This citation pertains to Facility Reported Incident (FRI) 2611699.Based on observation, interview, and record review, the facility failed to identify and mitigate environmental hazards, ensure the appropriate use of assistive devices, and implement care planned interventions resulting in falls for three Residents (#24, #25, #26) of three residents reviewed for accident hazards and supervision. This deficient practice resulted in actual harm when Resident #24 sustained multiple lower leg fractures requiring surgical intervention. Findings include:Resident #24 (R24)Review of R24's Electronic Medical Record (EMR) revealed initial admission to the facility on 8/4/23 with diagnoses including vascular dementia, major depressive disorder, and personality disorder. Review of R24's most recent Minimum Data Set (MDS) assessment, dated 8/5/25, revealed a Brief Interview for Mental Status (BIMS) score of 10, indicative of moderate cognitive impairment. Further review of the MDS indicated R24 was independent in walking distances up to 150 feet and transferring from a bed to chair.Review of the facility incident summary submitted to the State Agency (SA) on 9/2/25 at 12:12 PM read, in part: [R24] was observed on the floor in the doorway of the bathroom today at 0835 [8:35 AM]. She was noted to have blood on her left ankle. It appeared that she has an open fracture of the left ankle. She was walking with CNA [certified nursing assistant] from the bathroom after having a shower . She was nude other than a towel around her. She lost her balance on the floor transition. She went backwards hitting her head on the door, she then went down to the floor. [R24] was not moved from the floor due to probable fracture. EMS [Emergency Medical Services] was called at approximately 0845 [8:45 AM] Fractures confirmed at 1127 [11:27 AM] per verbal report, acute comminuted displaced distal tibial diaphyseal fracture, acute comminuted displaced distal fibular fracture, acute proximal fibular fracture [three fractures of the lower two leg bones].Review of the Emergency Department (ED) Consultation Report on 9/2/25 read, in part: .patient seen in emergency department after having a slip and fall in the shower at her facility. she does have an open fracture with exposed tibia on exam. she will require surgical irrigation and debridement with surgical fixation of her tibia and possible fibula.On 9/17/25 at 9:28 AM, R24 was observed sitting at the edge of bed, eating breakfast in her room. Adhesive strips were noted over surgical wounds on both sides of R24's left ankle as well as under and inside R24's left knee. This surveyor entered R24's room and asked how she was feeling to which she replied, So-so. My ankle hurts. R24 was asked the reason for the surgical wounds, she replied, I fell. Three breaks [fractures]. When asked the location of the fall, R24 pointed at the private bathroom located near the foot of her bed and stated, I slipped. When asked if she was showering at the time of the fall, R4 replied, Yes. R24 asked if the floor was wet at the time of the fall to which she responded, Yes then indicated she no longer wished to pursue the conversation.On 9/17/25 a telephone interview was conducted with CNA A who verified she was assisting R24 in the shower at the time of R24's fall on 9/2/25. CNA A stated R24 was finished showering and was wrapped in a towel making her way toward the bedroom to get dressed. CNA A recalled as R24 stepped over the threshold separating the bathroom tile from the bedroom linoleum, her leg slipped out from behind her, and she proceeded to fall backward and hit her head on the doorframe. CNA A stated, At that point, I watched her bone pop out of her leg. When asked about her positioning at the time of the fall, CNA A stated she was walking backward into the bedroom as R24 was walking forward, just because I know the floor is so slippery. CNA A was asked if she attempted to use a shower chair, a gait belt, or non-skid footwear as ways to increase safety on the slippery floor. CNA A stated R24 is usually hard-headed and at times will not allow it. When asked if she attempted to utilize or offer a shower chair, gait belt, or footwear to R24, CNA A replied, No, I just assumed from prior experience that she would decline.Review of an Incident Note written by Registered Nurse (RN) G, dated 9/2/25 at 9:21 AM, read, in part: Called to room found [R24] lying on floor post shower. During shower CNA witnessed [R24] slip and fall, hit back of head on door, no grip socks in place was just getting out of shower feet floor still wet .Review of the Root Cause Review, signed by the Director of Nursing (DON) on 9/5/25 read, in part: Environmental/Equipment Factors: Floor wet from shower.Behavioral Factors (aggression, noncompliance, etc.): none.On 9/17/25 at 10:15 AM, an interview was conducted with RN G who verified she was the floor nurse on duty at the time of the fall on 9/2/25. RN G was called into R24's room and visualized her on the floor coming out of the bathroom with an open fracture to her left lower leg. RN G stated, The floor was wet. I was mad because she [R24] didn't have a gait belt on, and she can be really impulsive. or even use a shower chair. When I was a CNA, I always dried them [residents] off thoroughly on a shower chair or bench and put footwear on them and a towel on the floor. RN G recalled when she completed a head-to-toe assessment upon entering the room, R24's feet were damp.On 9/17/25 at 10:48 AM, an interview was conducted with CNA D regarding expectations for assisting residents to complete a safe shower. CNA D stated, .instead of trying to do a transfer in the bathroom to get to their room, I get them all dry, their feet dry, get them clothed, their socks on, their shoes on [in the shower room]. It doesn't take a rocket scientist to know you can't have an elderly person walking barefoot on a wet floor. Bare minimum for any resident, you shouldn't be walking anywhere, let alone on slippery floors, with bare feet.Review of a Nurses Note, dated 9/6/25 at 14:17 [2:17 PM] read, in part: .[R24 is now a 2-person full lift transfer. She ambulates with her wheelchair.Review of R24's Medication Administration Record (MAR) revealed the following order, initiated 9/4/25, upon re-admission to the facility: Oxycodone HCl Oral Tablet 5 MG (milligrams), give one table my mouth every 6 hours as needed for severe pain.R24 was administered oxycodone 26 times between 9/4/25 - 9/16/25 for pain management related to the left lower leg fractures and subsequent surgical intervention.Resident #25 (R25)Review of R25's EMR revealed initial admission to the facility 7/14/25 with diagnoses including bilateral primary osteoarthritis of the knees and abnormalities of gait and mobility. Review of R25's most recent MDS assessment, dated 7/22/25, revealed a BIMS score of 7, indicative of severe cognitive impairment.Review of R25's EMR revealed the following Incident Note written by RN G on 9/3/25 at 19:42 [7:42 PM]: Called to room by [CNA B] said that [R25] slipped and fell. When I arrived, resident was laying on the bathroom floor supine no footwear or gait belt or towel on floor. Shower chair in SE [southeast] corner of shower.Lower back and pelvic girdle and hip discomfort upon palpation. Called [physician] for V.O. [verbal order] to send to ER [emergency room].On 9/17/25 at 10:49 AM, an interview was conducted with CNA B who stated she overhead R25 had fallen in the shower while she was being assisted by CNA C. CNA B stated when she arrived at the scene of the fall, the water was running and only one wheel [out of four] was locked on the shower chair.On 9/17/25 at 2:46 PM, an interview was conducted with CNA C who confirmed she was assisting R25 at the time of her fall. CNA C explained she positioned R25's wheelchair near the shower chair to help her transfer. CNA C recalled, I tried to lock the shower chair, but I must have unlocked the wheels by mistake. I also forgot to put a towel on the ground. she didn't have any shoes on at the time. When CNA C was asked if the water was running at the time of the fall, she stated, Yes, it was pretty slippery. CNA C stated when R25 attempted to transfer, the shower chair slipped out for underneath her, causing her fall backward on the shower tile. CNA C confirmed R25 was not wearing a gait belt at the time of the fall.Review of R25's plan of care revealed the following intervention, initiated 8/21/25: Transferring: CGA [contact guard assist] with gait belt and a 2ww [2 wheeled walker] for stand-pivot transfers.Review of a Witness Statement written by CNA D on 9/3/25 at 6:30 PM read, in part: [CNA C] came out of her [R25's] room and told me she slid to the floor. I ran in the room and found [R25] sitting in pain on the floor, she told me the shower chair slid away. The wheels were NOT locked, the floor was wet, and shower running. She [R25] was naked with bare feet on a wet floor!On 9/17/25 at 2:01 PM, an interview was conducted with CNA D who verified she was the first one on the scene after CNA C notified her of the fall. CNA D recalled, When I got there, the water was running, her wheelchair was pushed out behind her, she [R25] was on the floor, the shower chair was in front of her with only one wheel locked. I was mortified.Review of the Root Cause Review, signed by the DON on 9/5/25 read, in part: Environmental/Equipment Factors: No gb [gait belt], no footwear, no locked wheels.Resident #26 (R26)Review of R26's EMR revealed initial admission to the facility 8/1/24 with diagnoses including Alzheimer's disease and repeated falls.Review of an Incident Summary submitted to the SA on 8/5/25 at 2:19 PM read, in part: [R26] was observed on the floor in her room at 0745 [7:45 AM] this am [morning]. [R26] was observed to have a moderate amount of dried blood around her head. [R26] was assisted into full lift sling and lifted to her bed. During the transfer to the bed [R26] began to complain of right hip pain. [R26] was taken to [acute care hospital] for evaluation. [R26] was noted to have a right femur fracture and L2 [lumbar] compression fracture at that time.Review of the Root Cause Review, signed by the Assistant Director of Nursing (ADON) on 8/5/25 read, in part: Interventions/Corrections Implemented: bed alarm to alert staff when [R26] is getting out of bed.Review of R26's plan of care revealed the following intervention, initiated 8/5/25: [R26] uses a bed alarm. Please ensure proper place of alarm pad while [R26] is in bed or in her recliner.Review of an Incident Note written on 9/9/25 at 14:56 [2:56 PM] by RN I read, in part: RN responded to call light pulled out of wall in resident room. Upon entry into room resident was noted to be sitting on the floor with legs straight out in front of her, back against bed frame, left hand on floor supporting her upper body. She was sitting on her floor mat with grippy socks on, CNA was with her. Appears to have slid out of bed. Bed alarm was in place, however, was not on at time of fall.On 9/17/25 at 12:11 PM, an interview was conducted with CNA E who verified she first responded to R26's fall on 9/9/25. CNA E stated she was assisting with feeding in the dining room was she noticed R26's call light was going off. When she went to investigate, she found R26 on the floor with the pancake alarm at the foot of the bed. CNA E stated, When I got in there, I noticed that her [R26] bed alarm wasn't on. I think she coincidentally pulled the pancake alarm out of the wall on her way down. CNA E explained the bed alarms have a switch located on the side that allows them to be turned on or off. CNA E stated the CNA on the night shift who helped R26 to bed most likely forgot to turn it on. On 9/17/25 at 3:23 PM, an interview was conducted with the DON regarding recent falls at the facility. The DON stated it is expected all care planned interventions are in place. On 9/17/24 at 3:34 PM, an interview was conducted with the Nursing Home Administrator (NHA) and DON who understood the concerns related to the falls. Review of the facility policy, titled, Accidents and Supervision, reviewed 8/14/23, read, in part: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00135277. Based on interview and record review, the facility failed to provide appropriate behavioral health services for the expression of suicidal ideation for one Resident (#202) of three Residents reviewed for behavioral health. This deficient practice resulted in actual harm when Resident #202 intentionally overdosed on ibuprofen, resulting in the Resident's hospitalization with subsequent unresponsiveness requiring fluid resuscitation. Findings include: Resident #202 was admitted to the facility on [DATE]. A review of Resident #202's most recent, complete Minimum Data Set (MDS) assessment, dated [DATE] revealed diagnoses including dementia, anxiety disorder and bipolar disorder (disorder characterized by extreme alterations in mood from manic to severe depression). Further review of the MDS assessment revealed Resident #202 was independent for walking and transfers and required set up help only for dressing, eating and toilet use. Resident #202 scored 15 out of 15 on the Brief Interview for Mental Status, indicating she was cognitively intact. A review of Section D - Resident Mood Interview (PHQ-9), revealed Resident #202 reported feeling down, depressed or hopeless 7 to 11 days and reported having a poor appetite or overeating 12-14 days of the 14-day look back period. A review of Resident #202's hospital Emergency Department Report, dated [DATE] at 4:35 p.m., revealed the following: EMS [emergency medical services] apparently was called due to profound slurred speech and acute onset of altered mentation at 10 AM [10:00 a.m.] . patient is minimally following commands and per EMS is [sic] stopped responding with verbal stimuli in route . Assessment/Plan: Acute encephalopathy [altered brain function] . Further review of Resident #202's hospital documentation revealed the Resident's condition continued to worsen after hospitalization. A hospitalist note, dated [DATE] at 5:44 a.m., revealed the following: Contacted by nurse for patient being hypotensive and more lethargic. Normal saline 1L [one liter] bolus ordered followed with maintenance IV [intravenous] fluids at 125 cc/h, repeated labs showed worsening kidney function . by the end of my shift patient was waking up and becoming more alert, stated that she took 2 bottles of ibuprofen, intentional suicidal attempt, patient placed on suicide precautions . Focus Notes - Last 24 hrs [hours]: [DATE] 04:45 [4:45 a.m.] Patient unresponsive to sternal rub at shift change, day shift reports patient mentation waxes and wanes. Blood pressure soft. Provider paged to room to assess. 1 liter bolus given . [DATE] 05:53 [5:53 a.m.] Patient awake and verbalizing desire to end her life. Patient acknowledges taking two bottles of ibuprofen with the intent of ending her life prior to hospital admission . A review of Resident #202's Hospitalist Progress Note, dated [DATE] at 4:00 p.m., revealed the following: Assessment/Plan . 1. Acute encephalopathy suspect primarily [secondary to] NSAID [non-steroidal anti-inflammatory drug] overdose . 2. Intentional overdose of nonsteroidal anti-inflammatory drug (NSAID) as suicide attempt - after being admitted and mentation started to improve, pt [patient] woke and stated she took 2 bottles of ibuprofen as a suicide attempt. [Facility] confirmed with a receipt in her room of 2 ibuprofen bottles 200mg [milligram] tablets #100. They only found one empty bottle, however [patient] reported taking two. So she would have consumed 20,000 - 40,000mg of ibuprofen on 1/25 [[DATE]] at some point. [discussed with] poison control, reviewed current lab trends and clinical status . They noted that severe effects often occurs when doses of >400mg/kg [more than 400 milligrams per kilogram of body weight] are ingested, which was her case, and effects of acute encephalopathy would likely begin 6-8hr [six to eight hours] after ingestions, which seems consistent with the acuity of her encephalopathy onset . Drug screen reviewed: positive for ibuprofen . Psychiatric Issues depression, bipolar disorder no longer suspected, suspected personality disorder, PTSD [post-traumatic stress disorder] .3. Acute kidney injury suspect in setting of NSAID overdose, baseline Cr [creatinine: chemical indicative of how well the kidneys are filtering waste from the blood] 0.9 [mg/dL], peak at 1.8, now down to 1.3 . It was noted the hospital reference for normal creatinine levels were 0.6 mg/dL (milligrams per deciliter) - 1.1 mg/dL. A review of a hospital Suicide Severity Screening, dated [DATE] at 5:49 a.m., revealed Resident #22 was assessed to be a high risk for suicide. Further review revealed when asked In the past month have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?, Resident #202 responded, yes. A review of Resident #202's Psychiatric Progress Note, dated [DATE] at 4:37 p.m., revealed the following: . When asked why she wanted to kill herself, she stated, hell. When asked if she means that life feels like hell, she says, yes. When asked if she feels like living or dying today, she says, if [Resident #300] would just love me again . A review of Resident #202's facility electronic medical record (EMR) revealed the Resident was transferred to the emergency department for evaluation on [DATE]. Further review of the EMR revealed the following: [DATE] at 9:43 p.m. - Nurses Notes. 2000 [8:00 p.m.] nauseated with multiple episodes of vomiting. Weak, extensive assistance required transferring from toilet to bed. LOC [level of consciousness] altered, responds to verbal stimuli but very slowly . [DATE] at 10:15 a.m. - Behavior Note. Before breakfast this AM [morning] resident was quite lethargic. After removing blankets discovered she was incontinent of both bladder and bowel. This is unusual for her . [physician] came on unit and decided it would be best to send her out [to emergency department] for evaluation. Changes are too dramatic. [DATE] at 11:31 a.m. - . called [hospital, name redacted] and spoke with nurse caring for [Resident #202] to let them know we did find an empty 2 pack of ibuprofen., 100 caplets of 200 mg each, in her room hidden in a drawer. The bottles themselves have not been located. A review of Resident #202's physician progress note for the date of service [DATE], signed on [DATE] at 6:00 p.m., revealed the following: Chief Complaint/Nature of Presenting Problem: Emesis. History of Present Illness: . seen today for reports of multiple bouts of emesis . She has had significant change in level of consciousness. She is only oriented to person, not to place, time or situation . She does report being saddened by having separated rooms from her previous roommate . Assessment: . Decreased level of consciousness . escalation of care due to acute change . Major depressive disorder with single episode . feels her moods have slightly worsened. Recently had somewhat aggressive behavior . A review of an undated facility investigation report revealed Resident #202 and Resident #300 were married in a civil ceremony while residing at the facility. After the ceremony, the Residents resided in a double room together, until Resident #300's condition deteriorated, and family requested he be moved to a private room for comfort. According to a facility Witness Statement, signed by Social Services Designee (Staff) S and Registered Nurse (RN) T, dated [DATE], Resident #300 was moved to a private room on [DATE]. Further review of the Witness Statement, revealed the following: . went to speak to [Resident #300] about the room change. [Resident #202] was in room sleeping during the conversation but awoke when she heard us speaking. Please see attached progress note for more details . A review of the attached progress note, signed by Certified Nurse Aide (CNA) U and dated [DATE] at 2:50 a.m., revealed the following: Behavior Note. Late Entry. Resident was very upset about [Resident #300] getting moved to his own room. I was trying to comfort the resident and she made the statements she was going to kill herself [and] she wishes she could just die [and Resident #300] promised that they would die together. Resident was also asked if she knew what happened to [Resident #300's] necklace that he always wears, she responded with I know exactly where it is but I'm not telling. Resident did end up telling where it was. She stated that if she saw if on [Resident #300] she would rip it off him. During an interview on [DATE] at 12:05 p.m., CNA U confirmed the statements she recorded in the Behavior Note, on [DATE] at 2:50 a.m., to be true and accurate. CNA U reported she immediately notified Staff S and the nurse on duty at that time, of Resident #202's suicidal ideation and expressions of self-harm. CNA U stated she could not remember the exact time Resident #202 expressed the desire to die or the name of the nurse on duty whom she alerted to Resident #202's behavior. CNA U reported Resident #202 was upset about the CNA looking for Resident #300's necklace with his previous, deceased spouse's wedding band threaded on it. CNA U stated no room check for harmful objects or substances was conducted during her shift on [DATE]. CNA U stated after alerting nursing and Staff S of Resident #202's comments, she went about caring for other residents. Further review of Resident #202's EMR for [DATE], including all progress notes, assessments, physician notes and Behavioral Care Solutions (BCS) documentation revealed no follow-up to Resident #202's comments regarding the expression of suicidal ideation on [DATE]. A review of physician orders and point of care documentation revealed no initiation of suicide precautions, including a search of the Resident's room, prior to [DATE]. On [DATE] at 12:12 p.m., the Director of Nursing (DON) reported RN V cared for Resident #202 during the 7:00 a.m. through 7:00 p.m. shift on [DATE]. An attempt to reached RN V by telephone was made on [DATE] at 12:15 p.m. No return call was received prior to the end of the survey on [DATE]. During an interview on [DATE] at 11:20 a.m., Resident #202 confirmed she had intentionally taken two full bottles of ibuprofen prior to her transfer to the emergency department on [DATE]. Resident #202 could not recall how many pills but stated both bottles were full and she threw the empty bottles in her bathroom trash. Resident #202 stated she had counseling while hospitalized and now feels better. She stated Resident #300 passed away while she was hospitalized , and she never had the chance to say goodbye. Resident #202 reported she took the ibuprofen because she was in need of attention and was lonely. During an interview on [DATE] at 12:23 p.m., Staff S reported being unaware of Resident #202's verbal expression of suicidal ideation on [DATE]. Staff S stated she was not notified of Resident #202 commenting she wishes she could just die or that she was going to kill herself. Staff S confirmed no referral for evaluation of suicidal ideation by Behavioral Health or the physician was initiated prior to the Resident presenting with decreased level of consciousness on [DATE]. Further review of Resident #202's EMR revealed the following: [DATE] at 3:52 p.m. - Late Entry: RN [V'] and [Staff S] social services went to speak with [Resident #300]. [Resident #202] was in the room sleeping in the bed next to [Resident #300] . agreed with being in his own room, as he feels it will help him feel better. [Resident #202] was very upset . RN and [Staff S] assisted [Resident #202] out of the room to speak with her. [Resident #202] continued to state you are taking everything from me. tried to explain that the move was about [Resident #300] and his care and not about her. [Resident #202] continued to state that is was about her. [Staff S] and this RN [V] made multiple attempts to explain to [Resident #202] but she was not understanding. [Resident #300's] necklace [with deceased spouse's ring] was placed on his neck. Orders placed to check this every 2 hrs [hours] as [Resident #202] stated she would take it off him. [DATE] at 2:54 p.m. - [Resident #202] ambulated to inside of nurses' station to confront a staff member while she was giving report. [Resident #202] stated that she thought you were my friend. Staff member stated she was unaware of why resident was upset. Staff stated that she was just attempting to give report. [Resident #202] began to cry and became agitated and requested to speak to [Nursing Home Administrator, NHA]. [DATE] at 10:54 a.m. - Care plan and CNA tasks updated to reflect q 15 minute [every 15 minute] checks for her location. [Resident #202] is disruptive with care with her significant other [Resident #300] and must be accompanied when she visits with him. During an interview on [DATE] at approximately 11:15 a.m., the DON confirmed Resident #202 was not assessed for suicidal ideation or risk after the Resident made suicidal comments to CNA U on [DATE] or prior to her hospitalization on [DATE]. The DON stated it appeared the focus was on the care and comfort of Resident #300 and Resident #202's mental status was not sufficiently taken into account. The DON reported when a Resident expresses thought of self-harm, a complete assessment should be conducted by nursing staff, the physician notified and increased safety monitoring immediately implemented. A review of the facility policy titled Suicide Threats, dated [DATE], revealed the following: Resident suicide threats shall be taken seriously and addressed appropriately. Staff shall report any resident threats of suicide immediately to the Charge Nurse. The Charge Nurse shall immediately assess the situation and shall notify the Director of Nursing or Administrator of such threats. A staff member shall remain with the resident until the Charge Nurse arrives to evaluate the resident. After assessing the resident in more detail, the Charge Nurse shall notify the resident's attending physician and responsible party and shall seek further direction from the physician. Appropriate nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior. The resident surround should be searched for any objects that could be using in harming self. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. If the resident remains in the facility staff will monitor the resident's mood and behavior and update care plans accordingly until a physician has determined that a risk of suicide does not appear to be present.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00133945. Based on interview and record review, the facility failed to protect Resident (#100's) right to be free from neglect when the facility failed to ensure staff competency in following resident care plans and in the use of a mechanical lift during transfers. This deficient practice resulted in actual harm when Resident #100 sustained a fractured right femur, subsequent surgical repair and hospitalization. Findings include: A review of Resident #100's Minimum Data Set (MDS) assessment, dated [DATE], revealed she was admitted to the facility on [DATE] and had diagnoses including dementia, stroke, hearing loss and reduced mobility. A review of the MDS assessment Section C- Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) was not completed due to Resident #100 being rarely/never understood. The Staff Assessment for Mental Status revealed Resident #100 had impaired long and short-term memory and moderately impaired decision making. Further review of the MDS assessment revealed Resident #100 was assessed as having Functional Limitation in Range of Motion, in both lower extremities and required two-person, physical assistance for toilet use (how resident uses the toilet room . transfers on/off toilet, cleanses self after elimination . and adjust clothes .). A review of Resident #100's Electronic Medical Record (EMR), accessed on [DATE] at 10:39 a.m., revealed the following: [DATE] 01:06 (1:06 a.m.) Nurses Notes . Notified by CNA (Certified Nurse Aide H) at approximately 2145 (9:45 p.m.) this nurse was needed in rm (room), entered rm and found (Resident #100) laying on her bed and her CNA (CNA F) standing nearby, (CNA F) explained that (Resident #100) was slipping out of the standing (sit to stand lift used to assist resident to rise to a standing position on the lift base for transfer to another surface) lift sling and she was hanging there, so (CNA F) went outside the rm and yelled for help, (CNA G) came into the rm to help. (CNA G) lifted her (Resident #100's) upper half and (CNA F) took her (Resident #100's) legs and they put her into bed. During the transfer or while in the sling, (Resident #100) sustained a small skin tear to her right forearm. Once in bed (Resident #100) c/o (complained of) right leg pain. It hurt when her leg was moved. Per both (CNA F) and (CNA G) (Resident #100) did not fall or hit her leg during the transfer. Leg was examined and found to have a scratch down her right inner thigh. There was also a bruise behind her right calf. The age of the bruise is unknown to nurse . [DATE] 12:50 (12:50 p.m.) Nurses Notes . As the day went on (Resident #100) began to complain of increased pain . [DATE] 13:59 (1:59 p.m.) Nurses Notes . Assessment of right lower extremity revealed swollen right thigh . Palpation of the right thigh (Resident #100) complains of pain. Any movement of the thigh causes discomfort. Right inner thigh is larger than the other. Call to on call (physician) at 1500 (3:00 p.m.) . gave approval to send (Resident #100) for assessment . Director of Nursing (DON) informed via phone call at 1504 (3:04 p.m.) instructs to send via EMS (Emergency Medical Services) . A review of Resident #100's hospital History and Physical, dated [DATE] at 20:33 (8:33 p.m.), revealed the following, in part: Pt (patient) arrives via EMS from (facility) post fall last night. EMS (states) (facility) staff (state) it was a bad transfer . Assessment/Plan . 2. Femur fracture, right: Xray: Obliquely oriented fracture (angled fracture going completely through the bone, most often cause by fall or trauma) or spiral fracture (fracture winds around length of bone, twisting injury) through the distal diaphysis (bone shaft) of the right femur (thigh bone) . A review of Resident #100's Radiology Report, dated [DATE] at 5:55 p.m., revealed the following, in part: Findings . Obliquely oriented displaced (pieces of bone moved to the point a gap formed around the fracture) fracture of the distal right femoral diaphysis with rotational component. Medial displacement and rotation of the distal fracture fragment noted mild overlap of fracture fragments . A review of Resident #100's Orthopedic Consultation, dated [DATE] at 7:42 a.m., revealed the following, in part: Patient has been placed on the OR (Operating Room) schedule with the offer for surgical stabilization to assist with pain management and stabilization for transfers. This would be in the form of open reduction internal fixation of the femoral shaft . Diagnostic Results: Impression . There is oblique right mid to distal femur fracture . there is over 10 cm (centimeters) of shortening/overriding bone in these images. A review of an incident report dated [DATE] at 9:45 p.m., revealed the following: Witnessed Fall . (Resident #100) . Level of Consciousness: Alert. Mobility: Wheelchair bound. Mental Status: Oriented to Person. Predisposing Situation Factors: During transfer. It was noted there were no Predisposing Environmental Factors, or Predisposing Physiological Factors, marked regarding Resident #100's fall. A review of the investigation documents for (Resident #100) fall with fracture on [DATE], provided by the DON, revealed the following: As reported by (RN I) in her incident note and in personal interview . At approximately 2145 (9:45 p.m.) on [DATE] (CNA F) was providing (bedtime) care for (Resident #100). She (CNA F) had taken her to the bathroom in the sit to stand lift. Upon finishing she raised (Resident #100) up into a standing position with the sit to stand lift. Per an interview with (CNA F) the belt was snug, and the leg straps were on per instructions. (CNA F) stated that as she wheeled (Resident #100) out of the bathroom (Resident #100) let her legs go slack which caused her to almost slip out of the sling but due to the sling belt (Resident #100) was held up and did not fall to the floor . In both a personal interview and written statement by (CNA G) . it was learned (CNA G) was in the process of taking soiled linen to the hopper room when she heard (CNA F) call out for help. (CNA G) went in and saw (Resident #100) slipping out of the sling and that it was around her armpits. (CNA G) yelled for (CNA H) in case they needed another hand. Together, with (CNA G) controlling the lift, (CNA G) holding the sling/upper torso and (CNA F) taking (Resident #100's) legs they lifted her into bed. (CNA G) reports that (Resident #100) yelled out in pain and that (CNA G) thought the leg was turned. Further review of the facility investigation documents revealed the following: (Registered Nurse (RN) K)was the nurse on duty the next morning . mid-afternoon (RN K) noted through (Resident #100's) slacks that her right leg was swollen . (Resident #100) was having pain and the leg was shortened at that time . (RN K) notified the physician and sent (Resident #100) to the emergency room for evaluation. X-ray report revealed an obliquely oriented fracture or spiral fracture through the distal diaphysis of the right femur . (Resident #100) did undergo surgery at (acute care hospital) . (Resident #100) has been wheelchair bound for several years and has severe dementia . Her transfer status was to be done with 2 assists and sit to stand lift, however, (CNA F) stated she was unaware of this . The root cause of the fracture is undetermined. Theories are that it may have been a pathological fracture when she slid downward and that the leg straps held her calves in place putting pressure on the femur. There is also a thought that at the time it occurred it was not displaced but after sitting in a reclining position in the wheelchair the next morning . it became displaced and began to swell. A review of the interview statements included with the facility investigation documents revealed the following: Interview with (RN I) on [DATE]: (RN I) admits that (Resident #100) was having some pain but because (CNA F and CNA G) stated there was no fall and that (Resident #100) did not bump her leg on the lift she (RN I) did not do anything more. (RN I) did state that she observed a skin tear to the right inner thigh which she cleansed and dressed but did not see anything unusual about the appearance of (Resident #100's) leg . Interview with (CNA G) on [DATE]: When asked if the leg straps were intact, she could not recall . Interview with (CNA H) on [DATE]: When asked what she observed she stated that she saw (Resident #100) sitting on the floor beside the bed with the sling around her armpits. She did not know if the leg straps were on or not. She stated that (CNA G) picked her up by the upper torso and (CNA F) took her legs and lifted her up and into the bed. (CNA H) followed with the sit to stand lift which (Resident #100) was still attached to. (CNA H) said (Resident #100) complained of pain to the right leg and it appeared to her that it was turned inward. Interview with (CNA F) on [DATE]: (CNA F) stated that she had put the leg straps on the lift which was unreported and is policy. There is a handle on the back of the new slings for the sit to stand. (CNA G) lifted (Resident #100) with the handle and (CNA F) lifted by (Resident #100's) legs . we are a no lift facility . this was an improper transfer and (Resident #100) should have been lowered to the floor and a full lift used to put her into bed . It was also pointed out that the [NAME]/care plan stated that two staff should be with (Resident #100) when any type of lift is used . Further review of the facility investigation documents revealed the following: . some thoughts on what happened. The (right femur) fracture may have occurred when she began to slide out of the sling as her calves were still in the leg straps (fracture was mid-femur). Or did it happen when they picked her up by her legs and torso . A review of CNA F's undated, signed statement included we transferred (Resident #100) back to bed, (CNA H) noticed her right lower leg was turned toward her left leg . at this point I was concerned . (Resident #100) was in extreme pain. I was very concerned and returned to (Resident #100's) room approximately 15 (minutes) later, she was still in pain . (RN I) reassessed her and said she believed she was ok. A review of all accident and incident reports from [DATE] through [DATE] revealed on [DATE], Resident #100 fell when CNA F attempted to transfer the Resident, without assistance, using the sit to stand lift. Further review of the incident report titled Witnessed Fall, dated [DATE] at 10:05 p.m., revealed the following: The emergency call light went off in (Resident #100's room), followed (CNA M) . Entered room and found (Resident #100) sitting on her bottom on the floor with (CNA F), standing in back of (Resident #100) supporting her back and head. (Resident #100's) legs were still strapped to the new standing lift. (CNA F) stated I had to lower her to the floor because she was slipping out of the sling . Predisposing Environmental Factors: None. Predisposing Physiological Factors: Incontinent. Predisposing Situation Factors: Improper footwear. During transfer. Other Info: (CNA F) was transferring (Resident #100) in the new sit to stand lift and was getting her ready for bed. (Resident #100) was incontinent and barefoot. Further review revealed Immediate Action Taken: (CNA M) unfastened (Resident #100's) legs from the lift straps and lowered her legs to the floor . The signed investigation document attached to the fall reported included An intervention on the care plan was to have 2 staff present with the sit to stand . It was noted in review, Resident #100's legs were still strapped to the sit to stand lift upon staff entering the room and finding Resident #100 on the floor with CNA F. A review of Resident #100's care plan revealed the following plans were initiated, and active, prior to the Resident's fall on [DATE]: Focus: (Resident #100) is high risk for falls (related to) confusion, deconditioning, gait/balance problems. Date Initiated [DATE]. Goal: (Resident #100) will be free of minor injury through the review date. (Resident #100) will not sustain serious injury through review date. Date Initiated: [DATE]. Interventions: (Resident #100) to be sit to stand lift for transfers, downgrade PRN (as needed) to full lift when not actively assisting with BLE (bilateral lower extremities). Date Initiated: [DATE]. Two staff members to operate new lifts until everyone is comfortable. Date Initiated: [DATE]. Focus: (Resident #100 has an ADL (Activities of Daily Living) self-care performance deficit (related to) dementia. Date Initiated: [DATE]. Goal: (Resident #100) will maintain current level of function in all ADLs through the review date. Date Initiated: [DATE]. Interventions: Transfer - (Resident #100) requires extensive assistance by 2 staff to move between surfaces as necessary. Date Initiated: [DATE]. Focus: (Resident #100) Transfers. Date Initiated: [DATE]. Goal: (Resident #100 will maintain level of function through review date. Date Initiated: [DATE]. Interventions: (Resident #100) is a sit to stand lift with a medium sling for transfers. May downgrade to full lift when needed. Date Initiated: [DATE]. Two staff when sit to stand used. Date Initiated: [DATE]. During an interview on [DATE] at 1:00 p.m., the facility Training Coordinator, Licensed Practical Nurse (LPN) B reported after Resident #100's fall on [DATE], CNA F reported she did not feel comfortable using the sit to stand lifts. LPN B was asked what the procedure was for assessing staff competencies following accidents, including resident injuries during transfers. LPN B stated after a fall with injury the Interdisciplinary Team (IDT) review the incident reports and determine what they believe to be the cause of the fall and review the care plan for appropriateness. LPN B add that if failure to follow facility policies and care plans were believed to have contributed to the fall, staff would be re-educated, and competency assessed. LPN B stated CNA F was not retrained on lift use or competency assessed after the fall from the lift on [DATE] and before Resident #100 fell from the lift on [DATE]. LPN B reported after Resident #100's fall on [DATE], CNA F was scheduled to be re-trained and have competency assessed on using the sit to stand lifts but left employment with the facility prior to completion. LPN B stated all staff were trained in [DATE], when the facility received new sit to stand lifts, were instructed to use two-person assistance until comfortable using the lift and were to report if more training was needed. LPN B reported all staff are trained on the facility's no lift policy and should not physically lift a fallen resident from the floor, but instead get assistance and use a total, mechanical lift to transfer the resident for safety. On [DATE] at 2:00 p.m., LPN B was asked how someone could fall out of the sling on the sit to stand lift. LPN B stated she is unsure how Resident #100 could have slipped out of the sling, if the sling was appropriately secured to the Resident and the lift. She added that some residents may become weak during transfers, that is why Resident #100 was care planned for two-person assistance using the lift. LPN B reported after Resident #100's fall on [DATE], CNA F was instructed not to perform any lift transfers until she could be retrained and reassessed for competency. During an interview on [DATE] at 3:34 p.m., the DON reported she was aware Resident #100 had a previous fall on [DATE], while being transferred by CNA F using the sit to stand lift. The DON acknowledged CNA F did not follow Resident #100's care plan and transferred the Resident with the sit to stand lift without the presence or assistance of another staff member. When asked if CNA F was reassessed for competency using the new sit to stand lifts after the Resident's fall on [DATE], the DON stated she would expect the CNA to be assessed using the lift to determine teaching needs and safety using the lift. The DON reported she could not provide documentation of CNA F being reassessed for safety and competency in transferring residents using the sit to stand lift following the fall on [DATE]. The DON stated on [DATE], a nurse spoke with CNA F regarding the necessity of following Resident #100's care plan and not transferring the Resident alone. The DON confirmed CNA F transferred Resident #100 using the sit to stand lift on [DATE], without assistance and the Resident fell during the transfer. The DON also confirmed Resident #100 sustained a fracture during the transfer which required surgical repair and hospitalization. When asked if CNA F was aware of the possibility of the Resident falling if transferred with the sit to stand, without two-person assistance, the DON acknowledged CNA F should have been aware of the risk due to Resident #100's prior fall on [DATE]. The DON confirmed CNA F was no longer employed by the facility. A review of CNA F's Employee Disciplinary Notification, dated [DATE], revealed the following, in part: Major Infractions: Violation of Safety Rules. Failure to Follow Instructions/Policy/Procedures. Supervisor Remarks: You did not check the [NAME] (care plan) for the residents transfer status and inappropriately transferred the resident. The notification was signed by CNA F on [DATE]. On [DATE] at 11:26 a.m., an attempt was made to reach CNA F by telephone to confirm the CNA's written statement. No return call was received. On [DATE] at 11:36 a.m., an attempt was made to reach CNA G by telephone to confirm the CNA's written statements. No return call was received. CNA G was no longer employed by the facility at the time of the survey. On [DATE] at 11:42 a.m., an attempt was made to reach CNA H by telephone to confirm the CNA's written statement. No return call was received. CNA H was no longer employed by the facility at the time of the survey. Resident #100 returned to the facility on [DATE] at 4:45 p.m., following hospitalization for surgical repair of her right femur fracture. Further review of the EMR revealed Resident #100 expired at the facility on [DATE] at 9:16 p.m. A review of the facility policy titled Abuse, Neglect and Exploitation, dated [DATE], revealed the following, in part: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation . Definitions: Neglect means failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Prevention of Abuse, Neglect and Exploitation: B. Identifying, correcting and intervening in situations in which abuse, neglect . is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift . and to assure that the staff assigned have knowledge of the individual resident's care needs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00133945. Based on interview and record review, the facility failed to ensure appropriate assistance with bed mobility according to the resident care plan for one Resident (#102) of three residents reviewed for accidents. This deficient practice resulted in actual harm when Resident #102 fell from bed and sustained a head laceration requiring emergent transfer to the emergency department and sutures. Findings include: A review of Resident #102's Minimum Data Set (MDS) assessment, dated 12/08/2022, revealed the Resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety, muscle weakness and chronic pain. Resident #102 had severe, cognitive impairment. A review of a facility incident report, dated 12/9/2022 at 6:30 a.m., revealed the following, in part: (Resident #102). Incident Location: Resident's room. Incident Description: This nurse called to the resident's room stating the resident had rolled out of bed to the floor while the CNA (Certified Nurse Aide) was cleaning and changing the resident. The resident was observed on the floor next to her bed with an approximate 5 cm (centimeter) laceration on her left forehead. The laceration was bleeding. Pressure with a 4 x 4 gauze was given to the lacerated area until bleeding stopped. Ambulance was called and resident was transferred to (acute care hospital) for evaluation . Other Info: Resident was being cared for by her assigned CNA, being changed and cleaned after incontinence of bowel when resident rolled out of bed. A review of Resident #102's Emergency Department Report, dated 12/09/2022 at 7:33 a.m., revealed the following, in part: Physical Exam: Skin: Small superficial skin tear on left elbow region 1 cm in size . Similar 1 cm superficial laceration on left lateral hip. There is also a 3 cm laceration to the left eyebrow region gaping 1.6 cm . There are some exposed nerves that appear to be fully intact . Medical Decision Making: Patient is a full assist and as she was being transferred this morning apparently fell hitting her head causing a laceration to the left eyebrow region. This was witnessed by staff . she also sustained small skin tears to the left elbow and left hip region . Patient's forehead laceration is anesthetized and repaired (sutured) . A review of Resident #102's Electronic Medical Record (EMR) revealed the following: 12/9/2022 11:38 (a.m.). Nurses Notes: (Resident @102) returned at 0946 (9:46 a.m.) form (acute care hospital) . 9 sutures above left eyebrow . A review of a (Facility) Witness Statement, signed and dated by CNA C on 12/09/2022, revealed the following: I (CNA C) was changing (Resident #102) in her bed. I started off on the side away from the wall getting her cleaned and dressed . I moved her bed and got on the side next to the wall. While cleaning her . and holding her, (Resident #102) rolled off her bed. (Resident #102) hit her head, forehead, blood started coming out going everywhere . During a telephone interview on 2/10/2023 at 2:48 p.m., CNA C confirmed her written statement, dated 12/9/2022, to be true and accurate. CNA C added Resident #100 was hard to roll in bed. CNA C stated she unlocked the bed and moved the bed away from the wall to roll the Resident on the Resident's right side. When she rolled the Resident over, CNA C reported the Resident just kept rolling, and fell off the opposite side of the bed from where the CNA was standing. When asked if the Resident's care plan called for a two-person assistance with bed mobility, CNA C stated she did not look at the care plan, adding it did not occur to me. CNA C reported she had worked at the facility for five years and this incident never occurred before. A review of Resident #102's care plan revealed the following, in part: ADLs: (Resident #102) has an ADL (Activities of Daily Living) self-care deficit performance deficit (related to) dementia . Bed Mobility: [NAME] required extensive assistance by 2 staff to turn and reposition in bed as necessary. A review of the care plan revision timeline revealed the following: Bed Mobility: (Resident #102) requires extensive assistance by 1 staff to turn and reposition in bed (every) 2 hours and as necessary, Revision Date: 6/21/2022. Bed Mobility: (Resident #102) requires extensive assistance by 2 staff to turn and reposition in bed as necessary, Revision Date: 9/20/2022. Bed Mobility: (Resident #102) requires extensive assistance by 2 staff to turn and reposition in bed as necessary, Revision Date: 11/21/2022. During an interview on 2/10/2022 at 3:34 p.m., the Director of Nursing (DON) stated care plans should be checked by staff at the beginning of each shift, prior to caring for the residents, to determine if any changes have been made. The DON reported she was aware of the incident involving Resident #102 rolling off the bed while being repositioned by CNA C. When asked if the CNA C should have used another staff to assist in turning Resident #102, the DON stated she was unsure what level of assistance the Resident was care planned for at that time. The DON confirmed, staff should be following resident care plans to ensure safe care. A review of the facility policy titled Accident and Supervision, revealed the following, in part: Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 3. Implementing interventions to reduce hazard(s) and risk(s) . Definitions: Accident refers to any unexpected or unintentional incident, which results in injury or illness to a resident . Implementation of Interventions - using specific interventions to try to reduce a resident's risks form hazards in the environment. The process includes: . Documenting interventions (e.g., plans of action developed by the Quality Assurance Committee or care plans for the individual resident) . Resident specific approaches may include . Implementing specific interventions as par of the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #56 A review of the Progress Notes section of the Electronic Medical Record (EMR) revealed the following: 10/31/2022 (8:15 a.m.) Incident Note . Heard yelling out- entered room and observed resident lying on the floor alongside her bed, head @ foot of bed and feet @ head of bed, on her right side . She was very incontinent of urine, in her PJ's, w/o (without) footwear on, alarm in place, not sounding . During an interview on 11/29/22 at 3:24 p.m., Family Member (FM) X stated Resident #56 had falls a few days after her admission to the facility and ended up with two black eyes and bruised ribs with one out of place on August 19th, 2022. FM X stated she felt there were not enough staff to watch everybody. FM X stated she was ready to move Resident #56 out of the facility, but felt the staffing and care was much better now. A review of the incidents for Resident #56 revealed the following: A review of the incident report dated 6/10/22 at 6:30 p.m., revealed Resident #56 was heard yelling and was found lying on her back with blood coming from her right eyebrow. Non-skid shoes/socks were implemented after this fall. A review of the incident report dated 8/21/22 at 8:50 p.m., revealed Resident #56 was observed on the floor in front of the clean linen room for the unit. Resident # 56 was unable to say what she was trying to do. There was no new intervention identified in this incident following the fall. A review of the incident report dated 8/31/22 at 9:35 a.m., revealed Resident #56 was observed lying on her back, calling for help in the doorway of her room, and had fallen and hit her head. The incident report went on to discuss Resident #56 was persistently complaining of needing to go to the bathroom. Resident #56 was toileted after the fall and had a bowel movement. A review of the incident report dated 10/31/22 at 7:13 a.m., revealed Resident #56 was heard yelling out and upon entering the room was found lying on the floor next to her bed on her right side. On 11/29/22 at approximately 4:05 p.m., during an interview, the Director of Nursing (DON) was asked if non-skid shoes and socks would be a baseline care planning intervention for fall risk reduction. The DON stated yes, but Resident #56 would be one to take them off. The DON went on to stated Resident #56 was very ambulatory and often took herself to the bathroom. When asked if the other two interventions on her fall care plan should be baseline interventions, the DON agreed they would be considered baseline. On 11/29/22 at 4:15 p.m., during a follow-up interview, the DON acknowledged the care plans were not where they needed to be and were in the process of being cleaned up. When asked if she felt a toileting program would be appropriate, the DON agreed a toileting program would be appropriate for Resident #56. The DON also acknowledged encouragement of a resident who lacks cognitive ability to use a call light should not be encouraged to use the call light as an intervention and would not be appropriate. A review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #56, revealed short term and long term memory issues and Resident #56 was severely cognitively impaired. A review of the care plan High risk for falls, with an initiation date of 6/17/22, had interventions which included the following: Anticipate and meet (Resident #56)'s needs. Initiated on 6/17/22. Be sure (Resident #56)'s call light is within reach and encourage (Resident #56) to use it for assistance as needed. Initiated on 6/17/22 and revised on 11/18/22. Non-skid socks or shoes with non slip soles. Initiated on 6/10/22. Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bedbound. Initiated on 6/10/22. There were no other care planning interventions to address the falls sustained by Resident #56 on 8/21/22, 8/31/22 or 10/31/22. Deficient Practice #2 Based on observation, interview, and record review, the facility failed to prevent an elopement from the facility for One Resident (#67) of two residents reviewed for elopement. This deficient practice resulted in the potential for further elopements. Findings include: Resident #67 During an observation and interview on 11/28/22 at 2:01 p.m., Resident #67 was perseverating on going out to look at a fallen tree across the street. Resident #67 was upset that he was told he could not go and look at this tree that fell down. Resident #67 did not present as cognitively intact and demonstrated word salad communication at times during the interview. A review of an Elopement incident dated 10/14/22, revealed Front Desk Staff FF had let Resident #67 out of the facility. Staff FF thought Resident #67 was a visitor and let him out when Resident #67 identified himself as a visitor and stated he needed to go outside and get the keys out of his car. Five staff were on the unit at the time of the incident and the incident occurred while staff were getting residents ready for dinner per witness statements. A review of a Behavior Note dated 10/14/22 at 8:58 p.m., revealed the following: During dinner today, (Resident #67) was actively exit seeking. With redirection he sat down to eat his soup. This nurse was at the med cart prepping medication when I heard CNA ([Certified Nurse Aide] HH) yellout(sic) hey that's (Resident #67)! to which this nurse looked up and saw (Resident #67) walking outside in the parking lot with his walker .I talked to the front desk asking how hegot(sic) out without the alarm going off to which he stated (Resident #67) knocked on the door and told the front desk he was a visitor and needed to go out to his car and grab his keys, to which the front desk let him out and entered the code to the door, so the alarm did not go off .The front desk was unaware of who (Resident #67) was and did in fact believe he was a visitor . Author Licensed Practical Nurse (LPN) GG During an interview on 11/30/22 at 8:06 a.m., the DON was asked why there was nothing in the body of the policy to address elopement prevention, only what to do when an elopement occurs. The DON acknowledged the policy should include education to staff on how to prevent elopements from happening in the first place, and to make sure they are not letting out residents without supervision. During this interview, Receptionist II proceeded to show this surveyor a binder kept at the receptionist desk which contained pictures of all the residents at the facility. Receptionist II stated the facility has always had this binder at the desk as far as she knew. The DON stated she was not aware of this binder being located at the reception desk. Both the DON and Receptionist II agreed staff who sat at the desk should be aware of the binder and check it before letting anyone off the units and out of the building. During an interview on 11/30/22 at 3:49 p.m., LPN GG confirmed Staff FF had let Resident #67 off the unit and out of the facility under the premise he was a visitor and not an employee. LPN GG also confirmed Resident #67 was .very skillful in his exit seeking . and that she had educated Staff FF to please make sure to ask the nurse for the unit before letting anyone off the unit. A review of the care plan Elopement risk, for Resident #67, with an initiation date of 8/12/12 had the following interventions: 1:1 staff as necessary when agitated and exit seeking Initiated on 8/15/22. A name tag will be made up for (Resident #67) to be clipped to the back of his shirt to alert people that he is a resident of (facility). Initiated on 10/18/22. A picture of (Resident #67) is posted throughout the facility. He will also wear a picture/resident ID tag(to be provided). Initiated on 8/12/22. Call administrators cell phone number when agitated and unable to redirect so he can speak with him. Initiated on 8/12/22. Distract (Resident #67) from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. (Resident #67) prefers: Pepsi, talking about his past, Bingo, old shows and movies (TV land and westerns). Initiated on 8/12/22. Monitor location every 15 min. (minutes) Document wandering behavior and attempted diversional interventions in behavior log. Initiated on 8/12/22. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Initiated on 8/12/22. (Resident #67) triggers for wandering/elopement are looking for his car, getting [NAME](sic), getting to work, etc (Resident #67) behaviors is de-escalated by redirecting and listed interventions. Initiated on 8/12/22. The care plan provided by the facility did not show any new interventions to address Resident #67's specific elopement concern with staff not recognizing him and letting him out of the building. There was no education provided to all staff when this occurred to prevent new and agency staff from making the same mistake as Staff FF. There were agency staff working in the building at the time of this survey. Staff also failed to provide 1:1 supervision per the care plan when he was identified as actively exit seeking just prior to the incident during the dinner meal. This citation has 2 deficient practice statements (DPS) and pertains to intakes # MI00130986, #MI00132283 and #MI00125389. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to ensure thorough fall investigations were completed, interventions were in place, and new interventions were initiated to prevent falls for three Residents (#56,#62, and #66) out of six Residents reviewed for falls. This deficient practice resulted in repeated falls and a fall with fracture for Resident #62. Findings include: Resident #62 On 11/28/22 at 11:33 p.m., Resident #62 (R62) was observed up in her wheelchair near the door of her room in the hallway. R62 was attempting to self propel herself into her room. She was noted with a wheelchair alarm and a seat belt in place. R62 was asked how she was doing but did not respond. At this time, RN K and CNA G were both at the nurses station, out of view of R62 going into her room alone. CNA G was noted to be using his cell phone under the desk. On 11/29/22 at 12:27 p.m., R62 was observed self propelling in her wheelchair with her seat belt on back into her room. On 11/30/22 at 12:45 p.m., R62 was observed up in her wheelchair with her seat belt on. Certified Nurse Aide (CNA L) was observed putting the footpedals on R62's wheelchair. R62 was wearing slip on slippers with no back to the slipper. On 11/30/22 at approximately 4:21 p.m., R62 was observed in her wheelchair alone self propelling toward her bed and taking her slippers off leaving just her white socks on. On 12/1/22 at 11:08 a.m., R62 was observed up in her wheelchair in the common area outside of her room self propelling. R62's seat belt as not in place and the right food pedal was still on the wheel chair. A review of R62's medical record revealed she admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, diabetes, and repeated falls. A review of her 9/6/22 Minimum Data Set (MDS) assessment revealed she scored 0/15 on the Brief Interview for Mental Status (BIMS) assessment, indicating severely impaired cognition. This review showed she did not walk during the review period, required the extensive assistance of two plus staff for transfers, and used a wheelchair. A review of her previous MDS dated [DATE] revealed she scored 10/15 on the BIMS assessment, indicating moderately impaired cognition, walked and transferred with the extensive assistance of one staff member, and used just a walker. A review of a Physical Restraint/Alarm Evaluation/ Re-Evaluation for R62 dated 9/27/22 revealed the following: . Gets out of bed, stands from chair, recent hip fx (fracture) . Recommended three day trial of least restrictive physical restraint/alarm: Date : (blank) X Seat belt . There were no reminders checked off regarding the consent, order or care plan, and the final recommendation section was blank. There was no staff signature or signature date. A review of R62's fall Investigation and Investigation forms revealed the following: On 6/6/22 at 6:50 p.m., This nurse was in the nursing station getting report from (name of LPN R). We heard an alarm going off in the distance. I entered (R62's) room and observed (R62) sitting on the floor. (CNA J) was first in the room and saw the fall from the doorway. (R62) had stood up from her w/c and fell on her bottom . The Incident review form included the Intervention/Corrections implemented as Don't leave R62 unattended in her room (she does wheel herself in there so staff will need to be observant). On 6/11/22 at 1:45 p.m. was a fall in the Residents bathroom. LPN R had a gait belt around R62 but was unable to stop the resident from falling. On 7/1/22 at 4:40 a.m., (R62) was found by (CNAV) during bed checks. Resident was face down on floor . A review of CNA V's statement for this event revealed, .She (R62) was laying on her stomach next to bed . her pad alarm was in bed under her and did not activate (it was on). We did not hear anything and 2 of the 3 CNA's on unit were sitting in that side of living room close to room . and noted she last checked on the resident two hours prior. The Incident Review form noted, Her alarm was on but not in the proper place- she had moved them . Ensure alarms are in place during rounds. Review of the care plan revealed that the intervention to ensure alarms were out of R62's reach was already initiated on the care plan as of 1/27/21, and was revised on 5/3/22, and therefore should have been in place. On 7/5/22 at 2:00 a.m.(R62) observed on the floor on her right side . head under head of bed . red area at right hip, slight pain on palpation . shrinkage noted at the time of EMS exam . on call physician called, okay to send out for right hip evaluation . A review of the Incident Review form revealed, (CNA N) had just done a purposeful round and the alarm was on. When (R62) fell it was turned off. It was functional. The first thought was to place the alarm out of her reach but the cords are not log enough . the final decision was to put hip protectors on her. A review of CNA Ns statement revealed, Was in nurses station opening (name of EMR) to chart and check residents heart a loud crash noise ran to residents room and found her on the floor . On 7/9/22 at 6:40 p.m., .(CNA P), she states '(R62) is on the floor' this nurse entered the room and (R62) was observed on the floor on her left side . the alarm pad was observed between (R62's) legs and a towel around it. The alarm was 'on' but was not sounding due to the towel . The Incident Review form intervention was, Do not put a towel around the safety alarm. This was already a care planned intervention initiated in May 2022, that was not implemented prior to this fall. On 7/22/22 at 8:15 p.m., Nursing description: Walked by (R62's) room and witnessed her on floor of her room . (R62) has an indwelling foley catheter and the drainage bag was attached to the bed when she got up. She recently had an increased (sic) in her Sinemet d/t (due to) frequent falls . An email statement was attached to the report written by LPN U which revealed, This writer found (R62) on the floor she was sitting on her R (right) side with both hands on the floor . Her foley catheter bag was still attached to the bed . At the time of the fall she was lying in bed with slipper socks on but the alarm was not turned back on by the CNA when (R62) was last repositioned . There was no documentation of who the CNA was that failed to turn the alarm on and no indication if they were disciplined or educated. The intervention per the Incident Review form revealed, If (R62) is restless at night bring her out of her room for better observation and to lower her risk of falls. On 8/21/22 at 9:25 p.m., Heard (CNA J) calling out, 'Fall' . (R62) lying beside her bed with her right hand hanging onto the side rail. Her upper body and head were elevated off the floor. Blood was dripping from her right elbow . checked over again once back in bed. (R62) started to c/o (complain of) pain in her right upper leg. Pain was 10/10 when leg was palpated or moved slightly . EMS called @ (at) 2240 (10:40 p.m.) and here by 2250 (10:50 p.m.) . EMT's examined and questioned (R62) . pain was now 1/10 . she denied significant pain . Decision made not to send her to (Name of Hospital) . Foley tubing pulled taut when she got up. Hip protectors checked and on @ all times. They were not on . A statement from CNA J revealed, I heard bed alarm and saw call light flashing. Ran to (R62's) room and she was on the floor . I pull(sic) the alarm and call light out of the way and yelled for the nurse . A summary of the incident revealed, .The following Monday morning .she was still having pain of 10 out of 10 and ordered a 3-view X-ray of her right hip and a 2-view x-ray of her right femur. The results came back as a displaced fracture of the right femoral neck. She was then transported to (name of Hospital) for repair . The interventions for this fall are to place the foley bag in a basin on the floor. This is so when she gets up it is not hooked to the bed . She does have hip protectors ordered. At the time of the fall they had been taken to laundry and were drying . On 9/22/22 at 4:35 p.m., (LPN R) called to (R62's) room by (CNA P), (R62's) electric recliner was in the standing position. (R62) was lying on her left side on the floor in front of her chair, eye glasses lying on the floor lens missing . noted 3 cm wide bump on her forehead left of center . redness to left patella (knee) . A review of a witness statement with no name or date of writing revealed, At nurses station: Last saw (R62) at 4:20 pm - place ice pack on R (right) hip for c/0 pain. A review of a written summary for this event revealed, . It was apparent that (R62) had taken the control and lifted the chair into an upright position and then slid out onto her left knee and forehead. The lift control was removed and will be kept out of her reach . A review of the care plan revealed no intervention was initiated to keep the recliner control out of reach. On 9/26/22 at 5:15 p.m., (R62) was in the west living room. Sitting after an activity with a group of others. (LPN R) was in and out of the living room, passing medications. (R62's) alarm went off (LPN R) went to the alarm and saw (R62) holding herself off the floor by holding the wheel chair handle of the wheel chair in front of her . (R62's) feet and lower legs were caught in the foot pedals of her wheel chair . A review of the incident summary for this fall revealed, . Her feet were under her wheelchair foot pedals . There was (sic) 4 staff present on the floor at the time. The intervention was to have (R62) in line of sight anytime she is in the wheelchair . No new interventions regarding not leaving R62 with her foot pedals on the wheelchair unattended or when not being pushed. There was also no indication in the report if R62 had removed her own seat belt, or if it had not been placed back on by staff. On 11/25/22 at 7:25 a.m., (Nurses summary left blank) . other info: (R62) was attempting to get out of bed by herself. Alarm was sound but staff was unable to get to her before her knees were on the mat beside her bed. She was barefoot . Review of a witness statement by CNA M revealed, I was in the nurses station talking about Tksgvng (Thanksgiving) w/ (RN K) . Her (R62's) light went off, our convo (conversation) came to a stop as we made our way to (R62's) room. Her bed was all the (sic - way) to the floor her mat was in place, but her knees touch the mat. That was her fall. Under the section of when the resident was last checked, CNA M wrote, Last rounds. On 12/1/22 at 11:11 a.m., an interview was conducted with the Director of Nursing (DON) regarding R62's falls. When asked about the 7/1/22 fall where it indicated CNA's were sitting in the common area when it occurred, the DON made no comment. The DON was asked about the multiple falls (7/1/22 and 7/5/22 for example) where R62 was accused of turning her alarms off despite the care planned intervention from 2021 to keep the bed alarm out of reach. The DON stated, I don't remember if we got a longer cord? I don't remember to be honest. When asked about the 7/9/22 fall (alarm was wrapped in a towel), the DON stated, I don't know why they wrap it in a towel. Anyway's I talked to them and said don't do that . The DON was asked if since it was a previous fall intervention not to do that, if the CNA who had done it was disciplined or educated one on one for not following the care plan. The DON stated, It does (happen) if we can identify who it was (that did it), but I can't write everybody up if you don't know. When asked about the 7/22/22 fall (CNA did not turn alarm back on) the DON reported she didn't recall that fall and may not have been at the facility during that time. When asked about the 8/21/22 fall (hip protectors were not put on), the DON stated, That was (CNA J) . they (hip protectors) were both in the laundry room, one was drying and the other in a basket. After that we put two more pairs in the treatment room. When asked about there not being a discipline or education in CNA J's record for neglecting to follow the care plan and the fall resulting in a fracture, the DON just stated, She got educated. When asked if R62 was wearing appropriate footwear during the 9/22/22 fall, the DON reported, If you didn't see it (documentation) it probably wasn't there We generally make people take those (nonskid slippers) home. The ones you put your foot in and it just slides in, those are dangerous too. When asked if R62 had her alarming seat belt in place during the 9/26/22 fall as it was not noted in the report, the DON reported initially the belt was just a normal seat belt that didn't alarm. When asked about the foot pedals being left on if staff weren't around, the DON reported that she didn't know, but that staff have to have them on to push her. When asked about the 11/25/22 fall the DON indicated she was still investigating it. When asked about the concern of staff sitting at the nurses station and residents being found on the floor because the alarms are not answered in time, the DON reported the facility had already recognized that as an issue and were going to be fixing that. When asked about the intervention of R62 not having access to the recliner control, the DON provided no comment. A review of R62's fall care plan initiated on 6/6/21 revealed the following: .a seat belt will be placed on (R62's) wheelchair (9/28/22) .be sure (R62's) call light is within reach and encourage the (sic) her to used it . (6/6/21) . Bed alarm while in bed in addition continue to activate chair alarm when up. Place bed alarm control box out of (R62's) reach @ (at) all times. (initiated 1/27/21, revised 5/3/22). Do not leave (R62) in her room unattended in her w/c (wheelchair). She tends to self transfer to her recliner or bed. (6/7/22). Do not wrap alarm pad in a towel or place anything around it, the pressure/weight will prevent the alarm from sounding (7/9/22) . If she is awake at that time she should be assisted with morning care and brought out to the dining room (11/25/22) . Ensure seatbelt alarm is turned on when in w/c (9/29/22). Ensure that (R62) is wearing appropriate footwear-tennis shoes, when ambulating with her walker (initiated 6/6/21, revised 11/21/22). Ensure the alarms are in place during rounds (7/7/22) . Frequent purposeful rounds when (R62) is in her room (Initiated 5/20/22, revised 11/21/22). Gripper socks when in bed (8/22/22) . Hip protectors at all times (7/6/22) . If (R62) is restless bring her out of her room at night to better observe her and lower her risk of falling (initiated 7/22/22, revised 8/1/22). (R62) has 2 pair of hip protectors - if both are in laundry there are 2 spare pair in the household and a new pair in storage (9/19/22) . (R62) has been placed on high risk fall list. Her light is a priority (initiated 5/7/22, revised on 11/21/22) .(R62) uses a bed alarm on the back of her recliner and a chair alarm on the seat of her recliner. Make sure both are on when (R62) is in her recliner (6/21/22). (R62) uses pancake alarm. Ensure the device is in place and working properly (6/6/21). Make sure chair alarm is on and in working order (12/21/21). Make sure that (R62) has two cough drops on her bedside table (initiated 10/5/21, revised 11/21/22). Mat to be placed beside (R62's) bed while in it (8/22/22) . Safety alarm is not to be placed under cushions. blankets, or other items, as the additional weight/pressure prolongs the alarming (initiated 3/23/22, revised 9/27/22) . Between 7/1/22 and 12/1/22, R62 had eight falls. During three of the falls (7/22/22, 8/21/22, and 11/25/22), care planned interventions were not implemented and the 8/21/22 fall resulted in a fall with fracture and a decline in physical status. Two other falls documented R62 as turning her own fall alarm off, despite previous interventions to place the bed alarm box out of reach. Resident #66 On 11/28/22 at 11:36 a.m., Resident #66 (R66) was observed in her wheelchair near the staff bathroom. R66 was wearing a seatbelt and there was an alarm on her wheelchair as well. R66 was asking about the staff bathroom and when asked if she needed to go to the bathroom she stated she did. On 11/29/22 at 12:27 p.m., R66 was observed up in her wheelchair with the seatbelt on in the common area and hallway of her unit. Resident was being guided to the dining area for lunch. On 11/30/22 at 12:45 p.m., R66 was observed seated at the dining room table. She started to push her wheelchair backward and undid her seatbelt which started to alarm, and exclaimed Its loud! CNA M went over to R66 and stated, You keep unplugging it that's why it's being loud. Put it back together. R66 buckled the seatbelt and pushed R66 back toward the table. R66 started, to say I don't which CNA M interrupted with Do you need to do something? R66 quietly stated, Well no. CNA M informed R66 that she had not finished her lunch. On 11/30/22 at 4:20 p.m., R66 was in the common area of the unit and was observed unplugging her seat belt. Licensed Practical Nurse (LPN) R encouraged R66 to re-buckle her seat belt. LPN R stated to R66, Can you hook that up? Do you know why its on? to which R66 stated, Because they don't want me getting out. Approximately two minutes later R66 unplugged her seat belt again, and CNA O asked her to keep her seat belt on. R66 then asked this CNA O who was carrying a load of laundry to a room if she could help her and the CNA O responded No. On 11/30/22 at approximately 4:24 p.m., R66 was asked was observed aimlessly self propelling in the common area. When asked if there were any activities or things for her to do, R66 stated, Not really. A review of R66's medical record revealed she admitted to the facility on [DATE] with diagnoses including dementia, adjustment disorder, adult failure to thrive, and history of falling. A review of the most recent 11/1/22 Significant Change MDS Assessment revealed she scored 3/15 on the BIMS assessment, indicating severely impaired cognition and had no falls since readmission or the previous assessment. R66 was assessed as needing extensive assistance of two staff for toileting and bed mobility, and extensive assistance of one staff for ambulation. A review of her MDS assessment dated [DATE] revealed she required only supervision of one staff for toileting and bed mobility, no supervision or assistance for transfers, and just supervision of one staff for ambulation requiring no mobility devices. A review of a Facility Reported Incident (FRI) investigation for R66 for a Fracture of Unknown Source on 10/25/22 revealed the following: .At around 2130 (9:30 p.m.) (RN W) heard (CNA J) call out for help. (RN W) and (CNA P) responded to her call and observed (CNA J) supporting (R66) in the doorway to her room. (CNA J) stated that (R66) had cried out and said she could not walk. When (CNA J) heard her she was standing in the doorway. (R66) had been able to walk from her bed to the doorway without calling out. (R66) was very unsteady and complained of right knee pain. (R66) denied that anything happened and said she did not fall . once in bed (RN W) stated that (R66) again pointed to her kneed but then ran her hand up her thigh indicating that area hurt as well . The following morning (CNA M) called for (LPN R) to come to (R66's) room as she was having pain and she could not sit up or move her right leg without crying out . She (R66) had facial grimacing and was reluctant to move . There was no bruising or redness or any visible indication that she may have fallen . EMS transported (R66) to (name of Hospital) . an x-ray was done which revealed a mildly displaced fracture of the femoral neck without dislocation . (R66) had surgical repair of her hip at (Name of Hospital) on 10/25/22 and tolerated it well . This investigation did not have a conclusion section to discuss the investigation of the possible cause of the injury. A review of the witness statement written by RN S on the morning R66 was found unable to walk revealed, .(LPN R) stated (R66) has not been able to get out of bed this morning - and she (is) screaming in pain when R (right) thigh/hip is palpated . This RN attempted to palpate area - (R66) screamed in pain . no markings to show of any type of fall. Staff state no fall - (R66) stated 'I Fell' but unable to say how or when. (R66) is confused at baseline . A witness statement written by CNA J written 10/25/22 revealed, In living room with another resident when I heard (R66) yelling she needed help because she can't walk. Ran to her she at doorway was standing and tipping side ways. I put my arms around her and steady her and yelled for help. Waited for other staff to help assist/walk her to her bed . when asked what happened or if she fell she said No I don't know what happen (sic). This statement revealed R66 was last checked at 8:30 p.m. (an hour prior) and was noted to be sleeping at the time. A review of R66's incident and accident reports revealed the following: 11/6/22 4:50 p.m. (R66) had been sleeping in the recliner in the west lounge. This nurse (LPN R) and (CNA H) heard (R66's) chair alarm sounding, (LPN R) and (CNA H) were in the nurse's station and went running to the west lounge, before reaching the lounge there was a loud noise, found (R66) on her knees f[TRUNCATED]