**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #15 was admitted to the facility on [DATE] with diagnoses including Alcoholic Cirrhosis of Liver, Palliative Care, Depressive Disorders, Hallucinations, Chronic Pain, and Muscle Weakness. Review of the quarterly MDS assessment dated [DATE], showed Resident #15 had severe cognitive impairment, used a bed and chair alarm daily, used a wander guard alarm daily (the resident did not have a wander guard system in use), and did not reflect a diagnosis of hallucinations. Review of a Post Fall Observation Report dated 9/10/2023, showed Resident #15 had an unwitnessed fall from the chair with no injuries. The fall intervention was to place the chair alarm out of sight due to the resident had turned the chair alarm off. Review of a Post Fall Observation Report dated 9/23/2023, showed Resident #15 had an unwitnessed fall from the bed. The resident was observed lying on his back in the floor, the resident had turned the bed alarm off, and complained of back and shoulder pain. The resident was sent to the emergency room for evaluation and returned to the facility with no injuries. The fall intervention placed after the fall was to place a bolster mattress (a specialty mattress with foam sides to reduce the risk of rolling off the bed) to the bed. Review of the comprehensive care plan revised 9/25/2023, showed Resident #15's care plan had not been revised to include the fall intervention from 9/10/2023 to place the chair alarm out of sight, and the hallucination diagnosis. Further review showed the resident had a care plan for a wander guard. During an observation on 10/2/2023 at 11:45 AM, showed Resident #15 lying in bed with a bolster mattress, and no wander guard in use. During an observation on 10/3/2023 at 9:04 AM, showed Resident #15 lying in bed with a bolster mattress, and no wander guard in use. During an observation on 10/4/2023 at 10:34 AM, showed Resident #15 lying in bed with a bolster mattress, and no wander guard in use. Resident #17 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, Anxiety, and Muscle Weakness. Review of a Post Fall Observation Report dated 5/8/2023, showed Resident #17 had an unwitnessed fall in her room with no injury. The fall intervention placed after the fall was for the resident to be in a highly visible area when up in chair. Review of a Psychiatric Nurse Practitioner note dated 8/2/2023, showed .diagnosis .depression .insomnia .delusions .psychosis . Review of a quarterly MDS assessment dated [DATE], showed Resident #17 had severe cognitive impairment for daily decision making, was totally dependent on 2 persons for bed mobility, dressing, toileting, personal hygiene, bathing, and required extensive assistance of 2 persons with transfers. Further review showed the MDS did not reflect Resident #17 had the following diagnoses: Alzheimers Disease, Depression, Insomnia, Delusions, or Psychosis. The resident used a bed, chair alarm, and wander guard daily. Further review showed a restraint was not used. Review of the comprehensive care plan dated 9/7/2023, showed Resident #17 had decreased Activities of Daily Living (ADL) ability related to weakness and required 1 person staff assistance with bathing, hygiene, dressing, grooming, toileting, transfers, and had a wander guard to the lower extremity. Further review showed the resident was care planned for falls and the care plan had not been revised to reflect the fall intervention on 5/8/2023 for the resident to be in a highly visible area when up in chair. Continued review showed the care plan had not been revised to include diagnoses of Alzheimer's Disease, Depression, Insomnia, Delusions, or Psychosis, and the use of a restraint. During an observation on 10/2/2023 at 3:52 PM, showed Resident #17 seated in a broda chair in the hallway, reclined back, with a click seat belt, and chair alarm in use. Resident #17 attempted to release the click seat belt but was unable; no wander guard in use. During an observation on 10/3/2023 at 9:02 AM, showed Resident #17 seated in a broda chair in the hallway, with a click seat belt, and chair alarm in use; no wander guard in use. During an interview on 10/3/2023 at 4:05 PM, the DON confirmed Resident #15's care plan had not been revised to include the fall intervention from 9/10/2023 to place the chair alarm out of sight, and the hallucination diagnosis and Resident #15 did not have a wander guard in place. Further interview confirmed Resident #17 used a click seat belt, the resident could not release the seat belt, and it was considered a restraint. She also confirmed Resident #17 had a functional decline, required more assistance from staff, and the care plan had not been revised to reflect the decline. Continued interview confirmed Resident #17's care plan had not been revised to include a fall intervention after the resident sustained a fall on 5/8/2023, and after Resident #17 had recieved the diagnoses of Alzheimer's, Depression, Insomnia, Delusions, and Psychosis. The DON confirmed Resident #17's care plan showed the resident had a wander guard to the lower extremity (Resident #17 did not have a wander guard in use), and Resident #17's care plan did not reflect the resident's current care status. During an interview on 10/4/2023 at 3:20 PM, the MDS Coordinator confirmed she had not revised Resident #15 and #17's care plan to reflect the resident's current status. Refer to tag F-689 Based on facility policy review, medical record review, facility post fall investigation review, and interviews, the facility failed to revise the comprehensive care plan related to falls for 3 residents (Resident #14, #15, and #17) of 3 residents reviewed for falls which resulted in actual harm to Resident #14 when the resident fell and sustained a laceration to the left eye and required the area to have steri strips (wound closure tape) placed to close the wound, failed to revise the comprehensive care plan related to a wound for Resident #14 of 2 residents reviewed for wounds, failed to revise the comprehensive care plan related to a wander guard (a safety device used for high elopement risk) for 2 residents (Resident #15 and #17), failed to revise the comprehensive care plan for new diagnoses for 1 resident (Resident #15), and failed to revise the comprehensive care plan for a functional decline and restraint use for 1 resident (Resident #17) of 12 care plans reviewed. The findings include: Review of the facility policy titled, Fall Risks, revised 8/4/2023, showed .PURPOSE .To assist .in identifying residents at risk for falls and implementing appropriate interventions .Interventions are implemented for fall prevention, decreasing the risk of falls and harm from falls .Each fall will be evaluated .with interventions developed to reduce risk of recurrent fall (s) .determine what interventions should be to be implemented and update the resident's care plan . Review of the facility policy titled, Care Plan/Comprehensive Assessment, revised 11/4/2022, showed .To define the process for assessing and developing an individualized .plan of care of each resident .Review and revise care plans . Resident #14 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Type 2 Diabetes, Anxiety Disorder, and Chronic Kidney Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact, required 1-person assistance with transfers, had previously fallen, was at risk for pressure ulcers, and had no current wounds. Review of a Post Fall Observation report dated 5/30/2023, showed the report had been completed by Licensed Practical Nurse (LPN) #1 .Location of Fall .Resident Room .Resident stated she was going to put her blanket in the chair across the room .Medical Care Provided Post Fall .No Care Necessary .measures to be taken to prevent further falls .unable to stay in her room in chair by herself . Review of a nursing Progress Note dated 5/30/2023, showed LPN #1 documented .residents alarm sounded followed by her [Resident #14] yelling out .was sitting in the floor with no injuries .said she [Resident #14] was going to put .blanket in a chair .replaced in .chair and taken out to the front hall . Review of a Post Fall Observation report dated 7/30/2023, showed the report had been completed by LPN #1 .Location of Fall .Resident Room .Describe .resident was in floor out of her chair .Medical Care Provided Post Fall .Basic First Aid .cleaned and dried with NS [Normal Saline] and Steri strips applied and cover dressing .resident stated she was going to walk out to the garden . Review of a nursing Progress Note dated 7/30/2023, showed LPN #1 documented .Heard alarm went into residents room she was lying in the floor on her left side crying lying in small amt [amount] of blood coming from above her eye at her eyebrow .she [Resident #14] stated she was going out to the garden .cleaned and dried her laceration applied steri strips and a cover dressing .notified hospice of incident .hospice will be here [at facility] .to see if steri strips will be enough without stitches . Review of Resident #14's annual MDS assessment dated [DATE], showed a BIMS score of 8 which indicated the resident had moderate cognitive impairment, required 2-person assistance with transfers, had 2 or more falls, 1 with injury, was at risk for pressure ulcers, and had no current wounds. Review of Resident #14's Physician's Order dated 8/21/2023, showed .Stage I Ulcer and .SDTI [suspected deep tissue injury] .clean areas with Normal Saline, dry, apply foam heel dressing and change every other day .R [right] heel . Review of a Wound Report dated 8/29/2023, showed .