**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision for residents at high risk for falls and failed to implementing interventions for a resident with wandering behaviors. These failure applied to three of five residents (R52, R56, and R61) reviewed for falls and resulted in R52 sustaining a right hip fracture and a head injury requiring medical treatment. Findings include: Per the facility's incident log from 09/01/2024 - 03/24/2025 the facility has had 73 unwitnessed falls with 18 of them involving memory care residents, R52 had a fall each month from December 2024 - March 2025 with two of them being unwitnessed, and R61 had four falls within three weeks of admission with three of them being unwitnessed. 1. R52 is a [AGE] year-old female with a diagnosis history of Dementia with Behavioral Disturbance, Anxiety Disorder, Age Related Cataracts, and Stroke who was admitted to the facility 02/06/2019. The facility's incident log from 09/01/2024 - 03/24/2025 documents R52 had a witnessed fall on 12/18/2024 at 9:13 AM, and unwitnessed falls on 01/12/2025 at 4:30 AM, and on 02/09/2025 at 6:55 AM Per the facility's reportable event log received 03/24/2025 R52 had a fall on 12/18/2024 that resulted in a right hip fracture and a fall on 01/12/2025 that resulted in a laceration of her head. R52's quarterly Minimum Data Set, dated [DATE] documents she requires supervision or touching assistance for walking 10-150 ft. R56's fall risk assessments dated 12/18/2024 and 12/24/2024 documents she is at high risk for falls. R52's current care plan created 02/18/2019 documents she exhibits behavioral symptoms as evidenced by wandering and at times can be difficult to redirect and unaware of her safety needs with an intervention implemented 02/18/2029 of approaching/speaking in a calm manner and an intervention implemented 05/17/2019 of walking with R52 when she is wandering to ensure safety. R52's current care plan created 04/20/2019 documents she is at risk for falls related to diagnosis of dementia, confusion, poor communication/comprehension, poor safety awareness, wandering, and behaviors of feeling around door joints and attempting to open the door and leave the unit with intervention implemented 04/20/2019 including follow facility fall protocol, interventions implemented 03/21/2024 including staff to assist her in the dining room when meals are ready, allow her more sleep instead of having her wait in the dining room for meals; and intervention implemented 02/09/2025 of ensuring there is adequate supervision in the dining room. R52's current care plan created 12/19/2024 documents she has had an actual fall on 12/18/2024 which resulted in a fracture with interventions including staff checking her location and activity to ensure if she is properly and safely positioned in bed or chair/wheelchair. R52's current care plan initiated 01/12/2025 documents she had a fall on 01/12/2025 which resulted in a laceration on her left temple. Fall Risk Management report dated 12/18/2024 documents R52 was observed walking down the hall after breakfast towards the door and when she was getting close by the door the nurse called her trying to redirect her and she turned around quickly, lost her balance and fell landing on the right side of her hip. The facility's reportable event investigation report dated 12/19/2024 documents on 12/18/2024 R52 was observed walking towards the door and when she was getting close to it, the nurse called her and tried to redirect her, she turned around quickly, lost her balance, had a change in plain and was sent to the emergency room for further evaluation and treatment and was admitted with a right hip fracture. Fall Risk Management report dated 01/12/2025 documents at 4:30 PM R52 was found on the floor with a laceration on her head and was bleeding, while V20 (Nurse) was passing medications with her cart she turned around for a second and the next thing she heard behind her was the sound of a fall; contributing factors to R52's fall included confusion, impulsiveness, need for two person assistance with transfers, history of falls, observations of attempts at getting up without assistance recently, recently having surgery on her right hip, and diagnosis of fracture of right lower leg. R52's hospital discharge report dated 01/12/2025 documents she was diagnosed with a closed head injury, and scalp laceration and received laceration repair. The facility's reportable event investigation report dated 01/18/2025 documents R52 had an unwitnessed fall at approximately 4:40 PM on 01/12/2025 and sustained an approximately 3-centimeter laceration to her head, was sent to the emergency room for further evaluation and treatment and returned the same day to the facility with three staples to be removed in 7 days. Fall Risk Management report dated 02/09/2025 documents R52 had an unwitnessed fall and was observed sitting on the floor in front of her wheelchair by the dining room with the root cause being losing her balance and falling when attempting to stand up from her wheelchair. On 03/26/25 at 03:28 PM V18 (Restorative Nurse) stated he is the fall coordinator. V18 stated R52 has always been able to walk, and she fell on [DATE] due to suddenly turning around. V18 stated R52 had a fall at 4:30 PM on 01/12/2025. V18 stated R52 was sitting in the dining room and trying to stand. V18 stated a nurse was present and tried to catch her but didn't make it in time. V18 stated he believes the nurse was administering medications at the time. V18 stated there are usually a lot of residents in the memory care dining room. V18 stated usually there are two aides in the dining room at mealtimes and at that time there was not two aides possibly due to passing trays. V18 stated at least two aides are needed in the dining room for proper supervision. V18 stated on 02/09/2025 R52 was near the dining room in her wheelchair and attempted to stand up and loss her balance and fell. V18 stated this was an unwitnessed fall so there weren't any staff present. V18 stated there should be some staff present to monitor residents. On 03/27/2025 at 8:47 AM V2 (Director of Nursing) stated if there are several residents in the dining room, they would be sending more than one staff to supervise but it is not always their protocol to always assign and/or station two nurses or CNAs (Certified Nursing Assistant) at all times when residents are present in the dining room. V2 stated she understands that residents need supervision. V2 stated she was the one who conducted and completed the investigation after R52's fall incident and the nurse was by the dining room door beside her med cart where she can see the resident, but unfortunately, she wasn't able to get to the resident as fast as she could to prevent her fall. On 03/27/2025 at 10:19 AM V2 (Director of Nursing) stated on 01/12/2025 when R52 had a fall there were 36 total residents in the memory care unit. V2 reported there are 12 residents in the memory care unit that are at high risk for falls. In response to the surveyor asking if a nurse is the only staff in the dining room with multiple residents on the memory care unit, and she is passing medications while someone is falling, doesn't that make it difficult to assist the resident who begins to fall or even monitor all the residents present in the dining room; V2 replied that on 01/12/2025 the CNA (Certified Nursing Assistant) was asked to assist another resident with toileting and a nurse was in the dining room to oversee the residents while the other was helping with bringing residents to the dining room for dinner. On 03/27/25 at 03:03 PM V18 (Restorative Nurse) confirmed R52 and the nurse that witnessed her fall on 12/18/24 were inside the unit during the incident. V18 stated R52 and the other memory care residents usually roam around the memory care unit and wont usually attempt to leave and when they reach the exit door they turn back around. V18 stated if staff saw R52 approaching the memory care unit exit door they can monitor her to ensure she's ok and they usually just let the residents walk around. V18 stated in R52's particular situation on 12/18/2024 he can't think of anything the nurse could have done differently to prevent her fall because staff weren't expecting her to fall the way she did. V18 stated he doesn't think the nurse calling out to R52 could have startled her. V18 agreed the nurse was likely not close by R52 when she was approaching the door and therefore her voice calling out to R52 would not have been soft and low and agreed that the nurse would have had to call out to R52 loudly enough to be heard and get R52's attention. When asked by surveyor if the nurse could have just guided R52 away from the door rather than calling out to redirect her V18 could not provide any information. 2. R56 is a [AGE] year-old female with a diagnoses history of Alzheimer's, Dementia, Generalized Anxiety Disorder, Restlessness and Agitation who was admitted to the facility 04/12/2023. The facility's incident log from 09/01/2024 - 03/24/2025 documents R56 had an unwitnessed fall 03/21/2025 at 5:15 PM R56's current care plan created 04/25/2023 documents she is at risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension, and poor safety awareness with interventions implemented 04/25/2023 including follow facility fall protocol. R56's quarterly fall assessment dated [DATE] documents she is at high risk for falls. Fall Risk Management report dated 03/21/2025 documents R56 had an unwitnessed fall and was observed sitting on the floor on her right-side by the dining room and the root cause of the fall being she most likely fell asleep in her wheelchair while waiting for dinner. On 03/26/25 at 03:28 PM V18 (Restorative Nurse) stated according to the investigation of R56's fall on 03/21/2025 the nurse reported R56 fell asleep while sitting in her wheelchair and fell forward in the dining room. V18 stated this was an unwitnessed fall. V18 stated staff were likely passing trays and unable to catch R56. On 03/27/2025 at 10:19 AM V2 (Director of Nursing) reported the facility does have enough staff to assist the residents in the dining room. V2 reported the facility usually has nursing and activity staff present in the dining room during meals. In response to surveyor asking should there be multiple staff in the memory care dining room during mealtimes or when multiple residents are present; V2 reported they usually have 2 Nurses, 3 CNAs and 1 Activity Aide to assist with the residents. In response to surveyor asking why should there be multiple staff present in the memory care dining room during meal times or when there are multiple residents; V2 responded they have nursing to assist with feeding the residents and activities assist with passing the trays and just rounding to make sure residents have what they need. 3. R61 is a [AGE] year-old male with a diagnoses history of Dementia with Behavioral Disturbance, Encephalopathy, and Depression who was admitted to the facility 02/10/2025. On 03/24/25 at 10:57 AM Observed R61 in his room in his bed wearing a gown and protective sleeves over both his arms. Observed R61's right arm with multiple scabs and his right-hand knuckles with multiple scabs with dry blood sticking to the sleeve, a bruise, and a small bandage. The Facility's incident log from 09/01/2024 - 03/24/2025 documents R61 had a witnessed fall on 03/04/2025 at 8:30 AM, and unwitnessed falls on 02/13/2025 at 5:11 AM, 02/22/2025 at 2:30 PM, and 03/08/2025 at 11:05 AM. R61's admission Fall Risk assessment dated [DATE] documents he is at high risk for fall. R61's current care plan created 02/11/2025 documents he is at risk for falls related to generalized weakness, increased confusion, impaired cognition, altered mental status, and multiple medical conditions including activity intolerance and has exhibited behaviors of putting himself on the floor with intervention implemented 02/11/2025 of ensuring his call light is within reach and encouraging him to use it for assistance as needed, assessing and anticipating his personal needs and needs of activities of daily living such as toileting, incontinence care, eating etc. during rounds, ensuring he is centered in bed and bed bolsters are properly secured as appropriate and trunk and extremities are properly aligned and supported; intervention implemented 03/04/2025 of placing him in the dining room in the morning if he is observed up and awake if he will allow. R61's current care plan created 02/19/2025 documents he exhibits poor safety awareness and attempted to get out of chair/bed without staff monitoring and has difficulty comprehending redirection. Fall Risk Management report dated 02/13/2025 documents R61 had an unwitnessed fall in his room and was observed laying on the floor on his right side with his head at the foot of the bed and mattress halfway off the bed and tilted; R61 reported he slid off the bed; Contributing factors include being admitted to facility due to fall and increased confusion, observed with agitation and confusion, and having diagnoses including pneumonia and altered mental status; Root causes of the fall include R61 moving on his bed and the mattress tilted and he slid off to the floor. Fall Risk Management report dated 02/22/2025 documents R61 had an unwitnessed fall and was found on the floor in the hallway lying on his right side and his wheelchair behind him with the root cause being R61 making his way to the room from the dining room, wanting to go to the toilet, attempting to self-transfer without assistance, and losing his balance and falling. Fall Risk Management report dated 03/04/2025 documents R61 had an unwitnessed fall in his room and was observed sitting on the floor and reported he put himself on the floor; he was observed to have small scratches on both his knees with the root cause including attempting to get out of bed. Fall Risk Management report dated 03/08/2025 documents R61 had an unwitnessed fall and was observed lying on the floor on his right side by the hallway close to the nurses station and was observed with a bump on the right side of his forehead, skin discoloration, skin tears on multiple fingers on his left hand, skin tears on his right hand and right elbow and was sent to the emergency room for evaluation; R61 reporting he wheeled himself on his wheelchair and slipped from the wheelchair; the root cause of the fall includes R61 sliding down from his wheelchair. On 03/26/25 at 03:28 PM V18 (Restorative Nurse) stated R61 is very impulsive and has had previous attempts to get out of bed on his own before falling 02/13/2025 and interventions for this would include low bed, floor mats, encourage toileting, offering to get him up in the wheelchair when already awake, offering activities, and trying to redirect him. V18 stated R61 needs frequent supervision, and should be somewhere he can be monitored. V18 stated if R61 has been sitting in a place for a while he'll try to wheel himself somewhere. V18 stated R61's falls o 02/22 and 03/08 were due to him attempting to ambulate himself in the wheelchair and he will attempt to stand up. V18 stated interventions for this behavior is to have R61 close by staff for monitoring. On 03/27/2025 at 1:34 PM in response to surveyor asking would lack of supervision or insufficient supervision cause of fall to be unavoidable; V2 (Director of Nursing) replied that the need for supervision or level of supervision is a factor, depending on the resident and a high-risk resident that is not adequately supervised is more likely to have a fall than a more mobile resident. The facility's Fall Prevention and Management Policy received/reviewed 03/25/2025 states: The facility is committed to its duty of care to residents and patients in reducing risk, the number and consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained. High-Risk Precautions will be implemented to residents and patients whose scores on Resident/Family Notification fall Risk screen shows high risk with interventions including but not limited to meaningful and or scheduled rounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to properly monitor/supervise a high fall risk resident and ensure safety during incontinence care. This affected one of three (R2) residents reviewed for safety during care. This failure resulted in R2 rolling out of bed suffering a laceration to the head which required six sutures at the hospital. Findings Include: R2 is a [AGE] year old with the following diagnosis: malignant neoplasm of the stomach, dementia, anxiety disorder, and repeated falls. An Incident note dated 6/5/24 documents the CNA (V10 - Former CNA) called the nurse's attention to R2's room. R2 was observed lying on R2's left side on the floor with a red substance noted on the floor. R2 stated that R2 rolled out of bed. Pressure was applied to the head by wrapping with gauze to stop the bleeding. 911 was called. The Hospital Records dated 6/5/24 document R2 presented to the emergency department with a fall. R2 reportedly was reaching for an item and fell off the bed, striking the left side of the head on the ground. R2 was found in a pool of blood and complaining of pain in the left arm. A 2 cm x 2 cm laceration was noted over the left temple with a large hematoma and was pulsating blood. The laceration was closed with six sutures. A CT scan of the head was negative as well as a left forearm x-ray. R2's family member refused for R2 to return to the facility so R2 was admitted for placement. On 7/30/24 at 3:06PM, V6 (Nurse) stated V10 called V6 into R2's room due to R2 falling from the bed. V6 reported R2 had a laceration to the left side of the head and blood was coming out of the wound. V6 stated asking R2 what happened to which R2 replied that R2 rolled out of bed. V6 stated R2 was asked first what occurred before asking V10. V6 reported V10 also stated that R2 rolled out of bed while V10 was providing incontinence care. V6 stated R2 was able to move around the bed but needed staff assistance to completely turn over. V6 reported the bed was not in the lowest position at the time of the fall due to R2 being changed so R2 fell from a higher level. On 7/30/24 at 3:40PM, V7 (Restorative Nurse) stated R2 was a high fall risk due to having multiple falls, poor safety awareness, confusion, and not being physically able to move as normal. V7 reported the fall on 6/5 was due to R2 rolling out of the bed while R2 was being changed. V7 stated per V10's statement, R2 was being restless and V10 turned to grab something and when V10 turned back around R2 was rolling out of bed. V7 confirmed an intervention of bed bolsters should have been in place at the time of the fall. V7 reported R2 was a one person maximum assist with bed mobility. V7 stated once R2 was turned to the side, R2 was able to hold the side rail and assist, but R2 wasn't able to turn R2's self. V7 reported a resident should never be left unattended while they are laying on their side for safety reasons. V7 said, The proper positioning in the bed and monitoring is just safer for the resident and helps prevent any falls. On 7/31/24 at 9:56AM, V8 (DON) stated first speaking with V6 who told V8 that R2 rolled off the bed while being changed. V8 reported to the speaking with V10 about the incident. V8 stated V10 said V10 was changing R2's brief and turned R2 to the right side and V10 then began reaching for a new brief. V8 reported not being sure of V10's exactly location but was somewhere along the bedside. V8 said, She (V10) let go of the resident for a second. The resident rolled over onto her back then off of the bed. V8 stated R2 lost R2's balance after R2 rolled to R2's back and fell off the bed. V8 reported R2 is a high fall risk due to poor safety awareness, needing assistance with ADL care, lack of mobility, and previous falls. V8 stated R2 is alert and oriented times two with confusion. V8 reported R2 is a substantial/maximum assist with bed mobility but is able to move some and grab onto the grab bar when turned. V8 described the positioning device that is mentioned in the reportable is like a side rail, but it's a quarter of the size. V8 stated the positioning aide helps the resident hold on when they're being turned. V8 reported V10 did walk out during the interview due to getting flustered and resigned at that time. V8 stated R2 was sent to the hospital and ended up getting sutures to the laceration. On 7/31/24 at 11:08AM, V9 (Primary Physician) stated R2 had a laceration to R2's head from a fall. V9 reported R2 was being changed and fell from the bed. V9 stated R2 is a one assist. V9 reported the CNA was reaching over for a brief and during this time, R2 somehow fell from the bed. V9 stated R2 only had the capacity to hold R2's body to the side. V9 was unaware if R2 was on R2's side or R2's back when R2 rolled out the back. V9 reported V10 just went to grab something and R2 ended up rolling off the bed. V9 said, I'm not exactly sure how this would happen. She probably lost her balance somehow. On 8/1/24 at 9:09AM, V8 was unaware if the bolsters were on the bed at the time of the fall but stated if they were on the care plan then they should have been on the bed. V8 said, I think she just turned too quickly over to her back then rolled to her side off the bed. V8 confirmed R2 did roll off the same side the CNA was standing on. V8 stated the CNA was grabbing a brief to put on R2 but never left the bedside per V10's interview. When asked how R2 was able to roll so quickly to R2's back, left side, and then over the bolster before V10 stopped R2, V8 responded, I don't know how she was able to roll onto her back and then onto the floor so quickly without the CNA stopping her. I don't know. V8 reported R2 is a substantial/maximum assist with bed mobility but R2 can begin to roll R2's self to the side. On 8/1/24 at 9:17AM, V6 stated both R2 and V10 confirmed R2 rolled out of the bed causing the fall but V6 was unsure of the exact manner to which R2 fell out of the bed. V6 was not able to recall if the bed bolsters were in place. V6 reported R2 was lying on R2's left side but was on the right side of the bed if you are facing the bed at the foot. V6 said, When you are changing a resident everything you need should be at the bedside. If you need to go get something you forgot then the resident should be put back in the middle of the bed and the bed lowered to the floor. You shouldn't be grabbing for things even if they are closer because it takes your attention away from the resident and then accidents like this can happen. The surveyor called V10 throughout the survey to obtain an interview regarding the incident but a call was never returned. The Fall Event dated 6/5/24 documents R2 fell in R2's room. R2 was lying in the bed getting R2's brief changed immediately prior to the fall. R2 reported that R2 rolled out of bed. R2 is able to respond verbally per baseline. An injury to the top of the scalp was noted with a red substance coming from the scalp. The SBAR Communication Form dated 6/5/24 documents R2 was transferred to the hospital due to a fall. The Fall Investigation Report dated 6/5/24 documents at 6:45 PM, the CNA called the nurse to R2's room. R2 was observed lying on R2's left side next to the bed. R2 was bleeding from the face head area on the left side where R2 was lying. Pressure was applied with gauze bandages. R2 stated that R2 rolled out of bed. 911 was called. R2 was oriented to person and place per baseline. Predisposing factors of the fall are poor safety awareness, periods of agitation and restlessness, weakness, and use of psychotropic medication. The root cause of the fall documents after further investigation, staff was providing incontinence care to R2. R2 was lying on the right side in bed. As the CNA was reaching for the incontinent brief, R2 abruptly turned over onto R2's back. R2 then continued turning and was not able to grab the positioning device for control to stabilize R2's balance causing R2 to roll out of bed and onto the floor. The Final Incident Report dated 6/11/24 documents R2 is a long-term resident that resides on the dementia unit. R2 is alert and oriented times two with periods of confusion. R2 is able to move in bed with the help of the positioning device and one staff assist. R2 was observed on the floor next to R2's bed with a laceration to the left temple with bleeding. R2 was sent to the hospital and was admitted with a hematoma to the left temple and required six sutures to the laceration to the left temporal area. The CNA that was providing care at that time of the fall reported R2 was lying on the right side in the bed and the CNA was standing behind R2 on the other side of the bed. As the CNA was reaching for the incontinence brief at the bedside, R2 abruptly turned over onto R2's back. R2 continued turning to the left side and was not able to grab the positioning device to stabilize R2's balance. This caused R2 to fall onto the floor on the same side where the CNA was standing. The x-ray and CT of the cervical spine and head were done at the hospital and showed no acute abnormality. The Fall Assessment 4/26/24 documents a score of 24 indicating R2 is at high risk for falls. R2 has a history of multiple falls, has poor memory and recall ability, is totally incontinent of both bowel and bladder, has agitated behavior, requires hands on assistance to move from place to place, and has a decrease in muscle coordination. The Fall Risk assessment dated [DATE] documents a score of 27 indicating R2 is a high fall risk. A score of 16 or above indicates a resident is at high risk for falls. The Restorative Nursing Program Documentation dated 4/26/24 documents R2 has impaired mobility due to decreased range of motion related to generalized weakness, poor trunk control, and poor safety awareness. The Care Plan dated 5/24/20 documents R2 is at risk for falls due to poor safety awareness related to cognitive impairment, impaired mobility, and generalized weakness. An intervention on 5/12/23 documents bed bolsters were put in place. The Care Plan dated 8/10/22 documents R2 has had an actual fall with no injury. An intervention documented on 5/12/23 documents staff will ensure that R2 is centered in bed, positioning device is functional and up as appropriate, floor mats are in place as appropriate, and trunk and extremities are properly aligned and supported. The Care Plan dated 8/24/23 documents R2 has had an actual fall on 8/24/23, 9/2/23, 9/10/23, and 9/14/23 with no injury. An intervention documented on 9/14/23 documents staff will ensure that R2 is centered in the bed, position device is functional and up as appropriate, bed bolsters are properly secured as appropriate, and trunk and extremities are properly aligned and supported. The care plan with no date documents R2 is challenged by dementia and mental illness which impedes on R2's safety awareness and judgment. This care plan also documents R2 has an ADL self-care performance deficit related to weakness. An intervention documents R2 requires limited to extensive assist by one staff to turn and reposition in the bed as necessary. The Minimum Data Set (MDS) Section GG dated 4/26/24 documents R2 is a substantial/maximal assist indicating the staff member does more than half of the effort. The staff member lifts or holds the resident's trunk or limbs, and provides more than half the required effort. R2 is dependent when going from a sitting to a lying position indicating the staff member does all of the effort. R2 is not ambulatory. The facility provided the surveyor with a drawing of the incident to describe where the CNA was standing in relation to R2, the bed, and how close the bedside table was to the bed. According to the description of the incident and drawing, R2 should not have been able to turn from R2's right side to R2's back and over to R2's left side before being stopped or assisted by the CNA that was allegedly standing directly next to the bed. With the description of the incident and drawing, it can be determined that R2 was not properly monitored or supervised while the CNA was providing incontinent care if R2 had enough time to roll from R2's right side to R2's back then continue rolling onto R2's left side over the bed bolsters and then out of the bed. The policy titled, Fall Prevention and Management, dated 4/8/24 documents, Policy Statement: the facility is committed to its duty of care to residence and patients in reducing risk, the number and consequences of falls, including those resulting in harm and ensuring that a safe patient environment is maintained .Fall Interventions: a. Universal fall precautions/facility fall protocol will be implemented to all residents and admitted to the facility, regardless of risk scores.