**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall with fracture for one Resident (R19) of five residents reviewed for falls. This deficient practice resulted a tibial (lower leg) fracture, with increased pain. Findings include: Review of R19's Minimum Data Set (MDS) assessment, dated 11/15/23, revealed R19 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease and depression. R19 required assistance with toileting and was independent with transfers and walking. R19 was unable to participate in the Brief Interview for Mental Status (BIMS) assessment, showing severe cognitive impairment. The sensory assessment revealed R19 was sometimes understood, and sometimes able to understand. Review of R19's accident and incident report, dated 11/17/23 at 10:14 a.m., revealed R19 was found by a housekeeping staff yelling for help and was observed sitting on the floor at the end of the bed, with her legs out facing her closet. R 19 was holding her left lower leg and said it was painful. R19 stated, I fell. R19 was sent to the Emergency Department (ED). Review of R19's ED report, dated 11/17/23 at 17:36 p.m., showed R19 was diagnosed with a medial tibial fracture. R19 was non-weight bearing on the left lower extremity and provided a knee immobilizer brace. Review of R19's Electronic Medical Record (EMR) showed a fall evaluation report dated 2/18/23, which revealed a score of 16, indicating fall interventions were required. Review of Registered Nurse (RN) J's witness statement, dated 11/17/24, revealed, I was passing meds (medications). Heard [Staff K] call for help. Walked in room. [R19] was by the foot of the bed holding her foot, sitting on the floor .[R19] said her ankle hurt, [from the] knee to ankle .Floor was wet .I saw [Staff K] wiping up the excess liquid on the floor. Review of RN's Gs witness statement, dated 11/17/23, revealed, .Nurse reported a fall in [R19's] room .[R19] was holding left leg and crying out when she tried to move left leg .When asked where it hurt, [R19] stated, 'My leg,' .When I entered the room the floor under and around [R19] was wet. Upon assisting [R19] into bed, her pants were wet on her bottom area, causing wetness of the bed sheet .wetness was r/t [related to] the floor after mopping. Review of Staff K's witness statement, dated 11/17/23, revealed, I entered the room [D-14], to do my routine cleaning .Curtain drapes were closed. I began to mop the floor when I heard [R19], I .found her upright on the floor at the end of her bed .I placed a wet floor sign down before I entered the room I knocked and no one responded. [R19] always has left the curtain closed, so I assumed no one was inside the room . During an interview on 3/19/24 at 12:12 p.m., Housekeeping Staff E reported they would not have mopped R19's floor with R19 in the room, and clarified they only damp mopped the residents' room floors, per facility process. During an interview on 3/19/24 at 4:44 p.m., RN G reported they walked in R19's room after the incident occurred and observed R19 sitting on the floor in a puddle of water. They and staff intervened with considerable assistance as R19's leg was wedged between the back of the bed and against the closet, and she cried out in pain. RN G confirmed this was an avoidable accident due to the wet floor, and R19 was ambulatory at that time. RN G clarified there was a wet floor sign in the doorway, however R19 would not have been able to see it behind the pulled curtain. Review of R19's PAINAD [pain assessment for persons with advanced dementia], dated 11/17/23, after the incident, revealed a score of 5/10, indicative of moderate pain. Review of R19's November 2023 Medication Administration Record (MAR) revealed R19 was on scheduled Acetaminophen, with the dosing increased to 500 mg (from 325 mg), 2 pills by mouth, three times a day, for pain after the incident, from 11/18/23 to 11/30/23. Additionally, on 11/18/24 [upon return from the ED], Tramadol 5 mg [a narcotic pain medication] was prescribed for breakthrough pain, every 4 hours as needed (prn). The Tramadol prn was used 26 times for R19 from 11/18/24 to 11/30/24. R19 was only on Acetaminophen prior to the fall with fracture on 11/17/23. During an interview on 3/20/24 at 12:02 p.m., Surveyor reviewed R19's increased pain per the Medication Administration Record (MAR) with RN G, who confirmed R19 had increased pain after the injury and during her recovery period. During an interview on 3/20/24 at 10:20 a.m., the Rehabilitation Director, Occupational Therapist (OT) F, reported R19 