**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 25 sampled residents, a resident that was dependent on cares was left unattended in the shower, sustained a head laceration that required eight staples and six stitches, and the resident sustained a pelvic fracture. Resident identifier: 118. Findings included: Resident 118 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, fracture of pubis, subluxation of right shoulder joint, localized edema, dysphagia, history of falling, moderate protein-calorie malnutrition, and essential hypertension. Resident 118's medical record was reviewed on 5/20/24. A state optional Minimum Data Set (MDS) assessment dated [DATE], documented that resident 118 required extensive assistance of two plus persons for bed mobility, transfers, and toilet use. A quarterly MDS assessment dated [DATE], documented that resident 118 had a Brief Interview for Mental Status (BIMS) score of 6. A BIMS score of 0 to 7 would indicate severe cognitive impairment. On 1/29/24 at 10:08 AM, a Skilled Nursing Note documented Resident is A&Ox2 [alert and oriented to person and place] and speaks Cantonese only. Staff to anticipate her needs. Resident had no negative behaviors observed or reported this morning. Resident took her morning medications with applesauce with no difficulty swallowing. Resident is an extensive assist x [by] 2 person for ADL's [activities of daily living], bed mobility, and transfers. Resident users her wheelchair for mobility with extensive assist x 1 person. Resident is very limited with ROM [range of motion] r/t [related to] disease process. Resident is turned and repositioned q2h [every two hours] and prn [as needed] to prevent skin breakdown. Call light within reach. On 3/2/24 at 6:45 AM, a Nursing Progress Note documented Note Text: FALL EVENT: CNA [Certified Nursing Assistant] reported to RN [Registered Nurse] that resident has fallen on the floor while attempting her morning shower. RN approached and noted blood on residents face. CNA was applying pressure on the right side of her head to stop the active bleeding. RN observed her head and noted a laceration on the right side of her forehead. Resident was unresponsive to stimuli for a minute. She came back and became agitated and calling out words in her primary language. Vitals [vital signs] immediately taken BP [blood pressure] 169/83 HR [heart rate] 86 O2 [oxygen] 90% @RA [at room air], temp [temperature] 97.4F [Fahrenheit] by CNA and nursing student. RN meanwhile called provider to report and called 911. Report was given 911 representative. Patient family or daughter was notified over the phone. First responders arrived, report given with patient info and they told RN that she will be taken to the nearest hospital which is [name of hospital redacted]. On 3/2/24, an Emergency Department (ED) physician note documented . Alzheimer's dementia who presents to the emergency department from her care facility with concern of fall resulting in head trauma with a laceration. Unclear how the patient fell, as reported she fell while showering but patient is nonambulatory and has chronic contractures of her arms and legs. She was offered admission but family has decided they would like to put her back on hospice and send her back to her care facility. They do not want any further interventions and understands she could get worsening [sic] even die from these injuries and her electrolyte abnormalities, . ASSESSMENT AND PLAN: #Pelvic fractures . Nonoperative, Weight-bear as tolerated though nonambulatory at baseline, Unable to provide benefit with PT [physical therapy] #Age Indeterminate nondisplaced rib fractures . #Chronic right shoulder subluxation . #Forehead laceration Laceration was stapled by the ED attending . On 3/3/24 at 4:46 PM, a Nursing Progress Note documented Late Entry: Note Text: Late entry for 3/3/24: [name of hospice company redacted] nurse informed this nurse that resident had a fractured pelvis. Stated that is what was on the hospital discharge papers. Nurse assessed and no s/s [signs or symptoms] of pain while turning was observed. Resident has head laceration to the left side of her head. Resident has 8 staples and 6 stitches to head laceration. Wound shows no s/s of infection. Resident was more lethargic than her baseline. Resident would respond to verbal stimulation but would go right back to sleep. Resident requires O2 to maintain sats [saturations] > [greater than] 90%. O2 running at 2 L/min [liters per minute]. Resident lungs auscultated upper and lower lobes bilaterally with decreased sounds in the bases and crackles heard in the upper lobes with expiratory wheezing. Resident is sat up in bed to 30 degrees or more to help with her breathing. Resident is resting at this time with no s/s of distress. Staff to continue to monitor resident status throughout this shift. On 3/4/24 at 5:01 PM, a Nursing Progress Note documented Note Text: Resident had a recent fall with injuries. Resident has a head laceration to the left side of her head with 8 staples and 6 stitches. Wound shows no s/s of infection. Wound was cleansed with NS [normal saline] and pat dried with gauze. This nurse spoke with [name redacted], [name of hospice company redacted], and he verified that resident does have a pelvic fracture and fractures to her 4th and 5th rib on the left side. Resident shows no grimacing or guarding during cares. Today, resident asked, through translation through her