**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 40 residents, with 12 residents sampled, and one resident reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, interviews, and record review, the facility failed to provide a pressure reducing device on the bed to prevent a pressure injury for Resident (R) 2. On 07/11/24 the facility noted R2's previous pressure injuries were all closed. On 07/12/24, R2 was moved to a different room and the facility failed to move his air mattress for his bed to the new room. On 07/24/24, R2's left heal pressure injury re-opened and was identified as a stage three pressure injury (full thickness pressure injury extending through the skin into the tissue below). This placed the resident at risk to worsen his pressure ulcers and delayed healing. Findings included: - Resident (R) 2 's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and reduced mobility. The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 99, indicating severely impaired cognition. The resident had a total mood severity score of 02, indicating no depression and R2 had no behaviors. R2 required total assistance with activities of daily living (ADLs), which included bed mobility, toileting, dressing, and bathing. R2 was always incontinent of bladder. R2 had a stage two pressure ulcer (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) on admission. There was a pressure relieving device on the bed and the chair. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) did not trigger on the 10/25/23 MDS. The Pressure Ulcer CAA dated 11/02/23, documented an actual skin breakdown and R2 was at risk for further skin breakdown due to incontinence. Treatment and preventative measures were in place and the facility consulted a wound care physician. The facility would proceed with care planning to ensure that interventions were in place to heal an existing wound and prevent new skin breakdown. The Quarterly MDS dated 07/28/24, documented a BIMS of 99. R2 required total assistance of staff with ADLs. R2 had two stage three pressure ulcers, which were facility acquired and had pressure relieving devices on the bed and the chair. The 09/10/24 Care Plan documented interventions which included: On 08/04/22, staff were instructed to float R2's heels with pillows while in bed. Staff applied an air mattress to R2's bed. On 12/27/23, staff were instructed to apply podus boots (lightweight plastic shell with a liner to help treat and prevent lower extremity disorders) at all times. The Physician Orders dated 08/09/24 included instruction to staff not to provide whirlpool baths for R2 and if showers were done, they were to wrap the resident's left foot. The physician orders lacked any orders for treatment for R2's left foot pressure ulcers. Review of the Progress Notes from 01/01/24 to 09/10/24 documented the following: On 03/28/24 at 09:23 AM the Interdisciplinary Team (IDT) Wound Note revealed a stage three pressure wound to the left heel that measured 2.4 centimeter (cm) by 1.5 cm and 0.2 cm depth. The wound edges were irregular and noted a current treatment plan in place. On 04/16 /24, a Progress Note at 11:08 AM, wound care clinic staff had R2 admitted to a hospital for a worsened foot ulcer and noted the left heel wound required debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue). On 4/18/24, a Progress Note at 01:44 PM, R2 re-admitted back to facility. On 05/07/24, a Wound Consult Note, revealed the left heel wound measured 1.9 cm by 2.6 cm by 0.4 cm, the left lateral (pertaining to the side, away from the middle) foot wound measured 1.2 cm by 1 cm by 0.3 cm. Staff were to maintain heel foam pad at all times. On 06/20/24 , a Wound Consult Note revealed the resident's left heel wound measured 1 cm by 1.5 cm by 0.5 cm. The area was debrided by the physician. On 07/11/24, a Wound Consult Note revealed all of the resident's wounds were closed. Staff were to continue to off load the resident's heel and remove the Podus boot to prevent pressure to dorsal (back) and lateral foot. The resident would have a heel foam pad in place at all times, which was to be changed every two weeks. Staff were to monitor the areas daily and call if worsening. On 07/11/24 at 09:08 AM, Social Services Designee (SSD) K spoke with R2's family member to move R2 into a new room with a roommate, and the family agreed. On 07/17/24 at 10:55 AM, six days after the wounds closed, a Skin/Wound Note revealed the left foot dorsum (upper surface of the foot) wound measured 5 cm by 4 cm, the left heel wound measured 2 cm by 1.5 cm, the left side of the foot with a scabbed area that measured 1 cm by 1.5 cm with redness to the surrounding area that measured 8.5 cm by 2 cm. On 07/22/24 at 07:39 AM, a Skin/Wound Note revealed the left foot dorsum wound measured 4 cm by 2.2 cm, the left heel measured 2.5 cm by 1.7 cm, the left side of foot wound measured 2 cm by 1.3 cm, with no redness noted. On 08/01/24 at 08:17 AM, a Skin/Wound Note revealed the left foot dorsum had redness that measured 4 cm by 2.2 cm by 0.1 cm, the left heel wound