**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select incident reports, and staff interviews it was determined that the facility failed to consistently provide individualized fall prevention interventions planned to meet resident's safety and supervision needs based on known risk factors, history of falls and displays of unsafe behaviors to prevent falls for two residents (Resident 10 and 33) resulting in a serious injury, a fractured hip, to one resident (Resident 10) and failed to maintain an environment free of potential accident hazards in one resident's room (Resident 26) out of 13 sampled residents. Findings include: The facility policy entitled Falls dated as reviewed March 29, 2023, indicated that a care plan will be developed to address the resident's specific factors which may contribute to the resident's risk for falls. At the beginning of each shift, all nurse aides will participate in walking rounds where they will also check to be sure safety alarms are in place and functioning appropriately. If a resident should sustain a fall, the resident will be re-evaluated by the Physical Therapist for new recommendations to prevent further falls. Review of Resident 10's clinical record revealed admission to the facility on September 3, 2020, with diagnoses to have included senile dementia [is a group of symptoms that affects memory, thinking and interferes with daily life], anxiety, depressive disorder, and general deconditioning. The resident's care plan to address the resident's safety needs, initiated on September 3, 2020, indicated that the resident would remain safe and free from falls and injury with noted interventions that included assist of one with transfers, orient to call system as needed, bed to floor - locked in position and bilateral pressure alarm mats and bilateral floor mats. Review of Resident 10's quarterly Minimum Data Set (MDS a federally mandated standardized assessment process completed periodically to plan resident care), dated October 12, 2022, revealed that the resident was moderately cognitively impaired. The resident required extensive assistance of two plus-person physical assistance for bed mobility and transfers and required total dependence of two plus persons physical assist with toilet use. The resident was not steady and only able to stabilize with staff when moving from seated to standing position and with surface-to-surface transfer (transfer between bed and chair or wheelchair). The resident was always incontinent of bladder and bowel. The MDS also noted that the resident had fallen in the last month and had fallen in the last 2-6 months without fracture related to a fall in the last 6 months. A facility Incident Investigation Form dated November 4, 2022, at 7:40 AM, revealed that Resident 10 had an unwitnessed fall in the doorway of her room. Employee 1, a nurse aide, reported that the resident was walking down the hallway and that she helped her to get into her chair. Resident 10 climbed out of her chair and walked towards her room, into the doorway, and fell. The sustained a 4.0 cm x 4.0 cm scrape to her right knee and a 2.0 cm x 2.0 cm bruise on her left lower leg. The planned preventative measure was for the resident not to be left in the hallway near her room and the resident should be either in her room, or the dining/activities room, or by the nurse's station. The investigation form noted that the resident's safety plan of care was updated. There was no indication that therapy performed a re-evaluation after Resident 10's fall on November 4, 2022, as indicated in the facility's Fall policy. Review of Incident Investigation Form dated November 9, 2022, no time indicated, revealed that the resident had a witnessed fall in the dining room. The investigation noted that the witness to Resident 10's fall was Resident 26. Resident was severely cognitively impaired with a BIMS score 6. However, Resident 26 stated that she witnessed Resident 10 slide out of her chair and land on the floor of the dining room. Resident 26 stated that she tried to help Resident 10 get up and off the ground, but she could not help her. Additionally, Resident 26's witness statement indicated that someone picked her up and took her maybe to the bathroom but she did not know the name of the staff member who picked Resident 10 up from the ground. The Incident Investigation Form further revealed that the Director of Activities saw Resident 26 flailing her arms and pacing back and forth and went to investigate the situation. When the Director of Activities arrived at the area where the residents were assembled, at the other end of the activities/dining room, Resident 10 was sitting on the edge of her Geri Chair and presumed that she climbed back into her chair before she arrived at the area and assisted Resident 10 to sit back in her chair to prevent a fall. The Activities Director assumed that Resident 10 was about to fall out of her chair and did not realize that she already had fallen and was getting herself back into her chair when observed. There was no evidence that the resident's chair alarm was in place and sounding. The facility's investigation also noted that the activities aide, that was working on November 9, 2022, at the time Resident 10's fall was on lunch from 1:45 PM until 2:15 PM. There was no evidence of any staff supervising these residents assembled in the dining/activities room, including Resident 10, who was unsupervised at the time of the fall. Review of Employee 2's, Activity Aide, statement dated November 11, 2022, at 9:00 AM, revealed I was on my lunch break at 1:45 PM to 2:15 PM and when I came back at 2:15 PM, Resident 26 told me that Resident 10 fell out of her chair and how scared she was. Employee 2 noted that she asked Resident 10 about the fall and Resident 10 confirmed that she fell out of her chair. Employee 2's statement indicated that the incident happened in the dining/activity room and that Resident 10 did not report any pain until 6 PM that evening when she took the resident to the bathroom. On November 9, 2022, the resident complained that her right leg was bothering her and Employee 2 reported the incident to the charge nurse, Employee 5, a night shift RN. Review of a statement that was completed by Employee 3, a nurse aide, dated November 9, 2022, and signed by the employee on November 12, 2022, revealed that Resident 10 kept telling us she fell earlier. Employee 3 noted that she didn't witness the fall, but when she took the resident to the bathroom around dinner time the resident had more trouble standing and turning to go to the bathroom. The resident told Employee 3 that she had fallen earlier that day and that her leg hurt a little bit. According to Employee 3's statement Resident 10 claimed that she fell on the previous shift and the two girls had picked her up. The resident also stated that one girl had a ponytail and glasses and the other girl she couldn't remember. Employee 3's statement noted that the resident was not in a ton of pain, just said that her leg hurt. Employee 5 contacted the Director of Nursing (DON) at 8:15 PM on November 9, 2023, and reported that she checked Resident 10 over and that there was discomfort to the resident's leg, but the resident was able to lift the leg, and no deformities were noted to the leg. The preventative measure planned was to apply a pressure sensor alarm in the resident's chair. An Incident Investigation Form dated November 10, 2022, (no time indicated) revealed that Resident 10 had an unwitnessed fall in her room the night prior (November 9, 2022 - the same date as the resident's fall in the dining/activity room witnessed by Resident 26) and didn't report the fall to any staff until November 10, 2022, in the afternoon. Resident 10's attending physician assessed the resident and indicated that the resident stated that she had right leg pain and that she had fallen last night and put herself back into bed. Resident 10 was given a PRN (as needed) Tylenol and the attending MD ordered an X-ray of her right hip and femur. There was no indication of any alarms sounding at the time of the resident's reported fall from bed on November 9, 2022, although the resident's care plan identified that bilateral pressure alarm mats were to be placed on the resident's bed and floor mats on the sides of the bed. Review of the radiology report November 10, 2022, at 12:54 PM, revealed that the impression of the x-ray was an acute impacted fracture of the right femoral neck. At that time, Resident 10's attending physician ordered the resident be sent to the Emergency Department. Review of nursing documentation dated November 11, 2022, at 1:20 AM, revealed that Resident 10 was admitted to the acute care hospital and that the resident was to have a pre-op evaluation for repair of the right hip. Review of Resident 10's alarm monitoring records dated November 2022 revealed that the resident had a pressure sensitive alarm in place on the chair and bed, which were noted to be functioning at the time of her two falls on November 9, 2022. Interview with Employee 4, a unit clerk, on April 12, 2023, 1:00 PM, reported that Resident 10 had alarms in place prior to her falls on November 9, 2022, and prior to sustaining the fracture. Employee 4 confirmed that the facility's alarm records reflected that staff documented alarms were already in place and functioning at the time of the resident's fall. Employee 4 was unable to explain why the incident report noted the addition of a chair alarm on November 9, 2022, since it was already care planned and documented as in place. During an interview with the Nursing Home Administrator (NHA) on April 12, 2023, at 2:23 PM, it was revealed that the facility was unable to determine which staff members, if any, were in the dining/activity room supervising the residents at the time of Resident 10's fall from her chair in that area on November 9, 2022. The NHA confirmed that the facility failed to ensure supervision of a resident with a history of falls to prevent a fall with major injury, a fracture. Also, the NHA reported that based on the information gathered and staff statements obtained regarding Resident 10's two falls on November 9, 2022, the facility was not able to identify the staff members who may have assisted the resident back into her chair when she was on the floor in the dining/activity room and whether an alarm was present on the resident's chair at the time as noted on the alarm monitoring records. The NHA also verified that the facility failed to re-evaluate Resident 10 after each fall as indicated in the facility's Fall policy. Clinical record review revealed that Resident 33 was admitted to the facility on [DATE] with diagnoses to include after care following a fracture. A review of a quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was moderately cognitively impaired with a BIMS score of 11 (Brief Interview for Mental Status a tool used to screen and identify the cognitive condition of residents) and was independent for transfers, locomotion and toileting. A review of a facility incident investigation report dated March 16, 2023 at 12:40 P.M. revealed that staff observed Resident 33 in the hallway outside her room. Employee 5 (RN unit manager) heard Resident 33 yell out and fall to the floor, hitting her elbow. Employee 5 assessed the resident and helped the resident back to her bed. The resident was instructed to be more careful when walking. The resident, when interviewed, stated there was a chair in the hallway for me to sit on. When I was walking to the chair, I was holding onto the door and then the handrail, but the floor in my room and the hallway was so slippery that I fell. I had these socks (non-skid) on and still fell on my butt and hit my elbow. The facility investigation noted that the floor of Resident 33's room was found to be very dirty and slippery and outside of the resident's room, a slippery residue was found on the floor. The non-skid socks the resident wearing at the time of the fall were found to be worn and were replaced after the fall. A review of nursing documentation dated March 16, 2023 at 9:23 P.M. revealed, Resident 33 complained of right pelvic pain. She was noted to be very unsteady on her feet, her knees were buckling. The physician was notified and bilateral hips and pelvis xrays were ordered and completed. There were no fractures noted at that time. There were no additional interventions developed or implemented at that time to prevent falls to address the resident's unsteadiness during ambulation. A review of a nurses note dated March 17, 2023, at 9:21 P.M. revealed, Resident 33 was walking poorly, needed assistance to walk. A review of an incident report dated March 19, 2023, at 10:20 A.M. revealed Resident 33 was self ambulating to the bathroom. ( The bathroom is located across the hallway from the resident room. It is a communal resident bathroom) The resident began yelling out and her roommate rang her call bell. Employee 6, a nurse aide, stated that she went into the bathroom and found Resident 33. Resident 33 stated that she fell in the doorway of the bathroom while trying to get back to bed. The resident stated that she was able to get up from the floor and sat back on the toilet. Employee 6 called the licensed nurse who assessed the resident. Resident 33 was complaining of right knee and right hip/pelvis pain. Resident 33 was noted with unsteady ambulation. Upon assessment, the resident's right knee was reported with swelling and she was complaining of discomfort. The Physician was called and the resident was sent to the emergency room. A review of an xray report dated March 19, 2023 revealed, subtle nondisplaced fractures of the right sacral area and right pubic bones, but no acute fracture. New interventions planned after this fall were a therapy evaluation for transfer and ambulation status. There was no evidence at the time of the survey that interventions were implemented after the resident's March 16, 2023, fall and observed unsteadiness and difficulty ambulating on March 17, 2023, to include a therapy screening or evaluation for ambulation as noted in facility policy. Staff observed that Resident 33 exhibited unsteady ambulation and transfers and the resident incurred another fall 3 days later. During an interview March 13, 2023 at 11 A.M., the Director of Nursing confirmed that the facility failed to ensure the resident's non-skid socks were in good condition and not worn/threadbare, and that the resident was not timely referred to therapy for ambulation screening, as noted in facility policy, following the resident's fall on March 16, 2023, and prior to the resident's fall on March 19, 2023, which the resident also incurred while ambulating. Observation of resident room [ROOM NUMBER] on April 11, 2023, at 10:40 AM revealed that Resident 26 presently resided in the bed located by the door of this room. Resident 26, the resident assigned to the bed by the door, was fully ambulatory, but not present in the room at the time of the observations. Continued observation revealed that maintenance/hardware supplies were observed on the overbed table and unoccupied bed located by the window, on the window sill, and the floor of resident room [ROOM NUMBER]. On the overbed table, there was a glass framed wall plate with a side of the glass exposed, 4 white pieces of wood with loose screws, a black basket, and a white cable with ends exposed. There was a long piece of wooden wall molding on top of the unoccupied bed. On the window sill there were 4 metal shelf brackets, hard plastic baseboard molding, and a plastic outlet wall cover. On the floor beside the unoccupied bed there were pieces of grey plastic baseboard molding. Interview with the Nursing Home Administrator on April 12, 2023, at approximately 11:00 AM confirmed that the maintenance items left unattended in resident room [ROOM NUMBER] were a potential accident hazard to Resident 26, the ambulatory resident currently residing in that room. 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10 (a)(d) Resident care policies 28 Pa. Code 207.2 (a) Administrator's responsibility 28 Pa. Code 211.11 (d)(e) Resident care plan