**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 3 residents (R1) was transferred safely. This failure resulted in R1 falling and fracturing her right femur.The findings include: On 9/12/25 at 12:45 PM, V9 (Certified Nursing Assistant/CNA) said she was R1's CNA when R1 fell on the morning of 9/2/25. V9 said a couple days prior when she was caring for R1, R1 complained of arm pain and wanted to get up in her chair because of her arm pain. The morning of 9/2/25, R1 complained of right arm pain again and asked V9 to put her in her chair (recliner). V9 said she changed and dressed R1 with pants, shoes, socks, and a clean brief, then she helped position R1 on the side of her bed. V9 said she put the transfer aid device/lift machine, up against the bed and assisted R1 to put her feet on the platform, then R1 grabbed the bar and V9 used the back of R1's pants to help her stand up. V9 said the lift machine was so close to the bed, she couldn't get the paddles down, so she took the brakes off and pulled the lift machine out away from the bed. V9 said before she could get the paddles down, R1 said I'm falling and let go of the bar. V9 said she tried to grab the back of R1's pants/brief to somewhat catch her, so she didn't have a direct hit on the floor, but R1 ended up falling on the floor into a sitting position with her legs straight out. V9 said the machine got pushed out in front of R1. V9 said she went and told V8 (Licensed Practical Nurse/LPN). V9 said R1 was screaming at them and yelling that her leg hurt, that they broke her leg, and they dropped her on the ground. V9 said she felt that something was wrong, because R1 doesn't really yell at her like that. V9 said she should have used a gait belt when transferring R1. V9 said she was told R1 fractured her leg. V9 said she probably should have automatically had a gait belt on R1 when using the machine so she could have held it and prevented R1 from falling. V9 said she wasn't thinking there was going to be issues with the transfer, so she didn't use one.On 9/12/25 at 12:23 PM, V10 (Certified Nursing Assistant/CNA) said V9 came and got him because she needed his help because R1 was on the floor outside of her bathroom. V10 said V9 told him when she was putting the paddles (of the machine) in position, R1 sat back, and the paddles were not in place and R1 fell onto the floor. V10 said R1 did not have a gait belt on when he arrived to assist V9 with R1. V10 said you should always use a gait belt when transferring a resident, especially when using a device where the resident needs to pull themselves up. V10 said if a resident was having arm pain while preparing to use the lift machine to transfer them, he would stop the process. V10 said they are empowered to use their own judgement and could get a total lift device instead. V10 said R1 is a little feisty and unpredictable and he feels like there should be two persons to transfer R1 specifically. V10 said she can be rambunctious at times, and she doesn't want to help much at times. V10 said when using the machine, you scooch the machine right up to the resident, put their feet on the platform, lock the brakes, and the resident reaches for the bar. The staff member uses the gait belt to assist the resident to standing. Once they are standing securely, staff gets the paddles into position as quickly and as smartly as possible, then instructs the resident to lean back on their bottom. On 9/12/25 at 2:10 PM, V8 (LPN) said he was R1's nurse when she fell. V8 said V9 came to him and needed help with R1. V8 said when he got to R1's room, R1 was tangled in the lift machine in front of her bathroom door. V8 said she was dangling half in and half out of the lift. R1's feet were off the platform, her arms were draped over the grab bar, and one paddle was in the up position and the other was in the down position. V8 said R1 was hollering and screaming; she was hanging from the lift. V8 said R1 couldn't move because she was basically wedged in by the paddle. V8 said they moved the paddle and lowered R1 down to the floor. V8 said when using the machine, they are supposed to lock the brakes, use a gait belt to help the resident so they can grab the bar, and then engage the paddles so they can lean back/sit on them. V8 said R1 complained of right lower extremity pain, so he requested an Xray. V8 said R1 eventually went to the hospital and was diagnosed with a displaced fracture.On 9/12/25 at 11:35 AM, V3 (Director of Rehab/Physical Therapist) said when using a lift machine for a resident transfer, the machine is positioned directly in front of the resident, their feet go onto the platform, the machine is locked so it doesn't roll forward, then the resident reaches out and pulls themself to a standing position and the paddles are rotated down to form a seat and the resident's knee/shins saddle into the knee/shin pads and they sit onto the seat formed by the paddles. V3 said the machine can be used with one staff person with the resident wearing a gait belt. V3 said the resident has to have the core strength to pull themself up into a standing position.On 9/12/25 at 1:42 PM, V2 (Director of Nursing/DON) said R1 had been a transfer via the lift machine. V2 said R1 was getting weaker and either fell, or almost fell, so they changed her to a (name of a different kind of lift machine). V2 said R1 hated that lift because it was uncomfortable, so they went back to a (name of previous lift machine). V2 said R1 has not been ambulatory for at least two years. V2 said when using the lift machine, it is required to use a gait belt on the resident.R1's Detailed Summary (undated) provided by the facility shows R1's diagnoses include, but are not limited to, osteoarthritis, arthritis, tremor, unsteadiness on feet, need for assistance with personal care, muscle weakness (generalized), difficulty in walking, history of falling, and weakness. R1's Interdisciplinary Notes dated 9/2/25 at 6:33 AM show R1 was on the floor this morning from a transfer with the (name of lift machine). R1 did not have seat pads in place and was not standing up well, and she let go of the bar and went down to the floor. R1's legs caught and were tangled on the (name of lift machine). R1 was screaming about her right leg being broken. R1's current care plan provided by the facility shows R1 has a potential to fall due to impaired balance. R1 is unable to ambulate and has a history of falls. R1 has severely impaired cognition. R1 can become agitated with staff, combative, and verbally aggressive and resistive to cares. R1 requires extensive staff assistance for transfers. R1's Minimum Data Set, dated [DATE] shows R1 has severely impaired cognition and requires substantial/maximal assistance (helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with sit to stand, chair/bed-to chair transfer, roll left and right, sit to lying, and lying to sitting on side of bed.R1's results of her right femur Xray obtained on 9/2/25 show the Xray was taken due to right leg pain after a fall. The Impression shows a displaced periprosthetic fracture of the distal right femur.The facility's (name of lift) Transfer Aid Policy/Procedure (undated) shows the steps for use are to raise the two split seat units so they are parallel to the side of the device, have the patient positioned at the edge of the surface to be transferred from, move the (name of lift) in front of the patient and position the patient so their feet are firmly on the platform and their knees and shins are in contact with the two cupped kneepads. LOCK the casters, have the patient grasp the cross bar closest to them and, using their own strength, pull themselves up into a standing position securely on the base platform. Lower both of the split seat units into position to form a complete seat, then have the patient lower themselves down onto the seat while keeping their knees and shins in the kneepads while continuing to hold the cross bar with both hands. Then UNLOCK the casters and move the device to the new surface.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was safely positioned in bed for 1 of 3 residents (R2) reviewed for safety in the sample of 5. This failure resulted in R2 falling from her bed and sustaining a laceration requiring staples. The findings include: R2's physician visit form documents she was admitted to the facility on [DATE] with multiple diagnoses including vascular dementia, and history of falling. R2's quarterly resident assessment and care screening of 2/17/25 documents her to have severe cognitive impairment. Her mobility assessment shows she requires substantial/maximal assistance with rolling right to left. Meaning the helper provides more than half of the effort to perform the task. The 2/17/25 care plan for hospice services notes R2 requires extensive to dependent assistance with 1 staff for all cares and uses a mechanical lift for transfers. The facility incident report of 3/26/25 documents R2 had a fall at 4:50 AM in her bedroom by the bedside. The description of the incident was staff preparing resident to get up and resident rolled out of the bed and fell on the floor with head injury and bleeding. Sent to the ER (emergency room) for further evaluation. On 4/9/25 at 10:22 AM, V13 (Certified Nursing Assistant/CNA) said on the morning of 3/26/25, she was getting R2 ready to get out of bed. When she does care for any resident, she has the bed in the high position, so it is easier on her back, and she had R2's bed in the high position, probably to her waist or higher. V13 said during cares, R2 can either be stiff and difficult to move, or she is wiggly. V13 said on that morning, after she had R2 dressed, she rolled her towards the wall, and placed the mechanical lift sling under her and needed to pull it through. V13 said she moved R2's bed out from the wall, and standing between the wall and the bed, she rolled R2 towards the other side, and R2 began moving her legs and fell off the side of the bed. She said the bed had no side rails, so R2 just fell to the floor, landing on the concrete floor on her back. V13 said there was nothing she could do to stop it because she was on the opposite side of the bed. V13 said there was immediately blood present, and she notified the nurse. The ED (emergency department) report for 3/26/25 documents the reason for the visit was a laceration to the scalp. The physical exam shows a 1 cm (centimeter) laceration to the occipital (back of the head) area. The laceration repair included the placement of 4 staples. On 4/9/25 at 11:00 AM, R2 said she had no pain and forgot she had staples to her head. She was sitting up in her reclining wheelchair visiting with her sister. She had no bruising or signs of any further injury. On 4/9/25 at 2:30 PM, V2 (Director of Nursing) said the incident was reported to her, and she spoke with V13 about the details. She said V13 was by herself when providing care for R2, when she went to the opposite side of the bed, leaving R2 facing the open side of the bed. V13 reported to her, she was placing the mechanical lift sling when R2 put her foot out over the edge of the bed and fell because there was no one there to catch her. V2 said none of the beds have side rails, so there was nothing to catch R2. V2 said she did not know how high the bed was raised at the time of the fall; a lot of staff raise the beds for better body mechanics. She said maybe it was not safe to have 1 person providing care. And R2's fall mat should have been in place. On 4/10/25 at 8:20 AM, V12 (Licensed Practical Nurse/LPN) said on the morning of 3/26/25, V13 had poked her head out of R2's room and notified him of the fall. Upon arrival to R2's room he found her lying on the floor, face up with blood coming from her head. V12 said he immediately called 911 to have her sent out to the emergency room. He said R2 was on the concrete floor and the fall mat was off to the side. He observed R2's bed to be in a higher position, probably about 3 feet up in the air. The facility's 2018 falls and fall risk management defines a fall as unintentionally coming to rest on the ground, floor, or other lower level. Fall risk factors 1. Environmental factors that contribute to the risk of falls include c. incorrect bed height. 2. Resident conditions that may contribute to the risk of falls include: c. delirium and other cognitive impairment.

3. The admission MDS (Minimum Data Set) dated 6/27/24 documents R18 is cognitively intact, upper body dressing at partial/moderate assistance, lower body dressing at substantial/maximal assistance, and putting on/taking off footwear at dependent. The current Fall Care Plan for R18 documents R18 has the potential for falls due to impaired balance, requires one to one assist with standing and walking short distances and is a high risk for falls. This Care Plan also documents R18 fell on 7/17/24 with new intervention put in place to encourage R18 to stay where she is seated until staff can help her. The facility's final report and investigation dated 7/19/24 documents R18 had a fall on 7/17/24 while sitting on the side of the bed receiving staff assistance getting dressed and documents that a CT showed: subarticular sclerosis of the medial tibial plateau compatible with nondisplaced impaction fracture injury. The Progress note dated 7/17/24 at 9:06am documents at 7:45am resident (R18) was being assisted from bed. She was seated on the side of the bed. Resident (R18) scooted to the edge of the bed and slid off of the bed landing first on her knees and then forward on her forehead. No loss of consciousness. Large hematoma to forehead. Ice applied. This note also documents R18 received a Skin tear on left upper arm and a bruise to the left knee and complained of pain in her right knee. R18 sent to local hospital for evaluation. On 07/21/24 at 08:26 AM R18 noted to be lying in bed with a large, raised, pinkish-red bump to left