**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, record review and interview, the facility failed to follow the care plan for one (1) resident (Resident #57) reviewed for accidents/hazards. Care plan interventions included maintain environment free of clutter and safety hazards. Due to the failure of following the care plan, on 10/4/21, the resident was found on the floor by the bathroom in his/her room, which resulted in a skin tear to the lower spine and bruising to the right hand and forearm, resulting in harm to the resident. The resident's wheelchair was stored in the bathroom, which caused the resident to fall. The facility was aware the resident scored a 65 on the last quarterly fall risk assessment and had previous falls with fractures on 4/9/21 and 6/26/21. Findings include: Review of the policy titled Comprehensive Team Care Planning dated revision 5/18/2017 revealed: It is the policy of [NAME] Oak Management, Incorporated to provide care planning for all residents; to formulate individualized plans of care for each resident that will be an effective and useful approach, for providing quality care; and to help the resident meet his/her mental, emotional, social, and physical needs during his/her stay. This shall be a team approach for resolving the resident's problems or needs, with emphasis on normalization of daily life to the highest level of dignity and ability. The residents plan of care guides the necessary care and services based on the findings of the Resident Assessment Instrument (RAI). The services are implemented and updated on the care plan. Outcome evaluation and revisions for interventions/approaches are an ongoing process. Purpose: To look at a resident as a whole building on the individual resident characteristics, to develop an action plan to achieve resident objectives. Procedure: 1. Interdisciplinary Care Planning: A. The care plan team develops interventions appropriate for each resident based on the comprehensive assessment due at the completion of the Minimum Data Set (MDS) and the Care Area Assessment (CAA) summary protocol form. B. The planning for each resident must be interdisciplinary and involve at least one staff member from Social Services, Activities, Nursing, Dietary and other disciplines as indicated. C. Residents and/or their designated representatives are encouraged to participate in the development of their plan of care. Each resident will be invited to participate to the extent practicable or designated a representative to participate on his/her behalf. If a resident is unable due to mental or physical impairment, the resident's representative must be afforded the opportunity to represent the resident. An explanation must be included in the resident's medical record if the participation of the resident and his/her representative is determined not practicable for the development of the resident care plan. D. Any problems or needs that resident/representative addresses are incorporated in the Resident's Plan of Care (RPOC) by the involved discipline as appropriate. New condition existed upon admission to the facility. Any newly developed problems will have problem start date as date the problem is identified. E. The plan must specify goals and approaches to resolve the resident's identified problems or needs, accentuate resident strengths, acknowledge the resident's preferences and/or participation when appropriate, and be developed in coordination with the physician's orders. F. Similar problems should be combined when like goals and approaches are applicable. G. The resident/representative and team members sign the Resident Assessment Instrument (RAI) process review sheet indicating participation into developing the Plan of Care. Physician signs approval for current plan of care on the monthly physician orders and should also sign the RAI Process Review Sheet to indicate participation in the plan of care. A registered nurse must approve and sign all care plans, which may be indicated on the RAI Process Review Sheet. H. The care plan is consistently implemented by all personnel at all times of the day unless stated otherwise. I. Failure of the care plan team to acknowledge and pursue the problems identified by the resident's assessment will invalidate the entire process and not meet Federal Requirements. Review of the clinical record revealed Resident #57 was admitted to the facility on [DATE]. The resident was assessed on the Quarterly Minimum Data Set (MDS) assessment, dated 8/31/2021, to have diagnoses of Displaced Fracture of Neck of Femur, Dementia with Behaviors, Bradycardia, Hyperlipidemia, Anemia, Headaches, Psoriasis, Paroxysmal Atrial Fibrillation, Muscle Weakness, Hallucinations, Urine Retention, Bell's Palsy, Presence of Right Artificial Hip Joint, Heart Failure, Chronic Diastolic Congestive Heart Failure, Thrombophilia, Poly-osteoarthritis, Type 2 Diabetes Mellitus, and Alzheimer's late onset. Resident #57 had a Brief Interview for Mental Status (BIMS) score of three (3) indicating severely impaired cognition. The MDS revealed Resident #57 did not participate in skilled therapies, but received restorative nursing programs during the assessment review period. Under Section G functional status, the resident was coded as requiring one (1) person extensive assist from staff for activities of daily living including bed mobility, transfers, toileting, and the use of mobility devices such as wheelchair (manual or electric) and coded to have impairment on one side of the lower extremity. Review of the Care Plan dated, 4/19/21, and revised 6/24/2019, 7/1/2021 ongoing, revealed Resident #57 at risk for falls related to weakness, the most recent quarterly fall risk assessment score 65 resident high risk. Implement high risk fall preventions interventions. Under the goals section, maintain environment free of clutter. Under the interventions section, keep walker and/or wheelchair next to bed, check bed alarm for proper functioning, prior to resident being assisted to bed at night (HS), maintain environment free of clutter and safety hazards, increase rounds to check on resident more frequently, chair alarm until self-release belt for safety of resident related to falls, fall mats to both sides of bed with alarms, staff to apply non-skid socks, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Review of the facility's Morse Fall Risk Assessment fall risk quarterly assessment score, dated 4/19/2021, revealed Resident #57 had a total fall risk score of 65, indicating the resident was at high risk of falls. Review of the facility's Occurrence Report dated 10/4/21 at 9:00 p.m. revealed, Resident #57 got up from bed unattended to go to the bathroom and was noted to be on the floor in the doorway of the bathroom, when s/he called for assistance. Resident had skin tear in middle of lower spine from the wheelchair that was parked in the bathroom. Bed alarm not sounding however was checked post fall and did sound upon applying/releasing pressure. Recommendations, staff to ensure proper functioning of bed alarm before the resident goes down for the night. Do not store wheelchair in bathroom. Review of the facility's Occurrence Report dated 4/9/21, Resident #57 had a fall resulting in a hip fracture. Review of the facility's Occurrence Report dated 6/1/21, Resident #57 had a fall, no injury. Review of the facility's Occurrence Report dated 6/26/21, Resident #57 had a fall, resulting in a compression fracture to the Lumbar vetebra area #1. Review of the facility's Alarm Sign off Report dated 10/1/21-10/6/21, for shifts 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. revealed, the staff nurses indicated the alarm was working on each shift including 10/4/21 night of Resident#57's fall. The facility could not provide any in-services related to ensuring staff were educated on safe transfers or interventions to prevent falls; but provided in-services for safety in long term care setting dated 8/9/21 for all staff. Review of the facility's Head Trauma Protocol dated 10/4/21-10/6/21, revealed vital signs were completed every hour for four (4) hours, then every four hours (4) for 24 hours, then every shift for 48. An interview was conducted on 10/6/21 at 2:24 p.m. with Family of Resident #57 revealed, I am aware of the falls with injuries; this is tiresome. The facility can't prevent the falls, if s/he is going to get up, something needs to be done to prevent these injuries. S/he has alarms on the bed, wheelchair and anti-tippers as well, there have been times that I set off the bed alarm and they did not come or took them 20 minutes to answer the call light. S/he had falls at home and broke one hip and wrist, then broke the other hip here. The facility was aware of the fall risks upon admission. I feel they need to do more. An interview was conducted on 10/7/21 at 11:00 a.m. with the Director of Nursing (DON) and the Administrator while rounding on the unit, revealed the fall for Resident #57 just happened on Monday 10/4/21. We had not been able to fully investigate the incident. We expect staff, as much as possible, to ensure safety hazards are removed from the resident's room and the wheelchair to be out in the hallway or in the room when not in use. We may at times store the wheelchair in the bathroom but typically in