available at this time. [NAME] was given to resident by Maintenance manager. Maintenance Manager had been notified of wheels loose on resident's normal four wheel walker and needing it to be fixed or replaced. Review of the Fall Incident Report dated 11/1/24 at 7:38 AM for Resident #5 revealed, Nurse made aware of witnessed fall at 0738 from house keeping down [NAME] hall way. Resd (resident) utilizing new 3ww (wheeled walker) et was turning around when she lost her footing. Resd Observed lying on rt side, head against wall, sensation et movement to extremities, able to move rt hand when asked, unable to assess AROM (active range of motion) to rt (right) arm at this time as she was lying on it. Resd x1 (times one) assisted to chair in activity room, utilized walker with rt (right) hand, gripping activity director shirt with lt (left). 3x3cm (centimeter) bruise noted to rt (right) forehead .When skin protectant sleeve on rt arm rolled back up from obtaining BP (blood pressure) resd called out in pain. Swelling noted to rt arm et resd does not move extremity when asked. Verbal order to send to ER obtained at 0755 from [Name Redacted] fax out for signature .Ambulance arrived at 0835 (8:35 AM), paramedic notes crepitus to rt arm, when requested to transport to [Location Redacted] medics refuse as hey state We're not sure if its broken so we will start with x-ray in [Location Redacted]. [Resident #5] left facility via ambulance at 0841, MAR (Medication Administration Record)/TAR (Treatment Administration Record), IPOST (Iowa Physician Orders for Scope of Treatment), face sheet et hospital transfer form sent with. Per the Incident Report dated 11/1/24, Resident #5 had a bruise to the top of the scalp and pain score of 6. The Incident Note dated 11/1/2024 at 1:58 PM revealed, [Name Redacted] ER (Emergency Room) nurse from [Location Redacted] called facility, informed this nurse that [Resident #5's] humorous <sic> is shattered. [Resident #5] is to be transported to [Location Redacted], et ER has already notified POA (Power of Attorney). Review of a Radiology Report of the resident's right elbow completed on 11/1/24 at 9:45 AM, with reason for process documented as bruising around elbow and fall, revealed the following: Findings/Impression: Comminuted fracture of the distal humerus with separation of medial and lateral epicondyles. Note of 49 mm (millimeter) butterfly fragment. There is foreshortening and posterior displacement of the distal fracture fragments with respect of the proximal humerus. There is dislocation of the humeral ulnar joint. Review of Hospital Records dated with admission date 11/1/24, and date of discharge 11/4/24, revealed the following admitting diagnoses: fall, hematoma over R (right) frontal area, just above R eye, distal R humerus fracture, and slightly angulated/overlapping, and UTI (urinary tract infection). On 11/07/24 at 10:55 AM Staff F, Housekeeper queried regarding Resident #5. When queried if she was familiar with the resident, Staff F responded she was. When queried if she worked when the resident had fallen, Staff F explained here recently she was getting ready to mop the [NAME] hall, happened to turn, and [Resident] was losing balance when tried to turn her walker around. Staff F explained the resident's walker had gotten stuck when [Resident] was turning around and happened to lose balance. Staff F explained went to try to catch [Resident], and didn't get to her in time. Staff F queried where occurred, and responded between the activity door and [NAME] hall. Per Staff F, the resident had walker with her, and walker was 3 wheel walker the resident had recently gotten. When queried if Staff F saw resident fall, said yes. When queried what happened next, Staff F explained the resident had fell and hit head on the wall, and landed on her right side. When queried about visible injuries, Staff F responded she did not notice any visible injuries. Staff F acknowledged there were no staff around that (Staff F) saw when resident fell. Per Staff F, after the fall was a bruise on the resident's forehead. Staff F explained resident did not say anything when she fell, and did not call out or anything like that. On 11/7/24 at 11:50 AM, the Director of Nursing (DON) explained there was not a PT/OT evaluation done for Resident #5's 3 wheeled walker. The DON explained for a new piece of equipment, usually got from maintenance. The DON explained called maintenance because of resident's walker wheel. Per the DON, the resident was ordered to use 4 wheeled walker, and DON explained called to have it fixed and replaced with other 4 wheeled walker. The DON further explained facility was getting a new admission at the time, maintenance came out with a walker, was told it was the wrong walker, maintenance said it was brand new, and DON said it was wrong walker. The DON explained she went