**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #19 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus with diabetic neuropathy and anxiety disorder. A quarterly assessment, dated 04/06/22, documented the resident's cognition was intact. An incident report, dated 06/01/22, documented the resident spilled her cup of noodles on her the previous night and received burns with blisters to her left upper arm, neck, and chest area. On 06/24/22 at 12:31 p.m., the resident reported the water was too hot and the cup of noodles burned her when she spilled the noodles on her. The resident reported she picked up the cup and her arm jerked and water splashed her on the left upper arm and a few areas on her chest. The burn areas on her chest are now healed. The burn area to left inner arm is healing with no signs of infection. On 06/24/22 at 1:17 p.m., LPN #2 reported the resident still ate noodles almost on a daily basis either as a snack or for a meal if she did not like what was on the menu. The LPN was asked what intervention was put in place to prevent this type of accident from happening again. LPN #2 reported she educated the CNA's on her shift to read the back of the box, to follow the directions, and not to fill it with as much water. On 06/24/22 at 1:44 p.m., record review had no documentation of interventions to prevent this from happening again and the resident's care plan had not been updated. 5. Resident #23 was admitted to the facility on [DATE] with diagnoses of non-Alzheimer's dementia. An annual assessment, dated 08/09/21, documented the resident's cognition was severely impaired. The assessment documented the resident did not wander. An elopement risk assessment, dated 10/15/21, documented the resident was not at risk for elopement. The assessment documented the resident was at risk for personal injury related to wandering. An investigation report, for an incident on 01/01/22, documented the alarm for the exit door on the memory care unit had been going off due to the wind and maintenance was notified. The investigation report documented the staff reported the resident was put to bed at 9:30 p.m. The investigation report documented at approximately 9:45 p.m. the resident left the building through the exit door on the memory care unit and fell down resulting in a fractured clavicle and two fractured ribs. The investigation report documented the door alarm cord had been disabled. A video recording of the incident, on 01/01/22, showed the resident exited the building at 9:52 p.m. A video recording of the incident, on 01/01/22, showed the memory care staff sitting at the nurse station at 9:53 p.m. A nurse note, dated 01/01/22 at 10:30 p.m., documented, Incident Note Text: Around 22:15, a bell rang on front door and noted the police and a lady and stated that the lady called the police that there was a person lying on the pathway outside the building by the pathway to main road. Upon visualizing the person it was noted that it was our resident. Pulse was noted, skin was pale and cold, resident was confused and she was cold blankets were put on the resident as the EMS were on there [sic] way. Resident was sent to [hospital name deleted] for be Evaluation and treated. Daughter was notified. DON was notified. Hospital records, dated 01/01/22, indicated Res #23 arrived in the ED at 10:37 p.m. The xray reports documented the resident received a third rib fracture with trace adjacent pneumothorax on the right side, fourth rib fracture on the right side, and a fracture of the medial and lateral aspect of the right clavicle. A file containing corrective measures documented direct care staff were in-serviced on 01/03/22 to respond to all alarms, to look outside to make sure no residents were outside after an alarm, to not disconnect secondary alarms, and to round every two hours to include checking security of all doors. Documentation showed that a third alarm was ordered for the memory care exit door and the speaker was to be placed down the hall of the memory care unit. Documentation showed the maintenance man was to check door alarms monthly. A significant change assessment, dated 01/11/22, documented the resident did not wander. A care plan, dated 01/11/22, had no interventions pertaining to prevention of elopement documented after the resident's elopement. A facility policy titled, Staffing and Environment of the Special Care Unit, dated February 2022, was updated and documented all staff working in the memory care unit had to visualize every resident every 30 minutes during their shift and visually checked during rounds with outgoing shift. On 06/23/22 at 8:58 a.m., the administrator demonstrated the 3rd alarm, which was added to the memory care unit exit door, was in working order. The new alarm speaker was in hallway by resident rooms so it can be heard throughout the unit. On 06/23/22 from 2:30 p.m. to 3:19 p.m. the alarm on the exit door in the memory care unit was observed to sound approximately 19 times for about one second each time. No staff on the unit was observed to check the exit door. On 06/23/22 at 2:53 p.m. an unnamed staff member was observed entering the memory care unit and began to receive report from the CNA from day shift. The oncoming staff member and the leaving staff member were not observed to round and check the exit doors on the unit. On 06/23/22 at 3:22 p.m., CNA #3 reported rounds were done every two hours which included checking residents to make sure they were clean and dry. The CNA reported