Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent falls for two of six sampled residents (Residents 1 and 4) when: 1. Nursing staff were aware of Resident 1's cognitive impairment (difficulties with mental processes such as memory, attention, reasoning, and decision making), poor safety awareness, impulsive behaviors of getting up from bed without using the call light, history of falls, and did not implement effective interventions to prevent falls. These failures resulted in Resident 1 suffering avoidable falls on the following dates: 9/30/24, 11/5/24, 12/9/24, 12/16/24, 12/18/24, and 2/1/25. and placed the resident at risk for injury, pain. and suffering. These failures resulted in Resident 1's experiencing five unwitnessed falls prior to the avoidable fall on 2/1/25 with injury, sustaining a (laceration (cut in the skin caused by an injury) above the left eyebrow requiring transportation to the emergency department (ED) for sutures (a row of stitches holding together edges of a wound) and avoidable pain and suffering. Resident 1 had two additional avoidable falls. Resident 1 had a unwitnessed fall in his room on 3/11/25 sustaining a laceration to the forehead which required transportation to the emergency department for evaluation and a additional fall in his room on 3/12/25 opening the same area to his forehead and required transportation back to the emergency department for repair. Resident 1 was diagnosed with a subdural hematoma (pool of blood between the brain and its outermost covering) measuring up to 11 mm (millimeters) (unit of measure) in thickness. Resident 1 passed away on 3/17/25 at ACH from his injuries related to the fall on 3/12/25. 2. Resident 4 was assessed as being a fall risk, had poor safety awareness, impulsive behaviors of standing while unattended and multiple falls and the facility did not implement effective interventions to prevent falls, including adequate supervision consistent with the resident's needs, goals and care. This failure resulted in Resident 4 falling eight times in 30 days, placing him at risk for significant injuries and/or death. Findings: 1. During an observation on 2/13/25 at 8:15 a.m., in Resident 1's room, Resident 1 was lying in bed with eyes closed. Resident 1 had a sutured laceration above his left eye. Resident 1's bed was in low position, fall mat on the floor next to bed on left side, no fall mat on right side. Call light within reach. No staff present in the room. During a review of Resident 1's admission Record (AR- a document containing resident medical and personal information), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia[CE2] (a group of symptoms that affect memory, thinking, and social abilities), abnormalities of gait and mobility, and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 10 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1's cognition was moderately impaired. During a review of the Acute Care Hospital (ACH) document titled, Emergency Department Report, dated 2/1/25, the note indicated . patient is a 93 y.o. [year old] male . presents to the ED [emergency department] after fall. Per skilled nursing facility, patient had an unwitnessed ground level fall in his room between his bed and bathroom door .3-centimeter (unit of measure) (cm) linear (straight line) wound located on the face . Left eyebrow laceration was repaired . follow up for wound check and suture removal . During an interview on 2/13/25 at 9:35 a.m. with Certified Nurse Assistant, (CNA) 1 CNA 1 stated she had provided care for Resident 1 before and was familiar with him. CNA 1 stated Resident 1 was a high fall risk because he would get out of bed and stand without assistance. CNA 1 stated attempts to redirect Resident 1 or remind him to use the call light were not successful because the resident was disoriented and did not remember. CNA 1 stated, Resident 1 does not use his call light when getting out of bed and was not safe to get out of bed by himself. CNA 1 stated, Resident 1 was unsteady on his feet and needed supervision when standing. During an interview on 2/13/25 at 9:50 a.m. with CNA 2, CNA 2 stated she knew Resident 1 and had provided care for him before. CNA 2 stated, Resident 1 would wake up and try to get up out of bed without using the call light to ask for help. CNA 2 