**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not provide adequate supervision, monitoring, and personalized interventions to prevent accidents for 1 (R359) of 3 residents reviewed for falls out of a total sample of 22 residents. At the time of R359's admission, the facility failed to identify R359 as a high fall risk and failed to implement robust fall interventions at the time of admission. The facility failed to ensure neurological (neuro) checks were completed in accordance with the facility policy after two of the three falls. The facility failed to ensure assessments were completed by or with the oversight of a Registered Nurse (RN) for all three of R359's falls at the facility. The facility failed to timely notify R359's Nurse Practitioner (NP) and/or on call Physician after two of the three falls. The facility failed to ensure R359's Care Plan correctly reflected all fall interventions. The facility failed to ensure there was a system in place to promote discussion and corroboration on root causes and possible trends after all three of R359's falls. R359's third fall resulted in hospitalization from 11/26/22-12/2/22 for a right intertrochanteric femur fracture. Surveyor observed fall interventions not in place. Surveyor observed R359 in bed and fall mat sitting up against wall. Surveyor observed call light not in reach when R359 was sitting in wheelchair. Evidenced by: Facility policy entitled, Fall Policy, updated 12/2022, includes, in part: INTENT: All residents will receive adequate supervision, assistance, and assistive devices to aid in the prevention of falls. Each resident will be evaluated for safety risks including falls and accidents. Care plans will be created and implemented based on the individual's risk factors to aid in the prevention of falls. All falls are to be investigated and monitored. The facility will maintain a record that contains a list of all incidents and falls. The recording trends are reported and discussed at Quality Assurance Risk Management Committee Meetings monthly and quarterly. It is the policy of the facility to report Accidents and Incidents in accordance with State and Federal regulations. POLICY: 1. Evaluate and monitor resident for 72 hours after the fall, which include neuro checks. 2. Investigate fall circumstances. 3. Record circumstances, resident outcome, and staff response. 4. Contact provider regarding fall. 5. Contact POA regarding fall. 6. Contact family representative (if residents wishes). 7. Implement immediate intervention within first 24 hours. 8. Complete falls assessment. 9. Develop plan of care. 10. Monitor resident response. Facility policy entitled, Neuro Checks, updated 12/2022, includes, in part: INTENT: To ensure neuro checks are completed post fall. POLICY: 1. When a resident has a witnessed fall and does not hit their head, an initial neuro assessment does not need to be completed. However, a standard assessment needs to be completed, which includes vitals. a. If resident is within normal limits, no further assessments are required. b. If a resident is not within normal limits, follow up with MD and family representative (if appropriate) for further guidance. 2. When a resident has a witnessed fall and hits their head neuro checks need to be completed every 15 minutes for 1 hour, every 30 minutes for 2 hours, every 60 minutes for 4 hours and then every 4 hours for 16 hours. 3. When a resident has an unwitnessed fall and cannot confirm if they hit their head, neuro checks need to be completed following the above protocol. a. If the resident can verbalize, they did not hit their head, and is alert and oriented, a neuro assessment is not indicated unless the assessment shows otherwise. Facility policy entitled, no name provided, updated 12/22, includes, in part: Subject: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notify, consistent with his or her authority, resident's representative when there is a change requiring notification. INTENT: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Situations requiring notifications include: 1. An accident involving the resident which: a. Resulting in injury. b. Potential to require physician interventions Facility policy entitled, Comprehensive Resident Centered Care Plans, no date provided, includes, in part: INTENT: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident. Every resident will have an Interdisciplinary Care Plan, with the Interim Interdisciplinary Care Plan initiated within 24 hours of admission. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations, and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident. There will be ongoing documentation of the nursing process related to resident needs from admission to discharge. The interdisciplinary plan of care will be developed through collaborative efforts of the Interdisciplinary Team and other health care professionals. It will be consistent with the medical plan of care and those disciplines that have direct involvement with the resident's care. The resident and/or family member will be involved in the care planning. The care plan will contain information about the physical, emotional/psychological, psychosocial, spiritual, educational, and environmental needs as appropriate It is our purpose to ensure that each resident is provided with individualized, goal directed care, which is reasonable, measurable, and based on resident needs. A resident's care should have appropriate intervention and provide a means of interdisciplinary communication to ensure continuity in resident care 3. Each discipline will check and/or add interventions/approaches to include but not limited to a. The intervention statements describe those measures performed by the staff to help the resident achieve the expected outcomes. b. Interventional entries reflect activities that incorporate observations, assessments, management, and teaching components that will restore, maintain and /or promote the resident's well-being. c. Each planned intervention will be specific and include parameters for frequency and time schedule 3. The Care Plan will be updated and/or revised for the following reasons: .b. A change in planned interventions . R359 was admitted to the facility on [DATE] with a diagnoses including nontraumatic subarachnoid hemorrhage, respiratory failure, cerebral infarction, obesity, atherosclerosis of coronary artery bypass graft, exudative age-related macular degeneration left eye, mixed hyperlipidemia, atherosclerotic heart disease of native coronary artery, weakness, sequelae of trachoma, degenerative of macula unspecified eye, essential hypertension, disorder of arteries and arterioles, unspecified osteoarthritis, gastrostomy status, other long term drug therapy, and history of falling. R359's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 11/18/22, indicated R359's cognition was severely impaired with a BIMS (Brief Interview for Mental Status) score of 00 out of 15. R359's initial Fall Potential Assessment, dated 11/18/22 at 4:50 PM, indicates that R359 was low risk for falls at the time of admission. Under Criteria it states, regardless of score, any resident with previous falls will be considered high risk until fall free for six months. R359 experienced a fall at home prior to hospitalization and admission to the facility. R359's Physician order states, Enoxaparin Sodium Solution Prefilled syringe 30 MG/0.3 ML inject 0.3 ml subcutaneously in the morning for Anticoagulation. Start Date 11/19/22 0800 D/C Date 11/22/22 3:15 PM. R359's Bedside Individual Service Plan Report, dated 12/6/22, indicates the following, Bed mobility: 1 assist to turn and reposition in bed. Fall Risk be sure the residents call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Toilet use: 2 assist for toileting. Communication: resident prefers to communicate in Polish. Provide translator as necessary to communicate with the resident. Translator is son or device translator. Communication board also provided. Able to communicate by using a communication board, gestures, and a translator . Transferring: 2 assist to transfers with EZ stand. Eating: Mobility: Anticipate and meet needs. 1 assist for locomotion using wheelchair. It is important to note the Bedside Individual Service Plan Report is in each resident's room and utilized by the Certified Nursing Assistants (CNAs) and nursing staff. The document does not include robust personalized fall interventions at the time of admission or any interventions that were put in place after R359's three falls at the facility. R359's Comprehensive Care Plan, includes: 11/18/22 initiated: Fall Interventions: Anticipate and meet the resident's needs. 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 requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Ensure that the resident is wearing appropriate footwear. Follow facility fall protocol. PT (Physical Therapy) evaluate and treat as ordered of PRN (as needed). It is important to note the Comprehensive Care Plan that was initiated at the time of R359's admission to the facility, does not include personalized fall interventions. The Comprehensive Care Plan also did not include any interventions that were put in place after R359's three falls prior to the start of the annual survey. R359's Medical Record, includes: NN (Nurse Notes), FR (Fall Report), CP (Care Plan) R359's first fall was on 11/18/22 at 4:50PM: NN 11/18/22 22:21 (10:21 PM) LPN R (Licensed Practical Nurse) Resident fell in her room at 4:50 PM and hit her forehead. There is a bump and bruise in the middle of her forehead. Writer attempted neuro checks but was unable to assess mental status due to a language barrier. Resident also refused to have her vital signs checked. Writer called resident's son who helped translate, he asked resident if she was in any pain and she said no. NP updated. Writer attempted to call on-call physician, but the call center said there is no (Drs. Name) in their system. FR 11/18/22 16:50 (4:50 PM) Person Preparing Report: LPN R Incident Description: Resident was found on the floor in her room with a large bump on her forehead. The wheelchair was next to her with the brakes unlocked. There were no foot pedals on the chair. There were no obstacles on the floor. Writer contacted resident's son, who spoke with the resident on the phone to confirm she wasn't in pain. Resident refused to have her vital signs checked. Resident unable to give description. Immediate Actions Taken: PT found a smaller wheelchair so resident's feet can reach the floor more easily. Writer had resident's son explain the purpose of the call light to his mother. A sensor alarm was placed on the bed and the bed was put in the lowest position. Injury Type: No injuries observed at time of incident. Notes: Unable to determine mental status due to language barrier, resident was unable to understand or respond to questions. It is important to note an RN did not complete or provide oversight of the assessment that was attempted to ensure R359 was not injured. Neuro checks were not completed in accordance with the facility policy. Through interview and record review, it was discovered notification to the NP and/or on- call MD was not timely. The Fall Report indicates no injuries, but through observation, interview, and record review there was substantial bruising to the face. The interventions that were implemented were never added to R359's Comprehensive Care Plan or Bedside Individual Service Plan Report to ensure continuity of care and services. There is also no mention of a possible root cause to R359's first fall. R359's second fall was on 11/21/22 at 3:00PM: NN 11/21/2022 15:37 (3:37 PM) LPN S: at 15:00 (3:00 PM) resident was found on floor of her room. Appears she was attempting to self-transfer from bed into wheelchair. Bed alarm was sounding. Resident found lying on back. No evidence of pain with movement. ROM WNL (Range of Motion Within Normal Limits). MAE=.PERRLA (Moves All Extremities and Pupils Equal Round, Reactive and Accommodation) Small hematoma noted to back of head. Continues with facial bruising around both eyes, increase swelling noted from earlier this morning. Resident assisted off floor via Hoyer and 3 staff members. Assisted into wheelchair. Message left with NP, resident's HCPOA, (Health Care Power of Attorney) DON (Director of Nursing) notified. NN 11/21/22 17:00 (5:00 PM) LPN S: Received call from NP regarding fall from 11/18 and todays fall. Due to recent medical history and current treatment of Lovenox resident will be transported to ER via 911. HCPOA notified. Report called to ER. 11/21/2022 17:25 (5:25 PM) LPN S: Resident left facility via ambulance. 11/22/2022 3:32 AM Writer received a phone call from a nurse from hospital at midnight about resident returning home after been seen for a fall. Writer was informed that resident had a CT scan (Medical Imaging) bruising around both eyes. Scan came back negative. Resident arrived at the facility around 1:45 AM. Resident was accompanied by her two sons and two paramedics. Vitals taken: BP 117/45, Temp 98.1, 02 98% on room air, P 80. Resident denies pain. FR 11/21/22 15:00 (3:00 PM) Person Preparing Report: LPN S Incident Description: Resident found on floor lying on her back. Resident unable to give description. Assisted into wheelchair using Hoyer after evaluating for injuries. No injuries observed at time of incident. Other info: Language barrier. No witnesses found. NP J note from 11/21/22: On 11/18/22 late in the afternoon at approximately 1652 (4:52 PM) I was speaking with the nurse about another patient, and he informed me that a CNA (Certified Nursing Assistant) told him that R359 just fell. RN had not done assessment nor known method of which she fell (so- it was unknown if she slid to the floor vs. another method). I informed him when we were done on the phone to go do an assessment and he will likely have to call physician for support as I am off at 1700 (5:00 PM) LPN R called me back at 10:30 PM on Friday (I checked my messages on Monday 11/21/22) to inform me that she did apparently hit her forehead and lump from it. Son called and was on speaker phone to help communicate. R359 knows she has a bruise and had no pain. Body language relaxed. She didn't know what she was doing, just trying to get out of chair. PT assessed her. No signs or symptoms of injury (other than the head bruise on her forehead). Staff got her a new chair and put an alarm on her bed. Son thinks this won't be an issue because he talked to her on the phone to stay in bed. LPN R unable to determine mental status. Said she appears fine other than the lump on her forehead. I did review their charting and LPN R did try to call on call MD but had issues for unclear reasons. I did speak to DON at about 12:00 PM on 11/21/2022. I had not seen the patient yet, but I did inform him that I was notified at 1652 (4:52 PM) on Friday and informed the RN to do an assessment and likely needs to call on call MD. I went to see her on 11/21/22 at about 1400 (2:00 PM) and she appears to have terrible bilateral bruising around her eyes and on her forehead. I used interpretive services when I went to see her today. She denied headache, dizziness, or blurry vision. She said she felt well. I did offer to send her to the hospital, but she didn't want to go. She had a hard time talking through things. She did not know her location, date, or reason for being at the SNF. She couldn't recall the fall from September or the fall from Friday 11/18/22. It is a bit difficult to complete a neuro exam. She can move all extremities. She can somewhat squeeze my hand, but it is weak. She did not smile for me, and I am not sure if she simply didn't want to? I called and spoke with my medical director about this. I am concerned after seeing her today and the bilateral bruised eyes along with a left forehead bruise. She is on anticoagulation for I believe DVT (Deep Vein Thrombosis- blood clot) prophylaxis. Medical Director suggested that the best/safest route would be to still send her to the ER for a trauma evaluation, even if it is 3 days after the fall. This is day #3 after a fall, hitting head while on blood thinner. Son told me she said that she felt like her skull cracked. Her neuro exam wasn't terribly revealing other than she was confused- although it is unclear how much more from her baseline. She had a hard time grasping but I am not sure if that is a language barrier or not. While she seems stable on day #3, there is a chance that without diagnostics, she may have a head bleed or fracture. Son was ok with sending her to the ER for an evaluation. When I gave the order to the RN to go to the ER, I was told R359 fell today and hit her head again. I called report to ER. This is considered a level two trauma. The ambulance was coming to get her in the 30 minutes from the SNF, however with the series of events, I called LPN S back to call 911.I was able to ask son a few other background questions. His mom was independent prior to the fall and cognitively intact. Since the fall (fall in September prior to SNF), she has been mixed up on/off I also called clinic to discuss risks/benefits of Lovenox. We both agree-stop this medication. On 12/8/22 at 8:20 AM, NP J indicated on 11/18/22 at 4:52 PM she was discussing another resident with the nursing staff at the facility. The nursing staff indicated R359 had just had a fall, but that he was unaware of the specifics of the fall as it had just got reported to him by a CNA. NP J indicated she instructed the staff (LPN R) to complete an assessment and then call the on-call MD for support because she was off starting at 5:00 PM. NP J indicated she listened to her messages on 11/21/22 and that the nursing staff (LPN R) had called and left her a message at 10:30 PM reporting resident hit her forehead, that there was a lump on her head, and that he had called son to help translate. NP J indicated the message also stated resident knows she had a bruise on her head but denies pain. NP J indicated it looks like nursing staff had tried to call the on-call MD, but NP J cannot comment further on that. NP J does not know how hard nursing staff attempted to contact on-call MD. NP J indicated she saw R359 on 11/21/22 at about 2:00 PM. NP J indicated there was terrible bruising around resident eyes and forehead. NP J indicated she used the language translator line and that the resident denied blurry vision, pain, and resident indicated she did not want to go to the ER. NP J indicated she completed neuro check and that the resident could squeeze her hand lightly and that the resident didn't smile for her, NP J indicated she wasn't sure if the resident just didn't want to smile for her. NP J reported she couldn't tell if the resident had a change in condition. NP J indicated she then called her supervisor and surgery team. NP J indicated she called son to discuss further as well. NP J indicated everyone recommended R359 go to ER even with it being 3 days after the fall. NP J indicated had she known about R359 hitting her head she would have instructed her to go into ER after first fall due to the possibility of a bleed and given the fact that the resident is on an anticoagulant. NP J indicated she called the facility at 5:04 PM on 11/21/22 to instruct the facility to have R359 go to the ER. NP J indicated she talked to LPN S who reported to her that R359 had another unwitnessed fall and had hit her head earlier in the day. NP J indicated there were no messages from the facility regarding the second fall. NP J indicated she would expect if someone hit