**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Medical Diagnosis section in R14's Electronic Medical Record (EMR) included diagnoses of dorsalgia (back pain), scoliosis (curvature of the spine), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, fatigue, kyphosis (outward curvature of the spine), cervicalgia (neck pain), fracture of left clavicle (collarbone), shortness of breath, and panic disorder. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R14 had intact cognition, and required extensive assistance of one staff for activities of daily living (ADL). The MDS recorded R14 was not steady and was only able to stabilize with human assistance. R14had occasional incontinence of urine, received scheduled and as needed pain medication, and was short of breath with exertion. The MDS further documented R14 had one fall with no injury and one fall with injury. The Activity of Daily Living Care Area Assessment (CAA), dated 01/16/23, documented R14's family chose comfort care due to R14's decline. R14 needed extensive assistance with most of her ADL, and was failing to thrive. R14 had falls on 08/15/22 and 10/14/22. The CAA further documented R14 took two antidepressants (class of medications used to treat mood disorders), a Fentanyl (narcotic pain medication) patch, and had as needed pain and antianxiety (class of medications that calm and relax people) medications The Quarterly MDS, dated 04/03/23, documented R14 had moderately impaired cognition. The Quarterly MDS, dated 06/13/23, documented R14 had severe cognitive impairment, had other behavioral symptoms not directed toward others, and required extensive assistance of one staff for ADL. R14, received scheduled, as needed, and non-medication interventions for pain, and had a fall with major injury. The Care Plan, dated 10/27/22, documented R14 had the potential to fall down and hurt herself because of fatigue. The nurses needed to request a therapy screen for R14 if needed, and the nurse aides were to keep R14's room well lit when she was up and to remind her to get up slowly. On 04/16/23 the care plan added intervention to stay with R14 during toileting. On 04/24/23 the care plan further documented R14 had not met her goal of avoiding major injury due to a clavicle fracture. The Fall Note on 08/15/22 at 02:11 AM, documented the nurse heard a noise and R14 calling out for help. The nurse went to investigate and found R14 lying on her back in the bathroom with her head resting against the door frame. R14 had a hematoma to the right side of her head the size of a golf ball. R14 complained of pain in her head and buttocks. R14 was unable to tell the nurse what caused the fall. The note recorded R14 was independent, and had appropriate lighting and footwear on; her floor was clean and dry, and an assistive device (walker) was with the resident. The fall note further documented no new interventions at that time. The Fall Note, on 10/14/22 at 08:21 PM, documented R14 was getting ready for bed,and getting clothes to her closet, when she became unsteady and fell. R14 was sitting on her bottom with her head resting against the bed and her hand on her chest. R14 was very short of breath. Staff provided teaching on the use of the call light if R14 felt unsteady. The note documented no new interventions at that time, and stated the care plan was followed. The Fall Note on 04/21/23 at 11:30 PM, documented the nurse heard R14 scream and went to investigate. The nurse found R14 lying on her left side with her left arm behind her. Her oxygen tubing was off, and there was candy scattered on the floor. R14 reported pain to her left arm and was unable to move her left arm without pain. R14 went to the emergency room. The note documented no interventions at that time. R14 returned from the hospital with a left clavicle fracture. On 06/26/23 at 09:18 AM, R14 sat in her room, in a recliner. She wore oxygen via nasal cannula. R14 reported she no longer had shoulder pain from the fractured clavicle. She stated it was healed On 06/26/23 at 12:14 PM observation revealed Certified Nurse Aide (CNA) O assisted R14 to the bathroom. CNA O assisted R14 to a wheelchair and wheeled the resident into the bathroom. CNA O assisted R14 with toileting needs and then returned the resident to her recliner. CNA O reported R14 was usually continent, and used her call light, but recently had been calling out for assistance. On 06/27/23 at 09:40 AM, Administrative Nurse D stated the care plan had not been updated following the fall for R14 which resulted in a clavicle fracture. Administrative Nurse D and verified no new interventions were implemented to prevent further falls. Administrative Nurse D reported she had not reported the fall to the state agency because she thought if the care plan was followed, a report did not have to be made. The facility's undated Falls and Fall Risk, Managing policy documented based on previous evaluations and current data, the staff will identify interventions related to resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The facility failed to identify and implement interventions to prevent R14 from falling resulting in a major injury and placed the resident at risk of further falls. - R57's Electronic Medical Record (EMR) recorded diagnoses of atrial fibrillation (rapid, irregular heartbeat), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypertension (elevated blood pressure), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), pain, sleep disorder, and dystonia ( movement disorder that cause slow repetitive movements). The Quarterly Minimum Data Set, (MDS) dated [DATE], documented R57 had intact cognition, rejection of care behavior one to three days during the look back period, required extensive assistance with activities of daily living, was not steady and only able to stabilize with staff assistance, and used a walker. The MDS further documented R57 was frequently incontinent of urine, received an antidepressant (medication used to treat mood disorder) and hypnotic (medication used to induce sleep) on a routine basis. R57 used bed and chair alarms. The Fall Care Area Assessment (CAA), dated 03/21/23, documented R57 had a history of multiple falls, impaired balance, impulsivity, anxiety disorder and depression (mood disorder). R57 had multiple falls from self-transferring and walking without assistance. R57 had a chair and bed alarm to alert staff when he was moving about and to stay with him during toileting. The Care Plan dated 12/22/22, documented R57 needed assistance because of having physical challenges, and frequent falls. R57 had trouble making decisions. The care plan directed staff to transfer R57 with a gait belt, walk using a four wheeled walker; R57 wore a Wanderguard device (personal alarm which alerts staff when close to alarmed exits) on his left ankle. The care plan further documented R57 had the potential to fall and hurt himself because of Parkinson's disease. The care plan further directed staff to keep an eye on his behaviors, make sure the call light was within reach, establish an activity of daily living program, to stay with R57 during toileting, make sure glasses are within reach, encourage R57 to use assistance, and to report pain and behaviors to nurse. R57's Care Plan documented an intervention dated 12/29/22which directed R57 used an alarm on his bed, chair and floor. On 01/20/23 the plan documented R57 was to use gripper socks at bedtime. On 02/16/23 the plan was updated to direct R57 had the potential to fall and hurt himself due to Parkinson's disease and dementia/Alzheimer's disease. An intervention dated 06/20/23 directed R57 used a self-locking wheelchair. The Fall Note, dated 01/20/23 at 01:48 AM, documented R57 had just been assisted by a Certified Nurse Aide (CNA) with getting ready for bed, and he was sitting in his recliner watching television. The CNA then went to assist R57's roommate. The CNA reported hearing a thud and R57 was sitting on the floor in front of his recliner. The fall note documented no actions were needed and direct staff to continue to observe resident. The care plan was updated for R57 to wear slipper socks at bedtime and to give R57 frequent reminders to call for assistance when getting up. The Fall Note dated 01/20/23 at 10:34 PM documented staff checked on R57 because the room door was shut. R57 was sitting in his chair with blood on the floor and his left knee. R57's walker was folded and turned on its side. R57 informed staff he did fall. The pad alarm was on his table and unplugged enough not to alarm the pagers. R57 had previous skin issues to his left knee from a previous fall and had acquired new skin tears and abrasions to just below the left knee, left upper arm, left ankle and upper buttocks. The note documented R57 received education to use the call light and not to remove pad alarm from the chair. The Fall Note dated at 02/02/23 at 05:10 AM documented staff were notified by the alarm and found R57 sitting on the floor in his room. R57 had an abrasion to his left knee, which was cleansed, and a dressing applied. The note documented action taken was to observe, teach use of call light, and safe use of devices. The intervention listed to adjust toileting schedule and staff to frequently remind R57 to use his call light for assistance for his safety. The Fall Note dated 03/02/23 at 11:33 PM documented R57 was assisted to the bathroom with his walker and gait belt. R57 lost his balance and fell partially on the couch, landing on his left knee sustaining injury to left knee and first aid was immediately applied. The fall note documented no interventions at that time. The Fall Note dated 03/28/23 at 12:49 PM documented staff observed R57 starting to stand up from his recliner when he fell on his left knee. Staff were not able to get to the