**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to revise the care plan timely with effective interventions to prevent recurring falls for one (1) of thirty-six (36) sampled residents, Resident #38. Record review revealed Resident #38 fell on [DATE], 04/21/2021, 05/03/2021 twice, 05/06/2021. Continued review revealed the care plan revisions did not occur timely and the resident fell again on 05/18/2021. The facility transferred Resident #38 to an acute care facility where the resident was diagnosed with a fractured clavicle. The findings include: Review of the facility's policy, Comprehensive Person-Centered Care Plans (CCP), revised 2016, revealed a CCP included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. Care plans are revised as information about the residents and the resident's condition changes. Review of the policy Falls and Fall Risk Managing, revised March 2016, revealed the facility staff identified interventions related to the resident's specific risks. When a fall occurred the facility implemented additional or different interventions. In addition, if the underlying causes could to be identified or corrected, the facility would try various interventions based on the assessment until the falls were reduced, stopped or until the reason for the continuation of the falls were identified as unavoidable. In addition, the staff would monitor the residents response to the new interventions intended to reduce falls or risk of falls. Clinical record review revealed the facility admitted Resident #38, on 04/09/2021, with the diagnoses of Cerebral Infarction, Dementia, and weakness. Record review of the admission MDS, dated [DATE], revealed the facility assessed the resident's cognition with the Brief Interview for Mental Status (BIMS) with a score of fourteen (14) and deemed the resident interviewable. The facility assessed the resident as an extensive one person assist with transfer and toileting, and used hearing aids devices. Review revealed the facility developed a focus care plan for a risk of falls and communication. Review of Resident #38's CCP, dated 04/19/2021, revealed the facility developed a fall focus for impaired balance, weakness, poor safety awareness, and use of psychological medication. The fall focus interventions implemented on 04/19/2021 included assess/report decreased status, balance or motion, bed low, call light in reach with the staff to encourage the use and ask for assistance, encourage non-skid socks or footwear with transfers, room free of clutter, pharmacy reviews, and to see psychotropic care plan for possible side effects. Record review of facility event, dated 04/10/2021, revealed the facility report by RN #1 included staff witnessed the resident fall when he/she stood up from the wheelchair without assistance. Record review of the Resident #38's care plan revealed the facility revised the interventions related to the 04/10/2021 fall on 04/26/2021 for visual cue to call for assistance. The revision occurred sixteen (16) days after the fall. Record review of facility event, dated 04/21/2021, revealed the facility report by LPN #3 included an unwitnessed fall occurred and found the resident on the floor at the laundry hamper by the bed. Observations, on 06/14/2021 at 2:30 PM, revealed a white laundry hamper remained between the bed and the outer wall next to the Resident #38's bed. Record review of Resident #38's care plan revealed the facility revised the interventions related to the 04/21/2021 fall on 04/26/2021 to include a tool to reach with called a Reacher. The revision occurred five (5) days after the fall. Record review of facility event, dated 05/03/2021, revealed the resident fell at 10:15 AM and at 4:15 PM. RN #1 reported at 10:15 AM revealed an unwitnessed fall of the resident at the sink. The resident reported an attempt to wash his/her hands but the sink was not low enough for the resident to reach from the wheelchair. RN #1 report at 4:15 PM revealed a witnessed fall by another resident, Resident #38 fell in front of the door with a walker found on top of the resident. Record review of the Resident #38's care plan revealed the facility revised the interventions related to the 05/03/2021 fall on 05/06/2021 to include to encourage to wash hands before and after a meal. The facility revised the care plan three (3) days after the fall. Review of the event evaluation, dated 05/06/2021, revealed the facility evaluated the 4:15 PM fall on 05/03/2021 and concluded the walker needed to be removed from the immediate area when not in use by staff or therapy. However, review of the care plan revealed the facility did not revise the fall care plan to reflect the plan. Record review of facility event, dated 05/06/2021, revealed RN #2 reported the resident fell at the base of the door to the room. The resident had walked away from the wheelchair which remained at the resident's bedside. Record review of the Resident #38's care plan revealed the facility revised the interventions related to the 05/06/2021 fall on 05/20/2021 which included to encourage the resident to be out of the room while awake and fall