[Resident #14 .SDTI .R heel .Onset Date .8/21/2023 .healing . Review of the comprehensive care plan revised 10/2/2023, showed .Fall .Resident will remain free of fall related injury . Further review showed the care plan had not been revised to reflect a fall intervention when Resident #14 sustained a fall on 5/30/2023 (no injury). Continued review showed no fall intervention was initiated after the resident sustained a fall on 7/30/2023, and the care plan had not been revised to reflect a SDTI to Resident #14's right heel which was identified on 8/21/2023. Review of Resident #14's medical record showed the resident had not sustained a fall since the 7/30/2023 fall. During an interview on 10/2/2023 at 11:05 AM, Certified Nursing Assistant (CNA) #1 stated she was familiar with Resident #14 and cared for the resident routinely. Resident #14 was a high fall risk, had multiple fall interventions in place to include, if the resident was up in the broda chair (a wheelchair which provides supportive positioning), the resident was not left alone in the resident's room. CNA #1 was on duty when Resident #14 sustained a fall on 7/30/2023. The chair (broda chair) alarm sounded, CNA #1 stated she checked on the resident immediately, the resident was in her room, the resident had removed the self-release belt, was observed in the floor, and was bleeding from a cut on her eye (unable to recall which eye). Resident #14 had attended a church activity .someone from the church must have brought her [Resident #14] back to the room and did not know [Resident #14] should not be left alone in the room . During an interview on 10/2/2023 at 11:12 AM, LPN #1 stated she was familiar with Resident #14 and was the resident's routine nurse. The resident was a high fall risk with multiple interventions in place to include not left in the room alone when up in the broda chair. The LPN was on duty 7/30/2023 when Resident #14 sustained a fall. The resident had attended a church service at the facility, staff heard the chair alarm sound, checked on the resident immediately, the resident had removed the self-release lap belt, and was observed lying on the floor in a small amount of blood with a laceration to her left eye, above the eyebrow. LPN #1 cleansed the wound, applied steri strips, and notified hospice; the hospice nurse evaluated the resident and determined the resident would not require stitches. LPN #1 also stated .a church member must have brought her [Resident #14] back to her room and left her alone, we [facility staff] know not to leave her alone when she is up in the broda chair . During an interview on 10/4/2023 at 8:21 AM, the wound care nurse stated Resident #14 had a SDTI identified on 8/21/2023. The physician was notified, and wound care orders were received. She also stated the wound to Resident #14's right heel had improved and nearly healed. During an interview on 10/4/2023 at 2:13 PM, the Director of Nursing (DON) stated Resident #14 sustained a fall on 5/30/2023. The new fall intervention was for the resident not to be left in her room alone when the resident was up in the broda chair. The DON confirmed Resident #14's care plan had not been revised to reflect the new intervention. During an interview on 10/4/2023 at 2:17 PM, the DON stated Resident #14 sustained a fall on 7/30/2023. The resident was left alone in her room in the broda chair, the resident received a laceration to the left eyebrow, and the area required steri strip placement to close the wound. The DON confirmed the facility failed to revise and implement a fall intervention from 5/30/2023 which caused harm to Resident #14 when she sustained a fall with injury on 7/30/2023. The DON also confirmed a new fall intervention was not implemented after the resident fell on 7/30/2023, and the resident had not sustained any further falls. During an interview on 10/5/2023 at 2:39 PM, the DON confirmed Resident #14's care plan had not been revised to reflect the SDTI to the resident's right heel identified on 8/21/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #17 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, Anxiety, and Muscle Weakness. Review of a Post Fall Observation report dated 4/16/2023, showed .nurse was charting at nursing station when heard a bed alarm going off .she [ Resident #17 ] was standing at the air conditioner .Resident heard this nurse and tried to turn around when she fell against the wall and hit her left forearm on the bed side table. Resident slid to her bottom .Scrape noted to left forearm .No other injuries .measures to be taken to prevent further fall .continue plan of care . Further review showed no new fall intervention was placed after the fall and the fall investigation was not complete and thorough. Review of a Post Fall Observation report dated 5/8/2023, showed .