**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility admitted Resident #152 with diagnoses of Alzheimer's disease and brain cancer. The annual Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was a 5 out of 15, which indicated the resident was severely cognitively impaired. Since the previous assessment, the resident had one fall with no injury and two falls with injury. A review of the resident's care plan, last updated on 09/21/2021, indicated Resident #152 was at risk for falls related to poor safety awareness secondary to cognitive loss regarding Alzheimer's disease. The care plan also indicated the following: assistance need with activities of daily living; resident attempts to transfer to toilet; old compression fractures; use of antidepressants, pain, and cardiac medications; a fall on 09/12/2021 resulting in left humerus, left radial, and left femoral neck fractures. Interventions for the falls included the following: - Physical and occupational therapy referrals for changes in functional mobility, with an effective date of 09/26/2018. - Reminding Resident #152 to call for assistance with activities of daily living, especially transfers, with an effective date of 09/26/2018. - Observation for unsafe behavior, with an effective date of 09/26/2018. - Non-slip footwear, with an effective date of 10/04/2018. - Encouragement for use of hip guards, with an effective date of 04/25/2019. - Blood pressure and pulse monitoring weekly, with an effective date of 09/13/2019. - Pad sensor alarm to bed and chair, with an effective date of 05/12/2020. - Floor mats at bedside, with an effective date of 07/06/2021. There were no interventions listed on the resident's care plan regarding any falls that occurred in 2021, except for floor mats at bedside. A review of an injury and accident report indicated that on 06/09/2021 at 8:00 AM, the resident had an unwitnessed fall. Resident #152 stated the resident fell in their bedroom. A certified nursing assistant noticed a small abrasion on the back of the resident's head, behind the left ear, while showering the resident the same morning after the fall. The resolution listed on the report was that Resident #152 was educated on calling for help. Resident #152 stated, I just want to use the bathroom. The report indicated staff would continue to monitor and encourage the resident to use the call light. Following the fall on 06/09/2021, the care plan was not updated to reflect any new interventions. A review of a nursing progress note, dated 06/09/2021 at 2:45 PM, described the note as the initial fall-focused note and detailed the same information provided in the injury and accident report. At the end of the note, the writer had the option to list, New safety interventions added after this fall, and this section was left blank. A review of a nursing progress note, dated 06/09/2021 at 11:10 PM, described the note as the first follow-up fall-focused note. The additional interventions initiated and response to new interventions were left blank and did not identify any new interventions. A review of a progress note, dated 06/15/2021 at 3:36 PM, indicated the interdisciplinary team met regarding the fall on 06/09/2021. The new intervention initiated was alarm to chair. According to the care plan, the intervention of alarm to chair was already listed on the care plan with an initiated date of 05/12/2020. A review of an injury and accident report indicated that on 06/29/2021 at 2:00 PM, the resident had an unwitnessed fall. Resident #152 was found lying on the left side of their body on the floor between the door and the bed. Resident #152 was transferring themselves from the bed to the wheelchair. The wheelchair brakes were not locked. The resolution listed on the report indicated the resident stated, I forgot to lock my brakes. Resident #152 was educated on calling for assistance, and staff would continue to monitor. Following the fall on 06/29/2021, the care plan was not updated to reflect any new interventions. A review of a progress note, dated 06/29/2021 at 4:23 PM, detailed the same information provided in the injury and accident report. No new interventions were added, and additional comments were made stating that safety education was provided to the resident on locking the wheelchair brakes and using the call bell for assistance. A review of a nursing progress note, dated 06/29/2021 at 10:37 PM, described the note as the first follow-up fall-focused note. The additional interventions initiated and response to new interventions were left blank and did not identify any new interventions. A review of a nursing progress note, dated 06/30/2021 at 11:31 AM, described the note as the second follow-up fall-focused note. New orders were received for an x-ray for cervical, thoracic and lumbar spine, and bilateral hips due to the resident complaining of pain. The additional interventions initiated and response to new interventions were left blank. A review of a physician's progress note, dated 07/01/2021 at 2:59 PM, indicated the resident had a vertebral compression fracture of the L1/T12 site with an indeterminate age. New orders were given for pain medication and an orthopedic consult. A review of a progress note, dated 07/06/2021 at 12:13 PM, indicated the interdisciplinary team met regarding the fall on 06/29/2021. The new intervention initiated was floor mats. A review of an injury and accident report indicated that on 07/15/2021 at 11:50 AM the resident had an unwitnessed fall. Resident #152 spilled milk in their lap, self-ambulated to the bathroom without calling for help, and the resident's tab alarm alerted staff. Resident #152 was found on the floor, sitting with their back against the wall and their legs out in front of them. Resident #152 reported they just went down while trying to get to the toilet. There was no resolution given. Following the fall on 07/15/2021, the care plan was not updated to reflect any new interventions. A review of a progress note, dated 07/15/2021 at 2:40 PM, detailed the same information provided in the injury and accident report. The new interventions added were to educate the resident on the use of the call bell and calling for help. A review of a nursing progress note, dated 07/15/2021 at 11:50 PM, described the note as the first follow-up fall-focused note. The additional interventions initiated and response to new interventions were left blank and did not identify any new interventions. A review of a nursing progress note, dated 07/16/2021 at 6:54 AM, described the note as the second follow-up fall-focused note. The additional interventions initiated and response to new interventions were left blank. A review of a progress note, dated 07/20/2021 at 10:01 AM, indicated the interdisciplinary team met regarding the fall on 07/15/2021. The new intervention initiated was to remind the resident to call for assistance. A review of a social service progress note, dated 08/19/2021 at 4:23 PM, indicated the resident had cognitive impairment shown by memory loss, impaired decision-making skills, and episodes of confusion. A review of an injury and accident report indicated that on 09/12/2021 at 2:00 PM, the resident had an unwitnessed fall. Staff heard a loud bang, and Resident #152 screamed out. Staff noted the resident lying on the floor in the doorway of their bedroom, lying on the left side of their body with their left arm behind them. Resident #152 then turned themselves over onto their stomach. Resident #152 was transferred to the emergency room at 2:45 PM the same day. The resolution listed on the report was that the resident was transferred to the emergency room for evaluation of injuries, and the resident's care plan would be updated upon return. A Root Cause Analysis (RCA) would be completed to address the resident's fall, and an action plan would be created. A review of a progress note, dated 09/12/2021 at 2:00 PM, detailed the same information provided in the injury and accident report. No new interventions were added. A review of a Root Cause Analysis document indicated the document was completed on 09/30/2021 related to the fall on 09/12/2021 with major injury. Resident #152 sustained a left hip femoral neck fracture, impacted intra-articular left distal radius fracture, and a comminuted proximal left humeral head fracture. The Problem indicated Resident #152 had a history of gait instability and was found lying in the doorway of their assigned room. Resident #152 was last observed resting in their low bed with a fall mat on the floor and a tab alarm attached to the resident. Resident #152 removed the tab alarm and exited their bed. Resident #152 left their walker at the bedside and ambulated toward the doorway. Resident #152 fell due to ambulating without their walker and known gait instability. Resident #152 was diagnosed with a urinary tract infection during the hospital stay. The first part of the facility's action plan consisted of continuing to use the low bed, fall mat at bedside on the floor, fall socks, to move furniture away from the head of the bed to prevent injury, and to apply hip guards. The second part of the facility's action plan consisted of consideration of using a pad sensor alarm while the resident was in bed and to offer the resident fluid every shift to prevent dehydration. The third part of the facility's action plan consisted of providing frequent reminders for the resident to use their walker when ambulating. Resident #152 would use their wheelchair during recovery, with the goal of ambulating with a walker. The care plan was not updated to reflect any new interventions, following the root cause analysis. In an interview on 10/09/2021 at 8:40 AM, Assistant Director of Nursing (ADON) #1 stated the care plan should be updated and the interdisciplinary team had guidelines for interventions. ADON #1 stated, As long as we have some type of alarm in place and appropriate footwear, we make sure to provide education on call light use. ADON #1 stated that the facility had prevented numerous falls for Resident #152 and .there was really no other intervention we could put into place. We could get a sitter . During an interview on 10/10/2021 at 1:38 PM, the Administrator stated the expectation was that everything should be updated in the residents' care plans. A review of facility's policy and procedure titled, Interdisciplinary Care Planning and Assessment, revised 01/2021, indicated, care plans are revised as changes in the resident's condition dictates. Reviews are made at least quarterly. A review of facility's policy and procedure titled, Resident Safety Program - Fall Prevention, revised 07/2021, indicated, Procedure: A. A Morse Scale Falls Risk Assessment is completed upon admission and readmission, significant change assessment, quarterly assessment and after each fall event. B. Interventions are implemented based on risk areas identified by the falls risk assessment. The fall prevention/intervention guide may be utilized to assist in identifying and implementing appropriate interventions. C. Risk for falls and/or injury is identified and addressed in the resident's individualized treatment plan. D. Falls will be reviewed weekly by the interdisciplinary team and interventions adjusted and care plans updated as necessary. 3. The October 2021 computerized physician order (CPO) indicated the facility admitted Resident #105 with diagnoses which included paranoid schizophrenia, unspecified dementia with behavioral disturbance, wandering in disease classified elsewhere, restlessness and agitation, and severe psychotic features. The admission Minimum Data Set (MDS), dated [DATE], indicated the resident's cognition was moderately impaired with a SAMS (Staff Assessment for Mental Status). The resident required physical assistance of two persons for dressing and toileting. The resident required physical assistance of one person for personal hygiene. The resident required assistance with setup for bed mobility and eating. The resident exhibited behavioral symptoms such as kicking, hitting, pushing, scratching, grabbing, and sexual abuse directed towards others. The resident's identified symptoms put others at significant risk for physical injury. The resident significantly intruded on the privacy or activity of others. The resident exhibited these behaviors four to six times daily. The resident currently resided in a locked behavior unit. A review of Resident #105's medical record indicated a behavior care plan, dated 02/24/2020, indicated under the focus portion of the plan that Resident #105 resisted care and was combative (hitting/punching/slapping) with staff and at times requires additional certified behavioral technician (CBT) for provision of care. The focus portion also indicated Resident #105 wanders and the resident becomes very intrusive with peers, yells, curses, and threatens peers. Resident #105 takes food from peers' trays at times, becomes verbally and physically aggressive. The intervention portion of the care plan, last revised 02/27/2020, included the following: allow behaviors to continue in a safe manner if it assists with keeping Resident #105 calm, staff to monitor the effectiveness of techniques and report any changes to nurse, doctor, or interdisciplinary committee (IDC) team, offer appropriate seating areas to reduce agitation and over-stimulation, and offer distraction and remove from area when becoming agitated. A review of a facility incident report, dated 06/02/2021, indicated it was reported by an unidentified eyewitness that Resident #197 was propelling themself in their wheelchair on the [NAME] Unit hallway trying to get past Resident #105. The incident report indicated Resident #197 told Resident #105 to excuse them, and Resident #105 responded by punching Resident #197 with a closed fist, which caused a laceration to Resident #197's upper lip. The incident report indicated Resident #197 required an emergency room visit to get their upper lip sutured. A review of a facility incident report, dated 08/13/2021, indicated it was reported by an unidentified eyewitness that Resident #105 was sexually inappropriate with Resident #198. Per the incident report, Resident #105 was observed to have touched Resident #198 on their buttocks while Resident #198 was walking in an unidentified hallway. It was noted in the incident report that when Resident #198 questioned why Resident #105 touched them inappropriately, Resident #105 pushed Resident #198 to the floor. A review of a progress note, dated 10/07/2021, indicated Resident #105 pulled on Resident #234's hair. During an interview with the Activity Assistant (AA) on 10/10/2021 at 3:39 PM, the AA stated that he witnessed the encounter firsthand. Per the AA, Resident #105 pulled Resident #234's hair such that it caused Resident #234's head to tilt abruptly towards the side of the pull and the resident yelled out in a sound that indicated discomfort or pain. Per the AA, Resident #105 had a repeat encounter with Resident #234 within a space of a few minutes. The AA stated that he reported his observations to the nurse on the shift. A review of Resident #105's medical record indicated that for each of the identified incidents of abuse perpetrated by Resident #105 towards the identified residents, the facility failed to reassess Resident #105 and put new interventions in place to prevent further abuse. Specifically, a review of Resident #105's behavior care plan revealed the care plan was formulated between 02/24/2020 through 02/27/2020. There was no amendment to the resident's care plan to reflect that the facility attempted to address what the trigger was for Resident # 105 and to ensure that the resident did not continue to abuse other residents at the facility. During an interview on 10/07/2021 at 2:25 PM, Licensed Practical Nurse (LPN) #7 stated that Resident #105 was aggressive, combative, and not easily redirectable. LPN #7 stated that Resident #105 liked to say racial slurs and derogatory speech. She stated that Resident #105 got into other residents' personal space. LPN #7 stated that the resident had grabbed, hit, and punched staff and residents. LPN #7 stated, You need to know how to speak, in order to not get the resident agitated. LPN #7 reviewed Resident #105's care plan and acknowledged Resident #105's care plan related to the resident's behavior had not been updated after it was formulated on 02/24/2020 through 02/27/2020. LPN #7 stated that she had no remarks about the intervention portion of Resident #105's care plan which read, Allow behaviors to continue in a safe manner if it assists with keeping Resident #105 calm. During an interview on 10/09/2021 at 9:00 AM, Assistant Director of Nursing (ADON) #2 stated that Resident #105 had been very challenging with the resident's care. ADON #2 stated that Resident #105's behaviors created a stressful environment for other residents. The ADON verified there was no adjustment in Resident #105's care plan which reflected the facility intervened in ensuring Resident #105 did not continue to abuse residents at the facility. Specifically, ADON #2 verified that following Resident #105's initial encounter with Resident #197 as noted above, the facility had not reviewed or implemented new measures to ensure that Resident #105 did not continue to abuse residents at the facility. During an interview on 10/10/2021 at 3:02 PM, the Nursing Home Administrator (NHA) stated that when an abuse incident was reported to be repeatedly perpetrated by the same resident, he relied on nursing staff to tell him what they had done and their input on what they thought the facility should do differently. The NHA stated that he expected an investigation into all abuse allegations. Per the NHA, investigation was key to identifying the trigger for the aggressor, and it helped direct the proper intervention which helped to ensure residents at the facility continued to be free from abuse. A review of facility's policy and procedure titled, Interdisciplinary Care Planning and Assessment, revised 01/2021, indicated, care plans are revised as changes in the resident's condition dictates. Reviews are made at least quarterly. New Jersey Administrative Code § 8:39-11.2(e)2 Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to update person-centered care plans to reflect changes in interventions for three (Residents #152, #105, and #213) of 39 residents reviewed for care planning. The facility failed to update the accident/falls care plans with additional interventions after falls occurred for Resident #152 and Resident #213, which could have prevented Resident #152 from falling and sustaining a fracture. The facility also failed to update the behavior care plan for Resident #105. This had the potential to affect all residents. Findings included: 1. A review of Resident #213's quarterly Minimum Data Set (MDS), dated [DATE], indicated diagnoses including hypertension, obstructive uropathy, diabetes, personal history of traumatic fracture, and muscle weakness. The resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. The resident had one fall with injury. A review of a fall risk assessment titled, Morse Fall Scale Assessment, dated 08/17/2021, indicated Resident #213 was at moderate risk for falling. There was no other Morse fall scale completed after that date. A review of Resident #213's care plans, dated 08/31/2021, indicated the resident was at risk for falls, as evidenced by a history of falls, with the last fall on 09/18/2021. Interventions included the following: maintain bed in low position, tab alarm for safety to bed and wheelchair at all times, encourage to use appropriate assistive devices, encourage use of appropriate fitting, non-skid shoes, observe for unsafe behavior, remind to use the call light, and assist with toileting and meeting daily needs. The effective dates for the interventions were 08/31/2021. The care plan did not indicate any additional interventions to prevent falls after 08/31/2021. A review of Resident #213's progress notes indicated the resident sustained a fall on 09/10/2021. The notes indicated the fall occurred in the resident's room at 7:45 PM and was unwitnessed. An x-ray was obtained for complaints of back and hip pain, which indicated no injury. Following the fall on 09/10/2021, the care plan was not updated to reflect any new interventions. A review of Resident #213's progress notes revealed the resident sustained another fall on 09/18/2021 at 9:00 PM. The notes indicated the fall occurred in the hallway next to the resident's wheelchair and was unwitnessed. There was no injury documented. Following the fall on 09/18/2021, the care plan was not updated to reflect any new interventions. An observation of Resident #213 on 10/07/2021 at 7:52 AM revealed the resident sitting on the edge of the bed. The resident was observed to be very hard of hearing. There was no tab alarm (used to indicate if a resident is rising from a seated position), and the bed was not in the low position. An observation of Resident #213 on 10/08/2021 8:38 AM revealed the resident sitting on the edge of the bed. The resident became frustrated when answering questions. There was no tab alarm, and the bed was not in the low position. There was a fall mat next to the bed. On 10/08/2021 at 10:24 AM, an interview was conducted with Assistant Director of Nursing (ADON) #2. When asked if new interventions were put into place after the resident fell on [DATE], ADON #2 stated no. ADON #2 stated that the facility's interdisciplinary team met and concluded no interventions were needed. When asked if any interventions were put into place after the second fall on 09/18/2021, ADON #2 stated the interdisciplinary team did not feel any additional interventions were warranted. When asked if a new Morse fall scale assessment was completed after either fall, ADON #2 stated, no. When asked if the fall which occurred on 09/18/2021 may have been avoided if interventions were put into place after the fall that occurred on 09/10/2021, the ADON #2 stated, maybe. ADON #2 stated they would update the care plans. When asked why the tab alarm was not in place on 10/07/2021 and 10/08/2021, ADON #2 stated they were not sure but would in-service staff. When asked if ADON #2 was aware that per facility policy a Morse fall risk assessment was to be completed after each fall to identify risk areas, ADON #2 stated, no. ADON #2 confirmed there was only one fall risk assessment completed for Resident #213, which was on admission [DATE]). During an interview on 10/10/2021 at 1:38 PM, the Administrator stated the expectation was that everything should be updated in the residents' care plans. A review of facility's policy and procedure titled, Interdisciplinary Care Planning and Assessment, revised 01/2021, indicated, care plans are revised as changes in the resident's condition dictates. Reviews are made at least quarterly. A review of facility's policy and procedure titled, Resident Safety Program - Fall Prevention, revised 07/2021, indicated, Procedure: A. A Morse Scale Falls Risk Assessment is completed upon admission and readmission, significant change assessment, quarterly assessment and after each fall event. B. Interventions are implemented based on risk areas identified by the falls risk assessment. The fall prevention/intervention guide may be utilized to assist in identifying and implementing appropriate interventions. C. Risk for falls and/or injury is identified and addressed in the resident's individualized treatment plan. D. Falls will be reviewed weekly by the interdisciplinary team and interventions adjusted and care plans updated as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, facility policy review, and interviews, it was determined that the facility failed to ensure fall assessments were completed and interventions were put into place to decrease the likelihood of falls for 3 (Residents #161, #152, and #213) of 7 residents reviewed for falls. This failed practice resulted in Resident #152 falling and sustaining a fracture. Findings included: 1. The facility admitted Resident #152 with diagnoses of Alzheimer's disease and brain cancer. The annual Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was a 5 out of 15, which indicated the resident was severely cognitively impaired. Since the previous assessment, the resident had one fall with no injury and two falls with injury. A review of the resident's care plan, which was last updated on 09/21/2021, revealed Resident #152 was at risk for falls. Interventions for the falls included the following: - Physical and occupational therapy referrals for changes in functional mobility, with an effective date of 09/26/2018. - Reminding Resident #152 to call for assistance with activities of daily living, especially transfers, with an effective date of 09/26/2018. - Observation for unsafe behavior, with an effective date of 09/26/2018. - Non-slip footwear, with an effective date of 10/04/2018. - Encouragement for use of hip guards, with an effective date of 04/25/2019. - Blood pressure and pulse monitoring weekly, with an effective date of 09/13/2019. - Pad sensor alarm to bed and chair, with an effective date of 05/12/2020. - Floor mats at bedside, with an effective date of 07/06/2021. There were no interventions listed on the resident's care plan regarding any falls that occurred in 2021, other than the floor mats at bedside. A record review of the fall assessments indicated that on 06/29/2021 and 08/25/2021, Resident #152 was at a moderate risk for falls, and on 09/20/2021, the resident was at a high risk for falls. A review of an injury and accident report indicated that on 06/09/2021 at 8:00 AM, the resident had an unwitnessed fall. Resident #152 stated they fell in their bedroom. A certified nursing assistant noticed a small abrasion on the back of the resident's head, behind the left ear, while showering the resident the same morning after the fall. The resolution listed on the report was that Resident #152 was educated on calling for help. Resident #152 stated, I just want to use the bathroom. The report indicated staff would continue to monitor and encourage the resident to use the call lights. A review of a nursing progress note, dated 06/09/2021 at 2:45 PM, described the note as the initial fall-focused note and detailed the same information provided in the injury and accident report. At the end of the note, the writer had the option to list, New safety interventions added after this fall, and this section was left blank. A review of a nursing progress note, dated 06/09/2021 at 11:10 PM, described the note as the first follow-up fall-focused note. The additional interventions initiated and response to new interventions were left blank and did not identify any new interventions. A review of a progress note, dated 06/15/2021 at 3:36 PM, indicated the interdisciplinary team met regarding the fall on 06/09/2021. The new intervention initiated was alarm to chair. According to the care plan, the intervention of alarm to chair was already listed on the care plan with an initiated date of 05/12/2020. A review of an injury and accident report indicated that on 06/29/2021 at 2:00 PM, the resident had an unwitnessed fall. Resident #152 was found lying on the left side of their body on the floor between the door and the bed. Resident #152 was transferring themselves from the bed to the wheelchair. The wheelchair brakes were not locked. The resolution listed on the report indicated the resident stated, I forgot to lock my brakes. Resident #152 was educated on calling for assistance, and staff would continue to monitor. A review of a progress note, dated 06/29/2021 at 4:23 PM, detailed the same information provided in the injury and accident report. No new interventions were added, and additional comments were made stating that safety education was provided to the resident on locking the wheelchair brakes and using the call bell for assistance. A review of a nursing progress note, dated 06/29/2021 at 10:37 PM, described the note as the first follow-up fall-focused note. The additional interventions initiated and response to new interventions were left blank and did not identify any new interventions. A review of a nursing progress note, dated 06/30/2021 at 11:31 AM, described the note as the second follow-up fall-focused note. New orders were received for an x-ray for cervical, thoracic and lumbar spine, and bilateral hips due to the resident complaining of pain. The additional interventions initiated and response to new interventions were left blank. A review of a physician's progress note, dated 07/01/2021 at 2:59 PM, indicated the resident had a vertebral compression fracture of the L1/T12 site with an indeterminate age. New orders were given for pain medication and an orthopedic consult. A review of a progress note, dated 07/06/2021 at 12:13 PM, indicated the interdisciplinary team met regarding the fall on 06/29/2021. The new intervention initiated was floor mats. A review of an injury and accident report indicated that on 07/15/2021 at 11:50 AM, the resident had an unwitnessed fall. Resident #152 spilled milk in their lap, self-ambulated to the bathroom without calling for help, and the resident's tab alarm alerted staff. Resident #152 was found on the floor, sitting with their back against the wall and their legs out in front of them. Resident #152 reported they just went down while trying to get to the toilet. There was no resolution given. A review of a progress note, dated 07/15/2021 at 2:40 PM, detailed the same information provided in the injury and accident report. The new interventions added were to educate the resident on the use of the call bell and calling for help. A review of a nursing progress note, dated 07/15/2021 at 11:50 PM, described the note as the first follow-up fall-focused note. The additional interventions initiated and response to new interventions were left blank and did not identify new interventions. A review of a nursing progress note, dated 07/16/2021 at 6:54 AM, described the note as the second follow-up fall-focused note. The additional interventions initiated and response to new interventions were left blank. A review of a progress note, dated 07/20/2021 at 10:01 AM, indicated the interdisciplinary team met regarding the fall on 07/15/2021. The new intervention initiated was to remind the resident to call for assistance. A review of a social service progress note, dated 08/19/2021 at 4:23 PM, indicated the resident had cognitive impairment shown by memory loss, impaired decision-making skills, and episodes of confusion. A review of an injury and accident report indicated that on 09/12/2021 at 2:00 PM, the resident had an unwitnessed fall. Staff heard a loud bang, and Resident #152 screamed out. Staff noted the resident lying on the floor in the doorway of their bedroom, lying on the left side of their body with their left arm behind them. Resident #152 then turned themselves over onto their stomach. Resident #152 was transferred to the emergency room at 2:45 PM the same day. The resolution listed on the report was that the resident was transferred to the emergency room for evaluation of injuries, and the resident's care plan would be updated upon return. A Root Cause Analysis (RCA) would be completed to address the resident's fall, and an action plan would be created. A review of a progress note, dated 09/12/2021 at 2:00 PM, detailed the same information provided in the injury and accident report. No new interventions were added. A review of a progress note, dated 09/20/2021 at 4:01 PM, indicated the resident returned from the hospital with a left humerus fracture. A review of a Root Cause Analysis document indicated the document was completed on 09/30/2021 related to the fall on 09/12/2021 with major injury. Resident #152 sustained a left hip femoral neck fracture, impacted intra-articular left distal radius fracture, and a comminuted proximal left humeral head fracture. The Problem indicated Resident #152 had a history of gait instability and was found lying in the doorway of their assigned room. Resident #152 was last observed resting in their low bed with a fall mat on the floor and a tab alarm attached to the resident. Resident #152 removed the tab alarm and exited their bed. Resident #152 left their walker at the bedside and ambulated toward the doorway. Resident #152 fell, due to ambulating without their walker and known gait instability. Resident #152 was diagnosed with a urinary tract infection during the hospital stay. The first part of the facility's action plan consisted of continuing to use the low bed, fall mat at bedside on the floor, fall socks, move furniture away from the head of the bed to prevent injury, and apply hip guards. The second part of the facility's action plan consisted of consideration of using a pad sensor alarm while the resident was in bed and to offer the resident fluid every shift to prevent dehydration. The third part of the facility's action plan consisted of providing frequent reminders for the resident to use their walker when ambulating. Resident #152 would use their wheelchair during recovery with the goal of ambulating with a walker. On 10/08/2021 at 3:15 PM, Assistant Director of Nursing (ADON) #1 provided the injury and accident reports, as well as any fall assessments, for the resident within the last six months. ADON #1 verified there were three fall assessments that had been completed on the resident, which were 06/29/2021, 08/25/2021, and 09/20/2021. There were no fall assessments for 06/09/2021 or 07/15/2021. In an interview on 10/09/2021 at 8:40 AM, ADON #1 stated it was the facility's policy to complete a fall assessment after each fall, which was completed by the interdisciplinary team (IDT), and there should have been one completed after each fall for Resident #152. ADON #1 stated the care plan should be updated and the IDT team had guidelines for interventions. ADON #1 stated, As long as we have some type of alarm in place and appropriate footwear, we make sure to provide education on call light use. ADON #1 stated that the facility had prevented numerous falls for Resident #152 and .there was really no other intervention we could put into place. We could get a sitter . During an interview on 10/10/2021 at 1:39 PM, the Administrator stated the expectations of the facility was to provide care to prevent falls from occurring and to intervene after a fall to try to prevent further falls. The Administrator stated a fall should be documented in an incident report, and the interdisciplinary team would review the fall and seek to find interventions to prevent further falls. The Administrator also stated the interventions should be updated in the care plans and was disappointed they were not. Review of the facility's policy and procedure titled, Resident Safety Program/Fall Prevention, revised on 07/21, revealed, Policy: All residents who are at risk for falls will be identified through a comprehensive assessment process. This risk will be addressed in the resident's individualized treatment plan and evaluated through the IDC process .Procedure: A Morse Scale Falls Risk Assessment is completed upon admission and readmission, significant change assessment, quarterly assessment and after each fall .F. Falls will be reviewed weekly by the IDC team using the IDC team fall event review note, interventions adjusted, and care plans adjusted as necessary. 2. The facility admitted Resident #161 with diagnoses of history of falling, muscle weakness, and age-related osteoporosis. The quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 14 out of 15, which indicated the resident was cognitively intact. Since the previous assessment, the resident had one fall with no injury, two falls with injury, and one fall with major injury. A review of the resident's care plan, with a revision date of 08/31/2021, indicated the resident was at risk for falls that resulted in right hip surgery on 05/2021 and multiple rib displacements on 08/2021 and pain. Interventions listed included the following: - Observe Resident #161 for unsafe behavior and redirect accordingly, with an effective date of 5/26/2021. - Resident #161 to use comfortable, proper fitting non-skid shoes, with an effective date of 5/26/2021. - Monitor Bowel and Bladder needs, with an effective date of 05/26/2021. - Provide adequate lighting, with an effective date of 05/26/2021. - Encourage current activity level, with an effective date of 05/26/2021. - Tab alarm to bed and chair, with an effective date of 06/03/2021. - Pad alarm to bed and chair, with an effective date of 07/06/2021. - Keep bed in low position and call bell within reach, with an effective date of 07/06/2021 - Provide assistance as needed for activities of daily living (ADL), with an effective date of 07/06/2021. - Observe for signs of discomfort and monitor resident for complaints of pain and follow pain interventions as per doctor's orders, with an effective date of 07/06/2021. - Hip protectors at all times except for care, with an effective date of 07/07/2021. - Pressure relieving scoop mattress, with an effective date of 08/20/2021. - Keep call bell within reach, remind and encourage resident to use it before getting out of bed, with an effective date of 08/31/2021. A review of all of the resident's assessments indicated the resident had one fall assessment, which was completed on the day the resident was admitted , on 05/18/2021. There were no other fall assessments in the resident's electronic health record. A review of an injury and accident report indicated that on 06/01/2021 at 12:15 AM, the resident had an unwitnessed fall. The resident was found on the floor at bedside and stated they fell on their way back from the bathroom. The resolution listed on the report was that the resident was alert, awake, oriented, and able to make needs known. Resident #161 stated they fell on their way from the bathroom and believed it was their shoe that caused the fall. Staff were re-educated on monitoring the resident's footwear. The facility was to follow up with the resident's family member on providing appropriate footwear for the resident. A tab alarm was to remain in place as an intervention. A review of an injury and accident report indicated that on 07/06/2021 at 7:15 PM, the resident had an unwitnessed fall. The nurse was notified that the resident was lying on the floor on their left side in front of their closet. The resident's right shoe was off as well as the right side of the resident's pants. Resident #161 remained verbal and alert. Resident #161 stated, I was just standing still, and I don't know what happened. I just fell down. The resident was assessed, and there was bruising and a scrape on the resident's left elbow and left knee. Resident #161 complained of moderate pain to their left elbow and knee. There was no swelling or deformities noted. The resident was educated on safety. There was no resolution listed. A record review of an injury and accident report indicated that on 08/11/2021 at 8:30 PM, the resident had an unwitnessed fall. There was screaming heard coming from Resident #161's room, and the resident was found lying on their back beside their bed. Resident #161 stated they were trying to transfer themselves to the wheelchair, it moved, and they slid to the floor. Resident #161 sustained bruises to their upper back. The resolution listed on the report was to have an x-ray completed, which indicated multiple injuries noted to the rib area. Resident #161 was re-educated on the need to use the call bell for assistance. A tab alarm was to remain in place as an intervention. In an interview on 10/06/2021 at 3:48 PM, Resident #161 stated that it had been hard adjusting to moving into a nursing home facility. When asked if the resident had had any falls or hospitalizations since being admitted , the resident looked away from the surveyor and denied any falls or hospitalizations since being admitted . On 10/08/2021 at 3:15 PM, ADON #1 provided the injury and accident reports, as well as any fall assessments, for the resident within the last six months. ADON #1 verified there was only one fall assessment that had been completed on the resident, on 05/18/2021. In an interview on 10/09/2021 at 8:50 AM, ADON #1 stated Resident #161 should have had a fall assessment completed after each fall. In an interview on 10/10/2021 at 2:40 PM, the Administrator stated the Resident #161 should have had a fall assessment completed after each fall. During an interview on 10/10/2021 at 1:39 PM, the Administrator stated the expectations of the facility was to provide care to prevent falls from occurring and to intervene after a fall to try to prevent further falls. The Administrator stated a fall should be documented in an incident report, and the interdisciplinary team would review the fall and seek to find interventions to prevent further falls. The Administrator also stated the interventions should be updated in the care plans and was disappointed they were not. 3. A review of Resident #213's quarterly MDS Minimum Data Set (MDS), dated [DATE], indicated diagnoses including hypertension, obstructive uropathy, diabetes, personal history of traumatic fracture, and muscle weakness. The resident's Brief Interview for Mental Status (BIMS) score was 13, which indicated no cognitive impairment. The MDS indicated the resident had one fall with injury. A review of a fall risk assessment titled, Morse Fall Scale Assessment, dated 08/17/2021, indicated Resident #213 was at moderate risk for falling. There was no other Morse fall scale assessment completed after that date. A review of #213's care plans, dated 08/31/2021, indicated the resident was at risk for falls, as evidenced by a history of falls, with the last fall on 09/18/2021. Interventions included the following: maintain bed in low position, tab alarm for safety to bed and wheelchair at all times, encourage to use appropriate assistive devices, encourage use of appropriate fitting, non-skid shoes, observe for unsafe behavior, remind to use the call light, and assist with toileting and meeting daily needs. The effective dates for the interventions were 08/31/2021. The care plan did not indicate any additional interventions to prevent falls after 08/31/2021. A review of Resident #213's physician's orders, dated October 2021, indicated an order for a tab alarm to chair and bed at all times. The order date was 08/17/2021. There was no order for a low bed A review of Resident #213's progress notes indicated the resident sustained a fall on 09/10/2021. The note indicated the fall occurred in the resident's room at 7:45 PM and was unwitnessed. An x-ray was obtained for complaints of back and hip pain, which indicated no injury. There was no documentation to indicate if the tab alarm was in place at the time of the fall. A review of Resident's #213 IDT (interdisciplinary team) investigation dated 09/13/21 confirmed no interventions were put into place after the fall on 09/10/21. A review of Resident #213's progress notes indicated the resident sustained another fall on 09/18/2021 at 9:00 PM. The notes indicated the fall occurred in the hallway next to the resident's wheelchair and was unwitnessed. There was no injury documented. There was no documentation to indicate if the tab alarm was in place at the time of the fall. A review of Resident's #213 IDT investigation dated 09/24/21 confirmed no interventions were put into place after the fall on 09/18/21. An observation of Resident #213 on 10/07/2021 at 7:52 AM revealed the resident sitting on the edge of the bed. There was no tab alarm (used to indicate if a resident was rising from a seated position), and the bed was not in the low position. An observation of Resident #213 on 10/08/2021 at 8:38 AM revealed the resident sitting on the edge of the bed. There was no tab alarm, and the bed was not in the low position. There was a fall mat next to the bed. On 10/08/2021 at 10:24 AM, an interview was conducted with Assistant Director of Nursing (ADON) #2. When asked if new interventions were put into place after the resident fell on [DATE], ADON #2 stated, no. ADON #2 stated that the facility's interdisciplinary team met and concluded no interventions were needed. When asked if any interventions were put into place after the second fall on 09/18/2021, ADON #2 stated the interdisciplinary team did not feel any additional interventions were warranted. When asked if a new Morse fall scale assessment was completed after either fall, ADON #2 stated, no. When asked if the fall which occurred on 09/18/2021 may have been avoided if interventions were put into place after the fall that occurred on 09/10/2021, the ADON #2 stated, maybe. ADON #2 stated that the care plan would be updated. When asked why the tab alarm was not in place on 10/07/2021 and 10/08/2021, ADON #2 stated they were not sure but would in-service staff. ADON #2 stated the CNA had all the interventions on the Kiosk, which is where they document. When asked if ADON #2 was aware per facility policy a Morse fall risk assessment was to be completed after each fall to identify risk areas, ADON #2 stated, no. ADON #2 confirmed there was only one fall risk assessment completed for Resident #213, which was on admission [DATE]). During an interview on 10/08/2021 at 7:31 PM, a family member for Resident #213 stated the resident had sustained multiple falls at home. The family member stated that they and other family members were concerned about Resident #213's safety. During an interview on 10/10/2021 at 1:39 PM, the Administrator stated the expectations of the facility was to provide care to prevent falls from occurring and to intervene after a fall to try to prevent further falls. The Administrator stated a fall should be documented in an incident report, and the interdisciplinary team would review the fall and seek to find interventions to prevent further falls. The Administrator also stated the interventions should be updated in the care plans and was disappointed they were not. Review of the facility's policy and procedure titled, Resident Safety Program/Fall Prevention, revised on 07/2021, revealed, Policy: All residents who are at risk for falls will be identified through a comprehensive assessment process. This risk will be addressed in the resident's individualized treatment plan and evaluated through the IDC process .Procedure: A Morse Scale Falls Risk Assessment is completed upon admission and readmission, significant change assessment, quarterly assessment and after each fall .F. Falls will be reviewed weekly by the IDC team using the IDC team fall event review note, interventions adjusted, and care plans adjusted as necessary. New Jersey Administrative Code § 8:39-27.1(a)