**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility nursing staff failed to use the proper turning technique and ensure one of three sampled residents (Resident 1), received adequate supervision and assistance during pericare (cleaning a patient's genital and anal areas) to prevent falls when Resident 1 who was deemed fully dependent for toileting hygiene, experienced a fall on 9/7/25. The certified nursing assistant did not ensure implementation of effective intervention as the use of a draw sheet (sheet placed underneath a patient to assist with repositioning and transferring in a healthcare setting) or proper technique and positioning without draw sheet for Resident 1 in accordance with facility competency, training consistent with Resident 1's care's need. This failure resulted in Resident 1 sustaining an avoidable fall during pericare leading to a scalp laceration (cut or tear in the scalp, the outer layer of the head), traumatic brain injury (TBI - an injury to the brain caused by an external force) with Intracranial Hemorrhage (ICH- bleeding within the brain cavity), left rib fracture (broken rib), left pneumothorax (collapsed lung), and a manubrial fracture (break in the upper part of sternum, breast bone) requiring urgent transfer to an acute care hospital and admission to the Intensive Care Unit (ICU - unit in hospitals that provides round-the-clock monitoring and treatment for people with serious illnesses or injuries).During a review of Resident 1's 60-Day Physician recertification of Terminal illness, document signed by physician on 6/21/25, the document indicated Resident 1 was a [AGE] year-old female with primary hospice (comprehensive care program for terminally ill patients, focusing on comfort, quality of life, and symptom management rather than cure) diagnosis of Parkinson's (progressive disorder that affects movement, balance and coordination disease with comorbidities (medical condition that is simultaneously present with another disease or other conditions in a patient), conditions of hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormones, hormones essential for regulating metabolism, growth, and other bodily functions), hyperlipidemia (high level of fat in blood), depression (mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that can significantly impact daily life), dysphagia (difficulty swallowing food or liquids), Coronary Artery Disease (CAD - condition where the arteries that supply the heart with blood become narrowed or blocked, usually due to the buildup of fat) and pacemaker (implanted electronic device that sends electrical impulses to the heart to help it beat at a steady and appropriate rate). During a review of Resident 1's hospice note (HN) titled, [Skilled Nursing (SN)] For Routine Visit Summary, dated 8/28/25, the HN indicated, . [Resident 1] requires [one to one (1:1- one caretaker to one patient care model)] assist with meals . dependent in bathing, dressing, toileting, transferring, repositioning, and feeding. Patient bedridden [inability to get out of bed due to illness]. Requires changing and repositioning every two hours. Patient incontinent [unable to control your bladder or bowels, leading to leakage of urine or feces] of urine and feces. Contracture [permanent tightening and shortening of muscles leading to restricted movement in a joint] to right hand, and to [Bilateral (both) lower extremity] .Facility responsible for the 24-hour custodial care [assistance with daily activities like bathing, dressing, and eating, provided to individuals who cannot perform these tasks themselves] for the patient and will notify [company name] Hospice of changes in patient condition. During a review of the facility's document titled, COMPETENCY CHECK-MOVING A RESIDENT IN BED, dated January 2025, the document indicated, . Performance Criteria . MOVING RESIDENT TO SIDE OF BED . Stands on same side of bed to where resident will be moved . With a draw sheet: Rolls draw sheet up and grasps draw sheet with palms up. Puts one hand at resident's shoulders and the other at resident's hips. Applies on knee against side of bed, leans back, and pulls draw sheet and resident on the count of three. Without a draw sheet: Slides hands under head and shoulders and moves toward self. Slides hands under midsection and moves toward self. Slides hands under hips and legs and moves toward self .During a review of the document titled, [Emergency Medical Services (EMS)] Patient Care Report (3.5)x, dated 9/7/25, the document indicated, . Response Mode to Scene: Emergent (immediate response) . Lights and Sirens . Unit Arrived On Scene . 9/7/25 at 21:58 . unit left the Scene: 9/7/25 at 22:13 . Patient arrived at destination . 9/7/25 at 22:50 . arrived . patient laying supine on the linoleum floor with two pillows under her head, both saturated with blood. Per facility staff [unknown], [ Certified Nursing Assistant (CNA- a healthcare professional who provides basic patient care, such as assisting with daily activities, vital signs, and hygiene, under the supervision of a licensed nurse)] 's had patient in a standing position next to the bed when she slipped, fell, and hit her head causing a deep/ open head laceration [cut] approximately 2 [inches- unit of measurement] in length. Staff denies any LOC [loss of consciousness] but states patient immediately began vomiting and had 3 episodes of vomiting prior to EMS arrival. Manual C-spine [way to protect the person's neck and spine from moving] was held as wound was dressed with a pressure bandage and c-collar [support brace for neck and spinal cord] was placed . [Resident 1] was transported to [emergency room] .During a review of the Resident 1's History and Physical (H&P), dated 9/8/25 from Hospital A, the H&P indicated, Resident 1 was admitted on [DATE] after presenting to emergency department on transfer from care facility by EMS following a fall. The H&P indicated, .Assessment of New and Established Problems: [AGE] year-old female status post ground level fall with Scalp laceration, TBI, mild, with ICH, Left rib fracture, Left pneumothorax, Manubrial fracture . Plan and Recommendations: . Admit to ICU .During a record review on 9/12/25 at 1:42 p.m. with the Director of nursing (DON) and the Administrator of the facility (ADM), Resident 1's Medical Record (MR), with the admission date of 6/24/24 was reviewed. The review of progress note titled, Interdisciplinary Team [IDT - group of professionals including nurses, social workers, physical therapists, and others who collaborate to develop, implement, and evaluate a patient's comprehensive plan of care] note, dated 9/8/25, the IDT note indicated, . IDT for witnessed fall that occurs on 9/7/2025 around 10:00 PM. Discussed with IDT on 9/8/2025 at 9:00 AM. [CNA 1] informed Charge Nurse [CN 1]that resident had fallen in her room. Per [CNA 1], as she was performing a brief change for the resident had a bowel movement, she turned the resident on her right side, her feet dangled slightly off the bed, she stated to the resident do not move, as she pulled out the soiled brief from the resident and place it on the trash bag by her side, when she turned to