resident before the fall. The nurse found R57 sitting on his couch. R57 reported he wanted to see what laundry had put in his closet. The fall note further documented staff educated R57 on the importance of using the call light; R57had a bed alarm and chair alarm. He often attempted to ambulate in his room without calling for assistance and to give frequent reminders to use the call light to call and wait for assistance. No interventions at that time. The Fall Note dated 04/25/23 at 04:24 PM documented R57 was on his left knee in front of his bed. R57 reported he was trying to get into his wheelchair for supper and stated his call light was attached to his recliner and he should have used it. The chair alarm was working and answered promptly. The fall note further documented staff visited with R57 on the importance of using the call light to call staff for assistance and waiting for staff to get there to assist him. Resident verbalized understanding. No intervention was documented. On 06/26/23 at 03:38 PM observation revealed R57 sitting in his recliner watching television. R57 stated he had been admitted to the facility because of falling. He reported he was taking a sleeping pill and staff reported he had been walking around at night, but he does not remember this happening. R57 stated the facility wanted him to remain seated as the intervention to keep him from falling and when the alarms go off, they come running. He did report the staff remind him to use the call light and wait for assistance. R57 also reported he wanted to return home at the end of summer. On 06/27/23 at 09:45 AM Administrative Nurse D stated due to R57's intact cognition the facility had not implemented new interventions to prevent his falls. The facility's undated Falls and Fall Risk, Managing policy documented based on previous evaluations and current data, the staff will identify interventions related to resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The facility failed to identify and implement interventions to prevent R57 from falling which placed the resident at risk of further falls and injuries. The facility had a census of 66 residents. The sample included 18 residents, with 10 reviewed for falls. Based on observation, record review, and interview, the facility failed to ensure staff provided Resident (R)52 with his call light when he went to bed, resulting in a fall in which R52 obtained a right trimalleolar ankle fracture (a break in the lower leg section that form your ankle joint). The facility further failed to assess residents for safe lift chair use, after falls out of a lift recliner for R52 and R36. The facility failed to follow R36 and R46's plan of care which resulted in falls and failed to implement meaningful, resident centered interventions for R14 and R57. This placed the residents at risk for further falls and avoidable injuries. Findings included: - The Electronic Medical Record (EMR) for R52 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function), tremors (an involuntary quivering movement), and Parkinson's disease (a disorder of the central nervous system that affects movement). The admission Minimum Data Set (MDS), dated [DATE], documented R52 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, transfers, ambulation, wheelchair mobility, toileting, and personal hygiene. The MDS further documented R52 had unsteady balance, no functional impairments, and had no falls. The Annual MDS, dated 05/15/23, documented R52 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. The MDS further documented R52 had unsteady balance, no functional impairment, and had two or more non-injury falls. The Fall Care Area Assessment [CAA], dated 05/15/23, documented R52 wore non-skid shoes during the day and had a large landing mat in front of his recliner. The Fall Assessments, dated 07/14/22 and 05/15/23, document R52 at risk for falls. The Fall Care Plan, dated 05/19/23, initiated on 07/14/22, directed staff to remind him to ask for help, report changes in his abilities to the nurse, monitor his safety during activities. An update, dated 08/02/22, directed staff to ensure the skid strips were in place on the floor in front of R52's recliner. An update, dated 11/18/22, directed staff to ensure R52 wore non-skid shoes during the day. An update, dated 11/21/22, directed staff to ensure there was a landing mat in front of R52's recliner when he was in it. An update, dated 05/22/23, directed staff to monitor R52 every 30 minutes and make sure his bed was in low position. The Fall Investigation, dated 08/02/22 at 12:25 PM, documented R52 slid out of his recliner and was on the floor in front of the recliner, with his legs out in front of him. The investigation further documented the fall was unwitnessed and R52 slid onto the floor when he raised his lift recliner into an upright position. It directed staff to place skid strips in front of the