**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to develop and implement care plan interventions for two residents (Resident number 1, Resident number 2) out of three residents identified at risk for falls. Resident number 1 and Resident number 2 had falls that resulted in major injuries. The findings included: 1) Record review of the facility's MDS (Minimum Data Set) Comprehensive Assessment and Care Plan Policy and Procedure (effective 3/31/2022) documented the following: Policy-It is the policy to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of all residents will be completed in the format and in accordance with time frames; Procedure: 7) The facility will develop a comprehensive person-centered care plan for each resident in the nursing home facility that includes measurable objectives and timeframes to meet the resident's clinical, mental, psychosocial needs that are identified in the comprehensive assessment. Observation of Resident number 1 on 4/12/23 at 10:59 AM, revealed the resident was sitting up in a low bed with floor mats, tv on and the tube feeding machine was off. Attempted to interview the resident but she did not participate in the interview. Review of the Demographic Face Sheet for Resident number 1 documented the resident was admitted to the facility on [DATE] with diagnoses to include unspecified displaced fracture of fourth cervical vertebra, subsequent encounter for fracture with routine healing, unspecified displaced fracture of sixth cervical vertebra, subsequent encounter for fracture with routine healing, cognitive communication deficit, encounter for attention to gastrostomy, hemiplegia, anxiety disorder, major depressive disorder, mood disorder, dementia, insomnia, repeated falls, hypertension, glaucoma and parkinson's disease. The resident was discharged to the hospital on 3/27/2023 with a cervical spine fracture at C4 and C6 and readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident number 1 dated 1/16/23 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 12 out of 15 indicating mild cognitive impairment. The resident required extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and total dependence with one person physical assist for bed mobility and impairment on one side for the upper and lower extremities. Review of the Physician' s Order Sheets (POS) and Medication Administration Records (MAR) for Resident number 1 for March 2023 and April 2023 documented the following: Trazodone HCL oral tab (tablet) 50mg (milligrams) 0.5 tab via PEG (percutaneous endoscopic gastrostomy) tube HS (at night) for insomnia, Melatonin oral tab 5mg 1 tab via PEG tube HS for insomnia, Ramelteon oral tab 8mg (milligrams) 1 tab via PEG tube HS for insomnia, Plavix oral tab 75mg 1 tab via PEG tube in the evening for blood clots, Fall Precautions as care planned every shift for prevention of falls, Ensure fall precautions are in place as specified in the care plan (Start date 3/30/23), Floor mats every shift for safety (Start date 4/04/23), Low Bed every shift for safety (Start date 4/04/23) and Half Side Rail (1/2) every shift for safety precautions (Start date 4/04/23). Review of Resident number 1's Fall care plan dated 6/02/16 documented the resident was at risk for falls and fall related injuries related to history of falling, repeated falls, poor safety awareness, impaired mobility, tendency to over-estimate limits and diagnosis of parkinson's disease, dementia, difficulty in walking, unsteadiness on feet and Glaucoma; Goal: Resident will not sustain serious injury related to fall through the review date; Interventions: Bed in the lowest position at all times. Resident number 1 also had the following care plans: ADLs (activities of daily living), Communication, Impaired Cognitive Function/Dementia, Cardiac, Nutrition, Impaired Mobility, Insomnia/Restlessness, Antidepressant, Mood Problem, Parkinson's Disease and Glaucoma. Interview with Staff A, CNA (Certified Nursing Assistant) on 4/12/23 at 11:03 AM. She stated, Everyday she try to get out of the bed. I couldn't get to her in time. I had to pass all the trays by myself on that day and a lot of patients were waiting on me to get them showered and dressed. I was trying to get her ready to put her in the chair. I was brushing her teeth and I went to rinse out the tooth brush. The bed rails was half way up. While I was washing the tooth brush, I saw her foot on the floor and I tried to catch her but my foot got caught under the table and I almost fell myself. Since I couldn't catch her she fell out of the bed. When that happened, I went to call the nurse. She had blood under her head because she hit her head on the table. The nurse came and called everybody to assess her. I was suspended for 5 or 6 days. Interview with Staff B, Registered Nurse (RN), Unit Manager on 4/12/23 at 11:16 AM. She stated, When it happened the cna immediately called out for the nurse and she went in there. The nurse went to the room and the cna came to get me while the nurse was with the resident. The resident was on the floor applying pressure to the head where blood was coming from. They said call [emergency services] I rushed to the nurses station to call PAT [Patient Assessment Team] and [emergency services]. Doctors came into assess the patient, we had two doctors here on that day. We sent her out immediately via [emergency services]. All of our residents were on fall precaution. Floor mats were not used before, this is a new intervention. The low bed was not in effect when the fall, new intervention. We notified RISK and received in-service when she came back. She left on the 3/28 and returned on 4/07. When the resident fell and we found out she had a fracture, she was suspended. The resident had a cervical fracture due to the fall. She could have reported to the nurse, asked for assistance and place her in a supervised area. Safety is always first was emphasized in the in-service. Interview with the Director of Nursing (DON) on 4/12/23 at 12:10 PM. She stated, On 3/27/23, at 10:13 AM, resident had a witness fall in her room, The nursing assistant that was in the room at the time. According to the nursing staff she was providing ADL care and she stepped away to wash out a toothbrush. While in bathroom, she saw the resident trying to get out of bed. The nursing assistant ran to the resident but she tripped on the bedside table, her leg got stuck and she fell herself and that's when the patient fell and did not get to her on time. The resident was transferred out to Mt. [NAME]. She had a cervical spine fracture. She had a fall care plan. She needed to have the bed in the lowest position, according to cna statement it was. Floor mats were added after the fall. Before she had bed in a lowest position but now the bed is 8 inches off the floor, almost touching the floor. The cna was placed on administrative leave during our investigation, interview by risk management. Gave us her statement, she tripped on the bedside table. At the time the resident could not be left unattended. The bed side rails was down and she usually puts it back up when she steps away. If a staff member identify a patient is trying to get up or restless, not to walk away or get some assistance. She had already identified the patient was trying to get up. We determined that it was not intentional neglect that's why we didn't submit to the nurse board. Interview with the Director of Risk Management on 4/12/23 at 1:08 PM. She stated, On 3/27/23, I was informed the pt had a witnessed fall during ADL care. While providing care to the resident, she left the resident to go wash the toothbrush and when she went back the pt was attempting to get up by the time she trying to reaching the resident her foot got stuck by the bedside table and she almost fell. The resident had a fall. The cna called the nurse, the nurse came into the room and observed the resident. The nurse called the PAT (Patient Assessment Team) with two physicians, nurse manager, cna they assessed the patient and gave order to transfer her to the hospital. She had an injury and she was bleeding. We found out later a fracture of the cervical. Automatically the cna was on administrative leave until the investigation was completed. The Immediate Report and 5 day report substantiated neglect. The patient was attempting to get out of bed, she usually will keep the quarter side rail up and she didn't. I didn't report it to the board because she had been here for a while, she was not malicious and very remorseful and she did not put the side rails up. 2) Observation of Resident number 2 on 4/12/23 at 11:36 AM, revealed the resident was sitting in a wheelchair wearing glasses in the 5th floor dining room holding a toy cat. Attempted to interview the resident but she did not participate in the interview. Review of the Demographic Face Sheet for Resident number 2 documented the resident was admitted to the facility on [DATE] with diagnoses to include dementia, laceration of muscle and tendon of head, subsequent encounter, adult failure to thrive, fracture of sacrum, subsequent encounter for fracture with routine healing, hypertension, muscle weakness and unspecified abnormalities of gait and mobility. The resident was discharged to the hospital on 2/02/2023 with a hematoma to the head and a fracture to the sacrum and readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) admission Assessment for Resident number 2 dated 1/14/23 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 07 out of 15 indicating cognitive impairment. The resident required limited to extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and no impairments for the upper and lower extremities. Review of the Physician' s Order Sheets (POS) and Medication Administration Records (MAR) for Resident number 2 for February 2023 documented the following: Half Side Rail (1/2) every shift for to use during care and mobility (Start 3/05/23) and Fall precautions as care planned every shift for prevention (Start 2/09/23). Review of Resident number 2's Fall care plan dated 1/11/23 documented the resident had history of falls and remains at risk for further incidents related to gait/balance problems, needs assistance with daily activities, needs assistance with ADLs, diagnosis of dementia; Goal: Resident's risk for serious injury will be reduced through the review date; Interventions: Bed in low position (initiated 4/12/23) and call light within reach (initiated 3/14/23); Make frequent rounds when resident is in her room (initiated 3/14/23). Resident number 2 also had the following care plans: ADLs (activities of daily living), Dementia and Impaired Cognitive Function. Interview with the Director of Nursing (DON) on 4/12/23 at 12:22 PM. She stated, On 2/02/23, around 4 in the morning, the patient found on the floor in the bathroom doorway. Left side hematoma noted and bleeding. At the time did not complain of pain but was transferred out to hospital for further evaluation. She returned with a sacral fracture. She was care planned for falls. She did not require a lot of assistance. She was here for rehab to get better and go back home. Interview with Staff C, Licensed Practical Nurse (LPN) and the DON on 4/12/23 at 12:37 PM via telephone. She revealed that she was not involved in the incident. She let one of the nurses' use her sign-in ID to document the incident. Interview with the Director of Risk Management on 4/12/23 at 1:19 PM. She stated, On 2/02/23, she fell and had a hematoma. The doctor decided to send her out because she hit her head. No one was in the room with her when she fell. She had a fracture to the sacrum.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide adequate supervision to ensure the safety of vulnerable residents and to prevent falls that resulted in major injuries for two (Resident #1, Resident #2) out of three residents reviewed for falls. Resident #1 sustained a cervical spine fracture at C4 and C6 (cervical) and Resident number 2 sustained a hematoma to the head and a fracture to the sacrum. This practice has the potential to affect all 274 residents present in the facility at the time of the survey. The findings included: 1) Record review of the facility's Fall Prevention Policy and Procedure (effective December 1990, revised April 2021) documented the following: Procedures-1) When a resident is admitted to the facility: a) The nurse will complete a Fall Risk Screening Tool as part of the resident's admission evaluation; b) The Fall Risk Screening tool will determine if the resident is at a High, Moderate or Low Risk for Falls; c) Interventions and medication management will be planned implemented and documented according to each resident's risk level and individual needs; e) The residents fall risk status will be communicated to all staff members caring for the resident through the resident's care plan. Observation of Resident number 1 on 4/12/23 at 10:59 AM, revealed the resident was sitting up in a low bed with floor mats, tv on and the tube feeding machine was off. Attempted to interview the resident but she did not participate in the interview. Review of the Demographic Face Sheet for Resident number 1 documented the resident was admitted to the facility on [DATE] with diagnoses to include unspecified displaced fracture of fourth cervical vertebra, subsequent encounter for fracture with routine healing, unspecified displaced fracture of sixth cervical vertebra, subsequent encounter for fracture with routine healing, cognitive communication deficit, encounter for attention to gastrostomy, hemiplegia, anxiety disorder, major depressive disorder, mood disorder, dementia, insomnia, repeated falls, hypertension, glaucoma and parkinson's disease. The resident was discharged to the hospital on 3/27/2023 with a cervical spine fracture at C4 and C6 and readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident number 1 dated 1/16/23 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 12 out of 15 indicating mild cognitive impairment. The resident required extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and total dependence with one person physical assist for bed mobility and impairment on one side for the upper and lower extremities. Review of the Physician' s Order Sheets (POS) and Medication Administration Records (MAR) for Resident number 1 for March 2023 and April 2023 documented the following: Trazodone HCL oral tab (tablet) 50mg (milligrams) 0.5 tab via PEG (percutaneous endoscopic gastrostomy) tube HS (at night) for insomnia, Melatonin oral tab 5mg 1 tab via PEG tube HS for insomnia, Ramelteon oral tab 8mg 1 tab via PEG tube HS for insomnia, Plavix oral tab 75mg 1 tab via PEG tube in the evening for blood clots, Fall Precautions as care planned every shift for prevention of falls, Ensure fall precautions are in place as specified in the care plan (Start date 3/30/23), Floor mats every shift for safety (Start date 4/04/23), Low Bed every shift for safety (Start date 4/04/23) and Half Side Rail (1/2) every shift for safety precautions (Start date 4/04/23). Review of Resident number 1's Fall care plan dated 6/02/16 documented the resident was at risk for falls and fall related injuries related to history of falling, repeated falls, poor safety awareness, impaired mobility, tendency to over-estimate limits and diagnosis of parkinson's disease, dementia, difficulty in walking, unsteadiness on feet and Glaucoma; Goal: Resident will not sustain serious injury related to fall through the review date; Interventions: Bed in the lowest position at all times. Resident number 1 also had the following care plans: ADLs (activities of daily living), Communication, Impaired Cognitive Function/Dementia, Cardiac, Nutrition, Impaired Mobility, Insomnia/Restlessness, Antidepressant, Mood Problem, Parkinson's Disease and Glaucoma. Review of the incidents/falls log dated February 2023-April 2023, documented that Resident number 1 had a fall on 3/27/23. Review of the fall note progress notes for Resident number 1 documented the following: Dated 3/27/23 11:01-Fall Note: 10:13 AM Witnessed fall in patient room by CNA. 10:15 AM PAT [Patient Assessment Team] TEAM and 911 called. Upon arrival patient found on floor. Noted head injury with bleeding. Immediate first aide applied cervical stabilization and pressure to head injury. Vital signs taken. Head to toe palpation done no sign of pain response upon exam. 10:20 AM PAT Team arrived. Released care to PAT team. Patients primary physician is part of the PAT team. No notification needed via telephone. 10:24 AM Patient moved to sitting chair from floor after PAT Team evaluation. 10:25 AM Pressure bandage wrap applied to the patients head. Blood sugar level 111 obtained. Vital signs taken. 10:26 AM 911 arrived. Report given to emergency team by lead PAT team member. 10:27 AM Patient ambulated to stretcher. 10:28 AM Patient transported to ER [Mount S ]. 10:35 AM Patient relative called and notified of patients fall and transport to ER. Review of the five day federal report for Resident number 1 documented the following: While the CNA was providing care to the resident, the resident remained in bed; then the CNA went to go wash the resident's toothbrush in the bathroom. Upon returning to the bedside, the CNA observed the resident was attempting to get out of bed and she fell. The staff was put on administrative leave. Interview with Staff A, CNA (Certified Nursing Assistant) on 4/12/23 at 11:03 AM. She stated, Everyday she try to get out of the bed. I couldn't get to her in time. I had to pass all the trays by myself on that day and a lot of patients were waiting on me to get them showered and dressed. I was trying to get her ready to put her in the chair. I was brushing her teeth and I went to rinse out the tooth brush. The bed rails was half way up. While I was washing the tooth brush, I saw her foot on the floor and I tried to catch her but my foot got caught under the table and I almost fell myself. Since I couldn't catch her she fell out of the bed. When that happened, I went to call the nurse. She had blood under her head because she hit her head on the table. The nurse came and called everybody to assess her. I was suspended for 5 or 6 days. Interview with Staff B, Registered Nurse (RN), Unit Manager on 4/12/23 at 11:16 AM. She stated, When it happened the cna immediately called out for the nurse and she went in there. The nurse went to the room and the cna came to get me while the nurse was with the resident. The resident was on the floor applying pressure to the head where blood was coming from. They said call [emergency services] I rushed to the nurses station to call [P.A.T.] and [emergency services]. Doctors came into assess the patient, we had two doctors here on that day. We sent her out immediately via [emergency services]. All of our residents were on fall precaution. Floor mats were not used before, this is a new intervention. The low bed was not in effect when the fall, new intervention. We notified RISK and received in-service when she came back. She left on the 3/28 and returned on 4/07. When the resident fell and we found out she had a fracture, she was suspended. The resident had a cervical fracture due to the fall. She could have reported to the nurse, asked for assistance and place her in a supervised area. Safety is always first was emphasized in the in-service. Interview with the Director of Nursing (DON) on 4/12/23 at 12:10 PM. She stated, On 3/27/23, at 10:13 AM, resident had a witness fall in her room, The nursing assistant that was in the room at the time. According to the nursing staff she was providing ADL care and she stepped away to wash out a toothbrush. While in bathroom, she saw the resident trying to get out of bed. The nursing assistant ran to the resident but she tripped on the bedside table, her leg got stuck and she fell herself and that's when the patient fell and did not get to her on time. The resident was transferred out to Mt. [NAME]. She had a cervical spine fracture. She had a fall care plan. She needed to have the bed in the lowest position, according to cna statement it was. Floor mats were added after the fall. Before she had bed in a lowest position but now the bed is 8 inches off the floor, almost touching the floor. The cna was placed on administrative leave during our investigation, interview by risk management. Gave us her statement, she tripped on the bedside table. At the time the resident could not be left unattended. The bed side rails was down and she usually puts it back up when she steps away. If a staff member identify a patient is trying to get up or restless, not to walk away or get some assistance. She had already identified the patient was trying to get up. We determined that it was not intentional neglect that's why we didn't submit to the nurse board. Interview with the Director of Risk Management on 4/12/23 at 1:08 PM. She stated, On 3/27/23, I was informed the pt had a witnessed fall during ADL care. While providing care to the resident, she left the resident to go wash the toothbrush and when she went back the pt was attempting to get up by the time she trying to reaching the resident her foot got stuck by the bedside table and she almost fell. The resident had a fall. The cna called the nurse, the nurse came into the room and observed the resident. The nurse called the PAT (Patient Assessment Team) with two physicians, nurse manager, cna they assessed the patient and gave order to transfer her to the hospital. She had an injury and she was bleeding. We found out later a fracture of the cervical. Automatically the cna was on administrative leave until the investigation was completed. The Immediate Report and 5 day report substantiated neglect. The patient was attempting to get out of bed, she usually will keep the quarter side rail up and she didn't. I didn't report it to the board because she had been here for a while, she was not malicious and very remorseful and she did not put the side rails up. 2) Observation of Resident number 2 on 4/12/23 at 11:36 AM, revealed the resident was sitting in a wheelchair wearing glasses in the 5th floor dining room holding a toy cat. Attempted to interview the resident but she did not participate in the interview. Review of the Demographic Face Sheet for Resident number 2 documented the resident was admitted to the facility on [DATE] with diagnoses to include dementia, laceration of muscle and tendon of head, subsequent encounter, adult failure to thrive, fracture of sacrum, subsequent encounter for fracture with routine healing, hypertension, muscle weakness and unspecified abnormalities of gait and mobility. The resident was discharged to the hospital on 2/02/2023 with a hematoma to the head and a fracture to the sacrum and readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) admission Assessment for Resident number 2 dated 1/14/23 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 07 out of 15 indicating cognitive impairment. The resident required limited to extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and no impairments for the upper and lower extremities. Review of the Physician' s Order Sheets (POS) and Medication Administration Records (MAR) for Resident number 2 for February 2023 documented the following: Half Side Rail (1/2) every shift for to use during care and mobility (Start 3/05/23) and Fall precautions as care planned every shift for prevention (Start 2/09/23). Review of Resident number 2's Fall care plan dated 1/11/23 documented the resident had history of falls and remains at risk for further incidents related to gait/balance problems, needs assistance with daily activities, needs assistance with ADLs, diagnosis of dementia; Goal: Resident's risk for serious injury will be reduced through the review date; Interventions: Bed in low position (initiated 4/12/23) and call light within reach (initiated 3/14/23); Make frequent rounds when resident is in her room (initiated 3/14/23). Resident number 2 also had the following care plans: ADLs (activities of daily living), Dementia and Impaired Cognitive Function. Review of the incidents/falls log dated February 2023-April 2023, documented that Resident number 2 had a fall on 3/27/23. Review of the incidents/falls list dated February 2023-March 2023, documented that Resident number 2 had a fall on 2/02/23. Review of the abuse log dated February 2023-April 2023, documented that Resident number 2 was on the abuse log for neglect and the allegation was unsubstantiated. Review of the nursing note progress notes for Resident number 2 documented the following: Dated 2/02/23 04:30- 03:50 While on unit resident was heard moaning, assigned nurse went to check on her, she was found lying on her back in the doorway of the bathroom in a small pool of blood under her head. Resident was carefully put back to bed v/s and assessment completed, hematoma noted to the left parietal area, not bleeding presently, [emergency service] called, transfer order obtained from MD. [Emergency service] arrived at 04:05, left for MSMC at 04:08. Resident remained awake and alert throughout. She stated she was going to the bathroom without assistance. Message was left for residents son, residents son to call the unit. Review of the fall note progress notes for Resident number 2 documented the following: Dated 2/02/23 04:40-Fall Note: Patient found on the floor of bathroom doorway. On assessment blood was noted to be coming from head. The patient noted to have left sided hematoma. All extremities within range of motion. The resident was assisted back to bed. The patient denied pain. The nursing supervisor was on the unit at this time. The patient was transferred to [Mt. S Hospital] via emergency services; as per primary physician and made aware of patient condition. Emergency services were called and arrived to the unit. The patient's son was called, a voicemail was left for return call back. Review of the five day federal report for Resident number 2 documented the following: Around 11:30 AM, the Nurse Supervisor reported to Risk Management that resident sustained a fracture from a fall. Once the resident returned to the facility, the resident's fall care plan was reviewed and updated with new interventions and they will be followed. The resident will be closely monitored while her safety and comfort measures will be maintained. Interview with the Director of Nursing (DON) on 4/12/23 at 12:22 PM. She stated, On 2/02/23, around 4 in the morning, the patient found on the floor in the bathroom doorway. Left side hematoma noted and bleeding. At the time did not complain of pain but was transferred out to hospital for further evaluation. She returned with a sacral fracture. She was care planned for falls. She did not require a lot of assistance. She was here for rehab to get better and go back home. Interview with Staff C, Licensed Practical Nurse (LPN) and the DON on 4/12/23 at 12:37 PM via telephone. She revealed that she was not involved in the incident. She let one of the nurses' use her sign-in ID [identification] to document the incident. Interview with the Director of Risk Management on 4/12/23 at 1:19 PM. She stated, On 2/02/23, she fell and had a hematoma. The doctor decided to send her out because she hit her head. No one was in the room with her when she fell. She had a fracture to the sacrum.