resume care to the resident, she had fallen off the bed into the floor. [CNA 1] called another CNA [unknown] across the hallway to call and informed the [CN 1]. During a concurrent interview and record review on 9/12/25 at 1:55 p.m. with the DON, Resident 1's MR, dated 6/24/24 was reviewed. The DON stated she was present at the IDT meeting and the facility investigation indicated that CNA 1 was not being careful. The DON stated Resident 1 was in room [ROOM NUMBER] A, and the fall occurred on 9/7/24 at 10:00 p.m. The DON stated Resident 1's Brief Interview for Mental Status (BIMS - mandatory cognitive (the ability of the brain to think and reason) screening for residents, scored from 0-15, score of 13-15 indicating cognitively intact, score 8-12 moderate cognitive impairment, score 0-7 severe cognitive impairment ) was 0 and which indicated the resident was severely cognitive impaired. The DON stated Resident 1 was not restless, was not combative, was very light weight and was contracted [causes the joint to become stiff and fixed in a bent or flexed position, severely limiting a person's range of motion] in her extremities. The DON stated Resident 1 was fully dependent of care during toileting and repositioning. The DON stated CNA 1 cleaned Resident 1 and when CNA 1 turned to put the dirty brief in the trash, Resident 1 fell from the bed to the floor. The DON stated the facility investigation revealed CNA 1 did not have a draw sheet under the resident while turning and did not pull resident close to her as she should have based on her training and competency for repositioning of a resident in bed. The DON stated use of a draw sheet by CNA 1 and pulling Resident 1 close to her would have potentially prevented the fall. The DON stated Resident 1 was unable to hold on to assistive devices or support herself during the turning. The DON stated Resident 1's fall was preventable, and she expected CNA 1 to pay more attention, use assistance from another CNA if needed and follow her competency training (structured learning approach focused on developing specific, job-related knowledge and skills (competencies) that individuals must demonstrate before advancing). The DON stated the fall would have been potentially preventable if CNA 1 had followed the competency and training provided by the facility. The DON stated she was not sure why CNA 1 would ask the resident who was fully dependent for care and had a low BIMS score of 0 to Do not move and did not ensure safe positioning herself. The DON stated Resident 1 was also on an air pressure mattress (features a series of air cells that inflate and deflate in cycles to redistribute pressure across the body) which was provided by the Hospice company and was also one of the contributing factors to the fall. The DON stated she was unable to comment on the brand or type of mattress and since the incident, the facility notified the Hospice they were no longer using that particular air mattress and facility will arrange their own mattress. During a record review on 9/12/25 at 2:00 p.m. with the DON and the ADM, Resident 1's IDT note, dated 9/8/25 was reviewed. The IDT note indicated, . Assessment: [Licensed Vocational Nurse (CN 1)] and [Registered Nurse (RN)] immediately went into the room and found the resident on the right side of her bed, lying flat on her back with legs stretched out and arms crossed to her chest wearing only her shirt with no brief on. Upon assessment, blood was seen on the floor coming from the back of her head. There is an open laceration noted on the posterior [the back] part of her head. [CN 1] then placed a pressure dressing with gauze and bandage wrap. Resident was noted to be conscious and when asked what happened, she was able to answer and stated, I don't know. Pupils are [pupils are equal, round, reactive to light and accommodation (PERRLA)]. Vital signs checked and blood pressure was 134/75 within her normal limits. Resident was not moved due to head injury. A pillow with sheets was placed to her head to provide support. RN remained with the patient and [CN 1] called [NP] and informed him of the incident and ordered for the resident to be transferred out to acute [care hospital] for further evaluation and treatment. Per interview with the [CN 1], she stated that she was at the nurse's station doing her documentation, per her documentation, cause of fall was when the assigned CNA turned resident to her [resident 1] right side of the bed, CNA noted that resident did not have a draw sheet under her, as the CNA turned the resident, [Resident 1's] left leg fell forward [bringing] [Resident 1's] weight [down] and shifting her to fall off the bed and landed on the floor on her back. Resident's bed height was found at between waist and knee level Notification: MD notified of the incident and ordered to send resident out to [emergency room (ER)] for further evaluation and treatment. [Responsible person (RP)] was informed and [company name] Hospice. [Resident 1] was sent to [Hospital A] later on transferred to [Hospital B] . RP called the facility and stated that [Resident 1] is in [ Intensive Care Unit (ICU - is a hospital unit that provides specialized, round-the-clock care for critically ill patients with life-threatening injuries or diseases)], she has laceration on the back of her head with multiple internal hematoma [collections of blood in or around the brain], left rib 1-3 [indicates a serious injury requiring immediate medical attention] was fractured and punctured her lungs, and lumbar fracture [break in one of the five bones (called vertebrae) of lower back, part of spine supports most of body's weight] with internal bleeding. Root Cause Analysis: Resident's cause of fall was weakness and residents positioning during [Activities of Daily Living (ADL -which are the fundamental self-care tasks necessary for independent living, including bathing, dressing, eating, using the toilet, continence, and mobility)] care. During an interview on 9/12/05 at 2:41 p.m. with CN 1, CN 1 stated she had been working at the facility for almost two years and was familiar with Resident 1. CN 1 stated at the time of the incident she was at the nursing station and heard CNA 1 calling her name. CN 1 stated she was one of the first responders to Resident 1's room right after the fall. CN 1 stated she observed Resident 1 was lying flat on the right side of the bed. CN 1 stated CNA 1 informed CN 1 that CNA 1 was changing Resident 1's brief and Resident 1 slipped out of her hand. CN 1 stated Resident 1 fell to the right side of bed, Resident 1 was not wearing a brief and had a little bit of blood on floor next to Resident 1 and there was nothing on Resident 1's face. CN 1 stated she thought it was coming from Resident 1's head, she assessed Resident 1's vital signs and called to send Resident 1 out by ambulance to ER. CN 1 stated she notified the family and assisted the Emergency Medical Technician (EMT- a trained healthcare professional who provides immediate care to patients at the scene of an incident and transports them to a hospital). CN 1 stated CNA 1 turned Resident 1 and did not have a draw sheet under the resident as she should have one for repositioning residents. CN 1 stated CNA 1 was not able to pull [Resident 1] closer and when she turned [Resident 1], she lost her grip as she had a dirty brief in her other hand that she was putting in the trash. CN 1 stated, I would personally say yes [CNA] should have second person to assist with repositioning Resident 1. CN 1 stated Resident 1 should have a draw sheet under her while in bed. CN 1 stated this fall for Resident 1 happened around 10:00 p.m. and CNA 1 started her shift at 2:30 p.m. CN 1 stated she would have expected CNA 1 to have changed Resident 1's brief at least once or twice before and CNA 1 should have been aware Resident 1 did not have a draw sheet to securely reposition Resident 1 during pericare. CN 1 stated Resident 1 would not have moved unless she was being moved, Resident 1 was not combative and dependent on care. During a concurrent interview and record review on 9/12/25 at 2:59 p.m. with the Director of Staff Development (DSD), the facility's document titled, COMPETENCY CHECK-MOVING A RESIDENT IN BED, dated January 2025 was reviewed. The DSD stated she had been working as the DSD for two years. The DSD stated she assisted with the education and training of all staff. The DSD stated all CNAs received training on turning, positioning, and transfers of residents and during the training, CNAs were educated on when to ask for a second person for assistance while repositioning. The DSD stated she was familiar with Resident 1. The DSD stated Resident 1 required maximum assistance and may have required two people for assistance, however, one staff was sufficient for toileting needs. The DSD stated the facility used draw sheets and the purpose for the use of draw sheets was to help with repositioning, helped to safely turn the residents and assisted with safe mobility of the resident in bed by the CNA. The DSD stated she had reviewed the case and spoke with CNA 1. The DSD stated CNA 1 kept saying she was talking to Resident 1. The DSD stated she was unable to understand why CNA 1 would rely on Resident 1 and said, Don't move, to Resident 1. The DSD stated Resident 1 had a low BIMS and was not physically able to assist with repositioning or ensuring safety. The DSD also stated the IDT team and the facility leadership team reviewed the staffing for the day and the facility had sufficient staffing to accommodate another CNA to assist CNA 1 with turning Resident 1 safely. The DSD stated the document indicated the use of a draw sheet or following the process of positioning resident, without a draw sheet: Slides hands under head and shoulders and moves [resident] toward self [to avoid the potential for fall], as outlined in the competency would have potentially avoided the fall. The DSD stated it appeared Resident 1 was turned away instead of moving toward self by the CNA. The DSD stated she had provided in-services and training to all CNAs to ensure patient safety and avoid falls after Resident 1's fall. During an interview on 9/12/25 at 3:14 p.m. with the ADM, the ADM stated she had been at the facility in her role for two and half years. The ADM stated she was notified about Resident 1's fall by the DON the same day around 10:30 p.m. The ADM stated the following day, the DON and the ADM had a meeting with CNA 1 and also notified the family of Resident 1. The ADM stated the facility had an IDT meeting to discuss the root cause analysis (RCA - systematic approach to identifying the foundational causes of problems, rather than just addressing symptoms, to develop long-term solutions and prevent recurrence) and reported the incident to the regulatory authorities as required. The ADM stated CNA 1 should have positioned the patient closer to her during repositioning using a draw sheet or followed the process for repositioning residents without a draw sheet closer to her as mentioned in the competency and training. The ADM also stated the mattress topper should not have been used. The ADM stated the facility would be auditing and monitoring to ensure all residents' safety and reeducation was provided to CNAs. The ADM stated she expected staff to follow the facility policies, competency, and training and CNA 1 failed to follow facility competency and training and steps when moving Resident 1 safely. During a concurrent phone interview and record review on 9/15/25 at 1:45 p.m. with the DON, Resident 1's MDS RESIDENT ASSESSMENT AND CARE SCREENING, dated May 12, 2025, was reviewed. The MDS indicated . Section GG - Functional Abilities - . Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided . 01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity . 01 C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy [define], include wiping the opening but not managing equipment . 01 G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear . The DON stated the assessment was the most recent assessment for Resident 1. The DON stated she was familiar with the MDS assessment. The DON stated the MDS assessment was completed quarterly and yearly assessment for change and to see any condition changes. The DON stated assessment was for the overall resident condition and different areas were assessed to address any change in resident condition and to make sure resident care needs were met. The DON stated the MDS looked at what residents required and the MDS assessment was done by the facility. The DON further stated the care plan and goals were established based on the residents assessment. The DON stated she reviewed and was familiar with Resident 1's assessment. The DON stated the MDS assessment for Resident 1 indicated Resident 1 scored dependent which indicated, helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 people for toileting need. The DON stated she was unable to explain whether Resident 1 required two people for toileting needs and would have to defer to the MDS consultant. The DON stated she would assist with arranging a call with the MDS consultant to explain the scoring, however, at times, the facility did have two staff helping with Resident 1. The DON stated Resident 1 was dependent and one CNA was sufficient at times, depending on the care needs. The CNO stated Resident 1 was dependent on CNA 1 and CNA 1 should not have relied on Resident 1 to assist during repositioning. During a concurrent phone interview and record review on 9/15/25 at 2:03 p.m. with the Clinical Reimburse Specialist consultant (CRS), Resident 1's MDS RESIDENT ASSESSMENT AND CARE SCREENING, dated May 12, 2025, was reviewed. The CRS stated she reviewed the assessment for Resident 1 and for toileting needs, Resident 1 was scored as dependent. The CRS stated if one helper did all the effort required to reposition Resident 1, then one person was sufficient, otherwise assistance of two or more helpers was required to complete the activity. The CRS stated the MDS assessment was used to establish resident care needs and plan of care. During a phone interview on 9/16/25 at 10:40 a.m. with CNA 1, CNA 1 stated she had been working at the facility for two years. CNA 1 stated she was working with Resident 1 when Resident 1 had a fall at the facility. CNA 1 stated Resident 1 