**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the resident's environment was free from accident hazards for three (#95, #12 and #19) of eight residents reviewed for falls out of 53 sample residents. Resident #95, who had a previous history of falls at the facility and was identified to be at high risk for falling, experienced a fall on 1/9/24 which resulted in a left hip fracture that required hospitalization and a left partial hip replacement. The facility failed to ensure effective and timely interventions were in place after 11/27/23 to prevent Resident #95 from sustaining a fall on 1/9/24 which resulted in a left hip fracture. The facility failed to ensure effective interventions to prevent additional falls on 2/6/24 and 3/1/24. The facility failed to timely assess and notify providers of the fall on 1/9/24 until two hours after Resident #95 began complaining of left lower extremity pain, when pain medication and a hip x-ray was ordered. The facility failed to notify the provider for further orders when the x-ray was not completed until 12 hours after the - ray was initially ordered and 14 hours after Resident #95 began complaining of left lower extremity pain. The facility's failures to implement effective and timely fall interventions resulted in Resident #95 sustaining a fall resulting in a left hip fracture. Due to the facility's failure to follow-up timely with the provider after the resident's fall and complaints of pain, Resident #95's left hip fracture was not identified and treated in a timely manner. Resident #12 was admitted on [DATE] with a known history of repeated falls and fall with major injury. Resident #12 sustained a fall on 11/13/23 which resulted in an abrasion to the resident's back. The facility implemented a fall intervention for Resident #12's bed to be in the lowest position when she was in bed following the 11/13/23 fall, however, facility staff failed to implement the intervention or report the resident refused to allow her bed to be in the lowest postion. Resident #12 sustained a second fall on 1/20/24 which resulted in the resident being transferred to the hospital and receiving 12 staples for a laceration to the back of her head. The facility again failed to update Resident #12's care plan with additional interventions or reassess the resident's fall interventions to determine their effectiveness. Due to the facility's failure to implement and monitor the effectiveness of fall interventions, Resident #12 sustained a fall resulting in a laceration to the back of her head which required staples. Additionally, the facility failed to: -Ensure staff were implementing the fall interventions identified on Resident #19's care plan; and, -Ensure staff knew what person-centered fall interventions were to be implemented for Resident #19 and where to locate what interventions were to be implemented for the resident. Findings include: I. Facility policy and procedure The Fall Management System policy and procedure, reviewed December 2023, was provided by the nursing home administrator (NHA) on 3/7/24 at 1:20 p.m. It read in pertinent part, It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan intervention will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record. II. Resident #95 A. Resident status Resident #95, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included left femur fracture, vulvar cancer and dementia. The 1/20/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required supervision/touch assistance with transfers and toileting, set up assistance for eating and was independent with personal hygiene and bed mobility. The assessment documented the resident did not have any falls since the prior assessment or admission. B. Observations and resident interview On 3/5/24 at 1:26 p.m., Resident #95 was sitting in a wheelchair wearing non-skid socks. Resident #95's bed mattress was observed to have raised edges. -There was no bedside floor mat observed in the room and no signage to remind the resident to call for assistance was observed in the room. On 3/6/24 at 1:00 p.m., Resident #95 was lying in bed on a raised edge mattress. The resident's bed was in a low position. -There was no floor mat observed on the floor next to the resident's bed and no signage to remind the resident to use her call light for assistance was observed in the room. On 3/7/24 at 1:00 p.m., signage was observed taped to the wall at the foot of Resident #95's bed underneath the television. Resident #95 was interviewed on 3/7/24 at 1:00 p.m. She said the night she broke her hip she fell on the floor next to the bathroom. She said when they returned her to bed it hurt a lot. She said it took them a long time to call the doctor and finally call an ambulance to take her to the hospital. She said she did not know what hipsters were and she was not currently wearing them. C. Record review The fall care plan, initiated 10/13/21 revised 3/8/23, indicated Resident #95 had experienced a fall. Interventions included signage to remind the resident to call for help, therapy to focus on safety with turning and sitting safely in chairs, bed bolsters in bed, bed in lowest position, non-skid socks, needed items within reach and neurological checks. The actual fall care plan, initiated on 1/11/24, indicated Resident #95 had experienced an actual fall with a left hip fracture. Interventions included bed in lowest position, encourage resident to share feelings with staff and engage in meaningful activities, evaluate height of chair and assess for super hemi chair versus leg rests, floor mat when resident was in bed, monitor and report to physician for pain, bruises, change in mental status, offer and encourage resident to wear hipsters for protection and therapy consult. A comprehensive review of the care plan interventions included to ensure staff applied non-skid socks was added after an unwitnessed fall out of her wheelchair on 11/27/23. A comprehensive review of the care plan interventions revealed bed placed in lowest position on 1/11/24, floor mat when resident was in bed and hipsters on 1/18/24 after the resident experienced a fall with hip fracture on 1/9/24. -However, observations revealed there was no floor mat next to the resident's bed when she was in bed and the resident said she did not know what hipsters were and was not wearing any (see observations and resident interview above). A comprehensive review of the care plan interventions revealed bed bolsters applied on 2/6/24 after the resident experienced a fall rolling out of bed on 2/6/24. A comprehensive review of the care plan intervention revealed evaluation of wheelchair height and assess for hemi chair versus leg rests on 3/4/24 after the resident experienced a fall transferring from her wheelchair to the bed. The 11/27/23 nursing progress note revealed Resident #95 had an unwitnessed fall out of her wheelchair. The resident was combative and had an elevated blood pressure and pulse during the assessment. The resident was observed wearing fuzzy non gripping socks. The resident was sent to the emergency department for further evaluation for a change in behaviors. The 11/28/23 fall committee interdisciplinary team (IDT) progress notes documented interventions initiated ensuring staff encouraged the use of non-slip socks at all times and occupational therapy upon the resident's return from the hospital. The 12/14/23 fall risk assessment indicated Resident #95 was at high risk for falls. The 1/9/24 at 9:30 p.m. nursing progress notes documented a fall, witnessed by a certified nurse aide (CNA), while the resident was ambulating in the room. There was no visible injury upon assessment by the registered nurse (RN) and the staff assisted the resident into a wheelchair. -A comprehensive review of Resident #95's electronic medical record (EMR) failed to reveal documentation of a pain assessment before the resident was moved to the wheelchair. -There was no documentation of notification of the provider, director of nursing (DON) or family members immediately after the fall. The 1/9/24 at 10:30 p.m. nursing progress notes documented the resident was complaining of left lower extremity pain. The RN assessment indicated there was no swelling or bruising. The RN explained to the resident she did not have pain medication ordered. -There was no documentation to indicate the RN notified the provider or the fall at the time the resident was complaining of left lower extremity pain to obtain orders for pain medication or an x-ray. The 1/10/24 at 12:22 a.m. physician's order revealed Ibuprofen 400 milligrams (mg) one time only for pain. -The physician's order for pain medication was not obtained until two hours after Resident #95 began complaining of left lower extremity pain. The 1/10/24 at 12:23 a.m. nursing progress notes documented the resident was complaining of left lower extremity pain and was moving the leg minimally. No injury was noted. A left hip x-ray was ordered. -The order for the x-ray was not obtained until two hours after Resident #95 began complaining of left lower extremity pain. The 1/10/24 at 1:49 p.m. nursing progress notes documented an x-ray of the resident's left hip was obtained at 12:30 p.m. and results of a fractured hip was reported to the facility. Resident #95 was sent to the hospital via ambulance at 1:40 p.m. -The left hip x-ray was not obtained until 12 hours after it was ordered (14 hours after Resident #95 began complaining of left lower extremity pain). -The EMR failed to reveal documentation that the facility had notified the provider for further orders when the left hip x-ray was not completed in a timely manner. The 1/10/24 fall investigation documented a witnessed fall. The resident was ambulating in her room on 1/9/24 at 9:30 p.m. and fell on the floor onto her left side and did not hit her head. She had initially complained of right hip pain but later complained of left hip pain. She was assessed by two RN's. Orders were received for pain medication and a left hip x-ray. Resident #95 was sent to the hospital on 1/10/24 at 1:30 p.m. It documented the physician was notified at 1:25 pm. Family member was notified on 1/10/24 at 3:40 p.m. (Two hours after the resident was sent to the hospital). The 1/16/24 hospital records documented the resident was admitted on [DATE] with a closed fracture of the left hip. The resident underwent surgery for a partial left hip replacement. -A comprehensive review of Resident #95's EMR failed to reveal an IDT note post fall on 1/10/24. The 1/16/24 fall risk assessment indicated Resident #95 was at high risk for falls. The 2/6/24 nursing progress notes documented a witnessed fall when the resident rolled out of bed and fell onto her right side but did not hit her head. A physical assessment was performed and the resident had no obvious injuries and denied pain. She was assisted back to bed. The 2/6/24 fall IDT progress notes documented a fall with no injuries. Interventions added were bolsters to the bed. The 2/6/24 fall investigation documented a witnessed fall of the resident rolling out of bed and landing on her right side. It documented there was no physical injury on assessment and the resident denied pain. The resident was assisted back to bed and the bed was left in lowest position with call light in reach. -A review of the EMR did not reveal if the bed mat was in place during the 2/6/24 fall. The 3/1/24 nursing progress notes documented an unwitnessed fall when the resident was self transferring to the bed from the wheelchair. Resident was assisted to bed, bed lowered to the floor, bed mat in place and educated to use call light. Resident had no injuries, no pain, vital signs and neurological assessments were stable. Provider, DON and family were