stated, Resident 1 was unsteady on his feet and needed supervision when walking. During an interview on 2/13/25 at 10 a.m., with Licensed Vocational Nurse (LVN), LVN stated, Resident 1 was confused and a high risk for falls. LVN stated, Resident 1 does not follow commands and would try to get out of bed without help all the time. LVN stated, Resident 1 would get out of bed without using his call light, stands and tries to walk without supervision or assistance. LVN stated, Resident 1 did not have supervision on 2/1/25 when he got out of bed and fell in his room. LVN stated, Resident 1 needs supervision and continuous monitoring for his safety and was not provided. During an interview on 2/13/25 at 10:20 a.m., with CNA 3, CNA 3 stated, she had provided care to Resident 1 before and was familiar with him. CNA 3 stated, Resident 1 did not use his call light to ask for help. CNA 3 stated, Resident 1 was wobbly and unsteady when standing up. CNA 3 stated Resident 1 was not safe to get out of bed on his own and needed supervision because he was unsteady on his feet. CNA 3 stated, Resident 1 was impulsive and needed one-on-one monitoring (refers to providing residents, focused attention and monitoring, ensuring their safety and wellbeing) to keep him safe and prevent falls. CNA 3 stated one-on one supervision was not provided. During a concurrent interview and record review on 2/13/25 at 10:40 a.m., with Minimum Data Set Coordinator (MDSC), Resident 1's Minimum Data Set (MDS- a standardized assessment tool used for all residents in a skilled in nursing home) dated 2/5/25 was reviewed. The MDS Section C indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool that identifies cognitive impairment levels (0-7 Severe cognitive impairment, 8-12 Mild cognitive impairment and 13-15 Cognitive intact) score of 10, indicating Resident 1 had moderate cognitive impairment. The MDSC stated, Resident 1 would not remember to use the call light to ask for help. The MDSC stated, Resident 1 needed supervision when getting out of bed and when moving from sitting to standing. The MDSC stated, she knew Resident 1 fell in his room while getting out of bed and walking, and that no supervision was provided at the time of the fall on 2/1/25. The MDSC stated, Resident 1 needed supervision due to his cognitive impairment, impulsive behavior, and mobility issues. Resident 1 MDS Section GG (GG-focuses on residents' functional abilities), was reviewed. The MDS section GG indicated Resident 1 needed supervision for getting out of bed, standing, and walking. The MDSC stated, Resident 1's fall on 2/1/25 which resulted to a wound on his face and left eyebrow laceration which required a sutured could have been prevented had he been supervised when getting out of bed, moving from a sitting position to standing, and walking. The MDSC stated, it was the facility's responsibility to keep residents safe from falls resulting in injuries. The MSDC stated, Resident 1 was known to be impulsive, cognitively impaired, and had poor safety awareness. During an interview on 2/13/25 at 11:15 a.m. with CNA 4, CNA 4 stated, he was the CNA assigned to Resident 1 on 2/1/25. CNA 4 stated, Resident 1 was unsteady on his feet, impulsive, cognitively impaired, and had poor safety awareness. CNA 4 stated, Resident 1 would stand up and starts walking without asking for help. CNA 4 stated Resident 1 was wobbly and unstable when walking and was not safe on his own. CNA 4 stated Resident 1 does not recognize the risk of getting out of bed without help. Resident CNA 4 stated, he would walk by Resident 1's room and see him getting out of bed on his own, so he had to quickly enter the room to stop Resident 1 from falling. CNA 4 stated Resident 1 was a high fall risk and does not use his call light. CNA 4 stated, he had reminded Resident 1 to use his call light, but Resident 1 would still stand up and walk without assistance. During a concurrent interview and record review on 2/13/25 at 11:30 a.m. with the Assistant Director of Nursing (ADON), Resident 1's Medical Records (MR) was reviewed. The MR indicated Resident 1 had a fall on 2/1/25 in his room and suffered a laceration to his left brow with bleeding and bruising. The ADON stated, she knew Resident 1 was impulsive, cognitively impaired, and had poor safety awareness. The ADON stated Resident 1's fall on 2/1/25 could have been prevented if a one-on-one monitoring intervention had been put in place to keep him safe from falls. During an interview on 2/13/25 at 12 p.m. with Administrator (ADM), the ADM stated, we need to have the correct interventions in place to keep residents safe. The ADM stated it was our responsibility to keep residents safe. The ADM stated, we did not do enough fall interventions to keep Resident 1 safe from harm. During a concurrent interview and record review on 3/11/25 at 8:30 a.m. with the ADON, Resident 1's falls since 9/25/24 were reviewed. The falls were as follows: 9/30/24 at 12 a.m. Found on the floor next to bed 11/05/24 at 7:04 p.m. Found on the floor next to bed 12/09/24 at 4:00 p.m. Found on the floor next to bed 12/16/24 at 10:00 p.m. Found on the floor next to bed 12/18/24 at 9:09 a.m. Found on the floor next to bed 2/1/25 at 4:12 p.m. Found on the floor next to bed ADON stated, Resident 1's falls occurred while Resident 1 was in his room. ADON reviewed Resident 1's care plan dated 2/10/25, the care plan indicated, . resident is (high) risk for falls with injury r/t [related to] unsteady gait, poor balance . history of falls, poor safety awareness d/t [due to] DX [diagnosis] Dementia (a group of symptoms characterized by a decline in memory, thinking, and social abilities), hx [history of] multiple falls, non-compliance, impulsive behaviors . Interventions . Toileting scheduled . Anticipate and meet needs . Keep call light within reach . Educate remind resident to call for assistance with all transfers .encourage room change closer to the nurses station . Encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility .Falling Star Program [a program in nursing homes uses a visual cue, like a falling star graphic on resident's door, to flag high-risk fall residents] .Keep personal items frequently used within reach .Landing mat to left side of bed . IDT [Interdisciplinary Team- a group of healthcare professionals who collaborate to provide comprehensive, individualized care for residents] Recommends . Non-skid strips to left side of bed .Bowel and Bladder Program (a structured plan designed to help individual manage their bowel and bladder functions) every 2 hours .Room change closer to nurses station .Fall mats to both sides of bed .Falling Star Program .Educate remind resident to call for assistance with all transfers . The ADON stated Resident 1's falls occurred while he was in his room and the interventions of keeping call light within reach, and encouraging to use would not address the cause of the falls, which occurred when he was unsupervised in his room. During a concurrent observation and interview on 3/24/25 at 9:30 a.m. with LVN 2 in the hallway by Resident 1's room, the name tag listing name of residents in the room by the doorway was missing a name for Resident 1. LVN 2 stated, Resident 1 had a fall on 3/11/25 and 3/12/25. LVN stated, Resident 1 was sent to ACH on 3/12/25 and had not returned. During a telephone interview on 3/26/25 at 11:08 a.m. with CNA 5, CNA 5 stated, she was assigned to Resident 1on 3/12/25 at the time of his fall. CNA 5 stated, Resident 1 was confused and would get out of bed by himself to go to the bathroom. CNA 5 stated, we tried to keep an eye on him when passing by his room. CNA 5 stated, she walked by his room and saw Resident 1 lying on the floor at the foot of his bed and partially in the open bathroom door. CNA 5 stated, she did not witness the fall and found him on the floor. CNA 5 stated she ran into his room and saw a small puddle of blood by his head. CNA 5 stated, Resident 1 was groaning while on the floor. CNA 5 stated, Resident 1 was bleeding from his forehead and blood was running down his face when CNA 5 and LVN assisted him to a sitting position on the side of his bed. CNA 5 stated, staff member came into the room to assist her in changing Resident 1's shirt and jacket due to blood on his clothing. CNA 5 stated, she stayed with Resident 1 and assisted him back into bed. CNA 1 stated, Resident 1 vomited and she alerted the LVN. CNA 5 stated, she was not in the room at the time of the fall providing care to other residents in the room. During a telephone interview on 3/27 /25 at 10:27 a.m. with ADON, ADON stated, Resident 1 had an unwitnessed fall on 3/11/25 at 7:24 p.m. in his room. ADON stated, Resident 1 was found on the floor by his bed. ADON stated, Resident 1 was bleeding from his forehead and was sent to ACH. ADON stated, Resident 1 returned from ACH on 3/12/25 at 1:22 a.m. During a telephone interview on 3/27/25 at 1:00 p.m. with ADON, ADON stated, Resident 1 had a fall in his room on 3/12/25 at 7:03 p.m. ADON stated, Resident 1 was found lying on the floor and assisted back to bed by staff. ADON stated, Resident 1 was sent to ACH on 3/12/25 and has not returned. ADON stated, Resident 1 was taking [name of medication] to thin his blood which could cause excessive bleeding with any injuries from a fall. ADON stated, Resident 1 was a high fall risk due to the history of his falls and had the potential for life threatening outcomes. During a record review of the Resident 1's falls since 9/25/24 were reviewed. The falls were as follows: 9/30/24 at 12 a.m. Found on the floor next to bed 11/05/24 at 7:04 p.m. Found on the floor next to bed 12/09/24 at 4:00 p.m. Found on the floor next to bed 12/16/24 at 10:00 p.m. Found on the floor next to bed 12/18/24 at 9:09 a.m. Found on the floor next to bed 2/1/25 at 4:12 p.m. Found on the floor next to bed 3/11/25 at 7:24 p.m. Found on floor next to bed 3/12/25 at 7:03 p.m. Found on floor next to bed During a review of the Acute Care Hospital (ACH) document titled, ED Physicians Notes, dated 3/11/25, at 9:08 p.m. the note indicated ( . patient is a 93 y.o. [year old] male . presents to the ED [emergency department] after a fall out of bed and hit his forehead .2 cm (centimeter) (unit of measure) mid forehead superficial (occurring on the skin or immediately beneath it) abrasion (a area damaged by scrapping) .Diagnosis, Mechanical Fall, forehead abrasion, severe dementia . During a review of the Acute Care Hospital (ACH) document titled, ED Physicians Notes, dated 3/12/25, at 8:10 p.m. the note indicated ( . patient is a 93 y.o. [year old] male . presents to the ED [emergency department] after a fall out of bed and hit his forehead .CT scan of head was performed indicating Intracranial hemorrhage (life threatening medical emergency when blood leaks inside or between the brain and skull) of left frontal , subdural hematoma ( pool of blood between the brain and its outermost covering) measuring up to 11 mm (millimeters) (unit of measure) in thickness and small volume left parietal subarachnoid hemorrhage (a type of stroke where bleeding occurs in the space between the brain and the tissues covering it) . Patient presents after a fall with head trauma while on blood thinner medication placing him at high risk for intracranial hemorrhage .Intensive Care Unit (ICU) physician was consulted, who requested to transfer the patient to neuro [neurological] ICU .[Name of ACH] [Name of Neurosurgeon] was consulted who then spoke to family in regards to potential management for this patient .Eventually family decided that they do not want to pursue any neurological intervention and did not want him transferred to another facility .Prefer that the patient stays here at this hospital .Resident 1 passed away on 3/17/25 . During a record review of the Death Certificate for Resident 1, indicated . Cause of Death as Cardiopulmonary Arrest (Cardiac arrest-sudden loss of heart function) and Subdural Hematoma w/loc (loss of consciousness-unresponsive to stimuli) status . During a review of the facility's Policy and Procedure titled Falls and Fall Risk Managing, dated 3/2018, the P&P indicated, .Based on previous evaluations and current data, staff may identify interventions related to the resident's specific risks and causes in the attempt to reduce falls and minimize complications from falling .Resident centered fall prevention plans should be reviewed and revised as appropriate .If the resident continues to fall, the situation should be reevaluated to determine whether it would be appropriate to continue or change current interventions. During a review of the facility's P&P titled Safety and Supervision of Residents, dated 7/2017, the P&P indicated, . Our facility strives to make the environment as free from accident hazards as possible . Safety risks and environmental hazards are identified on an ongoing basis . When accident hazards are identified, the QAPI [Quality Assurance and Performance Improvement- is a data driven, proactive approach to improve the quality of care in nursing homes]/safety committee shall evaluate and analyze the cause(s) . Employees shall be trained on potential accident hazards and demonstrate competency . and try to prevent avoidable accidents . Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents . care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices . ` During a review of the facility's P&P titled Fall Prevention Program/Falling Star, updated 2/3/25, the P & P indicated .Staff to assist resident to the bathroom before meals, after meals, at bedtime and as needed .Resident not to be left alone in room while out of bed . During a review of a professional reference located at https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess2.html titled Module 3: Falls Prevention and Management, dated 10/2014, the reference indicated, . An important job for licensed nurses is to assess residents' risk of falling. This is best done using a protocol or instrument that asks the licensed nurse to look at or test several features about the residents . Implement an individualized care plan . nursing should add an individualized approach for falls to the resident's care plan . An individualized care plan for falls is not a one-time solution. Licensed nurses and other staff must revisit the plan to make sure it is effective in preventing additional falls and injuries from falls . 2. During a review of Resident 4's admission Record, undated, the admission record indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses which included fracture (break in bone) of the skull, muscle weakness, abnormalities of gait (pattern of walking) and mobility (ability to move freely), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), cognitive (relating to the mental process involved in knowing, learning, and understanding) communication deficit (communication difficulty caused by cognitive impairment), cerebral infarction (condition where blood flow to the brain is blocked, causing brain tissue damage), nontraumatic intracerebral hemorrhage (bleeding occurs within the brain tissue), traumatic subdural hemorrhage (collection of blood between the brain and inner layer of skull) and traumatic subarachnoid hemorrhage (type of stroke) with loss of consciousness (state of being awake). During a review of Residents 4's MDS assessment dated [DATE], indicated Resident 4's BIMS scored 09 of 15. The BIMS assessment indicated Resident 4's cognition was moderately impaired. During an interview on 4/3/25 at 2:56 p.m. with CNA 6, CNA 6 stated she was familiar with Resident 4 and had taken care of him prior to his discharge. CNA 6 stated Resident 4 was very confused, difficult to communicate with and impulsive. CNA 6 stated Resident 4 was very weak and unable to stand safely by himself but had behaviors of standing up suddenly and falling. CNA 6 stated Resident 4 was very confused and did not realize how weak he was and that it was not safe for him to stand on his own. CNA 6 stated at Resident 4 was on every 15-minute checks but still had falls. CNA 6 stated Resident 4 would have required one on one (1:1) supervision (constant staff supervision) to prevent him from falling. During a concurrent interview and record review on 4/3/25 at 3:29 p.m. with LVN 2 Resident 4's falls were reviewed. The falls were as follows: 1/19/25-Resident fell trying to get off bed 1/23/25-Resident fell getting out of wheelchair 1/28/25-8:45 a.m. Resident found on floor 1/28/25-3:17 p.m. Resident found on floor 2/2/25-Resident on floor, dragging self out of room asking staff to put him into wheelchair 2/4/25-Resident fell getting up from wheelchair across from nurses' station 2/10/25-Resident fell in dining room 2/14/25-Resident fell across from nurses' station LVN 2 stated Resident 4 was at high risk for falls because he had non-compliant behaviors, was constantly trying to get up unsupervised, had weak legs and poor balance. LVN 2 stated Resident 4's primary language was not English which caused some communication issues. LVN 2 stated she thought he could understand the reminders to call for help but could not retain it due to cognition. LVN 2 stated Resident 4 was stubborn and would continue to do what he wanted to do even if it