**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assess, document and provide pain management for one resident (R2) of three residents reviewed for change in condition. This failure resulted in no pain management provided for 7 hours after R2 fell and sustained a left hip fracture Findings include: Facility Policy/Pain Management and assessment dated [DATE] documents: Evaluation and Assessment: Comprehensive pain assessment tool will be completed upon admission, transfer or onset of new pain which includes: Quality of pain (e.g. burning, aching, numbness) Pain intensity (numeric, visual analog scale, or nonverbal behavior, changes in function observation) Changes in mood state (e.g. depression, anxiety) Location and/or radiation of pain Factors that palliate or provoke pain Characteristics of pain (i. e., stable, progressive, crescendo) Facility Policy/Change in Condition Procedure dated 9/21/2022 documents: The following guidelines will be utilized as appropriate to each situation and change in condition: Full assessment by nursing staff including but not limited to: Full Vital signs (Temperature, Pulse, Respirations, Blood Pressure and Oxygen Saturation) Level of consciousness; Respiratory status including last bowel movement and urine properties Functional status, Pain Glucose test if diabetic or decrease in level of consciousness. Progress Note dated 9/27/24 at 11:59pm indicates (R2) on floor, sitting on his bottom. (R2) claims he was looking for his remote. Vital signs within normal limits, no injuries, moves all extremities within normal limits. Progress Note dated 9/28/24 at 7am indicates R2 complained of hip pain 10/10 after fall last evening. Note indicates (R2) fell at 11:59pm 9/27/24, now complaining of pain and left leg appears to be externally rotated. No other progress notes or documentation regarding R2 was found between 9/27/24 at 11:59pm and 9/28/24 at 7am. Hospital ED (Emergency Department) Final Report Note dated 9/28/24 at 11:14am presented to the ED with left hip pain-swelling, stating he fell last night with pain persisting this AM. Note indicates R2 has a past surgical history of right hip fracture. Risk Management Incident Report dated 9/27/24 at 11:51pm indicates Level of Pain (post fall): Alert; wheelchair bound. Report does not include any actual documentation of R2's pain post fall. On 10/22/24 at 11:40am V6, CNA stated that she was sitting at the nurse station and heard a loud thud. V6 stated she left the nurses station and followed the sound of the thud and saw R2 on the floor in front of the sink. V6 stated R2's room is almost right next to the nurse station, R2's television is above the sink and R2 said he was trying to turn the television on. V6 stated she called V3, LPN who came in and barely did an assessment of R2 and then helped her get R2 back into his wheelchair. V6 stated she was holding the top half of R2 and V3 was holding his bottom half. V6 stated R2 was complaining of pain while they were trying to get him into the chair. V6 stated that night R2 would complain of pain and yell Ow! every time they turned and changed him when he was in bed, especially when turned to the left side. V6 stated R2 really couldn't roll onto the left side. V6 further stated When I found (R2) on the floor, he was completely on his left hip/side. He must have hit hard because the sound I heard from the nurses station was loud. V6 stated she did notify V3 about R2's pain throughout the night. On 10/22/24 at 12:30pm V3, LPN stated that she went to R2's room when she heard he was found on the floor. V3 stated that she and V6, CNA manually picked R2 up and put him in his wheelchair. V3 stated (R2) had no complaints of pain. V3 stated I rely on the CNA's to tell me. It was a busy night, I didn't reassess him. I gave (R2) meds in the morning (not for pain), he took it ok. There is not a spot to document pain on the Neuro sheet. I should've put in a progress note about R2's pain assessment. On 10/18/24 at 11:30am V5, LPN (Licensed Practical Nurse) stated she was told in report in the morning of 9/28/24 that R2 had an unwitnessed fall during the night (of 9/27/24) and was on neuro(logical) checks. V5 stated a CNA came to tell her that while she was providing cares to R2, he was complaining of pain on his left side. V5 stated the night nurse (V3) didn't say anything to her in report about R2 being in pain during the night. V5 