**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R36's face sheet documents that R36 was admitted to the facility on [DATE] with a diagnosis of right hip fracture, C5 compression fracture and L1 compression fracture resulting from a fall at home. R36's other medical diagnosis includes Unspecified Dementia, Anxiety Disorder, Major Depressive Disorder, Hypertension, and Hyperlipidemia. R36's Minimum Data Set (MDS), dated [DATE], documents R36 is severely cognitively impaired and is totally dependent on at least two staff members for bed mobility and transfers. The facilities incidents by incident type report, dated 11/13/2023, documents R36 has had a fall on 7/21/2023, 9/4/2023, 9/13/2023, 9/14/2023, and 10/19/2023. R36's Care Plan, dated 7/5/2023, documents the resident has had an actual fall. The root cause may be related to cognitive impairments as she does not understand limits, unaware of safety needs, poor balance, poor communication/comprehension and has an unsteady gait. Interventions: bed to be in low position, fall mat placed beside bed, bed against wall, foam positioning aids on both sides, staff educated on safe resident positioning, and continue interventions on the at-risk plan. R36's progress notes dated 7/21/2023 at 9:28 AM, documents, during breakfast resident rolled out of bed, no injuries from fall, and the right hip incision had nothing to do with the fall. The facility Incident Audit Report, dated 7/21/1023, documents the root cause of this fall was resident was not positioned in the center of the bed and rolled off edge of bed into floor. Intervention is staff education of safe positioning of residents. R36's progress notes, dated 9/4/2023, documents on doing rounds, CNAs found resident on the floor beside her bed, lying on her left side, head was rested up against bedside table and bleeding noted from right ear. Ambulance was called and resident was transported to the local emergency room. R36's ear injury was treated with medical glue and R36 returned to the facility. The facility Incident Audit Report, dated 9/4/23, documents the root cause of this fall was resident fell out of bed. Intervention is a fall mat on floor beside bed. Bed also to be in lowest position. R36's progress notes dated 9/13/2023 at 8:20 PM, documents resident noted on floor in her room. Laying on left side beside bed. Clothes and linens saturated with urine. Bed not in low position. Floor mat not in place. Small skin tear to left elbow. Cleansed and band aid applied. Resident assisted back to bed and care given. The facility Incident Audit Report, dated 9/14/2023, documents R36's bed was not in low position, floor mat was not in place and R36 was saturated with urine. Root cause of this fall was resident rolled out of bed. Intervention is foam positioning aids on each side of resident's bed while resident is in bed. R36's progress notes dated 9/14/2023, documents resident was on the floor next to her bed, nurse checked resident over, she was fine and voiced no complaints of pain. Fall was unwitnessed. The facility Incident Audit Report, dated 9/14/2023, documents the root cause of R36's fall was resident rolled out of bed. Mattress changed to better fit foam positioning aids. R36's progress notes dated 10/19/23 at 4:11 AM, resident found on the floor beside her bed face down and on right side. Noted to have a large goose egg above her right eye and facial bruising noted. The floor mat was on the opposite side of the bed and the foam positioning aid was slid off the bed on the floor also. The facility Incident Audit Report, dated 10/19/2023, documents the root cause of R36's fall was that resident rolled out of bed. Intervention will be a bolstered mattress. R36's fall risk assessment, dated 8/10/2023, documents R36 was high risk for falls with a score of 13. A score of 10 or more equals high risk. On 11/13/2023 at 9:10 AM, R36 was observed to have light blue/green bruising to the right side of her face near the temporal region. V12 stated the bruising was from a previous fall. On 11/14/2023 at 6:21 PM V10 (Licensed Practical Nurse) stated she (R36) did not have her bed in low position and her mat was not on the floor when she fell on September 13, 2023. On 11/15/2023 at 1:40 PM V2 (Director of Nursing) stated she would expect fall interventions to be in place according to the care plan. The Facility's Fall Prevention Policy, dated 11/10/18, documents To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. 1. Conduct Fall Assessments on the day of admission, quarterly, and with a change in condition. 2. Identify, on admission, the resident's risk for falls. All staff must observe residents for safety. If residents with a high-risk code are observed up or getting up, help must be summoned, or assistance must be provided to the resident. 3. Assessments of Fall Risk will be completed by the admission nurse at the time of admission. Appropriate interventions will be implemented for residents determined to be at high risk at the time of admission for up to 72 hours. 5. Immediately after any resident fall, the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. 6. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an AIM for Wellness form along with any new interventions deemed to be appropriate at the time. The unit nurse will also place any new interventions on the CNA assignment worksheet. 7. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan. Based on observation, interview, and record review, the facility failed to ensure there was sufficient supervision to prevent falls and ensure care plan interventions were appropriately in place for 2 out of 3 (R28, R36) reviewed for falls in a sample of 31. This failure resulted in R28 being sent to local emergency room with an acute to subacute right lateral 9th rib fracture, subacute to acute right anterolateral 3rd rib fracture and also had multiple healed rib fractures from other falls. Findings include: 1. R28's Face Sheet, print date of 11/16/23 documents R28 has the following diagnose Type II diabetes mellitus with hyperglycemia, multiple fractures of ribs, Alzheimer's disease, dementia, Hypertension. R28's Minimum Data Set (MDS), dated [DATE], documents R28 is severely cognitively impaired and requires substantial/maximal assistance with transferring, oral hygiene, toileting hygiene, shower/bath, dressing, and personal hygiene, he is frequently incontinent of bladder, and always continent of bowel. R28's Care Plan, not dated, documents the resident has had an actual fall. Root cause may be related to (r/t) Cognitive Impairment- Does not understand limits, Cognitive Impairment- unaware of safety needs, poor Balance, and unsteady gait. Interventions include but are not limited to for no apparent acute injury, determine and address causative factors of the fall, Major injury- Pressure alarm under buttocks and under torso while in bed, and Major injury- signage posted in room to use call light for assist. R28's Physician's Orders, dated 05/10/23, documents pressure pad alarm at all times. R28's Incident Audit Report, dated 10/06/23 at 5:38 AM, documents R28 had an unwitnessed fall. He was found face down on the floor beside his bed. R28 attempted to get up to the bathroom without calling for assistance. He had a hematoma noted to the top of his scalp. It further documents in the notes section root cause of this fall noted to be resident attempting to get out of bed to toilet self without assistance. Resident had shut off pressure alarm. Intervention is to place a pressure alarm under resident's bottom and another under his torso. R28's Progress Notes, dated 10/06/23 at 8:57 AM, documents the writer received in report R28 had and unwitnessed fall in his bedroom. He was found in the prone position attempting to roll over and get his self-up. He was noted to have a hematoma on his forehead above his left eye and he complained of pain and discomfort to his right arm/shoulder when the writer was assessing and doing range of motion. Neuro checks were in place due to it being an unwitnessed fall. His blood pressure at 6:25 AM was 158/101 and his pulse was 98. He was able to recall the fall to writer without difficulty he agreed to be sent out to the local hospital to be evaluated and treated, and doctor and his power of attorney was notified. R28's Hospital Report, dated 10/06/23 at 9:24 AM, documents Computed Tomography (CT) scan report impression: Acute to subacute right lateral 9th rib fracture. Subacute to acute right anterolateral 3rd rib fracture. Multiple healed rib fractures. On 11/14/23 at 1:43 PM, R28 is up and in his wheelchair. Tab alarm noted to be attached to the back of his shirt. No pressure pad alarm noted in his wheelchair. On 11/15/23 at 1:20 PM, R28 is lying in bed with his eyes open. Fall mat beside his bed, bed in low position, there was a tab alarm observed hooked to his shirt and the other end lying in his bed. There were no pressure pad alarms observed by this surveyor. On 11/15/23 at 1:22 PM, this surveyor went and asked V2 (Director of Nursing/DON) if R28 was supposed to have pressure pad alarms under him while he was in bed and she stated, yes. This surveyor asked V2 if she could please come down to R28's room. This surveyor and V2 went down to R28's room and V2 checked under R28 to see if he had pressure pad alarms under him and there wasn't any noted at this time. On 11/15/23 at 1:24 PM, V2 stated she would expect for the pressure pad alarms to be placed under R28 when he was in bed. On 11/16/23 at 10:00 AM, V4 (MDS Coordinator) stated they discontinued R28's tab alarm on 06/28/23, due to him taking it off and carrying it and then they ordered him the one pressure pad alarm. She said after the fall on 10/06/23, is when they ordered the second pressure pad alarm for him. V4 stated R28 should not have a tab alarm on. On 11/16/23 at 10:05 AM, this surveyor and V4 went down to R28's room together. R28 was observed to be sitting up in his wheelchair with a tab alarm placed on the back of his wheelchair and hooked to the back of his shirt. There was no pressure pad alarm noted to be under him at this time. V4 stated R28 should have a pressure pad alarm placed in his wheelchair and she said they are supposed to put it on R28 every time they change his position. On 11/16/23 at 10:35 AM, V4 stated she was just made aware the pressure pad alarms are broken and will be fixed and here within the next couple of hours. She said until the new/fixed pads get here they are using the pull tab alarm and doing 15-minute visual checks on R28. She said she isn't sure how long the pressure pad alarms have been broken she was just made aware of it today when she questioned staff about them. She said she would expect the Certified Nursing Assistants (CNAs) to notify the nurses and the nurses to notify management about the pressure alarms being broken so they could rectify the situation.

Based on interview and record review, the facility failed to ensure timely treatment for a change in condition for 1 of 3 residents (R2) reviewed for quality of care in the sample of 6. This failure resulted in a delay in treatment for left femur fracture around a previous left knee replacement. Findings include: 1. R2's Fall Risk Assessment, dated, 4/27/23 prior to fall incident date of 5/10/23, documented R2 was at High Risk for falls. R2's Minimum Data Set, dated , 4/27/23, documented mild impaired mental cognition. R2's Nurse's Notes, dated 5/10/23 (Wednesday) at 9:00PM, documents, resident lowered to floor in sit to stand (partial mechanical lift for transfers), no apparent injury. R2's Quality Care Reporting Form, dated 5/10/23 at 9:00PM, documented R2's fall location was in R2's room and reported by V7 (Certified Nurse Assistant/CNA) to V13 (Licensed Practical Nurse/LPN), with pain located to the left leg and knee with slight bruising to left knee. Physician notified on a date of 5/12/23. R2's Investigation Report for Falls, undated, documented R2 was transferred from a shower chair to bed using a partial standing mechanical lift (sit to stand), the lift belt buckle was not secure and R2 was barefoot after returning from a shower during the transfer. R2's Nurse's Note, dated 5/11/23 (Thursday) at 1:30AM, documents, resident c/o (complained of) left leg pain. Light bruising noted to left knee. Res (resident) yelling out in pain when left leg straightens. R2's Fax Transmittal Form to V14 (R2's physician), dated 5/11/23 at 1:19 PM, documents (R2) had to be lowered to the ground from the sit to stand machine and is c/o left knee and left leg pain-can we get an X-ray (radiology imagining)? with V14 documenting OK with a stamp date of 5/12/23 when re-faxed back to the facility. Also, a handwritten note from unknown nurse, documents, Xray needs scheduled Sat AM (Saturday morning-5/13/23). R2's Nurse's Note, documented by V6 (LPN), dated 5/13/23 (Saturday) at 8:00 AM, documented Xray scheduled for left knee and leg and residents was yelling out before breakfast. R2's Nurse's Note, dated 5/13/23 at 6:00 PM, documented R2 yells out in pain at times when moved or touched, outside Xray company is scheduled to come for Xray of left lower extremity. R2's Nurse's Note, dated 5/13/23 at 10:30 PM, documented, outside Xray company arrived at the facility to perform the Xray. R2's Radiology Report, for date of service 5/13/23 and faxed 5/14/23 at 01:?? AM (time cut off), documents, left knee replacement is identified. A fracture is noted involving the distal femur (lower part of thigh). The posterior lateral (back of knee on the outer side) displacement of fracture fragment is noted. R2's Nurse's Note, dated 5/13/23 [sic] at 2:30AM, documented report received of a left fracture of distal femur and faxed to the physician. R2's Nurse's Note, dated 5/14/23 at 6:30 AM, V6 documents, slight bruising to knee area noted. R2's Nurse's Note, dated 5/14/23 at 7:00 AM, documents, writer (V6) called Doctor, left message for the doctor to call the facility. At 7:05 AM, continues to document, V1 (Administrator) was made aware of Xray report. Nurse's Note continues to document at 8:15AM, a telephone physician order was received to send R2 to emergency department for evaluation and treatment and at 9:00 AM, R2 was transferred to Emergency Department. R2's Hospital consultation, dated 5/14/23 at 6:03PM, documented, left knee pain, Xray acute fracture of distal supracondylar femur around the femoral component of the replacement hardware acute comminuted fracture of the supracondylar distal fracture above the cemented femoral knee replacement. It also documents a preop assessment was done and R2 was cleared for surgical repair. On 5/18/23 at 1:50PM, V6 (LPN) stated she was scheduled to work on 5/13/23 (Saturday) morning at 6:00 AM, at 6:30 AM, had noticed a physician fax order for a Xray to be done, dated 5/11/23 on R2 which was located in a filing basket at the nursing station. V6 stated she went through R2's medical records Nurse's Notes and noticed R2 had a fall on 5/10/23 at 9:00PM and documentation on 5/11/23 early morning that R2 complained of left leg pain with bruising and no documentation on 5/12/23. V6 stated that she identified there was no treatment provided or if a nurse followed-up with the fax transmittal order that was submitted on 5/11/23 to V14 (Physician). V6 stated she notified V14 immediately at 8:00 AM, to receive an order that R2 receive a Stat (immediate) Xray due to visible bruising on the left knee and left inner thigh with decrease range of motion to that left leg. V6 continues to state, R2's Xray was not performed till 5/13/23 late at 10:30 PM, with results received on 5/14/23 around 1:00 AM in the morning that identified a fracture to the left femur and was not sent out for treatment till the morning of V6's shift at 8:00 AM. On 5/24/23 at 4:15 PM, V2 (Director of Nursing), stated the physician was notified on 5/11/23 for the Xray. V2 also stated this situation is subjective to the individual nurse. The facility's Notification for Change in Resident Condition or Status policy and procedure, dated 12/7/17, documents, The facility staff shall promptly notify physician of changes in the resident's medical/mental condition and/or status, further documents, a discovery of injuries, abnormal complaints of pain, a need to transfer the resident to a hospital/treatment center.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide safe transfers for 2 of 3 residents (R2, R6) reviewed for falls in a sample of 6. This failure resulted in R2's fall during a transfer sustaining a left leg fracture requiring surgical repair. Findings include: 1. R2's Fall Risk Assessment, dated 4/27/23 prior to fall incident date of 5/10/23, documented R2 was at High Risk for falls. R2's Minimum Data Set (MDS), dated [DATE], documented mild impaired mental cognition. R2's Physical Therapist Progress and Discharge summary, dated [DATE], documents, Discharge summary, patient progressed in muscle strength from start of care but was with limited progress due to poor safety with use of mechanical sit to stand Lift. Ultimately it was decided that patient is safer transferring with (full mechanical transfer lift) versus sit to stand (partial transfer lift) and CNAs (Certified Nurse Assistants) were instructed to continue to use (full mechanical transfer lift) with resident. R2's Physician Order Sheet (POS) dated 4/25/23, documented, may use (full mechanical lift) for transfers. R2's Nurse's Notes, dated 5/10/23 (Wednesday) at 9:00PM, documents, resident lowered to floor in sit to stand no apparent injury. R2's Investigation Report for Falls, undated, documented transfer from shower chair to bed using a standing mechanical lift, the lift belt buckle was not secure and R2 was barefoot after returning from a shower during the transfer. R2's Nurse's Note, dated 5/11/23 (Thursday) at 1:30AM, documents, resident c/o (complained of) left leg pain. Light bruising noted to left knee. Res (resident) yelling out in pain when left leg straightens. R2's Radiology Report, dated 5/13/23 and faxed 5/14/23 at 01:?? AM (time cut off), documents, left knee replacement is identified. A fracture is noted involving the distal (lower part of thigh) femur. The posterior lateral (back of knee on the outer side) displacement of fracture fragment is noted. R2's Hospital consultation, dated 5/14/23 at 6:03PM, documented left knee pain, Xray acute fracture of distal supracondylar femur around the femoral component of the replacement hardware acute comminuted fracture of the supracondylar distal fracture above the cemented femoral knee replacement. It also documents a preop assessment was done and R2 was cleared for surgical repair. R2's Care Plan, dated 1/13/22, documents, assist to transfer resident using mechanical device of (full mechanical lift device) and 2 staff members, and a revised handwritten, date of 1/25/23, documents, may use sit to stand for toileting and shower transfers, as needed. On 5/23/23 at 11:15AM, V8 (MDS Coordinator) stated the Interdisciplinary Team decided that R2 could use a Sit to Stand for transfers, as R2 requested the facility to use. V8 also stated there is no documented assessment of this change in R2's mode of transfer, however, R2 at times does well with a sit to stand but most the times she cannot. On 5/18/23 at 1:50PM, V6 (Licensed Practical Nurse/LPN), stated that R2 is not able to bear weight to her lower legs and requires the use of a full mechanical lift for all transfers. On 5/18/23 at 2:10PM, V7 (Certified Nurse Assistant/CNA), stated R2 had received a shower and was brought back to her room to be placed in bed, using a sit to stand. At this time, R2 was at the edge of the shower chair when being raised with sit to stand and her legs became weak and was lowered down to the floor with the sit to stand. On 5/23/23 at 1:40PM, V9, V10, and V11 (all CNAs) stated that R2 cannot stand, both of her feet are bowed outward, she cannot straighten her feet, she cannot bear weight with her legs, R2 requires a full mechanical lift for transfer. On 5/23/23 at 11:00AM, R2 was lying in bed, the left leg was propped up on a pillow with the leg wrapped in a support brace with dressings. R2's left and right feet were angled out away from her body and was unable to straighten her feet. On 5/23/23 at 4:20PM, V1 stated, so a re-assessment of R2's transfer status needs to be completed. 2. R6's POS, dated 4/27/23, documented high back wheelchair, may use (full mechanical transfer lift) as needed. R6's Care Plan dated 05/3/23 documented, dependent with transfer using (full mechanical transfer lift) and 2 staff members. On 5/23/23 at 2:38PM, V7 and V15 (CNAs) transferred R6, from the bed using a full mechanical lift. During the transfer, R6's bed was not locked and R6's high back wheelchair also was not locked when R6 was being lowered into the chair. The facility's Full Mechanical Lift Operating Instructions, dated 7/2014, documented to lift the patient while in bed, ensure the bed brakes are in locked position and lowered into a wheeled chair, ensure the chair wheels are locked. The facility's Fall Prevention policy and procedure, dated 11/18, documented, to provide for resident safety and to minimize injuries related to falls, decrease falls and still honor each resident's wishes/desires for maximum independence and mobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide supervision, investigate falls thoroughly to develop a root cause and analysis and implement progressive interventions to prevent falls for 2 of 5 residents (R1, R31) reviewed for falls. This failure resulted with R1 dislocating his shoulder multiple times, receiving 2 staples for a head laceration and hematomas. Findings include: 1. R1's admission Profile, undated, documents R1 was admitted on [DATE]. R1's September 2022 Physician Orders documents that R1 has diagnoses of Depression, Anxiety, and unspecified neuro cognitive disorder. R1's Minimum Data Set (MDS), dated [DATE], documents that R1 has moderately impaired cognition and is totally dependent on one staff member for locomotion on the unit using a wheelchair. R1's Care Plan, with start date of 2/18/22 documents Resident has risk factors that require monitoring and intervention to reduce potential for self-injury. (Consider medical conditions, sensory altercations, balance, gait, assistive devices, cognition, mood/behavior, safety awareness, compliance, medication, restrictions, restraints. Risk factors include poor safety awareness, dementia, agitation, anxiety, weakness as evidence by related diagnoses/ condition/history. R1's Goal for this problem documents Resident will follow safety suggestions and limitations with supervision and verbal reminders for better control of risk factors thru next 90 days. The following are R1's Care Plan Approaches/Interventions all dated 2/18/22: Review quarterly and prn (as needed) resident's ADL (activities of daily living), mobility, cognitive, behavior and overall medical status. IDT (Interdisciplinary team) review of changes and needs with Resident and/or responsible party (when choose to attend) during care plan. Discuss fall related (information to review and revise plan as needed; Review quarterly and as needed during daily care and services of resident's plan for safety, giving verbal cues as needed to gain resident participation in minimizing risk factor and injury, encourage and assist placement of proper non-skin footwear; Attempt to anticipate needs-toileting, hydration, hunger and provide care before resident attempt to fulfill on own; observe for unsteady/unsafe transfer or ambulation and provide stand by or balance support as needed; Fall risk assessment quarterly and as needed with change in condition or falls status; IDTG review of ADL status and fall potential changes in condition or fall status. Report significant finding to MD for follow up; Monitor for changes in condition such as appetite, sleep patterns, balance, ADL assist level, swelling, muscle weakness, less socialization. Report to nurse for follow up assessment and MD notification. An intervention, dated 2/11/22 documents Low bed. R1's Nurse's Note, dated 4/4/22 at 11:30 PM, documents, Res (Resident) fell in living room with injuries noted to Lt (left) temporal area and shoulder deformity. Sent to ER (Emergency Room). R1's Nurse's Note, dated 4/4/22 at 12:45 PM, documents, Res returned from ER (Emergency Room) with dx (diagnosis) of Anterior Dislocated of L shoulder, contusion to face, COVID 19, Broken collarbone. R1's emergency room documentation, dated 4/4/22, documents, Assessment/Plan: 1. Anterior dislocation of left shoulder. 2. Clavicle fracture. 3 Head contusion. 4. Neck Strain. Procedure: Attempted to reduce left shoulder dislocation multiple times without any success. Transfer to (regional) hospital. On 9/15/22 at 1:48 PM, surveyors were unable to view the fall investigations independently. At that time, V2 Regional Nurse, reviewed the investigation from 4/4/22 with the surveyor and stated, (R1) got up from his recliner. He had fallen asleep, and the aide went to clean the dining room. (R1's) alarm sounded and by the time the aide got to him he was on the floor. The emergency room could not do a closed reduction. He came back with both of his arms in a sling and a follow up appointment to the orthopedic doctor. (R1's) investigation showed that he woke up and was disorientated and tried to self-transfer and he fell. (R1's) new intervention was to not leave (R1) asleep in the lounge unattended. R1's Care Plan was reviewed and there was no documentation that this intervention was implemented to prevent R1 from future falls. R1's Nurse's Note, dated 4/5/22 at 1:30 PM, documents, Res is alert with confusion noted. Res constantly trying to get up on his own. R1's Nurse's Note, dated 4/5/22 at 7:30 PM, documents, Res (resident) observed on floor in room [ROOM NUMBER]. Res laying on abdomen with arms outstretched and legs outstretched. Res noted to have large s/t (skin tear) to lt (left) arm probably from ER (Emergency Room) visit from previous night. Res has laceration on Rt (right) brow with some slow to respond answers to questions. Res appears to be confused beyond his norm (normal). sent out to ER. R1's ED (Emergency Department) Physician note, dated 4/5/22, documents, History of Present Illness: [AGE] year-old man with a history of dementia brought to the emergency department after a fall in which he injured his head and his left shoulder per EMS (Emergency Medical Services). Witnessed fall from a standing position. No loss of consciousness. Patient was seen yesterday for a similar presentation and found to have a right clavicle fracture, left anterior shoulder dislocation and scalp contusions. Transferred to (regional) hospital for shoulder dislocation after several unsuccessful attempts were made here. There were abrasions and contusions on his face and forehead on the right last night. There are 2 new contusions today. R1's Nurses Note, dated 4/6/22 at 2:30 AM, documents, Res returned to via transport. Orders to see ortho r/t dislocation of lt. (left) shoulder from fall on 4/4/22. On 9/19/22 at 11:00 AM, V2, stated that she was unaware of this fall. There was no fall investigation for the fall on 4/5/22 for review. R1's Care Plan was not revised after this fall on 4/5/22, with progressive interventions to prevent him from future falls. R1's Nurse's Note, dated 4/27/22 at 8:00 PM, documents, Res fell in LR (living room) with gash to Rt side of head. Unable to assess fully r/t (related to) sending res out with head trauma. R1's Nurses Note, dated 4/27/22 at 10:00 PM, documents, ER called and sending res back res has 2 staples to Rt (right) side of head no other injuries. R1's ED (Emergency Department), dated 4/27/22, documents, Procedure: Scalp laceration right forehead 2 cm (centimeter) x (by) 0.5 cm no active bleeding local lidocaine 1% 5 cc (cubic centimeters) stapled with 2 closed the wound. On 9/15/22 at 2:15 PM, V2, reviewed the investigation and stated that R1 was resting in the recliner. V2 stated R1 tried to stand, and he fell. V2 stated that the new fall intervention is to always wear shoes because he only had on gripper socks. R1's Care Plan was not revised after this fall to prevent R1 from future falls. R1's Nurse's Note, dated 4/29/22 at 2330, documents, Resident was in low bed, alarm on alarm was sounding, resident on floor by bed. hematoma above L eye noted. On 9/19/22 at 11:55 AM, V2, Regional Nurse, stated, (R1) got out of bed and bumped head on foreign object. (R1's) intervention is to ensure to continue use of low bed. R1's Nurse's Note, dated 5/2/22 at 12:25 PM, Resident in w/c (wheelchair) in dining area. Resident attempted to stand out of w/c and fell to floor on L side. Hitting left side of head on floor 3 x 2 cm (centimeter) s/t noted to LFA (left forearm). Cleansed with (wound cleanser) dry dressing applied scant amount of serosanguinous drainage noted to L forehead. On 9/15/22 at 2:35 PM, V2, stated, (R1's) root cause for the fall on 5/2/22 was he attempted to self-transfer and 15-minute checks were initiated. R1's Care Plan was not revised after his fall on 5/2/22 with progressive interventions to prevent him from future falls. R1's MDS, dated [DATE], documents, R1 is moderately cognitively impaired and requires supervision of 1 staff member for ambulation and transfers. R1's Nurse's Note, dated 8/12/22 at 12:35 AM, documents, Writer called to resident room. Res is sitting in floor 1 cm skin tear noted to R elbow unable to reapproximate. area cleansed with (wound cleanser) steri-strips applied, thumb swollen and purple in color. Res c/o (complaint of) pain to Left finger and LFA, unable to perform pronation / supination to L arm. no other injuries apparent. Res sitting in chair at this time. R1's Nurses Note, dated 8/12/22 at 11:45 AM, Res returned to facility per facility van. L shoulder back in place. L thumb severely fractured and L pinky fx. (fracture) Splint in place to L hand and arm and ace wrap. R1's Hospital Emergency Department Discharge Instruction, dated 8/12/22, documents, Diagnosis: 1. Anterior dislocation of left shoulder. 2. Fracture of fifth metacarpal bone of left hand. On 9/15/22 at 2:36 PM, V2, stated, On 8/12/22 (R1) was found on the floor at 12:35 AM, just prior to this he was walking in the hallway to go back to his room. He stated that he got his foot caught on an extra cover and he fell. The new intervention for this fall is to ensure that blankets are not touching the ground and extra blankets are taken off the bed. On 9/19/22 at 12:15 PM, V20, Medical Director, was questioned about all R1's falls. V20 stated, It is obvious (R1) should be on one to ones (supervision). The facility made me aware of all of the fractures, but I was never made aware of the big picture that he had fallen that many times. On 9/19/22 at 3:10 PM, V8, Licensed Practical Nurse, stated, I am not sure what was going on with (R1) when he kept falling. They were using a wheelchair for him, and he just kept standing up and trying to walk. He then went out to (Behavioral Health) and when he came back, they just let him walk and he has been doing better. 2. R31's admission Sheet documented R31 was admitted to the facility on [DATE]. R31's Nurse's Note documented Res (Resident) arrived @ (at) facility per facility van into room (Room #)-see assessment. R31's Nursing admission Assessment, dated 6/2/22, documented R31's admitting diagnosis was brain hemorrhage. R31's Fall risk assessment, dated 06/02/2022, documented that she was a high risk for falls. R31's Baseline Care Plan, dated 06/02/2022, documented, High Risk Fall Assessment, Poor Safety awareness, Fall history and 15 (minute check). R31's 15 Minute Observation checklist, dated 06/02/2022 from 5:30 PM until 7:30 PM, documented that R31 was in her room, sitting in a chair and was anxious. No interventions for R31's anxiousness was documented. There was nothing in R31's Nurse's Notes regarding R31s anxious behaviors and what staff were doing to address her anxious behaviors while she was alone in her room. R31's Nurse's Note, dated 06/02/2022 at 7:30 PM, documented, (Resident) attempted to get up (without) assistance (and) was alerted to staff per call light. Staff found her on the floor (at) foot of bed, sitting on bottom. Top of head was rested up against the foot board, blood all over head (and) hands. (Small) pool of blood on the floor (and) (resident) states I fell headfirst. Able to answer all nurses questions correctly but due to recent bleeding in brain (resident) will be sent to (local hospital Emergency Room) for (evaluation) (and) (treatment). Administrator and (V18, Care Plan and MDS) aware. (Power of Attorney) (phone number) is not in chart. (Regional Hospital) was called (and) they would not give nurse any (information). (Administration) notified. R31's Investigation Report for falls, dated 06/02/2022, documented that she was seen at 7:25 PM and that she had a tab alarm in place. On 09/15/2022 at 02:10 PM, V2, Regional Nurse stated that R31's tab alarm was not sounding because it was in her hand when she fell. Report sent to the Illinois Department of Public Health, dated 06/09/2022, documented, .Tabs monitor was in resident's right hand. R31's Minimum Data Set (MDS), dated [DATE], documented that R31 required extensive assistance with transferring, frequently incontinent of bladder and occasionally incontinent of her bowels. R31's History of Present Illness from Trauma Center, dated 06/03/2022, documented, (R31) is a [AGE] year old female brought in by (Emergency Medical Service), ground transfer from outlying facility and was in cervical collar and boarded on presentation. The patient was involved in a fall from standing. Per report, (R31) was discharged earlier today after being admitted from 2/18 to 6/2/2022, patient was discharged to a nursing home. Patient was admitted for an intracranial hemorrhage, (Urinary Tract Infection) Hypertensive emergency, metabolic encephalopathy, and A-fib who was on coumadin which was stopped at time of discharge. Upon being discharged and admitted to the nursing home, patient was reported to be found lying on the floor on her back after an unwitnessed fall. It continues, At the (Outside Service Hospital), patient was reported confused and moaning. Imaging reported at the (Outside Service Hospital) found a C1-C2 fracture. Upon arrival to the trauma center, there was no (Outside Service Hospital) records to review. Patient is noted to have a small scalp laceration and surrounding hematoma. R31's Trauma CT Cervical Spine report, dated 06/03/2022, documented, Findings: Acute, mildly displaced type 3 fracture of the odontoid process. Mild dorsal subluxation of the lateral masses of C1 relative to C2. Moderate multilevel cervical spondylosis . It continues, Impression: Acute type 3 fracture of the odontoid process. On 09/14/2022 at 1:30 PM, V17, Assistant Director of Nurses (ADON), stated that when a resident falls, the nurses fill out the form and then the Interdisciplinary team (IDT) will meet and discuss the fall and then they will fill out the rest of Quality Care Reporting Form, the investigation. On 09/14/2022 at 2:00 PM V18, Minimum Data Set/Care Plan Coordinator, stated that R31 had a baseline care plan and it addressed her being a high risk for falls and that she should have been on 15-minute checks. On 09/15/2022 at 2:10PM, V2, Regional Nurse stated that she would expect the nurses and CNAs to do the 15-minute checks if it was on the care plan. She continued to state that the Investigation Report for Falls was an internal document, and that the facility would not give a copy to the state surveyor but was able to review the document. The Fall Prevention Policy, dated 11/10/18, documents, Policy: To provide for resident safety and to minimize injuries related to falls, decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Procedure: 5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. It continues, Report all falls during morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan.