**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision and a safe environment to prevent accidents for 1 of 6 residents reviewed for falls with injuries out of 49 sampled residents, (#7). Findings: Resident #7 was admitted to the facility on [DATE], with diagnoses that included history of falls, right hip fracture, dementia and adjustment disorder with anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], indicated resident #7 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. He required extensive assistance from two staff for bed mobility, transfers, locomotion on and off the unit and toilet use. Resident #7 was assessed to have unsteady balance and was only able to stabilize with staff assistance for transfers. Resident #7 used an assistive device, a walker, for ambulation. A Significant Change in Status MDS assessment dated [DATE], was completed after resident #7 sustained a fall on 4/20/21, resulting in a left humerus fracture. At that time, the resident was assessed to have a BIMS score of 5 decreased from 7 on the previous assessment. Resident #7 now required more assistance from staff and was totally dependent on two staff for transfers and toileting. Review of the Fall Care Plan dated 2/4/21, revealed resident #7 had been assessed to be a fall risk related to history of falls, impaired cognition, poor safety awareness, unsteady balance, incontinence and required extensive assistance with care. Intervention dated 2/4/21, included remind the resident to call for assistance by using the call bell and cue for safety awareness even though the care plan indicated he had impaired cognition and poor safety awareness. The Care Plan directed staff to assist with mobility, transfers and locomotion but did not specify number of staff required to assist. Review of resident #7's Resident Profile under Falls, the instruction sheet for Certified Nursing Assistants (CNAs) to provide care indicated staff were to keep call light in reach and encourage resident to call for assistance. On 5/10/21 at 10:37 AM, resident #7 was observed lying in his bed with a sling around his left shoulder and arm. He stated he fell and hurt his shoulder, but was unable to recall when, where or how the accident happened. During an interview and review of Incident Reports and Investigations on 5/13/21 at 8:30 AM, the Risk Manager (RM) stated resident #7 had 5 falls in the facility on 2/5/21, 2/11/21, 4/11/21, 4/19/21 and 4/20/21. The facility's investigation revealed on 2/5/21 at 10:36 AM, CNA F transferred resident #7 from bed to wheelchair as a 1-person transfer. The resident started to fall, and the CNA F lowered the resident to the floor. CNA F then left the resident to get help to make the transfer from the floor to the bed. The resident was assessed by Licensed Practical Nurse (LPN I), transferred back to bed with help from rehab staff. The resident later complained of back pain and the physician ordered a mobile x-ray of the pelvis/lumbar spine. The result was no acute fractures or dislocation. Review of the care plan and the facility's investigation report revealed no new interventions were developed and implemented to prevent resident #7 from falling during transfers. The report did not provide a detailed account of the last time the resident had been observed by staff or how often the resident was monitored for safety due to his risk for falls. Review of the Progress Note dated 2/9/21, at 8:40 PM, indicated resident (#7) had a history of recent falls in the facility and was assessed to be confused at times. The note revealed the resident was re-educated to not ambulate without assistance from staff. Six days later, on 2/11/21 at 9:30 PM, LPN G found resident #7 on the floor next to his bed. The resident was assessed by LPN G and transferred back to bed with help from 3 CNAs. He complained of right leg pain and a mobile x-ray of the right leg was ordered and reviewed by the physician, who ordered a follow-up with the orthopedic surgeon The Fall intervention added after the fall was continue to make frequent room rounds. The intervention did not include the required frequency of room round to prevent subsequent falls. The report showed the last time the resident had been observed by staff was at 7:30 PM, two hours prior to fall. Review of the Progress Note dated 2/12/21 at 4:02 PM, the day after the second fall indicated resident #7 was to be reminded to use call light for assistance. The intervention was not appropriate due to the resident's cognitive status and was ineffective in preventing his falls on 2/5/21 and 2/11/21. On 4/11/21 at 11:45 PM, the investigation report showed resident #7 suffered a third fall. LPN H found resident #7 on the floor next to his bed. When asked what happened, the resident stated he did not know. The resident was assessed to have no injuries and transferred back to bed. No documentation was available regarding staff who transferred the resident back to bed. The care plan was updated to include labs to rule out an infection and provide a high low bed. The incident report showed a new intervention to reconfigure the room but there was no indication this was done. Eight days later, on 4/19/21, at 7:00 PM, LPN J was called to the room by resident #7's roommate's visitor. LPN J observed the resident leaning on the bed with his feet resting against the wall. LPN J lowered the resident to the floor, assessed him to have no injuries and assisted him back to bed. The new fall care plan intervention noted in the investigation report was a scoop mattress for his bed which was not transcribe to the care plan that day. The report did not provide a detailed account of the last time the resident had been observed by staff. Less than twenty-four hours later, on 4/20/21 at 3:00 PM, LPN I was called to resident #7's room by his roommate. The resident was on the floor lying on his back and stated he was trying to go to the bathroom. LPN I assessed the resident, who had a bulge to his left shoulder and was not able to lift his left arm. The resident was transferred back to bed by 4 staff members. The physician was called and ordered the resident be sent to the hospital. The care plan was updated on 4/20/21, to include a scoop mattress and restated the existing intervention of frequent room checks. The intervention did not include the required frequency of room rounds to prevent subsequent falls. Review of a Progress Note dated 4/24/21 at 6:28 PM read the resident returned to the facility with a diagnosis of left humerus fracture. Surgery had not been performed related to the arm being too swollen. A sling was in place along with an order to follow up with the orthopedic surgeon. Review of the care plans revealed no new fall prevention interventions were developed on readmission. On 5/13/21 at 8:30 AM, the RM was asked how the facility staff would know how often to observe resident #7 as related to the term frequent checks. The RM was unable to be specific as a definite time frame had not been determined by the Interdisciplinary Team. The Risk Manager also stated she failed to get witness statements from all staff involved in resident #7's falls regarding frequency of safety checks by staff. The Risk Manager was unable to explain how staff would have been able to determine how often the resident needed to be observed. She said, staff need to check on the resident when they pass water, deliver meal trays and answer call lights. The Risk Manager was unable to explain how a resident (#7) with severely impaired cognition was going to remember to use his call light for assistance before getting out of bed unassisted. On 5/13/21 at 10:27 AM, LPN H said she was assigned to resident #7 on the night of his third fall but she did not remember when she last observed the resident before finding him on the floor. She said, We are supposed to check on the resident every two hours and as needed. She did not explain what as needed meant. On 5/13/21 at 10:39 AM, LPN J stated she was assigned to the resident on the evening of the fourth fall and did not remember the last time the resident had been observed before the fall. On 5/13/21 at 11:45 AM, Registered Nurse (RN) O stated she understood there needed to be a predetermined time frame for staff to do the safety checks to ensure safety of resident #7. She was not able to define frequent room checks and unable to state how staff would know how often to check on the resident. On 5/13/21 at 11:50 AM, LPN P stated the definition of frequent was not explicit enough to determine how often staff were required to check on resident #7. Review of the facility's policy Safety and Supervision of Residents reviewed 1/7/20, read Our facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision and assistance are provided as facility-wide priorities. The document indicated staff would be trained and in serviced to prevent avoidable hazards. The policy read, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident.