**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide oversight and prevent injury for two residents (Resident #1 and Resident #44) in a sample of 23 residents. Resident #1 was dependent on staff for transfers. When his/her electronic bed did not function properly, staff manually transferred the resident and caused a laceration to the resident's leg, which required emergency medical care, including sutures, antibiotic use to prevent infection, pain management medication, wound care and wound clinic appointments. Resident #44 had a history of falls and wandering and staff failed to provide oversight, resulting in an elopement that resulted in a fall with injury. The facility census was 55. 1.Review of Resident #1's undated face sheet showed the resident's diagnoses included dementia (a chronic condition that causes a decline in mental functioning, such as thinking, remembering and reasoning, to the point that it interferes with daily life), muscle weakness, difficulty in walking, reduced mobility, need for assistance with personal care, and type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high).Review of the resident's care plan, revised 07/18/25, showed the following:-Potential for alteration in skin integrity related to incontinence, decreased mobility, and multiple disease processes;-Avoid shearing resident's skin during positioning, transferring and turning;-Monitor skin during routine care and notify nurse of any abnormalities;-Provide assist of two staff using hoyer lift for all transfers;-At risk for bleeding due to daily use of antiplatelet medication;-Avoid hitting/bumping extremities during activities of daily living (ADL's) to prevent injury;-Maintain a safe environment to decrease risk of injury;-Observe for signs of active bleeding: sudden changes in mental status, lethargy.Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 09/04/25, showed the following:-Intact cognition;-The resident was dependent on staff for toileting, bathing, dressing, transfers and mobility;-The resident required a wheelchair for mobility and was dependent on staff for wheeling about. Review of the resident's progress note, dated 09/22/25 at 10:00 A.M., showed the following:-At 6:50 A.M., staff call Licensed Practical Nurse (LPN) P to the resident's room. The certified nurse assistant (CNA) was holding the resident's left lower extremity. A moderate amount of blood was seen on the towel. The resident had a large open laceration through several layers of skin and muscle. Staff applied pressure and called 911;-At 7:00 A.M., the resident's bleeding had stopped. The staff reported that the injury occurred with a transfer from the bed to the wheelchair. Staff do not know what could have caused the injury;-At 7:10 A.M., emergency medical services (EMS) arrived, report given and paperwork provided. Staff assisted the resident to the gurney via the hoyer lift. EMS bandaged the resident's left lower extremity;-At 7:15 A.M., EMS left the building. Staff placed a call to the resident's durable power of attorney (DPOA) to notify and to the physician on call for the medical director. Agreeable to send the resident to the hospital emergency room for evaluation and treatment;-At 7:20 A.M., called director of nursing (DON) to update and notify. Review of the facility incident reported, dated 09/22/25, showed the following:-Staff were in the resident's room to get him/her up out of bed for breakfast;-Staff noticed that the bed was not functioning appropriately and were unable to move the bed up and down;-The resident is a hoyer lift;-Staff were unable to get the hoyer lift underneath the bed for proper alignment to safely get the resident out of bed;-Staff provided a two person transfer to his/her wheelchair. During the transfer, the resident received a large open laceration to the left lower extremity;-Physician was notified and received an order to transfer the resident to the hospital for further treatment;-EMS notified and transferred to hospital emergency room (ER);-The resident received a laceration measuring 15 centimeters (cm) long with a depth of 10 millimeters (mm);-The resident will follow up with the wound clinic. Review of the resident's progress note, dated 09/22/25 at 10:06 A.M., showed the following:-Assessment of surroundings from LPN P with assistant director of nursing (ADON), CNA C and CNA S, revealed that injury possibly occurred while transferring the resident from the bed to the wheelchair; -Left lower extremity could have caught onto the wheelchair pedal while pedal was extroverted outward and lock piece was pointed outward. Review of the resident's progress note, dated 09/22/25 at 1:04 P.M. showed the following:-At 12:30 P.M., report received from hospital nurse that the resident will be returning with new orders for the resident to be seen at the wound clinic and to start antibiotic for 10 days, nursing facility to transport;-At 12:45 P.M., the resident returned to the facility via nursing facility transport, call placed to physician for pain management, new orders received for Tylenol (pain medication) 500 milligram (mg) two tablets every six hours as needed (PRN). Review of the resident's hospital record, dated 09/22/25, showed the following:-Patient presented to the emergency department via EMS with a laceration, onset prior to arrival;-Reportedly, staff was helping the resident out of the bed and got his/her leg tangled up with the railing/bar, causing a laceration to the left leg;-Patient had wound repaired;-Patient was given Cefdinir (antibiotic) 300 milligrams (mg) PO (by mouth) to initiate treatment of skin defect;-The wound had a three centimeter (cm) x two cm skin defect with subcutaneous (under the skin) tissue exposed;-Xeroflo packing (a type of dressing that keeps a wound moist) was placed and this will need to be changed twice daily;-Resident will be referred to the wound center for follow up;-Resident will need to have suture removal in 10 days approximately;-The resident will be transported back and is stable for discharge. Review of the resident's progress note, dated 09/23/25 at 12:11 P.M. showed the following:-Continues on antibiotic therapy for left leg laceration;-Leg remains bandaged at this time, left leg elevated to decrease swelling;-Received call from resident's daughter this morning with questions regarding left leg laceration and explained incident occurred with transfer and that possibly occurred from leg pushing against the wheelchair pedal lock as the wheelchair pedal was extroverted at the time of the incident, explained orders from the hospital, informed we are treating any possible infection with oral antibiotics, explained interventions put in place to prevent reoccurrence. Review of the resident's progress note, dated 09/29/25 at 10:12 A.M., showed the following:-A call was placed to the wound clinic to receive and update on his/her appointment; -Education was provided to all nursing staff that if a bed malfunctions, there is a manual crank arm in all closets within the rooms;-Education will be provided to staff that when transferring a resident, the pedals of the wheelchair needs to be removed for transfer then placed back on for transport. Review of the resident's care plan, revised 09/29/25, showed the following:-The resident was on antibiotic therapy related to a laceration of the left lower extremity;-The resident had alterations to his/her skin integrity related to a laceration to his/her left lower extremity;-The resident had potential for alteration in skin integrity related to incontinence, decreased mobility and multiple disease processes;-Avoid shearing resident's skin during positioning, transferring and turning;-Use lifting device when moving him/her in bed;-Provide assist with two staff using hoyer lift (mechanical lift device) for all transfers;-Use wheelchair for mobility; -The resident is at risk for falls related to history of falls and multiple disease processes;-At risk for bleeding due to daily use of antiplatelet medication (medications used to help prevent blood clots from forming in the arteries);-Avoid hitting/bumping extremities during activities of daily living (ADL's) to prevent injury;-Maintain a safe environment to decrease risk of injury;-No documentation of a manual crank being in the resident's closet if the bed would not raise or lower;-No documentation regarding pedals needing to be removed when transferring the resident into the wheelchair or pedals being put on prior to transport. Observation on 10/01/25 at 11:15 A.M. showed there was a manual crank in the resident's closet. Observation on 10/01/25 at 11:15 A.M. showed the following:-LPN P completed the resident's wound treatment to his/her left leg with the assistance of CNA O;-LPN P removed the resident's old dressing (dated 09/30/25) from the resident's LLE that was saturated with serosanguineous dressing (a type of fluid that contains both serum (clear, watery fluid) and blood) and placed it in the trash;-The wound had several sutures and an area at the end of the sutures that had some serosanguineous drainage, measuring 13.5 centimeters (cm.) long. Review of CNA C's written statement, dated 09/22/25, showed the following:-He/She and CNA S transferred the resident from the bed to the wheelchair due to the bed not raising;-Once the resident was in the wheelchair, he/she noticed the resident's leg bleeding. Review of CNA S's written statement, dated 09/22/25, showed the following:-He/She was working with CNA C and when getting the resident up, his/her bed wouldn't move, he/she then tried to unplug and replug the bed in and the bed still wouldn't move;-He/She and CNA C decided to two man the resident and somehow the resident's leg got cut open;-He/She and CNA C instantly started to apply pressure to the area and yelled for the nurse. Review of a written statement by LPN P, dated 09/22/25, showed the following:-He/She was called to the resident's room by staff at 6:50 A.M.;-He/She observed CNA holding the resident's left lower leg, a moderate amount of bleeding seen;-Staff reported that while transferring the resident from the bed to the wheelchair that the resident obtained a large, separated laceration, multiple skin layers seen;-Staff were unable to identify what caused the laceration;-Pressure applied and call placed to 911;-The resident denied pain until pressure was applied;-Bleeding stopped;-At 7:10 A.M., EMS arrived, report and paperwork given;-Staff assisted to gurney and resident left facility;-Assessment of surroundings with ADON and CNA C and CNA S revealed that injury possible occurred while transferring the resident from his/her bed to the wheelchair;-Left lower extremity could have caught onto the wheelchair pedal while pedal was extroverted outward and lock piece of foot pedal was sticking out near where laceration is located;-Orders received to send to ER for evaluation and treatment. During an interview on 10/02/25 at 6:56 P.M., the Director of Nursing (DON) said the following:-She would not expect staff to manually transfer a resident that should be a hoyer lift transfer;-She would expect staff to use the manual crank in the resident's closet if the bed would not raise or lower; -Wheelchair pedals should be removed prior to transferring the resident into the wheelchair to avoid catching in the wheelchair pedals that could cause injury. 