**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview conducted during a recertification survey the facility failed to ensure that adequate supervision and effective use of the facility's monitoring program to prevent falls and injuries were provided for 2 of 3 residents reviewed for accidents (Resident #10 and #12). Specifically, (1) Resident #10 was care planned to be on 30-minute monitoring after a 4/12/24 fall. Resident #10 had a second fall on 4/14/24 which resulted in a nondisplaced transverse fracture of the distal malleolus (a break in the small prominent bone on either side of the ankle) and the facility did not implement care plan changes to address recurrent falls and (2) Resident #12 had 6 falls between 9/16/23 and 5/3/24 and the facility did not implement new interventions, including toileting schedules and monitoring, as recommended on the Accident/Incident reports. This resulted in multiple hospitalizations and the resident sustained fractured ribs from the falls on 9/16/23 and 5/3/24. This resulted in actual harm that is not immediate jeopardy. Findings include: The January 2023 Fall Risk Assessment and Prevention policy and procedure documented it was the policy that all residents be free of falls, and free of injuries associated with falls. Implement common sense interventions to aide in the prevention of falls. There was no standard approach to planning preventative care. Each resident must have an individual plan considering risk factors, functional status, cognitive status and how the plan of care will affect the quality of life. 1) Resident #10 was admitted with diagnoses including but not limited to rheumatoid arthritis, anemia (low levels of healthy red blood cells), and hypertension (high blood pressure). The 10/10/23 care plan titled At Risk for Falls, documented actual fall/s 11/14/23, 11/29/23, 3/21/24, 4/12/24, 4/14/24 and 5/18/24. Interventions included but were not limited to place call bell within reach. The care plan documented the following undated intervention reminders to use the call bell, 30-minute monitoring, and toileting schedule. The 3/7/24 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented Resident #10 had severe cognitive impairment, no rejection of care, received partial/moderate assistance for chair to bed transfers, toilet transfers and ambulation up to 50 feet, was frequently incontinent of bladder and continent of bowel, was not on a toileting program, had 1 fall with no injury since admission or prior assessment and did not receive therapy. The 3/27/24 Fall Risk Assessment score is 10 (a score of 4 or more was considered at risk). The 4/12/24 Accident and Incident Report documented Resident #10 had an unwitnessed fall and was observed lying on the floor of their room on their left side at 6:00 PM. Contributing factor was dementia. The resident had COVID and was weak and more confused than normal. The resident was alert/confused. The resident was unable to state what happened. The resident was able to ambulate without obvious injury. The care plan was updated to reflect 30-minute monitoring. The 4/14/24 Accident and Incident Report documented Resident #10 had an unwitnessed fall and was observed at 3:00 PM on the floor at the foot of their bed near the bathroom door. The resident was last seen at 2:00 PM. The resident had COVID and was weak, had cognitive deficit and poor safety awareness. The resident was able to get around, when not sick, using a walker. The resident still felt they could use a walker. Slight bruising to the right ankle. There was no documented evidence in the electronic medical record to indicate 30-minute monitoring was put in place or that Resident #10 was on a toileting schedule as per care plan after the 4/12/24 fall and before the 4/14/24 fall. The 4/14/24 nursing progress note documented they were called to the room at 3:00 PM and the resident was sitting on the ground beside the bed. The bed was in the low position. The call bell was not ringing. The resident was unable to say what happened. The resident was able to move all extremities without complaint of pain. The extremities were equal in length, a slight bruise was noted to the right ankle, and continue to monitor. The 4/14/24 nursing progress note documented the resident's right ankle was noted with a hematoma and swelling. The resident was able to move the ankle with some pain noted. The resident was non weight bearing to extremities. Unable to keep the extremity elevated and the resident continued to move the leg off of the pillow. The medical doctor was made aware, and an order was received for an x ray of the right ankle. X Ray called and will be done tomorrow. The 4/17/24 X-Ray Report documented an unhealed non-displaced transverse fracture of the distal malleolus. No overlying soft tissue swelling. Correlate clinically for recent trauma. No significant arthritic changes. Mild soft tissue swelling over the lateral malleolus. Osteoporosis. During observation on 6/25/24 at 11:10 AM Resident # 10 was observed attempting to get out of bed without assistance and stated they had