**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, clinical record, and facility documentation, the facility staff failed to provide treatment and services to prevent a worsening stage three pressure ulcer for one of 12 residents, resulting in harm for Resident #8 (R8), and failed to assess and implement treatment timely for a stage three pressure ulcer for one of 12 residents in the survey sample, Resident #5 (R5). 1. R8 did not have an accurate skin assessment, resulting in a delay in treatment of a worsening stage three pressure ulcer/wound. 2. R5 had a delay in treatment of a stage three pressure ulcer/wound. The findings included: According to the clinical record, R8 was admitted to the facility with diagnoses that included, but not limited to hemiplegia, cerebral vascular accident, muscle weakness and aphasia. R8 had a 5 day minimum data set (MDS - assessment tool) dated 7/25/23 noted that the BIMS (Brief Interview of Mental Status) was unable to be obtained. The MDS coded R8 as requiring extensive assistance on staff for Activities of Daily Living care. Section M Skin Conditions of the MDS documented that R8 had a stage three pressure wound that was present upon admission. R8's clinical record included a skin observation tool dated 7/20/23 that indicated the coccyx had reddness and another one dated 7/27/23 that indicated the coccyx had a pressure area, but did not document the stage of the pressure wound. R8's admission assessment note, dated 7/19/23, documented that no wound was present, while a skilled note, dated 7/19/23, documented that R8 had a stage 3 pressure wound on the coccyx area. Another skilled note, dated 7/20/23, documented that no wound was present. However, none of the nurses notes included any description of the wound. R8's clinical record documented no notifications to the physician/provider about the pressure wound and listed no treatment orders for the pressure wound since admission to the facility on 7/19/23. Review of the wound consultant report, dated 7/24/23, documented a Stage 3 coccyx pressure wound was present on admission, with measurments of 1.0 cm x 1.0 cm x 0.2 cm depth (length by width by depth in centimeters). The note documented the coccyx wound had moderate amount of bloody drainage, no odor, and had reddened, fragile wound perimeters. A physician's order was entered on 7/26/23, upon recommendation from the wound consultant for treatment of the pressure wound to the coccyx. R8's treatment administration record (TAR) documented that the treatments were implemented on 7/27/23 as ordered. On 8/1/23, a comprehensive assessment, with a recommended change in treatment, was completed by the wound consultant. The assessment documented that the coccyx wound measured 3.5 cm x 2.0 cm x 2.0 cm, had moderate amount of bloody drainage, had reddened, fragile wound perimeters, and had a wound status that was noted as worsening. The wound consultant recommended cleansing the wound with 0.125% dakins solution, then apply dakins moistened fluffed gauze to wound bed, and cover with bordered foam and zinc barrier cream to reddended area. A physician's order was entered on 8/3/23, per the wound consultant's recommendation for the treatment change. R8's TAR documented that the treatment was implemented on 8/3/23. An interview was conducted with LPN# on 3/5/24 at 9:00 a.m. LPN# verbalized that the process for admission of a resident to the facility would include a head to toe assessment. LPN# verbalized that if a skin impairment was found, the process is to notify the provider, and to implement the orders given by the provider, unless the hospital sent wound treatment orders, which would be implemented. An interview was conducted with the wound consultant nurse practitioner (NP) on 3/5/24 at 12:35 p.m. The NP verbalized that the nurses notes are used for reference on the resident's skin obeservation on admission day. The NP verbalized that if no information is on the nurses notes, then the NP will talk to the resident. The NP verbalized that if the NP has never seen the resident before or anyone from the NP company, then the resident is considered a new patient for the company. An interview was conducted with license practical nurse (LPN#5 ) on 3/5/24 at 3:00 p.m. LPN# 5 verbalized that the process for admission of a resident to the facility would include a head -to-toe assessment. LPN#5 verbalized that if a skin impairment is found, the process is to notify the provider and to implement the orders given by the provider, unless the hospital sent wound orders, which would be implemented. An interview was conducted with a licensed practical nurse ( LPN#4, wound nurse). LPN#4 verbalized that the process for the skin observation tool on admission is that the floor nurse does the initial assessment when the patient comes into the facility and then a second skin assessment is completed after admission. LPN#4 verbalized that if the admission is Monday through Friday