**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 47 was admitted to the facility in 6/2023 with diagnoses including dementia with a behavioral disturbance. Resident 47's 6/18/23 admission MDS revealed the resident was severely cognitively impaired and not steady when moving from a seated to a standing position or when walking. The MDS also revealed the resident experienced a fall in the month prior to her/his admission to the facility, a fall in the two to six months prior to her/his admission to the facility and a fracture related to a fall in the six months prior to her/his admission to the facility. a. A review of Resident 47's clinical record revealed the resident experienced a fall in her/his room on 2/9/24 and 2/16/24 as a result of a failed attempt to self-transfer. Resident 47's 2/2024 Care Plan revealed the resident was at risk for falls related to her/his cognitive impairment, history of falls, lack of impulse control and unsteady gait (a person's manner of walking). The Care Plan indicated the resident was not to be left unsupervised in her/his room while awake as [Resident 47] may attempt to self-transfer to/from bed/wheelchair. Resident 47's 4/13/24 Fall/Post Fall Assessment revealed the following: -The resident experienced a fall at 2:30 AM in the resident's room. -The resident was in bed prior to the fall and found two feet from the transfer surface to the location of the fall. -A CNA found the resident with her/his hands resting on her/his roommate's bed with her/his right knee on the ground. -The resident was unable to provide a description of the fall event. -The new preventative plan was to perform frequent checks. The following questions from the Assessment were left unanswered: -When [was the resident] last visually observed? -When [was the resident] last toileted? -When [was the resident] last offered fluids? -When [was the resident] last repositioned? On 5/1/24 at 12:33 PM Staff 16 (LPN) stated she completed Resident 47's Fall/Post Fall Assessment on 4/13/24. Staff 16 stated she usually asked the resident's assigned CNA questions regarding care provided prior to a resident's fall but failed to do so in the case of Resident 47's fall on 4/13/24. Staff 16 stated staff typically checked on Resident 47 every few hours on night shift, and when Resident 47 was awake, she/he required eyes on [her/him] at all times because she/he was at risk for falls. On 5/1/24 at 2:37 PM Staff 17 (CNA) stated Resident 47 was considered a high fall risk and she usually checked on her/him around 11:30 PM to 12:00 AM and again around 2:00 AM. Staff 17 stated she found Resident 47 on 4/13/24 in her/his room kneeling down on one knee at [her/his] roommate's bed and could not recall when she last visually observed Resident 47, last toileted Resident 47, last offered Resident 47 fluids or last repositioned Resident 47 prior to this fall. Staff 17 stated she was not asked to provide any of these details at any point after the fall. On 5/2/24 at 8:58 AM Staff 18 (LPN) stated when Resident 47 was in bed, she expected CNAs to walk by the resident's room about every 10 minutes because she/he was a huge fall risk. Staff 18 stated sometimes [Resident 47] would stand up and the pressure light [would] not go off so it [was] really important staff [walked] the halls. On 5/2/24 at 12:09 PM Staff 2 (DNS) was informed of the findings of this investigation and stated doing rounds [was] the best way to prevent a resident from having falls. Staff 2 stated she expected staff to be peeking in resident rooms at least every 30 minutes when doing walking rounds at night. b. Resident 47's 4/30/2024 Care Plan revealed the resident was at risk for falls related to her/his cognitive impairment, history of falls, lack of impulse control and unsteady gait (a person's manner of walking). The Care Plan indicated the resident was not to be left unsupervised in her/his room (while awake) as [Resident 47] may attempt to self-transfer to/from bed/wheelchair and a pressure sensitive call light [was] to be placed between the bed fitted sheet and draw sheet to the left side of the resident when in bed for a fall intervention. A review of Resident 47's clinical record revealed the resident experienced a fall in her/his room on 2/9/24, 2/16/24 and 4/13/24 as a result of a failed attempt to self-transfer. On 4/30/24 at 12:47 PM Staff 19 (CNA) was observed to leave Resident 47's room, which left the resident alone in her/his room in bed. From the hallway, the resident was observed with her/his eyes open, lifted up her/his neck, looked around the room and moved her/his lips. Resident 47 removed her/his bedding from the top half of her/his body and stuck her/his right hand into the slats of the blinds on the right side of her/his bed. On 4/30/24 at 12:49 PM Staff 19 knocked on Resident 47's door to which the resident yelled yes and laughed as Staff 19 entered the room. Resident 47 and Staff 19 engaged in conversation, Staff 19 recovered the resident with her/his bedding and left the room. Resident 47 was observed to talk to her/himself as Staff 19 left the room. On 4/30/24 at 12:51 PM Resident 47 was observed to remove the bedding from the upper part of her/his body and sit up in bed. Resident 47 scooted her/himself to the edge of her/his bed. At 12:54 PM Resident 47 placed both of her/his feet on the ground, and with a hand to each side of her/his waist, began to rock as if attempting to initiate a sit-to-stand transfer. The State Surveyor entered the resident's room and activated her/his pressure sensitive