**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure the environment remained free from accident hazards and assistive devices to prevent accidents for 2 (R1 and R3) of 3 residents reviewed for falls. R1 had a fall while using a sit-to-stand lift on 10/12/2022 that was not reported, documented, or investigated. No interventions were put in place to prevent future falls or injuries. On 10/13/2022, R1 was using a sit-to-stand lift and had an unresponsive episode while sitting on the toilet with the sit-to-stand lift in place and R1 sustained a fractured humerus. No evaluation was completed on R1's use of the sit-to-stand lift to determine if the lift was appropriate for R1 to use after 10/12/2022 or if a total lift was more appropriate to prevent harm. R3 had a fall on 11/3/2022 and the interdisciplinary team determined a scoop mattress would be an appropriate intervention to prevent future falls. The scoop mattress intervention was not added to R3's Falls Care Plan. A scoop mattress was not observed on R3's bed. R3 had a fall on 12/5/2022 out of the wheelchair and Dycem was observed on R3's wheelchair cushion. The Dycem was not added to R3's Falls Care Plan. Findings: The facility Policy and Procedure entitled Accident(s), Incident(s), dated 7/30/2018, states: 2) An initial care plan will be developed for any resident that is determined to be at risk for falls. a) if at risk for falls, the house fall protocol will be implemented. 3) This care plan is communicated to appropriate staff members. 4) Care plans and assessments should be re-evaluated at a minimum of quarterly, with any new change of condition and/or accident/incident as deemed necessary. 5) If a fall occurs, the facility will provide nursing and/or emergency care as needed per facility's policy and procedure standards of practice and follow Incident Report Investigation Checklist. When an accident or incident occurs: .3) Complete Accident/ Incident Investigation Checklist at time of accident/incident with all staff present. a) If accident/incident is not witnessed; or the resident is not able to verbalize a probable cause; or the nurse is unable to determine a probable cause; or there is an injury in a suspicious location, and/or resident has injury has a suspicious [sic] origin i) The Nurse must interview staff on duty on the unit and take a statement from the staff members using Staff Statement Tool. ii) The Nurse or designee must interview the staff and write statements for the staff member.5) If a fall related incident: . i) Update fall assessment in electronic medical record prior to shift ending - nurse on duty is responsible; if completed by an LPNN, a RN must co-sign. ii) Update fall Care Plan with immediate fall interventions - nurse on duty is responsible.9) Add to 24-hour communication board. 10) IDT team will review accident/ incident next business day. R1 was admitted to the facility on [DATE] with diagnoses that include: Alzheimer's Disease, major depressive disorder, constipation, dysphagia, and anxiety disorder. R1's annual Minimum Data Set (MDS) assessment dated [DATE] indicated R1 had a severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 00 and coded R1 as needing extensive assistance with transfers, toilet use, dressing, and hygiene. R1 was admitted into Hospice on 11/15/2022 and passed away on 11/17/2022. R1 was not observed during the survey. R1's Activities of Daily Living Care Plan had the following interventions in place on 10/10/2022: -Toilet Use: extensive assistance of one with EZ stand, R1 wears incontinence brief, provide with perineal care and help adjust clothing. -Transfer: Extensive assistance from 1 person, a stand-up lift (may require 2 assist in/out of bed for setup/removal). R1's Falls Care Plan had the following interventions in place on 10/10/2022: -Anticipate and meet R1's needs. -Be sure R1's call light is within reach and encourage R1 to use it for assistance as needed; R1needs prompt response to all requests for assistance. -Educate about safety reminders and what to do if a fall occurs. -Fall mat next to bed when in bed. -Follow facility fall protocol. -Physical therapy evaluate and treat as ordered and as needed. -Review information on past falls and attempt to determine cause of falls; record possible root causes; alter/remove any potential causes if possible; educate as to causes. On 12/13/2022 at 12:54 PM, Surveyor requested all fall investigations regarding R1 from Director of Nursing (DON)-B. On the Request for Therapy Screen form, Rehab Director-D completed the form on 10/18/2022 indicating R1's foot slipped off the back of the foot plate of the EZ stand on 10/10/2022 and R1 was lowered to the floor. The Fall Care Plan was reviewed, and the Fall Care Plan indicated R1 had a fall on 10/10/2022 with the following intervention implemented on 10/18/2022: staff education and assess grip pad on foot plate of EZ stand. Surveyor did not find any documentation in R1's medical record of a fall that R1 sustained on 10/10/2022. DON-B provided Surveyor with the incident report that was initiated on 10/17/2022 of R1's fall dated 10/12/2022 in which R1's foot slipped in the EZ stand and R1 was lowered to the bed. The fall investigation stated it was later determined that R1 had been lowered to the floor and then transferred to the bed. In an interview with DON-B on 12/15/2022 at 1:19 PM, Surveyor asked DON-B to clarify the date of R1's fall because the Falls Care Plan and the Request for Therapy Screen form indicated the fall occurred on 10/10/2022. DON-B stated R1's fall occurred on 10/12/2022 and not 10/10/2022. DON-B stated the IDT was investigating another incident involving R1 when it was discovered that R1 had been lowered to the floor on 10/12/2022 by facility staff when R1's foot slipped from the EZ stand. DON-B was aware there was no documentation by nursing staff on 10/12/2022 of R1's fall and DON-B stated the nurse was educated in the proper documentation that was needed after a fall. Surveyor noted a late entry of the fall on 10/12/2022 was not put in R1's medical record . Surveyor noted no investigation into R1's fall with the use of the EZ stand was completed on 10/12/2022 and no interventions were implemented on 10/12/2022 to prevent future falls or injuries. Surveyor noted R1 was not assessed in the use of the EZ stand to determine if the EZ stand was an appropriate transfer device for R1. On 10/13/2022 at 7:13 AM in the progress notes, nursing charted the Registered Nurse (RN) was called into R1's room by a certified nursing assistant (CNA.) Nursing charted R1 was observed on the sit-to-stand lift slumped over to right side while sitting on the toilet. Nursing charted R1 was unresponsive for thirty seconds upon the nurse arriving in the room and R1 slowly regained responsiveness with verbal and tactile stimuli. Nursing charted R1's vital signs and noted R1 to be hypotensive (low blood pressure) 88/47, pulse 104, respirations 10-12. On 10/13/2022 at 7:33AM in the progress notes, nursing charted the Nurse Practitioner (NP) was called and was informed of R1's syncopal (passing out) episode. Nursing charted the NP gave orders to recheck R1's vital signs and monitor; the NP informed the nursing staff member that R1 was a comfort focus and to encourage fluids and eating. On 10/13/2022 at 10:12 AM in the progress notes, nursing charted Tylenol 650 mg was given to R1 for left shoulder pain. Surveyor noted R1 had not requested or complained of pain to the left shoulder in the past. On 10/13/2922 at 2:36 PM in the progress notes, nursing charted the NP was notified R1 was back to baseline, Tylenol was given for arm pain, and R1 did not have any more syncope episodes. On 10/13/2022 at 7:43 PM in the progress notes, nursing charted a blue/purple bruise was noted to R1's left upper arm during PM cares that measured 4 cm x 5 cm. On 10/14/2022 at 8:59 AM in the progress notes, nursing charted the CNA alerted the nurse that R1 had blister in the bruise on the left upper arm. Nursing charted the blood blister and bruising likely occurred on 10/13/2022 when R1 became unresponsive in the EZ stand and the skin was pinched. Nursing charted a further assessment showed increased pain, guarding (protecting arm,) and vocal complaints of pain from R1 was noted with touch and movement. Nursing charted the NP was notified and a new order for skin prep to blister twice daily and x-rays STAT (as soon as possible) to the left shoulder, clavicle, humerus, radius, and ulna were ordered. On 10/14/2022 at 12:26 PM in the progress notes, nursing charted the facility was notified that R1's x-ray of the left humerus indicated an acute fracture of the cervical neck. R1's Activities of Daily Living Care Plan was revised on 10/14/2022 with the following intervention: transfer R1 with a Hoyer lift. EZ stand transfers were discontinued. On 10/18/2022 at 09:54 AM in the progress notes, the IDT charted the root cause of R1's fall was due to R1's foot slipping from the EZ stand resulting in R1 needing to be lowered to the floor. The recommended interventions were staff education and assess the grip pad on the foot plate of the EZ Stand. Surveyor noted the IDT note on 10/18/2022 did not indicate when R1 had a fall from the EZ stand and no other documentation was found regarding a fall on 10/10/2022 or 10/12/2022. In an interview on 12/13/2022 at 1:30PM, CNA-C stated CNA-C got R1 up and transferred