**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to review, revise, and ensure interventions were implemented for a person-centered care plan for falls to address supervision for 1 of 3 residents reviewed for accidents of a total sample of 39 residents, (#1). Findings: Resident #1, a [AGE] year-old female, was admitted to the facility initially on 1/04/21, with her most recent readmission on [DATE]. Her diagnoses included, Multiple sclerosis, contracture of the left and right knees, history of falls, major depressive disorder, and cognitive communication deficit. On 4/12/23 the diagnosis of stable burst fracture of the first cervical vertebra was added. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 3/30/23, revealed the resident's cognition was moderately impaired, with a Brief Interview for Mental Status (BIMS) score of 09/15. Resident #1 required extensive assistance of two persons for bed mobility, dressing, toilet use and personal hygiene, and was totally dependent on staff for transfers. Her balance during transitions and walking, for surface-to-surface transfer was not steady and the resident was only able to stabilize with staff assistance. She had impairment in functional limitation in range of motion to both sides of her lower extremities. On 4/17/23 at 11:20 AM, resident #1's daughter stated her mother was a fall risk. She recalled her mother had 12 to 15 falls since she was admitted to the facility and added the facility knows she is at risk for falls. The daughter explained on 4/10/23, her mother fell from her wheelchair in the day room and broke her neck. She said her mother had reached for a cup that had dropped to the ground and when she reached to pick it up, she fell out of her wheelchair. She noted her mother was transferred to the hospital after the fall and was then sent to a higher level care of care for trauma. She conveyed surgery was not done but her mother had to wear a neck brace/collar for nine weeks. She stated she did not know what to do to keep her mother safe. On 4/19/23 at 4:39 PM, the resident's care plans at risk for falls related initiated 1/05/21, revised 12/17/21, and Actual fall initiated 1/28/23, revised 4/11/23, were reviewed with the Director of Nursing (DON). The care plans revealed the resident had falls on 2/12/21, 3/05/21, 5/21/21, 5/29/21, 7/13/21, 8/30/21, 9/2/21, 10/03/21, 9/12/22, 1/28/23, and 2/01/23. On 4/10/23 the resident fell from her wheelchair, sustained a neck fracture, and was transferred for a higher level of care. Care plan interventions included, ensure items in reach, raised edge mattress, medication review, bed in lowest position, call bell in reach, and therapy screens. There was no indication that supervision was addressed on the care plans. Care plan interventions did not address supervision, and when asked about supervision to mitigate the risk for falls, the DON said they could not provide one to one supervision all the time. However, there was no intervention for one-on-one supervision, or any additional monitoring to ensure resident #1's safety. On 4/19/23 at 11:38 AM, the Harborside Registered Nurse/Unit Manager (RN/ UM) stated care plans were updated with input from the leadership team. She explained that when a resident fell, the team discussed the fall and interventions were put in place. The resident's care plans for falls were reviewed with the RN/UM. She said she could not say what the level of supervision was implemented for the resident prior to her fall on 4/10/23. On 4/19/23 at 11:45 AM, the RN MDS Coordinator, stated that to develop a care plan, a review of the resident's clinical records would be conducted, which would include diagnoses, medications, documentation by nurses, and Certified Nursing Assistants, along with input from the resident, family/responsible party. He stated care plans were discussed during the risk meeting and morning meeting, and interventions would be a collaborative decision by the Interdisciplinary Team. The MDS Coordinator confirmed the resident had multiple falls since her admission to the facility, and that her cognition was moderately impaired. The resident's care plans for risk for fall, and actual falls were reviewed with the MDS Coordinator. He stated the care plans did not address level of supervision needed or frequent rounding for resident #1. The Facility's policy and procedure Person Centered Care Planning dated 8/16/22 read, The facility will develop a person-centered care plan that addresses the goals .needs . of the resident The care plan will reflect interventions that are person-centered, measurable, and include time frames to achieve the desired outcomes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide adequate supervision and monitoring for a vulnerable, physically, and cognitively impaired resident to prevent fall with major injury for 1 of 3 residents reviewed for accidents, of a total sample of 39 residents, (#1). This failure contributed to an unwitnessed fall resulting in a fracture of the cervical vertebra. Findings: Resident #1, a [AGE] year-old female, was admitted to the facility initially on 1/04/21, with her most recent readmission on [DATE]. Her diagnoses included, multiple sclerosis, contracture of the left and right knees, history of falls, major depressive disorder, and cognitive communication deficit. On 4/12/23 the diagnosis of stable burst fracture of the first cervical vertebra was added. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 3/30/23, revealed the resident's cognition was moderately impaired, with a Brief Interview for Mental Status (BIMS) score of 09/15. The assessment noted resident #1 required extensive assistance of two staff persons for bed mobility, dressing, toilet use and personal hygiene, and was totally dependent on staff for transfers. Her balance during transitions and walking, for surface-to-surface transfer was not steady and the resident was only able to stabilize with staff assistance. She had impairment in functional limitation in range of motion to both sides of her lower extremities. A nursing progress note documented by Licensed Practical Nurse (LPN) G dated 4/10/23 read, At approximately 7:20 PM this nurse heard the other nurse yelling help. Someone is on the floor Resident (#1) was lying on the floor in front of w/c (wheelchair) face-down and actively bleeding from forehead .Pressure applied to area and 911 called .Transported to (name of hospital) via ambulance. Review of the resident's Fall Risk Evaluation dated 2/14/2023 revealed a score of 18 and fall risk score on 4/13/23 was 24. The form did not have a key/legend to explain the score, category was 10 or above The hospital's history and physical dated 4/10/23 revealed her chief complaint was neck pain. The document read, per report, patient was reaching to grab something when she fell forward out of her wheelchair . Had complaints of severe neck pain .CT (Computerized Tomography) scan of her cervical spine demonstrated a C1(cervical) burst fracture. Trauma transfer was requested for higher level care .Forehead laceration and multiple areas of skin tears .CT head Impression: Frontal scalp laceration. CT c-spine: acute burst-type fracture. [NAME] fracture involving C1 vertebral body. The hospital Progress Note -Trauma dated 4/11/23 listed the resident's problems as active forehead laceration, Jefferson's fracture (C1 burst fracture with subluxation of the right lateral mass), right shoulder pain, friction burns/skin tears, and acute pain secondary to trauma. A Jefferson's fracture is another name for a bone fracture of the front and back arches of the C1 vertebra. (Retrieved on 4/28/23 from healthline.com) A C1 through C2 vertebrae injury is considered to be the most severe of all spinal cord injuries as it can lead to full paralysis. (Retrieved on 4/28/23 from www.spinalcord.com). The Neurosurgery consult dated 4/11/23 read, This accident has caused Jefferson's fracture and further maligned the upper cervical canal; there is more canal stenosis at C1\2 than prior. Because of her medical issues I prefer to treat her cervical fracture with a collar. She needs to wear it for 90 days at all times except to eat and shower. If she tends to fall out of a wheelchair then she should be bed bound for safety. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 4/12/23 revealed resident #1's diagnosis included, Trauma .fall from wheelchair. Resident #1's Admission/readmission Collection Tool dated 4/12/23 revealed the resident had cognitive impairment, was confused, oriented to place, and had poor trunk control. Documentation read, Resident has a fracture of the C1 has orders to keep her neck brace on at all times. On 4/17/23 at 11:20 AM, resident #1 was lying in bed on her back. She had a neck collar/brace on with dried blood to her right forehead, and in her hair. A dressing was noted to her left upper arm, dated 4/17/23. The resident's daughter was at the resident's bedside and verbalized the resident was a fall risk. The daughter said that on 4/10/23 her mother was in the dayroom by herself and her cup fell on the floor. She explained her mother reached for her cup and fell from her wheelchair. She said her mother was transferred to the hospital and a broken neck was identified. She said she was then transferred to a trauma hospital for higher level of care. The daughter indicated surgery was not done, and her mother had to wear neck brace/collar for nine weeks. She noted her mother had twelve to fifteen falls in the facility since her admission. She said the facility knows she was a fall risk, but she was alone in the dayroom. She stated she did not know what to do to keep her mother safe. On 4/18/23 at 9:54 AM resident #1 recalled she was by herself when she fell in the dayroom. She remembered it felt like she was on the floor forever before she was assisted but could not recall the details of the incident. On 4/18/23 at 3:10 PM, Certified Nursing Assistant (CNA) F confirmed she was assigned to resident #1 on the 3 PM to 11 PM shift on 4/10/23, the day of the incident. CNA F said the resident required total care and a mechanical lift for transfers. She recalled on 4/10/23, she transported resident #1 by wheelchair from the main dining room to the day room on the Harborside Unit. She said the resident always sat at a table in the day room and read. She remembered the resident wanted some water, and she provided it for her, and left the day room. She explained that she was in the shower room when a coworker called and told her that resident #1 was on the floor. CNA F said that when she went to the dayroom, the resident was on the floor face down, and blood was coming from her forehead. She noted the resident told her she tried to pick her cup off the floor and fell. The CNA indicated the nurse was in the day room when she arrived and 911 was called and transported the resident to the hospital. CNA F said the resident was placed in the dayroom, because she had a tendency of trying to get out of her wheelchair. She recalled three other residents were in the day room at the time she transferred the resident there. The CNA said no staff was in the dayroom when the resident fell, and said the last time she saw the resident was at 6:20 PM. She was aware the resident sustained a fractured neck, and said she now required three persons to provide care. She explained staff should check on residents every fifteen minutes if residents were assessed as being at risk for falls but she could not confirm if resident #1 was checked every fifteen minutes. On 4/18/23 at 3:23 PM, the Harborside Registered Nurse/Unit Manager (RN/UM) stated she was not at the facility when resident #1 fell and sustained a neck fracture. She said she was made aware of the incident when she came to work the following day and an investigation was initiated by the Assistant Director of Nursing (ADON) and herself. She explained they called the staff who worked on the 3 PM to 11 PM shift on 4/10/23 and obtained statements. She indicated the resident sat in her wheelchair after dinner in the Harborside day room when she dropped her cup, bent down to pick it up, and fell. She reported the resident sustained C-spine fracture. She identified their investigation showed two other residents were in the day room, but no staff were present. The RN/UM explained resident resident #1 was at risk for falls. She said that if residents were in the dayroom, they should always be supervised by a staff member. She conveyed staff on the 3 PM to 11 PM staff were scheduled to rotate in the dayroom at 30-minute increments to supervise residents. She could not provide a staff rotation schedule for 4/10/23 when the resident fell. On 4/19/23 at 9:05 AM, the Director of Nursing (DON) stated resident #1 had diagnosis of multiple sclerosis, had history of falls, and required maximum assistance from staff for her activities of daily living. She explained LPN G reported she gave pain medication to resident #1 at 7:00 PM on 4/10/23. At 7:20 PM, LPN G heard someone calling for help, as someone was on the floor. She indicated LPN H's statement revealed that around 7:30 PM she the resident said, oh Lord and observed resident #1 on the floor face down with blood coming from her face. The DON verbalized that all CNAs on the 3 PM to 11 PM shift on 4/10/23 were interviewed. She noted interviews revealed the resident had dinner and left the main dining room at 5:45 PM, by self- propelling herself to the Harborside day room where two other residents were. This contradicted CNA F's statement that she brought the resident in her wheelchair to the main dining room to the day room. The DON said CNAs were rotated in the day room in thirty minute increments. She explained on 4/10/23, CNA F, the resident's assigned CNA was giving a shower to another resident, one CNA was on break, and she was not sure of where the other two CNAs were at the time the resident fell. She indicated the two nurses, LPN G and LPN H were in the hallway giving medications. On 4/19/23 at 9:25 AM, the ADON recalled that on 4/11/23, she reviewed the fall incident and spoke to LPN H who saw the resident on the floor. LPN H told her she was at the nurses' station, and saw the resident in the day room, however, she did not see the fall. She noted LPN H only heard when the resident said, oh my God. The ADON said LPN H informed that when she went to the resident, she saw a cup on the floor. When she asked the resident what happened, the resident said she dropped her cup and was reaching for it. The ADON said the fall happened at the entrance of the Harborside day room. She recalled that Staff Development reached out to LPN G, the resident's primary nurse, who came back in and documented a statement. She verbalized the DON then took over the investigation. On 4/19/23 at 9:30 AM, the DON stated she was not at the facility when the incident occurred, and when she returned, she asked the UM to reach out to all the staff. She recalled the fall was discussed by the Interdisciplinary Team (IDT) on 4/11/23. She said the team did not think the fall was an adverse incident since the resident was able to make her needs known, could self-propel in her wheelchair, was in a reclining high back wheelchair, was positioned appropriately, and did not lack capacity. She said an incident report was not submitted to the Agency for Health Care Administration as this was not an injury of unknown origin, the facility knew what happened. She acknowledged the resident sustained a major injury as a result of the fall and was transferred to a higher level of care. On 4/19/23 at 4:39 PM, the resident's falls and care plan for falls were reviewed with the DON. The resident had falls on 2/12/21 at 4:30 PM, 3/05/21 at 6:56 PM, 5/21/21 at 11 AM, 5/29/21 at 3:30 PM, 7/13/21 at 8:40 PM, 8/30/21 at 11:40 AM, 9/2/21 at 1:41 PM when the resident fell from her wheelchair in the bathroom, on 10/03/21 the resident slid from her wheelchair, on 9/12/22 at 4:21 AM. On 1/28/23 at 1:08 PM, the resident was observed on the floor on her knees, complained of pain in both knees, and was sent to the hospital. On 2/01/23 at 5:15 AM, the resident was found lying on the floor mat with her head at the foot of her bed, and her feet towards the head of the bed. The resident said she was looking for her sister and slid off the bed. She stated she hit her right hip and knees, was medicated with Tylenol, and x rays of the hip, pelvic, femur, and knees were ordered by the ARNP. On 4/10/23 the resident fell from her wheelchair, sustained a neck fracture, and was transferred for a higher level of care. Care plan interventions included to ensure items within reach, a raised edge mattress, medication review, bed in lowest position, antibiotic therapy for urinary tract infection, call bell in reach, therapy to screen, and naps after lunch as tolerated. There was no indication on the care plans to address supervision of the resident despite being at risk for falls and twelve actual falls including the fall on 4/10/23 with major injury. When asked to speak about the level of supervision the resident required, the DON said they could not have one-on- one supervision all the time. There was however no intervention on the care plan for one to one supervision or any type of supervision to monitor the resident to mitigate risk for falls. On 4/19/23 at 10:48 AM, the Director of Rehab stated resident #1 had limited range of motion to her knees, and therapy worked with her heavily on wheelchair positioning. Resident #1's Occupational Therapy (OT) Evaluation & Plan of Treatment revealed the resident's start of care was on 4/13/23. The reason for the referral was Pt (patient) had a fall out of the w/c (wheelchair) resulting in a C1 Burst-Jefferson's fracture, now in a Miami J C collar on at all times except for eating and bathing. The document revealed that equipment prior to the resident's start of care included a standard wheelchair, and documentation indicated the resident had impaired safety awareness. The Physical Therapy (PT) Evaluation & Plan of Treatment with start of care on 4/13/23, indicated the resident was referred to PT following a fall out of her wheelchair with cervical fracture. The document read, This fall caused a [NAME] fracture and further malalignment of upper cervical canal. The evaluation indicates that equipment prior to onset/hospitalization included bilateral floor mats, hospital bed, and a standard wheelchair with pressure relieving cushion. On 4/19/23 11:09 AM, CNA E stated that resident #1 was able to make her needs know, but sometimes the evening shift reported periods of confusion. CNA E stated that if residents were at risk for fall, CNAs were told to place the residents in the day room, so nurses, and CNAs could monitor the residents. She said that up until resident #1's incident, no staff provided supervision in the day room. CNA E verbalized that during the day shift, activity staff were usually in the day room doing various activities, but not during the 3 PM to 11 PM shift. On 4/19/23 at 12:49 PM, the ARNP stated she assumed care for resident #1 on 3/01/23. She said the resident was assessed by psychiatry and was deemed to be lacking ability to make her own decision, prior to her fall on 4/10/23. The ARNP said the resident had an overall decline since March 2023, On 4/19/23 at 1:25 PM, in a telephone interview, LPN H recalled that on 4/10/23, resident#1 was trying to come out of the Harborside day room by self-propelling her wheelchair. LPN H said she was at the nurses' station cleaning her medication cart when she heard the resident say, oh my God. The LPN said she turned, and the resident was on the floor face down, gushing blood from her forehead. The resident told her she was trying to get her cup and complained of pain to her head. She noted the resident's assigned nurse, LPN G was in the long hallway giving medications and no staff member was in the day room. She said resident #1 was the only person in the dayroom at that time. On 4/19/23 at 1:42 PM, in a telephone interview, LPN G stated she worked on the 3 PM to 11 PM shift on 4/10/23 and confirmed that resident#1 was included in her assignment. LPN G verbalized that she knew the resident for quite some time and had seen the resident decline. She indicated sometimes the resident was confused and delusional. She recalled the last time she saw the resident on 4/10/23 was at 6:45 PM when she administered the resident's pain medication, Hydrocodone. She remembered the resident was in her wheelchair, watching television. The LPN recalled she left the resident in the dayroom close to the television, along with other residents who were watching television. LPN G stated she moved her medication cart down to the long hallway and was there when she heard LPN H yelling. When she went to the dayroom, the resident was on the floor face down at the doorway that opened to the nurses' station with her wheelchair behind her. She recalled the resident complained her head was hurting, and she was bleeding a lot from her forehead. She reported pressure was applied to the bleeding site and 911 was called. LPN G explained that staff were not necessarily rotated. to supervise residents in the day room for safety. She acknowledged there was no scheduled rotation for staff to supervise residents in the day room. The resident's care plan was reviewed with LPN G. She stated she had not reviewed the resident's care plan recently and reported that staff just knew to make visual observations of residents at risk for falls. She did not explain the level of supervision required for resident #1 with 12 previous falls. On 4/19/23 at 3:42 PM, the Director of Rehab stated the resident did not propel her wheelchair with her feet, but with her hands. She verbalized that Therapy had set her up in a raised wheelchair, and explained this meant the wheelchair had the ability to go higher or lower based on the resident's height. The Director of Rehab said Maintenance and PT had the resident's chair raised one inch higher, so that straight leg rest could be placed, and the resident's feet would fit on the leg rest without dragging. Review of the resident's clinical records revealed the wheelchair was never adjusted. The Director stated the straight leg rest were placed to prevent dragging of the resident's feet, and at the time of the fall the resident was in a standard wheelchair, not in a high back wheelchair. On 4/20/23 at 12:59 PM, in an interview with the Administrator and DON, the Administrator said the facility did not lack supervising the resident, since LPN H was within 16.3 feet of the resident. The DON stated she reviewed the regulatory guideline regarding adequate supervision, and feels that the facility was in compliance. When asked how much supervision resident #1 required to keep her safe, the Administrator said the resident needed no more supervision than anybody else. The DON said supervision would depend on the time of the day. When asked if the facility interviewed the resident regarding the incident, the DON stated the facility did not obtain a statement /interview from the resident. The resident's Fall Risk Evaluation dated 2/14/23, and 4/13/23 were reviewed with the DON, and an explanation of the score could not be provided. At 4:22 PM, the DON stated the Fall Risk Evaluation in the resident's electronic clinical records did not have a legend/key. She said that in discussion with the Regional nurses she was informed that on the Evaluation form if the score was 10 and above, fall prevention intervention measures should be implemented. Review of the facility's policy and procedure Fall Management revised on 4/07/22, and reviewed on 9/29/22, revealed residents would be assessed for any fall risks, and appropriate interventions to minimize the risk of injury related to the falls would be identified. The document read, Implement interventions, including adequate supervision .consistent with a resident's needs .care plan and current professional standards of practice in order to eliminate the risk if possible, and if not, reduce the risk of an accident .Adequate supervision is determined by assessing the appropriate level and number of staff required .and the frequency of supervision needed. Review of the Facility Assessment Template reviewed on 10/11/22 revealed the care and services offered to residents by the facility included Mobility and fall/fall with injury prevention