notified. The 3/1/24 fall risk assessment indicated Resident #95 was at medium risk for falls. The 3/4/24 IDT progress notes documented an unwitnessed fall with no injuries. Interventions added were occupational therapy to assess wheelchair. The 3/4/24 occupational therapy (OT) notes documented the resident had low safety awareness. Interventions included were increasing functional ability to use walker, education to lock brakes on wheelchair before standing. Resident required verbal and tactile cues. The CNA documentation for fall prevention devices (low bed, mats on floor, hipsters, visual checks, bolster pillow/concave mattress) in place from 2/7/24 to 3/6/24 revealed: -On 2/7/24 there was no documentation of bed mats on the floor or bolster pillow/concave mattress in place; -On 2/8/24 there was no documentation of hipsters in place; -On 2/9/24 there was no documentation of bed mats on the floor or hipsters; -On 2/10/24 there was no documentation of bed mats on the floor or hipsters; -On 2/11/24 there was no documentation of bed mats on the floor, hipsters or non-skid socks; -On 2/13/24 there was no documentation of bed mats on the floor; -On 2/14/24 there was no documentation of bed mats on the floor; -On 2/15/24 there was no documentation of bed mats on the floor; -On 2/16/24 there was no documentation of bed mats or non-skid socks; -On 2/17/24 there was no documentation of bed mats, hipsters or non-skid socks; -On 2/18/24 there was no documentation of low bed; -On 2/19/24 there was no documentation of bed mats on the floor or hipsters; -On 2/21/24 there was no documentation of bed mats on the floor; -On 2/22/24 there was no documentation of bed mats on the floor or non-skid socks; -On 2/23/24 there was no documentation of bed mats on the floor, non-skid socks, and visual checks by staff; -On 2/24/24 there was no documentation of bed mats on the floor or non-skid socks; -On 2/25/24 there was no documentation of bed mats on the floor or non-skid socks; -On 2/26/24 there was no documentation of bed mats on the floor or non-skid socks; -On 2/27/24 there was no documentation of bed mats on the floor or non-skid socks; -On 2/29/24 there was no documentation of bed mats on the floor or non-skid socks; -On 3/1/24 there was no documentation of bed mats on the floor or non-skid socks; -On 3/2/24 there was no documentation of bed mats on the floor or non-skid socks; -On 3/3/24 there was no documentation of bed mats on the floor; -On 3/4/24 there was no documentation of non-skid socks; -On 3/5/24 there was no documentation of bed mats on the floor or non-skid socks; and, -On 3/6/24 there was no documentation of bed mats on the floor. The visual bedside kardex report (a tool utilized by CNAs to provide consistent care) indicated safety interventions included signage to remind the resident to call for help, added 10/22/21, bed bolsters, bed in lowest position, monitor for increased fall risk with position changes, needed items within reach, hipsters applied daily as tolerated and resident was independent with transfers. D. Staff interviews CNA #4 was interviewed on 3/7/24 at 12:45 p.m. CNA #4 said residents at high risk for falls should have a low bed and call light in reach. She said CNAs accessed the point of care (POC) task section to find out what fall interventions were in place for the resident. She said Resident #95 required a low bed and a call light in reach and one person assistance to transfer from wheelchair to the bed but she was getting to the point where she could transfer herself. She said she did not know of any other interventions. She said she did not know the frequency to check on Resident #95 but they would check on her every so often. Licensed practical nurse (LPN) #1 was interviewed on 3/7/24 at 12:50 p.m. LPN #1 said fall interventions were populated in the treatment administration record (TAR). She said residents at high risk for falls should have interventions to include a call light in reach and a specialty bed. She said she did not know the specific fall interventions for Resident #95 but she said the resident should not be transferring herself from the wheelchair to the bed. After consulting with the DON on how to access the care planned interventions, LPN #1 said Resident #95's interventions included a low bed, call light in reach, fall risk assessments, signage in room to call for help, a walker to ambulate, therapy to work with resident and bed mats in place while in bed. The DON was interviewed on 3/11/24 at 9:32 a.m. The DON said when a fall occurred the fall was reported to the RN and the RN would conduct an assessment before the resident was removed from the floor. She said the provider, family and DON would be notified. She said risk management would be notified and a post fall IDT committee would meet the following day. She said the IDT committee did a root cause analysis with staff input for what interventions to put into place to help prevent further falls and minimize injury. The DON said interventions were care planned and placed on the Kardex for CNAs. She said CNAs did a shift end report to discuss what fall interventions were in place for residents at high risk for falls. She said CNAs accessed the Kardex for the current fall interventions and the POC task tab was for documentation. The DON said nurses accessed the care plan, progress notes and reviewed IDT post fall notes to get the most current information on fall interventions. She said nurses did not access fall interventions on the TAR. The DON said standard fall interventions included call light in reach, bed in low position, floor mats, reminder signs, work around preferences to avoid self transfers, medication reviews, and frequent rounding every two hours. Increased rounding occurred with staff input for frequently falling residents. Frequent rounding was care planned and documented. She said frequent round documentation was on a separate form that was carried with the nurses. The DON said Resident #95 had bed mats after returning from her hospitalization in January 2024, however, she said the floor mats had been removed as an intervention on 3/7/24 (during the survey) because it was a tripping hazard. She said when an intervention was removed it would be documented on the care plan. The DON said Resident #95 would remove the signage to call for assistance. She said Resident #95 had not been cleared by therapy to self transfer. She said failure to implement or monitor fall interventions could result in additional falls or injury. III. Resident #12 A. Resident status Resident #12, age [AGE], was admitted on [DATE]. According to the March 2024 CPO, diagnoses included chronic respiratory failure, cognitive communication deficit, lack of coordination, compression fracture of the first lumbar (lower back) vertebrae and repeated falls. The 1/27/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident required substantial assistance for bathing and transferring in and out of the shower; moderate assistance with dressing and personal hygiene, and bed/chair to chair transfers; and supervision or touching assistance with mobility and moving from a sit to stand position. The MDS assessment revealed the resident had a history of a fall with a major injury. B. Resident observations On 3/7/24 at 7:59 a.m., Resident #12 was lying in bed in her room with the lights off. Resident #12's bed was not in a low position and a wheelchair, walker and bedside table were next to the bed. On 3/7/24 at 8:54 a.m., Resident #12 was lying in bed awake and reading. -Resident #12's bed was not in a low position and a wheelchair, walker and bedside table were next to the bed. -A review of the Fall Prevention Devices task response history revealed the low bed task was marked completed at 8:51 a.m. on 3/7/24 (see below). On 3/10/24 at 7:50 a.m., Resident #12 was in her bed with the lights off. -Resident #12's bed was not in a low position. C. Record review Resident #12's electronic medical record (EMR) documented Resident #12 had two falls at the facility on 11/13/23 and 1/22/24. The 11/13/23 nursing progress notes documented at 6:20 p.m. a staff member heard Resident #12 yelling for help from her room. Upon entering the resident's room, Resident #12 was lying on her back with her walker standing upright at her feet. Her feet were facing the window and her head was facing the door. Resident #12 said she was at her sink and when she turned to walk back to her chair, her right knee gave out. A RN was called to assess the resident. The RN assessment indicated Resident #12 told the nurse that her arthritic right knee gave way and she fell on the floor, landing on her back. Resident #12 said she bumped her head. The 11/13/23 fall committee interdisciplinary team (IDT) note documented Resident #12 had an unwitnessed fall in her room resulting in a small abrasion to her back. -The IDT note did not include any interventions put into place except for placing the bed in the low position, which was initiated on 7/25/23, and a therapy evaluation, which was not new to the resident's comprehensive care plan. The 1/20/24 nursing progress note documented at 7:30 a.m. a nurse heard a loud sound and someone yell for help while administering medications. The nurse ran to Resident #12's room and found Resident #12 on the floor in a supine position (on her back) in front of the bathroom. Resident #12 said she was trying to go to the bathroom while using her walker and fell. Resident #12 denied pain and dizziness. A physical assessment was conducted on Resident #12 which revealed the resident was bleeding from the back of her head, with blood observed on the floor. The nurse applied compression at the site of bleeding and shouted for help. Vital signs were taken and neurological observations began. Resident #12 appeared disoriented with time. Facility staff called 911 and and Resident #12 was transferred to a local hospital at 8:00 a.m. The physician, DON and Resident #12's family were notified. The 1/22/24 fall committee IDT note documented Resident #12 had an unwitnessed fall in her room that resulted in a posterior (back of) scalp laceration. Resident #12 was subsequently sent to the emergency room where she received staples for a head laceration. -The IDT note did not include any additional interventions put into place besides putting the bed in the low position, which had already been in place since 7/25/23, therapy evaluation (put into place since the previous fall) and a pharmacy consult. -The facility continued to fail to put effective interventions into place to prevent further falls with injuries after the knowledge of the resident's history falls and actual recent falls. A 3/2/24 nurse practitioner (NP) note documented Resident #12 had a past medical history of recurrent falls, and was at high risk for falls due to her poor safety awareness and generalized weakness. Resident #12's Fall Prevention Devices task response history was reviewed from 2/11/24 to 3/10/24. A low bed was listed as a fall prevention device, however a clear pathway was not listed. The low bed was marked completed at least once per day during the review period, and there were no documented refusals by Resident #12 recorded by facility staff during the dates reviewed. Resident #12's kardex (electronic care summary) was reviewed. Resident #12's kardex did not list the intervention of a clear pathway on her kardex, which was used by the CNAs to ensure fall interventions were in place (see interview below). Resident #12's fall care plan, initiated on 7/25/23, documented Resident #12 was at risk for further falls related to medication side effects, a wedge compression fracture of lumbar (lower back region) and multiple falls. Resident #12 had additional post fall care plans initiated 11/13/23 and 1/22/24. The 1/22/24 fall care plan revealed she had a fall with injury requiring staples to her head. Pertinent fall care plan interventions included: -Be sure the call light was within reach and encourage the resident to use it to call for assistance as needed, initiated 7/25/23; -Maintain a clear pathway free of obstacles, initiated 7/25/23; -Resident needed a safe environment: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in a low position at night; side rails as ordered, handrails on walls, and personal items within reach, initiated 7/25/23; -Bed in lowest position, initiated 11/13/23; and -Bed in low position, initiated 1/22/24. -However, observations on 3/7/24 and 3/10/24 revealed interventions, such as the bed in the lowest position and an uncluttered pathway, were not being implemented (see below) and the investigation revealed Resident #12's refusal of interventions was not documented nor her care plan updated. D. Staff Interviews The DON was interviewed on 3/11/24 at 10:19 a.m. The DON said a clear pathway meant Resident #12's room should be cleared of items so the resident was able to ambulate safely in her room. The DON said the resident should have a clear space next to her bed so the resident could safely get to her wheelchair and walker to use them if needed. The DON said the bed in low position meant the bed should be in the lowest position while the resident was in the bed. CNA #1 and CNA #2 were interviewed on 3/11/24 at 1:20 p.m. CNA #1 said she used the kardex to see a resident's fall interventions. CNA #1 said Resident #12 should have a low bed when the resident was in bed, but Resident #12 did not like her bed low or her wheelchair and walker moved out of her reach. CNA #1 said Resident #12 was able to use the remote control for her bed and move her bed higher herself. CNA #1 said she had not reported Resident #12 refused to have her bed low to the nurse. CNA #1 said she was unsure if she was able to document in the resident's medical record her refusal of a fall intervention. CNA #2 said when Resident #12 refused to have her bed put in a low position, she would provide education to the resident on the importance of her bed being in a low position. CNA #2 said Resident #12 did not like her bed in a low position and Resident #12 used the remote to move her bed higher herself. CNA #2 said she was unsure if she was able to document Resident #12's refusal of fall interventions in the resident's electronic medical record. -However, there was no documentation in Resident #12's medical record that she did not like or refused to have her bed in a low position or assessments completed of the effectiveness of the fall interventions on Resident #12's comprehensive care plan. The assistant director of nursing (ADON) #1 was interviewed on 3/11/24 at 1:30 p.m. The ADON #1 said if a staff member marked the low bed task complete, her expectation was that the bed was in a low position. ADON #1 said Resident #12 was able to adjust the height of her bed herself, however that was not included in the comprehensive care plan and had not been evaluated during the IDT fall reviews for effectiveness. The DON was interviewed again on 3/11/24 at 1:54 p.m. The DON said she was not aware Resident #12 refused to have her bed in the low position and she expected the staff to mark the refusal in the fall prevention devices task history. The DON said Resident #12's comprehensive care plan should have been updated to include her refusals of fall interventions. The DON acknowledged that the resident's comprehensive care plan and medical record lacked the documentation to show the facility had evaluated the effectiveness of the current interventions to prevent further falls with injuries. E. Facility follow up The facility provided additional information regarding Resident #12 on 3/12/24 at 5:21 p.m. The facility provided a general statement regarding fall interventions. The statement documented, At the time of the fall or incident the nurse is to put an intervention in place and document that intervention they determine may keep the resident safe: the next business morning when the IDT reviews the risk management they may determine the intervention one nurse put in place with limited information was not appropriate, and discontinue, change or add to that intervention. -However, Resident #12's comprehensive care plan documented three separate fall care plans that included fall interventions with the intervention of a low bed initiated on 7/25/23 at the time of her admission to the facility, and added after Resident #12's falls on 11/12/23 and 1/20/24. -The facility failed to provide documentation the fall interventions, specifically that of a low bed and clear pathway, were implemented and the effectiveness of these interventions were monitored to modify the care plan as necessary and discontinue or change the intervention. Further documentation provided by the facility revealed in a note signed by the director of rehabilitation (DOR), Resident #12 was interviewed on 3/12/14 after the survey exit. The note documented Resident #12 reported she wanted the bed at mid height and did not want the bed in a low position. -There was no documentation provided that the fall intervention of a low bed implemented on 7/25/23, and added on 11/12/23 and 1/20/24 was effective, or that the facility staff followed up with Resident #12 on her refusals of the fall intervention prior to 3/12/24, after the survey exit. The facility also provided physical therapy progress notes for Resident #12. The physical therapy progress notes documented dates of service as 12/29/23 to 1/22/24. -The physical therapy notes did not provide documentation regarding the implementation or effectiveness of the fall intervention for Resident #12's low bed. The facility provided an undated care plan document that revealed no changes had been made to the care plan since the last care plan review (1/22/24). -The documentation failed to provide updated information to Resident #12's refusals, the effectiveness of her low bed fall intervention, or effectiveness of maintaining a clear pathway in Resident #12's room.IV. Resident #19 A. Resident status Resident #19, age [AGE], was admitted on [DATE]. According to the March 2024 CPO, diagnoses included stroke with paralysis of the left side, mild cognitive impairment and cognitive communication deficit. The 1/11/24 MDS assessment documented the resident had a moderate cognitive impairment with a BIMS score of twelve out of 15. She required a wheelchair for mobility and had functional impairments to her upper extremities on one side. The resident was unable to walk and required one-person limited assistance with locomotion. She required maximal assistance with showering, dressing, toileting, transfers and bed mobility. The assessment documented the resident had not had a history of falls and had not fallen in the six months prior to admission. B. Observations On 3/5/24 at 2:48 p.m., Resident #19 was sleeping in her bed. -The call light was hanging on the floor out of the resident's reach and no fall mat was[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure that residents who require colostomy services receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#130) of three residents reviewed for colostomy care out of 53 sample residents. Resident #130 was admitted to the facility on [DATE] with diagnoses of cognitive-communication deficit, anxiety disorder and with toxic megacolon (swelling and inflammation of the colon) that required a colostomy (a surgical operation in which a piece of the colon was diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon). Resident #130 required extensive assistance from staff for toileting and had a severe cognitive impairment according to the brief interview for mental status assessment. The facility failed to consistently assist Resident #130 with the care of the colostomy. The facility failed to ensure she was provided with proper education to continue to independently care for the colostomy based on her assistance and cognitive functioning. The facility failed to have a personalized care plan for Resident #130 ' s colostomy to include education to be provided or the goal of becoming independent with the care of her colostomy. Due to the facility's failures, Resident #130 was not provided with consistent care for her colostomy, which resulted in her bag often being full and smelling bad which embarrassed her and made her feel subhuman. The colostomy site was not consistently cleaned by staff and Resident #130 was not shown how to properly care for the site which caused it to be inflamed (red). Findings include: I. Professional reference The National Library of Medicine Colostomy Care, updated on 5/28/23 and retrieved on 3/13/24 from: https://www.ncbi.nlm.nih.gov/books/NBK560503/ revealed in pertinent part, The purpose of colostomy care was for skin protection and care for patient acceptance and to prevent stoma related complications. This activity outlines colostomy creation and care and highlights the role of the interprofessional team in evaluating and treating patients with this condition. Managing a colostomy is generally done by a nurse or an entero-stomal therapist, but providers should be aware of the stoma's condition in case intervention may be required. The 2-piece system consists of a base-plate with a removable ostomy bag attached to the skin. Although it is very durable and long-lasting, it requires an amount of skill to use, has a weaker adhesive, and does not fit very well. Before starting the procedure, all supplies should be arranged, and handwashing and donning of gloves should be done. The used stoma bag should be first emptied of all content, and then the flange removed by gentle traction on the bag or flange towards the stoma with counter-traction on the skin. An adhesive remover may also be used. The stoma and parastomal area should be gently cleaned with water and dabbed rather than scrubbed without using soap. The stoma should be assessed and must be moist, above skin level, and pink to red in color, and the peristomal skin should be normal. The surgeon should be notified of any deviation from this. The stoma should be measured, or the previous measurement remembered, and the size should not be more than 1/16-1/8. The peristomal skin should be dried appropriately to allow good seal formation. Adhesive pastes or powders may also be applied peristomally. The paper cover on the back of the flange is then removed with the border tape in place. It is then placed around the stoma and held for 1 to 2 minutes to create an adequate seal. If it is a 2-piece bag, it is clipped onto the flange. A belt may be applied around the abdomen and clipped to the sides of the flange to hold it in place. After this, safe disposal of the stoma bag, handwashing, and procedure documentation must be done. II. Resident #130 A. Resident status Resident #130, age [AGE], was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included toxic megacolon (swelling and inflammation of the colon), cognitive-communication deficit and anxiety disorder. According to the 12/14/23 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. She required extensive assistance from staff for toileting and supervision/touching assistance for personal hygiene. The resident had an ostomy. B. Observations and resident interview Resident #130 was interviewed on 3/7/24 at 9:28 a.m. The resident said she was required to change her colostomy bag. The resident said she did not always have the supplies to do the task. The resident said she would go days with her colostomy bag full and it would smell bad and was embarrassing. The resident said