**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews, the facility failed to protect the residents' right to be free from sexual abuse, psychosocial abuse, and neglect for 1 (#1) of 6 (#1, #2, #3, #R4, #R5, and #R6) sampled residents reviewed for abuse. The facility failed to protect Resident #1 from being sexually and psychosocially abused by Resident #2. This deficient practice resulted in an Immediate Jeopardy (IJ) situation on 08/01/2025 at 7:59 p.m., when Resident #2, a cognitively intact resident with a history of sexually inappropriate behaviors and a convicted sex offender, put his hand between Resident #1's upper thighs and touched her vaginal area. Resident #1 had a BIMS of 2, which indicated she was severely cognitively impaired. From 7:59 p.m. to 8:43 p.m. At 8:13 p.m., S9CNA witnessed the sexual abuse and failed to separate the residents. Resident #2 was observed in video footage to sexually abuse Resident #1 intermittently while Resident #1 attempted to stop the abuse. At 8:43 p.m., S7LPN and S11CNA witnessed the touching and intervened. After the incident, Resident #1 stated she told Resident #2 no. Interviews revealed the facility failed to monitor any of the remaining 28 female residents who could have been affected by the deficient practice after the sexual abuse occurred. As a result of the investigation, despite there not being a significant decline in mental or physical functioning for Resident #1, it could be determined a reasonable person would be likely to experience severe psychosocial harm as a result of the sexual abuse since a reasonable person would not expect to be treated in this manner in their own home or a health care facility. S1ADM was notified of the Immediate Jeopardy situation on 08/27/2025 at 4:15 p.m. This deficient practice continued at a potential for more than minimal harm for any of the 28 female residents residing in the facility who were not assessed after the incident. Review of the facility's policy dated 01/14/1999 and titled, Adult, Disabled Person, or Elderly Abuse-Recognition and Reporting revealed the following, in part:Sexual abuse: Includes any non-consensual sexual contact of any type with a resident including:Unwanted intimate touching of any kind especially of breast or perineal area.Procedure: To protect the resident from real or suspected.sexual abuse, staff shall safeguard the resident from the offending individual. Resident #1Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Alzheimer's Disease, Mood (Affective) Disorder, and Major Depressive Disorder. Review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/12/2025 revealed a Brief Interview for Mental Status (BIMS) of 2, which indicated Resident #1 was severely cognitively impaired. Review of the facility's Incident Log revealed, Resident #1 was involved in a Physical Aggression Received incident. Resident #1's Incident Report revealed the following, in part:Date: 08/01/2025 at 8:43 p.m. Person Preparing Report: S7LPNNursing Description: When S7LPN was walking up with S11CNA, S11CNA got her attention and pointed toward two residents in the front lobby in front of the nurse's station. S7LPN noticed Resident #2 had his hand between Resident #1's legs. S7LPN removed Resident #2's hand and separated the two residents. When S7LPN was speaking with Resident #1, she informed her Resident #2 said, Don't let no one see this. When Resident #1 was asked if she told Resident #2 no, she said, yes. S7LPN talked further with Resident #1, she asked if she could check her out and make sure that everything was ok. Resident #1 refused and put her right fist in the air saying she can handle anything that needs to be handled. At 10:12 p.m., local police arrived at the facility and spoke to Resident #1 and #2 regarding the incident. Information regarding both residents, as well as a typed statement, was given to the officers by S7LPN. Resident #1 remained at the nurse's station until she was ready to go to bed and at that time, she was assisted to the room and assisted to bed. S1ADM was notified. S2DON was made aware by S1ADM. Further review of Resident #1's Clinical Record revealed no new interventions or services to address the sexual abuse after the incident occurred. Resident #2Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Bipolar Disorder and Depression. Further review revealed Resident #2 had documentation showing he was a convicted sex offender. Review of Resident #2's admission Paperwork from a local hospital dated 11/24/2023 revealed the following, in part: Resident #2 was recently released from jail for not registering as a sex offender. Review of Resident #2's Quarterly MDS with an ARD of 07/23/2025 revealed a BIMS of 14, which indicated Resident #2 was cognitively intact. Review of Resident #2's current Care Plan revealed the following, in part:Created 02/26/2025Problem: The resident has a behavior problem: excessive masturbating and staying completely naked at all times when in room/makes sexual comments towards staff at times. Interventions: Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; intervene as necessary to protect the rights and safety of others; 05/15/2025: Intensive Outpatient Program (IOP) to be notified of increase in inappropriate sexual behavior. Further review of Resident #2's Clinical Record revealed the resident had not received psychiatric services to address the sexual behaviors since January of 2025. Review the facility's Incident Log revealed, Resident #2 was involved in a Physical Aggression Initiated incident. Resident #2's Incident Report revealed the following, in part: Date: 08/01/2025 at 8:43 p.m.Person Preparing Report: S2DONNursing Description: S7LPN informed me of the incident between Resident #2 and Resident #1. S11CNA and S7LPN noticed Resident #2 had his hand between Resident #1's legs. S7LPN removed Resident #2's hand and separated the two residents. I informed Resident #2 he was not allowed to touch the other residents. Resident #2 verbalized understanding. S7LPN notified S1ADM and doctor. Review of Resident #2's Police Incident Report revealed the following, in part:On 08/01/2025 at approximately 10:00 p.m., two officers were dispatched to the facility in regards to a sexual battery that had just taken place. Upon our arrival, we met with S7LPN. S7LPN began to tell us earlier in the night, she came upon Resident #2 fondling Resident #1 in the common area located in front of the nurse's desk. S7LPN stated as soon as she saw this, she removed Resident #2's hand. S7LPN said Resident #2 went to his room and she contacted both her boss and the police. S7LPN stated she saw Resident #2 with his hand buried between Resident #1's legs and he was using his thumb as if he was massaging Resident #1's vaginal area in a circular motion. I then spoke with Resident #1. Resident #1 stated Resident #2 was rubbing on her leg and she told him to leave her alone. Resident #1 seemed a little confused at the time, the longer we spoke, however she insisted Resident #2 was her friend, but that she had told him no when he began rubbing on her. After speaking with Resident #1, we were then taken to speak to Resident #2. Upon speaking with Resident #2, he stated he knew why we were there and that he had indeed touched Resident #1 in an inappropriate way and he was sorry, and he knew he had done wrong. It was at this time Resident #2 was told to have no further contact with Resident #1 and the matter was going to be investigated further, and it was possible he could be facing criminal charges because of the incident. On 08/25/2025 at 3:20 p.m., video footage of the incident was reviewed with S1ADM. S1ADM confirmed the following:08/01/2025 at 7:56 p.m., Resident #2 wheeled himself beside Resident #1, who was sitting directly in front of the nurse's station in her wheelchair. 7:58 p.m., Resident #2 was observed touching Resident #1's right shin.7:59 p.m., Resident #2's left hand moved from Resident #1's shin to between her upper thigh and vaginal area, outside of her pants. Resident #1 immediately put her hands on Resident #2's left arm.8:01 p.m., Resident #1 attempted to remove Resident #2's hand but was unsuccessful. Resident #2's hand remained between Resident #1's upper thighs until 8:12 p.m., when Resident #1 stood up. Resident #2's hand was observed going behind Resident #1's buttocks. 8:13 p.m., S9CNA was observed to walk within approximately 6 feet from where Residents #1 and #2 were and Resident #1 sat back down. S9CNA pointed at Resident #2, and was observed to say something, then S9CNA walked away. Resident #2's hand remained in between Resident #1's upper thighs when she sat down. 8:18 p.m., Resident #2 removed his hand from between Resident #1's thighs. 8:22 p.m., Resident #2 put his right hand between Resident #1's upper thighs and Resident #1 started tapping on the top Resident #2's hand. Resident #2 removed his hand at 8:23 p.m. when S8LPN and S17LPN was observed walking back to the nurse's station with their medication carts. 8:25 p.m., S8LPN was observed administering Resident #2 his medications and S17LPN was observed administering Resident #1 her medications, then both nurses walked away. 8:29 p.m., Resident #2 placed his left hand between Resident #1's upper thighs again and Resident #1 attempted to remove it. After attempting to remove it, it could not be determined where Resident #2's hand was until 8:42 p.m., when Resident #2's left hand was observed coming from behind the left wheel of his wheelchair. 8:43:37, Resident #2 was observed putting his left hand back between Resident #1's upper thighs and Resident #1 was observed slapping at his hand. 8:43:47, S11CNA was observed walking up the hall back to the nurse's station. S11CNA grabbed at S7LPN, who was walking beside her, and pointed towards Residents #1 and #2. S7LPN immediately removed Resident #2's hand from between Resident #1's thighs and separated the residents. S7LPN was observed talking to Resident #1 then she picked up the phone and called someone. 8:48 p.m., Resident #2 was brought to his room. On 08/26/2025 at 1:47 p.m., an interview was attempted with Resident #1. She was unable to be interviewed due to her cognitive status. On 08/26/2025 at 11:58 a.m., an interview was conducted with Resident #1's family member. He stated Resident #1 had been residing at the facility for a little over a month. He stated the facility notified him of the incident between Resident #1 and #2 on 08/01/2025. He stated he was told there was a gentleman resident in the common area with Resident #1, and he rubbed her between her legs. He stated he was told it was not skin to skin, but it was still inappropriate touching. He stated Resident #1 was confused. He stated if Resident #1 was cognitive, she would have been very upset that someone touched her inappropriately. On 08/25/2025 at 4:32 p.m., an interview was conducted with S9CNA. She said Resident #1 was not cognitively intact and Resident #2 was. She stated knew Resident #2 was a sex offender and explained when children came into the facility, the resident had to be moved to his room. S9CNA stated she worked the night of 08/01/2025, when Residents #2 sexually abused Resident #1. She stated Resident #1 was at the front of the nurse's station in her wheelchair. S9CNA stated she was sitting in the dining room charting, and she saw Resident #1 stand up. She stated Resident #2 was sitting to the right of Resident #1. She stated as Resident #1 was standing up, she was telling Resident #1 to sit down while simultaneously walking towards Resident #1. She stated as she got closer, she saw Resident #2 take his hand and touch Resident #1's vagina from the backside. She stated she told Resident #2 he could not touch her. She stated Resident #2 knew what he was doing and that it was sexual abuse. She stated she did not separate Resident #1 from Resident #2. She stated her first instinct was to report the incident to the nurse and she did not think to separate the residents. She stated she went to find a nurse to report it to and when she came back, staff were in the front lobby talking about Resident #2 sexually touching Resident #1. She stated she then notified S7LPN what she saw earlier. She stated she notified S1ADM. She stated after S7LPN and S11CNA saw Resident #2 touching Resident #1, the residents were separated, and Resident #2 was sent to a behavioral hospital. She stated Resident #2 had not been back to the facility since the incident occurred. On 08/26/2025 at 6:37 a.m., an interview was conducted with S7LPN. She stated Resident #2 was fully cognitive. She stated Resident #1 was not cognitive. She stated she was aware Resident #2 was a sex offender. She stated she worked the night of 08/01/2025, when Residents #2 sexually abused Resident #1. She stated after she completed her medication pass, S11CNA got her attention and pointed at Residents #1 and #2. She stated she saw Resident #2 with his hand in between Resident #1's legs rubbing her vagina violently. S7LPN stated Resident #2 had his fingers toward Resident #1's buttocks and his thumb was rubbing Resident #1's front vaginal area. S7LPN stated she physically removed Resident #2's hand and separated the residents immediately. She stated she asked Resident #1 what happened and Resident #1 said I told him no. S7LPN stated she called S1ADM immediately to report it. She stated S1ADM told her to call the police and file a report. S7LPN stated she heard Resident #2 tell the officers he was not in his right mind and stated he just wanted to feel her. She stated Resident #2 said he didn't want to get caught. She stated Resident #1 refused to be assessed afterwards for any injuries. She stated after the incident took place, S9CNA told her she had seen Resident #2 touch Resident #1's vagina earlier in the night. She stated the incident was sexual abuse because Resident #2 was cognitive and knew what he was doing and Resident #1 said no, and was not cognitive. She stated Resident #2 was sent to a behavior hospital after the incident and had not been back to the facility. On 08/25/2025 at 2:33 p.m., 08/26/2025 at 10:05 a.m. and 12:30 p.m., and 08/27/2025 at 6:37 a.m., attempts were made to contact S11CNA for interview with no answer. On 08/25/2025 at 2:41 p.m., an interview was conducted with a local Police Officer. He stated he could not remember the date, but he responded to a call at the facility regarding