**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries for one (#42) of two residents out of 50 sample residents reviewed for pressure ulcers. Resident #42, who was dependent on staff for all care and mobility and was known to be at risk for skin breakdown, developed a stage 3 pressure injury on 5/20/24 at the facility. The resident's care plan for skin breakdown failed to include interventions for repositioning the resident frequently to avoid potential pressure injuries. Observations during the survey revealed staff were not repositioning Resident #42 frequently in order to keep the resident from developing further pressure injuries. Additionally, the resident did not have the physician ordered wound treatment in place when the wound care physician (WCP) came to assess the resident's wound. Furthermore, the facility failed to accurately and consistently document the location of the resident's stage 3 pressure injury. Due to the facility's failures to ensure the resident's plan of care included appropriate pressure injury prevention interventions and ensure the resident was frequently repositioned by the staff, Resident #42 developed a stage 3 pressure injury to her left gluteal fold. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved from https://www.internationalguideline.com/guideline on 6/12/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Skin Integrity and Pressure Ulcer/Injury Prevention and Management policy and procedure, reviewed 3/31/23, was provided by the nursing home administrator (NHA) on 6/11/24 at 7:41 p.m. It read in the pertinent part, Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPIAP (National Pressure Injury Advisory Panel) and WOCN (Wound, Ostomy, Continent Nurses Society). A risk assessment tool (Braden Scale) determines the resident's risk for pressure injury development. The score is documented on the tool and placed in the resident's medical record using the appropriate form. A resident's risk may increase due to an acute illness or condition change (for example,upper respiratory infection, pneumonia, or exacerbation of underlying congestive heart failure) and may require additional evaluation. The frequency of assessment should be based upon each resident's specific needs. Certain risk factors have been identified that increase a resident's susceptibility to develop or impair healing of pressure injuries. Measures to maintain and improve the resident's tissue tolerance to pressure are implemented in the plan of care. All residents upon admission are considered to be at risk for pressure injury development due to medical issues requiring nursing care related to disease process and illness or need for rehabilitation services. Upon admission and throughout stay at a minimum a pressure redistribution surface (Group 1 mattress) is in use with turning and repositioning as needed with ADL care/assistance, incontinent care if needed to include skin barriers application as needed, preventative wheel chair cushion if indicated. Minimize injury due to shear and friction through proper positioning, transfers, and turning schedules (if indicated). Measures to protect the resident against the adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care. Reposition at least every 2-4 (two to four) hours as consistent with overall patient goal and medical condition. Utilize positioning devices to keep bony prominences from direct contact. When positioned in a wheelchair, the resident is to be placed on a pressure reduction device and repositioned. When skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident. III. Resident #42 A. Resident status Resident #42, over the age of 65, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included dementia, prediabetes, muscle weakness and anxiety. The 5/9/24 minimum data set (MDS) assessment documented the resident was rarely/never understood and the brief interview for mental status (BIMS) should not be performed. She had short and long term memory problems and her cognitive skills were severely impaired based on the staff assessment for mental status. She was dependent on staff for all care and mobility. The assessment indicated the resident did not reject care. B. Observations During a continuous observation on 6/6/24, beginning at 9:26 a.m. and ending at 11:35 a.m., the following was observed: At 9:26 a.m. Resident #42 was lying in bed on her back with her eyes closed. At 11:35 a.m. Resident #42 remained in bed on her back. -Staff did not enter the resident's room to reposition the resident during the continuous observation. During a continuous observation on 6/6/24, beginning at 1:07 p.m. and ending at 2:59 p.m., the following was observed: At 1:07 p.m Resident #42 was in bed on her back with her eyes closed. At 2:59 p.m., Resident #42 remained in bed on her back with her eyes closed. -Staff did not enter the resident's room to reposition the resident during the continuous observation. During a continuous observation on 6/11/24, beginning at 9:16 a.m. and ending at 11:51 a.m., the following was observed: At 9:16 a.m., Resident #42 was lying in bed on her back with her eyes closed. At 11:20 a.m., certified nurse aide (CNA) #7 entered the resident's room to provide incontinence care prior to the wound team's arrival. At 11:30 a.m. the wound team arrived to provide treatment to the resident's stage 3 pressure injury. -Staff did not enter the resident's room to reposition the resident during the continuous observation until just before the wound team's arrival. On 6/11/24 at 11:30 a.m. Resident #42's skin was observed with the wound care physician (WCP) and the assistant director of nursing (ADON). When the resident's brief was removed and she was rolled to the side, the physician ordered treatment was not on the wound. There was a small, open reddened area to the left gluteal fold. C. Record review Resident #42's skin integrity care plan, updated on 9/17/19, documented the resident was at risk for breaks in skin integrity due to limited mobility, weakness and incontinence. The interventions included keeping the skin clean and dry and performing weekly skin checks. -The care plan did not address the resident's risk for pressure injury or document the resident had a stage 3 pressure injury. -The care plan failed to include an intervention for repositioning and turning of the resident. The weekly skin check completed on 5/10/24 documented Resident #42 had no skin issues. The Braden Scale assessment completed on 5/17/24 documented Resident #42 was at high risk for developing pressure ulcers with a score of 11 out of 18. A late entry progress note dated 5/17/24 documented an area to the right gluteal fold with redness and a small open area. A referral was made to the in house WCP and notifications were made to the resident's provider and the DON. -The progress note documented the wound was on the resident's right gluteal fold, however, the wound was on the resident's left gluteal fold (see observation above and WCP note below). -The weekly skin check completed on 5/18/24 documented the skin check was not performed due to the resident sleeping. A progress note dated 5/21/24 documented the resident was seen by the wound care team regarding the left gluteal fold. The weekly skin check completed on 5/25/24 documented an issue with the right gluteal fold. -The weekly skin check documented the wound was on the resident's right gluteal fold, however, the wound was on the resident's left gluteal fold (see observation above and wound tracker note below). The wound observation tool completed on 5/28/24 documented the resident had a stage 3 pressure injury that was facility acquired on 5/20/24 to the left gluteal fold. Treatment included an air mattress and washing the wound with wound wash, and apply substance P (a wound healing treatment, honey and foam daily. The weekly skin check completed on 6/1/24 documented an ongoing issue with the right gluteal fold. -The weekly skin check documented the wound was on the resident's right gluteal fold, however, the wound was on the resident's left gluteal fold (see observation above and wound tracker note below) A review of the June 2024 CPO documented the following physician's orders: Cleanse area to right gluteal fold every day and as needed for soiling with wound wash, pat dry, apply medihoney and cover with foam dressing until resolved, ordered 5/28/24. -The physician's order, started on 5/28/24, documented the wound was on the resident's right gluteal fold, however, the wound was on the resident's left gluteal fold (see observation above and wound tracker note below) The wound tracker documentation on 5/28/24 identified a stage 3 pressure wound to the left gluteal fold, measuring 1.2 centimeters (cm) by 1.4 cm by 0 cm, with minimal serous drainage (drainage that forms as a clear, thin and watery fluid). The plan of care recommendations indicated the wound was to be washed with wound wash, and apply substance P, honey and foam daily. E. Staff interviews The WCP was interviewed on 6/11/24 at 11:38 a.m. The WCP said Resident #42's wound was a stage 3 pressure injury most likely caused by the edge of the incontinence brief on the resident. He said the resident should not have developed the wound. The WCP said he wanted the staff to reposition the resident frequently and offload when in bed. The ADON was interviewed on 6/11/24 at 11:38 a.m. The ADON said Resident #42 had a pressure injury and she was surprised it had developed. She said the staff should be repositioning the resident frequently and offloading the resident when she was in bed. CNA #4 was interviewed on 6/11/24 at 4:00 p.m. CNA #4 said residents with pressure injuries or who were at risk for pressure injuries should be repositioned every two hours to prevent further injuries and assist with healing. The director of nursing (DON) was interviewed on 6/11/24 at 4:00 p.m. The DON said all residents with pressure injuries or who were at risk of developing pressure injuries should be repositioned every two hours to prevent and help heal pressure injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide an environment as free of accident hazards as possible and ensure residents received adequate supervision and assistance devices to prevent accidents for one (#1) of three residents reviewed for accident hazards out of three sample residents. Resident #1 had a diagnosis of dementia with wandering and resided in a secure unit. Resident #1 sustained nine falls from 9/17/23 to 11/27/23. The facility failed to ensure appropriate interventions and adequate supervision were implemented to prevent major injuries, including a fracture of the left and right hips, which were sustained in two separate falls. Due to the facility's failures to implement effective interventions and adequate supervision, Resident #1 sustained a fracture of the left hip from a fall on 10/7/23. The facility failed to implement effective interventions and supervision when Resident #1 returned from the hospital on [DATE]. Following Resident #1's readmission to the facility, she sustained five more falls, obtaining a right hip fracture on 11/27/23. Additionally, the resident sustained a head laceration, a laceration above her right eye, skin tears and bruising to her upper and lower extremities from the multiple falls. Findings include: I. Facility policy The Fall Management policy, revised 4/7/22, was provided by the nursing home administrator (NHA) on 1/8/24 at 2:06 p.m. It documented in pertinent part, Avoidable accidents. This means that an accident occurred because the facility failed to identify environmental hazards and or assess individual resident risk of an accident, including the need for supervision and or assistive devices. Evaluate and analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards, risks as much as possible. Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident. Supervision or adequate Supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. The facility will assess the resident upon admission and readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. Residents will be assessed for fall indicators upon admission, readmission, quarterly, change in condition and with any fall utilizing the Fall Risk Assessment. During the admission and readmission process, a care plan will be developed and initiated by the admitting nurse on any residents assessed to be at risk for falls. Upon completion of the other interdisciplinary team's admission and readmission assessments, the interdisciplinary team will review any additional fall risk indicators and revise the resident's care plan as indicated. The interdisciplinary team will review and revise the care plan, if indicated, upon completion of each comprehensive, significant change and quarterly MDS (minimum data set assessment), upon a fall event and as needed thereafter. II. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included dementia, anxiety, wandering, right femur fracture, left femur fracture and a history of falls. The 12/14/23 minimum data set (MDS) assessment revealed that the resident had severe cognitive impairment and was unable to complete a brief interview for mental status (BIMS) assessment. Resident #1 had short and long term memory loss. She required substantial maximum assistance with transfers, toileting and bed mobility. Resident #1 was totally dependent on staff assistance for dressing and personal hygiene. The assessment documented the resident had a hip fracture and recent major surgery. B. Resident representative and frequent visitor interview A frequent visitor to the facility was interviewed on 1/8/23 at 12:40 p.m. She said she met with the facility after Resident #1 fell and broke her second hip on behalf of the resident's representative. The frequent visitor said she discussed with the facility putting a plan in place to prevent further falls and keep Resident #1 and other residents safe. The resident's representative was interviewed on 1/9/23 at 1:01 p.m. She said the resident had fallen and broken both hips and lacerated her head and eye while at the facility. She said therapy told her the resident needed to have a footboard or footrest on the wheelchair when she was in it, but the representative said they were never on. She said she paid one of her family members to go to the facility when she could not and stay with the resident during meals. The representative said the facility needed to have more eyes on Resident #1. The resident's representative said the staff appeared overwhelmed and short staffed. The resident's representative said the facility used wedges in the bed to keep the resident from getting up and the hospice provider had provided a new wheelchair. -There was no record of footrests or footboards in the progress notes or care plan (see below). C. Record review The fall care plan, initiated 11/18/22, documented the resident had a history of falls and was at risk for falls. The interventions were keep the call light in reach and orient to the room. -However, there were no additional fall interventions implemented with her known fall risk and history of falls. Interventions were not added to the care plan until after the resident had fallen multiple times (see below). 1. Fall on 9/17/23 On 9/17/23 at 12:25 a.m., the nursing progress notes documented the resident was walking backwards down the hall and fell. There was no injury. The fall care plan documented on 9/16/23 the staff were to encourage and assist Resident #1 to sit when she appeared unsteady. -However, there were no new interventions added to the care plan for the fall on 9/17/23. On 9/19/23 at 5:43 p.m. an interdisciplinary team (IDT) note documented the IDT met to review a recent event. There was no description of the event. The note documented the staff were educated to encourage the resident to sit when appearing unsteady and there were no new recommendations at that time. 2. Fall on 9/28/23 On 9/28/2 at 6:23 a.m. the nursing progress notes documented Resident #1 was found on the floor in her room when staff went into the room to check on her roommate. At 2:27 p.m. the nursing progress notes documented the family was notified of the fall and the resident would be evaluated by physical therapy (PT). The fall care plan included a PT evaluation on 9/28/23. 3. Fall 9/30/23 On 9/30/23 at 10:03 a.m. the nursing progress notes documented, witnessed fall, fading yellow green bruise to right knee and right elbow from previous fall. -It was unclear if this was a new fall or in reference to a previous fall. The only witnessed fall was on 9/17/23, prior to the unwitnessed fall 9/28/23. There was no further documentation in the nursing progress notes. -There were no changes to the care plan. On 10/4/23 at 3:12 p.m. a late entry documented the IDT met to review the recent event. The IDT note documented the resident had completed PT, no new interventions at this time, fall huddle complete. -It was unclear if this was related to the fall on 9/28/23 or 9/30/23. -The facility failed to implement new interventions and the resident continued to fall and fracture her left hip. 4. Fall on 10/7/23 with left hip fracture On 10/7/23 at 8:22 a.m. the risk management report documented the resident wandered into another resident's room and stumbled backwards attempting to sit in a chair. The resident had a wound to her left elbow and pain to her left leg. She was sent to the hospital. The report documented the resident had been having increased agitation since medication changes, wandered and ambulated without assistance. -There was no documentation of interventions for wandering into other resident rooms. The resident's antipsychotic medication Risperidone was discontinued on 9/30/23. The care plan was updated on 10/7/23 to encourage the resident to walk with a walker and PT to teach the resident to use a walker. -However, the resident was in the hospital with a hip fracture (see below). On 10/8/23 at 6:50 p.m. the nursing progress notes documented the hospital had called the facility to inform the facility the resident had surgery for the fracture in her left hip. On 10/10/23 at 6:44 p.m. Resident #1 returned to the facility from the hospital. On 10/11/23 at 12:55 p.m. the nursing progress notes documented the resident was working with PT and had a left hip fracture with surgical repair. The notes documented the resident frequently stood without assistance. -However, despite the residents' frequent standing without assistance, limited ineffective interventions were documented. The resident fell six more times and fractured her right hip (see below). On 10/12/23 at 3:31 p.m. an IDT progress note documented the incident was reviewed to include a discussion of new interventions. The progress note documented PT would work with the resident on ambulation with a walker and a medication review would be done by the pharmacy. -The specific incident that had been reviewed was not documented. On 10/12/23 the fall care plan was updated to include, anticipate the residents needs and encourage activities to promote exercise. On 10/17/23 at 10:42 a.m. the nursing progress notes again documented Resident #1 had dementia and would frequently stand without assistance. -However, limited interventions were provided for her impulsiveness. 5. Fall on 10/18/23 On 10/18/23 at 7:07 p.m. the risk management report documented the resident was sitting in a wheelchair near the nurse's station. The nurse noticed the wheelchair was empty and the resident was lying on the floor. The wheelchair brakes were not engaged. The resident had a 10 centimeter (cm) by 3 cm reddened area to her right shoulder and a raised area and bruising to the back of her head on the right side. The nurse documented therapy to assess for auto lock brakes on the wheelchair. The risk management report documented the resident was witnessed standing up and sitting down repeatedly. -There was no investigation as to why the resident was standing or what she may have needed. On 10/18/23 the care plan was updated to auto lock brakes to wheelchair. 6. Fall on 10/19/23 On 10/19/23 at 11:35 p.m. the nursing notes documented Resident #1 was lying on her back in front of her closet. The resident was advised to use her call light for assistance. -However, the resident had dementia with significant cognitive impairment according to her care plan. There was no investigation of what the resident may have been trying to do. On 10/19/23 at 11:45 p.m. the risk management report documented the resident was impulsive and repeatedly stood without assistance. On 10/19/23 the care plan documented a grab bar outside of the bathroom. Non skid strips in front of the closet. Mattress on floor next to bed. On 10/20/23 the care plan documented frequent checks for safety. Get the resident out of bed if she was restless and bring her in the common area. Offer a busy box for redirection and distraction. On 10/20/23 at 10:00 p.m. the nurse's notes documented the resident was on 15 minute checks and she had a fall mat next to her bed and wedge pillows in her bed. -There was no documentation the resident rolled out of bed. It was unclear what the wedge cushions in the bed were used for. After the sixth fall and fracture of the left hip, the facility implemented frequent safety checks. -However, the facility placed the resident in the dining room without supervision and she fell again resulting in a right hip fracture (see below). On 10/22/23 at 6:00 p.m. the skilled nursing progress notes documented the resident had COVID-19 and was more lethargic. The notes further documented the resident had dementia and would frequently stand without assistance. 7. Fall on 10/23/23 On 10/23/23 at 10:15 a.m. the risk management report documented the resident was in her room watching television at 10:00 a.m. and on the floor on the mat next to her bed at 10:15 a.m. There were no injuries documented. The report documented therapy would tilt her wheelchair and the resident was in isolation for COVID-19. The nursing notes further documented the provider was in and increased the resident's anti-anxiety medication. -However, there was no documentation the resident slid out of the wheelchair, only that she would stand without assistance as documented the previous day on 10/22/23. Tilting the wheelchair could prevent the resident from rising without assistance. -The care plan was reviewed. There was no new intervention on the care plan. Tilting the wheelchair was not on the care plan. On 10/23/23 at 4:42 p.m. the skilled nursing progress notes documented the resident would frequently stand without assistance. On 10/24/23 at 1:46 p.m. the nursing progress notes again documented the resident would frequently stand without assistance. On 10/25/23 at 4:41 p.m. the IDT progress notes documented incident reviewed. The note listed the previous interventions implemented for falls. -There were no new interventions documented. On 10/25/23 at 6:03 p.m. the skilled nursing progress notes documented the resident would frequently stand without assistance. On 10/30/23 at 10:36 a.m. the skilled nursing progress notes documented the resident would frequently stand without assistance. On 10/31/23 at 9:36 a.m. the skilled nursing progress notes documented the resident would frequently stand without assistance. On 11/6/23 at 10:17 a.m. the skilled nursing notes documented the resident would frequently stand without assistance. 8. Fall on 11/10/23 On 11/10/23 at 5:45 p.m. the risk management report documented the resident was sitting in the hall in her wheelchair. The resident fell and had moderate bleeding from the back of her head. The nursing notes documented she had a small laceration to the back of her head. The nursing note documented the resident's blood pressure began to drop she had smaller fixed pupils during the assessment and was not answering any questions or responding although she was awake and she was sent to the hospital. The report documented the resident had increased agitation and repeatedly tried to stand On 11/11/23 at 12:31 p.m. the nursing notes documented the resident returned from the hospital with no new orders and visible bruising to the back of the head. On 11/12/23 at 5:07 p.m. the nursing progress notes documented the resident was at the dining room table and continuously tried to get up. On 11/15/23 at 2:36 p.m., five days after the fall, the IDT notes documented a medication review had been done previously due to agitation. The IDT documented a weighted blanket would be used for comfort. -The weighted blanket did not indicate when she was supposed to have it on her for use as a fall intervention. -There were no additional interventions to determine if there was an unmet need that led to her impulsively getting up. 9. Fall on 11/27/23 On 11/27/23 11:35 a.m. the nursing notes documented the resident was in the dining room drinking fluids. The nursing staff wanted to obtain a urine analysis. The certified nurse aide (CNA) entered the dining room and observed the resident standing next to her wheelchair. The resident stepped to the right and fell. The resident had hit her right eyebrow on the floor causing a 0.5 cm laceration. The nurse documented the resident had a small laceration to the back of head. The resident had pain to her right thigh and was sent to the hospital at approximately 12:15 p.m. -The facility was aware the resident was impulsive and would stand up from her wheelchair in the dining room repeatedly. The investigation was unclear as to why she was left alone in the dining room. On 11/29/23 at 2:12 p.m. the IDT progress notes documented the resident would be taken to the dining room last and taken out first to monitor the resident. -There was no further investigation to determine if there was an unmet need and that was why she was trying to stand. On 12/1/23 at 9:00 a.m. the provider documented the resident readmitted to the facility from the hospital with a new diagnosis of fracture of the right hip. A hospice consult was ordered. The fall care plan was updated on 11/27/23 to take the resident to the dining room last when staff were present and monitor. The director of nurses (DON) provided a copy of the resident's activity notes for October to December 2023 on 1/8/24 at 2:00 p.m. She said the resident received supervision at activities. -The activity records were requested but not received for January 2024. -The activity records had multiple holes in the documentation. When activity was documented Resident #1 rarely participated passively, observed or actively participated. The October 2023 record revealed, other than meals or a snack the resident was at four activities for the month, twice in November 2023 and less than 10 times in December 2023. In three months, the resident participated in exercise twice in October 2023, none in November 2023 and three times in December. The DON provided a copy of psychiatric notes for October 2023 to December 2023 referencing the facility had been addressing the resident's anxiety as part of her falls. The notes documented in summary that the resident had been taken off her antipsychotic medication and was on a tapering up plan for anti-anxiety medication. She had dementia, depression, anxiety and a history of paranoia, sundowning (confusion in the late afternoon through the night) and agitation. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 1/8/23 at 10:54 a.m. She said she knew when a resident was a fall risk based on a report she received from the nurse. She said she did not know how else she would know if the resident was a fall risk. CNA #1 said for Resident #1 the staff tried to keep her call light in reach. She said she did not think this was a good intervention because of the resident's severe memory loss, she would not remember to use it. She said Resident #1 had fallen and broken both hips at the facility. CNA #1 said the last time she fell was in the dining room and she fell from her wheelchair. CNA #1 said she did not know what new interventions the facility had put in place to keep Resident #1 safe after her fall in the dining room. She said she tried to keep the resident in bed to keep her from falling because she had a lot of pain. The unit manager (UM) was interviewed on 1/8/23 at 11:03 a.m. She said when a resident [NAME] the nurse assessed the resident, notified the physician and family and started neurological checks. The UM said she was familiar with Resident #1. She said Resident #1 fractured her left hip when she tried to sit and missed a chair. She said she fractured her right hip when she stood up in the dining room without assistance and fell. She said the resident still tried to get up out of her wheelchair unassisted. The UM said currently the nursing staff had tried to keep her in bed between meals as a fall intervention. She said the family was present for most meals with her. The interim director of nursing (IDON), NHA and regional nurse consultant (RNC) were interviewed on 1/8/23 at 12:33 p.m. The NHA said the facility had reviewed the resident's falls, but said we can not supervise everyone, all the time. The NHA said the wedges on the resident's bed were being used for positioning not to keep the resident in bed. The RNC said the facility had a mock survey a few weeks ago and a lack of timely fall interventions implemented was identified in the mock survey. She said the facility had planned to complete training today on identifying the root cause of falls with nurse managers. She said the facility had written a performance improvement plan (PIP). The UM was interviewed again on 1/8/23 at 3:18 p.m. She said she wanted to revise her previous interview. She said the nursing staff tried to keep Resident #1 up out of bed, she would have so much agitation the staff would have to stay with her. IV. Facility follow up An undated document titled Plan of Correction (POC) for Adverse Events Packets, undated, was received from the NHA on 1/8/24 at 2:00 p.m. An email titled POC, dated 12/26/23 at 3:30 p.m. addressed to the NHA from the previous DON documented Here is the rough draft of the POC for adverse events. Let me know if you want me to add or change anything. The POC documented in pertinent part, Audits of incidents and adverse event packets weekly to ensure completion and accuracy. Education completed with the IDT team on completing assigned portions of adverse event packets in a timely manner. Fall Huddles to be completed in Grand Rounds every morning for falls recorded the previous day. Education on fall prevention and fall management completed at CNA Nurses meeting 11/28/23. Audit conducted on adverse event packets for the last three months to identify errors or incomplete. Those identified to be completed and corrected by the IDT team by 1/3/23. Daily audits of incident reports in morning meetings to identify possible Adverse event packets that are open will be discussed weekly by the IDT team to ensure accuracy and completion. Monthly quality assurance and performance improvement (QAPI) review. Education completed with nursing staff on 11/28/23 on fall prevention/management. Fall management education to be done at the monthly nursing meeting for a minimum of three months or until substantial compliance is met. Education with IDT team on adverse event packet 2/27/23. Weekly audits of adverse event packets, risk management, and incidents by IDT team. Weekly IDT meetings to ensure compliance with adverse event and event reporting. The POC addressed the accuracy and completion of adverse events including falls. -It did not address investigating the cause of falls or the appropriateness of interventions. On 1/8/23 at 2:03 p.m. the RNC provided an inservice sign in document titled, Mandatory CNA and Nursing Meeting, dated 11/28/23. Attached to the inservice sign in sheet was the Fall Management policy as documented above. -There was no further description of the meeting. -CNA #1, who was working with Resident #1, had not signed the inservice sheet. On 1/9/23 at 4:42 p.m. the NHA provided a timeline which documented the facility had provided occasional one-to-one care when the resident was agitated. The documentation revealed the intermittent one-to-one attention was when the staff redirected Resident #1 due to anxiety. This was no ongoing one-to-one supervision for safety.