[Resident #17 ] unbuckled Geri chair (a specialized chair for individuals with limited mobility) buckle and was found on the floor .heard moaning from room as staff entered room .Geri-chair was found in the middle of the room and resident was found lying on the floor in front of it .Medical Care Provided .No Care Necessary .measures to be taken to prevent further falls .Resident in highly visible area when up in chair . Review of a Post Fall Observation report dated 5/11/2023, showed .found on floor next to chair in .resident's room .What was resident's location prior to the fall .Bed .Medical Care Provided Post Fall .emergency room Visit .Evidence that resident hit left side of head .Describe measures to be taken to prevent further falls .[blank] . Further review showed no new fall intervention was placed after the fall and the fall investigation was not complete and thorough. Record review showed Resident #17's CT (Computed Tomography/a diagnostic imaging procedure) scan performed on 5/11/2023, was negative and the resident returned to the facility, and Resident #17 had not sustained a fall since 5/11/2023. Review of a quarterly MDS assessment dated [DATE], showed Resident #17 had severe cognitive impairment for daily decision making, required extensive assistance of 1 person with bed mobility, locomotion, and personal hygiene; required extensive assistance of 2 persons with transfers, dressing, toileting, and bathing. The resident had sustained falls since the last assessment. Review of a quarterly MDS assessment dated [DATE], showed Resident #17 had severe cognitive impairment for daily decision making, was totally dependent on 2 persons for bed mobility, dressing, toileting, personal hygiene, bathing, and required extensive assistance of 2 person with transfers. Review of the comprehensive care plan last reviewed 9/7/2023, showed Resident #17 was care planned for falls and the care plan had not been revised to reflect the fall intervention on 5/8/2023 for the resident to be in a highly visible area when up in chair. During an observation on 10/2/2023 at 3:52 PM, showed Resident #17 seated in a broda chair in the hallway, reclined back, with a click seat belt, and chair alarm in use. During an observation on 10/3/2023 at 9:02 AM, showed Resident #17 seated in a broda chair in the hallway, with a click seat belt, and chair alarm in use. During an interview on 10/4/2023 at 8:53 AM, the DON confirmed the fall investigations for Resident #17 for 4/16/2023 and 5/11/2023 were not complete and thorough. The DON also confirmed a new fall intervention had not been placed after the resident sustained a fall on 4/16/2023 and 5/11/2023. Refer to F-657 Based on facility policy review, medical record review, facility post fall review, and interviews, the facility failed to prevent accidents related to falls for 1 resident (Resident #14) of 3 residents reviewed for falls when a new fall intervention was not implemented which resulted in actual harm to Resident #14 when the resident fell and sustained a laceration to the left eye and required steri strips (wound closure tape) to close the wound, and failed to complete thorough fall investigations for 1 resident (Resident #17) of 3 residents reviewed for falls. The findings include: Review of the facility policy titled, Fall Risks, revised 8/4/2023, showed .PURPOSE .To assist .in identifying residents at risk for falls and implementing appropriate interventions .Interventions are implemented for fall prevention, decreasing the risk of falls and harm from falls .Each fall will be evaluated .with interventions developed to reduce risk of recurrent fall (s) . Review of the facility policy titled, Care Plan/Comprehensive Assessment, revised 11/4/2022, showed .To define the process for assessing and developing an individualized .plan of care of each resident .Review and revise care plans . Resident #14 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Type 2 Diabetes, Anxiety Disorder, and Chronic Kidney Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact, required 1-person assistance with transfers, and had previously fallen. Review of a Post Fall Observation report dated 5/30/2023, showed the report had been completed by Licensed Practical Nurse (LPN) #1 .Location of Fall .Resident Room .Resident stated she was going to put her blanket in the chair across the room .Medical Care Provided Post Fall .No Care Necessary .measures to be taken to prevent further falls .unable to stay in her room in chair by herself . Review of a nursing Progress Note dated 5/30/2023, showed LPN #1 documented .residents alarm sounded followed by her [Resident #14] yelling out .was sitting in the floor with no injuries .said she [Resident #14] was going to put .blanket in a chair .replaced in .chair and taken out to the front hall . Review of a Post Fall Observation report dated 7/30/2023, showed the report had been completed by LPN #1 .Location of Fall .Resident Room .Describe .resident was in floor out of her chair .Medical Care Provided Post Fall .Basic First Aid .cleaned and dried with NS [Normal Saline] and Steri strips applied and cover dressing .resident stated she was going to walk out to