Based on observation, interview, record review, and policy review, the facility failed to ensure, two of nine residents (R) reviewed for activities of daily living (ADLs) out of the total sample of 23 residents (R55 and R58) were provided restorative care and services to maintain their highest level of functioning resulting in a decline in function. In an interview with R55 she stated the facility cut its restorative care program in 2021. R55 and R58 declined in their ability to transfer, from being able to use a standing lift, in which they stood and participated in the transfer, to requiring the use of a Hoyer mechanical lift (lift designed to lift and transfer patients from one place to another) which was performed entirely by staff and without the residents' participation. The findings include: Review of the facility's policy titled, Restorative Nursing Programs, dated 02/01/2020, revealed It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Continued review revealed the Restorative nursing program referred to nursing interventions that promoted the resident's ability to adapt and adjust to living as independently and safely as possible. Further review revealed residents might receive restorative nursing services upon admission when not a candidate for specialized rehabilitation services, when restorative needs arise during the course of a longer-term stay, in conjunction with specialized rehabilitation therapy, or upon discharge from therapy. 1. Review of R55's undated Face Sheet located in the electronic medical record (EMR) under the Resident tab, revealed the facility admitted the resident on 07/15/2020, with diagnoses that included multiple sclerosis (MS), and contractures (a fixed tightening of muscle, tendons, ligaments, or skin) of the right and left ankles and left hand. Review of R55's Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 03/14/2024 of the EMR under the RAI (Resident Assessment Instrument) tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. Per the MDS review, the facility assessed the resident to be impaired in range of motion (ROM) to both sides on the lower extremities. Continued MDS review revealed the facility assessed R55 to require substantial/maximum assistance for upper body dressing and personal hygiene. Further review revealed the facility assessed R55 as dependent for dressing her lower extremities, for toileting, for rolling left and right, and for a bed to chair transfer. In addition, the facility also assessed R55 as using a motorized wheelchair for locomotion. Review of R55's Care Plan, dated 07/16/2020 and located in the EMR under the RAI tab, revealed the facility developed a problem for ADLs (Activities of Daily Living) functional status/rehabilitation potential. Continued review revealed the facility noted R55 had an ADL self-care performance deficit r/t (related to) activity intolerance, disease processes (MS), limited mobility, and musculoskeletal impairment. Per Care Plan review, the goal was, R55 will maintain some ability to assist with ADLs. Further review revealed the approaches (interventions) included: Mechanical lift (Hoyer) with two staff assistance for transfers dated 03/21/2022; bed mobility-requires extensive assist of one staff member, two to pull up dated 07/16/2020; encourage the resident to participate to the fullest extent possible with each interaction dated 07/16/2020. In addition, other approaches included: personal hygiene-requires extensive assist of one staff member dated 07/06/2020; PT (Physical Therapy/OT (Occupational Therapy) evaluation and treatment as per the medical doctor's orders dated 07/16/2020. During interview on 06/11/2024 at 10:08 AM, R55 stated she had MS and experienced a relapse with a decline in her physical abilities. She stated she received therapy and had been doing well initially, and when she came off therapy services, she received restorative nursing care which helped her to maintain her abilities. R55 stated however, the facility cut the restorative program in 2021 and although she received several rounds of therapy since then, when she discharged from therapy services she had not received restorative services to help her maintain her abilities after the restorative program was discontinued. The resident stated she previously used a standing frame as part of her restorative program and had been able to stand for up to 30 minutes. R55 stated, I have fallen well below baseline. I could transfer, with the assistance of staff, with stand and pivot then, and could sit on the side of the bed for 30 minutes independently. The resident stated now she could not participate in transfers and staff had to use a Hoyer mechanical lift to transfer her. Observation during the interview revealed R55 lying on her bed. During interview on 06/11/2024 at 4:31 PM, Registered Nurse (RN) 6 stated she had been employed at the facility prior to when R55 was admitted . RN 6 stated R55 was limited in her ADLs due to having use of her left hand only. She stated R55 had previously been able to do a transfer pivot or a transfer with the slide board; however, now staff used the Hoyer lift to transfer her because her legs were not working. RN 6 further stated the facility used to have a restorative nursing program, but did not currently have one. During an interview on 06/12/2024 at 11:47 AM, the Administrator stated he was aware of R55's desire to improve in her ADLs and stated she had received therapy. During interview on 06/12/2024 at 2:52 PM, the PT stated R55 had received therapy four times since 2022 with the most recent period being from 04/10/2024 through 05/09/2024. The PT stated initially R55 had maintained her abilities with the provision of therapy, and improved with bed exercises, positioning, and wore bilateral ankle orthotics, and maintained her ability to sit in the power wheelchair. The PT stated in R55's most recent round of therapy, the resident was transferred by therapy staff using the sit to stand transfer which required participation on her part. The PT stated however, R55 was currently not able to participate in transfers and was dependent on staff to perform transfers. The PT said during R55's most recent round of therapy her goals had been to use a standing frame and R55 made improvements and was able to stand for over 30 minutes. According to the PT interview, R55 could bear weight through her legs to increase her leg strength. The PT stated the facility provided no restorative services after therapy was discontinued. The PT further stated however, a restorative program would have been beneficial for R55, as the resident could have continued to use the standing frame. During interview on 06/14/2024 at 9:17 AM, Licensed Practical Nurse (LPN)/Unit Manager (UM) 2 for B Wing stated R55 was not able to stand. LPN/UM 2 verified the facility had no restorative program; however, further stated residents could participate in the activity departments' group exercises. During an interview on 06/14/2024 at 11:36 AM, Certified Nursing Assistant (CNA) 5 stated until approximately two years ago, she had been employed at the facility as the restorative aide. She stated she had provided restorative services for R55 and the resident had been able to use the standing frame and do exercises with her compromised hand. CNA 5 stated the therapists had developed the restorative programs for residents and she had been trained in what to do for the residents. She stated R55 benefited from the restorative program, as the resident had been able to stand (for up to 15 minutes), and her hand became more functional. The CNA said R55 was less able to assist when rolling in bed now due to her left hand not working as well as it previously had. She stated R55 did not stand anymore, and staff now used the Hoyer lift to transfer her. CNA 5 further stated R55 had previously been able to push herself up using the sit to stand transfer, and the resident had been consistently transferred using the sit to stand lift prior to the discontinuance of the restorative program. During an interview on 06/11/2024 at 3:42 PM, CNA 6 stated R55 had previously used the sit to stand lift or a sliding board for transfers; however, was no longer able to do that. CNA 6 further stated staff used the Hoyer lift to transfer R55 now. During interview on 06/14/2024 at 5:42 PM, the DON stated some of R55's strength had declined and verified the Hoyer lift was now used for her transfers. 2. Review of R58's undated Continuity of Care Document in the EMR under the RAI tab, revealed the facility admitted the resident on 01/30/2023 with diagnoses including cerebral infarction (stroke) and cognitive communication deficit. Review of the admission MDS Assessment with an ARD of 02/06/2023 in the EMR under the RAI tab, revealed the facility assessed R58 to have a BIMS score of five out of 15, which indicated the resident had severely impaired cognition. Continued MDS review revealed the facility assessed R58 to require extensive assistance with bed mobility, transfers, and locomotion on and off the unit. Further review revealed the facility additionally assessed R58 as not stable but was able to stabilize with staff's assistance for moving from seated to standing, walking, moving on and off the toilet, and surface to surface transfers. Review of the Quarterly MDS Assessment with an ARD of 04/30/2024 in the EMR under the RAI tab, revealed the facility assessed R58 to require substantial assistance for showers/bathing, upper body dressing, personal hygiene and was dependent for toileting/hygiene. Review of the MDS further revealed the facility also assessed R58 to be dependent for lower body dressing, going from sitting to lying, and from lying to sitting, ability to transfer from bed to chair and toilet transfer/ability to get on and off the toilet. Review of R58's Care Plan, dated 05/11/2023, in the EMR under the RAI tab, revealed the facility had developed a problem for the resident which stated, ADLs functional status/rehabilitation potential. (R58) has impaired ability to do ADLs R/T weakness, impaired cognition. Continued review revealed the goal was for R58 to, Maintain some ability to assist with ADLs. Review further revealed the interventions included for Transfers: Hoyer lift with two staff (dated 04/15/2024). Per review of the Care Plan, the interventions also included: assist the with ADLs such as bathing, dressing, toileting, and nail care (dated 04/10/2024); for bathing the resident needed assistance of two staff for showers (dated 05/11/2023); bed mobility needs extensive assistance of one staff for turning repositioning and two for pulling up the resident in bed (dated 05/11/2023); and for toileting R58 needs checked and changed at least every two hours for incontinency (dated 05/11/2023). Observation throughout the survey revealed R58 sat in a high back wheelchair which did not have footrests and the resident's feet touched the floor. The observations are as follows: on 06/10/2024 at 12:51 PM, R58 had just finished eating lunch and staff wheeled him into the dayroom adjoining the Linker dining room where a large screen TV was located; on 06/10/2024 at 1:10 PM, R58 was observed to ambulate a couple of feet in the dayroom toward the TV; on 06/11/2024 at 9:47 AM, R58 was seen sitting in his wheelchair in the day room, and was not observed to ambulate in the wheelchair; and on 06/12/2024 at 8:56 AM, R58 was observed sitting in his wheelchair in his room having just finished breakfast. During interview on 06/11/2024 at 3:52 PM, CNA 6 stated R58 was dependent on staff for the provision of all ADLs except for eating. CNA 6 stated when R58 had resided on the A Wing, he had been able to use the sit to stand lift and could get into the wheelchair. The CNA stated at that time R58 could pull himself up while using the sit to stand lift. CNA 6 said after R58's fall (on 04/13/2024) he had been transferred with a Hoyer lift and now was completely dependent on staff. The CNA further stated the CNAs did not complete range of motion (ROM) or other exercise programs with residents. During interview on 06/11/2024 at 4:59 PM, LPN 1 stated R58 had previously used the sit to stand lift; however, he had gotten weaker and lost the ability to bear weight. The LPN said R58 was not currently able to stand or pivot. Per interview, LPN 1 stated R58's knees buckled when staff were transferring him with the sit to stand lift and he had fallen (on 04/13/2024). The LPN stated R58's decrease in ADLs triggered a therapy referral and he had received therapy. According to LPN 1 however, once R58's therapy was discontinued, and as the facility did not have a restorative program, the resident had not received services to maintain his abilities. During interview on 06/12/2024 at 2:42 PM, the PT stated R58 was picked up by therapy after sustaining the fall on 04/13/2024, and the PT verified R58's fall occurred when staff were using the sit to stand lift the resident's knees buckled. The PT stated R58 most recently received therapy from 04/16/2024 through 05/15/2024. According to the PT in interview, R58 was admitted to the facility with bilateral knee flexion contractures, and the resident's contractures had worsened and he was no longer able to stand up. The PT said R58 would have to stand to bear weight while using the sit to stand lift and therefore he could no longer do that. Per the PT's interview, R58 made progress while receiving therapy in his leg extension. The PT stated the facility did not provide a restorative program from which R58 could have benefited, by the provision of range of motion (ROM) exercises. The PT further stated when R58 was first admitted to the facility, he had been more capable than he was now and had been able to get to his feet without the lift with staff's assistance. The PT additionally stated R58 could no longer get to his feet. During an interview on 06/14/2024 at 5:28 PM, the DON stated the Hoyer lift was used for R58 due to the resident experiencing the fall that occurred when staff were transferring him with the sit to stand lift on 04/13/2024. The DON verified R58 had not been on a restorative program while residing in the facility. The DON stated the facility's restorative program had not been in place since she started as the facility's DON (several years ago). According to the DON in interview, residents could maintain their abilities if they participated in the activity group exercise programs. During an interview on 06/12/2024 at 11:47 AM, the Administrator stated therapy taught residents exercises they could do independently to keep their current status after they were discharged from therapy. He stated the facility did not have a restorative nursing program in place as it had been discontinued during COVID. The Administrator further stated however, residents could go to a group exercise program offered by the activity department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of facility policy titled, Catheter Care, Urinary, last revised September 2014, revealed the purpose of this procedure is to prevent catheter-associated urinary tract infections. Maintain unobstructed urine flow by checking the resident frequently to be sure he/she is not lying on the catheter and to keep the catheter and tubing free of kinks, and the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site (Note: Catheter tubing should be strapped to the resident's inner thigh). After catheter care is provided, check drainage tubing and bag to insure that the catheter is draining properly. Record review revealed the facility admitted Resident #64 on 01/08/19, with diagnoses, which included Retention of Urine, Muscle Weakness, and Multiple Sclerosis. Review of the admission MDs assessment, dated 01/15/19, revealed the facility assessed Resident #64's cognition as intact, with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of Resident #64's Comprehensive Care Plan, dated 01/10/19, revealed staff are to provide urinary catheter care per facility policy. However, observations on 02/27/19 at 11:35 AM and 2:10 PM, revealed Resident #64's catheter clip was hanging near the drainage bag and the catheter tubing was not secured per facility policy. Interview with Resident #64 on 02/27/19 at 2:25 PM, revealed having the catheter tubing secured keeps it from getting caught up in the blankets. Interview with CNA #7 on 02/27/19 at 3:33 PM, revealed the catheter should be secured using the clip to keep the catheter from pulling. CNA #7 further stated the care plan should be followed when providing care to residents. Interview with the Assistant Director of Nursing (ADON) on 02/27/19 at 2:10 PM, revealed the catheter should be anchored and the clip in place to keep it from pulling. She stated she expected the aides to follow the residents care plan when providing care. Interview with the DON, on 02/27/19 at 3:27 PM, revealed she expected staff to follow the care plans. Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure each resident will have a person-centered comprehensive care plan implemented to meet his preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for four (4) of twenty-two (22) sampled residents (Residents #9, #39, #64, and #72). The facility care planned Resident #9 to require two (2) staff assist with Activities of Daily Living (ADL's) to include bathing and bed mobility. However, on 02/01/19, one (1) Certified Nurse Aide (CNA), instead of two (2) as per care planned, provided Resident #9 a bed bath and the resident's legs and feet went off the bed and pulled the resident to the floor. Resident #9's fall resulted in a fractured left femur and the resident was hospitalized from [DATE] to 02/07/19. Although surgical intervention was not performed, due to the resident's clinical condition and inability to use his/her legs due to having Multiple Sclerosis, the resident's pain increased tremendously after the fall. The resident stated at rest, the pain was dull and uncomfortable and rated it at a two (2) or three (3), on a scale of one (1) to ten (10), however, on movement, the pain was intense. In addition, staff failed to follow the care plan for Resident #72 related to providing nail care, Resident #39 related to dialysis access site assessments, and Resident #64 related to securing catheter and tubing. The findings include: Review of the facility's policy Comprehensive Care Plans, last revised 07/19/18, revealed a person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs, goals and preferences. Care plan interventions are implemented after consideration of the resident's problem areas and their causes. Interventions address the underlying source(s) of the problems area(s), rather than addressing only symptoms or triggers. The interventions will reflect action, treatment, or procedure to meet the objectives toward achieving the resident goal. 1. Record review revealed the facility admitted Resident #9 on 08/23/19 with diagnoses, which included Immobility Syndrome (Paraplegic); Muscle Wasting and Atrophy, Multiple Sites; Unspecified Lack of Coordination; and Multiple Sclerosis (MS). Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 12/04/18, revealed the facility assessed Resident #9's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of the Quarterly MDS revealed Resident #9 required extensive assistance of two (2) staff for bed mobility and total assistance of two (2) staff for bathing. Review of the Comprehensive Care Plans revealed Resident #9 had a self-care deficit in activities of daily living, initiated on 08/27/18, revealed interventions for extensive assist of two (2) staff for activities of daily living (ADL's) and mobility tasks, total assist if the resident was unable to participate, date initiated 09/10/18. However, review of the facility provided Fall Investigation Report revealed Certified Nurse Assistant (CNA) #1 gave the resident a bed bath without the assistance of another staff, and turned him/her to finish drying him/her when the resident's legs began to slide off the bed. CNA #1 was able to guide the resident's body off the bed onto the floor avoiding hitting his/her head on the ground. However, the fall resulted in a fractured left femur. Interview with Resident #9 on 02/26/19 at 2:26 PM and on 02/28/19 at 11:35 AM, revealed the resident does not have use of either lower extremity due to MS. Resident #9 stated on 02/01/19, the CNA was repositioning him/her and the resident was on his/her side when his/her feet and legs began to slip off the bed and then his/her body followed; and only one (1) CNA was present. Resident #9 revealed before the fall, one (1) and sometimes two (2) staff were present when providing care. Resident #9 stated his/her pain increased tremendously after the fall. The resident stated at rest, the pain was dull and uncomfortable and rated it at a two (2) or three (3), on a scale of one (1) to ten (10), however, on movement, the pain was intense. Interview with CNA #1 on 02/28/19 at 9:50 AM revealed she was assisting Resident #9 with bathing and dressing on 02/01/19 when the resident slipped off the bed. CNA #1 stated she was the only CNA assisting the resident at that time and she did not know the resident was care planned for two (2) assists for care and just always assisted the resident by herself. CNA #1 further stated each CNA has to complete and sign the care plan at the end of each shift indicating resident care had been provided according to the care plan. Interview with CNA #2 on 2/28/19 at 11:50 AM and CNA #3 on 02/28/19 at 11:59 AM revealed Resident #9 required two (2) staff assists for bed mobility and bathing before the 02/01/19 fall. Interview with Registered Nurse (RN) #1 on 02/28/19 at 1:25 PM revealed there was only one (1) CNA in the room at the time Resident #9 fell on [DATE]. RN #1 stated she did not know how much assistance the resident required according to the care plan. 2. Review of the facility policy titled, Care of Fingernails/Toenails, last revised October 2010, revealed the purposes of the procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes daily cleaning and regular trimming. Record review revealed the facility admitted Resident #72 on 02/27/18 with diagnoses, which included Idiopathic Peripheral Autonomic Neuropathy. Review of the Annual MDS assessment, dated 02/06/19, revealed the facility assessed Resident #72's cognition as intact with a BIMS score of fourteen (14), which indicated the resident was interviewable. Review of Resident #72's Comprehensive Care Plans revealed Resident #72 had an activities of daily living (ADL) self-care performance deficit with an intervention for the assistance of one (1) with personal hygiene and bathing. However, observations on 02/26/29 at 11:05 AM, on 02/27/19 at 10:01 AM, and on 02/27/19 at 1:45 PM revealed Resident #72's finger nails were long, some broken, with dried brown crusty matter under each nail on both hands. Interview with Resident #72 on 02/27/19 at 1:45 PM revealed he/she was embarrassed by the condition of his/her nails. Resident #72 stated he/she had not asked for assistance with them because his/her daughter usually takes care of them, and staff offered no nail care assistance. Interview with CNA #2 on 02/28/19 at 11:50 AM, revealed nail care should be provided daily and as needed per care plan. CNA #2 stated she had not noticed Resident #72's fingernails being dirty or long. Interview with RN #1 on 02/27/19 at 2:50 PM revealed Resident #72's nails should not be dirty like the resident's were. The RN stated nail care should be provided daily with ADL care, however, she had not noticed that the resident's nails were long and dirty. 3. Review of facility policy titled, End-Stage Renal Disease, Care of a Resident with, last revised September 2010, revealed residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff includes the care of grafts and fistulas. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/Dialysis care. Record review revealed the facility admitted Resident #39 on 02/11/11 with diagnoses which included End Stage Renal Disease and Unspecified Sequelae of Cerebral Infarction. Review of the Annual MDS Assessment revealed the facility assessed Resident #39's cognition to be intact with a BIMS score of fifteen (15), which indicated the resident was interviewable. Additionally, the MDS indicated the resident was receiving dialysis. Review of the Comprehensive Care Plans revealed Resident #39 needs dialysis on Mondays, Wednesdays, and Fridays, initiated 09/12/18 with an intervention to be alert to [access] site to left lower extremity for changes in skin condition, edema, bleeding, thrill, and bruit, initiated 12/18/18. However, review of the February 2019 Medication Administration Record (MAR), Treatment Administration Record (TAR), Dialysis Communication Forms, and Nursing Progress Notes revealed the access site was checked only two (2) times for signs and symptoms of infection or a thrill or bruit. Interview with RN #1 on 02/27/19, at 2:30 PM, revealed Resident #39 has an access device to the left groin for dialysis. The RN stated she checked the site dressing before the resident leaves for dialysis treatments and she checked for a thrill and bruit upon the resident's return to the facility, but does not document the assessments. The RN revealed there was no where to document the checks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review revealed the facility admitted Resident #21 on 02/18/19, with diagnoses which included Aphasia, Non-traumatic Intracerebral Hemorrhage, and Dysphagia. Further review revealed the admission MDS assessment had not yet been completed due to recent admission. Review of the Nurse's Progress Notes, dated 02/19/19 at 7:17 PM, revealed Resident #21 had an unwitnessed fall and was found lying on the mat beside his/her bed. However, review of Resident #21's Comprehensive Care Plan for high risk for falls dated 12/03/18, revealed no additional interventions were put in place after the fall on 02/19/19 per facility policy. Attempted telephone interview with LPN #2 on 02/28/19 at 11:57 AM and 2:45 PM, were unsuccessful. Interview with Registered Nurse (RN #1) on 02/28/19 at 1:25 PM, revealed the nurses do not get in to the care plans. She stated, The unit managers, when we have one, update the care plans. RN #1 further stated that new interventions should be initiated for each fall. Interview with RN #3 (Interdisciplinary Team {IDT} member) on 02/28/19 at approximately 12:26 PM revealed staff should discuss and find out the root cause of a fall and identify interventions and update the care plan. RN #3 stated the IDT team reviews the Incident report and if the incident report does not document the root cause or interventions are not listed then staff should follow up with nurse who completed the incident report. RN #3 stated it was the DON's or the Unit Manager's responsibility to document that missing information. Interview with MDS Coordinator (IDT Team Member) on 02/28/19 at approximately 12:59 PM revealed the staff protocol when a resident falls is for staff to make immediate changes to the Care Plan after the resident has a fall. The MDS Coordinator stated updating the care plan was the responsibility of the nurse The MDS Coordinator stated if information was not captured then during the morning meeting staff would gather all the required information before the meeting was over and the care plan would be updated before meeting was over. Interview with the Director of Nursing (DON) on 02/28/19 at 9:59 AM, revealed when a fall occurs the nurse caring for the resident was to complete an assessment of the resident, investigate the fall, and ensure interventions were put in place to prevent further falls. 5. A written statement provided by the Director of Nursing (DON), not dated, revealed, We follow the RAI Guidelines for care planning, development, implementation, reviewing, and revising. Review of the Resident Assessment 3.0 Users Manual, Version 1.6, October, 2018, revealed resident care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. Record review revealed the facility admitted Resident #56 on 07/26/18 with diagnoses which included Diabetes Mellitus, Hypertension, and Chronic Respiratory Failure. Review of the Quarterly MDS assessment, dated 02/04/19, revealed the facility assessed Resident #56's cognition as intact with a BIMS score of fourteen (14) indicating the Resident was interviewable. Observations on 02/26/19 at 8:13 AM, 11:39 AM, 2:23 PM, and 4:46 PM and on 02/27/19 at 8:03 AM, 8:27 AM, and 2:05 PM revealed Resident #56 resting in bed on his/her back without oxygen. Further observation revealed the nasal cannula was laying in the bed and not on the resident. In addition, interviews with LPN #1 on 02/26/19 at 4:46 PM, LPN #2 on at 5:03 PM and interview with Registered Nurse (RN) #2 on 02/28/19 at 12:32 PM revealed they were aware Resident #56 would remove his/her oxygen. However, further review of the Comprehensive Care Plan dated 03/26/18 revealed there was no documented evidence the care plan was revised to address the resident's non-compliance with wearing oxygen per RAI manual. Interview with the MDS Coordinator on 02/27/19 at 4:51 PM, revealed she would be responsible for updating the care plan of Resident #56's refusal/behavior of removing his/her oxygen. She stated she was only made aware yesterday, and nursing should have reported it to the Director of Nursing so the care plan could be updated to reflect the resident's behavior. Interview with the Director of Nursing (DON), on 02/28/19 at 5:58 PM, revealed she would have expected staff to document Resident #56's refusal to wear oxygen so the behavior could be appropriately care planned. 3. Record review revealed the facility admitted Resident #75 on 12/28/13 with diagnoses, which included Dementia without Behaviors, Muscle Wasting and Atrophy, Multiple Sites. Review of the Quarterly MDS Assessment, dated 02/11/19, revealed the facility assessed Resident #75's cognition as severely impaired with a BIMS score of three (3) which indicated the resident was not interviewable. Review of the Falls Investigation Report, dated 10/30/18, revealed there facility determined Resident #75 sustained a fall due to the resident's wheelchair brakes not locked, however, review of Resident #75's Comprehensive Care Plan at risk for falls, initiated on 05/15/18 and revised on 11/29/18, revealed the facility initiated an intervention on 10/30/18 to ensure the wheelchair brakes are locked while the resident is in bed related to resident's decreased safety awareness, remind resident. However, the facility assessed the resident had severe cognitive impairment with long-term and short-term memory loss, was not able to recall reminders or directions, and had poor safety awareness. Review of the Falls Investigation Report revealed Resident #75 revealed the resident sustained a fall with no harm on 11/06/18 at 5:48 PM, due to the resident attempting to go to the bathroom unassisted despite clear instruction from staff to wait for assistance. However, review of Resident #75's Comprehensive Care Plans revealed no documented evidence an intervention was implemented to try to prevent further falls per facility policy. Review of the Falls Investigation Report dated 12/27/18, and Nursing Progress Note dated 12/27/19 at 3:15 PM, revealed the facility determined Resident #75 sustained a fall with no harm in the rehab gym while attempting to self transfer from the wheelchair to rehab equipment without the wheels of the wheelchair locked. However, review of Resident #75's Fall Risk Comprehensive Care Plan revealed the intervention, previously added on 10/30/18, to ensure the wheelchair brakes were locked while resident was in bed related to the resident's decreased safety awareness, remind resident was re-dated 12/30/19 even though this fall was in rehab and not while in bed, the facility had assessed the resident's cognition as severely impaired, and the intervention was not effective as evidenced by another fall. There was no documented evidence the facility initiated a new intervention per facility policy. Based on interview, observation, record review, review of facility policy, and review of the Resident Assessment Instrument (RAI) manual it was determined the facility failed to ensure five (5) of twenty-two (22) sampled residents' person-centered, comprehensive care plans were reviewed and revised (Residents #75, #24, #18, #21 and #56). Resident #18 sustained unwitnessed falls on 07/03/18, 07/12/18, 07/16/18, 07/28/18, 08/02/18, 08/11/18, and 08/17/18; however, the facility failed to revise the care plan to address the resident's possible need for increased supervision to try to prevent further falls per facility policy. On 09/24/18, Resident #18 sustained an unwitnessed fall which resulted in an acute fracture of left hip that required surgery and hospitalization for four (4) days. The facility failed to follow facility policy and revise the care plan after the 09/24/18 fall. Further review revealed the facility failed to revise the care plan per facility policy after falls the resident also sustained on 10/01/18, 10/11/18, 11/01/18, 11/04/18, 11/10/18, 12/20/18, and 02/10/19. Resident #75 sustained falls on 10/30/18, 11/06/18, and 12/27/18; Resident #24's sustained falls on 09/25/18, 10/18/18, and 11/25/18; and Resident #21 had a fall on 02/19/19; however, the care plans were not revised to reflect appropriate interventions to prevent future falls per facility policy. In addition, observations revealed Resident #56 was not wearing oxygen as ordered and interviews revealed staff were aware of the resident's non-compliance with oxygen administration; however, the facility failed to review and revise Resident #56's Care Plan to address the resident's non-compliance per RAI manual. The findings include: Review of the facility policy titled, Falls and Fall Risk, Managing, last revised December, 2007, revealed if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 1. Record review revealed the facility re-admitted Resident #18 on 09/28/18 with diagnoses which included Fracture of left Femur, Muscle Weakness, Unspecified Abnormalities of gait and Mobility, History of Falling, Heart failure, Major depressive Disorder and Unspecified macular Degeneration. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/21/18, revealed the facility assessed the resident's Brief Interview of Mental Status (BIMS) score to be a nine (9), which indicated he/she was interviewable. Review of Facility Fall Incident Reports revealed Resident #18 had unwitnessed falls on 07/03/18, 07/12/18, 07/16/18, 07/28/18, 08/02/18, 08/11/18, and 08/17/18. The resident was found sitting on floor, on mat next to bed, in bathroom on floor, found scooting across mat. found on floor between wheelchair and chair, and found on floor at bathroom entrance with no injuries identified except on 08/17/18 when the resident was identified to have a skin tear. Review of the Comprehensive Care Plan dated 06/07/16 revealed interventions put in place after the falls for a medication review, labs ordered, blood pressure checked hourly, environmental review, urine analysis (UA) ordered, x-rays ordered, referral to therapy, remind resident to ask for assistance, and reorient resident to surroundings. However, there were no revisions to the care plan to address the resident's possible need for increased supervision related to the resident falling in his/her room on numerous occasions due to ambulating without assistance per facility policy. Review of a Nursing Progress Note, dated 9/24/18 at approximately 11:20 AM revealed Resident #18 had another unwitnessed fall and was discovered next to bed, sitting on mat, with a large bow above right knee near femur that was elevated and painful to touch. Further review revealed the resident's was sent to ER. Review of the Hospital Discharge summary, dated [DATE], revealed Resident #18 was diagnosed with an acute fracture of distal left femoral diaphysis (left upper leg) and a surgery was conducted on 09/25/18. Review of Resident #18's September and October 2018 Medication Administration Record (MAR's) reports revealed the resident required four (4) doses of pain medication during the entire month of September prior to the femur injury that occurred on 09/24/18; however, required pain medication daily for seven (7) days after being readmitted to the facility on [DATE]. Further review of the Comprehensive Care Plan dated dated 06/07/16 and 04/30/18 revealed no intervention were implemented to address the fall that occurred on 09/24/18 per facility policy. Further review of facility Incident Reports revealed Resident #18 sustained further unwitnessed falls in the facility that occurred on 10/01/18, 10/11/18, 11/01/18, 11/04/18, 11/10/18, 12/20/18, and 02/10/19 However, further review of the Comprehensive Care Plan dated 06/07/16 and 04/30/18 revealed there were no interventions put in place on 10/01/18, 10/11/18, 11/01/18, 11/04/18, 11/10/18, 12/20/18 and on 02/10/19; per facility policy. 2. Record review revealed the facility re-admitted Resident #24 on 01/15/19 with diagnoses which included Hepatic failure, Cognitive Communication deficit, Difficulty in Walking, Muscle Weakness, and Chronic Obstructive Pulmonary Disease. Review of the Quarterly MDS assessment, dated 12/27/18, revealed the facility assessed the resident's BIMS Score to be a fifteen (15), which indicated he/she was interviewable. Review of facility Fall Incident/Investigation Report dated 09/25/18 revealed Resident #24 was walking in his/her room and fell beside the bed, with no injury was noted. The report revealed the resident was wearing fuzzy socks at time of fall. Review of the Fall Incident Report dated 10/18/18 revealed Resident #24 was found in his/her bathroom floor, and the resident said he/she was weak and sat down on floor. Review of the Fall Incident Report dated 11/25/18 revealed the nurse heard Resident #24 yelling help, and found the resident on the floor face down at foot of bed with one sock on and one off. Resident #24 stated he/she was trying to put socks on and slid off bed onto floor face down. However, review of the Comprehensive Care Plan for Falls Risk, dated 09/22/18, revealed no additional or different interventions were implemented after the 09/25/18, 10/08/18, and 11/25/18 falls to try to prevent future falls per facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed the facility re-admitted Resident #18 on 09/28/18 with diagnoses which included Fracture of left Femur, Muscle Weakness, Unspecified Abnormalities of gait and mobility, History of Falling, Heart Failure, Major Depressive Disorder and Unspecified Macular Degeneration. Review of the Quarterly MDS assessment, dated 12/21/18, revealed the facility assessed Resident #18's cognition as moderately impaired with a BIMS score of nine (9), which indicated the resident was interviewable. Further review of the MDS assessment revealed transfer only occurred once or twice during the seven (7) day look back period, walk in room and in corridor did not occur at all, and locomotion on and off the unit only occurred once or twice during the seven (7) day look back period. Review of the Comprehensive Care Plan, Falls Risk, dated 04/30/18, revealed the resident was at risk for injury related to falls due to a history of multiple falls and at risk for falls due to chronically impaired strength, cognitive deficits, use of antidepressant medication and attempts self-transfer. Further review revealed the only intervention in place was to toilet resident upon rising, after meals, at bedtime and as needed. Review of Facility Fall Incident Reports revealed Resident #18 had unwitnessed falls on 07/03/18, 07/12/18, 07/16/18, 07/28/18, 08/02/18, 08/11/18, and 08/17/18. The resident was found sitting on floor, on mat next to bed, in bathroom on floor, found scooting across mat. found on floor between wheelchair and chair, and found on floor at bathroom entrance with no injuries identified except on 08/17/18 when the resident was identified to have a skin tear. However, further review of the report revealed there was no documented evidence the Nurse Supervisor/Charge Nurse and/or the Department Director or Supervisor determined any corrective action to try to prevent future falls per facility policy and protocol. Further review of the Comprehensive Care Plan dated 06/07/16 for the falls that occurred on 07/03/18, 07/12/18, 07/16/18, 07/28/18, 08/02/18, 08/11/18, and 08/17/18 revealed interventions put in place after the falls for a medication review, labs ordered, blood pressure checked hourly, environmental review, urine analysis (UA) ordered, x-rays ordered, referral to therapy, remind resident to ask for assistance, and reorient resident to surroundings. However, there were no interventions implemented to address the resident's possible need for increased supervision related to the resident falling in his/her room on numerous occasions due to ambulating without assistance. In addition, review of facility Falls Risk Assessments revealed the facility had not completed any falls risk assessments for Resident #18 after any of the falls that occurred per facility protocol. Review of a Nursing Progress Note, dated 9/24/18 at approximately 11:20 AM revealed Resident #18 had another unwitnessed fall and was discovered next to bed, sitting on mat, with a large bow above right knee near femur that was elevated and painful to touch. Further review revealed the resident's vital signs were checked, family and physician notified, and Resident #18 was sent to ER. Review of the Hospital Discharge summary, dated [DATE], revealed Resident #18 was diagnosed with an acute fracture of distal left femoral diaphysis (left upper leg) and an surgery was conducted on 09/25/18. Further review revealed during postoperative course the resident had a change in mental status, and a MRI brain scan revealed small acute infarcts of bilateral occipital lobes with no further action taken due to risk of side effect/benefit ratio was not favorable. Review of Resident #18's September and October 2018 Medication Administration Record (MAR's) reports revealed the resident required four (4) doses of pain medication during the entire month of September prior to the femur injury that occurred on 09/24/18. Further review revealed Resident #18 required pain medication daily for seven (7) days after being readmitted to the facility on [DATE]. Review of the facility Incident Reports for Resident #18 revealed no incident/investigation Report was completed for the fall that occurred on 09/24/18 that resulted in Resident #18 sustaining a left femur fracture per facility protocol. Further review of the Comprehensive Care Plan dated 04/30/18 revealed no intervention was implemented to address the fall that occurred on 09/24/18 per facility policy and protocol. Further review of facility Incident Reports revealed Resident #18 sustained further unwitnessed falls in the facility that occurred on 10/01/18, 10/11/18, 10/25/18, 11/01/18, 11/04/18, 11/09/18, 11/10/18, 12/20/18, 12/24/18, 12/29/18, 12/30/18, 01/12/19, 01/28/19, 01/10/19, and 02/20/19. The resident was found sitting on mat next to bed, found on floor in bedroom, found on floor in bathroom, found on floor in bathroom on coccyx with left arm on bar and right hand pulling emergency light, found on floor next to bed, found on floor in front of bathroom door at 5:30 AM, found on floor in another resident's bathroom yelling out for help, found sitting upright on floor beside wheelchair next to bed, and found lying on back on floor next to bed, with no injuries identified except on 10/01/18 and 10/25/18 when the resident was identified to have a skin tear. However, further review of the reports revealed there was no documented evidence the Nurse Supervisor/Charge Nurse and/or the Department Director or Supervisor determined any corrective action to try to prevent future falls per facility policy and protocol. Review of Nurse's Progress Note, dated 12/02/18 at 3:27 PM revealed risk management showed Resident #18 had falls that occurred in facility 11/26/18; however, there was no Fall Incident report completed per facility policy. Further review of the Comprehensive Care Plan dated 04/30/18 revealed there were no interventions put in place or any documentation that a current intervention remained relevant for the falls that occurred on 10/01/18 and 10/11/18 per facility policy. Further review of the care plan revealed an intervention was put in place for the fall that occurred on 10/25/18 which was a bed and chair alarm to address the resident's getting up without assistance from staff. However, further review of the care plan revealed there was no interventions put in place or any documentation that a current intervention remained relevant for the falls that occurred on 11/01/18, 11/04/18, 11/10/18, and 12/20/18 and on 02/10/19; per facility policy. Interview with RN #1 on 02/28/19 at 1:25 PM, revealed the nurses do not get in to the care plans. She stated, The Unit Managers, when we have one, update the care plans. RN #1 further stated that new interventions should be initiated for each fall. Interview (Post Survey) with MDS Coordinator on 03/19/19 at approximately 9:58 AM revealed she was not present during the morning meetings when Resident #18's falls were discussed prior to December 2018. However, the MDS Coordinator was unable to provide any information on the discussions in the morning meetings related to falls that occurred in December 2018 and after. The MDS Coordinator stated she was not sure if the root cause was identified in any of the falls and what if any, discussion there was related to assessing current or new interventions because she did not have the notes and she was not certain who would have those notes. Interview with the DON (IDT member) on 02/28/19 at 9:59 AM, revealed no incident/investigation report was completed for Resident #18's fall that occurred on 09/24/18 that resulted in a serious injury. The DON stated Resident #18 was transported to the hospital on [DATE] and admitted and only a progress note was completed. The DON stated there was no documentation to show that staff tried to identify the root cause of that fall, access if any interventions in place were effective, or if new interventions needed to be put in place to prevent any future falls. Interview (Post Survey) with DON on 03/19/19 at approximately 3:58 PM revealed due to system conversion in May 2018 and ongoing issues with staff's ability to input data and MDS staff turnaround there were two ongoing Care Plans for Resident #18 that staff would make revisions to. The DON stated the revisions made in July and August 2018 to the older care plan were not ongoing revisions and were in place to address those specific falls that occurred during that time. 3. Record review revealed the facility re-admitted Resident #24 on 04/13/18 with diagnoses which included Hepatic failure, Cognitive Communication deficit, Difficulty in Walking, Muscle Weakness, and Chronic Obstructive Pulmonary Disease. Review of the Quarterly MDS assessment, dated 12/27/18, revealed the facility assessed Resident #24's cognition as intact with a BIMS score of fifteen (15), which indicated the resident was interviewable. Review of the Comprehensive Care Plan, Falls Risk, dated 04/30/18, revealed Resident #24 was at risk for injury related to falls due to a history of multiple falls. Further review of the care plan revealed Interventions for staff to anticipate and meet resident's needs, keep resident's call light within reach and encourage resident to use for assistance as needed, promptly respond to all resident requests, educate resident/family members about safety reminders and what to do if a fall occurs, ensure resident is wearing appropriate footwear (tennis shoes) during the day, follow facility fall protocol, and PT to evaluate and treat as ordered. Review of facility Fall Incident/Investigation Report dated 09/25/18 revealed Resident #24 was walking in his/her room and fell beside the bed, with no injury was noted. The report revealed the resident was wearing fuzzy socks at time of fall. Review of the Fall Incident Report dated 10/18/18 revealed Resident #24 was found in his/her bathroom floor, and the resident said he/she was weak and sat down on floor. Review of the Fall Incident Report dated 11/25/18 revealed the nurse heard Resident #24 yelling help, and found the resident on the floor face down at foot of bed with one sock on and one off. Resident #24 stated he/she was trying to put socks on and slid off bed onto floor face down. Further review of all three Fall Incident reports, dated 09/25/19, 10/18/19, and 11/25/19, revealed there was no documented evidence the Nurse Supervisor/Charge Nurse and/or the Department Director or Supervisor determined any corrective action to try to prevent future falls per facility policy and facility protocol. Review of the Comprehensive Care Plan for Falls Risk, dated 09/22/18, revealed no additional or different intervention was implemented or any documentation that a current intervention remained relevant after the 09/25/18, 10/08/18, and 11/25/18 falls to try to prevent future falls per facility policy and protocol. Review of a Fall Incident Report dated 12/07/18 revealed Resident #24 was found on bathroom floor, sitting on buttocks up against the wall with legs in front of him/her; and, determined the resident lost his/her balance, Further review revealed the staff educated resident on calling for assistance when going to bathroom due to resident being noncompliant with using rollator when ambulating. Review of the Comprehensive Care Plan for Falls Risk, dated 09/22/18, revealed the care plan was not updated with an intervention after the fall on 12/07/18 until 12/12/18 (five {5} days later) with an intervention to educate resident on using rollator when using restroom and to use seat if he/she becomes weak. Review of a Fall Incident Report dated 02/15/19 revealed the nurse responded to Resident #24's call light and Resident #24 reported he/she fell down in bathroom because he/she lost his/her balance while trying to put on briefs. The report revealed Resident #24 stated he/she got up on his/her own from the fall but had bumped head when he/she fell. However, further review of the report revealed there was no documented evidence the Nurse Supervisor/Charge Nurse and/or the Department Director or Supervisor determined any corrective action to try to prevent future falls per facility policy and protocol. Review of the Comprehensive Care Plan for Falls Risk, dated 09/22/18, revealed the care plan was not updated until 02/18/19 (three {3} days later) with an intervention to add non-skid strips in Resident #24's bathroom. 4. Record review revealed the facility admitted Resident #75 on 12/28/13 with diagnoses, which included Dementia without Behaviors, Muscle Wasting and Atrophy, Multiple Sites. Review of the Quarterly MDS Assessment, dated 02/11/19, revealed the facility assessed Resident #75's cognition as severely impaired with a BIMS score of three (3) which indicated the resident was not interviewable. Further review of the Quarterly MDS revealed Resident #75 required extensive assistance of two (2) staff with bed mobility and limited assistance with two (2) staff for transfers. Additionally, the Quarterly MDS revealed the resident's balance during transfers and walking was not steady, and the resident was able to stabilize with human assistance. Resident #75 was mobile via wheelchair with extensive assistance and was non-ambulatory. Review of Resident #75's Comprehensive Care Plan, initiated on 05/15/18 and revised on 11/29/18, revealed Resident #75 was at risk for falls related to impaired mobility, strength, balance, endurance due to disease processes, recent falls and cognitive deficits. Further review of the care plan revealed interventions to keep the resident's wheelchair at bedside. Review of the Falls Incident/Investigation Report, dated 10/30/18 at 3:39 PM revealed Resident #75 was yelling out from the room help me! and upon entry to the room, the resident was on the floor lying on his/her back and when asked what happened, the resident was not able to tell the nurse. The resident's wheelchair was noted further away than normal, and the wheelchair brakes were not locked. The resident was assessed to be free from injuries. Further review of there report revealed neurological checks were initiated due to fall being unwitnessed; and, the immediate action was to assess and assist the resident up in the wheelchair and take to activities. However, there was no documented evidence the Nurse Supervisor/Charge Nurse and/or the Department Director or Supervisor determined any corrective action to try to prevent future falls per facility policy and protocol. Further review of Resident #75's Comprehensive Care Plan for risk for falls, initiated on 05/15/18 and revised on 11/29/18, revealed an intervention, dated 10/30/18, to ensure the wheelchair brakes were locked while the resident was in bed related to the resident's decreased safety awareness and to remind resident to ensure locked even though the facility had assessed the resident's cognition as severely impaired. Further record review revealed there was no documented evidence a Fall Risk Assessment was completed immediately after the 10/30/18 fall per the facility protocol. Review of the Nurse's Progress Note dated 11/06/18 at 11:00 AM, revealed Resident #75 had an unwitnessed fall with injury in the assigned bathroom, and the nurse assisted the resident to wheelchair. The note revealed the resident complained of pain at a ten (10) (on a pain scale of one {1} to ten {10}) and had a reddened area with multiple abrasions to the forehead. The Nurse Practitioner was notified with orders for Computed Topography (CT) of the head and evaluation received. The Note stated the resident was sent to the emergency room at 11:37 AM. Review of the CT scan report, dated 11/06/18, revealed a moderate size scalp hematoma over the anterior midline frontal bone with no acute skull fracture or intracranial hemorrhage identified. Further review of the Progress Notes revealed the resident returned to the facility on [DATE] at 5:34 PM. Review of a Falls Incident/Investigation Report revealed Resident #75 sustained a fall on 11/06/18 at 5:48 PM, when the resident attempted to go to the bathroom unassisted despite clear instruction from staff to wait for assistance. The resident struck his/her forehead during the fall and a silver dollar size bump was noted on the forehead, with no bleeding. Further review of the report revealed the immediate action taken was to send the resident to the emergency room. However, there was no documented evidence the Nurse Supervisor/Charge Nurse and/or the Department Director or Supervisor determined any corrective action put in place to try to prevent future falls per facility policy and protocol. Additional record review revealed a Fall Risk Assessment was not completed immediately after the 11/06/18 fall per facility protocol. However, a fall risk assessment was completed on 11/26/18 and revealed a fall risk score of fifty (50) which indicated the resident was at high risk. Further review of Resident #75's Comprehensive Care Plan for at risk for falls revealed no additional or different intervention was implemented or any documentation that a current intervention remained relevant after the 11/06/18 fall to try to prevent future falls per facility policy and protocol. Review of the Falls Investigation Report dated 12/27/18, revealed Resident #75 sustained a witnessed fall in the rehabilitation gym at 3:04 PM during physical therapy. Further review of the investigation report revealed the immediate action for the 12/27/18 fall was to check the resident's vital signs and notify the Nurse Practitioner and the resident's daughter. However, there was no documented evidence the Nurse Supervisor/Charge Nurse and/or the Department Director or Supervisor determined any corrective action to try to prevent future falls per facility policy and facility protocol. Review of the Nurse's Progress Note, dated 12/27/18 at 3:15 PM, revealed Resident #75 had fallen in the rehab gym while attempting to self transfer from the wheelchair to rehab equipment without the wheels of the wheelchair locked. The fall was witnessed and there were no injuries. Review of Resident #75's Fall Risk Comprehensive Care Plan revealed the intervention, previously added on 10/30/18, to ensure the wheelchair brakes were locked while resident was in bed related to the resident's decreased safety awareness, remind resident, was re-dated 12/30/19 even though this fall was in rehab and not while in bed, the facility had assessed the resident's cognition as severely impaired, and the intervention was not effective as evidenced by another fall. Further record review revealed a Fall Risk Assessment was not immediately completed per facility protocol. However, a Fall Risk Assessment was completed on 12/30/18 with a score of seventy-five (75), indicating the resident was a high risk for falls. 5. Record review revealed the facility admitted Resident #21 on 02/18/19, with diagnoses which included Aphasia, Nontraumatic Intracerebral Hemorrhage, and Dysphagia. Record review revealed the admission MDS assessment, had not yet been completed due to recent admission. Review of Resident #21's Comprehensive Care Plan dated 12/03/18, revealed the resident was high risk for falls related to paralysis and unaware of safety needs. Interventions date initiated 12/03/18, included anticipate and meet the resident's needs, follow facility fall protocol, and physical therapy to evaluate and treat as ordered Review of the Nurse's Progress Notes by LPN #2, dated 02/19/19 at 7:17 PM, revealed Resident #56 had an unwitnessed fall and was found lying on the mat beside his/her bed. Further review revealed two staff members assisted the resident with the use of a lift out of the floor and back to bed, with no injury noted and neurological assessments initiated. The facility was unable to provide any documented evidence the fall investigation was completed to determine the root cause of the fall and any action was taken to try to prevent future falls. Further review of the care plan revealed no additional interventions were put in place after the fall on 02/19/19. Attempted telephone interview with LPN #2 on 02/28/19 at 11:57 AM and 2:45 PM, were unsuccessful. Interview with RN #1 on 02/28/19 at 1:25 PM, revealed the nurses do not get in to the care plans. She stated, The Unit Managers, when we have one, update the care plans. RN #1 stated they did not have a Unit Manager at this time and new interventions should be initiated for each fall. Interview with RN #3 (IDT member) on 02/28/19 at approximately 12:26 PM revealed facility protocol when a resident falls was to assess the resident, get vitals, notify the physician and family, complete a post falls assessment, do Neurological checks if a head injury is suspected or if staff were unsure if head injury occurred, report to fall to the DON, discuss and find out the root cause of the fall and identify interventions, and complete a progress note, falls assessment, and an incident report. RN #3 stated staff then take the incident report to morning meetings, review the care plan, make sure current interventions are in place, and monitor resident for three (3) days, and complete a falls follow-up after three (3) days. RN #3 revealed the resident name goes on the white board after the fall is discussed in the first (1st) morning meeting post fall and the name in not erased until after three (3) days passes and there are no additional concerns. RN #3 stated IDT reviews the Incident report and if the incident report does not document the root cause or interventions are not listed then staff will follow up with nurse who completed the incident report. She stated then it was the DON's or the Unit Manager's responsibility to document that missing information. Interview with the MDS Coordinator (IDT member) on 02/28/19 at approximately 12:59 PM revealed facility protocol when a resident falls was for staff to take vital signs, assess the resident, assess for pain, call the physician and the family and notify the DON. The MDS Coordinator stated staff should make immediate changes to the care plan. The MDS Coordinator revealed updating the care plan was the responsibility of the nurse completing the incident/investigation report. She stated the nurse should assess what interventions needed to be put in place, and evaluate the resident, medications, any change in the residents behavior, antibiotics; then document that information in the progress notes or on the assessment. The MDS Coordinator stated if information was not captured, staff would gather the required information during the morning meeting and the Care plan would be updated before meeting was over. Further interview with the DON (IDT member) on 02/28/19 at 9:59 AM, revealed when a fall occurs, the CNA should notify the nurse, and the nurse caring for the resident should complete an assessment of the resident. The DON stated the nurse should investigate the fall, ensure an intervention was implemented. She revealed the nurse should document and educate the staff, notify the physician and family, and initiate the incident report. The DON further stated with every fall, a root cause should be determined. She stated the morning after the fall, the IDT should discuss the fall and review actions taken. She also stated a fall assessment should be completed on admission, with any new fall, quarterly and annually or with any significant change in condition. Interview (Post Survey) with DON on 03/19/19 at approximately 3:58 PM revealed all nurses can make revisions to care plans and it is not necessarily the job of the Unit Managers. The DON revealed there was a several month period when there was not a Unit Manager in that position. The DON further revealed it was her opinion that staff followed fall protocol even though there was no documentation to show that root cause analysis was completed on falls or that interventions were being assessed for effectiveness or that new interventions were being identified. Based on observation, interview, record review and review of facility policy, it was determined the facility failed to ensure five (5) of twenty-two (22) sampled residents received adequate supervision and assistance devices to prevent accidents (Residents #9, #18, #21, #24, and #75). Two of the five residents (Residents #9 and #18) sustained injury. The facility assessed and care planned Resident #9 at risk for falls and required two (2) staff to provide assistance with bed bath and bed mobility. However, on 02/01/19, Certified Nurse Aide (CNA) #1 failed to follow the care plan when he/she provided bathing care and assisted with bed mobility alone. Resident #9 fell from the bed and sustained a fractured left femur. Surgical intervention was not performed due to the resident's condition; however, the resident was hospitalization from 02/01/19 to 02/07/19. In addition, Resident #9 had an increase in pain and required an increase in pain medication. Review of the Falls Investigation Reports revealed Resident #18 sustained thirty (30) falls at the facility from 07/03/18-02/05/19. However, there was no documented evidence the Nurse Supervisor/Charge Nurse and/or the Department Director or Supervisor determined any corrective action to try to prevent future falls and revised the care plan to address the residents' need for increased supervision due to the numerous unwitnessed falls, per facility policy and interviews with Interdisciplinary Team {IDT} members related to the facility's falls protocol/process. In addition, staff failed to conduct Fall Risks assessments after each fall per facility protocol. Resident #18 sustained a left femur fracture that required surgical repair and he/she was hospitalized for four (4) days after a fall that occurred in the facility on 09/24/18. In addition, review of the Fall Investigation Reports revealed Resident #24 sustained falls on 09/25/18, 10/08/18, 11/25/18, 11/26/18 and 12/07/18; Resident #75 sustained falls on 10/30/18, 11/06/18, and 12/27/18; and Resident #21 sustained a fall on 02/19/19. However, the facility failed to conduct fall risks assessments and identify appropriate interventions to prevent future falls per facility policy and protocol. The findings include: Review of the facility's policy Falls and Fall Risk, Managing, revised December, 2007, revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. In conjunction with the Attending Physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. Review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting, last revised July 2017, revealed all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the Department Director or Supervisor shall promptly initiate and document investigation of the accident or incident. Any corrective action taken shall be included on the Report of Incident/Accident form. 1. Record review revealed the facility admitted Resident #9 on 08/23/18 with diagnoses, which included Immobility Syndrome (Paraplegic); Muscle Wasting and Atrophy, Multiple Sites; Unspecified Lack of Coordination; and Multiple Sclerosis (MS). Review of the Quarterly MDS Assessment, dated 12/04/18, revealed the facility assessed Resident #9's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) indicating the resident was interviewable. Further review of the Quarterly MDS revealed Resident #9 required extensive assistance of two (2) staff for bed mobility and total assistance of two (2) staff for bathing. Review of the Comprehensive Care Plan for at risk for falls related to impaired mobility/strength/sensation due to MS, recent left femur fracture, impaired range of motion, pain, muscle spasms, and use of psychotropic and opioid medications, created on 08/27/18 revealed to review information from past falls and attempt to determine cause of falls, record possible root causes, alter/remove any potential causes if possible, and educate resident, family, caregivers, interdisciplinary team as to causes. Review of the Comprehensive Care Plans revealed Resident #9 had a self-care deficit in activities of daily living except eating related to impaired mobility/strength/ endurance/ due to MS, initiated on 08/27/18. Further review of the care plan revealed Interventions to provide extensive assist of two (2) staff for activities of daily living and mobility tasks, total assist if the resident was unable to participate, date initiated 09/10/18. Review of a Fall Incident/Investigation Report revealed Resident #9 sustained a fall on 02/01/19 at 3:19 PM with no injuries. Further review of the report revealed CNA #1 reported to Registered Nurse (RN) #1 that she was giving the resident a bed bath and turned him/her to finish drying him/her when the resident's legs began to slide off the bed. CNA #1 was able to guide the resident's body off the bed onto the floor avoiding hitting his/her head on the ground. Further review revealed the immediate intervention was vitals and assessment done prior to moving the resident back to bed. Review of the Nurse's Progress Notes dated 02/01/19 at 3:57 PM, revealed the resident had a fall with the same description verbatim as the 02/01/19 Fall Investigation Report and also revealed upon assessment, the resident stated he/she was fine, nothing hurt. Further review of the note revealed the resident was unable to move his/her lower half related to MS and the resident was assisted to bed with a lift. The Nurse Practitioner and Power of Attorney were notified of the fall and the mobile x-ray company was notified for STAT x-rays. Further review of the Nurse's Progress Notes revealed a note dated 02/01/19 at 4:10 PM that was a duplicate entry of the 3:57 PM note and there was no further documentation about the resident until 02/06/19 at 1:44 PM which revealed the resident was in the hospital. Further review of the Nurse's Progress Notes revealed there was no documented evidence as to when and why the resident went to the hospital or how he/she was transported. Review of the Physician's Order Sheet for February, 2019, revealed an order dated 02/01/19 for STAT (immediately) x-rays to bilateral hips and STAT x-rays to bilateral femurs two (2) views related to a fall. Review of the x-ray results dated 02/01/19 at 6:45 PM, revealed x-rays were completed for bilateral hips and pelvis, which indicated an acute or subacute fracture of the left hip. Review of the Hospital Physician's Discharge summary dated [DATE], revealed Resident #9 was admitted to the hospital on [DATE] with diagnoses, which included Closed Fracture of Lateral Condyle of Left Femur with no surgical intervention. The resident was discharged back to the facility on [DATE]. Review of the Physician's Orders for February, 2019, revealed orders for Hydrocodone-Acetaminophen tablet 10-325, give one (1) tablet by mouth every six (6) hours as needed for moderate pain, and Hydrocodone-Acetaminophen tablet 10-325, give two (2) tablets by mouth every six (6) hours as needed for severe pain; initiated on 02/07/19, the day Resident #9 returned from the hospital. Review of the January 2019 Medication Administration Record (MAR) revealed Resident #9 required Hydrocodone-Acetaminophen 10-325 for moderate pain twenty-one (21)