**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to implement fall prevention interventions as described in the care plan for one of one (1) resident who fell and sustained injuries that required treatment at an emergency department. Findings include: 1. Review of the SD DOH FRI submitted on 2/2/25 at 10:34 a.m. revealed: *On 2/1/25 at 10:20 p.m., resident 1 was found lying face down on the floor next to his bed. -There was noticeable blood on the floor. -Resident 1 had a laceration near his right eye. -He was transported to the emergency department for further evaluation. -He received six sutures and was transported back to the facility. *The provider's investigation of the fall determined that resident 1's silent TABs alarm (a device that flashes at the nurses station to alert staff when resident stands up) was in his recliner at the time of the fall and the resident was in his bed. *The certified nursing assistant (CNA) that assisted resident 1 to bed had forgotten to move the TABs alarm when she assisted the resident to bed. *As a result of the fall, the provider updated resident 1's care plan and Kardex to have a TABs alarm in both his recliner and his bed at all times. *Director of nursing services (DNS) O placed a STOP, Wait for assistance sign in the resident's room as a reminder for resident to not get up without staff assistance. 2. Review of resident 1's electronic medical record revealed: *He was admitted to the facility on [DATE]. *His diagnoses included: repeated falls, generalized muscle weakness, Dementia (a group of symptoms affecting memory, thinking, and social abilities), use of anticoagulants (blood thinning medications). *His 6/3/25 Brief Interview for Mental status (BIMS) assessment score was 12, which indicated he was moderately cognitively impaired. *A progress note on 3/16/25 at 11:54 p.m. regarding his TABs alarm stated Alarm not placed under resident at bedtime, alarm pad found in recliner chair and resident is sleeping in bed. Resident [was] not woke [woken] up at this time to place under him d/t [due to] [the resident] sleeping soundly. Will monitor closely, night CNAs aware of this. *A progress note on 3/19/25 at 11:35 p.m. regarding his TABs alarm stated Not under resident in bed, alarm found in recliner chair and not connected. *Resident 1's 6/18/25 Kardex stated in the Monitoring section Personal Alarm: Silent TABs alarm used to alert staff of resident's movement and to assist staff in monitoring movement. Place TABs alarm in both bed and recliner at all times. Ensure this is used, plugged in, and functioning when [the resident is] in bed or [the] recliner. *Resident 1's 6/4/25 Care Plan Report indicated: *A Focus are of The resident has had an actual fall R/T [related to] epilepsy, dementia, muscle weakness, decreased balance as E/B [evidenced by] history of falls. *Goals for that area included Resident will be free of falls through the review date. Resident will be free of minor injury through the review date. Resident will not sustain serious injury through the review date. *Interventions included PERSONAL ALARM: Silent TABs alarm used to alert staff to resident's movement and to assist staff in monitoring movement. Place TABs alarm in both [his] bed and recliner at all times. Ensure this is used, plugged in, and functioning when [resident is] in bed or [the] recliner. 3. Observation and interview on 6/17/25 at 10:45 a.m. with resident 1 in his room revealed: *Resident stated he had lived there for the past couple years. *He had no obvious observed signs of bruising or injury. *His room was free of clutter. *He was sitting on his TABs alarm and his call light was within his reach. *There was no TABs alarm on his mattress. *There was no STOP, Wait for assistance sign on his wall. 4. Observation and interview on 6/17/25 at 1:20 p.m. with resident 1 revealed he was still sitting up in his chair, with the TABs alarm under him. 5. Interview on 6/17/25 at 2:20 p.m. with certified medication aide (CMA) M revealed: *Resident 1 should have had a TABs alarm in both his chair and on his bed. *That was to be documented in the resident's TAR (treatment administration record) by a nurse. 6. Interview on 6/17/25 at 2:30 p.m. with CMA L revealed: *There should be an alarm in the resident's chair and in his bed. *She was not aware why there was not two alarms because she was not usually assigned to that unit. 7. Interview on 6/17/25 at 3:45 with registered nurse (RN) N revealed she was the nurse assigned to work in resident 1's unit but was not aware if resident 1 should have one or two TABs alarms. 