daughter, [name redacted], that she wanted to use the restroom. Staff got resident up into her wheelchair and was able to use the restroom. Resident had a medium BM [bowel movement]. V/S [vital signs] taken BP: 122/58 P [pulse]: 76 R [respirations]: 16 T [temperature]: 97.7 O2: 87% on 2 L [liters] O2 via NC [nasal cannula]. O2 was titrated up to 3 L O2. While resident was on the toilet, resident had clear, yellowish emesis. Staff got resident into bed and raised the HOB [head of bed] to >30 degrees. Resident did eventually stopped vomiting. New order received from [name of hospice company redacted] on 3/4/24: 1. Albuterol 0.63 mg [milligrams]/3 ml [milliliters] 1 vial nebulize vial q4h [every four hours] PRN for SOB [shortness of breath]; 2. suction machine use yaunker suction PRN for secretions; 3. Keep HOB up 30 degrees at all times, do not lay flat; 4. 2 person assist for any moving/transferring of patient; 5. Please premedicate before any moves or brief changes. A care plan Focus dated 3/5/24, documented [Resident 118] is risk for falls r/t hx [history] of frequent falls. The interventions initiated on 3/5/24, included: a. Anticipate and meet resident 118's needs. Encourage to wait for assistance. b. Be sure bed was in low position and locked in place. c. Be sure resident 118's call light was within reach and encourage the resident to use it for assistance as needed. Resident 118 needs prompt response to all requests for assistance. d. Educate the resident, family, and caregivers about safety reminders and what to do if a fall occurs. e. Encourage to wear well-fitting, non-skid footwear when transferring and ambulating. f. Ensure adequate lighting in room. Check night lights and call lights at bedside, bathrooms and shower rooms, ensure call light was within reach. On 3/5/24 at 7:49 AM, a Nursing Progress Note documented Note Text: Resident had a recent [fall] with injuries. Resident has a laceration to the right side of her head with 8 staples and 6 stitches. Wound shows no s/s of infection. Resident also sustained fractured pelvis and the 4th and 5th ribs on her left side. Nurse educated staff on careful turning and repositioning during cares. Resident is premedicated before all cares for Pain. Resident had no s/s of pain with no facial grimacing or guarding during cares. V/S taken this morning BP: 105/56 P: 67 R: 16 T: 97.6 O2: 90% on 3L O2 via NC. Resident has expiratory wheezes and crackles. Nurse suctioned her this morning per MD [Medical Director] order. Lungs auscultated upper and lower lobes bilaterally with decreased sounds in the bases and crackles heard in the upper lobes. Resident is sat up to 30 degrees or more per MD order. Nurse observed right sided weakness. She is having a hard time getting her right arm up to her walker when she's using the restroom to help balance herself. Staff to stay with her while she's on the toilet. Resident is alert to self and is unable to appropriately communicate her needs r/t language barrier. Staff to anticipate needs and use her picture board to help convey her needs. Resident is more lethargic and did not wake during V/S this morning. Resident is turned and repositioned q2h and PRN to prevent skin breakdown. Staff to continue to monitor resident throughout this shift to ensure comfort and safety. Push pad call light is within reach. On 3/5/24 at 4:57 PM, a Nursing Progress Note documented Note Text : CNA informed nurse that resident wasn't responding to verbal or physical stimuli. Nurse went in and found resident not breathing and pale. Nurse auscultated heart for five minutes and heard no sounds. Time of death 1625 [4:25 PM] on 3/5/24. Family was present while nurse was listening to her heart. [Name redacted] from [name of hospice company redacted] was notified. On 5/21/24 at 12:15 PM, an interview was conducted with CNA 2. CNA 2 stated on the day in question it was resident 118's shower day. CNA 2 stated he put resident 118 in the shower chair and pushed resident 118 into the shower room. CNA 2 stated the shower room was in the resident's bathroom. CNA 2 stated the towels and gloves were in the chair in resident 118's room. CNA 2 state he grabbed the towels and gloves that were in the chair and when he came back to the shower room resident 118 was on the floor. CNA 2 stated there should have been two people for the transfer of resident 118 to the shower Chair. CNA 2 stated when he put resident 118 in bed he could do that by himself even though resident 118 was heavy. CNA 2 stated that CNA 3 had helped him transfer resident 118 to the shower chair and then CNA 3 left to go back to her section. CNA 3 stated that resident 118 only needed one person for the shower. On 5/21/24 at 2:51 PM, an interview was conducted with CNA 3. CNA 3 stated that she had helped CNA 2 transfer resident 118 from the bed to the chair but she did not help CNA 2 transfer resident 118 to the shower chair the night of the incident. CNA 3 stated that CNA 2 was tall and a big guy and he probably transferred resident 118 himself. CNA 3 stated that she had heard resident 118 scream but resident 118 was already on the floor when she had arrived at resident 118's room. CNA 3 stated that resident 118 was not able to sit in a chair by herself and that resident 118 would lean over. CNA 3 stated that the shower chair was a bench with holes and it did not have sides. CNA 3 stated resident 118 was a two person assist for transfers, resident 118 