**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a resident with adequate staff supervision during a shower for a resident who requires substantial maximal assistance with bathing/showering. This failure applies to one of three residents (R2) reviewed for accidents/supervision and resulted in R1 sustaining a femur fracture. Findings include: R2 has a diagnoses history of Paraplegia, Multiple Sclerosis, Morbid Obesity, and Cognitive Communication Deficit who was admitted to the facility 04/06/2024. The facility's Incident Investigation Report dated 04/09/2025 documents on 04/01/2025 R2 was taken for her regularly scheduled shower, she was set up with her items per usual with the shower chair locked, she reported she dropped the towel and when she reached down to grab the towel, she slid from the shower chair; Upon interview with the CNA (Certified Nursing Assistant) stated she set the resident up per her request, lathered the soap and towel and allowed her privacy per the resident's request; R2 was admitted to the hospital for closed fracture of the distal left femur; R2 is at high risk for falls due to weakness and impaired mobility, she is paraplegic, has limited range of motion to her left upper and lower extremities to where she will require staff assistance; based on staff interviews, R2 clearly prefers and or requests privacy during showers so staff should always respect that preference by allowing sufficient space and avoiding unnecessary exposure; This includes maintaining a respectful distance while offering assistance that maintains that privacy; Plan of care in place and updated. Witness statement from R2 dated 04/03/2025 documents the Director of Nursing called R2 on the phone to interview her regarding her fall in the shower room and R2 reported on 04/01/2025 her CNA (Certified Nursing Assistant) V4 set her up in the shower, when she reached for a towel that fell, she slid from the shower chair. Undated Witness statement from V4 (CNA) documents she placed R2 in the chair and transported her to the shower room and R2 informed her that she would use the call light when she was ready to come out so she will set everything up for her, R2 requested her privacy and she is alert and oriented to person, place, time, and situation; the chair was locked to secure her, R2 informed her she tried to reach and grab her towel and fell over in the chair. Undated Witness statements from V8 (Registered Nurse) and V9 (Licensed Practical Nurse) stated they heard R2 yelling for help in the shower room and responded to assist, and she reported she dropped her towel and fell from the chair. R2's Fall Risk Evaluation dated 04/06/2024 documents she had 1-2 falls in the past three months, and had predisposing risk factors including 1-2 predisposing diseases present, balance problem while standing, requires use of assistive devices, and takes 1-2 high risk medications. R2's Quarterly Minimum Data Set assessment dated [DATE] documents she requires substantial maximal assistance with most activities of daily living including bathing/showering self, and tub/shower and toilet transfers. R2's Current Care Plan initiated 04/08/2024 documents she has an ADL (Activity of Daily Living) self-care performance deficit related to Hemiplegia, Impaired balance, Limited Mobility, and Limited ROM. R2 has weakness and impaired mobility she has a diagnosis of Multiple Sclerosis. R2 is a paraplegic and has limited range of motion to her Left upper and Lower extremities. She requires staff assist. She has spasticity and rigidness to extremities that inhibit movement; she is non ambulatory and transfers via sit to stand with assist with interventions including: she requires extensive assist of (1-2) staff to provide bath/shower twice a week and as necessary; and R2 requires Mechanical Lift (sit to stand) with (2) staff assistance for transfers. R2's Current Care Plan initiated 04/08/2024 documents she is at risk for incontinence related to Impaired Mobility, Physical limitations due to weakness and impaired mobility, having diagnoses of Multiple Sclerosis, Paraplegia and requires staff assist; she is non ambulatory and transfers via sit to stand with assist with interventions including check every two hours, upon request, and as needed for incontinence. R2's Current Care Plan initiated 04/06/2024 documents she is at risk for falls due to weakness and impaired mobility, and diagnoses of Multiple Sclerosis and Paraplegia and has limited range of motion to her left upper and lower extremities, and requires staff assist; R2's Current Shower/Bathing Care Plan initiated 11/06/2024 documents she enjoys her shower on scheduled days and would prefer privacy at times. R2's Incident progress note dated 4/1/2025 at 5:00 PM documents she was heard screaming for help in the shower room. Staff observed she was on her knees, leaning forward with left shoulder against the wall then sat back placing her buttocks on the floor and legs bent backwards on each side. Shower room call light is not on. R2 verbalized that she is taking her shower and was trying to get a towel, but the chair flipped over, and she ended on the floor. Her left leg is in severe pain, and she complained of severe pain on left leg. Physician notified and ordered to call 911 due to possible fracture or dislocation; at 11:21 PM Post Fall Evaluation documents the fall was not witnessed. Fall occurred in the bathroom. Resident was reaching for item(s) at time of the fall; Fall resulted in an emergency room visit/hospitalization and R2 was admitted due to a closed fracture of left femur. R2's progress note dated 4/2/2025 at 03:03 AM documents she was admitted to Christ Hospital with an admitting diagnosis of a closed fracture to left femur. R2's Fall Risk assessment dated [DATE] documents she was heard screaming for help from the shower room, staff observed her on her knees with the shower room call light not on, she reported she was taking her shower and was attempting to get a towel, her chair flipped over and she ended up on the floor and her left leg is in severe pain with predisposing situational risk factors included requesting privacy during her shower. R2's Hospital Report dated 04/01/2025 documents she received an Orthopedic Surgery Consult due to left femur fracture, she presented with left knee pain after a fall in the shower, her Multiple Sclerosis limits her ability to ambulate, emergency department x-rays revealed a distal femur fracture. On 04/14/2025 at 10:19 AM V6 (Restorative Aide) stated she's worked in the facility for nearly five years. V6 stated she is familiar with R2 and she had been in the facility nearly a year. V6 stated R2 was very alert. V6 stated R2 did not have a history of refusing care. V6 stated R2 requires sit to stand assistance with a mechanical lift for transfers with two person assistance. V6 stated R2 was able to reposition her legs in the sit to stand equipment, could hold on to the bars on the mechanical lift however her hands were shaky. V6 stated R2 could sometimes unhook herself from the sling. V6 stated R2 needed staff to provide her with incontinence care and could not clean herself after an incontinent episode. V6 stated she has had experience showering R2 and R2 would allow her to be present while she was in the shower. V6 stated there is typically one person in the shower with R2. V6 stated R2 needed assistance with showering. V6 stated she would let R2 clean her face, neck and upper body and she would try to clean her bottom however because of the shakiness of R2's hands she would assist her with cleaning her lower body. V6 stated R2 has never asked her to be left unattended while in the shower. V6 stated if R2 did ask for privacy during a shower, she wouldn't be able to leave her unattended however she could have possibly turned her back or pulled the curtain closed. V6 stated however, she would not have been able to leave R2 unattended. V6 stated she cannot leave a resident unattended in the shower that is not independent. V6 stated she could notify the nurse that R2 requested privacy during a shower, but couldn't leave her unattended. On 04/14/2025 at 10:42 AM V7 (Certified Nursing Assistant) stated she has worked at the facility for four months and has worked with R2 only a few times. V7 stated R2 would ask for privacy while having a bowel movement and we would usually just step outside the door but never too far away. V7 stated R2 required sit to stand assistance with a mechanical lift for transfers with two-person assistance. V7 stated R2 is relatively independent and likes to do things on her own but during showers a staff would always be with her. V7 stated she has never provided a shower to R2 however if R2 requested privacy during a shower she would have closed the curtain and stayed inside the shower. V7 stated the shower is relatively big and she could stand on the opposite side with the curtain closed. V7 stated there is no situation she could think of where she would leave R2 alone in the shower. V7 stated she wouldn't leave R2 alone in the shower because of her fall risk and in case she needed help with something. On 04/14/2025 at 11:00 AM V4 (Certified Nursing Assistant) stated she did not work with R2 often. V4 stated R2 was alert and oriented times four. V4 stated 04/01/2025 may have been her first time working with R2. V4 stated she assisted R2 to the shower on 04/01/2025 sometime after 3PM during the second shift. V4 stated when she and R2 arrived to the shower, she set R2 up, handed her all her personal items, put on her shower cap and shoes, locked her chair, and handed her the call light because R2 requested for her to step out and give her privacy. V4 stated she insisted on staying in the shower to help R2, however R2 was adamant about her stepping out and giving her privacy to shower herself. V4 stated she stepped out of the shower within arm's reach and then afterward heard R2 fall in the shower. V4 stated R2 reported to her verbatim that she dropped her towel, tried to reach over and pick it up and ended up slipping out of the chair. V4 stated she was not inside the shower room when this incident took place but was within arm's reach outside the shower room door. V4 stated R2 required moderate assistance and sometimes supervision for the majority of daily tasks. V4 stated R2 requires a sit to stand for transfers which is provided by the aide but other than that can do things for herself. V4 stated R2 has physical limitations from the legs down but is able to perform other hygiene tasks on her own. V4 stated if residents that need assistance for transfers and hygiene tasks ask for privacy while showering, she has to respect that, and was always told they have the right to have privacy if they are alert and oriented. On 04/14/2025 at 12:11 PM V3 (Director of Nursing/Registered Nurse) stated she spoke to R2 on 04/03/2025 as part of the investigation into her fall incident on 04/01/2025. V3 stated R2 told her on 04/01/2025 she was in the shower washing her upper body, the towel dropped to the floor and she went down to grab the towel and she flipped over. V3 stated she asked R2 did she ask for assistance during this incident and asked her why didn't she pull the call light and R2 replied she had the call light and thought she could reach the towel herself and when she bent down the call light was no longer in reach. V3 stated when she interviewed V4 (Certified Nursing Assistant) she said she had literally just stepped outside the door because R2 insisted she wanted her privacy during her shower. V3 stated that V4 informed she set R2 up in the shower room, asked her if she wanted her to stay, R2 replied no she wanted her privacy, and V4 honored her request. V3 stated V4 reported her cart was across on the other side of the wall and she went to grab something off of the cart and R2 was heard yelling for help. V3 stated R2 requires sit to stand with transfers and as far as bathing she knows she requires the extensive assistance of one staff member but is care planned for two if she needs extra assistance because she has Multiple Sclerosis. V3 stated as far as she knows there is usually one staff assisting R2 with showers and they promote R2's independence with cleaning areas that she can reach and clean herself such as her upper body. V3 stated R2 can't reach her back or peri area. V3 stated based on the level of assistance R2 needs there should be a staff present as much as needed for her safety. V3 stated with R2 being a relatively younger lady we should provide a level of independence as well as keeping her safe so there's always a fine line and we have to keep them safe and promote their autonomy. V3 stated ways to promote privacy for R2 is having staff at arm's reach, if there's a shower curtain pull the curtain back, step off to the side, or be in a position to be able to reach her if she needs assistance such as if she drops a towel or if she's ready for them to wash her back or needs an extra item. V3 stated yes staff should educate R2 on her safety needs if she requests them to leave the shower room and provide her with privacy. V3 stated the shower bath policy states we should never leave the resident unattended and the fall management policy does state that the facility has to honor their preferences while keeping them safe and therefore V4 should have been with R2 but felt she was honoring her request for privacy as well. V3 stated, do we leave residents unattended?; no. V3 stated in this instance although R2 was asking for privacy and it was her choice, she cannot refute the policy. V3 stated if R2 still insists on privacy during showers the staff can ask the nurse for assistance as well. The facility's Shower/Tub Bath Policy received 04/10/2025 states: Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. The facility's Fall Management Policy received 04/10/2025 states: The facility's challenge is to balance protecting the resident's right to make choices and the facility's responsibility to comply with regulations. The responsibility to respect a resident's choices is balanced by considering the potential impact of these choices on other residents and the facility's obligation to protect the residents from harm. The facility will educate the resident regarding significant risks relate to a residents choice.

Based on observation, interview, and record review, the facility failed to ensure that 1 of 3 residents (R1) reviewed for abuse, was free from abuse from a staff member. This failure resulted in R1 suffering an abrasion to her face, sore ribs, and feeling angry and taken advantage of. Findings include: On 6/27/2023 at 11:45 AM, V1 (Administrator/Abuse Coordinator) states she reviewed tapes of the incident that occurred on 6/18/2023, resident was in and out of her room making noise. Resident attempted to leave and went downstairs at about 4:00 AM then went to her room. At around 6:15 AM, R1 came down again and got through the front doors. V5 (CNA) came downstairs and grabbed the back of R1's wheelchair and pulled R1 backwards, and V1 believes resident knocked her own glasses off her face. On 6/27/23 at approximately 2:35 PM, while reviewing incident video with V1 (Administrator/Abuse Coordinator). V1 states there is no one at the reception desk at 6:00 AM in the morning. Observed at 6:15:43 AM, R1 comes into view propelling herself in a wheelchair and pushing a rollator walker and approaches the exit door. R1 pushing on the bell (which V1 states alerts the staff) several times and fidgets with the door. Eventually R1 pulls open the sliding glass exit door at 6:17:03 AM and goes through the door into the vestibule. The second exit door opens automatically and R1 goes out the door and is sitting at the entrance of the facility. Observed at 6:17:46 AM, V5 (CNA) comes into view and walks out of the doors and without any pause or hesitation, immediately grabs the resident's wheelchair and starts to pull her backwards towards the sliding glass doors. R1 starts swinging her hands backwards as if trying to remove or keep V5 from moving her. V5 uses left hand and is consistently trying to move R1's hand. V5 at one point tries to propel R1 forward and R1's feet stops the forward progress. V5 then turns R1 backwards and pulls R1 into the vestibule. About halfway into the vestibule, R1 stands up and V5 immediately grabs R1 by the back of her shirt and pulls R1 down and backward into the wheelchair. R1 falls back into the chair and R1 rocks and tilts to the left side a couple of times before stabilizing. V5 then continues to pull the resident backwards in the wheelchair into the facility. V5 then sits in a chair in the lobby with R1 in front of her. R1 moves her upper body forward and V5 pulls her back by R1's shirt. R1 again starts to strike behind her. V5 then gets up and starts wheeling R1 backwards down the hallway. R1 starts resisting and swinging backwards. V5's left hand and arm is observed moving erratically with R1's and there is a lot of swinging and movement near the left of R1's face that is difficult to see on the video. R1 then tries to hold onto one of the side rails in what looks like an attempt to stop V5 from moving her. V5 pulls R1's hands away from the safety railings. V5 is holding onto R1's arms and at some point, during the scuffling, R1's glasses are knocked off. Observed at 6:19:23 AM, V6 (RN) coming down the hallway. V6 is seen talking to resident for a short time and R1 is talking and pointing. R1 is not swinging at V6 or trying to hit her. There is no physical altercation between V6 and R1. R1 appears to then leave with V6 calmly and voluntarily. On 6/27/23 at 2:47 PM, while still viewing the video tape of the incident surveyor asked V1 (Administrator) if she thought V5 did anything inappropriate in the video. V1 states she doesn't like the approach V5 took to go get R1. V1 states, She [V5] doesn't know how to handle aggressive resident's, which is apparent from this [video]. On 6/27/2023 at 11:02 AM, R1 states that V5 (CNA) worked every other day and is always nasty. R1 states that V5 was taunting her, and she went to go find the nurse to get medication. R1 states she didn't know why she was doing that, and she just ignored her. R1 states she couldn't find the nurse and she was done at this point. She took her stuff and walker. R1 states she went down to the first level with her stuff and went to open the door downstairs and the alarm went off. V5 states she tried to get up from the wheelchair to take her walker and leave. R1 states V5 (CNA) said Sit Down, and the CNA pushed her down into the chair. R1 states she tried to get up again to leave and the 2nd time she shoved me back into the chair and my glasses fell. I tried to get up a 3rd time and she closed fist punched me in the left eye. R1 states they have cameras in the facility. R1 states V5 (CNA) smacked her with a closed fist. R1 states, I certainly did not see that coming. R1 states she was wheeled to her room, and she called 911. On 6/29/2023 at 10:34 AM, R1 states, It made me angry when V5 was pushing me back when I wanted to leave. She had no right to put her hands on me. I have 4 broken ribs and it got irritated when she pushed me, and it was painful. She smacked me in the face with a closed fist. I was in shock that she punched me. I didn't think they were supposed to do things like that. While crying R1 states I was angry that V5 took advantage of my handicap, and I wasn't able to defend myself. I couldn't stand up and defend myself! On 6/28/23 at 1:59 PM, V5 states R1 and another resident were cursing, talking loud, and saying racist things. The first time R1 went to get on the elevator I attempted to stop her and she said, leave me the F*** alone. V5 states she called V6 the supervisor because the nurse was not available. Later she was doing her rounds and V9 (nurse) called her and said that R1 had gotten out and can she go get R1. V5 states R1 was inside the 2 glass doors, and I attempted to push her inside and she stopped. When I first saw her, I just grabbed the back of the wheelchair she was sitting in. I told her you can't go out the doors. I grabbed the wheelchair turned it and she kept stopping it with her feet, so I turned it around and backed into the door. Surveyor asked, At any point did the resident try to get out of the chair. V5 said, No she was just fighting a lot. She was swinging her arms back to hit me because she didn't want me pushing the wheelchair. Surveyor asked, At any point did you pull her back into the chair. V5 states, No, I didn't pull her back into the chair. She was always in the chair. V5 states R1 was alert and oriented and she (V5) had worked with her before. V5 states, Yes, at 6 am it was appropriate for her to pull R1 into the facility against her will. Surveyor asked, do you think it is appropriate to pull someone down from behind into a wheelchair. V5 states, No, of course not. They can hurt themselves. V5 states I would think that is abuse if I saw someone do that. Surveyor asked if it is appropriate to pull R1 back into the facility when she is fighting and saying she doesn't want to go in. There was a long pause and V5 said, Ordinarily, no. Surveyor asked, why was it okay to do it this time with R1. V5 states, because of the time of day and no one was waiting for her. On 6/27/2023 at 12:57 PM, V4 (Licensed Practical Nurse) states he remembers R1. V4 states, R1 was alert and oriented and cooperative. On 6/27/23 V3 (CNA) states R1 was a nice lady. V3 states R1 was alert and oriented and could transfer by herself. V3 states R1 kept to herself and stayed in her room. V3 states R1 was never combative, and she never got any reports that she was. On 6/28/2023 at 10:10 AM, V6 (RN) states R1 is completely alert and oriented. V6 states the first time V5 (CNA) called her because R1 had left the unit. V6 states she saw her downstairs. V6 states, R1 was saying she didn't want to be at the facility. V6 states she tried to calm her down and eventually got her to go back upstairs. V6 states she got a 2nd call, said the resident was trying to leave. V6 states when she got to the lobby, V5 was trying to get R1 back to the unit. V5 was wheeling her backwards and R1 was swinging and resisting by swinging her arms. V6 states, I intervened and told V5 to just go. V6 states she told R1 to calm down. She said she wanted to go. V6 states she told R1 leaving against medical advice (AMA) and R1 said she would sign anything because she wanted to go. I believe R1 is self-responsible for her care. She has the competence to sign the AMA form and leave if she wants. I believe that she has the right to leave, and we would just document that she refused to sign AMA if she didn't sign the form. V5 states, if she had seen R1 outside, the first thing she would do is talk to R1, tell her to stay calm, and redirect her to the facility. V6 states, I wouldn't approach the situation with aggression so that it does not escalate. Police report dated 6/18/2023 and reported at 6:20 AM documents: Officer was told when he arrived that R1 was sent to the hospital. Officer interviewed resident in the Emergency Room. R1 told officer she tried to leave the facility and was stopped physically by her CNA. R1 stated she was struck in her left eye by a closed fist of the CNA. R1 advised the officer that her CNA also pushed her by the shoulder into a chair. Officer observed redness upon R1's upper left cheek near her eye. Nurse told officer that R1 tried to leave and was told she couldn't leave based on her mind and no means of transport or shelter and that R1 was restrained at this time and the process was started to have R1 involuntarily committed. Hospital records dated 6/18/23 documents R1 reported that the CNA at the facility pushed her down into a chair and after that, punched her in the face. Page 11 documents: Patient presents to the emergency room with reports of abuse at her nursing home. Patient is to be Alert and oriented times 3. No evidence of active psychiatric disease clouding her decision making. Emergency Department (ED) Notes: Patient states: I was hit in the left eye by a CNA at the facility she was living. The CNA kept pushing her down every time she tried to get up. V15 (nurse) from the facility stated they were petitioning the patient, psych evaluation, due to patient attempting to leave against medical advice and being combative with the staff members. R1's left eye was noted to be red with a small abrasion. R1's MDS (Minimum Data Set) dated June 13, 2023, documents R1's cognition to be intact. R1's Abuse and Neglect Care Plans documents the following intervention: Approach in a friendly, calm manner; treat with dignity and respect. Dated 3/20/2023. The facility's Abuse Prevention Program policy dated 10-2022 documents the following. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to safely provide incontinence care to a resident by not having two staff members provide the care. This failure resulted in a resident hitting his head which resulted in a five day hospitalization for a subdural hematoma. This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 17. The findings include: R1's admission Record dated 6/16/23 shows he is a [AGE] year old male and his diagnoses include, but are not limited to, Alzheimer's disease, severe protein calorie malnutrition, type 2 diabetes, acute respiratory failure, attention and concentration deficit following non-traumatic subarachnoid hemorrhage, anemia, heart disease, disorder of the brain, encephalopathy, cerebral infarction, dementia, altered mental status, and anxiety. R1's Minimum Data Set (MDS) dated [DATE] shows R1 is not cognitively intact and requires extensive assistance by two or more staff members for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed). R1's current Care Plan provided by the facility shows R1 is blind, hard of hearing, and is on anticoagulant (blood thinners) therapy and therefore, should avoid activities that could result in injury. This same care plan shows R1 has an ADL (activities of daily living) self-care performance deficit and requires extensive assistance by two staff to turn and reposition him in bed and for his toileting needs. R1's Medication Review Report dated 6/16/23 shows R1 has an order for Apixaban (anticoagulant) to be given twice a day both prior to (4/25/23) and after R1 was hospitalized (5/31/23) for his head injury. R1's After Visit Summary from the hospital dated 5/31/23 shows he was hospitalized from [DATE] to 5/31/23. R1's Facility Transfer Report (FTR) dated 5/31/23 from the hospital shows R1's hospital admitting diagnoses includes intracranial hemorrhage for which he was admitted on [DATE]. The FTR includes a consult note from the hematologist with the reason for consultation being subdural hematoma on anticoagulation therapy. The FTR includes a Neurocritical Care Attending Note which shows, Patient is critically ill and at high risk of clinical deterioration due to acute subdural hematoma. The FTR includes a brain CT scan which shows, Impressions: New from prior study 4/20/23, a subtle small right frontoparietal hyperdense extra-axial fluid collection, most likely subdural hematoma. The facility's Incident Note for R1 on 5/27/23 at 7:12 AM shows Upon CNA during rounds resident was being cared for and was turned over in bed to be changed and was turned to (SIC) far and bumped his head against the siderail, with further observation resident noted having reddened area to right side of head. The facility's Health Status Note for R1 on 5/28/23 at 12:59 AM shows, Resident was admitted to hospital with admitting dx (diagnosis) right frontal subdural hematoma . On 6/16/23 at 9:28 AM, R1 was lying in his bed with his left leg hanging off the edge of the bed and his head about a third of the way down from the top of the bed. There was a sign above R1's head of bed showing R1 is blind and wears hearing aids. R1 was unable to engage in a conversation or answer questions. On 6/16/23 at 9:38 AM, V15, CNA, was observed as she provided incontinence care, including turning and positioning, to R1 without any other staff assistance. On 6/16/23 at 9:44 AM, V16, Licensed Practical Nurse (LPN), said R1 requires total assistance with his care. On 6/16/23 at 11:32 AM, V13, Certified Nursing Assistant (CNA), said she was providing incontinence care for R1. V13 said she turned R1 on his side and he jolted forward and hit his head on the side rail, so she went and got the nurse to assess him. When the nurse was finished, V13 finished cleaning R1 and was lowering R1's bed and the fan fell over and hit R1 on his head in the same area where he had just hit it on the side rail. V13 said there was a red area on R1's right temple area. V13 said she was providing R1's care by herself. V13 said R1 needs two people to do his incontinence care because he moves around a lot, but no one was helping her. On 6/16/23 at 11:17 AM, V14, LPN, said she was the day nurse the morning after R1 hit his head. V14 said R1 had a hematoma to his right frontal forehead. V14 said she told V2, (DON) Director of Nursing, that R1 was taking blood thinners and V2 recommended they send R1 to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure adequate supervision to resident (R58) who has multiple episodes of falls to prevent from future falls as indicated in his care plan. R58 was left unattended/unsupervised in the dining room and sustained a right hip fracture requiring hospitalization. This deficiency affects one (R58) of 3 residents in a sample of 26 reviewed for Fall prevention management. Findings include: R58 is admitted on [DATE] with diagnosis to include Dementia, Psychosis, Chronic Obstructive Pulmonary Disease and Depression. R58 is at high risk of falls. He has a total of 10 episodes of multiple falls from 5/17/21 to 4/19/22. Most recent fall sustained right hip fracture requiring hospitalization. R58's fall prevention care plan intervention dated 7/14/21 indicated: place resident in supervised area while awake. R58's progress notes dated 4/19/22 indicated: Unwitnessed fall at approximately 11:15pm, R58 sustained a fall while sitting in his wheelchair in the dining room. Staff responded to R58's call for help and the resident was found lying on his right. There was no break in his skin noted and R58 was complaining of right-sided hip pain. R58's physician gave orders to transfer him to hospital for further evaluation. Tylenol 650mg was given orally for pain. Vital signs: BP135/71, PR 68, RR 19, T-97.6F, 97% O2 sat on room air. On 4/21/22 at 2:02pm V2 Director of Nursing (DON) said that R58 is a demented resident who needs constant supervision/monitoring due to high risk of falls and multiple incidents of falls. He was placed in the dining room late in the evening for supervision because he tends to get out of bed when he was in his room. He was monitored by CNA, but staff left him unattended without informing the nurse on the floor that the CNA needs to leave R58 in the dining room. R58 was found on the floor complaining of right hip pain. R58 was sent out to the hospital for evaluation and was admitted for a right hip fracture. On 4/21/22 at 2:50pm, V2 DON said that they don't have a fall coordinator to complete the root cause analysis of the fall. V2 said that they usually discuss it during the morning meeting, but they have not done it this week due to current survey in the facility. R58 was re-admitted on [DATE] from the hospital with diagnosis of right hip fracture due to fall. R58's care plan was not yet updated as of 4/21/22. On 4/22/22 at 10:03am observed R58 lying in bed sleeping, his bed is pushed to the wall by the window and has floor mat on the right side of the bed. On 4/22/22 at 10:08am, V32 LPN said that she has been taking care of R58. He is confused, can be combative and resistive to care. He has poor safety awareness and attempts to get out from bed. He needs closer supervision due to his fall risk and multiple fall incidents. V32 said he had fall recently in the dining room and sustained right hip fracture. No surgery was ordered due to his age. They are keeping him in bed with 2-person log rolling using abductor pillow or 2 pillows. No abductor pillow or 2 pillows found at bedside of R58. On 4/22/22 at 10:11am, V11 RN said that he worked on 4/19/22 (3-11 shift) the day that R58 fell. V11 said that V14 CNA placed R58 in the dining room for closer supervision because he was restless, agitated and attempts to get out from bed. V11 said that V14 told him that she was leaving at 11pm when her shifts end, leaving R58 unattended in the dining room. V11 said that he did not go to the dining room because he must do his charting at the nursing station. V11 said that V33 CNA from 11-7 shift did not stay with R58 because she must do her rounds. Then V11 heard R58 yelling for help from the dining room. V11 said he found R58 lying on the floor on his right side and complaining of pain. R58 was sent to the hospital for evaluation per his physician order. V11 said that if he had sat next to R58 in the dining room then the fall could have been prevented. On 4/22/22 at 10:23am, V2 DON said that R58 should be placed by the nursing station rather than in the dining room for closer 1:1 supervision by V11. On 4/22/22 at 12:10pm, V33 said that she is the assigned CNA for R58 on 4/19/22. V33 said that they have 2 CNAs and 1 Nurse on 4th floor for 11-7 shift. V33 said that she arrives on the unit at 11pm and saw R58 in the dining room by himself. V33 said that the nurse did not tell her to stay with R58 in the dining room for close supervision. V33 said that she made her rounds and checked her other residents. V33 said that if she knew that she needed to stay with R58 for close supervision, she would've stayed with the resident and prevented the fall. Facility's fall risk screening policy indicated the nursing staff in conjunction with the attending physician, consultant pharmacist, therapy staff and others will seek to identify and document resident risk factors for falls. Interpretation and implementation: 1) Based on the result of screening a plan of care will be developed and updated as needed. This plan of care will be reviewed with the resident and his family for input and review. 6) The staff with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance, continence and cognition. 8) The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. 9) The care plan will be developed and updated including identified risk and developed interventions. Facility's fall committee: 1. On a daily basis the fall committee will review all accidents/incidents/unusual occurrences that have occurred within the last 24hrs period. 2. The facility's IDT (interdisciplinary team) will meet and review all resident accident/incidents/unusual occurrences. This team provides investigation and interventions. 3. Based on this review, the meeting will determine how or if the care plan goals and approaches need revisions or additions and or make other recommendations in an effort to prevent reoccurrences Facility's Fall prevention activities Pre and post falls 4. For residents who have been identified at risk for falls upon admission, a care plan shall be developed which includes the resident and his family input for interventions that have or have not worked in the past. Additional interventions will be developed to promote a safe environment. The residents' individual needs for staff assistance will be assessed. Then the resident will be a placed on a fall prevention program. 6. As a fall occurs the nurse on duty will initiate a new intervention to prevent further falls. The pan of care will be updated at this time. The revisions to the fall care will be monitored for effectiveness and adjustments made as needed. The fall committee will review the revised plan of care and the resident's response at fall committee.