**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R45's quarterly Minimum Data Set (MDS) dated [DATE], indicated R45 was cognitively impaired and had diagnoses of stroke, dementia, and Parkinson's disease. Furthermore, R45's MDS indicated R45 was a fall risk and required extensive assist with one person for transfers and ambulation. R45's fall Care Area Assessment (CAA) dated10/3/22, indicated R45 was a fall risk related to Parkinson's disease, impaired balance, gait problems and impaired judgement. R45's care plan revised 5/27/23, indicated R45 was a high fall risk related to impaired balance, stroke, and Parkinson's disease. Staff were directed to anticipate and meet my needs, assist to toilet per toileting plan, frequent safety checks, encourage use of call light and ensure it was within reach, and have walker in front of resident to assist with attempts to walk unassisted. A review of R45's fall risk management report indicated: -on 6/16/23, R45 had an unwitnessed fall in the lounge area. Approaches previously care planned was frequent safety checks and pivot transfer only. Approaches to prevent reoccurrence was staff to maintain frequent visual checks and continue to have staff monitor her when in the lounge and continue to educate to ask for assistance. -on 6/17/23, R45 had an unwitnessed fall in lounge area. Approaches previously care planned included constant visual checks and anticipating needs. Approaches to prevent reoccurrences was to continue with care plan. No new intervention indicated. -on 6/28/23, R45 had an unwitnessed fall in her room. Approaches to previously care planned included visual checks and toileting program. Approaches to prevent reoccurrences was a perimeter mattress. -on 7/3/23, R45 had a witnessed fall while trying to self-transfer in her room. R45 was sent to the emergency room for a face hematoma. Fall discussed in morning meeting and fall interventions remain in place. No new intervention indicated. -on 7/17/23, R45 had an un-witnessed fall and was found sitting on the floor outside nursing station. Fall discussed in morning meeting and R45 forgot to use call light for assistance and continued to self- transfer without walker. R45 will continue therapy. No new intervention indicated. -on 7/19/23, R45 had an unwitnessed fall in her bathroom with tube feeding pole tipped over and tube stretched. Approaches previously care planned include assistive devices of walker and wheelchair, to be in lounge for close monitoring, and permitter mattress. Approaches to prevent reoccurrence was to have call light in reach and educate resident to use and adjust tube feeding times. -on 7/21/23, R45 had a witnessed fall in the lounge. R45 got up from chair and was attempting to walk when she fell. Approaches to prevent reoccurrence was keep walker with seat in front of resident for use if attempts to self-transfer and continue therapy. R45's hourly rounding documentation from 7/26/23-8/2/23, was reviewed and lacked consistent documentation hourly rounding had occurred including an entire evening shift on 8/2/23. An observation on 8/1/23 at 9:46 a.m., R45 was sleeping in bed. R45's call light was on the floor to the right side of R45's bed and not in reach. Next to the door was a folded walker placed up against the wall. A 4-wheeled rolling walker with a seat was placed against the wall away from the bed and just in front of the door. An observation at 8/2/23 at 3:11 p.m., R45 was sitting in the wheelchair in the lounge area sleeping. At 3:30 p.m., nursing assistant (NA)-H pushed R45 back into her room. At 4:11 p.m. R45 was sitting in the wheelchair in her room. R45's call light was over by the bed and not in reach. A walker was folded up and placed against the wall and a 4-wheeled walker was close to the door. Neither of the walkers were in reach of R45. An observation on 8/2/23 at 8:09 a.m., R45 was seated in a chair in the lounge. R45's walker was not in the lounge and was noted in her room. When interviewed on 8/2/23 at 8:01 a.m., family member (FM)-A stated R45 was very impulsive and often attempted to get up without help and had multiple falls. FM-A further stated R45 required assistance with any transfer or ambulation. FM-A stated R45's walker was not always nearby and so when R45 would attempt to get up and walk, she would usually fall. FM-A discussed with the facility the desire to have R45's walker in place so maybe R45 would use it and not fall if attempting to self-transfer. FM-A thought this was happening. FM-A further verified R45 rarely used the call light and stated the facility tried to encourage her to use it but did not feel any education was going to