8. Interview on 6/17/25 at 3:50 p.m. with CNA E revealed: *There should have been two TABs alarms in resident 1's room. *She was aware there was only one alarm that was being transferred back and forth from his chair to his bed. *She reported that there had not been two alarms in resident 1's room recently due to a malfunction when using two alarms. *She explained that when there were two alarms, one would malfunction and alarm when the resident was not using it. *She stated that maintenance personnel had tried to repair the system but were unable to. -The solution to that was to remove the second TABs alarm from resident 1's room. *She was not aware of any other fall prevention interventions that had been put into place for resident 1. 9. Interview on 6/17/25 at 4:00 p.m. with resident 1's spouse revealed: *She felt resident 1 received good care at the facility. *She stated, I wish sometimes there were more staff, but they work very hard. *She reported that resident 1 had fallen and that required him to go to the hospital and receive sutures. 10. Interview on 6/17/25 at 4:15 p.m. with RN/clinical care leader (CCL) F revealed: *Resident 1's cognition varied (sometimes he was confused, sometimes he was not), which could make it difficult to provide his care at times. *She was aware he was care planned to have two TABs alarms in his room. *She was aware there was only one TABs alarm in his room. *She reported that the staff were performing more frequent rounding (visually checking on resident's status) to ensure their safety. 11. Observation on 6/18/25 at 9:05 a.m. revealed: *Resident 1 was not in his room. *There was one TABs alarm in his chair, and none on his bed. *There was no STOP, Wait for Assistance sign visible in his room. 12. Interview on 6/18/25 at 1:50 p.m. with DON B revealed: *She was familiar with resident 1's fall but was not employed by the facility when the fall occurred in February 2025. *She was not aware of the fall prevention interventions that were to have been put in place as a result of the February 2025 fall (additional TABs alarm and STOP, Wait for assistance sign) for resident 1. *She was not aware that only one alarm was being used for resident 1. *She agreed resident 1 could fall again. 13. Interview on 6/18/25 at 2:30 p.m. with administrator A revealed: *His goal was to eliminate the use of TABs alarms for residents in the facility. *He preferred to focus on completing more frequent rounding on the residents instead of relying on alarms. *He stated Frequent checks should have been added to resident 1's care plan after his fall. *He agreed resident 1 could fall again. 14. Review of the provider's 4/8/25 Fall Prevention and Management policy revealed: *Purpose, To promote resident well-being by developing and implementing a fall prevention and management program. To identify risk factors and implement interventions before a fall occurs. *Proactive Approach before a Fall Occurs (e.g., New Admit) procedure. -3. Care Plan the appropriate interventions, including personalizing all (SPECIFY) areas. -4. Communicate fall risks and interventions to prevent a fall before it occurs per the 24-Hour Report, care plan and Kardex, daily stand-up meeting, and/or Fall Committee meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Based on observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (39) who received a bodily injury from an undocumented fall. Licensed practical nurse (LPN) K failed to identify and accurately document and report timely to facility leadership an incident when one of one sampled resident (39) was lowered to the floor after her legs had buckled. A fibula fracture was determined later. Findings include: 1. Observation and interview on 10/15/24 at 5:15 p.m. with resident 39 in her room revealed: *The room was free from clutter and potential injury hazards. *She was sitting in her recliner watching TV with her legs not elevated and her call light was within reach. *She could not remember if she had fallen recently. 2. Review of resident 39's electronic medical record (EMR) revealed: *Her diagnoses included hypothyroidism, other amnesia, history of falling, and type 2 diabetes. *Physician progress notes on 5/17/24 at 10:30 a.m. indicated: -She complained of increased right knee pain. -She reported she had a previous fall and was concerned for injury to her knee. -Her knee appeared swollen and had tenderness. -A nurse reported she was having difficulty with ambulation. *Her nursing progress notes indicated: -On 5/17/24 at 3:19 a.m. administration of, acetaminophen oral tablet for pain related to her legs. -On 5/17/24 at 5:36 p.m. new orders from physician for, ice pack/cold pack to right knee 15 min on and then 2 hours off as needed for pain. -On 5/17/24 at 5:37 p.m. new orders from physican for, Biofreeze External Gel 4% (Menthol (Topical Analgesic)) Apply to knees topically four times a day for pain. -On 5/18/24 the X-ray results of her right knee shown, osteoarthritis, and unremarkable examination of tibia and fibula. -On 5/20/24 the X-ray results of her right knee shown, she has arthritis. -On 5/22/24 at 11:15 a.m. the resident was sent to hospital for, right lower extremity (RLE) concerns of cellulitis. -On 5/22/21 at 7:17 p.m. the hospital called, resident is going to be admitted for broken fibula [calf bone]. *There was no documentation found in her EMR of a fall that occurred from 5/9/24 through 5/22/24. *Her careplan indicated her fibula fracture was a result of a fall that occured on 5/11/24. *Interventions for falls in her care plan initiated on 11/29/23 included staff were to: -Educate resident/family/IDT as to causes of fall. -Remind resident not to bend over to pick up dropped items. Encourage the use of a grabber or to ask for assistance. *Interventions for falls in her care plan updated on 5/28/24 included she was to work with physical therapy/occupational therapy for strengthening, endurance, and safety awareness. *[NAME] as of 10/17/24 indicated: -She needed one staff assist with a walker and gait belt for ambulation. -She needed the assistance of two staff with a full body lift and an extra-large sling for transfers between surfaces. -Staff were to elevate feet when sitting up in chair to help prevent dependent edema. 3. Review of resident 39's 3/4/24 Sit-Stand-Walk Data Collection Tool assessment revealed: *She could bear weight on at least one leg. *She could extend at least one leg at the knee, flex her ankle and point her toes. *There was no indication of how she could pull herself to a standing position and maintain her position. *Interventions for ambulation and transfers between surfaces indicated the assistance of one staff member, walker, and gait belt. 4. Review of resident 39's 5/28/24 Sit-Stand-Walk Data Collection tool assessment revealed: *She could bear weight on at least one leg. *She could extend at least one leg at the knee, flex her ankle, and point her toes. *She could not pull herself to a standing position and maintain the position. *She would need the sit-to-stand equipment for transfers. *She was unsafe to ambulate. *Interventions for ambulating and transfers between surfaces indicated assistance of one staff member, walker, and gait belt. 5. Interview on 10/16/24 at 4:21 p.m. with certified nursing assistant (CNA) J regarding resident 39 revealed: *She needed the assistance of a sit-to-stand lift for transfers between surfaces prior to her fracture. *She always had ace wraps on her legs during the day for edema. *She was non-weight bearing when she had returned from the hospital. *She was in a boot that went up to her kneecap. 6. Interview on 10/17/24 at 7:32 a.m. with CNA G regarding resident 39 revealed: *She needed the assistance of a sit-to-stand lift between surfaces prior to going to the hospital because she had difficulty transferring because of pain. *She was sent out for X-rays after a potential injury was discussed. *She was in a boot and non-weight bearing status when she came back from the hospital. *Physical therapy had worked with her for a while, but she was not getting any better. *She was changed to use a full body lift for transfers. 7. Interview on 10/17/24 at 8:01 a.m. with administrator A regarding resident 39 revealed: *She was aware that there was no documentation of a fall that occurred. *She was on maternity leave when the fibula fracture was found. *She stated that agency LPN K had been with her when the fall occurred on 5/12/24. *LPN K had told her that she lowered resident 39 to the floor in the bathroom when her legs buckled. *When administrator A had asked LPN K why she had not documented the fall, LPN K stated she was not aware it was considered a fall. *Administrator A stated her expectation would be if she was there, she would have looked into the fibula fracture of unknown origin and started an investigation. *She was aware that a final report was not submitted to the Department of Health. 8. Interview on 10/17/24 at 8:21 a.m. with LPN K regarding resident 39's fall revealed: *She was not aware that the facility considered lowering a resident to the ground as a fall. *She had thought the resident needed the assistance of one staff with transfers. *Once the resident had been lowered to the ground, she needed multiple people to get her back up. *She did not believe the resident was hurt at the time of the incident. *Resident 39 needed a total body lift for transfers after her fracture and she cannot walk anymore. 9. Review of providers 7/29/24 Fall Prevention and Management policy revealed: *Purpose: - To promote resident well-being by developing and implementing a fall prevention and management program. - To identify risk factors and implement interventions before a fall occurs. - To give prompt treatment after a fall occurs. - To provide guidance for documentation. * Fall-refers to unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for employee intervention, is considered a fall. *e. Notify the physician and resident representative of the incident. * f. Complete Fall Scene Huddle Worksheet. * 16. Review and update the Care Plan with any changes/new interventions. * 17. Report to the state regulatory agency when appropriate. A. Based on interview, observation, record review, and policy review the provider failed to ensure the safety of one of one sampled resident (14 ) who required the assistance of two staff during transfers with a sit-to-stand mechanical lift. Findings include: 1. Interview and observation on 10/15/24 at 3:45 p.m. with resident 14 revealed: *He had gone to the hospital because he had been dropped from a lift in the shower room and hit his head. *He pointed to his head and said, that's what this bump is from. *He had a raised area on his left forehead and a brace on his left foot. 2. Review of resident 14's electronic medical record (EMR) revealed a progress noted dated 9/9/24: *CNA [certified nursing assistant] called nurse to tub room res laying on the floor, skin tear to left arm above elbow, measures 5x5x5 triangle shaped area, also has a bump on left forehead with abrasion resident right leg is turned inward resident c/o [complaints of] pain when tried to move right leg. Resident stated I was standing up to get on bath chair and I fell. VS [vital signs] and Neuro check done, d/t [due to] pain and leg turning inward PCP [primary care provider] call and sending res to ER [emergency room] via ambulance, will wait to transfer res from floor when EMS [emergency medical service] arrives, EMS arrived approximately 0815. 3. Interview on 10/16/24 at 1:40 p.m. with resident 14 revealed, he had stopped this surveyor in hall and asked what was found out about the lift and stated, That thing [the lift] is going to kill me. 4. Interview on 10/16/24 at 1:44 p.m. CNA O regarding resident 14's transfers revealed: *She would check his [NAME] for changes in how they were to help him transfer, but he used the sit- to-stand mechanical lift with the assistance of two staff. *She stated he didn't like to use the lift and could be ornery or stubborn about using it. *She stated she would report to the nurse if he had trouble with the lift and maybe they would maybe get therapy to reevaluate him. 5. Interview on 10/16/24 at 1:50 p.m. with licensed practical nurse (LPN) F regarding resident 14 revealed: *She was aware resident 14 did not like to use the sit-to-stand lift. *She thought it was safer than a pivot transfer (spinning to move while bearing weight on one or both legs) and resident 14 thought he could still pivot. *She was not aware of him being dropped from a mechanical lift but resident 14 had told her he thought staff were going to drop him. *She stated she could put in a request for therapy to reevaluate him and the mechanical lift, but she had not placed one yet. *She later returned and informed this surveyor she had checked, and he was currently working with physical therapy and the use of the mechanical lift. 6. Interview on 10/16/24 at 1:56 p.m. with resident 14 revealed he stated: *His left leg and arm were weak from a stroke. *Only one staff would come in when they used the mechanical lift. *When staff used the lift it would pull his toes right into the stopper on the footrest toward the person that operated the machine. *He reported to staff he didn't like the mechanical lift and did not feel safe in it, but they still used it. 7. Interview on 10/16/24 at 2:10 p.m. with physical therapist assistant (PTA) Q regarding resident 14 revealed he stated: *Resident 14 had not been dropped from a lift by staff. *Resident 14 would lean back in the lift and not work well with staff about the lift being used. *He stated he would hate to go back to using a Hoyer full body mechanical lift (total body mechanical lift) when resident 14 could stand up. *Resident 14 was currently working with therapy and he would get their notes for the last few weeks. 8. Interview and observation on 10/17/24 at 7:32 with CNA I during resident 14's transfer revealed: *Resident 14 was laying in bed with his legs hanging off the edge of bed. *CNA I stated that she would know how to care for residents because their information was on a [NAME] which contained information on how to care for a resident. -The [NAME] was updated timely. *While resident 14 was seated on the edge of the bed, CNA I placed the lift sling behind him and explained she would get him up with a stand lift by herself. *This surveyor stopped CNA I before she hooked the sling up to the mechanical lift and asked her if he needed two staff to assist with the lift for safety. *CNA I said she thought he was one assist but she would check his care plan and left the room. -CNA I then re-entered resident 14's room at 7:44 a.m. with CNA P and stated resident 14 was to have two staff to assist with the mechanical sit-to-stand lift and stated his care plan must have recently changed. *She agreed she had been transferring resident 14 by herself with the sit-to-stand mechanical lift. 9. Observation on 10/17/24 at 8:06 a.m. in the nurse's station revealed a whiteboard hanging on the wall near the entrance dated 10/16/24 at the top and had instructions written on it in orange to check [NAME] daily. 