**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 6 of 10 residents (R34, R11, R23, R2, R9, and R13) reviewed received adequate supervision and assistance devices to prevent accidents. * R34's fall on 10/29/24 was not thoroughly investigated and a root cause was not determined to help prevent additional falls. On 5/16/25, R34 fell, was transferred to the hospital, and diagnosed with a hip fracture. R34 had been observed prior to this fall coming out the bathroom by herself. The facility did not implement interventions after observing R34 coming out of the bathroom prior to R34's fall. R34 was not assessed by a Registered Nurse (RN) prior to being placed in a wheelchair after the fall even though there was an RN available. The facility's investigation did not include a root cause analysis of R34's fall to help prevent additional falls. * R11 fell from the wheelchair on 5/28/24. The facility did not conduct a thorough investigation as the facility did not investigate how R11 was seated in her wheelchair, the investigation does not include whether R11 was interviewed regarding the fall, and R11's fall care plan was not developed until 8/30/24. R11 fell on [DATE]. R11 was not transferred according to R11's plan of care when R11 fell. * R23's resident to resident altercation on 11/2/24 was not investigated and no revisions to R23's plan of care were implemented after R23's resident to resident altercation. * R2 sustained multiple falls from bed. The facility did not investigate how R2 rolled out of bed, did not determine if previous interventions were in place, did not consistently determine the root cause of R2's falls, and did not investigate how R2 fell from the bed multiple times when bilateral body pillows were in place. * R9 sustained a fall on 2/17/25. The facility did not thoroughly investigate this fall and did not determine a root cause. On 3/29/25, R9 had an unwitnessed fall. The facility did not thoroughly investigate this fall and did not investigate whether previous interventions were in place. R9's wander alert bracelet was observed on the metal bar on the back of R9's wheelchair. Per the manufacturer the wander alert bracelet should not be placed on this metal bar. * R13's intervention of fall mat was not in place and the body pillows were incorrectly placed when R13 sustained a fall on 2/4/25. On 3/29/25, R13 fell while attempting to self transfer. R13's new toileting plan was not added to the care plan until 5/19/25. On 4/1/25, R13 had a fall in another resident's bathroom. R13's care planned intervention of toileting after meals was not followed. On 5/3/25, R13 sustained a fall from bed. The facility did not thoroughly investigate this fall to determine if previous interventions were in place. During the survey, R13's body pillow was not placed correctly. R34 is being cited at severity level 3 (actual harm). R11, R23, R2, R9 and R13 are being cited at severity level 2 (potential for more than minimal harm). Findings include: The facility's policy titled, Falls Management and Prevention, and revised December 2024 under Policy documents: Residents are assessed for their risk of falling upon admission, significant change and quarterly thereafter. Resident with risk for falling will have interventions implemented through the resident centered care plan. When a resident experiences a fall, a licensed nurse assesses the resident's condition, provides care for, safety and comfort. Under Post Fall Procedure documents 1. When a resident falls the licensed nurse is notified. The nurse completes an assessment of the resident's condition including an interview, if possible, completion of vital signs and a body assessment. 2. The medical provider is notified of the fall and resident condition. Orders, if given, are implemented. 3. The resident's representative (as applicable) is notified of the fall and the resident's condition. 4. The DON (Director of Nursing) and Administrator or designees are notified of the fall. 5. The environment of the fall is evaluated for possible contributing factors and addressed. 1.) R34 was admitted to the facility on [DATE] with diagnoses that include dementia (loss of cognitive function that interferes with a person's daily life and activities), atrial fibrillation (irregular and rapid heart beat), and hypertensive heart disease with heart failure (prolonged high blood pressure that leads to the heart inability to pump blood effectively). R34's fall risk assessment dated [DATE] has a score of 12 (a score of 10 or higher indicates high risk of falling.) R34's nurses note dated 9/14/24, at 14:11 (2:11 p.m.), written by Licensed Practical Nurse (LPN)-W documents: Resident on report for being new admit to unit s/p (status post) multiple falls, encephalopathy, and AMS (altered mental status). Resident adjusting to unit well. AandO (alert and orientated) to self and place. Makes needs known. No issues or complaints. Ate well at meal times. Checked frequently to maintain safety. VSS (vital signs stable) per resident baseline. R34's Fall CAA (care area assessment) dated 9/18/24 under analysis of finds for nature of problem documents: Fall CAA triggered r/t (related to) recent fall at home with UTI (urinary tract infection), AMS (alerted mental status)/hospitalization. admitted for rehab with goal to dc (discharge) home. Resident requires moderate assist with most ADL (activities of daily living). BIMS (Brief Interview for Mental Status)-8. On scheduled diuretic, anticoagulant, antihtn (antihypertensive). Occasionally incontinent of bowel and bladder. No falls during look back. Remains a fall risk d/t (due to) cognitive impairment with poor safety awareness. Under the care plan considerations it documents: Fall CAA triggered r/t recent fall at home with UTI, AMS/hospitalization. admitted for rehab with goal to dc home. Resident requires moderate assist with most ADL. BIMS-8. On scheduled diuretic, anticoagulant, antihtn. Occasionally incontinent of bowel and bladder. No falls during look back. Remains a fall risk d/t cognitive impairment with poor safety awareness. R34's falls care plan initiated and revised 9/18/24 documents the following interventions: *Fall risk evaluation on admission, quarterly, and PRN (as needed). Post fall evaluation PRN. Initiated 9/18/24. *Labs when ordered, report abnormal findings to NP/PA/MD (Nurse Practitioner/Physician Assistant/Medical Doctor). Initiated 9/18/24. *Monitor for side effects of medication: *Cardiac medication as ordered. Monitor weekly vital signs and labs as ordered. *Psychotropic medications as ordered. BIMS (brief interview mental status) evaluation, sleep log, and behavior monitoring per protocol. *Narcotic pain medication as ordered. Monitor for side effects such as dizziness, lethargy, increased confusion, decreased respiration, and report to NP/PA/MD. Initiated 9/18/24. *Toileting per urinary/bowel section of this care plan. Initiated 9/18/24. *Fall risk. Initiated 9/27/24. *Bed in low position, call light within reach. Initiated 9/27/24. *Encourage [R34's first name] to be in common areas for supervision d/t (due to) frequent self transferring. She often refuses. Initiated 5/29/25. *Frequent safety checks to prevent falls. [R34's first name] self transfers and is non-compliant with call light d/t (due to) memory issues. Initiated and revised 5/29/25. R34's nurses note dated 10/29/24, at 22:20 (10:20 p.m.), written by Registered Nurse (RN)-BB documents: Writer was doing HS (hour sleep) med pass when CNA (Certified Nursing Assistant) answered a bathroom call light coming from residents' room. CNA yelled out to writer that resident was on the floor from doorway. Writer went into residents' room and found resident on the floor sitting straight up on bottom near residents' foot of bed. Writer asked resident what happened resident stated she just slid out of bed when trying to get up. Writer asked resident what she was trying to do and resident stated trying to get up to go by husband that was in the living room area of their room. Resident stated she did not have pain anywhere and did not hit head. Writer did a full Neurology assessment determined all WNL (within normal limits), Writer then took residents Vitals B/P (blood pressure): 106/69, HR (heart rate): 75, 02(oxygen): 98% RA (room air), T (temperature):97.7, R (respirations): 18. Resident was then Hoyered off the floor by writer and CNA into residents w/c (wheelchair). Neuro checks were then initiated. R34's progress note dated 10/31/24, at 10:03 a.m., written by Nursing Home Administrator (NHA)-A documents: IDT (interdisciplinary team) met to review fall from 10/29/24. Nursing, Soc. (Social) Services, therapy, and admin (Administrator) were in attendance. Documentation was reviewed. MD and patient representative were contacted. Neuro checks were initiated. Resident had moved from her private room to a shared room with her husband that date. Immediate intervention was to transfer resident to the bed on left side of room, which is similar to her previous bedroom set-up. Surveyor noted R34's fall care plan was not revised to include this intervention. Surveyor reviewed the facility's fall investigation for R34's fall on 10/29/24. The facility's fall investigation includes a fall statement from the CNA who found R34 on the floor but does not include any other staff statements or indications other staff who may have seen R34 were interviewed, how was R34 positioned in bed, and the root cause of this fall. R34's quarterly MDS (Minimum Data Set) with an assessment reference date of 4/14/25 has a BIMS (Brief Interview for Mental Status) score of 2 which indicates severe cognitive impairment. R34 is assessed as refusing care and wandering for 1 to 3 days during the assessment period. R34 is assessed as requiring set up for toileting hygiene, supervision for roll left and right, and chair/bed to chair transfer. R34 is occasionally incontinent of urine and continent of bowel. R34 is assessed as not having any falls since prior assessment period. R34's