stated she had another nurse (V8) came into R2's room and they both agreed R2 needed to go to the hospital for evaluation. V5 stated R2 was in a great deal of pain especially with any movement. No documentation of R2's pain at time of fall or anytime between time of fall at 11:59pm through 7am the following morning (9/28/24) was found or presented. No assessment or interventions to relieve R2's pain from after he fell was found or presented until the morning of 9/28/24 at 7am. Medication Administration Record (MAR) dated September 2024 indicates no pain medication was administered during the night of 9/27/24 through 9/28/24. Current Care Plan has no focus/problem area identifying R2's pain or interventions for pain management. On 10/22/24 at 10am R2 was sitting in his room in his wheelchair with a distressed facial appearance. R2 stated his back hurt and he wanted to lay down. R2 became teary-eyed while speaking. R2 stated this latest hip fracture was much more painful than his previous (right) hip fracture. R2 was unable to recall anything else from the night he fell (on 9/27/24) other than he was trying to turn on the television. At that time V5, LPN came in to assess R2 and stated that R2 is easily emotional especially when in pain. On 10/23/24 at 4:30pm V11, Medical Director stated there can be severe pain associated with a hip fracture, especially with movement. V11 stated there should be a policy to assess for pain after a fall and the policy should be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish appropriate fall interventions for one cognitively impaired resident (R2) and failed to prevent falls with injury for two of three residents (R1 and R2) reviewed for fall with injuries in a sample of three. These failures resulted in R1 requiring hospitalization, sustaining scalp lacerations and a cervical fracture, and subsequently resulting in R1's death, and R2 requiring hospitalization and sustaining a scalp laceration. Findings include: Facility Fall Policy, dated [DATE], documents: it is the policy of the Facility to provide guidelines for the appropriate handling of a resident's fall, accident or incident; the Facility recognizes each situation is unique and must be handled in the manner is most appropriate at the time and for the nature of the change in the condition; guidelines will be utilized as appropriate to each situation and change in condition. Facility Resident Rights Policy, dated [DATE], documents: It is the policy of the Facility to respect the rights of the resident by providing comprehensive care with an approach aimed at maintaining dignity while respecting the core rights of patients and residents as outlined by the State of Illinois, Illinois Department of Public Health, Centers for Medicare and Medicaid/CMS; recognizing society is dynamic and the rights of residents are continually evolving; and strive to improve the quality of care through a multi-disciplinary approach recognizing each resident is an individual with unique needs; and the Facility develops policies and procedures to assist in the support of patient's rights. Facility Assessment, dated [DATE], documents: Nursing Services, the Facility much have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the Facility's Resident population in accordance with the Facility Assessment required; the purpose of the Assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies and is used to make decisions and determine capabilities to provide services to residents in the Facility, to ensure each resident is provided care allows the resident to attain or maintain the highest practicable physical and mental well-being Facility Musculoskeletal System diseases/conditions of Muscle Weakness, Difficulty Walking, History of Falling and Fractures and Rheumatoid Arthritis, Compression Fractures and Joint Replacement (Hip and Knee); Specific Care or Practices with Mobility and Fall with Injury prevention with transfers, ambulation assistance ad Restorative Nursing; dealing with resident's Mental Health and Behavior by managing the medical condition and medication and identifying/implement interventions to help support individuals with issues such as dealing with Anxiety; assessment of medical conditions, early identification of complications and management of medical and psychiatric symptoms; provide support emotional and mental well-being; and identify hazards and risks