**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to develop a care plan for falls for 1 resident (Resident #3) of 4 residents reviewed for fall care plans. The findings include: Review of the facility's care plan policy last reviewed 5/2011 revealed .Plans of care will be developed that are .holistic .Care plans will establish goals and objectives specific to each need .Interventions will be listed and evaluated for effectiveness . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Repeated Falls, Muscle Weakness, and Difficulty in Walking, the resident discharged home with home health on 11/22/2023. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 scored a 14 on the Brief Interview of Mental Status (BIMS) assessment which indicated the resident was cognitively intact. The resident required assistance of 1 person with activities of daily living (ADL's). Review of a facility document titled, Fall Risk Evaluation, for Resident #3 dated 11/8/2023, revealed .if the total score is 10 or greater the resident should be considered at high risk for potential falls . Resident #3 scored a 10 on the evaluation which indicated the resident was at risk for falls. Review of the facility's fall investigation documentation for Resident #3 dated 11/10/2023 at 2:00 AM, revealed Resident #3 had an unwitnessed fall in his room. The resident had ambulated with a walker, on his own, to the bathroom. Upon return from the bathroom the resident's legs became wobbly, lost his balance, and fell on the walker receiving bruises to the right upper back and upper arm. The fall interventions in place prior to the fall included a yellow dot sticker on the outside of the residents room which alerted staff the resident was a fall risk, non-slip strips at the bedside, and bilateral bedrails. The intervention initiated after the fall was to encourage the resident to use his wheelchair to ambulate. Review of the care plan for Resident #3 dated 11/14/2023, revealed a care plan had not been developed to include the resident's risk for falls, did not include the resident had a fall on 11/10/2023, and the care plan had not been developed with any fall interventions. Review of the facility's fall investigation documentation for Resident #3 dated 11/15/2023 at 12:00 AM, revealed Resident #3 had an unwitnessed fall in his room while attempting to put clothes away. The resident stated he lost his balance and did not like to ask staff for help. Resident #3 received an abrasion the the left elbow. The new fall intervention included a reacher (device used for picking up objects) for the resident to use. Review of the care plan for Resident #3 revealed the care plan was not developed for falls with the fall interventions or risk of falls after the 11/15/2023 fall. During an interview on 6/3/2025 at 11:00 AM, the Administrator stated .no we did not put it on the care plan for falls it's not on there .the interventions were in place it just didn't get put on the care plan . The Administrator confirmed the facility failed to document Resident #3 was at risk for falls on the care plan and failed to develop a fall care plan to include the resident's fall interventions. During an interview on 6/4/2025 at 9:35 AM, the Physical Therapy Assistant Rehabilitation Director stated .I remember [Resident #3] he was a very tall man .I did get him a reacher for assistance with dressing .I got him a wheelchair and he had nonslip strips on the floor .he was alert and oriented and we educated him on the use of the call light and to ask for help .he had a walker and he used it but we told him it would be safter to use the wheelchair if he was doing any ambulation without us .the interventions for falls were in place .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to make a referral to the State-designated authority for a Level ll Pre-admission Screening and Resident Review (PASARR) after newly identified serious mental disorders were diagnosed for 1 resident (#6) of 10 residents reviewed for PASARR. The findings include: Resident #6 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety Disorder, Type 2 Diabetes Mellitus and History of Asthma. Continued review showed a diagnosis of Psychotic Disorder was added on 4/20/2023. Review of the most recent PASARR Level l Assessment for Resident #6 was completed on 12/16/2021. Continued review revealed a PASARR Level 2 Assessment was not completed for Resident #6, after the new diagnosis of Psychotic Disorder was added. During an interview on 8/1/2023 at 9:22 AM, the Minimum Data Set (MDS) Coordinator #1 and MDS Coordinator #2 confirmed Resident #6 was not referred to the State-designated authority for a PASARR Level 2 screening after the resident was diagnosed with a new serious mental health disorder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to develop a care plan addressing Hospice for 1 Resident (#4) of 25 residents reviewed for care plans. The findings include: Review of the facility policy titled Care Plans dated 5/2011, showed, .Care plans will