measured 3 cm by 3 cm by 0.3 cm with yellow drainage, the left side of the foot wound measured 1.8 cm by 1.5 cm by 0.1 cm with blood- tinged drainage. On 08/08/24 at 04:39 PM, a Wound Consultation Note revealed the resident's left heel re-opened and measured 2.5 cm by 2.5 cm by 0.7 cm, and the left lateral foot wound measured 1.5 cm by 2 cm. On 08/12/24 at 12:08 PM, a Skin/Wound Note revealed the left heel measured 2 cm by 1.7 cm by 0.2 cm and the wound to the left lateral foot measured 0.1 cm by 0.1 cm by 0.1 cm. There was moderate amount of purulent (producing or containing pus) drainage noted from the left heel. On 08/15/24 at 03:59 PM, a Wound Care Note revealed the left heel wound measured 2 cm by 2 cm by 0.3 cm and the wound to the left lateral foot wound measured 1.4 cm by 2 cm by 0.2 cm. Staff were to cleanse the wound with wound wash, pat dry and cover the heel and lateral foot with Aquacel Ag (dressing is indicated for the management of a variety of at risk/infected chronic and acute wounds) extra absorbent dressing. Staff would cover the top of the left foot with a foam pad and change the dressing two times a week. On 09/05/24 at 12:07 PM, a Wound Care Note revealed the left heel wound measured 1.7 cm by 1.8 cm by 0.1 cm and the left side of the foot wound measured 1 cm by 1 cm by 0.1 cm. The left dorsum wound measured 0.5 cm by 2 cm by 0.1 cm. Staff were to leave the dressing intact until the follow-up appointment. During an observation on 09/10/24 at 12:46 PM, R2 was in the dining room seated in wheelchair and had no seat cushion in the wheelchair. R2 had a blue foot bootie on his left foot with a brown dressing covering the foot, the right foot had a sock and both feet were placed in a foot cradle (cushioned back and side panels that are designed to help control foot drop). Observation revealed R2's bed lacked an air mattress. During an observation on 09/11/24 at 07:54 AM, R2 was in the dining room. R2 had a left heel bootie on his foot, a sock on the right foot and both feet were in a foot cradle. The wheelchair lacked a seat cushion and R2's bed lacked an air mattress. An interview on 09/11/24 at 08:00 AM revealed Licensed Nurse (LN) H confirmed R2's EHR lacked an order for the left foot wound received by the wound care clinic on 09/05/24. LN H revealed R2 should have both heels off loaded per physician's order and confirmed R2 had only a left foot bootie placed. An interview on 09/11/24 at 08:09 AM revealed Certified Nurse Aide (CNA) F confirmed R2 did not have a seat cushion under him on the wheelchair and stated that R2 only required a bootie on his left foot and never wore a right foot bootie. An interview on 09/11/24 at 10:20 AM revealed CNA F stated he assisted R2 to bed at approximately 10:00 AM and placed afoot bootie on the right foot and he placed the left foot bootie under the left heel. CNA F stated R2 did not have extra pillows in his room, and he placed R2's heel on the left bootie instead of in the bootie to off load the left heel, then CNA F confirmed that the bootie was not on correctly and was going to get pillows to off-load the heels. CNA F confirmed that R2 did not have an air mattress on his bed and stated that he had never seen one on R2's bed. An interview on 09/11/24 at 03:10 PM revealed Administrative Nurse B confirmed R2 should have had both heels off-loaded in the correct manner. Administrative Nurse B stated that R2's left heel wounds were chronic, non-pressure ulcers, that R2 had since admission. Administrative Nurse B was asked to clarify what stage, type of ulcer, and if the areas were facility acquired as documentation on the 07/28/24 MDS revealed two stage three facility acquired pressure ulcers. An interview on 09/11/24 at 03:43 PM revealed Administrative Nurse B confirmed R2 did not have an air mattress on his bed. Administrative Nurse B stated that R2's room had been changed a few weeks prior, and R2 always had an air mattress on his bed for at least a year. An interview on 09/11/24 at 04:00 PM revealed Administrative Nurse B confirmed R2 had facility acquired stage three pressure ulcers after she spoke to the wound care clinic nurse. Administrative Nurse B revealed that the areas were closed and healed on 07/11/24, and the pressure ulcers were facility acquired. On 09/11/24 at 04:40 PM, SSD K verified R2 moved to room his previous room on 07/12/24. Administrative Nurse B confirmed R2 did not have an air mattress when he moved to a different room and commented the facility had extra air mattresses and did not know why R2 was without an air mattress. The facility's policy Pressure Ulcer/Skin Breakdown dated April 2013 documented: Physicians shall help prevent and manage pressure ulcers, consistent with established guidelines. Incidence of new pressure ulcers will be minimized to the extent possible. Healing of existing pressure ulcers will be optimized to the extent as possible. The facility will be able to show failure of a pressure ulcer to heal was medically unavoidable. The facility failed to place interventions to prevent pressure injuries for