their head and is on an anticoagulant that this is considered a more urgent issue. NP J indicated she certainly checks her messages regularly but if she is driving between nursing homes, it might be an hour or more before she gets the message. NP J indicated she would expect the nursing home to page her immediately, and if needed call 911 depending on the situation and to use a little nursing judgement. NP J indicated given all this information she had received she instructed LPN S to call 911 immediately. It is important to note an RN did not complete or provide oversight of the assessment that was completed to ensure R359 was not injured at the time of the second fall. Neuro checks were not completed in accordance with the facility policy. Through NP interview and record review, it was discovered notification to the NP was not timely. There is no discussion or documentation of interventions or root cause to R359's second fall. R359's third fall was on 11/25/22 at 4:45 PM: NN 11/25/22 18:45 LPN T: Writer witnessed fall as walking pass the room at 4:45 PM as resident was falling, resident fell onto her right side of body and did not hit her head. Resident had one nonslip sock on and other foot barefoot. Vitals taken, BP:134/71, P:98,02:97%, R 19, T: 97.9, PERL, language barrier upon attempting to assess. Assisted resident into w/c (Wheelchair). Bruising present from previous recent falls. Notified DON, NP, and son of incident. NP states to continue to monitor for any changes and contact NP on call if needed. Resident is currently up in w/c, periodic checks being conducted per request of son. Call light within reach. FR 11/25/22 16:45 (4:45 PM) Person Preparing Report: LPN T Incident Description: Writer witnessed fall as walking pass the room, resident fell on right side of body, Language barrier upon assessment. Description: vitals taken, BP:134/71, P:98, 02:97%, R:19, T: 97.9, PERL, assessed and assisted into wheelchair, notified DON, NP, and son. No injuries observed at time of incident. Language barrier unable to assess and understand response or mental status. NN 11/26/22 7:23 AM LPN S at 6:45 AM writer entered room to check on resident due to her yelling. Writer noticed RLE (Right Lower Extremity) was rotated, shortened length compared to LLE (Left Lower Extremity), swollen, and bent at knee. Unable to perform any ROM (Range of Motion). Concern for fracture r/t (Related to) fall yesterday evening. New bruising noted to right knee. 911 called due to severe pain. Resident left facility at 7:15 AM. Son notified. NP notified. Reported called to ER. On call ADON notified. NN 11/26/2022 13:17 (1:17 PM) Resident admitted with right proximal femur fracture. It is important to note an RN did not complete or provide oversight of the assessment that was completed to ensure R359 was not injured at the time of the third fall. R359's third fall resulted in hospitalization from 11/26/22-12/02/22 for a right intertrochanteric femur fracture. The facility failed to internally investigate the fall that resulted in a major injury. The facility failed to update R359's Comprehensive Care Plan to include previous fall interventions and identify what new interventions needed to be in place. The facility failed to identify the root cause of the third fall. The facility failed to identify and discuss trends found in all three falls. At the time of re-admission, no new fall interventions were put in place. Surveyor attempted to call LPN T on 11/8/22 at 10:00 AM, but LPN T did not return call. LPN T is a staff from a staffing agency and was not on the schedule to work at the facility. On 12/7/22 at 9:45 AM, CNA U (Certified Nursing Assistant) indicated she thought all three of R359's falls were unwitnessed. CNA U indicated she provides frequent checks on R359 because she is at risk for falling. CNA U indicated that R359 has a fall mat in place and that her bed was rearranged so one side is up against the wall. CNA U indicated she thought the fall mat was put in place after the third fall but wasn't certain. CNA U indicated that she didn't know of any other fall interventions. CNA U indicated communication is challenging with R359 because she speaks Polish. CNA U indicated staff have tried Google translator but that they rely mostly on the family to translate. CNA U indicated R359 can read Polish and that there are several flash cards in her room that can be utilized as well. On 12/7/22 at 9:55 AM, LPN S indicated she was the LPN working down R359's hallway at the time of her second fall and was the LPN that identified R359 needed immediate care the day after R359's third fall. LPN S indicated she witnessed R359 falling on 11/21/22. (It is important to note this does not align with what the Nurses Note and Fall Report from 11/21/22 indicate.) LPN S indicated she saw R359 hit the back of her head. LPN S indicated she then followed policy and completed an assessment. LPN S indicated two therapists assisted her in completing the assessment. LPN S indicated that Monday-Friday therapy will assist with the assessment. If someone falls on the weekend, then a Registered Nurse may assist with the assessment. LPN S indicated after the fall R359 was able to move, wasn't complaining of pain, and LPN S did notice a bump on the back of R359's head. LPN S indicated since R359 was laying on the floor therapy and LPN S used a Hoyer lift to assist R359 in getting up. LPN S indicated they did have to wait a bit before sending her in. LPN S indicated she called NP and they were also waiting on the son to make a decision on if he wanted her sent to ER. LPN S indicated she called NP and left a message around 3:30 PM, the NP called back at 5:00 PM, and R359 was sent out at 5:25 PM. (It is important to note this does not align with NP's notes nor does it align with NP's interview.) LPN S indicated she thinks R359 had a bed alarm before the second fall, she thinks she might have a wheelchair alarm in place as well and does not know if any other fall interventions were in place. LPN S indicated she has never had difficulty completing assessments or vital checks on R359. LPN S indicated if R359 is refusing treatment there is something more going on, she might need to be changed or she's in pain. LPN S indicated after the 3rd fall on the morning of 11/26/22, she went to check on R359 to ensure she was safe. LPN S indicated she could hear yelling and crying. LPN S indicated right when I saw her, I could see her hip was fractured, it was around 6:45 AM. LPN S indicated third shift staff reported that R359 slept fine and had no issues all night. LPN S indicated she made the decision to call 911 immediately because R359 was experiencing so much pain. LPN indicated that fall interventions should be put in place immediately after a fall. LPN S indicated the interventions should be documented in the progress notes and on the Comprehensive Care Plan. LPN S indicated she has no idea who is responsible for putting the interventions into the Comprehensive Care Plan. It had always been the DON or MDS nurse in the past, but under new management, LPN S indicated she is unsure. LPN S indicated there is a CNA care card (Bedside Individual Service Plan Report) in each resident's room. This information comes from the computer system (Point Click Care). On 12/7/22 at 3:45 PM, LPN R indicated he was the LPN that was working on R359's hallway at the time of her first fall. LPN R indicated he didn't see the fall happen and it occurred just before supper time. LPN R indicated the language barrier was difficult. LPN R indicated R359 didn't seem to be in pain after the fall. LPN R indicated the wheelchair brakes were unlocked so maybe R359 had tried to stand up and fell, but he's not certain. LPN R indicated he called the son and he acted as a translator. LPN R indicated they got a smaller wheelchair that fit R359 better and that the son talked to R359 and reminded her to use her call light. LPN R indicated the son and LPN R completed the assessment. Three CNAs and LPN R assisted R359 in getting up and LPN R indicated there was no RN assisting or providing oversight of the assessment. LPN R indicated he tried to complete assessment and vitals, but R359 kept refusing and pushing him away. LPN R indicated there was a bump on R359's forehead after the fall. LPN R indicated he reported the fall to the NP while they were on the phone discussing a different resident. LPN R notified the son, left a message for the NP, and tried calling the on-call MD but they told him they didn't have a doctor under that name. There was no further attempt to notify. LPN R indicated he left a message for the NP, so he doesn't know what the follow up would have been. LPN R indicated they use an app to communicate with R359 and that her son showed staff this app. LPN R indicated Google translator seems to be working better as well. LPN R indicated he checks on R359 frequently, around once an hour. LPN R indicated the son is here often as well. LPN R indicated it is everyone's responsibility to put fall interventions in place and that he thinks the MDS (Minimum Data Set) nurse updates all interventions to the Care Plans. LPN R indicated he put the bed alarm in place after the first fall and he isn't certain what interventions were in place prior to the first fall. LPN R indicated there is a meeting every morning and maybe they discuss falls at that time, but he's not certain. LPN R indicated he did not feel R359's first fall was an emergency because there was no blood. LPN R described an emergency if someone falls, it's unwitnessed, possibly hit head and that there is blood. LPN R indicated if the above things do not occur, they complete neuro checks and with R359's first fall he attempted neuro checks, but R359 couldn't answer questions at all. LPN R