fall risk assessment dated [DATE] has a score of 19 (a score of 10 or higher indicates the resident is at high risk of falling). R34's nurses note dated 5/16/25, at 03:36 (3:36 a.m.), written by Registered Nurse (RN)-FF documents: Resident in [Room Number], [R34's name] was found on the floor in her room. Resident told nurse she was getting up to go to the bathroom and noted the floor was coming up to her. Resident hit the side of her head and has a bruised area that is 1.5cm (centimeter) x (times) 4.3cm and is raised. Resident C/O (complained of) left hip pain. Per nurse caring for resident the resident could not bear weight on her left leg. Nurse then went to see resident who was already in a w/c (wheelchair) and continued to c/o of left hip pain and resident was noted to have a low B/P (blood pressure) of 75/38 with a heart rate of 57. Resident denies being lightheaded or dizzy at this time. Message sent to Dr [Name] also at this time and will be sending resident out for evaluation. Will be sending resident out for evaluation at this time. The nurses note dated 5/16/25, at 05:54 (5:54 a.m.), written by Licensed Practical Nurse (LPN)-F documents: UWF (unwitnessed fall): CNA found res on the floor at 0250 (2:50 a.m.), sitting/lying in front of her bed with w/c (wheelchair) to her left, where it had been all NOC (night). Res (Resident) was witnessed walking in room per CNA who res was assigned and found, coming from BR (bathroom) earlier in NOC and was assisted back to bed w/(with) safety precautions in place and call light on chest. Rounds completed per CNA at 0100 (1:00 a.m.) and res toileted; per writer at 0200 (2:00 a.m.) and res asleep. Safety precautions/call light in place w/ BR light on. Injuries noted-left brow hematoma, c/o (complained of) left hip pain/disc (discomfort) noted. RN notified and escorted to room per writer and assessed. Writer initiated neuros checks per protocol. [Name] Ambulance called at 0345 (3:45 a.m.). V/S (vital signs) and res stable w/hypotension noted. BP increased as time went on per EMT (emergency medical technician) taking last BP before leaving unit at 0430 (4:30 a.m.). APAPx1 (acetaminophen times one) per pain/disc noted to left hip-7/10 and ineffective prior to leaving-6/10. RN notified MD/DON (Medical Doctor/Director of Nursing). Writer updated POA (Power of Attorney) son [Name] at 0354 (3:45 a.m.) and directed to have res transferred to [Name] hospital for eval/tx (evaluation/treatment), and POA will meet res there, appreciative for being notified per writer. Res was able to move all extremities w/ (with) noticeable, and c/o left hip pain noted. Writer will report off to AM (morning) RN to call [Hospital Name] for updated report. R34's nurses note dated 5/16/25, at 10:57 a.m., by RN-GG documents: Per SW (Social Worker) who spoke with son, resident is being admitted with hip fx (fracture). Surgery will be completed tomorrow. Son talked with resident's husband and explained what is happening. R34's progress note dated 5/16/25, at 16:21 (4:21 p.m.), written by Nursing Home Administrator (NHA)-A documents: IDT (interdisciplinary team) met to review fall from this am. Nursing, Soc. (Social) Services, and Admin (Administrator) were present. Documentation was reviewed. MD and patient representative were notified. Resident was noted to be hypotensive immediately after fall. She was transported to ER (emergency room) and admitted with hip fracture. Will assess resident for change of condition upon return, and update care plan as needed. Surveyor reviewed R34's fall investigation for R34's fall on 5/16/25. The check off sheet for falls documents: non compliant with call light; transfers. R34's fall care plan does not address R34 being non compliant with call light or transfers. The fall investigation was not thorough as this investigation does not include a root cause to help prevent further falls. R34 was readmitted to the facility on [DATE]. R34's fall care plan was not revised until 5/29/25. R34's significant change MDS with an assessment reference date of 5/24/25 has a BIMS score of 2 which indicates severe cognitive impairment. R34 is assessed as being dependent for toileting hygiene, roll left and right, chair/bed to chair transfer, and toilet transfer. R34 is assessed as always incontinent of urine and frequently incontinent of bowel. R34's fall CAA (care area assessment) dated 5/28/25 under analysis of findings for nature of problem documents: Fall CAA triggered r/t (related to) resident here for LTC (long term care). Recent fall at facility with femur fx (fracture)/hospitalization with surgical repair. readmitted for rehab with goal to stay LTC (long term care). Resident has dementia with poor safety awareness. BIMS-2. Resident is dependent on staff for most ADL (activities daily living). On scheduled antihtn (antihypertensive), diuretic, anticoagulant, antidepressant, PRN (as needed) opiate. Under care plan considerations documents Fall CAA triggered r/t resident here for LTC. Recent fall at facility with femur fx/hospitalization with surgical repair. readmitted for rehab with goal to stay LTC. Resident has dementia with poor safety awareness. BIMS-2. Resident is dependent on staff for most ADL. On scheduled antihtn, diuretic, anticoagulant, antidepressant, PRN opiate. On 6/12/25 at 7:24 a.m., Surveyor observed R34 in bed on the left side, there is a heels up pad and the call pad is within reach. Surveyor observed R34's bed is at a low position but not at the lowest position. On 6/12/25 at 10:04 a.m., Surveyor observed R34 in bed on the right side. There is a heels up pad and the call pad is within reach. Surveyor observed R34's bed is at a low position but not at the lowest position. On 6/16/25 at 8:32 a.m., Surveyor met with Registered Nurse/Unit Manager (RN/UM)-D to discuss R34. Surveyor asked RN/UM-D when R34 is in bed what position should R34's bed be in. RN/UM-D explained R34's bed should be in a low position, not the lowest position, as R34 self transfers from the bed and the bed should be locked. Surveyor inquired what frequent checks are. RN/UM-D informed Surveyor they round on residents more frequently than they normally do every two hours and if the call light is on they should get in there quick. Surveyor asked RN/UM-D who should Surveyor speak to regarding R34's fall investigations for R34's falls on 10/29/24 and 5/16/25. RN/UM-D informed Surveyor Surveyor should speak with DON-B and NHA-A as they track falls more than she does. On 6/16/25 at 8:39 a.m., Surveyor observed R34 sitting in a wheelchair in her room. On 6/16/25 at 12:05 p.m., Surveyor met with DON-B and Corporate Nurse (CN)-C to discuss R34's falls. Surveyor informed DON-B and CN-C R34's fall on 10/29/24 was not thoroughly investigated as there was only the staff statement from the CNA who found R34 but no other staff statements or indications other staff that may have seen R34 were interviewed, there is no indication as to how R34 was in bed, was she on the edge or in the middle of the bed, and root cause was not identified to help prevent further falls. R34's fall on 5/16/25, RN-FF's nurses note documents R34 was in the wheelchair. There was no RN assessment of R34 prior to R34 being transferred into the wheelchair. LPN-F's nurses note documents R34 was found coming out of the bathroom by herself earlier in the shift. There is no evidence staff increased rounds/checks on R34 after R34 was observed ambulating by herself or implemented any additional interventions to prevent R34 from getting up by self. Surveyor inquired if R34 fell at 2:50 a.m. why wasn't the ambulance called for almost an hour at 3:45 a.m. The facility's investigation does not include a root cause. DON-B did not provide Surveyor with any additional information regarding R34's falls on 10/29/24 and 5/16/25. 2.) R11 was originally admitted to the facility on [DATE]. R11's diagnoses include anxiety disorder, depressive disorder, and polyneuropathy (general term for peripheral nervous system disorders that impact nerve functions in multiple areas of the body). R11's mobility care plan initiated 8/6/24 includes an intervention of GG - Chair/Bed-to-Chair Transfer - EZ stand and 2 assist. Initiated 8/28/24 and revised on 8/30/24. R11's falls care plan initiated and revised on 8/20/24 documents the following interventions: *Call light within reach at all times. Initiated 8/30/24. *Fall risk evaluation on admission, quarterly, and PRN (as needed). Post fall evaluation PRN. Initiated 8/30/24. *Monitor for side effects of medication: *Cardiac medication as ordered. Monitor weekly vital signs and labs as ordered. *Psychotropic medications as ordered. BIMS (brief interview mental status) evaluation, sleep log, and behavior monitoring per protocol. *Narcotic pain medication as ordered. Monitor for side effects such as dizziness, lethargy, increased confusion, decreased respirations, and report to NP/PA/MD (Nurse Practitioner/Physician Assistant/Medical Doctor). Initiated 8/30/24. *Resident to wear proper and non slip footwear. Initiated 8/30/24. R11's fall risk assessment dated [DATE] has a score of 5 (a score of 10 or higher is high risk). R11's Quarterly MDS with an assessment reference date of 5/24/24 documents BIMS (Brief Interview for Mental Status) score of 15, which indicates that R11 has intact cognition. R11 is assessed as not having any behaviors. R11 is assessed as requiring substantial/maximal assistance for toileting hygiene, chair/bed to chair transfer, and toilet transfer. R11 is frequently incontinent of bowel and bladder. R11's nurses note dated 5/27/24 at 9:37 a.m., written by Licensed Practical Nurse (LPN)-DD documents: Resident had an unwitnessed fall @ (at) 0845 (8:45 a.m.) in room [Number]. Resident was placed in WC (wheelchair) by CNA (Certified Nursing Assistant) [Name] to get ready for a shower. CNA stated resident was weak so she proceeded to go get the EZ stand. CNA stated resident was safely sitting in wheel chair when she left the room and when coming back into the