**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the residents' environment remained as free of accidents or hazards as possible to prevent falls for one (#59) of five residents reviewed for falls out of 48 sample residents. Resident #59, who had a history of falling, required the use of a sit-to-stand mechanical lift for transfers. Per staff interviews (see interviews below), the use of the sit-to stand mechanical lift required that two staff members were present during resident transfers. On the night of 7/31/24, Resident #59 was being transferred to bed by a certified nurse aide (CNA). The CNA did not have another staff member present during the transfer and the resident sustained a fall. The CNA alerted the licensed practical nurse (LPN) to the resident's fall and the CNA and the LPN assisted Resident #59 back to her bed. On 8/1/24 Resident #59 was noted to have visible bruising and swelling to her right wrist and the day shift nurse called the physician who requested the resident be transferred to the hospital for further evaluation of her wrist. Resident #59 was diagnosed with a displaced fracture distal right radial metaphysis (a break at the end of the forearm bone near the right wrist) at the hospital. The facility investigated the fall and implemented immediate corrective actions and education to ensure staff were aware that all mechanical lift transfers required the use of two staff members. Although the facility implemented immediate changes in regards to Resident #59's fall with fracture due to the improper transfer with the mechanical lift, observations during the survey (see observations below) revealed the facility continued to have deficient practice in the area of accidents/hazards due to the facility staff failing to ensure fall interventions for Resident #59 were consistently in place. Findings include: I. Facility policy The Fall Risk Assessment policy, revised March 2018, was provided by the nursing home administrator (NHA) on 9/19/24 at 11:33 a.m. It read in pertinent part: The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff and others will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. The Falls Clinical policy, revised September 2012, was provided by the NHA on 9/19/24 at 11:33 a.m. It read in pertinent part: If the interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the interventions is resolved. II. Resident #59 A. Resident status Resident #59, age greater than 65, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included a fracture to the lower end of the right radius, anxiety disorder, epilepsy, dementia, chronic diastolic (congestive) heart failure, muscle weakness and repeated falls. The 8/14/24 minimum data set (MDS) assessment revealed Resident #59 had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. Resident #59 had an impairment to one of her upper extremities and used a wheelchair. B. Observations On 9/18/24 at 9:49 a.m. Resident #59 was sitting in her wheelchair in her room. The resident's call light was hanging behind her and was out of her reach. At 9:56 a.m. the interim director of nursing (IDON) entered the resident's room and placed the call light within the resident's reach. On 9/19/24 at 9:56 a.m. Resident #59 was asleep in her bed. The bed was in the lowest position, however a fall mat was not on the floor next to the bed. The fall mat was tucked in on the side of the closet. At 10:04 a.m. certified nurse aide (CNA) #2 entered Resident #59's room and placed the fall mat on the floor by the bed as the resident continued to sleep. C. Record review Resident #59 experienced a fall on 8/1/24. The facility failed to use the mechanical lift according to the facility's protocol which resulted in the resident falling to the floor which resulted in a fractured lower end of the right radius. The 8/6/24 interdisciplinary at risk note progress note documented a CNA reported Resident #59 slipped off the bed and onto the floor. She stated she had placed the resident on the bed, moved the lift and saw the resident start to slide. The CNA said the resident leaned to the right, struck the trash can with her right arm and then was able to sit herself up into a sitting position. The progress note documented the root cause of the fall was the resident was not positioned far enough back on the bed. Current interventions were a Call don't fall sign, anticipate the resident's needs, toilet with assistance and proper footwear. New interventions implemented were for the resident to be a full mechanical Hoyer lift with two staff members present during transfers. A physician's note dated 9/6/24 documented Resident #59 had functional impairments with potential high risk for frequent falls. The note documented the resident was on Keppra (a medication used to treat seizures/epilepsy) 500 milligrams (mg) two times per day. The note documented the resident was on fall precautions and staff was to monitor for neurological changes. The note further documented the resident had significant cognitive deficits and was at high risk of falls with physical injury. Resident #59's activities of daily living (ADL) care plan, revised on 9/16/24 (during the survey), revealed the resident had limitations in her ability to perform her ADLs. Interventions included providing extensive assistance with bed mobility, dressing and personal hygiene and transferring the resident with two staff using the medium yellow sling and the Hoyer lift. Resident #59's fall care plan, revised on 8/21/24, revealed the resident was at risk for falls due to a history of falling, decreased mobility, diabetes and hypertension (blood pressure) medications. Interventions included keeping the call light within reach and encouraging the resident to use the call light for assistance, promptly responding to the resident's call light (initiated 8/8/22), low bed and fall mat while in bed (initiated 8/5/24), posting a sign encouraging the resident to call for assistance (initiated 8/5/24) and placing a touch call light within reach (initiated 8/19/24). -However, the facility failed to ensure Resident #59's call light was within reach and the fall mat was on the floor by the resident's bed (see observations above). III. Staff interviews The IDON was interviewed on 9/18/24 at 9:56 a.m. The IDON said Resident #59's call light was supposed to be within reach of the resident. CNA #2 was interviewed on 9/19/24 at 10:04 a.m. CNA #2 said Resident #59 was a fall risk and needed the fall mat on the floor by her bed. CNA #2 said the fall mat was previously on the floor but she said she moved it when she assisted the resident earlier and forgot to put the fall mat back. Corporate consultant (CC) #2 was interviewed on 9/19/24 at 10:45 a.m. CC #2 said on 8/1/24 the day shift registered nurse (RN) noted Resident #59's arm was swollen and tender and the RN obtained a physician's order for an immediate x-ray. CC #2 said an investigation was started because the resident's fall resulted from a CNA transferring the resident with a sit-to-stand lift without a second staff person present. CC #2 said the licensed practical