**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and records review, the facility failed to ensure two of two sampled residents (Resident 1 and Resident 2) were free from accidents, when: 1. The facility did not provide two-person assistance to Resident 1 during care, when Resident 1 was dependent (resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) from staff to maintain perineal hygiene (washing the genital and rectal areas of the body) and to turn in bed. This failure resulted in Resident 1 rolling over while receiving perineal care and falling on the other side of the bed sustaining a left tibia (the inner and usually larger of the two bones of the leg between the knee and ankle) fracture (a break on the bone). 2. The facility staff took more than an hour to answer Resident 2's call light (an alerting device for nurses or other nursing personnel to assist a patient when in need), when Resident 2 turned on her call light for assistance to use the toilet. This failure resulted in Resident 2 falling on the floor while attempting to get out of bed without staff assistance, causing Resident 2 to experience neck pain and headache. Resident 2 subsequently was sent to the hospital for complaint of dizziness. Findings: Resident 1 A review of the admission Record indicated Resident 1 was admitted on [DATE], with diagnoses including but not limited to Cerebral Infarction (also known as stroke) and Muscle Weakness. A review of the Activities of Daily Living (ADL - the tasks of everyday life like eating, dressing, getting into or out of a bed or chair, turning in bed, taking a bath or shower, and using the toilet), Care Plan, revised on 9/23/21, indicated Resident 1 was totally dependent on staff for all ADLs. A review of the Minimum Data Set (MDS -health status screening and assessment tool used for all residents), dated 3/15/24, indicated Resident 1 had a BIMS score of 02 out of 15 points (Brief Interview for Mental Status, a 15-point cognitive [relating to the mental process involved in knowing, learning, and understanding things] screening measure that evaluates memory and orientation. A score of 00 to 07 is severe impairment). The MDS indicated Resident 1 had functional limitations in range of motion (ROM - the extent or limit to which a part of the body can be moved around a joint or a fixed point) to both upper and lower extremities. The MDS indicated Resident 1 was dependent on staff to maintain perineal hygiene and to turn in bed. A review of the Progress Note, dated 3/22/24 at 7:11 a.m., indicated around 6 a.m. on 3/22/24, Resident 1 fell out of bed. The Progress Note indicated Resident 1 had contusion (also known as bruise) and swelling close to her right eye. Resident 1 also had left shin swelling and bruising. The Progress Note indicated the NP (Nurse Practitioner - nurse who has advanced clinical education and training) ordered an X-ray (a type of medical imaging that creates pictures of the bones and soft tissues) and to send Resident 1 out to the hospital if her condition changed. A review of the X-ray report, dated 3/22/24 at 11:29 a.m., indicated Resident 1 had left tibia fracture. A review of the Progress Note, dated 3/23/24 at 1 a.m., indicated Resident 1 returned to the facility around 11 p.m., with a cast (holds a broken bone in place and prevents the area around it from moving as it heals) above her left knee. The Progress Note indicated Resident 1 had a fracture to her left tibia. During an interview with Unlicensed Staff A on 5/03/24 at 10:54 a.m., when Unlicensed Staff A was asked how much assistance was needed to turn Resident 1 in bed, Unlicensed Staff A stated Resident 1 was dependent from staff with turning and repositioning. When Unlicensed Staff A was asked how many staff were required to assist dependent resident with turning in bed, Unlicensed Staff A stated at least two staff. She stated Resident 1 had contractures (a fixed tightening of muscle, tendons, ligaments, or skin preventing normal movement of the associated body part) and could not help with turning. She stated she would always ask another staff to help her when providing care, for safety. During an interview with Licensed Staff B on 5/03/24 at 11:02 a.m., when Licensed Staff B was asked how much assistance was needed to turn Resident 1 in bed, Licensed Staff B stated Resident 1 was dependent on staff with turning and repositioning. During an observation in Resident 1's room on 5/03/24 at 11:08 a.m. with Licensed Staff B, Resident 1 was sitting on a geriatric chair (a large, padded chair that is designed to help seniors with limited mobility) with her right leg flexed and left leg extended. Resident 1 appeared uncomfortable, grimacing, face reddened and moaning. Resident 1 was nonverbal. During an interview with the Director of Nursing (DON) on 5/03/24 at 11:11 a.m., when the DON was asked about the fall incident on 3/22/24, involving Resident 1, the DON stated, when Unlicensed Staff C was providing care to Resident 1, Resident 1 inadvertently moved and accidentally fell on the other side of the bed. The DON stated Unlicensed Staff C could not move fast enough on the other side of the bed to catch Resident 1. When the DON was asked how many staff was required to assist a dependent resident with turning in bed, the DON stated usually one to two staff. During a telephone interview with Unlicensed Staff C on 5/03/24 at 12:16 p.m., when Unlicensed Staff C was asked about the fall incident involving Resident 1, Unlicensed Staff C stated he was providing care to Resident 1 when the incident happened. He stated Resident 1 was turned on her side when Resident 1 suddenly moved, rolled over and fell out of bed. When Unlicensed Staff C was asked how much assistance was needed to turn Resident 1 in bed, Unlicensed Staff C stated Resident 1 was dependent on staff with two-person assist. However, he stated he had been providing care to Resident 1 with no help from other staff for a long time and was familiar with Resident 1. Resident 2 A review of the admission Record indicated Resident 2 was admitted on [DATE], with diagnoses including but not limited to left side Hemiplegia (the loss of the ability to move [and sometimes to feel anything] one side of the body) and Hypertension (high blood pressure). A review of the MDS, dated [DATE], indicated Resident 2 had a BIMS score of 14 out of 15 (a score of 13 to 15 is cognitively intact). The MDS indicated Resident 2 required Substantial/maximal assistance (Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting, hygiene; toilet transfer; and chair/bed-to-chair transfer. Resident 2 was always incontinent (unable to voluntarily control retention of urine or feces in the body) with bowel and bladder function. A review of the ADL Functioning with Self-Care Deficit Care Plan, initiated on 3/25/24, indicated Resident 2 required substantial assistance with ADL. A review of the Progress Note, dated 4/23/24 at 8:01 p.m., indicated Resident 2 was found lying on her right arm on the left side of the bed and complained of neck pain and headache on 4/23/24. The Progress Note indicated Resident 2 was subsequently sent to the hospital on 4/23/24, for complaint of dizziness. During an interview with Unlicensed Staff D on 5/03/24 at 10:57 a.m., when Unlicensed Staff D was asked how much assistance was needed to transfer Resident 2 from her bed/wheelchair-to-bed, Unlicensed Staff D stated Resident 2 was dependent with transfer requiring two staff assistance. During an interview with Licensed Staff B on 5/03/24 at 11:05 a.m., when Licensed Staff B was asked how much assistance was needed to transfer Resident 2 from her bed/wheelchair-to-bed, Licensed Staff B stated Resident 2 was dependent with transfer requiring two staff assistance. During an interview with DON on 5/03/24 at 11:11 a.m., when the DON was asked about the fall incident on 4/23/24, involving Resident 2, the DON stated Resident 2 was taking Lactulose (used in the treatment of constipation (a problem with passing stool [poop]) and hepatic encephalopathy (a disorder caused by a buildup of toxins in the brain that can happen with advanced liver disease) causing Resident 2 to have loose bowel movement. She stated the CNA (Certified Nursing Assistant) had just gone to Resident 2's room to provide bowel incontinence care. The DON stated, when Resident 2 turned her call light again for assistance, the CNA was busy assisting other residents, and when the nurse went to answer Resident 2's call light, Resident 2 was already on the floor. During an observation and concurrent interview with Resident 2 in her room on 5/03/24 at 11:27 a.m., Resident 2 was sitting in her wheelchair waiting for staff to assist her back to bed. She stated she had asked the staff thirty minutes ago to assist her back to bed because her back was hurting but nobody had come to help her. When Resident 2 was asked about her fall incident on 4/23/24, Resident 2 stated she turned her call light for assistance because she was, all covered with poop. She stated an unidentified staff came and told her she would be right back. Resident 2 stated one hour, and twenty minutes past but nobody came to help her, so she decided to get up to use the toilet and fell on the floor. Resident 2 stated she had neck pain, headache and felt dizzy after the fall and ended up going to the hospital. When Resident 2 was asked how much help she needed to transfer from her bed to her wheelchair, Resident 2 stated her left side was paralyzed (unable to move or feel all or part of the body), and she always needed two persons to help her. A review of the Facility policy and procedure titled, Activities of Daily Living (ADLs), Supporting, revised on March 2018, indicated, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: . b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident receive care consistent with professional standards of practice when one out of two sampled residents (Resident 1), who entered the facility without pressure ulcers, did not develop pressure ulcers when Resident 1 developed 4 pressure ulcers: one stage 4 pressure ulcer (PU, the most serious type of pressure ulcer, it extend below the muscle, tendons, and in severe cases, the bone) on his sacrum (the bottom of the spine) and three stage 2 pressure ulcers (PU that extend through deeper tissue and fat but do not reach muscle or bone) on his right inner foot, left inner proximal (near the center) foot and left inner distal (away from the center) foot. These failures led to treatments with antibiotic (medicines that fight infections caused by bacteria) and debridement (the removal of dead or infected skin tissue to help a wound heal). These failures also led to Resident 1 not being able to reach his highest physical level of well-being. Findings: During a review of Resident 1 ' s face sheet (demographics), it indicated he was [AGE] years old with a diagnoses of Stage 4 Pressure Ulcer of the sacral region (the portion of the spine - the row of bones down your back, between your lower back and tailbone), Type 2 Diabetes Mellitus (DM, a disease that occurs when your blood glucose, also called blood sugar, is too high), Urinary Incontinence (the unintentional passing of urine) and Full Incontinence of feces (the accidental passing of bowel movements). His Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 9/25/23,Brief Interview for Mental Status Assessment (BIMS, a screen used to assist with identifying a resident's current cognition (the conscious and unconscious processes involved in thinking, perceiving, and reasoning) and to help determine if any interventions need to occur) indicated he had a moderately impaired cognition ( poor decision making, needs cues and supervisions with decision making). Resident 1 was dependent on staff assistance with his Activities of Daily Living (ADL ' s, activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Resident 1 was incontinent of bowel but wears a urinary catheter (a medical device, a tube that carries urine out of the bladder (urethra). His MDS section M skin assessment indicated he was at risk for developing pressure ulcers and he had 1 stage 4 pressure ulcer and 2 stage 2 pressure ulcers. In comparison, Resident 1 ' s MDS assessment section M (skin assessment) dated 1/27/23 indicated he was at risk for developing pressure ulcers and he had no pressure ulcers at that time. The MDS assessment dated [DATE] indicated Resident 1 was not on a turning and repositioning program (turning people to change their body position to relieve or redistribute pressure). During an interview on 1/28/23 at 2:11 p.m., Unlicensed Staff A stated residents could have pressure ulcer due to staff not turning and repositioning residents every 2 hours and not providing incontinence care every 2 hours. Unlicensed Staff A stated staff try their best, but it was difficult for staff to turn, reposition and provide incontinence care to the residents every 2 hours when they were frequently short staffed. Unlicensed Staff A stated not turning and repositioning resident and not providing incontinence care every 2 hours could lead to the development of pressure ulcer and wound infection. Unlicensed Staff A stated residents could get sick and hospitalized . During an interview on 11/28/23 at 2:33 p.m., Unlicensed Staff B stated to prevent pressure ulcer to develop, the facility policy was to ensure residents were provided incontinence care every 2 hours and as needed and turned and repositioned every 2 hours. Unlicensed Staff B stated these tasks were hard to follow as the facility was frequently short staffed. Unlicensed Staff B stated not turning and repositioning residents every 2 hours and leaving residents wet or soiled for prolonged time could lead to the development of pressure ulcer, pain and infection. During an observation on 11/28/23 at 2:51 p.m., Resident 1 was asleep while lying on his back. During a concurrent interview and electronic treatment administration record (eTAR, a system used by nurses in long term care facilities to ensure that treatment was rendered accurately and reliably) on 11/28/23 at 3:17 p.m., the MDS coordinator (a nurse that assess and evaluate the quality of care being given to long-term care residents)verified Resident 1 continued to be treated with an antibiotic per physician ' s order due to active wound infection and prophylaxis (all the things people do to prevent disease). During a concurrent interview and Braden skin assessment (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure ulcer)record review on 11/28/23 at 3:21 p.m., the MDS stated the initial Braden skin assessment done for Resident 1 on 7/17/2019 score was 17, indicating Resident 1 was at risk for pressure ulcer development. The MDS coordinator stated Resident 1 should have been placed on skin intervention such as turning and repositioning every 2 hours and incontinence care every 2 hours per facility policy. The MDS coordinator verified there was no wound Interdisciplinary Team (IDT, a group of dedicated healthcare professionals who work together to provide you with the care you need, when you need it) note created for the Resident 1 when he started acquiring pressure sores. The MDS coordinator stated there was no care plan that specifically addressed Resident 1 ' s risk factors for developing pressure ulcer when he was initially admitted . The MDS coordinator stated there were no care plans created when Resident 1 initially had an unstageable (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic (death of body tissue) tissue or by an eschar (dead tissue that sheds or falls off from the skin) pressure sore on his sacrum. The MDS coordinator stated Resident 1 ' s pressure ulcer care plan was not updated to reflect the status of the pressure ulcer on his right and left inner foot. The MDS coordinator stated the pressure ulcer care plan for sacrum and the right and left inner foot does not really reflect the current treatment being provided for the resident. The MDS coordinator stated care plans were supposed reflect current status, treatment and interventions being provided for the residents. The MDS coordinator stated that in this case, Resident 1 ' s care plan was not updated and was not reflective of Resident 1 ' s current pressure ulcer status. The MDS coordinator stated it was important a care plan was created and updated because this would help staff to determine what type of care the resident need. The MDS coordinator stated Resident 1 currently had 4 pressure ulcers, the biggest and the worst was the one on sacrum at stage 4. The MDS coordinator stated Resident 1 was admitted at the facility with no pressure ulcer. The MDS coordinator verified Resident 1 developed the pressure ulcers on his sacrum, right inner foot, left inner proximal foot and left inner distal foot at the facility. During an interview on 11/28/23 at 3:36 p.m., Licensed Staff C stated staff would need to closely monitor and assess residents for skin issues, turn and reposition residents at least every 2 hours and incontinence care should be provided every 2 hours to prevent pressure ulcer to develop. Licensed Staff C stated Resident 1 was dependent on staff for provision of care. Licensed Staff C stated Resident 1 ' s pressure ulcers could have been prevented if staff were monitoring and assessing Resident 1 ' s skin regularly and closely and Resident 1 was being turned and reposition every 2 hours regularly. Licensed Staff C stated it was difficult for staff to turn and reposition residents every 2 hours and provide incontinence care every 2 hours when the facility was frequently short staffed. When asked what could happen if residents were left in the same position for an extended period of time or if residents were left soiled or wet for extended period of time, Licensed Staff C stated residents could develop pressure ulcer, pressure ulcer will increase in size, pressure ulcer could worsen and wound infection could develop. During a visual observation on 11/28/23 at 4:48 p.m., Resident 1 was still in lying on his back. Resident 1 was observed in the same position as seen earlier today at 2:51 p.m. During a telephone interview on 11/30/23 at 1:16 p.m., the Administrator stated nurses were expected to document skin issues and treatment provided for the residents. The Administrator stated if the treatment order on the eTAR was left blank, it could mean that specific treatment was not done. The Administrator stated if it was not documented then it did not happen. When asked what the risk for missing treatment could be, he stated, if it was ordered by the physician then a treatment should be done. During a telephone interview on 11/30/23 at 1:38 p.m., the Director of Nursing (DON) stated staff were expected to document skin status of the residents weekly, and every time there were skin issues. The DON stated to prevent the development of pressure ulcer, staff were expected to turn and reposition the residents every 1 to 2 hours and to offer incontinence care and toileting every 1 to 2 hours as needed. The DON stated residents not being turned and repositioned every 1to 2 hours and residents being left soiled and wet for extended period could develop pressure ulcer and wound infection. When asked what the risk for resident could be if they have a pressure sore and was left wet or soiled for extended period, the DON stated, the wound could worsen and there was a possibility of wound infection. During a telephone interview on 12/1/23 at 2:24 p.m., when asked if she was aware there were no weekly skin checks being completed for Resident 1, the DON stated no. When asked if she was aware the pressure ulcer care plan for Resident 1 was not updated and does not reflect the current status of Resident 1 ' s pressure ulcer and treatment, the DON stated they were trying to do better. The DON stated they knew it was an issue. The DON verified the nurses were signing off on the eTAR indicating they were assessing the resident skin weekly, however the facility was not able to provide documentations nurses were assessing Resident 1 ' s skin weekly. When asked what the risk for the residents could be if staff were not assessing the resident skin weekly, the DON stated staff could miss a skin issue that was starting to develop, and this skin issue could worsen. The DON stated treatment should be done per physician ' s order. The DON stated if an eTAR was left blank, then it meant the treatment was not done. The DON stated it meant the physician order was not followed. When asked what the risk could be if a treatment for pressure ulcer was missed, the DON stated the wound could worsen and could be infected. During a telephone interview on 12/1/23 at 3:19 p.m., the MDS coordinator verified Resident 1 did not have documentations his skin was being assessed by the nurses weekly. The MDS coordinator stated since there were no documentations nurses were completing the weekly skin assessment, it meant the skin assessment was not done by the nurses. The MDS coordinator stated skin assessments were important to ensure prompt identification of skin issues and implementation of prompt treatment. When asked what the risk for the resident could be if staff were not assessing the residents ' skin weekly, the MDS coordinator stated staff could miss a skin impairment and may miss acquiring an appropriate treatment. The MDS coordinator stated this could result to worsening of the skin impairment, infection, and hospitalization. When asked what the risk could be if staff missed rendering a pressure ulcer treatment for a resident, the MDS coordinator stated wound could worsen and could get infected. A review of Resident 1 ' s eTAR indicated staff were signing the eTAR indicating they had completed a skin assessment audit once a week, the facility was not able to provide weekly skin assessments documentation for these dates: on 2/2023: 2/7/23, 2/14/23, 2/21/23 and 2/28/23, for 3/2023: 3/7/23, 3/14/23, 3/21/23 and 3/28/23, for 4/2023: 4/4/23, 4/11/23, 4/18/23 and 4/25/23, for 5/2023: 5/2/23, 5/9/23, 5/16/23, 5/23/23 and 5/30/23, for 6/2023: 6/6/23, 6/13/23, 6/20/23 and 6/27/23, for 7/2023: 7/4/23, 7/11/23, 7/18/23 and 7/25/23, for 8/2023: 8/1/23, 8/8/23, 8/15/23, 8/22/23 and 8/29/23, for 9/2023: 9/5/23, 9/12/23, 9/19/23 and 9/26/23, for 10/2023: 10/3/23, 10/10/23, 10/17/23, 10/24/23 and 10/31/23, for 11/2023: 11/7/23, 11/14/23, 11/21/23 and 11/28/23. A further review of Resident 1 ' s eTAR indicated the nurses missed the pressure ulcer treatments for Resident 1 on these dates in 2/2023: 2/18/23, 2/19/23 and 2/21/23, in 3/2023: 3/16/23 and in 4/2023: 4/4/23, 4/5/23, 4/6/23 and 4/13/23. A review of Resident 1 ' s medical record indicated there were no wound IDT notes created for Resident 1 when he started developing pressure ulcers. There were no IDT notes created for the stage 4 pressure ulcers on his sacrum, right inner foot and left proximal inner foot and left distal inner foot. A review of Resident 1 ' s pressure sore ulcer plan indicated he was started on antibiotic on 3/29/23 for wound infection. The pressure ulcer care plan did not indicate how to prevent Resident 1 from acquiring pressure ulcers, worsening of pressure ulcer and preventing his pressure ulcers from getting infected. The pressure ulcer care plan was not accurate and did not reflect the status of Resident 1 ' s pressure ulcer. The pressure ulcer care plan did not accurately reflect the current treatments for Resident 1 ' s pressure ulcers. There was no care plan created for the stage 2 pressure ulcer on Resident 1 ' s left proximal inner foot and left distal inner foot. A review of Resident 1 ' s MDS assessment dated [DATE] indicated Resident 1 was always incontinent of bowel and bladder and he was at risk for developing pressure ulcer but he had no pressure ulcer at that time. It also indicated he was not on turning and repositioning program. A review of Resident 1 ' s MDS assessment dated [DATE] indicated he was at risk for developing pressure ulcers and he had 2 stage 2 pressure ulcers and 1 stage 4 pressure ulcer. It also indicated Resident 1 was still not on turning and repositioning program. A review of Resident 1 ' s Admission/readmission Skin assessment dated [DATE] indicated he had no pressure ulcer. The Admit/readmission Assessment V2 dated 2/14/23 indicated there were no pressure sore noted however the wound communication log with the physician dated 2/8/23 indicated Resident 1 already had an unstageable pressure ulcer on his sacrum. The Admit/readmission assessment dated [DATE] indicated Resident 1 had a stage 4 pressure ulcer on his Coccyx with foul odor and copious (abundant) exudate. The wound communication log with the provider dated 3/29/23 indicated Resident 1 was started on oral antibiotic twice a day for 7 days for wound infection. A review of the nurse progress note dated 11/7/23 11:42 indicated Resident 1 was on antibiotic for wound infection on left foot and sacrum. A review of the facility ' s policy and procedure (P&P) titled Pressure Injury Risk Assessment, revised 3/2020, the P&P indicated the purpose of the pressure injury risk assessment is to identify all risk factors and then to determine which can be modified and which cannot .risk factors that increases risk susceptibility to develop or to not heal pressure injury include malnutrition, impaired/decreased functional mobility, exposure of skin to urinary and fecal incontinence, altered skin status over pressure points .the risk assessment should be conducted as soon as possible after admission not later than 8 hours after admission was completed .once the assessment is conducted and risk factors identified and characterized, a resident centered care plan can be created to address the risk factors .repeat the risk assessment weekly for the first 4 weeks, if there is a significant change in condition or as often as required based on resident ' s condition.conduct a comprehensive skin assessment with every risk assessment .if a new skin alteration is noted, initiate a (pressure or non pressure sore) form related to the type of alteration in skin .develop an resident centered care plan and interventions based on the risk factors identified . effects of the interventions must be evaluated .care plan must be modified as the resident ' s condition changes or if current interventions are deemed inappropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure residents were provided an environment that is free from accident hazards over which the facility has control when staff failed to identify, evaluate, analyze hazards and risks and implement interventions to reduce hazards and risks for using a low air loss mattress (LAL, an air mattress covered with tiny holes. These holes are designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture) to prevent avoidable accidents for one out of three sampled residents (Resident 1). These failures resulted in Resident 1 fall incident on 11/4/23 and Resident 1 being sent to the hospital for further evaluation and treatment. This fall incident also resulted in Resident 1 sustaining a laceration (a cut, referring to a skin wound which tends to be caused by blunt trauma- an injury of the body by forceful impact such as falls) on his anterior scalp (located just in front of the head). The fall also resulted in swelling, contusion (a bruise, an injury in which the skin is not broken), hematoma (a collection of blood outside of blood vessels) and small areas of subarachnoid hemorrhage (bleeding in the space that surrounds the brain) in the left frontal (front most part of the brain, important for voluntary movement, expressive language and for managing higher level executive functions) and temporal lobes (part of the brain that sits behind the ear, functions include hearing, memory and learning) of his brain. Findings: During a review of Resident 1 ' s face sheet (demographics), it indicated he was [AGE] years old with a diagnoses of Pressure Ulcer of the sacral region (the portion of the spine - the row of bones down your back, between your lower back and tailbone) stage 4, Type 2 Diabetes Mellitus (DM, a disease that occurs when your blood glucose, also called blood sugar, is too high), Urinary Incontinence (the unintentional passing of urine) and Full Incontinence of feces (the accidental passing of bowel movements). His Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 9/25/23,Brief Interview for Mental Status Assessment (BIMS, a screen used to assist with identifying a resident's current cognition (the conscious and unconscious processes involved in thinking, perceiving, and reasoning) and to help determine if any interventions need to occur) indicated he had a moderately impaired cognition ( poor decision making, needs cues and supervisions with decision making). Resident 1 was dependent on staff assistance with his Activities of Daily Living (ADL ' s, activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Resident 1 was incontinent of bowel but wears a urinary catheter (a medical device, a tube that carries urine out of the bladder (urethra). During an interview on 11/28/23 at 2:11 p.m., Unlicensed Staff A stated to prevent falls, staff should monitor residents every 30 minutes. Unlicensed Staff A stated residents who were unable to move in bed should still be monitored and ensured they were in the right position in bed, so they do not roll off the bed. Unlicensed Staff A stated bed should be in lowest position to prevent injury when a resident falls. Unlicensed Staff A stated sometimes staff could not monitor resident frequently or every 30 minutes because they have a lot of residents to care for so resident sometimes end up on the floor with injury. When asked if staff regularly monitors his LAL mattress to ensure it was working properly and not deflated, she stated no. During an interview on 11/28/23 at 2:33 p.m., Unlicensed Staff B stated Resident 1 was dependent on staff for provision of care. Unlicensed Staff B stated Resident 1 hardly moves in bed. Unlicensed Staff B stated falls usually happens when there ' s short staffing. Unlicensed Staff B stated Resident 1 ' s bed was about at hip level when he fell. Unlicensed Staff B stated for some reason, Resident 1 ' s bed could not really be placed in lowest position. Unlicensed Staff B stated Resident 1 was a fall risk so his bed should be in the lowest position to prevent injury in case he falls. Unlicensed Staff B stated the facility ' s fall policy was to monitor residents every 2 hours or more if needed. Unlicensed Staff B stated sometimes it was difficult to monitor residents every 2 hours especially if they were short staffed. During an interview on 11/28/23 at 3:25 p.m., Licensed Staff C stated Resident 1 was a high fall risk. To prevent falls, Licensed Staff C stated staff should be monitoring residents every 2 hours. Licensed Staff C stated Resident 1 was totally dependent on staff for provision of care. Licensed Staff C stated Resident 1 was mostly in bed. During an interview on 11/28/23 at 3:27 p.m., the Minimum Data Set coordinator (MDS coordinator, assess and evaluate the quality of care being given to long-term care residents)stated Resident 1 fell because he had a LAL mattress. The MDS coordinator stated one of the LAL mattress tubes was undone or unlatched so the LAL mattress deflated a bit and then Resident 1 slid off the mattress. During an interview on 11/28/23 at 3:36 p.m., Licensed Staff C stated Resident 1 ' s fall could have been prevented if staff were monitoring Resident 1 regularly and ensuring his LAL mattress was functioning well. Licensed Staff C stated to lessen the risk of fall, staff should monitor residents for safety every 2 hours or more often. Licensed Staff C stated every 2 hours monitoring could be difficult especially if the facility was short staffed. During an interview on 11/28/23 at 3:51 p.m., Licensed Staff D stated to decrease risk of falls staff should monitor residents every 2 hours. Licensed Staff D stated this every 2 hour rounding would be too hard to do at times if the facility was short staffed. During a concurrent interview, care plan (a summary of a person's health conditions, specific care needs, and current treatments, it should outline what needs to be done to manage the residents care needs), nursing note, fall risk assessment (an assessment that checks to see how likely it is that you will fall) and computed tomography scan (CT, a diagnostic imaging procedure that uses a combination of X-rays (a type of radiation called electromagnetic waves, X-ray imaging creates pictures of the inside of your body) and computer technology to produce images of the inside of the body) result record review on 11/28/23 at 4:20 p.m., the MDS coordinator stated for fall prevention, staff should check and monitor residents every 2 hours or more frequently if needed. The MDS coordinator stated fall risk assessments were completed on admission/readmission, when there was a fall incident, and quarterly. The MDS coordinator stated Resident 1 fell in the early morning of 11/4/23 and Resident 1 was sent to hospital on [DATE] at 1:04 a.m. The MDS coordinator stated, the fall progress note dated 11/4/23 04:13 a.m. was not what the facility expected. The MDS coordinator stated when she looks at the progress note she wanted to find out what happened, but this progress note does not have any of that. The MDS coordinator stated Resident 1 ' s fall could have been prevented and stated they could have done a better job with keeping him safe. The MDS coordinator stated fall risk assessment should be completed quarterly and any time there was a fall incident. The MDS coordinator stated, Resident 1 ' s fall risk assessment should have been done on 5/2023, 8/2023 and 11/2023. The MDS coordinator stated fall risk assessment for 5/2023 and 8/2023 were missed, which meant the facility policy was not followed. The MDS coordinator stated the fall risk assessment was done to ensure risk and changes were noted so an appropriate intervention could be implemented as needed based on Resident 1 ' s fall risk assessment. The MDS coordinator stated if a fall risk assessment was not done, new risks and needs would not be identified, and no new interventions would be in place to decrease risks of falls. A review of the result of the CT scan of the brain without contrast done at the hospital on [DATE] indicated Resident 1 had swelling, contusion, and small areas of subarachnoid hemorrhage in the left frontal and temporal lobes of the brain. The MDS coordinator stated these findings were new and was a direct cause of the fall on 11/4/23. A review of the fall care plan dated 2/23/23 only had 2 interventions which was to anticipate his needs and provide devices as needed. The MDS coordinator stated the care plan does not have an intervention that would prevent Resident 1 from falling. The MDS coordinator stated there was no fall care plan created after Resident 1 fell on [DATE]. The MDS coordinator stated fall care plan were important to identify needs and mitigate risks factors. The MDS coordinator stated if a fall care plan was not created, it could lead to safety risk because resident needs would not be identified, and intervention could not be implemented. The MDS coordinator stated having a care plan could help identify what the residents ' needs were. When asked if staff should be monitoring the LAL mattress for functionality, ensuring tubes were not dislodged and the bed was not deflated, the MDS coordinator stated yes. When asked if the there was a documentation the nurses or CNAs were monitoring the LAL mattress for functionality, ensuring tubes were not dislodged and the bed was not deflated, the MDS stated she was not aware there were any documentations regarding staff monitoring the LAL mattress for functionality, ensuring tubes were not dislodged and the bed was not deflated. When asked if the facility staff now had a tracking log or a monitoring log to ensure the LAL mattress was functioning well and the tubes were well connected and not dislodged and the mattress was not dedflated, she stated no. The MDS coordinator stated there were no documentation to prove staff were monitoring the LAL mattress was functioning well, the tubes were well connected and not dislodged and the LAL mattress was not deflated even before Resident 1 fell. The MDS coordinator stated monitoring LAL mattress if it was functioning well, the tubes were well connected and not dislodged, and the mattress was not deflated could have possibly prevented Resident 1 from falling off his bed due to a deflated LAL mattress. The MDS coordinator stated it was important to monitor the LAL mattress was working well and the tubes are intact, connected, not dislodged and mattress not deflated for safety reasons and to prevent another fall incident due to deflated LAL mattress. During a concurrent interview and care plan record review on 11/28/23 at 5:09 p.m., the MDS coordinator stated there was no care plan for Resident 1 ' s fall incident on 11/4/23 and there was no IDT fall meeting done as well. The MDS coordinator stated it was a safety risk if a fall care plan and IDT meeting was not done with regards to fall incidents. The MDS coordinator stated it was important to create a fall care plan and complete an IDT to identify problem and implement intervention to decrease likelihood of falls and injuries. During a telephone interview on 11/29/23 at 4:29 p.m., Licensed Staff E stated there were no documentation to prove staff were monitoring Resident 1 ' s LAL mattress for functionality, ensuring tubes were connected and the mattress was not deflated. During a telephone interview on 11/30/23 at 1:16 p.m., the Administrator stated falls were a change in condition and as such the IDT should meet to discuss fall during the clinical meeting. The Administrator stated the IDT meeting was to talk about root cause analysis and possible interventions to prevent the fall incident to occur again. When asked if staff were expected to monitor the LAL mattress to ensure it was functioning well and the tubes were connected properly, the Administrator stated that Resident 1 ' s cause of fall was sliding off the LAL mattress due to deflated mattress caused by tube not connected properly so staff were expected to monitor the LAL mattress was functioning well and the tubes were connected properly as often as needed. The Administrator was not able to provide documentations that would verify staff were monitoring the LAL mattress was functioning well and the tubes were connected properly. When asked if the staff were expected to create a care plan after a fall incident, the Administrator stated yes. During a telephone interview on11/30/23 at 1:38 p.m., the Director of Nursing (DON) stated staff were expected to create a care plan for every fall incident. The DON stated she was aware there was no care plan created for Resident 1 ' s fall incident on 11/4/23. The DON stated it was expected that staff monitor the LAL mattress was functioning well and the tubes were connected properly as often as needed. The DON stated they do not have a documentation to prove staff were monitoring the LAL mattress was functioning well and the tubes were connected properly. The DON stated it was important staff were monitoring the LAL mattress was functioning well and the tubes were connected properly to prevent another fall incident caused by a LAL mattress deflating. The DON stated there should be an IDT completed for Resident 1 ' s fall incident on 11/4/23, however there was none completed for this incident. The DON was also aware there was no care plan created for Resident 1 ' s fall on 11/4/23. The DON stated creating a care plan and completing an IDT meeting for the fall incident was important for resident ' s safety, so the team could discuss resident ' s status, the cause of the fall, interventions to prevent further occurrence of fall incidents and to prevent injury. During a telephone interview on 12/1/23 at 2:24 p.m., the DON verified there was a fall care plan on 9/2020 about a perimeter mattress. When asked what a perimeter mattress was, the DON stated it was a type of bed that was slightly raised at the sides to keep the resident positioned at the center. The DON verified Resident 1 was not using a perimeter mattress when he fell. The DON verified the fall care plan was not updated to reflect the perimeter mattress was not appropriate for use based on Resident 1 ' s current condition. The DON stated it was expected that care plans were current and updated. The DON stated it was important care plans were followed. When asked if Resident 1 ' s fall incident on 11/4/23 could have been prevented, the DON stated yes. The DON stated the fall care plan should have been updated to ensure current interventions were appropriate. The DON stated it was important care plans address the issue and the fall risk. A review of the facility ' s policy and procedure (P&P) titled Falls and Fall Risk, Managing revised 3/2018, the P&P indicated the staff with the input of the attending physician will implement a resident centered fall prevention care plan to reduce the specific risk factors of falls for each residents at risk or with a history of falls . in conjunction with the consultant pharmacist and nursing staff , the attending physician will identify and adjust medications that may be associated with increased risk of falling, or indicate why those medications could not be tapered or stopped . in conjunction with the attending physician , staff will identify and implement relevant interventions to try to minimize serious consequences of falling.