room resident was found on knees with lower legs behind buttock. Resident was safely lowered flat to the floor with pillow behind head so writer could take vital signs and start neuro check. Resident was able to move arms and legs and stated she did not hit her head when asked. Resident is alert and orientated and rated pain an 8 on a scale from 1-10 10 being the worst pain. Pain is located in legs and residents normal edema is present. POA (Power of Attorney), DON (Director of Nursing), Doctor, [Managed Care Name] were notified. Residents shower was completed with no noted skin issues. R11's progress note dated 5/28/24, at 10:33 a.m., written by Nursing Home Administrator (NHA)-A documents: IDT(Interdisciplinary team) met to review unwitnessed fall from 5/27/24. Nursing, SS (Social Service), admin (Administrator), and therapy present. Resident had been transferred into her wheelchair and was waiting for CNA to return for shower. When CNA returned to her room, resident was on her knees. MD and family were notified. Resident was unable to state what she was trying to do. Nursing will check orthostatic blood pressures and request lab work as resident said that she felt weak. Resident is currently receiving PT (physical therapy) intervention. Surveyor reviewed the facility's fall investigation for R11's fall on 5/27/24. The facility did not conduct a thorough investigation as the facility did not investigate how R11 was seated in her wheelchair, the investigation does not include whether R11 was interviewed regarding the fall, did not determine a root cause, and R11's fall care plan was not developed until 8/30/24. R11's quarterly MDS with an assessment reference date of 8/21/24 has a BIMS score of 14 which indicates intact cognition. R11 is assessed as not having any behaviors. R11 is assessed as requiring partial/moderate assistance for toileting hygiene, chair/bed to chair transfer, and toilet transfer. R11 is frequently incontinent of bowel and bladder. R11's fall risk assessment dated [DATE] has a score of 7 which indicates low risk. R11's nurses note dated 10/5/24, at 22:52 (10:52 p.m.), written by Registered Nurse (RN)-BB documents: CNA assigned to resident came to writer and mentioned that resident had fallen and was on the floor during transferring. Writer took vital cart into resident room and assessed resident ROM (range of motion) which was WNL (within normal limits). Denied hitting head or any injuries. Resident states CNA was inexperienced and unable to transfer resident right and she slid to the floor. Resident was lifted off the floor via Hoyer, vitals were taken B/P (blood pressure): 123/69, HR (heart rate): 62, T (temperature): 96.8, R (respirations): 20, 02 (oxygen): 93% RA (room air). R11's progress note dated 10/7/24, at 16:47 (4:47 p.m.), written by NHA-A documents: IDT (interdisciplinary) met to review fall from 10/5/2024. Nursing, Soc. (Social) Services, Therapy and Admin were present. Documentation was reviewed. MD and patient representative were notified. Neuro checks were not necessary as fall was witnessed and resident did not hit her head. Therapy will provide resident specific transfer training with CNA that was assigned. In addition, resident specific transfer training will be arranged for all CNAs that have been hired since September 1. Surveyor reviewed the facility's investigation which included only a fall statement dated 10/5/24 from CNA-SS, the CNA who was with R11 when R11 fell. R11 was not transferred according to R11's plan of care as the mobility care plan indicates R11 is transferred with an EZ stand and 2 assist. R11's fall CAA (care area assessment) dated 12/3/24 documents under analysis of findings section: Fall CAA triggered r/t (related to) resident here for LTC (long term care). Dx (diagnoses) of COPD (chronic obstructive pulmonary disease), DM (diabetes mellitus) (high blood sugar) with neuropathy. Resident is dependent to supervision with ADLs (activities daily living). On scheduled antihtn (antihypertensive), diuretic, diabetic meds, anticoagulant and non narcotic pain meds. Frequently incontinent of bladder and occasionally incontinent of bowel. 1 fall without injury in the last quarter. Under the care plan considerations it documents: Fall CAA triggered r/t resident here for LTC. Dx of COPD, DM with neuropathy. Resident is dependent to supervision with ADLs. On scheduled antihtn, diuretic, diabetic meds, anticoagulant and non narcotic pain meds. Frequently incontinent of bladder and occasionally incontinent of bowel. 1 fall without injury in the last quarter. On 6/11/25 at 10:40 a.m., Surveyor spoke with R11 who was sitting in a wheelchair with the call light in reach in R11's room. Surveyor asked R11 if she remembers her fall in October. R11 informed Surveyor the CNA was new and she told the CNA when she had me situated she was not right and was going down. Surveyor asked R11 what she meant by she was not right. R11 informed Surveyor she had her on the edge of the chair, went down with both legs under her. Surveyor asked R11 if the CNA was using a gait belt. R11 replied no. Surveyor asked R11 if the CNA was using a mechanical lift. R11 replied no. Surveyor asked R11 if there is anything else she remembers. R11 replied all I remember is I laid there for quite a while with my legs under me. She finally went and got help. On 6/16/25 at 12:01 p.m., Surveyor met with Director of Nursing (DON)-B and Corporate Nurse (CN)-C regarding R11's falls. Surveyor informed DON-B the facility did not conduct a thorough investigation as the investigation didn't include a root cause, how R11 was seated in the wheelchair, or whether R11 was interviewed regarding the fall. Surveyor also informed DON-B and CN-C there is not a fall care plan until 8/30/24. CN-C reviewed R11's care plans and informed Surveyor there was not a care plan prior to 8/30/24. Surveyor informed DON-B and CN-C R11 had a fall on 10/5/24 with a CNA. According to R11's care plan, R11 should have been transferred with an EZ stand and 2 assist. 3.) R23's diagnoses includes Alzheimer's Disease, dementia, depressive disorder, and anxiety disorder. Surveyor reviewed R23's care plans and noted the following: Elopement risk initiated and revised 4/25/24; PASAAR (Pre admission Screening and Resident Review) initiated 4/25/24; Psychosocial Well Being, Adjustment New Admission, Unfamiliar with staff routine, environment initiated 4/25/24; Advanced Directives initiated 4/25/24; Discharge Planning initiated 5/15/24; Nutrition Alteration initiated 4/29/24 and revised 2/13/25; Communication Problem initiated and revised 5/2/24; Falls initiated and revised 5/2/24; Pain initiated and revised 5/2/24; Oral/Dental Health Problems initiated and revised 5/2/24; Potential for Impaired Visual Function initiated and revised 5/2/24; Potential for Constipation initiate [NAME] revised 5/2/24; Potential Fluid Deficit initiated and revised 5/2/24; Impaired Cardiac Status initiated and revised 5/2/24; Hospice Care initiated 5/13/24 and revised 6/4/24; Risk for Ineffective Peripheral Tissue Perfusion initiated 6/25/24; AROM (active range of motion) Restorative Nursing Program initiated and revised 6/26/24; Transfer Restorative Nursing Program initiated and revised 6/26/24, Self Care initiated and revised 9/10/24, Bowel and Bladder initiated and revised 5/19/25, Chronic/Progressive decline in Intellectual functioning initiated and revised 4/25/24; Mobility initiated and revised 9/10/24; Potential for Impaired Skin Integrity initiated and revised 2/17/25; Feelings of sadness, emptiness, anxiety, uneasiness, depression characterized by ineffective coping, low self esteem, tearfulness, motor agitation, withdrawal from care/activities initiated 4/25/24 and revised 5/2/24; Activities initiated 11/14/24 and revised 2/13/25; Cognition initiated and revised 5/29/25; Anti-anxiety medication initiated and revised 5/12/25; and Antidepressant medication initiated 5/12/25. R23's Annual MDS (minimum data set) with an assessment reference date of 5/13/25 has a BIMS (brief interview mental status) score of 3 which indicates severe cognitive impairment. R23 is assessed as not having any behavior other than wandering 1 to 3 days during the assessment period. R23 receives hospice services. R23's nurses note dated 11/2/24, at 12:31 p.m., documents Resident has a red mark to L (left) cheek and a bruised scratch to L neck. Skin is intact with no bleeding. Noted bruised scratch to L neck. Both areas were cleaned with an alcohol wipe. Scratches occurred from another resident. Both residents were separated. R23's nurses note dated 11/2/24, at 13:15 (1:15 p.m.), documents: POA (Power of Attorney) updated @ (at) 1316 (1:16 p.m.). R23's nurses note dated 11/2/24, at 15:09 (3:09 p.m.), documents: Writer went to check on residents L cheek and L neck scratches. No marks noted to L cheek. Noted scratch to L lower neck. Skin remains intact. R23's nurses note dated, 11/3/24 at 03:31 (3:31 a.m.), documents: Resident is on report for incident that occurred on 11/2/24 with another resident. Resident has small red scratch to left side of neck. Skin is intact. No mark noted on left cheek. Resident has been sleeping well this noc (night) and voices no C/O's (complaint of) of any pain. No Bx's (behaviors) this noc. Surveyor noted none of R23's care plans were revised and/or a resident to resident care plan was not initiated following R23's incident on 11/2/24. On 6/11/25 at 3:10 p.m., during the end of the day meeting with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B, Surveyor requested any investigation the facility did for R23's resident to resident altercation which occurred on 11/22/24. On 6/16/25 at 9:06 a.m., Surveyor received a statement that is not signed or dated which documents: Re: Incident 11/2/24 Resident #1 was showing signs of distress and was in the hallway calling out. She had already received medication for pain and anxiety. [R23's first name], being the compassionate soul that she is, went over to the resident in an