to the toilet using the EZ stand on 10/13/2022. CNA-C stated CNA-C was washing R1 up with R1 standing in the EZ stand, and R1 went limp so CNA-C lowered R1 onto the toilet and ran to the door, yelled for help and put all the call lights on in the room. CNA-C stated the nurse came to do vital signs, got R1 aroused awake and went to call the NP. CNA-C stated CNA-C attempted to get R1 up again using the EZ stand and R1 passed out again, so CNA-C lowered R1 to toilet and left to get CNA-F. CNA-C stated CNA-C and CNA-F attempted to get R1 up again to put the Hoyer lift sling under R1 using the EZ stand and R1 passed out again. CNA-C and CNA-F got the Hoyer lift and transferred R1 back to bed. CNA-C stated R1 had total of three episodes of unresponsiveness and the nurse was aware of all of them but was only present for the first episode. CNA-C stated CNA-C became aware R1 has had fainting episodes in the past but only through word of mouth and had never experienced it until the episode on 10/13/2022. Surveyor asked CNA-C if R1 had complained of any pain. CNA-C stated R1 was saying ow when being lifted in the sling with the Hoyer lift. In an interview on 12/13/2022 at 2:44 PM, Surveyor spoke with Rehab Director-D regarding the request for a therapy screen for transfer assessment after the fall on 10/12/2022 when R1's feet slipped off EZ stand. Rehab Director-D stated the form was completed on 10/18/2022 after the IDT meeting of which Rehab Director-D is a part of met on 10/17/2022. Rehab Director-D stated the NP discontinued the transfer assessment order from R1's fall on 10/12/2022 due to R1 sustaining a fractured arm on 10/13/2022 and being on comfort care. Rehab Director-D stated R1 was never assessed for transfer status after the fall on 10/12/2022. Rehab Director-D stated R1 was last seen for therapy on 2/2022 for physical therapy and Occupational therapy for position changes. Rehab Director-D stated R1 was given another wheelchair at that time. Rehab Director-D stated the IDT meets daily and investigates the falls of residents from the previous day. Rehab Director-D stated Rehab Director-D did not know why the IDT did not meet after the fall on 10/12/2022 until 10/17/2022. On the Request for Therapy Screen form completed on 10/18/2022, the interventions listed on the form were to educate the nurse and Certified Nursing Assistant (CNA) regarding reporting incidents, proper transfer training, and maintenance work order to check the foot plate of the EZ stand. The request of the therapy screen originated from the Fall Committee. The therapy response to the request per Rehab Director-D was discontinued due to R1's current status on 10/18/2022 with an arm fracture and the request for comfort care. In an interview on 12/13/2022 at 2:52 PM, Surveyor asked Registered Nurse (RN)-E about R1 after the syncopal episodes on 10/13/2022. RN-E stated RN-E was told about the bruise on R1's arm on the bicep area from the CNA. RN-E stated RN-E went to assess R1 and R1 had no pain at the time and no swelling noted. RN-E stated RN-E was moving R1's arm around and R1 never said anything about pain. RN-E stated R1 had no complaints of pain all shift and was surprised when came RN-E came in the next day and the area was more bruised. RN-E stated RN-E figured it was because when R1 was slumped over during the fainting episode, maybe R1 was pulled by the CNA to sit up. RN-E was not aware of R1 having difficulty with the EZ stand or previous episodes of syncope while in EZ stand. In an interview on 12/15/2022 at 11:16 AM, Surveyor asked CNA-F about R1's episode of unresponsiveness on 10/13/2022. CNA-F stated CNA-F was called to R1's room by CNA-C to help with R1's transfer with the EZ stand because R1 had passed out. CNA-F was unsure if R1 ever came to when trying to get up off toilet. CNA-F remembered R1 saying ow when being transferred in the Hoyer lift. CNA-F stated CNA-F did not hear a crack or pop when lifting R1 up. CNA-F did not recall hearing about an incident of R1's feet slipping off the EZ stand during a transfer. In an interview on 12/15/2022 at 12:57 PM, Surveyor spoke with Rehab Director-D who had talked with other rehab staff and looked back at notes for clarification after the last interview with Surveyor. Rehab Director-D clarified that initially the IDT did not think R1 had a fall on 10/12/2022, but when the IDT reviewed the information on 10/17/2022, they felt R1 had a fall and then the investigation with staff interviews began. In an interview on 12/15/2022 at 1:20 PM, Surveyor asked Director of Nursing (DON)- B about R1's fall on 10/12/2022. DON-B stated that R1's fall on 10/12/2022 was brought to DON-B's attention on Monday 10/17/2022. DON-B