**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure residents received adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (R) reviewed for elopement (R16.)Facility elopement assessment upon R16's admission indicated R16 was an elopement risk. The facility did not pick up on this conclusion and did not put measures in place to prevent elopement. On 06/09/2025, R16 eloped from the facility, fell on the railroad tracks approximately 0.4 miles from the facility, and was brought to R16's family members house/R16's former home by persons who found R16. The facility was not aware of R16's elopement until R16's family member notified the facility that R16 had eloped to R16's family members house and sustained a fall. R16's family member brought R16 to the Emergency Room, where R16 was diagnosed with abrasions to R16's forehead, right knee, and right hand.The failure to provide adequate supervision to prevent R16 from eloping from the facility created a finding of Immediate Jeopardy that began on 06/09/2025. The Nursing Home Administrator (NHA)-A and Director of Nursing (DON-B) were notified of the immediate jeopardy on 07/15/2025 at 1:35 PM. The immediate jeopardy was removed and corrected on 06/12/2025. The deficiency is being cited as past noncompliance.Findings include:The facility's policy titled Elopements and Wandering Residents, dated 03/21/2025, documents i 3. The Facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering . b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements.R16 was admitted to the facility on [DATE] with diagnoses of Dementia (the loss of cognitive function, including memory, thinking, and reasoning, that interferes with daily life) and falls.R16's admission Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS documents that R16 requires supervision or touching assistance to walk 10 feet, requires supervision or touching assistance to walk 50 feet with two turns, and requires supervision or touching assistance to walk 10 feet on uneven surface.R16's Activities of Daily Living care plan noted an intervention of AMBULATION: 50 feet with 2 wheeled walker and CGA. (Contact Guard Assist)R16's admission elopement assessment, dated 05/05/2025, documents, Any 3 or more risk factors indicate the resident is at risk for elopement. Surveyor noted the following three areas were marked for R16: Does the resident ambulate independently, with or without the use of an assistive device? (i.e. walker, cane or wheelchair). 3. Does the resident have a diagnosis of Dementia, OBS, Alzheimer's, Intellectual/Developmental Disability, Delusions, Hallucinations, Anxiety disorder, depression, bipolar, and/or Schizophrenia?. 2. Cognitively impaired with poor decision-making skills (i.e. disorientation, cognitive deficits, disorganized thinking? Surveyor noted the acknowledgment section documents R16 is not an elopement risk but was checked for 3 risk factors.Surveyor reviewed the Facility Reported Incident (FRI), dated 06/09/2025, which documents R16 was sitting outside the facility enjoying the sun and decided R16 wanted to visit R16's daughter's house which is 0.7 miles away from the facility. The facility's self-report documents that R16 was found 0.4 miles away from the facility by a passerby on the sidewalk after falling on the railroad tracks. R16's family member notified the facility that R16 was with the family member and R16 was ok. R16 was taken to the emergency room by R16's family member with no concerns found from the fall.Surveyor noted that on 06/09/2025, the official temperature was 66 degrees Fahrenheit around 2 PM when R16 eloped from the facility. Surveyor noted that the speed limit in front of the building is 30 miles per hour (mph) and changes to 25 mph where R16 was found.On 07/14/2025, at 11:38 AM, Surveyor interviewed NHA-A regarding R16's elopement. NHA-A indicated that marking 3 sections on the elopement assessment would indicate an elopement risk. NHA-A indicated that R16 had never actually eloped and would not be considered an elopement risk. NHA-A explained that R16 just wanted to go to R16's daughter's house but while R16 was walking across the railroad tracks, NHA-A believes R16's walker got stuck in the ruts in the railroad track and fell. NHA-A was unsure of how long R16 was gone from the facility and said would get back to Surveyor with that information. NHA-A indicated the facility has revised the elopement assessment since R16's elopement, reeducated staff on signing residents in and out, asking nursing staff if unsure of a resident's status, and residents who require supervision going outside.On 07/14/2025, at 1:44 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C regarding R16's elopement. ADON-C indicated that based on R16's admission elopement assessment, R16 should have been considered an elopement risk. ADON-C informed Surveyor that the Nurse Practitioner (NP) should have been notified of the elopement risk and that further assessments would have been needed and checks on R16 to ensure safety. ADON-C explained that R16's family member encouraged R16 to be able to go outside, but ADON-C indicated R16 would go outside to the activity patio not to the front of the building with no supervision.On 07/14/2025, at 1:56 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B indicated that based on R16's admission elopement assessment, R16 should have been an elopement risk, and a Wanderguard should have been implemented and discussed with R16's Power of Attorney (POA). DON-B indicated that DON-B and ADON-C are responsible for reviewing the elopement assessments and expect staff to notify DON-B or ADON-C of any residents at risk for elopement.On 07/14/2025, at 3:27 PM, Surveyor interviewed Receptionist-E. Receptionist-E informed Surveyor that on the day R16 eloped from the facility, Receptionist-E was transitioning shifts with Receptionist-F. R16 asked to go wait outside for R16's family member to take R16 for an appointment. Receptionist-E informed Surveyor that transition of shifts occurred around 2PM, and both Receptionists were present. Receptionist-E looked through the wander list and did not see R16 on the list. Receptionist-E had to leave for an appointment and indicated that Receptionist-F took over from there.On 07/14/2025, at 3:41 PM, Surveyor interviewed Receptionist-F. Receptionist-F indicated that R16 eloped during the shift's transition period, around 2PM. R16 came through the secured double doors to the reception area, without setting off the door alarm and asked to go outside to wait for R16's family member to pick R16 up for an appointment. Receptionist-F indicated that R16 was not on the wander list and R16 was allowed to go wait outside. About 30 minutes later, Receptionist-F received a phone call from R16's family member, indicating R16 was with R16's family member. They had not been aware R16 was missing until the phone call from R16's family member. R16's family member informed Receptionist-F that R16 was going to be taken to the emergency room by R16's family member for evaluation of an unwitnessed fall. Receptionist-F indicated that training and reeducation was provided by the facility on how reception is to inquire with nurses prior to allowing residents outside.R16's Hospital After Visit Summary (AVS), dated 06/09/2025 documents diagnoses that include: abrasions (a superficial injury to the skin that results from rubbing or scraping against a rough surface) to R16's forehead, right knee, and right hand.R16 was readmitted back into the facility on [DATE].Surveyor noted that the only path of travel that R16 could have taken using the sidewalk would be to travel North, then turn right (heading East), toward the railroad tracks. Surveyor noted there is only one sidewalk on the avenue where the train tracks are located. After reviewing the path that R16 took to her relative's house, Surveyor noted that R16 had to cross a two-lane road, at an uncontrolled intersection, to walk on a sidewalk. Otherwise, R16 would have had to walk in the street towards the railroad tracks.The failure to provide adequate supervision to prevent R16 from eloping from the facility created a reasonable likelihood for serious harm, thus leading to a finding of Immediate Jeopardy that began on 06/09/2025. The Nursing Home Administrator (NHA)-A and Director of Nursing (DON-B) were notified of the immediate jeopardy on 07/15/2025 at 1:35 PM. The immediate jeopardy was removed and corrected on 06/12/2025 when the facility completed the following:* Residents that do not have an activated power of attorney will be signed out of the facility in order to track residents going in and out of the facility.* Residents that have an activated power of attorney are only to be outside of the facility, with staff supervision, or under the supervision of their power of attorney.* Education to staff on residents signing in and out and activated residents being supervised when outside of the facility at all times.* All residents in the facility were re-evaluated for elopement risk on 6/9-6/11 (New evaluation that was implemented 6/9/25)* Tested wander system for effectiveness and alarm audibility. All magnetic lock doors were checked on 6/9/25 and 6/12/25 for functionality.* The resident that was affected added to the wander log and wander guard placed on resident upon arrival back to facility, education to resident and family on wander guard and elopements.* Immediate staff educated on new wander risk residents elopement risk residents were added to binder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility did not ensure that 1 of 4 residents (R1) was free from verbal and mental abuse. Certified Nurse Aide (CNA) D intentionally moved R1's call light out of his reach and closed his door, thereby taking away R1's ability to summon assistance in the event of an emergency or need. CNA D reported her actions to RN E (Registered Nurse); however, RN E did not report the incident to the Administrator. This allowed CNA D to work 3 shifts at the facility following the incident before she was suspended. The facility's failure to ensure residents were free from abuse created a finding of immediate jeopardy that began on 10/19/24. Surveyor notified the Nursing Home Administrator (NHA) of the immediate jeopardy on 11/8/24 at 11:10 a.m. The immediate jeopardy was removed on 11/8/24, however continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation, dated 10/22/24, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .The facility will have written procedures that include: reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . Review of the facility's policy titled, Compliance With Reporting Allegations of Abuse/Neglect/Misappropriation, revised 07/2021, revealed, It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes .When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated: The Licensed Nurse will: a. Respond to the needs of the resident and protect him/her from further incident .Remove the accused employee from resident care areas .Notify the Director of Nursing and Administrator .Notify the attending physician, resident's family/legal representative, and Medical Director .Complete an incident report and initiate an investigation .Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident .Suspend the accused employee pending completion of the investigation . R1 was readmitted to the facility on [DATE] with diagnoses that included traumatic spinal cord dysfunction and quadriplegia. R1's Care Plan dated 02/01/23 stated, .Be sure puff call light is in reach . Review of R1's annual Minimum Data Set (MDS), dated [DATE], revealed R1 is cognitively intact. The MDS recorded R1 had functional limitations in range of motion on the upper and lower extremities bilaterally and was dependent on staff for all activities of daily living. Review of the facility's investigative file for the incident between R1 and CNA D revealed the following: A statement from LPN F (Licensed Practical Nurse) dated 10/24/24 stated, Resident stated that CNA D was mean to him, he asked her to change him, and she refused, and they started arguing, she then got mad at him removed his call light which he blows into, turned out the lights on him and shut the door. He also stated that she wouldn't even change him the next day because she didn't like him and that he could starve to death. A statement from DON B (Director of Nursing) stated, 10/24/24 LPN G reported to me that (R1) had reported to her that CNA D had taken his mouthpiece call light system out of his mouth to where he couldn't reach it then turned lights out and closed his door after having an argument. I went to see R1 to discuss his allegation. R1 stated that CNA D had taken his mouthpiece out of his mouth and moved it out his reach then left his room closing his door. Stated she had worked on Sunday, Monday and Wednesday. Stated this happened on Wednesday pm shift after having an argument with her. He also stated that she came into his room about 4:00 pm and he told her he had 'pooped' and needed changed but she left the room and never came back. R1 also stated that she said to him 'I don't need you, you need me.' I asked R1 who replaced your mouthpiece? He stated the nurse RN H replace it and opened his door .He is able to speak but no movement and uses mouthpiece for contacting staff for his needs . A statement from RN E notes, 10/25/24 Re: Incident involving R1. Resident put his call light on, and CNA D went to answer it. A couple minutes later, I, RN, came down the hall, and noted resident's door closed, which was strange. I thought maybe he was getting cares. However, when I got to the nurses' station, I noted the CNA sitting there. I asked her why was R1's door closed, and she replied that she shut it, and took away his call light. She stated they had some words, both of them calling each other names. She stated she got angry, took away the call light and slammed the door closed. I told her that she can not [sic] do that, and that I gave him back his call light and opened the door. I told the CNA not to go back into the resident's room, that she would need to switch him with another CNA. After giving the resident back his call light and opening up his door; the resident stated he feels better and now safer. An undated statement from CNA notes, Hello [Administrator], On Sunday October 20th, I went to answer [R1]'s light. He [unknown] been upset already. I asked him if he needed something he started complaining about his [unknown] so I told him I would go get the nurse then he started yelling at me getting real disrespectful calling me fat bitches multiple times and threatened to slap me. I told him I'm not gonna be too many fat bitches and for him to go ahead and slap me. He then threatened to have someone come up to the job to fight me. So I told him go ahead. After that I left out his room. On Monday October 21 I didn't have much going on with him except he accused me of doing something to his food so he didn't want it. On Wednesday October 23rd I didn't have much going on with him. I told the other aide that worked with me that she would have to take him cause of our interaction. I thought she agreed to. At the end of shift the nurse did come ask all of us who had him. I told her I thought the other aide did but she said no so I said I'll go in his room only if someone else comes in there with me because I didn't want him saying I tried to do something to him. The nurse said no I don't want you going in there cause he won't let you touch him and so he doesn't say anything else to you so I didn't. Also, another aide did go in his room answer his light told him she would go get someone for him. He's just overall a hard person to deal with especially when things don't go his way. [unknown] of the other aides and nurses don't like to go in his room because he's too much . A statement from CNA I, dated 10/31/24, stated, On 10/23/24 I was standing outside R1's room talking to CNA D. I saw his light come on so I answered it. He told me that he needed to be changed and he had been waiting. I told him I was going to pass it to his aide. CNA D was standing outside the door. She was shaking her head no. I came out asked her why she not doing him [sic]. She told me because he called her a fat bitch and that he was going to slap her. And she can refuse to do him. I replied no you can't refused [sic] to do him, but he can refuse you as his aide. She told me I didn't know what I was talking about . Review of CNA D's Individual Timecard revealed she worked on 10/20/24, 10/21/24, and 10/23/24. The surveyor was unable to determine which hallway she had worked on. During an interview on 11/07/24 at 5:00 PM, RN E stated that on 10/19/24, she had stepped away from the unit and on returning to the unit about 9:20 PM, she noticed R1's door was closed which was not normal. She stated CNA D was observed seated at the nurses' desk, and when asked why the door was closed, CNA D stated R1 and she had words with each other, calling one another names about 9:00 PM. RN E stated CNA D reported that R1 called her a fat ass bitch. RN E stated CNA D further stated she had removed R1's puff activated call light from his reach and slammed his door shut. RN E stated she told CNA D what she did was not appropriate, and she went to his room. RN E stated she opened his door and returned his call light to him and asked if he was OK or scared of anyone including CNA D, and that R1 told her he was not afraid of anyone. RN E stated the problem started on Saturday 10/19/24, not on a weeknight. RN E stated she removed CNA D from R1's care around 9:20 PM, and that CNA D sat at the nurse's station until she clocked out at 9:58 PM on 10/19/24. RN E reported R1 was without his puff call light for 20 to 30 minutes. RN E confirmed she did not report the incident to the NHA A (Nursing Home Administrator). She stated she felt that she had handled the situation, and she was unaware she could call the Administrator, no matter what time it was. RN E stated she was unaware CNA D should have been suspended following the incident. During an interview on 11/07/24 at 9:45 AM, NHA A stated he felt RN E had addressed the issue; however, he had two concerns. He stated he was concerned that he was not notified immediately, and that CNA D was not sent home but only removed from R1's care. NHA A stated he and the DON had provided education to RN E related to abuse, reporting allegations of abuse to the Administrator immediately, and the facility's policy and procedure related to adhering to federal guidelines for reporting allegations of abuse. NHA A stated he had informed RN E that he was available, no matter the time of the day. During an interview on 11/08/24 at 5:50 PM, DON B confirmed she expected staff to notify her of any issues or concerns with residents. She stated her expectation was to be notified of allegations of abuse immediately. DON B confirmed she provided education to RN E related to abuse and reporting allegations of abuse to her or NHA A immediately. During an interview on 11/08/24 at 5:59 PM, R1 stated he was unable to provide the exact date of the incident. He stated he and CNA D had some words, and he called her a name. He stated she called him a name as well but could not remember what it was. He stated he was not afraid of any staff and was alright. The Surveyor attempted to reach CNA D on 11/07/24 and 11/08/24. Messages were left, but no return phone call was received. CNA D left R1 alone in the dark and without R1's communication, thus depriving R1, a resident who is dependent on staff for all activities of daily living, of the ability to communicate his needs to staff. CNA D was allowed to continue to work on the same unit on two additional shifts, creating opportunity to further retaliate against R1. The failure to ensure residents were free from abuse or the ongoing threat of abuse created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the immediate jeopardy on 11/8/24 when the following was completed: RN E was given a verbal education on abuse policy, reporting compliance, and to always contact the Administrator if there are any allegations of abuse on 10/25/2024 CNA D was removed from resident care on 10/24/2024 prior to the start of shift. All nursing staff will be re-education on abuse, neglect and misappropriation policy education; abuse reporting and compliance policy; resident call light accessibility. Administrator or designee to orient all new staff on the abuse reporting policy and how to contact those individuals 24/7. Director of Nursing or designee to provide education on abuse reporting policy monthly at staff meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Examples 3 and 4. Falls: The facility policy, entitled Falls - Clinical Protocol, revised March 2018, states: Assessment and Recognition . 2. In addition, the nurse shall assess and document/report the following: a. Vital signs b. Recent injury, especially fracture or head injury c. Musculoskeletal function . d. Change in condition or level of consciousness e. Neurological status f. Pain g. Frequency and number of falls since last physician visit h. Precipitating factors- details of how fall occurred. i. All current medications, especially those associated with dizziness or lethargy. j. all active diagnoses 3. The staff and practitioner will review each resident's risk factors for falling and document in the medical record. 5. The staff will evaluate, and document falls that occur while the individual is in the facility. 6. Falls should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position. b. Those that occur while upright and attempting to ambulate. c. Other circumstances such as sliding out of a chair or rolling from a low bed to the floor. 7. Falls should also be identified as witnessed or unwitnessed events. Cause Identification: 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. 2. If the cause of a fall is unclear, or if a fall may have significant medical cause . or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops until a reason is identified for its continuation. 3.) R70 was admitted to the facility on [DATE] and has diagnoses that include rheumatoid arthritis, fibromyalgia, severe dementia with psychotic disturbance, agitation, mood disturbance, and other behavior disturbance, type 2 diabetes, post-traumatic stress disorder, major depressive disorder, and unspecified psychosis. R70's admission minimum data set (MDS) dated [DATE] indicated R70 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 11 and assessed R70 as needing extensive assistance with 2 staff members for bed mobility, transferring, and toileting. R70 was assessed as needing extensive assist with one staff member with dressing, hygiene, and bathing, and one staff member assist walking with a walker. R70 was occasionally incontinent of urine and wore an adult brief. R70's admission falls risk score assessment dated [DATE] indicated R70 was at moderate risk for falls with a score of 15. R70's Risk for injury related to falls due to deconditioning, incontinence, weakness, impaired mobility, and gait care plan was initiated on 6/29/2023 with the following interventions: - Physical therapy (PT), Occupational therapy (OT), Speech therapy (ST) to evaluate and treat as indicated. - Be sure my call light is within reach when I am in my room and encourage me to use it before attempting to transfer. - Make sure that my floor/path is clutter free and properly lighted. - Anti-rollback brakes to wheelchair (initiated 8/29/2023) - Anti-tippers to front of wheelchair R70's visual/ bedside Kardex reports has the following interventions in place: SAFETY: - All staff to remain watchful of me and alert to my safety - Anti-rollback brakes to wheelchair - Anti-tippers to front of wheelchair - Be sure my call light is within reach when I am in my room and encourage me to use it before attempting to transfer - Encourage me to use bell to call for assistance - Ensure I have unobstructed path to the bathroom - Floor mat next to bed - Make sure that my floor/path is clutter free and properly lighted - Provide me with an environment with adequate lighting, free of glares as much as possible On 9/1/2023 at 4:43 PM in the progress notes, nursing charted R70 had unwitnessed fall around 2:45 PM. R70 alert and responsive. R70 was found lying on R70's left side on the floor. R70 stated R70 hit head and complained of left hip and knee pain. Nursing charted there was no active bleeding or visible injuries. Nursing notified the Nurse Practitioner (NP) and received orders to send R70 to the emergency room for evaluation. On 9/1/2023 at 11:20 PM in the progress notes, nursing charted R70 returned to the facility around 11:15 PM with no new orders. On 9/6/2023 at 9:43 AM in the progress notes, nursing charted R70 was discussed with the interdisciplinary team (IDT) regarding fall on 9/1/2023. R70 transferred self in room and fell onto left side, complained about hitting head and left hip pain. Immediate intervention: R70 sent to the emergency room for evaluation. Interventions: fall mat, NP and Power of Attorney (POA) in agreement with plan of care. Care plan updated. Surveyor reviewed the fall investigation for R70's fall on 9/1/2023. Surveyor noted that the investigation did not include staff interviews to determine what interventions were in place at the time of the fall, what R70 was doing prior to the fall, or when R70 was last checked on prior to R70's fall on 9/1/2023. There was no root cause analysis done to determine why R70 fell. Surveyor also noted that the immediate intervention was to send R70 to the emergency room to be evaluated, but the fall mat was not initiated until 9/6/2023. On 11/29/2023 at 3:46 PM, Surveyor informed Director of Nursing (DON)-B of Surveyor's concern that R70 did not have a thorough investigation completed for the fall on 9/1/2023. DON-B expressed understanding and would see if DON-B could find any other information regarding R70's fall on 9/1/2023. On 11/30/2023 at 10:48 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-N who stated when a resident falls, LPN-N will gather vital signs and notify a Registered Nurse (RN) on duty right away to assess the resident. LPN-N stated that a fall sheet is filled out and given to the quality assurance coordinator (QAC)-F. LPN-N stated that the information from the fall gets put into IRIS in the computer and a fall report is generated. On 12/4/2023 at 9:00 AM, DON-B provided Surveyor a sheet with a summary statement and root cause for R70's fall on 9/1/2023; the sheet was written and signed on 12/1/2023. Surveyor shared concerns that the information still did not provide information regarding why R70 had a fall and what R70 was doing prior to the fall, what interventions were in place, and interviews with staff to help determine when R70 was last checked on or observed by staff. DON-B expressed understanding. No further information provided at this time. 4.) R53 was admitted to the facility on [DATE] with diagnoses that include Dementia with severe agitation, adult failure to thrive, panic disorder, type 2 diabetes, insomnia, and anxiety disorder. R53's Minimum Data Set (MDS) dated [DATE] indicated R53 had severely impaired cognition with a Brief Interview of Mental Status (BIMS) score of 4 and the facility assessed R53 as needing extensive assist with one staff member for bed mobility, dressing, and eating, and being total dependence with one staff member for toileting, hygiene, and bathing. R53 is on Hospice and required a Hoyer lift transfer with two staff members into a Broda wheelchair. R53 was incontinent of bowel and bladder and wears an adult brief. R53's falls risk assessment score dated 7/2/2023 indicated R53 was a high risk for falls with a score of 21 and R53's most recent falls risk assessment dated [DATE] indicated R53 was still a high fall risk with a score of 20. R53's risk for injury related to falls due to confusion, deconditioning, gait/balance problems, incontinence, and unaware of safety needs care plan was initiated on 3/1/2022 with the following interventions in place: - (R53) has behaviors of placing self on floor - (R53) has behaviors of scooting/crawling on floor - Encourage me frequently to ask for assistance or use call bell for any assistance - Encourage me to be in common areas when I am awake. - Please check and change or toilet me often to prevent me from self-transferring or self-toileting to prevent falls or injuries. - Be sure my call light is within reach when I am in my room and encourage me to use it before attempting to transfer. - I need activities that minimize the potential for falls while providing diversion and distraction. - I need to be evaluated for, and supplied appropriate adaptive equipment or devices as needed. Re-evaluate as needed for continued appropriateness. - Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility as tolerated. - Ensure that I am wearing appropriate footwear when out of bed. - Make sure that my floor/path is clutter free and properly lighted. - Keep my bed in low position when I am in it to prevent me from rolling out and being injured. - (R53) was moved closer to nurses' station (initiated 3/2/2022) - Provide frequent reminders to ask for assistance, rather than attempting to provide self-care (initiated 5/17/2022) - Safety mat next to bed to prevent injury (initiated 6/4/2022) - Insure Broda chair is reclined to prevent falling forward (initiated 6/14/2022) - Check every two hours while in bed (initiated 10/10/2022) - Frequent rounding while in bed (initiated 10/5/2023) - Bed moved against left side of wall. Fall mat to be placed on right side of bed (initiated 10/30/2023) R53's visual/bedside Kardex reports has the following interventions in place: Safety: - Be sure my call light is within reach when I am in my room and encourage me to use it before attempting to transfer. - Bed moved against left side of wall. Fall mat to be placed on right side of bed. - Encourage me to use bell to call for assistance. - Ensure that I am wearing appropriate footwear when out of bed. - Frequent rounding while in bed. - Insure Broda chair is reclined to prevent falling forward - Keep my bed in low position when I am in it to prevent me from rolling out and being injured. - Make sure that my floor/path is clutter free and properly lighted. - Please check and change or toilet me often to prevent me from self-transferring or self-toileting to prevent falls or injuries. - Provide frequent reminders to ask for assistance, rather than attempting to provide self-care. - Resident was moved closer to the nurse's station. - Safety mat next to bed to prevent injury. Surveyor noted that there is no mention of R53's behaviors of placing self on floor or R53's behaviors of scooting/crawling on floor on the Kardex that staff use, specifically the certified nursing assistants (CNAs) to use as a quick reference for the care of R53. On 10/1/2023 at 10:58 AM in the progress notes, nursing charted nursing was brought to R53's room and R53 was observed sitting on buttocks with back to bed sitting on mat and was bleeding on the left side above R53's eye. RN called to assess R53, Hospice and (power of attorney) POA also informed, and Hospice will be out to assess R53. R53 has skin tear measuring 1.0 CM X 0.1 CM, cleaned with normal saline. Neurological check and range of motion within normal limits. R53 placed on twenty-four hour board for monitoring. R53 has no complaints of pain or discomfort thus far. On 11/28/2023 at 7:50 AM, Surveyor went on to the unit to make observations of staff and residents. Surveyor was standing in hallway across from R53's room. Surveyor observed staff walking in the hallway, Certified Nursing Assistant (CNA)-L and Licensed Practical Nurse (LPN)-N walked past R53's room and went into another resident's room across the hall with a Hoyer lift. On 11/28/2024 at 8:04 AM, Surveyor observed R53's feet in the doorway of R53's room. Surveyor walked over to R53's room and observed R53 sitting on the floor and scooting to the doorway. Surveyor went to get facility staff to assist R53. After R53 was assessed, staff used a Hoyer lift to lift R53 off the floor and put R53 in her bed. On 11/28/2023 at 8:12 AM, CNA- L provided cares for R53 and got R53 dressed for the day. Surveyor asked CNA-L when was the last time CNA-L checked in on R53. CNA-L replied it was earlier that morning and R53 was sleeping in bed. CNA-L stated CNA-L was surprised R53 was up at the current time because R53 usually sleeps in later. Surveyor asked if R53 often rolls out of R53's bed. CNA-L replied staff like to keep a close eye on R53, so staff do frequent checks on R53. On 11/29/2023, Surveyor requested fall investigations for R53's falls. On 11/29/2023 at 2:45 PM, Director of Nursing (DON)-B and associate executive director (AED)-C brought in fall investigation packets for Surveyor. DON-B stated that since the falls on 10/1/2023 and 11/28/2023 were situations where R53 crawled out of bed and scooted on floor and R53 is care planned to do that, fall investigations were not initiated. On 11/29/2023 at 3:09 PM, Surveyor expressed concern to DON-B, Nursing Home Administrator (NHA)-A, and AED-C that both situations were unwitnessed so it's unclear if R53 crawled out of bed since the falls were not investigated and root cause analysis were not performed to determine why R53 ended up on the floor. DON-B stated that the interdisciplinary team (IDT) had a brief huddle and determined that both falls should have been investigated on 10/1/2023 and 11/28/2023 even if it is stated on R53's care plan and facility staff will receive education. On 11/29/2023 at 3:46 PM, DON-B reported to Surveyor that staff is currently working on the fall investigation packet for R53's fall on 11/28/2023. On 11/30/2023 at 10:48 AM, Surveyor interviewed (LPN)-N who stated when a resident falls LPN-N will gather vital signs and notify a registered nurse (RN) on duty right away to assess the resident. LPN-N stated that a fall sheet is filled out and given to the quality assurance coordinator (QAC)-F. LPN-N stated that the information from the fall gets put into IRIS in the computer and a fall report is generated. On 11/30/2023 at 3:48 PM, Surveyor interviewed RN-J who stated the fall process for the facility is when a resident falls, a RN has to assess the resident to make sure the resident is ok or needs further evaluation. RN-J stated if a RN is not available then DON-B is always available by phone and staff are to call physician right away. RN-J said that the facility is a no lift facility so the staff should get a Hoyer lift to lift the resident off the floor and start a fall investigation packet that includes: what the resident was doing before the fall, diagram of the scene of the fall upon arrival, what interventions were in place at time of fall, immediate interventions implemented after fall, root cause statement, witness statements, and resident gets put on 24 hour board for monitoring and fall investigation gets reviewed with management team next day. On 12/4/2023 at 9:00 AM, QAC-F provided Surveyor a sheet with a summary statement and root cause for R53's fall on 10/1/2023. The sheet was written and signed on 12/1/2023 by DON-B and QAC-F. Surveyor noted same concerns that there were no staff interviews obtained to determine cause of fall, what R53 was doing prior, and when R53 was last checked on prior to fall. On 12/5/2023 at 8:53, QAC-F provided Surveyor a fall investigation for R53's fall on 11/28/2023. Surveyor was also provided a list of facility staff that were educated on all falls on 11/29/2023 and 11/30/2023. DON-B stated they are continuing the education, so all staff receives it. Surveyor reviewed the fall investigation for R53's fall on 11/28/2023. Surveyor noted there were no witness statements included in the investigation including Surveyor's observation of R53 on R53's floor on 11/28/2023. On 12/5/2023, Surveyor shared concerns with DON-B, NHA-A, AED-C, and QAC-F regarding R53's investigations into falls on 10/1/2023 and 11/28/2023 were not initiated or have a thorough investigation and root cause analysis into the falls. No further information was provided at this time. Based on observation, interview, and record review, the facility failed to ensure that 1 (R255) of 1 resident reviewed for elopement was provided with safety measures, interventions, and assessments to prevent elopement and ensure safety. The facility also did not ensure 3 (R70, R53, and R255) of 4 residents reviewed for safety and supervision received an environment free of accident hazards, adequate supervision, and assistive devices to prevent accidents. ~ R255 was found outside the facility on 5/7/23 with multiple abrasions to his body and face. R255 stated he was going to the gas station to buy beer. R255's Power of Attorney (POA) was contacted and still wanted R255 to be able to go outside independently if he chose to. The facility did not assess R255 at this time to determine his level of safety awareness and his ability to safely be outside alone and did not put any added supervision or interventions in place to keep him safe. This was despite the encounter on 5/7/23 finding R255 in the facility parking lot with injuries. The facility did document an Elopement Assessment that put him at risk for elopement. On 6/2/23, R255 was again found outside the facility attempting to go the gas station for beer. Again, the facility did not assess R255 regarding safety awareness and his ability to safely be outside alone and did not put in any added supervision or interventions to keep him safe. On 6/5/23, R255 was found in the middle of the street with traffic stopped in both directions. The street has a speed limit of 40 miles per hour and is Highway 32 in Milwaukee County. The facility's failure to assess, supervise, and intervene on previous elopements of R255 created a finding of Immediate Jeopardy (IJ) that began on 5/7/23. Surveyor notified Nursing Home Administrator (NHA)-A and Associate Executive Director (AED)-C of the IJ on 12/4/23 at 1:47 PM. The immediate jeopardy was removed on 6/6/23. The deficient practice continues at a scope/severity level of D (potential for harm/isolated) related to the following examples involving R70, R53, and an additional example regarding R255. ~ R70 did not have a thorough investigation or root cause analysis done for a fall that occurred on 9/1/2023. ~ R53 did not have a fall investigation initiated for falls that occurred on 10/1/2023 and 11/28/2023 until Surveyor asked for the fall investigations on 11/29/2023. ~ R255 had a history of sexual abuse with female residents. R255 was found entering other residents' rooms and touching their personal belongings. R255 was put on 1 hour checks for sexual expressions. On 9/7/23, R255 was found touching another female resident's breast in the common area noting increased supervision was not effective. Findings include: Surveyor reviewed facility's Elopements and Wandering Residents policy with a revised date of 8/12/2022, which documented: Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. 5. Procedure for Locating Missing Resident a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. internal alert code). b. The designated facility staff will look for the resident. c. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The administrator or designee should also notify the company's corporate office. d. DON or designee shall notify the physician and family member or legal representative. e. Police will be given a description and information about the resident; include any photos. f. All parties will be notified of the outcome once the resident is located. g. Appropriate reporting requirements to the State Survey agency shall be conducted. 6. Procedure Post-Elopement a. A nurse will perform a physical assessment, document, and report findings to physician. b. Any new physician orders will be implemented and communicated to the family/authorized representative. c. A social service designee will re-assess the resident and make any referrals for counseling or psychological/psychiatric consults. d. The resident and family/authorized representative will be included in the plan of care. e. Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. f. When repeated elopement attempts occur, after the facility has exhausted possible care approaches, the resident may be referred for alternate placement in an appropriate facility. g. Documentation in the medical record will include: findings from nursing and social service assessments, physician/family notification, care plan discussions, and consultant notes as applicable. R255 was admitted to the facility 6/24/21 with diagnoses that included Alzheimer's Dementia, Dementia with Behaviors, and Major Depressive Disorder. Surveyor reviewed R255's MDS (Minimum Data Set) with an assessment reference date of 7/31/23. Documented under Cognition was a BIMS (brief interview mental status) score of 07 which indicated severely impaired cognition. Surveyor reviewed R255's Progress Notes. Documented on 5/7/23 at 4:28 PM was, [POA]-A was notified that resident was found outside the facility. Skin assessment was performed when resident was brought back to facility and abrasions were noted at right knee, right side of right eye, nose and chin. Minimal bleeding noted. Documented on 5/7/23 at 7:18 PM was, Resident is alert and oriented. Is able to propel self. [POA-O] is in agreement to him going outside independently. [POA-O] request facility provide nonalcoholic beer. Will discuss in [interdisciplinary team (IDT)] in am and follow up with primary physician and [POA-O]. It was noted R255 was attempting to go to the gas station for beer. Surveyor reviewed R255's Electronic Medical Record (EMR). There were no Care Plan Interventions or Safety Assessments after R255 left the building on 5/7/23 except an Elopement Assessment that documented R255 at risk for elopement. Although POA-O wanted R255 to be able to go outside independently, the facility is responsible for R255's safety; the facility did not assess R255 safety awareness or his ability to be safely outside without supervision. On 12/4/23 at 10:36 AM, Surveyor interviewed Social Services Director (SSD)-K. Surveyor asked if R255 was ever provided nonalcoholic beer as R255's POA suggested. SSD-K stated she was not made aware of the request but she would have followed up on it because there is nonalcoholic beer available at the facility. On 6/1/23, an MD order was put in R255's chart that documented, Monitor location, activities, and sexual expression [every (Q)] hour. Chart in [EMR]. Every hour for sexual expression. Documented in R255's Progress Notes on 6/2/23 at 3:30 PM was, at [3:15 PM] observed resident outside in parking lot. he was in his [wheelchair (w/c)]. approached resident. asked him where he was going. he pointed at the nearest gas station. indicating he wants a beer. redirected resident back into facility . R255's EMR showed there were no Care Plan, Interventions, or Safety Assessments after R255 left the building on 6/2/23. Documented in R255's progress notes on 6/5/23 at 4:00 PM was, Resident noted in middle of street in front of building trying to cross to the other side. Resident not using cross walk and had traffic stopped in both directions. Writer started to approach and called the nursing supervisor. Documented on 6/5/23 at 6:24 PM was, Writer immediately responded to phone call from staff nurse and was able to redirect resident out of the street and back into the facility. Writer was unable to determine what resident was attempting to do or why due to him being mainly Serbian speaking. Resident does have [activated POA-O]. In the past [POA-O] has wanted [R255] to be able to sit outside front entrance without restriction. Writer called [POA-O] to discuss the above event, resident's poor safety awareness/decision making, possible outcomes of the above event as well as intervention strategies. [POA-O] in agreement that resident's actions demonstrate poor decision making ability as well as poor safety awareness. Discussed use of wander guard to alert staff of resident's attempts to exit facility so that he could be redirected. [POA-O] informed that resident would no longer be able to sit outside by himself but that she would be able to take him out during her visits and that resident would still be able to use activity patio with staff supervision. [POA-O] states that she understands this and is in agreement with placement of wander guard for resident safety . Surveyor observed the street in front of the facility and noted no traffic lights or stop signs, and the speed limit is 40 miles per hour. Surveyor also noted the street is Highway 32. Surveyor reviewed R255's Elopement Assessment from 6/5/23 that documented R255 at risk for elopement. Surveyor reviewed R255's Comprehensive Care Plan that was initiated 6/6/23 after the third elopement from the facility. Documented was: Focus: I am an elopement risk/wanderer [as evidenced by (AEB)] Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness, Significantly intrudes on the privacy or activities. Goal: My safety will be maintained through the review date. Interventions: - Monitor location hourly and [as needed (PRN)]. Document wandering behavior and attempted diversional interventions. - WANDER ALERT: Assure Wanderguard is located on my left ankle and functional Q (each) night shift. Expires 6/8/24. - Redirect me away from exit doors. Talk to me in a calm, reassuring manner. On 12/04/23 at 10:22 AM, Surveyor interviewed Receptionist-V. Surveyor asked if she remembered R255 being on 1 hour checks. Receptionist-V stated she did not remember ever being informed of that regarding R255. Surveyor asked when the desk is staffed. Receptionist-V stated 8:00 AM to 8:00 PM. Surveyor asked how she knows what residents wander and are at risk for elopement. Receptionist-V showed Surveyor a binder with face sheets, lists, and pictures. Surveyor asked what she does if these residents try to leave the facility alone? Receptionist-V stated, redirect them and let staff know. Surveyor asked if R255 was ever on this list. Receptionist-V stated yes, after he received a Wanderguard. Surveyor noted the Wanderguard was placed 6/5/23 on the 3rd elopement from the facility. On 11/29/23 at 10:02 AM and 11:11 AM, Surveyor interviewed Assistant Executive Director (AED)-C. Surveyor asked why, after the 5/7/23 elopement, there were no safety assessments and why R255 was allowed to go outside independently again without supervision for safety. AED-C stated POA-O still wanted R255 to have the freedom to go outside, go to the gas station. Surveyor asked if there was an incident report or safety assessment. AED-C stated no. Surveyor asked what is the process to make sure a resident is safe to be out of the facility independently? AED-C stated the facility would assess to make sure they are safe and know their surroundings. Surveyor asked why this was not done for R255? AED-C stated that was his first time leaving the building and they did not feel he was an elopement risk. On 11/29/23 at 1:26 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and AED-C. Surveyor asked about the Elopement Assessment completed 5/7/23. NHA-A stated the Interdisciplinary Team (IDT) met and stated he was not a risk for elopement so they did not add any elopement interventions at that time. AED-C stated he had money in his pocket and knew where he was going so he had a purpose so they did not consider it an elopement. Surveyor noted the Elopement Assessment assessed him at risk and R255 eloped again on 6/2/23 for the same reason. AED-C stated he was on increased monitoring. Surveyor noted the monitoring was for sexual expressions. NHA-A stated R255 was monitored for all sorts of things including behaviors, sexual expressions, where he went throughout the building. Surveyor noted that the 1 hour checks did not start until 6/1/23. Surveyor asked what was done after the 6/2/23 elopement? AED-C stated POA-O was updated and she still wanted him to be able to go outside independently. Surveyor asked why he wasn't assessed for safety at this time? AED-C stated he would look into that. Surveyor asked what changed on 6/5/23 that led the facility to add a care plan and Wanderguard on that date? NHA-A stated when we found him (R255) in the middle of the street (Highway 32) and we brought him back in, he was not making sense. AED-C stated POA-O was updated was agreeable for him to wear a Wanderguard. AED-C stated at this point he (R255) needed to be more secure for safety. On 12/4/23 at 8:19 AM, Surveyor interviewed NHA-A. NHA stated after a timeline was developed NHA-A noted there were no interventions put in place after R255 eloped from the facility on 5/7/23. NH[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide care and treatment in accordance with professional standards of practice for 1 out of 1 residents (R1) who experienced a fall resulting in a significant head injury. * On [DATE] at approximately 1:30 PM, Certified Nursing Assistant (CNA)-E was turning and repositioning R1 in order to provide incontinence care to R1 while he was in bed. R1 rolled from the bed to the floor, hitting his head on the metal frame of the bed side table. R1 was noted to have a contusion with bleeding to the forehead. CNA-E sought the assistance of another CNA and together the two CNAs used a Hoyer lift to put R1 back into bed prior to a Registered Nurse (RN) assessing R1 for injury. Once in bed, R1 was assessed by the nurse. The Nurse Practitioner-F (NP) gave orders to send R1 to the emergency room by calling 911. Instead of calling 911, Licensed Practical Nurse (LPN)-H called for a private ambulance company to transport R1 to the emergency room. It was noted that the fall occurred at approximately 1:30 PM, and R1 was not transported to the emergency room until 2:15 PM. R1 was noted to be on a blood thinner and was excessively bleeding from the contusion on R1's forehead. On [DATE], R1 was admitted into the hospital with a subdural hematoma. R1 received staples and sutures to the forehead and was admitted into the Intensive Care Unit (ICU). R1 was discharged from the hospital and readmitted into the facility on [DATE]. The hospital discharge instructions included for R1 to have follow up, within 2 weeks, with a CT scan of the head that the hospital had scheduled for [DATE]. Once the CT scan was obtained, R1 was to be seen by Neurosurgery which the hospital scheduled for [DATE]. Facility staff noted it would be difficult to obtain transportation for the CT scan on [DATE] at the time indicated for R1. The facility proceeded to change the appointment for the CT scan without notifying the Neurosurgical clinic to discuss if it would be alright for R1 to have the CT scan after the 2-week timeframe already established in the hospital discharge. In addition, R1 attends Dialysis 3 times weekly. R1 returned to dialysis for treatment after his discharge from the hospital and readmission into the facility. The facility did not communicate to the dialysis center the significance of R1's head injury and his sustaining a subdural hematoma. On [DATE], the dialysis center staff noted R1 had a less than 1 minute seizure like activity and tried to call the facility to communicate this information. The facility did not respond to this phone call and the dialysis center then communicated the seizure activity on the paper communication sent with R1 back to the facility. The facility did not review the dialysis center's written communication regarding R1's seizure activity and therefore was not aware of R1 having a seizure at dialysis. The facility was not able to monitor and follow-up with R1's primary physician regarding R1's seizure activity. On [DATE], R1 became unresponsive and 911 was called. R1 was admitted into the hospital with an extensive brain bleed, seizure, and plural effusion. R1 was placed on comfort care and passed away on [DATE]. The facility's failure to provide the necessary care and treatment for R1 by not ensuring an RN assessment was completed following R1's fall with an active bleeding head injury and prior to transferring R1 back to bed, calling a private ambulance versus calling 911 therefore delaying treatment, the failure of the facility to consult with the physician of the delay in R1 having a CT scan of his head within 2 weeks of hospital discharge (per hospital instructions) and follow-up with neurosurgery, the failure to communicate to the Dialysis Center about R1's subdural hematoma, and the failed communication between dialysis and the facility regarding R1's seizure-like activity on [DATE] created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator-A and Assistant Executive Director-C of the immediate jeopardy on [DATE] at 12:45 PM. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity of D as the facility continues to implement and monitor its action plan. Findings include: Surveyor reviewed the facility's Head Injury policy which was revised 03/2022. The policy indicated in part: Policy: It is the policy of this facility to report head injuries to physician and implement interventions to prevent further injury. Policy Explanation and Compliance Guidelines (includes): 1.) Assess resident following a known, suspected, or verbalized head injury. The assessment shall include, at a minimum: e.) any injuries to head, neck, eyes or face, including lacerations, abrasions, or bruising. 2.) Call 911/EMS and attempt to stabilize the resident's condition if respiratory distress or a hemorrhaging wound occurs. Surveyor's review of Long Term Care Facility Outpatient Dialysis Services Coordination Agreement dated [DATE] includes in part; B.) Obligations of Long-Term Care Facility and/or Owner 1.) ESRD (end-stage renal disease) Residents Information. The Long-Term Care Facility shall ensure that all appropriate medical and administrative information accompanies all ESRD Residents at the time of referral to the ESRD Dialysis Unit. This information shall include, but is not limited to, where appropriate, the following: e.) Treatment presently being provided to ESRD Residents, including medications. 