**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the Comprehensive Care Plan was implemented for one (1) of four (4) sampled residents (Resident #17). The facility care planned Resident #17 to require extensive assistance of two (2) staff for turning, repositioning, and bed mobility. However, on 02/21/2022, Certified Nursing Assistant (CNA) #1 provided incontinent care for Resident #17 alone, and without the care planned assistance of two (2) staff members. During the provision of incontinent care by only CNA #1, Resident #17 rolled off the bed and was observed as bleeding from his/her face. Resident #17 was transferred to the hospital emergency room and subsequently admitted to the hospital with diagnoses of Fracture of the lower end of his/her left femur, Fracture of the nasal bones, and Maxillary Fracture (a complex group of facial fractures) to the left side of the face. The findings include: Review of the facility policy titled, Care Plan dated August 2015, revealed a Comprehensive Plan of Care was to be developed and implemented for each resident that included measurable objectives and timetables for meeting a resident's identified medical, nursing and mental/psychosocial needs. Per review, the Interdisciplinary Team (IDT) along with the resident, family members, or legal representative, were to develop and implement the comprehensive, person-centered care plan for each resident. Residents' Comprehensive Plan of Cares were to be developed within seven (7) days of their admission, then quarterly and with a significant change of condition thereafter. Further review revealed residents' care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Review of the medical record for Resident #17 revealed the facility admitted the resident on 12/23/2019, with diagnoses which include with the following diagnoses: Type 2 Diabetes Mellitus, Dementia, and Paroxysmal Atrial Fibrillation. Review of the Significant Change of Status Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #17 as severely cognitively impaired as evidenced by the Brief Interview for Mental Status (BIMS) score of three (3). Review of the Comprehensive Care Plan for Resident #17 revealed the facility had care planned the residents for falls dated 01/10/2022, related to a history of falls prior to admission, his/her diagnosis of Dementia, and due to decreased mobility from a recent hospitalization. Continued review revealed Resident #17's care plan contained an bed mobility intervention, with an initiated date of 01/10/2022, which noted the resident required assistance of two (2) staff to turn and reposition in bed every two (2) hours. Continued review revealed a previous intervention noting Resident #17 required assist of two (2) staff for toileting initiated on 01/10/2022 which had been documented as resolved. Review revealed an intervention initiated 03/09/2022 (after the incident on 02/21/2022), which stated due to Resident #17's poor safety awareness he/she was to have a low bed at all times. Further revealed an intervention initiated 03/23/2022, noting Resident #17 was not toileted and required total assist with check and change every two (2) hours. Review of the facility's [NAME] (a document used by CNA's which noted a resident's care plan interventions) for Resident #17 dated 02/20/2022 and 02/21/2022, revealed the resident required extensive assistance of two (2) staff for turning and repositioning regarding his/her bed mobility. Further review of the [NAME] revealed Resident #17 required extensive assistance of two (2) staff also for toileting. Interview with Licensed Practical Nurse (LPN) #1 on 04/13/2022 at 9:30 PM, revealed she was a contracted agency nurse and 02/20/2022 had been her first night working at the facility. Per interview, LPN #1 had received a fast track orientation. She stated on 02/21/2022 at 5:30 AM, CNA #1 was yelling for help from a resident's room and she went to that room to assist. LPN #1 revealed upon walking into the room she observed the resident lying on the floor bleeding from the left side of his/her forehead. According to LPN #1, she obtained the resident's vital signs, initiated neurological (neuro) checks of the resident, and obtained an order to send Resident #17 to the emergency room (ER). Continued interview revealed Emergency Medical Services (EMS) staff arrived and placed Resident #17 stretcher left facility at 5:49 AM to transport the resident to the ER. LPN #1 stated CNA #1 told her she had been changing Resident #17 and the resident placed his/her left leg over the right leg, then rolled out of bed. Further interview revealed LPN #1 knew Resident #17 required two (2) staff persons assistance for his/her incontinent care. LPN #1 revealed she had been under the impression CNA #1 was also aware the resident required two (2) person assist for incontinent care. Review of the hospital Emergency Department (ED) Provider's Notes dated 02/21/2022, revealed Resident #17 had complex left facial fractures with depression of the left orbital floor, extensive facial swelling, and depressed nasal bone fractures. In addition, continued review revealed Resident #17's x-ray results of the left lower extremity revealed a comminuted (where a bone is broken, splintered, or crushed into a number of pieces) and somewhat impacted (when a bone is driven into another bone from the force of an injury) fracture involving the distal femoral diametaphysis. Interview with Registered Nurse (RN) #2 on 04/14/2022 at 1:10 PM, revealed she had been working the night shift on 02/21/2022 with CNA #1. According to RN #2, she and CNA #1 had been performing the last rounds of residents