**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interview, for the resident (Resident #12) reviewed for accidents, the facility failed to provide adequate supervision for a resident at risk to fall, who was placed in a common area to be closely watched and fell, sustaining an acute fracture at the base of the femoral neck. Additionally, the facility failed to maintain supervision during shift changes, ensure staff assignment/accountability, timely identify and report significant changes in condition, and implement care plan interventions.The findings include:Resident #12's diagnosis included Alzheimer's Disease and dementia. The care plan dated 05/2/2025 indicated Resident #12 was at risk for falls due to poor communication/comprehension, impaired mobility, impaired cognition, resistance to care and the use of psychiatric and cardiac medications. Interventions included to provide non-skid footwear when ambulating or mobilizing in the wheelchair, encourage Resident #12 to be out of the bedroom when awake for socialization and/or recreational activities, offer diversional activities such as music, snacks, toileting, ambulating, fluids, puzzles, therapy evaluation and treat as indicated and to check the medication regimen with the pharmacist regarding medications that increase risk for falls. The care plan dated 05/05/2025 indicated Resident #12 had a deficit in functional mobility with interventions including 2-person assistance for transfers and bed mobility and ambulation only with the rehab/therapy department. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #12 was severely cognitively impaired, used a walker and a wheelchair, required maximum assistance for sit to stand and transfers, was dependent on staff for ambulating 10 feet and had no signs of pain. The MDS further indicated Resident #12 had no falls in the last 6 months prior to admission, had no falls since admission to the facility and was receiving physical and occupational therapy. A nursing note dated 05/09/2025 at 4:23 AM indicated Resident #12 was resistive with hands-on care, confused and had no complaints of pain. An SBAR Summary (standard format for organizing and conveying information) dated 05/09/2025 completed by the charge nurse (LPN #5) at 11:00 PM indicated Resident #12 had a fall which occurred at the change of shift resulting in a skin tear and no evidence of pain. The Reportable Event Form completed by LPN #5 dated 05/09/2025 indicated Resident #12 had an unwitnessed fall at 10:57 PM while in the dining room and sustained a skin tear to the right elbow. Resident #12 was alert, restless, agitated and confused at times, had poor safety awareness and made several attempts to ambulate unassisted. Resident #12 required assistance of 2 for transfer and bed mobility, assist of 1 person for activities of daily living and ambulates only with therapy. Further, no change in mental status or physical status was noted except for a skin tear of the right elbow for which treatment was provided. The APRN and family member was notified. Range of motion (ROM) was within normal limits, no internal or external rotation of limb per the Registered Nurse The form was signed by the Administrator dated 05/20/2025. A Nursing Pain Tool evaluation dated 05/09/2025 at 11:00 PM indicated Resident #12 had no pain at the present time or during the last 5 days. An order note dated effective 05/10/2025 at 2:02 AM written by the second shift Nursing Supervisor, (RN #5), indicated on 05/09/2025 at 10:57 PM Resident #12 was sitting in the dining room in a wheelchair, stood up and was on the floor with a skin tear on the right outer elbow. The APRN was notified and a treatment order for the elbow skin tear was obtained at 11:16 PM. After a body audit was conducted, including range of motion (ROM) and neurological checks Resident #12 required 3 staff members to stand and transfer to the wheelchair. The resident representative was notified of the incident by the charge nurse at 11:16 PM. A Change in Condition (CIC) follow-up note dated 05/10/2025 at 07:02 AM by the 11:00 PM - 7:00 AM charge nurse (LPN #4) indicated Resident #12 had no complaints of pain or distress, neurological evaluation continues in progress with no attempts to get out of bed and slept well. A Medication Administration Note dated 05/10/2025 at 08:04 PM indicated Tylenol 325mg, 3 tablets were given to Resident #12 orally for moderate pain. Tylenol was effective with no pain on reevaluation. A late entry note for 05/10/2025 at 08:04 PM indicated LPN #4 was present with nurse aide NA #8 providing incontinent care. Resident #12 was at his/her baseline confusion with pushing staff away with his/her hands and kicking both legs while in bed. Resident #12 indicated his/her leg hurts. LPN #4 indicated Resident #12 was independently, actively, moving both legs up and down without difficulty, noting no observable abnormalities including changes in skin color, bruising, redness or swelling. Tylenol was given for stated leg pain with positive effect, and the resident was observed in bed resting and slept the remainder of the shift. A Physical Therapy Treatment Encounter Note dated 05/11/2025 at 11:17 AM indicated Resident #12 had dementia and was a fall risk. The note indicated Standing at the Rolling walker 2 times for 1 minute and 1 time for 45 seconds was completed with minimum assistance of the therapist. Sit to stand to the rolling walker with minimum to moderate assistance of the therapist and verbal cues for proper sequencing was completed. The note further indicated Resident #12 was resistant to therapy saying, I can't and refused walking. A Change in Condition Follow-Up Note dated 05/11/2025 at 06:02 PM indicated no changes in range of motion or immobility. A Change in Condition Follow-up Note dated 05/12/2025 at 07:37 AM indicated in Resident #12 was post fall day #3 with a skin tear to the right elbow, no signs or symptoms of pain, agitation noted only when providing care and slept well. A Health Status Note Dated 05/12/2025 at 12:15 PM written by RN #6 indicated she notified the APRN that Resident #12 had right leg pain and would not allow her to touch the leg to assess. A late entry note dated 05/12/2025 at 3:11 PM by RN #6 indicated she was notified by the nurse aide that Resident #12 had right leg pain and on assessment of the right leg and hip Resident #12 flinched. The APRN was notified. A Progress Note Dated 05/12/2025 at 1:42 PM written by APRN #1 indicated the reason for the visit to Resident #12 was for complaints of right leg/hip pain. The assessment identified Resident #12 was complaining of right leg pain (s/p fall 05/09/2025, 3 days ago) but due to dementia was unable to articulate the exact location of the pain but pain was noted to the right hip on palpation and the resident had difficulty lifting the right lower extremity. As a result, x-rays to rule out a fracture and Tylenol 1000mg orally 3 times a day for pain control was ordered. A Health Status Note dated 05/13/2025 at 11:49AM indicated the x-ray provider called to report Resident #12 had an acute right hip fracture. The nursing supervisor and APRN were updated and orders were obtained to send Resident #12 to the hospital emergency room for further evaluation. After the responsible family member was notified, the resident was transferred to the hospital via ambulance leaving the facility at 11:50 AM. A reportable event form, event first known to the facility dated 05/13/2025 at 12:00 PM resulted in a serious injury. It further indicated Resident #12 had an unwitnessed fall on 05/09/2025 at 11:00 PM and on 05/12/2025 Resident #12 was noted to be guarding the right lower extremity and complaining of leg pain. Subsequently Resident #12 was evaluated by APRN #1 and scheduled Tylenol for pain was ordered along with x-rays. The x-rays indicated an acute nondisplaced fracture at the base of the femoral neck (hip fracture) and Resident #12 was transferred to the hospital. A statement from LPN #5, who worked on 5/9/2025, dated 05/15/2025 (6 days after the fall) indicated she was monitoring Resident #12 and other residents in the common area and when the oncoming shift nurse arrived LPN #5 left to complete the narcotic count. LPN #5 indicated she did not see the resident fall but found the resident on their right side on the floor complaining of pain to the right elbow where a skin tear was noted. A facility interview with LPN #4 completed during their investigation dated 05/15/2025 (6 days after the fall) indicated on 05/10/2025 s/he assisted NA #8 to provide incontinent care as the nurse aide indicated the resident was being combative with care. During care Resident #12 complained of right leg pain and remembering the fall on 05/09/2025, LPN #5 administered Tylenol for the pain and upon reevaluation the resident indicated no further pain. The Reportable Event Summary dated 05/19/2025 indicated during Resident #12's hospitalization the resident underwent open reduction and internal fixation (ORIF) surgery to repair the right hip fracture and was readmitted to the facility on [DATE].An interview, facility document and clinical record review with RN #3, the regional RN, on 09/12/2025 at 10:45 AM indicated upon further investigation after the fracture was discovered, s/he noted on 05/10/2025 at 08:04 PM, Resident #12 had complained of right leg pain, the nurse administered Tylenol but did not report the pain to the supervisor or the physician. RN #3 identified staff had moved Resident #12 to the dining room for falls with other residents at risk to be closely watched, but at the change of shift no one was watching Resident #12 while the charge nurses were counting the narcotics. RN #3 stated the facility does not provide 1:1 supervision. Interview with the Director of Nursing Services (DNS) on 09/15/2025 at 01:50 PM indicated on 9/16/2025 at 11:05 AM interview with LPN #5 (charge nurse for Resident #12 at the time of the fall on 05/09/2025) indicated Resident #12 had already been toileted and provided care, was sitting close to the nurse's station in the dining room. LPN #5 indicated residents who were seated in the dining room are those who are restless or cannot sleep and are brought to the dining room so staff can keep an eye on them. The nurse aides are assigned a half hour at a time during the shift. LPN #5 indicated she was not aware of which staff member was scheduled to watch Resident #12 at the change of shift when the fall occurred. LPN #5 indicated she did not tell the nurse aides to be sure someone was watching the residents in the dining room while the two charge nurses were counting the narcotic medications. LPN #5 indicated other staff were at the nursing station due to change of shift but could not remember who. LPN #5 indicated NA #12 had most likely left the unit before 11:00 PM to report to another unit s/he was scheduled to start working at 11:00 PM stating the nurse aides give each other report at the change of shift and if they are leaving the unit they report to staff before doing so. An interview with RN #5 on 09/16/2025 at 11:38 AM who worked as the 3:00 PM - 11:00 PM nursing supervisor on 05/09/2025 indicated s/he was called to the unit due to a resident fall. After assessing Resident #12's range of motion, there were no leg length changes, no external rotation, no pain or abnormalities. There was a skin tear on the elbow. The on-call APRN service was called, the fall and resident condition was reported, a treatment order obtained, and the charge nurse called the family member. An interview on 09/16/2025 at 11:58 AM with NA #10 who worked the 3:00 PM - 11:00 PM shift on 5/9/2025 indicated s/he was coming back from a resident room and when passing the dining room was asked by the nurses to come help them as Resident #12 was on the floor. NA #10 indicated there were assignments indicating who and when each staff member was assigned to watch the residents in the dining room area further indicting not knowing who was assigned and added it was the change of shift, and everyone was getting ready to leave. An interview on 09/16/2025 at 12:16 PM with LPN #4 who worked second shift (3:00 PM - 11:00 PM) on 5/10/2025 and first and second shifts (7:00 AM - 3:00 PM and 3:00 PM- 11:00 PM) on 05/11/2025 indicated the nurse aide asked him/her to assist with Resident #12 due to the resident being combative while trying to provide incontinent care. While assisting NA #8 with providing care to Resident #12, NA #8 indicated to LPN #4 that Resident #12 was having leg pain. LPN #4 indicated Tylenol was given for pain and was effective later when the resident was reevaluated and the resident slept the remainder of the shift. LPN #8 indicated the 3:00 PM - 11:00 PM supervisor did not come to the unit to obtain report at the end of the shift and LPN #8 indicated she did not call the supervisor to report the pain because it was relieved with the Tylenol provided. Further, the resident was moving his/her legs and was not screaming in pain and the supervisor would only be notified when the pain medication does not work. LPN #4 who worked the next day (5/11/2025) indicated Resident #12 was already up in the wheelchair when seen and had no complaints of pain or discomfort and had visitors who stayed for quite some time and offered no concerns. Attempts were made on 09/16/2025 at 12:48 PM to contact NA #8, the third nurse aide who worked 05/09/2025 3:00 PM - 11:00PM (second shift) and worked second shift on 05/10/2025 who provided incontinent care to Resident #12 and reported Resident #12 had complained of leg pain, were unsuccessful. An interview on 09/16/2025 at 01:02 PM with RN #6 who worked first shift on 05/12/2025 indicated noticing Resident #12 had pain and flinched when touched and notified the APRN who was in the facility and ordered x rays.An interview on 9/17/2025 at 7:23 AM with NA #12 who worked 5/9/25 second shift (3:00 PM -11:00 PM) and was assigned to provide care for Resident #12 indicated Resident #12 was always on the move further indicating care and toileting had been provided around 09:45 PM then the resident was brought to the dining room/lounge area to be watched. NA #12 identified Resident #12 cannot be placed in bed until later when the resident shows signs of being tired because he/she would try to get out of bed unassisted and could fall. NA #12 indicated not knowing who was assigned to watch the residents in the dining room/lounge area at the time. NA #12 left the unit at about 10:53 PM to report for duty for the 3rd shift on another unit at the facility. NA #12 further indicated about 10 minutes after leaving the unit, a nurse aide came to find her on the new assigned unit to provide an investigation statement to be completed by NA #12 as Resident #12 had a fall. NA#12 indicated not being able to remember where the staff were on the unit when s/he reported to them s/he was leaving the unit for the next shift but did indicate staff would have been at the nurse's station or the Kiosk at the end of the shift preparing to leave. The facility policy Labeled Fall Prevention Program indicated that all residents would be evaluated for risk for falls on admission, readmission, and with a change of condition. Residents at high risk for falls would have interventions initiated to prevent falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the environment was free from hazards when the resident hit his/her leg on the side rail during a transfer resulting in a laceration that required 15 sutures. The findings include: Resident #1 had diagnoses that included difficulty in walking, muscle weakness, and unsteadiness on his/her feet. The admission [NAME] Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and was dependent for transfers. The Resident Care Plan (RCP) dated 7/30/2024 identified Resident #1 had a deficit in self-care and mobility. Interventions directed to transfer with the assistance of 2 without an assistive device. Review of a physician's order dated 7/30/2024 directed pivot assist of two (2) staff for transfers without assistive device. Review of a facility incident report dated 7/31/2024 at 5:15 PM identified Resident #1 hit his/her leg against the side rail during a transfer and sustained a laceration on the left lower leg. The report indicated the side rail was padded after the incident. Review of the facility reportable event dated 7/31/2024 identified at 7 PM, Resident #1 required two (2) staff extensive assist for transfers, and during a transfer Resident #1 hit his/her leg against the side rail sustaining a laceration to the left lower extremity. Resident #1 was transferred to the hospital for evaluation. Record review identified Resident #1 returned from the hospital on 8/1/2024 and received 15 sutures to repair the laceration. The incident summary dated 8/5/2024 identified two (2) staff performed the transfer and during the transfer, Resident #1 extended his/her legs upwards hitting the siderail of the bed. Additional information dated 8/9/2024 identified Resident #1 sustained a 12-centimeter (cm) laceration and required sutures. Record review failed to identify that the resident was assessed for the use of the side rails, consent for the use of the side rails was obtained, and no physician's order that directed the use of the side rails for Resident #1. Review of the, Room of the Day Maintenance record, dated 6/24/2024 identified the bed was checked and was ok. Interview with NA #1 on 8/27/2024 at 11:09 AM identified she and NA #2 transferred Resident #1 back to bed on 7/31/2024 and during the transfer the resident hit his/her leg on the side rail. After Resident #1 was in bed, NA #1 and NA #2 noted Resident #1 had sustained a laceration to his/her left lower leg. Interview with NA #2 on 8/27/2024 at 12:30 PM identified after transferring Resident #1 into bed on 7/31/2024 they noted Resident #1 had a laceration on his/her leg. NA #2 stated there was no laceration prior to the transfer. Record review and interview with the DNS and Corporate Clinical Nurse on 8/27/2024 at 1:01 PM identified on 7/31/2024 Resident #1 sustained a laceration to his/her left lower leg by hitting the bedrail during the transfer from the wheelchair into bed. The DON stated upon investigation it was identified there was an edge on the bottom of the side rail, blood was noted on the bottom of the bedrail, and Maintenance padded the bedrail until rubber plugs could be ordered. Interview with the Director of Maintenance on 10/2/24 at 9:38 AM identified Resident #1's bed had a half side rail on both sides of the bed. The Director of Maintenance further stated that he had never been asked to remove or zip tie/secure Resident #1's side rails. Interview and record review with the DNS on 10/2/2024 at 11:39 AM identified Resident #1 did not have a physician order, an assessment or consent for use of the side rails. The DNS was unable to explain why the side rails were in use and that Maintenance could remove the rails if requested.