it made her feel subhuman. The resident said the nurses would not let her change the bag until it tore. The resident said she had cleaning supplies but was never shown how to use them. The resident said she would clean the site with a wet wipe or toilet paper. The resident said the staff showed her once but had never looked at the site after that. The resident said her skin around the stoma site was cherry red. The resident said she had been asking to change her bag since 10:30 p.m. the night before and they did not provide her with a bag until 9:20 a.m. The resident's clothing, which she wore to bed, had leakage from the stoma site on them. The trash can in the bathroom had the used colostomy bag with fecal matter, toilet paper and wet wipes. C. Record review According to a 12/8/23 surgical discharge summary documented the resident had a total abdominal colectomy and ostomy. According to the cognitive care plan dated 12/8/23 documented the resident had short-term memory loss. Interventions included the following: Use simple directive sentences. Give step-by-step instructions one at a time as needed to support cognitive function. The resident required supervision/assistance with all decision-making. According to the colostomy care plan dated 12/11/23 documented the resident had a colostomy. Interventions included the following: staff should encourage good nutrition and hydration to promote healthier skin. Follow facility protocols for injury treatment. Keep the resident ' s skin clean and dry. Use a pressure-relieving/reducing mattress to protect the skin while in bed. The resident should avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. -However, the care plan did not include the education procedure for the resident or the goal of becoming independent with the care of her colostomy. According to the medication administration note dated 1/20/24 documented the resident was not available for education and assistance with learning to care for colostomy. According to social services dated 1/23/24 documented if the resident moved in with her husband, she would need to be educated on emptying and placing back the colostomy bag. III Staff interviews Certified nurse aide (CNA) #3 was interviewed on 3/12/24 at 9:00 a.m. CNA #3 said the resident needed help with colostomy care. CNA #3 said the resident was not discharged due to her inability to perform colostomy care independently. Licensed practical nurse (LPN) #1 was interviewed on 3/11/24 at 10:37 a.m. She said the resident performed her colostomy care by herself. LPN #1 said the nursing staff educated the resident on proper colostomy care. LPN #1 said the nursing staff did not have a standard way to perform education or return demonstration. LPN #1 said the tasks in the treatment administration record were reminders for staff to ask the resident if she had performed the tasks. The director of nursing (DON) was interviewed on 3/11/24 at 3:14 p.m. The DON said individuals who perform colostomy care should be assessed to ensure the resident performed the task safely. The DON said nurses performed the colostomy care because the certified nurse aides (CNAs) were not qualified to accomplish the task. The DON said the nurse staff should continue to oversee the colostomy care. The DON said the nursing staff did not have a standard education plan for educating residents about colostomy care. The DON said the resident needed to be able to perform colostomy care to be discharged safely. The DON said the resident should not use toilet paper to clean her stoma site. The DON said the resident was able to communicate her needs clearly and accurately. The DON said the colostomy bag should be emptied when it was full. The DON said the staff should bring the resident supplies when the resident asked for them. The DON said there would be no leakage if the bag was placed properly. IV. Facility follow-up The NHA provided the following information post survey on 3/12/24 at 5:29 p.m. It read in pertinent part, According to the interdisciplinary team (IDT) care plan review team meeting, dated 3/8/24, the resident said she could perform colostomy care; however the IDT team said the resident continued to require oversight from staff. -The IDT meeting confirmed that the resident continued to require oversight from staff. In addition, according to the MDS assessment (see above) she required extensive assistance from staff. According to the BIMS assessment dated [DATE], the resident scored 15 out of 15. -The facility changed the residents BIMS score from a six (severe cognitive impairment) out of 15 to a score of 15 (cognitively intact) out of 15 after the survey. A signed document dated 3/12/24 from Resident #131 outlining the steps required to perform colostomy care and the resident acknowledged that she understood and could perform these steps. -However, this had not been completed prior to the survey and the document did not include a demonstration back from the resident. A progress note dated 3/12/24 documented the resident was able to complete the return demonstration of colostomy care. -However, there was no documentation during or prior to the survey that the resident was able to complete colostomy care with return demonstration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#26) of three out of 53 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Resident #26 displayed slurred speech, confusion, and left sided weakness resulting in an admission to the hospital on 1/17/24. It was concluded he had suffered from a stroke and was readmitted to the facility on [DATE]. On 1/21/24, the resident weighed 161.9 pounds (lbs). On 2/19/24, a month later, Resident #26 weighed 143.3 lbs. which was a 11.49% weight loss and a difference of 18.6 lbs. On his next weight on 3/7/24 (during the survey), the resident weighed 137.6 lbs. which was a 3.98% loss and a difference of an additional 5.7 lbs with a total of 18.6 lbs and 15.02% weight loss. According to the change of condition minimum data set (MDS) assessment dated [DATE], the resident required maximum assistance with eating. The MDS revealed the resident relied on the staff for more than 50% of the task of eating. The resident was participating in speech and occupational therapy to improve his oral intake and functional ability to eat. Education was provided to the staff caring for him on techniques and risks for the resident to improve his oral intake. Based on observations and interviews, it was determined the staff were not consistently providing the resident the level of assistance required according to his functional limitations and this contributed to his significant weight loss. Findings include: I. Resident #26 A. Resident status Resident #26, age [AGE], was admitted to the facility on [DATE]. According to the March 2024 computerized physician's orders (CPO), diagnoses included diabetes mellitus type II, dementia, and heart disease. The 1/24/24 MDS assessment showed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of twelve out of 15. The resident required maximum assistance with personal hygiene and eating. The resident required total assistance with bed mobility, toileting, dressing, showering, and transfers. The resident had an impairment to one side of his body causing functional limitations. The resident had a swallowing disorder with loss of liquids/solids from his mouth when eating, coughing and choking during meals, and complaints of pain or difficulty with swallowing. B. Resident observations The resident was observed on 3/5/24 at 12:25 p.m. in the dining room of the secured unit. Certified nurse aide (CNA) #11 provided the resident with a mechanically altered meal. The plate was placed in front of the resident but no staff members sat down with the resident. The resident was able to lift a regular cup of fluids and drink after a lot of effort with his right hand. The occupational therapist (OT) sat down with the resident at 12:33 p.m. and adjusted his clothing protector. She left the table at 12:34 p.m. to locate a cup of ice cream for Resident #26. The resident kept trying to get the attention of the staff by saying excuse me several times. CNA #8 sat down with the resident at 12:36 p.m. and assisted him one spoon of his lunch. The OT returned at 12:37 p.m. and provided the resident with a cup of ice cream. The resident displayed left sided weakness when trying to lift the ice cream cup in front of him. He was able to feed himself ice cream with his right hand and hold the cup with his left hand while OT provided encouragement and cues to the resident. The OT left the table at 12:38 p.m. CNA #11 sat down at the resident's table at 12:38 p.m. and assisted the other resident sitting at the table with his meal. The speech therapist (ST) came at 12:41 p.m. and was providing instruction to the staff to remind the resident to clear his throat when eating and take sips of fluids in between bites of food. ST left at 12:46 p.m. During the continuous observations, the resident coughed three times while eating his ice cream. The staff did not respond when the resident coughed. CNA #8 came at 12:28 p.m. and asked the resident if he was done with his lunch. The CNA took the plate away and scrapped it in the trash. He was then taken to the common area at 12:49 p.m. During the meal, the resident was observed to have drank three cups of fluids, ate one bite of his lunch plate, and completed one cup of ice cream. Resident #26 was observed on 3/6/24 at 12:33 p.m. in the dining room of the secured unit. The meal was placed in front of the resident at 12:40 p.m. The resident attempted to lift his right arm to the plate and struggled when he got his arm caught under the table. The resident called out to CNA #5 stating I need help at 12:40 p.m. The CNA walked past the resident and did not acknowledge him. At 12:43 p.m. Resident #26 called out to CNA #5 again for assistance and CNA #5 sat down with the resident. The resident was able to get his arm from under the table and the CNA provided the resident with a cup of ice cream. Once the resident began eating the ice cream independently, CNA #5 left the table at 12:44 p.m. At 12:49 p.m the resident was able to get one spoon of food from his meal plate into his mouth after several attempts. The resident still had fluids in his mouth he had not swallowed when he put the food into his mouth. At 12:53 p.m., the resident saw CNA #5 and requested assistance. CNA #5 sat down and assisted the resident. The resident was cooperative and when he wanted another bite, he opened his mouth freely. Twice CNA #5 tried to put food into the resident's mouth while he was still chewing and CNA #5 was looking away. Both times, the resident put his hand up to prevent the CNA from putting food into his mouth. The CNA did not speak to the resident, provide encouragement or cueing during the meal. The CNA assisted the resident three spoons of food between 12:53 p.m. and 12:58 p.m. After the resident put his hand up the second time, the CNA stopped feeding him. The CNA left the table at 12:58 p.m. At 1:00 p.m., CNA #8 took the resident's plate and scraped it in the trash. C. Record review The ADL comprehensive care plan revised on 9/16/19 revealed the resident had self care deficits related to a history of falls, dementia, and physical limitations. Interventions initiated on 3/7/24 (during survey) included cueing and one-on-one assistance for eating. The nutrition care plan initiated 1/21/24 revealed the resident had a nutrition problem related to a new stroke and dysphagia (difficulty swallowing). The resident had triggered a significant weight loss and required a mechanically altered diet related to chewing/swallowing difficulties. The resident had difficulty feeding himself at times related to a stroke affecting his non-dominant left side. Interventions initiated 3/7/24 (during survey) included to provide vanilla ice cream and mildly thick liquids during meals and occasionally assist/cue with eating. -The care plan did not indicate the resident refused meals or had unavoidable weight loss. The March 2024 CPO revealed the following physician orders: Speech therapy (ST) evaluate and treat- ordered on 1/20/24; Occupational therapy (OT) evaluate and treat- ordered on 1/20/24; Physical therapy (PT) evaluate and treat- ordered on 1/20/24; Regular diet, minced and moist, mildly thick with vanilla ice cream at all meals- ordered 3/7/24 (during survey); and Boost (supplement drink) high calorie- three times a day- ordered 3/8/24 (during survey) - this was the only nutritional supplement ordered for the resident while he was experiencing significant weight loss since his readmission back to the facility. A review of progress notes dated 2/12/24 to 3/11/24 revealed: NP progress note dated 2/12/24 revealed the resident had a recent stroke 1/17/24. The resident was at weight loss/malnutrition risk. He was being followed by the registered dietitian (RD) for nutritional supplement recommendations. The resident had a diagnosis of dysphagia and staff were to monitor for difficulty swallowing and signs of aspiration. NP progress note dated 2/19/24 revealed the resident was on a diabetic diet, minced and moist with mildly thick liquids. The NP documented weight loss was likely expected and unavoidable due to the disease progression, multiple comorbidities, and sporadic intakes (eating). If weight loss continued, it was suggested to consider a hospice evaluation and referral. -However, according to the NP interview (see below), the NP was not aware the nutritional interventions for his weight loss were being consistently provided. NP progress note dated 2/28/24 revealed the resident had failed to thrive since the stroke. Oral intakes were less than 25% and to consider hospice if weight loss continued. NP progress note dated 3/4/24 revealed the resident continued with poor oral intakes and nutritional guidance was provided by the RD. It was suggested to consider hospice for the resident. -NP notes failed to reveal the NP was aware the level of assistance required for intakes was not being consistently provided to mitigate weight loss and failure to thrive. Resident weights reviewed from 1/21/24 to 3/7/24 revealed: 1/21/24 161.9 lbs. was the resident's weight immediately after the stroke. 1/29/24 156.2 lbs. which was a 3.52 % loss. 2/7/24 150.0 lbs. which was a 3.97 % loss. 2/12/24 143.8 lbs. which was a 4.13 % loss. 2/19/24 143.3 lbs. which was a 0.35 % loss. 3/7/24 137.2 lbs. which was a 3.98 % loss. From Resident #26's readmission to the facility on 1/21/24 to 3/7/34 (during the survey process), the resident lost a total of 18.6 lbs and 15.02% weight loss. Nutrition assessment dated [DATE] revealed the resident would be trialed on a scoop plate. Intake was 0-50% and the resident required assistance with meals. -It did not include any other nutritional interventions to prevent further loss of weight. A review of the resident's medical record did not reveal any additional nutritional assessments since his continued significant weight loss. Daily skilled progress notes dated 3/6/24 revealed the resident had active symptoms of dysphagia and complaints of difficulty or pain with swallowing. He held food in his mouth/cheeks or residual food in mouth after meals. He coughed or choked during meals or when swallowing medication. Nutritional approaches include mechanically altered diet and thickened liquids. -Condition follow up progress note dated 3/6/23 revealed current conditions: resident not eating 50% of meal, or not drinking 50%. Physical therapy notes dated 1/22/24 revealed the resident had been referred post stroke. His prior level of ADL functioning was independent and currently was maximum assistance for ADLs. A review of occupational therapy notes dated 1/23/24 to 3/11/24 revealed: Occupational therapy notes dated 1/22/24 revealed the occupational therapist (OT) provided the resident with assistance for self-eating tasks. The RN was provided education by OT to provide the resident with one-on-one staff assistance with eating tasks at all times. Occupational therapy notes dated 1/23/24 revealed the resident required one-on-one staff assistance for self feeding. Occupational therapy notes dated 1/24/24 revealed the resident required moderate assistance to complete self-eating and drinking tasks. Education was provided to the RN on techniques to promote the use of the left upper extremities (arm/hand) as able with increased cues. Occupational therapy notes dated 1/25/24 revealed the resident completed the self feeding task with OT assistance with initiation of positioning of left upper extremity and hand over hand to initiate grasp on the cup while using utensils in right upper extremity. The resident required verbal, visual, and tactile cues. Education was provided to the RN and CNA staff via a visual demonstration on techniques. The staff verbalized understanding of the education. Occupational therapy notes dated 1/31/24 revealed the resident completed the self feeding and drinking task with verbal, visual, and tactile cues for continuum of task. RN and CNA staff were educated to incorporate left upper extremity throughout tasks via facilitating grasp onto plates and cups as well as having left upper extremity positioned into immediate midline (chest area) positioning with tasks. Occupational therapy notes dated 2/1/24 revealed the resident completed the self feeding and drinking task with overall moderate assistance. Education was provided to staff on proper wheelchair positioning and set up of bilateral upper extremities with a focus on grasping cups, plates, and bowls with his left hand. Occupational therapy notes dated 2/12/24 revealed the resident was noted with increased oral intake of food and completed the self feeding and drinking task with minimal assistance. Education was provided to the RN and CNA staff on positioning modifications and setup for self feeding and drinking throughout the meal. Occupational therapy notes dated 2/13/24 revealed the resident required minimal assistance with maximum verbal cues for self pacing during eating and drinking tasks. The resident tended to eat and drink with increased speed and overall decreased safety awareness. The RN was present and aware of intermediate coughing and recommendations for one-on-one staff assistance with alternating the residents food and liquid intake at a slower pace. Occupational therapy notes dated 2/15/24 revealed the resident completed self feeding and drinking tasks with minimal assistance and maximum assistance for verbal, visual, and tactile cues for sequencing and self safe pacing throughout. Occupational therapy notes dated 2/29/24 revealed the resident was able to complete the self feeding tasks while sitting in his wheelchair at the tabletop. The resident was able to scoop and transport food to his mouth with verbal and visual cueing to initiate the task and the resident was able to attend self feeding task following cueing to improve self eating and nutrition. Occupational therapy notes dated 3/5/24 (during survey) revealed the resident completed the self feeding and drinking task with multiple trials. Overall minimal assistance provided with hand over hand to initiate grasp onto bowl with hand left hand to complete task with right upper extremity for feeding. Increase time required for cueing for attention to task and safe sequencing. Occupational therapy notes dated 3/7/24 (during survey) revealed education was completed with RN, CNA, and memory care staff with training on recommendations for one-on-one staff assistance with meals for cueing. The staff were educated on the resident's ability to physically complete self feeding tasks with use of his right upper extremity with recommendations to incorporate/facilitate grasp of left upper extremity onto plates and bowls throughout the meal. It was recommended by OT for staff to encourage the resident to complete eating independently as he is able to. However, if the resident is fatigued and not able to complete the task on his own, staff are to provide assistance. The staff are to encourage the resident to eat at a slower pace with smaller bites while checking occasionally for pocketing (storing food inside mouth and not swallowing.) The staff verbalized understanding of education with visual demonstration provided. A review of speech therapy notes dated 1/23/24 to 3/11/24 revealed: Speech therapy notes dated 1/23/24 revealed the resident had been started on minced and most texture food with mildly thick liquids. For meal tasks, the resident successfully responded 55% of the time with therapeutic attempts and 75% of the time if given tactile cues and visual aides during meal. Speech therapy notes dated 1/26/24 revealed the resident required moderate to maximum cueing to remain attentive to meal tasks. The resident ate rapidly using large bites and talked with food in his mouth. Exhibited coughing after swallowing 50%-60% of the time. Speech therapy notes dated 2/13/24 revealed the resident would leave his drinking cup tipped at his mouth for several seconds and required maximum cueing to complete follow through of the drinking task. There had been a positive impact on drinking when a spouted cup (a cup with a lid and a spout to drink out of to decrease fluid flow) was presented. Speech therapy notes dated 2/14/24 revealed the resident completed more efficient swallowing of mildly thick liquid drinking tasks when intake was provided by on-one-on staff in a quiet environment. Speech therapy notes dated 2/21/24 revealed the nurse had reported to the ST the resident had episodes of choking on his own saliva when taking medications. Speech therapy notes dated 2/26/24 revealed ST was to begin trialing a spouted cup. Speech therapy notes dated 3/4/24 revealed the resident benefited when an adaptive cup with straw was used to assist with drinking Speech therapy notes dated 3/11/24 revealed ST was working with the resident on identifying food items to add to the resident's diet to promote adequate nutrition. III. Staff interviews CNA #10 was interviewed on 3/6/24 at 9:16 a.m. She said Resident #26 needed staff to sit with him, prompt him and assist him to eat. CNA #8 was interviewed on 3/6/24 at 9:36 a.m. She said Resident #26 needed staff to sit with him and prompt him to eat meals. He would feed himself independently sometimes but staff had to sit with him, cue, and prompt him. She said if the staff put a plate of food in front of him and walked away, he would not eat. CNA #11 was interviewed on 3/6/24 at 9:51 a.m. She said Resident #26 required total assistance to include assistance from staff to eat his meals. She said he was not able to eat independently. The registered dietitian (RD) was interviewed on 3/6/24 at 9:57 a.m. She said Resident #26 had a stroke recently and had swallowing difficulties. He required thickened liquids and had decreased intakes. The resident required a lot of help with eating to include cueing, prompting and assistance at times. The OT had tried a scoop plate and a cup and a lid to assist the resident with eating. She said in order to monitor the effectiveness of feeding interventions, staff needed to weigh the resident weekly. The RD said she did not know why weekly weights were stopped 2/19/24. The RD said she put a boost supplement into place, however did not have any other documented nutritional interventions. The ST and OT were interviewed on 3/6/24 at 10:10 a.m. The ST said she had been working with the resident