**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the State licensure regulations, job description review, policy review, medical record review, review of facility investigations, observation, and interview, the facility failed to ensure the environment was free from accident hazards when dangerously elevated hot water temperatures were measured for 8 of 69 (Resident Rooms #13, #17, #18, #86, #89, #90, #91, #93) rooms, and when the facility failed to provide a safe environment and adequate supervision to prevent falls and injury for 7 of 7 (Resident #2, #11, #21, #28, #46, #52, and #54) sampled residents reviewed for accidents. On 6/24/2024 and 6/28/2024, dangerous elevated hot water temperatures ranging from 123 degrees Fahrenheit (F) to 130 degrees Fahrenheit (F) were observed in 8 of 69 (Resident Rooms #13, #17, #18, #86, #89, #90, #91, #93). Two Residents who were physically and/or cognitively impaired (Residents #43 and #52) resided in a room with elevated dangerous hot water temperatures and two residents were able to access the hot water in their rooms. Two cognitively intact (Residents #40 and #55) stated the water would get too hot. The facility's failure to prevent the dangerously elevated hot water temperatures placed all residents with the ability to access the hot water in Immediate Jeopardy. The facility's failure to implement effective fall interventions resulted in actual harm when Resident #11 fell and sustained a closed fracture (broken bone) of the left distal femur (large upper bone of the leg). The failure of the facility to maintain safe hot water temperatures placed all residents with access to these rooms in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance has caused, or has potential to cause serious injury, harm, impairment, or death to a resident). The facility's census was 63. The Administrator, Director of Nursing (DON) and the Maintenance Supervisor were notified of the Immediate Jeopardy (IJ) for F689 on 6/24/2024 at 3:23 PM, in the facility Conference Room. An acceptable allegation of removal was received on 6/25/2024 at 12:38 PM. On 6/28/2024 beginning at 8:38 AM, while attempting to validate the allegation of removal, dangerously elevated hot water temperatures ranging from 122.5 degrees F to 123.6 degrees F were observed in resident rooms #13, #17 and #18. The Administrator was notified of the Immediate Jeopardy (IJ) for the amended F689 on 6/28/2024 at 10:47 AM, in the facility Conference Room. An extended survey was conducted 6/26/2024 through 6/28/2024. The Immediate Jeopardy for F-689 began on 6/24/2024. The Immediate Jeopardy is ongoing. The findings include: 1. Review of the State Licensure Regulations, CHAPTER 0720-18 STANDARDS FOR NURSING HOMES revised July 2022, revealed at 720-18-.08 17 (c), Water distribution systems shall be arranged to provide hot water at each hot water outlet at all times. Hot water at shower, bathing and hand washing facilities shall be between 105°F and 115°F. 2. Review of the undated ADMINISTRATOR JOB DESCRIPTION revealed .Position Purpose .Leads, guides, and directs the operations of the healthcare facility in accordance with local state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents .Plans, develops, implements, evaluates, and directs the overall operation of the facility as well as its programs and activities in accordance with current state and federal laws and regulations .Leads and coordinates .management team meetings to discuss priorities and develop solutions .Knows and understands general nursing practices and procedures .Code of Federal Regulations, Appendix PP State Operations Manual .collaborates with members of the interdisciplinary team .to resolve issues . Promotes .effective communication .Ensures the facility's plan of correction response to any regulatory, inspection survey is completed, adequate, implemented, and timely .Communicates directly with .medical staff, nursing staff .department heads, and members of the interdisciplinary team to coordinate care .Responds and resolves complaints and concerns . Protects residents from abuse .Follows established infection control policies . Review of the undated DIRECTOR OF NURSING JOB DESCRIPTION revealed .Position Purpose .Planning, organizing, developing, and directing the overall operations of the Nursing Service Department in accordance with local, state, and federal standards and regulation, established facility policies .to provide appropriate care and services to the residents .Communicates policies and procedures to nursing staff and monitors staff practices and implementations .Participates in daily or weekly management team meetings to discuss .resident change in status, complaints, or concerns .Ensures delivery of .quality care .Oversees resident incidents .daily .reports them promptly to the Administrator .for appropriate action .Monitors for allegations of potential abuse or neglect .and participates in the investigative process .Acts in an