**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00138570. Based on observation, interview, and record review, the facility failed to provide care planned interventions to maintain functional strength to prevent falls, in one of three reviewed for falls (Resident #1), resulting in multiple falls and injuries including a fracture. Findings include: Resident #1 (R1) R1 was observed sitting in her wheelchair on 9/06/23 at 10:55 AM. R1's Minimum Data Set (MDS) dated [DATE] indicated she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a brief performance-based cognitive screener, score of 04 (00-07 Severe Impairment). The same MDS indicated R1 required extensive assistance of one person for transfers. Incident Report dated 3/08/23 at 7:01 AM indicated R1 lowered herself to the floor from her wheelchair. Witness statements dated 3/07/23 indicated R1 fell on 3/07/23 at 11:00 PM when attempting to transfer self. Progress note dated 3/08/23 at 8:51 PM revealed R1's family stated R1 thought she could do things on her own and would not ask for assistance. The same note indicated R1's physician was reviewing R1's medications. Incident Report dated 4/18/23 at 4:03 PM indicated R1 was observed sitting on a pillow and scooting out to the hallway; and prior to incident had been observed resting in bed. The same report indicated the plan was to keep R1's wheelchair within reach and have physical therapy evaluate. R1's Physical Therapy Discharge summary dated [DATE], revealed she had received physical therapy services following a fall at the facility. R1 had a history of Alzheimer's Dementia, Depression, Peripheral Neuropathy (nerve damage), and orthostatic hypotension (blood pressure changes when moving from lying to sitting or sitting to standing position). The same discharge summary indicated R1's gait was not functional and should be completed with 2 assist if done by nursing with high top tennis shoes and would benefit from attending exercise based activity programming and recumbent cross trainer bike with staff assist to get on and off the machine. The same note recommended R1 use a recumbent cross trainer three times a week as tolerated. R1's activities of daily living (ADL) care plan dated 6/04/21, indicated the nurse assistant/nurse were to assist R1 in use of recumbent cross trainer for 10 minutes. In review of R1's care plans, walking with 2 assist with high top tennis shoes or any walking program was not on any of R1's care plan's in order to maintain functional status gained from physical therapy. Incident Report dated 5/19/23 at 3:50 PM indicated R1 had been observed on the floor in her room. Incident Report dated 5/27/23 at 4:47 PM revealed R1 was observed crawling on the floor in her room and wanted to get into her wheelchair. Nurses Note dated 5/28/23 at 2:47 PM revealed R1 had a fall on 5/28/23 at 6:13 PM and was seen by the nurse assistant crawling on the floor in her room next to her bed. The same note revealed R1's care plan was reviewed. The same note revealed a nurse assistant that worked on second and third shift, reported R 1 was restless in the evening time, typical to behavior; and she had a pattern of falling around those times. The same note indicated the intervention to prevent future falls was to refer to Primary Physician or Nurse Practitioner (NP) for a medical review and possible need for any pharmacological interventions. Incident Report dated 7/02/23 at 7:20 AM revealed R1 was found sitting on the floor next to her bed with a laceration above her left eyebrow. The same report indicated R1 had fell when getting up from her bed. R1 was unable to answer questions including her name, where she was or what year it was. R1 was transferred to the emergency department and a computed tomography (CT) scan was obtained. CT scan dated 7/02/23 at 7:50 AM revealed a supraorbital (above eye) scalp hematoma (blood collects under skin forming a lump) and a new mildly displaced fracture of the right nasal bone as well as an old healed right clavicle (collarbone) fracture. Incident Report dated 7/23/23 at 11:08 PM revealed R1 was observed on the floor at the side of her bed sitting on top of pillows. Incident Report dated 8/02/23 at 6:00 PM revealed R1 fell at nurses station from her wheelchair. A medication review was included on the same report to prevent further occurrences. Incident report dated 8/17/23 at 10:24 PM revealed R1 was observed on the floor in the hallway lying partially on her side; R1 reported she had hit her head. A hematoma was noted on R1's forehead. Physician Progress Note date 8/22/23 at 12:07 PM indicated since R1's fall on 8/17/23, she had not attempted to get out of bed and was not able to feed herself. R1 was noted with lethargy and followed minimal commands. 8/23/23 at 3:57 PM indicated R1 was transferred to the emergency department due to facial rash and nonspecific skin eruption; it was unclear if the rash was due to the bruise on her forehead versus the rash around her nose and mouth. The same notes indicated a repeat CT scan was obtained and lubricating lotion was recommended for her rash. Director of Nursing (DON) B was interviewed on 9/07/23 at 2:39 PM and stated the facility did not have a restorative nursing program and the nurse assistants were responsible in providing restorative care. DON B stated in the same interview that only therapy staff assist residents with using the recumbent cross trainer machine. DON B stated in the same interview the interdisciplinary team did not consider a beveled edge walkable floor mat next to R1's bed as a intervention to prevent injury from falls because they did not have those kinds of fall mats at the facility. Physical Therapist (PT) C was interviewed on 9/07/23 at 3:32 PM and stated therapy did not assist residents with the recumbent cross trainer machine after discharged from therapy. PT C stated in the same interview that nursing was responsible for assisting R1 with the recumbent cross trainer machine recommended by therapy following her discharge from physical therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #28 (R28): Review of the medical record reflected R28 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included metabolic encephalopathy, adult failure to thrive, chronic kidney disease and diabetes. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/15/23, reflected R28 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R28 required extensive assistance of one person for many activities of daily living, including but not limited to bed mobility, transfers, walking in the room, locomotion on and off the unit. R28 was not coded as having any wounds. On 05/03/23 at approximately 10:40 AM, R28 was observed seated in a wheelchair in her room. R28 stated she had some sores but was unsure if they were present before she admitted to the facility. On 05/04/23 at 9:15 AM, R28 was observed lying on her left side in bed, watching TV. She reported she had absolutely no concerns with her care. Everyone has been really super. She reported she was able to turn and reposition herself in bed and sit up independently. She stated they told her she had fallen since she had been here. She reported sliding out of the bed. Upon interview, she acknowledged there are things she does not remember. A Skin and Wound Evaluation for 4/16/23 reflected an in-house acquired open lesion to the sacrum, measuring 1.1 centimeters (cm) in length by (x) 0.8 cm in width. There was no description of the wound bed, and there were no additional assessments of the area after 4/16/23. Progress of the wound was marked as New. During an interview on 05/08/23 at 11:04 AM, Director of Nursing (DON) B reported R28 had a spot on her sacrum that measured 1.1 cm x 0.8 cm and healed on 4/16/23. DON B reported the picture showed a pink area with a bit of a scab on it. She reported the staff nurse was supposed to document that the area was healed, and Nursing Home Administrator (NHA) A closed (healed) the wound assessment on 4/25/23 at 11:47 AM. DON B reported R28 had a history of a pressure ulcer to that area. DON B was notified of the request to observe R28's skin, including her sacrum/coccyx and left foot during scheduled treatments on 5/9/23. On 05/08/23 at 1:00 PM, R28 was observed seated in her wheelchair, in her room, watching TV. She was wearing gripper socks on both feet, with her feet resting on the floor. Review of wound notes by Wound Doctor Q reflected R28 was seen on 4/14/23 for an open sacral lesion that measured 1.1 x 0.8. The note reflected treatment was going to include MediHoney, collagen and foam dressing, to be changed three times a week and as necessary. Review of the April 2023 TAR reflected those orders were not implemented and continued to reflect Coccyx: cleanse with NS [normal saline], pat dry and place optifoam over wound every day shift for wound care. During an interview on 05/09/23 at 12:15 PM, DON B was notified that R28's treatments had already been documented as completed for the day, and the Survey Team had not been made aware for the previously requested observation. DON B was asked if she knew why the treatment was not updated to reflect Wound Doctor Q's treatment recommendation for the coccyx, as referenced in his Progress Note for 4/14/23. DON B believed Wound Doctor Q healed that area and that there was no need for the recommended treatment. This citation pertains to intake MI00131462. Based on observation, interview, and record review, the facility failed to implement pressure ulcer interventions and treatments for two (Resident #28 and Resident #29) of three reviewed, resulting in the worsening of a pressure ulcer for Resident #29 and the potential of a worsening pressure ulcer for Resident #28. Findings include: Review of the medical record revealed R29 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer to the left heel, diabetes, and chronic kidney disease stage 3. Review of the MDS with an Assessment Reference Date (ARD) of 3/13/23 revealed R29 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), required extensive assistance of two people for bed mobility, and was not on a turning/repositioning program. Review of the Braden Scale for Predicting Pressure Sore Risk dated 3/6/23, revealed R29 scored 16 (15-18 is at risk). Review of the Admission/re-admission Evaluation dated 3/6/23 revealed Stage 1 pressure ulcer-staged by RN [Registered Nurse] to R29's left heel. Review of the Skin & Wound Evaluation dated 3/7/23 (day after admission) revealed R29 had a stage one pressure ulcer that measured 0.9 centimeters (cm) x 0.5 cm. Review of R29's Physician's Orders and Treatment Administration Records (TARs) revealed on 3/6/23, border form was ordered for R29's left heel but was never applied or implemented. The order was discontinued on 3/7/23. No treatments were documented as completed on 3/6/23 or 3/7/23. Starting on 3/8/23, skin prep was ordered to apply to bilateral heels every day for protection. Skin prep was