was near their prior level of function (prior to the 11/17/23 fall), and had been on therapy caseload since the fall. OT F reported R19 went from a wheelchair and non-weight bearing at the time of the fall to ambulating without a device. OT F reported they had been informed R19 fell on a wet floor and acknowledged a wet floor left for a cognitively impaired resident in their room would be concerning and dangerous. During an interview on 3/20/24 at 10:50 a.m., Staff I confirmed housekeeper, Staff K, was the staff involved in the incident, and did not follow their policy and process for cleaning the floors in the facility. Staff I reported Staff K received verbal disciplinary action. Staff I stated the typical process would be for staff to knock on the door and receive a response, and said, We are never going to mop if there is a resident in the room . There should have never been a wet floor; you are supposed to wring out the mop. It should be a damp mop . Staff K did wet mop the room . Review of Staff K's, One to One Inservice Record, dated 11/17/23, revealed, Inservice Topic/Title: 5-step cleaning method w/ [with] concentration on floors .The 5-step method is used to clean a resident's room. 'Damp mopping' is required, not wet mopping . The Inservice included a verbal review and return demonstration and was signed by the Environmental Services Director (EVS), Staff I. Review of the policy, Accidents and Supervision, revised 12/27/23, revealed, Each resident will be assessed for accident risk and will receive care and services in accordance with their individualized care plan. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring effectiveness and modifying interventions when necessary. Definitions: Accident refers to any unexpected or unintentional incident, which results in injury or illness to a resident .Fall refers to unintentionally coming to rest on the ground, floor, or other lower level .Hazards refers to elements of the resident environment that have the potential to cause injury or harm. Risk refers to any external factor, facility characteristic ( .physical environment) or characteristic of an individual resident that influences the likelihood of an accident .Identification of fall risk .Upon identification of risk for falls, the following interventions may be considered when developing the baseline or comprehensive care plan for the resident: a. Implementing universal environmental interventions that decrease the risk of resident falling, including, but not limited to: .A clear pathway to the bathroom or bedroom doors . During an interview on 3/20/24 at 11:17 a.m., Surveyor reviewed concerns related to R19's fall with fracture, including increased pain and pain medication, and her non-weight bearing status at the time of the incident. The Nursing Home Administrator (NHA) reported they understood the concerns and presented a Past Noncompliance document. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: Housekeeping staff have been reeducated on following the 5-staff (sic) cleaning method with a concentration on cleaning floors. The mop head should be damp and not wet. Floors may not be damp mopped while an independently mobile resident is in the room. CENA's (aides) and nurses were educated housekeeping staff cannot damp mop floors while a resident is in the room. QAPI (quality assurance and performance improvement) committee reviewed policies and procedures related to the incident and deemed them appropriate. The facility was able to demonstrate monitoring of the corrective action and maintained compliance by completing random weekly audits of housekeeping staff to ensure that floors were damp mopped only when a resident was not in the room. Center audits were to be reviewed by the Interdisciplinary team and at QAPI {commitee) to identify any trends and to prompt additional actions where needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate monitoring of a high risk resident (Resident #66) for inadequate intake of foods and fluids during a COVID infection. This deficient practice resulted in Resident #66 having an acute change in condition requiring hospitalization where she was found with acute dehydration and septic shock and expired seven days after readmission to the facility. Finding include: Resident #66 (R66): A review of R66's medical record revealed she admitted to the facility on [DATE] with diagnoses including quadriplegic cerebral palsy, dysphagia, hx (history) of sepsis, and dementia. A review of R66's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed she scored 6/15 on the Brief Interview for Mental Status (BIMS) assessment, indicating moderately impaired cognition. This assessment also showed she required limited assistance of one staff for eating. A review of a 1/10/23 Dietary Progress note by former Registered Dietitian (RD) H revealed, Weight Warning. Value: 118.8 (pounds) . -5.0% change . -7.5% change . -10.0% change (13.3%, 18.2 (pounds)) . records show wt (weight) has fluctuated 118-125# (pounds) x 1 month Eating (about) 25-50% of meals, refused 7 meals x 1 week . continue to monitor nutrition intake and wt. There were no nutrition notes after this in R66's record. Further review of R66's progress note revealed the following: 1/23/23 Site of infection: COVID+ . During outbreak testing resident tested COVID+ on POC (point of care) test. R/T (related to) dementia diagnoses resident will quarantine in own room . 1/24/23 . Res (resident) presents as fatigued and possibly a decreased appetite but is otherwise asymptomatic at this time . 2/2/23 . COVID+. FATIGUE. 2/3/23 Resident has had multiple episodes of emesis this shift. Afebrile, no other symptoms . 2/4/23 Sent to (name of emergency room) . Emesis x 3 on 2-3-23 evening. Current s/s (signs and symptoms), BP (blood pressure) 72/47, resp (respirations) 14, lethargic, confused, diaphoretic, cool to touch . A review of R66's hospital records revealed the following: A review of the 2/4/23 emergency room notes revealed, . Reexamination/Reevaluation: The patient was noted to be persistently hypotensive despite having multiple boluses of fluids. She received 30 mL/kg bolus and an additional liter on top of this. Her pressures were not improved . she has a acidosis noted, likely secondary to lactic acidosis. Patient has end organ injury including mental status changes, acute kidney injury. She does appear dehydrated this is possibly compounding her clinical picture . A review of the 2/4/23 Hospital History and Physical revealed, . coming from (name of facility); woke up unusually difficult and diaphoretic this am. Hypotensive for ems . pt (patient) c/o (complaints of) abd (abdominal) pain w (with) palpation . per nursing home report, patient had not been complaint of anything prior to this morning, with no unusual coughing . patient had been positive for COVID-19 on 1/23 . husband also reports that patient had been her usual cheerful self this past week . A 2/5/23 progress note stating, . pt (patient) had some bloody mucosy stool, I sent labs and HGB (hemoglobin) was 10.5 and HCT (hematocrit) was 33.1 . A review of a 2/5/23 hospital progress note revealed, . Assessment/Plan: Acute Dehydration. Acute Kidney Injury. Altered Mental Status. Chronic Anemia. Lactic Acidosis. Septic shock . last stool prior to admission . Alk phos (alkaline phosphate) elevation . suspect in setting of dehydration/shock . A review of the hospital orthopedic notes revealed: 2/4/23 . Brought from (name of facility) this am (morning) due to change in health status and difficulty arousing. Has a UTI (urinary tract infection), but with shoulder history, will have shoulder aspirated to ass (assess) for recurrent infection. Can begin antibiotics after aspiration and will discuss . 2/7/23 . didn't have enough fluid for aspiration earlier in admission . A review of R66's 2/7/23 Dietary Progress note revealed, . Malnutrition screen score 2 or greater . Pt has been losing weight over the past 6 months, only accepting of sweet such as pudding, ice cream, ensure . RN at (name of facility) reports unintended, progressive weight loss over the past 6-12 months that had stabilized recently . EMR weight . May 2022 66.7-72.4 kg . 10-17% weight loss since May 2022 (9 months) . nutrition diagnosis: Unintended weight loss related to decreased ability to consume sufficient energy (dementia) as evidenced by Weight loss of 10-17% since May 2022 (9 months), decreased oral intake per SNF (skilled nursing facility) staff . A review of the Intensivist Hospital notes revealed: 2/7/23 . regarding sepsis/shock, patient also appears to be dehydrated, possible with poor pre-hospitalization oral intake at (name of facility). Urinalysis consistent with UTI but culture negative . cardio/hemodynamics: . likely component of hypovolemia (low blood volume). Resolved after 7 L (liters of fluids) and 5 kg (kilogram) net gain since admit .Infectious disease: . source unclear; urine culture negative . CXR (chest xray) negative, renal US (ultrasound) negative, shoulder joint without significant fluid on US . vanco (antibiotic) stopped today; will continue empiric Zosyn until blood cultures final tomorrow . A review of R66's Intake and Output (I and O's) from 2/4/23 - 2/8/23 revealed she received over 9000 mL of a variety of IV fluids (0.9% sodium chloride, Dextrose 5% in water, and lactated ringers). A review of the blood cultures on 2/24/23 revealed no growth found even after five days (no source of infection). A review of the urine cultures taken on 2/4/23 revealed no growth found. A review of the microbiology results revealed no evidence of viral, bacterial, or parasitic infection. A review of R66's facility progress notes revealed she readmitted to the facility on [DATE] and was admitted to hospice the same day. No progress notes were documented from 2/14/23 through 2/17/23. The last progress note for R66 on 2/17/23 at 1:03 a.m. revealed, (Name of R66) deceased 2/16 time of death 2350 (11:50 p.m.) . A review of R66's Food acceptance records prior to her hospitalization on 2/4/23 revealed the following average intakes: 1/26/23: accepted only 15% at one meal, refused the other two meals 1/27/23: 25% at all three meals 1/28/23 38% average across three meals 1/29/23: 13% average of three meals 1/30/23: Refused all three meals 1/31/23 18% average intake among three meals 2/1/23 0% (no intake at any meals) 2/2/23 Accepted 25% of two meals only. 2/3/23 Refused every meal. In the one week prior to her hospital transfer, R66 refused or ate 0% at meals 11 meals (11 refusals out of 3 meals per day for 7 days = refusal rate of 52%), which was a marked increase from her normal refusal rate of 18% (11 refusals in 60 meals between 1/1/23 and 1/21/23). A review of R66's fluids in the seven days prior to her hospitalization on 2/4/23 revealed an average of 601 mL of fluids per day as follows: 1/28/23: 1280 milliners (ml) fluid intake 1/29/23: 910 mL 1/30/23: 240 mL 1/31/23: 500 mL 2/1/23: 340 mL 2/2/23 700 mL 2/3/23: 240 mL A review of R66's average intake of fluids calculated for 1/1/23 - 1/27/23 was 876 mL per day. A review of R66's weights in the vitals section of her medical record revealed the following: 1/19/23 120.1 pounds 1/28/23 120.5 pounds 1/29/23 118.6 pounds 1/30/23 119.4 pounds 1/31/23 115.7 pounds. A review of R66's Medication Administration Record (MAR) for March 2023 showed two additional weights: 2/1/23 115.7 pounds and 2/3/23 115.7 pounds. A review of R66's bowel log revealed in the 7 days prior to her hospital transfer on 2/4/23, R66 only had two medium sized bowel movements. A review of R66's care plan for hydration revealed, The resident has potential for fluid deficient r/t decreased intake, modified diet/thickened liquids, cognitive impairment developed on 5/28/20. The interventions included, Encourage resident to drink fluids of choice: (Chocolate milk, water) dated 1/25/23 and Monitor/document/report nurse/MD PRN an s/sx dehydration: decreased or no urine output, concentrated urine . new onset confusion . fatigue/weakness . recent/sudden weight loss . initiated 1/25/23. The intervention of Offer/encourage fluid intake with meals, med pass, with cares, during activities was also added to the care plan on 1/25/23. A review of R66's care plan for COVID-19 infection initiated on 1/23/23 revealed, The resident has or is suspected to have COVID-19 . Monitor for anorexia or lack of appetite (1/23/23) . A review of R66's care plan for nutrition initiated 10/12/22 revealed, Resident is at risk for nutritional declines related to nutritionally pertinent diagnosis of dementia, B 12 deficiency . non-detrimental wt loss. Hx (of) poor PO (oral) intake d/t (due to) dementia . Monitor FAR (Food Acceptance Record) and fluid intake and offer alternative choices for refused food and fluids PRN (as needed) (6/4/2020) . A review of R66's provider notes dated 2/13/23 and 2/25/23 revealed no mention that R66 had been diagnosed with the primary diagnosis of acute dehydration. NP I had only discussed the history of R66's shoulder surgeries and that R66's family was choosing palliative care. On 3/30/23 at 3:03 p.m., an interview was conducted with the Director of Nursing (DON). The DON was asked about R66's noted decline in weight and intake of fluids and food prior to her hospitalization on 2/4/23. The DON reported that they had found she was having issues with her shoulder so they got an appointment for orthopedics. The DON reported that R66 had multiple episodes of emesis and was found to have infection in her shoulder prostheses. The DON was asked why the hospital documentation was stating the hospital had noted that they could not find a source of infection. The DON reported that something must have been brewing. When asked why NP I had not even noted the hospitals diagnosis of acute dehydration and concern for inadequate intake prior to admit, the DON provided no answer. A review of a handwritten paper scanned into R66's electronic medical record revealed, 2/10/2023 . Admit to (Name of Hospice) Dx (Diagnosis): Sepsis . This was signed as a verbal order from the hospice physician. No other hospice documentation was found in R66's record. A review of R66's death certificate revealed her cause of death as End Organ Failure and Septic Shock, with the approximate interval between onset and death listed as 2 weeks. A review of the facility policy titled, Nutritional Assessment revised on 1/1/22 revealed, . 1. The Dietitian or Registered Dietetic Technician (as allowed by state regulations), in conjunction with the nursing staff and healthcare practitioners, will complete a nutritional assessment for each resident upon admission, annually, and as indicated by a Significant change in condition . 6. Once risk factors for impaired nutrition are identified, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preferences . A review of the facility policy titled, Weight Monitoring revised on 1/1/22 revealed, . the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical condition demonstrates that this is not possible . 7. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions . e. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00132096 Based on observation, interview and record review, the facility failed to prevent a fall with major injury for one Resident (#308) of four residents reviewed for falls. This deficient practice resulted in a laceration to the right forehead above the eyebrow requiring sutures, surgical intervention for a fracture of the left tibia, and a subsequent required hospital stay. Findings include: A review of the Electronic Medical Record for Resident #308 revealed an initial admission date to the facility on 7/7/22 with diagnoses including repeated falls, cognitive social or emotional deficit following cerebral infarction, weakness, cerebral infarction (Stroke 8/24/22), Dysphagia (difficulty swallowing 8/24/22), muscle weakness, abnormalities of gait and mobility, cerebral infarction due to occlusion or stenosis of right anterior cerebral artery, and fracture of shaft of left tibia (10/15/22). On 3/14/23 at approximately 1:35 p.m., Resident #308 was observed working in therapy. Two therapy staff were observed on both sides of Resident #308 during the observed therapy session. Therapy staff had to actively assist Resident #308 to stay upright in the sitting position while performing removal of plastic pegs and placing them into a container. Resident #308 had observable difficulty with trunk control and was leaning/falling to her right during the therapeutic exercise. Resident #308 would have fallen on the floor to her right side if staff were not in attendance. During an interview on 3/14/23 at 2:57 p.m., Family Member (FM) A stated she had received a call from the facility indicating Resident #308 had fallen out of a wheelchair and hit her head and was sent to the hospital to be checked out. FM A stated she had a conversation with Registered Nurse (RN) B regarding the details of what happened. FM A stated RN B told her Resident #308 had fallen out of a wheelchair and not the chair she was supposed to be in which was a cardiac chair. When asked why she was in a wheelchair, FM A stated she was in attendance, at a doctor's appointment, for a follow-up with FM A, and recalled Resident #308 was in a regular wheelchair during the appointment. When asked who had made the notification to the family, FM A stated someone named (RN C) called her and told her she had fallen out of a wheelchair and had hit her head and sustained a laceration to her forehead. FM A stated the laceration had to be sutured at the hospital and the doctor at the hospital informed FMA that Resident #308 had also sustained a Left Tibia Fracture. FM A stated she asked RN B to pass along that she wanted to know what exactly happened, and why Resident #308 was left in a wheelchair unattended. FM A stated RN B told her this would not have happened if she was on duty, and said she would pass her request on to administration, but never heard back from the facility. A review of the EMR progress notes for Resident #308 revealed the following: 9/29/2022 (5:05 p.m.) Nurses' Notes . Resident (#308) was sitting in wheelchair and reached for bag of popcorn that fell on the floor and fell out of the chair face first. Resident (#308) cut above her right eye and complains of left ankle pain. (Author: RN D) A review of unwitnessed incident report dated 9/29/23 at 4:53 p.m., revealed Resident #308 had fallen on the floor face first, sustaining a cut above the right eye, and was complaining of left ankle pain. Resident #308 was sent to the hospital. The mental status section of the incident report was left blank. Predisposing Environmental Factors were marked as having none. Predisposing Physiological Factors was marked as Confused. Predisposing Situational Factors was marked as Other and described as Resident (#308) was in wheelchair and fell forward out of the chair [NAME] leaning forward. No further investigation into the fall was completed by facility leadership. No new intervention was identified following the fall. A review of the hospital records for Resident #308 revealed the following: Face sheet dated 9/29/22: admission to the emergency room (ER) on 9/29/22 with an admitting diagnosis of FALL ON THINNERS EMS (emergency medical services) STS (states) Informed Consent for Procedure dated 9/30/22: Left tibia intramedullary nailing and revision open reduction internal fixation left fibula which was signed by Resident #308's Power of Attorney (POA). Discharge Documents dated 10/3/22: All Diagnoses This Visit: . Facial Laceration Fracture of left tibia and fibula . Hospital Course: 75 y/o (year old) with history of stroke, was residing at (the Facility), wheelchair-bound. (Resident #308) fell out of a wheelchair with resultant left leg fractures. 1. Fracture of left tibia and fibula -Fell out of wheelchair at (the facility) -Has proximal left tibia and fibular nondisplaced fractures; history of left ankle ORIF (open reduction internal fixation) in May s/p (status post) 9/30 Intramedullary nailing left tibia with removal of hardware left fibula and extension of fibular plating L (left) leg is paralyzed 2nd (secondary) to CVA (stroke) . History and Physical dated 9/29/22: Chief Complaint: c/c (chief complaint) pt (Resident #308) arrives via EMS post slip out of wheel chair, pt hit head, lac (laceration) to right eye, denies LOC (loss of consciousness), on Lovenox (anticoagulant), pt includes right knee pain and left ankle pain . . 2. Fracture of left tibia and fibula --Fell out of wheelchair at (the facility) --Has proximal left tibia and fibular nondisplaced fractures; history of left ankle ORIF in May --Orthotech (orthopedic technician) called in for splinting --Ortho (Orthopedic Physician) contacted by ED (emergency department) --Patient made NPO (nothing by mouth) after midnight; 1 L (liter) NS (normal saline) ordered total --Keep bed rest until seen by ortho --Planning to continue home prophylactic Lovenox . . Diagnostic Results TIBIA/FIBULA Xray: Oblique (slanted) fracture of the proximal (near center of the body) left fibula, minimally displaced. There is a transverse fracture of the distal tibial diaphysis (midsection) just above a fixation plate with multiple screws fixating the distal aspect of the fibula. There is minimal posterior apex (highest part) angulation of this fracture. A fixation screw is demonstrated fixating the medial malleolus (inner ankle bone). There is an oblique fracture of the mid to distal left tibial diaphysis with 1/2 shaft with displacement of the distal fracture fragment medially with posterior apex angulation . A review of a orthopedic progress note for Resident #308, dated 12/8/22 read in part: Date of Surgery: 9/30/22 Procedure Performed: Intramedullary nailing LEFT tibia with removal of hardware left fibula and extension of fibular plating . Surgical History: . Open reduction internal fixation left trimalleolar ankle fracture: 5-24-2022 . During an interview on 3/15/23 at 10:07 a.m., RN C stated he recalled the incident and had recalled assisting RN D with the filling out an assessment to send Resident #308 to the hospital for an evaluation. RN C acknowledged Resident #308 was highly impulsive and stated she used a geri-chair when she was out of bed. RN C acknowledged Resident #308 would have been unsafe to be left in a regular wheelchair. During an interview on 3/15/23 at approximately 11:30 a.m., Certified Nurse Aide (CNA) F stated she was assigned to the B-hall by herself on the day of the fall incident with Resident #308. CNA F stated she knew she was out on an appointment because she was told in report by CNA G. CNA G also indicated to CNA F, Resident #308 was not supposed to remain in the wheelchair when she came back, without direct supervision because of Resident #308's impulsiveness and risk of tipping out of the wheelchair. CNA F stated she asked CNA H who had transported Resident #308 to a doctor's appointment, what had happened. CNA F indicated CNA H stated he had told someone Resident #308 was back in her room in a wheelchair, but could not remember who. CNA F stated CNA I, CNA J, and CNA K were all working that afternoon, and they all said they were unaware Resident #308 was back in her room in a wheelchair. During an interview on 3/15/23 at approximately 11:53 a.m., CNA H stated he did take her to an appointment the day of the incident. CNA H stated he came back with Resident #308, took Resident #308 to her room, and stated he gave her a call light. CNA H stated he told a female CNA, whom he could not identify, Resident #308 was back and in her room. CNA H stated he also indicated to the unknown female CNA, Resident #308 was very tired and she should get Resident #308 back to bed in short order. CNA H confirmed no staff were in the room when he left Resident #308 in the wheelchair with a call light. CNA H denied being informed Resident #308 could not be left alone in a wheelchair by anyone from therapy. During an interview on 3/15/23 at approximately 12:23 p.m., CNA G confirmed a regular wheelchair was supposed to be used for appointments and therapy only. CNA G confirmed she could be left alone in her geri-chair with her call light, but if she was in a wheelchair, she had to have eyes on her at all times due to behaviors and leaning forward. During an interview on 3/15/23 at approximately 12:25 p.m., OTR L, stated the biggest problem Resident #308 had hypertonicity, which affected her entire left side with left sided neglect. OTR L indicated Resident #308's cognition was very impaired and she was highly impulsive. OTR L indicated the therapy staff made it very clear to the facility staff, Resident #308 was not to be left in a wheelchair, including a tilt-back chair without supervision. OTR L confirmed this was communicated to CNA H on the day of the transport to a medical appointment by OTR M. OTR L stated she was aware Resident #308 was left alone in a wheelchair and confirmed the fall and subsequent major injury was a direct result of being left unsupervised in the wheelchair. OTR L stated Resident #308 was not safe to be left in an upright position without constant supervision due to her impulsivity and poor safety awareness from her stroke. OTR L reiterated everyone in the facility was aware Resident #308 could not be left alone, unsupervised, in a wheelchair. During an interview on 3/15/23 at 2:38 p.m., OTR M confirmed CNA H had asked for a wheelchair with a reclining back for Resident #308 to be transported to a medical appointment on the day of the incident. OTR M stated he provided such a wheelchair and indicated he had communicated to CNA H, Resident #308 was under no circumstances to be left in the wheelchair alone and unsupervised when returning to the facility. OTR M stated the facility was using a geri-chair prior to the incident for Resident #308 to be up in when out of bed because she was not safe in a wheelchair due to impulsivity and poor safety awareness. A review of the Occupational Therapy notes for Resident #308 revealed the following: 9/29/22 at 11:38 a.m. - Precautions: (Resident #308) is a fall risk and has poor safety awareness and judgement . (Resident #308) required max assist to sit up on the edge of the bed and max assist to maintain sitting balance at the edge of the bed. (Resident #308) required max assist with a stand pivot from the bed to the W/C . W/C (wheelchair) Mngmt (management): analysis of patient's body alignment and functional skills in new or existing W/C and assessment of current seating system for appropriate modifications . (Author: OTR M) 9/22/22 at 4:51 p.m. - Precautions: (Resident #308) is a fall risk and has poor safety awareness and judgement . Facilitation of sitting at the edge of bed to increase strength, balance, safety awareness, and functional activity tolerance for increased function with ADLs. (Resident #308) required minimal to maximal assistance for balance sitting at the edge of bed with RUE (right upper extremity support of bed. Increased assistance required with movement of LE (lower extremity) . (Author: OTR N) 9/8/22 at 3:44 p.m. - Precautions: (Resident #308) is a fall risk and has poor safety awareness and judgement . Transfer training from w/c to standing completed 2 times with (Resident #308) requiring Max A (maximal assistance) with mod (moderate) vc's (verbal cues) for carry over with toilet transfers . (Author: OTR L) 9/7/22 at 3:00 p.m. - Precautions: (Resident #308) is a fall risk and has poor safety awareness and judgement . Mod (moderate) assist provided to improve (Resident #308) positioning while eating a meal. (Resident #308) was able to complete self-feeding with MOD I (modified independence) assist when sitting upright in her gerry (sic) chair . (Author: OTR M) A review of the Physical Therapy notes for Resident #308 revealed the following: 9/27/22 at 4:09 p.m. - . Sitting balance at edge of bed with mod/max assist, verbal and tactile cues for anterior weight shifting in order to prevent posterior LOB (loss of balance). Bed to Broda (reclining type chair, similar to geri chair) transfer with Sara lift, verbal cues for posture, max assist for set up . (Author: Physical Therapy Assistant (PTA) O, co-signed by Registered Physical Therapist (RPT) P) 9/26/22 at 1:27 p.m. - . completed bed mob (mobility) with P mod (partial moderate assist) to roll L (left) S Max (substantial maximal assistance) to roll R (right) and S Max for lying to sitting from R side, stand pivot transfer with 2 person S Max assist bed to cardiac chair (geri chair) . (Author: RPT P) 9/15/22 at 3:30 p.m. - . Static sitting at edge of bed with min (minimal) -max (maximal) assist, verbal cues for posture and anterior lateral weight shifting in order to prevent LOB. Patient sits at edge of bed ~ 10 mintues (sic) with progressively increased physical assist . (Author: PTA O, co-signed by RPT P) 8/30/22 at 4:41 p.m. - . training in supine/side lying to/from sitting edge of bed and training in safe sit to stand mobility using (sit-to-stand) lift to cardiac chair (geri-chair) Dependent transfer . (Author: RPT P) Upon request for all falls sustained by Resident #308, the facility provided an additional incident report dated 7/15/22. Resident #308 slid out of her wheelchair and was found sitting on her foot pedals. The incident report indicated Resident #308 had other instances of . events of placing herself on fall mat next to the bed on the floor . However, there were no additional incident reports provided for those incidents. The immediate action was as follows: Speak with resident (#308). Offer to place in wheelchair. We have ordered a geri chair for resident . The geri chair was not noted anywhere on the care plan review located below. A complete care plan review for Resident #308 from the initial admission date of 7/7/22 revealed the following: The . limited physical mobility . care plan for Resident #308 . related to CVA with significant left sided deficit, left ankle fracture with ORIF ., with a date initiated of 7/11/22 revealed the following: Locomotion interventions indicating Resident #308 required the use of a wheelchair, despite multiple staff acknowledging she should have been in bed or a geri-chair, unless directly supervised by staff in a wheelchair. The . at risk for falls . care plan reflected Resident #308 . related to: CVA with significant left sided deficit, left ankle fracture with ORIF . revealed the following interventions: Goal: To reduce the risk of serious injury in the event of a fall through the review date (date initiated 7/7/22) . The care plan failed to address supervision needs when in a wheelchair as several staff identified in interviews and failed to address the need for a geri-chair. There were no other interventions to address Resident #308's need for direct supervision when sitting in a wheelchair. Three RN's, two OTR's, and two CNA's indicated Resident #308 required direct supervision when sitting in a wheelchair and the use of a geri-chair for any unsupervised periods out of bed. The RN's and CNA's stated they were made aware of this need by therapy. The care plan failed to address Resident #308's use of a geri-chair for safety. There was no indication Resident #308 had poor trunk control and what safety measures should be in place to prevent falls contained in the care plan. There were no new interventions evident/applied to the fall care plan after the first fall on 7/15/22. A review of the facility policy, Fall Prevention Program, with a revised date of 1/1/22, read in part: . 6. When any resident experiences a fall, the facility will: . e. Review the resident's care plan and update as indicated . . g. Obtain witness statements in case of injury .