Based on interviews and record review, the facility failed to prevent an injury of unknown origin which occurred for one resident. This affected one of three residents (R1) reviewed for injury of unknown origin. This failure resulted in R1 sustaining an undetermined injury of an acute left humeral neck with displaced transverse fracture.Findings Include:R1's referral package dated 8/17/22 documents: past medical history of falls, osteoporosis and closed hip fracture. R1 was admitted with the diagnosis of Age-Related Osteoporosis without current pathological fracture. Minimal data set section C (Brief interview for mental status) dated 6/3/25 document a score of four (4) which indicates severe cognitive impairment. Section GG (functional abilities) documents: R1 required substantial/maximal assistance with upper body dressing, the ability to dress and undress above the waist: including fasteners, if applicable. Event report dated 6/29/25 documents: At approximately 4:00pm on 6/29/25, the assigned V6 (CNA) reported to V8 (nurse) that following taking R1's blood pressure with the vital machine there was a discoloration to her left arm. V8 and another nurse went to assess and noted a mild discoloration to R1 left arm where the cuff was applied. Action taken: range of motion within normal limits, R1 denied pain, MD notified of temporary discoloration that appears to have resolved. R1's X-ray requisition dated 7/1/25 documents reason: unable to move left arm. Radiology report dated 7/1/25 document: Impression: Left humerus (long bone in the upper arm neck extending from the shoulder to the elbow) with complete transverse fracture with displacement. V8's witness statement dated 7/2/25 documents: continues to monitor R1 with no worsening and it seemed to resolve.On 7/15/25 at 9:35am, V9 (nurse) said on Sunday June 29th at the end of her day shift, and the beginning of V8's (nurse) shift which was the evening shift (3pm-11pm), V8 asked V9 to look at R1. V9 said, R1 was observed with bruised area to the left upper arm. V6 reported taking R1's vitals, V9 said V8 was asking R1 questions about her left arm. V9 said, R1 was unable to report how she got the bruise or an incident. V9 denies knowledge of incident/abuse involving R1. On 7/15/25 at 10:07am, V6 (CNA) said, when he did his rounds and passed water to R1 around 2:30pm -3:00pm, R1 was relaxing perfectly fine in bed. V6 said, about an hour later he took R1's vitals. V6 said, R1 made a face when he took off the blood pressure cuff off her arm. V6 said, he informed the nurse who instructed V6 to update him if R1's bruise got worst. V6 said, R1's bruise was a little red. V6 said, R1's bruise did not get worst. V6 said, he asked R1 what happened, R1 denied fall or abuse. Vital report dated 6/28/25 and 6/29/25 taken by V6 (CNA) documents lying/r/arm. On 7/18/25 at 2:15pm, V2 said, r indicates Right arm.On 7/15/25 at 12:08pm, V1 (administrator) said R1's bruise was not an injury of unknown origin R1's left arm fracture was. V1 said, she does not know when R1's fracture occurred. V1 said, staff saw the discoloration to R1's arm after V6 (CNA) removed the blood pressure cuff. Then an x-ray was ordered which resulted in a fracture. V1 said, R1 did not have a traumatic event. V13 (nurse practitioner) said, R1's fracture was pathological. R1 had a diagnosis of osteoporosis and osteopenia. On 7/15/25 at 1:11pm, V16 (orthopedic specialist) said, R1's fracture was due to either a fall on the ground landing on her left arm or someone moved R1 attempting the wrong way, lifting by R1's arm instead of R1's core. Pathological fractures are due to underlying conditions associated with cancers/tumor. V16 said, a blood pressure cuff did not cause R1's fracture. R1 is not a healthy person but none of her current diagnosis would be associated with her fracture. V16 said, bruising/blood takes three to five days to come out of the bone, travel through the muscle and appear on the skin. On 7/15/25 at 1:29pm, V13 said, staff called him to report R1's bruise. Staff reported R1 had a routine blood pressure and when the cuff was removed, she had a bruised area where the cuff had been placed. V13 said he asked what happened, staff denied pain initially, fall or trauma. R1 had osteoporosis. R1's bruising increased. R1 complained of mild pain. R1 had swelling noted to her left upper arm. V13 said, he ordered an x-ray which resulted in a transverse fracture. V13 said, R1 was discharged to the hospital for further evaluation. No surgery was indicated. R1's fracture could be from osteoporosis or from normal activities of living (ADL) i.e. R1 could have been moving and the bone just snapped or with ADL care when staff was helping resident. R1 was on prednisone which can demineralized the bones. V13 said, he did not review the x-ray result, speak with any of the hospital doctors or the orthopedic doctor in order to determine the root cause of R1's fracture. V13 said, he cannot differentiate the cause of R1's fracture. V13 said, he relied on staff's information. V13's practitioner note dated 7/7/25 documents: Member (R1) with significant past medical history of osteoporosis, hypothyroidism, severe calories malnutrition and based on review of hospital note, her (R1) acute displaced fracture to left humerus is mostly due to pathological fracture. Per staff, on 6/30/25 evening, R1's blood pressure taken and they noted to have bruises to the left upper arm where blood pressure cuff was placed. In the morning, staff noted that the bruising worsened, with swelling, complaint of pain with limited movement of her left arm.On 7/15/25 at 3:52pm, V2 (Director of Nursing) said, R1's fracture was perceived to be from the blood pressure cuff compression. V2 said, she was not sure why R1's arm did not bruise with the other daily blood pressures that were taken prior to the bruised area being found. V2 said, R1's body was changing and at that time the blood pressure was taken, it could have been a change in R1's body resulting in a bruised arm after the blood pressure cuff was removed.Hospital paperwork dated 7/2/25 documents: R1 with past medical history of age-related osteoporosis and functional quadriplegia who presented from nursing facility for evaluation of left upper extremity bruising, Unknown if R1 had a fall or when R1 incurred injury to left arm. Per emergency room physician discussion with primary care provider, there were no documented fall at skill nursing facility but patient (R1) was being lifted from bed to wheelchair and back to bed with a mechanical lift during which injury may have been possible. X-ray note acute displaced fracture of left proximal humerus.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor a resident (R2) sitting on the side of the bed when preparing R2 for a transfer when R2 reached for an item on the ground causing R2 to fall off the bed for one out of three residents reviewed for falls in a total sample of eight. The failure resulted in R2 needing to be hospitalized after suffering a laceration to the head and a subarachnoid hemorrhage. Findings Include: R2 is an [AGE] year old with the following diagnosis: traumatic subdural hemorrhage, aphasia, hemiplegia affecting the left side, glaucoma, and cognitive communication deficit. Nursing note dated 4/5/25 documents the CNA reported to the nurse that as the CNA was turning to grab R2's wheelchair, R2 fell forward from a sitting position on the side of the bed. R2 struck R2's head on the nightstand before landing on the floor on the left side. The nurse assessed R2 and noted a small laceration to the left side of the forehead with moderate bleeding. A pressure dressing was applied by the wound nurse. 911 was called and took R2 to the hospital for an evaluation. R2 was admitted to the hospital. Nursing note dated 4/5/25 at 11:50 PM documents R2 was transferred to a different hospital with a diagnosis of left subdural hematoma. The Hospital Transfer Form dated 4/5/25 documents the reason for transfer was fall. A laceration was noted to the left side of the head. R2 was documented as being a high fall risk. The Emergency Department Records dated 4/5/25 document R2 presented to the emergency room for a witnessed fall. R2 has no recollection of the fall and does not know why R2 was sent to the emergency department. Per the facility, R2 fell while being transferred from the bed to the wheelchair. R2 was not a reliable historian. Upon physical examination, there was a concern for a forehead laceration. A CT of the head was completed and showed a small subdural hematoma along the left cerebral convexity, and a small hemorrhagic contusion to the left frontal lobe. The x-ray of the pelvis showed an irregularity along the lesser trochanter of the femur, which could be concern for fracture. R2 had a laceration repair at 11:59 AM. The laceration was about 3 cm in length and repaired with steri-strips. R2 was then transferred to another hospital as a trauma patient. A follow up CT scan was completed at this hospital, which showed a decrease in size of the frontal lobe contusion since yesterday. There is small residual hyperdense focus. No new hemorrhage was identified. The subarachnoid hemorrhage has resolved. The MRI of the left hip did not show any evidence of a left hip or proximal femur fracture. There is mild subcutaneous edema within the left lateral hip. The Facility Incident Report dated 4/11/25 documents the CNA assisted R2 with ADL care. The CNA reached to position the wheelchair for transfer when R2 reached for eyeglasses on the floor and fell forward, landing on the left side before the CNA could assist R2. The CNA immediately alerted staff for assistance. A body assessment was completed and an open area to the left side of the forehead was noted. First aid was administered and a dry dressing was applied. When interviewed, R2 said, I was reaching. Prior to the incident, R2 was sitting comfortably with the bed in the lowest position. New orders were received to send R2 to the emergency room for further evaluation. R2 was transferred to a different hospital and admitted with a small left subdural hematoma. Repeat CT scan revealed this small hematoma resolved and did not require any surgical intervention. On 5/13/25 at 2:06PM, V2 (CNA) stated V2 was doing morning care and was getting R2 dressed and washed up. V2 sat R2 on the side of the bed and R2 was sitting up. V2 reported R2 reached down on the side of the floor and fell out of the bed. V2 stated V2 always has to coach R2 when V2 is with R2 because R2 has a habit of reaching. V2 reported R2 wasn't a high fall risk at the time of the fall and is a one assist with transfer and walking. V2 stated V2 was facing R2 when R2 was reaching but V2 was setting up the wheelchair so V2 didn't see R2 begin to fall. V2 reported V2 was maybe a foot or two away from R2 when the fall occurred. V2 stated V2 set the wheelchair down right in front of R2 so the wheelchair was in between V2 and R2. V2 reported V2 usually sets up the wheelchair in the way because R2 has never had a problem with falling forward before. V2 stated R2 had a cut to R2's head. V2 was unaware if R2 was in physical therapy at the time of the fall. On 5/14/25 at 11:50AM, R2 was sitting at the dining room table waiting for lunch. R2 stated R2 was comfortable speaking in the dining room. R2 reported having a fall about a month ago. R2 was not able to remember what caused the fall. R2 stated R2 couldn't remember anything until R2 was at the hospital and hospital staff told R2 that R2 fell. R2 pointed to R2's left side of the top of the head and told the surveyor that this is where R2 hit R2's head during the fall. There is a healed scar about 1.5 inches long. R2 was not able to remember if R2 had any other injuries. R2 could not remember who was in the room with R2 during the fall. R2 stated R2 now has a reacher to grab things so R2 won't bend down anymore. R2's mental status was assessed. R2 knew R2's name, birthday, and that R2 was in a nursing facility in Chicago. R2 was unable to state the date or the name of the town. On 5/14/25 at 11:59AM, V4 (Nurse) stated V2 informed V4 that R2 was on the floor so V4 went to assess R2. V4 reported R2 had bleeding coming from the left side of the top of the head and a dry dressing was put on it after the wound nurse looked at it. V4 stated R2 was sent out via 911 per the physician's orders. V4 knew R2 couldn't move one side of the body due to stroke but V4 couldn't remember what side. V4 reported R2 is not a high fall risk and is not confused. V4 stated V2 told V4 that R2 was leaning forward out of the bed and was trying to grab something and fell. V4 was not aware of R2 having that behavior. On 5/14/25 at 1:02PM, V6 (Therapy Director) stated when R2 was in therapy before the fall, R2 was moderate assist with transfers. V6 reported transfers were rough for R2 so R2 was referred to therapy for that reason. V6 stated R2 had fairly good trunk control. V6 reported R2 can follow directions and knows who you are but won't remember what day it is. On 5/14/25 at 1:45PM, V10 (Medical Director) stated a radiologist will report any kind of bleed even if the bleed is small in the brain. V10 reported if there is an area the radiologist sees that is hyperdense focus it means that area of the brain on the scan was brighter than it should have been, but it is usually a really tiny area only millimeters long. V10 stated the hyperdense focus could be from a bleed that has a large sized hematoma to accompany it which would be caused by trauma. V10 reported if a resident has a certain behavior that puts them at risk of being harmed then it is the responsibility of the facility to prevent any harm from that behavior as best as possible by putting in interventions that address the behavior. On 5/14/25 at 2:07PM, V9 (DON) stated V9 does all the reportable investigations for falls with injury. V9 reported R2 had a witnessed fall with a laceration to the head. V9 stated V2 told V9 that V2 turned to get the wheelchair for R2 when R2 leaned forward and fell before V2 could react. V9 denied R2 remembering the fall. V9 reported R2 was admitted to the hospital so they could rule out a subarachnoid bleed in the brain. V9 stated the subarachnoid bleed was ruled out but R2 needed to stay in the hospital about three to four days for monitoring. V9 was not able to answer if the brain bleed was ruled out then why was it added to R2's diagnoses on the face sheet? V9 said, That is a question for MDS. V9 reported R2 also had a laceration repair of the forehead while at the hospital which has now healed. V9 stated a reacher was put in place after the fall to prevent any additional falls from happening in this manner. V9 reported R2 is a fall risk but not a high fall risk because R2 is not confused. V9 stated R2 does have a history of a stroke with weakness or paralysis to one side. On 5/14/25 at 2:53PM. V13 (MDS Nurse) stated V13 reviews the most recent assessment and plan from the physician in the hospital records upon a resident's return to the facility. V13 reported V13 uses active diagnoses to update the resident's face sheet. V13 stated R2 had a follow up with neurosurgery to see if R2 was able to restart the anti-platelet medication after having the brain bleed. The Fall Report dated 4/5/25 documents the CNA was providing R2 morning ADL care. The CNA just changed R2's clothing and sat R2 on the side of the bed to get R2 into the wheelchair. The CNA reported turning to retrieve the wheelchair when R2 leaned forward from a sitting position at the side of the bed, causing R2 to destabilize and fall forward. R2 struck R2's head on the nightstand before landing on the left side. R2 said, I fell onto the floor. I am OK but my head hurts. R2 denied any other pain or discomfort. R2 is noted with a small laceration to the left forehead with moderate bleeding. 911 was called to take R2 to the hospital for further evaluation. The Hospital Records dated 4/7/25 document R2 has a history of cerebral vascular accident with residual left sided hemiparesis. R2 presented as a trauma transfer for mechanical fall R2 was being transferred from the wheelchair when R2 became lightheaded and fell forward, hitting R2's head but did not lose consciousness. The initial CT scan of the head showed a small subdural hematoma with serial CT scans showing the hematoma was stable. Per neurosurgery, no surgical interventions are recommended, but will continue to hold the anti-platelet medication until follow up. An MRI of the left femur revealed there was no evidence of acute fracture. Assessment and plan documents a mechanical fall with a subdural hematoma. This is the documentation that V13 referenced and showed the surveyor for the diagnosis of subdural hematoma that was entered on R2's face sheet upon return to the facility. The Physical Therapy progress report dated 3/7/25 through 4/2/25 documents R2 is a fall precaution with aphasia and left sided weakness. R2 needs partial/moderate assistance from going from a sitting to standing position and transfers. R2 needs supervision or touching assistance with walking. Picking objects up off the floor is documented as not applicable. Continue therapy is recommended to increase lower extremity range of motion and strength, minimize falls, and promote safety awareness. The note dated 4/2/25 documents skilled interventions focused on instruction in scooting techniques to facilitate upright posture and proper positioning in wheelchair and training and safe sit to stand/stand to sit mobility. The After Visit Summary dated 4/30/25 documents R2 had a follow up with neurosurgery and was cleared to resume the anti-platelet medication. This was a follow up due to the subdural hematoma and fall. The Fall Risk Evaluation dated 11/2/23 documents a score of 15 indicating R2 is at high risk for falls. This assessment was completed post fall. R2 has decreased mobility, is confused/has impaired memory or judgment, is incontinent, and above 75. No other fall risk evaluations were completed again until 4/5/25. This fall risk evaluation document a score of four indicating R2 is not at risk for high fall. A score of 10 or higher makes a resident high risk for falls. When looking at the assessment, it is incorrectly coded, giving R2 a lower score. If the assessment was properly charted, R2 would have a score higher than 10 making R2 a high fall risk. The Functional Abilities and Goals dated 2/7/25 document R2 needs substantial/maximal assistance with bed mobility, going from a sitting to standing position, and transfers. Picking up an object from the floor was not attempted due to medical condition or safety concerns. The Care Plan dated 11/3/23 documents R2 is at high risk for falls related to impaired mobility and strength, decline in cognition, potential medication side effects, unsteady gait, and diagnosis of cerebral infarct with left hemiplegia. Interventions put in place after the fall on 4/5/25 include educate R2 on the importance of complying with safety measures and document understanding of education and instances of noncompliance, encourage use of and provide a reacher as needed to assist R2 with getting items from hard reach areas, and encourage appropriate use of the walker and wheelchair. The Care Plan dated 11/8/23 documents R2 is memory, impaired, and has difficult with decision-making, insight, logic, planning, and organization of thoughts. The Care Plan dated 11/9/23 documents R2 is on antiplatelet therapy and is it risk for adverse side effects. The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental status score at 11 (moderate cognitive impairment). Section GG of the MDS indicates R2 has an upper extremity impairment to one side. R2 needs substantial/maximal assistance with bed mobility and transfers. The policy titled, Fall Prevention and Management, dated 2/2025 documents, General: This facility is committed to maximizing each resident's physical, mental, and social well-being. While preventing falls is not possible, the facility will identify and evaluate those residents at risk or fall, plan 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** B. On 7/25/24 at 3:13PM V10 (Nurse) said, R3 was wheelchair bound, very weak and could not articulate well. V10 said, V13 (CNA) updated her that R3 was yelling when she touched his left leg. R3 had a history of left knee pain. V10 said, R3 allowed her to move his left leg. R3 was in pain. V10 said, R3 had a facial grimace when she attempted to reposition R3's leg while he was in the wheelchair. V10 said, she lifted R3's leg up and down while R3 sat in his wheelchair. V10 demonstrated lifting her leg by gathering both hands underneath her posterior thigh just behind her bent knee and lifted her leg up, with her foot coming off the floor a few inches while she sat in the chair. V10 did this motion once as an example of how she assessed R3 while he was sitting in his wheelchair. V10 said, she administered, R3's scheduled muscle rub to the knee and gave an acetaminophen. V10 said, she was not sure what happen after that because she ended her shift earlier than scheduled. V10 said, R3 was sent to the hospital the following day. R3 was diagnosis with a fracture. V10 said, she thought R3 was having knee pain. On 7/25/24 at 3:30PM, V13 (CNA) said, she was passing dinner trays, R3 was in his room sitting by the closet which was odd. Normally, R3 was in the hallway, self-propelling in his wheelchair using his feet and the handrail to go back and forth in the hallway. R3 normally ate in the dining room. V13 said, she placed R3's dinner tray on his bedside table. V13 said, she noticed R3's left leg was bent completely back up under his wheelchair. V13 demonstrated how R3 was sitting in his wheelchair by scooting towards the edge of her seat and placing her leg, with a bent knee behind her completely under her chair. V13 said, she tried to move R3's leg. R3 was in so much pain. R3 was unable to report what happen. V13 said, she informed V10. On 7/26/24 at 1:33PM, V18 (PAN Nurse) said, R3 was observed in the bed moaning and groaning in pain. The nurse should have assessed R3's pain by completing a comprehensive head to toe assessment which includes vitals, range of motion to limbs, extending and flexing extremities, asking the resident if something happen, notified MD/family and followed given orders. R3 required staff assistance for transfers. R3 was able to self- propel with feet once in wheelchair. On 7/30/24 at 3:55pm, V32 (Nurse) said, R3's words and actions contradicted each other. R3 will say he is not in pain while guarding or holding on to a body part. On 7/31/24 at 12:58pm, V33 (Medical Doctor) said, she was not notified of R3's change of condition on 6/13/24. Severe osteoporosis/osteopenia can contribute to a fracture but whatever trauma happen to R3's leg that caused his leg to be bent completely under his wheelchair was the cause of his hip fracture. V33 said, she was notified about R3's fracture after he returned from the hospital. V33 said, she would expect the nurse to lay R3 down on his bed and complete a full body exam to include range of motion of the extremities after R3 was groaning with facial grimacing and yelling out in pain. R3 would have had severe pain with a hip fracture. V33 said, she would have ordered a stat x-ray had she been informed of R3's change of condition. Most hip fractures are caused by a traumatic event. V33 said, she does not know exactly how R3 fractured his hip. R3 has a diagnosis of prostate cancer but there was no documentation that R3's cancer metastasized to his bones in R3's medical record therefore it cannot be considered as a factor. Nursing note dated 6/13/24 written by V10 at 18:36 (6:36pm) documents: Prior to dinner CNA (V13) attempted to reposition resident's (R3) left foot to bring side table towards him. Resident (R3) voiced vulgar language and told the V13 to get away from him and also grimaced. Nurse observed R3, R3 grimaced, when moving left leg but not right leg. R3 voiced he was not in pain but did mumble something incoherent. R3 was sitting in wheelchair at time of assessment and refused to go in bed. Resident was observed in room, ambulating in wheelchair but resident did not leave the room during the evening. PRN acetaminophen administered and pain ointment was administered. Left hip was touched, no abnormal reaction to touching site. Knee was assessed as resident refused care, no signs of dislocation fracture or bruising to site. Medication appeared effective. No signs of pain assessed prior to leaving. Witness stated written by V10 documents at approximately 18:15 (6:15pm) on 6/13/24: C.N.A (V13) requested she observe R3. While sitting in his wheelchair R3 was observed with resistance to moving his left lower extremity (LLE) and would not move his left foot. R3 exhibited grimacing and stated leave me alone when the C.N.A (V13) attempted to assist with mobility. V10 assessed R3's left ankle and LLE for any signs of injury. NO sign or symptoms of injury were observed. Witness stated written by V25 dated 6/14/24 documents: during the shift change, second shift CNA stated, she noticed something with his (R3) leg when [NAME] was putting him to bed the night before, V25 then squeezed his (R3) knee again, got no reaction but when I tried to move his leg, he reacted in pain. Telehealth evaluation dated 6/14/24 documents: R3 started to have left leg pain, therefore he had x-ray left hip, knee and left ankle. Left hip revealed impacted fracture of left femoral neck. R3 complained of pain with movement of hip and leg. This is an acute new problem. R3 condition is worsening pain. Transfer to emergency department. Diagnostic Order dated 6/14/24 at 15:29 (3:29pm) documents: left knee, three view, left hip, unilateral with pelvis. Facility radiology result report dated 6/14/24 at 20:55 (8:55pm) documents: impression pelvis: impacted transcervical fracture of the left lower neck with varus deformity. Hospital paperwork dated 6/14/24 documents: He (R3) has been complaining of severe left hip pain which prompted them (facility) to get an x-ray. R3 was able to answer yes and no to questions. Musculoskeletal: Left lower extremity is shortened. Cat scan (CT) pelvis without contrast dated 6/15/24 document: New acute transcervical left femoral neck fracture with marked impaction and varus angulation demonstrated. No dislocation. Diagnosis: Closed hip fracture. A. Based on interview and record review, the facility failed to follow physician orders by not obtaining a urinalysis and culture for one resident who was identified as being incontinent of urine with a new onset of lethargy. This affected one of three residents (R4) reviewed for physician orders. This failure resulted in R4 being sent to the hospital with a diagnosis of urinary tract infection and sepsis. B. Based on interview and record review, the facility conduct a comprehensive body assessment on a resident observed with his left leg/knee contorted under his wheelchair, facial grimacing and yelling out with movement. This affected one of three residents (R3) reviewed for quality of nursing and assessment. This failure resulted in R3 waiting twenty hours for an x-ray order which resulted in a diagnosis of a new acute transcervical left femoral neck fracture with marked impaction and varus angulation. Findings include: A. R4 was admitted to the facility on [DATE] with a diagnosis of hemiplegia, abnormalities of gait, weakness, depression, hypertension, functional quadriplegia, and compression of the brain. R4'as physician order dated 6/4/24 at 8:05PM documents: STAT chest x-ray, STAT CBC, CMP and Urinalysis with culture and sensitivity. On 7/26/24 at 12:26pm, V14(Lab Tech) said they did not receive any notification from the facility for any urine collection pick ups and did not receive any urine specimens from the facility for R4. On 7/31/24 at 11:32AM, V19(Nurse Consultant) said the facility practice on obtaining a urinalysis from an incontinent patient, would be to get an order for urine straight cath from the doctor and family consent. Staff should let the doctor know if unable to obtain urine specimen. The staff will usually get the sample during night shift or earlier because the lab will pick up specimens in the morning. V19 said the lab comes every morning to the facility. On 7/31/24 at 9:17AM, V36(NP) said if R4 had an order for urinalysis, she would expect staff to have collected specimen prior to hospitalization. Staff should have called to obtain order for straight cath if no urine was able to be obtained especially in an incontinent resident within first day. V36 denies receiving any calls related to R4 needing a straight cath order. V36 said she does not recall receiving any calls related to a change in mental status for R4 and said if she did, she would have sent R4 to the hospital immediately because she was a new admit and a change in her condition. R4's hospital record dated 6/6/24 documents: R4 presents from facility with altered mental status. R4 opens eyes to name but unable to answer questions or follow commands. R4's white blood count was 12.6 high (normal range 4.2-11.0). Clinical impression documents sepsis, tachycardia and acute urinary tract infection. R4s urinalysis dated 6/6/24 documents urine color orange; appearance turbid; occult blood large (normal is negative); leukocytes large (normal result negative), bacteria moderate (normal result none); Mucous present. Urine culture collected 6/6/24 and completed 6/9/24 documents greater than 100,000 Escherichia coli. Blood culture collected 6/6/24 and completed 6/9/24 documents Escherichia coli. R4's Minimum Data Set, dated [DATE] documents under section H bowel and bladder under urinary continence documents always incontinent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R8 admitted in the facility on [DATE] under hospice care and expired in the facility on [DATE]. R8 has diagnoses of Metabolic Encephalopathy, Malignant Neoplasm, Anemia, Type 2 Diabetes, Pain in Right Hip, and Convulsion. R8 has a BIMS of 3 (Severe Cognitive Impairment). R8 had 2 fall incidents in the facility. Fall incidents dated [DATE] and [DATE]. R8 has care plan for high risk for fall with an initial date of [DATE]. R8 has care plan for high risk for falls related to impaired mobility and history of seizure with a created date of [DATE] and revised date of [DATE]. R8's [DATE] fall incident reads in part: R8 was observed on the floor, during final rounds laying on the right side, using right arm to support his head. When R8 was asked what happened. R8 was unable to explain what happened, but when asked if he was trying to turn, R8 said yes. R8 fall care plan updated after the first fall on [DATE] and intervention added was provide perimeter pillows dated [DATE]. R8's [DATE] fall incident reads in part: Nurse was called and notified by R8's family member who was visiting R8 that R8 was on the floor mat. Upon entering the room, writer observed R8 on the floor mat. R8 was rounded on 10 minutes before the incident. R8 was in bed sleeping and bed in low position. No injury. Assisted back to bed with 2 staff. R8 fall care plan updated after the second fall on [DATE] and interventions added were bed bolsters for perimeter awareness and rounding for prompt assist for change in position, toileting, offer fluids, and ensure resident is warm and dry dated [DATE]. On [DATE] at 2PM, V31 (Complainant) stated that another family member came in before her and saw R8 on the floor next to his bed. V31 stated that this family member recorded the time that the nurse was made aware of the fall. V31 stated her family member stopped recording when V31 arrived on the scene. V31 observed R8 on the floor, no staff with the resident just the other family member. V31 reported that 2 female staff members entered the room and assisted in placing back R8 into his bed. They waited 13 minutes with no staff watching R8 and R8 was left on the floor. Review of family's attached video with this complaint. Video shows V28 (Nurse) walking in the room. R8 on the floor, laying on floor mat with pillow on his head. Nurse left the room. Video ended. On [DATE] at 2:40PM, V7 (IP Nurse, covering DON) stated that for any fall incident, the team will meet and discuss the root cause analysis. Based on the fall, they will add interventions appropriate for the resident. For R8's fall incident on [DATE], the team doesn't know how R8 really fell, might be due to R8 was restless and maybe repositioning himself in bed. We added perimeter pillows after the first fall. Floor mats were in place the morning of [DATE], before his 2nd fall. Due to the fall of [DATE], pillows were used to tuck on his side that will give awareness to R8 that he is close to the edge of the bed. Somedays R8 was more alert than other days, the intervention added would be helpful on the days R8 was more alert. V7 stated that after R8's second fall the team added interventions of monitoring and bolster small foam, which is a little more solid than a pillow. During R8's health decline, that was when the falls happened. In general, CNAs or staff that found the patient on the floor, has to call or yell out for help or push the call light; but stay in the room because we don't want the resident to move until they are assessed by a nurse.They need to assess the resident before moving and placing the resident back to bed. The nurse has to give an okay in order for them to move the resident. Our expectation is for the staff to keep an eye on the patient to prevent anything else that could happen with the patient. Expectation to call for assistance immediately, we have plenty of people around to help. Fall Prevention and Management Policy with a revised date of 1/2024, reads in part: This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. 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 existing plan of care shall be evaluated and modified as needed. A fall risk evaluation will be completed on admission, readmission, and quarterly, significant change and after each fall. Care plan to be updated with new interventions based on the root cause analysis after each fall occurrence. Based on observation, interview and record review, the facility failed to implement effective individualized fall interventions to include supervision/monitoring and reduce the risk of multiple falls. This affected two of three residents (R2, R8) reviewed for falls prevention interventions. This failure resulted in R2, who had a diagnosis of Dementia and Alzheimer's disease and identified as high fall risk sustaining a second unwitnessed fall from bed requiring hospitalization for an acute comminuted displaced fracture of the bilateral nasal bones and one centimeter lip laceration. In addition, the facility left R8 unsupervised on the floor for 13 minutes following an unwitnessed. Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, weakness, and dementia. Resident's brief interview for mental status score dated [DATE] documents a score of 3/15 which indicates severe cognitive impairment. R2's fall risk assessment dated [DATE] documents a score of 21 which indicates a high fall risk. R2's incident report dated [DATE] documents: Certified nursing aide reported to nurse that R2 was on the floor. Observed patient lying on her back on the floor at the base of the bed. Resident stated that she fell. The patient was unable to say why she got up but did say that she hit her head when she fell. Under mental status documents oriented to person. Under predisposing physiological factors: confused, hypotensive, gait imbalance and impaired memory. R2's fall management meeting form documents under root cause observed in a prone position on the floor in her room apparent roll from bed. Intervention placed floor mats while in bed. R2's incident report dated [DATE] documents: Nurse informed by staff patient is on the floor. Nurse entered room and observed patient lying on the floor on the right side with blood noted on the left side of the face and on the floor. Bed observed in low position with floor mats on both sides of the bed. Resident said I was looking for friends. Under injury, skin tear to left knee and face. Under mental status documents oriented to person. Under predisposing physiological factors: confused, hypotensive, gait imbalance and impaired memory. Under predisposing situation factors ambulating without assist. R2's fall management meeting form documents under root cause observed on the floor mat in her room Resident said she was looking for friends; confusion contribute to attempt to self transfer and get up. Intervention placed room change closer to nursing station. R2's facility state report dated [DATE] documents: R2 fall resulted from confusion related to dementia leading to either roll from bed or R2 attempting to get up without assistance per staff resulting in mechanical fall. On [DATE] at 2:58PM V13 (Restorative Nurse) said R2 was admitted with standard fall precautions in place: Document signs and symptoms of adverse effects of medication on resident; Encourage resident to keep room free of obstacles/ clutter; Keep bed in lowest position; Keep frequently used items within reach; Monitor labs/ notify MD of abnormal findings; Notify MD and family of any new fall; Skilled therapy as ordered; Staff to assist as needed. After the fall on [DATE] the interventions added were Floor mats while in bed and rounding for prompt assist for change in position, toileting, offer fluids, and ensure resident is warm and dry. V13 was asked was there individualized preventive fall interventions implemented for R2 after the first fall and V13 said No. V13 said floor mats are not a preventive fall intervention. Floor mats are utilized to minimize injury to the resident. V13 was asked were floor mats an effective intervention if R2 sustained a nasal fracture for the fall on [DATE]. V13 said the floor mats do not prevent someone from falling. V13 was asked about the intervention (rounding for prompt assist for change in position, toileting, offer fluids, and ensure resident is warm and dry) and asked how often rounding would occur. V13 said rounding would be done every 2 hours unless otherwise specified. V13 said all residents are rounded on every two hours and that is in place for all residents. R2's care plan Date Initiated: [DATE] Created on: [DATE] documents the following interventions: Document signs and symptoms of adverse effects of medication on resident; Encourage resident to keep room free of obstacles/ clutter; Keep bed in lowest position; Keep frequently used items within reach; Monitor labs/ notify MD of abnormal findings; Notify MD and family of any new fall; Skilled therapy as ordered; Staff to assist as needed. Floor mats while in bed Date Initiated: [DATE] Created on: [DATE]. Rounding for prompt assist for change in position, toileting, offer fluids, and ensure resident is warm and dry Date Initiated: [DATE] Created on: [DATE]. Falling Star Program Date; Move resident to room with optimal visual access from the nurse's station; Orient resident to surroundings frequently, including location of bathroom, dining room, bedroom and activity locations; Provide proper, well maintained footwear; wing mattress Initiated: [DATE]. On [DATE] at 1:00pm, V16(Therapy Director) said R2 was seen by occupational therapy on [DATE]. At that time R2 required moderate assistance which means 50% help by one person to complete transfers and bed mobility. R2 required frequent cueing during therapy due to cognition. R2's therapy evaluation dated [DATE] documents under fall risk does patient feel unsteady when standing documents an answer of yes; does patient feel unsteady when walking documents an answer of yes; Under balance patient stands without upper extremity support with assistive device as needed x ten seconds? Documents no. Under reason for therapy: Patient presents with impairments in balance, dexterity, fine motor coordination, gross motor coordination, mobility, strength, attention, follow through, planning problem solving, self modification, self monitoring, interpersonal routines/behavior, and use of coping strategies resulting in limitations and /or participation restrictions in the areas of self care, mobility, and general tasks and demand which requires skilled OT services. R2'a hospital record dated [DATE] documents under physical exam: Small laceration to bridge of nose approximately one centimeter. Additional small laceration upper lip, approximately 1.5 cm in length and small interior upper lip laceration. Under laceration upper exterior lip 1 cm length and 0.5cm depth, repair method tissue adhesive. Under CT facial bones impression documents: mildly comminuted displaced acute fractures of the bilateral nasal bones. Facility fall prevention and management policy reviewed 1/2024 documents: The facility is committed to maximizing each resident's physical, mental and psychosocial well-being. 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 resident existing plan of care shall be evaluated and modified as needed. Resident at risk for falls will have fall risk identified on interim plan of care with interventions implemented to minimize fall risk. A fall risk evaluation Is completed by the nurse, a score of ten or greater indicates the resident is high risk for falls. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have effective fall interventions in place for a resident assessed to be at risk for falls and failed to provide two staff assist when providing assistance with Activities of Daily Living (ADL) per the resident's plan of care. This failure applied to one (R3) of three residents reviewed for falls and resulted in R3 sustaining a fall while being provided with care from one staff and resulted in R3 being transferred to the hospital and diagnosed with a subdural hematoma measuring 2mm. R3 subsequently returned to the facility with a neck collar and gastrostomy feeding tube (G-Tube). Findings include: R3 is an [AGE] year-old female who has resided at the facility since 2022, with past medical history including, but not limited to Chronic obstructive pulmonary disease, dementia, heart failure, hypertension, hypothyroidism, etc. Fall risk assessment dated [DATE] and 4/22/2023 score R3 as a 13, indicating that resident is at risk for falls. Facility minimum data set (MDS) assessment dated [DATE] section C (Cognitive) documented a BIMS score of 7 for R3, section G (functional) of the same assessment coded R3 as requiring extensive assistance with two-person physical assist for all ADLs. Fall care plan initiated 1/29/2022 states the following: Resident is a high fall risk due to decreased mobility and strength, potential medication side effects, history of falls, etc. Interventions include: encourage to transfer and change positions slowly, provide assist to transfer and ambulate as needed, provide two persons assist during bed turning for hygiene, Bed in low position, etc. Progress note dated 1/3/2024, documented by V21 (LPN) states: Certified Nurse Assistant (CNA) informed writer that resident rolled out of bed while lying on right side during care. Resident was reaching toward dresser then stated I'm falling CNA could not catch her. Upon assessment writer noticed raised area to top of head on left side. Hospital record dated 1/3/2024 states in part, [AGE] year-old female with history of COPD, Dementia, history of heart failure . Presenting to hospital after falling out of bed in her nursing home. Patient was found to be more altered, and CT of the head was notable for a small traumatic subdural hematoma measuring 2mm. On 1/19/2024, V16 (RN) documented the following: readmitted [AGE] year-old . from hospital via ambulance and two paramedics, resident arrived wearing a cervical collar that must remain in place for 6 to 8 weeks, g-tube placed 01/17, resident is NPO. On 2/29/2024 at 2:45PM, V16 (RN) said that R3 was a very sweet lady, she was bedridden but makes her needs known to staff, she will always ask staff to open her candy and place them on her bedside table, R3 cannot reach further than her bedside table, she cannot reach her drawer, always ask staff to get the candy from her drawer and open them. Prior to the fall R3 does not move and was dependent on staff for ADLs, staff always need assistance to turn and hold her, will say that R3 requires 2-person assistance for ADLs to be on the safe side. R3 came back from the hospital with a G-Tube, a cervical collar and was not doing good, just went downhill. On 2/29/2023 at 1:43PM, V13 (LPN) said that she recalls R3, she was alert and oriented x2, incontinent of bowl & bladder, and non-ambulatory. Resident did not have a G-Tube before the fall, she cannot do much for herself, staff must feed her, resident cannot use her hands and cannot reach to her drawer to get anything. V13 said she would use 2-person assist with R3 for ADLs due to her weight, it depends on the CNA but most of them ask for help. On 2/29/2024 at 1:55PM, V14 (Restorative CNA) said that R3 requires mechanical lift for transfers, she does not get out of bed, she needed 2 people to help her turn, V14 came to work after the resident was sent out to the hospital after she fell. V14 has done range of motion exercises with resident, she came back from the hospital with a neck brace and a G-tube. V14 stated that R3 requires two people to turn her, and she has assisted other CNAs in providing ADL care to R3. R3 did not have any floor mat prior to her fall. On 3/4/2024 at 11:55AM, V19 (LPN/Restorative) said that she oversees fall care plans, the initial fall assessment is done upon admission, quarterly and when there is a fall. R3 requires extensive assistance with ADLs, she was a high fall risk and had interventions like low bed, resident does not have a floor mat before the fall, and there were no additional interventions after the fall. On 3/4/2024 at 4:13PM, V22 (LPN) said that R3 was alert x 1 to 2, she can tell you what she wants and can refuse some stuff sometimes. V22 was not present but was told that staff rolled resident away from her, resident started to reach to her drawer for candy and staff could not pull her back. V22 stated that she in-serviced the CNA about compliance to resident's care plan. R3 was a two-person assist at that time as indicated in her care plan. CNA stated that she was not aware, but resident's level of care is also listed in the [NAME] patient information sheet that is available to the CNAs and it is their responsibility to know the type of care a resident requires. On 3/4/2024 at 3:24PM, V21 (LPN) said that she recalls R3, she was a total care. V21 is not sure if R3 is a fall risk, resident returned from the hospital with a G-tube after the fall, R3 does not get out of bed and did not have any interventions before the fall, resident did not have a floor mat before the fall. On 3/4/2024 at 1:58PM, V20 (CNA) said that she recalls R3, she was a total care, incontinent of bowel and bladder and she has always taken care of her by herself, never called anyone to assist her with the resident. V20 said that she was taking care of R3 the day she fell, she was in the middle of changing resident when she started asking for a candy that the family brings for her. V20 said she had gloves on and told resident to wait for her to finish, resident started reaching to her drawer for the candy and V20 could not reach her to pull her back on the bed. V20 said that she was told that R3 was a two person assist and that it was in her care plan but at the time she was not aware of that. V20 stated that she was in-serviced after the fall on getting another staff for assistance and resident fall risk. On 3/5/2024 at 12:53PM, V26 (Attending Physician) said that R3 came back from the hospital with a G-tube and cervical collar, resident was alert to self prior to the fall and denies pain, compliant with medications and dependent on staff for ADLs. V26 was asked if R3 declined after the fall and he said, definitely, with a cervical collar and subdural hematoma, resident declined. Fall prevention and management policy revised 1/2024 states in general that the facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing care plan shall be evaluated and modified as needed. Under guidelines, the policy states in part: 1. A fall risk evaluation will be completed on admission, readmission, and quarterly, significant change and after each fall. 2. Residents at risk for falls will have fall risks identified on the interim plan of care with interventions implemented to minimize fall risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R5 was admitted with Vascular Dementia, Metabolic Encephalopathy, Hypertension and a history of falls. Brief interview for mental status dated 10/6/22 documents a score of seven which indicates severely impaired. Section G (functional status) documents: R5 requires extensive assistance with one person physical assist with bed mobility and toilet use, extensive assistance with two person assist with transfers and walking in room/corridor did not occur. Balance during transition and walking documents: R5 was not steady, only able to stabilize with staff assistance moving from seated to standing position. R5 had lower extremity (hip, knee, ankle, foot) impairment on both sides. Care plan intervention dated 10/1/22 documents: Encourage to transfer and change position slowly, reinforce need to call for assistance, therapy evaluation and treatment per orders. On 3/1/23 at 4:45pm, V3 (ADON) said, R5 had a fall trying to ambulate to the bathroom. R5 had a history of being on the edge of the bed trying to get up. I would inform the staff to assist R5 with transfers. R5 was an extensive one person assist with transfers. The intervention to provide assist to transfer and ambulate as needed was not effective due to R5 being provided extensive assistance with two person assist with transfers upon admission. Progress note dated 10/3/2022 documents: Informed by CNA, patient (R5) was on the floor. Observed R5 sitting on the end of bed next to bathroom door. Brief saturated. Fall report dated 10/03/22, physical performance limitation documents: R5 had difficulty maintaining sitting balance and was incontinence. Care plan initiated 10/1/22 documents: R5 was at risk for fall due to impaired mobility. Interventions dated 10/3/22 and 10/4/22 documents: Bed in lowest position, staff to toilet before bed, provide assist to transfer and ambulate as needed. Investigation report dated 10/4/22 documents: towards end of shift, CNA rounding, seen R5 in the room on the floor. R5 displayed poor safety awareness, Witness statement dated 10/3/22 documents: R5 said, she was trying to use the bathroom. On 3/1/23 at 4:45pm, V3 (ADON) said, R5 had a fall on 10/8/22, there was not any interventions implemented for that fall. Progress Note 10/8/2022 documents: R5 noted sitting on her buttocks facing the wall next to the window, alert and oriented times 1-2. R5 was asked where she was trying to go, she stated she did not know. Physician note dated 10/8/22 documents: R5 was discovered between her bed and the wall mostly on her buttock. Fall report dated 10/8/22, physical performance limitation documents: R5 had difficulty maintain sitting/standing balance with gait and musculoskeletal problems. Care plan initiated 10/1/22 did not document any intervention for R5's fall dated 10/8/22. Investigation report dated 10/10/22 documents: R5 displayed poor safety awareness. On 3/1/23 at 4:45pm, V3 (ADON) said, R5 had a fall on 10/19/22, the intervention was a low bed. R5 had a low bed on 10/13/22. The intervention for 10/19/22 may have not been the most effective due to R5 already having a low bed. Maybe we should have given R5 scoop mattress to help prevent falls from the bed. Progress noted dated 10/13/22 and 10/19/22 documents: R5 in low bed. Notified by CNA that R5 was observed sitting on floor next to bed in the dark. R5 stated I don't know when asked how she got onto floor. Fall report dated 10/19 documents: R5 difficult maintaining sitting/standing, need to rock body or push off on arms chair when standing up from chair and impaired balance during transitions. Disease and conditions: loss of arm or leg movement, declines in function status, incontinence, chronic or acute condition resulting in instability, muscle weakness, impulsivity or poor safety. Care plan intervention dated 10/19/22 documents low bed. On 3/1/23 at 4:45pm, V3 (ADON) said, the scoop/perimeter mattress should have been given prior to this fall. Progress note dated 11/2/2022 documents: R5 observed lying on the floor pulling out clothes in her night stand next to her bed. Resident unable to tell staff how she got on floor. Care plan intervention dated 11/2/22 documents scoop/perimeter mattress. On 3/1/23 at 4:45pm, V3 (ADON) said, R5 had a fall on 11/6/23. It was determined that nothing was on the floor. R5 was not trying to pick up anything up from the floor. We implemented to keep common items within reach. V3 was asked, how keeping common items within reach was an effective intervention when R5 wasn't reaching for any items on the floor. V3 said, R5 didn't have any more falls after 11/6/22. Progress note dated 11/6/2022 documents: R5 was observed on the floor next to her bed. Roommate stated that patient was trying to get something off the floor. Resident unable to tell staff what happen. Care plan intervention dated 11/7/22 documents: have commonly used articles within easy reach. Based on interview and record review, the facility failed to supervise and implement effective interventions to prevent or reduce the risk of falling for cognitively impaired residents. This affected 2 of 3 residents (R2, R5) both reviewed for falls and fall prevention. This failure resulted in R2 being sent to the local hospital post fall. R2 was assessed with a subdural hematoma. R5 has been involved in at least 5 unwitnessed fall incidents. Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of dysphagia, hypertension, venous insufficiency, pleural effusion, acute respiratory failure, and Alzheimer's. R2's brief interview for mental status dated 11/21/22 s score 1/15 which indicates severe cognitive impairment. R2 section G dated 11/21/22 documents one person assists for bed mobility, transfer, walk in room, dressing eating, toilet use and personal hygiene R2 progress note dated 11/16/22 documents: resident observed climbing out of bed, making unsafe transfer. Redirected but not successful, assisted to wheelchair brought to hallway for close monitoring. R2's progress note dated 11/17/22 at 1:30 documents: Resident observed climbing out of bed, making unsafe transfer. Redirected but not successful. Assisted to wheelchair and brought to hallway for monitoring. R2's progress note dated 11/17/22 at 5:29 documents: Resident requested to get back onto bed. Assisted back to bed by CNA. Bed in low position and locked, call light within reach. R2's progress note dated 11/17/22 at 5:40 documents: Resident observed sitting on the floor, next to her bed. Bed in low position. Resident brought to the hallway for close monitoring. Resident educated on the use of call light and waiting for help. R2's incident report dated 11/17/22 documents under investigation report: R2 is alert and oriented x1, requires staff assist with most activities and activities of daily. She has poor safety awareness. Resident noted sitting on the floor next to the bed after several attempts to stand due to dementia. R2 progress note dated 11/23/22 by V18 (Nurse) documents: resident had witnessed fall in bedroom without injury. MD notified with no new orders. R2 fall assessment dated [DATE] documents time of fall 11/23/22 at 17:20. Under physical limitations: impaired balance; musculoskeletal problem; gait problem. Under disease and conditions: impulsivity or poor safety awareness. On 3/1/23 at 420PM, V3 Assistant Director of Nursing (ADON) and V29 (Unit Manager) said R2's fall interventions were effective because R2 could use a call light. When asked if R2 was able to understand the need of when to push the call light and not just being physically able to push the call light, V29 said at times she knows and other times she does not know. When asked about the resident cognition, V29 said R2's brief interview score for mental status indicate severe impairment but that could vary on day and time. When asked how reenforce need to call for assistance is an effective intervention for a resident with cognitively impairment? V3 said she did not fall again. On 3/2/23 at 4:38PM, V2 Director of Nursing (DON) said R2 needed one to one supervision to prevent falls. Staff would take turns monitoring her, but we do not provide one to one and depends on staffing. R2's progress note dated 12/7/23 documents transfer to the hospital due to change in condition and lethargy. R2's plan of care dated 11/15/22 documents at risk for falls due to impaired balance. Interventions dated 11/15/22 document: provide assist to transfer and ambulate as needed; refer to therapy plan of treatment; therapy evaluation and treatment. Interventions dated 11/17/22 document: bed in low position; diagnostic labs; evaluate medications if patient demonstrates changes in mental status, Activities of daily living function, appetite, neurologic status; scoop mattress. Interventions dated 11/24/22 documents reenforce need to call for assistance. Local hospital record dated 12/7/22 documents: new right parietal convexity 8mm thickness subdural hematoma with layering hyperdensity posteriorly concerning for ongoing bleeding, no midline shift or herniation. R2 progress note dated 11/23/22 by V18 (Nurse) documents: resident had witnessed fall in bedroom without injury. MD notified with no new orders. R2 fall assessment dated [DATE] documents time of fall 11/23/22 at 17:20. Under physical limitations: impaired balance; musculoskeletal problem; gait problem. Under disease and conditions: impulsivity or poor safety awareness. On 3/1/23 at 5:49PM, V18 said she did not witness R2's fall and unable to recall who or any other details from R2's fall. R2 progress note dated 11/28/22 documents: patient with increased anxiety and restlessness. Seen by Nurse practitioner, new orders noted. On 3/2/23 at 4:38PM, V2 said the facility is unable to provide any incident or other documents related to R2's fall on 11/23/22. V2 said they are unable to determine who witnessed R2 fall, or any other information related to the fall except for what was written in the nursing note. There is no documentation if resident hit her head, just that there were no visible injuries. If it's a witnessed fall staff are expected to conduct a head-to-toe assessment, which is documented in the incident report. It is the policy of the facility if they hit their head they are sent to the hospital for evaluation. Facility post fall evaluation dated 11/21 documents: Falls are a common source of patient injury. Identifying fall risk factors is an important nursing evaluation process that occurs throughout a patients stay. In the event of that a patient does experience a fall, a comprehensive clinical evaluation by the nurse supervisor is important to determine the extent of the injury and need for additional intervention. The licensed nurse's evaluation of the patient condition after a fall, identification of changes in condition and recognition of emergent situations is critical to achieving positive outcomes. The licensed nurse is responsible for completing this evaluation and reporting changes in condition to the attending physician whenever any symptom, sign or apparent discomfort is sudden in onset, a marked change in relation to usual symptoms or unrelieved by initial interventions. Documentation of change in condition is completed using the SBAR process. R2's admission hospital record dated 10/29/22 documents under CT scan of head documents: No acute intra cranial hemorrhage, acute transcortical infarct or mass effect. On 3/2/23 at 3:01PM, V32 (MD) said a subdural hematoma is usually caused by a fall. V32 said the subdural hematoma could possibly be from the fall on 11/23/22. On 2/28/23 at 2:26pm, V14 (CNA)said R2 was a fall risk. R2 was confused and tried to get up all the time. We would redirect her. She had a scoop mattress but that did not stop her, and she could still get out of bed. R2 had a lot of falls on the second shift. R2 had more than 2 falls. Local hospital record dated 12/7/22 documents: new right parietal convexity 8mm thickness subdural hematoma with layering hyperdensity posteriorly concerning for ongoing bleeding, no midline shift or herniation. Local hospital record dated 12/19/22 documents: patient likely has multifactorial encephalopathy related to infectious and metabolic etiologies. Since she has risk factors, I will rule out acute neurologic event like stroke or subclinical seizures. According to Medline plus, a subdural hematoma is a collection of blood between the covering of the brain (dura) and the surface of the brain. Under causes: a subdural hematoma is most often the result of a severe head injury. This type of subdural hematoma is among the deadliest of all head injuries. This often results in brain injury and may lead to death. Subdural hematomas can also occur after a minor head injury. The amount of bleeding is smaller and occurs more slowly. This type of subdural hematoma is often seen in older adults. These may go unnoticed for many days to weeks and are called chronic subdural hematomas. Some subdural hematomas occur without cause.

Based on interview and record review, the facility failed to effectively monitor and ensure adequate hydration was provided to prevent dehydration. This affected 2 of 3 (R5 and R1) residents reviewed for dehydration. This failure resulted in R5 being found tachypneic, tachycardic and with tongue hanging to the side of her face. R5 was sent to the local hospital and diagnosed with dehydration and hypernatremia. R1 was sent to the local hospital and diagnosed with hypernatremia. Findings Include: R5 had the diagnosis of Vascular Dementia, Chronic Kidney Disease, Metabolic Encephalopathy, Hypercalcemia and Hypertension. Brief interview for mental status dated 10/6/22 documents a score of seven which indicates severely impaired. Section G (functional status) documents: R5 requires extensive assistance with one person physical assist with eating. Physician order sheet dated 12/01/22 documents: Pureed diet and nutritional shake. On 3/2/23 at 12:34pm, V22 (Medical Doctor) said, R5's fluid volume was down. Dehydration can cause no urine based on low volume intake. On 3/2/23 at 3:10pm, V32 (Medical Doctor) said, R5 was on furosemide which usually keeps sodium levels down. Dehydration is caused by not enough fluids. R5 was not on dialysis. Nutrition note dated 10/5/22 documents: R5 averages only ~ 50% meal consumption since admission. Lab results dated 12/19/22 at (1621/4:21pm) documents: Sodium 149 High (H) - (normal range 138-147). Progress note dated 12/20/22 at (2106/9:06pm) documents: lab reviewed, new order intravenous (IV) fluid times one liter, contact pharmacy for fluid and (IV) pump. EMAR and skilled nursing note dated 12/21/22 at (0611/6:11am) awaiting arrival from pharmacy. R5 to start IV fluids when arrives from pharmacy (0618/6:18am). Medication Administration record dated 12/21/22 documents one liter of sodium chloride was given at (2050/8:50pm). Lab results dated 12/23/22 documents: Sodium 151 High (H) - (normal range 138-147). R5 electronic record dated 12/23/22 did not document any interventions. Physician order sheets dated 12/1/22 did not document any ordered related to the sodium level. Medication Administration record dated 12/23/22 did not documents any interventions related to the 12/23/22 sodium level. Physician note dated 12/30/2022 documents: Seen R5 after nurse stated she did not seem like herself. Assessed patient (R5) was lethargic, not responding. R5 was visibly tachypneic although saturating well, and tachycardic. R5 was in bed, tongue was hanging to the side of her face, and she was not opening eyes not responding to voice, or touch. Hospital paperwork dated 12/30/22 documents: Sodium 160 High (H) - (normal range 135-145). Intervention altered mental status since 12/28/22 subdual non-verbal (off baseline), hypernatremia, electrolyte abnormalities, dehydration, very dry mucous membranes treated with bolus of 0.9 normal saline. Hydration Management Guidelines dated 1/22 did not apply. R1 had the diagnosis of Dementia and failure to thrive. Section G functional status dated 1/24/23 documents: R1 requires extensive assistance with one person physical assist with eating. Physician order sheet dated 2/1/23 enhanced pureed diet with house shakes three times a day. On 3/1/23 at 2:22pm, V22 (Medical Doctor) said, staff should have to give R1 water to prevent the dehydration. On 3/1/23 at 5:30pm, V30 (Nurse) said, R1 was dehydrated from not drinking a lot. On 3/2/23 at 11:30am, V2 (DON) said, I am not able to provide reports from R1 speech session. On 3/2/23 at 12:34pm, V22 (Medical Doctor) said, dehydration can cause no urine based on low volume intake. Surveillance note date 1/26/23 document: Appetite poor, family states R1 did not urinate today. R5 states burning with urination. CNA reports, R5 did urinate. Bladder scan 23ml seen in bladder at this time. Service Log dated 2/6/23 documents: R1 was seen by speech on 1/20/23, 1/22/23, 1/27/23 and 1/28/23. Lab report dated 1/30/23, 1/31/23 document sodium 150 (normal range 138- 147) note dated 1/30/23 documents: Sodium 150, oral fluids encouraged. BMP will be repeated. Lab report dated 2/1/23 document sodium 152. Progress note dated 2/1/23 documents: D5 1 liter infusing. Lab report dated 2/3/23 document sodium 150. No intervention documented. Run sheet dated 2/4/22 documents: services were called for R1 for abnormal labs indication sodium level of 150. Nurse reports R1 has not been eating or drinking since admission date of 1/18/22. Sodium levels have stayed in 150 for the past four days, attempted saline bag with no change in condition. Hospital paperwork dated 2/4/23 documents: Chief complaint: abnormal lab. Hypernatremia. Hydration Management Guidelines dated 1/22 did not apply. Hydration policy dated 2/2023 documents: This policy allows for each resident to be provided with sufficient fluid intake to maintain proper hydration and health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a plan to prevent or reduce the risk of falling for a high risk fall resident also assessed to have bilateral lower extremity weakness. This affected 1 of 3 residents (R1) reviewed for fall prevention. This failure resulted in R1 having 2 falls in three days subsequently sustaining a left hip fracture. Findings Include: R1 is a [AGE] year old with the following diagnosis: vascular dementia, cognitive communication deficit, and reduced mobility. R1 admitted to the facility on [DATE] and discharged on 11/28/22. The Incident Report dated 11/25/22 documents R1 was observed sitting in the wheelchair near the nurse's station and the next time R1 was seen again, R1 was sitting on the floor in the hallway. R1 was admitted from the hospital for weakness after a UTI. R1 also has dementia and impaired safety awareness. R1 does not remember what R1 was trying to do prior to the fall. R1 kept on attempting to stand without an assist and fell to the ground. A Nursing note dated 11/28/22 documents R1 was placed in the wheelchair in position at the nurse's station for supervision while the assigned CNA passed out dinner trays to the rest of the residents. R1 is confused and has a diagnosis of vascular dementia. R1 has a history of being a wanderer and a history of falls. During that shift, R1 stated multiple times to the nurse that R1 wanted to leave the facility and wanted to be taken home. Several attempts were made by staff to redirect R1 and to keep R1 occupied while attempting to do other duties. After dinner, the CNA washed R1 and put R1 to bed. The bed was in the lowest position. The call light was put within reach. R1 was made comfortable, and the TV was turned on for entertainment. The nurse and the CNA took turns rounding on R1. Around 7:21 PM, the nurse was informed by another CNA that R1 was lying in the floor in the hallway. This was an unwitnessed fall. R1 reported pain to the left hip and refused to allow staff to move R1. Transportation was arranged to take R1 to the hospital. R1's family and the doctor were notified. A Physician note dated 11/28/22 documents R1 is a wanderer and has been getting out of bed. Unfortunately, staff doesn't have the coverage to watch R1, and R1 was found at the end of the hall on the floor. It was an unwitnessed fall. R1 is complaining of left hip pain and was transferred to the hospital for further evaluation. The Incident Report dated 11/28/22 documents the nurse was answering call lights on the 200 hall when a CNA came and informed the nurse that R1 was down in the hallway of the 100 hall. R1 reported having pain in the left hip. R1 had to be redirected multiple times by staff. R1 reported wanting to leave the facility that evening. R1 was washed and put to bed. R1 was checked on multiple times and appeared to be relaxing in bed without incident. The CNA and nurse were attending to other residents at the time of the unwitnessed fall. R1 was sent to the hospital for evaluation. R1 is alert and oriented to person only with periods of confusion. R1 has poor safety awareness, requiring frequent supervision. The Hospital Records dated 11/28/22 document R1 presented to the emergency room after having a fall and landing on a hard surface. R1 has a history of dementia and is not a reliable historian. R1's only complaint is left hip pain. R1 is able to wiggle toes and flex and extend the ankle on the left foot. There is no movement of the left hip secondary to pain. An X-ray of the left hip shows a left femoral neck fracture. R1 will be admitted to the hospital for medical clearance and then surgical procedure. On 12/15/22 at 3:47PM, V6 (Physical Therapist) stated, We were working on balance and strength with R1. We were also working on getting in and out of bed and walking. I would say R1 had moderate to severe cognitive deficits. Nursing does the interventions, but we will communicate with them things that we find during our therapy sessions. R1 was a high fall risk due to R1's cognition, and not having a steady gait without an assistive device. We educate the staff on our concerns with what R1 has during therapy and told them that R1 needed supervision because she was not steady. R1 also had an issue with R1's knees giving out when R1 would walk. That is why we were working on strengthening and balance with R1. On 12/15/22 at 4:02PM, V7 (CNA) stated, I had R1 for the first fall. R1 was sitting in the geri chair at the nurse's station before dinner. R1 got up and started walking alone and just fell. R1 fell a couple feet from the nurse's station. I saw R1 go down. R1 didn't trip over anything; R1 just couldn't walk anymore and fell down. I was coming out of another patient room, and I was about 20 feet from R1. I was providing patient care for about 15 to 20 minutes and no one else was at the nurse's station. R1 is very active and has a wiggly gate. We try to keep eyes on her as much as possible, but we do have other residents we need to care for. I don't know what intervention was put in place after that for R1. We will try to just keep an eye on R1 and trade off with the other nurses and CNAs on the floors with who is watching R1. I don't think R1 was a high fall risk because I don't remember R1 having a yellow band on. R1 was able to do everything on R1's own. R1 just was a little wobbly. On 12/16/22 at 11:38AM, V8 (CNA) stated, I was in another room doing patient care when R1 fell. I didn't see or hear the fall. I heard another staff member say R1 was on the ground in the hallway. R1 stays in the room [ROOM NUMBER]XX which is right next to the nurse's station, and R1 ended up walking all the way down to room [ROOM NUMBER]XX before R1 fell. That is in the middle of the hall. R1 got out of bed and walked down the hall after being put to bed around 7:30PM. I would say the fall was probably 30 or 45 minutes after that. Before that, R1 was sitting in a chair at the nurse's station. R1 is a busybody. We kind of just keep an eye out for R1 but we can't watch R1 and do patient care at the same time. R1 was just antsy. I'm not sure if R1 was a high fall risk. I don't remember it saying that in the chart. I was never told that R1 had any other falls. The nurse would tell us if R1 had other falls in report. R1 was only steady on R1's feet for a couple steps then it would seem like R1 wants to go down. I think R1 was just weak. The nurse will tell you about the new interventions that are put in. I don't know what was put in after this fall or if R1 had any others. On 12/16/22 at 12:46PM, V12 (Nurse) stated, I got report from the dayshift nurse, and she told me that the R1 normally has a sitter but that day the sitter did not show up. R1 was at the nurse's station when I got there, and I sat with R1 for a while the CNAs did their care and passed the dinner trays. After R1 was finished eating, the CNA went to lay R1 down in bed to put R1 to sleep for the night. We try to keep tabs on R1 and do the best we can. I had to start passing my medication on the other wing so I will check on R1 as I walked by. When I was on the other wing, passing my medication and another CNA came by and told me that they saw R1 on the floor. I immediately went to go assess R1 and she told me she was fine but when R1 tried to move, R1 had hip pain. R1 did have a history of falls and had a fall a couple days before. We were still doing neuro checks on R1 from the previous fall. I know R1 has dementia and goes in and out of confusion. I had to go finish passing my medication, and the CNAs had to go finish up with patient care for the other residents. R1's fall was not witnessed. I was not told how R1 walks. This was my first time with R1. I would say R1 was put down around 630 and probably just before 730, I was told R1 was on the ground. R1 made it all the way down to the middle of the hallway before falling down. We just look in the chart to see what (interventions) someone should have in place. I don't remember being told anything that R1 was weak, but I knew R1 was a high fall risk because R1 already had another fall. On 12/20/22 at 11:04AM, V14 (Primary Physician) stated, R1 is only alert and oriented times one. Physical therapy will eval the residents and help make suggestions on what is best for them. That is up to nursing and rehab to put in the interventions to help prevent the falls. On 12/20/22 at 11:18AM, V2 (DON) stated, For this fall, R1 was found down in the hallway. When I interviewed the CNA, she said she put the bed in the low position, gave R1 the call light, and put the TV on to give her a little bit of light and background noise in the room. The CNA left the room and went to go collect the other trays and take care of the other residents. The nurse went to pass medication to other residents. A different CNA found R1 on the floor. For her the interventions were a low bed, monitor for assist to transfer and ambulate, reinforced need to call for assistance, report, any pain or new bruises that would suggest a fall, and physical therapy to evaluate and treat. Some of the interventions are put in at the admission time, others are put in after the physical therapy evaluation, and then other interventions are put in after a fall. Yeah, R1 was a high fall risk from admission. We consider anyone with dementia, unsteady gait, and needing more attention a high fall risk. Interventions are put in based on what type of fall occurred to prevent it from happening again. On 12/20/22 at 12:33PM, V3 (Nurse Manager) stated, R1 has dementia, and is very impulsive. R1 has no regards to safety. The initial intervention for the fall is put in by the nurse. We make the interventions based off of what their diagnosis is along with the fall that occurred to make it appropriate to prevent further fall. The Physical Therapy Evaluation and Plan of Treatment dated 11/16/22 documents R1 needs partial to moderate assistance with walking secondary to knees giving out. R1 exhibits uneven, step length, decreased accuracy of movements, and in adequate knee extension any instability. R1 has impaired right and left lower extremity strength. The Physical Therapy note dated 11/25/22 documents the right lower extremity has tendency to buckle down during ambulation. The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score as a 7 (severe cognitive impairment). Section G of the MDS dated [DATE] documents R1 needs an extensive one person, physical assist with bed mobility and locomotion on unit. An extensive two person physical assist with transferring and walking in the room is needed for R1. When moving from a seated to a standing position and when walking R1 is not steady and is only able to stabilize with staff assistance. The Care Plan dated 11/15/22 documents R1 is at risk for falls due to unsteady gait. The following interventions are documented on 11/15/22: provide assist to transfer in ambulate as needed, reinforce need to call for assistance, therapy, evaluation and treatment for orders, report development of bruises/pain/change in mental status/ADL function/appetite/neurological status per facility guidelines post fall. The following interventions are documented on 11/18/22: bed in low position. The following interventions are documented on 11/28/22: monitor for unassisted transfers. There are no documented interventions regarding R1's weak lower extremities or R1's knees giving out while ambulating. The policy titled, Falls Practice Guide, dated 11/2020 documents, The purpose of the falls practice guide is to describe the process steps for identification of patient. Fall risk factors, and interventions and systems that may be used to manage falls . Upon admission, review hospital, discharge records, transfer sheets or other data regarding the patient's history of, or risk factors for, experiencing a fall. Interview the patient and family or responsible party about the patient's history of falls, possible causes of those falls in interventions that did, or did not work to prevent further falls. Complete the patient admission/re-admission screen, answering the specific questions regarding the patient's history of actual falls and ongoing risk for falls. Some risk factors or conditions that may predispose a patient to a fall may include, but are not limited to: musculoskeletal conditions, that impair strength, history of falls, orthostatic, hypotension, depression, urinary or fecal urgency, visual, or hearing impairments, peripheral neuropathy's, history of vestibular, disease, unsteady gait, muscle weakness, syncope, stroke, transient, ischemic, attack, age, greater than 80 years, cognitive impairment, dementia, use of assistive devices, physical restraints, medication's, and physical environment .Based on the findings of the MDS and the CAAs, following review of risk factors, environmental factors in other clinical conditions, the patient's initial care plan is updated or a comprehensive care plan is developed to include individualized patient interventions that focus on the patient's risk factors . Interventions are clear, specific, and individualized for the patient's needs . The care plan is revised as clinically indicated to meet the patient's current needs.