recliner. Review of the EMR lacked documentation an assessment was completed to determine R52's safe use of a lift chair. The Fall Investigation, dated 09/03/22 at 04:42 PM, documented R52 slid out of his recliner and obtained a laceration (cut) to the bridge of his nose and his forehead. The investigation documented staff reviewed safety measures with R52 and instructed him to call for assistance and directed him not to elevate his chair. The investigation documented staff felt it was doubtful R52 would retain the information they provided. The EMR lacked documentation an assessment was completed to determine R52's safe use of a lift chair. The Fall Investigation, dated 11/19/22 at 10:43 PM, documented R52 slid out of his recliner and staff observed him lying on the floor on his back. The investigation further documented the lift chair remote was clearly marked with up and down arrows on it. The investigation documented staff encouraged R52 to call for assistance prior to raising the chair up, but with R52's moderate impaired cognition, he may not always remember to call for assistance. The investigation directed staff to place a landing pad in front of R52's lift chair. The Fall Investigation, dated 05/20/23 at 07:45 AM, documented R52 was found lying on his back on the left side of the bed with his head slightly up on a bedside table and his legs straight out in front of him. The investigation further documented R52 had an abrasion (scrape) to the outer right ankle which measured 4.0 centimeters (cm) by 2.0 cm, and an abrasion to the right side of his head with a small amount of bleeding present, which measured 9.0 cm by 4.0 cm. The investigation documented R52 complained of right ankle pain; there was swelling but no deformity noted. R52 stated he was getting up to get his call light, that was still in his recliner, to call for assistance and fell. The investigation documented R52's call light should always be in reach. The investigation further documented the facility sent R52 to the emergency room for evaluation and he returned at 12:00 PM with non-weight bearing orders, a splint, and orders to see an orthopedic doctor for surgical repair, as he had a right trimalleolar ankle fracture. The Witness Statement, dated 05/20/23 documented Certified Nurse Aide (CNA) M reported R52 used his call light to tell staff he was ready to go to bed. CNA M documented she was training another CNA and together, they assisted R52 from the recliner to his bed. CMA M stated staff forgot to give R52 his call light. CNA M further documented he did not check on R52 after placing him in bed because it was almost at the end of the shift. The Physician's Order, dated 05/25/23, directed staff to ensure strict elevation of R52's right foot/ankle, non-weight bearing of his right lower extremity, keep splint in place, and plan for a surgical fixation on 05/31/23. On 06/21/23 at 03:00 PM, observation revealed R52 sat in his recliner with his feet elevated, and a call light at his side. There was a fall mat in front of the recliner. Further observation revealed R52 had a fracture boot on his right leg. R52's representative was in the room and stated R52 broke his leg because he did not have his call light, when he was in bed. On 06/26/23 at 12:30 PM, observation revealed CMA R and CNA N attached the sling underneath R52 to the full body lift. CNA M stood behind R52 to maneuver him to the recliner as CMA R used the lift controls to raise him up and take him to his recliner. Further observation revealed CMA R lowered R52 into his recliner, elevated his feet, gave him his call light, and put the fall mat in front of the recliner. On 06/26/23 at 12:30 PM, CNA M stated R52 broke his leg trying to get to his call light when he was in bed. CNA M stated staff check on R52 every 30 minutes since the fall. CNA M further stated R52 had other falls out of his recliner when he would elevate the chair, but not since he broke his leg. On 06/26/23 at 03:30 PM, Licensed Nurse (LN) G stated R52 had falls out of his recliner and staff tried to put a chair alarm in the recliner but as R52 elevated the recliner, the alarm pad would fall out, so staff took his alarm away. LN G further stated R52 had a fall with a fracture and the interventions after the fall were a low bed, 30-minute checks, and a fall mat in front of the recliner. LN G said staff made sure R52 had his call light and staff documented that, every shift, in the Medication Administration Record. On 06/27/23 at 09:45 AM, Administrative Nurse D stated staff did not follow R52's care plan and did not give R52 his call light, resulting in a fall where R52 broke his leg. Administrative Nurse D further stated staff tried different interventions to prevent falls for R52 when he was in his recliner. Administrative Nurse D verified the facility had not completed an assessment for the safe use of lift chairs. The facility's undated