sexual battery at the beginning of the month. He stated when he arrived to the facility, S7LPN told him she witnessed Resident #2 inappropriately touching Resident #1 between her legs, in her vaginal area. He stated S7LPN told him she had to physically remove Resident #2's hands from Resident #1's vaginal area, then she stated she separated them. He stated he spoke to Resident #1 first. He stated Resident #1 told him Resident #2 had been rubbing her between the legs and she told Resident #2 to stop and he didn't. He stated Resident #1 had some confusion but was able to recall what happened. He stated he then spoke to Resident #2. He stated Resident #2 admitted he touched Resident #1 between the legs and Resident #2 said he was sorry. The officer stated after interviews, statements, and camera footage, he put charges on Resident #2. He stated the facility sent Resident #2 to a behavioral hospital the next day. The officer stated the incident between Resident #1 and Resident #2 was sexual battery. He stated Resident #1 did not consent and probably could not consent to the touching due to her mental status. He stated Resident #1 told Resident #2, no, and he still proceeded to touch her inappropriately. On 08/27/2025 at 8:10 a.m., an interview was conducted with S12NP. He stated he was familiar with Resident #2. He stated at the beginning of the year, Resident #2 was in the IOP program and received group therapy and individual counseling for bipolar and depression. He stated Resident #2 responded well to the program and his symptoms of bipolar and depression improved with medication changes. He stated Resident #2 completed his treatment at the beginning of the year and was discharged from the program. He stated he was not notified Resident #2 was having increased inappropriate sexual behaviors in May. He stated if Resident #2's behaviors had become a problem, he would have expected staff to notify him to address the behaviors. He stated he was not notified by the facility Resident #2 sexually abused Resident #1 on 08/01/2025. He stated he had not evaluated Resident #1 or #2 since the incident, and stated he needed to. On 08/26/2025 at 2:25 p.m., an interview was conducted with S2DON. She stated Resident #2 was cognitive and Resident #1 was not. She stated on 08/01/2025, she was notified of the incident between Resident #1 and #2 by S1ADM. She stated she was told Residents #1 and #2 were in front of the nurse's station and Resident #2 had his hand between Resident #1's legs, touching her inappropriately. She stated S7LPN separated the residents then notified S1ADM. She stated Resident #1 would not allow the nurse to assess her. She stated later on, while the CNA was changing her, the nurse assessed for scratches, bruises, discoloration, and injury. She stated the resident had no physical injuries. She stated Resident #2 remained in his room until he was sent to a behavioral hospital the next day. She stated Resident #1 was able to tell S7LPN she told Resident #2 no when he was touching her. S2DON stated Resident #1 was touched without her consent and it was wrong. S2DON stated since the incident, Resident #1 did not receive a formal mental status or psychiatric evaluation to assess for psychosocial abuse. She stated S12NP had not been notified of the incident. She further confirmed S12NP was not notified of Resident #2's increase in sexually inappropriate behaviors in May per his care plan intervention. She stated she was unaware Resident #2 was a sex offender until after the incident between Resident #1 and #2. She stated prior to the incident, there was no facility policy for the admission of sex offenders and there was no interventions in place to protect other residents from Resident #2. She verified she watched the video footage and confirmed S9CNA should have separated Residents #1 and #2 after she witnessed Resident #2 touch Resident #1's vaginal area to prevent the abuse from continuing. She stated to her knowledge, none of the cognitive female resident's had been asked if they had been touched inappropriately by another resident. She stated there had been no monitoring related to abuse since the incident. She stated since the incident, staff had been in-serviced on separating the resident's for safety first, then reporting, but there was no monitoring in place. On 08/26/2025 at 3:14 p.m., an interview was conducted with S1ADM. He stated on 08/01/2025 at 8:45 p.m., S7LPN reported the abuse of Resident #1 by Resident #2. S1ADM stated S7LPN saw Resident #2 rubbing Resident #1's vaginal area. He stated he notified S2DON and told S7LPN to call the police and complete a physical assessment on Resident #1. He stated Resident #1 refused the assessment. He stated a psychiatric evaluation was not completed for Resident #1 after the incident to