**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician orders for one of three residents (Resident 1) when: 1. A physician order for Resident 1's use of an abduction pillow (device used to separate the legs and stabilize the hips) was not carried out upon admission to the facility; and, 2. The facility staff failed to transcribe the physician orders for hip precautions (restrictions for after having a total hip replacement), and use of an abduction hip brace (device to maintain correct body alignment and reduce the risk of dislocation) on the Treatment Administration Record (TAR). These failures prevented the Resident 1 from receiving the necessary treatment prescribed by the physician and had the potential for joint repair dislocation, which would jeopardize the rehabilitation of Resident 1. Findings: Review of Resident 1's face sheet (brief summary of a resident's important information) indicated she was admitted on [DATE] with diagnoses including aftercare following joint replacement surgery, presence of right artificial hip joint, dementia (a decline in mental capacity affecting daily function), difficulty in walking, muscle wasting and atrophy (decrease in size). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 6/10/22, indicated she had a BIMS (Brief Interview for Mental Status) score of 6 (a score of 0 to 7 indicates severe cognitive [i.e. thinking, reasoning, or remembering] impairment). Resident 1 required extensive assistance (requiring staff to provide weight-bearing support) for bed mobility (moving in bed), and toileting. Resident 1 was dependent on staff for transfers and had impaired range of motion (the full movement potential of a joint) in the right lower extremity. 1. Review of Resident 1's acute hospital Discharge Orders/Instructions, dated 6/6/22, indicated, physical activity restricted, Abduction Pillow while in bed. Review of Resident 1's skilled nursing medical record revealed there was no physician order for an abduction pillow while in bed and there was no documentation that the facility was using an abduction pillow for Resident 1. During an interview and concurrent record review with registered nurse A (RN A) on 9/27/23 at 4:25 p.m., he stated he was the facility's admission nurse and had admitted Resident 1 on 6/6/22. RN A was asked about Resident 1's hospital discharge order for an abduction pillow while in bed. He confirmed there was an order for an abduction pillow and stated, I don't see that I carried that order out . I don't know how I missed that. RN A stated, The abduction pillow should be transcribed as an order and will appear on the TAR. The nurses will initial every shift that the abduction pillow is in place. RN A stated the licensed nurse's documentation is necessary to show the facility is following the physician order for the abduction pillow to be used by Resident 1 while in bed. 2. Review of Resident 1's Physician Order, dated 6/6/22, that indicated, Total hip precautions: No hip flexion greater than 70 degrees, no hip adduction (movement towards the midline of the body), no internal rotation of operative hip. These positions can cause the hip to dislocate (displaced from its normal position). Review of Resident 1's Physician Order, dated 6/6/22, that indicated, Weight bearing as tolerated. Weight bearing on the right lower extremity with hip abduction brace when out of bed. Review of Resident 1's medical record revealed there was no documentation that the facility was following total hip precautions as ordered by the physician, and no documentation that Resident 1 was using a hip abduction brace when she was out of bed. During an interview and concurrent record review with registered nurse A (RN A) on 9/27/23 at 4:25 p.m., he confirmed Resident 1 had physician orders for total hip precautions and to use a hip abduction brace when out of bed. RN A stated the orders were not transcribed correctly; so, the orders did not appear on Resident 1's TAR. RN A stated, I don't know what happened, the orders need to be on the TAR. He confirmed there was no documentation the facility was observing total hip precautions or using a hip abduction brace when Resident 1 was out of bed. During an interview and concurrent record review with the nursing supervisor (NS) on 10/5/23 at 11:58 a.m., she was asked to review Resident 1's orders for total hip precautions and a hip abduction brace when out of bed. The NS was asked where in Resident 1's record the licensed nurses document that total hip precautions were observed and that Resident 1 used a hip abduction brace when out of bed. The NS stated, I don't know why those orders are not in Resident 1's TAR . they should be. That's where the licensed nurses will document. The NS stated when the abduction brace and total hip precaution orders are transcribed correctly, they will appear on the TAR. The nurses will initial every shift they are observing total hip precautions and the abduction brace is in place as ordered. NS indicated the licensed nurses' documentation is necessary to show the facility is following the physician orders. The NS confirmed there was no documentation the facility was observing total hip precautions or using a hip abduction brace