Based on clinical record review, observations, policy review, and staff interviews the facility failed to protect residents from accidents and injuries to include failing to implement interventions to reduce risks for 1 of 3 residents (Resident #15) reviewed for falls. The facility reported a census of 51. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 9/5/24 documented an admission date of 12/02/22 and a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented diagnosis of Alzheimer's Disease, anxiety disorder and muscle weakness. The MDS revealed total dependence of 2 or more helpers to complete oral, upper and lower body dressing, putting on/taking off footwear and partial to moderate assistance with sit to stand and transfers. The MDS also revealed the resident had fallen since the prior assessment and had injuries. Review of Resident #15's Care Plan with an initiation date of 12/18/22 revealed Resident #15 was at risk for falls. On 10/3/23 updated to required assistance of 1 with transfers. Care plan documented updates to risk for falls interventions/task on followings dates: 7/19/24 Offer to assist me with positioning at the dinner table. 8/26/24 Encourage me to carry Reacher in my wheelchair to retrieve items off the floor when out of my room. 11/24/24 Therapy to assess for new wheelchair cushion to ensure proper positioning. 12/5/24 Care Plan updated to assist resident with moving foot pedals back while sitting at the Dining Room table. The Incident Report dated 11/1/24 at 2:55 pm documented the resident was on her bottom next to the door that separates the dining room and bird room. The Five Whys Worksheet for the fall documented a new intervention for aides to assist resident in adjusting her foot pedals. The Incident Report dated 11/24/24 at 6:55 pm documented the resident was found on the floor under the wheelchair crying and stating she leaned forward and fell out of the chair. She stated she leaned forward and fell. The Five Whys Worksheet for the fall 11/24/24 documented the intervention for therapy to assess for wheelchair cushion that encourages appropriate positioning. The Incident Report dated 12/5/24 at 5:10 pm documented the resident was found on the dining room floor crying and had a jagged laceration to her head. A puddle of blood under the resident's head. The resident unable to state what happened. The report documented the wheelchair food pedals were forward. Review of the Electronic Healthcare Record (EHR) tab titled, Progress Notes, revealed the following falls and injuries: On 12/5/24 at 8:37 pm resident #15 was found by a staff member laying on the dining room (assist side) floor. Resident was crying. Resident had a jagged laceration to her head. A puddle of blood was on the floor underneath her head. Resident had shoes on both feet. Resident crying stating I'm sorry unable to describe what she was attempting to do. Resident assisted by EMS to wheelchair for treatment of laceration to head. Care Plan updated to assist resident with moving foot pedals back while sitting at DR table. On 11/24/24 at 9:20 pm resident found on the floor in the hallway under wheelchair. Crying stated leaned forward and fell out of chair. On 11/1/24 at 3:07 pm resident was found on the floor near the dining room and bird room. On 10/25/24 at 4:54 am resident complained of pain in her left forearm from a recent fall, area raised, pain upon palpitation. On 8/26/24 at 1:19 pm dietary staff observed resident attempting to reach for a muffin on the floor and fell to the floor, hitting her head on the table. On 7/20/24 at 12:43 pm resident fell to the floor in assisted dining side, wheelchair on the side, left pedal under her left hip. Resident told staff she was trying to pull left foot pedal back to scoot herself closer to the table. On 7/5/24 at 1:29 pm resident fell out of her wheelchair during a self-transfer. Injuries sustained to face: pink area to the forehead with blood noted by a staff member. During an observation on 12/10/24 at 10:45 am, Resident #15 noted to have an abrasion to her forehead. Observed the resident sitting in a wheelchair while she observed an activity. The wheelchair had 2 foot pedals locked in place while residents' feet rested on the floor. During the dining room (DR) observation on 12/10/24 from 12:00 pm to 1:00 pm, Resident #15 noted to self-propel in her wheelchair between dining room tables and after the meal service was completed, headed to her room, with the foot pedals locked in place, restricting her ability to extend her feet forward, causing her feet to tangle and bend under the wheelchair several times. Towards the end of this observation, a staff member approached the resident who by then partially slid towards the edge of the seat. The staff member placed Resident #15's feet onto the foot pedals and then assisted with the transfer. During the subsequent observation on 12/11/24 at 9:48 am, Resident #15 attended the activity in the common area, sitting in the wheelchair with the foot pedals locked in place, feet on the floor. During an interview on 12/11/24 at 9:57 am with Staff D, Certified Medication Aide (CMA), Staff D stated Resident #15 had frequent falls and slid out of her wheelchair often; recently therapy recommended a different seat cushion but it was not in place to her knowledge. Staff D, CMA further stated she would pull the resident up in the wheelchair if she saw her sliding out of it since the resident didn't have a strong core/torso. In an interview on 12/12/24 at 9:50 am with the Director of Rehabilitation, it was revealed that Resident #15 had been ordered a different cushion pad and there were some modifications made to her wheelchair. His knowledge of the Resident #15 included: staff assist with transferring since unable to lock the wheelchair on her own, history of sliding out of the wheelchair and poor safety awareness. Physical Therapy was attempted but unsuccessful due to Resident's physical limitations and only Occupational Therapy was in place. In an interview on 12/12/24 at 11:00 am with the Director of Nursing, she stated Resident #15 was able to reposition herself in the wheelchair and needed her foot pedals locked in place while she did it. After reviewing the Care Plan intervention dated 12/5/24 with the intervention to move foot pedals back while sitting at the DR table, she confirmed it was not followed by the facility staff. The facility provided policy titled Falls and Fall Risk, Managing revised March 2018, documented: Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, 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. 2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 3. Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc. 4. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period. 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. 7. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. 8. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. 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. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.