that LPN#4 completes the second skin assessment, as the wound consultant comes in twice weekly and completes a skin assessment. LPN#4 reviewed R8's clinical record and verbalized that no treatment was started from admission date of 7/19/23 until 7/27/23, adding that the nurses should have implemented skin care. When asked to identify the initial findings, the LPN#4 verbalized that there was some discrepancy from what the admitting nurse noted on admission skin assessment and what the wound nurse noted on their first skin assessment after admission. A review of the facility documents was conducted on 3/5/24. The facility policy titled, Skin Assessments, read in part, A licensed nurse will ensure that the skin risk assessment is done upon admission, care plan specific interventions will be developed based on skin risk assessment outcomes. The facility policy titled, Pressure Ulcer Monitoring and Documentation, read in part, A licensed nurse will assess patients for the prescence of pressure ulcers/injuries and if a pressure ulcer/injury is present, the nurse will evaluate for complications. Provide pain management prior to treatment of the pressure ulcer. The facility documentation of staff education, with the title of Basic Wound Care for Nurses and Aides, read in part, Documentation for wounds should include wound type, exudate, and the type of dressing that will be used . that all wounds should be correctly assessed and documented weekly in the resident's chart. On 3/5/24 at 5:00 p.m., the director of nursing (DON) verbalized that the process for skin observation on admission is for the nurse to assess, then if something is found the nurse is to notify the physician, to obtain an order, to implement the order, and to notify the wound nurse the following day, so the wound nurse can follow up. The DON stated, Skin assesssments not being conducted has been a pattern that has been identified. The DON verbalized that the same wound nurse makes rounds with the NP weekly for consistancy and that education is being provided to the nursing staff. The DON verbalized that wound orders should be implemented by the nurse that is making rounds with the NP and the orders should be entered while doing the rounds. These findings were reviewed with the director of nursing (DON), Administrator, and the regional clinical nurse during a meeting held on 3/5/24 at 5:00 p.m. On 3/6/24 at 2:08 p.m., the Administrator verbalized that with R8's medical conditions, that even though no treatment had been started, I don't know if there would have been a different outcome for this residen.t On 3/6/24 at 2:30 p.m., these findings were reviewed with the DON, Administrator, and regional clinical nurse and no other information was provided prior to exit conference. 2. R5 did not have a comprehensive assessment completed for 3 days after a pressure ulcer was identified. A treatment order was not implemented for R5's pressure ulcer until eleven days after the ulcer was identified. According to the clinical record, R5 was re-admitted to the facility on [DATE], with diagnoses that included, but not limited to, adult failure to thrive, pressure ulcer to sacal region Stage 3, hypertension, and anemia. A discharge return anticipated MDS (Minimum Data Set - assessment tool), dated 1/29/24, assessed R5 with no cognitive impairments. The Section M (Skin Conditions) documented R5 had a stage three pressure ulcer upon discharge to the hospital. Documentation indicated R5 returned to the facility on 2/3/23 with pressure ulcer. R5's nursing notes were reviewed from 2/4/24 through 2/7/24 and no documentation for the pressure wound was noted. R5's clinical record included a hospital record dated 1/31/24 that documented the Stage 3 pressure injury. On 2/3/24, the admission skin assessment documented that R5 had a stage 1 pressure ulcer on the sacral area. On 2/6/24, the wound consultant documented a Stage 3 to coccyx, with measurements of 0.3 cm x 0.2 cm x 0.6 cm prior to debridement (cutting away of dead tissue) and 0.4 cm x 0.2 cm x 0.2 cm depth post debridement. It was also noted that the wound perimeters were fragile, with a moderate amount of bloody drainage, for which treatment was recommmended. The NP assessed R5 on 2/13/24 for wound debridment without a change in the treatment. The NP followed up with R5 on 2/20/24 and 2/27/24 and documented the wound was improving. On 3/5/24, the NP documented that the occyx wound had resolved. Review of R5's TAR indicated treatments were started on 7/27/23 and were being carried out. Interview was conducted with LPN#4 (wound nurse) on 3/5/24 at 3:20 p.m. LPN#4 verbalized that there is a break in communication with the nurses about staging the wounds. LPN#4 reviewed R5's clinical recorded and verbalized that the treatment ordered was not updated until 2/14/24 by LPN#4 and that the wound should have been treated sooner. Interview was conducted with LPN#6 on 3/5/24 at 3:51 p.m. A review was done with LPN#6 to explain the skin assessment part of the admission note. LPN#6 verbalized that the hospital had documented the wound as a stage 3 in their report. LPN#6 verbalized that a skin assessment was completed, the dressing covering the coccyx wound was removed, and a skin observation was made, but that the wound . had appeared to be a stage 1 to me, not a stage 3 wound. A review of the facility documents was conducted on 3/5/24. The facility policy titled, Skin Assessments, read in part, A licensed nurse will ensure that the skin risk assessment is done upon admission, care plan specific interventions will be developed based on skin risk assessment outcomes. The facility policy titled, Pressure Ulcer Monitoring and Documentation, read in part, A licensed nurse will assess patients for the prescence of pressure ulcers/injuries and if a pressure ulcer/injury is present, the nurse will evaluate for complications. Provide pain management prior to treatment of the pressure ulcer. The facility documentation of staff education, with the title of Basic Wound Care for Nurses and Aides, read in part, Documentation for wounds should include wound type, exudate, and the type of dressing that will be used . that all wounds should be correctly assessed and documented weekly in the resident's chart. On 3/5/24 at 5:00 p.m., the director of nursing (DON) verbalized that the process for skin observation on admission is for the nurse to assess, then if something is found, the nurse is to notify the physician to obtain an order, to implement the order, and to notify the wound nurse the following day, so the wound nurse can follow up. The DON stated, Skin assesssments not being conducted has been a pattern that has been identified. The DON verbalized that the same wound nurse makes rounds with the NP weekly for consistancy and that education is being provided to the nursing staff. The DON verbalized that wound orders should be implemented by the nurse that is making rounds with the NP and the orders should be entered while doing the rounds. On 3/6/24 at 2:30 these findings were reviewed with the DON, Administrator, and regional clinical nurse and no further information was provided prior to exit conference

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #71 was admitted to the facility with the following diagnoses, including but not limited to: Left femur fracture, dementia, protein-calorie malnutrition, and hypertension. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 08/04/2022 assessed Resident #71 as having problems with both long and short term memory, as well as severely impaired with daily decision making skills. On 09/06/2022 at approximately 12:30 p.m., the lunch time meal was observed, Resident #71 was sitting up in her wheelchair, her lunch tray was on a table in front of her. She was attempting to feed herself. Her napkin was crumpled in the middle of her plate, her cold drink was spilled onto the tray, the plate, the table, her clothes, and the floor. She was asked if she needed any help. She stated, I spilled it. A nurse in the hallway was asked to come to the room. She spoke with Resident #71 and went to get her another tray and drink. On 09/07/2022 at approximately 8:30 a.m., Resident #71 was observed sitting in her bed. Her breakfast was on the bedside table in front of her. The front of her gown was wet. She had her coffee cup in her hand and was attempting to get it to her mouth. The coffee spilled down the front of her gown. CNA (certified nursing assistant) #1 was in the adjacent room. She was called to Resident #71's bedside and told about the spilled coffee. She removed the cup from Resident #71's hand. She was asked if the coffee cup was hot to touch, she nodded her head. She was asked if Resident #71 was hurt. She left the room and spoke with RN (registered nurse) #1. RN #1 came to the room. She and CNA #1 removed Resident #71's gown. Her chest was not red and she denied pain. The MDS (ARD 08/04/2022) was reviewed at approximately 8:45 a.m. Under section G, Functional Status, Resident #71 was assessed as a 1/2 for eating, meaning Supervision-oversight, encouragement, or cueing/One person physical assist. The care plan was reviewed. The Focus area ADL (activities of daily living) . contained the following intervention regarding eating: (Resident name) is able to feed herself after set up. she needs encouragement to complete meals. CNA #1 was interviewed at approximately 9:00 a.m. regarding Resident #71. CNA #1 stated that Resident #71's dementia had gotten worse over the last couple of weeks. She stated, She's been spilling more, her hand motions are more jerky. She was asked if the facility had cups with lids. She stated, The lids we have right now don't really fit the cups. She was asked if the facility had cups with spouts to prevent spills She spoke with LPN (licensed practical nurse) #5 who stated, We have those cups, we'll get her one to use (Name of Resident #71) just came out of isolation for COVID, before that she was up and around the unit. She hasn't gotten her strength back .she also needs to be up in the chair when she's eating not sitting up in the bed, that will help .I will update the care plan. During the lunchtime meal on 09/07/2022 Resident #71 was observed with a plastic cup, with handles on each side, and a spout on the lid. There were no spills observed. The above information was discussed during an end of the day meeting on 09/07/2022. The administrative team was asked if there was an assessment done regarding hot liquid safety. The corporate nurse consultant stated, The company has one, but I don't know if it has been implemented here. I will look. On 09/08/2022 a hot liquid assessment for Resident #71 was presented. It was dated 06/14/2022. The resident was not assessed as being at risk for drinking hot liquids. The corporate nurse consultant was asked if there was a policy on when the hot liquid assessment should be done. During a meeting on 09/08/2022 at approximately 10:30 a.m., the corporate nurse consultant stated that there was no policy regarding the hot liquid assessment, but it should be done quarterly, annually, and if there was a change. No further information was obtained prior to the exit conference on 09/08/2022. Based on staff interview, clinical record review, facility document review and during the course of a complaint investigation, the facility staff failed to ensure adequate supervision and/or interventions for the prevention of falls for one of 25 residents (Resident #111), which resulted in actual harm and failed to ensure one of 25 residents (Resident #7) was safe when consuming hot liquids. Findings include: 1.) Resident #111's diagnoses included, but were not limited to: ataxia [impaired coordination] following a non-traumatic intracerebral hemorrhage, myelodysplastic syndrome, pancytopenia, headache, anemia, cognitive communication deficit, abnormalities of gait and mobility, lack of coordination, dysphagia, mild protein calorie malnutrition, high blood pressure, atrial fibrillation, vertigo [dizziness/off balance feeling] and fracture of right femur. The most recent full MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 11, indicating moderate impairment in daily decision making skills. The resident was assessed as requiring extensive assistance of two staff for transfers, bed mobility, dressing, eating and toileting. The resident was assessed as requiring total assistance of two staff for bathing. The resident was coded as incontinent of bowel and bladder A complaint investigation was conducted on Resident #111 on 09/06/22 through 09/08/22. An allegation within the complaint alleged that the resident had multiple falls at the facility, with the last fall (on 08/07/22) resulting in Resident #111 sustaining a right fractured hip. Resident #111's clinical records were reviewed and revealed the following: An admission assessment dated [DATE] and timed 2:50 PM documented, .on arrival: cognitively intact .Does the resident exhibit any signs of or complain of .pain? no admission Narrative note: Resident admitted from [name of hospital] following brain bleed and stroke. No surgical intervention pursued. Vitals are stable and c/o of headache persistently. Able to make all needs known. PT and OT will evaluate. History noted for pancytopenia, HTN, afib, CVA. Family in to visit. Monitor closely . Nursing notes were then reviewed and revealed that the resident had a fall on the following days: On 7/12/2022 at 6:27 PM, a skilled nursing note documented, .Nursing Focus: Continues skilled nursing care due to intracerebral hemorrhage. A&O (alert and oriented) x 2. Takes medication whole .2 person assist with ADLs. Incontinent to bowel and bladder No other complaints at this time . On 7/13/2022 at 6:00 PM, a nursing noted documented, .Alert Note .Patient found on the floor at 1500 [3:00 PM], fell from w/c [wheelchair], head was resting under the chair, patient indicated that he did hit head. 911 called . patient transported .Daughter .aware .VS [vital signs] stable post fall. A fall risk assessment dated [DATE] documented that the resident was on an antihypertensive and anti-seizure medication, the resident was chair bound, incontinent and had improper body position. The assessment did not address the areas of unsafe behavior or mobility (those areas were blank). This assessment did not indicate by a score and/or other means that the resident was at risk for fall or was at high risk for falls. A fall investigation dated 07/13/22 and timed 3:00 PM was reviewed and documented that the resident was, on an anti-seizure medication, was not alert and oriented, was confused and disoriented, was restless and was in the resident's room at the time of the fall, did not call for help and that the call light was not in reach and that the resident was not wearing proper shoes and that the resident had cognitive impairment. The fall on 07/13/22 was unwitnessed and occurred in the resident's room. There were no specific details in the investigation regarding the circumstances around the fall and there were no interviews from staff. The resident's CCP (comprehensive care plan) was then reviewed and documented, .ensure the resident wears shoes when ambulating created on: 07/07/2022, place bed in lowest position while resident is in bed created on: 07/07/2022, place common items within reach of the resident created on: 07/07/2022, remind the resident to use their call light to ask for assistance with ADLS created on: 07/07/2022, reorientation to the room to assist the resident to familiarize created on: 07/07/22, therapy referral created on: 07/07/2022 .ACTUAL FALL: [Name of Resident #111] is at risk for injury from fall/falls. Resident had a fall. Created on: 07/14/2022, The resident will resume usual activities without further incident through the review date. Continue interventions on the at-risk plan Created on: 07/14/2022 . On 07/27/22 at 4:50 PM, a skilled nursing note documented, .weakness. He is alert and oriented to self, cognitive status varies .no complaints of pain .Continues to be a two assist for transfers and ADL's . The resident's physician's orders were reviewed. A bed alarm was ordered on 07/27/22. The resident's July 2022 MARs (medication administration records) were reviewed. The MARs documented the bed alarm order on the MAR and it was signed off that this intervention was in place for the resident from 07/27/22 through 07/31/22. The resident's CCP was updated and documented, .bed alarm to bed created on: 07/28/2022 . On 7/30/2022 at 5:48 PM an SBAR [situation-background-assessment-recommendation] Summary note documented, .The Change In Condition/s reported on this Evaluation are/were: Falls .Code Status: DNR .Recommendations: n/a .New Testing Orders .n/a .New Intervention Orders: Other - n/a . On 7/30/2022 at 5:51 PM a progress note documented, .Health Status Note .Resident found sitting beside his bed, range of motion indicates no injury, assisted up off floor by 2 staff. Resident was belligerent when writer explained to him that he should always ring for assistance if he wants to get out of bed or back to bed. Stated I wanted to get up. Wife .informed. MD made aware. The fall on 07/30/22 was an unwitnessed fall. There was no fall investigation and/or fall risk assessment for the fall on 07/30/22. There was no information regarding the bed alarm, if it was in place and/or sounding. On 08/04/2022 at 7:21 PM, a progress note documented, .Fall Note .Skin tear on right shin. No other injuries noted at this time .What interventions were in place at the time of the fall?: Chair alarm, What are the risk factors that could have contributed to the fall?: Confusion and gait imbalance, What new interventions were implemented in response to the fall?: Education regarding call bell usage, Was the Provider/resident and RP notified at the time of the fall?: Yes . A late entry note documented, .Post Fall Documentation Late Entry: Situation: Date and time the fall occurred: 08/04/2022 4:00 PM .Background: Circumstances of the fall: unknown . Assessment (RN)/Appearance (LPN): Current status of the resident's injuries or reports of pain from the fall: no c/o pain .Recommendations: Interventions currently in place to prevent additional falls: Bed alarm and bed in lowest position .Resident's response to new interventions: no response A fall investigation dated 08/04/22 and timed 7:15 PM documented the resident was on an antihypertensive, was not alert and oriented, was confused and disoriented, was restless, the fall was in resident's room, did not call for help, call bell in reach and was wearing appropriate footwear and contributing factors was cognitive impairment. There was no specific information regarding the circumstances of the fall in this investigation or any interviews from staff. There was no information regarding the bed alarm, if it was in place and/or sounding. A fall risk assessment dated [DATE] documented that the resident was on an antihypertensive medication, tried to stand, transfer, or walk alone unsafely, propels or walks alone in unsafe places, uses assistive devices inconsistently, and that the resident was incontinent. The fall risk assessment did not address the resident's gait and balance [that section was blank] and the assessment did not provide a score or a means to quantify the resident's risk for falls. The fall on 08/04/22 was unwitnessed and occurred in the resident's room. A practitioner note dated 8/4/2022 and timed 1:00 AM documented, .Encounter . Date of Service: 08/04/2022 Visit Type: New Evaluation .This patient is a pleasant [AGE] year-old Caucasian male currently in the skilled nursing setting following a recent hospitalization .Nursing staff reports this patient has been having episodes of increased irritability and agitation and poor safety awareness. The patient's PCP recently started this patient on Depakote 125 mg twice daily dosing for improved mood stabilizing properties. The patient is also on Remeron 15 mg nightly for insomnia and depression. The patient appears to be tolerating these medications without any adverse side effects. When the patient is seen today he is noted to be lying down in bed and is in no obvious pain or discomfort. The patient is notably only oriented to person and somewhat to place . This provider assessed the patient's pain on a 0-10 pain scale and the patient reports a pain level of 0 .The patient does report minimal anxiety and depressive symptoms due to being in the skilled nursing setting .Care Plan Recommendations: Continue the medications at current dosages as the patient is stable at this dose and dose reduction would likely cause a deterioration of the patient's psychiatric illnesses/symptoms .Monitor patient for mood changes or behaviors: i.e. agitation/aggressiveness, irritability, sleep disturbances, appetite disturbances, significant change in energy level, paranoia, hallucinations, erratic behaviors, change in LOC, mood lability, anxiety, SI/HI, or potential side effects to current psychiatric medications. If any noted please notify TeamHealth . The resident's CCP was again reviewed. An intervention was added on 08/05/22, .Keep resident in high traffic area for safety Created on: 08/05/22 . On 08/06/2022 at 6:33 PM a skilled note documented, .Observations .BP 133/76 .bowel Status: incontinent .Pain: no .Non Pharmacological interventions provided: [blank] Pharmacological interventions provided: [blank] .Continues skilled nursing care due to intracerebral hemorrhage. A&O x 2 .2 person assist with ADLs .Resident fell this evening. States he slipped out of the bed. No injuries noted. Will continue to monitor for any changes. Vitals are within normal limits. A fall investigation dated 08/06/22 and timed 6:24 PM documented that the resident was on an antihypertensive, was alert and oriented, was not confused/disoriented, was calm, the fall occurred in the resident's room, he did call for help, call light was in reach and was wearing the proper footwear and contributing factors were listed as fatigue/weakness. There was no specific information regarding the circumstances of the fall or any interviews from staff. There was no information regarding the bed alarm, if it was in place and/or sounding. The fall on 08/06/22 was unwitnessed and occurred in the resident's room. On 08/07/22 2:19 PM, a progress note documented, .health Status Note . Resident had a fall after lunch in his room. CNA [certified nursing assistant] found resident at the foot of the bed laying on his left side. Resident states he was trying to get up to go to the bathroom. After examining resident, he presented with right side hip pain that was radiating down his leg. Skin tear was noted to right elbow. Vitals were stable. Resident states he also hit his head. Notified weekend supervisor [also known as LPN #1] and stated nurse was sending him to [name of hospital] ER due to possible fracture. Notified DON. Unable to get MD on the phone. Call and let emergency contact know and they were going to meet resident at the hospital. The fall on 08/07/22 that resulted in the resident sustaining a right hip fracture was unwitnessed and occurred in the resident room. There was no investigation completed on this fall. There was no documentation regarding the resident's bed alarm, whether it was in place and/or functioning. There were no interviews from staff regarding this fall. Resident #111 had the fall with injury on 08/07/22. The resident was sent to the hospital and admitted and returned to the facility on [DATE]. The resident's hospital Discharge summary dated [DATE] documented, .primary discharge diagnosis: Acute intertrochanteric fracture of the proximal RIGHT femur, closed, presumed pathologic due to osteoporosis .confusion, presumed not new since stroke .chronic pancytopenia, likely myelodysplastic syndrome variant .He was admitted on [DATE] after a fall out of bed. He was found to have an acute right hip fracture .hospital list: fall, closed right hip fracture . On 09/07/22 at 3:50 PM, LPN#1 [also known as the weekend supervisor] was interviewed regarding Resident #111's fall on 08/07/22 [Sunday]. LPN #1 stated that she remembered the resident and that he would get up and try to self transfer and fell and broke his hip. The LPN stated he would attempt to self transfer and we (staff) continually reminded him not to get up and to use the call bell. The LPN stated that the resident was confused and that this was an unwitnessed fall. The LPN was asked if an investigation was done on this resident for this fall. The LPN stated, As far as I know we did. The LPN then looked in the resident's record and stated that she did not see an investigation for that fall for Resident #111. No further information was provided by LPN #1. On 09/08/22 at 8:48 