could not walk, and resident 118 was total dependent with cares. CNA 3 stated that resident 118 was a one person assist for showers. On 5/21/24 at 3:01 PM, an interview was conducted with the PT Director. The PT Director stated that resident 118 was never able to ambulate while resident 118 was a resident at the facility. The PT Director stated that resident 118's right ankle had limited ROM and the left ankle was more so limited. The PT Director stated that resident 118's right hand had limited ROM. The PT Director stated that resident 118 was able to sit in a chair unassisted. The PT Director stated if the shower chair had a back rest he would think that resident 118 would have been able to sit up. The PT Director stated that resident 118 would sit in the bedside chair for extended periods. On 5/21/24 at 3:13 PM, an interview was conducted with Medication Technician (MT) 3. MT 3 stated she was not working the night that resident 118 fell. MT 3 stated the day that resident 118 was getting her shower the staff were not using the shower chair that should have been used. An observation was conducted with MT 3 of a similar shower chair that was used when resident 118 fell. The shower chair was observed to be a bench with holes and the bench had a back rest attached. An observation was conducted with MT 3 of a similar shower chair that resident 118 should of been using. The shower chair was observed to look like a bedside commode with arm rest but according to MT 3 the one resident 118 used was smaller. MT 3 stated that resident 118 did not lean when sitting in a chair and was more ridged. MT 3 stated that resident 118 was dependent on all cares. MT 3 stated that resident 118 was not able to hold onto the arm rests of the shower chair and the arm rests were more for security. MT 3 stated that resident 118 had limited ROM in her hands but would hold onto a walker from a sitting position in the wheelchair. MT 3 stated resident 118 would not be able to grasp the walker to get up and walk. On 5/21/24 at 3:30 PM, an interview was conducted with RN 2. RN 2 stated it was early morning and she had just started her shift. RN 2 stated that she liked to do rounds to look in on the residents to see how they were doing and resident 118 was sleeping. RN 2 stated the CNA went to shower resident 118 and it happened so fast. RN 2 stated that resident 118 was bleeding from the head and she had applied pressure to the area. RN 2 stated that resident 118 usually required one person for showers. RN 2 stated that resident 118 was very low maintenance. RN 2 stated that resident 118 spoke Cantonese and the family was very involved. RN 2 stated that during the day resident 118 would sit in her chair and would have a walker in front of her. RN 2 stated that having the walker in front of resident 118 was a mental thing and resident 118 had her bags on the walker. RN 2 stated that resident 118 could not pull herself up or walk. RN 2 stated it was an unfortunate event. On 5/22/24 at 12:49 PM, an interview was conducted with the Director of Nursing (DON). The DON stated they had continued education with the staff regarding gathering supplies before going into the shower and using the call light to ask for assistance. The DON stated that she would have not thought that resident 118 could not be left alone. The DON stated that resident 118 would sit on the edge of the bed. The DON stated that resident 118 did not have to have the walker to sit on the edge of the bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 2 out of 23 sampled residents, residents did not receive preventative interventions and/or adequate supervision to prevent falls and accidents from occurring. Resident identifiers: 2 and 35. Findings included: 1. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, chronic osteomyelitis of left thigh, non-pressure chronic ulcer of left thigh with necrosis of muscle, severe protein-calorie malnutrition, acute respiratory failure with hypoxia, staphlococcus, proteus, essential hypertension, postpolio syndrome, paraplegia, chronic pain syndrome, and retention of urine. On 10/24/22 at 12:38 PM, an interview was conducted with resident 2. Resident 2 stated that he had fallen at the facility. Resident 2 stated that he had broken his leg during one of the falls. Resident 2 stated that he was dumped out of the shower chair by accident by a Certified Nursing Assistant (CNA). Resident 2 stated the staff thought his leg was sprained but resident 2 stated his leg hurt too bad to be a [NAME]. Resident 2 stated the CNA turned the shower chair around with him in it and the CNA was not paying attention when he fell out of the shower chair. Resident 2's medical record was reviewed on 10/25/22. A Care Plan Focus initiated on 4/8/22 documented FALLS [name of resident 2 removed] is at risk for falls r/t [related to] postpolio syndrome, long term use of opioid medications, fall hx [history]. Interventions included, but not limited to, Staff educated regarding shower chairs and safe transfers. Initiated on 2/2/22. On 2/4/22 at 4:25 PM, a Fall incident report documented Nursing Description: Aide [CNA] had just finished showering resident and was trying to wheel him back towards his bed in the shower chair when it tipped over. That specific shower chair needs to be pulled backwards instead of pushed forward so it doesn't tip, aide said she forgot about that. Resident Description: Resident stated that he didn't