**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promptly identify a change in condition and act upon those changes for 1 resident (R4) out of 4 residents reviewed for quality of care, resulting in R4 experiencing unnecessary pain, a delay in evaluation and surgical intervention for a femur fracture. Findings: Resident #4 (R4) Review of an admission Record revealed R4 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: difficulty in walking, muscle wasting and atrophy, need for assistance with personal care, weakness, history of falls prior to admission, and dementia. Review of R4's Brief Interview for Mental Status (BIMS) dated 11/26/24 revealed a score of 11, out of a total possible score of 15, indicating R4 was moderately cognitively impaired. (Last assessment obtained prior to his fall on 1/12/25.). R4's BIMS dated 1/17/25 revealed a score of 15, indicating R4 was cognitively intact. During an interview on 01/23/2025 at 11:15 AM, R4 reported that on 1/12/25 he slipped and fell in the bathroom which resulted in him experiencing pain in his right hip. R4 reported he was assisted back to bed following the fall but experienced significant pain with movement stating he was too painful to move. R4 reported that he couldn't get out of bed and remained in his bed until his transfer to the hospital on 1/14/25. R4 reported that he wanted to go (to the hospital) sooner and was unsure of the cause of the delay in transfer. During an interview on 01/23/2025 at 12:05 PM , Family Member/Emergency Contact (FMEC) C reported that R4 sustained a fall on Sunday 1/12/25 and his wife went to the facility to assess his condition. FMEC C reported that at that time he was in bed and was reporting pain. FMEC C stated that R4 just stayed in bed because he couldn't do anything else and reported as long as he was not moved and remained in bed his pain was manageable. FMEC C reported that it wasn't until Tuesday (1/14/25) that they determined he needed to be evaluated in the emergency department to identify the root cause of his pain/change in condition. FMEC C reported he met R4 at the hospital where he was in shock to find out the extent of R4's injuries and the number of fractures sustained from the fall as well as the need for immediate surgical intervention and was concerned with the delay in his transfer to the hospital with the significant injuries. Review of R4's Incident Report dated 1/12/25 revealed, This was at the beginning of shift he was in bed watching tv. I passed his meds and he took them with no issues. Moments later he put his call light on and before we was able to answer it I heard him at his doorway and when I turned around and noticed him standing with urinal in hand he lost his balance and landed on his right side, no head injuries or any other injuries noted during shift. He was really confused and stated that he was going to bathroom .Notes: 1/13/2025 Resident seems really confused UA (urinalysis) collected to rule out possible UTI (urinary tract infection). 1/13/2025 (no time documented) F/u (follow up) to resident fall on 1/12/25. Therapy attempted to screen this day post fall and resident refused due to new onset of pain .Noted resident is not bearing weight on the right leg. Increased ADL assistance provided. PA (physician assistant) notified and new order obtained for Xray of rt (right) femur/hip for dx (diagnosis): hip pain. Resident has 0/10 pain at rest, non- pharmalogical (sic) pain interventions in place. (Company name omitted) notified of new orders for Xray and will be completed within 24 hours . Confirming the facility was aware that the resident was experiencing pain with movement and had a change of condition of (inability to bear weight on right leg and altered mental status). The resident was not sent to the emergency department despite the change of condition both physically and cognitively and the knowledge that an xray could not be immediately obtained. Review of R4's Post Fall Evaluation dated 1/12/25 revealed, Confused a&o x 1-2 (alert and oriented to person, place, time, situation is x4) .unknown baseline but was told by other staff members that he's normally not that confused (indicating a change in R4's mental status) .he lost his balance and landing sitting up at the right side. He didn't hit his head and denied any pain or discomfort .monitoring throughout shift . Review of R4's Resident At Risk dated 1/13/25 revealed, .Action Taken: Assessed head to toe, rom (range of motion), v/s (vital signs), more confusion ua completed. There was no documentation revealing the outcome of the range of motion assessment despite documentation that R4 was no longer able to bear weight on his right leg and had pain with movement. Review of R4's Order Details dated 1/13/25 at 5:39 PM revealed, X-Ray for right femur/hip DX: Hip Pain. Review of R4's Electronic Medical Record revealed no documentation that the x-ray could not be completed or that the physician was notified of the delay in treatment. Review of R4's Occupational Therapy Missed Visit Details dated 1/13/25 revealed, Pt (patient) unable to be seen today due to having a fall this morning and having right hip pain. Pt unable to stand following fall and 2PA (2 person assist). Nursing addressing . Review of R4's Interdisciplinary Team note dated 1/13/25 revealed, Fall 1/12/25 @ 7:15pm .Resident currently on PT/OT case (physical therapy/occupational therapy) load and when OT approached for treatment that day, he stated he could not participate r/t (related to) too much pain in his right LE (lower extremity/leg), nursing notified of change. Review of R4's Occupational Therapy Treatment Encounter Note dated 1/14/25 revealed, .nursing stated that awaiting xray to come in for stat (immediate) order . Review of R4's Provider Progress Note dated 1/14/25 . Patient had a fall yesterday morning landing on his right hip. He has been unable to weight bear since the fall. Xray was ordered yesterday but has not been done yet. Pain is getting worse as he is requiring being turned q 2 hours for (sic) prevent pressure areas. Discussed with nursing for patient to be sent out for xray and evaluation as if xray is negative, then why can he not weight bear. Nursing will notify Primary care . Extremities .Positive pain noted of the right hip/thigh with any movement . Currently unable to bear weight on right LE . Confirming a delay in obtaining the xray. Review of R4's Pain Summary revealed pain scores of 0/10 indicating no pain. Important to note R4 stated he did not experience pain at rest, only with movement. Review of R4's Electronic Medical Record revealed no comprehensive physical assessments or comprehensive pain assessments following the fall assessment to identify the quality of pain (sharp, dull, achy), aggravating factors (movement), the physical appearance of the injured leg, his cognitive status (had the confusion resolved or continued), or the results of his urinalysis. Review of R4's Tasks for lying to sitting, sitting to standing, and toileting from the time of the fall on 1/12/25-1/14/25 revealed R4 was no longer performing these tasks as he had before and either required a significant change in assistance or did not perform the task. Review of R4's Nurses Note dated 1/14/2025 at 09:02 AM revealed, Resident is c/o pain to left and right hip. Resident has had recent fall and fell on right hip. EMS notified to transfer resident to (name omitted) hospital for evaluation. Son notified of transfer. Review of R4's Nurses Note dated 1/14/2025 at 9:16 AM revealed the ambulance arrived to transport R4 to the emergency department at that time. Approximately 38 hours from the time of the fall. Review of R4's Emergency Department Progress Note dated 1/14/2025 1:26 PM revealed, . presents to the (name omitted) emergency department via EMS (emergency medical services/ambulance) for evaluation following a fall which occurred 2 days prior to arrival . The patient is a resident at [NAME] Manor and reports he had a mechanical fall in the bathroom on the evening of 1/12 .He was helped back to bed and was not ambulatory from that time. He had right hip tenderness which was aggravated by any kind of movement .Imaging studies revealed a right intertrochanteric femur fracture, right inferior pubic ramus fracture, possible sacral insufficiency fracture, and small right retroperitoneal hematoma .Right lower extremity shortened and externally rotated (physical deformity in his right leg) . Review of R4's hospital Tertiary Trauma Survey (trauma provider consultation) dated 1/15/2025 revealed, .Extremities: Neurovascular intact bilaterally, 2+ pulses bilateral radial bilateral DP pulses, external rotation of the right lower extremity that is slightly shortened. Pain over the right hip on palpation. Plan: Right intertrochanteric femur fracture Right inferior pubic ramus fracture Possible acute sacral insufficiency fracture Right retroperitoneal hematoma -Hemoglobin 7.6 from 7.9 from 8.2 Acute blood loss anemia -Likely related to #1 and #2 . Confirming a physical change in R4's right leg from the injury identified by a second provider. During an interview via email on 1/23/2025 at 3:37 PM, Director of Nursing (DON) was asked for documentation of additional monitoring/assessments regarding R4's injury and/or mental status change based on the note monitoring throughout shift on the Post Fall Evaluation dated 1/12/25. DON replied There was a provider who saw him on 1/14 and then he was sent out d/t the pain. There were interventions that she did nonpharmalogically r/t the pain that day- relaxation, positioning and rest- noted on 1/13. Confirming additional monitoring/assessments had not been completed. DON was asked to provide documentation as to why the x-ray was not completed and/or physician notified it could not be completed on 1/13/25. DON stated, The xray was ordered but he went out the hospital and it was done there. There was no documentation provided for the rationale of the delay of the xray or physician notification. During an interview via email on 1/23/2025 at 7:00 PM, DON stated, per our conversation we discussed nurses making a fall progress note every shift for three days, however per our policy there is just to be an assessment done for 72 hrs and doesn't indicate the frequency. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Assessing the characteristics of pain allows you to understand the type of pain, its pattern, and the types of interventions that bring relief .Quality: People use a variety of words to describe the quality of their pain (e.g., pain, ache). Ask patients to describe their discomfort using their own words whenever possible; then use these words consistently to obtain an accurate report. For example, say, Tell me what your discomfort feels like. What do you call it? The patient may describe the pain as aching, crushing, throbbing, sharp, or dull. If the patient reports the pain as dull, ask if it is still dull or if it has changed when you return to assess the patient's pain .Aggravating and precipitating factors: Various factors or conditions bring on or make pain worse. Ask a patient to describe activities that cause or aggravate pain, such as physical movement, positions, drinking coffee or alcohol, urination, swallowing, eating food, or psychological stress. Also ask them to demonstrate actions that cause a painful response, such as coughing or turning a certain way .Behavioral effects: When a patient has pain, assess verbalization, vocal response, facial and body movements, and social interaction. A verbal report of pain is a vital part of assessment. You need to be willing to listen and understand. When a patient is unable to communicate pain, it is especially important for you to be alert for behaviors that indicate it (Box 44.9). [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1141-1143). Elsevier Health Sciences. Kindle Edition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake # MI00149549 Based on observation, interview, and record review, the facility failed to ensure a resident was transferred following care planned interventions and standards of practice for 1 resident (Resident #1) out of 4 residents reviewed for accidents and safety, resulting in R1 sustaining a preventable fall with facial bruising and lacerations requiring hospital treatment. Findings: Resident #1 (R1) Review of an admission Record revealed R1 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: difficulty in walking, muscle wasting and atrophy, and need for assistance with personal care. Review of R1's Brief Interview for Mental Status (BIMS) dated 12/17/24 revealed a score of 12, out of a total possible score of 15, indicating R1 was moderately cognitively impaired. R1 had a fall at the facility on 11/7/24 and 12/30/24 confirming she was a high risk for falls. During an observation on 01/22/2025 at 11:48 AM, R1 was sitting up in a wheelchair in her room and was noted to have yellow/blue/gray bruising around her right eye spreading down to her cheekbone. Review of R1's Physical Therapy Discharge Summary dated 12/20/24 revealed, .Discharge Recommendations: 1 PA (physical assist) for all functional mobility, RW (rolling walker) use while ambulating with staff . Review of R1's Care Plan last revised 12/19/24 revealed, AMBULATION/WALKING: Resident is limited assist x1 with rolling walker . Review of R1's Care Plan last revised 1/14/25 revealed, AMBULATION/WALKING: Resident is limited assist x1 with rolling walker. Walk to and from the bathroom with gait belt and rolling walker . During an interview on 01/23/2025 at 9:47 AM, Family Member/Guardian (FMG) A reported that R1 had fallen on 1/13/25 in the early morning. FMG A reported that she met with R1 the day of the fall and R1 reported to her that her bed was broken and moved when they were attempting to transfer her back to bed. FMG A reported that a facility nurse called her to notify her of R1's fall and reported that R1 was leaning towards the right during a transfer and the Certified Nursing Assistant (CNA) lost control resulting in R1 falling and smashed her face on the frame of the bed. FMG A reported that R1 was to be transferred with her walker and a gait belt to be safe and the CNA did not follow her care planned interventions for transfer. FMG A reported she discussed her concerns with R1's bed not locking to a facility nurse and the nurse reported to her that when R1's style of bed was in the lowest position the wheels would not lock which was also confirmed by maintenance staff. FMG A reported the CNA lacked the education/understanding of the mechanics of R1's bed and should have ensured the bed was in a locked position prior to transferring R1. The facility nurse reported to FMG A that R1's fall was preventable, and the CNA should have ensured the bed was locked, a gait belt in place, and her walker utilized during R1's transfer back to bed. Review of R1's Interdisciplinary Note dated 1/13/25 revealed, 1/13/25 @ 2am Resident was being assisted back from the bathroom by CNA and was transferring