2. The facility did not have a policy for wander guards/alarms that addressed ensuring an alarm being loud enough to be heard throughout the building. 3. Review of Resident #44's undated face sheet showed the resident's diagnoses included dementia (a chronic condition that causes a decline in mental functioning, such as thinking, remembering and reasoning, to the point that it interferes with daily life), Alzheimer's disease (a progressive and irreversible brain disorder that gradually destroys memory and thinking skills, eventually leading to the inability to carry out simple daily tasks).Review of the resident's significant change MDS, dated [DATE], showed the following:-The resident had intact cognition;-The resident used a walker mobility device;-The resident required supervision or touching assistance with walking;-Wander/Elopement alarm used daily. Review of the resident's care plan, revised 07/28/25, showed the following:-The resident requires wander guard secondary to increased instances of wandering and increased confusion related to dementia progression;-Check function of alarm every shift;-Personal alarm placed on resident. Review of the resident's nursing note, written by Licensed Practical Nurse (LPN) B, dated 08/28/25 at 5:00 P.M., showed the following:-While pharmacy delivery driver was at the facility making a delivery, the driver told this nurse that there was a resident with a walker sitting outside on the porch; -When the driver left, he/she came back into the facility and stated that the same resident was trying to get into his/her car and had fallen;-Upon going outside, this nurse found the resident with wander guard attached to his/her walker; had not heard alarm going off prior; checked and verified that wander guard was working. Review of the resident's nursing note, written by the ADON, dated 08/28/25 at 8:07 P.M., showed the following:-She was in her office working and overheard a conversation in the hallway that someone had fallen outside and then heard several staff members run by;-She followed the staff members outside and saw the resident sitting upright on his/her bottom in the parking lot;-The resident was just off of the sidewalk in the parking lot with his/her back leaned up against a vehicle;-The charge nurse (LPN B) and Certified Nurse Assistant (CNA) H and CNA Q were outside with the resident;-The resident was repeating that he/she fell off of the sidewalk and that his/her lower legs/feet hurt;-She assisted LPN B with assessing the resident; no injury noted in the parking lot; -Assisted the resident to stand with gait belt and assist of two; once standing, pivot transferred the resident to the wheelchair;-The pharmacy driver was standing outside of the vehicle; he/she had seen the resident outside when he/she entered the building and the resident had started walking down the sidewalk; when he/she returned to the parking lot after dropping off the medications, the resident was on the ground in front of the vehicle, so he/she went and informed the nursing team;-Took the resident inside for further assessment; the resident reported his/her wrist hurt; assessment found two injuries, an abrasion to the right hip measuring 5.0 centimeters (cm) x 5.0 cm and a second abrasion to the right elbow measuring 2.0 cm x 1.0 cm;-The resident requested to go to bed; once in bed, the resident began reporting severe pain to his/her lower legs and then reported pain to bilateral (both) hands;-The resident observed to have facial grimacing while informing this nurse about his/her pain;-Call made to resident's durable power of attorney (DPOA) regarding the unwitnessed fall outside and informed no injury noted besides two small abrasions, but that the resident was complaining of severe pain; this nurse would like to send resident out to the emergency room (ER) for evaluation to be safe;-The DPOA stated that the resident had hardware in his/her right hip and would like him/her sent to a specific hospital for evaluation since that is where his/her orthopedic surgeon was located;-ADON called 911, emergency medical services (EMS) arrived, report given, and resident taken to requested hospital ER. Review of the facility incident report, dated 08/28/25, showed the following:-The resident was outside sitting on the front porch when the pharmacy delivery driver came to deliver medications;-LPN B checked in the medications at that time and the delivery driver went back out to leave and found the resident on the ground by a vehicle;-The pharmacy driver came back into the facility to let LPN B know;-Staff then went outside to assess the resident and then placed the resident in a wheelchair to transport him/her back inside the facility;-The ADON reassessed the resident and noted complaints of pain to the resident's wrist and lower extremities;-Abrasions noted to the resident's right hip and right elbow;-The resident's DPOA was notified of the incident and requested the resident be send to the hospital for further evaluation;-The on-call physician was notified;-The resident's wander guard was assessed for proper functioning and it was functioning appropriately;-Education will be provided to all staff on wander guard policy; -When the resident returns to the facility, staff will do hourly visual checks to monitor for safety. Review of a written interview statement dated 08/28/25 at 5:52 P.M., the resident told the ADON the following: -He/She fell off of the sidewalk and he/she hurts so bad;-He/She was just trying to do everything; just walking down the sidewalk and fell off;-He/She was outside enjoying the weather just on a walk. During an interview on 10/02/25 at 12:36 P.M., the resident's family representative said the resident was not supposed to go outside without someone with him/her. Review of the pharmacy deliver driver's written statement, dated 08/28/25, showed the following:-On Thursday, August 28, 2025 at 4:55 P.M., he/she pulled up to the facility to deliver medication;-When he/she pulled up, there was a resident sitting on the porch;-When he/she was getting the medication out of the car, the resident got up with his/her walker and started walking towards his/her vehicle;-He/She went inside and delivered the medication;-He/She let LPN B know there was a resident outside with their walker going towards his/her vehicle;-When LPN B was done signing for the medication, LPN B gave him/her the medication returns and he/she walked out the door to leave;-As soon as he/she walked out the door, he/she saw the resident on the ground and immediately went back into the facility to let LPN B know that he/she needed to get someone because the resident was on the ground;-LPN B got other workers and they all came outside and checked out the resident before getting him/her off of the ground and taking him/her back inside. Review of Dietary Aide W's written statement, dated 08/28/25 at 6:36 P.M. showed the following:-He/She saw the resident in the hallway around 4:45 P.M. coming up the 200 hall;-He/She did not see the resident go outside;-He/She did not hear the door alarm going off;-He/She did notice earlier that day that the resident seemed a little off; the resident seemed to be wandering and was combing his/her hair with a fork at breakfast and he/she reported it to the charge nurses RN D and LPN A. Review of Dietary Aide X's written statement, dated 08/28/25 at 6:29 P.M. showed the following:-He/She did not see the resident outside;-He/She did hear the door alarm go off, but saw a person walking into the building, the person was not the resident;-While looking at the door, while the alarm was going off, he/she did not see the resident anywhere. Review of CNA T's written statement, dated 08/28/25 at 7:03 P.M., showed the following: -He/She saw the resident at 4:45 P.M. when he/she went to get the resident up for supper; The resident was in his/her room, stood up on his/her own, and walked down the 200 hall on his/her own;-When he/she came out of another room, he/she found the resident going down the 300 hall and he/she redirected the resident towards the dining room; he/she did not follow the resident to the dining room because he/she was going to get another resident;-He/She did not hear the door alarm going off at any point. During an interview on 10/27/25 at 3:05 P.M., CNA T said the following:-The resident resided on the 200 hall and was walking down the 300 hall when he/she noticed him/her going the wrong direction;-He/She was halfway down the 300 hall, heading into another resident's room to get another resident up for dinner and redirected the resident into the correct direction of the dining room to go to dinner;-He/She did not walk with, or assist the resident, to the dining room;-He/She never heard the alarm go off down the hallway and didn't realize that the alarm couldn't be heard from down the hallway until after the incident;-He/She does not recall any specific in-servicing or education following the incident regarding the wander guard or any other education on elopement;-He/She was not even aware that the resident had a wander guard on. Review of CNA H's written statement, dated 08/28/25 at 6:57 P.M. showed the following:-He/She did not see the resident outside until he/she was asked to come help the resident up after the fall;-He/She was in the dining room around 4:45 P.M. to assist residents with meal service;-He/She did not hear the door alarm go off at any point. Review of CNA U's written statement, dated 08/28/25 at 6:54 P.M. showed the following:-He/She was in the dining room around 4:30 - 4:45 P.M. to assist residents with meal service;-He/She did not hear the door alarm go off at any point. Review of CNA I's written statement, dated 08/28/25 at 6:51 P.M., showed the following:-He/She went to the dining room around 4:50 P.M. to start assisting residents;-He/She did not hear the door alarm go off at any point. Review of CNA Q's written statement, dated 08/28/25 at 6:48 P.M., showed the following:-He/She did not see the resident outside until he/she was called to help because the resident fell;-He/She went to the dining room at 4:45 P.M. to help assist residents;-He/She did not hear the door alarm go off at any point. Review of LPN B's written statement, dated 08/28/25 at 7:10 P.M., showed the following:-The last time he/she had seen the resident was when he/she had sent CNA T to get the resident and he/she saw the resident going down the hall toward the dining room; the resident was ambulating by himself/herself with his/her walker;-He/She was at the dining room around 4:30 P.M. to finish passing medications;-He/She did not hear the door alarm go off at any point. During an interview on 10/27/25 at 4:11 P.M., LPN B said the following:-All of nursing staff was responsible for keeping an eye on the resident and watching all of the residents;-He/She had CNA T redirect the resident toward the dining room for supper when the resident was walking down the wrong hallway and that was the last he/she saw of the resident until he/she found the resident outside;-CNA T pointed the resident in the direction of the dining room;-The resident was up ad lib (as desired) and did not require stand by or contact guard assistance;-When the pharmacy delivery driver told him/her that there was a resident out on the front porch, he/she did not go out to check on the resident because there are a lot of residents that can go out on the porch;-The pharmacy delivery driver did not tell him/her that the resident was walking toward the vehicle; he/she had just told him/her that the resident was sitting on the porch;-From the time the pharmacy delivery driver entered and alerted him/her that the resident was on the porch, about 15-20 minutes elapsed between checking in the medications and the delivery driver finding the resident on the ground when he/she left;-He/She did not hear the alarm;-He/She would not be able to hear the alarm if he/she was down the 200 or 300 hall; he/she or any staff would have to be in the main area or near the exits/doors in order to hear the alarm;-Staff should be able to hear the alarm if in a room or at least down the hallway;-This is the first time an incident like this has occurred, so no one realized that the alarm could not be heard;-He/She cannot recall any in-servicing or education after the incident. During an interview on 10/02/25 at 1:02 P.M., LPN P said the following:-It is a concern that the wander guard alarm can only be heard if you are near the exit doors; -Even if you can hear it when you are near, it is not loud enough to be noticeable - it's not alarming enough;-If he/she is in a room or down the 200 or 300 hallway, he/she would not be able to hear the alarm. Observation on 10/02/25 at 1:00 P.M. showed CNA LL take the resident's walker to the exit to sound the audible alarm for a test and it was not very loud; could hear it only near the main entrance or near exit door. During an interview on 10/02/25 at 2:00 P.M., the maintenance director said that he checks the door alarms daily. He was unaware staff was not able to hear the alarm sounding throughput the facility. Review of the ADON's written statement, dated 08/28/25 at 7:45 P.M., showed it included the following:-Administrator present in facility and made aware of incident;-Called and updated DON;-Conducted interviews with all in house staff at time of incident;-No staff members report having seen the resident go outside or being outside before being made aware of the fall;-Only dietary staff member reports having heard the door alarm going off this evening but stated when he/she looked at the door, a younger aged person he/she did not know was entering the building; he/she did not see the resident at that time. During an interview on 10/27/25 at 2:32 P.M., the ADON said the following:-She is the one that did all of the interviews with staff after the incident;-She could not recall who the dietary staff member was that did hear the alarm but stated that the dietary aide was a fairly new employee and didn't know what the alarm meant, so he/she did not report the alarm to anyone when he/she heard it go off;-She provided immediate in-servicing and education to the dietary aide and also followed up with more in-servicing for all staff regarding the wander guard policy;-They began doing hourly checks on the resident after the incident;-She believes it was CNA T that was the last person that had seen the resident walking down the wrong hall and pointed the resident in the direction of the dining room to go to dinner, but did not walk with the resident as he/she was going to get other resident's up for dinner;-She is unsure if the wander guard alarm can be heard if you are in a resident's room or down the hallway, but believes that you should be able to hear it from all of the main areas of the building; It can definitely be heard near the exits and in the main areas of the building;-There had been no previous reports or concerns brought to her attention regarding not being able to hear the alarm;-The pharmacy driver had seen a resident outside when he/she walked in (and we have residents that sit outside often), so when the driver reported it to the nurse, they signed in the medications, then the nurse headed to check on the resident, the pharmacy driver had walked out right before him/her and saw the resident on the ground; it was probably only 5 - 10 minutes from the time the driver came in to drop off the medication until the time they went back outside to find the resident on the ground;-The business and main offices are near the front door, but at the time that the incident occurred, all of the main office staff were already gone for the day, so the only staff that were around the front were dietary workers and aides that were coming and going, bringing residents into the dining room;-The facility is not a locked facility, so they do not have staff monitoring the doors at all times. During an interview on 10/02/25 at 6:56 P.M., the Director of Nursing (DON) said the following:-She would expect the wander guard alarm to be heard by all staff in all areas;-The wander guard alarm might not be heard down the hall, but you are able to hear it from the core areas;-They began hourly monitoring of the resident after this incident. MO 2603355MO 2603421MO 2624115

Based on observation, interview, and record review, the facility failed to document and implement fall interventions to prevent falls for one resident (Resident #1), in a review of five sampled residents. On 07/06/25, staff failed to implement all interventions to prevent falls, including wedge cushions, while the resident was in bed. The resident rolled out of bed which resulted in a fracture of the tibia (a break of the larger of the two bones in the lower leg). The facility census was 55.Review of the facility's Fall Policy, dated 11/14/18, showed the following:-Purpose was to prevent a fall from occurring by identifying conditions and risk factors that typically lead to a fall. Protect the resident from injury in the event a fall does occur, and to provide care to a resident who has fallen by performing assessments, documentation, and early intervention;-Complete comprehensive care plan by day 20 (following admission) using information from Care Area Assessments along with resident and family discussion of interventions if necessary. More individualized risk mitigation techniques based on more comprehensive fall assessment. Update care plan quarterly with resident and family discussion;-Post fall without injury, staff are to utilize the fall investigation form and chart the circumstances of the fall in the electronic medical record;-Fall and injury prevention included keeping call lights and personal items within resident's reach;-Fall interventions include low beds, fall mats, cradle mattress, toileting program, physical therapy screening, increase in assistance, directed activities, and increased monitoring. 1. Review of Resident #1's Care Plan for falls, dated 1/21/25, showed the following:-The resident was at high risk for falls related to a history of falls and multiple disease processes;-An update, dated 4/18/25, for a bolster mattress on the resident's bed;-An update, dated 4/22/25, to make sure the resident's wheelchair cushion was tied to his/her chair or he/she had anti-slip material between cushion and wheelchair; Review of the facility's fall event report, dated 04/26/25, showed the following:-On 04/26/25 at 9:20 P.M., the resident was found on the floor at his/her bedside;-The resident said he/she rolled out of bed;-Staff transferred the resident to the bed and positioned him/her with wedge cushions. Review of the resident's care plan interventions, dated 04/26/25, showed for staff to assure the resident was positioned in the center of his/her bed. (Staff did not document to use wedge cushions to position the resident in bed.) During an interview on 07/24/25 at 11:50 A.M., the Care Plan Coordinator said the following:-The charge nurses documented immediate interventions after a resident fell;-When the interdisciplinary team (IDT) met, they reviewed the interventions that the charge nurse put into place and determined the appropriateness and/or made changes as needed;-Once the IDT determined interventions, they were added to the resident's care plan and verbally communicated to care staff;-After the resident's fall on 04/26/25, the charge nurse documented in the event report to use wedge cushions, but she did not document the use of them in the resident's care plan;-There was no IDT meeting documented to discuss the resident's fall on 04/26/25 or interventions added following the fall;-She was not aware the resident used wedge cushions while in bed. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 04/28/25, showed the following:-His/Her diagnoses included non-traumatic brain dysfunction, aphasia (loss of ability to understand or express speech caused by brain injury), dementia, and Parkinson's disease (a progressive disease of the nervous system marked by tremor muscular rigidity and slow imprecise movements);-He/She was usually understood;-His/Her cognition was moderately impaired;-He/She was dependent on staff for all transfers;-He/She had two non-injury falls since prior assessment (01/28/25);-He/She had one fall resulted in injury since prior assessment (01/28/25). Review of the resident's Fall Risk Assessment, dated 04/28/25, showed the following:-History of one or more falls within the previous six months;-Was on one or more high fall risk drugs;-Required assistance or supervision for mobility, transfer, or ambulation;-High risk for falls. Review of the resident's care plan intervention added on 05/01/25 showed to always keep the call light within the resident's reach in his/her room and to answer all calls for assistance promptly. Review of the facility's fall event report, dated 05/02/25, showed the following:-On 05/02/25 at 2:22 P.M., staff found the resident on his/her hands and knees beside the bed with his/her head resting on the chair cushion next to the bed;-The resident said he/she was trying to reach his/her water;-The resident's water was out of his/her reach;-The resident's call light was pinned to the top of the bed and out of reach. Review of the facility's fall event report, dated 07/06/25, completed by Registered Nurse (RN) F, showed the following:-On 07/06/25 at 9:45 A.M., staff found the resident on his/her right side on the fall mat next to his/her bed;-The resident had been in bed prior to the fall;-Staff noted the interventions were effective, but there was no documentation what interventions were used;-Staff did not review or update the care plan. Review of the resident's nurse's note, dated 07/12/25 at 7:17 P.M., showed the following:-The resident's spouse reported the resident complained of left knee pain;-Assessment showed swelling of the left knee;-Staff notified the physician and sent the resident to the hospital for evaluation and treatment. Review of the resident's nurse's note, dated 07/13/25 at 2:31 A.M., showed the hospital reported the resident had a posterior proximal fracture of the tibia and a fiberglass splint was placed on the resident's foot to the knee. During an interview on 07/23/25 at 12:45 P.M., Certified Nurse's Assistant (CNA) said the following:-He/She had only worked at the facility for a couple of months and had cared for the resident much;-He/She and CNA B assisted the resident to bed on 07/06/25, but did not place wedge cushions next to the resident because he/she did not know to use them and did not see the wedge cushions in the resident's room; -Staff conducted walking rounds, but communication was poor. Staff did not communicate to him/her to use wedge cushions to position the resident in bed;-He/She had not reviewed the care plan for care interventions and relied on what staff reported to him/her when caring for the residents. During an interview on 07/23/25 at 1:04 P.M., CNA B said the following:-He/She was new to the facility and 07/06/25 was the first time he/she assisted with the resident's care;-He/She and CNA A assisted the resident to bed on 07/06/25, but did not place wedge cushions next to the resident because he/she did not know to use them, and he/she did not see the wedge cushions in the resident's room;-He/She received one day of orientation on each hall working with other staff to get to know the residents and the care they required;-He/She could look at the resident's care plan to review specific care interventions, but he/she had not. During an interview on 07/23/25 at 3:00 P.M., Licensed Practical Nurse (LPN) C said the following:-The resident's fall interventions included wedge cushions in place when the resident was in bed to prevent the resident from falling out of bed;-The wedge cushions were implemented as an intervention to prevent falls prior to the resident rolling out of bed on 07/06/25;-Staff should know to put the wedge cushions in place when the resident was in bed;-He/She was unsure if the wedge cushions were documented on the resident's care plan since he/she was not responsible for documenting interventions on the care plans. During an interview on 07/24/25 at 2:20 P.M., RN F said the following:-The resident was supposed to have wedge cushions on both sides while he/she was in bed to prevent the resident from rolling out of bed;-CNA A and CNA B, who provided care for the resident on 07/06/25, were new and were not aware to use the wedge cushions;-Failure to use the wedge cushions was partly his/her fault for not providing proper education to the new CNAs;-He/She was unsure if the wedge cushions were documented on the resident's care plan; he/she did not have much to do with the care plans;-The resident could be left unattended in his/her room if all interventions, including low bed, fall mat, and wedge cushions were utilized properly. During an interview on 07/23/25 at 4:00 P.M., the Director of Nursing (DON) said the following:-Staff were to use the wedge cushions to assure the resident was positioned in the center of the bed;-The wedge cushions should be documented in the resident's care plan and should have been utilized on 07/06/25 to prevent the resident from rolling out of bed;-Staff verbally communicated interventions;-All staff had access to the resident's care plan, and he/she expected staff, especially new staff, to review the care plan to understand the interventions the resident required;-Call lights were supposed to always be in reach;-The Care Plan Coordinator was responsible for updating the care plans with new fall interventions after the fall;-After investigation of the resident's fall on 07/06/25, it was determined the fracture occurred because of the resident falling out of the bed on 07/06/25. During an interview on 07/23/25 at 4:18 P.M., the Administrator said he expected staff to follow all interventions identified to prevent the resident from falling.

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