**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined the facility failed to implement the comprehensive care plan for one (1) of twenty-two (22) sampled residents, (Residents #18). Resident #18 was care planned to be up in wheelchair (w/c) with supervision; however, the facility failed ensure the resident was supervised when in wheelchair and the resident sustained a fall which resulted in a fracture to the resident's right femur and elbow which required surgical intervention. In addition, the resident was care planned for staff to establish a voiding pattern for the resident; however, further review of the record revealed there was no documented evidence staff attempted to determine the resident's voiding pattern. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, last revised December 2016, revealed the comprehensive, person centered care plan will describe services to be furnished to attain or maintain the resident's highest practicable physical, mental, psychosocial, and functional needs is developed and implemented for each resident. Assessments of the residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Record review revealed the facility admitted Resident #18 on 11/19/18 with diagnoses which included Unspecified Dementia Without Behavioral Disturbance, Age-Related Osteoporosis Without Current Pathological Fracture, Unspecified Atrial Fibrillation, Scoliosis, and History of Falling. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident 18's cognition was severely impaired with a Brief Interview of Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Review of the Comprehensive Care Plan revealed an intervention dated 02/07/19 for Resident #18 may be up in w/c while being supervised by staff. However, review of Resident #18's Interdisciplinary Post Fall Review revealed, on 04/16/19 at 3:15 PM, the resident was in w/c and in an attempt to ambulate, the resident had an unwitnessed fall and was found on the floor in front of the doorway to his/her room. The resident had no supervision at time of fall. Resident #18 was sent to the ER for evaluation and admitted for Fracture of Right Femur and Displaced Fracture of Right Ulna (right elbow) which required surgical intervention. Resident #18 was hospitalized [DATE] through 04/22/19. Review of Resident #18's Comprehensive Care Plan for Resident has Bladder and Bowel Incontinence, dated 02/21/19, revealed an interventions to establish voiding patterns and provide incontinence care every shift and whenever necessary (prn). However, further record review revealed there was no documented evidence the facility tried to establish a voiding pattern for the resident. Interview with the Unit Manager, on 05/10/19 at 2:30 PM, revealed the facility failed to record Resident #18's toileting pattern and staff were expected to implement the care plan. Interview with the Director of Nursing (DON), on 05/10/19 at 12:45 PM, revealed Resident #18 was not implemented on toileting schedule to establish voiding pattern due to his/her cognition and she expected staff to implement the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to update and revise the care plan for three (3) of twenty-two (22) sampled residents, related to falls, wound care, and incontinent care (Residents #18, #58, and #31). Resident #18 had a fall on 01/03/19 due to getting up without assistance and not calling for assistance as care planned; however, the facility failed to revise the care plan to address the resident getting up without assistance and not using call light. On 01/30/19, Resident #18 sustained another fall due to not using call light and getting up without assistance again which resulted in the resident sustaining a fracture of the left hip which required surgery. Resident #58 had a fall on 12/14/19 and 01/09/19, however, the facility failed to revise the care plan with appropriate interventions to address the root cause of the fall per facility policy. Resident #58 was getting up and ambulating with asking for assistance. Resident #31 was identified to have a pressure ulcer to the buttock on 05/07/19; however, the licensed staff failed to revise the care plan to address the care and treatment of the pressure ulcer. The findings included: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, last revised December 2016 revealed a comprehensive centered, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. Assessments of the residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the facility's policy titled, Falls Management Program Guidelines, dated 12/01/18, should a resident experience a fall, the attending nurse shall put interventions in place to reduce risk of repeat episode. The Interdisciplinary Team (IDT) should evaluate the appropriateness of the interventions. The resident care plan should be updated to reflect, any new or change in interventions. 