**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, review of clinical records, select facility policy and fall incident reports, and staff interviews, it was determined that the facility failed to consistently implement, and evaluate the effectiveness, of planned individualized fall prevention measures and provide sufficient staff supervision at the level and frequency required, of residents identified as at high risk for falls and known unsafe behaviors to prevent falls resulting in serious injuries, a fractured femur, for one resident (Resident 98) and a fractured neck for one resident (Resident 56), and failed to provide necessary assistance devices and assure that the resident's environment was free of potential accident hazards to prevent a fall and injuries, abrasions and bruises, to one resident (Resident 39) out of nine residents sampled for accidents. Findings include: A review of the facility policy titled Managing Falls and Fall Risk, last reviewed by the facility on January 2, 2024, indicated that it is the facility's policy to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Also, the policy indicates that if interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention has resolved. A clinical record review revealed that Resident 98 was initially admitted to the facility on [DATE], with diagnoses to include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and a history of repeated falls with significant injuries including a fracture of the right femur (thigh bone) and a fracture of the left radius (the radial bone is one of the two large bones of the forearm). Resident 98's care plan, initially dated October 25, 2022, revealed that Resident 98 was at-risk for falls with behaviors that do not allow staff to assist, including swinging at staff during redirection. The resident's care plan also noted the use of both chair and alarms, initiated November 12, 2022 and December 5, 2022, respectively. A Physical Therapy Discharge summary dated [DATE], indicated that Resident 98 required the assistance of one staff member for ambulation. A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 27, 2023, revealed that Resident 98 was severely cognitively impaired with a BIMS score of 01 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment). This quarterly MDS assessment dated [DATE], Section G0300 Balance during Transition and Walking, indicated that Resident 98 was not steady when moving from a seated to a standing position or when walking and was only able to stabilize with staff assistance. A review of facility fall reports revealed that between July 2023 and September 2023 Resident 98 fell five times before falling on September 29, 2023, and sustaining a serious injury. The facility's fall investigations identified that Resident 98 had four unwitnessed falls during this time period. A facility fall report noted that Resident 98 had an unwitnessed fall on July 13, 2023, at 7:00 PM in her bathroom. Staff found the resident on the bathroom floor, near her wheelchair. No injuries were noted. The facility developed an intervention for staff to toilet Resident 98 each day at 7:00 PM. Facility fall reports revealed that Resident 98 had an unwitnessed fall on July 14, 2023, at 4:15 PM in the hallway. Staff found the resident on the floor lying in front of her wheelchair. No injuries were noted. An intervention was developed to evaluate labs and obtain a urine analysis A physician progress note dated July 31, 2023, indicated that the resident's recent labs, urine, medications, and medication management were reviewed. The entry noted that Resident 98's plan was being formulated. A facility fall report noted that Resident 98 had an unwitnessed fall on July 29, 2023, at 2:15 PM in the hallway. Staff found the resident on the floor in the doorway outside of her room. No injuries were noted. A care plan intervention was developed for staff to conduct 15-minute safety checks of the resident. The 15 minute safety checks of the resident were discontinued on July 31, 2023. A fall risk assessment dated [DATE], indicated that Resident 98 was at high risk for falls. A facility fall report noted that Resident 98 had an unwitnessed fall on August 19, 2023, at 9:05 PM near her room doorway. Staff found the resident lying on the floor in the doorway of her room. The preventative approach was developed for staff to restart every 15 minute safety checks, which was planned after the fall on July 29, 2023. An additional care plan intervention was developed for staff to check the resident's alarm pads to ensure proper placement. A review of the resident's clinical record and task and intervention tracking documentation revealed no evidence that staff were conducting every 15-minute checks of Resident 98 as a safety measure, after the resident's fall on August 19, 2023. Nursing documentation dated August 2023, indicated that the resident continued frequent attempts to ambulate without staff assistance. A nursing progress note dated August 22, 2023, at 2:04 PM indicated that Resident 98 was self-rising and attempting to ambulate at times. Nursing noted that redirection was unsuccessful at times but does well with one-to-one interaction. A nursing note dated August 22, 2023, at 7:06 PM indicated Resident 98 was frequently yelling out and attempting to stand and ambulate from the wheelchair. A nursing progress note dated August 23, 2023, at 3:22 AM indicated that Resident 98 was attempting to self-transfer out of bed. Staff assisted the resident into a wheelchair and to the nurse's station. Nursing progress note dated August 23, 2023, at 2:45 PM indicated that Resident 98 displayed frequent self-rising attempts. A nursing progress note dated August 23, 2023, at 6:11 PM indicated that the resident made multiple attempts at standing and ambulating without assistance this shift. The also entry noted that the resident does well with one-on-one assistance. Nursing noted on August 24, 2023, at 2:32 PM that Resident 98 continued with impulsive self-rising or attempting to ambulate unassisted. A nursing progress note dated August 25, 2023, at 11:19 PM indicated that Resident 98 displayed multiple behaviors, to include standing up frequently, kicking at staff, slapping, and poking staff. The entry noted Resident 98 enjoys one-on-one (interaction) but reverts to the same behavior when left by herself. Nursing noted on September 21, 2023, at 1:34 AM that Resident 98 made multiple attempts to get out of bed without assistance. The entry further noted that that reorientation, redirection, and distraction were attempted and failed. The resident's care plan included interventions to mitigate Resident 98's risk of falls as of September 29, 2023, including a chair alarm, ensuring the resident was wearing appropriate footwear when ambulating or mobilizing in a wheelchair, giving the resident a cat to hold to keep her busy in one spot, keeping frequently used articles within reach of the resident, 15 minute safety checks, and keeping the resident out at the nurse's station when restless to have staff around for close observation. However, review of the resident's clinical record, Resident 98's task and intervention tracking and fall investigation reports for September 29, 2023, revealed no documented evidence that staff had implemented all planned interventions in accordance with her care plan for mitigating her risk of falling. Specifically, the clinical record, task documentation and intervention tracking failed to reveal documented evidence that staff had implemented the follow care planned interventions: (1) provided Resident 98 with her toy cat to hold to keep her busy in one spot: (2) ensured that frequently used articles were within reach of Resident 98: or (3) conducted 15-minute safety checks. A nursing progress note dated September 29, 2023, at 11:16 AM indicated that staff found Resident 98 lying on her back with her left leg flexed near her wheelchair near the nurse's station. The resident was yelling out in pain. The note indicated that neurological checks were initiated and that a cold pack was provided to the resident. A mobile x-ray report dated September 29, 2023, at 11:44 AM indicated that Resident 98 had a mildly displaced, impacted, and angulated acute subcapital fracture of the proximal left femur. The nursing progress note dated September 29, 2023, also noted that the resident's x-ray was positive for a proximal femur fracture and the Certified Registered Nurse Practitioner (CRNP) evaluated the resident. The resident was transferred to the emergency room A facility investigation report dated September 29, 2023, indicated that Resident 98 had an unwitnessed fall near the nurse's station at 11:15 AM. Staff found the resident lying on her back with her wheelchair alarm sounding. A witness statement dated September 29, 2023, provided by Employee 5, a Licensed Practical Nurse (LPN), indicated that she did not witness Resident 98 fall. Employee 5, LPN, indicated that the last time she saw the resident was at 9:30 AM when administering medication. Employee 5, LPN, indicated that she was in the hallway administering medications when she heard a thump and saw the resident on the floor next to her wheelchair. Employee 5, LPN, indicated that Resident 98 was evaluated, and nursing supervisor notified about the incident. A witness statement dated September 29, 2023, provided by Employee 7, Nurse Aide (NA), indicated that she did not witness Resident 98 fall. Employee 7, NA, indicated that she last saw Resident 98 at 9:30 AM. A witness statement dated September 29, 2023, provided by Employee 6, Nurse Aide (NA), indicated that she did not witness Resident 98 fall. Employee 6, NA, indicated that the last time she saw Resident 98 was at 9:30 AM in front of the resident's room. A witness statement dated September 29, 2023, provided by Employee 8, Registered Nurse (RN), indicated that she did not witness Resident 98 fall. Employee 8, RN, indicated that the last time she saw Resident 98 was 11:00 AM in her wheelchair near the nurse's station. A hospital discharge summary indicated that Resident 98 was admitted on [DATE], due to a fall with hip pain and a fracture. The report indicated that Resident 98 underwent open reduction and internal fixation surgery (ORIF- a type of surgery that is used to repair broken bones) to repair a fracture of her left femoral neck. The resident was discharged from the hospital on October 2, 2023. Nursing noted on October 2, 2023, at 9:20 PM that Resident 98 was readmitted to the facility with intact surgical wound dressings. During an observation on January 7, 2024, at 12:51 PM, Resident 98 was observed seated in a wheelchair near the nurse's station. Resident 98 was observed moving from a seated position to a standing position multiple times, which caused her alarm to engage and disengage. There were no employees present at the nursing station, but after 60 seconds, Employee 3, Registered Nurse (RN), responded to Resident 98's alarm. Employee 3, RN, was observed talking to Resident 98. During an interview on January 9, 2024, at approximately 9:30 AM, the Director of Nursing (DON) confirmed that the facility was unable provide documented evidence of consistent implementation of planned safety and fall prevention measures, including sufficient staff supervision, to prevent Resident 98's fall and serious injury on September 29, 2023. A review of the clinical record of Resident 39 revealed admission to the facility on September 19, 2019, with a history of falls with fracture and heart failure. A review of the resident's annual MDS assessment dated [DATE], revealed that the resident was moderately cognitively impaired and required extensive staff assistance with activities of daily living, including bed mobility, transfers, and toileting. Review of Resident 39's care plan, last revised February 25, 2020, indicated that the resident was at risk for falls related to a history of falls, non-compliance with transfer status, impaired balance, impaired coordination, weakness, pain, and medication. Planned interventions for prevention included a high-density contour mattress, bilateral fall-[NAME] mats to the bedside, transfer via mechanical lift, keep pathways clear and free of clutter, maintain call bell within reach, and non-skid footwear at all times. According to the care plan, Resident 39 also utilized bilateral bed enablers (side rails) to assist in bed mobility, which was initiated October 7, 2019. Nursing noted on November 24, 2023, at 1:28 PM that the resident was transferred to another room for isolation precautions after testing positive for COVID. Nursing progress notes dated November 28, 2023, at 7 PM indicated that staff found the resident found face down on the floor next to the bed with arm of bed side table underneath right upper leg. The resident sustained abrasions to right upper thigh, the bridge of her nose was swollen with slight bruising, redness and swelling was observed on the left temporal area, and the resident complained of left shoulder pain. An x-ray was ordered due to complaints of left shoulder pain, which was negative for fracture or dislocation. A review of a facility investigation dated November 28, 2023, at 5:45 PM indicated that the resident had an unwitnessed fall from the bed. At time of event, the resident stated that she forgot I didn't have my handrails (side rails on the bed {enablers}). Facility description of potential contributing factors identified that when the resident was moved to another room for isolation, the temporary room's bed had an air mattress versus a high-density contour mattress, no bilateral bed enablers, and fall mats were not in place on each side of the bed. The facility failed to implement the resident's fall prevention measures when the resident was transferred to the temporary room for isolation precautions for COVID. The bed in which the resident was placed had a different type of mattress, no enabler bars and no fall mats were placed on the floor at the bedside. In response to the resident's fall from bed on November 28, 2023, the facility planned the immediate interventions of removing the air mattress and replace it with the appropriate mattress and apply bilateral enablers (side rails on the bed). Interview with the Director of Nursing on January 9, 2024, at approximately 2:00 PM confirmed that the facility failed to implement Resident 39's planned interventions, and assure that the resident's temporary environment was free of potential accident hazards, to prevent the resident's fall with injuries. Clinical record review revealed that Resident 56 was admitted to the facility on [DATE], for short-term therapy after a fall at home during which the resident sustained a hip fracture. The resident had a history of repeated falls and a diagnosis of rheumatoid arthritis. The resident's care plan, dated November 5, 2023, indicated that the resident was at risk for falls with an intervention for staff to be sure that the resident's call light was within reach, to encourage the resident to use it for assistance, and education to the resident on safety issues. The care plan also included an intervention for the resident's bed to be in lowest position, dated November 8, 2023. A review of a facility fall investigation report dated November 6, 2023 at 2:53 PM revealed that staff observed Resident 56 on the floor, next to the foot of the resident's bed. According to the report, he stood up and stepped out of the wheelchair. The investigation indicated that it appeared that he was attempting to pick up something from the floor. The noted intervention was to refer the resident to therapy for a reacher with associated education. A review of a facility investigation report dated December 10, 2023 at 5:30 AM revealed that staff found Resident 56 laying on the floor, on his right side, between the beds in his room. He told staff he was going to the ball game. He had a small bump on the top of his forehead approximately one inch under his hairline. Neuro checks were initiated. He had non skid socks on and was last given care at 5 AM The physician was contacted and because this resident was taking an anticoagulant medication (Eliquis) he was transferred to the hospital for evaluation. New interventions to prevent falls dated December 10, 2023, was for the resident to wear non-skid socks, although the facility's fall investigation report indicated that the resident was wearing non-skid socks at the time of this fall. Nursing documentation dated December 10, 2023 at 5:48 AM revealed that staff in the hall, heard Resident 56 say I hope that doesn't happen again. Staff went into the resident's room and found the resident lying on the floor, between both beds. The resident was facing his bed. Staff assessed the resident to have two small superficial open areas noted to the top of the forehead, approximately one inch inside the hairline. The area had a small, elevated purplish discolored lump at the site of the open area, no further bleeding or drainage noted. The resident's physician and responsible party notified. The ambulance was called and the resident was transported to the hospital for treatment. The emergency room staff contacted the facility and relayed information that the resident was being admitted to the hospital for a non-displaced fracture of the base of the odontoid in the cervical region (of the neck), and was to be seen by neurology services and also that the resident had a urinary tract infection. A review of hospital documentation dated December 12, 2023 at 7:39 A.M. revealed a CT scan (a computerized x-ray imaging procedure) revealed that Resident 56 had an acute type 2 odontoid fracture, undisplaced fractures of posterior arch C1 (cervical 1 vertibra). The hospital placed an Aspen collar (cervical collar, also known as a neck brace) on the resident and the resident was admitted to the facility on [DATE]. A significant change MDS assessment dated [DATE], revealed that the resident was moderately cognitively impaired with a BIMS score of 8 and was dependent on staff for activities of daily living. A review of a facility investigation dated December 26, 2023 at 4:30 P.M., revealed Resident 56 was found on the floor. His Aspen collar was in place. He had been sitting in the wheelchair at the time of the fall and was incontinent of bowel at that time. The resident stated that he was trying to go to the bathroom for a bowel movement. The noted intervention was to offer toileting at 4 PM daily and the additions of bed and chair alarms. A review of a facility investigation report dated December 30, 2023 at 3:45 P.M. revealed that Resident 56 was found on the floor in his room from bed. Planned interventions added at the time of this fall was to add bilateral fall mats next to his bed. A nurses note dated December 30, 2023 at 6:08 PM revealed that at 3:45 PM that date staff found the resident sitting on the floor next to his bed. He stated he was trying to get to call his wife. The facility failed to demonstrate the implementation of necessary fall prevention approaches, including sufficient staff supervision of resident with a known history of falls and identified at risk for falls to prevent repeated falls and serious injury. The facility failed to re-evaluate the effectiveness of existing planned safety measures as the resident continued to fall and revise the resident's fall prevention plan accordingly to include increased supervision of the resident, which was confirmed during interview conducted on January 10, 2024, at 10 AM with the Director of Nursing. 28 Pa. Code 201.18 (e)(2.1) Management 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on a review of clinical records and select facility fall investigation reports and staff interviews, it was determined that the facility failed to provide necessary assistance devices as planned to safely transfer a resident identified at high risk for falls to prevent a fall resulting in a serious injury, a fractured tibia/fibula, sustained by one resident out of five residents reviewed for accidents/falls (Resident 42). Findings included: Review of Resident 42's clinical record revealed admission to the facility on September 19, 2019, with diagnoses that included a history of falling and abnormal gait. Resident 42 was identified at high risk for falls based on the resident's history of falls and abnormal gait. A review of resident's care plan for the problem/need of fall prevention dated August 31, 2022 indicated that the resident was to be transferred with a Vanderlift (a mechanical lift). An incident report completed by the facility on September 19, 2022, at 9:29 p.m. indicated that Resident 42 was in the bathroom with Employee 1 (CNA) and Employee 2 (CNA) for toileting. Employee 1 and 2 were attempting to transfer the resident from the toilet back into the wheelchair when her right leg gave out. The nurse aides indicated that they lowered the resident to the floor and the resident's right leg bent under her. The resident expressed pain in her right lower extremity and x-rays were ordered. X-ray results indicated the resident had a fracture of the right tibia and fibula (lower leg fracture). There was no indication Employees 1 and 2 used a Vanderlift to transfer the resident from the toilet to the wheelchair at the time of the resident's fall resulting in serious injury on September 19, 2022. Interview with the Administrator on November 15, 2022 at 2:05 p.m. confirmed that Resident 42 required the use of the mechanical lift, the Vanderlift, for safe transfers. The Administrator confirmed that Employees 1 and 2 failed to use the necessary assistance device to transfer the resident resulting in the resident's fall with injury on September 19, 2022. This deficiency is cited as past non-compliance. The facility's corrective action plan was to assess Resident 42 for proper transfer status and to update the care plan. All residents were audited for their current transfer status, care plan and cardex information. Corrections were made when found. Staff inserviced on proper transfer techniques. Any new nurse aides working in the facility will be paired up with an experienced nurse aide for transfers. Audits were completed weekly with results reported to the QAPI committee by the Director of Nursing. This plan of correction was completed by October 13, 2022. Refer F726 28 Pa. Code: 211.11(d) Resident Care Plans 28 Pa. Code: 211.12 (a)(c)(d)(3)(5) Nursing Services