**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for 3 of 5 sampled residents (Resident #26, Resident #2 and Resident #10) reviewed for accidents, the facility failed to follow the plan of care resulting in a fall with major injury (Resident #26) and failed to ensure a transfer was provided according to physician order (Resident #2) and failed to implement interventions according to the plan of care resulting in falls (Resident #10). The findings include: 1. Resident #26's diagnoses included dementia, cognitive communication deficit, history of falls, and traumatic subdural hemorrhage. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3) and required moderate assistance with transfers, bed mobility and sitting to standing. The MDS further identified Resident #26 required moderate assistance with dressing and supervision with toileting, had two or more previous falls and was always incontinent of bowel and bladder. The facility Morse Fall Scale evaluation dated 11/15/23 identified Resident #26 as a high fall risk. The Resident Care Plan dated 11/22/23 identified Resident #26 as at risk for falls, at risk for incontinence and at risk for impaired communication related to dementia and a hearing deficit. The RCP included interventions of applying gripper socks at bedtime, placing a call light within reach, offering toileting every 2 hours, and checking Resident #26 every 2 to 3 hours and as needed for toileting needs. Review of the facility Event Report dated 11/22/23 by RN #2 identified that on 11/22/23 at 9:30 PM, Resident #26 was found on the floor in front of his/her bathroom, sitting upright, with both lower extremities curled towards his/her back. The Event Report identified Resident #26 stated he/she hit his/her head on the floor and Resident #26 was transferred to the hospital for further evaluation. The Event Report further identified Resident #26 was barefoot when discovered and his/her shoes were located at the bed side. The Event Report indicated Resident #26 did not put his/her shoes on prior to getting out of bed and did not request assistance for toileting. Review of a statement dated 11/22/23 by NA #8, who was assigned to provide care for Resident #26 during the 3 PM to 11 PM shift on 11/22/23, identified NA #8 changed (referring to incontinent care) Resident #26 at around 2 PM then further identified Resident #26 was in his/her bed at around 7:30 PM to 8 PM, wearing pajamas, and indicated Resident #26 changed into pajamas by his/herself. The statement did not indicate toileting was provided every 2-3 hours according to the plan of care or indicate if footwear was on prior to or at the time of the incident. Review of a statement dated 11/22/23 by LPN #1, who was assigned to provide care for Resident #26 during the 3 PM to 11 PM shift on 11/22/23, identified no indication of Resident #26's status prior to the fall incident. The statement did not identify the last time Resident #26 was toileted or if footwear was on at the time of the incident. Review of a statement dated 11/22/23 by NA #1 who worked during the 3 PM to 11 PM shift on 11/22/23 identified no indication of Resident #26's status prior to the fall incident and no indication of care or toileting provided to Resident #26 prior to the fall incident. Review of an email correspondence on 11/23/23 between the Director of Nursing (DNS) and RN #2 indicated RN #2 interviewed NA #1, who also worked during the 3 PM to 11 PM shift on 11/22/23, regarding the fall incident, and that NA #1 stated she did not toilet Resident #26 at all during the 3 PM to 11 PM shift on 11/22/23 and that Resident #26 frequently toilets him/herself and does not require assistance. Review of the hospital Discharge summary dated [DATE] identified a 5-day hospital admission with a transfer to the surgical intensive care unit for hourly neuro monitoring from 11/22/23 to 11/24/23. Resident #26 was then transferred to the hospital floor for further monitoring until discharge back to the facility on [DATE]. Hospital diagnoses related to the fall incident on 11/22/23 are as follows: a primary diagnosis of trauma secondary to a ground level fall with multiple subarachnoid hemorrhages (SAH) and several other diagnoses to include Bifrontal SAH anteriorly/inferiorly extending superiorly along the left, subtle right parietal SAH, subtle right temporal/occipital SAH, small anterior falx subdural hematoma extending to the right frontal convexity, nondisplaced occipital bone fracture extending to foramen magnum, right occipital hematoma. Interview with NA #8 on 10/11/24 at 11:48 AM identified Resident #26 often exhibited wandering behaviors and once awake would begin to walk. NA #8 identified Resident #26 dressed him/herself at bedtime on 11/22/23. NA #8 identified she saw Resident #26 in bed with pajamas on and did not provide any further care for Resident #26 once he/she was observed in bed. NA #8 identified she did not pull the blankets back to check that gripper socks were in place as directed in the plan of care. 2. Resident #2 had diagnoses that included dementia and osteoarthritis. The Minimum Data Set assessment dated [DATE] identified Resident #2 had moderate cognitive impairment (Brief Interview for Mental Status (BIMS) score of 12) and required a 2 person assist with bed mobility, transfers and toileting. The Resident Care Plan dated 5/20/24 identified Resident #2 had impaired cognition, an ADL deficit and was at risk for falls. Interventions directed to explain procedures prior to beginning and to provide an assist of 2 with transfers and toileting. Physician orders dated 5/21/24 directed an assist of 2 with toileting at wheelchair level during the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts and to provide transfers using a Hoyer lift (mechanical device used to move residents with limited mobility) during the 11:00 PM to 7:00 AM shift. A Nurse's note dated 7/10/24 at 11:03 PM identified Resident #2 was assisted to the floor in the bathroom by his/her assigned Nurse Aide (NA #1). Resident #2 was unable to hold weight in a panic and was assisted to the floor. The assessment further identified Resident #2 had no change in mobility status, did not hit his/her head, was stable, and cognition was at baseline. A facility Reportable Event Investigation Statement dated 7/10/24 completed by NA #1 identified that at 10:45 PM, Resident #2 was being transferred from the toilet to his/her wheelchair when he/she started to panic and fell. An interview with the Director of Rehabilitation (DOR) on 10/15/24 at 11:18 AM identified