to advance his diet from the current texture for resident preference. The resident had swallowing difficulties, was at risk for aspiration and weight loss. The OT said she had instructed staff to put items in the resident's left hand for stability and to encourage him to use his right hand to utilize the utensils to feed himself. He currently needed one-on-one supervision for meals to include at minimum prompting to eat. The resident did not eat independently. She had provided education to the CNAs several times on how to provide the resident adequate eating assistance. Based on her assessment of the resident, he could benefit from therapy. Hospice was intended for residents who could not benefit or participate in therapy. The OT said to determine if a resident could no longer benefit from therapy, the facility needed to exhaust all interventions. To exhaust all interventions, the interventions needed to be tried as intended and on a consistent basis. The director of nursing (DON) was interviewed on 3/7/24 at 10:52 a.m. She said Resident #26 had decreased oral intake since his stroke in January 2024. The DON had considered referring the resident for hospice but wanted to exhaust all possible interventions before referring them. The CNAs provided assistance to the resident during meals by encouraging, cueing or physically assisting him with a spoon. The DON said according to the staff, sometimes the resident would feed himself if the staff put his meal plate in front of him. The DON had not observed the resident during meals. The resident was weighed weekly and the DON was not aware the resident had not been weighed since 2/19/24. Speech therapy had been working with the resident on intake and swallowing difficulty but the DON did not know the interventions therapy had recommended for eating assistance. She did not know what interventions therapy had instructed the CNAs to use with the resident and if the CNAs had been consistently using the interventions. The physician had recommended hospice for the resident but the DON said she did not know if the physician knew the eating assistance interventions were not being followed consistently. The NP was interviewed on 3/11/24 at 11:18 a.m. He said resident #26 recently had a stroke and had begun losing weight related to a failure to thrive. He said he was not aware there were eating assistance interventions that were not being used with the resident consistently. The NP said he had never observed the resident eating or drinking but had just assumed the staff were doing all available interventions. He said he thought the resident was receiving the care and services required and still losing weight, however that was not the case based on the observations throughout the survey. IV. Facility follow-up On 3/13/24 at 3:32 p.m. an updated care plan was provided by the NHA. The documents were as follows: The nutrition care plan revised 3/13/24 (after survey) revealed the resident had a nutrition problem related to a new stroke and dysphagia. The resident meet criteria for significant weight loss. Unavoidable noted due to comorbidities. Multiple interventions will still be attempted and in place. -The facility identified the resident's significant weight loss as unavoidable, however based on the observations during the survey process, Resident #26 did not receive the care and services required to meet his nutritional needs. The facility failed to identify that the resident was not receiving the eating assistance he required while he continued to lose a significant amount of weight. The facility failed to put significant nutritional interventions into place, failed to conduct regular nutritional assessments and observations of the resident during meals and address his continued significant weight loss. -No new interventions were put into place in the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Resident #119 A. Resident status Resident #119, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician's orders (CPO) diagnoses included legal blindness, cognitive communication deficit, muscle wasting and weakness, abnormalities of gait and mobility, and repeated falls. The minimum data set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition as evidenced by a brief interview for mental status with a (BIMS) score of five out of 15. The resident had severely impaired vision, adequate hearing, and did not reject care. The resident required extensive assistance from one staff member for toileting and personal hygiene. The resident needed limited assistance (guided maneuvering) with bed mobility and transfers. The resident used a manual wheelchair in the community and required supervision or assistance with moving from a sitting to standing position and transferring from surface to surface. The resident can walk 50 feet with supervision and staff assistance but was unable to maintain balance without staff support. The resident had a fall history admission to the facility and had one fall with minor injury (lacerations cuts/skin tears and bruising) since admission. B. Resident observations and interviews On 11/28/22 from 9:33 a.m. to 10:45 a.m. Resident #119 was observed. Resident #119 was sitting in a manual wheelchair at the bedside yelling out for staff to come into the room to talk with him. The resident had a call light in reach, but was unable to use it to call for staff assistance. Even when prompted to use the call light the resident was not able to activate the call light. Staff did not enter the room for the entire observation. At 10:47 a.m., Resident #119's roommate entered the hallway looking for staff; no staff were around. The roommate said Resident #119 had been calling out for staff assistance for sometime and no staff had come into help Resident #119. The roommate said Resident #119 had periods of confusion and had had numerous falls while living in the facility; so the facility recently moved Resident #119 into the room to be with another person. The roommate said he had been watching out for Resident #119 since he moved in. When he saw Resident #119 get up out of the wheelchair and head to the bathroom he went to help him get on the toilet because Resident #119 was not walking well. He said he was afraid Resident #119 would fall if he did not help and Resident #119 would not wait until he went for staff help. The roommate said Resident #119 was still on the toilet and needed staff to help him finish, get cleaned up and back to his wheelchair safely. I've done all I can do for him. -No staff were in the hall; the floor nurse, who was down the hall at the nurses desk was alerted that Resident #119's roommate helped Resident #119 to the bathroom and get on the toilet to go to the bathroom; and that Resident #119 needed staff assistance to finish using the toilet and get back to his wheelchair. On 12/5/22 at 8:53 a.m. Resident #119 was observed sitting in a manual wheelchair at bedside with a rolling over the bed table placed in front of him. Resident #119 was holding the call light in his hands but had not pressed the call light for staff assistance. The resident was observed standing up and walking forward pushing the bedside table with his body, as he walked. When asked where he was headed the resident responded to the bathroom. Verbal attempts to cue the resident to sit back down until staff could arrive to assist the resident to the bathroom were unsuccessful. The resident continued to walk forwards towards the bathroom while pushing the table forward with his lower body. The resident did not seem to realize the table was in the way and made no attempts to move the table from his walking path. The resident was very unbalanced and unsteady while walking and was reaching for objects that were not there in an apparent attempt to steady himself. The resident's roommate assisted in alerting staff to the resident's need for assistance; and a staff arrived to assist the resident to the bathroom. Resident #119's roommate was interviewed on 12/5/22 at 11:30 a.m. The roommate said Resident #119 was blind and seemed very confused. Resident #119 had lucid moments but mostly did not make sense in conversations. Resident #119 was particularly confused and night yelling out and talking with people who were not there. The roommate said he felt sorry for Resident #119 and felt he was responsible to watch out for Resident #119 to make sure he remained safe. C. Record review The comprehensive care plan initiated 9/14/22 and updated 12/6/22 documented a care focus for fall prevention and the goal for this care focus was the resident will resume usual activities without further incident. Interventions included the following: -Offer and encourage the resident to eat his meals in the dining room within line of sight. -Place a mattress on the floor (discontinued 12/6/22) -Place a mattress on the floor next to the bed, as a floor mat; -Offer assistance to get out of bed around 6:30 a.m., if awake; -Offer and encourage hip protectors and helmet (discontinued on 12/6/22 per resident choice); -Place a raised edge mattress on the resident's bed; -Continue interventions on the at-risk plan. Fall history in past 60 days Review of Resident #119's medical record revealed the resident had seven falls in the 60 days immediately following admission. The resident entered the facility being a known fall risk. The resident sustained minor injuries in each of the seven documented falls. Each fall required first aid treatment. Based on the nursing assessment the resident showed poor safety awareness and memory deficits which prevented the resident from being able to remember safe practices such as using the call light to ask for staff assistance when attempting transfers, walking and wanting to use the bathroom. Fall prevention intervention failed to provide the resident consistent assistance to prevent falls with injury (see post fall notes below). Post fall note dated 9/14/22 at 1:35 p.m. revealed: Resident #119 was found at his bedside on the floor. Staff heard a noise, entered the resident's room, and found Resident #119 at bedside on the floor with non-skid socks on; the call-light within reach. Resident #119 was unable to say how or why he fell. Resident #119 sustained an abrasion to the back of his head and right flank area. The resident was oriented to person and place (at baseline) and denied pain. LPN #4 encouraged Resident #119 to use his call light and wait for assistance prior to attempting ambulation (getting up and standing on his own). Resident #119 was agreeable, yet,was forgetful. LPN #4 recommended increased rounds to monitor safety. New interventions included: provide an edge raised mattress and increasing rounds to check on the resident. Post fall note dated 9/26/22 at 5:46 p.m. revealed: Resident #119 was found lying on the floor mat next to his bed. The resident sustained a left upper extremity skin tear 4.0 cm by 1.0 cm. The resident had on non-skid footwear; the bed was in the lowest position; the call light was in reach; and the floor mat was in place. Resident #119 said he was trying to go home and was unable to recall details of fall prevention education. New interventions included: continue to provide therapy to increase the resident's strength and endurance; evaluate the resident's room and bed, offer hipsters (cushioned hip protectors); offer a protective helmet; and place the mattress on the floor. Post fall note dated 9/26/22 at 6:49 a.m. revealed: Resident #119 was found on the floor on his knees next to the bed. The resident sustained a left upper arm skin tear measuring 2.5 centimeters (cm) by 1.0 cm and was incontinent of urine. The room was dark and the bedside table was within reach. The resident was assisted into his