**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, it was determined the facility failed to develop and implement the Comprehensive Care Plan for each resident to meet the resident's medical, and nursing needs that are identified in the comprehensive assessment for one (1) of thirty-three (33) sampled residents (Resident #95). Review of Resident #95's Comprehensive Care Plan (CCP), revised 07/17/19, revealed the resident was to use the walker whenever up and should not try to transfer or walk alone. According to the facility Gait Belt Policy, undated, staff was to use gait belts for residents that did not have a steady gait while ambulating or transferring; however, Resident #95's CCP was not developed with an intervention for use of the gait belt. On 07/23/19, State Registered Nurse Aide (SRNA) #2 did not implement Resident #95's CCP related to ensuring the resident utilized the walker, nor did she use the gait belt when she transferred the resident from the bed, then ambulated the resident to the bathroom. Upon entering the bathroom, the resident sustained a fall in front of the toilet. On 07/23/19 at approximately 12:10 PM, LPN #1 obtained a Physician's Order for an X-ray due to the resident continuing to complain of pain after administration of Tylenol (medication for pain relief), and after staff identified the resident was not crossing his/her legs as was the resident's usual routine. On 07/23/19 at approximately 2:15 PM, Resident #95 was transferred to the Hospital and admitted with a diagnosis of Closed Displaced Fracture of the Left Femoral Neck and underwent a Total Left Hip Arthroplasty. (Refer to F-689) The findings include: Review of the facility's Comprehensive Care Plan Policy, dated 01/10/18, revealed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment. Further review of the Policy, revealed specific resident problems would be addressed in the Care Plan, and information in the Care Plan was derived from resident assessments. Per Policy, all disciplines have access to the Care Plan. Interview with the Minimum Data Set (MDS) Nurse, on 10/11/19 at 11:06 AM, revealed the Resident Assessment Instrument Version 3.0 Manual, was used as a guide for developing and implementing the CCP. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of Resident #95's clinical record revealed the facility admitted the resident on 11/18/11, with diagnoses including, but not limited to Malaise, Difficulty in Walking, Heart Failure, Dementia, Type 2 Diabetes, and Anxiety. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 05/23/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (03) out of fifteen (15), revealing severe cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assistance (resident involved in activity and staff providing weight bearing support) of one (1) staff for bed mobility, transfers, toilet use and personal hygiene. Per the MDS Assessment, the resident was continent of bowel and frequently incontinent of bladder. Review of Resident #95's Comprehensive Care Plan (CCP), initiated 11/21/11 and revised revised 07/17/19, revealed the resident had the potential for falls related to history of falls, forgetfulness, medication use and balance falters without walker. The goal revealed the resident would be free of any fall related injuries. There were several interventions including assist the resident away from the table after meals; redirect if going into another resident's room; call light within reach and encourage use for assistance; remind resident to ask for assistance with transfers when feeling weak or tired or during the night; and remind resident as often as necessary to use the walker whenever up and not to transfer or walk alone. However, the Care Plan was not developed with a specific intervention to use a gait belt for transfers and ambulation. Interview with the Administrator, on 10/10/19, revealed the facility was unable to submit for review Resident #95's Nursing Assistant's [NAME] (Nurses Aide Care Plan) which was in affect on 07/23/19, as it was not a part of the permanent record. Review of Resident #95's Accident/Incident Report, signed on 07/23/19 at 6:01 PM, by LPN #1, revealed Resident #95 sustained a fall with injury on 07/23/19 at 7:30 AM, in the resident's bathroom. According to the Report, the resident was assisted out of bed by SRNA #2, who took the resident to the bathroom. Per the Report, the resident turned to sit on the toilet and sat on the floor in front of the toilet, and there was no equipment used during the event. Further review revealed there was no injury or deformity noted, Range of Motion (ROM) per usual, and positive pulses. The resident complained of leg pain and Tylenol was administered. Additional review of the Report, revealed the Physician and the responsible party was notified on 07/23/19 at 9:15 AM. Further, the resident was transferred to the emergency room (ER) on 07/23/19. Review of Resident #95's Hospital Discharge summary, dated [DATE], revealed the resident was admitted on [DATE], after sustaining a fall in the nursing home resulting in a Fracture of the Left Femoral