On 04/29/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were free from abuse. On 04/29/25 at 4:35 p.m., the Oklahoma State Department of Health verified the existence of an IJ situation. On 04/29/25 at 4:37 p.m., the administrator was notified of the immediate jeopardy situation. An immediate jeopardy template was provided to the administrator. On 05/02/25 at 9:40 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility plan of removal showed: All staff will immediately be educated by facility Administrator on the facility updated policy regarding resident to resident altercations. They will be educated on ensuring the safety and well-being of all residents by preventing, identifying, and managing resident-to-resident altercations. When a resident poses a risk to others, immediate action will be taken, including 1:1 supervision and, if necessary, removal or transfer to a more appropriate setting. Education will be verified using a sign in sheet. Employee names and time of call will be documented. All residents will be reassessed for active behavior issues to determine the risks for future altercations. Physician will be notified if any resident is displaying current behaviors. Interventions will be implemented and care plans updated as needed. A resident safe survey will be conducted on all verbal residents to determine if residents feel safe within the facility. Counseling services will be offered and provided as needed. Non-verbal communication tools such as an emotions picture card will be used to determine if non-verbal residents feel safe. Staff will be trained to recognize signs of discomfort, fear, or distress, and respond in calm, and respectful ways. A QAPI meeting led by the Administrator will be completed immediately to address safety concerns in the facility, abuse prevention, and prevention of resident-to-resident altercations. The IJ was lifted, effective 05/02/25 at 1:00 p.m., when all components of the plan of removal had been completed. Resident interviews and staff interviews were completed regarding abuse. A review of the 'Abuse-Reportable Events' updated policy, resident assessments, and staff education regarding abuse was completed. 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 residents were free from abuse for 1 (#2) of 5 sampled residents reviewed for abuse. The administrator identified 44 residents resided in the facility. Findings: An undated facility policy titled RESIDENT CODE OF CONDUCT, read in part, The following code of conduct is effective in order to protect the rights and safety of all residents that reside here at [name withheld]. VIOLATION OF ANY OF THE FOLLOWING ACTS COULD/WILL CONSTITUTE CAUSE FOR DISCHARGE FROM THE FACILITY: .Disorderly, immoral, or indecent conduct, inappropriate language.Any form of physical violence including throwing objects toward other residents or staff.Willful or careless disregard of name calling/racial slurs toward a resident with the intent to cause emotional distress.Any violation of resident/staff rights, including threats of any nature A facility policy titled Abuse-Reportable Events, revised January 2018, read in part, Mental and Verbal Abuse: (as stated in guidance to Surveyor in CMS SOM Section PP F600) Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse is a type of mental abuse and includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend or disability.Physical abuse: (as stated in guidance to Surveyor in CMS SOM Section PP F600) Physical action within the definition of abuse, including, but not limited to, hitting, slapping, punching, and kicking. It also includes controlling behavior through corporal punishment. 1. An undated face sheet showed Res #1 had diagnoses which included paranoid schizophrenia, mood disorder, post-traumatic stress disorder, brief psychotic disorder, and depression. An incident report, dated 09/26/24, showed an allegation of abuse. The report showed Res #1 kicked another resident in the face because they were cussing at them. The report showed local law enforcement escorted Res #1 to the hospital for a psychological evaluation. A progress note, dated 09/26/24, showed the resident returned to the facility from the hospital. The note showed the resident was evaluated by mental health, medications were adjusted, and was not a harm to themselves or anyone else. A quarterly assessment, dated 10/24/24, showed Res #1 had a BIMS of 11 and was moderately impaired cognitively. The assessment showed Res #1 had verbal behaviors toward others. An incident report, dated 10/26/24, showed an allegation of abuse for Res #1. The report showed Res #1 was yelling at another resident, hit them in the head twice, and started kicking them. The report showed Res #1 was placed on observation and was pending admission into an inpatient facility. A progress note, dated 11/15/24 at 2:37 p.m., showed Res #1 was walking to their room saying, Go ahead and call the police and I'll kill you, you B***h. The note showed the resident