**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 34 resident, with 12 sampled, including seven residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide an environment free from accident hazards for five residents. The facility failed to include fall prevention interventions on the care plan for Resident (R)238, who fell and sustained deep lacerations to his face, which required transfer to the ER and sutures/stitches and glue as treatment. The facility further failed to implement new care plan interventions to prevent further falls for R31 and failed to investigate the fall experienced by R24. The facility also failed to ensure staff did not leave R10 unattended in his bathroom, attached to the sit to stand mechanical lift (helps transfer patients from one seated surface to another) and staff also did not provide adequate supervision to R18 when staff left R18 unattended in his room and R18 attempted to self-transfer from his wheelchair. These deficient practices could potentially result in an injury. Findings included: - Review of the Electronic Health Record (EHR) revealed Resident (R)238 had the following diagnoses: extradural and subdural abscess (cavity containing pus and surrounded by inflamed tissue that is inside your skull or near your spine), Methicillin susceptible staphylococcus aureus infection (MRSA - a type of bacteria resistant to many antibiotics), sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infections which cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to the medical emergency, septic shock), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), severe protein-calorie malnutrition, acute kidney failure, and management of a vascular device. Review of the 09/25/24 admission Minimum Data Set revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident had a total mood severity score of seven, which indicated mild depression. The MDS documented R238 had functional limited range of motion impairment to bilateral (both) upper and lower extremities. R238 utilized a wheelchair for mobility. He was dependent with toileting, personal hygiene, and wheelchair mobility. He required substantial to maximal assistance with lower body dressing, applying footwear and going form laying to sitting position. He required partial to moderate assistance with upper body dressing, rolling from one side to the other in bed and going from a sitting to laying position, moving from a sitting to a standing position and transferring from a chair to a bed. R238 was totally incontinent of bowel and had a urinary catheter. He had a fall within the last month prior to admission, also had a fall in the last two to six months prior to admission, and a fall with a fracture in the 6 months prior to admission. Review of the Falls Care Area Assessment (CAA) dated 10/01/24, revealed R238 had falls prior to admission that resulted in fractures. He was impulsive and had a mild cognitive deficit and resistive to care at times. Review of the 09/21/24 Baseline Care Plan revealed R238 had a history of falling. The baseline care plan lacked interventions to prevent falls. Review of the 09/26/24 Neurological Check List revealed the facility completed one neuro check. Review of the resident's Care Plan revealed a new focus added on 09/27/24 to address the fall on 09/26/24. R238 had an actual fall with serious injury, poor balance, and unsteady gait. Prior to admission R238 had several falls at home. Staff were to assist the resident in a recliner or a bed when taking him into his room. Review of the assessments revealed a Morse Fall Scale assessment (a fall risk assessment that predicts the likelihood of falls) completed on 09/20/24 and on 10/08/24, and both assessments documented a score of 95, indicating R238 was a high risk for falls. Review of the assessments tab revealed two Skin Assessments completed on 09/27/24 indicating a laceration with no location documented, that measured 5.8 centimeters (cm) by 1.2 cm and required stitches on 09/26/24, and a 3.9 cm by 3.1 cm abrasion to the left shoulder. Review of the 09/26/24 at 04:04 PM Incident Note revealed R238 fell at 01:50 PM and was on his right side in front of his wheelchair with Administrative Nurse B applying pressure to the left side of his head. There was blood on the floor, his shirt, and his face. He was alert and talking but did not make sense. The resident reported pain to his head, legs, shoulders, and back. There were three lacerations (wound to the skin) to his left side of his head, above the eyebrow, next to the left eye, and under the left eye. Staff later noticed that his eyeglasses had fallen off him and had a piece of skin attached to them. R238 was not sure how he fell or what caused him to fall. The brakes were locked on the wheelchair and the catheter bag was attached to the wheelchair. The facility transferred R238 to the Emergency Department at a hospital. Review of the 09/26/24 at 08:01 PM Health Status Note revealed R238 received