forehead, bilateral eyes with dark, purple discoloration around orbits and chin area. R18 stated that Wednesday (7/17/24) she was getting out of bed when she slid off the side onto the floor hitting her face on the metal base of the over bed table. R18 stated she went to the hospital and was found to have a crack in her leg below her right knee. R18 stated she is to wear a brace to her right leg and a brace to her right wrist. Neither brace noted in room. On 07/22/24 at 12:45 PM R18 noted sitting in wheelchair in room with Lower Extremity brace to right leg and feet on wheelchair pedals. Bruising to face is turning green in color today. On 07/24/24 at 11:20 AM R18 noted to be sitting alone in her wheelchair in her room. A Falling star sticker noted on R18's door and on her wheelchair. On 7/24/24 at 09:30 AM V9 (CNA) stated on 7/17/24 that she was assisting R18 with dressing with bed at mid-level when V13 (CNA) came into R18's room to ask a question. V9 stated she turned her head toward V13 and answered question. V13 gasped causing V9 to turn back to R18 and noted R18 laying on the floor. V9 stated she should not have turned away from R18 because fall would not have happened. On 07/24/24 at 09:40 AM V10 (Registered Nurse/RN) stated she was called to R18's room by V13 stating R18 had fallen. V10 entered R18's room and V9 was kneeling next to R18 laying on the floor. V10 stated she assessed R18's vital signs, did a neurological check, cleaned and bandaged skin tear to left arm and assessed R18's range of motion (ROM). During ROM V10 noted a small bruise to R18's left knee and R18 complained of soreness to her right knee. V9 and V13 put R18 in bed and R18 was sent to local hospital for evaluation. Based on observation, interview, and record review the facility failed to follow the facility's fall program and provide supervision for three (R15, R18, and R60) of six residents reviewed for falls in the sample of 28. These failures resulted in: R15's hospitalization resulting from nasal fractures; R18's hospitalization resulting from a tibial fracture; and R60's hospitalizations resulting from a right hip fracture and then left hip fracture. Findings include: The facility's undated Managing Falls and Fall Risk policy and procedure, documents: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. Monitoring Subsequent Falls and Fall Risk: 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling . 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. The Falling Star Program sign documents A falling star is placed on the doorway and w/c (wheelchair) if resident meets the following criteria: 1) Has had more than 2 or more falls in the past 3 months. Follow these Falling Star Guidelines: 1) Do Not leave unattended in the bathroom or room (if up in w/c), 2) Refer to restorative, 3) Attempt to keep in highly visible area when up in w/c. The facility's Falling Star Program, dated 6/1/2023, documents Upon admission, the nursing staff will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. The fall risk assessment will be used to implement the Falling Star program to alert staff that a resident has a higher risk for falling. The Falling Star symbol will be placed on the resident's name tag and wheelchair if applicable. The Falling Star program would be implemented if the resident triggers high risk for falls per the fall assessment. The interventions for the Falling Star program should be resident specific and follow the care plan. On 7/23/24 at 3:39 pm, V3 (Chief Nursing Director) and V2 (Director of Nursing/DON) stated they do all the reportable fall incidents together to determine route cause and make sure there are interventions in place. On 7/24/24 at 10:55 am, V3 (Chief Nursing Director) confirmed the Falling Star Program posted signage was for residents who are at a high risk for falls, depends on the resident, and resident specific. V3 confirmed these residents should not be left unsupervised. 