mat. However, the resident fell on [DATE] and fractured his/her left clavicle. The facility did not revise the care plan until after the resident fell which resulted with an injury. Interview with LPN #3, on 06/12/2021 at 7:07 PM, revealed when resident's fall the facility policy included to start a new intervention to decrease the potential for a fall. The LPN revealed she put the intervention for Resident #38 on the event report. The LPN revealed she could put the new intervention on the care plan they started. However, she let the Assistant Director of Nursing (ADON) or Director of Nursing (DON) review the intervention on the report sheet and if they decided they wanted to keep it then the care plan could then revised. The LPN revealed the revision of a care plan after a fall ensured the resident's new intervention documented the care the resident required to prevent a fall. The LPN revealed the facility should revise the care plan by the next day of a residents fall because it left the opportunity for falls to continue and then the resident would get hurt. Interview with RN #1, on 06/15/2021 at 2:18 PM, revealed the facility expected staff to start a new intervention immediately after a resident fell. The RN revealed Resident #38 fell the first day after admission and on 05/03/2021 under her care. The RN revealed she documented the new intervention in the event report and then the care plan should be revised. However, the RN revealed to have difficulty with the electronic program with access and navigation and therefore lets the managers revise the care plan. The RN revealed the revision to the actual care plan needed to occur within one to two days to decrease the chance of another resident fall. The RN revealed 5 to 16 days as to long to revise a care plan and it put the resident's safety at risk. The RN further revealed the facility reviewed the falls once a week. Interview with the MDS coordinator, 06/20/2021 at 9:30 AM, revealed she revised care plans quarterly and with significant changes. She revealed she did not revise care plans after the resident fell in the facility. She revealed she did not attend the fall committee meeting every week. She revealed the clinical nursing staff were responsible to revise the care plan for new intervention for a fall and she had no involvement with the process. Interview with the Assistant Director of Nursing (ADON), on 06/20/2021 at 11:12 AM, revealed the facility committee for falls met once a week to review the fall event reports for the facility. The ADON revealed the facility committee only met once a week and several weeks were missed last month. The ADON revealed the resident's revisions after a fall occurred immediately after the resident fell and should be completed by the staff. The ADON revealed with the weekly review the committee reviewed the new intervention and would decide if the intervention met the root cause and revised the care plan further if necessary. The ADON revealed the clinical team had not audited the care plans for timely or appropriate revisions. Interview with the DON, on 06/23/2021 at 4:30 PM, revealed she expected staff to revise the resident care plans at all the time of a fall to ensure resident remained as safe as the facility attempt. The DON revealed she knew some staff had difficulty using the electronic care plan program. The DON revealed she assigned the fall event review and care plan revisions for the fall review process to the ADON. The DON revealed the fall committee which consisted of the ADON and the Therapy Director met once a week for review and revisions of care. The DON revealed she was unaware of issues with revisions of the care plan in required to the length of time or staff not completing the revision the day of the incident. However, she was aware the fall committee had not met for several weeks in a row. The DON revealed the clinical team did not complete audits of resident care plans in order to identify issues. The DON revealed to have identified areas of education needs with staff which included care planning and revision of the care plan. Interview with the Administrator, on 06/24/2021 at 2:52 PM, revealed the facility did not identify issues for revisions of resident care plans. He revealed the facility revised the resident care plans with any significant change. He revealed the resident had a right to refuse the care plans. He revealed with the discussion of quality of care the resident had a right to fall and the facility could not prevent a fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review record revealed the facility admitted Resident #2 on 06/04/2019 with diagnoses of Alzheimer's, Dementia without behaviors and Insomnia. Review of Resident #2's Minimal Data Set (MDS), dated [DATE] revealed the facility assessed the resident to require physical help with baths, with support of one (1) staff and extensive assist of one (1) staff for bed mobility, to transfer, for toilet and for personal hygiene. Record review revealed the facility assessed Resident #2 with a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15) which indicated moderate cognitive