**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview, and policy review the facility failed to provide adequate nursing supervision to prevent an accident and injury by leaving a resident that needed assistance with transfers, was a high risk for falls, and care planned to not leave unattended in the bathroom, unattended on the toilet and the resident fell and received an abrasion to the elbow and abrasion to the hip/buttock for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) for Resident #1, dated 1/23/25, documented a Brief Interview for Mental Status score of 10, indicating moderate cognitive impairment for decision-making. The MDS included diagnoses of Non-Alzheimer's Dementia, Parkinson's disease (progressive neurological condition), anxiety disorder, and depression. The MDS documented the resident required substantial/maximal assistance with toilet transfers, used a walker and wheelchair (w/c) for mobility, and used a bed and chair alarm daily. The MDS indicated the resident was always incontinent of bladder, frequently incontinent of bowel, and was dependent on staff for toilet hygiene. The Care Plan for Resident #1, revised on 4/30/24, included a focus area of resident at risk for falls related to impaired balance, poor safety awareness, functional impairment, and/or the use of medications that may increase fall risk and a history of falls. A Care Plan intervention of do not leave resident in bathroom unattended was initiated on 5/8/24. Observation on 3/31/25 at 11:28 AM, Resident #1 was in a recliner in the living room area with an alarm pad in the recliner. A Certified Nursing Assistant (CNA) placed a gait belt on the resident and attempted to assist the resident to stand, the resident was not standing well, so another CNA assisted to transfer the resident from the recliner to the w/c, with the pad alarm moved to the W/C. Incident Report for Resident #1 for un-witnessed fall dated 1/18/25 at 4:50 PM, documented: Incident location in South Shower. Found resident on the floor, partially on top of the w/c scale in the south bath, bowel movement (BM) and blood visible. Resident awake, alert and breathing. Trauma assessment, treated wounds, staff who left the resident was sent home until investigation completed. Resident not taken to hospital. Injuries observed at time of incident: abrasion right buttock, abrasion and bruise right rear thigh, skin tear of right elbow and back of right hand. Predisposing factors: confused, gait imbalance, impaired memory, using walker, ambulating without assistance, and resident was left on the toilet in the south bath unattended by Training Nurse Assistant (TNA), nursing was unaware resident was in the bathroom, and unaware he was unattended. Resident #1's Progress Note titled Post Fall Evaluation, dated 1/18/25 at 5:47 PM, documented: 1/18/25 at 4:50 PM fall was not witnessed, attempting to get out of the bathroom unassisted, was left on the toilet unattended in the south bath by the TNA with the door closed, no other staff were aware resident was in there, injuries of multiple skin tears, abrasions and bruises, and skin tear on right and left elbow. Resident #1's Health Status Note dated 1/19/25 at 4:52 AM, documented: follow-up from fall on 1/18 25, resident complaining of pain to right arm and right flank/back area, has an abrasion to the right elbow/forearm, bandage changed due to bleeding through. Review of Resident #1's two Non-pressure Skin Assessments dated 1/20/25: a. Follow-up assessment for a skin area first observed on 1/17/25 for a skin tear of the right elbow (with multiple tears from previous fall on 1/17/25) that was 10 centimeters(cm.) length X 3.2 cm. width X 0.1 cm. in depth and described as wound bed is bright red, with moderate amount of bright red blood and physician notified on 1/17/25. b. Follow-up assessment for a skin area first observed on 1/20/25 for a bruise of the right buttock that was 10 cm. length X 10 cm. width and described as bruise is light purple, has an abrasion 1.5 cm. X 4 cm. X 0.1 cm. and physician notified on 1/17/25. Interview on 4/7/25 at 5:00 PM, Staff A, Registered Nurse (RN) stated she works 2 days a week and completes the skin assessments. Staff A stated skin assessment forms were not completed on 1/18/25, the day of Resident #1's fall, so she completed the skin assessments on 1/20/25 for the injuries from Resident #1's fall on 1/18/25. Staff A reviewed the skin assessments dated 1/20/25 and confirmed the skin assessments she completed on 1/20/25 she had incorrectly dated as 1/17/25 and should have been dated as 1/18/25 for the date first observed and related to the fall on 1/18/25. Staff A stated at the time of the assessment, the skin tear on the right elbow was large, as the tear started above the right elbow, continued down, around and to below the elbow and had areas where the top layer of skin was missing and open and then patches that did have the top layer of skin in place. Staff A stated she completed the weekly assessment of the right elbow skin tear today and has healed to 0.2 cm. length X 0.5 cm. width X 0.1 cm. depth. Review of Fall Scales completed 11/13/24 - 1/18/25 for Resident #1, documented a total score of 45 and higher represented a high risk for falling: 11/13/24 with score of 80, 1/4/25 and 1/18/25 both with score of 110. Interview on 3/31/25 at 11:29 AM, Staff B, Certified Nursing Assistant (CNA) stated Resident #1 is an assistance of 1 staff for transfers. Staff B stated she knows the residents as she has worked at the facility awhile but staff can look up the residents' level of care in the CNA binder, also had pocket care plans when the facility had agency staff but she does not use personally. Staff B stated if a resident's status changes the changes are put in the communication book. Staff B stated Resident #1 is not to be left alone on the toilet as the resident has an alarm and any resident with an alarm she would not leave alone on the toilet. Interview on 3/31/25 at 11:33 AM, Staff C, CNA stated Resident #1 is a staff assistance of 1 with transfers but sometimes she uses 2 staff due to the alarm pad getting transferred also. Staff C stated the resident has a history of falling. Staff C stated the facility has a communication book for resident care changes and also has pocket care plans. Staff C stated any resident with an alarm she would not leave on the toilet alone, that Resident #1 is not to be left alone in the bathroom and he has an alarm. Interview on 3/31/25 at 11:50 AM, the Administrator/Director of Nursing (ADM/DON) stated the [NAME] is the most updated information for staff to look for the residents' care needs and the facility is no longer using pocket care plans. The ADM/DON stated on 1/22/25 she put a note in the communication book for the staff, due to Resident #1 being left alone on the toilet and falling on 1/18/25. Review of Resident List Report dated 1/22/25, revealed a list of the current residents with a note stating: People highlighted do not leave in the bathroom or on the bedside commode alone. Make sure you are following the [NAME] in the computer. We do not use pocket care plans any more. Resident #1 was highlighted, with a total of 9 resident names highlighted. Note was signed by the ADM/DON. Interview on 4/1/25 at 9:30 AM, Staff D, TNA started working at the facility 11/5/24 and received orientation with another CNA for 1 month. Staff D stated on 1/18/25 around 4:15 PM, Resident #1 was in the living room and trying to get up on his own to go to the bathroom. Staff D stated he took the resident to the south shower bathroom. Staff D stated he couldn't find a big enough brief for the resident so he went to the resident's room to get a brief and left the resident on the toilet. Staff D stated about 4:30 PM, while he was getting the brief from the resident's room, Staff G, Licensed Practical Nurse (LPN) radioed and told him to go to dinner. Staff D stated he was intimidated by Staff G, as she liked to pick on him and just was not thinking and Staff D went to dinner as he was told and forgot to tell someone that the resident was in the shower room on the toilet. Staff D stated it was his mistake. Staff D stated he came back after his meal break and Staff G asked Staff D if he had left Resident #1 alone in the bathroom. Staff D told Staff G that he did leave the resident alone in the bathroom. Staff D stated Staff G told him to leave for the rest of the day. Staff D stated he received a 3-day suspension and the ADM/DON educated him on not leaving residents alone, to look at the sheet in the communication book for residents' transfer assistance needed, and to call for help if needed. Staff D stated he was aware Resident #1 should not be left alone on the toilet as he had been verbally told by other CNAs during his training. Interview on 4/1/25 at 10:08 AM, Staff E, CNA stated areas to find the residents' care status are the resident's care plan or [NAME] and communication book. Staff E stated she would not leave any resident alone on the toilet that needs assistance. Staff E stated the residents that are in the living room are the residents they keep an eye on due to risk for falls, and she would not leave Resident #1 on the toilet alone as he is one of the residents in the living room that they keep a close eye on. Interview on 4/7/25 at 12:45 PM, Staff F, Certified Medication Aide (CMA) stated on 1/18/25 after 4 PM, she was doing the afternoon medication pass and did not see Resident #1 in the living room, so she figured staff had the resident in the bathroom or dining room. Staff F stated she then went looking for Resident #1 and found him in the south bath. Staff F stated the resident was on the floor by the scale, with his pants down to his knees and his legs out in front of him, with a huge skin tear on his right arm, and his arm bleeding a lot. Staff F stated she assumed the resident had been on the toilet and tried to get out of the bathroom. Staff F stated she called for the nurse on the walkie-talkie and Staff G came in and checked the resident, got stuff for the resident's arm, and staff got the resident cleaned up. Staff F stated at the time she did not know who had left the resident in the bathroom as are not supposed to leave the resident alone on the toilet. Staff F stated she was later told Staff D had left Resident #1 alone on the toilet. Interview on 4/7/25 at 1:00 PM, Staff G stated she was working on 1/18/25 and it was after 4:00 PM. Staff G stated Resident #1 was typically in the recliner in the living room, as he was a high fall risk and had a chair alarm. Staff G stated the CNAs started breaks at 4:00 PM and staggered their breaks every 15 minutes, so there are 2 CNAs on the floor. Staff G stated she and Staff F noticed Resident #1 was not in his recliner and started to question where the resident was. Staff G stated Staff F found the resident in the south bath. Staff G stated the resident had a skin tear on his right arm at the elbow and there was blood and BM on the floor, with the resident lying partially on the weight scale and partially on the floor. Staff G stated she completed an assessment on the resident and the resident was alert, conscious, and cussing he wanted to get up. Staff G stated staff got the resident cleaned up and out to the living room. Staff G stated she asked Staff D if he put the resident in the south bath and Staff D said yes. Staff G stated Staff D told her he took the resident to the south bath right before another staff went to break, which would have been approximately 4:15 PM. Staff G stated Staff D reported to her that he went to answer another call light. Staff G stated Staff D went to break at 4:30 PM and was on break when the resident was found in the south bath. Staff G stated she notified the ADM/DON and told Staff D to go home per the ADM/DON's instruction. Staff G stated the resident also had an abrasion on his right hip area and the next day had bruising on his right hip/buttock. Facility policy Falls Assessment Protocol revised 1/4/17, revealed residents identified as high risk for fall will have fall interventions implemented and interventions for reducing the residents' risks for falls will be resident specific and based on assessment findings. Facility policy Minimum Standards of Personal Cares dated 2024, revealed: Minimum standards will be used for all aspects of personal care for residents. If a resident requires care other than that established in the minimum standards, that care will be described in the resident's care plan. It is each staff member's responsibility to be knowledgeable of each resident's care plan and to meet each resident's individual need by following these minimum standards and the resident care plan. Interview on 4/1/25 at 3:45 PM, the ADM/DON stated she felt Staff D knew not to leave Resident #1 alone on the toilet, felt he was busy, made a mistake, and listened to the charge nurse when she told him to go to break. The ADM stated Staff D received a 3-day suspension and education due to the incident. The ADM/DON stated her expectation to not leave any resident that needs assistance alone on the toilet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, and staff interviews, the facility failed to adequately supervise residents at risk for falls for 2 of 3 residents reviewed (Resident #190 and #32). Resident #190 had a history of trying to get up by himself and not waiting for the staff to help him. Resident #190 required staff assistance of one with transfers. On 9/19/21, as a different resident walked by Resident #190's room, they noticed him on the floor. The other resident called for staff assistance. Once staff arrived they discovered Resident #190 lying on his left side complaining of pain to his left hip. Despite observing Resident #190 on his left side and complaining of pain to his left hip, three staff members assisted him off the floor and into his bed. After Resident #190 got into bed, the nurse noticed his hip appeared fractured. The nurse transferred Resident #190 to the hospital, where he received a diagnosis of a displaced mildly comminuted intertrochanteric fracture of his left femur (broken left hip). On the day of the fall, the staff witness reports documented that the last time the staff observed Resident #190 was while he ate at supper. One staff member reported they thought Resident #190 was independent with toileting. In interviews with the staff, a few staff members reported the resident showed increased confusion the week before his fall. Some of the staff reported that Resident #190 should be the first one helped after supper to prevent him from self-transferring. Resident #32 admitted to the facility on [DATE] following a fall at home resulting in a pelvic fracture. Resident #32's Baseline Care Plan indicated he had behavior concerns of getting up alone and safety concerns of a history of falls with a broken pelvis. Resident #32 required an assistance of one staff member with ambulation (walking). On 4/23/22, a Therapist discovered Resident #32 lying on his right side at 7:30 AM. At the time of assessment, Resident #32 complained of his right hip and groin hurting. Despite staff observing Resident #32 laying on his right side and complaining of hip pain, the nurse and Certified Nurse Aide (C.N.A.) assisted him into his wheelchair. Resident #32 transferred to the hospital and had an X-Ray that revealed a right femoral neck fracture (right broken hip) with some displacement of the fracture fragments. The facility reported a census of 42 residents. Findings include: 1. Resident #190's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS revealed that Resident #190 required limited physical assistance of one staff member for bed mobility and transfers. Resident #190 required physical assistance of one staff member for ambulation, dressing, toilet use, and personal hygiene. The MDS identified the resident's balance during transitions and walking, was not steady and he was only able to stabilize with staff assistance. The MDS indicated Resident #190 used a walker and wheelchair for mobility. The MDS documented diagnoses of orthostatic hypotension and non-Alzheimer's dementia. The MDS identified Resident #190 had a history of falls without injury. The Care Plan revised 9/10/21 identified Resident #190, as a risk for falls related to his impaired balance, poor safety awareness, neuromuscular, functional impairment, and/or his use of medication that could increase the risk of falls. The Care Plan interventions included: a. Date Initiated 9/21/21: Reminder signs posted in the resident's room to use a pendent and/or call light then wait for assistance. b. Revision date 8/12/21: Call pendent used to ask for assistance whenever or wherever Resident #190 was located throughout the facility c. Revision date 8/12/21: Encourage the resident to ask for assistance from the staff d. Revision date 8/12/21: Encourage the resident to participate in activities that promote exercise, physical activity for strengthening, and improved mobility e. Revision date 8/12/21: Ensure the resident wore appropriate footwear when ambulating or using his wheelchair f. Initiated 1/23/29: Follow facility fall protocol g. Revised 8/12/21: Keep the resident's personal items; wheelchair, walker and call light within his reach h. Initiated 1/23/20: Monitor, document, report for 72-hours to the physician any signs or symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, or agitation. The Care Plan revised 9/10/21, identified Resident #190 had self-care deficit as evidenced by Resident #190 required assistance with his activities of daily living (ADL's), impaired balance during transitions, incontinence, and the need for assistance with walking. The Care Plan interventions included: a. Revision date 6/3/21: Ambulation: assist of 1 staff with use of forward wheeled walker (FWW) b. Revision date 8/12/21: Mobility: assist of 1. Staff to push Resident #190's wheelchair for long distances. Resident #190 could propel himself at times c. Revision date 6/3/21: Toilet use: assist of 1. Provide incontinence cares with each incontinent episode as the resident allowed d. Revision date 8/19/21: Transfer: assist of 1 with an FWW Resident #190's Care Plan revised 9/10/21 identified the resident had impaired cognitive function and/or impaired thought processes as evidenced by short-term memory deficit, long-term memory deficit, impaired decision making, and/or impaired ability to understand others. The Care Plan interventions included: a. Revision date 8/12/21: Communication: Face the resident when speaking, make eye contact, and reduce any distractions. The resident could understand consistent, simple, and direct sentences. Provide the resident with necessary cues, stop, and return if he becomes agitated. b. Revision date 8/12/21: Use task segmentation to support short-term memory deficits and break down tasks to one step at a time. The Progress Notes for Resident #190 revealed: On 9/9/21 at 10:24 AM, the Health Status Note (HSN) documented that the staff observed the resident wheeling himself in his wheelchair in the wrong direction, going towards his room. The staff noticed a change in the resident's cognition and the resident reported his memory felt worse. The resident required increased assistance from the staff. On 9/16/21 at 5:02 PM, the HSN recorded that the resident transferred himself to the bathroom independently and sustained a skin tear. On 9/20/21 at 12:32 AM, the Incident Note documented that at approximately 7:00 PM another resident found Resident #190 on the floor. Resident #190 laid at the foot of the bed with his back to the wall, with his legs crossed, and he complained of left hip pain. Resident #190 said he attempted to go to bed and he observed a piece of paper on the floor. Resident #190 continued reporting that when he attempted to pick up the paper, his right foot slid, and he fell on his left hip. Resident #190 reported increased pain to his left hip. Three staff manually lifted Resident #190 and placed him in bed. Upon inspection, the left hip appeared fractured. Resident #190 was transported to the local emergency room (ER), at 8:30 PM the ER reported to the facility that Resident #190 went to surgery. The Fall Scale dated 9/1/21, identified Resident #190 at a high risk for falls with a score of 90. The score calculated from Resident #190's history of falls, more than one diagnosis, use of a walker, impaired gait (walk), and mental status. The Fall Investigation - Quality Improvement Document dated 9/19/21 at 7:00 PM recorded that Resident #190 attempted to self-transfer from his bed to his chair and his foot slipped. As Resident #190 fell, he landed on his left hip. The document questioned the following interventions a. Did the resident have an alarm - No alarm b. Was the resident's call light on - No c. Was the resident's call light within reach - yes d. Was the Care Plan followed - yes e. Was an assistive device being used - no f. Were there any environmental hazards present - Resident #190 had a box at the foot of his bed and he was trying to walk to his bed without assistance. The hospital Imaging Report dated 9/19/21 indicated Resident #190 had a displaced and mildly comminuted intertrochanteric fractured left femur (bony areas on the femur where the thighbone attaches to the hip broke into multiple pieces). Written Statements The Written Statement dated 9/19/21 completed by Staff O, RN, documented that Resident #190 became more confused the week before and attempted to transfer by himself to bed. The documentation indicated that the floor wasn't wet, the resident had on clothes, and shoes. Staff O documented that the resident needed an alarm. The Written Statement dated 9/19/21 completed by Staff P, CMA (certified medication aide), documented Resident #190 was really confused lately. Staff P documented that the resident was confused lately, he did not and had not used his call light that was attached to his chair. Staff P documented that Resident #190 stood behind his wheelchair independently at 2:30 PM on 9/19/21. Staff P informed Resident #190 to use their call light. The Written Statement dated 9/19/21 completed by Staff Q, CNA, documented Resident #190 seemed more confused. Staff Q documented that the last time she saw the resident was at supper. Staff Q reported the last time Resident #190 used the toilet was before supper. The Written Statement dated 9/19/21 completed by Staff R, CNA, documented that Resident #190 seemed more confused throughout the day. Staff R documented last seeing Resident #190 at supper and he went to the toilet before supper. Staff interviews On 4/4/22 at 9:36 AM, Staff J confirmed Resident #190 transferred himself to the bathroom on 9/16/21. Staff J denied knowing of any interventions put into place at that time to prevent falls. Staff J reported that at one time Resident #190 had an alarm. Staff J said she didn't know if the fall occurred during that time frame. Staff J stated eventually the facility did implement alarms for Resident #190. On 4/4/22 at 9:57 AM, Staff K reported that she was unsure if Resident #190 was independent at the time of his fall on 9/19/21. Staff K stated Resident #190 required assistance with staff for care, but she believed he ambulated himself to the bathroom. Staff K explained that the nursing staff checked on the resident regularly and the resident used his call light. Staff K said that Resident #190 would turn on his call light in the morning when he was ready to get up. Staff K reported if there were any changes with Resident #190, it would be communicated in the CNA binder at the nurse's station. Staff K stated they did not know if any additional interventions were implemented related to the resident's increased confusion. Staff K stated Resident #190 was intelligent and would outwit the staff. Staff K reported that she felt all the staff checked on the resident frequently to see if he needed assistance. Staff K remarked that they didn't work at the time of the fall on 9/19/21. On 4/4/22 at 11:15 AM, the MDS Coordinator explained that communication with the CNA's and nurses occurred between shifts if a resident had a change in condition. The MDS Coordinator added that an intervention was implemented for Resident #190. They put a sign on Resident #190's wall and a sign on his walker. The MDS Coordinator denied knowing of additional interventions put in place to prevent falls. The MDS Coordinator stated after supper, Resident #190 would propel himself to his room. If the staff saw the resident, they were to encourage him to stay in the main lobby. The MDS Coordinator reported that the resident required assistance with toilet use, transfers, and personal hygiene at time of the fall. On 4/4/22 at 11:35 AM, Staff J commented that she reviewed Resident #190's Care Plan from 9/16-9/19/21. During that time frame no additional interventions were added related to the resident getting up without assistance and/or related to his increased confusion. Staff J remarked that August 2021 was the last time Resident #190's fall interventions were revised. On 4/4/22 at 12:59 PM Staff L stated Resident #190 preferred to stay up late. Staff L stated Resident #190's routine after supper was to go to the recliner. Staff L said Resident #190 was one of the last residents to go to bed, at around 10:00 PM. Staff L reported that Resident #190 had a history of getting up without assistance. The facility put signs in his room to use his call light and to ask for help. One sign was placed on his walker and another on the wall beside his bed. Staff L explained they didn't recall when the signs were placed. Staff L remarked that the current DON and Administrator investigated Resident #190's fall on 9/19/21. Staff L stated the resident had been hallucinating and had an alarm placed, but didn't know when it was placed. Staff L added that the resident had incontinent issues and saw a mental health provider with numerous medication changes all at once due to his cognitive issues. Staff L commented notifying a change in resident's condition to the CNA's by report and/or the communication binder. On 4/4/22 at 2:51 PM Staff B, CNA, stated Resident #190 had increased difficulty with transfers and required increased assistance from staff. Staff B didn't remember if Resident #190 ever got up without waiting for assistance. On 4/4/22 at 3:15 PM, Staff S, CNA, reported that at times Resident #190 transferred himself without using his call light or without waiting for assistance from the staff. Staff S said that Resident #190 got a personal alarm after he fell and broke his hip. Staff S added that right after supper Resident #190 was transferred right away to the recliner in his room. Staff S wasn't sure what happened the night of his fall, as she didn't work that night. If the facility was short staffed, they would leave Resident #190 in the living room. If Resident #190 was left in the living room he would take himself to his room and attempt to self-transfer. Staff S said that the resident would stay in the recliner and then turn the light on when he was ready for bed. Staff S commented that the resident became more confused before his fall on 9/19/21, she didn't know if additional interventions were put into place. Staff S remarked that before his fall on 9/19/21, Resident #190 couldn't alert staff of the need to use the bathroom, because he wasn't aware of the need to go. On 4/4/22 at 4:19 PM Staff M reported that Resident #190 was very forgetful and didn't use the call light or wait for assistance from the staff. Staff M stated that Resident #190 had alarms in place, a note by his bed, and a note on his walker to remind him to ask for help. On 4/5/22 at 7:37 AM Staff T, CNA, reported that Resident #190 had alarms in place before his fall on 9/19/21, but they weren't enforced. Staff T explained that the resident didn't always have the alarms in place, and they weren't used consistently. Staff T added that after supper Resident #190 was the first one done and he would take himself in his wheelchair half-way to his room. Staff T added that the staff would assist Resident #190 to his room, help him to the bathroom, and assist him into the recliner. Staff T commented that the resident used a call pendant or the staff would stop in his room between 6:45 PM and 7:00 PM to see what time Resident #190 wanted to go to bed. Staff T explained that Resident #190 went to bed later, as he was one of the last ones. Staff T said that Resident #190 would not tell the staff when he needed to use the bathroom, as he didn't know. Staff T stated she would check on Resident #190 every 2 hours and offer him the bathroom, but he was incontinent. Staff T said Resident #190 always attempted to self-transfer and didn't wait for assistance from the staff. On 4/5/22 at 7:44 AM, Staff U, CNA, recalled Resident #190's fall and hip fracture, but said she wasn't working at the time. Staff U stated the resident became more unsteady and had a long history of not waiting for staff's help. Staff U reported that if Resident #190 had a wheelchair or walker in reach he would attempt to self-transfer. Staff U reported that it wasn't uncommon for Resident #190 to get up with his walker and go. Staff U stated that once staff took Resident #190 to his room, they knew he needed assistance with the bathroom. After he used the bathroom, the staff assisted Resident #190 to the recliner so he wouldn't transfer himself. Staff U remarked that she knew the resident would transfer himself if he went to his room without staff. On 4/5/22 at 7:56 AM Staff V, CNA, said Resident #190 self-transferred all the time. Staff V reported that she found the resident taking himself to the bathroom at night. Staff V explained that at times the resident used the call light, but he usually got up by himself and went to the bathroom. On 4/5/22 at 9:33 AM, the DON reported that the Resident #190 started to use an alarm after his fall on 9/19/21. The DON stated that she discussed with the staff the need to take the resident back to his room and transfer him right away after meals to his recliner. The DON denied documentation of that, but reported that she did have a discussion to take Resident #190 to his room after meals and transfer him to his recliner. The DON stated Resident #190 propelled himself independently in his wheelchair to his room after meals. The DON denied knowing what Resident #190 did after supper on the night of his fall. The DON stated Resident #190 was incontinent of urine, but didn't know if he had a toileting program, the staff did go in more frequently to assist and encourage Resident #190 to use the toilet. The DON added that the resident would deny the need of assistance from the staff. After his fracture, he required total assistance from the staff. The DON discussed the resident's changes and reminded the CNA's to assist the resident, but denied documentation of the education. The DON reported that the CNA's didn't always read the communication book and a lot of the communication occurred by word of mouth. On 4/5/22 at 10:28 AM Staff W, CNA, stated that the resident had a history of not waiting for staff to assist him with transfers. Staff W added that the resident got up a ton without staff assistance. Staff W reported that the resident did not use his call light and would just get up without help. Staff W declared that Resident #190 was incontinent of urine. Staff W explained that when Resident #190 became incontinent he knew and attempted to take himself to the bathroom. Staff W reported that she usually helped him after meals. Staff W explained that she would assist the resident to his room and transfer him to the recliner after helping him in the bathroom if needed, but didn't think she worked the night of his fall. Staff W remarked that Resident #190 was a fall risk, so she checked him a couple of times. Staff W stated that the resident preferred to go to bed later, and liked to stay up in his recliner. 2. Resident #32's MDS assessment dated [DATE], identified a BIMS score of 12, indicating moderately impaired cognition. The MDS revealed the resident required limited physical assistance of one to two staff for bed mobility, transfers, ambulation, toilet use, and personal hygiene. The MDS coded the resident's balance during transitions and walking as not steady and only able to stabilize with staff assistance. The MDS documented diagnoses of hypertension, vertigo (dizziness), and ataxia (impaired balance). The MDS identified that the resident had a fall in the last month prior to his admission to the facility and one fall with a major injury since admission to the facility. Resident interview On 3/29/22 at 12:45 PM, during the initial tour, observed Resident #32, well-groomed, in his recliner. Resident #32 explained that he attempted to go home the week before on his birthday, just a few weeks ago. Resident #32 explained that it didn't work out because he fell and broke his ribs. After that he came back to the facility. Resident #32 stated that he required assistance from the staff to get up with his walker. An observation showed a urinal in a bucket beside the recliner. Resident #32 explained that he previously fell and got a fracture while at the nursing home, however, he wasn't able to recall the specifics due the length of time that passed. The Baseline Care Plan with an admission date of 4/21/21, identified Resident #32: a. Cognition - alert/cognitively intact b. History of falls - history of a fall resulting in a broken pelvis c. Behavior concern - Resident #32 does get up alone d. Assist of one with bed mobility, transfer, walking, toilet use, and locomotion e. History of falls with injury Progress Notes review On 4/21/21 at 3:41 PM, the admission Summary identified Resident #32 admitted to the facility from the local hospital. At the time of admission Resident #32 noted to be alert and oriented x 3 (person, place, and time), in good spirits, and accepting of his placement for skilled services. The resident identified with a history of falls and a bed alarm while in the hospital during the night. The resident had vertigo at times and required assistance of 1 with a forward wheeled walker. Resident #32 received orientation to the facility, room, call light, and meal time. On 4/22/21 at 3:06 PM, the Skilled Evaluation identified that Resident #32 obeyed commands and alert and oriented x 3. Resident #32 displayed a pleasant mood without behaviors. On 4/23/21 at 1:20 PM, the Health Status Note (HSN) documented that the aide heard Resident #32, then found him on the floor in the bathroom. Resident #32 denied hitting his head but did complain of pain to his right hip. The head-to-toe assessment revealed no shortening or rotation of his right leg. The staff assisted Resident #32 to his wheelchair with an assistance of three. Resident #32 did not apply pressure to his right leg. The staff notified the son and sent Resident #32 to the local emergency room. On 4/24/21 at 4:12 PM, the HSN revealed that the resident had surgery for a right hip repair. Clinical record review The Fall Investigation - Quality Improvement Document dated 4/23/21, no time, completed by Staff Y, Licensed Practical Nurse (LPN) identified Resident #32 fell in the bathroom. Resident #32 reported that he just fell. The following interventions were reviewed and answered by Staff Y a. Did Resident #32 have a personal alarm, chair alarm, or bed alarm? If Resident #32 used any type of alarm, was it on and functioning? - not applicable b. Was Resident #32's call light on - no c. Was Resident #32's call light in reach of resident - no d. Was Resident #32's Care Plan followed - yes e. Was an assistive device in use - yes f. Was there any environmental hazards present - no The undated Facility Investigation identified a Therapist found Resident #32 on the floor in the bathroom on 4/23/21 at 7:30 AM. The Therapist observed the call light on and notified the nursing personnel immediately of Resident #32's fall. The Rehab Communications dated 4/23/21 indicaed Resident #32 requires staff assistance of one staff with transfers and gait with FWW to patient's tolerance or two to three times daily. The Occupational Therapy Plan of Care dated 4/21/22 documented precautions of a fall risk. Resident #32 required supervision or touching assistance, helper provides verbal cues and/or touching/steadying for mobility toilet transfer. Assistance may be provided throughout the activity or intemittently. The Emergency Room's X-Ray report dated 4/23/21 at 11:36 AM revealed Resident #32 had a right femoral neck (a hip fracture involving the thigh bone just below the ball-and-socket hip joint) fracture. Staff Interviews On 4/4/22 at 9:23 AM Staff J, Registered Nurse (RN), confirmed the Baseline Care Plan contained only an admission date of 4/21/21 with undated interventions. Staff J reported the facility implemented a checklist for Baseline Care Plans completed in the resident's electronic health record (EHR). The facility started to use a Baseline Care Plan on the computer, which made it consistent for all staff and dated. Staff J stated that when the Baseline Care Plan was completed on paper, it was a hot mess. Staff J reported the facility nurses were instructed on how to implement fall interventions in the resident's EHR. Staff J remarked that the nurses however, documented the intervention in the resident's progress notes and the MDS nurse added the intervention to the resident's Care Plan in the EHR. Staff J said that when the nurse admits a resident to the facility, they complete the Admit Screener and initiate a Baseline Care Plan, then the Certified Nurse's Aides (CNA) were able to access the Care Plan interventions through the [NAME] in the EHR. Staff J explained that with new admissions to the facility, a document titled admission Care Plan was placed in the CNA's communication book to make the CNA's aware of the new resident needs. Staff J reported being unaware of the fall interventions in place for Resident #32 at the time of his admission on [DATE]. Staff J reported being unaware of the length of time Resident #32's call light was on before therapy found him on the floor on 4/23/21. Staff J remarked they were unaware if Resident #32 preferred to get up early. Staff J commented that Resident #32 wasn't much of a breakfast person, however, it was possible he was at the time of the fall. On 4/4/22 at 11:10 AM, the MDS Coordinator confirmed that she couldn't determine the dates of interventions on Resident #32's Baseline Care Plan. The MDS Coordinator stated with each new resident's admission a document that provided the information for care was placed in the CNA's binder at the nurse's station. The MDS Coordinator denied knowing how long Resident #32's call light was on before therapy found him on the floor on 4/23/21. The MDS coordinator remarked that due to Resident #32's admission on [DATE], the facility staff didn't know the resident's routine, and if he preferred to get up early. The MDS Coordinator added that when Resident #32 returned to the facility on 4/26/21, the Baseline Care Plan received updated interventions for the admission date of 4/21/21. The MDS Coordinator confirmed that the facility should have dated the new interventions. On 4/4/22 at 11:30 AM, Staff J stated the CNA received the undated document titled admission Care plan, at the time of Resident #32's admission on [DATE]. On 4/4/22 at 12:54 PM, Staff L, RN (the former Director of Nursing, DON), stated at the time of Resident #32's admission to the facility on 4/21/21, he was alert and oriented x 3. Staff L stated Resident #32 turned on his call light, but didn't wait for staff to assist him to the bathroom. Staff L remarked that Resident #32 told the MDS Coordinator that he thought he could make it to the bathroom by himself and that he should have waited for assistance. Staff L explained that the call light record checked at the time of the fall, showed the call light wasn't on even five minutes. Staff L denied knowing when the report had been printed out. Staff L stated that the CNA's headed to Resident #32's room first thing due to the call light being on. Resident #32 was one of the first residents to get up in the mornings per his preference. Staff L stated Resident #32 used his call light; but he just didn't wait for staff assistance. Staff L denied knowing that Resident #32 got up without assistance before the fall. Staff L denied knowing if Resident #32 was incontinent at the time of the fall. On 4/4/22 at 4:19 PM, Staff M, CNA, said that when Resident #32 first admitted to the facility on [DATE], he was confused and required staff assistance from one person. Staff M stated that the nursing staff reminded the resident to use his call light. Staff M stated she believed Resident #32 had an alarm in place due to a band on his wrist from the hospital, indicating a fall risk. Staff M stated Resident #32 used a urinal beside his recliner and he was continent of urine. On 4/5/22 at 9:27 AM, the DON didn't know how long Resident #32's call light was on at the time of the fall on 4/23/21. The DON denied knowing when therapy completed the screening evaluation for Resident #32. The DON reported that the nurse who completed the admission Assessment, completed the admission Care Plan sheet provided to the CNAs. The staff attempted to do a small huddle to review the new admission, however, it didn't always happen. The DON added she implemented starting the Baseline Care Plan in the resident's EHR, connecting it to the CNA's tasks for the new resident.