**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible. The facility did not implement new interventions and increase supervision when needed to prevent accidents for 2 of 3 residents (R) (R1, R2) reviewed.-R1 is at risk for falls and fell on [DATE], 12/30/24, 01/01/25, 01/09/25, 05/13/25, 06/06/25, 08/04/25, 08/05/25, and the facility did not place new interventions or increase supervision to prevent further fall incidents. On 08/06/25, x-ray results revealed a left humeral head fracture. On 08/08/25, additional x-rays of left knee related to complaints of pain, revealed an acute transverse non-displaced fracture of the mid portion of the left patella. The facility failure to place new interventions and increase supervision for R1 led to harm, when R1 suffered a left humeral head fracture and an acute transverse non-displaced fracture of the mid portion of the left patella. This example is cited at a scope/severity level of G.-R2 was at risk for falls. R2 has had a fall resulting in a fractured right ankle on 6/29/25. On 8/26/25 and 08/27/25, R2 continues to self-transfer without assist increasing risk for a fall. No new interventions were put into place to prevent further fall incidents. The failure of the facility to implement interventions to prevent future fall incidents due to R2 self-transferring will be a deficient practice cited at a scope/level severity of D.Findings include:Facility policy titled, Fall Protocol, dated reviewed in February 2025, states in part:.Definition: A fall refers to unintentionally coming to rest on the ground, floor, or other lower level.An episode where resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall.Procedure: After a fall:-If a resident has fallen or is observed on the floor without a witness to the event, nursing staff will evaluate for possible injuries to the head, neck, spine, and extremities.-Nursing staff will notify the resident's Attending Physician/Nurse Practitioner for injuries or alteration in function. If the residents Attending Physician/Nurse Practitioner is not available, or the fall occurs outside normal business hours the nurse may notify the on-call physician to update him/her about the fall and obtain any necessary orders/treatments. A provider will be notified of the fall and resulting injuries at the time of the fall of significant injuries occur including: any injury to the head or face, open cuts or skin tears, new onset or change in pain, any change in condition or functional ability, or any other injury deemed significant by the nurse on duty or Registered Nurse (RN) on call. If there are no significant injuries or changes in function, the Medical Doctor/Nurse Practitioner (MD/NP) may be notified via fax or on the next business day.-Nursing staff will observe for delayed complications of a fall each shift for approximately seventy-two hours after an observed or suspected fall. Findings will be documented in the resident's medical record.-Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility, changes in level of responsiveness/consciousness and overall function.-An incident report will be completed for all falls whether witnessed or not. Nurse on duty and nurse managers will work collaboratively to make sure all notifications are completed. Nursing management team will ensure completion of the Interdisciplinary Review portion of the incident.Identifying causes of a fall or fall risk:-Within 24 hours of a fall, the nursing staff will begin to identify possible or likely causes of the incident.-Nursing management will review the resident's history of falls for any identifiable patterns.-IDT meets weekly to review falls and discuss patterns or trends.Documentation: When a resident falls, the following information should be recorded in the resident's medical record:-Vital signs-Injuries-Any first aid or treatment rendered.-Notification of physician and family.-Completion of the Incident Report.