impairment. Review of Resident #2's Physician's Orders revealed on 02/12/2020, the Medical Director (MD) ordered leg protectors to be on both legs at all times except at bath without an end date. Review of Resident #2's last Care Plan conference dated 06/15/2021, revealed the resident was identified with skin impairments because of thin and fragile skin on 06/13/2019. Resident #2 was to have leg protectors on both legs at all times except for baths/showers. Continued review revealed the resident was to have Ointment to bilateral legs as ordered, every evening. No new orders or interventions after 04/22/2021 event. Review of Resident #2's Progress Notes completed by Licensed Practical Nurse (LPN) #2 on 04/22/2021 at 9:54 AM as a late entry, revealed, at 7:00 AM on this day LPN went to perform weekly skin assessment and noted a dry dressing to right leg. Night shift nurse did not know anything about the dressing on resident's leg. Removed dressing and noted a skin tear 3.5 x 4 cm (centimeters) with bruising 6 x 10 cm with minimal red blood drainage, no signs or symptoms of infection . Resident did not know what happened. Review of the facility's Event Report dated 04/22/2021 at 7:00 AM, revealed LPN #2 had documented on the Event Report, Resident stated someone told (him/her) something happened but was unsure what they said. LPN #2 documented he was unable to determine what caused this event. Review of the Point of Care History (used to track Activity of Daily Living (ADL) care)revealed CNA #13 provided care for Resident #2 on 04/20/2021 thru 04/22/2021. CNA #13 provided care for the resident on 04/21/2021 to 7:00 AM on 04/22/2021. Review of a written statement signed by the Assistant Director of Nursing (ADON) dated 04/22/2021 revealed on 04/22/2021, a nurse noted during skin assessment there was a dressing to a skin tear (ST) to right lower extremity. Upon investigation, it was noted CNA #13 caused a ST to lower extremity during care on 04/20/2021 related to rings worn on her fingers during care. CNA failed to report incident to nurse. CNA applied dry dressing over ST. DON spoke with CNA regarding incident. CNA #13 verbally admitted to causing ST to resident lower extremity. CNA was given disciplinary action for failure to report a new skin event and ultimately terminated from (facility) on 04/21/2021. The above statement dates were in conflict with the Event completed by LPN #2 on 04/22/2021. Review of facility's Powerful Moment (coaching form) completed by the ADON on 04/22/2021 for CNA #13 revealed the Powerful Moment was triggered because on 04/22/2021 staff cared for a resident while wearing inappropriate attire (i.e., excessive jewelry, large jewels) resulting in a resident injury. This document also revealed CNA #13 was reeducated on what consists of appropriate and inappropriate attire for work and why it posed a risk to residents when not adhered to. It was documented this reeducation was delivered over the phone on 04/22/2021, no time was provided. This form was signed by the ADON and DON. On 06/16/2021 at 9:36 AM, attempted to reach Certified Nursing Assistant (CNA) #13 for an interview, left a voice message and did not receive a call back. On 06/17/2021 at 9:50 AM, attempted to reach CNA #13 through her emergency contact and the phone number was no longer in service. Interview with LPN #2, on 06/18/2021 at 11:40 AM, revealed he found a new bandage on Resident #2's leg when he did routine skin assessment on 04/22/2021 at 7:00 AM. He described the bandage as still wet. LPN #2 stated CNA #13 had provided care to the resident the night prior. He also stated he had spoken with Registered Nurse (RN) #3 and she informed him nothing had been reported to her on night shift. LPN #2 stated, I did not see the staff member do it, I cannot say if (CNA #13) actually did it but I reported it up the chain. Interview with RN #3, on 06/16/2021 at 10:15 AM, revealed she had worked at the facility for ten (10) years. She revealed LPN #2 called her to Resident #2's room around 7:00 AM and informed her that resident had a new skin tear with a bandage on it. RN #3 reported she was not aware of a skin tear and did not know how it happened. She revealed CNA #13 had provided care for Resident #2 on the night shift and she could have caused it. RN #3 reported it was out of a CNA's scope of care to place a bandage on a resident and any new concerns should have been reported to her. She stated she believed the CNA hid it because she had been involved in the other incident on 04/21/2021 at 7:30 PM. 3. Record review revealed the facility admitted Resident #20 on 07/31/2021 with diagnoses of Dementia without behaviors, Anemia, Anxiety Disorder, Osteoporosis and Cerebral infraction. Review of Resident #20's Quarterly MDS dated [DATE] revealed the facility assessed the resident with a BIMS'score of ten (10) out of fifteen (15) which indicated moderate cognitive impairment. The facility assessed the resident as an extensive assistance of two (2) staff for bed mobility and for transfers. Resident #20 was noted to have impairments to both upper and lower left extremities and was wheelchair bound. Review of Resident #20's Comprehensive Care Plan last revised 05/21/2021 revealed the resident required an assist of two (2) staff for transfers with the use of the gait belt (created 08/12/2020) no new interventions in place after the 04/22/2021 Event. Additionally the care plan revealed the resident was to be encouraged to wear proper footwear and non-skid socks at transfer. Review of Resident #20's Progress Notes completed by RN #2 on 04/22/2021 revealed CNA was transferring resident from chair to bed, resident was sliding and CNA lowered resident to the floor. No injuries were noted, NP and family notified. Review of the facility's Event Report completed by RN #2 on 04/22/2021 at 2:37 PM, revealed CNA #11 transferred the resident and he/she began to slide at which time the CNA lowered the resident to the floor. The Event listed prior interventions in place as resident's wheelchair, call light within reach and bed in lowest position and interventions put in place after Event non-skid socks (which were already care planned on 08/12/2020). Review of the Event by ADON, DON and RM revealed the CNA assisted the resident during a transfer from wheelchair to bed, and the resident's feet began to slide. The CNA lowered the resident to the floor. Wheelchair brakes were locked. Shoes were not applied prior to transfer, resident wearing slippery socks. Resident had a cerebral infraction which affected left dominate side, unsteadiness on feet and generalized muscle weakness and lack of coordination. Intervention put in place was reeducation to staff regarding safe footwear during transfer. Staff reeducated regarding following most current plan of care. Record review revealed the facility provided a Powerful Moment (coaching tool) for CNA #11 dated 05/03/2021, triggered by assisted fall with resident being lowered to the floor due to improper footwear being placed on resident. Education was provided to CNA #11 to remind her gait belts must be used with all transfers. Resident must be wearing appropriate footwear (non-skid socks/shoes) prior to start of transfer also to ensure most current care plan is followed. This document was signed by the ADON and CNA #11. Interview with CNA #11 on 06/23/2021 at 2:20 PM, revealed she had worked at the facility for about three (3) months but had provided resident care for thirty (30) years. She revealed when she started at the facility she was trained by another CNA but could not recall who it was. She revealed she shadowed the CNA for three (3) or four (4) days and could not recall if she had a checklist that was completed. Additionally, she revealed she was not required to show any skills before she completed care for residents. She reported she had done it for so long she should know what to do. Continued interview with CNA #11, revealed she was informed by the CNA who trained her that Resident #20 was a stand and pivot for transfer. She stated she did not review the care plan to ensure that was correct. She revealed it was her responsibility to look at and follow the care plan and failure to do so could result in injury to residents. She revealed she tried to provide the best care she could for all residents. RN #2 could not be reached for interview; she no longer worked at the facility and would not return phone calls. Interview with LPN #4 on 06/17/2021 at 11:00 AM, revealed care plans were made based on assessments that the RN completed to meet their care needs. She also revealed care plans should be created in such a way to ensure residents were safe. LPN #4 revealed the care plan should always be followed and that was the best way to protect residents from harm. However, LPN #4 revealed she did not know the care plan policy. 4. Review of the facility's policy, Gait Belt, revised August 2019, revealed that as it is indicated by the resident's need, all staff are required to use the proper number of staff to assist and the correct devices (such as a gait belt, walker, rails, mechanical lift, etc.) for transfers. Review of the facility's Event Report, dated 04/21/2021 at 8:01 PM, revealed Resident #108 was transferring from the wheelchair to bed when a laceration was obtained. Per the report, Certified Nursing Assistant (CNA) #13 said that the resident was trying to self-transfer into bed when she entered the room and the resident was about to fall and the CNA caught the resident. Further review revealed she did not know what caused the laceration. Per the report, Resident #108 stated CNA #13 kept telling the resident to stand up, and that he/she could stand up. The resident said that they told the CNA that they could not stand, and that they only had socks on. The CNA continued to assist resident to bed without shoes on while the resident slid. The resident did not recall how he/she received the laceration. Record review revealed the facility admitted Resident #108 on 10/22/2020 with diagnoses that included Dementia without Behaviors, Atrial Fibrillation, Major Depressive Disorder, Hypertension, Psychotic Disorder with hallucinations, Delusional Disorders, Acute Kidney Failure, Cardiomegaly, Anxiety, history of Neoplasm of Breast, and Congestive Heart Failure. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #108's was assessed with a Brief Interview for Mental Status (BIMS) exam and the resident's BIMS score was ten (10). Continued review revealed he/she was an extensive assist with transfers. Review of the care plan, dated 05/14/2021, revealed that Resident #108 was to wear non-skid socks or properly fitted footwear and a gait belt for any transfers. Continued review revealed that a walker was also care-planned to be used with one (1) person assist for all transfers. Unable to interview Resident #108, as the resident no longer resided at the facility. Unable to interview Certified Nursing Assistant (CNA) #13 after repeated attempts. She was called on 06/16/2021 at 3:00 PM and on 06/18/2021 at 2:58 PM with no answer and a message left on voicemail. No return phone call received at this time. Interview with Registered Nurse (RN) #3, on 06/17/2021 at 9:30 AM, revealed that on 04/21/2021 around 7:30 PM, CNA #13 came to the nursing station and asked the RN to come check out Resident #108 in their room. When RN #3 entered the room she saw the resident laying in bed with blood everywhere. CNA #13 said what happened was that the resident was getting up on their own and was falling and she caught them and somehow the resident got injured, but she did not know how. After assessing the resident and talking to them, the RN asked another nurse Licensed Practical Nurse (LPN) #2 to come in and assess the resident also. The two (2) nurses decided that the resident needed to go out to the hospital and resident was sent out. The next morning RN #3 reported to the Director of Nursing (DON) what had happened. Interview with Licensed Practical Nurse (LPN) #2, on 06/16/2021 at 11:50 AM, revealed that RN #3 did ask him to come in room and assess the resident. They decided to send the resident to the hospital. He stated that normally the resident was a pretty good transfer. LPN #2 stated that CNA #13 stated that the resident slipped during transfer, but after further talking with the resident privately, the resident said that they could not get up and the CNA kept telling the resident that they could. The resident stated that he/she even told the CNA that they just had socks on and the CNA continued to make the resident get up and transfer. LPN #2 stated that after the resident returned from the hospital the resident came back with no stitches just a dressing. He stated that days later, the resident ended up acquiring cellulitis in the area where the laceration was and was started on antibiotics. Interview with Certified Nursing Assistant (CNA) #14, on 06/18/2021 at 9:15 AM, revealed that she never knew Resident #108 to try to get up on his/her own. She said before the incident it would take one person to transfer the resident, but after the incident, the resident started to need two (2) people for assistance with transfers. She said it was not due to the resident's mobility getting worse, but due to the resident being scared to get up and transfer. Interview with Certified Nursing Assistant (CNA) #10, on 06/18/2021 at 09:50 AM, revealed that Resident #108 never tried to get up on their own. She said the resident's mobility did change after incident. The resident slowed down. She said once the resident received the laceration, he/she started to get more scared to get up and was not himself/herself. Interview with the Assistant Director of Nursing (ADON), on 06/18/2021 at 2:10 PM, revealed that she had heard from nurses about a new skin issue going on with Resident #108. She said it was initially reported that CNA #13 caught resident from falling. Continued interview revealed that with further investigation it was determined from the resident that he/she actually did not have footwear on and slipped and got a laceration from wheelchair. The ADON stated that the CNA should have followed the care plan. She stated if the care plan was not followed, it could cause the resident injury and provide unsafe care. She stated everyone was responsible for resident safety, all the time. Interview with Director of Nursing (DON), on 06/23/2021 at 11:21 AM, revealed that she terminated CNA #13 the next day after the incident. She said she interviewed Resident #108 and the resident said that he/she told the CNA that he/she could not stand up but, the CNA got him/her up anyway and then the resident slipped and hit his/her leg on the bed. She said after she interviewed the resident she then called CNA #13 and educated her and then terminated her. She stated that LPN #2 stated on 04/22/2021 that he did not trust CNA #13 taking care of his residents. She stated that it was the responsibility of the facility to keep residents safe. The DON stated the care plan should be followed when transferring residents and staff should also listen to the resident. Interview with the Administrator, on 06/19/2021 at 10:54 AM, revealed that he expected the care plans to be followed, as well as respecting resident rights or wishes at the same time. He states he did not know anything about the incident with Resident #108. Based