at shift change they checked the residents to make sure they are clean and dry, emptied trash cans, and gave report about what happened during the shift to the oncoming staff. The CNA did not report the exit door was to be checked. On 6/23/22 at 3:26 p.m., CNA #4 reported that rounds were every two hours and the residents were checked and toileted as needed. The CNA reported rounds with the outgoing shift consisted of checking residents to make sure they were clean and dry, and made sure trash and laundry was picked up. The CNA did not report the exit door was to be checked. On 06/23/22 at 3:30 p.m., CNA #5 reported rounds with the oncoming shift consisted of checking residents to make sure they were clean and dry, to make sure trash and laundry were picked up. The CNA reported rounds were done every two hours to check and toilet the residents. The CNA did not report the exit door was to be checked. On 06/23/22 at 4:33 p.m., CNA #6 reported she was working the 3-11 shift the day Res #23 eloped. The CNA reported she performed patient care, made sure the residents were clean and dry, made sure they were in the right rooms, and reported they kept the residents' doors open because so many were a fall risk. The CNA reported rounds were every two hours to perform the same duties as throughout the shift. The CNA did not report being instructed to check that the exit door was secured. On 06/23/22 4:39 p.m., the administrator was informed staff members did not report they had been visualizing the exit doors on their rounding. The administrator was asked how the facility made sure the CNAs were checking the exit door alarms to ensure they were working? The administrator reported there was no documentation of monitoring kept by the memory care staff to ensure the exit door and alarms were being checked. The administrator stated the only documentation of the door being checked was the documentation of the monthly check performed by maintenance. Based on record review, observation, and interview, the facility failed to ensure interventions and supervision were in place to prevent accident hazards including falls, elopement, and burns, for five (#12, 19, 23, 29, and #56) of five residents reviewed for accidents and falls. The facility failed to ensure: a. steps to prevent reoccurrence of falls were put in place for Res #12, 29, and #56. Res #56 sustained a laceration to their head which required sutures. Resident #12 had sustained a hematoma to her forehead. Res #29 sustained a skin tear from a fall on 01/23/22, a bruise to the right side of his head on 05/06/22, and a laceration to his scalp on 05/09/22. b. staff members monitored the external door of the memory care unit to ensure they were securely closed and the alarms were functional for Res #23. A hospital examination summary documented Res #23 had sustained a right third rib fracture with a trace adjacent pneumothorax, a fourth rib fracture on the right, and fracture of the medial and lateral aspect of the right clavicle when the resident fell outside during an elopement from the Memory Care unit. c. interventions were put in place to ensure Res #19's cup of noodles prepared by staff were not so hot as to cause burns if spilled for Res #19. Res #19 spilled a cup of noodles prepared by staff resulting in burns to the upper chest/neck and the left arm. The facility identified one resident who had eloped, one resident who sustained a burn, and the fall tracking reports documented residents in the facility had fallen 219 times in the previous six months. Findings: A facility policy, titled FALL INJURY PREVENTION, read in part: .4. ANY INFORMATION RECEIVED REGARDING A RESIDENT'S FALL RISK WILL BE RELAYED TO THE CAREPLAN COORDINATOR SO THAT MEASURES CAN BE IMPLEMENTED TO PREVENT FALL INJURIES AND ATEMPT [sic] TO DECREASE FALL OCCURANCES. IF THE MEASURES IMPLEMENTED ARE NOT EFFECTIVE, THEN THE CAREPLAN WILL BE MODIFIED TO BETTER SUIT THE RESIDENT . 1. Res #56 had diagnoses which included fracture of unspecified neck of right femur, dementia, and lumbago with sciatica. An admission assessment for Res #56, dated 12/29/21, documented the resident was severely impaired in cognition, required supervision with most ADLs, and had a fall prior to admission. The care area assessment documented falls had triggered for care planning. A review of the resident's care plan did not document a fall prevention care plan had been developed for Res #56. An incident report, dated 02/22/22, documented Res #56 was putting on her sock and walking to her shoes when she slipped and fell to the floor. The incident report documented Res #56 was unable to move her right leg. The incident report documented the resident was sent to the emergency department. An incident report, dated 02/28/22, documented the resident fell trying to get to the restroom. The incident report documented the resident was holding onto her ribs and complaining of pain. The incident report documented petechia to the rib area. The incident report documented the resident was educated to use the call light, the staff were to check on her more frequently, and were to move the pressure pad to her wheelchair when she would go to the dining area. A significant change assessment for Res #56, dated 03/02/22, documented Res #56 required extensive assistance with bed mobility, limited assistance with transfers, had one fall with major injury, and did not walk. A care plan, updated on 03/04/22, documented Res #56 had an ADL deficit related to her fall on 02/22/22 