**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 7) was free from accidents, when Resident 7, who was identified as being at-risk for falls with a history of multiple falls in the facility, fell and was injured when left unattended in her unlocked wheelchair on 8/31/23. This failure resulted in Resident 7 being sent to the general acute care hospital (GACH) for evaluation. Resident 7 was diagnosed with an odontoid fracture (break of the second bone in the neck) and was hospitalized from [DATE] to 9/8/23. Findings: During a review of Resident 7's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis which included Alzheimer's Disease (a progressive disease with memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment. Disease involves parts of the brain that control thought, memory and language), Bilateral (both ears) hearing loss, age-related osteoporosis (bones become weak and brittle) without current fracture (broken bones). During Resident 7's stay at the facility, she had been diagnosed with cerebral vascular accident disease (CVA- an interruption of blood flow to the brain-stroke), generalized muscle weakness, and cognitive communication deficit (ability to think, learn and remember). During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 7's MDS assessment indicated Resident 7's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 99 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). A BIMS summary score of 99 indicated Resident 7 was unable to complete the interview. The BIMS assessment indicated Resident 7 had a severe cognitive impairment (a person that has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). During a review of Resident 7's Care Plan (CP), dated 9/12/22, the CP indicated, Focus .At risk for falls and fall related injuries due to history of falls, impaired safety awareness due to cognitive deficit (impairment of an individual's mental process which affects how an individual understands and acts in the world), diagnosis of Alzheimer's Disease .CVA, generalized weakness, osteoporosis, history of fracture .hearing loss .Resident requires extensive assist (direct physical help from another individual for weight-bearing support) with Activities of Daily Living (ADL- Activities such as toileting, brushing teeth, putting on clothes, feeding oneself), bed mobility and transfers. Resident observed with episode of bending forward when up in wheelchair .on 4/16/23 resident was noted lying on the floor in between the wheelchair and bed .on 6/4/23, residents' half of the body was laying on the floor mat with bed at the lowest position .on 8/31/23, resident fell forward from wheelchair .Goal: Minimize risk for falls and fall related injuries through next 90 day review .Interventions: .Continue with PT [Physical Therapy] focus on safe transfers and wheelchair positioning/posture, date initiated 4/19/23 . During a review of Resident 7's Fall- Nurses Note (NN), dated 8/31/23, the NN indicated, .CNA (Certified Nursing Assistant) writer, ' Resident is on floor in room, she fell from her wheelchair .I was going to put her in bed because she was sleepy, I walked out from the room to get the lift [device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone] that was outside the resident's door and I hear a patient screaming from room [number], I went to look really quick at her and when I came back, patient was on the floor.' Upon writer entering resident's room, resident was noted leaning forward with top of head on the floor mat that was placed by the wall (floor mat was placed by the wall in order to have space for the lift) patient was noted with more inclination towards left upper extremities, knees were down on floor. Upon assessment writer noted [Resident 7] with facial grimaces and raised bump to [left] side of head, abrasion to 3rd [left] finger, bruise to 2nd [left] finger and [left] metacarpal (finger). Writer asked patient is she was ok, [Resident 7] stated, ' I don't know . Writer and fellow nurse noted increased in facial grimaces, episodes of moaning and an increase in [blood pressure] . per [Medical Doctor] to transfer resident to hospital for further evaluation . During a review of Resident 7's Fall Assessment-Post Incident (FAP), dated 8/31/23, the FAP indicated, (Resident 7) . Category: High Risk .Type: Initial Post Incident . Default Category: High Risk . 3. History of falls within last six months: 1 – 2 times . 9. Confined to a Chair: If resident cannot walk even when assisted by staff are they: 1. Confined to a chair and oriented . 11. Gait [the pattern that a person walks] Analysis: . 11. Not applicable- bed/chair bound . During a review of Resident 7's Progress Notes (PN), dated 9/6/23, the PN indicated, .Event being reviewed: .unwitnessed fall at resident's room on 8/31/23 at 3:15 p.m., . Root Cause Analysis for event: .Resident possibly fell asleep while sitting up in a wheelchair, then fell forward to the floor in the resident's room. Prior to the fall, resident was wheeled by the Certified Nursing Assistant to the resident's room to put her back to bed when CNA and licensed nurses noted resident sleepy while sitting up in a wheelchair in front of the nurse's station. Assigned CNA just stepped out outside the room by the resident's door to get the [brand name] lift (equipment to lift a resident who cannot support their own body weight), when CNA came back to the room resident was on the floor. Resident was noted in prone [lying face down] left side lying position with top of head touching the floor mat (floor mat was against the wall) .Interventions initiated and residents response/compliance with intervention: .Resident was on the floor- noted a raised bump to left side of head, abrasion (skin scrape) to third left finger, purplish discoloration to second left finger and left metacarpal (finger) .resident remains awake, conversant and with confusion .noted increased in facial grimaces, episodes of moaning when touching left hand and increased blood pressure of 166/85 mmHg (millimeters of mercury-unit of measurement) when resident was in bed . Ambulance was called immediately .Medical Doctor (MD) notified with new order to send out resident to emergency room for further evaluation .update was given at the facility that resident has a neck fracture .Resident was admitted due to ground level fall with odontoid fracture [break of the second bone in the neck]. During a review of Resident 7's Summary Report of Meeting: In-Service [training] (SRM), dated 8/31/23 and 9/1/23, the SRM indicated, .Meeting Notes: Method of Presentation: Lecture, Discussion . Subjects Covered: At-risk for fall residents .Summary and Conclusions: .Do not leave unattended in the room when up in wheelchair . During an interview on 9/8/23 at 12:50 p.m., with the Director of Nursing (DON), the DON stated on 8/31/23 Resident 7 was tired and sleepy in her wheelchair located at the nurse's station and CNA 2 took the resident back to her room. The DON stated when CNA 2 got back to Resident 7's room, she heard another resident yell from across the hall and went to that room to check on her leaving Resident 7 alone in the wheelchair. The DON stated CNA 2 left Resident 7 by herself for a minute or two and when she came back to Resident 7, she was lying face down on the floor. The DON stated Resident 7's safety was put at-risk when CNA 2 left Resident 7 up in the wheelchair and left the resident's room. The DON stated the fall was avoidable and CNA 2 should not have left Resident 7 unattended when Resident 7 was sleepy sitting in the wheelchair. The DON stated Resident 7's fall resulted in an injury and hospital admission. The DON stated Resident 7 had a history of falls at the facility including a prior fall on 4/16/23 where she fell forward in her wheelchair. The DON stated Resident 7 had a fall-risk score that resulted in being a high-risk for falls resident. The DON stated Resident 7 required extensive assistance (individual cannot perform any ADL or weight bearing without another person providing assistance) for all transfers. During an interview on 9/8/23 at 2:30 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she was the CNA responsible for Resident 7's care when Resident 7 fell. CNA 2 stated she knew Resident 7 was a high fall-risk and had cared for her many times before. CNA 2 stated Resident 7 needed staff for basically everything and required extensive assistance. CNA 2 stated on 8/31/23 Resident 7 was leaning forward in her wheelchair and looked tired and uncomfortable at the nurse's station. CNA 2 stated she wheeled Resident 7 back to her room with the intention of putting her in bed. CNA 2 stated she parked Resident 7 in her room in front of the dresser facing her bed. CNA 2 stated Resident 7's feet were flat on the floor and she did not lock the wheelchair. CNA 2 stated she left Resident 7's room to get the lift to put her in bed when she heard a resident across the hall yell something. CNA 2 stated she left Resident 7 for around a minute. CNA 2 stated when she came back into Resident 7's room, she was face down on the floor and her face appeared to hit the floor. CNA 2 stated she should have never left Resident 7 up in the wheelchair by herself in the condition she was in. CNA 2 stated she did not meet the expectation of the facility which was to stay with Resident 7 and not leave her alone. CNA 2 stated Resident 7 fell because she left her unattended. During an interview on 9/8/23 at 4:45 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the nurse responsible for Resident 7 at the time of the fall. LVN 1 stated Resident 7 had fallen before and was a high fall-risk resident. LVN 1 stated CNA 2 took Resident 7 to her room because she was tired. LVN 1 stated CNA 2 left Resident 7 by herself in her room, and she fell forward out of her wheelchair hitting the ground. LVN 1 stated when she came to the room Resident 7 had a big bump on her forehead with facial grimacing and appeared to be in pain. During an observation on 9/15/23 at 11:30 a.m., Resident 7 was sitting in her wheelchair, asleep, in front of the nurse's