on interview, observation, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to provide a safe environment for four (4) of thirty-six (36) sampled residents (Residents #2, #20, #38 and #108). The facility admitted Resident #38 with a known history of falls, and assessed the resident to be at high risk for falls and had poor cognitive memory. Resident #38 had five (5) falls in four (4) weeks. Staff educated the resident, who had poor cognitive memory, to remember to use the call light to call for the immediate intervention with the fall. The resident had a fall on 05/06/2021. However, the facility did not implement a new intervention until 05/20/2021, after the resident had a fall on 05/18/2021, which resulted in a fracture to the left clavicle. In addition, the facility failed to provide a safe environment for Residents #2, #20 and #108. Resident #2 sustained a skin tear during personal care provided by staff wearing jewelry. The facility assessed Resident #20 as a two (2) person assist, required a gait belt and gripper socks. Staff transferred the resident with one aide and no equipment, the resident fell and sustained a laceration. The facility assessed Resident #108 as a two (2) person assist for transfers. However, staff transferred the resident with one aide; the resident had a fall during the transfer. The findings include: Review of the facility's policy, Falls and Fall Risk Managing, revised March 2016, revealed staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident's fall and to try to minimize complications from a fall. According to the Minimum Data Set (MDS), the definition of a fall included the unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an external force (push from another resident). When a fall occurred despite initial interventions, the facility would implement additional or different interventions. In addition, if the underlying causes could be identified or complement additional or different interventions the facility would try various interventions based on the assessment until the falls were reduced, stopped or until the reasons for the continuation of the falls were identified as unavoidable. In addition, the staff would monitor the resident's response to the new interventions intended to reduce falls or the risk of falls. Review of the facility's policy, Fall Risk Assessment Policy, undated, revealed the nursing staff along with others would seek to identify and document the resident's risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Upon admission, the facility would identify the resident's falls within the past ninety (90) days; the resident's risk of falls; assess underlying medical conditions which increased the risk of injury of falls; Activity of Daily Living (ADL) capabilities, and cognition which may increase the resident's risk of falls; and, modify fall risk factors and interventions to minimize the risk factors which were not modifiable. Review of the facility's policy titled, Accident and Incidents-Investigating and Reporting undated, revealed all accidents and incidents involving residents on the facility's property shall be investigated and reported to the Administrator (ADM). The management team shall promptly initiate and document the investigation of the accident or incident. The Director of Nursing (DON) ensured the Administrator received a copy of the report. The Charge Nurse was promptly notified of any change in condition to a resident. Review of the facility's policy titled, Safety and Supervision of Residents, undated, revealed safety risks and hazards were identified on an ongoing basis through a combination of employee training, monitoring and reporting process, Quality Assurance and Performance Improvement (QAPI) reviews of the incidents and accidents. Further review of the facility's policy revealed when accident hazards were identified QAPI shall evaluate and analyze the cause and develop a way to mitigate the hazards. Additionally, this policy revealed employees were trained on potential accident hazards and demonstrated competency on how to identify and report them. Review of the facility's, Employee Handbook dated 2019, revealed under the Appearance/Uniform tab; excessive jewelry was not permitted. 1. Record review revealed the facility admitted Resident #38, on 04/09/2021, with the diagnoses of Cerebral Infarction, Dementia, and weakness. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident's cognition with the Brief Interview for Mental Status (BIMS) with a score of fourteen (14) and deemed the resident was interviewable. The facility assessed the resident with a history of falls prior to the admission, and the resident had one (1) fall since admission to the facility. Further review revealed the MDS Care Area Assessment (CAA) triggered for falls risk and care planning for fall risk. Review of Resident #38's History and Physical, dated 04/12/2021, revealed the facility admitted the resident for therapy after treatment for an acute mild stroke. The provider assessed the resident with delirium, confusion, and difficultly holding attention. Review of the Physician's Order's, 04/09/2021, revealed the resident received Eliquis (blood thinner) two point five (2.5) milligrams (mg) twice a day and received Lasix (diuretic) twenty (20) mg every morning. Review of the Fall Risk Assessment, dated 04/10/2021 at 1:23 AM, revealed the resident scored an eleven (11). The assessment score of ten (10) or higher revealed a high risk for falls. Review of the Baseline Care Plan, dated 04/12/2021, revealed the facility initiated the baseline care plan for care related to an acute infarction. The interventions to meet the immediate needs of the resident included: place the bed in low position, place nonskid socks to feet when not wearing appropriate footwear, and one person assist with transfers, ambulation, and toileting. Review of the St. Louis University Mental Status (SLUMS) examination, dated 04/30/2021, revealed the facility assessed the resident for cognitive impairment and dementia with a total score of thirteen (13) out of thirty (30). The score of 13 revealed the resident exhibited dementia. Review of the facility's Event Report, dated 04/10/2021 at 12:00 PM, revealed Registered Nurse (RN) #1 documented Emergency Medical Staff (EMS) observed Resident #38 fall after the resident stood up from a sitting position in the wheelchair. The facility staff's new interventions included to remind the resident to use the call light and ask for assistance, and signs were posted in the room. Interview with RN #1, on 06/15/2021 at 2:18 PM, revealed the RN had provided care for Resident #38 since admission. The RN stated the resident presented on admission with severe confusion, lack of safety awareness and short term memory loss. RN #1 stated on admission, the resident often attempted to get up from the w/c, transfer to the toilet without help, and staff frequently reminded the resident to use the call bell. However, the resident remembered at the moment of instruction and forgot when staff left the room or area because of the resident's confusion. The RN revealed the EMS staff observed the resident stand from the w/c and fall forward while in the resident's room on 04/10/2021 at 12:00 PM. Further interview revealed the resident sustained a skin tear from the fall and did not know if the facility's fall protocol included to start a new intervention after a fall, but she knew the completion of the Event Report required a new intervention after the fall until the managers reviewed the report. The RN stated the facility's basic interventions for all residents on admission included a low bed, gripper socks, and use of the call bell for assistance. RN #1 further revealed after the initial three (3) interventions, the only other intervention the facility could do included to remind the residents to use the call bell for assistance, verbally and they posted signs in the room. Continued review of the facility's Event Report, dated 04/10/2021 at 12:00 PM, revealed RN #1 noted staff determined the resident did not call for assistance and the immediate intervention the RN placed included to remind the resident to not get up without staff's assistance. However, the resident's admission diagnoses included a cerebral infarction (stroke) and dementia; and, RN #1 stated the resident had severe confusion, lacked safety awareness, and could not remember due to short term memory issues. Further review revealed the facility closed the event and did not update the care plan until 04/26/2021, sixteen days (16) after the fall. Review of the Nurse's Progress Note, dated 04/11/2021 at 3:23 AM, revealed staff assessed the resident with confusion and redirected the resident to sit down in the w/c multiple times because the resident would stand up from the w/c. Interview with Family #10, on 06/15/2021 at 3:33 PM, revealed the facility reported the resident had a fall by the white laundry hamper in the resident's room. The family reported they washed and returned the clean clothes for the resident and picked up the laundry several times a week. Family #10 stated when they visited the day of the fall, the resident focused, and apologized for the smell in the room of the soiled cloths in the hamper. The family revealed the resident explained staff removed the resident's soiled sleep pants and placed the soiled pants into the hamper without bagging or rinsing out the pants. The family revealed the resident had memory issues but would understood the pants would start to stink and probably went to the hamper to rinse the pants out before the family came. Review of the facility's Event Report, dated 04/21/2021 at 6:02 AM, revealed Licensed Practical Nurse (LPN) #3 documented Resident #38 had a fall and the resident across the hallway observed the fall and activated the call bell to alert staff. The resident, who alerted staff, reported Resident #38 pushed the white laundry hamper and slipped between the basket and the bed. The LPN noted the resident did not lock the wheels to the chair. LPN #3 noted the w/c was the only intervention used prior to the fall. Review of Nurse's Progress Note, dated 04/21/2021 at 2:38 AM, revealed the nurse observed the resident attempt to self-transfer to use the bathroom. Further review revealed the nurse encouraged the resident to use the call bell for assistance. However, the nurse noted the resident remained alert with periods of confusion. Record review revealed the facility admitted Resident #18, (Resident #38's) on 12/08/2020, with the diagnoses of Diabetes, Heart Failure, and Hypertension. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident's cognition with the Brief Interview for Mental Status (BIMS) with a score of fourteen (14) and deemed the resident interviewable. Interview with Resident #18, on 06/14/2021 at 2:00 PM, revealed he/she alerted staff that Resident #38 had a fall on 04/21/2021. The resident stated he/she observed Resident #38 try to get into the laundry hamper by the resident's bedside. Resident #18 stated the resident stood up while he/she held onto the basket, the hamper slid, and the resident fell. Observations, on 06/14/2021 at 2:30 PM, revealed a white laundry hamper remained between the bed and the outer wall next to Resident #38's bed. Interview with LPN #3, on 06/12/2021 at 7:07 PM, revealed Resident #38 would constantly stand up out of the chair, attempt to transfer, or attempt to walk without staff. The LPN revealed staff would verbally redirect and educate the resident to call for assistance with the activation of the call light. LPN #3 stated the resident's memory could be good one day and bad the next day so verbal reminders for the resident to call for help did not work, but staff still tried with the resident's poor safety awareness. The LPN stated the facility placed gripper socks, kept the bed low, ensured the call bell was within reach, signs were in the room, and staff checked on residents at night with rounds when they peered into rooms as they passed. Review of the facility's Event Report, dated 04/21/2021 at 6:02 AM, revealed LPN #3's immediate intervention included to remind the resident to call the nursing staff for assistance and secure the call bell to the resident's chair. However, the facility closed the Event Report and updated the care plan on 04/26/2021, five (5) days after the event and added a device called a Reacher (equipment to aide the resident to reach for item) to the resident's fall interventions. According to the facility's policy, the facility's investigation would find the underlying cause and implement additional or different interventions to prevent additional falls related to the investigations findings. However, observations revealed the white laundry hamper remained next to the resident's bed and accessible to the resident. Observation, on 06/14/2021 at 1:20 PM, revealed the Reacher laid on the resident's table and his/her cell phone laid on the opposite side of the table away from the resident. During the interview, the cell phone rang, the resident got up from the wheelchair, attempted to walk, and reach the phone instead of the use of the Reacher, which was in front of the resident. Review of the facility's Event Report, dated 05/03/2021 at 10:15 AM, revealed RN #1 documented staff found Resident #38 on the floor on his/her back in front of his/her sink in the resident's room. This incident was noted as an unwitnessed fall. Further review revealed the resident reportedly had attempted to wash his/her hands at the sink. The interventions prior to the fall included the w/c, call light and nonskid shoes. The nurse's intervention to further reduce the occurrence of a fall included to encourage the resident to use the call bell. However, the facility's policy stated the facility would implement additional or different interventions to prevent additional falls. Review of the facility's second Event Report, dated 05/03/2021 at 4:15 PM, (two falls on the same day) revealed according to RN #1, staff found Resident #38 with a walker on top of him/her with the resident on his/her back on the floor at the entrance to the room. The facility's previous interventions implemented included the call bell, w/c and walker prior to the fall. RN #1 assessed the resident with no injuries, and placed the resident back into his/her wheelchair. Continued review of the facility's Event Reports revealed the facility's immediate intervention on, 05/03/2021 at 10:15 AM, was the resident's sink was not low enough for the resident to access, but sanitizer was available on the wall. Interventions for the fall 05/03/2021 at 4:15 PM included to clip the call bell to the resident's wheelchair, place oxygen to the resident, and reinforced to the resident to use the call light for assistance for the immediate new intervention to prevent further falls. Further review revealed the facility closed the event on 05/06/2021 and updated the intervention on 05/06/2021. The interventions included to encourage the resident to wash his/her hands before and after meals. However, the event report noted the sink was not low enough for the resident with a wheelchair and observations reveal the sanitizer dispenser height did not allow the resident to reach it from the wheelchair. Interview with RN #1, on 06/15/2021 at 2:18 PM, revealed staff continually reminded the reside[TRUNCATED]