2.) Interchange of Information. The Long-Term Care Facility shall provide for the interchange of information useful or necessary for the care of the ESRD Residents, including a contact person at the Long-Term Care Facility whose responsibilities include assisting with the coordination of Renal Dialysis Services for ESRD residents. R1 was admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, other nontraumatic intracerebral hemorrhage, epilepsy, type 2 diabetes mellitus with diabetic chronic kidney disease, aphasia, heart disease, end stage renal disease, peripheral vascular disease, and vascular dementia. R1's Fall Risk assessment, dated [DATE], assessed R1 as a high risk for falls. R1's Quarterly MDS (Minimum Data Set) dated [DATE] documents a BIMS (Brief Interview of Mental Status) of 5 indicating R1 is severely cognitively impaired. R1 has an activated POA (Power of Attorney). R1's functional status for bed mobility, transfers, dressing, and toilet use are all assessed as extensive assist with two + person physical assist. R1's physician orders include Plavix Oral tablet 75mg (milligrams) once daily and Aspirin oral tablet 81mg once daily for anticoagulants and Vimpat tablet 150mg - give 0.5 tablet by mouth two times a day for seizures, order date [DATE]. The Misconduct Incident Report dated [DATE] and submitted by the facility, documents on [DATE] at 1:30PM, R1 was receiving cares from CNA-E after having a bowel movement. While CNA-E turned R1 on R1's left side, R1 rolled off the bed. R1 hit his head on the foot of the bedside table. The Nurse assessed R1 and observed a contusion to middle of the forehead. R1 was assisted off the floor by two CNAs with a Hoyer lift and pressure was applied to contusion. R1 was sent to the emergency room (ER.) On [DATE], at 11:32 AM, Surveyor interviewed CNA-E who stated R1 rolled off the bed during cares and hit his head on the foot of the bedside table. CNA-E stated R1 was bleeding from the forehead. CNA-E stated she panicked and left the room to find help. CNA-E reported she found another CNA who helped her transfer R1 off the floor and back into bed with the Hoyer lift. When R1 was in bed CNA-E then went to get a nurse. CNA-E reported a Registered Nurse (RN) and Licensed Practical Nurse (LPN) came to assess R1. R1 was actively bleeding from the middle of the forehead so CNA-E held pressure on the injury. The nurse then contacted the Nurse Practitioner in the building to come and assess. Surveyor asked CNA-E why she moved R1 back into the bed after a fall with head injury and she stated she was scared. On [DATE], at 12:00 PM, Surveyor interviewed Assistant Executive Director-C regarding R1's fall. Assistant Executive Director-C confirmed it is their policy that when a resident has a fall, they are to be assessed by a RN before moving the resident from the ground. On [DATE], at 9:53 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-H who stated she was working on the day R1 fell out of bed. LPN-H stated RN-G informed her of the fall and together they responded to R1's room. LPN-H stated R1 was in bed and was bleeding from the middle of the forehead. LPN-H stated RN-G assessed R1 and the NP in the building was called. Surveyor asked LPN-H if it was protocol to place a resident back in bed after a fall and she stated, no, that residents are to remain on the ground until an assessment is completed. LPN-H reported CNA-E was new to skilled care and that she panicked and moved R1 back into bed. LPN-H informed Surveyor the NP came to the room and ordered R1 to be sent out. Nurse Practitioner (NP)-F's encounter noted dated [DATE] documents, Provider was asked to urgently see patient for concerns of head trauma. Per staff, R1 was receiving cares after a bowel movement and rolled off the bed and onto the floor, hitting his head on the bed side table. Lying in bed - wet towel on his head - actively bleeding from wound to center top forehead. Large amount of blood present in his hair and on his pillow. PLAN: Staff instructed to hold pressure and call 911. Needs urgent evaluation of his head - on blood thinners with prior history of VP shunt. Will need imaging to ensure no hemorrhaging. On [DATE], at 9:53 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-H. LPN-H stated she called [Bell] Ambulance as that was what she thought she was told to do. LPN-H informed Surveyor a few days later she was reeducated and told if a resident has a head injury, they should be sent out 911. LPN-H stated when [Bell] Ambulance arrived, they told her that 911 should have been called as R1 was on blood thinners and actively bleeding from the head. Licensed Practical Nurse (LPN)-H called for a private ambulance company to transport R1 to the emergency room, rather than calling 911. It was noted R1's fall occurred at approximately 1:30 PM, and R1 was not transported to the emergency room until 2:15 PM. R1 was noted to be on a blood thinner and was excessively bleeding from the contusion on R1's forehead. On [DATE], R1 was admitted to the hospital. The hospital admission note, dated [DATE], documents, CT of the head was obtained, showing new subdural hematoma along the right tentorium, and along the posterolateral margin of the right temporal lobe. Neuro critical care and neurosurgery teams were contacted. Patient's wife was also contacted. She confirmed Do Not Resuscitate status and did not want any neurosurgical treatments. Decision was made to admit the patient to the ICU (Intensive Care Unit) at this facility. DDAVP was recommended by critical care, as the patient is on aspirin and on dialysis. R1 was discharged from the hospital and readmitted back into the facility on [DATE]. Surveyor continued to review R1's medical record which included the Hospital Discharge summary dated [DATE]. The Hospital Discharge Summary documents under Impression and interventions: Acute traumatic subdural hematoma. History of intraventricular hemorrhage (2017). Seizure disorder. No seizure overnight. Neurosurgical evaluation in 2 weeks, antiplatelet therapies on hold until evaluated as outpatient by Neurosurgery. SC (subcutaneous) Heparin ok. Repeat CT head prior to outpatient evaluation by Neurosurgery. R1's Hospital After Visit Summary documents that an appointment for CT head without contrast was scheduled for [DATE] and a follow up virtual visit with Neurosurgery was scheduled for [DATE]. NP-F Encounter note dated [DATE] documents, Large wound to center top of the forehead. 6 staples present. Plan: Follow up CT of head on [DATE] and follow up with Neurology as ordered. Epilepsy - stable, no seizure activity - seizure precautions. Continue Vimpat as ordered. History of falling - stable - fall precautions and bleeding precautions - continue Plavix and aspirin as ordered. Surveyor reviewed skilled/episodic notes for R1 from [DATE], [DATE], and [DATE] through [DATE] and all document generic neurological assessments completed and do not document any neurological changes to baseline. Surveyor notes there are no physician orders for neurochecks post fall to be completed once R1 returned from the hospital on [DATE]. On [DATE], at 1:36 PM, Surveyor interviewed the Interim Director of Nursing/Assistant Director of Nursing (IDON)-D who informed Surveyor that per hospital discharge paperwork a CT scan was scheduled for [DATE] at 5:00 PM. IDON-D stated the facility could not provide transportation at that time of day due to R1 using a Broda chair, so she had asked the scheduler to reschedule the scan. The CT scan was rescheduled for [DATE] for the morning. IDON-D stated they did not call the Neuro Clinic to ask if it was okay to reschedule this appointment after the recommended 2 weeks. IDON-D also stated she did not notify the NP (Nurse Practitioner) of the change and that the NP does not have direct access to the internal shared drive that is used by the facility to house resident appointments. On [DATE], at 2:00 PM, Surveyor interviewed NP-F who informed Surveyor that a CT scan of R1 was most likely scheduled to determine if the brain bleed was growing or not however, she explained she does not have a neuro background. NP-F stated she was not aware initially that the CT scan for [DATE] was rescheduled however she did find out after the fact. Surveyor asked NP-F if neurochecks for individuals after a head injury should be completed and NP-F stated neurochecks are usually completed 72 hours after a head injury and she would not typically order ongoing neurochecks. NP-F indicated it would be based on facility policy and that she was not aware of this facility's policy. Surveyor noted R1's daily progress notes regarding R1's staples and sutures do not include any documentation of any redness, drainage, or signs of infection from [DATE] through [DATE]. A Physician order dated [DATE] indicated to remove the 2 staples and 5 sutures from R1's forehead. NP-F Encounter note dated [DATE] documents, The provider was called to the patient's room to evaluate him as the nurse was removing his staples and sutures and noted what appeared to be pus coming from his head wound .The wound has started to dehisce again and is bleeding. Wound edges are red, extending into the surrounding tissue. The wound has also started to swell again. The wound was irrigated with normal saline and purulent drainage was noted as well .Follows with Wound MD in house. Plan: send to ER (emergency room) for evaluation and treatment. Wound appears to be infected and has now started to dehisce. Needs evaluation from MD as well as possible imaging. R1's After Visit summary from the ER, dated [DATE], documents a diagnosis of infected wound and doxycycline (antibiotic) was started. R1 returned back to the facility. NP-F Encounter note dated [DATE] documents, Seen for follow up after ER visit .It does not appear any lab work or imaging was done in the ED (Emergency Department). R1 was returned with orders for doxycycline for wound infection. Plan: Continue doxycycline as ordered, wound MD to see in the AM (morning), follow up CT of head on [DATE] and follow up with Neurology as ordered. On [DATE], R1 was sent to Hemodialysis. Review of the Hemodialysis Communication form dated [DATE], documents, 1 small less than 1 minute seizure-like activity. Surveyor noted there was no indication the facility had notified dialysis of R1's head injury from the fall that occurred on [DATE] resulting in a subdural hematoma. Surveyor also reviewed the facility's nursing progress notes after [DATE] through [DATE] and there was no indication of the facility monitoring or following up on R1's seizure-like activity while at dialysis on [DATE]. On [DATE], at 9:31 AM, Surveyor interviewed Registered Nurse (RN)-G who stated she did complete the hemodialysis communication forms on [DATE], [DATE], and [DATE]. RN-G could not explain why she did not communicate to dialysis that R1 had a subdural hematoma due to a fall on [DATE]. On [DATE], at 11:09 AM, Surveyor call the Hemodialysis Clinic and spoke to the clinic manager. Clinic Manager explained that during R1's dialysis on [DATE] they observed seizure-like activity. The medical doctor on site assessed R1, administered normal saline, and determined not to send R1 to the ER. Clinic Manager stated they tried calling the facility however no one picked up, so they documented the seizure-like activity on the communication form. On [DATE], at 8:49 AM, Surveyor interviewed the IDON -D. Surveyor showed IDON-D a copy of the Hemodialysis Communication form dated [DATE] which documented, 1 small less than 1 minute seizure-like activity. IDON-D stated they were not aware of any seizure like activity at dialysis. IDON-D stated usually the dialysis center will send a resident to the ER if they have any seizure-like activity and then call and let us know. IDON-D informed Surveyor that typically the nurse on duty is responsible to complete the top portion of the form and fill in any relevant information, like any recent changes in condition and then the dialysis center completes the bottom portion of the form and when the resident returns to the facility the form is reviewed by the nurse on duty. IDON-D stated this was obviously missed .No one said anything and nothing is documented. Surveyor asked IDON-D if she would have known about R1's seizure activity while at dialysis would anything have been done differently? IDON-D responded with they would have notified the NP, obtained lab work on seizure medication, put resident on the 24 hour board for closer monitoring, and the NP may have even sent R1 out to ER. R1's facility progress notes continued to indicate: Progress Note dated [DATE] at 17:44 (5:44 PM) documents, Writer was called into this room and noted this PT (patient) to be unresponsive, SPO2 (oxygen saturation) at 86%, emesis behind his head and in his mouth. O2 (oxygen) applied at 2 LPM (liters per minute.) 911 called and NP updated about sending this PT out to the ER. Progress Note dated [DATE] at 22:18 (10:18PM) documents, .updated about this PT who was admitted with an extensive brain bleed, midline shift of about 6mm, pleural effusion and seizure. PT is on comfort care there and will either stay there to pass or family will take him home from there to pass. R1 expired on [DATE]. On [DATE], at 11:35 AM, Surveyor informed Assistant Executive Director-C of the concerns regarding R1's fall on [DATE] and the facility's failure to provide necessary care and treatment to R1 by not having an RN assess R1 immediately following a fall from bed with a head injury and prior to being transferred off of the floor. Surveyor shared concerns R1 was sent out by private ambulance and not 911 when R1 had a head injury which caused a delay in treatment. Surveyor shared with Assistant Executive Director-C the concern regarding the facility not checking with R1's physician in regard to delaying the CT scan of the head and follow-up with neurosurgery. Surveyor shared concern with lack of communication with the Dialysis Center informing them of R1's subdural hematoma and the missed communication regarding R1's seizure activity during dialysis treatment. There is no evidence the facility responded and followed up on this seizure-like activity and provided monitoring and MD notification for follow up. The facility's failure to ensure an RN assessment was conducted prior to transferring R1 back to bed, the failure of not calling 911 for R1 who had a head injury with bleeding, the postponement of obtaining a CT scan without physician consultation, the lack of communication with dialysis and missed communication of R1 having a seizure, and the lack of monitoring and follow up of R1 having a seizure created a reasonable likelihood for serious harm, thus creating a finding of immediate jeopardy. The immediate jeopardy was removed on [DATE] when: * On [DATE], the facility created a protocol on follow-up appointments that are critical, including that the ordering physician must be notified of appointment changes. Any appointment being rescheduled from the original schedule must have approval from the prescribing physician prior to making the changes. * On [DATE], the facility reviewed the falls policy and created protocol on post resident fall transfers. * All resident falls now require RN assessment prior to resident movement or transfer. * On [DATE], the facility reviewed hemodialysis policy and created communication protocol and processes with dialysis teams to allow for improved communication between facility and dialysis center. * Staff nurse will communicate via communication tool or record in writing to dialysis center including any changes to the residents condition since last treatment. * DON or designee to review all communication sheets prior to scanning into resident digital record. * All nursing staff were trained and educated prior to their next scheduled shift on understanding follow up to critical appointments, communication with the ordering physician on any changes or delays in the original appointment. * All nursing staff were educated on falls protocol and when to transfer a resident post fall. Training included education to report falls to Supervisor or RN. * All nurses were educated on dialysis communication protocol including the introduction of new dialysis communication tool/record. * All nursing staff were education on when to call 911 versus when to utilize private ambulance services. * Audits: - Critical Appointment Rescheduling - nursing staff will show competency of education, DON or nurse designee will audit 10 employees per week for 8 weeks, 10 employees per month for 4 months, 10 employees per quarter for 2 quarters, results will be reviewed with QA meeting for any further recommendations or updates to education or process. - Falls and Post Fall - nursing staff will show a competency of policy and training, DON or nurse designee will audit 10 employees per week for 8 weeks, 10 employees per month for 4 months, 10 employees per quarter for 2 quarters, results will be reviewed with QA meeting for any further recommendations or updates to education or process. - Dialysis Communication Protocol - nurses will show competency in updated protocol, DON or nurse designee will audit 10 employees per week for 8 weeks, 10 employees per month for 4 months, 10 employees per quarter for 2 quarters, results will be reviewed with QA meeting for any further recommendations or updates to education or process. - When to call 911 - nursing staff will show competency in updated protocol, DON or nurse designee will audit 10 employees per week for 8 weeks, 10 employees per month for 4 months, 10 employees per quarter for 2 quarters, results will be reviewed with QA meeting for any further recommendations or updates to education or process. - All audits will be presented in our Quality Assurance Performance Improvement Committee to monitor education provided as well as results of audits on competency and adherence to training received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not provide 2 out of 5 residents (R1 & R8) reviewed for falls with the supervision and assistance necessary to prevent accidents. * R1 was assessed to need 2 staff assistance for transfers and bed mobility. R1 was also assessed to need 2 staff assistance for personal cares due to left sided hemiparesis. On [DATE], Certified Nursing Assistant (CNA)-E was providing incontinence cares to R1, who was in bed, with no other assistant. As R1 was rolled to his left side and CNA-E proceeded to change R1's brief, R1 rolled from the bed, falling to the floor. R1 hit his head on the metal base of the bedside table. CNA- E did not follow R1's care plan by having 2 staff members assist with R1's turning and repositioning in bed while performing incontinence cares. This fall resulted in R1 obtaining a contusion to the forehead which was actively bleeding. R1 was on medication that causes the thinning of R1's blood and it was noted that R1 was bleeding excessively. R1 was sent to the emergency room and was admitted with a diagnosis of a subdural hematoma. R1 received staples and sutures to the forehead and was admitted into the Intensive Care Unit (ICU.) R1 was readmitted into the facility on [DATE]. On [DATE] while removing the sutures, the area appeared infected and R1 was sent to the emergency room and diagnosed with an infection. R1 was placed on an antibiotic and returned to the facility. On [DATE], R1 became unresponsive and was readmitted into the hospital with extensive brain bleed, seizure, and pleural effusion. R1 was placed on comfort care and expired on [DATE]. The facility's failure to provide the necessary assistance as directed in R1's care plan with the use of 2 staff for turning, repositioning, and with personal cares while in bed created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator-A and Assistant Executive Director-C of the immediate jeopardy on [DATE] at 12:45 p.m. The immediate jeopardy was removed on [DATE]. However, the deficient practice continues at a scope/severity of D (potential for harm/ isolated) as the facility continues to implement and monitor its action plan and as evidenced by: * On [DATE], R8 fell in the bathroom when left alone for privacy. R8 did not use the call light for assistance. A fall assessment completed on [DATE] indicated R8 to be at high risk for falls. R8's care plan was updated to re-educate R8 to use the call for assistance however R8's [NAME] was not updated to include instructions for nursing staff on the type of assistance R8 needs when toileted. Additionally, R8's fall care plan included interventions to prevent the potential for injury for any further falls such as the use of a low bed. On [DATE] R8 was observed sleeping in bed. The bed was not in the low position. Findings include: Surveyor reviewed the facility's policy Falls Clinical Protocol revised [DATE], which includes in part the following: Cause Identification: (includes) 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Monitoring and follow-up: (includes) 1. The staff, with the physician's guidance, will follow-up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. a. Delayed complications such as late fractures and major bruising may occur hours or days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. R1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction affecting left dominant side, other nontraumatic intracerebral hemorrhage, epilepsy, type 2 diabetes mellitus with diabetic chronic kidney disease, aphasia, heart disease, end stage renal disease, peripheral vascular disease, and vascular dementia. R1's Fall Risk assessment, dated [DATE], assessed R1 as a high risk for falls. R1's Quarterly MDS (Minimum Data Set) dated [DATE], documents a BIMS (Brief Interview of Mental Status) of 5 indicating R1 is severely cognitively impaired. R1 has an activated POA (Power of Attorney.) R1's functional status for bed mobility, transfers, dressing, and toilet use are all assessed as extensive assist with two + person physical assist. R1's physician orders include Plavix Oral tablet 75mg (milligrams) once daily and Aspirin oral tablet 81mg once daily for anticoagulants and Vimpat tablet 150mg - give 0.5 tablet by mouth two times a day for seizures, order date [DATE]. Plavix is an antiplatelet medication. According to WebMD, Easy bleeding/bruising are side effects of Plavix and persons taking it should take precautions to lower the risk of being cut. https://www.webmd.com/drugs/2/drug-5869/plavix-oral/details R1's care plan dated [DATE] documents R1 as being at risk for injury due to falls due to incontinence, unaware of safety needs, needs assistance with mobility. Interventions include keep bed in low position when R1 is in it to prevent R1 from being injured if R1 rolls out with a start date of [DATE] and fall mat placed at bedside to prevent injury related to fall with a start date of [DATE]. R1's care plan also documents an ADL (activities of daily living) self-care performance deficit due to need for assistance with mobility, stroke, incontinence, dementia, anemia, and ataxia with interventions that include 2 staff members to reposition and turn in bed with a start date of [DATE]. Other interventions include, totally dependent on staff for toileting with a start date of [DATE] and bed to be located against wall at all times, left side of body should be located closest to wall with a start date of [DATE]. R1's CNA [NAME] documents bed mobility: requires 2 staff members to reposition and turn in bed and transferring: requires 2 staff assist with transfers. The Misconduct Incident Report submitted by the facility, dated [DATE], documents on [DATE] at 1:30PM R1 was receiving cares from CNA-E after having a bowel movement. While CNA-E turned R1 on R1's left side R1 rolled off the bed. R1 hit the head on the foot of the bedside table. Nurse assessed R1 and observed a contusion to middle of the forehead. R1 was assisted off the floor by two CNAs with a Hoyer lift and pressure applied to contusion. R1 was sent to the emergency room (ER.) Nurse Practitioner (NP)-F encounter note dated [DATE] documents, Provider was asked to urgently see patient for concerns of head trauma. Per staff, R1 was receiving cares after a bowel movement and rolled off the bed and onto the floor, hitting his head on the bed side table. Lying in bed - wet towel on his head - actively bleeding from wound to center top forehead. Large amount of blood present in his hair and on his pillow. PLAN: Staff instructed to hold pressure and call 911. Needs urgent evaluation of his head - on blood thinners with prior history of VP shunt. Will need imaging to ensure no hemorrhaging. R1 was admitted to the hospital on [DATE]. The hospital admission note dated [DATE] documents, CT of the head was obtained, showing new subdural hematoma along the right tentorium, and along the posterolateral margin of the right temporal lobe. Neuro critical care and neurosurgery teams were contacted. Patient's wife was also contacted. She confirmed Do Not Resuscitate status and did not want any neurosurgical treatments. Decision was made to admit the patient to the ICU at this facility. DDAVP was recommended by critical care, as the patient is on aspirin and on dialysis. R1 was discharged from the hospital on [DATE]. The Hospital Discharge summary dated [DATE] documents under Impression and interventions: Acute traumatic subdural hematoma. History of intraventricular hemorrhage (2017). Seizure disorder. No seizure overnight. Neurosurgical evaluation in 2 weeks, antiplatelet therapies on hold until evaluated as outpatient by Neurosurgery. SC Heparin ok. Repeat CT head prior to outpatient evaluation by Neurosurgery. Surveyors continued review of R1's medical record, which documented in part: R1's daily progress notes regarding R1's staples and sutures do not include any documentation of any redness, drainage, or signs of infection from [DATE] through [DATE]. Surveyor noted a Physician order to remove 2 staples and 5 sutures to forehead dated [DATE]. NP-F Encounter note dated [DATE] documents, The provider was called to the patient's room to evaluate him as the nurse was removing his staples and sutures and noted what appeared to be pus coming from his head wound .The wound has started to dehisce again and is bleeding. Wound edges are red, extending into the surrounding tissue. The wound has also started to swell again. The wound was irrigated with normal saline and purulent drainage was noted as well .Follows with Wound MD in house. Plan: send to ER (emergency room) for evaluation and treatment. Wound appears to be infected and has now started to dehisce. Needs evaluation from MD as well as possible imaging. R1's After Visit summary from the ER, dated [DATE], documents a diagnosis of infected wound and doxycycline (antibiotic) was started. R1 returned back to the facility. R1's Progress Note dated [DATE] at 17:44 (5:44 PM) documents, Writer was called into this room and noted this PT (patient) to be unresponsive .911 called and NP updated about sending this PT out to the ER. Progress Note dated [DATE] at 22:18 (10:18 PM) documents .updated about this PT who was admitted (to hospital) with an extensive brain bleed, midline shift of about 6mm, pleural effusion and seizure. PT is on comfort care there and will either stay there to pass or family will take him home from there to pass. R1 expired on [DATE]. On [DATE] at 11:32 AM, Surveyor interviewed CNA-E who stated R1 rolled off the bed during cares and hit his head on the foot of the bedside table. CNA-E stated R1 was bleeding from the forehead. CNA-E stated she panicked and left the room to find help. CNA-E reported she found another CNA who helped her transfer R1 off the floor and back into bed with the Hoyer lift. When R1 was in bed CNA-E then went to get a nurse. CNA-E stated a Registered Nurse (RN) and Licensed Practical Nurse (LPN) came to assess R1. R1 was actively bleeding from the middle of the forehead so CNA-E held pressure on the injury. The nurse then contacted the Nurse Practitioner in the building to come and assess. CNA-E explained she was trained R1 was a one person assist for ADL cares. She was not aware R1 required two-person physical assist. CNA-E explained she recently was retrained for several days and she is now aware R1 was a two person assist. On [DATE] at 12:00 PM, Surveyor interviewed the Assistant Executive Director-C regarding R1's fall. Assistant Executive Director-C informed Surveyor R1 was a 2 person transfer at the time of the fall and that CNAs have access to resident information on the [NAME] on tablets and staff can ask a nurse if they have any questions. Assistant Executive Director-C explained CNA-E was recently hired at the facility in [DATE] and received Relias training and shadowing with another seasoned CNA for 2 shifts prior to working independently with residents. Assistant Executive Director-C stated when they were made aware of R1's fall, after investigating they felt it would be best to give CNA-E, 6 additional shifts to train with a seasoned staff. Assistant Executive Director-C explained CNA-E was retrained on safe patient handling and resident centered cared. Retraining occurred [DATE] through [DATE]. Surveyor asked if retraining occurred with all staff and Assistant Executive Director-C stated they had only focused retraining CNA-E. Surveyor asked Assistant Executive Director-C if there is a system in place to monitor staff following resident care plans. Assistant Executive Director-C said no. Assistant Executive Director-C reported training of staff and following care plans are not a topic reviewed at Quality Assurance and Performance Improvement at meetings at this time. On [DATE], at 11:35 AM, Surveyor informed Assistant Executive Director-C of the concerns regarding R1's fall on [DATE]. CNA-E was not following R1's care plan to prevent the fall from occurring, which caused R1 to sustain a subdural hematoma. The facility did not complete a thorough investigation of the fall to determine all the facts and training of all staff was not included as part of their follow up. The facility's failure to follow R1's care plan and provide the necessary assistance with bed mobility during incontinence care lead to a fall with injury (subdural hematoma,) creating a finding of immediate jeopardy. The immediate jeopardy was removed on [DATE] when: * The facility reviewed the care plan policy and created a protocol with education for how to access care plans on various devices in the facility within the electronic medical record. * The facility updated fall assessments for each resident in the facility. * Initiated a facility wide audit of all resident care plans to ensure each resident has a comprehensive ADL care plan with complete interventions. Conducted audits to review care plans and to ensure care plans reflect current fall risks as well as interventions. Audits to begin on [DATE]. Identified resident's care plan was updated on [DATE] with current ADL needs. The Director of Nursing (DON) or designee will complete the audit. The Regional Clinical Director will verify the audit for completeness. Audits completed by [DATE]. * All nursing staff will be trained prior to the beginning of their next scheduled shift on care plans, understanding care plans and how to access care plans and [NAME]'s. All Nursing staff will be re-educated on use of care cares and where to find updates and changes to the resident's [NAME]. The DON or designee will re-educate. Education will begin [DATE] and will be completed before the start of their next shift. * Facility implemented shift huddles including nurses and CNAs to identify and communicate care plan changes to CNA staff on their respective assignments. * All care plan changes will be listed on Nursing 24 hour board for communication. Nurse leaders will communicate care plan updates through the nursing 24 hour communication board. Certified nursing Assistants and Nurses will be responsible for reviewing and initialing the 24 hour communication board prior to the beginning of each shift. This new process will be initiated on [DATE] and an audit will begin on [DATE]. Administrator or designee will audit daily to ensure each staff member is reviewing and singing the 24 hour communication board. * Care plans nursing staff will show competency in resident care plans and show competency with accessing care plans in real time, DON or nurse designee will audit 10 employees per week for 8 weeks, 10 employees per month for 4 months, 10 employees per quarter for 2 quarters, results will be reviewed with QA meeting for any further recommendations or updates to education or process. * All audits will be presented in the Quality Assurance Performance Improvement Committee to monitor education provided as well as results of audits on competency and adherence to training received. The deficient practice continues at a scope and severity level of D (potential for harm/isolated) as evidenced by: 2. Surveyor reviewed the facility's Comprehensive Care Plans policy and procedure implemented on [DATE] as it pertains to updating care plans with any resident changes: .Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan of each Resident, consistent with Resident rights, that includes measurable objectives and timeframes to meet a Resident's medical, nursing, and mental and psychosocial needs are identified in the Resident's comprehensive assessment. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . R8 was admitted to the facility on [DATE] with diagnoses of Burns involving 10-19% of body surface with third degree burns, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Need for Assistance with Personal Care, Transient Cerebral Ishemic Attack, Peripheral Vascular Disease, Chronic Kidney Disease, Stage 4, Absence of Right Great Toe, Major Depressive Disorder, and Unspecified Mood Disorder. R8 is his own person. R8's admission Minimum Data Set (MDS) dated [DATE] documents R8's Brief Interview for Mental Status (BIMS) score is 13, indicating R8 is cognitively intact for daily decision making. R8's MDS also documents that R8 requires limited assistance for bed mobility, extensive assistance for transfers of 2, and extensive assistance for toileting of 1. R8 has range of motion impairment on one side of lower extremity. R8's MDS states R8 is only able to stabilize with staff assistance for walking/moving from seated to standing. Surveyor reviewed R8's admission Care Area Assessment (CAA) signed [DATE] which documents R8 is at risk for falls due to history of falls, weakness, impaired mobility, and gait. Surveyor reviewed R8's electronic medical record (EMR) and notes R8 does not have an admission fall assessment completed. On [DATE] at 3:30 PM, Administrator (NHA)-A confirmed fall assessments should be done at time of admission on all residents. Surveyor was provided R8's [NAME] on [DATE], a tool nursing staff utilizes to be informed of how to care for R8 and notes the following for: Safety -Be sure call light is within reach when R8 is in room and encourage R8 to use it before attempting to transfer -Ensure R8 has unobstructed path to bathroom -Ensure appropriate footwear when out of bed -Keep bed in low position when R8 is in to prevent R8 from rolling out and being injured -Make sure floor/path is clutter free and properly lighted -Re-education on use of call light-verbalized and demonstrated understanding Toileting -ADL: Toilet Use On [DATE] at 9:55 AM, Surveyor interviewed Interim Director of Nursing (IDON)-D in regards to what ADL: Toilet Use means on R8's [NAME]. IDON-D stated, It means that it is not filled out. IDON-D agreed that a CNA or nurse would not know how to care for R8's toileting needs. IDON-D indicated it is not clear if R8 can be left alone in the bathroom or not. Surveyor reviewed R8's comprehensive care plan for falls and activities of daily living (ADLs) (toileting specific) and noted the following: 1. R8 has an ADL Self Care Performance Deficit-initiated [DATE] -Toileting: R8 is a stand pivot transfer from the wheelchair to the toilet. R8 utilizes a 2 wheeled walker, gait belt, and assist of 1 for toilet transfers Initiated [DATE] -Toilet Use: R8 needs extensive assistance from staff for toileting/incontinence care. Initiated [DATE] On [DATE] at 9:55 AM, IDON-D stated that 'extensive assistance' means that R8 requires physical help from staff to get on and off the toilet. IDON- D agreed that as of [DATE], it is unclear based on R8's comprehensive care plan whether R8 requires extensive assistance of 1 or 2 staff. IDON- D stated that R8's care plan had been revised on [DATE] after Surveyor left the facility. Care plan includes: 2. R8 is at risk for injury due to falls due to gait/balance problems, incontinence, psychoactive drug use, unaware of safety needs-initiated [DATE] -Encourage to be in common areas when awake-Initiated [DATE] -Re-education on use of call light-verbalized and demonstrated understanding-Initiated [DATE] -Be sure call is within reach when in room and encourage to use it before attempting transfer-Initiated [DATE] -Need activities that minimize the potential for falls while providing diversion and distraction-Initiated [DATE] -Encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility as tolerated-Initiated [DATE] -Ensure wearing appropriate footwear when out of bed-Initiated [DATE], Revised [DATE] -Make sure floor/path is clutter free and properly lighted-Initiated [DATE], Revised [DATE] -Keep bed in low position when in it to prevent me from rolling out and being injured-Initiated [DATE] and RESOLVED on [DATE] On [DATE] at 6:40 PM, R8 had a fall in