stitches. Review of the 09/26/204 at 08:01 PM Health Status Note revealed new orders to apply ice as needed and provide wound treatment. Review of the Health Status Note on 09/26/24 at 11:31 AM, revealed that staff checked on R238 every two hours He responded when questioned, refused vital signs and assessment. No further documentation found on checks or assessments. Review of the Health Status Note on 09/27/24 at 6:23 PM, revealed that the nurse spoke to the hospital and they stated R238 had a computed tomography scan (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) that was clear. EHR lacked documentation from the hospital that a CT scan was completed or results. Review of the hospital's Discharge Instructions revealed R238 had multiple deep lacerations to the forehead and left cheek area which required glue and stitches. The instructions included warnings for Head Injury Precautions: An observer must check on the patient frequently for 24 hrs. Also watch for signs and symptoms of infection. On 10/08/24 at 09:02 AM, R238 stood in front of his reclining chair in his room and attempted to push himself up to a standing position. During an interview on 10/08/24 at 12:52 PM, Certified Nurse Aide (CNA) J reported she was to review the care plan in EHR for all the residents' care needs. She also reported that the nurses were to write on the communication board in the EHR to notify staff of a change of care for residents. During an interview on 10/08/24 at 03:25 PM, License Nurse (LN) K reported if a resident had a fall the nurse would assess the resident make sure they are safe, determine a root cause a neurological assessment (is a series of tests and questions that evaluate a person's nervous system) would be completed for 72 hours. If the resident had a high enough BIMS and could tell the staff, they did not hit their head, no neurological assessment was required. LN K reported they would update the family or responsible party, physician, Administrative Nurse B and Administrative Staff A if a resident fell. During an interview on 10/09/24 at 12:45 PM, Administrative Nurse C revealed when a resident entered the facility the nurse completed a baseline care plan. Administrative Nurse C revealed it was printed and reviewed with the family and/or the resident, signed, and uploaded to the EHR. The facility policy Fall Follow-Up Protocol dated 01/01/24 documented each resident will be provided services to ensure that the resident's environment remains as free from accident hazards as possible, and each resident receives adequate supervision and assistive devices to prevent accidents. Every resident will be assessed for casual risk factors for falling at the time of admission, and after every fall and develop interventions to prevent further falls. Fall interventions are documented on the care plan. The facility policy Care Planning Policy last reviewed on 01/01/24 documented the Baseline Care Plan will be developed within 48 hours of admission and will include Falls and Safety concerns. A written summary of the Baseline Care Plan will be presented to the resident and/or their representative if desired. Documentation that the summary was offered must be made in the chart. The Baseline Care Plan will be started at admission and contains information that staff will utilize to care for the resident. The facility failed to provide an environment that remained free from accident hazards for R238, who had a history of falls, when the facility failed to include fall prevention interventions on the care plan. R238 fell and sustained deep lacerations to his face, which required transfer to the ER and sutures/stitches and glue as treatment. - Review of The Electronic Medical Records (EMR) for Resident (R)18 included the diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), abnormal posture, cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dysphagia (swallowing difficulty), hemiplegia (paralysis of one side of the body), repeated falls, non-suicidal self-harm (intentional self-inflicted bodily harm without intent to kill themselves), and disorders of bone density and structure (disorders involve a loss of bone mass and changes in the bone's internal structure). A review of R18's Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of five, indicating severe impairment of cognition. The resident had a total mood severity score of one, indicating minimal depression. The MDS indicated he required total dependence on staff for toileting, dressing, and transfers. The MDS noted he required staff supervision for locomotion and eating his meals. The resident had hallucinations and delusions present, with no other behaviors noted. The resident required antipsychotic, antidepressant, anticoagulant, diuretic, opioid, and antiplatelet medications. The resident was frequently incontinent of bowel/bladder, no falls in since the last assessment documented. Review of the Falls Care Area Assessment dated 06/20/24 revealed R18 had