for residents. Facility Registered Nurse/RN Job Description, undated, documents: direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations and guidelines govern the long-term care facility; ensure all nursing personnel assigned to you comply with the written policies and procedures established by the Facility; responsible for complying with Facility policies and procedures and making recommendations for revisions; complete accident/incident reports and document appropriately; provide direct resident care as needed; implement and maintain established nursing objectives and standards; makes periodic rounds to observe and evaluate the resident's physical and emotional status to ensure continuing quality resident care; assures resident care delivery in accordance with Facility policies and procedures; responsible for competent administration of care; answers call lights promptly; ensures a safe environment; and reports incident's to the Director of Nursing/DON or Designee immediately. Facility Certified Nursing Assistant/CNA Job Description, undated, documents the purpose of this position is to assist the Nurses in providing of resident care primarily in the area of the daily living routine; knowledge of Department of Public Health (IDPH) regulations as related to duties; answer call lights promptly; check on all new resident and re-admissions; responsible for well-being and nursing care of all residents assigned to the his/her unit while on duty; and detect and report situations have a high probability of causing accidents or injuries to residents. 1. R1's Serious Injury Incident and Communicable Disease Report, dated [DATE] at 9:34 am, documents R1's fall with physical harm or injury. The report documents R1 was transported and admitted to the local hospital Emergency Department with a Grade Three Odontoid Fracture/Laceration. The report states R1 stood up from R1's recliner and reached for R1's walker and fell forward hitting R1's head on the bedside table. R1 was noted to have two lacerations to the scalp ad R1 complained of neck pain and right hip pain. R1 was sent to the local hospital for treatment and was noted to have a seven centimeter/cm laceration to R1's lateral scalp, a three cm laceration vertical in between eyebrows and a Grade Three Odontoid Fracture requiring sutures to the lacerations and a cervical fusion of the Cervical (C1-2). The report documents R1's Care Plan and interventions were updated. R1's Physician Order Sheet/POS, dated [DATE], documents R1 admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Unspecified Trochanteric Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing and Rheumatoid Arthritis. The POS also documents a Physician Order for Anxiety Medication (Alprazolam oral tablet 0.25 milligram/mg every eight hours for anxiety) and Anti-depressant Medication (Mirtazapine one tablet 7.5 mg at bedtime) and to monitor for side effects of falls, orthostatic hypotension, motor changes and behavior and mood changes. The POS also documents a Physician Order for Physical Therapy, Occupational Therapy and Speech Therapy. R1's Physical Therapy/PT Evaluation and Plan of Care, dated [DATE] through [DATE], document R1 was receiving PT Therapy for a Trochanteric Fracture of the Right Femur and was discharged on [DATE] with recommendations for independent transfers using an assistive device (walker) or requires supervision and/or cueing to complete the task without an assistive device. R1's current Care Plan does not document R1's Fall Interventions/Fall Risk, Activities of Daily Living level of assistance, therapy recommendation, assistive devices, R1's diagnoses, medications or R1's cognition. R1's Care Plan documents two areas of care (Do Not Resuscitation Code Status and Activity preference). R1's Minimum Data Set/MDS, Section GG, dated [DATE] and [DATE], documents R1's functional ability requires supervision/touching assistance (verbal cues and/or touching/steadying and/or contact guard assistance) for sit to stand position, chair/bed transfer and walking ten feet. R1's Fall Risk Assessment, dated [DATE], documents R1 is a High Fall Risk (11). The Fall Risk Assessment documents R1 has had no falls in the last three months, requires assistive devices, takes three/four high fall risk medications, and has three or more predisposing conditions increase R1's fall risk. R1's Nursing Note, dated [DATE] at 9:14 