**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#92) of three residents reviewed for pressure injuries out of 29 sample residents remained free from worsening of a pressure injury. Resident #92, was admitted on [DATE] for short term rehabilitation with a goal to return home. The resident was admitted to the facility without any skin conditions. The resident had a fall on 4/5/23 in which he sustained a right hip fracture. In addition, the resident had a subsequent fall on 4/20/23 in which he refractured his right hip around the periprosthetic (structure in close relation to an implant), a distal femur fracture (fractures of the thigh bone that occur just above the knee joint) and nondisplaced left superior pubic fracture (a break in one of the bones that make up the pelvis) The resident sustained numerous falls including two falls with major injuries during his care at the facility that led to his functional decline (cross-reference F689). Due to the resident's functional decline staff were required to turn and reposition the resident to prevent pressure injuries from forming and or subsequently worsening. The facility failed to implement effective interventions to prevent the resident's open areas (discovered on 4/17/23) from progressing to an unstageable pressure injury (4/21/23). Findings include: I. Professional reference The National Pressure Injury Advisory Panel, https://npiap.com/page/PressureInjuryStages accessed on 5/12/23 read in pertinent part: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. The National Pressure Injury Advisory Panel (NPIAP), Prevention and Treatment of Pressure Ulcers reads that steps to prevent the emergence of pressure ulcers in individuals identified as being at high risk include scheduled repositioning to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: -Positioning that places pressure on the pressure ulcer should be avoided. -The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -Signs of deterioration in the wound should be addressed immediately. -The assessment should include: location, category/stage, size, tissue type, color, peri-wound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. II. Facility policies and procedures The Pressure Ulcer/Injury Risk Assessment policy and procedure, dated March 2023, was provided by the social services quality mentor (SSQM) on 5/10/23. In pertinent part it read: to assess and implement interventions as appropriate to reduce the likelihood of development of pressure injuries, and that a resident who has a pressure injury receives appropriate care and services to promote healing and to prevent additional pressure injuries. Daily monitoring with accompanying documentation should include: an evaluation of the status of the dressing, including tissue surrounding the pressure injury. Interventions to protect against the effects of pressure, friction, and shear include: reduce pressure over bony prominences by offloading and positioning and develop turning and repositioning plans for residents in bed or chair. A care plan will be developed with a plan of care in conjunction with the multidisciplinary team based on the individual's goals. Provide dressing and treatments as ordered by the physician and per the plan of care. III. Resident #92 A. Resident status Resident #92, age [AGE], was admitted on [DATE] and passed away on 5/7/23. According to the May 2023 computerized physician orders (CPO), diagnoses included unspecified dementia without behavioral disturbance and muscle weakness. The 3/3/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score five out of 15. The resident required supervision with transfers, walking in the room, dressing, toileting and personal hygiene. He was always continent of the bowel and bladder. The resident was not at risk for developing a pressure ulcer and the resident was not admitted with a pressure ulcer. B. Representative interview The resident's wife was a resident at the facility and resided in the same room as Resident #92. The resident's wife was interviewed on 5/3/23 at 3:15 p.m. She said the wound started shortly after he fell and the facility barely checked on it. Resident #92 would be lucky to even have them reposition him every four to six hours, sometimes it could be as long as 12 hours. The nursing staff did not consistently change the dressing. Resident #92 did not receive an air mattress until hospice got involved, but he was already bed ridden and was waiting to pass away since his fall on 4/11/23. C. Record review The Braden Scale Observation/Assessment (for predicting pressure sore risk), dated 2/28/23, revealed a score of 22, which indicated the resident was not at risk for the development of pressure injuries. The resident was in the hospital 4/5/23 to 4/8/23 from a fall where he sustained a right hip fracture (cross-reference F689) making him at increased risk for developing pressure injuries with reduced mobility. The Braden Scale Observation/Assessment, dated 4/9/23 (after the resident sustained six falls with injury and a decline in cognition and function), revealed a score of 13, which indicated the resident was at moderate risk for the development of pressure injuries. -No specific interventions were noted in the assessment. The Braden Scale Observation/Assessment, dated 4/11/23, revealed a score of 15, which indicated the resident was at risk for the development of pressure injuries. -No specific interventions were noted in the assessment. The Braden Scale Observation/Assessment, dated 4/21/23, revealed a score of 14, which indicated the resident was at moderate risk for the development of pressure injuries. The Braden Scale Observation/Assessment , dated 4/26/23, revealed a score of 13, which indicated the resident was at moderate risk for the development of pressure injuries. -No specific interventions were noted in the assessment. The incident report dated 4/17/23, revealed Resident #92 acquired a skin injury that was not pressure related. The resident was observed with a skin injury not pressure related. The root cause of the incident: decreased mobility with incontinence. Treatment required: area cleansed and barrier cream applied. Interventions put into place: Barrier Cream - facility protocol. Referrals made: wound nurse and medical doctor (MD) were notified. The nursing note dated 4/17/23 at 1:37 p.m. revealed call placed to MD #1 requesting treatment orders and to inform him about a top layer skin shearing to right medial buttocks nickel sized area and noted surrounding area with blanchable redness up to coccyx site. Return call pending and placed skin protocol. -The wound care physician assessed the resident on 4/27/23 (see below). The resident was in the hospital from a fall from 4/20/23 to 4/22/23 due to a fall (cross-reference F689). The 4/20/22 hospital documentation revealed the resident's skin was warm, dry, no erythema (superficial reddening of the skin) and no rash. The nursing progress dated 4/22/23 read, The resident has a bruise on left elbow and small bruises to right hand and upper arm, two small open areas to buttocks near coccyx. -The resident was readmitted from the hospital with two small areas to his buttocks near his coccyx. There were no measurements or indication the resident had a pressure injury after being readmitted from the hospital. Five days later the resident had an unstageable pressure ulcer with 100 percent slough (dead tissue, often yellow/white in color and can be spongy or creamy in texture). -There were no physician's orders for the two open areas to his buttocks near coccyx indicated on the 4/22/23 progress note until 4/27/23 (see below). According to the physician orders, the resident was admitted to hospice care on 4/23/23 for progressive decline in cognitive and functional status. The physician's order dated 4/27/23 revealed an order that read Sacral wound clean with normal saline or wound cleanser, apply Medihoney and cover with foam dressing every day shift every Tuesday, Friday, Sunday for pressure wound. -The order was not carried out by nursing staff on 5/2/23. -The order was discontinued on 5/4/23 (during the survey process) and updated. The updated order read sacral wound clean with normal saline or wound cleanser, apply Medihoney and cover with foam dressing every day shift every Monday, Wednesday, Friday for pressure wound. -The physician's orders did not include an order for turning and repositioning. -The physician's orders did not include an order for an air mattress. The wound care physician note dated 4/27/23 read, hospice to provide air mattress. -The air mattress was provided by hospice on 4/24/23 (seven days post wound identification by the RN; the resident was at risk of pressure injury after returning from the hospital with a hip fracture on 4/8/23. The wound care note dated 4/27/23 revealed Date of Onset: 4/21/23; type of wound: pressure; site of wound and current measurements: sacrum 3 x 1.5 x 0.2 (centimeters); stage of wound if injury is pressure related: unstageable; wound bed description: 100 (percent) slough. Surrounding skin condition: mild erythema (abnormal redness of the skin or mucous membranes due to capillary congestion, as in inflammation.) Interventions in place/equipment: reposition, hospice to provide air mattress; current treatment order: honey, foam; progress of wound: readmitted with pressure injury. Comments: education provided, updates to family, resident, MD, care plan updates, consults: end of life. The wound care note dated 5/4/23 revealed Date of Onset: 4/21/23; type of wound: pressure; site of wound and current measurements: sacral 3 x 2 x 0.1; stage of wound if injury is pressure related: unstageable; wound bed description: 100 eschar (collection of dry, dead tissue within a wound.); surrounding skin condition: mild erythema. Interventions in place/equipment: air mattress; current treatment order: honey, foam; progress of wound: co change; comments: education provided, updates to family, resident, MD, care plan updates, consults: end of life, not eating, hospice care. The 5/2/23 nutrition/dietary note revealed Resident with unstageable pressure injury on sacrum. His condition is declining, admitted to hospice. Nurse reports his oral intakes are very poor, closes lips, gets combative when encouraged to eat/drink. Currently unrealistic to meet estimated needs for wound healing. Will continue with order for oral supplements-provide as accepted and tolerated. Will monitor. The comprehensive care plan for pressure wound, initiated on 3/2/23 and revised on 5/8/23 revealed the resident was readmitted with an unstageable pressure wound to the sacrum due to decreased mobility, cognitive deficits, poor appetite, incontinence and end of life. -The care plan revealed the resident was readmitted with an unstageable pressure injury. The care plan is in contrast with the nursing progress note (see above). On 4/19/23 the care plan was updated with following interventions: Encourage adequate by mouth (po) intake and acceptance of registered dietician's recommendations to aid in wound healing, reposition frequently for comfort throughout shift, utilize pressure relieving devices/adaptive equipment when appropriate to potential pressure areas. The resident uses pressure relieving mattress. -Pressure relieving equipment was not provided until 4/24/23 (five days after the care plan's start date of the intervention). -Repositioning frequently, which did not provide a defined standard of care for the staff to follow. The treatment administration record (TAR) did not include physician recommendations for offloading and or repositioning. -The facility was unable to provide task documentation to evidence the resident was repositioned. -The task ADL-self mobility was reviewed from 4/9/23 to 5/7/23 indicated the resident was turned on average every 7.5 hours per 24 hours within the last 30 days. IV. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 5/9/23 at 10:17 a.m. He said he was new to the unit, but provided care for the resident for a few weeks. The care he provided consisted of ensuring the resident was provided meals, toileted, repositioned and checked on. The CNA said the resident had a small pressure injury and the nurse primarily provided the interventions to treat it. Nurses would place a pad to protect the pressure injury and would apply cream to it, otherwise the CNA did not provide the resident with any other care to the pressure injury. CNA #5 was interviewed on 5/9/23 at 10:27 a.m. She said she worked with the resident since he was admitted to the facility. The care she provided to him changed during his time as a resident. Initially, upon admission the resident was independent and did not require much assistance and the resident was able to use his call light, walk and eat. Once the resident fell and broke his hip he required extensive assistance. Staff had to change him, turn him and assist him with eating. The CNA said the resident had a small pressure injury, the nurse would place a patch to protect the pressure injury and CNA staff would turn and reposition the resident about every two hours. Registered nurse (RN) #2 was interviewed on 5/9/23 at 10:46 a.m. He said he worked with the resident intermittently over the course of his stay. The care he provided to the resident consisted of ensuring medications were administered and ensuring the resident was assisted with eating, toileted, assisted with physical mobility and educated on call light use. The pressure injury developed towards the end of his stay. The pressure injury started when he stayed more in bed. The registered dietitian (RD) was interviewed on 5/9/23 at 11:46 a.m. She said the resident did not trigger for weight loss and the resident was doing well until he declined after the fall on 4/19/23. Treatment was recommended for pressure injuries, however, at the time of the recommendations the resident was no longer swallowing. Therefore, the supplement would not have made a difference because the resident refused at that point. The physical therapy assistant (PTA) was interviewed on 5/9/23 at 12:35 p.m. She said the resident initially was able to reposition himself without assistance from admission until his second fall (occurred on 3/16/23). After the second fall, the resident required one to two person assistance for repositioning. Nurse practitioner (NP) #1 was interviewed on 5/9/23 at approximately 1:30 p.m. NP #1 said he reviewed the resident's labs and the review indicated that skin breakdown was not related to a protein deficiency and the resident did not suffer from end of life skin failure (Kennedy ulcers). NP#1 said the pressure injury developing was avoidable. The director of nursing (DON) was interviewed on 5/9/23 at approximately 3:30 p.m. She said the resident was assessed upon admission for pressure injury risk. However, the resident was not at risk on admission and the only risk factor was nutrition. The resident became at risk after his first fall (occurred on 4/5/23) that led to hospitalization. She said nursing staff should follow the wound care orders and the interventions listed on the resident's care plan. Additionally, staff should reposition the resident and or offload him every two hours to prevent pressure injuries from developing and or worsening. The nursing home administrator (NHA) was interviewed on 5/9/23 at 3:45 p.m. He said there were no updates for interventions from the first fall (occurred on 4/5/23) for pressure injuries. He said there was an opportunity there; repositioning would have been an appropriate intervention to prevent pressure injury from developing and would have promoted healing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure one (#92) of six residents reviewed for accidents out of 29 sample residents remained as free from accident hazards as possible. Resident #92, was initially admitted for short term rehabilitation on 2/28/23 with a goal to return home. He was identified as a high fall risk and as a high elopement risk upon admission. The resident had numerous predisposing factors which included: dementia, confusion and poor safety awareness. The facility failed to develop, communicate and implement effective interventions to prevent the resident from: eloping on one occasion and falling seven times within a period of two months. The resident sustained major injuries from two out of seven falls which led to hospitalization. Due to the facility's failures, the resident was sent to the emergency department (ED) for an evaluation which identified the resident sustained an acute hip fracture to the right hip subsequent to a fall on 4/5/23 requiring surgery and hospitalization. The resident was discharged from the hospital on 4/8/23 and returned to the nursing facility. The resident refractured his right hip around the periprosthetic (structure in close relation to an implant), a distal femur fracture (fractures of the thigh bone that occur just above the knee joint) and nondisplaced left superior pubic fracture (a break in one of the bones that make up the pelvis), subsequent to a fall on 4/20/23 (12 days after the resident returned from the initial ED visit to the nursing facility). Subsequently, he declined, developing an unstageable pressure injury (cross-reference F686). The resident was admitted to hospice care and passed away on 5/7/23 (16 days after being readmitted from the ED on 4/21/22). Findings include: I. Facility policies and procedures The Fall Management policy, dated 3/10/23, was provided on 5/8/23 by the nursing home administrator (NHA). The policy read A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. To be effective, a fall reduction program is characterized by four components: -Fall risk evaluation -Care planning and implementation of interventions -Ongoing evaluation process Quality Assurance Performance Improvement (QAPI) -A commitment by caregivers to make it work. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Resident and resident representative will be invited to all care plan meetings. The interventions are to be re-evaluated when a resident falls. II. Resident #92 A. Resident status Resident #92, age [AGE], was admitted on [DATE] and passed away on 5/7/23. According to the May 2023 computerized physician orders (CPO), diagnoses included unspecified dementia, without behavioral disturbance, benign prostatic hyperplasia and muscle weakness. The 3/3/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score five out of 15. The resident required supervision with transfers, walking in the room, dressing, toileting and personal hygiene. He was always continent of bowel and bladder. The fall section revealed the resident did not have a fall in the last six months prior to admission. The prognosis section revealed the resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. The behavior section indicated the resident did not resist the care, he did not have hallucinations, delusions or other types of behaviors. B. Resident observations The resident was observed on 5/3/23 at 3:10 p.m. The resident was laying down in bed on his back with his eyes open. The resident's mattress appeared to be winged on the edges. The resident was non-verbal, however, he would emit sound to indicate pain and or attempt to communicate. A fall mat was observed under his bed (the fall mat protruded approximately one foot from the edge of the left side of the bed upon entry and obstructed the entryway to the residents room). C. Representative interview The resident's wife was a resident at the facility and resided in the same room as Resident #92. The resident's wife was interviewed on 5/3/23 at 3:15 p.m. She said her husband had become bed ridden and was awaiting his last days since he has fallen so many times and injured himself. The resident has declined that he was unable to speak, eat and was no longer who he once was since he was first admitted . She said the facility did not do much to prevent his falls. The nursing staff at the facility mostly provided education on call light use. The resident's wife said she asked staff to raise the guard rails on the side of the bed to prevent him from getting out of bed but nursing staff refused. The resident's wife said they barely checked on him (every four to six hours) throughout the day and night and they mostly relied on the resident to use his call light if he needed something, which he would not remember to do. Furthermore, the resident's wife said she would not be able to use the call light for him because she was unable to monitor the resident all the time, especially when she was asleep. The facility gave him a urinal and told him to use it, however, he did not want to use the urinal. The facility tried to do more after his last fall on 4/19/23. The facility obtained a winged mattress and put a fall mat on the floor, however, the mat did not help because it was under the bed and was a tripping hazard to get into the bathroom or even to try and open the room door. The resident's wife said she almost tripped on it a few times. Even with everything the facility tried to do, it was too late. Resident #92 was admitted to hospice and awaited to pass after 4/19/23. The last thing the facility offered the resident's wife was to transfer him to a secured unit away from her. She said she did not know how being locked up in a different unit was going to do anything for him since he just laid in bed all day. She said she questioned why the facility wanted to separate the resident and his wife during his final days. D. Record review The resident was assessed for wandering upon admission on [DATE]. The wandering assessment revealed the resident was at an increased risk for wandering outside the facility. The care plan for elopement, initiated on 2/28/23 and revised on 4/9/23, revealed the resident had potential for elopement risk/wandering due to decline in cognition related to dementia diagnosis. Interventions included: Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is the resident looking for something? The resident was wandering to look for his wife and asked for transportation to go home. Intervene as appropriate; distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. The care plan for elopement prevention, initiated on 2/28/23 and revised on 3/21/23, revealed the resident required placement on a secure neighborhood due to elopement attempts. Interventions included: Resident will be accompanied when going off of the unit/neighborhood and staff to monitor safety of exit seeking by redirecting away from doors, engage in meaningful activity. -The facility failed to maintain interventions listed for elopement prevention as the resident was able to elope out of the building on 3/3/23 (see below). The resident was assessed for fall risk on several occasions since 2/28/23. Specifically, he was assessed on 2/28/23, 3/3/23, 3/16/23, 3/29/23, and 4/21/23. He consistently scored high risk for falls. The care plan for activities of daily living (ADLs), initiated on 3/2/23 and revised on 5/8/23, revealed that the resident had potential for self care related deficit due to unsteady and or shuffling gait. Interventions included to provide assistance with bed mobility, bathing, and toileting. Additionally, the resident required the use of a walker for mobility. The care plan for physical mobility initiated on 3/2/23 and revised on 5/8/23, revealed that the resident was weight bearing and was able to ambulate with assistance. The care plan for falls, initiated upon admission on [DATE] and revised on 5/8/23, revealed the resident was at risk for falls due to confusion , deconditioning, gait/balance problems, history of falls, poor communication/comprehension, unaware of safety needs ,hearing problems and wandering. Interventions included: to make sure call light was within the reach and encourage resident to use it, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, encourage rest periods when signs of fatigue are noted, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensure adequate lighting and visual aids are in place on admission, assess for communication needs as indicated, ensure appropriate positioning in center of bed, provide assistance with repositioning as indicated, ensure the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, physical therapy (PT) to evaluate and treat as ordered or as needed (PRN). Intervention added on 3/26/23 (after fall #3, see below); staff to check on the resident frequently at night for toileting needs to help decrease risk for falls. Intervention added on 3/27/23 (after fall #4, see below); encourage the resident to use the urinal to void and call for assistance to help decrease risk for falls. Intervention added for a sensor light in the room (sensor triggered night light). Intervention added on 4/4/23 (after fall #5, see below); remove extra layer of sheets on wheelchair cushion prior to assisting resident to wheelchair as needed. Staff to ensure wheelchair brakes are on during transfers to help decrease his risks for falls. Intervention added on 4/17/23 (after fall #6, see below); review information on past falls and attempt to determine the cause of falls. Record possible root causes, and remove any potential causes if possible. Educate resident/family/caregivers/integrated multi-disciplinary team (IDT) as to causes, per IDT review resident to move to a bigger room. Intervention added on 4/19/23 (after fall #7, see below) to review medications and order labs as needed. Intervention to place fall mat at bedside as needed. -There were no interventions added to the care plan for the resident after his fall #1, #2, #4 and #6 (that resulted in a hip fracture). Interventions were added 12 days after fall #6. -Interventions that were added were not effective such as education due to poor memory and dementia. -The resident required supervision assistance from staff with his activities of daily living and often the interventions added (see below) after the resident fell were to provide Resident #92 with education, redirection and encouragement. Interventions were not defined, verbiage used such as frequently were subjective to staff and did not specify clear direction to ensure the resident's safety was maintained to prevent falls. 1. Elopement Incident on 3/3/23 (within 72 hours of admission) The incident report dated 3/3/23, revealed Resident #92 eloped out of the facility on 3/3/23 around 3:10 p.m. The resident was found on the west side of the building, exited through the back door. The resident was brought back inside. The resident remained confused, looking for his wife who is in the hospital. Consent obtained from the resident's wife to place resident in the dementia unit due to wandering and exit seeking behavior. 2. Fall #1 on 3/3/23 The incident report dated 3/3/23, revealed Resident #92 sustained a fall on 3/3/23 around 3:39 p.m. The resident was observed tripping over cement barrier on west side of the building related to confusion looking for his spouse. The resident was assisted back to the facility by four staff members and assisted to the memory unit, footwear evaluated. Predisposing factors for the fall were listed as hearing impairment and wandering. No injuries observed at the time of the incident. The IDT review, dated 3/9/23 (six days after the elopement and fall#1) revealed resident sustained an unwitnessed fall on 3/9/23, the root cause of the fall was identified as resident noted with unsteady gait, poor safety awareness, noted outside on uneven ground. Interventions included resident was assisted to locked unit 5, footwear assessed for proper footwear. Treatment required included neurological checks (a series of questions and tests to check brain, spinal cord, and nerve function) for the next 72 hours. -The facility was unable to provide documentation to evidence the neurological checks and vitals were completed after the fall; as indicated in the risk management review note under treatment required (see above). -The physician was notified and no response was documented, no further orders were given. -The resident's care plan was not updated with any new interventions to prevent resident from falling. 3. Fall #2 on 3/16/23 The incident report dated 3/16/23, revealed Resident #92 sustained a fall on 3/16/23. Resident #92 was found kneeling on the floor holding on to his wheelchair, walker overturned on the floor, wife at side. Resident stated he needed to pee. Predisposing factors were identified as confused, gait imbalance, identified as high risk for falls, ambulating without assistance, on the way to the bathroom and using a walker. Immediate action taken revealed registered nurse (RN) assessed, assisted back into wheelchair, urinal given and demonstrated on use. After voiding, grippy socks put on and with stand by assist, walker was utilized to ambulate back to bed. Instructed resident to call for assistance and to use the urinal for urination, verbalized understanding. Encouraged spouse to call for staff assist as needed. The IDT review, dated 3/23/23 revealed resident sustained a witnessed fall on 3/16/23, the root cause of the fall was identified as poor safety awareness, unsteady gait/dementia, says he had to pee. Interventions included encourage the resident to use the urinal to void, call for assistance for needs. -The resident's care plan was not updated with any new interventions to prevent resident from falling. -The physician was notified. -The facility was unable to provide documentation to evidence the nursing evaluation occurred post fall for neuro checks and vitals. 4. Fall #3 on 3/26/23 The incident report dated 3/26/23, revealed Resident #92 sustained a fall on 3/26/23 around midnight. A certified nurse aide (CNA) advised the RN that during rounds the resident was observed on the floor between the bed and the bedside table. The resident's wife stated she believes he was attempting to stand up to use his urinal but unsure on how the resident fell. Immediate actions taken revealed resident was assessed by the nurse, and a set of vital signs were obtained. RN completed the initial RN assessment and the CNA assisted with getting the resident back in bed. Neurological checks were started on the resident and the provider was notified. No injuries were observed at the time of the incident. Predisposing factors were identified as poor lighting, gait imbalance, hearing impairment, incontinent and ambulating without assistance. -The incident report did not mention any other immediate interventions to prevent the resident from falling. The IDT review, dated 4/3/23 revealed resident sustained an unwitnessed fall on 3/26/23, the root cause of the fall was identified as poor safety awareness. Interventions included staff to check on resident periodically at night for unmet needs, toileting, to help decrease risk for falls. -The IDT review did not define periodical checks, which was subjective to staff and did not specify clear direction to ensure the resident's safety was maintained to prevent falls. -The resident's care plan was updated with the following interventions: staff to check on the resident frequently at night for toileting needs to help decrease risk for falls. -Frequent checks were subjective to staff and did not specify clear direction to ensure the resident's safety was maintained to prevent falls. -No additional interventions were added to keep the resident from falling besides frequency of rounding. -The physician was notified with no response documented, no further orders given. -The facility was unable to provide documentation to evidence the nursing evaluation occurred post fall for neurological checks and vitals. 5. Fall #4 on 3/27/23 (second fall in 26 hours) The incident report dated 3/27/23, revealed Resident #92 sustained a fall on 3/27/23 at 1:34 a.m. (this was his second fall in 26 hours). Resident assessed by RN, no injuries noted. Resident present with confusion due to dementia. MD (medical doctor) to review medication and staff to encourage toileting before bed time. The resident was unable to give a description. No injuries observed at time of incident. The resident reported no pain. Predisposing factors were identified as poor lighting, impaired memory, poor safety awareness, hearing impairment, fall in the past 30 days, incontinent, poor impulse control and high risk for falls. -The incident report did not include any immediate interventions that were put in place to prevent any further falls. The IDT review, dated 3/28/23 noted as a late entry by administration, revealed the resident sustained an unwitnessed fall on 3/27/23. The root cause of the fall was identified as poor safety awareness. Confusion due to dementia. No treatment was required. Interventions included the medical Doctor (MD) to review medications. Staff encouraged to toilet resident before bed. -The IDT review did not address the fact that the resident was confused, had poor impulse control, impaired memory and poor lighting to be able to see clearly and utilize the urinal and or call light. -The resident's care plan was not updated with any specific interventions based on the cause of fall. -The facility was unable to provide documentation to evidence the nursing evaluation occurred post fall for neurological checks and vitals. 6. Fall #5 on 4/4/23 The incident report dated 4/4/23, revealed Resident #92 sustained a fall on 4/4/23 at 1:13 p.m. RN alerted that the resident was on the floor. RN observed the resident on his buttocks between his bed and the wheelchair. The resident apparently landed on his buttocks and right elbow. Initially the resident complained of slight pain to his right elbow. Five minutes later the resident denied any pain. Range of motion adequate in all extremities. Vital signs taken were stable. No redness, bleeding or open skin involved. The resident's wife was in the room when the incident occurred. Immediate interventions included the resident was assisted back into the wheelchair. Therapy to screen, evaluate and treat as indicated. The resident presents with poor safety awareness due to dementia. Resident's wife reported that the resident slid to the floor. The resident noted with extra layer of sheets on his wheelchair cushion. Fall consistent with the resident sliding to the floor due to an extra layer of sheet on his wheelchair. Extra layer of sheet removed. Predisposing factors were identified as poor lighting, impaired memory, poor safety awareness, hearing impairment, fall in the past 30 days, ambulating without assistance and on the way to the bathroom. Other information section revealed the resident was confused, hearing impaired with unsteady gait, despite repeated warnings, he kept trying to go to the bathroom by himself. The IDT review, dated 4/4/23 noted as a late entry by administration, revealed the resident sustained a witnessed fall on 4/4/23. The root cause of the fall was identified as poor safety awareness due to dementia. Extra layers of sheet on his wheelchair.No treatment was required and no injuries were observed at the time of the incident. Interventions included extra sheets removed from wheelchair. Therapy to screen, evaluate and treat as indicated. A referral was made to the MD for further review. -The documentation was incomplete and did not include whether the MD was notified of the event. -The facility was unable to provide documentation to evidence the nursing evaluation occurred post fall for neurological checks and vitals. 7. Fall #6 on 4/5/23 (second fall within 24 hours) The incident report dated 4/4/23, revealed Resident #92 sustained a fall on 4/5/23 at 1:14 p.m. (this was his second fall 24 hours) RN answered the call light and observed the resident on the floor between his walker, bedside table and his wife's bed. He fell again per wife. Sustained a cut on the back of his left hand, dorsal (back) surface. The resident complained of right hip pain. Range of motion to upper and lower extremities adequate. Vital signs taken. Alert but confused. Moaning in pain and touching his right hip. Immediate interventions included give pain medication and sent out to hospital. Predisposing factors were identified as confused, impaired memory, hearing impairment, fall in the past 30 days, identified as high risk for falls and ambulating without assistance. Other information section revealed the resident was in the presence of his wife this afternoon. The resident did not use his call light and probably got confused and forgot. -The IDT review was not completed for this incident. -The facility was unable to provide documentation to evidence the nursing evaluation occurred post fall for neurological checks and vitals. -The resident's care plan was not updated with any specific interventions based on the cause of fall. The hospital documentation revealed the resident sustained an acute right femoral fracture which required intramedullary nail placement surgery (surgery to repair a broken bone and keep it stable by placing a permanent nail or rod into the center of the bone.) The resident was discharged from the ED on 4/8/23 and returned to the facility. The skilled nursing progress note dated 4/16/23 revealed the resident had right hip surgery on 4/6/2023 and had noticeable cognitive decline after the surgery. 8. Fall #7 on 4/19/23 The incident report dated 4/19/23 revealed that Resident #92 sustained another fall on 4/19/23 around 8:00 p.m. During CNA rounding, the CNA informed the nurse that the resident was observed on the floor. Upon entry, the resident was on the floor in a fetal position grimacing in pain. The resident's wife was unsure how the resident fell, she was asleep and heard the resident fall. RN completed an RN assessment, resident assisted with toileting and the resident was placed back in bed. The resident stated he was attempting to walk to the restroom when he fell. The immediate action taken revealed the resident was given as needed (PRN) oxycodone 5 mg (pain medication) and repositioned the right lower extremity with a pillow under the knee. The resident presented with poor safety awareness, confused and present with poor judgment regarding functional limitation. Neurological checks initiated. MD notified and x-ray ordered. Resident encouraged to use call light, frequent checks initiated by staff. Therapy to screen and evaluate plan of care as indicated. Predisposing factors were identified as poor lighting, confused, gait imbalance, impaired memory, pain, restlessness, recent change in ability to transfer/ambulate, hearing impairment, fall in the past 30 days, identified as high risk for falls, poor impulse control, weakness, poor safety awareness, recent room change and ambulating without assistance. The IDT note dated 4/21/23 noted as a late entry by administration, revealed the resident sustained an unwitnessed fall on 4/20/23, in contrast with the correct event date of 4/19/23. The root cause of the fall was identified as poor safety awareness due to dementia, lack of knowledge regarding functional limitations, attempting to ambulate without using call light for assistance, x-ray treatment required and ordered. Interventions included placement to the dementia unit due to confusion, frequent checks initiated, therapy to screen for a toileting plan. -The IDT note was incomplete; the MD notification had no documented response provided. The nursing note dated 4/20/23 revealed X-rays taken on resident's right hip and knee. Unofficial results show fracture. Provider notified and ordered to send the resident out to the hospital for evaluation and treatment. Report called to hospital. The follow up note dated 4/20/23, completed by nurse practitioner (NP) #1 revealed, The (patient) is seen for a reported fall to which he apparently was up, lost his footing, and slammed onto his right lower extremity directly to knee. The patient has significant pain to palpation of his knee. It is rather edematous (swelling caused by excess fluid in body tissues), painful, mild crepitus (crackling or grating sound caused by bones rubbing against each other), mild deformity. It is reasonable to consider the outcomes of residents with cognitive deficits that have multiple falls with injuries such as this resident and we will provide and aid in facilitation of regaining his strength and healing but ultimately concerned of a pending global decline. The hospital encounter notes dated 4/20/23 revealed, Varus angulation (excessive inward angulation of the distal segment of a bone or joint) across the fixation site (previous surgery site) appears to be new and likely represents an acute injury. 2. Acute periprosthetic fracture (fractures that occur in association with an orthopedic implant) of the distal right femur at the level of the distal interlocking screw. 3. Acute nondisplaced fracture of the left superior pubic ramus(a break in one of the bones of the pelvis). The nursing note dated 4/22/23 revealed, The resident returned from the hospital and continues on observation with new fracture to upper right thigh and hip. Immobilizer in place to right leg. A nursing progress note dated 5/7/23 revealed in part, Physician pronounced death of resident at 8:07 a.m. on May 7, 2023. Time of death was 03:40 a.m. Resident's condition had been declining for several weeks after 2 falls with many fractures. Resident had a rapid decline overnight and death was not unexpected. III. Staff interviews CNA #4 was interviewed on 5/9/23 at 10:17 a.m. He said he was new to the unit, but provided care for the resident for a few weeks. The care he provided consisted of ensuring the resident was provided meals, was toileted, repositioned and checked on. The resident never used the call light while he provided care for him. During the time CNA #4 provided care to the resident, the resident fell and then was hospitalized . After the fall, the resident did not eat anymore and stayed in bed. CNA #4 said he was not aware of any fall interventions due to the resident being on end of life care and was on his way to pass. CNA #5 was interviewed on 5/9/23 at 10:27 a.m. She said she worked with the resident since he was admitted to the facility. The care she provided to him changed during his time as a resident. Initially, upon admission the resident was independent and did not require much assistance and the resident was able to use his call light, walk and eat. Once the resident fell and broke his hip he required extensive assistance. Staff had to change him, turn him and assist him with eating. The resident wandered at times because he would try to look for his wife. The interventions put in place to prevent the resident from wandering were to walk with staff assistance back to the room and two hour checks; the checks were not documented. The resident was at risk for falls and he had two interventions in place which included keeping an eye on him and ask him if he needed to use the restroom. The resident was not on a toileting program and although he was always educated on call light use, he would never remember to use it but his wife would use it for him as much as she could. RN #2 was interviewed on 5/9/23 at 10:46 a.m. He said he worked with the resident intermittently over the course of his stay. The care he provided to the resident consisted of ensuring medications were administered and ensuring the resident was assisted with meals, toileted, assisted with physical mobility and educated on call light use. The resident hardly used the call light but his wife used it for him. The resident was at risk for wandering and he was placed on a one-to-one with staff (according to the director of nursing the resident was within line of sight) to prevent him from attempting to elope. Interventions put in place to prevent falls included ensuring the call light was in reach and checking in as often as possible between 10 to 15 minutes. The resident's wife was educated to use the call light anytime the resident got up. The resident did have dementia before the fall, but after the fall he was unable to comprehend the use of call light for help. After the resident fell the first time, staff hoped he was going to recover, after the second fall the physician notified staff that the resident was not going to survive. The falls were due to the resident's dementia and he did not follow or comprehend the plan of care for him such as call light use and he overall had poor safety awareness. The physical therapy assistant (PTA) was interviewed on 5/9/23 at 12:35 p.m. She said the resident's cognition was a little difficult to work with. At first the resident was admitted to rehabilitation to get him back to where he was. The resident was hard of hearing but was pleasant and nice. The resident used a walker to walk and a needed staff stand by assistance to get in and out of bed. He was modified to independent or staff to be close stand by; he would go to the bathroom on his own. A few days after admission he wandered off and fell because he was looking for his wife. The resident was supposed to be checked on frequently, however the PTA was uncertain at what intervals. Subsequently, he had a few falls and declined cognitively and functionally after each fall. The PTA had to increase safety cueing and visual scanning due to the resident's poor carry over of education, cognition and unsteady gait. The interventions recommended by the PTA included his bed in the lowest position, decreased clutter in his room, education to wife and safe walks to the bathroom with staff. The PTA did not recommend the fall mat because of the potential of the resident tripping due to unsteady balance/gait. The resident participated in the exercise program but was not evaluated again after each fall only when he broke his hip he was evaluated. The PTA said after he fell and broke his hip he sustained another fall which led to his overall decline.The resident's numerous falls contributed to his admission to hospice care due to high pain and his impacted ability to do anything and it was excruciating for him to get out of bed. NP #1 was interviewed on 5/9/23 at approximately 1:30 p.m. NP #1 said areas of opportunity existed related to fall prevention. Interventions could have been in place such as placement on the memory care unit and toileting interventions by staff. The NP acknowledged the falls the resident experienced did contribute to the overall decline in function. The director of nursing (DON) was interviewed on 5/9/23 at approximately 3:30 p.m. She said the resident was assessed upon admission for both fall risk and elopement risk.[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #70 A. Resident status Resident #70, age [AGE], was initially admitted on [DATE] and readmitted on [DATE]. According to the February 2022 computerized physician orders (CPO), diagnoses included vascular dementia with behavioral disturbance and contracture to right and left knee. The 1/6/22 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of zero out of 15. She required extensive assistance with bed mobility, dressing, personal hygiene and toileting. It documented the resident had falls and one with injury. B. Record review The comprehensive care plan revised with last revision on 5/11/21, identified Resident #70 was high risk for falls related to impaired balance, unsteady gait, incontinence, communication deficit and cognitive deficits. It further documented Resident #70 intentionally lower herself from bed to floor and seat herself on the ground or floor at times, as well as crawl on floor. Interventions included: to observe for unsteady gait, anticipate and meet the resident's needs, frequent checks, apply nonskid socks as resident will allow, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance, Monitor and assist as necessary when she attempts to sit and/or crawl on the ground or floor every shift and as needed and monitor for falls when she is performing exit seeking behaviors. C. Fall incident report investigation The Post Fall Investigation documented 10/2/21 was reviewed. It documented the resident called for a nurse to come to her room. She was observed sitting on her buttocks in the doorway. It documented resident had done this before, likes to crawl. Immediate action taken was assisted resident from floor, assessed all extremities, no injury found. -There was no intervention put in place until the risk management review (see below). The Risk Management note documented on 10/4/21 was reviewed. It documented the resident had an unwitnessed fall on 10/2/21. It documented the root cause was the resident sitting on the edge of bed when wanting to get up and will scoot off the bed. Intervention was staff to get resident up when sitting on the edge of bed. The Post Fall Investigation documented 10/12/21 was reviewed. It documented the resident being observed on the floor near roommate ' s bed. It documented her wheelchair was close by but was full of clothes. It documented resident was assessed and there was no injury. Immediate action taken was resident assessed and there was no injury. -There was no intervention put in place until the risk management review (see below). The Risk Management note documented on 10/14/21 was reviewed. It documented the resident had an unwitnessed fall on 10/12/21. It documented the root cause was resident behavior was to crawl on the floor related to not being able to stand. Intervention put in place was for staff to make frequent rounds and offer assistance. The Post Fall Investigation documented 1/1/22 was reviewed. It documented the certified nurse aide(CNA) called a nurse to the resident's room. It documented the resident was found on the floor on her left side next to the dresser. It documented the resident was assessed and she sustained a large hematoma on her left forehead. It further documented she was given two Tylenol for pain. -There was no intervention put in place until the risk management review (see below). The Risk Management note documented on 1/3/22 was reviewed. It documented the resident had an unwitnessed fall on 1/1/22. It documented the root cause was that the resident was attempting to get out of bed unassisted. Intervention put in place was for staff to make frequent rounds when the resident was in bed. -The resident had multiple falls (see above) in which one of the falls resulted in an injury. The facility failed to update the care plan with interventions to prevent fall from reoccurring. The intervention often put in place were frequent rounds, which was ineffective in preventing the resident from falling. IV. Resident #29 A. Resident status Resident #29, age [AGE], was admitted on [DATE]. According to the February 2021 computerized CPO, diagnoses included cerebral vascular accident (CVA) and stroke. The 12/3/21 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of nine out of 15. He required extensive assistance with bed mobility, dressing, personal hygiene and toileting. It documented the resident had falls. B. Record review The comprehensive care plan revised on 9/10/21, identified Resident #29 was at high risk for fall related to deconditioning, gait/balance problems and incontinence. Interventions included: to anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance, ensure that the resident is wearing appropriate footwear when mobilizing in wheelchair and the resident needs a safe environment with: the bed in low position at night, personal items within reach, fall mats next to bed while in bed, nonskid strips next to bed. C. Fall incident report investigations The Post Fall Investigation documented 10/8/21 was reviewed. It documented the CNA observed resident lying on the right side, middle of the room on the floor. It documented resident said he was going to the bathroom and did not think he needed his walker. It documented the resident was assessed and there was no injury. -There was no intervention put in place until the risk management review (see below). The Risk Management note documented on 10/14/21 was reviewed. It documented the resident had an unwitnessed fall on 10/8/21. It documented the root cause was the resident did not use a walker to go to the bathroom. Intervention was staff to remind resident to utilize his walker when getting up without assistance. The Post Fall Investigation documented 11/5/21 was reviewed. It documented the CNA responding to the resident ' s call light. It documented the CNA told the resident he was going to get help to assist him. It further documented when the CNA arrived back to the room, the resident was on the floor. It documented the resident was assessed and there was no injury. -There was no intervention put in place until the risk management review (see below). The Risk Management note documented on 11/10/21 was reviewed. It documented the resident had an unwitnessed fall on 11/5/21. It documented the root cause was the resident did not want to wait for staff to get another person to help with transfer. Intervention put in place was for staff to get staff assistance before entering the room to assist the resident to transfer. The Post Fall investigation documented 1/9/22 was reviewed. It documented the resident was observed sitting on his buttocks up against his bed with his legs in front of him. It documented the resident was assessed and there was no injury. -There was no intervention put in place until the risk management review (see below). The Risk Management note documented on 1/10/22 was reviewed. It documented the resident had an unwitnessed fall on 1/9/22. It documented the root cause was the resident was attempting to stand unassisted. Intervention put in place was for staff to remind resident to wait for assistance when putting on call light. -The care plan was not updated with interventions after multiple falls (see above). V. Resident #50 A. Resident status Resident #50, age [AGE], was admitted on [DATE]. According to the February 2021 computerized CPO, diagnoses included unsteady on feet and muscle weakness. The 12/21/21 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required supervision with bed mobility and transfer. It documented the resident had fallen. B. Record review The comprehensive care plan revised on 2/9/21, identified Resident #50 was at high risk for fall related to vision/hearing deficits and psychotropic drug use. Intervention included the resident needs a safe environment with: even floors free from spills and/or clutter, adequate glare-free light; a working and reachable call light, the bed in low position at night, handrails on walls, personal items within reach. Anticipate and meet the resident's needs, ensure walker was near resident when in bed or in a chair. The Post Fall investigation documented 12/4/21 was reviewed. It documented the resident was found by the snack machine on her knees holding on to the back of the soda. Resident was assessed and a bruise was noted on the left elbow. -There was no intervention put in place until the risk management review (see below). The Risk Management note documented on 12/8/21 was reviewed. It documented the resident had an unwitnessed fall on 12/4/21. It documented the root cause was the resident was getting items from the vending machine and lost balance and fell to her knees. Intervention put in place was for staff to remind resident to use her walker at all times and request assistance as needed. -The care plan was not updated after the fall with intervention (see care plan above). VI. Staff interviews The director of nursing (DON) was interviewed on 2/7/22 at 1:18 p.m. She said the interdisciplinary team (IDT) was responsible to update the resident care plan after each fall with interventions. She said it was a team ' s effort to update the care plan. She said the residents care plan should have been updated with interventions to enable staff to know what interventions were put in place to prevent the fall from reoccurring. She said she would immediately audit all residents who had a fall to ensure their care plans were updated with the current interventions. Based on record review and interviews, the facility failed to ensure four (#66, #70, #29 and #50) of six residents reviewed for accidents out of 35 sample residents remained as free from accident hazards as possible. Resident #66, who was identified as a high fall risk, had numerous predisposing factors which included dementia, confusion, unsafe sleeping habits, and poor safety awareness. The facility failed to develop, communicate and implement effective interventions to prevent the resident from falling on multiple occasions. Due to the facility's failures, the resident sustained an acute distal ulna fracture to her left wrist subsequent to a fall on 1/18/22 requiring hospital treatment for trauma to the left wrist and pain. In addition, the facility attributed the forearm fracture to a fall on 1/5/22 (13 days previous) and 1/8/22 (10 days previous). The facility failed to conduct an investigation to determine if the resident had a subsequent fall after 1/8/22. Additionally, the facility failed to update the comprehensive resident care plan with person centered, effective interventions post fall for Resident #70, #29 and #50. Findings include: I. Facility policy and procedure The Fall Management policy, revised 9/10/19, was provided on 2/2/22 by the nursing home administrator (NHA). The policy read A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. To be effective, a fall reduction program is characterized by four components: -Fall risk evaluation -Care planning and implementation of interventions -Ongoing evaluation process Quality Assurance Performance Improvement (QAPI) -A commitment by caregivers to make it work. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Resident and resident representative will be invited to all care plan meetings. The interventions are to be re-evaluated when a resident falls. II. Resident #66 A. Resident status Resident #66, age [AGE], was admitted on [DATE]. According to the February 2022 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), and dementia with behavioral disturbance. The 1/7/22 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score three out of 15. The resident required supervision with transfers, walking in the room, dressing, toileting and personal hygiene. She was always incontinent of the bowel and bladder. The fall section revealed the resident did not have a fall in the last six months. -However she had one fall since last assessment. The behavior section indicated the resident did not resist the care, she did not have hallucinations, delusions or other types of behaviors. B. Resident observations The resident was observed on 1/31/22 at 12:55 p.m. The resident was sitting at the edge of the recliner with closed eyes. A four wheel walker was parked next to the resident on the left side. -At 2:57 p.m. the resident was asleep at the edge of the seat of her recliner. She rested her head and both hands on her lap and was asleep. On 2/1/22 at 10:56 a.m. resident was sleeping in the recliner, in the same position as above. The walker was parked on the right side from the resident. No fall mat observed on the floor. C. Family interview The resident's daughter was interviewed on 2/9/22 at 3:15 p.m. She said her mother had a single size bed and she would just sit on it and flop over, or she would slip off the bed and fall. She said the recliner was delivered a couple of weeks ago in January 2022 and staff were reporting to her that that really helped with falls. She said her mom probably needs a floor mat on the floor to cushion her falls and she asked staff to provide that. She said her mom had dementia and had an inability to remember things and to follow the instructions. -The resident required supervision assistance from staff with her activities of daily living and often the interventions added (see below) after the resident fell was to provide Resident #66 with education, redirection and encouragement. D. Record review The resident was assessed for fall risk on several occasions since 11/1/21. Specifically, she was assessed on 11/11/21, 1/3/22, 1/5/22, 1/8/22, and 1/21/22. She consistently scored high risk for falls. The care plan for activities of daily living (ADLs), initiated on 6/29/19 and revised on 8/27/2020, revealed that the resident had potential for self care related deficit due to cognitive deficit. Interventions included to provide supervision with transfers, bed mobility, and toileting. The care plan for physical mobility initiated on 12/28/21 and revised on 1/4/22 (at time of the survey), revealed that the resident was using a four wheel walker for ambulation, and she needed reminders to use it. The care plan for falls, initiated on 6/29/19 and revised on 12/30/21, revealed the resident was at risk for falls due to cognitive status, poor safety awareness, and history of falls. Interventions included to make sure call light was within the reach and encourage resident to use it (initiated in 2019); intervention to ensure that the resident was wearing appropriate footwear, and to discuss with the family option to use a recliner as resident did not like to sleep with her feet on the bed was added 1/5/22 (after fall #3, see below). Intervention to provide assistance and redirection as tolerated to empty items from purse as it can become quite heavy and increase fall risk with poor balance, and to encourage resident to lay in bed with legs on top of bed was initiated 12/30/21 (after the fall #1) and revised on 1/5/22 (at the time of the survey). -There were no interventions added to the care plan for the resident after her fall #2, #4, #5 (that resulted in ulnar fracture), and fall #6 (after the resident was readmitted from the emergency room with a splint on her left arm). 1. Fall #1 on 12/27/21 The incident report dated 12/27/21, revealed Resident #66 sustained a fall on 12/27/21 around 10:30 a.m. Resident was observed sitting on the floor next to her bed complaining of right knee, hip and head pain. Resident was assessed by a registered nurse and later refused the x-ray from x-ray tech. Predisposing factors for the fall were listed as weakness, and ambulating without assistance in a way to the bathroom. -The incident report did not include any immediate interventions that were put in place to prevent any further falls. The IDT (also called Risk Management) review, dated 12/29/21 revealed resident sustained unwitnessed fall by rolling out of the bed. Interventions included to assist the resident with care related to her increased pain and to empty out the purse which is very heavy that she carries on her shoulder every day. -The IDT review did not mention any intervention related to the actual cause of fall that was unassisted transfer to the bathroom. The resident's care plan was updated with intervention to provide assistance and redirection as tolerated to empty items from the purse as it can become quite heavy and increase fall risk with poor balance. Encourage me to lay in bed with legs on top of bed. 2. Fall #2 on 1/1/22 The incident report dated 1/1/22, revealed Resident #66 sustained a fall on 1/1/22. Resident #66 was found on the floor, and had a little abrasion on her nose. Resident stated she fell from the bed, she was sleeping and lost her balance, she was not walking. Predisposing factor was identified as restlessness with a note the resident was sleeping at the end of the edge on her bed, and refused to move to the center of the bed. -The incident report did not include any immediate interventions that were put in place to prevent any further falls. The IDT review, dated 1/5/22 revealed resident sustained unwitnessed fall on 1/1/22, the root cause of the fall was identified as resident lays in bed with feet hanging off the bed. Interventions included educate the resident and encourage to lay with her feet up on the bed. -The resident's care plan was not updated with any new interventions to prevent resident from falling. 3. Fall #3 on 1/5/22 The incident report dated 1/5/22, revealed Resident #66 sustained a fall on 1/5/22 around midnight.Nurse heard a loud noise and resident yelled out 'oh man' , when nurse entered the room, resident was sitting on her bottom on the side of her bed. Resident stated she fell out of bed. Resident was assessed by the nurse, and had no obvious injuries. Resident was educated on the importance of laying down in bed correctly, and the resident continued to insist on sleeping in a sitting position. Predisposing factors were identified as confusion, impaired memory, poor safety awareness, and high risk for falls. -The incident report did not mention any other immediate interventions besides providing education to the resident, even though the resident did not respond to the education and continued to sleep in a sitting position. The IDT review, dated 1/5/22 revealed resident sustained unwitnessed fall on 1/5/22, the root cause of the fall was identified as resident lays in bed with feet hanging off the bed. Interventions included speaking with the family and asking for a recliner since the resident was not cooperative with proper positioning in bed. -The IDT review did not assess the potential factors of resident's non-compliance with proper positioning, and did not mention what was done to keep the resident from falling until the family delivered the recliner. In addition, the facility wanted the family to provide the recliner instead of providing it in order to prevent future falls. -The resident's care plan was updated with the following interventions: Ensure that the resident is wearing appropriate footwear. Talk with family about getting a recliner as the resident does not like to sleep with feet on the bed. -No additional interventions were added to keep the resident from falling until the arrival of the recliner. 4. Fall #4 on 1/5/22 (second fall in the last 24 hours) The incident report dated 1/5/22, revealed Resident #66 sustained a fall on 1/5/22 at 11:45 a.m. (this was her second fall in less than 24 hours). Resident was sitting on the floor with back resting against the bed, and assisted her up off the floor after assessment. Resident reported no pain, but can ' t make the connection that not sitting on the edge of the bed will keep her from falling. The resident was encouraged to sit in a lazy boy recliner. Resident prefers to sit on the edge of her bed, she then falls asleep and slops off the bed onto the floor landing on the floor mat. She has on proper shoes, a large coat, and her purse heavy with bits and scraps of papers. She did not allow staff to unload the purse, she was not interested in a better sitting position, removing clutter from her bed, or sitting in the recliner. Predisposing factors were identified as confusion, impaired memory, poor safety awareness, and high risk for falls. -The incident report did not include any immediate interventions that were put in place to prevent any further falls. The IDT review, dated 1/7/22 revealed resident sustained unwitnessed fall on 1/5/22, the root cause of the fall was identified as resident sitting on the edge of bed and attempting to lay down. Interventions included to encourage resident to sit in a chair not on the edge of the bed. Encourage her to clear off her bed. -The IDT review did not address the fact that the resident was confused and was refusing staff assistance on proper way of sleeping. -The resident's care plan was not updated with any specific interventions based on the cause of fall and resident's lack of response to education. 5. Fall #5 on 1/8/22 The nursing progress note on 1/8/22 documented resident sitting up on the floor leaning against the recliner with legs bent at knees. Resident complained of right arm, and leg pain. Stated she hit her head but was unable to say if the floor or the recliner. No bumps or redness to head. No evidence of injury, bleeding, swelling. Able to move all limbs.Call light was clipped to the bed. Resident was wearing shoes. It appears the resident was getting up in hurry to go smoke. Bilateral hand grip strong. Hip Bones even. Speech at baseline, no change in mental status. Resident educated to get up out of bed slowly. Staff will place her walker next to the bed. The IDT note dated 1/10/22 revealed that Resident #66 had a fall on 1/8/22 when she was hurring to get outside to smoke. Intervention included not to remind residents about smoking times. -There was no incident report for this fall -The resident's care plan was not updated with any new interventions. The nurse's note on 1/10/22 documented resident still continues to sleep sitting up in bed despite continuous education, frequent checks throughout the night to make sure resident is staying on the bed. The nurse's note on 11/17/22 documented resident needs a fall mat placed by bed for safety precaution as she refuses to actually lay in her bed. Resident only sits on the edge of bed all hours of day and night. -No follow up notes on if the floor mat was obtained for the resident. 6. Change of condition on 1/18/22 (identified bruising) The incident report dated 1/18/22 revealed that a certified nurse aide (CNA) reported to the nurse that the resident had bruises to left eye and left side of forehead. The resident was unable to recall the origin of the bruises. Under the section of immediate actions it was documented that the resident denied any pain, and she had multiple falls in the last month. Neurological checks were completed and were at the baseline. The IDT note dated 1/19/22 revealed that Resident #66 had bruises due to previous falls. Interventions were to monitor the bruises. -The last documented fall was on 1/8/21, therefore it was unclear if it took 10 days for bruises to appear or if the resident had additional falls that were not documented. The nurses note on 1/20/22 at 7:04 a.m. documented, Bruise on left eye, purple in color. The resident seems to be lifting the sleeve of her clothes when moving left arm to aid movement. Complained of pain and rated pain as four out of 10, gave Tylenol, resident went back to sleep. -At 11:55 a.m. it was documented Increased pain and swelling to left wrist post possible fall. Resident has great difficulty moving left wrist on its own and is using her right hand to lift her left arm/hand. X-ray order placed to be completed as soon as possible. -At 4:27 p.m. documented by medical provider: got message about patient with acute distal ulna fracture to the left arm. Please send the patient to the hospital to immobilize the hand. According to the admission summary, the resident was admitted to the emergency department (ED) on 1/20/22 at 6:32 p.m. Resident sustained a fall two days ago when she fell on her left side and injured her left arm. She was diagnosed with trauma with left wrist injury and pain. Splint was applied to stabilize the left ulnar fracture and the resident was discharged back to the facility on the same day. 7. Fall #6 on 1/21/22 The incident report dated 1/21/22 revealed that Resident #66 sustained another fall on 1/21/22. Resident found on the floor in room alone in front of her armchair trying to get up. Resident complained of pain in left wrist and arm, no other injuries observed. Resident was very restless and was unable to wait for a registered nurse to assess prior to moving. The resident was assisted to a standing position and then back into the chair. Neuros (neurological checks) started. Resident was reminded to ask for assistance when needed. Call light within reach. The IDT note dated 1/23/22 revealed that Resident #66 had a fall on 1/21/22. The resident was not able to say what happened. No additional findings were documented. Intervention was listed as daughter to buy her a recliner as she does not sleep laying flat straight in bed. -It was unclear if resident already had a recliner as this intervention was mentioned initially on 1/5/22 after the fall #3 and #4, and on 1/8/22 after resident's fall #5 she was leaning against the recliner. -No additional interventions were added to the resident's care plan. E. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 2/3/22 at 3:30 p.m. She said she worked the shift when a resident was sent to the ED for the evaluation. She said she noticed swelling on the resident's arm and the resident was not using her arm with movement. She said she contacted her physician who ordered an x-ray. RCNA #2 was interviewed on 2/7/22 at 9:30 a.m. She said she was a restorative aide, but worked with Resident #66 on many occasions as a CNA. She said the Resident #66 was confused, did not follow the recommendations. She frequently refused or would take off her splint. She said the resident was able to ambulate with a four wheel walker and required assistance with personal care and ambulation. Regarding the falls, she said the plan was to check on the resident frequently and when passing by to make sure she was properly positioned in the recliner. She said the resident frequently fell asleep leaning forward. CNA #4 was interviewed on 2/7/22 at 11:30 a.m. She said she was an agency CNA and was new to the unit. She said she did not know how much assistance Resident #66 required, she said she would ask other CNAs that were working with her. She said to her knowledge, the resident ambulated with a walker and should be reminded to use it every time she was up. She said these were the interventions to keep the resident safe from falling. LPN #1 was interviewed on 2/7/22 at 11:30 a.m. He said the resident was confused due to her dementia diagnosis. He said the resident was recently hospitalized and diagnosed with ulnar fracture. He said he did not work the shift when fall occurred. He said for fall prevention staff were checking on the resident frequently due to her unsafe habit of sleeping on the edge of the bed or the recliner. He said the resident occasionally refused care such as wearing the splint but was otherwise cooperative. She said when one of the residents sustained the fall, nursing responsibility was to assess the resident for injury, notify family, physician and follow any received orders from the physician. She said nurses were expected to fill out an incident report and put in place immediate interventions to keep the resident safe and prevent any additional falls. The director of rehabilitation (DOR) was interviewed on 2/7/22 at 3:00 p.m He replied to the questions via email. He said the resident was not currently receiving physical or occupational therapy services. The most recent evaluation was completed between 12/27/21 and 1/5/22 in response to resident's falls. The resident was provided with a four wheel walker which significantly improved her balance and decreased her fall risk. In addition, education was provided to the resident and staff to utilize the rolling walker with mobility. The resident's care plan was updated to include use of the rolling walker with mobility. The DON was interviewed on 2/7/22 at 4:30 p.m. She said after she reviewed Resident #66's record, she identified some confusing and incomplete documentation about the potential fall on 1/18/22. She said she completed the investigation regarding the events on 1/18/22 and determined that the resident had a fall on that day (see below facility follow-up documentation). She said she prepared an education list on the items that she planned to educate nurses immediately. Specifically on proper documentation of falls, assessment by a registered nurse and reporting to her or manager on duty. She demonstrated the list of educational topics. She said this was not new, but since 75% of staff who currently were working in the building were agency staff, she felt that they needed to be educated on post fall interventions and proper documentation. Regarding safety interventions, she said the resident was on frequent checks by nurses and CNAs to encourage the resident to lean backwards in the reclined for her safety. She said the resident was resistant to follow the recommendation and this was why they continued to check on her. She said the entire team was responsible for updating the care plans with new interventions but she had not had a chance to review them to make sure everything was written down what was attempted to prevent the resident from falling. F. Facility follow-up before the survey exit on 2/7/22 During the interview DON on 2/7/22 provided following documents: QAPI meeting notes regarding the falls for Resident #66, investigation of events on 1/18/22 with conclusion that resident sustained a fall, interviews with staff who were working on 1/18/22, and list of items that she planned to educate nurses and CNAs.