Every finding on record at Boyce Manor Nursing Home

Based on record review and interview, the facility failed to ensure a RN for at least 8 consecutive hours a day, 7 days a week and employ a DON during the months of 07/2026 and 08/2026. The administrator identified 45 residents resided in the facility. Findings: An undated facility policy titled STAFFING POLICY, read in part, A registered nurse will be employed full time on the day shift, with coverage 7 days a week, as the facility's director of nursing services. A calendar for 07/2026 showed no RN coverage on 07/13/26, 07/14/26, 07/15/26, 07/17/26, 07/20/26, 07/21/26, 07/24/26, 07/27/26, 07/28/26, 07/29/26, 07/30/26, and 07/31/26. The calendar showed no DON from 07/13/26 through 07/31/26. A calendar for 08/2026 showed no RN coverage on 08/03/26, 08/04/26, 08/05/26, 08/06/26, 08/07/26, 08/10/26, and 08/12/26. The calendar showed no DON from 08/01/26 to current date. On 08/13/26 at 12:00 p.m., the administrator stated the facility was currently without a DON. The administrator stated the DON quit on 07/10/26 and the facility had been without a DON since. The administrator stated the facility had days they did not have RN coverage.

On 04/29/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were free from abuse. On 04/29/25 at 4:35 p.m., the Oklahoma State Department of Health verified the existence of an IJ situation. On 04/29/25 at 4:37 p.m., the administrator was notified of the immediate jeopardy situation. An immediate jeopardy template was provided to the administrator. On 05/02/25 at 9:40 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility plan of removal showed: All staff will immediately be educated by facility Administrator on the facility updated policy regarding resident to resident altercations. They will be educated on ensuring the safety and well-being of all residents by preventing, identifying, and managing resident-to-resident altercations. When a resident poses a risk to others, immediate action will be taken, including 1:1 supervision and, if necessary, removal or transfer to a more appropriate setting. Education will be verified using a sign in sheet. Employee names and time of call will be documented. All residents will be reassessed for active behavior issues to determine the risks for future altercations. Physician will be notified if any resident is displaying current behaviors. Interventions will be implemented and care plans updated as needed. A resident safe survey will be conducted on all verbal residents to determine if residents feel safe within the facility. Counseling services will be offered and provided as needed. Non-verbal communication tools such as an emotions picture card will be used to determine if non-verbal residents feel safe. Staff will be trained to recognize signs of discomfort, fear, or distress, and respond in calm, and respectful ways. A QAPI meeting led by the Administrator will be completed immediately to address safety concerns in the facility, abuse prevention, and prevention of resident-to-resident altercations. The IJ was lifted, effective 05/02/25 at 1:00 p.m., when all components of the plan of removal had been completed. Resident interviews and staff interviews were completed regarding abuse. A review of the 'Abuse-Reportable Events' updated policy, resident assessments, and staff education regarding abuse was completed. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to ensure residents were free from abuse for 1 (#2) of 5 sampled residents reviewed for abuse. The administrator identified 44 residents resided in the facility. Findings: An undated facility policy titled RESIDENT CODE OF CONDUCT, read in part, The following code of conduct is effective in order to protect the rights and safety of all residents that reside here at [name withheld]. VIOLATION OF ANY OF THE FOLLOWING ACTS COULD/WILL CONSTITUTE CAUSE FOR DISCHARGE FROM THE FACILITY: .Disorderly, immoral, or indecent conduct, inappropriate language.Any form of physical violence including throwing objects toward other residents or staff.Willful or careless disregard of name calling/racial slurs toward a resident with the intent to cause emotional distress.Any violation of resident/staff rights, including threats of any nature A facility policy titled Abuse-Reportable Events, revised January 2018, read in part, Mental and Verbal Abuse: (as stated in guidance to Surveyor in CMS SOM Section PP F600) Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse is a type of mental abuse and includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend or disability.Physical abuse: (as stated in guidance to Surveyor in CMS SOM Section PP F600) Physical action within the definition of abuse, including, but not limited to, hitting, slapping, punching, and kicking. It also includes controlling behavior through corporal punishment. 1. An undated face sheet showed Res #1 had diagnoses which included paranoid schizophrenia, mood disorder, post-traumatic stress disorder, brief psychotic disorder, and depression. An incident report, dated 09/26/24, showed an allegation of abuse. The report showed Res #1 kicked another resident in the face because they were cussing at them. The report showed local law enforcement escorted Res #1 to the hospital for a psychological evaluation. A progress note, dated 09/26/24, showed the resident returned to the facility from the hospital. The note showed the resident was evaluated by mental health, medications were adjusted, and was not a harm to themselves or anyone else. A quarterly assessment, dated 10/24/24, showed Res #1 had a BIMS of 11 and was moderately impaired cognitively. The assessment showed Res #1 had verbal behaviors toward others. An incident report, dated 10/26/24, showed an allegation of abuse for Res #1. The report showed Res #1 was yelling at another resident, hit them in the head twice, and started kicking them. The report showed Res #1 was placed on observation and was pending admission into an inpatient facility. A progress note, dated 11/15/24 at 2:37 p.m., showed Res #1 was walking to their room saying, Go ahead and call the police and I'll kill you, you B***h. The note showed the resident was then on the couch mumbling about killing people. A progress note, dated 11/15/24 at 3:30 p.m., showed Res #1 entered a facility office and reported, Im ready to go to the hospital or jail, I keep f****** having these sexual hallucinations and Im sick of it, I'll kill everyone in here!! A progress note, dated 11/15/24 at 8:45 p.m., showed the resident returned to the facility from the emergency room with no new orders. The note showed the resident continued to mumble about killing people and calling staff b*****s and prostitutes. An incident report, dated 01/10/25, showed an allegation of abuse for Res #1. The report showed Res #1 was cussing at another resident. The report showed Res #1 was transferred to inpatient for psychological treatment. A quarterly assessment, dated 01/13/25, showed Res #1 had a BIMS of 13 and was cognitively intact. The assessment showed Res #1 had no physical behaviors and had verbal behaviors that occurred one to three days. An incident report, dated 04/16/25, showed an allegation of abuse for Res #1. The report showed Res #1 punched Res #2 in the face several times. The report showed Res #1 was verbally abusive to Res #2 and proceeded to hit Res #2 after yelling at them unprovoked. The report showed the resident was sent to behavioral health inpatient for a psychological evaluation. A care plan, with updated intervention through 04/17/25, showed interventions put in place after the 01/10/25 incident were relisted interventions from the 10/26/24 incident. The care plan showed interventions listed after the 04/16/25 incident was every 15 minute checks after episodes of physical violence until evaluated by physician and send for mental health evaluation as ordered. On 04/28/25 at 12:20 p.m., the administrator stated when the incident occurred the residents were separated. The administrator stated Res #1 was placed on every 15 minute observations until leaving the facility. On 04/28/25 at 4:05 p.m., the care plan coordinator reviewed Res #1's care plan. The care plan coordinator stated the care plan relisted interventions that had already been implemented regarding the problem identified of agitation and aggressive behavior. The coordinator stated there was no new interventions for the incident occurring on 01/10/25. The coordinator stated new interventions should be put in place if agitation and aggressive behaviors continue. On 04/29/25 at 9:20 a.m., CNA #1 stated Res #1 had behaviors since admission. The CNA stated Res #1 cussed at staff and stated they were going to kill staff. The CNA stated they were aware of Res #1 pushing Res #2 on three different occasions, the last time resulting in Res #1 hitting Res #2 on the head. CNA #1 stated there was no way to know when the resident would have aggressive behaviors, it would just happen. CNA #1 stated they would separate Res #1 from other residents and ask for staff assistance. On 04/29/25 at 3:23 p.m., the DON stated Res #1 was last seen by the psychiatrist was June 2024. The DON stated the physician's office reported Res #1 did not have any scheduled appointments. 2. An undated face sheet showed Res #2 had diagnoses which included paranoid schizophrenia, pseudobulbar affect, and major depressive disorder. The annual assessment, dated 04/03/25, showed Res #2 had a BIMS of 8 and was moderately impaired cognitively. The assessment showed Res #2 did not have verbal or physical behaviors toward others. A progress note, dated 04/16/25, showed Res #2 reported to staff Res #1 was verbally abusing them unprovoked. The note showed Res #2 reported Res #1 hit them in the face and right ear multiple times. The note showed the local police department was called and staff assisted with Res #1 being taken out of the facility for evaluation of aggressive behaviors. The care plan, updated 04/16/25, showed Res #2 was hit by another resident and she may be at risk for fear. The interventions showed to allow the resident to verbalize her feelings and to reassure the resident they were safe. On 04/29/25 at 9:00 a.m., Res #2 was sitting on the side of their bed wearing a jacket and watching television. On 04/29/25 at 9:02 a.m., Res #2 stated they were currently not afraid. The resident stated they were afraid of Res #1 and hoped they did not return to the facility. The resident stated in a tearful voice Res #1 might kill them.

Based on record review and interview, the facilty failed to review and revise the care plan for 1 (#1) of 5 sampled residents whose care plans were reviewed. The administrator identified 44 residents resided in the facility. Findings: An undated face sheet showed Res #1 had diagnoses which included paranoid schizophrenia, mood disorder, post-traumatic stress disorder, brief psychotic disorder, and depression. An incident report, dated 09/26/24, showed an allegation of abuse. The report showed Res #1 kicked another resident in the face because they were cussing at them. The report showed local law enforcement escorted Res#1 to the hospital for a psychological evaluation. An incident report, dated 10/26/24, showed an allegation of abuse for Res #1. The report showed Res #1 was yelling at another resident, hit them in the head twice, and started kicking them. The report showed Res #1 was placed on observation and was pending admission into an inpatient facility. An incident report, dated 01/10/25, showed an allegation of abuse for Res #1. The report showed Res #1 was cussing at another resident. The report showed Res #1 was transferred for inpatient treatment. A care plan, with updated intervention through 04/17/25, showed interventions put in place after the 01/10/25 incident were relisted interventions from the 10/26/24 incident. The care plan showed interventions listed after the 04/16/25 incident was every 15 minute checks after episodes of physical violence until evaluated by physician and send for mental health evaluation as ordered. On 04/28/25 at 4:05 p.m., the care plan coordinator reviewed Res #1's care plan. The coordinator stated the care plan relisted interventions that had already been implemented regarding the problem identified of agitation and aggressive behavior. The coordinator stated there was no new interventions for the incident occurring on 01/10/25. The coordinator stated new intervention should be put in place if agitation and aggressive behavior continue.

Based on record review and interview, the facility failed to ensure residents were bathed according to physician orders for two (#3 and #29) of three sampled residents reviewed for bathing. The MDS coordinator reported 48 residents resided in the facility. Findings: A Shower/Tub Bath policy, revised 10/2020, documented the purpose of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. 1. Res #3 admitted to the facility with diagnoses which included schizophrenia, hypotension, and pain in thoracic spine. A physician's order, dated 04/19/24, documented bathing two times weekly and PRN. The resident's record documented the resident missed three of four opportunities for a shower from 01/10/25 to 01/25/25. On 02/09/25 at 2:42 p.m., the resident reported they did not get showers like they were supposed to. On 02/10/25 at 3:07 p.m., the ADON reported the showers or refusals were not being documented, so they could not say if the resident had a shower during that time. 46216 2. Res #29 admitted to the facility on [DATE] with diagnoses which included need for assistance with personal care and muscle wasting and atrophy. A physician's order, dated 12/14/24, documented bathing two times weekly and PRN. On 02/09/25 at 3:02 p.m., Resident #29 reported they had not received a bath in two weeks. Resident #29's record review for 12/14/24 through 02/10/24 documented no baths/showers were given 12 out of 17 opportunities. On 02/10/24 at 1:54 p.m., the MDS coordinator stated they had no other documentation of showers/baths.

Based on observation, record review, and interview, the facility failed to ensure RN coverage for eight consecutive hours seven days per week. The MDS coordinator identified 48 residents resided in the facility. Findings: A PBJ Staffing Report, dated 07/01/24 through 09/30/24, documented no RN hours on 08/17/24, 08/18/24, 09/01/24, 09/09/24, 09/14/24, 09/15/24, 09/28/24, and 09/29/24. A facility Time Detail Report, did not document RN coverage for eight consecutive hours on 08/31/24, 09/01/24, 09/14/24, 09/15/24, 09/28/24, 09/29/24, 10/15/24, 10/16/24, 10/19/24, 10/25/24, 10/26/24, 11/01/24, 11/10/24, 11/15/24, 11/16/24, 11/23/24, 11/24/24, 11/28/24, 11/29/24, 11/30/24, 12/13/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24, 01/01/25 - 01/12/25, 01/16/25, and 01/17/25. On 02/11/25 at 9:05 a.m., the administrator stated they had no further documentation for RN coverage on the dates above.

