**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure staff provided residents with adequate supervision for four Residents (#22, #26, #1, and #8), out of 16 sampled residents, and an environment free from accident hazards on two of two units in the facility. Specifically, the facility failed to ensure: 1. For Resident #22, that effective care plan interventions were developed and implemented to prevent a fall with major injury; 2. For Resident #26, that effective care plan interventions were developed and implemented to prevent seven falls; 3. For Resident #1, that effective care plan interventions were developed and implemented to prevent three falls; 4. For Resident #8, that effective care plan interventions were developed and implemented to prevent four falls ; 5. The clean utility room on Unit 4 was locked and hazardous items including topical treatments were securely stored and not accessible to wandering residents; and 6. Medications were not left unsecured and accessible to residents on a medication cart on Unit 3. Findings include: Review of the facility's policy, Fall Prevention Program, last revised 8/2021, included, but was not limited to: -Goal: To identify residents at risk for falls and assure appropriate intervention for prevention of falls are implemented. To prevent injury with falls to the extent possible. -Procedure: Residents determined to be high risk for falls, may have the following preventative measures implemented: -Physical Therapy screen and follow recommendations -Frequent visual safety checks at regular intervals if necessary -Residents determined to be at risk will have the potential for falls reviewed at the weekly RISK team meeting and addressed on their care plan with the appropriate interventions documented. The CNA [Certified Nursing Assistant] assignment will indicate the resident is at risk for falls -The CNA Care Plan/Assignment & Resident Care -Plan will be updated with any change when the change occurs FALLS: 1. Resident #22 was admitted to the facility in March 2018 with diagnoses including dementia and a history of falls. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #22 requires extensive assistance of two staff for transfers, bed mobility and utilized a wheelchair. The assessment indicated the Resident was unsteady and only able to stabilize with assistance when moving from a seated position to standing. Review of Resident #22's Interdisciplinary Care Plans included, but was not limited to: -Problem: Resident is at risk for falling related to a history of falls, dementia, incontinence and poor safety awareness (3/6/18) -Approach: Keep visible when up due to impulsive and history of falls (12/7/21); No chuck pad on wheelchair to prevent sliding from chair (7/6/20); Prefers to stay up until 10:00 P.M. (2/28/21); Encourage resident to assume a standing position slowly (3/6/18); Give resident verbal reminders not to ambulate/transfer without assistance (3/6/18); Keep bed in lowest position with brakes locked (3/6/18); Prompted toileting every A.M., P.M., before/after meals, bedtime and as needed (3/6/18) -Goal: Resident will remain free from injury with fall initiated (9/20/20) Review of the medical record indicated Resident #22 had seven falls from December 2021 to October 2022. Review of the falls indicated: 1.12/7/21 at 8:15 A.M., Resident was found on the floor mat next to bed. Review of the documentation failed to indicate what interventions were in place at the time of the fall, or interventions implemented to reduce the risk of future falls. 2. 2/9/22 at 10:15 P.M., Resident was found on the floor in the bathroom doorway in his/her room. Intervention identified to prevent the risk of falls was an eval. Review of the medical record failed to indicate an eval was conducted. No new interventions were put in place to prevent further falls. 3. 2/13/22 at 4:15 A.M., Resident was found on the floor mat next to bed. Intervention identified to prevent the risk of falls was an eval. Review of the medical record failed to indicate an eval was conducted. No new interventions were put in place to prevent further falls. 4. 6/18/22 at 10:00 A.M., Resident was found on the floor in the dining room on his/her back with blood coming from the head area. Review of the documentation failed to indicate what interventions were in place at the time of the fall. Intervention identified to prevent the risk of falls was an eval. A staff statement (CNA) indicated Resident #22 was toileted at 8:00 A.M. and was last seen sleeping in his/her wheelchair in the unit dining room. Review of the medical record failed to indicate any new interventions to prevent further falls. Review of a 6/18/22 Nursing Progress Note indicated that at approximately 10:00 A.M., the Nurse and CNA heard a thump, saw Resident #22 on the floor in the unit dining room on his/her back with blood coming from his/her head. The Resident was sent to the emergency room for evaluation. Review of the medical record and Hospital Discharge summary, dated [DATE], indicated Resident #22 presented to the Emergency Department after having an unwitnessed fall from his/her wheelchair with a head strike and laceration to the right forehead. The documentation indicated facility staff report the Resident slides out of his/her wheelchair occasionally. The assessment and plan indicated the Resident did not sustain a fracture but had a large forehead laceration and hematoma. The wound was cleaned and was going to be repaired by the PA (Physician's Assistant), however the size of the hematoma made it impossible to approximate the wound edges. Even with removal of some clot, the wound was too gaping to suture. Review of a 6/19/22 Nursing Progress Note indicated the forehead laceration measured 4.9 centimeters (cm) x 1.5 cm. 5. 7/25/22 at 4:00 A.M., Resident was found on the floor mat next to bed. Intervention identified to prevent the risk of falls was a PT eval. Review of the medical record failed to indicate a PT eval was conducted and no interventions were implemented to prevent further falls. 6. 9/19/22 at 10:30 P.M., Resident was found on the floor mat next to bed. Intervention identified to prevent the risk of falls was PT to screen. Review of the Rehabilitation Screen documentation failed to indicate any new interventions were recommended. 7. 10/5/22 at 12:32 A.M., Resident found on the floor mat next to bed. Intervention identified to prevent the risk of falls was screen. Review of the Rehabilitation Screen documentation failed to indicate any new interventions were recommended. During an interview on 10/7/22 at 11:30 A.M., the surveyor and Nursing Supervisor reviewed Resident #22's falls. The Nursing Supervisor said that the team had discussed different interventions to prevent falls but had not implemented any. She could not explain why the Resident's fall on 6/18/22 was unwitnessed and the care plan intervention of being kept visible when up due to impulsive behavior was not implemented . The Nursing Supervisor confirmed that no new interventions have been developed or implemented to prevent Resident #22 from having further falls. Review of the medical record on 10/20/22 indicated that Resident #22 was found on the floor mat next to bed. Intervention identified to prevent the risk of falls was a raised perimeter mattress placed on the Resident's bed. 2. Resident #26 was admitted to the facility in August 2017 with diagnoses including hypertension. Review of the 8/22/22 Minimum Data Set assessment indicated that Resident #26 requires supervision for transfers, walking in his/her room, toileting and personal hygiene. The assessment also indicated that the Resident is unsteady while walking, turning around, turning around and facing the opposite direction while walking and moving on and off the toilet. Review of interdisciplinary care plans included, but was not limited to: Problem: Resident is at risk for falling related to unsteady gait, psychotropic medication use (8/22/17) Approach: Keep call light and personal items in reach at all times (8/22/17); Encourage resident to use environmental devices such as hand grips, handrails, etc. (8/22/17); Provide verbal cues to stand tall and slow down during ambulation (12/9/19); Per request of Resident, handheld assist as required (2/6/20); Extra railing added along the wall to the bathroom for extra support (2/7/20) Goal: Resident will be free from injury (9/3/20) Review of the medical record indicated Resident #26 had seven falls from February 2022 to October 2022. Review of the falls failed indicated: 1. 2/18/22 at 1:45 A.M., Resident was found lying face down on the floor next to bed with pants around his/her ankles. A bruise was noted to the Resident's forehead and a skin tear to his/her left elbow. Review of documentation failed to indicate what interventions were in place at the time of the fall, or interventions implemented to reduce the risk of falls. 2. 4/3/22 at 12:15 A.M., Resident was found sitting on his/her buttocks in front of the toilet. Intervention identified to prevent the risk of falls was PT screen. Review of the Rehabilitation Screen documentation failed to indicate any new interventions were recommended. 3. 4/12/22 at 8:45 P.M., Resident was found on the floor lying on his/her right side in the bathroom. Intervention identified to prevent the risk of falls was PT screen. Review of the Rehabilitation Screen documentation indicated a recommendation for Occupational Therapy (OT) to evaluate and treat the Resident to increase safety and independence in room. The Physician wrote an order for an OT evaluation and treatment. Review of the 5/24/22 OT evaluation indicated the treatment plan would include therapeutic activity, therapeutic exercise, self-care/home management and balance twice a week for eight weeks. The OT evaluation failed to indicate any Resident specific interventions staff could implement to prevent further falls. 4. 5/21/22 at 9:05 P.M., Resident was found sitting on the floor in the bathroom. The section of the report to identify steps taken to prevent recurrence was blank. Review of the medical record failed to indicate any new interventions were implemented to prevent further falls. Review of a 5/27/22 OT treatment note indicated that while transferring to the toilet, Resident #26 continues to be unsafe due to increased knee flexion and shuffling gait. 5. 5/29/22 at 6:58 A.M., Resident was found on the floor in his/her room by custodial staff. The section of the report to identify steps taken to prevent recurrence was blank. Review of a 6/10/22 OT treatment note indicated Resident #26 presents with impaired insight into errors and deficits, requiring maximum cueing to maximize safety. Review of a 9/13/22 OT treatment note indicated Resident #26 walked to the bathroom with distant supervision and cueing and education for safety. 6. 10/2/22 at 8:44 P.M., Resident was found on the floor sitting on the floor in the bathroom. Interventions identified to prevent the risk of falls was: placed on falling star prevention program, encourage resident to ring call bell in bathroom for dressing/undressing. During an interview on 10/20/22 at 11:44 A.M., Physical Therapist (PT) #1 said she is aware Resident #26 has had multiple unwitnessed falls in the bathroom. She said the Resident participates in the Vitality program three days a week (ambulation by rehabilitation staff). The surveyor and PT reviewed the Resident's OT notes and were unable to identify any approaches identified for staff to implement to prevent further falls. She said every two-hour toileting program or increased supervision are interventions that could be implemented to prevent further falls, but she could not explain why they have not been attempted. During an interview on 10/20/22 at 12:25 P.M., Nurse #2 said that Resident #26 gets weak and falls in the bathroom. The surveyor asked Nurse #2 if she has any ideas of how to prevent the Resident from falling again and she said that he/she may be receptive to every 2-hour toileting, or distant supervision. The Nurse did not know why these interventions had not been attempted. 3. Resident #1 was admitted in 4/2010 with diagnoses which included, dementia in other diseases, bipolar disorder, delusional disorders, anxiety disorder, unspecified, and Parkinson's Disease. The Resident's BIMS (Brief Interview for Mental Status) score of 6 out of 15, indicated the presence of severe cognitive impairment. Additionally, the Resident was identified by the facility to be at high risk for falls, according to a John Hopkins Fall Risk Assessment score of #18 (>#13 High Risk). According to the Resident's Plan of Care for: Resident at risk for falling R/T Parkinson's disease, history of falls, poor safety awareness, was revised on 10/20/2022 (date of survey). The Goal was-Resident will remain free from injury. Approaches to achieve the goal were as follows: Start Date 10/18/22 -Resident identified as a fall risk. Place resident on Falling Star program. Start Date 7/30/2020 -Wander Guard placed on w/c (wheelchair) for safety. Start Date 4/30/2010 -Do not leave alone in bathroom. -Encourage resident to assume a standing position slowly. -Encourage resident to use environmental devices such as hand grips, hand rails, etc. -Give resident verbal reminders not to ambulate/transfer without assistance. -Keep call light in reach at all times. -Keep personal items and frequently used items within reach. -Provide resident with safety device /appliance: Gait belt, wheelchair. -Provide toileting assistance QAM, Before/after meals, HS and PRN. -Reacher within reach at all times. -Wheelchair for all mobility. Further Record review on 10/20/22, indicated that, despite the Plan of Care to prevent accidents and injury, the Resident experienced a total of 3 falls between the period of 5/2022 to 9/22/22 as indicated below: 1. On 5/13/2022 at 7:10 A.M., the Resident reportedly slid out of the wheelchair to the floor across from the nurse's station in the hallway by the clean utility room. The Resident was assessed by the nurse and no injuries were reported. The incident report indicated that steps taken to prevent recurrence included: PT eval (physical therapy) evaluation, refused wedge, frequent positioning, at times the Resident sits on the edge of the wheelchair. No additional interventions were listed following this fall to provide increased supervision and safety. 2. On 9/16/2022 at 2:45 A.M., the Resident was reportedly found lying on the floor (unwitnessed) in his/her room, sustained bruises to bilateral hands, right arm skin tear and bruises/abrasions on right lower leg. The incident investigation indicated that a PT eval would be done to prevent recurrence. No other interventions were listed to prevent further falls/injury, provide adequate supervision, and maintain the Resident's safety. 3. On 9/18/22 at 5:05 P.M., the Resident was reportedly found on the floor (unwitnessed) by a CNA (certified nursing assistant) on his/her knees with his/her head laying on the mattress at the foot of the bed. Interventions listed to prevent recurrence included use of the reacher (resident stated reaching for it unknown what) Encourage out of bed for meals d/t (due to) impulsivity. Although interventions were considered for this Resident, the Resident would not reliably remember information provided by staff, due to his/her severe cognitive decline. No additional interventions were implemented to provide greater supervision to maintain the Resident's safety and prevent injury. On 10/20/22 at 11:11 A.M., the Resident was observed in her room, sitting in his/her wheelchair, unsupervised, watching television. The Resident appeared to recognize this writer, and with garbled speech commented on their clothing. The Resident was observed rummaging through his/her drawers, wanted to shut his/her TV off but had difficulty doing so due to his/her debility in movement. Several minutes later, the Resident propelled the wheelchair to the doorway to his/her room, unsupervised, and appeared unsure of what to do. The Resident was non-ambulatory. The Administrator was interviewed on 10/20/22 at 1:50 P.M., regarding the frequent falls for this Resident, one fall with skin tears and bruises, and the risk for additional falls and injury remained due to ineffective safety interventions and supervision. The Administrator said that interventions to prevent falls had not been effective. 4. Resident #8 was admitted in 9/2017 with diagnoses which included unspecified dementia with behavioral disturbance. The medical record indicated that the Resident scored a 4 out of 15 on the BIMS (Brief Interview for Mental Status), which indicated severe cognitive impairment. Therapy indicated on 9/5/22, that an assist of 1 person continued to be required for all stand pivot transfers and the Resident was able to propel the wheelchair using BLE (bilateral lower extremities). On 9/5/22, a John Hopkins Fall Risk Assessment was performed which indicated a score of #18, placing the Resident at high risk for falls. The Resident's plan of care to address Falls was reviewed and indicated the following goals and interventions: GOAL: Resident will remain free from injury. Start Date: 9/26/2017 Approach: Provide toileting assistance per resident's toileting schedule -Give resident verbal reminders to use her call bell and wait for staff to assist her. Keep personal items in reach -Call light and personal items within reach. Night light on at HS (hour or sleep) Start Date: 12/14/21 Approach: Call before you fall/reminder sign posted at wheelchair height. Start Date: 10/18/22 Approach: Resident identified as a high risk for falls. Resident placed on Falling Star program. Falling star placed in resident shadow box for fall identification. Start Date: 10/19/22 Approach: Resident falls identified when reaching for items. Table ordered to allow resident to wheel wheelchair into, edges to prevent cards from slipping off, and is adjustable to resident. 1. On 6/15/22 at 5:00 P.M., the Resident fell and was found on the floor (unwitnessed) next to his/her wheelchair. Review of the incident/accident report, indicated that when asked, the Resident said that he/she was standing and reaching and then, I don't know. A small hematoma was found on the back of the Resident's head. The incident/accident report indicated that steps taken to prevent recurrence was a PT screen. 2. On 8/3/22 at 2:30 P.M., the Resident was found on the floor (unwitnessed) in his/her room next to his/her wheelchair. The incident/accident report indicated that the Resident was able to move all extremities, vital signs were stable, the Resident was alert and answering questions appropriately. The Resident was unable to state how he/she fell. The wheelchair was at reach beside the Resident. A reddened area was noted at the right, lower rib cage which resolved after 10 minutes. Steps taken to prevent recurrence noted on the incident/accident report were, PT eval and new tray table attempt for cards. No additional interventions were considered to prevent further falls/injury to the Resident. Physical therapy's evaluation of the Resident on 8/4/22, indicated, Frequent visual checks by all staff recommended and anticipation of needs to limit his/her reaching far forward. 3. On 8/17/22 at 1:45 P.M., Resident was reportedly heard yelling help. According to the incident/accident report, upon entering the room, the nurse found the Resident lying on the floor on his/her left side between the radiator and the closet. The Resident was alert, assessed by the nurse, and found to have no injuries. The incident/accident report indicated that, steps taken to prevent recurrence were, -encourage Resident to ring call bell for fallen cards, and -continue to reinforce call bell use. (Resident with severe dementia) 4. On 9/13/22 at 6:33 A.M., the Resident was found (unwitnessed) sitting on the floor in his/her room leaning against the bed. According to the incident/accident report, the Resident fell out of bed while trying to get to his/her wheelchair to use the bathroom. No apparent injuries were noted. The incident/accident report indicated that steps taken to prevent recurrence included, -educate resident on importance of waiting for assistance. -Reinforce call bell use. (Resident with severe dementia) In spite of approaches listed in the Resident's plan of care, the facility failed to provide adequate supervision and effective/appropriate interventions to prevent falls/accidents. Interview with the administrator on 10/20/22 at 1:55 P.M., said that the facility had a significant number of falls. She acknowledged that interventions, at times, were not effective and did not necessarily take into account the unique behaviors of residents and patterns associated with the falls. SAFETY HAZARDS 5. On 10/4/22 from 1:30 P.M. to 1:56 P.M., the surveyor observed two residents wandering the hallway on Unit 4 (secured unit/Memory Impaired). There was no facility staff visible in the unit hallway at the time of the observation. On 10/4/22 at 1:57 P.M. on Unit 4, the surveyor approached a closed door labeled clean utility. The door had a numerical combination lock on it, but the door was not pulled tight and secured and was easily pushed open. The room contained an unlocked treatment cart with a plastic caddy placed on top of the cart containing a bottle of fingernail polish remover, 12 bottles of fingernail polish, and one wooden manicure stick. The drawers of the treatment cart contained: -Drawer #1: two boxes of zinc oxide skin protectant ointment, two boxes of hemorrhoidal ointment, two tubes moisture barrier antifungal cream, one bottle of skin prep spray. -Drawer #2: one box of 200 alcohol prep wipes -Drawer #3: one bottle of fecal occult blood developing solution, one bag of wooden specimen sticks -Drawer #4: one box of Bacitracin Zinc antibiotic ointment Shelves in the clean utility room contained: -five bottles of baby powder -16 bottles of moisturizing body lotion with mineral oil -22 bottles of deodorant -15 bottles of shampoo -13 bottles of body wash -14 bottles of hand sanitizer -five cans of shaving cream -one box of 144 packets of Bacitracin antibiotic ointment -four boxes of zinc oxide ointment -30 packets of white petroleum skin protectant -three boxes of denture cleanser tablets -seven boxes of denture adhesive -seven boxes of toothpaste -18 bottles of mouthwash During an interview on 10/4/22 at 2:08 P.M., the surveyor showed Nurse #1 the unsecured clean utility room door. Nurse #1 pushed open the door and said the room is supposed to be locked at all times. 6. On 10/20/22 from 12:18 P.M. to 12:22 P.M., the surveyor observed one resident wandering the hallway on Unit 3. There was no facility staff visible in the unit hallways at the time of the observation. On 10/20/22 at 12:22 P.M. on Unit 3, the surveyor observed a medication cart positioned against the nursing station desk (opposite side that faces the unit dining room). There were 26 medication cards filled with prescription medication, two boxes of inhalers and a bag filled with medications and treatments on top of the medication cart. The surveyor observed Nurse #2 and a Certified Nursing Assistant in the unit dining room approximately 30 feet away from the medication cart. The line of sight from the dining room to the medication cart was obstructed by walls surrounding the nursing station. At 12:24, Nurse #2 approached the surveyor at the medication cart and said that she had to change out an oxygen tank for a resident seated in the dining room. She said that before changing the oxygen tank, she should have either locked the medications in the cart or brought them to the medication room.