**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake Number 1316000. Based on observation, interview and record review, the facility failed to provide adequate supervision, ensure comprehensive investigations of falls, and implement meaningful interventions to prevent falls for two residents (# 701 and #702) of three residents reviewed, resulting in falls with injury including nasal bone fractures, the necessity for emergency medical treatment, and unnecessary pain. Findings include: Resident #701:On 8/6/25 at 12:30 PM, Resident #701 was observed in their room in bed with their eyes closed in the locked dementia unit of the facility. The Resident's call light was next to the Resident's bed and not within easy reach.Record review revealed Resident #701 was admitted to the facility on [DATE] with diagnoses which included mood disorder, major depressive disorder, anxiety, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required set up to moderate assistance to complete Activities of Daily Living (ADLs) including supervision/touching assistance with ambulation.An interview was completed with Registered Nurse (RN) A on 8/6/25 at 12:45 PM. When queried regarding Resident #701, RN A revealed the Resident was in the locked dementia unit because they are very confused and had even tried to break windows and doors to get out. With further inquiry, RN A revealed the Resident has a court appointed guardian. RN A was asked if Resident #701 had any falls while at the facility and stated, Yes, when they first got here. When queried if the Resident was injured from the fall, RN A responded that they had two black eyes. When asked if they were working when Resident #701 fell, RN A responded they were not.At 2:00 PM on 8/26/25, Resident #701 was observed in their room in bed.Review of Resident #701's Electronic Medical Record (EMR) revealed a care plan entitled, (Resident #701) is at risk for fall related injury and falls R/T (related to): Dementia (Created and Initiated: 5/1/25). The care plan included the interventions:- Encourage the resident to wear appropriate footwear as needed. Replace resident's worn out shoes r/t incident 5/4/25 (Created and Initiated: 5/1/25; Revised: 7/18/25)- Keep the resident's environment as safe as possible with: even floors free from spills and/or clutter; adequate lighting; call light within reach, commonly used items within reach, avoid repositioning furniture and keep the bed in the appropriate (Created and Initiated: 5/1/25)- Provide resident with activities that minimize the potential for falls while providing diversion and distraction (Created and Initiated: 5/1/25)- Put the call light within reach and encourage her to use it for assistance as needed (Created and Initiated: 5/1/25)A second care plan entitled, (Resident #701) has a functional ability deficit and requires assistance with self-care/mobility R/T: dementia (Initiated and Revised: 5/1/25). The care plan included the intervention, Ambulation/Walking: Resident Supervision/touching assist with one helper (Initiated and Revised: 5/1/25).Review of Resident #701's Nursing Comprehensive Evaluation dated 5/1/25 at 1:54 PM revealed the Resident was at risk for falls.Review of skin assessment documentation in Resident #701's EMR revealed no documentation of facial bruising.Further review of Resident #701's EMR revealed the following progress notes:- 5/4/25 at 3:15 AM: Nurses Notes. Resident came to nurse's station and stated, ‘I think I fell'. Resident's mouth was bleeding and resident had blood on their hands. Resident was assessed and neuros initiated. Swelling and bruising noted to nose and lower lip. Resident's face and hands were cleansed of blood and upon changing resident's clothing noted resident's shoes were worn and rubber soles were peeling back at the toe area. Resident also c/o (complain of) left knee pain. Noted small abrasion to lateral side of patella and slight bruising to medial side. Care plan updated with intervention to replace resident's worn shoes. Just prior to incident had been observed ambulating towards dining room. Upon this writer's investigation of incident resident was asked what happened and replied, I was chasing the dogs'. This writer and CNA (Certified Nursing Assistant) noted blood on dining room floor and chair shortly after incident.- 5/5/25 at 11:52 AM: Nurses Notes. Facial bruising to both orbits, chin, and swollen bottom lip.- 5/6/25 at 5:49 PM: Nurses Notes Day 3 of incident/fall. Resident has no injuries. has bruising surrounding eyes, but does not complaint of pain. complained that lip was sore, which it is swollen.- 5/8/25 at 11:16 AM: Resident At Risk. being reviewed by the IDT r/t incident that occurred on 5/4/25. shoes were worn with a floppy bottom and where removed and gripper sock provided until new shoes are purchased.- 5/23/25 at 9:15 AM: Psychiatry Follow up -history of Alzheimer's disease dementia with agitation. recent fall with facial bruising .On 8/7/25 at 9:55 AM, Resident #701 was observed standing in the dining/activity room of the locked dementia unit with staff present providing touching assistance. The Resident was wearing sweatpants. The sweatpants were long, and the Resident was walking on the pants with the heel of their shoe. When spoke to, Resident #701 was unable to provide meaningful responses to questions.Facility provided Incident and Accident (I &A) Report for Resident #701 revealed the Resident had one fall on 5/4/25 at 12:30 AM. The report detailed, 3. Describe the position the resident was observed: Resident came to nurses' station and stated, ‘I think I fell'. had blood on hands and face. 4. Fall Summary: Self-reported fall. 5. Fall Location: Dining room/day room. 9. Footwear at time of fall: Shoes. Gripper socks. 19. Were there any changes in the resident's normal routine? (Resident #701) is a new resident and had been observed wandering in unit since admission. pleasantly confused.Recreation of the Last 3 Hours Before Fall: Resident was observed wandering hallway of unit since beginning of shift. has been their normal routine. (Resident) was assisted to bed but stayed there for five minutes and was up walking around again. Root Cause of this Fall: Footwear. Resident's worn-out shoes will not be given to them to wear. Need to be replaced.A phone interview was attempted to be completed with Registered Nurse (RN) C on 8/7/25 at 2:07 PM. A voicemail message with return number was left.An interview was conducted with CNA B on 8/7/25 at 2:14 PM. When queried if they recalled working the midnight shift on 5/3/25 to 5/4/25 when Resident#701 fell, CNA B confirmed they did and stated, It was one of those Saturdays. CNA B was asked what happened and stated, I was at the nurses station, got a drink, and that's when (Resident #701) came up to me with their face all bloody. CNA B was asked what all bloody meant and replied, It was dripping from their nose and by their mouth and got on their shirt. When asked how they knew where the Resident fell, CNA B stated, The nurse figured it out. When asked if they recalled anything else, CNA B stated, I was the only one (CNA) there. It was just me and the nurse there. We tried to get (Resident #701) to bed and they got up. When queried regarding the reason Resident #701 has fell and if they had tripped over anything, CNA B replied, I think it was their shoes. They were split at the sole where it meets the shoe. When queried regarding the Resident's shoes, CNA B revealed they had not checked the Resident's shoes. CNA B was asked where and when Resident #701 has last been observed by staff and revealed they were unsure. CNA B then stated, It is exceptionally hard to keep track of all the residents when there is only one CNA and one nurse in the dementia unit. CNA B elaborated, Everyone who is walking around is so hard to keep track of when we were working really short. When asked how many CNAs normally work in the locked dementia unit on the midnight shift, CNA B replied, Normally have two. When queried if they thought Resident #701 would have fell if they would have had two CNAs working to assist in supervising and monitoring the Residents, CNA B replied, No.An interview and review of Resident #701's I & A was completed with the Administrator on 8/7/25 at 2:29 PM. When queried regarding the root cause of Resident #701's fall on 5/4/25, the Administrator verbalized staff identified the Resident's shoes were coming apart. When asked why the Resident was wearing shoes that were a trip hazard with soles that were separating, the Administrator indicated the Resident was a new admission and those were most likely the shoes they brought to the facility with them. When queried if staff are supposed to check shoes and clothing prior to resident use for safety, the Administrator stated, If they (staff) notice the soles are separate from the shoes then they should not use them. The Administrator was then asked where staff are supposed to chart injuries such as bruising in the EMR and replied, It should be in the skin assessment. When queried why Resident #701's facial bruising/black eyes were not documented in their skin assessments, an explanation was not provided. When queried where the staff were at the time of the fall, the Administrator was unable to provide a response. The Administrator was then asked if the facility/unit was short staffed when Resident #701 fell and replied, Not that I know of. There are always two CNAs and one nurse on the (dementia) unit. When asked why staff stated there was only one CNA working in the dementia unit when Resident #701 fell, the Administrator revealed they would need to review staffing documentation. When queried if one CNA and one nurse on the locked dementia unit would be able to supervise all residents on the unit, considering the resident population who reside on the locked unit, a response was not provided. Staffing documentation was requested from the Administrator at this time.On 8/7/25 at 2:50 PM, a follow-up interview was completed with the Administrator. The Administrator confirmed there was only one CNA and one nurse working in the locked dementia unit when Resident #701 fell. No further explanation was provided.Resident #702:On 8/6/25 at 12:15 PM, Resident #702 was in their room in bed. From the hallway, significant dark purple colored bruising was observed on the Resident's face. The bruising was present around both eyes and their mouth and significant edema was present on the top of their left eye.Record review revealed Resident #702 was admitted to the facility on [DATE] with diagnoses which included depression, anxiety, and dementia with psychotic disturbance. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required substantial to total assistance for bed mobility, transferring, and mobility. The MDS further detailed the Resident has a history of falls prior to admission and had one fall since admission.Review of Resident #702's EMR revealed a care plan entitled, (Resident #702) is at risk for fall r/t weakness, impaired memory, hx (history) of falls, new environment (Initiated: 7/11/25; Revised: 7/25/25). The care plan included the interventions:- Do not leave resident unattended in bathroom (Initiated: 7/11/25)- Keep within visual proximity of staff when up in wheelchair (Initiated: 7/11/25)- Lock brakes on wheelchair prior to transfers (Initiated: 7/11/25)- Provide resident with activities that minimize the potential for falls while providing diversion and distraction (Initiated: 7/11/25)- Memory Brakes to w/c (wheelchair) (Initiated: 7/11/25; Revised: 7/14/25)- Dysem under the wheelchair cushion (Initiated: 7/22/25)- Recline w/c seat back d/t incident 7/24/25. Sent to ER for Eval: antibiotic started for UTI (Urinary Tract Infection), IV fluids, sutures to left eye (Initiated: 7/24/25; Revised: 7/25/25).Review of documentation in Resident #702's EMR revealed the following:- 7/11/25 at 11:20 AM: Nursing Summary. arrived at 1120 via EMS from Hospital. has dx (diagnosis) of Dementia with behaviors. admitted r/t recent fall at home. Per hospital (Resident #702) laid on floor for 19 hours following fall. 2 assist for transfers and bed mobility. Alert only to self.- 7/11/25 at 10:18 PM: Nurses Notes. (Resident #702) was at table in activity room on A wing. This author looked up to see (the Resident) stand and immediately their wheelchair rolled away behind them. went to eval (the Resident) . noted to be sitting on buttocks with head up. Stated ‘I bonked my head'. Kept within visual proximity.- 7/18/25 at 1:16 PM: Resident At Risk. Fall from w/c 7/11. had a witnessed fall from w/c while attempting to stand and w/c rolled away behind them. Care plan updated for memory brakes to w/c.- 7/22/25 at 2:31 PM: Nurses Notes. Resident was observed on the floor in the activity room with back to her wheelchair and knees slightly bent and right hand in the air with left hand on lap. Resident was wearing gripper socks at time of incident. states slid out of wheelchair. Resident has small abrasion to the middle of back.- 7/24/25 at 12:04 PM: Resident At Risk. On 7/22/2025 at 1330, (Resident #702) was observed on the floor in the activity room. abrasion noted to back. had been sitting in w/c prior. Dycem applied to w/c seat to help prevent sliding.- 7/24/25 at 2:05 PM: Nurses Notes. This writer was by room [ROOM NUMBER] walking towards the A-wing nurses' station, when the resident was observed leaning over the left side of chair. This writer called out to staff that was at the nurses' station but had their back to (Resident) that was going to fall. Staff attempted to intervein but (Resident) was already falling. Resident hit floor. face first with no attempts to cushion fall. was laying facedown. moderate amount of blood on the floor. was gently rolled over and noted to having two lacerations to face, one below left eyebrow and one on the side of left nose. Pressure and ice was applied. was wearing gripper socks, and in a high traffic area in front of the a-wing nurses station by the activity room door. Care plan updated to have wheelchair seat tipped back.On 8/6/25 at 3:45 PM, Resident #702 was observed sitting in a wheelchair at a table in the dining/activity room of the locked dementia unit. The Resident's legs were positioned on the wheelchair leg/footrests. Deep, dark purple colored bruising was present around both the Resident's eyes. The bruising was darker and more prominent under their eyes. There was deep, dark purple colored bruising surrounding the Resident's mouth and on their cheeks with noticeably more bruising on the left side. The left eye upper orbit area was notably and significantly edematous. The dark purple colored bruising was present on the Resident's neck and chest. The visible bruising on the Resident's chest was lighter in color. When asked what happened, Resident #702 did not provide a response. Resident #702 was pleasantly confused and unable to provide meaningful responses to questions.A review of documentation in Resident #702's EMR revealed ER hospital discharge documentation dated 7/24/25. The documentation included the following:- ED Provider Notes. Presents to the ER. reportedly rolled out of wheelchair sustained a laceration to left orbit. Physical Exam. has a proximally 2.5 cm (centimeter) linear laceration to the inferior left lateral orbit. laceration to the bridge of the nose. Both lacerations surrounded by acute contusion changes and mild edema. ED Course. fall. evaluate for traumatic injury. Left orbit laceration is repaired. wound is approximated using multiple sutures. CT images revised. nasal fx (fracture). urinalysis shows evidence of urinary tract infection (UTI). - CT head. Soft tissue edema overlying the nose, left side greater than right with nondisplaced left and right nasal bone fractures with slight right nasal deviation.A review of the facility provided I & A and investigation documentation for Resident #702 revealed the following:- 7/11/25 at 6:25 PM: Fall Description Details. 1. What did the resident they were trying to do just before they fell? Couldn't verbalize. 2. Factors observed at the time of the fall: Wheelchair/bed brakes unlocked. witnessed. 3. Describe the position the resident was observed: Sitting on buttocks hands at side. 4. Fall Summary: Fall to the floor (witnessed). 5. Fall Location: Activity Room. 6. What was the Resident doing during or just prior to fall. attempting to stand up from wheelchair. 9. Footwear at time of fall: Shoes. 13. Continent. Fall Huddle: Brakes weren't locked on w/c. Initial Interventions: Kept within visual proximity of staff in activity room and with nurse. New Intervention after IDT Review. antiroll brakes.- 7/22/25 at 1:30 PM: Fall Description Details. 1. What did the resident they were trying to do just before they fell? Slid out of w/c. 3. Describe the position the resident was observed: Sitting on coccyx with back facing w/c knees slightly bent. 4. Fall Summary: Observed on the floor (unwitnessed). 5. Fall Location: Activity Room. 9. Footwear at time of Fall? Gripper Socks. Re-Creation of Last 3 Hours Before Fall: Resident was down in the dining room for lunch until about 12:15- 12:30 PM and then was in the activity room up until incident. Resident had been toileted just prior to going for lunch. Root Cause of this Fall: Mood or mental status- Slid out of w/c trying to get up w/o assistance. Initial Interventions: Dycem under w/c cushion.- 7/24/25 at 2:05 PM: 1. What did the resident they were trying to do just before they fell? Unable to give description. 2. Factors observed at the time of the fall: Resident lost their balance. Lost strength/appeared weak- leaning over in w/c. 3. Describe the position the resident was observed: Face down with arms at sides and legs straight out towards w/c. 4. Fall Summary: Fall to the floor (witnessed). 5. Fall Location: Hallway. 6. What was the Resident doing during or just prior to fall. attempting to stand up from wheelchair. Re-Creation of Last 3 Hours Before Fall: Resident was down in the dining room for lunch from 11a-12p then was up by nurses station until toileted at 12:49 PM then back by nurses station until incident. Root Cause of the Fall: Vital signs abnormal. Medical status/Physical condition/Diagnoses. Mood or mental status. Describe initial interventions to prevent further falls: Recline w/c seat back. New interventions after IDT review: Sent to ER for Eval - IV (Intravenous) fluids, antibiotic for UTI, Sutures to left eye. 7/24/25 at 8:20 PM: Was sent out to ER again for low O2 (Oxygen saturation). Was transferred to (tertiary hospital) and admitted to ICU (Intensive Care Unit) with Saddle Embolism (uncommon blood clot in the bifurcation of the main pulmonary artery which can lead to sudden hemodynamic collapse and death).This I &A included a typed and unsigned document which detailed, Incident Date: 7/24/25 at 2:05 PM. Reported Incident: Resident was observed leaning over the left side of chair out by nurses' station. Resident was observed falling to the floor face first with no attempts to cushion fall, landing face down. Staff attempted to intervene but did not get to (resident)in time, (Resident) was already falling. moderate amount of blood on the floor. was gently rolled over and noted to (have) two laceration to face, one below left eyebrow and on the side of left nose. Sent to ER for evaluation r/t lacerations and bleeding. Interviews:- RN D was interviewed 7/24/25. I was by room [ROOM NUMBER] walking towards the A-wing nurses' station when the resident was observed leaning over the left side of chair, I called out to staff that was at the nurses' station but (staff) had their back to (resident) that was going to fall. Staff attempted to intervention was (resident) was already falling. Resident hit floor with face first and no attempt to cushion fall. was lying face down.- CNA E was interviewed on 7/24/25. stated I heard (RN D) yell for help. I tried to get to (Resident #702) before they fell but I couldn't get to them in time. fell to the floor on their face.- Licensed Practical Nurse (LPN) F was interviewed on 7/24/25. I was behind the desk charting and did not see (Resident #702) fall.Investigation Conclusion: DON spoke with LPN F evening of 7/24/25, Resident was being sent back from the hospital with 7 sutures in left eye and IV antibiotics for UTI. returned to (facility) at 6:00 PM with orders for IVAB (Intravenous antibiotics), IV fluids for dehydration, vaginal cream for infection.On 8/7/25 at 9:55 AM, Resident #702 was observed sitting at a table in their wheelchair in the dining/activity room of the locked dementia unit of the facility. The bruising on the Resident's face remained unchanged and both their feet were positioned on the wheelchair leg/footrests.An interview was completed with Therapy Staff G and Occupational Therapist (OT) H on 8/7/25 at 11:40 PM. When queried regarding Resident #702's falls in the facility, OT H stated, She was on (therapy) caseload at the time of the fall. When queried if Therapy evaluated and/or recommended Resident #702's wheelchair seat be tilted back following their fall on 7/24/25, OT H replied, No. OT H and Therapy Staff G both verbalized the tilted seat was a nursing intervention and therapy was not involved with the intervention. When queried if therapy services typically evaluates residents was tilted wheelchair seats, Therapy Staff G revealed nursing staff will often implement the intervention to hinder resident's from getting out of the chair by themselves. When queried if Resident #702 was supposed to have footrests in place on their wheelchair all the time when sitting stationary, both OT H and Therapy Staff G responded they were.An interview and review of Resident #702's I & A was completed with the Administrator and Director of Nursing (DON) on 8/7/25 at 12:15 PM. When queried regarding Resident #702's fall on 7/11/25, the Administrator verbalized the Resident attempted to stand up from their wheelchair with the brakes unlocked and fell. When queried where facility staff were when the Resident fell, the Administrator and DON were unable to provide a response. When queried if the Resident was cognitively able to remember to lock the brakes on the wheelchair prior to standing, the Administrator indicated the Resident had just been admitted and anti-roll back brakes were added to the Resident's wheelchair following the fall. When queried if the leg/footrests were present on the Resident's wheelchair at the time of the fall, the Administrator and DON revealed they did not know. The I & A for the fall on 7/22/25 was reviewed next. When asked, the Administrator and DON verbalized the Resident had an unwitnessed fall in the Activity Room. When asked if residents are left unattended in the Activity Room, the Administrator verbalized they are. When queried where the Resident fell in the Activity Room, the Administrator and DON were unable to provide an explanation. When queried if leg/footrests were present on the wheelchair when Resident #702 fell, the Administrator replied, I don't know. When asked how they determined Resident #702 slid out of their wheelchair when the fall was unwitnessed, the Administrator revealed it was from what staff had told them. When queried why that was not included in the fall investigation, an explanation was not provided. When queried regarding the fall on 7/22/25, the Administrator stated the facility staff was unaware Resident #702 had nasal bone fractures when they returned from the ER. When queried if the Resident had leg/footrests in place at the time of the fall, the Administrator and DON were unable to provide an explanation. When queried why Resident #702 was sitting at the nurses' station without any activities, an explanation was not provided. When asked how tilting the wheelchair seat back was an appropriate and effective intervention when the Resident fell over the side of their chair and the inconsistencies between the EMR and I & A documentation but did not provide further explanation. When queried regarding the pattern of the falls, all being from their wheelchair when unattended, the effectiveness of the interventions, and the lack of comprehensive investigation in order to implement meaningful interventions, the Administrator and DON verbalized understanding. No further explanation was provided.A tour of the A unit hall was completed on 8/7/25 at 12:50 PM. room [ROOM NUMBER] was noted to be approximately halfway down the hall, slightly past the angle, between the end of the hall and the nurses' station.On 8/7/25 at 1:20 PM, an interview was conducted with RN D. When queried regarding Resident #702's fall on 7/24/25, RN D stated, (Resident #702) was sitting in front of the nurses' station. A CNA was at the desk (nurses' station) with their back towards the Resident. (LPN F) was on the computer at the nurses' station. RN D continued, (Resident #702) was bent over left side arm of the wheelchair. I was too far away to do anything, and I yelled to (CNA E). RN D verbalized CNA E responded but was not in time. RN D stated, (Resident #702) fell over the arm of the wheelchair. When asked to clarify if they were saying Resident #702 feel over the side and the arm of the wheelchair, RN D confirmed. RN D demonstrated the Resident leaning over the left side of their wheelchair arm and then falling. When asked if the wheelchair tipped when the Resident fell, RN D replied, The wheelchair stayed upright. RN D was asked how the Resident landed and replied, When (Resident #702's) face landed, they went flat. When queried where they were in relation to the wheelchair, RN D replied, Their left hip was where the left front wheel (of wheelchair) would have been. RN D was asked if Resident #702 had foot pedals/leg rests in place on their wheelchair and revealed they did not remember. When queried if they observed blood, RN D revealed there was instantly blood observed on the floor. RN D revealed Resident #702 had a laceration right above their left eye and on the left side of nose. RN D indicated Resident #702 wore glasses and they thought the glasses may have caused the lacerations. When queried if Resident #702's glasses where still on after the fall, RN D stated, No, I don't believe they did. When asked where Resident #702's glasses were, RN D replied, Not sure. When asked if Resident #702 was attempting to stand from their wheelchair when they fell, RN D replied, No. When queried why the I &A report for the fall specified the reason for the fall because the Resident was attempting to stand up, RN D replied, (LPN F) did the paper (I & A) and I did the computer documentation. RN D reiterated the Resident fell out of the side of their wheelchair and stated, It looked like they were reaching for something.An interview was conducted with CNA E on 8/7/25 at 1:34 PM. When queried regarding Resident #702's fall on 7/24/25, CNA E stated, I did not witness it. When asked what happened, CNA E stated, I heard from the room I was in. I was in room [ROOM NUMBER] and I heard (RN D) yell they're gonna fall. When queried regarding RN D stating they were at the nurses' station, CNA E replied, I was not at the nurses' station and indicated they did not know why RN D said that. CNA E was asked what they saw and stated, (Resident #702) next to their wheelchair with their face to the floor. When queried if the foot pedals were on the wheelchair, CNA E replied, I don't recall. CNA D was asked if the Resident was bleeding and stated, Yes, it looked like their glasses sliced under their eye. When queried where the Resident's glasses were after the glass, CNA E was unable to recall. CNA E was asked what direction the Resident was facing when they were sitting in their wheelchair prior to the fall and stated, They were facing directly towards the nurses' station. When queried why Resident #702 was sitting by the nurses' station, CNA E replied, So we could try to prevent a fall because (Resident #702) is one of those who would try to get up. When queried if the Resident was given anything to do and/or occupy themselves with while sitting near the nurses' station, CNA E revealed the Resident did not have an activity or anything to do while sitting near the nurses' station. When asked if there was TV in that area for the Resident to watch, CNA E responded that there was not a TV. When asked if there was a facility activity at that time, CNA E revealed there is one activity staff for an activity, and they cannot closely supervise watch all the residents especially when they are a high fall risk like Resident #702 which is the reason Resident #702 was positioned near the nurses' station. When asked if staff sitting at the nurses station are able to visualize residents over the desk/counter ledge when they are seated, CNA E responded they could not. When queried how beneficial it is to position high fall risk residents near the nurses' station when they are unable to be visualized and without something to occupy them, CNA E verbalized understanding but did not provide further explanation. When queried if they were working when Resident #702 fell on 7/11/25 or 7/22/25, CNA E stated, I think (Resident #702) fell as we were leaving on 7/11/25 and was unable to provide an information pertaining to that fall. CNA E verbalized they were working when the Resident fell on 7/22/25. When asked what happened, CNA E indicated the fall was unwitnessed. When queried what happened, CNA E revealed the Resident was sitting in the dining/activity room and stated, (Resident #702) kept scooching their butt forward (in their wheelchair) and we kept scooting them back. When queried if there are no staff in the dining/activity room when residents are present, CNA E replied, Not always. At that time, we could have been at half-staff because of lunch breaks. CNA E then stated, They do activities in the dining room but activity staff are not present in the room when an activity is not ongoing. When queried if the leg/footrests were in place on Resident #702's wheelchair at the time of the fall, CNA E indicated they were on the wheelchair and stated, I think they were off to the side. When queried how the staff determined the Resident slid off the wheelchair and did not attempt to stand and fall and stated, I imagine (Resident #702) was scootching forward to stand and then fell. CNA E was asked if they recalled any additional information regarding Resident #702's falls and stated, I don't know why they didn't move (Resident #702) after the first or second fall to the (locked dementia) unit. (Resident #702) is someone who needs someone to talk to and to be entertained, or else they are getting up and trying to do something.An interview was completed with LPN F at 2:25 PM on 8/7/25. When queried regarding Resident #702's fall on 7/24/25, LPN F verbalized they were sitting at the nurses' station, were unable to see over the ledge of the nurses' station, and did not see the Resident fall. LPN F indicated they heard RN D yell and stated, Before I could even lift my head up, (Resident #702) had fell and hit their face on the floor. LPN D indicated they responded to the Resident after the fall. When asked if the Resident had leg/footrests in place on their wheelchair when they fell, LPN D revealed they did not remember. When queried why Resident #702 was sitting in their wheelchair in front of the nurses' station, LPN F revealed the Resident was a high fall risk and they were placed there so staff could visualize them. When asked if the Resident had or was given anything to occupy them while sitting near the nurses'

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00145606. Based on observations, interviews and record review, the facility failed to protect Resident #2's right to be free from sexual abuse by Resident #1 for one resident (Resident #2) of four residents reviewed for abuse, resulting in Resident #1 being observed to make non-consensual contact with Resident #2's perineal area, with a finger in Resident #2's brief, while Resident #2 was lying in bed, resulting in psychosocial harm, trauma and/or fear using the reasonable person concept and the potential for injury. Findings include: Resident #1: A review of Resident #1's medical record revealed an admission into the facility on 2/5/24 with diagnoses that included stroke, depression, anxiety disorder, adjustment disorder with depressed mood, cognitive communication deficit and intracranial injury. A review of the Minimum Data Set (MDS) assessment revealed the Resident had a Brief Interview of Mental Status (BIMS) score of 15/15 that indicated intact cognition, functional limitation in range of motion with impairment on one side of upper and lower extremity. Further review of the medical record revealed the Resident had a Guardian as the responsible party. On 7/22/24 at 11:55 AM, an observation was made of Resident #1 sitting in his wheelchair in his room. The Resident's hair was disheveled, not combed/brushed and had long facial hair. The Resident was dressed. The Resident was interviewed, answered some simple questions, was difficult to understand, and wandered off topic to talk of his brother. The Resident indicated he could not move his right arm, that was positioned on the side of his thigh, but reported he could move his wheelchair on his own and the Resident moved the wheelchair back from where he was originally seated in his room. After leaving Resident #1's room, an observation was made of Resident #2's room that was down the hall towards the nurses' station and down another hall a short distance from the nurses' station. A review of Resident #1's medical record revealed the following progress notes: -Dated 6/6/24 at 11:08 AM, .3 episodes of yelling with abusive language toward caregivers and 2 episodes of physical aggression toward care givers past week per behavior monitoring log. Individual interventions utilized once and effective per behavior monitoring. Occasional episodes of anger and frustration per nursing notes. He was noted to become angry about his mechanically altered diet and threw his plate on the floor in the dining room [ROOM NUMBER]/3/24 . -Dated 6/28/24 at 8:31 AM, Cena (certified nursing assistant) staff observed resident inside a female room today-he was observed self propelling his wheelchair toward her bed. He has been advised not to be allow in this female resident room several times in the past, but he keep going into her room daily per staff reporting to me. Will continue to monitor. He was taken out of her bedroom into his room and advised that he is not allow in any female room unless is consented. -Dated 6/28/24 at 17:45 (5:45 PM), Behavior Note, Cena staff came to me to report that resident was observed again in the same prior female room than earlier. He was right by her bed side. He was again told that he was not allowed to be in there, and resident got angry and preside to cuz (cuss) f* you B*s, and preside to spit at staff in rage. Staff removed him from her room. -Dated 6/28/24 at 19:45 (7:45 PM), Nurses Notes, Resident was observed sitting at another resident's bedside with hand on brief. Resident was immediately removed from room and return to his room. At this time the resident will be placed on 1 on 1 supervision while awake. Per Resident #1's medical record, the Resident had a room change from room [ROOM NUMBER]-B to room [ROOM NUMBER]-B. Resident #2 resided in room [ROOM NUMBER]-A. Resident #2: A review of Resident #2's medical record revealed an admission into the facility on 6/25/13 with diagnoses that included epilepsy, dementia, anxiety disorder, weakness, hypoxic ischemic encephalopathy and anoxic brain damage. A review of the MDS assessment revealed the Resident had severely impaired cognitive skills, had functional limitation in range of motion with impairment of bilateral upper and lower extremity, and was dependent for activities of daily living and transfers. On 7/22/25 at 12:02 PM, an observation was made of Resident #2 positioned in a Geri-chair, that was reclined, propelled by staff to her room. On 7/22/25 at 12:09 PM, an observation was made of Resident #2 lying in bed with her eyes closed. The Resident did open her eyes when her name was called but did not make eye contact or acknowledge surveyor was in the room. The Resident was covered with a light blanket. Her hands and arms were bent, arms close to her body, fingers bent towards the palm of her hand with two fingers out straight and ridged on one hand. The Resident did not communicate with the surveyor. A review of Resident #2's progress notes in the medical record revealed the following: -Dated 6/28/24 at 14:35 (2:35 PM), Social Services Note, Spoke with father/Guardian (Name) and informed him a male resident has brought (Resident #1's name) flowers and attempted to visit her in her room. The staff have been redirecting the male resident away from (Resident #2's name) room. Her father expressed appreciation at redirecting the male resident and asks the staff continue to do so. (Resident #2's name) has exhibited no s/s (signs/symptoms) of distress. -Dated 6/28/24 at 21:42 (9:42 PM), Behavior Note, I was notified at 1945 (7:45 PM) that (Resident #2's name) had Resident (#1's initials) sitting at her bedside with his hand on top of her brief. (Resident #2) was reported to be sleeping and did not wake up. Social Services made aware. When arriving at the building the resident still remains asleep with no psychosocial distress noted or reported from staff. Will continue to observe. A review of the facility's report of incident revealed the following: -Date of incident: 6/28/24 -Time of incident: 7:45 PM -Reported Incident: At 19:45 PM (7:45 PM) resident (#1's name) was witness in resident (#2's name) room. He was observed by the charge nurse sitting next to her bed with his hand on top of her brief. The witness stated that he had a finger partially present in the brief by her thigh. Resident (#2's name) was asleep when this was observed and did not wake up. The nurse immediately separated the two residents and resident (#1's name) was returned to his room and placed on 1 on 1 supervision. Legal parties were notified along with physician at time of incident. -Interviews: Nurse A: Interview completed with (Nurse A). She stated that at approximately 1945 PM she entered room [ROOM NUMBER]-A. Upon entering the room she noted that resident (#1) was sitting next to Res. (#2)'s bed. He was sitting on the left side of her bed with his wheel chair next to the bed. Resident is flaccid on right side and only has control of his left side due to hemiparesis form TBI (traumatic brain injury). When (Nurse A) entered the room she noted that he was sitting parallel to Res. (#2). Her blanket/sheet was only partially on her. She was lying in bed with her legs spread apart; which is typically for Res. (#2) related to her spasticity from her anoxic brain injury. Resident (#1) had his left hand by (Resident #2)'s left thigh with his index finger in her brief. Res. (#2) was asleep at the time and did not wake up. (Nurse A) immediately separated the two residents. (Resident #1) became upset with (Nurse A) and began calling her a liar. CNA (Certified Nursing Assistant) C: Interviewed (CNA C) about the incident from 6/28/24. (CNA C) stated that his interaction with (Resident #2) occurred after the incident. He stated that he helped him into his room, and getting him ready for bed. He stated that he was saying the word finger and pussy. But was very difficult to understand, and (CNA C) stated that it was difficult to tell if he was stating to him what he was accused of, or what he did . CNA B: Interviewed (CNA B) in regards to incident on 6/28/24. (CNA B) stated that she had been his assigned CNA that shift (7 a-7). She stated that (Resident #1) had made approximately 2 attempts to go into (Resident #2's) room and visit with her. Each time he was intercepted and redirected. (CNA B) stated that they told him he could not visit with her in her room, but that they would bring her out in a public area if he would like to visit. He would become upset and was yelling Fuck Autumnwood and it's my right. (CNA B) stated he was becoming agitated and spitting and yelling at the staff. -Investigation Conclusion: At 19:45 PM resident (#1) was witnessed in resident (#2's) room. He was observed by the charge nurse (Nurse A) sitting next to her bed [parallel] with his hand on her left thigh by her brief area. (Nurse A) also stated he had his left index finger inserted in her brief. Her brief remained intact. Resident (#2) was asleep when this was observed and did not wake up. The nurse immediately separated the two residents. (Nurse A) was attempting to explain to him that he could not be in the room and the resident grew increasing upset and started to yell at the nurse calling her a liar. The resident was removed back to his room. (Resident #2) remained asleep and had no signs of any psychosocial harm . On 7/22/24 at 1:23 PM, an interview was conducted with Social Service (SS) D regarding the incident between Resident #1 and Resident #2 on 6/28/24. The SS was queried regarding Resident #2's communication with others and the SS reported Resident #2 was a vulnerable adult, she can make eye contact, she can let you know her basic needs by yelling out, grunts and groans, and say yes and no. The SS indicated that after the incident occurred, he had been notified of the incident, came into the facility that night, had seen Resident #2, reported Resident #2 had been sleeping, had not woken her up, and covered the first one-to-one shift with Resident #1. The SS was asked about Resident #1 in contact with Resident #2 prior to the incident on 6/28/24 when witnessed at Resident #2's bedside with his hand on her brief and a finger inside the brief. The SS stated, Multiple times he (Resident #1) tried to engage with (Resident #2), and reported another day when Resident #1 was in Resident #2's room. The SS reported he had told Resident #1 that he could not go into her room. When asked about Resident #1 giving a flower to Resident #2 on 6/28/24, the SS reported the Resident had gone out to the courtyard and picked the flowers. The SS reported he had contacted Resident #2's guardian who did not want her alone with Resident #1. The SS reported that when Resident #1 had gone into Resident #2's room before, they had changed Resident #1's room further away from Resident #2's room. A review of Resident #1's census revealed a room change on 6/19/24 from room [ROOM NUMBER] to 106. The SS reported that Resident #1 was angry when we removed him from her room and stated, We wanted to try and keep everyone safe and told him he could not be in her room, when asked why they were alerted to change his room, the SS stated, (Resident #2) was a vulnerable individual and we were trying to prevent him from going into her room. The incident on 6/28/24 was reviewed with the SS. A review of the Resident witnessed with his finger inside her brief, the SS reported that was all they knew had happened and reported they can't go with anything but the facts, we don't know what happened prior but that he was witnessed with his hand on her brief and a finger inside the brief. On 7/22/24 at 2:02 PM, CNA B returned a phone call and was interviewed regarding the incident between Resident #1 and Resident #2 on 6/28/24. The CNA reported she had assigned care of Resident #1 on 6/28/24. The CNA indicated that Resident #1 had made attempts to keep going down to Resident #2's room that day and stated, We had to keep an eye on him. The CNA reported that Dietary staff had brought trays down and said he was in her room, and they had gotten a CNA to go down there and take him out. We were all watching, and he tried multiple times to go down there. The CNA stated, at 6ish he was going into her room, and he got very irate, screaming at me, that it was his right to go down there. The CNA reported she explained it was Resident #2's right for privacy and reported Resident #1 got really upset, swearing at me, started spitting in my face. The CNA reported that she took him out of the room to the Nurse (Nurse A) and told her what happened and left Resident #1 with the nurse. The CNA stated, I was told the next day about it. I heard that he was caught in her room with his hand in her pants. The CNA was asked about Resident #1's interactions prior with Resident #2. The CNA indicated Resident #1 had given Resident #2 a flower and Resident #2 had responded with a smile. When asked if Resident #2 followed simple commands, the CNA stated, Not very well. When asked how Resident #2 communicated, the CNA reported that given time the Resident could give out a short response and reported she hollers out. When questioned about Resident #1's interactions with other Residents, the CNA indicated Resident #1 was not very social person, keeps to himself, had tried one other time with her (Resident #2), passed out [NAME] to staff and to her (Resident #2). On 7/22/24 at 2:52 PM, an interview was conducted with the Administrator (NHA) regarding the incident on 6/28/24 when Resident #1 made sexual contact with Resident #2. The NHA indicated that the Nurse had contacted her immediately and she had come in to get interviews with the people at the facility. When asked if she was aware of multiple attempts of Resident #1 in contact with Resident #2, the NHA stated, Yes, and reported that Resident #1 verbalized that he for any reason, they were very similar, he was in the situation that she was in and felt connected to her, he felt bad for her and wanted to visit with her. The NHA reported that Resident #1 had been in her room before and we had switched his room and moved Resident #1 further from Resident #2. Resident #1 with a history of being in Resident #2's room prior, had multiple attempts to get into Resident #2's room the day of the incident and had emotional outburst with the CNA prior to the incident was reviewed with the NHA. The NHA indicated that Resident #1 had been put on one-to-one staffing to resident but reported had not had any other incidents and had been taken off the one to one. When asked about a lack of documentation of a skin assessment after the incident, the NHA stated, I am sure they did but just didn't document it. Resident #1 was witnessed with a finger in Resident #2's brief and was not witnessed until this point was reviewed with the NHA. The NHA stated, don't really know what happened prior to being discovered, and reported the Nurse should have done and document a skin assessment. When asked about the time period that the Resident #1 was not visualized by staff when he had entered Resident #2's room, the NHA was unsure and reported Nurse A had gone into the nutrition room to talk to a CNA, when they were done, Resident #1 was not insight and she went down there to check Resident #2's room and Resident #1 was in her room and prior to that Resident #1 had been brought to the dining room for dinner after the incident with CNA B. A review of the facility policy titled Abuse Prohibition Policy, effective 10/14/22, revealed, Policy: Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse . To assure guests/residents are free from abuse, neglect, exploitation, or mistreatment, the facility shall monitor guest/resident care and treatments on an on-going basis. It is the responsibility of all staff to provide a safe environment for the guests/residents . Sexual Abuse is non-consensual sexual contact of any type with a guest/resident. Sexual abuse is defined as non-consensual sexual contact of any type with a guest/resident. Sexual abuse includes, but is not limited to: unwanted intimate touching of any kind especially of breasts or perineal area . C. Prevention: .8. Staff will be instructed to report any signs of stress from family and other individuals involved with the guest/resident that may lead to abuse . and intervene as appropriate .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake Number MI00137710. This Citation has two Deficient Practice Statements (DPS). DPS #1: Based on observation, interview and record review, the facility failed to ensure that appropriate interventions were in place to secure a resident in a van during a transport to prevent a fall with serious injury for one resident (Resident #8) of 5 residents reviewed for falls and accidents, resulting in Resident #8 falling out of a wheelchair in a facility van and sustaining two right leg fractures. Findings Include: Resident #8: Accidents A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #8 revealed the resident was admitted to the facility on [DATE] with diagnoses: history of a brain tumor, morbid obesity, heart disease, fibromyalgia, depression, chronic pain, and neuropathy. The MDS assessment dated [DATE] indicated the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 14/15 and the resident needed some assistance with all care; and could feed self and perform oral care with set up assistance. On 3/18/24 at 11:05 AM, during a tour of the facility, Resident #8 was observed awake, lying in bed. The resident stated, I broke my right leg in two places when I was riding in the van going to my doctor's appointment. The resident said a facility Staff member T was driving the van. Resident #8 stated, He forgot to put my seat belt on. My leg is still sore, but it is mostly healed. I'm not walking on it; I broke it in 2 places. The resident said she also had prior falls at the facility. She said she has pain, but pain medicine helps. A review of the Incident and Accident report dated 11/1/2023 and facility investigation revealed Resident #8 was riding in a facility van with Driver T. The driver stepped quickly on the van brakes to avoid a collision, as another car pulled out in front of him and the resident flew forward out of her wheelchair. The resident was tangled between the two front seats. The van driver could not move the resident and drove her to the ER. The facility investigation determined the driver secured the wheelchair to the van floor, but he did not use the seat belt appropriately to secure the resident while she was sitting in the wheelchair. He placed the seat belt straps under the armrests on the wheelchair instead of appropriately around the resident. A review of the progress notes revealed the following: 11/1/2023 3:43 PM a nurses note, Per transportation driver, while on the way to an appointment . they were cut off by another vehicle on the road. Driver hit the brakes in an effort to avoid collision with the other vehicle . However, when he hit the brakes (Resident #8) slid forward out of her wheelchair, with her legs extended out in front of her between the front seats of the van . 11/1/2023 7:53 PM a nurses note, Resident LOA (leave of absence) 0615 am to (doctor) appointment. Returned 1707 (5:07 PM from hospital) . Resident has (diagnosis) Closed fracture Distal end of right Fibula and Tibia. Soft cast in place. Ice applied for comfort to right leg . 11/1/2023 10:46 PM a nurses note, . reported pain 9/10 in bilateral legs . 11/2/2023 at 12:16 PM a resident at risk note, Resident is being reviewed by IDT (interdisciplinary team) related to incident that occurred on 11/1/2023 at 0715 (am) . Intervention implemented: Staff education related to resident positioning and safety devices in the transportation van . 11/3/2023 at 9:50 PM a nurses note, . rates pain at 10 prior to scheduled Tylenol and Norco . 11/14/2023 at 11:26 PM a nurses note, Resident continues to be on scheduled pain medications that has been limited effective per resident . 11/17/2023 at 11:44 PM a nurses note, . residents tibia/fibula x-ray, .Acute distal tibial shaft fracture. Acute distal fibular shaft fracture. Moderate soft tissue swelling seen on the ankle . On 3/19/2024 at 1:00 PM, the facility provided a packet of past non-compliance related to the fall with fracture incident that occurred during van transport for Resident #8. The facility said the incident occurred on 11/1/2023 and they said they provided staff education and attained compliance on 11/10/2023. The packet incident and investigation were further reviewed. This surveyor requested to review the education provided to the staff and to review competencies for Van driver T completed prior to the incident. On 3/19/24 at 4:29 PM the Director of Nursing/ DON was interviewed related to education provided to the Van drivers/ Transporters: CNA/Driver U and CNA/ Q. Driver T did not have education related to proper use of the van seatbelt for residents prior to the incident. On 3/20/2024 at 11:00 AM reviewed the education file for Van Driver T. He did not have education related to proper use of the seatbelt in the van to secure a resident in a wheelchair. A review of the facility provided document titled, Q'straint: Use and Crae Manual-QRT-360 4-Point Wheelchair Securement System, dated 2014 revealed, . Compliant shoulder and pelvic belt restraint must go across occupant's shoulder and pelvic (lap), and not be worn twisted or held away from the occupant's body by wheelchair components A review of the facility policy titled, Transportation of a Resident in Facility Van, dated 12/30/2022 and revised 2/9/2023 provided, Residents will be safely transported via the facility transport van. The transport driver will meet the requirements of the job description for transport van driver. Processes are in place to promote the safety of residents and employees during transport in company vehicles and to minimize resident/employee injury . Keep all seat belts, safety restraints, and wheelchairs secure following the manufacturer's instructions . The driver will have documented wheelchair transportation safety training . The wheelchair is secured following manufacturer's guidelines and facility procedure upon entering the vehicle . Vehicle driver training: 1. An employee may not attempt to transport a wheelchair user in the van without having been instructed on proper operation of wheelchair securement and occupant restraint systems. 2. All vehicle drivers are trained using education materials before transporting resident in the van. 3. Training includes viewing the Q'straint QRT system video (or system specific to the van used), a demonstration of the use of the wheelchair lift and restraint system, completion of the competency checklist and return demonstration. 4. The competency will be completed initially and annually. DPS #2: Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place and supervision was provided to prevent a fall with injury for one resident (Resident #22) of 5 residents reviewed for falls/accidents, resulting in Resident #22 falling out of a chair, hitting her head and suffering an epidural hematoma. Findings Include: Resident #22: Accidents A record review of the Face sheet and MDS assessment indicated Resident #22 was admitted to the facility on [DATE] with diagnoses: history of a stroke, heart disease, depression, history of delusions, and obesity. The MDS assessment dated [DATE] indicated the resident had moderate cognitive loss with a BIMS score of 10/15 and the resident needed assistance with all care. On 3/18/2024 12:32 PM during a tour of the facility, Resident #22 was observed leaving the main dining room. She was slowly wheeling her wheelchair. Her right eye and forehead were covered in purple, yellow bruises. On 3/19/2024 at 10:15 AM, Resident #22 was observed in her room, sitting in her bedside chair. She said she fell at the facility when she was walking on her own. A lift sling was observed underneath the resident. She said she previously had a stroke and had right sided weakness. Her right hand had a splint on it, It just won't do what I want. A record review of the Incident and Accident reports for Resident #22 revealed she had fallen previously on 10/9/23, 1/9/24 and 3/8/2024: 10/9/2024 at 6:50 PM- Resident in room . Resident room [ROOM NUMBER] A in hallway going to his room and told CENA (certified nursing assistant), Someone is yelling. CENA approached room and observed Resident (#22) sitting on floor at end of her bed. Resident stated, I stood up from my wheelchair and sat down. I was trying to walk to bathroom. Resident did not use call light . Impairment of memory wait for assistance . 1/9/2024 at 6:55 PM- Resident was lying on her back with her knees bent in the middle of her room next to her wheelchair. Resident has skin tear to the top of her right hand . and she has a hematoma to the right side of her forehead . I was trying to clean up my blankets and stuff by the wall and fell out of my chair and hit my head on the floor, I rolled over and tried getting myself up but couldn't . care plan updated to encourage resident to ask for assistance . Predisposing Physiological Factors: confused . impaired memory .weakness . gait imbalance . 3/8/2024 at 4:40 PM- At 1640 (4:40 PM) resident was observed on the floor curled in a slight fetal position on her right side with her feet facing the bathroom door, head & body between the register & bed with top of head facing the register & the right side of her face lying on the floor. Moderate amount of blood noted at head level. Her glasses were beneath her right temporal lobe, one lens was out . There was an immediate golf ball sized nodule with bruising on the right upper forehead. There was a 1.5 cm & a 2 cm linear laceration above the right eye . She stated she was attempting to stand to walk into the bathroom & went down on her right side . order obtained to transfer to (hospital) for evaluation . 1735 (5:35 PM) ambulance arrived for transfer . impaired memory, gait imbalance. Incontinent . orthostatic bp's (blood pressures) were added to the care plan x 3 days . A review of the summary report of the incident for Resident #22 on 3/8/2024: . Report received from nurse at (hospital) stating that resident had a small brain bleed and fracture to the right skull . sent to (another hospital) where CT scan was repeated on 3/9/2024 . hyper dense right frontal scalp hematoma . no skull fracture . A review of the progress notes for Resident #22 identified the following: 2/22/2024 at 3:55 PM a nurses note, This writer was walking past the Internet café and observed the resident sitting in a regular chair next to the table in front of the fish tank, attempting to stand to transfer back into her w/c (wheelchair) . Resident educated on the importance of asking staff for help to move from one chair to another and she replied, Ok, but I can do it myself, I just did. 2/26/2024 at 4:40 PM: This nurse walking past resident entrance door. Noticed resident in her recliner reaching for her wheelchair. Nurse asked, . Do you need help: Resident stated, Yes. I want to get in this wheelchair and go eat. Nurse stayed with resident until mechanical lift available . 3/4/2024 at 12:45 PM: Resident observed . Motioning to self-transfer from her wheelchair to her recliner in her room . CENA's x 2 mechanical lift transfer done from wheelchair to her recliner. 3/8/2024 at 8:26 PM: At 1640 resident was observed on the floor curled in a slight fetal position on her right side . Moderate amount of blood noted at head level . There was an immediate golf ball sized nodule with bruising on the right upper forehead. There was a 1.5 cm and a 2 mm linear line laceration above the right eye . Lying blood pressure was obtained 181/138 & upon being assisted to sitting position on floor she c/o (complained of) dizziness with position change, sitting BP was 181/85. Unable to stand for standing BP . A review of the Care Plans for Resident #22 identified the following: (Resident #22) has the potential for impaired communication related to word finding difficulty at times secondary to CVA (stroke), date initiated 6/2/2023 and revised 9/6/2023 with intervention Anticipate and meet needs as needed, date created and initiated 12/31/2020. (Resident #22) has incontinence of bowel and bladder and is at risk for UTI's and skin breakdown related to cognitive impairment, decreased mobility, date created 1/12/2021 and revised 12/7/2022 with intervention Check resident q 2 hours and prn (as needed) for incontinence . date initiated and revised 1/12/2021. (Resident #22) is at risk for fall related injury and falls related to CVA with right sided deficits, weakness, poor safety awareness, hallucinations and delusions, believes that she is able to self transfer and ambulate independently, date created 12/31/2020 and revised 3/13/2024 with intervention: Tilt wheelchair seat back, 6/29/2022; Refer to psych services related to hallucinations and delusions that may have contributed to fall on 3/8/2024, created and initiated 3/8/2024 and revised 3/13/2024.; Put the residents call light within reach and encourage him/her to use it for assistance as needed, initiated 12/31/2020 and revised 3/13/2024; Note put outside of Resident Bathroom Door Remember to ask for assistance when using bathroom, date initiated 10/9/2023; Increase CENA rounding/offers to go to restroom, date initiated 3/18/2022 and revised 12/16/2022. Resident #22 had repeated attempts to transfer herself from chair to chair, bed to chair or chair to bathroom. The staff documented the resident had poor memory and cognitive decline, but interventions were to remind her to use her call light and a note to ask for assistance. An intervention mentioned increased nurse aide rounding, but it didn't specify how often. The resident's blood pressure was very high (181/138) after falling on 3/8/2024 and then lower (181/85) upon sitting and an intervention on the incident report said to monitor for 3 days; this was when the resident was hospitalized for the head injury. Monitoring did not resume when the resident returned to the facility. The resident's falls were all before or after a meal. This was not addressed by the facility. Resident #22 was observed attempting to stand and transfer self on several occasions prior to the fall with head injury on 3/8/2024 that required hospitalization: 2/22/2024, 2/26/2024, 3/4/2024. There were no additional interventions to aid in preventing the resident's continued falls with injury. On 3/19/24 at 2:00 PM, the DON was interviewed related to Resident #22's recurrent falls. Reviewed the nursing documentation that the resident was repeatedly attempting to stand and transfer self, but interventions were not specific to address the resident's risk for falls. She said the facility was working on falls. A review of the facility policy titled, Fall Management, origination date 5/1/2010 and revised date 9/22/2023 provided, The facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Each resident is assisted in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate . A plan of care is developed and implemented .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** According to International NPUAP/EPUAP (National Pressure Ulcer Advisory Panel/ European Pressure Ulcer Advisory Panel; a group of experts who serve as the authoritative voice in pressure injuries) defined pressure injury stages. (A) Stage I-nonblanchable erythema. (B) Stage II-partial thickness skin loss with exposed dermis. (C) Stage III-full-thickness skin loss. (D) Stage IV-full-thickness skin and tissue loss. (E) Unstageable pressure injury-obscured full thickness skin and tissue loss. (F) Deep tissue pressure injury-persistent non-blanchable deep red, maroon, or purple discoloration. (2016 NPUAP Pressure Injury Staging Illustrations from http://www.npuap.org/resources/educational-and-clinical-resources/pressureinjurystagingillustrations/. Used with permission of the National Pressure Ulcer Advisory Panel March 2018. © NPUAP.) Nursing and Patient Care Considerations: Prevent Pressure Ulcer Development-1. Provide meticulous care and positioning for immobile patients. (a.) Inspect skin several times daily. (b.) Wash skin with mild soap, rinse, and pat dry with a soft towel. (c.) Lubricate skin with a bland lotion to keep skin soft and pliable. (d.) Avoid poorly ventilated mattress that is covered with plastic or impermeable material. (e.) Employ bowel and bladder programs to prevent incontinence.(f.) Encourage ambulation and exercise. (g.) Promote nutritious diet with optimal protein, vitamins, and iron. Resident #3: According to admission face sheet, Resident #3 was an [AGE] year-old female admitted to the facility on [DATE], readmitted on [DATE], with diagnoses that included Cardiac, Depression, Atrial Fibrillation, Congestive Heart Failure, High Blood Pressure, and other complications. According to Minimum Data Set (MDS) dated [DATE], Resident #3 scored a 15 out of 15 on the Cognition Assessment indicating no cognition impairment. The MDS also coded Resident #3 as requiring extensive two person assist for Bed Mobility, Toileting and Transfers. According to section 'M' skin on MDS, Resident #3 was coded as 'Yes' to having Pressure Ulcers, and 'No' to turning and repositioning. Pressure Ulcer location documented as Coccyx. Review of Resident #3's initial admission MDS, dated [DATE], coded Resident #3 as 'No' to having Pressure Ulcers. Review of MDS dated [DATE], coded Resident #3 as 'Yes' to having a Pressure Ulcer and documented a Stage II. Further Review of MDS's from dates of 9/28/21, through 5/9/22, coded Resident #3 as 'No' to having Pressure Ulcers. (area healed). Review of MDS dated [DATE], coded Resident #3 as 'Yes' to having Pressure Ulcers, as a Stage II, and 'No' to turning and repositioning. Review of MDS dated [DATE], coded Resident #3 as 'Yes' to having Pressure Ulcers, as a Stage II, and 'No', to turning and repositioning. Review of MDS dated [DATE], coded Resident #3 as 'Yes' to Stage III Pressure Ulcer. (worsening/progression from Stage II to Stage III). Review of MDS dated [DATE], coded Resident #3 as 'Yes' to having a Pressure Ulcer and documented a Stage II, and 'No' to turning and repositioning. (The Pressure Ulcer was reversed Staged from a III to a II). Review of Point Click Care (PCC) weekly Skin and Wound-Total Body Skin assessments (tool used by nurses to capture wounds or other skin conditions) was done from a time frame of 5/30/22, through 2/14/23. Review of the Weekly Skin assessments, under the column to Enter the number of New Wounds were all documented as 0 (reflecting no new wounds). Review of the Skin assessments reflected that nursing staff were documenting the assessments as performed, but failed to capture the re-opening of Coccyx wound Stage II or Stage III wound. Review of Skin Policy documented . Under: 11. A weekly total body skin evaluation is completed for each guest/resident by the licensed nurse. The licensed nurse will document findings of the skin evaluation. The CNA's will report any new skin impairment to the licensed nurse that is identified during daily care. 12. If a new area of skin impairment is identified, notify the guest/resident, responsible party, attending physician, DON/designee and treatment team, if applicable. 13. Guest's/resident's with pressure injury and lower extremity ulcers will be evaluated, measured and staged weekly (pressure injury and vascular ulcers only) in accordance with the practice guidelines until resolved. A photo may be initiated unless the guest/resident refuses. 14. The licensed nurse will notify the attending physician with any changes as needed. 15. A Guest/Resident at Risk meeting will be conducted at least monthly by the Interdisciplinary Team (IDT). During the meeting, the IDT will evaluate guest/resident skin changes, review treatment modalities, interventions and will make recommendations as needed. Care plans and guest/resident [NAME] will be updated accordingly. Guests/residents reviewed for skin alterations are as follows: - Newly developed vascular, diabetic/neuropathic and pressure injuries. - Any pressure or non-pressure area that has shown no signs of healing within a two week time frame. - New admissions/readmissions with skin conditions (pressure related, non-pressure related, arterial, venous insufficiency, and/or diabetic/neuropathic, surgical sites, rashes, dermatologic conditions, skin tears, etc.). 16. The DON/designee will document any changes in the care plan/[NAME] at the meeting. 17. Quarterly, a system audit of the Skin Management Guideline is conducted by the DON/designee to ensure ongoing compliance in all areas. Results will be reported to the QAPI committee for trending, analyzing and recommendations. 18. The pressure injury incidence rate is calculated monthly, submitted, and reviewed through QAPI to analyze and identify trends. The DON provided some documentation on a piece of paper with measurements of Resident #3's Pressure Ulcer. According to the documentation, Resident #3 had a Pressure Ulcer on 6/22/22, measuring 0.86 X 0.73 X 0.5 (Length, Width, and Depth). According to the measurements dated: 8/11/22, measurements were 1.08 X 0.67 X 0.4. 10/4/22, measurements were 1.35 X 1.82 X 1.0. (wound is larger). 11/1/22, measurements were 1.37 X 1.41 X 1 and documented as Stage III. Observation of Wound Care for Resident #3 was performed on 2/9/23, at 11:30 AM, with Registered Nurse D and Licensed Practical Nurse H. Resident #3 was 2-person assisted over to her right side, and the old dressing was removed by RN D. The Wound Base appeared deep, dark pink, and at a Stage III, with scant amount of scattered slough, noted to the base. RN D was asked what the Stage of the wound was currently, and indicated it now was a Stage III. RN D continued with the dressing change and verbalized the area looks better than before, and that at one point there had been some tunneling to the wound. RN D was asked about the progression from a Stage II to a Stage III and then a Stage II, documented in the wound evaluation. RN D verbalized she had just recently had the conversation with her Director of Nursing, who educated her on not to reverse stage pressure ulcers. RN D indicated the wounds becomes a healing Stage III not a II and not to reverse Stage a wound. Review of previous treatment dated 1/27/23 - 2/8/23, was After cleaning the coccyx with Normal saline, apply medi-honey, pack Aquacell silver into the wound and cover with Optifoam every shift for a Stage II. Review of the Wound Evaluation dated 2/7/23, by RN D documented on the form a Stage III Pressure Ulcer, In-house Acquired, with a start date of 8/19/22. The measurements documented were: 1.42 X 1.14 X 0.2 cm (centimeters). Review of current active treatment orders reflected an order dated 2/11/23, After cleaning coccyx with Normal Saline, Collagen AG [SIC] and cover with a composite dressing every day shift for a Stage III. The DON was interviewed on 2/16/23, and was shown the Weekly Skin Assessments did not reflect a change in the Pressure Ulcer for Resident #3 or capture the re-opening in 6/2022, and indicated she had seen that. The DON also verbalized Resident #3 does not like to be moved. Based on observation, interview and record review, the facility failed to prevent the development of facility-acquired pressure ulcer injuries for two residents (Resident #3, Resident #66), resulting in facility-acquired (in-house) development of pressure ulcers, pain, discomfort, and the likelihood for prolonged illness or hospitalization. Findings include: Record review of the facility 'Skin Management' policy dated 12/15/2022, revealed it is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. Record review of facility provided 'NPIAP (National Pressure Injury Advisory Panel) Pressure Injury Stages' undated 2 pages, revealed a pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure of pressure in combination with shear. Stage 3 Pressure injury- Full-thickness skin loss: Full-thickness loss in skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss is an Unstageable Pressure injury. Unstageable Pressure Injury- Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer injury will be revealed. Resident #66: Record review of Resident #66's admission assessment dated [DATE] revealed coccyx wound and left medial ankle small scab and skin on bilateral lower extremities dry and scaly. There was no note related to the right heel area. Observation and interview on 02/08/23 at 01:13 PM Resident #66's buttocks area was noted with wound vac in place and occlusive dressing. Right foot dressing to heel is black in color dressing dated 2/8/23. Observation of Resident #66's left outer ankle with dressing dated 2/8/23. Resident #66 stated it (left outer ankle wound) seems bigger. Observation on 02/9/23 at 09:18 AM of Resident #66 seated up in wheelchair in her room, was going to wound clinic today for sacral wound care via transit. At around noon Resident #66 came back from the appointment. Resident #66 wanted to sit up in the wheelchair for noon meal. Record review of wound measurements and interview on 02/9/23 at 10:59 AM of handwritten timeline provided by the Director of Nursing (DON). The DON stated that the coccyx/sacral wound was upon admission [DATE], and the right Heel started on 12/30/2022 was facility acquired. Right medial malleolus facility acquired started on 2/7/2023. Left Calf started on 2/3/23 facility acquired. Record review of Resident #66's electronic medical record revealed that on 12/22/2022 the resident was sent to the hospital. Record review of hospital wound documentation noted on 12/25/2022 right heel pressure injury present upon admission as deep tissue injury. Record review of Resident #66's December 2022 Treatment Administration Record (TAR) revealed that bilateral heels treatment of cleanse with wound cleaner and pat dry every shift (12 hours) started on 12/5/2022. December 13th evening shift and December 15th morning shift were missing documentation of completion. In an interview on 02/10/23 at 8:10 AM of Resident #66 sitting up in wheelchair in room with breakfast tray on bedside table. Bilateral green puff boots on feet. Resident #66 stated that she got the right heel sore from being in the wheelchair and It is painful at times. Resident #66 stated that its black and her left lateral ankle also started at the facility. Resident #66 stated that she came in here to the facility with only the one sore on her butt area, but currently has more than just the one. Resident #66 stated she feels she's falling apart. Observation and interview on 02/10/23 at 12:57 PM with Registered Nurse (RN) M of Resident #66's right heel wound. Resident #66 lying in bed. RN M cut the right heel dressing down the top and lifted the right heel upward. The state surveyor observed blood tint purulent (puss) yellow drainage with odor, running drainage pouring out of heel area as heel was elevated onto the dressing. Right heel is open with drainage and odor. Observation on 02/10/23 01:01 PM of Resident #66's left lateral ankle with open area appears to be Stage III with bloody drainage noted. Observation and interview on 2/14/2023 at 1:25 PM of Resident #66 getting ready for a shower- revealed Certified nurse assistant (CNA) R and CNA S undressed resident. Observation of right heel dressing dated 2/13/2023 and left lateral ankle dressing dated 2/14/2023. Registered Nurse (RN) D entered room to disconnect sacral/coccyx wound vac device. The curtain to the bed was stuck on the far side of the bed close to the walk near the call light wall device. Every time the room door opens the resident is exposed to hallway. Observed the brief removed with BM noted in rectal area. Observed Hoyer transfer with Invacare Reliant 450 Hoyer lift with purple trimmed sling used. Resident was placed into the PVC shower chair. Resident #66 complained of butt/back pain. Resident #66 was covered and taken to A-wing shower room by CNA S. In the shower room came RN D, to remove dressings from lower extremities. Observation of right heel dressing of ABD pad with krelix wrap. Observed right heel with open wound with purulent (Puss) drainage noted, wound is open and skin black in color with noted drainage. RN D stated that a new order needs to be written to add the ABD pad to the dressing. Observation of Resident #66's left lateral ankle dressing removed, observed a 2 x 2 gauze pad with Silver AG (debride) packed into the wound bed. Observed left lateral wound was open with depth. Record review of Resident #66's electronic medical record revealed that the left lateral calf wound started on 2/3/2023 with a skin assessment as in-house acquired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake Numbers MI00127323, MI00127700, MI00127808, MI00133739, and MI00134334. Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure adequate supervision and implementation of planned, timely, and meaningful interventions to prevent falls and monitoring following falls for six residents (Resident #54, Resident #59, Resident #69, Resident #275, Resident #281, and Resident #282) of nine residents reviewed. This deficient practice resulted in lack of notification of responsible parties, lack of monitoring and assessment following falls, multiple residents experiencing repeated falls including falls with injury, Resident #282 suffering a laceration on their head and finger, Resident #275 falling eight times with various injuries including a right hip fracture, Resident # 54 falling 17 times with subsequent left and right hip fractures, Resident #59 suffering a hip fracture, Resident #281 suffering a laceration to their head requiring emergency medical treatment, unnecessary pain, and the likelihood for decline in overall health status. Findings include: Resident #54: Review of intake documentation revealed two Facility Reported Incidents (FRI) pertaining to Resident #54. One FRI report detailed Resident #54 had an unwitnessed fall in the facility on 3/9/22. This fall resulted in Resident #54 sustaining a left hip fracture. The second FRI report revealed Resident #54 had another unwitnessed fall in the facility on 3/22/22 and suffered a right hip fracture. Both fractures necessitated emergency medical treatment and surgical intervention. On 2/8/23 at 8:40 AM, Resident #54 was observed in the central activity room of the locked memory care unit. The Resident was sitting in a wheelchair with bilateral leg rests in place. The wheelchair was noted to have rollback locks brakes on the wheels (metal section which goes around the back of the wheels which stops the wheelchair from rolling backwards). When spoke to and asked basic questions, Resident #54 did not provide meaningful responses. On 2/8/23 at 9:44 AM, Resident #54 was sitting in the wheelchair in the same place/position as previous observation. An interview was conducted with Registered Nurse (RN) M on 2/8/23 at 9:58 AM. When queried regarding the rollback lock brakes on Resident #54's wheelchair, RN M revealed the facility calls them Memory brakes. RN M was asked the reason for the memory brakes and indicated they had been in place for a while due to Resident #54 falling in the facility. When asked, RN M revealed they were not aware of the Resident having any recent falls with injury but had multiple falls in the past. On 2/8/23 at 11:32 AM, Resident #54 was observed sitting in the same place in the Activity room in their wheelchair. The Resident's head was down, their eyes were closed, and an uneaten food tray was on the table in front of them. Record review revealed Resident #54 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), anxiety, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required extensive, one-to-two-person assistance to perform all Activities of Daily Living (ADL) with the exception of supervision for locomotion. The MDS detailed the Resident did not have any falls since readmitted to the facility. Review of Resident #54's MDS assessment dated [DATE] revealed the Resident required supervision to complete ADL including hygiene, toileting, bed mobility, and locomotion on the unit. The MDS assessment dated [DATE] revealed Resident #54 required extensive assistance to perform all ADL with the exception of eating. Review of documentation in Resident #54's Electronic Medical Record (EMR) and Incident and Accident (I & A) Reports revealed the following pertaining to falls: - 3/1/22 at 1:27 AM: Nurses Notes . 00:55 (12:55 AM) . Resident observed on floor in hallway sitting on buttocks leaning against door of room [ROOM NUMBER]. Nursing staff was alerted to position after the door had been heard slamming open into the metal closet doors in room [ROOM NUMBER]. Resident states was struck by another resident . - 3/1/22: I & A Report . Time: 00:55 (12:55 AM) . Location: Hallway . Observed on floor . Location of Injury: L (left) side of neck . Activity Before: Ambulation . Observed on floor in hallway sitting on buttocks leaned against door . states was struck by another resident (Resident #276) . Interventions Implemented: (Blank) . An undated and unsigned typed investigation summary report was provided in addition to the I and A report. The typed document indicated interviews were completed with Resident #54, Resident #276, and Licensed Practical Nurse (LPN) U. The interviews did not provide any additional, pertinent information regarding the fall. The typed document detailed, Investigation Summary: after interview and investigation, the facility was unable to substantiate that an incident occurred . no witnesses to the alleged incident . - 3/9/22 at 10:31 AM: Nurses Notes . Writer alerted by housekeeper that (Resident #54) was laying on the floor in their room. Writer arrived to resident's room and observed (Resident #54) laying on right side on bedroom floor with knees drawn up to almost fetal position. Resident was in bare feet . When asked what happened, resident stated, 'I was going to the bathroom and lost my balance'. (Resident #54) has an abrasion on their nose . also reporting pain in left hip and guarding left hip. There is a bruise present on left hip . unable to extend left leg r/t (related to) pain . resident transported to (local Hospital) for further evaluation. - 3/9/22: I & A Report . (No Time) . Location: Resident Room . Observed on floor (unwitnessed) . Type of Injury: Abrasion . Fracture? . Bruise . Location of Injury: Abrasion on nose; painful left hip . Activity Before: Ambulation . Observed Resident laying on floor on right side with knees drawn up . abrasion on the end of nose and reports pain to left hip which is guarding and is bruise . Transferred to (hospital) at 11:15 (AM) . Interventions Implemented: Keep w/c next to bed . Documentation of FRI submission and an undated and unsigned typed investigation summary report was also provided with the I and A form. Review of the summary documentation detailed, Reported Incident: On 3/9/22 at approximately 10:30 AM, (Resident #54) was observed on the floor of their bathroom by housekeeping staff . was unable to extend left and had a bruise noted to left hip. Resident was sent to (local hospital) for x-rays of the left hip which revealed a fracture. Resident Protection: (Resident #54) was assessed . noted to be guarding left hip. Nursing staff stayed with (Resident) until EMS arrived and took to (local hospital) where was noted to have sustained a hip fracture during the fall . transferred to (tertiary hospital) for orthopedic intervention . Interviews: (Resident #54) was interviewed on 3/9/22 at the time of the fall . stated 'was trying to go to the bathroom' and lost their balance . Registered Nurse (RN) M was interviewed on 3/9/22 just after the fall . stated that (Resident #54) will stay in bed until around lunch time . said they were heading down to pass (Resident #54) their medication when was alerted by (Housekeeper V) that (Resident #54) was on the floor . Housekeeper V was interviewed on 3/9/22 just after the fall . stated they had cleaned (Resident #54's) room and they were sleeping in bed. (Housekeeper V) left the room and proceeded to clean other rooms nearby. (Housekeeper V) heard a 'thump' sound and went into (Resident #54's) room and observed them on the floor . (CNA W) was interviewed on 3/9/22 just after the fall. (CNA W) stated (Resident #54) was in bed prior to the fall . stated (Resident #54) does not sleep with sock or pants on and had not been to the bathroom yet that day because they were still sleeping. This would explain why (Resident #54) was observed without socks or pants on at the time of the fall . Investigation Conclusion . (Resident #54) is staff supervision for ambulation and will ambulate around the secure unit most of the day . if gets tired, will use a wheelchair for locomotion but doesn't use it very often. (Resident #54) takes themselves to the bathroom independently and does not require staff assistance . was noted to not have pants on or have socks on feet at the time of the fall . has returned to the facility after undergoing orthopedic intervention for fractured hip . - 3/12/22 at 9:07 PM: Resident arrived via ambulance at 1900 (7:00 PM) from (Tertiary Hospital- hospital which provides specialized care and services) Resident is alert with confusion. C/o (complain of) pain to left hip/leg. Dressing to left hip/thigh dry and intact . Pleasant and cooperative with staff . - 3/13/22 at 5:27 PM: Nurses Notes . Observed (Resident #54) laying on the floor next to bed on right side . right arm was folded under head . left arm was at side. Both . legs were bent slightly at the knee. Writer and 2 aids lifted resident back into the bed . has an abrasion on right elbow, 2 small abrasions on right hand and 2 purple areas on right hand at 4th and 5th knuckle. When writer asked (Resident #54) what was trying to do, replied, I don't know. ROM (Range of Motion) WNL (Within Normal Limits) for right leg and bilat arms. Neurochecks initiated and WNL at this time . - 3/13/22: I & A Report . Time: 17:25 (5:25 PM) . Resident room . Observed on floor (unwitnessed) . Type of Injury: Abrasion . Bruise . Location of Injury: Right elbow; right hand abrasions X 2, bruises R hand . Observed resident laying on the floor next to bed on right side on ride side. Abrasion right elbow. Abrasions right hand, bruises X 2 right hand over 4th and 5th knuckles . Abrasions washed with NS. Left open to air . Interventions Implemented: Perimeter guard mattress . - 3/15/22 at 9:11 PM: Nurses Notes . Resident found on floor in front of w/c (wheelchair). No visible injuries . - 3/15/22: I & A Report . Time: 21:00 (9:00 PM) . Activity Room . Observed on floor (unwitnessed) . Activity Before: w/c . Resident fell forward out of w/c . - 3/16/22: I & A Report . Time: 06:30 (AM) . Resident room . Observed on floor (unwitnessed) . Activity Before: Bed . Resident found beside bed laying on right side in a puddle of liquid . Interventions Implemented: Unknown- Resident is confused and forgetful . Note: There were no progress notes related to this fall in Resident #54's EMR - 3/16/22 at 9:42 AM: Nurses Notes . Sent to (local hospital) for x-rays and increase pain r/t (related to) falls . - 3/17/22 at 12:50 AM: Nurses Notes . Resident found on floor beside bed, call light within reach, grippy sox's (sic) on . - 3/17/22: I & A Report . Time: 00:30 (12:30 AM) . Resident Room . Observed on floor (unwitnessed) . Activity before: Bed . Found on floor beside bed laying on R hip. No c/o pain . Interventions Implemented . Resident needs a bed alarm . - 3/17/22 at 12:00 PM: Resident At Risk . Reviewed Clinical Indicator: Resident is being reviewed by the IDT (Interdisciplinary Team) related to incidents this month. (Resident #54) had one on 3/9 and was sent out to the hospital and was readmitted back on 3/12 to the facility. Resident had an incident on 3/13/22 at 1725 (5:25 PM) in room . was lying on the floor next to bed as had rolled out of bed. On 3/15 at 2100 (9:00 PM), resident was in wheelchair when slid forward out of wheelchair. Resident had another incident on 3/16/22 at 0630 (AM) in resident room . was on floor besides bed laying on right side in liquid on the floor. Resident was incont (incontinent) of urine at this time. On 3/17/22 at 0030 (12:30 AM), Resident was on the floor beside bed laying on right side. Action Taken . No injuries were noted for 3/15, 3/16 and 3/17. On 3/13/22 was noted that resident had abrasion to right hand and (bruises) to right hand, was cleansed and treated . - 3/22/22 at 11:48 PM: Nurses Notes . Resident found on floor in Activity room, laying on right side. Rom full, except for left upper leg r/t hip surgery . suggested the use of a lap buddy (restraint device positioned in front of Resident in wheelchair to prevent standing) to remind them to stay seated . - 3/22/22: I & A Report . Time: 2145 (9:45 PM) . Location: Activity Room . Observed on floor (unobserved) . Activity Before: W/C . Resident found laying on right side about 3 (feet) from w/c) . Interventions Implemented: Can we try a lap buddy while in a w/c . - 3/23/22 at 9:30 AM: Nurses Notes . Writer has call out to (Health Care Provider [HCP]) r/t increasing pain in right hip post fall last night, blood in urine with Lovenox (medication administered by subcutaneous injection to prevent blood clots) therapy . - 3/23/22 at 1:35 PM: Nurses Notes . (Resident #54) is experiencing increased pain and decreased ROM (in) right leg s/p (status post) fall 3/22. X-rays have been ordered . - 3/23/22 at 5:00 PM: Nurses Notes . (HCP) notified r/t no results on right hip Xray. (HCP) looked at report and advised hip is fractured and to send resident out for further evaluation. - 3/23/22 at 5:05 PM: Nurses Notes . EMS (Emergency Medical Service) dispatched to transfer resident . At 17:26 (5:26 PM) administrator notified of hip fx (fracture) and that resident being transferred for further treatment. At 17:45 (5:45 PM) resident taken via EMS to ER for further evaluation/treatment . - 3/29/22 at 5:30 PM: Nursing Summary . Resident arrived via EMS at 1730 (5:30 PM) . resident verbalized pain . - 4/8/22 at 2:04 PM: Resident At Risk . Late Entry: Reviewed Clinical Indicator: Resident reviewed by IDT r/t fall that occurred on 3/22/22 at 2145 (9:45 PM) . was observed on lying on right side on the floor of the activity room. Resident stated . was trying to get up and walk. Action Taken . immediately assessed by nurse, with no injury noted. Resident was noted to have c/o pain and decreased ROM in right hip/leg the following day. X-rays showed an acute fracture. Resident sent to hospital for further evaluation. Upon return from hospital, Lap buddy applied to wheelchair. Consent for device obtained . - 4/9/22: I & A Report . Time: 01:10 (AM) . Resident Room . Observed on floor (unobserved) . Activity Before: Bed . Resident found laying on . side about 3 (feet) from bedside . Interventions . Interventions Implemented: Reminded Resident bilateral broken hips need to heal before walking . - 4/9/22 at 3:29 AM: Nurses Notes . Resident found on floor at 0110 (1:10 AM), laying on left side about 3 (feet) from bed . No complaints of pain. Assisted to w/c and placed in Activity room to be watched closer and lap buddy in place. - 4/9/22 at 3:34 AM: Nurses Notes . Resident found on floor in room [ROOM NUMBER] (other residents' room) in the bathroom sitting on bottom . Note: An I and A report for this fall was not provided by the facility. - 4/23/22 at 7:22 AM: Behavior Note . Resident frequently self-transferring throughout shift . was reminded many times that we do not wish for them to fall, but resident has short memory and does not recognize physical limitations. Pain was addressed with minimal effectiveness. (Resident #54) continues to repeat 'please help me, please help me' . - 4/25/22 at 5:00 AM: Nurses Notes . resident has been monitored this shift thus far for poor safety awareness. Attempting multiple times to self-transfer (unsuccessful) while in room and in activity room . - 4/28/220 at 4:46 AM: Nurses Notes . Resident repeatedly self-transferring this night and not asking for assistance. - 5/1/22: I & A Report . Time: 23:20 (11:20 PM) . Location: Resident Bathroom . Observed on floor (unwitnessed) . Activity Before: Bed . Resident found laying on back, beside bathroom door . Interventions Implemented: Observe for fatigue and unsteadiness and encourage rest periods prn (as needed) . - 5/1/22 at 11:42 PM: Nurses Notes . Resident found on floor in front of the bathroom. No visible signs of injuries . - 5/2/22 at 7:45 AM: Nurses Notes . (Resident #54) observed on floor in room [ROOM NUMBER] (not Resident's room) just outside bathroom door sitting on bottom with knees bent and both feet flat on the floor . was assisted to standing position by 2 (Certified Nursing Assistants [CNA]) and put back into w/c . denied any pain . Gripper socks in place. Resident stated, 'I can't remember when asked what was trying to do . will encourage (Resident) to stay in areas that staff are present so staff can assist when needed . - 5/2/22: I & A Report . Time: (Blank) . Location: room [ROOM NUMBER] (not Resident #54's room) . Observed on floor (unwitnessed) Activity Before: Self transferring in/out of bathroom . Interventions Implemented: Encourage to stay in areas where staff continuously present . Place signs on resident's bathroom to direct to their room . - 5/2/22 at 10:54 AM: Resident At Risk Reviewed Clinical Indicator: Resident is being reviewed by the IDT r/t incident that occurred on 5/1/22 at 2320 (11:20 PM). Resident was observed laying on back, beside bathroom door. Gripper socks on. Resident had previously been in bed . Resident does have poor safety awareness. Dx. of Dementia and resides in our Memory Care Unit. Resident frequently self-transfers. Intervention initiated: Resident will change to bed B which will put closer to the bathroom to improve successful self-transferring . - 5/3/22 at 2:01 AM: Nurses Notes . resident observed sitting on the floor between FOB (foot of bed) and room register holding onto the door handle of the BR (bathroom) door. Denies pain, or hitting head . did take off night gown, and only brief and gripper socks on. Brief was dry. No injuries observed or stated by resident. Stated, 'I was trying to go in there to go pee' indicating BR . - 5/3/22: I & A Report . Time: 02:00 (AM) . Location: Resident room . Observed on floor (unwitnessed) . Activity Before: Bed . Observed sitting on the floor between FOB and room register holding onto door handle of the BR (bathroom) door . Interventions Implemented: Bed side commode chair with bed against wall ? under the bed light (sic) . - 5/5/22 at 3:17 PM: Nurses Notes . Resident alert per usual. 0830 am Resident yelling 'Help Me, Help Me' from hallway Nurse at Medication Cart went to where the Noise was and observed Resident sitting halfway out of wheelchair. Nurse with assist of 2 repositioned Resident into wheelchair . noted Resident stated 'I was standing' . - 5/8/22 at 9:33 AM: Nurses Notes . (Resident #54) was observed sitting on the floor in the dining room stated was trying to transfer from/c into dining room chair . sitting on buttocks with feet flat on the floor and knees bent. Gripper socks in place . left hand was up on the dining room chair . right hand was on the floor . right hand has a skin tear at base of fingers between 1st and 2nd fingers. Skin tear washed with NS (Normal Saline), TAO (Triple Antibiotic Ointment) applied and covered area with Band-Aid . assisted to feet x 2 assist . - 5/8/22: I & A Report . Time: (Blank) . Location: Dining room . Observed on floor (unwitnessed) . Injury: Tissue/Skin Tear . Right hand at base of fingers between 1st and 2nd finger . Resident observed sitting on floor in dining room . skin tear right hand Interventions Implemented: Offering restroom more frequently; encourage to sit with staff in Activities/Dining Room . - 5/14/22: I & A Report . Time: 2200 (10:00 PM) . Location: Activity Room . Observed on floor (unwitnessed) . Activity Before: Sitting in activity room watching the ball game . Resident found sitting on floor next to w/c . Interventions Implemented: Resident removed lap buddy. Replaced lap budded and explained that its there to remind them they need help to stand up r/t 2 broken hips . - 5/14/22 at 11:28 PM: Nurses Notes . Resident found sitting upright on the floor. States was going home. States nothing hurts . assisted back into chair by 3 people, and was them taken to bed . - 5/15/22: I & A Report . Time: 2230 (10:30 PM) . Location: Dining Room . Observed on floor (unwitnessed) . Activity Before: W/C . Resident attempted to transfer from w/c Removed lap buddy and attempted to stand beside w/c. Sat on floor when couldn't bear own weight . Interventions Implemented: Remind resident to leave lap buddy on. Remind CNAs to replace lap buddy when off . - 5/15/22 at 11:38 PM: Nurses Notes . Resident was found on the floor again tonight with no injuries . Resident removed lap buddy again . - 6/14/22: I & A Report . Time: 2100 ((:00 PM) . Location: Hallway . Slid out of W/C . Requested Resident to sit back in w/c and they slid forward out of chair on all 4's .Interventions Implemented: Replace lap buddy in w/c . - 6/14/22 at 10:36 PM: Nurses Notes . Resident was in hallway by Nurses cart and put themselves on the floor. (Resident #54) bent forward and went to hands and knees. No injuries . Assisted back into chair by 3 people and continued to roam the halls . - 6/15/22 at 1:28 PM: Behavior Note . (Resident #54) will not leave lap buddy in place . continues to remove lap buddy when staff applies it to w/c . continues with poor safety awareness and requires frequent prompts to not try and stand or transfer independently . - 6/16/22 at 2:54 PM: Resident At Risk . Resident reviewed for incident that occurred on 6/14/22 . Resident observed bending forward in wheelchair and sliding out onto hands and knees. Staff unable to intervene quickly enough to prevent fall . - 7/17/22 at 1:24 AM: Nurses Notes . Observed on floor in Activities R (right) side position. W/C beside them. Head next to the courtyard door. Denies pain . Denies hitting head . Observed blood R wrist. Cleansed area with normal saline and applied x 3 steri-strips at skin tear area. Also observed area where a scab had been taken off and it too was bleeding. Simple dressing then was applied. There was bruising at base R hand #4 and #5 digit that, per staff, had been there previously . - 7/17/22: I & A Report . Time: (Blank) . Location: Activity Room . Observed on floor (unwitnessed) . Injury: Tissue/Skin Tear . Right wrist skin tear, scab removed at approx. same area . Observed on floor, right side position. W/C beside them. Head next to courtyard door. Observed blood at right wrist. Cleansed area with normal saline. 3 steri strips applied, covered with simple dressing . Interventions Implemented: Lap buddy check on TAR (Treatment Administration Record) and Kardex Q (every) S (shift) QD (every day). Nursing will monitor and document . - 1/23/22: I & A Report . Time: 1518 (3:18 PM) . Location: (Resident Room) . Resident was found sitting by side of the bed with back towards the bed with knees up. Resident tried to self-transfer. Wheelchair sitting to the right side. Upon arrival noted call light was on and resident said, 'I need help, are you my helper.' Resident incontinent of urine . Immediate Action Taken: Changed resident and provided with fluids . Predisposing Environmental Factors: Other (not specified) . Predisposing Physiological Factors: Recent Illness, Weakness/Fainted, Hypotensive (low blood pressure), Incontinent, Recent change in medication . Predisposing Situation Factors: During transfer . - 1/23/23 at 4:01 PM: Nurses Notes . Resident found sitting on the floor with back side to the bed. Wheelchair to right side. Resident tried to self-transfer and had (call) light on calling for assistance. Assisted to standing position with 2 assist. Denies any pain. No injuries noted. Resident incontinent of urine . The facility provided I and A Reports for Resident #54 did not contain detailed information regarding the falls, analysis to determine the cause, and/or initial/final interventions to prevent further falls. On 2/9/23 at 2:55 PM, Resident #54 was observed sitting in the Activity Room of the Memory Care unit of the facility in their wheelchair. Resident #54 was unable to provide meaningful responses when asked questions. An interview was completed with the Administrator on 2/10/23 at 3:30 PM. The Administrator was asked if there was any additional documentation pertaining the I and A's for the falls and replied, No. The Administrator indicated they provided all available information. Review of Resident #54's care plans revealed a care plan entitled, (Resident #54) is at risk for fall related injury and falls R/T: decreased safety awareness, weakness. Due to cognitive impairment, (Resident) does not recall they can't get up and ambulate independently . remains at risk for continued falls (Created: 7/7/21; Initiated: 4/6/22; Revised: 5/18/22). The care plan included the interventions: - Encourage the resident to wear appropriate footwear as needed (Created and Initiated: 7/7/21) - Keep the resident's environment as safe as possible with even floors free from spills and/or clutter; adequate lighting; call light within reach, commonly used items within reach, avoid repositioning furniture and keep the bed in the appropriate position (Created and Initiated: 7/7/21) - PT/OT evaluate and treat as ordered or PRN (as needed) (Created and Initiated: 7/7/21) - Provide resident with activities that minimize the potential for falls while providing diversion and distraction (Created and Initiated: 7/7/21; Revised: 7/8/21) - Put the resident 's call light within reach and encourage them to use it for assistance as needed (Created and Initiated: 7/7/21; Revised: 3/13/22) - Lay out resident's clothes for the day at the foot of bed (Created: 8/3/21; Initiated: 4/6/22; Revised: 12/16/22) - Offer assistance, encourage frequent rest periods or using w/c for mobility (Created 11/17/21; Initiated: 4/6/22; Revised: 12/16/22) - Keep wheelchair next to bed to remind to use it (Created: 3/9/22; Initiated: 4/6/22; Revised: 12/22/22) - Color contrasted press pad call light (Created: 3/17/22; Initiated and Revised: 1/24/23) - Perimeter guard mattress (Created: 3/13/22; Initiated: 4/6/22; Revised: 12/16/22) - Pommel (seat cushion with a raised, block area between the legs intended for positioning and posture support- not to restrict freedom of movement) cushion to wheelchair (Created: 3/17/22; Initiated: 4/6/22; Revised: 12/16/22) - Encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as: PT/OT as ordered (Created, Initiated, and Revised: 4/9/22) - Room changed to higher traffic area (Created and Initiated: 4/11/22; Revised: 12/16/22) - Observe for fatigue and/or unsteadiness and encourage rest periods as needed (Created and Initiated: 5/1/22) - Place sign on resident's bathroom door to direct back to their room (Created and Initiated: 5/2/22; Revised: 12/16/22) - Resident changed to bed B to make bed closer to the bathroom (Created and Initiated: 5/2/22; Revised: 12/16/22) - Bed placed against wall (Created and Initiated: 5/3/22; Revised:12/16/22) - Press pad alarm pigtailed to call light (Created: 5/3/22; Initiated: 4/6/22; Revised: 12/16/22) - Memory brakes to wheelchair (Created and Initiated: 5/9/22) - Review information on past falls and attempt to determine the root cause of the falls (Created and Initiated: 5/16/22) - Staff education to assist resident to room/bed or high traffic area after meals (Created and Initiated: 5/17/22; Revised: 12/16/22) - Place call bell in activity lounge to enable resident to call for assistance (Created and Initiated: 5/17/22; Revised: 12/16/22) - Dycem to w/c (Created and Initiated: 6/15/22; Revised: 12/16/22) - Tilt wheelchair seat back (Created and Initiated: 7/18/22) - A color contrasted call light was set up in residents' room (Created and Initiated: 1/26/23) The following discontinued interventions were also noted in the care plan: - RESOLVED: Staff will offer toileting every hour and encourage (Resident #54) to stay in activities room or dining room where staff present and can assist him. Fall occurred 5/8/22 (Created and Initiated: 5/8/22; Resolved (discontinued): 5/17/22) - RESOLVED: Resident removed lap buddy. I put lap buddy back on and explained that it is there to remind them that they shouldn't stand without help' (Created and Initiated: 5/15/22; Resolved: 5/17/22) - RESOLVED: Lap buddy to wheelchair (Created: 3/22/22; Initiated and Resolved: 12/21/22) Resident #54 had another care plan entitled, (Resident #54) has an ADL Self Care Performance Deficit and requires assistance with ADL's and mobility r/t: Confusion secondary to dementia, poor safety awareness, weakness, balance deficit, history of BIL (bilateral) hip fractures (Created: 7/8/21; Revised: 8/30/22). The care plan included the interventions: - May use standard wheelchair for locomotion (Created and Initiated: 7/8/21) - Bed Mobility: Resident requires extensive of one staff assist to reposition and turn in bed (Created: 7/9/21; Initiated: 4/5/22; Revised 8/4/22) - Transfer: Resident requires extensive of one staff assist for transfers (Created: 7/9/21; Initiated: 4/5/22; Revised: 8/4/22) - Dressing: Resident requires extensive assistance of one staff for dressing (Created: 7/9/21; Initiated: 4/5/22; Revised: 8/4/22) - Toilet Use: Resident requires extensive assistance of one staff to use toilet (Created: 7/9/21; Initiated: 4/5/22; Revised: 8/4/22) - Ambulation: Resident is able to ambulate with extensive assistance of one staff and a rolling wheeled walker (Created and Initiated: 4/5/22; Revised 8/4/22) Note: A walker was not observed in Resident #54's room and the Resident was not observed ambulating with staff and a walker at any time during the survey. The care plan also included one discontinued intervention which detailed, Resolved: Ambulation: Resident requires supervision of staff to ambulate (Created: 7/9/21; Initiated and Resolved: 4/5/22) On 2/10/23 at 7:56 AM, Resident #54 was observed in their room. The Resident was sitting in their wheelchair with a meal tray in front of them. The Resident's head was down, and their eyes were closed.