prior to the incident, Resident #2 required an assist of 2 for transfers to the toilet during the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts and Hoyer lift transfers during the 11:00 PM to 7:00 AM shift. The DOR further identified Resident #2 should have been transferred from the toilet to his/her wheelchair with an assist of 2. Resident #2 was provided an elevated toilet seat after the incident. An interview with NA #1 on 10/15/24 at 1:44 PM identified she was assigned to provide care for Resident #2 during the 3:00 PM to 11:00 PM shift on 7/10/24. NA #1 identified she knew Resident #2 required an assist of 2 with transfers, however, demonstrated that Resident #2 could stand with an assist of 1 while utilizing the grab bar to perform duties and then transfer back to the wheelchair. NA #1 identified that on 7/10/24, she began independently transferring Resident #2 to his/her wheelchair. NA #1 identified Resident #2 panicked, and NA #1 placed her foot behind Resident #2's body, pushed the wheelchair out of the way and eased him/her to the floor. An interview with NA #3 on 10/15/24 at 2:02 PM identified she was also assigned to provide care for Resident #2 during the 3:00 PM to 11:00 PM shift on 7/10/24. NA #3 identified she was aware Resident #2 required an assist of 2 with transfers. NA #3 further identified that there was no request for assistance with Resident #2 on 7/10/24 and that she was only made aware that Resident #2 had fallen when she heard NA #1 call for help. An interview with the Director of Nursing on 10/15/24 at 3:09 PM identified Resident #2 required an assist of 2 at the time of the fall and that Resident #2's transfer status was reviewed after the fall with no changes. 3. Resident #10 had diagnoses that included left femur fracture, dementia, repeated falls and restlessness and agitation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), required partial/moderate assistance with toileting, personal hygiene and transfers. The MDS identified Resident #10 occasionally experienced urinary incontinence. The Resident Care Plan (RCP) dated 5/24/24 identified Resident #10 as a fall risk related to cognition, diagnosis of dementia, ADL decline, history of repeated falls, incontinence and attempts to get up on his/her own. Interventions included offering toileting every hour while awake and to remain with Resident #10 near the bathroom while toileting. The RCP identified Resident #10 had urinary incontinence and included an intervention to check Resident #10 every 2 to 3 hours for toileting needs. The Resident Care Card (RCC) identified Resident #10 as a high fall risk with a history of a hip fracture and directed incontinence care every 2-3 hours, to offer toileting every half hour while awake and not to leave Resident #10 alone in the bathroom. a. Review of the Reportable Event form dated 6/3/24 identified Resident #10 was observed sitting on the bathroom floor at 7:40 PM. Review of a written statement by LPN #2 dated 6/3/24 identified Resident #10 was incontinent of stool at the time he/she was found on the bathroom floor. Review of a written statement by NA #1 dated 6/3/24 identified she was the NA assigned to care for Resident #10 during the 3 PM to 11 PM shift on 6/3/24. The statement written by NA #1 did not include information about toileting or any care provided for Resident #10 throughout the shift. During an interview with NA #1 on 10/16/24 at 11:11 AM, NA #1 indicated she remembered the fall incident that occurred on 6/3/24 and she remembered writing her statement. NA #1 identified she did not toilet Resident #10 prior to the fall in the bathroom and stated her reason for not toileting Resident #10 was because most of the time he/she goes to the toilet on his/her own. NA #1 further identified Resident #10 forgets to use the call bell when he/she needs help and indicated it is difficult to keep an eye on Resident #10 because there are other residents who need tending to. NA #1 indicated that even if Resident #10 is brought to the bathroom, he/she will still go on his/her own and further stated this is not someone you can keep tabs on, even if you toilet him/her every 2 hours, he/she will still go by himself/herself. b. Review of the facility Post Fall Evaluation by RN #2 dated 10/14/24 identified Resident #10 fell in the bathroom at 8:52 PM while attempting to self-transfer to the toilet and was incontinent at the time of the fall. Review of the Reportable Event Investigation Statement form by NA #5 dated 10/14/24 identified the last time care was provided to Resident #10 prior to the incident was at 3:30PM and further down the form identified Resident #10 was last toileted at 7:30 PM. Interview with NA #5 on 10/15/24 at 9:32 AM identified she was assigned to provide care for Resident #10 on 10/14/24 during the 3 PM to 11 PM shift. NA #5 indicated Resident #10 was more anxious and agitated than usual. NA #5 further identified Resident #10 was hyper focused on having his/her wanderguard bracelet (wearable alert device for residents who are at risk for wandering) removed and was arguing with another resident at the nurse's station for most of the shift. NA #5 identified that prior to the fall in the bathroom at 8:52 PM, she last brought Resident #10 to the bathroom at 3:30 PM. NA#5 identified she did not bring Resident #10 to the bathroom at 7:30 PM but, instead, asked Resident #10 if she needed to go to the bathroom. Interview with the Director of Nursing (DNS) on 10/15/24 at 11:47 AM indicated that although Resident #10 is severely cognitively impaired, at times Resident #10 knows when he/she needs use the bathroom. The DNS further identified that Resident #10 may not always answer questions appropriately or be able to make decisions based on his/her severe cognitive impairment and Resident #10 should be toileted according to a schedule. The facility Fall Prevention and Management policy states, in part, residents who are identified as a fall risk will be care planned and individualized interventions and precautions will be noted to avoid falls. The policy directed a safe environment with the least restrictive measures while promoting the highest possible independence. The Facility policy titled Urinary Incontinence - Clinical Protocol states, in part, based on assessment, staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence patterns. The facility Accidents and Incidents - Reporting and Investigating policy states, in part, all accidents, incidents, or events involving residents shall be reported and investigated.