This citation pertains to Complaint #2610789.Based on interview and record review, the facility failed to adequately assess, monitor, and treat in a timely manner a resident's change in condition for one (R801) of one resident reviewed for change in condition, resulting in family calling 911 and the resident requiring treatment for hypoglycemia (low blood sugar) with a blood glucose level of 24 milligrams per deciliter (mg/dl). Findings include:A review of a complaint submitted to the State Agency revealed the complainant received a call from R801 on 9/8/25 at approximately 6:00 AM and the resident's speech was slurred, and the complainant could not understand him. The complainant contacted 911 because they were concerned R801 could be having a stroke. When the complainant provided the resident's name to the 911 operator, the operator told them R801 had been calling 911 since 3:00 AM for help and when an officer arrived at the facility, they were told by the staff R801 was fine. The complainant further noted that around 3:00 AM, they talked to a Certified Nursing Assistant (CNA) at the facility who asked them if R801 normally had difficulty speaking. The complainant told the CNA No and a nurse (Licensed Practical Nurse - LPN 'A') was put on the phone. The nurse told the complainant that R801 was fine and was just kicking his feet. The complainant told the nurse that was not the baseline for the resident, and something was wrong. It was further noted in the complaint that when the complainant got to the facility, EMS (emergency medical services) was loading R801 into the ambulance and he was taken to the hospital. The complainant alleged R801's blood sugar at the hospital was 24 (mg/dl) and he could not see, speak and barely move. According to the complainant, once R801 stabilized and was able to speak again, he said when he lost his vision and could not speak normally, he was afraid he was having a stroke, so he started calling out for help but was ignored by LPN 'A'. R801 was able to get a hold of his phone and called 911 and when the officer arrived, LPN 'A' told the officer nothing was wrong with the resident. The resident continued to call out for help and called 911 again and was told by LPN 'A' to stop calling 911 because he was bothering them. At that time, R801 called the complainant. The complainant alleged the facility was negligent in not addressing R801's change in condition when he was no longer at his baseline. A review of additional information provided by the complainant revealed they were notified that R801 had a bottle of acetaminophen and an electronic cigarette, and they thought he overdosed and was being monitored. An unannounced, onsite investigation was conducted on 9/11/25.A review of R801's hospital Discharge Summary revealed a diagnosis of hypoglycemia (According to the American Diabetes Association, https://diabetes.org/living-with-diabetes/hypoglycemia-low-blood-glucose, Low blood glucose is when blood sugar levels fall below 70 mg/dl).A review of R801's Emergency Documentation revealed R801 was brought to the emergency department (ED) on 9/8/25 at 6:38 AM. The following was documented, .Chief complaint: difficulty speaking .brought in by EMS for possible stroke. Last known well time was around midnight. Patient was noted to have difficulty speaking around 3 AM . Accu-Chek (blood glucose test) per EMS was 67 (mg/dl). Patient had slurred speech and right sided facial droop and weakness .Accu-Chek (in ED triage) was noted to be 27 therefore patient was given amp of D50 (50 milliliter container of Dextrose 50 percent solution) .patient's symptoms improved and patient is back to baseline. Serial Accu-Checks were performed in the ED his glucose did drop down to 44 therefore he was started on IV (intravenous) dextrose received another amp of D50 and the patient was fed .Final impression: Hypoglycemia A review of R801's clinical record revealed R801 was admitted into the facility on 9/2/25 and discharged to the hospital on 9/8/25 with diagnoses that included: major contusion of the left kidney, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. A review of a Nx (Nursing) admission Assess (Assessment) form dated 9/2/25 revealed R801 was alert and oriented times four (to person, place, time, and situation), was on two liters of oxygen via nasal cannula, and required extensive assistance with bed mobility.A review of a Change in Condition Evaluation form dated 9/8/25 at 7:53 AM revealed R801 had Altered mental status change that started on the night of 9/8/25. The most recent blood pressure and temperature was from 9/7/25 at 11:04 AM and the blood glucose level was from 9/7/25 at 9:07 PM. It was documented on the evaluation that R801 had Increased confusion .abrupt significant change in cognitive function from usual .general weakness .mumbling of words/incoherent speech .physical aggression .kicking, disorientation and mumbling .acute decline in ADL (activities of daily living) abilities .unable to console, distract or reassure . It was documented the symptoms got better since the change in condition occurred when the nasal cannula was on nose. It was documented the primary care clinician was contacted on 9/8/25 at 5:46 AM and they said to keep an eye on him. A review of a Transfer Form dated 9/8/25 revealed it was not completed and was in progress. It was documented R801 was sent to the hospital on 9/8/25 at 6:30 AM for altered mental status. It was documented report was called in by Family.A review of R801's progress notes revealed the following:A Nurse's Note dated 9/7/25 at 11:06 AM that documented, resident alert, pleasant, makes needs known .denies pain. benefits from use of supplemental oxygen via nasal cannula. uses call light appropriately to make needs known .A Nurse's Note dated 9/8/25 at 3:52 AM, written by LPN 'A', documented, At approximately 03:30 am during routine rounding, resident was observed highly disoriented. He was kicking with his legs and mumbling and jumbling words that are incoherent. Resident also refused and kicked the phelebotomist that came to draw his blood. Nasal cannula was not on his nose. O2 (oxygen) sat (saturation) at the time was 79% RA (room air). Writer observed resident holding a (brand name) vape type of smoking pipe (electronic cigarette) in his left hand. One more piece of (brand name) vape and one container of Extra strength (brand name acetaminophen) was also found in resident's bag. Writer succeeded in putting back his nasal canula back on. His Current SPO2 (oxygen level) 98%, P (pulse) 68, R (respiratory rate) 22, B/P (blood pressure) 152/68, T (temperature). Resident currently calm and stable with eyes closed .Will continue to monitor.A Nurse's Note dated 9/8/25 at 5:43 AM, written by LPN 'A', documented, Resident awake now but still mumbles in his speech. He even dialed 911 with his phone and (city name) police came for wellness check and left. (Physician 'C') notified and she ordered that we continue to keep eye on him. Writer notified DON (Director of Nursing) as well. Will continue to monitor. A Nurse's Note dated 9/8/25 at 6:20 AM, written by LPN 'A', documented, Resident's family called the facility and stated that they have called 911 on behalf of the resident, and that they will come and take him to hospital. Writer notified DON and she okayed the request.A Physician's Note dated 9/8/25 at 6:49 PM, written by Physician 'C', documented, I received a call this morning from the nurse at the facility that resident is acting different, he was combative, restless and calling 911, per the staff when EMS arrived he was checked and found stable, so he was not transferred out, the nurse checked on him again and he did mention he is improving and back to his baseline so the recommendations is to monitor his progress, blood work, and UA (urinalysis) ordered.On 9/11/25 at 10:32 AM, an interview was conducted with CNA 'B' via the telephone. CNA 'B' was assigned to R801 on the midnight shift of 9/7/25. When queried about what happened with R801 on that shift, CNA 'B' reported R801 was normal for the first half of the shift and then R801's roommate called her in. When CNA 'B' entered R801's room, R801 was moaning and groaning and kicking in the air. CNA 'B' tried to get close, but he kept kicking. CNA 'B' explained R801 did not appear to notice that she was there. CNA 'B' got LPN 'A'. LPN 'A' saw a vape pen in R801's hand and took it out of his hand. CNA 'B' reported there was a half bottle of acetaminophen extra strength, and they were unsure if R801 took any of it. CNA 'B' further explained, LPN 'A' told her to get R801's vital signs and to monitor him. According to CNA 'B', R801's vital signs were normal when she took them. Around 5:30 AM, R801's family member called the facility and spoke with CNA 'B' and said R801 called them and they thought he was having a stoke because he could not talk. CNA 'B' checked on R801 and stated, To me he seemed the same. When queried about what she meant by the same, CNA 'B' reported he still seemed disoriented and unable to talk. CNA 'B' reported she got LPN 'A' and asked him to assess R801. LPN 'A' took over the phone call with the family, but the family had already contacted 911 at that point. CNA 'B' reported she thought R801 called 911 earlier because the police came, but EMS did not. They did not take R801 to the hospital until family called 911.On 9/11/25 at 11:25 AM, an interview was conducted with LPN 'A' via the telephone. LPN 'A' was assigned to R801 on the midnight shift of 9/7/25 going into 9/8/25. When queried about how he was alerted of R801's change in condition on 9/8/25, LPN 'A' reported around 3:30 AM he entered the room during routine rounding and saw him kicking with his legs and shouting. LPN 'A' reported R801 was not in his usual mood so I noticed something was really off. LPN 'A' reported R801's the nasal cannula that delivered R801's oxygen was out of his nostrils so he reapplied the oxygen and waited until his O2 came back up from 79% to the upper 90s. LPN 'A' reported once the oxygen level increased R801 stopped kicking. LPN 'A' further reported he noticed R801 had something in his hand which was identified as a vape. LPN 'A' reported they looked around and found another vape and a bottle of acetaminophen extra strength that was only one quarter full. LPN 'A' explained he was really concerned because the acetaminophen did not come from the facility and after finding the vapes my instinct told me he was under the influence of something or that he overdosed. LPN 'A' said he first contacted the DON who said he would be relieved by the Assistant Director of Nursing (ADON) in the morning and she would take the vapes and medication that was found. The DON also instructed to contact Physician 'C'. LPN 'A' reported he tried to contact Physician 'A' multiple times and she answered the phone around 4:00-4:30 AM. Physician 'C' asked what R801's condition was at that time and told her He is gradually coming back and not kicking anymore and she said to keep an eye on him. LPN 'A' said some time after that, a police officer arrived at the facility and said someone called 911. LPN 'A' went to R801's room with the police and he opened his eyes and kind of responded and the police said That's ok. He's in a safe place. He looks stable. When LPN 'A' asked why the police came, they said the call they received was a desperate call so they wanted to do a wellness check. LPN 'A' said EMS did not come with the police and no physical assessment was done on R801 at that time. LPN 'A' explained later there was a phone call from family and they said EMS was on their way to pick up R801. A few minutes EMS arrived.At that time, LPN 'A' was asked about the progress note at 5:43 AM that documented R801 was still mumbling his speech and called 911 and what he did about that. LPN 'A' explained that was when the police came and left. When queried about R801's mumbling and incoherent speech documented at 3:52 AM and 5:43 AM and if that was normal for R801, LPN 'A said R801 improved from the first time when he was kicking. LPN 'A' said when he first assessed R801 around 3:30 AM, R801 was kicking and mumbling and You couldn't even hear him speaking at all at that time. After he applied the oxygen, the kicking stopped, but R801 was still mumbling. LPN 'A' reported when the police came after R801 called 911, R801 started talking but it was not coherent. It was not as audible as it was before. LPN 'A' reported R801 typically had clear speech. When queried about whether he explained the changes in speech to Physician 'C' and the DON, LPN 'A' said he told them he was getting better. When queried about what that meant, LPN 'A' stated, I just meant compared to when I first saw him. Not compared to his baseline. When queried about why R801 was not assessed medically when the police arrived and sent to the hospital since R801 called 911, LPN 'A' reported the police said they were just there to make sure nobody escaped but said R801 was the person who called, and his phone was observed by the resident. When queried about whether R801's blood sugar was taken at any time during R801's change of condition since he had diabetes, LPN 'A' reported it was taken but he did not document it anywhere. On 9/11/25 at 12:36 PM, an interview was conducted with Physician 'C' via the telephone. When queried about what LPN 'A' contacted her about regarding R801 on the midnight shift of 9/7/25, Physician 'C' reported the nurse called and said R801 was acting different. That he was kicking and combative, but that he calmed down and returned to baseline. When queried about what was explained to her about R801's speech, Physician 'C' reported There was nothing about the speech. When queried about what was said about the acetaminophen and vapes found in R801's room, Physician 'C' said the nurse mentioned the vape, but she was unaware there was a concern that R801 took acetaminophen. Physician 'C' said because LPN 'A' said R801 was back to baseline she told him to continue to monitor the resident. When queried about whether she was aware R801 contacted 911, Physician 'C' said the nurse told her R801 called 911 and that EMS came and checked him out and they said he was fine. Physician 'C' said she thought he was back to baseline so said to continue to monitor him. Physician 'C' reported when the family called with concerns, that was when she said to send him out right away, but family already called 911. Physician 'C' planned to see R801 that morning, but he had already been transferred to the hospital. On 9/11/25 at approximately 1:00 PM, an interview was conducted with R801's roommate (at the time of the change in condition on 9/8/25). When queried about what happened with R801, R801's roommate said he pressed his call light because R801 was yelling help. R801's roommate said R801 kept calling 911 that night and screaming out which was not typical for the resident. R801's roommate said the police showed up and left and then EMS came later, and he went to the hospital.On 9/11/25 at 2:15 PM, an interview was conducted with the DON. When queried about what was reported to her regarding R801 on the midnight shift of 9/7/25, the DON reported the nurse called her and said R801 was a little agitated and wasn't sleeping and that a vape was found in his hands. The nurse said he took vitals, they were within normal range, and he said he was going to contact the physician. The DON reported the nurse was not sure if R801 had taken something but that R801 was improving. When queried about whether LPN 'A' reported R801 was improving since the change of condition or improving back to his baseline, the DON stated, That nurse wouldn't know his baseline because it's on the midnight shift. When queried about whether she was aware R801 called 911 that night, the DON reported she was aware. When queried about the facility's protocol if a resident contacted 911, the DON reported They didn't think he needed to go. When queried about whether she was aware that R801 was unable to talk clearly from the time the change of condition was identified and continued to have mumbled speech, the DON stated, He must have been talking to them (the police) because they didn't think he needed to go and further stated, Nursing judgment is subjective. When queried about whether a resident had the right to go to the hospital even if they were assessed as stable, the DON said if the resident called and stated he wanted to go, then he would be sent out. When queried about any grievances filed regarding R801, the DON said family wanted the nurse's last name and there was some confusion over who he was talking to on the phone because he asked for a nurse but gave CNA 'B's name. When queried about whether the facility conducted any investigation regarding R801's change in condition, the DON said an investigation was done to make sure the CNA was not giving family information that should have been given by the nurse. At that time, the DON was asked to provide the investigation, and she said she was not sure she had anything documented. When queried about whether she knew what happened with R801, the DON said she thought he was being discharged to another facility and was treated for hyperglycemia (high blood sugar). When queried about whether R801's blood sugar should have been checked as part of the nursing assessment during a change in condition, the DON said she thought it was. A review of an investigation provided by the facility revealed nothing about R801's change in condition and was only to address whether CNA 'B' gave the phone to LPN 'A' when R801's family called.A review of a facility policy titled, Acute Condition Changes - Clinical Protocol, undated, revealed, in part, the following, .Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician; for example, history of present illness and previous and recent test results for comparison .Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident's current symptoms and status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00140638 This citation has two deficient practices. Deficient practice #1 Based on observation, interview and record review the facility failed to consistently monitor and ensure appropriate interventions were in place for one (R171), a severely cognitively impaired resident with a history of falls and wandering, out of four residents reviewed for abuse/accidents, resulting in multiple falls leading to a hip fracture, skin tears requiring sutures, bruising, pain and hospitalizations. Findings include: On 1/22/24 at approximately 1:09 PM, R171 was observed in their room in bed. The resident had gauze wrapped around their left wrist and lower arm. The resident was alert. When asked questions regarding the gauze on their arm and possible falls in the facility, R171 was not able to provide any specific responses and appeared extremely confused as to their present location. Review of R171's clinical record revealed the resident was initially admitted to the facility on [DATE], had readmits on 12/30/23, and the last admission date was 1/15/24. The resident had diagnoses that included: repeated falls, unspecified dementia, left acetabulum fracture and bipolar disorder and Wernicke's Encephalopathy (brain damage often caused by lack of vitamin B1 for those with an alcohol disorder). A review of the resident Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 6/15 (severely cognitively impaired) and required extensive one person assist for most activities of daily living. Continued review of R171's clinical record documented, in part, the following: 4/14/23: Hospital Physical Therapy/Discharge Notes: .Reason for admission: .confirmed Right Proximal humerus fracture .Precautions: fall precautions/weight bearing restrictions .personal safety alarm .Mental status: confused .Cognitive Function: attention deficit; executive function deficit; memory deficit; safety deficit .requires cues/redirection to tasks .short term member impaired; long term memory impaired . 4/17/23 Nurse Note: .resident arrived from (name redacted) Hospital. He had a fall at home and tripped over something and fractured right humorous . 4/21/23 Physician's Note: .history of falls .RT (right) Humerus Neck FX (long arm/shoulder fracture) . 4/22/23 (11:45 PM): Resident is alert but confused. Resident has been self-transferring to chair this shift . 4/24/23 Social Services Note: .met with the resident as he was presenting with confusion and appeared easily distracted. He was unfocused during the conversation and inquired about contacting the police .Shared with him that he was in a nursing home setting .his speech becomes non-sensical and appears easily distracted. 4/24/23 (12:17 PM)Nurses Note: resident is very confused .can't find his room .thinks he is in a recreation center .hx (history) of delirium . 4/24/23 (4:32 PM) Nurses Note: resident walking in the hallway without assistive device, wearing socks (no shoes), unsteady gait, using walls for support, staff witnessed him walking and approaching to help, he reached forward to grab the door handle .lost his footing falling backward landing flat on back, hitting head on floor. Also witnessed by visitor .he bounced his head off the floor.using three staff to get up off the floor .decreased alertness and more confused .Swelling noted to back of head. Physician notified, 911 called for transport. 6/3/23 (6;36 PM) Nurse Note: .resident did not have a foley bag attached .became upset when we attempted to attach the bag. When asked why the bad<sic> wasn't there resident stated, I fell out of bed and this lady came and picked me up and put me on the couch. I thought there was something wrong with it, so I threw it away . 6/15/23 (6:27 PM) Nurses Note: .resident continues to wander the halls has entered into a female's room . 7/7/23 (11:58 PM) Nurses Note: .resident was observed on floor with blood everywhere around him Resident stated, I fell. Resident is AxOX1 and is unable to give an accurate description. Resident was wearing grip socks. Call light was not initiated . Observed a deep laceration on the right arm d/t (due to) fallen on the waste basket .order given to send resident to the ER (Emergency Room) . 7/8/23 (6:42 AM) Nurses Note: .returned at 6:15 AM from (name redacted) Hospital due to fall on 7/7/23 .suture x3 and open area approx. 5-6 inches in length . 7/30/23 (7:40 PM) Nurse Note: .Resident had witnessed fall on his left side in dinning room while attempting to transfer from couch without assistance .Resident has c/o (complaints of) left hip pain. Resident had half of left middle fingernail breakoff with blood present . 7/31/23 (10:27) Nurses Note: .bleeding around the tip of finger and nail bed; resident needs more assistance and direction unable to follow direction without repeating them multiple times and help guiding him . 7/31/23 (11:16) Physician's Note: .patient had fall 7/30/23 .C/O left hip pain .also had nail evulsion left middle finger . 7/31/23 (9:57 PM) Nurses Note: .notified nurse that resident had a fall c/o left hip pain 10/10 .bandage placed on finger . 7/31/23 (10:27 PM) Nurses Note: post fall huddle .care plan modified to let CNAs (Certified Nurse Assistant) and nurse know that I am forgetful and a high fall risk and to assist me if they see me transferring or ambulating unassisted . 8/2/23 (11:05 AM) Nurses Note: .resident shower and hair wash .difficult for resident to stand and transfer .left hip purple bruise noted approx. 10 cm (centimeters)x 2cm .c/o of pain .all transfer done with 2 assistance and walker . 8/2/23 (11:29 AM) Physician's Note: Patient is alert oriented times 1. Patient had a fall on 7/30/23 .Xray left hip negative .however patient unable to move in bed. Refused to stand or sit due to pain. Very confused .will transfer to hospital for CT (Computed Tomography) hip and Pelvis . 8/9/23 (11:14) Physician's Note: .transferred to hospital after fall . c/o severe pain left hip .CT left hip positive for closed acetabular fx (fracture of hip socket most commonly occur due to high energy event .some older people with osteoporosis may obtain them following a fall) .patients Eliquis decreased due to h/o (history of) multiple falls high risk of bleeding . 8/10/23 (3:58 PM) Nurses Note: .taking with resident he stated, my family thinks I'm not safe here . 8/12/23 (7:41 PM) Nurses Note: .observed resident attempting to get out of bed . 8/19/23 (4:47 PM) Nurses Note: .enter room .found resident standing at the end of bed . 8/29/23 (11:00 PM) Nurses Note: .resident very confused .resident up and walking without assistance . 9/1/23 (7:08 PM) Nurses Note: .resident continues to be confused .getting up walking, attempted to leave the facility door at end of hallway .resident had a fall at the beginning of the shift in the hallway . 9/2/23 (4:05 AM) Nurse Note: .follow up post fall reminded resident to use a call light for assistance . 9/7/23 (11:24 PM) Behavior Note: .resident is alert x1 to name only Resident has been wandering all over the building .11:30PM: resident found in room [ROOM NUMBER] looking for wife and mother . 10/16/23 (3:28 PM) Nurses Note : .Resident told CNA that he had fallen. CNA then alerted writer about incident. Writer entered room and saw resident lying in bed .tv was knocked over with broom and dustpan on top of it, with his folding chair knocked over next to tv .resident bed side table next to bed .resident c/o right shoulder pain resident has large scrape on left lower back .new orders for x-ray . 10/18/23 (10:55 AM) Physician Note: .Patient had an unobserved fall on 10/16/23 .COVID test positive .Not oriented to time, place or person . 10/27/23 (4:07 AM) Nurses Note: .Resident's CNA (hereinafter CNA C) notified writer that resident was on the floor in room (number redacted) .writer rushed to room . and observed resident sitting on his buttocks .residents wheelchair was upside down lying on the floor . Resident (hereinafter R18) told writer he was sleeping, he felt someone touching his groin area . he observed resident (R171) . he quickly jumped up, kicked, smacked and pushed him away. Thorough head to toe assessment done .Abrasion .with minimal bleeding noted on resident's left elbow . will continue to monitor . 10/29/23 Nurses Note: . dressing in place on arms and lower back due to scrapes from observed on floor yesterday after noon . 11/2/23 Nurses Note: .q 15-minute checks . resident observed in another residents room . 11/30/23 Nurses Note: .resident was walking .observed going into another residents room .resident at first refused to leave .redirected back to his room . 12/2/23 (2:49 AM) Incident Note: .On 12/2/23 at approximately 200 AM resident was observed on the floor in front of the bathroom during 15 minute check . Resident was observed lying on his left side . upon assisting resident to their feet .there was urine and a spot of blood on the floor . resident presented with new skin tear to left forearm . new intervention: ensure proper footwear as tolerated and assist resident to restroom at the beginning, middle and end of the 3rd shift . 12/17/23 Unusual Occurrence Note: .CNA called out for help from resident's room. Observed resident on the floor feet under bed leaning on left hip and elbow .resident confused .need to encourage resident to call for help when getting up . 12/20/23 Nurse Note: .CNA observed laying on the floor in the hallway in front of room [ROOM NUMBER] . 12/20/23 Nurse Note: .Post fall intervention to place a nonslip pad on his wheelchair . 12/21/23 Nurse Note: .check in from fall earlier today .lunch delivered, and client was sitting in wheelchair eating-next observed laying on the floor next to the bed .bleeding from right hand and elbow. Bruise and light abrasion on right temple .neuro checks restarted - pupils reactive at first, now sluggish-speech was clear earlier, now talking gibberish .send to ER for evaluation . 12/21/23 Hospital Records: .History of Present Illness .Patient .presents today from Skilled Nursing Facility .patient is brought in by EMS (Emergency Medical Services) for evaluation after multiple falls, most recently at 2PM. He has ecchymosis (bruising) to R (right) temple area, so he hit his head at some point today .patient is completely unreliable historian . 12/30/23 Nurses Note: .admitted from (name redacted) Hospital .resident has multiple bruises noted on arms .alert to person only . 1/16/23 (10:32 PM) Nurses Note: .resident has been wandering around the building in WC (wheelchair). Found resident in 2pt. (patient) rooms, resident is very confused . 1/18/23 (3:11 PM) Nurses Note: .on my rounds at 11:15 AM could not open residents' door, resident yelled stopped. Observed resident on the floor inside the door lying on his back, blood smeared all over the floor, feet were facing the door, head at closet door. WC was locked at bedside resident was assisted to a sitting position and lifted into WC. Pressure applied to wounds on right hand .continue 15-minute checks . A review of R171's care plan revealed, in part, the following: Focus: I have potential/actual ADL (activities of daily living) deficit (created 4/17/23) . Interventions: Ambulation x1 person assist using 2WW (two-wheel walker) initialed 4/19/23 .Ambulation x2 person assist using 4WW (date initialed 1/2/24) .Transfer x1 person assist (date initiated 1/2/24) . Focus: Risk for falls r/t recurrent falls closed head injury .Guest frequently self-transfers reminders to call for help and wait until staff gets there. (created on 4/17/23 and Initiated on 1/2/24) .Interventions: Access and treat pain (initiated 9/26/23) .Call light accessible (initiated 4/17/23) .Education provided on call light use and waiting for help for transfers (date initiated 7/10/23) .Encourage resident to participate in activities outside of room (date initiated 4/25/23) .Explore seizure warning signs .(date initiated 1/19/23) .Floor mat at bedside as needed (12/18/23) .I am forgetful and a high fall risk assist me if you see me transferring or ambulating unassisted (date initiated 12/11/23) .I will try to remember to use my call light and wait for help (date initiated 5/20/23) .I will wear non-skid footwear for all transfers and walking (date initiated 4/17/23) .Orient to surroundings (initiated 4/25/23) .Please leave a light on in my room at night for safety since I forget to use my call light when I need to get up (date initiated 11/5/23) .Please place a slip pad on my wheelchair to promote safety (date initiated 12/20/23) .Staff to assist with toileting at the beginning, middle and end of 3rd shift (date initiated 12/2/23) .Staff to ensure proper footwear as tolerated during rounds (Date initiated 12/2/23) . Focus: Behaviors- He has poor social boundaries and hx of entering other residents' room without permission .He has minimal incite and will need to keep his hands to himself. Eliminate any sexual comments or behaviors .requires redirection as he will not stay on task. He has poor incite and expresses that he has no recollection of being in a room that is not his due to memory impairments (created on 10/24/23) .Interventions: 15-minute checks r/t increased behaviors (Date initiated 10/27/23) . On 1/23/24 at approximately 11:00 AM, an interview was conduced with Social Worker (SW) B. SW 'B was queried as to the R171 regarding issues of wondering, touching other residents and continuous falls. SW B noted they were very familiar with R171 and noted that there had been several issues regarding care prior to entering the facility and during their stay. On 1/4/23 at approximately 10:15 AM an interview and record review were conducted with the Director of Nursing (DON). Corporate Nurse D was present during the meeting. The DON noted that they had been working at the facility for approximately 10 months. The facility provided IA (Incident/Accident) reports that mirrored many of the notes pertaining to falls as addressed above. During the interview the nursing notes and the IAs were reviewed to determine the interventions that were implemented and used to try to limit the falls/accidents for R171. The DON reported that the facility was attempting to keep a good eye on the resident but noted that he wandered and is often non-compliant despite being educated. Initial interventions added to the care plan for R171, with a history of falls, included: ensuring the resident used their call light, ensure call light was in reach, tried to keep the resident involved in activities and remind the resident not to transfer on their own where discussed. When asked about how educating the resident, who per several nursing notes indicated that the resident has severe confusion and was non-compliant, would adhere to the education provided, the DON reported that he was different when he entered and had a higher BIMS score and they believed he would adhere. The DON was asked about the interventions implemented following the resident's fall's on 7/7/23 (fall that required sutures at the hospital) and on 7/30/23 that resulted in a fracture of the hip and a hospital stay. The DON noted that the facility determined the resident needed items rearranged in their room to try to prevent fall/injury. The DON was asked about continuous falls, including the fall that occurred when R171 wondered into R18's room and was kicked by R18 and fell to the ground. The DON reported that following the incident on 10/27/23 the facility implemented 15-minute checks to try to prevent additional falls, as well as preventing the resident from entering other residents rooms. When asked about the fall that occurred the next day (10/28/23), the DON noted that the fall most likely occurred sometime between the 15-minute checks. Continued review of R171's fall interventions include keeping the 15-minute checks along with additional interventions that included increase toileting, footwear, slip pads, increased lighting and fall mats. As the resident's record indicated, multiple falls continued following those interventions The DON was queried as to whether the facility considered implementing 1:1 care for R171 to prevent falls and wandering as the interventions that were utilized were not preventative. The DON did not provide a direct response. Review of the facility policy titled Fall Reduction Program (9/25/16) revealed, the following: Purpose: To provide a safe environment for residents, modify risk factors, and reduce risk of falls related to injury .Procedure: .Implement and indicate individualized interventions .Initiate safety interventions and update care plan as applicable .Discuss and determine root cause .Identify any additional interventions .Determine the need for ongoing assessments/interventions based on MDS reviews, fall risk history .Trends/patterns will be evaluated by the QAPI (quality assurance performance improvement) team towards improvement in the Falls Reduction Program . Deficient Practice #2 R171 and R18 Based on observation, interview and record review the facility failed to ensure the safety of two residents (R171 and R18) out of four residents reviewed for accidents/abuse. Findings include: A FRI (facility reported incident) was submitted to the State Agency (SA) that reported R18 kicked R171 after R171 entered into R18's room and allegedly touched R18's groin area. A review of the facility IA (incident/accident) report and accompanied documents revealed, in part, the following: Summary of Investigation: On 10/27/23, R18 was interviewed and reports that in the middle of the night he felt someone touch him in his groin area, he reports that he had a brief on, and pajama pants and it was on top of the clothing. He reports he was startled; it was dark in the room and he woke from his sleep and kicked at the person next to his bed (hereinafter R171). He reports that the person was sitting in a wheelchair at his bedside, when he kicked at him his wheelchair tipped over and landed on the floor .Conclusion: .R18 does not deny kicking R171 .R171 will remain on Q 15-minute checks and will be reevaluated later . Investigation Summary: Interview with R18 (10/27/23): It was night, the lights were out, and it was dark. I was asleep. It was ten minutes after twelve. I was hot that night, so I was sleeping on top of my blankets. I woke up and he was rubbing on me near my growing <sic> area on the outside of my pants. I hollered at him to stop but he kept rubbing, so I kicked him a couple of times and he fell to the floor. I yelled and pushed the call light to get some help. Nurse A and Certified Nursing Assistant (CNA) C came then I told them what happened. Interview with R171(10/27/23): R171 doesn't remember falling, doesn't remember getting out of bed, and cannot tell me if he is in pain. He answered I don't think so to everything that I asked. R171 has a BIMS (Brief Interview for Mental Status) score of 6. (*Severely cognitively impaired). He cannot recall the month or date. He can repeat the month, the date and the year. He knows his birthday but is not able to remember age. Interview with CNA C: I was in the room with (name redacted) resident and I came out and seen that the call light was on for (R171). When I arrived, I saw that R171 was on the floor. R18 told me that R171 was trying to touch him in the bed. He said he kicked at him, and he fell backward in the wheelchair and landed on the floor. I went and told the nurse immediately. Interview with Nurse A: Around like 12:30, CNA C called me and told me R171 was in R18's room on the floor and had a fall. He went into R18's room and touched him while he was sleeping and R18 pushed him away with his foot. R171 fell to the floor . On 1/22/24 at approximately 1:09 PM, R171 was observed in their room. The resident was alert. When asked questions regarding falls in the facility, including falls in other resident's room, R171 was not able to provide any specific responses and appeared extremely confused. On 1/22/24 at approximately 1:14 PM, R18 was observed in bed. The resident was alert and able to answer all questions asked. When queried as to the incident involving R171, R18 reported that in October 2023, during the nighttime, R171 entered into their room. They were sleeping at the time and the lights were off in the room. They felt someone touching them near their groin area and they kicked them. R18 noted that the resident was R171 and after they kicked them their wheelchair tipped over. When asked if R171 had ever done that to them before, R18 reported that they had not, but did not the resident had wandered into their room before and noted that a few days ago, they entered again and they got the resident to leave the room. R18's roommate also reported that that on the night of 10/27/23, they heard R18 yelling at R171 to stop but R171 was not listening and then they tried to help but could not get up fast enough and R171 was on the floor. On 1/23/24 at approximately 9:57 AM, an interview was conducted with Nurse E who was working on the hall where both R18 and R171 resided. When queried as to R171, Nurse E reported that the resident is known for wondering in and out of residents rooms. Has sustained several falls. Nurse E reported that R171 is on 15-minute checks but continues to wander and fall. On 1/23/23 at approximately 12:56 PM, CNA C was interviewed on the phone. CNA C was asked if they were familiar with the incident that occurred between R171 and R18 on 10/27/23. The CNA reported that they remembered that they were assigned to the hall where both the residents resided and when a call light was pressed they found R171 on the floor and was told by R18 that the resident had entered the room and touched the resident private area and R18 kicked R18. When asked if they were familiar with R171 they indicated that they were and noted that the resident was always going in and out of other resident's rooms. On 1/24/23 at approximately 10:15 AM an interview and record review were conducted with the Director of Nursing (DON). Corporate Nurse D was present during the meeting. A discussion concerning R171 continuous falls was conducted, including the incident that occurred when R171 entered R18's room and started touching R18 in the groin area and R18 kicked R171 causing him to fall to the ground. The DON reported that the incident did occur however due to R171's decreased cognition and continuous confusion the facility was not able to determine if the initial touch was meant to be sexual. However, the DON did report that the R171 had a history of wandering into other resident's rooms. The DON reported that following the incident R171 was placed on 15-minute checks. *It should be noted that following the incident on 10/27/23 the resident continued to enter other resident's rooms despite having alleged 15-minute checks.