R2, who developed two preventable, facility acquired, stage 3 pressure injuries. This placed the resident at risk to worsen his current pressure ulcer or develop more skin issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 40 residents, which included 12 residents sampled and three reviewed for accidents and accident hazards. Based on interviews, observations, and record review, the facility failed to provide an environment free of accident hazards for the residents of the facility when the facility failed to properly store chemicals in an unlocked cabinet in an unlocked room and when the facility stored chemicals along a rail in the hallway. Additionally, the facility failed to ensure R26, who was identified by the facility as confused and independently mobile with aggressive and wandering behaviors, remained free of accident hazards when R26 put scissors in his pocket and wandered inside the facility. Furthermore, the facility failed to ensure that two residents, Resident (R) 22 and R8, remained free of accident hazards related to falls when the facility failed to appropriately investigate, develop, and implement appropriate interventions to prevent multiple falls for R22 related to continued use of a powered lift chair, or develop any new interventions for R8. These deficient practices resulted in R8 falling and sustaining a fracture (broken bone) to her left humerus (upper arm bone) and left fourth rib which required a hospitalization. Findings included: - Review of the Electronic Health Record (EHR) for Resident (R) 8 included diagnoses of osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), history of falling, repeated falls, generalized muscle weakness, lack of coordination, and dementia (a progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated [DATE], documented R8 as unable to complete the Brief Interview for Mental Status (BIMS) assessment and staff assessed R8 to have severely impaired cognition. The assessment documented R8 required substantial or maximal assistance from staff for cares. R8 was frequently incontinent of bladder and always incontinent of bowel. The assessment documented that R8 had no falls since the previous assessment. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated [DATE], documented R8 as deceased ; however, the surveyor observed R8 in the facility on [DATE], [DATE], [DATE], and [DATE]. The Quarterly MDS dated [DATE], documented R8 as unable to complete a BIMS assessment and staff assessed R8 to have severely impaired cognition. The assessment documented R8 as dependent on staff for toileting, bathing, and all forms of hygiene and required substantial or maximal assistance for all other cares except eating, which was required supervision/setup. R8 was frequently incontinent of bowel and always incontinent of bladder. The assessment documented that R8 had a fall since the previous assessment. The [DATE] Care Plan documented R8 was at risk for falls and listed the following interventions: On [DATE], staff would monitor for changes in R8's condition that may warrant increased supervision or assistance and notify the charge nurse. On [DATE], staff would provide frequently used items within easy reach. On [DATE], family reported R8 was forgetful and would benefit from consistency in her room. She was unable to use a walker due to difficulty remembering to use it. On [DATE], staff would request physical/occupational therapy to evaluate and treat the resident as needed. On [DATE], staff would encourage the resident to visually survey the area prior to stepping away to walk. On [DATE], activities staff would provide mid-morning and mid-afternoon activities, one on one to keep R8 busy and mobile. On [DATE], staff placed a night light in R8's room so she was able to see after dark. Review of the EHR Safety Device Consent dated [DATE], documented a safety assessment for turn bars only and lacked safety assessment for a powered lift chair. Review of the EHR Fall Risk assessments revealed on [DATE], the facility documented a fall risk score of 22, which indicated R8 was a high risk for falls. The Progress Notes dated [DATE] documented R8 experienced a witnessed fall and landed on her left side, she then repositioned herself to her back. Review of the facility Fall Investigation revealed on [DATE] at 05:20 PM, R8 fell without injury. The facility's root cause analysis determined R8 had a lack of safety awareness, which caused the fall. The fall investigation report documented the immediate and permanent care plan interventions were that staff would provide a smaller recliner that was a better fit for R8. The resident's Care Plan documented on [DATE] staff would provide a smaller recliner that was a more appropriate fit for R8; however, the facility lacked evidence of the implementation of this intervention. The Progress Notes dated [DATE] documented R8 was found sitting on the floor near the bed with bed linens wrapped around her legs. The fall investigation report documented the immediate and permanent care plan interventions were that staff would provide more