be useful as R45 wouldn't remember. When interviewed on 8/2/23 at 9:06 a.m., NA-C stated R45 was able to make some needs known when asking simple questions. NA-C stated sometimes R45 wanted to walk in her room to the bathroom and when she wanted to walk a walker and gait belt was used. If R45 did not want to walk, a gait belt was used to transfer into the wheelchair and R45 was wheeled into the bathroom and then transferred with assist of one. NA-C stated R45 did not wait for help and really did not use the call light. R45 was quick and so staff had her out in the lounge most of the time so there was more staff around. NA-C staff would place R45's walker next to the door or away from her so she would be discouraged from using it. When interviewed on 8/2/23 at 9:06 a.m., licensed practical nurse (LPN)-A stated after a resident falls, the floor nurse filled out a risk management form to document what happened and some immediate interventions. LPN-A stated usually, the interventions that are put in place was to keep call light in reach and re-educate about call light use. LPN-A stated R45 was impulsive and a high risk for falls. Currently, R45 was on hourly checks by either the NA or the nurse. Upon review of the hourly checks, LPN-A verified there was some missing times, and the entire evening shift was blank from 8/2/23. When interviewed on 8/3/23 at 1:53 p.m., registered nurse (RN)-B stated falls were discussed in morning meetings and the root cause and interventions were discussed and nurse managers update care plan and care sheets. RN-B stated R45 was very impulsive and had some changes in mobility related to a stroke. R45 did not use a call light and would walk without her walker. RN-B stated family wanted R45's walker next to her so if she did get up R45 may use it. RN-B verified some of the interventions listed for R45 may not be appropriate or individualized due to R45's impulsiveness and stated R45 was now on hourly checks as well. RN-B expected staff to follow the fall interventions on R45's care plan and care sheets. A facility policy titled Fall Risk Assessment revised 4/2022, directed staff to implement individualized fall precautions for all residents who are at risk for falls. Furthermore, the policy directed staff to initiate, review and revise the care plan as appropriate and communicate interventions to staff. Based on observation, interview, and record review, the facility failed to implement individualized fall interventions for 2 of 3 residents (R27, R35) and failed to ensure a route cause analysis was completed and new interventions were implemented following a fall for 1 of 1 resident (R6), who was at risk for and had a history of falls. This resulted in harm when R6 had a subsequent fall on 5/16/23 and sustained a lumbar fracture. Findings include: R6's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of congestive heart failure (CHF), unspecified fall, abnormalities of gait and mobility, low back pain, and history of falling. It further indicated R6 was independent with all activities of daily living (ADL), occasionally incontinent of bladder, frequently incontinent of bowel, had a previous fall history prior to admission, and had received an antidepressant 7/7 and a diuretic 6/7 days in the look back period. R6's Care Area Assessment (CAA) dated 5/4/23, indicated R6 was at risk for falling and risk factors included: history of falling, incontinence, orders for scheduled antidepressants, cardiovascular (heart) medications, diuretics, and diagnoses of depression, dementia, arthritis, diabetes mellitus, and CHF. R6's care plan dated 4/28/23 included R6 was at high risk for falls related to a history of impaired mobility, diabetes, dementia, CHF, a history of falls, and a recent fall on 5/16/23. It further included interventions to anticipate and meet the resident's needs, ensure his call light was within reach and encourage him to use it for assistance as needed, promptly respond to all requests for assistance, educate resident/family/caregivers about safety reminders and what to do if a fall occurs, follow facility fall protocol, provide a safe environment, place walker within reach, frequent reminders to use call light, physical therapy to evaluate and treat as ordered or as needed. R6's care plan dated 5/12/23, indicated R6 had an ADL self-care performance deficit related to weakness, recent closed fracture of L2 vertebrae (lumbar fracture) with interventions of toilet use: independent. Extensive assist by 1 staff for toileting as needed. and transfer: independent. Extensive assistance by 1 staff to move between surfaces every shift as necessary. It further indicated R6 had limited physical mobility with an intervention of ambulation: independent. Limited assist of 1 staff as needed, uses a walker. A review of R6's fall risk management reports indicated: -On 5/9/23, indicated R6's call light was on, when NA went to resident's room and found him on the floor. Upon arrival, noticed the resident was sitting on the floor near the foot of the bed and his back was resting on the TV table/wall by the bathroom door. R6 stated he was trying to go to bed, lost his balance, bumped his armpit on the bedframe and fell but he did not hit his head. The risk management lacked any documentation of an investigation, root cause analysis, or new interventions to prevent future falls. Approaches previously care planned: call light within reach. Approaches to prevent reoccurrences: encouraged to use call light when he needed assistance. -On 5/17/23, indicated R6 was found sitting on the floor in his bedroom. He stated I lost my balance and ended up on the floor sitting on my bottom. It further indicated, an investigation and interview with staff and resident indicated that care plan interventions were in place. Resident was independent with his ADL's, elder (resident) has a history of falls due to unsteady gait and weakness. Approaches previously care planned: call light within reach and encourage to use call light when he needed assistance and frequent visual checks. Approaches to prevent reoccurrences: frequent reminders to use call button for assistance, place walker within reach, and frequent visual checks. -On 6/18/23, indicated nursing assistant found R6 sitting on the floor against the wall in his bathroom. R6 stated he saw broken pieces of glass on the floor, and he was trying to kick it aside, lost his balance, and fell. It further indicated an investigation and interview with staff and R6 indicated care plan interventions were in place. Approaches previously care planned: Education provided to R6 to call for assistance. Approaches to prevent reoccurrences: staff will continue frequent visual checks and R6's son brought a reacher from home to assist him to pick up objects off the floor. -On 7/22/23, indicated R6 fell in the bathroom at around 8:00 p.m. He was found sitting on the floor, blood flowing from the back of his head. The writer called for emergency services to transfer him to the hospital for further examination and treatment. It further indicated an investigation and interview with staff and R6 indicated the care planned interventions were in place. Resident had some degree of cognitive impairment which limits his understanding of his physical limitations. He needs contact guard assistance of 1 with ambulation/transfer from room to the bathroom/hallway due to unsteady gait and was care planned as such, however, after review of R6 care plan it lacked documentation of the need for contact guard assistance of 1 with ambulation/transfer. R6 prefers to be independent with ADL's. Approaches previously care planned: staff will continue to encourage elder to call for assistance. Approaches to prevent reoccurrences: offer to toilet every 2-3 hours and as needed and continue frequent visual checks. R6's progress note dated 5/17/2023, indicated R6 complained of severe pain 10/10 in his lower back. Resident had a fall at 2100 (9:00 p.m.) while trying to ambulate to the restroom. Call to provider to request an x-ray and pain medication. Per physician, send patient to the hospital. R6's progress noted dated 5/17/2023 at 13:19 (1:19 p.m.) indicated R6 was sent to the hospital by ambulance for evaluation. His son was notified and will meet R6 at the hospital. R6's progress noted dated 5/17/2023 at 15:52 (3:52 p.m.), indicated called the hospital for an update, spoke with the nurse (unknown) who stated, elder was admitted with lumbar spine compression fracture, spine surgery was consulted, and they want him to wear a brace for 8-10 weeks while the fracture heals. Unable to determine a discharge date . During an interview on 8/3/23 at 11:40 a.m., the nurse manager registered nurse (RN)-A stated the process when a resident fall was for the nurse to assess the resident, make sure they don't have a fracture, check their vital signs, and their range of motion (ROM). If the resident was suspected of having a fracture, the nurse should leave them on the floor, call 911, and then notify the doctor, family, nurse manager, director of nursing (DON), and administrator. RN-A stated since she was the nurse manager it was her responsibility to investigate the incident and try to figure out the cause. The nurses would be responsible for taking the resident's VS and performing neurological checks for 72 hours (after the fall occurred) and the DON would look at the camera footage to see the last time staff was in the resident's room. RN-A further stated they discuss each fall at the IDT meeting and put measures in place to prevent future falls, but any nurse can put interventions in place. RN-A verified R6 had fallen on 5/9/23 and there was no documentation that an investigation, route cause analysis, or new interventions had been put into place stating, I probably investigated this, but I probably didn't document it. RN-A further stated R6 wanted to be independent and therefore won't put on his call light, stating it wasn't an appropriate fall intervention. She also stated R6 had a fall intervention of frequent checks but was unable to give a specific amount of time of how often frequent checks should be done. RN-A stated she doesn't like to give a specific time because staff might be busy with other elders [residents]. I encourage night shift to take a peek on him at night, because one of R6's falls was during the night. RN-A also verified R6 had an intervention for staff to offer to assist him to use the toilet, but he does not wait for assistance and toilets himself, therefore it was not an appropriate intervention. R6's care plan indicated he was independent with transfers and mobility but needed assistance of 1 staff as needed. RN-A was unable to explain how staff were supposed to make that determination and stated the therapy department was responsible for determining how much assistance R6 needed. During an interview on 8/3/23 at 3:03 p.m., the director of nursing (DON) stated the process for when a resident fall would be to report the fall to a nurse (if it is an NA), the nurse would complete an assessment, take VS, and then once the resident had been taken care of, record it in risk management. If the nurses document it the correct way it will automatically go into the progress notes. The risk management talks about the assessment and what interventions to put in place. Whoever (nurse) was responsible for the resident should try to put in a new intervention, they also know they can call the DON and and she will help them come up with some interventions. The nurses are responsible for filling out an incident report and the next working day they review the fall in the IDT meeting. They (management) investigates the fall and do a root cause analysis. If it happened in a common area or a resident's room, they look at the cameras to give them clues on what was going on at that time and put any new interventions in place. The DON stated she makes sure a follow up note has been done, the nurse filling out the report signs off on it, the nurse manger, and the administrator. The DON verified there was no root cause analysis or new interventions implemented following R6's fall on 5/6/23. She also stated regular rounding should be done every 2-3 hours, and frequent checks were considered more than that. There's not really a checklist, or a set time. The DON verified if R6 wasn't using his call light and was toileting himself without asking for assistance then those wouldn't be appropriate interventions. During a continuous observation on 8/3/23 following events occured: -7:56 a.m. R6 came out of his room, with his back brace on and walked down the hallway independently (using his walker) to the dining room and sat down at the table. There was no staff present in the hallway while he was walking. -8:02 a.m. R6 was sitting at dining room table, eating breakfast. -8:24 a.m. R6 stood up from the table independently, grabbed onto his walker (which was sitting next to him), and walked down the hallway to his room, went in and shut the door. There was no staff in the hallway while he was walking. -9:01 a.m. R6 was in his room with the door closed, no staff have checked on him or offered to assist him to use the toilet. -9:26 a.m. R6 was in his room with the door closed, no staff have checked on him or offered to assist him to use the toilet. -9:58 a.m. NA-I entered R6's room and asked him if he needed anything. R6 stated he hadn't seen the nurse yet and NA-I offered to get the nurse for him. It had been approximately 1.5 hours since staff had checked on/seen R6. During interview on 7/31/23 at 9:57 a.m., R6 stated he doesn't need assistance with cares, (getting up, walking, or using the bathroom) and he doesn't use his call light because he doesn't need help. R6 further stated he doesn't remember any one at the facilty telling him he needed to use his call light before getting up. During an interview on 8/3/23 at 7:58 a.m., NA-J stated R6 needs assistance with cares but he doesn't use his call light to request help. During an interview on 8/3/23 at 9:55 a.m., RN-C stated nursing assistants are supposed to do rounds every 2-3 hours and frequent checks should be done every hour. During an interview on 8/3/23 at 10:01 a.m., NA-K stated R6 was independent but he needed assistance from staff to check on him after he goes to the bathroom to clean up after him and he doesn't use his call light when he needs to use the bathroom or to get up and walk around. NA-K stated frequent checks should be done every 2-3 hours but R6 doesn't need frequent checks. During an interview on 8/3/23 at 1:30 p.m., the rehabilitation program manager stated they received orders for therapy for R6 on 5/15/23, due to a history of falls, back pain, and lumbar fracture. R6 had a PT evaluation on 5/22/23, was discharged on 6/12/23 due to a hospitalization, and then started again on 6/19/23. R6 has PT but was not on an ambulation or gait program. The rehabilitation program manager further stated R6 shouldn't be walking independently. He needs supervision, he abandons his walker, and he's not been cleared by therapy to ambulate independently. R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 had severe cognitive deficits and was unable to complete the Brief Interview for Mental Status (BIMS) assessment, required extensive assist of two staff with bed mobility and toileting and one person assist with transfers. R27's diagnoses included non-traumatic brain dysfunction and Alzheimer's disease. R27's fall care plan dated 4/7/22, indicated R27 had a high risk for falls with interventions which included, call light is within reach and encourage me to use it for assistance; floor mat next to bed, updated on 8/1/23 for the new intervention implemented for the fall on 7/25/23. Physician progress notes dated 7/26/23, indicated facility updated triage yesterday that patient fell overnight and had pain to right knee. X-ray was done yesterday which found comminuted intra-articular fractures (a fracture that crosses into the surface of a joint, resulting in damage to the cartilage) in the right tibia. R27's Falls Risks Evaluation dated 7/30/23, indicated date of last fall on 7/25/23, new intervention included a matt on the floor just in case she falls, which is unlikely because she is not able to move in bed without assistance. R27's nursing assistants care sheets undated, indicated Safety: fall risk: place call light within reach, prefers bed in low position at all times, frequent visual checks and floor mat next bed (SIC). During the following observations R27 did not have a floor mat in her room or on the floor near her bed: -8/1/23, at 11:35 a.m., no floor mat in place near bed. -8/1/23, at 4:47 a.m., no floor mat in place near bed. -8/1/23, at 6:39 a.m., no floor mat in place near bed. -8/2/23, at 8:37 a.m., no floor mat in place near bed. -8/2/23, at 1:55 p.m., no floor mat in place near bed. While observing R27 on 8/3/23 at 9:08 a.m., one floor mat was noted to right side of bed near window, however, the left side of R27's bed had no floor mat near bed which is the side of the bed R27 gets out of bed on. During observation and interview on 8/2/23 at 9:18 a.m., nursing assistant (NA)-A and another NA were getting R27 changed in bed. No floor mat was near bed or in room. When asked if R27 had a floor mat, NA-A stated she had never seen a floor mat in R27's room. During interview with nurse manager (NM) on 8/2/23 at 2:42 p.m., NM stated after R27's fall on 7/25/23, NM implemented floor mat to floor, and updated the care plan and nursing assistants care sheets as a fall intervention. During interview on 8/3/23 at 11:42 p.m., family member (FM)-A stated usually visited with R27 around 2-3 times a week and the sister also visited about 3-4 times a week. FM-A stated had never seen a floor mat when came to visit resident prior to 8/3/23. FM-A was visiting with R27 during interview with surveyor on 8/3/23. When interviewed on 8/2/23 at 3:00 p.m., NA-B stated, When I take care of a resident, I look at the nursing assistant care sheets to know how to care for the resident. I have never seen a floor mat in R27's room and I have worked here for about two months and have been working with R27. When interviewed on 8/3/23 at 4:18 p.m., director of nursing (DON) explained she was told the floor mat had been implemented right after R27's fall on 7/25/23 and did not know until today when the NM mentioned to her the floor mat was not placed until after interview with surveyor on 8/2/23. DON stated she believed NM got busy and did not get a chance to place the floor mat timely, per care plan intervention for falls.