**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow their interventions of ensuring residents were adequately supervised who were identified as high risk for falls when left unattended, failed to modify fall prevention interventions post fall and failed to ensure a resident who is at high risk for falls whom repeatedly exhibited unsafe behaviors when in a reclining chair, was safely positioned in a reclining chair and adequately supervised during care. This failure applies to three of three (R1, R2 and R3) residents reviewed for accidents and resulted in R1 sustaining a facial fracture and intracranial hemorrhage from a fall. Findings include: 1. R1 is a [AGE] year-old female with a diagnoses history of Dementia, Insomnia, Muscle Wasting and Atrophy, and a history of falling who was admitted to the facility 07/04/2023. R1's Functional Abilities Minimum Data Sets dated 07/09/2024, 10/09/2024, 01/07/2025, and 03/30/2025 document she is dependent on staff for all activities of daily living and mobility activities. R1's current Fall care plan initiated and created 12/08/2024 documents she is at risk for falls due to functional deficits with the intervention initiated and created on 04/06/2025 of staff to monitor resident frequently to ensure proper reposition and safety in chair or bed. R1's current ADL (Activities of Daily Living) care plan initiated and created 12/16/2024 documents she requires assistance with daily care needs related to dementia, and muscle wasting and atrophy at multiple sites with interventions including one person assistance with bathing, toileting, dressing, and eating; and the intervention initiated 03/31/2025 and revised 04/14/2025 of mechanical lift with two-person assistance for transfers. R1's Restorative Comprehensive assessment dated [DATE] documents her fall risk factors included a history of falls or post fall fracture in the past 1-6 months, a fall risk score of 10 or above indicates high fall risk, and a final score for her of 21. R1's progress notes from February - April 2025 document multiple observations of behaviors. R1's progress note dated 04/06/2025 at 4:47 AM created by V8 (Registered Nurse) on 04/06/2025 at 6:28 AM documents she had a fall at 4:47 AM. CNA (Certified Nursing Assistant) notified writer that resident was in the chair and she turned to get blanket and resident tried to get up and fell, hitting head on bed. Resident assessed by this writer and noted cut to right cheek and under chin. Resident also noted bleeding from nose and mouth. Physician made aware and stated to send resident out to the hospital emergency room. R1 sent out via ambulance. R1's progress note dated 4/6/2025 at 12:01 PM documents she was admitted at Christ Hospital with a facial fracture and Intracranial hemorrhage. R1's Fall Risk Management Incident Report dated 04/06/2025 documents that at 4:47 AM she had a fall, V9 (Certified Nursing Assistant) reported that while she was providing care and placed R1 in a chair she turned around to grab something and the resident fell from the chair to the floor hitting her head on the bed, she was observed with bleeding in her face including from the nose and mouth and complained of pain; she requires total assistance with activities of daily living and transfers and the root cause of her fall is noted as having poor trunk control, and when placed in her geriatric chair by staff she fell out of the chair head first hitting the bed frame then the floor; her mental status was documented as not being oriented or oriented to person only; predisposing factors were noted to include confusion and impaired memory, gait imbalance, and weakness; the physician was notified and ordered she be sent out to the hospital emergency room for evaluation and her Power of Attorney [NAME] Fields was also notified; Interventions implemented in response to the fall included monitor her frequently to ensure proper repositioning and safety in chair. The facility's Incident Investigation report received 04/15/2025 documents on 04/06/2025 at approximately 4:47 AM R1 was observed on the floor in her bedroom by the facility aide and was unable to verbalize what occurred in the room. R1 was admitted to the Hospital with a facial fracture and intracranial hemorrhage. It is determined that R1 attempted to get up from her wheelchair and had a fall. Staff were interviewed and reported that R1 was sitting in the wheelchair and attempted to get up and fell forward. Witness statement from V9 (Certified Nursing Assistant) dated 04/06/2025 documents she was assigned to work with R1, when finished putting on R1's clothes she transferred her to the chair and then turned around to get a plastic bag to place the dirty linen in which was on the other bed in the room and heard a noise then turned her head and observed R1 on the floor. V9 stated she immediately called the night nurse and told her that R1 had fallen. Witness statement from V8 (Registered Nurse) dated 04/06/2025 documents the CNA (Certified Nursing Assistant) informed her at 4:47 am that R1 fell from her wheelchair, the CNA reported that she turned around to grab something and R1 fell when trying to get up; R1 fell forward out of chair. On 04/16/2025 at 10:23 AM V11 (Certified Nursing Assistant) stated she has worked with R1. V11 stated she would position R1 in her (Reclining) chair at a slightly tilted angle because if the chair is lowered too far back it could be considered a restraint. V11 stated R1 would like to sit straight up on the edge of her (Reclining) chair. V11 stated when R1's (Reclining) chair was tilted back she would sometimes attempt to sit up however if her chair is tilted back she couldn't get up. V11 stated R1 would attempt to sit up once or twice when receiving incontinence care. V11 stated she uses a sit to stand most of the time to transfer R1 and needs assistance with transferring her. On 04/16/2025 at 11:15 AM V6 (Therapy Director) stated (Reclining) and Geriatric chairs are used for reclining due to cognition and for residents who require two-person assistance or a mechanical lift. V6 stated there should not be one person assistance for residents who use a (Reclining) or Geriatric chair. On 04/16/2025 at 11:54 AM Observed with V7 (Minimum Data Set Director) when a care planned intervention of keep clean and dry was entered in the facility's electronic medical record system to R1's care plan; the intervention was automatically categorized as initiated and created for the date it was entered of 04/16/2025. Observed in the facility's electronic medical record system the intervention in R1's care plan of mechanical lift with two-person assistance for transfers was categorized as initiated 03/31/2025 and revised 04/14/2025. On 