was not safe. LVN 2 stated Resident 4 was never placed on 1:1 supervision, and the only way to prevent falls would have been for staff to always stay with the resident. LVN 2 stated she would keep the resident close to the nurse's station when she was sitting there, and he did not fall when she had him under constant supervision because she could redirect him quickly. Resident 4's fall risk scores (0-8 low risk, 9-15 moderate risk, 16-42 high risk) were reviewed. Resident 4's fall risk scores were reviewed as follows: 1/17/25 score 10, moderate risk for falls 1/23/25 score 14, moderate risk for falls 1/28/25 score 22, high risk for falls 1/28/25 score 20, high risk for falls 2/4/25 score 20, high risk for falls 2/10/25 score 20, high risk for falls 2/14/25 score 22, high risk for falls LVN 2 stated Resident 4 was a moderate risk for falls when he was admitted but his fall risk increased as he continued to have falls. Resident 4's care plans were reviewed, LVN 2 stated she was unable to locate any fall risk care plan interventions before his first fall on 1/19/25. LVN 2 stated there were no fall prevention interventions in the care plan until his fall on 2/4/25. LVN 2 stated Resident 4 was on hourly checks, but it was not documented on the care plan and should have been. LVN 2 stated care plans were important because they direct the resident's care. LVN 2 stated care plans were used to involve the residents in their care, indicate what interventions are needed to meet their needs, included details about the resident's life including the treatments provided and physician ordered interventions. During a telephone interview on 4/4/25 at 7:50 a.m., with Family Member (FM) 2, FM 2 stated he was Resident 4's responsible party. FM 2 stated Resident 4 had frequent falls while at the facility and he did not feel like the facility did enough to prevent the resident's falls. FM 2 stated Resident 4 was agitated which caused him to stand up frequently and then he would fall, but he did not feel like the facility addressed the issue and the resident kept falling. During a review of Resident 4's Nurse's Note, dated 1/19/25, the note indicated, . At around 0120 [1:20 a.m.], writer was sitting at nurses station charting . notified by resident roommate, that roommate had fell trying to get off bed . Upon entering the room, the resident was found on the floor on right side of his bed, facedown with head facility the head of the bed . resident stated was trying to go to the restroom. Resident stated to have a headache . During a review of Resident 4's Interdisciplinary Team (IDT-Interdisciplinary Team- involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities for the best interest of the resident) note dated 1/29/25 at 10:21 a.m., the IDT note indicated, . IDT met on 01/20/25 to discuss resident's fall on 01/19/25 . IDT intervention: Resident added to B&B program X4 hours . During a review of Resident 4's SBAR, dated 1/23/25, the SBAR indicated, . change in condition, symptoms, or signs observed and evaluated is/are: Falls . 01/23/25 . During a review of Resident 4's Alert Charting, dated 1/23/25 at 9:10 p.m., the note indicated, . Approximately 2110 [9:10 p.m.] . notified by staff member, resident fell trying to get out of wheelchair . resident was found on the floor on left side, face down . resident stated was trying to get to bed . During a review of Resident 4's IDT Note, dated 1/24/25, the note indicated, . IDT met to discuss resident's fall on 01/23/25 . IDT intervention: Non-skid material to wheelchair & Resident will be added to falling star program. Resident's last fall was 01/19/2025 . During a review of Resident 4's SBAR, dated 1/28/25 at 8:50 a.m., the SBAR indicated, . writer was called into resident room by residents roommate. Upon entering room, resident found on the floor on his bottom, his head against roommates' foot board . During a review of Resident 4's Nurses Notes, dated 1/28/25 at 3:25 p.m., the note indicated, . called into resident room by CNA and activity director stating that resident was on floor kneeling with back to bed and him facing the table. Writer went to go observe and noted resident was on floor on both knees with back to bed and him facing the table. Resident wheelchair was next to him . During a review of Resident 4's Nurse's Note, dated 2/4/25 at 2:00 p.m., the note indicated, . resident sitting across from nurses station, resident [resident] stood up and was very unsteady and week [weak] . This writer attempted to reach resident to sit him back in wheelchair and resident fell onto floor, fall witnessed and resident assisted back onto his feet and placed back in wheelchair . During a review of Resident 4's IDT Note, dated 2/5/25 at 9:54 a.m., the note indicated, . IDT met to discuss resident's fall on 02/04/2025 . IDT intervention: Resident placed on 1 hour checks. SSD [Social Services Director] scheduled a care conference for 02/14/2025 to discuss POC [plan of care] with family . During a review of Resident 4's Nurse's Note, dated 2/10/25 at 7:50 a.m., the note indicated, . On 2/10/25 at approx. [approximately] 0655 [6:55 a.m.] CNA called writer to dining room due to resident having unwitnessed fall. Upon entering dining room resident noted to be laying on floor on his bottom his wheelchair behind him . Resident was noted with no socks . During a review of Resident 4's IDT Note, dated 2/11/25 at 9:36 a.m., the note indicated, . IDT met to discuss [discuss] resident's fall on 02/10/2025 . IDT recommendations: Sensory pad to bed & wheel chair. Nursing to obtain consent . During a review of Resident 4's SBAR, dated 2/14/25, the SBAR indicated, . change in condition . Falls . 02/14/2025 . Writer approaching nurses station and CNA states resident had fallen. Resident noted to be sitting in wheelchair. CNA x2 had assisted resident back to chair without waiting for writer to asses resident . Resident continued to stand up being non compliant . Resident unable to give description . During a review of Resident 4's IDT note, dated 2/17/25 at 4:47 p.m., the IDT note indicated, . IDT met to discuss resident's fall on 02/14/2025 . Resident is currently out at acute care hospital. Upon his readmission resident will be placed on Q2 [every two] hour checks . During a concurrent interview and record review on 4/4/25 at 9:12 a.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 4 was a resident at the facility for one month. The ADON stated, he had a few falls. I'm not sure how many. Resident 4's fall risk care plan was reviewed. The care plan indicated, . Resident is at risk for falls with or without injury . unwitnessed fall on 1-19-25 . witnessed fall on 1-23-25 . witnessed fall 2/4/25 . Unwitnessed fall 2/10/25 . Unwitnessed fall 2/14/25 . Date initiated 1/17/2025 . Will minimize risk for falls to extent possible . Date initiated: 2/4/25 . Add sensor pad [a device used to monitor patients to ensure they do not rise from the bed or chair on their own to reduce falls] to bed and wheelchair . Date initiated: 2/04/25 . Add to B&B [bowel and bladder program-scheduled toileting] Q [every] 2 hours . Anticipate and meet needs . falling star program . Keep bed in low position with brakes locked . Keep call light within reach . Keep personal items frequently used within reach . Non skid material [flexible material used to prevent slipping] to w/c [wheelchair] . The ADON stated she was unable to find a fall risk care plan with interventions before 2/4/25. The ADON stated care plans were used to provide person-centered care for each resident and should have measurable objectives and the interventions reflecting the residents abilities to perform ADLs and transfers. The ADON stated the cause of Resident 4's falls was his need to get up. The ADON stated the facility did not place Resident 4 on 1:1 supervision, but he was placed on every hour checks. The ADON stated Resident 4 did continue to have falls while on every hour supervision. The ADON stated Resident 4 should not have stood up without staff assistance because he needed supervision for safety. Resident 4's Nurse's Note, dated 2/2/25 at 7:57 p.m. was reviewed. The note indicated, . Upon shift change, resident on the floor on his bottom dragging himself out of room asking staff to put him in his wheelchair . staff transferred resident from floor to w/c. Resident noncompliant with use of call light, and wheelchair . The ADON stated the note did not specify the resident fell and she was unsure what dragging himself out of room referred to. Resident 4's SBAR, dated 2/2/25 was reviewed and indicated, . lump to left forehead, No changes o[TRUNCATED]