**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, observations and staff interviews, the facility failed to implement Care Plan interventions based on a root cause analysis of a resident's specific fall risks in order to prevent a fall with a major injury for 1 of 3 residents reviewed for falls(Resident #103). The facility reported a census of 54 residents. Findings: The Entry Minimum Data Set (MDS) Assessment Tool, dated 5/31/23, stated the resident admitted to the facility on [DATE]. The 1/19/17 facility policy Resident Falls, directed staff regarding the procedure following a fall. The policy did not address the implementation of interventions to prevent falls for residents who had not fallen but had risks. A 5/31/23 11:59 a.m., a Nurse's Note stated the resident admitted for respite cares(temporary care of a person when their primary caregiver required a break). A 5/31/23 Fall Risk Evaluation stated the resident was at risk for falls due to intermittent confusion, 1-2 falls in the past 3 months, poor vision, and balance problems. The Baseline Care Plan, dated 5/31/23, stated the resident had a history of falls. The following section Interventions was blank. The Care Plan had a crossed out entry which stated the resident was an assist of 1 with a gait belt. This entry stated d/c(discontinue) and there was another undated entry which stated the resident required a mechanical lift. The Baseline Care Plan lacked further interventions related to the resident's risk of falls. A 6/1/23 admission Note stated the resident took herself to the bathroom using her walker. A 6/1/23, 1:09 a.m. admission Note documented the resident awake in bed and wondering why she was here. A 6/1/23 3:30 p.m. Nurse's Note stated a Certified Nursing Assistant (CNA) noticed the resident sitting on the floor between her bed and the recliner. Her right leg had external rotation and the resident transferred to the hospital. A 6/2/23 Hospital History and Physical stated the resident fell and had a right femoral(referring to the femur leg bone) neck fracture. A 6/12/23 9:23 a.m. admission Note stated the resident readmitted to the facility following a hospital stay for a diagnosis of hip fracture and surgery. A 6/13/23 Physical Therapy (PT) Evaluation and Plan of Treatment stated the resident fell and sustained a right femoral neck fracture which required surgical repair. On 7/11/23 at 12:25 p.m., Staff A, CNA and Staff B, CNA transferred the resident from her wheelchair to her bed using a mechanical lift. On 7/12/23 at 10:01 a.m., Staff C, Registered Nurse (RN) stated on the morning of the resident's fall, the resident went to the bathroom by herself and Staff C educated her to utilize the call light. Staff C stated at the time of the fall, she heard a noise and walked in and observed the resident sitting on the floor with her back up against the wall. She stated she noticed some rotation of her leg and transferred her to the hospital. On 7/12/23 at 11:32 a.m. Staff E, Certified Medication Aide (CMA) stated she and Staff F, CNA discovered the resident on the floor in her room with her back against the bed. She stated the resident had a hold of her call light but it was not on. Staff E stated it seemed the resident thought the call light was a phone and someone was calling her. She stated they informed the nurse and she assessed her. On 7/12/23 at 11:47 a.m., Staff F stated on the morning of the resident's fall, she observed the resident walking down the hallway after breakfast alone with her walker and the resident asked what she was suppose to do. Staff F stated she redirected her back to her chair. On 7/12/23 at 12:29 p.m., Staff D, Licensed Practical Nurse (LPN) stated he worked the night the resident arrived and stated he sat at the Nursing Station and the resident suddenly appeared. He stated he did not know why the resident was up but thought maybe she was just confused or bored. On 7/12/23 at 1:43 p.m., Staff G, Care Plan Coordinator, stated upon admission, staff carried out a Fall Assessment and if they were a high risk, they would come up with something extra. She stated if residents started getting up on their own, they would implement another intervention. On 7/12/23 at 2:17 p.m., the Director of Nursing (DON) stated PT evaluated the resident upon admission and deemed her an assist of 1. She stated she was not aware that the resident got up on her own prior to the fall but would want to know so they could have looked into it differently.