frequent rounding. Review of the facility Fall Investigation revealed on [DATE] at 10:06 PM, R8 fell and obtained a minor injury. The facility's root cause analysis lacked determination causal factors for the fall. The fall investigation report documented the immediate and permanent care plan interventions were that staff would provide more frequent rounding. The resident's Care Plan documented on [DATE] that staff would provide frequent rounding however, the facility lacked evidence of the implementation of this intervention. Review of the EHR Fall Risk assessments revealed [DATE], the facility documented a fall risk score of 15, which indicated R8 was a moderate risk for falls. The Progress Notes for R8 lacked an entry with a description related to fall on [DATE]. The fall investigation report lacked an immediate intervention to mitigate fall risk for the remainder of the shift. The fall investigation report documented the permanent care plan documented staff would cue and sit with R8 to ensure that R8 ate the meal or snack provided. Review of the facility Fall Investigation revealed on [DATE], R8 fell and obtained a minor injury. The facility's root cause analysis determined that R8 was hungry and attempted to ambulate without staff assistance. The fall investigation report lacked an immediate intervention to mitigate fall risk for the remainder of the shift. The fall investigation report documented the permanent care plan documented staff would cue and sit with R8 to ensure that R8 ate the meal or snack provided. The resident's Care Plan documented on [DATE] that staff would sit with R8 to provide cues and assistance with any snacks or meals provided. The Progress Notes dated [DATE] documented staff discovered R8 at approximately 05:30 AM, on the ground on her knees, and noted she had a minor injury to the left elbow. The facility's fall investigation report documented that the immediate intervention was that staff would close monitoring for remainder of shift. The facility's fall investigation report permanent care plan documented staff would unplug recliner and switch to a manual recliner when possible. Review of the facility Fall Investigation revealed on [DATE], R8 fell and obtained a minor injury. The facility's root cause analysis determined R8 raised a powered lift chair to its full height and fell. The facility's fall investigation report documented that the immediate intervention was that staff would closely monitor the resident for the remainder of the shift. The facility's fall investigation report permanent care plan documented staff would unplug recliner and switch to a manual recliner when possible. The resident's Care Plan documented manual recliner on [DATE]; however, the surveyor observed R8 resting in powered lift chairs on [DATE], [DATE], [DATE], and [DATE]. Review of the EHR Fall Risk assessments revealed the on [DATE], the facility documented a fall risk score of 25, which indicated R8 was a high risk for falls. The Progress Notes dated [DATE] at 09:25 PM documented staff discovered R8 on the ground on her left side in her doorway, with a minor injury to the left elbow. Review of the facility Fall Investigation revealed on [DATE], R8 fell and obtained a minor injury. The facility's root cause analysis determined R8 had limited safety awareness. The fall investigation report documented the immediate intervention was that staff would perform more close monitoring of the resident. The fall investigation report documented the permanent care plan intervention was staff would offer toileting with all bed checks. The resident's Care Plan documented on [DATE] staff would offer toileting with all bed checks to prevent the resident from attempting to ambulate without assistance from staff. Review of the EHR Fall Risk assessments revealed on [DATE], the facility documented a fall risk score of 22, which indicated R8 was a high risk for falls. The Progress Note dated [DATE] at 01:27 AM, documented R8 was given pain medication for the fall that occurred on [DATE] at 09:25 PM and lacked documentation of the location or severity of the pain. The Progress Note dated [DATE] at 03:24 PM, revealed an unknown Certified Nurse Aide (CNA) staff reported to the nurse R8 had pain and swelling to the left shoulder. The nurse assessed R8 and documented swelling and bruising from R8's shoulder to her elbow on the left arm, documented she notified R8's primary care physician (PCP), and noted she left a message for the PCP. The Progress Note dated [DATE] at 03:55 PM, revealed R8's PCP returned the phone message and gave a telephone order to obtain an x-ray of the resident's left upper arm and left shoulder. The Progress Note dated [DATE] at 09:14 PM, revealed the consultant x-ray provider notified the facility that R8 had a displaced fracture (a traumatic bone break where two ends of the bone separate out of their normal positions) of the left humerus and a fractured left fourth rib. The facility staff notified R8's PCP and received orders to maintain current treatment to maintain R8's comfort and notify