wheelchair, provided with non-skid socks, and a floor mat was placed next to the bed. New interventions included: providing the resident a floor mat at bedside and offering the resident assistance to get out of bed around 6:30 a.m. Post fall note dated 9/27/22 at 11:53 p.m. revealed: Resident #119 was found lying on the floor at the bedside face down position. The resident sustained a laceration to the left eyebrow measuring 3.0 cm by 1.0 cm and complained of a headache and generalized pain. Resident #119 was transported to the hospital emergency room for further evaluation. A computerized tomography examination (CT scan) and x-rays revealed no skull fracture, hemorrhage or fractures. Interventions included: continue to offer hipsters, helmet, and floor fall mat. Post fall noted dated 10/10/22 at 11:07 a.m. revealed Resident #119 was observed laying on the floor next to his wheelchair in the resident dining room. Resident #119 said he wanted to walk home. The resident was wearing shoes at the time of the fall and had been waiting for the meal to be served. The resident was assessed there were no injuries but the resident was found to have poor safety awareness and impaired memory. New interventions included: for the resident to not be left unattended when in the dining room at meal time and to provide the resident with continuous one to one assistance during meals. Post fall note dated 11/7/22 at 2:16 p.m. revealed Resident #119 was found on the floor with his lower body on the bed and head and upper body on the floor. The resident sustained a contusion (bruising) to his forehead and skin tear to the left forearm and elbow. The resident denied pain. Resident #119 told staff he was trying to get into bed. New interventions included: place the resident's bed in the lowest position; provide a wedge side mattress; continue to provide the floor fall mat, remove the bed frame and place the resident's bed mattress on the floor. Post fall noted dated 11//7/22 at 5:17 p.m. revealed Resident #119 was found laying flat on the floor. Resident #119 told staff he was trying to go to the bathroom and fell. The resident sustained redness, and swelling to the left side of his head with mild pain; and a skin tear with bleeding to the left forearm and elbow. Interventions included a reminder for the resident to call for staff assistance when he needed to use the bathroom. D. Staff interviews The director of rehabilitation (DOR) was interviewed on 12/1/22 at 5:20 p.m. The DOR said fall prevention was a team effort and the interdisciplinary team (IDT) had tried multiple interventions to protect the Resident #119 from falling, including hipsters and a helmet but the resident did not like them and refused to wear them. The DOR said Resident #119 was impulsive and did not remember to use his call light and was prescribed medication that increased his fall risk. The director of nursing (DON) was interviewed on 12/5/22 at 3:56 p.m. The DON stated fall prevention rounding occurs to check on residents and if a resident falls a registered nurse was responsible to complete a full resident assessment. The resident physician was notified after a resident falls; and that physician would also assess the residents. The medical director and IDT reviewed all resident fall events to ensure appropriate fall precautions are in place. The DON acknowledged the facility relied heavily on agency staff due to facility staff turnover which contributed to resident falls. V. Facility follow up On 12/1/22 the nursing home administrator (NHA) provided a copy of the performance improvement plan (PIP) for falls dated 10/18/22. The NHA said the facility was working on reducing resident falls and had been successful in reducing resident falls by 5% in November 2022. The facility was still working to reduce falls even further. The PIP for fall prevention revealed the facility planned to provide nursing and management staff additional education on the facility fall policy and procedures; care plan process for fall prevention; and improved documentation of resident falls, in the month of December 2022. Based on record review, observations, and interviews, the facility failed to ensure three (#19, #7 and #119) of seven residents reviewed out of 55 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to develop and implement person-centered care plans that identified the residents' fall risk; included effective fall reduction interventions; and implement and provide timely and consistent fall prevention interventions, for Residents #19, #7 and #119. Resident #19 was identified as a fall risk within the comprehensive care plan. The facility failed to provide sufficient supervision and training for caregivers to prevent falls and injuries. The fall risk care plan was put into place on 12/10/2020 which identified the resident as a fall risk. On 9/4/22, Resident #19 fell during a staff assisted transfer from the resident's wheelchair to a weight chair and sustained a fracture to the right tibia, a bone in the ankle. Documentation revealed the resident fell forward out of the chair onto the floor, landing on the knees, resulting in a fracture to the ankle. The resident was being assisted during the transfer by one staff. The resident was assessed by the facility nurse after the fall but was not sent to the emergency room for assessment and treatment of the sustained fracture until the following day when the resident complained of increasing pain and swelling of the right ankle. Following the resident fall on 9/4/22 the resident had four additional falls within a 76 day period of time, resulting in multiple bruises and a hematoma (pooling mass of mostly clotted blood formed under the skin) to the forehead. Resident #7 was admitted on [DATE], the facility's secure memory care unit. Upon admission the resident was assessed to be at risk for falls related to being a new admission, poor balance and medication side effects. The care plan documented the resident should have appropriate non-slip footwear when ambulating. On 11/26/22 the resident was walking outside while wearing flip flop footwear on the patio on an uneven surface and fell off the sidewalk. The cause of the fall was determined to be improper footwear. Resident #7 was continuing to wear non-skid socks with sandals and was observed during the survey on 11/28/22 and 11/30/22 to still be wearing slip-on sandals with no straps to secure the footwear onto the resident's feet. The facility's failure to ensure the resident was wearing appropriate footwear while walking on a pathway with uneven edges where the resident slipped off the path caused the resident to sustain a contusion (bruising and swelling) around his right eye and a laceration to the forehead, needing hospital assessment and treatment with sutures. Additionally the resident continued to be at risk for additional falls. Additionally, the facility failed to provide adequate supervision to a resident identified as high fall risk based upon the resident's assessment needs for Resident #119. Findings include: I. Facility policy The Fall Management policy and procedure, revised June 2018, was provided by the nursing home administrator (NHA) on 12/7/22 at 11:40 a.m. It revealed in pertinent part, It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. On admission, the fall risk evaluation will be completed to determine his/her risk for sustaining falls. Each resident is assisted through providing adequate supervision, assistive devices, and functional programs as appropriate to prevent accidents. The resident's care plan will be updated. The QAA (quality assurance) Committee will analyze trends related to falls and will determine if further intervention is needed. II. Resident #19 A. Resident status Resident #19, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the December 2022 computerized physician orders (CPO), the diagnoses included epilepsy, age-related macular degeneration (vision loss or blurry vision), osteoarthritis in the right hip, schizophrenia, and fracture of right tibia with routine healing. The 10/27/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident required extensive assistance with activities of daily living; including two plus staff physical assistance for transfers between surfaces; when moving from a sitting to standing from a chair/wheelchair or from the side of the bed; and when using the toilet. The resident needed one staff member to provide physical assistance for bed mobility, personal hygiene and dressing. The MDS revealed the resident had two or more falls without injury. -However, Resident #19 suffered a fall on 9/4/22 that resulted in a fracture which is considered a major injury. B. Observations During continuous observation on 11/30/22 from 8:46 a.m. to 10:29 a.m., Resident #19 was observed: -At 8:46 a.m., a certified nurse aide (CNA) got Resident #19 out of bed and into the wheelchair. The resident was reaching for items that may or may not have been present. The resident was seen leaning forward in the wheelchair reaching for an item on the floor. The resident was wearing a walking boot on the right foot. -At 9:20 a.m., the resident was seen leaving the room after breakfast self-propelling in a wheelchair with no supervision. -At 9:56 a.m., the resident was brought back to the room by the assistant director of nursing (ADON) #1. The resident stayed in the room sleeping in the wheelchair until 10:29 a.m. C. Record review The fall prevention care plan, initiated on 12/10/2020, revised on 12/15/21, documented the resident was a fall risk related to epilepsy, impared mobility, and weakness. The interventions included anticipating the resident's needs, keeping the call light within reach, and checking the brakes on the wheelchair. -The care plan did not document the resident's need for two staff to assist with safe transfers. The cognitive care plan, initiated on 1/3/2020 and revised on 5/9/22, documented the resident was at risk for cognitive function and thought processes related to disease process. The goal was for the resident to be able to communicate basic needs on a daily basis. Interventions included giving step by step instructions one at a time to support cognitive function, communicate by speaking face to face, reducing distractions and using direct simple sentences with necessary cues. The visual impairment care plan, initiated on 8/6/19 and revised on 5/6/2020, documented the resident was at risk for impared visual function related to macular degeneration. Interventions included monitoring for loss of mobility, double or tunnel vision, hazy or blurred vision. The activities of daily living (ADL) care plan, initiated on 12/10/2020, documented the resident had ADL self care deficits. Interventions included: transfers required participation of two staff members for moving from a sitting to a standing position; coming to a standing position from sitting in a chair/wheelchair or from the side of the bed, and when transferring from surface to surface. The bowel and bladder incontinence care plan initiated on 8/6/19 documented the resident had the potential for bowel and bladder incontinence. Interventions included: encouraging fluid to promote prompt voiding (urinating) response and monitoring for signs and symptoms of a urinary tract infection (UTI). The fall risk assessment dated [DATE], documented the resident had a history of three or more falls within the last 90 days; was disoriented; had poor eyesight; required use of an assistive device for balance; took three to four different medications and had predisposing factors that could lead to falls. The assessment revealed the resident was at a high risk level for falling and indicated interventions should be put promptly into place. D. Resident falls The resident medical record from 9/1/22 to 11/28/22 was reviewed; the record documented the resident had five falls in an approximate 76 day period of time; resulting in a fractured ankle, numerous bruises and a hematoma to the forehead (see below): 1. 9/4/22 fall occuring during staff assisted care Fall notes dated 9/4/22 at 8:22 p.m., documented that while receiving staff assistance to transfer from a wheelchair to the weight scale chair the resident slipped off the chair to the floor landing on both knees. The resident was unable to make the full transfer from one surface to the other; and CNA #1 who was assisting the resident with the transfer assisted the resident to the floor. The resident was assessed by the facility nurse to not be injured. -Only one staff member was present to assist the resident with the transfer from one chair to the other. The facility failed to assist and perform the resident transfer to meet the resident's needs as care planned (see above). Fall notes dated 9/5/22 at 2:20 p.m., documented the resident was assessed to have edema (swelling), bruising, and pain to the right ankle; and the resident was unable to bear weight on the right leg. The resident was placed on bed rest with the right lower leg elevated all shift. The physician was notified and an x-ray was ordered. A fall committee IDT (interdisciplinary team) note dated 9/7/22 documented the resident had a fall on 9/4/22, witnessed with injuries. The resident complained of right knee pain on 9/5/22 at 9:00 a.m., and was unable to put any weight on the right leg. An x-ray was ordered by the physician. The resident was sent out to the emergency room and returned to the facility on 9/6/22, with a diagnosed fracture of the right distal tibia (ankle). Hospital treatment notes dated 9/6/22 documented the resident was assessed to have a fractured ankle confirmed by x-ray. The hospital treated the resident's injury and provided the following treatment orders: a splint was placed on the right ankle. 2. 10/23/22 unwitnessed fall Nursing notes dated 10/23/22 documented that at 7:00 a.m. the resident was discovered sitting on the floor next to the bed. The resident said she rolled out of bed because the bed was wet with urine. The resident was reassured, assisted onto the wheelchair, and reeducated on safety awareness. The resident was not injured. A fall committee IDT note dated 10/24/22 documented the resident's fall on 10/23/22, and that it was expected that the resident would develop bruising after the fall. The new intervention to be added to the resident's care plan was for staff to offer help and assist the resident to get out of bed before 7:00 a.m. -There was no documentation for an intervention specific to offering the resident toileting assistance in the early morning hours. 3. 10/25/22 unwitnessed fall Nursing notes dated 10/25/22 at 1:19 p.m. documented that the resident was assessed for injuries because she was found on the floor at the bedside crawling towards her wheelchair. Nursing assessment revealed the resident had no apparent injuries; but was restless; had poor self awareness of physical ability; was acting spontaneously; and trying to ambulate without assistance. The nurse tried to educate the resident to use the call light for assistance but the resident was unable to reorient. Nursing was encouraging the resident to rest for periods between ADLs to help prevent fatigue. A fall committee IDT note dated 10/26/22 documented the resident was expected to develop bruising from the fall. New interventions included blood work and health review. 4. 10/27/22 unwitnessed fall Fall notes dated 10/27/22 documented the resident was found on the floor, in a sitting position, at bedside. The resident was very confused and unable to explain what happened. A registered nurse (RN) assessed the resident for injuries and none were found. Interventions included having a fall mat placed at bedside, with the bed in the low position, and the call light within the resident's reach. A fall committee IDT note dated 10/27/22 documented bruising was anticipated. Interventions included ordering a urinalysis assessment. 5. 11/20/22 unwitnessed fall Nursing notes dated 11/20/22 at 10:30 a.m. documented the resident was found sitting on the floor at bedside. The resident said she was sitting in her wheelchair and bent forward to pick her spilled food up off the floor and fell. The resident was assessed for injuries and found to have suffered a hematoma to the right side of the forehead. An ice pack was applied. The resident was assisted back to the wheelchair and was reminded to use the call light to call for assistance. A fall committee IDT note dated 11/21/22 documented the resident had a forehead hematoma with bruising that measured 4 centimeters (cm) by 3 cm. The new intervention was to encourage the resident to attend meals in the dining room. E. Staff interviews ADON #1 was interviewed on 11/30/22 at 10:22 a.m. ADON #1 said some residents fall frequently due to a history of falls and deficits. He said that staff were expected to keep an eye on residents who were assessed to be at high risk for falling to prevent falls. He said that fall history was documented in the resident's care plan and the information should be passed on in report (giving the information from nurse to nurse at shift change) and was accessible to nursing staff in the resident record. Licenced practical nurse (LPN) #1 was interviewed on 11/30/22 4:03 p.m. LPN #1 said that the staff were trying to get a weight on resident #19 on the night of 9/4/22 and the resident fell during the transfer and fractured her ankle. LPN #1 said the fracture was healed now, however the resident was unable to walk. The resident requires the use of a mechanical lift to get out of bed and for all transfers (from surface to surface). The resident was able to stand and pivot to transfer from surface to surface, but this required two staff for the task. RN #2 was interviewed on 12/1/22 1:01 p.m. RN #2 said that CNA #1 was transferring resident #19 (on 9/4/22) when the resident fell and broke her ankle. RN #2 said that Resident #19 was a two person assist for transfer and the CNA should have had another staff to assist with the resident transfer. The director of nursing (DON) was interviewed on 12/05/22 5:37 p.m.; the assistant nursing home administrator (ANHA) was present. The DON said that Resident #19 was being transferred to the weight chair and fell forward onto her knees. The DON said that when a resident required the assistance of two staff to complete a transfer, the CNA performing the transfers could ask the nurses for help if they could not find another CNA to assist. The DON said documentation did not reveal if there were two CNAs performing this task or who the CNAs or nurses were during the transfer of Resident #19 when she fell. The DON said the CNAs and nurses completed the same competencies and those were completed in June of 2022 or when a new employee was hired. The interventions were tailored to each resident the longer they stayed at the facility, if there was a concern, and when falls occurred. The DON said that all employees had completed the fall precaution training. III. Resident #7 A. Resident status Resident #7, age [AGE], was admitted on [DATE]. According to the December 2022 computerized physician orders, diagnoses included Alzheimer's disease, gout of right ankle and foot, and bilateral osteoarthritis of knee. The resident resided in the memory care unit. The 10/21/22 minimum data set assessment indicated the resident had severe cognitive impairment with a brief interview for mental status score of four out of 15. It indicated supervised one person assistance for locomotion on unit and extensive one person assistance for locomotion off unit. It indicated a wheelchair was coded for mobility devices. It indicated the resident did not wander. B. Resident representative interview The resident's representative was interviewed on 11/29/22 at 11:29 a.m. She said Resident #7 had a fall recently. She said he put on his coat and went outside because he wanted to leave. She said by the time staff found him he was around the building. She said the nurse was able to ask him to come back inside. She said while the nurse was walking with him he fell and hit his head. She said he had to be sent out to get stitches. She said she had brought him new slippers but she could not find them in his room. She said when she visited him one day he was wearing someone else's sweatpants and they were too long and a fall hazard. She said she had not seen any activities happening during her visits but activities would help keep the residents busy. C. Observations Resident #7 was observed on 11/28/22 at 10:12 a.m. ambulating around the unit. He was wearing non-skid socks with sandals that appeared to be made of plastic material. He asked if there was a back window he could look out in order to see if his truck was parked outside. Resident #7 was observed on 11/30/22 at 11:41 a.m. ambulating to lunch. He was wearing non-skid socks with sandals. Resident #7 was observed on 12/1/22 at 12:55 p.m. at a table in the dining room. He appeared to be asleep in a chair and was wearing non-skid socks with no shoes. D. Record review The fall investigation was provided by the nursing home administrator (NHA) on 11/30/22 at 4:00 p.m. It indicated the resident had a fall on 11/26/22 while outside. It indicated the predisposing situational factors were active exit seeker, wanderer, and improper footwear. It indicated the family had given him flip flops that may have caused him to trip. Progress notes for Resident #7 revealed the following: On 11/26/22 a progress note was completed and indicated Resident #7 was wearing his coat and went to the door to the patio. He went outside and the alarm was set off. A nurse went to the door and turned off the alarm and followed the resident. The resident had walked to a back corner of the patio. The nurse asked him to come back inside to eat lunch and the resident agreed. The resident had on flip flops over socks and stepped off the sidewalk edge. It indicated the nurse broke his fall but he bumped the right side of his forehead on the sidewalk edge. The resident had an open laceration and the nurse held pressure while emergency services were notified. On 11/26/22 a progress note was completed that indicated the resident returned from the hospital with sutures to his forehead and a contusion around his right eye. It indicated brain scans were identified as normal. The resident denied pain. On 11/28/22 a progress note was completed related to a fall committee meeting. It indicated injuries from the fall on 11/26/22 were a laceration to forehead with bruising anticipated. It indicated a new intervention as encouraging to wear appropriate footwear when ambulating. The fall care plan, revised 10/17/22, indicated Resident #7 was at risk for falls related to being a new admission, poor balance and medication side effects. Interventions included ensuring the resident was wearing appropriate footwear when ambulating or wheeling in a wheelchair, maintaining a clear pathway, avoiding rearranging furniture, and keeping needed items within reach. An additional fall care plan, revised 11/28/22, indicated Resident #7 had fallen on 10/31/22 and 11/26/22. Interventions included checking range of motion, ensuring proper footwear when ambulating, and neurological and vital checks as ordered. E. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 11/28/22 at 3:00 p.m. He said Resident #7 had a black eye and stitches because he fell recently. He said there were no other injuries. Certified nurse aide (CNA) #5 was interviewed on 11/30/22 at 10:28 a.m.