indicated in an emergency he wouldn't wait very long to call 911. LPN R indicated he doesn't know if there is a standard practice for wait time before calling 911. LPN R indicated R359's fall didn't appear urgent because there were no signs of anything broken, no signs of injury, and nothing was hurting. LPN R indicated R359 knew she had a bruise on her head, but through discussion with the son, it appeared the bruise did not hurt. On 12/7/22 at 5:46 PM, Surveyor observed R359's fall mat up against wall and R359 lying in bed. Surveyor asked two CNAs that were working down R359's hallway if the mat should be down. CNA V indicated she puts the mat down when R359 is sleeping in bed. Surveyor asked if mat should be down any time R359 is in bed. Both CNAs indicated they had just assisted R359 with eating her supper. Surveyor observed CNAs going in to R359's room and starting to assist with personal cares. Surveyor also observed on 12/7/22, R359 sitting in her wheelchair and call light out of reach. Call light was on other side of bed closest to bedroom wall. R359 would not have been able to reach call light if she needed to. On 12/8/22 at 10:30 AM, R359's son was visiting R359. Son was able to act as a translator for Surveyor. R359's son indicated he knows the root cause of the three falls at the facility. The son indicated R359 was attempting to the use the bathroom and self-transferring for all three falls. R359's son indicated he feels his mother has good days and bad days, and after her fall at home she has been experiencing memory loss. The son indicated he acts as translator, but that sometimes he can't answer his phone right away since he must work. The son indicated that he wants to assist with translating because he can tell when his mother is not being truthful. The son reported his mom will tell you things she thinks you want[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility did not ensure a resident who is fed by enteral means receives the appropriate treatment and services for 1 of 1 Residents (R38) receiving enteral nutrition out of a total sample of 22 Residents. R38's enteral nutrition (tube feeding) was not running for an unknown amount of time on 12/7/22. R38's blood sugar went low requiring an IM (Intramuscular) injection of glucagon to be administered. (Glucagon injection is an emergency medicine used to treat hypoglycemia (low blood sugar)) This is evidenced by: Per CMS (Centers for Medicare and Medicaid Services) Continuous feeding is the uninterrupted administration of enteral formula over extended periods of time. Enteral feeding (also referred to as tube feeding) is the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum. The facility's policy titled, Enteral Feeding, with an updated date of 10/2022, indicated, in part: Intent: It is the policy of the facility to provide adequate nutrition and hydration to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance to State and Federal regulation. Procedure: .6. A resident who is fed by gastrostomy/jejunostomy tube shall receive the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and to restore, if possible, normal eating skills .12. Prior to the flushing of a feeding tube, the administration of medication via a feeding tube, or the providing of tube feedings, the nurse performing the procedure ensures the proper placement of the feeding tube . R38 was originally admitted to the facility on [DATE] with diagnoses that include, in part: Other nontraumatic intracerebral hemorrhage; Dysphagia .; Aphasia .; Gastrostomy Status; and Type 2 Diabetes Mellitus . On 9/22/22, R38's Significant Change MDS (Minimum Data Set) indicates a BIMS (Brief Interview for Mental Status) should not be conducted as R38 is rarely/never understood. Section B indicates R38 has absences of spoken words and is rarely/never understood or able to understand others. Section G, functional status, indicates R38 is totally dependent on staff for bed mobility, transferring, dressing, eating, and personal hygiene. R38 has a J-tube, which is a tube placed through the skin of the abdomen into the small intestine. (Of note, Surveyor noted discrepancies in the orders regarding whether R38 had a J-tube or a G-tube. Surveyor discussed with ADON F (Assistant Director of Nursing) who informed Surveyor that R38 currently has a J-tube in place not a G-tube.) R38's December 2022 Physician Orders, indicate R38's diet as: J-tube; Nepro at 35ml/hr. continuously by pump every day and night shift for nutrition. Order and Start Date indicate 8/15/22. R38's TAR (Treatment Administration Record) indicates the following: --Treatment: J-Tube: very [sic] placement prior to any use two times a day. Start Date 12/27/21. 12/7/22 at 8:00AM is signed out. --H2O flush: 120cc every 4 hrs. every 4 hours for Hydration. Start Date 11/18/22. 