am, documents R1's medication administration of Alprazolam Oral Tablet 0.25 milligram/mg, one tablet by mouth, due to R1 being anxious and nervous about spouses' condition (spouse death). Facility Monthly Fall Tracking Forms, dated [DATE] through [DATE], were reviewed. The Fall Tracking Forms document a fall with injury for R1, in R1's room, on [DATE] at 9:34 am. R1 was admitted to the local Hospital. R1 had sustained a bone fracture (Cervical/C1 fracture) and laceration. The Tracking Form also documents R1 has a history of falls. No intervention was documented. R1's Nursing Note, dated [DATE] at 5:55 am, documents, (R1) was tearful this morning. Attentive listening provided with one on ones. States does not wish for anxiety medication at this time. R1's Nursing Notes, dated [DATE] at 10:08 am, document, Staff heard (R1) yelling for help. Upon entering room, noted (R1) lying semi-prone on right side on floor over the top of (R1's) bedside table. Moderate amount of bright red blood noted on head and on floor under (R1). Pressure held to lacerations (twice) on forehead. Repositioned to back and table removed from area. R1 complained of pain in neck and right hip. Emergency (911) called. Daughter called and informed of fall and transport to hospital. (V1/Administrator) notified of fall. R1's Nursing Note, dated [DATE] at 12:27 pm, documents, Family came into facility and stated (R1) has cervical fractures (C1 and C3) and is being transferred to (hospital) via air-evacuation. R1's Nursing Note, dated [DATE] at 12:47 pm, documents the local hospital was called and stated, (R1) was airlifted to hospital with Cervical (C1) fracture. R1's Hospital Record, dated [DATE], documents R1 presented to the Trauma Center with a Chief Complaint of Category Three Trauma and fall. admitted with Diagnoses including Odontoid Fracture, Fall, Closed Odontoid Fracture, Scalp Laceration and Facial Laceration. R1 required surgery (closed reduction of C1-C2 Dislocation). The record documents R1 was sitting in recliner and when standing up, R1 reached for walker and fell forward hitting a nearby table to R1's scalp/face. R1 presented to local hospital where imaging showed a Grade Three Odontoid Fracture. R1 was subsequently transferred to a higher level of care. The record documents a seven centimeter/cm scalp laceration was cauterized to reach metastasis and a three cm veridical laceration in between eyebrows, and multiple bruises to extremities. The record documents R1 had recent Right Hip surgery. The hospital timeline documents R1 admitted to Intensive Care on [DATE], transferred out of Intensive Care on [DATE] and then back to Intensive Care on [DATE] at midnight. On [DATE] at 6:58 pm, R1 was transferred out of Intensive Care and then expired on [DATE] at 3:21 am. R1's Certificate of Death, dated [DATE], documents R1's cause of death as Pneumonia, Odontoid Fracture and Ground Level Fall. On [DATE] at 9:15 am, V2 (Director of Nursing/DON) stated, (R1's) Care Plan is not completed and should document R1's Fall Risk status. (R1's) Fall Risk Assessment does document (R1) was identified as a High Risk for falls. V2 verified R1's Care Plan was incomplete and only had two areas of concerns, Activity and Code Status. On [DATE] at 9:15 am, V1 (Administrator/ADM) stated, (R1's) spouse died on [DATE], just two days before (R1) fell out of chair. Staff heard (R1) fall and went in to (R1's) room. (R1) was laying over the bedside table with lacerations to (R1's) head and was complaining of neck and hip pain. We sent (R1) to (local hospital) and then they life flighted (R1) to a hospital in [NAME]. R1 was independent and able to get up and move around (R1's) room by herself and without any assistance. (R1) was alert and oriented after the Cervical surgery and then all of the sudden (R1) ended up in Intensive Care and ended up dying days later, on [DATE]. On [DATE], at 2:00 pm, V1 (Administrator) stated, It makes sense how you should not just educate someone with memory problems for a fall intervention. R1's Care Plan does not document any level of assistance or care needs R1 requires. V1 verified R1 admitted to the facility on [DATE] with a Right Femur Fracture, Rheumatoid Arthritis and receiving medication for anxiety disorder. V1 verified R1 was receiving Physical and Occupational Therapy for the Right Femur Fracture and R1's current Care Plan did not have the required documentation to care for R1 and R1's medical record had conflicting documentation on R1's level of Cognition and Activities of Daily Living assistance needs. 