**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/17/24 at 3:25 PM, an undated treatment bandage was observed on the right forearm near the elbow of resident #84. The resident stated someone put the bandage on a couple of days ago after an injury. Review of resident #84's Progress Notes, the record of weekly skin checks indicated on 10/07/24, the resident had a skin tear to right elbow. On 10/12/24, the resident had a skin tear to right elbow and treatment was in progress, and on 10/16/24, the weekly skin check also indicated the resident had a skin tear to right arm. On 10/17/24 at 3:27 PM, Registered Nurse (RN) I verified there was an undated bandage on right upper arm near the elbow of resident #84. RN I removed the bandage and noted there to be a gauze dressing under the bandage which was saturated with blood. She confirmed this finding and stated she would change the dressing. RN I then checked the computer record for a physician's treatment order and found there was not one. She stated she needed a physician's order for treatment so she would reach out to the physician for one. The G and R Unit Manager also present verified there was not a physician order for this treatment. She confirmed all treatment needed a physician's order to be provided. The facility's policy entitled Wound Treatment Management dated 3/01/22 and revised 3/01/24, revealed the facility was to provide evidence-based treatments in accordance with current standards of practice and physician orders. This would include dating a bandage when it was placed along with the method used to clean the wound, the type of dressing, and the frequency the dressing was to be changed. Based on observation, interview, and record review, the facility failed to provide immediate and thorough nursing assessment and treatment services related to burns for 1 of 2 residents, (#27), and failed to obtain an order for treatment and date a treatment dressing for 1 of 2 residents reviewed for pressure wounds, (#84), of a total sample of 37 residents. The facility's failure to ensure a complete and timely assessment including accurate identification of burns resulted in actual harm. Resident #27 was transferred to a higher level of care initially for treatment and was transferred again to another hospital with a specialized burn unit. Resident #27 was admitted to the stepdown trauma unit with second degree burns to her left arm, left hand, abdomen and left thigh. She remained there for 5 days. Findings: Cross reference F689 and F813 1. Resident #27 was admitted to the facility on [DATE] with diagnoses to include left sided hemiplegia and hemiparesis, type 2 diabetes mellitus with diabetic neuropathy (nerve damage caused by diabetes), and contracture of the left hand. Hemiplegia and hemiparesis are similar in that they describe effects to one side to your body.hemiplegia refers to one sided paralysis while hemiparesis refers to one sided weakness, (retrieved from www.my.clevelandclinc.org on 10/21/24). The resident's quarterly Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 8/21/24, revealed the resident was cognitively intact with a Brief Interview of Mental Status of 14/15. The record revealed the resident had left sided weakness and paralysis due to a stroke. Her left hand was contracted. The MDS indicated she was a set up assistance for eating and could feed herself. Review of Order Summary Report revealed an order dated 10/02/24 for triple antibiotic cream to be applied to a skin tear to left hand. Review of the Weekly Skin Check Sheet dated 10/02/24 revealed the sheet was incomplete/blank except for the date and the nurse's signature. Review of a Nurse's Progress Note dated 10/02/24 at 7:33 PM, by Licensed Practical Nurse (LPN) J revealed, the Certified Nursing Assistant (CNA) notified him that resident #27 burned herself with a noodle soup that she was eating. He documented that, Upon assessment resident have a skin tear on left hand. No complaint of pain /discomfort. Physician notified as well her daughter. There was no further documentation from LPN J or other nurses regarding the assessment/reassessment or treatment for resident #27 in the medical record. On 10/15/24 at 3:45 PM, the Administrator provided an overview of the investigation. She said on 10/02/24 at about 5:30 PM resident #27 had a cup of noodle soup that you add water to and cook in the microwave. Resident #27 asked CNA K to heat it for her and the CNA took it to the unit kitchen and cooked it in the microwave. The Administrator explained the food should have been heated in the kitchen. She stated CNA K told the Administrator it was dinner time, and she warmed up soup for resident #27. The CNA said she rested the soup on the table and then resident #27 tried to move a plate and it bumped the soup. CNA K said she tried to catch it, but it spilled on the resident's left arm. The CNA stated she reported it to the nurse. The Administrator stated she asked CNA K to demonstrate what happened and as CNA K was setting the soup down resident #27 hit the cup with a plate and it spilled toward the resident spilling onto her. The Administrator reviewed the statement from resident #27's assigned LPN J who wrote that CNA K notified him that resident #27 burned herself while she was eating noodle soup. He wrote that upon his assessment the resident had a skin tear on her left hand. He indicated he notified the physician as well as the resident's daughter. The Administrator stated the Director of Nursing (DON) called her around 9:00 PM the night of the incident and explained resident #27 was sent to the hospital. She recalled the DON told her that resident #27 got burned, and after the family came in 911 was called and resident was transported to the hospital. The Administrator stated it did not sound like an urgent situation to her. She said the DON told her the soup got spilled on resident #27's hand and she was treated. She explained she was trying to figure out why resident #27 had to go out if she received treatment. The Administrator stated the incident was being discussed in the morning meeting when the daughter arrived. The Administrator remembered resident #27's daughter came to see her the next morning, 10/03/24. She was upset that the staff did not respond appropriately to her mom. The Administrator explained resident #27's daughter showed her a picture of the resident's arm and it had some discolored skin. There were other areas on her arm that did not look like they were treated. The Administrator stated the daughter explained when she arrived to the facility to see her mother, the nurse was passing medications and CNA K was working in the fall risk area. The daughter stated she knew accidents happened, but the staff did not act concerned about her mother's burns. The Administrator explained the daughter told her that resident #27 called her and told her she needed to come here to see her. The daughter said her mother was in pain when she arrived at the facility around 6:30 or 6:40 PM on 10/02/24 and explained LPN J was still passing medications and had not been back to see resident #27 after the initial visit so the daughter called 911. The Administrator was asked if LPN J should have done a head-to-toe assessment when he first went to see resident #27 and her response was, LPN J stated he treated what he saw and went on to do medication administration. On 10/14/24 at 6:45 PM, via the telephone, resident #27's daughter stated CNA K fixed a cup of soup and after she set it on the table, the soup spilled on her mother. The daughter explained she received a call from the nurse that her mother was burned. The daughter said she came to the facility and spoke to the Supervisor who had no idea her mother was burned. She stated the Supervisor told her he would get the nurse, and they could discuss what happened, but when he found the nurse, the Supervisor went into the room and talked to him. The daughter said she got upset because the nurse and Supervisor were supposed to discuss what happened with her and they went in a room to talk amongst themselves. The daughter said she called 911 because she felt her mother needed to go to the hospital, and the police because she wanted to find out what happened. The daughter explained the Emergency Personnel took her mother to a nearby Hospital emergency room where she was assessed. Shortly afterwards the hospital transferred her to the to the specialized burn unit at a larger Level One hospital. The daughter stated when resident #27 got to the first hospital, they had to pour some kind of liquid on her clothes to remove them, as she the wet clothes had not been removed from the burned areas of her skin by the nursing home staff for almost two hours. She said after that is when they decided to send her to the larger hospital with the burn unit. She remained in the hospital a total of 5 days with second degree burns. On 10/16/24 at 1:47 PM, LPN J was interviewed by telephone. He stated CNA K had called him to say resident #27 burned herself while she was eating noodle soup. He stated he went to the room and the resident was sitting in her wheelchair. LPN J stated he asked the resident what happened and she said see my hand? He recalled the resident told him she had spilled the hot soup and he saw a skin tear on the resident's left arm. The LPN said he left resident #27 sitting in her wheelchair and went to the nurses' station, and called the doctor and daughter about what happened. He stated he came back to the resident's room and applied an antibiotic ointment to the resident's left arm as ordered by the physician then went back out to continue his medication pass. LPN J verified he was not aware the resident had spilled the hot soup on her left leg and stomach. He replied, No she did not tell me that. The LPN stated he did not notice her clothing was wet and had not performed a head-to-toe assessment when he learned of the incident. LPN J explained he was going to reassess resident #27 later when he finished his medication pass. A second degree or deep partial thickness burn involves damage or destruction of the first and second layers of the skin, which will be painful and often blistered. A full thickness burn can destroy nerves so pain might not be felt and will often look brown, black, or white and feel dry and leathery. You should go to the Emergency Department if the skin looks leathery, or there are patches of brown, black or white or if the burn