**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations record reviews, interviews, and facility protocols, the facility failed to follow the care plan for the prevention of falls for one (1) resident (Resident #57) and for providing showers for one (1) resident (Resident #98). The sample included 25 residents. Resident #57 had 28 falls and the staff did not consistently follow the care plan and the resident sustained two (2) forehead lacerations, one (1) requiring stitches, and one (1) required to be glued closed. Resident #98's was care planned to receive two (2) showers a week and the staff did not provide the showers as planned. Findings include: Review of the facility's protocol titled; Interdisciplinary Care Planning dated 3/2018 revealed the resident's care plan was a communication tool that guided members of the interdisciplinary healthcare team in how to meet each individual resident's needs. It also identified the types and methods of care the resident should receive. The care plan should describe the services the facility was to provide. The Care Plan process included the assessment, planning implementation, and evaluation. 1. Review of Resident #57's clinical record revealed the admission date of 1/7/2020. The diagnoses included: Dementia without Behavioral Disturbance, Cognitive Communication Deficit, Major Depressive Disorder, Disorder of Muscle, and Atrial Fibrillation. Review of Resident #57's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score of six (6) with a score of zero to seven (0-7) indicating severe cognitive impairment. The resident displayed inattention and disorganized thinking that fluctuated and did not display behaviors. The MDS documented the resident required supervision with bed mobility, transfers, walking, locomotion, and dressing. The resident required limited assistance with toileting. Resident #57 utilized a walker and a wheelchair and had one (1) fall without injury since the previous assessment. Review of Resident #57's Care Plan in place on 12/31/2020 listed the fall interventions: encourage to transfer and change positions slowly, have commonly used articles within easy reach, assist to transfer and ambulate as needed, anti-roll backs to wheelchair, assist when the resident becomes fatigued, assist with toileting upon rising, at hour of sleep (HS) and before and after meals, encourage and remind him/her to use his/her walker, keep bed at wheelchair height, medication review, offer and assist with toileting, place walker within easy reach, provide and assist with nonskid socks, reinforce need to call for assistance, assist with toileting hygiene, and reinforce wheelchair safety as needed such as locking brakes. Review of the facility provided Timeline, the Fall Investigations, and the Care Plan interventions revealed: 1/30/21 at 7:15 a.m. - staff found the resident on the floor in the bathroom, the resident did not have on socks or shoes on per the care plan. 2/1/21 at 11:15 a.m. - staff found the resident on the floor in his/her bathroom. The resident sustained a Small goose egg to back of head. Staff did not assist the resident to the bathroom as care planned. 2/9/21 at 10:00 a.m. - staff found the resident sitting on the floor between his/her bed and the window. Staff did not assist the resident with transfers and ambulation as care planned. 2/22/21 at 12:05 a.m. - staff heard a loud noise and crying and found the resident on the floor at the foot of the bed, the resident's head was under the bed. Staff did not assist the resident with transfers and ambulation as care planned. 3/2/21 at 6:45 p.m. - staff found the resident sitting on the floor in his/her room. Staff did not assist the resident with transfers and ambulation as care planned. 3/17/21 at 12:30 a.m. - staff found the resident on the floor in his/her room. Staff did not assist the resident with transfers and ambulation as care planned. 3/18/21 at 6:43 a.m. - staff found the resident on the floor in his/her room. Staff did not assist the resident with transfers and ambulation as care planned. 3/26/21 at 5:45 a.m. - staff found the resident on the floor at the foot of the bed. The resident sustained a Crushing skin wound to left forehead. Staff did not assist the resident with transfers and ambulation as care planned. 4/5/21 at 9:30 a.m. - staff found the resident laying on the floor in his/her room. The resident sustained a laceration to the forehead and was sent to the emergency room (ER). 4/6/21 at 3:00 a.m. - staff found the resident on the floor next to his/her bed. The resident sustained a large hematoma on the right side of [his/her] forehead. Staff did not assist the resident with transfers and ambulation as care planned. 4/6/21 at 7:20 a.m. - staff found the resident on the floor next to his/her bed. Resident sustained a hematoma to the posterior right side of the head. Staff did not assist the resident with transfers and ambulation as care planned. 4/15/21 at 5:10 a.m. - staff found the resident on the floor in his/her room. Staff did not assist the resident with transfers and ambulation as care planned. 4/20/21 at 4:14 a.m. - staff heard the resident yelling and found the resident on the floor in his/her room. Staff did not assist the resident with transfers and ambulation as care planned. 4/30/21 at 2:20 a.m. - staff found the resident on the floor between his/her bed and window. Staff did not assist the resident with transfers and ambulation as care planned. 5/3/21 at 2:44 p.m. - staff found the resident on the floor in their room. Staff did not assist the resident with transfers and ambulation as care planned. 5/4/21 at 10:30 a.m. - staff found the resident on the floor next to his/her bed. Staff did not assist the resident with transfers and ambulation as care planned. 5/6/21 at 2:45 a.m. - staff found the resident on the floor next to his/her bed. The resident sustained an abrasion to the forehead. Staff did not assist the resident with transfers and ambulation as care planned. Staff added the intervention for the use of a scoop chair to help with safety. 7/2/21 at 3:30 p.m. - staff heard yelling and found the resident on the floor in his/her room. Staff added the intervention to keep the resident within close observation at the Nurses' Station for safety as he/she would allow during waking hours. Staff did not assist the resident with transfers and ambulation as care planned. 7/4/21 at 5:18 a.m. - staff found the resident on the bathroom floor. Staff did not provide assistance with toileting as planned. 9/14/21 at 1:30 a.m. - staff heard a loud noise and yelling and found the resident on the floor in his/her room. The resident sustained an open laceration to the left temple area in the hair line. Staff transferred the resident to the Emergency (ER). The resident received three (3) sutures. Staff did not assist the resident with transfers and ambulation as care planned. 9/20/21 at 5:50 a.m. - staff found the resident on the floor in the bathroom. The facility did not provide an investigation of this fall. Staff did not assist the resident to the bathroom as care planned. 9/24/21 at 5:45 a.m. - staff found the resident lying on the floor at the foot of his/her bed. Staff did not provide assistance with transfers and ambulation as care planned. 10/5/21 at 6:28 a.m. - staff heard a loud noise then yelling and found the resident on the floor next to his/her bed. The resident sustained a five (5) cm laceration to the mid forehead. The ER closed the laceration with skin glue. Staff did not provide assistance with transfers and ambulation as care planned. 10/19/21 at 2:05 p.m. - Housekeeping Manager found the resident on the bathroom floor. Staff did not assist the resident with toileting as care planned and did not keep the resident at the Nurses' Station as care planned. 11/11/21 at 6:20 a.m. - staff heard a loud noise and crying and found the resident on the floor at the foot of the bed. Staff did not provide assistance with transfers and ambulation as care planned. The Fall Investigations lacked evidence the facility provided the interventions as planned. Observation on 11/30/21 at 11:35 a.m. revealed the resident sat across from the Nurses' Station with an approximate one (1) inch by two (2) inch dark scab on the top/middle section of the forehead. Observation on 12/1/21 at 12:09 p.m. revealed the resident's room door closed. Upon entrance to the room, the resident was sitting on the side of the bed eating his/her lunch. The resident's rollator was on the other side of the overbed table. No staff was present with the resident. Staff did place the resident at the Nurses' Station for close observation for safety, as added to the care plan on 7/2/21. Observation on 12/2/21 at 10:20 a.m. revealed the resident lying in bed on his/her back. The rollator was at the bedside, but no scoop chair was noted in the room. As added to the care plan on 5/6/21. Observation on 12/3/21 at 10:30 a.m. revealed the resident's door opened and upon entering, observation revealed the resident in the bathroom pulling up his/her pants. No staff was with the resident. 2. Review of Resident #98's clinical record documented the diagnoses included: Anxiety Disorder, Major Depressive Disorder, Spastic Hemiplegia, Multiple Sclerosis, Stiff-Man Syndrome, and Diabetes. Review of Resident #98's Care Plan dated 11/2/21 listed the intervention to assist the resident to bathe/shower as needed. Review of Resident #98's [NAME] (identified as the Care Guide for the Certified Nursing Assistants (CNAs) dated 12/1/21 listed the intervention for staff to shower/bathe the resident Wednesday and Saturday evenings Review or the Shower Documentation provided by the facility for the period of 10/3/21 to 12/2/21 revealed Resident #98 should have received 17 showers but only received sic (6) showers and one (1) documentation that the resident refused a shower. Interview with CNA #16 on 12/2/21 at 10:45 a.m. revealed the facility provided each resident two (2) showers a week, per the [NAME]/Care Guide. Interview with Licensed Practical Nurse (LPN) #6 on 12/2/21 at 10:46 a.m. revealed the facility's protocol was for the staff to bathe the residents two (2) times a week. Interview with Unit Manager (UM) #17 on 12/2/21 at 11:02 a.m. revealed staff should bathe the residents two (2) times a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews, and review of facility protocol, the facility failed to investigate the causative factors of the falls, failed to provide interventions as planned and failed to provide effective interventions for the prevention of falls for one (1) of two (2) residents reviewed for falls. (Resident #57) Resident #57 experienced 28 falls since 1/1/21 resulting in two (2) head lacerations requiring sutures or skin glue to treat. Findings include: Review of the facility protocol titled, Falls Practice Guide dated 12/2011 documented the Falls Practice Guide was an approach that used the nursing process framework: assess, plan, implement and evaluate. The comprehensive care plan was developed to include individualized resident interventions that focused on the resident's risk factors. The approaches for fall interventions were clear, specific, and individualized for the resident's needs. Review of Resident #57's clinical record revealed the admission date of 1/7/2020. The diagnoses included: Dementia without Behavioral Disturbance, Cognitive Communication Deficit, Major Depressive Disorder, Disorder of Muscle, and Atrial Fibrillation. Review of the clinical record revealed the resident had 13 falls from admission on [DATE] to 12/31/2020. Review of Resident #57's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score of six (6) with a score of zero to seven (0-7) indicating severe cognitive impairment. The resident displayed inattention and disorganized thinking that fluctuated and did not display behaviors. The MDS documented the resident required supervision with bed mobility, transfers, walking, locomotion and dressing. The resident required limited assistance with toileting. Resident #57 was not steady but able to stabilize without staff assistance with walking and turning around. The resident was not steady and not able to stabilize without staff assistance with moving on and off the toilet, surface with surface transfers and moving from a seated to standing position, Resident #57 utilized a walker and a wheelchair and had one (1) without injury since the previous assessment. The MDS documented the resident did not receive therapy or restorative services. Review of the clinical record revealed Resident #57 had eight (8) falls since the previous assessment completed on 1/3/21 and not the one documented on the MDS dated [DATE]. Review of Resident #57's Care Plan in place on 12/31/2020 listed the fall interventions: encourage to transfer and change positions slowly, have commonly used articles within easy reach assist to transfer and ambulate as needed, anti-roll backs to wheelchair, assist when the resident becomes fatigues, assist with toileting upon rising, at hour of sleep (HS) and before and after meals, encourage and remind him/her to use his/her walker, keep bed at wheelchair height, medication review, offer and assist with toileting, place walker within easy reach, provide and assist with nonskid socks, reinforce need to call for assistance and assist with toileting hygiene, and reinforce wheelchair safety as needed such as locking brakes,. Review of the facility provided Timeline, the Fall Investigations, and the Care Plan listed the following 28 falls with injuries noted and interventions documented since 1/1/21: 1/30/21 at 7:15 a.m. - staff found the resident on the floor in the bathroom, the resident did not have on socks or shoes. 2/1/21 at 11:15 a.m. - staff found the resident on the floor in his/her bathroom. The resident sustained a Small goose egg to back of head. Staff added the intervention to refer to the Nurse Practitioner (NP) for labs and rehab to screen for safety awareness. 2/9/21 at 10:00 a.m. - staff found the resident sitting on the floor between his/her bed and the window. Staff added the intervention to encourage the use of the wheelchair. 2/22/21 at 12:05 a.m. - staff heard a loud noise and crying and found the resident on the floor at the foot of the bed, the resident's head was under the bed. The resident sustained an abrasion to the nose from his/her glasses. 3/2/21 at 6:45 p.m. - staff found the resident sitting on the floor in his/her room. The resident sustained a small hematoma to the right side of the forehead. Staff added the intervention to encourage the resident to allow staff to monitor for safety. 3/17/21 at 12:30 a.m. - staff found the resident on the floor in his/her room. 3/18/21 at 6:43 a.m. - staff found the resident on the floor in his/her room. Staff added the intervention to administer medications per Physician's Orders. 3/26/21 at 5:45 a.m. - staff found the resident on the floor at the foot of the bed. The resident sustained a Crushing skin wound to left forehead. The area was bleeding and staff applied a dry dressing. Staff added the intervention for a night light to brighten the room and rehab to screen for knee weakness. 4/5/21 at 9:30 a.m. - staff found the resident laying on the floor in his/her room. Staff documented that at 9:20 a.m. the resident was sitting on the side of the bed eating breakfast. The resident sustained a laceration to the forehead and was sent to the emergency room (ER). Staff added the intervention for Pharmacy to assist with medication review (which they do monthly). 4/6/21 at 3:00 a.m. - staff found the resident on the floor next to his/her bed. The resident sustained a large hematoma on the right side of [his/her] forehead. 4/6/21 at 7:20 a.m. - staff found the resident on the floor next to his/her bed. Resident sustained a hematoma to the posterior right side of the head. Staff added the intervention for pillows to define borders of the bed. 4/15/21 at 5:10 a.m. - staff found the resident on the floor in his/her room. Staff added the intervention for a medication review for a supplement for increased risk and history of urinary tract infections (UTI) and refer to therapy plan of treatment for more detail. 4/20/21 at 4:14 a.m. - staff heard the resident yelling and found the resident on the floor in his/her room. Staff added the intervention to check the resident's orthostatic blood pressures to determine irregularities. 4/30/21 at 2:20 a.m. - staff found the resident on the floor between his/her bed and window. 5/3/21 at 2:44 p.m. - staff found the resident on the floor in their room. There was no Nurse's Note or Investigation of this fall, only listed on the Timeline the facility provided. 5/4/21 at 10:30 a.m. - staff found the resident on the floor next to his/her bed. The resident was calling out for help. Staff added the intervention for Physical Therapy (PT) to screen for balance issues. The facility did not provide an investigation of this fall. 5/6/21 at 2:45 a.m. - staff found the resident on the floor next to his/her bed. The resident sustained an abrasion to the forehead. The facility did not provide an investigation of this fall. 5/6/21 at 9:30 a.m. - resident was sitting in his/her locked wheelchair, leaned over to pick up a piece of paper and fell out of his/her wheelchair. Staff added the intervention to elevate the head of bed as tolerated and to encourage use of a scoop chair (low to the ground chair that tilted) as tolerated. The facility did not provide an investigation of this fall. 5/7/21 at 10:30 a.m. - staff found the resident on the floor in his/her room. The resident stated he/she rolled out of bed. Staff added the intervention for the Physician to review the resident's medication and move to a room closer to the Nurses' Station. The facility did not provide an investigation of this fall. Review of the Physician's orders revealed an order dated 5/5/21 for PT and Occupational Therapy (OT) secondary to frequent falls. Review of Resident #57's Rehabilitation Screening dated 5/13/21 documented the resident may benefit from skilled therapy services. Review of the clinical record and therapy provided documentation lacked evidence the resident received the therapy services. 7/2/21 at 3:30 p.m. - staff heard yelling and found the resident on the floor in his/her room. Staff added the intervention to keep the resident within close observation at the Nurses' Station for safety as he/she would allow during waking hours and a low bed. The facility did not provide an investigation of this fall. 7/4/21 at 5:18 a.m. - staff found the resident on the bathroom floor. Staff again added the intervention to toilet the resident upon rising, before and after meals and at HS as he/she will tolerate. The facility did not provide an investigation of this fall. 9/14/21 at 1:30 a.m. - staff heard a loud noise and yelling and found the resident on the floor in his/her room. The resident sustained an open laceration to the left temple area in the hair line. Staff transferred the resident to the Emergency (ER). Staff again added the intervention for the Physician to review the resident's medications. The resident received three (3) sutures. The facility did not provide an investigation of this fall. 9/16/21 at 10:40 p.m. - staff found the resident on the floor in his/her room. The resident stated, This bed is not big enough for my boyfriend and me. Staff added the intervention for lab work related to hallucinations. The facility did not provide an investigation of this fall. 9/20/21 at 5:50 a.m. - staff found the resident on the floor in the bathroom. The facility did not provide an investigation of this fall. 9/24/21 at 5:45 a.m. - staff found the resident lying on the floor at the foot of his/her bed. Staff added the intervention to attempt the use of a hand bell. 10/5/21 at 6:28 a.m. - staff heard a loud noise then yelling and found the resident on the floor next to his/her bed. The resident sustained a five (5) cm laceration to the mid forehead. Staff transferred the resident to the ER. Staff added the intervention to set up a care plan meeting with the provider and Interdisciplinary team (IDT). The ER closed the laceration with skin glue. 10/19/21 at 2:05 p.m. - Housekeeping Manager found the resident on the bathroom floor. The resident stated, [name] was just talking to me . Staff added the intervention for a protective helmet as the resident would allow. 11/11/21 at 6:20 a.m. - staff heard a loud noise and crying and found the resident on the floor at the foot of the bed. Bleeding from crack in scab at top of forehead that [he/she] received from previous fall. Staff added the intervention for therapy to evaluate for knee buckling. Review of the falls lacked consistent investigations of the falls, lacked consistent determination of the causative factor for the falls and lacked interventions based on the causative factors. The Fall Investigations lacked evidence the facility provided the interventions as planned. Observation on 11/30/21 at 11:35 a.m. revealed the resident sat across from the Nurses' Station with an approximate one (1) inch by two (2) inch dark scab on the top/middle section of the forehead. Observation on 12/1/21 at 12:09 p.m. revealed the resident's room door closed. Upon entrance to the room the resident was sitting on the side of bed eating his/her lunch. The resident's rollator was on the other side of the overbed table. No staff were present with the resident. Staff did place the resident at the Nurses' Station for close observation for safety, as added to the care plan on 7/2/21. Observation on 12/2/21 at 10:20 a.m. revealed the resident lying in bed on his/her back. The rollator was at the bedside, but no scoop chair noted in the room, as added to the care plan on 5/6/21. Observation on 12/3/21 at 10:30 a.m. revealed the resident's door opened and upon entering, observation revealed the resident in the bathroom pulling up his/her pants. No staff were with the resident. Interview with Licensed Practical Nurse (LPN) #6 on 11/30/21 at 11:35 revealed the wound/abrasion to the top of the resident's head was due to a fall. Interview with Certified Nursing Assistant (CNA) #16 on 12/2/21 at 10:45 a.m. revealed for the prevention of falls, the staff keep a good eye on the resident. CNA #16 stated the resident was continent and wore pull-ups and was able to do his/her own toileting. CNA #16 was asked about the use of the scoop chair and where it was located. After looking, CNA #16 found the scoop chair in the locked shower room. Interview with LPN #6 on 12/2/21 at 10:46 a.m. revealed, if a fall occurred the nurse completed an assessment of the resident, notified all parties, obtained witness statements, and documented the fall on the 24-hour report. The Fall Team reviewed all the falls. The nurse tried to put an intervention in place right after the fall. LPN #6 stated Resident #57 fell due to confusion, age, was able to ambulate, and the resident felt they could walk. LPN #6 stated the fall interventions included: encourage the resident to use the walker, encourage the resident to call us prior to transferring him/herself, monitor the resident's whereabouts frequently. LPN #6 stated there was no set timeframe for the frequency of monitoring. LPN #6 stated the staff should open the resident's room door to lay eyes on the resident. LPN #6 stated the resident toileted him/herself. Interview with Unit Manager (UM) #17 on 12/2/21 at 11:02 a.m. revealed after a resident fell the nurse working the unit would fill out the Incident Management with a detailed report of what happened, including items like the bed height. The nurse would also get witnessed statements. UM #17 stated if the resident was at risk for falls, we would just monitor them as they have the right to fall. The nurse working can add an intervention to prevent further falls. The facility does not have a real fall program. The facility discussed all falls at the morning meetings which included the Administrator, UMs, Director of Nursing (DON), Therapy, Dietary, maintenance, housekeeping, MDS Coordinator, Social Worker and Discharge Planner. UM #17 stated Resident #57 fell due to being [AGE] years old, demented and wanted to go back to Connecticut. The facility had tried a helmet, but the resident could not wear it due to the wound on his/her head. We have also tried a knee brace, pain gel for his/her knee, a night light and frequent checks. When asked how frequently the staff should check on Resident #57, UM #17 said at least every hour. Interview with the Rehab Director on 12/2/21 at 11:25 a.m. revealed Resident #57's left knee buckled at times. He/she stated therapy had ordered a knee sleeve for the resident, but it had not come in yet. Interview with the DON on 12/2/21 at 1:29 p.m. revealed when a resident fell the nurse on the floor completed an incident report and notified the physician and family. The nurse should put an intervention in place immediately. During the morning meetings the clinical staff discuss all the falls that occurred since the previous meeting. The clinical staff consisted of the DON, UMs, MDS Coordinator, Administrator, Dietitian, Therapy, and Activity staff. During the meeting we would review the fall, including what happened and what cause the fall and the interventions in place. Resident #57 was admitted due to him/her falling at home. The DON stated Resident #57's causes for his/her falls was he/she did not remember things, the resident thought they could do for him/herself and the resident toileted him/herself. For Resident #57's fall interventions we brought in his/her family. The family stated the resident would have UTIs that caused him/her to fall but we checked, and the resident did not have a UTI. Interview with the Administrator on 12/3/21 at 10:00 a.m., he/she knew the facility had completed the investigations for all of Resident #57's falls but was unable to find them per their protocol to review the circumstances surrounding a resident's fall. Interview with the Rehab Director on 12/3/21 at 10:15 a.m. regarding the 5/13/21 Rehab Screen indicating the resident may benefit from skilled therapy, stated due to the resident's insurance the request for therapy would have been e-mailed to the Business Office to follow up on but those e-mails were automatically deleted after four (4) months. The Rehab Director further stated if the resident was added to the PT schedule, those schedules were deleted after five (5) months. The Rehab Director stated he/she did not know why the resident was not picked up for therapy.