2. R2's Serious Injury Incident and Communicable Disease Report, dated [DATE] at 10:00 am, documents R2's fall with physical harm or injury. The Report documents R2 was transported and admitted to the local hospital for a fall in R2's room. R2 fell and hit R2's head on roommates' bed and was found to have a scalp laceration. R2 leaned forward to grab something and fell out of R2's wheelchair hitting R2's head on roommate's bed. R2 was found to be laying on the floor beside roommate's bed and R2's wheelchair was sitting in the hallway. R2 received five staples to the laceration and admitted for observation of seizure activity, then re-admitted to facility on [DATE]. R2's Hospital Record, dated [DATE], documents R2's Chief Complaint as an unwitnessed fall from a wheelchair with head injury (struck head on floor), unknown loss of consciousness, staff states mental status is altered and R2 sustained a Right Posterior Scalp Laceration. The record documents R2 was alert upon arrival, does not answer questions appropriately and is confused at baseline. The record documents the Nursing Home staff stated R2 has frequent falls, is ambulatory minimally with staff assistance only and spends most of time in wheelchair. The record documents R2's Medical Diagnoses including Bipolar Disorder, Left Eye Blindness, Borderline Personality Disorder, Cerebral Vascular Accident/CVA, Pseudo seizures and Vascular Dementia. R2 received a Comminuted Tomography/CT scan showed evidence of scalp trauma in the Right Occipital Region. R2's current Care Plan documents R2 has blindness in the Left Eye, had a Right Humerus Fracture, orders for medication administration of an Anti-depressant and Anti-psychotic, alteration in ability to care for self and needs assistance, requires extensive one to two staff assistance with transfers and requires an assistive device. The Care Plan also documents R2 is a high risk for Falls. R2's Care Plan documents an intervention for R2's falls on [DATE] and [DATE] as Education; [DATE] and [DATE] falls as continue current Care Plan; and [DATE] fall as putting a sign on the mirror to remind R2 to stay seated when washing hands. R2's MDS, Section GG (Functional Abilities and Goals) documents R2 requires partial/moderate assistance with sit to stand, chair/bed-to chair transfer and walking ten feet. R2's Fall Risk Assessment, dated [DATE] and [DATE], documents R2 is disoriented to person, place and time, has had three or more falls in past three months, is chairbound and requires assistance, poor eyesight, balance problems, requires assistive devices, takes three/four high risk medications and has one/two predisposing Diagnosis and a Fall Risk Score of 20 (High Risk). R2's Fall Risk Assessment, dated [DATE], documents R2 has a Fall Risk Score of 22 (High Risk). Facility Monthly Fall Tracking Forms, dated [DATE] through [DATE], document falls for R2: in R2's room on [DATE] at 1:40 pm, no injury and the intervention was education resident ; in R2's room on [DATE] at 1:15 pm, no injury and the intervention was to continue current care plan; [DATE] at 2:15 pm in R2's bathroom, with no injury and the intervention was to keep R2 in areas of visualization unless in bed; [DATE] at 3:55 pm in 'other' location, no injury and the intervention was Occupational Therapy to evaluate and treat; [DATE] at 5:34 pm in hallway and R2 sustained a scratch to R2's face and the intervention was for staff to close R2's door when R2 leaves room; [DATE] at 4:45 pm in R2's room with no injury and the intervention was to put a sign on the mirror to remind resident to stay seated when washing hands; [DATE] at 10:55 pm in R2's bathroom with no injury and the intervention was to frequently toilet R2; [DATE] at 10:00 am in R1's room, R2 was admitted to the local Hospital and sustained a laceration and required five staples to the scalp and the intervention was to move closer to the nurses station; [DATE] at 6:26 pm in R2's room and R2 sustained remained in the Facility and sustained an abrasion to the scalp and the intervention was to educate R2 on asking for help; [DATE] at 3:00 pm in R2's room, with no injury and the intervention was to continue plan of care; and on [DATE] at 2:45 pm in R2's room, does not document any injury or fall intervention. On [DATE] at 11:20 am, R4 (R2's roommate) stated, (R2) falls a lot. She just fell a little while ago and bumped her 'noggin' and had to go to the hospital. They tell (R2) to sit down but she has a head injury from a long time ago and does not have good memory, she just does not understand all the time. On [DATE] at 11:29 am, R2, was sitting in wheelchair in dining room, with anti-tippers on wheelchair and stated, I have bad eyesight. Every time I fall, they tell me to put my call light on, but I do not always remember and honestly, they take too long to answer my call light. I get impatient, and they take too long to get to me, and I just get up and do it myself, and is usually when I fall. On [DATE], at 2:00 pm, V1 (Administrator) stated, I do not think some of the interventions, such as education, are appropriate for (R2's) falls, because she does have memory issues. (R2) has definitely had a lot of falls, but we are not always sure what are the best interventions. V1 verified R2's [DATE] fall resulted in a scratch to R2's face and on [DATE], R2's fall required emergent hospital care for five staples to a scalp laceration and R2's [DATE] fall resulted in an abrasion to R2's scalp.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to implement appropriate person centered fall interventions. This failure resulted in multiple falls with injuries for two residents (R1, R2) reviewed for falls in a sample of three. This failure resulted R2 requiring medical attention for head lacerations and hematomas at the local hospital on multiple occasions. Findings include: Facility Fall Policy, revised 8/1/22, documents: It is the policy of this Facility to provide guidelines for the appropriate handling of a resident's fall, accident or incident; and each situation must be handled in the manner that is most appropriate at the time and for the nature of the change in condition. Facility Fall Monthly Tracking Logs, dated 1/1/23 through 1/31/23, were reviewed. The Fall Log documents that R1 had falls two falls on 1/14/23, and one fall on 1/17/23 and 1/28/23. The Fall Log documents that R2 had two falls on 1/9/23, and one fall on 1/11/23, 1/12/23, 1/14/23 and 1/30/23. 1. R2's current Care Plan documents that R2 has diagnoses including Osteoarthritis, Chronic Obstructive Pulmonary Disease, Unspecified Abnormalities of Gait and Mobility. R2's Minimum Data Set/MDS dated [DATE], documents R2 has a Brief Intermittent Mental Status/BIMS (score of 13/15) showing that R2 has minimal cognitive impairment. R2's MDS also documents that R2 requires extensive staff assistance of two persons for bed mobility and transferring and extensive staff assistance of one person for toileting. R2's Fall Report, dated 1/7/23 at 2:45 pm, documents that R1 had an unwitnessed fall while self ambulating with a wheeled walker in R2's room. R2 stated, I caught the edge of the bed and I fell over. R2 sustained two skin tears, one on each leg, and the skin tears were cleansed and bandaged. R2's Medication Administration and Treatment Administration Record does not document Physician Orders for treatment or monitoring of R2's skin tears. R2's current Care Plan documents an intervention of ensure the call light is in reach. R2's Fall Report documents that R2 had an unwitnessed fall on 1/9/23 at 12:15 pm. R2 was found on the floor with buttocks with back against her bed, overhead table was over resident, and resident's legs were over the bottom bar of the overhead table. The intervention was educated on the need for calling for assistance. R2's Fall Report documents that R2 had an unwitnessed fall on 1/9/23 at 8:45 pm. R2 was taking self to bathroom and fell backwards in room. R2 was found lying on back with walker at bedside and bleeding noted under R2's head. R2 sustained a one centimeter/cm laceration to the posterior left side of the head with a golf ball size hematoma. R2 stated, I was going to the bathroom and fell backwards. R2 denied dizziness and R2's blood pressure was 150/86. The intervention was for orthostatic blood pressure checks for three days. R2 was sent to the local hospital for evaluation and treatment and returned to the facility with four staples to the laceration. The Facility Local Health Department Serious Incident Report, dated 1/10/23, documents that R2 sustained a fall on 1/9/23 at 8:45 pm. R2 was discovered on the floor of her room with her walker lying