establish goals and objectives specific to each need . Resident #4 was admitted to the facility on [DATE] with diagnoses including Dementia, Chronic Obstructive Pulmonary Disease and Alzheimer's Disease. Continued record review of a Physician order dated 4/4/2023, showed, .Admit to .hospice for end stage senile degeneration of the brain . Review of a comprehensive care plan for Resident #4, initiated on 12/10/2020 and revised on 8/1/2023, showed a care plan had not been developed to address the hospice care and specific needs for Resident #4. During an interview on 8/2/2023 at 10:55 AM, the Minimum Data Set (MDS) Coordinator #1 and MDS Coordinator #2 confirmed a care plan had not been developed to address the hospice care and specific needs for Resident #4.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of fall investigation documentation, observation, and interview, the facility failed to implement the comprehensive care plan for falls for 1 resident (#48) of 3 residents reviewed for falls of 27 residents reviewed. The findings include: Review of the facility policy Interdisciplinary Team Care Plan, reviewed 5/2011, revealed .Interdisciplinary plans of care are developed, implemented, coordinated, and evaluated . Medical record review revealed Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Generalized Anxiety Disorder, Impulse Disorder, Hepatic Failure, Atherosclerotic Heart Disease, and Osteoarthritis. Review of a Fall Investigation dated 5/12/19 revealed Resident #48 had an unwitnessed fall out of bed without injury. Further review revealed the intervention put in place to prevent future falls was an evaluation by Occupational Therapy [OT]. Medical record review of Resident #48's Quarterly Minimum Data Set, dated [DATE] revealed the resident was moderately cognitively impaired. Further review revealed the resident required the extensive assistance of 2 persons for transfer, bed mobility, and toileting. Medical record review of Resident #48's fall risk assessment dated [DATE] revealed a total score of 16 indicating the resident was a high risk for falls. Review of a Fall Investigation dated 6/2/19 revealed Resident #48 had an unwitnessed fall in the hallway outside his room without injury. Further review revealed the intervention put in place to prevent future falls was a medication adjustment. Medical record review of Resident #48's Annual Minimum Data Set, dated [DATE] revealed the resident was moderately cognitively impaired. Further review revealed the resident required the extensive assistance of 2 persons for transfer, bed mobility, and toileting. Medical record review of Resident #48's fall risk assessment dated [DATE] revealed a total score of 16, indicating the resident was a high risk for falls. Review of a Fall Investigation, dated 8/17/19, revealed Resident #48 had an unwitnessed fall in the bathroom in front of the toilet which resulted in a minor injury. Further review revealed the intervention put in place to prevent future falls was a .commode extender [a raised toilet seat] . Medial record review of Resident #48's current comprehensive care plan dated 12/1/17 and updated 8/19/19 revealed .[Resident #48] is at risk for falls .Low rider [type of chair] [with] Dysem [nonslip padding to prevent sliding] x 2 [2 pieces] .Add commode extender . Medical record review of Resident #48's Quarterly Minimum Data Set, dated [DATE] revealed the resident was moderately cognitively impaired. Further review revealed the resident required the extensive assistance of 2 persons for transfer, bed mobility, and toileting. Medical record review of Resident #48's fall risk assessment dated [DATE] revealed a total score of 13, indicating the resident was a high risk for falls. Observation of Resident #48's bathroom on 11/6/19 at 8:49 AM, in the resident's room revealed no commode extender on the resident's toilet. Interview with the Director of Nursing (DON) on 11/6/19 at 8:50 AM, in the hallway outside the resident's room, confirmed a commode extender was not in place. Observation of Resident #48 on 11/6/19 at 10:52 AM, near the Alzheimer's Unit activities/dining room, revealed the Dycem (non-slip material) x 2 (2 pieces) was not in place under the chair cushion or on top of the chair cushion in the resident's chair. Interview with the Quality Assurance (QA) nurse on 11/06/19 at 10:54 AM, near the Alzheimer's Unit activities/dining room, confirmed the Dysem x 2 was not in place to prevent the resident from sliding out of his chair. Interview with the DON on 11/06/19 at 11:26 AM, in the conference room, confirmed the facility failed to implement the resident's care planned interventions of commode extender to the resident's toilet and Dysem to the resident's chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of fall investigation documentation, observation, and interview, the facility failed to ensure fall interventions were in place to prevent future falls for 1 resident (#48) of 3 residents reviewed for falls. The findings include: Review of the