nurse (LPN) from the night of the fall (7/31/24) did not identify any problems or pain with the resident and the resident's representative was not notified right away. CC #2 said the CNA transferred the resident back to bed along with the LPN and the LPN admitted he did not follow the proper steps after a fall. She said the CNA used the sit-to-stand alone and transferred the resident into bed. CC #2 said the CNA notified the LPN the resident fell. CC #2 said the CNA and LPN were suspended pending the facility investigation. CC #2 was interviewed again on 9/19/24 at 11:36 a.m. CC #2 clarified Resident #59 was transferred to the side of her bed and her feet were still on the base of the sit-to-stand when the CNA pulled the lift away from the resident. CC #2 said this was what caused Resident #59 to fall. IV. Facility follow-up The NHA provided follow-up documentation (after the survey) on 9/23/24 at 5:36 p.m. It read in pertinent part: The community self-identified some concerns related to the facility will ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and resident choices. The facility will ensure that the fall management policy is followed per corporate and state regulations. Corrective action: 1. A resident (Resident #59) was sent to the emergency room (ER) for an x-ray due to a change in pain rating, and a swollen wrist and arm. The resident had a fall on 7/31/24. 2. An investigation started immediately upon the radiology report findings. 3. The nurse who failed to document fall assessment, post fall follow up and notification of family was suspended on 8/7/24. 4. Interview with resident, NHA and social worker on 8/6/24. 5. Spoke with resident's daughter on 8/5/24. 6. Notified the medical director (MD) on 8/1/24. 7. CNA suspended pending investigation on 8/5/24. All residents that reside in the facility are at potential risk as every resident has the potential of falling. Facility will review the last 30 days of resident falls to identify any injury that might have occurred and went unreported or unassessed. Facility will review the last two weeks of the 24-hour report to identify any change of condition that was not assessed and followed up on. Issues identified will be addressed at that time. Facility will review residents who require mechanical lift transfers and ensure transfer status is on the residents' care plan. Starting 8/5/24, all nursing staff will be educated by the director of nursing (DON) or designee on ensuring two staff are present for all mechanical lift transfers, the facility fall management and investigation policy, to include safe positioning of resident in a bed, documentation required post fall including assessment and notification of resident after a fall. An attendance sheet will be reconciled with an active staff roster and nursing staff that were unable to attend will be provided with one-on-one re-education. The interdisciplinary team (IDT) will review each business day any concerns from the prior business day and ensure residents who have experienced any change in condition have been appropriately assessed and any follow up has been documented and reported to family and MD. The DON or designee will conduct record reviews post fall to ensure policy and procedures were followed weekly for four weeks, then monthly for two months, then as needed thereafter. DON or designee will observe three random staff utilizing a mechanical list weekly for four weeks, then monthly for two months, then as needed thereafter. Any non-compliance finding will be dealt with immediately. All findings will be tracked and trended and reported to the quality assurance performance improvement (QAPI) committee monthly for three months and then as needed to ensure the plan is implemented, sustained and evaluated for its effectiveness. Date of compliance was 8/9/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#34) of three residents out of 50 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Resident #34 was admitted to the facility for long-term care on 6/30/24 with diagnoses of age-related osteoporosis, hypokalemia (low potassium levels in the blood), hypocalcemia (low calcium levels in the blood), hypomagnesemia (low magnesium levels in the blood), cognitive communication deficit and cerebral infarction (stroke). Upon admission, on 6/30/24, the resident weighed 103.4 pounds (lbs). The 7/2/24 nutritional evaluation determined the resident was malnourished. The facility implemented snacks three times a day, however the facility did not have a system in place to monitor the resident's acceptance of the nutritional intervention. The resident's weight continued to decrease. On 9/17/24, Resident #34 weighed 87.5 lbs. Resident #34 had sustained a 15.9 lbs weight loss in three months (15.38%), which was considered a severe weight loss.The facility failed to implement person centered nutritional interventions when the resident's weight continued to decline until the resident sustained severe weight loss. Additionally, the facility failed to provide the resident with adequate assistance during meals and offer the resident meals. Findings include: I. Professional reference Treating Weight Changes in Long-Term Care, published 6/14/22, was retrieved on 9/25/24 from https://dietitiansondemand.com/treating-weight-changes-in-long-term-care/ It read in pertinent part, Any time a nutrition intervention is ordered or discontinued, the nutrition plan of care should reflect the current status of the resident. This helps keep everyone on the same page. A nutrition intervention is only effective when it is implemented. Be sure to communicate any changes to the nutrition plan of care with nursing and other clinical staff. II. Resident #34 A. Resident status Resident #34, age greater than 65, was admitted on [DATE]. According to the September 2024 computerized physician order (CPO), diagnoses included age-related osteoporosis, hypokalemia, hypocalcemia, hypomagnesemia, cognitive communication deficit and cerebral infarction. The 8/22/24 minimum data set (MDS) assessment revealed Resident #34 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment indicated the resident could eat independently. -However, observations revealed the resident had difficulties eating and spilled food on herself and the floor related to her tremors. The 7/4/24 MDS assessment documented the resident was 60 inches tall (five foot) and weighed 102 lbs. It indicated the resident had not had any significant weight gain or weight loss in the last six months. The MDS assessment did not indicate the resident had swallowing difficulties. B. Observations and interviews On 9/16/24 during a continuous observation, from 10:30 a.m. to 11:30 a.m., the following was observed: At 10:50 a.m. Resident #34 was in the dining room. Resident #34 was eating independently. Resident #34 was served french toast, eggs, sausage, bacon and toast. The resident's upper extremities were shaking with tremors. Resident #34 scooped some food on her spoon and as she lifted the spoon to her mouth, her tremors caused the food to fall off the spoon before she