which resulted in a right fractured hip. The care plan documented the resident now required extensive assistance with self care and ADL needs. The care plan documented to ensure Res #56 was wearing comfortable non slippery shoes, and restorative care. The care plan documented interventions to prevent falls which included staff were to assist her to the bathroom before and after each meal and before bed, ensure the call light was within reach, ensure a floor free from spills and clutter, activities to minimize falls, provision of a glare free light, use of a safety alarm, to keep personal items within reach, to keep the bed in the lowest position, and to follow the fall protocol. An incident report, dated 03/07/22, documented Res #56 fell in front of her recliner without injury. No new STPR were added to the care plan. An incident report, dated 03/09/22, documented Res #56 fell on the floor without injury when trying to get to her bed. No STPR were documented. An incident report, dated 04/27/22, documented Res #56 was found sitting upright in the closet. The incident report documented Res #56 was complaining of a headache with visual disturbances and hip pain. The incident report documented Res #56 was sent to the emergency room. No STPR were documented. An incident note, dated 05/05/22, documented Res #56 was found sitting on the floor holding on to her recliner. The note documented the resident stated she was not hurting bad and was provided Tylenol. The note did not document STPR for falls. An incident note, dated 05/25/22, documented Res #56 was found on the floor in her room with copious amounts of blood on the floor in front of the resident. The note documented the chair alarm was actively working and in place. The note documented Res #56 had sustained a large laceration above the right eyebrow and was sent to the hospital where the resident received sutures. The note documented Res #56 was placed on hourly rounding for seven days. An incident report, dated 05/25/22, documented Res #56 was found in the floor in her room. The incident report documented the batteries were changed on her chair alarm. No STPR were documented. An incident note, dated 05/28/22, documented a CNA had found Res #56 on the floor in her room. The note documented the resident was not injured. The note did not document STPR of falls. A quarterly assessment, dated 06/01/22, documented Res #56 was severely impaired in cognition, required limited to extensive with most ADLs , and had experienced two or more falls with no injury, two or more falls with injury, and two or more falls with major injury. A care plan note, dated 06/03/22, documented Res #56 had a fall and sustained a head injury requiring sutures. The note documented Res #56's family refused a room change to allow the staff to visualize the resident via passerby supervision. The note documented to continue the plan of care and added no other STPR of falls. On 06/21/22 at 2:30 p.m., Res #56 was observed sitting alone in the dining room. The resident was observed counting straws and was unable to clearly answer interview questions. On 06/24/22 at 1:59 p.m., MDS coordinator #2 reported she was aware of Res #56 recent falls. The MDS coordinator reported she had not updated the care plan with any STPR after each fall. At that time, the DON reported she had only worked as the DON since 06/20/22 and the ADON was not available for interview. 2. Res #12 had diagnoses which included dementia, seizures, and cerebral infarction. A care plan, dated 09/16/20, documented Res #12 was a moderate risk for falls related to confusion and unaware of safety needs. The care plan documented to keep the call light within reach, place a fall mat next to her bed, follow the fall protocol, footwear to include non-skid shoes, to keep the area free from obstructions, and to provide for activities to minimize the potential for falls. An annual assessment for Res #12, dated 9/26/21, documented the resident needed extensive assistance with bed mobility and transfers and did not walk. The assessment documented Res #12 had not fallen since the previous assessment. The care area assessment documented falls were triggered for care planning. An incident note, dated 01/08/22, documented the staff had found Res #12 on the floor sitting in front of the chair. The incident note documented the STPR as CNAs educated to assist Res #12 to her wheelchair instead of her recliner for meals. An incident note, dated 01/17/22, documented Res #12 was found on the floor with her blankets around her. The incident note documented Res #12 was not injured. The incident note did not document any STPR for falls for Res #12. An incident note, dated 02/18/22 documented Res #12 fell from her wheelchair in the dining room. The note documented Res #12 had sustained a hematoma to her forehead and the facility initiated neuro checks on the resident. The note did not document any STPR for falls. An incident note, dated 03/22/22, documented the housekeeper had found Res #12 on the floor of her room. The note documented it appeared Res #12 had set her recliner in an upright position and then slid out of it and onto the floor and documented the resident did not appear to have injured herself. The incident report documented the STPR was to place the remote of the recliner into the pocket of the recliner to prevent the resident from accidentally dumping herself out of the recliner. A quarterly assessment, dated 03/27/22, documented Res #12 was severely impaired in