1. Record review revealed the facility admitted Resident #18 on 11/19/18 with diagnoses which included Unspecified Dementia Without Behavioral Disturbance, Age-Related Osteoporosis Without Current Pathological Fracture, Unspecified Atrial Fibrillation, Scoliosis, and History of Falling. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/24/19, revealed the facility assessed Resident #18's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Review of the Resident #18 Interdisciplinary Post Fall Review revealed on 01/03/19 at 7:30 AM, Resident #18 had an unwitnessed fall in his/her room while getting dressed and sustained a laceration to back of the head. Resident #18 was sent to the emergency room (ER) and returned to the facility with sutures to the laceration. Review of Resident #18's Comprehensive Care Plan for Resident at Risk for Falls, dated 11/19/18, revealed an intervention dated 01/03/19 to keep resident's walker within reach to provide visual prompts; however, the intervention was not appropriate per facility policy as it did not address the root cause of the fall which was the resident getting up without supervision and not using the call light to call for assistance. Review of the Interdisciplinary Post Fall Review revealed on 01/30/19 at 8:30 PM, Resident #18 had been in the bed and was found on the floor by staff lying next to his/her bed due to the resident attempting to get up without assistance. The resident complained of hip pain and was sent to the ER for evaluation and treatment and admitted to the hospital due to a Left Femur Fracture which required surgical intervention. Interview with Licensed Practical Nurse (LPN) #2, on 05/09/19 at 5:00 PM, revealed Resident #18 had multiple falls since admission. LPN #2 stated the resident ambulated with a walker on admission; however, he/she had no safety awareness of his/her capabilities. She revealed Resident #18's falls were not witnessed by staff and the Interdisciplinary Team (IDT) was responsible to update the resident's care plan. 2. Record review revealed the facility admitted Resident #58 on 06/15/1916 with diagnoses which included Alzheimer's Disease, Muscle Wasting and Atrophy, Dysphagia, Unspecified lack of Coordination, Repeated Falls, Unsteadiness on Feet, Major Depressive Disorder, Anxiety Disorder and Dementia. Review of Quarterly Minimum Data Set (MDS) assessment, dated 04/12/19, revealed the facility assessed this resident's Brief Interview for Mental Status (BIMS) score as a five (5), which indicated this resident was not cognitively intact and not interviewable. Review of Facility Fall Incident Report revealed Resident #58 had a fall on 12/14/18 in which the resident was observed by staff ambulating in the hallway next to another resident's doorway before stumbling and falling hitting his/her head on the doorway. Review of the Comprehensive Care Plan dated 06/02/17 for falls revealed an intervention was put in place on 12/14/18 to encourage resident to allow staff to assist with mobility; however, the intervention was not appropriate per facility policy due to Resident #58 not being cognitively intact, impaired thought process, forgetful, confusion and short attention. Review of Interdisciplinary Post Fall Review revealed Resident #58 had a fall on 01/09/19 as staff found the resident on the floor in the dining room when another resident yelled out. Review of a Hospital Discharge summary, dated [DATE] revealed Resident #58 was diagnosed with a closed head injury as a result of the fall that occurred on 01/09/19. Further review of the Comprehensive Care Plan for falls dated 06/02/17 revealed an intervention was put in place to encourage resident to sit in common area when awake to provide increased supervision. However, the intervention was not appropriate as observation of the facility Common's area on multiple occasions on 05/09/10 and 05/10/19 revealed there were no staff present and the nurses' station did not face the common's area directly which created several blind spots that would prevent staff from having direct oversight of resident's in that area. Interview with Registered Nurse (RN) #1 on 05/10/19 at 10:05 AM, revealed Resident #58 sustained a fall on 01/09/19 when he/she attempted to get up from his/her wheelchair and ambulate in the dining room. RN #1 stated Resident #1 should have had increased supervision after the fall on 12/14/18. She revealed the resident should not have been in the independent dining room due to there being only one staff member to assist. Interview with the Unit Manager, on 05/10/19 at 2:30 PM, revealed care plan interventions were reviewed after each fall during the facility's morning meeting and interventions not appropriate were revised. She stated she was responsible to ensure interventions were added to Resident #18's care plan after each fall. Interview the Director of Nursing (DON), on 05/10/19 at 12:45 PM, revealed the nurse caring for residents after each fall was responsible to review and revise care plan interventions. She stated each