back into bed when she began leaning and CNA lost control of the transfer and resident fell, hitting her head on the bed frame. Laceration to right side of face, sent to ER (emergency room) for evaluation and returned w/ (with) tests negative .Staff educated to use gait belt and utilize RW (rolling walker) for transfers and ambulation in room. Review of R1's Hospital Record dated 1/13/25 revealed, .The patient is a [AGE] year-old female presents to the ED with fall and skin tear below her right eye .The wound is too close to the eyelid and the skin is too thin for primary closure with sutures or Dermabond. A nonadherent dressing was placed . Review of R1's Post Fall Evaluation dated 1/13/25 revealed, Fall Description Details .Getting back into bed after using the bathroom .w/c (wheelchair) next to bed. CNA assisted resident to standing position-lost balance (and) resident fell .gait belt not in use. Describe initial intervention to prevent future falls: Gait belt to be used during transfers (and) walker-CNA educated . During an interview on 1/23/25 at 9:26 AM, Director of Nursing (DON) confirmed that CNA B did not use a gait belt while transferring R1 which resulted in a fall with a facial laceration. DON reported that due to R1's improper transfer a meeting was scheduled for CNAs for gait belt/transfer education. During an interview via email on 01/23/2025 at 3:37 PM, DON reported that prior to R1's fall, the use of a gait belt was not on R1's care plan because it is a standard of practice. DON stated that due to the statement that the bed moved during the transfer we wanted to cover all bases and just replace the bed. Review of a Disciplinary Action Record for CNA B dated 1/16/25 revealed, Date of Infarction: 1-13-25 .Care plan not being followed. Resident was transferred without a gait belt .(CNA B) stated she helped the resident (R1) off the toilet (and) didn't use gait belt. She stated the bed moved (and) that's why/how the resident moved (and) hit her head. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Several methods are used to help a patient ambulate. For those who can bear weight easily provide support at the waist with a gait belt so that the patient's center of gravity remains midline. The belt helps you to stabilize patients if they lose their balance. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 796). Elsevier Health Sciences. Kindle Edition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision and assistance for 2 Residents (R2 and R4) to prevent falls, resulting in R2 sustaining multiple falls with injuries and loss of use of her arms and R4 remaining at high risk of falls with injuries. Findings include: Review of R2's face sheet, dated 8/25/23 revealed R2 was an [AGE] year old female admitted to the facility on [DATE] and had diagnoses that included: dementia, wedge compression fracture of sacrum (2/15/23), wedge compression fracture of 5th lumbar vertebra (2/14/23), fracture of the 1st lumbar vertebra (12/28/23, fracture of 4th lumbar vertebra (12/28/23), difficulty walking, muscle wasting, need for assistance with personal care, and fracture of T11-12 vertebra (11/5/21). R2 was not her own responsible party. Review of R2's care plan dated 3/10/23 revealed R2 had a laceration to her right brow r/t (related to) a fall. Review of R2's care plan dated 3/10/23 revealed R2 had a skin tear to her right-hand r/t (related to) a fall. Review of R2's care plan dated 4/4/23 revealed R2 was exhibiting an increase in behaviors of wandering and entering other resident rooms. R2 was swearing/yelling at staff with redirection and delusional thinking that her bedding needs to be changed but when staff look at the bedding the bedding was dry. R2 was prone to urinary tract infections which often increased her behavioral issues. Review of R2's care plan dated 5/15/23 revealed R2 had a red area on her back related to a fall. Review of R2's activity of daily living care plan created on 2/14/23 revealed R2 required assist of 2 people for bed mobility, and a back brace on, as of 5/8/23 R2 was no longer able to walk, required assistance of 2 people for dressing, required staff assistance with toilet use; as of 5/25/23 R2 was not able to use a toilet and required a bed pan with assist of 2 people. On 2/15/23 R2 was independent feeding herself and as of 5/25/23 R2 was totally dependent for feeding. Review of R2's fall care plan initiated on 2/14/23 and last revision on 5/26/23 revealed R2 sustained the following injuries related to falls, compression fractures of L 3 and 5, T11 and T12. R2 was known to self-transfer and did not ask for assistance to get out of her wheelchair or bed. Review of the interventions revealed no information on how the facility planned to supervise R2 when she was awake due to knowing R2 would try to self-transfer and had sustained multiple injuries from self-transferring. Review of R2's, Minimum Date Set (MDS), a nursing assessment, dated 2/20/23, section G revealed R2 required extensive assistance of 1 