attempt to console her. Resident #1, not recognizing the gesture due to her dementia and distress, reached out to grab [R23's first name] shirt. With this motion [R23's first name] received a small scratch on the left side of her neck. The residents were moved apart. At the time, [R23's first name] apologized saying that she was just trying to help out. She was not negatively affected by the interaction. This was not interpreted as a resident-to-resident altercation - it was not confrontational, intentional or willful. The behavior did not continue. It was not felt to be reportable. On 6/16/25 at 12:12 p.m., met with Director of Nursing (DON)-B and Corporate Nurse (CN)-C. Surveyor asked DON-B if DON-B knew who the other resident involved in the resident to resident altercation with R23 was. DON-B replied that was my question, believe it was [Name of R13]. Surveyor inquired if there was an investigation as Surveyor only received a statement which Surveyor read to DON-B and CN-C. DON-B informed Surveyor that was NHA-A's note. CN-C informed Surveyor Surveyor should speak with NHA-A or Director of Social Services (DSS)-K. On 6/16/25, at 12:18 p.m., Surveyor asked DSS-K if she was aware of an altercation on 11/2/24 with R23 and another Resident. DSS-K replied vaguely and explained NHA-A was more involved. Surveyor asked DSS-K if she knew who the other resident was. DSS-K informed Surveyor she thinks it was R295. Surveyor asked DSS-K if there was an investigation. DSS-K informed Surveyor when they talked about it there was a misunderstanding as R295 didn't do anything intentionally, she was anxious and R23 was trying to help. Surveyor informed DSS-K the altercation may not have had to be reported to the state agency but should have been investigated. On 6/16/25, at 2:46 p.m., Surveyor showed NHA-A the statement Surveyor was provided and asked who wrote this statement as it's not dated or signed. NHA-A informed Surveyor she did. Surveyor asked who was the other resident involved[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R3 was admitted to the facility on [DATE] with a primary diagnosis of parkinsonism. R3's admission Minimum Data Set (MDS) assessment completed 1/2025 documents that R3 has no cognitive impairment, upper extremity impairment on one side, wheelchair for mobility, does not walk and requires staff assistance with ADLs. R3's Care Area Assessment (CAA) for Falls documents under the Analysis of Findings section: The Fall CAA triggered related to recent fall at home with hospitalization. R3 requires maximum to moderate assist with most ADLs. There were falls reported at home prior to hospitalization and no falls in look back period. On 4/23/25 at 9:30 AM, Surveyor interviewed, and observed, R3 in R3's room. R3 was sitting in their wheelchair with their feet firmly on the ground. R3 had sneakers on their feet. R3 stated they had 2 falls in the facility. The first fall was from the wheelchair. R3 stated the staff told them a driver was here to transport them to an appointment. R3 thought the appointment was a video conference. R3 stated their foot got into the wheelchair wheel and they fell forward. R3 stated they had to get stitches on their head. R3 stated the second fall was from their bed. They remember something fell and they reached for it and kept going. R3 stated they did not have any injuries from the second fall. R3 has not had any falls since then. R3 stated these falls occurred just after their admission to the facility. R3 uses a wheelchair for mobility and requires staff assist with mobility. R3 does not propel self in wheelchair. R3 had a physical therapy evaluation completed on 1/20/25. This evaluation documents: - transfer with 2 staff and Sara Steady (sit-to-stand). - maximum assist with lower and upper dressing. - moderate staff assist with bed mobility. - is a fall risk. - spastic left upper extremity limiting functional ability. R3's progress notes on 2/4/25 at 2:55 PM, by Registered Nurse (RN)-C, document: RN-C was getting shift report and a Transport Driver arrived to pick up R3 for an appointment. They had Certified Nursing Assistant (CNAs) transfer R3 into their wheelchair. One CNA was pushing R3 in their wheelchair to their doorway. The second CNA had the wheelchair pedals in their hands to place on the wheelchair. Then the Transport Driver knocked on the Nurses Station window and told RN-C R3 had fallen. R3 was not sure what happened and just stated they went forward. R3 was bleeding from their forehead. After RN-C assessment, 911 was called, R3 was sent to the hospital. R3's emergency room (ER) record on 2/4/25 documents: R3 fell forward from their wheelchair and hit their forehead on the ground. R3 did not lose consciousness. R3 is on blood thinners. R3 received 4 sutures in their forehead and was discharged back to the facility. R3's Plan of Care (POC) for Falls, created on 1/23/25, with a target date of 4/25/25. Interventions include: -2/5/25 bed in low position with mat on floor next to bed. Clip call light to resident's blanket/gown. (This was added after the fall from the bed.) - 1/23/25 Fall prevention/reduction precautions per facility protocol. - 2/5/25 Foot pedals to be applied (at time of sitting in chair) to wheelchair for out of facility appointments. (This was added from the fall from wheelchair.) -1/23/25 call light in reach. - 1/23/25 Labs when ordered, report abnormal findings to Nurse Practitioner/ Medical Doctor/Physician Assistant. - 1/23/25 Reinforce need to call for assistance. - 1/23/25 Toileting per urinary/bowel section of the care plan. R3's Plan of Care (POC) for Mobility, created on 1/23/25, with a target date of 4/25/25, Interventions include: - 1/23/25 Staff assist of two to transfer resident using the Sara Steady. - 1/20/25 unable to walk. R3 uses a wheelchair for mobility and is wheeled by staff. The wheelchair pedals were not applied with mobility. On 4/23/25 at 12:45 PM, Surveyor interviewed CNA-E. CNA-E was present when R3 fell from their wheelchair. CNA-E was getting R3's wheelchair pedals. R3 was being wheeled out of their room by CNA-D. CNA-E wanted to put the wheelchair pedals on in the hallway. CNA-E did not see what caused R3 to fall forward. The CNA-E typically applies wheelchair pedals. R3 fell before they could apply them. On 4/23/25 at 12:53 PM, Surveyor interviewed CNA-D. CNA-D stated they were wheeling R3 out of their room. They wanted to apply the wheelchair pedals in the hallway. CNA-D stated R3 just fell forward. They thought R3 passed out or something. R3 is alert and oriented, and did not say anything. CNA-D does not know how R3 fell out of the wheelchair. CNA-D stated CNA-E was behind them with the wheelchair pedals. CNA-D stated it happened fast and they could not stop R3 from falling. On 4/23/25 at 2:25 PM, Surveyor interviewed RN-C. RN-C did not see what caused R3 to fall forward. R3 did not have foot pedals on the wheelchair and would assume their foot hit the wheel. RN-C stated R3 had no foot injury. R3 was alert the whole time. R3 fell in front of their room. RN-C assessed R3 for injury and vital signs, then sent them out 911 for head bleeding. On 4/24/25 at 2:00 PM, Surveyor shared R3 fall concerns with Nursing Home Administrator (NHA)-A, Executive Director (ED)-F, and Director of Nurses (DON)-B. No additional information was provided. Based on interview and record review, the facility did not ensure residents received adequate supervision to prevent accidents for 2 of 3 residents (R1 and R3) reviewed for falls. *R1 had four unwitnessed falls that were not thoroughly investigated to determine a root cause and develop interventions that addressed the cause to prevent future falls. R1 had a fifth unwitnessed fall that resulted in a displaced left femoral neck fracture. *R3 did not have wheelchair pedals on when moving in R3's wheelchair. R3 fell and received sutures on their forehead. Findings include: The facility's policy and procedure titled, Falls Management and Prevention last revised December 2024, documents: Purpose: Fall risk assessment, identification and implementation of appropriate interventions as necessary, to maintain resident safety, prevent falls and reduce further injury from falls . Policy: Residents are assessed for their risk of falling upon admission, significant change and quarterly thereafter. Residents with risk for falling will have interventions implemented through the resident centered care plan. When a resident experiences a fall, a licensed nurse assesses the resident's condition, provides care for, safety and comfort. Procedure . 3. Residents at risk for falls have an individualized resident centered care plan developed. Care plan interventions are based on the finding of the fall risk assessment. 4. Additional professionals may be contacted to provide assessment and/or interventions regarding fall risk and prevention, including but not limited to, attending physician/provider, pharmacist, physical therapist, occupational therapist, and speech therapist. 5. Residents are provided education, as appropriate, regarding her/his fall risk and interventions to reduce falls based on the fall risk assessment . Post Fall Procedure 1. When a resident falls the licensed nurse is notified. The nurse completes an assessment of the resident's condition including an interview, if possible, completion of vital signs and a body assessment . 5. The environment of the fall is evaluated for possible contributing factors and addressed. 6. The interdisciplinary team reviews the fall and care plan changes and may, if needed, implement additional interventions. 7. Additional professionals may be contacted to provide assessment and/or interventions regarding fall risk and prevention, including but not limited to, attending physician/provider, pharmacist, physical therapist, occupational therapist, and speech therapist. 8. Documentation of the above items is completed . 1.) R1 was admitted to the facility on [DATE] on hospice services with pertinent diagnoses that include Pulmonary Heart Disease and Chronic Diastolic Heart Failure. R1's admission Assessment Minimum Data Set (MDS) with an assessment reference date of 12/18/2024 documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. R1 was assessed as being understood by others and able to understand others with clear comprehension. R1 was assessed as having adequate vision. The MDS documents R1 was assessed to have no behaviors exhibited during the look back period and the behavior section indicates neither hallucinations or delusions were present. R1's MDS indicates there is no impairment to R1's upper or lower extremities and R1 uses a walker or wheelchair for mobility. R1 is occasionally incontinent of bowel and bladder, and per the MDS no trial of a toileting program was attempted. R1's Fall Risk Assessment completed on 12/21/24 documented R1 is at risk of falls with a score of 12. R1's care plan for Bowel and Bladder: I am incontinent of Bowel and Bladder at times. I require assistance with toileting was initiated on 12/13/2024 with the following interventions: -Bowel and bladder evaluation with screening on admission and quarterly with treatment plan annually and PRN. Created on: 12/13/2024 -Bowel medications as ordered. Record BMs every shift as they occur. Monitor bowel record daily for constipation. Notify NP/PA/MD should a pattern of constipation occur. Created on: 12/13/2024 -Provide adequate nutrition and hydration. Provide water at the bedside, encourage Resident to drink to remain hydrated. Created on: 12/13/2024 -Staff assist to transfer on/off toilet per mobility section of this Care Plan. Created on: 12/13/2024 -Staff assist with peri cares and manipulating clothing as needed. Created on: 12/13/2024 -Staff assist with toileting tasks per resident request. Created on: 12/13/2024 Surveyor noted there is no toileting plan identified in the bowel and bladder care plan. R1's care plan for Mobility: I need assist with Ambulation, transfers, and bed mobility due weakness. I am at risk for a decline in ambulation d/t (due to) respiratory failure was initiated on 12/13/2024 with the following interventions: -Provide assistance with bed mobility as necessary. Created on: 12/13/2024 -Staff assist of one to provide assist for resident to transfer using a gait belt and walker Created on: 12/13/2024 -Staff to ensure call light is in resident's reach while in room and encourage to use it to make needs known. Created on: 12/13/2024 Surveyor was unable to locate documentation of Staff assist to transfer on/off toilet per mobility section of this Care Plan information in the mobility section of R1's care plan. R1's Falls care plan: I am at risk for falls due to declining mobility, chronic respiratory failure was created on 12/13/2024 and initiated on 12/19/2024 and has the following pertinent interventions: -Fall risk evaluation on admission, quarterly, and PRN. Post fall evaluation PRN. Created on: 12/19/2024 -Monitor for side effects of medication: *Cardiac medication as ordered. Monitor weekly vital signs and labs as ordered. *Psychotropic medications as ordered. BIMS evaluation, sleep log, and behavior monitoring per protocol. *Narcotic pain medication as ordered. Monitor for side effects such as dizziness, lethargy, increased confusion, decreased respirations, and report to NP/PA/MD. Created on: 12/19/2024 -PT to eval and treat per hospice orders and company. Created on: 01/20/2025 o RESOLVED: Toileting per urinary/bowel section of this care plan. Created on: 12/19/2024 R1's care plan for I require a Transfer Restorative Nursing Program due to weakness was initiated on 12/20/24 with the following interventions: -Refer to Therapy if needed. Created on: 12/20/2024 -RN to evaluate the Restorative Nursing Program periodically and make changes if indicated. Created on: 12/20/2024 -Staff report changes in resident participation to nursing staff. Created on: 12/20/2024 R1's care plan for I require an ambulation Restorative Nursing Program due to weakness was initiated on 01/17/2025 with the following interventions: -Refer to Therapy if needed. Created on: 01/17/2025 -RN to evaluate the Restorative Nursing Program periodically and make changes if indicated. Created on: 01/17/2025 -Staff report changes in resident participation to nursing staff. Created on: 01/17/2025 Surveyor noted restorative walking was the intervention that was added after R1's 1/5/25 fall but was not added to R1's care plan until 1/17/25. R1's care plan for I require an AROM Restorative Nursing Program due to weakness was initiated on 12/20/2024 with the following interventions: -Refer to Therapy if needed. Created on: 12/20/2024 -RN to evaluate the Restorative Nursing Program periodically and make changes if indicated. Created on: 12/20/2024 -Staff report changes in resident participation to nursing staff. Created on: 12/20/2024 Surveyor noted the post fall interventions for R1's toileting plan and call don't fall signs were not added to the care plan. The admission fall interventions of mat next to bed and bed in lowest position were not located in R1's care plan. Surveyor noted that the admission fall interventions of mat next to bed and bed in lowest position when resident is in it were on the Kardex which is used by Certified Nursing Assistants (CNA) to complete cares for residents. Surveyor noted that the interventions for sign posted call don't fall to remind resident to use call light for safety and toilet resident upon rising before and after meals at HS (bedtime) and prn. Toilet resident upon request were added to the Kardex only and not R1's care plan. Per an interview with the Nursing Home Administrator (NHA)-A on 4/23/25, at 12:16 PM, NHA-A had to reactivate R1's record to print the Kardex for Surveyor which changed all of the dates interventions were initiated to 4/23/25. R1's physician order dated 12/16/25 documents: Oxygen on at all times. Every shift. Surveyor noted no liter setting identified, or monitoring of resident oxygen saturation level included with order. R1's admission progress note written on 12/12/2024 documents: Resident is a new admit, from vitas hospice facility . primary diagnosis Pulmonary Heart Disease and Chronic Diastolic Heart Failure . Fall risk due to HX (history) of attempting to self transfer at night. Fall mat on floor and bed in lowest position. Resident is a 1 assist transfer with walker. Resident is on continuous O2 NC (oxygen nasal cannula) at 3L (liters), does take off at time and become Hypoxic with delusions of seeing a women named Katie. Resident is Regular diet, thin liquids allergy to lactose. Resident is on Vitas Hospice . resident is continent of bowel and bladder and noted as a fall risk with intervention of fall mat. Surveyor noted R1 was a known fall risk at admission with the interventions of fall mat and bed in low position in place on Kardex, but not in R1's care plan. Surveyor reviewed R1's fall packet for the fall that occurred on 12/21/24 at 3:00 AM. This was an unwitnessed fall in which R1 was noted as attempting to self toilet and was found on the floor next to the bed which was in lowest position with fall mat next to it, call light noted as in reach. Per the report R1 was last toileted at 2:30 AM. An intervention for a toileting plan upon rising, before and after meals, at bedtime, and as needed was initiated on the Kardex, but not to R1's care plan. R1's progress note written on 12/21/2024, at 04:15 AM, documents:: Patient was found in the floor. 'Patient stated was trying to get to the bathroom and fell. Patient states not hitting her head and forgot to press the call light' . Bed was at lowest position floor mat next to bed, call light within reach. R1's interdisciplinary progress note written 12/23/2024, at 10:18 AM, documents:: IDT (interdisciplinary team) team met to review the fall. Intervention put in place to set up toilet plan. Offer toileting upon arising before and after meals before bed PRN and per resident request. Surveyor noted this fall occurred in the early morning, not when the resident was rising for the day. Surveyor noted the toileting plan was added to R1's Kardex but not R1's care plan. Surveyor reviewed R1's fall packet for the fall that occurred on 1/5/25 at 5:15 PM. It was documented that R1 was last seen at 5:10 PM in bed. The CNA reported R1 stated that she got up to move a plant and tripped over her own feet. Then got up, put on call light and laid in bed. An intervention to start restorative walking was initiated. R1's progress note written on 1/5/2025 at 5:56 PM, documents: Resident in bed CNA reports she has a large egg sized swelling of a hematoma to left forehead resident states she fell and got herself back in bed after attempting to move a plant to her dresser. She did not use her walker or use her call light until after the fall. Also she has a skin tear slightly larger than a pea to her left forearm with a hematoma approx (approximately) 1.5 inch in diameter . Hospice notified and they will send out a nurse for further eval (evaluation) . Hospice documented a Focus Visit on 1/5/25 at 9:25 PM, Resident had a fall with a golf ball sized hematoma to the left forehead above the eye with bruising surrounding. Patient rated pain/discomfort at 6/10 and stated that she had 2 more hours before she could have pain medication. MD (medical doctor) was called and gave new pain medication orders. Neuro (neurological) check was negative. ROM (range of motion) per resident baseline. Patient stated that she wanted to move her plants. The hospice Interdisciplinary Plan of Care Revision/Physician Order dated 1/5/25, documents: a change in the morphine order and ice packs to hematoma TID (three times per day) x 2 days for 20 minutes. Surveyor noted the IDT team met on 1/15/25 and determined the intervention of restorative walking was to be added. Surveyor reviewed R1's fall packet for the fall that occurred 1/6/25 at 4:05 AM. It was documented that R1 had an unwitnessed fall while attempting to self toilet. R1 was found on the floor next to R1's bed and fall mat. The CNA documented that the walker was in bathroom doorway and so was O2 (oxygen) cord. It was documented that the last time R1 was toileted was 3:00 AM. The intervention added was call don't fall sign to remind resident for safety. R1's progress note written on 1/6/2025 at 05:00 AM, documents: Staff heard resident calling out 'help.' She was found on the floor in the middle of her room lying slightly on her right side. Her walker and her nasal cannula were both in the bathroom. BP (blood pressure) was 139/63 and heart rate was 123. Spoke with Hospice Nurse and she is aware of VSS (vital signs stable). She stated resident does have a history of orthostatic hypotension and also A.fib (atrial fibrillation). They will send out a Hospice nurse sometime today. Resident denies pain/discomfort. Soft touch call light within reach right by her hand. She was instructed to use it. The interdisciplinary note written on 1/8/2025, at 11:53 AM, documents: The IDT meet to review fall. intervention will post signs call don't fall to remind resident to use call light for safety. Surveyor reviewed R1's fall packet for the fall that occurred on 1/15/25 at 6:45 AM. It was documented that R1 had an unwitnessed fall while attempting to self toilet. R1 was found in the bathroom on the floor. It was documented that R1 was last toileted 2 hours before and last seen 5-10 minutes prior. An intervention to ask hospice physical therapy to work with resident was initiated. R1's progress note written on 1/15/2025 at 07:41 AM, documents: Resident was found sitting on her bathroom floor leaning up against the wall. Her oxygen was on and in place. She stated 'I had to go to the bathroom but I don't know what happened.' Denied hitting her head. Old bruising and old hematoma noted to her L (left) temple and cheek from a previous fall in the recent past. She was incontinent of urine. BP was 99/59 and resident has a hx of Orthostatic Hypotension. She was hoyered back to the bed with assist of 2 . Hospice will be coming in to assess the resident. Hospice documented a Focus Visit on 1/15/25 at 5:45 PM; the Interventions Performed section documents: Patient had a scheduled visit for a follow up fall. Patient denied any pain/discomfort. No new onset of bruising/bleeding noted, VSS and WNL (within normal limits). Patient alert and oriented. ROM (range of motion) per patient baseline. The interdisciplinary note written on 1/15/2025 at 10:58 AM documents: IDT team met to review fall resident is in hospice but still feels like she can get up and wants to maintain as much as her functional status as she can. Resident has states use it or lose it despite education provided to resident to ask for assistance. Intervention: set resident up to work with restorative CNA to help with ambulation. R1's interdisciplinary note written on 1/16/2025 at 08:10 AM, documents: IDT met to review fall. Resident very much thinks she can do more then she can. Call placed to Hospice to get order for PT (physical therapy) eval for safety. Hospice got order and will send out their PT to work with resident. R1's progress note written on 1/17/2025, at 08:37 AM, documents: Hospice called . in regard to resident falling and her last fall on 1/15/2025. The IDT team would like to know about PT eval for safety since resident continues to want to be up and active as much as possible and she has had a few falls. Awaiting a return call from hospice. Surveyor noted that discrepancy of 1/16/25 IDT note reading hospice got order and will send out their PT and the 1/17/25 progress note that facility was awaiting a return call from hospice regarding PT. R1's Hospice documentation Nursing-Updated Comprehensive Assessment, dated 1/17/25, documents: in the Prevent falls section to assess environment, provide frequent checks, anticipate patients needs. Surveyor was unable to locate documentation of hospice providing physical therapy intervention. Surveyor reviewed R1's fall packet for the fall that occurred on 1/21/25 at 7:34 AM. It was an unwitnessed fall. It was documented that R1 states was sitting on edge of bed and slid down. It was documented that R1 was wearing socks, no floor mat was down, the bed was in lowest position. For the question last time resident toilet n/a (not applicable) was the answer. R1's progress note written by LPN-G on 1/21/2025 at 08:43 AM, documents: Resident is on the board for an UWF (unwitnessed fall) this AM shift at 0730. Writer was headed to another room and noticed room [ROOM NUMBER] call light was on. Writer knocked on the door to room [ROOM NUMBER] and resident was sitting on the floor next to bed. Bed was in the lowest position. Floor mat was not in place. Resident was dressed, but no shoes on. Resident had c/o (complaints of) pain to left leg. Left leg appears to be rotated out and shorter than right leg. PRN pain medication given. Writer checked ROM and started neuro checks. Writer called for assistance and CNA helped writer mechanical lift resident back into bed. Resident stated that she slid off the side of her bed onto the floor. X-Ray ordered (#46320150) . R1 was found on the floor by an LPN. The LPN and CNA used a hoyer to get R1 back into bed. A Registered Nurse (RN) did not assess R1 until after the transfer back to bed. R1's progress note written on 1/21/2025 at 11:11 AM, documents: Called trident care for an ETA (estimated time of arrival), ETA is about 11:40 AM. Called POA . Son does not wish for resident to be sent to the ER(emergency room). Would like to wait for in house X-Ray. Son does not want any surgical intervention just pain management at facility. Called and spoke with . Vitas hospice regarding the above . Hospice stated will be in for a visit shortly. Hospice documented a Focus Visit on 1/21/25 at 12:00 PM, The Interventions Performed section reads writer received call from DON stating patient had sustained a fall with possible hip fracture. DON stated mobile x ray was contacted and awaiting arrival. Writer called family to update and family instructed patient should not go to hospital . instead pain should be managed at facility. Doctor put in orders to increase morphine and add Ativan and senna. Writer went to facility to assess patient's pain level and discovered patient rated pain 20/10 when she is turned. Writer informed doctor and he suggested foley placement . R1's progress note written on 1/21/2025 at 1:20 PM, documents: X-Ray results are fracture of the LEFT femoral neck with displacement of the distal fragment. Femoral head appropriately positioned. Joint space narrowing. Mild soft tissue swelling. ROM intact. Conclusion is Acute, displaced left femoral neck fracture as noted. Hospice updated on X-Ray results. Surveyor noted in just over a month R1 had five falls at the facility. Three were recorded as self transfers to use the bathroom. The post fall statements do not document whether R1 was wearing oxygen at the time of falls, one documents: oxygen line was in bathroom, not on R1. At the time of the last fall, the intervention of floor mat was noted to not be in place resulting in R1 sustaining a displaced left femoral neck fracture. Hospice documented a Psychosocial/Spiritual Updated Comprehensive Assessment on 1/21/25, which reads in part she was participating in facility activities before her recent fall and going out to dining room for meals. The Response to Care section reads bedrest after a fall, sustained left hip fracture. The hospice social worker (SW) added to the comment section, patient sustained a left hip fracture after falling from the bed today. SW met with patient, her son and daughter in law (DIL). Provided emotional support. DIL advised that this was patients 4th fall at this facility. Patient used to fall at home as well despite having a caregiver. Patient was waking up at night to use bathroom without asking for help. R1's progress note written on 1/23/2025 at 09:30 AM, documents: Resident was found pulseless around 0920. Hospice called to notify. Hospice nurse in at this time. R1's interdisciplinary note written on 1/27/2025 at 8:44 PM, documents: IDT met to review fall from 1/21/25 . Documentation was reviewed . Patient was receiving hospice services and POA chose to have no surgical intervention, no hospitalization, comfort measures only. Care plan included morphine for pain management, foley catheter for bladder management, and air mattress replacement for pressure reduction. Surveyor reviewed R1's Medication Administration Record (MAR) and it was documented that the first PRN morphine was administered to resident at 8:14 AM, on 1/21/25, after the fall. None had been administered prior to the fall. On 4/23/25 at 10:56 AM, Surveyor interviewed LPN-G who responded when R1 was found on the floor after R1's fifth fall at the facility. Per LPN-G, the girls came to get LPN-G who called hospice and asked what to do as resident was in a lot of pain. LPN-G got orders from hospice for an Xray. R1's bed was made, R1 was dressed, and laying on the floor. Surveyor asked if a Registered Nurse (RN) assessed R1 and was told guessing somebody from management came in there. Surveyor asked about R1 prior to the fall and was told R1 was active, when R1 would self transfer staff would remind R1 to call for help, up until the last fall R1 could walk with a walker and assist of 1. On 4/23/25 at 10:58 AM, Surveyor interviewed CNA-I who saw R1 on the floor. CNA-I came in at 7 AM that day for work, R1's room door was slightly open, R1 was not up when CNA-I came in. CNA-I went to resident across the hall first because that call light was on. When CNA-I stepped back out in hall, while resident was in bathroom, CNA-I saw the nurse in with R1 who was on the floor. LPN-G was the only nurse to assess R1 before they got R1 off the floor and in bed using a Hoyer lift. Hospice came in and put a catheter in because using the bed pan hurt R1 so much. Staff gave R1 medication for the pain. On 4/23/25 at 11:02 AM, Surveyor interviewed CNA-H who helped Hoyer lift R1 back to bed. It was just CNA-H and LPN-G with R1 until the DON came. There was no fall mat on the floor. On 4/23/25 at 12:38, Surveyor interviewed DON-B who stated they were walking by when staff were getting resident into bed and went in. DON-B assessed resident. Not sure if fall mat was on the floor. Prior to the fall, resident was an assist of one with a walker. After the fall, resident had orders to stay in bed. On 4/23/25 at 1:53 PM, Surveyor interviewed Hospice Manager-J and confirmed R1's admission to hospice was for pulmonary heart disease. Hospice was notified of R1's previous falls and the nurse tried to do education with R1 not to self transfer. Hospice Team Manager-J shared that R1's quality of life changed after the fall. Before that, R1 was an assist of 1, then declined fast after the fall. Hospice Manager-J stated there is a correlation there that the fall expedited R1's death. On 4/23/25 at 2:52 PM, Surveyor interviewed Medical Doctor (MD)-K who stated that R1 had heart and respiratory issues. The last note MD-K had on R1 was dated 1/16/25 and at that time there had not been any changes in R1's condition. R1 had multiple issues, the fall could have accelerated R1's passing of course. Could R1 have lasted longer without the fall, it's possible, but can't say it was the cause of death. Pain control would have been MD-K's recommendation, no surgery at R1's age. On 4/24/25 at 9:32 AM, Surveyor interviewed NHA-A who is part of the interdisciplinary team and decision making for interventions after a fall. After the first fall, R1 stated that R1 still feels can get up and wants to use it so doesn't lose it. As falls progressed, facility felt R1 was so functional that they wanted restorative to help with ambulation and staff to walk with R1 to keep skills up. Surveyor asked why the signs to remind to call when R1 fell at 4 AM. Per NHA-A, R1 had toileted self and was on the way back to bed when fell. After they put R1 in bed they reminded R1 to use the call light and put it by R1's head. They then put the signs up as reminder to call for help. Per NHA-A since R1 was a hospice patient they asked hospice about therapy involvement because R1 is going to try to keep doing this. On 4/24/25 at 12:03 PM, Surveyor interviewed NHA-A regarding why some interventions were on the Kardex but not the care plan. Per NHA-A, nurses were used to putting interventions in the task list with old computer system. In Point Click Care, the new system, it's done differently. They did education with nurses back in July or August. Surveyor notes the training was months before R1 admitted to facility and nurses still weren't doing care plan correctly. On 4/24/25 at 1:20 PM, Surveyor interviewed NHA-A about R1 being monitored for delusions due to hypoxia per the admission progress note and was told that they were not monitoring R1, they had no reason to believe there was an issue. There is no documentation that supports the admission progress no[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that Residents without a Pressure Injury (PI) do not develop pressure injuries, and receive appropriate care, treatment, & preventative measures to promote healing for 1 (R2) of 3 Residents reviewed for pressure injuries. R2 developed a coccyx pressure injury which was identified on 12/03/22. The treatment was not implemented until 12/05/22. On 12/06/22, Facility staff assessed R2's pressure injury and incorrectly staged the pressure injury as Stage 2 when there was 70% slough. R2's pressure injury continued to be incorrectly staged, the care plan was not revised after R2 developed the pressure injury, and R2's heels were observed not being offloaded according to the plan of care. Findings include: R2's diagnoses include unspecified protein calorie malnutrition, dementia, anxiety, depressive disorder, and peripheral vascular disease. R2 started receiving hospice services on 11/28/22. The risk for pressure ulcers care plan initiated 5/11/17, includes the following interventions: * Air mattress: ensure is on and functioning properly. Dated 8/19/17. * Cleanse perineal area well with each incontinence episode. Dated 5/11/17. * Consult Dietitian for nutritional assessment, and MD (medical doctor) if impaired skin integrity is noted. Dated 5/11/17. * Elevate heels off bed. Dated 1/26/21. * Monitor skin weekly on scheduled bath day to assure skin remains intact. Dated 5/11/17. * Offer afternoon nap, encourage side lying position to relieve pressure off coccyx dated 8/1/21 & revised 8/23/21. * Record percentage of meal consumed. Dated 5/11/17. * TX's (treatments) per MD order. Dated 5/11/17. The [NAME] as of 1/3/22 under skin section documents * Elevate heels off the bed. Not dated. * Ensure air mattress is on and working. Dated 5/1/2022. * MONITOR - Turn and Reposition Q2Hr (every two hours). Dated 10/17/19. * Monitor for changes in skin integrity. Not dated. * Offer afternoon nap. Encourage side-lying position to relieve pressure off coccyx. Dated 3/26/2021. The skin only evaluation dated 11/21/22 documents Skin: Skin warm & dry, skin color WNL (within normal limits) and turgor is normal. Skin Issue: #001: Needs Review. Issue type: Redness. Location: Buttocks - generalized. Painful: No. Skin note: Bed bath given per resident request. Redness to buttocks present; cream applied. Completed Clinical Suggestions: Surveyor noted there is no documentation after completed clinical suggestions:. The Braden assessment dated [DATE] documents a score of 12 which indicates high risk. The skin only evaluation dated 11/28/22 documents Skin: Skin warm & dry, skin color WNL (within normal limits) and turgor is normal. Skin Issue: #001: Needs Review. Issue type: Redness. Location: Buttocks - generalized. Painful: No. Completed Clinical Suggestions: Surveyor noted there is no documentation after completed clinical suggestions:. The significant change MDS (minimum data set) with an assessment reference date of 12/1/22, documents a BIMS (brief interview mental status) score of 2 which indicates severe impairment. R2 requires extensive assistance with one person physical assist for bed mobility, transfer, & toilet use, requires supervision with one person physical assist for eating, is always incontinent of urine & occasionally incontinent of bowel. R2 is at risk for pressure injuries and is coded as not having any pressure injuries. The nurses note dated 12/3/22, at 6:39 p.m., documents, Resident noted to have a stage 2 pressure ulcer during cares tonight above the coccyx area. Weight off loaded to her side using a pillow. [Name of] hospice nurse notified. Nurse will be out this evening to assess. There was no revision in R2's at risk for pressure ulcer care plan after R2 developed a stage 2 coccyx pressure injury. The nurses note dated 12/4/22, at 6:30 a.m., documents, Alert. Has pressure ulcer to coccyx site. Cream applied. Site is clean with no bleeding. No pain and or itching. VSS (vital signs stable). The nurses note dated 12/4/22, at 1:57 p.m., documents, Writer was told by the last shift nurse that a Hospice RN (Registered Nurse) was coming today to eval resident's coccyx wound. No one has come to the facility yet; awaiting Hospice nurse. Drsg (dressing) in place is clean, dry, and intact. The nurses note dated 12/4/22, at 4:44 p.m., documents, Hospice nurse in to assess open area on coccyx. Wound size is 2.0 cm (centimeter) x 1.0 cm. Treatment orders received and placed in orders in TAR (treatment administration record). There was no revision in R2's at risk for pressure ulcer care plan. The nurses note dated 12/4/22, at 6:35 p.m., documents, Foam dressing applied to open wound above coccyx. Area cleansed and resident off loaded coccyx to side with pillow. The physician's telephone orders dated 12/5/22, documents Hospice order: Wound care Change every 72 hr (hour) & PRN (as needed). Cleanse coccyx area with mild soap & H2O (water) F/B (followed by) N/S (normal saline) wound cleaner. Pat dry with gauze. Apply skin prep/therahoney if indicated. F/B optifoam. Surveyor noted this is two days after R2's pressure injury was identified. Review of R2's December 2022 TAR (treatment administration record) reveals the coccyx treatment started on 12/5/22. There were no other coccyx treatments documented on R2's December 2022 TAR. The nurses note dated 12/5/22, documents Resident remains on 24 hour report for O/A (open area) on coccyx. Dressing CD&I (clean dry and intact). No drainage noted. Wound care weekly and PRN (as needed). Reposition with rounds when in bed. Denies any pain or discomfort. The physician note dated 12/5/22, documents Patient with decline, weight loss. Now on hospice care. Appetite poor. Denies pain. No fevers or chills. No CP (chest pain), palpitations, or dizziness. No SOB (shortness of breath), DOE (dyspnea on exertion), or cough. No N/V (nausea/vomiting) or abdominal pain. No signs or symptoms of GI (gastrointestinal) bleed. No dysuria or hematuria. No agitation or anxiety. Surveyor noted this physician note does not include R2's pressure injury. The nurses note dated 12/6/22, documents Resident is being monitored for stage 2 PI (pressure injury) to coccyx. Wound rounds were completed today by DON (Director of Nursing) and CCMs (Clinical Care Managers). Dressing completed by them today. Resident has lower intake and is currently on hospice. Resident has air mattress on bed at this time. Cushion in w/c (wheelchair). Resident lays down after every meal per request. The wound assessment dated [DATE] for week 1 documents Stage/type as 2. Measurements for length are 2.3, width 1.7, and depth 0.1. Exudate is serosangious. For tissue type, color/percent/location is checked for granulation 30% & slough 70%. The wound margins is defined and surrounding tissue intact. The current treatment documents cleanse/SP (skin prep) or therahoney as indicated f/b (followed by) optifoam at HS (hour sleep) MWF (Monday, Wednesday, Friday). Current prevention interventions documents frequent turns while in bed (refuses