to her side and had a laceration to the back of her head. R2 was returning from the bathroom and fell backwards striking her head on the floor. R2 was sent out to the local Hospital's Emergency Department for evaluation and returned to the facility with four staples to the laceration to the back of R2's head. The Report documents that R2 has a secondary diagnosis including abnormalities of gait and mobility. R2's Hospital Emergency Department discharge instructions, dated [DATE], documents that R2 was evaluated for a head laceration due to a fall. R2 received staples to the head laceration. Orders were received that R2 should have the staples removed in seven to ten days and should be evaluated in one to two days for redness or drainage. R2's Fall Report, dated 1/11/23 at 6:30 am, documents that R2 sustained an unwitnessed fall while self transferring to the bathroom. R2 was noted to be laying on the left side with legs wrapped around the legs of R2's walker. R2 was wearing non-slip socks and R2's call light was not activated. No injuries were noted and R2's current Care Plan documents that R2 was moved closer to the nurses station for monitoring. R2's Fall Report, dated 1/11/23 at 3:15 pm, documents that R2 sustained a staff assisted lowering to the floor fall. R2 was ambulating with staff to the smoking break with a wheeled walker. R2 stated, My leg got weak and I could not make it any further. No injuries were noted and R2's current Care Plan documents an intervention of R2 using a wheelchair to go outside to smoke. R2's Fall Report, dated 1/14/23 at 11:10 pm, documents that R2 sustained an unwitnessed fall. A loud crash was heard and R2 was noted to be laying on the floor by the bathroom door. R2 was noted to have a laceration on the back of R2's head with a moderate amount of bleeding. R2 was sent to the local hospital for evaluation and treatment. R2 returned to the Facility with a treatment (Dermabond) to the laceration. A CT was performed and all results were negative. R2's current Care Plan documents an intervention of Call Don't Fall signs to be placed in R2's room. R2's Physician Order Sheet, Medication Administration and Treatment Administration Sheets and Nursing Notes do not document Physician Orders for treatment or monitoring of R2's laceration. The Facility Local Health Department Serious Incident Report, dated 1/15/23, documents that R2 sustained a fall on 1/14/23. R2 was noted to be on the floor by the bathroom. R2's walker was on the floor next to her and no other trip hazards were identified. (R2) was assessed and noted to have a small laceration to the upper posterior aspect of her head which was bleeding. R2 was sent to the local Hospital's Emergency Department for evaluation and treatment. R2's laceration was glued (Dermabond) and R2 returned to the facility. R2 had slipper socks on and R2's call light was not activated at the time of the incident. R2's Hospital Computed Tomography/CT Report, dated 1/15/23, documents that R2 had a CT and the impression was that R2 had a left posterior parietal scalp hematoma. R2's Hospital Emergency Department discharge instructions, dated [DATE], documents that R2 was evaluated for a ground level fall and a laceration of the occipital region of the scalp. R2's Fall Report, dated 1/30/23 at 10:35 am, documents that R2 sustained an unwitnessed fall. R2 was found sitting on buttock next to R2's bed. R2 stated, I was trying to get my phone charger. R2 stated that R2 hit head. R2 was sent to the local hospital for evaluation and treatment. A CT of the head was performed with no findings and returned to the Facility. R2's current Care Plan documents an intervention to make sure that items are within reach of resident. R2's Hospital Emergency Department discharge instructions, dated [DATE], documents that R2 was evaluated for a closed head injury due to a fall sustained on 1/30/23. The Commuted Tomography (CT) results show a scalp hematoma. On 1/31/23, at 12:05 pm, R2 had a laceration to the back of the head with dark brown appearance and matted uncombed hair. R2 stated, I have tripped over my walker and stuff before and had a few falls that sent me to the hospital. The last time I went I had to get another gash 'glued.' On 1/31/23, at 11:01 am, V5 (Assistant Director of Nursing/DON) stated, For (R2's) first fall on 1/7/23, the intervention was to make sure that the call light was in reach. Then (R2) had two falls on 1/9/23, and the intervention for the fall at 1/9/23 at 12:15 pm, we educated on the need for calling for assistance. Then for the 1/9/23 at 8:45 pm fall, we thought maybe (R2's) blood pressure was dropping when (R2) stood up, so the intervention was for orthostatic blood pressure's for three days. Obviously, the first two interventions did not work because (R2) was not asking for help or activating the call light. (R2's) legs would give out and that is why (R2) fell on 1/11/23. I am not sure why (R2) was not asking for help or putting on her call light. I am not sure if some of these interventions were right for her, because she kept falling. It is hard to do the right intervention. On 2/1/23 at 11:30 am, V5 (Assistant Director of Nursing/DON) stated, Some of the interventions were probably not the best but it is difficult to find the right intervention sometimes. I understand that you should not use things like education and stuff when finding an intervention for a confused person, that is probably not the best intervention. 2. R1's current Care Plan documents that R1 has diagnoses including Hemiplegia and Hemiparesis, unspecified Cerebrovascular Disease affecting Left Non-Dominant side; History of Falling, other Symptoms and Signs involving the Musculoskeletal System, other Symptoms and Signs involving Cognitive Functions and Awareness and Dementia. R1's Minimum Data Set/MDS dated [DATE], documents that R1 has a Brief Intermittent Mental Status/BIMS (score of 0/15) showing that R1 is rarely or never understood and has moderately impaired cognitive skills for daily decision making. The MDS also documents that R1 requires staff assistance of one person for bed mobility, transferring and toileting. R1's Fall Report, dated 1/14/23 at 3:15 pm, documents that R1 had an unwitnessed fall while transferring self to the bathroom and was noted sitting on her bathroom floor. R1's current Care Plan documents that the intervention was frequent checks. R1's Fall Report, dated 1/14/23 at 6:45 pm, documents that R1 had an unwitnessed fall while self transferring to bed. R1 was noted on the floor in front of wheelchair in between the bed and window. R1 was unable to recall the events. R1's Care Plan documents that Gripper strips were placed on the side of the bed on the door side. R1's Fall Report, dated 1/17/23 at 8:00 pm, documents that R1 had a witnessed fall. R1 was laying on left side with head on bedside table leg with bleeding noted above the left eye. R1 had support stockings on and R1's slipper socks were on the floor. Noted that R1's call light was not activated but within reach. R1's Nursing Note documents that on 1/18/23, at 2:46 pm, V7 (R1's Physician) was notified of R1 not extending the right lower extremity and grabbing right thigh in pain. Requesting an order for an X-Ray. V7 stated, It is okay to do an X-ray but X-rays usually do not show fractures. If the X-ray comes back okay and (R1) is still having pain, get a Commuted Tomography (CT) without contrast. R1's Nursing Notes and Medication Administration Records, dated 1/17/23 through 1/27/23 document R1 receiving pain medication. R1's Medical Record does not document an order for a CT or CT results. R1's Fall Report, dated 1/28/23 at 11:08 am, documents that R1 had an unwitnessed fall out of bed. R1 was noted to be on the floor next to R1's bed on the right side. R1's current Care Plan documents that R1 to be positioned in the center of the bed. On 2/1/23, at 11:44 am, V8 (Registered Nurse) stated, When a resident falls, we should try and put the right intervention in to place, sometimes it is hard, especially when someone falls a lot. We fax the Doctor and do a Risk Management Form that gets reviewed by the Department Heads for appropriate interventions. Sometimes we do not hear right back from the Doctor. On 2/1/23, at 10:26 am, V7 (Medical Director) stated, Sometimes I do not get notification of falls until many days later, we are trying to work on this. so that Residents can be treated and monitored adequately. Sometimes I do not get notification of a fall until days later. The Facility should be making the appropriate interventions on an individualized case by case. We are trying to work together to find the right cause of the falls, I have really been looking at the Gradual Dose Reductions of Medications that the Facilities keep wanting to put people on too.