**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the resident environment was free from accident hazards and adequate supervision was provided for three (#3, #5 and #6) of four residents reviewed out of 11 sample residents. Resident #3 was a known fall risk and the facility failed to consistently implement interventions to prevent her falls. After the resident had a fall on 11/12/23 in the morning, the facility implemented gripper socks/shoes. Subsequently, the resident had another fall on 11/12/23 due to her slipping on the floor and did not have appropriate footwear. The facility failed to initiate and complete neurological assessments, STAT (urgent, rush) x-rays ordered timely to the service provider, communicate to nursing staff/providers the resident had significant pain levels with movement and investigate the root cause. The resident was sent to a hospital for treatment and had pelvic and sacral bone fractures. Resident #5 was a known fall risk and the facility failed to implement effective interventions to prevent her falls. The resident fell on 7/13/23 when she tried to use a mobile book cart to ambulate to the bathroom. The resident sustained a hip fracture. She fell again on 7/23/23 in a similar manner when she tried to use the bedside table to ambulate. The facility failed to ensure neurological assessments were performed after the resident returned from the hospital for both falls. In addition, the facility failed to ensure Resident #6 was transferred appropriately using a gait belt that caused a fall and neurological assessments were consistently done after she hit her head during the fall. Findings include: I. Facility policy/procedures and facility form The Fall Management policy, reviewed 1/12/2020, was provided by the nursing home administrator on 12/26/23 at 10:17 a.m. The policy revealed the facility would identify each resident who was at risk for falls, would plan care and implement interventions to manage falls. The facility would manage falls by providing an environment that was free from potential hazards. A resident fall management program would be implemented that educated staff in creative, functional strategies while recognizing resident's rights and their need to maintain the highest practical level of function. A fall could be defined as, when a resident was found on the floor, a resident slid to the floor unassisted, a resident rolled off the bed or chair onto the floor, a resident fell off or out of equipment/apparatus used for therapy or a transfer. A fall also included when a resident tripped or slipped and complained of or sustained bodily injury or an episode where a resident lost his or her balance and would have fallen, were it not for staff intervention (intercepted fall). A fall might also be reported by a resident, visitor, or family member. The procedures included that: qualified staff assessed all residents for fall risk through the admission Nursing Assessment form upon admission, quarterly, and with a significant change; upon determination that the resident was at risk, the qualified staff created an individualized plan of care that included the appropriate preventative interventions to reduce the potential for a fall; part of the management program was the implementation of visual identifiers for those residents at risk; if a fall occurred, the qualified staff assessed for injury from the fall, immediately investigated the reason and determined the intervention to prevent future falls, complete the Incident/Accident Report; the resident's physician and family were notified; all reports of resident falls within the facility were monitored through the quality assurance and performance improvement (QAPI) process within the community at the Standards of Care Meeting; and data was also reported in the community's monthly QAPI Meeting. This policy did not include any information to implement and complete neurological assessments in a timely manner. The Neurological Record Time Tracker form, not dated, was provided by the director of nursing (DON) on 12/27/23 at 4:01 p.m. The purpose of this form was to only help each shift keep track when neurological assessments were due. All neurological assessments and vital signs were to be documented in the facility's computer system and not on paper. Nursing staff were to write on this document, when the neurological assessments were due and to check them off when they were completed. The neurological assessment frequency was every 15 minutes' times 4, every 30 minutes' times 4, every 1 hour times 4, every 4 hours' times 4 and every 8 hours' times 4. II. Resident #3 A. Resident status Resident #3, age over 65, was admitted on [DATE] and discharged on 11/15/23. According to the November 2023 computerized physician orders (CPO), diagnoses included a non-displaced fracture of the seventh cervical vertebra with routine healing, dementia, altered mental status, lack of coordination, muscle weakness, cognitive communication deficit, abnormalities of gait/mobility, pain and age related osteoporosis with current pathological fracture with routine healing. The 11/15/23 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15 with no behaviors. The resident's admission functional abilities/goals for mobility revealed the resident required partial to moderate staff assistance for sit to stand transfers, chair to bed or bed to chair transfers and toileting transfers. B. Record review Care plan for fall risk was initiated on 11/20/23 related to a fall on 11/12/23, history of hypertension and a high fall risk score on 11/11/23. This was evidenced by generalized weakness, mildly/moderate impaired cognitive status and limited need for transfer assistance. Some of the interventions included, for the resident to wear appropriate footwear when out of her room, administer first aid as needed, anticipate the resident's needs, check the resident frequently, assess the contributing factors related to a fall history, keep the call light and most frequently used personal items within reach, remind the resident to call when needing assistance, splint/brace to be used to stabilize extremity, assess medications for contributing factors, assist the resident with toileting as needed, assess for potential fall-related injury prevention (circumstances, location, medication, new or worsening medical problems), assess/monitor vital signs, include orthostatic blood pressure readings, neurological assessment, evaluate for head, neck, spine, and/or extremity injuries, monitor the use of anticoagulants which create a significant risk for serious injury, complete a physical exam for potential injuries, ensure the resident's clothing did not cause tripping, ensure rubber-soled, heeled shoes or non skid slippers were worn (11/13/23) and resident's family did not want resident to wear gripper socks (11/13/23). Fall risk assessment dated [DATE] at 4:47 a.m. revealed a score of nine or high risk. 1. Fall one Nurse note dated 11/12/23 at 4:43 a.m. by a licensed practical nurse (LPN) #1 revealed this nurse was notified by a certified nurse aide (CNA) the resident was sitting on the floor. This nurse observed the resident sitting up on her bottom next to the right side of her bed. The resident was barefoot in the dark room. The resident said she was trying to get up to adjust her legs and slid out of the bed. A registered nurse (RN) was notified and the assessment was completed. There was no sign of injury at this time. The resident's neurological assessments, vital signs and ranges of motion were within normal limits. The resident was transferred back into bed by this nurse and a CNA. The resident's call light was within reach. Incident/accident report dated 11/12/23 at 4:43 a.m. revealed the resident had an unwitnessed fall in her room at 3:45 a.m. This nurse was notified by a CNA that the resident was sitting on the floor. LPN #1 observed the resident sitting up on the floor, on her bottom next to the right side of the bed. The resident was barefoot in her dark room. The resident said she was trying to adjust her legs and slid out of bed. The resident was self-transferring from her bed and did not have on non-skid socks (inappropriate footwear). A RN was notified and the assessment was completed. There were no apparent injuries and the resident had a pain level of zero. Neurological assessments were implemented. The resident was transferred back into bed by this nurse and a CNA. The resident was currently in bed with a call light within reach. The interdisciplinary management team (IDT) section revealed this was a newly admitted resident with significant cognitive deficit and poor safety awareness. The resident was barefoot and attempted to transfer from her bed independently. The new intervention would be to have the resident wear gripper socks, when she was not wearing shoes. Neurological assessments were started on 11/12/23 at 3:45 a.m. and concluded on 11/12/23 at 2:30 p.m. Each of the 13 neurological assessments for fall one were completed according to the facility's electronic neurological assessment program. Fall risk assessment dated [DATE] at 6:44 p.m. revealed a score of seven or high risk. 2. Fall two Nurse note dated 11/12/23 at 6:57 p.m. by LPN #1 revealed this nurse was notified by a resident's family member that a resident had fallen in the dining room. This nurse observed the resident lying on her right side in the dining room. The resident said she got up because she wanted to get out of the chair and slipped due to a slick floor. The resident said she did hit her head at the time of the fall. A RN was notified. The resident's ranges of motion (ROM) and neurological assessments were within normal limits. The resident was hypertensive at the time of the fall and her oxygen saturations were observed to be low. The resident was transferred back into her wheelchair by staff. Oxygen was started to increase saturation levels. Pain assessment dated [DATE] at 6:49 p.m. revealed a score of zero. The assessment did reveal the resident had a headache at this time that was described as achy. Incident/accident report dated 11/12/23 at 6:57 p.m. revealed the resident had an unwitnessed fall in the dining room at approximately 6:08 p.m. LPN #1 was notified by a resident's family member that a resident had fallen in the dining room. This nurse observed the resident lying on her right side in the dining room. The resident said she got up because she wanted to get out of the chair and slipped due to a slick floor. The resident also states she did hit her head at time of fall. A RN was notified. The resident's ranges of motion and neurological assessments were within normal limits. The resident was hypertensive at the time of the fall and her oxygen saturations were observed to be low. The resident was transferred back into her wheelchair by staff. Oxygen was started to increase saturation levels. The IDT's section revealed this resident was nearly admitted and was impulsive at times. The resident attempted to get out of her chair and ambulate without assistance. The new intervention was for the resident to have appropriate footwear on when she was out of her room to ensure resident safety. -However, the intervention for the fall that morning was for the resident to have gripper socks and/or shoes. Neurological assessments for fall two started on 11/12/23 at 6:08 p.m. and concluded on 11/15/23 on the night shift. There were a total of 21 neurological assessments to be completed by the nursing staff for the second fall. Eleven neurological assessments were completed according to the facility's electronic neurological assessment program. -Ten neurological assessments were not completed according to the computer generated neurological assessment program for a specific date and time. The nursing staff documented the resident was not available on 11/12/23 at 9:53 p.m., 10:53 p.m., 11:53 p.m., and also on 11/15/23 during the night shift (four of the missing eleven times). The resident was in the facility during those specific dates and times. Nurse note dated 11/13/23 at 6:42 a.m. revealed this nurse called a named service contractor to request a STAT (immediate, quick) x-ray to the resident's right hip/femur/pelvis due to pain post fall. This pain was consistent throughout the night and during transfers. A physician's assistant (PA) approved the request for the STAT x-ray. The resident was currently in a wheelchair at the nurse's station. PA progress note dated 11/14/23 at 11:32 a.m. revealed the resident had a choking episode at the time she arrived at the facility. The resident was unable to speak and unable to get a good cough. This episode slowly improved and her airway was cleared prior to emergency services arriving at the facility. There was no need to do the Heimlich maneuver. By the time the emergency services arrived at the facility, she had cleared the blockage and was breathing better. The resident declined transport to the hospital because she had cleared her blocked airway before they had arrived. -The note did not mention the resident's two falls on 11/12/23. Physician's history and physical note dated 11/15/23 at 1:30 p.m. revealed the resident was admitted to the facility for convalescence and rehabilitation. The resident had upper thoracic spine pain and on work-up was found to have a seventh thoracic (T7) compression fracture with approximately 60% height loss. The resident had terrible osteoporosis throughout the cervical thoracic and lumbar spine. -The note did not reveal any information on the resident's two falls or the choking incident. The radiographic service provider completed the x-ray on 11/14/23 at 2:01 p.m. related to pain in the right hip and leg. The x-rays were reviewed by a physician on 11/14/23 at 3:34 p.m. The pelvic x-ray impression did not reveal any fractures or dislocations of the pubic rami (pelvic) or the bilateral hip joints. The right hip x-ray impression did not reveal any fractures or dislocations and the pubic rami were intact. The right femur x-ray impressions did not reveal any fractures or dislocations and the hip joint was grossly intact. A nursing note dated 11/15/23 at 7:37 a.m. (late entry for 11/14/23) revealed the DON noticed the order for a STAT x-ray and called to the mobile radiology provider to verify that the order had been placed. The order had not been placed as of this time and the DON placed the STAT order and notified the resident's provider. PA progress note dated 11/15/23 at 12:38 p.m. revealed this was a follow up visit for a chest x-ray after the choking episode and leg pain after a fall. The staff feel the resident would benefit from a scheduled muscle relaxer. The resident had a diagnosis of a compression fracture (T7-T8) and was having back pain. The resident was now better from her previous choking episode. The resident's diagnosis of pain was reported as stable. -This note did not mention the resident's x-rays impressions on 11/14/23. Nurse note dated 11/15/23 at 3:30 p.m. revealed the as needed follow up for an oxycodone 5 milligrams tablet, administer orally every four hours, as needed, for moderate pain (4-6) administered at 1:29 p.m., was ineffective for the resident's pain of 8 out of 10 on the pain scale. Physician's order dated 11/15/23 at 4:04 p.m. revealed to transfer the resident to the hospital related to pain. A nursing note dated 11/15/23 at 4:19 p.m., by the DON, revealed the resident had increased anxiety and panic related to severe pain that increased with the fall on 11/12/23. The resident also had a choking episode this morning and was now requiring oxygen to keep saturations above 90%. The resident's provider was notified of the resident's increased pain and oxygen needs. An order was received to send the resident to the hospital emergency room for evaluation and treatment. The resident's family was at bedside and in agreement. Nurse note dated 11/15/23 (note timed) by a LPN revealed the PA was notified and ordered the resident be transported to a named hospital emergency department due to severe pain in the right hip and leg. At 3:30 p.m., the resident was transported by emergency medical technicians (EMTs) using a stretcher. The resident's power of attorney (POA) was present. This note was electronically signed on 11/20/23 at 11:19 a.m., by the DON. The hospital's admission documentation dated 11/15/23 at approximately 4:30 p.m. revealed the resident fell two days ago and had negative outpatient x-rays. The resident had worsening pain and difficulty weight bearing. The PA at the facility was consulted and admission for pain management was arranged. The resident was admitted to the emergency department (ED) after a mechanical fall. The resident's most recent fall was on 11/12/23 and was seen in urgent care and had a negative x-ray report. The resident was admitted to medicine service for pain management. Computer tomography (CT) and x-rays were obtained. Hospital orthopedics were consulted for evaluation and treatment of sacral bone fracture and an inferior pubic rami fracture (pelvis). This was the initial encounter for the closed non-displaced fracture of the sacrum and an initial encounter for the closed fracture of the ramus of the right pubis. The patient was seen in consultation by orthopedic surgery and the fractures were deemed to be non-operative. Nurse note dated 11/20/23 at 12:25 p.m. (late entry for 11/13/23) by the DON revealed she was the nurse manager on call and received a call from LPN #1 regarding the resident's fall in the dining room. The resident did not complain of any pain. LPN #1 and the DON performed the assessment of the resident. The resident had baseline ranges of motion in the lower extremities and her back brace was in place. The resident had no identified shortening of either lower extremity and no internal or external rotation of either extremity. The DON requested LPN #1 to start neurological assessments according to facility protocol. C. Staff interviews LPN #1 was interviewed on 12/26/23 at 8:26 p.m. She said the resident was a high fall risk. She said the resident had an unwitnessed fall on 11/12/23 at 4:43 a.m. The resident fell in her room and did not have any injuries. She said the resident stood up and slipped on a dry floor. The resident did not have any socks on her feet at this time. LPN #1 said she did an assessment of the resident, called the DON over the phone and gave her a report. The DON gave permission to move the resident from the floor to her bed. She said it took herself and two CNAs to move the resident with the use of a gait belt. She said neurological assessments were started. LPN #1 said the resident had a second fall in the dining room on 11/12/23 at 6:57 p.m. with no injuries. The LPN did the physical assessment, called the DON and gave a report over the phone. The DON said it was okay to move the resident from the floor to a wheelchair. She said it took herself and two CNAs to move the resident with the use of a gait belt. She said neurological assessments were started. LPN #1 said on several neurological assessments for the resident's second fall, she documented the resident was unavailable; when the resident was asleep. She said there was absence of computerized neurological assessments at the specified dates/times for the resident's fall in the dining room. She said for unwitnessed falls with head injuries, neurological assessments were conducted to look for widening pulse pressure, differences in pupils of the eyes, alertness and if the resident became sleepy. She said if neurological assessments were not completed, the resident might experience unnoticed hemorrhages, fractures, brain bleeds, body bleeds, abnormal ranges of motion and they might die. LPN #1 said on 11/13/23 at 6:42 a.m. she called the resident's provider and requested a STAT x-ray of the resident's right hip/femur/pelvis due to pain after a fall. The resident had consistent pain throughout the night and during transfers. The resident's PA approved the request for the STAT x-ray. She said she did not call the x-ray services. She said she passed the x-ray order to the oncoming nurse for the next shift. She said the x-rays taken on 11/14/23 were negative for fractures. She said she did not call the resident's family regarding the x-ray findings. She said she did, however, call the resident's family for the fall in the resident's room and for the fall in the dining room. She said she was not aware of the hospital findings of fractures. She said the nurse note dated 11/15/23 by the DON as a late entry for 11/14/23 at 7:37 a.m. related to a STAT x-ray order verification; the order had not been placed. The STAT x-ray order was placed at this time and the provider was notified of the delay. The medical director (MD) was interviewed on 12/27/23 at 8:00 a.m. She said she observed the resident one time. She said portable x-rays were typically of bad quality and they only get one view. She said portable x-rays at times did not demonstrate fractures. She said hospital x-rays and CT scans would demonstrate the actual problems. She said STAT x-ray services should occur in less than four hours. The DON was interviewed on 12/27/23 at 9:43 a.m. She said the resident had poor cognition and safety awareness. She said the resident was a high fall risk. She said both falls were on 11/12/23. She said the resident was not immediately sent to the hospital emergency room because there were no noted injuries and/or pain at the time of the falls. The DON said the resident's first unwitnessed fall was on 11/12/23 at 3:45 a.m. in the resident's bedroom. The resident was ambulating to the bathroom by herself. She said the resident did not receive any injuries from this fall. She said LPN #1 did the resident's assessment, called the DON and they assessed the resident together. She said the resident had a second unwitnessed fall on 11/12/23 at 6:08 p.m. in the dining room. The resident pushed her wheelchair back, stood up and fell. She said LPN #1 assessed the resident after the fall and called the DON. There were no observed injuries from this fall. The DON said the resident did complain of pain on 11/13/23 to her provider. The DON said a LPN received an order for a STAT x-ray on 11/13/23 at 6:42 a.m. The LPN did not call the x-ray service provider. The DON said she saw the x-ray order lying on the desk at the nurse's station. She said she called the x-ray service company and was notified the x-ray order had not been received. She said she ordered the x-ray on 11/14/23 at approximately 9:00 a.m. and the x-ray services were completed at 2:01 p.m. The x-rays were read by a physician at 3:34 p.m. She said the x-rays demonstrated the resident did not have any fractures. She said a STAT x-ray should be taken in four hours or less. The DON said when a nurse checked a box in the computer that neurological assessments should be started, the computer would automatically auto-populate (generate) the sequences of dates/times the neurological assessments should be conducted. She said there were missing neurological assessments for the second fall on 11/12/23 at 6:08 p.m. She said the staff documented the resident was not available, when the resident was in the facility. She said a resident should be awakened, if they were sleeping, to complete the neurological assessments. The nursing staff should not document the resident was not available, when they were sleeping. She said the resident had the right to refuse and the documentation should show a refusal. The DON said all of the neurological assessments should have been completed according to the computerized sequence. She said neurological assessments were conducted to observe for alteration in the resident's mentation, pupil reactivity, bleeding, muscle strength, pain, ranges of motion and for stable vital signs. She said if the assessments were not completed the nursing staff might not recognize a brain bleed, swelling of the brain, limitation in ranges of motion, increased pain and the potential for death. The DON said on 11/14/23 at 11:32 a.m. emergency medical services (EMS) arrived at the facility related to a choking episode the resident had in the dining room. The resident was not taken to the ER at this time. She said by the time the ambulance got here, the resident had cleared the obstruction and was breathing better. She said on 11/15/23 at 4:19 p.m. she wrote a progress note that revealed the resident had increased anxiety and panic related to severe pain that increased with the fall on 11/12/23. The resident had a choking episode this morning and was now requiring oxygen to keep saturations above 90%. The resident's provider was notified of the resident's increased pain and oxygen needs. An order was received to send the resident to the ER for evaluation and treatment. The resident's family was at bedside and in agreement. Nursing staff notified the PA, who ordered the resident be transported to the ER. The resident was transported due to severe right hip/leg pain at 3:50 p.m. utilizing a stretcher and emergency medical technicians (EMTs). The DON said she talked with the resident's son on 11/15/23 about his concern regarding her anxiety. She said she also talked with the resident's provider, who had observed the resident on this date. She said in the afternoon, a CNA was taking the resident's vital signs and observed low oxygen saturation levels. The CNA wanted an assessment from an agency nurse but did not feel the nurse was taking her seriously. The DON went and assessed the resident. The DON said the resident was crying, anxious, pointed to her lower back bottom area and said she was in pain. The pain was worse during transfers and better with not moving. The resident's son was present and the DON talked with both of them. The DON felt that the resident should go to the ER, even though the previous x-rays were negative. She said the resident at first did not want to go; however, the resident and the son eventually agreed to have the resident sent to the ER. The DON said there had been times that portable x-rays did not demonstrate anything and hospital diagnostics did demonstrate issues. The DON said the fall interventions in place, were to ensure the resident's bed was in the lowest position, frequent checks, encourage the resident to wear shoes and the use of non-skid socks. The resident's son did not want her to wear non-skid socks because she was from Hawaii and he felt that it would be safer for her to go barefooted. -However, this was added to the care plan on 11/13/23 after the resident had fallen twice and there was no education on the risks associated with the resident continuing to go barefoot and fall risk. The DON said on 11/16/23 during a quality assurance performance improvement (QAPI) falls meeting, the resident's incident reports were reviewed and discussed. The PA was interviewed on 12/27/23 at 11:34 a.m. He said the resident fell on Sunday (11/12/23). He said he was called on 11/13/23 at 6:42 a.m. to approve a request for STAT x-rays, which he did. He said the physician notes dated 11/13/23 at 1:30 p.m. did not mention the falls on 11/12/23. He said on 11/14/23 at 8:00 a.m. the resident was choking in the dining room, was able to clear the food and emergency medical services were called. He said the Heimlich maneuver was not performed. He said EMS arrived, the family member was in the dining room and told him that a mobile x-ray service was already coming to take x-rays. Since an x-ray service was to be completed today, the family member agreed to also have a chest x-ray taken at the same time in the facility. The PA offered the resident and the family member to have the resident sent to the hospital emergency room for the x-rays and they declined. He said he did an assessment of the resident and she did not have any pain on palpation of her hips. The PA said he was not in the facility when the x-ray technicians arrived. He said the family member came up to him and asked about the x-rays impressions on 11/15/23 at approximately 9:00 a.m. He said he reviewed the x-ray report and the chest x-rays were clear with no pneumonia. The PA said all of the portable x-rays of the hip, pelvis and femur were also normal with no fractures. The PA said each time he had observed and talked with the resident, she did not complain of pain. He said when he palpated the resident's pelvis, she did not mention any concerns with this area. The PA said on 11/15/23 he talked with facility therapy services related to the resident having some back pain when they moved her and about muscle spasms. The pain was not going down her leg. The PA said he was not told by therapy that the resident had significant pain, when he asked if the pain was coming from her back. They felt a muscle relaxant would be beneficial and he ordered a muscle relaxant. The PA said when the resident's family member told him the resident was yelling out in pain related to her leg; he was unable to recreate the pain the family member talked about. The PA said on 11/15/23 at approximately 4:00 p.m. he received a call and was told the resident was yelling out in uncontrolled pain and he ordered the resident to be sent to the ER. The occupational therapist (OT) was interviewed on 12/27/23 at 2:11 p.m. She said she had worked with the resident. She said based on her behaviors, the resident had significant pain with sit to stand transfers. She was unable to verify the location of the pain. Her note on 11/15/23 at 2:52 p.m. revealed the resident was emotional. She worked with the resident with her activities of daily living (ADLs) to help calm her down. She said she was unsure if she knew the resident had fallen twice on 11/12/23. The physical therapist (PT) was interviewed on 12/27/23 at 2:26 p.m. She said on 11/14/23 at 4:39 p.m. she wrote a therapy note that read the resident was on the toilet in her bathroom and had pulled the call light. She and a student decided to help the resident off the toilet. They used a named steady machine (the resident pulled themselves up to stand). This was a two person and a machine transfer. She said the resident complained of severe (very vocal yelling/groaning) pain and pointed to her right hip just at the femur head. The resident did not point to the sacral area. She said she typically told nursing staff if a resident was in severe pain. She wrote a therapy note on 11/15/23 at 4:09 p.m. that the resident had severe pain from sitting to standing (unable to remain standing). She said she talked with the PA related to the resident's muscle spasms in the low back interfering with therapy. She said she asked the PA if there was anything that could be given to the resident for muscle spasms. III. Resident #5 A. Resident status Resident #5, age over 65, was admitted on [DATE]. According to the November 2023 CPO, diagnoses included displaced intertrochanteric fracture of the right femur with routine healing, orthopedic aftercare, wedge compression fracture of a lumbar vertebrae, fracture of the superior rib on the right pubis, presence of right artificial hip, unsteadiness of feet, pain, bradycardia, metabolic encephalopathy (brain disorder), personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. The 5/29/23 MDS assessment revealed the resident had a moderate cognitive impairment with a BIMS score of eight out of 15 with no behaviors. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting and personal hygiene. B. Record review Fall risk assessment dated [DATE] revealed a score of 12 or high risk. Care plan for being a fall risk related to a fall with a fracture on 7/13/23 and 7/14/23, history of hypertension, high fall risk was updated on 12/26/23 (during the survey). This was evidenced by right lower extremity weakness, mildly/moderate cognitive impairment, wears glasses, limited transfer assistance. Some of the interventions were administer first[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents were kept free from significant medication errors for one (#1) out of three sample residents. Resident #1 was admitted on [DATE] with a diagnosis of hepatic encephalopathy, a nervous system disorder brought on by severe liver disease; when the liver does not work properly, toxins build up in the blood. These toxins can travel to the brain and affect brain function. Resident #1 had a physician's order for lactulose (a laxative medication which assists in eliminating ammonia from the body) 20 grams/30 milliliters (ml) oral solution 30 ml by mouth four times per day for hepatic encephalopathy. On 6/9/23, Resident #1 was noted to have a decline in mental status. The resident was minimally responsive to stimuli and was unable to answer questions or open her eyes. Resident #1 was sent to the hospital per family request. At the hospital, it was discovered that Resident #1's ammonia level was 122 umol (micromole)/L (liter). Per the hospital lab work, a normal ammonia level range was 9-30 umol/L. Resident #1's ammonia level prior to admitting to the facility on 5/26/23 was 22 umol/L. During investigation to determine the cause of Resident #1's high ammonia level, it was discovered that the resident had missed several doses of her lactulose medication because the medication was unavailable. Facility staff did not notify the pharmacy to reorder the medication until the morning of 6/9/23, the same day the resident was sent to the hospital. Additionally, the physician was not notified that the resident was out of the lactulose medication, and licensed practical nurse (LPN) #2 gave the resident another laxative medication without a physician's order as she was under the erroneous assumption that Resident #1 was receiving lactulose for constipation and not for hepatic encephalopathy. The facility failed to notify the pharmacy or the physician in a timely manner that Resident #1 was out of lactulose medication and had missed several doses. Due to the facility's failures, Resident #1 suffered a toxic buildup of ammonia in her body which resulted in an intensive care unit (ICU) stay during her hospitalization. Findings include: I. Professional reference According to the American Liver Foundation (3/16/23) Treating Hepatic Encephalopathy, retrieved on 8/7/23 from https://liverfoundation.org/liver-diseases/complications-of-liver-disease/hepatic-encephalopathy/treating-hepatic-encephalopathy/, Hepatic encephalopathy (HE) is a condition that causes temporary worsening of brain function in people with advanced liver disease. When your liver is damaged it can no longer remove toxic substances from your blood. These toxins build up and can travel through your body until they reach your brain, causing mental and physical symptoms. HE is a serious but treatable condition if caught early and treated promptly. Symptoms often resolve when triggering factors are treated. It's important to continue treatment for as long as necessary to keep HE from coming back. Once symptoms become severe, HE can quickly worsen and become a medical emergency resulting in prolonged hospitalization. Lactulose works by drawing water from your body into your colon, which softens stools and causes you to have more bowel movements. This helps to lessen the absorption of toxins in your intestines by flushing toxins out of your system. It reduces the amount of ammonia in your blood by drawing the ammonia into the colon where it is removed from the body and helps during HE recurrences and makes them less likely to occur. The best way to reduce the risk of HE recurrence is to manage your liver disease and stay on maintenance therapy with lactulose, as directed by your doctor. II. Facility policy and procedure The policy for medication administration was requested from the nursing home administrator (NHA) three times between 8/3/23 and 8/7/23. The NHA did not provide the policy. III. Resident #1 status Resident #1, age [AGE], admitted on [DATE] and discharged to the hospital on 6/9/23. According to the June 2023 computerized physician orders (CPO), diagnoses included hepatocellular carcinoma (liver cancer), cirrhosis of the liver, and hepatic encephalopathy. The 5/30/23 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required one-person extensive assistance for bed mobility, transfers, dressing, and personal hygiene. She required two-person extensive assistance for toilet use. IV. Record review A review of Resident #1's June 2023 CPO revealed a physician's order for lactulose 20 grams/30 ml oral solution 30 ml by mouth four times per day for hepatic encephalopathy. The order had a start date of 5/26/23. Review of Resident #1's medication administration records (MAR) from 5/26/23 through 6/9/23 revealed the resident did not receive the lactulose medication on 6/7/23 at 8:00 p.m., 6/8/23 at 8:00 a.m. and 6/8/23 at 8:00 p.m. -The MAR documented the resident received the lactulose medication on 6/8/23 at 12:00 p.m. and 4:00 p.m., however, during the facility's investigation of the missed medication doses LPN #2 stated that she had given the resident a different laxative medication without a physician's order at those administration times and the resident did not actually receive the correct medication. -Review of Resident #1's comprehensive care plan, initiated 5/26/23, revealed the resident did not have a care plan to monitor for her diagnosis of hepatic encephalopathy or have any interventions in place for staff to monitor the resident for signs of ammonia toxicity such as confusion and disorientation, excessive sleeping and changes in consciousness. Review of Resident #1's electronic medical record (EMR) revealed the following physician progress note: 6/7/23: Resident is seen in their private room resting comfortably. Resident's plan and progress was discussed with nursing staff, primary team, and therapy. Resident is making progress in therapy. Resident tells me that she's feeling better this morning. She is asking for her lactulose. She tells me that her pain has been better since starting gabapentin. She denies any pain currently. She tells me since starting gabapentin her pain has been mild. She denies any new or worsening musculoskeletal or neurological pain complaints. No uncontrolled pain reported by nursing or therapy. She denies any side effects to gabapentin. No new issues with bowel or bladder control. denies any chest pain, cough, nausea, vomiting, diarrhea, constipation, fever, or chills. is eating well and sleeping well. no further questions or concerns. -Despite the physician's progress note documentation that Resident #1 was asking for her lactulose, no follow up was done by the physician or the facility to ensure the resident's medication was available. Review of Resident #1's EMR revealed the following nurse progress notes: 6/7/23: Placed call to pharmacy regarding resident being out of lactulose. -The progress note was documented by LPN #2 as a late entry on 6/9/23 at 12:21 p.m. (after Resident #1 had been transferred to the hospital and admitted ). 6/8/23: Placed call to pharmacy regarding resident being out of lactulose. Pharmacy staff stated that medication will be delivered on the next run. Resident alert and oriented, no signs/symptoms of discomfort or changes. -The progress note was documented by LPN #2 as a late entry on 6/9/23 at 12:22 p.m. (after Resident #1 had been transferred to the hospital and admitted ). 6/9/23 at 3:56 a.m: Resident's mental status has declined. She does not make eye contact. You have to like bring her back into the conversation. She will answer 'yes' but then she kind of fades off. She was taking her medications whole with no issues, would take the cup and put them in her mouth and take them but I could not get her to open her mouth or hold the cup this evening. Also was kicking at certified nurse aide (CNA) during being changed. Will inform the physician of the change in status. Also called the pharmacy about her lactulose that is not here and they once again said it would be on the next run. Resident denies any pain. When asked she says 'I'm fine, how are you?'. She has been very restless. Was able to get a couple of her medications down her and she is finally resting at this time. Vital signs within normal limits. Will continue to monitor. -Despite the progress note documenting the provider would be notified, notification to the provider did not occur until after 7:00 a.m. 6/9/23 at 7:30 a.m. (documented as a late entry on 6/9/23 at 3:01 p.m.): This nurse went to assess resident related to LPN stating the resident had an acute change of condition. Upon assessment, the resident noted to look as though she was sleeping, she would grimace with some stimuli, however she wasn't able to answer questions or fully open her eyes. Vital signs stable, breathing was normal with no dyspnea or labored breathing. Provider and family notified. Family said they would be right in. Once the family arrived the resident wouldn't wake up for him either and he requested the resident go to the hospital. Provider notified of the family's preference and received an order to transfer. 6/9/23 at 7:33 a.m: Provider notified of change in condition. Stated to call the family. This nurse called the family and they stated they would be right in. 6/9/23 at 7:50 a.m. (documented as a late entry on 6/9/23 at 2:55 p.m): At 7:50 a.m., resident was transferred to hospital per power of attorney (POA) request. Provider aware, POA at facility at time of transfer and escorted resident to the hospital. 6/9/23 at 12:34 p.m.: Call received from hospital that resident is being admitted . MAR faxed to the hospital at hospital request. Review of documents from Resident #1's hospitalization on 6/9/23 revealed the following: History of present illness: Patient is a [AGE] year old female. Patient unable to provide history as she is altered. Per facility and son, had been maintained on lactulose after discharge but ran out, has not been getting lactulose for several days. This morning they could not wake her up and she was turning more yellow. Had just been admitted for fall and discharged to rehabilitation. Per son, they missed some doses but he is not sure how many. Assessment/Plan: History of hepatic encephalopathy and patient presented altered with ammonia level of 122 up from 22 a couple weeks ago, per report rehabilitation facility ran out of lactulose several days prior, had been doing well on regular lactulose, CT head normal. V. Interviews Registered nurse (RN) #1 was interviewed on 8/3/23 at 12:59 p.m. RN #2 said she was an agency nurse and had only worked at the facility for two days. She said if medications were not available the pharmacy and the physician should be notified. LPN #1 was interviewed on 8/3/23 at 1:12 p.m. LPN #1 said if medications were not available the pharmacy and the physician should be notified and the nurse should check the emergency medication kit in the facility to see if the medication was on hand. The nursing home administrator (NHA) and the assistant director of nursing (ADON) were interviewed together on 8/3/23 at 2:05 p.m. The ADON said the night nurse noticed Resident #1 was out of lactulose on the evening of 6/7/23 and informed the day nurse (LPN #2) about it. She said the night nurse did not notify the physician or the pharmacy about the medication not being available. The ADON said LPN #2 also did not notify the physician or the pharmacy about the unavailable medication and Resident #1 missed at least four doses of the medication. She said LPN #2 admitted that she gave the resident another laxative medication in place of the lactulose which was unavailable. She said the Resident #1 did not have a physician's order for the medication that was given and the medication would not have been as effective as the lactulose for eliminating ammonia from the body. The ADON said if a resident's medication was unavailable, the nurse should notify the pharmacy immediately to reorder the medication. She said the physician should also be notified immediately that the resident had missed doses of the medication and see if the physician wanted to prescribe another medication until the unavailable medication was delivered from the pharmacy. The ADON said the process for notifying the pharmacy and the physician when medications were unavailable was part of the nurse's orientation checklist, however, the ADON looked at the checklists and confirmed that the information was not specifically mentioned on the checklist. The NHA said the facility investigated the missed doses of lactulose and concluded Resident #1 had missed at least four doses of the medication. She said LPN #2 admitted she had given an alternative laxative without a physician's order in place of the lactulose. The NHA said LPN #2 did not call the pharmacy or notify the physician that the resident had missed some doses of the lactulose. She said the pharmacy and the physician should be notified immediately if medications were unavailable and a resident missed doses of medication. The NHA said the director of nursing (DON) completed a competency evaluation for medication administration with LPN #2 following the incident with Resident #1. She said all nurses were educated on the proper procedures regarding who to notify when residents' medications were unavailable. The pharmacy consultant (PC) was interviewed on 8/3/23 at 2:40 p.m. The PC said the pharmacy had not received a call from the facility to reorder the lactulose medication for Resident #1 until the morning of 6/9/23. He said the pharmacy refilled the medication and it was sent to the facility later that same day. He said he was unaware the resident had missed any doses of the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#5) of three residents received adequate supervision to prevent accidents out of six sample residents reviewed. The facility failed to develop and implement a person-centered care plan that identified the resident's fall risk and put effective interventions into place to reduce falls and prevent injury for Resident #5. Resident #5 was identified as a fall risk within the comprehensive care plan. The facility failed to identify the resident's patterns throughout the day and failed to have personalized and effective interventions in place to prevent falls. The fall risk care plan was put into place on 12/6/22 which identified the resident as a fall risk. On 12/6/22, Resident #5 fell in her room and complained about left hip pain. An x-ray was ordered for her hip and pelvis. She was mildly confused after she fell. The facility updated her fall risk care plan to include assisting the resident with activities of daily living and assisting the resident with toileting, however did not determine the root cause of the falls nor add any additional person-centered interventions. The resident fell again, twice on 12/12/22, for which she sustained a fracture to the left hip. Cross-reference F659: the facility failed to ensure an assessment was completed by a registered nurse (RN) following a fall. Findings include: I. Facility policy and procedure The Fall Management policy and procedure, reviewed 1/12/22, was provided by the nursing home administrator (NHA) on 3/15/23 at 2:00 p.m. It revealed, in pertinent part, Upon determination that the resident is at risk, the qualified staff creates an individualized plan of care that includes the appropriate preventative interventions to reduce potential for fall. II. Resident #5 A. Resident status Resident #5, age [AGE], was admitted on [DATE] and discharged on 12/14/22. According to the December 2022 computerized physician orders (CPO), the diagnoses included Parkinson's disease, neuropathy, fracture of sacrum, unsteadiness on feet, weakness, need for assistance with personal care and repeated falls. The 12/11/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of eight out of 15. She required extensive assistance of two with transfers, dressing, toileting and personal hygiene. It indicated that the resident had sustained a fall in the last month and had a fracture related to a fall within the last six months. B. Record review The cognitive deficit care plan, initiated on 12/5/22, documented the resident had cognitive deficit related to decision-making. The interventions included monitoring the resident for any changes or decline in cognitive status, allowing the resident to make simple decisions, allowing the resident ample time to absorb and respond to information and avoiding changes in the resident's environment. The impaired physical mobility care plan, initiated on 12/5/22, documented the resident needed maximum assistance with activities of daily living (ADLs). The interventions included providing an occupational and physical therapy evaluation as needed and providing the appropriate level of assistance to promote the safety of the resident. The fall risk care plan, revised on 12/13/22, documented the resident was at risk related to a high fall risk score. The interventions included administering first aid as needed, assessing the contributing factors to the resident's fall history, assessing for potential fall-related injury prevention, assessing medications for contributing factors, assisting the resident with activities of daily living (ADL) as needed, assisting the resident with toileting as needed, keeping the call light and most frequently used personal items within reach, keeping the resident's glasses clean and fit with adequate prescription, making sure that the staff members were aware that the resident was at high risk for falls, and provide a physical therapy referral as needed. -The fall risk care plan did not include any individualized person-centered interventions. It did not document the resident's daily routine nor input from the resident's family to determine effective interventions to prevent falls and injuries. The 12/6/22 fall risk assessment revealed the resident required assistance for mobility, transfers and was non-weight bearing. It also indicated that she had sustained a fall in the last six months. -The resident scored an 11 out of 18, which indicated the resident was a high fall risk and interventions should have been promptly put into place. However, based on the comprehensive fall care plan, person-centered interventions were not put in place, even though the facility was aware the resident had a history of falls and was at a high fall risk. 1. Fall incident on 12/6/22 The 12/6/22 nursing progress note documented at 3:56 p.m. Resident #5 was found on the floor in her bedroom and complained of left hip pain. The physician was notified and ordered an x-ray of the pelvis and hip. -It did not indicate the facility had determined the root cause of the fall. 2. Fall incidents on 12/12/22 The 12/12/22 nursing progress note documented at 3:22 p.m. the resident told the nurse that she slid down to the ground (unknown from where) and was laying on the floor next to the bed on her back. -The care plan revealed that the following interventions were added: administering first aid as needed, assessing for potential fall-related injury prevention, looking at circumstances, location, medication, new or worsening medical problems, assessing medication for contributing factors, and keeping glasses clean and fit with an adequate prescription. -There was no documentation to determine the root cause of the fall, nor a person-centered immediate intervention to prevent additional falls or potential injuries. The 12/12/22 nursing progress note documented at 3:29 p.m., only seven minutes following the first fall, the resident had sustained another fall. The certified nurse aide (CNA) found the resident, on the right side of her body, lying on the floor, away from the bed. She had a new bruise on her left upper extremity close to her elbow. -There was no documentation to determine the root cause of the fall. The December 2022 medication administration record (MAR) revealed that the resident reported generalized pain on 12/13/22 at 7:00 a.m. Her pain level was a 2 out of 10 (with 10 being the worst pain on the scale). -On 12/14/22, two days after the resident sustained two falls, the resident reported severe pain to her left hip. Oxycodone 5 milligrams (mg) was administered on 12/14/22, however the resident reported the pain medication did not provide any relief. -The physician ordered an x-ray of the hip. The preliminary findings showed distortion to the left femoral head. The doctor was notified and the resident was sent to the hospital. The resident did not return to the facility. -The 12/14/22 finalized x-ray report documented an impacted displaced left-sided subcapital fracture to the left hip. The facility failed to determine the root cause of the falls for Resident #5 and put effective person-centered interventions into place to prevent the resident from continued falls and subsequent fracture. C. Staff interviews CNA #1 was interviewed on 3/15/23 at 12:28 p.m. She said that the care plan provided information if a resident was considered a high fall risk She said a resident who was a high fall risk should be checked on frequently throughout the day. She said following a fall, a huddle would occur to determine things they could put in place to prevent future falls. Licensed practical nurse (LPN) #4 was interviewed on 3/15/23 at 12:31 p.m. She said for residents who were considered a high fall risk, potential interventions included increasing the frequency of checking on the resident, adding fall mats and a stoop mattress (lipped mattress with raised edges). She said the NHA, director of nursing (DON), assistant director of nursing (ADON) and MDS coordinator determined the interventions put into place following a fall. She said the interventions should be documented on the comprehensive care plan and in the nurse's notes. LPN #4 said the interventions should be based on the resident and individualized. She said the CNAs were notified of interventions verbally and on the white board inside the resident's room. It would also be documented in the plan of care for CNAs. The DON was interviewed on 3/15/23 at 12:44 p.m. The DON said following a fall, the staff had a huddle meeting to talk about the circumstances of the fall, put an immediate intervention into place, complete an incident report and perform a change of condition assessment. The DON reviewed the comprehensive care plan for Resident #5 and confirmed person-centered interventions were not put into place upon the resident's admission or following the fall sustained on 12/6/22 to prevent additional falls. She said Resident #5 had been admitted to the facility following a sustained fall at home. She said Resident #5 was a high fall risk upon admission to the facility.