04/16/2025 at 1:47 PM V5 (Restorative Nurse) stated the mechanical lift was implemented for R1 due to the extensiveness of her fall and her total dependence. V5 stated since R1 is totally dependent, she should be a two-person assistance however she feels one person assistance is adequate to transferring R1. V5 stated a (Reclining) chair should be reclined and if it is reclined it is not impossible but highly unlikely that the resident will fall out of it. V5 stated she isn't sure if R1's (Reclining) chair was reclined on the day she fell because she fell forward and injured her face which may indicate the chair was in an upright position however she couldn't confirm this. On 04/16/2025 at 2:41 PM V3 (Vice President of Clinical) stated if a mechanical lift is being used there should be two people assisting. V3 stated mechanical lifts are used for resident's who require total assistance and are dependent however this intervention is used on a case-by-case basis. V3 stated what could have been done differently to prevent R1's fall was having the necessary items close by so the staff would have what they needed for the resident. On 04/17/2025 at 12:09 PM In response to surveyor's request for information on what behaviors was R1 being monitored for and documented as being observed by staff in several behavior progress notes between February 02 and April 03, 2025 V1 (Administrator) replied per the CNA's (Certified Nursing Assistant) R1's behavior can range from swinging her arms in the air to leaning forward. On 04/15/2025 at 3:20 PM V5 (Restorative Nurse) stated R1 requires full assist with all activities, she can lift either of her arms and has range of motion but can't lift her arms on cue, and doesn't do anything on her own. V5 stated R1 is 79 pounds and light however we have her in a (Reclining) chair because her trunk support isn't there and for this reason shouldn't be sitting up in a wheelchair. 2. R2 is a [AGE] year-old female with a diagnoses history of Central Nervous System Cancer, Muscle Wasting and Atrophy, Morbid Obesity, Spinal Stenosis, and Stage 3 Chronic Kidney Disease who was admitted to the facility 01/31/2025. On 04/16/2025 AT 9:12 AM Observed R2 in the unit 2 Long Term Common/Dining Area without other residents present and staff walking around the surrounding area. Observed R2 sitting in a (Reclining) chair slightly reclined. R2 stated she had fallen out of bed 2-3 months ago onto a mat, then fell again about a month later while sitting on the edge of her bed when she started to slide and couldn't stop herself. R2's Current Fall Care Plan initiated and created on 01/31/2025 documents she is at high risk for falls related to repeated falls with an intervention initiated 02/08/2025 including staff to monitor resident frequently to ensure safety. R2's Fall Risk Assessment Incident Report dated 02/05/2025 documents she was observed on the floor in the dining room and reported she was trying to sit up in the wheelchair; the root cause was determined to be she has poor thought process, very impulsive, and stood up from her wheelchair and fell with an intervention implemented of encouraging staff to continue to monitor and redirect her; there was no one identified to have witnessed the fall. R2's Fall Risk Assessment Incident Report dated 02/08/2025 documents she was observed on the floor near her bed during rounds and reported she was trying to get out of the bed and she sustained an abrasion on her right knee; there was no one identified to have witnessed the fall; the root cause was determined to be her having poor thought process and being very impulsive with an intervention implemented of encouraging staff to continue to monitor and redirect her. R2's Fall Risk Assessment Incident Report dated 02/27/2025 documents she was observed on the floor next to her bed and she reported she needed to get up and she slid on her bottom; her assigned CNA (Certified Nursing Assistant) reported she left he with her breakfast tray; the root cause was determined to be poor though process and being very impulsive with an intervention implemented of educating staff to bring her to the common area for close monitoring. 3. R3 is an [AGE] year-old male with a diagnoses history of Dementia, Generalized Muscle Weakness, and Difficulty Walking who was admitted to the facility 11/30/2024. R3's Current Fall Care Plan initiated and created on 12/09/2024 documents he is at risk for falls due to diagnoses of functional deficits, muscle weakness, and dementia with interventions created on 01/22/2025 of staff to monitor him frequently. R3's Fall Risk Assessment Incident Report dated 01/19/2025 documents he had an unwitnessed fall, with an intervention implemented of staff monitoring him more frequently. R3's Fall Risk Assessment Incident Report dated 02/01/2025 documents he was in the common area and slid out of his chair onto his buttock, while V12 (Certified Nursing Assistant) was observing in the dining room he stood up from his chair in the day room and was observed sitting on the floor with an intervention implemented of staff monitoring him more frequently. R3's Fall Risk Assessment Incident Report dated 03/16/2025 documents he was observed sitting on the floor on his buttocks in front of the (Reclining) chair in the dining room and when he was asked what happened he stated he slid out of the chair, there was no one identified to witnessed the fall; an intervention was implemented of reminding staff to monitor him more frequently; he was not receptive to education due to a diagnosis of dementia. R3's Fall Risk Assessment Incident Report dated 03/20/2025 documents he stood up from the (Reclining) chair and fell onto his buttocks in the dining room and the fall was unwitnessed; the writer of the report was alerted by the CNA (Certified Nursing Assistant) that he stood up from the (Reclining) chair and fell onto his buttocks in the dining room; the root cause was determined to be R3 standing up out of his chair unassisted and not making safe decisions due to dementia with an intervention implemented of reminding staff to monitor him more frequently. On 04/15/2025 at 3:53 PM V5 (Restorative Nurse) stated she is the fall coordinator. V5 stated she and physical therapy perform assessments to determine if residents need to use a (Reclining) chair. V5 stated residents are assessed for (Reclining) chair use on admission and if there are any significant changes in their physical ability. V5 stated upon admission therapy screens all residents and will give recommendations and she performs a follow up assessment and most of the time she uses their recommendations because they are more skilled in that area. V5 stated R2 and R3 use (Reclining) or