to go the bathroom. Resident #10 had one sock on the right foot, and no sock on the left foot. Both sneakers were on the floor next to the chair. The call bell was wrapped around the right upper siderail and dangling down to the floor. The call bell was not within the resident reach. At 11:13 AM facility staff was made aware Resident #10 was attempting to get up out of bed without assistance. During observation on 6/26/24 at 9:03 AM Resident #10 was observed in bed. Resident #10 had one sock on the right foot and no sock on the left foot. The call bell was on the chair next to the bed, and not within reach. During observation on 6/27/24 at 1:07 PM Resident #10 was in the main lobby and requested to go back to their room. Certified Nurse Assistant #2 returned the resident to their room placed them in bed with a blanket covering and left the room. The call bell was wrapped around the right upper siderail and dangling to the floor. The call bell was not within the resident's reach. Certified Nurse Assistant #2 did not ask Resident #10 if they needed to be toileted prior to placing the resident back to bed. During observation on 6/27/24 at 4:54 PM Resident #10 was observed sitting up at the edge of the bed on the right side attempting to get up unassisted as they stated help me, help me, please take me to the bathroom. The call bell was wrapped around the right upper siderail and not within the resident's reach. During an interview on 6/27/24 at 4:42 PM when asked where they documented safety monitoring and the toileting schedule for Resident #10, Certified Nurse Assistant # 1 stated Resident #10 had never been on a toileting and/or safety monitoring schedule. Certified Nurse Assistant #1 stated that most days Resident #10 preferred to stay in their bed and they checked on them maybe 3 times during their shift. Certified Nurse Assistant #1 stated they often found Resident #10's call bell on the siderail and dangling to the floor on either side of the bed and not within the resident's reach when starting their shift. During an interview on 6/27/24 at 5:00 PM Registered Nurse #1 stated Resident #10 would yell out when they had to go to the bathroom, but they were not sure if the resident was incontinent or on a toilet schedule. Registered Nurse #1 stated they did not know if Resident #10 had falls in the past, but due to the resident's current state they would assume Resident #10 was high risk for falls. Registered Nurse #1 stated if a resident were high risk for falls, they should have the call bell within reach at all times and be frequently supervised. Registered Nurse #1 stated the care plan would direct toileting and fall risk needs, but they did not have access to the care plans. When asked how certified nurse assistants received information regarding resident care needs, Registered Nurse #1 stated they only provided the certified nurse assistants with report if something was going on with the resident otherwise the certified nurse assistants reported to each other. During an interview 6/28/24 at 11:17 AM Certified Nurse Assistant #2 stated they were not certain if Resident #10 had falls in the past, or if they had ever been on 30-minute monitoring. Certified Nurse Assistant #2 stated they would not know how to document resident monitoring. Certified Nurse Assistant #2 stated Resident # 10 loved to sleep in bed, so they put the resident back to bed after breakfast. Certified Nurse Assistant #2 stated Resident #10 was not currently on a documented toileting or monitoring schedule and they checked on the resident every 2 hours when they were in bed. During an interview on 6/28/24 at 11:50 AM the Medical Director stated everybody in the nursing home was a high risk for falls. The physician stated when a resident had a fall, they were educated on the use of the call bell. The physician stated they were part of the QAPI (Quality Assurance and Performance Improvement) and that they reviewed falls, performance and improvement plans. During an interview on 7/1/24 at 11:22 AM the Director of Nursing stated they believed the fall care plan had been updated after the 4/12/24 fall to reflect 30-minute monitoring. The Director of Nursing stated they had also discussed the resident being placed on a toilet schedule during the fall meetings and that a toilet schedule should have been put in place but was not. The Director of Nursing stated they were responsible for ensuring monitoring of residents for fall prevention and documentation for such monitoring was done. The Director of Nursing stated they were not able to locate documentation to support that monitoring for Resident #10 occurred or remained ongoing as per care plan intervention. The Director of Nursing stated they were responsible for ensuring that care plan interventions were developed and effective. The Director of Nursing stated they were responsible for supervising staff during the week and supervisors were responsible during the weekends. The Director of Nursing stated whenever they noticed Resident #10's call bell was not within reach they put it within the residents reach. The Director of Nursing stated they had not educated staff regarding the call bell not being kept within the resident's reach. During an interview on 7/1/24 at 12:45 PM the Administrator stated they had been the Administrator onsite since October 2023 and had not identified any concerns with how the facility operated. The Administrator stated they approved Accident and Incident reports submitted by the Director of Nursing. The Administrator stated that during fall meetings they discussed what transpired and what was put in place for each resident to prevent future reoccurrence. The Administrator stated they did not recall being made aware of any resident being seriously injured related to falls. 2) Resident #12 was admitted to the facility on [DATE] with diagnoses and conditions including Congestive Heart Failure (heart pumps inadequately causing fluid overload), Diabetes (uncontrolled blood sugar), and Depression (sadness). The admission Minimum Data Set (MDS; a comprehensive resident assessment tool) dated 4/17/23, documented Resident #12's cognition was intact. The resident was always incontinent of bladder and frequently incontinent of bowel. Resident #12 required extensive assist of 1 person for toileting, bed mobility, transfer, walking in room and locomotion on and off the unit. Comprehensive Person-Centered Care Plan dated 4/10/23 documented Resident #12 was at risk for falls. Interventions dated 7/10/23 included ensuring the call bell was within reach at all times and was answered in a timely manner; encourage to call for assistance; regularly orient to environment; and provide family/resident education on falls prevention. An Accident/Incident Report dated 9/16/23 documented on 9/16/23 at 11:20 PM the nurse was called to the resident's bathroom, observed resident on floor on their back, resident complained of low back pain and able to move legs. Resident #12's color was pale and had seizure like activity for short period, head fell back, and eyes were wide open. The recommendation was for medical workup and was sent to the hospital. The Accident/Incident report also recommended to monitor resident every 2 hours. The nursing progress note dated 9/17/23 at 6:40 AM, documented the resident was admitted to the hospital for syncope(losing consciousness)/fall. The Hospital Visit Summary dated 9/20/23, documented the resident's discharge diagnoses included pacemaker, fall, and closed fracture multiple ribs of right side. The nursing progress note dated 9/20/23, documented the resident was readmitted to the facility. There was no documented evidence to include 2-hour monitoring as recommended on the Accident/Incident report dated 9/16/23. An Accident/Incident Report dated 9/21/23 documented at 2:00 PM the resident was assisted to bathroom by the Certified Nurse Assistant. The Certified Nurse Assistant left the resident alone and resident fell off the toilet to floor. The resident was sent to Emergency Department for evaluation. The recommendation was for 1 hour monitoring when in room and not to be left alone on toilet. Hospital records dated 9/21/23 to 9/28/23 documented the resident passed out after having a bowel movement while getting up from the toilet. The diagnosis was defecation syncope. The resident also needed a change for his pacemaker and was transferred to another hospital for the procedure. The nursing progress note dated 9/28/23 for 3-11 PM, documented the resident returned to the facility with a pacemaker replacement due to syncope. Review of the resident record revealed no documented evidence the recommendation for 1 hour monitoring when in room and not to be left alone on toilet was put in place. The new admission rehabilitation evaluation and recommendation dated 9/29/23, documented the resident was non-ambulatory with nursing staff, may only ambulate during therapy as appropriate. Do not leave resident unattended in the toilet. Keep resident in supervised area during working hours. There was no documented evidence of the care plan being revised with the recommendations from the Rehabilitation Department. A nursing note dated 10/5/23 at 3:11 PM, documented Resident #12 was observed lying on the floor in the bathroom, reported hitting the side of their forehead, and complained of nausea and right hip pain, pupils reacting to light able to move upper extremities. The family member was made aware, and the resident was transferred to the hospital. There was no documented evidence of an investigation being completed or an Accident/Incident report for 10/5/23. During an interview on 7/01/24 at 3:28 PM, the Director of Nursing stated an Accident/Incident report was not done for 10/5/23 as they were not told about the incident. A Physical Therapy note dated 10/11/23 at 12:40 PM, documented the resident required extensive assist of 1 for transfers. The resident was non ambulatory with nursing staff and could ambulate only with rehabilitation staff at this time. The resident required supervision at all times especially in the toilet due to history of multiple falls. A Physical Therapy note dated 10/17/23 at 9:38 