the bathroom and did not sustain an injury. R8 was assisted to the toilet by a CNA. R8 requested privacy for a few minutes so CNA left R8 alone and informed R8 to pull the cord or call out for assistance and went to the room next door to assist another resident. A loud bang was heard and CNA immediately went to check on R8 and observed R8 on the floor. It is documented that R8 did not use the cord. Surveyor notes that a registered nurse (RN) assessment was completed, and then R8 was mechanically lifted from the ground. Neuro-checks were completed as well as physician and family notification. A fall assessment was completed on [DATE] at 7:30 PM for R8 which documents a score of 17, indicating R8 is high risk for falls. Surveyor notes that R8's comprehensive care plan was updated to re-educate R8 to use the call for assistance, however, R8's [NAME] which instructs nursing staff on what type of assistance R8 requires for toileting was not updated. On [DATE] at 8:05 AM, Surveyor observed R8 in bed sleeping, and the bed is in the regular position and was not in low position as indicated in R8's fall care plan dated [DATE]. On [DATE] at 8:17 AM, Surveyor observed Occupational Therapist (OT) I enter R8's room. Surveyor asked OT I if R8's bed was in the low position. OT I stated it did not look like it was and then said, Why? Is that on the care plan? OT I then demonstrated for Surveyor that R8's bed was not in the low position and stated, I would have to say the bed was not in the low position. On [DATE] at 8:40 AM, Surveyor spoke to Medication Tech (MT)-J who also floats as a Certified Nursing Assistant (CNA) when needed. On this day, MT-J was assigned to R8 as a CNA. MT-J stated that MT-J's initial rounds when coming on shift is just to make sure all MT-J's Residents are breathing. MT-J stated this morning, MT-J just put an eye on R8. MT-J indicated that MT-J knew R8 was to be in a low bed, observed R8's bed to not be in the low position, however, confirmed that MT-J did not put the bed in low position upon observation. MT-J stated, It was a snafu that I did not check the bed. MT-J informed Surveyor that MT-J did not check R8's [NAME] prior to going into the room to review R8's care instructions. MT-J stated R8 is extensive assistance for toileting, which means giving R8 time in the bathroom and assisting R8 on and off the toilet. MT-J would step out of the room to go get supplies. MT-J does attend the 'huddle' in between shifts and sometimes checks the 24 hour board for any changes. On [DATE] at 9:55 AM, Surveyor spoke to IDON-D in regard to R8's bed not being in the low position. IDON-D confirmed that R8's [NAME] and comprehensive care plan document R8 should be in a low bed, and if that is what is documented then the expectation would be that when R8 is in bed, the bed should be in the low position. IDON-D understands the concern. On [DATE] at 10:24 AM, Surveyor shared the concern with NHA-A and Assistant Executive Director (AED)-C that R8's [NAME] documented R8 is to be in a low bed for safety to prevent injury and this was not followed by MT-J. Surveyor also shared that R8's [NAME] was not updated with care instructions after R8's [DATE] fall in the bathroom. Both NHA-A and AED-C understood the concerns and provided no further information at this time. On [DATE] at 2:48 PM, AED-C acknowledged that R8's intervention of a low bed was added on [DATE], 11 days after admission, but nobody from the clinical team is able to provide a reason why the intervention was added and then resolved today after Surveyor informed the facility of R8's bed being in the regular position.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that residents were free from abuse for 2 of 2 (R58 and R237) residents reviewed for sexual abuse. In addition, the facility did not provide a safe resident environment to protect other residents from abuse. On 6/2/22, R237 reported an allegation of sexual abuse. The facility did not assess R237, did not investigate what occurred, did not implement increased monitoring of the accused R41, did not revised the accused R41's care plan to put measures in place to prevent further abuse. On 6/11/22, R58 was involved in an incident of sexual abuse by R41. When staff notified R58's family, they asked to have a psychologist talk to R58 due to a history of abuse. The facility did not thoroughly investigate this incident of sexual abuse. The facility placed R41 on 15 minute checks which were not consistently implemented. R41 wheels himself about the facility and staff on different units were not aware of R41 needing supervision. Although not a smoker, R41 goes outside to sit on the patio which is not supervised. In addition, Surveyor was informed R41 had a room change as a result of this incident however; R41 was noted to be residing in the same room. The facility did not implement interventions to protect residents from abuse. The facility's failure to keep residents free from sexual abuse due to the facility's inaction after each incident, such as not reporting, not investigating, not assessing and not putting interventions in place to prevent further abuse placed female residents at risk for further abuse and created a situation of immediate jeopardy beginning on 6/2/22. Administrator A was notified of the immediate jeopardy on 8/11/22 at approximately 12:00 PM. The immediate jeopardy was removed on 8/19/22; however, the deficient practice continues at a scope and severity level of E (potential for harm/pattern) as the facility continues to implement and monitor its action plan. Findings include: The Facility policy titled: Abuse, Neglect and Exploitation revised 7/2022 documents (in part) . .Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect exploitation and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual Abuse is non-consensual sexual contact of any type with a resident. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting and kicking. It also includes controlling behavior through corporal punishment. Mental abuse includes, but is not limited to humiliation, harassment, threats of punishment or deprivation. Neglect means failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Mistreatment means inappropriate treatment or exploitation of a resident. III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as the identify when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. F. Providing residents, representatives and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 5. Focusing the investigation on determining if abuse, neglect, exploitation and/or mistreatment has occurred, the extent, and cause, and; 6. Providing complete and thorough documentation of the investigation. VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation. B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during during and after the investigation, as needed. VII. Reporting/Response 1. Reporting of alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal; 4. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect occurred and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and/or improved to protect residents receiving services; c. Training of staff on changes made and demonstration of staff competency after training is implemented; d. Identification of staff responsible for implementation of corrective actions; e. The expected date for implementation; and f. Identification of staff responsible for monitoring the implementation of the plan. R41 was involved in 2 alleged sexual abouse allegations with the first incident occurring on 6/2/22 involving R237 and a second incident occurring on 6/11/22 involving R58. R41 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's Disease and Dementia. R41's Annual Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 11 indicating moderate cognitive impairment for daily decision making skills. R41's daughter was Power of Attorney (POA) until an Incapacity assessment dated [DATE] recommendations documented: De-activate POA for Healthcare. Is able to evaluate information well enough to give informed consent. R41's Annual Minimum Data Set (MDS) dated [DATE] section E0200: Behavioral Symptoms - Presence & Frequency documents: A. Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) - 0. Behavior not exhibited R237 admitted to the facility on [DATE] and discharged on 6/30/22. Diagnoses included: Attention Deficit Hyperactivity Disorder, Dementia, Major Depressive Disorder and Rheumatoid Arthritis. R237's BIMS dated 6/23/22 documented a score of 13 - indicating R237 as cognitively intact for daily decision making skills. R58 admitted to the facility on [DATE] and has diagnoses that include: Schizophrenia, Major Depressive Disorder and Anxiety Disorder. R58's Quarterly MDS dated [DATE] documents a BIMS score of 15 - indicating cognitively intact for daily decision making skills. During review of a Facility Reported Incident dated 6/11/22 (which involved R41), Surveyor located progress notes entered on 6/4/22, which documented the Nurse Practitioner was called to inform about accusations against R41. Surveyor asked Director of Nursing (DON)-B about the progress notes on 6/4/22 which documented accusations against R41 and monitoring closely due to accusations. Surveyor asked DON-B if R41 had previous incidents of sexual abuse. DON-B stated, Well, there was one time when he touched or rubbed another female residents' arm. Surveyor asked what accusation the progress notes on 6/4/22 was referring to. DON-B reported he did not know, but will find out. No additional information was provided by DON-B. Nursing Home Administrator (NHA)-A provided Surveyor with a Facility Reported Incident dated 6/4/22. This Facility Reported Incident included the following; Clinical Care Manager (CCM)-K statement dated 6/4/22 documents, On 6/2/22 (R237) reported to me that a male resident kissed her on the cheek. R237 did not know who the resident was and reported it did not really bother her. Surveyor noted CCM-K did not get a full statement from R237 about what had occurred and did not follow up or investigate the allegation regarding R237 allegedly reporting being kissed on the cheek. On 6/3/22 when CCM-K was leaving the building, R237 informed CCM-K she knew who the resident was. CCM-K stated: OK, you could let me know when I return. Surveyor noted although R237 informed CCM-K she could identify the resident involved in the alleged sexual abuse, CCM-K did not follow up or investigate the allegation. On 6/4/22 CCM-K received a call from the Registered Nurse (RN) stating that R237 is telling them that the man touched her nightgown that day (6/2/22) also. CCM-K interviewed R237 on the phone and R237 stated R41 came into her room, lifted her nightgown and pointed at her private area and gestured for her to move her leg. R237 reported he lifted up the night gown, pointed at her private area, smiled and said me and you like he wanted sex. He kissed her cheek and she told him no way and to go away. CCM-K's statement further documented DON-B was notified and she was directed to tell the RN to do the follow-up. There was no evidence an assessment was completed on R237 to determine her ability to consent. Surveyor noted there was no follow up or thorough investigation related to the allegation of sexual abuse involving R237 and R41. R41 does not have a care plan related to sexual behaviors. There was no evidence of increased monitoring of R41. There was no psychiatric or psychotherapy interventions to determine the possible cause of R41's behavior. There was no evidence the facility implemented any interventions following the incident on 6/2/22 to keep R237 and other residents safe, placing other residents in the facility at risk for sexual abuse. Nine days later, on 6/11/22, another incident of sexual abuse occurred, this time between R41 and a different female resident (R58). Graduate Practical Nurse (GPN)-E's statement documented she was walking down the hall and noticed R58 sitting on the couch. R41 was sitting behind R58 with his hand in the back of her brief near her butt. GPN-E told R41 to take his hand out R58's pants. The residents were separated and went back to their rooms. R58 was asked if she was OK and she reported yes, he was just rubbing my back. GPN-E reported the incident to the Supervisor. Surveyor was unable to locate evidence an interview was completed with R58 following the incident. There was no assessment of R58 to determine her ability to consent. On 8/8/22 at 1:30 PM Surveyor asked DON-B if he had any additional information regarding the investigation and incident between R41 and R58. DON-B reported he did not have any additional information. Surveyor advised the investigation did not include an interview with R58, and asked if there were any other staff or resident interviews. DON-B stated, I guess there isn't. On 8/7/22 at 2:19 PM Surveyor spoke with R58 in her room about the incident involving R41. R58 reported she was in the TV room and R41 placed his right hand near her groin (demonstrating with her right hand). Surveyor asked if R41's hand was on the inside or outside of her pants, to which she stated, Inside. R58 reported she did not ask R41 to put his hand in her pants, but did not tell him no, and did not stop him. R58 reported she let him do it for awhile, then told him to stop after a couple minutes. Surveyor asked if this bothered her, R58 replied, No. It's fine. I'm a grown woman. On 8/9/22 NHA-A provided an interview with R58 dated 6/11/22. Licensed Practical Nurse (LPN)-N statement documented, On 6/11/22 at roughly 3 :00 PM, she interviewed R58. R58 was asked how she was feeling, which she reported fine. She was asked about the interaction with R41. R58 reported he started to rub her shoulders and back, she liked it and it felt good. She did not ask him to do this. She stated he was touching inside the front of her pants. She reported she was not sad, upset or scared. LPN-N reassured her she did nothing wrong, and she was safe. Registered Nurse (RN)-O statement dated 6/11/22 documented he spoke to DON-B and was informed to keep the residents separated and start 15 minute checks for R41. RN-O called R58's son and daughter-in-law. Family in agreement but added that resident (R58) has had similar issues in her past and they would like to have psychologist talk with resident during the next visit to the facility. R58's Psychiatric consult dated 7/8/22 documents (in part) .resident states doing good, feels mental health is stable, does not want medications adjusted. Denies auditory or visual hallucinations. Surveyor noted there was no mention of the sexual abuse incident between R58 and R41. After reviewing the 6/11/22 Facility Reported Incident, Surveyor spoke with DON-B who stated, Staff was there and said they were both being flirty with each other. Surveyor located no documentation in the facility self report or staff statements to support this statement. DON-B reported staff intervened when it turned to inappropriate touching. Surveyor asked DON-B if he interviewed the residents involved. DON-B stared at Surveyor and did not answer. After a long pause, DON-B reported he would look to see if there was any more information somewhere else. Surveyor asked if R41 speaks English. DON-B reported he does speak English, but has some cognitive deficits. Surveyor asked DON-B what was done after the incident. DON-B reported R41 was moved to another unit and 15 minute checks were initiated. Surveyor noted the facility made no revisions to R41's care plan following either sexual abuse incident on 6/2/22 or 6/11/22. R41 has no care plan interventions related to sexually inappropriate behavior, and no care plan about 15 minute checks or increased monitoring. R41's Certified Nursing Assistant (CNA) care card did not include documentation of behaviors or increased monitoring. CNA behavior charting included a standard template which included a column sexually inappropriate which Surveyor noted included no check marks for the past 30 days. There was no documentation of any further inappropriate sexual behavior or wandering into other resident rooms since the last incident on 6/11/22. DON-B reported R41 transferred rooms after the incident on 6/11/22. Surveyor's review of R41's census revealed R41 has resided in the same room (on Skylight East) since November 2021 and was not moved as DON-B reported. In addition, 15 minute checks were not consistently completed. Surveyor's review of documentation revealed 15 minute check forms missing for 6/21/22, 6/28/22, 6/29/22, 6/30/22, 7/18/22, 7/22/22 and 7/25/22. Surveyor reviewed 5 random 15 minute check forms for R41 which revealed incomplete documentation, indicating monitoring of R41 was not consistently completed: Time started at midnight through 11:45 PM: 6/16/22 - blank/no entry of monitoring for the hours of 7:30 AM - 2:45 PM. 6/22/22 - blank/no entry of monitoring for the hours of Midnight - 6:15 AM or 3:15 PM - 11:45 PM. 6/27/22 - blank/no entry of monitoring for the hours of Midnight - 6:15 AM or 3:15 PM - 11:45 PM. 7/9/22 - blank/no entry of monitoring for the hours of Midnight - 2:30 PM. 7/23/22 - blank/no entry of monitoring for the hours of 6:45 AM - 2:45 PM. On 8/8/22 at 11:10 AM Surveyor spoke with Certified Medication Aid (CMA)-D who works on Skylight north (back of building where R41 resides). CMA-D reported she is familiar with R41. She reported R41 is on 15 minute checks and stated, We all know if he's up and around in his wheelchair to keep eye on him, he can be a little grabby with women. On 8/8/22 at 11:23 AM Surveyor spoke with Graduate Practical Nurse (GPN)-E who works on R58's unit. GPN-E reported she is familiar with R41 and who stated, Oh yes, I am very aware of (R41), he's on 15 minute checks. Surveyor asked if this is documented anywhere. GPN-E stated, Not really, pretty much everyone knows to keep eye when he is tooling around in his wheelchair. Surveyor asked GPN-E if she knew why R41 was to be monitored, to which she replied, He's had some incidents with some of the female residents. When asked what type of incidents, GPN-E stated, Touching them. On 8/8/22 at 11: 35 AM Surveyor spoke with RN-F who works on the Heritage unit (front of building near entrance). RN-F reported she knows who R41 is stating, I know he wheels himself around in the wheelchair. RN-F reported R41 does come to the front of the facility, on