his [sic] his head when he fell, just landed on shoulder. Injuries Observed at Time of Incident bruise, right inner ankle, bruise, right outer ankle. Level of pain 4/10. On 2/5/22 at 4:58 PM, a Nursing Progress Note documented Resident c/o [complains of] pain continuing in right foot. Area that is bruised has increased from 1x1 cm [centimeter] in two spots to three 3x3 cm spots on foot. Swelling has also increased. Notified on-call doctor and received order for ankle and foot x-ray to rule out fracture. [Name of x-ray company removed] x-ray tech [technician] arrived at 1700 [5:00 PM] and is getting x-ray. Will update physician and PCC [Point Click Care] with results. Resident is his own responsible party. On 2/5/22 at 5:05 PM, a Lab/XRAY documented Type of Lab/XRAY Completed: 3-view ankle and 3-view foot Abnormal Results?: Fx [Fracture] of tibia and fibula New Orders or Redraws?: Order for rigid walking boot to keep foot in correct position. Order to set up ortho [orthopedic] consult next week. Changing oxycodone 10 mg [milligrams] from tid [three times daily] to q6h [every 6 hours], adding new order for ibuprofen 800 mg q8h [every 8 hours] PRN [as needed] x 14 days for breakthrough pain. On 2/5/22 at 8:07 PM, a Nursing Progress Note documented Received order from [Name of physician removed] to send resident to ER [Emergency Room] to assess fx. [Name of Ambulance company removed] EMTs [Emergency Medical Technicians] picked him up at 1800 [6:00 PM]. They weren't sure which hospital would take him but said that it would probably either be [name of hospital removed] or [name of hospital removed]. Administered scheduled oxycodone and methadone to resident before he left in an attempt to manage pain before leaving. On 2/5/22 at 9:13 PM, a Lab/XRAY documented Type of Lab/XRAY Completed: Right ankle and right foot 3-view x-ray Abnormal Results?: Right ankle: There are acute osteoporotic fractures involving distal tibial metaphysis and distal fibular metastasis without significant displacement. Ankle joint is still maintained. There is significant soft tissue swelling. IMPRESSION: Acute distal tibia and fibula fractures. New Orders or Redraws?: Sent to ER to have fx assessed and fitted with boot. On 2/6/22 at 12:29 AM, a Nursing Progress Note documented Resident was brought from the [name of hospital removed] at 23.30 [11:30 PM] pm by [name of Ambulance company removed] [NAME] [sic] having Diagnosed Closed rt [right] ankle fracture & F/U [follow up] orthopedic Surgeon. Resident is alert & oriented, asked for HS [at bedtime] meds [medications] & went to sleep v/s [vital signs] BP [blood pressure] 116/55, pulse 87, Resp [respirations] 18, Temp [temperature] 98.6 & O2 [oxygen] sat [saturations] 93 . Will cont [continue] to monitor. On 2/7/22 at 5:23 PM, a Skilled Progress Note documented Alert and oriented. Uses electric w/c [wheelchiar] for mobility. Feeds himself. Verbalizes needs. Currently NWB [non-weight bearing] to his right leg d/t [due to] closed ankle fx. To f/u with orthopedic. Not yet scheduled. Resp even and unlabored. On 2/8/22 at 5:01 PM, a Skilled Progress Note documented Resident is alert and oriented x 3-4 [oriented to person, place, time, and situation]. resident co [complains] generalized increased pain andesp [sic] d/t right ankle fx. Resident has breakdown on his gluteal area. Right ankle splinted. Resident is able to make needs known. Resident oob [out of bed] in electric chair this morning. New orders for scheduled tylenol 650 mg q 6 hrs. On 2/9/22 at 11:13 AM, a Skilled Progress Note documented Resident is alert and oriented x4. Resident c/o generalized increased pain d/t right ankle fx. Resident has breakdown on his gluteal area. Right ankle splinted. Resident is able to make needs known. F/u ortho appt [appointment] scheduled today at 1300 [1:00 PM]. New orders for scheduled Tylenol 650 mg q6h. Resident stable today. Will update with any new orders from appt. On 2/9/22 at 8:24 PM, a Nursing Progress Note documented [Name of physician removed] ordered to increase Oxycodone to q4h [every 4 hours] prn x 10 days then back to original order. On 2/10/22 at 12:54 PM, a Skilled Progress Note documented [Name of resident 2 removed] is AXOx4 [alert and oriented to person, place, time, and situation]. He is able to make his wants and needs known. He has been pleasant and cooperative with all aspects of care. He continues to c/o generalized increased pain d/t right ankle fx. Continues to have breakdown on his gluteal area with treatments being followed per MD [Medical Director] order. Right ankle is casted. A care plan intervention initiated on 2/18/22, documented CNAs educated on transfers and proper use of shower chair. [Note: No new interventions were implemented. The same intervention was initiated on 2/2/22, Staff educated regarding shower chairs and safe transfers.] On 3/9/22 at 12:01 PM, a COMMUNICATION - with Physician documented Situation: Ortho follow-up appt with [name of physician removed] at [name of hospital removed] Background: Orders to continue vitamin D3, continue cast x 4 weeks, follow-up appt in 4 weeks (left copy of order for appt coordinator), continue NWB. Notified house physician, no other orders. Resident stable. On 10/25/22 at 1:11 PM, an interview was conducted with Restorative Nurse Assistant (RNA) 1. RNA 1 stated when she showered a resident she would ask the resident if it was there shower day, if the resident would like a shower, and what clothes would the resident like to pick out. RNA 1 stated if the resident could walk or use a walker RNA 1 would assist the resident to walk to the shower room. RNA 1 stated if the resident used a wheelchair RNA 1 would take the resident to the shower room in a wheelchair. RNA 1 stated the shower chair was located in the shower room. RNA 1 stated she would use the shower chair to move the resident if the resident required the hoyer lift to transfer. RNA 1 stated that she would transfer the resident from the bed with the hoyer lift to the shower chair with two CNAs. RNA 1 stated that she pushed the shower chair forward with the resident facing the direction she was moving. RNA 1 stated that she had never had a shower chair tip over. RNA 1 stated that resident 2 should be transferred with the hoyer lift but resident 2 did not like the hoyer lift. RNA 1 stated that two CNAs' would transfer resident 2 to the shower chair by lifting him. RNA 1 stated that resident 2 had an accident in the shower chair one time. RNA 1 stated that she heard that the CNA had pushed the shower chair with resident 2 in the shower chair and RNA 1 thought the wheel was not working very well and the CNA pushed the shower chair harder and the wheel got stuck. RNA 1 stated that the CNA that was pushing resident 2 did not work at the facility anymore. On 10/25/22 at 2:22 PM, an interview was conducted with CNA 4. CNA 4 stated that she was a shower CNA. CNA 4 stated that she transported the residents to the shower room in the shower chair. CNA 4 stated there were two shower chairs, a small shower chair and a big shower chair. CNA 4 stated that she had no issues with the shower chairs. CNA 4 stated that resident 2 used the small shower chair. CNA 4 stated that resident 2 required a two person transfer to the shower chair and CNA 4 would put a towel under his legs. CNA 4 stated that resident 2 did not have any accidents with her. CNA 4 stated that resident 2 told her that he had an accident when the CNA transferred the resident from his motorized wheelchair to the bed. CNA 4 stated that resident 2 required two persons for a transfer. On 10/26/22 at 10:52 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated the CNA was helping resident 2 and the shower chair only worked if pushed backwards. RN 2 stated that the CNA was pushing resident 2 forward in the shower chair and resident 2's foot got stuck somehow and the shower chair may have tipped. RN 2 stated that the CNA forgot that she needed to push the shower chair backwards. RN 2 stated that she had understood that if resident 2's feet were not stuck under the chair it would not have been an issue. RN 2 stated that the weight of resident 2 falling caused the break. RN 2 stated that she helped resident 2 back to bed and resident 2 had no pain until the next day and his ankle swelled more. RN 2 stated that was the first time she had heard of the shower chair having problems. RN 2 stated that she had not seen that shower chair in the facility since the incident. RN 2 stated that the CNA involved in the accident stopped working at the facility a few months ago. On 10/26/22 at 1:26 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident had a fall the nursing staff would do an assessment of the resident if the resident was on the floor. The DON stated if the resident hit their head the staff would start neurological checks for 72 hours after the fall. The DON stated that staff were to Notify the MD, family, and case manager. The DON stated after everything was completed the staff were to watch the resident. The DON stated if the resident had an injury the staff were to get clarification from the MD. The DON stated if the resident had broken bones the staff were to get an x-ray or send the resident to the hospital with guidance from the MD. The DON stated that the staff were to do as much diagnostics in house as they could. The DON stated the facility had a funky shower chair that was a newer shower chair and resident 2 was getting a shower from one of his favorite CNAs. The DON stated that the shower chair was designed to be pulled backwards. The DON stated that the CNA was pushing resident 2 forward in the shower chair at resident 2's request and the shower chair abruptly stopped and resident 2 fell out of the shower chair. The DON stated that resident 2 had no bruising at the time of fall. The DON stated that the MD was notified and resident 2 was his own representative. The DON stated that the next day bruising was noticed on resident 2 and a X-ray was obtained. The DON stated that resident 2 had lack of feeling in his lower extremities. The DON stated the shower chair and all similar shower chairs were thrown out and new shower chairs were purchased. The DON stated that the CNAs and nurses had to pass competencies with the new shower chairs. The DON stated the incident was a singular incident and interventions were implemented immediately. 2. Resident 35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, depression, restless leg syndrome, type 2 diabetes mellitus with diabetic chronic kidney disease and diabetic neuropathy, severe protein-calorie malnutrition, opioid dependence, essential hypertension, pulmonary hypertension, chronic atrial fibrillation, chronic diastolic congestive heart failure, peripheral vascular disease, chronic obstructive pulmonary disease, stage 3 chronic kidney disease, and repeated falls. On 10/24/22 at 11:05 AM, an interview was conducted with resident 35. Resident 35 stated she had a fall three to four weeks ago. Resident 35 stated the bed pushed her out and it flipped over. Resident 35 stated that she had a new bed now. Resident 35 stated that she had cut her knee when she fell and had to have 15 stitches in her right knee. Resident 35 stated that her knee was healing very well, and staff were quick to help when she fell. Resident 35's medical record was reviewed on 10/27/22. On 9/7/21, an Alert Charting documented that resident 35 was a High Risk for falls. On 11/19/21 at 4:09 PM, a Fall incident report documented an Incident Description Nurses were called over radio to assist a patient at the front entrance parking lot. Pt [Patient] was found supin [sic] on parking lot floor next to open car door. Patient was A&Ox3 [alert and oriented to person, place, and time], Asked if pt was in pain and pt responded no. Assessed for any lacerations, bruises, bumps or any bleeding and all negative. PERRLA [pupil, equal, round, reactive to light and accommodation] intact. Denied any headaches, neck pain, or lingering pain. Resident Description Pt stated she just fell. Husband [name removed] stated he thought he had her and was not able to tolerate all the weight. Immediate Action Taken Patient was pulled up and transferred to wheel chair with the help of another nurse and therapy director. Pt was brought back into bldg. [building] and assessed for 30 mins [minutes] Vital signs WNL [within normal limits]. Asked by DON if she felt comfortable of [sic] going home and if she was going to have some help getting [sic] out of the care. Pt stated she would ask neighbors for help with trasnferring [sic] out of car when arriving at home. No injuries observed at time of incident. On 11/19/21, an Alert Charting was Incomplete and a fall risk score was not documented. On 11/19/21 at 5:16 PM, a Skilled Progress Note documented Resident is alert and oriented x3 with some forgetfulness. Resident is pleasant and cooperative. PRN Medications given whole with water, no issue noted. Resident uses call light to use toilet instead of brief. Pt happy to go home today. On 11/20/21 at 5:18 PM, a Skilled Progress Note documented Resident is alert and oriented x3 with some forgetfulness. Generalized weakness. Resident is pleasant and cooperative. PRN Medications given whole with water, no issue noted. Resident uses call light to use toilet instead of brief. Pt re-admitted today around 1800. On 11/23/21, an Alert Charting was Incomplete and a fall risk score was not documented. A care plan Focus initiated on 11/28/21, documented RESOLVED: ACTUAL FALL The resident has an actual [fall] on 11/19/21. The Goal initiated on 11/22/21, documented RESOLVED: The infection will resolve without complication by the next review. The Interventions initiated included the following: a. RESOLVED: Call light within reach.Date initiated 11/23/21 and date resolved 1/4/22. b. RESOLVED: Educate family, significant other, & visitors of importance of quarantine/transmission based precautions in room on admission & for out of facility absences, LOA [leave of absence], appointments, etc. per facility policy. Date initiated 11/22/21 and date resolved 1/4/22. c. RESOLVED: PT [physical therapy]/OT [occupational therapy] to treat as ordered. Date initiated 11/23/21 and date resolved 1/4/22. On 12/15/21, an Alert Charting documented that resident 35 was a High Risk for falls. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 35 had a Brief Interview for Mental Status (BIMS) score of 14. A BIMS score of 13 to 15 indicated the resident was cognitively intact. In addition, resident 35 required extensive assistance of one person for transfers, locomotion on and off unit, dressing, toilet use, and personal hygiene. On 2/2/22 at 9:10 PM, a Fall incident report documented an Incident Description Aides called me into resident's room and stated that they found her on the ground. Aides had been rounding on all residents regularly all evening and her door was open. They had changed her brief 1-2 hours before her fall. Resident Description Resident stated that she had to go to the bathroom and got out of bed by herself. She made it to the wall by her bed by herself and lost her balance and fell to the floor. She fell onto her right hand and back but stated that she lifted her head up so she wouldn't hit it. She stated that she forgot that she should have used her call light. An order was received from physician to send resident to emergency room for x-ray. No signs or symptoms of injury but acute pain from right shoulder all the way down the arm. [Note: Resident 35 did not have a care plan in place to prevent falls. The previous care plan was resolved on 1/4/22.] On 2/2/22, an Alert Charting documented that resident 35 was a High Risk for falls. On 2/2/22 at 11:22 PM, a Diagnostic Radiology report from the Medical Center documented that an x-ray of the right shoulder with three views was obtained. Resident 35 had a mildly displaced and angulated fracture at the surgical neck of the humerus. On 2/3/22 at 1:38 PM, a Nursing Progress Note documented Resident was seen at [name of Medical Center removed] after an unwitnessed fall. Discharge Dx [diagnoses]: Fall, right Shoulder fracture and UTI [urinary tract infection] symptoms. Follow up appt to be made with [name of physician removed]. Order state to leave shoulder immobilizer or sling in place (adjust so that hand is level with elbow). Apply ice pack to sight for 20 min [minutes] q [every] 1-2 hrs [hours] day one then 3-4 times a day for 2-3 days then as needed. Sling is to remain in place until appt. New order for Norco 5/325 for prn pain po [by mouth] q4h prn x 2 days. On 2/15/22 at 5:24 PM, a Nursing Progress Note documented Resident returned from [Name of Orthopedic physician removed] F/U for shoulder fracture. Orders are for PT to RUE [right upper extremity], hand/wrist and elbow - ROM [range of motion] as tolerated. Forward hang of right shoulder. Follow up in 3 weeks. On 2/17/22 at 10:37 AM, an Orders-Administration Note documented Hand/Wrist and Elbow: ROM as tolerated. Passive only flexion to right shoulder. Every shift Notified Therapy to see if they will follow up. [Note: There were no therapy notes located within resident 35's medical record for the timeframe indicated.] On 3/11/22 at 2:44 PM, a Nursing Progress Note documented Resident returned from appt with new orders: Wean out of sling. Okay to progress range of motion and strengthening at the shoulder but limit to less than 5 lbs [pounds]. Return in 6 weeks with repeat XR [xray]. Resident is own rp [representative] and aware. On 3/31/22, an Alert Charting was Incomplete and a fall risk score was not documented. On 4/16/22 at 12:54 PM, a Lab/XRAY documented a 2-view right shoulder x-ray for follow up orthopedic appointment. Impression documented a surgical neck fracture with impaction present of the right shoulder. Resident stable. On 6/14/22, an Alert Charting was In Progress and a fall risk score was not documented. A quarterly MDS assessment dated [DATE], documented that resident 35 had a BIMS score of 99. A BIMS score of 99 indicated the resident was unable to complete the interview. In addition, resident 35 required extensive assistance of one person for transfers, walk in room, locomotion on and off unit, dressing, toilet use, and personal hygiene. On 8/2/22 at 4:19 AM, a Nursing Progress Note documented Resident had a unwitnessed fall off the bed. Resident found sitting on the floor leaning against the side of the bed. She states she had a dream and rolled off the bed, right knee scraping the side of the bed and having a laceration up to her bone. Left hand also got a small laceration. Resident fully conscious, states that did not hit her head. Vitals stable. Resident helped back into bed with keeping leg stable. Leg raised on pillows and iced. Called 911 and resident is taken to the hospital. On 8/2/22 at 4:54 AM, a Fall incident report documented an Incident Description Resident found sitting on floor leaning against the left hand side of the bed yelling for help. Resident visibly has a big deep laceration on right knee the size of the the [sic] length of the knee and a smaller one on left hand the size of 1 inch x 1 inch. Resident is conscious and responsive and does not appear to have hit her head. Resident Description Resident states she had a bad dream and rolled off the left side of the bed. She states she did not hit her head, does not feel any dizziness or feel any discomfort or pain in chest. On 8/2/22, an Alert Charting documented that resident 35 was a High Risk for falls. On 8/2/22 at 10:39 AM, a Nursing Progress Note documented Resident returned from hospital. With her knee laceration sutured. Left forearm laceration bandaged. She was also treated for atrial fibrillation and given a dose of metoprolol IV [intravenous]. House NP [Nurse Practitioner] and notified. On 8/2/22, the Medical Center Discharge Handout documented that resident 35 had a fall from bed, knee laceration, and rapid atrial fibrillation. Resident 35's right knee required 15 sutures. On 8/2/22 at 10:45 AM, a Nursing Progress Note documented Resident also stated that her righ [sic] knee hit the bottom of the sink cabinet when she fell. That's where she believes she cut her knee open. On 8/26/22, an Alert Charting documented that resident 35 was a Low Risk for falls. A care plan Focus initiated on 8/26/22, documented [Name of resident 35 removed] is high risk for falls r/t generalized weakness, repeated falls in facility, confusion/poor safety awareness. The Goal initiated on 8/26/22, documented [Name of resident 35 removed] will not sustain serious injury through the review date. The Interventions initiated included the following: a. RESOLVED: Anticipate and meet the resident's needs. Encourage to wait for assistance. Date initiated 11/23/21 and date resolved. 11/28/21. b. Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Date initiated 11/22/21. c. Call don't fall sign added to room. Date initiated 2/18/22. d. Continually educate the resident regarding safety issues. Date initiated 11/23/21. e. RESOLVED: Educate family, significant other, & visitors of importance of quarantine/transmission based precautions in room on admission & for out of facility absences, LOA, appointments, etc. per facility policy. Date initiated 1/4/22 and date resolved 4/17/22. f. Encourage Resident to wait for assistance. Date initiated 10/25/22. g. Encourage to wear well-fitting, non-skid footwear when transferring/ambulating. Date initiated 2/18/22. h. Ensure proper body positioning. Date initiated 10/25/22. i. Keep room free of clutter and ensure objects the resident may need are within reach. Date initiated 10/25/22. j. Make sure eyeglasses are clean & properly fitting. Date initiated 11/23/21. k. Monitor for