was then on the couch mumbling about killing people. A progress note, dated 11/15/24 at 3:30 p.m., showed Res #1 entered a facility office and reported, Im ready to go to the hospital or jail, I keep f****** having these sexual hallucinations and Im sick of it, I'll kill everyone in here!! A progress note, dated 11/15/24 at 8:45 p.m., showed the resident returned to the facility from the emergency room with no new orders. The note showed the resident continued to mumble about killing people and calling staff b*****s and prostitutes. An incident report, dated 01/10/25, showed an allegation of abuse for Res #1. The report showed Res #1 was cussing at another resident. The report showed Res #1 was transferred to inpatient for psychological treatment. A quarterly assessment, dated 01/13/25, showed Res #1 had a BIMS of 13 and was cognitively intact. The assessment showed Res #1 had no physical behaviors and had verbal behaviors that occurred one to three days. An incident report, dated 04/16/25, showed an allegation of abuse for Res #1. The report showed Res #1 punched Res #2 in the face several times. The report showed Res #1 was verbally abusive to Res #2 and proceeded to hit Res #2 after yelling at them unprovoked. The report showed the resident was sent to behavioral health inpatient for a psychological evaluation. A care plan, with updated intervention through 04/17/25, showed interventions put in place after the 01/10/25 incident were relisted interventions from the 10/26/24 incident. The care plan showed interventions listed after the 04/16/25 incident was every 15 minute checks after episodes of physical violence until evaluated by physician and send for mental health evaluation as ordered. On 04/28/25 at 12:20 p.m., the administrator stated when the incident occurred the residents were separated. The administrator stated Res #1 was placed on every 15 minute observations until leaving the facility. On 04/28/25 at 4:05 p.m., the care plan coordinator reviewed Res #1's care plan. The care plan coordinator stated the care plan relisted interventions that had already been implemented regarding the problem identified of agitation and aggressive behavior. The coordinator stated there was no new interventions for the incident occurring on 01/10/25. The coordinator stated new interventions should be put in place if agitation and aggressive behaviors continue. On 04/29/25 at 9:20 a.m., CNA #1 stated Res #1 had behaviors since admission. The CNA stated Res #1 cussed at staff and stated they were going to kill staff. The CNA stated they were aware of Res #1 pushing Res #2 on three different occasions, the last time resulting in Res #1 hitting Res #2 on the head. CNA #1 stated there was no way to know when the resident would have aggressive behaviors, it would just happen. CNA #1 stated they would separate Res #1 from other residents and ask for staff assistance. On 04/29/25 at 3:23 p.m., the DON stated Res #1 was last seen by the psychiatrist was June 2024. The DON stated the physician's office reported Res #1 did not have any scheduled appointments. 2. An undated face sheet showed Res #2 had diagnoses which included paranoid schizophrenia, pseudobulbar affect, and major depressive disorder. The annual assessment, dated 04/03/25, showed Res #2 had a BIMS of 8 and was moderately impaired cognitively. The assessment showed Res #2 did not have verbal or physical behaviors toward others. A progress note, dated 04/16/25, showed Res #2 reported to staff Res #1 was verbally abusing them unprovoked. The note showed Res #2 reported Res #1 hit them in the face and right ear multiple times. The note showed the local police department was called and staff assisted with Res #1 being taken out of the facility for evaluation of aggressive behaviors. The care plan, updated 04/16/25, showed Res #2 was hit by another resident and she may be at risk for fear. The interventions showed to allow the resident to verbalize her feelings and to reassure the resident they were safe. On 04/29/25 at 9:00 a.m., Res #2 was sitting on the side of their bed wearing a jacket and watching television. On 04/29/25 at 9:02 a.m., Res #2 stated they were currently not afraid. The resident stated they were afraid of Res #1 and hoped they did not return to the facility. The resident stated in a tearful voice Res #1 might kill them.