the PCP if R8 became uncomfortable. Review of the Progress Note dated [DATE] at 05:48 PM, revealed staff called the hospital and were advised that R8 admitted to the medical floor due to a fracture of the left humerus. The Progress Notes lacked additional documentation related to how, when, or why the resident was transferred to the hospital. Review of the Progress Note dated [DATE] at 03:00 PM, revealed R8 arrived to the facility with a report from the hospital noting R8 was not a candidate for surgical repair of the left arm and orders to apply ice to the affected area as needed for pain or swelling, R8 was to wear a sling on the left side at all times for four weeks, and staff were not to use the left arm to assist the resident with cares. Review of the facility Fall Investigation revealed on [DATE], R8 fell and obtained a minor injury. The facility's root cause analysis determined that R8's limited safety awareness caused the fall. The fall report documented that the immediate intervention was that staff would perform more close monitoring with one-on-one supervision as much as possible. The fall investigation report documented the permanent care plan intervention was documented as staff asked R8's family to bring a TV to her room so staff would place the TV on a music channel then wait to see if she was willing to lay and watch television and sleep. The Progress Notes for R8 lacked documentation related to the [DATE] fall. The resident's Care Plan included an intervention dated [DATE], which documented family would bring R8 in a television and staff were to put it on a music channel which would allow her to watch, relax, and sleep. Review of the Progress Note dated [DATE] at 03:22 AM, staff documented a witnessed fall when R8 attempted to stand unassisted from a wheelchair without additional injuries; however, the facility lacked a fall investigation related to this fall. The resident's Care Plan included an intervention dated [DATE], which indicated staff had a meeting with family regarding additional interventions to prevent R8 from falling again with suggestions made that staff would implement with the goal to keep R8 calm; however, no additional information was provided. Review of the EHR Fall Risk assessments revealed on [DATE], the facility documented a fall risk score of 26, which indicated a high risk for falls. The resident's Care Plan included an intervention dated [DATE], which directed staff would offer to take R8 to the bathroom during all overnight bed checks to prevent her from self-ambulation attempts. The Progress Notes dated [DATE] at 04:19 PM, revealed staff documented a witnessed fall without injury when R8 attempted to stand from a recliner with the footrest in the up position. The fall investigation report documented the immediate and permanent care plan interventions were that staff would offer snacks/drinks frequently. Review of the facility Fall Investigation revealed on [DATE], R8 fell without injury. The facility's root cause analysis determined R8 attempted to stand without staff assistance. The fall investigation report documented the immediate and permanent care plan interventions were that staff would offer snacks/drinks frequently. The resident's Care Plan documented on [DATE] staff would frequently offer snacks/drinks to R8 however, the facility lacked evidence of the implementation of this intervention. Review of the EHR Fall Risk assessments revealed on [DATE], the facility documented a fall risk score of 23, which indicated a high risk for falls. The Progress Notes revealed on [DATE] at 05:28 PM, staff documented a fall without injury when R8 attempted to ambulate without staff assistance. Review of the facility Fall Investigation revealed on [DATE], R8 fell without injury. The facility's root cause analysis determined that R8 attempted to stand without staff assistance. The fall report lacked an immediate intervention performed by staff to mitigate the risk of falls for the remainder of the shift. The permanent care plan intervention was staff should monitor for items left on the floor or any items the resident may have dropped and assist with picking them up. Review of the resident's Care Plan revealed the following interventions: On [DATE], staff would perform rounds frequently and offer R8 toileting assistance. On [DATE], staff would maintain an environment that was clutter-free, provide adequate lighting, and ensure personal items were within reach. On [DATE], staff would provide assistive devices as needed. On [DATE], staff would review information on past falls to determine causes of falls. Review of the EHR Fall Risk assessments revealed on [DATE], the facility documented a fall risk score of 15, which indicated R8 was a moderate risk for falls. Observations on [DATE] at 12:50 PM, [DATE] at 07:40 AM, and [DATE] at 10:00 AM revealed R8 in a powered lift chair recliner in the common area near the nurses' station with her eyes closed. Observation on [DATE] at 12:00 PM, revealed R8 in a powered lift chair recliner in the common area near the nurses' station with her eyes closed. Two unknown CNA staff assisted R8 to an upright seated position using the powered mechanism of the lift chair, then performed a two-person pivot-transfer from recliner to R8's wheelchair and assisted R8 to the dining area for the noon meal. On [DATE] at 12:04 PM, CNA F stated when a resident fell, CNA staff should ensure the resident was safe, then alert other staff that assistance was required, and would notify the nurse. Upon the arrival of the nurse, then CNA staff would follow the instructions of the nurse. CNA F was unable to recall specific interventions for R8 and stated that they would refer to the CNA book at the nurses' station or R8's care plan on the EHR for guidance. On [DATE] at 12:14 AM, CNA E stated that when a resident fell, CNA staff would ensure the resident was safe and call for help, which included calling the nurse. Once the nurse arrived, then CNA staff would follow the instructions of the nurse. CNA E was unable to recall any information specific to R8's falls and stated that interventions to prevent falls for R8 could be found in the resident's care plan, which was accessible in the EHR on either the computers or tablets or in the CNA book in the nurses' station. On [DATE] at 12:24 PM, Licensed Nurse (LN) D stated after a fall, the CNA staff would ensure the resident was safe and call for help, which included the nurse. When the nurse arrived, they would assess the resident for injuries and give aid if appropriate. Immediately following the fall, the nurse would notify the PCP, the resident's representative, Administrative Nurse B and/or Administrative Staff A. Immediately after the required notifications were made, the nurse would fill out a fall report in the EHR and collect witness statements from all nursing (CNA, Certified Medication Aides [CMA], LN) personnel on duty at the time of the fall. The nurse would then hold a fall huddle with the staff to initiate an investigation to determine the root cause of the fall and develop an immediate intervention to mitigate the risk of falls for the remainder of the shift. The nurse would also perform and document ongoing assessments for fall follow up which may or may not include neurological (pertaining to the brain) assessments if needed for 72 hours (3 days) after the fall. On the next business day, Administrative Nurse B would review the documentation and add a permanent care plan intervention on the resident's care plan and place the update in the CNA book at the nurses' station. Additionally, LN D stated that she was unsure if residents were assessed for safety related to the safe operation of powered lift chairs. During an interview with Administrative Nurse B on [DATE] at 12:36 PM revealed after a resident fell, she expected staff to perform a huddle to discuss what happened, develop an immediate intervention to prevent further falls, then staff would complete a risk management module. All nursing staff were expected to fill out a witness statement, then make appropriate notifications. The Director of Nursing (DON) reviewed fall charting and added interventions to the individual resident care plans after a fall. Administrative Nurse B reported resident cares were driven by the care plan and stated it was her expectation the care plan would be revised with a new and unique intervention related to each specific fall. Administrative Nurse B further confirmed if the facility did not identify the cause of a fall they could not say if interventions in place for fall were appropriate. Administrative Nurse B stated duplicate or similar care plan interventions were unacceptable and confirmed the resident had duplicate/similar care planned interventions for multiple falls. Administrative Nurse B stated care planned interventions should be new, unique to the fall, and measurable. She also confirmed the facility lacked appropriate follow up for all falls in the resident's progress notes. The nurse should initiate and document ongoing assessments for 72 hours (3 days) for fall follow up and include neurological assessments if needed. Administrative Nurse B stated that the previous DON was responsible for the information prior to the [DATE] fall and she was unable to provide an explanation as to why the expectations were not met. Administrative Nurse B stated that all residents who use powered lift chairs should have a Safety Device Consent assessment in their EHR to determine whether they could safely utilize a piece of powered equipment. She confirmed R8 had severely impaired cognition and could not be assessed for safe use of a powered lift chair. Further, confirmed that the Safety Device Consent in R8's EHR, dated [DATE] lacked a safety assessment for a powered lift chair. The facility's undated Fall Guidelines - Assessing Falls and Their Causes documented staff were to observe a resident who fell for delayed complications for approximately forty-eight (72) hours and would document the findings in the resident's EHR. Additionally, staff would, in collaboration with the interdisciplinary team (IDT - a team of