**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure one resident (Resident 1) received treatment and care in accordance with the facility's Infection Control policy for influenza (flu- an illness caused by a virus [a germ] that is spread from person to person) when: Licensed Nurses (LNs) did not notify Resident 1's doctor (MD) that Resident 1 had symptoms of the flu and a report of Resident 1had been exposed to a family member who tested positive for flu; LNs did not notify the MD the facility ran out of flu tests; LNs did not place Resident 1 on droplet precautions (measures implemented to prevent the spread of infection when a person who is infected with a pathogen [germs that cause disease] coughs, sneezes, or talks);These failures resulted in Resident 1's hospitalization from 4/27/25 up to 5/6/25 where she was diagnosed with Influenza A and Acute Hypoxemic Respiratory Failure (AHRF, a serious condition where the respiratory system can't maintain adequate oxygen levels in the blood, potentially leading to organ dysfunction), received a new order for supplemental oxygen (additional oxygen to a person who is not receiving enough oxygen from the air they breathe), and decreased the facility's potential to prevent the spread of flu among other residents, visitors, and staff.Findings:A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] at the age of [AGE] years old.A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/27/25, indicated the primary reason for Resident 1's admission was due to a medically complex condition (a broad category of illnesses, diseases, or impairments that require extensive and ongoing medical care, often involving multiple body systems and comorbidities [simultaneous presence of two or more medical conditions in a patient]) including a diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing),.A review of Resident 1's admission Summary progress note, dated 4/24/25, indicated Resident 1 presented to the facility with stable (within normal limits [WNL] or acceptable ranges) vital signs (measurements of the body's most basic functions) including pulse (number of times the heart beats within a minute) at 94 beats per minute (bpm), and oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) at 94% without the use of supplemental oxygen.A review of Resident 1's nurse health status note, dated 4/24/25 at 4:06 p.m., indicated Resident 1's daughter notified Licensed Nurse (LN) A that Resident 1 had been exposed to a family member who tested positive for flu. The note also indicated Resident 1 had complained of sore throat and earache earlier that day.A review of Resident 1's nurse health status notes, for dates 4/24/25 and 4/25/25 did not indicate Resident 1's physician was notified that Resident 1 had been exposed to flu, had a reported symptom consistent with flu, and had not been tested for flu due to the facility not having flu testing supplies.A review of Resident 1's health status note, dated 4/26/25 at 9:56 p.m., indicated, [Resident 1's] daughter expressed concern regarding her mother's respiratory status. She requested that MD be notified regarding her concern that [Resident 1] may have flu.[with] [temperature] 98.7 [Fahrenheit, a unit of measure] ([Resident 1's] daughter notes that this is a high temp [temperature] for her mother.A review of Resident 1's health status note, dated 4/27/25 at 2:59 p.m., indicated, .[Resident 1] with elevated temp noted 99.1 [Fahrenheit].with episode of cough noted.family requesting to see MD; MD will be in on 4-28.A review of Resident 1's incident note, dated 4/27/25 at 11:30 p.m. indicated, .[Resident 1's] daughter called [facility] at approximately [4:30 p.m.] to report her concern that [Resident 1] had loose stools x2 [two times]. next call from [Resident 1's daughter] came after approximately one hour.that [Resident 1] had another loose stool.that [Resident 1] needed to be transferred to ‘the hospital' because ‘you are not doing anything for her'. [Resident 1] left [facility] with EMS [emergency medical services] staff at approximately [7 p.m.].[Resident 1] had resisted having vitals taken.A review of Resident 1's incident note, dated 5/11/25, indicated, late entry /addendum for 4/27/25: assessment of time.Timing of [Resident 1's] discharge from [facility] with EMS Paramedic staff is now estimated to be between [9:15 p.m.] and [9:30 p.m.] .A review of the emergency department (ED, provides unscheduled outpatient services to patients whose condition requires immediate care) provider note, signed 4/28/25, indicated on 4/27/25 Resident 1 was, .[brought in by ambulance] from [skilled nursing facility] for concerns of flu.HR [heart rate, the number of times the heart beats per minute] 140s, [O2 sat] 92% . placed on [supplemental oxygen].Triage vital signs Temp 99 [Fahrenheit], Heart rate 153, [Respiratory Rate] 35, [O2 sat] 97% [on supplemental oxygen].presenting with shortness of breath. wheezing [a high-pitched sound made when breathing is restricted/obstructed in the lungs] and rhonchi [low-pitched, continuous, snoring or gurgling sounds heard in the lungs, resulting from mucus or other secretions obstructing the larger airways] present. Sepsis [a life-threatening response to infection] was present on arrival, specifically at [9:45 p.m.].ED diagnosis:1. Acute hypoxemic respiratory failure. 2. Influenza A. A review of Resident 1's Hospital Discharge summary, dated [DATE], indicated, . Date of admission: [DATE] Date of discharge: [DATE].Hospital summary.[Resident 1] with complain [sic] of shortness breath, sore throat, cough.Acute respiratory failure with hypoxia [condition with low oxygen] and hypercapnia [condition with high levels of carbon dioxide].Influenza A.COPD with exacerbation [worsening of a disease or its signs and symptoms]. Per [oxygen] eval, [Resident 1] will benefit from PRN [as needed] [supplemental oxygen] to keep [O2 sat] above 92% .[supplemental oxygen] has been ordered and will be delivered to [home health agency]. [Resident 1] influenza positive.COPD made worse by influenza a. discharge disposition: home with home health.During an interview on 7/29/25 at 10:20 a.m., LN A stated when a facility received a report that a resident was exposed to flu, [AD1] the facility would test the resident for flu as a precautionary measure. LN A acknowledged Resident 1 had not been tested for the flu at the facility because there were no flu test kits available. LN A stated that since there was no confirmation Resident 1 was positive for flu, Resident 1 could only be suspected of having the flu virus. LN A stated testing for flu was important to protect the residents and provide Resident 1 with the appropriate treatment. LN 1 clarified, when a resident tested positive for flu, the resident should be put on transmission-based precaution (TBP, an infection control measures used in healthcare settings to prevent the spread of pathogens that can be transmitted through contact with an infected patient, their body fluids, or contaminated surfaces or objects). LN A added placing a resident who tested positive for flu on TBP was for everyone's safety and to prevent outbreaks (a sudden increase in the number of cases of a disease in a specific area or population over a short period). During a concurrent interview and record review on 7/29/25 at 10:26 a.m. with the facility's Infection Preventionist (IP, a healthcare professional who specializes in preventing and controlling infections in healthcare settings), Resident 1's nurse health status notes, dated 4/24/25 through 4/25/25, were reviewed. The IP verified Resident 1's daughter had reported that Resident 1 was exposed to flu. The IP stated that since the family member told the facility staff Resident 1 was exposed to flu, the facility staff should have tested Resident 1 for flu. The IP stated the flu test was not done on Resident 1 because the facility ran out of flu tests. The IP stated it was important to do the flu test to determine Resident 1 flu status and to provide appropriate treatment. The IP verified the nurse health status notes dated 4/24/25 through 4/25/25 did not indicate the MD was notified Resident 1 was exposed to flu, suspected of having flu since she reported a symptom consistent with flu, or that the facility was unable to test Resident 1 for flu virus due to facility's lack of flu test. The IP verified, Resident 1's electronic health record did not indicate Resident 1 was placed on any TBP.During a concurrent interview and record review on 7/29/25 at 11:21 a.m., with the IP, the facility's policy and procedure (P&P) titled Infection Control Plan- Influenza, dated 02/2024 was reviewed. The IP verified that based on their flu plan, which the facility follows, Resident 1 was considered a suspect for flu and should have been tested for flu, placed on droplet precautions and immediately started on antiviral medication. The IP confirmed that none of those actions were done for Resident 1. The IP stated it was important to test Resident 1 for flu to know her flu status and to be able to treat her right away. The IP stated placing Resident 1 on droplet precaution ensures the safety of everyone and could help prevent outbreaks.During a concurrent interview and record review on 7/29/25 at 11:50 a.m. with the Director of Nursing (DON), Resident 1's nurse health status notes from 4/24/25 through 4/27/25 and Resident 1's electronic medication administration record (EMAR, a digital system used to track and document the administration of medications, ensuring accuracy and timeliness in medication delivery) for April 2025 was reviewed. The DON verified Resident 1 should have been tested for flu upon report she had been exposed to flu and was symptomatic but was not tested due to lack of a flu test kit. The DON verified that when Resident 1 was admitted on [DATE] and up to the time Resident 1 was sent out to the hospital on 4/27/25, Resident 1 was not tested for flu, did not receive any antiviral medications nor was placed on droplet TBP. The DON confirmed Resident 1 was sent to the ED due to concern from Resident 1's daughter that Resident 1's condition was worsening and the belief that the facility was not taking care of Resident 1. The DON verified the facility's flu policy and procedure (P&P) was not followed, since Resident 1 was suspected of flu, Resident 1 should had been tested for flu, should have been placed on droplet TBP and should have been started on antiviral medication.A review of the facility's P&P titled Infection Control Plan-Influenza (Residents/Patients), last reviewed on 2/2024, the P&P indicated, .Healthcare clinic infection control lead and clinical staff will evaluate, observed or report residents with symptoms and implement daily surveillance and/or testing and symptoms screening.LTC [long term care] residents who have confirmed or suspected influenza should receive antiviral treatment immediately as antiviral treatment works best when started within the first 2 days of symptoms.communications/notifications to residents physicians.A review of the Center for Disease Control and Prevention (the national public health agency for the United States) document titled, Treating Flu with Antiviral Drugs, dated 9/11/24, indicated, .Treatment of flu with flu antiviral medications works best when started within 1-2 days after flu symptoms begin. Flu antiviral drugs can lessen symptoms and shorten the time you are sick. It's very important that flu antiviral drugs are started as soon as possible to treat patients who are. at increased risk of serious flu complications based on their age or underling health conditions, if they develop flu symptoms. For example, people with asthma and chronic lung disease.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of fourteen sampled residents (Resident 34 and Resident 190) at risk for falls, were provided with supervision (visual checks) by direct care staff and had effective revisions and implementation of their nursing care plans to prevent further falls to keep them safe. Facility policies on safety and management of falls were not followed. As a result, Resident 190 suffered two falls with major injuries, consisting of hip fractures, at the facility, and one fall with no injuries. This caused severe pain to Resident 190 and may have contributed to her death, just 7 days after her last fall with major injury. Resident 34 fell 7 times in 4 months due to lack of supervision, revision, and implementation of care plans to prevent falls. This had the potential to result in falls with major injuries for Resident 34. Findings: Resident 190 Record review of the facility Face Sheet (Facility Demographic) indicated Resident 190 was admitted to the facility on [DATE] with medical diagnoses including History of Falling (History of having suffered falls, which may indicate increased risk for future falls), Alzheimer's Disease (A progressive brain disorder that slowly destroys memory and thinking skills), Restlessness and Agitation. Record review of Resident 190's MDS (Minimum Data Set-An assessment tool) dated 1/14/24 indicated her BIMS (Brief Interview of Mental Status-A cognition [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 3, which indicated her cognition was severely impaired (A score of 1-7 indicates the cognition is severely impaired, 8-12 indicates the cognition is moderately impaired, and 13-15 indicates the cognition is intact). This document also indicated under section GG (Section of the MDS that evaluates the amount of assistance a patient needs) dated 1/14/24, that Resident 190 required partial to moderate assistance with toileting and personal hygiene. Record review of an undated facility document titled, POST FALL INVESTIGATION, provided by the Director of Nursing (DON) on 7/12/24 at 9:30 a.m., in response to a request for a policy on neurological checks (A healthcare provider's evaluation of a person's nervous system after a fall to help determine the extent of damage from head trauma), indicated that after a resident fall, the following tasks were required to be completed, Complete Post Fall investigation Report .Complete Risk Management in [Electronic documentation system] .Update care plan on falls .Initiate Q30 (Every thirty minutes) checks for the next 72 hours .Complete neuro (neurological)-check (paper form). Neurological checks, as indicated in this form titled, POST FALL INVESTIGATION, were required to be performed every thirty minutes for 72 hours after the fall. Record review of a facility document titled, Falls Risk Assessment, dated 10/16/23, indicated Resident 190 was at medium (Moderate) risk for falls. During a concurrent interview and record review with the DON on 7/11/24 at 9:38 a.m., Resident 190's care plans for falls were reviewed. There were no care plans created prior to the first fall on 1/01/24. The DON stated she would look to see if she could find one but did not provide this care plan. 1st Fall Record review of a progress note dated 1/01/24 at 2:45 p.m., indicated, Resident [Resident 190] called help, help from her room. Entered room with CNA (Certified Nursing Assistant). Resident is on the floor on her L (Left) side next to her bood (Sic, possibly meant bed). Resident unable to explain what happened .L hip is tender to touch. Pain intensifies with movement and attempt to reposition .911 called for transport to [General Acute Care Hospital (GACH)] .Resident left for hospital 15.20 (3:20 p.m.). Record review of a progress note dated 1/01/24 at 10:47 p.m., indicated, Received a phone call .on resident [Resident 190] status, resident has a left hip fracture with possible surgery. Record review of a facility physician progress note dated 1/13/24 at 7:35 a.m., indicated, [Resident 190] is a [AGE] year old female who was living in the healthcare center of [Name of facility] and sustained a fall resulting in left hip fracture. Patient was subsequently transferred to [name of GACH]. Patient underwent successful left hip hemiarthroplasty (A surgery to repair half of a hip joint after a traumatic injury in which the femoral head (Upper joint of the thigh bone) is fractured. Record review of a facility document titled, Fall Risk Assessment, dated 1/02/24 at 11:35 a.m., indicated Resident 190 was at low risk for falls, although she had just fallen the day before, on 1/01/24 and suffered a hip fracture. During a concurrent interview and record review with the DON on 7/11/24 at 9:38 a.m., the document, Falls Risk Assessment, dated 1/02/24 at 11:35 a.m., was reviewed. The DON stated this document was completed inaccurately, since it indicated Resident 190 had no history of falls within the last three months, was ambulatory and continent, and was taking only two medications increasing her risk of falls, when she was taking eight medications. The DON stated Resident 190 did have a history of falls within the last three months, since she had fallen on 1/01/24, required supervision with ambulation, and was incontinent (Inability to control the bowels and bladder) at times. The DON confirmed this assessment indicated Resident 190 was at low risk for falls due to the inaccurate responses submitted. Record review of a care plan for falls initiated on 1/08/24 (no time documented) for Resident 190, listed the following interventions to prevent further falls, Keep call light in reach at all times .Keep personal items and frequently used items within reach .Anticipate needs and meet on timely basis. There were no interventions in the care plan aimed at increasing supervision for Resident 190. During a concurrent interview and record review with the DON on 7/11/24 at 9:38 a.m., the care plan for falls initiated on 1/08/24 (no time documented), was reviewed. The DON confirmed there were no interventions to increase supervision for Resident 190 in the care plan, but supervision was increased through rounds completed every two hours by staff, which were initiated on 1/17/24 (17 days after the first fall with major injury) and provided the documents titled, RESIDENTS ON TOILETING SCHEDULE, dated 1/17/24 through 2/27/24. Record review of the documentation for staff rounding titled, RESIDENTS ON TOILETING SCHEDULE, from 1/17/24 to 2/27/24 indicated there were several shifts and hours of the day, when Resident 190 was not checked, as the boxes were left empty. For example, on 2/25/24, Resident 190 was required to be checked at 7:00 a.m., 9:00 a.m., 11:00 a.m., and 1:00 p.m., but the documentation indicated she was not checked at all throughout morning shift. This was repeated on multiple occasions, such as on 2/15/24 for morning shift, 2/17/24 for night shift, 2/26/24 for evening shift, 2/27/24 for night and evening shifts, etc. Record review of interdisciplinary team (IDT) meetings titled, [Name of Facility], a Community of Seniors Clinical Sign in Sheet, dated 1/10/24 at 10:25 a.m.,1/16/24 at 10:35 a.m., 1/17/24 at 10:25 a.m., and 1/19/24 at 10:30 a.m., indicated Resident 190 returned from the GACH to the facility on 1/08/24, and was admitted to hospice (Palliative services aimed at keeping resident comfortable at the end of life) on 1/19/24. There was no documentation in these IDT meeting reports that Resident 190 suffered a fall with major injury at the facility. This was confirmed by the DON during an interview on 7/11/24 at 9:38 a.m. 2nd Fall Record review of a progress note dated 1/30/24 at 9:25 a.m., indicated, Resident [Resident 190] is OOB (Our of bed) for meals eating breakfast in the dining area. @0925 (At 9:25 a.m.) resident fall (Sic) in the wheelchair at dining area .no skin tear, denies hitting head and no discoloration. During a concurrent interview and record review with the DON on 7/11/24 at 9:38 a.m., the care plan for falls revised on 2/02/24 (3 days after the fall) for Resident 190 was reviewed. This care plan for falls included only two new written interventions. One of the newly written interventions indicated, Toiletted (Sic. Assisted to use the restroom) QAC (Before meals), PC (After meals), HS (Before bedtime) and PRN (As needed). The DON confirmed this new intervention was already in place before the fall on 1/30/24, although it had not been formally written before in the care plan. The second intervention indicated, Close monitoring for safety. The DON confirmed the resident continued the same rounding schedule by staff every two hours (Since 1/17/24), therefore, there was no increased supervision for Resident 190. The DON stated they did increase visual checks for Resident 190 but did not have any documentation of it. Record review of the documentation for staff rounding titled, RESIDENTS ON TOILETING SCHEDULE, initiated on 1/17/24 indicated Resident 190 continued to be checked every two hours, despite the fall on 1/30/24. 3rd Fall Record review of a progress note dated 2/20/24 at 8:36 a.m., indicated, Rd [Resident 190] was found on the floor .She was on the floor on her right side at the base of the floor mat next to her bed .she was not complaining of pain at the time .She was lifted back to her bed and she started to complain of right inner thigh pain. Record review of a progress note dated 2/21/24 at 11:40 a.m., indicated, Resident is on S/p (Status post) unwitnessed fall Day 2 .Right hip fracture .Administrator, DON .was notified with the result of the Right Hip X-ray. Record review of a facility document titled, NEUROLOGICAL ASSESSMENT FLOW SHEET, indicated staff documented neurological checks only from 2/20/24 at 12:15 a.m., to 2/20/24 for, NOC (Night shift, no specific hours documented). This was less than the 72 hours required in the document titled, POST FALL INVESTIGATION (Above). This was confirmed by the DON during an interview on 7/11/24 at 9:38 a.m. Record review of a, Falls Risk Assessment, for Resident 190 dated 2/20/24 at 6:37 p.m., indicated Resident 190 was at high risk for falls. During a concurrent interview and record review with the DON on 7/11/24 at 9:38 a.m., Resident 190's care plan for falls, updated on 2/20/24 (No time documented) was reviewed. The care plan only had one intervention aimed at preventing further falls. This intervention indicated, Remind resident not to get up by herself. Frequent checks. The DON confirmed this was the only intervention to prevent further falls, as other interventions had the intention of keeping the resident comfortable. The DON confirmed reminding the resident not to get up by herself was not appropriate as the resident's cognition was severely impaired. The DON stated she had no documented evidence supervision was increased after this fall, as they continued with the same rounding by staff every two hours. Record review of the documentation for staff rounding titled, RESIDENTS ON TOILETING SCHEDULE, from 1/17/24 through 2/27/24 indicated staff continued to check on Resident 190 every two hours, despite the fall on 2/20/24 which resulted in a fracture. During an interview on 7/11/24 at 9:38 a.m., the DON was asked to provide care plans for the two hip fractures caused by Resident 190's falls at the facility. During an interview on 7/11/24 at 1:44 p.m., the DON confirmed there were no care plans found specifically for the care of Resident 190's hip fractures. Record review of nursing progress notes (see below for dates and times) indicated Resident 190 experienced moderate to severe pain levels during her last days at the facility related to her right hip fracture, before passing away on 2/27/24 at 4:10 p.m., as follows: a) Progress note dated 2/21/21 at 11:40 a.m., indicated, Resident c/o (Complained of) 7/10 (Pain scale where 0 indicates no pain, and 10 is the worst pain experienced in a person's lifetime. A pain level of 0-2 = mild, 3-5 = moderate, and 6-10 = severe) r/t (Related to) Right hip fracture. b) Progress note dated 2/22/24 at 8:21 a.m., indicated, resident able to verbalize pain to rt (Right) hip . c) Progress note dated 2/22/24 at 11:40 a.m., indicated, Resident c/o pain 8/10 during turning and repositioning r/t right hip fracture. d) Progress note dated 2/22/24 at 3:51 p.m., indicated, Resident c/o pain when she moved . e) Progress note dated 2/23/24 at 9:34 a.m., indicated, received resident in bed .able to vocalize pain to right upper leg . f) Progress note dated 2/23/24 at 6:21 p.m., indicated, resident verbalized pain with mobility. Record review of a progress note dated 2/27/24 at 5:49 p.m., indicated, resident's dtr (Daughter) present at bedside, notified passed away around 410 pm (4:10 p.m.). During an interview with the DON on 7/11/24 at 9:38 a.m., she stated the facility needed improvement in several areas of managing falls, such as completing the fall risk assessments accurately, care planning after every fall, and documentation of the visual checks. Resident 34 Record review of the facility Face Sheet indicated Resident 34 was admitted to the facility on [DATE] with medical diagnoses including Hemiplegia (Complete or severe loss of strength on one side of the body), & Hemiparesis (One-sided muscle weakness), Aphasia (Inability to speak or understand, or both), and Anxiety Disorder (Intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident 34's MDS dated [DATE] indicated she was completely dependent on staff for toileting, personal hygiene and bed-to-chair transfer. Record review of a facility document titled, Falls Risk Assessment, dated 1/26/24 at 6:33 p.m., indicated Resident 34 was at high risk for falls. Record review of a care plan for prevention of falls for Resident 34 initiated on 1/23/24, indicated, [Resident 34] is at High risk for falling R/T (Related to) recent hospitalization .Keep call light in reach at all times .Keep personal items and frequently used items within reach .anticipate needs. During an interview with the Director of Staff Development (DSD) on 7/11/24 at 3:30 p.m., the DSD was asked in writing and verbally to provide the following documents: a) All documentation of Resident 34's falls since 1/01/24 to the present. b) All care plans updated or revised after every fall since 1/01/24 to the present. c) All neurological checks performed after every fall since 1/01/24 to the present. d) All fall risk assessments performed after every fall since 1/01/24 to the present. During an interview with the DSD on 7/12/24 at 9:51 a.m., she provided some of the documents requested on 7/11/24 at 3:30 p.m., but stated she could not find them all. The DSD stated she was providing what she was able to find regarding the above request. The documents not provided by the DSD are written below. 1st Fall Record review of a progress note dated 2/07/24 at 7:55 a.m. indicated, Incident Date: 02/07/2024, Incident Time: 05:00 .resident found with bedding on the floor on right side of bed lying on her weak/right side at 5am (5:00 a.m.) when this nurse went to check on her. Record review of a Falls Risk Assessment, dated 2/08/24 at 6:57 p.m., indicated Resident 34 was at high risk for falls. During concurrent record review and interview with the DSD on 7/12/24 at 7:50 a.m., the care plan for falls initiated on 2/07/24 was reviewed. This care plan indicated, frequent checks per facility protocol (The care plan did not indicate how often, or how this was going to be monitored) .request cradle mattress from hospice. This was confirmed by the DSD. During an interview with the DSD on 7/12/24 at 9:51 a.m., she provided some of the documents requested on 7/11/24 at 3:30 p.m., but the neurological checks after the fall on 2/07/24, was not included. The DSD stated she was providing what she could find. 2nd Fall Record review of a progress note dated 2/18/24 at 3:52 p.m., indicated, Resident had an unwitnessed fall at around 0900 (9:00 a.m.) in the morning (The morning of 2/18/24). Resident was seen sitting on the right side of her bed in a sitting position with her back leaning on her bed. During a concurrent interview and record review with the DSD on 7/12/24 at 7:50 a.m., the care plan for falls initiated on 2/18/24 was reviewed. The care plan did not contain any new interventions to prevent falls, or increased supervision. The interventions included, Neurochecks (Neurological assessments) as per facility protocol .VS (Vital Signs-Clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) .Monitor for pain. This was confirmed by the DSD. During an interview with the DSD on 7/12/24 at 9:51 a.m., she provided some of the documents requested on 7/11/24 at 3:30 p.m., but the neurological checks and fall risk assessment after the fall on 2/18/24, were not included. The DSD stated she was providing what she could find. 3rd Fall Record review of a care plan for falls initiated on 3/13/24 indicated, Fall-3/5/24-no injury (No time of the fall documented). During an interview with the DSD on 7/12/24 at 9:51 a.m., she provided some of the documents requested on 7/11/24 at 3:30 p.m., but specific documentation on the fall that occurred on 3/05/24, was not included. The DSD stated she was providing what she could find. Record review of a facility document titled, MORSE FALL-Senior Living (Fall risk assessment), dated 3/05/24 at 6:41 p.m., indicated Resident 34 was at high risk for falls. Record review of the care plan for falls initiated on 3/13/24 (8 days after the fall on 3/05/24) indicated, Activity staff will provide 1:1 (One staff to one resident) visit for socialization .Call light is present and within reach .Staff to anticipate needs .The resident is mostly bedbound r/t personal preference, physical impairment. Record review of a facility document titled, RESIDENTS ON TOILETING SCHEDULE, initiated on 3/05/24 and active through 7/11/24, indicated Resident 34 was placed on a schedule for staff checks every two hours. This document indicated there were several shifts and hours of the day, when Resident 34 was not checked, as the boxes were left empty. On 3/05/24, Resident 34 was required to be checked for evening shift at 3:00 p.m., 5:00 p.m., 7:00 p.m., and 9:00 p.m., according to the form. This document indicated Resident 34 was not checked at all throughout evening shift on 3/05/24. Record review of neurological checks initiated on 3/05/24 at 8:30 a.m., indicated they were not conducted every 30 minutes as required (The POST FALL INVESTIGATION, provided by the Director of Nursing (DON) on 7/12/24 at 9:30 a.m., above, indicated neurological checks were to be conducted every 30 minutes for 72 hours after a resident fall). On 3/05/24, the documentation indicated neurological checks were completed at 4:15 p.m., and again at 8:15 p.m. (4 hours later), and again at 12:15 a.m., (4 hours later). The next time neurological checks were documented for Resident 34 was on 3/06/24 for AM (Morning shift, which started at 7:00 a.m.). 4th Fall Record review of a care plan for falls initiated on 3/13/24 indicated, Fall-3/15/24-no injury (No time of the fall documented). Record review of the care plan for falls initiated on 3/13/24 indicated the care plan was not revised or updated after the fall on 3/15/24. This was confirmed by the DSD during an interview on 7/12/24 at 7:50 a.m. Record review of a facility document titled, Fall Risk Evaluation, dated 3/05/24 at 4:03 p.m., indicated Resident 34 was at risk for falls. Record review of a facility document titled, RESIDENTS ON TOILETING SCHEDULE, initiated on 3/05/24 and active through 7/11/24, indicated Resident 34's supervision was not increased from the original checks conducted every two hours by staff despite the fall on 3/15/24. This was confirmed by the DSD during an interview on 7/12/24 at 7:50 a.m. 5th Fall Record review of a progress note dated 4/13/24 at 9:10 p.m., indicated, PT (Patient [Resident 34]) found on the floor during routine check around 445pm (4:45 p.m. on 4/13/24). Staff assisted back to bed, no visible injuries. Record review of a facility document titled, MORSE FALL-Senior Living (Fall risk assessment), dated 4/13/24 at 10:43 p.m., indicated Resident 34 was at high risk for falls. Record review of the care plan for falls initiated on 3/13/24 indicated the care plan was not revised or updated after the fall on 3/15/24. This was confirmed by the DSD during an interview on 7/12/24 at 7:50 a.m. Record review of a facility document titled, RESIDENTS ON TOILETING SCHEDULE, initiated on 3/05/24 and active through 7/11/24, indicated Resident 34's supervision was not increased from the original checks conducted every two hours by staff, despite the fall on 4/13/24. This was confirmed by the DSD during an interview on 7/12/24 at 7:50 a.m. 6th Fall Record review of a progress note dated 4/15/24 at 9:55 p.m., indicated, During morning rounds right after am report at 7:30 am (On 4/15/24), resident found on the floor mat next to bed. Record review of a facility document titled, MORSE FALL-Senior Living, dated 4/15/24 at 10:44 p.m., indicated Resident 34 was at high risk for falls. Record review of the care plan for falls initiated on 3/13/24 indicated only two new interventions were added to the care plan after the fall on 4/15/24. These two new interventions were added on 4/19/24, four days after the fall, and indicated, Continue with the plan of care to frequently check the resident .Request [Hospice] scheduled visit to offset private caregiver time when possible. The care plan did not specify what frequently check the resident, meant, or how it was monitored. This was confirmed by the DSD during an interview on 7/12/24 at 7:50 a.m. Record review of a facility document titled, RESIDENTS ON TOILETING SCHEDULE, initiated on 3/05/24 and active through 7/11/24, indicated Resident 34's supervision was not increased from the original checks conducted every two hours by staff, despite the fall on 4/15/24. This was confirmed by the DSD during an interview on 7/12/24 at 7:50 p.m. Record review of neurological checks initiated on 4/15/24 at 7:30 a.m., indicated they were only conducted from 4/15/24 at 7:30 a.m. to 4/16/24 for PM, which was approximately 40 hours, and not the 72 hours required in this form (The form, POST FALL INVESTIGATION (above), provided by the Director of Nursing (DON) on 7/12/24 at 9:30 a.m., indicated neurological checks were to be conducted every thirty minutes for 72 hours after a resident fall). 7th Fall Record review of a progress note dated 4/24/24 at 6:13 p.m., indicated, Resident noted to be on floor laying on R (Right) side. Assessed-No apparent injuries. Record review of a facility document titled, MORSE FALL-Senior Living, dated 4/24/24 at 10:44 p.m., indicated Resident 34 was at high risk for falls. Record review of the care plan for falls initiated on 3/13/24 indicated it was revised after the fall on 4/24/24, but only one new intervention was added. The new intervention was added on 7/11/24 (more than 2 months after the fall on 4/24/24) and indicated, Follow facility fall protocol. The care plan did not indicate to increase supervision. This was confirmed by the DSD during an interview on 7/12/24 at 7:50 a.m. Record review of a facility document titled, RESIDENTS ON TOILETING SCHEDULE, initiated on 3/05/24 and active through the 7/11/24, indicated Resident 34's supervision was not increased from the original checks conducted every two hours by staff, despite the fall on 4/24/24. This was confirmed by the DSD during an interview on 7/12/24 at 7:50 a.m. Record review of neurological checks initiated on 4/24/24 at 4:45 p.m., indicated they were not conducted every 30 minutes as required (The form, POST FALL INVESTIGATION (above), provided by the Director of Nursing (DON) on 7/12/24 at 9:30 a.m., indicated neurological checks were to be conducted every thirty minutes for 72 hours after a resident fall). On 4/25/24, the documentation indicated neurological checks were completed at 12:30 a.m., and again at 4:30 a.m. (4 hours later), and again at 8:30 a.m., (4 hours later). The next time neurological checks were documented for Resident 34 was on 4/25/24 for PM (Evening shift, which started at 2:30 p.m.). During a concurrent observation and interview with Unlicensed Staff S, assigned to Resident 34, on 7/08/24 at 3:14 p.m., he was asked if Resident 34 was able to speak. Unlicensed Staff S stated he did not know, as he was unfamiliar with Resident 34. Resident 34 was observed awake in bed, with the bed in the lowest position, right next to another bed, and a mat on the floor. Unlicensed Staff S stated he was from a registry company. Unlicensed Staff S was asked the reason Resident 34 had a mat right next to her bed, and another empty bed to the right of her bed. Unlicensed Staff S stated not knowing the reason. Unlicensed Staff S was asked if Resident 34 was at risk for falls. Again, Unlicensed Staff S stated not knowing the answer to the question. During an interview on 7/09/24 at 11:45 a.m., Unlicensed Staff E stated she was a private caregiver for Resident 34, hired by Resident 34's family. Unlicensed Staff E stated she worked with Resident 34 from Monday through Friday from 9:00 a.m., to 2:00 p.m. Unlicensed Staff E stated that if she did not notify facility staff Resident 34 needed to have her brief changed, they did not come to check on her every two hours, and even when notified, they had still left her up to thirty minutes with a soiled brief. Unlicensed Staff E also stated that most of the time, when she came to the facility at 9:00 a.m., Resident 34's breakfast tray was observed sitting on her bedside table, untouched and cold, waiting for her to assist Resident 34 with the meal. Unlicensed Staff E also stated the facility often assigned unfamiliar staff to Resident 34, including registry staff. During a concurrent interview and record review with the DSD on 7/12/24 at 7:50 a.m., after reviewing the care plans for falls, supervision documentation, fall risk assessments and other documents related to falls (Dates and specific titles of each document mentioned above, in falls 1 through 7), the DSD stated Resident 34's fall management process needed improvement. During a phone interview on 7/12/24 at 8:31 a.m., Anonymous Witness G stated being very dissatisfied with Resident 34's care at the facility. Anonymous Witness G stated she had hired a private caregiver to care for Resident 34 from 9:00 a.m. to 2:00 p.m., because she felt Resident 34 was not receiving the care she needed. Anonymous Witness G stated she made arrangements to transfer Resident 34 out of the facility on 7/11/24. Anonymous Witness G stated she had brought up resident care issues with the DON, but the DON never followed up on them. Anonymous Witness G stated being aware Resident 34 had fallen multiple times at the facility. During an interview with Licensed Staff D on 7/12/24 at 12:00 p.m., she was asked how often Resident 34 was required to be checked by staff when she was still residing at the facility. Licensed Staff D stated Resident 34 was required to be checked every two hours, which corroborated that supervision requirements were never changed for Resident 34 despite multiple falls at the facility. Record review of the facility policy titled, Accident Prevention/Mitigation and Response, last reviewed in November of 2023, indicated, Avoidable Accident: means than an accident occurred because the facility failed to: Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk .Monitor the effectiveness of the interventions and modify the care plan as necessary .Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment.

Based on interviews and record reviews, the facility failed to 1. provide supervision and assistance for a toileting needs for one out of two sampled residents (Resident 4). 2. ensure the pharmacist conduct a medication regimen review (MRR, a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions) for fall to prevent avoidable accidents or falls. These failures led to Resident 4 ' s unwitnessed fall that resulted to hospitalization due to left leg severe pain. While at the hospital, Resident 4 was diagnosed with closed fracture (a break in the bone) of neck of left femur (thigh) and subsequently had to undergo left hip fracture hemiarthroplasty (a type of partial hip replacement procedure that involves replacing half of the hip joint). Findings: During a review of Resident 4 ' s face sheet (demographics), it indicated she had a diagnoses of Essential Hypertension (high blood pressure that is not due to another medical condition), Hyperlipidemia (an elevated level of lipids - like cholesterol, a waxy, fat-like substance that your body needs for good health, but in the right amounts and triglycerides, a major form of fat stored by the body, in your blood) and Acute Respiratory Failure (occurs when your lungs cannot release enough oxygen into your blood). Her Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 9/9/2023, Brief Interview for Mental Status Assessment (BIMS, a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur) score was 7 indicating severely impaired cognition (the conscious and unconscious processes involved in thinking, perceiving, and reasoning). Resident 1 needed limited assistance (the resident is highly involved in performing a given activity, and yet still receives physical help in performing the activity) to extensive assistance (resident performed part of activity while staff provided 50 percent (% , a number that tells us how much out of 100) or more assistance and includes weight-bearing (the amount of weight a resident puts on a body part) support by staff of 1 staff when performing her Activities of Daily Living (ADLs, activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Resident 4 needed a limited assistance of 1 staff during toileting. During an interview on 9/20/23 at 11:31 a.m., Licensed Staff E stated it was the facility ' s policy to ensure the residents' were safe all the time. Licensed Staff E stated, if staff were not monitoring residents who were fall risk, every 2 hours or more often as needed and not assisting residents to the toilet every 2 hours and as needed, it could put residents' safety at risk. Licensed Staff E stated these could result to injury, fracture, and hospitalization. During an interview on 9/20/23 at 11:36 a.m. with Unlicensed Staff B and C, Unlicensed Staff B stated the facility ' s policy for falls includes toileting residents every 2 hours and checking on residents every 2 hours. Unlicensed Staff B stated the facility need to make sure residents were always safe. Unlicensed Staff C stated if residents who were at risk for falls were not monitored closely, it could lead to injury and fracture. During an interview on 9/20/23 at 11:43 a.m., Licensed Staff C stated to decrease likelihood of fall, staff needs to monitor, check on residents every 2 hours and provide toileting every 2 hours. Licensed Staff C stated it was the facility ' s responsibility to ensure resident ' s safety. During an interview on 9/20/23 at 12:04 p.m., the Rehabilitation Director stated she was aware Resident 4 was a high fall risk. The Rehabilitation Director stated she was not aware of the details of Resident 4 ' s fall incident. During an interview on 9/20/23 at 12:09 p.m., Resident 4 stated she do not recall all the incidents regarding her fall. Resident 4 stated she does remember needing to use the bathroom prior to her fall. Resident 4 stated staff usually assists her when going to the bathroom. Resident 4 stated she did not recall if staff assisted her to the bathroom prior to her fall. During an interview on 9/20/23 at 12:52 p.m., the Director of Nursing (DON) and the Director of Staff Development (DSD) stated it was the facility ' s policy to ensure fall risk residents were on frequent rounding and toileting. The DSD stated this meant monitoring, rounding or toileting the residents every 2 hours and as needed. The DON and the DSD stated Resident 4 was a high fall risk. During a nursing note dated 9/9/23 1:06 a.m. record review, the nursing note indicated Resident 4, while going to the bathroom, slipped and fell on the floor on 9/9/23 at 12:20 a.m. The nursing note indicated Resident 4 was experiencing severe pain and was unable to be assisted back to bed so 911 ( the telephone number used to reach emergency medical, fire, and police services) was called. The nursing note also indicated Resident 4 was transferred to the emergency department on 9/9/23 at 12:50 a.m. During a review of the anaesthesia (a medication used to stop you from feeling pain during surgical or diagnostic procedures) preprocedure evaluation note from the hospital dated 9/9/23 12:40 p.m., it indicated Resident 4 was diagnosed with closed fracture of neck of left femur. It indicated Resident 4 would have left hip fracture hemiarthroplasty surgery. During a telephone interview on 9/21/23 at 4:06 p.m., the DON stated there was no MRR for fall done by the pharmacist before and after Resident 4 ' s fall incident. A review of the nursing note dated 9/9/23 1:06 a.m. indicated Resident 4 fell on 9/9/23 at 12:20 a.m. while going to the bathroom. A review of the daily charting note by a CNA dated 9/8/23 indicated Resident 4 was last toileted at 8:36 p.m. meaning she was last toileted almost 4 hours before her fall. During a review of the facility ' s policy and procedure (P&P) titled Accident Prevention/Mitigation and Response dated 4/2023, the P&P indicated it was the facility's policy , to the extent possible/feasible/practicable make proactive efforts to eliminate or reduce the risk of accidents occurring in the facility .provide each residents with adequate supervision .the nursing staff, attending physician and consultant pharmacist will review for medications or medication combinations that could relate to falls or fall risks

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide sufficient nursing staff with appropriate competencies and skills to supervise and adequately care for one of 3 sampled resident ' s (Resident 1), when Resident 1, who had Dementia (memory loss) was reminded by staff to call for assistance with transfers resulting in falls and a fractured right femur (thigh bone). Findings: During a review of Resident 1 ' s Profile Face Sheet, on 3/30/23, Resident 1 ' s Face Sheet, indicated, diagnosis of Dementia. During an interview on 3/30/23 at 2:20 p.m., with DON, she stated, she was aware Resident 1 had fallen and this was Resident 1 ' s second fall within one month. Both falls occurred in the bathroom where Resident 1 was found on the floor calling for help. DON stated she read the hospital report and in both falls Resident 1 sustained a right femur fracture. DON stated, she received a text at the time of the fall on 3/24/23 around 8:00 a.m. from Licensed Staff C alerting her Resident 1 had fallen. DON stated, she checked the chart and Resident 1 had a BIMS (score assigned for memory, orientation, and judgement ability) of 9 (out of 15 possible) and a diagnosis of dementia. During an interview on 3/30/23 at 3:10 p.m., Unlicensed Staff A stated, she heard a crash while she was in room [ROOM NUMBER] next to room [ROOM NUMBER] where she heard the crash coming from. Unlicensed Staff A stated, she then heard a man yell help. Unlicensed Staff A, stated, she walked to room [ROOM NUMBER] where Resident 1 resided, and she found Resident 1 laying on the floor on his right side. Unlicensed Staff A yelled for a nurse at which time Licensed Staff C came to the room to assess Resident 1. Unlicensed Staff A stated she never heard the nurses call light sounding or saw the nurses light on when she entered room [ROOM NUMBER]. Unlicensed Staff A stated after Licensed Staff C came into room [ROOM NUMBER], Licensed Staff C then called for Licensed Staff B to assist with Resident 1. During an interview on 3/30/23 at 2:45 p.m. with Licensed Staff C, stated she went to room [ROOM NUMBER] on 3/24/23 around 8:30 a.m. after hearing Unlicensed Staff A call for help. Licensed Staff C said, she saw Resident 1 lying on the floor in the bathroom in room [ROOM NUMBER]. Licensed Staff C stated, she did not see or hear the nurses light when she entered Resident 1 ' s room. Licensed Staff C stated, she asked Resident 1 if he hit his head and Resident 1 responded, no. Licensed Staff C called Resident 1 ' s primary nurse, Licensed Staff B to room [ROOM NUMBER]. Licensed Staff B performed Neurological examination (nervous system evaluation) on Resident 1. Licensed Staff C stated, Resident 1 ' s neurological evaluation was within normal limits. Licensed Staff C stated, she assisted 3 staff members who assisted Resident 1 back to his wheelchair. Licensed Staff C stated she called the MD1 and contacted the Resident ' s Representative after the fall. Licensed Staff C stated MD1 ordered an X-ray (picture) of Resident 1 ' s right femur but Resident 1 ' s pain was escalating so MD1 requested Resident 1 be transferred to the hospital immediately instead of waiting for Xray. During an interview on 3/30/23 at 3:40 p.m., with Licensed Staff B, she stated, she was the primary nurse for Resident 1 on 3/24/23 at 8 a.m. Licensed Staff B stated on 3/24/23 around 8:00 a.m. she was busy passing medications to other residents when she heard Licensed Staff C call for help in room [ROOM NUMBER]. Licensed Staff B stated, when she entered the room, the nurses light was not on, and she saw Resident 1 lying on the floor in the bathroom. Licensed Staff B stated, she performed a neurological evaluation, and she asked Resident 1 if he hit his head and Resident 1 responded, no. Licensed Staff B stated Resident 1 ' s neurological exam was normal, so they moved Resident 1 back to his wheelchair. Licensed Staff B stated Resident 1 has a diagnosis of dementia and when staff instruct him to put on his call light on if he needs to get out of bed or another task Resident 1 forgets what you have instructed him to do. Licensed Staff B stated Resident 1 has a Wander guard but that doesn ' t help if he is getting out of bed when he doesn ' t put his nurses light on. During a review of Resident 1 ' s medical records, Post Fall Investigation dated, 3/24/23, authored by Licensed Staff B, indicated, resident lost his balance, found on floor alone and unattended, confused and disoriented at the time, and no meds given in last 8 hours. During an interview with Resident 1 ' s Family Representative on 3/30/23 at 4 p.m., Family representative expressed concerns that Resident 1 did not have his walker in his room for a few days before the fall that occurred on 3/24/23. Family Representative stated, she noticed that the staff at this facility are spread thin. When family representative queried if Resident 1 was using the walker to ambulate, she said no, he uses the wheelchair but sometimes transfers and pivots with the walker. During an interview with Resident 1 on 3/30/23 at 4:10 p.m., Resident 1 was queried by this surveyor if he knew where he was? Resident 1 said no. Resident 1 queried by this surveyor if he remembered falling recently. Resident 1 responded; no. Resident 1 queried by this surveyor if he knew who the Family Representative was standing next to his bed, Resident 1 smiled and said, yes. This surveyor noticed a yellow sign at the left side of Resident 1 ' s bed. The sign was observed to have written on it, Dad, don ' t get up, you have a broken leg. Family Representative stated, he forgets his leg is broken and tries to get up. During an interview with Unlicensed Staff E at 4/3/23 at 11 a.m., Unlicensed Staff E stated, he is employed directly by a health care agency and was filling in that day when Resident 1 fell. Unlicensed Staff E was queried by this surveyor about Resident 1 ' s fall and he stated, I had 8 residents at the time of breakfast and had to make sure they got their meals on time. Unlicensed Staff E stated, he had 2 residents who required me to feed them. Unlicensed Staff E stated, I was in the dining room with my back to Resident 1 while I was feeding Resident 3. Unlicensed Staff E stated, Resident 1 apparently left the dining room while my back was turned toward Resident 1 when I was busy feeding Resident 3. Unlicensed Staff E stated, he did not see Resident 1 leave the dining room. Unlicensed Staff E queried if there were any other staff assisting him in the dining room? Unlicensed Staff E responded yes, there was another CNA (Certified Nursing assistant) from the agency in the dining room off and on because he was also handing out breakfast trays. Unlicensed Staff E stated, Unlicensed Staff D was busy feeding Resident 2. Unlicensed Staff E stated Resident 1 has Dementia and is very forgetful and left the dining room when he was instructed to wait until someone could take him back to his room. Unlicensed Staff E queried by this surveyor if he had any Dementia training with his current employer within the last year and he responded, no. During an interview with Unlicensed Staff D on 4/4/23 at 1:10 p.m., Unlicensed Staff D stated, he works directly for an agency and comes to work at the facility sometimes. Unlicensed Staff D stated, there was only Unlicensed Staff E and me in the dining room and we both had residents to feed and other residents to pass breakfast trays to on the unit. When Unlicensed Staff D was queried as to Resident 1 whereabouts after Resident 1 left the dining room, Unlicensed Staff D stated, I saw him in the hallway wheeling himself back to his room. Unlicensed Staff D stated, he asked him what do you want to do? Unlicensed Staff D stated, Resident 1 responded, he wanted to go to bed and take a nap, so I helped him back to bed. Unlicensed Staff D stated, he had to feed Resident 2, so he told Resident 1 to put his light on if he needed to get up. Unlicensed Staff D stated he had heard about Resident 1 ' s fall later on in his shift but was not involved with Resident 1 when it occurred. Unlicensed Staff D queried by this surveyor if he had any training in Dementia? Unlicensed Staff D stated, no, I just know residents with Dementia forget a lot. During a review of Resident 1 ' s records, an email dated 4/3/23, authored by Unlicensed Staff I, indicated the facility has, no Dining Observation Policy but it is a standard practice to have staff (Licensed Nurse and Certified Nursing Assistant) present in the dining room during meals. During a review of Resident 1 ' s Neurological Assessment Flow Sheet, dated 3/24/23, authored by Licensed Staff B, Flow Sheet indicated Resident 1 ' s Neurological Assessment immediately following his fall were within normal limits. During a review of Resident 1 ' s MDS, Section C, dated 3/3/23, authored by Licensed Staff H, BIMS 9, Recall 1, Resident is a 2 person assist for transfers, Toilet use Resident is a 2 person assist. During a review of Resident 1 ' s Care Plan dated, 2/27/23, no Dementia interventions were noted for monitoring of safety precautions for Resident 1 ' s decrease memory recall of staff instructions as it pertains to ambulation and transfers. During a review of Resident 1 ' s Physical Therapy Note, dated 3/23/24, authored by Licensed Staff G, indicated Resident 1, was weight bearing as tolerated but Resident 1 demonstrates ability to weight bear only partially on right lower extremity due to right hip pain. Precautions: Fall risk and Dementia. During a review of Resident 1 ' s Interdisciplinary Note, dated 3/24/23, authored by DON, This morning Resident 1 attempted to self-transfer from wheelchair to the bathroom and fell, and landed on the same surgical side. A staff from nearby location heard the noise and ran to check and found the resident was already on the floor lying on this right side. At first the doctor ' s advice to get an Xray and applied Lidocaine patch to area. Nursing applied Lidocaine patch and ice immediately to area of pain. The resident also received Tylenol 100 mg and Oxycodone 5 mg. Then the doctor decided to send the resident to the ED instead, for further evaluation. Family was also notified. Nursing staff called ED (emergency department) instead, for further evaluation. Nursing staff called ED and found that the resident had re-injured previously repaired right hip fracture. Per resident ' s son, a surgical procedure is scheduled on the next day. During a review of Resident 1 ' s nurses note, dated 3/29/23, authored by Licensed Staff F, indicated, admitted from hospital via Gurney after stay in the hospital due to right hip fracture post fall 3/24/23. Current Conditions indicate, Cognitive status: Alert with confusion and forgetfulness During a review of the facility ' s policy and procedure titled, Sufficient and Competent Staffing, dated 2/2023, indicated, it is the policy of The Redwoods, A community of Senior to provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and facility assessment. Applicable Redwoods personnel will develop, implement, and maintain an effective training program for all new existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. We determine the amount and types of training necessary based on their facility assessment. Definitions: Staff: Includes employees, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident ' s plan of care. Personnel hired for positions in this facility shall meet the qualification of the job or be trained to perform those duties. Training Program: Competency Based Education and Training is defined as a measurable pattern of knowledge, skills, abilities, behaviors, communication abilities to perform specific tasks and assignments with success. A continuing competency-based education program is conducted for all staff at the facility, to promote and measure specific competencies and skill sets necessary to provide related services to meet resident needs, safety of the resident while considering the resident ' s choices, rights, physical, mental, and psychosocial well-being based on the facility assessment. Orientation and ongoing training and competency will include, but not be limited to (as applicable to job duties) Resident rights and facility responsibilities, person-centered care, behavioral health, care of the cognitively impaired and dementia management. Pertinent information pertaining to staffing in the facility (e.g., turnover trends, staffing levels, CMS data NNPPD data, etc.) shall be routinely reviewed at the QAA Committee meetings. On an as-needed basis, the committee may initiate performance improvement projects in response to negative trends/patterns. During a review of facility ' s policy and procedure titled, Accident Prevention / Mitigation and Response, dated, 1/2023, indicated, It is the policy of The Redwoods to the extent possible/feasible/practicable ensure that the environment remains free of accident hazards, make proactive efforts to eliminate or reduce the risk of accidents occurring in the facility, provide each resident with adequate supervision and assistance devices so as to prevent accidents, as well as to comprehensively respond when an accident occurs. Avoidable Accidents: means that an accident occurred because the facility failed identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or Evaluate analyze the hazards and risks and eliminate them, if possible, or , if not possible, identify and implement measures to reduce the hazards/risks as much as possible, and / or Implement interventions, including adequate supervision and assistive devices, consistent with a resident ' s needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident; and or monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standard of practice. Personnel shall conduct/complete routine and as-needed safety walks/inspections/audits of the facility. In general, all staff are responsible for identifying, reporting, and/or resolving any hazards/unsafe conditions within the facility. Based on previous evaluations and current data, the staff will identify interventions related to the resident specific risks and causes to try to prevent the resident from falling and to try to minimize complication from falling. The nursing staff, in conjunction with the attending physician, consultant, pharmacist therapy staff and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan abased on relevant passement information. The staff, with the support of the attending physician, will evaluate functional psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living capabilities, activity tolerance, continence, and cognition. The staff, with the input of the attending physician will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.

Based on observation, interview and record review, the facility failed to assess, prevent, and treat a wound for one of thirteen residents (Resident 14) when the facility admitted Resident 14 with right shoulder Anti-subluxation brace/sling (a medical device intended to protect the shoulder joint from partial dislocation cause by caused by paralysis or injury in the shoulder joint capsule), and no weekly skin assessment was done. This failure resulted in Resident 14 developing a wound inside her right armpit with infection, and there was no current wound assessment and wound care order from the Physician. Findings: During a review of Resident 14's medical record, the facility admitted Resident 14 on 12/30/21. The Skin Evaluation Form dated 12/30/22, indicated Resident 14's skin had no existing issues. The Baseline care plan dated 1/3/22, indicated Resident 14 was at risk for skin breakdown and skin would be checked weekly and new skin concerns would be reported to the doctor for treatment and follow up. The Nursing Notes dated 2/11/21, indicated there was an open wound with pus on Resident 14's right armpit and her Physician was notified. Resident 14 had a physician order for Cephalexin (a medication) for wound infection ordered on 2/11/22. During an interview on 2/14/22, at 2:52 p.m., Staff M stated Resident 14 had a wound on her right armpit, and it was caused by the brace digging into her skin. During an interview on 2/15/22, at 10:06 a.m., Staff H stated Resident 14 has an unhealed wound on her right armpit, and it was caused by the brace digging to her skin. Staff H stated that Resident 14 did not have treatment orders for her wound. Staff H stated staff would sometimes use saline on the wound and then covere it with a dressing. Staff H stated treatments were completed by the afternoon staff. When asked how staff knew if a wound is getting better or worse, Staff H did not verbalize a response. During an interview on 2/16/22, at 2:40 p.m., with the Director of Rehab (DOR), she stated Resident 14 was admitted to the facility with the right anti-subluxation brace. The DOR stated her department did not provide training to direct staff on the use of the brace. The DOR stated the brace might have contributed to Resident 14's right armpit wound development. During an interview on 02/16/22, at 3:47 p.m. the DON stated the right armpit wound was possibly due to the sling digging through her skin, and it was possible staff did not know how to use it appropriately. The DON also stated there was no need to investigate the cause of the wound because we already knew it was from the sling. During interview and concurrent Resident 14's record review, on 2/16/22, at 3:58 p.m., the DON verified Resident had one Skin Evaluation Form dated 12/30/21. The DON verified there was no documentation to show weekly skin assessments were completed. The DON verified there was no Care plan for the right armpit wound and the Anti-Subluxation brace/sling. The DON verified there was no documentation for wound care treatment. · During an observation and concurrent interview on 2/17/21 at 4:30 p.m. with the DON and Staff C, Staff C looked at Resident 14's right armpit. DON and Staff C verbalized that the wound presented with slough (yellow/white material in the wound bed). The DON directed Staff C to call the doctor for wound treatment order. The DON did not provide policies and procedures for Brace/Sling use and Pressure Ulcer Prevention when requested.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview on 2/15/22 at 10:34 a.m., Family Member 1 stated Resident 13's multiple falls in the past year was a factor in hiring a part-time private caregiver for him. Family Member 1 stated, We understand the staff could get busy, and thought the private caregiver could help keep Resident 13 company. A review of Resident 13's face sheet indicated he was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (a progressive brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), and unspecified dementia without behavioral disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems, but does not include disruptive mood and behavior such agitation, aggression, disinhibition, and sleep disturbances). During an interview on 2/16/22 at 2:13 p.m., Staff J stated Resident 13's last fall was a long time ago. Staff J stated she would try and sit close to him [Resident 13], or always check on his room when the private caregiver leaves. Staff J confirmed it was not always possible to stay at Resident 13's bedside if other residents were calling for help. A review of Resident 13's Care Plans and interventions revealed: a. Falls Care Plan, dated 05/27/21, indicated, unwitnessed fall with no apparent injuries . Check on resident frequently when care partner if not present . b. Falls Care Plan, dated 06/02/21, indicated, Unwitnessed Fall - no injuries . Do not leave resident [sic] in room by himself when awake if companion [sic] is not present . c. Falls Care Plan, dated, 06/10/21, indicated, unwitnessed fall in the bathroom with no injury . Monitor resident in the bathroom at all times . Continue to monitor resident . Monitor resident while using the toilet . Check resident. d. Falls Care Plan, dated 08/28/21, indicated, unwitnessed [sic] fall with no apparent injuries . Keep bed in lowest position and call light within reach. Ensure resident is toileted accordingly . e. Falls Care Plan, dated 01/5/22, indicated, unwitnessed fall in his room with no injury . ensure resident is dry and clean, toileted and is comfortable. Lower bed in lower position. Monitor resident Q-shift (every shift) and PRN (as needed) . During a concurrent interview and record review of Resident 13's care plans on 2/18/22 at 10:30 a.m., Staff B confirmed Resident 13 had repeated falls and stated she expected the staff to frequently round and check on him [Resident 13] after his private caregiver leaves. When asked if the facility has identified such efforts as effective and adequate for Resident 13's pattern of unwitnessed falls, Staff B did not respond. During an interview on 2/15/22 at 11: 17 a.m., Resident 20 stated he had a fall about two months ago. Record review revealed Resident 20 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (a progressive brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), and generalized weakness. During an interview on 2/16/22 at 2:25 p.m., Staff O stated Resident 20 was at risk for falls. When asked how the staff knows which interventions were needed to prevent Resident 20 from further falls, Staff O stated, It's general -- lowering the bed, keeping the call lights close, removing clutter in the room, and ensuring the residents get adequate sleep. Staff O stated, I don't think there's any specific interventions for [Resident 20]. A review of Resident 20's chart revealed IDT (Interdisciplinary Team) Notes indicating Resident 20 sustained falls without injuries on 12/21/21, 12/19/21 and 12/7/21. Further record review revealed there were no care plans developed or revised to address Resident 13's multiple falls during December 2021. During an interview and concurrent record review on 2/16/22 at 10:35 a.m., Staff B confirmed Resident 20 did not have any fall care plans initiated. When asked if there should have been one, Staff B stated, Yes. During an interview on 2/18/22 at 2:59 p.m., Staff A confirmed resident falls continue to be a concern in the facility. Staff A stated they had new bed- and chair-pad alarms, but were currently not being used, as they have been broken since last fall [season]. A review of the facility policy titled, Falls and Fall Risk, Managing, dated March 2018, indicated, The staff, with the input of the attending physician, will implement a resident-centered fall prevention pan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . Staff will try various interventions, based on assessment of the nature or category or falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . The staff will monitor and document each resident's response to interventions intended to reduce calling or the risks of falling . Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance to prevent falls for 5 out of 13 sampled residents (Resident 130, Resident 133, Resident 26, Resident 13, and Resident 20) when the facility did not accurately assess residents for their risk of falls, did not timely implement, or attempt to implement, appropriate fall prevention interventions, and did not revise or update fall prevention care plans with additional or different interventions after a fall. These failures resulted in significant injury when Resident 130 sustained a broken right hip after a fall and placed at risk residents at a greater risk for falls, harm, and possibly cause a decline in Residents' health condition. Findings: Resident 130 During a review of the clinical record for Resident 130, the Minimum Data Set ([MDS] a comprehensive, standardized assessment of each resident's functional capabilities and health needs), dated 2/9/22, indicated Resident 130 was admitted to the facility on [DATE]. The Care Area Assessment ([CAA] reflects conditions, symptoms, and other areas of concern identified or suggested by MDS findings) section indicated Resident 130's assessment triggered 8 care areas. The assessment identified dementia, falls, and rehabilitation potential as areas Resident 130 needed further assistance with. The assessment indicated the facility marked all 8 triggered areas as Addressed in Care Plan. During a review of the facility policy and procedure titled, Fall Risk Assessment, updated 3/2018, indicated the facility would document risk factors for falls and establish a resident-centered falls prevention plan. The policy indicated staff and attending physician would collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. During an observation, on 2/14/22, at 11 a.m., Resident 130 was lying in bed with his eyes closed. The bed was flat and approximately 3 feet off the ground, not in its lowest position. No observation of any indication Resident 130 had been identified as a resident at risk for falls. The bed in the lowest position, padded mats placed on either side of the bed and alarms with sensors that alert if a resident attempted to change positions were seen in use throughout the building. None of those interventions were seen in Resident 130's room. During a concurrent observation and interview on 2/15/22, at 3 p.m., with Staff L, in the hallway in front of Resident 130's room, Staff L looked into the room at the empty bed and stated Resident 130 was sent out to the hospital because he fell. During a concurrent interview and record review on 2/15/22 at 5:18 p.m., with Staff B and Staff Q, Resident 130's Electronic Medical Record (EMR) was reviewed. Staff Q reviewed the Interdisciplinary Notes and confirmed the notes indicated Resident 130 had fallen on 2/5/22, 2/12/22, and 2/14/22. Staff Q reviewed Resident 130's Care Plan and stated there was no nursing care plan to address Resident 130's risk for falls. Staff B and Staff Q reviewed Resident 130's care plan and stated there was no nursing care plan created to address Resident 130's actual falls until 2/14/22. Staff B stated there should have been a nursing care plan since his admission on [DATE] to address Resident 130's risk for falls. Staff B stated the documentation reviewed did not meet the facilities expectations for processing new admissions or for resident falls. Staff Q stated doctors orders, the care plan and its interventions were used as indicators to add specific tasks to the Point of Care section of the EMR. Staff Q stated the Point of Care section listed all the tasks and vital information Certified Nurses Assistants (CNA) used for them to provide adequate assistance and supervision during tasks of daily living. Staff B was unable to provide documentation to show Resident 130's functional abilities and limitations were input into Resident 130's EMR Point of Care section for direct care staff to review. The point of Care section of Resident 130's EMR was blank. When asked how a CNA would know what assistance or safety precautions Resident 130 needed, Staff B stated the staff all talk to each other, they knew from verbal report. Staff B stated the lack of documentation could have contributed to Resident 130's 3 falls in 13 days. During a review of the Electronic Medical Record (EMR) for Resident 130, the Profile Face Sheet indicated his admission date was 2/2/22. The record indicated Resident 130 was admitted with a diagnosis of Squamous Cell Carcinoma (cancer that develops in the thin, flat cells that make up the outermost layer of your skin). During a review of the Electronic Medical Record (EMR) for Resident 130, the admission History and Physical, dated 2/2/22, indicated on 1/25/22 Resident 130 was seen at an acute hospital after he fell at home. During a review of the EMR for Resident 130, the Interdisciplinary Note, dated 2/3/22, indicated Resident 130 was confused and attempted to get out of bed many times. There was no documentation of the fall on 2/5/22, Staff B was unable to show a post fall assessment, or a care plan, or a new change of condition incident note. Staff B stated all 3 of those documents were expected for every fall. Staff B Staffed in addition to the original assessments, nurses should chart a note related to the fall every shift for 72 hours. Staff Q reviewed the ID notes and found one that indicated charting for multiple reasons including a fall on the previous shift. During a review of the EMR for Resident 130, the Interdisciplinary Note, dated 2/13/22, indicated Resident 130 was found on the floor next to his bed on 2/12/22 at 6 p.m. The note indicated a significant amount of blood was observed on the floor near Resident 130's head. The note indicated Resident 130 stated he got out of bed to go to the hospital because they have good coffee there. A review of the care plan indicated Resident 130's risk for falls was not identified or care planned at the time of admission or after the first fall on 2/3/22. The facility did not put any interventions in place to reduce the risk of falls. The EMR indicated the post fall assessment and charting was not done. No interventions were put into place to prevent Resident 130 from additional falls. During a review of the EMR for Resident 130, the Interdisciplinary Note, dated 2/14/22, indicated at 10 a.m. Resident 130 was found on the floor close to his bed on his back with his legs bent. The note indicated Resident 130 stated he was going to the roof. The note indicated Resident 130 complained of right hip and knee pain after the fall. The note indicated Resident 130's pain had gotten worse over time; x-rays were ordered. During a review of the physical medical chart for Resident 130, the Physicians Orders page, dated 2/14/21 indicated portable x-rays of the right hip and right knee after the fall were ordered. The page indicated at 4:30 p.m. the doctor ordered the x-rays to be upgraded to STAT (a common medical abbreviation for urgent or rush) status. The page indicated at 7 p.m. the doctor ordered Oxycodone (a narcotic medication used to treat moderate to severe pain) Five milligrams (mg a unit of weight measurement) to be given by mouth every four hours as needed for moderate pain. The page further indicated the doctor ordered Oxycodone ten mg to be given by mouth every four hours as needed for severe pain. The page indicated on 2/15/22 the doctor ordered the facility to transfer Resident 130 to the acute hospital for evaluation. During a review of the Electronic Medical Record (EMR) for Resident 130, the Discharge summary, dated [DATE], indicated Resident 130 fell out of bed on 2/14/22 and sustained an intertrochanteric right femoral neck fracture (the right hip bone fractured in the area between the ball joint and the leg bone). Resident 133 During a concurrent interview and record review on 2/15/22 at 5:08 p.m., with Staff B and Staff Q, Resident 133's EMR was reviewed. Staff Q reviewed the ID notes and confirmed the notes indicated Resident 133 had fallen on 2/12/22 while attempting to walk by herself to the bathroom. Staff Q reviewed the record and stated the facility had identified Resident 133 as being at risk for falls. Staff Q was unable to find documentation to show the facility had interventions in place to prevent falls. Staff B stated she was not aware Resident 133 had sustained a fall since admission on [DATE]. Staff B stated the fall was not reported to management and therefore not discussed at the daily Stand up meeting. Staff Q reviewed the EMR and was unable to find a Change of Condition assessment, or an incident tracking note, or a post fall assessment. Staff B confirmed those reports should have been completed by the licensed nurse on the shift the fall occurred. Staff B confirmed this did not meet facility expectations for nursing responsibilities after a fall. Staff Q reviewed the care plan and stated Resident 133 did not have a nursing care plan the EMR. Staff B reviewed the blank page and stated there should be a nursing care plan for every identified care area. A review of Resident 26's face-sheet indicated, Resident 26 was admitted with a diagnosis that included Parkinson's disease (a progressive brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), history of Falling, and unsteadiness on feet. During an interview on 2/16/2022 at 1:35 p.m., Resident 26's daughter stated she is worried about her father's increased number of falls. The daughter stated her father just returned two days (2/12/22) ago from (name) (acute care) hospital because of a fall. The staff told her, the CNA (Certified Nursing Assistant) could not watch her father all the time and suggested that she might consider getting a 1:1 (one-on one) sitter (one person who will only monitor one resident), but we would have to pay out of pocket for that care. During an interview on 2/17/2022 at 4:17 p.m., Staff Q was asked what they do to monitor Resident 26 for falls. Staff Q stated when a resident fell, she completed an assessment of the Resident and made sure they were not injured. She stated they called the physician, DON (Director Of Nursing), and responsible party and placed the resident on neuro checks (assessment of mental status and motor responses, including reflexes, to determine whether the nervous system is impaired including vital signes) following the facility process. Staff Q showed the documented records for the fall, and the neuro checks she completed for the 2/11/22 fall. When asked to see the other documentation for previous falls that occurred for Resident 26, Staff Q stated she did not find them in the medical record. Review of Resident 26's care plan and interventions for falls revealed dates of falls that had occurred. Review of the clinical records did not show any documentation for the interventions or monitoring that were performed for each of the falls listed in the Care Plan. There were no IDT notes or Physician notes to show a cause analysis was conducted for the increased falls. Review of the facility Policy and Procedure titled, Fall Monitoring dated January 14, 2014, indicated, vital signs including neuro check will be monitored for 72 hours post fall. Procedure: 1. Vital signs, including neuro checks, will be obtained and documented . 2. Charting will be performed every shift for 3-days post fall.