12/7/22 at 12:00AM, 4:00AM, 8:00AM and 12:00PM are signed out. R38's Care plan for ADL (Activities of Daily Living) self-care performance deficit . indicates, in part: Interventions: Eating: R38 is NPO (nothing by mouth), dependent on staff to use feeding tube for nutrition and hydration. Date Revised: 10/4/22 . On 12/7/22 at 12:04 PM, Surveyor went to R38's room to observe LPN G (Licensed Practical Nurse) administer medications via R38's J-tube. Upon entering the room, it was noted that the tube feeding line was not connected to R38's J-tube and was not running. The end of the tube feeding line was capped and sitting on the feeding pump. LPN G indicated the Hospice Aide may have disconnected the line during cares and did not reconnect. LPN G indicated the Hospice Aide did not report this to her. LPN G then attempted to perform a 30cc gravity flush. The flush was not going through and LPN G attempted troubleshooting by milking the J-tube tubing. LPN G stopped further attempts and informed Surveyor she was going to call for assistance. After returning, LPN G tested R38's blood sugar and reported it was 80 and indicated, I need to get someone. At 12:21 PM, DON B (Director of Nursing) arrived in R38's room to assist LPN G. DON B indicated he was concerned the J-tube was clogged. DON B was able to unclog the J-tube, perform placement check and flush J-tube. DON B indicated he used tepid water for the flush. DON B indicated the tube feeding bag/tubing should be exchanged prior to re-starting the tube feeding. LPN G began to gather supplies for this. At approximately 12:45 PM, Surveyor interviewed DON B and asked if it is acceptable for the hospice aide to unhook the tube feeding from a resident without getting a staff member. DON B indicated because of their training they are able to disconnect for cares, but they should alert the nurse on duty that they have done that so we can come in and double check that it is running when they are done. At 12:55 PM, R38's tube feeding remained unconnected as LPN G indicated that she could not locate the correct tube feeding bag/tubing for the pump they are utilizing. LPN G indicated she had called for assistance. LPN G performed a recheck of R38's blood sugar which she reported to Surveyor was 64. At 12:59 PM, ADON F arrived to the room to assist LPN G. At 1:01 PM LPN G informed ADON F that R38's blood sugar was 64. ADON F indicated that LPN G should follow the order for that blood sugar. LPN G asked ADON F, IM, and ADON F indicated yes. At 1:04 PM, LPN G indicated she was administering 1mg IM glucagon to R38. At 1:09 PM ADON F was priming tube feeding line while LPN G was preparing medications to administer. At 1:17 PM R38's tube feeding was connected and turned on. At 1:20 PM LPN G performed a blood sugar check on R38 and reported it was 140. Surveyor asked LPN G if she recalled the last time she had been in to check on R38 prior to coming in at noon when the tube feeding was found disconnected. LPN G indicated, probably like 9 to 9:30 AM. Surveyor asked LPN G if she knew how long the Hospice Aide was here. LPN G indicated about an hour to an hour and a half. Surveyor asked LPN G if she knew when the Hospice Aide arrived. LPN G indicated no. On 12/7/22 at 1:25 PM, Surveyor interviewed CNA H and asked when she last checked on R38 before noon. CNA H indicated, around 10 AM. Surveyor asked CNA H if she knew when the Hospice Aide was with R38. CNA H indicated between 8am and 11am. Surveyor asked CNA H if she was knew when the Hospice Aide left. CNA H indicated no. (Of note, attempts to contact the Hospice Aide for interview were unsuccessful.) On the morning of 12/8/22, Surveyor interviewed DON B and asked how frequently staff should be checking on R38. DON B indicated, I would expect them to be checking her frequently. At a minimum every 30-45 minutes, can be the CNA or the nurse and just going in and checking on her and making sure everything is still functioning in the room. Surveyor asked DON B when staff is going in to check on R38, should they be ensuring that the tube feeding is connected and running? DON B indicated, yes, should be making sure things are the way they are supposed to be. On 12/8/22 at 9:41AM, Surveyor asked DON B what the expectation is of facility staff and hospice staff when hospice comes for a visit with a resident in regard to communication. DON B indicated when they enter the building, they should talk to the nurse and tell them who they are, why they are here, is there anything I need to know. Report off to the nurse after the visit and communicate any recommendations, updates, what they did. R38 receives all her nutrition through her tube feeding. The facility did not ensure that R38's tube feeding was connected and running per the physician orders. The tube feeding was disconnected for an unknown amount of time on 12/7/22. R38's blood sugar dropped during this time and required an intervention of intramuscular glucagon to raise her blood sugar.