Neck. Further review revealed the resident underwent a Total Left Hip Arthroplasty. According to the Summary, the resident tolerated the procedure and his/her post op course was without complications. Per the Summary, the resident was discharged to the nursing home and needed to follow up with Orthopedics. Instructions included WBAT (Weight Bearing As Tolerated) with post op hip precautions. Interview on 10/11/19 at 8:52 AM, with SRNA #2, revealed the SRNAs utilized the [NAME] (Nurse Aide Care Plan) as a reference for providing care to residents which included the type of assistance and assistive devices needed to transfer and ambulate a resident. Per interview, this [NAME] was on the I-PAD tablet computer. Per interview, she was assigned to Resident #95 on 07/23/19, and was aware the resident was care planned to require one (1) staff and the walker for transfers, toileting and ambulation. Further, she was aware she needed to use a gait belt to transfer and ambulate the resident as per facility policy. However, she stated on 07/23/19 at approximately 7:30 AM, she transferred the resident from bed and then ambulated the resident without a gait belt or walker to the bathroom, by holding both of the resident's hands while she (SRNA #2) walked backwards facing the resident. Additional interview revealed she did not follow the resident's CCP or [NAME] related to using a walker to transfer and ambulate the resident, even though the walker was in the resident's room. Further, she did not follow facility protocol related to using a gait belt for Resident #95 while transferring and ambulating the resident. Interview with Licensed Practical Nurse (LPN) #1, on 10/11/19 at 9:15 AM, revealed she was assigned to Resident #95 on 07/23/19, and was alerted by SRNA #2 about 7:30 AM, that the resident sustained a fall in the restroom. Per interview, she immediately entered Resident #95's restroom, and observed the resident was on the floor. She stated she assessed the resident to include checking his/her skin for any bruising, or swelling, and also assessed his/her range of motion (ROM). Per interview, she also obtained the resident's vital signs and assessed him/her for pain. She stated she did not identify the resident had sustained any injury and the resident did not complain of pain. Per interview, she assisted SRNA #2 with lifting the resident off the floor and onto the toilet. LPN #1 stated a little while later SRNA #2 alerted her the resident was complaining of left leg pain, and she administered Tylenol which was ordered as needed (PRN). Further, the resident continued to complain of pain and staff identified the resident was not crossing his/her legs as usual. She stated at approximately 12:00 PM, she notified the Physician and obtained an order for a Stat X-ray. Per interview, at approximately 2:00 PM, the Physician called and orders were received to transfer the resident to the hospital emergency room for evaluation. Additional interview with LPN #1, revealed SRNA #2 informed her she did not use the gait belt as per protocol, nor did she ensure the resident used the walker as per the CCP and [NAME], when she transferred the resident from the bed and ambulated the resident to the bathroom. Per interview, if SRNA #2 had implemented Resident #95's CCP related to ensuring the resident used the walker, and if the gait belt had been utilized, this fall with major injury may have been avoided. Interview with the Clinical Care Coordinator Nurse, on 10/11/19 at 12:10 PM revealed the SRNAs utilized the [NAME] (Nurse Aide Care Plans) per the I-Pad tablet computer, as a reference for providing care. Per interview, the [NAME] was created from the CCP and therefore included interventions related to technique and equipment needed for transfers and ambulation. She stated SRNA #2 did not implement the CCP or [NAME] related to ensuring Resident #95 used the walker, nor did she use the gait belt as per protocol, on 07/23/19. Per interview, the resident sustained a fall with major injury as a result. Interview with the Minimum Data Set (MDS) Nurse, on 10/11/19 at 11:06 AM, revealed he followed CMS guidelines and the RAI Manual when developing or revising Care Plans. Per interview, the SRNAs had access to the CCP and specific items rolled over to the [NAME] (Nurse Aide Care Plan) such as transfer technique and any adaptive equipment needed such as walkers. Per interview, the SRNAs used the CCP and the [NAME] as a guide for providing care to residents. He further stated gait belts were not care planned because staff was knowledgeable it was facility policy to use gait belts for any residents who had an unsteady gait. Additionally, he stated all staff should provide care as per the CCP to ensure the residents received necessary care to meet their needs and to ensure the residents' safety. Interview with the Director of Nursing (DON), on 10/11/19 at 1:45 PM, revealed it was her expectation standards of practice, regulations, and the facility's policy be maintained related to development and implementation of the care plan. She acknowledged Resident #95's CCP interventions related to ensuring the resident used a walker for transfer and ambulation should have been implemented on 07/23/19 in an attempt to prevent falls. Further, she acknowledged the CCP should be developed to include any special safety devices or adaptive equipment utilized for transfers and ambulation. Interview with Administrator, on 10/11/19 at 2:15 PM revealed she expected the facility's policies and regulations to be followed related to developing and implementing the CCP. Per interview, it was important to use the gait belt for assistance with transfers and ambulation as per facility protocol; however, she acknowledged Resident #95's CCP was not developed with this intervention. Further interview revealed Resident #95's CCP should have been implemented related to ensuring the resident used the walker on 07/23/19, in an attempt to prevent injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility Policies, it was determined the facility failed to ensure adequate supervision and assistive devices to prevent accidents for one (1) of ten (10) sampled residents reviewed for falls out of a total sample of thirty-three (33) residents (Resident #95). Resident #95 was assessed by the facility to require the extensive assist of one (1) staff for transfers, ambulation, and toileting per the Quarterly Minimum Data Set (MDS) Assessment, dated 05/23/19. According to the Comprehensive Care Plan, revised 07/17/19, the resident was to use the walker whenever up and should not try to transfer or walk alone. Per the facility Gait Belt Policy, undated, staff was to use gait belts with residents that did not have a steady gait while ambulating or transferring. However, on 07/23/19 at 7:30 AM, State Registered Nurse Aide (SRNA) #2 transferred the resident from the bed and ambulated the resident to the bathroom without a gait belt or the use of the walker. Instead, SRNA #2 walked backwards in front of the resident, while facing the resident, and holding both the resident's hands. Upon entry to the bathroom, the resident started to urinate and sustained a fall. After the fall, Resident #95 was assessed by Licensed Practical Nurse (LPN) #1 with no injuries noted, and LPN #1 and SRNA #2 manually transferred the resident from the floor to the toilet. Subsequently, after SRNA #2 provided incontinence care to the resident, she independently transferred the resident from the toilet to the wheelchair, and at that time the resident complained of pain in the left leg. SRNA #2 immediately informed LPN #1, who did not complete another assessment of the resident, but administered Tylenol (medication to relieve mild to moderate pain). At approximately 12:10 PM, LPN #1 obtained a Physician's Order for an X-ray after the resident further complained of pain and staff noticed the resident was not crossing his/her legs as usual. On 07/23/19 at approximately 2:15 PM, Resident #95 was transferred to the Hospital and admitted with a diagnosis of Closed Displaced Fracture of the Left Femoral Neck and underwent a Total Left Hip Arthroplasty. (Refer to F-656) The findings include: Review of the facility's Fall Management Policy, undated, revealed care and assistance will be provided to maintain the resident's highest practicable level of well-being, which includes minimizing the risk for falls. Further review revealed Individual resident needs for staff assistance and equipment during toileting, transfer, ambulation and all activities of daily living will be assessed and addressed as appropriate via the RAI (Resident Assessment Instrument) process to determine if residents are at risk (for falls) and implement interventions to minimize the risk for falls. Additionally, the Fall Committee will review each resident who had a fall as well as the interventions that are in place to minimize the risk of falls, and shall try to determine the root cause of the fall. Review of the facility's Gait Belt Policy, undated, revealed gait belts are to be used with residents that do not have a steady gait while ambulating or transferring for the purpose of safety. Review of the facility's Accidents/Incidents Policy, undated, revealed the facility would take necessary precautions to minimize the incidence of accidents and incidents involving residents, staff, and visitors. Review of Resident #95's medical record revealed the facility admitted the resident on 11/18/11, with diagnoses including, but not limited to Malaise, Difficulty in Walking, Heart Failure, Dementia, Type 2 Diabetes, and Anxiety. Review of the Observation Detail List Report, dated 04/02/19, under the section titled, Fall Risk, revealed the resident scored a thirteen (13) indicating the resident was at high risk for falls. The risk factors included: change in gait pattern when going through doorway; ambulatory but incontinent; medications; history of falls; and cognitive issues. Review of Resident #95's Quarterly Minimum Data Set (MDS) Assessment, dated 05/23/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (03) out of fifteen (15) revealing severe cognitive impairment. Continued review revealed the facility assessed the resident as requiring extensive assistance (resident involved in activity and staff providing weight bearing support) of one (1) staff for bed mobility, transfers, toilet use and personal hygiene. The facility further assessed the resident as continent of bowel and frequently incontinent of bladder. Review of the Comprehensive Care Plan, initiated 11/21/11, revised 07/17/19, revealed the resident had the potential for falls related to history of falls, forgetfulness, medication use and balance falters without walker. The goal stated the resident would be free of any fall related injuries. Interventions included assist the resident away from the table after meals; redirect if going into another resident's room; call light within reach and encourage use for assistance; remind resident to ask for assistance with transfers when feeling weak or tired or during the night; and remind resident as often as necessary to use the walker whenever up and not to transfer or walk alone. However, the Care Plan was not developed with a specific intervention to use a gait belt for transfers and ambulation. Interview with the Administrator, on 10/10/19, revealed the facility was unable to review or print Resident #95's Nursing Assistant's [NAME] (Nurse Aide Care Plan) which was in effect on 07/23/19, as it was not a part of the permanent record. Review of Resident #95's Progress Note, dated 07/23/19 at 7:30 AM, completed by LPN #1, revealed Resident #95 was taken to the bathroom by SRNA #2, and when the resident went to sit on the commode, he/she sat in the floor in front of the commode instead. Per the Note, the resident complained of pain in the left leg, and the leg was not bruised, or bleeding and there was no deformity. Further review revealed the resident was given Tylenol for pain, and the nurse would monitor the resident. Review of the subsequent Progress Notes, dated 07/23/19 at 12:10 PM, completed by LPN #1, revealed the resident continued to complain of pain in the left leg. Resident usually crossed his/her legs, but did not today. Per the Note, a message was sent to the on call Physician and an order was received to obtain an X-ray of the resident's left hip and pelvis. Resident's Daughter informed. Call placed to obtain an X-ray. Per the Note, Radiology was at the facility at 1:51 PM and performed an X-ray. Review of the Imaging Result Report, dated 07/23/19, revealed a Sub Capital Fracture of the Femoral Neck with Varus angulation and overriding. Pelvic ring intact. Impression: Sub Capital Fracture of the Left Femoral Neck. Review of the Progress Note, dated 07/23/19 at 2:01 PM, revealed a message was sent out to the Physician. Per the Progress Note, dated 07/23/19 at 2:15 PM, the resident was transferred to the hospital for evaluation and treatment related to the X-ray results. Review of Resident #95's Progress Note, dated 07/23/19 at 5:56 PM, completed by the Clinical Care Coordinator, revealed the fall that occurred on this date at 7:30 AM was reviewed. Staff present with resident were interviewed. Staff entered room to assist resident to bathroom and up for the day. Resident sat on the side of the bed, and staff assisted to ambulate by hand to the bathroom without difficulty. Resident began to turn to sit onto the commode and sat down on the floor in front of the toilet. Staff was unable to determine if the resident's leg gave out when the resident sat on the floor. X-ray obtained and resident sent to emergency room (ER) for evaluation. Spoke with ER at this time, and Orthopedics to evaluate in the AM (morning). Review of Resident #95's Accident/Incident Report, completed on 07/23/19 at 6:01 PM, by LPN #1, revealed Resident #95 sustained a fall with injury on 07/23/19 at 7:30 AM, in the resident's bathroom. Per the Report, the resident was assisted out of bed by SRNA #2, who took the resident to the bathroom. The resident turned to sit on the toilet and sat on the floor in front of the toilet. Further, there was no injury or deformity noted, Range of Motion (ROM) per usual, and positive pulses. Per the Report, the resident complained of leg pain and Tylenol was administered. Additional review of the Report, revealed there was no equipment used during the event. Further review of the Report, revealed the Physician and the responsible party were notified on 07/23/19 at 9:15 AM. Per the Report, the resident was sent to the emergency room (ER) on 07/23/19. This Report was not signed by the Director of Nursing (DON) or Administrator. Per the Accidents/Incident Post Fall Observation/Root Cause Analysis, completed 07/23/19 at 5:59 PM, by LPN #2, revealed the resident's usual ambulatory status was assist times one (1) as the resident displayed poor safety awareness and judgement and had a history of falls. According to the Report, the root cause was the resident turned to sit on the commode and sat on the floor. Further, the Plan of Care to prevent further falls would be re-evaluated when the resident returned from the hospital. This was not signed by the Director of Nursing (DON) or Administrator. Review of the Hospital Discharge summary, dated [DATE], revealed Resident #95 was admitted on [DATE], after sustaining a fall in the nursing home resulting in a Fracture of the Left Femoral Neck. Per the Summary, the resident underwent a Total Left Hip Arthroplasty, Further, the resident tolerated the procedure and his/her post op course was without complications. The resident was discharged to the nursing home and needed to follow up with Orthopedics. Continued review of the Summary, revealed instructions for WBAT (Weight Bearing As Tolerated) with post op hip precautions. Interview on 10/10/19 at 11:42 AM, with SRNA #2, revealed she used the [NAME], which was on the I-PAD tablet computer as a reference for providing care to residents which included the type of assistance and assistive devices needed to transfer and ambulate a resident. Per interview, her normal routine prior to Resident #95's fall on 07/23/19, was to assist the resident out of bed, and walk with the resident to the bathroom, and assist him/her with washing up. She stated she was aware the resident was to be transferred and ambulated with a gait belt and walker; however, on the morning of 07/23/19, she assisted the resident out of bed and walked with the resident to the bathroom by holding both the resident's hands while she (SRNA #2) walked backwards facing the resident. Per interview, she did not use the gait belt, nor did she ensure the resident was using the walker. Further, after the resident entered the bathroom, all of a sudden he/she started urinating and started to fall. Per interview, she tried to lower the resident to the floor; however, was unable to do so. Additional interview with SRNA #2, revealed she immediately went to get LPN #1, who took the resident's vital signs and checked his/her range of motion. Per interview, the resident had no complaints at that time. Further, interview revealed after LPN #1 assessed the resident, she and LPN #1 manually lifted the resident up and sat him/her on the toilet. Per interview, after she finished providing incontinence care, she transferred the resident independently from the toilet to the wheelchair and during the transfer, the resident said, Ouch and started complaining of left leg pain. Continued interview revealed she notified LPN #1 of the resident's complaints of pain, and the nurse did not assess the resident again, but did give the resident Tylenol. Per interview, she then pushed the resident in the wheelchair to the dining room for breakfast. Further interview with SRNA #2, revealed after breakfast she pushed the resident in his/her wheelchair into the television room as was the normal routine. She stated she noticed later on that day at approximately 12:00 PM, the resident was not crossing his/her legs as usual, and had further complaints of pain, and she reported this to LPN #1. She further stated LPN #1 called the Physician and received an order to obtain an X-ray. Per interview, after the X-ray was obtained, the resident was transferred to the hospital. SRNA #2 further stated she felt bad about the incident as she had not used the gait belt, nor was the resident using the walker when she was ambulating the resident, and the resident sustained a fall with major injury. Interview with Licensed Practical Nurse (LPN) #1, on 10/10/19 at 11:28 AM, and on 10/11/19 at 9:15 AM, revealed she was assigned to Resident #95 on 07/23/19. Per interview, on that date about 7:30 AM, SRNA #2 alerted her to come quickly to Resident #95's restroom because the resident had sustained a fall. LPN #1 stated she immediately entered the resident's restroom, assessed the resident, and obtained vitals. Per interview, the resident had no outward rotation, no shortening of the lower extremities, no bruising or swelling, and did not complaint of pain with her assessment. Additional interview with LPN #1, revealed a little later on the morning of 07/23/19, she was alerted by SRNA #2, the resident complained of left leg pain and she gave the resident Tylenol, but did not reassess the resident. Further, the resident complained of pain again that morning; however, she was waiting to see if the Tylenol was going to be effective. Per interview, at approximately 12:00 PM, staff noticed the resident was not crossing his/her legs as he/she normally did. She stated she then notified the Physician and obtained an order for a Stat X-ray. Per interview, at approximately 2:00 PM, the Physician called and orders were received to transfer the resident to the hospital for further evaluation. Continued interview with LPN #1, revealed SRNA #2 informed her she did not use the gait belt, nor did she ensure the resident used his/her walker on the morning of 07/23/19, when she assisted the resident to the bathroom. LPN #1 stated SRNA #2 informed her, she had ambulated the resident to the bathroom by holding the resident's hands. Per interview, the resident was care planned to use the walker for transfers and ambulation at the time of the fall. Further, it was facility protocol to ensure the gait belt was used for transfers and when ambulating residents so the resident's weight could be managed and distributed, and to help prevent injury to residents or staff. Additional interview revealed since the resident returned from the hospital, he/she was no longer ambulatory, but was up in the wheelchair a lot and wore Hip abductors twenty- four (24) hours a day. Observation of Resident #95, on 10/08/19 at 11:30 AM and 10/09/19 at 12:20 PM, revealed the resident was in the television room sitting in the wheelchair with Hip Abductors in place to the resident's knees. When the Surveyor attempted to interview the resident, he/she just smiled and looked around. Review of Resident #95's Progress Note, dated 07/26/19 at 2:44 PM, completed by the Clinical Care Coordinator, revealed the resident returned to the facility via wheelchair van, and the resident's Daughter was with the resident. Per the Note, the resident was Assist to transfer to bed Weight Bearing as Tolerated (WBAT). Skin assessment performed, and dry bandage to left lateral hip with twenty (20) staples present and edges well approximated. No discoloration noted with scant amount of red scabbing observed near the staples. Further review of the Note, revealed the Daughter stated the family had discussed the resident's overall condition and cognition decline and were considering changing the resident's code status. Will be in to visit on Monday 07/29/19, to revisit and possibly make changes on that date. Discussed Resident's medications upon return, verbalized understanding. Interview on 10/11/19 at 8:30 AM, with the Clinical Care Coordinator for the House Hold Unit 4, where Resident #95 resided, revealed prior to Resident #95's fall on 07/23/19, the resident could walk with a walker and one (1) staff, and a gait belt was to be used for transfer and ambulation. She further stated SRNA #2 did not use a gait belt, nor did she ensure the resident used the walker when transferring and ambulating the resident on 07/23/19. Per interview, it was facility protocol to use gait belts when transferring or ambulating residents because if a resident's balance was off, it was easier to stabilize the resident who was wearing a gait belt. Per interview, Resident #95 was no longer ambulatory. Review of the Physician Order Report, revealed Physician's Orders dated 07/27/19 for Physical Therapy Evaluation and treatment and continued treatment five (5) times a week for eight (8) weeks for therapeutic activities, gait training, Therapeutic exercises, manual therapy for diagnoses of difficulty walking and weakness status post left hip fracture. The order was discontinued on 08/16/19. Review of the Physician's Progress Note, dated 08/19/19 at 3:28 PM, revealed Resident #95's Daughter was at the resident's bedside. Per the Note, the resident had a progressive downhill course since his/her hospital stay with dementia symptoms, apathy, and reduced intake. Daughter feels resident would not wish to go through further hospitalizations, tests, etc. We agree to treat symptoms aggressively for comfort and dignity, change to comfort and palliative regimen. Interview with the Director of Nursing (DON), on 10/11/19 at 1:45 PM, revealed she did not work at the facility at the time of Resident #95's fall, as she just started at the facility in August 2019. Per interview, she expected the facility's policy and protocols, regulations and standards of practice to be maintained related to accidents/injuries and falls. She stated she also expected staff to provide necessary supervision and a safe environment to all residents. Per interview, it was her expectation for the gait belt to be placed on the residents requiring assistance and ensure necessary assistive devices were used related to transfers and ambulation. Interview with Administrator, on 10/11/19 at 2:15 PM revealed she expected regulations and facility policies to be followed in order to prevent accidents and injuries. Additionally, she expected the staff to use the gait belts on all residents unless contraindicated and to implement the residents' care plans regarding adaptive equipment. Per interview, the gait belt was a tool to assist with safe transfers and ambulation and if not used, a fall could occur. Per interview, all falls were discussed with the clinical team each morning and the clinical team made an attempt to identify the root cause of the falls. Per interview, from there appropriate interventions were discussed to prevent accidents/injuries or falls of the same nature. When questioned if administrative staff had reviewed this fall and had identified the root cause, she stated SRNA #2 should have used a gait belt and the walker when transferring and ambulating the resident, and acknowledged this root cause should have been documented on the Post Fall Observation/Root Cause Analysis form. Additional interview, revealed the interdisciplinary team had identified there was a recent increase in falls and a falls committee was created in August 2019 to meet twice a week. Per interview, the facility had also implemented a manager on duty for each shift to check on residents who were at high risk for falls to try to identify fall hazards and minimize falls.