-New interventions to minimize risk for further falls .Example 1R1 was re-admitted to the facility on [DATE], readmitted on [DATE], with following diagnosis, in part, Parkinson's disease, insomnia, weakness, idiopathic progressive neuropathy, atherosclerotic heart disease, chronic kidney disease stage 3, primary osteoarthritis, gout, dysphagia, dementia, major depression, essential primary hypertension, hypothyroidism, and unsteadiness.R1's Minimum Data Set (MDS) assessment, completed on 06/09/25, confirmed R1 scored 13/15 during a Brief Interview for Mental Status (BIMS), indicating intact cognition. R1 was at risk for falls. R1 requires minimal assistance from staff for toileting, sit to stand, transferring, dressing lower body, and putting on/taking off footwear.R1's MDS dated [DATE] confirmed R1 requires substantial to maximal assistance from staff for toileting, sit to stand, transferring, dressing lower body, and putting on/taking off footwear. R1's Activities of Daily Living (ADL)s care plan states:-TRANSFER: Independent in the facility with Four-wheeled walker (FWW) revised on 09/26/24.-AMBULATION: Independent in facility with FWW revised on 09/26/24.-AMBULATION: Contact Guard Assist (CGA) x1 in facility with FWW revised on 12/30/24.-AMBULATION: CGA x1 with gait belt in facility with FWW revised on 03/27/25. R1's fall care plan states:-Physical Therapy (PT) evaluate and treat as ordered initiated on 08/14/20.-Educate resident about safety reminders. Initiated on 08/15/20.-Encourage resident to seek assist with transfer initiated on 06/29/23.-Ensure call light in reach and encourage resident to use for assistance. Initiated on 05/30/24.-Ensure walker is within reach in recliner. Initiated on 05/30/24.-Dycem cushion in recliner per resident. Initiated on 06/17/24.-Signage in room for assistance with moving items created 09/24/24.-Signage in room to ring for assistance with moving items and to ring for assist prior to transferring. Revised 01/14/25.-Ensure walker is within reach when in recliner and when in wheelchair in room. Initiated on 08/05/25.On 08/29/25 at 10:34 AM, Surveyor reviewed nurse progress notes for R1's falls:Falls on 12/24/24, 12/30/24, 01/01/25, 01/09/25, 05/13/25, 06/06/25, 08/04/25, 08/05/25, 08/20/25, and 08/21/25.On 12/24/24 at 2:53 PM, Note Text: At 1:20pm CNA found res [R1] on her floor and called RN to room. Res [R1] was lying on her back with head up against the armoire. Noted skin tear right hand. Res [R1] stated she did hit her head. Res [R1] denied hurting anywhere else. Res [R1] stated she was in her w/c and had gotten up and was going for her walker and fell. She said it happened fast, but she thinks she landed on her knees then fell over on her side and then rolled on her back. She was assisted to standing with 2 assists, no marks noted on her head, back or shoulders. Skin tear right hand 1.5cm, cleansed with normal normal saline (NS) and flap of skin put in place and steri-strips use for wound closure. Band-Aid on for protection. Blood Pressue (BP):133/75 Pulse (P):79 beats per minute (bpm), Respirations (R):16 per minute Temperature: 97.5, Oxygen (O2) saturation (sat):98% room air. Neurological (Neuro's) assessments within normal limits (WNL), strong equal hand grasp, able to raise arms as previous, as left arm does not go up as high. Able to kick out legs and stood well. Pupils Equal, Round, Reactive to Light (PERRL). After res [R1] had been up in chair for a few minutes, she complained of (c/o) left shoulder pain, then a bit later c/o right knee pain and a little while after that c/o right hip pain. No marks had been found, and range of motion (ROM) remained unchanged. Offered ice packs but she denied these. Then at 2 PM, res [R1] walked with 1 assist and walker out to dining room (DR), followed with wheelchair (w/c) and played bingo.Facility did not implement new interventions for R1 to decrease or prevent R1 from falling.On 12/30/24 at 10:32 AM, Note Text: At 9:45am, CNA called RN to room, res [R1] was found on floor. Res [R1] was lying on her back with walker near her. She was alert and oriented as usual. Stated she was going to the bathroom and just fell down. ROM as previous. Continues with sore right hip but had good ROM. PERRL. Assisted to standing, no redness or marks to head, back or buttocks. Assisted into w/c. Vital Signs Stable (VSS) and neuro's WNL, see sheet. Res [R1] taken to the bathroom then laid down. Nurse Prctitioner (NP) and son notified.Facility did not implement new interventions for R1 to decrease or prevent R1 from falling.On 01/01/25 at 12:55 PM, Note Text: 12:40 PM, res [R1] was