to the admission, staff had the resident sitting in a chair, maintenance gave 3 wheeled walker, and definitely should not have. The DON explained did not know if was another 4 wheeled walker or not, and didn't have access to storage. The DON explained if a witnessed fall, they would do statements and had a fall report checklist. Per the DON, statements were turned into the DON if witnessed, otherwise everything was typed into notes in [electronic health record system]. The DON statements for witnessed falls were very rare, and most if not all were unwitnessed. When queried about root cause analysis, the DON explained do follow up when go though the fall incident report. When queried where would find root cause, the DON explained it was also in the incident report, and did not know if it was printed into the incident report or not. On 11/12/24 at 11:38 AM, Staff E, Registered Nurse (RN) queried about resident's arm/injury. Staff E responded the resident had four breaks, and was just told she fell. Staff E further explained was not present when it happened, and got it in report. Per Staff E, the resident normally had a 4 wheel walker with seat, the bearings were out she guessed, and someone got the resident a 3 wheeled walker. Staff E explained a staff member (Staff I, Certified Nursing Assistant) said they were not getting resident up with the 3 wheeled walker, and another staff member said the resident had used it yesterday fine, and would get her up. Per Staff E, Staff I had already said wanted no part in that. Staff E queried what she thought about the 3 wheeled walker, and provided the following description: little kid's walker, very tiny width, handles, no seat, really narrow and didn't look maneuverable. Staff E further explained in a conversation with staff member (staff member who had previously said not getting resident up with 3 wheeled walker), Staff E told Staff I they called it, [Resident #5] broke arm. On 11/12/24 at 2:19 PM an interview completed with Staff D, Licensed Practical Nurse (LPN) who had completed the resident's incident report on 11/1/24. Staff D explained she didn't see it happen, and Staff F, Housekeeping witnessed and brought to attention. Per Staff D, resident in hall, walked independently with walker, and had new walker that Staff D not aware of at all. Resident #5 using new walker, was normally pretty steady, could have lost balance, and fell right side. Per Staff D, the resident was not in pain, was able to move, and was holding onto walker with broken arm. Staff D explained Resident #5 pretty much non-verbal, and when ask if in pain the resident doesn't say anything. Staff D further explained with upward motion and bringing geri sleeve up, the resident cried out in pain. Staff D explained she contacted medics and family, and when the medics got there didn't think the arm was broken, Staff D tugged geri sleeve again, and the resident screamed in pain. Per Staff D, medics said didn't think was broken and to start x-ray in [Location Redacted], while the other medic felt crepitus. Per Staff D, the resident did have a bump on the head. On 11/18/24 at 8:54 AM, Staff I, Certified Nursing Assistant (CNA) explained, in part, Resident #5 walked with a front wheeled 4 wheel walker, because she could not do a 3 [NAME] had never been trained on it. When queried if Resident #5 ever had a 3 wheeled walker, Staff I responded two weeks ago before fall had the bearing going out of her (Resident #5's) walker and maintenance gave her a 3 wheel walker. Per Staff I, she thought the resident got the walker on a Thursday, Staff I had worked that night 10 to 6, and Friday morning the resident had it sitting there. Staff I explained she did not get Resident #5 out of bed because Staff I did not feel comfortable. Per Staff I, that morning (Resident #5) fell. Staff I explained Resident #5 was like a cylinder and Staff I did not feel comfortable to use the 3 wheel walker. Per Staff I, the resident stayed in bed until the day shift got her up, and Staff I asked the nurse if was ok to leave Resident #5 in bed until the day shift as there were no notes for her to use it (3 wheel walker). Staff I explained just played it safe. When queried about communication would occur, Staff I explained usually in nurses notes, and during report when walked in room checked resident if something different, then would ask the nurse. Per Staff I, she passed it to day shift, and they said would check into it. Observation on 11/05/24 at 12:36 PM revealed Resident #5 in the common area with bruising present to the right side of the resident's head. Resident had green bruise to right forehead. No staff observed in line of sight of the nursing desk/common area at time of observation. There was a housekeeping staff observed in the North hall. Other staff not observed to be present. Observation on 11/13/24 at 9:59 AM revealed Resident #5 in wheelchair in the common area. On 11/13/24 at 12:13 PM, the Maintenance Supervisor interviewed about Resident #5's walker. Per the Maintenance Director, somebody said the resident's walker wheels were acting weird, the Maintenance Supervisor looked at it, and the bearings were popped out. The Maintenance Supervisor explained found other one (walker) that had brought in. The Maintenance Supervisor described the walker with the bearings popped out as a walker with 4 wheels with handles and breaks on it. The replacement walker was described as follows by the Maintenance Supervisor: Had same stance, 3 wheels, and had break cables like the resident was used to. When queried if facility had any 4 wheel walkers available, the Maintenance Supervisor responded just the ones without wheels that put tennis balls on. The Maintenance Supervisor queried not like the walker the resident had, and confirmed. Per the Maintenance Supervisor, he was not sure where the 3 wheeled walker came from, it was in facility's storage. When queried if any staff expressed concerns with using the 3 wheeled walker for the resident, the Maintenance Supervisor denied, and explained he adjusted the handles down to meet the height of the resident's old one (walker) so it was the same height. On 11/19/24 at 2:56 PM the facility's Administrator explained was not the fault of the walker, was the fault of her (Resident #5's) feet. Per the Administrator, had done education about with any change in equipment, maintenance, therapy, and the DON review. The Administrator then explained she was not sure the cause was related to the resident's footing. When queried regarding an evaluation for a resident's new piece of equipment, the Administrator explained should be evaluated by therapy. When queried if there should be an evaluation when going from 4 wheel to 3 wheel walker, the Administrator responded yes. b. Review of Resident #5's Care Plan dated 4/2/21 and revised 2/15/24 revealed, [Resident #5] requires assist with ADL's (activities of daily living) due to impaired mobility, recent hip fx (9/2023), Alzheimer with dementia, diabetes mellitus, anemia, edema, neurogenic bladder, atrophy of muscles, depression/anxiety, TIA & CVA. The Intervention revised on 9/10/24 revealed, ASSISTIVE DEVICES: w/w (wheeled walker); w/c (wheelchair) PRN (as needed) for appointment. Observation conducted 11/5/24 at 12:41 PM revealed Staff C, Certified Nursing Assistant (CNA) assisted Resident #5 down the hallway in the wheelchair, and the resident's right foot observed off of the foot pedal and skimmed across the floor while the resident was assisted. 2. Review of the Minimum Data Set (MDS) assessment for Resident #22 dated 6/21/24 revealed the resident scored 1 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident severely cognitively impaired. Per the assessment, the resident had not had any falls since admission, entry, reentry, or prior assessment, had physical behavioral symptoms 1-3 days, had verbal behavioral symptoms 4-6 days, and other behavioral symptoms 1-3 days, and wandered 1-3 days. The resident's MDS dated [DATE] revealed the resident scored 00 out of 15 on BIMS exam, which indicated severely impaired cognition. Per this assessment, Resident #22 had falls since admission, entry, reentry, or prior assessment, two with no injury and two with injury (except major). The Care Plan dated 6/17/24 revised 10/14/24 revealed, [Resident #22] is at risk for falls and has had a fall related to impaired balance, poor safety awareness, functional impairment and the use of medications that may increase falls risks. a. 6/17/24 Fall with injury b. 6/24/24 Fall without injury c. 7/2/24 Fall without injury d. 7/5/24 Fall without injury e. 9/3/24 Fall with skin tear f. 9/30/24 unwitnessed fall without injury g. 10/9/24 unwitnessed fall without injury h. 10/14/24 witnessed fall with skin tear Interventions per Resident #22's Care Plan included the following: a. (Initiated 7/2/24, revised 9/10/24): Dycem placed below and on top of cushion in wheelchair. b. (Initiated 9/30/24): Educate and encourage family visits for orientation purposes. c. (Initiated 9/30/24): Educate family about fall risks and increased weakness due to resident weight loss and refusal to eat much at meal or snack times. d. (Initiated 6/17/24, revised 6/19/24): Ensure [Resident #22] is wearing appropriate footwear when ambulating or utilizing their wheelchair. Resident prefers to wear open toe shoes. e. (Initiated 6/19/24, revised 9/10/24): Fall mat at bedside. f. (Initiated 6/17/24): Follow all facility protocol related to falls ie: initiation of neuros (if applicable), fall report/investigation, immediate interventions and long term interventions, informing of physician/family. g. (Initiated 6/17/24, revised 9/10/24): Gripper socks in place when out of bed. h. (Initiated 7/5/24, revised 9/10/24): [Resident #22] was given a different wheelchair that Dycem holds to better than previous wheelchair. i. (Initiated 10/14/24): Offer and encourage resident to rest between meals or when she appears drowsy in wheelchair. j. (Initiated 6/17/24, revised 9/10/24): PT/OT (physical therapy/occupational therapy) to eval and treat if appropriate due to fall. k. (Initiated 10/9/24): Reorient resident to her own room and belongings any time that she is found in the hallways. l. (Initiated 9/3/24, revised 9/10/24): Staff to check on resident frequently when in the area that resident is in. Review of Incident Reports and the clinical record for Resident #22 revealed the following: The Incident Report dated 6/17/24 at 9:00 AM revealed, This nurse was in another resident's room when I heard a yell, walked out the door, resident sitting on floor near North hall back door, with back against wall .R (right) leg moved without pain, L (left) leg-hip pain. Dr. notified, verbal orders to send resident to ER (Emergency Room) for evaluation and treat for pain to L hip. A predisposing situation factor was improper footwear. The Immediate Action Taken section revealed, ask family about replacing shoes. Discharge instructions from the Emergency Department dated 6/18/24 at 9:47 AM revealed, L (left) hip fx (fracture)-nonsurgical, walk with walker. Review of the Physician Note dated 6/20/24 revealed, in part, the following for Resident #22: Alert and oriented to person. Dementia. Episodes of confusion and disorientation. She has been having delusions about her medications and staff .She has a history of osteoporosis and hip fractures .She was sent to the ED (Emergency Department) after a fall on 6/17/24 and was found to have a left hip fracture. Uncertain if it was new or a previous fracture. It was non-surgical. The Nursing Note dated 6/19/24 at 1:02 PM revealed, Fall Interventions: fall mat next to bed, gripper socks on at all times when out of bed, PT/OT eval and treat if appropriate. The Incident Report dated 6/24/24 at 5:05 PM revealed, Was called to room [number redacted] to find resident sitting on her hands and knees in front of the bathroom facing the bathroom in front of her w/c (wheelchair). The Immediate Action Taken section revealed, in part, was helped by 2 CNAs and gait belt to her w/c then she was transferred to the bathroom, resident was then brought to the nurses station where this writer was able to have one on one with resident, to help with redirecting of resident. The Incident Report dated 7/2/24 at 10:45 AM revealed, Resident was wheeling herself down west hallway, the 2nd door on the left she tried to open, shaking the door handle, when it didn't open resident slid herself, cushion and all to the floor. Witnessed by activity aide, resident, didn't hit head. The Immediate Action Taken section revealed, Place dycem below cushion in wheelchair and on top of cushion in wheelchair. The Incident Report dated 7/5/24 at 1:28 PM revealed, Activity director notified this nurse of resd seated on the floor at 1328 (1:28 PM). Resd previously exit seeking. Resd observed by front lobby entrance seated in front of w/c on w/c cushion dycem in place below et (and) on-top of w/c cushion. AROM (active range of motion) intact, x3 skin tears to outer rt (right) forearm from elbow down 1.7x1cm, 2x1cm, 0.8x0.5cm, areas cleansed with steri strips put in place. The Immediate Action Taken section revealed, New w/c provided that is more suitable for dycem to prevent sliding out. Review of a Fax dated 7/25/24 revealed, in part, post fall injuries x3 skin tears from elbow down to rt (right) outer forearm 1.7x1cm, 2x1 cm, 0.8x0.5cm areas cleansed et approximated c (with) steri strips. The Immediate Action Taken section revealed, New w/c provided that is more suitable for dycem to prevent sliding out. The Incident Report dated 8/22/24 at 1:43 PM revealed, This nurse was called to the reception/lobby area. Resident suffered an unwitnessed fall. [Resident #22] was lying flat on the floor with legs out. Blood noted on right side of forehead with bruising. Bleeding stopped by providing pressure to the area. Resident voices complaints of pain from hitting head on floor. The Immediate Action Taken section revealed, Resident wearing sandals at time of incident, sandals removed and resident allowed grip socks to be placed. Review of the Nursing Note for Resident #22 dated 8/22/24 at 1:43 PM revealed, in part, This nurse was called out to reception/front lobby. [Resident #22] was noted to be lying on the floor with legs outstretched near chairs/table. Blood noted to left forehead. Staff and other residents reporting she fell. Staff did not witness event. The N-Weekly Non Pressure Wound Assessment V2 Form completed 8/22/24 at 3:52 PM revealed the following: FYI (for your information) post fall skin assessment was written on the form. A wound was documented to the resident's face described as follows: rt (right) orbital 1.3x0.3cm (centimeter) laceration with surrounding bruise of 7x7cm. Review of Resident #22's Care Plan to address falls lacked documentation of the resident's fall with injury in the list of resident's falls in the focus area of Resident #22's Care Plan, and lacked any interventions added in August 2024. The Incident Report dated 9/3/24 at 3:44 PM revealed, Called 15:30 (3:30 PM) to North hallway, unwitnessed fall, when resident was with Administrator and another resident standing nearby. Resident was standing and talking when I started initial assessment. Resident denies pain of discomfort at this time Skin tear to right upper arm 5'' x1.5''. The Immediate Action Taken section documented an assessment of the resident. Review of a Fax dated 9/3/24 at 3:50 PM revealed, in part, unwitnessed fall skin tear to right arm. The Fall-Initial Note dated 9/3/24 at 3:30 PM revealed the following cause: Unwitnessed fall due to confusion. The Incident Report dated 9/30/24 at 2:35 PM revealed, This nurse heard a loud thud, entered lobby to find resident laying on her right side with her wheelchair tipped over top of her. The Immediate Action Taken section revealed, ROM (range of motion) assessed without any abnormal range of motion observed or reported. Resident assisted with x2 assist to wheelchair. Resident denies pain. Review of a Fax dated 9/30/24 at 2:35 PM revealed, unwitnessed fall from wheelchair. no injuries observed at this time. Will monitor per policy. Review of the Fall Risk Evaluation dated 9/30/24 revealed Resident #22 scored 17 on the assessment, which indicated high risk. The Incident Report dated 10/9/24 at 12:45 PM revealed, This nurse alerted by housekeeping that this R (resident) was on the floor and the drawers on other R dresser were open and (et) R arm was in one sleeve of jacket .R was helped up into her wheelchair et back to her room et laid down. R is unable to respond correctly as is her usual. The Immediate Action Taken section revealed, R (resident) helped off floor and taken to bed. Per the Incident Report, a predisposing situation factor was bare feet or inappropriate footwear. The Fall Risk Evaluation dated 10/9/24 revealed Resident #22 scored 21 on the assessment, which indicated high risk for falls. The Incident Report dated 10/13/24 at 6:02 PM revealed, Resident sitting in w/c by nurses desk, slipped to floor hitting left elbow on wall on the way down. The Immediate Action Taken section revealed, Vitals, assisted back into w/c cleansed and applied dressing to elbow. The Fall Risk Evaluation dated 10/13/24 revealed Resident #22 scored 25 on the assessment, which indicated high risk. Observation on 11/13/24 at 10:02 AM revealed Resident #22 tilted back in broda chair in the television area/nursing station in the front of the facility. On 11/13/24 at 9:09 AM, Staff C, Certified Nursing Assistant (CNA) queried if at facility when Resident #22 had fallen, and responded she was sure she was. Staff C explained now the resident did not ambulate at all, and explained the resident went downhill really fast. Staff C explained she thought a lot of the resident's falls happened on the weekends. When queried how fall risk was communicated, Staff C explained usually through the nurses on report. When queried if the resident's current wheelchair was from hospice, Staff C acknowledged it was. Staff C explained the resident was in a regular wheelchair before, and wasn't working out too well. Staff C explained the resident was leaning over and leaning too forward, and was so much comfier in chair and looked so much better in it too. On 11/13/24 at 12:55 PM, Staff G, Registered Nurse (RN) explained when she first went to the facility, resident was walking. Staff G explained not having enough staff at the facility because they were all out on break instead of watching residents Per Staff G, she had CNAs on break all the time not telling that they went on break. Per Staff G, the resident started failing and was put on hospice. When queried if she had ever worked when the resident had fallen, Staff G denied. When queried about increased monitoring for the resident, Staff G responded just the behaviors, explained the resident had tried to bite a staff member when intervened, and further explained made sure to keep an eye on her and know where was at, at least where located. On 11/18/24 at 10:36 AM, interview conducted with Staff J, CNA regarding Resident #22 and falls. When queried if she had been at facility when Resident #22 had fallen, Staff J replied always. Per Staff J, when resident first at facility would walk, would put self on the floor, and was care planned now for laying on the floor. When queried if Resident #22 was someone who could be left in the common area