a high risk for falls related to having a history of falls, medications he received, and a history of CVA. R18 needed assistance with transfers due to a history of falls, weakness, and physical performance limitations affecting his balance, gait, strength, and muscle endurance. Risk factors included falls and other major/minor injuries related to falls. Review of the 04/05/24, Quarterly MDS revealed the resident had a BIMS score of 4, which indicated moderately impaired cognition. The resident had episodes of behaviors that included delusions and hallucinations. The MDS indicated he required maximum assistance for most cares. R18 used a wheelchair and walker for mobility. The resident had a fall in the last 2 to 6 months prior to admission/entry to the facility or reentry or most recent assessment. The resident had one fall identified since the prior assessment without injury. Review of the Morse Fall Scale (an assessment tool utilized to determine an individual's risk or likelihood of falls) dated 01/10/24, 04/09/24, 06/17/24, 08/04/24 and 09/18/24 revealed the resident had a high risk for falls. Review of the 09/20/24 at 10:30 AM Nurse Note revealed the Certified Medication Aide (CMA) arrived at the resident's room at approximately 10:30 AM. Upon entering R18's room the resident was found on the floor in front of the bathroom. The staff charted that R18 was toiled last at 09:30 AM and there was an abrasion noted on the left side of the resident's temple. His doctor was notified and aware that R18 was on prescribed blood thinners. The resident's record revealed only one fall follow up documented on 09/21/20 at 02:24 directly after his fall. Review of the 09/19/24, completed Care Plan revealed an intervention initiated dated 09/20/24, which stated for staff to please encourage the resident to be in the commons area when in wheelchair. If in his room the resident must be transferred to the bed or recliner. Intervention initiated dated 04/28/23, revised dated 10/13/23 stated, when the resident fell asleep in his wheelchair, staff were directed to assist him to the bed or recliner to sleep. During an interview on 10/09/24 at 10:13 AM, R18 stated he would rather sleep in his recliner than his wheelchair but, would prefer his bed over anything. R18 stated if he really wanted to move to the recliner, he could do it himself. During an observation on 10/09/24 11:43 AM, R18 uncovered his bed, which was left in a high position. R18 reached for his 3/4 side rail and attempted to transfer himself into his bed. On 10/09/24 at 10:25 AM, Certified Nurse Aide (CNA) N stated R18 required checks every two hours, and staff toileted him at that time. When R18 fell asleep in his wheelchair he only slept for short periods of time and in small intervals. He did not like to be confined or not able to get up and move when he felt that he wanted to. When he woke up, he was startled and delusional. On 10/09/24 at 03:30 PM, Licensed Nurse (LN) K stated R18 would be checked every two hours. LN K stated he used to have the tendency to go back to his room to attempt to go to bed, now R18 was not to stay in his room anymore. This change was to allow for staff to have eyes on him continuously. The expectation was that if R18 was sleeping in his wheelchair staff would offer to assist him into a recliner to sleep in the living area where everyone could visually keep an eye on him. Staff could offer to assist him into bed and place his bed in lowest position with his fall mat down so he could rest. Being left to sleep in his room while in his wheelchair was not an approved options for the resident. On 10/09/24 at 01:11 PM, Administrative Nurse C stated R18 was expected to have eyes placed on him every 30 minutes. If R18 was sleeping in his wheelchair, in his room, then the staff were to put him in the recliner in his room and if that was not available the other option was to offer the resident the recliner that was in the day room. The facility's Behavior Management for Dementia Care policy dated 01/01/24 documented the facility would promote person-centered care and consider all the resident's needs, not just medical or physical. The policy further documented the resident had the right to live in a safe, structured, and predictable environment. The facility failed to provide an environment free of accident hazards when staff left R18 unattended in his wheelchair, in his room after multiple assessments that documented him as a high risk for falls. This deficient practice placed R18 at continued and on-going risk for accident hazards which had the potential to negatively impact R18's physical and psychosocial well-being. - Review of the Electronic Health Record (EHR) revealed R10 had the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), west Nile virus (WNV - a virus that is spread by mosquitos that can cause critical illness that can include encephalitis [inflammatory condition of the brain]), cataract (clouding of the lens of the