person for bed mobility, extensive assistance of 2 people for transfers, R2 did not walk in the last 7 days, and required extensive assistance of 1 person to use the toilet. Review of R2's, Minimum Date Set (MDS), a nursing assessment, dated 5/5/23, section G revealed R2 required extensive assistance of 1 person for bed mobility, extensive assistance of 2 people for transfers, did not walk in the last 7 days, and required extensive assistance of 2 people for toilet use. Review of the facility fall timeline for R2, provided by the Director of Nursing (DON) on 8/23/23 at 5:26 PM, revealed R2 had 11 falls from 12/15/23 to 5/21/23. The causes of the falls included unsafe transfers (no indication of being assisted when transfers resulted in falls), weakness, independent toilet use (no indication she was assisted when falls occurred in bathrooms. Interventions did not include any increased supervision except for 2 occasions. During an interview with the Director of Nursing (DON) and Unit Manager F on 8/25/23 at 8:45 AM, R2's fall timeline provided by the DON was reviewed. The DON and UM F confirmed R2 required physical assistance with all of her activities of daily living, R2 was not her own responsible party, R2 did not have any safety awareness and had repeated falls with injuries throughout her stay in the facility. The DON and UM F confirmed they only implemented interventions to attempt to supervise R2 after two of her halls. The DON and UM F denied any process of assessing the safety interventions placed for effectiveness. The DON denied any tracking of unsafe behaviors like self-transferring. The DON denied any assessments being completed for toilet needs, wake or sleep cycles. The DON and UM F confirmed they did not place any interventions that required staff to supervise R2 while awake. Review of R2's incident and accident report dated 5/21/23 at 9:20 AM, revealed Licensed Practical Nurse (LPN) C completed the incident report. The report indicated R2 had an unwitnessed fall in the hall. R2 was found on her stomach with her legs extended, left arm to side of body and right arm under her chest. R2's wheelchair was near her feet, and it was facing the door. R2 reported she hit her head and she had a red area in the center of her forehead. R2 reported she was bending over to pick something up when she fell out of her wheelchair. The following injuries listed, 1) reddened skin right knee, 2. injury right palm unable to determine, 3. Redden skin face. R2's wheelchair brakes were not locked, she was confused, had impaired memory. Review of R2's, Post Fall Evaluation, dated 5/21/23 at 9:20 AM, revealed she had an unwitnessed fall when she tried to pick stuff up and was found lying in the hall on her stomach with her legs extended, left arm to the side of her body and right arm under her chest. Three hours before the fall R2 received her morning care, ate breakfast and was out socializing in the hallway. The intervention to prevent falls listed that R2 was sent to the emergency room for evaluation and treatment. During a telephone interview with LPN C on 8/23/23, LPN C was provided the documentation she placed on R2's incident and accident report on 5/21/23. LPN C recalled R2 had multiple falls while in the facility and they all tried to keep an eye on her. LPN C said she would try to keep R2 with her at the medication cart while she passed medication. LPN C said she could not take R2 into residents' rooms and she had 24 other residents to care for that day. LPN C recalled seeing R2 in the hall moving about in her wheelchair independently. LPN C said she normally works with Certified Nurse Aides (CNA's) D and E on Sundays and could not recall what the CNA's were doing at the time of the fall. LPN C said the facility does not have any program in place to supervise their wandering residents with poor safety awareness. LPN C said we just to our best to monitor their location while we provide care. Review of R2's hospital emergency room report dated 5/21/23 revealed R2 fell in the nursing home and sustained cervical cord compression injury with myelopathy (compression of the nerves in the neck causing loss of movement and pain). R2 was admitted to the hospital for observation and was discharge back to the facility on 5/24/23. Review of R2's emergency room report dated 5/25/23 at 12:29 AM revealed R2 was admitted back to the hospital after being discharge back to the facility on 5/24/23. R2 was coughing and vomiting. R2 was in a neck collar. R2's fall on 5/21/23 resulted in a C3/4-disc displacement that resulted in loss of movement and weakness in all 4 extremities. R2 was admitted and had neurological work ups. It was determined R2 was not a surgical candidate and due her poor prognosis she was place on palliative care. Review of hospital physician note dated 5/31/23 at 7:46 AM revealed, R2 passed away and was pronounced dead per nursing protocol. All records related to R2's falls was requested on 8/23/23 at 12:16 PM. There was no indication which staff were working at the time of R2's falls other than the incident report generated by LPN C. There were no interviews of staff provided. Telephone calls were made to contact CNA D and E to confirm whether they provided care for R2 on 5/21/23 when she fell, and CNA D and E did not return telephone calls. Timeline of falls indicated: Review of R2's incident and accident report dated 5/13/23 at 21:10 (9:10 PM) revealed R2 was in another resident's room attempting to use the toilet and an unknown CNA witnessed R2 slide off a shower chair. R2 sustained a 3 cm x 4 cm red area to her right upper back. R2 had been observed 10 minutes prior to the fall in a hallway. R2 refused assistance to use the toilet at 19:34 (8:34 PM). R2 had been talking about going home since 18:00 (6:00 PM). Review of the Post Fall Evaluation for R2 dated 5/13/23 at 9:10 PM, revealed, R2 self-transferred in another resident's bathroom and fell back on a shower chair. R2 had been wandering and talking about going home since 6:00 PM. R2 was assisted back to her room several times. The intervention placed post fall was to offer R2 assistance with toilet use after supper. (staff did encourage R2 to use the toilet prior to this on 5/13/23 and it was not successful at stopping this fall). Review of R2's incident and accident report dated 5/10/23 at 17:35 (5:45 PM) revealed R2 had an unwitnessed fall in her bathroom and was found by a social services employee. An unknown CNA assisted R2 back into her wheelchair. The report indicated R2 was walking without assistance and has problems with balance. There was no indication of an assessment or injuries. Review of R2's, Post Fall Evaluation dated 5/10/23 at 17:45 (5:45 PM), revealed R2 had an unwitnessed fall in her bathroom. R2 had last been observed at 17:15 (5:15 PM). R2 was her normal self that day. Review of R2's incident and accident report dated 4/30/23 at 23:40 (11:40 PM) revealed, R2 had an observed fall in her room. R2 was found on the floor on her left side in front of her wheelchair that was about 3 feet from R2's bed. R2 said she was trying to straighten up the blankets on her bed. The immediate action taken was to monitor for signs and symptoms of a urinary tract infection (UTI). The report revealed R2 frequently self-transfers, and they put her back brace in R2's chair to encourage her to use it when she gets up. The report indicated R2 was confused, had impaired memory and had a recent change in cognition. There was not assessment or indication of any injury. Review of R2's, Post Fall Evaluation dated 4/30/23 at 23:40 (11:40 PM) revealed R2 had an unobserved fall in her room. R2 was confused and this was her normal mental status. R2 was assisted to the toilet at 11:00 PM and was observed in bed around 11:20 PM. They were going to continue to monitor for signs and symptoms of a UTI, there was no indication of any injury. No new interventions to increase supervision or assistance were located. Review of R2's Post Fall Evaluation, dated 3/31/23 at 14:40 (2:40 PM) revealed, R2 self-transferred and slipped out of her wheelchair. Root cause of the fall with abnormal vital signs, amount of assistance in effect and medical status/physical condition/Diagnoses, no intervention to increase supervision or assistance were located. Review of R2's Post Fall Evaluation, dated 3/10/23 at 1:40 AM revealed, R2 had an unwitnessed fall in her room. R2 was found on the floor and her wheelchair brakes were not locked. R2 was observed up in her room [ROOM NUMBER] minutes prior to the fall rummaging through her drawer. The root cause of the fall was mood or mental status. No intervention to increase supervision or assistance was located. New interventions were dycem (equipment in seat of wheelchair to prevent sliding) and anti-rollbacks (self-applying wheelchair brakes). Review of R2's Post Fall Evaluation, dated 2/9/23 at 4:30 PM revealed, R2 had an unwitnessed fall in her bathroom when she self-transferred. R2 was sent to the emergency room for evaluation. The root cause was environmental factors/items out of reach. No interventions to increase supervision or assistance were located. The only intervention listed was to remove a shelving unit. Review of R2's Post Fall Evaluation dated 12/28/22 r 9:15 PM, revealed, R2 had an unwitnessed fall in her room attempting to self-transfer, R2 was seen 30 minutes prior to the fall, the root cause was medical status/Physical condition/Diagnoses and mood or mental status. The intervention was to move her room closer to the nurse's station. Review of R2's Post Fall Evaluation dated 12/25/22, at 8:36 AM, revealed R2 had an unobserved fall in her room attempting to self-transfer the root cause was medical status/Physical condition/Diagnoses. No intervention to increase supervision or assistance was located. Interventions listed were sent to the emergency room and continue to treat for a urinary tract infection. Review of R2's Post Fall Evaluation dated 12/15/22 at 7:55 PM, revealed R2 had an unwitnessed fall in her room when she was walking independently. R2 was known to have increased confusion for the last 2 days and her oxygen levels were in the 80's. The root cause was medical status/Physical condition/Diagnoses. No intervention to increase supervision or assistance was located. The interventions listed were applied oxygen, sent to emergency room and assist with transfers. Review of R2's Post Fall Evaluation dated 12/15/22 at 3:45 PM, revealed R2 had an unwitnessed fall in the bathroom when she self-transferred to the toilet. No root cause was provided. No intervention to provide increased supervision or assistance was located. The intervention was to change out the toilet riser. Resident (R4) Review of R4's face sheet dated 8/23/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: difficulty in walking, weakness, need for assistance with personal care, fracture of the 4th cervical vertebra, dementia, and history of falling. R4 was not her own responsible party. Review of R4's fall timeline provided by the Director of Nursing (DON) on 8/24/23 at 3:14 PM, revealed R4 had 3 falls in the last 5 months. The fall on 4/12/23 was caused by a medication, the fall on 4/17/23 was caused by R4 not using her walker and loss of balance and the fall on 8/8/23 was caused by a seizure. Review of R4's fall care plan dated revision on 6/7/23 revealed, R4 was a risk for falls related to a C4 fracture, unsteadiness prior to admission, weakness, decreased mobility, poor safety awareness, anemia, and dementia. Interventions did not include how R4 was to be supervised when she was awake. Review of R4's activities of daily living (ADL) care plan dated revision on 6/7/23 revealed R4 required physical assistance of one person for transfers as of 6/7/23. R4 required physical assistance of one person with a rolling walker for walking as of 6/7/23 and revision on 8/24/23. R4 was listed as being independent with toilet use as of 6/7/23 and revision on 6/12/23. R4 was observed in her room in a lazy boy style chair on 8/23/23 at 3:00 PM, R4's eyes were closed and she did not respond to calling her name. There were no staff visible in the hall and no staff in R4's room. R4 was not supervised at this time. Review of R4's Physical Therapy Evaluation dated 4/19/23 revealed, Patient referred to PT (physical therapy) due to exacerbation of decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability to safely ambulate, reduced functional activity tolerance, reduced static and dynamic balance and increased need for assistance form others indicating the need for PT to assess functional abilities, increase independence with gait, facilitate (l) with all functional mobility, promote safety awareness, enhance rehab potential, improve dynamic balance, increase functional activity tolerance, increase LE (lower extremity) ROM (range of motion), and strength and facilitate discharge planning. Review of R4's Post Fall Evaluation, dated 4/12/23 at 12:00 PM revealed, R4 had an unobserved fall in her room, she was found in front of her recliner. The hall huddle note revealed, R4 grabbed her wheelchair instead of her walker when she got up despite the walker being in reach. The root cause of the fall was vital signs abnormal or significant, blood pressure increased and medication. No intervention to increase supervision was noted. The only intervention was to have the one of R4's medications evaluated. Review of R4's Post Fall Evaluation, dated 4/17/23 at 18:30 (6:30 PM) revealed, R4 had an unwitnessed fall in her room. R4 was care planned to be independent with transfers and was self-transferring. The fall huddle revealed, Resident ambulating with out walker in room, causing her to lose her balance. The root cause was mood or mental status. No intervention to increase supervision or assistance with located the intervention was to have physical therapy evaluate and obtain labs/clinical evaluation. Review of R4's Post Fall Evaluation dated 8/8/23 at 7:37 AM revealed, R4 had a fall in her room that was observed by R4's roommate. The root cause was seizure activity. Intervention was to provided physical assist of one person for transfers. No intervention was located to indicate how the facility was going to supervise R4 to ensure she received assistance with transfers. During an interview with Unit Manager, Registered Nurse G on 8/25/23 at 10:25 AM, UM G confirmed R4 had 3 falls in the last 5 months, and R4 cannot remember to use her call light for assistance. R4 was assessed to need assistance with walking and transfers. R4 spends most of her time in her room and has continued to self-transfer and walk without assistance. UM G said they do not track her unsafe behaviors like walking and self-transferring. UM G denied doing any wake/sleep pattering or assessments for toileting needs. UM G denied implementing any increased supervision and assistance for R4. UM G denied any ongoing assessment of new interventions to prevent falls. UM G said the care plan for falls is addressed post fall and quarterly.