stated the investigation into the incident found it was a fall and that R1 had to be lowered to the floor when the feet slipped off the EZ stand. DON-B stated the CNA went to get a nurse and the nurse stated it was ok to put R1 back to bed without assessing R1. DON-B stated staff have been educated as a whole about using EZ stands and all the gripper strips on the EZ lifts have been changed. DON-B stated LPNs are instructed to call 911 if no RN is in the building and this policy has been implemented after R1's fall occurred. On 12/15/2022 at 2:25 PM, Surveyor met with Nursing Home Administrator (NHA)-A and DON-B to review the concerns regarding R1's falls and transfer status. Surveyor shared the concern R1 had a witnessed fall on 10/12/2022 while using the EZ stand that was not documented in R1's medical record and no investigation to the cause of the fall or interventions were completed until 10/18/2022, six days after the fall occurred. Surveyor shared the concern R1 was not assessed to determine if the EZ stand transfer was an appropriate transfer device after the fall on 10/12/2022 and R1 sustained a fractured arm on 10/13/2022 while using an EZ lift. No further information was provided at that time. *)R3 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, diabetes, heart failure, coronary artery disease, anxiety, and alcohol abuse. R3's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R3 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 8 and codded R3 as needing extensive assistance with bed mobility and transfers and did not ambulate in the room or hallway. R3 had a history of falls prior to admission and was admitted to the facility after sustaining a fracture to the left hip that was surgically repaired. R3's Risk for Falls Care Plan was initiated on 8/12/2022 with the following interventions: -Be sure the call light is in reach and encourage R3 to use it for assistance as needed. R3 needs prompt response to all requests for assistance. -Ensure R3 is wearing appropriate footwear (shoes or gripper socks) when ambulating or mobilizing in wheelchair. -Follow facility fall protocol. R3's Risk for Falls Care Plan was revised on 9/3/2022 with the following intervention: ensure R3 has heel lift boots on at all times when in bed to off load. R3's Risk for Falls Care Plan was revised on 9/22/2022 with the following intervention: place wheelchair within reach at all times. On 11/1/2022 at 12:30 AM in the progress notes, nursing charted R3 was found lying on the right side on the floor next to the bed. R3 was assessed by a Registered Nurse (RN) and was found to have no injuries and no complaints of pain. Nursing charted R3 had heel boots on, the call light was in reach, the bed was in low position and the care plan was followed. Nursing charted R3 had last been seen at 12:10 AM. Nursing charted R3 stated R3 had been dreaming and rolled off the bed. Nursing charted the immediate intervention put in place was a fall mat. On 11/1/2022 at 9:47 AM in the progress notes, the interdisciplinary team (IDT) met and determined the fall mat was an appropriate intervention. R3's Risk for Falls Care Plan was revised on 11/1/2022 with the following intervention: 11/1/2022 fall - mat on floor next to bed. The facility implemented a second Risk for Falls Care Plan on 11/2/2022 with the following interventions: -Assist R3 with ambulation and transfers, utilizing therapy recommendations. -Determine R3's ability to transfer. -Evaluate fall risk on admission and as needed. -If a fall occurs, alert provider. -If a fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol. -If R3 is a fall risk, initiate fall risk precautions. On 11/3/2022 at 5:28 PM in the progress notes, nursing charted R3 was found lying down net to the bed with blankets around R3's body. Nursing charted R3 was down for a nap and R3 stated R3 rolled off the bed. Nursing charted the fall mat was in place and R3 did not sustain any injuries. On 11/4/2022 at 9:52 AM in the progress notes, the IDT determined a scoop mattress was an appropriate intervention to prevent future falls. Surveyor noted R3's Risk for Falls Care Plan was not revised to include the scoop mattress intervention. On 12/5/2022 at 7:45 PM in the progress notes, nursing charted R3 had been sitting in the wheelchair watching TV and the wheelchair was noted to be tipped forward and R3 was sitting on the foot pedals. Nursing charted R3 had reached forward and slid off the seat. Nursing charted Occupational Therapy evaluation for wheelchair positioning was the immediate intervention. On 12/6/2022 at 9:47 AM in the progress notes, the IDT determined Dycem on the cushion and a therapy evaluation were appropriate interventions to prevent future falls. Surveyor noted R3's Risk for Falls Care Plan was not revised to include the Dycem on the wheelchair cushion or a therapy evaluation. In an interview on 12/13/2022 at 1:05 PM, Licensed Practical Nurse (LPN)-G stated resident care plans are on the back of the resident's bathroom door so anyone can help with transfers or any other cares or see what is on the care plan. On 12/13/2022 at 1:25 PM, Surveyor observed R3 sleeping in bed. The bed was in a low position, a fall mat was on the floor next to the bed, and the call light was in reach. The mattress in place was not a scoop mattress. Multiple pillows were placed on the side of the bed opposite the wall. Surveyor observed Dycem on R3's wheelchair cushion. Surveyor observed R3's Care Plan on the back of the bathroom door. A scoop mattress and Dycem for the wheelchair cushion were not listed on the care plan. In an interview on 12/13/2022 at 2:30 PM, Surveyor asked Certified Nursing Assistant (CNA)-C if R3 had any interventions in place to prevent falls. CNA-C stated R3 gets a fall mat on the floor, but CNA-C stated R3 had only been on the unit for a couple of weeks so did not know R3 very well yet. Surveyor asked CNA-C if R3 should have Dycem in the chair. CNA-C stated the Dycem may have been put in the chair from the other unit to keep R3 from sliding out of the chair because R3 had really long legs, but CNA-C did not know if the Dycem should have been on the cushion or not. On 12/15/2022 at 10:30 AM, Surveyor observed R3 asleep sitting in the wheelchair in R3's room. The call light was in reach, the fall mat was up against the wall, and the mattress in place on the bed was a regular mattress, not a scoop mattress. In an interview on 12/15/2022 at 11:10 AM, Surveyor asked Director of Nursing (DON)-B what the facility process was for reviewing and revising Care Plans. DON-B stated Care Plans are reviewed quarterly, with significant changes, and as needed. Surveyor asked DON-B how falls are investigated, and Care Plans revised after a fall. DON-B stated the IDT meets the next day after a fall occurs to review the fall and determine interventions to address the cause of the fall and then the Care Plan is updated with that intervention. DON-B stated the nursing process is used to develop Care Plans and education has been started with the nurses on the floor to update Care Plans. In an interview on 12/15/2022 at 1:00 PM, Surveyor asked Rehab Director-D if R3 was screened on 12/5/2022 after R3 slid out of the wheelchair. Rehab Director-D stated R3 was already on case load and the fall on 12/5/2022 was discussed on 12/6/2022 with the IDT, of which Rehab Director-D is a part of. Rehab Director-D stated Dycem under the wheelchair cushion is standard for all residents. Rehab Director-D stated R3 has a small upper body and long legs so Rehab Director-D may have put the Dycem on top of the wheelchair cushion at that time but could not recall for certain. Rehab Director-D stated since R3 was already on Physical Therapy caseload, options had been prepared prior to therapy seeing R3 to address the fall out of the wheelchair and the Dycem was implemented on 12/7/2022 when R3 was seen by therapy. Surveyor asked Rehab Director-D if a scoop mattress was discussed with the IDT after R3's fall on 11/3/2022. Rehab Director-D could not recall a scoop mattress as part of the conversation. In an interview on 12/15/2022 at 1:19 PM, Surveyor reviewed with DON-B R3's falls. Surveyor asked DON-B if R3 had a scoop mattress placed on the bed after the fall on 11/3/2022 when the scoop mattress was the recommendation. DON-B stated DON-B would check with maintenance to see if a scoop mattress was ordered and placed on the bed. DON-B stated R3 had changed rooms in the last week or so and the scoop mattress may not have moved with R3. Surveyor asked DON-B if R3's Care Plan should have been revised with Dycem on top of the wheelchair cushion after R3's fall on 12/5/2022. DON-B stated Dycem is a standard on all wheelchairs under the cushion and the Dycem on top of the cushion should have been added to the Falls Care Plan because that is an extra intervention. In an interview on 12/15/2022 at 2:00 PM, DON-B provided the maintenance work order for R3's scoop mattress: the mattress was ordered and placed on the bed on 11/4/2022. DON-B stated R3's bed was not moved when R3 changed rooms. R3 changed rooms on 11/29/2022. DON-B stated if the scoop mattress had been on the Care Plan, the scoop mattress would have moved with R3, or the staff would have been aware R3 needed a scoop mattress. Surveyor noted R3 did not have a scoop mattress on the bed since 11/29/2022. No further information was provided at that time.