Based on record review and interview, the facility failed to ensure MDS assessments were coded accurately for two (#26 and #29) of sixteen sampled residents whose MDS assessments were reviewed. The MDS coordinator reported 48 residents resided in the facility. Findings: 1. Res #26 admitted to the facility with diagnoses which included schizoaffective disorder, post traumatic stress disorder, and persistent mood disorder. An annual assessment, dated 11/07/24, documented the resident had weight loss. A review of the resident's record documented the resident had a weight gain of 1.69% in six months and 0.42% in one month. On 02/10/25 at 2:15 p.m., the MDS coordinator reported weight loss should not have been documented on the annual assessment. 2. Res #29 admitted to the facility on [DATE] with diagnoses which included end stage renal disease and dependence on renal dialysis. An admission assessment, dated 12/20/24, did not code Resident #29 had received dialysis on admission or while a resident of the facility. On 02/10/25 at 1:12 p.m., the MDS coordinator stated Resident #29 received dialysis on Monday, Wednesday, and Fridays. On 02/10/25 at 1:13 p.m., the MDS coordinator stated Resident #29 had received dialysis prior to admission and during their stay. On 02/10/25 at 1:14 p.m., the MDS coordinator stated Resident #29's admission assessment had not been properly coded. 46216

Based on record review and interview, the facility failed to complete quarterly MDS assessments timely for one (#26) of sixteen sampled residents reviewed for MDS assessments. The MDS coordinator reported 48 residents resided in the facility. Findings: Res #26's record documented an annual assessment dated [DATE]. The resident's record did not contain an assessment since the annual in November 2024. On 02/10/25 at 2:07 p.m., the MDS coordinator reported the MDS assessments should have been completed.

Based on record review and interview, the facility failed to ensure a PRN order for an antianxiety medication had a 14 day stop date for one (#26) of five sampled residents reviewed for unnecessary psychotropic medications. The MDS coordinator reported 48 residents resided in the facility. Findings: Res #26 admitted with a diagnosis of anxiety. A physician's order, dated 06/27/24, documented lorazepam (a benzodiazepine) 1 mg. Special Instructions: Give one tablet (1 mg) by mouth every 12 hours as needed for anxiety. The order did not document a stop date. On 02/10/25 at 2:15 p.m., the corporate nurse consultant reported the PRN order should have had a 14 day stop date.

On 12/16/24 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect Res #1's right to be free from abuse. Res #1 was assaulted by Res #2 resulting in stab wounds which required sutures. On 12/16/24 at 11:24 a.m., the Oklahoma State Department of Health verified the existence of an IJ situation. On 12/16/24 at 12:48 p.m., the administrator was notified of the immediate jeopardy situation. On 12/16/24 at 4:00 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility plan of removal documented: a. all staff education - abuse and neglect policy and procedures and resident to resident conflicts. All staff will be educated with a sign in sheet that are currently working in the facility. Any remaining staff will be called and educated over the telephone. Employee names and time of call will be documented; b. behavior monitoring - currently in progress. All residents' charts will be reviewed for active behavior issues. Physician will be notified if any resident is displaying current behaviors. Interventions will be implemented and care plans updated as needed. Any resident assessed to be under the influence of alcohol will be monitored one on one until the physician is notified for further instructions. All residents with a diagnosis of alcoholism will be assessed and their care plan will be updated; and c. upon completion of the immediate corrections, audit and observations will continue by the administrator and director of nursing for 90 days. The IJ was lifted, effective 12/17/24 at 12:50 p.m., when all components of the plan of removal had been completed. The deficient practice remained as isolated with potential for harm to the residents. Based on observation, record review, and interview, the facility failed to ensure residents were free from abuse for two (#1 and #2) of six sampled residents reviewed for abuse. Res #1 was assaulted by Res #2 resulting in stab wounds which required sutures. The DON identified 48 residents who resided in the facility. Findings: An undated Resident Code of Conduct policy, read in part, The following code of conduct is effective in order to protect the rights and safety of all residents that reside here at [name withheld]. Violation of any of following acts could/will constitute cause for discharge from the facility: Under the influence/possession of alcohol, drugs, non-prescribed narcotics, or in any physical condition making it unsafe for residents or staff within the facility; any form of physical violence including throwing objects toward other residents or staff; unauthorized possession of firearms or other weapons on nursing home property; and any violation of residents/staff rights, including threats of any nature. An Abuse - Reportable Events policy, revised January 2018, read in part, It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person .When an employee becomes aware of an allegation or suspicion of abuse .the charge nurse will: asses the resident or resident(s) .notify the administrator .begin taking written statements from the person reporting the allegation or suspicion and any witnesses including staff, family, and/or residents .After investigation, administration will analyze the occurrence to determine what changes, if any, are needed to the policies and procedures to prevent further occurrences. 1. Res #1 was admitted with diagnoses which included anxiety and paranoid schizophrenia. An annual assessment, dated 05/10/24, documented Res #1 was cognitively intact, had minimal depression, and had not exhibited behaviors. 2. Res #2 was admitted with diagnoses which included alcohol abuse and major depressive disorder. A care plan, dated 12/06/21, documented Res #2 often had verbal outbursts towards staff. The care plan documented a goal was the resident would not exhibit behaviors harmful to self or others. An annual assessment, dated 01/15/24, documented the Res #2 was cognitively intact, had mild depression, and had not exhibited behaviors. A nurse note, dated 03/24/24, documented Res #2 was witnessed as intoxicated by staff. The note documented empty alcohol bottles were observed in the resident's room. A nurse note, dated 06/07/24, documented Res #2 verbally threatening physical harm to another resident. A nurse note, dated 10/27/24, documented Res #2 was in another unnamed resident's room yelling and cussing. The note documented Res #2 was removed from the other resident's room, but continued to yell/cuss and attempted to fight the other resident. The note documented Res #2 smelled of alcohol and an empty alcohol bottle was found outside in the courtyard trash can after the incident. There was no documentation of an incident report or investigation regarding the above incidents. There was no documentation of Res #2's behaviors documented in the care plan. An OSDH initial incident report form, dated 11/09/24, documented Res #1 stated Res #2 had entered their room while they were asleep and attacked them with a weapon. The report documented Res #1 appeared beaten with a bruised and bleeding face, blood running out of their right arm, and a puncture wound with moderate bleeding on their right foot. A staff witness statement, dated 11/09/24, documented Res #2's room was searched after the incident. The statement documented two small trash cans full of vodka and mouthwash bottles were observed. A hospital emergency room report, dated 11/09/24, documented Res #1 presented to the hospital with stab wounds to the right heel and right forearm, bruising to the left eye, and other various scratches/lacerations. The report documented Res #1 required sutures to close the wounds to the right heel and right forearm. An OSDH final incident report, dated 11/11/24, documented Res #2 was presently in jail and had been charged with first degree assault and battery. On 11/25/24 at 10:50 a.m., the DON stated Res #2 had a history of occasional alcohol abuse while residing in the facility. The DON stated they thought family members or other residents had provided Res #2 with the alcohol. They stated the resident had been counseled regarding the prohibition of alcohol within the facility in the past. The DON stated Res #2 was intoxicated on the day the assault on Res #1 occurred. They stated a pocket knife had been found that was used in the attack. The DON stated the facility was unable to determine which resident had the pocket knife prior to the assault. On 11/25/24 at 12:00 p.m., Res #1 was observed in their room. Res #1 stated they were assaulted with a pocket knife by Res #2 a few weeks ago. Res #1 stated they had a history of not getting along with Res #2. They stated they had never been physically attacked prior to the incident. Res #1 stated they received two wounds that required sutures and feared for their life on the day of the assault. On 11/27/24 at 9:00 a.m., the DON stated no interventions had been initiated or documented in Res #2's care plan to prohibit abusive behavior related to alcohol use. They stated Res #2's past incidents of abusive behavior should have been reported and investigated by the facility. It was documented Res #2 no longer resided in the facility.

Based on record review and interview, the facility failed to report an allegation of abuse to OSDH within two hours and failed to report an allegation of resident-to-resident abuse for two (#1 and #2) of six sampled residents reviewed for abuse. The DON identified 48 residents who resided in the facility. Findings: An Abuse - Reportable Events policy, revised January 2018, read in part, It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person .Abuse-2 hour limit .If the events that cause reasonable suspicion result in serious bodily injury, the report must be made immediately after forming the suspicion (but no later than two (2) hours after forming the suspicion) .All alleged allegations of abuse will be reported to the appropriate state agency and to all other agencies as required by regulation. 1. Res #1 was admitted with diagnoses which included anxiety and paranoid schizophrenia. An annual assessment, dated 05/10/24, documented the resident was cognitively intact, had minimal depression, and had not exhibited behaviors. An OSDH initial incident report form, dated 11/09/24, documented Res #1 stated Res #2 had entered their room while they were asleep and attacked them with a weapon. The report documented Res #1 appeared beaten with a bruised and bleeding face, blood running out of their right arm, and a puncture wound with moderate bleeding on their right foot. A fax transmission report documented the incident report was submitted to OSDH on 11/10/24. On 11/27/24 at 8:45 a.m., the DON stated the altercation between Res #1 and Res #2 occurred around lunch time on 11/09/24. They stated the initial OSDH report was not submitted within the required two hour timeframe. 2. Res #2 was admitted with diagnoses which included alcohol abuse and major depressive disorder. An annual assessment, dated 01/15/24, documented the resident was cognitively intact, had mild depression, and had not exhibited behaviors. A nurse note, dated 10/27/24, documented Res #2 was in another unnamed resident's room yelling and cussing. The note documented Res #2 was removed from the other resident's room, but continued to yell/cuss and attempted to fight the other resident. The note documented Res #2 smelled of alcohol and an empty alcohol bottle was found outside in the courtyard trash can after the incident. There was no report to OSDH regarding the incident located. On 11/27/24 at 8:30 a.m., the DON stated an allegation of abuse regarding Res #2 on 10/27/24 was not reported to OSDH. The DON stated allegations involving physical abuse were supposed to be reported, but they were not aware verbal allegations should be reported also.

Based on record review and interview, the facility failed to submit PBJ data to CMS for the third quarter of the fiscal year for 2023. The DON identified 56 residents resided in the facility. Findings: The PBJ Staffing Date Report documented the facility failed to submit data for the third quarter of 2023 (April 1 - June 30). On 12/07/23 at 11:29 p.m., the administrator reported she was not aware that the PBJ had not been submitted.

Based on observation, record review, and interview, the facility failed to ensure food was stored and prepared under sanitary conditions. The dietary manager identified 55 residents who received meals from the kitchen and one resident who received nutrition via tube feeding. Findings: On 12/04/23 at 8:30 a.m., an environmental tour of the kitchen was completed. The floors had dirt and food debris. There were five bowls of cereal, uncovered on tray, with cereal lying around the bowls on a shelf in the storage room. The grill had grease, food particles, and had a brown and black substance on the edges. The staff stated the grill had not been used today. The oven had a brown and black substance on the walls and doors. On 12/04/23 at 8:44 a.m., the DM stated the oven and grill was cleaned weekly. The DM stated the cleaning schedule documented the oven and grill was cleaned over the weekend two days ago. The DM stated it did not look like the oven and grill had been cleaned. The DM stated the kitchen floor was to be swept and mopped at 11:00 a.m. and at the end of the day daily. The DM stated it did not look like the floor had been swept and mopped last night. On 12/04/23 at 8:50 a.m., the ice machine in the resident dining room was checked for cleanliness using a white clean napkin. The ice drop had a pink slime when wiped with the napkin. On 12/04/23 at 8:52 a.m., the DM stated they did not know what the pink substance was and the ice machine was cleaned once a week by maintenance. A form, titled Ice Machine Cleaning Schedule, documented the ice machine was last cleaned on 11/28/23. On 12/04/23 at 10:40 a.m., the maintenance staff stated they did not know what the pink substance was on the ice machine, but was going to clean it.