the Heritage unit, and she sometimes sees him go outside to sit. Surveyor asked RN-F if she has been informed of anything else regarding R41 such as increased monitoring, to which she replied, No. Surveyor had observations of R41 sitting alone outside near the front entrance of the facility while on Survey. On 8/10/22 at 2:11 PM Surveyor spoke with the Social Service Director (SSD)-C and asked what she could tell about the incident on 6/11/22 involving R41 and R58. SSD-C stated, Well, I know he tried to kiss her, and that's about it. SSD-C denied knowing anything else about the incident and reported DON-B was more involved. Surveyor asked SSD-C about the statement from R58's family that she has had similar issues in her past and they would like to have psychologist talk with her. Surveyor asked if she knew what issues the family was referring to. SSD-C stated, No, but maybe it has to do with her ex-husband taking advantage of her. When asked what she meant, SSD-C stated, Her sister-in-law told me her ex-husband took advantage of her sexually and she did not want her ex-husband to be allowed to take her out of the facility. SSD-C reported this conversation occurred after R58 was admitted to the facility and before the sexual incident between R58 and R41. The facility was aware of R58's history of sexual abuse and the care plan was not revised to include information or interventions related to her previous sexual abuse. The facility was aware of the allegation of sexual abuse that occurred between R41 and R237 on 6/2/22. The facility did not complete a thorough investigation of the allegation and no interventions were implemented to keep R237 and other residents safe. Nine days later a second incident involving sexual abuse occurred this time between R41 and R58, with R58 having a history of sexual abuse by her ex-husband. The facility did not complete a thorough investigation and appropriate interventions were not implemented to keep R58 and other residents safe. R41 is mobile throughout the facility and staff on other units are not aware of his sexual behavior and increased monitoring, placing other vulnerable residents at risk. Neither R237 nor R58 appeared overly distressed or upset by what had occurred. R58 even stated that it didn't bother her - she was a grown woman. It should be noted, however, given R58's history of sexual abuse, that she may have been used to being used and abused and that this was a familiar pattern to her to which she was accustomed. Her reaction was markedly incongruent to what a reasonable person might experience. Using the reasonable person concept, R58 or any other resident who is sexually abused could feel Recurrent (i.e., more than isolated or fleeting) debilitating fear/anxiety that may be manifested as panic, immobilization, screaming, and/or extremely aggressive or agitated behavior(s) (e.g., trembling, cowering) in response to an identifiable situation (e.g., approach of a specific staff member). A person who has been sexually assaulted could also experience Ongoing, persistent expression of dehumanization or humiliation in response to an identifiable situation . The failure of the facility to keep residents free from sexual abuse due to the facility's inaction after each incident, such as not reporting, not investigating, not assessing and not putting interventions in place to prevent further abuse placed female residents at risk for further abuse. This created a reasonable likelihood for serious harm and, thus, created a finding of immediate jeopardy beginning on 6/2/22. The immediate jeopardy was removed on 8/19/22 when the facility: Medication reviews were conducted, psych evaluations conducted and the Medical Doctor reviewed the residents identified in this deficiency. Education Policy and procedural updates were completed and non-Pharmacological Interventions identified for clinical staff. Staffing changes were made to protect the residents from the alleged perpetrator. Per policy on Abuse, Neglect, and Exploitation increased supervision was provided for the perpetrator. A policy for Sexual Expression for residents was developed, brought through the Quality Assurance Program Improvement (QAPI), implemented and educated on. Staff were educated on the policy for Sexual Expression of Residents as well as abuse, neglect and exploitation, and compliance with reporting allegations of abuse/neglect/exploitation. Social Service, ADON, Unit Managers, Administrator and Associate Administrator received training trained on Sexuality and Intimacy in Long Term Care. Assessments were completed for all residents using sexual expression assessment. A care conference will be held for residents following the display of sexual expression where it will be determined the capacity of consent and review of solution that best meets the needs of and the protection of those involved. Care plan audit were conducted for residents identified through sexual expression assessment with updates as needed. Cardex Updates were completed for all residents identified through sexual expression assessment. Residents displaying inappropriate sexual behaviors will be referred for a psychologist consult. Any state reported incident will be evaluated through the RISK process as well as APIA. APIA will review residents who triggered sexual expression assessment with the Medical Director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility did not ensure 3 (R56, R12 and R71) of 3 residents received adequate supervision by staff to prevent accidents *R56 is severely cognitively impaired and was identified to be at high risk for elopement. R56 eloped from the facility on 5/31/22 after a staff person disabled the wanderguard alarm because of the number of times R56 had set it off. R56 was found approximately 1 mile from the facility without proper footwear in rainy weather. Staff was not aware that R56 had left the building for approximately 75 minutes before they noticed her missing and local law enforcement. The facility's failure to ensure a door alarm was activated to alert staff if a resident with a Wanderguard bracelet attempted to leave out the door, the failure to have a care planned approach to monitor/supervise R56's whereabouts, the failure to know of R56's whereabouts and to conduct a thorough investigation into the elopement created a condition of an immediate jeopardy starting on 5/31/22. The immediate jeopardy began on 5/31/22. NHA (Nursing Home Administrator)-A was notified of the immediate jeopardy on 8/11/22 at 12:00 PM. The immediate jeopardy was removed on 8/19/22. The deficient practice continues at a scope and severity level of E (potential for harm/pattern) as the facility continues to implement and monitor the effectiveness of their removal plan and as evidenced by the following noncompliance for R12 and R71. * The facility did not conduct a through investigation when facility staff spilled a hot beverage on R12's lap. * R71 was admitted with a fractured neck following a fall at assisted living and wears a cervical collar. R71 fell 15 times in 4.5 months following admission. The facility did not conduct through investigations of R71's falls including a root cause analysis and did not revise R71's care plan to reduce the risk of further falls and injury. Findings include: 1. R56 was admitted to the facility on [DATE] with diagnoses of subdural hemorrhage, metabolic encephalopathy and dementia without behavioral disturbance. R56's admission MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 03, indicating R56 is severely impaired for daily decision making skills. R56's admission MDS indicates resident requires supervision to limited assistance with activities of daily living including transfers and ambulation. Resident's gait is coded as not stable but able to stabilize without staff assistance. R56 does not require the use of mobility devices. R56's admission MDS indicates R56 exhibits wandering behavior on a daily basis. An Elopement assessment dated [DATE] indicates R56 is at risk for elopement. R56's comprehensive care plan dated 5/24/22 indicates resident is at risk for falls and includes intervention of wearing proper footwear when out of bed. R56's comprehensive care plan dated 3/28/22 indicates R56 is at risk for elopement due to attempts to leave facility. Interventions include; Redirection of [R56] from exit doors, Distract from wandering with pleasant diversion including offering activities and snacks, and Placement of Wanderguard bracelet to the left ankle. R56's Wanderguard is to be checked for placement every shift and checked for function on night shift by nursing staff. This is being documented by nursing staff on the R56's MAR (Medication Administration Record). Surveyor reviewed R56's medical record. Surveyor noted a Facility self report dated 6/7/22. The facility's self report indicates on 5/31/22 at 10:23 PM, R56 was found to be missing by facility staff. ADON (Assistant Director of Nursing)-H via phone directed nursing staff to initiate a missing resident code at the facility and to call local law enforcement. ADON-H notified DON (Director of Nursing)-B. NHA (Nursing Home Administrator)-A was notified of missing resident via phone. Per Police report, officers arrived at the facility on 5/31/22 at approximately 10:34 PM. Facility staff showed police officers the facility's wandering book which included photos of R56. On 5/31/22 at approximately 10:37 PM, Police were called to investigate a suspicious person from a concerned citizen in the community. Officers found R56 approximately 1 mile from the facility wearing a hooded sweatshirt, pants and stocking feet with no shoes. Police returned R56 to the facility on 5/31/22 at approximately 11:00 PM. A head to toe assessment was conducted upon resident's return which found resident to be without injury. Residents pants and socks were notably soiled with mud as it had been raining off and on during the evening of 5/31/22. Surveyor noted the National Weather Service indicated that the lowest recorded temperature on 5/31/22 was 57 degrees Fahrenheit. Surveyor could not confirm through documentation or interviews conducted by facility staff that R56 had been seen on 5/31/22 after 6:30 PM. On 8/10/22 at 4:00 PM, Surveyor met with NHA-A to discuss R56's elopement and elopement investigation. Surveyor asked NHA-A if the facility has cameras for surveillance. NHA-A informed Surveyor on 5/31/22 an agency nurse presumably became annoyed with the number of times R56 set off the Wanderguard alarm to the doorway at the end of the hall, and she turned off the alarm. NHA-A reported they had video footage of a former agency nurse, who is no longer employed by the facility, disabling the skylight north exit doors code alert system, leaving the exit without an engaged alarm. Surveyor noted there were 4 residents with Wanderguard bracelets on this unit; all would have had the opportunity to leave out the unalarmed door at the end of the unit. Surveyor asked NHA-A if they had conducted interviews of facility staff who worked on 5/31/22 in relation to R56's elopement. NHA-A told Surveyor that it hadn't occurred to him to interview staff because of the video footage of the individual eloping through the Skylight North exit door. NHA-A reported R56 was in the facility until approximately 9:15 PM when there was footage of an individual exiting through the Skylight North exit door. Surveyor asked how it was confirmed that the exiting individual was R56. NHA-A told Surveyor that it was difficult to see the camera footage due to condensation on the camera lens from rain. NHA-A indicated at 10:30 PM staff noticed R56 was missing and were unable to find him in the building. The LPN called ADON-H who instructed LPN to initiate a code and to call local law enforcement. Police arrived at 10:34 PM. Police responded to a call placed by a concerned citizen and located R56. The police returned R56 to the facility on 5/31/22 at about 11:00 PM. R56 was not injured. On 8/10/22 at 10:05 AM, Surveyor interviewed Maintenance Director-U. Surveyor asked Maintenance Director-U who is responsible for checking the functionality of the facility's code alert system. Maintenance Director-U informed surveyor that they had not been checking the facility's exit doors for code alert functioning until 8/8/22. Maintenance Director-U informed surveyor that they are planning to check exit doors for code alert system every Monday, Wednesday, and Friday. On 8/10/22 at 1:35 PM, Clinical Care Manager-K was interviewed by Surveyor. Surveyor asked Clinical Care Manager-K how nursing staff would know how to identify a resident who is at risk for elopement. Clinical Care Manager-K told Surveyor that residents who wander would be listed in the facility's wander books, which are available at the main entrance, activity department, maintenance department, kitchen and nursing station. The wander books include resident photos, demographic information and location of their Wanderguard devices. Surveyor asked Clinical Care Manager-K how often a resident who is at risk for elopement should be checked on by staff. Clinical Care Manager-K told Surveyor that if a resident is at risk for elopement that they should be checked on frequently. Surveyor asked Clinical Care Manager-K to define what frequently would mean to them. Clinical Care Manager-K told Surveyor that they would expect a resident at risk for elopement to be checked on about every 15 minutes. On 8/10/22 at 3:20 PM, Surveyor conducted an interview with ADON-H. Surveyor asked ADON-H how nursing staff would know how to identify a resident who is at risk for elopement. ADON-H told Surveyor that residents who wander would be listed in the facility's wander books. Surveyor asked ADON-H how often a resident who is at risk for elopement should be checked on by staff. ADON-H K told Surveyor that if a resident is at risk for elopement that they should be checked on at least every half hour. Surveyor asked ADON-H what they had recalled about R56's elopement on 5/31/22. ADON-H told Surveyor that they had not been in the building at the time of R56's elopement but received a call from facility staff asking for direction. ADON-H had spoken to a nurse who is no longer is employed by the facility and directed them to initiate a wandering code at the facility and to call the police. ADON-H then notified DON-B. ADON-H did not have any further involvement related to R56's elopement investigation. Surveyor asked NHA-A how often the code alert system should be checked for functioning. NHA-A says that they would like the system checked daily but knows that it has not recently been checked daily due to changes in maintenance staff. NHA-A told surveyor that they are in negotiations to upgrade the code alert system at this time as their system is antiquated. Surveyor shared concerns related to R56's elopement on 5/31/22 related to the facility's inability to identify when R56 was last checked on and staff disabling the facility's door alarm system allowing for R56 to elope without the door alarm sounding. R56 wandered approximately 1 mile from the facility while raining without appropriate footwear. This facility is also located on a high traffic state highway. R56's elopement care plan was not updated after R56's elopement on 5/31/22, which causes continued concern for R56's safety. The facility's failure to ensure a door alarm was activated to alert staff if a resident with a Wanderguard bracelet attempted to leave out the door, the failure to have a care planned approach to monitor/supervise R56's whereabouts, the failure to know of R56's whereabouts, and the failure to conduct a thorough investigation into the elopement created a reasonable likelihood for serious harm given R56's cognitive status and the facts that R56 was outside at night in rainy conditions. This led to a finding of immediate jeopardy starting on 5/31/22. The IJ was removed on 8/18/22 when; ~ Assessments were conducted for all residents identified to be at risk for wandering. ~ Orders were updated to include Wander Guard Placement for all residents who need wander guards. ~ Care plan audits were conducted for all residents identified to be at risk for wandering. Cardexs were updates for all residents identified to be at risk for wandering. ~ The facility's Wander books were updated including policy and demographics. The Wanderguard books were updated to include distractions specific to each resident at risk. Structured activities, diversions, re-orientations strategies, food, television and conversations for identified residents. ~ 15 minute checks for preventative measures were implemented for resident identified in this deficiency. ~ Education for all staff on Elopement and Wandering resident policy was completed including tips for elopement prevention. Non-Pharmacological interventions were discussed for nursing staff. ~ The Procedure for wander/door alarm inspection for maintenance was updated. Nursing staff demonstrated deactivation and activation of the door alarm system. Alarm keys were removed from all key rings but for the supervising nurse set and DON. The door alarm will be replaced when able. ~ Elopement drills will be performed weekly X4, bi-weekly X2 months, monthly X3, and quarterly thereafter for 6 months. Results will be brought through Quality Assurance Process Improvement (QAPI). ~ Door alarm audits daily for 30 days and 3 x week for 11 months. Results will be brought through QAPI. QAPI to review quarterly residents at risk for wandering with the Medical Director. The deficient practice continues at a scope and severity level of E (potential for harm/pattern) as evidenced by; 2. On 8/7/22 at 11:20 a.m. R12 informed Surveyor about three or four months ago she received a burn on her leg. Surveyor inquired what had happened. R12 explained a dietary worker was bringing in her tray, the cup of coffee was knocked over and scalded her legs. R12 indicated there was a sheet and blankets over her legs and she couldn't take the blanket off which was full of hot coffee. R12 informed Surveyor the dietary worker didn't know what to do and she asked him to take off the sheet. The nurses note dated 4/8/22 documents when staff brought her supper tray to her room res (resident) moved her TV tray and a cup of coffee spilled on her right lower leg no redness noted no blisters applied cold