**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#2) of three residents reviewed for accidents out of three sample residents. Resident #2 admitted to the facility on [DATE] with a history of falls. Resident #2 sustained a fall on 11/21/24, 11/29/24, 1/4/25 and 1/23/25. After the resident sustained falls, the facility failed to implement timely interventions. On 1/23/25 the resident attempted to self transfer in the shower room where she fell and sustained a hip fracture. Review of Resident #1's electronic medical record (EMR) identified the facility failed to implement timely and effective interventions and ensure environmental hazards did not contribute to Resident #1's falls. Findings include: I. Facility policy and procedure The Accidents and Incidents-Investigating and Reporting policy, revised July 2017, was provided by the nursing home administrator (NHA) on 3/6/25 at 6:02 p.m. The policy read in pertinent part, All accidents or incidents involving residents, employees, visitors, vendors, occurring on premises shall be investigated and reported to the administrator. The policy identified the following steps that should be taken after the initial data was collected: The nurse supervisor/charge nurse and or the department director or supervisor shall complete a report of incident /accident form and submit the original to the director of nursing (DON) services within 24 hours of the incident or accident. The DON shall ensure that the administrator receives a copy of the incident/accident form on each occurrence. The incident/accident reports will be reviewed by the safety committee for trends related to the accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. II. Resident #2 A. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the March 2025 computerized physician's orders (CPO), diagnoses included acute and chronic respiratory failure with hypoxia, history of falling, generalized muscle weakness, abnormalities of the gate and mobility, need for assistance with personal care, cognitive communication deficit, difficulty walking and unspecified dementia, severe, without behavioral disturbance. The 2/19/25 minimum data set (MDS) assessment documented Resident #2 had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. Resident #2 required substantial/maximal assistance from a sit to stand position and was dependent on staff for a toilet transfer. She used a wheelchair for mobility. The MDS assessment indicated Resident #1 did not have rejections of care, physical or verbal behaviors directed to others or other behaviors or other behavioral symptoms not directed at others. The MDS assessment identified Resident #2 had a history of falls. According to the MDS assessment, Resident #2 had two falls without injury and one fall with a major injury since her admission or in the past six months and one fall without injury since her last assessment. B. Record review The fall care plan, initiated 11/20/24 and revised 12/10/24, identified Resident #2 was at risk for falls related to bladder and/or bowel incontinence, generalized weakness, history of falls and needing assistance with activities of daily (ADL). The fall interventions, initiated on 11/20/24, directed staff to implement preventative fall interventions/devices, ensure call light was in reach and needed items were within reach, educate the resident how to use the call light and monitor her for changes in mobility. The fall interventions, initiated on 12/10/24, directed staff to provide Resident #2 with non-skid footwear, conduct physical therapy (PT)/occupational therapy (OT) and speech therapy evaluations, educate the resident and her family to call for assistance before transferring and provide food and drinks within reach. The fall interventions, initiated on 12/12/24, indicated Resident #2 was impulsive, over estimated her abilities and needed to be kept within line of sight. The 12/12/24 fall intervention directed staff to place her in a recliner. The 12/12/24 fall intervention, revised on 1/22/25, directed staff to place anti-roll backs on her wheelchair. The fall intervention, initiated on 1/7/25, identified Resident #2 was placed on a toileting program. -The facility failed to implement timely interventions after Resident #2 sustained a fall on 11/21/24, 11/29/24 and 1/23/25. 1. Fall on 11/21/24 - unwitnessed The fall occurrence note, dated 11/21/24, identified Resident #2 was found on the floor in her room by a certified nurse aide (CNA). According to the note, Resident #2 was found on her back between the foot of the bed and the bathroom. The resident was toileted and brought to the nurse's station to keep within sight. The note documented the nurse completed a physical assessment to include range of motion. The resident was not able to move her right arm related to the presence of a right arm sling after a fall prior to her admission. The note documented the resident had a bump on the crown of her head but it was not known if the bump occurred at the time of the 11/21/24 fall or if the resident had the bump prior to her admission to the facility (11/20/24) from a fall at home. The note indicated the resident was not able to tell staff what happened other than she fell. Factors of the fall were identified as poor lighting and confusion. The 11/26/24 interdisciplinary team (IDT) meeting note identified Resident #2 was last toileted at 4:00 a.m. and checked at 4:45 a.m. The call light was in reach, her bed was in a low position, her wall light was on, she was incontinent at the time of the fall and was wearing socks. According to the note, the resident complained of shoulder and head pain. No other injuries were noted at the time of the incident. The nursing recommendation was to place the resident in a recliner in the line of sight. -The note did not identify if the socks the resident was wearing were non-skid or not. -The IDT note did not identify if the bump on her head occurred at the time of the 11/21/24 fall or if she had the bump from her last fall at home. -The review of the care plan did not identify new interventions were updated on the fall care plan until 12/12/24, three weeks after the 11/21/24 fall. 2. Fall on 11/29/24 - witnessed The 11/29/24 fall occurrence note identified Resident #2 had a fall. According to the note, a CNA observed Resident #2 attempting to transfer herself from her wheelchair to the recliner in the living room and she sat on the floor between two recliners. The resident had non-slip shoes on and her wheelchair was in front of her. The note indicated there were no injuries and she was placed in a recliner near the nurse's station. -The fall occurrence note identified Resident #2 was not placed in a recliner by staff as recommended in the 11/21/24 IDT note. The 12/3/24 IDT meeting note identified the recommendation after the fall was to implement a restorative program. -The restorative program for Resident #1 was not implemented until 12/13/24, two weeks after the fall (see interview below). -The review of the care plan did not identify that the restorative program was implemented as recommended on 12/3/24 by the IDT. 3. Fall on 1/4/25 - witnessed The 1/4/25 fall occurrence note identified Resident #2 was observed sliding from the recliner, down to the floor before staff could intervene. There were no injuries identified. According to the note, the resident stated she was going to the restroom. The 1/7/25 IDT note documented a video surveillance recording identified Resident #2 scooted herself over the edge of the recliner, walked around the foot rest, lost her balance and landed on her buttocks on the recliner foot rest which caused the recliner to tip forward. The resident slid down the foot rest and landed on the left side of her body. According to the note, there were no injuries and she denied any new or increased pain. The note indicated the resident did not ask to go to the restroom or was able to remember to ask for help. The nursing recommendations were to place the resident on a bowel and bladder toileting program. 4. Fall on 1/23/25 - unwitnessed The 1/23/25 fall occurrence note identified Resident #2 was found in a shower room on the floor at 7:45 a.m. The shower room door was propped open by a stool and unlocked. Resident #2 was laying on the floor on her right side with her pants pulled down below her knees. Her wheelchair was to the left of the resident and the brakes were unlocked. She was wearing non-slip shoes at the time of the fall. According to the note, during the nurse's physical assessment, the resident grabbed her right lower extremity in pain. Resident #2 had redness and light colored bruising to her right hip and a skin tear measuring 3 centimeters (cm) by 3 cm on her right knee. The note indicated the resident was sent to the hospital for an evaluation and treatment. The note documented the resident was last checked on at 7:40 a.m. Resident #2 was forgetful and overestimated her limitations. The bathing rooms were immediately locked. The 1/23/25 change in condition note identified Resident #2 returned to the facility with a diagnosis of a right femoral head fracture. Her family declined surgery. The note indicated the resident was on comfort-focused care. The note indicated the resident was attempting to crawl out of bed after returning from the hospital. The resident was placed in a recliner in view of the nurse's station due to her high fall risk. The 1/28/25 IDT meeting note identified staff were educated to keep doors locked for safety concerns as the nursing recommendation. -The fall care plan did not identify new care plan interventions were added after Resident #2 had another fall during a self-transfer that resulted in a broken hip (see care plan above). C. Education The 1/23/25 staff education sheet was provided by the NHA on 3/6/25 at 6:17 p.m. The education sheet identified 75 staff members were educated to keep all of the doors in the hallways locked, except for the resident's rooms. It indicated doors could not be propped open or left unlocked for staff convenience. According to the provided education, leaving the doors open was extremely dangerous. Staff was expected to frequently check all the doors on the hallways to ensure the hallway doors were properly closed and locked. The education indicated that disciplinary action would be taken if the doors were not secured. The 1/28/25 staff education participation record on reporting was provided by the NHA on 3/6/25 at 6:02 p.m. According to the education record, 71 staff members were informed/reminded to report changes, loss of balance (without a fall), falls, slips, trips, physical contact, choking, behaviors or any change of condition in a resident to the nurse. The education record documented it was the nurse's responsibility to document and assess once it was reported to the nurse. III. Staff interviews The DON was interviewed on 3/6/25 at 4:14 p.m. The DON said after a fall she conducted a fall investigation. She said during a fall investigation, she would look for any injuries/skin issues and review prior skin checks. She said if there were new injuries, she would look at the resident's environment to see if there was anything that the resident could have bumped into. The DON said staff documented the details of each fall in the risk management incident report and a fall occurrence note. She said she and the IDT reviewed who found the resident and at what time, how the resident was found, including the position of the resident, what the resident was wearing on their feet at the time of the fall, what was the lighting in the fall location, when was the resident last checked on and last toileted, was the resident continent at the time of the fall, was the resident wearing oxygen if they had a physician's order, was the call light in reach at the time of the fall, was it witnessed, was there a head injury and who was notified after the fall. The DON said Resident #2's fall on 11/29/24 was witnessed by a CNA. The resident was self transferring to a recliner in the living room. When Resident #2 was last checked on, she was continent. She was wearing non-skid shoes and the lighting was dim. The DON said the intervention was to continue to work with restorative nursing. She said Resident #2 started on a restorative nursing program on 12/13/24 after her November 2024 falls. The DON said the fall on 1/4/25 happened at the nurse's station. The resident landed on her left side of her body. The DON said the nurse was alerted when she heard a noise. The DON said it was not documented if Resident #2 was continent at the time of the fall, when she was last toileted or when she was last checked on. She said it was not documented what the resident was wearing on her feet at the time of the fall. The DON said the resident was able to say she was trying to go to the bathroom at the time of the fall. She said a bowel and bladder program was added to Resident #2's care plan and the CNA communication sheet/[NAME] on 1/7/25. The DON said Resident #2's fall on 1/23/25 resulted in a hip fracture. She said the resident was found in the shower room lying on her right side. The DON said it was not documented what time the resident was last toileted other than it was on the night shift. She said the resident was last checked on at 7:40 a.m. She said she did not check if the resident was asked to use the toilet at 7:40 a.m. The DON said the resident normally needed assistance to use the toilet. She said she did not know who last checked on the resident before she fell. The DON said the resident was not able to say what happened or why she was in the shower/tub room but she assumed the resident was attempting to use the toilet because her pants were down and she was near the toilet. The DON said the door to the shower/tub room was propped open, allowing Resident #2 to enter the room. The DON said she did not know why the door was propped open and the light was on. The DON said the day staff said it was open when they arrived on shift. The DON said she questioned the night staff but no one could tell her why the door was left open. The DON said after reviewing the fall investigations, she felt she needed to ask more questions to get a better idea of all the fall details and what all happened. She said she saw areas where she could work on improving with her fall investigations. The NHA was interviewed again on 3/6/25 at 5:28 p.m. The NHA said Resident #2's fall on 1/23/25, which resulted in a hip fracture was because she self transferred herself to the toilet in the shower room. The NHA said Resident #2 used the toilet and then fell. The NHA said the door to the shower room should not have been left open for her to be able to enter. The NHA said the staff were educated to close and lock the doors. The NHA said falls were reviewed with the IDT and the new fall interventions were updated by the DON in the care plan within a week of the fall. CNA #4 was interviewed on 3/6/25 at 6:49 p.m. She said she worked with Resident #2 at night and would help other CNAs toilet her. She said she was not aware of a bowel and bladder toileting schedule for her, but she said Resident #2 was toileted every two hours, which was standard for any resident who needed assistance. The DON was interviewed again on 3/6/25 at 6:55 p.m. The DON said Resident #2 would try to get up and go to the bathroom by herself and not tell anyone. She said the care planned intervention bowel and bladder program for Resident #2 after her 1/4/25 fall meant she would be toileted every two hours. The DON said all residents were checked on every two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #58 A. Resident status Resident #58, over the age of 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included cerebral infarction (stroke), hemiplegia (paralysis to one side of the body), and Alzheimer's disease. According to the 4/11/24 MDS assessment, Resident #58 had significant cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. Resident #58 required significant assistance with transferring, toileting, walking and incontinence care. The resident was dependent on staff for lower body dressing. B. Record review A review of the comprehensive care plan, dated 5/7/24 (during the survey), documented the resident was at risk to fall. Pertinent interventions included a bed alarm, fall mat near the bed, diversional activity items, resident education, food and fluids within reach, bed in low position, call light within reach at all times, monitoring mobility changes, non-skid footwear, a scoop mattress, therapy evaluations, a touchpad call light, anti-rollbacks to wheelchair, medication and sleep review by the physician and a recliner. -The bed alarm and touchpad call light interventions were documented in the progress notes after separate falls on 3/20/24 and 4/5/24 but were not added to the care plan until 5/7/24 (during the survey). -The comprehensive care plan failed to identify, review or change interventions after either the 4/19/24 fall or the 4/29/24 fall documented in the electronic medical record (EMR). Review of progress notes revealed Resident #58 fell on 4/19/24 and 4/29/24. The incident report for the fall that occurred on 4/19/24 was reviewed and documented on 4/22/24. -There were no new interventions implemented after the fall to prevent a recurrence. The incident report for the fall that occurred on 4/29/24 was reviewed and documented on 4/30/24. No injuries were reported from the fall. -There were no new interventions implemented after the fall to prevent a recurrence. C. Staff interviews CNA #2 was interviewed on 5/7/24 at 3:03 p.m. CNA #2 said they worked with the resident frequently. CNA #2 said Resident #58 had fallen a lot and that nursing staff did what they could to prevent it. CNA #2 said Resident #58's bed alarm did not prevent falls for the resident and it was only used for staff notification that the resident had already fallen. CNA #2 said the bedside fall mat had been helping the most and the resident had fallen more than a dozen times since the resident arrived at the facility on 3/19/24. The director of nursing (DON) was interviewed on 5/8/24 at 11:29 a.m. The DON said there was no documentation of interventions being added, changed, or updated following Resident #58's falls on 4/19/24 and 4/29/24. The DON and the NHA were interviewed together on 5/9/24 at 1:48 p.m. The NHA said Resident #58 was very restless and could fall even in the close presence of nursing staff. The NHA said staff often kept Resident #58 at the nurses' station because he suddenly changed disposition from asleep to awake and would try to walk unassisted. The NHA and the DON said there were no additional interventions identified or changed after the 4/19/24 or 4/29/24 falls. The NHA said the facility should have identified additional measures to help keep Resident #58 safe and prevent further falls. The NHA said Resident #58's family preferred not to use antipsychotic medications and this was an additional challenge for the facility to prevent falls for the resident. Based on observations, record review and interviews, the facility failed to ensure the residents' environment remained as free of accidents/hazards as possible prevent falls for two residents (#3 and #58) of four residents reviewed for falls out of 41 sample residents. Resident #3, who had a history of falling, was admitted on [DATE] and readmitted on [DATE]. Resident #3's fall care plan, dated 4/5/23, documented the resident was to wear non-skid socks as a fall intervention. On 4/16/23 Resident #3 sustained an unwitnessed fall. There were no new fall interventions added to the resident's care plan until 6/16/23, when an intervention for a scheduled toileting program was implemented. However, the care plan did not specify when the resident was to be toileted. Between 7/1/23 and 1/19/24, Resident #3 sustained six more falls. Several of the falls during that time frame occurred while the resident was attempting to take himself to the bathroom, however, the facility failed to ensure staff was following a toileting schedule for the resident as had been care planned on 6/16/23. Additionally, the facility failed to ensure other care planned interventions were in place at the time of several of the falls, including the intervention for the resident to wear non-skid socks. The facility identified for the resident's falls on 7/1/23 and 7/14/23 that the resident's oxygen levels in his blood were low which potentially was a factor for the falls, however, the facility failed to implement a fall intervention in regards to the resident's use of his oxygen. The facility failed to implement new fall interventions after the resident's falls on 7/1/23, 7/14/23, two falls on 8/2/23 and 8/14/23. On 1/29/24, Resident #3 sustained an unwitnessed fall. At the time of the fall, the care planned intervention of the resident wearing non-skid socks was not followed and the resident's blood oxygen level was again low. The fall resulted in a hip fracture which required the resident to be transferred to the hospital for surgical repair of the fracture. Resident #3 was readmitted to the facility on [DATE]. The facility failed to implement any new fall interventions after the resident returned to the facility following repair of the fracture. On 4/17/24, Resident #3 sustained another fall when he was not wearing non-skid socks. The facility again failed to implement any new fall interventions until 5/7/24 (during the survey). Due to the facility's failures to ensure staff were consistently following care planned fall interventions for Resident #3 and the failure to implement new fall interventions after each fall, Resident #3 sustained a fall which resulted in a major injury. Additionally, the facility failed to consistently identify, implement, review and update Resident #58's fall care plan with effective interventions to prevent further falls from recurring Findings include: I. Facility policy The Falls Clinical Protocol policy, revised March 2018, was provided by the corporate consultant (CC) on 5/9/24 at 1:58 p.m. According to the policy, many falls were isolated to individual incidents, however, a few residents fell repeatedly. Those residents often had an identifiable underlying cause.The nurse should assess and document the precipitating factors and details on how the fall occurred. The staff and the physician should identify pertinent interventions to try to prevent subsequent falls and address the risks of clinically significant consequences of the falls. The policy outlined the need and process for the fall cause identification, treatment and management, and monitoring and follow up. The policy read in pertinent part: For an individual who has fallen, the staff and the practitioner will begin to try to identify possible causes within 24 hours of the fall. Often, multiple factors contribute to a falling problem. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions based on assessment of nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. The staff and the physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed; for example, if the problem that required the intervention has been resolved by addressing the underlying cause. If the individual continues to fall, the staff and the physician will reevaluate the situation and consider possible reasoning for the resident's falling (instead of, or in addition to those that have been identified) and also reconsider the current interventions. II. Resident #3 A. Resident status Resident #3, over the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, history of falling, other abnormalities of the gait and mobility, generalized muscle weakness, age related osteoporosis, chronic obstructive pulmonary disease, hypoxemia, dependence on supplemental oxygen, neurocognitive disorder with Lewy bodies, unspecified intellectual disabilities, cognitive communication deficit and Parkinson's disease with dyskinesia (impairment in voluntary muscle movements). According to the 3/21/24 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The MDS assessment did not identify the resident had any falls or fractures since his last assessment. According to the assessment, the resident was occasionally incontinent of urine. The MDS assessment marked the resident was not on a bowel and bladder toileting program. The resident had no behavioral symptoms or rejections of care. The assessment read the resident did not have alarms in place which monitored the residents movement and alerted staff when movement was detected. B. Observations Resident #3 was assisted out of the dining room by the environmental service director (ESD) on 5/6/24 at 12:03 p.m. He was reminded to use his call light. The resident had a low bed and a fall mat in front of his bed. The ESD left the resident's room. At 12:05 p.m. Resident #3 started to propel himself in his wheelchair into the bathroom. A certified nurse aide (CNA) walking passed the room saw the resident and quickly entered the room asking him to wait for her. The CNA assisted the resident in the bathroom. At 12:12 p.m. the CNA assisted the resident out of his room and into the living room. The resident was not transferred to a recliner (see interview below). Resident #3 was observed in the dining room on 5/7/24 at 2:29 p.m. during a bingo activity. He stood up from his wheelchair. The activity assistant (AA) #1 did not notice the resident standing up. The AA was alerted and assisted him back down to his wheelchair and offered him a tissue/napkin. She locked the resident's right brake and continued with the activity. At 2:37 p.m. Resident #3 stood up from his wheelchair again while he attempted to pull his pants slightly up from the back and sat back down. On 5/8/24 at 2:12 p.m. Resident #3 sat in the living room in a regular upright chair. The resident did not sit in a recliner and he was not wearing his oxygen. On 5/9/24 at 8:35 a.m. Resident #3 attempted to self transfer from his wheelchair to a couch in the front lobby. The resident had one hand on the arm of the wheelchair as he stood. His wheelchair was at an angle and not directly behind him. The resident's arms and legs shook. He was not able to complete the pivot towards the couch. Staff was not present as he attempted to transfer. The resident was not in view of staff or the hallway. The business office manager (BOM) was alerted to the fall risk as she walked down the hallway. The BOM assisted the resident to the couch and notified other staff. C. Record review The fall care plan, dated 4/5/23, read Resident #3 was at risk for falls related to neurocognitive disorder with Lewy bodies, Parkinson's disease, history of falling, and unsteadiness on feet. The care plan goal was to minimize Resident #3's risk for falls and injuries. Care planned interventions initiated on 4/5/23 directed staff to: -Educate the resident and family to call for assistance before transferring; -Ensure food and fluids were within reach; -Implement preventative fall interventions/devices; -Ensure his call light was within reach and educate the resident how to use call light; -Ensure needed items were within reach; -Ensure the resident wore non-skid footwear; and, -Have physical therapy, occupational therapy, evaluate the resident. The activity of daily living (ADL) care plan, initiated 4/5/23, identified Resident #3 had a self-care performance deficit related to unspecified intellectual disabilities, neurocognitive disorder with Lewy bodies, and Parkinson's disease. 1. Fall #1 The 4/16/23 fall occurrence evaluation identified Resident #3 had an unwitnessed fall on 4/16/23 at 5:00 p.m. The CNA was notified by Resident #3's roommate of the fall. The CNA entered the room and observed the resident in his recliner. The resident had a red mark on his right upper back. The resident said he was walking to the bathroom and fell on his buttocks and his back hit the window sill or his recliner. The resident said he slipped out of his wheelchair. The evaluation read the resident was incontinent of his bladder and was unaware of his limitations. -Review of the above care plan did not identify new interventions that were put in place after the 4/16/23 fall. New fall care planned interventions were not initiated until 6/16/23 (two months after the fall). According to the 6/16/24 care plan, a toileting schedule was created for Resident #3. -The care plan did not identify when the resident was scheduled to be toileted. Additional interventions included: -Place the bed against the wall; -Place the wheelchair within reach; and; -The use of a low bed and fall mat. 2. Fall #2 The 7/1/23 fall occurrence evaluation identified Resident #3 had a witnessed fall on 7/1/23 at 5:15 a.m. The resident was not injured. The nurse saw the resident try to walk to the bathroom. Resident #3 lost his balance and fell to the floor on his buttocks. The bed was in a low position at the time of the fall and his call light was within reach. The resident did not attempt to push his call light. The lights were off at the time of the fall. The resident had socks on at the time but the socks were not the non-skid socks. -The evaluation did not identify why the resident was not wearing non-skid socks as was care planned. The resident could not explain why he fell. The evaluation did not identify if the resident was wearing oxygen at the time of his fall. The evaluation read Resident #3's most recent oxygen saturation levels were 79% on room air and 95% on four liters per minute (lpm) of oxygen. -Review of the above care plan did not identify new fall interventions that were put into place after the 7/1/23 fall to the bathroom. 3. Fall #3 The 7/14/23 fall occurrence evaluation identified Resident #3 had an unwitnessed fall on 7/14/23 at 1:30 p.m. No injuries were observed. The resident was observed on the floor in his room laying on his left side in front of his wheelchair and recliner. The wheelchair brakes were locked and the call light was attached to his recliner. The evaluation identified non compliance with transfers, the recliner, the two end tables and a dresser were potential contributing factors to the fall. The resident said he was going to the bathroom when he fell. The evaluation did not identify when the resident was last toileted, despite the care plan documenting that a toileting schedule had been implemented as a fall intervention for the resident on 6/16/24. -The evaluation did not identify what type of footwear the resident had on at the time of his fall. The resident's most recent oxygen saturation levels were 82% on room air. The evaluation read the resident declined to wear his oxygen. The 7/25/23 long term care evaluation read on 7/14/23 the housekeeper found Resident #3 on the floor after she heard a noise from his room. A 7/26/23 health status note identified Resident #3 was injured during the 7/14/23 fall. According to the note, he had fading bruises to his left hip and left shoulder from his previous fall. The review of the above fall care plan did not identify new fall interventions that were put into place after the 7/14/23 fall while attempting to go to the bathroom, including reviewing for new placement of the resident's furniture. -The fall care plan did not include the resident's oxygen use or his refusal to wear oxygen, increasing his fall risk. 4. Fall #4 The 8/2/23 health status note read the resident was shuffling when ambulating to the bathroom. The 8/2/23 fall occurrence evaluation identified Resident #3 had an unwitnessed fall on 8/2/23 at 6:45 p.m. The resident was not injured. The resident was observed sitting on the floor on the side of his wheelchair in front of his recliner. The wheelchair brakes were not locked. His call light was within reach. Resident #3's pants were around his legs as he laid on his right side. The resident said he needed to go to the bathroom. -The evaluation did not identify when the resident was last toileted, despite the care plan documenting a toileting schedule had been implemented as a fall intervention for the resident on 6/16/24. Contributing factors included a cluttered room and the resident forgot to use the call light. -The review of the above care plan did not identify new fall interventions were care planned, including ensuring the room was clutter free/free of obstacles. 5. Fall #5 The 8/2/23 fall occurrence evaluation identified Resident #3 had a second fall on 8/2/23. The second fall occurred at 8:00 p.m. in his room. The fall was not witnessed. The evaluation read no injuries were observed. The resident was observed sitting on the floor next to his bed. His call light was in reach. -The resident was not wearing non-skid socks, despite the care plan documenting that non-skid socks were implemented as a fall intervention on 4/5/23. The resident said he was going to the bathroom. -The evaluation did not identify when the resident was last toileted, despite the care plan documenting a toileting schedule had been implemented as a fall intervention for the resident on 6/16/24. -The review of the above care plan did not identify new fall interventions were care planned after the two falls on 8/2/23. The 8/3/24 incident note read Resident #3 had a 1 centimeter (cm) by 1 cm bruise on his left buttocks due to his recent fall. The 8/3/23 wound evaluation note read the resident had new treatment orders for scattered bruising due to his recent falls. According to the wound evaluation his right buttocks had a 2 cm by 2.2 cm bruise, a 5.5 cm by 10.5 cm bruise on his left upper arm, a 0.5 cm by 4 cm bruise on his chest, and two bruises to his left shoulder measuring 3 cm by 4.3 cm and 2 cm by 3.5 cm. 6. Fall #6 The 8/14/23 fall occurrence evaluation identified Resident #3 had a witnessed fall on 8/14/23 at 2:00 p.m. The resident was not observed to be injured. He was observed by a staff member to walk unassisted. The resident lost his balance and was lowered to the floor onto his buttocks.The resident was continent of bowel and bladder and was attempting to go into the bathroom. The resident said he needed to go to the bathroom. -The evaluation did not identify when the resident was last toileted, despite the care plan documenting a toileting schedule had been implemented as a fall intervention for the resident on 6/16/24. -The evaluation did not identify what footwear the resident was wearing at the time. -The evaluation did not identify if the resident was wearing his oxygen at the time of the fall. According to the evaluation, the resident refused to use his walker and would not call for assistance. -The review of the above fall care plan did not identify new fall interventions were care planned after the 8/14/23 fall. -The fall care plan did not identify the resident refused to use his walker. -The care plan did not identify an intervention for frequent monitoring of the resident related to his lack of call light use. The 8/15/23 interdisciplinary (IDT) note read the IDT team reviewed his falls. The nursing recommendations were a bowel and bladder program. The note read most of the falls were due to the resident needing to go to the bathroom. He was placed on a bowel and bladder program so staff would take him to the bathroom at least every two hours. According to the IDT note, the resident continued to attempt to use the bathroom without asking for assistance. Resident #3 was very focused on the task of going to the bathroom and not having an accident. He did not remember to ask for help. The note read the behavior was a usual behavior for the resident for many years, however, he had become more weak. He had tremors and had impaired coordination with his movements. The resident was working with restorative nursing for strengthening. The restorative program would start incorporating call light use prior to the bathroom in attempts to teach him to use the call light. The review of the incontinence care plan, initiated 4/5/23, read Resident #3 had episodes of bowel and bladder incontinence related to cognitive impairment, generalized weakness, pain and Parkinson's disease. The care plan intervention, dated 8/23/23, directed staff to assist Resident #3 with toileting every 2 hours and as needed. The fall care plan identified an added fall intervention on 12/18/23 of wheelchair anti-roll back breaks. 7. Fall #7 The 1/19/24 fall occurrence evaluation identified Resident #3 had an unwitnessed fall on 1/19/24 at 9:05 a.m. The evaluation read there were no injuries observed. The nurse was notified Resident #3 was on the floor in his room. The resident was observed sitting on the floor in front of his recliner. The resident was assisted back into his recliner. The resident said he slid out of his chair. The resident was educated and encouraged to use his call light. -The evaluation did not identify the foot wear the resident wore at the time of the fall. The evaluation read the resident's most saturation levels were at 90% on room air. The evaluation did not identify if the resident had his oxygen on at time of the fall. The evaluation did not identify if the resident had to use the bathroom or was incontinent at the time of the fall. The evaluation did not include if the recliner was reclined back at the time of the fall. The evaluation did not identify the resident's recliner was assessed for safety. The review of the fall care plan identified wheelchair brake extenders were added to the care plan on 1/19/24 as a fall intervention after the 1/19/24 fall. -However, according to the fall evaluation, Resident #3 fell out of his recliner, not his wheelchair, therefore the wheelchair brake extenders were not an appropriate intervention for the resident's fall from his recliner. -The care plan did not identify new interventions pertaining to the resident's recliner. The 1/22/24 IDT note read the IDT reviewed the 1/19/24 fall. The resident frequently self transferred and had been reminded to ask for assistance with transferring. According to the note, his previous interventions were brake extenders, anti-roll back and anti-tip brakes to his wheelchair. The new intervention would be to add a chair alarm to his wheelchair to notify staff to help the resident transfer one he initiated. -However, according to the fall evaluation, Resident #3 fell out of his recliner, not his wheelchair. -The review of the care plan identified the alarm was not placed on the resident's care plan until after his 1/29/24 fall with major injury. 8. Fall #8 The 1/29/24 fall occurrence evaluation identified Resident #3 had an unwitnessed fall on 1/29/24 at 8:45 p.m. The evaluation read the resident was assessed for injuries and assisted into bed by three staff members. The resident was unable to explain what happened. -The resident was not using oxygen, not calling for assistance and did not have non-skid/slip socks on at the time of the fall, despite the care plan documenting that non-skid socks were implemented as a fall intervention on 4/5/23. The resident's most recent oxygen saturation levels were 86% on room air. The evaluation read there were no injuries observed. The evaluation did not identify if the resident fell from his wheelchair, his recliner, or his bed. -The evaluation did not include when the resident was last checked on or when he was last toileted, despite the care plan documenting a toileting schedule had been implemented as a fall intervention for the resident on 6/16/24. The evaluation did not identify if the resident was incontinent at the time of the fall or if he had to use the bathroom. The evaluation did not identify if the resident's pull alarm was sounding at the time of the fall (see below). The 1/29/24 change in condition note read the resident had several complaints of upper thigh pain. The provider was notified on 1/29/24 at 10:17 p.m. The 1/29/24 health status note read Resident #3 left the facility by ambulance at 10:30 p.m. to the hospital emergency room for an evaluation. The 1/30/24 IDT note read Resident #3 was admitted to the hospital with a left hip fracture. He was expected to have surgery. The resident's safety interventions included anti-roll back and anti-tip brakes to his wheelchair and a pull tab alarm. According to the note, the IDT would re-evaluate his interventions once he returned back to the facility. The IDT note did not include additional fall investigation information that was not already included in the fall occurrence evaluation. The 1/30/24 health status note read the facility contacted the intensive care unit (ICU) and was informed the resident would probably have surgery on 1/30/24. The 2/2/24 health status note read Resident #3 was readmitted to the facility on [DATE] from the hospital. The resident was admitted with a diagnosis of a displaced intertrochanteric fracture of left femur. The resident had a large amount of bruising covering his entire left leg. The 2/2/24 hospital discharge instructions read the resident had a left hip fracture and a closed intertrochanteric fracture of the left femur. The review of the fall care plan identified an alarm was added on 1/29/24. -The care plan did not identify the type or where the alarm was placed. The fall care plan did not have additional new fall interventions added to the care plan until 3/11/24, over a month after the resident returned to the facility after a major fall with injury. According to the fall care plan, staff should monitor the resident for changes in his mobility. The ADL care plan interventions, initiated 3/11/24, read the resident required two person assistance for bed mobility, transfers and toileting. The 3/14/24 health status note read the resident had new recommendations from occupational therapy (OT) regarding the resident's wheelchair. A low back wheelchair was recommended for positioning and mobility. According to the note, the resident no longer used a high back wheelchair so his anti tip backs were no longer helpful to him. Therapy discontinued the resident's wheelchair alarm and offered to let him rest in the recliner, which he agreed to. 9. Fall #9 The 4/17/24 fall occurrence evaluation read Resident #3 fell on 4/16/24 at 9:15 p.m. The fall was unwitnessed. Resident #3 was observed sitting on the floor leaning against the bed. -Resident #3 had regular socks on, despite the care plan documenting that non-skid socks were implemented as a fall intervention on 4/5/23 . Resident #3 did not use the call light prior to getting up. His oxygen was removed. The resident was assisted to bed and his oxygen was placed back on him. The resident did not have injuries observed. The resident said he was trying to get to the bathroom. According to the evaluation, the contributing factors of the fall were poor lighting, wearing of regular socks (not non-skid), and failure to use the call light. He was incontinent but continued to get to the toilet. The fall care plan after the 4/16/24 fall identified the care plan intervention to mark the residents low bed and fall mat, implemented on 6/16/23 as a fall intervention, was revised on 4/18/24. The 4/18/24 IDT note read staff would add a low bed and a fall mat. -However the care plan identified a fall mat and low bed was already in place as of 6/16/23. The review of the progress notes identified the resident had a low bed as of 3/26/23. -The fall care plan identified no new interventions were put into place until 5/7/24 during the survey period. The care plan read non skid strips were initiated on 5/7/24. -The care plan did not identify where the non-skid strips were added. A 5/7/24 health status note read the resident had a new order for grip tape to the bathroom floor noted due to previous falls. D. Staff interviews The director of nursing (DON) and the nursing home administrator (NHA) were interviewed together on 5/9/24 at 11:23 a.m. The fall investigations were reviewed with the DON and the NHA. The DON said fall investigations should be conducted after each fall. She said she would want a clear investigation so staff could determine what happened to help with the prevention of future falls. Resident #3's 1/29/24 fall with major injury was reviewed with the NHA and DON. The NHA said the resident was found on his hands and knees on the floor. He did not have pain initially and was assisted to bed. The resident was reassessed after later complaints of pain and was sent to the hospital for an evaluation. The NHA said she did not know who found the resident after he had fallen. The NHA said the fall report did not identify when the resident was last checked on or when he was last toileted. She said staff were to do rounds every two hours on the resident. She said when a CNA would start their shift at 6:00 p.m.,after a report was given, the CNA would start rounding every two hours on all residents on their designated hall. The DON and the NHA said the fall documentation did not identify if the resident was incontinent at the time of the fall or if he needed to use the bathroom when he was found. The NHA said the documentation did not identify environmental factors in his room such as lighting. The documentation did not identify where the resident