**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R24 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease with late onset, delirium due to known physiological condition (progressive disease that destroys memory and other important mental functions), repeated falls, and other disorders of bone development and growth, right tibia, and right fibula. R24 currently has an activated health care power of attorney (HCPOA). R24's Quarterly Minimum Data Set (MDS) completed 3/3/25 documents short and long term memory impairment and R24 is severely impaired for daily decision making. R24 has range of motion impairment (ROM) on 1 side of lower extremity. R24 requires substantial/maximum assistance for mobility and partial/moderate assistance for transfers. No trial of bladder and bowel toileting program is documented on R24's MDS. R24 is frequently incontinent of bladder and bowel. R24's Care Area Assessment (CAA) for at risk for falls completed 9/26/24 documents R24 is at risk for falls as evidenced by history of fall prior to admission and with last fall of 9/10/24 with no injury. A significant change MDS was completed at this time due to right rib fracture with increased pain and need for more assistance with upper extremity activities of daily living. The goal is to be free from major injury if a fall will occur. Care plan will address to minimize risk and maintain current level of functioning. R24's Comprehensive Care Plan documents the following applicable targeted problem related to R24's falls: (R24) is high risk for falls due to confusion, gait/balance problems, incontinence, poor communication/comprehension, unaware of safety needs, impulsive Initiated 5/26/24 Interventions include: -Anticipate and meet (R24's) needs Initiated 5/27/24 -Be sure (R24's) call light is within reach and encourage (R24) to use it for assistance as needed. (R24) needs prompt response to all requests for assistance Initiated 5/27/24 -Ensure (R24) is wearing appropriate footwear (not specified for R24) when ambulating or mobilizing in wheelchair Initiated 5/27/24 -Follow facility fall protocol Initiated 5/27/24 -Reclining wheelchair with elevating leg rests to increase comfort Initiated 5/28/24 -Low bed Initiated 5/29/24 -Fall mat Initiated 6/1/24 R24's care plan for bowel incontinence initiated 5/26/24 includes for interventions dated 5/26/24: Check resident every two hours and assist with toileting as needed. Observe pattern of incontinence, and initiate toileting schedule if indicated. Provide bedpan upon rising, after meals, and HS (bedtime). Provide loose fitting, easy to remove clothing. Provide peri care after each incontinent episode. R24's care plan for functional bladder incontinence r/t (related to) activity intolerance, dementia, impaired mobility. Interventions include: Clean peri-area with each incontinence episode. Encourage fluids during the day to promote prompted voiding responses. Ensure the resident has an unobstructed path to the bathroom. Establish voiding patterns. Monitor and document intake and output as per facility policy. (R24) has acute pain due confusion, gait/balance problems, incontinence, poor communication/comprehension, unaware of safety needs, impulsive 10/8/24 re-admit falls, minimally displaced right 9th lateral rib fracture, nondisplaced L lateral 10th rib fracture, Right posterior 10th rib fracture, Left 4th vertebral body fracture Initiated 5/26/24 Revised 10/8/24 All interventions implemented for pain were initiated on 5/27/24 with no new interventions implemented on 9/14/24 and/or 10/8/24 after R24 sustained multiple rib fractures. R24's Fall Risk Evaluation on 5/25/24 had a score of 13 which determined R24 is at risk for falls. Surveyor notes that on admission R24 was at risk for falls. On 5/25/2024, at 11:57 PM, Registered Nurse (RN)-CC documented: (R24) admitted status post fall and right angulated distal tibia/fibula fracture. (R24) oriented to self no complaints of pain except with movement to right lower extremity, multiple attempts at self-transfer noted, soft touch call light placed and bed in lowest position. Surveyor notes that R24 was admitted to the facility as a result of a fall at home which resulted in a fracture. RN-CC is documenting on day of admission that R24 is attempting to self-transfer multiple times potentially demonstrating further impulsive behaviors. Surveyor notes the facility should have been aware of this potential to self-transfer. On 5/26/24, R24 is evaluated for repositioning bars and determined to be placed on bed to assist R24 with bed mobility and transfers. Surveyor reviewed the facility fall investigations for R24. R24 has had 11 falls from the day of admission, 5/25/24 to 4/3/25. R24 has had an injury of unknown origin that was discovered 3 days after an attempt to self transfer and a fall with major injury on 10/4/24 that led to multiple additional rib fractures. Fall 1 On 5/26/24 at 8:00 PM, (the day after admission) R24 had an unwitnessed fall with no injuries. R24 was found in the common area lying on the floor by the table on R24's right side. Staff reported they last witnessed R24 wandering the unit after dinner. The intervention put into place post fall, was to order a reclining wheelchair with leg rests. R24's care plan was updated on 5/28/24 for R24 to be in a reclining wheelchair with elevating leg rests to increase comfort. On 5/26/2024, at 8:00 PM, Licensed Practical Nurse (LPN)-DD documented: R24 found on floor in common area on R24's right side. No complaints of pain or discomfort. No changes in orientation noted. With the help of CNA's (certified nursing assistants) and medication tech and we were able to get R24 up off the floor into R24's wheelchair and neuron (sic)checks were started. On 5/28/24, Director of Nursing (DON)-B documented: Interdisciplinary Team (IDT) review of fall. R24 was dry and wearing shoes. R24 is a new admit who was admitted within 72 hours. New intervention: Ordered reclining wheelchair with elevated leg rests for increased comfort. Surveyor noted the facility fall report and IDT note post fall does not show a root cause analysis to determine what led R24 to fall and whether it was related to R24 being uncomfortable. Fall 2 On 6/1/24 at 3:15 PM, R24 had an unwitnessed fall with no injuries. R24 was found sitting on the floor next to R24's bed. R24 was found sitting in the upright position by the foot of the bed facing the window with R24's back leaning against the bed. R24 was found to be incontinent of stool at the time of the fall. On 6/1/24, R24's care plan was updated to place a fall mat next to R24's bed. On 6/1/2024, at 3:15 PM, RN-E documented: Staff found R24 sitting on the floor next to bed. Alert, O (oriented) x1 (self) confused per usual baseline, observed R24 sitting upright position by the foot of the bed facing the window with R24's back leans (sic) against the bed with bed at lowest position, incontinent of stool at the time of fall. Stated that R24 did not hit R24's head and no evidence of any injury to scalp, Able to move all extremities without complaints of any pain or discomfort, Range of motion (ROM) with in normal limits (WNL) per R24's baseline. Staff on unit provided cares then Hoyered R24 to R24's wheelchair and brought at (sic) unit common area. On 6/3/24, DON-B documented: IDT review of fall. Incontinent of stool and wearing gripper socks. R24 was in bed prior to fall. R24 is impulsive with history of falls. R24 has low bed. Mat was placed. 2nd shift to check and change at start of shift. Surveyor noted, the facility fall report does not indicate when R24 was last toileted or if R24 was offered a bed pan after the lunch meal and whether R24 voided or not as the plan of care for bowel incontinence indicated as interventions. The care plan for bowel incontinence indicated to establish voiding patterns however, Surveyor noted the care plan did not include specific times to offer voiding to R24 to decrease the risk of falls and incontinence. Surveyor noted R24's care plan was updated 6/1/24 to place a mat next to R24's bed. Surveyor noted R24's plan of care for falls, bowel, and bladder incontinence were not updated to include 2nd shift to check and change at start of shift. Fall 3 On 6/18/24 at 2:45 PM, R24 had an unwitnessed fall with no injuries. R24 was found on the floor mat, next to bed, with R24's back against the bed. R24's fall investigation documents the intervention is to keep R24 up after lunch for activities. On 6/18/2024, at 2:45 PM, RN-EE documented: Unwitnessed fall at 2:45 PM. Found R24 was sitting on the floor mat, leaning back against to (sic) the bed. Bed was (sic) low position, no injury noted. Neuro (neurological) check WNL. Denies any pain or discomfort. R24 is confused as usual. Has history of frequent falls. Assessment done. Assisted R24 to get into the bed. Interventions were in place at the time of fall: Call light was within reach. Low bed, floor mat on. R24 was dry at the time of fall. new intervention: monitor closely when R24 is in the bed On 6/19/24, DON-B documented: IDT review of fall. Diagnosis include Alzheimer's and hip fracture. R24 has history of falls with impulsiveness. Surveyor noted there is no updated care plan intervention for R24's fall on 6/18/24. Surveyor noted the post fall documentation indicates interventions to keep after lunch for activities and monitor closely while in bed where documented but not updated on the plan of care. Surveyor noted there is no root cause analysis completed to establish R24's usual pattern as R24's second and 3rd fall occurred at 3:15 PM and 2:45 PM respectively. Fall 4 On 7/1/24 at 7:30 PM, R24 had an unwitnessed fall with no injuries R24 was found on R24's left side, on the floor mat next to R24's bed. It was determined that R24 was incontinent of bowel and bladder at time of fall. On 7/1/2024, at 7:30 PM, RN-E documented: Staff found R24 lying on R24's left side on the floor mat, able to move all extremities on R24's own with complaints pain or discomfort. Incontinent of urine and BM (bowel movement) at the time of fall. ROM-WNL On 7/2/24, DON-B documented: IDT review of fall. R24 was wearing gripper socks. R24 is a check and change. R24 is impulsive with history of falls. New intervention to include check and change after supper. Surveyor noted R24's plan of care for bowel and bladder incontinence had as interventions to establish a void pattern at the time of admission. Surveyor noted R24's incontinence care plan does not indicate an individualized voiding pattern being established for R24. R24's plan of care for bowel incontinence included interventions to offer a bed pan after meals and check resident every two hours and assist with toileting as needed. The post fall documentation does not include details to complete a root cause analysis to include when R24 was last toileted/voided. Surveyor notes there is no new care plan intervention for R24's fall on 7/1/24. The intervention to check and change R24 after supper was not part of a voiding pattern and R24 was already to be offered a bed pan after meals. Fall 5 On 8/23/24 at 10:30 AM, R24 had an unwitnessed fall with no injuries. R24 was found on R24's right side lying on the floor in R24's room. It appears R24 slid out of the wheelchair. On 8/23/24, R24's care plan was updated to place Dycem in R24's wheelchair. In a late entry note on 8/24/24 at 3:55 PM, LPN-FF documented: Fall occurred in R24's room. Reason for the fall was evident. Reason for fall: Resident slipped out of chair, Pre-Fall: Fall Risk Score: 11 Post-Fall: Fall Risk Score: 13. Floor mat was on floor: Yes. Wheelchair was involved in fall. Wheelchair was unlocked at time of fall. Wheelchair footrest(s) were not in the way at the time of fall. Wearing glasses at the time of the fall: No. Footwear at time of fall: Shoes. Bedside call light on when Resident was found: Yes. Resident recently tested positive for Covid-19 and on isolation in room On 8/26/24, DON-B documented: IDT review of fall. R24 was dry and wearing shoes. Surveyor noted R24 was in isolation in her room at the time of the fall. The facility had previously noted R24 is impulsive and made attempts to self-transfer. R24 was not assessed for the need for increased supervision with R24 being isolated in their room. Surveyor noted the post fall documentation does not indicate if the previous intervention to elevate R24's legs on footrests & reclining wheelchair had been implemented or if it was an appropriate intervention to remain on the care plan. Surveyor notes the facility did not establish a root cause analysis as to where was R24 found in the room and when staff last observed and assisted R24. Fall 6 On 9/5/24 at 4:15 pm, R24 had an unwitnessed fall with no injuries observed at the time of the fall. R24 was found on the floor in front of the chapel after attending mass. The incident description includes there were other residents around R24 at the time of the fall and were unable to explain the incident. Staff was not around her during the fall. On 9/5/2024, at 4:36 PM, RN-GG documented: R24 found sitting on the floor in front of the wheelchair at the chapel. Looks like R24 did try to get up from wheelchair after mass . Staff was not around R24 during the fall. On 9/6/24 at 9:30 AM, DON-B documented an incident note indicating: IDT review of fall. CNA went to transport resident from Chapel and noted resident sitting on the floor in front of her w/c (wheelchair), other resident (sic) and parishioners present but unable to describe incident. Resident was wearing shoes. Denied pain, no injuries noted. Resident was confused per usual. Dx (diagnoses) includes dementia, not able to state what happened. BIM score 2. Pivot transfer with 1 assist and walker. Spoke with activity, states resident gets restless after chapel, and she is usually one of the first to be brought back. Activity department was on an outing at the time. New intervention: Resident to be one of the first to be picked up from chapel. Staff statement as part of the fall investigation interview form include as answers to the question: why do you think the resident fell (bathroom, item out of reach)? Resident needs one to one supervision, confused. In response to the question, we need to do something to help this resident so that he/she do not fall again. You may know this resident better than others. What should we do to try to prevent another fall? Staff documented one to one supervision. Surveyor noted the facility did not consider increased supervision as part of a fall intervention despite this being R24's 6th fall from possible attempts to self-transfer. Attempted self-transfer On 9/10/24 R24 at 3:02 pm R24 is observed sitting on the garbage can outside of the bathroom and back leans (sic) against the wall. No c/o (complaints of) pain or discomfort. Able to move all extremities. Immediate action was to assist resident back to wheelchair with the assist of 1 staff. The only predisposing factor identified is memory impairment. Surveyor noted the incident report does not indicate when staff last observed or assisted R24. The staff statement, post fall, documents as an answer to question 7: Why do you think the resident fell? Probably trying to go to the bathroom. Question 12 asks: We need to do something to help this resident so that he/she does not fall again. You may know this resident better than others. What should we do to try to prevent another fall? Staff documented: Offer toilet or monitor resident's (sic) not to be alone in her room during the day. Surveyor noted this is the second recommendation from staff to increase R24's supervision as an intervention to prevent falls. The progress notes related to the 9/10/24 attempted self-transfer were dated 9/17/24 and 9/18/24. On 9/17/24 at 3:02 pm it is documented: Residents (sic) observed sitting on the garbage can back leans (sic) against the wall, outside the bathroom, no c/o any pain or discomfort, able to move all extremities. The IDT reviews was documented on 9/18/24 at 9:30 am indicating Resident was observed sitting on the garbage can with back against the waif (sic). W/C and garbage can in same plane. No injuries noted. Staff encouraged to have resident in common area to watch Television or do manual activities. Surveyor noted there is no updated intervention added to R24's care plan post attempted self-transfer on 9/10/24. Surveyor noted, R24 had a previous intervention recommended following a 6/18/24 fall to keep R24 up after lunch to participate in activities that had not been implemented or added to R24's plan of care. Surveyor noted there is no root/cause analysis of this incident. Surveyor noted that the facility still has not establish a voiding pattern for R24. Injury 1 On 9/13/2024, at 5:30 PM, LPN-F documented: Sitting at table in television room. Every few minutes R24 grimaces and holds right rib area. Son is visiting and sitting next to R24. Son said it seems like area only has pain when R24 moves a certain way. Writer asked R24 to turn a few different ways and seems R24 has pain when R24 leans to R24's left. Also has pain if area is touched. RN supervisor is made aware, and he said will come assess as soon as he can On 9/14/24 an x-ray is obtained. x-ray results document that frontal view of chest and oblique views of right ribs demonstrate a mildly displaced fracture of the right lateral 9th rib. Mineralization is decreased. There are no bony lesions. Impressions: Acute right rib fracture as above On 9/15/2024, at 9:45 PM, RN-GG documented: Incident: R24 was complaining of pain on R24's upper part of right side of the body while touching on 9/14/24 and no bruise or other injuries noted. MD and family updated and ordered x-ray and monitor for pain. R24 had an unwitnessed fall on 9/5/24 with no injuries or pain. Body check is done today and noted small bruise on left hip [2cm x 3cm] yellowish color and started to fade away. On 9/15/24, the facility submitted a facility reported incident (FRI) for an injury of unknown origin. The FRI documents abuse unsubstantiated related to injuries. Surveyor noted that on 9/20/24, the facility updated R24's fall care plan with the intervention for R24 to be the first to be put to bed after dinner. It is not clear why the facility added this as an intervention at this time. Fall 7 and 2nd Injury On 10/4/24 at 6:45 PM, R24 had an unwitnessed fall. R24 was found on the floor on R24's left side and R24's head resting on the wall. R24 was in R24's wheelchair brushing teeth and CNA left to get a small cup to rinse R24's mouth. The incident report indicates R24 was confused as usual. R24 sustained an abrasion to the left elbow and middle back-small bump on top of the head and slight pain on R24's buttocks at time of fall. R24 received Tylenol prior to fall. Later complaints of lower back pain and as needed Naproxen is given and was not effective and R24 is crying with pain. On 10/4/24, R24's care plan was to ensure all hygiene items are at the sink. On 10/4/2024, at 8:50 PM, RN-GG documented: R24 had an unwitnessed fall from wheelchair in R24's bathroom. R24 was in her wheelchair and brushing R24's teeth and CNA went to get small cup to rinse R24's mouth. She found R24 on the floor laying left side and head was resting on the wall. Seemed to be R24 stood up from wheelchair . R24 was sent to the emergency room for evaluation on 10/4/24 and was discharged on 10/7/24. R24's discharge summary documents the following discharge diagnoses: .Mechanical fall complicated by minimally displaced right lateral 9th rib fracture, nondisplaced left lateral 10th rib fracture, likely subacute right posterior 10th rib fracture, nondisplaced bilateral posterior 11th rib fracture. Subacute L4 vertebral body fracture . A CT trauma chest abdomen pelvis with contrast was completed: .Age-indeterminate fracture involving L4 vertebral body which appears to be involved with Paget's disease (a disease that disrupts replacement of old bone tissue with new bone tissue). Plan: .Monitor for now, per HCPOA no desire for consideration for operative management. On 10/9/24, Physician (MD)-HH documented R24 has .multiple comorbidities requiring intensive management. Safety and supportive care with restorative program. 1. Multiple closed fractures of ribs both side with routine healing, subsequent encounter History of falls Minimally displaced right lateral 9th rib fracture Nondisplaced left lateral 10th rib fracture Right posterior and bilateral posterior rib fractures . According to [NAME] Orthopedics Services the following defines bone fractures: Displaced- .The break goes completely through the bone and causes a gap where the bone breaks, which often requires surgery to repair. Occurs when the broken bone fragments move out of their normal alignment. Trauma such as fall or direct impact on the bone Subacute-A fracture that occurs between 5 and 13 days after initial injury. A fracture that has begun to heal, typically 72 hours and 6 weeks after the initial injury, marking a transition from the acute to the proliferative healing phase. Considered to be in the healing stage. Surveyor noted R24 had a care planned intervention to anticipate R24's needs at the time of this fall. Surveyor noted that the facility established an intervention for staff to make sure hygiene supplies are set up prior to cares post fall but the facility did not document R24 should be supervised during cares. The staff statement, post fall, documents as an answer to question 12: We need to do something to help this resident so that he/she does not fall again. You may know this resident better than others. What should we do to try to prevent another fall? Staff documented: could not leave unattended. Despite indicating R24 should not be left unattended, increased supervision was not added as a safety intervention to R24's care plan. Fall 8 On 11/15/24 at 9:15 PM, R24 had an unwitnessed fall with no apparent injuries at the time of the fall. R24 was found sitting on the floor mat and R24 was incontinent of both bowel and bladder. On 11/15/24, at 10:06 PM, R24's medical record documents: Call received from Med tech (medication technician) and informed R24 had an unwitnessed fall. This writer went to R24's room and found sitting on floor mat and bed was low. R24 was wet and had BM (bowel movement), R24 went to bed after 6.30 PM and toileted On 11/18/24 DON-B documented: IDT review of fall. R24 was wearing socks. Bed was in low position and found on mat. R24 was wet and soiled with BM. Staff to put R24 on toilet before bed . Surveyor noted the facility investigation does not include when R24 was last seen by staff after being placed in bed after 6:30 PM, or if R24's call light was within reach or on at the time of the fall. The IDT identified a new fall prevention intervention of assisting R24 to the toilet before bed. Surveyor noted at the time of the fall R24 was found to be wet and soiled with BM. Surveyor notes the facility did not a complete a bowel and bladder patterning assessment to help prevent falls. Surveyor noted R24's care plan included to check resident every two hours and assist with toileting as needed. It is not included in the post fall investigation whether staff assisted R24 between 6:30 PM and the time of the fall at 10:06 PM. Surveyor also noted R24 has a plan of care for insomnia despite the indication R24 was in bed as early as 6:30 PM. Fall 9 On 1/4/25 at 6:15 PM, R24 had a witnessed fall with no injuries observed at time of incident. Documentation states that a CNA reported checking on R24 and found R24 in the bathroom, R24 stood up and went down to the floor on buttocks but did not hit R24's head. On 1/4/25, R24's care plan was revised for R24 to be toileted after dinner. Surveyor noted this was already an intervention on R24's care plan since 5/26/24. On 1/4/2025, at 8:38 PM, R24's medical record documents: CNA reported that she was checking R24 and found R24 in the bathroom standing and while entering to the bathroom R24 just stood up and lost the balance and went down to the floor with R24's buttocks and head was not hit On 1/6/25 DON-B documented: IDT review of fall. R24 was wearing socks and dry. Staff to toilet R24 after dinner . Surveyor notes the fall investigation does not document when R24 was last seen or assisted by the staff to the bathroom if the call light was on at the time of the fall. Surveyor notes had the facility done a root cause analysis of R24's falls, the facility would have recognized that R24's previous falls related to needing to go to the bathroom were approximately at similar times of the day and an individualized voiding plan has still not been completed for R24. Fall 10 On 2/16/25 at 12:00 AM, R24 had an unwitnessed fall. R24 was found kneeling on the floor next to R24's bed. On 2/16/2025, at 00:48 AM, RN-BB documented: While doing the rounds writer saw R24 is kneeling on the floor, helped R24 to lay back in bed. On 2/17/25 DON-B documented: IDT review of fall. Bed was in lowest position. R24 was dry and wearing gripper socks. New intervention to provide a night light. Surveyor notes there is no root cause analysis by the facility as to why R24 may be attempting to get out of bed. Review of R24's care plans indicate the facility added interventions that include: -Can be combative with cares. Do not leave unattended if R24 is in wheelchair; Initiated 2/14/25. -Transfer: Extensive assist of 1 with wheeled walker, gait belt and pivot; Initiated 2/14/25; Provide night light; Initiated 2/16/25. Fall 11 On 3/16/25 at 7:30 AM, R24 had an unwitnessed fall. R24 was found sitting on the mat, back towards bed, brief off, BM and urine on mat, BM, and urine in bed. On 3/16/2025, at 8:56 AM, RN-II documented: R24 was found sitting on the floor mat next to bed, no injuries. Assisted off floor mat with mechanical lift. On 3/17/25 DON-B documented: DT review of fall. Night shift to toilet during final rounds Surveyor notes that 6 falls that R24 had were related to R24 attempting to self-transfer and being incontinent at the time of the fall however, the facility did not complete an individualized bowel and bladder voiding pattern in order to establish an individualized voiding care plan to potentially decrease R24's risk for falls. Surveyor notes as R24 continued to fall, the facility did not complete assessments on R24's routine and usual pattern of activity in order to prevent future falls which may result in significant injury. Observations On 4/1/25, at 7:08 AM, Surveyor observed R24 in a low bed with mat on the ground on the left side of bed. R24's bed is pushed against the wall and R24 has bilateral re-positioning bars on the bed. On 4/1/25, at 8:56 AM, Surveyor observed R24 in the common area in a high back wheelchair with no foot pedals on. On 4/2/25, at 7:36 AM, Surveyor observed R24 in a low bed, mat next to the bed, sleeping. On 4/3/25 at 7:32 AM, Surveyor observed R24 in a low bed with mat, sleeping. Surveyor noted that per R24's care card R24 is to be first to get up at 7:00 AM, but Surveyor has 3 observations where R24 is still in bed after this time. On 4/3/25, at 8:03 AM, Surveyor observed R24 in the common area in a wheelchair with no foot pedals on the chair. However, Surveyor notes this was an intervention on 5/28/24 that elevating leg rests be placed on the wheelchair. On 4/1/25, at 3:26 PM, Surveyor requested R24's fall investigations for further review by Surveyor from Nursing Home Administrator (NHA)-A and DON-B. Surveyor asked who the best person would be to discuss R24's multiple falls and DON-B indicated DON-B would be the best person. On 4/2/25, at 12:08 PM, Surveyor was sharing concerns with NHA-A about R24's falls. NHA-A informed Surveyor, It's her right to fall, we just avoid a major injury. On 4/2/25, at 12:59 PM, Surveyor was discussing R24's 9/15/24 right rib fracture. NHA-A informed Surveyor that the facility completed an FRI for the right rib fracture. NHA-A shared they do not believe the 9/15/24 fracture is related to R24's falls. NHA-A shared that R24 went out on a walk in the community and went over multiple bumps and uneven pavement and believes the right rib fracture is related to this memory care event. On 4/2/25, at 3:07 PM, Surveyor shared the concern that R24 has had multiple falls since admission to the facility, with R24 being at risk for falls since admission and many of the details that would be part of a root cause analysis were not included in the post fall details of R24's falls to help establish individualized interventions for R24 to prevent falls. Surveyor shared observations during the survey of R24's care plan not being implemented. Based on observation, interview, and record review, the facility did not ensure residents received adequate supervision and assistive devices to prevent accidents for 2 of 6 residents (R291 and R24) reviewed for accidents. The deficient practice has the likelihood of affecting a pattern of residents at the facility has 14 residents who utilize lifts for transfers. * R291 had a care planned approach to use a Hoyer lift (a full body transfer lift that uses a sling to fully support the resident during the transfer) for transfers. R291's family brought in a sling they had purchased from an outside vendor. The facility did not ensure the sling was appropriate for R291's size/weight and also did not ensure the sling was appropriate to use with the Hoyer lift used in the facility. On 2/8/25, staff were transferring R291 with the Hoyer lift and the sling purchased by the family. R291 slid out of the sling and fell to the floor sustaining a subdural hematoma and laceration to the back of the head. R291 ultimately, was transported to the hospital and received 10 staples to the back of their head. R291 returned to the facility but was sent back to the hospital for additional care for their injuries. The facility did not have a system where residents were assessed to determine the correct size sling to safely transfer each resident. There was also no system in place to ensure slings were compatible with the lift(s) used in the facility. During the survey, staff were observed using random slings not assigned to the resident regardless of lift used or size of the individual resident to ensure safety. During interviews, facility staff were unaware of manufacturer's recommendations for specific use of slings and whether the sling being utilized for a transfer was safe for the resident to use. The facility's failure to assess each resident's individual needs and to provide appropriate slings for transfers created a finding of immediate jeopardy that began on 2/8/25. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the immediate jeopardy on 4/3/25 at 12:35 PM. The immediate jeopardy was removed on 4/4/25, however, the deficient practice continues at a scope and severity of a G (actual harm/isolated) based upon the additional example regarding R24. * Since R24's admission in May of 2024 R24 has had 11 falls in the facility. On 10/4/24 R24 fell when left unattended during personal hygiene in the bathroom when staff did not anticipated R24's needs when providing cares. R24 sustained multiple fractures of her ribs at this time. Prior to 10/4/24 R24 had an injury of unknown origin this involved a fracture of one rib that was discovered 3 days after an attempt to self transfer. The facility did not collect or analyze the details regarding each of R24's falls or attempts to self transfer to develop an individualized, comprehensive plan of care to prevent future falls. R24 was known to be incontinent upon admission and was known to be impulsive. The [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1 of 3 Resident #9 Abuse Interview with NHA and DON 01/24/24 11:19 AM Came to the facility from AL for increased in care. were receiving 1:1 caregiver. Doing well sharing the room. Different interventions, at first slept in the same bed, family never wanted them in the same room always. Situation were they were seeking out for each other, and it was a safety situation because they were pulling on each other. Them seeking out companionship became then stopped and stated, in order for them to get a restful night, needed to separate them out so they can still see each other. Aggressive or negative contact between the two of them? - 1/24/23 bed was in the same room together beds together, grabbing and pulling at clothing. Discoloration to Mrs. [NAME]. Investigation completed. 5/28/23 1800 - CNA reported [NAME] punched Mrs. [NAME]. beds were separated at that time. Upon admission physical contact was never shared with us that there was sexual contact still between the two residents. Refused to acknowledge that it could be an intimate setting. No assessment of consent was obtained prior to admission, NHA stated she does feel that [NAME] would be able to consent. 1/24 incident - Separate residents - frequent checks and separate beds with floor mat in-between. In investigation, staff had felt that they shouldn't sleep in the same the same bed because he is aggressive together. Investigation showed no injuries and [NAME] was pleasant and calm. 72 hour monitoring would have been put in place. Police were not contacted. No additional staff statements, just two. Visually seen grabbing and undressing her. Would need to refer to flowsheet, on whether it was res-to-res. NHA brought in flowcharts. Witness statements stated that they saw him pulling on her. Review of flowchart completed with NHA, it was not an injury of unknown origin because the redness went away. NHA acknowleded that she did not submit report to SA for any of the below listed incidents or injuries of unknown origin. Request Injury of Unknown 6/5; 8/30; 12/17; 3/21; 5/5; 12/22 Investigation: 1/24; 1/30; 5/28 01/24/24 02:14 PM Interview with [NAME], CNA - [NAME] can get agitated at times when trying to get him up. He may grip and make noises, but has never hurt her. States that sometimes he will yell at [NAME], but usually it is [NAME] who does the talking. Never really had an issue with them sharing a room. 01/24/24 04:06 PM - Interview with [NAME], Hospice RN. States that she has worked with both residents for sometime. Notes that they are only oriented to themselves and each other. [NAME] sees psych for med management due to yelling out. [NAME] is more repetitive behavior. Has no concerns with their interactions or sharing a room. When she is here they are usually on the opposite side of the table. Does recall that they needed to have beds separated because [NAME] would reach for [NAME]. No aggression that she is aware of. 01/24/24 05:32 PM Phone call with POA - [NAME] - states no concerns. He is an MD and he knows his parents very well. His dad has a brain disease which may cause some issues. Is on medications, when he goes to the bathroom he feels better. It was parents dying wish to share room. Facility does a great job and does well accommodating them. [NAME], [NAME] RM: [ROOM NUMBER] Approach: 01/22/24 10:36 AM Sleeping admit date : [DATE] BIMS: 06 Triggers: Hospice; Ltd ROM w/o Svs Observation: Sleeping in bed, bed at regular height. under covers. Husband in bed next to her. lights off. 01/22/24 10:38 AM - CNA entered room with lift. knocked on door and announced self. 01/22/24 01:27 PM - Spoke with [NAME]. Stated she likes it here. Was recently ill, but feeling better now. Likes living with spouse, and being able to be with him all the time. Observed with shawl on and sitting in lounge area watching TV. Husband sitting across from her. 01/24/24 01:14 PM - Observed [NAME] in the lounge with husband sitting across table from her. Resident is asleep. Observed NHA approach [NAME] and ask if she likes living with her husband. [NAME] indicated yes. Concerns: 1/10/24 MD note indicates DX of vascular dementia. Resident is on several psychotropic medications and a antipsychotic. Additional DX of OCD, Bipolar Disorder, Anxiety and Depression. [NAME], [NAME] RM: [ROOM NUMBER] Approach: 01/22/24 10:36 AM Sleeping admit date : [DATE] BIMS: 00 - Staff assessment for severely impaired. Triggers: Alz/Dementia w/Antipsyh; Hospice Observation: Resident is in low bed, lights off, door slightly ajar. Wife is in bed next to resident, also asleep. Resident is partially clothed, just a sheet. 01/24/24 01:14 PM - Observed resident sitting in lounge area with wife across from him at the table. Resident is reading the newspaper. NHA approached resident and asked if he likes living with his wife. His response was yes. TIMELINE R9 admitted to SNF on 1/5/23 from independent living. Diagnoses: Hemiplegia and hemiparesis with frontal lobe and executive function deficit following a cerebrovascular disease affecting right dominant side, anxiety disorder, psychotic disorder with delusions due to known physiological condition, mild cognitive impairment of uncertain or unknown etiology. MDS dated on 1/10/24 with BIMS of 6. R9 has an activated POA. 1/24/23- 1/25/23 Late Entry: Note Text: IDT team review of skin concern: Resident husband who sleeps right next to resident in same room different bed, pulled up closely to resident per family request, was grabbing and undressing resident per normal behavior. When staff came in to separate and assist both residents in re-dressing, redness/bruise to R eyelid along with multiple bruises and redness and old various stages of bruises to bil arms/hands. Resident confused alert to self/husband/family does not remember what happened or if husband hurther when asked. Res husband unable to give statement d/t advanced dementia. Resident and resident husband were naked at beginning of shift as well and new redness to R eyelid not noted at that time, separated resident's and residents' husband bed with frequent checks, floor mat placed between residents. Hospice, Dr,[NAME] and POA [NAME] made aware. Concern: Witnessed grabbing and undressing her. Also found naked at beginning of shift in which staff went in to separate and redress them. R9 statement was I don't know and He's a good man. Intervention: Separate residents beds, frequent checks, floor mat placed between residents beds. - No monitoring documentation received. - Redness was no longer there when assisted with cares at midnight and 2AM. Witness statements: B. [NAME] - Does this all the time; shouldn't sleep together, both are aggressive with each other. D. [NAME] - The two should be separated he's aggressive with her often. 1/30/23- 1/30/2023 09:30 Note Text: IDT Team review of Fall with skin injury. Unit Nurse heard resident husband reciting [NAME] Prayer and movement in room. Unit nurse went in to check on both residents and Observed resident laying on floor mat next to husband bed on R side, with husbandpulling at both arms. Unit nurse noted blood and attempted to move resident onto her back and noted large skin tear along with aggressive behavior from husband pulling and grabbing at resident's right arm. Resident yelling out/aggressive/agitated;staff was unable to separate residents so that nurse can fully assess, husband hitting, grabbing and holding onto wife's arms and grabbing at residents skin tear. Unit nurse had to move bed/pull mat on floor with resident laying on it away from husband's bed and grasp, hoyer sling utilized to get resident into bed, after removing husband from room, resident started grabbing at gown which was wrapped up on R arm and RFA skin tear, ST measuring 16cm x 6cm with active bleeding/seeping wound with half dollar sized hematoma at distal end of wound, area washed with NS and skin flaps unable to be approximated. Resident yelling, 911 called for resident transfer to ER to see if they could do more with wound. Resident's beds were separated by floor mat approx 58in. Dr.[NAME], Hospice and POA, [NAME] was notified. New intervention for sleep assessment on [NAME] and [NAME], Ensure beds are separated by being on opposite wall. Call placed to [NAME] An pharmacy consultant, Medications reviewed, states psych meds arelow doses and continue with Psych consult. Son aware of interventions and is in agreement. Comments: When returned from hospital applied Vaseline gauze, Xray obtain. CTOH obtained. Documentation on NP note 1/30/23 states resident was in severe pain, screams in pain with any movement of the arm requiring morphine and another longer acting pain med. Sleep assessment completed for [NAME] and [NAME] (not obtained) and psych consult LPN - shouldn't sleep in same room, needs her own call light, pulled out of bed by husband. [NAME] - get them a 1:1 Interview [NAME] - VM left 1/24/24 3:43 PM 3/21/23 0530 R (9) yelling agitated and hitting self in the face trying to get husband to get up and come by her. CNA went to get assistance and when returned R (9) was falling out of bed attempting to get up. CNA noted bruise to L eye, skin tear on leg from lifting her to the wheelchair. Actions: CNA called RN supervisor to report. Bruise/aggression/agitation noted. Transferred R (9) out of room to common area for 1:1 monitoring. RN supervisor identified multiple old purple bruising to left arm and BLE's. Left shin skin tear cleansed and steri strips applied. Rn attempted to place ice on left eye for swelling - refused. R (9) was giving Ativan and MSO4 Would calm for moments and then back to yelling and hitting self/clapping demanding to go to husband, smashing arms into w/c armrest remove clothing and kicking staff. 12x7 maroon bruise to r upper bicep with some light-yellow halo around scratches to r back. R (9) unable to explain how areas obtained Discussed behavior with NP would like resident seen by psych on 3/23/23, continue prn Ativan. Hospice and POA notified. Two staff members directly involved wrote up their witness statement. 5/5/23 6/5/23/23-Injury of unknown cause (there is one on 5/21/23 but not documented until 6/5/23 see last paragraph): Skin Injury Date: 6/5/2023 at 11:40 PM: RN supervisor was assessing R9's skin injury to left hand, noted purple bruising to right middle finger and pinky finger, AROM WNL, no c/o pain. R9 unable to describe what happened or how bruises occurred but denies being frightful, call light in reach. MD/POA updated, treatment applied. Note dated as late entry on 6/6/23 at 9:30 AM: IDT team review of skin concern: Unit nurse reports, R9 was eating breakfast at the common area table. CNA noticed two fluid filled blisters on the index and middle finger of left hand, [NAME] side had opened, Nurse went to assess resident. Cleaned area with normal saline and bandage. Nurse checked to see if injury was caused by breakfast food being reheated to hot, the food was warm, plate and bowl were cold. NOC nurse Supervisor was assessing R9's skin injury to left hand and noted purple bruising to right middle finger and pinky finger. R9 noted with recent episode of combativeness and resistive with cares. R9 requires supervision with meals, transfer with extensive assist of one. Skin is fragile and on daily aspirin. No new interventions noted or care plan updated. Skin Injury Date: 6/6/2023 at 3:30 AM: RN supervisor assisted with R9's cares and rebandaged open areas on left middle/index finger, noted 1 cm x 1 cm circular maroon bruise to left bicep and 7 cm x 3 cm bruise to right calf. R9 unable to give description. Area assessed, no swelling or pain noted. NP and POA notified. RN also documented R9 having old discolored/scar tissues to bilateral lower extremities/shins/calf d/t previous areas of skin impairment, R9 denied being scared/unable to describe how areas occurred, no pain, slight agitation with PRN Ativan, will continue to monitor. 6/6/23 at 4:40 AM hospice was updated on bruising and awaited call back. Note dated as late entry on 6/7/23 at 9:30 AM: IDT team review of bruises. No new interventions noted or care plan updated. 6/6/23 RN documented interview regarding scratched to right cheek that occurred on 5/21/23.m Per RN's description of the incident both R9 and R4 were agitated/yelling/while RN assisting R4 first; R9 was clapping/yelling and scratching at R9's face, RN turned and tried to reassure R9, RN noticed R9 with a small scratched to right cheek with blood on fingernails, another staff was in the room with RN at the time. R9's statement is I love R4 so much. RN wrote on interview question sheet, needs increase psych meds. 13 staff members completed interviewed question forms. 5/28/23 at 1800-Resident to Resident Altercation Summary: R4 was observed punching R9 in the right side of face. Staff reported incident and an internal investigation was started by the facility. This incident occurred in the facility hallway. Both residents were sitting in wheelchairs. R9 shouted at R4 and he punched [NAME] in the face. Residents were separated. Assessment completed by the facility for both residents: Painad was completed indicated as zero, resident smiling, inexpressive, relaxed and no need to console No injuries were observed on residents Predisposing environmental factors none were identified Predisposing physiological factors were confused, impaired memory Predisposing situation factors were identified as none POA HC was notified and physician PRN Lorazepam was administered to R4 after the incident One staff member was interviewed on 5/28/23 at 6pm indicating observing R4 punching R9 1X in the right side of her face, further indicating that we separated them to calm them down. CNA indicated that R9 was aggravating him that's what started it. Facility utilized P00361 resident to resident altercation flowchart to determine if the incident was reportable. NHA determined that the there was no suffer of pain, physical injury or psychological or emoitional harm as a result of the altercation and therefore did not report to the state agency. No further investigation. No care plan changes for either resident, no new interventions. No monitoring of residents after incidents for psychosocial harm. 12/17/23- Injury of Unknown Origin Incident Report - 12/17/23 6:30 PM Staff reported to nurse R9 had a 3 cm x 3.5 cm bruise to right eye lateral area. R9 is oriented to self, speech clear, no complaints of pain or discomfort to bruise area and no swelling noted. R9 unable to give description of injury. Immediate Action Taken: ice for comfort, MD, hospice and POA aware. Not taken to hospital. Predisposing physiological factors were confused and impaired memory Interview Questions for Incident: Employees interviewed. One person suggested R9 may have leaned onto EZ stand. One person suggested R9 bumped eye during a transfer. Nobody else knew. IDT Note dated 12/18/23 at 2:12 PM stated review of statements from staff, R9 is known to lean to right/rest head on the handle of the EZ stand lift while sitting on the toilet, edge of bed. What they didn't do - Care plan not changed/updated. No skin assessment attached to investigation. On 1/24/24 at 3:38 PM Surveyor interviewed [NAME] CNA who has worked here 8 years. Both at table in dining room with other residents and staff. Mostly don't really care for being put to bed. They are put to bed at same time. At 7:30-8 pm they go to bed. Once they are in the bed they are fine. Giving cares is difficult. Kind of fight back. Separate beds, same room. When someone else is near husband she gets upset. If you give her meds, he yells at them because they don't know. No injuries. Would report to nurse and supervisor. None reported. [NAME] gets a little aggressive at 3 am. Not towards wife. [NAME] sleeps through night. She has [NAME], Interviewed 3:47 PM, [NAME] cna, agency, once a week will work with [NAME], other days of weeks on other units. Started 3-4 months ago. Never saw aggression towards wife. None to husband. She constantly tells her how much she loves him. He loves her, sometimes the words don't come out. Interactions full of love. He reaches and is rough we he grabs stuff, because if she gets close enough, he will grab for her, he has a strong grip, like a vice, he can move the whole table. Not malicious, just wants to grab her lovingly. Care plan of sitting across from each other arm distance away. On wall in room sign to keep residents separated. He's assuming reason why. She small lady could hurt her if grabbed out of bed. They are both unable to get out of bed, bed lowest, fall mats that are thick on floor, once up they put them up d/t trip hazards. Never fell out of bed that he knows of. Not been interviewed that he knows of regarding the two residents. Viewed res room. Call lights are spliced from one wall unit, but they each have their own. 12/22/23 at 1845- R4 injury of unknown cause: CNA went to resident room to provide cares, saw large bruise to RT Wrist. CNA indicated did not see bruise there yesterday, bruise is dark blue in color measuring 12x6cm. R9 denied pain to area, ROM normal, R9 does use EZ stand for transfers, also R9 and husband R4 are in room together and in isolation, in the past, R4 has grabbed R4s arms and squeezes them, staff would have to go place R4 further away from R9. Assessments completed by facility: Immediate action taken by facility: R9 observed leaning to right side due to COVID, generalized decline, resident leaning and arm is against wheelchair so pillow placed so arm is not in between self and wheelchair. Painad was completed indicated as zero, resident smiling, inexpressive, relaxed and no need to console No injuries were observed on residents Predisposing environmental factors none were identified Predisposing physiological factors were recent illness Predisposing situation factors were identified as other (describe) uses wheelchair- other described as uses EZ stand for transfers, also in isolation with R9 has in the past frequently observed grabbing R9s arms. No witness found POA notified Physician notified POA HC was notified and physician One CNA interviewed indicating not sure what occurred, may have occurred in the room? Further indicated that did not witness incident, not sure what happened and CNA indicated maybe R4 grabbed R9, was not sure who was involved One CNA interviewed indicating no idea what happened, and that R9 is unable to indicate what occurred. One CNA interviewed indicating no idea what happened and not working at the time of incident. One CNA interviewed indicating no idea what happened and not working at the time of incident. One CNA interviewed indicating no idea what happened and not working at the time of incident. One CNA interviewed indicating no idea what happened and not working at the time of incident. One CNA interviewed indicating no idea, but observing R4 sometimes having R9 hand, but not really knowing. One CNA interviewed indicating not knowing what happened, was not working at the time No other investigation information completed, no conclusion no interventions, was not reported to the SA, Police. No further information. Progress notes: 1/2/2024 09:30 Incident Note Note Text: IDT team review of skin tear. CNA reported she was taking resident to the bathroom when she became combative and started swinging her arms causing skin tear to left hand. Skin is thin and frail. RN and unit nurse assessed area, area was cleansed with NS and approximated with steri strips. RN supervisor instructed CNA to stop providing cares when resident becomes upset or combative. Dr.[NAME] and POA [NAME] made aware. 12/17/2023 19:00 Incident Note Note Text: POA, [NAME], MD and Hospice updated r/t Bruise to Rt Lateral eye 12/17/2023 18:30 Incident Note Note Text: Staff reported to writer r/t a bruise(3cm x3.5cm) to RT eye lateral area, Residents alert, Oriented to self, speech clear, no c/o pain discomfort to bruise area and no swelling noted 9/29/2023 09:30 Incident Note Note Text: IDT team review of fall: Staff observed residents lying on her RT side on the floor in the common area facing and close to [NAME](spouse), stated take care of [NAME], I love him. Dry and wearing shoes Alert, responsive, denies any pain or discomfort from the fall. Prior to fall resident was sitting in w/c yelling [NAME] had to go to the bathroom. Per staff resident did not want to use the bathroom. Bim score 7, transfer via EZ stand. Dx include Anxiety disorder and cognitive impairment. Pastoral care present in IDT. Resident is strong in the Catholic Faith. Resident will be given a Rosary to redirect focus on her husband. Hospice, son [NAME] and Dr. [NAME] aware. 9/12/2023 09:30 Incident Note Note Text: IDT team review of skin tear: CNA states she lifted resident leg and placed leg on the foot pedal to take resident from common area to her room, While propelling resident to her room, she kicked her leg off the foot pedal causing leg to hit the w/c pedal causing a 2.5 x 0.5cm skin tear with bruising to periwound. Area was cleansed with NS, adaptic applied and wrapped with kerlix. Resident skin is thin and fragile. Eucerin cream is applied to BLE daily. MD, POA [NAME] and Hospice made aware. 