wash cloth to area immediately, no increase in warmth to area. 3 blankets were on res at the time the coffee spilled on res, res requested to go to ER (emergency room) writer called [name of] her son and made aware. [name of] NP (nurse practitioner) aware [name of] ambulance called to transport to ER (emergency room). RN (Registered Nurse) supervisor was present with writer for skin check. The nurses note dated 4/8/22 documents, On call RN made aware of res going to ER and the spilled coffee that occurred. The nurses note dated 4/8/22 documents res returned to facility. right lower leg wrap with kerlix and Vaseline gauze. res had no c/o (no complaint) pain or discomfort at this time. new order received. The hospital after visit summary dated 4/8/22 under diagnoses documents thermal burn & superficial burn of right lower leg, initial encounter. The physician order with an order date of 4/8/22 includes a treatment of cleanse right lower leg with normal saline, pat dry, apply Vaseline gauze and wrap with kerlix daily. This treatment was discontinued on 5/9/22. The nurses note dated 4/9/22 documents, Resident in good spirits. No c/o discomfort to RL (right lower) calf. Area that sustained burn is wrapped. Res stated they told her to leave wrap on a few days. She also stated that the bed she was in at hosp (hospital) had a scale and she weighed 55kg (kilograms). The nurses note dated 4/9/22 documents, Resident monitored for RLE (right lower extremity). Lower leg is wrapped. No drainage. Complaining of burning sensation. Given Tylenol for comfort twice this evening. The nurses note dated 4/10/22 documents, Pt (patient) is being followed for RLE where coffee got spilled. Pt is alert and orientated per baseline. RLE wrapped. Pt has no c/o pain or discomfort at this time. Pt is in bed sleeping. The dietary note dated 4/11/22 includes documentation of Resident is being followed for coffee got spilled, resident agreed to special mug with cover for beverages. Kitchen aware. On 8/8/22 at 1:41 p.m. Surveyor asked CCM (Clinical Care Manager)-K if she was aware of R12 being burned by spilled coffee. CCM-K informed Surveyor apparently there was a day the tray tipped in the room and R12 was burned with coffee. CCM-K informed Surveyor she was not working that day but knows R12 was on report after. On 8/8/22 at approximately 3:00 p.m. Surveyor asked Administrator-A for the Facility's investigation regarding R12 being burned by coffee. On 8/9/22 at 8:42 a.m. Surveyor asked Administrator-A if there is an investigation for when R12 was burned by spilled coffee. Administrator-A informed Surveyor he is still looking for the investigation and wasn't aware of the incident until yesterday. On 8/9/22 at 12:52 p.m. Surveyor asked Administrator-A if he was able to locate an investigation for R12. Administrator-A informed Surveyor he has an IRIS which is the Facility's incident report which he will bring to Surveyor. On 8/9/22 at 1:03 p.m., Surveyor reviewed the Facility's incident report dated 4/8/22 which documents for initial reported description, When staff brought her supper tray to her room res (resident) moved her TV tray and a cup of coffee spilled on her right lower leg no redness noted no blisters applied cold wash cloth to area immediately. no increase in warmth to area. 3 blankets were on res at the time of the coffee spilled on res. res requested to go to ER (emergency room) writer called [name of] her son and made aware. [Name of] NP (Nurse Practitioner) aware [name of]ambulance called to transport to ER. RN supervisor was present with writer for skin check. Under immediate action reported documents cool wash cloth applied blankets removed skin check done. Under section for review follow up for contributing factors is checked for Patient/Family - Failure to Follow Plan of Care. The Facility did not investigate R12's burn caused by spilled coffee to prevent further occurrences to R12 or other Residents. There is no evidence the Facility investigated the temperature of coffee when Residents receive this beverage to determine if the temperature is too hot, if there are other Residents at risk and what interventions were implemented to prevent this occurrence to other Residents. 3. The Fall and Fall Risk, Managing Policy from 2001 Med-Pass Inc (Revised March 2018) under the section Resident-Centered Approaches to Managing Falls and Fall Risk documents If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. R71 was admitted to the facility on [DATE] with diagnoses which includes dementia with behavioral disturbances, hypertension, anxiety disorder, panic disorder, and depressive disorder. The at risk for injury related to falls care plan initiated 3/1/22 & revised 6/6/22 has the following approaches: * Encourage me frequently to ask for assistance or use call bell for any assistance. Initiated & revised 3/1/22. * Encourage me to be in common areas when I am awake. Initiated & revised on 3/1/22. * Encourage me to walk short distances assisted by staff when physically able, to avoid attempting self ambulation. Initiated 7/13/22. * Insure Broda Chair is reclined to prevent falling forward. Initiated 6/14/22. * Please check and change or toilet me every midnight to prevent me from self transferring or self toileting d/t TTWB (toe touch weight bearing) status and to prevent falls or injuries. Initiated & revised 3/1/22. * Provide frequent reminders to ask for assistance, rather than attempting to provide self care. Initiated 5/17/22. * Resident was moved to room closer to nurses station. Initiated 3/2/22. * Safety mat next to bed to prevent injury. Initiated 6/4/22. * PT (physical therapy) evaluate and treat as ordered or PRN (as needed). Initiated & revised 3/1/22. * Be sure my call light is within reach when I am in my room and encourage me to use it before attempting to transfer. Initiated & revised 3/1/22. * Educate me/family/caregivers about safety reminders and what to do if a fall occurs. Initiated & revised 3/1/22. * I need activities that minimize the potential for falls while providing diversion and distraction. Initiated & revised 3/1/22. * I need to be evaluated for, and supplied appropriate adaptive equipment or devices as needed. Re-evaluate and as needed for continued appropriateness. Initiated & revised 3/1/22. * Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility as tolerated. Initiated & revised 3/1/22. * Ensure that I am wearing appropriate footwear when out of bed. Initiated & revised 3/1/22 * Make sure that my floor/path is clutter free and properly lighted. Initiated & revised 3/1/22. * Keep my bed in low position when I am in it to prevent me from rolling out and being injured. Initiated 3/1/22. The actual fall with no injury care plan initiated & revised on 3/1/22 includes approaches of: * Continue interventions on the at risk plan. Initiated & revised 3/1/22. * For no apparent acute injury, determine and address causative factors of the fall. Initiated & revised 3/1/22. * Keep resident in common areas when awake for safety due to severe dementia and anxiety. Initiated & revised 3/1/22. * Monitor/document/report PRN ( as needed) x (times ) 72h (hour) to MD (medical doctor) for s/sx (signs/symptoms): Pain, bruises, change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Initiated & revised 3/1/22. * Neuro-checks x 5 hours. Initiated & revised 3/1/22. * Pharmacy consult to evaluate medications. Initiated & revised 3/1/22. * Promote activities that promote exercise and strength building where possible. Provide 1:1 activities if bed bound. Initiated & revised 3/1/22. * PT (physical therapy) consult for strength and mobility. Initiated & revised 3/1/22. The admission MDS (Minimum Data Set) with an assessment reference date of 3/2/22 has a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. R71 requires extensive assistance with two plus person physical assist for bed mobility, transfer, & toilet use, ambulated in room once or twice with two plus person physical assist, is occasionally incontinent of urine and continent of bowel. R71 is coded as having fallen within one month of admission, fell during two to six months prior to admission and had a fracture related to a fall in the six months prior to admission. R71 has fallen since admission with no injury. The Fall CAA (Care Area Assessment) dated 3/11/22 under analysis of findings for nature of the problem/condition documents [AGE] year old female patient with Dx (diagnoses) of multiple fractures, dementia, HTN (hypertension), anxiety, depression, GERD (gastroesophageal reflux), failure to thrive, DM2 (diabetes mellitus), HLD (hyperlipidemia), Vitamin D deficiency, insomonia, and glaucoma admitted to facility status post fall who demonstrates decreased mobility, weakness, and pain. Patient had unwitnessed fall in room on 3/1/22; was sent to ER (emergency room) for evaluation with no injury noted. CAA triggered due to need for staff assistance to stabilize during transfers and ambulation, recent history of fall with fracture prior to admission, fall in facility post admission, and use of antianxiety and antidepressant medications. The fall risk assessment dated [DATE], 3/15/22, 3/17/22, 3/26/22, 3/27/22, 4/12/22, 4/18/22, 5/12/22, 5/16/22, 6/4/22, 6/8/22, 6/13/22 & 7/13/22 all have scores indicating R71 is at high risk for falls with the exception of 4/6/22 which has a score indicating moderate risk. The nurses note dated 3/1/22 documents Resident is alert and can make needs known. Resident tried self transferring several times. Resident also had complaints of wanting to go to the bathroom, and was toileted several times with 2 outputs. No complaints of pain, burning or any discomfort with urination. Resident has a neck collar on that should remain on at all times. Resident is a high fall risk. No cough, no SOB (shortness of breath), no respiratory issues, and no sudden loss of taste. No complaints of pain or discomfort noted. Will continue to monitor. FALL #1 The nurses note dated 3/1/22 documents Resident had unwitnessed fall in her room. She was sitting on the floor next to bed, head up and arms and legs at normal position. Able to move upper and lower extremities. No respiratory distress. No s/s (signs/symptoms) of active bleeding. No new skin issues noted. [name of] NP (Nurse Practitioner) was notified. Order to send her for evaluation. [name] was also notified. VSS (vital signs) stable. The Resident Fall Data Collection Tool for fall dated 3/1/22 under summary statement/root cause documents Resident admitted to SNF (skilled nursing facility) post fall in assisted living resulted in resident going to hospital and fracture of C, C2 diagnosed. C-Collar was on at times. Resident very anxious (baseline). Doesn't use call light for assistance. Resident on commode and attempted to transfer self to bed. Resulted in resident losing balance. Resident sent to ER for evaluation related to her already diagnosed C1-C2 fracture as a precautionary measure. Sent back, no new orders or diagnosis related fall. Moved to room closer to nurses station. R71's falls care plan was updated 3/2/22 with the intervention to move to a room closer to nurses station. FALL #2 The nurses note dated 3/15/22 documents Observed res (resident) lying on her right side in fetal position in skylight south dining room area. Wheelchair was behind res. no c/o (complaint of) pain or discomfort. cervical collar in place. ROM WNL (range of motion within normal limits) RN (Registered Nurse) present. Called [name] and order to send out to [name of hospital] ER (emergency room). Contacted friend [name]. [Name of] ambulance contacted. Res remained on the floor. Pillow placed under her head. T (temperature) 97.6 P (pulse) 72 R (respirations) 18 B/P (blood pressure)125/71 Pox (pulse oximetry) 98 RA (room air). The nurses note dated 3/16/22 documents 0050 (12:50 a.m.) return from ER per stretcher, assisted back to bed by [name of] EMS (emergency medical services), no new order received from ER. The IRIS (incident report) dated 3/15/22 under initial reported description documents Unwitnessed fall. Resident was found lying on the floor on her right side in a fetal position. No respiratory distress. Able to move upper and lower extremities. No skin injuries were noted. No s/s of active bleeding. No s/s of pain. Under contributing factors is checked for patient/family - failure to follow plan of care & patient/family - patient altered mental status. The Resident Fall Data Collection Tool for fall dated 3/15/22 under summary statement/root cause documents Observed resident in skylight south dining room lying on right side in fetal position. Denies pain. Range of motion within normal limits for resident cervical collar in place T97.6, B/P (blood pressure) 125/71, pulse 72, respiration 18, Pox 98% on room air. Sent resident out to [name of hospital] per order to send when fall present. order received to send to emergency room. remained on the floor pillow placed under head. RN (registered nurse) present. This is a summary statement and does include a root cause for R71's fall. This fall data collection tool does not include staff statements/interviews as to who last observed R71, when was she observed, were prior interventions in place, etc. The RN Supervisor/Unit Manager Review is blank for summary statement/root cause. R71's falls care plan was not revised until 5/17/22. FALL #3 The nurses note dated 3/17/22 documents Resident was in the dining room eating breakfast and somehow got up and walked away from her Broda chair. Found by staff on the floor. Writer was called to assess resident. Resident on the floor with her cervical collar in place. Resident denied pain when asked. Resident to be sent out to hospital for eval and treat for existing neck injury. Updated Guardian [name] and informed NP [name]. Called up [name of] Ambulance for transport and [name of hospital] nurse [name] for report. The nurses note dated 3/17/22 documents Resident was very restless and keep trying to get out of Broda chair. Requested for toileting and toileted x (times) 3. Unable to redirect. 1:1 supervision given until 2100 (9:00 p.m.) No new injury noted from her fall. C Collar in place. Transfer with 1 assist. Occasional calling out for help. The IRIS (incident report) dated 3/17/22 under initial reported description documents Resident was eating breakfast in the dining room in Lead unit and was sitting in Broda chair. Somehow stood up and walked away from chair. Resident has history of multiple falls. Under contributing factors is checked for patient/family - failure to follow plan of care & patient/family - patient altered mental status. The Resident Fall Data Collection Tool for fall dated 3/17/22 under summary statement/root cause documents Resident is a fall risk. Has been in bed or Broda chair and walking away from it. Resident this morning was in lead dining room sitting in Broda chair and somehow stood up and walked away from Broda chair. Found lying on the floor. The RN Supervisor/Unit Manager Review for summary statement/root cause documents Resident has history of multiple falls. Has anxiety self transfers. This fall data collection tool does not include staff statements/interviews as to who last observed R71 & when, were prior interventions in place or the root cause of R71's fall. R71's falls care plan was not revised until 5/17/22. FALL #4 The nurses note dated 3/26/22 documents Resident found on the floor @ 11:30 a.m. Found side lying on the floor next to Broda chair in dining room in lead unit. Resident is alert. Cervical collar in place. Informed NP [name]. Updated Guardian [name]. Called up [name] Ambulance to transport . Called up [hospital name] ER nurse [name] to give report. Sent resident to ER for further eval and treat. Left message to phone of Caseworker [name] to call facility for update. The nurses note dated 3/26/22 documents Pt returned from ER with NNO (no new orders) at this time. The IRIS (incident report) dated 3/26/22 under initial reported description documents Found resident lying on her side on the floor next to Broda chair in Lead dining room. Under contributing factors is checked for communication - language barrier or comprehension deficit, patient/family - failure to follow plan of care & patient/family - patient altered mental status. The Resident Fall Data Collection Tool for fall dated 3/26/22 under summary statement/root cause documents Resident frequent faller. Somehow resident walked away from Broda chair while in the dining room. The RN Supervisor/Unit Manager Review for summary statement/root cause documents Resident frequent falls history. Resident tries to self transfer most of the time. This fall data collection tool does not include staff statements/interviews as to who last observed R71 & when, were prior interventions in place or the root cause of R71's fall. R71's falls care plan was not revised until 5/17/22. FALL #5 The nurses note dated 3/27/22 documents was notified by RN supervisor that my resident fell. The aides on that hall said they found her on the floor crawling to her bed, she was in her wheelchair the last they saw her. I notified the doctor on call as well as her #1 emergency contact. I called [name] but they told me to call 911 because they already had two pickups from this facility. Vital signs 116/68 Pulse 77 T 97.3 and R 18. No pain or injuries noted. The nurses note dated 3/27/22 documents Writer called [hospital name] ER and was told the pt will be discharged back to the facility shortly. The nurses note dated 3/28/22 documents No new orders from the ER. Surveyor was not provided with an IRIS (incident report) for R71's 3/27/22 fall. The Resident Fall Data Collection Tool for fall dated 3/27/22 under summary statement/root cause documents Resident found on floor crawling to bed, was in wheelchair. The RN Supervisor/Unit Manager Review for summary statement/root cause was not included in this resident fall data collection tool. This fall data collection tool does not include staff statements/interviews as to who last observed R71 & when, were prior interventions in place or the root cause of R71's fall. R71's falls care plan was not revised until 5/17/22. FALL #6 The nurses note dated 4/3/22 documents Patient noted to be lying on right side on dining room floor on Skylight South unit. UWF (unwitnessed fall) with abrasion noted to left knee. RN (Re[TRUNCATED]