discontinued on 3/15/23. Review of R29's At Risk for Alteration in Skin Integrity care plan initiated on 3/7/23 revealed elevate heels as able was implemented on 3/7/23, pressure redistributing device on bed/chair was implemented 3/7/23, use pillows/positioning devices as needed was implemented 3/7/23, and EHOB boots to bilateral feet were implemented on 3/12/23. The Skin & Wound Evaluation dated 3/11/23 revealed R29's pressure ulcer was a deep tissue injury (persistent non-blanchable deep red, maroon, or purple discoloration) that measured 0.8 cm x 1.2 cm. The wound bed was documented as 100% eschar (dead tissue/unstageable). Review of R29's Pressure Ulcer to Left Heel care plan initiated 3/13/23 revealed EHOB boots were implemented 3/13/23, pressure redistributing support surface was implemented 3/13/23, and repositioning during Activities of Daily Living (ADLs) was implemented on 3/13/23. According to the TAR on 3/15/23, a Hydrofera Blue dressing was applied to R29's left heel. The order was to change the dressing every three days. The dressing was changed four days later, on 3/19/23. The Hydrofera Blue dressing was discontinued on 3/23/23. The Skin & Wound Evaluation dated 3/19/23 revealed a 1.7 cm x 2.3 cm deep tissue injury with light serious drainage and macerated surrounding tissue. According to the Order Summary and TAR, on 3/23/23 the treatment order was changed to cleanse with normal saline, apply skin prep, and apply optifoam every two days. The treatment was not documented as completed and the order was discontinued on 3/24/23. On 3/24/23 the order was changed to normal saline, medi honey, and a dry dressing daily. The Skin & Wound Evaluation dated 3/24/23 revealed a1.2 cm x 0.8 cm unstageable (obscured full-thickness skin and tissue loss) pressure ulcer due to slough and/or eschar; however, the wound bed was documented as 20% granulation tissue without any documentation of the amount of slough and/or eschar. Review of the MP Wound Progress Note dated 3/24/23 revealed I am going to change the plan .3. pressure reducing seat cushion, 4. pressure reducing heel boot, 5. pressure reducing air mattress, 6. turn and reposition per facility . The Skin & Wound Evaluation dated 3/31/23 revealed a 2.4 cm x 1.6 cm unstageable pressure ulcer due to slough and/or eschar with a wound bed of 70% granulation tissue and 30% slough. Review of a General Progress Note dated 4/6/23 revealed .consider referral to wound clinic .Elevate left heel off bed at all times . The Skin & Wound Evaluation dated 4/7/23 revealed a 1.7 cm x 2.1 cm unstageable pressure ulcer due to slough and/or eschar with a wound bed of 100% eschar. Review of the Wound Care Initial Consultation, History and Physical dated 4/7/23 revealed R29's pressure ulcer was 100% stable black eschar and measured 1.73 cm x 2.06 cm. The consultation revealed If patient sits in bed, appropriate offloading mattress .Frequent turning and positioning every two hours to the best of her ability to offload the area. Review of the care plans revealed turning and repositioning every two hours was not implemented. The Skin & Wound Evaluation dated 4/14/23 revealed a 3.1 cm x 1.6 cm unstageable pressure ulcer due to slough and/or eschar. The assessment did not reflect any additional wound characteristics (i.e. wound bed, drainage). The Skin & Wound Evaluation dated 4/21/23 revealed a 2.5 cm x 1.8 cm unstageable pressure ulcer due to slough and/or eschar with a wound bed of 100% eschar. Review of the Radiology Report dated 4/21/23 revealed R29's left heel soft tissues appear swollen with ulceration .findings suspicious for calcaneal osteomyelitis [inflammation of bone due to infection], recommend MRI. The Skin & Wound Evaluation dated 4/28/23 revealed a 1.3 cm x 2.2 cm unstageable pressure ulcer due to slough and/or eschar with a wound bed of 100% eschar. Review of the MRI dated 5/4/23 revealed R29 had osteomyelitis of the left heel. R29 was on IV antibiotics for osteomyelitis. The Skin & Wound Evaluation dated 5/5/23 revealed a 2.6 cm x 1.8 cm unstageable pressure ulcer due to slough and/or eschar; however the wound bed was documented as 60% granulation without any documentation of the amount of slough and/or eschar. On 05/3/23 at 09:41 AM, R29 was observed sitting in a wheelchair in her room. Both feet were wrapped with kerlix and boots were in place. R29 reported she developed a pressure ulcer on her left heel due to her heel rubbing on the bed. R29 reported she was on IV antibiotics for an infection in her left heel. R29 did not recall elevating her feet off the bed prior to the development of the pressure ulcer. R29's bed was observed with a bariatric mattress that was not an alternating pressure mattress. On 5/8/23 at 10:05 AM, R29 was observed in bed while staff were providing care. R29 did not have an alternating pressure mattress on her bed. In an interview on 05/8/23 at 11:08 AM, Director of Nursing (DON) B reported it was her understanding that R29 was admitted to the facility with the left heel deep tissue injury. DON B reviewed R29's wound assessments and agreed that on 3/6/23 and 3/7/23, the wound was documented as a stage 1 pressure ulcer to the left heel. DON B reported R29 now had osteomyelitis to the left heel. DON B reported the facility's standard mattresses were foam mattresses and that R29 should have had an alternating pressure mattress in place since 3/13/23. DON B reported the skin prep was started on 3/8/23 and agreed there was no documented preventative treatment completed on 3/6/23 or 3/7/23. DON B entered R29's room and reported the mattress on the bed was a standard foam mattress and not an alternating pressure mattress. On 05/9/23 at 09:41 AM, Licensed Practical Nurse (LPN) K was observed performing a skin check on R29. LPN K reported R29 was also due for dressing changes. LPN K began by removing R29's boots and dressings dated 5/8/23 from both feet. LPN K then placed both of R29's heels directly on a bath blanket. R29 had a pillow under her legs, but the pillow did not prevent her heels from resting on the bed. R29's left heel was observed with a a pressure ulcer. LPN K completed the remainder of the skin check and then left the room to obtain wound care supplies. When asked about the left heel pressure ulcer, R29 stated I just didn't get moved enough. R29 went on to further explain that she thought staff put something under her legs to elevate her heels when she first came in, but her heels still touched the mattress. LPN K returned at 10:00 AM to perform wound care. R29's heels were still resting on the mattress at that time. LPN K cleansed R29's left heel with normal saline, patted dry, applied betadine to the wound, applied calcium alginate to the wound, placed an ABD pad over, and then wrapped with kerlix. Review of the Physician's Order dated 5/7/23 revealed left heel cleanse with NS [Normal Saline] apply collagen to heel and wrap with kerlix every day and PRN [as needed]. The treatment was scheduled for Mondays, Wednesdays, and Fridays. In an interview on 05/9/23 at 10:26 AM, LPN K was asked about the treatment orders for R29's left heel. LPN K showed the order for betadine to left heel, soak 4x4 gauze with betadine, and wrap with kerlix. There was not an active treatment for 5/9/23 which reflected the order that was placed on 5/7/23 for normal saline, collagen, and kerlix. In an interview on 05/9/23 at 11:34 AM, DON B reported R29's betadine order was supposed to be discontinued and the order for collagen was to be completed on Mondays, Wednesdays, and Fridays. DON B reported she did not recall that calcium alginate was ever an order for R29's pressure ulcer. DON B reported R29 now had an alternating pressure mattress in place. In an interview on 05/10/23 at 09:34 AM, Maintenance Director (MD) E reported work orders were usually not filled out for mattresses. MD E reported Housekeeping Director (HD) F kept track of when specialty mattresses were put into place. In an interview on 05/10/23 at 09:38 AM, HD F reported as of 1/1/23, she did not keep track of mattresses; however, the requests were still done through email. HD F reported she looked back and found that the only conversation related to R29's bed was for a bariatric mattress and a trapeze. HD F reported R29 first received an alternating pressure mattress on 5/8/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement effective interventions to prevent falls for four (Resident #11, #13, #20, and #464) of five reviewed for accidents, resulting in reoccurring falls (Resident #13), falls with the potential for major injury (Resident #464) and falls with major injury (Resident #11 and #20). Findings Include: Resident #13 Review of an admission Record revealed Resident #13 (R13) admitted to the facility on [DATE] with pertinent diagnoses which included bilateral hearing loss, anxiety, osteoporosis, major depressive disorder, overactive bladder, delusional disorders, vascular dementia, and cognitive communication deficit. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/6/23, reflected R13 scored zero out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R13 did not walk and required extensive of two or more people for transferring and toileting. In an observation on 05/03/23 at 09:58 AM, R13 was observed resting in bed with her eyes closed. R13 had a Broda chair (wheelchair that provides tilt-in-space positioning, recline and leg rest adjustments) in her room. R13 did not have a non-skid mat on the seat of the Broda chair. R13's television was off. In an observation on 05/04/23 at 01:01 PM, R13 was seated in her Broda with a blanket covering her, slightly reclined back. R13 had a tablet on a stand in front of her but was not watching the content playing on the device. R13 had a blanket but did not have any other materials with her at the time of observation. In an observation on 05/04/23 at 01:50 PM, R13 was observed seated on her bottom on the floor in front of R13's Broda chair. Staff members were assessing and assisting to R13. In an observation on 05/04/23 at 01:53 PM, R13 was assisted back into the Broda chair and wheeled to the vicinity of the nurse's station. R13 had a blanket on her but had no other materials with her at the time of observation. An observation was made of the seat of the Broda chair, and it did not appear that R13 had a non-skid mat underneath her bottom on the seat of the chair. In an observation on 5/04/23 at 1:56 PM, the staff member at the nurse's station left the area. R13 was left unsupervised by facility staff members for approximately five minutes. In an observation 05/04/23 at 02:37 PM, R13 was seated in her Broda chair and slightly reclined back in the vicinity of the nurse's station. R13 appeared to have slid down significantly from her previous position with her buttocks towards the edge of the seat. R13 was attempting to lean up out of chair. A staff member approached R13 and wheeled R13 away from the nurse's station and down the hall. R13 was not repositioned in the Broda chair. In an interview on 05/04/23 at 02:05 PM, Licensed Practical Nurse (LPN) CC reported that she did not witness the fall that R13 sustained. LPN CC reported that the iPad in front of her prior to falling was for entertainment purposes, to watch tv and stuff. Review of the Care Plan revealed R13 had an At Risk for Falls Care Plan initiated on 12/1/2020. Some listed interventions included assist patient near nurses' station if she is becoming restless in her chair, ensure patient has her baby doll when sitting in her chair, leave TV [television] on at bedtime with low volume, non-skid surface to wheelchair, reposition in Broda chair when noted restless or agitated, and watching iPad while in Broda chair of favorite show and music. Review of the Care Plan revealed R13 had an increased risk of fracture related to Osteoporosis Care Plan initiated on 01/16/2022. Interventions included to monitor for risk of falls and educate resident, family/caregivers on safety measures that needed to be taken in order to reduce risk of falls. Review of the same Care plan revealed R13 had bilateral hearing loss and an Activities of Daily Living deficit Care Plan which revealed R13 wore glasses. Review of the Assessment tab located in the Electronic Medical Record revealed R13 had 18 Fall Assessments from falls sustained from 1/1/23 until 5/8/23. In an observation on 05/08/23 at 09:58 AM, R13's Broda chair was in R13's room. R13 was using the restroom at the time. There was no non-skid mat observed on R13's Broda chair. In an interview on 05/08/23 at 12:53 PM, Certified Nursing Assistant (CNA) EE reported that R13's fall interventions included ensuring R13's toileting needs were tended to, ensuring the bed is in the lowest position, not leaving R13 unattended in her room, and leaving her up by the nurse's station for increased supervision purposes. CNA EE stated that R13 does not respond much to the iPad. When queried about the non-skid pad that is Care Planned as a fall intervention, CAN EE reported that she [R13] used to have one but the facility got rid of them. CAN EE also reported that R13 had hearing loss but did not have hearing aids and has glasses, but they were in her drawer and not used. In an observation on 05/08/23 at 10:08 AM, R13 was wheeled out of her room by a staff member and parked in the vicinity of the nurse's station. The staff member walked away from R13. At 10:32 AM, a staff member approached R13 and removed her from the nurse station and into her room. R13 had no direct supervision for the 24 minutes that R13 was left in the vicinity of the nurse's station. In an observation on 05/08/23 at 10:46 AM, R13 was resting in bed with her eyes closed. R13's television was turned off and the Broda chair did not have a non-skid mat on the seat. In an observation on 05/09/23 at 10:15 AM, R13 was observed in the hall seated in her Broda chair, slightly reclined back, with a blanket. R13 did not have a baby doll with her at the time of observation. In an interview on 05/08/23 at 02:29 PM, LPN CC stated that fall interventions for R13 included keeping her at the nurse's station, toileting before and after meals, ensuring she had her blanket and baby doll and providing fluids after meals. When quired about the non-skid mat, LPN CC reported that the facility got rid of them and was no aware of any alternative for the non-skid mat. LPN CC reported that R13 did not having hearing aids or require the use of glasses. In an interview on 05/11/23 at 10:28 AM, Director of Nursing (DON) B reported that she was aware of R13's frequent falls and was going to start implementing risk management meetings with the facilities Interdisciplinary Team in the near future to monitor, track and trend resident falls. DON B confirmed that one of R13's fall interventions was to park her near the nurse's station to provide increased supervision. DON B reported that the facility does have and utilize the use of non-skid mats but was not certain why R13 did not have one on her Broda chair. Resident #20 Review of an admission Record revealed Resident #20 (R20) admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses which included traumatic subdermal hemorrhage with loss of consciousness, adult failure to thrive, dementia, Alzheimer's disease, repeated falls, glaucoma, and visual disturbance. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/22/23, reflected R20 scored zero out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R20 required extensive of one person for transferring and toileting. In an observation on 05/04/23 at 01:01 PM, R20 was seated in a wheelchair in her room with a blanket on her lap. R20's call light was clipped to her right side but was hanging out of reach. R20 yelled out can I go back to bed now? There was no response from staff. In an observation on 05/04/23 at 01:14 PM, R20 yelled out Can I go back to bed? There was no response from staff even though there were two staff members approximately 6 feet outside of R20's room. In an observation on 05/04/23 at 01:22 PM, R20 called out I need to go to the bathroom, and I need to go back to bed. A staff member passed by as R20 was calling out but did not respond to the request. In an observation on 05/04/23 at 01:37 PM, a Certified Nursing Assistant (CNA) approached this surveyor for an interview when R20 called out I need to go to the bathroom. The CNA then tended to R20. In an observation on 05/08/23 at 12:44 PM, R20 was seated in her wheelchair and parked in the middle portion of her room. R20 did not have a call light within reach. Review of a Progress Note dated 3/7/2023 at 5:39 PM revealed .on 3/4/23 @ [at] 930am, staff observed resident [R20] resting on the floor on her eft [sic] side near the bed of her roommate, her walker upright in front of her. She was unsure if her head made contact with anything. She stated she was trying to go back to bed after using the restroom following breakfast . She was incontinent at time of incident Immediate intervention: assist w/ [with] toileting following breakfast. CP (care plan) updated. Review of an Incident report dated 3/4/23 at 9:35 AM revealed resident observed lying on the floor on her left side near roommates' bed .fall interventions already in place: have commonly used articles within reach, provide assistance to transfer and ambulate as needed. New intervention toilet before and after meals . Review of a Progress Note dated 4/10/2023 at 07:38 AM revealed R20 observed lying on the floor face/body down next to bed. Resident stated, I was trying to get back into bed. Resident states hitting head and having 7/10 pain in head .Resident assisted off floor by EMS [Emergency Medical Service] and transported to ER [Emergency Department] for further evaluation. An Incident Report dated 4/10/23 revealed that the fall occurred at 4/10/23 at 7:15 AM. The Incident report provided by a Certified Nursing Assistant on 4-10-23 revealed resident toileted on midnight shifting [sic] observed resting in bed approx. 0700 [AM]. fell 0710 [AM]. A Patient Safety Note dated 4/11/2023 at 10:47 AM revealed R20 states she was getting up to go to bathroom .New intervention to update plan of care includes bed against wall. Interventions in place at time of fall include commonly used articles within reach, assist to use restroom after breakfast, encourage to change positions slowly . Review of the Hospital Paperwork dated 4/11/23 revealed R20 sustained a subdermal hematoma (A condition due to bleeding under the membrane covering the brain called, the dura) and was admitted to the Critical Care Unit. Review of the Care Plan revealed R20 had an At Risk for Falls Care Plan initiated on 4/6/2020. Interventions included administer medications per physician's order, encourage to transfer and change positions slowly, evaluate medications if patient demonstrates changes in mental status, provide assistance to transfer and ambulate as needed, refer to the therapy plan of treatment in the medical record for more detail, and therapy evaluation and treatment per orders. In an interview on 05/08/23 at 02:37 PM, Licensed Practical Nurse CC reported that R20 is hard of hearing and seldomly uses her call light. R20's preferred method of asking for assistant was to call out. Review of the [NAME] (portion of the Electronic Medical Record commonly used by Certified Nursing Assistants to communicate residents needs) revealed R20 required assistance to the restroom after breakfast and before staff leave room, place call light in patient hand for ease to access . In an interview on 05/10/23 at 10:03 AM, Certified Nursing Assistant (CNA) FF reported that R20 makes her needs known by calling out for help but at times, R20 will use the call light appropriately. CNA FF reported that staff will pin the call light to R20 to help with locating the call light when needed. In an observation in 05/11/23 at 09:17 AM, R20 was in bed with her eyes closed. R20's bedside table was located at foot of bed. R20's water was located on the bedside table, which was out of reach from R20. R20's call light was observed on the floor, out of reach from the resident. In an interview on 05/11/23 at 10:28 AM, Director of Nursing (DON) B reported that R20 did sustain a fall in April when R20 rolled out of bed and was transferred out to the hospital. DON B reported that R20's current fall interventions included assisting R20 to the restroom after breakfast, have R20's bed against wall, transfer change position slowly, evaluate medications, and keep commonly used articles within reach. When asked to define commonly used articles, DON B stated drinks, bedside table, call light, and whatever the resident preference might be. Resident #464 Review of an admission Record revealed Resident #464 (R464) admitted to the facility on [DATE] with pertinent diagnoses which included heart failure, dementia, difficulty in walking, cognitive communication deficit, weakness, anxiety, major depressive disorder, and expressive language disorder. A Social Services Note dated 4/24/23 revealed that R464 scored 4 out of 15 on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R464's Kardax (computer program that communicates resident's care needs to staff) reflected R464 requires one person guidance and physical assistance for transfer. In an observation on 05/03/23 at 12:02 PM, R464 was seated in the dining room at a table and speaking with a Hospice staff member. R464 was in his wheelchair and wearing standard socks. A Progress Note dated 4/23/2023 at 2:45 PM revealed R464 was observed crawling on the floor in his room. When asked what happened, patient states, This is the only way I can get around. An Incident Report dated 4/23/23 revealed R464 was discovered on the floor by his bed, sitting on his bottom. R464 did not sustain any injuries but was unsure how he fell out of his bed. A Progress Note dated 4/24/2023 at 10:15 PM revealed R464 was discovered crawling on the floor in his room at 9:30 PM. When asked why he was on the floor, R464 replied I was trying to get up. An Incident Report dated 4/24/23 revealed R464 was attempting to stand throughout the shift and was eventually discovered on the floor in his room during a routine check. The same Incident Report revealed that R464 was in need of incontinent care at the time of the fall. R464 was educated to use his call light if he needed anything. A Progress Note dated 4/25/2023 at 02:01 AM revealed R464 was observed sitting on his bottom on the floor in his room. R464 was wearing one shoe on his foot and incontinent at the time of his fall. An Incident Report dated 4/25/23 confirmed R464 was incontinent upon discovery. R464 was placed in his wheelchair and moved out into the hallway. A Progress Note dated 4/30/2023 at 7:34 AM revealed R464 was observed on the floor in the dining room. R464 was unable to describe how the fall occurred. An Incident Report dated 4/30/23 revealed R464 self-transferred out of his bed and into his wheelchair. R464 propelled himself down to the dining room where the fall took place. Review of the Care Plan revealed R464 had an At Risk for Falls Care Plan initiated on 4/21/23. Interventions included reenforce the need to call for assistance, provide assistance to transfer and ambulate as needed, and have commonly used articles within easy reach. On 4/26/23 additional interventions were added to include refer to the therapy plan of treatment located in the medical record and preference to crawl on the floor. Review of the same At Risk for Falls Care plan revealed addition interventions were added on 5/8/23 to include decrease activity and stimulation at times of increased anxiety and stress. In an interview on 05/08/23 at 12:58 PM, Certified Nursing Assistant (CNA) EE reported that R464 will occasionally crawl on the floor. CAN EE reported that R464 is a one assist for transfers but occasionally self-transfers. In an interview on 05/09/23 at 11:58 AM, Director of Nursing (DON) B reported that Incident Reports are completed by staff after a fall and any interventions implemented after a fall should go into the care plan. The staff should also be implementing an immediate fall intervention after a resident sustains a fall. If staff requires assistance formulating an intervention, the fall can be referred to the Interdisciplinary Team to help come up with additional or appropriate interventions. Regarding R464's fall on 4/23/23, the intervention was to care plan R464's preference to crawl on the floor. After the fall on 4/24/23 the intervention was staff to assist with call light within reach and educated on call light use. When queried if R464 was likely to benefit from reeducation with a low BIMS, DON B responded that he would not. After R464's fall on 4/25/23, DON B reported that the intervention was to refer to Physical and Occupational therapy for an evaluation. After the fall that R464 sustained on 4/30/23, DON B reported that the fall intervention implemented was to decrease activity stimulation at all times to decrease anxiety and review the care plan. When asked if DON B would consider a more appropriate intervention such as a toileting schedule considering R464 was incontinent for two of his four falls, she replied that she felt that would be an appropriate intervention. An email was sent on 5/9/23 to Nursing Home Administrator (NHA) A requesting documentation of R464's Physical and Occupational therapy evaluation. NHA A responded via email at 3:39 PM reporting None- he came in hospice. Resident #11 (R11): Review of the medical record reflected R11 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included cerebral infarction, flaccid hemiplegia affecting left non-dominant side and unspecified intellectual disabilities. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/24/23, reflected R11 scored nine out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R11 did not walk and required extensive assistance of one to two or more people for most activities of daily living. R11 was coded for fall with major injury. On 05/03/23 at 1:51 PM, R11 was observed in bed, with the head of the bed elevated and the bed height in a low position. Upon entering the room, R11 was asking for help. He was lying with his head towards the wall at the right bedside while trying to maneuver his body towards the left side of the bed. R11 was saying help me. A pillow was observed on the floor at the left bedside. With his requests for help, R11 was asked how he alerted staff of his needs. R11 indicated he wanted up. Review of R11's Incident Reports since 1/1/23 reflected four falls. An Incident Report for a fall on 1/21/23 at 10:31 AM reflected the Certified Nurse Aide (CNA) yelled down the hall to nurse at 9:55 AM and stated R11 was lying on the floor. Upon entering the room, R11 was observed lying on the floor, turned to his side, in front of his wheelchair. R11 laughed and stated he was fine. The documented cause reflected R11 slid out of wheelchair onto floor and when asked if he wanted to lay down, he said yes. The corrective action reflected R11 was assessed and an intervention for R11 to lie down between meals if he is wanting to lie down. R11's Care Plan reflected an intervention that was initiated and created on 1/21/23 and revised on 1/24/23 to offer/assist R11 to return to bed for rest after breakfast. An Incident Report for a fall on 1/30/23 at 12:59 PM reflected the CNA informed nurse that R11 had fallen out of his wheelchair. Upon entering R11's room, he was observed lying on the floor in front of his wheelchair. He was assessed for injuries, placed in his wheelchair via hoyer lift (mechanical lift), vital signs were obtained, and the call light was placed in reach. The cause of the fall was documented that R11 slid out of his wheelchair, onto the floor. The corrective action reflected R11 was assessed for injuries, placed in his wheelchair and vital signs were obtained. The Investigation Report for the same fall reflected R11 had a history of sliding out of his wheelchair, and a non-slip grip would be placed in the wheelchair. R11's Care Plan reflected an intervention that was initiated on 1/30/23 and created on 2/2/23 to encourage use of non-slip pad in wheelchair and encourage/assist R11 to be out in common area of nursing station when out of bed, for enhanced safety. An Incident Report for a fall on 1/30/23 at 1:32 PM reflected the CNA informed the nurse that R11 was on the floor in the hallway. The nurse observed R11 in the hallway, lying in front of his wheelchair. He was assessed for physical injury, vital signs were obtained, hoyered into bed, positioned for comfort, bed placed in lowest position and call light placed in reach. The cause was documented as R11 sliding himself to the floor. The corrective action was to remove his wheelchair. The Investigation Report for the same same fall reflected when R11 was out of bed, offer and assist him to sit in the hallway, close to the nurse's station, for closer supervision, as R11 allowed. R11's Care Plan reflected an intervention that was initiated and created on 1/31/23 for offering and assisting R11 to sit in the hallway, close to the nurses station, for closer supervision when out of bed, as R11 allowed. An Incident Report for a fall on 2/18/23 at 9:20 AM reflected R11 was found on the floor by the nurse around 8:50 AM. There was a significant amount of blood on the floor. Once R11 was cleaned up, he was noted to have a gash on the bridge of his nose, some swelling and a bruise on the side of his forehead. R11 was assessed for visible injuries and pressure was held related to bleeding. Emergency Medical Services (EMS) was called, and R11 sent to the emergency room (ER) for evaluation due to hitting his head. The documented cause of the fall reflected R11 fell out of his wheelchair while in his room. The corrective action reflected staff was re-educated about encouraging R11 to sit at the nurse's station or out in hallway while up in his wheelchair. Hospital Records reflected R11 had a laceration to the bridge of his nose, requiring three sutures (stitches). Additionally, there were comminuted left and right nasal bone fractures and probable remote type I odontoid process (part of the neck) fracture without displacement. R11's Care Plan reflected an intervention for routine safety checks when R11 preferred to stay in his room, dated 2/19/23. During an interview on 05/08/23 at 9:57 AM, CNA P reported she was not sure if R11 would be classified as a fall risk. She reported R11 had fallen a few times when she had been on duty and had trips to the ER. On 05/09/23 at 2:51 PM, R11 was observed lying in bed, with the bed height in low position. R11 had a standard size bed, not a bariatric bed, as indicated on the Care Plan. On 05/11/23 at 9:12 AM, R11 was observed seated in a specialty wheelchair, watching TV in his room. Rear anti-tip bars were observed on the wheelchair. No call light was observed in R11's reach. A perimeter mattress without linens was observed on the bed. The mattress was observed to be a standard size, not bariatric as care planned. An overbed table was near R11's right side. A bottle of pop with a straw was observed on the dresser, under R11's TV. When asked if staff had offered to take him out of his room this morning, R11 denied. On 05/11/23 at 9:19 AM, CNA Z stated R11 had been up since about 6:00 AM and had been in his room since after breakfast. On 05/11/23 at 9:23 AM, R11 continued to be observed seated in his room, in a specialty wheelchair. He was observed using his feet to slightly and intermittently move the wheelchair back and forth. At 9:24 AM, he was observed moving the wheelchair towards the dresser and was attempting to move his torso forward. Upon entering the room and speaking with R11, he asked for his pop (which was on the dresser). R11's roommate overheard the request and stated he turned the call light on for R11. R11's roommate reported R11 had a call that he used, but it was probably on his bed. At 9:30 AM, Licensed Practical Nurse (LPN) GG entered R11's room, in response to the call light. R11's roommate notified LPN GG that he had the call light on for R11. LPN GG was overheard asking R11 if he wanted his pop and stated to R11 that he was on thickened liquids, so he had to thicken the pop before giving it to him. The cap was placed on the pop, which was left on R11's dresser. The nurse exited the room at 9:32 AM, after telling R11 he would get him pop that was thickened. An order dated 12/2/22 reflected R11 was on a regular diet with pureed texture, .2 Mildly Thick consistency [liquids]. During an interview on 05/11/23 at 10:25 AM, CNA Z reported when R11 was up in his chair, she kept an eye on him all the time. She reported R11 went to the dining room that morning and returned to his room around 9:00 AM. CNA Z reported R11 could not be in the bathroom alone but thought he could be in his room, in his wheelchair, alone.