facility staff consisting of members of various departments including but not limited to; dietary, nursing, maintenance, therapy, etc.), identify possible or likely causes of the incident and lacked instructions for staff to follow to correct the causes of the incident. The facility failed to implement interventions after multiple falls to provide an environment free of accident hazards for a dependent resident with severely impaired cognition and a known history of repeated falls. R8 fell twice on [DATE] and was injured, fell on [DATE] and was injured, fell on [DATE] and was injured, fell on [DATE] and was injured (two fractures and a hospitalization), fell on [DATE] and was injured, fell on [DATE] and was not injured, and fell on [DATE] and was not injured. This deficient practice resulted in actual harm to the physical and psychosocial well-being of R8. - Observation on [DATE] at 10:45 AM, revealed a container of sanitizer wipes for surfaces and reusable medical equipment sat on top of the handrail in the 200 hall. The sanitizer wipes container was labeled Keep out of reach of children. On [DATE] at 11:42 AM, Housekeeping Supervisor X, unknown housekeeper and unknown laundry aide observed walking past the container of sanitizer wipes stored on the top of the handrail in the 200 hall. On [DATE] at 12:10 PM, Licensed Nurse (LN) H identified the sanitizer wipes as hazardous chemicals since the manufacturer's label documented to keep out of reach of children and stated that the container of wipes should be stored in the medication room, in the supply room, or in a (unsecured) bag hanging from mechanical lifts. LN H then removed the container of wipes and placed it in an unsecured bag and hung it from a mechanical lift that was stored in the hallway. On [DATE] at 01:51 PM, during an environmental tour with Maintenance Director O in the activities room, a large metal cabinet with two full-length doors was unlocked and contained the following hazardous chemicals with Keep out of reach of children on the manufacturer's labels: 1. One container of Germicidal (sanitizing) wipes. 2. Two cans of paint plus primer. 3. One can of spray adhesive. 4. One can of extra hold hairspray. 5. One container of mosaic stone cement. 6. Two containers of nail polish remover. In addition, there was assorted nail care accessories which included nail polish, clippers and scissors. On [DATE] at 03:00 PM, Administrative Nurse B confirmed the above findings and stated that her expectation was for all chemicals and sharp objects to be secured behind a locked door or cabinet. Administrative Nurse B identified four residents who were independently mobile and had cognitive impairment that included confusion. The facility's undated Poisonous and Toxic Materials documented that all containers of poisonous and toxic materials would be prominently marked or labeled for easy identification and when not in use would be stored on shelves that were used for no other purpose. The policy lacked documentation related to keeping chemicals away from residents and/or secured behind a locked door or cabinet. The facility failed to provide an environment free of accident hazards when the facility failed to appropriately store hazardous chemicals. - Review of the Electronic Health Record (EHR) for Resident (R) 26 included diagnoses of altered mental status (state of awareness that was different from the normal awareness of a person), dementia (a progressive mental disorder characterized by failing memory, confusion) and Wernicke's encephalopathy (a brain and memory disorder that causes confusion, ataxia [impaired ability with muscle coordination], eye problems and memory loss). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The assessment documented that R26 had a PHQ-9 score of 0, which indicated no indications for depression and no behaviors documented. R26 required partial/moderate assistance of staff for dressing and footwear, and supervision for all other cares except eating which required setup and supervision. R26 performed toileting independently. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated [DATE], documented that R26 had a diagnosis of dementia with cognitive loss. The [DATE] Care Plan documented R26 displayed wandering behaviors and included multiple interventions for staff to promote safety. The [DATE] Care Plan documented R26 had a history of inappropriate behaviors that included agitation and aggression and intermittent refusal of care and provided the following interventions: Staff would reorient and redirect R26 as needed, dated [DATE]. Staff would allow R26 time to calm down and reapproach at a later time, and monitor for and document each behavioral event, dated [DATE]. Staff would evaluate the need for a referral to psychological services and offer psychosocial support, dated [DATE]. Staff would interact in an empathetic and supportive manner, dated [DATE]. Staff would attempt to allow resident time then reapproach, regarding verbal aggression to staff, dated [DATE]. The Physician's Orders documented the following: Monitor