without staff watching her, Staff J responded no, and further explained the resident still had energy and strength to sit self up, and personally she wouldn't do so. Staff J explained now resident in a wheelchair, and have caught her trying to stand up to side of wheelchair, trying to dangle legs. Staff J explained when the resident used to have an actual wheelchair she would get up and start walking down the hallways, and now the resident had a reclining wheelchair. On 11/18/24 at 8:59 AM, Staff I, CNA acknowledged Resident #22 had fallen a couple of times, and not for Staff I. Staff I explained when resident at the front desk liked to climb out of geri chair, and eased self down or sat down. When queried what the resident tried to do, Staff I explained the resident was busy, felt needed to go shopping, traveling, and was in her own world. Staff I further explained the resident had their current chair for a month/month and a half, and could get out of it. Per Staff I, even though it tilted rolled off to the side, and explained the resident was very agile. When queried about watching persons in the lobby, Staff I explained it depended upon who it was, and explained the following pertaining to Resident #22: If people like [another resident redacted] or [Resident #22], tried to keep someone up there behind the desk, a couple times would get laundry to have them help fold towels, and keep them busy, get them out of their bubble so not so agitated. On 11/19/24 at 2:59 PM, the Administrator queried if she had been at facility when Resident #22 had fallen, and denied. The Administrator explained for the last six to eight weeks the resident had been pretty much wheelchair bound. 3. On 11/6/24 at 6:06 a.m., Staff B Licensed Practical Nurse(LPN) placed Resident #6's Lisinopril(a blood pressure medication) 5 milligrams(mg) and Olanzapine(an antipsychotic) 10 mg into a medication cup and placed it on top of the medication cart. Staff B left the medication cart and entered the medication room and closed the door. The Director of Nursing(DON) was present on the other side of the nursing station but left the vicinity for approximately 1 minute. When the DON returned, Staff B was still in the medication room. The DON picked up the medications and when Staff B returned to the cart, she handed the medications back to her. Untitled facility lists documenting cognitive status and mobility, listed 13 cognitively impaired, independently mobile residents. The facility policy Storage of Medications, revised 4/2007, stated the facility would store all drugs in a safe, secure, and, orderly manner. On 11/19/24 at 1:57 p.m., the Administrator stated medications should not be left unattended. 4. The Minimum Data Set(MDS) assessment tool, dated 3/14/24, listed diagnoses for Resident #2 which included seizure disorder, anxiety disorder, and depression. The MDS stated the resident required partial to moderate assistance to transfer from chair to bed and listed his cognitive skills for daily decision making as moderately impaired. Care Plan entries, dated 5/17/13, stated the resident had the potential for uncontrolled seizures resulting in a safety hazard and falls and stated he would have no major injury related to his seizure disorder. An 8/1/19 Care Plan entry directed staff to keep a gait belt on the resident when he stood while dressing and to keep ahold of him by the gait belt so he could be assisted if he lost his balance. A 9/16/20 Care Plan entry directed staff to quickly assist the resident to lie down if he felt a seizure coming on. A 10/25/21 Care Plan entry stated the resident required the assistance of one staff member for transfers. Care Plan entries, dated 4/11/22, directed staff to not leave the resident alone during a seizure and protect from injury. The Care Plan directed staff to help the resident to the floor to prevent injury if the resident was not in bed. Care Plan entries, dated 6/24/24, stated the resident was at risk for falls related to impaired balance, poor safety awareness, neuromuscular/functional impairment, and the use of medications that may increase fall risks related to a diagnosis of seizure disorder. The entries directed staff to encourage him to ask for assistance when transferring, check on him frequently, and offer assistance with any activities of daily living(ADLs). a. Resident #2 Falls A 5/12/24 BHCP-Falls9 Report stated a Certified Nursing Assistant(CNA) assisted the resident to transfer from the wheelchair to the bed and he lost his balance and fell to the side . The CNA was unable to stop his fall and was not using a gait belt during the transfer. The resident sustained a bruise to the left iliac crest(the upper portion of the frontal pelvic bone). A 6/22/24 6:22 p.m. Incident Note stated the resident placed his call light on during meal time and the nurse left to [TRUNCATED]