eye), contracture (abnormal permanent fixation of a joint or muscle), and motor neuron disease (a condition that causes weakness in the muscles, leading eventually to paralysis). Review of the 06/20/24,admission Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The resident required maximum assistance with toileting, personal hygiene, rolling side to side, changing positions, transferring, propelling in wheelchair for mobility, and upper body dressing. The assessment documented no falls in the last month prior to admission/entry. Review of the 03/29/24, Quarterly MDS revealed the resident had a BIMS score of 10, which indicated moderately impaired cognition. The resident had episodes of behaviors that included delusions. The resident required maximum assistance for all cares and used a wheelchair for mobility. The assessment documented that R10 had impairment with both the upper and lower extremities. The resident had one fall identified since the prior assessment without injury. Review of the Morse Fall Scale (an assessment tool utilized to determine an individual's risk or likelihood of falls) dated 02/07/23, 05/02/23, 08/02/23, 10/15/23, 01/03/24, 04/05/24, 06/17/24 and 09/18/24 revealed the resident had a high risk for falls. Review of the Assessments lacked a safety assessment for R10 to be safely left unattended while attached to a mechanical lift. Review of the 08/31/24, Care Plan revealed an intervention dated 01/31/22 and revised 01/17/24, which stated the resident required extensive to total assistance of two staff to move between surfaces. He used the sit-to-stand lift (a mechanical lift that assists persons who are unable to bear weight to maintain a standing position) for all transfers. This intervention documented the resident as being a fall risk related to deconditioning, hearing problems, decreased mobility, and left sided weakness. On 08/15/23 at 07:24 PM, Therapy Notes revealed the resident faced multiple barriers to their treatment including severe skilled caregiver shortage, local deficiency of needed health care workers, and cognitive communication deficit precautions. The goal for the resident was stated as being able to reduce dependency on care staff by knowing foot and hand placement on the mechanical lift by following verbal cues. Caregivers and the resident received training on how to operate equipment safely and appropriately. During an observation on 10/07/24 at 10:43 AM, Certified Medication Aide (CMA) M and Certified Nurse Aide (CNA) N transferred R10 to the toilet with the use of a sit-to-stand lift. Staff left R10 in the lift sling and attached to the lift. They locked the lift before leaving the resident to check on other residents in the house. At 11:01 AM both staff came back to R10's room and assisted him from the bathroom. On 10/07/24 at 11:34 AM, R10 stated that he can wait up 30 minutes for staff to be available to transfer him from the toilet due to them getting busy helping others. On 10/09/24 at 10:20 AM, Certified Nurse Aide (CNA) N stated when they took R10 to the bathroom, sometimes they left R10 hooked up to the sit-to-stand lift while R10 was on the toilet. (CNA) N stated that was to allow R10 watch TV and allowed CNA N to check on other residents. CNA N stated it was R10's preference and R10 enjoyed watching TV while in the bathroom when having a bowel movement. On 10/09/24 at 03:08 PM Certified Medication Aide (CMA) Q stated residents were never to be left alone in the bathroom while still attached to the sit-to-stand lift, if staff were not within the line-of-sight. If staff needed to leave to answer another call light, staff should remove the sling from the resident and remove the lift unless the resident was care planned that the lift could be locked for them to hold on to for stability. On 10/09/24 at 03:24 PM, Licensed Nurse (LN) K stated residents would be within line-of-sight of a staff member when attached to the sit-to-stand lift and in the bathroom. LN K further stated residents should not be left alone while attached to a mechanical lift. On 10/09/24 at 01:20 PM, Administrative Nurse C stated if a resident was in the bathroom, on the toilet, and attached to the sit-to-stand lift she expected staff locked the lift before leaving the resident alone. Staff were to give the resident their call light if the resident was working with therapy. Staff should know which residents could be left alone due it being documented in the care plan. The facility assumed that everyone could be safely left alone unless it was documented that they should not. Therefore, if a resident was not safe to be left in the bathroom alone, while attached to the sit-to-stand lift, the facility would have that specifically put on their care plan to let staff know if they could not be safely left alone. The facility's position would be to error on the side that they could safely be left attached to the lift unsupervised rather than the resident was unsafe to be unattended while attached to the lift. On 10/09/24 at 06:28 PM, Administrative Staff A stated a resident being left attached to a sit-stand lift alone in the bathroom, unsupervised was a safety concern and that was not an acceptable expectation for staff performance. Additionally, Administrative Staff A stated that there was a high potential for danger in this practice, staff were educated multiple times regarding this topic, and all staff should be aware that this was not what was unacceptable practice. The facility's Mechanical Lift Transfer policy dated 01/2024, documented that after positioning resident, staff would lower the lift enough to allow unhooking and removal of sling straps. Staff would then remove the sling straps and back the lift away from resident. The staff would remove sling from resident by reversing installation procedure. The facility failed to provide an environment free of accident hazards when staff left R10, with multiple assessments that documented a high risk for falls, unattended in the bathroom while attached to a mechanical lift. This deficient practice placed R10 at continued and on-going risk for accident hazards which had the potential to negatively impact R10's physical and psychosocial well-being. - The Electronic Health Records (EHR) documented R31 had the following diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion), abnormalities of gait and mobility and muscle weakness. The 01/21/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of four, indicating severely impaired cognition, the depression score was two, indicating minimal depression and she had no behaviors. R31 required maximal assistance with activities of daily living (ADLs), with toileting hygiene, transfer, showering, personal hygiene and upper body dressing. The 01/29/24 Functional Abilities Care Area Assessment (CAA) documented R31 required substantial assistance with ADL's related to healing fractures of a shoulder and pelvis and was at risk for decline in ADLs, contractures (abnormal permanent fixation of a joint or muscle) and skin integrity. The Falls CAA triggered secondary to impaired gait and mobility and R31 required assistance for transfers. Contributing factors included history of falls prior to admission, weakness, and physical performance limitations. Risk factors included falls and other major/minor injuries related to falls. The 09/19/24 Quarterly MDS documented a BIMS score of four, indicating severely impaired cognition. R31 required maximal assistance with bathing, bed mobility and transfers. She required moderate assistance with toileting, dressing, personal hygiene, and ambulation. No falls documented. The 10/07/24 Care Plan Lacked any safety interventions to prevent falls until R31 had a fall on 02/17/24. Staff instructed to assist applying socks footwear in the morning, date completed 02/27/24, which was ten days after the fall. Staff were instructed to monitor and document for risk of falls and educate the resident, family, and caregivers on safety measures that need to be taken to reduce risk for falls. R31 was at high risk for falls and staff instructed to provide call light and encourage the resident to use a call bell. R31 required prompt response to all requests for assistance. Staff instructed to apply appropriate footwear when ambulating or mobilized in wheelchair, all initiated on 04/10/24. The Progress note on 02/17/24 at 08:20 AM, staff found R31 on the floor, seated upright at the foot of the bed attempting to put on her socks. No injuries noted, two staff assisted R31 off the floor and transferred the resident to a wheelchair. On 01/08/24, 01/17/24, 04/09/24, 07/09/24 and 09/16/24, a Morse fall scale (is a rapid and simple method of assessing a patient's likelihood of falling) completed all assessments were scored at 55, indicating a high risk for falling. The facility failed to provide a fall investigation upon inquiry. On 10/07/24 at 11:00 AM, R31 was in her room watching television her call pendant was placed on a table that was behind the resident out of reach and sight. Her call bell was located on the other side of her bed not in reach. R31 reported she was not sure if she required staff to assist her with ambulation. On 10/08/24 at 11:55 AM, R31 seated in dining room with a call pendant (a wearable call light system) around her neck. On 10/09/24 at 01:33 PM, R31 seated outside in front of a facility building and had her call pendant around her neck. R 31 reported, she loved to sit outside to get fresh air. On 10/08/24 at 01:10 PM, Certified Nurse Aide (CNA) J reported that she reviews the care plan in EHR for all the residents' care needs. She reported that the nurses should write on the communication board in EHR to notify staff of any change of care for residents. On 10/08/24 at 03:25 PM, License Nurse (LN) K reported if a resident had a fall, the nurse would assess the resident, make sure they were safe, determine a root cause and a neurological assessment (is a series of tests