Based on record review, and staff interview, the facility failed to provide adequate assessment and timely intervention for 1 of 4 residents reviewed (Resident #1). On 4/15/23 at 2:50 a.m. Resident #1's alarm sounded and as staff responded they heard a thud and found resident laying on the floor on his right side. Facility staff failed to complete a thorough assessment which included range of motion (ROM) and failed to initiate neurologic checks following the unwitnessed fall. Additionally, the staff failed to complete a follow up assessment following the fall when pain was noticed during transfer with weight bearing. At 6:38 a.m. resident was assessed for ongoing right leg pain. Resident noted to have external rotation of the right leg, resident was transferred to the local ER and was diagnosed with right femoral neck fracture (hip fracture) and admitted to the hospital for surgery to repair. The facility reported a census of 44. Findings include: The Minimum Data Set (MDS) assessment with a reference date of 3/6/23 for Resident #1 identified severely impaired cognitive skills for decision making. The MDS further revealed the resident required assistance of one for transfer, and walking. The resident had diagnosis that included Alzheimer's disease, and overactive bladder. An Un-witnessed Fall Report initiated on 4/15/23 at 2:50 a.m. by Staff A, Licensed Practical Nurse (LPN) documented that Resident #1 had been found lying on the floor near the entry door. Nurse assessed the resident, skin was intact. Bed was in lowest position. Certified Nursing Assistant (CNA) reported resident had been changed one hour prior. Resident confused, unable to report what was doing prior to the fall. No signs of discomfort, no signs of bone fracture noticed, all extremities working well. Resident helped with assist of two back to bed. Review of an Investigation Summary prepared by the Director of Nursing (DON) revealed Staff B, CNA responded to floor alarm sounding in Resident #1's room. Before entering the room, she heard a thud. Found resident lying on the floor approximately 15 feet from his bed on his right side. Resident had been checked at 2:00 a.m. In an interview with the DON, Staff B, CNA reported that the resident complained of right leg pain when assisted to bed. However, Staff A, LPN documented no pain with transfer with weight bearing. A Progress Note dated 4/15/23 at 3:33 a.m., Staff A, LPN documented CNA entered the resident room and found lying on the floor. No discomfort or pain reported, resident was transferred with two assist with gait belt to bed, able to bear weight. Recommendations included, resident to be checked every 30 minutes. The clinical record lacked documentation of ROM, further assessment or documentation, or neuro checks by Staff A, LPN. A Progress Note dated 4/15/23 at 6:38 a.m. initiated by Staff C, LPN documented she was summoned to Resident #1's room. CNA informed resident had yelled out in pain when she tried to touch right leg. LPN assessed right leg noted externally rotated. No bruising noted at that time. Resident would not allow staff to touch right leg. Family notified and requested transfer out to local hospital. 911 called for transfer to local emergency room for evaluation via ambulance. Staff C, LPN further documented at 6:54 a.m. that ambulance arrived and resident assisted to stretcher and left for local ER. During an interview on 8/17/23 at 9:51 a.m. Staff C, LPN stated she had arrived to work at 4:00 a.m. on 4/15/23 but Staff A, LPN was working Resident #1's unit until 6:00 a.m. so wasn't involved with the fall until she was summoned via the walkie at 6:38 a.m. Recalled the CNA reported she was going to lotion his legs, when she touched him he yelled in pain which prompted her to call for a nurse. When Staff C, arrived at the bedside she noticed that the right leg was externally rotated and initiated arrangements to transfer out. Staff C responded that she had not received a verbal report on the fall from Staff A, LPN prior to his shift ending and would have expected follow up and ongoing assessment for injuries and neuro checks to have been initiated with an unwitnessed fall. Confirmed this had not occurred. In an interview on 8/17/23 a.m. the DON stated that staff are expected to follow the protocols identified for fall response and neurologic checks. Additionally, would expect staff to monitor for changes as they provided care to the resident. The DON stated that that Staff A, LPN had failed to assess ROM to include observation of external and internal rotation, failed to complete neurologic checks as indicated in the fall policy, and failed to complete follow up assessments. Based on these identified issues associated with a fall with a negative outcome and resident not assessed in a timely manner Staff A was terminated immediately. Review of a hospital document titled History and Physical report dated 4/15/23 at 9:37 a.m. revealed the resident fell at the facility. Resident complained of severe pain at 6:00 a.m., was brought by ambulance where x-rays demonstrated a displaced femoral neck fracture. Orthopedic consultation has planned surgical repair this morning. Review of a facility Corrective Action Form signed on 4/26/23 documented Staff A was terminated for lack of assessment of fall and falsification of documentation. The issues identified in the document included: Lack of ROM assessment including external and internal rotation, failure to complete neuro checks as indicated by facility policy, and no follow up assessment was completed after the fall. The document noted Staff A, LPN refused to sign. Review of an undated facility policy titled Fall Prevention and Response Policy included, when a fall occurs: initiate neurologic checks if the fall was unwitnessed, post fall documentation includes intervention, response to interventions, effectiveness of interventions, and injuries noted, and documentation of post-fall status will occur in progress notes every shift for at least 72 hours and as needed. Review of an undated facility policy titled Neurological Assessment included: Neurological assessments are indicated following an unwitnessed fall. Perform neurological checks with the frequency as per the falls protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated mildly impaired cognition. The same MDS revealed the resident had diagnoses of hypertension (high blood pressure), peripheral vascular disease (reduced blood flow to legs), peripheral venous insufficiency (circulation issue causing blood to pool in legs), edema, peripheral neuropathy (damaged nerves cause numbness in feet), and 1 venous and arterial ulcer (wound) was present. Observation on [DATE] at 1:59 PM revealed the resident had swollen feet and legs, she was wearing edema wear during observation. The Progress Note dated [DATE] at 3:30 PM revealed the resident had increasing pitting edema to bilateral lower extremities, 2+ to right lower extremity, 3-4+ to left lower extremity. Resident has had 7 lbs. weight gain in past month. Lungs with diminished bases. No dyspnea noted. Oxygen saturation 94% on room air. The Individual Care Plan, undated, revealed interventions directing staff the resident was to be weighed weekly or as specified by physician and to monitor weight as ordered and report 3-4 pound weight gain in 1 week. The Weight Summary dated [DATE] revealed the resident's weights from [DATE] to [DATE]. The resident's weight was documented 2 times in 5/22 and 7/22, the remaining weights were taken monthly. The Medication Review Report dated [DATE] signed by a physician lacked orders for frequency of weight measurements. In an interview on [DATE] at 9:21AM, the Director of Nursing (DON) reported she would expect a resident's weight be obtained as directed by their care plan. Based on record review and staff interview, the facility failed to provide adequate assessment and timely intervention for a change in condition for 2 of 2 resident's reviewed (Resident #104, and #3). Resident #104 fell and sustained a head injury and fracture of the C1 vertebrae (neck) on [DATE]. On [DATE] the resident had pain documented on the Treatment Administration Record (TAR) with no documentation interventions were implemented to relieve the pain. The resident also had a change of condition with his oxygen (O2) saturation (sat) dropping to 52% (normal above 90%) and respirations 30 (normal 16-20) and labored around 9:30 a.m. The facility failed to assess the resident's lung sounds related to the change. On [DATE] at 1:45 a.m. (approximately 16 hours after the drop in O2 sats) the resident left by ambulance to the emergency room with pain documented at a 6, respirations of 44, and crackles throughout his lungs. The resident went into respiratory arrest and died in the ambulance. Resident #3 had edema (swelling) in the lower extremities and a care plan intervention to weigh weekly. The facility failed to follow through with the intervention. The facility reported a census of 55 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #104 scored 2 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident required extensive assistance with bed mobility, transfers, walking in the room, dressing, toilet use and personal hygiene. The resident required limited assistance with walking in the hallway. The resident's diagnoses included non-traumatic brain dysfunction, dementia with lewy bodies, and a stroke. The Progress Notes dated [DATE] at 12:02 a.m. documented the resident had an unwitnessed fall at 10:55 p.m. in his room. The nurse aide heard a sound and found him on his right side next to his bed bleeding from his head. The nurse evaluated the resident, called the wife at 11 p.m. and asked for permission to send him to the emergency room (ER) to be evaluated and treated. The hospital called at 11:02 p.m. to get a telephone order to send the resident. At 11:08 p.m. 911 called and they had to try to find an ambulance since all those around were dispatched out with other calls. At 11:35 a.m. dispatch called back and said another ambulance would transfer the resident. At 11:55 p.m. the ambulance came and transported the resident onto the gurney, leaving the facility at 12 a.m. The resident was alert after the fall and only complained of his head hurting in the general area where his head bled from. They cleaned the resident up with sodium chloride (NaCl), and gauze placed on his head with pressure to help with the bleeding. His wife would be at the hospital waiting for his arrival. A hospital Emergency Department note dated [DATE] documented the resident had a laceration of the head and a C1 cervical fracture. The history of present illness (HPI) documented a resident with dementia in the memory care unit apparently sustained a fall earlier in the night and had a laceration on the right eyebrow. The resident had some neck pain, and also pain in the pelvis. He had a stellate (a tear in the skin caused by blunt trauma) laceration above the right eyebrow, and hematoma or swelling around that area, approximate 5 or 6 cm total length. Basically gouged into the center of the stellate laceration and it kind of stretched the tissue due to frailty and old age. It had continuous oozing without a pressure dressing. The laceration measured 5 cm to 2 cm. The resident had a very irregular wound. He had Computed Tamography (CT) of the cervical spine without contrast. The findings included fractures of both the anterior and posterior arches of C1. The anterior arch fracture was distracted (widened) by about 11 mm. The Progress Notes dated [DATE] at 9:48 a.m. documented the Resident returned via ambulance at 9:05 a.m. The ER Dr. consulted with a neuro-surgeon. The resident with C1 fracture and felt not a candidate for surgery. He received a soft collar to wear. Per the Dr. notes they were to do best they could to keep collar on but understood it may be difficult to do. The resident had multiple sutures on top of his forehead. They were to leave the pressure bandage on for 48 hours then apply an ointment. Sutures should be removed in 10-14 days at follow-up appointment. The resident also needed a neck x-ray to assess the break. Both orbital areas were very bruised and swollen. Told if became too anxious they were to call the ER for orders of a calming type medication. Also, if presented to be in excessive pain they could call. The Care Plan identified an actual post incident [DATE] when the resident sustained a C1 fracture. The interventions included monitoring the resident for a sudden increase of pain to the neck area or any other sudden unexplained pain, or sudden loss of sensation. Contact the Physician promptly with any concerns. If medication needed for pain call the ER. The Progress Notes dated [DATE] at 9:30 a.m. documented the on duty nurse reported the resident's oxygen (O2) saturation (sat) had dropped and she put him on oxygen. The nurse stated she tried calling the Physician's office but she was not in. The nurse went into the resident's room to assess him. The resident noted to be laying in bed with eyes closed, oxygen on per nasal cannula. The resident's spouse present. The nurse asked the spouse if she could do anything for the resident or her. The nurse brought the spouse a cup of coffee. As leaving the unit, the spouse came out of resident's room and stated the resident wanted a drink of water and he had to poop. The nurse suggested staff use the potty chair on wheels and transfer the resident from the bed and let him use the bathroom. Staff agreed and the nurse left the unit. At 9:50 a.m. the nurse paged to the unit. Upon entering room, nurse (Staff N Registered Nurse) noted to be taking vitals on the resident laying in bed. Staff P Licensed Practical Nurse (LPN), stated the resident became unresponsive on the toilet so they laid him back down in bed. The nurse asked if he had a bowel movement and the other nurse stated yes. This nurse stated that he may have had a vagal response. The nurse asked the resident's spouse if she would like the resident to be sent to the hospital and the wife stated no, she wanted him to be comfortable and to stay at the facility. The nurse told the on duty nurse the spouse's wishes and reminded the on duty nurse to contact the doctor regarding the episode and need for O2 and to document. The [DATE] Medication Administration Record (MAR) showed the resident had an order for Tylenol Tablet 325 mg 2 tablet by mouth every 4 hours as needed for mild pain. The resident last received Tylenol for pain on [DATE] at 7:17 a.m. with pain documented at 6 (0 no pain, 10 worst pain) and indicated it was effective. The Treatment Administration Record (TAR) documented the resident's pain on [DATE]: a. 4 at 4 a.m. b. 4 at 8 a.m. c. 3 at 12 p.m. d. 0 at 6 p.m. e. not assigned a number at 8 p.m. f. and a 6 on [DATE] at 12 a.m. The clinical record lacked documentation the facility implemented interventions to help relieve the pain. The Progress Notes dated [DATE] at 2:09 p.m. documented the resident was unresponsive while using the bathroom for 1-2 minutes. The resident had been weak and sleepy during the a.m. shift. The resident's 02 was down to 52% (90-100 normal) started O2 at 2 liters. Fax sent to the doctor and family notified. Vitals temp 97.7, pulse 46 (normal 60-100), B/P 110/46, respirations 30 (normal 12-20) with labored breathing. He refused his meals and noon shakes. A fax dated [DATE] notified the Physician of the resident's condition. The resident fell [DATE] with sutures at the forehead and soft neck collar. The resident's O2 sat dropped down to 52 %, and the nurse started O2, and the resident had labored breathing. The resident complained of abdominal pain, and request to use the restroom. In the process he became unresponsive for 1-2 minutes while sitting on the bathroom. His oxygen started going up to 74 %. Would keep monitoring him. Asked if the Physician would recommend continuing the O2, and how long. The Advanced Registered Nurse Practitioner responded to continue O2 at 2-3 liters to maintain O2 sats greater than 90% until progress report on [DATE] to the Physician. On [DATE] at 9:17 p.m. the resident refused to cooperate and became more combative when obtaining vital signs and assessment. He refused to put the oxygen back on but agreed to be changed and repositioned in bed. The resident refused his medications and meals. The resident slept peacefully in his room at that time. The Progress Notes dated [DATE] at 9:50 p.m. documented the fax came back to continue O2 per nasal cannula 2-3 liters to maintain O2 sats greater than 90%. Continue O2 continuously until progress report on Thursday, 1-6-22 to the physician. The Progress Notes dated [DATE] at 1:15 a.m. documented a call placed to the ER to get in touch with the on-call regarding the resident. The resident's vital signs were (VS) 97.4-108-44 O2 at 2 L NC. The resident's lung sounds had crackles throughout, and audible gurgling. The resident unable to verbalize the presence of pain, restless, moving his legs out of bed. A call placed to update the spouse. The on-call updated on the resident. Received an order to send resident to the ER for further evaluation. The spouse would follow the ambulance to the ER. The Progress Notes dated [DATE] at 1:55 a.m. documented the ambulance arrived 1:40 a.m. departed with the resident at 1:45 a.m. The ambulance personnel called at 1:52 a.m. and stated the resident quit breathing and asked if he had a do not resuscitate (DNR) and he did. The spouse followed behind the ambulance. The Progress Notes dated [DATE] at 2:49 a.m. documented the ER called and stated the resident passed away [DATE] at 2:15 a.m. with the spouse at the bedside. A hospital Discharge Plan dated [DATE] documented the resident dead on arrival to the hospital. The clinical impression: death due to respiratory arrest, C1 cervical fracture, and dementia. The history of present illness (HPI) documented the resident with a recent fall at the nursing home sustaining a laceration to his head and a C1 fracture. The Emergency Medical Service (EMS) was called today due to increasing respiratory difficulty. Upon arrival they said he had a pulse and breathing, however, shortly after coming out into the cold air he respiratory arrested. They did assist the the resident with bag mask ventilation although they did not find it to be that effective. He lost his pulse enroute. Because he had a DNR they did not do further intervention. On [DATE] at 1:20 p.m. the resident's spouse stated on [DATE] the resident was not doing well. She went and spent time with him and went home to eat. She came back and the SW told her he was resting and she didn't need to be there. She went home and that was her biggest regret. He died in the ambulance and she didn't get to be with him. On [DATE] at 11:15 a.m. the Physician's Assistant (PA) stated she would definitely expect the resident's lung sounds to be assessed with a low O2 sat, and closely monitored. On [DATE] at 12:30 p.m. Staff O Registered Nurse (RN) Director of Nursing (DON) at the time, stated she was called to the unit because the resident became unresponsive (the a.m. of [DATE]). They had oxygen on him but she did not know the O2 sat dropped down to 52. She would expect an assessment of the resident's lung sounds. That may have changed their response. She did talk to the resident's spouse (that morning) but maybe didn't know the full extent of his condition. On [DATE] at 4:50 p.m. Staff P Licensed Practical Nurse (LPN) stated she could not remember details. When looking at documentation she said she did neuro checks on the resident and his O2 sat was 52. He had labored breathing. She started oxygen. Then he became unresponsive on the commode. She called the other nurse (Staff N RN) to see what she thought of him. The other nurse called the DON. She said she did not check his lungs because others were assessing him. She didn't know who assessed what. On [DATE] at 11:44 a.m. Staff N RN remembered Staff P calling her back to the unit [DATE] to see what she thought. She was maybe in the unit 5 minutes and called the DON. She did not do any assessment of the resident. On [DATE] at 2:40 p.m. Staff M RN worked at the facility a few shifts for agency. She worked [DATE] overnight into [DATE]. She worked south hall. She didn't know why she went back to the unit but the resident clearly needed pain medication. When she asked the resident about pain he squeezed her hand. He had crackles throughout his lungs with labored breathing. He wasn't taking pills and he needed something in liquid form. She thought he needed Morphine. She said something should have been done before this. She had the other nurse come to the unit, (Staff L RN). She helped with phone calls. She did not feel the resident just suddenly got this way. On [DATE] at 3:19 p.m. Staff L stated she worked the night the resident died. When she went to the unit he was in bad shape. She thought he should have had something done sooner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to assure a resident had the identified interventions in place to prevent a fall with a major injury for 1 of 6 residents reviewed (Resident #104). Resident #104 had an intervention for a bed alarm to alert staff to his getting up. On 12/31/21 the resident sustained a fall in his room with no alarm. The resident sustained a head injury requiring sutures and C1 (neck) fracture. The facility reported a census of 55 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #104 scored 2 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident required extensive assistance with bed mobility, transfers, walking in the room, dressing, toilet use and personal hygiene. The resident required limited assistance with walking in the hallway The resident's diagnoses included non-traumatic brain dysfunction, dementia with lewy bodies, and a stroke. The resident had 2 falls without injury, and 2 falls with non-major injury since the prior assessment. The Care Pan identified the resident a high risk for injury and potential falls due to impaired balance, weakness, and need for assistance with mobility. Interventions included: A bed alarm would be used to alert staff to his getting up, initiated 12/8/21. A Tracking Record for Improved Patient Safety (TRIPS) form documented the resident fell on [DATE] at 7 p.m. The resident self transferred and walked with his walker. The root cause identified the resident stated he lost his balance. The immediate intervention was close monitoring. A TRIPS form documented the resident fell on [DATE] at 9 p.m. The root cause of the fall identified as decreased mental, cognitive and neuromuscular systems. The immediate intervention was a bed alarm. A TRIPS form documented the resident fell on [DATE] at 2:34 p.m. The resident fell trying to sit back on a chair. The immediate interventions included reminding the resident to check before sitting, and monitoring the resident closely in and out of his room. A TRIPS form by Staff J Licensed Practical Nurse (LPN) documented the resident fell on [DATE] at 10:55 p.m. The resident was alone and unattended. The alarm was not attached to the bed. The root cause of the fall was the alarm was not plugged in, in order for the resident to get help. The Progress Notes dated 1/1/22 at 12:02 a.m. documented the resident had an unwitnessed fall at 10:55 p.m. in his room. The nurse aide heard a sound and found the resident on his right side next to his bed bleeding from his head. He evaluated the resident, and called the wife at 11 p.m. and asked for permission to send him to the emergency (ER) to be evaluated and treated. The hospital called at 11:02 p.m. to get a telephone order to send the resident. At 11:08 p.m. 911 called and they had to try to find an ambulance since all around us were dispatched out with other calls. At 11:35 a.m. dispatch called back and said another ambulance would transfer the resident. At 11:55 p.m. the ambulance came and transported him onto the gurney, leaving the facility at 12 a.m The resident was alert after the fall and only complained of his head hurting in the general area where his head bled from. They cleaned the resident up with sodium chloride (NaCl), and gauze placed on his head with pressure to help with the bleeding. His wife would be at the hospital waiting for his arrival. A hospital Emergency Department note dated 1/1/22 documented the resident had a laceration of the head and a C1 cervical fracture. The history of present illness documented a resident with dementia in the memory care unit apparently sustained a fall earlier in the night and had a laceration on the right eyebrow. The resident had some neck pain, and also pain in the pelvis. He had a stellate (tear in the skin caused by blunt trauma) laceration above the right eyebrow, and hematoma or swelling around that area, approximate 5 or 6 cm total length. Basically a gouged into the center of the stellate laceration and it kind of stretched the tissue due to frailty and old age. It had continuous oozing without a pressure dressing. The laceration measured 5 cm to 2 cm. The resident had a very irregular wound. The resident had Computed Tamography (CT) of the cervical spine without contrast. The findings included fractures of both the anterior and posterior arches of C1. The anterior arch fracture was distracted (widened) by about 11 mm. The Progress Notes dated 1/1/22 9:48 a.m. documented the Resident returned via ambulance at 9:05 a.m. the ER Dr. consulted with a neuro-surgeon. The resident with C1 fracture and felt not a candidate for surgery. He received a soft collar to wear. Per the Dr. notes they were to do the best they could to keep the collar on but understood it may be difficult to do. The resident had multiple sutures on top of his forehead. They were to leave the pressure bandage on for 48 hours then apply an ointment. Sutures should be removed in 10-14 days at follow-up appointment. The resident also needed a neck x-ray to assess the break. Both orbital areas were very bruised and swollen. The were told if he became too anxious they were to call the ER for orders of a calming type medication. Also, if presented to be in excessive pain they could call. On 7/26/22 at 1:20 p.m. the resident's spouse stated she kept a diary of events. She said the night he fell they called her and she went to the hospital, getting there before he did. She could not understand why they didn't answer the alarm before he fell, they never explained that to her. She said he had a broken neck and had stitches on top of his head. She could not understand how that happened. He went back to the facility at 9:30 a.m. the next morning. On 7/26/22 at 3:02 p.m. Staff K Certified Nursing Assistant (CNA) worked 2-10 p.m. the night he fell. She didn't remember putting him to bed. He was supposed to have a bed alarm on. She gave report at 10 p.m. and didn't remember checking the alarm. She assumed it was on. On 7/27/22 at 9:51 a.m. Staff R CNA worked the night the resident fell and went to the hospital. He didn't recall report that night. He said he was sitting when he heard a bang and then found the resident on the floor and bleeding from the head. On 7/27/22 at 12:30 p.m. Staff O Registered Nurse (RN) stated she was the former Director of Nursing (DON) and was in that position when the resident fell and sustained the injuries 12/31/21. She said apparently the resident did not have the alarm on at the time. Action was taken immediately to correct the problem. During an observation on 7/28/22 at 11:35 a.m. the current DON and Office Manager (OM) demonstrated the bed alarm. The office manager sat up and stood. The alarm sounded as soon as she stood up off of it. The DON stated if the alarm were on the night he fell, it should have sounded alerting staff to check on him. On 7/28/22 at 3:19 p.m. Staff L RN stated she worked the night the resident fell and had a fracture. She said he did not have the alarm on.