geriatric chairs. V5 stated if a resident can't sit up safely or doesn't have proper trunk control in a wheelchair, they are placed in a (Reclining) or Geriatric chair. V5 stated the restorative assessment is used to determine if a resident needs a (Reclining)/Geriatric chair. V5 stated when R1 is sitting in the (Reclining) chair it should be tilted back and should not be sitting up for because of her poor trunk control. On 04/16/2025 at 12:23 PM V5 (Restorative Nurse) stated R3 is at high risk for falls. V5 stated R3 had an unwitnessed fall on 01/19/2025 that occurred in the hall and it was his first fall in the facility since his admission in November. V5 stated R3's first few falls were attempts to self-transfer or get up on his own. V5 stated fall interventions are updated after reviewing fall incidents and when needed. V5 stated the intervention implemented after this fall was for staff to monitor R3 more frequently. V5 could not explain what more frequently meant and stated every one to two hours was adequate monitoring for him. V5 stated R3's next fall was on 02/01/2025 where he slid out of a chair in the common area, and this was witnessed by V12 (Certified Nursing Assistant) who was written up for not actively attending to him during sitting time. V5 stated sitting time includes staff monitoring in the dining/common areas for 30-minute intervals. V5 stated R3's next fall was on 03/16/2025 in the common area when he got out of his chair. V5 stated the intervention implemented was reminding staff to monitor him more frequently because he was not receptive to education on asking for assistance due to his dementia. V5 stated R3's next fall was on 03/20/2025 when he stood up out of his chair in the dining room and the intervention was staff being reminded to monitor him. V5 stated she doesn't know how to answer the surveyors question of was R3 being adequately supervised however he should have been. V5 stated she doesn't believe there were any other interventions required for R3 and in order to move you have to be raising up to do so if there was someone there watching him they should be intervening when he attempts to ambulate or transfer. V5 stated R2 fell on [DATE] in the dining room when she slid from her wheelchair while trying to sit up in the chair. V5 stated the intervention for this fall was encouraging staff to monitor and redirect the resident. V5 stated R2 fell on [DATE] and was observed on the floor in her room near her bed during rounds. V5 stated R2 is at high risk for falls and she attempts to transfer herself. V5 stated the intervention for this fall was to have a floor mat in place when in bed. V5 stated R2 had a fall on 02/27/2025 in her room while sitting on the edge of her bed. V5 stated the CNA (Certified Nursing Assistant) had left the room to get her clothes from another area and when she returned R2 was on the floor and reported that she wanted to get out of bed. V5 stated the intervention for this fall was educating staff to bring her to the common area for close monitoring and she shouldn't have been left because she tries to get things on her own. V5 stated the CNA was educated not to leave R2 by herself. V5 stated it had already been established that R2 would attempt to self-transfer prior to this last fall for R2. The facility's Fall Prevention and Management Policy, dated January 2023 documents: The facility is committed to maximizing each residents physical well-being. The facility will facilitate as safe an environment as possible. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Failures at this level required more than one deficient practice statement. A. Based on interview and record review, the facility failed to utilize two persons assist for bed mobility (R1), failed to utilize a gait belt to assist with transfers (R18), failed to ensure wheelchair leg supports were in place during transport (R9), and failed implement an effective plan to prevent or reduce the risk of falling with injury for a resident identified to be at risk for falling out of bed (R13). This affected (R1, R9, 18, and R13) reviewed for safety during care and fall prevention interventions on the sample list of 21. This failure resulted in R1 rolling off the bed onto the floor while staff was providing care. R1 sustained an impacted/displaced fracture to the left upper arm with abrasion to the left knee and toe. R9 sustained a closed nondisplaced fracture of the metatarsal bone of the right foot while being transported in the wheelchair by staff, and R13 being involved in an unwitnessed fall incident sustaining a closed displaced fracture of the right femoral neck and closed fracture of the orbital of the right zygomatic bone. B. Based on interview and record review, the facility failed to supervise and monitor a resident with a history of wandering behavior (R12). This affects two of three residents reviewed for supervision and safety on the sample list of 21. This failure occurred when (R12) wandered into (R11's) room and resulted into a resident-to-resident altercation, R12 hit R11's arms with a remote control, and R11 hit R12 back on the hand. Findings Include: a) R1 had the diagnosis of need assistance with personal care, reduced mobility, muscle wasting and atrophy, dizziness and giddiness. Minimal data set dated [DATE] documents: section C (cognitive pattern) documents a score of fifteen which indicates cognitively intact. Section G (function status) documents: R1 required extensive assistance with two person physical assist with bed mobility (how resident moves to and from lying position, turns side to side and position body while in bed) and toilet use. R1 care plan dated 1/25/23 documents: R1 is at risk for fall due to general weakness. On 10/20/23 at 11:28am, R1 who was assessed to be alert to person, place and thing said, she had diarrhea, V4 (cna) was providing incontinence care. V4 rolled her over but she was not over far enough. R1 said, she did not having any bed rails. V4 rolled me over little more, R1 said, her legs started too slid off the bed. R1 said, she fell out the bed, hit the radiator then the floor on her left side. R1 said, she hit her head, skinned her knee and fractured her shoulder and elbow. R1 said, her pain was a ten out of ten. R1 said, staff caused her more pain by trying to get her up off the floor. R1 said, she could not straighten up her left arm. On 10/24/23 at 10:15am, V9 (nurse) said, V4 (cna - certified nursing assistant) informed me, R1 had fallen off the bed. R1 was on the floor against the wall and complaining of shoulder pain, we could not get R1 up off the floor based on R1's position. V9 said, she had to call 911. V4 was the only cna in R1's room providing care. R1 required two person assist with being changed/ incontinence care and transfers. On 10/24/23 at 11:24am, V10 (ADON- Assistant Director of Nursing) said, if a resident requires two person assistance with bed mobility and toileting means two staff members need to assist with those items/bed mobility and toileting. Progress note dated 4/13/2023 documents: (V9) Writer was called into (R1) patient's room by (V4) cna. V9 went into room and observed R1 lying on the floor against the wall next to bed on her left side. V9 asked R1 what happened and R1 stated, I was lying on my side while V4 was changing me and when I was going to lay back my hand gave out and I fell off the bed. R1 said, she hit the back of her head and complained of left shoulder pain ten out of ten. Unable to get R1 off the floor with mechanical lift due to position R1was lying on floor. 911 called. Event Report dated 4/13/23 documents: witnessed fall. Location of injury: left should pain, range of motion painful/limited in upper extremity and rotation/deformity of upper left extremity. First aid-immobilize/splint area. Sent to emergency room for evaluation. Incident Investigation: R1 explanation of the incident: slid of the bed. Mode of transfer: two staff maximum. Fall observation dated 4/13/23 documents: V4 was present in room at the time of fall. R1 fell off the bed. Two person assist. Fall root cause analysis form dated 4/13/23 documents: root cause determination: slid out of bed during changing. New Interventions and recommendations need to be implemented: Staff educated to use two person assist with transfer and change. Facility reportable dated 4/20/23 documents: R1 expressed, I'm sliding, I'm sliding and reached out to brace herself on the wall that was a few feet from the bed. Hospital paperwork 4/13/23 documents: R1 presented with to the emergency room after a fall causing injury to head and left shoulder. R1 rolled on the bed on her side with the help of the side earlier this morning. R1 rolled over all the way, left shoulder, left side of forehead to floor with no loss of consciousness but R1 complained of pain to left shoulder with decreased movement. Chest x-ray of R1's left should showed evidence of an acute fracture was noted in the humeral head (upper arm) extending from the humeral tuberosity (the bump of bone at top of the upper arm that serves as the attachment for two rotator cuff muscles) to the humeral neck which is impacted and displaced (shift out of placed). R1 also had an abrasion to anterior left knee and left toe. R9 was diagnosed with generalized osteoarthritis, intervertebral disc degeneration (lumbar region) difficulty walking and restless leg syndrome. On 11/02/23 at 2:21PM, R9 who was assessed to be alert to person, place and time said, she was being pushed in her wheelchair to physical therapy by V27 (restorative aide). R9 said, she had one foot crossed over the other with both of her legs raised/extended out in front of her. R9 said, her legs got tired, her right leg slipped down, buckled underneath the wheelchair and she fell forward landing on her knee. On 11/7/23 at 2:41PM, V26 (restorative nurse) said, R9 was being pushed in the wheelchair by the V27. R9 was holding her feet up. R9's foot drop while she was being pushed causing her to fall forward out of the wheelchair. R9 did not have any leg rest because she normally self -propel. R9 should have had leg rest while being pushed. On 11/7/23 at 3:02PM, V27 said, she was pushing R9 from unit one to unit two, R9 normally does not get tried. R9 was holding her legs out and up in front of her, flipped over and fell out the chair hitting her knee first on the ground. Progress note dated 9/7/23 documents: R9 stated, I fell. I fell right knee first, my right ankle twisted a little bit but I'm fine I didn't hit my head or anything my brain is still intact, my right foot got stuck under the chair as I was being pushed by restorative (V27). R9 denied pain, I get a pain pill in couple of hours. NP (nurse practitioner) made aware ordered x-ray of the right knee/ankle. Post fall observation dated 9/7/23 documents: root cause of the fall: R9's right foot got stuck under her wheelchair while being pushed down the hall. Witnessed V27. Additional fall follow-up questions dated 9/7/23 documents: V27 was pushing R9 in wheelchair, told R9 to hold legs up and let V27 know if legs get tired. V27 was pushing R9, R9 placed her foot on the floor and fell forward without warning landing on the floor. X-ray results dated 9/8/23 documents: right knee: soft tissue swelling with uncomplicated revised right knee arthroplasty. Right ankle: findings are concerning for an acute to subacute, avulsion fracture of the avulsion fracture of anterior talus. Hospital paperwork dated 9/8/23 documents: Reason for visit: fall, knee/ankle injury. R9 said, she is wheelchair-bound for issues with mobility and that she was being wheeled by a CNA yesterday. R9 states, that her feet were not resting on the foot rest and that they got dragged under her and she fell forward onto her knees and twisted her right ankle. R9 denied utilizing her hands to stabilize herself. R9 said, she was feelings pain mainly at the top of her foot where her shoes lay. X-ray right foot documents: Closed oblique nondisplaced fracture of metatarsal bone of right foot (5 digit). Assisting a client to use the wheelchair not dated given was created after R9's fall. Employee in-service dated 9/10/23 documents: All residents must have leg rest on their wheelchair during transport. R18 was diagnosis with Dementia, cognitive communication deficit, hemiplegia and hemiparesis following unspecific cerebrovascular disease affecting right dominate side, abnormalities of gait and mobility, repeated falls, need for assistance with personal care, muscle wasting and atrophy. Minimal data set section C (cognitive pattern) brief interview for mental status dated 10/12/23 document a score of eleven which indicated moderately impaired. Section G (functional status) dated 4/11/23 document: R18 need extensive assistance with one person physical assist with transfers. Balance during transitions and walking documents: surface to surface transfer (transfer between bed and chair or wheelchair) not steady, only able to stabilize with staff assistance. Quarterly Observation dated 4/18/123 documents: R18 was at high risk for falls. On 11/2/23 at 12:56PM, R18 who was pleasantly confused, said, she was in the shower by herself, had a fall and an unknown female co-peer helped her up off the floor. On 11/3/23 at 1:13PM, R18 was observed being transferred from the wheelchair to the bed safely by one staff member who used a gait belt. On 11/7/23 at 1:08PM, V25 (cna) said, she transfers R18 safely by herself utilizing a gait belt. On 11/07/23 at 1:22PM, V23 (cna) said she, (on 6/16/23) was transferring R18 from her wheelchair to the shower chair, She instructed R18 to hold on to the shower bar, told R18 they were getting ready to turn/pivot, as R18 turned, R18 fell down. V23 said, she did not use a gait belt with R18's transfer. On 11/7/23 at 2:55PM, V2 (DON- Director of Nursing) said, CNA's must use a gait belt for all transfers to help support the resident and break falls. Nursing note dated 6/16/23 documents: V23 (cna) notified writer that while assisting R18 to the shower chair the R18's knees buckled. V23 helped lower R18 to the ground. R18 complained of leg pain. Event report dated 6/16/23 documents: While assisting R18 to shower chair, R18's knees buckled and V23 help lower R18 to the ground. Fall root cause analysis dated 6/16/23 documents: R18 knees buckled during transfer to shower chair. Incident Investigation documents: Resident's explanation of incident: My legs gave out. Activity: getting ready for shower. Aide with resident at the time of event. Gait belt policy dated 2/23 documents: a gait belt is a safety device made of cloth that buckles securely around a resident's waist. The device provides a secure grasping surface to aid during transfer and ambulation. Commonly used for residents who are at risk for falls and those who require assistance during transfers. A gait belt can support a lower to the floor if the resident begins to fall or loses balance during transfer or ambulation. If the resident has one side weakness, position the destination surface (wheelchair, commode or chair) on the resident's unaffected side, grasp both side of the using an underhand grip. b. Facility Initial reported incident, dated 8/25/23 reads in part: R11 was sitting in R11's room reading and R12 independently wheeled in and approached R11's table that was next to R11. R12 started reaching for things and R11 reports that R12 hit R11, so R11 hit R12 back. R11 yelled for help and the staff immediately intervened and came to help R12 out of R11's room, R11 has a broken fingernail. Body checked refused by R11 and R12 will be completed. No other injuries noted at this time. Investigation initiated. Final report reads in part: R11 claims R12 came in to R11's room and hit R11 with remote control and the bedside table was between them, it was also being pushed at R11. R11 claims she was defending self and hit R12 on the hand. R12 is blind and R12 was not aware R12 was in wrong room. R11 has had daily follow up with nursing and did develop a slight bruising to R11's right forearm. On 11/8/23 at 11:30AM, R11 reported that back in August, R11 was in her room, up on her wheelchair, next to her bed; and bedside table was in front of her. R11 stated she was reading and dozed off and when R11 opened her eyes, R11 saw R12 on his wheelchair in her room, right in front of her, and dragging R11's cup on R11's table. R11 yelled and told R12, it is my cup, don't take it. R12 said to R11 this is my cup and my room. R11 then reported that R12 grabbed the remote and hit R11's right arm, and so R11 reported in hitting the arm of R12 to stop R12 from hitting R11 with a remote. Maintenance passed by and saw the incident and reported it to the nurse. The nurse then took R12 away of R11's room. R11 also reported that two month prior to this incident, approximately Month of May 2023, same resident (R12) wandered in R11's room. R11 coming from her shower, R11 entered her room and saw R12 in her bed, asleep. R11 yelled and asked the staff to take R12 off R11's bed. R11 reported that there were two separate occasions when R12 wandered in R11's room. On 11/8/23 at 11:10AM, V14 (Unit Manger) stated that nurses are around and other staff to keep a close look and monitor R12. Our intervention is to toilet or ask R12 if R12 needs to lay down back to bed if observed wandering the unit. Staff would ask R12 if he needs to use the toilet or assist him back to bed. On /9/23 at 915AM V1 (Administrator) stated that R11 reported the incident to V1. I think R12 may have wandered in R11's room few times before, With R11 as soon as R12 enters room R11 was able to redirect R12, except from the last incident when R11 I believe reported she fell asleep and did not see R12 came in her room. Staff knew R12 is a wanderer. My expectation is for staff to monitor all of our wandering residents. Staff to redirect R12 if noted wandering in the hallway. R12 was going in the dining because it was about the time for dinner, nurse thought R12 was going in the dining for dinner but somehow ended up in R11's room. On 11/9/23 at 9:30AM, V2 (DON) R12 has blindness and staff to redirect. Continue to guide R12. Able to move around and to keep his independence but for staff to redirect if observe with wandering behavior in the unit. We also encourage R12 to participate in activity to be able to monitor and R12 to stay occupied and not wanders the unit. Care plan for R12 dated 8/25/23 reads R12 often wanders in his wheelchair and goes into other resident rooms. Intervention: Staff will provide activities for R12, activity boards, folding clothes. Music therapy etc. Care plan for R12 dated 5/17/23 reads R12 experiences wandering and at times takes things that are not his. Interventions: Maintain calm environment and approach R12, and remove R12 from non-patient areas and return items that R12 may pick up. Care plan for R12 dated 5/15/23 reads R12 experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety). Interventions: Wander guard for safety. Check placement every shift; Approach from the front. Walk in step with R12 first before redirecting; If R12 looks for family/significant other, reassure that others know where to find him/her; Maintain a calm environment and approach with R12; When R12 begins to wander, provide comfort measures for basic needs such hunger or toileting; And when R12 becomes physically abusive, stop and try later. Do not force to do task. Care plan for R12 dated 3/2/23 reads R12 experiences wandering by entering rooms of his peers and attempt to lay in their beds. Interventions: Approach from the front. Walk in step with R12 first before redirecting; and when R12 begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, restless etc). R12 progress notes reviewed dated 3/1/23 and reads in part: R12 was seen in the bed of another resident. Incident was reported to R12's nurse. Other resident was not in the room at the time of this incident. R13 was admitted to the facility on [DATE] with a diagnosis of anemia, hypothyroidism, hypertension, atrial fibrillation, history of falling, and osteoporosis. R13's minimum data set dared 6/6/23 under functional status bed mobility (how a resident moves to and from a lying position, turns side to side, and positions body while in bed documents a score of 4 for self-performance which indicates total dependence- full staff performance every time during entire seven day period under support a score of two which indicates one person physical assist R13's point of care charting dated 7/13/23 documents under how resident moves in bed a score of four which indicates total dependence; Staff support provided for bed mobility documents a score of two which indicates one-person physical assist. R13's fall care plan interventions dated 9/8/22 documents: implement exercise program that targets strength, gait and balance; increased staff supervision with intensity based on resident need; obtain order for vitamin D, provide individualized toileting interventions; assessment and treatment for postural hypotension. R13's fall investigation dated 7/14/23 documents: was the cause of the fall known- No resident was in bed during sleep hours; Activity at time of fall- laying in bed; what fall interventions are listed on care card- documents not applicable for all except low bed which is not checked and documents error. floormat which documents started intervention placed on care card; were the interventions in place working at the time of the fall documents not applicable. What did the resident say they were trying to do or where were they going- she did not know how she fell. Under incident investigation documents resident explanation of incident- Roll out of bed. R13's fall risk assessment dated [DATE] documents a score of 13. Total score of 10 or above deems client at risk: initiate precautions R13's physical therapy plan of care dated 4/12/23 documents under mobility roll left to right prior level substantial/maximal assist-helper does more than half the effort. Helper lifts or holds trunk limbs and provides more than half the effort; under current level resident refused. R13's final fall reportable dated 7/25/23 documents: Upon further investigation, it has been determined that R13 experienced a fall while attempting to self-reposition and resident rolled over causing a change in plane. Staff were interviewed and were able to confirm that R1 was laying in bed with her call light within reach prior to fall. Per staff interviews R13 had received peri care 15 minutes prior. Upon interview R13 was unable to recall how she fell and was not able to communicate additional events surrounding the fall. R13 was heard yelling out by CNA while rounding and upon entry to the room R13 was observed lying on her right side on the floor parallel to the bed on top of the metal base of bedside table wrapped in bed linen. CNA notified nurse for further assessment. R13 was immediately assessed, and first aid care rendered. R13 was sent to emergency room for further evaluation and treatment. R13 returned to the facility with diagnosis of closed displaced fracture of the right femoral neck, nondisplaced fracture along the temporal process of the right zygoma, and adjacent fracture of the right lateral orbital wall. On 11/7/23 at 1:44PM, V26 (restorative nurse) said R13 had been provided incontinence care about 15 minutes prior to fall. Staff was in the next room when they heard R13 fall. R13 was wrapped in her sheets and rolled out of bed. No side rails on bed and unclear if any halo bar in place. When asked how did R13 roll out of bed when she needs assistance with bed mobility, V26 said she was unsure. On 11/7/23 at 3:42PM, V28 (Certified nursing assistant,CNA) said she provided incontinence care to R13 and roommate between four and five in the morning. R13 preferred to sleep in a fetal position and said R13 was in the middle of bed and bed in lowest position upon leaving the room. V28 said she went to the next room across the hall and heard help me and saw R13 on the floor in fetal position on top of bedside table base. Nurse came and she was assisted back to bed. She had a call light and can use it if she needs assistance, no behaviors that day, no changes observe that shift. On 11/8/23 at 12:34PM, V32 (rehab director) said R13 was dependent on staff for transfer and bed mobility in April of 2023. Rolling R13 refused but previously required a maximum assist. On 11/21/23 at 9:27AM, V49 (nurse) said she was nurse on duty at time of incident. V49 said staff informed her that R13 had a fall and when she entered the room, R13 was on the floor next to her bed on the bottom part of the bedside table. V49 said R13's bed was not in the lowest position but was not super high, unable to give any further details. R13's hospital record dated 7/14/23 documents under visit diagnosis: closed displaced fracture of right femoral neck and closed fracture of orbital portion of right zygomatic bone According to national library of medicine dated 6/27/22 fracture of zygoma is the second most common fracture of the face which can cause significant cosmetic and functional deformity. Fractures of the zygoma are almost always the result of high impact trauma. The most common mechanisms are assault, motor vehicle collisions, falls and sporting injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficiency requires two deficient practice statements. 1. Based on observation, interview, and record review, the facility failed to ensure that residents were free from falls by not implementing interventions according to the resident centered care plans and facility protocols for supervision. These failures applied to three of three (R47, R90, and R92) residents reviewed for accidents and supervision and resulted in R90 experiencing repeated falls; R92 requiring three staples to the back of the head as a result of a head injury from a fall; and R47 sustaining a right femoral neck fracture as a result of a fall. 2. Based on interview and record review, the facility failed to supervise a resident with known wandering behaviors and failed to prevent a resident from to wandering into another resident's room and relieving himself. This failure applied to two (R15 and R22) of two residents reviewed for supervision. Findings include: 1.A. R47 is an [AGE] year-old female who originally admitted to the facility on [DATE]. R47 has multiple diagnoses including but not limited to the following: nondisplaced fracture of right fibula, cerebral infarction, hemiplegia, dementia, muscle wasting, abnormalities of gait and mobility, need for assistance with personal care, lack of coordination, and type II DM. On 4/11/23 at 10:15AM, R47 was observed to be lying in bed with facial grimacing. R47 said she was having pain to her right hip and wanted to get out of bed. Attempted to interview R47 about fall incident on 4/1/23. R47 said she knows she recently hurt her hip from a fall, but she does not remember what had happened. At 10:30AM, V19 (Licensed Practical Nurse/LPN) was interviewed regarding R47. V19 said she was not present when R47 fell, but she knows she fell in the dining room during dinner shift, and she broke her hip. Facility progress note dated 4/1/23 at 6:41PM states in part but not limited to the following: R47 was observed on the floor in the dining room near the table, lying on R47 back with knees bent next to resident wheelchair and complaining of right-side hip pain. R47 said she was reaching for something for another resident and slipped and fell. On 4/12/23 at 2:42PM, V29 (Restorative Licensed Practical Nurse) was interviewed regarding incident with R47. V29 said R47 fell in the dining room during dinner time on 4/1/23. She said she was reaching for something that had fallen on the floor. Says no staff were in the dining room at this time. V2 (DON) interjected and said actually V28 (Certified Nursing Assistant/CNA) was in the dining room charting at the time of the fall, but her view was obstructed. On 4/13/23 at 10:29AM, V28 was interviewed regarding incident on 4/1/23 with R47. V28 said she was standing outside the dining room charting on a mobile laptop by the nursing station. V28 heard a loud bang and looked behind but did not see anything. A couple minutes later, I walked in the dining room to check what happened and I saw R47 on the floor screaming. She was on her bottom with her knees bent. I asked her what happened and R47 said she was reaching for something and fell. This happened around the end of dinner time. I was not assigned to supervise the dining room; I was charting near the nursing station. There was no other CNA present in the dining room at the time of the fall. At the end of the meal, the CNA assigned to the dining room will transport residents back to their rooms. There are times when a CNA may not be present in the dining room during this time. Hospital Inpatient Discharge summary dated [DATE]-[DATE] state in part but not limited to the following: Active Hospital Problems: Closed right hip fracture; Summary of admission and hospital course: [AGE] year-old female who presented to the emergency department with a mechanical fall. In the emergency department, she was found to have acute subcapital right femoral neck fracture with posterior angulation. R47 care plan with start date of 10/20/22 started in part but not limited to the following: Problem: R47 is at risk for falls due to weakness, impaired balance, decreased cognition, on psychotropic medication, and incontinence. Goal: R47 will be free of falls Approaches: Increased staff supervision with intensity based on resident need. Per Minimum Data Set Section G and GG with date of 1/19/23 states in part but not limited to the following: Balance during transitions and walking: moving from seated to standing position: not steady, only able to stabilize with staff assistance; Mobility: picking up object: the ability to bend/stoop from a standing position to pick up a small object: dependent- helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers required for the resident to complete the activity. On 4/11/23 at 11:40AM, ten residents were observed in the dining room, with no CNA or supervision. At 11:55AM, R61 was observed assisting residents and putting clothing protectors on residents. No staff observed in dining room at this time. At 12:20PM, V18 (Certified Nursing Assistant/CNA) came in the dining room to help serve lunch. V18 was interviewed regarding supervision in the dining room. V18 said there should be one CNA in the dining room during meals; however, we have to transport the residents back to their rooms after meals. There may not be supervision in the dining room when we are transporting people. There are some residents that need assistance during mealtimes as well. I do not feel as if one CNA is enough to supervise the residents. At 1:10pm, it was observed to have six residents in the dining room with no staff present. At 1:20PM, R47 stopped this surveyor and asked if she could go back to her room. No staff present in the dining room at this time. On 4/12/23 at 2:50PM, V2 (DON) was interviewed regarding supervision. V2 said, my expectation of supervision during mealtimes is that a staff member is present throughout the entire meal while residents are in the dining room. If a resident is requesting to be transported elsewhere, they should notify another CNA or staff member to supervise while they are not present. 1.B. On 04/10/23 at 11:32 AM, observed R90's bed not in lowest position. R90 stated the remote to his bed doesn't work. R90 stated he is getting tired of calling them to ask for his bed to be adjusted. R90 stated he fell out of bed the other day while asleep, so they try to keep his bed low to the floor. R90 stated his bed should be lower but he can't adjust it. On 04/11/23 at 3:25 PM, observed R90's bed raised approximately 1.5 to 2 feet from the floor. Observed V30 (Licensed Practical Nurse/LPN) lower R90's bed manually from his foot board because his bed remote control was not working. Fall Log Received 04/11/24 from Facility Documents R90 had falls 12/01/22 at 10:27 AM, 12/07/22 at 10:27 AM, 12/24/22 at 10:00 PM, 12/28/22 at 7:33 AM and at 2:02 PM, and 04/02/23 at 10:52 PM. R90's current care plan documents he is at risk for falls with interventions including ensure (trade name) a tool aid for picking up things that are out of reach, is within reach, educate resident to use (trade name) tool aid as needed, and use call light for assistance, and ensure the bed height is at its lowest position, Increased staff supervision with intensity based on resident need, resident is educated on using proper body mechanics when repositioning in bed, ensure floor mat is in place, be sure resident call light is within reach and encourage the resident to use it for assistance as needed. The residents prompt response to all requests for assistance. R90's progress note dated 12/01/2022 at 09:57 PM documents writer was made aware by CNA (Certified Nursing Assistant) that resident was on the floor on the side of the bed. Fall was unwitnessed, and resident stated that he was trying to sit in the chair. R90's progress note dated 12/24/2022 10:15 PM documents at approx. 10pm resident was observed by CNA laying on the floor. Resident stated he had a fall while trying to reposition for comfort. R90's progress note dated 12/28/2022 07:45 AM documents at approximately 7:10 AM, resident was observed on the floor in prone position by staff. Resident stated he didn't fall but slid out of bed to the floor; at 02:15 PM CNA staff reported to writer that resident was on the floor, writer noted resident lying on the floor next to bed. R90's progress note dated 04/02/2023 10:40 PM documents writer called to room and witnessed resident on hands and knees on the floor. Writer asked resident what he was trying to do, and he stated, I was reaching for something on my dresser and ended up on my hands and knees. I really didn't even fall. I never touched the floor fully my body didn't hit anything. The resident stated he was reaching for something on his dresser when he fell. On 04/12/23 at 02:57 PM, V29 (Restorative Licensed Practical Nurse/Fall Coordinator) and V2 (Director of Nursing/DON) stated that staff needed to be educated on R90's specific needs and ensuring staff observe his care plan for fall interventions. V29 and V2 agreed that R90's bed should be in the lowest position. V29 stated if a resident is at risk for falls and their bed is not in lowest position as included in their fall interventions, they could fall, and anything can happen. On 04/13/23 from 1:51 PM - 2:09 PM, V2 (DON) stated a root cause analysis should be completed after each fall. V29 (Restorative Licensed Practical Nurse/Fall Coordinator) stated R90 has a behavior of adjusting his bed with his remote. V29 stated this behavior would contribute to his fall risk factors as well as him attempting to reposition himself in bed and transfer himself. V29 stated R90 does need increased supervision based on his fall history which would include frequent every hour - hour and a half. 1.C. 04/10/23 11:50 AM, R92 was not in his room during resident screening and was later seen at the dining area sitting with about five other residents. No staff member noted in the dining area. Resident was awake and alert but unable to answer any questions. 04/11/23 at 10:05AM, R92 was observed in the dining area with other residents, there were no staff members in the dining area with the residents. 04/12/23 11:45AM, R92 was observed in the dining area with other residents from 11:30AM to 11:45AM, there were no staff in the dining area or the nursing station. Review of facility fall log showed that R92 had an unwitnessed fall in his room on 1/3/2023 with no injuries, the intervention for that fall incident was to increase staff supervision and redirect as needed. On 3/21/2023, facility documented another unwitnessed fall in the resident's room with a head injury, was sent to the hospital and returned to facility with three staples to the back of his head. Writer was alerted to patient's room by therapy staff. Writer observed patient lying supine on floor next to his wheelchair. Writer asked resident what happened. Resident stated, I was reading my daily chronicles, one of them fell on the floor and I reached to pick it up, then I fell on the floor. Resident placed into bed with a mechanical lift. Head to toe body assessment done and noted 2cm cut to back of head and bleeding noted. Pressure and ice pack applied to back of head. bleeding stopped. (Trade Name) wound closure tape applied. No loss of consciousness. No complaints of pain voiced. Vitals taken: 145/66,62,17,98.0,97% O2 room air. Neuro checks initiated. Writer notified Hospice and ok to send to hospital for further evaluation. NP made aware. left voicemail for patient's son(s). DON made aware. (ambulance) called for pick up. (ambulance) arrived and pt exited facility on stretcher. will try again later to call son(s). R92's medical record includes documentation, 03/21/2023 07:29 PM: Resident alert and verbally responsive. Behavior calm and cooperative. Resident denies pain or discomfort at this time. Skin assessment completed revealing a laceration with 3 staples to back of head s/p fall. No swelling, drainage, or other s/s of infection at this time. Resident returned to a position of comfort with bed in lowest position and call light attached. Resident arrived back on the unit alert and in stable condition via ambulance. Neuro check WNL and all vitals stable. No signs nor complaints of any distress. Able to move all extremities. R92 arrived on the unit with three staples that was placed to posterior head and orders to leave in place for 7-10 days. Both (son) and NP made aware of arrival on unit and resident clinical situation. Monitor closely, frequent rounds, and all safety measures in place. Will continue to monitor. Facility policy titled Falls and Fall Risk, managing with revision date of 3/2019 states in part but not limited to the following: Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident-centered approaches to managing falls and fall risk: The staff will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. 2. R22 is a [AGE] year-old male who was admitted to the facility 11/16/2021 and has diagnoses that include: dementia, lack of coordination and a history of falls. On 4/10/23 at 09:37 AM, R15 said one-time R22 came into her room, urinated in a cup, and left it on her table. Another time he came into her room and defecated on the floor and smeared it all over. Facility Concern Form: dated 3/20/23 states R15 complained about another resident going into her room. Summary of Findings determined that the confused resident is in the same room down a different hall. This resident wanders, gets confused, and then goes into R15's room and starts to clean up or remove items that are unfamiliar. Resolutions signed by V1 Administrator) said that family of this resident was contacted and asked to find a dementia unit what would better meet the needs of the resident as he is unable to be redirected easily and is upsetting the alert residents. 04/12/23 04:18 PM, V7 (Assistant Administrator) confirmed the wandering resident to be R22 and said there were concerns with R22 going into R15's room and care plans were updated to reflect that provided redirection. His room was equidistant to R15's room, and there was at least one incident where he used her toilet and missed. We had to get housekeeping to clean it up. Progress note dated 03/15/2023 at 12:34 PM stated: This writer made several attempts and left [Voice Mail] messages on 3.14.23 and 3.15.23 to son of resident (R22) regarding his increased wandering. Writer will [follow up] with another phone call. [Social Services] will continue to provide therapeutic services as needed. 04/12/23 02:52 PM, V2 (DON) stated, I think given certain residents and staff attempts to do. The residents have the right to manipulate themselves. If a resident is cognitively impaired, rounding, supervision, meaningful activities, asking for family to be more active. We expect for the residents to be supervised by staff ideally at all times. According to our payroll-based journal (PBJ) we have enough staff to provide this supervision.