the hallway. For the fall on 10/4/21, what we know is the wheelchair was in the resident's bathroom, the bed alarm did not sound, but the light was flashing when staff entered the room. Our expectation is that staff ensure the alarms are working and charted on the Medication Administration Record (MAR) each shift. An interview conducted on 10/7/21 at 11:08 a.m. with Certified Nursing Assistant (CNA) #3 revealed, Resident #57 requires one person assist with ADLs, I recall the fall back in April of this year, I was walking down the hallway and noticed the resident on the floor by the entryway of the room. We have been in-serviced on trip hazards, but since the resident is non-mobile, we store the wheelchair in the hallway. An interview conducted on 10/7/21 at 11:16 a.m., with Licensed Practical Nurse (LPN) #2 revealed, We are responsible for checking the alarms each shift and charting them in the MAR. Resident #57 has alarms on the wheelchair and bed. We do two (2) hour checks and frequently by walking past the room and looking in on the resident. S/he is one (1) to two (2) persons assist with ADLs. The wheelchair is stored in the room or the hallway when not in use. We ensure the room stays free of clutter. An interview conducted on 10/7/21 at 2:53 p.m. with Certified Nursing Assistant (CNA) #4 revealed, Resident #57 yelled out and I went into the room. S/he was on the floor outside the bathroom door with his/her back up against the wheelchair. I asked what s/he was doing, and the resident stated I was going to the bathroom. CNA #4 further revealed, I did not hear the bed alarm go off. The resident has an alarm on the bed. The light was flashing but the alarm was not sounding. I called for the nurse because the resident stated s/he was hurting. The nurse assessed the resident who had a skin tear to the lower back. I turned the alarm off and back on again, it still did not sound, the nurse checked it also. I was informed to start the hourly vitals and was not sure who stored the wheelchair in the resident's bathroom. The Licensed Practical Nurse assigned to Resident #57 was unavailable for interview, however, per the statement made on the facility's Occurrence Report, dated 10/4/21 revealed, resident got up from bed un-attended, was noted on the floor in doorway of bathroom near back of wheelchair that had been placed in bathroom, evidently scraped the residents back. Fall causing skin tear. Recommendation, do not store wheelchair in bathroom.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, interviews, and review of facility policy, it was determined for one (1) of 26 sampled residents (Resident #57) the facility failed to ensure that the resident's environment remained free of accidents and hazards as possible, and that the resident received adequate supervision as well as assistance to prevent accidents. The facility failed to ensure resident's safety by not ensuring the wheelchair was properly stored (located in resident's bathroom) by staff resulting in the resident falling in the doorway of bathroom and hitting his/her back on the wheelchair causing a skin tear to lower back and bruising to the right hand and forearm, resulting in harm to the resident. Resident #57 was assessed to require extensive assistance from staff for activities of daily living (ADLs) which included supervision and assistance to keep the resident safe and prevent injuries. Resident #57 was known to have a history of falls resulting in injuries that included fractures while in the facility. Findings Include: Review of the policy entitled. The Fall Management Program, no date revealed, PROGRAM: This policy applies to the staff at the healthcare center. The Fall Management Program has been developed to assist facilities in identifying strategies to minimize the risk of falls for residents and still maintain the highest practical level of functioning and mobility through comprehensive analysis of physical, mental, and psychosocial conditions and the development and implementation of an individualized plan of care. The Fall Risk Data Collection Tool (electronic user define assessment (UDA) determines program placement. 9. Fall Management Program: The following are recommended steps to carry out the Fall Management Program: Completion of Fall Risk Data Collection Tool (electronic UDA), during the admission/readmission process and quarterly. Medication review and clinical condition assessment as needed. Assessment of each resident for history of falls. Environment check of resident's immediate environment taking into consideration the listed Environmental Factors. Interim plan of care to be developed during the admission process for each resident. Newly admitted residents must be identified to all staff through the Daily Shift report, inter-department meetings, and/or the interdisciplinary team meetings. 2. Determination: The determination of the fall risk is necessary to identify those residents who are not only at risk, but also determine factors that place them at risk. Fall risk approaches can then be tailored and individualized. A resident is placed in a Fall Risk Program when one or more of the following apply: Fallen in last thirty days. Ambulatory with uncontained incontinence. Current risk symptoms for falls and not physically or cognitively able to request assistance. Non-ambulatory and attempts to get out of bed or chair without assistance. Interdisciplinary Team/Falls Committee recommends placement. Individual factors compounding risks. When initiating a Fall Management Program, current in-house residents are reviewed using the Fall Risk Data Collection Tool (electronic user defined assessment i.e., UDA) to determine program placement. An investigation will be completed after a fall, regardless if sustained injury, using the Fall Investigation Form. Following investigation, appropriate interventions will be implemented to reduce the risk of further falls. The Fall Risk Data Collection Tool (electronic UDA) is completed quarterly. Attention to environmental risk factors may reduce the incidence of falls. Attention to physical and cognitive status changes may also reduce incidence of falls. Attention to past life experiences also contribute to reducing the incident of falls. 3. Staff Education: Introduction: Falls represent a serious hazard for the older person, posing a threat to their quality of life. A fall is an unintentional change in position coming to rest on the ground, floor, or onto the next surface (e.g., onto a bed, chair, or bedside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Falls include any fall no matter whether it occurred at home, while out in the community, in an acute hospital or a nursing home. Falls are not a result of overwhelming external force. (e.g., a resident pushes another resident.) Risk Factors: Internal Psychological External Internal Factors: Aging process-Diminished sensory perception. Psychological Factors: Denial of limitations/fall External Factors: Ground surfaces Lighting Stairways Bathrooms Furniture Equipment Other 4. Determination: Determining the fall risk is necessary to identify those residents who are not only at risk, but also to determine factors that place them at risk. Fall Risk Data Collection Tool (electronic UDA). 5. Fall Risk Data Collection Tool: History of falls past ninety (90) days. Internal Risk Factors. Perceptual. Medication. Appliances. 6. Interventions: Identify and treat internal factors. Identify and reduce environmental hazards. Assess gait and balance. Evaluate footwear. Review medications. Review daily routine. Prevent unsafe transfers and ambulation. Address social and psychological needs. 7. Objective: To attempt to provide an environment as free from accidental hazards as possible and provide adequate supervision and assistive devices to attempt to reduce the risk for occurrences. A fall from a nursing home resident may result in one or more of the following: Decreased body system functioning. Decreased mobility leading to development of pressure ulcer, contractures, muscle atrophy/weakness. Disability. Increased susceptibility to disease/infections. Injury. Psychological complications (fear of standing or walking). Reduction in Activities of Daily Living (ADLs). Death. 8. Definitions: For the purpose, of this program the following definitions will be taken into consideration: Accidents Hazards: Physical features in the nursing facility environment that can endanger a resident's safety. Environment: Refers to any area in the facility that is frequented by residents, including the residents' rooms, bathrooms, hallways, activity areas and therapy areas, an uncluttered environment is neat and well kept. Resident Rooms: Pathways from bed to bathroom are kept unobstructed. Cognitive Status: The residents ability to problem solve, decide, remember, be aware of and respond to safety hazards. 9. Occurrence Report: To document all occurrences to residents, employees, and visitors. Procedure: 1. Resident a.) Provide emergency care. b.) Chart occurrence on clinical record. c.) Enter on acute board. Key Points: Notify physician, family, and nursing supervisor. Include all pertinent observations. Obtain individual staff statements for current shift and at least two previous shifts for any/all occurrences not witnessed. Supervisor will investigate occurrence, complete report form, and submit to nursing office before the end of tour of duty. Submit completed Occurrence Report to nursing supervisor as soon as possible during tour of duty. Charge nurse or designee to escort the employee to the nearest hospital emergency room/and or designated physician as indicated. Give description of the circumstances surrounding the occurrence. Include findings by nursing personnel and descriptive statements of occurrence from resident, visitor, employee involved, witness, or individual who first reports occurrence. Document only the facts. Include all pertinent observations. Review of the clinical record revealed Resident #57 was admitted to the facility on [DATE]. The resident was assessed on the Quarterly Minimum Data Set (MDS) assessment, dated 8/31/2021, to have diagnoses of Displaced Fracture of Neck of Femur, Dementia with Behaviors, Bradycardia, Hyperlipidemia, Anemia, Headaches, Psoriasis, Paroxysmal Atrial Fibrillation, Muscle Weakness, Hallucinations, Urine Retention, Bells Palsy, Presence of Right Artificial Hip Joint, Heart Failure, Chronic Diastolic Congestive Heart Failure, Thrombophilia, Poly-osteoarthritis, Type 2 Diabetes Mellitus, and Alzheimer's late onset. Resident #57 had a Brief Interview for Mental Status (BIMS) score of three (3) indicating severely impaired cognition. The MDS revealed Resident #57 did not participate in skilled therapies but received restorative nursing programs during the assessment review period. Under Section G functional status, the resident was coded as requiring one (1) person extensive assist from staff for activities of daily living including bed mobility, transfers, toileting, and the use of mobility devices such as wheelchair (manual or electric) and coded to have impairment on one (1) side of the lower extremity. Review of the Care Plan dated, 4/19/21, and revised 6/24/2019, 7/1/2021 ongoing, revealed Resident #57 at risk for falls related to weakness, the most recent quarterly fall risk assessment score 65, showing resident at high risk. Implement high risk fall prevention interventions. Under the goals section, maintain environment free of clutter. Under the interventions section, keep walker and/or wheelchair next to bed, check bed alarm for proper functioning, prior to resident being assisted to bed at night (HS), maintain environment free of clutter and safety hazards, increase rounds to check on resident more frequently, chair alarm until self-release belt for safety of resident related to falls, fall mats to both sides of bed with alarms, staff to apply non-skid socks, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Review of the facility's Morse Fall Risk Assessment fall risk quarterly assessment score, dated 4/19/2021, revealed Resident #57 had a total fall risk score of 65, indicating the resident was at high risk of falls. Review of the facility's Occurrence Report dated 10/4/21 at 9:00 p.m. revealed, Resident #57 got up from bed unattended to go to the bathroom and noted to be on the floor in the doorway of the bathroom, when s/he called for assistance. Resident has skin tear in middle of lower spine from wheelchair that was parked in the bathroom. Bed alarm not sounding however was checked post fall and did sound upon applying/releasing pressure. Recommendations, staff to ensure proper functioning of bed alarm before the resident goes down for the night. Do not store wheelchair in bathroom. Review of the facility's Occurrence Report dated 4/9/21, Resident #57 had a fall resulting in a hip fracture. Review of the facility's Occurrence Report dated 6/1/21, Resident #57 had a fall, no injury. Review of the facility's Occurrence Report dated 6/26/21, Resident #57 had a fall, resulting in a compression fracture to the Lumbar area #1. Review of the facility's Alarm Sign off Report dated 10/1/21-10/6/21, for shifts 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. revealed, the staff nurses indicated the alarm was working on each shift including 10/4/21 night of Resident #57's fall. The facility could not provide any in-services related to ensuring staff were educated on safe transfers or interventions to prevent falls; but provided in-services for safety in long term care setting dated 8/9/21 for all staff. Review of the facility's Head Trauma Protocol dated 10/4/21-10/6/21, revealed vital signs were completed every hour for four (4) hours, then every four hours (4) for 24 hours, then every shift for 48. Observation of Resident #57 on 10/6/21 at 11:55 a.m., dressed well-groomed sitting up in wheelchair doorway of his/her room, seat belt alarm on and non-skid shoes. Fall mats to both sides of the bed. Observation of Resident #57 on 10/6/21 at 1:20 p.m., revealed resident was dressed and well- groomed sitting up in wheelchair at bedside table eating lunch. Dressed and well-groomed with non-skid shoes on and call light was within reach. Fall mats to both sides of the bed. Bed alarm working. Observation of Resident #57 on 10/6/21 at 2:24 p.m., revealed resident sitting up in wheelchair in the room, dressed and well-groomed had on non-skid shoes visiting with son; surveyor tested the alarm on bed, and it was working. Fall mats to both sides of the bed. Observation of Resident #57 on 10/7/21 at 10:43 a.m., revealed resident resting in bed, alarm on and call light in reach. Fall mats to both sides of the bed. Wheelchair not stored in bathroom. Bed alarm working. Observation of Resident #57 on 10/8/21 at 9:15 a.m., revealed resident sitting up in bed eating breakfast, fall mats to both sides of the bed, call light in reach and wheelchair noted in room and not the bathroom. An interview was conducted on 10/6/21 at 2:24 p.m. with Family of Resident #57 revealed, I am aware of the falls with injuries, this is tiresome the facility can't prevent the falls, if s/he is going to get up, something needs to be done to prevent these injuries. S/he has alarms on the bed, wheelchair and anti-tippers as well. There have been times that I set off the bed alarm and they did not come or took them 20 minutes to answer the call light. S/he had falls at home and broke one hip and wrist, then broke the other hip here. The facility was aware of the fall risks upon admission, I feel they need to do more. An interview was conducted on 10/7/21 at 11:00 a.m. with the Director of Nursing (DON) and the Administrator while rounding on the unit, revealed the fall on 10/4/21 for Resident #57 just happened on Monday. We had not been able to fully investigate the incident. We expect staff as much as possible to ensure safety hazards are removed from the resident's room and the wheelchair to be out in the hallway or in the room when not in use. We may at times store the wheelchair in the bathroom, but typically in the hallway. For the fall on 10/4/21, what we know is the wheelchair was in the resident's bathroom, the bed alarm did not sound, but the light was flashing when staff entered the room. Our expectation is that staff ensure the alarms are working and charted on the Medication Administration Record (MAR) each shift. An interview conducted on 10/7/21 at 11:08 a.m. with Certified Nursing Assistant (CNA) #3 revealed, Resident #57 requires one person assist with ADLs. I recall the fall back in April of this year, I was walking down the hallway and noticed the resident on the floor by the entryway of the room. We have been in-serviced on trip hazards, but since the resident is non-mobile, we store the wheelchair in the hallway. An interview conducted on 10/7/21 at 11:16 a.m., with Licensed Practical Nurse (LPN) #2 revealed, We are responsible for checking the alarms each shift and charting them in the MAR. Resident #57 has alarms on the wheelchair and bed, we do two (2) hour checks and frequently by walking past the room and looking in on the resident. S/he is one (1) to two (2) persons assist with ADLs. The wheelchair is stored in the room or the hallway when not in use, we ensure the room stays free of clutter. An interview conducted on 10/7/21 at 2:53 p.m. with Certified Nursing Assistant (CNA) #4 which revealed, Resident #57 yelled out and I went into the room s/he was on the floor outside the bathroom door with back up against the wheelchair. I asked what s/he was doing, and the resident stated I was going to the bathroom. CNA #4 further revealed, I did not hear the bed alarm go off, the resident has an alarm on the bed, the light was flashing, but the alarm was not sounding. I called for the nurse because the resident stated s/he was hurting. The nurse assessed the resident who had a skin tear to the lower back. I turned the alarm off and back on again. It still did not sound. The nurse checked it also. I was informed to start the hourly vitals and not sure who stored the wheelchair in the resident's bathroom. The Licensed Practical Nurse assigned to Resident #57 was unavailable for interview, per the statement made on the facility's Occurrence Report, dated 10/4/21, which revealed the resident got up from bed unattended, was noted on the floor in the doorway of bathroom near the back of the wheelchair that had been placed in bathroom, which evidently scraped the resident's back. Fall causing skin tear. Recommendation, do not store wheelchair in bathroom.