facility policy Interdisciplinary Team Care Plan, reviewed 5/2011, revealed .Interdisciplinary plans of care are developed, implemented, coordinated, and evaluated . Medical record review revealed Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Generalized Anxiety Disorder, Impulse Disorder, Hepatic Failure, Atherosclerotic Heart Disease, and Osteoarthritis. Review of a Fall Investigation dated 5/12/19 revealed Resident #48 had an unwitnessed fall out of bed without injury. Further review revealed the intervention put in place to prevent future falls was an evaluation by Occupational Therapy [OT]. Medical record review of Resident #48's Quarterly Minimum Data Set, dated [DATE] revealed the resident was moderately cognitively impaired. Further review revealed the resident required the extensive assistance of 2 persons for transfer, bed mobility, and toileting. Medical record review of Resident #48's fall risk assessment dated [DATE] revealed a total score of 16 indicating the resident was a high risk for falls. Review of a Fall Investigation dated 6/2/19 revealed Resident #48 had an unwitnessed fall in the hallway outside his room without injury. Further review revealed the intervention put in place to prevent future falls was a medication adjustment. Medical record review of Resident #48's Annual Minimum Data Set, dated [DATE] revealed the resident was moderately cognitively impaired. Further review revealed the resident required the extensive assistance of 2 persons for transfer, bed mobility, and toileting. Medical record review of Resident #48's fall risk assessment dated [DATE] revealed a total score of 16, indicating the resident was a high risk for falls. Review of a Fall Investigation dated 8/17/19 revealed Resident #48 had an unwitnessed fall in the bathroom in front of the toilet which resulted in a minor injury. Further review revealed the intervention put in place to prevent future falls was a .commode extender [a raised toilet seat] . Medial record review of Resident #48's current comprehensive care plan dated 12/1/17 and updated 8/19/19 revealed .[Resident #48] is at risk for falls .Low rider [type of chair] with Dysem [nonslip padding to prevent sliding] x 2 [2 pieces] .Add commode extender . Medical record review of Resident #48's Quarterly Minimum Data Set, dated [DATE] revealed the resident was moderately cognitively impaired. Further review revealed the resident required the extensive assistance of 2 persons for transfer, bed mobility, and toileting. Medical record review of Resident #48's fall risk assessment dated [DATE] revealed a total score of 13, indicating the resident was a high risk for falls. Observation of Resident #48's bathroom on 11/6/19 at 8:49 AM, in the resident's room revealed no commode extender on the resident's toilet. Interview with the Director of Nursing (DON) on 11/6/19 at 8:50 AM, in the hallway outside the resident's room, confirmed a commode extender was not in place. Observation of Resident #48 on 11/6/19 at 10:52 AM, near the Alzheimer's Unit activities/dining room, revealed the Dycem (non-slip material) x 2 (2 pieces) was not in place under the chair cushion or on top of the chair cushion. Interview with the Quality Assurance (QA) nurse on 11/06/19 at 10:54 AM, near the Alzheimer's Unit activities/dining room, confirmed the Dysem x 2 was not in place to prevent the resident from sliding out of his chair. Interview with the DON, on 11/6/19 at 11:26 AM, in the conference room, confirmed Resident #48 had 3 falls in the past 6 months, confirmed Resident #48 was identified as a high risk for future falls, and confirmed the facility failed to ensure the resident's commode extender and Dysem to chair was in place to prevent future falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to ensure a resident's care was supervised by a Physician for the delivery of Oxygen for 1 resident (#16) of 37 residents reviewed. The findings include: Medical record review revealed Resident #16 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including Dysphagia, Fracture to Right Tibia, and History of Falling. Medical record review of the Nurses Note dated 6/13/18 at 6:40 PM, revealed, Resident arrived @ [at] 6:00 PM via EMS [emergency medical service]. A&O [alert and oriented] X 3 .Resident is on O2 [Oxygen] 2 LPM [liters per minute] via NC [nasal cannula] .Resp [respiration] even and unlabored . Observation on 9/24/18 at 10:00 AM, in the resident's room, revealed Resident #16 receiving oxygen at 2 LPM via NC Continued observations throughout the survey beginning on 9/24/18 through 9/26/18 revealed Resident #16 resident receiving O2 at 2 LPM via NC. Medical record review of the Physicians Recapitulation orders for September 2018 revealed no documentation of a Physician's order for Resident #16 to receive O2. Interview with the Director of Nursing on 9/26/18 at 2:02 PM, at the South Wing nurse's station, confirmed the resident was readmitted to the facility on [DATE] and did not have an order for the oxygen therapy.