AM, documented nursing staff could ambulate the resident to and from the bathroom using rollator with 1 assist for safety. Do not leave the resident unsupervised while at the bathroom due to history of multiple falls. A new care plan intervention dated 10/20/23 documented the following: Bed in lowest position; Proper footwear/nonskid footwear with rubber soles; Evaluate for orthostatic hypotension; Rehabilitation screen to assess need for therapy/positioning--assistive devices as indicated; Use diversional activities and encourage participation in activities. The Accident/Incident Report dated 11/4/23 documented they were called to the resident's room and the resident was observed on their left side on the floor, resident stated they attempted to get out of bed without calling for assistance. Educated to ask for assistance able to move all extremities. The Care plan was updated in resident chart for a floor mat left side. The Accident /Incident Report recommended floor mat and 15-minute monitoring. There was no documented monitoring and no documented instructions for the Certified Nurse Assistant to do 15-minute monitoring. Review of the resident's care plan documented a fall on 11/11/23; however, no other documentation including an Accident/Incident report was found for this fall. The Accident/Incident Report dated 12/27/23 documented at 7:44 AM, the resident fell was observed lying on the floor on their back, knees bent, feet facing bathroom door. The resident attempted to get up and did not ring bell. The documented recommendation was to set up the resident on the night get up schedule (the overnight shift gets the resident up for morning care), and toileting schedule 6:00 -7:00 AM. There was no documented evidence on Certified Nurse Assistant instructions of a toileting schedule for Resident #12. The Accident/Incident Report dated 5/3/24 documented at 3:04 AM the resident fell and had a skin tear. Resident #12 got up to go to the bathroom and did not use the call bell. It further documented the resident had poor safety awareness, cognitive deficits and was self-directed. Resident #12 was sent to the hospital due to seizure like activity. The documented recommendation was for resident to be put on a toileting schedule. Nursing note dated 5/10/24 documented the resident was readmitted to facility from the hospital on 5/9/24 and had sustained rib fractures from their fall on 5/3/24. Review of Resident #12's medical record revealed no documented evidence the resident was ever put on 2-hour, 1 hour, or 15-minute monitoring as planned on the Accident/Incident reports dated 9/16/23 to 5/3/24. There was no documented evidence on the Certified Nurse Assistant instructions for the recommended toileting schedule for Resident #12. On 6/26/24 at 4:00 PM, as the surveyor was approaching Residents #12's room, the Certified Nurse Assistant was observed walking toward the room and stated they were toileting the resident. The resident had been left in the bathroom unattended. There was a sign on the bathroom door that read Do not leave wheelchair in bathroom if left unattended. Please do not leave resident unsupervised in bathroom. On 6/27/24 at 10:29 AM, Resident #12 was observed lying in bed. The bathroom door was open and an alarm on door trim upper left side was observed. Resident #12 was interviewed and stated the alarm was used to notify nursing they were using the bathroom. They stated it was put in place when they were having a lot of falls. Stated they did not use it much now. They stated the device needed to be turned on and bathroom door kept closed, and then when the door to bathroom was opened, the alarm would sound. On 6/27/2024 at 11:24 AM, a family member of Resident #12 stated Resident #12 had a history of falls prior to admission to the facility and after Resident #12 was admitted they began falling in the facility. Resident #12 and family were offered an alarm on resident's bathroom door as an intervention to prevent further falls around September or October of 2023. The resident's family agreed to have alarm placed on the door. On 6/28/24 at 9:17 AM, Resident #12 stated the last fall they had was bad and they were still recovering. They stated they were still waiting to see if the swelling of the hematoma goes down and they might need surgery. On 6/28/24 at 10:25 AM, Certified Nurse Assistant #4 stated Resident #12 was alert and oriented and supposed to ring bell when they needed assistance. On 5/3/24, during the overnight shift, the resident used the urinal then started to be sick and was unable to really tell you what happened. Certified Nurse Assistant #4 stated usually when they worked the overnight shift, they did not get residents up, they just changed them. Certified Nurse Assistant #4 stated there were no new interventions in place for toileting Resident #12. On 6/28/24 at 10:26 AM, Certified Nurse Assistant #8 stated they were assigned to Resident #12 and had been working at the facility since February 2024. Certified Nurse Assistant #8 stated Resident #12 could not be in their wheelchair in their room alone because they would use the bathroom unassisted. Certified Nurse Assistant #8 stated because the resident was mobile, for safety precaution, Resident #12 should be out in the common areas where they could be supervised. Certified Nurse Assistant #8 stated there was not a toileting schedule for Resident #12 and they were unaware of any planned monitoring schedule. Certified Nurse Assistant #8 stated during report after the resident's last fall, the nurse told them verbally that the resident could not be left alone in their room, but it was not on the care instructions. On 06/28/24 at 10:28 AM, the Resident #12 was observed in his room alone, sitting in his recliner chair with a wheelchair nearby. On 6/28/24 at 10:43 AM, Licensed Practical Nurse #3 stated they were notified at change of shift of residents who were at risk for falls and those residents needed to be brought to the common area. Licensed Practical Nurse #3 stated Resident #12 was supposed to be in the common area and that basically every resident went to the common area for lunch and stayed there after lunch. Licensed Practical Nurse #3 stated they did not know how the facility identified residents at risk for falling and was unaware of any documented monitoring for residents at risk for falls. They stated they just kept an eye on those at risk. Licensed Practical Nurse #3 stated Resident #12 used their call bell and sometimes it took a long time to answer call bells especially if they had no help to do cares, treatments, and when there was a shortage of Certified Nurse Assistants. On 6/28/24 at 10:38 AM, Certified Nurse Assistant #5 stated they were usually assigned to Resident #12 on the overnight shift. Certified Nurse Assistant #5 stated they were off the night of the most recent fall but when they returned to work nothing was changed, there were no new interventions. Certified Nurse Assistant #5 stated the alarm on the bathroom door was there the whole time they have worked with the resident. Certified Nurse Assistant #5 stated there was no toileting schedule put in place. Certified Nurse Assistant #5 stated they did frequently monitor all residents but was not told to do 15-minute monitoring for Resident #12 and had not documented any type of monitoring. On 06/28/24 at 11:15 AM, the resident was observed on the toilet with the wheelchair in front of him and Licensed Practical Nurse #3 was standing outside of the room in the corridor. Licensed Practical Nurse #3 stated that resident rang the bell to use the bathroom and they were outside of the room to give the resident privacy because they were having a bowel movement. Licensed Practical Nurse #3 stated there was no documented 15-minute checks. Licensed Practical Nurse #3 stated they were not aware of the motion sensor on resident's bathroom door. On 06/28/24 at 11:50 AM, Medical Director and primary physician for residents at the facility stated everybody in the nursing home was at high risk for falls. Medical Director stated Resident #12 had a fall and was hospitalized with a pneumothorax (collapsed lung), hematoma and rib fractures. The Medical Director stated the interventions in place prior to hospitalization were to do a rehabilitation referral, educate resident and in-service staff. On 6/28/24 12:24 PM, Physical Therapist #1 stated the resident was moderate to high risk for falls and had multiple falls at the facility. Physical Therapist #1 stated their recommendation was to keep the resident supervised and not leave the resident unattended while in the bathroom. Physical Therapist #1 stated when they wrote their notes with recommendations for changes, it was the responsibility of the charge nurse or Director of Nursing to read their notes. On 7/01/24 at 10:35 AM, Resident #12 was observed in the recliner chair alone. Resident #12 stated they liked to go the common area but most of the time the staff did not bring them there. On 7/01/24 at 2:34 PM, the Director of Nursing stated the staff were aware of the toileting schedule and they were not sure why it was not implemented. They stated the care plan might not have been updated, but the staff were made aware. The alarm on the bathroom door was supposed to be turned on all the time and the resident would get annoyed and would turn it off with their reacher (device used to assist in grabbing items that the resident cannot reach). The Director of Nursing stated the staff should still be using the alarm. The Director of Nursing stated when toileting the resident the Certified Nurse Assistant must stay in the room or right outside of the bathroom to give them privacy but should not be down the hall. The Director of Nursing stated Resident #12 sustained a hematoma and fractured ribs with the fall in May 2024, and did not remember the time the resident fractured ribs in September 2023. The Director of Nursing stated when Resident #12 was in the recliner the staff checked on them but there was not documentation of that monitoring. The Director of Nursing stated the staff should be checking on Resident #12 often but would not specify how often. 415.12(h)(2)