involves the hands, airway, face or genitals. The first thing you should do if someone has a burn is to take off any contaminated clothing unless it is sticking to you and wash the affected area with plenty of cool water for up to 60 minutes. As soon as possible any clothing or jewelry should be removed, unless they are stuck to the burn, then it should be covered with something clean. Consequences of burn injuries that may progress without treatment include ischemia (obstruction of blood flow) due to increased swelling (edema), and infection, (retrieved on 10/31/24 from www.healthdirect.gov). On 10/17/24 at 11:30 AM, the DON stated she would expect the nurse would immediately complete a head-to-toe assessment and provide any necessary emergency treatment as ordered if a resident had a burn or any injury. She explained because it was a burn it should never had been presented to the physician as a skin tear. She added, the resident should have been reassessed because the skin did not always show the extent of the burn(s) right away. On 10/16/24 at 1:10 PM, via telephone interview resident #27 stated the burn occurred around dinner time, on 10/02/24 approximately 5:00 to 5:30 PM. The resident stated staff brought her meal tray and she was eating a piece of pie. She said she tried to move the pie when the cup of noodles spilled the very hot liquid all over. She said when the hot liquid hit her skin it hurt and she started screaming and hollering. Resident #27 said CNA K called the nurse and told him that a couple noodles got spilled on her and by the time LPN J got there her arm was burning. Resident #27 said LPN J later put something on her arm. The resident said she told the nurse her stomach and leg were burning, but he did not even look at it. Resident #27 explained she then called her daughter and told her she needed to come. The resident stated by the time her daughter got there she had a blister down to her thumb. She said her daughter called 911 and the police and she went to the hospital. Resident #27 said when she arrived at the hospital, they poured something on her to remove the clothes that were now stuck to her burned skin. She stated the doctor told her she had second degree burns and they gave her something for pain so she was out of it. The resident said she then went to the burn unit. She explained she could move her arm and leg now, but her stomach still hurt where it was burned. She said she got medication for the pain that took the edge off, so she could move her leg but when they get her up for therapy it hurts. The resident stated, They did not change me I went to the hospital in the same wet clothes. Review of the burn unit hospital records for resident #27, dated 10/02/24, skin assessment revealed, Partial thickness burn wounds with blistering to the left dorsal forearm extending to the lateral aspect of the base of the thumb and extending mid-way to the ventral aspect of the forearm. The open areas blanch well. Partial thickness burn wounds with blistering to the left lower anterior abdominal wall, left anterior and posterior thigh. The total body surface area prior to debridement is approximately 4 %. Mental status: She is alert and oriented to person, place and time. Review of the Skin Assessment Policy, dated 3/01/22 and revised 3/01/24, revealed a full body, or head-to-toe skin assessment would be conducted by a licensed or registered nurse upon admission/re-admission, and at least weekly thereafter and may also be performed after a change of condition. Patients with burn injuries are complex and have high mortality. Burns are traumatic injuries that can cause profound shock within minutes and can affect every body system. Nurses must prioritize assessment of the airway, the cause of burn, depth, and TBSA [total body surface area] during the initial screening. These assessments are important to appropriately resuscitate the patient and decrease the risk of burn shock. Patients with burns are at considerable risk for infection and hypothermia. Nurses should keep patients warm and transfer them to a certified burn center as soon as possible for the best outcomes. Providing early, quality nursing care to patients with burns will make all the difference in the outcome, (retrieved on 10/22/24 from www.nursingcenter.com/cearticle).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent an avoidable accident for a resident by not checking the temperature of microwaved noodles provided by staff for 1 of 2 residents reviewed for accidents, of a total sample of 37 residents, (#27). The facility's failure to provide a policy and ensure all staff were educated regarding the heating and reheating of resident food resulted in actual harm. Resident #27 was transferred to a higher level of care, then transferred again to another hospital with a specialized burn unit. Resident #27 was admitted to the stepdown trauma unit with second degree burns to her left arm, left hand, abdomen and left thigh. She remained in the hospital for 5 days. Findings: Cross reference F684 and F813 Resident #27 was admitted to the facility on [DATE] with diagnoses to include left sided hemiplegia and hemiparesis (one sided weakness and paralysis), type 2 diabetes mellitus with diabetic neuropathy (diabetic nerve damage), and contracture of the left hand. The resident's quarterly Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 8/21/24, revealed the resident was cognitively intact with a Brief Interview of Mental Status of 14/15. The record revealed the resident had left sided weakness and paralysis due to a stroke. Her left hand was contracted. The MDS read she was a set up assistance for eating and could feed herself. Review of a Nurse's Progress Note dated 10/02/24 at 7:33 PM, by Licensed Practical Nurse (LPN) J revealed, the Certified Nursing Assistant (CNA) notified him that resident #27 burned herself with a noodle soup that she was eating. He documented that, Upon assessment resident have a skin tear on left hand. No complaint of pain /discomfort. Physician notified as well her daughter. There was no further documentation from LPN J or other nurses regarding the assessment/reassessment or treatment for resident #27 in the medical record. On 10/14/24 at 11:30 AM, resident #11 (roommate of #27) stated she did not see what happened when her roommate got burned, but she heard her and CNA K both scream. She recalled when she looked over CNA K said the soup spilled on her roommate. Resident #11 stated that CNA K made the cup of noodles frequently for resident #27. On 10/14/24 at 6:45 PM, via the telephone, resident #27's daughter stated CNA K fixed a cup of soup and after she set it on the table, the soup spilled on her mother. The daughter explained she received a call from the nurse that her mother was burned. The daughter said she came to the facility and spoke to the Supervisor who had no idea her mother was burned. She stated the Supervisor told her he would get the nurse, and they could discuss what happened, but when he found the nurse, the Supervisor went into the room and talked to him. The daughter said she got upset because the nurse and Supervisor were supposed to discuss what happened with her and they went in a room to talk amongst themselves. The daughter said she called 911 because she felt her mother needed to go to the hospital, and the police because she wanted to find out what happened. The daughter explained the Emergency Personnel took her mother to a nearby Hospital emergency room where she was assessed. Shortly afterwards the hospital transferred her to the to the specialized burn unit at a larger Level One hospital. The daughter stated when resident #27 got to the first hospital, they had to pour some kind of liquid on her clothes to remove them, as she the wet clothes had not been removed from the burned areas of her skin by the nursing home staff for almost two hours. She said after that is when they decided to send her to the larger hospital with the burn unit. She remained in the hospital a total of 5 days with second degree burns. A second degree or deep partial thickness burn involves damage or destruction of the first and second layers of the skin, which will be painful and often blistered. A full thickness burn can destroy nerves so pain might not be felt and will often look brown, black, or white and feel dry and leathery. You should go to the Emergency Department if the skin looks leathery, or if there are patches of brown, black or white or if the burn involves the hands, airway, face or genitals. Consequences of burn injuries that may progress without treatment include ischemia (obstruction of blood flow) due to increased swelling (edema), and infection, (retrieved on 10/31/24 from www.healthdirect.gov). On 10/16/24 at 1:10 PM, via telephone interview resident #27 stated the burn occurred around dinner time, on 10/02/24 at approximately 5:00 to 5:30 PM. The resident stated staff brought her meal tray and she was eating a piece of pie. She said she tried to move the pie when the cup of noodles spilled the very hot liquid all over. She said when the hot liquid hit her skin it hurt and she started screaming and hollering. Resident #27 said CNA K called the nurse and told him that a couple noodles got spilled on her and by the time LPN J got there her arm was burning. Resident #27 said LPN J later put something on her arm. The resident said she told the nurse her stomach and leg were burning, but he did not even look at it. Resident #27 explained she then called her daughter and told her she needed to come to the facility. The resident stated by the time her daughter got there she had a blister down to her thumb. The resident explained her daughter called 911 and said, They did not change me I went to the hospital in the same clothes. At the hospital, she recalled they poured something on her to remove the clothes that were now stuck to her burned skin. She stated the doctor told her she had second degree burns and they gave her something for the pain. The resident said she then went to the burn unit at another hospital. She explained she could move her arm and leg now, but her stomach still hurt where it was burned. She said she got medication for the pain that took the edge off, so she could move her leg but when they get her up for therapy it hurt. Review of the burn unit hospital records dated 10/02/24, skin assessment for resident #27 revealed, Partial thickness burn wounds with blistering to the left dorsal forearm extending to the lateral aspect of the base of the thumb and extending mid-way to the ventral aspect of the forearm. The open areas blanch well. Partial thickness burn wounds with blistering to the left lower anterior abdominal wall, left anterior and posterior thigh. The total body surface area prior to debridement is approximately 4 %. Mental status: She is alert and oriented to person, place and time. On 10/15/24 at 3:42 PM, the Administrator stated on 10/02/24 at about 5:30 PM, resident #27 had a cup of noodle soup that you add water to and cook in the microwave. The resident asked CNA K to prepare it for her which she did. The Administrator stated the food should have been heated in the kitchen, instead of on the unit. The Administrator stated a few weeks prior to the incident she was given a stack a paper from the Weekend Supervisor. It included an in-service regarding a resident asking for food to be reheated because one of the nurses had the misconception that the resident food could be reheated on the unit. The Administrator stated she had the microwaves removed from the units and they had a conversation about not reheating food outside of the kitchen. The Administrator said, somehow there was still one microwave available. The Administrator conveyed that CNA K told her she was not aware of that in-service. On 10/16/24 at 10:41 AM, the former Director of Nursing (DON) who was DON at the time of the incident, stated she was not sure what the food policy was regarding heating or rewarming food for residents. She stated the Administration staff discussed rewarming the food due to a grievance, and that staff were supposed to take it to the kitchen if it needed to be warmed or rewarmed. The DON stated the staff did not get educated at that time. On 10/16/24 at 11:01 AM, the Assistant Director of Nursing (ADON) said the staff had not been educated about warming food prior to the incident. On 10/17/24 at 2:30 PM, the Administrator added the facility looked to see if there was any education provided to the staff regarding heating and reheating food, at any time prior to her administration and were unable to find any record. On 10/16/24 at 1:47 PM, LPN J stated he had never received education regarding heating/reheating food to the appropriate temperature to ensure the food provided was at a temperature to minimize the risk for burning or scalding residents. He stated he was not aware that CNA K had been making the noodles for the resident in the microwave. He said he did not recall ever seeing a thermometer in the unit kitchen to take the temperature of the food. On 10/16/24 at 4:55 PM, LPN L stated he was the Evening Supervisor on the night that resident # 27 was burned. He stated he did not recall getting education regarding heating and reheating resident food. He also said he could not recall seeing a thermometer in any of the unit kitchens for taking the temperature of the food. On 10/15/24 at 5:25 PM, and again on 10/16/24 at 11:37 AM attempts were made to contact CNA K by phone. Voice mail was left with both calls and no return response from the CNA was received. CNA K was no longer employed by the facility. Policy review revealed the facility food policies, Safety of Hot Liquids no date, Food Safety Requirements date implemented 3/01/22, revised 6/01/24, Use and Storage of Food Brought in by Family and Visitors dated 3/01/21 and revised 4/01/23, did not include instructions for staff to take food for the residents to the kitchen to be heated/reheated, nor any guidance for appropriate temperatures for the heating/reheating of food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement appropriate interventions to include provision of adequate supervision to prevent a fall with major injury for 1 of 1 resident reviewed for accidents, of a total sample of 31 residents, (#11). The facility's failure to increase supervision for a resident with a history of repeated falls resulted in actual harm for resident #11. Findings: Review of the medical record revealed resident #11 was admitted to the facility on [DATE] with diagnoses including seizures, dementia, anxiety, and hypertension. He was hospitalized on [DATE] after a fall with major injury and readmitted from the hospital on [DATE] with additional diagnoses of traumatic subdural hemorrhage, repeated falls, weakness and paralysis of the left side and visiospatial deficit and spatial neglect following a stroke. A subdural hemorrhage is bleeding between the covering and surface of the brain that is often the result of a severe head injury. Compression of the brain can cause brain injury or death (retrieved on 3/22/23 from www.medlineplus.gov). Visiospatial deficit and spatial neglect are common consequences of a one-sided brain injury. Persons who suffer from these conditions do not process visual stimuli and images on one side of the body (retrieved on 3/22/23 from www.medscape.com). The Minimum Data Set (MDS) quarterly assessment with assessment reference date of 9/08/22 showed the resident had a Brief Interview for Mental Status score of 4 out of 15, which indicated the resident was severely cognitively impaired. The MDS assessment noted there were no behavioral symptoms or rejection of care and treatment, and the resident required extensive staff assistance for bed mobility, and limited assistance for eating during the look back period. Fall risk evaluations completed on 8/14/22 and 10/26/22 identified the resident as high risk for falls. A Change in Condition form dated 8/14/22 indicated resident #11 was observed sitting on the floor beside his bed. A Change in Condition dated 10/26/22 indicated resident #11 was observed on the floor. Review of a Nursing Progress Note dated 11/15/22 at 9:47 AM, revealed resident #11 was found on the floor in the television room. He informed nursing staff he was asleep and slid out of his chair. Review of a Change in Condition form dated 11/20/22 read, Resident fell out of wheelchair and hit his head. The document indicated resident #11 grimaced and complained of pain, level 8 on a 0 to 10 scale, to the right side of his forehead. The resident required emergency medical transport to the hospital for evaluation and treatment. Review of resident #11's medical record revealed a care plan, initiated on 1/28/20, that indicated he was at risk for falls. The goals, revised on 8/16/22, included minimizing the risk of sustaining serious injury and an intervention directed nursing staff to anticipate and meet the resident's needs. A care plan for an actual fall was initiated on 1/22/20 and had a goal of minimizing the risk of further incidents. An intervention dated 1/24/20 indicated staff were to place items on the right side of the resident's body. An approach dated 2/17/22 directed staff to encourage and assist him to be in the day room or dining room when in the wheelchair. The care plans did not specify the level of supervision or frequency of monitoring required to prevent falls and/or injury, and ensure the resident's safety. The resident's care plan was revised on 11/30/22, five days after readmission from the hospital where he was treated for a subdural bleed, to include increase supervision. However, the care plan still did not provide specific instructions for staff regarding the frequency of rounds and whether or not the resident needed be monitored in a fall prevention program. On 3/09/23 at 5:39 PM, Licensed Practical Nurse (LPN) B stated she observed resident #11 as he fell from his wheelchair to the floor near the entrance door in the dining room on 11/20/22. The LPN recalled she looked around the room for staff and observed two Certified Nursing Assistants (CNAs) behind the double doors, where they were not able to visualize or supervise residents. LPN B stated she evaluated resident #11, noted a large, raised area on his forehead, and immediately initiated emergency medical services to transport him to the hospital. She recalled the residents in the dining room required supervision because they were at risk for falls. LPN B stated she believed the fall could have been prevented if residents in the dining room had been supervised. She stated the two CNAs told her they were not supervising residents in the dining room as they were on their break. On 3/09/23 at 5:58 PM, the Activities Director stated she knew which residents were at risk for falls as they were supervised by a CNA in the common area on the unit. She stated those residents required staff assistance to get to the dining room for activity functions. She explained a CNA remained in the area by those residents for safety. She stated resident #11 was not included in the group of residents with known risk for falls on 11/20/22. The Activities Director recalled on that day, she heard a loud bang in the dining room, looked around, and saw resident #11 on the floor. She stated she did not see the resident fall as she was on the other side of the dining room. On 3/09/2023 at 6:28 PM, the Director of Nursing (DON) acknowledged resident #11 had not been provided with increased supervision although he had a history of multiple falls prior to the fall with major injury on 11/20/022. The DON explained residents identified as at risk for falls should participate in the fall program, and be supervised around the clock. He verified resident #11 should have been placed on close supervision prior to his fall with major injury on 11/20/22 because he had falls before this happened. The facility's policy and procedure for Topic: Fall Prevention Program (undated) indicated the facility would .implement specialized safety precautions to ensure safety. of residents identified to be at risk for falls. The procedure indicated specific interventions for residents deemed to be at high risk for falls included alarms, floor mats, bed bolsters, appropriate recreational activities, and increased supervision, i.e. ½ hour observations/monitoring rounds. The facility's policy and procedure for Topic: Risk Management (undated) revealed avoidable accidents occurred when the facility failed to Implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident; and/or monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current standards of care. The document indicated supervision was an intervention utilized to mitigate fall risk. Adequate supervision was noted to be the type and frequency of supervision required to meet a resident's person-centered care needs.