**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two (#1 and #27) of three residents out of 39 sample residents. Resident #27, who was known to be at risk for skin breakdown due to immobility, developed two stage 3 pressure injuries to his left and right ischium (lower part of the pelvic bone that helps absorb weight when sitting) on 4/17/24. Resident #27's care plan documented the resident was to be offered repositioning at night during care and encouraged to lie in bed after lunch. Additionally, the resident was always incontinent of urine and frequently incontinent of bowel. However, the care plan failed to include an intervention to encourage the resident to reposition while he was sitting in his recliner and offer toileting/incontinence care to the resident frequently. Continuous observations during the survey revealed Resident #27 was not offered frequent repositioning or toileting by the staff. Due to the facility's failures to provide Resident #27 with timely interventions, such as frequent repositioning and incontinent care, the resident developed two Stage 3 pressure injuries to his left and right ischium. Additionally, Resident #1, who was frequently incontinent of urine, always incontinent of bowel and at risk for developing pressure injuries due to a decrease in mobility, was identified by a nurse to have an open area to her coccyx on 4/1/24 during a routine skin assessment. However, there was no further documentation in the resident's electronic medical record (EMR) to indicate the wound care physician (WCP) was notified of the wound and no new physician's orders were obtained to treat the wound. On 4/14/24, Resident #1 it was identified by another nurse that she had pressure wounds on her coccyx and left buttock. A physician's order was obtained for wound treatment. The facility failed to initiate a treatment to the unstageable pressure wounds to Resident #1's coccyx and left buttock for 13 days following the initial identification. Furthermore, Resident #1's care plan failed to include interventions for frequently repositioning the resident while she was in her recliner and providing frequent incontinent care. Continuous observations during the survey revealed Resident #1 was not offered frequent repositioning or toileting by the staff. Due to the facility's failures to provide Resident #1 with timely interventions, such as frequent repositioning and incontinent care, the resident developed unstageable pressure injuries to her coccyx and left buttock. Findings include: I. Professional reference The Pressure Ulcer and Other Wounds in the Post-Acute and Long-Term Care Settings (2018), retrieved on 4/29/24 from https://online.fliphtml5.com/zlds/jffd/#p=2, revealed in pertinent part Employ repositioning or offloading measures for wound prevention. According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved on 4/29/24 from https://www.internationalguideline.com/guideline, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Pressure Injury Prevention and Management policy and procedure, dated November 2022, was received from the nursing home administrator (NHA) on 4/25/24 at 8:47 a.m. It revealed in pertinent part To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries. Preventative interventions can be, but not limited to, frequent position changing and support of pressure points, adequate hydration and nutrition, appropriate exercise and movement, frequent perineal care and application of barrier cream for incontinence, proper lifting technique, correct application of pressure relieving devices and frequent inspection and assessment of skin integrity. Compliance with interventions will be documented in the medical record. III. Resident #27 A. Resident status Resident #27, age greater than 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included heart failure, type II diabetes, chronic kidney disease and atrial fibrillation (abnormal heart function). The 3/21/24 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. He required extensive one to two person assistance with toileting, transfers and bed mobility. He required set up assistance with personal hygiene and eating. The assessment documented Resident #27 was at risk for developing pressure injuries but did not have a pressure injury. B. Observations On 4/22/24 at 12:35 p.m. Resident #27 was sitting in his recliner in his room. On 4/23/24, during a continuous observation beginning at 10:35 a.m. and ending at 2:04 p.m., Resident #27 was sitting in his recliner. At 12:22 p.m. Resident #27's lunch tray was delivered by CNA #1. Resident #27 remained sitting in his recliner for lunch. -CNA #1 failed to offer Resident #27 repositioning or toileting before lunch. At 2:04 p.m. Resident #27 was assisted by CNA #1 and licensed practical nurse (LPN) #1 to lay in bed. CNA #1 exited Resident #27 room with a trash bag containing Resident #27's brief. The brief was observed to be visibly wet as the inside of the trash bag was noted to be wet. -Resident #27 was not provided with toileting or repositioning in his recliner for three hours and 30 minutes. On 4/24/24 at 1:04 p.m. the regional nurse consultant (RNC) assessed the edge of the cushion Resident #27 was sitting on in his recliner and said it was a gel type cushion. The RNC assessed Resident #27's air mattress and said it was a mattress that could alternate pressure. On 4/24/24 at 2:00 p.m. Resident #27's wound care was observed with the wound care physician (WCP). The old dressings were removed from the resident's wounds and the wound beds were pink with no signs of infection. The wounds were cleaned with normal saline, skin prep applied to the peri wounds, honey gel applied to the wound beds and covered with border dressings. -On 4/24/24 at 2:30 p.m. the gel cushion in Resident #27's recliner did not have cushion cover on it and the resident was sitting directly on the plastic surface of the gel cushion. C. Record review Resident #27's comprehensive care plan, dated 3/27/24, revealed Resident #27 had a potential for impairment to skin related to decreased mobility. The interventions included a pressure reducing cushion to chair and mattress (initiated 8/3/22), offering to reposition Resident #27 at night during care and encouraging the resident to lie on his bed after lunch (initiated on 1/20/23). -The care plan only addressed repositioning the resident during night care and not throughout the day. The 4/17/24 skin and wound evaluation form identified two new stage three pressure injuries to the left and right ischium. The wound appeared pink and moist with no signs of infection. The wound area was cleansed with Dakin's, honey gel was applied to the wound bed, skin prep the peri wound and covered with border gauze. Resident #27's 4/19/24 Braden scale (a tool used to determine the risk of pressure injury development) revealed Resident #27 was at risk of developing a pressure ulcer. It revealed his skin was occasionally moist requiring an extra linen change daily. Resident #27 was chair fast, his ability to walk was severely limited and he was unable to bear weight and required assistance into a chair or wheelchair. Resident #27 had very limited mobility, was able to make occasional slight changes in body position but was unable to make frequent or significant changes independently. Resident #27's April 2024 CPO revealed the following physician's order: Cleanse the left and right ischium with Dakin's (specialized wound cleaner), apply honey gel (used to remove dead tissue)to the wound bed, skin prep the peri wound (area around the opening) and cover with border gauze dressing once daily, ordered on 4/18/24. Resident #27's initial wound physician visit on 4/17/24 revealed stage three pressure injuries to both the right and left ischium. The left ischium wound measured 3.4 centimeters (cm) by 2 cm by 0.2 cm with 100% granulation (new connective tissue) tissue and minimal drainage. The right ischium measured 1 cm by 2.5 cm by 0.2 cm with 100 % granulation tissue and no drainage. Orders were given to cleanse the wounds with Dakin's, apply skin prep to peri wounds, apply honey gel to wound beds and cover with bordered gauze dressings daily and as needed. -Review of Resident #27's care plan, progress notes and MDS assessment did not reveal any documentation which indicated the resident frequently refused care or repositioning (see interviews below). D. Staff interviews CNA #1 was interviewed on 4/23/24 at 4:10 p.m. CNA #1 said Resident #27 was changed this morning (4/23/24) when he got up and then when he was laid in bed around 2:00 p.m. CNA #1 said Resident #27 did not always tell staff when he needed to be changed so staff should be checking in with him every couple of hours. CNA #1 was aware Resident #27 had a wound on his bottom and should be offered repositioning. CNA #1 said Resident #27 often refused to be repositioned when asked, however, she said the resident had not refused care that day (4/23/24). CNA #1 did not know where to document any refusal of care for repositioning. -Despite CNA #1's interview indicating Resident #27 frequently refused repositioning, the resident's EMR did not reveal documentation that the resident refused care or repositioning (see record review above). -Despite CNA #1's interview indicating Resident #27 should be offered repositioning and staff should check on him every couple of hours, the resident was not offered repositioning during continuous observations for three and half hours (see observations above). LPN #1 was interviewed on 4/23/24 at 4:21 p.m. LPN #1 said she was unaware Resident #27 had not been offered repositioning in at least three and a half hours. LPN #1 said Resident #27 would benefit from repositioning due to the pressure injuries on his bottom. The WCP was interviewed on 4/24/24 at 2:29 p.m. The WCP said he was unable to determine if Resident #27's pressure injuries were avoidable or unavoidable as he was still speaking with facility staff to determine possible causes of the wounds. The WCP said facility staff told him Resident #27 refused to change positions and preferred to sit in his recliner during the day. -However, there was no evidence of documented refusals of care (see record review above). IV. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the April 2024 CPOs, diagnoses included diabetes mellitus (abnormal blood glucose), dementia (memory impairment) and chronic kidney disease (abnormal kidney function). The 4/9/24 MDS assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. She required substantial assistance for transfers, toileting, dressing and supervision for eating. The assessment documented the resident was at risk of developing a pressure injury but did not have a pressure injury. B. Observations On 4/22/24 at 10:30 a.m. Resident #1 was sitting in her recliner leaning to her left side. On 4/22/24 at 1:35 p.m. Resident #1 was sitting in her recliner and continued to lean to her left. On 4/23/24, during a continuous observation beginning at 10:35 a.m. and ending at 2:51 p.m., Resident #1 was sitting in her recliner, leaning to her left side. At 12:22 p.m. Resident #1's lunch tray was delivered while the resident was asleep and remained sitting in the recliner. At 12:34 p.m. LPN #1 entered Resident #1's room, woke the resident up and offered her assistance with eating. Resident #1 said she was not having a good day because her bottom hurt. LPN #1 told Resident #1 that she got a new dressing on her bottom and the wound physician would be in the next day. -LPN did not offer repositioning to the resident. At 2:26 p.m. LPN #1 entered Resident #1's room and told the resident as soon as the CNA returned from lunch, she would assist the CNA to lay the resident in bed. Resident #1 remained sitting in the recliner leaning to her left side. -At 2:51 p.m. LPN #1 and CNA #1 entered Resident #1's room with the sit to stand mechanical lift. Resident #1 was assisted with the use of the sit to stand lift to the bathroom. Resident #1's brief was removed and was observed to have been soiled with bowel and urine. -Resident #1 was not provided with toileting or repositioning in her recliner for four hours and 15 minutes. LPN #1 collected items to complete the resident's dressing change due to the dressing being soiled. CNA #1 used the sit to stand lift to take Resident #1 out of the bathroom. The old dressing was removed and noted to be soiled with feces on the edges of the dressing. The wound bed to the coccyx was pink and moist and the area around the wound was nonblanchable (discoloration of skin that does not turn white when pressed) when the nurse pressed the surrounding tissue with her finger. The left buttock wound had eschar (dead tissue) around the upper edge of the wound and yellow tissue (slough) throughout. The surrounding tissue of the wound was nonblanchable. LPN #1 cleaned the wounds with Dakins, dried the wounds with gauze, applied skin prep to the peri wounds, added honey gel to the wound beds, and covered the wounds with a border dressing. Resident #1 told LPN #1 it hurt when the nurse was cleaning the wounds. On 4/24/24 at 1:01 p.m. Resident #1 was observed to be seated on a cushion in her recliner. The RNC touched the chair cushion without moving Resident #1 from her seated position in the recliner and identified the cushion as a standard foam cushion. The RNC identified the resident's pressure relieving mattress as an air mattress that could alternate pressure. On 4/24/24 at 2:10 p.m. Resident #1's wound dressing changes were observed with the WCP. The coccyx wound had a pink wound bed. The wound area was cleansed with Dakin's, dried with gauze, skin prep was applied to the periwound, honey gel was applied to the wound bed and the area was covered with border gauze. The left buttock wound was observed to have yellow colored tissue in the center and the upper corner of the wound was observed to have eschar (dead tissue). The wound area was cleaned with Dakin's, dried with gauze, skin prep was applied to the peri wound, honey gel was applied to the wound bed and the area was covered with border gauze. C. Record Review Resident #1's comprehensive care plan, dated 3/29/24, revealed potential impairment to skin related to decreased mobility with interventions of pressure reducing cushion while up in chair, pressure reducing mattress and follow facility protocol for treatment of injury, initiated 12/13/22. Apply nutrishield cream to coccyx every shift and at each incontinence episode initiated on 5/24/23 -There was no intervention for repositioning or frequent incontinent care documented on Resident #1's care plan Resident #1's 1/7/24 Braden scale assessment revealed Resident #1 was at moderate risk for developing pressure injuries. It revealed Resident #1's skin was very moist requiring extra linen changes, the resident was chair fast (requiring assistance to a chair or wheelchair) and had very limited mobility (unable to make frequent or significant changes independently). Resident #1's weekly skin assessment dated [DATE] revealed the resident had an open area starting on her coccyx but did not document a stage of the wound or measurements. It revealed Resident #1 was more comfortable lying on her sides than lying flat because lying flat caused her extreme pain. -The assessment did not document Resident #1 frequently refused repositioning (see interviews below). -There was no progress note indicating whether or not the WCP was notified of the wound and no new physician orders were added for treatment of the wound. Resident #1's weekly skin assessment dated [DATE] revealed a pressure injury to the resident's coccyx but had no measurements or narrative notes. -There was no progress note indicating whether or not the WCP was notified of the wound and no new physician orders were added for treatment of the wound. A progress note dated 4/14/24 revealed CNAs were changing Resident #1 and an open area to the resident's coccyx measuring 2 cm by 2.2 cm was found. The area was cleaned and a dry dressing was applied. Resident #1 also had a shearing area to the left buttock measuring 3 cm by 2.2 cm, the area was cleansed with normal saline and nutrashield cream was applied. The nurse notified the unit manager to speak with Resident #1's representative about getting a new cushion for her wheelchair. -The wounds were initially identified by a nurse on 4/1/24, however, there was no further documentation of the wounds or treatment orders obtained until 4/14/24. -There was no documentation to indicate whether a new cushion was provided to Resident #1. Resident #1's April 2024 CPO documented the following physician's orders: Pressure relief mattress: check inflation and settings every shift, ordered on 2/2/24. Apply nutrishield cream to coccyx every shift and with every incontinence episode, ordered on 5/23/23. Wound care order for coccyx: Clean open areas to coccyx with normal saline and apply dry dressing once daily, ordered on 4/14/23. -The order did not specify a treatment for the left buttock wound. -The order was not put into place until 13 days after the initial identification of the open area to Resident #1's coccyx. Wound care order for coccyx and left buttock, cleanse with Dakin's, apply honey gel to wound bed, skin prep the periwound and cover with border gauze once daily, ordered on 4/18/24. The WCPs initial encounter with Residents #1's wounds for the coccyx and left buttock on 4/17/24 revealed the coccyx and left buttocks were unstageable pressure injuries. The coccyx wound measured 1.1 (cm) by 1 cm by 0.1 cm and the left buttock wound measured 0.9 cm by 1.3 cm by 0.1. -Review of Resident #1's care plan, progress notes and MDS assessment did not reveal any documentation which indicated the resident frequently refused care or repositioning (see interviews below). D. Staff interviews CNA #1 was interviewed on 4/23/24 at 4:10 p.m. CNA #1 said residents should be offered toileting or repositioning every two hours to ensure they were not soiled and to off load pressure areas. CNA #1 said Resident #1 would not call if she was soiled so staff needed to offer toileting and check her for incontinence episodes. CNA #1 said Resident #1 was changed around 9:00 a.m. and then at around 3:00 p.m. (on 4/23/24). CNA #1 did not have a response as to why Resident #1 was not offered repositioning or toileting in almost six hours. CNA #1 said Resident #1 had wounds on her buttocks. -Despite CNA #1's interview indicating Resident #1 should be offered repositioning and staff should check on her every couple of hours, the resident was not offered repositioning during continuous observations for four hours and 15 minutes (see observations above). LPN #1 was interviewed on 4/23/24 at 4:21 p.m. LPN #1 said residents should be offered repositioning every two hours especially if they had pressure injuries or were at risk of developing pressure injuries. LPN #1 said repositioning would be beneficial to residents with pressure injuries to promote healing. LPN #1 was unaware if Resident #1 was not offered repositioning or toileting between 10:35 a.m. and 2:51 p.m. LPN #1 said Resident #1 had not had the pressure injuries long but would refuse staff when she was asked to reposition. LPN #1 said she had not documented any Resident #1 refusal of repositioning. -Despite LPN #1's interview indicating Resident #1 frequently refused repositioning, the resident's EMR did not reveal documentation that the resident refused care or repositioning (see record review above). The WCP was interviewed on 4/24/24 at 2:10 p.m. The WCP said he felt Resident #1's pressure injuries were avoidable but when he talked with the facility staff he was told Resident #1 refused to change positions. -However, there was no documented refusal of care (see record review above). V. Additional interviews The WCP was interviewed again on 4/24/24 at 2:48 p.m. The WCP said Resident #1's and #27's wounds would benefit from frequent positioning changes despite them both sitting on cushions when up in their recliners. The WCP said a pressure injury could develop within two hours and incontinence increased the risk of a wound developing or worsening. The WCP said wound textbooks recommended a resident in bed be repositioned every two to three hours and, when in a chair, they should be repositioned every two hours to offload pressure. The director of nursing (DON) was interviewed on 4/25/24 at 10:10 a.m. The DON said Resident #1 started having skin issues on 4/1/24, however, she said the floor nurse did not relay this information to the unit manager. The DON said Resident #1's skin issue was brought up again on 4/14/24 by another nurse. She said the facility started to review what could have caused the wounds and found the weekly skin documentation dated 4/1/24. The DON said the facility immediately started wound care treatment for Resident #1's wounds on 4/14/24 and had the WCP see the resident on his next wound round visit, which was 4/17/24. The DON said Resident #1 did not like to be repositioned and liked to sit in her recliner. The DON said Resident #27 did not like to be moved from his recliner but should still be offered position changes every two hours. -Despite the DON's interview indicating Resident #1 and Resident #27 frequently refused repositioning, the residents' EMRs did not reveal documentation that the residents refused care or repositioning (see record review above). -The DON did not provide any documentation for refusal of care for Resident #1 or Resident #27. The DON said residents should be repositioned every two hours to help prevent pressure injuries and promote wound healing if they had a pressure injury. The DON said if a resident refused to be repositioned it should be documented in the nurses progress notes. The DON said residents should be offered toileting upon rising, before and after meals and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the resident was treated with respect and dignity and care was provided in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life and recognized the resident individuality for one (#1) resident out of five sample residents. Specifically, the facility failed to answer the resident's call light and provide services in a timely manner to the resident. The resident said it could be frustrating at times and he reacted with behaviors of becoming angry, calling out for help, and banging on walls. This caused the resident distress. Findings include: I. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease, essential hypertension, post-polio syndrome, diabetes mellitus type 2, osteoarthritis of left shoulder, lack of coordination, and muscle weakness. The 11/25/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He exhibited verbal behaviors. He required extensive assistance of two staff members with mobility and activities of daily living (ADLs). He had two or more falls with no major injuries. II. Resident interview Resident #1 was interviewed on 11/30/22 at 9:30 a.m. He stated he frequently waited 30 minutes to an hour for his call light to be answered. He stated the staff also frequently came into his room, turned off his call light and told him they would be back but did not return. He stated the long call light wait times were very frustrating for him and he did yell out and bang on walls at times when waiting for long periods of time for the care and services he wanted and needed. III. Family interview The resident's representative was interviewed on 12/1/22 at 11:00 a.m. He stated he had witnessed long call light wait times while visiting in the facility. He stated the resident could be impatient and demanding at times, though he should not have to wait for 40 minutes to an hour for care. IV. Record review An ADL care plan initiated on 8/19/2020 and revised on 9/6/22 read: I have an ADL self-care performance deficit r/t (related to) muscle weakness from chronic obstructive pulmonary disease, type 2 diabetes mellitus, primary generalized osteoarthritis, hypertension, insomnia, and vitamin D deficiency. Please provide a consistent rotation of staff for my care needs to improve motivation, flexibility, & learning. Interventions included: Please provide a consistent rotation of staff for my care needs to improve motivation, flexibility, & learning. Tips for caring for me: Attempt to get me up first thing in the day; Communicate times with me in advance; Remind me others need morning care too when I use call light frequently and you will be back soon; Remember I may have 'unmet needs' and I need your help; Assure me you are here to help me, please no arguing; Please don't take any issues personally; If I am safe, leave the room and come back with help if needed; Stay calm and gentle - you are the amazing professional here!; Ask for help from leadership communicating with me - THEY WILL HELP YOU. A behavior care plan initiated on 2/15/21 and revised on 10/17/22 read: I exhibit the following behaviors: Verbal aggressive behaviors: Screaming, cursing, negativism, verbally degrading staff, verbal aggression. Told staff he would defecate on the floor in the past to get attention. Placed himself on the floor in the past to get attention. Banging very loudly on the wall for attention (within just a few minutes of being in the bathroom). Interventions included: Anticipate and meet my needs. Make sure I feel heard by using rephrasing and feedback; Encourage me to express my feelings appropriately. Use active listening and respond to my feeling and tone; Explain all procedures to me before starting and allow me time to adjust to changes; Explain/reinforce to me why my behavior is inappropriate and/or unacceptable; Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Review of the resident's progress notes revealed the resident had exhibited behaviors of being demanding and impatient with staff since admission. Behaviors included yelling out, banging on walls, and pulling the call light out of the wall. Review of the resident's call light record from 10/30/22 to 11/30/22 revealed 77 call light times that were over 20 minutes long. Sixteen call lights were between 30 and 40 minutes, 10 were between 40 and 50 minutes, six were between 50 and 60 minutes, eight were over an hour and one was over two hours. V. Staff interviews Registered nurse (RN) #1 was interviewed on 11/30/22 at 9:45 a.m. She stated call lights should not remain on past 15 minutes, but the facility staff tried to get to them as soon as possible. Licensed practical nurse (LPN) #1 was interviewed on 11/30/22 at 9:50 a.m. She stated the resident call lights would ideally be answered within five minutes. She stated it was not always possible to answer call lights that quickly. She stated she felt ten minutes was too long and she would probably get frustrated and upset if she had to wait longer than ten minutes. She stated she had worked with Resident #1 and he wanted care immediately when putting on his call light and would yell out if the call light was not answered immediately. She stated the staff tried to get him up first thing in the morning. Certified nurse aide (CNA) #1 was interviewed on 11/30/22 at 10:01 a.m. He stated the residents should not wait longer than ten minutes to have their call light answered. He stated he worked with Resident #1 and he expected care immediately after he activated his light. CNA #2 was interviewed on 11/30/22 at 10:07 a.m. She stated she tried to get to resident call lights within five minutes. The nursing home administrator (NHA) was interviewed on 11/30/22 at 12:00 p.m. She stated the facility had been working on call light timeliness in the facility. She stated 15 minutes was acceptable and 20 minutes was not desirable. She stated anything over 30 minutes was a real concern and residents should not have to wait that long. She stated the call light system in the facility was all digital to devices the staff carried with them while working and administration also had devices and could monitor call light times remotely. She stated there was no light outside the resident rooms or audible alert for a call light activation, so some of the long call light times were from staff forgetting to deactivate the call. The director of nursing (DON) was interviewed on 12/1/22 at 1:30 p.m. She stated resident call lights should not go longer than 15 minutes at the most. She stated the facility staff including administrative staff were working very hard to decrease call light wait times. She stated Resident #1 received care from staff and they would leave the room and he would put his call light on right after staff left for more care and he did not accept staff explaining there were other residents who needed care as well. She stated the resident also frequently would not let staff turn off his light and return to provide the care and would insist the light stay on until staff could return. She stated the residents should not have to wait 30 minutes or longer for care to be provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure effective fall interventions were in place to prevent resident falls for two (#85 and #300) of four residents reviewed for falls out of 34 sample residents. Record review and interview revealed the facility failed to effectively and consistently develop and implement care plan interventions to ensure the residents were provided the assessed levels of supervision recommended by nursing and therapy staff. Resident #85 had a history of falls with fractures. The facility was aware upon Resident #85's initial admission on [DATE], that she had a history of falling and had a prior fracture to her right femur. Documentation starting in December 2019, with her second fall revealed the resident was experiencing increased confusion and unsteadiness of her gait/balance and her care plan documented that she was at significant risk for future falls due to weakness, impulsivity, and unawareness of safety needs. The facility failed to reassess, develop and implement care planned interventions to effectively prevent a fall where the resident sustained a major injury. Resident #85 fell three times while in care of the facility. The first two falls occurred on 2/25/19 and 12/12/19 when the resident tried to get up unassisted. The most recent fall occurred on 1/30/2020 while the resident was trying to get into bed and did not have non-slip socks on per her care plan. The latest fall resulted in the resident sustaining a major injury requiring surgical intervention to repair damaged bone and tissue of both the femur (thigh bone) and the tibia (shinbone). The femoral bone was fractured at both ends, the head of the bone and at just above the knee joint. The tibia was fractured at the top of the bone just below the knee. The hospital discharge report dated 2/2/2020 documented this degree of damage was caused by a hard hit to the joint. The facility was also aware upon Resident #300's 2/8/2020 admission of her history of falling, she had been a resident of this facility on the transitional care neighborhood (TCN) unit, months prior, to recover from a fractured right hip after falling at home. The facility was aware, based on the hospital referral document dated 2/8/2020, at her admission, that she was in a weakened condition due to gastrointestinal illness and risk for falling. However, the facility failed to assess, communicate and implement effective fall prevention measures to prevent a fall within two days of admission to the TCN for rehabilitation services. Findings include: I. Facility policies and procedures The Fall Prevention and Management policy, last reviewed January 2019, was provided by the director of nursing (DON) on 2/11/2020 at 1:15 p.m. The policy read in pertinent part: As a facility that provides care and services to seniors and promotes a culture of safety. It is important to prevent and manage falls in order to minimize the harm and potential risk to residents. -The purpose of the fall prevention and management program is to identify residents and areas at risk for falls, initiate interventions to prevent and respond to falls and thus reduce the risk of injury due to falls. -Falls are the leading cause of morbidity (illness) and mortality (death) among nursing home residents and can result in serious injury, especially hip fracture. -Previous falls, especially recurrent falls and falls with injury, are the most important predictors of future falls and injurious falls. Muscle weakness and gait problems account for about 24 percent of nursing home falls. -Fall risk assessment will be completed upon move-in, with signifying changes in condition, readmission, quarterly and annually. The fall risk assessment will result in person centered care planning to reduce the risk of falls, if appropriate. -Fall prevention: It is the goal of this facility to prevent falls in all areas of care and services and it is the responsibility of all associates to prevent falls, striving to provide the safest environment possible. Skilled neighborhoods may offer the following fall prevention interventions based on response to individualized needs: fall risk assessment, low bed, fall mat, appropriate footwear, intentional rounding, education to resident and families, life enrichment activities focused on strengthening and balance, environmental assessment, to keep it clean and free of clutter and hazards, person centered fall interventions fall prevention care planning, referral to rehab services, quality improvement projects, environmental safety rounding, providing adequate lighting, routine preventative equipment, maintenance program ,oxygen tubing management, hip protectors, wheelchair positioning, toileting plan, moving resident's suite closer to nurses area, removing clutter/equipment, pharmacy review of medications, alterations in resident's area to allow easy accesses to desired items, increased need for supervision, call light positioning, and wet floor signs available in each neighborhoods for use in the event of a spill, medication review for high risk fall medications and so forth. -Designated associates will perform quality improvement to reduce falls, as needed. A request was made for policies on assisting dependent residents with activities of daily living (ADL) and transfers on 2/11/2020 at 4:50 p.m. The DON said the facility did not have policies on either topic but provided procedural instructions for transfers and assistance to ambulate, on 2/12/2020 at 8:00 a.m. The procedural guide documented step by step instructions for assisting a dependent resident, but did not document taking the residents assessed ability or therapy recommendations for transfer techniques into account. II. Resident #85 A. Resident status Resident #85, age [AGE], admitted on [DATE]. According to the January 2020 computerized physician's orders (CPO) diagnosis included right open femur fracture, Parkinson's disease, dementia and bipolar disorder. The 1/9/2020 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 14 out of 15. She required supervision- oversight, encouragement and/or cuing form one staff person with transfers; toileting; locomotion on and off the unit bed mobility; and dressing. She was not able to stand from a seated position, transfer form surface to surface, walk short distances, or turn around while walking without assistance form one staff and a walker to stabilize and balance. She used a manual wheelchair to get around the community. She did not refuse care. She was on routine antipsychotic medication, and last received occupational therapy on 11/12/19 and physical therapy on 3/5/19, and was not on a restorative nursing program. She had two falls since admission. B. Resident interview Resident #85 was interviewed on 2/10/2020 at 11:44 a.m. She said she had fallen about a week ago when she was trying to get into bed. Staff were not available to help me get into bed; sometimes it takes a little longer for them to answer my call light and I thought I could get in bed by myself. I got up out of my chair; I slipped and fell. I probably should have waited for staff to help me. The doctor said I broke my bone right in half. It's hard to believe because it's a pretty big bone (she pointed to her thigh). They haven ' t changed the bandage yet, so I'm not sure how it looks under there. Staff will help me with things if I ask them to when they are here helping me. The resident showed the fracture site, it was covered with a long bandage from hip to just below the right kneecap. The bandage was starting to come loose, but looked clean and covered the wound. Resident #85 was interviewed again on 2/11/2020 at 1:50 p.m., during a resident group meeting with six other residents present. Resident #85 said we can have long waits for staff to answer our call lights. I think they could use more help. I don ' t push the button unless I absolutely have to, it takes a lot out of me to sit and wonder who is coming or when they will show up to help me. I feel unimportant when I have to wait a long time to get help; I don ' t think I am a priority when the staff stop in only to turn off my light and tell me they will be right back and they don ' t come right back. C. Record review The resident's comprehensive care plan reflecting move in date 2/20/19 revealed the following care plan needs, it read in pertinent part: Focus - ADLs: I have an ADL self-care performance deficit Fatigue, impaired balance. Date initiated: 2/25/19. Goal: I will maintain my current level of function. Date initiated: 6/5/19 Interventions/tasks: -I will improve my current level of function. Date initiated: 2/25/19 -Bathing/showering: I need limited physical assistance. Date initiated: 6/5/19, revision on 12/5/19. Focus-Dressing: I need supervision and cueing by staff to provide assistance for dressing. Date initiated: 6/5/19, revision on 6/5/19. -Toileting use: I require supervision and cuing by staff to provide assistance with toileting. Do Not Leave me alone on the toilet until I have been evaluated. Date initiated: 6/5/19, revision on 6/5/19. -Transfer: I require extensive and limited physical assistance by staff to provide assistance to move between surfaces. Date initiated: 6/5/19, revision on 9/3/19. -ADL - bed mobility every shift. Date initiated: 2/20/19 -ADL - dressing assistance every shift. Date initiated: 2/20/19. -ADL - toilet use assistance ever shift. Date initiated: 2/20/19. -ADL - bathing assistance every Monday and Thursday. Date initiated: 2/20/19, revision on 1/20/20. -ADL - transfers assistance every shift. Date initiated: 2/20/19. Focus- falls: I am at high risk for falls, related to deconditioning/weakness and a history of past falls. Date initiated: 3/2/19. Goal: -I will be free of falls. Date initiated: 3/2/19. -I will be free of minor injury. Safety measures will be maintained to prevent or lessen any injury from a fall. Date initiated: 3/2/19. Interventions/tasks: -Educate and remind me about safety reminders and what to do if a fall occurs. Date Initiated: 3/2/19. -Ensure that I am wearing appropriate non skid footwear when ambulating or mobilizing in my wheelchair. Date initiated: 3/2/19. -Despite the care plan documenting that staff should ensure the resident was wearing non slip socks when ambulating or mobilizing when in her wheelchair the resident did not have non slip socks or other non slip footwear on the day the she fell and fractured her femur and tibia bones. Focus- falls: I have had one fall with no injury in the last quarter. Related to deconditioning/weakness, impulsivity and unawareness of safety needs. Date initiated: 2/25/19., revision on 1/21/2020. Goal: Fall related complications such as injury or change in cognitive function, will be promptly assessed and treated to prevent adverse outcomes. Date initiated: 2/25/19. -I will be free of minor injury. Date Initiated: 2/25/19 -I will resume usual activities without further incident through. Date initiated: 2/25/19. -Underlying medical conditions causing or contributing to the event will be evaluated. Date initiated: 2/25/19. Focus - I have Diabetes Mellitus I am insulin dependent. I am at risk for hypoglycemia and hyperglycemia. Date initiated: 6/5/19. Goal: I will have no complications related to diabetes. Date initiated: 6/5/19. Interventions/tasks: Monitor/document/report signs and symptoms of hypoglycemia; examples include by not limited to confusion, lack of coordination and staggered gait. Date initiated: 6/5/19. The point of care system (POC) documented customized care assistance and level of service provided by the CNAs. The documentation showed the residents abilities and need for staff assistance varied but the care plan did not document development of care interventions to address the unpredictable nature of her ability to transfer herself. Nursing note dated 12/1/19 at 8:01 a.m., read in pertinent part: Daily skilled note: Short-term memory impairment, impaired decision making ability, sleeps very soundly and is forgetful. Up and dressed this morning at 5:30 a.m., she thought it was evening. Has periods of increased confusion. Functional status: Balance/gait impaired balance weakness. Nursing note dated 12/12/19 at 4:35 p.m. Read: Incident note: Resident found lying on floor with her head on pillow, alert and oriented times three, states she was getting up to water her plants, and she went one way and the wheelchair went the other way. Resident did not put brakes on the wheelchair before attempting to stand up, did not call for assistance, states landed on buttock, denies hitting head or loss of consciousness, vital signs stable, no obvious deformities, range of motion (ROM) to extremities without pain or discomfort, resident assisted by two person to standing position and assisted to sitting on side of bed, no injuries noted, neuro checks initiated and were within normal limits. Will continue to monitor, call light within reach, resident resting quietly on low bed. Nursing note dated 12/13/19 10:13 a.m., read in pertinent part: Incident note: Resident up to wheelchair this morning needing limited physical assistance of one staff. Nursing note dated 1/1/2020 at 9:22 a.m., read in pertinent part: Change of condition note: Resident presented with increased confusion this morning. She attempted to go into another resident's room, talking about needing to write on the chalkboards. Vital signs: oxygen saturation was 88 percent on room air, 92 percent while on two liters of oxygen by nasal cannula, blood pressure 151/78, pulse 103 beats per minute, respirations 18 breaths per minute even and unlabored, temperature was 98.4 degrees Fahrenheit, blood sugar was 545, lung sounds clear, abdomen soft resident denies pain or burning with urination. Physician notified, labs and urine analysis ordered. Treatment provided for resident symptoms. Physician visit note dated 1/2/2020, revealed the resident was seen by the nurse practitioner (NP) for an acute/reassessment visit, the resident in bed when examined the NP did not observe her walk or stand and balance. The note documented: The physician's office was notified of a change in condition starting on 1/1/2020. The resident had increased confusion and elevated fasting blood sugar (FSBS) levels . Blood/lab work and urinalysis ordered. The documented results of the medical exam and chart review included prescribed antibiotic treatment for a urinary tract infection (UTI) and continued close monitoring of blood glucose levels due UTI with elevated FSBS and glucose in urine. Fall assessment dated [DATE] revealed the resident was at a moderate risk for falls with a score of 5.5 out of 15 (any score over 10 indicates a high risk for falls). She was on high risk medication (antidepressant, antihypertensive, antipsychotic, cardiovascular and hypoglycemic medication) with numerous health conditions placing her at increased risk for falls. She was not steady on her feet, and used a walking aid device. The assessments accuracy is in question because the assessor did not answer all questions and did not document the resident prior fall over the prior six months (fall date - 12/12/19). If this question was answered correctly it would have brought her score to an 8.5 out of 15 making her a higher risk rating for falls or even a higher if other questions were not answered accurately. The POC documented customized care assistance and level of service provided by the CNAs to the Resident #85 on a day to day basis revealed the following care service and care needs: Transfer assistance: The documented outcomes of the resident's ability for self-performance and how resident moved between surfaces including to or from the bed, chair, wheelchair and standing position (excludes to/from bath/toilet) between 1/13/2020 and 1/30/2020 revealed: While the resident was able to perform transfers independently on an occasional basis; she needed assistance from one staff at least once daily, some days she needed physical assistance, supervision, cuing and/or encouragement more than once a day for successful transfers between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). -The resident's need for assistance varied from day to day with no consistent pattern of need. This care task area showed the resident's need and level support needed was not predictable. Movement support: The documented outcomes of the resident's ability to move between locations in her room and adjacent corridor on same floor between 1/13/2020 and 1/30/2020 revealed: The resident needed daily assistance to provide guided maneuvering of limbs or other non-weight-bearing assistance, supervision, cuing and/or encouragement from one staff to move about. On the day the resident fell and fractured her femur (1/30/2020), she needed and received weight-bearing support by staff to move between locations. -This care task area showed the resident's need and level support needed was not predictable. Dressing support: The documented outcomes of the resident's ability to put on, fasten and take off all items of clothing, including putting on and removing footwear between 1/13/2020 and 1/30/2020 revealed: The resident needed daily physical assistance, supervision, cuing and/or encouragement from one staff to get dressed. She needed assistance at least once daily, some days she needed staff assistance more than once throughout the day. -This care task area showed the resident's need and level support needed was not predictable. Walking: The documented outcomes of the resident's ability to walk in her room between 1/13/2020 and 1/30/2020 revealed this service was not applicable; she did not perform this task independently or with staff assistance. Monthly nursing observation dated 1/22/2020 revealed the resident had short-term memory impairment with impaired decision making ability. Nursing note dated 1/30/2020 at 9:30 p.m., read in pertinent part: Incident note: At around 8:00 p.m., the CNA notified this writer that the resident is on the floor. Per assessment, the resident stated, I was transferring from my wheelchair to bed then I slid and fell on my right hip and right knee. Resident denies hitting her head. Neuro checks were initiated and were within normal limits per resident's baseline. ROM to both upper extremities were within normal limits. No pain noted with ROM to both upper extremities. ROM within normal limits to both lower extremities. Pain/discomfort noted to right hip and right knee with ROM. No visible injuries noted. Vital signs stable, blood glucose of 174. No signs of symptoms of hypo/hyperglycemia noted. Resident was assisted to bed. Tylenol 1000 milligrams (mg) was administered for pain. Resident did not place her call light for help before transfer. Call light was within reach. She was not wearing non-skidding socks. Her wheelchair brakes were not on prior transfer. Physician notified me and x-ray was ordered. According to the nursing note dated 1/30/2020 at 9:30 p.m., Resident #85's fall occurred in her room on 1/30/2020 at approximately 8:00 p.m. as she was attempting to transfer herself without staff assistance and without safe and proper footwear, she slipped and fell. Staff found the resident lying on the floor on her right side and noted in the facility investigation report that the predisposing factor to her fall was transferring without staff assistance and improper footwear (not wearing non slip socks), as she was wearing regular socks (see DON interview below), without the plastic grip strips on the bottom. However, the resident's comprehensive care plan documented an intervention that the resident needed daily supervision assistance from staff to get dressed; daily extensive and/or limited physical assistance to transfer from surface to surface; and for staff to ensure she was wearing appropriate non skid footwear when ambulating and moving about in order to be free of minor injury and prevent or lessen any injury from a fall. These interventions were not followed consistently and Resident #85 sustained a major injury from falling. Nursing note dated 1/31/2020 at 12:48 a.m., read: Radiology Note: Result called in to physician's office, received orders to send resident to the hospital. Hospital admission and treatment paperwork dated 1/31/2020 revealed in pertinent part: The resident was seen in the emergency room for right leg pain following a fall at the facility on 1/30/2020 at approximately 8:00 p.m. She was evaluated and treated for both proximal (upper end) and distal (lower end) right femur fractures. The hospital assessed treatment plan documented: -Patient without urinary complaints, but did have significant pyuria (pus typically form a bacterial infection) in her urine sample. Treat for acute cystitis (inflammation of the urinary bladder) with intravenous antibiotics. -Distal femur fracture from a mechanical fall. X-ray confirmed a comminuted (a break or splinter of the bone into more than two fragments) intra-articular (crossing into the joint) supracondylar (just above the joint) distal femoral fracture, comminuted intra-articular proximal tibia (widest part of the shin bone near the knee) fracture. Pain management provided in the emergency room, via a nerve block. -Surgical correction to repair fractured bone on 2/1/2020. Social services summary note dated 2/5/2020 3:00 p.m., read in part: Change of condition summary: Resident recently fell while transferring self and broke her femur. After acute hospital stay, she returned to the rehab transitional care unit neighborhood for skilled therapy/treatment. She will eventually return to her long term care suite. Resident is alert times three, indicated she has broken several other bones in her past and glad to have returned from the hospital to her home. She will have weekly progress grand round meetings with the interdisciplinary team (IDT) and her family. Social services will continue to follow for support services and monitor for needs. Fall risk assessment dated [DATE] revealed the resident was at high risk for falls. She had one fall since the last quarterly fall assessment and was on high risk medication (antidepressant, cardiovascular and narcotic analgesic medication) with numerous health conditions placing her at increased risk for falls. She was not able to attempt standing without assistance needed assistance with toileting and was confined to a chair. D. Staff interviews The DON was interviewed on 2/11/2020 at 4:35 p.m. The resident's fall investigative report was reviewed during the interview. The DON said Resident #85 fell on 1/30/2020. Following a resident fall the nursing staff would assess the resident for potential injuries and provide medical care as needed. A registered nurse (RN) conducts a full assessment of the resident's condition and makes notifications to the physician, family and other appropriate persons. The staff will hold a post fall huddle to determine potential factors in the fall. The IDT is notified of all falls and they will review the falls to ensure a systematic approach to identify, evaluate, implement and monitoring of all contributing factors to eliminate and prevent future falls to the degree possible. I conducted a full investigation of the incident. We have a new system that incorporates the nursing note from the resident's electronic record and merges it with the investigative database. I review the nurse's notes detailing the fall, injury and treatment notes, and the 72 hour report notes looking for predisposing factors relating to the resident's fall. The investigative report for Resident #85s fall on 1/30/2020 showed the RN on duty assessed the resident's condition and found no injuries during the immediate assessment. The nurse provided Tylenol for expressed pain, and assisted the resident to bed. The nurse made sure the call light was in reach and educated the resident to use her call light to ask for staff help with transfers, the resident agreed to this. Based on the investigative findings there were no predisposing factors noted other than the resident had on regular socks and was not wearing non skid socks. Also the resident had not locked her wheelchair prior to attempting to transfer herself to bed. The resident's pain continued to worsen and x-ray results confirmed she fractured her femur. The resident was transported to the hospital on 1/31/2020 at 12:48 a.m., she had surgery on 2/1/2020 and returned to the facility on 2/5/2020. The DON said the care plans are updated by the unit managers and the minimum data set coordinator and CNA and nurses were responsible to make sure care planned interventions were carried out. The CNA would have primary responsibility to make sure the resident had on non slip footwear for safe transfers. CNA #6 was interviewed on 2/12/2020 at 10:24 a.m. He said the CNAs are responsible to offer reminders to residents to be safe and put on non slip socks or other non slip footwear. Some residents are more fashion minded than others so we would have to work with them to make sure they are safe when walking around and transferring from place to place. If non slip socks are ordered for fall prevention we make sure to help the resident to put them on in the morning when assisting then to get dressed and throughout the day we would make sure they had on non slip footwear before any transfers and we would also check their feet for compliance with wearing the non slip socks at ever encounter. If the resident refused due to fashion sense or other personal preference, we would work with the resident and nurses to find an acceptable solution and document any refusal to comply with the order for safety. I am not aware of Resident #85 ever refusing to wear non slip socks when encouraged to wear them. RN #4 was interviewed on 2/12/2020 at 10:34 a.m. RN #4 said ensuring safe transfer and making sure the resident wears safe footwear is a twofold process. The CNAs use and access POC care plans to see the types and levels of care needs of each individual resident that they should be attending to. If a resident is at risk for falls there should be a care planned intervention under the safety care task section in POC which address interventions for safe transfers including nonslip and safe footwear. The CNAs should check the resident for application of safe footwear at the beginning of each shift, throughout the shift; during check-ins and each time they see or interact with the resident to ensure the resident has the prescribed intervention in place. Staff should not assist a resident with transfer unless the prescribed safety interventions are in place and they should intervene if they see a resident in an unsafe situation. If the resident was prescribed to wear non slip socks for fall prevention it should be on the resident's treatment administration record (TAR) and the nurse should be checking for compliance during medication pass and at every encounter. We have extra non slip socks in the clean utility room, and staff can pass them out to any resident in need. The nurse looked at the resident TAR and was unable to find an order for application of non slip cocks, but said the order should have been there. The nurses are primarily assigned the task of updating the care plan but sometimes it gets hectic on the unit. If we are not able to make the updates, due to patient care needs we will pass the task of updating to the care plan to the unit manager. In addition the CNAs will alert us to changes in care needs when POC is indicating a care need that is no longer relevant and we can go into the system and update the care plan. III. Resident #300 The resident fell in her room on 2/10/2020 sometime between 7:28 a.m. and 7:48 a.m. when the certified nursing aide (CNA) left her unassisted in the bathroom. The resident was left alone standing at the sink brushing her teeth when she lost her balance and fell. The resident was found minutes later, lying on the floor in the bathroom after the fall. The facility failed to provide a sufficient level of supervision and assistance per the resident's assessed need, as documented in the 2/9/2020 therapy assessment, to ensure the resident was safe. A. Resident status Resident #300, age [AGE], admitted on [DATE]. According to the January 2020 computerized physician's orders (CPO), diagnoses included difficulty walking, history of right femur fracture, muscle weakness and essential primary hypertension. The MDS had not been completed as the resident was recently admitted less than 14 days ago. The initial nursing assessment dated [DATE] revealed Resident #300: -Was admitted due weakness and chronic diarrhea lasting six days. -Had full use of both upper and lower extremities. She had a gait disturbance and was unsteady and needed assistance from one staff person for transfers and walking using a walker and a wheelchair for longer distances. -Was alert and oriented to person, place, time and situation. The admission physical therapy evaluation and plan of treatment dated 2/9/2020 revealed: Referral: The resident was referred for skilled physical therapy services due to decreased functional activity tolerance, decreased functional strength, decreased balance and decreased independence with functional mobility. Precautions: Resident was a fall risk. Functional and underlying impairments: The resident required: Hand on assistance of one or more staff cuing for the majority of tasks. She became dizzy upon sitting up; she had poorly controlled descent (ability to lower herself into a seated position) and required assistance for immediate standing balance; and she had reduced proactive and reactive balance with weakness in the muscles that aid in the ability to extend the trunk and hip for movement. B. Resident interview Resident #300 was interviewed on 2/10/2020 at 9:44 a.m. The resident was lying flat on her back, she said I'm not doing so well, I just fell. The girl helped me to the bathroom but she didn ' t have time to help me brush my teeth. She helped me back to my recliner. After she left I got up and went to the bathroom to brush my teeth and wash my face. She came in to check on me in the bathroom, but did not stay. She left me alone to finish brushing my teeth. As I was finishing, I turned and lost my balance; I fell. I must have laid on the floor for 15 minutes before they came in to help me up. The nurse hasn ' t been back in to see me and I'm in terrible pain. My left side hurts terribly, I can barely move my leg. They better help me, I wish they would hurry up. I recently healed from a braking my right hip after a fall at home. C. Record review The fall risk assessment dated [DATE] revealed the resident was assessed to be at high risk for falls with a score of 15 out of 1. She was not steady and only able to stabilize with assistance. Ambulates with problems, assistive device and required assistance. Daily skilled observations note dated 2/8/2020 and 2/9/2020 revealed the resident had unsteady gait requiring supervision and weakness. She needed partial to moderate assistance with toileting, bed mobility, moving from a sitting to standing position, and chair to chair transfers due to extreme weakness. The admission physical therapy evaluation and plan of treatment dated 2/9/2020 documented the following test measures and outcomes based on the assessment completed on 2/9/2020. This section revealed the resident needed supervision and touching assistance with lying to sitting on the side of the bed, sitting to lying and ro[TRUNCATED]