assess for psychosocial abuse. He stated after watching the video footage, the incident was sexual abuse. He further confirmed S9CNA should have separated Residents #1 and #2 after she saw Resident #2 touch Resident #1's vagina to prevent the abuse from continuing. He confirmed it was 30 minutes from the time S9CNA witnessed the sexual abuse to the time S7LPN stopped the sexual abuse. He stated he found out Resident #2 was a sex offender on 08/04/2025, when a staff member notified him. He stated on 08/04/2025, he was also notified Resident #3 was a sex offender as well. He stated since the incident, staff had been in-serviced to separate the residents for safety first then report the abuse immediately. He stated none of the cognitive female residents had been asked if they had been touched inappropriately by another resident. He stated no monitoring related to abuse had occurred since the incident. He stated prior to the incident, there was no facility policy for the admission of sex offenders. He stated going forward, no sex offenders will be admitted to the facility. The Immediate Jeopardy was removed on 08/28/2025 at 5:20 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Plan of RemovalF600: The facility failed to ensure Resident #1, a cognitively impaired resident, was free from sexual and psychosocial abuse by Resident #2, a cognitively intact resident who had a history of sexually inappropriate behaviors. Resident #2 was a convicted sex offender prior to admission to the facility.Plan of Correction-All residents have the potential to be affected-Effective 08/27/2025, S2DON and Designee will conduct Life Rounds on all female residents and body assessments on BIMS > 9 to make sure residents feel safe and are not being abused by another resident.-Effective 08/27/2025 and ongoing until completed, S1ADM will educate/train staff through in-service before the start of their shift on Adult, Disabled Person, or Elderly Abuse Recognition and Reporting. This will be monitored by S1ADM/Designee for all shifts for the next 30 days, utilizing the audit tool and employee roster.-08/04/2025 admission Policy developed for the acceptance of sex offenders by the S18CEO. -08/04/2025 Per Policy, current residents' sex offender status have been checked, and all potential residents will be checked before admission by the S6SW/Designee. This will be monitored by S1ADM/Designee for the next 30 days and ongoing upon notification of potential residents.-08/06/2025 S6SW notified residents, families, and responsible parties of sex offenders being housed in the facility and will continue to be monitored by S1ADM/Designee. -08/04/2025 The remaining sex offender in the building was educated through in-service by S1ADM on the appropriate protocols of the facility and will be monitored closely by S1ADM/Designee through observation daily, as long as the resident resides in the facility.-08/05/2025 Staff educated through in-service by S1ADM on protocols and actions to take for the remaining sex offender. This will be monitored closely S1ADM/Designee through observation daily, as long as the resident resides in the facility.-The facility will ascertain substantial compliance by 08/28/2025.

Based on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision by failing to ensure 1 (#18) of 3 (#18, #23, and #46) residents care planned for hourly rounding received adequate supervision to prevent falls. This deficient practice resulted in an immediate jeopardy situation for Resident #18, on 02/27/2024 at 12:00 a.m. when staff failed to perform hourly rounding on Resident #18. The facility's video footage revealed no staff entered Resident #18's room from 12:00 a.m. until 3:17 a.m. then did not enter again until 4:24 a.m. Resident #18 was found on the floor of her room by staff on 02/27/2024 at 4:24 a.m. after Resident #18's roommate verbally called out for staff to come help Resident #18. Resident #18 was transferred to the emergency room and diagnosed with a Right Humerus Fracture. Nursing and CNA staff interviews revealed staff did not know Resident #18 should have been rounded on hourly to decrease falls. S1ADM was notified of the Immediate Jeopardy on 02/29/2024 at 1:53 p.m. The Immediate Jeopardy was removed on 02/29/2024 at 4:38 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Findings: Review of the facility's policy titled, Fall Assessment revealed the following, in part: Policy: All falls are reviewed in the morning meetings to determine possible interventions for each resident with a fall on an individualistic basis. Residents' who have been determined as a frequent faller will have increased observation in order to prevent falls. Review of Resident #18's Clinical Record revealed a facility admission date of 03/02/2018 and diagnoses which included Repeated