**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility documentation review, medical record review, hospital record review, and interviews, the facility failed to implement care plan interventions for 3 of 12 sampled residents (Resident #30, Resident #50, and Resident #75) reviewed for falls with injury which resulted in actual harm. Resident #30 had a laceration, bruising and bump to the head that required one staple. Resident #50 had a contusion to right hip and shoulder. Resident #75 had a left forehead laceration, approximately 5 mm [millimeter] requiring steri-strips with an acute traumatic subdural hematoma). The findings include: Review of the facility policy titled, Nursing Services revised 2/2022 revealed, .The care plan serves as a guide for care decisions and is made available for use by all patient care personnel . Review of the undated facility policy titled, Fall Prevention Program revealed, .Purpose: To reduce patient's risk of falling .Apply fall risk interventions as appropriate for the patient . Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included Senile Degeneration of Brain, Unspecified Fracture of Right Pubis, and History of falling. Review of the current Care Plan for Resident #30 revealed a problem/assessment for falls. Interventions included, .Approach start date: 05/03/2021 Bolsters to both sides of bed to form perimeter .04/02/2021 Apply fall mats to left and right sides of bed .04/02/2021 Bed in safest, lowest position . Review of the Progress Notes for Resident #30 dated 8/5/2022 revealed, .04:30 AM Pt [patient] was found on floor at 0315 by tech .Fall interventions were not in place at time of fall. She had rolled out of bed and hit her head .sent to [Named Hospital] .received one staple at the ER [emergency room] .08/25/2022 05:19 PM Post fall investigation summary: Patient was FOF [found on floor] on 8/5/22 at 3:45 AM after rolling out of bed. Careplanned bolsters and fall mats not in place at time of fall .Pt sustained laceration, bump, and bruising to top of head, was sent to ER, and returned with staple to laceration .Physical Therapy . Review of the hospital records for Resident #30 dated 8/5/2022, revealed she was admitted to the emergency department with a laceration to her scalp. Continued review revealed the laceration was closed with 1 staple. Radiological exam revealed soft tissue swelling of the frontal scalp. Review of the facility document titled, FSI-Fall Scene Investigation Report, dated 8/5/2022 revealed, .Fell out of bed. Bolsters/fall mats not in place .Root Cause of this Fall .Assistive/Protective device .Pt did not have bed bolsters in place . Review of the East Hall CNA shift report form revealed Resident #30 was not listed as a fall risk and not indicated as on the Fall Focus Program. During a telephone interview on 10/18/2022 at 5:04 PM, Licensed Practical Nurse (LPN)#1 confirmed Resident #30 had a fall and sustained a laceration to her head which required a staple closure. She stated the Certified Nursing Assistant (CNA) was not aware of Resident #30's required interventions. She stated the bed bolsters and the fall mats were not in place at the time of the fall. She confirmed Resident #30's care plan included bed bolsters and fall mat interventions related to her high fall risk evaluation. During an interview on 10/19/2022 at 12:35 PM, Physical Therapy Assistant #1 stated he had completed the investigation for Resident #30's fall with injury. He confirmed the fall interventions were not in place at the time of the fall on 8/5/2022. During an interview on 10/19/2022 at 5:00 PM, the Director of Nursing (DON) confirmed Resident #30's fall with injury resulted when care planned interventions were not implemented. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included History of Falling, Cerebral Infarction, and Dementia. Review of the Significant Change in status assessment dated [DATE], revealed Resident #50 was admitted to the facility on [DATE] and had Brief Interview for Mental Status Score (BIMS) of 15 which indicated intact cognitive abilities. Continued review revealed he required extensive assistance of 2 or more caregivers for bed mobility, total dependence on transfers of 2 or more caregivers, extensive assistance for dressing of 1 caregiver, and extensive assistance for toileting of 2 or more caregivers. Review of the Care Plan for Resident #50 revealed, .Fall risk for injury related to physical limitations in functional mobility .history of falls . Approach for fall prevention included, . 