10. Interview on 10/17/24 on 8:09 a.m. with LPN L regarding resident 14 when transferred with the mechanical lift revealed: *He was a fall risk and staff should use two people when using the mechanical lift. *He thought the [NAME] was updated timely to include that information. 11. Interview on 10/17/24 at 8:12 a.m. with director of nursing (DON) B regarding resident 14's fall and transfers with a mechanical lift revealed: *Resident 14 had fallen in the tub room while one staff was assisting, but he did not fall from the mechanical lift. *CNA I was not involved with that transfer and fall but CNA R was. *She was disappointed CNA I used the mechanical sit-to-stand mechanical lift without the assistance of an additional staff person for resident 14. *She stated, That is a big deal we had recently done training on 9/19/24 because he had fallen. *CNA I was trained on 10/4/24 regarding transfers and [NAME]'s updated for transfers. *She stated, CNA R was not available for interview because she had called off work for the last two days. 12. Review of resident 14's 9/9/24 fall investigation revealed: *CNA R indicated resident 14, Was going to get a w/p [whirlpool] bath. He stood up at the bars and turned to sit and his good leg gave out on him and down he went. -The root cause of resident 14's fall was indicated as, Lost balance and fell, resident did not have a gait belt on when nurse entered room. -Summary of meeting: Resident found to not have fracture after being sent to the emergency department for evaluation. Investigation revealed resident was being transferred via one assist versus care planned sit-stand lift, this was how all consistent care givers were transferring resident. -Conclusion: Use sit-to-stand for all transfers, ensure appropriate room arrangement to accommodate lift use. -Additional Care Plan/Nurse aide assignment updates, CNA received coaching by the DON on 9/12/24, education provided to CNAs and nurse re: use of [NAME] and how to request that transfer status be updated, Resident noted to have concerns about sit-to-stand lift and request part B therapy to work with resident on safe transfers in the lift. 13. Interview on 10/17/24 at 10:20 a.m. with DON B revealed: *DON B verified at the time of resident 14's fall incident on 9/9/24 resident 14 was transferred with the assistance of one staff and did not use a gait belt and she did not use the sit-to-stand mechanical lift. -She stated CNA R admitted to all of that. 14. Review of resident 14's care plan regarding transfers between surfaces revealed it was updated on 9/16/24 and instructed staff to use a mechanical sit-to-stand for transfers with assistance of two staff. Resident 14's transfer information on his [NAME] matched those instructions. 15. Review of resident 14's 9/23/24 - 10/21/24 physical therapy evaluation and treatment plan revealed he would work with therapy to imporve his strength his left hip and knee and upper extremities needed to assist with transfers. 16. Review of the provider's 7/29/24 Fall Prevention and Management policy revealed: *Purpose: -To promote resident well-being by developing and implementing a fall prevention and management program. -to identify risk factors and implement interventions before a fall occurs. -To give prompt treatment after a fall occurs. -To provide guidance for documentation. *Falls - refers to unintentionally coming to rest on the ground floor or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen if not for employee intervention, is considered a fall. A fall without injury is still a fall. *Proactive Approach before a Fall Occurs procedure: -3. Care Plan the appropriate interventions, including personalizing all (SPECIFY) areas. -4. Communicate fall risks and interventions to prevent a fall before it occurs per Fall Committee meetings. -12. If appropriate, contact the physician for a referral to therapy and communicate this to resident an family.' -14. Communicate that a fall has occurred during shift change and daily stand-up meetings in the preferred method of communication. The PCC Shift and 24 Hour report are available options. -16. Review and update the Care Plan with any changes/new interventions.