On 12/16/24 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect Res #1's right to be free from abuse. Res #1 was assaulted by Res #2 resulting in stab wounds which required sutures. On 12/16/24 at 11:24 a.m., the Oklahoma State Department of Health verified the existence of an IJ situation. On 12/16/24 at 12:48 p.m., the administrator was notified of the immediate jeopardy situation. On 12/16/24 at 4:00 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility plan of removal documented: a. all staff education - abuse and neglect policy and procedures and resident to resident conflicts. All staff will be educated with a sign in sheet that are currently working in the facility. Any remaining staff will be called and educated over the telephone. Employee names and time of call will be documented; b. behavior monitoring - currently in progress. All residents' charts will be reviewed for active behavior issues. Physician will be notified if any resident is displaying current behaviors. Interventions will be implemented and care plans updated as needed. Any resident assessed to be under the influence of alcohol will be monitored one on one until the physician is notified for further instructions. All residents with a diagnosis of alcoholism will be assessed and their care plan will be updated; and c. upon completion of the immediate corrections, audit and observations will continue by the administrator and director of nursing for 90 days. The IJ was lifted, effective 12/17/24 at 12:50 p.m., when all components of the plan of removal had been completed. The deficient practice remained as isolated with potential for harm to the residents. Based on observation, record review, and interview, the facility failed to ensure residents were free from abuse for two (#1 and #2) of six sampled residents reviewed for abuse. Res #1 was assaulted by Res #2 resulting in stab wounds which required sutures. The DON identified 48 residents who resided in the facility. Findings: An undated Resident Code of Conduct policy, read in part, The following code of conduct is effective in order to protect the rights and safety of all residents that reside here at [name withheld]. Violation of any of following acts could/will constitute cause for discharge from the facility: Under the influence/possession of alcohol, drugs, non-prescribed narcotics, or in any physical condition making it unsafe for residents or staff within the facility; any form of physical violence including throwing objects toward other residents or staff; unauthorized possession of firearms or other weapons on nursing home property; and any violation of residents/staff rights, including threats of any nature. An Abuse - Reportable Events policy, revised January 2018, read in part, It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person .When an employee becomes aware of an allegation or suspicion of abuse .the charge nurse will: asses the resident or resident(s) .notify the administrator .begin taking written statements from the person reporting the allegation or suspicion and any witnesses including staff, family, and/or residents .After investigation, administration will analyze the occurrence to determine what changes, if any, are needed to the policies and procedures to prevent further occurrences. 1. Res #1 was admitted with diagnoses which included anxiety and paranoid schizophrenia. An annual assessment, dated 05/10/24, documented Res #1 was cognitively intact, had minimal depression, and had not exhibited behaviors. 2. Res #2 was admitted with diagnoses which included alcohol abuse and major depressive disorder. A care plan, dated 12/06/21, documented Res #2 often had verbal outbursts towards staff. The care plan documented a goal was the resident would not exhibit behaviors harmful to self or others. An annual assessment, dated 01/15/24, documented the Res #2 was cognitively intact, had mild depression, and had not exhibited behaviors. A nurse note, dated 03/24/24, documented Res #2 was witnessed as intoxicated by staff. The note documented empty alcohol bottles were observed in the resident's room. A nurse note, dated 06/07/24, documented Res #2 verbally threatening physical harm to another resident. A nurse note, dated 10/27/24, documented Res #2 was in another unnamed resident's room yelling and cussing. The note documented Res #2 was removed from the other resident's room, but continued to yell/cuss and attempted to fight the other resident. The note documented Res #2 smelled of alcohol and an empty alcohol bottle was found outside in the courtyard trash can after the incident. There was no documentation of an incident report or investigation regarding the above incidents. There was no documentation of Res #2's behaviors documented in the care plan. An OSDH initial incident report form, dated 11/09/24, documented Res #1 stated Res #2 had entered their room while they were asleep and attacked them with a weapon. The report documented Res #1 appeared beaten with a bruised and bleeding face, blood running out of their right arm, and a puncture wound with moderate bleeding on their right foot. A staff witness statement, dated 11/09/24, documented Res #2's room was searched after the incident. The statement documented two small trash cans full of vodka and mouthwash bottles were observed. A hospital emergency room report, dated 11/09/24, documented Res #1 presented to the hospital with stab wounds to the right heel and right forearm, bruising to the left eye, and other various scratches/lacerations. The report documented Res #1 required sutures to close the wounds to the right heel and right forearm. An