administrative capacity in the absence of the administrator . Review of the undated MAINTENANCE DIRECTOR JOB DESCRIPTION revealed, .Position Purpose .Directs .Maintenance Department in accordance with current federal, state, and local standards, guidelines, and regulations governing the facility and to assure the facility is maintained in a safe and comfortable manner .Ensures proper planning, direction, participation, and supervision of both preventative and unplanned maintenance and repair activities in the facility which includes .plumbing .Develops and implements preventative maintenance tasks .instructions, and procedures for the preventative maintenance of the facility .Ensures the facilities compliance with the law and other regulatory terms such as safety .Performs and monitors required inspections of facility equipment .Maintains a safe and secure working environment free of .situations that could cause harm .to residents, families, visitors . 3. Review of the facility policy titled, .FALL PROGRAM GUIDELINES, dated 11/8/2019, revealed FALL RISK ASSESSMENT PURPOSE: IDENTIFY RESIDENTS AT RISK FOR FALLS AND APPLY MEASURES TO REDUCE THE OCCURRENCE OF ALL RELATED INCIDENTS .Complete a Fall Risk Assessment form on admission, quarterly and prn [as needed]. A resident who scores 7 or higher on the Fall Risk Assessment will be considered high risk for falls. If it is determined that a resident is high risk for falls perform the following: Review and assess on a quarterly basis or with significant changes- resident's fall history, environmental factors and mediation use which could contribute to the risk of falling .Perform personal assessment on resident to address factors which would increase fall risk with annual MDS [Minimum Data Set] assessments or any significant changes of status .Assess resident for need to use adaptive equipment that could decrease fall risk, such as, walker, quad cane, body alarm, low bed or other adaptive equipment as determined on an individual basis .Care plan risk factors and any interventions in place for each individual based on their specific needs .Fall Risk Assessment will include assessment of anticoagulant use with severely impaired cognitive residents . Review of the facility policy titled, .POST FALL GUIDELINE, dated 11/8/2019, revealed PURPOSE: TO EVALUATE EACH INDIVIDUAL FALL AND DETERMINE NEW INTERVENTIONS FOR THE EVENT OF FUTURE FALLS .Complete Post Fall Investigation Form immediately after a fall for each resident when a fall occurs .The immediate intervention of Q 15 [every 15] minute checks will act as a care planned intervention until the Fall Committee meets and reviews the fall; At that time of the Fall meeting the immediate intervention will become void .The Fall Committee will collaborate and form a fall intervention based on the resident's individual needs and medical condition .The Fall Committee Leader will complete a Fall Investigation and develop a summary of the events surrounding each individual fall. 4. The surveyor's thermometer was calibrated (a procedure using ice water to ensure the thermometer is measuring correctly) before water temperature checks were obtained. The surveyor's hot water temperature checks in resident rooms on 6/24/2024 beginning at 10:11 AM, revealed the following: room [ROOM NUMBER] was 130 degrees F. room [ROOM NUMBER] was 122 degrees F. room [ROOM NUMBER] was 122 degrees F. room [ROOM NUMBER] was 130 degrees F. The Maintenance Director and the surveyors' hot water temperature checks using a calibrated thermometer in resident rooms on 6/24/2024 beginning at 12:11 PM, revealed the following: room [ROOM NUMBER] was 126 degrees F. room [ROOM NUMBER] was 125 degrees F. room [ROOM NUMBER] was 123 degrees F. room [ROOM NUMBER] was 123 degrees F. room [ROOM NUMBER] was 123 degrees F. The Maintenance Director and the surveyor's hot water temperature checks using a calibrated thermometer in resident rooms on 6/28/2024 beginning at 8:38 AM, revealed the following: room [ROOM NUMBER] was 123.6 degrees F. room [ROOM NUMBER] was 123.6 degrees F. room [ROOM NUMBER] was 122.5 degrees F. 5. Review of the current MDS assessments revealed Residents #43 and #52 were cognitively and/or physically impaired, and the residents had access to the hot water with the dangerously elevated hot water temperatures. The facility provided a list of residents who wander. The list revealed Residents #43 and #52 were cognitively impaired and had been identified by the facility as Residents with wandering behaviors (random, repetitive, or aimless locomotion/movement throughout an area) and had the potential to be affected by dangerously hot water temperatures. 6. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses including Fracture of the Right Femur, Fracture of Shaft of Right Radius, and Dementia. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #17 scored a 6 on the Brief Interview for Mental Status (BIMS) which indicated the Resident was severely cognitively impaired. Observation and interview in Resident #17's bathroom with the Maintenance Director present on 6/28/2024 at 8:45 AM, revealed a hot water temperature of 122.5 degrees F in the hand sink. The Maintenance Director stated, It's out of range, too high. 7. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Dysphagia, Anxiety, Hypertension and Osteoarthritis. Review of the admission MDS dated [DATE], revealed Resident #40 scored a 14 on the BIMS, which indicated the resident was cognitively intact. Resident required moderate assistance with Activities of Daily Living (ADLs). Observation and interview in the Resident #40's room on 6/24/2024 at 9:38 AM, revealed the Resident was sitting up in a chair his room. The Resident reported that water was hot when washing hands in the bathroom. Resident #40 resided in a room which measured a dangerously hot water temperature of 123 degrees F. 8. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and Diabetes. Review of the admission MDS dated [DATE], revealed Resident #41 scored a 15 on the BIMS, which indicated the Resident was cognitively intact. Observation and interview in Resident #41's bathroom with the Maintenance Director present on 6/28/2024 at 9:40 AM, revealed a hot water temperature of 123.6 degrees F in the hand sink. The Maintenance Director stated, It's too high . 9. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Major Depression, Asthma, and Urinary Tract Infection. Review of the Physician's Order dated 8/10/2023, revealed WANDER GUARD TO LEG AS ORDERED . Review of the quarterly MDS dated [DATE], revealed Resident #43 scored a 4 on the BIMS, which indicated the Resident was severely cognitively impaired. The Resident required moderate assistance from staff to perform ADLs. Observation and interview in the Resident #43's room on 6/24/2024 at 9:33 AM, revealed the Resident was resting in bed and was asked about the water temp in her bathroom. The Resident stated the water gets too hot and will scald you if you don't add cold water with the hot water. Resident #43 resided in a room which measured a dangerously hot water temperature of 123 degrees F. Observation and interview in the Resident #43's bathroom with the Maintenance Director present on 6/24/2024 at 12:09 PM, revealed a hot water temperature of 123 degrees F in the hand sink. The Maintenance Director stated, It's hot. It's over the limit today girls. We had trouble with that boiler [water heater], so I had to turn it up. 10. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE], with diagnoses including Dementia, Diabetes, Chronic Obstructive Pulmonary Disease, Depression, and Heart Failure. Review of the quarterly MDS dated [DATE], revealed Resident #44 scored a 15 on the BIMS, which indicated the Resident was cognitively intact. The Resident required supervision assistance of staff to perform ADLs. Observation and interview in Resident #44's bathroom on 6/24/2024 beginning at 12:15 PM with the Maintenance Director present revealed a hot water temperature of 125.8 degrees F. The Maintenance Director stated, This is my fault. I did not turn the boiler [water heater] back down. The Maintenance Director was asked when the boiler was turned up. The Maintenance Director stated, Last week sometime maybe Monday [6/17/2024] .We had a bird get in the pipe. The Maintenance Director was asked what the boiler was usually set on. The Maintenance Director stated, 120. The Maintenance Director was asked what the boiler temperature was turned up to. The Maintenance Director stated, 134. Observation of the North Hall utility room on 6/24/2024 at 12:19 PM with the Maintenance Director present revealed a water heater that was set at 135 degrees F. 11. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE], with diagnoses including Coronary Artery Disease, Heart Failure, Cerebrovascular Vascular Accident, and Dementia. Review of the significant change MDS dated [DATE], revealed Resident #52 scored a 6 on the BIMS, which indicated he was severely cognitively impaired. Resident #52 resided in a room which measured a dangerously elevated hot water temperatures of 123 degrees F and had the ability to access the hot water. 12. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE], with diagnoses including Hypertension, Chronic Kidney Disease, Chronic Diastolic Heart Failure, Asthma, Depression, and Coronary Artery Disease. . Review of the quarterly MDS dated [DATE], revealed Resident #55 scored a 14 on the BIMS, which indicated the Resident was cognitively intact. Resident #55 required maximum assistance of staff to perform ADLs and the use of wheelchair required for mobility. Resident #55 resided in a room with a dangerous hot water temperature of 126 degrees F and the ability to reach the water. 13. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Congestive Heart Failure and Coronary Artery heart Disease. Review of the admission MDS dated [DATE], revealed Resident #59 scored a 5 on the BIMS, which indicated the Resident was severely cognitively impaired. Observation and interview in Resident #59's bathroom with the Maintenance Director present on 6/28/2024 at 8:45 AM, revealed a hot water temperature of 122.5 degrees F in the hand sink. The Maintenance Director stated, It's out of range, too high. During an interview on 6/24/224 at 12:20 PM, the Maintenance Director was asked how often water temperatures were checked. The Maintenance Director stated, Once a week . During an interview and observation of the North Hall Utility Room on 6/24/2024 at 12:49 PM, the Maintenance Director was asked, what was the difference in a water heater and a boiler. The Maintenance Director stated, They both do the same thing . The Maintenance Director confirmed the facility had a water heater, but he referred to it as a boiler. The Maintenance Director was asked what alerted him that there was a problem with the water temperature last week. The Maintenance Director stated, The water temps [on the North Hall] were off. They were 103-110 [degrees F.]. The Maintenance Director was asked if he had documented the water temps from the North Hall. The Maintenance Director stated, No, because I got them [water temps] back where they were supposed to be. The Maintenance Director was asked if the water temperatures were rechecked after the water heater had been turned up. The Maintenance Director stated, Yes. Thursday [6/20/2024] or Friday [6/21/2024]. The Maintenance Director was asked if these water temperature checks were documented. The Maintenance Director stated, No ma'am. The Maintenance Director was asked how the bird got in the water heater pipe. The Maintenance Director stated, It's a gas water heater. The Maintenance Director pointed to a pipe coming from the water heater and going to the wall, and stated, That is an exhaust pipe that lets fumes out. Observation outside the building revealed a white pipe sticking out from the side of the building with a mesh covering the end. The Maintenance Director confirmed the end of the pipe had been uncovered since the water heater was installed on 9/8/2021, and that he had placed the mesh on the end after 2 birds got in the pipe. The Maintenance Director stated, That is a vent to let the exhaust fumes out, the birds getting in stopped the fumes from getting out and the hot water heater shut off. The Maintenance Director confirmed he was the only one who checked water temperatures in the resident rooms. The Maintenance Director was asked should he have documented when the water temperatures were low. The Maintenance Director stated, No I had one that was right. I only have to have one from each hall. I don't have to document them all unless you all have changed your guidelines. The Maintenance Director was asked should he have documented that he had rechecked the water temps later in the week once he had increased the temperature of the water heater. The Maintenance Director stated, Last Friday [6/21/2024] I was good, and I needed to turn it back down .I didn't turn it back down. During an interview on 6/24/2024 at 1:22 PM, the Administrator was asked if she was aware there were some problems with the water temperatures last week. The Administrator stated, No ma'am. The Administrator was asked were you notified that there was a problem and the Maintenance Director had to turn up the temperature on the water heater. The Administrator stated, No, not that I recall. The Administrator was asked, have you been notified today that you have water temperatures greater than 120 degrees. The Administrator stated, No ma'am. During an interview on 6/24/2024 at 3:02 PM, the Administrator was asked who monitored water temperatures. The Administrator stated, That would be [named the Maintenance Director]. The Administrator was asked do you expect him to notify you if the water temperatures are out of range. The Administrator stated, Yes. The Administrator was asked what staff should do if they think the water is too hot. The Administrator stated, They should call [named the Maintenance Director] .he is always on call . The Administrator was asked were you aware of any problems with the water temperatures. The Administrator stated, No ma'am. The Administrator was asked has [the Maintenance Director] reported any problems with the water temperatures today. The Administrator stated, No ma'am. During an interview on 6/24/2024 at 3:10 PM, the Maintenance Director confirmed he checked water temperatures weekly. The Maintenance Director was asked, when did he notice the water temperature was low last week. The Maintenance Director stated, They [facility staff] called me and told me they didn't have no hot water. The Maintenance Director was asked who called him. The Maintenance Director stated, I'm not for sure, a CNA [Certified Nursing Assistant] or the hairdresser .I found the bird in there, so I boosted the temps up [on the hot water heater] to get it where it needed to be, because I needed to get my water temps. I told the guy who works with me, we aren't going to record these temps yet . The Maintenance Director was asked, when staff called you, did you put in a work order. The Maintenance Director stated No, I just started addressing the problem. The Maintenance Director was asked when you have a problem like the one last week [with the water temperatures] do you let the Administrator know. The Maintenance Director stated, I try to, but I don't tell her every little thing. During an interview on 6/28/2024 at 9:20 AM, the Administrator confirmed the Maintenance Director had notified her that there was a problem with the water being too hot but did not tell her the temperature of the water. During an interview on 6/28/2024 at 4:11 PM, the Administrator confirmed she had not notified the Medical Director of the Immediate Jeopardy and that the facility had not conducted an ad hoc [when necessary] QAPI [Quality Assurance Performance Improvement] meeting related to the water temperatures. 14. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], and a reentry date of 5/11/2024, with diagnoses including Left Femur Fracture, Alzheimer's Disease, Malnutrition, Glaucoma, Osteoporosis, Congestive Heart Failure, and Insomnia. Review of the Care Plan dated 7/5/2023, revealed .Fall r/t [related to] poor safety awareness . Offer toileting at bedtime and upon rising. Review of the quarterly MDS dated [DATE], revealed Resident #11 scored an 8 on the BIMS, which indicated severe cognitive impairment, and required moderate assistance with bed mobility and sit to stand, maximum assistance with toileting and toilet transfer, and was always continent of bowel and bladder, was not on a toileting program, and experienced two (2) or more falls with no injury since admission or prior assessment. Review of Resident #11's Un-witnessed [Fall Report], for Fall #1, dated 12/13/2023 at 5:31 AM, revealed .This nurse heard a sound come from resident's room, as this nurse entered the room nurse observed resident sitting in the floor .Resident states she had an accident and was trying to get cleaned up and fell .assisted to W/C [wheelchair] .Bed linen changed. Resident assisted back to bed .Oriented to Person .Incontinent .Ambulating without Assist .Improper Footwear . Review of Resident #11's Post Fall Evaluation dated 12/13/1033 at 5:47 AM, revealed .Wheelchair was involved in fall. Wheelchair was not locked at time of fall .Footwear at time of fall: Bare feet .Resident was not using cane/walker as instructed .Resident was using incontinent supplies at time of fall. Incontinent at time of fall: Yes. Bedside call light on when Resident was found: No . Review of the FALL COMMITTEE MEETING dated 12/13/2023, for Resident #11 revealed .INTERVENTION: Offer toileting @ [at] HS [hours of sleep] and upon rising . Review of the revision to Resident #11's care plan dated 12/14/2023 revealed the intervention for falls was, .12/14/2023 Anti-rollbacks to w/c [wheelchair] . Review of the facility's Un-witnessed [Fall Report], for Resident #11's Fall #2, dated 12/18/2023 at 2:16 PM, revealed .observed her [Resident #11] laying on the floor .Resident states she was trying to put away her clothes that were in the basket. She said had one hand on the basket and the other on the walker and fell over the walker .Confused .Gait Imbalance .Improper Footwear .Using [NAME] . Review of the FALL COMMITTEE MEETING dated 12/18/2023, for Resident #11 revealed INTERVENTION: Encourage family to put away laundry once returned . Review of the revision to Resident #11's care plan dated 12/18/2023 revealed, . Encourage family to put away laundry when brought . Review of Resident #11's Un-witnessed [Fall Report], for Fall #3, dated 12/26/2023 at 4:59 AM, revealed .Resident observed sitting in floor between bed and wheel chair [wheelchair] .Non-skid socks placed on Resident .Resident states she was attempting to get into wheel chair because it was storming outside and slid between the bed and the chair .Confused .Impaired Memory .Ambulating without Assistance .Improper Footwear . Review of the FALL COMMITTEE MEETING dated 12/27/2023, for Resident #11 revealed INTERVENTION: Ensure w/c [wheelchair] is beside Bed for Convivence [convenience] . Review of the revision to Resident #11's care plan dated 12/27/2023 revealed, . Ensure w/c is beside bed for convenience. Review of Resident #11's Un-witnessed [Fall Report], for Fall #4, dated 2/9/2024 at 5:15 AM, revealed .Resident observed sitting on the floor in her room .Resident was wearing regular socks and no shoes at the time .resident stated she was going to the bathroom .Current UTI (Urinary Tract Infection) .Ambulating without Assistance .Improper Footwear . Review of the FALL COMMITTEE MEETING dated 2/9/2024, for Resident #11 revealed INTERVENTIONS: Bowel and Bladder while awake . Review of the revisions to Resident #11's care plan dated 2/9/2024 revealed, . B&B [bowel and bladder] program q [every] 2 hrs [hours] while awake . Review of the quarterly MDS dated [DATE], revealed Resident #11 scored a 3 on the BIMS, which indicated the Resident was severely cognitively impaired. Resident #11 used a walker and wheelchair for mobility, received moderate assistance for sitting to standing and walking 10 feet, and maximum assistance with bed mobility, transfer, and toileting. Resident #11 was frequently incontinent of bladder, always continent of bowel, was not currently on a toileting program (such as scheduled toileting, prompted voiding or bladder training). The MDS documented the Resident had one fall since the previous assessment. Review of Resident #11's Un-witnessed [Fall Report], for Fall #5, dated 3/5/2024 at 4:39 AM, revealed .Resident sitting on buttocks with feet towards bathroom. Resident states she was trying to go to the bathroom to see what her husband was doing in there .Impaired Memory .Ambulating without Assist . Review of the FALL COMMITTEE MEETING dated 3/5/2024, for Resident #11 revealed INTERVENTIONS: Pressure Alarm [to bed] during sleep hours . Review of the revisions to Resident #11's care plan dated 3/5/2024 Pressure alarm to bed during sleep hours .MD [Medical doctor] to do medication review d/t [due to] increased confusion. Review of Resident #11's Un-witnessed [Fall Report], for Fall #6, dated 4/13/2024 at 4:05 PM, revealed .CNA [Certified Nursing Assistant] tried to transfer resident from toilet to w/c [wheelchair] but resident would not sit in chair. CNA lowered resident to the floor . Review of the FALL COMMITTEE MEETING dated 4/15/2024, for Resident #11 revealed INTERVENTION: Therapy to screen . The facility was unable to provide evidence of a therapy screen. Review of Resident #11's Un-witnessed [Fall Report], for Fall #7, dated 4/17/2024 at 9:50 AM, revealed .went into resident room notice [noticed] her laying on the floor against the door . Review of Resident #11's care plan interventions dated 4/18/2024 revealed, . Nursing staff to re-educate resident on safety awareness during transfers. There was no documentation for Therapy to screen Resident #11 per the Fall Committee interventions. Review of the FALL COMMITTEE MEETING dated 4/18/2024, for Resident #11 revealed INTERVENTION: Refer to MD or NP [Nurse Practitioner] to Assess . The medical record revealed the NP assessed Resident #11 on 4/19/2024. There were no new recommendations or interventions implemented to prevent Resident #11 from further falls. Review of Resident #11's Witnessed Fall [Fall Report], for Fall #8, dated 5/2/2024 3:30 PM, revealed .CNA entered the room and resident [Resident #11] was standing in the middle of the room. Resident would not sit in w/c . CNA lowered resident to the floor and went for help .Oriented to Person .Confused .Ambulating without Assist . Review of the FALL COMMITTEE MEETING dated 5/3/2024, revealed INTERVENTION: Provide door Alarm to Bathroom door . Review of Resident #11's Un-witnessed [Fall Report], for Fall #9, dated 5/5/2024, revealed .observed resident on the floor .Resident stated she was trying to get some panties .Confused .Gait Imbalance .Recent change in Cognition .Ambulating without Assist . Review of the FALL COMMITTEE MEETING dated 5/6/2024, for Resident #11 revealed INTERVENTION: MD [medical doctor] to perform Med [Medication] Review secondary to increased confusion . The facility was unable to provide evidence of an immediate med review performed for the resident's 5/5/2024 fall. Review of the revisions to Resident #11's care plan dated 5/6/2024, revealed . NP [Nurse Practitioner] to assess resident. There was no documentation to include the intervention of adding a door alarm to the bathroom door until 5 days after the 5/2/2024 fall (on 5/7/2024). There was no evidence of how adding a door alarm to the Resident bathroom door would prevent further falls. Review of Resident #11's Un-witnessed [Fall Report], for Fall#10 dated 5/8/2024, revealed .Called to the room per housekeeping that resident [Resident #11] was on the floor. Observed her [Resident #11] laying on left side. Tried to move resident but she started yelling out. Left resident comfortably on the floor to get more assistance and called for [abbreviation for local emergency medical services (EMS)]] .resident stated she was getting her coat out [of] the closet so they could get out of facility .Resident was sent to [named hospital] .Injuries Observed at Time of Incident .left trochanter (hip) .Left ankle (outer) Level of Pain .7 .Mobility: Ambulatory with assistance . Record review revealed Resident #11 was admitted to the hospital on [DATE] - 5/13/2024 with a Left Fractured Femur. The Resident's family declined surgical intervention and the Resident was discharged back to the nursing facility with a 2-week Orthopedic consult and activities as tolerated. Review of the annual MDS dated [DATE], revealed Resident #11 had a BIMS score of 2, which indicated severe cognitive impairment. Resident #11 had physical [TRUNCATED]