signs and symptoms of discomfort, i.e., pain, anxiety, thirst or hunger and the need to toilet. Date initiated 10/25/22. l. Pt/ot evaluate and treat as ordered or PRN. Date initiated 1/4/22. m. RESOLVED: UA [urinalysis] to be done. 2/4/22. Date initiated 8/26/22 and date resolved 10/25/22. n. Visual Cue to use call light (Call don't fall). Date initiated 2/4/22. [Note: The care plan was initiated on 8/26/22, after resident 35 had a fall that resulted in a right shoulder fracture and a fall that resulted in a laceration of the knee to the bone that required sutures.] On 10/25/22 at 11:20 AM, an interview was conducted with CNA 1. CNA 1 stated if a resident was found on the floor, she would use the radio to call for help, tell the nurse, ask the resident if he or she was okay, ask what happened, stay with the resident and assist the nurse, and explain what happened. CNA 1 stated the fall prevention measures for resident 35 included to put bed in low position, check on resident frequently, put table close so resident 35 could reach water and personal items, and make sure the call light was within reach. On 10/25/22 at 12:12 PM, an interview was conducted with CNA 2. CNA 2 stated that resident 35 had not had any recent falls. CNA 2 stated interventions used to prevent falls were to put bed in low position and answer call lights quickly. On 10/25/22 at 2:42 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 35 had not had any recent falls. On 10/26/22 at 1:25 PM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that resident 35 had not had any recent falls. The CNA Coordinator stated interventions in place to prevent falls were to keep resident 35's door open, help resident 35 to the bathroom or change her in bed, round every two hours or more frequently, put personal items and call light close to resident 35, put bed in lowest position, make sure resident 35 wore shoes or grippy socks with transfers. On 10/26/22 at 2:20 PM, an observed was conducted of resident 35 in bed watching TV, the door was open, bed in lowest position, call light in reach, and a Call, don't fall sign was observed on the bathroom door. On 10/27/22 at 1:20 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 35 had not had any recent fall. CNA 3 stated that she ensured that resident 35's bed was down, the call light was answered, the door was kept open, and CNA 3 would check resident 35 every time she went by the room. CNA 3 stated that resident 35 stayed in the bed most of the time. On 10/27/22 at 2:13 PM, an interview was conducted with the DON. The DON stated pre-fall interventions included call don't fall signs posted in the resident room, education and talking to the resident, and reminding the resident to use the call light. The DON stated an initial fall assessment would be completed and frequent rounding was done. The DON stated that after a fall the resident was assessed for injuries. If the resident hit their head the staff would initiate neurological checks. If the fall was unwitnessed and the resident was not able to state what happened, the nurse would assess and initiate neurological checks. The DON stated the nurses would notify the MD and family after the assessment and ensure the resident was safe. The DON stated the staff were to send the resident to the hospital or conduct diagnostics if needed. The DON stated that staff were to treat the resident as ordered. The DON stated that the care plan should be updated after each fall or injury. The DON stated the care plan to [NAME] or point of care should be updated for the CNAs and nurses would have access to the care plan. The DON stated she would expect to see new interventions identified after each fall. The DON stated that resident 35's fall on 11/19/21, happened at resident 35's house. The DON stated that she did not know the full details, resident 35 was discharged from the facility at the time and came back the same day. The DON stated that resident 35 had no injuries identified after the fall. The DON stated that resident 35's husband stated that resident 35 fell. The DON stated that upon readmission resident 35 had no injuries noted. The DON stated the fall resident 35 had on 2/2/22, was an unwitnessed fall and resident 35 was on her way to the bathroom. The DON stated that resident 35 should have used the call light and she did not. The resident was A&Ox3. The interventions were to use call light, and to send resident 35 for an x-ray due to her complaints of shoulder pain. The DON stated that the intervention was to use the call light as resident 35 stated she had not done. The DON stated that the fall on 8/2/22, the resident reported she had a bad dream and fell out of bed. The DON stated that resident 35 refused to have the bed in a low position. It should be noted that no documentation could be found for the refusal of this intervention. The DON stated that resident 35 had fall mats in place prior to the fall and they helped to break the fall. The DON stated the laceration was because resident 35 twisted and fell and she caught her knee under the sink. The DON stated that they placed foam on the area under the sink where she lacerated her leg after the fall occurred. The DON stated that the bed was placed next to the sink. The DON stated that she asked resident 35 if they could move her bed and the resident said no. The DON stated they did not identify this as an intervention and they did not document it anywhere.