the garden . Review of a nursing Progress Note dated 7/30/2023, showed LPN #1 documented .Heard alarm went into residents room she was lying in the floor on her left side crying lying in small amt [amount] of blood coming from above her eye at her eyebrow .she [Resident #14] stated she was going out to the garden .cleaned and dried her laceration applied steri strips and a cover dressing .notified hospice of incident .hospice will be here [at facility] .to see if steri strips will be enough without stitches . Review of an annual MDS assessment dated [DATE], showed a BIMS score of 8 which indicated the resident had moderate cognitive impairment, required 2-person assistance with transfers, and had 2 or more falls, 1 with injury. Review of the comprehensive care plan revised 10/2/2023, showed .Falls .Resident will remain free of fall related injury . Further review showed the care plan had not been revised to reflect the fall intervention after Resident #14 sustained a fall on 5/30/2023 (no injury) and 7/30/2023. Review of Resident #14's medical record showed the resident had not sustained a fall since 7/30/2023. During an observation on 10/2/2023 at 11:00 AM, showed Resident #14 lying in a low bed, bed mat in place, bed alarm in place, and one side of the bed against the wall. Further observation showed the resident had a broda chair in the room with a self-release belt, and chair alarm attached midway down the back of the chair. During an interview on 10/2/2023 at 11:05 AM, Certified Nursing Assistant (CNA) #1 stated she was familiar with Resident #14 and cared for the resident routinely. Resident #14 was a high fall risk, had multiple fall interventions in place to include, if the resident was up in the broda chair (a wheelchair which provides supportive positioning), the resident was not left alone in the resident's room. CNA #1 was on duty when Resident #14 sustained a fall on 7/30/2023. The chair alarm sounded, CNA #1 stated she checked on the resident immediately, the resident was in her room, the resident had removed the self-release belt, was observed in the floor, and was bleeding from a cut on her eye (unable to recall which eye). Resident #14 had attended a church activity .someone from the church must have brought her [Resident #14] back to the room and did not know [Resident #14] should not be left alone in the room . During an interview on 10/2/2023 at 11:12 AM, LPN #1 stated she was familiar with Resident #14 and was the resident's routine nurse. The resident was a high fall risk with multiple interventions in place to include not left in the room alone when up in the broda chair. The LPN was on duty 7/30/2023 when Resident #14 sustained a fall. The resident had attended a church service at the facility, staff heard the chair alarm sound, checked on the resident immediately, the resident had removed the self-release lap belt, and was observed lying on the floor in a small amount of blood with a laceration to her left eye, above the eyebrow. LPN #1 cleansed the wound, applied steri strips, and notified hospice; the hospice nurse evaluated the resident and determined the resident would not require stitches. LPN #1 also stated .a church member must have brought her [Resident #14] back to her room and left her alone, we [facility staff] know not to leave her alone when she is up in the broda chair . During an observation on 10/3/2023 at 8:30 AM, showed Resident #14 seated in a broda chair near the nurse's station with a self-release belt and chair alarm in place, alarm out of her reach. During an observation on 10/3/2023 at 2:07 PM, Resident #14 was seated in a broda chair in the hallway with a self-release belt, the chair alarm was in place, and out of the residents reach. During an observation on 10/4/2023 at 7:40 AM, Resident #14 was seated in a broda chair in the dining room with a self-release belt in place with an alarm to the back of the chair out of reach. During an interview on 10/4/2023 at 2:13 PM, the Director of Nursing (DON) stated Resident #14 sustained a fall on 5/30/2023. The new fall intervention was for the resident not to be left in her room alone when the resident was up in the broda chair. The DON confirmed Resident #14's care plan had not been revised to reflect the new intervention. During an interview on 10/4/2023 at 2:17 PM, the DON stated Resident #14 sustained a fall on 7/30/2023. The resident was left alone in her room in the broda chair, the resident received a laceration to the left eyebrow, and the area required steri strip placement to close the wound. The DON confirmed the facility failed to revise and implement a fall intervention from 5/30/2023 which caused harm to Resident #14 when she sustained a fall with injury on 7/30/2023. The DON also confirmed a new fall intervention was not implemented after the resident fell on 7/30/2023, and the resident had not sustained any further falls.