frequently), nutritional or medical interventions ensure 4 oz qid (four times daily). Surveyor noted R2's pressure injury was incorrectly staged as a Stage 2 pressure injury does not have slough and 70% slough would be unstageable. There was no revision in R2's at risk for pressure ulcer care plan after this assessment. The late entry nurses note dated 12/7/22, documents Resident was seen for unit wide skin assessment on 12/6/22. Continued recent stage 2 PI to coccyx area measuring 2.3 x 1.7 x 0.1. Resident recently joined [name of] hospice and has orders as follows: HOSPICE ORDER: Cleanse coccyx area with mild soap and water/NS wound cleaner. Pat dry with gauze. Apply Skin prep/Therahoney if indicated. Apply Optifoam dressing. Change Q72 hr and prn at bedtime. Will follow with weekly wound rounds. The wound assessment dated [DATE], for week #2 documents Stage/type as 2. Measurements for length are 1.8, Width 1.6, and Depth 0.1. The tissue type, color/percent/location is checked for granulation 100%,. The wound margins are defined & surrounding tissue is intact. For current treatment & current preventative interventions Same is documented. Surveyor noted R2's pressure injury continues to be incorrectly staged as 100% granulation tissue would be a Stage 3. There was no revision in R2's at risk for pressure ulcer care plan after this assessment. The wound assessment dated [DATE], for week 3 documents Stage/type 2. Measurements for length are 1.0, width 0.7, and depth 0.1. The tissue type, color/percent/location is checked for 100% granulation. The wound margins are defined & surrounding tissue is intact. For current treatment & current preventative interventions Same is documented. Surveyor noted R2's pressure injury continues to be incorrectly staged and there was no revision in R2's at risk for pressure ulcer care plan after this assessment. The wound assessment dated [DATE], for week 4 documents stage/type 2. Measurements for length are 0.4 & width 0.2. The tissue type, Color/percentage/location checked for 50% epithelial & 50% granulation. The wound margins are defined & surrounding tissue intact. For current treatment documents cleanse/SP/Optifoam Q72 hours and PRN (as needed). The current preventative interventions document Frequent Repo. (repositioning) Nutritional and/or medical interventions ensure 4 oz QID. Surveyor noted R2's pressure injury continues to be incorrectly staged and there was no revision in R2's at risk for pressure ulcer care plan after this assessment. The wound assessment dated [DATE], for week 5 documents Stage 2. Measurements for length are 1.8 & width 0.6. For tissue type color/percentage/location checked for 100% epithelial. The periwound wound margins are closed & surrounding tissue is discoloration. For current treatment is cleanse/sp/optifoam Q72 hours & prn. The current preventative interventions documents frequent repo/cover for protection. Nutritional and/or medical interventions documents ensure qid 4 oz (ounce). Surveyor noted R2's pressure injury continues to be incorrectly staged and there was no revision in R2's at risk for pressure ulcer care plan after this assessment. On 1/3/23, at 9:27 a.m. Surveyor asked RN (Registered Nurse)-F if there are any residents on the unit with pressure injuries or any other skin concerns. RN-F informed Surveyor [name of R2] has Stage 2 pressure injury on the coccyx. Surveyor inquired if this pressure injury was facility acquired or was R2 admitted with the pressure injury. RN-F informed Surveyor facility acquired. On 1/3/23, at 9:33 a.m., Surveyor observed R2 in bed on her right side, head of the bed elevated, and on an air mattress. R2 asked Surveyor when are they going to get her up. On 1/3/23, at 9:48 a.m. Surveyor observed R2 propelling her high back wheelchair by moving her feet down the hallway. Surveyor observed there is a cushion in the wheelchair. On 1/3/23, at 10:33 a.m., Surveyor observed R2 sitting in a high back wheelchair in the hallway opposite the nurses station. On 1/3/23, at 11:16 a.m., Surveyor observed R2 continues to be sitting in a high back wheelchair in the hallway adjacent to the nurses station. On 1/3/23, at 12:23 p.m., Surveyor observed CNA (Certified Nursing Assistant)-H with gloves on place a gait belt around R2 and transfer R2 from the wheelchair into bed. CNA-H lowered R2's pants, unfastened the incontinence product, removed a disposable wipe from the container and wipe R2's frontal perineal area. R2 was positioned on her side and CNA-H wiped R2's rectal area with a wipe. Surveyor observed there was a foam dressing dated 1/3/23 on R2's coccyx area. CNA-H placed an incontinence product under R2 told R2 she could go back, fastened the incontinence product & pulled up R2's pants. CNA-H placed a pillow under R2's lower legs. Surveyor observed R2's heels are resting directly on the pillow. CNA-H covered R2 with a blanket, placed a body pillow along the right side, removed R2's glasses, lowered the bed, elevated the head of the bed and placed the call pad within reach. On 1/3/23, at 2:22 p.m., Surveyor observed R2 continues to be in bed on her back. Surveyor observed R2's heels are not being offloaded. On 1/4/23, at 7:33 a.m., Surveyor asked CNA-I if R2 usually lays down after breakfast. CNA-I informed Surveyor R2 lays down after breakfast, gets up for lunch, then lays down after lunch. Surveyor inquired if she got R2 up this morning. CNA-I replied no and explained third shift got R2 up. On 1/4/23, at 7:36 a.m., Surveyor observed CNA-I place a bath blanket on R2's bed and place gloves on. CNA-I placed a gait belt around R2 and transferred R2 onto the bed. CNA-I removed the gait belt & R2's shoes and then swung R2's legs so R2 was laying on her back. CNA-I placed a pillow under R2's calves and placed gripper socks on R2. Surveyor observed R2's heels are resting directly on the pillow and are not being offloaded. CNA-I covered R2 with a blanket, placed a body pillow along the right side, elevated the head of the bed, provided R2 with a drink of water, placed the bed in the low position and placed the call light in R2's reach. On 1/4/23, at 9:31 a.m., Surveyor observed R2 continues to be in bed on her back and R2's heels are not being offloaded. On 1/4/23, at 12:52 p.m., Surveyor observed R2 in bed on her back with the head of the bed elevated. There is a pillow under R2's lower legs. R2's heels are resting directly on the pillow and are not being offloaded. On 1/5/23, at 8:28 a.m., Surveyor observed R2 in bed on her right side with the air mattress on. On 1/5/23, at 8:31 a.m. Surveyor asked CNA-N if CNA-N could accompany Surveyor to R2's room. Surveyor asked CNA-N to lift R2's bedding so Surveyor could observed R2's feet. Surveyor observed R2 is wearing stockings on her feet and R2's heels are resting directly on the mattress. On 1/5/23, at 11:20 a.m., Surveyor asked RN (Registered Nurse)-F if R2's heels should be offloaded. RN-F replied yes and explained they put a pillow under her knees. Surveyor informed RN-F of the observations of R2's heels not being offloaded. On 1/5/23, at 11:37 a.m., Surveyor asked CNA-G if R2 likes to lay on her side. CNA-G replied no not really and explained she likes to lay on her back with pillows on each side of her. On 1/5/23, at 12:23 p.m., Surveyor met with DON (Director of Nursing)-B to discuss R2's pressure injury. Administrator-A was also in the office during this time. Surveyor asked DON-B how R2 developed the coccyx pressure injury. DON-B informed Surveyor R2 is on hospice, spends most of the day in bed, they encourage turning and repositioning but R2 often refuses. DON-B informed Surveyor this area has opened in the past and they had a covering for protection. Surveyor informed DON-B Surveyor didn't note any order or documentation in the TAR (treatment administration record) regarding a dressing for protection. DON-B informed Surveyor they may have taken the order out when there was a change. DON-B looked at R2's electronic medical record and informed Surveyor there was an order in 5/13/18 for skin prep and an dressing but that was for an open area. Surveyor asked DON-B to look at R2's October & November 2022 TAR for the protection treatment. DON-B informed Surveyor the protection treatment was discontinued 8/22/22 and they just had on an air mattress and try to do frequent repositioning. DON-B informed Surveyor they have a body pillow on both sides, R2 won't let them turn her terribly far, she is one that eats breakfast and then goes back to bed and does the same for lunch. Surveyor asked DON-B when she did the assessment on 12/6/22 why did she stage the pressure injury as stage 2? DON-B replied because it was open with slough in there & staged as stage 2. Surveyor informed DON-B the pressure injury was incorrectly staged as 70% slough should have been staged as unstageable. DON-B informed Surveyor the next week was granulation so it was a Stage 2. Surveyor informed DON-B there is not granulation tissue in a Stage 2 and should have been a Stage 3. Surveyor informed DON-B Surveyor was unable to locate any revisions in R2's at risk for pressure ulcer care plan. Administrator-A informed Surveyor she does not see a revision. Surveyor informed DON-B and Administrator-A of the observations of R2's heels not being offloaded according to the plan of care. On 1/9/23 the Facility emailed the following: 12/5/2022 note from [Name] ON CALL VISIT R/T TO WOUND TO COCCYX - PATIENT IN BED ON ARRIVAL - PATIENT A/O X 1 TO SELF, NO S/S OF PAIN OR SOB. PATIENT ANSWERING QUESTIONS APPROPRIATELY, VSS TAKEN AND NOTED. SKIN ASSESSMENT COMPLETED, UNSTAGEABLE WOUND TO COCCYX MEASURING APPROXIMATELY 2.0CM X 1.0CM WOUND COVERED WITH YELLOW SLOUGH. WOUND CARE ORDER OBTAINED. PATIENT BECAME EXTREMELY AGITATED MIDWAY THROUGH WOUND ASSESSMENT AND REFUSED WOUND CARE TO BE COMPLETED. WRITER UPDATED FACILITY NURSE [name] OF PATIENTS REFUSAL TO WOUND CARE. PATIENT WELL PALLIATED AT END OF VISIT. WRITER UPDATED RN CM VIA TEAMS. This information does not change the deficient practice.