**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an environment and required devices to prevent accidents for one of three residents (Resident 47) when Resident 47 had unlocked wheelchair/bed brakes on 1/17/20 and at the time of her fall, on 10/8/19. Resident 47 had also not received an ultra low bed, anti-slid guards, per the plan of care. Furthermore, the facility did not ensure Resident 47 had a fall mat after the fall on 10/8/19. This deficient practice resulted in Resident 47 sustaining a fractured (broken) right clavicle (collarbone) due to an unwitnessed fall on 10/8/19. This deficient practice also raised the risk of reoccurring falls for Resident 47. Findings: During a review of Resident 47's Resident Face Sheet (face sheet), (undated), the face sheet included, a medical diagnoses of Alzheimer's disease (a type of brain disorder causing memory, thinking and behavior problems), old myocardial infarction (the blockage of oxygen rich blood to a section of heart muscle), difficulty in walking, history of falling, muscle weakness, and prediabetes (a condition where blood sugar levels were higher than normal). During a review of Resident 47's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 11/25/19, the MDS indicated, Resident 47 scored a three on the Brief Interview for Mental Status (a structured cognitive test), meaning Resident 47 had severe cognitive impairment. The MDS also indicated, Resident 47 needed physical assistance from one person with transferring (moving between surfaces) and moving in the room. A review of Resident 47's Interdisciplinary Team Notes . Post Fall/Fall Scene Investigation Report (post fall investigation report), dated 10/8/19, the post fall investigation report indicated, on 10/8/19, Resident 47 fractured her right clavicle after the resident had an unwitnessed fall, at 11:45 a.m. The post fall investigation report added, the resident lost balance and fell when she tried to self-ambulate and used the side table as a walker. The post fall investigation report indicated, Wheelchair/bed brakes [were] unlocked at the time of the fall. The post fall investigation report added Resident 47 needed assistance from two certified nursing assistants and one charge nurse, at the time of the fall. During a review of Resident 47's progress notes on 1/16/20 included, notes written by the resident's health care provider and by other disciplines (e.g. nursing, hospice, and the registered dietitian). The progress notes indicated, on 10/8/19, a certified nursing assistant found Resident 47 lying on her bedroom floor. The progress notes indicated, on 10/8/19, Resident 47 reported she was standing up from her bed and was holding onto the bedside table; the bedside table slid, and she lost balance and fell onto her right side. The progress notes included, no documentation the resident's items were within reach and fall precautions were implemented at the time of the fall. The progress notes included, no documentation of Resident 47 having an ultra low bed or anti-slid guards between 10/7/19 and 10/14/19 (including the time of the fall). The progress notes also indicated, Resident 47 received an order for a floor mat and an x ray (using electro magnetic radiation to take images of the inside of the body) of the right shoulder after the fall, on 10/8/19. During a review of Resident 47's radiology (a branch of medicine that uses imaging technology to diagnose and treat disease) interpretation, dated 10/8/19, the radiology interpretation indicated, the resident's oblique fracture involving the lateral aspect of the right clavicle was most likely acute. In other words, the break in the resident's right collar bone occurred suddenly and recently and sudden. During a concurrent observation and interview on 1/14/20, at 9:19 a.m., with Resident 47, in the bedroom of Resident 47, Resident 47 sat in a wheel chair and followed simple questions and/or directions. Resident 47 had instances of repeating herself and answering interview questions inappropriately. A sheet of paper on the resident's bedroom wall included an alert indicating Resident 47 was at risk for falls. There wasn't a floor mat, an ultra low bed, or any anti-slid guards in Resident 47's bedroom. During a review of Resident 47's .Fall Risk Observation (FRO), dated 8/26/19, the fall risk observation indicated, Resident 47 received a fall risk score of 14; a fall risk score of ten or higher .represents a high risk for fall. The FRO indicated, the resident had not been referred to a fall prevention program or any other program. The FRO further indicated the resident's current care plan was continue[d], and not updated. During a review of Resident 47's comprehensive care plan on 1/16/20, the comprehensive care plan included, the revision history and the comprehensive care plan in place at the time of the fall on 10/8/19. Resident 47's most recent comprehensive care plan (as of 1/16/20) included, a fall risk care plan which had edits to the focus and goal on 12/16/19, but the approaches were not edited after 4/30/19. The resident's fall risk care plan included, approaches such as anti-slid guards on the entire length of the floor on the right side of the resident's bed, switching the resident's bed to an ultra low bed, and ensuring the resident's equipment was within reach. The comprehensive care plan included, another care plan regarding the resident's right clavicle fracture sustained after an unwitnessed fall, which was created on 10/8/19 and edited on 12/15/19 (most recent date as of 1/16/20); the care plan regarding the resident's right clavicle fracture sustained after an unwitnessed fall included, approaches such as placing the resident in a fall prevention program and providing a floor mat. During an interview on 1/16/20, at 9:24 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 47 had confusion and balancing issues and was at risk for falls. CNA 1 stated, She [Resident 47] could walk in her room by herself [time frame not provided], except when going to the bathroom . now she needs more physical help. When asked about Resident 47's fall on 10/8/19, CNA 1 responded she wasn't there [did not witness] when Resident 47 was falling, but saw the resident after the fall. CNA 1 stated she was unable to provide details on where the resident's items were, or the height of the resident's bed, at the time of the fall. When asked how was the staff preventing Resident 47 from falling, CNA 1 gave responses such as keeping the bed and wheel chair locked, placing the resident's objects within reach, and having the resident's bed in the lowest position. During a concurrent interview and observation on 1/16/20, at 9:36 a.m., with CNA 1, in the bedroom of Resident 47, CNA 1 asked for the type of bed Resident 47 had, CNA 1 responded a regular bed. After lowering Resident 47's bed to the lowest position, CNA 1 stated the height of Resident 47's bed was not lower than a regular bed. CNA 1 stated, Resident 47 had not been using an ultra low bed at the time of the fall, on 10/8/19. When asked where was Resident 47's floor mat, CNA 1 was unable to find a floor mat in the resident's bedroom. CNA 1 then stated, the resident had not been using a floor mat, adding she can't remember when the floor mat was provided for Resident 47. When asked how using ultra low bed and a floor mat affected a resident's fall, she stated the ultra low beds and a floor mat reduced the impact from a resident's fall. When asked for a description of anti-slid guards, CNA 1 replied, They were used on a floor to reduce sliding. CNA 1 added, there were no anti-slid guards in the Resident 47's bedroom. When asked were anti-slid guards used at the time of Resident 47's fall (on 10/8/19), CNA 1 responded, No . During a concurrent record review and interview on 1/16/20, at 2:33 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 47 was at risk for falls and was in a fall prevention program. LVN 1 stated, Resident 47 needs more assistance than what was needed a year ago. LVN 1 further stated, Resident 47 had unwitnessed fall resulting in a fracture. When asked for details about the fall. LVN 1 stated Resident 47 was found on the floor in her bedroom. LVN 1 stated, the certified nursing assistant entered the resident's bedroom and helped the resident before she arrived, so she was unable to describe where the resident's equipment was, or whether the call light was on or off, at the time of the fall. LVN 1 added, she was unable to provide further information, except that Resident 47 had a history of not using the call light. When asked to provide any care plans with information on falls, at the time of resident's fall, on 10/8/19, LVN 1 reviewed the comprehensive care plan in place at the time of resident's fall, on 10/8/19, and was only able to provide the resident's fall risk the care plan. LVN 1 stated, the care plan shows the resident needed an ultra low bed mattress and anti-slid guards on the floor, at the time of the fall, on 10/8/19. LVN 1 was then asked to review Resident 47's most current (as of 1/16/20) comprehensive care plan for any care plans with information on falls. LVN 1 provided the resident's fall risk care plan and stated the care plan's approaches we're not edited after 4/30/19 and the approaches needs to be edited. LVN 1 then provided the care plan regarding the resident's right clavicle fracture sustained after an unwitnessed fall, and stated this care plan was created after the resident's fall on 10/8/19. LVN 1 could not provide any other care plans with information on falls in Resident 47's most current (as of 1/16/20) comprehensive care plan. LVN 1 reviewed Resident 47's progress notes, between 8/1/19 and 1/16/20, and Resident 47's post fall investigation report, dated 10/8/19. LVN 1 stated, there was no documentation which indicated Resident 47 had been provided an ultra low bed mattress and anti-slid guards on her bedroom floor. During a concurrent interview and observation on 1/16/20, at 2:46 p.m., with LVN 1, in the hallway, Resident 47 sat in her wheel chair while LVN 1 tested the locks on the wheel chair brakes LVN 1 stated, Resident 47's wheelchair brakes were unlocked. LVN 1 added, the brakes on the bed and wheel chair needed to be locked too. LVN 1 added, locking the brakes on the bed and the wheel chair was a standard nursing practice which prevents the bed or wheel chair from rolling or sliding when force or pressure was applied to the bed or wheel chair, e.g. during transferring. During a concurrent interview and observation on 1/16/20, at 2:47 p.m., with LVN 1, in the bedroom of Resident 47, LVN 1 stated, there was no floor mat, ultra low bed, or anti-slid guards in the resident's bedroom. LVN 1 was asked to describe the anti-slid guards, LVN 1 replied, They are used on the floor to prevent falls . [because] it prevents sliding . LVN 1 lowered Resident 47's bed to the lowest position and stated the resident's bed was not lower than a normal resident's bed. When asked when was the last time Resident 47 used an ultra low bed or had anti-slid guards in the resident's bedroom, LVN 1 stated, Never. LVN 1 stated, she did not remember when the floor mat was last used for Resident 47. LVN 1 was asked how a floor mat and ultra low beds affects a resident's fall. LVN 1 replied the use of an ultra low bed and/or a floor mat (or floor mats) reduces the impact of fall which in turn lessened the damage or injury from a fall. During a concurrent interview and observation on 1/16/20, at 3 p.m., with CNA 5, in the bedroom of Resident 47, CNA 5 was unable to find an ultra low bed, the anti-slid guards, or a floor mat in the resident's bedroom. CNA 5 stated Resident 47 had not previously used an ultra low bed or the anti-slid guards. CNA 5 added he did not see the floor mat and was unable to remember when the floor mat was last used. During an interview on 1/17/20, at 8:38 a.m., Rehabilitation Director (Rehab Director) and Physical Therapist (PT), Rehab Director and PT were instructed to describe how to prevent falls and reduce an injury from a fall. Rehab Director stated, . lower the bed . lock the bed . lock the wheel chair .[using] floor mats . PT stated, he agreed with Rehab's answers and added keeping frequently used objects within reach. When asked what anti-slid guards were used for, Rehab Director stated, .To prevent falls by reducing sliding . Rehab Director added sliding results from not enough friction between the floor and another surface; sliding raises the likelihood of slipping and the loss of balance, increasing the risk for falls. PT stated It [anti-slid guards] adds traction. PT added, traction reduced or prevented the sliding motion that often causes a loss of balance and a fall. Rehab Director and PT were asked had Resident 47 been using an ultra low bed, a floor mat, or had anti-slid guards in the resident's bedroom. Rehab Director answered, no. PT denied Resident 47 had been using an ultra low bed or anti-slid guards. Rehab Director further stated, she was unsure if Resident 47 used a floor mat. PT also stated he did not know if Resident 47 used a floor mat. Rehab Director added, Nursing does [the placing and removal of] the floor mats . During a concurrent interview and observation on 1/17/20, at 9:53 a.m., with PT, in the bedroom of Resident 47, Resident 47 laid in bed without a floor mat on the ground. PT could not find a floor mat in the resident's bedroom. When asked about Resident 47's bed, PT stated the resident was using a regular bed, and not an ultra low bed. PT added the height of the resident's bed needs to be lowered to prevent falls. After lowering the height of the bed, PT stated there wasn't a difference between the height of Resident 47's bed and a standard bed in the facility. When instructed to find where Resident 47's bedroom had anti-slid guards, PT stated there were none. During a review of the facility's policy and procedure (P&P) on accident prevention, revised 9/1/16, the P&P indicated, . the facility strives to provide an environment that is free from hazards The P&P added the care and services provided are designed to maximize the safety of the environment, identify residents who are risk of accidents and/or falls and to plan care and implement procedures to prevent avoidable accidents and/or falls; in addition, the facility's care and services are also designed to provide to identified residents who present risks for unavoidable accidents and/or falls and to plan care and implement procedures to minimize unavoidable accidents and/or falls. The P&P continued, Any resident receiving a fall risk score of 10 or above is considered at high risk for potential falls. The resident is placed on a prevention program and the program is care planned[.] The P&P further indicated the interdisciplinary will review, assess, and develop the care plan after a fall occurred. During a review of Resident 47's MDS, dated [DATE], indicated Resident 47 needed only supervision transfers and walking in the room; whereas the MDS dated [DATE] and onwards indicated the resident needed physical assistance with walking and transferring; for example, Resident 47's Significant Change of Status MDS, dated [DATE] (most recent MDS prior the resident's fall on 10/8/19), indicated Resident 47 needed physical assist from two people to transfer and assistance from one person to walk in the room. MDS dated [DATE] and 8/26/19, included a completed care area assessment summary. Both of which included, falls as a triggered care area and that was documented to be addressed in the care plan. During a review of Resident 47's fall risk care plan and resident's right clavicle fracture sustained after an unwitnessed fall, on 1/17/20, included, no documentation of the fall prevention program was added to either of the two care plans prior to 10/8/19. The care plan regarding the resident's right clavicle fracture sustained after an unwitnessed fall had not included a goal involving the resident's falls. The approaches in the resident's fall risk care plan also indicated Resident 47 needed supervision with transfers which was inconsistent with the level of assistance and support Resident 47 required, per the documentation in the post fall investigation, dated 10/8/19 and the MDS dated [DATE] and afterwards.