got the spoon to her mouth. Resident #34 was not offered assistance during the entire brunch meal. Resident #34 left the dining room at approximately 11:30 a.m. The majority of the residents' food was on the floor. On 9/17/24 during a continuous observation of the dinner meal, beginning at 5:00 p.m. and ending at 5:19 p.m., the following was observed: At 5:00 p.m. Resident #34 was in bed and she received her meal. The resident was served mechanical soft salisbury steak, green beans, mashed potatoes with gravy and peach cobbler. At 5:05 p.m. the resident took two bites of her dinner. She began to cough. At 5:19 p.m. certified nurse aide (CNA) #4 removed Resident #34's tray. Resident #34 had only eaten two bites of her dinner. CNA #4 did not offer an alternative meal option. The resident had her meal for 19 minutes before it was removed and she was not offered assistance to eat. On 9/19/24 at 1:30 p.m. CNA #2 began passing the siesta meal which consisted of two pieces of cheese and three crackers with lemonade. At 1:43 p.m. CNA #2 returned the meal cart to the kitchen. The residents who resided on Resident #34's hallway were not offered the siesta meal, including Resident #34. CNA #2 was interviewed at 1:45 p.m. CNA #2 said she returned the cart with cheese and crackers to the kitchen when all of the residents were served. CNA #2 said she picked up the meal cart at the beginning of the hallway and turned left down the smaller hallway. CNA #2 said she was not aware Resident #34's hallway was not served the siesta meal. At 1:48 p.m. CNA #2 removed the siesta meal cart from the kitchen and served the siesta meal to Resident #34 and the other residents on her hall. The resident took a few bites of the crackers but did not eat the cheese. The resident did not receive any assistance to eat. On 9/19/24 at 6:55 p.m. Resident #34 was lying in bed. She had her head slightly lifted and was eating a shake with a spoon. Resident #34 had spilled the shake on herself. Resident #34 said she needed assistance with eating. CNA #5 was interviewed at 6:57 p.m. CNA #5 said Resident #34 was independent with eating and was able to feed herself. CNA #5 said she was going to check on the resident. C. Record review Resident #34's nutritional care plan, initiated on 7/1/24, revealed the resident was at risk for the inability to maintain her nutrition. Interventions implemented on 7/1/24 included inviting the resident to activities that promoted additional intake, monitoring, documenting and reporting signs or symptoms of dysphagia (swallowing difficulties), monitoring, documenting and reporting signs or symptoms of malnutrition, occupational therapy screening and providing the resident with adaptive equipment for feeding as needed, providing and serving a no added salt diet as ordered per the family's request and recording each meal, the registered dietitian (RD) was to evaluate and make diet change recommendations as needed, speech pathology screening as needed and weighing the resident per facility protocol. Resident #34's activities of daily living (ADL) care plan, revised on 7/29/24, revealed the resident ate food independently. Resident #34's nutrition care plan, revised on 9/3/24, revealed the resident had a Carnation shake (nutritional supplement) added to each meal tray. Resident #34's weights were documented in the resident's electronic medical record (EMR) as follows: -On 6/30/24 Resident #34 weighed 103.4 lbs; -On 7/1/24 Resident #34 weighed 102 lbs; -On 7/10/24 Resident #34 weighed 98.7 lbs; -On 7/16/24 Resident #34 weighed 100.6 lbs; -On 7/23/24 Resident #34 weighed 97.6 lbs; -On 7/30/24 Resident #34 weighed 98.9 lbs; -On 8/1/24 Resident #34 weighed 98.4 lbs; -On 8/13/24 Resident #34 weighed 96.2 lbs; -On 8/20/24 Resident #34 weighed 96.7 lbs; -On 8/27/24 Resident #34 weighed 92.6 lbs; -On 9/2/24 Resident #34 weighed 90.6 lbs; -On 9/10/24 Resident #34 weighed 89.7 lbs; and, -On 9/17/24 Resident #34 weighed 87.5 lbs. -Resident #34 sustained a 7.8 lbs (7.9%) weight loss from 8/1/24 to 9/2/24 in one month, which was considered severe. -Resident #34 lost 15.9 lbs (15.38%) from 6/30/24 to 9/17/24 in three months, which was considered severe. A skilled evaluation note entered in Resident #34's EMR on 6/30/24 revealed the resident was able to orally take in nutrition and hydration. The resident had no symptoms of a swallowing disorder. Difficulty in chewing was documented. The resident was offered assistance with meals which included set up and feeding assistance as needed and nutritional supplements were ordered with meals. The 7/2/24 mini nutritional assessment (MNA) revealed the resident weighed 102 lbs on 7/1/24 and the resident did not have a decreased food intake. The resident was unaware if she had lost any weight in the past three months. The resident was able to get out of her bed or chair but was not eating in the dining room. Resident #34 suffered psychological stress in the past three months and the resident had mild dementia. Resident #34 scored a six out of 14 on the nutritional assessment, which indicated she was malnourished. The 7/2/24 dietary profile revealed the resident was prescribed a no added salt diet, regular food texture and thin liquids. The assessment indicated the resident was not taking nutritional supplements before she was admitted to the facility and was not taking nutritional supplements at the time of the assessment. Resident #34 needed partial assistance during meals. On 7/6/24 Resident #34's diet order was changed to a no added salt diet, regular texture and thin liquids. The 7/9/24 nutrition risk review note revealed the resident was admitted on a regular diet that was changed based on the family's request. Resident #34 was able to eat with set up assistance at meals and her intakes were improving. The nutrition risk review note recommended offering snacks three times a day and weekly weights for four weeks then monthly weights if Resident #34's weight was stable. -Review of the resident's EMR indicated the resident was consuming 0 to 25% of the snacks the majority of the time in the last 30 days. -The task for eating support documented (from 8/21/24 to 9/19/24) revealed the resident required supervision with eating 37 times out of 150 meals, 17 times she required limited assistance out of 150 meals and four times required extensive assistance out of 150 meals. On 7/16/24 Resident #34's diet order changed from a no added salt diet, regular texture and thin liquids to a no added salt diet, mechanical soft texture and nectar thickened liquids. On 8/5/24 Resident #34's diet order changed from a no added salt diet, mechanical soft texture and nectar thickened liquids to a no added salt diet, mechanical soft texture and thin liquids. The 8/28/24 physician note revealed the nurse practitioner (NP) was notified the resident had lost some weight and the nurse thought the resident was feeling depressed. The resident confirmed with the NP that she was depressed and not having much of an appetite. The resident was offered Remeron antidepressant (medication used as an appetite stimulant) and declined. The 9/3/24 weight change note documented the resident had lost 5.2 % of her weight in one month. The resident was offered Remeron by her provider and refused, though the resident also had some depression. The registered dietician (RD) offered a protein shake with each meal and the resident agreed. The RD recommended liberalizing the resident's no added salt diet due to poor intake. The 9/17/24 nutrition note revealed the interdisciplinary team (IDT) notified the staff that the resident needed assistance at meals. The 9/18/24 weight change note revealed the resident lost 9.3% of her weight in one month and a severe weight change was noted. The resident needed more assistance during meals and the resident's EMR indicated needing anywhere from set up assistance to being fully dependent on staff during meals. The RD encouraged the resident to eat her meals in the dining room at the assistance table. The resident agreed to use Remeron for depression and increased appetite. The resident was accepting Carnation supplements 50 percent of the time. The RD encouraged small and frequent meals and ordered MedPass 60 milliliters (ml) three times a day and monitored weights weekly. -A review of the resident's EMR did not include documentation indicating the facility was monitoring the amount the resident was consuming of the Carnation supplement to determine if it was an effective intervention. A review of the September 2024 CPO revealed the resident had the following physician's orders: Carnation Breakfast Essential (nutritional supplement) two times a day, ordered on 9/3/24. Obtain weekly weights due to significant weight loss, ordered on 9/9/24. Mirtazapine (Remeron) seven and a half milligrams (mg) every day for an appetite stimulant, ordered on 9/12/24. TwoCal (nutritional supplement) three times a day, ordered on 9/17/24. III. Staff interviews Registered nurse (RN) #2 was interviewed on 9/18/24 at approximately 4:30 p.m. RN #2 said Resident #34 was able to feed herself, but she required supervision and encouragement. She said at times the resident fed herself better than other days as she had had a decline. The registered dietitian (RD) was interviewed on 9/19/24 at 3:39 p.m. The RD said Resident #34 had a severe weight loss of 9.3% within a month (8/18/24 to 9/18/24). The RD said she started the resident on a protein shake and the resident was offered an appetite stimulant but the resident refused the medication at the time. She said Resident #34 had a diet change which liberalized her previous diet. The RD said Resident #34 was on weekly weights and a TwoCal nutritional supplement in addition to the Carnation shakes she received at meals. The RD said the shake consisted of peanut butter, banana and heavy cream. The RD said if the resident had not eaten her meal, the staff needed to offer an alternative meal. The RD said she spoke to Resident #34 on 9/18/24 and she agreed to have more assistance from staff during her meals. The RD said when she had spoken to the resident, she put out a communication to the interdisciplinary team so they would be aware of the changes. The RD said she sent the changes for Resident #34 on 9/18/24 at 3:29 p.m. from her conversation with the resident that she would like to have assistance with meals. The RD said she also updated Resident #34's [NAME]. She said Resident #34 was on a mechanical soft texture and was not supposed to receive crackers from the siesta meal. The RD said she relied on the nursing staff to ensure everyone received their meals since the facility offered five meals a day and that residents were not skipped. The interim director of nursing (IDON) was interviewed on 9/19/24 at 4:00 p.m. The IDON said Resident #34 fed herself independently but needed more cueing and assistance. The IDON said the RD was reviewing the resident and Resident #34 was also reviewed in the nutrition at-risk meeting. The dietary manager (DM) was interviewed on 9/19/24 at 4:30 p.m. The DM said the facility provided five meals a day, per the residents' preferences. The five meals included continental breakfast that was served at 7:00 a.m., brunch that was served at 10:30 a.m., siesta that was served at 1:30 p.m., dinner was served at 4:00 p.m. and the nightcap meal was served at 6:30 p.m. The DM said the facility did not have a system in place to track the five meals offered on the facility's meal plan or snacks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** V. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the March 2022 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbance, depressive disorder, type 2 diabetes, hypertension and COVID-19. The 12/25/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of four out of 15. She required extensive assistance of two people with bed mobility, dressing, toilet use, personal hygiene, limited assistance of two people with transfer, and extensive assistance of one person with eating. The resident resided in the memory care unit. B. Observation On 3/14/22 at 12:47 p.m., Resident #2's bed position was very high. It was positioned sideways so Resident #2 was facing the window and the bed height was above the window sill which was approximately four feet. There was no fall mat near the bed. At 4:53 p.m., Resident #2's bed remained in the same position and height. Registered nurse (RN) #1 went in to assist Resident #2 with eating pudding. RN #1 stood while providing assistance due to the bed height. The bed height was near RN #1's shoulder position when standing. The RN #1 was observed to leave the room and the resident remained in the high position in bed. There was no fall mat near the bed. Resident #2's bed remained in the same position and height during the next three days from 3/15/22 to 3/17/22 when observed between 9:00 a.m. to 5:00 p.m. There was no fall mat near the bed. C. Record review The fall risk care plan, revised on 6/21/21, revealed Resident #2 was at an increased risk for falls related to dementia with poor safety awareness, the use of antidepressant and antipsychotic medications, diagnosis of diabetes and hypertension. -The care plan did not indicate elevated bed height as a potential fall risk factor. -There was no care plan indicating if elevated bed height was a personal preference. The activity of daily living (ADL) care plan intervention dated on 3/15/22 revealed Resident #2 was in end stage dementia and bed bound most of the time. She required total dependence of two people using a mechanical lift for transfers getting out of bed. -However, the care plan did not provide any direction on the resident bed height. D. Staff Interview Certified nurse aide (CNA) #2 was interviewed on 3/17/22 at 11:39 a.m. She said Resident #2 liked to look out the window, they kept it up high because it was her quality of life to look out at the window. She said the bed was originally at the regular height. The bed could be adjusted up and down, it had been elevated for a couple of months. The hospice registered nurse (HRN) was interviewed on 3/17/22 at 11:45 a.m. She said Resident #2 enjoyed looking out the window. The HRN said she had observed Resident #2's bed in the high position when she visited. She had educated the staff about lowering the bed recently. She said a bed that high could pose danger to anyone, those you think can't move are the ones that end up moving. She said it would be best to lower the bed. The social service director (SSD) was interviewed on 3/17/22 at 3:12 p.m. The SSD said she was not aware Resident #2's bed was in a high position.She said she did not think staff was supposed to keep the bed that high. She knew Resident #2 liked to look out the window, but keeping the bed up high was not one of the family's requests during care plan meetings. The director of nursing (DON) was interviewed on 3/17/22 at 6:30 p.m. The DON said said the bed was elevated in the high positon for her to look out the window, and the staff would lower the bed when it got dark outside. She said it would be safe since Resident #2 could not move and could not roll off the bed. Based on record review, observations and interviews, the facility failed to ensure four (#15, #16, #49, and #2) of five residents received adequate supervision to prevent accidents out of 40 sample residents reviewed. Specifically, the facility failed to develop and implement a person-centered care plan that identified the resident's fall risk and put effective interventions into place to reduce falls and prevent injury for Resident #15, #16 and #49. Resident #15 was identified as a fall risk within the comprehensive care plan. The facility failed to identify the resident's patterns throughout the day and put personalized and effective interventions into place to prevent falls. The fall risk care plan was put into place on 1/4/18 which identified the resident as a fall risk. On 6/25/21, Resident #15 fell in her room and sustained a fracture to the right clavicle, fracture to the right maxillary sinus, subdural hematoma (blood on the brain) and had stitches around her right eye requiring hospital treatment. The facility put a room camera in her room with a monitor at the nursing station and a low bed with a safety mat. After the initial fall and major injury, the resident fell an additional six times, one with another major injury on 9/6/21, a distal radius fracture (two forearm bones on the thumb side) and ulna fracture (forearm bone on the pinky finger side). Resident #16, who was a documented fall risk upon admission to the facility, fell on [DATE] and sustained a distal clavicle fracture. The facility failed to put person-centered approaches in place to prevent falls and subsequent major injury. Resident #49 was documented to be at an increased risk for falls. The resident sustained two falls within two days. The facility failed to put any person centered approaches in place to prevent additional falls. Furthermore, the facility failed to update each resident's plan of care with person-centered approaches and evaluate interventions already in place for effectiveness to prevent further falls and injuries. In addition, the facility failed to ensure Resident #2's bed was in a safe position. Findings include: I. Facility policy and procedure The Fall Management policy and procedure, undated, was provided by the nursing home administrator (NHA) on 3/17/22 at 7:00 p.m. It revealed, in pertinent part, A careful review and analysis of the possible contributing factors with or without injuries is completed using the QAPI (quality assurance and performance improvement) post fall investigation form. The director of nursing (DON), or designee, analyzes the results for trends and patterns in the resident's falls to use as a basis for implementation of process improvement. The resident's attending physician reviews individual cases with multiple falls, to modify interventions as indicated. II. Resident #15 A. Resident status Resident #15, age [AGE], was admitted on [DATE] and readmitted [DATE]. According to the March 2022 computerized physician orders (CPO), the diagnoses included dementia without behavioral disturbance, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, displaced fracture of the shaft of the right clavicle (6/25/21), and muscle wasting. The 1/29/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. She required extensive assistance of one person with bed mobility, transfers, dressing, toileting and personal hygiene. She required limited assistance of one person for walking in the room and corridor. It indicated the resident had one fall since her admission or prior assessment with no injury. B. Observations During a continuous observation on 3/16/22 beginning at 9:30 a.m. and ended at 12:30 p.m. the following was observed: -At 9:30 a.m. Resident #15 was observed sitting in her wheelchair in her room. She was in front of her night stand going through the drawers. She said she was leaving and needed to pack her room. She said he needed boxes. -At 10:21 a.m. the activity staff member entered the resident's room. He provided the daily chronicle to the resident and then exited the resident's room. -At 10:46 a.m. the resident wheeled herself down the hallway from the dining room to the nursing station. She asked licensed practical nurse (LPN) #1 if her dad was there. The nurse told her no and the resident wheeled herself down the hallway and into her room. LPN #1 continued to sit at the nursing station and typing on the computer. A video monitor system was added after the resident's fall on 6/25/21 to monitor the resident's movement, in which the camera was located on a table in the room pointed at her bed. She did not look at the video monitors at the nursing station. The sound on the monitor indicated it was on mute. There was no other way for the staff to be notified if the resident had movement other than the monitor located at the nursing station. -At 10:48 a.m. Resident #15 returned to the nursing station and asked for the phone. LPN #1 told her to wait for a few minutes. Resident #15 asked if she could reach for the phone. LPN #1 said no. A few minutes later, LPN #1 handed the resident the phone. The resident asked for the nurse to assist her with the phone number and the nurse asked her to wait while she answered a phone call. A few minutes later, LPN #1 asked the resident for the phone number. RN #2 did not turn the portable phone on, but pushed the numbers. She told the resident the phone was not working. The director of nursing (DON) arrived and asked the resident if she could take her down to the dining room. Resident #15 said she wanted to make a phone call. The DON told the resident she could make a phone call after the resident ate in the dining room. The DON then wheeled the resident to the dining room. -At 11:13 a.m. Resident #15 returned to the nursing station and asked to use the phone. LPN #1 told the resident the phone was not working and to come back in 30 minutes. The resident wheeled herself back to her room. LPN #1 continued to type at the computer. She did not look at the video monitors while she was sitting at the nursing station. -At 11:19 a.m. the resident returned to the nursing station looking for boxes. -At 11:23 a.m. the resident returned to her room. -At 11:30 a.m. a certified nurse aide (CNA) entered the nursing station. She did not look at the video monitors. -At 11:35 a.m. the CNA left the nursing station. -At 11:40 a.m. the resident returned to the nursing station and began asking multiple staff members for boxes. She was observed asking four staff members for a box. Each staff member told her they did not have any boxes and did not know where to go to find one. C. Record review The cognitive loss care plan, initiated on 2/25/2020 and revised on 5/11/2020, documented the resident had cognitive loss related to dementia and age related decline. It indicated the resident had severe cognitive and memory loss with delusions at times, was often reassured but quickly forgets. The interventions included: the family consoles with her, remind the resident that her family has taken her cane and crutches homes, reassure and reorient the resident as needed and write notes to remind the resident of the things she perseverates on as a reminder. The activities of daily living (ADL) care plan, initiated 10/12/18 and revised on 6/2/21, documented the resident had limitations in her ability to perform ADLs with decreased independence with mobility related to a cerebral vascular accident (CVA). The interventions included: use the bars on the bed to assist with positioning. The activity care plan, initiated on 5/21/2020 and revised on 1/17/22, documented the resident enjoyed visiting with her family, friends, Bingo, exercise programs, bible study, going on walks with the facility staff outdoors and daily fun packs. The interventions included to provide the daily chronicle, provide the monthly activity calendar, invite the resident to activities such as bingo and exercise group and offer snacks from the snack cart. The fall risk care plan, initiated on 1/4/18 and revised on 5/19/21, revealed the resident was at risk for falls related to the diagnosis of unspecified open-angle glaucoma, essential hypertension, cerebral infarction and asthma. It indicated the resident was on medications that could increase the resident's risk of falls and she required assistance with ADLs. The interventions included: the resident did not remember to ask for assistance with mobility, keep the resident's room door open, added a room monitor, obtain anti-rollbacks for the wheelchair, increased staff monitoring for 72 hours, request lab work, encourage fluids, anticipate the resident's needs, be sure the resident's all light is in place and encourage the resident to use it, educate the resident and family about safety reminders and what to do if a fall occurs, and follow the facility fall protocol. The 2/23/22 fall risk assessment documented the resident had a history of one to two falls within the previous 90 days, was easily distracted, had periods of altered perception or awareness of surroundings, episodes of disorganized speech, periods of restlessness, periods of lethargy, mental function varied over the course of the day and wandered. It indicated the resident had moderately impaired limited vision but could identify objects, did not have steady balance and was only able to stabilize with physical assistance. The resident scored a 19, which indicated the resident was a fall risk and interventions should have been promptly put into place. 1. Fall incident on 6/25/21 The 6/25/21 change of condition progress note documented the resident was found on the floor, yelling for help at approximately 5:30 a.m. The resident was found on the right side with blood coming from her head. The resident complained of right shoulder pain. The resident was sent to the hospital for further evaluation and treatment. -At 9:30 a.m. the resident's son called the facility and informed the nurse the resident had sustained a right clavicle fracture and had to get stitches around her right eye. -At 10:12 p.m. the resident returned from the hospital with a diagnosis of a fracture to the right clavicle, fracture to the right maxillary sinus and a subdural hematoma. The 6/25/21 fall investigation documented the resident was found on the floor on the right side of the hallway with the wheelchair tipped over. The resident had blood coming from her forehead, complaint of pain to the right knee, had impaired range of motion to the clavicle and a laceration above the eyebrow. The nursing staff used a lift to get the resident off the ground and place her into her bed. The resident was sent to the hospital for further evaluation. The interventions included increasing staff observation, placing a room monitor in the resident's room during sleeping hours and placing the call light by the resident's bed. The 6/26/21 nursing progress note documented Resident #15 remained unaware of her safety needs. The nurse found the resident standing next to her bed and ambulating to the door. The nurse documented that she provided a friendly reminder to the resident. The 6/28/21 nursing progress note documented the resident's bed was in the low position with a landing strip in place and staff monitored the resident's movement with a camera monitor. -This intervention was not noted on the fall risk care plan. 2. Fall incident on 9/6/21 The 9/6/21 nursing progress note documented at 9:00 p.m. the resident was found on the floor in the bedroom. The resident sustained a compound fracture to the left wrist and was sent to the hospital for further evaluation and treatment. The 9/7/21 interdisciplinary team (IDT) note documenting the fall was reviewed by the IDT. The IDT recommended increasing the monitoring of the resident for 72 hours and re-evaluating the resident upon her return from the hospital. The 9/6/21 fall investigation documented the resident was found on the floor in her room. Upon assessment, the resident had a compound fracture to the left wrist and was sent to the emergency room. It indicated the resident would be reassessed when she returned from the hospital. -It did not include any interventions to prevent further falls or injuries. The 9/8/21 nursing progress note documented the resident returned to the facility from the hospital with a diagnosis of a distal radius fracture (two forearm bones on the thumb side) and ulna fracture (forearm bone on the pinky finger side). It indicated to continue to monitor the resident, place the call light within reach and put the bed in the low position with the fall mat in place. -These interventions were put into place following the resident's fall with a major injury on 6/26/21. The fall risk care plan was not updated and did not document any new interventions or the re-evaluation of the interventions that were in place to determine their effectiveness. 3. Fall incident on 12/2/21 The 12/3/21 IDT progress note documented the resident had a fall in her room. She sustained a skin tear to the right forearm. It indicated the resident did not remember to request for assistance with mobility. The interventions included to increase monitoring of the resident for 72 hours, keep the resident's door open and continue with the room monitor in place. The 12/2/21 fall investigation documented the resident was found on the floor in her room. The resident sustained a skin tear to the right forearm and the right elbow. The interventions included monitoring the resident for 72 hours following the fall. The fall risk care plan documented the circumstances of the fall including the skin tear to the right forearm sustained by the resident. It indicated to increase staff monitoring for 72 hours and keep the resident's door open. -It did not document any further interventions put into place to prevent the resident from continued falls. -The facility failed to re-evaluate the interventions in place to ensure effectiveness to prevent the resident's continued falls and injuries. 4. Fall incident on 12/17/21 The 12/17/21 fall investigation documented while attempting to transfer herself from the toilet to the wheelchair, the resident fell to the ground. The breaks were not locked on the resident's wheelchair. The intervention included adding an antilock brake to the resident's wheelchair. -There was no further documentation of the incident in the resident's medical record. The fall risk care plan was updated to include the anti-rollback brakes for the resident's wheelchair. 5. Fall incident on 2/1/22 The 2/1/22 fall investigation documented the CNA reported the resident was found sitting on the floor next to her bed. She was attempting to grab a picture off the wall and fell down. -There were no noted interventions identified in the fall investigation. The fall risk care plan was updated with the circumstances of the fall. -It did not include any additional interventions. -There was no further documentation of the incident in the resident's medical record. 6. Fall incident on 2/23/22 The 2/23/22 change of condition progress note documented the resident was found sitting on the floor on the safety mat with the bed in the low position. The resident sustained a skin tear on the right hand. It indicated there were no recommendations at this time. The 2/23/22 fall investigation documented the resident was found on the floor next to her bed. The resident sustained a skin tear to the right hand. She said she was trying to go to the bathroom, but her knees wouldn't let me. -There were no noted interventions identified in the fall investigation. The 2/23/22 IDT progress note documented interventions were in place and reduced the potential for injury. The fall risk care plan documented the circumstances of the fall and to increase staff monitoring for 72 hours. -It did not document any additional interventions or the re-evaluation of the current interventions to determine their effectiveness. C. Staff interviews CNA #3 was interviewed on 3/17/22 at 11:34 a.m. She said if a resident was found on the floor, she said she would call for the nurse or another CNA. She said she would stay with the resident while the nurse assessed the resident. She said Resident #15 was very confused. She said the resident went to the staff and asked for boxes so she could leave. She said the resident would ask for the phone to call her son or her parents. She said the resident had worked with the resident for many years. She said the resident required assistance with all activities of daily living. She said the resident would try and take herself to the bathroom, or transfer herself from the bed to her wheelchair, but would lose her balance and fall. She said the resident was considered a high fall risk. She said the resident had fallen a lot in the past. She said the staff would try to redirect the resident throughout the day. She said the resident had a camera in her room with the monitor located at the nursing station. She said she was busy most of the day and was not able to check the monitor. She said whoever was at the nursing station should keep watch over the monitors. She said the monitor was to help watch the resident to ensure she did not fall. She said the monitor had been in place for a long time. She said the resident had fallen a few times since the monitor was put in place. She said the resident was not on a low bed. She said she was unsure of any fall interventions in place for the resident other than the video monitor. She said fall interventions were not included on the tasks in the point of care (POC) electronic charting system. LPN #1 was interviewed on 3/17/22 at 11:45 a.m. She said when a resident fell, the nurse should assess the resident for injuries. She said the nurse will complete the risk management form, the fall risk assessment and notify the resident's family and the physician. She said the nurse should determine what immediate interventions should be put into place. She said the IDT reviewed the falls and updated the resident's care plan. She said Resident #15 was a high fall risk. She said the resident had fallen and sustained a few fractures in the past six months. She said she had fallen a lot. She said the staff tried to redirect the resident throughout the day. She said the resident was confused and required assistance with transfers and other ADLs. She said the resident would forget to ask for assistance. She said the video monitor was used to keep an eye on the resident. She said whoever was at the nursing station should keep an eye on the monitors. She said she did not always have time to sit at the nursing station and watch the monitors. She confirmed the sound was on mute on all of the video monitors. She said the resident's bed should be in the low position when she was in the bed with a safety mat on the floor. She said the staff tried to keep the resident out of her room because that was where she often fell. She said the resident would often come to the nursing station to ask to use the phone. She said sometimes they helped the resident call her family and the other times they told her the phone was broken and redirected her down the hallway. The DON was interviewed on 3/17/22 at 12:52 p.m. She said each fall was reviewed by the IDT. She said the IDT discussed the circumstances around each fall, put interventions into place and updated the care plan each morning. She said all interventions should be re-evaluated quarterly to determine if they were effective and after each fall. She said all fall interventions should be included on the CNA tasks. She said Resident #15 was considered a high fall risk. She confirmed Resident #15's care plan had not been updated or interventions re-evaluated for effectiveness prior to the resident's fall on 6/25/21. She said after the fall on 6/25/21, the facility placed a camera with a monitor at the nursing station to be able to monitor the resident at night and increased staff observations of the resident. She said the nurse at the nursing station should check the monitors regularly while sitting at the desk. She said the staff observations were not at a specified interval and not documented in the resident's medical record. She said monitoring was usually for 72 hours and was a community standard with any change of condition. She said the resident's care plan was not updated to include interventions following the fall on 9/6/21, 12/3/21, 2/1/22 and 2/23/22. She confirmed fall interventions were not documented on the CNA tasks for the resident. She said that there was a pattern to the resident's falls. She said almost all of the falls occurred in the resident's room. She said the monitor was not effective if she continued to fall in her room. The DON and the clinical consultant were interviewed on 3/17/22 at 2:33 p.m. The clinical consultant said after each fall, the facility monitored the resident for 72 hours, did lab work and encouraged fluids. She said monitoring for 72 hours after a change of condition was a community standard. The clinical consultant said doing lab work showed the facility provided personalized interventions because it was the resident's labs that were being drawn and reviewed. She said offering fluids was considered a person-centered intervention because it was the staff encouraging fluids. She confirmed there were no documented interventions other than the lab work, 72 hour monitoring, and the encouragement of fluids for the 9/6/21, 12/2/21, 2/1/22 and 2/23/22 falls. She said the personalization of the resident's care was indicated in the activity care plan. She said the facility staff provided the resident things to do throughout the day to distract the resident, address her needs and keep her from falling (however, the resident sustained six falls in eight months with two falls causing major injuries). She said they provide her with activity items at the nursing station. -However, based on observations, LPN #1 did not provide the resident with assistance when she asked to call her family. LPN #1 told the resident the phone was not working and to come back later. The resident left the nursing station and went back to her room. LPN #1 did not offer the resident any activities or redirection. Multiple staff members did not provide the resident with an alternate activity when she asked for boxes, in fact they told her they did not have any and walked away from the resident. Multiple staff members were observed at the nursing station and did not look at the camera monitors. III. Resident #16 A. Resident status Resident #16, age [AGE], was admitted on [DATE]. According to the March 2022 CPO, the diagnoses included Alzheimer's disease, muscle wasting, unsteadiness on feet and non-displaced fracture of the lateral end of the left clavicle. The 1/29/22 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. She required extensive assistance of one person with bed mobility, transfers, dressing, toileting and personal hygiene. It indicated the resident had sustained a fall with a major injury since the previous assessment period. B. Record review The ADL care plan, initiated on 5/21/21 and revised on 6/1/21, revealed the resident had limitations in the ability to perform ADLs related to Alzheimer's disease. The interventions included: the resident requiring assistance with bed mobility, dressing, personal hygiene, transfers and eating. The fall risk care plan, initiated on 5/21/21 and revised on 5/31/21, documented the resident was at risk for falls related to poor safety awareness, a diagnosis of Alzheimer's disease and balance problems. The interventions included: educate the resident and family about safety reminders and what to do if a fall occurs, increase staff monitoring, obtain a therapy referral as ordered by the physician, ensure the resident is wearing appropriate footwear and clothing, ensure the walker and call light are within reach, remind the resident to use the call light for assistance and provide a safe environment free of clutter. The 5/21/21 admission fall risk assessment documented the resident was a high fall risk with a history of falls in the previous six months. It indicated the resident was weak and overestimated or forgot her limits. The 6/1/21 plan of care progress note documented the resident was admitted to the facility. The resident was at an increased fall risk related to poor safety awareness with a diagnosis of Alzheimer's disease and balance problems. -The facility failed to ensure person-centered interventions were put into place upon the resident's admission to the facility, for which it was identified the resident was a high fall risk. The facility did not update the plan of care since the resident's admission to the facility to ensure effective interventions were in place to prevent sustained injuries from a fall. 1. Fall incident on 12/30/21 The 12/30/21 nursing progress note documented the resident was found on the floor by the foot of the bed on the right side at 12:40 p.m. The resident was assisted back to bed and assessed by the registered nurse (RN). The RN documented the resident did not sustain an injury. -Approximately an hour later, the resident was brought to the nursing station complaining of left shoulder pain. The resident's daughter was present and insisted the resident be sent to the hospital for an x-ray. The physician ordered for the resident to be sent to the hospital for an evaluation. -The resident returned from the hospital at approximately 5:05 p.m. with a diagnosis of a distal clavicle fracture caused by the fall. The 12/30/21 fall investigation documented the resident was found lying on the floor at the foot of the bed on the right side. The resident was unable to give a description of what happened. The facility identified impaired memory, confusion and weakness as predisposing factors to the fall. -It did not include any interventions that were documented on the care plan upon the resident's admission to the facility. -Following the fall, the facility failed to put any interventions into place, other than increasing staff monitoring with no documentation in the resident's medical record as to how often the staff monitoring would occur. The facility failed to ensure interventions were in place since the resident's admission to prevent the fall and subsequent fracture. C. Staff interviews CNA #4 was interviewed on 3/17/22 at 11:40 a.m. She said Resident #16 was very confused and was considered a high fall risk. She said the resident required staff hands on assistance for all ADLs. She said the resident was able to transfer herself, but was not safe to do so. She said the resident did not usually use the call light. LPN #1 was interviewed on 3/17/22 at 11:46 a.m. She said Resident #16 was not considered a high fall risk. She said the resident was easy and took a long time to wake up. She said she required assistance with ADLs. She said she was not sure if there were any fall interventions in place for Resident #16. IV. Resident #49 A. Resident status Resident #49, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the March 2022 CPO, the diagnoses included muscle weakness, dementia without behavioral disturbance, cognitive communication deficit, difficulty walking and lack of coordination. The 2/10/22 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of six out of 15. She required extensive assistance of one person with bed mobility, transfers, dressing, toileting and personal hygiene. It indica[TRUNCATED]