4/11/2022 bed in lowest, safest position .9/10/2022 Bumpers in place while pt [patient] is in bed. Educate staff to keep bed in low position while pt is in bed . Review of Resident #50's Safety Events - Fall dated 9/10/2022, revealed, .05:23 AM pt was found on the floor .pt stated that he was asleep in bed and next thing he knew he was in the floor .pt was assisted back to bed lifted manually by 4 people .once back in bed pt c/o [complained of] severe right hip pain .upon examination pt hip found to be internally rotated with resistance to ROM [range of motion} and was shorter than left leg .pain med admin [administered] with little help. MD notified, order given to transport pt to hospital for further evaluation . Continued review of the Safety Events - Fall revealed, .9/10/2022 at 10:18 AM pt returned from ER [Emergency Room] with diagnosis of contusion to hip and shoulder . Further review of the Safety Events - Fall revealed, .10/6/2022 05:16 PM post fall investigation summary: Pt was FOF [Found on floor] beside bed on 9/10/22 at 3:48 AM after rolling out of bed while sleeping. Pt was sleeping on winged mattress and fall mats were in place, but bed was not in lowest position . Review of Resident #50's Fall Investigation Report dated 9/10/2022, revealed, .Factors observed at time of fall .Bed height not appropriate .Describe initial interventions to prevent future falls .educate staff to have bed in low position . Review of Resident #50's ER visit dated 9/10/2022, revealed Diagnosis of Pelvic and Right shoulder Contusion. During an interview on 10/19/2022 at 1:55 PM, the Physical Therapist Assistant (PTA) confirmed Resident #50's bed was not at the appropriate height which contributed to his injury on 9/10/2022. During an interview on 10/19/2022 at 4:20 PM, the DON confirmed she would expect Certified Nursing Staff to lower a resident's bed to the lowest position prior to leaving the resident's room after providing care. Review of the medical record revealed Resident #75 was readmitted to the facility on [DATE] with diagnoses which included [NAME]-[NAME] Syndrome [autoimmune disorder characterized by muscle weakness], Myasthenia Neoplasm, and Alzheimer's Disease. Review of Resident #75's Quarterly MDS dated [DATE] revealed Resident #75 had a BIMS score of 99 indicating the resident could not complete the assessment. Continued review revealed Resident #75 required extensive assistance for bed mobility and transfers with two staff. Resident #75 had bilateral impairment of the upper extremities. Review of Resident #75's Care Plan interventions dated 1/6/2021 revealed .keep bed in low position. Ensure safe environment, free from clutter and obstacles . Review of the facility's documentation dated 8/2/2022 revealed .Summoned to Pt [patient] room at 11 pm per CNA [Certified Nurse Aide]. Pt laying on floor on left side on top of fall mat. Pt nursing alert. Baseline orientation Normal. Noted bleeding on floor. Pt assessed for injury 1/2 inch. Laceration to left side of forehead. First aid initiated. MD notified. with orders received for transfer to ER [emergency room]/ via ambulance for further eval [evaluation]. Pt wife notified .this nurse took call from ER at this time stating they were admitting patient for observation noted Subdural Hematoma [blood between brain and its outermost covering], nonsurgical .On 8/2/2022 at 11:00 PM, Patient was FOF [found on floor] beside bed on fall mat. CNA reports that patient had been changed within an hour of incident, but bed was apparently not in lowest position . Review of the History and Physical dated 8/3/2022 revealed .admission Diagnosis 1. Status post bed height fall with blunt head trauma and 5 mm [millimeter] left forehead laceration, reapproximated with Steri-strip with secondary 2.5 cm [centimeter] acute traumatic Subdural Hematoma .This is a [AGE] year old nursing home resident with [NAME]-[NAME] Syndrome and Dementia, who is non ambulatory and nonverbal who last evening fell from bed height. He did sustain blunt head trauma with 5 mm laceration to left forehead and was found to have 2.5 mm acute Subdural Hematoma . During an interview on 10/19/2022 at 2:15 PM, the PTA stated he had interviewed another agency CNA who assisted Resident #75 from the floor and she revealed the bed was not in the lowest position and the bedside table was close to the side of the bed. During a telephone interview on 10/19/2022 at 4:57 PM, Registered Nurse (RN) #3 stated she was at the nurses' station and a LPN had approached her and told her Resident #75 had fallen out of bed. Resident #75 was found on the floor facing the door. During an interview on 10/19/2022 at 3:14 PM, the DON stated she had not reviewed the post fall investigation for Resident #75. The DON expected staff to ensure a resident's bed was in a low position and the floor was clutter free before exiting the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility documentation review, medical record review, and interviews, the facility failed to protect 3 of 12 sampled residents (Resident #30, Resident #50, and Resident #75) reviewed related to falls with injury which resulted in actual harm (Resident #30 had a laceration, bruising and bump to the head that required one staple. Resident #50 had a contusion to right hip and shoulder. Resident #75 had a left forehead laceration, approximately 5 mm [millimeter] requiring steri-strips with an acute traumatic subdural hematoma). The Findings include: Review of the facility policy titled, Incident and Accident Process revised 8/13/2013 revealed, .examples of incidents/accidents are: Falls, Found on floor . Review of the facility policy titled, Nursing Services revised 2/2022 revealed, .The care plan serves as a guide for care decisions and is made available for use by all patient care personnel . Review of the undated facility policy titled, Fall Prevention Program revealed, .Purpose: To reduce patient's risk of falling .Apply fall risk interventions as appropriate for the patient . Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included Senile Degeneration of Brain, Unspecified Fracture of Right Pubis, and History of falling. Review of the current Care Plan for Resident #30 revealed a problem/assessment for falls. Interventions included, .Approach start date: 05/03/2021 Bolsters to both sides of bed to form perimeter .04/02/2021 Apply fall mats to left and right sides of bed .04/02/2021 Bed in safest, lowest position . Review of the Progress Notes for Resident #30 dated 8/5/2022 revealed, .04:30 AM Pt [patient] was found on floor at 0315 by tech .Fall interventions were not in place at time of fall. She had rolled out of bed and hit her head .sent to [Named Hospital] .received one staple at the ER [emergency room] .08/25/2022 05:19 PM Post fall investigation summary: Patient was FOF [found on floor] on 8/5/22 at 3:45 AM after rolling out of bed. Careplanned bolsters and fall mats not in place at time of fall .Pt sustained laceration, bump, and bruising to top of head, was sent to ER, and returned with staple to laceration .Physical Therapy . Review of the hospital records for Resident #30 dated 8/5/2022, revealed she was admitted to the emergency department with a laceration to her scalp. Continued review revealed the laceration was closed with 1 staple. Radiological exam revealed soft tissue swelling of the frontal scalp. Review of the facility document titled, FSI-Fall Scene Investigation Report, dated 8/5/2022 revealed, .Fell out of bed. Bolsters/fall mats not in place .Root Cause of this Fall .Assistive/Protective device .Pt did not have bed bolsters in place . Review of the East Hall CNA shift report form revealed Resident #30 was not listed as a fall risk and not indicated as on the Fall Focus Program. During a telephone interview on 10/18/2022 at 5:04 PM, Licensed Practical Nurse (LPN)#1 confirmed Resident #30 had a fall and sustained a laceration to her head which required a staple closure. She stated the Certified Nursing Assistant (CNA) was not aware of Resident #30's required interventions. She stated the bed bolsters and the fall mats were not in place at the time of the fall. She confirmed Resident #30's care plan included bed bolsters and fall mat interventions related to her high fall risk evaluation. During an interview on 10/19/2022 at 12:35 PM, Physical Therapy Assistant #1 stated he had completed the investigation for Resident #30's fall with injury. He confirmed the fall interventions were not in place at the time of the fall on 8/5/2022. During an interview on 10/19/2022 at 5:00 PM, the Director of Nursing (DON) confirmed Resident #30's fall with injury resulted when care planned interventions were not implemented. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included History of Falling, Cerebral Infarction, and Dementia. Review of the Significant Change in status assessment dated [DATE], revealed Resident #50 was admitted to the facility on [DATE] and had Brief Interview for Mental Status Score (BIMS) of 15 which indicated intact cognitive abilities. Continued review revealed he required extensive assistance of 2 or more caregivers for bed mobility, total dependence on transfers of 2 or more caregivers, extensive assistance for dressing of 1 caregiver, and extensive assistance for toileting of 2 or more caregivers. Review of the Care Plan for Resident #50 revealed, .Fall risk for injury related to physical limitations in functional mobility .history of falls . Approach for fall prevention included, . 4/11/2022 bed in lowest, safest position .9/10/2022 Bumpers in place while pt [patient] is in bed. Educate staff to keep bed in low position while pt is in bed . Review of Resident #50's Safety Events - Fall dated 9/10/2022, revealed, .05:23 AM pt was found on the floor .pt stated that he was asleep in bed and next thing he knew he was in the floor .pt was assisted back to bed lifted manually by 4 people .once back in bed pt c/o [complained of] severe right hip pain .upon examination pt hip found to be internally rotated with resistance to ROM [range of motion} and was shorter than left leg .pain med admin [administered] with little help. MD notified, order given to transport pt to hospital for further evaluation . Continued review of the Safety Events - Fall revealed, .9/10/2022 at 10:18 AM pt returned from ER [Emergency Room] with diagnosis of contusion to hip and shoulder . Further review of the Safety Events - Fall revealed, .10/6/2022 05:16 PM post fall investigation summary: Pt was FOF [Found on floor] beside bed on 9/10/22 at 3:48 AM after rolling out of bed while sleeping. Pt was sleeping on winged mattress and fall mats were in place, but bed was not in lowest position . Review of Resident #50's Fall Investigation Report dated 9/10/2022, revealed, .Factors observed at time of fall .Bed height not appropriate .Describe initial interventions to prevent future falls .educate staff to have bed in low position . Review of Resident #50's ER visit dated 9/10/2022, revealed Diagnosis of Pelvic and Right shoulder Contusion. During an interview on 10/19/2022 at 1:55 PM, the Physical Therapist Assistant (PTA) confirmed Resident #50's bed was not at the appropriate height which contributed to his injury on 9/10/2022. During an interview on 10/19/2022 at 4:20 PM, the DON confirmed she would expect Certified Nursing Staff to lower a resident's bed to the lowest position prior to leaving the resident's room after providing care. Review of the medical record revealed Resident #75 was readmitted to the facility on [DATE] with diagnoses which included [NAME]-[NAME] Syndrome [autoimmune disorder characterized by muscle weakness], Myasthenia Neoplasm, and Alzheimer's Disease. Review of Resident #75's Quarterly MDS dated [DATE] revealed Resident #75 had a BIMS score of 99 indicating the resident could not complete the assessment. Continued review revealed Resident #75 required extensive assistance for bed mobility and transfers with two staff. Resident #75 had bilateral impairment of the upper extremities. Review of Resident #75's Care Plan interventions dated 1/6/2021 revealed .keep bed in low position. Ensure safe environment, free from clutter and obstacles . Review of the facility's documentation dated 8/2/2022 revealed .Summoned to Pt [patient] room at 11 pm per CNA [Certified Nurse Aide]. Pt laying on floor on left side on top of fall mat. Pt nursing alert. Baseline orientation Normal. Noted bleeding on floor. Pt assessed for injury 1/2 inch. Laceration to left side of forehead. First aid initiated. MD notified. with orders received for transfer to ER [emergency room]/ via ambulance for further eval [evaluation]. Pt wife notified .this nurse took call from ER at this time stating they were admitting patient for observation noted Subdural Hematoma [blood between brain and its outermost covering], nonsurgical .On 8/2/2022 at 11:00 PM, Patient was FOF [found on floor] beside bed on fall mat. CNA reports that patient had been changed within an hour of incident, but bed was apparently not in lowest position . Review of the History and Physical dated 8/3/2022 revealed .admission Diagnosis 1. Status post bed height fall with blunt head trauma and 5 mm [millimeter] left forehead laceration, reapproximated with Steri-strip with secondary 2.5 cm [centimeter] acute traumatic Subdural Hematoma .This is a [AGE] year old nursing home resident with [NAME]-[NAME] Syndrome and Dementia, who is non ambulatory and nonverbal who last evening fell from bed height. He did sustain blunt head trauma with 5 mm laceration to left forehead and was found to have 2.5 mm acute Subdural Hematoma . During an interview on 10/19/2022 at 2:15 PM, the PTA stated he had interviewed another agency CNA who assisted Resident #75 from the floor and she revealed the bed was not in the lowest position and the bedside table was close to the side of the bed. During a telephone interview on 10/19/2022 at 4:57 PM, Registered Nurse (RN) #3 stated she was at the nurses' station and a LPN had approached her and told her Resident #75 had fallen out of bed. Resident #75 was found on the floor facing the door. During an interview on 10/19/2022 at 3:14 PM, the DON stated she had not reviewed the post fall investigation for Resident #75. The DON expected staff to ensure a resident's bed was in a low position and the floor was clutter free before exiting the room.