1. R15's Face Sheet includes the following diagnoses for R15 as: Alzheimer's Disease, Unspecified Dementia, Generalized Anxiety Disorder, Major Depressive Disorder, Cognitive Communication Deficit, Lack of Coordination, and Need for Assistance with Personal Care. The Annual MDS (Minimum Data Set) Assessment for R15, dated 6/20/24, documents R15 with severe cognitive impairment and requires substantial to maximal assistance with toileting hygiene, bathing, lower body dressing, personal hygiene. R15 requires partial to moderate assistance with oral hygiene, upper body dressing and is dependent for putting on/removing footwear. R15 requires substantial to maximal assistance with all mobility. The Fall Risk Assessment for R15, dated 3/25/24 and 6/20/24, document a fall risk score of 13 and 12 respectively and documents A score of 10 or more indicates High Risk for Falls. The current Care Plan for R15, documents R15 has potential to fall due to impaired balance, requires one-to-one assist to transfer with a non-mechanical lift, and does not call for assist consistently. R15 requires extensive assistance from staff with bed mobility, dressing, bathing, hygiene, transfers, and toileting. This same Care plan documents R15 had prior falls on 9/25/23, 12/20/23, and 2/28/24. Interventions include to assist with reposition every two hours and as needed. An intervention was added after R15's 9/25/23 fall to not be left unattended in her room while sitting in her wheelchair. The Progress Note for R15, dated 7/18/24 at 5:54 pm, documents (R15) unwitnessed fall from w/c to floor in hallway. Nurse sitting at nurse's station and heard. (R15) observed lying on right side, right arm under body, (R15) facing the floor. (R15) bleeding from nose and above left eye. Cool compress applied to side of nose and left eye. R15 sent to the local hospital for evaluation and treatment. The Progress Note for R15, dated 7/18/24 at 9:28 pm, documents R15 returned from local hospital with fractured nose and to apply ice and elevate head of bed for comfort. Hospice service was notified, and new order received for safety mats at bedside. Discoloration right eye and nose and bruise to right elbow. The Incident Report for R15, dated 7/18/24 at 5:30 pm, R15 had unwitnessed fall in the hallway from her wheelchair to the floor resulting in bruising with bleeding from contusion. R15 has a history of multiple falls, R15 was leaning forward in her wheelchair and fell out. R15 complained of pain and was sent to the local hospital for evaluation. The Hospital Discharge paperwork, dated 7/18/24, includes a Maxillofacial (face and jawbones) CT (Computed Tomography), dated 7/18/24 that documents findings as: Mildly displaced left greater than right nasal bone fracture, slightly deviated to the left. Overlying nasal bridge swelling. Right preseptal periorbital superior orbital rim contusion. There is minimal fluid stranding left ethmoid air cells. Impression: Right superior periorbital soft tissue preseptal contusion changes. Suspect nondisplaced bilateral nasal bone fractures. On 7/21/24 at 9:57 am, R15 was sitting in recliner lounge chair with her eyes closed. Yellow and green fading discoloration was noted surrounding R15's bilateral eyes and to bridge of R15's nose. R15's wheelchair was across the room out of R15's reach with a Falling Star sticker attached to the back of her wheelchair and name plate on doorway, a non-mechanical lift was in R15's bathroom and floor fall mats were in an upright position leaning against the wall. On 07/23/24 at 10:55 AM, R15 was sitting on the toilet in her bathroom with a non-mechanical lift placed in front of her and there were no staff present. At 10:57 AM, V8 (Certified Nursing Assistant/CNA) entered R15's bedroom, walked into R15's bathroom, assisted R15 off the toilet with the non-mechanical lift, assisted R15 to sit in the wheelchair, and pushed R15 out of the bedroom into the hallway. On 7/23/24 at 11:04 AM, V8 (CNA) stated R15 does not generally get up by herself. On 7/24/24 at 10:45 AM, R15's bathroom call light illuminated outside of R15's bedroom. Entered R15's bedroom with V3 (Chief Nursing Director) and observed R15 sitting on the toilet in the bathroom, a non-mechanical lift in front of her, and no staff present. V3 assisted R15 off the toilet with the non-mechanical lift and assisted R15 to sit in the wheelchair. A Falling Star sticker was attached to the back of R15's wheelchair and posted to R15's name plate at entrance of bedroom. A Falling Star Program instruction sheet was posted on the Nurses Station peg board documenting Do Not leave unattended in the Bathroom or room (if up in w/c) and Attempt to keep in highly visible area when up in w/c. On 7/24/24 at 10:55 AM, V3 (Chief Nursing Director) stated she does not feel that R15 is unsafe on the toilet. R15's 7/18/24 fall was in the hallway, due to R15 leaning in the wheelchair and R15 had not done that before and hasn't done that since her fall. On 7/24/24 at 11:15 am, the video surveillance, dated 7/18/24, was reviewed with V3. This video shows R15 sitting in her wheelchair, leaning forward, head positioned over her knees, bilateral arms over wheelchair armrests, hands holding onto the chair wheels, propelling her wheelchair out of her bedroom with no staff supervising. R15 continued to attempt to propel the wheelchair forward, head moving forward until she fell out of the wheelchair, hitting her head on the floor. On 7/24/24 at 10:56 AM, V11 (Licensed Practical Nurse/LPN) stated the Falling Star program is for residents at risk for falls and they should not be left in their room. We usually keep them near the nurse's station. On 7/24/24 at 10:59 AM, V12 (CNA) stated the stars on the doors are for residents who are at risk for falling. They should not be left in the bathroom by themselves. V12 stated R15 will try to get up by herself at times, and I would not leave her in the bathroom by herself. We try to keep her near the nurse's station so we can keep an eye on her. 2. R60's Face Sheet includes the following diagnoses: Dementia, Cognitive Communication Deficit, Fracture of Left Femur, Fracture of Right Femur, Fracture around Internal Prosthetic Hip Joint, Unsteadiness on Feet, and Need for Assistance with Personal Care. The admission MDS (Minimum Data Set) Assessment for R60, dated 2/4/24, documents R60 with severe cognitive impairment with no functional limitations in range of motion. R60 requires partial to moderate assistance of staff for all activities of daily living, dependent for lower body dressing and putting on footwear, and requires partial to moderate assistance for all mobility. R60 has a history of falls within the last 2 to 6 months prior to admission and one fall without injury since admission and was not receiving skilled therapy services. The Quarterly MDS Assessment for R60, dated 5/26/24, documents R60 with moderately impaired cognition, functional limitation in range of motion to one lower extremity, now requiring substantial to maximal assistance for toileting hygiene, bathing, lower body dressing, footwear, personal hygiene. R60 now requires substantial to maximal assistance with all mobility. R60 with falls in last month, falls in last 2 to 6 months, fracture related to falls, and receiving skilled therapy services. The Fall Risk Assessments for R60, dated 2/4/24, 3/6/24, 4/24/24, and 5/24/24 document R60 with fall risk scores greater than 10. These forms also document A score of 10 or more indicates High Risk for Falls. The current Care Plan for R60, documents R60 with dementia, confusion, and severe impaired cognition requiring cues and supervision for safe decision making, monitor positioning while in wheelchair and assist as needed. Needs reminders of using the call light. Fall risk-staff to monitor. Will try to self-transfer at times, has a hx (history) of falls and has poor safety awareness. R60 requires one-to-one assist to stand and walk short distances, and history of self-transfers. R60 has had five unwitnessed falls and two witnessed falls between 2/21/24 through 5/16/24 with unwitnessed fall on 4/20/24 resulting in a right hip fracture and 5/16/24 unwitnessed fall resulting in a left hip fracture. Interventions include Offer bed or recliner after meals; Toilet prior to putting in recliner or offered to stay up; Monitor positioning when in wheelchair and assist as needed. The Incident Report and Fall Investigation for R60, dated 2/21/24 at 6:30 pm, documents R60 had an unwitnessed fall in her room trying transfer from her wheelchair to her bed, and doesn't remember to use her call light for assistance. The interventions were to ask R60 if she wanted to sit in her recliner or go to bed after meals and R60 was educated to use her call light and for staff to check on R60. The Incident Report and Fall Investigation for R60, dated 3/2/24 at 9:00 am, documents R60 had unwitnessed fall in her room from her recliner and was found scooting on her buttocks from her room into the hallway looking for help. The reports document R60 had taken off her slippers, does not use the call light, is unaware of her limitations, requires one-to-one assist to stand. The intervention listed was for staff to ensure R60 is toiled prior to placing in recliner or wheelchair. The Incident Report and Fall Investigation for R60, dated 3/19/24 at 6:35 pm, documents R60 had a witnessed fall in the Activity Center during Bingo, was moving back and forth in her wheelchair, and slid out onto the floor on her buttocks. The investigation documents R60 has a history of falls, does not use her call light, requires one-to-one assist for transfers and ambulation. Dementia is main factor related to this fall, as well as her previous level of independence. The intervention listed is for staff to monitor R60's positioning when up and to assist as needed. The Incident Report and Fall Investigation for R60, dated 4/20/24 at 10:10 pm, documents R60 had an unwitnessed fall in her room from bed and found on the floor next to her bathroom during the CNA care rounds, was sent to the local hospital and diagnosed with a right hip fracture requiring surgical repair. This investigation documents R60 is non-verbal, and grimacing in pain when attempts to move right hip and leg, sent to the local hospital, diagnosed with a right hip fracture requiring surgical repair. The immediate intervention listed was for bed to be in the lowest position. The Incident Report and Fall Investigation for R60, dated 5/12/24 at 1:00 pm, documents R60 had an unwitnessed fall from her wheelchair in front of the Nurse's Station and was found sitting on the floor in front of her wheelchair. R60 was trying to get out of the wheelchair. This investigation documents R60 does not ask for assist and requires one-to-one assist with transfers and ambulation. V12 and V14 CNAs were in other resident rooms assisting and V15 RN (Registered Nurse) was downstairs in another part of the facility, indicating R60 was left unsupervised. Intervention listed was to lay R60 down after lunch and staff were educated Do Not leave (R60) alone. The Incident Report and Fall Investigation for R60, dated 5/14/24 at 8:00 am, documents R60 had witnessed fall during therapy services, became weak and shaky, and was lowered to the floor. The intervention listed was to work slowly and monitor R60 and for blood work review. The Incident Report and Fall Investigation for R60, dated 5/16/24 at 6:15 pm, documents R60 had an unwitnessed fall in the hallway, self-transferred from her wheelchair, walked to the nurse's medication cart, picked up the pill crusher mechanism, which is heavy and fell to her left side. R60 was sent to the local hospital and diagnosed with a left hip fracture requiring surgical repair. This investigation documents R60 is currently receiving therapy for her right hip fracture, is unsafe to be up without one-to-one assist, and will self-transfer without asking for assist. R60's room was moved this day closer to nurse's station. This investigation also documents V14 (CNA) had taken meal trays downstairs, V16 (CNA) was in another resident room assisting, and V17 (Licensed Practical Nurse/LPN) was downstairs in another part of the facility, indicating that R60 was left unsupervised. On 7/21/24 at 9:00 AM R60's doorway held a name plate with a Falling Star sticker and fall mats were upright resting against the wall. R60 was not in her room at this time. On 7/21/24 at 10:00 AM, and 7/22/24 at 3:00 pm, R60 was sitting in a wheelchair across from the nurse's station with a Falling Star attached to the back of R60's wheelchair. On 7/24/24 at 10:44 AM, R60 was sitting in a wheelchair across from the nurse's station with no staff supervising. On 7/24/24 at 10:59 AM, V12 (CNA) stated the stars on the doors are for residents who are at risk for falling. They should not be left in the bathroom by themselves. V12 stated R60 will try to get up by herself at times, and I would not leave her in the bathroom by herself. We try to keep her near the nurse's station so we can keep an eye on her. On 7/23/24 at 3:39 pm, V3 (Chief Nursing Director) and V2 (DON) confirmed R60 had an unwitnessed fall in her bedroom, by her bathroom, went out to the local hospital and received surgical repair of her right hip on 4/20/24. V3 stated the Intervention for R60's fall was not to leave her in her room when she is up in a wheelchair. V3 stated R60 was previously on the memory care unit prior to coming to the rehab floor where she was with her husband and was able to be up and about independently. R60 was not used to asking for help and is confused. We watched R60's fall on 5/16/24 on the camera and R60 just got up, walked to the medication cart, picked up the pill crusher and fell over and not sure what you mean by root cause of the fall. R60 has Dementia, is confused, and a high risk for falls. V3 and V2 stated they are unsure of fall interventions or route cause for R60's fall on 5/16/24. V3 stated R60 doesn't know what is going on and doesn't know why she fell. V3 stated the facility doesn't do one-on-one monitoring, the CNAs have to answer call lights, and the nurse was passing medications when R60 fell on 5/16/24. V3 stated We always have enough staff on that floor. The current Care Plan for R60 does not reflect R60's individualized specific needs related to her previous falls. There is no documented evaluation for the various interventions based on R60's assessment, nature and category of her falls, and no monitoring or response to implemented failed or successful interventions, resulting in continued falls for R60.