the resident for target behaviors including yelling at staff, resisting cares, hitting others and inappropriate behaviors, two times per day for behavior monitoring, dated [DATE]. Monitor the resident for inappropriate behaviors, wandering, verbal aggression, two times per day for behavior monitoring, dated [DATE]. The Assessments reviewed and lacked safety assessment for R26 to keep or have access to sharp/dangerous objects. The [DATE] to [DATE] Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented monitoring of behaviors. The Progress Notes reviewed [DATE] to [DATE] revealed multiple entries where staff documented rejection of cares, aggression, and agitation towards staff and wandering behavior that included wandering into other resident's rooms. On [DATE] at 11:45 AM, an observation revealed R26 in his room with scissors and nail clippers. R26 became verbally aggressive with survey team when an interview attempted. R26 placed the scissors in the front pocket of his trousers and walked angrily from the room down the hallway. On [DATE] at 07:46 AM, R26 wandered in the hallway with a furrowed brow and scowl expression. On [DATE] at 12:04 PM, Certified Nurse Aide (CNA) F stated that all dangerous items such as chemicals and sharp objects (knives, scissors, etc.) should be locked up and should not be accessible to residents. On [DATE] at 12:14 PM, CNA E stated that dangerous objects such as chemicals, knives or scissors should be locked up and inaccessible to residents. On [DATE] at 12:24 PM, Licensed Nurse (LN) D stated that dangerous items such as chemicals, knives or scissors should be secured in such a way that prevents residents from having access to them. On [DATE] at 03:00 PM, Administrative Nurse B stated that her expectation was for all dangerous items which included chemicals, knives, scissors, and nail clippers to be secured and not available to residents. Administrative Nurse B identified four residents in the facility that were independently mobile and confused, that included R26. Further, Administrative Nurse B identified R26 as a resident who displayed intermittently aggressive behaviors and should not have access to sharp objects. The facility lacked a policy related to securing potentially hazardous objects. The facility failed to ensure that R26, a resident that the facility identified as confused and independently mobile with aggressive and wandering behaviors when R26 put scissors in his pocket and wandered inside the facility. This put this resident at risk for self -injury as well as the residents of the facility at risk for potential of harm related to unsecured sharp objects. - Review of the Electronic Health Record (EHR) for Resident (R) 22 included diagnoses of history of falling, chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and bipolar disorder (a major mental illness that caused people to have episodes of severe high and low moods). The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented that R22 utilized a walker or wheelchair for locomotion and required extensive assistance of all cares of two staff members except eating which was performed independently. R22 was always incontinent of urine and occasionally incontinent of bowel. R22 received opioid (class of drug used to treat moderate to severe pain) five of the seven days in the look-back-period and received oxygen. The assessment documented that R22 did not fall since the previous assessment. The Falls Care Area Assessment (CAA) dated [DATE], documented that R22 had a history of falls related to her need for assistance with transfers. The Quarterly MDS dated [DATE], documented a BIMS score of 10, which indicated moderately impaired cognition. The assessment documented R22 was dependent on staff for bathing and toileting and required substantial/maximal assistance for all other cares except eating, which required partial assistance. R22 was always incontinent of urine and occasionally incontinent of bowel and received an antidepressant (a class of medications used to treat mood disorders and relieve symptoms of depression) and oxygen. The assessment documented that R22 fell since the previous assessment. The [DATE] Care Plan documented R22 was at risk for falls related to poor safety awareness, unsteadiness, COPD and hospice/end-of-life care and listed the following interventions: On [DATE] documented staff should place non-skid surface in a chair to prevent her from sliding out of chair, initiated on [DATE] and revised date of [DATE]. Staff would maintain a clutter free environment; free from spills with adequate lighting and place personal items within reach, initiated on [DATE]. Staff would ensure items are within reach, initiated on [DATE]. Staff would ensure the call light was within reach and encourage the resident to call for help, initiated on [DATE]. On [DATE], staff educated to ensure that water pass performed on both shifts and placed within the reach of resident, initiated on [DATE]. Staff would provide appropriate footwear with transfers and ambulation, initiated on [DATE]. Staff would