lowered to the floor during a staff assisted transfer. res [R1] did not hit her head, c/o rt knee discomfort, already has a bruise there from previous fall. BP 92/46, P 81, R 18, T 97.6, and notifications done.Facility did not implement new interventions for R1 to decrease or prevent R1 from falling.On 01/02/25 Bactrim started after R1 had UTI.On 01/09/25 at 10:57 PM, Note Text: Unwitnessed fall at 7:20 p.m.; [R1] found sitting with back partially against her armoire. Resident [R1] did report she hit her head; no bump or red mark seen. Neuro check started and WNLs; vital signs stable. ROM without difficulty or pain. Assisted into standing position and into wheelchair. Stood on feet without difficulty. Update sent via fax to [name of hospital].Facility did not implement new interventions for R1 to decrease or prevent R1 from falling.On 05/13/25 AT 10:34 AM, Note Text: Res [R1] was lowered to the floor in her room with assist of one when walking with the walker. did not hit head or knees. had fainting spell which lasted a few seconds assisted back into w/c with assist of two. No injuries. B/P 103/63, P 74, R 18. Notifications done.Facility did not implement new interventions for R1 to decrease or prevent R1 from falling.On 06/06/25 at 12:58 PM, Note Text: Resident [R1] in her bathroom with CNA and she needed to be lowered to the floor due to (d/t) weakness. No injury noted at this time. Staff assisted resident [R1] to her bed and is resting. B/P 145/97, P 73, R 18, O2 sats 97% room air.Facility did not implement new interventions for R1 to decrease or prevent R1 from falling.On 06/06/25 at 2:20 PM, Late entry charted on 06/10/25 at 9:21 AM, Late Entry:Note Text: Fax sent to Dr. [name] to notify of resident being lowered to the floor without injury.Facility did not implement new interventions for R1 to decrease or prevent R1 from falling.On 08/04/25 at 9:37 PM, Note Text: Found lying on left side on the floor in her room at 1855. ROM assessed before getting resident [R1] off floor and is within normal limits. Three assist to help her off floor and into wheelchair. She had gotten up to go in her closet, did not ask for assistance. Skin tear noted on left elbow, Mepilex applied. She reports hitting her head and small lump noted, no redness or bruising to area. At first reported back pain, within 15 minutes denied having any pain.Facility did not implement new interventions for R1 to decrease or prevent R1 from falling.On 08/05/25 at 1:35 PM, Note Text: found res [R1] on floor by staff member, states she was reaching for her walker and fell. c/o back pain left shoulder and elbow pain, also knee pain. assisted with gait belt and 3 to standing and into w/c, wants to stay in w/c to go to bingo. VSS. notifications done.Facility did not implement new interventions for R1 to decrease or prevent R1 from falling.On 08/06/25 at 4:01 PM, Note Text: Received call from NP [name] that x-ray results showed a probable non-displaced intra-articular fracture of the radial head to left arm. To set-up an ortho appt for further f/u. R1 and R1's son updated on results and follow-up.Facility did not implement new interventions for R1 to decrease or prevent R1 from falling after injury of radial head of left arm resulted on x-ray. On 08/06/25 at 4:56 PM, Note Text: NP [name] updated on resident c/o knee pain and swelling/bruising noted upon writer looking at knee. New order for x-ray to left knee. Also new order for sling to left arm as tolerated. Discussed new orders with resident [R1].Facility did not implement new interventions for R1 to decrease injury or prevent R1 from falling.On 08/07/25 at 1:10 PM, Late Entry:Note Text: CNA showed RN light bruising to the back of resident's [R1] head which resident reports is from recent fall with hitting head. Will monitor until resolved.On 08/08/25 at 12:20 PM, NP notified facility of left knee x-ray results. X-rays reveal an acute transverse non-displaced fracture of the mid portion of the left patella.On 08/29/25 at 9:41 AM, Surveyor interviewed R1's Family Member (FM) C and asked FM C to describe what FM C knows about R1's falls. FM C stated the facility should be doing more for R1's confusion. FM C stated it's getting to be an everyday occurrence. FM C stated R1 would be walking with staff