and questions that evaluate a person's nervous system) would be completed for 72 hours. If the resident had a high enough BIMS and could tell the staff they did not hit their head, then no neurological assessment would be required. Staff should update the family or responsible party, physician, Administrative Nurse B and Administrative Staff A. On 10/09/24 at 09:30 AM, LN K reported nurses do not update care plans in the EHR, she reported that an intervention should be immediately completed after an incident and communicated on the communication board in EHR. LN K reported that Administrative Nurse B or Administrative Nurse C should add the intervention to the care plan in the EHR. If neither of them was in the facility, they were to update the care plan the next day. The staff are responsible to read and review the care plan. On 10/09/24 at 09:44 AM, Administrative Nurse C reported her expectation for staff was to stay with the resident to ensure safety, alert the nurse who would assess and render aid as needed, investigate the root cause, develop an immediate intervention to mitigate risks for the remainder of the shift, then the interdisciplinary team would meet on the next morning or business day to develop a permanent care plan entry. On 10/09/24 at 01:35 PM, Certified Medication Aide (CMA) P reported R31 liked to sit outside, and staff were responsible to apply her call pendant when R31 was not in her room. She reported R31 will sometimes not call staff and she required staff assistance with transfers and ambulation. The facility policy Fall Follow-Up Protocol dated 01/01/24, documented each resident will be provided services to ensure that the resident's environment remains as free from accident hazards as possible, and each resident receives adequate supervision and assistive devices to prevent accidents. Every resident will be assessed for casual risk factors for falling at the time of admission, and after every fall and develop interventions to prevent further falls. Fall interventions are documented on the care plan. The facility failed to provide an environment that remained free from accident hazards for R31 when the facility failed to place effective interventions in place for this resident with a history of falls. - Review of the Electronic Health Record (EHR) for Resident (R)24 revealed diagnoses that included diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and unspecified epilepsy (a brain disorder characterized by repeated seizures and glaucoma (abnormal condition of elevated pressure within an eye which can cause loss of vision). Review of the 05/02/24 Annual Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The resident required supervision/setup assistance with eating and bathing but was otherwise independent with all cares. The resident used a walker. The resident had no falls since the previous assessment. Review of the Falls Care Area Assessment (CAA) dated 05/02/24 revealed R24 utilized a walker for ambulation and had a history of falls with injury prior to admission and several falls without injury since admission. Review of the Activities of Daily Living (ADL) Functional / Rehabilitation Potential CAA, dated 05/02/24 revealed R24 utilized a walker. Review of the 07/18/24 Quarterly MDS revealed the resident had a BIMS score of 15, which indicated intact cognition. The resident required supervision/setup assistance with eating and bathing but was otherwise independent with all cares. The resident used a walker. The resident had no falls since the previous assessment. Review of the Assessments Morse Fall Scale (an assessment tool utilized to determine an individual's risk or likelihood of falls) dated 02/16/24, 05/01/24, 05/05/24 and 07/16/24 revealed the resident had a high risk for falls. Review of the 10/08/24 Care Plan, revealed R24 was at high risk for falls related to a recent fall at home with injury and diagnoses that included epilepsy, weakness and impaired balance. The care plan included the following interventions: On 09/21/23, staff would ensure a shower chair was on a level surface during showers. On 09/25/23, staff would reeducate R24 to utilize his walker for ambulation (walking) and not rely on furniture and remind R24 to use the call light if something needed to be picked up from the floor. Staff would further ensure that R24's call light was within reach. On 01/17/24, R24 had an actual fall without injury and instructed staff to remind R24 to change positions more slowly for safety. Review of the 10/08/24 Care Plan lacked an intervention related to the fall on 06/21/24. Review of the 06/21/24 at 07:39 PM Progress Note documented staff found R24 on the floor in the pantry area at around 06:00 PM. R24 stated that he was trying to get a soda and fell, denied injury, and declined to allow staff to assess him for injuries. Two staff assisted R24 off the floor. The documentation lacked an intervention to possibly prevent the resident from another fall.  [TRUNCATED]