Based on observation, interview, and record review, the facility failed to ensure a resident without pressure-related skin impairment did not develop a pressure injury for 1 of 2 residents reviewed for pressure injuries. Following the development of a pressure ulcer, no initial assessment was documented, and no documented treatment was given for 4 days and interventions were not routinely documented as completed by the plan of care. This deficient practice resulted in Resident 12 developing a facility acquired stage III pressure ulcer (Full-thickness skin loss with damage to subcutaneous tissue. The ulcer may extend into the subcutaneous tissue layer. Granulation tissue and epibole [rolled wound edges] are often present. No exposure of bone, tendon, or muscle. The sore looks like a crater and may be foul-smelling on the coccyx that led to a colonization of MRSA (Methicillin-resistant Staphylococcus aureus) in the wound. (Resident 12) Finding includes: During an observation and interview on 11/7/24 at 12:20 P.M., Resident 12 was lying in bed on a pressure reducing air mattress. The resident indicated she had a wound on her coccyx that developed in the facility. During record review on 11/8/24 at 1:40 P.M., Resident 12's diagnoses included, but were not limited to, chronic kidney disease, vitamin deficiency, atrial fibrillation, and chronic obstructive pulmonary disease. A Braden scale, completed on 3/18/23, indicated Resident 12 was at risk for pressure. Resident 12's most recent Quarterly Minimum Data Set (MDS) assessment, dated 9/7/24, indicated the resident had moderate cognitive impairment, used a wheelchair for mobility, required partial to moderate assistance with rolling side to side, moving from lying to sitting position, and moving from sitting to standing position. The resident was occasionally incontinent of bladder and frequently incontinent of bowel, was at risk for the development of pressure injuries, had no unhealed pressure injuries, and was on a turning and repositioning program. Resident 12's current physician orders included, but were not limited to, Candida Auris swab of wound on buttocks. One time only for testing (11/8/24), dressing change to coccyx: cleanse with wound cleanser, pat dry. Pack with 1/4 packing strip moistened with NaCl (sodium chloride), cover with bordered gauze dressing. Initial and date, every day shift for wound care, and as needed for soiled or dislodged dressing (started 11/1/24), and barrier cream, apply to buttock/coccyx topically as needed for wound prevention, incontinent episodes, and Incontinent care every shift per protocol (started 11/23/28). An Activity Participation Note, dated 9/9/24 at 4:20 P.M., indicated the resident had a recent decline in group activity participation. Resident 12 bases active participation in activities on mental mindset and physical ability each day. Resident 12 still wishes to participate in activities but struggles to attend some days due to increasing physical limitations. Resident 12's care plan included, but was not limited to, resident has potential for skin breakdown such as pressure ulcers due to decreased mobility, variable need for assistance with Activities of Daily Living (ADLs), occasional incontinence of bladder (revised 9/10/24). Interventions included, but were not limited to, offer/assist with toileting as needed, observe for decline in continence status and notify the physician as needed. Resident is occasionally incontinent of bladder due to variable need for assistance with ADLs, diagnoses of stress incontinence (revised 9/10/24). Interventions included, check routinely for incontinence, and provide incontinent care as needed, observe skin condition during toileting and incontinent care. Notify the nurse of any abnormal findings. A Nurse's Note, dated 9/16/24 at 8:25 A.M., indicated staff reported Resident 12 was needing assistance with meals and experienced increased incontinence. The resident had an area on her coccyx. Staff will attempt to get the resident to the dining room for meals. The resident's decline was reported to the physician and Nurse Practitioner (NP). The note did not include an assessment or further information regarding the area on the coccyx. No documentation of the area on the coccyx was found in the resident's record prior to 9/16/24. Resident 12's care plan was updated to include: resident has Stage III pressure ulcer to coccyx due to immobility (initiated 9/17/24). Interventions included but were not limited to, the resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. A Physician's Visit Note, dated 9/18/24 at 1:05 P.M., indicated the physician was in to see Resident 12 and the resident had experienced a noted decline. Resident 12 voiced no complaints. An increase in incontinence and generalized weakness as well as a decline of ADL's was reported to the physician. No new orders were given by the physician. A Weekly Skin Assessment Note, dated 9/18/24 at 3:49 P.M., indicated a recent wound to coccyx was evaluated by RN 11 and treatment orders were received. A review of Resident 12's Medication Administration Record/ Treatment Administration Record (MAR/TAR) for the month of September 2024 included a wound treatment order of, dressing change to coccyx: Lift dressing daily to assess and apply Medihoney (wound dressing containing Leptospermum honey). If the dressing comes dislodged prior to dressing change, use triad paste (wound dressing) until next scheduled dressing application, every day shift for wound care (started 9/18/24). No other wound treatments were ordered or documented as completed prior to 9/18/24. An as needed (PRN) order for barrier cream to buttocks/coccyx topically as needed for wound prevention/ incontinent episodes was not documented as administered during the month of September 2024. A Weekly Wound Assessment, dated 9/17/24 at 11:38 A.M., indicated a facility-acquired stage III pressure ulcer on Resident 12's coccyx measured 4 cm (centimeters) L (length) x 5.5 cm W (width) x 0.1 cm D (depth) and was acquired on 9/14/24. The assessment indicated the wound bed contained 25% epithelial tissue, 25% granulation tissue, 25% slough, and 25% necrotic tissue with minimal serous drainage and that an odor was present. This was documented as the first observation from the wound nurse, and included a new treatment order, a request for an air mattress, and indicated the resident was on a turning and repositioning routine. A Wound Assessment, dated 9/24/24, indicated a facility-acquired stage III pressure ulcer on Resident 12's coccyx measured 4 cm L x 4 cm W x 0.1 cm D. The assessment indicated the wound bed contained 25% epithelial tissue, 25% granulation tissue, 25% slough, and 25% necrotic tissue with moderate serous drainage, and an odor was present. A Wound Assessment, dated 10/1/24, indicated a facility-acquired stage III pressure ulcer on Resident 12's coccyx measured 1cm L x 2 cm W x 0.2 cm D and described tunneling or undermining of 0.8 cm at 12 o'clock. The assessment indicated the wound bed contained 25% epithelial tissue, 10% granulation tissue, 65% slough with moderate serous drainage and that an odor was present. A Wound Assessment, dated 10/8/24, indicated a facility-acquired stage III pressure ulcer on Resident 12's coccyx measured 0.8 cm L x 1.5 cm W x 0.3 cm D and described tunneling or undermining of 0.4 cm at 12 o'clock. The assessment indicated the wound bed contained 25% epithelial tissue, 10% granulation tissue, 65% slough with moderate serous drainage and that an odor was present. A Wound Assessment, dated 10/15/24, indicated a facility-acquired stage III pressure ulcer on Resident 12's coccyx measured 1 cm L x 1.8 cm W x 0.1 cm D and described tunneling or undermining of 0.8 cm at 12 o'clock. The assessment indicated the wound bed contained 25% epithelial tissue, 25% granulation tissue, 50% slough with minimal drainage and that an odor was present. No changes to the plan of treatment. A Wound Assessment, dated 10/22/24, indicated a facility-acquired stage III pressure ulcer on Resident 12's coccyx measured 2 cm L x 1.5 cm W x 0.8 cm D and described tunneling or undermining of 1.2 cm at 12 o'clock and that the wound was worsening. The assessment indicated the wound bed contained 25% epithelial tissue, 50% granulation tissue, 25% slough with minimal drainage. A Wound Assessment, dated 11/5/24, indicated a facility-acquired stage III pressure ulcer on Resident 12's coccyx measured 1 cm L x 1.2 cm W x 0.1 cm D and described tunneling or undermining of 0.4 cm at 12 o'clock. The assessment indicated the wound bed contained 25% epithelial tissue, 75% granulation tissue with minimal drainage. A review of Resident 12's documented tasks for Turn and Reposition Every 2 Hours & PRN from 10/10/24 to 11/7/24 included that no documentation of turning and repositing had occurred on 10/11/24, 10/14/24,10/17/24, and 10/26/24. A Lab Results Report, dated 11/12/24 at 8:18 A.M., included results for Resident 12's wound culture that indicated the wound was positive for MRSA. During an observation and interview on 11/12/24 at 11:40 A.M., RN 11 provided Resident 12's wound treatment and completed a weekly wound assessment. A sign indicated that the resident was on enhanced barrier precautions and a bin of personal protective equipment was located outside the resident's room. RN 11 indicated that Resident 12's wound has recently been cultured and tested positive for MRSA. RN 11 indicated that the wound was healing well and was going to complete the treatment order as it was ordered at the time by packing the wound, however felt wound packing was no longer needed due to healing and nearly no depth to the wound. The wound measured 1.2 cm L x 1 cm W x 0.1 cm D and with 0.2 cm tunneling at 12 o'clock. RN 11 indicated at the time the wound developed, Resident 12 was experiencing a decline in abilities and was having significant loose stools with an increase in incontinence. Resident 12 had a history of bouts of loose stools due to a prior diagnosis. During an interview on 11/13/24 at 1:00 P.M., LPN 9 indicated Resident 12 had a decline in September but had bounced back well. During that time, she required more assistance and did not want to get out of bed. During an interview on 11/13/24 at 1:40 P.M., the ADON (Assistant Director of Nursing) indicated that the resident was having increased incontinence of bowels due to loose stools and developed a small area on coccyx on 9/14/24. The ADON indicated the wound developed during the weekend and could not explain why no documentation of the wound was made from 9/14/24 through 9/16/24 or why no documented treatment was completed before 9/18/24. The ADON indicated that if a new area is observed by staff, the charge nurse on duty should be notified and administer a temporary treatment until new orders are received by either the physician or wound nurse. According to the National Library of Medicine (ncbi.nlm.nih.gov), clinical signs that a pressure ulcer may be infected include, malodorous, purulent exudate, excessive draining, bleeding in the ulcer, and pain. On 11/14/24 at 10:46 A.M., the MDS nurse provided an undated facility policy, titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol. The policy indicated, Assessments and Recognition .the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue . Treatment/Management 1. The physician will order pertinent wound treatments . 3.1-40(a)(1) 3.1-40(a)(2) 3.1-40(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise care plans and follow interventions to reduce the risk of falls for 2 of 4 residents reviewed for accidents. This deficient practice resulted in a fall with fractures requiring hospitalization and a fall with a closed head injury requiring hospitalization. (Resident M, Resident P). Findings include: 1. On 9/19/23 at 1:13 P.M., Resident M's clinical record was reviewed. Resident was admitted on [DATE]. Diagnoses included, but were not limited to, Alzheimer's Disease, Major Depressive Disorder, and Diabetes Mellitus. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 5/14/23, indicated Resident M had severe cognitive impairment, required extensive assistance of 2 or more staff for bed mobility and transfers and a total assistance of 2 or more staff for toileting and bathing, and had no falls since the prior MDS assessment on 4/5/23. Current physician orders included, but was not limited to: Low bed at all times while in bed and not receiving care, dated 8/31/23. Toe touch weight bearing on the left side, dated 8/25/23. Maintain Post total hip precautions for L (left) hip arthroplasty, dated 5/25/23. A current falls care plan, revised 7/17/23, indicated Resident M was at risk for falls due to a history of a wedge compression fracture and included the interventions: Staff to ensure resident using walker at all times while ambulating, dated 11/11/22. Relocate closer to Nurse's station when out of isolation, dated 4/4/23. Assistive device front wheeled rolling walker, dated 11/21/22. Encourage and educate resident on using the call light when needing assistance. Clip call light to shirt for visual reminder when in chair or bed in room, dated 11/21/22. Low bed, dated 8/30/23. Non skid footwear at all times, dated 11/21/22. Non skid strips left side of bed, dated 7/18/23. Therapy as ordered, dated 11/21/22. Transfer assist with 1 staff assist, gait belt and walker at all times, dated 11/21/22. The clinical record indicated Resident M had fallen 5 times since admission. On 11/10/22 at 4:15 A.M., Resident M sustained an unwitnessed fall while attempting to ambulate to the bathroom. The intervention staff to ensure resident using walker at all times while ambulating was added to the care plan. On 11/21/22 the following interventions were added: assistive device front wheeled rolling walker, Encourage and educate resident on using the call light when needing assistance. Clip call light to shirt for visual reminder when in chair or bed in room, non-skid footwear at all times, Therapy as ordered, and transfer assist with one staff member, gait belt and walker at all times. On 4/3/23 at 1:00 P.M., Resident M sustained an unwitnessed fall. At that time, the resident was in isolation for COVID-19. The resident was unable to recall what happened and was sent to the ER (emergency room) for treatment and evaluation. The intervention relocate closer to nurse's station when out of isolation was added to the care plan on 4/4/23. A progress note, dated 5/16/23, indicated that Resident M had been complaining of left hip pain especially when in therapy and was ordered to get a left hip x-ray. A progress note, dated 5/17/23, indicated the x-ray showed an old femoral neck fracture with moderate displacement and bone resorption without callus formation. The resident was sent to the hospital. A progress note, dated 5/18/23, indicated the resident was scheduled for hip surgery. Resident M was readmitted to the facility on [DATE]. On 6/28/23 at 4:15 P.M., Resident M sustained a witnessed fall while attempting to stand up unassisted from the bed. The fall was witnessed by maintenance staff. The resident hit his head on his bedside table and complained of left hip pain. The resident was sent to the ER. The intervention non skid strips left side of bed was added to the care plan on 7/18/23. A progress note, dated 6/28/23 at 6:04 P.M., indicated the resident would be admitted to the hospital with a fracture to his left femur and would require surgery. Resident M was readmitted to the facility on [DATE]. On 8/22/23 at 8:30 P.M., Resident M sustained a witnessed fall. Staff observed the resident sliding from the bed onto the floor landing on his buttocks, but was unable to reach the resident in time to stop the fall. The care plan was not updated with an intervention. The clinical record lacked documentation of an IDT (interdisciplinary team) meeting. Fall Documentation, dated 8/23/23, indicated the resident needed a low to the floor bed. On 8/25/23 at 2:45 A.M., Resident M sustained an unwitnessed fall while attempting to get out of bed. Resident was observed sitting on the floor with both legs out in front of him. At that time, he complained of left hip pain, the left leg appeared to be longer than the right leg and was rotated inward, and resident was unable to move his left leg. The resident was sent to the ER. The intervention low bed was added to the care plan. The clinical record lacked documentation of an IDT meeting. The low bed was added to the care plan on 8/30/23. A progress note, dated 8/25/23, indicated Resident M had a left hip fracture that would be repaired nonsurgically. Orders were given to get repeat films in 2 weeks, monitor pain relief at the facility, and to be toe touch weight bearing on the left side. On 9/18/23 at 10:05 A.M., Resident M was observed lying in bed. The bed was raised. There was a sign next to the bed that indicated Put my bed back in lowest position before you leave! Thank you!. There were no skid strips next to the bed. On 9/20/23 at 8:35 A.M., the resident was observed sitting in his recliner in his room. There were no skid strips next to the bed, no walker in the room, and the call light was wrapped around the bed side rail. On 9/20/23 at 10:52 A.M., OT (occupational therapist) 27 and PT (physical therapist) 19 indicated that Resident M came off of toe touch weight bearing orders last week and was now full weight bearing for transfers. They indicated that the resident used a walker previously, but had not used a walker for a while now. On 9/20/23 at 3:22 P.M., Resident M was observed lying in bed. The bed was raised. At that time, the DON (Director of Nursing) indicated the bed was not in its lowest position and it should be. On 9/21/23 at 9:18 A.M., QMA (Qualified Medication Aide) 2 indicated fall interventions for Resident M were a low bed, assistance of 2 staff for transfers using a gait belt, and skid strips next to the bed. At that time, QMA 2 indicated the skid strips were not there. On 9/21/23 at 9:23 A.M., CNA (Certified Nurses Aide) 7 indicated she was not sure what fall interventions were in place for Resident M. On 9/21/23 at 2:52 P.M., Resident M was observed lying in bed. The bed was raised. At that time, the DON indicated the bed was not in the lowest position and should be. She indicated that all staff were gathered earlier that morning and inserviced about Resident M's bed being in the lowest position.2. On 9/19/23 at 2:16 P.M., Resident P's clinical record was reviewed. Diagnosis included, but were not limited to, dementia and non-traumatic brain dysfunction. admission date was 10/11/22. The most recent quarterly MDS Assessment, dated 7/13/23, indicated a severe cognitive impairment. Resident P required extensive assistance of two staff with bed mobility, transfers, eating, and toileting, and was totally dependent of two staff for bathing. Resident P had experienced one fall with injury since the previous assessment. A falls risk assessment, dated 10/12/22 indicated a moderate fall risk on admission. Current physician orders included, but were not limited to, the following: pommel cushion for positioning, dated 3/21/23. A current risk for falls care plan, dated 10/12/22, included, but were not limited to, the following interventions: Fall mat placed at bedside, dated 6/14/23. If resident is in a stationary chair, keep wheelchair out from resident reach/vision to prevent resident from attempting to transfer without assistance, dated 11/4/22. Non skid footwear at all times, dated 10/12/22. Fall incident reports since admission included the following falls: Fall 1 11/4/22 at 12:10 P.M. Fall was witnessed. Resident stood up from a chair, pushed her wheelchair over, and sat on the floor. She did not hit her head. The new intervention at that time was to move wheelchair out of reach, and the care plan was updated. Fall 2 12/4/22 at 12:15 P.M. Fall was not witnessed by staff. Resident stood from wheelchair attempting to get into bed and fell per roommate, resulting in a facial laceration. First aid applied, and resident was sent to the emergency room (ER). At the ER, a CT of cervical spine without contrast and CT of the head without contrast were both negative for injury. The following day, 12/5/22, the Interdisciplinary Team (IDT) reviewed the fall and agreed that an appropriate intervention following the fall was a pad alarm at all time. The falls care plan was not updated with a new intervention. Fall 3 12/29/22 at 7:30 A.M. Fall was not witnessed. Resident fell while ambulating in her room, and hit back of head. Resident was sent to the ER, where she fell again. Resident received three staples to a laceration on the back of head, and a CT was negative. Upon return from the ER, and alert note dated 12/29/23 indicated a new intervention for a self release alarm belt. The falls care plan was updated. Staples were removed 1/13/23. Fall 4 1/16/23 at 11:35 P.M. Fall was not witnessed. Resident was found with neck cocked to the left side against the wall with blood on the wall. The resident was pale and with loss of consciousness, as she was staring with eyes deviated up not blinking or moving. When assessed, pupils were slightly unequal. The roommate indicated the resident had gotten up to walk and tried to grab the wheelchair and fell. Resident regained consciousness after about a minute, and was sent to the ER, where she received three staples to the back of the head (in a different area than the previous fall). Prior to the fall, an alert note dated 1/15/23 indicated resident got up out of bed and ambulated in the hall, she is placed in her wheelchair, she is making repeated attempts to ambulate on her own, her gait is too unsteady for this, she is toileted given tylenol and put back to bed, no further attempts to ambulate on her own, bed alarm in place. The falls care plan was not updated with a new intervention. Staples were removed on 1/27/23. Fall 5 6/13/23 at 3:30 P.M. Fall was not witnessed. Resident was found on the floor with a large hematoma on the left side of the forehead and dilated pupils. Resident was alert to staff, and blood pressure was elevated at 206/93. Resident was sent to the ER and returned same day. An alert note dated 6/13/23 at 8:04 P.M. indicated Resident received back from hospital with a diagnosis of closed head injury and scalp hematoma, hematoma and bruising noted on the left forehead and a dressing noted on the left elbow . Prior to the fall, on 6/13/23 at 1:35 P.M., an alert note indicated resident noted to be trying to exit the foot of her bed, this resident returned to the correct position per 1, bed in low position and her mat in place. Care plan was updated on 6/14/23 for fall mat at bedside. Progress notes included, but were not limited to, the following: 10/22/22 at 12:39 P.M. admission . While in ER(9/26)fell and hit head causing a hematoma on scalp . 1/17/23 at 2:39 P.M. Res [resident] is lethargic and unable to stand w/o [without] max assist of 2 . 1/30/23 at 1:26 P.M CNAs' reported concern to this RN about residents L [left] facial droop. Resident was laying asleep on her left side in recliner with pull tab alarm on, after receiving morning medication. When resident awoke CNAs took resident to dining room to eat. CNAs statedresident [sic] had L flaccid arm and not making eye contact. Upon RN assessment resident sitting in w/c [wheelchair] leaning to left, but this position not abnormal for resident, neither is residents L facial droop. RN walked behind residents left side, she turned andlooked [sic]. Walked to residents' right side, she turned and looked . RN does not see any indication to send resident to hospital at this time 1/30/23 at 3:37 P.M. Nurse Practioner visit indicated no new orders 2/13/23 at 6:46 A.M. this resident is sitting on the floor at this time. The clinical record lacked any other information related to the fall. 3/6/23 at 12:09 P.M. Resident has slid out of w/c twice in front of nurses. Did not hit head, no injuries. [psych services] called for recommendation. The clinical record lacked any other information related to the fall. 3/6/23 at 12:45 P.M. OK to increase Klonipin [sic] [an anti-anxiety medication] to 0.5mg TID [three times a day] 3/14/23 at 10:42 A.M. HOLD [medication orders] PER LPN/resident lethargic 3/18/23 at 1:48 P.M. HOLD this noon clonazepam [an anti-anxiety medication] per LPN d/t sleeping, lethargy 6/15/23 at 9:57 A.M. Therapy came to RN and expressed concern that resident is lethargic. Asleep in the chair with head lying R [right] side. Resps [respirations] 17 even/ unlabored. Resident arouses to stimuli, moves all extremities. Hematoma to L eye unchanged, scabbed over . Continue to monitor 6/30/23 at 12:21 P.M. resident was in bed lying on back and vomitted [sic] small amount. lungs sounded wet upper anterior and diminished throughout posteriorly. when turned to listen she coughed pretty forcefully clearing some. resident was gotten up in chair. reported that resident had vomited couple times past few days. went and listened to resident again and upper airway has cleared some. she is in no distress. abdomen is soft but bowel sounds are diminished. texted [Nurse Practitioner] all the above. awaiting further instructions 6/30/23 at 2:02 P.M. [Nurse Practitioner] here to see resident. resident looks better. lungs fairly clear diminished posteriorly. BS hypoactive. she is in no distress. no new orders at this time. resident in bed with head of bed elevated 7/5/23 at 2:52 P.M. follow stroke protocol and send to ER for CT scan of brain. Sedating meds held at lunch. Sent to ER . 7/6/23 at 6:02 P.M. Res admitted with Pneumonia. Will continue to follow up 7/8/23 at 5:00 P.M. resident returned from the hospital per transport and is in a wheelchair at this moment, resident transferred per 1 without difficulty, this resident has a fixed glaze at this time and her pupils do not react to light, facial features are not bilateral, adrooping [sic] noted on the left side of her mouth, an MRI in hospital showed negative for stroke [two days prior], bruising noted on her right wrist and left top of her hand, red sacrum covered with a mepilex at this time, 127/69,P80, T98, R16,02 sat is 93%, resident is in bed on her left side and the bed is in low position, call bell at bedside although resident never utilizes it, no attempts to get out of bed, she is trying to sleep 7/8/23 at 7:32 P.M. after 2 attempts made to feed this resident but still not waking up, will try snacks later if she wakes up, in bed in low position, no attempts made to get out on own 7/10/23 at 10:22 A.M. Res has been noted to pocket food at meals. Oral care after meals has Un swallowed food. Res is having difficulty swallowing since return from hospital. left side of face has droop and res tends to lean to left side. Will report to Speech therapist and have evaluated. Will monitor 7/14/23 at 5:48 P.M. I spoke with [POA] and stated that [resident] is declining and could benefit from a hospice evaluation, [POA] approved completely that we could implement hospice, hospice will be notified . 8/5/23 at 6:08 P.M. Resident has appeared restless throughout this shift more so after 12p, fidgeting around while in w/c causing chair alarm to sound, as well as while in bed, had to be assisted from fall mat in bdrm [bedroom] back into bed multiple x's [times] after 1200 On 9/20/23 at 8:38 A.M., Resident P was observed sitting in a high back wheelchair in the common area with an alarm box hanging from the back of it and clipped to the collar of her shirt. The back of the wheelchair was observed with the left anti-tipper facing down and engaged, and the right was facing up. Resident P was observed to rock back and forth in the wheelchair. On 9/21/23 at 1:33 P.M., Resident P was observed during the survey on the floor between the bed and a mat on buttocks wearing incontinence brief and no pants. The fall mat was observed 1-2 feet from the bed. Resident P was observed grimacing and moaning. The sock on the left foot was hanging halfway off. Staff was notified and assisted the resident back into the bed. Once back in the bed, Resident P was observed to move around a lot. On 9/21/23 at 2:19 P.M., the Director of Nursing (DON) indicated Resident P had been care planned to come off of the bed onto a mat, and because of that would not be considered a fall every time she rolled out of bed. At that time, Resident P's care plan were reviewed with the DON and she indicated that intervention had not been care planned as intended. On 9/22/23 at 9:25 A.M., Resident P was observed lying in bed. Resident P's wheelchair was observed beside the foot of the bed within sight of the resident. On 9/22/23 at 11:22 A.M., the DON indicated Resident P's wheelchair should be out of reach as well as out of sight while lying in the bed. On 9/25/23 at 9:26 A.M., Resident P was observed sitting in a high back wheelchair in the common area with no socks or shoes on. On 9/21/23 at 2:10 P.M., the DON indicated that, after a fall, the IDT meets and the care plan should be updated with a relevant intervention that is different than before. On 9/21/23 at 12:49 P.M., the Administrator provided a current non-dated Falls and Fall Risk policy that indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . a fall is defined as Unintentionally coming to rest on the ground, floor or other lower level . Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred . If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . This Federal tag relates to complaint IN00417903. 3.1-45(a)