AM, RN #3 [also known as the corporate nurse] presented information regarding Resident #111. The RN stated that they had an investigation for the resident's falls for 07/13/22, 08/04/22, and 08/06/22 and also did fall risk assessments [documented above], but they did not have an investigation for the unwitnessed falls on 07/30/22 or on 08/07/22 when the resident sustained a femur fracture. The RN stated that the resident was sent out to the hospital on those days. The fall investigations and fall risk assessments were reviewed and RN #3 was made aware that the fall risk assessment did not score the resident for fall risks. The RN stated that she was aware of that and that they (facility) were working on a scoring system to better assess fall risk residents. The RN was made aware that the fall investigations were vague and did not provide any real details surrounding the resident's falls and did not have any staff interviews and/or statements that may provide additional information surrounding the falls. The RN was made aware of the serious concerns regarding the resident repeat falls and the resident's fall on 08/07/22, which resulted in harm. On 09/08/22 09:06 AM, LPN (Licensed Practical Nurse) #7 was interviewed regarding Resident #111. LPN #7 stated that the resident used to be in room [ROOM NUMBER] and that she normally worked that area and worked with that resident. The LPN stated, Since the resident first came to us, he was ., I wouldn't use the word non-compliant, but he was hard to get to do stuff, he didn't want to eat or drink, he'd raise the bed up and down and he was a big fall risk. We had to keep encouraging him to use the call bell, he would keep attempting to get up. We had an extended bed for him [he was tall] and he had a bed alarm .I think he had a bed alarm, he didn't have a chair alarm. LPN #7 further stated, When he came back from the hospital he was on hospice and they [hospice] ordered fall mats and had them delivered and we put them down, I remember because they were pink. I think he was in the chair some and we'd bring him out in the hall, but that was rare. He was a big sleeper and spent a lot of time in his room and in bed. For the most part while I was here he wanted to stay in the bed and sleep. The day he fell the last time [08/07/22], I did not hear an alarm that day, I'm not sure if it was on or not, but I had heard that in the past and remembered the sound it was really loud and annoying, but I didn't hear it that day. One of the girls working was a TNA (temp nurse aid) she is no longer working here and a CNA I don't recall her name. He (Resident #111) was my patient and I was doing med pass when that happened. Of course, it was an unwitnessed fall and from what I understand the CNA took the [lunch] tray in and left and then went to get his roommates tray and came back and he (Resident #111) was on the floor. He was not a big drinker and didn't eat much and we would have to encourage him. LPN #7 was asked who updates the care plans. The LPN stated that she thought it would be the unit managers or MDS, but she had not done that. The LPN stated that the Unit Manager was LPN #1 when the resident's last fall occurred, I believe it was a Saturday or Sunday and LPN #1 was the supervisor. LPN #7 stated that she went to the resident's room immediately, checked the resident out, checked his vitals, and stated, 'for me to even touch his leg he was screaming in pain.' LPN #7 stated that she went and got LPN #1 and they both went to the resident and both agreed that he needed to be sent out. LPN #7 stated that the resident's wife was there just before the resident fell and stated that his wife did tell the TNA that he had attempted to get up before she left. LPN #7 stated that she did not hear the resident's wife say that, but that is what the TNA told her and reported to her after the fall occurred. LPN #7 stated that 911 was called and when EMS [emergency medical services] got here, he [resident] was in so much pain that they had to medicate him and stated that she believed they gave him IV [intravenous] fentanyl to get him on the gurney because he was in so much pain. LPN #7 stated, He never did use the call bell to my knowledge. The LPN stated that she worked with him frequently and the resident seemed to decline pretty fast and the resident was typically quite most of the time. LPN #7 stated that she did not recall the resident being combative with care or anything like that. LPN #7 stated that was the first time he fell on her shift. LPN #7 stated, I had a feeling that was going to happen with him anyways. The facility's fall policy was presented, Falls Management Program .considers all patients to be at risk for falls and provides and environment as safe as practicable .a fall risk assessment will be completed upon admission, readmission, quarterly, and significant change of condition .incorporate identified interventions into the Comprehensive care plan .discuss risks and interventions .do not move or reposition until a licensed nurse has completed a physical and mental assessment .assess, intervene, and promptly provide the necessary interventions for any patient experiencing a fall .notify physician, responsible party and EMS .post fall include neurological assessment if the fall was unwitnessed .complete post fall assessment to determine, to the extent possible the cause of a patient fall .Investigate the fall, and record findings surrounding the fall .A licensed nurse will review, revise and implement interventions to the care plan based on: post fall assessment findings, review device assessment, review of fall risk assessment .unit manager will review the incident report and any post fall follow up .each fall will be reviewed for causative factors utilizing the post fall assessment, device assessment and incident report .the unit manager verifies care plan revisions, patient monitoring, appropriate referrals . On 09/08/22 at 10:19 AM, the survey team met with the administrator, DON, and corporate nurse. The staff were made aware of serious concerns regarding repeated falls for this resident and specifically the fall 08/07/2, which resulted in fractured hip. The facility staff were made aware of the concerns regarding the lack of supervision and/or interventions for the prevention of falls for this resident, who had been identified as known as being at risk. The facility staff stated that they would look for any additional information. On 09/08/22 at approximately 11:10 AM, the DON, administrator and corporate nurse returned and stated that they had additional information. The DON stated that the discharge summary documented that the resident's fracture was pathological and that it could not be proven that this fall (the fall from the bed on 08/07/22) is what caused the resident's fracture. The DON was made aware that the discharge summary documented, that the resident had an Acute intertrochanteric fracture of the proximal RIGHT femur . presumed pathologic due to osteoporosis. The discharge summary also that the resident had a fall out of bed and was found to have an acute right hip fracture and was then admitted to the hospital. The DON was also made aware according to Resident #111's clinical records, Resident #111 did not have a previous diagnosis of osteoporosis or a current diagnosis of osteoporosis. The facility staff were made aware that through the complaint investigation and interviews, the resident was in severe pain after the fall that resulted in the hip fracture and that, according to interviews the resident was screaming out in pain when the nursing staff attempted to touch and assess the resident's leg. It was also reported that the EMS had to medicate the resident to be able to get the resident on the gurney due to the severity of the pain he was experiencing. The DON, administrator and corporate nurse were also made aware that the resident's care plan was not updated with new fall interventions and/or supervision and that there was no investigation completed by the facility of this unwitnessed fall. The DON stated that they had interventions in place, but they weren't on the resident's care plan and they (staff) discussed the falls in their meetings and presented documentation to the survey team. The information documented, .7/13/22 [name of resident] fall ? head injury resident to ED for evaluation/continue interventions.[no new interventions added] 08/4/22 [name of resident] fall skin tear on right shin area resident will be place in a highly trafficked area when up to assist with fall prevention [this intervention was added to the care plan] .08/06/22 [name of resident] fall none [injury] resident will be monitored for adverse effects of medications to assist with fall prevention [this intervention was added to the care plan on 08/08/22 after the fall with injury] .08/07/22 [name of resident] fall right hip pain resident sent to ER for evaluation . No information was presented for the fall on 07/30/22. The facility staff were made aware that these interventions were the same interventions already in place and that the only new intervention for actual fall prevention was putting the resident in a high traffic area which was implemented on 08/05/22. The facility staff were also made aware that the all of the resident's falls occurred in the resident's room (not in a high traffic area) and all of the resident's falls were in unwitnessed. No further information and/or documentation was presented prior to the exit conference on 09/08/22 at 11:45 AM to evidence that adequate supervision and/or interventions were implemented for Resident #111 for the prevention of falls, which subsequently resulted in injury. Resident #111 had a total of five falls between 07/06/22 and 08/07/22. The resident sustained a right hip fracture as result of the last fall on 08/07/22 (the resident's last fall). This is a complaint deficiency.