and she was by herself in another resident's room when the incident of Resident #17 falling out bed occurred. RN #2 stated she assumed CNA #1 had decided to go ahead and start Resident #17's on her own without assistance. She further revealed the [NAME] in Point Click Care was the care plan used by staff for knowing residents's care needs. Interview with CNA #3 on 04/14/2022 at 1:58 PM, revealed he had been working at the facility for almost three (3) years, and knew Resident #17 was an assist of two (2) staff before the incident and currently still was. According to CNA #3, the [NAME] was available on the computer at the nurse's station for staff to review, and was staff could find out what kind of care to provide for their residents. Further interview revealed the Assistant Director of Nursing (ADON), who was also the MDS Nurse, updated residents' care plans and Kardexes. Interview with CNA #8 on 04/14/2022 at 2:05 PM, revealed she had worked for the facility for three (3) years. According to CNA #8, newly admitted residents Kardexes were kept on the inside of their closet doors for approximately two (2) weeks after admission for staff to review; however, the [NAME] was also always on the computer for them to review. Further interview revealed Resident #17 had previously and still was an assist of two (2) staff for incontinent care. CNA #8 stated most of the facility residents were an assist of two (2) staff. Interview with CNA #6 on 04/15/2022 at 9:30 AM, revealed the [NAME] was located on the computer at the nurse's staff. Per CNA #6, staff were supposed to look at their assigned residents Kardexes at the beginning of their shift. Further interview revealed if staff did not follow the residents' care plans/Kardexes the resident or staff could get hurt. Interview with CNA #7 on 04/15/2022 at 9:45 AM, revealed that she had worked at the facility for seven (7) years. Continued interview revealed the facility's [NAME] was where staff looked to see what kind of care a resident needed. Per CNA #7, Resident #17 was an assist of two (2) staff for everything except eating and doing small Activities of Daily Living (ADLs) like brushing his/her own hair. Further interview revealed the facility staff received training at monthly meetings, through inservices, and on modules on the computer. Interview with CNA #1 on 04/19/2022 at 7:30 AM, revealed she had been certified as a CNA for a little over a year and worked for a contract agency. CNA #1 revealed the first assignment she had been given by the contract agency was working at the facility. She stated she had been oriented for approximately a week when first starting work at the facility. Per interview, while being oriented she had written down the amount of assistance each resident needed that she observed being cared for. Continued interview revealed CNA #1 had cared for Resident #17 while working at the facility, and had reviewed the resident's [NAME] during that time. CNA #1 stated the night of the incident, 02/21/2022 she felt she was familiar with Resident #17's care needs, and had not reviewed his/her [NAME] prior to providing care of the resident. According to CNA #1, on the night of the incident when entering Resident #17's room she noticed his/her bedrails were no longer on the bed. CNA #1 stated she had gone into Resident #17's to provide incontinence care by herself, and turned the resident onto his/her sides with the bed in position that was about waist high to her. She revealed she noticed only the Chux pad and drawsheet needed changing, so she assisted Resident #17 to lie flat on his/her back while she obtained her supplies from the end of the bed. Per CNA #1, while she was obtaining her supplies Resident #17 crossed his/her left leg over the right leg and then rolled out of his/her bed onto the floor. She stated she called for the nurse to come to Resident #17's room, and the nurse came, looked at the resident, took his/her vital signs, and started neuro (neurological) checks of the resident. Further interview revealed Resident #17 was sent out to the hospital by the nurse. CNA #1 further stated she had been charting Resident #17 as an extensive assist, as that was what she had thought the resident was. The CNA stated she had observed other CNA's providing care for Resident #17 by themselves. She additionally stated the contract agency she worked for notified her approximately two (2) hours before she was to work again at the facility after the incident, to let her know her contract had been canceled by the facility. Interview with the Administrator on 04/15/2022 at 10:15 AM, revealed her expectations were for all staff, including CNA #1, to have provided the assist of two (2) staff to change Resident #17 as per the resident's care plan/[NAME]. The Administrator revealed all staff were expected to receive shift report from the staff leaving, and to read their assigned residents' [NAME] before providing the residents' care. Further interview revealed when a resident required a two (2) person assist the assigned staff person was expected to wait for assistance from another staff member, and not provided care alone. The Administrator revealed staff education had been provided and was still ongoing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents received adequate supervision and assistive devices to prevent accidents (Resident #17). The facility assessed and care planned Resident #17 to be at risk for falls and to require the assistance of two (2) staff for bed mobility and incontinent care. However, on 02/21/2022 Certified Nursing Assistant (CNA) #1 provided incontinent care to the resident without the assistance of another staff member as per the care plan. As a result, Resident #17 rolled off the side of the bed during the incontinent care provided by CNA #1. The resident sustained left facial fractures and left hip fracture as a result of rolling off the bed which required surgical intervention. The findings include: Review of the facility's policy titled, Incidents and Accidents, dated August 2015, revealed an incident report was to be completed for any occurrence including, but not limited to falls or suspected falls, including fractures and head injuries which were to be reported immediately. Review revealed the resident was not to be moved unnecessarily until his/her condition had been assessed. Per review of the policy, a full body assessment was to be completed and documented on the post fall skin assessment form, and the resident's neurological signs were to be assessed as appropriate. Continued review revealed the Physician was to be notified and orders obtained for care, and the resident's family notified of the accident, resident's status and orders obtained for care. Review revealed the resident was to be transferred to the emergency room as needed, and his/her Plan of Care updated as necessary with implemented interventions. According to review of the policy, a fall screening was to be performed on any resident's falls or suspected falls. The policy review revealed the Director of Nursing and Administrator, or designee were to be immediately notified and would notify the [NAME] President of Clinical Operations when incidents were reported to the State Agency and as necessary. Further review revealed interventions were to be documented in the facility's incident reporting system as well as in the Nurse's Notes, and resident's plan of care (acute). Review further revealed an internal incident/accident report was to be completed for quality assurance purposes, and witness statements completed with signatures. Review of the facility policy titled, Resident Safe Environment, dated August 2015, revealed the facility promoted and maintained each resident's dignity and independence in a safe environment. Per review, the standard of the policy was to evaluate all residents for fall risk by using the fall evaluation form initially, quarterly, and as indicated by the interdisciplinary review of incident evaluations. Further review of the policy revealed staff were to report any unsafe acts promptly and initiate team evaluations. Review of Resident #17's medical record revealed the resident was admitted to the facility on [DATE], with the following diagnoses: Dementia, Type 2 Diabetes Mellitus, and Paroxysmal Atrial Fibrillation. Review of the Significant Change of Status Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #17 to have a Brief Interview for Mental Status (BIMS) score of three (3) which indicated severe cognitive impairment. Review of Resident #17's Comprehensive Care Plan, revealed a Focus for falls related to his/her Dementia diagnosis, a history of falls prior to admission and his/her decreased mobility from a recent hospitalization dated 01/10/2020. Review of the Care Plan revealed an intervention for Resident #17's bed mobility which noted the resident required assistance of two (2) staff to turn and reposition in bed every two (2) hours, with an initiation date of 01/10/2020. Continued review revealed an intervention for the resident to have a low bed at all times due to poor safety awareness with an initiation date of 03/09/2022. Further revealed under toilet use an intervention documented stating Resident #17 was not toileted and required total assistance for a check and change every two (2) hours initiated on 03/23/2022. In addition, a previous resolved intervention was noted Resident #17 required assistance of two (2) staff for toileting which had been initiated on 01/10/2020. Review of Resident #17's [NAME] (a facility document utilized by CNAs noting each residents' care needs), dated 02/20/2022, and 02/21/2022, revealed for bed mobility Resident #17 required extensive of two (2) staff to turn and reposition in bed, and for toileting. Review of the Morse Fall Scale document dated 12/13/2021, revealed a score of fifty-five (55) for Resident #17, a score of forty five (45) or higher, indicated the resident was at a high risk for falls. Further review of the facility's Morse Fall Scale documents for Resident #17 revealed a Fall Scale dated 02/21/2022, which noted the resident had a score of fifteen (15), a score of zero (0) to twenty four (24), indicated the resident was at a low risk for falls. Observation on 04/12/2022 at 9:10 AM, of Resident #17 revealed the resident lying on his/her bed with eyes open. Interview with Resident #17 at the time of observation revealed the resident stated his/her name and stated he/she liked to stay in bed. No facial deformities noted. Review of the facility's investigation's summary dated 02/21/2022, revealed the Interdisciplinary Review Committee (IRC) had reviewed an incident which had occurred on 02/21/2022. Review revealed Resident #17 had not had any falls in the last two (2) years; however, on last rounds on 02/21/2022 at 5:30 AM, CNA #1 had been changing Resident #17 without assistance of another staff. Review revealed during CNA #1 changing Resident #17, the resident kicked his/her leg over and rolled off the bed. Per review, an Acute Care Plan had been initiated, the facility's Physician and Power of Attorney (POA) had been notified of the incident. Continued review revealed Resident #17 was sent out to the emergency room (ER) for evaluation and treatment after the fall, and admitted to the hospital with facial fractures and a left hip fracture. Further review revealed the agency CNA's contract was terminated for failure to follow Resident #17's care plan. Review further revealed the the facility identified the cause of the incident as CNA #1 performing Resident #17's care without the care planned assistance of two (2) staff. In addition, a Quality Assurance (QA) meeting was conducted and an inservice for staff implemented regarding reviewing residents' Kardexes. Review of CNA #1's statement, from the facility's investigation dated 02/21/2022, revealed she had been on the right side of Resident #17's bed and had the resident turn over towards her to roll up the Chux (a disposable protective pad) and draw sheet (a sheet utilized to assist with moving people in bed) during incontinence care. Continued review revealed CNA #1 had documented she had moved to the left side of Resident #17's bed and had the resident roll towards her again, as she had seen she needed to remove the Chux pad and drawsheet completely from under the resident. Review revealed CNA #1 had Resident #17 lay flat and pulled the draw sheet up halfway, telling the resident to hold on, we're about to roll. Further review revealed Resident #17 placed his/her left leg over his/her right leg and was rolling off the bed before she realized it. Review further revealed CNA #1 ran to the other side of Resident #17's bed as soon as possible and observed the resident lying on the floor in a cradle position. Review of the Emergency Department (ED) Provider's Note dated 02/21/2022, revealed a Computerized Tomography (CT) scan had been performed of Resident #17's face, and x-rays performed of the resident's lower extremity. Continued review revealed the CT scan results of Resident #17's facial bones without contrast showed complex left facial fractures with depression of the left orbital floor (bones surrounding the eyeball), depressed nasal bone fractures and extensive left facial swelling. Further review revealed the results of the left knee x-ray noted a comminuted (where the broken ends of a bone are shattered into many pieces) and somewhat impacted fracture (when broken ends of a bone are jammed together by the force of an injury) involving the distal femoral diametaphysis. Interview on 04/13/2022 at 9:30 PM, with Licensed Practical Nurse (LPN) #1 revealed she was an agency(contracted) nurse, and had worked her first night at the facility on 02/20/2022. Per interview, LPN #1 had received a fast track orientation for working at the facility prior to her shift on 02/20/2022. She stated on the morning of 02/21/2022 at 5:30 AM she was passing residents' medications when she heard CNA #1 yelling for help from a resident's room (Resident #17's room) and she went to the room to assist. Continued interview revealed when she walked into the resident's room she observed the resident lying on the floor, and bleeding on the left side of his/her forehead. According to LPN #1, she obtained the resident's vitals (vital signs), started performing neuro checks(neurological checks), and obtained an order to send the resident to the emergency room. LPN #1 stated Emergency Medical Service (EMS) staff arrived, placed the resident on a stretcher, and left facility at 5:49 AM to transport him/her to the emergency room. Further interview revealed CNA #1 stated she had been changing the resident when the resident crossed his/her left leg over the right one and then rolled out of bed. Licensed Practical Nurse (LPN) #1 further stated she had known the resident was a two (2) person assist for incontinent care, and had been under the impression CNA #1 had also been aware of that information as the CNA had been working at the facility for a while. In addition, LPN #1 stated she had notified the resident's POA, the DON and Administrator, and filled out the necessary paperwork regarding the incident. Interview further revealed Resident #17's fall and injuries could have been prevented had CNA #1 waited for assistance from another staff member. Interview on 04/14/2022 at 1:10 PM, with Registered Nurse (RN) #2 revealed she had been working on the facility's night shift with CNA #1 on 02/21/2022. Per interview, she had been a CNA herself at the time of the incident and had been performing last rounds with CNA #1. She revealed she had been in another resident's room providing care when CNA #1 was assisting Resident #17 with incontinence care and experienced the fall from the bed. RN #2 stated she was aware at the time of the incident that Resident #17 was a two (2) person assist for turning, changing, and toileting. Further interview revealed she assumed CNA #1 decided to start caring for Resident #17 on her own, as she had not waited for assistance. RN #2 stated the [NAME] in the facility's Point Click Care computerized system was the residents' care plan staff referred to know the residents' care needs. In addition, RN #2 revealed CNAs and nurses received report from the staff going off shift before starting their work, and she always looked at the [NAME] each shift too to see whether any changes had occurred. Interview on 04/14/2022 at 1:58 PM, with CNA #3 revealed he had been a CNA working at the facility for almost three (3) years. He stated the [NAME] was available on the computer at the nurse's station and was where you find out what kind of care residents needed. Further interview revealed the MDS Nurse updated residents' care plans and Kardexes. CNA #3 further stated Resident #17 was an assist of two (2) staff for care before 02/20/2022, and still was currently. Per interview, CNA #3 revealed if Resident #17 had the assistance of the required two (2) person assist, then he/she would try to help roll himself/herself. Further interview revealed when a resident was a two (2) person assist, he always let the residents know to wait and someone would be right with them to assist them. Interview on 04/14/2022 at 2:05 PM, with CNA #8 revealed she had been working at the facility for three (3) years. She stated for new admits the [NAME] was kept on the inside of their closet doors for approximately two (2) weeks for staff to refer to; however, was always on the computer also for review. Further interview revealed she had known Resident #17 was an assist of two (2) staff for incontinent care, and most of the facility's residents were assist of two (2) staff. CNA #8 further stated if a resident was a two (2) person assist she went and got someone to help her. In addition, she revealed she the MDS Nurse made necessary changes to residents' care plans and Kardexes. Interview on 04/15/2022 at 9:30 AM, with CNA #6 revealed she had been a CNA for three (3) years. Continued interview revealed the [NAME] for residents was located on the computer and staff were supposed to look at it at the beginning of their shift to know what care residents needed. CNA #6 stated if a resident's care plan/[NAME] was not followed a resident or staff could get hurt; however, was not aware of any staff not following residents' Kardexes. Interview with CNA #7 on 04/15/2022 at 9:45 AM, revealed that she had been with the facility for seven (7) years. Continued interview revealed the [NAME] was where you go to see what kind of care a resident needed. CNA #7 stated Resident #17 was an assist of two (2) staff for everything except eating or small Activities of Daily Living (ADLs such as brushing his/her hair. Further interview revealed staff received training at monthly meetings, during inservice education, and on modules on the computer. Interview on 04/19/2022 at 7:30 AM, with CNA #1 revealed she worked through a contract agency, and had been a CNA for a little over a year. She stated her first assignment as an agency CNA had been at the facility, and she had worked at the facility for a little over a year. The CNA stated she had reviewed Resident #17's [NAME] previously when working at the facility and provided care for the resident. However, had not reviewed the [NAME] the night of the incident as she felt she was familiar with the resident's care. CNA #1 revealed when she walked into Resident #17's room that night she had noticed there were no longer any bedrails on his/her bed. Per interview, Resident #17 had bilateral siderails on his/her bed. CNA #1 stated Resident #17's bed had been in the low position when she went in to provide his/her incontinent care; however, she moved it higher to provide the resident's care. Continued interview revealed CNA #1 turned Resident #17 over onto his/her right side towards her in order to roll up the Chux pad and draw sheet. Continued interview revealed CNA #1 then moved to the other side of Resident #17's bed, rolled the resident onto his/her left side, and observed she just needed to change the Chux pad and draw sheet. She stated she assisted Resident #17 to lie flat on the bed, pulled the sheet halfway up and went to get her supplies which were lying at the end of the bed. CNA #1, while she was at the end of the bed Resident #17 placed his/her left leg over the right leg and in doing so, rolled out of the bed onto the floor. She revealed Resident #17 was curled in a somewhat fetal position on the floor after rolling out of the bed, and was bleeding from his/her head and elbow. The CNA stated she went to the resident's side to look at him/her and make sure he/she was okay. She stated she called for the nurse to come, and the nurse looked at the resident, took his/her vitals, started neuro checks and sent the resident out to the hospital. CNA #1 revealed she had been oriented for approximately one (1) week when she first started working at the facility, and during that time had written down how much assist each resident needed according to what she observed during her orientation. Further interview revealed she had thought Resident #17 was an extensive assist and had been charting the resident as such since she started working at the facility. CNA #1 further revealed she had seen other CNA's going into Resident #17's room to change him/her by themselves. In addition, she stated the contract agency she was employed through called her approximately two (2) hours before she was to work her next shift at the facility, and told her the facility had canceled her contract. Interview on 04/15/2022 at 10:15 AM, with the Administrator revealed she expected all staff, including CNA #1, to provide assist of two (2) staff to change Resident #17 as per his/her care plan/[NAME]. Continued interview revealed staff were expected to obtain shift report from the off going staff, and to read the [NAME] for all their assigned residents before providing care for their assigned residents. Interview revealed when a resident was a two (2) person assist, staff members were expected to provide the care residents required. The Administrator stated education had been provided after the incident and was ongoing. Per interview, the facility identified the CNA's failure to follow Resident #17's care plan as the root cause of the incident. Further interview revealed for the agency staff the facility utilized a fast track orientation was provided by facility staff. In addition, the Administrator revealed spot checks were being performed visually and verbally by administrative staff after the incident.