**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policies, the facility failed to have an effective system to ensure care plans were revised to provide necessary interventions for supervision and monitoring for residents to prevent falls/accidents for 8 of 10 sampled residents, (Resident (R)10, R15, R27, R51, R75, R93, R111, and R274). The facility failed to thoroughly investigate and evaluate residents' falls by performing root cause analysis (RCA) to determine the root cause of the numerous residents' falls in order to review/revise the residents' care plans to prevent additional falls and injuries for residents. In addition, the facility failed to ensure residents' comprehensive care plans (CCP) were reviewed/revised for each of the residents' falls, and failed to ensure the date was noted when care plan interventions were initiated. The findings include: Review of the facility's policy titled, Falls Management/Prevention, revised 07/2024, revealed the purpose of the policy was to establish a program to identify residents with risk factors that might place them at risk for falls. Per review, the purpose also included to manage residents who experienced a fall to minimize the risk of a fall recurring or minimize the risk of injury related to a fall. Continued review revealed the facility was to screen all residents to identify possible risk factors that might place a resident at risk for falls. Policy review revealed the facility would additionally screen residents for possible risk factors to evaluate those risks and implement interventions to reduce the risks and observe the interventions and modify as necessary. Further review revealed the facility was to investigate any resident fall to determine the root cause and appropriate interventions were to be put in place to minimize the risk of recurrence and the risk of injury related to a fall. In addition, policy review further revealed the current care plan interventions were to be reviewed and revised or if no care plan was in place, one was to be developed to minimize the risk of recurrence and the risk of injury related to a fall. Review of the facility's policy titled, Care Plan Policy & Protocol dated 09/2017 revealed the care plan was to be updated as indicated with changes in condition, physician orders, fall interventions, etc. The policy stated the Kardex was also to be utilized as a guide for nurse aides in providing care on a daily basis and changes would be made when indicated. According to the policy, the Kardex was to reflect person-centered care preferences. Review of the facility's Minimum Data Set (MDS) Coordinator job description dated 09/25/2024, revealed the MDS Coordinator was to achieve the organization's goals for positive outcomes by effective processes, monitoring, and training. Further review revealed the MDS Coordinator was to implement systems that lead to appropriate MDS completion and submission, care planning, and accurate reporting of quality measure data. 1. Review of the facility's, admission Record for R10 revealed the facility admitted the resident on 08/18/2022, with diagnoses which included unspecified dementia and anxiety. Review of the Quarterly MDS Assessment with an Assessment Reference Date (ARD) of 02/20/2024, revealed the facility assessed R10 to have sustained two (2) or more falls since the previous assessment, two (2) falls with injury. Further review revealed the facility also assessed R10 as dependent and needing staff assistance with ambulation, toileting, transfer, and dressing. Further review revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating R10 was unable to complete the assessment. Review of the Fall Risk assessment dated [DATE] for R10, revealed a score of 16 noted, which indicated the resident was at high risk for falls. Further review revealed R10 had experienced three (3) or more falls in the past three (3) months; was chairbound, required assist with elimination, and had a balance problem when standing. Review of the facility's, Comprehensive Care Plan (CCP) for R10 revealed the facility developed a falls care plan dated 02/22/2024, which noted the resident was at risk for falls related to a history of a falls which resulted in a right hip fracture; falls at home prior to admission; history of dementia, and cognitive loss; forgetting his physical limitations and attempting to get up without staff assistance. Per review, the goal dated 06/16/2024, stated the resident would be protected from falls through the next review date with a target date of 09/18/2024. Continued review of the CCP, revealed 26 interventions documented which were undated. Further review revealed it could not be determined which interventions were in response to a fall. Additionally, it could not be determined if the interventions were implemented prior to a fall or if the care plan interventions were reviewed/revised after each fall. Review of the facility's, Health Status Note, dated 02/23/2024 at 4:35 PM, revealed R10 had been found sitting on the floor in his room in front of the doorway facing out into the hall. Continued review revealed R10 had not been wearing footwear and was unable to explain how he fell. Per review, a head-to-toe assessment was completed with pain noted with movement of R10's left leg/hip, and redness and bruising noted to the resident's right outer ankle with no inward/outward rotation noted to the bilateral lower extremities. Further review revealed the facility transferred R10 to the hospital and the resident's representative was notified. Review of the Health Status Note for R10 dated 02/23/2024 at 8:12 PM, revealed the Medical Director was notified the resident had been transferred to a local hospital and diagnosed with a fractured left femur. Review of R10's hospital, Discharge Summary, dated 02/28/2024, revealed the resident had undergone surgery on the hip on 02/25/2024 for a left hemiarthroplasty (surgery replacing the hip joint ball portion with an artificial surface, leaving the socket intact). The hospital discharged R10 back to the facility. Review of the facility's, Fall Incident Report, (FIR) for R10's fall on 02/23/2024, revealed no documented evidence of a root cause analysis (RCA) for the fall, which resulted in the resident's hip fracture. Per review, there was nothing documented related to a RCA performed to determine if R10's current fall interventions had been implemented prior to the fall or to evaluate whether there was a need to modify interventions to prevent recurrence. The review revealed it could not be determined if new CCP interventions were developed for R10 after the 02/23/2024 fall as the CCP interventions were undated; and there was no documentation noting the resident had sustained the fall with injury. Review of the facility's, Fall Risk Assessment, dated 02/28/2024 for R10, revealed the resident had a score of 18 indicating R10 was at high risk for falls. Record review revealed R10 was noted as disoriented to person, place, and time at all times. Continued review revealed R10 had sustained three or more falls in the past three months, was chairbound and required assist with elimination. Further review revealed the resident was noted to have a balance problem when standing and walking, and required the use of an assistive device; however, the type of device was not specified. Review of the facility's document titled, Incidents by Incident Type, dated 02/28/2024 through 08/28/2024, revealed R10 experienced nine witnessed falls and 10 unwitnessed falls for a total of 19 falls during the six-month timeframe. Further review of the facility's documentation and record review revealed no documented evidence R10's falls were investigated to determine the root cause of the falls. The review revealed no documented evidence the facility revised the resident's CCP interventions in attempts to prevent additional falls/injuries for R10. 2. Review of R15's, admission Record revealed the facility admitted the resident on 09/16/2019, with diagnoses including paranoid schizophrenia, history of falls, history of left hip fracture, dementia, and Alzheimer's. Review of R15's Quarterly MDS Assessment with an ARD date of 04/12/2024, revealed the facility assessed the resident to have a BIMS score of 99, which indicated R15 was unable to complete the interview. Further review revealed the facility assessed the resident as dependent and to require substantial maximum assist by staff with dressing, ambulating, toileting and transferring. Review of R15's Fall Risk Assessment (FRA) dated 01/12/2024, revealed the facility assessed the resident to have a score of 12, indicating a high risk for falls. Further review revealed R15 was at high risk for falls due to: not being ambulatory; chairbound; intermittently confused; and requiring assist with elimination. Further review of the FRA history revealed no documented evidence of a quarterly FRA for R15 having been completed after the 01/12/2024 assessment to identify risks and hazards related to falls. Review of the facility's CCP for R15, revealed a care plan for falls initiated 01/16/2024, which noted the resident was at high risk for falls due to her diagnoses of osteoarthritis and osteopenia; medication use; of history of falls, history of left hip fracture; impaired cognition; and requiring total staff assistance to complete activities of daily living (ADLs). Continued review revealed the goal dated 05/09/2024, revealed R15 was to be protected from falls through the next review period with a target date of 11/19/2024. However, R 15 sustained a fall with injury on 04/29/2024. Review further revealed the facility noted 14 interventions which were not dated to specify when the CCP was update/revised. 3. Review of R111's, admission Record revealed the facility admitted the resident on 01/22/2024, with diagnoses including muscle weakness, unspecified fracture of the left acetabulum (hip), lack of coordination, and unspecified dementia. Review of the facility's FIRs from 03/11/2024 until 08/17/2024, revealed R111 had sustained 16 falls during that time period. Continued review revealed there was no documented evidence the facility conducted fall investigations to determine the root cause of the falls in order to review/revise individualized resident-centered interventions to prevent further falls. Review of R111's FIR dated 06/14/2024, revealed the resident sustained a fall and was screaming and saying her hip was killing her. Further review revealed the facility transferred R111 to the emergency room (ER) for evaluation. R111 sustained a right hip fracture with this fall. Review of the facility's documentation and record review revealed after R111 returned to the facility there was no documented evidence the facility reviewed/revised the resident's CCP with additional interventions to prevent additional falls. Review further revealed the resident sustained two additional falls on 07/26/2024 and 08/17/2024. 4. Review of R27's, admission Record revealed the facility admitted the resident on 06/21/2016, with diagnoses of generalized muscle weakness, spondylosis without myelopathy of lumbar spinal region, other lack of coordination, osteoarthritis, and difficulty in walking. Review of R27's, Quarterly MDS Assessment with an ARD of 06/11/2024, revealed the facility assessed R27 as having a BIMS score of 11 out of 15, which indicated moderate cognitive impairment. Continued review of the MDS revealed the facility assessed the resident to require assist with transfer; supervision or touching assist with chair/bed to chair (wheelchair) transfer and toileting; and partial/moderate assistance with shower/bathing care. Review of R27's CCP, last reviewed/revised on 08/13/2024, revealed on 03/13/2024, the facility noted the resident was at high risk for injury related to falls. Per review, R27 was at risk for injury from falls due to decreased mobility skills; frequently incontinent of bladder and bowel; edema to bilateral lower extremities, and history of falls at home prior to admission. Continued review revealed the goal stated the resident was to be protected from falls through the next review with a target date of 09/24/2024. Review of the care plan interventions dated 07/06/2016 revealed they included: bed in lowest position; transfer resident safely with assist; keep personal items and call light within reach; encourage use of call light when needing assistance as needed; check every two (2) hours and as needed (PRN) for incontinent episodes;. fall risk assessment quarterly and as needed (PRN); and non-skid footwear (shoes or socks). Further review of R27's CCP revealed no documented evidence a RCA was completed after the resident sustained falls on 03/25/2024, 05/25/2024, 06/01/2024, and 06/23/2024, in an attempt to review/revise the CCP with interventions to prevent reoccurrence. Additionally, there was no documented evidence the CCP was revised to include interventions related to supervision and monitoring prior to the resident's fall with significant injury resulting in a right hip fracture on 07/31/2024. Review of the facility's,Un-witnessed Fall Incident Report dated 06/23/2024 at 2:25 AM for R27, revealed the resident had been found lying on the floor on her back. Continued review revealed R27 was noted to have a skin tear/abrasion to the right and left upper inner arms. Per review, description of the immediate action taken revealed the facility assessed R27 for injuries; and the skin tears were cleansed with normal saline and an aquacel foam dressing was applied to the right and left upper inner arms. Review of the facility's, At Risk for Falls CCP for R27, provided on 08/29/2024, revealed a hand-written care plan dated 06/23/2024, to place a bolster on the right side of the resident's bed. However, further review revealed no documented evidence of interventions revised/updated for supervision and monitoring of R27 after the resident's fall on that date, even though the resident had sustained three (3) falls from 03/25/2024 to 06/23/2024. Review of the facility's, Un-witnessed Fall Incident Report, dated 07/31/2024 at 5:53 PM, for R27 revealed the resident had been found lying on the floor in her room beside her bed. Per review, the nurse performed a head-to-toe assessment of R27, who was alert. Further review revealed a small skin tear was noted to R27's fourth (4th) finger on her left hand. Review of the facility's Provider Progress Note for R27 dated 08/02/2024 at 9:59 AM, revealed the resident sustained a fall from the bed on 07/31/2024. Continued review revealed R27 had been complaining of right leg/hip pain with movement, with the plan to x-ray right hip and pelvis. Review of R27's Health Status Note, dated 08/02/2024 at 1:20 PM, revealed the resident complained of pain in her right hip. Further review revealed the physician was made aware with a new order received for x-ray of R27's right hip and leg. Review of the X-ray report, dated 08/02/2024 at 5:28 PM revealed R27 had a suspected slight impacted sub capital femoral neck fracture (a type of hip fracture that occurs at the junction of the femoral head and neck). Review of the Emergency to Hospital-admission