Based on observation, record review, and interview, the facility failed to maintain an infection control program for transmission based precautions for one (#11) of one residents reviewed for transmission based precautions. The DON identified one resident currently on transmission based precautions. Findings: A form, titled Infection Control Isolation Policy, documented when isolation precautions are implemented the charge nurse was to determine the type of isolation per CDC guidance to be used, review isolation procedures with the nursing assistants providing care, and post appropriate isolation sign on the room entrance so all would be aware of isolation procedures in effect. A policy, with the subject of Infection Control-Clostridium Difficile, documented the staff were to wash their hands after assisting the resident with ADL care and after removal of personal protective clothing. Res #11 was readmitted to the facility with a diagnosis of enterocolitis due to C-Diff. The care plan, dated 08/22/23, documented the resident was receiving antibiotics for pneumonia and C-diff. The care plan documented staff were to follow universal/standard precaution to prevent cross contamination and spread of infection. The care plan documented the staff was to follow isolation precautions according to facility policy if necessary. The five day assessment, dated 09/04/23, documented the resident had a diagnosis of enterocolitis due to C-diff. On 12/04/23 at 10:54 a.m., the resident's door was open and the resident was lying in bed. There was no signage on or near the door alerting staff or visitors the resident was on transmission based precautions or what PPE was required. On 12/06/23 at 8:01 a.m., CNA #1 stated a gown and gloves were required when entering the resident's room. The CNA stated before leaving the resident's room they removed their gown and gloves, then used the alcohol based hand sanitizer in the hallway. The CNA stated they would locate a sink in a empty resident room, the utility room, or the staff break room the wash their hands. On 12/06/23 at 9:06 a.m., the DON stated there was no signage on the resident's door and should be regarding transmission based precautions for the resident. The DON was made aware of a CNA process for hand hygiene for the resident on contact precautions for C-diff. The DON stated the staff needed education regarding the requirement to wash their hands with soap and water and not use alcohol based hand gel for a resident on contact precautions for C-diff.

Based on record review and interview, the facility failed to ensure MDS assessments were submitted and accepted by CMS no later than 14 days calendar days after completion. The DON identified 56 residents resided in the facility. Findings: A batch transmittal report, dated 12/05/23, documented nine MDS assessments submitted later than 14 days after completion. On 12/05/23 at 2:59 p.m., Corporate Nurse #1 reported they knew the assessments were late and were trying to catch them up.

Based on record review and interview, the facility failed to complete quarterly assessments every three months for three (#1, 4, and #11) of 24 sampled residents MDS records were reviewed. The administrator identified 56 residents who resided in the facility. Findings: 1. Resident #11 had diagnoses which included pneumonia, enterocolitis due to clostridium difficile, hypertension, chronic pain, psychosis, and schizoaffective disorder. The resident's EHR documented an admission assessment dated [DATE]. A quarterly assessment dated [DATE] was documented as still in process and had not been accepted. On 12/05/23 at 2:58 p.m., Corporate Nurse #1 stated they were aware the MDS assessments were behind and not completed in the required time frames. 43023 2. Res #4 had diagnoses which included anxiety, diabetes, and hypertension. An annual assessment, dated 08/13/23, was documented in the EHR. A quarterly assessment, dated 11/13/23, was documented as In Progress in the medical record. 46582 3. Res #1 had diagnoses which included schizophrenia and hypertension. A quarterly assessment, dated 08/18/23, was documented in the EHR. A quarterly assessment, dated 11/18/23, was documented as In Process in the medical record. On 12/05/23 at 2:40 p.m., the DON stated the MDS coordinator had been off work for the past four weeks and all of the MDS assessments were behind.

Based on record review and interview, the facility failed to ensure comprehensive assessments were completed within 14 days after admission for three (#55, 58, and #59) of 24 residents whose MDS assessments were reviewed. The Long-Term Care Facility Application for Medicare and Medicaid form documented 56 residents resided in the facility. Findings: 1. Res #58 was admitted on [DATE] with diagnoses which included schizoaffective disorder, acute embolism and thrombosis of the deep veins in lower extremities, and hypertension. On 12/04/23 at 2:00 p.m., Res #58's record was reviewed and documented an admission assessment as In Process. 43023 2. Res #55 was admitted to the facility on [DATE] with diagnoses of schizophrenia, anxiety disorder, and depression. A review of Res #55's assessments documented the admission assessment, dated 11/14/23, was still in progress and not completed. 33097 3. Resident #59 was admitted to the facility on [DATE] with diagnoses which included history of benign neoplasm of the brain, alcohol abuse, cerebral edema, epilepsy, pain, and mild cognitive impairment. The resident's EHR documented the MDS admission assessment dated [DATE] was still in process and had not been accepted. On 12/05/23 at 2:40 p.m., the DON stated the MDS staff had been off work for the past four weeks. The DON stated the admission assessment for resident #59 had not been completed within the 14 day required time period. On 12/05/23 at 2:58 p.m., Corporate Nurse #1 reported they knew the assessments were behind and were trying to catch them up.

Based on record review and interview, the facility failed to ensure ABN and NOMNC notices were signed and/or acknowledged by the resident and/or representative for two (#11 and #36) of two residents who were discharged from Part A skilled services with benefit days remaining and remained in the facility. The Beneficiary Notice worksheet identified five residents who were discharged from Part A skilled services with benefit days remaining in the previous six months. Findings: 1. Res #11 was admitted to part A skilled services on 09/01/23, discharged from skilled services on 10/26/23, and remained in the facility. Res #11's ABN and NOMNC beneficiary notices, dated 10/24/23, had no signature or documentation of acknowledgement by the resident or resident representative. 2. Res #36 was admitted to part A skilled services on 05/02/23, discharged from skilled services on 07/18/23, and remained in the facility. Res #36's ABN and NOMNC beneficiary notices, dated 07/17/23, read in part, .Pt unable to sign r/t physical/cognitive state . There was no documentation of acknowledgment of the notices from the resident's representative. On 12/06/23 at 8:30 a.m., the administrator stated the ABN and NOMNC notices for Res #11 and Res #36 should have been signed by the resident or their representative. They stated if the resident was unable to sign due to physical/cognitive decline, the resident's representative should have been notified for acknowledgement. The administrator stated there was no additional documentation of representative acknowledgement of the ABN or NOMNC notices for Res #11 or Res #36.

Based on record review and interview, the facility failed to ensure the physician responded to a pharmacist MRR in a timely manner and according to the facility policy for two (#31 and #6) of five sampled residents reviewed for unnecessary medications. The Long-Term Care Facility Application for Medicare and Medicaid form documented 56 residents resided in the facility. Findings: A Pharmacy Consulting Recommendation Policy & Procedure policy, undated, read in part, .The appropriate time frames for the different steps in the MRR process: within 5 business days from the pharmacist visit, the facility will send the MRR reports to the residents' physicians for review, with-in another 5 business days the physician will act on the MRR and return to the facility and with-in another 5 business days the facility will act on the recommendations if applicable and the total process will be with-in a month timeframe . 1. Res #31 had diagnoses which included alcohol dependence with withdrawal delirium, post-traumatic stress disorder, and major depressive disorder. A physician order, dated 12/08/21, documented to administer Klonopin 1 mg twice daily for alcohol dependence with withdrawal delirium. A quarterly assessment, dated 10/23/23, documented the resident was cognitively intact, required set-up assistance with most ADLs, and received antianxiety medication. A MRR, dated 07/18/23, documented a request for a GDR on Res #31's Klonopin. The MRR documented the physician agreed to the reduction request on 08/28/23. 2. Res #6 had diagnoses which included bipolar disorder, major depressive disorder, and vascular dementia. A physician order, dated 06/04/20, documented to administer fluoxetine (Prozac) 20 mg daily for major depressive disorder. A quarterly assessment, dated 06/11/23, documented the resident had severe cognitive impairment, required limited assistance with most ADLs, and received antidepressant medication. A MRR, dated 07/20/23, documented a request for a GDR on Res #6's Prozac. The MRR documented the physician declined the reduction request with rationale on 08/28/23. On 12/06/23 at 2:41 p.m., the DON stated the physician did not respond to the July MRR request for Res #31 and Res #6 within the required timeframe. They stated the physician must have addressed both the July and August MRRs on 08/28/23.

Based on observation, record review, and interview, the facility failed to maintain acceptable weight parameters and provide nutritional supplements as ordered by the physician for one (#11) of three residents who were reviewed for weight loss. The DON identified three residents with significant weight loss in the past six months. Findings: Res #11 was admitted to the facility with schizoaffective disorder, bulimia nervosa, muscle wasting and atrophy, weakness, and iron deficiency anemia. The resident's EHR documented on 06/01/23 the resident weighed 100 pounds. There was not a weight documented for July 2023. The EHR on 08/07/23 documented the resident weighed 96.8 pounds. A physician order, dated 08/07/23, documented the resident was to receive a cup of sherbet twice a day between meals. There was no documentation in the resident's record of the resident receiving the sherbet. An MDS 5 day assessment, dated 09/04/23, documented the resident was moderately impaired for daily decision making and received a therapeutic diet. The assessment documented the resident weighed 97 pounds. The assessment documented the resident had not had a weight loss of 5% or more in the last month or a loss of 10% or more in the last six months. The EHR on 09/15/23 documented the resident weighed 90 pounds. A physician order, dated 10/17/23, documented the resident was to receive a house supplement three times a day with meals. There was no documentation the resident was receiving the supplement. There was not a weight for October 2023. The EHR documented on 11/03/23 the resident weighed 83.4 pounds. A dietary note from the dietician, dated 11/17/23, documented the resident weighed 83 pounds. The note documented the resident had a significant weight loss of 13% in three months. The note documented to notify the physician and recommended house supplements twice a day. There was no documentation the physician was notified of the significant weight loss or the dietician's recommendation. The EHR documented on 11/17/23 the resident weighed 80 pounds. The EHR documented on 12/01/23 the resident weighed 78 pounds. The care plan, dated 12/01/23, documented the resident had an excessive weight loss as evidenced by the resident refusing to eat, refusing most medications, and c-diff infection continued since last admission. The goal was for the resident not to have further weight loss and will maintain weight at present level or show stable increase to ideal body weight range. Interventions were for staff to obtain weekly weights, record percentage of snacks and/or supplements as ordered, and notify the physician of weight loss. On 12/04/23 at 10:55 a.m., the resident was lying in bed watching television. The resident stated the staff told them they had lost weight. The resident stated she ate when she was hungry. On 12/06/23 at 11:34 a.m., the DON stated they were responsible for informing the physician of the dietician's recommendations. They stated most of the time a verbal communication was given, but sometimes a fax was sent. The DON stated for the resident a verbal communication was made regarding the resident's weight loss to the physician. The DON stated no new orders were received regarding the residents weight loss. The DON stated there was no documentation regarding the resident receiving a house supplement or the sherbet between meals. On 12/06/23 at 11:50 a.m., a meal service was observed. The resident did not receive a house supplement with their meal. On 12/06/23 at 12:10 p.m., CNA #1 stated the resident had not been receiving a sherbet supplement between meals. On 12/06/23 at 2:23 p.m., the DM stated there was no sherbet currently in house. The DM stated they had placed on order for the sherbet and was to be on the delivery truck next week. Stated there was no documentation regarding providing the sherbet between meals as ordered by the physician. The DM stated they had been providing the sherbet with the lunch and supper meals.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for one (#58) of 15 sampled residents whose care plans were reviewed. The Long-Term Care Facility Application for Medicare and Medicaid form documented 56 residents resided in the facility. Findings: Res #58 was admitted on [DATE] with diagnoses which included schizoaffective disorder, acute embolism and thrombosis of the deep veins in lower extremities, and hypertension. There was no comprehensive care plan for Res #58 in the clinical record. On 12/07/23 at 9:00 a.m., the DON stated a comprehensive care plan had not been completed but should have been.

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents who had fallen had interventions put in place to prevent the recurrence of falls. Res #25 had experienced five falls in eight months with one fall resulting in a hematoma with a laceration requiring sutures to close. Res #40 experienced nine falls over the previous 12 months with several falls resulting in bruising, scrapes, and lacerations. Res #28 experienced 17 falls over the previous 12 months with one fall resulting in a fractured nose. On [DATE] at 2:14 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation related to falls. On [DATE] at 2:17 p.m., the administrator was notified of the IJ situation. On [DATE] at 5:51 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: [DATE] Boyce Manor IJ Plan of Removal for Fall Prevention Completion Date [DATE] 11:00 PM All Staff Education Fall Prevention Policy Clinical Staff Education 1. Fall Prevention Policy 2. Incident/Accident Policy 3. Fall Interventions 4. Root Cause Analysis 5. Fall Risk Assessments 6. Fall Care Plans Update Fall Risk Assessments on all residents Update Fall Care Plans for residents if applicable Implement Fall Intervention Book for all staff Fall Care Plans and Interventions Updated for the 3 affected residents The Administrator and Clinical Managers will review all incidents/accidents daily at the morning meeting to ensure completion with root cause established. They will monitor for appropriate fall intervention, updated fall risk assessment, and updated fall care plan. Monitoring will be continuous. The IJ was lifted, effective [DATE] at 9:53 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern with potential for harm to the residents. Based on record review, observation, and interview, the facility failed to place interventions to prevent the recurrence of falls for three (#25, 28, and #40) of three residents reviewed for falls. The facility administrator reported 18 residents had fallen in the previous six months. Findings: 1. Res #28 had diagnoses which included epilepsy, conversion disorder, diabetes mellitus, lack of coordination, muscle weakness, unsteadiness on feet, psychotic disorder, moderate intellectual disabilities, and cirrhosis of the liver. A care plan, titled Falls, dated [DATE], documented a goal of no falls with injury for 90 days. The care plan was last reviewed on [DATE]. A second care plan for falls, titled [name deleted] has experienced an actual falls r/t impaired cognition, impaired decision making, disease process, and medication, dated [DATE], documented dates of falls the resident experienced with interventions put in place to prevent recurrence. This care plan was last reviewed on [DATE]. A nurse note, dated [DATE], documented a CNA/CMA overheard a male resident yelling at someone and when she responded to the room found this resident lying on the floor. The STPR was to attempt to keep this resident out of other resident rooms. The resident's care plan was not updated with this fall intervention. A nurse note, dated [DATE], documented the resident was found on the floor by a hospitality aide. The resident had experienced a laceration over the right eye. The accompanying incident report documented the resident received six sutures to the forehead. The care plan documented an intervention of reorient confused resident as necessary. An additional care plan update, dated [DATE], documented to monitor for signs and symptoms of any pending seizure activity and safety of the resident. A nurse note, dated [DATE], documented the resident was found on the floor by a hospitality aide. The note documented the resident was convulsing and had a distant stare, tongue protruding, and the resident would not allow a blood pressure reading. The note documented the resident had a red area to the right forehead and on the left arm. No STPR were documented. A nurse note, dated [DATE], documented the resident was sitting on her wheelchair when the staff heard her hit the floor. The note documented there were no visible injuries, however the resident would not respond and she was sent to the emergency room . The accompanying incident report, dated [DATE] documented the fall and an intervention to place a fall mat beside the resident's bed. The care plan was updated with the new intervention of placing fall mats beside bed on floor while the resident was in bed. The note documented the resident had been in her wheelchair and not in bed when this fall occurred. A nurse note, dated [DATE], documented the resident was found on the floor in her room. The note documented the resident had discoloration to the left hip and elbow. The resident's care plan was updated with Increased staff supervision with intensity based on resident need. A nurse note, dated [DATE], documented the nurse was called to the room by a CNA. The resident complained of pain to the left leg and had two small open reddened spots to the left knee, a small open sore to top lip. The note documented the resident stated she had fallen out of bed. The corresponding incident report documented a STPR of check resident every hour and to ensure she has her helmet on. The care plan was not updated with the intervention of every hour visual checks. The facility was unable to produce documentation the hourly visual checks had been implemented. A nurse note, dated [DATE], documented the resident was found in the floor by a CNA with a laceration above the right eye, swelling of the face, abrasions to both arms, bleeding from the mouth and nose. The note documented the resident was sent to the emergency room . No STPR were documented. A nurse note, dated [DATE], documented the resident was found on the floor in another resident's room. The note documented the left facial area was swollen and the resident complained of pain to the left hand. The note documented the resident's gums were bleeding and the resident was sent to the emergency room . No STPR was documented. A follow up note on the fall, dated [DATE], documented the resident's left eye was swollen and matted shut and her left cheek was swollen and discolored. A quarterly assessment, dated [DATE], documented Res #28 was moderately impaired in cognitive skills for daily decision making, and required limited to total assistance with most ADLs. The assessment documented the resident did not walk and had experienced falls in the ,d+[DATE] months prior to admission, entry, or reentry. The assessment documented two or more falls resulted in no injury and two or more falls resulted in minor injury. A nurse note, dated [DATE], documented a CNA found the resident on the floor in her room and the resident was bleeding from her head. The note documented the resident's Hospice was contacted and did not want the resident sent out. No STPR was documented. An unsubmitted annual assessment, dated [DATE], documented Res #28 was moderately impaired in cognitive skills for daily decision making, and required limited to total assistance with most ADL. The assessment documented the resident did not walk and had experienced falls in the ,d+[DATE] months prior to admission, entry, or reentry. The assessment documented two or more falls resulted in no injury and two or more falls resulted in minor injury. A nurse note, dated [DATE], documented the resident was sitting in her wheelchair in the dining room when she leaned forward to pick something off the floor and fell on to her forehead and nose. The note documented the resident sustained a laceration to the middle of the forehead with a large amount of bleeding and swelling of her nose. The note documented the resident was sent to the emergency room . No STPR of falls was documented with this fall. A nurse note, dated [DATE], documented the resident had fallen in another resident's room. The note documented the previous laceration to the resident's forehead which had been dermabonded was bleeding and the resident was bleeding from the nose. The note documented the bridge of the resident's nose was very swollen and blood was coming out of her mouth. The note documented the resident was sent to the emergency room . The resident's care plan for falls was updated with Keep personal items and frequently used items within reach on [DATE]. The resident fell in another resident's room. A third care plan for falls titled [name deleted] IS AT Risk for falls R/T IMPAIRED COGNITION, MEDICATION, documented a goal of no falls with injury for 90 days. The care plan was last reviewed on [DATE]. A nurse note, dated [DATE], documented the resident had fallen in another resident's room without injury. No STPR was documented. A nurse note, dated [DATE], documented the resident was found lying on the floor in her room with blood on the floor. The note documented the resident had sustained a laceration above the left eyebrow. The note documented the facility tried to steri-strip the laceration closed but where unable to keep the closures in place. The note documented the resident was then sent to the emergency room . No STPR was documented. A nurse note, dated [DATE], documented the resident was waiting outside of the dining room for a meal when she leaned forward and fell out of the wheelchair. The note did not document any injury. No STPR was documented. A nurse note, dated [DATE], documented the resident was found on her bedroom floor, face down, and had a large amount of blood coming from her nose and mouth along with swelling. The note documented the resident was sent to the emergency room . The accompanying incident report, dated the same day, documented the resident had sustained a fractured nose. No STPR was documented. A nurse note, dated [DATE], documented the resident had an unwitnessed fall in her room. The note documented the resident appeared uninjured but was very lethargic, and would only respond to touch. The note documented it was hard to determine if the resident had sustained any new injuries as she was swollen and very bruised from the previous fall. No STPR was documented. A nurse note, dated [DATE], documented the resident had experienced a witnessed fall in the common area. The note documented the resident was medicated for pain and since the fall had been very lethargic and responsive only to touch. No STPR was documented. On [DATE] at 12:40 p.m., the resident was observed lying in bed while a CMA attempted to administer medications. The resident did not arouse when spoken to or touched by the CMA. After some time, the resident opened her eyes and was administered the medication by the CMA. At that time the CMA reported this was very unusual behavior for her. The resident's face appeared very swollen and bruised. On [DATE] at 12:43 p.m., the CNA/RA reported the resident had fallen while trying to transfer. On [DATE] at 3:47 p.m., a family member reported the facility notified her when the resident fell . The family member stated the resident fell frequently and recently broke her nose. On [DATE] at 1:32 p.m., the DON and MDS coordinator #2 were interviewed regarding the falls and STPR. The MDS coordinator stated she was aware new interventions should have been tried with each fall and the interventions should have been documented in the care plan. The DON stated the facility did not have a fall program and if there were any other interventions she would not know where they were documented. The MDS coordinator stated the resident only had quarterly fall assessments. A nurse note, dated [DATE], documented the resident expired at the facility. 2. Res #25 had diagnoses which included chronic obstructive pulmonary disease, muscle weakness, unsteadiness on feet, conversion disorder with seizures or convulsions, vascular dementia, and cerebellar stroke syndrome. A care plan, titled ''[name deleted] has experienced actual fall,'' dated [DATE], documented the resident had experienced several falls. The care plan was last reviewed on [DATE] and last revised on [DATE]. A second fall care plan, dated [DATE], documented the resident was at risk for falls due to medication and impaired cognition. A nurse note, dated [DATE], documented the resident was found on the floor in the back lobby and had apparently fallen out of the wheelchair. The note documented the resident had a large contusion to her forehead and bruising to the left cheek. The note documented the resident was sent to the emergency room . The care plan was updated to include physical therapy and occupational therapy. An annual assessment, dated [DATE], documented Res #25 was severely impaired with cognitive skills for daily decision making, required limited to extensive assistance with ADLs, and had not experienced any falls. The care area assessment triggered falls for care planning. A nurse note, dated [DATE], documented the resident was found lying face down in the Hall 200 lobby. The note documented the resident had a bump on the left forehead. No STPR were documented. A nurse note, dated [DATE], documented the resident was found on the floor during physician rounds with a large amount of blood coming from her forehead. The note documented the resident was sent to the emergency room and was treated for a contusion, hematoma, and laceration. The note documented Res #25 received sutures to her forehead. The accompanying incident report documented the fall but did not document STPR. A quarterly assessment, dated [DATE], documented Res #25 was severely impaired with cognitive skills for daily decision making, required total assistance with ADLs, and had one fall with no injury. A nurse note, dated [DATE], documented the nurse was called to the resident's room by another resident who observed the resident on the floor. The note documented the resident sustained a small knot to the forehead, and some redness to both knees. The accompanying event report documented the fall but no STPR were documented. A nurse note, dated [DATE], documented the resident was attending a church service in the lobby when she leaned over and fell on to her left side. Neither the nurse note or the accompanying event report documented STPR of falls. On [DATE] at 1:13 p.m., the DON and MDS coordinator #2 were interviewed and reported they were notified of falls by reviewing the nurses notes unless it was a reportable fall which would be reported by a phone call by the facility staff. The MDS coordinator stated they were notified of falls in the daily meeting as well. The MDS coordinator stated she did an intervention for the [DATE] fall of obtaining a new wheelchair for the resident, but had not put it in place as yet. She stated she instructed staff to put her in her recliner or in bed rather than leaving her up on her wheelchair. The MDS coordinator stated she did not update the care plan with the new interventions and had not documented them anywhere else. 3. Res #40 had diagnoses which included acute and chronic respiratory failure with hypoxia, weakness, lack of coordination, age-related debility, and bradycardia. An admission assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making and required extensive assistance with ADLs. The Care Area Assessment documented falls were triggered for care planning. A nurse note, dated [DATE], documented the resident was lying on the other bed in her room when she fell between the bed and the wall. The note documented the fall was unwitnessed and the resident stated she hit her head but no injury was found. A care plan, dated [DATE], was initiated to prevent falls. The care plan was last revised on [DATE] and reviewed on [DATE]. A nurse note, dated [DATE] documented the resident had experienced an unwitnessed fall and related she bumped her head. The note documented the resident had mild chronic pain unrelated to the fall. The accompanying incident report documented the fall and to increase staff supervision with intensity based on resident needs. The plan of care was not updated. A nurse note, dated [DATE], documented the resident was found on the floor by a CNA. The note documented the resident was not injured but was more confused and weaker than normal. The note documented the resident was sent to the emergency room . No STPR were documented. A nurse note, dated [DATE], documented the resident had an unwitnessed fall when the resident's wheelchair tilted back. The note documented the resident had a bump on the back of her head. The accompanying incident report documented the fall. There were no STPR documented. A nurse note, dated [DATE], documented the resident was seen by a CNA crawling on the floor outside of her room. The note stated the mattress was off the bed, the chair was tipped over as wall the bedside table. The note documented the resident was not injured. The accompanying event incident report documented the fall. No STPR were documented. A nurse note, dated [DATE], documented the resident experienced an unwitnessed fall on the couch in the back lobby. The note documented the resident could not remember how she fell and had not sustained any injuries. No fall investigation was provided. No STPR were documented. A nurse note, dated [DATE], documented the resident tried to get into bed when she fell on to the floor and sustained scratched to her lower right leg. The note documented first aide was applied. The care plan was updated to give the resident verbal reminders to not transfer or ambulate without assistance. A nurse note, dated [DATE], documented the resident reported falling out of bed to a CMA. The note documented the resident had a small knot to the posterior scalp and a large bruise to the right shoulder blade, and abrasion scrape to the left upper thigh, dark bruising to the right hand and forearm, and dark bruises to the posterior upper arm/axilla area. The note documented two skin tears to the right shin area. No STPR was documented. A quarterly assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making and required extensive assistance with ADLs. The assessment documented the resident had one fall with no injury and one fall with minor injury. A nurse note, dated [DATE], documented the resident was found on the floor in her room by staff. The note documented the resident was not injured and staff were instructed to check on the resident more frequently which was an intervention utilized previously. The plan of care was not updated. On [DATE] at 1:02 p.m., the DON and MDS coordinator #2 were interviewed and reported the above falls did not all have interventions to prevent recurrence of falls. The MDS coordinator stated all the falls should have had new interventions care planned.