Falls and Fall Risk Assessment policy documented staff would document risk factors for falls in the resident's record and the physician would identify medical conditions affecting fall risks. The staff would evaluate, and document falls that occur while the individual was in the facility, identify them as witnessed or unwitnessed, and attempt to define possible causes of the fall. Based on the assessments, the staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. If underlying causes could not be readily identified or corrected, staff would try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason was identified for its continuation. The staff would monitor and document the individual's response to interventions intended to reduce falls or the consequences of falling. If interventions have been successful in preventing falling, the staff would continue with current approaches or reconsider whether these measures were still needed if the problem that required the interventions had resolved. If the resident continued to fall, the staff and physician would re-evaluate the situation and consider other possible reasons for the resident's falls and would reevaluate the continued relevance of current interventions. The facility failed to provide a safe environment for R52 when staff failed to place his call light within reach. As a result, R52 attempted to get his call light and subsequently fell and broke his leg. The facility further failed to assess R52's ability to safely use a lift chair after multiple lift chair related falls. - The Electronic Medical Record (EMR) for R36 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), cerebral infarction (a disruption of blood flow to the brain due to problems with the blood vessels that supply it), major depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R36 had severely impaired cognition and required extensive assistance of two staff for bed mobility, toileting, and extensive assistance of one staff for transfers, ambulation, dressing, and personal hygiene. The assessment further documented R36 had unsteady balance, upper and lower functional impairment on one side, and had two or more non-injury falls. The Quarterly MDS, dated 05/02/23, documented R36 had severely impaired cognition and required extensive assistance of two staff for bed mobility, toileting, and extensive assistance of one staff for transfers, ambulation, mobility in his wheelchair, dressing, and personal hygiene. The MDS further documented had unsteady balance, upper and lower functional impairment on one side, and one non-injury fall. The Fall Assessments, dated 11/25/22 and 05/02/23, documented R36 was at risk for falls. The Fall Care Plan, dated 05/02/23, initiated on 07/25/22, directed staff to request a therapy screen if needed, use a bed alarm, stay with the resident during toileting, make sure his important items were within reach, assist R36 with transfers or when he walked, remind R36 to ask for help, and place a mat on the floor beside the bed in case he rolled out. The update, dated 01/16/23, directed staff to visualize R36 in the mornings at shift change. The update, dated 01/26/23, directed staff to use an alarm on his chair. The Fall Investigation, dated 01/26/23 at 07:45 PM, documented staff heard someone yelling for help and was R36 was discovered on the floor holding on to the footrest of the recliner, which was slightly open. The note further documented Social Services X and a Certified Nurse Aide (CNA) got R36 up and took him into the bathroom before a nurse could assess him for injuries. The investigation documented, due to R36's cognition, he did not always comprehend what was safe and had attempted to get up on his own without calling for assistance after his guest left. The Fall Investigation, dated 04/29/23 at 07:00 PM, documented R36 slid out of his recliner and education was provided to staff to make sure R36's chair alarm was under him when he is in his recliner. The investigation further documented R36 had severely impaired cognition and did not comprehend what was safe. The Fall Investigation, dated 05/28/23 at 09:30 PM, documented R36 was found on the floor in his room with the recliner controller in his hand; the chair was elevated in an up position. R36's drinks were spilled all over the floor, and he was still covered with a blanket he had on while in his recliner. The intervention directed to keep the remote for the recliner out of the resident's reach. The investigation further documented, R36 had severely impaired cognition and did not comprehend what was safe; it was felt by administration that keeping the recliner controller out of reach was not the appropriate intervention for this resident. R36's EMR lacked evidence the facility assessed for safe use of a lift chair. On 06/22/23 at 11:50 AM, observation revealed CNA O and CNA MM attached the sit to stand lift sling around the