**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during an Extended Standard survey started on 7/17/23 and completed on 7/25/23, the facility did not ensure that each resident received adequate supervision to prevent accidents for one (Resident #43) of 10 residents reviewed. Specifically, the facility failed to provide adequate supervision to provide a safe environment for Resident #43, who is severely cognitively impaired with a history of resident-to-resident altercations because of unsafe wandering into other residents' rooms. Subsequently, Resident #43 had 8 documented falls from 3/4/23 to 7/21/23 and changes in the plan have been ineffective. This resulted in no actual harm with the likely hood for more than minimal harm that is Immediate Jeopardy and Substandard Quality of Care to Resident #43's health and safety. The policy and procedure (P&P) titled Accident/Incident - Investigation & Reporting documented the purpose was to provide the guidelines for completion, investigation, care plan interventions and regulatory reporting of all Accident & Incidents (A/I); to ensure timeliness of such reporting, and to ensure the appropriate follow-up and monitoring post-incident occurs. Upon the observation or report of an accident and/or incident the staff member must report the occurrence immediately to the charge nurse and the nursing supervisor. This includes a potential for harm that may occur based on an unsafe condition, item, and or situation. Immediate action(s) must be taken at the time of the incident to keep the resident in the safest environment. Action(s) will be noted on the A/I. The immediate action(s) will be reviewed by the Interdisciplinary Team and evaluated and/or altered if indicated. The resident's Care Plan and profile sheet will be updated by the team at this time. 1. Resident #43 was admitted to the facility with diagnoses of dementia with agitation, anxiety disorder and depression. The Minimum Data Set (MDS- a resident assessment tool) dated 6/13/23 documented the resident was severely cognitively impaired, wandered daily and had several falls since prior assessment with and without injuries. The current comprehensive care plan (CCP) initiated on 3/3/23 Resident #43 was at risk for falls related to an unsteady gait, confusion, and behaviors. Documented interventions included to encourage the resident to wear appropriate footwear when walking. A safe environment with even floors free from spills and/or clutter, adequate glare-free light, handrails on walls, and personal items within reach. Additionally, Physical Therapy (PT) was to evaluate and treat as ordered and as needed. Place a workable call light within reach and encourage resident to use it. Initiated 3/6/23 the CCP documented Resident #43 was independent with ambulation requiring occasional checkups/redirection, out of bed (OOB) to standard chair in a supervised area. The CCP documented the PT following evaluations: - 3/4/23 Physical Therapy (PT) consult completed, there were no documented added safety interventions. - 3/14/23 PT consult completed, documented a recommendation to be in supervised offer resident to lay down and to place resident in bed when tired. Resident keeps walking even once tired. - 4/12/23 PT consult completed, provide daily checkups and to monitor resident whereabouts. - 5/7/23 PT and OT (Occupational Therapy) consult completed and therapy program. - 5/12/23 PT consult completed. There were no documented changes in therapy plan. The CCP was revised on 6/14/23 to include Resident #43 removes their helmet frequently and staff was to assist as needed. The helmet was implemented via physician orders on 5/15/23. The CCP documented Resident #43 had dementia with psychosis, anxiety, and depression. The resident was easily distracted with the inability to concentrate, inability to problem solve, lacked acceptance to current condition, was not easily redirected and had behaviors directed at others (swears at staff, swings their cane, and wanders with no destination). Documented interventions dated 3/4/23 included to allow resident time to answer questions, verbalize feelings and fears. Consult with pastoral care, social services, and psychosocial services as needed (PRN), encourage socialization, provide 1:1 support PRN, provide opportunities for resident family to participate in care. When conflict arises, remove resident to a calm safe environment. Additional interventions dated 4/28/23 documented to redirect PRN and 5/8/23 staff will redirect resident away from the short hall, and out of other's rooms when possible. The CCP and [NAME] identified as current and dated 7/20/23 did not document person- centered interventions to meet the residents specific needs to prevent the resident from wandering. Changes in the CCP have not been effective to prevent potentially avoidable accidents. The CCP did not document or include social and recreational preferences. The physicians Order Summary Report dated 3/3/23 through 7/31/23 documented an order dated 5/15/23, Must wear helmet for protection at all times as tolerated every shift for frequent falls with head trauma. Review of Resident #43's Accident/ Incident (A/I) Reports dated 3/3/23 through 7/21/23 revealed the following: -3/4/23 at 2:36 PM, the resident had a witnessed fall. The resident sat self on the floor in hallway. The report documented the resident had no injuries. -3/14/23 at 7:30 PM, the resident had a witnessed fall. The resident was noted to be leaning backwards more than normal. The resident was ambulating past the nurse's station holding onto a wheelchair and fell backwards hitting the back of their head on the floor, sustaining a hematoma (collection of blood under the skin). The A/I report documented the resident had very poor safety awareness would not rest when they were tired and continued to walk even when unsafe. The plan was for staff to encourage the resident to rest when tired. - 4/12/23 at 3:50 PM the resident had an unwitnessed fall and was found lying on the floor in another resident's room on their left side. The resident complained of some pain to their neck and had a nickel sized contusion (soft tissue injury) on their left temple and bruising to their face. The report documented for staff to do daily checkups and monitor whereabouts. - 4/27/23 at 11:22 AM documented a physical incident. Resident #43 ambulated into Resident #60's room. Resident #60 was observed dragging Resident #43 on the floor out of their room. Resident #43 was assisted to a recliner in the common area for lunch, and a stop barrier sign placed across Resident #60's door. In addition, Other Information documented, Resident #43 has severe dementia, they ambulate independently and wanders in and out of rooms without purpose, their safety awareness is limited. The report documented resident-to-resident physical abuse. - 4/30/23 at 2:28 PM, the resident had an unwitnessed incident and was found lying in doorway of Resident #60's room. Resident #43's head was toward the hallway and Resident #60 was standing by #43. Resident #60 continuously opens their door and takes down the barrier stop sign, that is to keep others out of their room. Resident #43 continuously wanders in and out of residents' rooms, lying on beds and just wanders in without purpose. The A/I report documented that staff will continue to redirect as able. Resident #43 continues to wander even when tired. (Redirection previously implemented 4/28/23) - 5/7/23 at 5:58 PM, the resident had a witnessed fall. Resident #43 was holding onto Certified Nursing Assistant (CNA) #13 shirt, so they didn't fall. CNA #13 turned around observed the resident fall, hitting their head on the wall, and falling to the floor. Resident #43 had been ambulating throughout the day leaning to the side. The report documented Resident #43 had advanced dementia, resists sleeping and continuously ambulates even when tired. When the resident was put into bed, the resident gets right up. When assisted to a chair, the resident gets right up. -5/8/23 at 5:15 PM documented a physical incident. At 4:15 PM, Resident #43 was witnessed walking out of Resident #60's room while Resident #60 was walking into their room. When they met, Resident #60 reached out and placed both their hands on Resident #43's upper chest, collar bone/shoulder areas and pushed Resident #43. Resident #43 fell backwards onto their buttocks/back and bumped their head on the floor. The incident report documented, the physical contact was inappropriate and had the potential to cause physical harm and was considered resident-to-resident abuse. Will continue to redirect Resident #43 when wandering into other rooms as is possible. -5/9/23 at 9:11 PM documented a physical incident. Resident #43 wandered into Resident #39's room, Resident #39 pulled Resident #43 down causing Resident #43 to lay on their back across Resident #39's abdomen. Resident #39 was witnessed holding Resident #43 in place while hitting Resident #43 in the chest with a closed fist. The report documented the physical contact was inappropriate and was the definition of physical resident-to-resident abuse. Resident #43 was placed on 15 min checks for their safety. Resident #43 continues to wander throughout the unit without purpose or direction. - 5/12/23 at 8:07 PM documented the resident had a witnessed fall. Resident #43 was reaching for something on the floor, lost their balance and fell, hitting their head, sustaining a hematoma on their forehead. Resident #43 was assisted to bed, they got back up and began to again wander the unit. Resident #43 wanders without direction or purpose regardless of how tired they are. - 7/19/23 at 12:50 PM documented the resident had a witness fall. Resident #43 had a fall in dining room in front of another resident's tray table. A visitor reported they witnessed Resident #43 reach for another resident's food which was on a movable tray table, and the other resident pulled the tray table back causing Resident #43 to lose their balance and fall. The incident report documented, CP as followed. There were no additional interventions implemented on the A/I report or documented in the CCP. - 7/21/23 at 2:00 PM the resident had an unwitnessed incident and Resident #43 observed lying on their right side on the floor in front of the nurses' station, their helmet was not on. Neuro checks were initiated. During observations on 7/17/23 at 2:51 PM and 7/18/23 at 8:43 AM Resident #43 was observed to be ambulating aimlessly with a shuffled gait throughout the unit hallways without a soft helmet on their head. There was no staff intervention or redirection. During a continual observation on 7/19/23 at 9:59 AM through 10:18 AM Resident #43 was not wearing a helmet as planned. Observations revealed the following: 9:59 AM- Resident #43 was walking independently throughout the hallway. Staff assisted the resident to the dining room and encouraged Resident #43 to sit in a standard chair. Resident #43 sat down for 60 seconds then stood up and walked from the standard chair to the nearest furniture 5 feet away and was continuously touching furniture (table, chairs) and other residents as they passed by them. Resident #43 used the hallway railing to aimlessly walk on the unit's short hall. 10:02 AM- Resident #43 entered Resident #17's room on the short hall and laid down on the bed near the window. Resident #17 was in the room. At 10:07 AM, staff removed Resident #43 from Resident #17's room and allowed Resident #43 to continue to independently walk hallways of the short hall following and holding onto the handrails, without their helmet in place as planned. 10:18 AM- Resident #43 walked independently into the dining room following the wall of the dining room, sat down on Resident #110's lap for 5 seconds, and then got up and continued to walk aimlessly. There was no staff in the area at this time. During intermittent observations on 7/19/23 revealed the following: 12:40 PM- Resident #43 was walking with a shuffled gait leaning forward with two staff members arm in arm and sat the resident in a stationary chair for lunch. Resident #43 was not wearing a soft helmet. The staff encouraged Resident #43 to sit down and eat their meal. 12:52 PM- Resident #43 (without staff intervention) walked independently out of the dining room through the doorway nearest the long hall. Resident #43 continued to walk and guide themselves by holding onto and touching the nurses' station desktop until they reached the dining room doorway nearest the short hall on the opposite side of the dining room. At 12:53 PM, Resident #43 re-entered the dining room from short hall side, and a noise was heard. Resident #43 was laying on the floor on their left side, and their head was on the floor. Resident #43 was on laying on the floor in front of a resident that was seated eating lunch in a stationary chair with a rolling tray able in front of them. Staff assisted Resident #43 to a standing position and walked the resident to their room at 12:58 PM. 12:59 PM- the Assistant Director of Nursing (ADON) exited Resident #43's room. Resident #43 was observed walking independently in their room towards the roommate's side of the room without a helmet. At 1:15 PM Resident #43 continued to walk independently around their room on the roommate's side of the room without their helmet in place as planned. During an interview on 7/19/23 at 1:00 PM, the ADON stated they were in Resident #43's room to assess the resident after a fall. The ADON stated that Resident #43 was constantly walking independently. When they placed the resident in bed or a chair they would not stay there and would continue to get up and walk. During intermittent observations on 7/20/23 revealed the following: 7:15 AM- Resident #43 was in bed sleeping and there was no helmet located in the resident's room. 8:31 AM- Resident #43 was seated in the dining room without their helmet in place. During an interview on 7/20/23 at 8:32 AM, CNA #7 stated they provided care to Resident #43 that morning and that they did not know if the resident had a history of falls, or if they were to wear a helmet. CNA #7 stated there was not a helmet in the resident's room. During an interview on 7/20/23 at 8:37 AM, CNA #4 stated they were familiar with Resident #43 and provided care to Resident #43 on 7/17/23 and 7/19/23. CNA #4 stated that Resident #43 wandered all the time, and often will lean forward when they were tired but would not stop walking. CNA #4 stated they were not aware of any safety interventions for the resident. They further stated they do not believe the resident had a helmet for their safety and has not seen the resident wear a helmet. During an interview on 7/20/23 at 8:43 AM, CNA #8 stated they were familiar with Resident #43 and stated the resident wandered all the time. The resident was supposed to wear a helmet, but Resident #43 refused to wear it. Therefore, they do the best they could redirecting the resident as needed but the resident doesn't stop wandering. During an interview on 7/20/23 at 9:24 AM, Licensed Practical Nurse (LPN) #14 stated Resident #43 was supposed to wear a helmet for their safety, but the resident refused the helmet. LPN #14 stated they were not aware of any additional interventions. LPN #14 stated they would expect staff to ambulate with Resident #43 if they were tired or wandering unsafely. During an interview on 7/20/23 at 10:32 AM, CNA #9 stated they provided care to Resident #43 on 7/14/23, 7/15/23, 7/16/23 and 7/18/23 and did not offer to put the helmet on because the resident refuses the helmet. CNA #9 stated the helmet was for the resident's safety related to their frequent falls, hitting their head and there were not any additional interventions. CNA #9 stated Resident #43 wandered all the time on the unit and wandered into other resident's rooms. Staff do the best they can to redirect Resident #43. During intermittent observations on 7/21/23 revealed the following: 9:14 AM- Resident #43 was laying on Resident #39's bed (previous resident to resident incident 5/9). Staff redirected Resident #43 out of the room. 1:39 PM- Resident #43 was laying on their left side on the floor in front of the nurses' station. The resident did not have a helmet in place, there was no staff at nurses' station or in the hallways. The LPN #2 Unit Manger (UM), in their office near the nurses' station. The LPN #2 UM was made aware that Resident #43 was on the floor. During an observation and interview on 7/24/23 at 7:42 AM, Resident #43 walked independently in the hallway without their helmet in place. Resident #43 then walked into and laid down on Resident #34's bed with visibly wet pants. At 7:43 AM, LPN #2 UM assisted Resident #43 out of Resident #34's room. At that time LPN #2 stated Resident #43 was incontinent of urine and should not be wandering into other resident's rooms for their safety. LPN #2 UM stated Resident #43 currently doesn't have a helmet in place because it was lost 7/21/23 in the afternoon and they were unable to find it. During an interview on 7/24/23 at 10:57 AM, CNA #12 stated they worked 7/22/23 and 7/23/23 during the evening shifts. CNA #12 stated that staff were unable to find the helmet, and Resident #43 was placed on 1:1 supervision (constant staff member). CNA #12 stated there were no additional interventions put into place after the 1:1 was stopped on 7/22/23. The resident continued to wander on the unit, and in and out of other resident's rooms. CNA #12 stated they continued to redirect the resident when they were able but that did not prevent the resident from wandering into other resident's rooms. During an interview on 7/24/23 at 11:32 AM, LPN #1 stated they were unable to locate Resident #43's helmet since 7/21/23 in the afternoon. LPN #1 stated that 1:1 supervision was put into place for 24 hours but should have been for the entire weekend or until the helmet was found. LPN #1 stated that staff do the best they can by redirecting the resident, but the resident wanders aimlessly on the unit and enters other resident's rooms frequently. LPN #1 stated they were unable to prevent Resident #43 from wandering into other resident's rooms unless they can provide 1:1 supervision and there was not enough staff to accommodate that intervention. LPN #1 stated they believed they were unable to provide a safe environment. During an interview on 7/24/23 at 11:53 AM, LPN #2 UM stated if Resident #43 refused the helmet, they expected the staff to attempt to reapply the helmet a few times. LPN #2 UM stated when the helmet was missing on 7/21/23 in the afternoon they asked the Administrator for 1:1 supervision for the resident's safety. The Administrator approved 1:1 supervisor for 24 hours but could not provide a 1:1 any longer than the 24 hours because there was not enough staff. LPN #2 UM stated Resident #42 continued to independently wander without the helmet on Sunday 7/23/22 and during the morning of 7/24/23 because the helmet was unable to be located. LPN #2 UM stated the staff do the best they can by redirecting Resident #43, but they were unable to prevent the resident from entering other resident's rooms. LPN #2 stated they believed the facility was unable to provide a safe environment for this resident. During an interview on 7/24/23 at 12:47 PM, the Director of Nursing (DON) stated they were unaware Resident #43 refused the helmet and there were no additional interventions for the resident's safety. The DON stated, staff do the best they could by redirecting the resident. The DON stated they reviewed of the A/I reports and had not asked the Administrator for additional staff to provide oversight for Resident #43. The DON stated they had been made aware the Administrator provided a 1:1 staff member for Resident's #43 on Friday (7/21) for 24 hours but had not inquired why. The DON stated the only intervention that would provide a safe environment for Resident #43 was a 1:1 supervision, 24 hours 7 days a week, and the facility was unable to meet the resident's needs. The DON stated they were not able to keep Resident #43 in a safe environment. During an interview on 7/24/23 at 1:49 PM, the Administrator stated there were many wandering residents on this unit, that's what they do, it's a dementia unit. I can't stop them from falling, wandering and going into other resident's rooms. There were stop signs and special door handles but Resident #43 continued to wander. Staff continued to try their best to keep the resident safe, but they were unable to prevent them from wandering. The Administrator stated they did not have any additional interventions at this time for Resident #43 and a 1:1 was provided to the unit on Friday for only 24 hours, as !:1 was not a long-term intervention. Based on the survey team's observations, staff interviews and record review the survey team declared the facility removed the immediacy as of 7/25/2023 at 3:00 PM prior to exit. Corrective actions the facility took to remove the immediacy included: 1. A 1:1 Staff member was assigned to Resident #43. 2. Care plan interventions were updated to include 1:1 supervision at all times, and an interdisciplinary team meeting was held on 7/24/24 to discuss Resident #43 specific interventions. 3. Facility provided immediate staff education to all nursing staff regarding 1:1 supervision and Resident #43 specific activities interventions. Ongoing education occurred shift to shift forward to ensure all nursing staff were educated. Facility anticipated 90 % (percent) of all education would be completed 7/25/23 by 3:00 PM. Continuous education would continue until 100 % of all scheduled nursing staff were educated including agency staff. Any staff scheduled off would be educated prior to the start of their shift. 10 NYCRR 415.12(l)(2)(ii)