**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #13's medical record revealed the facility admitted the resident on 12/03/2021 with diagnoses of Parkinson's disease with dyskinesia (involuntary, erratic writhing movements of the face, arms, legs, or trunk), epilepsy, spondylosis (age related wear and tear of the spinal disks), and history of multiple fractures of the pelvis with unstable disruption of the pelvic ring. Review of Resident #13's admission Minimum Data Set (MDS) Assessment, Section C, Brief Interview for Mental Status (BIMS), dated 12/10/2021, revealed a score of fourteen (14) of fifteen (15), which indicated no cognitive impairment. Review of Resident #13's Fall Risk Assessment, dated 12/03/2021, revealed the facility assessed Resident #13 as having poor vision, balance problems while standing and walking, decreased muscular coordination, was jerking/instable when making turns, and required the use of an assistive device (a walker or wheelchair). Further review of the assessment revealed Resident #13 had a history of three (3) or more falls in the last three (3) months and had neuromuscular and orthopedic limitations. Resident #13's fall risk score was documented as twenty-two (22) where a score of ten (10) or more indicated a high risk for falls. Review of #13's admission Comprehensive Care Plan (CCP), dated 12/03/2021, revealed the facility assessed the resident as at risk for falls related to weakness, limited mobility, tremors, medication use, a history of falls, and diagnoses of Parkinson's disease (a neurological disorder with involuntary tremors/jerking movements, epilepsy (a seizure disorder), and osteoporosis (brittle/fragile bones). Further review revealed goals that included fall prevention approaches to help minimize fall risk. Interventions or approaches, dated 12/03/2021, included to make sure the call light was accessible in the bed or in the chair in the room, check regularly to assure resident safety and needs were met, and be aware that some medications increased the risk of falls. Interventions/approaches added on 12/16/2021 included the bed was to be kept in the lowest position to minimize the risk of injury if a fall occurred while trying to get out of bed, care items were to be kept in the same place and within reach, reminders to ask for help rather than try getting up alone, and to call for assistance before attempting to transfer, ambulate, or go to the bathroom were to be implemented. Review of Resident #13's Fall Risk Assessment, dated 05/23/2022, revealed the resident had been assessed as having balance problems while standing and walking, decreased muscular coordination, a change in gait pattern when going through a doorway, was jerking/instable when making turns, and required the use of an assistive device (a walker or wheelchair). Further review of the assessment revealed Resident #13 had a history of one (1) or two (2) falls in the last three (3) months and had neuromuscular, psychiatric, or cognitive and orthopedic limitations. Resident #13's fall risk score was documented as eighteen (18) where a score of ten (10) or more indicated a high risk for falls. Review of Resident #13's Quarterly Minimum Data Set (MDS) Assessment, Section C, Brief Interview for Mental Status (BIMS), dated 04/29/2022, revealed a score of fourteen (14) of fifteen (15), which indicated no cognitive impairment. Review of section GG of the same assessment revealed the facility assessed Resident #13 as requiring partial to moderate assistance with one (1) staff person for toileting and supervision assistance with one (1) staff person for transfers. a) Review of Resident #13's Progress Note dated 06/17/2022 at 3:49 PM by LPN #20, revealed she heard screaming from Resident #13's room and found the resident lying in the doorway of her room. LPN #20 documented Resident #13 had stated he/she was fixing his/her wheelchair and fell and was screaming that he/she had broken his/her hip. LPN #20 documented she placed a pillow under Resident #13's head, assessed him/her, called 911, notified the physician, called report to the hospital, and notified Resident #13's daughter he/she was being sent to the emergency room (ER). Review of Resident #13's Post Fall Risk Observation dated 06/17/2022 at 3:39 PM, revealed LPN #20 had documented she heard screaming from Resident #13's room, and upon entering Resident #13's room, she found Resident #13 lying in the inside doorway of his/her room, screaming he/she had broken his/her hip and the pain was terrible. LPN #20 further documented she placed a pillow under Resident #13's head and assessed his/her vitals, while the resident remained in place on the floor. LPN #20 documented Resident #13 stated he/she was standing up fixing the seat of his/her wheelchair when he/she fell. LPN #20 documented she called aides to the room to sit with Resident #13, notified the physician, called 911, called report to the ER, and notified Resident #13's daughter. Further review revealed LPN #20 documented after Emergency Medical Technicians (EMTs) arrived, she and the two (2) EMTs picked Resident #13 up from the floor and transferred him/her to a stretcher, paperwork for Resident #13 was provided, and Resident #13 was sent to the ER. Continued review revealed Resident #13 was assessed to have had a history of falls both prior to and since admission to the facility and to have had three (3) or more falls within the last three (3) months. Resident #13's contributing factors were assessed as Neuromuscular/Functional to include Parkinson's. Resident #13's Fall Risk Score was determined to be ten (10), with any score between zero and ten (0-10) indicating an average fall risk. Review of the evaluation notes section revealed Resident #13 was standing in his/her room fixing the wheelchair cushion, lost his/her balance, and fell to the floor. Review of #13's Progress Note dated 06/24/2022 at 5:00 PM by LPN #18 revealed Resident #13 was re-admitted to the facility from the hospital after surgery to the left hip for a fracture with ten (10) staples, which were dry and intact. Review of Resident #13's CCP for falls initiated on 12/03/2021 and revised on 12/16/2021 revealed no added interventions related to the fall and hip fracture. Review of Resident #13's Quarterly Minimum Data Set (MDS) Assessment, Section C, Brief Interview for Mental Status (BIMS), dated 08/16/2022, revealed a score of thirteen (13) of fifteen (15), indicating no cognitive impairment. Review of Section GG of the same assessment revealed Resident #13 was assessed as requiring partial to moderate assistance with one (1) staff person for toileting and partial to moderate assistance with one (1) staff person for transfers. b) Review of Resident #13's Progress Note dated 11/10/2022 at 1:22 PM by LPN #18, revealed she was called to Resident #13's room by staff, and the resident was noted to be lying parallel to the left side of the bed on the floor closest to the window. Resident #13 stated he/she was trying to make the bed on his/her own while sitting up in the wheelchair, the front wheel of the wheelchair got caught on something, and he/she fell out of the wheelchair. Per the note, the facility assessed Resident #13 for pain and injury at that time, and neither were found. Then, at approximately 3:00 PM, swelling and bruising were noted at the right side of Resident #13's hand near the thumb. The note stated the physician was notified, and an X-ray was ordered. Review of Resident #13's Progress Note dated 11/10/2022 at 7:48 PM by LPN #22, revealed she had received the X-ray results which showed a fracture of Resident #13's right thumb. Resident #13's daughter/responsible person had been notified, and LPN #22 documented Resident #13's daughter had expressed concern about Resident #13 attempting to keep his/her independence and continuing to attempt to get up on his/her own. LPN #22 documented Resident #13's daughter stated, [the resident is] stubborn and is going to do what [he/she] is going to do. Review of Resident #13's medical record revealed no Post Risk Fall Observation had been documented. Review of Resident #13's CCP for falls initiated on 12/03/2021 and revised on 12/16/2021 revealed no added interventions related to the fall and thumb fracture. Review of Resident #13's Quarterly Minimum Data Set (MDS) Assessment, Section C, Brief Interview for Mental Status (BIMS), dated 12/31/2022, revealed a score of twelve (12) of fifteen (15), indicating moderate cognitive impairment. Review of Section GG of the same assessment revealed the facility assessed Resident #13 as requiring partial to moderate assistance with one (1) staff person for toileting and supervision assistance with one (1) staff person for transfers. c) Review of Resident #13's Progress Note dated 02/01/2023 at 12:42 PM, revealed Resident #13 was found on the floor in his/her room with his/her legs out into the bathroom floor with blood coming from Resident #13's head. The facility assessed Resident #13 to be alert and stated that he/she was just trying to go stand for a moment to readjust himself/herself in the wheelchair in the bathroom and lost his/her balance, falling into the shower enclosure. Per the note, a call was placed to 911 for transport to the emergency room (ER) for evaluation and treatment due to Resident #13 having an unwitnessed fall and two (2) open areas to the front of his/her head. Review of Resident #13's Progress note dated 02/02/2023 at 5:14 PM, revealed Resident #13 had returned from the ER with a diagnosis of left clavicle (collar bone) fracture and a bruise to the forehead. Resident #13 was noted to be alert with a sling to his/her left arm in place. Review of Resident #13's Post Fall Observation Report dated 02/01/2023 at 5:43 PM by LPN #1, revealed he documented Resident #13 was found on the floor of the shower stall lying on his/her left side bleeding from the head and with complaints of pain to the left shoulder. Further review revealed the facility assessed Resident #13 to have been attempting to self-transfer in response to the need to use the bathroom. Resident #13 was documented as having decreased range of motion or voluntary movement of an extremity, unsteady gait, poor safety awareness, episodes of dizziness, pain issues, poor judgement, and bladder/bowel incontinence. Resident #13 additionally had used a wheelchair for mobility assistance and had a history of falls since admission to the facility and a history of falls in the last thirty (30) days. Per the report, the resident also had one (1) or two (2) falls within the last three (3) months. Resident #13's contributing factors were assessed as perceptual, Neuromuscular/Functional to include Parkinson's, psychiatric or cognitive, and orthopedic. Resident #13's Fall Risk Score was determined to be twenty-three (23), with any score above ten (10) indicating a high fall risk. Review of Resident #13's Progress Note dated 02/02/2023 at 6:32 AM, revealed the Minimum Data Set Nurse #1 (MDS #1) had documented Resident #13 had sustained a new left clavicle fracture. The note also stated because of the nature of the fracture, all aspects of Resident #13's care would be impacted, and a Significant Change in Status Assessment would be completed within fourteen (14) days. Review of Resident #13's CCP for falls initiated on 12/03/2021 revealed on 02/02/2023 the approach/intervention to help arrange an appointment with the physician for pain management and a medication review had been added related to the fall and left clavicle fracture. Review of Resident #13's Quarterly Minimum Data Set (MDS) Assessment, Section C, Brief Interview for Mental Status (BIMS), dated 04/14/2023, revealed a score of eleven (11) of fifteen (15), indicating moderate cognitive impairment. Review of Section GG of the same assessment revealed Resident #13 was assessed as requiring partial to moderate assistance with one (1) staff person for toileting and partial to moderate assistance with one (1) staff person for transfers. d) Review of Resident #13's Progress Note dated 04/26/2023 at 4:38 PM, revealed Resident #13 was found by staff during rounds lying on his/her back on the floor next to the bathroom. The note documented Resident #13 had stated his/her chair had fallen out from under him/her, and he/she hit the floor. Per the note, neurological checks were begun, and Resident #13 was documented as being concerned with eating supper in the dining room. The note further documented at 6:00 PM Resident #13 had stopped the nurse in the hallway and stated, something is really wrong, my neck and the whole left side of my head hurts. The note further documented Resident #13 was transported to the hospital. Review of Resident #13's Progress Note dated 04/26/2023 at 10:45 PM, revealed the emergency room had called and reported Resident #13 was diagnosed with a closed cervical vertebra (C1) [NAME] fracture and admitted to the hospital. Per the note, treatment was non-surgical, and the resident was to wear a cervical collar for twelve (12) weeks. Review of Resident #13's Progress Note dated 05/01/2023 at 5:50 PM, revealed Resident #13 had returned to the facility via stretcher awake, alert, and oriented with a cervical-collar brace intact to neck. Review of Resident #13's Post Fall Observation Report dated 04/26/2023 untimed and unsigned, revealed Resident #13 was alert and oriented times three (3) with reliable safety awareness, had adequate vision, and required the use of an assistive device for balance and gait. Resident #13's history of three (3) or more falls in the last three (3) months was noted. Resident #13's contributing factors were assessed as Neuromuscular/Functional to include Parkinson's and orthopedic. Resident #13's Fall Risk Score was determined to be fifteen (15), with any score above ten (10) indicating a high fall risk. Review of Resident #13's CCP for falls initiated on 12/03/2021 revealed on 04/26/2023 the approach/intervention to apply Dycem (an adhesive film) to the wheelchair seat to help maintain proper positioning while in the wheelchair had been added related to the fall and C1 [NAME] fracture. Review of Resident #13's Quarterly Minimum Data Set (MDS) Assessment, Section C, Brief Interview for Mental Status (BIMS), dated 08/04/2023, revealed a score of twelve (12) of fifteen (15), indicating moderate cognitive impairment. Review of section GG of the same assessment revealed Resident #13 was assessed as requiring partial to moderate assistance with one (1) staff person for toileting and assistance with one (1) staff person for transfers. e) Review of Resident #13's Progress Note dated 10/21/2023 at 11:00 AM, revealed Resident #13 was observed lying on his/her left side in the bathroom on the floor by the sink with bleeding from the top of the forehead. Resident #13 had reported that he/she was attempting to go to the restroom. It was noted that the resident's call light was not on at the time of the event. Per the note, Emergency Medical Services (EMS) was called, and Resident #13 was transported by ambulance to the ER. Review of Resident #13's Post Fall Observation Report dated 10/21/2023 at 11:35 AM by LPN #1, revealed Resident #13 was found in the bathroom lying on his/her left side next to the sink. The facility assessed Resident #13 to have been attempting to get out of the wheelchair without assistance, and the call light was not on in the resident's room. Resident #13 was assessed to have decreased range of motion or voluntary movement of an extremity, unsteady gait, displayed poor safety awareness, had episodes of dizziness, poor judgment, and bowel or bladder incontinence. Continued review revealed Resident #13 utilized a wheelchair for assistance which was in use at the time of the fall. The immediate intervention documented was for Resident #13 to utilize the call light when needing to get out of the wheelchair. Resident #13's Fall Risk Score was determined to be eighteen (18), with any score above ten (10) indicating a high fall risk. Review of Resident #13's CCP for falls initiated on 12/03/2021 revealed on 10/21/2023 the approach/interventions to check on Resident #13 every two (2) hours while in bed, to assess needs every shift, and review medications with the neurologist had been added related to the fall and C1 [NAME] fracture. Review of Resident #13's Progress Note dated 10/21/2023 at 7:10 PM, revealed Resident #13 returned to the facility on [DATE] at 7:10 PM. Record review revealed on 12/01/2023 from 9:00 to 9:20 AM, Resident #13 was observed self-propelling in the wheelchair very slowly and deliberately using only his/her feet. Resident #13 was observed rocking the wheelchair forward and backward several times to get over the threshold strips in the doorways between the hall and his/her room, between the kitchenette and bedroom, and between the bedroom to the restroom. In an interview on 12/01/2023 at 9:20 AM, Resident #13 stated he/she would not try and get out of the wheelchair on his/her own because he/she was not strong enough to do it. Resident #13 stated he/she had fallen nineteen (19) times since he/she came to the facility. Resident #13 also stated he/she did not have to wait long for staff to come if he/she put the call light on but stated he/she sometimes thought he/she could do things for himself/herself, did not call for assistance, and then realized after he/she had fallen that he/she should not have done that. A sign with call, do not fall written on it was observed on the wall in Resident #13's bathroom between the sink and toilet which was not visible if the resident was sitting on the toilet. When asked if he/she had difficulty getting the wheelchair through the doorways of his/her room into the bathroom or the kitchenette, Resident #13 stated yes but that was where the trash cans were located. Resident #13 stated he/she was not participating in therapy anymore because it was not doing any good. In an interview on 12/01/2023 at 9:30 AM with Licensed Practical Nurse (LPN) #9, he stated he had been a nurse since 2001 and had been at the facility since October 2022. He stated he usually worked the floor for the 300 and 400 units but was currently filling in as the Unit Manager. LPN #9 stated Resident #13 was very impulsive and did not have great safety judgment/awareness. He further stated Resident #13 also had obsessive compulsive disorder (a psychological condition in which excessive thoughts lead to repetitive behaviors) and was constantly picking things off the floor like lint and tissue. He stated even though staff encouraged Resident #13 to call for assistance, he/she did not always listen. LPN #9 also stated after a fall, the document trail should be started immediately. He stated a Fall Observation Report should be completed in the resident's record, and there was a paper at the nurse's station which was a step-by-step guide for the nurses on how to complete the form. LPN #9 stated if a fall was unwitnessed, neurological checks would be started. He stated his expectation was that a care plan intervention would be placed immediately based on what happened with the resident at the time. However, he stated some floor nurses did that, and some did not. LPN #9 stated the Unit Managers and the Director of Nursing also put interventions in and would be responsible for making sure an intervention was placed during the daily Interdisciplinary Team (IDT) review. In an interview on 12/01/2023 at 10:10 AM with LPN #1, he stated after a fall, a post fall assessment was documented in the resident's record, and an event form was completed. He stated the nurses did a head-to-toe assessment, a skin assessment, and a range of motion check on the resident. He stated if the fall was unwitnessed, neurological checks would be started on the resident; and if there was a wound, an order would be obtained for a treatment. LPN #1 stated Resident #13 had obsessive compulsive disorder and had very specific needs like having to pick up anything that was on the floor. He stated Resident #13 required constant reinforcement to use the call light and still attempted to get up on his/her own. He stated caring for Resident #13 and keeping him/her safe was a real challenge. LPN #1 stated care plan interventions should be based on what the resident was doing at the time of the fall, and the Unit Managers and the Director of Nursing updated them during the IDT meetings. He stated Resident #13 tended to roll away from the call bell and then attempted to get up per self. In an interview on 12/01/2023 at 10:25 AM with State Trained Nurse Aide (STNA) #1, she stated Resident #13 was determined to get up per self. STNA #1 stated she remembered one time she had checked on Resident #13, and he/she was sitting by the window in his/her wheelchair. She stated, by the time she got to the nurse's station, in less than a minute, Resident #13 had fallen onto the floor. She further stated she could not believe that had happened because she had just checked on Resident #13. In a telephone interview on 12/01/2023 at 6:45 PM with Resident #13's daughter, she stated the resident was a clean freak and could not leave anything on the floor. She stated the resident had to pick it up so he/she leaned forward and sometimes fell out of the wheelchair. Resident #13's daughter further stated the facility was looking into a seat cushion that sloped backwards for Resident #13's wheelchair so he/she will not be able to stand up or lean forward so easily on his/her own. Resident #13's daughter stated she was not sure the resident had the hand strength to use a Reacher (a hand tool used to extend a person's length of reach with a pincher end that was controlled by the person's hand grip). Resident #13's daughter further stated the resident always wanted to try and do things for himself/herself and was going to do whatever he/she wanted to do. Resident #13's daughter stated she had discussed her parent's situation with the neurologist and had been told increasing impulsiveness was an expected behavior and was a progression of the Parkinson's, and there was no medication that could help with it. She also stated the facility notified her of all Resident #13's falls, changes in condition, and medication changes. In a telephone interview on 12/01/2023 at 7:01 PM with LPN #20, she stated she had worked at the facility for five (5) years and with the company for ten (10) years. She stated she currently worked at the sister facility and was on duty at this facility the night Resident #13 fell and broke his/her hip. She stated she could not remember if she was working as a floor nurse or as a manager. LPN #20 stated Resident #13 had a bad habit of bending over and trying to pick up stuff off the floor while sitting in his/her wheelchair as well as trying to stand on his/her own without assistance. She stated Resident #13 needed constant reminders to call for assistance. LPN #20 stated on the night of the incident, she heard a scream and found Resident #13 lying on the floor between his/her room and the hallway with the wheelchair at his/her feet, not tipped over. LPN #20 stated the neurologist told her the impulsiveness was a natural progression of the Parkinson's, and there was no medication for it. LPN #20 stated there was one time an STNA had checked in on Resident #13, and less than a minute later, Resident #13 had fallen to the floor. She stated it was her expectation residents were kept as safe as possible. In an interview on 12/03/2023 at 1:15 PM with the Therapy Director (TD), she stated Functional Maintenance Programs (FMP) for Long Term Care residents could be indefinite in length and was available to all residents. The TD stated there was an FMP Nurse at the facility, and nursing staff was assigned the FMP tasks for residents. She stated she was not sure where resident participation in the program was documented by nursing. The TD explained FMP was implemented when a resident discharged from Physical Therapy/Occupational Therapy/Speech Therapy services. The TD stated in the case of Resident #13, therapy services could evaluate Resident #13 for the difficulty he/she was having with propelling the wheelchair over the doorway transition strips and also for a reacher to aid Resident #13 with picking up objects that were out of reach; they just needed a referral from nursing. The TD also confirmed that Resident #13 was on Palliative Care (care that focuses on pain and symptom relief from diseases as opposed to curing the illness), which did not impact referrals for therapy. During the interview, the TD stated the last therapy evaluation for Resident #13 was on 07/11/2023 for eating while in his/her cervical collar. The TD stated what she knew of Resident #13 was that he/she was very independent, determined, and set in his/her ways. She also stated Resident #13 had a history of refusals to participate, for example when and how and which activities he/she would participate in. The TD agreed maintaining resident safety was one of the most important responsibilities of the facility. In an interview on 12/04/2023 at 10:10 AM with Physical Therapist (PT) #2, he stated Resident #13 had been on an FMP from 05/19/2023 to 11/17/2023 and had been on therapy services multiple times but was discharged for refusing to participate. He stated Resident #13's last documented therapy evaluation was for Speech Therapy and diet recommendations while he/she was wearing a cervical collar for a C1 [NAME] fracture. PT #2 stated during Resident #13's participation in the FMP, the program included ambulation of the resident on days he/she felt strong enough and his/her Parkinson's symptoms were not increased. He stated, on the average, Resident #13 participated in therapy/FMP once a week. PT #2 further stated Resident #13 had a history of being extremely independent, not liking to ask for assistance, and his/her compliance with interventions was not consistent. PT #2 also stated the TD attended IDT meetings which was the main way information was exchanged between all the care disciplines, and a referral for therapy services could be made at any time by nursing. He stated the Therapy department also had weekly meetings to discuss resident progress and discharge plans. He stated he felt like Resident#13 could be rounded on every fifteen (15) minutes and it would not make any difference because the resident was going to continue to get up on his/her own as long as he/she could. In an interview on 12/04/2023 at 1:09 PM with Occupational Therapist #2 (OT #2), she stated she had not been Resident #13's therapist since 2020, and OT #1 had been his/her primary therapist more recently. OT #2 stated she knew Resident #13 was very impulsive and independent which was challenging with his/her Parkinson's diagnosis. She also stated Resident #13 could not propel himself/herself in the wheelchair with his/her hands and was dependent on using his/her feet to move the wheelchair. OT #2 stated she did recall OT #1 had evaluated Resident #13 for a wedge cushion or a rear sloped wheelchair seat to aid in keeping him/her from falling forward out of his/her wheelchair. She further stated the issue with a wedge cushion or rear sloped wheelchair seat was that it lifted Resident #13's feet higher up off the floor, and then he/she was unable to use his/her feet to move the wheelchair. She further stated a lower wheelchair was considered and was found to be impractical because Resident #13 was not able to reach the sink and personal items on the counter or bedside table. OT #2 stated finding the balance between securing Resident #13's safety and fall prevention without impeding his/her independence was challenging. She stated, as far as she knew, there had been no mention of the threshold/transitional area in the doorways and changes in flooring being a challenge for Resident #13 was mentioned to the OT. She stated OT #1 was on maternity leave and unavailable for interview. In an interview with the Director of Nursing (DON) on 12/02/2023 at 3:30 PM, she stated she had provided Resident #13 with a reacher, an additional waste can in his/her room near the bed and had also spoken to maintenance about the flooring in the threshold/transitional spaces in Resident #13's room. She stated the safety of the residents was a team effort and was every staff member's responsibility. In an interview on 12/02/2023 at 4:15 PM with the Director of Maintenance (DM), he stated he was not aware of any work orders for room modifications in Resident #13's room. He further stated the facility planned to change the carpet in the halls due to wear, but he was not aware of any plans for any replacement of flooring from carpet to tile in any resident's room. 3. Review of Resident #17's medical record revealed the facility admitted him/her on 04/08/2022, with diagnoses which included dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance; anxiety disorder, unspecified; and morbid (severe) obesity due to excessive calories. Review of Resident #17's Quarterly Minimum Data Set (MDS) Assessment, dated 01/04/2023, revealed the facility assessed the resident as severely cognitively impaired, as evidenced by the Brief Interview for Mental Status (BIMS) score of one (1) of fifteen (15). Continued review of the MDS Assessment, Section GG, Activities of Daily Living, revealed the facility assessed Resident #17 to require extensive assistance of two (2) staff for toilet transferring and using the Hoyer lift (brand of a full body mechanical lift) and assistance of two (2) staff members for transferring from bed to wheelchair. Review of Resident #17's Comprehensive Care Plan (CCC), dated 12/29/2022, revealed the facility had care planned the resident as at risk for falls related to decreased mobility, episodes of incontinence, cognitive deficits, and requiring assistance of two (2) with transfers. Continued review revealed interventions which included total assistance of two (2) staff members; ensure a safe environment free of clutter: call light was accessible whether in bed or in a chair; and notify Physician and family as needed. Continued review revealed on 01/04/2023, the resident required a mechanical lift for transfer from the bed to chair and the assistance of two (2) with Sara lift (a sit-to-stand mechanical lift) for toilet transfer. Further review of the care plan revealed the facility also care planned Resident #17 to require total assistance with activities of daily living (ADL's) related to decreased mobility, incontinence, and dementia. Review of the facility's policy titled, Mechanical Lift, no date, revealed the facility required two (2) people in attendance for the use of all mechanical lifts. Observation of Resident #17 on 12/02/2023 at 10:10 AM, revealed the resident sitting in his/her wheelchair with the legs extended outward and sitting next to his/her spouse, Resident #32, in the common area next to the fireplace. Interview with Resident #17 was not possible due to his/her disease process, but Resident #32 provided information regarding the accident. Resident #32 stated, I have gotten [two (2)] different stories on the incident, one being that the fracture occurred before the fall and the other being the fracture occurred after the fall. [He/she] is doing fine now. Review of Resident #17's Progress Note dated 01/08/2023 at 7:43 PM and signed by Licensed Practical Nurse (LPN) #22, revealed Resident #17 presented with a 2.5 centimeter (cm) by 5 cm dark purple bruise to the left ankle, with edema, redness, warmth to the area as well as painful to touch. State Trained Nurse Aide (STNA) #38 reported the resident was lowered to the floor in the bathroom on the first shift, after losing her/his strength while transferring. Per the note, Resident #17 was unable to recall any injuries, and the resident was up in the wheelchair with no complaints at dinner time. The note stated the physician was notified and awaiting a response. Review of Resident #17's Post Fall Observation with Fall Risk Observation Report, dated 01/08/2023 and initiated by Licensed Practical Nurse (LPN) #20, revealed at 2:00 PM, Resident #17 was b[TRUNCATED]