resident and hooked the sling to the lift. R36 HELD onto the handles and STAFF stood him up to transfer him to the toilet. On 06/22/23 at 11:55 AM, CNA O stated R36 used to sit in his room but since he had falls, staff kept him in the living room area unless his family was visiting. CNA O stated R36 had falls out of his recliner; he would elevate the recliner and slide out. On 06/26/23 at 12:22 PM, Licensed Nurse (LN) H stated R36's falls were out of his recliner, so now R36 stayed out in the living room area. On 06/27/23 at 09:45 AM, Administrative Nurse D stated R36 had falls from his recliner and the facility had looked into doing the lift chair/recliner assessments. She said staff keep R36 in the living room area unless his family was with him in his room. The facility's undated Falls and Fall Risk Assessment policy documented staff would document risk factors for falls in the resident's record and the physician would identify medical conditions affecting fall risks. The staff would evaluate, and document falls that occur while the individual was in the facility, identify them as witnessed or unwitnessed, and attempt to define possible causes of the fall. Based on the assessments, the staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. If underlying causes could not be readily identified or corrected, staff would try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason was identified for its continuation. The staff would monitor and document the individual's response to interventions intended to reduce falls or the consequences of falling. If interventions have been successful in preventing falling, the staff would continue with current approaches or reconsider whether these measures were still needed if the problem that required the interventions had resolved. If the resident continued to fall, the staff and physician would re-evaluate the situation and consider other possible reasons for the resident's falls and would reevaluate the continued relevance of current interventions. The facility failed to assess cognitively impaired R36 for safe lift chair use and failed to follow his plan of care which resulted in falls. This placed the resident at risk for further falls and injury. - The Electronic Medical Record (EMR) for R46 documented diagnoses of dementia without behavioral disturbances (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and seizures (violent involuntary series of contractions of a group of muscles). The Annual Minimum Data Set (MDS), dated [DATE], documented R46 had severely impaired cognition and required extensive assistance of two staff for transfers, dressing, toileting, and extensive assistance of one staff for bed mobility, ambulation, and personal hygiene. The assessment further documented R46 had unsteady balance, no functional impairment, had one fall with injury, and used a bed, chair, and wander alarm daily. The Quarterly MDS, dated 05/22/23, documented R46 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and extensive assistance of one staff for mobility in her wheelchair, dressing and personal hygiene. The assessment further documented R46 had unsteady balance, no functional impairment, two or more non injury falls, and used a bed alarm daily. The Fall Assessments, dated 10/13/22 and 05/22/23 documented R46 at risk for falls. The Care Plan, dated 05/23/23, initiated 07/27/22, directed staff to request a therapy screen if needed, monitor her toileting program, make sure important items are within reach, keep room well lit, use a bed and chair alarm, use a standard walker and use agait belt with one staff assistance. The update, dated 01/23/23, directed staff to not leave R46 unattended in the dining and activity room. The Fall Investigation, dated 10/08/22 at 04:45 PM, documented R46 was in the bathroom with staff and as the Certified Nurse Aide (CNA) pulled down R46's pants, R46 fell forward, landed on her knees, and sustained an abrasion (scrape) to her right knee. The investigation further documented R46's walker was in the southwest corner of the restroom away from the resident and when the nurse asked where the walker was positioned at the time of the fall, the CNA stated it was where it was located when the nurse entered the room. The nurse asked the CNA why it was not in front of the resident with the brakes locked, the CNA could not give an answer. The investigation documented the CNA was educated to have the resident's walker in front of her and the brakes locked when she was standing. The Fall Investigation, dated 06/01/23 at 06:05 PM, documented R46 was in the activity room in her wheelchair. Staff walked out of the room and when they returned, R46 scooted out of the wheelchair and was seated on the wheelchair pedals. The investigation documented R46 had severely impaired cognition and did not comprehend what was safe and staff were educated to follow R46's care plan. On 06/22/23