was her last patient of the night to be checked if a brief change was required. CNA 1 stated she knocked on Resident 1's door and explained she was there to change Resident 1. CNA 1 stated, I closed the curtain, I gathered my stuff, bags, wipes, and brief. I checked her, she had a bowel movement. I explained I am going to change her. I proceeded with her, her foot was dangling. I began to turn her, and I pivoted to turn to throw away the soiled brief and next thing she fell to the floor. CNA 1 stated she was working by herself with Resident 1. CNA 1 stated she did not recall pulling Resident 1 closer to herself. CNA 1 stated she was still in shock and could not recall all the details, however, she did recall changing Resident 1's brief earlier in the day around 4:30 p.m. CNA 1 stated she recalled turning Resident 1 away from herself before the fall, and she fell while turning. CNA 1 stated she was on the opposite side [away from the side resident was facing] of Resident 1 and Resident 1 was facing the wall and the sliding door away from her. CNA 1 stated Resident 1 was very stiff and was not moving at all. CNA 1 stated Resident 1 did not have chucks [disposable absorbent under pads to protect the bed from spills or leakage often due to incontinence] or a draw sheet under her. CNA 1 stated Resident 1 should have chucks or a draw sheet as she was dependent. CNA 1 stated she did not recall seeing Resident 1 earlier without a draw sheet. CNA 1 stated Resident 1 was also on an inflatable bubbly mattress and it was set to a certain pressure. CNA 1 stated she should have called for help. CNA 1 stated if another person was present during repositioning, it would have helped to prevent the fall. CNA 1 stated the use of a draw sheet during repositioning would have helped prevent the fall for Resident 1. CNA 1 stated the facility normally had one person assisting Resident 1 with repositioning. CNA 1 stated she never had any residents fall during her care and this was the first time any resident under her care experienced a fall and she had learned from this experience. During a review of the facility's policy and procedure (P&P) titled, QUALITY OF CARE Accident Hazards / Supervision / Devices, dated 7/2018, the P&P indicated, .Purpose .To provide an environment that is free from controllable accident hazards and provision of supervision and devices needed to prevent avoidable accidents .The facility will provide an environment that is as free of accident hazards as is possible and provide supervision and assistance devices to residents to avoid preventable accidents .Efforts to minimize risk to residents will include individualized, resident-centered interventions to reduce individual risks related to hazards in the environment .interventions will be modified when necessary .individualized interventions will be developed to reduce the potential for accidents .Staff will be trained on the use of assistive devices and transfer equipment .The devices and transfer techniques will be reflected in the resident's comprehensive care plan .During a review of the facility's document titled, JOB DESCRIPTION NURSING ASSISTANT - CERTIFIED, undated, the document indicated, . Essential Functions . Observe and practice safety according to facility policy and procedure . Demonstrate and able to explain proper body mechanics in all patient handling interactions & processes . Perform the following according to policy and procedure . Apply proper lifting and transferring techniques . Safety: Know and follow all Company policies, regulations and requirements . Demonstrate safe practices in regard to resident's comfort and safety by applying knowledge of proper body alignment for self and resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safety and protection for one of three sampled residents (Resident 2) was free from abuse and neglect when Resident 1 had a known history of sexual behaviors that was care planned and interventions were not implemented for Resident 1. On 12/30/23, Certified Nursing Assistant (CNA) 2 noticed Resident 1 in the dining room unsupervised, CNA 2 neglected to implement care planned intervention leaving Resident 1 unattended. Resident 1 touched Resident 2 ' s breast in front of her husband during a visit. This failure resulted in the lack of supervision of Resident 1 in the dining room with a female resident present and resulted in the violation of Resident 2 ' s dignity, which could have resulted in humiliation, and psychosocial harm for a reasonable person. Resident 2 had severe cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions) and she did not like it when her breast was touched. Findings: During a review of Resident 1's admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included Alzheimer ' s (affects memory, thinking and behavior) During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment dated 11/16/23, it indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 10 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment, 99 severely impaired ). The BIMS assessment indicated Resident 1 had moderate cognitive impairment. During a concurrent observation and interview on 1/17/24 at 1:20 p.m. with Resident 2, in Resident 2 ' s room, Resident 2 was lying in bed. Resident 2 stated she did not know the resident that touched her on her breast and stated, I didn ' t like it one bit I am a girl. During a review of Resident 2's admission Record undated, the admission record indicated, Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included Parkinsonism (disorder affecting the nervous system) and major depressive disorder (feeling of sadness and loss of interest). During a review of Resident 2's MDS Assessment dated 12/27/23, indicated Resident 2's BIMS assessment score was 99. The BIMS assessment indicated Resident 2 had severe cognitive impairment. During an interview on 1/17/24 at 1:32 p.m. with Resident 4, Resident 4 stated she had witnessed Resident 1 act inappropriately with his genitals (sexual reproductive organs located outside the body) in front of residents in the past. Resident 4 stated she had also seen Resident 1 touch another resident ' s breast couple months ago. During a review of Resident 4's MDS assessment dated [DATE], indicated Resident 4's BIMS assessment score was 15. The BIMS assessment indicated Resident 4 was cognitively intact. During an interview on 1/17/24 at 1:51 p.m. with Activities Director (AD), AD stated there was care planned intervention developed on 6/2023 due to Residents 1 ' s inappropriate behavior with females. The plan was to supervise Resident 1 when he left his room and that she told the activities staff to ensure Resident 1 was not left alone in the dining room. AD stated Resident 1 could propel himself in his wheelchair but staff would bring him to the dining room at times and that no one should bring him to the dining unless staff were present. During an interview on 1/17/24 at 1:58 p.m. with Activities/Certified Nursing Assistant (ACNA), ACNA stated on 12/30/23 at 9:30 a.m. she was offering coffee to residents in their rooms and was going to have coffee in the dining room at 10 a.m. ACNA stated Resident 1 has had past inappropriate behaviors with her such as asking her to go to bed with him. ACNA stated on 12/30/23, Resident 2 ' s husband informed her that Resident 1 touched his wife ' s breast. ACNA stated she was not in the dining room at the time the incident on 12/20/23 , and that Resident 1 should not have been left unattended in the dining room due to his inappropriate behaviors with females. ACNA stated she had witnessed Resident 1 touch another resident ' s breast couple months ago in the dining room prior to the incident on 12/30/23. During an interview on 1/17/24 at 2:04 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, on 12/30/23 Resident 3 informed him that Resident 1 touched Resident 2 ' s breast while Resident 2 was sitting with her husband. CNA 1 stated he was aware of Resident 1 ' s inappropriate sexual behaviors and that Resident 1 had touched his butt in the past. CNA 1 stated Resident 1 should be monitored when in the dining room because Resident 1 had inappropriate sexual behaviors and does not control his impulses. CNA 1 stated prior to the incident on 12/30/23 he knew the care planned intervention to not allow Resident 1 in the dining room unsupervised. During an interview on 1/17/24 at 2:23 p.m. with Resident 5, Resident 5 stated Resident 2 was a pervert [sexual behaviors that are considered particularly abnormal] and that he would make sexual comments or expose his genitals. During a review of Resident 5's MDS assessment dated [DATE], indicated Resident 5's BIMS assessment scored was 13. The BIMS assessment indicated Resident 5 was cognitively intact. During a concurrent interview and record review on 1/17/24 at 2:41 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 2 ' s Progress Notes (PN), dated 12/30/23 was reviewed. The PN indicated, .moved Male Resident back to [room number] because he touched this resident's left breast . The husband reported to the CNA while visibly upset that the Male Resident touched the left breast of this resident, his wife. Upon seeing the incident, the Husband told the Male Resident to ' Stop, that is my wife ' . The Male Resident then answered back to the husband, ' I do what I f----[profanity] please and it is not your business. ' . [Resident 2] stated that ' that person touched me ' , while touching her left breast . This CN [charge nurse] spoke with [Resident 2] and asked her what had happened. She stated that ' that person touched me ' , while touching her left breast . LVN 1 stated Resident 1 has a history of making sexual comments and that it was common for Resident 1 to make comments such as nice [butt] and nice body. During an interview on 1/17/24 at 2:49 p.m. with Resident 3, Resident 3 stated he was in the dining room on 12/30/23 when Resident 1 touched resident 2 ' s breast in front of Resident 2 ' s husband. Resident 3 stated, it was not right I did not like seeing that at all and that Resident 1 is always doing something perverted. Resident 3 stated as soon as Resident 1 is left unattended he will act up and do something inappropriate such as exposing his genitals or touching females. During a review of Resident 3's MDS Assessment, dated 12/9/23, the MDS assessment indicated, Resident 3 ' s BIMS assessment scored was 15. The BIMS assessment indicated Resident 3 was cognitively intact. During an interview on 1/17/24 at 2:57 p.m. with Social Services (SS), SS stated she followed up with Resident 2 on 1/2/24. SS stated Resident 2 was confused and did not remember the inappropriate touching that occurred on 12/30/23. During a concurrent interview and record review on 1/17/24 at 3:28 p.m. with Licensed Vocational Nurse Unit Manager (LVNUM), Resident 1 ' s PN dated 5/18/23 was reviewed. The PN indicated, . Activities notified nurse resident asking another resident to show him her breasts in the dining area. Resident was then taken back to his room . Resident 1 ' s Psychiatric Assessment (PA) dated 6/20/23 was reviewed. The PA indicated, .Staff reported . had inappropriate sexual behavior towards the female, but no grabbing or touching . The PN dated 7/20/23 was reviewed, the PN indicated, .[Resident 1] was trying to grab RSA [recreational assistant]breast and he also was trying to touch the bottom of a resident ' s family member . LVNUM stated Resident 1 had a care plan intervention to only sit with male residents and not to be left alone with female peers. LVNUM stated Resident 1 had known inappropriate sexual behaviors. During a concurrent interview and record review on 1/17/24 at 3:41 p.m. with AD, Resident 1 ' s Care Plan (CP) dated 6/5/23 was reviewed. The CP indicated, .During group programs [Resident 1] is encouraged to sit with only males residents .[Resident 1] is not left alone with female peers when group programs are over encouraging [Resident 1] to move to small dining room to watch his favorite tv programs westerns . AD stated when Resident 1 had inappropriate behavior, the plan was to put him at a table by himself in the dining room because he was inappropriate with females. AD stated she would ensure that staff were present when she would conduct activity in the dining room and not leave Resident 1 alone. During an interview on 1/30/24 at 9:40 a.m. with CNA 2, CNA 2 stated Resident 1 was able to propel himself with the wheelchair around the facility. CNA 2 stated Resident 1 had inappropriate behavior and would touch female staff. CNA 2 stated on 12/30/23 she saw Resident 1 in the dining room and without staff in the dining room. CNA 2 stated the inappropriate touch could have been avoided if there was staff present in the dining room. CNA 2 stated she should have ensured staff were present in the dining room but didn ' t. During a telephone interview on 1/30/24 at 10a.m. with Family (FM), FM stated he was seated in the dining room on 12/30/23 with his wife. FM stated there was no staff present, a resident went to his wife and touched her breast. FM stated, he told the resident, get your hands off my wife. FM stated Resident 1 responded by telling FM that Resident 1 can do as he [explicit language] pleased. FM stated that he did not want anyone to touch his wife inappropriately. During a concurrent interview and record review on 1/30/24 at 12:30 p.m. with Administrator (ADM), the facility policy and procedure (P&P) titled Comprehensive Care Plans dated 11/2017 was reviewed. The policy indicated, .The facility Interdisciplinary Team (IDT) will develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, physical, mental, and psychosocial needs .Interventions identified by the comprehensive care plan will be provided by qualified, competent persons .Resident care needs and care plan interventions will be communicated to direct care staff . ADM stated staff should follow the care plan and should have not left Resident 1 alone in the dining room. ADM stated she would not want this to happen to her herself or her family member. ADM stated care planned interventions should be implemented and Resident 1 should have been supervised because of his inappropriate behaviors with females. During a review of the facility P&P titled Freedom From Abuse, Neglect and Exploitation, dated 11/2017 , the P&P indicated, The facility will provide a safe resident environment and protect residents from abuse .Definition of Sexual Abuse: Non-consensual sexual contact of any type with a resident .Cognitive impairment or mental disorder does not preclude a resident from being abusive .Facility will assess the resident and care plan intervention to address resident behaviors that may indicate for abusive .sexual .Resident outcomes that will be considered in instances of sexual abuse may include, but not limited to .depression .anxiety .fear of being alone .fear of the dark .nightmares .disturbed sleep .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a resident-centered comprehensive care plan for one of three sampled residents (Resident 1) when Resident 1 with known inappropriate sexual behaviors was left unattended on 12/30/23 in the dining room. On 12/30/23, Certified Nursing Assistant (CNA) 2 noticed Resident 1 in the dining room unsupervised, CNA 2 did not implement care planned intervention to not leave Resident 1 alone with female peers. CNA 2 left Resident 1 unattended, Resident 1 touched Resident 2 ' s breast. This failure resulted in the lack of supervision of Resident 1 in the dining room with a female resident present and resulted in the violation of Resident 2 ' s dignity, which could have resulted in humiliation, and psychosocial harm for a reasonable person. Resident 2 had severe cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions) and she did not like it when her breast was touched. Findings: During a review of Resident 1's admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included Alzheimer ' s (affects memory, thinking and behavior) During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment dated 11/16/23, it indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 10 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment, 99 severely impaired ). The BIMS assessment indicated Resident 1 had moderate cognitive impairment. During a concurrent observation and interview on 1/17/24 at 1:20 p.m. with Resident 2, in Resident 2 ' s room, Resident 2 was lying in bed. Resident 2 stated she did not know the resident that touched her on her breast and stated, I didn ' t like it one bit I am a girl. During a review of Resident 2's admission Record undated, the admission record indicated, Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included Parkinsonism (disorder affecting the nervous system) and major depressive disorder (feeling of sadness and loss of interest). During a review of Resident 2's MDS Assessment dated 12/27/23, indicated Resident 2's BIMS assessment score was 99. The BIMS assessment indicated Resident 2 had severe cognitive impairment. During an interview on 1/17/24 at 1:32 p.m. with Resident 4, Resident 4 stated she had witnessed Resident 1 act inappropriately with his genitals (sexual reproductive organs located outside the body) in front of residents in the past. Resident 4 stated she had also seen Resident 1 touch another resident ' s breast couple months ago. During a review of Resident 4's MDS assessment dated [DATE], indicated Resident 4's BIMS assessment score was 15. The BIMS assessment indicated Resident 4 was cognitively intact. During an interview on 1/17/24 at 1:51 p.m. with Activities Director (AD), AD stated there was care planned intervention developed on 6/2023 due to Residents 1 ' s inappropriate behavior with females. The plan was to supervise Resident 1 when he left his room and that she told the activities staff to ensure Resident 1 was not left alone in the dining room. AD stated Resident 1 could propel himself in his wheelchair but staff would bring him to the dining room at times and that no one should bring him to the dining unless staff were present. During an interview on 1/17/24 at 1:58 p.m. with Activities/Certified Nursing Assistant (ACNA), ACNA stated on 12/30/23 at 9:30 a.m. she was offering coffee to residents in their rooms and was going to have coffee in the dining room at 10 a.m. ACNA stated Resident 1 has had past inappropriate behaviors with her such as asking her to go to bed with him. ACNA stated on 12/30/23, Resident 2 ' s husband informed her that Resident 1 touched his wife ' s breast. ACNA stated she was not in the dining room at the time the incident on 12/20/23 , and that Resident 1 should not have been left unattended in the dining room due to his inappropriate behaviors with females. ACNA stated she had witnessed Resident 1 touch another resident ' s breast couple months ago in the dining room prior to the incident on 12/30/23. During an interview on 1/17/24 at 2:04 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, on 12/30/23 Resident 3 informed him that Resident 1 touched Resident 2 ' s breast while Resident 2 was sitting with her husband. CNA 1 stated he was aware of Resident 1 ' s inappropriate sexual behaviors and that Resident 1 had touched his butt in the past. CNA 1 stated Resident 1 should be monitored when in the dining room because Resident 1 had inappropriate sexual behaviors and does not control his impulses. CNA 1 stated prior to the incident on 12/30/23 he knew the care planned intervention to not allow Resident 1 in the dining room unsupervised. During an interview on 1/17/24 at 2:23 p.m. with Resident 5, Resident 5 stated Resident 2 was a pervert [sexual behaviors that are considered particularly abnormal] and that he would make sexual comments or expose his genitals. During a review of Resident 5's MDS assessment dated [DATE], indicated Resident 5's BIMS assessment scored was 13. The BIMS assessment indicated Resident 5 was cognitively intact. During a concurrent interview and record review on 1/17/24 at 2:41 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 2 ' s Progress Notes (PN), dated 12/30/23 was reviewed. The PN indicated, .moved Male Resident back to [room number] because he touched this resident's left breast . The husband reported to the CNA while visibly upset that the Male Resident touched the left breast of this resident, his wife. Upon seeing the incident, the Husband told the Male Resident to ' Stop, that is my wife ' . The Male Resident then answered back to the husband, ' I do what I f----[profanity] please and it is not your business. ' . [Resident 2] stated that ' that person touched me ' , while touching her left breast . This CN [charge nurse] spoke with [Resident 2] and asked her what had happened. She stated that ' that person touched me ' , while touching her left breast . LVN 1 stated Resident 1 has a history of making sexual comments and that it was common for Resident 1 to make comments such as nice [butt] and nice body. During an interview on 1/17/24 at 2:49 p.m. with Resident 3, Resident 3 stated he was in the dining room on 12/30/23 when Resident 1 touched resident 2 ' s breast in front of Resident 2 ' s husband. Resident 3 stated, it was not right I did not like seeing that at all and that Resident 1 is always doing something perverted. Resident 3 stated as soon as Resident 1 is left unattended he will act up and do something inappropriate such as exposing his genitals or touching females. During a review of Resident 3's MDS Assessment, dated 12/9/23, the MDS assessment indicated, Resident 3 ' s BIMS assessment scored was 15. The BIMS assessment indicated Resident 3 was cognitively intact. During an interview on 1/17/24 at 2:57 p.m. with Social Services (SS), SS stated she followed up with Resident 2 on 1/2/24. SS stated Resident 2 was confused and did not remember the inappropriate touching that occurred on 12/30/23. During a concurrent interview and record review on 1/17/24 at 3:28 p.m. with Licensed Vocational Nurse Unit Manager (LVNUM), Resident 1 ' s PN dated 5/18/23 was reviewed. The PN indicated, . Activities notified nurse resident asking another resident to show him her breasts in the dining area. Resident was then taken back to his room . Resident 1 ' s Psychiatric Assessment (PA) dated 6/20/23 was reviewed. The PA indicated, .Staff reported . had inappropriate sexual behavior towards the female, but no grabbing or touching . The PN dated 7/20/23 was reviewed, the PN indicated, .[Resident 1] was trying to grab RSA [recreational assistant]breast and he also was trying to touch the bottom of a resident ' s family member . LVNUM stated Resident 1 had a care plan intervention to only sit with male residents and not to be left alone with female peers. LVNUM stated Resident 1 had known inappropriate sexual behaviors. During a concurrent interview and record review on 1/17/24 at 3:41 p.m. with AD, Resident 1 ' s Care Plan (CP) dated 6/5/23 was reviewed. The CP indicated, .During group programs [Resident 1] is encouraged to sit with only males residents .[Resident 1] is not left alone with female peers when group programs are over encouraging [Resident 1] to move to small dining room to watch his favorite tv programs westerns . AD stated when Resident 1 had inappropriate behavior, the plan was to put him at a table by himself in the dining room because he was inappropriate with females. AD stated she would ensure that staff were present when she would conduct activity in the dining room and not leave Resident 1 alone. During an interview on 1/30/24 at 9:40 a.m. with CNA 2, CNA 2 stated Resident 1 was able to propel himself with the wheelchair around the facility. CNA 2 stated Resident 1 had inappropriate behavior and would touch female staff. CNA 2 stated on 12/30/23 she saw Resident 1 in the dining room and without staff in the dining room. CNA 2 stated the inappropriate touch could have been avoided if there was staff present in the dining room. CNA 2 stated she should have ensured staff were present in the dining room but didn ' t. During a telephone interview on 1/30/24 at 10a.m. with Family (FM), FM stated he was seated in the dining room on 12/30/23 with his wife. FM stated there was no staff present, a resident went to his wife and touched her breast. FM stated, he told the resident, get your hands off my wife. FM stated Resident 1 responded by telling FM that Resident 1 can do as he [explicit language] pleased. FM stated that he did not want anyone to touch his wife inappropriately. During a concurrent interview and record review on 1/30/24 at 12:30 p.m. with Administrator (ADM), the facility policy and procedure (P&P) titled Comprehensive Care Plans dated 11/2017 was reviewed. The policy indicated, .The facility Interdisciplinary Team (IDT) will develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, physical, mental, and psychosocial needs .Interventions identified by the comprehensive care plan will be provided by qualified, competent persons .Resident care needs and care plan interventions will be communicated to direct care staff . ADM stated staff should follow the care plan and should have not left Resident 1 alone in the dining room. ADM stated she would not want this to happen to her herself or her family member. ADM stated care planned interventions should be implemented and Resident 1 should have been supervised because of his inappropriate behaviors with females. During a review of the facility P&P titled Freedom From Abuse, Neglect and Exploitation, dated 11/2017 , the P&P indicated, The facility will provide a safe resident environment and protect residents from abuse .Definition of Sexual Abuse: Non-consensual sexual contact of any type with a resident .Cognitive impairment or mental disorder does not preclude a resident from being abusive .Facility will assess the resident and care plan intervention to address resident behaviors that may indicate for abusive .sexual .Resident outcomes that will be considered in instances of sexual abuse may include, but not limited to .depression .anxiety .fear of being alone .fear of the dark .nightmares .disturbed sleep .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a fall risk care plan for one of three sampled residents (Resident 352) when: Resident 352's fall risk was determined to be high risk for falls on 4/5/19 and care plan interventions were not developed to keep her safe, free from falls and fall related injuries. This failure resulted in Resident 352's fall, a laceration to the bridge of her nose, a hematoma [a solid swelling of clotted blood within the tissues], discoloration to the left side of her head, pain and a left hip fracture which required surgical repair for the hip fracture and a nine-day hospitalization. Findings: During an interview with Licensed Vocational Nurse (LVN) 3, on 5/23/19, at 8:25 a.m., LVN 3 stated Certified Nursing Assistant (CNA) 3 notified him of Resident 352's fall on 4/9/19 at 10:45 p.m., during the night. LVN 3 stated he went to Resident 352's room and found her on the floor facing down without wearing a gown and without socks [hospital gown wrapped around lower part of her body]. LVN 3 stated Resident 352 was full of blood (hair, face, and hands) and a laceration was noted on the bridge of her nose. LVN 3 stated Resident 352 was admitted to the facility on [DATE] and was a low fall risk. LVN 3 stated, [Resident 352] was very confused, wanted to get up and go to the restroom. [Resident 352] was [frequently] reminded that she just went to the bathroom. LVN 3 stated he did not review the fall risk assessment and was not aware Resident 352 was a high risk for falls. During an interview with CNA 3, on 5/23/19, at 8:50 a.m., CNA 3 stated, It was during shift change .when I saw [Resident 352] on the floor with her face down at the foot of the bed. She spilled her drinks and urinated on the floor. [Resident 352] was very consistent in saying I want to pee all of the time but would not pee [when taken to the restroom]. CNA 3 stated Resident 352 frequently requested to use the restroom and would not urinate after being taken to the restroom. CNA 3 stated Resident 352 was confused and exhibited anxiety by frequent requests to use the restroom. CNA 3 stated she did not know Resident 352's fall risk score. CNA 3 stated she did not have information about Resident 352's fall risk and was not informed by the licensed nurses or CNA's who previously cared for Resident 352 of her risk. During a review of Resident 352's face sheet (a document with personal identifiable and medical information) undated indicated Resident 352 was admitted to the facility on [DATE] with diagnoses which included unsteadiness on feet, pain, muscle weakness, age related osteoporosis (weak and brittle bones). During a review of the clinical record for Resident 352, the Minimum Data Set (assessment of healthcare and functional needs) assessment dated [DATE], indicated Resident 352 had short and long term memory impairment. The MDS document indicated Resident 352 was moderately impaired in decision making during activities of daily living and required cues and supervision. During a review of the clinical record for Resident 352, Resident 352's initial nursing admission assessment dated [DATE], indicated Resident 352 required limited assistance (guided maneuvering of limbs) of one staff member for toilet use. During a review of the clinical record for Resident 352, the nurse's progress notes dated 4/9/19, at 10:45 p.m., indicated, CNA notified [Charge Nurse] that [Resident 352] had fallen in her room. Upon entering room noted that [Resident 352] was on the floor near her bed. [Resident 352] had her gown wrapped around the lower part of her body. [Resident 352] was noted to be bleeding from a laceration on her nose. A hematoma and discoloration to the left side of her head was noted at that time also. [Resident 352] complained of pain . During a concurrent interview and record review with the Registered Nurse (RN), on 5/24/19, at 2:31 p.m., the RN reviewed Resident 352's initial fall risk assessment on admission dated 4/5/19, and stated the score was 10 which indicated Resident 352 was at high fall risk. The RN reviewed Resident 352's care plan and stated there was a fall risk care plan dated 4/10/19 developed after Resident 352's fall with injury. The RN stated she could not find a baseline care plan initiated within 48 hours of Resident 352's admission which would have reflected Resident 352's fall risk and fall risk interventions. The RN stated the second shift (the evening shift) nurse was responsible to complete the baseline care plan. The RN stated, I was the first shift nurse and I did not complete the fall risk assessment because it was not assigned to me. The RN stated she had not reviewed Resident 352's fall risk assessment prior to Resident 352's fall and consequently she was not aware of Resident 352's high risk for falls. The RN stated if she would have been aware then she would have ensured Resident 352's safety was maintained by implementing care plan interventions which addressed Resident 352's fall risk within 48 hours from her admission to the facility. The RN stated, I don't have any specific monitoring for her. The RN stated Resident 352's was extremely confused. The RN stated, I told [Unit Manager] (UM) of her behavior [anxiousness] and confusion but I did not follow up [checked] with the [UM]. The RN reviewed Resident 352's care plan and was unable to find a care plan that addressed Resident 352's confusion and behaviors which could increase Resident 352's fall risk. During a concurrent interview and record review with the UM, on 5/24/19, at 3:18 p.m., the UM reviewed Resident 352's date of admission and stated Resident 352 was admitted to the facility on [DATE]. The UM stated, We have interdisciplinary team (IDT) (a group composed of a licensed nurse, a physician, a social worker and dietician) that goes over [care plans] in the stand-up meeting every day. The UM stated the IDT missed Resident 352's care plan initiation for fall risk within 48 hours of admission. The UM stated the care plan was very important in the care of all residents because it painted a picture of the care and interventions they required. The UM stated Resident 352's fall could have been avoided and it was not. During a concurrent interview and record review with the Director of Nursing (DON), on 5/28/19 at 11:18 a.m., the DON reviewed Resident 352's clinical record and stated Resident 352 was admitted to the facility on [DATE]. The DON stated there was no baseline care plan documented within 48 hours of admission that indicated Resident 352 was a high fall risk. The DON reviewed Resident 352's initial fall risk assessment dated [DATE] and stated the fall risk score was 10 which indicated Resident 352 was a high risk for fall. The DON stated, [Resident 352] was admitted on a Friday [4/5/19] it was the weekend and nobody audited the [for the completion of Resident 352's] care plans. It should have been audited on Monday [4/8/19] but it was missed. During a telephone interview with the MD on 5/28/19, at 4:10 p.m., The MD stated he was aware Resident 352 fell on 4/9/19. The MD stated he ordered x-ray on 4/10/19. The MD stated, When I order x-ray, it was stat [needed immediately] especially after [Resident 352] fell and resident had osteoporosis. The MD stated when Resident 352 verbalized 8 out of 10 left lower leg pain he was not notified by the nurse and he should have been notified. MD stated, I would like to be notified for any change of condition especially for 8/10 pain, elevated temperature, cannot move extremities especially after a fall. An x-ray is always a stat order for a resident with a history of fall. If I was notified about the change of condition, I would have ordered to send [Resident 352] right away to acute hospital. I will consider to send the resident to hospital since resident has history of fall and a case of osteoporosis. During a review of the hospital clinical record for Resident 352, the Emergency Department, Physician, and discharge Notes dated 4/11/19 through 4/19/19, indicated, [Resident 352] . with hip pain and swelling .received 100 mcg [micrograms - unit of measurement] Fentanyl [strong pain medication] in route [in the ambulance, on the way to the hospital] . x- ray confirmed . left intertrochanteric [hip bone] fracture [brake], with dislocation, positive ST [soft tissue] swelling . [received blood transfusion] . patient diagnosis Dehydration and [left ] hip fracture [remains] poor functional status [surgery for repair of left hip fracture] . patient has not improved despite aggressive medical management . Patient placed on palliative care [specialized medical care for patients with life-limiting medical conditions] . 4/19/19 discharged to [name] hospice [end of life care] . During a review of the facility policy and procedure titled, Comprehensive Care Plan, Baseline Care Plan dated 11/17, indicated, Purpose: Facility will complete and implement a baseline care plan within 48 hours of a resident's admission. The care plan is intended to promote continuity of care and communication among staff, increase resident safety, minimize potential adverse events that may occur right after admission. Policy: Facilities are required to develop a baseline care plan within the first 48 hours of admission which provides for the provision of effective and person-centered care to each resident and their representative. The care plan is a balance between conditions and risks affecting resident's health and safety, and the resident's goals and choices . During a review of the facility policy and procedure titled, Falls and Fall Risk, Managing dated 12/07, indicated, Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . 1. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions .