**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate supervision for a dependent resident to prevent a fall, thoroughly investigate a fall, implement post fall interventions, and report a fall timely to the physician and resident representative for three of four residents (R1, R2, R3) reviewed for falls on the sample list of 18. This failure resulted in R1 falling in the bathroom after being left unattended and sustaining a head laceration requiring two staples. Findings include: 1.R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. This same MDS documents R1 is independent with cares and uses both a walker and wheelchair. R1's MDS in progress dated 1/24/24 indicates R1 requires maximum assistance of one person for toileting, upper and lower body dressing and moderate assistance for chair/bed to chair transfer. R1's undated Face Sheet documents diagnoses of Other Frontotemporal Neurocognitive Disorder, Need for Assistance with Personal Care, History of Falling, Unsteadiness On Feet. R1's Fall Risk Assessment, dated 10/20/23, documents R1 is at risk for falls. R1's Nursing Progress Notes dated 1/3/24 at 4:14 pm document R1 was observed on the bathroom floor next to the toilet. R1 was unable to provide details leading up to the fall. Upon assessment, bleeding was noted to the back of R1's head. Pressure was applied; however, the bleeding was unable to be controlled. R1 was transported to the hospital. R1's ED (Emergency Department) Report dated 1/3/24 documents, R1 had a fall while on the toilet and hit (R1's) head resulting in complaints of pain and a laceration to the back of the head. R1's laceration was repaired and R1 was returned to the nursing facility. R1's Nursing Progress Notes dated 1/3/24 at 10:55 pm documents R1 returned to the facility with two staples in the back of the R1's head with a scant amount of bleeding. On 1/29/24 at 10:30 am, V7 Certified Nursing Assistant (CNA) stated V7 got R1 up from bed for dinner and took R1 to the restroom. V7 explained V7 left R1 alone on toilet to go check on another resident and upon returning to R1's room, noted R1 on the floor. V7 stated R1 had attempted to stand up and pull up R1's own pants. V7 stated R1 has always used the call light to alert staff when R1 needs help but failed to use the call light at this time. V7 stated V7 immediately called the nurse in to access R1 and R1 was sent to the hospital. On 1/29/24 at 1:50 PM, V3 Assistant Director of Nurses (ADON), stated R1 fell on 1/3/24 at 3:30 PM while in the bathroom alone. V3 stated residents should not be left alone in the bathroom. R1's Nurse Progress Note, dated 12/1/23 at 6:37 AM, documents, R1 was calling out and was observed on floor in front of R1's bed, sitting on a pile of blankets and sheets. The progress notes reflect, On coming nurse RN (Registered Nurse) to contact POA (Power of Attorney), On call physician and PCP (Primary Care Provider. There is no further documentation indicating that notifications were completed. On 1/29/24 at 1:50 pm, V3 ADON (Assistant Director of Nursing) stated, in the presence of V1 Administrator and V2 DON (Director of Nursing), family notification is to be documented in the medical chart either in a progress note or in the fall investigation. V3 confirmed there is no progress note stating the family had been notified, only that the night nurse endorsed this task to the dayshift nurse. 2. The facility's Incident by Incident Type Log dated 1/29/24 documents R2 had a fall on 12/9/23. R2's Unwitnessed Fall Report dated 12/9/23 documents the CNA (Certified Nursing Assistant) reported that R2 was on the floor. This report did not contain an investigation identifying the root cause of the fall; however, it does document a post fall intervention of frequent checks to be implemented. R2's Care Plan dated 5/25/23 documents R2 is at high risk for falls related to Confusion, Gait/balance problems, Incontinence, and Psychoactive drug use. This Care Plan does not document the new intervention of frequent checks from R2's 12/9/23 fall. On 1/29/24 at 1:50 PM, V1 Administrator, V2 DON (Director of Nursing) and V3 ADON (Assistant Director of Nursing) all stated that the care plan should be updated to reflect new interventions as listed on the Fall Report. V3 acknowledges that the care plan did not contain the intervention of frequent checks of R2 from the 12/9/23 fall. 3. R3's Fall Risk assessment dated [DATE] documents R3 is a moderate fall risk. R3's MDS (Minimum Data Set) dated 9/19/23 documents R3 has severe cognitive impairments and requires extensive assistance of one staff for transfers. R3's Unwitnessed Fall Report dated 11/3/23 documents CNA (Certified Nursing Assistant) found R3 sitting on R3's buttocks, on the floor next to the bed, leaning against the bed. R3's call light was on. R3 stated R3 pressed the call light after sliding off the bed and explained R3 was trying to get to the bathroom. R3's bed was very wet from being incontinent and (R3) was trying to get to the bathroom. The facility did not provide a fall investigation with documented root cause of the fall or what new interventions were implemented. R3's Care Plan dated 10/11/23 documents, R3 is at risk for falls due to gait/balance problems and incontinence with interventions including: anticipate and meet needs, be sure call light is within reach and encourage R3 to use it for assistance as needed. Respond promptly to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Ensure R3's bed is in lowest position and floor mats are in place. Ensure R3 is sitting in the wheelchair properly. Offer earlier times to get up in the morning if R3 is awake. Staff to get R3 ready for the day at the end of midnight shift due to R3's pattern of wanting to get up earlier and attempting to do so without assistance. Staff to offer snack, drink, and activity while waiting for breakfast. Staff to provide frequent checks to ensure proper alignment in bed. Reposition as needed and use smaller blankets on bed to prevent R3 from getting tangled up in covers. This care plan does not document any new fall interventions since 8/1/23. On 1/29/23 at 12:15 pm, V1 Administrator stated the facility normally investigates falls, especially if there is injury, but did not do one with R3's 11/3/23 fall. V1 also verified that since there was no fall investigation, there were no new post fall interventions implemented. The facility's Fall Prevention and Post Fall Management Policy dated 8/8/23 documents the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and other members of the multidisciplinary team, will seek to identify and document resident risk factors for falls and establish a resident centered falls prevention plan based on relevant assessment information. The staff will seek to identify environmental factors that may contribute to falling, implement a resident centered fall prevention plan to reduce the specific risks factor(s) of falls for each resident at risk or with a history of falls, and implement relevant interventions to try to minimize serious consequences of falling. Resident responses to interventions will be monitored and if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change the current interventions. Continue to collect and evaluate information until the cause of the falling is identified or it is determined that the cause cannot be found. When a fall occurs, the following information should be recorded in the resident's medical record: the condition in which the resident was found, assessment of the data including vital signs and any obvious injury, interventions or treatment administered, notification of the family and physician, and appropriate interventions taken to prevent future falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident did not develop a pressure ulcer, failed to complete an initial or weekly wound assessments and failed to refer resident to the dietician for an evaluation of nutritional interventions to promote healing for one of three residents (R3) reviewed for pressure ulcers on the sample list of six. This failure resulted in R3 acquiring an unstageable pressure ulcer to the right heel on 1/11/23 and not receiving nutritional interventions to promote healing until 3/21/23. Findings Include: The facility's Skin Integrity-Pressure Ulcers/Pressure Injury Policy dated 12/4/2017 documents any resident who is admitted without a pressure ulcer/pressure injury will not develop a pressure ulcer/pressure injury unless clinically unavoidable and a resident who has a pressure ulcer/pressure injury will receive care, services to promote healing, prevent infection (to the extent possible), and prevention of additional pressure ulcers/pressure injury. A pressure ulcer/Injury refers to the localized damage to the skin and/or the underlying soft tissue usually over a bony prominence or related to a medical device or other device. Avoidable means the resident developed a pressure ulcer/injury and that the facility did not do one of more of the following: evaluate the resident's clinical condition and pressure ulcer/pressure injury risk factors; define and implement interventions that are consistent with the resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Unstageable encompasses three different scenarios: having a non-removable dressing in place that cannot be removed, slough and/or eschar, known but not stageable due to coverage of the wound bed by slough and/or eschar, or suspected deep tissue injury in evolution. Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. To prevent a pressure ulcer/pressure injury, the facility will identify whether the resident is at risk for developing or has a pressure ulcer/pressure injury upon admission and thereafter; evaluate resident specific risk factors for changes in the resident's condition that may impact the development and/or healing of a pressure ulcer/pressure injury, implement/monitor/modify interventions to attempt to stabilize, reduce or remove the underlying risk factors. Using the Skin Risk Breakdown Assessment Tool which includes categories for sensory perception, moisture, activity, mobility, nutrition and friction, make consideration of those individual scores that place a resident at risk and refer to the prevention guidelines for interventions. R3's MDS (Minimum Data Set) dated 1/2/23 documents R3 requires extensive assist of two staff for bed mobility and transfers and is at risk for pressure ulcers. R3's Skin Breakdown Risk assessment dated [DATE] documents R3 is at high risk for skin breakdown. R3's Care Plan dated 12/29/22 documents R3 is at risk for potential pressure ulcer development related to urinary incontinence and immobility with interventions to educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, monitor/document/report PRN (as needed) any changes in skin status; appearance, color, wound healing, sign/symptoms of infection, wound size (length, width, and depth) and stage of wound, and thoroughly cleanse and dry peri area with each incontinent episode. R3's Nursing Progress Notes document the following: 12/29/22 - R3 was admitted to the facility status post hospitalization for a fractured right hip. There is no documentation of any pressure ulcers upon admission, only of a surgical wound to the right hip. 1/11/23 - R3 noted to have a wound to the right heel, which was measured and logged in the wound documentation. Dry dressing applied. R3 tolerated well. Complaints of pain to area when touched. There is no documentation in R3's medical record that the RD (Registered Dietician) was notified of R3 having a wound until 3/28/23. R3's 3/28/23 Nutritional Assessment by V13 RD documents R3 is receiving a magic cup daily, has a fractured hip and blister to the right heel and is experiencing right foot pain. R3's laboratory results dated [DATE] document an albumin level of 2.7, normal is 3.5 - 5.0 and a total protein level of 4.9, normal is 6.3-8.3. R3's Only Wound Evaluations/Assessments in R3's Medical Record are as follows: 1/11/23 - R3 has a wound measuring 0.56 cm (centimeters) by 0.97 cm but does not document the size, stage or characteristics of the wound. 1/15/23 - R3 has a blister to the right heel, in house acquired, of unknown age measuring 5 cm by 4.43 cm but does not document the stage or characteristics of the wound. 1/28/23 - R3 has a blister to the right heel, in house acquired, of unknown age, measuring 3.21 cm by 3.79 cm. 3/26/23 - R3 has a blister to the right heel, in house acquired, of unknown age, measuring 2.1 cm by 3.57 cm. 4/1/23 - R3 has a blister to the right heel, in house acquired, measuring 3.95 cm by 2.37 cm. R3's Wound Care Telemedicine Initial Evaluation Notes dated 2/10/23 by V14 Wound Physician documents R3 has an unstageable, full thickness, pressure ulcer to the right heel measuring 5 cm by 4 cm covered in 50% thick adherent devitalized necrotic tissue and 50% dermis with moderate serous drainage. R3's Wound Care Telemedicine Follow Up Evaluations document the following: 3/3/23 - unstageable, full thickness, pressure ulcer to the right heel measuring 5 cm by 4 cm, covered 100% by a thick adherent devitalized necrotic tissue with light serous drainage. No change to the wound. 4/14/23 - unstageable, full thickness, pressure ulcer to the right heel measuring 5 cm by 3 cm, covered 100% with thick adherent devitalized necrotic tissue with no exudate. No change to the wound. R3's April 2023 Physician Orders documents an order to Cleanse the right heel wound with normal saline and pat dry. Then apply betadine and wrap with gauze three times per week. These orders also document an order dated 3/21/23 for a Magic Cup {Nutritional Supplement} QD (daily), which was then increased to BID (twice a day) on 4/12/23. R3's March 2023 MAR (Medication Administration Record) documents R3 did not receive the ordered magic cup on the 21st, 24th, 25th and 26th. R3's April 2023 MAR does not document R3 received the magic cup BID {with breakfast and supper} as ordered from the 12th - 16th. On 4/17/23 at 9:05 am, R3 was brought breakfast and did not receive the ordered magic cup. On 4/17/23 at 10:30 am, V4 RN (Registered Nurse) confirmed R3 was supposed to get a magic cup as a nutritional supplement but did not get it at times due to the supplier being out of them. V4 stated the magic cups are served with meals and come out of the kitchen. On 4/17/23 at 10:38 am, V12 Dietary Aide confirmed the facility was out of magic cups for a while but currently has them. V12 stated V12 is not sure why R3 did not receive it today with breakfast. On 4/13/23 at 1:45 pm, R3 was lying in bed, on a regular mattress. V4 RN (Registered Nurse) removed the dressing to R3's right heel to reveal an approximate. 4 cm x 3 cm hard black eschar area to the right heel. V4 completed the dressing change as ordered. On 4/17/23 at 1:13 pm, V13 RD stated normally V13 is notified of wounds by V2 DON (Director of Nursing) or the nursing staff and if a resident has a wound, I (V13) normally throw the kitchen sink at them; reviewing their intakes, weight history, any current supplements, if they are taking them or not, and if the wound isn't healing, what else needs changed. Just try to find the breakdown. V13 stated V13 will write a progress note and/or complete a nutritional assessment for the resident when V13 is notified of skin breakdown, and with no assessment completed until 3/28/23, V13 guesses V13 wasn't notified until 3/28/23 but will have to check V13's records. V13 stated V13 isn't sure what V13 would have recommended at the time for R3 when R3 developed the pressure ulcer to the right heel., V13 stated, I (V13) would have done something, probably liquid protein. V13 also stated V13 hates to say R3 not receiving the supplement when the wound first developed, or as ordered since it was started, is contributing to the wound not healing because nutrition is just one corner stone of the healing process but with R3's albumin level and total protein level being low and the fact R3 has an unstageable pressure ulcer and significant weight loss, R3 needs something more than what (R3) is getting. On 4/17/23 at 1:46 pm, V2 DON stated, when a resident develops a new pressure ulcer, the nurses should measure the wound, call family, and the physician to get order for treatment or a wound consult visit. The floor nurses should also call the RD or email the RD for possible interventions. V2 also stated the facility at times will put residents into a specialty mattress if the wound is a recurring problem or if it isn't getting better with the current treatments but hasn't investigated doing that for R3. On 4/17/23 at 2:22 pm, V2 DON stated the Wound Evaluations of R3's pressure ulcer that were provided are the only ones the facility has completed. V2 explained V2 would like the evaluations to be done weekly but that is a work in progress. On 4/18/23 at 10:01 am, V14 Wound Physician stated V14 has seen R3 via Telemedicine visits only and the facility staff are providing the measurements and condition of the wound to V14. V14 stated V14 is being told the pressure ulcer isn't draining anymore and that is what V14 was managing is the drainage aspect, so in that case, the pressure ulcer is now stable. Nutritional interventions such as Vitamin C, multivitamins, and/or extra protein would help to heal the wound. On 4/18/23 at 11:29 am, V13 RD stated after looking back on V13's notes, V13 had not been informed of the pressure ulcer when it first developed, it wasn't until R3 also had a weight loss that V13 was notified. I have already spoken with V2 and V3 ADON (Assistant Director of Nursing) and we are coming up with a new way for V13 to be notified so that this doesn't happen again in the future. V13 explained, supplements absolutely aid in healing of the wound and had I (V13) been notified of the wound upon development, I (V13) would have at least put (R3) on a multivitamin and possibly liquid protein also but you have to look at the whole picture. At that point, I (V13) believe (R3) was eating well because (R3's) weight was stable. (R3) had just broken (R3's) hip prior to the development so that is part of looking at the whole picture of what is going on with someone. Hopefully we {facility} will start to see some improvement in the wound now with these additional supplements. On 4/18/23 at 1:50 pm, V2 DON in the presence of V1 Executive Director and V3 ADON stated looking back on R3's situation and with R3 just having a fractured hip and not being mobile, R3 would have been a candidate for a special pressure relieving mattress and that R3 should have had one. V2 confirmed there were no pressure relieving interventions in place upon admission to prevent R3 from developing a pressure ulcer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete thorough post fall investigations for two residents (R1, R4). The facility also failed ensure a resident was supervised and using the appropriate transfer devices to prevent a fall for one of three residents (R1) reviewed for falls on the sample of six. This failure resulted in R1 falling while standing unassisted in the bathroom, sustaining a head laceration requiring four staples. Findings include: The facility's Fall Reduction Policy dated last revised on 1/5/2021 with next review dated 1/5/2022 documents that this policy is intended to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes identifying, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks and monitoring effectiveness and modifying interventions when necessary. The policy states that all residents will be assessed on admission, following a fall, quarterly per guidelines or if the Interdisciplinary Team (IDT) recognizes a change in condition and that all residents are assessed on admission using the admission Nursing Evaluation and following Minimum Data Set (MDS) protocol thereafter. The policy states residents identified as being at risk for falls will have individualized care plan intervention. IDT Falls Committee will meet on an ongoing basis to review fall analysis. This policy documents procedure following a fall is outlined in the Incident Reports policy which includes completion of Incident Report, documentation in IDT notes, 72-hour monitoring, Fall Risk Evaluation Tool, and review and update of Plan of Care. The facility's Incident Reports - Clinical Department policy dated 9/3/2009 documents an incident is any happening which is not consistent with the routine operation of the facility or the care of a particular resident. It may be an accident or a situation which might result in an accident. The nurse should complete an incident report after each incident for example falls. The policy states this facility shall notify the Department of Public health of any accident or incident, which has, or likely to have a significant effect on the health, safety, or welfare of our resident and in implementing this policy the following shall apply to ensure appropriate follow-up care in the event of an accident/incident. The residents power of attorney for health care, physician, and supervisor should be notified. After the residents cared for, the incident report and incident management investigation tool should be completed in its entirety by the nurse. Any recommended intervention should be carried out to prevent event from reoccurring. A complete report will be filed on the approved incident form. No incident report or copies are to be placed in the medical record. Incident reports are to be reviewed by the director of health care services or designee and the administrator as appropriate. Incidents resulting in injury should be forwarded to corporate director of risk management for example falls resulting in serious injury/illness or death. The policy states a descriptive summary of each incident or accident shall be recorded in the progress notes or nurses notes for each resident involved and the facility shall maintain a file of all written reports of incidents or accidents involving residents. The facilities Incident Reports - Clinical Department policy does not include the facility is to complete 72-hour monitoring, Fall Risk Evaluation Tool, and review and update of Plan of Care as the facility's Fall Reduction Protocol documents the Incident Reports - Clinical Department policy will outline. 1. R1's Minimum Data Set (MDS) dated [DATE] documents R1's balance during transitions and walking as, not steady, only able to stabilize with staff assistance. R1's Incident Report dated 1/1/23 at 2:36pm documents R1 had a witnessed fall on 1/1/23 at 9:35am. This report documents V21, Certified Nursing Assistant (CNA) called V4, Registered Nurse (RN) to R1's room. R1 was laying on R1's back on the floor in R1's bathroom with bright red blood on the back of R1's head, which was actively bleeding. V21 stated V21 was providing care, turned for a brief moment and R1 lost R1's balance and fell straight back. There is no documentation into an investigation of details of what care was being provided, where R1 was and what R1 was doing just before R1 fell, or why/where V21, CNA turned away from R1. R1 told V21 immediately after the fall, I (R1) can't see. Within a few seconds R1 was able to see the CNA. This report documents R1 was unable to provide further details. This report documents V4, RN and V21 attempted to sit R1 up after assessing R1. R1 cried out in pain to the lower back. This report documents predisposing physiological factor of gait imbalance and that R1 was ambulating without assist. There is no documentation that a gait belt was in place while R1 was standing in R1's bathroom. This report documents R1's Care Plan was reviewed and implemented a new intervention post fall to have Physical Therapy evaluate and treat. There is no documentation of the root cause of this fall. R1's medical records do not document 72-hour post fall monitoring as per the facility's policy. R1's Neurological check documentation is incomplete. R1's Hospital Records dated 1/1/23 document R1's Computed Tomography of the Head or Brain without Contrast results dated 1/1/23 document no acute Intracranial abnormality and a right posterior parietal scalp hematoma. These records document R1's X-ray of the left hip with pelvis results dated 1/1/23 at 2:43pm documenting there is no fracture or acute abnormality. This report documents degenerative changes of the lower lumbar spine. There is no documentation of additional lumbar spine radiology tests on 1/1/23. R1's Hospital Records dated 1/9/23 document R1 arrived at the local emergency room with complaints of increased confusion ongoing since 1/1/23 after sustaining a fall and that R1 had been seen at another local emergency room on 1/1/23 where R1 was diagnosed with a Urinary Tract Infection (UTI) and staples were placed in R1's head. R1 has chronic pain but R1's lower back pain has increased. These records document R1's initial Computed Tomography (CT) scan was abnormal in which R1 was evaluated by neurosurgery at the bedside. These records document R1 was also found to have L1 (Lumbar Vertebrae) compression fracture. These records document CT of Abdomen and Pelvis with Contrast Results dated 1/9/23 at 3:13pm documenting, there is a slight concave compression of the L1 inferior endplate with slight increased density of this segment. Consider MRI (Magnetic Resonance Imaging) if indicated for a questionable subtle acute compression fracture of the L1 vertebral body. These records also document CT of the Brain without Contrast results including Low-density/chronic left subdural fluid collection/hemorrhage and that this report flagged for provider attention. These records document Assessment/Plan including L1 Compression Fracture and a Left Convexity Subdural Hygroma VS Subdural Hematoma. R1's Neurosurgery Consultation dated 1/9/23 documents R1 has a Mild Compression Fracture of unknown Chronicity and a small left convexity Subdural Hygroma verses Chronic Subdural Hematoma. This consultation documents R1 is not a candidate for kyphoplasty at this given time and no neurosurgical intervention indicated at this time. The handwritten report notes dated 1/10/23 from the local hospital document the facility received information that R1 had a L1 compression fracture in addition to a Urinary Tract Infection. On 4/17/23 at 11:15am, V4, Registered Nurse (RN) stated V4 was notified that R1 was on the floor. R1 was on R1's back with a wound to right side of R1's head that was bleeding. V4 stated V21, CNA said V21 was within arm's reach of R1 and saw R1 falling and was not able to reach R1. V21 stated V21 was by R1's recliner and R1 was at the sink in the bathroom. V4 stated R1 requires a stand by assist while standing and ambulating and that V21 was aware as V4 notified V21 on 1/1/23 before the fall. V4 stated V21 was also aware that V21 was to stay with/right beside R1 when R1 was standing. V4 stated R1 hit R1's head pretty hard. V4 stated R1 complained of (R1's) back hurting, tried to sit (R1) up a little but (R1) was in excruciating pain to R1's back. V4 stated R1 was crying out in pain to R1's back so they did not move R1 and called 911 to transport R1 to the hospital. V4 stated R1 has a history of chronic back pain, but never the level of severity R1 had after falling on 1/1/23. On 4/20/23 at 1:40pm, V2, Director of Nursing (DON) stated the fall investigations are completed by the floor nurses. V2 stated the Interdisciplinary team (IDT) meetings discuss and decide appropriate interventions related to each fall. V2 stated, if needed V3, Assistant Director of Nursing (ADON) and V2 look in to the fall more and get additional information if needed and update care plan. V2 stated the IDT works on the root cause of the fall together and there is a page in the electronic charting for incidents where that is documented. I do not recall what the root cause of R1's fall was on 1/1/23. The box that is empty on the fall report is where that information should be regarding the root cause. I think V3 talked to V21, CNA. V2 thinks V21 told V2 that V21 turned around to grab some type of linen and that V21 was right next to R1. V2 stated R1 was standing at R1's sink with R1's walker but did not have a gait belt on and should have. V2 was unsure if R1 was wearing R1's shoes. V2 stated V21, CNA was terminated, due to the fall as well as issues with other staff. 2. R4's Fall Risk assessment dated [DATE] documents R4 is a high risk for falling. R4's Progress Notes dated as follows document: 2/6/23 at 4:57pm - Diagnosis: Right elbow fracture, post fall 2-1-23. Alert to self only, confused. Right arm in splint with ace wrap. 2/14/23 at 4:28pm - Description of event: R4 noted to be sitting on the floor in front of recliner with back leaning against recliner. Staff states R4 had been transferred to the recliner 5 minutes prior to watch television. Current Evaluation: R4 denies pain at this time. Assessment for Injury: No acute injury. New interventions put in place: (blank) R4's Incident report documents on 2/14/23 at 4:10pm, R4 was found sitting on the floor in front of recliner with R4's back leaning against the recliner. Staff stated R4 had been transferred to R4's recliner 5 minutes prior to watch television. This report documents R4 was unable to give a statement, R4 was assessed for injury and assisted in to the wheelchair. This report documents there were no witnesses found. This report documents added to care plan to provide (R4) with activities that serve as distractions to help prevent R4 from falling. There is no documentation of witness statements from staff as to when R4 had been toileted, if R4 was incontinent at the time of the fall or if R4's call light was in reach. There is no documentation as to if R4 was wearing proper footwear. There is no documentation as to the root cause of R4's fall on 2/14/23. R4's medical records do not document a fall risk assessment post R4's fall on 2/14/23. On 4/20/23 at 1:40pm, V2, DON stated V2 did not believe the facility documented which staff were responsible for R4 at the time of R4's fall on 2/14/23. V2 stated V2 does not believe any witness statements were received from staff. V2 stated R4 kept stating R4 had to urinate, even with the urinary catheter being in place, even though it was draining okay, of which none of that information is documented in the investigation. V2 stated the facility policies are needing reviewed and that there have been a lot of corporate changes and that is who reviews/updates policies.