Discharge Summary, dated 08/08/2024, revealed R27 initially presented from a skilled nursing facility after a fall with an initial trauma scan revealing right femoral neck fracture. Per review, orthopedic surgery was consulted and after discussion with the family and the surgery team, a decision was made to manage the fracture nonoperatively with weight bearing as tolerated and pain control prn (as needed) given baseline bed bound status. Review of the facility's, Risk for Falls CCP with an initiated date of 06/12/2024, revealed a hand-written revised fall intervention dated 07/31/2024, to include placing the bed in the lowest position. Continued review of R27's CCP during the survey from 08/25/2024 through 08/30/2024, revealed no further newly documented fall interventions initiated on the resident's CCP related to the resident's recent fall with hip fracture on 07/31/2024. Per review of R27's CCP Risk for Falls on 09/25/2024, revealed an updated intervention dated 08/13/2024, for the resident's bed to be in lowest position with bilateral floor mats. Review of the facility's Kardex for R27 revealed a Care Plan Update dated 09/23/2024, with a Problem related to Resident attempts at times to get out of bed without any assistance, with an intervention to have bilateral floor mats. Additionally, continued review of R27's CCP revealed no updated/revised interventions implemented for the hospital discharge recommendations, dated 08/08/2024, regarding the resident's decline in mental status and Activities of Daily Living (ADL) function and change in assistance requirement such as weight bearing status as tolerated, the need for a therapy screen, pain control as needed, and bed bound status. Further record review for R27 revealed no documented evidence an updated fall risk assessment was completed after the resident's fall with fracture, to assess for the need to update/revise the resident's CCP. In interview with R27's daughter-in-law on 09/25/2024 at 5:35 PM, she stated she and her husband, visited R27 one to two times a week. She stated she just did not feel staff were checking on R27 routinely or like they should due to too many falls experienced by the resident. The daughter-in-law stated on her visits, she had found the resident lying in bed soaked with urine and stool, pouring down her legs. She stated staff had just recently placed the floor mats on the floor by R27's, because the mats had not been there prior to the past weekend. The daughter-in-law stated it would have been nice if the mats had been down when R27 attempted to get up on her own out of bed and fell sustaining a fractured hip. In interview with R27's Representative on 09/28/2024 at 1:40 PM, he stated the resident had declined in the past year and was now wheelchair bound, too unstable to stand, incontinent of bowel and bladder and required more assistance. He stated staff contacted him over and over about finding R27 lying on the floor, after trying to go to the bathroom on her own. The Representative stated R27 would ring her call bell, but obviously they (staff) were not coming, or not in a sufficient time because the last fall, she broke her hip. He stated he felt if R27 had fallen that many times attempting to get up on her own. The Representative stated staff should have done something sooner for prevention of falls, instead of waiting until after she had another fall with a hip fracture before putting mats on the floor at the resident's bedside. During an interview with Licensed Practical Nurse (LPN) 4, on 08/29/2024 at 3:31 PM, she stated when R27 sustained the fall she had been caring for the resident. She stated R27 had been attempting to transfer without assistance when she had the fall from the bed and injured her hip resulting in the fracture. The LPN stated staff were aware R27 got up and down by herself at times; although, the resident required assistance. She stated staff could not stop R27 from getting up (on her own) even though they had tried to reeducate her. LPN4 stated, unfortunately, this last fall ended up in a fracture, and the resident was now bedridden. During interview with Certified Nursing Assistant (CNA) 4, on 08/29/2024 at 2:00 PM, she stated R27 required one (1) person assist when getting out of bed and transferring to a wheelchair. She stated however, before R27's fall with the fracture, she had been able to get up and do for herself and staff checked on the resident at least every two (2) hours. During continued interview with CNA4, on 08/29/2024 at 2:00 PM, she stated the nurses and Clinical Coordinators (CCs) should review areas that caused the resident's fall, such as with R27 and her trying to get up without assistance, and reaching for her personal need items. CNA4 stated R27 required one (1) assist with staff help when getting up out of bed and with transfer to wheelchair; although, before her fall she was really independent and was able to get up and do for herself. Before, R27 only required assist with bathing, and transfer assist from bed to chair. She stated staff would check on R27 at least every two (2) hours; however, the resident was out of her room a lot in her wheelchair. During an interview with LPN1, on 08/29/2024 at 2:50 PM, she stated, R27 was usually up in her wheelchair and out and about in the facility. She stated however, since R27's injury (hip fracture), the resident had been more reserved and quieter, and was just giving up and staying in her bed and room a lot more. LPN1 stated before the fall, R27 required two (2) staff to assist with all care areas. She stated the nurses and leadership were responsible for trying to figure out what caused the resident's falls and ensure care plans were updated/revised with interventions that were implemented and effective. In interview with Minimum Data Set Nurse (MDS) 1 on 09/30/2024 at 9:50 AM, he stated he was not sure as to why interventions were not being reviewed/revised and implemented appropriately. He stated, in reference to R27, the interventions at that time were generalized, not resident specific related to the resident's falls. MDS1 stated he felt there had been a lot of errors, such as important documentation missing from the incident reports, and nurses not initiating immediate interventions after the falls. 5. Review of R274's, admission Record revealed the facility admitted the resident on 01/11/2013, with diagnoses of aphasia, anxiety disorder, vision loss, Alzheimer's disease, and dementia. Further review revealed R274 had contractures of the: left and right shoulders, elbows, hands and knees. Review of R274's Quarterly MDS with an ARD of 02/23/2022 revealed the resident had a severe vision impairment and was totally dependent on two plus persons for personal hygiene and bathing. Review of R274's CCP dated 12/06/2021, revealed no documented evidence the facility updated/revised the care plan for the resident's bathing needs related to the multiple contractures. Additionally, there was no documented evidence the facility ensured interventions were in place to prevent accidents during bathing for R274, even though the resident was severely contracted. Review of R274's hospital records dated 07/09/2022, revealed the resident sustained an angulated spiral fracture of the midshaft of the humorous at the facility. Further review revealed that injury was initially identified as an injury of unknown source and later determined to have occurred on 07/06/2022 when staff bathed the resident. 6. Review of R51's, admission Record revealed the facility admitted the resident on 02/13/2024, with diagnoses that included: unspecified dementia, anxiety disorder, Parkinson's disease, other lack of coordination, essential tremor, generalized muscle weakness, and unsteadiness on feet. Review of the facility's, Quarterly MDS Assessment with an ARD of 08/21/2024 for R51, revealed the facility identified R51 to have had three falls since the previous assessment. Review of the facility's incident reports, dated 03/02/2024 through 09/12/2024, for R51 revealed the resident sustained 35 falls during that timeframe without serious injury. Further review revealed the facility failed to evaluate the falls for causal factors and failed to ensure R51's care plans were revised/updated to include individualized resident-centered care plan interventions to prevent falls for the resident. Review of the facility's CCP for R51 dated 02/13/2024, revealed the facility identified a care plan for the resident as at risk for falls related to history of falls, age, and diagnosis of Parkinson's disease. Continued review revealed the goal was for R51 to have decreased risk for injury related to unavoidable falls through the next review. However, further review revealed the care plan interventions were not revised/updated with resident-centered interventions. In addition, the care plan review revealed the dates interventions were initiated did not correlate with R51's falls in the facility. 7. Review of R93's, admission Record revealed the facility admitted the resident on 11/08/2022, with diagnoses to include anxiety, unspecified dementia, and chronic obstructive pulmonary disease (COPD). Review of the facility's, Quarterly MDS Assessment, dated 07/25/2024, revealed the facility assessed the resident to have a BIMS score of 11 out of 15 indicating the resident had moderate cognitive impairment. Continued review revealed R93 sustained two (2) or more falls since the previous assessment without injury. Further review revealed the facility assessed R93 as independent with chair/bed-to-chair transfer; and as able to ambulate ten (10) feet independently. In addition, the review revealed the facility also assessed R93 to require supervision or touching assistance with transfer to toilet. Review of the facility's Fall Incident Reports, dated 06/06/2024 through 09/25/2024 revealed R93 sustained 27 falls in that time period. Review of the facility's CCP for R93 revealed the facility initiated a falls care plan on 01/24/2024, for the resident as at risk for falls related to: a history of multiple falls during the reference period and prior to admission; the resident's cognitive impairment and physical limitations and inability to recognize her limitations or risks. Continued review revealed a goal initiated on 07/29/2024, for R93 to be protected from falls through the next review date with a target date of 11/10/2024. Further review revealed an intervention initiated on 08/23/2024, for R93 to be educated on asking for assistance even though the resident was moderately cognitively impaired. Additional review of the care plan revealed no documented evidence the facility revised/updated R93's CCP to include additional interventions to assist in preventing further falls for the resident. 8. Review of R75's, admission Record revealed the facility admitted the resident on 06/15/2020, with diagnoses of tremors, Parkinson's disease, and neuropathy. Review of the facility's Quarterly MDS with an ARD of 06/10/2024, revealed the facility assessed R75 to have a BIMS score of 15 out of 15, indicating R75 was cognitively intact. Review of the facility's, Fall Risk Assessment for R75 dated 01/22/2024, 03/12/2024, 09/04/2024, and 09/10/2024, revealed the facility assessed the resident as at high risk for falls. Review of R75's Progress Notes revealed the resident sustained 14 falls from 02/28/2024 through 09/23/2024. Review of R75's CCP revealed the facility initiated a focus (care plan) on 03/12/2024 for the resident being at risk for falls. Continued review revealed the goal noted R75 would have a decreased risk for injury related to unavoidable falls. However, review of R75's CCP revealed no documented evidence the facility evaluated the 14 falls for causal factors in order to review/revise the resident's care plan interventions in order to prevent further falls. During an interview, on 08/29/2024 at 2:00 PM, with CNA4, she stated each resident had a paper copy of their Kardex, located behind the nurse's station, which was the guide the CNAs used to provide resident care. CNA 4 stated the Kardex was to be reviewed each change of shift during rounds, and the nurses also told the CNAs if there were changes in a resident's care needs. The CNA stated after a resident sustained a fall, the nurse decided on an immediate fall intervention after consulting with other nurses, or a supervisor as needed for the fall intervention. CNA 4 stated residents' fall interventions were updated every day by the Clinical Coordinators (CCs) and the MDS Nurses added them to the CNAs' Kardex. During an interview, on 08/29/2024 at 2:50 PM, with Licensed Practical Nurse (LPN) 1, she stated during the day, the CC, and the Director of Nursing (DON) were notified of any resident falls. She stated that after hours, the on-call supervisor was notified of the falls. LPN1 stated after a resident sustained a fall, she attempted to find out what the resident had been doing prior to the fall and reviewed the Kardex to see what interventions were already in place. She stated she then attempted to update/revise the resident's care plan and initiate a new immediate fall intervention. The LPN stated she added the new intervention to the incident report, which was completed for each fall. Per LPN 1's interview, the CC and DON then completed their part of the incident report after they determined the root cause of the fall and checked if the new intervention was appropriate and made changes/revisions if needed. She further stated sometimes one on one (1:1) supervision was needed for residents with a lot of falls, and she felt like there was enough staff to do that in order to provide closer monitoring. During an interview on 08/29/2024 at 3:58 PM with the Clinical Coordinator (CC) 1, she stated she was in charge of the 100 Unit. She stated when a resident sustained a fall, she determined the cause of the fall, implemented an intervention to prevent recurrence, and updated the resident's care plan and Kardex with the new intervention. CC1 stated she also assessed the effectiveness of the new intervention. She stated if a resident had frequent falls, increased confusion, or increased behaviors, that might call for increased supervision. Per the CC's interview, in that case, there would be a need for a Physician's Order and that intervention would be added to the resident's CCP and Kardex. She stated all care plan interventions for residents should be dated in order to identify which interventions were added after which fall. During an interview, on 08/30/2024 at 9:06 AM, with CC2, who was over the 200 unit, she stated when a resident sustained a fall, the CC or on-call supervisor collaborated with the nurse completing the incident report to decide on an immediate appropriate intervention. She stated all falls were then discussed during the Monday through Friday morning clinical meetings with the interdisciplinary team (IDT). CC2 stated during the morning meetings they discussed residents who experienced frequent falls, their care plans, the falls policy and fall interventions and revised residents' care plans as needed. During an interview on 08/30/2024 at 9:30 AM with the MDS Nurse, he stated he completed residents' MDS Assessments on admission, annually, quarterly and with a significant change. He stated he developed or revised care plan interventions with the MDS Assessments. The MDS Nurse stated the facility worked together as an IDT related to revising residents' care plan interventions related to falls. He further stated staff were made aware of new fall interventions verbally by the CCs after the care plans were updated during the morning clinical meeting. During an interview, on 08/29/2024 at 4:40 PM, with the DON, she stated after a resident's fall, the nurse caring for the resident was to complete a Fall Incident Report. She stated the nurse was to include the details of the fall, the cause of the fall, and the immediate intervention to prevent recurrence on the Fall Incident Report. The DON stated the Fall Incident Reports were reviewed by the CCs. She stated residents' CCP should be revised with appropriate interventions related to the root cause of a fall to prevent recurrence. The DON stated all leadership was involved in the discussion of falls during daily weekday clinical meetings and during monthly Quality Assurance (QA) meetings. Per the DON in interview, she stated she did believe some of the residen[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility's policies, the facility failed to have an effective system to ensure adequate supervision and monitoring to prevent falls/accidents for eight (8) of ten (10) sampled residents reviewed for falls/accidents, Resident (R)10, R15, R27, R51, R75, R93, R111, and R274. The facility had a total of 346 falls during the six (6) month time period from 02/28/2024 to 08/28/2024, and an additional 26 falls from 08/29/2024 to 09/25/2024. However, the facility failed to thoroughly investigate and evaluate the falls to determine the root cause of each fall; and, failed to develop individualized care plan interventions to prevent further falls/injuries for each resident. The findings include: Review of the facility's policy titled, Falls Management/Prevention, revised 07/2024, revealed the purpose of the policy was to establish a program to identify residents with risk factors that might place them at risk for falls. Policy review revealed its purpose also included establishing a program for managing those residents who experienced a fall to minimize the risk of a fall recurring or minimize the risk of injury related to a fall. Continued review revealed all residents were to be screened to identify possible risk factors that might place them at risk for falls. Per policy review, the facility was to evaluate those risks and implement interventions to reduce the risks, observe the interventions and modify the intervention as necessary. Continued review of the Falls Management/Prevention, policy, revised 07/2024, revealed the facility was to investigate any resident fall to determine the root cause and put appropriate interventions in place to minimize the risk of recurrence and risk of injury related to a fall. Policy review revealed the facility was to complete a fall risk assessment for each resident on admission/readmission, quarterly and with any significant change. The policy review revealed upon completion of the risk assessments a plan was to be developed to address any risk factors identified. Further review revealed the facility was to notify the Physician and resident's representative when a fall occurred; complete an incident report; and complete a fall risk assessment of the resident every shift for 72 hours. The review revealed the current care plan interventions were to be reviewed/revised or if no plan of care was in place, one was to be developed to minimize the risk of recurrence and risk of injury related to a fall. In addition, tracking and trending was to occur for all falls. Review of the facility's policy titled, Falls Prevention Program, revised 07/2024, revealed its purpose was to allow residents to be mobile safely. Per review of the policy section titled, After High-Risk Residents Are Identified, revealed the facility was required to implement or modify safety measures and refer the resident to occupational or physical therapy for evaluation as indicated. 1. Review of R10's admission Record revealed the facility admitted the resident on 08/18/2022, with diagnoses which included unspecified dementia, and anxiety. Review of Rl0's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 02/20/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete the interview. Further review revealed the facility assessed Rl0 as having sustained two (2) or more falls since the previous assessment, two (2) with injury. Further review revealed the facility assessed R10 as dependent and as needing staff assistance with ambulation, toileting, transfer and dressing. Review of Rl0's Fall Risk Assessment (FRA) dated 02/20/2024, revealed a score of 16, indicating the resident was at high risk for falls. Further review revealed R10 was intermittently confused, was chairbound, and required assist with elimination. In addition, the facility assessed the resident to have a balance problem when standing and to have had three (3) or more falls in the past three (3) months. Review of the facility's Comprehensive Care Plan (CCP) revealed a care plan for falls dated 02/22/2024, related to the resident being at risk for falls due to having falls prior to admission, history of a fall resulting in a right hip fracture, dementia, forgetting his physical limitations, and attempting to get up without staff assistance. Per review, the goal dated 06/16/2024, stated R10 was to be protected from falls through the next review date with a target date of 09/18/2024. Continued review revealed interventions which included fall mats at bedside and a low rise chair. Further review revealed 26 interventions were in place on R10's care plan; however, it could not be determined which intervention were in response to which of the resident's falls. Additionally, review also revealed it could not be determined if interventions were implemented prior to the resident's fall or if the interventions were reviewed/revised after each fall. Review of R10's Health Status Note dated 02/23/2024 at 4:35 PM, revealed the resident had been found sitting on the floor of his room in front of the doorway with his bed noted in the lowest position with the fall mat in place. Per review, Rl0 had not been wearing footwear and had been unable to explain how he fell. Continued review revealed a head-to-toe assessment was completed with redness and bruising noted to Rl0's right outer ankle with no inward or outward rotation noted to the bilateral lower extremities. Further review revealed R10 was noted to have pain on movement of his left leg/hip. Review of the facility's Fall Incident Report, for the fall R10 sustained on 02/23/2024 fall, revealed no documented evidence the facility performed a root cause analysis (RCA) in order to evaluate whether the current fall interventions were implemented prior to the fall or to evaluate the need to modify interventions to prevent recurrence. Further review revealed it could not be determined if new fall interventions were implemented for the fall as R10's fall care plan interventions were not dated, and there was nothing noted indicating the resident sustained the fall with injury. Review of R10's Health Status Note dated 02/23/2024 at 4:57 PM, revealed the resident was leaving the facility via stretcher with Emergency Medical Services (EMS) to the hospital emergency department (ED). Continued review revealed R10's representative was notified of the fall and transfer to the ED. Review of R10's Health Status Note dated 02/23/2024 at 8:12 PM, revealed the Medical Director was notified the resident had been transferred to a local hospital and diagnosed with a fractured left femur. Review of R10's hospital Discharge Summary dated 02/28/2024, revealed the resident had undergone hip surgery on 02/25/2024, for a left hemiarthroplasty (surgical procedure to replace the ball portion of the hip joint with an artificial surface, while leaving the socket intact). Further review revealed R10 was being discharged back to the facility. Review of R10's Health Status Note at the facility dated 02/28/2024 at 6:08 PM, revealed the resident returned to the facility with sutures and a dressing in place to the left hip surgical site. Further review revealed R10 had a therapy evaluation ordered for getting out of the bed into the chair. Review of the facility's Fall Risk Assessment dated 02/28/2024 for R10, revealed the resident scored 18 indicating R10 was at high risk for falls. Per review, R10 was disoriented times three (to person, place, and time) at all times and had sustained three (3) or more falls in the past three (3) months. Further review revealed R10 was chairbound and required assistance with elimination; had a balance problem while standing/walking; and required the use of an assistive device (type of device was not specified on the Assessment). Review of the facility document titled, Incidents by Incident Type for the time period of 02/28/2024 through 08/28/2024, revealed R10 sustained nine (9) witnessed falls and ten (10) unwitnessed falls for a total of 19 falls during that six (6) month timeframe. Per review of the document, the falls occurred on the following dates: 04/25/2024; 05/07/2024; 05/09/2024; 05/20/2024; 05/29/2024; 06/07/2024; 06/16/2024; 06/21/2024; 07/18/2024; 07/18/2024; 07/24/2024; two falls on 07/28/2024; 07/31/2024; 08/01/2024; 08/04/2024; 08/12/2024; 08/15/2024; and 08/20/2024. 06/21/2024,07/18/2024,07/24/2024, 07/27/2024, 2 falls on 07/28/2024,07/31/2024,08/01/2024,08/04/2024, 08/12/2024,08/15/2024, and 08/20/2024. The facility provided Facility Incident Reports (FIRs) for all of R10's falls listed above. However, review of the facility's documentation and review of R10's medical record revealed no documented evidence the facility performed RCA for all the resident's falls in order to evaluate if fall interventions had been implemented or to evaluate the need to modify interventions to prevent recurrence. Additionally, review revealed it could not be determined if there were new fall interventions implemented for the falls as the falls care plan interventions were undated. Observation on 08/25/2024 at 12:00 PM, revealed R10 sitting up on the bed being assisted with the lunch meal by an aide. Continued observation revealed no visual evidence fall mats or a low rise chair were at R10's bedside, as per the resident's care plan. Observation on 08/26/24 at 10:40 AM, revealed R10 was lying on the bed on his right side with knees drawn up. The resident did not respond to the State Survey Agency (SSA) Surveyor's greeting or questions. Further observation revealed no fall mats or low rise chair were visible at R10's bedside (as per the resident's care plan). In interview on 09/25/2024 at 2:47 PM, and review of R10's falls, with MDS Nurse 1, he stated there was not enough information on the FIRs to determine if the care plan interventions in place for the resident at the time of each fall were being implemented. He stated there was also not enough information determine whether the care plan interventions had been reviewed prior to determining if a new fall intervention was needed. MDS Nurse 1 stated in effort to reduce the number of falls and decide on appropriate fall intervention for any resident, the fall interventions in place at the time of the fall, should be reviewed to decide if they were effective or not. 2. Review of the facility's admission Record for R15 revealed the facility admitted the resident on 09/16/2019, with diagnoses including dementia, Alzheimer's, paranoid schizophrenia, history of falls, osteoarthritis, osteopenia, history of left hip fracture, history of cerebrovascular accident, and lack of coordination. Review of the facility's Quarterly MDS Assessment with an ARD date of 04/12/2024, revealed the facility assessed R15 as having a BIMS of 99, indicating the resident was unable to complete the interview. Further review revealed the facility also assessed R15 as dependent and needing substantial maximum assistance of staff with ambulation, toileting, transfer, and dressing. Review of the facility's Fall Risk Assessment dated 01/12/2024 for R15, revealed a score of 12, indicating the resident was at high risk for falls. Per review, the criteria for R15 being at high risk for falls included: being intermittently confused; being chairbound and requiring assist with elimination; and not being ambulatory. Review of the facility's Fall Risk Assessment (FRA) history noted for R15 revealed no documented evidence of a quarterly FRA completed after the 01/12/2024 assessment, as required per facility policy, to identify risks and hazards related to falls. Review of the Comprehensive Care Plan (CCP) for R15 revealed the facility care planned the resident for falls, (with an initial date of 01/16/2024). Continued review revealed R15 was at high risk for falls due to her diagnoses of history of falls, history of left hip fracture, history of cerebrovascular accident, medication use, impaired cognition, and requiring total staff assistance to complete activities of daily living. Per review, the goal dated 05/09/2024, revealed R15 was to be protected from falls through the next review period with a target date of 11/19/2024. Further review of the falls care plan revealed 14 interventions in place which were undated. Further review of R15's care plan initiated on 01/16/2024, revealed the interventions referenced the call light being within the resident's reach twice. Record review revealed on 04/29/2024, R15 sustained a fall which resulted in a closed comminuted left humeral fracture. However, there was no documented evidence the facility investigated the incident to determine the root cause of the fall. Review of the facility's Incident Note with an effective date of 04/30/2024 at 7:08 PM for R15, documented by Registered Nurse (RN) 6, revealed she had been called into the resident's room by the 200-unit Supervisor and an (unidentified) Certified Nursing Assistant (CNA) informed her R15's arm needed to be assessed. Per review, upon arrival to R15's room, RN 6 observed the resident lying on her back on the fall mat next to the bed. Continued review revealed R15 moaned and verbalized profanity when her arm was touched, with calming measures provided during the assessment. Further review revealed R15 had redness and swelling noted at the shoulder area which was warm to the touch, with a smaller discolored area noted to the inner shoulder area. Review further revealed R15 was noted to have redness without swelling above and inside the antecubital area. In addition, review revealed an order was obtained to transfer R15 to the local ED for further evaluation, and the resident was transferred to the hospital. Review of R15's Health Status Note with an effective date of 04/30/2024 at 9:50 PM (created as a late entry note), documented by RN 1, revealed on 04/29/2024 at 10:00 PM, he was approached by a CNA and was informed R15 was lying on the floor. Per review, RN1 documented Licensed Practical Nurse (LPN) 2 went to R15's room where the resident was lying on her back next to her bed on the fall mat. Continued review revealed staff assessed R15 head-to-toe for injury and none were found, and the resident was assisted back to bed. Further review revealed R15 had no complaints of pain or discomfort, and the bed was placed in the lowest position with the call bell within reach. Review of R15's hospital Nursing Assessment dated 04/30/2024, revealed the resident was assessed as: alert and disoriented to person, place, and time; cognitively impaired; combative; agitated and physically aggressive. Continued review revealed the skin to R15's left upper extremity was assessed as bruised and swollen. Further review revealed R15 got her arm tangled up in bed sheets and had a spiral humeral fracture (a bone break occurring from a twisting injury) which was comminuted (a bone broken into three or more pieces) and displaced. RN1 stated in interview, on 08/26/2024 at 3:06 PM, the night R15 fell (04/29/2024) a CNA (he could not recall which CNA) informed him and LPN2 the resident had sustained a fall. He stated LPN 2 assessed R15 for him and informed him the resident had no injuries and no pain and seemed alright. RN1 stated when he passed R15's at 6:00 AM on 04/30/2024, he did not notice anything out of the ordinary with the resident. He stated he was the nurse assigned to R15 that evening (04/29/2024) and had not been aware of any injury to the resident until the next day when he returned to work. The RN stated due to poor communication between himself and LPN2 they failed to notify R15's doctor, and responsible party (RP). He further stated they also failed to document R15's fall in the progress notes, fill out an incident form, and notify the oncoming shift of the resident's fall. Review of the facility's Long-Term Care Facility-Self-Reported Incident Form, completed by the Administrator, revealed that R15 had been sent to the hospital for bruising and swelling of the left upper extremity on 04/30/2024 at 1:00 PM. Continued review revealed the hospital x-ray identified a fracture of the resident's left humerus. Per review, the injury was reported to the Department of Community Based Services (DCBS) on 04/30/2024 at 3:43 PM, as an injury of unknown origin. Further review revealed the cause of the injury was not identified until 04/30/2024, when the midnight shift staff arrived and reported R15 had sustained a fall on 04/29/2024 at 10:00 PM. In addition, the Administrator noted due to miscommunication between RN1 and LPN2 they failed to: complete the incident report; failed to notify the Medical Director and resident's Guardian; and failed to report the fall to the oncoming shift. Review of the facility's, Interdisciplinary Meeting dated 05/02/2024, labeled as the Root Cause Analysis (RCA) for R15, revealed no documented evidence of the root cause of the resident's fall. Per review, it was noted R15 required a shower on 04/29/2024 after a bowel movement for hygienic reasons between 7:30 PM to 8:30 PM. Continued review revealed the Interdisciplinary Team (IDT) addressed R15's preference for morning showers and that the resident became more agitated as the day progressed. However, further review revealed no documentation of any behaviors by R15 that preceded the fall. Additional review revealed R15's CCP was to be updated to show her morning (AM) shower preference and that her bed should be in the lowest position with no side rails. Observation of R15 on 09/26/2024 at 8:56 AM, revealed the resident lying on her bed with the call light placed on the recliner out of the resident's reach. At the time of observation, R15 stated she was looking for the white thing wrapped in tape that made people come. An additional observation of R15 on 09/26/2024 at 7:05 PM, revealed R15 lying on her bed with the call light out of the resident's reach in the recliner. In interview with the Quality Nurse/Staff Development Coordinator/Infection Prevention Nurse (QN/SDC/IP), on 08/29/2024 at 1:00 PM, she stated it was the facility's expectation for all falls to be reported to the on-call Supervisor, the resident's representative, and the Nurse Practitioner (NP). In interview on 08/30/2024 at 8:49 AM, the Director of Nursing (DON) stated RN1 and LPN2 should have clarified who was going to complete the fall investigation and notification to the provider and the resident's responsible party. She stated the two nurses thought the other one had reported the fall to the (medical) provider and the resident's representative. Per the DON's interview, it was the facility's policy and expectation for all resident falls to be reported to the NP, resident's representative, and the supervisor, and for an incident report to be completed. She further stated LPN2 and RN1 were re-educated on notifying the provider and the resident's responsible party, as well as completing the necessary documentation after a resident's fall. In interview on 08/30/2024 at 10:00 AM, the Administrator stated it was the facility's policy and expectation for all resident falls to have an incident report completed. In interview on 08/30/2024 at 11:18 AM, the NP stated she was in the facility five days a week to assess residents for acute issues or complaints, and post falls. She stated she was (first) notified of R15's fall on 04/30/2024 when she arrived at the facility. The NP further stated when any resident fell, the (medical) provider on call should be notified immediately. In interview on 09/26/2024 at 9:18 AM, RN7 stated call lights should be placed within a resident's reach to ensure the resident could make their needs known to staff. The RN stated that prevented a resident from attempting a task alone that could lead to an injury. 3. Review of the facility's, admission Record for R111 revealed the facility admitted the resident on 01/22/2024, with diagnoses including unspecified fracture of the left acetabulum (hip), unspecified dementia, muscle weakness, and lack of coordination. Review of the facility's Quarterly MDS with an ARD of 04/30/2024 for R111, revealed the facility assessed the resident to have a BIMS score of five, which indicated the resident had severe cognitive impairment. Continued review of the MDS revealed the facility also assessed R111 to have had two or more falls since the previous assessment and was dependent on maximum staff assistance with ambulation, transfers, toileting, and dressing. Review of the facility's Fall Risk assessment dated [DATE] for R111, revealed a score of 15 which indicated the resident was a high fall risk. Continued review of the Assessment revealed the facility also assessed R111: to have intermittent confusion with one to two falls in the past three months; as ambulatory; to have incontinence; and to require the use of an assistive device. Review of the facility's Fall Risk Assessment for R111 dated 03/30/2024, revealed the document was marked incomplete and the resident's risks and hazards related to falls were not identified. Per record review, prior to the 03/30/2024 Fall Risk Assessment, R111 had sustained four falls: one on 03/11/2024, which resulted in a knot on the back of the resident's head; one on 03/14/2024, which resulted in no injury; and two falls on 03/16/2024 with no injuries. Review of the facility's CCP initiated on 01/23/2024, revealed the facility care planned R111 as at risk for falls related to a history of falls, impaired cognition, decreased physical mobility, incontinent of bowel and bladder, and history of fractures. Per review, the goal was for R111 to be protected from falls through the next review date of 05/09/2024. Continued review revealed interventions that included a pommel cushion (a specialized cushion to promote proper positioning), dycem (a non-slip material), and anti-tippers to R111's wheelchair; and side rails up; bolsters to the bed with the bed in the lowest position; fall mats in place beside the bed; and green tape to the call light which was to be within reach. Further review revealed R111's interventions were not resident-centered and the dates the interventions were initiated did not correlate with the falls the resident sustained in the facility. Review of the facility's document titled, Incidents by Incident Type, dated 02/28/2024 through 08/28/2024, revealed R111 sustained two witnessed falls and 14 unwitnessed falls for a total of 16 falls during that time period. Review of the facility incident reports (FIRs) dated 03/11/2024, 03/14/2024, 03/16/2024, 04/14/2024, 04/26/2024, 04/30/2024, 05/28/2024, 05/09/2024, 05/12/2024, 05/19/2024, 05/23/2024, 06/09/2024, revealed R111 sustained falls without serious injury while in the facility. Further review revealed no evidence the facility determined the root cause of the resident's falls or developed individualized care plan interventions for R111 to prevent additional falls/injury to the resident. Review of the facility's FIR dated 06/14/2024, revealed R111 had sustained an unwitnessed fall in her room. Further review revealed R111 was screaming and saying her hip was killing her. Additional review revealed R111 was sent to the emergency room (ER) for evaluation. Review of the facility's, Health Status Note for R111 dated 06/14/2024 at 7:05 AM, revealed the resident screamed every time she tried to move her hip and the resident's right foot had an outward rotation. Continued review revealed R111 was observed holding the front area of her hip screaming with pain. Per review, the Physician on call was made aware of R111's pain with new orders received to send the resident to the ED for evaluation of her right hip and leg. EMS was notified to transport R111 to the ED for evaluation and report was given to the ED. Review of R111's hospital Discharge Summary dated 06/21/2024, revealed the resident had an readmission date of 06/14/2024 for a right hip fracture with an open reduction and internal fixation repair on 06/16/2024. Continued review revealed R111 was cleared for discharge back to the facility with weight bearing as tolerated to her right lower extremity and dressing changes as ordered. Additional review of R111's CCP revealed there was no documented evidence the facility determined the cause of the resident's fall on 06/14/2024 and no evidence of new interventions implemented to prevent falls for the resident. Review of the FIRs dated 07/26/2024 and 08/17/2024, revealed R111 had sustained additional unwitnessed falls in the facility. Further review revealed there was no documented evidence the facility determined the cause of R111's falls or implemented individualized care plan interventions to prevent further falls for the resident. Observation of R111 on 08/26/2024 at 1:35 PM and on 08/27/2024 at 10:00 AM, revealed the resident sitting up in a wheelchair. Observations of R111 on 09/25/2024 at 12:34 PM; 09/26/2024 at 9:00 AM; and on 09/27/2024 at 8:50 AM However, further observation revealed no pommel cushion was observed in R111's wheelchair. Observation of R111 on 09/30/2024 at 8:45 AM, revealed the resident lying on the bed with family at bedside. Further observation revealed dycem in R111's wheelchair, but no pommel cushion was on the wheelchair seat. In interview on 09/25/2024 at 12:34 PM with R111, revealed she knew she had fallen and broken her hip, but could not remember when she had fallen. R111 stated she had learned' her lesson and knew to ask for help before getting up out of the wheelchair. In interview with Family Member (FM) 5 on 09/26/2024 at 12:33 PM, she stated she was aware of R111's issue with falling as the resident had fallen at home and that's why we brought her here. FM 5 stated R111 had fallen at home and fractured her pelvis and left hip before coming to the nursing facility. She stated she was not sure about the facility staffing being an issue, but stated she had seen fewer staff members on weekends compared to staff on the weekdays. The FM further stated she was aware call lights took longer to be answered by staff on the weekends. In interview with Clinical Coordinator (CC) 1 on 09/26/2024 at 3:12 PM, she stated she had been the CC for about nine months and was aware R111 had sustained multiple falls. CC1 stated scheduled toileting, call light within reach, and bed in lowest position were routine interventions for all residents, so those interventions would not be considered individualized. She stated most of R111's interventions were not effective as the resident had multiple falls and looking back now, she saw the same interventions being put in place with no real evaluation of the effectiveness of those interventions. CC1 stated the incident reports were changed after the State Survey Agency (SSA) Surveyors left the facility the last time as we realized you can't prevent future falls if you don't know what happened before. CC1 also stated performing the root cause analysis for all falls was not put in place by the facility until September 2024. 4. Review of R27's admission record revealed the facility admitted the resident on 06/21/2016, with diagnoses that included a history of falls prior to admission, spondylosis without myelopathy of lumbar spinal region, generalized muscle weakness, difficulty in walking, and osteoarthritis. Review of the facility's Fall Risk Assessments for R27 dated 02/02/2024 at 3:20 PM, and 03/11/2024 at 1:32 PM, revealed the facility assessed the resident as a high risk for falls. Review of the Quarterly MDS Assessment with an ARD of 06/11/2024 for R27, revealed the facility assessed the resident as having a BIMS score of 11 out of 15, which indicated moderate cognitive impairment. Continued review of the MDS assessment specific to behaviors revealed R27 had a history of rummaging. Per review, the facility assessed R27 to require supervision/touching assist with chair/bed to chair (wheelchair) transfer, and toileting related to incontinence of bowel and bladder; and moderate assist with shower/bathing care. In addition, review of the MDS fall history assessment for R27, since admission, revealed one fall with no injury. However, review of the facility's fall incident reports revealed R27 sustained a total of three falls from admission through the assessment date of 06/11/2024. Review of R27's CCP revealed on 03/13/2024 staff identified the resident as at high risk for injury related to falls. Review of R27's care plan, revealed the care plan was not fully developed with individualized, resident specific interventions to prevent reoccurrence of the multiple falls the resident encountered related to self-transfers and falling out of bed. In addition, there was no documented evidence an RCA had been performed in order to evaluate if interventions were implemented prior to a fall or reviewed/revised after a fall. Review of the facility's Fall Incident Reports, dated 03/25/2024,05/25/2024, 06/01/2024, and 06/23/2024 revealed the resident sustained falls in the facility without serious injuries. However, review further revealed no documented evidence the facility thoroughly investigated the falls to determine the root cause of R27's falls, nor that individualized care plan interventions were developed/implemented to prevent further falls for the resident. Review of the Provider Progress Note dated 08/02/2024 at 9:59 AM for R27, revealed the resident had sustained a fall from the bed on 07/31/2024, with complaints of right leg/hip pain with movement. Review of the facility's Health Status Note dated 08/02/2024 at 1:20 PM for R27, revealed the resident complaining of pain in the right hip. Continued review revealed the Physician was made aware with a new order for x-ray of R27's right hip and leg. Review of the Express Mobile Diagnostic Services x-ray report dated 08/02/2024 at 5:28 PM, revealed R 27 had an impacted sub-capital femoral neck fracture (a type of hip fracture that occurs at the junction of the femoral head and neck). Review of the Emergency to Hospital-admission Discharge Summary dated 08/08/2024 for R27, revealed the resident presented initially with a fall from the skilled nursing facility with a right femoral neck fracture. Per review of the Summary, Orthopedic Surgery was consulted and after discussion with the surgery team and family a decision was made to manage the fracture nonoperatively with weight bearing as tolerated and pain control PRN (as needed). Review of R27's CCP Risk for Falls with an initiated date of 06/12/2024, revealed a revised fall intervention (hand-written) dated 07/31/2024, to have the bed in the lowest position. Continued review revealed there were no additional newly documented fall interventions initiated for R27 after the fall with a hip fracture on 07/31/2024. Per review, there were no new interventions related to R27's hospital discharge recommendations, dated 08/08/2024, in regards to R27's decline in mental status, and Activities of Daily Living (ADL) function or change in assistance requirement. Furthermore, there was no documented evidence an updated fall risk assessment was completed after R27's fall with fracture. During interview with R27 on 09/25/2024 at 12:40 PM, she stated the only problem she had was that the aides just took their time, no hurry getting to you. R27 stated she could use the call light, but the aides would only come when they wanted too, so she would took herself to the bathroom. She stated she could recall a little about her falls. R27 stated, [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for the management of falls for five of ten sampled residents, (Residents (R)10, R15, R93, R111, and R274). Review of the facility's document titled, Incidents by Incident Type, dated 02/28/2024 through 08/28/2024 revealed the facility noted 44 witnessed falls and 302 unwitnessed falls for a total of 346 fall during that six month time period. Further review revealed 42 of the 346 falls had an injury noted. However, the facility's administration failed to evaluate the falls through Root Cause Analysis (RCA) to determine the cause of the falls in order to review/revise the residents' comprehensive care plans with interventions to assist in prevention of further falls or to prevent further injuries from falls. Refer to F689 and F657. The findings include: Review of the facility's, Job Description-Administrator, on page four (4) under the Miscellaneous Section revealed the Administrator was to assure all residents received care in a manner and an environment that maintained or enhanced their quality of life. Continued review revealed the Administrator would also serve on the Quality Assurance and Assessment Committee as directed. Further review revealed the Administrator additionally was to assure each resident received the necessary nursing, medical and psycho-social services to attain and maintain the highest possible mental and physical functional status as defined by their comprehensive assessment and care p On 02/23/2024, R10 sustained a fall which resulted in a fractured left femur and subsequent surgery to replace the femoral head with a prosthesis on 02/25/2024. From 04/25/2024 through 08/20/2024, R10 sustained 19 more falls with no documented evidence the facility investigated to determine the root cause of the falls. On 04/30/2024, R15 sustained a fall which resulted in a closed comminuted (a bone breaking in pieces) left humeral fracture with no documented evidence a root cause analysis was conducted for the fall. On 06/24/2024, R111 sustained a fall which resulted in a fracture of the right hip. From 03/11/2024 through 08/17/2024, R111 experienced a total of sixteen (16) falls with no documented evidence the facility determined the root cause of the falls. On 07/09/2024, R274 was diagnosed with a fracture of the left humerus with no documented evidence a root cause analysis was conducted to determine the cause of the injury. R93 sustained 18 falls from 06/06/2024 through 8/25/2024, with no documented evidence root cause analysis was conducted for the falls. In interview on 08/29/2024 at 2:50 PM with Licensed Practical Nurse (LPN) 1 she stated she had worked at the facility for eight years and usually worked on the 200 unit. LPN1 stated she felt the facility's nursing staff and leadership could not identify the missing link that would solve the falls problem. In interview on 08/29/2024 at 3:31 PM with LPN 4 she stated she had worked at the facility for a year and a half. LPN 4 stated she thought there were four to five falls a day at the facility; however, she did not think that (number) was alarming. In interview on 08/30/2024 at 9:30 AM with the MDS Nurse, he stated he had been in his role since May/2024. He stated he was not sure of the number of facility falls for the past six months. The MDS Nurse further stated he would have to find out who the person responsible for tracking and trending of the falls. In interview on 08/29/2024 at 1:00 PM with the Quality Nurse/Staff Development Coordinator/Infection Prevention Nurse (QN/SDC/IP) she stated she attended the facility's QAPI meetings and quarterly met with the team and falls were addressed (at those meetings). The QN/SDC/IP stated she did not know how many resident falls had occurred in the facility in the past six months. Per the QN/SDC/IP, the Administrator did the tracking and trending of falls. In interview on 08/30/2024 at 11:18 AM with the NP, she stated she had worked at the facility for almost two years, and was in the facility five days a week. Per the NP, she was notified of a resident's fall if it happened during her on call week, which was once every six weeks. She stated she attended the facility's IDT meetings, but was not a part of any discussion on falls. She stated she had never been in an IDT where repeated falls for residents was discussed. She stated she had never been invited to a discussion about falls. In interview on 08/29/2024 at 4:40 PM with the DON, she stated she had been in her role for two and a half years. She stated the fall incident report was completed by the nurse caring for the resident at the time of the fall. Per the DON, the incident report included the fall details, possible cause, and an immediate intervention. She stated the incident report was reviewed by the CCs and all falls were discussed every morning in the morning meeting. The DON further stated the tracking and trending of falls was completed by the Administrator. In interview on 08/30/2024 at 3:23 PM with the Medical Director, he stated he had been the facility's Medical Director for about eight years. He stated he was in the facility routinely at least once a month. Per the Medical Director, he was provided a report in the facility's QAPI meetings for (residents') falls. The Medical Director stated in general, the NP had a better idea of what to do for individual residents because she knew them better. In interview on 08/29/2024 at 12:45 PM with the Administrator, she stated she was responsible for the tracking and trending of falls based on the reports she pulled from the facility's electronic charting system where the incident reports were entered by staff after a resident's fall. The Administrator stated the (falls) analysis included: the resident; time of the fall; area of the fall; what the resident was doing; intervention placed; and any injury. She stated the facility had a Performance Improvement Plan (PIP) in process (currently) for falls; however, she gave no date of initiation of the PIP. According to the Administrator, she knew there were a large number of residents' falls in the facility in May/2024. However, she stated the facility did not begin investigating each resident's fall to determine the cause of the fall until August/2024 (after the State Survey Agency (SSA) identified the problem) Review of the facility's QAPI documentation on 09/25/2024 revealed the facility had not began reviewing residents' falls until August/2024.

Based on observation, interview, record review, review of the facility's fall report documentation and Quality Assurance Performance Improvement (QAPI) Policy, the facility failed to maintain an effective, comprehensive, data driven QAPI program which focused on criteria for outcomes and quality of life related to falls for 8 of 10 sampled residents, (Residents (R)10, R15, R27, R57, R75, R93, R111, and R274. Review of the facility's Incidents by Incident Type, documentation dated 02/28/2024 through 08/28/2024, revealed the facility had a total of 346 resident falls during that six-month timeframe. Review of the facility's QAPI documentation however, revealed no documented evidence the facility brought the issue of multiple residents' falls to the QAPI Committee prior to August 2024. The facility's QAPI program failed to develop and implement plans with corrective actions, such as performing RCA, in order to decrease the number of residents' falls and any additional fall related injuries of the residents. Refer to F689 and F657. The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Policy, revised on 03/2019, revealed its governing body and administration, in the interest of providing high quality resident care, were to support and maintain an effective facility wide QAPI program. Per policy review, the professional and administrative staff were to monitor and evaluate the appropriateness of resident care and clinical performance of the resident care staff. Continued review revealed the Administrator was responsible for the establishment and maintenance of the facility's QAPI program with input from professional and ancillary staff of the facility as necessary. Review of the policy revealed the QAPI program was to include administration, resident assessment, and comprehensive resident care planning. Per policy review, through QAPI monitoring and the (QAPI) Committee review there was to be review of incidents, accidents and unusual occurrences. Policy review revealed the QAPI Committee was to prioritize topics for Performance Improvement Plans (PIPs) based on the current needs of the facility. Further review additionally revealed the PIP team was to carry out the action plan in an attempt to prevent future events and promote sustained improvements through identifying RCA as possible. In addition, policy review revealed the QAPI Committee was to meet quarterly to review continuous quality improvement (CQI) activities, recommend action to address concerns, and follow up on the status of all recommendations. Review of the facility's document titled, Key Personnel and QA Committee, revealed the members of the team included: the Administrator, Director of Nursing (DON), Clinical Coordinators (CCs), the Minimum Data Set (MDS) Coordinators, the Infection Preventionist (IP)/Staff Development Coordinator (SDC), the Activity Director (AD), the Director of Social Services (DSS), the Maintenance Director (Maint), the Dietary Manager (DM), the Housekeeping Director (HD), Accounts Receivable (AR), Medical Records (MR), the Nursing Secretary (NS) and the Medical Director (MD). Review of the facility's document for falls titled, Incidents by Incident Type, dated 02/28/2024 through 08/28/2024, revealed the facility had a total of 346 falls during that six-month timeframe, 302 unwitnessed falls and 44 witnessed falls. Record review revealed the facility's analysis of the fall incidences by month detailed: 44 falls in 03/2024; 36 falls in 04/2024; 91 falls in 05/2024; 50 falls in 06/2024; 71 falls in 07/2024; and 45 falls that occurred from 08/01/2024 through 08/28/2024. However, further review of the facility's documents revealed the facility's Administration failed to provide documentation of the facility investigating each resident's falls and performing RCA to identify the root cause of the large number of falls. Additionally, the facility's Administration failed to provide documented evidence of the development and implementation of interventions to prevent or reduce further resident falls and injury. On 02/23/2024, R10 sustained a fall which resulted in a fractured left femur and subsequent surgery to replace the femoral head with a prosthesis on 02/25/2024. R10 sustained 19 more falls, from 04/25/2024 through 08/20/2024, with no documented evidence the facility investigated the falls and performed root cause analysis (RCA) to determine the root cause of the falls. On 04/30/2024, R15 sustained a fall which resulted in a closed comminuted (a bone breaking in pieces) left humeral fracture with no documented evidence RCA was conducted for the fall. From 03/11/2024 through 08/17/2024, R111 experienced a total of 16 falls with no documented evidence the facility determined the root cause of the falls. On 06/24/2024, R111 sustained a fall which resulted in a fracture of the right hip. On 07/09/2024, R274 was diagnosed with a fracture of the left humerus with no documented evidence RCA was conducted to determine the cause of the injury. R93 sustained 18 falls from 06/06/2024 through 8/25/2024, with no documented evidence RCA was conducted of the falls. Review of the facility's QAPI documentation on 09/25/2024 revealed the facility began reviewing residents' falls in August 2024. Further review revealed no documented evidence the facility brought the issue of multiple residents' falls to the QAPI Committee prior to August 2024. In interview with the 100 Unit Clinical Coordinator (CC) on 08/29/2024 at 3:58 PM, she stated nurses were responsible for completing the Fall Incident Reports and she reviewed the Reports and then sent them to the DON. The CC stated she did not know what the DON did with the Fall Incident Reports from there. She further stated the Administrator tracked and trended residents' falls. An interview with the Minimum Data Set (MDS) Nurse 1 on 08/30/2024 at 9:30 AM, revealed the facility's fall incidents were no different than anywhere else and he did not feel like there were a lot of falls at the facility. The MDS Nurse stated he was not sure of the number of residents' falls that had occurred over the last six months and was not sure who was responsible for monitoring interventions to ensure they were effective. He stated he was aware of one resident who had been placed on 1:1 supervision and now had decreased falls as a result. The MDS Nurse stated he was not aware who had the responsibility for tracking and trending of residents' falls. In interview with the Quality Nurse/Staff Development Coordinator/Infection Preventionist (QN/SDC/IP) on 08/29/2024 at 1:00 PM, she stated she was present at the QAPI (Committee) meetings. She stated she also met with the team where they discussed falls but, she did not know the number of falls occurring (in the past six months). The QN/SDC/IP further stated tracking and trending of residents' falls was done by the Administrator. In interview on 08/29/2024 at 4:40 PM, with the DON, she stated the Fall Incident Report was completed by the nurse caring for the resident who sustained a fall. She stated the Incident Report included the fall details, the possible cause, and an immediate intervention to implement. The DON stated the Incident Report was reviewed by the CCs and all resident falls were discussed every day in the morning meetings. She stated the tracking and trending of falls was completed by the Administrator. Per the DON, she reviewed the falls, the documentation, and fall interventions for appropriateness and effectiveness with the Interdisciplinary Team (IDT). The DON stated the facility just did not have the staff to provide 1:1 supervision for residents because staffing was difficult to secure. In interview with the Administrator on 08/29/2024 at 12:45 PM, she stated she had the responsibility of tracking and trending residents' falls. The Administrator stated her tracking and trending of falls was based on the reports she pulled from Point Click Care (PCC), the facility's electronic charting system) where staff entered the Incident Reports related to falls. She stated falls analysis incorporated the following information: the resident sustaining the fall; time of the fall and what the resident had been doing at the time of fall; area of the fall; any injury; and any intervention(s) put in place. Per the Administrator, all residents sustaining falls were discussed in the daily clinical meetings and the CCs and the Therapy Director (TD) were included in those meeting in order to work on developing interventions for those residents. She further stated the facility had a Performance Improvement Plan (PIP) in place for all the falls; however, she did not include the date the PIP was initiated. In another interview on 08/30/2024 at 10:00 AM, the Administrator stated the big picture (for the facility's falls) was falls were being reviewed broadly before, but now staff met and discussed falls during the daily and weekly meetings. She stated she was aware there were a large number of falls in the facility in May 2024; however, the facility did not begin investigating each resident fall to determine the cause of the fall until August 2024, after the State Survey Agency (SSA) identified the problem. During an interview with the Nurse Consultant and Administrator on 08/30/2024 at 10:35 AM, the QAPI information on tracking and trending of falls for 05/2024, 06/2024 and 07/2024 was provided. Review of the facility's QAPI documentation provided titled, Falls Track and Trend for May/2024, June/2024 and July/2024 revealed it comprised: the residents' names and room numbers; and the date, time and location of the fall. Continued review revealed the documentation also noted what immediate action was taken, whether a fall was witnessed or unwitnessed, and any predisposing environmental or physiological factors. However, further review revealed no documented evidence a RCA was included for the resident falls on the Falls Track and Trend for May/2024, June/2024 and July/2024 documentation. An interview with the Nurse Practitioner (NP) on 08/30/2024 at 11:18 AM, revealed she was notified of a resident's fall if it happened during her on call week which was once every six weeks. She stated she saw the residents for post fall assessments and attended the facility's IDT meetings; however, she was not a part of any fall's discussion. The NP stated the IDT meeting topics varied; however, there had been no discussion of resident falls in the meetings (she attended). She stated repeated resident falls were discussed in the facility's QAPI meetings, where the Medical Director was part of residents' falls discussion. The NP further stated she had never been invited to any meetings where (residents') falls were discussed. In interview with the Medical Director on 08/30/2024 at 3:23 PM, he stated routinely he was in the facility at least once a month. He stated he attended the QAPI (Committee) meetings and was given a report of residents' falls in those meetings that were provided by the Nursing Department. The Administrator stated the report he received included what resident or staff education needed to be done, and what care plan interventions needed to change for the (involved) resident. He further stated the NP had a better idea of what individual residents needed as she knew the residents better. In additional, he stated he expected reporting of falls and documentation to be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #59's medical record revealed the facility admitted the resident on 02/27/17 with diagnoses including Muscle Weakness, Lack of Coordination, Dementia, and Chronic Obstructive Pulmonary Disease. A review of Resident #59's MDS assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of five (5). Further review of the MDS revealed the facility assessed the resident to require extensive assistance from staff with personal care and grooming. A review of Resident #59's plan of care dated 05/15/19 revealed the resident was to have nail care weekly and as needed. Review of Resident #59's daily SRNA assignment sheet revealed documentation that staff had performed nail care for the resident on 06/23/19. However, observations of Resident #59 on 06/25/19 at 10:29 AM and 12:31 PM, and on 06/27/19 at 2:29 PM revealed the resident's fingernails were long with a large amount of brown-colored substance underneath all the nails. Interview with SRNA #12 on 06/27/19 at 2:59 PM revealed she had cared for Resident #59 on 06/26/19 and 06/27/19. The SRNA stated she was responsible to review the resident's [NAME] at the beginning of the shift and prior to providing care. Although the SRNA stated she had signed the resident assignment sheet indicating she had completed all required care, the SRNA stated she had failed to check Resident #59's fingernails to ensure they were clean and trimmed on 06/26/19 and 06/27/19. 4. Review of Resident #85's medical record revealed the facility admitted the resident on 12/28/17 with diagnoses including Contractures and Lack of Coordination. Review of Resident #85's MDS assessment dated [DATE] revealed the facility assessed the resident to be severely cognitively impaired. Further review of the resident's MDS revealed the resident was totally dependent on staff for all activities of daily living. Review of Resident #85's Comprehensive Care Plan dated 05/13/19 revealed the resident was to have bilateral hand rolls in place, but did not specify a specific timeframe for the hand rolls to be utilized. Observations of Resident #85 on 06/25/19 at 9:34 AM, on 06/26/19 at 8:31 AM and 1:12 PM, and on 06/27/19 at 10:40 AM, revealed the resident only had a rolled washcloth present in the right hand, and not bilaterally as directed on the resident's plan of care. Interview with SRNA #10 on 06/27/19 at 1:28 PM revealed she was aware that Resident #85 was to have bilateral hand rolls, and stated she had just noticed the hand roll was missing from the resident's left hand. SRNA #10 stated she had just failed to ensure the hand rolls were present bilaterally as required. Interview with the Unit Manager for Resident #59 and Resident #85's unit on 06/27/19 at 2:43 PM revealed SRNAs were responsible to review each resident's [NAME] prior to caring for the resident at the beginning of each shift to ensure they were knowledgeable of the care each resident required. The Unit Manager stated it was the facility's expectation that staff would follow each resident's plan of care and if the resident refused care or if it could not be provided as directed the nurse would be notified. The Unit Manager stated that nail care was to be performed by the SRNAs unless the resident was a diabetic or it was otherwise noted in the resident's plan of care. LPN #5 observed Resident #59's fingernails on 06/29/19 at 2:43 PM, and agreed it appeared staff had not recently performed nail care for the resident. Further interview with the Unit Manager revealed the SRNA should have been monitoring Resident #85 to ensure the resident's hand rolls were in place as required. In addition, the Unit Manager stated if the SRNA caring for the resident signs the resident's assignment sheet, this indicated all care required to be performed had been completed. However, the Unit Manager was unable to state why staff had not completed Resident #59's nail care and ensured that both of Resident #85's hand rolls were in place as indicated on each of the residents' care plan. Interview with the DON on 06/28/19 at 11:09 AM revealed SRNAs were expected to make rounds with the offgoing shift and review each resident's [NAME] to ensure they were knowledgeable of the resident's care needs. The DON stated she made rounds daily to ensure staff were following resident care plans. The DON acknowledged that the SRNA and nurses assigned to care for Resident #59 and Resident #85 should have made sure that the residents were provided the care they had been assessed to require. 2. Review of Resident #70's medical record revealed the facility admitted the resident on 05/08/19 with diagnoses including Right Traumatic Ankle Fracture, Dislocation of the Right Shoulder, and Muscle Weakness. A review of Resident #70's MDS assessment dated [DATE] revealed the facility had assessed the resident to be cognitively impaired with a Brief Interview for Mental Status (BIMS) score of three (3) and to require total assistance of two (2) staff members for turning and repositioning. A review of Resident #70's plan of care dated 05/21/19 revealed the resident was at risk for falls related to a fall at home that resulted in the right traumatic ankle fracture and dislocation of the right shoulder, which the resident had on admission. Interventions initiated by the facility to prevent further injury to the resident included the utilization of two (2) staff members for bed mobility. Observation of Registered Nurse (RN) #1 conducting a skin assessment of Resident #70 on 06/27/19 at 1:40 PM revealed the resident had a cast to the right lower extremity and a sling to the right arm. In addition, during the skin assessment RN #1 was observed to turn and reposition the resident alone without assistance from another staff member. Interview with RN #1 conducted on 06/27/19 at 3:57 PM, revealed the RN stated she did not routinely provide care to Resident #70 and had not reviewed the resident's plan of care prior to providing care to the resident on 06/27/19. RN #1 stated she was not aware the resident required two (2) staff members for bed mobility. Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure the Comprehensive Care Plan was implemented for four (4) of thirty-one (31) sampled residents (Residents #59, #70, #85, and Resident #105). The facility assessed and care planned Resident #105 and Resident #70 to require the assistance of two or more staff members with bed mobility. However, on 05/26/19, at approximately 1:30 PM, SRNA #3 attempted to reposition Resident #105 in bed without another staff member present. As a result, the resident sustained a fall from the bed and fractures to the left ankle. The facility had also assessed Resident #70 to require two staff members for turning and repositioning; however, on 06/27/19, Registered Nurse (RN) #1 was observed to turn and reposition the resident without another staff member present. In addition, the facility assessed Resident #59 to require extensive assistance with personal care and grooming. However, observations on 06/25/19 and 06/27/19, revealed the resident's fingernails were long with a brown substance noted to be present under the nails. Review of Resident #85's Comprehensive Care Plan revealed the resident was to utilize bilateral hand rolls. However, observations of Resident #85 on 06/25/19, 06/26/19, and 06/27/19, revealed the resident only had the hand roll present to the right hand, and not bilaterally as required. The findings include: Review of the facility's Care Plan Policy and Protocol, revised September 2017, revealed the facility would develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the resident's comprehensive assessment. The policy further stated that a [NAME] (nursing assistant care plan) would be utilized as a guide for Nursing Assistants to provide care to the resident on a daily basis. 1. Review of Resident #105's medical record revealed the facility admitted the resident on 12/12/12. The resident's diagnoses included Diabetes Mellitus, Persistent Vegetative State, Tracheostomy, and Contractures of the Upper and Lower Extremities. Review of Resident #105's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and the resident was communicative. The facility also assessed the resident to require the assistance of two (2) or more staff members for bed mobility. Review of Resident #105's Comprehensive Care Plan, initiated on 10/11/17, revealed the facility identified the resident to be at risk for falls related to a history of falls, impaired cognitive status, and being dependent on staff for all transfers. Interventions initiated included notifying the physician if a fall occurred. Review of Resident #105's [NAME] revealed the resident was totally dependent on staff for care needs and required the assistance of two (2) staff members for bed mobility. Review of a facility Investigation Summary, dated 06/07/19, revealed the facility discovered on 05/31/19, that the resident had been diagnosed with fractures of the left ankle, which were of unknown origin to the facility. Subsequently, the facility initiated an investigation and determined that SRNA #3 had attempted to provide care and reposition the resident by herself on 05/26/19, resulting in the resident sustaining a fall from bed. Interview with SRNA #3 on 06/19/19 at 12:25 PM revealed on 05/26/19 she was caring for Resident #105 and was attempting to clean the resident after tube feeding had leaked out onto the resident and the resident's bed. SRNA #3 stated she was aware that resident #105 required two staff members for bed mobility; however, the SRNA stated she was unable to find any staff to assist her, so she decided to provide the care by herself. The SRNA stated she knew to follow the resident's plan of care, which dictated that two (2) staff members were required for repositioning the resident. The SRNA stated as she was rolling the resident toward her, the resident's lower half fell onto the floor, and she was able to lower the resident's upper half onto the floor also. SRNA #3 stated she obtained the assistance of Licensed Practical Nurse (LPN) #4 and LPN #11 to get the resident off the floor and back into bed. According to the SRNA, LPN #4 assessed the resident and found no injuries other than a red area to the resident's back. Interview with LPN #4 on 06/19/19 at 4:05 PM and 06/26/19 at 5:18 PM revealed she acknowledged that SRNA #3 had reported Resident #105's fall to her and she assessed the resident; the LPN denied helping SRNA #3 place the resident back into bed. LPN #4 also stated the only area found on the resident during the assessment was a red area to the back. However, the LPN failed to document the incident in Resident #105's medical record, failed to complete an incident report, and failed to notify other staff or administration that the resident had sustained the fall. In addition, the LPN took no further action related to SRNA #3 failing to follow the resident's care plan. Review of hospital x-ray results for Resident #105, dated 05/31/19, revealed the resident had an oblique (diagonal break) mildly comminuted (splintering of the bone) and laterally angulated (displaced) fracture through the distal fibula toward the head of the ankle joint, comminuted and distally displaced fracture at the base of the medial malleolus (end of shin bone) and an oblique minimally displaced fracture of the posterior malleolus (inner side of the ankle at the end of the tibia). An observation of Resident #105 on 06/28/19 at 10:40 AM, revealed the resident made no attempt to communicate, and was contracted in all four extremities including both hands being contracted shut and the lower extremities being contracted into a fetal position. Further observation revealed the resident had a splint in place to the left ankle. Interview with the Clinical Coordinator for Resident #105's unit, on 06/20/19 at 2:50 PM, revealed instructions on the [NAME] were to be utilized by the SRNAs to provide care to each resident. The Clinical Coordinator stated she and another supervisor were working the unit that day due to call-ins. However, The Clinical Coordinator stated SRNA #3 did not ask them for help. Interview with the Director of Nursing (DON) on 06/26/19 at 4:07 PM and 06/28/19 at 12:46 PM revealed the [NAME] was developed from information utilizing the resident's MDS assessment. The DON stated staff were in-serviced quarterly on following each resident's individualized plan of care. The DON stated she and nursing staff monitor care by conducting rounds every two (2) hours and observing care to include ensuring staff are using the appropriate amount of assistance during care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure one (1) of thirty-one (31) sampled residents received quality care based on the comprehensive assessment of the resident and the resident's comprehensive person-centered care plan. On 05/28/19, staff assessed Resident #105's left foot to be red, swollen, and hot to touch. Although staff notified the resident's physician on 05/28/19 and an order for a Doppler ultrasound of the left foot and the initiation of an antibiotic was obtained, staff failed to follow up on the ordered ultrasound results and failed to monitor the resident's left foot/ankle. In addition, there was no documented assessment of the resident or the resident's left ankle area until 05/31/19, despite interviews with staff, including the LPN caring for the resident who stated purple discoloration was present to the area on 05/29/19 and 05/30/19. On 05/31/19, an x-ray of Resident #105's left ankle revealed fractures of the left distal fibula (bone in the lower leg) and malleolus (bony prominence on each side of the ankle). Furthermore, after the facility initiated an investigation into the resident's left ankle fracture, it was discovered the resident had sustained a fall from bed on 05/26/19, while State Registered Nursing Assistant (SRNA) #3 was providing care to the resident in absence of additional staff, which the resident had been assessed to require. However, although SRNA #3, Licensed Practical Nurse (LPN) #4, and LPN #11 knew the resident had fallen out of bed on 05/26/19, none of the staff reported the fall to other facility staff including administrative staff, they failed to complete an incident report, and failed to document the fall, until after the resident had been diagnosed with the fractures, five (5) days after sustaining the fall. The findings include: Review of the facility's Notification of Change in Resident's Status policy, not dated, revealed staff would notify the attending physician or their alternate, along with the resident's representative when any change in a resident's condition occurred. However, the policy did not address staff providing ongoing monitoring or follow-up with the resident after the change in condition. Interviews on 06/26/19, at 9:45 AM with the Clinical Coordinator for Unit 100, at 10:45 AM with the Clinical Coordinator for Unit 200, at 10:54 AM with the Staff Development Coordinator, and at 4:07 PM with the Director of Nursing (DON) revealed that although the facility's policy did not address ongoing monitoring after a change in a resident's condition, the facility had an established procedure for staff to follow. All the staff interviewed stated that after a resident had experienced a change in condition, the physician was notified and nursing staff were to document the change of condition in the resident's medical record and inform oncoming staff of the resident's condition at shift change. In addition, nursing staff were required to assess and document on the resident's change in condition at a minimum once every shift until the problem/condition was resolved. Review of Resident #105's medical record revealed the facility admitted the resident on 12/12/12, with diagnoses including Diabetes Mellitus, Persistent Vegetative State, Tracheostomy, and Contractures of the Upper and Lower Extremities. Review of Resident #105's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the facility was unable to conduct a Brief Interview for Mental Status (BIMS) score assessment, due to the resident's severely impaired cognitive status. Further review of the resident's MDS revealed the facility assessed the resident to have no behaviors and to require extensive assistance with all activities of daily living. The facility assessment determined that the resident needed at least two (2) staff members for bed mobility. Resident #105 was also non-ambulatory, had limitations in both upper and lower extremities, was non-mobile, and was not transferred out of bed. In addition, the resident's weight was 181 pounds. Observation of Resident #105 on 06/28/19 at 10:40 AM during a skin assessment revealed the resident had contractures to all four extremities. The resident's hands were in a closed position with rolled washcloths placed in each hand and the resident's knees were contracted into a fetal position. The resident did not respond during the skin assessment nor did the resident respond to verbal communication. The resident was also observed to have a tracheostomy (an opening in the neck into the windpipe) and tube feeding infusing. Review of Resident #105's [NAME] (nurse aide care plan), not dated, revealed the resident was dependent on staff for care and required the assistance of two (2) staff members for bed mobility. Review of Resident #105's nursing notes dated 05/28/19 at 12:00 PM, revealed Registered Nurse (RN) #8 contacted the resident's physician related to the resident's left foot being red, swollen, and hot to touch. Interview with RN #8 on 06/21/19 at 10:58 AM, revealed she called the MD regarding the resident's left lower leg/ankle having a swollen reddish-purplish bruise approximately eight (8) inches in length. RN #8 stated she informed the oncoming nurse of the resident's ankle area, and that the resident's temperature was elevated. Further review of Resident #105's nursing notes dated 05/28/19 at 12:00 PM revealed the physician ordered Resident #105 to have a Venous Doppler Ultrasound (diagnostic test to check circulation) to rule out a blood clot in the left lower extremity and for antibiotic therapy to be initiated for suspected cellulitis. Review of the diagnostic results revealed the Venous Doppler was completed by the contract company on 05/28/19. However, there was no further assessment or documentation made related to the resident's left lower extremity until 05/31/19 (three days later), when a nursing note was made related to contacting the diagnostic contract company who had completed Resident #105's Venous Doppler Ultrasound on 05/28/19, to obtain the results of the test. Interview with The Unit Manager for Resident #105's unit on 06/20/19 at 2:50 PM and on 06/26/19 at 9:45 AM, revealed that although the result of the Venous Doppler was faxed to the facility on [DATE] at 8:44 PM, the results were negative for a blood clot. Therefore, the LPN stated because the result was ok, she took no further action regarding the Doppler results or Resident #105's left lower extremity. The LPN stated it was her responsibility to ensure the results got to the nurse caring for the resident, who in turn was to notify the resident's physician. However, there was no evidence found to indicate the Doppler results were reported to the resident's physician until 05/31/19. Review of a nursing note dated 05/31/19 revealed the facility contacted the diagnostic contract company and was informed the result of the Doppler test on Resident #105's lower extremity was negative for a blood clot. Further review of the nursing documentation revealed Resident #105's physician was notified of the Doppler results and an order was received for the resident to have an x-ray of the left lower extremity. Review of the nurse's note dated 05/31/19 at 9:50 AM revealed the diagnostic contract company came to the facility and obtained an x-ray of Resident #105's left lower extremity. Review of the x-ray results from the diagnostic contract company dated 05/31/19 revealed marked flexed contractures and an acute distal fibular fracture. Review of the nurse's notes dated 05/31/19 revealed Resident #105's physician was notified of the x-ray results and new orders were received to send the resident to the hospital for further evaluation and treatment. Review of hospital x-ray results for Resident #105, dated 05/31/19, revealed the resident had an oblique (diagonal break) mildly comminuted (splintering of the bone) and laterally angulated (displaced) fracture through the distal fibula toward the head of the ankle joint, comminuted and distally displaced fracture at the base of the medial malleolus (end of shin bone), and an oblique minimally displaced fracture of the posterior malleolus (inner side of the ankle at the end of the tibia). Review of a facility investigation initiated on 05/31/19, revealed on 05/31/19 the facility was notified that Resident #105 had been diagnosed with fractures of the left ankle, which were of unknown origin. Further review revealed the facility initiated an investigation. Review of the facility's investigation summary dated 06/07/19, revealed that through the facility's investigation, it was determined that on 05/26/19, during day shift (exact time unknown) State Registered Nursing Assistant (SRNA) #3 had had been providing care to Resident #105 without assistance from another staff member and subsequently, Resident #105 fell from the bed during care. Continued review of the investigation summary revealed Licensed Practical Nurse (LPN) #4, who was caring for Resident #105 on 05/26/19, had been aware that the resident had fallen out of bed while SRNA #3 had been providing care to the resident without another staff member present. However, LPN #4 failed to report the incident to any other staff including supervisory staff of the facility. Review of Resident #105's medical record and nursing notes dated 05/26/19, revealed no documentation of the resident's fall from the bed on 05/26/19, and no evidence that an incident report was completed. Interview with SRNA #3 on 06/19/19 at 12:25 PM and on 06/25/19 at 10:00 AM revealed on 05/26/19 while repositioning Resident #105 in bed, SRNA #3 attempted to provide the care by herself because she could not find another staff member to assist her. She stated she was aware the resident required two (2) staff members for bed mobility. The SRNA stated the resident's bottom half slipped out of the bed. The SRNA stated after the resident's bottom half slipped out of bed, she helped the rest of (his/her) body on down in the floor. SRNA #3 stated she reported the incident to LPN #4 and LPN #11, who according to SRNA #3, both assisted her in placing Resident #105 back into bed. Continued interview with SRNA #3 revealed while caring for Resident #105 again on 05/29/19, she noticed the resident's left foot was swollen and black and blue in color. The SRNA stated she immediately reported the resident's swollen and discolored foot to LPN #4. Interview with LPN #4 on 06/19/19 at 4:05 PM and on 06/26/19 at 5:18 PM, revealed she had been working on 05/26/19 when SRNA #3 came to get her related to Resident #105. LPN #4 stated SRNA #3 told her about the resident falling onto the floor while repositioning the resident in bed by herself. However, LPN #4 denied assisting CNA #3 to place the resident back into bed, stating when she arrived at the room the resident was already back in bed. LPN #4 stated she performed an assessment of the resident and the only injury she observed was a red area to the resident's back around the shoulder area. LPN #4 stated she did not report the fall to any other staff or the resident's physician and did not document the fall or complete an incident report. The LPN also stated that although she knew SRNA #3 had not provided care according to the resident's assessed needs, she did not take any action related to the CNA or report the CNA's failure to provide appropriate care to Resident #105. LPN #4 stated she should have reported the incident and the CNA's actions, but failed to do so because she did not want to get SRNA #3 in trouble. Continued interview with LPN #4 on 06/19/19 at 4:05 PM and on 06/26/19 at 5:18 PM revealed she also cared for Resident #105 on 05/29/19 and assessed the resident after SRNA #3 reported the swelling and discoloration to the resident's left lower extremity. She stated the resident's ankle area was bruised, but she did not call the physician to report the bruising, did not report the bruising to other facility staff, or document the bruising and assessment of the resident's left ankle in the medical record. In addition, LPN #4 stated she also cared for Resident #105 on 05/30/19, and the resident's left ankle was deep purple in color. However, again LPN #4 stated she did not call the physician to report the bruising, did not report the bruising to other facility staff, or document the bruising and assessment of the resident's left ankle in the medical record. In addition, LPN #4 stated she never considered that the bruising and discoloration to Resident #105's left lower extremity could have been related to the fall the resident sustained on 05/26/19, until 05/31/19, when she heard the resident's left ankle was fractured and she connected the injury with the fall. Further interview with LPN #4 revealed she stated in a perfect world she would have documented the assessments of the resident's left lower extremity she had made on 05/29/19 and 05/30/19, but stated, It was really busy. Interview with LPN #11 on 06/19/19 at 8:00 PM, revealed the LPN denied knowing anything about the resident's fall. Interview on 06/22/19 with SRNA #8 at 8:32 PM revealed she had cared for Resident #105 on 05/30/19 on night shift and had noted the resident's left lower extremity was swollen with purple bruising. SRNA #8 stated she reported the bruising/swelling to the nurse, and was told it had already been reported. Interview with SRNA #9 at 8:23 PM revealed she had cared for Resident #105 sometime at the end of May (could not recall exact date) and stated the resident's left foot/ankle was swollen with purple bruising. SRNA #9 stated she reported the ankle/foot to the nurse who said the swelling had already been reported. Interview with LPN #6 on 06/20/19 at 12:21 PM revealed she had cared for Resident #105 on 05/31/19 during day shift and had noted the resident's left leg/foot was swollen and purple in color. The LPN stated she thought the bruised area looked like an injury. The LPN stated she notified the DON who asked her to check on the Doppler results from the venous ultrasound performed on the resident's left lower extremity on 05/28/19 (three days earlier). LPN #6 stated she called the diagnostic contract company who informed her the Doppler results were negative for a blood clot, and she then reported the negative results to Resident #105's physician. Further interview with LPN #6 revealed at that time the physician gave an order for the resident to have an x-ray of the left lower extremity, which revealed the fracture to the resident's left ankle. LPN #6 stated the physician was notified of the x-ray results and the resident was transferred to the hospital. Interview with the Director of Nursing (DON) on 06/26/19 at 4:07 PM revealed on 05/31/19, an SRNA asked her to look at Resident #105's leg. The DON stated the resident's leg was discolored and purple. The DON stated she asked the nurse to call the contracted diagnostic company and obtain the Doppler results from the test performed on 05/28/19, and then notify the resident's physician. The DON stated once the facility became aware that the resident had a fractured left ankle, an investigation was initiated. According to the DON, SRNA #3, LPN #4, and LPN #11 were interviewed during the investigation but did not report the resident's fall on 05/26/19. However, the DON stated after hearing a rumor that the resident had fallen out of bed while being repositioned, the staff were interviewed again. The DON stated initially the staff denied having knowledge of a resident fall, until SRNA #3 finally told what happened. The DON stated SRNA #3, LPN #4, and LPN #11 were all terminated from employment at the facility due to the incident. Interview with the Administrator on 06/26/19 at 11:05 AM revealed the facility started an investigation on 05/31/19 due to the injury of unknown origin to Resident #105's ankle. The Administrator stated staff who had worked with Resident #105 were interviewed including SRNA #3, LPN #4, and LPN #11, and asked if they had observed any change in the resident's condition or left lower extremity, and none of the staff reported the fall. The Administrator stated the first time she or the DON became aware of a possible fall was after hearing about a rumor that SRNA #3 had provided care to the resident alone, and the resident had sustained a fall from bed. The Administrator stated after initially denying the incident, SRNA #3 eventually admitted what had occurred on 05/26/19, but stated LPN #4 continued to deny the allegation. However, the Administrator stated during the third interview with LPN #4, she acknowledged that she had been aware of Resident #105's fall on 05/26/19, although the LPN continued to deny assisting SRNA #3 to place the resident back into bed. Interview with Resident #105's physician on 06/20/19 at 4:55 PM revealed on 05/28/19, the facility notified her that the resident was running a fever and his/her left ankle was red and hot. The Physician stated that based on that assessment she suspected the resident had cellulitis and so she ordered antibiotics for the resident and a Doppler ultrasound to the left lower extremity to rule out a possible blood clot. However, she stated she did not receive the results of the Doppler ultrasound until three days later, on 05/31/19. The physician stated she was never informed that Resident #105 had any bruising to the left lower extremity until 05/31/19. The physician stated had she been notified of bruising to the area she would have immediately ordered further diagnostic testing, including obtaining an x-ray.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #70's medical record revealed the facility admitted the resident on 05/08/19 with diagnoses including Right Traumatic Ankle Fracture, Dislocation of the Right Shoulder, and Muscle Weakness. Further review of the resident's medical record revealed the resident had sustained the ankle and shoulder injury during a fall at home prior to admission. Review of Resident #70's Minimum Data Set assessment dated [DATE] revealed the resident was assessed to have impaired cognition with a Brief Interview for Mental Status score (BIMS) of three (3) and was non-ambulatory. In addition, the facility had assessed the resident to require total assistance of two staff members for bed mobility and positioning, and to require staff assistance for stability with transfers. Review of Resident #70's fall risk plan of care dated 05/21/19, revealed the resident required two (2) staff members for turning and repositioning. Observation of Resident #70 on 06/27/19 at 1:40 PM during a skin assessment performed by RN #1 revealed the resident had a cast to the right lower extremity and a sling to the right arm. Further observation revealed RN #1 turned and repositioned the resident in bed without assistance of another staff member, which the facility had assessed the resident to require. Interview with RN #1 on 06/27/19 at 3:57 PM, revealed the RN was not aware that Resident #70 required two staff members for turning and repositioning. RN #1 stated she did not usually take care of the resident and was not familiar with the resident's care needs. An interview with the DON on 06/28/19 at 12:47 PM revealed since RN #1 was not familiar with the resident, she should have reviewed the resident's record prior to caring for the resident. The DON stated the nurses were required to monitor staff to ensure resident care was being provided appropriately and safely. Therefore, the DON stated that since RN #1 was not familiar with the resident's care needs, she failed to provide the resident with safe care and would have been ineffective in monitoring the staff to ensure they provided appropriate safe care to residents. According to the DON she made rounds in the facility daily to monitor residents and staff to ensure the plan of care was followed and was not aware RN #1 had not utilized the correct number of staff to care for Resident #70 in order to protect the resident from accidents and injury. Based on observation, interview, record review, and review of facility policy, the facility failed to provide supervision to prevent accidents for two (2) of thirty-one (31) sampled residents (Resident #70 and Resident #105). On 05/26/19, State Registered Nurse Aide (SRNA) #3 was repositioning Resident #105 in bed without assistance from another staff member, which the facility had assessed the resident to require. Subsequently, on 05/31/19, five days later, Resident #105 was diagnosed with a fractured left ankle. In addition, observation on 06/27/19 revealed Registered Nurse (RN) #1 turned and repositioned Resident #70 in bed without assistance from another staff member, which the resident was assessed to require. The findings include: Review of the Incident Investigation Policy, not dated, revealed, It is the policy of the facility that a Resident Incident Report will be completed with any incident to track, trend, and determine possible cause and develop an intervention to prevent reoccurrence. The policy stated staff were to notify the supervisor of any incident, and the supervisor was to notify the Director of Nursing and/or Administrator if necessary. Review of the facility's Protocol for Turning and Repositioning, not dated, revealed residents were to be turned and repositioned at a minimum every two (2) hours or more frequently based upon their individualized plan of care. 1. Review of Resident #105's medical record revealed the facility admitted the resident on 12/12/12, with diagnoses including Diabetes Mellitus, Persistent Vegetative State, Tracheostomy, and Contractures of the Upper and Lower extremities. Review of Resident #105's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired, was non-verbal, unable to understand, non-mobile, and required extensive assistance of two plus staff members for bed mobility. Review of the [NAME] (care plan used by nursing assistants to care for residents) for the resident revealed the care needs the facility had assessed the resident to require were present, including the amount of assistance Resident #105 required for bed mobility. On 05/31/19, the facility discovered that Resident #105 had been diagnosed with an oblique (diagonal break) mildly comminuted (splintering of the bone) and laterally angulated (displaced) fracture through the distal fibula toward the head of the ankle joint, comminuted and distally displaced fracture at the base of the medial malleolus (end of shin bone), and an oblique minimally displaced fracture of the posterior malleolus (inner side of the ankle at the end of the tibia). The cause of the injuries to Resident #105 were unknown by the facility and therefore an investigation of the injury was initiated. Review of the facility's Investigation Summary dated 06/07/19 revealed during the investigation, the facility discovered that Resident #105 had fallen out of bed onto the floor on 05/26/19, while being repositioned by SRNA #3 without assistance from another staff member, which the facility had assessed the resident to require. Further review of the Investigation Summary revealed SRNA #3 stated she notified Licensed Practical Nurse (LPN) #4 and LPN #11 that the resident had fallen from bed while she was providing care without an additional staff member present, and both nurses assisted SRNA #3 in getting the resident up off the floor and back into bed. Although the summary revealed that LPN #4 acknowledged knowing the fall had occurred and assessing the resident for injury, both LPN #4 and LPN #11 denied assisting SRNA #3 to put the resident back into bed. In addition none of the staff reported the incident to other facility staff, including the Director of Nursing (DON) or Administrator. Interview with SRNA #3 on 06/19/19 at 12:25 PM revealed on 05/26/19 she was caring for Resident #105 and noticed the resident's tube feeding had leaked onto the resident and onto the bed. SRNA #3 stated she attempted to find help to change the resident because she was aware that the resident required two (2) staff members for bed mobility and positioning. However, the SRNA stated when she could not find any staff to help her, she decided to change the resident by herself. The SRNA stated she knew to follow the resident's [NAME], which stated the resident required the assistance of two (2) staff members for bed mobility and repositioning, but did not want to wait until assistance was available. The SRNA stated as she was turning the resident towards her, the resident's buttocks and feet came out of the bed onto the floor, and she was able to hold onto to the resident's upper half and lower it onto the floor. SRNA #3 stated she left the room to get LPN #4 and LPN #11, who helped her get the resident back into bed. SRNA #3 stated after the resident was back in bed, LPN #4 assessed the resident. Interview with LPN #4 on 06/19/19 at 4:05 PM and 06/26/19 at 5:18 PM revealed she had been caring for Resident #106 on 05/26/19 when SRNA #3 came and got her and LPN #11 stating come with me, it's (Resident #105). LPN #4 stated they started toward the resident's room, but LPN #11 was called away by another staff member. The LPN stated she and SRNA #3 proceeded to the resident's room. LPN #4 stated SRNA #3 told her that she had attempted to change/reposition Resident #105 by herself and that the resident had fallen out of bed, but according to LPN #4 the resident was back in bed when she entered the room. LPN #4 stated LPN #11 entered the room while SRNA #3 was telling her what happened. LPN #4 stated she assessed Resident #105, and only noted a red area to the resident's upper back. LPN #4 stated, I can't believe SRNA #3 attempted to reposition Resident #105 by herself, because the resident was difficult to position with two (2) staff members since he/she is so contracted. LPN #4 stated she did not document or report the incident, because she did not want to get SRNA #3 in trouble. Interview with LPN #11 on 06/19/19 at 8:00 PM revealed she had worked on 05/26/19 and SRNA #3 had asked her and LPN #4 to come to Resident #105's room, saying something was wrong with the resident. The LPN stated she started to go and was pulled away to help with another resident. LPN #11 stated when she arrived in the resident's room a few minutes later, LPN #4 asked her to look at a bruise on the resident's back. LPN #11 stated no one told her that the resident had fallen or that the resident had been in the floor. Observation of Resident #105 on 06/28/19 at 10:40 AM, revealed the resident was contracted in all four (4) extremities, with the resident's lower extremities contracted into the fetal position. The resident's left lower extremity had a splint in place. The resident made no attempt to communicate and did not appear to understand what was being said to him/her. Interview with the Director of Nursing (DON) on 06/26/19 at 4:07 PM and on 06/28/19 at 12:46 PM revealed staff were in-serviced/educated at least quarterly regarding following the resident care plan. The DON stated the Clinical Coordinators develop the [NAME] from the care plan directing the care the SRNAs provide for the residents. To ensure staff were following the care plan, nurses and administrative nurses were to do every two (2) hour rounds to observe repositioning and ensure appropriate care was provided. The DON stated if a problem was discovered, the resident was immediately cared for, then the actions of the staff were addressed. The DON stated SRNA #3, LPN #4, and LPN #11 were all terminated from employment at the facility. Interview with the Administrator on 06/26/19 at 11:05 AM revealed the usual number of staff were in place on 05/26/19, when Resident #105 sustained the fall. The Administrator stated there had been staff call-ins during SRNA #3's shift, but stated administrative staff had covered. The Administrator stated that after a fall or change in condition the resident should be assessed every shift for at least seventy-two (72) hours.