call light. At 12:55 PM Staff 19 returned to the resident's room and was informed of the resident's movements and that the pressure sensitive call light did not activate indepently. On 4/30/24 at 1:02 PM Staff 19 stated Resident 47 experienced multiple falls and was the one [he] mainly worried about. Staff 19 stated when Resident 47 was awake and in [her/his] room, [she/he] would mostly likely stand up. Staff 19 stated Resident 47 was not supposed to be left alone in her/his room if she/he was awake. Staff 19 confirmed Resident 47 was awake when he re-entered the resident's room at 12:49 PM and he should have assisted the resident out of bed and brought her/him to an area where she/he could have been supervised. On 5/1/24 at 11:10 AM Staff 26 (CNA) stated Resident 47 was a fall risk because she/he tried to stand up independently all of the time but was unable to do so safely now that her/his toes were removed. Staff 26 stated if Resident 47 was awake, she preferred [her/him] to have supervision. On 5/1/24 at 2:06 PM Staff 20 (RN) stated Resident 47 was considered a fall risk as she/he was impulsive and did not remember she/he required assistance with transfers. Staff 20 stated Resident 47 would loose her/his balance as soon as she/he stood and tried to move from a spot with her/his right foot due to having her/his toes amputated. Staff 20 stated if Resident 47 was restless in bed, which included moving her/his blankets around, staff should offer to assist the resident out of bed. On 5/2/24 at 12:09 PM Staff 2 (DNS) acknowledged the findings of this investigation and stated if Resident 47 was moving around in bed, her expectation was for the CNA to check if Resident 47 was soiled, and if not, assist her/him up out of bed. Based on observation, interview and record review it was determined the facility failed to ensure staff followed the care plan related to fall safety and provide sufficient supervision to prevent a fall for 2 of 2 sampled residents (#s 306 and 47) reviewed for accidents. This failure resulted in resident 306 having a fall with serious injury including a left shoulder fracture, a rib fracture and periprosthetic fracture involving the left greater trochanter (fracture of a previously-repaired hip) which required emergency medical services and treatment at the hospital. Findings include: 1. Resident 306 was admitted to the facility 1/2023 with diagnoses including right leg fracture and right shoulder fracture. A review of Resident 306's 1/17/23 admission MDS revealed she/he was cognitively intact and required extensive assistance from two or more staff to transfer on and off the toilet. Resident 306's care plan dated 1/11/23 directed caregivers to provide her/him with two person stand pivot physical assist to transfer and to encourage her/him not to ambulate without assistance. On 5/1/24 at 5:28 PM Staff 25 (Agency CNA) stated on 5/7/23 she responded alone to Resident 306's call for assistance. Staff 25 stated Resident 306 told her she wanted to use the commode in her/his bathroom. Staff 25 stated she asked Resident 306 what she needed to do to help her/him and Resident 306 told her she/he only needed her/his cane. Staff 25 stated she offered to get her/his wheelchair but Resident 306 told her she was only there to help with her/his pants. Staff 25 stated Resident 306 walked to the bathroom, leaned forward to lock the door to the adjoining resident room and fell forward hitting her/his head and landing on her/his left side. On 5/1/24 at 6:06 PM Resident 306 stated Staff 25 assisted her/him to the bathroom using a manual wheelchair on 5/7/23 without the assistance of any other caregiver. She/he stated Staff 25 did not provide her/him with a gait belt to transfer. Resident 306 stated she/he stood up to transfer to the commode in her/his bathroom, tried to lock the door to the adjoining bathroom and fell forward hitting her/his head and landing on her/his left side. Resident 306 stated, I think she was pulling the wheelchair out when I was trying to do that and it tripped me. On at 5/1/24 5:38 PM Staff 27 (LPN) stated she worked with Resident 306 on 5/7/23 and Staff 25 provided care alone for her/him at the time of the fall. Staff 27 stated she expected CNAs to consult residents' care plans or [NAME] before working with the resident and the [NAME] tells how they transfer, ambulate and toilet. That is what they should be following. Staff 27 reported they called 911 because she/he was in an awquard position and they were not confident they could get her up and the paramedics could assess [her/him] for other injuries. A review of Resident 306's hospital notes revealed she/he was sent to the emergency departement on 5/7/23 after she/he fell in the facility. Resident 306 was sent back to the facility but then returned and was admitted to the hospital on [DATE] and treated for anemia and the following injuries she/he sustained as a result of the fall on 5/7/23: -Left shoulder fracture -5th rib fracture -periprosthetic fracture involving the left greater trochanter (fracture of a previously-repaired hip) Resident 306's Hospital Discharge Summary indicated she/he was discharged from the hospital and returned to the facility on 5/12/24. A review of the facility's internal investigation completed by Staff 1 on 5/12/23 revealed Staff 25 did not follow Resident 306's care plan at the time of the fall. On 5/3/24 at 10:28 AM Staff 1 stated she expected CNAs to follow residents' care plans and Staff 25 knew where to find Resident 306's transfer status but did not follow it.