OSDH final incident report, dated 11/11/24, documented Res #2 was presently in jail and had been charged with first degree assault and battery. On 11/25/24 at 10:50 a.m., the DON stated Res #2 had a history of occasional alcohol abuse while residing in the facility. The DON stated they thought family members or other residents had provided Res #2 with the alcohol. They stated the resident had been counseled regarding the prohibition of alcohol within the facility in the past. The DON stated Res #2 was intoxicated on the day the assault on Res #1 occurred. They stated a pocket knife had been found that was used in the attack. The DON stated the facility was unable to determine which resident had the pocket knife prior to the assault. On 11/25/24 at 12:00 p.m., Res #1 was observed in their room. Res #1 stated they were assaulted with a pocket knife by Res #2 a few weeks ago. Res #1 stated they had a history of not getting along with Res #2. They stated they had never been physically attacked prior to the incident. Res #1 stated they received two wounds that required sutures and feared for their life on the day of the assault. On 11/27/24 at 9:00 a.m., the DON stated no interventions had been initiated or documented in Res #2's care plan to prohibit abusive behavior related to alcohol use. They stated Res #2's past incidents of abusive behavior should have been reported and investigated by the facility. It was documented Res #2 no longer resided in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents who had fallen had interventions put in place to prevent the recurrence of falls. Res #25 had experienced five falls in eight months with one fall resulting in a hematoma with a laceration requiring sutures to close. Res #40 experienced nine falls over the previous 12 months with several falls resulting in bruising, scrapes, and lacerations. Res #28 experienced 17 falls over the previous 12 months with one fall resulting in a fractured nose. On [DATE] at 2:14 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation related to falls. On [DATE] at 2:17 p.m., the administrator was notified of the IJ situation. On [DATE] at 5:51 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: [DATE] Boyce Manor IJ Plan of Removal for Fall Prevention Completion Date 11-30-22 11:00 PM All Staff Education Fall Prevention Policy Clinical Staff Education 1. Fall Prevention Policy 2. Incident/Accident Policy 3. Fall Interventions 4. Root Cause Analysis 5. Fall Risk Assessments 6. Fall Care Plans Update Fall Risk Assessments on all residents Update Fall Care Plans for residents if applicable Implement Fall Intervention Book for all staff Fall Care Plans and Interventions Updated for the 3 affected residents The Administrator and Clinical Managers will review all incidents/accidents daily at the morning meeting to ensure completion with root cause established. They will monitor for appropriate fall intervention, updated fall risk assessment, and updated fall care plan. Monitoring will be continuous. The IJ was lifted, effective [DATE] at 9:53 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern with potential for harm to the residents. Based on record review, observation, and interview, the facility failed to place interventions to prevent the recurrence of falls for three (#25, 28, and #40) of three residents reviewed for falls. The facility administrator reported 18 residents had fallen in the previous six months. Findings: 1. Res #28 had diagnoses which included epilepsy, conversion disorder, diabetes mellitus, lack of coordination, muscle weakness, unsteadiness on feet, psychotic disorder, moderate intellectual disabilities, and cirrhosis of the liver. A care plan, titled Falls, dated [DATE], documented a goal of no falls with injury for 90 days. The care plan was last reviewed on [DATE]. A second care plan for falls, titled [name deleted] has experienced an actual falls r/t impaired cognition, impaired decision making, disease process, and medication, dated [DATE], documented dates of falls the resident experienced with interventions put in place to prevent recurrence. This care plan was last reviewed on [DATE]. A nurse note, dated [DATE], documented a CNA/CMA overheard a male resident yelling at someone and when she responded to the room found this resident lying on the floor. The STPR was to attempt to keep this resident out of other resident rooms. The resident's care plan was not updated with this fall intervention. A nurse note, dated [DATE], documented the resident was found on the floor by a hospitality aide. The resident had experienced a laceration over the right eye. The accompanying incident report documented the resident received six sutures to the forehead. The care plan documented an intervention of reorient confused resident as necessary. An additional care plan update, dated [DATE], documented to monitor for signs and symptoms of any pending seizure activity and safety of the resident. A nurse note, dated [DATE], documented the resident was found on the floor by a hospitality aide. The note documented the resident was convulsing and had a distant stare, tongue protruding, and the resident would not allow a blood pressure reading. The note documented the resident had a red area to the right forehead and on the left arm. No STPR were documented. A nurse note, dated [DATE], documented the resident was sitting on her wheelchair when the staff heard her hit the floor. The note documented there were no visible injuries, however the resident would not respond and she was sent to the emergency room. The accompanying incident report, dated [DATE] documented the fall and an intervention to place a fall mat beside the resident's bed. The care plan was updated with the new intervention of placing fall mats beside bed on floor while the resident was in bed. The note documented the resident had been in her wheelchair and not in bed when this fall occurred. A nurse note, dated [DATE], documented the resident was found on the floor in her room. The note documented the resident had discoloration to the left hip and elbow. The resident's care plan was updated with Increased staff supervision with intensity based on resident need. A nurse note, dated [DATE], documented the nurse was called to the room by a CNA. The resident complained of pain to the left leg and had two small open reddened spots to the left knee, a small open sore to top lip. The note documented the resident stated she had fallen out of bed. The corresponding incident report documented a STPR of check resident every hour and to ensure she has her helmet on. The care plan was not updated with the intervention of every hour visual checks. The facility was unable to produce documentation the hourly visual checks had been implemented. A nurse note, dated [DATE], documented the resident was found in the floor by a CNA with a laceration above the right eye, swelling of the face, abrasions to both arms, bleeding from the mouth and nose. The note documented the resident was sent to the emergency room. No STPR were documented. A nurse note, dated [DATE], documented the resident was found on the floor in another resident's room. The note documented the left facial area was swollen and the resident complained of pain to the left hand. The note documented the resident's gums were bleeding and the resident was sent to the emergency room. No STPR was documented. A follow up note on the fall, dated [DATE], documented the resident's left eye was swollen and matted shut and her left cheek was swollen and discolored. A quarterly assessment, dated [DATE], documented Res #28 was moderately impaired in cognitive skills for daily decision making, and required limited to total assistance with most ADLs. The assessment documented the resident did not walk and had experienced falls in the 2-6 months prior to admission, entry, or reentry. The assessment documented two or more falls resulted in no injury and two or more falls resulted in minor injury. A nurse note, dated [DATE], documented a CNA found the resident on the floor in her room and the resident was bleeding from her head. The note documented the resident's Hospice was contacted and did not want the resident sent out. No STPR was documented. An unsubmitted annual assessment, dated [DATE], documented Res #28 was moderately impaired in cognitive skills for daily decision making, and required limited to total assistance with most ADL. The assessment documented the resident did not walk and had experienced falls in the 2-6 months prior to admission, entry, or reentry. The assessment documented two or more falls resulted in no injury and two or more falls resulted in minor injury. A nurse note, dated [DATE], documented the resident was sitting in her wheelchair in the dining room when she leaned forward to pick something off the floor and fell onto her forehead and nose. The note documented the resident sustained a laceration to the middle of the forehead with a large amount of bleeding and swelling of her nose. The note documented the resident was sent to the emergency room. No STPR of falls was documented with this fall. A nurse note, dated [DATE], documented the resident had fallen in another resident's room. The note documented the previous laceration to the resident's forehead which had been dermabonded was bleeding and the resident was bleeding from the nose. The note documented the bridge of the resident's nose was very swollen and blood was coming out of her mouth. The note documented the resident was sent to the emergency room. The resident's care plan for falls was updated with Keep personal items and frequently used items within reach on [DATE]. The resident fell in another resident's room. A third care plan for falls titled [name deleted] IS AT Risk for falls R/T IMPAIRED COGNITION, MEDICATION, documented a goal of no falls with injury for 90 days. The care plan was last reviewed on [DATE]. A nurse note, dated [DATE], documented the resident had fallen in another resident's room without injury. No STPR was documented. A nurse note, dated [DATE], documented the resident was found lying on the floor in her room with blood on the floor. The note documented the resident had sustained a laceration above the left eyebrow. The note documented the facility tried to steri-strip the laceration closed but where unable to keep the closures in place. The note documented the resident was then sent to the emergency room. No STPR was documented. A nurse note, dated [DATE], documented the resident was waiting outside of the dining room for a meal when she leaned forward and fell out of the wheelchair. The note did not document any injury. No STPR was documented. A nurse note, dated [DATE], documented the resident was found on her bedroom floor, face down, and had a large amount of blood coming from her nose and mouth along with swelling. The note documented the resident was sent to the emergency room. The accompanying incident report, dated the same day, documented the resident had sustained a fractured nose. No STPR was documented. A nurse note, dated [DATE], documented the resident had an unwitnessed fall in her room. The note documented the resident appeared uninjured but was very lethargic, and would only respond to touch. The note documented it was hard to determine if the resident had sustained any new injuries as she was swollen and very bruised from the previous fall. No STPR was documented. A nurse note, dated [DATE], documented the resident had experienced a witnessed fall in the common area. The note documented the resident was medicated for pain and since the fall had been very lethargic and responsive only to touch. No STPR was documented. On [DATE] at 12:40 p.m., the resident was observed lying in bed while a CMA attempted to administer medications. The resident did not arouse when spoken to or touched by the CMA. After some time, the resident opened her eyes and was administered the medication by the CMA. At that time the CMA reported this was very unusual behavior for her. The resident's face appeared very swollen and bruised. On [DATE] at 12:43 p.m., the CNA/RA reported the resident had fallen while trying to transfer. On [DATE] at 3:47 p.m., a family member reported the facility notified her when the resident fell. The family member stated the resident fell frequently and recently broke her nose. On [DATE] at 1:32 p.m., the DON and MDS coordinator #2 were interviewed regarding the falls and STPR. The MDS coordinator stated she was aware new interventions should have been tried with each fall and the interventions should have been documented in the care plan. The DON stated the facility did not have a fall program and if there were any other interventions she would not know where they were documented. The MDS coordinator stated the resident only had quarterly fall assessments. A nurse note, dated [DATE], documented the resident expired at the facility. 2. Res #25 had diagnoses which included chronic obstructive pulmonary disease, muscle weakness, unsteadiness on feet, conversion disorder with seizures or convulsions, vascular dementia, and cerebellar stroke syndrome. A care plan, titled ''[name deleted] has experienced actual fall,'' dated [DATE], documented the resident had experienced several falls. The care plan was last reviewed on [DATE] and last revised on [DATE]. A second fall care plan, dated [DATE], documented the resident was at risk for falls due to medication and impaired cognition. A nurse note, dated [DATE], documented the resident was found on the floor in the back lobby and had apparently fallen out of the wheelchair. The note documented the resident had a large contusion to her forehead and bruising to the left cheek. The note documented the resident was sent to the emergency room. The care plan was updated to include physical therapy and occupational therapy. An annual assessment, dated [DATE], documented Res #25 was severely impaired with cognitive skills for daily decision making, required limited to extensive assistance with ADLs, and had not experienced any falls. The care area assessment triggered falls for care planning. A nurse note, dated [DATE], documented the resident was found lying face down in the Hall 200 lobby. The note documented the resident had a bump on the left forehead. No STPR were documented. A nurse note, dated [DATE], documented the resident was found on the floor during physician rounds with a large amount of blood coming from her forehead. The note documented the resident was sent to the emergency room and was treated for a contusion, hematoma, and laceration. The note documented Res #25 received sutures to her forehead. The accompanying incident report documented the fall but did not document STPR. A quarterly assessment, dated [DATE], documented Res #25 was severely impaired with cognitive skills for daily decision making, required total assistance with ADLs, and had one fall with no injury. A nurse note, dated [DATE], documented the nurse was called to the resident's room by another resident who observed the resident on the floor. The note documented the resident sustained a small knot to the forehead, and some redness to both knees. The accompanying event report documented the fall but no STPR were documented. A nurse note, dated [DATE], documented the resident was attending a church service in the lobby when she leaned over and fell on to her left side. Neither the nurse note or the accompanying event report documented STPR of falls. On [DATE] at 1:13 p.m., the DON and MDS coordinator #2 were interviewed and reported they were notified of falls by reviewing the nurses notes unless it was a reportable fall which would be reported by a phone call by the facility staff. The MDS coordinator stated they were notified of falls in the daily meeting as well. The MDS coordinator stated she did an intervention for the [DATE] fall of obtaining a new wheelchair for the resident, but had not put it in place as yet. She stated she instructed staff to put her in her recliner or in bed rather than leaving her up on her wheelchair. The MDS coordinator stated she did not update the care plan with the new interventions and had not documented them anywhere else. 3. Res #40 had diagnoses which included acute and chronic respiratory failure with hypoxia, weakness, lack of coordination, age-related debility, and bradycardia. An admission assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making and required extensive assistance with ADLs. The Care Area Assessment documented falls were triggered for care planning. A nurse note, dated [DATE], documented the resident was lying on the other bed in her room when she fell between the bed and the wall. The note documented the fall was unwitnessed and the resident stated she hit her head but no injury was found. A care plan, dated [DATE], was initiated to prevent falls. The care plan was last revised on [DATE] and reviewed on [DATE]. A nurse note, dated [DATE] documented the resident had experienced an unwitnessed fall and related she bumped her head. The note documented the resident had mild chronic pain unrelated to the fall. The accompanying incident report documented the fall and to increase staff supervision with intensity based on resident needs. The plan of care was not updated. A nurse note, dated [DATE], documented the resident was found on the floor by a CNA. The note documented the resident was not injured but was more confused and weaker than normal. The note documented the resident was sent to the emergency room. No STPR were documented. A nurse note, dated [DATE], documented the resident had an unwitnessed fall when the resident's wheelchair tilted back. The note documented the resident had a bump on the back of her head. The accompanying incident report documented the fall. There were no STPR documented. A nurse note, dated [DATE], documented the resident was seen by a CNA crawling on the floor outside of her room. The note stated the mattress was off the bed, the chair was tipped over as wall the bedside table. The note documented the resident was not injured. The accompanying event incident report documented the fall. No STPR were documented. A nurse note, dated [DATE], documented the resident experienced an unwitnessed fall on the couch in the back lobby. The note documented the resident could not remember how she fell and had not sustained any injuries. No fall investigation was provided. No STPR were documented. A nurse note, dated [DATE], documented the resident tried to get into bed when she fell on to the floor and sustained scratched to her lower right leg. The note documented first aide was applied. The care plan was updated to give the resident verbal reminders to not transfer or ambulate without assistance. A nurse note, dated [DATE], documented the resident reported falling out of bed to a CMA. The note documented the resident had a small knot to the posterior scalp and a large bruise to the right shoulder blade, and abrasion scrape to the left upper thigh, dark bruising to the right hand and forearm, and dark bruises to the posterior upper arm/axilla area. The note documented two skin tears to the right shin area. No STPR was documented. A quarterly assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making and required extensive assistance with ADLs. The assessment documented the resident had one fall with no injury and one fall with minor injury. A nurse note, dated [DATE], documented the resident was found on the floor in her room by staff. The note documented the resident was not injured and staff were instructed to check on the resident more frequently which was an intervention utilized previously. The plan of care was not updated. On [DATE] at 1:02 p.m., the DON and MDS coordinator #2 were interviewed and reported the above falls did not all have interventions to prevent recurrence of falls. The MDS coordinator stated all the falls should have had new interventions care planned.