and get these dizziness and blackout spells and fall. Staff would have to catch her. FM C said R1 had a fall on 08/04/25 in the evening and the facility called her and said that R1 had fallen but no concerns at this time other than a little scrape on the elbow. FM C stated that on the next day, they called again and her that R1 fell on [DATE] in the daytime. Then a couple days after that R1 fell again. FM C stated the facility has done nothing to prevent R1 from falling. FM C stated it wasn't until 7 or 8 days later that R1 had staples placed in the elbow. FM C stated that while R1 was seeing the doctor he refused to look at the x-rays for R1's knee because the nursing home did not let the doctor know of the knee issue. So, then it was a separate visit days later that the review of knee x-rays took place to see that R1 had broken her left leg from one of the falls. Surveyor asked FM C if there were any interventions put into place to prevent R1 from falling. FM C reported to Surveyor that FM C did not feel facility did anything to manage R1 from falling. FM C reported to Surveyor that R1 was up walking around and now is not transferring independently in facility. FM C reported that R1 needs assistance.On 08/29/25 at 10:15 AM, Surveyor interviewed R1 and asked R1 if R1 had significant pain anywhere after falling. R1 reported that R1 had elbow pain. Surveyor asked R1 how R1 is feeling now. R1 reported they just took out staples yesterday and so elbow feels a lot better, Surveyor asked if R1 had surgery on elbow. R1 stated, No I did not have surgery. Facility told me I had a skin tear, but I couldn't see it. They placed staples in elbow. On 08/29/25 at 2:31 PM, Surveyor interviewed Resident Manager D and asked Resident Manager D to review R1's falls on 12/24/24, 12/30/24, 01/01/25, 01/09/25, 05/13/25, 06/06/25, 08/04/25, 08/05/25, 08/20/25, and 08/21/25 with Surveyor. Surveyor asked Resident Manager D why interventions were not placed after R1 fell on [DATE], 12/30/24, 01/01/25, 01/09/25, 05/13/25, 06/06/25, 08/04/25, and 08/05/25. Resident Manager D reported that Resident Manager D is unsure why fall interventions were not placed after R1's falls. Resident Manager D reported that DON B is working with providing education to staff on nurses implementing interventions for residents that fall right away instead of waiting for other staff responsible for reviewing care plans to implement interventions on business days. Resident Manager D reported that all nurses need to be implementing new interventions after every fall within 24 hours of resident falling instead of waiting until staff are in the business office to review and implement.On 08/29/25 at 3:50 PM, Surveyor interviewed Licensed Practical Nurse (LPN) E and asked what LPN E's process is after a resident fall. LPN E reported that after a fall event occurs LPN E would assess resident from head to toe to make sure resident is ok. LPN E then notifies provider of the resident's falls right away with assessment conclusion and ask for any orders needed to treat resident. Surveyor asked LPN E to explain the event that occurred with R1 on 08/21/25 when R1 was transferred to the ER. LPN E reported to Surveyor that LPN E took R1's vitals twice before R1 was taken by EMS. LPN E then documented R1's prognosis before being transferred out to the hospital on report sheet that then gets entered by Director of Nursing (DON) B into the record. LPN E could not find documentation in R1's record. Surveyor requested LPN E gather a copy of the report sheet LPN E documented on R1's vitals and assessment from 08/21/25. LPN E provided Surveyor with report sheet documentation. Surveyor found minimal information from LPN E's documentation. Surveyor could not find the pertinent information on R1's fall on 08/21/25. LPN E reported that LPN E must have not documented any other information pertaining to R1's fall on 08/21/25.Surveyor could not find valid education regarding correct process for implementing new interventions per resident falls as indicated during the interview with Resident Manager D. No other documentation was given to Surveyor at this time.Example 2 R2 was admitted to the facility on [DATE], with following diagnoses including cerebral infarction, hemiplegia affecting right dominant side, weakness, difficulty in walking, fusion of spine cervical region, constipation, Parkinson's disease, insomnia, weakness, depression, and essential primary hypertension. R2's Minimum Data Set (MDS) assessment, completed on 08/20/25, confirmed R2 scored 15/15 during a Brief Interview for Mental Status (BIMS), indicating intact cognition. R2 was at risk for falls. R2 requires partial to moderate assistance from staff for toileting, sit to stand, transferring, dressing lower body, and putting on/taking off footwear. R2's Activities of Daily Living (ADL)s care plan dated 06/02/25 states:Ambulation: Not currently. Wheelchair to all destinations, initiated on 06/02/25 and revised on 07/01/25. Ensure call light is within reach and encourage resident to use it to seek assistance when needed, initiated on 06/02/25. Bed mobility: Assist of one, initiated on 06/02/25.Transfer EZ-stand assist of one, initiated on 06/02/25 revised on 08/11/25. R2's fall care plan initiated on 06/02/25 and revised on 06/02/25:Anticipate and meet the residents needs initiated on 06/02/25.Follow facility fall protocol initiated on 06/02/25.PT evaluate and treat as ordered initiated on 06/02/25.Be sure the resident's call light is within reach and encourage resident to use it for assistance as needed, initiated on 06/03/25.Signage to ring for assistance prior to attempting to transfer initiated on 06/30/25. Keep grabber within reach when resident in her room, initiated on 07/01/25. Surveyor reviewed DON B's fall investigation for R2's fall, which states in part: On 06/29/25, [R2] had an unwitnessed fall. On 07/03/25, [R2] had x-rays ordered by provider for right ankle after complaints of it hurting and [R2's] husband unable to transport [R2] in his personal vehicle as she was having hard time with transferring. [R2] is using Hoyer for transfers at this time. On 07/07/25, facility was notified that [R2] had a fracture of the right ankle. ([R2] would complain about pain minimally between this time frame and staff were able to minimize occurring pain with use of interventions set in place. [R2] has now a Reacher to grab items from ground. [R2] frequently at times is forgets to use call light for assistance. [R2] is doing well and was upset with herself for falling.) Surveyor did not find documentation in DON B's investigation report for R2's second fall on 06/30/25. Surveyor reviewed R2's progress notes, On 06/03/25 at 5:28 AM, Note Text: She was assisted by 2 staff with the EZ stand to the bathroom. She is admitted due to some failure to thrive and inability to walk safely.On 06/29/25 at 9:54 PM, Note Text: Transcribed from incident report: Resident was found by staff lying flat on her back in the middle of her room. Resident states I was leaning over to grab my sock off the floor and I leaned too far and fell right on my face. Resident denies any pain. Resident denies any numbness or tingling in her extremities. Resident can move all extremities equally and against resistance. A small bruise is noted above resident's right eye as well as a red abrasion below resident's right eye. Initial vitals were bp - 137/88, pulse - 75, respirations - 19, temp - 97.2. Resident's pupils are equal, round and reactive to light and accommodation and resident is A and O x4. Resident would not like any family notified. No other injuries noted at this time. On call RN notified. On call provider called and updated on injuries.Facility did not implement new interventions for R2 to decrease injury or prevent R2 from falling.On 06/30/25 at 2:42 PM, Note Text: 1:30pm. found res [R2] sitting on the floor in front of her bed, had been laying down and sat up and was trying to reach her w/c and sat down on the floor. denies injury and denies hitting head. vss. notifications done.Facility did not implement new interventions for R2 to decrease injury or prevent R2 from falling. On 08/21/25 at 10:29 AM, Note Text: Care conference held for resident [R2] for quarterly review. Husband in attendance along with Resident Care Manager (RCM), Social Service Director (SSD), and Activities Director (AD). Resident [R2] unable to attend, as she had a possible seizure in the bathroom (BR) just prior to care conference and getting sent to ER for eval. R2 has had 2 falls since her last assessment date. One fall resulting in a right tibia fracture. Denies any recent pain. Has a chronic indwelling urinary catheter. She is to see urology in September for further follow-up (f/u), as catheter has been recently placed due to d/t urinary retention. She is always continent of bowel. She will ring for assistance when needing to use the restroom. Participates in PT and Occupational Therapy (OT) to regain strength and mobility.Facility had no documentation of R2's event in the bathroom such as vital signs and assessments with the result of R2 being transferred to the ER. Facility did not implement new interventions for R2 to decrease injury or prevent R2 from falling. On 08/21/25 at 3:08 PM, Note Text: Received call from RN from hospital stating they will be sending resident [R2] back. ER thinks she had a vasovagal episode. Her delta troponin was negative, and Electrocardiogram (EKG) showed sinus bradycardia (slow heart rate). On 08/21/25 at 8:48 PM, Note Text: Resident [R2] returned from ER at 5:00 PM, came to the dining to eat supper, after supper writer witnessed resident attempt to self-transfer from wheelchair to recliner, writer reminded resident [R2] to push the call light and wait for help, resident verbalized understanding and pushed call light and waited for assistance to transfer.Facility did not implement new interventions for R2 to decrease injury or prevent R2 from falling.On 08/26/25 at 1:52 PM, Note Text: Increased attempts to self-transfer to toilet and bed. Son visiting today, and alerted staff to resident [R2] attempting to get onto toilet independently.Facility did not implement new interventions for R2 to decrease injury or prevent R2 from falling On 08/27/25 at 2:58 PM, Note Text: Resident [R2] noted to have attempts to self-transfer. Also noted to be day 5 with no bowel movement (BM). It is possible these two things are related. NP to review bowel regimen and adjust as indicated.Facility did not implement new interventions for R2 to decrease injury or prevent R2 from falling.On 08/29/25 at 9:25 AM, Surveyor interviewed R2 and asked R2 how R2's fall happened on 06/29/25 and 06/30/25. R2 stated, I saw something on the ground and was trying to pick it up when I fell forward. I was admitted to the facility due to weakness and falls. My goal was to get stronger and get home. Sometimes I have been getting confused. Surveyor asked R2 if R2 received a nurse assessment from head to toe after R2 fell on floor in June. R2 reported that R2 does not remember an evaluation completed after R2 fell. Surveyor asked R2 if R2 was in pain after falling. R2 reported I wasn't in too much pain until later in the day. On 08/29/25 at 2:31 PM, Surveyor asked Resident Manager D why there was no documentation in R2's record pertaining to the fall on 06/30/25 and the last fall where R2 had to be transferred to ER for passing out and falling in bathroom when being transferred via EZ-Stand in bathroom. Resident Manager D reported that there should be documentation in the record, but the nurse did not complete the documentation electronically. Resident Manager D reported expectation is that all staff document in record the process of what led up to the event, if vitals were completed or not, results of the vitals, assessments, etc. and documentation when provider was notified, and what the orders were to support R2 during R2's event. Resident Manager D reported that LPN E should have documented this pertinent information in R2's record pertaining to the fall that led to the ER. Surveyor asked Resident Manager D if interventions should have been placed right away for R2 to not fall again on 06/29/25. Resident Manager D reported that fall interventions should have been placed on 06/29/25 right away or extra supervision to prevent the fall on 06/30/25. Resident Manager D reported to Surveyor that DON B is working with staff on making sure that fall interventions are put into place right away versus waiting for the next business day when office staff are in place. Surveyor could not find valid education regarding correct process for implementing new interventions per resident falls as indicated during the interview with Resident Manager D. No other documentation was given to Surveyor at this time.