9/11/2023 20:30 Incident Note Note Text: According to CNA ,CNA picked up the resident leg and put it on the foot pedal and trying to take resident from common area to room, on the way resident kicked off the leg from the pedal and hit the leg on the pedal and got skin tear [2.5 cm x 0.5 cm ] to left back of the leg .surrounding area is bruised. Area cleaned and applied dressing , updated to MD and POA 8/30/2023 18:13 Incident Note Note Text: IDT Team review of skin tear: Unit Nurse was called to resident room by cna d/t dried blood noted sticking together on top sheet and ST noted to L shin. Res with previous purpura/maroon like bruising to L shin with ST on side of purpura like bruising. Resident skin is frail, dry and thin. Area measured 4.0 x 2.0cm, area cleansed with NS and approximated, 2 steri strips applied. Nursing order written for Eucerin cream BID. Hospice and [NAME] NP made aware. Call placed to POA [NAME], Phone out of service. Callplaced to [NAME] 2nd POA and made aware. 6/26/2023 09:30 Incident Note Note Text: IDT team review of fall. Unit nurse went into room to check on resident. Resident was observed naked laying on her right side on floor mat next to bed. Bare feet and dry. Denies pain. Staff reports resident was trying to get to her husband who was in next bed asleep.Resident has had several falls from bed looking for Spouse. Family does not want the two separated. Bim score 7.Resident has several interventions in place, body pillow, bari bed, thick floor matt, medication review and toileting plan.Staff reports sheets are slippery. Spoke with [NAME] RN from hospice, informed of slippery sheets. States will order non slippery sheets. MD and POA [NAME] aware. Resident also had temp of 99.1. MD aware,would like for staff to monitor. 6/20/2023 13:30 Incident Note Note Text: IDT team review of fall. Resident was observed on floor next to bed, states she was trying to get to [NAME], her spouse who was in the bed next to her. She was bare feet and dry. Denies pain. No injury noted. Bim score 7, cognitively impaired, Hx of falls and Dx of Anxiety. Husband and spouse slept together upon admission and had to be seperated due to aggressive towards each other. IDT team discussed separating the 2 by moving [NAME] to the other side of the room but feels may cause increase Anxiety which contribute to increase in falls. Care Conference was held today with POA via phone. APOA was appreciative for all we do in relation to falls. POA, [NAME] does not want his mom and dad to be seperated. IDT team recommend getting a big Pillow with a picture of [NAME]. Hospice was in attendance and will get a pillow and have [NAME] picture on it. Will continue with current Goal to prevent major injury. MD and POA aware. 6/12/2023 09:30 Incident Note Late Entry: Note Text: IDT team review of fall: Unit nurse entered resideen room and observed resident on the floor sleeping on floor mat naked and dry, states she was trying to get to her husband who was in the bed next to hers. Resident was angry and combative. No signs of pain indicated, no injury noted. Resident has a hx of falls with several related to trying to get to husband. Couple beds were together when first admitted . Beds had to be seperated due to the couple being aggressive towards each other. Resident has a dx ofCognitive impairment, anxiety disorder and hx of falls. Bim score 7. Current interventions include, low bed, fall mat, dycem, medication review, sleep assessment, bigger bed that was switched out with Bariatric bed, Psych consult and attempted night shift get up. Current fall mat switched out for thicker floor mat. MD, APOA [NAME] and Hospice made aware. 6/12/2023 09:30 Incident Note Late Entry: Note Text: IDT Team review of fall: CNA reporting she heard the bang when resident fell. Resident on floor repeating where is [NAME]. resident was reaching out for his hand. Resident hit her left eye brow on the nightstand creating a laceration. Pressure held for bleeding and Tylenol later given for pain. Hospice nurse Steri Stripped the Left eyebrow. Eye beginning to bruise.Couple beds were together when upon admission. Beds had to be seperated due to the couple being aggressive towards each other. Resident hasa dx of Cognitive impairment, anxiety disorder and hx of falls. Bim score 7. Current interventions include, low bed, fall mat, dycem, medication review, sleep assessment, bigger bed that was switched out with Bariatric bed, Psych consult and attempted night shift get up, Goal is to prevent Major injury with falls. Night stand was rearranged. MD, POA and Hospice aware. 6/7/2023 09:30 Incident Note Late Entry: Note Text: IDT team review of Bruise: RN supervisor was assisting with cares and rebandaging open areas on L middle/index finger and noted 1.0cm x 1.0cm circular [NAME] bruise to L bicep and 7.0 x 3.0cm bruise to R calf. No swelling noted. Denies pain or discomfort.Resident unable to state what happened due to cognitive impairment.Resident skin is frail, on daily Aspirin. Transfer via 1 assist. Recent episode of combativeness and resistive with cares.Dx includes cognitive impairment and Psychotic disorder with Delusions.[NAME] NP, Hospice ([NAME] RN) and son [NAME] made aware. 6/6/2023 09:30 Incident Note Late Entry: Note Text: IDT team review of skin concern: Unit nurse reports, resident was eating breakfast at the common area table. CNA noticed two fluid filled blisters on the index and middle finger of left hand, [NAME] side had opened. Nurse went to assess resident. Cleaned the area with normal saline and bandage. Nurse checked to see if injury was caused by breakfast food being reheated to hot. The food was warm, plate and bowl were cold. Noc RN supervisor was assessing residents skin injury to L hand and noted purple bruising to R middle finger and pinky finger. Resident noted with recent episode of combativeness and resistive with cares. Resident requires supervision with meals, transfer with extensive assist of one. Bim score 8, dx include Anxiety and Psychotic disorder with delusions.Skin is fragile. On daily Aspirin. MD,Hospice and POA.[NAME] aware. 6/5/2023 10:45 Incident Note Late Entry: Note Text: At 1030, resident was eating breakfast at the common area table. CNA noticed two fluid filled blisters on the index and middle finger of left hand, [NAME] side had opened. Nurse went to assess resident. Cleaned the area with normal saline and bandage. Nurse checked to see if injury was caused by breakfast food being reheated to hot. The food was warm, plate and bowl were cold. 5/29/2023 09:30 Incident Note Late Entry: Note Text: IDT team team review of physical aggression.CNA observed resident's spouse strike her on the right side of her face. The 2 were immediately separated. No bruising, pain or injury was noted. No further harm to harm towards one another. This was a 1 time episode. 5/28/2023 18:58 Incident Note Note Text: CNA reported that I Observed [NAME] punching [NAME] in the right side of her face, so we separated them to calm them down .[NAME] was aggravating him that's what started it 5/22/2023 09:30 Incident Note Late Entry: Note Text: IDT team review of skin abrasion: Staff noted Resident being agitated d/t husband being agitated and calling out. While staff was doing cares on husband first. Resident was scratching/rubbing face and clapping and obtained a small abrasion to a mole to R side of her face, area with small amt bleeding, cleansed and band aid applied, bleeding subsidized. Nails were short and jagged; so nails trimmed and filed. Hospice, NP and POA, [NAME] aware. 5/8/2023 09:30 Incident Note[TRUNCATED]