station. Resident 7 had black and purple under each eye and on both eye lids. Resident 7 had a grey neck brace on and a 1-inch (unit of measurement) circular bump on her forehead above her left eye. During a review of Resident 7's History and Physical (H&P), from Hospital 1, dated 8/31/23, the H&P indicated, .Chief Complaint: .Patient presents with Fall .Ground level fall unwitnessed at skilled nursing facility (SNF) .Mechanism of injury: .unable to provide history. Per Emergency Medical Systems deformity to wrist and hematoma [swelling that is filled with blood caused by a break in the wall of a blood vessel] to face .Per son SNF called says she fell from her chair was down for at most 15 minutes .Past medical history: .does not want any surgeries .Objective: Physical Exam- .Mental status: mumbling incoherent speech .Head: .hematoma to face .Face: hematoma to left forehead .Extremities: Left upper extremity [a part of the body, such as a hand or a foot]: Chronic deformity to left wrist, ecchymosis (type of bruise) to 2nd and 3rd finger and tender to palpation (a method of feeling with the fingers or hands during a physical examination) . Assessment/Plan: .Odontoid fracture [a broken bone in the neck] .Hematoma of scalp .large, to left forehead .Ground-level fall .Plan: Admit medicine and surgery to follow . During a review of Resident 7's Discharge Summary (DS), from Hospital 1, dated 9/8/23, the DS indicated, admit date : [DATE], discharge date : [DATE] .Chief complaint: Fall .admission diagnosis: Odontoid fracture .Discharge Diagnoses: .(Principal) Odontoid Fracture, hematoma of scalp, confusion, Ground-level fall .Alzheimer's dementia with anxiety .Resolved Hospital Problems: No resolved problems to display . Images: .XR (X-Ray) Spine Cervical (neck) .Result date: 9/6/23 .stable transverse (lying across, crosswise or from left to right) odontoid process fracture .Computed Tomography (CT- diagnostic imaging procedure) Cervical (spine) with Contrast (a substance injected into an intravenous (in the vein) line that causes the particular organ/tissue/bone under study to be seen more clearly) result date: 8/31/23 .Impression: 1. There is a nondisplaced transverse (bone not moved far enough to be out of alignment) odontoid fracture .3. The bones are osteopenic (bone loss) .CT Head without Contrast, Result Date 8/31/23 . Impression: 1. Large area of soft tissue contusion (bruise to an area of the body that is not bone) with hematoma of the left forehead and frontal area extending cephalad (toward the head) . During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated July 2023, the P&P indicated, .Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . A fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force . when a resident is found on the floor, a fall is considered to have occurred .Fall Risk Factors: .Resident conditions that may contribute to the risk of falls include: .lower extremity weakness .functional impairments .Medical factors that contribute to the risk of falls include: .neurological disorders; and balance and gait disorders . Resident-Centered Approaches to Managing Falls and Fall Risk .The staff .will implement resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident or with a history of falls . If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant .Monitoring Subsequent Falls and Fall Risk .The staff will monitor and document each resident's response to interventions intended to reduce falling or risk of falling .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents' right to receive written notice, including the reason for the change, before the resident's room or roommate was changed, was not supported for 16 of 26 sampled residents (Resident 1,2,3,4,5,7,8,9,11,12,13,14,15,16,18,22) when Resident 1, Resident 2, Resident 3, Resident, 4, Resident 5, Resident 7, Resident 8, Resident 9, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 18 and Resident 22 were moved from their assigned room to another room in the facility without first receiving written notice. Resident 1 was moved to another room on 12/5/22 without first receiving written notice, including the reason for the room change and 15 other residents were moved without first providing residents' written notice and reason for the room change. These failures resulted in a situation where residents' rights were not protected and honored. Subsequent to the room change, Resident 1 experienced sadness, periods of uncontrollable crying, not wanting to participate in facility activities and mental anguish. Resident 2 on 10/7/22 (date of room change), experienced sadness and uncontrollable crying and on 10/13/22 stated he did not want to live. Resident 4 was moved rooms on 11/9/22 and experienced feeling twisted around and angry. Resident 4 stated it affected her physically by causing upset stomach and digestive issues. Resident 11 experienced feeling ignored and insulted like she didn't have a mouth or a brain. The failures associated with Residents 1, 2, 4 and 11 resulted in a pattern of actual harm. This facility practice placed 14 residents (Resident 3, Resident 4, Resident 5, Resident 7, Resident 8, Resident 9, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 18, Resident 22) at a potential to experience feelings of anxiety and insecurity and could lead to emotional distress and decline in their well-being. Findings: During an interview on 12/9/22, at 12:46 p.m., with the Activities Assistant (AA), the AA stated, the ADM and the AC had been moving residents in the facility without their consent. The AA stated they were moving long term residents to new rooms. The AA stated, Resident 1 was moved to another room on 12/5/22. The AA stated, Resident 1 had been refusing to transfer rooms, so staff were directed to move her belongings to a new room while Resident 1 was out of the room. The AA stated, residents at the facility had the right to refuse room changes. The AA stated, he had told the ADM that residents had the right to refuse room changes. The AA stated, the ADM told him he was going have the staff start charting negative behaviors to provide a reason for changing a resident's room. During a phone interview on 12/9/22, at 6:30 p.m., with the Administrator (ADM) 1, ADM 1 was made aware Resident 1 suffered harm caused by moving resident to another room. The ADM 1 stated he did not know how changing residents' rooms could cause harm to the residents. During an interview on 12/12/22 at 12:22 p.m., with the admission Coordinator (AC), the AC stated, he started working as the AC on 11/12/22. The AC stated he had been assisting with room changes since the Social Services Director (SSD) 1 left the facility at the end of November. The AC stated the process for room changes at the facility should have been that the SSD, MDS Coordinator and the ADM 1 would meet for an Interdisciplinary Team (IDT) meeting and discuss resident room changes. The AC stated the facility's process for room changes was not followed due to the facility not having an SSD. The AC stated the SSD would document what was discussed in a care conference note and document the room changes in the Electronic Medical Record (EMR). The AC stated he had not attended any IDT meetings regarding room changes. The AC stated he had not read the facility's policy and procedure for room changes. The AC stated that he was documenting notes in the Electronic Medical Record (EMR) regarding resident room changes. The AC stated the facility had hired a new SSD on 12/7/22. The AC stated the new SSD had not been involved in room changes. The AC stated the new SSD had not been working with him on resident room changes. The AC stated moving a resident from one room to another to take an admission was not an acceptable reason for a room change. The AC stated the residents' rooms at the facility were their home. The AC stated he had not ever provided a written notice with reason for room change to residents or Responsible Party's (RP, a person that is responsible for making decisions for another person) for residents that moved to new rooms. During an interview, on 12/13/22, at 1:30 p.m., with ADM 1, ADM 1 stated, This facility had been a long-term care (LTC) skilled facility for many years. The residents and staff had been here for years. I would like for this facility to grow and have a Short Term Unit more Medicare . Rehabilitation (Physical Therapy, Occupational Therapy). ADM 1 stated, Room changes were, and are being made and many staff don't like change. ADM 1 stated, Resident 1 is very manipulative . She makes false allegations, throws urine in her roommate's bed, water on the floor, and turns on the television too loud . We had to move her to another room. The reason she does these acts . she wants to be in one bed-bedroom, alone, no roommates. During a concurrent interview and record review on 12/13/22, at 1:35 p.m., with ADM 1, ADM 1 stated the Policy and Procedure (P& P) for Room Changes was revised on 9/27/2017. ADM 1 presented a binder titled, QAPI (Quality Assurance/Performance Improvement) 2022. The QAPI dated 10/2022 did not indicate the Quality Assurance members (including the Medical Director, ADM 1, Director of Nurses, Department Heads) had reviewed nor approved the P & P for Room Changes. When asked who made decisions to change the resident's rooms, ADM 1 stated, The Interdisciplinary Team (IDT) does but if emergency move/room transfers are needed, the Licensed Nurses will initiate the move and report up . we use Notice for room changes. During an interview on 12/14/22, at 9:35 a.m., with the SSD 2, SSD 2 stated she started working at the facility on 12/7/22. SSD 2 stated she had worked as an SSD for 8 years at a different facility. SSD 2 stated she had not been involved in room changes at the facility. SSD 2 stated she had not seen the facility's policy and procedure for room changes. SSD 2 stated the process for room changes based on her professional work experience, was for the IDT to meet and discuss why the room change was necessary. SSD 2 stated if the resident requested a room change and there were no beds available or if there was no available room at the facility, the facility must provide resident with options. SSD 2 stated an example of options would be to wait for a bed to become empty or come up with other interventions. During an interview on 12/15/22, at 4:41 p.m., with ADM 1, ADM 1 stated ultimately, he was responsible for resident's room changes. During an interview, on 12/18/22, at 2:10 p.m. to 3:22 p.m., with the DON, the DON stated, From when I started in 10/17/22, I know of 22 resident room change . I was not involved in initiating nor had any knowledge until after the 21 room changes had been completed. The administrator (ADM 1) and the admissions coordinator were the ones who made decisions for room changes. DON stated, I am only aware of Resident 1's room changes . Resident 1 was moved to prevent altercation between her and her roommate. Resident 1 threw urine toward roommate (urine did not get to the roommate). DON stated, The facility did not provide a copy of the room change notice to the residents and their responsible parties (RP), for all 22 residents. DON stated, Residents have rights to refuse room transfers . If the resident or RP refuses the room change, then we must respect the resident's right to refuse and document their refusal. DON stated, ADM 1 had the ultimate responsibility to run the facility and ensure the rights of all residents are respected . right to be treated with dignity and respect and/or right to refuse room transfers. During an interview, on 12/20/22, at 9:56 a.m., with Director of Rehabilitation (DOR), DOR stated he had been employed at this facility since 7/15/2019. The DOR stated, There are many facility- specific changes. We are transitioning from Long Term Care (LTC) Skilled Nursing Facility (SNF, a facility that provides 24-hour skilled nursing care) to Short-Term (Medicare/Rehab) facility. The DOR stated, During a stand-up (meetings that are regularly held to provide status reports) back in 10/2022, ADM told us there would be many room/bed changes to be made to support filling up/admit and build census up with Medicare/Short term residents. During a review of Resident 1's admission Record (AR), dated 12/13/22, the AR indicated Resident 1 was admitted to the facility on [DATE]. The AR indicated Resident 1 had diagnoses of Anxiety Disorder (mental condition characterized by excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension), Major Depressive Disorder (a mental condition characterized by a persistently depressed mood and long term loss of pleasure or interest in life), recurrent (the experience of additional episodes of depression after periods of time without symptoms), Unspecified Dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), unspecified severity, without behavioral disturbance, Psychotic (related to or affected with a psychosis) Disturbance, Mood Disturbance, and anxiety, Schizoaffective Disorder (a combination of symptoms of schizophrenia [a disorder that affects a person's ability to think, feel and behave clearly] and mood disorder). During a review of Resident 1's Minimum Data Set (MDS - a comprehensive, standardized assessment of each residents' functional capabilities and health needs), dated 11/23/22, the MDS indicated, Resident 1 had a BIMS (Brief Interview for Mental Status) of 14 (a score of 0-7 suggests severe impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact). During a review of the facility's document Census, (undated), the Census indicated Resident 1 was in room [ROOM NUMBER] B from 12/20/20 to 10/05/22. Resident 1 was moved on 10/5/22 from room [ROOM NUMBER] B to 30 B. Resident 1 was moved on 11/9/22 from room [ROOM NUMBER] B to room [ROOM NUMBER] B. Resident 1 was moved on 12/5/22 from room [ROOM NUMBER] B to room [ROOM NUMBER] B. During an interview on 12/9/22, at 2:06 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she had worked at the facility for 5 years. CNA 2 stated, she was familiar with Resident 1. CNA 2 stated, Resident 1 was moved to a new room (29 B) without her consent. CNA 2 stated, when Resident 1 was in her old room (41 B), she was out of her room all the time and would eat her meals in the dining room. CNA 2 stated, since Resident 1 was moved to the new room, Resident 1 no longer ate her meals in the dining room. CNA 2 stated, after Resident 1 was moved to the new room she had not seen Resident 1 leave the room. During an interview on 12/9/22, at 2:09 p.m., with CNA 3, CNA 3 stated she had worked at the facility for 4 years. CNA 3 stated, she was familiar with Resident 1. CNA 3 stated, Resident 1 had been moved multiple times in the facility. CNA 3 stated, when Resident 1 was in her old room she used to participate in activities and ate in the dining area. CNA 3 stated, after Resident 1 was moved to the new room she had stopped participating in activities and no longer ate in dining room. During an interview on 12/9/22, at 2:15 p.m. with CNA 5, CNA 5 stated she had worked at the facility for 20 years. CNA 5 stated, she was familiar with Resident 1. CNA 5 stated, when Resident 1 was in her old room she used to get out of her room and walk around the facility. CNA 5 stated, that since Resident 1 was moved to the new room she has not been out of bed. CNA 5 stated, Resident 1 had rights and should not have been moved without her consent. CNA 5 stated, Resident 1 felt like her old room was her home. CNA 5 stated, she would feel horrible and sad if she was moved from her home without consent. During an observation on 12/9/22, at 2:20 p.m. in Resident 1's new room (room [ROOM NUMBER] B), Resident 1 was lying in bed wearing a red shirt, covered by a blue blanket. Resident 1's eyes were closed. Resident 1's head was at the foot of the bed and her feet were at the head of the bed. Resident 1's walker and bedside table were next to the bed. During a concurrent observation and interview on 12/9/22, at 5:36 p.m., with the AA, in Resident 1's new room (29 B), Resident 1 was lying in bed covered with a blanket. Resident 1's head was located at the foot of the bed and her feet were at the head of the bed. The AA stated, Resident 1 used to hang out by her door when she was in her old room. The AA stated, Resident 1 had not been getting out of bed since being moved to the new room. Resident 1 stated, she was moved to another room without her consent. Resident 1 stated, she had been in room [ROOM NUMBER] B for a long, long time. Resident 1 stated, room [ROOM NUMBER] B was her home. Resident 1 stated, the ADM told her she would be moved to another room. Resident 1 became tearful and distressed. Resident 1 stated, when she thinks about being moved to her new room she cries. Resident 1 became tearful and wiped tears from her eyes. Resident 1 stated she makes decisions for herself. Resident 1 stated, she was not provided with a written notice with reason for moving rooms. Resident 1 stated she liked to go to the dining room when she was in her old room. Resident 1 stated she used to go to Bingo when she was in her old room. Resident 1 stated she had not been going to Bingo or eating in the dining room because she was sad. Resident 1 stated, she had not been leaving her room since being moved to the new room. Resident 1 wiped away tears from her eyes. Resident 1 stated, she would feel better if she was back in her old room. Resident 1 stated, if she was back in her old room, she would do activities again and would eat in the dining room again. During a review of Resident 1's facility's document Social Services Quarterly Progress Note (SSQPN), dated 6/2/22, the SSQPN indicated, . Resident is alert and oriented . Able to make her needs known to staff. Good short and long term memory . She enjoys sitting in the halls talking to other peers or just watching others . Also enjoys standing and looking out her window. Attends BINGO at times . During a review of Resident 1's facility's document SSQPN, dated 9/30/22, the SSQPN indicated, . Resident is alert and oriented . Able to make her needs known to staff. Good short and long term memory . Mood . Involve in activities of her choice (Bingo, morning social) She enjoys sitting in the halls and talking to other peers or just watching others . Also enjoys standing and looking out her window. Attends BINGO at times. Will sit in the door way during the day. When the weather is cooler will sit on the Patio . Resident also refuses to move to another room to stating No I'm not moving this is my place . Signed by [SSD 1] . Signed Date 11/23/22 . During an observation on 12/12/22, at 12:02 p.m., in the dining room, Resident 1 was absent from the dining room. During an observation on 12/12/22, at 12:04 p.m., in Resident 1's room, Resident 1 was lying in bed. Resident 1's head was at the foot of the bed and her feet at the head of the bed. Resident 1 was eating food in her bed. During a concurrent interview and record review, on 12/12/22 at 12:22 p.m., with the AC, Resident 1's MDS Section E, dated 11/6/22, was reviewed. The MDS indicated Resident 1 had no physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), no verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) and no other behavioral symptoms that were not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Resident 1's MDS section E, dated, 12/1/22, was reviewed. The MDS indicated Resident 1 had no physical behavioral symptoms directed towards others, no verbal behavioral symptoms directed towards others and no other behavioral symptoms that were not directed towards others. The AC stated, Resident 1 had no behaviors documented in the MDS on 11/6/22 and 12/1/22. The AC stated there should be behaviors documented in the MDS if a resident is exhibiting behaviors. The AC stated, he was shocked that Resident 1 did not have behaviors documented in the MDS. The AC stated an example of an appropriate reason to do a room change at the facility would be for a resident needing an isolation room. The AC stated the facility's designated room for isolation was room [ROOM NUMBER]. The AC stated Resident 1 had moved rooms on 10/5/22. The AC stated the reason for the room change was noted as Resident 1 was not keeping the room clean and not wanting others in the room. The AC stated an appropriate reason for a room change would be if someone needed an isolation room. The AC stated not keeping a room clean or not wanting others in the room was not an appropriate reason for a room change. The AC stated a room change for not cleaning a room or wanting others in the room was not an appropriate reason to change rooms. The AC stated, Resident 1 yelled at her roommate's family members, so she was moved to another room on 12/5/22. The AC stated the ADM wanted to move the residents that were the problem out of the room, stating It's not fair to the other person in the room, they weren't the one causing the problem. 00 During a review of Resident 1's Notification of Room/Roommate Change (NOR/RC), dated 10/5/22, the NOR/RC indicated Resident 1 moved rooms on 10/5/22, at midnight. Resident 1 was notified of the room change at 10/5/22 at midnight. The reason for change was Medical Management (isolation, acuity (the severity of a person's illness and the level of attention or service they will need from professional staff), medical treatments, etc.) . Comments: Resident was not keeping the room clean, not wanting others in the room. During an observation on 12/12/22, at 1:47 p.m., in Resident 1's room, Resident 1 was lying in bed with eyes closed. Resident 1's head was at the foot of the bed and her feet were at the head of the bed. During an interview on 12/12/22, at 3:46 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated he had worked at the facility for four years. LVN 2 stated, he had not witnessed Resident 1 having behaviors at the facility. LVN 2 stated, room changes at the facility were happening almost every day. LVN 2 stated he used to see Resident 1 go to the dining area all of the time when she was in her old room (41 B). LVN 2 stated, prior to her room change Resident 1, was really out of her room all the time. LVN 2 stated, he had not seen Resident 1 at all recently. LVN 2 stated, resident 1 stopped eating in the dining room after being moved to her new room. During a concurrent observation and interview on 12/12/22, at 4:09 p.m., with CNA 2 in Resident 1's room, Resident 1 was sitting up in bed. CNA 2 stated Resident 1 was not her normal, seems sad and crushed. Resident 1 stated, she ate lunch in her room. Resident 1 stated she used to go to the dining area but stopped after being moved to new room. Resident 1 stated she had friends close to her old room and she missed them. Resident 1 stated she used to go outside with them and talk. Resident 1 stated she felt like I'm nothing here. During an interview on 12/12/22, at 4:45 p.m., with LVN 1, LVN 1 stated, Resident 1 was moved from her old room to her new because the room was needed for another resident. LVN 1 stated, Resident 1 liked her old room and felt it was her home. LVN 1 stated, Resident 1's mood while in her old room was content. LVN 1 stated, when Resident 1 was in her old room she usually participated in Bingo and was always in the dining room, always sitting in the hallway with Resident 2 and another resident. LVN 1 stated, after Resident 1 had moved to a new room she had not seen Resident 1 leave her room. LVN 1 stated, she had tried to get Resident 1 to dine in the dining room again but she would not budge. LVN 1 stated, Resident 1 would lie in bed all day. LVN 1 stated, not participating in activities and lying-in bed all day were signs and symptoms of depression. During a review of Resident 1's Care plan, (undated), The Care Plan indicated, Resident 1 had a diagnosis of depression manifested by sad pained facial expressions. Resident 1's Care Plan dated 8/31/22, indicated Resident 1 had the potential for complication related to depression with intervention/tasks of Targeted behaviors monitored daily a) withdrawal from activities b) tearfulness/crying c) verbalization for sadness. During a review of the facility's document Medication Administration Record (MAR), dated 11/1/22 through 11/30/22, the MAR indicated Resident 1 was being monitored for episodes of sad facial expression and tearfulness [every] shift related to MAJOR DEPRESSIVE DISORDER . During a concurrent interview and record review on 12/12/22, at 4:55 p.m. with CNA 1, Resident 1's Participation Record, dated 12/2022 was reviewed. The Participation Record indicated Resident 1 had attended coffee social and bingo on 12/3/22 and 12/4/22. CNA 1 stated coffee social and bingo are activities that are held outside of a resident's room. CNA 1 stated Resident 1 had not participated in coffee socials or bingo since changing rooms on 12/5/22. During a concurrent observation and interview on 12/13/22, at 10:26 a.m., with Resident 1 in Resident 1's room, Resident 1 was wearing a red top and covered with a blue blanket. Resident 1 stated she did not go to the dining room for dinner the day before. Resident 1 stated she would not dine in the dining room until she was moved back to her old room (41 B). During an interview on 12/13/22, at 11:42 a.m., with CNA 4, CNA 4 stated she had worked at the facility for about a year. CNA 4 stated, she worked with Resident 1 five days a week. CNA 4 stated, Resident 1 was in her old room for 2 years. CNA 4 stated, Resident 1 missed her old room and thought of it as her home. CNA 4 stated, Resident 1 talked a lot before she was moved to the new room. CNA 4 stated, Resident 1 would sit in the hallway and talk to people passing by. CNA 4 stated, since Resident 1 was in her new room she stopped going to the dining area, stopped leaving her room and laid in bed and stared off into the distance. CNA 4 stated, she would feel sad and powerless if she was moved from her home when she did not want to be. CNA 4 stated, it was important for residents to have a choice for where they live so they would feel stability and safety in their setting. During an observation on 12/13/22, at 12:14 p.m., in the dining room, Resident 1 was not present for noon-time meal. During a concurrent observation and interview on 12/13/22, at 5:53 p.m., with CNA 3, in Resident 1's room, Resident 1 was sitting up eating off a plate that was placed on top of her walker's seat cushion. CNA 3 stated, Resident 1 wanted to go back to her old room. Resident 1 became tearful when talking about wanting to return to her old room. Resident 1 stated, I just want to be in my old room. During a concurrent interview and record review on 12/16/22, at 3:25 p.m., with the Dietary Manager (DM), Dining Location Assignment, dated 12/8/22 was reviewed. The Dining Location Assignment indicated, Resident 1 was not eating breakfast, lunch or dinner in the dining room. The DM stated, Resident 1 used to come down to the dining room for lunch or dinner and sit at table 1 but she was no longer participating in dining in the dining room. During a concurrent interview and record review on 12/17/22, at 4:00 p.m. with LVN 1, Resident 1's EMR (undated) was reviewed. Resident 1's EMR indicated Resident 1 had been moved five times since October 2022. LVN 1 stated reason for resident 1's room change on 10/5/22 was medical management. LVN 1 stated there was no definition for why medical management documented for the move. LVN 1 stated Resident 1 was moved on 11/9/22 for safety. LVN 1 stated there was no definition for the reason safety was documented for the move. LVN 1 stated resident was moved on 12/5/22 with the reason for safety. LVN 1 stated no written notice with reason for room change was documented. LVN 1 stated if written notice was not provided then residents rights were not respected. LVN 1 stated there was a Progress Notes on 12/5/22 in the EMR stating due to resident behaviors over the weekend. Resident notified of room change this morning. LVN 1 stated the documentation was a late entry (when a pertinent entry is missed or not written in a timely manner, a late entry is used to enter the information in the medical record) by the AC. During a concurrent observation and interview on 10/12/22, at 12:32 p.m., with Resident 2, in the dining room, Resident 2 was sitting in a wheelchair with glassy-eyed (having a fixed stare and a wide-eyed appearance, due to boredom, lack of emotion, attention, or interest) expression. Both corners of Resident 2's mouth were pointed downward. Resident 2 stated he had moved into a new room (14 C) at the facility. Resident 2 stated he did not want to move to the new room. Resident 2 stated he did not know why he had to move to a new room. Resident 2 stated he was sad in his new room. Resident 2 stated he had been in his old room (38 B) for 5 years. During a review of Resident 2's admission Record (AR), dated 10/13/22, the AR indicated Resident 2 was admitted to the facility on [DATE]. The AR indicated Resident 2 had diagnoses of Major Depressive Disorder, Recurrent. During a review of Resident 2's facility's document Census List dated 12/13/22, the Census List indicated Resident 2 was moved on 10/7/22 to room [ROOM NUMBER] C. During a review of Resident 2's MDS, dated 8/25/2022, the MDS indicated Resident 2 had a BIMS of 11 (a score of 0-7 suggests severe impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact). During an interview on 10/12/22, at 12:38 p.m., with the Family Member (FM), the FM stated Resident 2 was a positive person prior to being moved to his new room. The FM stated, Resident 2 was good friends with another resident (Resident 27) who lived in a room right across from Resident 2's old room. The FM stated, Resident 2's old room was right across the hall from Resident 27. The FM stated his new room was on the other side of the facility, far away from Resident 27 and that made him sad. The FM stated Resident 2's old room [ROOM NUMBER] B was his home. The FM stated, Resident 2 had patio access in his old room and liked to go outside often. The FM stated, Resident 2 had become depressed and withdrawn after being moved to his new room. The FM stated, Resident 2 had told her he doesn't want to live anymore after moving to his new room. The FM stated, Resident 2's mouth had turned down after he moved to his new room. The FM stated, Resident 2 cried when he talked about the room change. The FM stated, Resident 2 was moved for financial reasons. During an interview on 10/12/22, at 1:58 p.m., with the Social Services Director (SSD) 1, SSD 1 stated she and the Administrator (ADM) 1 were responsible for resident room changes. The SSD stated the process at the facility for room changes was to notify the resident or the RP to the room change. The SSD stated Resident 2 was moved to a new room on 10/7/22. The SSD stated she did not speak with Resident 2's RP about the room change. The SSD stated previous residents at the facility had room changes when the facility needed an isolation room or to make a private room for a resident who is in the process of dying. The SSD stated Resident 2 was moved to a new room to make his old room available for new residents discharged from the hospital. During an observation on 10/12/22, at 2:02 p.m., in Resident 2's new room three beds were seen. The new room did not have an attached patio. The new room had a window next to the furthest bed. Resident 2 was not in the new room. During a concurrent observation and interview on 10/12/22, at 2:02 p.m., with Resident 25, in Resident 25's room (Resident 2's old room) there were 2 beds in the room. The first bed (A Bed) was occupied by Resident 25. The second bed (B Bed) was empty. The room had a sliding glass door that led to an outside patio area. Resident 25 stated his previous roommate was Resident 2. Resident 25 stated Resident 2 was moved to another room. Resident 25 stated he had been in his room for 3 years. Resident 25 stated Resident 2 was in the room for longer than 3 years. Resident 25 stated ADM 1 wanted him and Resident 2 to move out of the room so the room could be used for new residents coming from the hospital to the facility. During a review of Resident 25's MDS, dated 8/26/2022, the MDS indicated Resident 25 had a BIMS of 15 (a score of 0-7 suggests severe impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact). During an interview on 10/12/22, at 2:40 p.m., with LVN 8, LVN 8 stated, she was the nurse assigned to Resident 2 when he lived in his old room. LVN 8 stated, she was working the day Resident 2 was moved to a new room. LVN 8 stated Resident 2 came to her tearful and emotionally sad and stated he did not want to move to a new room. LVN 8 stated, Resident 2 did not understand why he had to move to a new room. LVN 8 stated, Resident 2 had a sad face where his bottom lip was turned down. LVN 8 stated, Resident 2 liked to talk to another resident across from him that spoke his primary language. LVN 8 stated, Resident 2 was moved to make room for hospital admissions of residents and to quarantine (a state, period or place of isolation in which people that may have been exposed to infectious disease are placed) new admissions. During an interview on 10/12/22, at 2:46 p.m. with the RP, the RP stated, Resident 2 was happy when he in previous room, prior to the room change. The RP stated, she was notified of Resident 2 moving rooms by Resident 2 calling her. The RP stated, Resident 2 did not want to move rooms. The RP stated, Resident 2 did not know why he was moving rooms. The RP stated, Resident 2 called her while he was being moved to the new room. The RP stated, Resident 2 had been in his old room for 5-6 years. The RP stated, she came down to the facility on [DATE] and requested to speak with ADM 1 regarding the room change. The RP stated, she did not give consent for Resident 2 to be moved to another room. The RP stated she was not given the option for Resident 2 to stay in his old room. The RP stated, Resident 2 was moved for financial reasons and continue caring for others being discharged from the hospital. The RP stated, Resident 2 continues to call her nightly and cry about the room change. The RP stated, Resi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to prevent falls, for one of five sampled residents (Resident 27), when Resident 27 had known behavior of getting up unassisted from bed, was assessed as being a high fall risk, had a history of falls (2/6/22, 2/27/22, 4/2/22 and 4/11/22) in the facility, and the facility did not develop and implement interventions that were person-specific in the comprehensive care plan to prevent Resident 27 from falling. This failure resulted in Resident 27 getting out of bed unassisted on 4/11/22. Resident 27 fell and sustained a displaced right intertrochanteric fracture (broken hip bone that have moved out of their normal position) and right anterolateral (in front and to the side) second, third, fourth, fifth, sixth and seventh rib fractures and experienced pain. Resident 27 required surgical intervention and required hospitalization at the acute care hospital from [DATE] to 4/16/22 (four days). Resident 27 experienced severe pain and a change of mobility and ability to perform activities of daily living due to the fall with injury. Findings: During a review of Resident 27's, admission Record (a document with personal and medical information), dated 4/21/22, the admission Record indicated Resident 27 was admitted to the facility on [DATE], with diagnosis which included intracerebral hemorrhage (bleeding into the brain tissue), borderline personality disorder (mental illness that severely impacts a person's ability to regulate their emotions), history of falling, history of traumatic fracture and pain. During a review of Resident 27's, Minimum Data Set (MDS assessment of healthcare and functional needs) assessment, dated 2/4/22, the MDS assessment indicated Resident 27's Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgement) assessment score was five out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment) indicating Resident 27 had severe cognitive impairment in decision making. During a review of Resident 27's MDS Assessment Section G, dated 2/4/22 (prior to fall on 4/11/22), the MDS assessment indicated, A. Bed mobility- how resident moves to and from lying position, turns side to side, and positions body while in bed .2. Limited assistance .2. One person physical assist .B. Transfers- how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position .2. Limited assistance .2. One person physical assist . C. Walk in room-how resident walks between locations in his/her room .7. Activity occurred only once or twice .1. Setup help only . E. Locomotion on unit- how resident moves between locations in his/her room and adjacent corridor on the same floor .1. Supervision .1. Setup help only .F. Locomotion off unit- how resident moves to and returns from off-unit locations .1. Supervision .1. Setup help only .G. Dressing- how resident puts on fastens and takes off all items of clothing .2. Limited assistance .2. One person physical assist .I. Toilet use- how resident uses the toilet room .3. Extensive assistance .2. One person physical assist .J. Personal hygiene- how resident maintains personal hygiene .2. Limited assistance .2. One person physical assist . During a review of Resident 27's MDS Assessment Section G, dated 4/27/22 (post fall on 4/11/22), the MDS assessment indicated, A. Bed mobility- how resident moves to and from lying position, turns side to side, and positions body while in bed .3. Extensive assistance .2. One person physical assist .B. Transfers- how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position .3. Extensive assistance .2. One person physical assist . C. Walk in room-how resident walks between locations in his/her room .8. Activity did not occur .8. ADL activity itself did not occur . E. Locomotion on unit- how resident moves between locations in his/her room and adjacent corridor on the same floor .3. Extensive assistance .2. One person physical assist .F. Locomotion off unit- how resident moves to and returns from off-unit locations .3. Extensive assistance .2. One person physical assist .G. Dressing- how resident puts on fastens and takes off all items of clothing .3. Extensive assistance .2. One person physical assist .I. Toilet use- how resident uses the toilet room .4. Total dependence .2. One person physical assist .J. Personal hygiene- how resident maintains personal hygiene .3. Extensive assistance .2. One person physical assist . During an interview on 4/21/22, at 9:22 a.m., with Certified Nursing Assistant (CNA) 4, she stated she had worked in the facility for nine months and had taken care of Resident 27 prior to resident 27's fall on 4/11/22. CNA 4 stated Resident 27 had episodes of confusion and had a history of getting out of bed unassisted and not calling for assistance. CNA 4 stated Resident 27 did not like using her call light and tried to do everything herself. During an interview on 4/21/22 at 10 a.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated she was an LVN employed through a Registry/Agency (employees that can be hired out for temporary or long-term work) utilized by the facility as needed for staffing needs. LVN 5 stated she was assigned to work the morning shift (7 a.m. to 3 p.m.) and was assigned to Resident 27 today (4/21/22). LVN 5 stated she had worked with Resident 27 once, prior to Resident 27's fall on 4/11/22 and twice since Resident 27 returned from the General Acute Care Hospital (GACH) (4/16/22). LVN 5 stated Resident 27 had a history of transferring herself unassisted. During an interview on 4/21/22, at 10:57 a.m., with the Physical Therapist (PT), the PT stated PT worked with Resident 27 on 4/4/22 and Resident 27 was discharged from PT services on 4/11/22 because Resident 27 had a fall on 4/11/22 and was sent out to GACH. The PT stated Resident 27 was very high-risk for fall. The PT stated Resident 27 was impulsive (act suddenly), had a history of falling and not following cueing (reminders). The PT stated she attended Interdisciplinary Team (IDT) meetings and she remembered discussing during an IDT meeting to keep Resident 27 in a wheelchair in a supervised area has worked and recommended to have one on one (referring to one staff and one resident) care. The PT stated she did not know if the facility followed her recommendation to provide one on one supervision. During a telephone interview on 7/6/22, at 4:14 p.m., with CNA 5, CNA 5 stated she was assigned to work the afternoon shift (2:30 p.m. to 11 p.m.) on 4/11/22 and was assigned to Resident 27. CNA 5 stated Resident 27 ate dinner in her room and she helped her to bed. CNA 5 stated Resident 27 tried to get out of bed unassisted and not calling for assistance prior to Resident 27's fall. CNA 5 stated she was charting in the hallway, when she heard Resident 27 calling out for help. CNA 5 stated she responded to Resident 27 and found Resident 27 sitting on the floor next to her bed. CNA 5 stated Resident 27 complained of pain to the charge nurse while the nurse performed Resident 27's body assessment. CNA 5 stated she was not sure where resident 27 complained of pain. CNA 5 stated Resident 27 had a history of getting out of bed unassisted and not asking for assistance. During a concurrent telephone interview and record review on 7/6/22, at 4:38 p.m., with LVN 1, Resident 27's medical records were reviewed. LVN 1 stated he worked on 4/11/22, the afternoon shift (2 pm-11:30 p.m.). LVN 1 stated prior to Resident 27's fall on 4/11/22, Resident 27 was alert with confusion and forgetfulness. LVN 1 stated after Resident 27's fall on 4/11/22, Resident 27 was more confused. LVN 1 stated on the day of the fall, he did not remember where Resident 27 was, but Resident 27 was usually up in her wheelchair, in the hallway, near the nurse station. LVN 1 reviewed Resident 27's medical record, specific to his note titled, Event Initial Note dated 4/11/22 at 8:30 p.m. LVN 1 stated he walked down the hallway, then he heard Resident 27 calling out in Spanish, Help me, help me. LVN 1 stated he ran towards Resident 27's room and found Resident 27 sitting on the floor between her bed and wheelchair. LVN 1 stated Resident 27 stated she tried to transfer herself from the wheelchair to bed unassisted and lost her balance and ended on the floor. LVN 1 stated Resident 27 had a history of falls, getting out of bed unassisted, and she did not like using her call light to ask for assistance. LVN 1 reviewed Resident 27's fall care plan dated 2/7/22, LVN 1 stated the interventions were, .Monitor for post fall injuries . Neurochecks (evaluation of a person's nervous system) to be performed . Therapy to screen post fall . LVN 1 reviewed Resident 27's fall care plan dated 2/27/22, LVN 1 stated the interventions were: .Check range of motion . Monitor/document/report PRN (as needed) X 72h (seventy two hours) to MD (Medical Doctor) for s/sx (signs and symptoms) Pain, bruises, change in mental status . Neuro-checks x24 hours. LVN 1 reviewed Resident 27's fall care plan dated 4/2/22, LVN 1 stated the interventions were: .Monitor for 72hrs (hours) for delayed injuries . Monitor for pain Qshift (every shift) .Neurochecks for 72 hrs . LVN 1 stated the interventions were not patient-centered and did not prevent Resident 27 from falling again. During a concurrent observation and interview on 8/1/22, at 10:22 a.m., in Resident 27's room, Resident 27 sat at the edge of the bed, there was a floor mat (floor covering that is placed on the floor) on the floor. Resident 27 was unable to be interviewed. During a concurrent interview and record review on 8/5/22, at 9:35 a.m., with the Infection Preventionist (IP)/Minimum Data Set Nurse (MDS), Resident 27's medical records were reviewed. The IP/MDS stated Resident 27 was considered high risk for falls and all four of Resident 27's falls (2/6/22, 2/27/22, 4/2/22 and 4/11/22) were due to Resident 27 transferring self-unassisted and not asking for assistance. The IP/MDS reviewed Resident 27's fall care plan dated 2/7/22, which indicated, .Focus: At risk for injuries due to recent fall on 2/6/22 due to poor safety awareness and wanting to take self to the bathroom . Interventions: Monitor for post fall injuries for 72 hours . Neurochecks to be performed . Therapy to screen post fall . The IP/MDS reviewed Resident 27's fall care plan dated 2/27/22, which indicated, .Focus: Resident had a claimed fall with no injury . Interventions: Check range of motion (Specify #) times daily . Monitor/document/report PRN X 72 h to MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture (position), agitation . Neuro-checks x24 hours . The IP/MDS reviewed Resident 27's fall care plan dated 4/2/22, which indicated, .Focus: unwitnessed fall . Interventions: Monitor for 72 hrs for delayed injuries . Monitor for pain Q shift . Neuro checks for 72 hrs . The IP/MDS reviewed Resident 27's fall care plan dated 4/11/22, which indicated, .Focus: Fall 4/11/22 due to attempting self transfer . Interventions: Assess for pain every shift and during routine rounds . Bed in low position . Call light placed within reach and instruction given to press on the button if she needs to get up or needs any assistance . Inform resident about the importance of locking wheelchair before transferring . Neurocheck started . Pharmacy to review medications . Resident was having pain and sent out to ER (emergency room) for further evaluation . The IP/MDS stated, .The interventions were not appropriate and not resident-centered, the interventions did not address the causes of falls, the facility should have tried to do more . The IP/MDS reviewed Resident 27's medical record titled, Risk for falls, dated 7/24/18, which indicated, .Score: 14 Category: Resident at risk . A. Risk for falls 1. LOC (level of consciousness- term used to describe a person's awareness and understanding of what is happening in their surroundings)/MENTAL STATUS/COGNITIVE SKILLS . 4. Intermittent confusion .3. Ambulation (ability to walk)/Elimination Status . 2. Chair bound-requires assist with elimination . 7. Medications: Response based on the following type of medications: anesthetics (drug to induce insensitivity to pain), antihistamines (medication used to block the action of histamines [allergic reactions]), antihypertensives (medication used to lower blood pressure), Antiseizures (medication used to prevent uncontrolled electrical disturbance in the brain), Cathartics (medication to stimulate bowels), Diuretics (water pills, help rid your body of salt and water), Hypoglycemics (medication used to lower sugar levels in blood), Narcotics (medication used to treat moderate to severe pain) . 4. Takes 3-4 of these medications currently and/or within last 7 days . The IP/MDS stated Resident 27's fall risk score was 14, which meant Resident 27 was high risk for falls. The IP/MDS stated Resident 27 was at risk for falls since she was admitted in the facility on 7/24/18. During a review of Resident 27's Medical Record titled, Fall Assessment-Post Incident, dated 4/2/22, the Fall Assessment -Post Incident, indicated, .Category: High Risk . 3. History of falls within last six months . Multiple Falls 4. Medication Use . hypoglycemia (condition in which your blood sugar level is lower than the standard range) . Antihypertensive . NSAID's (non-steriodal anti inflammatory drug- drug class to reduce pain, decreases inflammation, decreases fever, and prevents blood clots) . Psychotropics (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) . Sedatives/Hypnotic's chemical substance used to reduce tension and anxiety and induce calm or to induce sleep) 9. Confined to a chair: .Confined to a chair and disoriented . 11. Gait (walk) Analysis . Unable to independently come to a standing position. Exhibits loss of balance while standing . Requires hands-o assistance to move from place to place . Uses an assistive device, e.g. cane, walker . During a concurrent interview and record review on 8/5/22, at 1:14 p.m., with the Director of Nursing (DON), the DON reviewed Resident 27's fall care plans dated 2/7/22, 2/27/22, 4/2/22 and 4/11/22 and stated the care plans for Resident 27 were not resident specific and the interventions did not help to prevent additional falls. The DON stated the care plan interventions should have been more resident specific to address the cause of each fall. During a review of Resident 27's Event Initial Note, dated 4/11/22 at 20:30 [8:30p.m.] the Event Initial Note indicated, .Event Type: S/P (status post) unwitnessed fall . Time of event: 2030 [8:30 p.m.] . Detailed description of event . Writer heard 'Ayuda me cai [speaking in Spanish].' Help I fell . resident sitting on the floor next to her bed and wheelchair . Patients description of event: Resident verbally stated she was trying to transfer from the wheelchair to her bed when she lost her balance and fell on her bottom . New Interventions initiated (should address any abnormal assessment findings): Neurochecks . During a review of Resident 27's Event follow up note, dated 4/12/22 at 7:56 a.m. the Event follow up note indicated, .Event Type: S/P unwitnessed fall .Full Range of Motion Assessment findings (i.e. [example] wnl [within normal limit] for resident, or describe abnormal findings): .Severe pain to right lower extremity . Describe any new injuries or complaints of new pain or enter none: Severe pain to right lower extremity . Treatment for injuries/pain r/t [related to] event responding to treatment or resolving: .at around 7:30 a.m. while receiving care resident started c/o [complained of] severe pain to right lower extremity, refused to be turned d/t [due to] pain. Resident was noted to be touching right hip area with two hands while grunting with a tense body posture . New orders received/New treatments initiated: Sent out to [name of general acute care hospital] for further evaluation, to rule out fx [fracture] r/t severe pain . During a review of Resident 27's medical record titled, Transfers/Discharge Report, dated 4/12/22, the reported indicated, . Chief Complaint (reason for transfer) Severe pain to right hip s/p Fall ibuprofen (type of pain medication) at 700 a.m. During a review of Resident 27's medical record titled, Acute Care Surgery Service Discharge Summary, dated 4/16/22, the record indicated, .admit date : [DATE], discharge date : [DATE] . Injuries: R (right) intertrochanteric femur (thigh bone) fracture (s/p IMN [intramedullary nail- metal rod that is inserted into the cavity of a bone and across the fracture] with orthopedics (medicine dealing with the correction of deformities of bones or muscles) 4/13). Right rib fractures 2-7 (two to seven) . admission diagnosis: Fall from ground level .Result Date: 4/12/22 .Displaced right intertrochanteric fracture is demonstrated .Right anterolateral second, third, fourth, fifth, sixth and seventh rib fractures .Proximal right femoral shaft intertrochanteric fracture . During a review of facility's policy and procedure (P&P) titled, Care Plan, Comprehensive Person-Centered dated 2018, the P&P indicated, Policy Statement .A comprehensive, person-centered care plan with measurable objectives and timetables to meet the resident's physical, psychosocial and function needs is developed and implemented for each resident. Policy Interpretation and Implementation .1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .7. The comprehensive, person-centered care plan will .a. Include measurable objectives and timeframes .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems . k. Reflect treatment goals, timetables and objectives in measurable outcomes .m. Aid in preventing or reducing decline in the resident's function status and/or functional levels .o. Reflect currently recognized standards of practice for problem areas and conditions .8. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan .9. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . During a review of the facility's P&P titled, Falls and fall Risk, Managing, dated 2018, the P&P indicated, .the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications . will implement a resident-centered fall prevention plan to reduce specific factors of falls . Staff will monitor and document each resident's response to interventions intended to reduce falling . If resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . During a review of the facility's P&P titled, Assessing Falls and Their Causes, dated 2018, the P&P indicated, .provide guidelines for evaluating/gathering data on a resident after a fall and to assist staff in identifying causes of the fall .Review the resident's care plan to assess for any special needs of the resident . Refer to resident-specific evidence including medical history, known functional impairment . During a review of the facility's P&P titled, Falls-Clinical Protocol, dated 2018, the P&P indicated, .Assessment and Recognition .While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause .the nurse shall assess and document/report .All current medications, especially those associated with dizziness or lethargy .Cause Identification .For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall .Often, multiple factors contribute to a falling problem .Treatment/Management .the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .Monitoring and Follow-Up .If the individual continues to fall, the staff .will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from accidents for one of five sampled residents (Resident 45), when Resident 45 was identified as being at risk for falls with a history of multiple falls in the facility and the care plan intervention to place the bed in the low position was not implemented on 12/27/21. This failure resulted in Resident 45 experiencing an unwitnessed fall from the bed on 12/27/21 onto the floor. After the fall, Resident 45 experienced left side pain and was sent to the general acute care hospital (GACH) for evaluation. Resident 45 was diagnosed with a left femur fracture (broken thighbone) and required surgical repair and was hospitalized from [DATE] to 1/4/22 (eight days). After the fall, Resident 45 experienced a decline in mobility and pain due to the fall and injury. Findings: During a review of Resident 45's admission Record (document containing resident demographic information and medical diagnosis), dated 1/5/22, the admission record indicated Resident 45 was admitted to the facility on [DATE]. Resident 45's diagnosis included .ALZHEIMER'S (progressive disease that destroys memory and other important mental functions) .PULMONARY EMBOLISM (condition in which one or more arteries in the lungs become blocked by a blood clot) .ACUTE EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VEINS OF LOWER EXTREMITY BILATERAL (blood clot forms in one or more of the deep veins in the body) .DEMENTIA (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) .MAJOR DEPRESSIVE DISORDER (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) . (MORBID (SEVERE) OBESITY (commonly defined as being 100 pounds over ideal body weight) .FRACTURE OF LEFT FEMUR MUSCLE WEAKNESS .DIFFICULTY WALKING . During a review of Resident 45's Care Plan (CP) dated 10/26/21, the CP indicated, .At risk for falls related [disease] of Alzheimer's Dementia, Major Depressive Disorder, Obesity, Pulmonary Embolism, DVT (deep vein thrombosis), LE (lower extremity) muscle weakness; not steady and requiring assistance by staff with walking, toileting, and sit to stand, and poor safety awareness .Resident slid from bed while sitting at the edge of bed on 12/12/2020; [status post] unwitnessed on 12/22/2020 in room; on 1/21/21 CNA (Certified Nursing Assistant) was assisting resident with the walker to the bathroom and he just stopped walking and kneeled down by the doorway to the bathroom-CNA helped lower him to the floor. 2/8/2021, resident as noted laying on the floor. On 5/25/2021 resident rollover from bed. Unwitnessed fall on 8/29/2021 with a redden area to left side of thigh. Unwitnessed fall on 12/04/2021 self-transfer from bed to wheelchair. Unwitnessed fall on 12/11/21 self-transfer from wheelchair to bed. Date initiated: 10/14/2020 .Goal Minimize risk for falls and fall related injuries. Date Initiated: 10/14/2020 .Target Date: 1/24/2022 .Interventions .Assess for pain and medicate as needed .Bed in low position . During a review of Resident 45's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 10/21/21, the MDS indicated Resident 45's Brief Interview for Mental Status (BIMS -an evaluation of attention, orientation and memory recall) score of 4 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 4 had severe cognitive impairment. During a review of Resident 45's Progress Note (PN), dated 12/27/21, the PN indicated, .[status post] Unwitnessed fall Date of Event: 12/27/21 Time of Event: [8:15 p.m.] . Writer heard resident verbally yelling for help upon entering residents room writer noticed resident laying on his left side next to his bed. Resident [45] [complained of] pain to [left] hip. Writer administered [as needed] Medication. Resident [45] was lifted with lyft [sic] and placed in bed. No delayed injuries noted except [complaints of left] hip .Resident verbally stated [h]e just fell down .Patients description of event: Resident verbally stated He just fell down .If Fall note-injury how patient was found, environment footwear, last toileted, [Fasting Blood Sugar-amount of sugar in the blood overnight] if diabetic (a person who's body cannot turn sugar into energy): Resident was found in a side laying position to [left] side, resident was wearing non-skid socks, last time toileted was one hour ago .Author [Licensed Vocational Nurse1] . During a review of Resident 45's Neuro Check (an evaluation of person's nervous system), dated 12/27/21, the Neuro Check indicated, .Was there any injury sustained .Yes .If yes, explain .Resident [complains of] [left] hip pain .Change in range of motion .Yes .If yes, explain .unable to move [left lower] Body extremity .Is resident experiencing any pain .Yes .If yes, explain in detail .[blank] . During a review of Resident 45's Fall Assessment-Post Incident, dated 12/27/21, the Fall Assessment-Post Incident indicated, .History of falls within last six months .1-2 times . During a review of Resident 45's Pain Assessment-Post Incident, dated 12/27/21, Pain Assessment-Post Incident indicated, .Pain location and characteristics .Based on appropriate pain scale for Resident, what is the current level of pain? .0 .If able to verbalize what is the Residents acceptable level of pain? .0 .What appears to increase the resident's pain? . Moving resident [left] hip .What is most likely cause of pain? .Resident fell on [left]side and hurts to [left] hip . During an observation in 1/5/22, at 2:05 p.m., in Resident 45's room, Resident 45 was asleep in bed, snore like sounds were heard. Resident 45 was unable to be interviewed. During a concurrent observation and interview on 1/5/22, at 2:45 p.m., with Registered Nurse (RN) 1, at the nurse's station, Resident 45 was observed calling out for assistance in the room. RN 1 stated, Resident 45 had returned to the facility from a GACH today (1/5/22) and Resident 45 was non weight bearing (when an area of the body cannot withstand pressure from body weight) on his left side. RN 1 stated, Physical Therapy (PT) needed to assess him in order to determine the assistance Resident 45 needed. RN 1 stated, prior to Resident 45's fall on 12/27/21. RN 1 stated Resident 45 was able to get up and use the bathroom prior to his 12/27/21 fall with assistance and post fall (1/5/22) Resident 45 could not get up, he needed to use a urinal (a vessel into which a bedridden person urinates) at his bedside. During an interview on 1/5/22, a 2:57 p.m., with RN 2, RN 2 stated, Resident 45 did not complain of pain prior to his fall on 12/27/21. RN 2 stated, after the fall Resident 45 complained of left sided pain. RN 2 stated, Certified Nursing Assistance (CNA) 3 found Resident 45 on the floor on 12/27/21. During an interview on 1/5/22, at 3:10 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, he entered Resident 45's room on 12/27/21, when Resident 45 was on the floor. LVN 1 stated, CNA 3 called out for assistance with Resident 45. LVN 1 stated, Resident 45 was on the floor next to his bed. LVN 1 stated, Resident 45 wanted to be placed back into bed after the initial fall assessment was completed and that Resident 45 had no visible injuries and Resident 45 said he was ok. LVN 1 stated after placing Resident 45 back into bed, Resident 45 complained of pain to the left side of his body. LVN 1 stated he called an ambulance to transfer Resident 45 to a GACH. During a review of Resident 45's Care Conference Summary v2.0 (Care Conference), dated 1/14/22, the Care Conference indicated, .Nursing .Summary of Nursing Services/Concerns .[Resident 45] does [complain of] pain to the left leg due to recent fracture of the femur that was a result of a fall. [Status post open reduction and internal fixation (ORIF- a type of surgery that is used to repair broken bones that need to be put back together) to [his] left femur .At this time requires extensive to total assist with [Activities of Daily Living-ADLs] such as bed mobility, toileting, personal hygiene and bathing. Resident [45] does not transfer at this time per [Doctors] orders due to being toe touch weight bearing (resident can place their toe on the ground for very subtle balance) on the left leg only but unable to tolerate .Medication Changes/Concerns .none .Falls/Accidents .Briefly describe any falls/accidents. If none, Enter none .none .Signed By .MDS Coordinator .Signed Date .01/27/2022 .Therapy/Restorative .Summary of Therapy/Restorative Services or Concerns .[Resident 45] presents with [left] hip [fracture with] new ORIF from acute .and has been currently on therapy services to address pain, functional mobility, [lower extremity strength, activity tolerance .Signed By .[Physical Therapy] .Date .01/14/22 . During a review of Resident 45's Care Plan, dated 4/22/22, Resident 45's Care Plan indicated, .Resident [45] has physical functioning deficit related to: Total dependency with Mobility impairment, [status post Open Reduction Internal Fixation for Broken (surgery to fix a severely broken bone)] to left femur . Date Initiated: 01/06/2022 . During a review of Resident 45's Section G Functional Status (Section G) (prior to fall on 12/27/21), dated 12/27/21, Section G indicated, .Activities of Daily Living (ADL) Assistance (term used in healthcare to refer to person daily self-care activities ability) .ADL Self Performance .Coding .2. Limited assistance-resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance .C. Walk in room-how resident walks between locations in his/her room .2 .D. Walk in corridor-how resident walks in corridor on unit .2 .F. Locomotion off unit-how resident moves to and returns from off-unit locations .2 . During a review of Resident 45's Section G Functional Status (Section G) (post fall 12/27/21) dated 7/14/22, the Section G indicated, .Activities of Daily Living (ADL) Assistance .ADL Self Performance .Coding .8. Activity did not occur .C. Walk in room-how resident walks between locations in his/her room .8 .D. Walk in corridor-how resident walks in corridor on unit .8 . F. Locomotion off unit-how resident moves to and returns from off-unit locations .8 . During an interview on 7/28/22, at 3 p.m., with CNA 3, CNA 3 stated, on 12/27/21, he had placed Resident 45 in his wheelchair at approximately 6 p.m. CNA 3 stated, he was not Resident 45's assigned CNA for the shift. CNA 3 stated, when he walked by Resident 45's room at approximately 7:45 p.m., Resident 45 was in his bed. CNA 3 stated, he had not placed Resident 45 in his bed and the bed was not in the lowest position from the floor. CNA 3 stated, after he passed Resident 45's room and turned the corner, he heard Resident 45 yell out for help and when CNA 3 returned to Resident 45's room, Resident 45 was on the floor. CNA 3 stated, it was important that Resident 45's bed be placed in the lowest position because he was considered a fall risk. During a concurrent observation and interview on 8/4/22, at 3:52 p.m., with CNA 3, in Resident 45's room, Resident 45 was in his bed. Resident 45's bed was observed at a height that was not in the lowest position. CNA 3 stated, when Resident 45 had fallen out of bed on 12/27/21, Resident 45's bed was raised slightly higher. CNA 3 raised the height of Resident 45's bed. CNA 3 was observed with a measuring tape. CNA 3 measured the height of Resident 45's bed, the height of Residents 45 bed was 22 inches (unit of measurement) from the bottom of the mattress to the floor. CNA 3 stated, Resident 45 was a fall risk, and the bed should always be at the lowest height. CNA 3 lowered Resident 45's bed to the lowest position and measured the height from the bottom of the mattress to the floor, the height measurement was 14 inches (a difference of 8 inches). CNA 3 stated, before Resident 45's fall on 12/27/21, Resident 45 was able to assist with transfers, however Resident 45 is a two person transfer now (post fall). During an interview on 8/4/22, at 4:05 p.m., with LVN 1, LVN 1 stated, Resident 45 was more mobile prior to his fall on 12/27/21 than he was on 1/5/22. LVN 1 stated, prior to Resident 45's fall on 12/27/21 fall, Resident 45 could assist with moving himself in his bed. LVN 1 stated, Resident 45 post fall on 12/27/21 was a two-person transfer. During an interview on 8/5/22, at 10:03 a.m., with the Director of Physical Therapy (DPT), the DPT stated, prior to 12/27/21, Resident 45 was a sit to stand mid assist (when a resident needs minimal assistance to move from sitting to standing) and had a higher level of function. The DPT stated, Resident 45 post fall on 12/27/21 is a two-person transfer with a mechanical lift (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone). During a review of Resident 45's [X-Ray] (picture through the body to see bones) Femur Left Final Result (XR femur), dated 12/28/21, the XR femur indicated, .REASON FOR EXAM .Fall .Pain .FINDINGS/IMPRESSION .Comminuted (bone that is broken in at least two places), mildly displaced fracture of the subtrochanteric (below the femur) left femur with 1.4 [centimeter-cm unit of measurement] displacement . During a review of Resident 45's [X-Ray] Hip Left Complete (XR hip), dated 12/28/21, the XR hip indicated, .REASON FOR EXAM .Fall .Pain .FINDINGS/IMPRESSION .Comminuted oblique (incline) fracture of the proximal (near center) femur just below the intertochanteric (area of femur where angle changes) region. There is a 9 [millimeter-mm unit of measurement] displacement . During a review of Resident 45's, Patient Care Timeline 12/27/21 to 12/30/21 (PCT), the PCT indicated, .12/27/2021 .[10:26 p.m.] . Patient arrived in the [Emergency Department (ED)] .[10:33 p.m.] Pain Assessment Pain Scale Used: Faces Wong-Baker Faces Scale (patients are not able to understand the standard 0-10 pain scale): 2-Hurts a little bit .[10:35 p.m.] ED Fall Risk .Fall Risk: High Risk .12/28/2021 .[1:05 a.m.] fentanyl (powerful drug used in the treatment of severe pain) .injection 25mcg (micrograms-unit of measurement) .[3:00 a.m.] .fentanyl .injection 25 mcg .[3:10 a.m.] .[Patient] was placed in bucks traction (used for fractures in the lower body) .[6:33 a.m.] morphine (drug used to relieve pain) injection 4 mg (milligrams- unit of measurement) .[6:38 a.m.] Pain Assessment .Pain Scale Used: Faces .[NAME] Faces Scale: 8-Hurts a whole lot .Pain Type: Acute pain .Pain Location: Leg .Pain Orientation: Bilateral (both sides) .Pain Quality 1: Aching .Patients Acceptable Level of Pain: No Pain .Pain Intervention(s): Medication .[9:50 a.m.] .Pain Assessment .Pain Assessment Pain Scale Used: 0-10 .Rank your current pain where 0 is no pain and 10 is severe pain: 10 .Pain Type: Acute pain .Pain Intervention(s): Medication .[9:54 a.m.] morphine injection 4 mg .[2:15 p.m.] . Pain Assessment .Pain Assessment Pain Scale Used: 0-10 .Rank your current pain where 0 is no pain and 10 is severe pain: 10 .Pain Type: Acute pain .Pain Location: Leg .Pain Intervention(s): Medication .[2:24 p.m.] .morphine injection 4 mg .12/29/2021 .[11:40 a.m.] . Pain Assessment .Pain Assessment Pain Scale Used: 0-10 .Rank your current pain where 0 is no pain and 10 is severe pain: 6 .Pain Type: Acute pain .Pain Intervention(s): Medication .[11:58 a.m.] .HYDROmorphone (drug used to relieve severe pain) .injection 1 mg . During a review of Resident 45's Operative Report, dated 1/1/22, the Operative Report indicated, .DATE OF OPERATION: 12/30/2021 .POSTOPERATIVE DIAGNOSIS: Left subtrochanteric hip fracture .OPERATIVE PROCEDURE: Intramedullary nailing (a permanent nail or rod is placed into the center of the bone), left hip fracture . During a review of Resident 45's Discharge Summary (from the acute care hospital), dated 1/4/22, the Discharge Summary indicated, .the patient took a fall before his presentation, suffering left hip pain. Workup significant for left hip fracture requiring ORIF . During a review of the facility's policy and procedure (P&P) titled, Assessing Falls and Their Causes, dated 2018, the P&P indicated, .Falling may be related to underlying clinical or medical conditions, overall functional decline, medication side effects, and/or environmental risk factors Appropriate interventions taken to prevent future falls . During a review of the facility's P&P titled, Falls-Clinical Protocol, dated 2018, the P&P indicated, .Assessment and Recognition .While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause .Often, multiple factors contribute to a falling problem .Treatment/Management .the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .Monitoring and Follow-Up .If the individual continues to fall, the staff .will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions . During a review of the facility's P&P titled, Falls and Fall Risk, Managing, dated March 2018, the P&P indicated, .Based on previous evaluations and current date, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .Resident-Centered Approaches to Managing Falls and Fall Risk .The staff .will implement resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident or with a history of falls . If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant .Monitoring Subsequent Falls and Fall Risk .The staff will monitor and document each resident's response to interventions intended to reduce falling or risk of falling .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions .