**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to provide appropriate assistive devices and staff supervision while walking to two cognitively impaired, high-risk falls residents (R1, R2) out of 3 residents reviewed for incidents/accidents. These failures resulted in R1 bumping R1's nose on the hallway countertop and sustained a nasal fracture. Findings Include: R1's clinical records show an initial admission date of 11/30/22 with included diagnoses but not limited to Unspecified Dementia Without Behavioral Disturbance, Unspecified Psychosis, History of Falling, and Altered Mental Status. R1's Minimum Data Set (MDS) dated [DATE] shows R1 has severe cognitive impairment and requires supervision or touching assistance with walking. R1's fall risk evaluation dated 9/09/24 shows R1 is at high risk for falls. This fall risk evaluation also shows R1 has unsteady gait, has memory problem, and is able to walk with assistance and/or assistive device. R1's restorative mobility evaluation dated 9/09/24 shows R1 uses a walker. R1's fall care plan initiated on 12/06/22 shows R1 is at risk for falls related to impaired balance, weakness, and activity intolerance. This care plan also shows that R1 is ambulatory and uses a rolling walker with cueing assistance. One of the fall interventions in the fall care plan reads in part, I have periods of forgetfulness. I would like staff to frequently reorient me to my surroundings (date initiated 12/06/22). R1's Activity of Daily Living (ADL) care plan date initiated on 11/30/22 shows R1 requires cueing to partial assistance with ADLs (transfers, walking), and R1 primarily utilizes a walker but oftentimes is forgetful to use a walker for ambulation; therefore, R1 is at risk for falls/injury. One of the interventions reads in part, Provide [R1] with reminders to use [R1's] walker, cue/assist if necessary (date initiated 9/09/24). The facility's final incident report sent to the state agency on 9/20/24 at 7:00 PM documents in part: On 9/13/24, at about 7:10 PM, [R1] was ambulating in the hall while holding hands with another female resident [R2]. The other resident began to fall, and as [R1] was still holding onto [R2's] hand, [R1] was pulled forward and bumped [R1's] nose on the hallway railing. [R1] did not fall or have a change in plane, [R1] was noted with swelling and skin tear measuring 0.2x0.5cm [centimeters] to the nose. Minimal bleeding noted. Abrasion was cleansed and covered with a band aid. Pain medication administered and ice pack applied. Neurochecks initiated. [V16 Advanced Practice Nurse] was notified with order to send to ED [Emergency Department] for evaluation. This report also documents that R1 was transferred to the acute hospital via emergency [911] where R1 was diagnosed with closed fracture of nasal bone and returned to the facility on 9/14/24 at 1:20 AM. R1's progress notes documented by V12 (Licensed Practical Nurse) indicates that per ER [Emergency Room] department, R1 has a bilateral nasal bone fracture and will return to the facility. R1's hospital discharge instructions printed on 9/13/24 at 10:58 PM documents that R1's was seen for a fall and [R1] hit [R1's] nose with a diagnosis of Closed fracture of nasal bone, initial encounter. R2's clinical records show an initial admission date of 4/29/22 with included diagnoses but not limited to Unsteadiness on Feet, Adult Failure to Thrive, Other Abnormalities of Gait and Mobility Unspecified Dementia Without Behavioral Disturbance, and History of Falling. R2's MDS dated [DATE] shows R2 has severe cognitive impairment and requires supervision or touching assistance with walking. R2's fall risk evaluation dated 8/16/24 shows R2 is high risk for fall. This fall risk evaluation also shows R2 has unsteady gait, has memory problem, is able to walk with assistance and/or assistive device, and just had a fall. R2's fall care plan initiated on 6/11/22 documents in part: R2 is at high risk for falls related to a history of falls, behaviors, current medication use, poor safety awareness, unsteady gait, and disease process. R2 ambulates with use of walker with cueing and redirection from staff due to wandering behaviors. One of the fall interventions in the fall care plan reads in part, Assist [R2] with walking, remind [R2] of safety precautions as needed. May require frequent reminders and cuing of assistance requires for ambulation (date initiated 6/21/22). Another fall care plan intervention reads in part: Use of assistive device during ambulation to prevent falls (date initiated 6/11/22). R1's behavior care plan initiated on 6/16/22 documents in part: R2 exhibits poor safety awareness and will walk without R2's walker or regard to R2's own safety which increases R2's risk for falling and/or obtain an injury. One of the interventions reads in part, Provide frequent cues and redirection to wait for staff assistance (date initiated 6/16/22). The facility's change in condition form for R2 dated 9/13/24 at 7:10 PM documents in part: R2 holding hands with another resident coming out of the room. The other resident tripped over [R2], and R2 sat down on the floor. Head to toe assessment done, no skin alteration noted, no injury. Vitals taken all within normal limits, denies pain. [R2] alert and oriented x 1, range of motion within the baseline. On 1/12/25 at 10:50 AM and 1:03 PM, interviewed V10 (Agency Registered Nurse) and stated that V10 is the nurse in charge for R1 and R2. V10 stated that R1 needs one person assistance when walking with the use of a rolling walker. V10 stated R1 is confused. V10 stated that R2 is also ambulatory using a rolling walker. V10 stated R2 needs one staff assistance with walking because R2 gets confused and forgetful and is high fall risk. On 1/12/25 at 11:02 AM, interviewed V2 (Director of Nursing) and stated that V2 witnessed the incident that happened with R1 and R2 on 9/13/24 at around 7:10 PM. V2 stated, I went to the floor to do rounds. When I came out the elevator, I turned left to go down the hall and saw [R1] and [R2] walking together. There were no staff walking with them. [R1 and R2] were not using their walkers. [R1] was holding [R2] and walking together. Back there on the third-floor unit there is a cove. There is a countertop on the hallway like an island. I saw [R2] began to fall and [R1] was holding on to [R2] they were walking face to face holding each other's both hands. [R2] was walking backwards and then [R2] lost [R2's] balance and fell backwards. [R2] kind of slid down the wall. [R2's] back was leaning on the wall. [R1] was still holding [R2's] hands and went forward hitting [R1's] face on the countertop. [R1] had a nasal bone fracture. [R1] went to [Acute] hospital. V2 stated that fall assessment is completed upon admission, post fall, quarterly, and re-admission. V2 stated that the fall assessment's purpose is to assess the resident they are high fall risk. V2 stated that the care plan would address fall interventions to prevent from residents' from falling. V2 stated fall interventions include the resident's needs, based on the fall assessment, and is updated based on the root cause analysis post fall. V2 stated that R1 ambulates by herself with a walker and is quite independent. V2 stated that R2 has a walker needs assistance with walking. V2 stated that R2 is very forgetful and needs multiple re-direction. V2 stated that R2 needs staff assistance with walking, toileting, and transfer. A follow up interview conducted with V2 on 1/12/25 at 3:47 PM and stated that there were no other staff witnesses for R1 and R2's incident. On 1/12/25 at 1:10 PM, a phone interview conducted with V12 (Licensed Practical Nurse) and stated that R1 has dementia, walks with a walker, and wanders around. V12 stated that when R1 she walks somebody has to be with [R1]. V17 stated, We have to keep an eye on [R1] and supervise [R1]. [R1] is high risk for fall. [R1] forgetful. [R1] uses a rolling walker, and [R1] needs to use that all the time. [R2] also walks with walker and is more disoriented than R1. [R2] only speaks Spanish a little bit English. [R2] needs supervision at all times when walking. [R2] is a high fall risk. [R2] also needs rolling walker at all times. Surveyor asked V12 regarding the incident that happened on 9/13/24 with R1 and R2. V12 stated, I can't recall the exact time. I was passing medication at that time. It was evening meds. I can't recall the exact time. [V2] brought to my attention that [V2] witnessed [R1] and [R2] were walking holding hands. They were not using the walkers. [R1] lost balance and bumped [R1's] nose on the countertop by the front of [R1's] room. I did a full assessment for both. I took care of [R1]. [R1] was not complaining of pain after the incident but [R1] was holding [R1's] nose. We saw discoloration on [R1's] nose, no bleeding, just a superficial cut on the bridge of [R1's] nose. At that time [R1] did not complain of pain. [R1's] vitals were stable. We called 911 and the doctor. V12 stated that R1 came back to the facility the same night with nasal fracture as R1's diagnosis. On 1/12/25 at 4:38 PM, a follow-up phone interview was conducted with V12. V12 stated that V12 cannot recall what time the last time [V12] saw R1 and R2 before the incident. V12 stated that [V12] can only remember that R1 was in the dining room and R2 was in R2's room the last time V12 saw R1 and R2. On 1/12/25 at 1:33 PM, interviewed V13 (Restorative Licensed Practical Nurse) and stated that the Section GG of the MDS shows the resident's functional assessment, including their mobility assessment. V12 stated that if the resident 's MDS is coded supervision or touching assistance for example if a resident is walking with a walker, the staff should be cuing, reminding, or guiding the resident during walking activity. On 1/12/25 at 3:37 PM, I attempted to conduct a phone interview with V14 (Former Certified Nursing Assistant/CNA). Surveyor asked about the incident with R1 and R2 on 9/13/24. V14 stated that V14 is very sick and can't talk. V14 refused to be interviewed. On 1/13/25 at 10:24 AM, a phone Interview conducted with V18 (Nurse Practitioner) and stated that V18 knows about the incident that happened on 9/13/24 between R1 and R2. V18 stated that R1 sustained the nasal fracture from the incident and was sent to the hospital. V18 stated that based on R1 and R2's cognitive and mobility statuses, R1 and R2 need staff supervision when walking and needs frequent monitoring. Surveyor asked V18 that if staff supervised and monitored R1 and R2 with walking would the incident had been prevented. V18 stated, I'm sure the incident would not happen. On 1/13/25 at 10:33 AM, a phone interview conducted with V2 and stated that for confused residents who are high risk for falls, fall interventions that the staff should be doing are frequent monitoring, re-direction, and to make sure residents are engage with activities. V2 stated that frequent rounding means the staff (Nurses and CNAs) are checking on residents every half hour. The facility's Fall Occurrence policy dated 7/26/24 documents in part: It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and reevaluated and revised as necessary. Those identified as high risk for falls will be provided fall interventions. The facility's General Care policy dated 7/30/24 documents in part: It is the facility's policy to provide care for every resident to meet their needs. Upon admission or readmission, the facility will evaluate the resident for physical and psychosocial needs. Physical needs would include, but are not limited to ADL, wound care, medical needs, etc. Psychosocial needs would include but are not limited to areas of mental and psychosocial well-being. The facility will assist the resident to meet these needs, unless it shows that the resident's needs cannot be met in the facility.

Based on interviews and record reviews, the facility failed to follow its intravenous therapy policy and accurately assess and monitor resident's signs/symptoms/change of condition, which resulte in delay of care and resulted in MRSA spread causing decline in resident's health, with infection to knee and MRSA pneumonia for one resident's (R422) PICC (peripherally inserted central catheter) out of three reviewed for change in condition in a sample of 37. This failure resulted in R422 developing chills, elevated white blood cell count, and malaise. R422 was transported to the hospital and diagnosed with MRSA infection of PICC line causing MRSA infection of right knee and MRSA pneumonia. Findings include: On 4/26/24 at 8:56 AM, V14 RN (Registered Nurse) stated that PICC (peripherally inserted central catheters) dressing is changed weekly. V14 stated that all the needed supplies are in kit. V14 stated that when you record arm circumference and external catheter length, the previous documented result will appear so that you can compare previous result with current result. V14 stated that 1-2cm difference in arm circumference would not be considered significant but more than that would be considered significant, resident could have edema. V14 stated that the physician should be notified of any changes. V14 stated that the differences in external length catheter could signify concern with catheter position not in correct place and physician should be notified. V14 stated that PICC line insertion site is monitored for signs/symptoms of infection every shift; monitor for swelling, redness, pain at insertion site. V14 stated that when he provided care for R422 the end of February and early March, R422 was complaining of right knee pain. V14 stated that he did not report pain to physician because he believed it was chronic pain. R422's TAR (Treatment Administration Record), dated February and March 2024, notes R422's right upper arm midcircumference measurement on 2/25/24 was 33cm (centimeters), on 3/3/24 it was 23cm (centimeters); and on 3/10 it was 34cm. R422's MAR (Medication Administration Record), dated March 2024, notes R422 received Acetaminophen 650mg (milligrams) for complaints of right knee pain on 3/7, 3/8, 3/11, 3/13, and 3/14. On 4/26/24 at 9:30 AM, V15 NP (Nurse Practitioner) stated that every facility has PICC line protocol and that staff are trained on changing dressing with aseptic technique. V15 stated that when V15 saw R422, there were no signs of infection (redness or swelling) observed at PICC line insertion site. V15 stated that during R422's stay at this facility, staff informed V15 of inability to draw blood from PICC line. V15 stated that R422 was transported to the hospital for further evaluation. V15 stated that the emergency room staff were able to get PICC line working properly after flushing line. V15 stated that when R422 came back from hospital visit, R422 complained of not feeling well. V15 stated that laboratory testing was done and R422's white blood cell count was 19 (normal range is 3.9-11). V15 stated that she believes R422's PICC line became infected from the emergency room staff flushing PICC line and not using aseptic technique. V15 stated that R422 had MRSA (methicillin resistant staphylococcus aureus) infection in PICC line causing MRSA infection in right knee and in lungs. V15 stated that the hospital was unable to determine if MRSA had spread to R422's heart because heart testing was unable to be done due to R422's comorbidities. When questioned how would a PICC line become infected with MRSA, V15 stated MRSA infection due to not using aseptic technique while providing care for PICC line. R422's medical record notes the following: On 2/26/24, R422's white blood cell count was 10.1. On 2/28/24, the nurse noted R422 sent to the hospital to assess and exchange PICC line placement due to no blood return. R422 scheduled/ expected to return today with new picc line. V16 RN noted R422 returned from the hospital at 5:00 PM. The PICC line remained the same. It was flushed in the emergency room and happened to be working fine. The x-ray was done to verify the location. On 3/4/24, R422's white blood cell count was 8.2. On 3/11/24, R422's white blood cell count was 11.5. On 3/14/24, R422's white blood cell count was 19.5. R422's medical record notes the following: On 1/23/24, R422 was admitted to this facility with a right upper arm PICC line, arm circumference 28cm (centimeters). R422's TAR (Treatment Administration Record), dated February and March 2024, notes R422's right upper arm mid-circumference measurement on 2/25/24 was 33cm (centimeters), on 3/3/24 it was 23cm (centimeters); and on 3/10 it was 34cm. R422's pre-admission hospital record, dated 12/18/23-1/23/24, notes R422 was found to have cardiogenic shock secondary to acute decompensated heart failure. An echocardiogram on 1/3/2024 showed an ejection fraction of 10-15%, and a right heart catheterization indicated elevated filling pressures. Left anterior descending artery in heart showed 99% occlusion. R422's left ventricle showed severe dilation. On 2/26, the nurse practitioner noted R422's right lower extremity with 2+ edema (swelling). On 2/28, nurse practitioner noted R422 with bilateral lower extremity edema. R422's progress notes, dated 3/14/24, notes at 1:55 PM, R422 complained of body malaise, bilateral lower extremities with edema. Stayed in bed, WBC (white blood cell count) 19.5 (normal range 3.9 - 11). At 2:43 PM, R422 still complained of body malaise and bilateral lower extremity pain. R422's hospital record, dated 3/14/24-3/25/24, notes R422 presented from this facility due to laboratory abnormalities. R422 reports 48 hours prior to hospitalization she developed severe pain in right knee which interfered with her ADLs (activities of daily living). She had chills/shaking, but no fevers. It also hurts to take deep breaths. 24 hours ago developed shortness of breath. Physical examination noted lungs with poor inspiratory effort. 2+ pitting edema bilateral lower extremities. Right knee swollen, warm, effusion present. Active and passive ROM (range of motion) severely limited. R422 alert and oriented x 4. Speech clear. Generally weak, especially lower extremities. Elevated white blood cell count, suspect pneumonia as there is right perihilar fulness/haziness, pleuritic chest pain and new oxygen requirement. PICC (Peripherally inserted central catheter) inserted right arm on 1/7/24. R422 with septic knee, and MRSA (methicillin resistant staphylococcus aureus) bacteremia (likely due to PICC infection, and then causing the MRSA septic knee and MRSA pneumonia- PICC was partially displaced on arrival to hospital). PICC removed 3/16 given MRSA bacteremia. Given MRSA in the knee, taken for a right knee washout with orthopedics on 3/17. This facility's intravenous therapy policy, revised 8/7/23, notes all intravenous access will be assessed by the nurse to ensure that no signs and symptoms of infection and infiltration are left unaddressed. All central line dressings (PICC line) will be changed every 7 days. The length of the external catheter and extremity circumference will be measured weekly to monitor movement and edema (swelling).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to identify supervision needs and implement measures to reduce fall risk for a confused resident at risk for falls, failed to implement plan of care interventions and falls policy to prevent resident's fall and injury. This failure affects 1 (R1) of 3 residents reviewed for accidents/incidents in the sample and resulted in R1 being emergently transferred to the hospital for hip fracture with surgical intervention. Findings include: R1 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Retention of Urine, Unspecified; Polyosteoarthristis, Unspecified; Atrioventricular Block, Second Degree; Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, and Anxiety; Altered Mental Status, Unspecified; Unspecified Symptoms and Signs Involving Cognitive Function and Awareness; Unspecified Hearing Loss; Adult Failure to Thrive; and Fracture of Unspecified Part of Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing. According to most recent MDS (Minimum Data Set) before the fall (that occurred on 10/26/2023) dated 09/01/2023, under section C, R1 has BIMS (Brief Interview of Mental Status) score of 2 indicating severe cognitive impairment; under section G, R1 needs extensive assistance, one person physical assist for transfers, and R1 not steady, only able to stabilize with staff assistance moving from seated to standing position. Per record review, Fall Risk Evaluation dated 09/01/2023 reads in part, Score 4; scoring: 0-7 = low risk. Per record review, Fall Risk Evaluation dated 10/26/2023 reads in part, Score 13; scoring: 8 and above = high risk. Per record review, R1's fall care plan reads in part, R1 has unsteady balance, able to stabilize without staff assist, please monitor R1's balance and assist as needed. I (R1) would like staff to address my needs with a prompt response to all requests for assistance. On 11/13/2023 at 10:07 AM, Surveyor interviewed V8 (Licensed Practical Nurse) who related the following in summary but non-verbatim: Nurses round on residents upon beginning of their shift; however, there is no rounding schedule for nurses. Certified Nursing Assistants are our eyes and ears, and they do the rounding. When we have agency CNAs, we, floor nurses, orientate them upon beginning of their shift to familiarize them with residents. There is also a list that summarizes high fall risk residents and their needs for agency staff to review. Residents' names who are on high risk for fall are also marked with gold leaf as a visual reminder. On 11/15/2023 at 02:08 PM, Surveyor interviewed V2 (Director of Nursing/Interim Falls Coordinator) who related the following in summary but non-verbatim: The expectation on staff rounding is to have nurses and CNAs round at the beginning of their shift and at least every couple of hours throughout the rest of the shift for both, nurses and CNAs. On 11/13/2023 at 10:18 AM, V8 (LPN) provided memory care unit high risk fall residents' list. List reviewed, R1 not included on the high risk fall list. On 11/13/2023 at 10:23 AM, R1 not in the room at this time. No gold leaf observed by R1's name outside of the room. On 11/13/2023 at 10:35 AM, Surveyor interviewed V6 (Agency Certified Nursing Assistant) who related the following in summary but non-verbatim: Nurses give us verbal update on residents' needs, but I am not aware of any resident list pertaining to their specific needs, I've never seen it before. On 11/13/2023 at 02:42 PM, Surveyor interviewed V6 (Agency Certified Nursing Assistant) who related the following in summary but non-verbatim: We are vigilant when working on the third floor because it is dementia unit. I remember R1. I was the one who took care of him on the evening of 10/26/2023. R1 usually goes to bed around 7.30 pm. That evening, I came out of adjacent room, peaked into R1's room and noticed, that he was sitting on the edge of the bed, ready to be assisted to go to bed for the night. I asked R1 to give me a minute while I go to throw away the garbage. When I came back, R1 was already on the hallway floor with his walker beside him and his roommate standing next to him. R1 was complaining of left leg pain. I notified the nurse and R1 was sent to the hospital via 911. R1 is confused, requires 1 person assist with Activities of Daily Living and walking, although he often walks by himself, always with the walker. I don't consider R1 safe to walk by himself. R1 doesn't use a call light and is forgetful. R1 tends to walk out of the room when he needs something instead of using call light. Additionally, R1 is hard of hearing. On 11/13/2023 at 3:50 PM, Surveyor interviewed V9 (Licensed Practical Nurse) who related the following in summary but non-verbatim: On the evening of 10/26/2023, R1 was in the new room when he fell. R1 was not aware of new surroundings since he was moved to the new room the day before. R1's roommate thought that R1 was knocking on the door, and pushed the door as R1 was standing in the doorway. R1 might have gotten startled and fell in the hallway, right outside of the room. V6 (CNA) alerted me about the fall. I approached R1 and assessed him, including vital signs, neurological check, and checked for leg shortening as he was complaining of left leg pain. I asked R1 what happened, but he was unable to recall. R1 was just holding onto his leg, saying that it hurts. We treat all residents on memory unit as a fall risk. Fall risk resident have gold leaf by their names. R1 was ambulatory with a walker but very confused. R1 needed assistance with some Activities of Daily Living and one person assist with getting in and out of the bed. Per record review, hospital record dated 11/01/2023 reads in part, R1 presents to the hospital status post hip fracture. On 10/28 (2023) R1 underwent a left hip open reduction and internal fixation surgery and required postoperative pain management. On 11/13/2023 at 04:12 PM, R1 observed asleep in the bed at this time. Bed alarm pad underneath the resident, bed alarm monitor stored away in the drawer, in the nightstand, next to the R1's bed. On 11/14/2023 at 11:51 AM, Surveyor interviewed V2 (Director of Nursing/Interim Falls Coordinator) who related the following in summary but non-verbatim: R1's fall investigation consisted of staff and roommate interview, we also discussed R1's fall during interdisciplinary team meeting. R1's post fall precaution interventions are: reorienting to surrounding environment and bed alarm; R1's fall precaution interventions previous to the fall were: call light within reach and proper footwear. R1 wasn't a fall risk resident before the fall. We came to this conclusion based on R1's assessments including: no previous falls, whether there was significant change, additionally, we observed R1. R1 was safe to walk unassisted. We determined that the fall that occurred on 10/26/2023 was unavoidable because R1 was pushed by the door. On 11/14/2023 at 3:00 PM, Surveyor interviewed V5 (Restorative Nurse/Interim Fall Coordinator) who related the following in summary but non-verbatim: On 09/01/2023, I assessed R1's Minimum Data Set, section G -Functional Status, based on CNAs documentation, restorative aid comments, and my own assessment. For sit to stand transfer, R1's functional status was graded as 3 - extensive assistance and 2 - one person assist because the CNA placed gait belt on R1 and pulled him up, R1 needed 50% assistance from staff, was unable to complete the task independently. Before the fall on 10/26/2023, R1 wasn't high risk fall resident; however, after the incident, R1 became a high risk fall resident. R1 needs now physical and occupational therapy due to incident/fracture. R1 is not safe to ambulate with a walker like he used to, he uses wheelchair now. On 11/15/2023 at 9:50 AM, Surveyor interviewed V7 (Nurse Practitioner) who related the following in summary but non-verbatim: R1 is a [AGE] year old male who's minimally verbal, doesn't answer questions, follows minimum commands, and is confused, only able to state his name. R1 is also hard of hearing. The main issue when communicating with R1 is not so much trouble hearing, it is his progressive dementia due to old age. I last assessed R1 before the fall (that occurred on 10/26/2023), on 08/08/2023. I didn't see him walk at that time, and even before then, R1 was mostly in his bed. R1 had overall decline in health since August of 2023. I performed full assessment, including chest x-ray and blood work, but there has not been indication of an ongoing infection, R1 has been just declining due to his age. Surveyor further clarified, if I said (R1), I'll back in a minute, just wait for me would R1 be able to understand that command? V7 (NP) stated, No, I doubt R1 would understand that. On 11/15/2023 at 2:48 PM, Surveyor interviewed V10 (Nurse Practitioner 2) who related the following in summary but non-verbatim: (Nurse Practitioner) I've been taking care of R1 for the last year, I see him about once a month. The biggest communication issue with R1 is that he can't hear but just agrees with you; and it has been especially challenging with staff wearing masks. R1 would not remember to use the call light taking his BIMS score into consideration, and his dementia also plays a big role. High-Risk Fall Identification Process policy, not dated, reads in part, The visual identifier is used to identify residents who are on the program. The identifier may be in place next to the resident's name outside of the room. By making it easy to identify high-risk resident's, staff can quickly initiate action to reduce the risk of falling and injuries. Fall Occurrence policy dated 07/17/2023 reads in part: It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. If a resident had fallen, the resident is automatically considered as high risk for falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate supervision is provided to one resident (R1) who is at risk for falls and has had history of multiple falls in the past out of 3 residents reviewed for supervision. This failure resulted to R1 sustaining laceration on right forehead which required sutures and resulted to subarachnoid hemorrhage, displaced fracture right zygomatic arch, fracture of the right inferior orbital wall, fracture of the right superior orbital wall and fracture of the right frontal sinus. R1 was admitted to the facility on [DATE]. R1's Minimum Data Set with a Target date of 12/28/2022 under Brief Interview for Mental Status documents a score of 3/15 which indicates cognitive impairment. R1's Progress notes dated 12/7/22 documents in part: At around 7:15 PM, Resident fell in the dining room, was found on the floor of the dinning (sic) room in the prone position, He was assessed for injuries, bleeding on face was noted with a 3 cm deep cut on R eyebrow, ice pack and sterile gauze were applied on wound site until bleeding stopped. 911 called at 7:18 PM, and resident has been transported to xxx hospital at 7:30 pm. R1's Fall Risk assessment dated [DATE] documents a score of 14 which indicates that R1 is a high fall risk. R1's Fall List documents that R1 had a fall incident on the following dates: 12/7/22, 8/29/22, and 6/17/22 within the last 6-8 months. R1's Fall Care Plan with 12/7/22 revision date documents in part: R1 is at high risk for falls related to: recent fall, Cognitive impairment, Anxiety, Anemia, History of falling, Altered mental status, Left hemi post subdural hemorrhage, Dementia, anemia, cardiac dysrhythmias, CHF, anxiety, depression, schizophrenia, violent behavior, current medication orders for antipsychotics and antidepressants, and incontinence. Due to R1's diagnosis of psychosis, he is noted with periods of agitation and delusional thoughts placing him at high risk for fall/injury. R1 is noted with increase anxious behaviors placing him at risk for fall/injury. Hospital records document result of CT of the brain under Findings in part as: There is a small amount of subarachnoid hemorrhage and intraparenchymal hemorrhage in the right anteroinferior frontal lobe. CT of the facial bones under Findings also document: There is a dispalced fracture of the right zygomatic arch. There is a fracture of the right inferior orbital wall without herniation of the intraorbital contents. There is also a fracture of the right superior orbital wall that extends to involve the frontal sinus. The inner table of the right frontal sinus is fractured and there is pneumocephalus. R1 also had laceration of the right forehead which was sutured in the Emergency Room. On 2/10/22 at 11:17 AM, R1 observed sleeping in bed, bed on low position, with bed alarm, landing pads on both sides of the bed, white noise player on. R1's wheelchair was observed with bolsters on both hand rails. When asked if he recalls his fall incident on 12/7/22, R1 did not respond. Further questioning still did not yield any response from R1. R1 was murmuring something unintelligible. When asked if he is in any pain, R1 did not respond. On 2/10/22 at 12:45 PM, V13, Certified Nursing Assistant/CNA, assigned to R1 at the time of the fall stated, I was the CNA assigned to R1 that shift. Dinner usually starts around 6:00 PM. I fed R1 his dinner, R1 is a feeder. R1 ate everything. I was cleaning up the dining room so R1 stayed in the dining room. There were other residents in the dining room. At that time, I don't really know who was watching the residents in the dining room. Usually one of us is usually there. I can't remember who was in charge of supervising the residents in the dining room at that time. R1 is high risk for falls. R1 shouldn't be left in the dining room unsupervised. I was in and out of the dining room. I did not witness R1 falling. The last time I saw R1 was around 7 PM and then I proceeded to pick up the trays from the other residents' rooms. On 2/10/22 at 12:05 PM, V12, Restorative Nurse stated, I am in charge of investigating fall incidents and updating care plans. For R1, based on my investigation, his fall could be more because of his diagnosis or his behaviors that contributed to him falling. R's fall occurred in the dining room around 7:30 PM. We did put R1 on behavior monitoring when he returned from the hospital. V13 was the CNA in charge of R1 at that time. The CNA said that she put R1 in the dining room around dinner time which would have been around 6 PM. The CNA was there when it happened. She didn't witness the fall because she was putting trays away. For R1 if he is calm, he usually stays in the dining room after dinner. When there's people in the dining room, there should be a staff member supervising the residents. My root cause analysis showed that his behavior contributed to the fall occurrence. On the behavior monitoring for 3 days, I didn't observe any new behaviors that might have contributed to that fall. On 02/10/2023 at 1:38 PM, V11, R1's Physician when asked if she was informed about R1's fall incident on 12/7/22 stated, I'm sure I was informed about R1's fall incident. During my last assessment with R1, all I remember was that the patient was in a wheelchair and he was trying to get up and he was sliding from his chair constantly. And you cannot talk to him, about the dangers, about his surroundings. I tried to call the CNA to pull him back up on the chair. R1 was doing it constantly. You cannot keep patient in bed all the time. I think he (R1) will benefit from social interaction and activities. When he (R1) was on the chair, he (R1) constantly gets up. He (R1) is calmer when he is in bed. When he (R1) is in the chair, he needs constant supervision. In his wheelchair, he (R1) probable needs 1:1. I am told there is always somebody sitting there in the dining room. When I visit the facility, I usually see the breakfast service. During meal time, there's always somebody in the dining based on my observation. I am usually there during breakfast, there is always at least 4 staff members in the dining room. I don't know how can R1 be left unattended. But I am not there during dinner time. On 2/10/22 at 2:02 PM, V7, Licensed Practical Nurse/LPN stated, I was the nurse assigned to R1 on 12/7. R1 was in the dining room when he fell. I was passing medications and then I was told by one of the nurses that R1 had a fall. R1 was bleeding, we put ice pack on him and I went and called 911. R1 got admitted with Subarachnoid hemorrhage. R1 usually eats dinner in bed, most of the time he eats in bed but that day he ate in the dining room. The incident happened after dinner. There's always somebody in the dining room to watch the residents in the dining room. I did not witness the fall. When asked why that day R1 ate dinner in the dining room, V7 responded, I don't know but when the assigned CNA asked me if R1 should get up and go to the dining room for dinner, I told the CNA to get him up. On 2/10/22, during interviews, V5, V8 and V9, CNA's who worked on 12/27/22 3-11 shift, all denied they were assigned to supervise R1 while he was in the dining room. V5, V8 and V9 all stated that were not assigned to supervise the residents who were still in the dining room after dinner time. On 2/10/22 at 2:21 PM, V10, Certified Nursing Assistant/CNA stated, When R1 fell, I was in the dining room but I was asking another resident if she wants to go back to bed. No I was not assigned to supervise in the dining room after dinner, I had already watched the dining room before that time, I don't know who was assigned to watch the dining room at time. It wasn't me who was assigned to watch the dining room, I had already watched the dining room earlier. Surveyor told V10 that on the 12/27/22 Assignment Sheet which the facility provided to me, her name was listed as the CNA in charge of watching the dining room from 7-7:30 PM, which was the time R1 fell. V10 stated, Yes, I was in the dining room but like I said I was there but I was talking to another resident and by the time I turned around R1 was already on the floor.