**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -R21 was readmitted to the facility on [DATE] with diagnoses which included unspecified dementia (a clinical syndrome that occurs when a person has dementia but it can't be diagnosed as a specific type), unspecified severity, with other behavioral disturbance (a pattern of disruptive behaviors that can cause problems in social, home, and school settings) and delirium (a mental state that causes a person to be confused, disoriented, and have reduced awareness of their surroundings) due to known physiological condition. Review of the annual Minimum Data Set (MDS) (Comprehensive) assessment dated [DATE] revealed the resident scored 12 on the Brief Interview for Mental Status (BIMS) assessment, indicating moderately impaired cognition. An Incident Note dated [DATE] at 3:12 PM revealed the resident was the recipient of physical aggression from another resident (R206). -R206 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and delirium due to known physiological condition. The admission MDS assessment dated [DATE] revealed the resident scored 9 on the BIMS assessment, indicating moderately impaired cognition. An Incident Note dated [DATE] at 3:59 PM revealed R206 initiated physical aggression with another resident (R21). Review of the facility's investigation report dated [DATE], revealed the charge nurse heard some verbal commotion as she was at the Household 1 nursing station. The commotion was coming from down the hallway. Just as the nurse looked that direction, she witnessed both residents parked parallel to one another and verbally exchanging words. Then, R206 swung her arm out and hit R21 on the right arm. From the opposite direction, another staff witnessed R206 also hit R21's right cheek. The two staff members who observed the altercation immediately intervened and ran over to separate the two residents. An interview was conducted on [DATE] at 2:15 PM with a Certified Nursing Assistant (CNA14). She stated that R206 would go into R21's bathroom and sometimes they would have altercations about it. She stated that they moved R206 to another room, but R206 would tend to stay around R21's room. She stated that staff would separate the residents and that R206 was on 15-minute checks for the longest time because of her behavior. During an interview conducted on [DATE] at 2:41 PM with a Licensed Practical Nurse (LPN2). She stated that R21 was always doing things to the other residents, and that R206 went into everybody's room. She stated that at that time, they just kept them separated. She stated they would take R206 back to her room, but she just couldn't comprehend that. R21 was educated to come to staff, but they couldn't always keep an eye on them. She stated that she saw R206 raise her fist and hit R21 on the right arm. Another staff (CNA15) saw R206 hit R21 in the right cheek. She stated that she thought R21 might have had a little bit of redness, she couldn't really remember. She stated that R206 was not hit. On 0927/24 at 1:13 PM an interview was conducted with the Director of Nursing. She stated that supervision was one of the hardest challenges, and day shift was really, really busy. She stated that she was trying to emphasize that the charge nurse goes rounding with the CNA's so they that things are getting done. She stated that she tries to educate the charge nurses because it was hard to say that supervision was being done. She stated that it was unfortunate that the blanket waiver for unit aides was lifted, so they don't have them anymore. She stated that they were really helpful and prevented a lot of incidents. She stated that the intervention was to keep the residents apart as much as possible, and to have the social worker to educate them on not behaving like that. She stated that they still slipped through, and that staffing-related issues were one of the biggest challenges right now. A request was made for the Resident Supervision and Dementia Care policies. The Assistant Director of Nursing indicated that they did not currently have policies on resident supervision and dementia care. Based on interview and record review, the facility failed to protect the resident's right to be free from neglect (R106) and failed to protect residents' right to be free from physical abuse by another resident for (R)(R2 and R27) for 7 sampled residents reviewed for abuse as evidenced by: 1. Failed to ensure resident-centered care and treatment was provided in accordance with professional standards of practice to 1 of 6 sampled residents (R) (R106) reviewed for accidents. Licensed Practical Nurse (LPN) 6 failed to conducted neuro checks to assess for neurological changes and ensure timely interventions after R106's unwitnessed fall, 2. Failed to provide adequate supervision for 1 of 6 sampled residents (R106) reviewed for accidents to prevent recurrent falls when one to one staffing was recommended but not provided, 3. Failed to provide sufficient certified nursing aides (CNA)s on R106's unit for 7 of 16 days when R106 fell. 4. Failed to ensure 1 of 6 sampled staff (LPN6) reviewed completed required annual training including Fall prevention and management during the past two years. The cumulative effect of these failures contributed to environment of neglect. The failure to implement 1:1 monitoring as assessed and identified to ensure resident's safety given repeated falls, failure to ensure staff completed training on fall prevention and management, failure to conduct neuro checks after unwitnessed fall and failure to ensure sufficient nurse staffing to ensure resident safety resulted in harm to R106 who required hospitalization, ventilator care, surgery and subsequently died after final fall in the facility. In addition, the facility failed to: 5. Ensure R27 was free from physical abuse when R106 hit him in the face and pulled his arm. 6. Ensure R2 was free from physical abuse when R21 hit her in the face. These failures placed R27 and R2 at risk for pain and a diminished quality of life. Findings include Review of facility policy Abuse-Investigation and Reporting, revised [DATE], documented Neglect/Mistreatment was defined as failure to give appropriate care, ignore or disregard Residents shall not be subject to abuse by any individual which includes .other residents. The policy outlined that abuse included physical abuse such as hitting/slapping grabbing . Review of Resident 106's (R106) record documented the resident was admitted on [DATE] with diagnosis including dementia, diabetes, frequent falls, orthostatic hypotension (sudden drop in blood pressure when you stand up from a sitting or lying position) and stroke. R106's Minimum Data Set (MDS-assessment tool), dated [DATE], documented resident's brief interview for mental status was 12 of 15, indicating moderate cognitive impairment and required supervision or touch assistance when transferring from chair to bed or walking 50 feet while using a walker. Resident was transferred to the hospital on [DATE]. Review of R106's care plan documented resident was at risk for falls related to history of recurrent falls, wandering, confusion and gait (walking) imbalance with goal that resident would not sustain serious injury related to fall. Actions to achieve goal included follow facility fall protocol to prevent fall and monitoring protocol with start date [DATE] and had unwitnessed fall on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] and witnessed fall on [DATE] and [DATE]. Please monitor his vital signs, neuro checks, pain, skin condition, ROM (range of motion) and delayed injuries. Follow the facility protocol for monitoring s/p (status post, after) fall condition with start date [DATE]. Review of facility's fall incident reports documented resident had 16 falls during four-month stay. Falls on [DATE] (unwitnessed), [DATE] (unwitnessed), [DATE], [DATE], [DATE] (unwitnessed), [DATE] (unwitnessed), [DATE], [DATE] (unwitnessed), [DATE] (unwitnessed), [DATE] (unwitnessed), [DATE] (unwitnessed), [DATE] (unwitnessed), [DATE](unwitnessed), [DATE] (unwitnessed), [DATE], [DATE] (unwitnessed). Twelve of the 16 falls were unwitnessed. 1. Neuro checks (Please also refer to F689) Review of facility's Falls and Fall Risk Managing policy, dated 1/2024, documented under section Steps (Post Fall) 30 minutes 3. neurological checks: Required for all falls with head injury or unwitnessed falls. a. Neurological checks include assessing: i. Glasgow Coma Scale [a tool used to measure a person's level of consciousness and how responsive they are], ii. LOC (level of consciousness), iii. Orientation, iv. Movement in Extremities, v. Pupil size and reaction and vi. Speech and Responses. b. For 72 hours at a frequency of: i. q (every) 15 min(utes)x1 hour, ii. q30 min(utes) x 1 hour, iii. q1 hourx4 hours, iv. q4 hoursx24 hours, then v. qshift x72 hours, 4. Monitor vital signs, 5. Monitor for signs/symptoms of delayed injury (i.e., bruising, bleeding, fracture). 1 hour: 2. Complete the following documentation: a. Post Fall Screening Sheet .e. Neurological Checklist with a head injury and unwitnessed fall (UDA)(user defined assessment) PROGRESS NOTES Review of R106's progress notes, dated [DATE] at 8:46 PM, Licensed Practical Nurse (LPN)6 documented Informed by another resident (R), R106 was sitting on floor in the Great Room. No wheelchair in area and attempting to get up but not calling out. Resident's wheelchair was found in room [ROOM NUMBER] by bathroom door and bed linen in room was ruffled up. Resident was attempting to get up during assessment. No injury noted, no bump on head, no bleeding. Resident questioned if he was hurting or if he bumped his head. Denied both and wanted to get up. Resident asked if he needed to go to the hospital - denied. Resident was then assisted to w/c. Continuing on VS [vital signs] from recent fall earlier. Phone cont(inue) busy. Review of R106's progress notes, dated [DATE] at 10:57 PM LPN6 documented During shift report, CNA (Certified Nursing Aide) reported Resident (R106) having multiple episodes of emesis (vomiting). Near beginning of shift CNA reported Resident vomited; VS [vital signs] taken, BSL @ (blood sugar level at) 223. Elevated BP, confused and aggressive. Review of R106's progress notes, dated [DATE] at 2:58 AM LPN6 documented Resident reported with bout of emesis this shift approx(imately) 2000 (8PM). VS taken and CNA reported elevated BP (blood pressure). Resident monitored by CNA, attempting to get up OOB (out of bed), bed alarm sounding d/t (due to) continued restlessness. During bed checks, Resident sleeping w/ (with) legs hanging off the side of the bed, 1/2 dressed and partly exposed. Assisted CNA with getting Resident back into bed and changed. Encouraged Resident to rest and he calmed down.Called to room when emesis reported. VS cont(inue) w/ elevated BP, skin cool to the touch, staff reported Resident did not look right/normal. Called ER (emergency room) and spoke w/ Nurse [Name of nurse], we would send Resident in via facility van. Returned to Resident and was informed Resident was now unable to stand, more lethargic, VS unchanged and cont(inue) cool to touch. Called ER, then EMS for transport. Resident left facility at 2340 (11:40 PM) FALL INVESTIGATION Review of facility incident witness report form, dated [DATE] at 8:30 PM, documented by LPN6 showed checkmark in box for Other and a checkmark was not shown in box for Fall for type of incident. The details section documented Alerted to (R106) was sitting on floor in Great Rm (room) but another resident. No calling out observed. When notified by staff, Resident wanted assist to get off of floor. During the assessment of Resident, CNAs attempted to get Resident up but were told to wait since Resident had to be assessed. Resident told staff I slipped when asked. But no w/c (wheelchair) nearby. WC found in RM [ROOM NUMBER] with alarm sounded and muted. Resident assisted off of floor to w/c x3 staff. While being assess Resident denied hitting head, denied pain, denied wanting to go to the hospital. Just wanted to get up. Resident on AC (alert charting) for recent fall, no new protocol continued. Resident cont(inued) with ongoing behavior prior to fall. Had resident sit in w/c-later assisted to room. Review of facility incident witness report form, dated [DATE] at 8:15 PM, documented by LPN2 showed checkmark in box for Fall as type of incident with details At approx(imately) 2015 (8:15 PM) I was completing treatments in (nursing unit). I had gathered my supplies and was entering RM [ROOM NUMBER] when I heard [name being called], I leaned back out of the room and resident [room number of resident] was pointing into the living room area. As I looked in that direction, I observed [R106] lying on the floor near the [unit] kitchenette. [Name of LPN6] was nearby and I asked her Did you guys put [R106] on the floor? He's on the floor. [LPN6] walked over and observed resident then called to the night CNAs The following documents were not provided by facility for [DATE] fall, which were required per facility policy after an unwitnessed fall, including: 1. Post Fall Screening form which is a checklist to determine why resident fell such as what type of footwear resident was wearing, if environment was clear or cluttered, was resident confused or dizzy, was resident wearing glasses or hearing aide, if there were skin tears, lacerations or any injuries, immediate blood pressure, oxygen saturation level, heart rate, temperature, pain level, level of consciousness. 2. Interdisciplinary Post-Fall Assessment form which describes fall, outlines the number of falls in the last 30, 90 and 180 days, if there were recent medication changes, pattern of current falls such as time of day, six month review of falls and if there were any patterns or trends related to falls, probable cause of falls, root cause analysis of falls, recommendations from the review by IDT (Interdisciplinary Team), and care plan revisions. 3. Neurological check form that documented initial assessment of resident's pupil size and reaction to light, movement of extremities, vital signs, and level of consciousness. 4. Post Fall-Nurse Neurological Check Guidelines that documented assessment of resident's pupil's reaction to light, able to follow finger, verbal responses, pain level and level of consciousness every 15 minutes for 1 hour, every 30 minutes x4, every hour x4, every four hours x4 and every shift x3. 5. 72-hour intentional rounding after fall that assessed and documented pain, positioning, peri-needs and possessions such as call light within reach, glasses, water and environmental conditions every hour. INTERVIEWS During an interview on [DATE] at 7:36 AM LPN2 stated that when residents have an unwitnessed fall she completes neuro checks and completes fall packet which includes neuro checks every 15 minutes x4, then every 30 minutes x4 and so forth as outlined on form. LPN2 stated that she checks on the resident's level of consciousness, if the resident is alert, lethargic, nonresponsive, the resident's pupils reaction to light, size, extremity strength, weakness, and take their vitals. LPN6 stated when R106 fell on [DATE] she had worked the day shift and her shift ended at 7:30 PM but was doing a last minute treatment on R106's unit when she heard a resident calling her name who directed her that R106 was on the floor. LPN2 stated that she asked LPN6 if she put R106 on the floor and LPN6 said no and then LPN6 called the CNAs over to help. LPN2 stated that R106's fall was unwitnessed because R106 was found on the floor and staff did not put R106 on the floor. During an interview on [DATE] at 2:48 PM Assistant Director of Nursing (ADON) who was also the facility's Quality Assurance and Performance Improvement and Infection Preventionist (ADON/QAPI/IP) stated that R106 had multiple falls in the facility and confirmed during resident's four month stay in the facility, resident had 16 falls, which were both witnessed and unwitnessed. ADON/QAPI/IP confirmed that when resident have an unwitnessed fall, nursing is directed to complete fall packet which includes post fall screening form, neurological check form, post fall nurse neurological check guidelines and 72 hour intentional rounding form. ADON/QAPI/IP further stated that licensed nurses should complete neuro check form for the specific time period as outlined on the form such as every 15 minutes x4, then every 30 minutes x4 to check for concussion or effects of head injuries. ADON/QAPI/IP stated that R106 had a witnessed fall on [DATE] and an unwitnessed fall on [DATE] and she should have received a fall packet including fall sheet and neuro checks for the [DATE] fall but didn't. ADON/QAPI/IP stated that when she did not receive the fall packet at the end of the day on [DATE], she asked LPN6 for the fall packet and LPN6 responded that she didn't complete the fall packet including neuro checks. ADON/QAPI/IP stated that she reviewed the video footage for R106's [DATE] fall and saw that R106 tripped and fell near the kitchenette, and LPN6 was not observed to complete a neuro assessment or vital signs after the fall but should have. The next day in the evening, R106 vomited and wasn't himself so he was sent to the emergency room. ADON/QAPI/IP stated that LPN6 no longer works at the facility. ADON/QAPI/IP stated that it was important to do neuro checks for the frequency and duration because of latent effects, residents can have a change in level of consciousness later and R106 didn't have nausea/vomiting for almost 24 hours after his fall. During an interview on [DATE] at 9:34 AM Medical Doctor (MD)1 confirmed he was R106's physician, resident had multiple falls and it was important to do neuro checks for 48-72 hours after falls because of latent injuries and possible concussion. MD1 further stated that it was important to watch for neuro changes that so actions can be taken as soon as possible. MD1 confirmed that resident's vomiting and change in mental status the day after a fall could be contributed to a head injury from the fall. MD1 also confirmed that after resident was transferred to the emergency room, he was air lifted to nearby hospital as family wanted everything done, resident was full code, and resident was found to have a subdural hematoma that required ventilator support, surgery, intensive care services and subsequently died. During an interview on [DATE] at 9:21 AM Director of Nursing (DON) stated that staff are expected to complete neuro checks and continue assessments for 72 hours after an unwitnessed fall because there could be delayed effects, and this was not done for R106 during his last fall in the facility. 2. 1:1 supervision (Please also refer to F689) Review of R106's care plan documented resident was at risk for falls related to history of recurrent falls, wandering, confusion and gait (walking) imbalance with goal that resident would not sustain serious injury related to fall. Actions to achieve goal included follow facility fall protocol to prevent fall and monitoring protocol with start date [DATE] and monitor (R106)'s location frequently and assess his needs. Assist with toileting, transferring and walking as need. (R106) requires every 15 minutes safety check with start date [DATE]. Review of fall incident reports documented: *Fall on [DATE] at 7:31 AM was unwitnessed. Wheelchair rolled while resident was attempting to transfer, breaks were unlocked, resident confused, impulsive, no safety awareness and sustained bruises from fall. The interdisciplinary team recommendations included 1:1 supervision (1 staff member dedicated to supervising R106, ratio of 1 staff to 1 resident). 1:1 supervision was not added to resident's care plan. *Fall on [DATE] at 5:10 AM was unwitnessed. Resident was found in the living room and sustained abrasions to his head and both knees. Resident stated, I hit my head. The wheelchair alarm was delayed. Resident transported to the emergency room. The interdisciplinary team recommendations included 1:1 monitoring. 1:1 monitoring was not added to resident's care plan. *Fall on [DATE] at 9:00 PM was unwitnessed in hallway, in great room. Resident stated, I was trying to go to the bathroom, got up from wheelchair while in great room to go to the bathroom and fell in the hallway. The interdisciplinary team recommendations included 1:1 monitoring (not available at facility at this time) and constant redirection. 1:1 monitoring was not added to resident's care plan. During interview on [DATE] at 2:48 PM ADON/QAPI/IP stated that she conducted fall investigations which included reviewing documents in fall packet such as incident witness report forms, post fall screening form, neurological check form, post fall nurse neurological check guidelines and video footage and she completed the Interdisciplinary Post-Fall Assessment form with the input from the interdisciplinary team which included unit charge nurses, Director of Nursing, social workers, MDS nurse, Housekeeping, Maintenance, and sometimes activities and the lead CNA. When asked what were some of the root cause analysis of the falls and interventions to prevent recurrent falls ADON/QAPI/IP mentioned several actions and stated that resident was a high fall risk, would sundown in the evenings, and resident was sometimes confused, reorientation didn't always work, he had orthostatic hypotension, impulsive behaviors of getting up all the time, and he sometimes turned off the wheelchair and bed alarms so we couldn't rely on them. When asked about the level of supervision, ADON/QAPI/IP stated that they had every 15-minute safety checks, but we didn't have 1:1 even though it was something that we recommended but we don't have that level of funding for staff to sit with him. When staff had free time, they sat and kept an eye on him, but we were short on staff and didn't have the adequate staff he needed, on nights we sometimes had only two CNAs and the nurse was passing medications. ADON/QAPI/IP stated that the only intervention that would keep R106 safe would be 1:1 supervision but the facility could not provide that level of supervision because the facility did not have the staff. ADON/QAPI/IP acknowledged the facility was responsible for keeping R106 safe and the facility did not provide adequate supervision to R106. During an interview on [DATE] at 9:21 AM DON stated that facility was short staffed and unit aides used to provide 1:1 monitoring but unit aides were lost when the covid waivers went away. DON confirmed R106 was inadequately supervised because he really needed 1:1 monitoring which the facility could not provide. DON further stated that they were trying to get R106 to a memory care facility, but it was not covered under resident's insurance. 2. Staffing (Please also refer to F725) Review of Facility Assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) received from facility on [DATE], dated [DATE], documented eight CNAs were needed on the weekdays and six CNAs were needed on the weekends/holidays. Under another section of Facility Assessment titled Staff Type/Plan, the following was documented for Direct care staff: 1:10-15 resident ratio Days and 1:10-15 resident ratio Nights. Facility Assessment also documented there were 27 residents on B wing (where R106 resided) in January to [DATE]. During a concurrent interview and joint review of Facility Assessment on [DATE] at 2:32 PM ADON/QAPI/IP stated that the facility assessment was based on resident acuity. When asked to explain the Facility Assessment and how many CNAs were needed during the weekdays and weekends for each shift, ADON/QAPI/IP stated that it is three CNAs per each unit (male household and female household) on day shift and the same on night every day. ADON/QAPI/IP also stated that the facility was so short staffed with licensed nurses and CNAs that they could not account for someone like R106 who needed 1:1 supervision. Review of C.N.A Weekly Group Schedule for [DATE] to [DATE], documented less than required 3 CNAs worked on R106's unit seven times during the specific date and times when R106 fell. During a concurrent interview and joint review of CNA schedule and CNA punch timecards, Payroll Specialist (PS) confirmed two CNAs worked on the specific dates and shifts below. *On [DATE] at 5:50 PM R106 fell and two CNAs worked, less than required 3 CNA worked. *On [DATE] at 6:00 PM R106 fell and two CNAs worked, less than required 3 CNA worked. *On [DATE] at 7:31 AM R106 fell and two CNAs worked, less than required 3 CNA worked. *On [DATE] at 6:05 PM R106 fell and two CNAs worked, less than required 3 CNA worked. *On [DATE] at 5:10 AM R106 fell and two CNAs worked, less than required 3 CNA worked. *On [DATE] at 6:00 PM R106 fell and two CNAs worked, less than required 3 CNA worked. *On [DATE] at 9:00 PM R106 fell and two CNAs worked, less than required 3 CNA worked. During an interview on [DATE] at 9:21 AM DON stated that facility was short staffed and unit aides used to provide 1:1 monitoring but unit aides were lost when the covid waivers went away. DON confirmed R106 was inadequately supervised because he really needed 1:1 monitoring which the facility could not provide. DON further stated that they were trying to get R106 to a memory care facility, but it was not covered under resident's insurance. 4. Annual trainings (Please also refer to F726) During a concurrent interview and record review on [DATE] at 10:35 AM ADON/QAPI/IP stated that she oversaw nursing staff training which was completed and documented through Relias system. ADON/QAPI/IP further stated that the facility did not have a policy for staff competency but stated all nursing staff including licensed nurses were required to minimally complete 22 modules each year which included module Preventing Falls: An Interdisciplinary Approach. ADON/QAPI/IP provided copy of LPN6's official transcript which showed during 2022, a half hour training titled About Falls was completed. Preventing Falls training or any training regarding Falls was not completed in 2023 and 2024. In addition, 10 of the 22 required training was not completed in 2022, 21 of the 22 required training was not completed in 2023 and 22 of the 22 required training was not completed in 2024. ADON/QAPI/IP confirmed LPN6 did not complete required annual training during 2022, 2023 and 2024 which was expected for all nursing staff. ADON/QAPI/IP stated that LPN6 was notorious for not completing training and LPN6 was informed verbally and in writing to complete training, but trainings were not completed. During an interview on [DATE] at 9:21 AM DON stated that the expectation is staff complete required training annually and when it is overdue it should be completed as soon as possible but it was so difficult because facility was so crunched and short with staffing. RESIDENT to RESIDENT ABUSE Review of R27's progress notes dated [DATE] at 10:35 PM documented R27 was hit in the face by [R106]. R27 was noted to have minimal amount of redness to the right side of his face. Review of facility's alleged abuse investigation, dated [DATE] documented that Licensed Nurse Aide (LNA)2 observed on [DATE] at 7:20 PM that R106 hit R27 on the right side of R27's head/face. R27 was parked in front of R106, R27 turned around to see what was happening and R106 grabbed R27's right arm and was aggressive towards him/shaking R27. R27 was trying to pull his arm back as he was sitting away from R106. LNA2 stated that she yelled stop, don't do that, let him go and ran over to have R106 let go. The two residents were separated. Protective measures to ensure that further abuse, neglect does not occur included .(R106) to be monitored frequently, not able to provide 1:1 monitoring at this time IDT (interdisciplinary team) recommended the following changes in facility procedures of a plan of care frequent monitoring of (R106)---as staffing allows. During a concurrent interview and record review on [DATE] at 3:45 PM ADON/QAPI/IP reviewed facility's investigation that included video footage and ADON/QAPI/IP confirmed that R27 was abused when R106 hit R27's face and grabbed R27's arm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** * For Resident 207: R207 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia (a condition that causes a person to lose the ability to think, remember, and reason to the point that it interferes with their daily life, with no specific diagnosis) and wedge compression fracture (a type of vertebral fracture that occurs when the front of the vertebra collapses, giving the bone a wedge shape) of unspecified lumbar vertebra (lower back), initial encounter for closed fracture. A limited physical mobility and self-care deficit care plan initiated on [DATE] had a goal which indicated the resident required assistance with ADLs (Activities of Daily Living). Interventions included PT/OT (Physical Therapy/Occupational Therapy) evaluation and treatment as ordered. According to the ADL (Activities of Daily Living) Index Report (meaures a person's ability to perform activities of daily living), provided by the Minimum Data Set (MDS) nurse, dated [DATE] revealed the resident was determined to have an ADL score of 0, indicating the resident was totally dependent. The Nursing admission Screening/History dated [DATE] revealed the resident was totally dependent for locomotion and that she used a wheelchair (w/c). A risk for falls care plan initiated on [DATE] related to age-related physical disability and generalized weakness had a goal for the resident to be free from falls. Interventions included to plan to fit w/c with appropriate cushion and to evaluate the resident's environment to identify factors known to increase risk of falls. Review of the admission MDS (comprehensive) assessment dated [DATE] revealed the resident scored 6 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Section GG (Functional Abilities and Goals) revealed the resident required substantial/maximal assistance for ADLs including rolling left to right, lying to sitting on the side of the bed, chair to bed transfers, and that she was dependent for wheeling 50 feet with two turns, and/or 150 feet in a corridor or similar space in her w/c. A Restorative Note dated [DATE] at 11:13 AM stated, [The resident] refused PT [Physical Therapy] evaluation again today. States that her joints hurt her too much when she exercises. She has poor rehab potential, even PROM [passive range of motion] exercises would cause her pain/discomfort with poor outcome to regain any functional increase in joint ROM [Range of Motion]. Review of the ADL Index Report dated [DATE], through [DATE], revealed an ADL score of 0, indicating total dependence. The Incident Witness Report Form dated [DATE] AM (no time specified) included for an unwitnessed fall with skin tear. The details of the incident included, I was finished helping her and took her out of the room. I went to the next room to help another get ready for the morning . The nurse came into the room and said, Come help me, [R207] is on the floor down the hallway. [R207] scoots forward in her chair like she does in bed. Licensed Nursing Assistant (LNA2) signed the statement. On [DATE] at 7:52 AM a Nursing Progress Note included that the writer was in the hallway passing medications and had her back to the resident that was coming down the hallway in the w/c. Writer turned around and resident was laying on the floor in front of the w/c with the w/c cushion laying on top of her. The EMT's (Emergency Medical Transport) arrived at 6:00 AM. At 6:10 AM EMT's lifted the resident to the stretcher and departed for the ED (Emergency Department). The facility investigation showed that the last time the CNA viewed the resident before she fell was 5:15 AM. The documentation indicated the nurse saw the resident propelling herself at 5:40 AM. According to the documentation, the resident used her w/c for ambulation and was able to propel herself slowly. Review of the Emergency Medicine History and Physical Report (H&P, acute care hospital report) dated [DATE] included the following diagnoses: right frontal scalp cephalohematoma (a hemorrhage of blood between the skull and the fibrous sheath that covers bones), multiple right-sided rib fractures (7th, 8th, 9th and 10th ribs), skin tears (right hand and right shoulder), right clavicle (collarbone) fracture, and UTI (urinary tract infection.) The Inpatient H&P (acute care hospital report) dated [DATE] at 10:51 PM included that the resident met the criteria for inpatient status. Rationale for an inpatient admission was supported by clinical presentation, medical comorbidities, and risk for adverse clinical outcome. The execution of the patient's plan of care was expected to span at least two midnights and could not be rendered safely in a setting of lower acuity. The Interdisciplinary (IDT) Post -Fall assessment dated [DATE] included, The charge nurse was in the hallway passing meds and had her back turned to the resident that was coming down the hallway in the w/c. The nurse turned around and saw the resident laying on the floor in front of the w/c. The time of day was noted at 5:45 AM and the activity was documented as Ambulation. Independent in w/c. A probable cause for this fall based on review and investigation included, 1. Ambulating self in w/c slowly, using handrails for help, going to dining room for breakfast. 2. Air purifier left on the floor, got in the resident's way, had to go around. 3. Scooted self toward edge of w/c seat. 4. Leaned forward too far and fell forward out of w/c. Recommendations from review from the IDT team included, 1. Staff assist with ambulation. 2. Proper positioning in w/c - double check. 3. Remove hazards/clutter on floor. On [DATE] at 12:21 PM a Communication with Family/NOK (Next of Kin)/POA (Power of Attorney) included that R207's family member came to the facility and informed the SSC (Social Services Coordinator) that the resident had deceased that the hospital at 7:00 AM. On [DATE] at 8:59 AM a phone interview was conducted with the Physical Therapist (PT). He stated that dependent for wheelchair mobility meant the resident could not propel the w/c on their own, meaning someone has to push the w/c for them. He stated that R207 had refused therapy services because the exercises caused her more pain. He stated that in her situation, she was dependent on staff for everything including transfers and mobility - including pushing the w/c. He stated that he did not recall the resident pitching forward in her w/c, but that he had only seen her a couple of times because she had refused services. During an interview with a Licensed Practical Nurse (LPN2) on [DATE] at 3:08 PM, she stated that the resident leaned forward while propelling and would hold onto the handrail and pull herself. She demonstrated by sitting toward the front edge of her chair and by leaning her body forward over her knees. She stated, Maybe she leaned too far forward. An interview was conducted on [DATE] at 12:43 PM with (LNA3). She stated that the resident needed full care and that she was dependent. She stated that they had to put the resident back to bed after each meal because she couldn't sit too long. She was very fragile. She stated that the resident was not able to push her own w/c. She said the resident was really weak and even a light touch would hurt her. During an interview conducted on [DATE] at 1:00 PM Certified Nursing Assistant (CNA13) stated that R207 was able to wheel herself a short distance. But, she stated, it was not safe for her to push herself because she would lean forward too much. She stated that she would always offer to push her when she saw the resident leaning forward. She stated that she would tell the resident to sit back and that she would push her. On [DATE] at 1:07 PM an interview was conducted with CNA14. She stated that the resident was total care. She stated that the resident required help in bed and with transfers, but she could push herself in her w/c a little way. She stated that the resident would hold the handrail and pull herself. She stated the resident used to lean forward a lot and it was not safe. They used to push her. She stated that when she would try to pull herself by the handrail, they would tell her not to do that. On [DATE] at 1:13 PM an interview was conducted with the Director of Nursing (DON). She stated that supervision was one of the hardest challenges, and day shift (7:00 AM to 7:00 PM) was really, really busy. She stated that she was trying to emphasize that the charge nurse goes rounding with the CNA's so they know that things are getting done. She stated that she tries to educate the charge nurses because it was hard to say that supervision was being done. She stated that she reviewed the video footage from the morning R207 fell. She stated that the morning she fell, she was propelling herself down the hallway. She pushed her chair around the air purifier that was in the hall and was heading back towards the wall/handrail area, scooting along. She said she saw the resident scoot off the front of her chair and fall out of her chair onto her head and shoulder. She stated that LPN3 saw her coming. She stated that the resident was supposed to be getting a [NAME] cushion to prevent the cushion from slipping forward - she was supposed to be getting one of those. She stated that when the resident fell, her cushion fell on top of her. She stated that R207 was dependent for w/c mobility, meaning she should have had somebody pushing her. On [DATE] at 12:35 PM during an interview with the MDS nurse, she stated that an ADL Index score of 0 indicated that the resident was not functional/total care. * For Resident 156: Review of admission MDS assessment dated [DATE] revealed the facility admitted R156 on [DATE] with diagnoses of non-Hodgkin lymphoma, adult failure to thrive, pain in right knee, unsteadiness on feet, repeated falls, mechanical ptosis (a condition in which the upper eyelid droops, sags or falls over the eye) of bilateral eyelids, paralytic ptosis of right eyelid, and need for assistance with personal care. R156's cognitive function was assessed to be intact scoring 13 out 15 on a Brief Interview for Mental Status. The assessment indicated R156 exhibited rejections of care 1 to 3 days during the 7 previous days. The initial nursing assessment dated [DATE] indicated R156 required staff assistance with transfers and a ADLs. The note read, Resident is very unsteady gait/poor balance and needs assistance x 1. Very High Risks for fall. Under observations it read, needs full assistance with transfers and ambulation - not safe to ambulate by self. The facility developed a care plan focus upon admission for R158's risk for falls with a goal of being free from injury. Interventions included to provide assistance with transfers and ambulation, anticipating R158's needs, keeping the call bell within reach, providing a safe environment, the use of chair and bed sensors, follow facility fall protocol, ensure appropriate footwear, and keeping the environment free of clutter. Review of the April fall log provided by the facility revealed R158 had three falls in April on, [DATE], [DATE], and [DATE]. All three were unwitnessed falls. Review the facility's investigation into the falls provided by the facility revealed the root cause of the falls included R156 self-transferring, not asking for assistance, and failing to lock the brakes of the wheelchair. The IDT documented two recommendations on the Post-Fall assessment dated [DATE]: Encourage using call light for assistance - refuses @ times. And Antiroll back wheelchair. An anti-roll back device is a braking mechanism that automatically locks rear wheelchair wheels when a patient stands. Additional review of the facility fall logs for May, June, July, August revealed R158 had 5 additional falls in May ([DATE], [DATE], [DATE], [DATE], and [DATE]); 3 falls in June ([DATE], [DATE], and [DATE]); 2 falls in July ([DATE], and [DATE]); and 2 falls in August ([DATE] and [DATE]). Additional review of the facility fall investigations revealed 6 of the 12 falls between May and August ([DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]) identified not locking wheelchair breaks as a root cause. The IDT identified a component of non-compliance to their efforts to educate R158 to ask for assistance before getting up, and/or to lock her wheelchair breaks for all 15 falls. Additional review of the care plan for falls revealed frequent updates related to educational interventions for safety, fall events, and monitoring, however the care plan lacked the recommended intervention of using anti-rollback device on the wheelchair. The facility reported the [DATE] fall to CMS as a fall with major injury. The report indicated neuro checks were initiated with findings that right eye was not reactive to light, though R156 has problems with that eye. R156 was sent to the local hospital for evaluation after R156 complained of left arm pain. Hospital records included a CT of the head completed on [DATE] which read, Acute subdural hematoma over the right anterior frontal lobe. During an interview with the Assistant Director of Nursing (ADON) who was also the facility's Quality Assurance and Performance Improvement and Infection Preventionist (ADON/QAPI/IP) on [DATE] at 09:57 AM, R156's falls and fall investigations were reviewed. ADON/QAPI/IP described R156 as aware of where she is, who she is. She was identified as a fall risk. We had no issues the first couple of days. Then we would get notifications she having difficulty going to bed, impulsive getting up on her own. We oriented to her environment and the call light . we would find her getting up and rummaging through her drawers, and staff heard the shower on, [she was showering independently]. At first, with those reorientations or reminders she was receptive and after a while she would become aggressive and lash out. ADON/QAPI/IP confirmed the IDT identified R156 as being resistant to requesting assistance, and frequently did not lock her wheelchair breaks before self-transferring. When asked the IDT recommendation on [DATE] for an anti-roll back device, ADON/QAPI/IP confirmed it was a recommendation. She stated, We talked about it, we had some available, we just didn't go back to revisit it. When asked why a recommendation by the IDT would not be implemented ADON/QAPI/IP replied, I don't know, probably busy. She described the IDT as including all department heads, and confirmed when a recommendation was made, it was not assigned to anyone specific to follow through on it. She stated if a device was issued it would be on the care plan. She stated she would review and provide additional documentation if a device was issued. Additional documentation was not provided prior to the survey exit. During an interview on [DATE] at 04:35 PM, Restorative Nurse's Aide (RNA) confirmed the facility had several anti-rollback devices for wheelchairs. She described they had a nurse who ordered them. It is for a resident that gets up and . she demonstrated on a wheelchair in the rehab gym how the device engaged the wheels and prevented the wheelchair from rolling back. RNA was not aware of a system for knowing who has one on their chair or not. She stated, nobody is charting it. When asked if she recalled R156, she confirmed she was familiar with the resident. She stated R156 did not have an anti-rollback device on her chair and showed the surveyor R156's chair. Observed the wheelchair shown, stored in the rehab gym, had R156's name on it. It did not have an anti-rollback device on it. Review of progress note type: Discharge summary dated [DATE] revealed R156 was still in the hospital, and the family reported R156 would be starting rehab. Review of facility policy titled Falls and Fall Risk Managing dated - read under the policy statement, Based on previous evaluations and current data, the staff shall identify interventions related to the resident's specific risks and causes to try to reduce falls, reduce injuries, and minimize complications related to falls and identify residents at risk for falls. Based on observations, interviews, review of records, and policy, the facility failed to ensure that 3 of 6 residents reviewed for accidents (Residents (R) 207, R106, and R156) did not sustain preventable falls with major injuries. Specifically, 1) The facility failed to conduct neuro checks after an unwitnessed fall, ensure neuro checks conducted were consistent with their policy, implement fall interventions, and provide adequate supervision for R106. R106 had 16 falls during his four-month stay, including three falls where the facility recommended 1:1 monitoring which was not implemented. After the series of falls where 1:1 monitoring was recommended but not implemented, R106 had four additional unwitnessed falls. After the last unwitnessed fall, the assigned LPN failed to conduct neuro checks as required by facility policy and professional standards of practice. The facility's failure caused harm to R106 who had repeated falls in the facility with the last fall resulting in transfer to the Emergency Department, where R106 was diagnosed with a subdural hematoma (serious condition usually caused from a head injury when blood collects between the brain and its outermost covering), requiring hospitalization, ventilator support, and ultimately died. 2) The facility failed to implement an intervention of an anti-rollback device which the IDT recommended for the prevention of falls for R156. R156 had 15 falls during their stay in the facility, half of which involved R156 not locking her wheelchair breaks, and all of which involved R156's non-compliance with following facility education to request assistance with transfers and ambulation. The facility's failure caused harm to R156 who had repeated falls in the facility and resulted in transfer to the Emergency Department where R156 was diagnosed with a subdural hematoma, requiring hospitalization. 3) The facility failed to ensure one resident (R207), with assessed ADL dependence and severe cognitive impairment received mobility services/assistance to propel her wheelchair to ensure she did not sustain a preventable fall with major injury, hospitalization, and death. Cross reference to F600 Findings include * For Resident 106: Review of Resident 106's (R106) record documented the resident was admitted on [DATE] with diagnosis including dementia, diabetes, frequent falls, orthostatic hypotension (sudden drop in blood pressure when you stand up from a sitting or lying position) and stroke. R106's Minimum Data Set (MDS-assessment tool), dated [DATE], documented resident's brief interview for mental status was 12 of 15, indicating moderate cognitive impairment and required supervision or touch assistance when transferring from chair to bed or walking 50 feet while using a walker. Resident was transferred to the hospital on [DATE]. 1. Neuro checks Review of facility's Falls and Fall Risk Managing policy, dated 1/2024, documented under section Steps (Post Fall) 30 minutes 3. neurological checks: Required for all falls with head injury or unwitnessed falls. a. Neurological checks include assessing: i. Glasgow Coma Scale [a tool used to measure a person's level of consciousness and how responsive they are], ii. LOC (level of consciousness), iii. Orientation, iv. Movement in Extremities, v. Pupil size and reaction and vi. Speech and Responses. b. For 72 hours at a frequency of: i. q (every) 15 min(utes)x1 hour, ii. q30 min(utes) x 1 hour, iii. q1 hourx4 hours, iv. q4 hoursx24 hours, then v. qshift x72 hours, 4. Monitor vital signs, 5. Monitor for signs/symptoms of delayed injury (i.e., bruising, bleeding, fracture). 1 hour: 2. Complete the following documentation: a. Post Fall Screening Sheet .e. Neurological Checklist with a head injury and unwitnessed fall (UDA)(user defined assessment) Review of R106's care plan documented resident was at risk for falls related to history of recurrent falls, wandering, confusion and gait (walking) imbalance with goal that resident would not sustain serious injury related to fall. Actions to achieve goal included follow facility fall protocol to prevent fall and monitoring protocol with start date [DATE] and had unwitnessed fall on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] and witnessed fall on [DATE] and [DATE]. Please monitor his vital signs, neuro checks, pain, skin condition, ROM (range of motion) and delayed injuries. Follow the facility protocol for monitoring s/p (status post, after) fall condition with start date [DATE]. PROGRESS NOTES Review of R106's progress notes, dated [DATE] at 8:46 PM, Licensed Practical Nurse (LPN)6 documented Informed by another resident (R), R106 was sitting on floor in the Great Room. No wheelchair in area and attempting to get up but not calling out. Resident's wheelchair was found in room [resident's room] by bathroom door and bed linen in room was ruffled up. Resident was attempting to get up during assessment. No injury noted, no bump on head, no bleeding. Resident questioned if he was hurting or if he bumped his head. Denied both and wanted to get up. Resident asked if he needed to go to the hospital - denied. Resident was then assisted to w/c. Continuing on VS [vital signs] from recent fall earlier. Phone cont(inue) busy. Review of R106's progress notes, dated [DATE] at 10:57 PM LPN6 documented During shift report, CNA (Certified Nursing Aide) reported Resident (R106) having multiple episodes of emesis (vomiting). Near beginning of shift CNA reported Resident vomited; VS [vital signs] taken, BSL @ (blood sugar level at) 223. Elevated BP, confused and aggressive. Review of R106's progress notes, dated [DATE] at 2:58 AM LPN6 documented Resident reported with bout of emesis this shift approx(imately) 2000 (8PM). VS taken and CNA reported elevated BP (blood pressure). Resident monitored by CNA, attempting to get up OOB (out of bed), bed alarm sounding d/t (due to) continued restlessness. During bed checks, Resident sleeping w/ (with) legs hanging off the side of the bed, 1/2 dressed and partly exposed. Assisted CNA with getting Resident back into bed and changed. Encouraged Resident to rest and he calmed down. Called to room when emesis reported. VS cont(inue) w/ elevated BP, skin cool to the touch, staff reported Resident did not look right/normal. Called ER (emergency room) and spoke w/ Nurse [Name of nurse], we would send Resident in via facility van. Returned to Resident and was informed Resident was now unable to stand, more lethargic, VS unchanged and cont(inue) cool to touch. Called ER, then EMS for transport. Resident left facility at 2340 (11:40 PM) FALL INVESTIGATION Review of facility incident witness report form, dated [DATE] at 8:30 PM, documented by LPN6 showed checkmark in box for Other and a checkmark was not shown in box for Fall for type of incident. The details section documented Alerted to (R106) was sitting on floor in Great Rm (room) but another resident. No calling out observed. When notified by staff, Resident wanted assist to get off of floor. During the assessment of Resident, CNAs attempted to get Resident up but were told to wait since Resident had to be assessed. Resident told staff I slipped when asked. But no w/c (wheelchair) nearby. WC found in [another resident room] with alarm sounded and muted. Resident assisted off of floor to w/c x3 staff. While being assess Resident denied hitting head, denied pain, denied wanting to go to the hospital. Just wanted to get up. Resident on AC (alert charting) for recent fall, no new protocol continued. Resident cont(inued) with ongoing behavior prior to fall. Had resident sit in w/c-later assisted to room. Review of facility incident witness report form, dated [DATE] at 8:15 PM, documented by LPN2 showed checkmark in box for Fall as type of incident with details At approx(imately) 2015 (8:15 PM) I was completing treatments in (nursing unit). I had gathered my supplies and was entering [another resident's room] when I heard [name being called], I leaned back out of the room and resident [room number of resident] was pointing into the living room area. As I looked in that direction, I observed [R106] lying on the floor near the [unit] kitchenette. [Name of LPN6] was nearby and I asked her Did you guys put [R106] on the floor? He's on the floor. [LPN6] walked over and observed resident then called to the night CNAs The following documents were not provided by facility for [DATE] fall, which were required per facility policy after an unwitnessed fall, including: 1. Post Fall Screening form which is a checklist to determine why resident fell such as what type of footwear resident was wearing, if environment was clear or cluttered, was resident confused or dizzy, was resident wearing glasses or hearing aide, if there were skin tears, lacerations or any injuries, immediate blood pressure, oxygen saturation level, heart rate, temperature, pain level, level of consciousness. 2. Interdisciplinary Post-Fall Assessment form which describes fall, outlines the number of falls in the last 30, 90 and 180 days, if there were recent medication changes, pattern of current falls such as time of day, six month review of falls and if there were any patterns or trends related to falls, probable cause of falls, root cause analysis of falls, recommendations from the review by IDT (Interdisciplinary Team), and care plan revisions. 3. Neurological check form that documented initial assessment of resident's pupil size and reaction to light, movement of extremities, vital signs, and level of consciousness. 4. Post Fall-Nurse Neurological Check Guidelines that documented assessment of resident's pupil's reaction to light, able to follow finger, verbal responses, pain level and level of consciousness every 15 minutes for 1 hour, every 30 minutes x4, every hour x4, every four hours x4 and every shift x3. 5. 72-hour intentional rounding after fall that assessed and documented pain, positioning, peri-needs and possessions such as call light within reach, glasses, water and environmental conditions every hour. INTERVIEWS During an interview on [DATE] at 7:36 AM LPN2 stated that when residents have an unwitnessed fall she completes neuro checks and completes fall packet which includes neuro checks every 15 minutes x4, then every 30 minutes x4 and so forth as outlined on form. LPN2 stated that she checks on the resident's level of consciousness, if the resident is alert, lethargic, nonresponsive, the resident's pupils reaction to light, size, extremity strength, weakness, and take their vitals. LPN6 stated when R106 fell on [DATE] she had worked the day shift and her shift ended at 7:30 PM but was doing a last minute treatment on R106's unit when she heard a resident calling her name who directed her that R106 was on the floor. LPN2 stated that she asked LPN6 if she put R106 on the floor and LPN6 said no and then LPN6 called the CNAs over to help. LPN2 stated that R106's fall was unwitnessed because R106 was found on the floor and staff did not put R106 on the floor. During an interview on [DATE] at 2:48 PM Assistant Director of Nursing (ADON) who was also the facility's Quality Assurance and Performance Improvement and Infection Preventionist (ADON/QAPI/IP) stated that R106 had multiple falls in the facility and confirmed during resident's four month stay in the facility, resident had 16 falls, which were both witnessed and unwitnessed. ADON/QAPI/IP confirmed that when resident have an unwitnessed fall, nursing is directed to complete fall packet which includes post fall screening form, neurological check form, post fall nurse neurological check guidelines and 72 hour intentional rounding form. ADON/QAPI/IP further stated that licensed nurses should complete neuro check form for the specific time period as outlined on the form such as every 15 minutes x4, then every 30 minutes x4 to check for concussion or effects of head injuries. ADON/QAPI/IP stated that R106 had a witnessed fall on [DATE] and an unwitnessed fall on [DATE] and she should have received a fall packet including fall sheet and neuro checks for the [DATE] fall but didn't. ADON/QAPI/IP stated that when she did not receive the fall packet at the end of the day on [DATE], she asked LPN6 for the fall packet and LPN6 responded that she didn't complete the fall packet including neuro checks. ADON/QAPI/IP stated that she reviewed the video footage for R106's [DATE] fall and saw that R106 tripped and fell near the kitchenette, and LPN6 was not observed to complete a neuro assessment or vital signs after the fall but should have. The next day in the evening, R106 vomited and wasn't himself so he was sent to the emergency room. ADON/QAPI/IP stated that LPN6 no longer works at the facility. When asked about if the frequency and duration for neuro checks on the post fall nurse neurological check guidelines form should match the facility's fall policy, ADON/QAPI/IP stated yes. Joint review of two documents comparing frequency, duration, and content was conducted and ADON/QAPI/IP confirmed that the form did not direct nurses to assess for movement of extremities, pupil size, and instead of monitoring for neuro checks every 4 hours for 24 hours, the form only directed staff to monitor for every 4 hours four times (shortened duration of monitoring by 8 hours). ADON/QAPI/IP stated that due to the format of the form, staff were not monitoring neuro checks per facility policy which was based on policy reference source of Glascow coma scale and medpass and that shouldn't have happened. ADON/QAPI/IP also stated that it was important to do neuro checks for the frequency and duration because of latent effects, residents can have a change in level of consciousness later and R106 didn't have nausea/vomiting for almost 24 hours after his fall. During an interview on [DATE] at 9:34 AM Medical Doctor (MD)1 confirmed he was R106's physician, resident had multiple falls, and it was important to do neuro checks for 48-72 hours after falls because of latent injuries and possible concussion. MD1 further stated that it was important to watch for neuro changes so action can be taken as soon as possible. MD1 confirmed that resident's vomiting and change in mental status the day after a fall could be contributed to a head injury from the fall. MD1 also confirmed that resident was transferred to the emergency room, was air lifted to nearby hospital as family wanted everything done, resident was full code, and resident was found to have a subdural hematoma that required ventilator support, surgery, intensive care services and subsequently died. During an interview on [DATE] at 9:21 AM Director of Nursing (DON) stated that staff are expected to complete neuro checks and continue assessments for 72 hours after an unwitnessed fall because there could be delayed effects, and this was not done for R106 during his last fall in the facility. Review of Emergency Department (ED) note, dated [DATE], showed R106 was well known to the ED and had a history of frequent falls. His last visit to this ED was due to a fall on [DATE] with an atraumatic head CT (noninvasive imaging involving x-rays and computer showing no trauma). He was seen in ED for lethargy and vomiting 3 times tonight at the nu[TRUNCATED]