fall was also reviewed in morning meeting by the IDT which consists of the DON, Assistant DON, Unit Manager, MDS Coordinator, and Therapy Director. She revealed Care Plan interventions were reviewed for the resident, and if decided interventions needed to be more specific for that resident, then revised at that time. 2. Record review the facility readmitted Resident #31 on 09/10/18 with diagnoses which included Vascular Dementia With Behavioral Disturbance, Diabetes Type ll, Mood Disorder With Depressive Features, and Disorder of the Skin and Subcutaneous Tissue, Unspecified. Review of the Quarterly MDS assessment, dated 03/11/19, revealed the facility assessed Resident #31 as cognitively intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS assessment revealed the facility assessed the resident at risk for developing pressure ulcer/injury. Observation during Resident #31's incontinent care on 05/09/19 at 10:25 AM, and interview with Certified Nurse Aide (CNA) #8, on 05/10/19 at 2:00 PM revealed the resident had a Stage II pressure ulcer to upper right buttock and it was identified on 05/07/19. However, review of Resident #31's Comprehensive Care Plan titled, Potential Impairment to Skin Integrity dated 05/24/18, revealed there was no documented evidence the care plan was revised to include the Stage II pressure ulcer and with interventions to address the care of the pressure ulcer. Interview with the Unit Manager (UM), on 05/10/19 at 2:30 PM, revealed she expected the nurse who identified pressure ulcer to review and revise the care plan with interventions to minimize potential of any further pressure ulcer and/or skin breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed the facility admitted Resident #58 on 06/15/16 with diagnoses which included Alzheimer's Disease, Muscle Wasting and Atrophy, Unspecified lack of Coordination, Repeated Falls, Unsteadiness on Feet, Anxiety Disorder, and Dementia. Review of Discharge MDS assessment dated [DATE] revealed the facility assessed Resident #58's cognition as severely Impaired with a BIMS score of five (5) which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident required supervision with transfers and and was able to ambulate independently with the use of a walker. There were no falls indicated for that review period. Review of the Comprehensive Care Plan for Falls Risk, dated 06/02/17, revealed Resident #58 was at risk for injury related to confusion, high risk medications, balance and cognitive deficit, a history of multiple falls, and at risk for future falls. Further review revealed interventions to encourage participation and plan diversional activities that are of resident's interest. Review of the ADL care plan revealed Resident #58 was care planned for assist of one (1) or two (2) staff for transfers. Further review of the Comprehensive Care Plan revealed Resident #58 was also care planned for impaired cognition, impaired thought process, forgetfulness, confusion and short attention span. Review of Interdisciplinary Post Fall Review revealed Resident #58 had a fall on 01/09/19 as staff found the resident on the floor in the dining room when another resident yelled out. Review of a Hospital Discharge summary, dated [DATE] revealed Resident #58 was diagnosed with a closed head injury as a result of the fall that occurred on 01/09/19. Further review of the Interdisciplinary Post Fall Review revealed there was no documented evidence the facility determined the root cause of the fall per facility policy. The facility put an intervention in place to encourage resident to sit in common area when awake to provide increased supervision. However, observation of the facility Common's area on multiple occasions on 05/09/10 and 05/10/19 revealed there were no staff present and the nurses' station did not face the common's area directly which created several blindspots that would prevent staff from having direct oversight of resident's in that area. Interview with Registered Nurse (RN) #1 on 05/10/19 at 10:05 AM, revealed Resident #58 was observed walking in the hallway on 12/14/18 with the assistance of a walker when he/she lost lost his/her balance and fell down hitting head. RN #1 stated Resident #58 sustained another fall on 01/09/19 when he/she attempted to get up from his/her wheelchair and ambulate in the dining room. RN #1 revealed another resident yelled out that Resident #58 was falling and staff ran towards Resident #58 but was unable to reach Resident #58 before he/she fell onto the ground hitting head. RN #1 stated Resident #1 should have had increased supervision after the fall on 12/14/18. She revealed the resident should not have been in the independent dining room due to there being only one staff member to assist than in the other dining room in which there are several staff members and one would have most likely been closer to resident to stop any unassisted transfers and most likely prevented the fall. Interview (Post Survey) with Unit Manager, on 06/14/19 at 10:50 AM, revealed following a resident's fall, a fall investigation begins, and the clinical staff member on call is notified. She stated the information is obtained post fall, and the attending nurse and clinical staff member collaborate to determine root cause of fall and interventions are put in place. She further revealed the attending nurses failed to initiate a Interdisciplinary Post Fall Review, Fall Risk Assessment, and document the root cause and interventions for each of Resident #18's falls as indicated per facility policy. Interview the Director of Nursing (DON), on 05/10/19 at 12:45 PM, revealed the nurse caring for Resident #18 at each fall was responsible to initiate a Fall Investigation, Fall Risk Assessment, and review and revise care plan interventions. She stated each fall is was reviewed in morning meeting by the IDT which consists of the DON, Assistant DON, Unit Manager, MDS Coordinator, and Therapy Director. She revealed Care Plan interventions were reviewed for the resident, and if decided interventions needed to be more specific for that resident, then revised at that time. The DON stated I would expect the nurses to assess for reason of fall, interventions to decrease fall, and revise interventions at that time. The DON stated she felt the interventions were appropriate for Resident #18 because the resident's cognition was moderately intact at the time. Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent avoidable accidents for two (2) of five (5) sampled residents who were reviewed for falls (Residents #18 and #58). Resident #18 was assessed and care planned at risk for falls on admission. Resident #18 sustained three (3) falls with major injuries on 01/03/19, 01/30/19 and 04/16/19 while in his/her bedroom; however, the facility failed to identify the resident was getting up without supervision and not using the call light to call for assistance and no interventions were put in place to address the resident getting up/ambulating without assistance per facility policy. In addition, the facility failed to conduct a post fall assessment after each fall per the facility policy. The resident sustained a fractured left hip from the 01/03/19 fall which required surgery and a fractured right femur (thigh) and displaced fracture of right ulna (right elbow) from the 04/16/19 fall, which required surgery. The findings included: Review of the facility's policy titled, Falls Management Program Guidelines, dated 12/01/18, revealed the facility strives to maintain a hazard free environment, mitigate fall risk factors, and implement preventive measures. The fall risk assessment is included as part of the admission, quarterly, and when a fall occurs. Identified risk factors should be evaluated for the contribution they may have to the resident's likelihood of falling. Care plan interventions should be implemented that address the resident's risk factors. Should a resident experience a fall, the attending nurse shall complete a fall assessment to include an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode, and a review by the Interdisciplinary Team (IDT) to evaluate thoroughness of the investigation and appropriateness of the interventions. The resident care plan should be updated to reflect, any new or change in interventions. Record review revealed the facility admitted Resident #18 on 11/19/18 with diagnoses which included Unspecified Dementia Without Behavioral Disturbance, Age-Related Osteoporosis Without Current Pathological Fracture, Unspecified Atrial Fibrillation, Scoliosis, and History of Falling. Review of the admission Fall Risk Assessment, dated 11/26/18, revealed Resident #18 scored seventy (70) on the assessment indicating he/she was at high risk for falls. Further review of the assessment revealed a score of forty-five (45) or greater, meant the resident was at high risk for falls. Review of Resident #18's admission MDS assessment, dated 11/26/18, revealed the facility assessed Resident #18's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of ten (10) which indicated the resident was interviewable. Further review of the MDS assessment revealed the resident required encouragement and supervision for transfer and ambulation. Review of Resident #18's Comprehensive Care Plan for Resident at Risk for Falls, related to history of falling and dementia, dated 11/19/18, revealed interventions to be sure call light was within reach and to encourage the resident to use it for assistance as needed. Review of the Resident #18 Interdisciplinary Post Fall Review revealed on 01/03/19 at 7:30 AM, Resident #18 had an unwitnessed fall in his/her room while getting dressed and sustained a laceration to back of the head. Resident #18 was sent to the emergency room (ER) and returned to the facility with sutures to the laceration. The facility determined the root cause of the fall was the resident lost his/her balance while standing without walker. However, further review revealed there was no documented evidence the facility identified the resident fell due to being up without supervision and failed to use the call light to call for assistance per assessment/care plan. Further review of the Comprehensive Care Plan revealed an intervention was put in place to keep resident's walker within reach to provide visual prompts; however, the intervention did not address the root cause of the fall per facility policy. In addition, the facility failed to complete a falls risk assessment after the fall per facility policy. Review of the Interdisciplinary Post Fall Review revealed on 01/30/19 at 8:30 PM, Resident #18 had been in the bed and was found on the floor by staff lying next to his/her bed with complaint of hip pain. The facility determined the root cause of the fall was the resident had poor recall and judgement; however, there was no documented evidence the facility identified the resident was attempting to transfer/ambulate without supervision or calling for assistance per assessment/care plan. In addition, further review of the record revealed there was no documented evidence a Fall Risk assessment was completed after the fall per facility policy. Resident #18 was sent to the ER for evaluation and treatment and admitted to the hospital due to a Left Femur Fracture which required surgical intervention. Resident #18 was in the hospital from [DATE] through 02/02/19. Further review revealed the IDT determined the resident would be reassessed upon reentry to facility. Review of the Comprehensive Care Plan revealed an intervention dated 02/07/19 (five (5) days after return from hospital) that resident may be up in wheelchair (w/c) while being supervised by staff. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/24/19, revealed the facility assessed Resident #18's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Further review of the Quarterly MDS revealed Resident #18 was totally dependent for bathing, required extensive assistance of one (1) person with bed mobility and hygiene, extensive assistance of two (2) with transfers, and ambulation did not occur. Review of Resident #18's Interdisciplinary Post Fall Review revealed, on 04/16/19 at 3:15 PM, Resident #18 was in w/c and in an attempt to ambulate, the resident had an unwitnessed fall and was found on the floor in front of the doorway to his/her room. Resident #18 was sent to the ER for evaluation and admitted for Fracture of Right Femur and Displaced Fracture of Right Ulna (right elbow) which required surgical intervention. Resident #18 was hospitalized [DATE] through 04/22/19. Further review of the record revealed there was no documented evidence a fall assessment was completed after the fall and there was no evidence the facility identified the resident was up in wheelchair without supervision at the time of the fall instead of with supervision per care plan. The IDT recommendations related to fall revealed was for Resident #18 to have a medication review and to move him/her in to room closer to nursing station; however, observations during facility survey (05/07/19 through 05/10/19) revealed the resident remained in the same room (8-B) he/she was in at the time of the fall. Interview with Resident #18's Daughter/Responsible Party, on 05/08/19 at 10:16 AM, revealed resident had several falls over past five (5) months while at the facility. She stated she chose to send the resident to the facility due to repeated falls at home because the resident failed to use his/her walker. She revealed due Resident #18's Dementia diagnosis and repeated falls she felt it was best for her parent to be in a supervised environment. She further stated her parent's falls in the facility had resulted in a laceration to head that required sutures, a fracture to left hip, and fractured right elbow and right hip on last fall. She further revealed she felt the falls caused a decline in resident's condition, in addition to the dementia. and she was not aware of anything the facility had done to keep the resident from falling. Interview with Certified Nursing Assistant (CNA) #1, on 05/09/19 at 11:35 AM, revealed Resident #18 was a fall risk however, he/she would forget to use his/her walker and fail to use the call light at times. She stated Resident #18's supervision was not increased related to frequent fall history and the resident failing to use walker and/or call light when needed. Interview with Licensed Practical Nurse (LPN) #2, on 05/09/19 at 5:00 PM, revealed Resident #18 had multiple falls since admission. LPN #2 stated the resident ambulated with a walker on admission; however, he/she had no safety awareness of his/her capabilities. She revealed Resident #18's falls were not witnessed by staff and she was unable to recall if a Fall Assessment was conducted with each fall and stated the IDT was responsible to update the resident's care plan.