Falls, Altered Mental Status and Dementia Unspecified Severity with Agitation. Review of Resident #18's Quarterly MDS with an ARD of 12/29/2023 revealed she required staff assistance with toileting and transfers. Review of Resident #18's current Care Plan revealed the following, in part: Problem onset of 10/01/2020 Problem: Falls Interventions: Start date 02/05/2024-Hourly checks Review of Resident #18's fall intervention task for hourly rounding revealed S24CNA documented the task as complete on 02/26/2024 at 8:32 p.m. Further review revealed no documentation the task was documented as completed on 02/27/2024 by S24CNA. Review of the facility's Incident Log dated February 2024 revealed the following, in part: Resident #18 had falls on the following dates: 02/05/2024 and 02/27/2024. Review of Resident #18's Incident Reports revealed the following, in part: 02/05/2024 at 1:56 p.m. Incident Type: Non-Witnessed Fall Immediate Actions Taken: Staff to check on resident hourly. 02/27/2024 at 5:00 a.m. Incident Type: Non-Witnessed Fall Review of Resident #18's Nurses' Notes dated February 2024 revealed the following, in part: 02/05/2024 at 2:31 p.m. Staff to check on resident hourly. Review of Resident #18's Emergency Department Nurse's Note dated 02/27/2024 at 5:02 a.m. revealed the following, in part: Presenting complaint: Patient reports that she fell walking to the bathroom. Patient also reports pain in her right arm from her shoulder to right wrist. Review of Resident #18's Right Humerus X-ray dated 02/27/2024 revealed the following, in part: Impression: Proximal Humeral abnormalities with total shoulder arthroplasty device and intramedullary rod across the proximal Humerus and possibly Mid Humerus Fractures. The Mid Humerus fracture is new from the 2023 exam but the Proximal Humeral abnormalities appear stable. Review of Resident #18's Right Shoulder X-ray dated 02/27/2024 revealed the following, in part: Impression: There is a non-displaced fracture in the distal diaphyseal portion of the Right Humerus. An intramedullary nail crosses fracture. An interview was conducted with S4CNAS on 02/27/2024 at 2:08 p.m. She stated Resident #18 was a fall risk and required staff assistance with transfers and toileting. She stated on 02/27/2024 around 4:30 a.m., Resident #18 was found on the floor in her room lying on her back. She stated the CNAs were scheduled a fall intervention tasks in the computer to document fall monitoring for Resident #18 every two hours. She reviewed Resident #18's electronic record and confirmed the fall monitoring interventions assigned to the CNAs were scheduled for every one hour not two hours. She stated she did not know Resident #18 required hourly rounds beginning on 02/05/2024. An interview was conducted with S31CNA on 02/27/2024 at 2:32 p.m. She stated she was assigned to Resident #18 today, who was a fall risk and required staff assistance with transfers and toileting. She stated there was a fall monitoring task assigned to the CNAs in the computer to monitor Resident #18 every two hours to prevent falls. She stated she documented the task was completed, but did not know Resident #18 should have been checked on hourly to prevent falls. An interview was conducted with S22LPN on 02/27/2024 at 3:03 p.m. She stated she was assigned to Resident #18 today, who was a fall risk and required staff assistance with transfers and toileting. She stated after a resident had a fall, the CNAs were scheduled fall intervention tasks in the computer to document on every two hours. She reviewed the electronic record for Resident #18 and confirmed she was care planned for hourly checks initiated on 02/05/2024. She stated she did not know Resident #18 should have been checked on every hour to prevent falls. An interview was conducted with S3ADON on 02/27/2024 at 3:50 p.m. She stated after a resident had a fall, the CNAs were scheduled fall intervention tasks in the computer to complete and document on. She reviewed the electronic record for Resident #18 and verified the CNAs were assigned an hourly rounding task after a fall on 02/05/2024. She stated Resident #18 was a fall risk, and to prevent falls, the CNAs were to monitor her hourly. An interview was conducted with S24CNA on 02/27/2024 at 4:13 p.m. She stated Resident #18 was a fall risk and required staff assistance with transfers and toileting. She stated she worked on 02/26/2024 from 6:00 p.m. to 6:00 a.m. and was assigned to Resident #18. She stated she transferred Resident #18 into bed around 12:00 a.m. and did not know when she rounded on Resident #18 after that. She stated Resident #18 fell around 4:00 a.m. to 4:30 a.m. She stated there was a task assigned in the computer for the CNAs to monitor Resident #18 every two hours to prevent falls. She stated she documented the task was completed, but was unaware it had to be completed hourly. She stated had she known she would have checked on Resident #18 more often. She stated the nurses rounded on Resident #18, but not sure when or how often as there was no set rounding schedule. An interview was conducted with S7LPN on 02/27/2024 at 4:30 p.m. He verified he worked on 02/26/2024 from 6:00 p.m. to 6:00 a.m. and was assigned to Resident #18, who was a fall risk. He stated sometime after 4:00 a.m., he found Resident #18 on the floor in her room and S23LPN brought the resident to the emergency room. He stated after a resident had a fall, the CNAs were scheduled fall intervention tasks in the computer to complete and document on every two hours. He stated interventions to prevent Resident #18 from falling were rounding every two hours. He stated he was not aware Resident #18 was care planned for hourly rounding to prevent falls. An interview was conducted with S4CNAS on 02/28/2024 at 11:09 a.m. She stated Resident #18 had frequent falls. She stated she and the nurses were responsible for notifying the CNAs of any new interventions to prevent resident falls. She stated after Resident #18's fall on 02/05/2024, the CNAs were scheduled fall intervention tasks in the computer to complete and document on. She stated she and the CNA's documented the task was completed, but were unaware it had to be completed hourly. She stated she was not aware of a rounding schedule for the nurse and CNAs. An interview was conducted with S6LPN on 02/28/2024 at 12:02 p.m. She stated she was assigned to Resident #18 who was a fall risk. She stated after a resident had a fall, the CNAs were scheduled fall intervention tasks in the computer to complete and document on. She stated she was not aware an hourly rounding fall intervention was assigned to the CNAs for Resident #18. She stated staff not rounding hourly could contribute to Resident #18's falls. An interview was conducted with S32CNA on 02/28/2024 at 1:42 p.m. She stated Resident #18 was a fall risk and required staff assistance with transfers and toileting. She stated there was a task assigned in the computer for the CNAs to monitor Resident #18 every two hours to prevent falls. She stated she documented the task was completed, but was unaware it had to be completed hourly. She stated she did not recall any staff notifying her to round on Resident #18 hourly to prevent falls. An interview was conducted with S30LPN on 02/28/2024 at 1:57 p.m. She stated Resident #18 was a fall risk and required assistance with toileting and transfers. She stated Resident #18 had frequent falls. She stated after a resident had a fall, the CNAs were scheduled fall intervention tasks in the computer to complete and document on. She stated staff rounded every two hours on the residents. She stated she was not aware Resident #18 should have been rounded on hourly to prevent falls. An interview was conducted with S3ADON on 02/29/2024 at 2:40 p.m. She stated she was unaware the CNAs were documenting Resident #18's fall monitoring tasks for hourly rounding as completed, but were unaware Resident #18 should be rounded on hourly. She stated she would expect staff to document only care and interventions provided. She stated she expected staff to know what interventions were in place to prevent resident falls. An interview was conducted with S2DON on 02/29/2024 at 2:45 p.m. She stated she was unaware the CNAs were documenting Resident #18's fall monitoring tasks for hourly rounding as completed, but were unaware Resident #18 should be rounded on hourly. She stated she would expect staff to document only care and interventions provided. She stated all staff had access to the resident's care plans and interventions in the computer. She stated she expected staff to know what interventions were in place to prevent resident falls. She stated there had been no specific monitoring to ensure the CNAs implemented and documented interventions initiated for resident falls accurately and there should have been. Review of video footage without audio was conducted with S1ADM on 02/28/2024 at 12:23 p.m. and revealed the following: Location: Hall B 02/27/2024 from 12:00 a.m. until 4:55 a.m. No staff were observed entering Resident #18's room from 12:00 a.m. - 3:17 a.m. and from 3:23 a.m. - 4:24 a.m. An interview was conducted with S4CNAS on 02/28/2024 at 1:15 p.m. She stated S24CNA was assigned to Resident #18 on 02/26/2024 from 6:00 p.m. - 6:00 a.m. An interview was conducted with S1ADM on 02/28/2024 at 1:20 p.m. He reviewed Resident #18's care plan and confirmed an intervention for hourly rounding was added on 02/05/2024 after the resident had a fall. He confirmed Resident #18 was not rounded on hourly by staff on 02/27/2024 from 12:00 a.m. to 3:17 a.m., and should have been.