**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe and hazard free environment for two of three sampled residents (Resident 1 and Resident 2), when: 1. Licensed Vocational Nurse (LVN) 1 left Resident 1 unattended and unsupervised at Nurse's Station 3, on 2/14/2025. 2. Activity Staff (AS) 3 left Resident 1 at Nurse's Station 3, without verifying there was a charge nurse present to supervise Resident 1, on 2/14/2025. 3. On 2/25/2025, Resident 1 did not have bilateral fall mats (a cushioned floor pad designed to help prevent injury should a person fall) at her bedside, as ordered by the physician. 4. On 2/25/2025, Resident 1 did not have fall risk indicators outside of her room, or on her Geri-chair (a large, padded chair with a wheeled base, designed to assist individuals with limited mobility), in accordance with Resident 1's care plan. 5. A Morse Fall Scale assessment (a clinical assessment tool used to predict a patient's risk of falling) was not conducted following Resident 2's fall on 12/25/2024. 6. On 2/26/2025, Resident 2 did not have fall risk indicators outside of her room, or on her wheelchair, in accordance with Resident 2's care plan. These deficient practices resulted in Resident 1 falling on 2/14/2025 and sustaining a displaced subcapital left femoral neck fracture (a broken bone in the upper part of the left thigh bone, where the broken pieces are significantly displaced from their normal position) requiring surgical intervention in a general acute care hospital (GACH). These deficient practices also placed Resident 1 and Resident 2 at risk for further falls and fall related injuries. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was most recently re-admitted to the facility on [DATE]. Resident 1's admitting diagnoses, as of 2/18/2025, included generalized muscle weakness, left thigh bone fracture, history of falling, dementia (a progressive state of decline in mental abilities), epilepsy (a chronic brain disorder characterized by recurrent seizures, which are brief episodes of abnormal brain activity that can cause involuntary movements, loss of consciousness, or other symptoms), and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 1's History and Physical (H&P), dated 1/10/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P did not indicate diagnoses of osteoporosis or osteopenia (a condition characterized by low bone mineral density, which makes bones weaker and more prone to fractures). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/13/2025, the MDS, indicated Resident 1 had memory problems and severely impaired cognition (a significant decline in cognitive abilities that interferes with daily life and independence). The MDS indicated Resident 1 had impairments to her lower extremities (hip, knee, ankle, and foot) on both sides of her body. The MDS indicated Resident 1 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed. The MDS indicated diagnoses of lack of coordination and generalized muscle weakness. During a review of Resident 1's care plan titled At risk for fall, dated 1/10/2025, the care plan indicated staff were to provide frequent visual monitoring of Resident 1 to reduce the risk of falls and/or injury. During a review of Resident 1's Morse Fall Scale Assessment, dated 1/11/2025, the assessment indicated Resident 1 was at high risk for falls due to impaired gait (an abnormal walking pattern), and overestimation (judging something too highly), and/or forgetfulness of her ability to walk safely. During a review of Resident 1's Change of Condition (COC) assessment, dated 2/14/2025 at 3:10 PM, the COC indicated on 2/14/2025 Resident 1 had a witnessed fall, in the hallway. The COC indicated Resident 1 reported a 4 out of 10 pain (0: no pain, 1 to 3: mild pain, 4 to 6: moderate pain, and 7 to 10: severe pain) to her left hip. The COC indicated Resident 1 was administered Tylenol 650 milligrams (mg, a unit of dose measurement) for pain. The COC indicated Resident 1's physician was notified of the fall and the physician ordered for an immediate x-ray (a procedure that uses radiation to create images of the inside of the body) to rule out broken bones. During a review of the facility record titled Investigation Statement, dated 2/14/2025 at 3:10 PM, the record indicated a handwritten statement by Licensed Vocational Nurse (LVN) 1 regarding Resident 1's fall on 2/14/2025. The record indicated on 2/14/2025 (no time specified), Resident 1 was sitting in a wheelchair near the nurse's station. The record indicated LVN 1 was assisting another resident in the hallway when Resident 1 fell. During a review of Resident 1's COC assessment, dated 2/14/2025 at 9:45 PM, the COC indicated the x-ray revealed Resident 1 had an acute (severe and sudden in onset) left thigh bone fracture related to a witnessed fall. The COC indicated Resident got up unassisted and lost her balance. The COC indicated Resident 1 reported an 8 out of 10 pain. The COC indicated staff administered Norco 5/325 mg (a combination medication used to relieve severe pain when other pain medication was insufficient) for pain. The COC indicated Resident 1's physician gave an order for the resident to be a transferred to a GACH for evaluation and treatment of the left thigh bone fracture. During a review of Resident 1's progress note, dated 2/14/2025 at 11:45 PM, the progress note indicated Resident 1 was transferred to the GACH on 2/14/2025 at 11:30 PM. During a review of Resident 1's GACH record titled History and Physical, dated 2/15/2025 (untimed), the record indicated Resident 1 was brought to the GACH after falling onto her left side while trying to walk. The record indicated a plan to admit Resident 1 to the medical-surgical unit (a unit for patients recovering from surgery, preparing for surgery, or managing various medical conditions). During a review of Resident 1's GACH record titled Radiology Report, dated 2/15/2025 at 2:23 AM, the record indicated an x-ray was taken of Resident 1's left hip. The record indicated Resident 1 had a displaced subcapital left femoral neck fracture. During a review of Resident 1's facility progress note, dated 2/15/2025 at 1:42 PM, the progress note indicated Resident 1 was admitted to the GACH and in the process of being referred to, and evaluated by, an orthopedic physician (a physician who treats injuries and diseases involving muscles, bones, joints, ligaments, and tendons) for a possible left hip hemiarthroplasty (surgical replacement of half of the hip joint) related to her fracture. During a review of Resident 1's GACH record titled Discharge Summary Notes, dated 2/17/2025 at 8:07 AM, the record indicated a final diagnosis of acute left femoral neck fracture. The record indicated Resident 1's conservator (a person appointed by a court to manage her care) declined to provide consent for orthopedic surgery (a surgical procedure on the musculoskeletal system), and Resident 1 was to be discharged back to the facility. During a review of Resident 1's facility progress note, dated 2/18/2025 at 11:45 AM, the progress note indicated Resident 1 was re-admitted to the facility on [DATE]. During a review of Resident 1's medical record titled Routine Pain Assessment Flowsheet, undated, and Pain Assessment Flowsheet, undated, the records indicated Resident 1 received Norco 5/325 mg for the following pain levels: 1. On 2/20/2025 at 3:00 AM: 7/10 pain to her left lower extremity (leg). 2. On 2/20/2025 at 9:00 AM: 8/10 pain to her left lower extremity. 3. On 2/21/2025 at 5:00 AM: 7/10 pain to her left lower extremity. 4. On 2/21/2025 at 11:30 AM: 7/10 pain to her left lower extremity. 5. On 2/22/2025 at 9:00 AM: 8/10 pain to her left lower extremity. 6. On 2/22/2025 at 2:00 PM: 8/10 pain to her left lower extremity. 7. On 2/24/2025 at 9:00 AM: 8/10 pain to her left lower extremity. 8. On 2/25/2025 at 9:00 AM: 7/10 pain to her left lower extremity. 9. On 2/27/2025 at 9:00 AM: 8/10 pain to her left lower extremity. 10. On 2/27/2025 at 2:30 PM: 7/10 pain to her left lower extremity. During a telephone interview on 2/26/2025 at 9:14 AM, with LVN 1, LVN 1 stated she was Resident 1's Charge Nurse the afternoon of 2/14/2025, and was aware Resident 1 was at risk for falls. LVN 1 stated she was supervising Resident 1 at the nurse's station and there were no other staff present when Resident 1 fell. LVN 1 stated she did not ask any staff member to supervise Resident 1 before leaving the resident unattended at the nurse's station. LVN 1 stated she was down the hall from Resident 1, with her back towards the resident, when she heard Resident 1's wheelchair alarm. LVN 1 stated she turned around and saw Resident 1 standing up and holding onto the armrest of her wheelchair for support. LVN 1 stated she was too far away from Resident 1 to intervene, and she observed Resident 1 fall to the ground onto her left side. LVN 1 stated Resident 1 denied any pain during the shift, prior to the fall, but complained of pain to her left hip after the fall. LVN 1 stated she should not have left Resident 1 unattended and unsupervised at the nurse's station. LVN 1 stated the fall could have been prevented if Resident 1 was not left unsupervised. During a telephone interview on 2/26/2025 at 4:43 PM, with Registered Nurse (RN) 1, RN 1 stated Resident 1's care plan intervention of frequent visual monitoring meant Resident 1 should not be left unattended. RN 1 stated to implement this intervention, Resident 1 should always be within a supervising staff member's line of sight. RN 1 stated leaving a resident who required frequent visual monitoring unattended could result in a fall and injury. During a concurrent interview and record review, on 2/27/2025 at 1:02 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Safety and Supervision of Residents, revised 1/2025, was reviewed. The DON stated the P&P indicated resident supervision was a core component for resident safety. The DON stated LVN 1 should not have left Resident 1 unattended because Resident 1 was known as a high risk for falls. The DON stated LVN 1 should have ensured another staff was supervising Resident 1, before leaving the resident at the nurse's station. 2. During a review of the facility record titled Investigation Statement, dated 2/18/2025, untimed, the record indicated a handwritten statement by Activity Staff (AS) 1 regarding Resident 1's fall on 2/14/2025. The record indicated on 2/14/2025 (time unspecified) Resident 1 was in the dining room requesting to be taken back to her room. The record indicated an unidentified staff wheeled Resident 1 to an unspecified nurse's station. During a concurrent interview and record review, on 2/25/2025 at 1:03 PM, with AS 1, the facility record titled Investigation Statement, dated 2/18/2025 (time unspecified), was reviewed. AS 1 stated the staff member who took Resident 1 to the nurse's station was identified as AS 3. During a telephone interview on 2/25/2025 at 2:11 PM, with AS 3, AS 3 stated in the afternoon, of 2/14/2025, she took Resident 1 from the dining room to Nurse's Station 2 for supervision because the resident was at risk for falls. AS 3 stated she parked Resident 1's wheelchair at the nurse's station and informed an unidentified individual, who was sitting at the nurse's station, that she (AS 3) was leaving Resident 1 there. AS 3 stated she assumed the individual at the nurse's station was a nurse and (she) returned to the dining room. AS 3 stated she could not state the name of the individual who was sitting at the nurse's station, and did not verify the individual was Resident 1's Charge Nurse. During a telephone interview on 2/26/2025 at 9:14 AM, with LVN 1, LVN 1 stated she was Resident 1's Charge Nurse the afternoon of 2/14/2025. LVN 1 stated she did not recall being notified by AS 3 that Resident 1 was at Nurse's Station 3 for supervision. During a concurrent interview and record review, on 2/27/2025 at 1:02 PM, with the DON, the facility's P&P titled Falling Star Program, revised 1/2025, was reviewed. The DON stated the P&P indicated staff were required to inform the Charge Nurse whenever a resident was transferred to a supervised area, including the nurse's station. The DON stated clinical staff (directly related to patient care) and non-clinical staff (not directly providing care or treatment) both had access to and sometimes sat at the nurse's stations. The DON stated it was not safe to assume an individual was a licensed nurse because they were seated at the nurse's station. The DON stated AS 3 should have verified Resident 1's Charge Nurse was aware Resident 1 was being left at the nurse's station. The DON stated this would ensure Resident 1 received adequate supervision by a qualified staff person. The DON stated lack of supervision placed Resident 1 at risk for falls. 3. During a review of Resident 1's care plan titled At risk for fall, dated 1/10/2025, the care plan interventions indicated Resident 1 was to have bilateral floor mats to minimize potential injury from falls. During a review of Resident 1's active physician order, dated 2/18/2025, the order indicated Resident 1 was required to have bilateral floor mats to minimize potential injury from falls. During an observation on 2/25/2025 at 1:43 PM, at Resident 1's bedside, Resident 1 was observed lying in bed . No fall mats were observed at Resident 1's bedside. During a concurrent observation and interview on 2/25/2025 at 2:32 PM, at Resident 1's bedside, with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 did not have fall mats to either side of her bed. CNA 1 stated Resident 1 did not have fall mats the entire day. CNA 1 stated the purpose of the fall mats was to prevent or minimize risk of injury from a fall. During a concurrent interview and record review, on 2/27/2025 at 1:09 PM, with the DON, Resident 1's physician order dated 2/18/2025, and a photo of Resident 1's room and bedside, taken 2/25/2025 at 1:52 PM, were reviewed. The DON stated the physician order indicated Resident 1 should have bilateral floor mats at her bedside. The DON stated the photo indicated Resident 1 did not have bilateral floor mats as ordered. The DON stated Resident 1 was at risk for injury because the fall mats were not available to reduce the impact of a fall. 4. During a review of Resident 1's care plan titled Falling Star Program ., dated 2/14/2025, the care plan indicated Resident 1 was to have two yellow star-shaped indicators on her wheelchair and outside of her room by her nameplate. During an observation on 2/25/2025 at 1:52 PM, outside of Resident 1's room, Resident 1's nameplate affixed to the wall outside the resident's room did not have star-shaped indicators next to Resident 1's name. During a concurrent observation and interview on 2/25/2025 at 2:35 PM, with CNA 1, in the hallway outside of Resident 1's room, Resident 1's Geri-chair did not have any star-shaped indicators attached to it. CNA 1 stated the star-shaped indicators alerted staff that a resident was at risk for falls. CNA 1 stated Resident 1 used a Geri-chair instead of a wheelchair because she had left thigh bone fracture. During a concurrent observation and interview on 2/25/2025 at 2:39 PM, with CNA 1, the nameplate outside of Resident 1's room was observed. CNA 1 stated Resident 1 did not have any star-shaped indicators next to the resident's name to indicate Resident 1 was a fall risk. During a concurrent interview and record review, on 2/27/2025 at 1:11 PM, with the DON, Resident 1's care plan titled Falling Star Program ., dated 2/14/2025, and the facility's P&P titled Falling Star Program, dated 1/2025, were reviewed. The DON stated the care plan and P&P indicated Resident 1 was required to have two star-shaped indicators next to her name on the nameplate outside of her room, and on her wheelchair and/or Geri-chair. The DON stated the purpose of the star-shaped indicators was to provide a visual reminder to staff of the resident's fall risk, and to remind them to implement the required fall prevention interventions. The DON stated that without the star indicators, staff might not remember or know to implement fall precautions, placing the resident at risk for falls. During a review of the facility's P&P titled Falling Star Program, dated 1/2025, the P&P indicated any resident with a fall while admitted to the facility would be included in the Falling Star Program and was to have star indicators on their door nameplate and wheelchair, if applicable. The P&P indicated there should be two star-shaped indicators if the resident had sustained a fall in the facility. 5. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's admitting diagnoses included abnormalities of gait (pattern of walking) and mobility, generalized muscle weakness, Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) with dyskinesia (involuntary, repetitive, and abnormal movements). During a review of Resident 2's H&P, dated 11/26/2024, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderately impaired cognition (a decline in thinking and memory that makes it hard to complete complex tasks). The MDS indicated Resident 2 required substantial to maximal assistance from staff to get dressed and maintain personal hygiene after voiding or having a bowel movement. The MDS indicated Resident 2 required partial to moderate assistance from staff for mobility while in bed, to get out of bed, and when transitioning from bed to wheelchair, or wheelchair to bed. During a review of Resident 2's care plan titled Falling Star Program ., dated 12/21/2024, the care plan indicated Resident 2 was to have two yellow star-shaped indicators on her wheelchair and outside of her room by her nameplate. During a review of Resident 2's COC assessment, dated 12/25/2024, the assessment indicated on 12/25/2024 Resident 2 had an unwitnessed fall. The COC indicated staff found Resident 2 lying on her back on the floor near the foot of her roommate's bed. The assessment indicated Resident 2 had an abrasion (scrape or superficial injury) on her left arm and complained of a 3 out of 10 pain. During an observation on 2/25/2025 at 1:52 PM, outside of Resident 2's room, the nameplate outside of Resident 2's room did not have star-shaped indicators next to Resident 2's name. During a concurrent observation and interview, on 2/26/2025 at 1:20 PM, with LVN 2, Resident 2's wheelchair was parked outside of Resident 2's room in the hallway. LVN 2 stated the wheelchair had Resident 2's room and bed indicated on the back of the seat, but did not have any star-shaped indicators attached to it. During a concurrent interview and record review on 2/27/2025 at 1:14 PM, with the DON, Resident 2's COC assessment, dated 12/25/2024, and care plan titled Falling Star Program ., dated 12/21/2024, were reviewed. The DON stated the COC assessment indicated on 12/25/2024 Resident 2 had an unwitnessed fall but a Morse Fall Scale assessment was not done after the fall. The DON stated it was the facility's policy to conduct a fall assessment after any fall, to identify Resident 2's level of risk for falls. The DON stated the assessment would also prompt a review of Resident 2's fall risk care plans to identify if there was a need for new or revised fall prevention interventions. The DON stated a Morse Fall Scale assessment should have been done and failure to complete one placed Resident 2 at risk for repeat falls. The DON stated Resident 2's care plan indicated Resident 2 required star-shaped indicators on her wheelchair and on her nameplate outside of her room. The DON stated the failure to implement the star-shaped indicators placed Resident 2 at risk for falls. During a review of the facility's P&P titled Falling Star Program, dated 1/2025, the P&P indicated fall risk assessments were to be completed as needed. Based on observation, interview, and record review, the facility failed to maintain a safe and hazard free environment for two of three sampled residents (Resident 1 and Resident 2), when: 1. Licensed Vocational Nurse (LVN) 1 left Resident 1 unattended and unsupervised at Nurse's Station 3, on 2/14/2025. 2. Activity Staff (AS) 3 left Resident 1 at Nurse's Station 3, without verifying there was a charge nurse present to supervise Resident 1, on 2/14/2025. 3. On 2/25/2025, Resident 1 did not have bilateral fall mats (a cushioned floor pad designed to help prevent injury should a person fall) at her bedside, as ordered by the physician. 4. On 2/25/2025, Resident 1 did not have fall risk indicators outside of her room, or on her Geri-chair (a large, padded chair with a wheeled base, designed to assist individuals with limited mobility), in accordance with Resident 1's care plan. 5. A Morse Fall Scale assessment (a clinical assessment tool used to predict a patient's risk of falling) was not conducted following Resident 2's fall on 12/25/2024. 6. On 2/26/2025, Resident 2 did not have fall risk indicators outside of her room, or on her wheelchair, in accordance with Resident 2's care plan. These deficient practices resulted in Resident 1 falling on 2/14/2025 and sustaining a displaced subcapital left femoral neck fracture (a broken bone in the upper part of the left thigh bone, where the broken pieces are significantly displaced from their normal position) requiring surgical intervention in a general acute care hospital (GACH). These deficient practices also placed Resident 1 and Resident 2 at risk for further falls and fall related injuries. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was most recently re-admitted to the facility on [DATE]. Resident 1's admitting diagnoses, as of 2/18/2025, included generalized muscle weakness, left thigh bone fracture, history of falling, dementia (a progressive state of decline in mental abilities), epilepsy (a chronic brain disorder characterized by recurrent seizures, which are brief episodes of abnormal brain activity that can cause involuntary movements, loss of consciousness, or other symptoms), and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 1's History and Physical (H&P), dated 1/10/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P did not indicate diagnoses of osteoporosis or osteopenia (a condition characterized by low bone mineral density, which makes bones weaker and more prone to fractures). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/13/2025, the MDS, indicated Resident 1 had memory problems and severely impaired cognition (a significant decline in cognitive abilities that interferes with daily life and independence). The MDS indicated Resident 1 had impairments to her lower extremities (hip, knee, ankle, and foot) on both sides of her body. The MDS indicated Resident 1 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed. The MDS indicated diagnoses of lack of coordination and generalized muscle weakness. During a review of Resident 1's care plan titled At risk for fall, dated 1/10/2025, the care plan indicated staff were to provide frequent visual monitoring of Resident 1 to reduce the risk of falls and/or injury. During a review of Resident 1's Morse Fall Scale Assessment, dated 1/11/2025, the assessment indicated Resident 1 was at high risk for falls due to impaired gait (an abnormal walking pattern), and overestimation (judging something too highly), and/or forgetfulness of her ability to walk safely. During a review of Resident 1's Change of Condition (COC) assessment, dated 2/14/2025 at 3:10 PM, the COC indicated on 2/14/2025 Resident 1 had a witnessed fall, in the hallway. The COC indicated Resident 1 reported a 4 out of 10 pain (0: no pain, 1 to 3: mild pain, 4 to 6: moderate pain, and 7 to 10: severe pain) to her left hip. The COC indicated Resident 1 was administered Tylenol 650 milligrams (mg, a unit of dose measurement) for pain. The COC indicated Resident 1's physician was notified of the fall and the physician ordered for an immediate x-ray (a procedure that uses radiation to create images of the inside of the body) to rule out broken bones. During a review of the facility record titled Investigation Statement, dated 2/14/2025 at 3:10 PM, the record indicated a handwritten statement by Licensed Vocational Nurse (LVN) 1 regarding Resident 1's fall on 2/14/2025. The record indicated on 2/14/2025 (no time specified), Resident 1 was sitting in a wheelchair near the nurse's station. The record indicated LVN 1 was assisting another resident in the hallway when Resident 1 fell. During a review of Resident 1's COC assessment, dated 2/14/2025 at 9:45 PM, the COC indicated the x-ray revealed Resident 1 had an acute (severe and sudden in onset) left thigh bone fracture related to a witnessed fall. The COC indicated Resident got up unassisted and lost her balance . The COC indicated Resident 1 reported an 8 out of 10 pain. The COC indicated staff administered Norco 5/325 mg (a combination medication used to relieve severe pain when other pain medication was insufficient) for pain. The COC indicated Resident 1's physician gave an order for the resident to be a transferred to a GACH for evaluation and treatment of the left thigh bone fracture. During a review of Resident 1's progress note, dated 2/14/2025 at 11:45 PM, the progress note indicated Resident 1 was transferred to the GACH on 2/14/2025 at 11:30 PM. During a review of Resident 1's GACH record titled History and Physical, dated 2/15/2025 (untimed), the record indicated Resident 1 was brought to the GACH after falling onto her left side while trying to walk. The record indicated a plan to admit Resident 1 to the medical-surgical unit (a unit for patients recovering from surgery, preparing for surgery, or managing various medical conditions). During a review of Resident 1's GACH record titled Radiology Report, dated 2/15/2025 at 2:23 AM, the record indicated an x-ray was taken of Resident 1's left hip. The record indicated Resident 1 had a displaced subcapital left femoral neck fracture. During a review of Resident 1's facility progress note, dated 2/15/2025 at 1:42 PM, the progress note indicated Resident 1 was admitted to the GACH and in the process of being referred to, and evaluated by, an orthopedic physician (a physician who treats injuries and diseases involving muscles, bones, joints, ligaments, and tendons) for a possible left hip hemiarthroplasty (surgical replacement of half of the hip joint) related to her fracture. During a review of Resident 1's GACH record titled Discharge Summary Notes, dated 2/17/2025 at 8:07 AM, the record indicated a final diagnosis of acute left femoral neck fracture. The record indicated Resident 1's conservator (a person appointed by a court to manage her care) declined to provide consent for orthopedic surgery (a surgical procedure on the musculoskeletal system), and Resident 1 was to be discharged back to the facility. During a review of Resident 1's facility progress note, dated 2/18/2025 at 11:45 AM, the progress note indicated Resident 1 was re-admitted to the facility on [DATE]. During a review of Resident 1's medical record titled Routine Pain Assessment Flowsheet , undated, and Pain Assessment Flowsheet, undated, the records indicated Resident 1 received Norco 5/325 mg for the following pain levels: · On 2/20/2025 at 3:00 AM: 7/10 pain to her left lower extremity (leg). · On 2/20/2025 at 9:00 AM: 8/10 pain to her left lower extremity. · On 2/21/2025 at 5:00 AM: 7/10 pain to her left lower extremity. · On 2/21/2025 at 11:30 AM: 7/10 pain to her left lower extremity. · On 2/22/2025 at 9:00 AM: 8/10 pain to her left lower extremity. · On 2/22/2025 at 2:00 PM: 8/10 pain to her left lower extremity. · On 2/24/2025 at 9:00 AM: 8/10 pain to her left lower extremity. · On 2/25/2025 at 9:00 AM: 7/10 pain to her left lower extremity. · On 2/27/2025 at 9:00 AM: 8/10 pain to her left lower extremity. · On 2/27/2025 at 2:30 PM: 7/10 pain to her left lower extremity. During a telephone interview on 2/26/2025 at 9:14 AM, with LVN 1, LVN 1 stated she was Resident 1's Charge Nurse the afternoon of 2/14/2025, and was aware Resident 1 was at risk for falls. LVN 1 stated she was supervising Resident 1 at the nurse's station and there were no other staff present when Resident 1 fell. LVN 1 stated she did not ask any staff member to supervise Resident 1 before leaving the resident unattended at the nurse's station. LVN 1 stated she was down the hall from Resident 1, with her back towards the resident, when she heard Resident 1's wheelchair alarm. LVN 1 stated she turned around and saw Resident 1 standing up and holding onto the armrest of her wheelchair for support. LVN 1 stated she was too far away from Resident 1 to intervene, and she observed Resident 1 fall to the ground onto her left side. LVN 1 stated Resident 1 denied any pain during the shift, prior to the fall, but complained of pain to her left hip after the fall. LVN 1 stated she should not have left Resident 1 unattended and unsupervised at the nurse's station. LVN 1 stated the fall could have been prevented if Resident 1 was not left unsupervised. During a telephone interview on 2/26/2025 at 4:43 PM, with Registered Nurse (RN) 1, RN 1 stated Resident 1's care plan intervention of frequent visual monitoring meant Resident 1 should not be left unattended. RN 1 stated to implement this intervention, Resident 1 [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent an avoidable fall for one of one sampled resident (Resident 7) by failing to: 1. Provide Resident 7 with the required minimal assistance and supervision from staff when toileting. 2. Follow Resident 7's scheduled toileting plan and ensure the resident was assisted by staff to the toilet or offered a commode and/or bed pan as needed, upon waking in the morning, and before breakfast as per the facility's policy titled, Toileting Program. These deficient practices resulted in Resident 7's having an avoidable fall with subsequent transfer to a general acute care hospital (GACH) for treatment. Resident 7 was diagnosed with a right forehead laceration (deep cut in skin) with hematoma (pool of blood collecting under the skin) and an acute minimally displaced type 3 dens (neck bone) fracture (break in the bone). Findings: During a record review of Resident 7's admission Record (face sheet), the face sheet indicated Resident 7 was admitted to the facility on [DATE]. Resident 7's diagnoses included atrial fibrillation (abnormal heartbeat), heart failure (heart muscle does not pump blood as well as it should), difficulty walking, muscle weakness, type 2 diabetes (body cannot process glucose [sugar] normally), and dementia (general term of loss of memory, language, problem-solving and other thinking abilities). During a review of Resident 7's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/22/2022, the MDS indicated Resident 7 expressed ideas and wants and understood verbal content. The MDS indicated Resident 7 had severely impaired cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. The MDS indicated Resident 7 required limited one-person physical assistance (resident is highly involved in activity; received physical help in guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility and personal hygiene, and an extensive assistance with transfer, walking in the room and corridor, dressing, and toilet use. The MDS indicated Resident 7 was occasionally incontinent ([inability to control] less than seven episodes) of bladder but continent of her bowels. According to the MDS, Resident 7 was placed in the toileting program (scheduled toileting) with decreased wetness experienced because of the program. During a record review of Resident 7's Morse Fall Scale (used to estimate a resident's fall risk) initiated on 5/16/2022, the fall scale indicated Resident 7 was a high fall risk with a score of 80 (high risk indicates a score of 45 or more, moderate risk was between 25-44, small risk was for 0- 24) and had multiple risk factors that predisposed the resident to falls. The risk factors indicated Resident 7 had the following: 1. A history of falls, 2. Multiple medical diagnosis, 3. Used crutches, cane, or walker, 4. Weak gait (stooped but able to lift head without losing balance, steps are short and resident shuffles), and 5. A problem with overestimating or forgetting limits. During a record review of Resident 7's care plan titled, Self-care Deficit and activities of daily living ([ADL] daily tasks involving personal care) Decline, initiated 5/17/2022, the care plan indicated Resident 7 would be assisted with ADLs as needed. During a record review of Resident 7's care plan titled, Risk for Fall, initiated 5/17/2022, the care plan indicated Resident 7 would receive frequent visual monitoring, functional mobility training, bowel and bladder retraining, Occupational therapist ([OT] healthcare professional assists residents to develop, recover, improve, or maintain skills needed for working and daily living) assessment and toilet program as indicated. During a record review of Resident 7's Physical Therapy ([PT] medical specialist who help improve residents' movements) Evaluation and Plan of Treatment dated 5/17/2022, the evaluation indicated Resident 7 exhibited impaired coordination, muscle weakness and reduced functional activity tolerance (individuals' ability to tolerate completing their activities of daily living). The evaluation indicated Resident 7 was noted with decreased functional mobility and increased risk for falls. PT recommended treatment to improve functional mobility and promote safety awareness. Treatment approaches may include therapeutic activities and exercises, and gait training therapy. During a review of Resident 7's OT Evaluation dated 5/17/2022, the evaluation indicated Resident 7 needed minimal assist (resident requires small amount of help to accomplish activity and requires no more help than touching and expends 75 percent or more of the effort) with toileting. During a record review of Resident 7's Certified Nurse Assistant (CNA) ADL flow sheet, regarding toilet use, the flow sheet, for the month of June 2022, indicated CNA did not provide a one-person physical help and minimum assistance to Resident 7 for the following dates: a. From 6/1/2022 to 6/6/2022 and 6/10/2022. CNA guided the resident with no physical assist b. On 6/11/2022 (date of Resident 7's fall), no documented evidence of any type of CNA assistance noted. During a record review of Resident 7's Bowel and Bladder Assessment (tool used to determine how the facility needs to address a resident's toileting needs) dated 5/17/2022, the assessment indicated Resident 7 scored a 16, (score of 0 to 15 meant candidate for bowel and bladder training, 16 to 19 meant the resident should be on a scheduled toileting plan, 20 or above the resident was not a candidate for toileting program nor bowel and bladder training) which indicated Resident 7 should be on a scheduled toileting plan. The assessment indicated Resident 7 was identified as having the following triggers: 1. Frequently incontinent for one or more years. 2. Occasionally incontinent with bowels. 3. Confused. 4. Diagnosed with an old stroke (blood flow to brain is stopped and can cause numbness or weakness or confusion or loss of balance) or debilitating disease (disease that affects physical abilities that affect brain function and impair thought process). 5. Uncooperative. 6. Requiring one person assist with transfer and ambulation with or without assistive devices. 7. High risk for dehydration (condition when person use or lose more fluids than the person takes in). During a record review of Resident 7's Scheduled Toileting Plan for the month of June 2022, there was no documented evidence Resident 7 was assisted to the toilet or offered a urinal/ commode/ bed pan as scheduled on 6/10/2022 and 6/11/2022 (day of the fall) on the night and day shifts. During an interview with Licensed Vocational Nurse (LVN) 1 on 6/24/2022 at 10:59 a.m., LVN 1 stated he was doing a medication pass on 6/11/2022 at approximately 8:40 a.m., when LVN 1 responded to Registered Nurse (RN) 1's call for assistance in Resident 7's restroom. LVN 1 stated upon entry to Resident 7's restroom, Resident 7 was observed sitting upright on the floor of the restroom. LVN 1 stated there was blood observed on the floor and on Resident 7's head. LVN 1 stated Resident 7 reported she was trying to use the restroom and fell. LVN 1 stated Resident 7 did not use the call light. LVN 1 stated he assessed Resident 7, applied pressure to the resident's head, rendered first aid, and called 911. LVN 1 stated Resident 7 was transferred to a general acute care hospital (GACH) for further evaluation. During a concurrent interview and record review on 6/24/2022 at 11:05 a.m. with RN 1, Resident 7's Morse Fall scale dated 6/11/2022, was reviewed, RN 1 stated from 5/17/2022 to 6/11/2022, Resident 7 walked to the restroom unassisted and independently. RN 1 stated Resident 7 would hold on to things or furniture to keep her balance. Resident 7's Morse fall scale dated 6/11/2022 indicated Resident 7 used furniture for support, she was weak and had a history of falling. Per document, Resident 7 overestimates and forgets limits. RN 1 stated Resident 7 needed a one-person physical assist. RN 1 stated she was doing morning rounds on 6/11/2022, at approximately 8:30 a.m. she noticed Resident 7 was not in her bed. RN 1 stated she went to Resident 7's restroom., at approximately 8:40 a.m., and observed Resident 7 sitting on the restroom floor. RN 1 stated she called for help. During a telephone interview with Certified Nurse Assistant (CNA) 2 on 7/15/2022 at 2:58 p.m., CNA 2 stated on the morning of 6/11/2022, before the breakfast trays came out, CNA 2 assisted Resident 7 up out of bed and onto her wheelchair. CNA 2 stated she did not assist Resident 7 to the restroom when Resident 7 woke up nor before breakfast. CNA 2 stated by the time she returned to Resident 7's room at approximately 8:30 a.m., the nurses were in the room and Resident 7 was observed on the restroom floor. During a telephone interview with CNA 3 on 7/15/2022 at 4 p.m., CNA 3 stated she knew Resident 7 urinated a lot. CNA 3 stated Resident 7's functional ability for toileting varied. CNA 3 stated sometimes staff would supervise, and sometimes staff would provide limited to extensive assistance to Resident 7. During a concurrent interview and record review on 7/18/2022 at 12:10 p.m. with LVN 3, Resident 7's scheduled toileting plan for the month of June 2022 was reviewed, LVN 3 stated from 5/17/2022 to 6/11/2022, Resident 7 usually went to the toilet by herself. LVN 3 stated Resident 7 was occasionally supervised meaning staff just looked at the resident and no physical assistance was involved. LVN 3 confirmed there was no documented evidence that Resident 7 was taken to the restroom before breakfast on 6/10/2022 and 6/11/2022; and as needed upon waking during the night shift (11 p.m. to 7 a.m.) on 6/11/2022. LVN 3 stated Resident 7's scheduled toileting plan for the month of June 2022 indicated the night shift before Resident 7 fell, for eight (8) hours on 6/11/2022, and approximately one (1) hour during the day shift before breakfast, on the day she fell, Resident 7 was not assisted to the toilet or offered a commode and/or bed pan as scheduled. LVN 3 stated since Resident 7 was on a toileting schedule plan, the CNAs should have taken the resident to the restroom when she woke up, before breakfast, and as needed on 6/11/2022. LVN 3 stated not taking Resident 7 to the restroom as scheduled increased the risk of incontinence and increased the risk that Resident 7 would attempt to go to the bathroom by herself. LVN 3 stated it was not safe because Resident 7 did not call for help and she was a high risk for falls. During an interview with the Director of Nurses (DON) on 7/18/2022 at 12:27 p.m., the DON stated staff should have assisted Resident 7 to the restroom as indicated in the occupational therapist (OT) assessments and MDS assessments. The DON stated CNAs should have also taken Resident 7 to the bathroom before breakfast and when she woke up on 6/11/2022 AM shift. The DON stated doing so might have prevented Resident 7 from walking to the restroom herself and falling. During a record review of Resident 7's GACH History and Physical (H/P) dated 6/11/2022, the H/P indicated Resident 7 reported going to the restroom three times but did not remember the fall. The H/P indicated Resident 7 complained she had been urinating a lot and reported the dysuria (discomfort or burning urination) to staff. Resident 7's right eyebrow laceration was repaired with sutures (sterile surgical threads used to repair cuts) and Resident 7 was admitted to the hospital for continued evaluation. During a record review of Resident 7's Computed Tomography ([CT] diagnostic imaging that produces images of the inside of the body showing bones, muscles, fats, organs, and blood vessels) of the Head without contrast (a dye or other substance that helps show abnormal areas inside the body) completed on 6/11/2022 at 11:17 a.m., the CT findings indicated right fontal scalp (right forehead area) laceration (cut through the skin) and hematoma (pool of blood under the skin). During a record review of Resident 7's CT of the Spine Cervical (back and neck) without contrast dated 6/11/2022 at 11:32 a.m., the CT findings indicated an acute minimally displaced type 3 dens (neck bone) fracture (break in the bone) with broken bone through the cervical 2 vertebrae [also called the axis or the neck bone, part that enables head rotation]). During a record review of Resident 7's Neurosurgery (specializing in injury or disorders of brain, spinal cord and spinal column, and peripheral nerves) Consult Note dated 6/18/2022 at 8:03 a.m., the note indicated no surgical intervention at present time but Resident 7 needed to wear a cervical collar (medical device used to support a person's neck) at all times and follow up in the Neurosurgery Clinic in 6 weeks. During a record review of facility's undated policy and procedure (P/P) titled, Toileting Program, the P/P indicated the toileting program was to promote continence with bladder function and attempt to decrease episodes of incontinence in residents. The P/P indicated the resident will be assisted to the toilet, commode or offered a bed pan or urinal upon awakening, after meals, after naps and before bed. Toileting will be offered every three to four hours during waking hours and at least two times during sleeping hours. The P/P indicated the toileting will be documented in the plan of care. During a record review of the facility's P/P titled, Falls and Fall Risk Managing, revised 10/2020, the P/P indicated 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. The staff, with the input and interdisciplinary team, will identify appropriate interventions to reduce the risk of falls. During a record review of the facility's undated LVN job description, the job description indicated the LVN implements the resident plan of care and evaluates resident response. The job description indicated the LVN was responsible for providing direct nursing care to the residents and supervision of nursing activities performed by nursing assistants in accordance with current federal, state, and local standards, guidelines and regulations and company policies and procedures to ensure that the highest degree of quality care was always maintained.