**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 03/06/25 at 5:40 p.m., an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to implement their abuse policy and procedure by not: a. consulting with the attending physician to identify treatable conditions such as acute psychosis; b. making any changes to care plan approaches to any and all involved individuals; c. documenting in the residents clinical record all attempted interventions and their effectiveness; and d. consulting psychiatric services for asssistance in assessing the resident, identifying causes, and developing a care plan for interventions and management necessary or as may be recommended by the attending physician or interdisciplinary team after a allegation of sexual abuse. A facility policy titled Resident - Resident Altercations, revised September 2022, read in part, If two residents are involved in an altercation, staff: . c. notify each resident's representative and attending physician of the incident; d. review the events with the nursing supervisor and director of nursing services, and evaluate the effectiveness of the interventions meant to address distressed behaviors for one or both residents; e. consult with attending physical to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem; f. make any necessary changes in the care plan approaches to any and all involved individuals; g. document in the residents' clinical record all interventions and their effectiveness; icons psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for interventions and management as necessary, as may be recommended by the attending physician or interdisciplinary care planning team. 1. Resident #20 was admitted to the facility on [DATE] with diagnoses which included acute and hypoxic respiratory failure and major depressive disorder. Resident #20's admission assessment, dated 01/28/25, showed Resident #20's BIMS score was 15 and their cognition was fully intact. Resident #20's progress note, dated 02/23/25 at 1:35 p.m., read in part, A [gender withheld] resident [Resident # 44] went into [Resident #20's] room on Sunday 02/23/25. [They] stood in front of [their] wheel chair and pulled their pants down and was humping in front of [Resident #20]. [Resident #20] yelled for [Resident #44] to get out of their room, [Resident #44] did not leave so [Resident #20] turned on their call light and started screaming and [Resident #44] left. An OSDH form 283, dated 02/23/25, showed Resident #44 went into Resident #20's room naked and straddled Resident #20 while holding their private parts in their hand. The form showed Resident #20 screamed for help. A review of Resident #20's electronic health record did not document the following after the incident of sexual abuse on 02/23/25: a. Resident #20's physician was notified after the incident; b. interventions were addressed by the nursing supervisor after the incident; c. the attending physician was consulted to identify treatable conditions such as psychosis; d. any changes made to the care plan after the incident; e. documentation of interventions and their effectiveness; and f. psychiatric services was consulted as needed for assistance in assessing the resident. On 03/03/25 at 12:16 p.m., Resident #20 stated Resident #44 came into their room naked and straddled their legs while they were sitting in their wheel chair in the afternoon. Resident #20 stated they shut their eyes and yelled for help until staff came. Resident #20 stated Resident #44 ran from their room when they yelled for help. Resident #20 stated they were fearful during and after the incident and had difficulty falling asleep since the incident. Resident #20 stated their physician was not notified of the incident. On 03/06/25 9:27 a.m., Resident #20 stated their counselor, which was previously established by their family representative, was not made aware of the incident and they had not received any psychological assessment since the incident on 02/23/25. Resident #20 stated they were having trouble sleeping since the incident due to recalling the traumatic incident when they closed their eyes. Resident #20 stated they reported to nursing staff and nurse aides they were fearful of the opposite sex and was having trouble sleeping since the incident on 02/23/25. On 03/06/25 at 10:17 a.m., Resident #20's family representative was asked how Resident #20 was doing since the incident on 02/23/25. They stated Resident #20 had difficulty sleeping since the incident, was afraid to have the door closed, was fearful of the opposite sex, and was afraid to be alone since the incident. They stated the facility did not set up any psychological counseling for the resident. On 03/06/25 at 11:15 a.m., the DON stated they would have to contact the family representative to determine if the Resident #20 had a psychological services referral made. 2. Resident #44 admitted on [DATE] with diagnoses which included acute kidney failure, morbid obesity, and cellulitis. Resident #44's admission assessment, dated 02/11/25, showed the resident's BIMS score was 13, their cognition was mildly impaired, they had physical behaviors directed toward others one to three days, and wandered one to three days during a seven day look back period. Resident #44's progress note, dated 02/23/25 at 12:15 p.m., read in part, I let [them] know that [they] went into a [gender withheld] resident's room and pulled [their] pants down, [they] were standing in front of the resident and was humping. On 03/06/25 at 6:41 a.m., the dietary manager stated Resident #20 told them another resident went into their room and exposed themselves and asked if they wanted some of this. The dietary manager stated Resident #20 reported to them they were having trouble sleeping since the incident. On 03/06/25 at 9:00 a.m., the DON stated they were informed of the incident on 02/23/25 involving Resident #44 going into Resident #20's room naked and straddling Resident #20 while naked and masturbated. The DON stated Resident #20 knew they were okay because they were aware Resident #44 had impaired cognition. The DON stated Resident #20 was not assessed for psychosocial injury, was not referred to psych services after the incident, and was not assessed by nursing or a physician after the incident. The DON was asked to review the facilty's Resident - Resident Altercations policy. The DON stated the policy was not followed. On 03/11/25 at 8:49 a.m., CNA #9 was asked about the incident on 02/23/25. They stated a resident notified them there was another resident that went into another residents room naked with their pants down. CNA #9 identified Resident #20 as the victim and Resident #44 as the aggressor. CNA #9 stated the agency nurse named never assessed the resident or got up out of their chair. CNA #9 was asked if Resident #20 had any changes since the incident. CNA #9 stated sometime mid week after the incident Resident #20 asked for help to be put to bed. CNA #9 stated an hour later Resident #20 was screaming and stated they saw Resident #44 when they closed their eyes. On 03/06/25 at 5:35 p.m., the OSDH office was notified and verified the existence of the IJ situation. On 03/06/25 at 5:40 p.m., the administrator was notified of the presence of an immediate jeopardy situation related to not implementing the abuse policy and procedure. The IJ template was provided to the administrator. On 03/07/25 at 10:56 a.m., an acceptable plan of removal was approved by OSDH. The plan of removal, read in part, [name of facility withheld] [address withheld] Plan of Removal for IJ at '[name of facility withheld].' .The likelihood of any other serious harm or event of abuse, neglect or misappropriation no longer exist after this plan has been completed as of 03/06/25. The plan of removal included the following components; a .Resident #20 was assessed on 03/06/25 by APRN [advanced practical registered nurse] for any signs of sexual abuse and orders to be followed for further treatment or evaluation, b. Resident #44 is no longer in the facility, c. the [name of police agency with held] police department was notified of an allegation of sexual abuse on 02/23/25 at 11:55 a.m., d. all nursing staff were in-serviced on the abuse, neglect, and misappropriation policies and procedures and ensure residents are free from abuse, neglect, and misappropriation by midnight on 3/6/25. Any nursing staff not currently in the facility will be in-serviced before returning to work, e. staff members were interviewed regarding any allegations of sexual abuse on 02/24/25 and there were no allegations reported, f. interviews were conducted with 5 residents with BIMS of 9 or higher on 02/24/25 and no allegations were reported, g. interviews conducted with all residents with BIMS of 9 or higher on 03/06/25 and no allegations were reported, H. all licensed staff were in-serviced on consulting with physician on behaviors such as acute psychosis and psychosocial needs, I. residents who were not able to be interviewed were assessed for any signs of abuse, J. follow up assessments were initiated every shift for resident #20 daily until no signs of negative outcomes and no negative psychosocial needs, K. resident #20 was referred to psych services for ongoing evaluation related to any negative outcomes from event on 02/23/25 and any other psychosocial needs, L. the facility in-service all staff on documentation of events related to abuse including any interventions in the clinical record and the effectiveness of interventions will be monitored by staff daily until compliance is achieved and appropriate practitioners including psych daily and after each visit until compliance is achieved, and M. the likelihood of any other serious harm or event of abuse, neglect or misappropriation no longer exists after this plan has been completed as of 03/06/25. On 03/07/25 at 5:30 p.m., the IJ was lifted when all components of the plan of removal were completed. The following documentation was reviewed: a. Resident #20's psychological assessment dated [DATE]; b. Residents #44's discharge summary; c. nursing in- service documentation on abuse; d. Resident #20's follow up assessments; e. Resident #20's psych referral; and f. safe survey interviews with residents. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to ensure their abuse policy and procedure was implemented for 1 (#20) of 3 sampled residents reviewed for abuse. The administrator identified 44 residents resided in the facility. Findings: 1. On 03/03/25 at 12:16 p.m., Resident #20 was observed crying and visibly traumatized while conveying the incident which occurred on 02/23/25. A facility policy titled Identifying Types of Abuse, revised 09/2022, read in part, the following situations are recognized as those that are likely to cause psychosocial harm, which may take months or years to manifest and have long-term effects on the resident and his or her relationship with others: a. Sexual assault. A facility policy titled Resident - Resident Altercations, revised September 2022, read in part, If two residents are involved in an altercation, staff: . c. notify each resident's representative and attending physician of the incident; d. review the events with the nursing supervisor and director of nursing services,and evaluate the effectiveness of the interventions meant to address distressed behaviors for one or both residents; e. consult with attending physical to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem; f. make any necessary changes in the care plan approaches to any and all involved individuals; g. document in the residents' clinical record all interventions and theory effectiveness; icons psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for interventions and management as necessary, as may be recommended by the attending physician or interdisciplinary care planning team. Resident #20 was admitted to the facility on [DATE] with diagnoses which included acute and hypoxic respiratory failure and major depressive disorder. Resident #20's admission assessment, dated 01/28/25, showed Resident #20's BIMS score was 15 and their cognition was fully intact. An OSDH form 283, dated 02/23/25, showed Resident #44 went into Resident #20's room naked and straddled Resident #20 while holding their private parts in their hand. The form showed Resident #20 screamed for help. A review of Resident #20's electronic health record did not document the following after the incident of sexual abuse on 02/23/25: a. Resident #20's physician was notified after the incident; b. interventions were addressed by the nursing supervisor after the incident; c. the attending physician was consulted to identify treatable conditions such as psychosis; d. any changes made to the care plan after the incident; e. documentation of interventions and their effectiveness; and f. psychiatric services was consulted as needed for assistance in assessing the resident. Resident #20's progress note, dated 02/23/25 at 1:35 p.m., read in part, A [gender withheld] resident [Resident # 44] went into [Resident #20's] room on Sunday 02/23/25. [They] stood in front of [their] wheel chair and pulled their pants down and was humping in front of [Resident #20]. [Resident #20] yelled for [Resident #44] to get out of their room, [Resident #44] did not leave so [Resident #20] turned on their call light and started screaming and [Resident #44] left. On 03/03/25 at 12:16 p.m., Resident #20 stated Resident #44 came into their room naked and straddled their legs while they were sitting in their wheel chair in the afternoon. Resident #20 stated they shut their eyes and yelled for help until staff came. Resident #20 stated Resident #44 ran from their room when they yelled for help. Resident #20 stated they were fearful during and after the incident and had difficulty falling asleep since the incident. Resident #20 stated their physician was not notified of the incident. On 03/06/25 9:27 a.m., Resident #20 stated their counselor, which was previously established by their family representative, was not made aware of the incident and they had not received any psychological assessment since the incident on 02/23/25. Resident #20 stated they were having trouble sleeping since the incident due to recalling the traumatic incident when they closed their eyes. Resident #20 stated they reported to nursing staff and nurse aides they were fearful of the opposite sex and was having trouble sleeping since the incident on 02/23/25. On 03/06/25 at 10:17 a.m., Resident #20's family representative was asked how Resident #20 was doing since the incident on 02/23/25. They stated Resident #20 had difficulty sleeping since the incident, was afraid to have the door closed, was fearful of the opposite sex, and was afraid to be alone since the incident. They stated the facility did not set up any psychological counseling for the resident. On 03/06/25 at 11:15 a.m., the DON stated they would have to contact the family representative to determine if the Resident #20 had a psychological services referral made. 2. Resident #44 admitted on [DATE] with diagnoses which included acute kidney failure, morbid obesity, and cellulitis. Resident #44's admission assessment, dated 02/11/25, showed the resident's BIMS score was 13, their cognition was mildly impaired, they had physical behaviors directed toward others one to three days, and wandered one to three days during a seven day look back period. Resident #44's progress note, dated 02/12/25 at 12:37 a.m., showed Resident #44 was making statements about a nurse making them feel some type of way when they came around. Resident #44 was redirected and the CNA reported to nursing staff the resident's behaviors. Resident #44's progress note, dated 02/13/25 at 5:19 a.m., showed Resident #44 was seated in the dining room and was talking to themselves loudly. The note showed Resident #44 was redirected for cussing and yelling by staff. The note showed all redirections and reorientations were unsuccessful. Resident #44's progress note, dated 02/13/25 at 12:29 p.m., showed Resident #44 was expressing concerns that someone was poisoning them. The note showed Resident #44 expressed they were being poisoned by their guardian. Resident #44's progress note, dated 02/14/25, showed Resident #44 was in dining room early and was continuing to yell out and have conversations with self. Resident #44's progress note, dated 02/17/25 at 11:12 p.m., showed Resident #44 refused medication and accused a day time nurse of poisoning them. The note showed the DON was notified of the behavior. Resident #44's progress note, dated 02/19/25 at 5:40 a.m, showed Resident #44 was pacing the halls, repeatedly pulling call lights in in bathrooms, attempting to wander down other halls, accusing staffing of poisoning them, got agitated with redirections, and refused to go to bed. Resident #44's progress note, dated 02/20/25 at 9:55 p.m., showed Resident #44 was in the day room slapping themselves in the head and the furniture hard repeatedly while having a conversation with themselves. The note showed Resident #44 was redirected due to scaring other residents. The note showed during the same shift Resident #44 had to be redirected because they were wandering through the corridors and looking into other residents' rooms. The note showed redirection was met with agitation. Resident #44's progress note, dated 02/21/25 at 4:19 a.m., showed Resident #44 was in common area slapping themselves on the thighs, head, and the arms of the chair. The note showed the Resident #44 continued to wander the dining area talking to themselves, then went to their room, and was pacing in circles. Resident #44's progress note, dated 02/21/25 at 8:40 p.m., showed Resident #44 attempted to follow a visitor out the door with a bag of clothes. The note showed Resident #44 was redirected back to their room. Resident #44's care plan, dated 02/21/25, read in part, Disturbed thought processes related to altered perceptual state as evidenced by delusions, hallucinations, and disorganize thinking . a. establish reality based communication; b. Monitor and document thought content; and c. refer to mental health services prn. Resident #44's clinical record did not show their physician was notified prior to 02/23/25 when behaviors were documented starting on 02/11/25 and it did not show Resident #44 was referred to mental health services. Resident #44's progress note, dated 02/23/25 at 1:01 p.m., read in part, resident reported this resident was in a [gender withheld] residents room with [their] pants down trying to 'hump' resident. Family, DON, and ADON notified. Resident #44's progress note, dated 02/23/25 at 12:15 p.m., read in part, I let [them] know that [they] went into a [gender withheld] resident's room and pulled [their] pants down, [they] were standing in front of the resident and was humping. The note showed Resident #44 was transported by EMS to the hospital, family was notified, and an emergency discharge was issued. On 03/06/25 at 9:00 a.m., the DON stated they were informed of the incident on 02/23/25 involving Resident #44 going into Resident #20's room naked and straddling Resident #20 while naked and masturbated. The DON stated Resident #20 knew they were okay because they were aware Resident #44 had impaired cognition. The DON stated Resident #20 was not assessed for psychosocial injury, was not referred to psych services after the incident, and was not assessed by nursing or a physician after the incident. The DON was asked to review the facilty's Resident - Resident Altercations policy. The DON stated the policy was not followed. On 03/11/25 at 8:49 a.m., CNA #9 was asked about the incident on 02/23/25. They stated a resident notified them there was another resident that went into another residents room naked with their pants down. CNA #9 identified Resident #20 as the victim and Resident #44 as the aggressor. CNA #9 stated the agency nurse named never assessed the resident or got up out of their chair. CNA #9 was asked if Resident #20 had any changes since the incident. CNA #9 stated sometime mid week after the incident Resident #20 asked for help to be put to bed. CNA #9 stated an hour later Resident #20 was screaming and stated they saw Resident #44 when they closed their eyes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. An undated facility policy titled Smoking Policy - Residents, read in part, Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: current level of tobacco consumption; method of tobacco consumption (traditional cigarettes, electronic cigarettes, pipe, etc.) desire to quit smoking; and ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Resident #30 had diagnoses which included dementia, shortness of breath, and chronic obstructive pulmonary disease. A care plan, revised 07/26/23, showed the resident was a smoker. The documented smoking interventions included: a. can smoke unsupervised; b. instructed about smoking risks, hazards, and about available smoking cessation aids, c. instructed about the facility policy on smoking, including: locations, times, and safety concerns; d. notify charge nurse immediately if resident was suspected of violating facility smoking policy; and, e. to observe clothing and skin for signs of cigarette burns. A quarterly assessment, dated 02/06/25, showed Resident #30's cognition was intact with a BIMS score of 13. On 03/04/25 at 11:30 a.m., Resident #30 stated they carried their own cigarettes and lighter and smoked whenever they wished and without supervision. Resident #30 denied having a smoking assessment performed or having been instructed by the facility on the risks, hazards, available smoking cessation aides, or smoking policy. Resident #30 stated they pretty well figured out all the information as to where to smoke and knew when to smoke depended on who was working and when. On 03/12/25 at 9:20 a.m., the administrator stated there were two residents who were independent with smoking and carried their own cigarettes and lighter. The administrator stated the assessments were in the computer under the assessment tab. The administrator stated the assessments should have been there under safety, but they would consult with the MDS coordinator to find out where the assessments were located. On 03/12/25 at 9:52 a.m., the administrator and MDS coordinator stated the smoking assessment was in with the care plan. The MDS coordinator stated they re-assessed the resident once a year and with any changes. The MDS coordinator stated they would re-assess the resident earlier if the resident incurred something like a stroke. On 03/17/25 at 1:35 p.m., the MDS coordinator stated the resident's smoking care plan did not have the necessary components of the smoking evaluation. The MDS coordinator stated there was no other documentation related to the resident's smoking evaluation/assessment. On 03/05/25, an immediate Jeopardy was determined to exist related to the facility's failure to implement fall interventions for Resident #3 who had severe cognitive impairment and was a high fall risk. A quarterly MDS assessment, dated 10/11/24, showed Resident #3 had one non injury fall and two or more falls with injury. Resident #3's Morse Fall Scale assessment, dated 09/24/24, showed Resident #3 was a high fall risk. On 11/03/24, Resident #3 fell from the bed with no injury. Resident #3's Morse Fall Scale assessment, dated 12/03/24, showed Resident #3 was a high fall risk. On 12/29/24, Resident #3 had an un-witnessed fall from their bed and had a small bruising noted to the right eyebrow and a small skin tear noted to their right hand. Resident #3's Morse Fall Scale assessment, dated 12/31/24, showed Resident #3 was a high fall risk. On 02/08/25, Resident #3 had a fall from the bed with no injury. On 02/22/25, Resident #3 had an unwitnessed fall from their wheel chair resulting in Resident #3 being transported to the ER and diagnosed with blunt head trauma, nasal bone fracture, and contusion. There were no additional interventions added to Resident #3's care plan after the falls on 11/03/24, 12/29/24, 02/08/25, and 02/22/25. On 03/05/25 at 10:50 a.m., the Oklahoma State Department of Health was notified and verified the existence of a IJ situation. On 03/05/25 at 12:28 p.m., the administrator was notified of the IJ situation and provided the IJ template. On 03/06/25 at 12:28 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The actions to remove the immediacy of the alleged deficient practice, read in part, a. facility will ensure that all residents are free from certain injuries and that proper interventions are in place and documented; b. Resident # 3 was assessed on 03/05/25 by physician for any signs of injury related to certain injury; c. Resident #3 will be placed into increased observation to monitor for ongoing risk for certain injury; d. all nursing staff will be in-serviced on assessment of certain injury and implementation of interventions and policy and procedure related to falls and fall intervention; e. all residents with a fall within the last 30 days will be assessed for proper interventions; f. facility implemented a procedure on 03/05/25 and notified all staff of interventions of the Falling Star Program. The Director of Nursing has and will oversee the program and update accordingly and will hang at head of bed and write interventions on the back and document on careplan; g. all interventions have been documented on all resident's careplan and will be monitored by director of nursing daily until compliance is achieved;and h. plan is complete, likelihood of serious injury or harm will no longer exist as of 03/06/25. The IJ was lifted, effective 03/07/25 at 5:30 p.m., when all components of the plan of removal had been verified as completed. The following documents were reviewed for removal of the IJ situation: a. Resident #3's assessment on 03/05/25; b. in- service documentation for an assessment of certain injury and implementation of interventions and policy and procedure related to falls and fall intervention; c. all high fall risk residents' care plans for updated fall interventions; and d. falling stars above high fall residents' beds for interventions. The deficient practice remained isolated with the potential for more than minimal harm. Based on observation, record review and interview, the facility failed to implement interventions after falls to prevent accidents for 1 (#3) and failed to assess a resident who smoked for safety to prevent accidents for 1 (#30) of 3 residents sampled reviewed for accident hazards. The ADON identified 10 residents were high fall risk and seven residents who smoked. Findings: 1. On 03/03/25 at 12:05 p.m., Resident #3 was observed in dining room being assisted with eating in a geriatric chair with bruising on their face under both eyes and cheeks. The resident was unresponsive to questions. A facility policy titled Falls and Fall Risk, Managing, revised 03/2018, read in part, Based on previous evaluations and current data, the staff will identify interventions related to the residence, specific risk and causes to try and prevent the resident from falling and try to minimize complications from falling .the staff, with input of the attending physician, will implement a resident - centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of fall .if falling recurs, despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. A facility policy titled Care Plans, Comprehensive Person- Centered, revised 03/2022, read in part, The comprehensive care, person centered care plan: .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being .Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the residence, problem areas, and their causes, and relevant clinical decision making .when possible, interventions addressed the underlying sources of the problem areas, not just the symptoms or triggers. Resident #3 was admitted on [DATE] with diagnoses which included type 2 diabetes mellitus, syncope and collapse, and chronic kidney disease. Resident #3's Morse Fall Scale assessment, dated 06/03/24, showed Resident #3 was a high fall risk. A witnessed fall report, dated 08/18/24, read in part, Focus charting related to this nurse was walking past residents room and observed resident attempting to self transfer. Landing on their right side onto the floor, skin tear noted to right shin measuring 1 cm x 3 cm, and skin tear below left knee measuring 1.5 cm x 1.5 cm, move limbs appropriately. Resident denies pain discomfort, did not hit their head,assisted resident into wheelchair, denies pain or discomfort at this time Physician notified with orders to dress skin tears, resident unable to give description. The report showed predisposing physiological factors related to the falls included, confused, drowsy, gait imbalance, impaired memory, and weakness/fainted. There was no documentation the care plan was updated with new specific interventions after the fall until 11/08/24 when a fall mat was added to the care plan. Resident #3's Morse Fall Scale assessment, dated 09/24/24, showed Resident #3 was a high fall risk. An un-witnessed fall report, dated 11/03/24 read in part, Resident was found laying on the floor mat next to bed dirty from bowel movement. Residence range of motion is WNL for resident right side. Weakness is norm. Small bruise noted to left upper thigh and left lower leg. No other visible injuries noted at this time. The report showed incontinence was the only predisposing physiological factors contributing to the fall. There was no documentation the care plan was updated with new specific interventions after the fall. Resident #3's Morse Fall Scale assessment, dated 12/03/24, showed Resident #3 was a high fall risk. Resident #3's Morse Fall Scale assessment, dated 12/31/24, showed Resident #3 was a high fall risk. An un-witnessed fall report, dated 12/29/24, read in part, Call to residents room by CMA. Resident noted to be laying on right side with head on the floor. Small bruising noted to the right eyebrow. Clean and implied stair strips, small skin tear noted to right hand, clean and applied stair strips. Resident assisted up off the floor by this nurse and CMA. No other injuries noted. The report showed predisposing physiological factors were resident was confused, incontinent, and had impaired memory. The report showed predisposing situation factors as ambulating with without assist. There was no documentation the care plan was updated with new specific interventions after the fall. Resident #3's comprehensive assessment dated [DATE], showed Resident 3's BIMS score was 00 indicating their cognition was severly impaired and they did not have any falls since admission/entry or reentry or prior Assessment. An un-witnessed fall report, dated 02/08/25, read in part, Nurse was notified by CNA staff that resident was on floor in resident room. Upon entering the room resident was lying on the right side with pillow under head for support placed by CNA staff. Resident vital signs taken and BP 150/180 obtained per manual cuff. Resident denies pain at this time, but is unable to state what happened. Resident assisted from floor to sitting position by nursing staff and then assisted from sitting position to wheelchair. Resident assessed for injury and noticed a small knot on the back of residents head. Resident also had some bruising to right lower leg and some redness to right hip. Resident denies pain at this time. Resident placed in bed by nursing staff after evaluation and clothes changed. The report showed predisposing environmental factors of furniture and predisposing physiological factor such as incontinent, gait imbalance, and impaired memory. There was no documentation the care plan was updated with new specific interventions after the fall. Resident #3's care plan, revised on 02/12/25, read in part, a.be sure [Resident #3] call light and frequently use items are within reach and encourage [them] to use call for assistance as needed. [Resident #3] needs prompt response to all request for assistance. Date initiated 07/11/23; b. follow facility fall protocol Date initiated 07/11/23; c. for fall noted 10/20/24, staff to monitor positioning when bed to ensure that [they] are in the center of the bed. Date initiated 10/21/24; e. for fall noted 10/21/24, Q 2 hour safety checks when in bed Date initiated 10/22/24; f. for fall noted 10/23/23 , ensure [Resident #3] is wearing non-slip footwear Date initiated 01/30/24; g. for fall noted 11/13/23, Encouraged [Resident] to stay in common areas when out of bed Date initiated 01/30/24; h. for fall noted 11/22/23, Encourage assist [Resident #3] to lie down following lunch date initiated 01/30/24; i. for fall noted 11/07/23, monitor [Resident #3] for needs and respond promptly to any needs noted date initiated 01/30/24; j. for fall noted 04/04/24, monitor resident for fatigue and encourage [them] to take rest date initiated 4/5/24; k. for fall noted 08/18/24, fall mat in place when in bed date initiated 11/8/24; l. for fall noted 09/10/24, ensure that bed is in lowest position when resident is in bed date initiated 11/8/24; and m. for fall noted 09/03/24, Q 1 hour safety checks times 30 days date initiated 9/3/24. An un-witnessed fall report, dated 02/22/25, read in part, Called by CMA to common area to see resident laying in the floor on their right side. The resident was bleeding from their nose and forehead. Staff quickly started putting cool compresses on them to stop the bleeding. Called place to 911 for transfer to [name of hospital withheld]. Resident had a knot on their forehead, and their nose was swollen. EMS and nursing home staff transferred patient to stretcher after C collar was applied. The physician, DON, and family notified. The report showed predisposing physiological factors as confused, incontinent, gait imbalance, and impaired memory. An OSDH 283 report, dated 02/22/25, read in part, Resident [Resident #3] had an unwitnessed fall in the dayroom. [They] were sent to [name of hospital withheld] for an evaluation. Resident returned the following day with a dx of nasal bone fracture. Resident #3's admission hospital records, dated 02/22/25, showed Resident #3 was sent to the ER with a head injury caused by a fall and diagnoses was a frontal scalp edema/hematoma and nasal bone fracture. Resident #3's physician order, dated 02/28/25, read in part, May use Geri chair for poor balance and trunk control. The ordered did not have a start date and the intervention was not in the care plan. On 03/05/25 8:50 a.m., the MDS coordinator stated they were responsible for updating the care plans. The MDS coordinator was asked what should happen after a resident had a fall. The MDS coordinator stated after the resident was assessed, there would be an intervention right away in the incident report, and an intervention would be added after each fall in the care plan. The MDS coordinator was asked what dates did Resident #3 have falls. The MDS coordinator stated 01/10/23, 11/07/23, 11/22/23, 11/23/23, 04/04/24, 08/18/24, 09/03/24, 09/10/24, 10/21/24, 11/03/24, 12/29/24, 02/08/25, and 02/22/25. The MDS coordinator was asked what interventions were added to the care plan for the falls on 11/03/24,12/29/24, 020/8/25, and 02/22/25. The MDS coordinator stated no interventions were added to the care plan after the falls. The MDS coordinator was asked if the policy and fall protocol was followed. The MDS coordinator stated, No, I get busy and sometimes I'm not always communicated a fall. The MDS coordinator was asked if Resident #3 was significantly harmed in any of the falls. The MDS coordinator stated, The last one [they] fell and broke [their] nose causing bruises to the face. On 03/05/25 at 9:23 a.m., CNA #9 was asked how they knew what interventions were in place to prevent falls for Resident #3. CNA #9 stated they are told verbally mostly for new residents and they used the care plan. CNA #9 stated there should be a chair alarm in Resident #3's wheel chair, they laid the resident down when they were sleepy, and used a fall mat. CNA #9 was asked if there were any other interventions for Resident #3 to prevent falls. They stated, Not that I know of. On 03/06/25 at 12:40 p.m., the MDS coordinator was asked if Resident #3's annual assessment, dated 01/13/25 was accurate based upon stating there were no previous falls. The MDS coordinator stated the assessment was not accurate. On 03/06/25 at 8:24 a.m., the DON was asked how they knew if CNAs and agency staff were aware of what interventions were in place for residents to prevent falls. The DON stated, The care plan mostly and verbal communications in the morning meeting. The DON was asked what interventions were added to the care plan after the falls on 11/03/24,12/29/24, 02/08/25, and 2/22/25. The DON stated, None , they did not follow our policies.