cognition, required extensive assistance with most ADLs, and did not walk. The assessment documented the resident had one fall without injury. The care plan, last reviewed on 03/29/22, did not document the new intervention of eating in her wheelchair instead of her recliner or to place the remote of the recliner in the pocket of the recliner to prevent accidental activation. An incident note, dated 06/15/22, documented housekeeping found Res #12 on the floor of her room between the recliner and her wheelchair. The incident note documented it appeared Res #12 had not injured herself. The incident note documented a STPR as Dysem (an anti-slip material) in the resident's wheelchair to prevent her from sliding out again. The care plan was reviewed and did not document the new intervention. On 06/24/22 at 10:00 a.m., Res #12 was observed sleeping in her recliner. The resident's wheelchair was observed and did not have Dysem in the seat. A fall mat was observed in the room, half way slid under the bed. A fall alarm was not observed. On 06/24/22 at 10:44 a.m., CMA #1 and CNA #1 were asked about fall prevention for Res #12 and stated Res #12 was supposed to have Dysem in her wheelchair. The CMA and CNA stated the aides were in a learning circle meeting and only CNA #3 was on the floor to care for the residents. On 06/24/22 at 10:45 a.m., CNA #2 stated Res #12 had a fall alarm. On 06/24/22 at 10:46 a.m., CMA #1 entered Res #12's room and stated the resident's wheelchair did not have a sheet of Dysem in it to prevent slipping. The CMA stated the resident had a fall mat as well but did not know if it was still an intervention since the resident had been reassigned to a room out of the Memory Care unit. On 6/24/22 at 10:28 a.m., CNA #3 was asked about fall interventions for Res #12. CNA #3 stated Res #12 required extensive assistance and was unable to provide additional fall prevention interventions. CNA #3 was asked where to look for interventions and stated they should have been documented on the residents' care plan. CNA #3 stated she could also ask a Charge Nurse. On 06/24/22 at 12:03 p.m., RN #1 stated she did the fall tracking and the Charge Nurses were to update residents' care plans after falls. On 06/24/22 at 12:08 p.m., RN #2 reviewed Res #12's care plan and stated it had not been updated. The RN stated the facility had not provided the appropriate interventions to prevent the reoccurrence of falls. 3. Resident #29 was admitted on [DATE] and had diagnoses which included dementia, displaced fracture of neck of left femur, history of falling, and abnormalities of gait and mobility. An incident note, dated 01/08/22, documented Res #29 had fallen in his bathroom. The STPR was documented as Resident could benefit us [sic] of Pressure Alarm. Educated resident to use call light when he needs help. A health status note, dated 1/8/22, documented the resident's right hip had a non-displaced fracture. An admission assessment, dated 01/16/22, documented Res #29 was severely impaired in cognition, required limited to extensive assistance with ADLs and did not walk. The admission assessment documented Res #29 had a fall with fracture prior to admission. The care area assessment documented falls were triggered for care planning. An incident note, dated 01/17/22, documented Res #29 was found lying on his left side with his walker and cane knocked over beside him. The note did not document where this fall had occurred. The note documented Res #29 refused to go to the emergency room and a mobile xray was ordered. The STPR of falls for Res #29 was documented as resident educated to use call light to let staff assist resident with his needs An incident note, dated 01/21/22, documented Res #29 was found on his knees beside of his bed. The note documented Res #29 denied injury. The note documented a pressure pad was applied to Res #29's bed. A plan of care note, dated 1/23/22, documented Res #29 was found on the floor between his bed and recliner. The note documented Res #29 had a skin tear which was treated with steri strips. The note documented Res #29 stated he was had put his call light on and waited for some time then tried to go to the bathroom on his own. The note documented staff members educated the resident to wait on staff even if he has to wait a little longer because he fell two days in a row. The note stated the pressure pad for the resident could not be located so a clip alarm was placed on Res #29's wheelchair. The resident's care plan was not updated to include a clip alarm on the resident's wheelchair. A care plan note, dated 1/24/22, documented Res #29 was heard yelling out and was found on his back in the bathroom floor. The note documented Res #29 was hurting but refused to go to the emergency room. The note documented Res #29 stated he was trying to clear out the shower so he could take a shower. The note documented the nurse educated him to wait on staff because he will get injured if he continued to walk without assistance. The note documented the clip alarm was located on Res #29's bed and was placed on the resident. The note did not document STPR of the falls. An incident note, dated 02/11/22, documented an unidentified CNA was pushing Res #29 out of his room when his foot was caught under the wheelchair flipping him out of the wheelchair onto his face. The STPR was documented as ensuring foot pedals were applied to the wheelchair. A plan of care note, dated 02/13/22, documented Res #29 refused to allow the foot pedals to be on his wheelchair. No other STPR was documented since the foot pedals were not to be used. A plan of care note, dated 02/16/22, documented Res #29 was found on the floor in front of the recliner next to the bed. The note documented Res #29 had removed the clip alarm and placed it in his wheelchair. No injuries were documented. No STPR was documented. An incident note, dated 03/03/22, documented Res #29 had activated the bathroom call light. The note documented Res #29 was found on the floor in front of the toilet and was without injury. The note documented Res #29 reported he was trying to go to the bathroom. The note documented a bed alarm was placed under the resident to prevent further falls. An incident note, dated 03/03/22, documented Res #29 was found on the floor next to his bed. The note documented Res #29 was not injured and the clip and bed alarm were in place and functioning. No STPR was documented in the incident note. An order note, dated 03/04/22, documented Res #29 had fallen two times in 24 hours and asked for labs and a urinalysis. The note documented orders were obtained. A plan of care note, dated 04/16/22, documented Res #29 was found on the floor in his room and was attempting to get back in his wheelchair. The note documented Res #29 was not injured. The note documented to encourage the resident to use call light and ask for assistance when attempting to transfer. The note did not document new STPR to prevent falls. A quarterly assessment for Res #29, dated 04/18/22 documented Res #29 was moderately impaired in cognition, required limited assistance with most ADLs, and did not walk. The assessment documented Res #29 had a fall with fracture prior to admission and two or more falls since admission. A care plan, reviewed on 04/18/22, documented Res #29 was at risk for falls and had fallen in the past 2-6 months. The care plan documented the following interventions as bed alarm, anticipate Res #29's needs, call light in reach and encourage him to use it, activities to promote exercise, appropriate footwear, follow fall protocol, keep environment free from spills, clutter, provide glare free light, bed in the low position, and ensure his personal items are within reach. A care plan note, dated 05/01/22, documented when a CNA responded to a call light, Res #29 was found on the floor in the bathroom. The note documented the resident stated he slid out of his wheelchair and hit his head on the floor and complained of hip pain. The STPR was documented as Dysem placed in wheelchair at that time. A care plan note, dated 05/06/22 documented Res #29 fell in his room an sustained a bruise to the right side of his head. The note documented the resident grimaced when his right arm was moved and orders for an xray of the right shoulder was obtained. The note did not document STPR. An incident note, dated 05/09/22 documented a CNA had found Res #29 on the floor at the foot of his bed next to his wheelchair. The note documented a laceration to the left side of Res #29's scalp which stopped bleeding when pressure was applied. The STPR was documented as resident educated to use call light when needing to ambulate from bed/wheelchair. A care plan note, dated 05/25/22, documented Res #29 was found on the floor in front of the toilet. The note documented the wheelchair alarm was in place and working. The note did not document a STPR. An incident note, dated 06/05/22, documented Res #29 was lying on the floor on his left side with his left arm under him. The note documented Res #29 stated he was trying to get out of his recliner. The note documented Res #29 had been incontinent of urine and the floor was wet. The note documented to use a chair alarm when the resident was in the recliner. An incident note, dated 06/19/22, documented Res #29 was found sitting on the floor in front of the bathroom door. The note documented the clip alarm was on the chair but not attached to Res #29. The note documented the resident was unharmed and staff were educated on the importance of ensuring the clip alarm was attached to the resident. No STPR was documented regarding this fall. On 06/22/22 at 9:18 a.m., Res #29 was observed sitting in his wheelchair in his room. He stated he had fallen several times and got hurt once. Res #29's wheelchair was observed to have a chair alarm attached. On 06/24/22 at 10:31 a.m., Res #29 was observed to have moved several objects to his bed. A battery operated toothbrush was observed on his bed with the battery compartment opened and the batteries were not in the compartment. One battery was observed on the floor and Res #29 was observed to try to operate a grab extender to pick up the battery. Res #29 stated he was unable to make the grab extender work. On 06/24/22 at 10:45 a.m., CMA #1 and CNA #1 were asked about fall prevention for Res #29 and stated Res #29 was supposed to have a chair and bed alarm. They were unaware of any other interventions put in place to prevent Res #29 from falling. On 6/24/22 at 10:28 a.m., CNA #3 was asked about fall interventions for Res #29. CNA #3 stated this resident was a one person assist and did not know of any fall interventions for Res #29. On 06/24/22 at 12:21 p.m., LPN #1 stated the charge nurses were to put new interventions in place whenever a resident had fallen. The LPN reviewed Res #29's care plan and stated the interventions on the care plan were not appropriate for this resident as his recall was so poor. She stated the staff should have provided new interventions with each fall.