was found in his room such as in front of his wheelchair or bed. The documentation did not identify what the resident was doing before he fell. The NHA said staff interviews pertaining to the fall were not collected. The NHA said the resident was usually able to say what happened or what he was trying to do at the time of fall. The NHA said the fall documentation read that the resident was not able to explain what happened. The NHA and DON said the fall documentation identified the resident did not have his oxygen on or non-skid socks and there were no other fall-related factors documented. The NHA said she did not know why the resident did not have non-skid socks on, other than the possibility he did not want to wear them. She said he was very routine. -However, the resident was not care planned for refusing to wear non-skid socks. The NHA said the resident had low oxygen saturation levels at the time of the fall. The staff had to remind him to wear his oxygen all the time. The DON said Resident #3 needed to wear oxygen for COPD. She said when he did not wear his oxygen, he was at an increased risk f[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure effective fall prevention interventions for one (#51) of seven residents reviewed for falls of 30 sample residents. Specifically, the facility failed to: -Accurately assess Resident #51 for fall risk after a fall outside of the facility; -Implement immediate actions to prevent further falls/incidents after Resident #51 reported a fall; -Reassess Resident #51's risk for falls after the resident reported a possible fall; -Conduct a timely investigation after Resident #51 reported a fall; -Ensure Resident #51's call light was within reach; and -Ensure adequate supervision to prevent unsafe resident self-transfers. Record review showed the resident was evaluated for increasing weakness concerns by nursing staff, and a risk for falls after a fall outside of the facility. Interviews with the director of nursing showed the resident was declining prior to his fall with injury; however, there were no new interventions implemented at that time to prevent falls. These failures resulted in the resident experiencing one self-reported fall and three unobserved falls, one of which resulted in a hip fracture requiring hospitalization with surgical intervention of the fracture. Findings include: I. Facility policies and procedures The Preventing Falls policy, no date of inception or revision, provided by the nursing home administrator (NHA) on 1/23/2020 at 10:00 a.m., documented identifying residents at high risk and planning appropriate care and keeping necessary items within reach can reduce the risk for falls. Residents at high risk for falls were those with a history of falls, those who use assistive devices, and those with changes in health status. The facility shall investigate cause of accidents as per facility accident/incident protocol, monitor the residents response to the accident, develop and implement an individualized plan as part of the care plan, and evaluate and revise the plan as needed. Preventing falls was the responsibility of all staff members and the resident, the staff must be sure the environment was safe, health needs were met, and the residents had the necessary information to promote their own safety. The Accident/Incident Report policy, no date of inception or revision, provided by the NHA on 1/23/2020 at 9:12 a.m., documented the accident/incident report was completed for all unexplained bruises or abrasions, all accidents or incidents where there was injury or the potential to result in injury: allegations of theft and abuse reported by residents, visitors, or others; and resident to resident altercations. An investigation would be initiated within 24 hours of the discovery of a resident with an injury of suspicious or unknown origin, or receipt of an allegation of abuse. Investigation and findings must be documented and submitted to the long term care facilities medical staff for review. II. Resident #51 A. Resident status Resident #51, age [AGE], was admitted [DATE]. According to the January 2020 computerized physician orders (CPO), diagnoses included Parkinson's disease, dementia with Lewy bodies, chronic obstructive pulmonary disease, and dependence on supplemental oxygen. According to the 9/10/19 minimum data set assessment (MDS), the resident was moderately imparied cognitively with a brief interview for mental status (BIMS) score of eight of 15. The resident did not reject evaluation of care including activities of daily living. The resident required limited one person physical assistance with transfers and bed mobility, toilet use, and personal hygiene. The resident was not steady but able to stabilize without human assistance with walking, turning, moving on and off the toilet, and moving from a seated to standing position. The resident used a walker, exhibited shortness of breath with exertion such as walking, and was occasionally incontinent of urine. B. Resident interview Resident #51 was interviewed on 1/20/2020 at 3:41 p.m. The resident said he fell a few weeks back trying to go to the bathroom and hurt his leg. He said it hurt him, but the facility gave him some medicine which helped. III. Record review A. Resident care plan The resident's care plan, problem onset 3/13/13 and revised 3/10/18, showed the resident had a potential for alteration in skin integrity related to dependency on staff/family for assistance with ADLs and cares with occasional incontinence. The resident problem of diagnosis of osteoporosis with potential for fracture or injury was initiated on 3/13/13, with an approach to ensure room was free of clutter and safety hazards and to ensure the residents call light and frequently used items were within easy reach, and to answer light promptly. The resident's problem onset for potential for injuries/falls as he was ambulatory and has a portable oxygen tank that he keeps on his walker was initiated 3/15/13 and revised 3/1/18. Approaches to this problem were to ensure the room was kept free of clutter and safety hazards, and keep call light and frequently used items were within easy reach. B. Resident falls 1. Fall number one a. Resident accident/incident report A resident accident/incident report, completed 9/10/19, showed the resident experienced a fall outside of the facility while out on pass. The Resident stated he fell on the concrete and hit only his right hand. A bruise was noted to the right hand of the resident. The incident was not reported immediately by the resident or the group that took the resident out on pass. Immediate post incident action was to encourage residents to notify staff when a fall occurs so that the staff could take immediate care of the resident. A narrative of the investigation, completed by the director of nursing (DON), on 9/10/19 read, Resident reports that while he was out on pass with (local community group), he fell on the sidewalk. Resident states that he wasn't paying attention, and just fell. Resident's disease has progressed, and after discussion with PT (Physical therapy) and management, will have the resident use a wheelchair when going out on pass. Neuros were started as per protocol once staff were notified of the fall, all neuros and vital signs have been within normal limits. No other injuries noted other than the bruise to hand. b. Fall risk assessments 1) September 2019 assessment A fall risk assessment completed 9/19/19 (nine days after incident report) showed: Type of fall assessment: Monthly Mental Status: Score 0 as resident was assessed to be alert and oriented x 3, or comatose Falls in past three months: Score 0 as resident was assessed to have had no falls in last three months. Ambulation/Elimination status: Score 0 as resident was ambulatory and continent Vision status: Score 0 as resident vision was assessed as adequate with or without glasses. Gait Balance: Score 1 as resident required use of assistive devices such as walker. Systolic Blood pressure: Score 0 no drop between lying and standing, or not done. Medications: Score 2 as resident took 1-2 of fall risk medications in the last 7 days. Predisposing diseases: Score 2 as resident had 1-2 predisoposing conditions. Total score of 5, 10 or above deems high risk for falls and should be monitored closely for fall precautions. 2) October 2019 assessment The October 2019 fall risk assessment was the same selections and score as the September 2019 assessment. Fall risk assessments were requested for up to current January 2020; however, only up to October 2019 were provided. c. Occupational therapy notes An occupational therapy daily treatment note, completed 9/19/19, showed the resident was having more difficulty with walking when on outings and was in need of a wheelchair. An occupation therapy plan of care evaluation, completed more than a month later on 11/2/19, showed the reason for referral was due to increased weakness noted. Orders received to upgrade his restorative program. The resident had been at the long term care facility since 3/2013 and had been mobile around the facility with a four wheeled walker, but nursing stated that recently he had seemed less steady and more fatigued after returning from outings. Therapy precautions in place were oxygen, falls, tremors, and lewy body dementia. d. Facility failure The facility selected on both the September and October 2019 fall risk assessments the resident had no previous falls in the last three months. However, the incident report, dated 9/10/19, showed the resident experienced a fall while outside of the facility on pass and suffered a bruise to his right hand. This section of the fall risk assessment should have been selected as score 2 as the resident experienced 1-2 falls in the past three months. Under the section of ambulation/elimination, the facility selected the resident was ambulatory and continent. However, according to the resident's MDS assessment and care plan, the resident experienced episodes of incontinence. The facility should have selected score 4 ambulatory and incontinent, which would have increased the resident's total fall risk score to 11 making the resident at risk for falls. 2. Fall number two a. Accident/incident report An accident/incident report, dated 12/18/19 at 7:30 p.m., completed due to bruises of unknown origin, documented an unobserved fall with head bump/injury in the resident room. Staff observation notes showed the right side of the resident's face was swollen, hard, warm, and bruises under chin. The resident reported, I hit something going to the bathroom. Actions taken were noted to be neuro checks, offered ice packs but patient declined. There were no interventions documented under the the section actions taken to prevent further accident/incidents. b. Record review A nurse's note dated 12/18/19 at 7:30 p.m. read, Certified nurse aide (CNA) reported to this nurse that the resident's right cheek was swollen. The nurse assessed it, cheek was warm to touch. Resident denied pain. CNA after getting vital signs noticed when resident laid down that there was bruising under the chin, upon reassessing and interviewing the resident, neuros were started. Resident stated he hit his cheek on something while going to the bathroom. This nurse questioned resident as to if he fell. The resident did not answer the question directly but did say he may have put himself on the bathroom floor. There was bruising, two large one small, under chin and redness throughout. There was a hard spot in the middle of cheek on the right side of the face, vital signs within normal limits, temp was a low grade fever in the 99's. Resident resting, call light within reach, resident refused ice pack. A nurse's note on 12/19/19 at 12:00 p.m. documented the resident had increased swelling, redness, and warmth to the right ear and neck area. The resident was started on antibiotic therapy for suspected cellulitis. The follow up investigation from the reported fall from the resident, completed by the director of nursing (DON) and dated 12/20/19 no time stamp (more than 24 hours after resident self-reported possible fall), documented, Resident reports he thinks he fell out of bed causing the injury to his ear. However, resident did not call for help to get up before fall or report the fall until staff noticed ear. Resident has a scratch to his right ear, believed to be caused by resident himself, as resident has been seen on several occasions sitting in his recliner scratching at neck, face, mostly due to his Parkinson tremors. Suspected that the resident scratched self, causing wound then infection. If resident did fall, the resident would not have the ability to get up off the floor on his own and would need assistance. Since the resident did report a fall, routine neuros started per protocol and antibiotics started for wound/cellulitis. There was no fall risk assessment provided after the resident self-reported fall. Further nursing notes and the December 2019 medication administration record showed the resident was diagnosed with the shingles virus (cause of the bruising) and started on by mouth antivirals on 12/20/19 then intravenous antivirals on 12/24/19. c. DON interview The DON was interviewed on 1/23/2020 at 9:48 a.m. The DON said when a resident reported a fall they would make sure they are safe. If they determined the resident was OK to keep in house they would start vital signs, neuro checks, and monitor the resident. They would immediately start an investigation to determine the cause of the fall. She said investigations of falls were completed by her, and depending on when the fall happened it could impact the investigation. If it were to happen on the weekend when she was not there, she would conduct it when she returned to the building. She said even if the resident was not alert and oriented she would still ask the resident to see if they could recall the accident. She said she sometimes would start the investigation right away, but not get to the report for a couple days. She said the investigations and actions to be put in place were documented on the accident/incident reports. She said the resident's self-reported fall on 12/18/19 looked like classic cellulitis from a scratch, but the resident said he must have fallen and since he reported a fall they started their fall protocol on the resident. The DON said she was unsure of why the staff member did not document any actions to prevent further incidents on the investigation incident form, and the delay on the follow up investigation not being dated until 12/20/19 could have been because she didn't get to the report until that day. She said they honestly did not feel like the resident fell so no changes were made to his care plan in relation to falls, only to the skin issues at the time. She said the bruising was caused by the shingles rash. She said it was determined the resident could not have gotten up off the floor because they felt he was physically unable to due to needed physical assistance to do almost all things. d. Facility failure The facility failed to implement immediate actions to prevent further incidents after Resident #51 self-reported a possible fall. An investigation into the resident's fall was delayed, and not completed in a timely manner. No changes were made to the resident's care plan in relation to falls or new interventions or precautions put in place to prevent further falls. Therapy documentation showed the resident was referred for increasing weakness by nursing, and fall precautions were part of the therapy plan. Interventions after the first fall outside of the facility were to encourage the resident to report falls so staff could take care of the resident. The resident reported a possible fall; however, no further interventions were noted. e. Nursing notes A nursing note dated 12/26/19 at 3:00 p.m., showed Resident #51 was on intravenous therapy without complaints of dizziness on that shift. The resident was reminded to call for assistance with transfer. A nursing note, same date 12/26/19 no time stamp, showed the resident was more tired than baseline and fluids were encouraged. 3. Fall number three a. Accident/incident report An accident/incident report, completed 12/26/19 at 8:25 p.m. provided by the facility, showed the resident experienced an unobserved fall without head injury in the resident's room. The staff observation of accident documented a certified nurse aide (CNA) was walking down the hall and saw Resident #51 on his knees by his bed. Actions taken were documented, the RN was notified, an assessment completed, and vital signs and neuro checks were completed. Actions taken to prevent further accident/incidents were noted to remind the resident to use his call light when needing assistance. b. Nurse's note The registered nurse's note from 12/26/19 at 8:30 p.m. revealed the resident was found on the floor by a CNA, when the nurse arrived the resident was sitting on the bed. Neuro checks and vitals were within normal limits. The resident at that time denied pain, and the family and facility administration were notified of the fall at 8:43 p.m. The resident stated he reached for the TV remote and fell on the floor but he was not very descriptive about the incident. Resident then received intravenous (IV) medication which at the end of the treatment the IV infiltrated, the resident still denied pain from the fall at that time. The nurse reported she was helping the resident stand and the resident was not able to bear weight and complained of right knee pain. The physician was notified of the change in condition and the resident was transported to the local emergency department. The nurse noted the x-ray from the hospital showed a right hip fracture, and he was reported to have abnormal labs (unrelated to fall) and would be kept inpatient. A follow up nursing note dated 12/27/2019 at 4:25 a.m. documented the hospital had called the facility relaying the resident's family decided on surgery and Resident #51 was transported to a larger medical center in a nearby city. c. Hospital inpatient records Hospital records from Resident #51's inpatient stay, admission date 12/27/19, showed the resident required surgical intervention with a right hip nail for a right osteoporotic intertrochanteric fracture status post ground level fall. 4. readmission and fall number 4 a. Resident #51's face sheet and progress notes showed he was readmitted to the facility on [DATE]. b. Accident/incident report An accident/incident report dated 1/4/2020 at 5:30 p.m., showed the resident was found on the floor near his wheelchair on his knees while going to or from the bathroom alone. Immediate actions taken were noted to include vital signs and neuro checks, and an assessment of his range of motion with lower and upper extremities which were within normal limits. Further post-incident actions were noted the resident was placed near the nurses station. c. Investigation A follow up investigation, dated 1/6/2020 at 6:12 p.m., completed by the DON, documented the resident reported he did remember falling onto his knees, but he could not recall what made him fall or how he fell. The resident stated he had been on some different medications, and maybe that was the cause. The resident had recently returned from the hospital after hip fracture and forgot to call and ask for help with transfers; no new injuries were noted from the fall or new medications. 5. Fall number 5 a. Accident/incident report According to the accident/incident report dated 1/8/2020 at 1:45 p.m., the resident was found on the floor after the hall CNA and MDS nurse heard a loud noise. The resident's window was broken. Immediate actions taken were neuro checks, the resident was removed from the area of broken glass, vital signs and range of motion assessed. The resident was toileted and showered to ensure all broken glass was off the resident. Other immediate post-incident actions were noted to encourage the resident to ask for help and use his call light, and to remind the resident he has to get assistance now since returning home from the hospital after having surgery from his hip fracture. b. Investigation An investigation, completed by the DON on 1/8/2020, revealed the resident reported he was getting up to go to the bathroom before he went in his pants. The resident apologized several times for falling and breaking the window. The DON was present at the time of the incident and assisted with the assessment. The resident forgets he recently had a hip fracture and surgery for this fracture, and forgets he needs assistance with transfers and ADLs now. Re-education and reminders to resident. No injuries noted from fall. Resident was taken to bathroom and toileted after assessment and determined to be stable. The resident's IV pole was determined to be the cause for the glass breaking as the investigations showed the resident grabbed the IV pole as he was falling and the pole hit the window. IV. Observations On 1/20/2020 at 3:27 p.m., Resident #51 was observed in his room self transfering from his recliner to his wheelchair. The resident appeared to be unsteady and shaking due to his disease process. CNA #7 was observed rushing to the resident's room and was overheard telling the resident he was not supposed to get up by himself. At 3:46 p.m. after CNA #7 toileted the resident and returned him to his recliner, the CNA left the room with the call light out of reach of the resident. An unknown maintenance staff member was also observed entering the resident's room to help the resident with his television remote, and after the maintenance staff left, the call light was still out of reach of the resident. On 1/21/2020 at 8:43 a.m. Resident #51 was observed in the resident common area self transferring from a recliner to his wheelchair. The resident was having difficulty pivoting to the wheelchair and was up for several seconds before the activities director noticed him and came over to help him. On 1/21/2020 at 11:55 a.m. CNA #7 was observed exiting Resident #51's room after assisting the resident with toileting. The call light was observed to be over on the resident's bed out of reach while he was in the recliner. On 1/22/2020 at 4:38 p.m. Resident #51 was observed standing in his room, hunched over and shaking while unsteadily holding on to his wheelchair, attempting to pivot. There were no staff around. His call light was attached to his recliner and not within reach. V. Staff interviews CNA #1 was interviewed on 1/22/2020 at 1:04 p.m. She said Resident #51 required extensive assistance with cares after his recent hip injury. She said he used to require limited assistance with his walker, but now they had to toilet, dress, and help him with almost everything. She said he was not supposed to self transfer, but he loved to try. Because of that he was one they had to watch all the time. She said they tried to keep him up front by everyone and staff, so they could keep an eye on him. She said they don't take him back to his room by himself because he would just try to get up by himself. She said Resident #51 did not like to use his call light, but instead he liked to verbally ask for his needs. However, she said with reminding he would sometimes use the call light. She said prior to the fall he wasn't a fall risk and he did not have many falls. She said he was walking with a regular walker with wheels prior to the injury. After the fall she said they could not leave him alone anymore. She said he did not refuse care and was very nice, and he was very alert and oriented and able to make his needs known. She said prior to leaving a room all staff should ensure residents' beds were in the lowest position if they were in bed, and their water and call light were within reach. RN #1, also the facility charge nurse, was interviewed on 1/22/2020 at 2:00 p.m. She said she had been working at the facility for a year and was familiar with Resident #51's cares. She said Resident #51 required pretty extensive assistance with everything, but he could feed himself. She said he was not supposed to self-transfer and they tried to keep a close eye on him. She said prior to the fall with his injury, he was very mobile with a walker. She said they were trying to keep Resident #51 up front so they could see him, but when in his room they really tried to encourage him to ask for assistance and use his call light. She said prior to his fall he was not a fall risk, but interventions in place were assistance with using the restroom and using his call light. She said most of the time he was alert and oriented and able to make his needs known, but sometimes he could be disoriented to time. She said there were a lot of times the resident would use his call light as he was already transfering himself. She said the resident's mobility had decreased and assistance needs increased since the fall with the injury, but he had not really complained of pain. She said staff should ensure residents' call lights were within reach, beds in the lowest position, and water or anything they needed were within reach prior to leaving a resident's room. The DON was interviewed on 1/23/2020 at 9:48 a.m. She said all staff, not just nursing, should make sure residents' needs had been met, call light within reach, and anything they needed like water were within reach prior to exiting a resident's room. She said Resident #51 was not as alert and oriented as he used to be, and some days were better than others. She said he was not always able to make his needs known. She said he almost always needed full assist with cares now, but even prior to the fall with injury he needed more assistance due to a slow decline. She said he had a lot of shaking and tremors and required lots of assistance because of that prior to his fall. After the fall she said mostly an increased need with transfers was required due being more cautious with his hip. She said he would use his call light as he was transferring and lacked the cognition to wait for assistance from staff. She said the call light was not appropriate for the resident, and a lot of the time he would yell at them to ask for help especially before the fall. Now, he was using the call light just as he transferred. She said he had not been a fall risk prior to the fall, but he was placed on IV therapy prior to the fall. She was unsure if IV therapy increased the risk for falls. She said Resident #51 was not supposed to self transfer, and they were working on that as much as they could. She said interventions after the fall were trying to help as much as possible not to transfer alone, and keeping the resident in activities so he could be supervised, as well as working with therapy. She said Resident #51 had fallen again since the fall with the hip fracture, and they were trying with the resident. She said every time he fell they tried to keep him out of his room as much as possible without neglecting his wants to be in his room. They were trying to respect his wishes at the same time.