**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #3's face sheet showed the following: -admission date of 12/30/24; -Diagnoses included cognitive communication deficit, muscle weakness, osteoarthritis, low back pain, abnormality of gait and mobility, insomnia, and left hip fracture. Review of the resident's care plan, dated on 12/30/24, showed the following: -Resident at risk for falls related to altered cognition and impaired mobility; -Staff to keep call light in reach, monitor for any change in condition, provide standby assistance for mobility, complete my fall risk assessment quarterly and as needed, and ensure appropriate footwear that fits well, fastens securely, and has nonskid soles. Review of the resident's fall event report, dated 01/04/25, showed the resident had an unwitnessed fall. Resident was observed on floor with possible injury to the left hip. Staff began neuro checks and completed full assessment. Resident complained of moderate pain to left hip. Review of the resident's nurses' notes showed staff documented the following: -On 01/04/25, at 11:05 P.M., resident was found on the floor on his/her back. Resident complained of left hip pain. Physician ordered on-site x-ray and mobile x-ray unable to respond until 8:00 A.M. Physician was made aware; -On 01/05/25, staff noted x-ray negative. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's admission MDS, dated [DATE], showed the following information: -Resident had moderately impaired cognition; -Resident dependent on assistance for wheelchair mobilization, dressing, personal hygiene, bed mobility, standing from sitting, and bed/chair transfers; -Ambulation did not occur during the 7-day look back period. Review of the resident's fall event report, dated 01/16/25, showed the following: -An unwitnessed fall with injuries and skin tears to left forehead and left wrist; -Staff began 72-hour neurochecks per protocol and to document appropriately; -Staff document full assessment documented and complaint of left leg pain; -Interventions immediate measures of first aid. Preventative interventions of encouraged to use call light for assistance; -Outcome of interventions: no interventions used, resident in bed resting at this time. Review of the resident's nurses' notes showed staff documented the following: -On 01/16/25, at 12:55 A.M., resident was alert and oriented to person and place with periods of confusion and restless at times and easily redirected; -On 01/16/25 at 10:05 P.M., aide reported a fall. Nurse observed resident lying down on his/her left side with skin tears to forehead that measured 0.4 centimeters (cm) and left wrist 1.0 cm. Resident complained of pain and was unable to tell staff what happened. Staff obtained order for x-ray in the morning. Staff will continue to monitor; -On 01/17/25, at 12:05 A.M., resident alert to person and place with periods of confusion, trying to get out of bed without assistance. Resident required total assist with cares and used wheelchair for mobility; -On 01/17/25, at 9:23 A.M., resident noted to have left hip fracture related to fall on 01/16/25 that was confirmed by mobile x-ray. Family advised and physician advised of results. Resident sent to hospital at 9:10 A.M. for evaluation and treatment. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. 3. Review of Resident #4's face sheet showed the following: -admission date of 12/31/24; -Diagnoses included arthritis, osteoporosis, left pubic fracture (on admission), insomnia, restlessness and agitation, hallucinations, repeated falls (on admission), osteoarthritis to right shoulder, and chronic pain. Review of the resident's admission MDS, dated [DATE], showed the following information: -Resident had moderate to severely impaired cognition; -Resident required partial to moderate assistance for toileting hygiene and upper body dressing; -Resident required substantial to maximal assistance for bed mobility, standing from sitting, bed/chair transfers, and ambulation of 10 feet. Review of the resident's care plan, dated 12/31/24, showed the following: -Resident at risk for falls related to history of falls, altered cognition, impaired mobility, medication regimen, general debility, and disease processes; -Staff to avoid clutter on floor surface, complete fall risk assessment quarterly and as needed, ensure appropriate footwear that fits well, fastens securely, and has nonskid soles, and place a fall mat next to the bed. Review of the resident's fall event report, entered 01/01/25 at 1:16 A.M., showed the following: -Event date of 12/31/24 at 6:30 P.M.; -Resident found lying in floor next to bed; -Unwitnessed fall. Staff began 72-hour neurochecks per protocol and to document appropriately; -Full assessment documented with no injuries noted and resident denied pain. Resident exhibited agitation, anxiety, and confusion; -Resident placed at nurses' station for monitoring; -Falls Prevention Program initiated and care plan updated. Review of the resident's fall event report, entered 01/01/25 at 1:44 A.M., showed the following: -Event date of 12/31/25 at 8:00 P.M.; -Resident found by staff lying in floor of room next to bed; -Interventions was left blank; -No injuries noted; -Vital signs documented; -Falls Prevention Program initiated and care plan updated. Review of the resident's fall event report, entered 01/01/25 at 2:41 A.M., showed the following: -Event date of 01/01/25 at 1:00 A.M.; -Resident found lying in floor of room next to bed and stated, I had to help my roommate. Resident had placed roommate in chair; -Interventions were left blank; -Resident refused vital signs and full assessment; -Falls Prevention Program initiated and care plan updated. Review of the resident's fall event report, entered on 01/01/25 at 5:57 A.M., showed the following: -Event date of 01/01/25 at 5:57 A.M.; -Resident found lying in floor next to bed and unable to state what happened; -Unwitnessed fall and staff began 72-hour neurochecks per protocol and to document appropriately; -No injuries noted and resident denied pain; -Interventions of other and left blank. Outcome of interventions noted no interventions used; -Falls Prevention Program initiated and care plan updated. Review of the resident's nurses' notes showed staff documented the following: -On 12/31/24, at 6:30 P.M., resident found by staff lying in floor of room next to bed and unable to say what occurred. Staff noted no injuries and placed resident back in bed. Staff informed physician and family; -On 12/31/24, at 8:00 P.M., resident found by staff lying in floor next to bed and unable to say what occurred. Staff noted no injuries and placed resident in wheelchair and brought to nurses' station for observation. Staff informed physician and family; -On 01/01/25, at 1:00 A.M., resident found on floor next to bed. Resident stated he/she had to help his/her roommate and had gotten roommate up to wheelchair. Resident refused vital signs and full assessment. Resident placed in wheelchair and sat by nurses' station for monitoring; -On 01/01/25, at 5:52 A.M., resident found lying on floor of room next to bed and unable to state what occurred. Staff noted no injuries noted and placed resident back in bed. Staff informed family of all falls and physician to be notified by day shift; -On 01/01/25, at 5:59 A.M., resident found lying in floor of room next to bed with no injuries noted. Resident refused assessment and staff informed family informed; -On 01/01/25, at 6:13 A.M., staff informed Assistant Director of Nursing (ADON) of all falls. Review of the resident's care plan showed staff did not update the care plan with the falls or new interventions to prevent future falls. Review of the resident's fall event report, entered on 01/07/25 at 2:52 P.M., showed the following: -Event date of 01/07/25 at 2:51 P.M.; -Resident found on floor beside his/her bed; -The fall was unwitnessed fall and staff begin 72-hour neurochecks per protocol and to document appropriately; -Resident had bruising/hematoma with no location noted; -Interventions included rest, fall mat placed, and use of relaxation techniques such as white noise, soothing music, fish tank; -Outcome of interventions were somewhat effective; -Falls Prevention Program initiated and care plan updated. Review of the resident's nurse's note dated 01/08/25, at 12:57 A.M., showed the resident continued on fall monitoring and had a bruise to right side of face from previous fall. Vital signs and range of motion (ROM) within normal limits (WNL) to baseline. Resident did not complain of pain or discomfort. Staff will continue to monitor. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's fall event report, entered on 01/10/25 at 1:57 P.M., showed the following: -Event date of 01/09/25 at 7:45 P.M.; -Observed resident on floor beside bed with no injury noted and neurochecks initiated; -Resident had dozed off. Resident assisted up with two assist. Resident stated that he/she was trying to get into bed, but didn't quite make it. Neuros initiated and baseline for resident. Resident with advanced dementia and no retention to educate. Vital signs stable. Staff assisted to bed with bed in low position and mat beside bed. -Fall was unwitnessed and staff began 72-hour neurochecks per protocol and to document appropriately; -Mental status of confusion and sleepiness; -Possible contributing factors included recent decline in ADLs (activities of daily living) abilities and dementia; -Resident on antipsychotics and anti-anxiety medications; -Interventions of fall mat placed, ensure necessary items are in reach, and assist resident to bed when tired were somewhat effective; -Falls Prevention Program initiated and care plan updated. Review of the resident's nurse's notes showed a late entry dated 01/10/25, at 2:04 A.M., for 01/09/25 at 7:59 P.M. Resident observed lying on floor beside bed. Resident had dozed off. Staff assisted resident up with two assist. Resident stated that he/she was trying to get into bed, but didn't quite make it. Neuros initiated and baseline for resident. Resident with advanced dementia and no retention to educate. Vital signs stable. Staff assisted to bed with bed in low position and mat beside bed. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's fall event report, entered on 01/10/25 at 2:03 P.M., showed the following: -Event date of 01/10/25 at 2:00 P.M.; -Observed on the floor at the foot of his/her bed with no injury and neurochecks initiated; -Resident stated he/she went to get up to put him/herself to bed and slipped and fell. Resident denied pain or discomfort; -Fall was unwitnessed fall and staff began 72-hour neurochecks per protocol and to document appropriately; -No changes in mental status; -Interventions noted to ensure necessary items are in reach and assist resident to bed when tired; -Falls Prevention Program initiated and care plan updated. Review of the resident's nurse's note dated 01/10/25, at 2:08 P.M., showed the resident was observed lying on the floor at the foot of his/her bed. Resident stated that he/she went to get up to put him/herself to bed and slipped and fell. Resident denied any pain or discomfort and had full range of motion (FROM). Neurochecks initiated and at baseline for resident. Staff notified physician and family. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's fall event report, entered on 01/14/25 at 5:54 P.M., showed the following: -Event date of 01/14/25 at 12:00 P.M.; -Witnessed fall with no injury; -Interventions of non-slip socks; -Falls Prevention Program initiated and care plan updated. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's fall event report, entered on 02/09/25 at 11:57 A.M., showed the following: -Event date of 02/09/25 at 10:00 A.M.; -Resident was heard to yell out. Upon entering room staff observed resident sitting on the floor. Resident stated he/she was trying to go to the bathroom and slipped and fell. Brief noted on the floor with a puddle under resident's feet. Resident had a small laceration to back of head and right elbow. Area to back of the head cleaned with wound cleanser and covered with one steri-strip. Resident denied pain and neurochecks initiated; -Fall was unwitnessed fall and staff began 72-hour neurochecks per protocol and to document appropriately; -No change in mental status; -Immediate intervention of first aid; -Falls Prevention Program initiated and care plan updated. Review of the resident's nurse's note dated 02/09/25, at 10:10 A.M., showed resident was heard to yell out. Upon entering room resident was observed sitting on the floor. Resident stated he/she was trying to go to the bathroom and had slipped and fell. Brief noted on the floor with a puddle under resident's feet. Resident had small laceration to back of head and right elbow. Area to back of the head cleaned with wound cleanser and pressure applied until bleeding stopped. Area to right elbow cleansed with wound cleanser and covered with one steri-strip. Resident denied any pain or discomfort. FROM to all extremities. Resident assisted up via two staff members. Staff initiated neuros and at baseline for resident. Staff notified physician and family. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's fall event report, entered on 02/23/25 at 10:04 A.M., showed the following: -Event date of 02/23/25 at 6:30 A.M.; -Fall was witnessed. Resident was sitting at the nurses' desk and stood up out of her wheelchair, slipped on the floor, fell, and hit her head on the counter with no injuries noted. Staff completed full assessment and neurochecks initiated. Staff will continue to monitor. Review of the resident's nurse's note dated 02/23/25. at 6:30 A.M., resident was sitting at the nurses' desk and stood up out of her wheelchair, slipped on the floor, fell, and hit her head on the counter with no injuries noted. Resident had FROM to all extremities. Resident assisted up via two staff members. Staff initiated neuros and resident at baseline for resident. Staff notified physician and family. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Observation on 02/27/25, at 9:30 A.M., showed the resident rested in bed that was was in the lowest position. A wheelchair was positioned close to the bed. A fall mat was folded in half and was standing on edge at the foot of the bed. Observation on 02/27/25, at 10:56 A.M., showed the resident rested in bed with his/her eyes closed. A fall mat was fold up and positioned at the foot of the bed. Observation on 02/28/24, at 2:15 P.M., showed the resident rested on his/her bed. A wheelchair was positioned close to the bed with wheels locked and a fall mat was folded up close to the vacant bed across the room. The resident's doorframe did not have a maple leaf magnet attached to it. 4. Review of Resident #5's face sheet showed the following: -admission date of 04/15/24; -Diagnoses included Alzheimer's disease with late onset, dementia, delusions, history of repeated falls, and difficulty with near vision. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -No ambulation and used manual wheelchair, assisted by staff; -Dependent on others for eating, hygiene/bathing, dressing, sitting/lying/ sitting/standing, and chair/bed transfers; -No functional limitation on upper or lower extremities; -Falls since prior assessment (quarterly (dated 10/16/24)) were two without injury, two with minor skin injury, and none with major injury. Review of the resident's significant change MDS assessment, dated 01/26/25, showed the following; -Severely impaired cognition; -No ambulation, manual wheelchair assisted by staff; -Dependent on others for eating, hygiene/bathing, dressing, sitting/lying, sitting/standing, and chair/bed transfers; -No functional limitation on upper or lower extremities; -No falls since prior assessment. Review of the resident's care plan, initiated on 04/15/24 and last reviewed/revised 01/29/25, showed the following; -Resident required assist of one to two staff for ADLs related to severe cognitive loss, impaired mobility, weakness, and disease processes; -Resident preferred to be in the floor at times and this was a long-term habit; -Resident up daily to a wheelchair via one to two assist and required assistance for locomotion; -Resident at risk for falls related to history of falls, impaired safety awareness, impaired mobility, medication regimen, general debility, and disease processes; -Resident slept on mattress in the floor to ensure safety and was personal preference to sleep in the floor; -Initiate facility fall protocol; -Avoid clutter on the floor surface; -Complete a fall risk assessment quarterly and as needed; -Ensure resident wears appropriate footwear that fits well, fasten securely, and has non-skid soles; -If resident falls, do an assessment, including vital signs, prior to moving. Review of the resident's fall event report, entered on 12/01/24 at 5:46 P.M., showed the following: -Event date of 12/01/24; -Witness stated resident was rocking in wheelchair, pushing table, and suddenly slid out of wheelchair onto floor. Witness stated resident did not hit head. Resident agitated and appeared anxious. Certified medication technician (CMT) to give resident medication for anxiety. Staff assisted resident assisted up into wheelchair and placed at table to eat dinner. Staff Will continue to monitor; -No pain reported and no injury noted; -Immediate interventions of none. Preventative interventions of fall mat placed and shoes with non-skid soles; -Falls Prevention Program initiated and care plan updated. Review of the resident's nurse's note, dated 12/01/24, showed witness stated resident was rocking in wheelchair, pushing table, and suddenly slid out of wheelchair onto floor. Witness stated resident did not hit head. Resident agitated and appears anxious. CMT to give resident anxiety medication. Staff assisted resident up into wheelchair and placed at table to eat dinner. Staff will continue to monitor. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's fall event report, entered on 12/08/24 at 2:52 P.M., showed the following: -Event date of 12/08/24; -Resident observed on floor in hallway following his/her attempting to stand up from his/her wheelchair. Resident sustained no visible injury. Extremities all move within normal limits for resident. There was no shortness, rotation, or deformation noted in any extremity. Neuros initiated and are within resident's baseline. Following assessment resident was assisted to standing position with assist of two staff and placed back in wheelchair. Staff attempted notification to durable power of attorney (DPOA) and phone not working. Staff notified physician and received no new orders. Staff will continue with ongoing monitoring;. -No pain reported and no injury noted; -No mental changes; -No interventions; -Care plan not reviewed; -Falls Prevention Program initiated and care plan updated. Review of the resident's nurse's note, dated 12/08/24 at 2:53 P.M., showed resident observed on floor in hallway following his/her attempting to stand up from his/her wheelchair. Resident sustained no visible injury. Extremities all move within normal limits for resident. There was no shortness, rotation or deformation noted in any extremity. Neuros initiated and were within resident's baseline. Following assessment resident was assisted to standing position with assist of two staff and placed back in wheelchair. Staff attempted notification to DPOA and phone not working at this time. Staff notified physician notified with no new orders received. Staff will continue with ongoing monitoring. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's fall event report, entered on 12/10/24 at 4:13 P.M., showed the following: -Event date of 12/10/24; -No pain reported and no injury noted; -No immediate interventions and preventative interventions implemented and care plan updated - other, describe below; -Describe other measures, if necessary: (left blank); -Care plan not reviewed; -Outcome of interventions was ineffective, describe below; -Describe outcome of interventions: (left blank); -Falls Prevention Program initiated and care plan updated. Review of the resident's nurse's note dated 12/10/24, at 4:09 P.M., showed resident witnessed attempting to stand and falling to the floor in the process. Resident did not strike head. Resident without complaint or expression of pain. Resident without any obvious deformity or shortening of limbs. Resident noted at baseline for ROM. Vital signs within normal limits. Staff assisted resident back into wheelchair with two assist. Staff notified physician, responsible party, and DON. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's fall event report, entered on 12/18/24 at 6:24 A.M., showed the following: -Event date of 12/18/24; -Resident sitting nurses' station and fell out of wheelchair onto right side. A skin tear of 0.5 cm noted to right elbow. Staff applied dressing; -Unwitnessed fall and staff must begin 72-hour neurochecks per protocol and document appropriately; -No pain reported and no injury noted; -No immediate interventions. Preventative interventions implemented (care plan updated) - adjust bed to lowest level, fall mat placed, shoes with non-skid soles, and assist resident to bed when tired; -Care plan not reviewed; -Outcome of interventions was effective; -Falls Prevention Program initiated and care plan updated. Review of the resident's nurse's note dated 12/18/24, at 6:24 A.M., showed resident was sitting behind nurses' station in his/her wheelchair when he/she attempted to stand up, resulting in falling to the floor. Event was witness by staff. Small skin tear noted to the left elbow with no other injury noted at this time. Resident was assisted to standing position and placed back in wheelchair. Neuros not initiated due to resident not hitting head. Physician and responsible party to be notified by oncoming nurse. Staff will continue with ongoing monitoring and nurse on duty informed. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's fall event report, dated 12/19/24, showed the following: -Event date of 12/19/24; -Observed on floor, neuros initiated, bruising and raised area to the left side of face; -Unwitnessed fall and staff must begin 72-hour neurochecks per protocol and document appropriately; -No pain reported; -Injury of bruising, bump; -No change in mental status; -Immediate intervention of rest and preventative interventions implemented of other, describe below; -Describe other measures: (left blank); -Outcome of interventions: no interventions used; -Notifications made: (none indicated); -Care plan not reviewed; -Falls Prevention Program initiated and care plan updated. Review of the resident's nurse's note dated 12/19/24, at 10:39 A.M., showed resident was standing at the desk and lost his/her balance, falling and hitting the left side of his/her head/face on the floor. Resident denied pain at this time and neuros initiated. Vitals have been recorded within normal limits. Staff notified DON and called family who did not answer. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's fall event report, entered on 12/22/24 at 3:23 P.M., showed the following: -Event date of 12/22/24; -Unwitnessed fall on 12/22/24, in the hallway; -Resident was sitting in wheelchair at nurses' station; -Unwitnessed fall, staff must begin 72-hour neurochecks per protocol and document appropriately; -No pain reported; -Injury of bump to left side of forehead and rub burn; -Mental status of anxiety, confusion, and restlessness; -Immediate interventions of rest and preventative interventions implemented of assist resident to bed when tired; -Outcome of interventions noted as effective; -Care plan not reviewed; -Falls Prevention Program initiated and care plan updated. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's nurse's note dated 02/24/25, at 11:05 A.M., showed resident sitting behind nurses' desk and slid out of chair onto floor in front of medication room door. Staff unable to stop resident from having fall. Incident witnessed by staff. ROM within normal limits for resident and no injuries noted at this time. Staff notified physician and responsible party. Staff assisted resident from floor with two staff and placed back in wheelchair. Review of the resident's fall event reports showed no entry pertaining to the fall on 02/24/25. Review of the resident's care plan showed staff did not update the care plan with the fall or new interventions to prevent future falls. Review of the resident's quarterly Evaluation Notes, documented by MDS Coordinator B, showed the following: -Quarterly falls from 02/21/24 - 06/19/24: 15 falls; 7 with injury, 8 without injury; interventions reviewed and appropriate; -Quarterly falls from 06/20/24 to 09/04/24: 1 fall with no injury, 3 falls with injury; interventions reviewed and appropriate; will continue plan of care; -Quarterly falls from 09/05/24 to 12/13/24: 16 falls - 12 falls with no injury, 4 falls with injury; interventions reviewed and appropriate; will continue plan of care. Observation on 02/27/25, at 10:35 A.M., showed the resident rested in bed, which was positioned low to the floor. A thick fall mat was positioned close to the bed and a rubber type mat was positioned lengthwise from the fall mat toward the sink and vanity area of the room. Observation on 02/27/25, at 10:54 A.M., showed the resident called out with a loud noise and no words were used. A CNA and the facility Administrator both entered the room to respond. The Administrator told the surveyor the resident's care plan indicated the resident would crawl out of bed onto the fall mat, and would crawl and scoot around on the floor, but didn't ever go too far from his/her bed. The mats were in place to protect him/her from falls and from hurting his/her knees. Observation on 02/28/25, at 2:14 P.M., showed a maple leaf magnet on the top left side of the resident's doorframe. 5. During an interview on 02/28/25, at 2:17 P.M. CNA J said he/she did not know why there was a leaf on some residents' doors. The CNA was unaware of the Falling Leaf Program. During an interview on 02/28/25, at 9:15 A.M., CNA G said the following: -He/she gets the nurse if a resident has a fall. The nurse assesses the resident; -He/she helps by getting vitals signs and will assist with getting the resident up; -Generally, he/she will then turn the television on or put resident into bed depending on why the resident fell; -He/she was generally made aware if a resident had a fall by what is passed on in report; -He/she was not aware of the falling leaf program. He/she was not aware of anything marking the door frame of residents that have had falls or are a high fall risk; -Resident's that have interventions for falls should have it on their care plan. The nurse should pass on any interventions to the staff. During an interview on 02/28/25, at 9:36 A.M., CNA I said the following: -He/she was not aware of what the falling leaf program was; -If a resident falls he/she goes to get the nurse; -The resident was assessed and he/she assisted with getting vital signs; -Generally, he/she was told about new falls and interventions in report; -He/she thought fall interventions should be on the care plan. During an interview on 02/28/25, at 2:18 P.M., Hospitality Aide (HA) K said he/she did not know why there was a leaf on some residents' doors. The HA was unaware of the Falling Leaf Program. During an interview on 02/28/25, at 2:20 P.M., CMT L said the leaf magnet on a resident's door means they are a fall risk and staff should monitor them more often. During an interview on 02/28/25, at 9:23 A.M., LPN H said the following: -The residents are assessed after a fall by the nurse and the nurse then will provide immediate interventions of pain medication or first aide if needed. The physician is notified immediately if there is injury or suspected injury; -The staff generally keep a close eye on the residents after they fall; -He/she was not aware of there being anything on the resident's doorways that lets staff know they are a high falls risk, but it is generally passed on in report. He/she was not aware of the falling leaf program; -He/she believed the facility fall protocol was regarding completing an event and fall follow up assessments for 72 hours; -The DON decided on further interventions; -The interventions for falls should be added to the residents' care plans. During an interview on 02/28/25, at 9:00 A.M., RN F said the following: -He/she was not sure what the exact policy and procedure was after a resident falls; -He/she was not sure what the falling leaf program was; -He/she assesses the resident after a fall. The nurse fills out the event and continues monitoring for 72 hours once per shift; -Fall prevention depends on the mechanism of the fall; -He/she thought the fall would be investigated and then interventions should be added to the care plan; -He/she was not sure who adds the interventions to the care plan. During an interview on 02/28/25, at 1:36 P.M., MDS Coordinator N said the following: -Resident care plans are updated with each fall quarterly. New interventions should be added to the care plan; -He/she did not update the care plan after each fall; -The intervention depended on what the reason was for the fall; -If a resident had repeated falls they should be on the falling leaf program; -The DON puts leaves up on the doorway of residents who have had multiple falls so that staff is aware and checks on them more often; -They put that on the care plan as the fall protocol; -The nurses do not update the care plan with interventions; -The staff discussed falls at the morning meeting and weekly for residents at risk; -He/she kept putting in interventions for falls until they felt like they are maxed out. During an interview on 02/28/25, at 2:14 P.M., MDS Coordina[TRUNCATED]

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to ensure the safety of all residents when lack of staff supervision on the locked special care (memory) unit resulted in extended resident to resident interaction that ended with one resident (Resident #2) pushing one resident (Resident #1) to the floor resulting in one resident (Resident #1) sustaining a hip fracture. A sample do 25 residents were reviewed in a facility with a census of 94. Review of the facility policy titled, Routing Monitoring of Events (Incidents and Accidents), dated 11/14/16, showed the following: -This is a general guideline for event monitoring, to include, but not limited to bruises, skin tears, and falls; -Event prevention and actions to minimize them are ongoing each shift/day. Staff should report and/or take action for circumstances that may result in an event or lessen the likelihood of an event; -Events are reviewed at the time of occurrence by staff on duty, looking for causes and or methods/actions to minimize future occurrence; -Events are monitored/reviewed by management daily, not including weekends and holidays. However, events triggering the abuse prohibition protocol are reported to the nurse on call after hours, weekends, and holidays; -Education is ongoing with all staff. Event education is routinely completed at staff meetings and immediately as required/applicable. 1. Review of the Facility Assessment Tool (an assessment used to make decisions about direct care staff needs, and what resources are necessary to care for the residents), dated 02/24/23, showed the following: -The average daily census was 105 to 120 residents; -The average number of residents who required one to two staff assist for transfer was 40% to 60%; -The average number of residents who required one to two staff assist for toileting was 40% to 60%; -Day shift needed three to five licensed nurses, two to four certified medication technicians (CMTs), and four to sixteen nurse aides; -Night shift needed two to three licensed nurses, and three to nine nurse aides. (The Facility Assessment Tool showed the home did not address the staffing needs specific to the special care unit in the Facility Assessment.) Review of the Facility Staffing Roster, dated 07/19/23 through 08/15/23, showed the following on overnights: -Two nurses in the building, with no nurse was in the memory unit; -Four to five aides in the building, with one being in the memory unit. Review of the facility's Daily Census Report, dated 08/13/23, showed 17 residents in the memory unit as of midnight on 08/13/23, with six of those residents requiring one to two assist for transfer and toileting. Review of the Facility Fall Log, dated 07/16/23 to 08/16/23, showed 12 falls occurred on the memory hall, with three occurring during the overnight shift. 2. Review of Resident #1's face sheet showed the following: -admission date of 05/08/23; -Diagnoses included unspecified intellectual disabilities, epilepsy (a disorder in which nerve cells activity in the brain is disturbed, causing seizures), repeated falls, unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescence, and a history of traumatic brain injury (TBI-a brain injury caused by an outside force, usually a violent blow to the head). Review of Resident #1's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff), dated 08/03/23, showed the following: -The resident was severely cognitively impaired; -Wandering occurred one to three days of the seven day look back period (the period of time the evaluation was done); -The resident required setup to one person assist for eating, toileting, and transfers. Review of Resident #1's care plan, updated 08/12/23, showed the following: -Resident has a tendency for wandering (moves with no rational purpose, seemingly oblivious to needs or safety) while dragging personal belonging behind him/her (i.e. clothing, purses, chair); -Required assist of one staff for all activities of daily living (ADLs-transfers, toileting, bathing, dressing, grooming) related to impaired mobility and weakness at times and disease processes. Including hygiene and toileting; - Resident is at risk for complications and physical injury related to seizure disorder. Review of Resident #1's nursing notes showed the following: -On 07/04/23, at 8:42 A.M., staff documented the resident was standing at nurses' station after bath and fell straight backwards hitting his/her head on floor. Resident obtained skinned left arm with hematoma (bruising). The resident was noted to be having grand mal seizure (a type of seizure that causes strong muscle movements on both sides of your body, including convulsions), both eyes turning towards the right, snorting and shaking lasted approximately two minutes. A pillow was placed under his/her head and he/she was turned on his/her side with another licensed practical nurse (LPN) at his/her side. The resident came out of the seizure, stood up by him/herself, was unsteady on his/her feet, and was assisted by the certified nurse aide (CNA) and nurse to ambulate. Staff administered as needed (PRN) Ativan (an anti-seizure medication). Staff notified the resident's responsible party to see what his/her wishes were. Responsible party asked for staff to monitor. Staff notified the physician with no new orders written. Staff notified the Assistant Director of Nursing (ADON). Staff assisted the resident to bed and resident is resting with his/her eyes closed at this time. Vital signs are high on blood pressure, neurological checks (an assessment to evaluate the resident's level of mental function) intact (no change to level of consciousness, movement to all four extremities or unchanged from baseline, pupil reactions equal and brisk, hand grip equal and strong or unchanged from baseline, speech unchanged from baseline), and at baseline, his/her right eye is starting to darken, and a small bump noted to right lower base of skull; -On 07/21/23, at 5:05 P.M., staff documented the resident was observed sitting on the floor of his/her room leaning against sink console surrounded by books and two purses. The resident was unable to relate how or what occurred but it was noted during the assessment, a red purse strap was wrapped around his/her leg and he/she had previously trying to carry large load of books/magazines. No marks or sign of injury apparent. The resident was restless and not wanting to sit still for complete vital signs. Resident had normal movement with no pain displayed. Neuro-checks within normal limits. Staff called the nurse practitioner at 4:50 P.M. and the responsible party at 4:55 P.M. The resident is calm at present time and allowing further assessments and vital signs; -On 07/26/23, at 9:45 A.M., staff documented the resident has been taking all the chairs from around nurses' station to his/her room along with several overhead tables. The physician was present and observed behaviors. Staff administered PRN Ativan one hour prior. Physician gave an order to give an extra dose of Ativan. Staff administered the dose and the resident is still moving chairs. He/she is not easily able to be redirected; -On 07/26/23, at 5:55 P.M., staff documented the resident continued to take all chairs around the nurses' station to her room along with the overhead tables, then poured water pitcher on floor. The floor was cleaned up, and chairs were attempted to be replaced at desk. The resident continued to move chairs back to his/her room. Staff administered PRN medication with no relief; -On 07/28/23, at 10:13 A.M., staff documented the resident up to nurses' station taking everything to his/her room, all the books, paperwork, gloves, supplies, all items were taken off the desk and put into the med room. Staff administered PRN medication for wandering, attempting to get in med room, and rummaging; -On 07/30/23, at 9:10 A.M., staff documented the resident has been pacing and wandering much of the morning. His/her appetite remained good. He/she been somewhat irritable and trying to drag furniture off to his/her room. Upon attempting to take chairs to room, staff noted resident had some unsteadiness of gait and would have fallen with the chair if staff had not intervened. Staff administered a PRN medication for anxiety. The resident continued to display agitation upon not letting him/her drag chairs. Staff attempted diversion with walking. Resident was calmer after walking in courtyard. Upon return inside consented to lie down for rest; -On 08/01/23, at 8:13 A.M., staff documented the resident had been agitated and restless all morning, he/she had been moving chairs and overhead tables from nurses' station to her room, and when staff attempted to remove excess chairs and tables from his/her room he/she tried to throw him/herself backwards. The resident has been a one-on-one (a care giver providing support specifically to one individual) this morning. Staff administered PRN medication with little relief. He/she is also taking things from nurses' station. The resident's purse keeps getting wrapped around his/her feet and had to be removed several times. He/she remains a high fall risk due to TBI, seizure history, and poor insight to safety from TBI; -On 08/02/23, at 8:18 A.M., staff documented the resident has been up pacing and pulling chairs and tables and the dehumidifier into his/her room. The night shift reported he/she has been up since 3 A.M. and was throwing him/herself backwards when asked to leave the chairs and tables alone. He/she had several chairs already in his/her room. Staff administered PRN medication with some relief. When the resident has these behaviors he/she was working him/herself up and crying. He/she was helped back to bed and is resting peacefully at this time face is more relaxed; -On 08/02/23, at 5:40 P.M., staff documented the resident continued to pace and pull chairs and tables into his/her room. He/she becomes agitated when chairs are removed from the room and he/she is not allowed to pull on them. The chairs pose a trip hazard. He/she is unsteady on his/her feet, and when the chairs are removed he/she throws him/herself backwards and repeats over and over chairs, chairs. The responsible party states the resident had an interest in chairs at home. The resident has been unable to be redirected today. His/her appetite is poor, and he/she does not want to sit still long enough to eat. He/ she did nap for a short time today; -On 8/03/23, at 8:58 A.M., staff documented the resident is pacing and attempting to drag chairs to his/her room. He/she is unaccepting of redirection and yelling and holding onto furniture. A PRN dose of Ativan was given. The resident consented to go on a walk with staff and then lie down for rest. -On 08/06/23, at 5:58 P.M., staff documented the resident has been moving all the chairs and overhead tables from the dining room and around the nurses' station to his/her room. He/she has knocked over several of them when dragging them, has gone through all the drawers and cubby holes at nurses' station and taking anything he/she can get. He/she has been rummaging in other residents' rooms as well. He/she is difficult to redirect. Staff administered PRN medication with no relief; -On 08/08/23, at 4:10 P.M., staff documented that at 3:15 P.M., the resident was observed pushing the over bed table behind the nurses' desk. When the table became caught on a chair, the resident pulled back on the table and fell backwards to the floor and bumped the back of his/her head on another chair. Neuro-checks were initiated with normal results. The resident had a small bump on upper right side of his/her head. No redness or tenderness was observed. No other marks or sign of injury were apparent. Staff notified the physician and responsible party; -On 08/09/23, at 4:06 P.M., staff documented the resident had been wandering in the hallways, holding on to two purses and books. He/she had dropped the books he/she was holding numerous times and bent over to pick them up. He/she is also picking up the trash cans and carrying them up and down the hallways. The resident is pleasant, but busy; -On 08/10/23, at 3:19 P.M., staff documented the resident wandered up and down the hallways and was unsteady on his/her feet, but can correct unless he/she was upset than he/she throws him/herself backwards. He/she was carrying two purses and drops things at times then bends down to pick them up. He/she does fall at times. He/she has a bruise on top of his/her head at this time, but no signs or symptoms of pain; -On 08/13/23, at 2:45 A.M., staff documented the CNA reported that he/she came out of bathroom from assisting another resident when he/she saw Resident #1 on the floor. The resident was crying and had his/her hand on his/her right mid lateral (outer) leg. Staff notified the responsible party, Assistant Director of Nursing (ADON), and physician with no new orders at that time; -On 08/13/23, at 4:30 A.M., staff documented a telephone order was received for an x-ray to the resident's right lower extremity; -On 8/13/23, at 4:59 A.M., staff documented resident's responsible party to transport resident to emergency room (ER) for x-ray. Staff informed him/her that the physician had ordered an x-ray, but the responsible party opted not to wait for the mobile x-ray to arrive. Encouraged to keep staff posted on resident's condition; -On 08/13/2023, at 10:47 A.M., staff documented a call was received from the responsible party who informed staff that resident had a fractured hip and would be having surgery later that day. Review of Resident #1's hospital records, dated 08/13/23, showed the following: -The resident was admitted for further evaluation of a closed intertrochanteric (the upper thigh bone) fracture of the right hip, sustained after a fall at his/her living facility. 3. Review of Resident #2's face sheet showed the following: -admission date of 08/02/23 -Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) restlessness and agitation, and insomnia (persistent problems falling and staying asleep). Review of Resident #2's discharge MDS, dated [DATE], showed the following: -The resident was moderately cognitively impaired; -He/she required one person for assist for ADLs; -He/she exhibited wandering four to six days of the seven day look behind period, but no other physical or verbal behaviors. Review of Resident #2's care plan, updated 08/15/23, showed the following: -The resident required assist of one for all ADL's related to occasional weakness and disease processes, including transfers and toileting; -He/she has a tendency for wandering (moves with no rational purpose, seemingly oblivious to needs or safety). (Staff did not address any other behaviors in the care plan.) Review of Resident #2's nursing notes showed the following: -On 08/02/23, at 5:44 P.M., staff documented the resident had been pacing in hallways introducing self to everyone. He/she was pleasant and cooperative. Resident testing all the doors and setting off alarms. Resident was able to be redirected at this time; -On 08/02/23, at 7:47 P.M., staff documented the CNA reported that the resident continued with extreme aggressive behaviors (pushing on all exit doors, throwing things at others, trying to exit through windows). Staff notified the on-call nurse practitioner (NP) regarding residents behaviors and received new order for lorazepam (an anti-anxiety medication) 0.5 milligrams (mg), one tablet by mouth (PO) times one dose. The new order was entered in the medical record and med pulled from the emergency kit (STAT safe); -On 08/02/23, at 10:37 P.M., staff documented the CNA and CMT reported to this nurse that the resident was having suicidal ideations. The resident told the CMT that he/she wished the lorazepam was poison, wanted to climb to out of windows on the memory unit and walk out into traffic, and wanted to know if he/she climbed up on the desk and jumped would it kill him/her. The resident was assisted to bed by two staff members due to the effectiveness of one dose of lorazepam. Staff notified on-call for the physician, the NP, the Director of Nursing (DON), and ADON. Staff implemented 15-minute checks. The responsible party was called and message left to return call to facility at his/her convenience. Staff made aware of checks and resident was resting in bed with his/her eyes closed at this time; -On 08/03/23, at 6:40 A.M., staff documented the resident pulled two fire alarms in the memory unit. He/she is anxious and stating that we have to get out of here, we are all going to burn. Staff reassured resident that there was not a fire and everyone is safe. The resident continued pacing toward doors. Staff called the NP with a report of the incident. A new order for lorazepam 0.5 mg every 6 hours was written. Staff will administer as soon as available from STAT safe; -On 08/05/23, at 12:07 A.M., staff documented the resident was wandering the unit. He/she ambulating with a steady gait. He/she attempted to exit earlier and was redirected with some success. The resident is resting quietly at this time, and remains on 15 minute monitoring for behaviors; -On 08/05/23, at 6:34 A.M., staff documented the resident remained on 15 minute monitoring for suicidal ideations. He/she had no plan, but voiced the idea. The resident was in his/her room at this time with the door barricaded by the sofa. He/she stated he/she is ok, with no suicidal ideations. The resident is up wandering in his/her room; -On 08/05/23, at 4:45 P.M., staff documented the resident has been up pacing in the hallways and asking to smoke numerous times. He/she had been taken out several times. His/her responsible party came to visit and stayed approximately 30 minutes. The resident was upset after the responsible party left. The responsible party voiced his/her concerns about the resident doing self-harm and stated he/she tried at home. The resident said he/she wanted to die after the responsible party left. The resident pacing hallways and setting off alarms. He/ she did get outside and tried to get out the gate. Staff administered a PRN medication and he/she is on the psychiatrist's list for next week. The resident is on one-on-one care at this time; -On 08/05/23, at 6:06 P.M., staff documented the resident had been crying and putting him/herself on the floor and praying to die. He/she has not voiced any plans or suicidal ideation. Resident has not been eating or drinking, and is more depressed after his/her responsible party leaves. Staff notified the physician and a new order was received for Remeron (an antidepressant) 7.5 mg at bedtime. Staff made the responsible party aware. The resident had set off every alarm in unit and had been outside several times; -On 08/06/23, at 1:16 A.M., staff documented the resident is resting quietly this shift. He/she was wandering the memory unit earlier and attempting exit seeking; -On 08/06/23, at 12:52 P.M., staff documented the resident was witnessed falling in front of the nurses' station. The resident had been up pacing. His/her gait was unsteady. He/she made quick turns and walks with his/her head facing the ground. The resident fell to the right side, causing a skin tear to his/her right elbow. Staff assessed the resident and first aid administered to his/her arm. Staff notified the ADON and attempted to call the responsible party. Neuro checks were intact and at baseline. Resident had previous old bruise to left forehead, his/her range of motion was within normal limits, and he/she had no complaints of pain; -On 08/06/23, at 2:32 P.M., staff documented the resident slept in a chair for a short time, woke up and started running. He/she is very unsteady on his/her feet and has almost fallen several times. The resident did have a witnessed fall and hit his/her head. He/she is very impulsive, at times does put him/herself on the floor and cover his/her head and prays and cries. The resident has not been as tearful today; -On 08/07/23, at 4:48 P.M., staff documented resident to be praying God take me, I want to die. What have I done to deserve this, over and over. Attempted to redirect and reassure resident, but he/she is having difficulty accepting. The responsible party in to visit and expressed concern regarding resident's continuing statements about wanting to die. -On 08/09/23, at 3:01 P.M., staff documented the resident was attempting to break the glass doors in the dining room with a metal chair, is wandering into the other residents' rooms, and tearing up the rooms. Staff to administer PRN medication and monitor the resident for falls; -On 08/09/23, at 3:53 P.M., staff documented the resident is wandering the hallways, took the fire extinguisher out of the holder on wall, and attempted to hit the CNA with it. He/she had also tried to tear up the fax machine on the memory unit. Staff administered PRN medication, but it was ineffective. The resident had been having hallucinations and stated the CMT is in the medication room lighting candles. The CMT is preparing drinks for residents. The resident is one-on-one at this time. He/she was seen by the NP earlier this day; -On 08/10/23, at 9:44 A.M., staff documented the resident had been up wandering the halls, exit seeking, trying all the doors and setting alarms off. He/she had been at the nurses' desk attempting to argue with staff and had been in other residents' rooms attempting to take their belongings. The resident had been verbally abusive with staff and wanting to go out and smoke repeatedly. He/she had attempted to take the drawers out of copy machine. Staff administered a PRN medication; -On 08/10/23, at 3:49 P.M., staff documented the resident had been pacing the hallways, had been up to nurses' station numerous times, had been going into other residents' rooms and taking things, and was setting off the alarms on the doors. Staff administered a PRN medication and was awaiting relief; -On 08/11/23, at 8:34 A.M., staff documented the resident was up all night and had been very agitated this morning. He/she had been pacing halls and threatening nurse physically, but no physical contact made. The resident did follow staff while passing medications and obtaining blood sugars. Staff administered PRN medication. The resident is now resting peacefully; -On 08/11/23, at 3:11 P.M., staff documented the resident had been agitated this afternoon and asked to go smoke frequently. Staff reminded resident of the smoking times. The resident was cursing at the nurse and flipping the nurse the bird. He/she was able to be redirected away from nurses' station, but is coming by nurses' station and making threatening and vulgar remarks. Staff contacted the NP. Staff were waiting for a return call; -On 08/11/23, at 5:00 P.M., staff documented the NP gave a one-time order for Haldol (an antipsychotic medication) 1 mg intramuscularly (IM-injected into the muscle) for behaviors. Staff notified the responsible party; -On 08/11/23, at 6:00 P.M., staff documented the resident was not as agitated, but was still exit seeking and setting off all the alarms; -On 08/13/23, at 9:43 A.M., staff documented that at 6:35 A.M., the resident was observed after being awakened from dozing in a chair near the nurses' station, take two steps while turning, fall against the doorway, and hit his/her head on door frame. The resident then fell on his/her left side. Neuro-checks initiated were initiated. The resident complained of pain to his/her left hip, but was able to straighten his/her leg with no rotation and the left leg was even with the right leg. The resident was lifted into a wheelchair with an assist of two staff. The resident continued to complain of left hip pain, stating my hip is out of place. No misalignment was apparent. Staff called the physician at 7:52 A.M. and order was received for stat (immediate) left hip and pelvis x-rays. Staff called the responsible party at 8:02 A.M., and notified him/her of the event and x-ray orders. Resident resting in bed at this time per request. Staff administered Tylenol for continued pain. Staff called the mobile x-ray company notified of the order for x-rays; -On 08/13/23, at 10:23 P.M., staff documented that at 8:30 P.M., staff received the x-ray results of intertrochanteric fracture of left hip. Staff notified the physician at 8:30 P.M. and orders were received at 8:35 P.M. to transport resident to hospital. At 8:40 P.M., staff notified the responsible party and ADON of orders. The resident was transported via ambulance at 8:55 P.M., to the hospital. 4. Review of the Facility Investigation, dated 08/13/23, showed the following: -On 08/13/23, at 2:45 A.M., video footage noted Resident #1 approach Resident #2 three times in quick succession; -On two occasions, it appeared Resident #2 motions for Resident #1 to stay away; -On the third interaction/push, Resident #1 fell to the ground; -Upon staff observation of Resident #1, fall protocols were initiated; -No staff or residents reported knowledge or observation of the event; -Resident #1 and Resident #2 were the only observable individuals during the event that resulted in a fall. Review of summary of interview with witness on the Facility Investigation showed the following: -Recorded documentation by Registered Nurse (RN) A addressed the event as observed on floor due to no staff witnesses. Notifications to the Primary Care Provider (PCP) and responsible party were completed and documented. Orders for an x-ray was issued, but not completed as the responsible party elected to transport the resident to the emergency room. Observation of the facility video footage on 08/15/23, at 1:40 P.M., showed the following: -On 08/13/23, at 2:10 A.M., Resident #1 was leaned over in front of the memory care nurses' station with a bag. Resident #2 was standing at a chair behind him/her. No staff was visible; -Resident #2 walked behind and around the left side of Resident #1, behind the side of the nurses' station, and Resident #1 followed; -Resident #2 pushed Resident #1 back, Resident #1 stumbled, but did not fall; -Resident #1 went back towards Resident #2; -Resident #2 pushed Resident #1 again, Resident #1 fell, landing on his/her right side next to the nurses' station; -No staff was visible throughout the video. Review of CNA B's written statement, dated 08/13/23, showed the following: -At around 2:30 A.M., on 08/13/23, CNA B was in the shower room helping a resident. While CNA B was in the shower room, he/she could hear Resident #1 crying. CNA B rushed out to find him/her laying on his/her right side crying out for his/her purse that was in Resident #2's hands. CNA B got the purse back, then helped Resident #1 off the floor and into a chair. After Resident #1 was in a chair, he/she repeated the word Devil while looking at Resident #2. Resident #1 continued to cry and complain of pain in his/her right hip and upper right thigh. During an interview on 08/16/23, CNA B said he/she works overnights and has worked all the units. He/she has worked on the Faith Unit (the memory care unit). After 10:00 P.M., he/she is usually the only staff on the memory unit. If he/she needs help, he/she has to call another unit. If no one is available, he/she waits until someone is available, which is usually around 20 minutes. He/she said that happens often. Over the past couple weeks, the acuity of the hall has become heavy. He/she hadn't seen any interactions between Resident #1 and Resident #2, but Resident #2 had been having behaviors. Both residents had been being up most nights. It was a challenge being in the memory unit alone with both residents up. CNA B said he/she did not call for help on the night Resident #1 fell, because the residents were not interacting with each other before the fall. Normally he/she could take someone to the restroom with no issues. The CNA said there is not enough staff on the memory unit to meet the residents' needs and they cannot provide oversight. Review of the Maintenance Supervisor's Statement, undated, showed the following: -He/she said the camera time is off approximately 40 minutes; -At 2:11 A.M., on 08/13/23, Resident #1 and Resident #2 were at the nurse's desk; -Resident #1 walked up to Resident #2, and Resident #2 pushed Resident #1 away; -Resident #1 walked back to Resident #2, and Resident #2 pushed Resident #1 away again; -When Resident #1 went up to Resident #2 the next time, Resident #2 pushed Resident #1 and Resident #1 fell; -The aide was in the shower room toileting another resident. When the aide came out, he/she assisted Resident #1 to sit in the chair and got on the phone. 5. During an interview on 08/15/23, at 8:10 P.M., Nursing Assistant (NA) C said he/she had worked on the memory unit, and after 10:00 P.M., he/she is alone. He/she did not feel there was enough staff to meet the residents' needs. Once the residents are in bed, it is better, but trying to get everyone in bed is a challenge. When he/she needs assistance from another staff member, he/she calls to another hall for assistance. It usually takes a minute for staff to respond. He/she was aware of Resident #2 having behaviors towards staff members. 6. During an interview on 08/16/23, at 9:35 A.M., LPN D said he/she always worked on the memory unit. There are at least five residents that require two person assist depending on the day, sometimes six. During the day, there are three staff, at night one aide and a nurse floats between the memory unit and another unit. If an aide goes in a room to take care of a resident, that leaves the hall basically uncovered. The aide doesn't usually call for assistance unless there is a problem or they are going on break. Resident #1 was very protective of his/her belongings. LPN D said he/she had not seen anyone take Resident #1's belongings. Resident #2 had behaviors and was aggressive to staff. There had been four broken hips occur in the last two months on the memory unit. On a good night, one staff member might be enough, otherwise, no. The aide should call for assistance before going into a room to perform cares. A resident to resident altercation could occur in a matter of minutes. 7. During an interview on 08/16/23, at 9:45 A.M., LPN E said he/she floats to different units to assist when needed. He/she has heard of the memory unit being short staffed overnight, having one aide overnight, and a nurse going back and forth between the memory unit and another unit. Some nights he/she would consider that appropriate and some nights not appropriate. If residents are still up wandering in the unit, the aide should call for assistance before assisting another resident in their room. 8. During an interview on 08/16/23, at 12:25 P.M., CNA F said there was not enough help in the memory unit. It was difficult to perform ADLs for the residents. He/she has taken care of Resident #1 and Resident #2. Resident #2 had behaviors that consisted of aggression towards staff. The aide was afraid Resident #2 would hurt someone if staff did not intervene. He/she said he/she did not believe one staff is enough at night to prevent residents from wandering into the other residents' rooms. He/she hears from the night shift that they need more help. 9. During an interview on 08/16/23, at 10:20 A.M., the Nurse Practitioner said she was aware of both resident's behaviors. It is up to the facility to determine staffing for the halls. If the staff feel they need more assistance, they should let the Director of Nursing (DON) know. 10. During an interview on 08/16/23, at 1:18 P.M., the DON and Administrator said staffing is based on a reasonable census and acuity of the residents. They look at the acuity of the residents and base it on that and the facility assessment tool. No one had brought concerns to the DON or Administrator regarding Resident #1 or Resident #2. They were aware after the fact. MO00222956