for Resident 1. Review of Resident 1's Clinical Notes – Nursing Progress Notes, dated 6/24/22, indicated an order was received from Resident 1's physician for x-rays of bilateral hips. Review of the Radiology Report, dated 6/25/22, indicated right femoral arthroplasty (thigh reconstructed joint) dislocated from the parent acetabulum (socket part of the hip joint). Review of Resident 1's Clinical Notes – Nursing Progress Notes, dated 6/27/22, indicated physician orders to send Resident 1 to the emergency room for further evaluation. Review of Resident 1's Emergency Department – Provider Notes, History and Physical, dated 6/27/22, indicated Resident 1 was unable to adequately work in physical therapy due to pain. An assessment X-ray report indicated Resident 1 had a dislocation of the right hip and to admit to orthopedics for reduction (bone realignment) in the OR (operating room). Review of the California Nursing Practice Act Rules and Regulations, Division 2, Chapter 6, Article 2. Scope of Regulations 2725 (b) indicated, The practice of nursing within the meaning of this chapter means . (2) Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist (medical specialist for treatment of foot problems), or clinical psychologist (specialist in the treatment of mental, emotional, and behavioral disorders), as defined by Section 1316.5 of the Health and Safety Code. Review of the facility's policy titled Charting and Documentation, revised 12/2022, indicated documentation of treatments should include the date and time the treatment was provided, the name and title of the individual who provided the care, any assessment data obtained during the treatment, and whether the resident refused the treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) received necessary care and services to achieve and maintain her highest practicable health and well-being when: 1. Staff did not develop an individualized resident-centered care plan to address Resident 1's use of a CAM (controlled ankle movement) boot, 2. Licensed nurses did not follow-up with the physician for clarification of instructions for Resident 1's CAM boot, 3. Licensed nurses did not assess and monitor Resident 1's surgical incision on the right ankle, and 4. Licensed nurses did not follow the manufacturer's guidelines to perform circulation checks for the CAM boot that was applied by Resident 1's orthopedic surgeon. These failures negatively affected the Resident 1's health and well-being when her right foot developed two deep tissue injuries (DTI, injury to underlying tissue below the skin's surface that results from prolonged pressure in an area of the body). Findings: Review of Resident 1's face sheet (a summary of important information) indicated she was admitted on [DATE] with diagnoses including fracture of the right tibia (one of the bones of the lower leg), osteoporosis (condition that causes the bones to become brittle and fragile), respiratory failure (the body is unable to effectively transfer oxygen and carbon dioxide), atrial fibrillation (irregular heart rate), chronic respiratory failure (the inability to effectively exchange gasses in the lungs), chronic obstructive pulmonary disease (lung disease that causes obstruction of airflow and interferes with normal breathing), congestive heart failure (inability of the heart to pump blood with normal efficiency), anemia (low levels of healthy red blood cells), rheumatoid arthritis (inflammatory disease that affects the joints). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/11/23, indicated she had a BIMS (Brief Interview for Mental Status) score of 5 (a score of 0 to 7 indicates severe cognitive impairment) and required extensive assistance (staff provide weight-bearing support) for bed mobility (moving in bed), and toileting. Resident 1 was dependent on staff for transfers and had impaired range of motion (the full movement potential of a joint) in the right lower extremity. Review of Resident 1's Braden scale assessment (tool used in wound assessment) dated 2/9/23 indicated, she had a score of 14 (a score of 13-14 represents a moderate risk for developing pressure ulcers). 1. Review of Resident 1's admission Evaluation assessment dated [DATE], indicated resident's primary admitting diagnosis was, encounter for after care following surgery, and identified the presence of a cast on Resident 1's right lower leg. Review of Resident 1's orthopedic surgeon's progress notes dated 2/17/23, indicated a CAM boot was applied to the right lower leg. Review of Resident 1's clinical record indicated there was no care plan initiated for Resident 1's use of the CAM boot. There were no nursing measures in place to assess the skin and monitor the skin integrity of Resident 1's right lower leg. During an interview and concurrent record review with the director of nursing (DON) on 7/31/23 at 11:05 a.m., she stated there was a care plan developed for Resident 1's cast on admission but confirmed there was no care plan developed for the CAM boot when it was applied to Resident 1's right lower extremity on 2/17/23. The DON stated the facility should have developed a care plan specifically for the CAM boot to include nursing interventions to monitor the skin, reposition and monitor for pressure related injury. When the DON was asked how nursing staff was assessing the skin on Resident 1's right lower leg, she responded we could not do any skin assessments of Resident 1's right lower leg because we were not taking the CAM boot off. Review of the facility's policy titled Comprehensive Person-Centered Care Plans, revised March 2022, indicated assessments of residents are ongoing and care plans are revised as information about the resident and the resident's conditions change. 2. Review of Resident 1's orthopedic doctor's progress notes, dated 2/17/23, indicated, Sutures removed; strips applied; leave strips to fall off; no dressing required; CAM boot applied; WBAT (weight bearing as tolerated) in CAM boot RLE (right lower extremity); shower OK; continue gentle PT (physical therapy)/OT (occupational therapy); patient should only bear weight as tolerated; Call with questions. During an interview and concurrent record review with the nursing supervisor (NS) on 6/15/23 at 2:00 p.m., she was asked if Resident 1's record indicated any doctor's orders for the CAM boot, specifically if there were any doctor's orders indicating if the CAM boot could be removed or if it was to be worn 24 hours a day. The NS stated, I do not see any orders for the CAM boot . Some doctors have the boot always stay on. The NS was questioned if the 2/17/23 physician's progress note entry, shower OK, indicated the boot can be taken off for a shower. She responded, I can't tell from this physician's progress note .it does not say . There are no specific doctor's orders about the CAM boot . If I were the one to receive this physician's progress note, I would have called the orthopedic doctor to clarify if the CAM boot could be removed for the shower. The NS stated Resident 1's physician should have been called to obtain orders related to removal of the CAM boot. During an interview and concurrent record review with the DON on 7/7/23 at 1:30 p.m., she acknowledged there were no doctor's orders for Resident 1's CAM boot and no specific order to indicate if the CAM boot could be removed by facility staff. She stated a variety of boots and splints are worn by their residents and the orders to remove them will vary according to their physicians. The DON stated, since there were no orders to remove Resident 1's CAM boot, the staff did not remove it. She further stated that Resident 1, Had a fracture and we did not want to do anything that would disrupt the healing process; so, we never took the CAM boot off. She acknowledged the staff should have called Resident 1's orthopedic doctor to clarify what she wanted in terms of the CAM boot for this resident. The DON stated, If there are questions about when to wear it or if it should be taken off, then we should ask the doctor. A review of Resident 1's (nursing) clinical notes report, dated 3/11/23, indicated Resident 1's son removed the CAM boot and requested a licensed nurse do a skin assessment of Resident 1's right lower leg. The report also indicated dark brown discolored skin was observed on Resident 1's right foot located at the right heel measuring 3 centimeters (cm, unit of measure) by 3 cm and at the right upper plantar area (area of the bottom of the foot opposite the heel) measuring 3 cm by 3 cm. The report indicated the licensed nurse contacted Resident 1's medical doctor and received orders to treat the deep tissue injuries on Resident 1's right foot. During an interview with Resident 1's orthopedic surgeon (OS, physician specializing in correcting bone and muscle deformities) on 7/13/23 at 3:00 p.m., she was asked if Resident 1's pressure ulcers on the right lower leg could be attributed to the wearing of the CAM boot. The OS stated, 100% .the DTIs can be attributed to the CAM boot .I was surprised that they were not removing it. She further stated the CAM boot is a removable device and the expectation is that the skin will be assessed at regular intervals, and the CAM boot would be removed in order to accomplish this. The OS stated the nursing staff should, certainly have a plan of care for removable orthosis (brace or other devices to correct alignment or provide support) that involves skin checks .that is just typically done as a nursing measure. 3. Review of Resident 1's Internal Medicine History and Physical, dated 2/10/23, indicated she had a diagnosis of fracture of the right tibia and had an open reduction and internal fixation (ORIF, type of surgery used to stabilize and heal a broken bone) on 2/2/23 in the acute hospital prior to her admission to the facility. Review of Resident 1's admission Evaluation Assessment, dated 2/9/23, indicated Resident 1 was admitted with a cast on her right lower leg (which was removed during an appointment with her orthopedic surgeon on 2/17/23). Review of a physician progress note, dated 2/17/23, indicated, sutures removed; strips applied .leave strips to fall off; no dressing required . During an interview and concurrent record review with the DON on 7/31/23 at 11:05 a.m., she acknowledged Resident 1 had a surgical repair of her fractured right lower leg. The DON was asked if the surgical site should be monitored after the cast was removed from Resident 1's right lower leg on 2/17/23. The DON stated there are physician orders for care of a surgical site, dressing changes, and monitoring for signs of infection when residents have had surgical procedures. She further stated, There are no physician orders for surgical site care of Resident 1's right lower leg . In this resident's case, the CAM boot was left on and there were no treatments done to the surgical site. When the DON was asked if a surgical site should be monitored until healed, she stated, Yes surgical sites should be monitored .I do not see any orders to monitor the surgical site for Resident 1 .the CAM boot remained on; so, we did not monitor the surgical site. 4. During a phone interview with the orthopedic technician (OT), from Resident 1's orthopedic surgeon's office on 7/31/23 at 4:30 p.m., she stated Resident 1 was fitted with an immobilization device to the right lower leg during her orthopedic appointment on 2/17/23. The OT identified the make and model of Resident 1's immobilization device applied. A review of the manufacturer's guidelines for this device indicated, Caution: Be sure the patient performs circulation checks. If a loss of circulation is felt, or if the walker feels too tight, release contact closure straps and adjust to a comfortable level. If discomfort continues, the patient should contact their medical professional immediately. Review of Resident 1's physician order dated 2/10/23 indicated, Cast Care: Cast on right lower leg. Monitor for foul odors, changes in sensation, swelling, burning, numbness, tingling, skin discoloration, paralysis, white or cool toes or fingertips, warm spots, soft areas, cracks in cast. Notify MD as needed. A review of the treatment administration record (TAR) indicated licensed nurses followed the physician order for cast care and monitored Resident 1's casted right lower extremity from 2/10/23 until 2/21/23. There was no documented monitoring of Resident 1's right lower leg after the cast was removed and the CAM boot was applied on 2/17/23. During an interview and concurrent record review with the licensed vocational nurse A (LVN A) on 7/17/23 at 1:00 p.m., she acknowledged Resident 1 had a CAM boot applied on her right lower leg on 2/17/23. When LVN A was asked what nursing measures would be initiated when a resident is wearing a CAM boot, she replied, I would expect to do checks on the affected part in the CAM boot, check for color, circulation, movement, and pain. LVN A reviewed Resident 1's clinical record and acknowledged there was no documentation indicating monitoring was done for Resident 1's right lower leg when the CAM boot was in place and LVN A stated there should be. Review of the facility's policy titled Prevention of Pressure Injuries, revised April 2020, indicated for device-related pressure injuries to monitor regularly for comfort and signs of pressure-related injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from abuse when Resident 1 alleged a facility staff of sexually assaulted Resident 1, the facility did not inform the primary physician regarding the sexual assault allegation and did not have evidence that staffs provided a follow-up monitoring of Resident 1 after the allegation of sexual abuse. Resident 1's care plan was not updated to address the abuse allegation, and the facility did not report the sexual abuse allegation to the California Department of Public Health (CDPH). These failures resulted in Resident 1 had psychosocial (relating to the interrelation of social factors and individual thought and behavior) and emotional distress from the alleged sexual abuse. Review of Resident 1's face sheet indicated she was admitted to the facility on [DATE] with a diagnosis that includes peri (around) prosth fracture (fractures around joint replacement prostheses) around internal prosth (prosthesis, a device that is placed inside a person's body during a procedure to permanently replace a body part) right knee and discharged on 8/10/22. Review of Resident 1's minimum data set (MDS, an assessment tool) dated 6/11/22 indicated she has a Brief Interview for Mental Status (BIMS) score of 14 (a score of 13-15 indicates intact cognition). Review of Resident 1's toileting and dressing care plan dated 6/20/22, indicated she needed extensive assistance with both. Review of the compliant intake received by the CDPH on 11/29/22, indicated Resident 1 alleged certified nursing assistant A (CNA A) sexually assaulted Resident 1. The intake indicated the alleged incident took place on 6/27/22 in the facilty. Review of Resident 1's Interdisciplinary Team (IDT, team members from different departments involved in a resident's care) notes, dated 6/28/22, indicated Resident 1 stated she had been violated by her assigned aide during morning shift change on 6/27/22. The IDT note indicated that the facility notified the CDPH, Law Enforcement, and Long Term Care Ombudsman (an organization that the representatives assist the long term care facilities residents for the health and safety issues). Review of the facility's investigative report dated 6/28/22, indicated on 6/27/22, assigned CNA A put ointment on Resident 1's private area during the care, Resident 1 felt that CNA A put his hand in her private area two times. Resident 1 felt a true violation had occurred. Resident 1 has no diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) or cognition impairments. The facility investigation report indicated .substantiated sexual abuse upon interview with Resident 1. During an interview with the administrator (ADM) on 11/30/22 at 10:05 a.m., he stated CNA A was from a nursing registry and did not come back to the facility after the allegation against him. ADM also stated the previous director of nursing (DON) made the investigative report and CNA A was not investigated because he did not return to the facility after the allegation. ADM stated Resident 1 was discharged from the facility sometime in August 2022. The ADM provided the SOC 341 (Sate of California Report of Suspected Dependent Adult/Elder Abuse) document dated 6/28/22 which indicated telephone report made to the Law enforcement. The ADM stated he knew the SOC 341 was sent to CDPH on same day of 6/28/22 and would provide the evidence. The ADM provided the SOC 341 document sent to the Ombudsman but not to the CDPH. The ADM stated the reporting was handled by the previous executive director and he was not sure if the investigative report was also sent to CDPH on same time. During a concurrent interview and record review with the director of nursing (DON) on 11/30/22 at 10:25 a.m., DON reviewed Resident 1's progress notes and care plan regarding the sexual allegation. There was no follow up documentation from the licensed nurses or social service department indicated staff follow up with Resident 1 regarding the sexual allegation including the physical and emotional assessment. There were no documents indicated the facility notify the primary physician regarding Resident 1's sexual assault allegation. There was no updated care plan to address Resident 1's sexual allegation incident. The DON also reviewed Resident 1's other documents for the allegation and did not find notification of Resident 1's primary physician and licensed nurses' follow up documentation. The DON stated the license nurses should do 72-hour monitoring for Resident 1 and the social service should do 72-hour psychosocial assessment for Resident 1 regarding post sexual abuse allegation. DON stated Resident 1's care plan should have been updated to address the allegation. The DON stated it was important to have a follow up assessment by either the licensed nurses or social service department for any allegation of abuse for the residents. During a telephone interview with the Ombudsman on 12/5/22 at 8:35 a.m., she stated she received the SOC 341 from the facility and remembered Resident 1 called her to report about the sexual allegation. The Ombudsman stated Resident 1 indicated she (the resident) was distraught about what happened to her regarding the sexual abuse allegation. Review of the Centers for Medicare & Medicare Services (CMS) complaint/Incidents tracking system (the complaints and incidents report to CDPH, CDPH is the agency for CMS to investigate these complaints/incidents) on 12/1/22, indicatedthere was no report that the facility reported to CDPH about Resident 1's sexual abuse allegation. Review of the facility's policy, Elder Abuse Prevention, Identification, Response, Reporting, dated 11/28/16, indicated team members are expected to prevent, identify, respond to and report allegations of elder abuse according to the steps of this procedure .identification of abuse, resident assessments which reflect unusual bruising, wounds or patterns of skin trauma not caused by resident self-inflicted injury , response to allegations or witnessed events, revise the resident's care or service plan if the resident's needs change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow their pressure ulcer (PU, ijuries to skin and underlying tissue resulting when soft tissue is compressed between a bony prominence and an external surface for a long period of time) prevention policy for one of two sampled residents (Resident 16) with a PU. The facility did not plan for or implement the intervention to protect Resident 16's left heel from undue pressure by keeping it off of the bed. This failure resulted in Resident 16 developing a facility-acquired Stage III PU (involves full-thickness skin loss and extends into the tissue beneath the skin, forming a small crater) on his left heel. Findings: Review of Resident 16's clinical record indicated he was admitted to the facility on [DATE] with diagnoses of rhabdomyolysis (a serious syndrome due to muscle injury which results in the death of muscle fibers and their release into the bloodstream) and Type II diabetes (a chronic condition which affects the way the body processes blood sugar). Review of Resident 16's Nursing admission Assessment dated 10/14/19, indicated on initial assessment Resident 16 did not have a wound on his left heel. Review of Resident 16's Minimum Data Set (MDS, an assessment tool) dated 10/15/19, indicated Resident 16 was immobile in bed and required extensive assistance of one person to turn side-to-side and to position self while in bed. The same MDS indicated Resident 16 did not have any pressure wounds when admitted and had a brief interview of mental status (BIMS) score of 9 (scores of 8-12 points indicates moderately impaired thinking and memory). A review of Resident 16's Care Plan dated 10/14/19, indicated Resident 16 was at risk for impairment of skin integrity on admission. The Care Plan indicated there was no intervention written to float heels (keep heels off of the bed) until 11/23/19, after the discovery of Resident 16's left heel PU. Review of Resident 16's Committee Review Progress Notes dated 11/26/19 at 10:30 a.m., indicated the committee met to discuss Resident 16's newly acquired left heel pressure ulcer discovered on 11/24/19. The committee noted Resident 16 had been at risk for pressure injury and recommended to keep feet elevated off of the bed at all times while in bed. Review of the physician wound service (PWS) Initial Wound Evaluation and Management Summary dated 11/27/19, indicated Resident 16 had a Stage III PU of the left heel for at least seven days duration (11/20/19). The PWS recommended to off-load heel wound (keep left heel up and not touching the bed) and to reposition resident according to facility protocol. Review of Resident 16's Treatment Administration Record (TAR) dated October through December, indicated Resident 16 was turned every two hours since admission beginning on 10/16/19 but there was no indication Resident 16's heels were offloaded from the bed. During an observation on 12/18/19 at 10:50 a.m., Resident 16 was lying in bed with lower legs elevated with two pillows and received assessment and treatment to his left heel by the PWS. PWS confirmed Resident 16's left heel Stage III PU developed after he was admitted to the facility. During an interview with the interim director of nursing (IDON) on 12/19/19 at 9:39 a.m., she stated the facility identified Resident 16's left heel wound was preventable. The IDON stated the conference team identified the problem of Resident 16's left heel wound and ordered a physician led inservice regarding prevention of pressure wounds and how Resident 16's pressure wound could have been prevented, held on 12/11/19. The IDON stated staff had not taken measures to offload Resident 16's heels and prevent the development of his pressure wound. The DON stated going forward residents at risk for pressure ulcers would be provided with foam boot heel protectors to help offload feet while in bed. Review of the facility's 2010 policy, Prevention of Pressure Ulcers, indicated pressure ulcers are usually formed when a resident remains in the same positon for extended periods of time causing increased pressure and a decrease in blood circulation to the area . a common site is where the bone is near the surface of the body including the heels . for residents who required assistance while in bed, change position at least every two hours and off-load heels (keep heals off of the bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to plan for and implement new post-fall interventions to prevent falls for one of six sampled residents (Resident 4) with falls. These failures resulted in Resident 4 falling six times between 4/17/19 and 8/15/19, and on the sixth fall, Resident 4 sustained a right hip fracture. Findings: A review of Resident 4's clinical record indicated diagnoses of dementia (decline in mental abilities and memory affecting judgment and behavior), muscle weakness, difficulty in walking and intracapsular fracture of right femur (occurs when the top part of the femur (leg bone) is broken; the ball on the top of the femur has broken off at its junction within the hip joint). A review of Resident 4's general acute care hospital (GACH) emergency department History and Physical (H&P) dated 8/16/19, indicated Resident 4 was admitted to the GACH for treatment of a right hip fracture resulting from a fall on 8/15/19. A review of Resident 4's Progress Notes (PN) dated 8/24/19 at 7:59 a.m., indicated Resident 4 was readmitted to the facility on [DATE] with a diagnosis of open reduction and internal fixation (ORIF, a surgery in which the doctor makes an incision (cut) to reach the bone and move it back into normal position) following a right intracapsular femur fracture. The PN further indicated Resident 4 had a right hip incision (surgical cut) covered by a gauze dressing. A review of Resident 4's minimum data set (MDS, an assessment tool) dated 5/31/19, indicated a brief interview of mental status (BIMS) score of 0 (scores of 0 indicate resident was not able to answer questions which tested thinking and memory correctly). The same MDS indicated Resident 4 required the physical assistance of one person to provide weight bearing support to transfer between the bed and the wheel chair (WC) and between the WC and the toilet. The same MDS indicated Resident 4 was able to use the walker and the WC for mobility. A review of Resident 4's Morse Fall Scale dated 5/30/19, indicated Resident 4 scored 80 (scores of 45 or higher indicate a high risk for falls). A review of Resident 4's Post Fall Assessments, indicated the following: 1) 4/17/19: Unwitnessed fall from bed with no injury; resident wheels herself to the bathroom and does not call for help. 2) 6/11/19: Unwitnessed fall from bed resulting in a bleeding skin tear on the back of her left hand, resident was incontinent during event. 3) 6/19/19: Unwitnessed fall to floor near bathroom with no injury; wheel chair (WC) next to resident. 5) 8/14/19: Unwitnessed fall from bed with no injury while attempting to get into her WC. A review of Resident 4's post-fall Committee Reviews (CR), indicated the following recommendations and interventions: 1) 4/19/19: Provide in-service training to team to keep WC locked when not in use. 2) 6/12/19: Continue the rehabilitation nursing assistant (RNA) program and anticipate toileting needs; toilet resident before breakfast. 3) 6/21/19: Continue RNA program and anticipate toileting needs. 4) 8/5/19: Found on floor in sitting position 10: 40 p.m. Continue RNA program and anticipate toileting needs; check on resident hourly and toilet resident before bed. 5) 8/16/19: Post-Fall CR for fall of 8/14/19 and 8/15/19 recommendations: Upon return from GACH Resident 4 will transfer to a room close to the nurse's station where she will always be in site of staff in the station. During a review of Resident 4's 2019 fall care plan (CP, a written document which provides a means of communication among healthcare providers to achieve health care outcomes) indicated the following interventions to prevent falls: CP interventions in place prior to the above committee recommendations: • Anticipate and meet Resident 4's needs (Initiated 2/26/17). • Increase RNA program to five days per week (Initiated on 2/26/17; was not cancelled but was repeated during a revision on 4/17/19). • Keep wheelchair locked while not in use (Initiated on 2/26/17; was not cancelled but was repeated during a revision on 4/17/19). New CP interventions initiated after Resident 4's falls: 1) Fall of 4/17/19: In-service team to keep WC locked while not in use. 2) Fall of 6/11/19: Date of fall and new interventions were not found on the CP. 3) Fall on 6/19/19: New interventions were not found on the CP 4) Fall on 8/1/19: Hourly rounding for safety; toilet resident before going to bed. 5) Fall on 8/14/19: • Make sure bed is in locked position • The resident needs activities that minimize the potential for falls while providing diversion and distraction. 6) Fall on 8/15/19: Change resident's room to a room closer to the nurses' station. A review of Resident 4's admission Record, indicted Resident 4 was readmitted to the facility to room [ROOM NUMBER] on 8/23/19 and Resident 4's previous location was room [ROOM NUMBER]. During an observation on 12/18/19 at 9 a.m., room [ROOM NUMBER]'s location was observed at the end of a hall, farthest from the nurse's station. room [ROOM NUMBER]'s location was observed across from and in view of the nurse's station. During an interview with CNA H on 12/18/19 at 9:45 a.m., she stated she worked with Resident 4 before her injury of 8/15/19. CNA H stated she did not remember nurses telling her to check on Resident 4 every hour. CNA H stated the CNA's were busy and were not able to watch on her all the time. During an interview and record review with the interim director of nursing (IDON) on 12/18/19 at 10:15 a.m., she stated the post-fall committee should have recommended new interventions to prevent Resident 4 from having further falls for the falls on 6/11/19 or 6/19/19. The IDON stated toileting Resident 4 before breakfast and before bed were not new interventions, but were usual expectations of a certified nursing assistant (CNA). The IDON stated interventions which could have been recommended by the committee to prevent further falls were: to move Resident 4 closer to the nurses' station at an earlier date, to order physical therapy (PT) or occupational therapy (OT) for a strengthening evaluation and to provide written instructions of interventions to the CNA. The IDON stated the facility was unable to track if Resident 4 was actually checked on or toileted more than one time per shift due to the limitations of the facility's electronic documentation system which only allowd the CNA to document toileting and safety monitoring one time per shift. During an interview with CNA C on 12/18/19 at 1:30 p.m., she stated she knew Resident 4 well and was often assigned to her. CNC C stated before Resident 4's hip injury of 8/15/19, the nurses did not tell her to check on or toilet Resident 4 every hour or any other time frame. CNA C stated she was often busy with other residents and unable to check on Resident 4. CNA C stated Resident 4 was confused and never used her call light. CNA C stated an order for safety checks every 15 minutes and Resident 4's move to a room closer to the nurse's station may have helped to prevent Resident 4's falls and injury. CNA C stated Resident 4's room used to be room [ROOM NUMBER] located at the end of the hall farthest from the nurses station. A review of Resident 4's MDS dated [DATE], indicated post-injury of Resident 4 required extensive assistance with two people for toileting and did not walk in or out of her room. Review of the facility's 2007 policy Falls and Fall Risk, Managing, indicated if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . if underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable.