**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, resident interview, staff interviews, and facility record review, the facility failed to provide adequate nursing supervision to prevent a fall that caused a distal femur fracture, need for hospitalization, pain control and decline in the resident ' s physical ability for 1 of 14 residents reviewed (Resident #29). The facility reported a total census of 41 residents. Past Noncompliance determined during the annual recertification survey of a facility incident that occurred on 1/22/24 regarding deficiency F689 with a scope and severity of a Level G. The facility provided evidence of education to the staff member directly involved in the facility incident that occurred on 1/23/24. The remainder of the nursing staff received education on 1/31/24. Findings included: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #29 documented diagnosis of hemiplegia, seizure disorder, traumatic brain injury (TBI). The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The MDS identified Resident #29 with limitation in movement and impaired range of motion to one side of the body, upper extremity and lower extremity. The MDS also showed Resident #29 dependent on a helper for all effort, or the assistance of two or more helpers is required for toileting hygiene. The Care Plan dated 10/26/23 for Resident #29 identified stand-pivot transfers with assistance of two staff and a gait belt. Do not use his bathroom, use the bedside commode. The Fall Risk assessment dated [DATE] for Resident #29 identified the resident to be a moderate fall risk. The Incident Report dated 1/22/24 at 7:18 PM for Resident #29 identified staff called the nurse to the resident ' s room. The nurse observed the resident laying on his left side with legs outstretched. The nurse noted the resident ' s pants were down. The resident reported he tried to pull up his pants while turning then lost his balance. The resident informed the nurse that he thought his leg was broken. The Progress Note dated 1/22/24 at 7:25 PM for Resident #29 identified staff witnessed a fall then called 911 to assist the resident. Resident #29 transferred to the emergency room (ER) by Emergency Medical Technicians (EMT). The emergency room Discharge Plan dated 1/22/24 for Resident #29 revealed an x-ray diagnosis of a left distal femur T-shaped fracture. Resident #29 transferred to a hospital with a higher level of care for orthopedic services. The Hospital Records dated 1/22/22 at 1:57 AM showed Resident #29 admitted for a left distal femur fracture. The History of Present Illnesses explained Resident #29 lost his balance and fell while he attempted to transfer. Resident #29 reported dull pain in the left leg. The Orthopedic Consultation dated 1/23/24 at 6:40 AM identified Resident #29 sustained a left intra-articular distal femur fracture. Resident #29 reported pain around the left knee. The orthopedic surgeon recommended surgical management. The Operative Report dated 1/23/24 at 5:28 PM for Resident #29 confirmed the diagnosis of a left intra-articular distal femur fracture, closed, displaced. The post operative plan included non-weight bearing left lower extremity of likely 8 weeks, gentle range of motion for the left knee as pain allows. Post surgery the resident received intravenous (IV) antibiotics and pain medication. The surgeon also ordered apixaban 2.5 mg by mouth twice a day for 30 days to prevent blood clots. The Final Report dated 1/29/24 for Resident #29 identified the discharge orders included the following: Mechanical lift for transfers. Bedrest. Gentle range of motion to left knee as pain allows. No weight bearing to left left for likey 8 weeks. Physical Therapy and Occupational Therapy consults. Foley Catheter. Surgical dressing instructions. The Discharge summary dated [DATE] for Resident #29 indicated Tylenol and hydrocodone ordered for pain, and apixaban ordered to prevent a blood clot. The Physician Orders for Resident #29 the following pain medication ordered upon readmission to the facility on 1/29/24: Hydrocodone-Acetaminophen 7.5-325 milligrams (MG) 1 tablet every four hours as needed for moderate pain. Hydrocodone-Acetaminophen 7.5-325 milligrams (MG) 2 tablet every four hours as needed for severe pain. The January 2024 Medication Administration Record (MAR) revealed Resident #29 received hydrocodone for pain as follows: 1/29- 2 times for a total of 2 tablets, 1/30- 2 times for a total of 2 tablets, 1/31- 3 times for a total of 4 tablets. The February 2024 Medication Administration Record (MAR) revealed Resident #29 received hydrocodone for pain as follows: 2/1- 1 time for a total of 1 tablet, 2/2- 1 time for a total of 2 tablet, 2/3- 2 times for a total of 4 tablets, 2/4- 2 times for a total of 4 tablets, 2/5-2 times for a total of 4 tablets, 2/6- 3 times for a total of 6 tablets 2/7- 4 times for a total of 8 tablets, 2/8- 1 time for a total of 2 tablet, 2/9- 3 times for a total of 6 tablets, 2/10-1 time for a total of 2 tablet, 2/11- 1 time for a total of 2 tablet, 2/12- 3 times for a total of 4 tablets, 2/13- 2 times for a total of 4 tablets, 2/14- 3 times for a total of 6 tablets, 2/15- 2 times for a total of 4 tablets, 2/16- 1 time for a total of 2 tablet. In an interview on 5/28/24 at 1:03 PM, Resident #29 stated, I was standing to use my urinal, one of my legs gave out from underneath me. Resident #29 reported that one Certified Nursing Assistant (CNA) hung onto him as he used the urinal. Resident #29 stated, I fell to the floor, had a dull pain that wasn ' t sharp. In an interview on 5/28/24 at 1:36 PM, Staff E, CNA reported she assisted Resident #29 to use the urinal while he stood at bedside. When Resident #29 finished urinating, Staff E assisted him to pull up one side of his pants. While Resident #29 attempted to pull up the other side of his pants, the resident leaned forward, causing him to fall in a forward direction. Staff E reported Resident #29 hit his head on the bedside commode and complained of left leg pain. Staff E reported to be the only CNA in the room at the time of the fall. When asked if there should have been two CNA ' s, Staff E replied, Yes, but my partner was on break and the nurse gets mad, so I didn ' t ask her. I usually ask for help. When asked if Staff E used a gait belt, she replied, No, he usually refuses, so I didn ' t ask. In an interview on 5/29/24 at 8:48 AM, Staff F, Licensed Practical Nurse (LPN) reported staff called her to Resident #29 ' s room. Staff F found Resident #29 lying on the floor, on his left side, in front of his nightstand. Resident #29 reported he tried to pull up his pants but fell and suffered from left leg pain. Staff F asked Staff E, CNA if she helped the resident. Staff E replied, Resident #29 insisted on pulling up his pants himself. Staff F reported Resident #29 lacked wearing a gait belt when she entered the room. Staff F then instructed Staff E to use the gait belt when getting the resident up. Staff F further stated, and I told Staff E to make sure she used it. When asked if Staff E assisted the resident to use the urinal alone, Staff F stated, yes. In an interview on 5/29/24 at 3:06 PM, the Director of Nursing (DON) reported the facility lacks policies related to gait belt usage and falls. The facility followed regulations and standard practices. In an interview on 5/30/24 at 8:10 AM, the DON reported Staff E failed to follow Resident# 29 ' s care plan by not waiting for another staff member before she provided Resident #29 with assistance for standing and using the urinal. The DON stated, Staff E was probably trying to help because the resident would have been in a hurry, and probably not wanting to wait for another staff member, but Staff E should have waited until someone was available. The DON reported that she planned to talk to the nurse about being more approachable, so that others can ask for help when needed. The DON also reported Staff E should have used a gait belt. The DON explained Resident #29 usually refused the gait belt because it was too tight. The DON has since ordered a larger gait belt and educated the resident regarding safety precautions. The DON stated, he ' s compliant now. The Comprehensive Care Plans policy last revised on 1/30/2024 identified The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview the facility failed to appropriately inspect bed rails in the facility for 1 of 1 resident reviewed (Resident #8). The facility reported a census of 41 residents. Past Noncompliance determined during the annual recertification survey of a facility incident that occurred on 12/25/23 regarding deficiency F909 with a scope and severity of a Level G. The facility provided evidence of the bed being changed out with safe bed rails. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 documented diagnoses of diabetes mellitus, neurogenic bladder and hypertension. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Interview on 5/28/24 at 11:34 a.m., with Resident #8 revealed her bed rail had been loose and when she was being assisted the side rail broke off of the bed and she fell off of the side of the bed. Review of Resident #8 ' s Progress Notes revealed the following: a. On 12/26/23, Resident #8 being seen after going to the emergency room (ER) on 12/23/23 for left shoulder pain and returning to the facility on the same day. While in the ER an x-ray was obtained of the left shoulder which showed advanced degenerative change. Nursing staff also express resident fell out of bed yesterday. b. On 12/27/23 at 10:51 p.m., Resident #8 reports pain to the left shoulder and arm. As needed, tramadol has been effective. Resident #8 is lying in her new bed and it is in the lowest position. c. On 12/28/23 at 11:03 a.m., Resident #8 returns from doctor appointment with order for non-weight bearing to left shoulder. Follow-up with CT scan of left shoulder. d. On 1/17/24 at 1:11 p.m., CT results received impression: Acute intra-articular fracture of the anterior aspect of the glenoid with maximum distraction of fracture fragments in the order of 3 mm. e. On 3/28/24 at 10:54 a.m., Resident #8 returns after seeing the doctor with the following noted healed fracture no restrictions. Review of facility provided Incident Report dated 12/25/23 revealed while resident was being repositioned in bed, the side rail became disengaged and resident rolled off side of bed. Resident #8 states while trying to help them change me, I grabbed ahold of the rail as I was turning and I started falling. Review of the facility provided document titled Timeline of Incident revealed on 12/25/23 at 2:05 p.m., Resident #8 was lying in bed while she was being assisted by staff. Staff went to reposition her to her left side, Resident #8 went to grab her bed rail to hold on to and the bed rail broke apart from the bed frame causing Resident #8 to fall out of bed onto her left side. Staff brought in a replacement bed with functioning bed rails.On 1/17/24 the facility was notified by the physician Resident #8 had an acute fracture. Review of the CT shoulder imaging dated 1/8/24 revealed in the findings there is an acute appearing intra-articular fracture of the anterior aspect of the glenoid with maximum distraction of fracture fragments in the order of 3 mm. Interview on 5/29/24 at 9:53 a.m., with Staff A, Licensed Practical Nurse (LPN) was just coming onto shift when the staff called her down to Resident #8 ' s room. When Staff A entered the room Resident #8 was laying on the floor face down with the bed rail broke off of the bed. Resident #8 was assessed and assisted back into bed with the hoyer lift. Interview on 5/29/24 at 10:29 a.m., with Staff B, Certified Nursing Assistant (CNA) revealed she had assisted Staff C, CNA with Resident #8 into bed to change her brief. Staff B revealed when Resident #8 rolled onto her left side she grabbed the bed rail and the rail broke and Resident #8 fell to the floor. Staff B further revealed she had noticed the bed rail was a little loose but it had been that way for awhile and she didn ' t think it would break. Interview on 5/29/24 at 12:20 p.m., with Staff C, CNA revealed she had been assisting Staff B, CNA with Resident #8. Staff C revealed Resident #8 rolled onto her left side and the side rail on the bed broke and Resident #8 fell out of the bed onto the floor. Interview on 5/29/24 at 12:41 p.m., with Staff D, Maintenance Director revealed the beds have a tab on the rail that holds them in place and a pin that keeps them locked. The side rail was bad on both sides from what appears to have been bent from a bigger person pulling on the side rails on each side. The tab was bent so much that the pin that keeps the rail in place wasn ' t able to hold it any longer. Review of facility provided document titled Work History Report with created date of 5/29/24 revealed preventative maintenance with a due date of 11/30/24 and 12/31/24 under task completion revealed no action recorded. Review of the facility provided instructions titled Beds- Electric: Inspect Bed Rails dated 5/29/24 at 2:57 p.m., revealed items identified as poor condition should be removed from service. Maintenance check included ensuring that the rails engage and lock as specified and tighten, adjust or replace any parts such as end caps, knobs, bolts, screws, ect. that are loose, show signs of wear or are missing. Interview on 5/29/24 at 3:19 p.m., with the Administrator revealed the previous maintenance guy had been doing the bed checks and he retired at the beginning of November and the facility was without a full-time maintenance person. The bed rail inspections did not get done in November or December. After the incident happened, the facility realized the bed rail inspections were not being. The Administor further revealed he trained the new maintenance guy on how to do the bed rail inspections and they are now being completed.