**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to comprehensively assess pressure ulcer (PU) development, implement appropriate interventions to prevent PU's and notify the provider of changes for 1 of 3 residents (R1) who entered the facility without pressure ulcers. This resulted in harm when R1 devleoped a stage 3 pressure ulcer. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance. Findings include Definitions: Blister-a bubble of fluid under the skin. A pressure ulcer can develop into blisters and open sores, which can then become infected and grow deeper until they reach muscle, bone or joints. Stage 3 pressure ulcer is characterized by full thickness skin loss and may be deep. They affect the top two layers of skin and fatty tissue. Unstageable pressure ulcers develop from long-lasting pressure on the skin and means the full depth of the ulcer cannot be measured with slough or eschar obstructing the wound bed. R1's face sheet dated 2/20/25 identified R1 had diagnoses of fracture of right femur, there was no indication R1 had a current pressure ulcer. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 did not have cognitive impairment and was dependent on staff for all care areas. R1 did not have a pressure ulcer. R1's care plan dated 12/4/24, identified R1was at risk for skin breakdown. Interventions included follow facility protocol/regimen for treating breaks in skin integrity/pressure ulcers. Document all new abnormal skin findings. If skin is reddened, bruised, or has open areas, report to licensed staff. Skin mattress [pressure reducing mattress] on bed. Monitor skin with cares, showers, and as needed. R1's progress note dated 12/17/24, identified a fluid filled blister that measured 2.0 cm x 0.5 cm on left upper thigh/buttock region. Believed to be from R1's personal wheelchair being too tight, with difficulty applying mechanical lift sling around R1. R1 received a new wheelchair. There was no indication the physician was notified of the impaired skin integrity. R1's occupational therapy notes with dates ranging from 12/4/24-1/23/25, identified on 12/18/24 R1 had a care conference and R1 had been transitioned from her personal 18 inch width wheelchair to a 22 inch width wheelchair. R1's progress note dated 12/21/24, identified R1's blister popped and a new dressing was applied. R1's record on 12/21/24 did not identify what type of dressing was applied nor did it include a comprehensive assessment that identified the wound was a pressure ulcer. Additionally, R1's care plan did not address the wound. R1's progress note dated 12/24/24, identified left upper thigh/buttock fold older blister now open. Wound bed moist, without noted bleeding and edges flaking. Measured 1.0 cm x 1.5 cm. Scant green drainage noted to old dressing, no odor. Continued with blanchable redness to peri-wound that measured 3.0 cm x 1.0 cm. Foam border applied. Clinical nurse manager updated. R1's a nursing order on 12/28/24 to monitor blister to left upper thigh/buttock fold until healed, every day and evening shift for blister. On 12/30/24, a nursing order for left upper leg blister directed: clean with normal saline and pat dry. Place silicone bordered foam dressing daily and discontinue when healed. R1's progress note dated 12/29/24, identified registered nurse (RN)-D assessed old blister site to left upper thigh. Area was open, moist, a mepilex in place with moderate amount of green drainage noted to the old dressing. No odor to wound. Base of wound had some slough noted along with some purple discoloration. No depth to wound. Wound edges irregular. Periwound red and blanchable. Area measured 1.0 cm x 0.5 cm. New mepilex placed. R1's progress note dated 12/31/24, the left thigh blister popped and measured 1.5 cm x 1.5 cm x 0.1 cm depth. R1's progress note dated 1/5/25, identified R1's dressing to left upper thigh was removed and was covered in 50% serosanguinous (thin, often slightly yellow, with a light pink tinge) drainage. R1's progress note dated 1/9/25, indicated the IDT reviewed R1's wound and noted there were not any concerns. No other information was identified. R1's progress note dated 1/13/25, identified R1 was seen by certified nurse practitioner (CNP)-A for a recertification visit. The note did not indicate the CNP was made aware of the wound at the time of the visit. R1's progress note dated 1/14/25, identified there was not a blister anymore, the area is an open wound that measured 3.5 cm x 4.0 cm x 0.5 cm depth. The wound bed is beefy red, with a small area of white and gray/black. No odor. Peri wound intact redness from moisture. R1's progress note dated 1/16/25, identified no blister to the area anymore, the area is an open wound that measured 3.5 cm x 4.0 cm x 0.5 cm. The wound bed is beefy red, with a small area of white and gray/black. Peri wound intact redness from moisture. No odor at this time. R1's progress note dated 1/16/25, indicated the IDT reviewed R1's wound and noted there were not any concerns. No other information was identified. R1's progress note dated 1/22/25 at 7:10 a.m. identified a moderate amount of slough (dead cells, debris, and remnants of tissue that have not undergone proper breakdown and removal from the wound bed that can prevent or slow down healing) present to left upper thigh/buttock crease wound. R1's progress note dated 1/23/25, identified area is no longer a blister. It is an open wound that measured 3.5 cm x 4.0 cm x 0.5 cm. Area is red with slough present. Mild odor noted. No complaints of pain at site. R1's physician discharge note dated 1/23/25, identified R1 had a pressure ulcer of left buttock that was unstageable. Reported to CNP-A today. Nursing had been treating with mepilex, and per report thought initially to be related to mechanical lift as blister had developed. Unstageable pressure ulcer at least a stage 3 as central portion of slough and eschar (dead tissue that develops on severe wounds usually stage 3 or 4 pressure injuries) present. Wound characteristics: full thickness pressure ulcer, unstageable but at least stage 3. Measured at 8.0 cm x 5.0 cm x unable to determine depth. Moderate exudate (drainage). Eschar/slough at center measured 3.0 cm x 1.8 cm. Irregular wound edges. Peri wound is blanchable. Tenderness with palpation at center of wound. Slight odor but no other symptoms or signs of infection. R1 was discharging to assisted living and additional orders for nursing services in relation to wound care was requested. Discussed with clinical manager consideration of a different method of mechanical lift transfer, changing from straps to a sling or other option that would reduce pressure applied during transfers. Wound care orders included: alternating pressure air mattress or pressure reducing mattress if air mattress unavailable, up to 30 degree turn side to side, head of bed when in bed; reposition every two hours or per tissue tolerance, reposition assistance or reminders to be provided on a regular basis based on patient condition, wheelchair or chair cushion per occupational therapy recommendations, elevate heels while in bed. Daily clean with vashe (wound cleanser made of pure hypochlorous acid to fight bacteria and infection) and rough gauze in circular motion, apply thin layer of medihoney to wound base, cover with silicone bordered dressing, closely monitor wounds, looking for signs and symptoms of infection. Contact provider if the patient develops: new wound or change in a wound, drainage from the wound increases, sudden increase in pain or new pain in the wound, area around the wound gets red, swollen, or painful to touch, wound color changes from pink or red to a tan, brown or black color, patient has a fever, or if the wound order gets worse. R1's progress note dated 1/23/25, identified R1 was seen by CNP-A for discharge and acknowledged the aforementioned orders given by the CNP. However, identified direction to reposition every hour. At 2:36 p.m., licensed practical nurse (LPN)-D notified assisted living registered nurse (ALRN) of the pressure ulcer and ALRN came to facility to assess. They are able to complete the wound care and can accept R1 1/24/25. In review of R1's wound tracking/progress notes between 12/21/24 through 1/23/25, it was not evident the facility had appropriately staged the wound after the blister had ruptured and continued to deteriorate, not evident of assessment to determine appropriate care plan interventions to prevent the pressure ulcer from worsening and new ulcer development. Further not evident the physician was notified for appropriate treatment orders until 1/23/25. During a phone interview on 2/18/25 at 10:45 a.m., ALRN stated R1 had went to the nursing home for short term rehabilitation and was returning to assisted living facility when completed. ALRN went to facility on 12/30/24 to assess R1 for return. Facility reported to ALRN that R1 had been pinched by the mechanical lift shift on 12/29/24 and received a blister to the left upper thigh/buttock region. ALRN assessed the area and measured it at 1 centimeter (cm) x 1cm with a pinhole opening in the middle of it. ALRN received weekly updates from facility therapy department but was not informed of the wound worsening. ALRN went to the facility on 1/23/25 to assess the wound. Assessment included the wound measurement at 8cm x 5cm and was unstageable. ALRN stated they did an emergency readmission to their facility due to lack of care at the facility. During a phone interview on 2/19/25 at 9:39 a.m., family member (FM)-A stated the facility had not contacted him about the blister and the worsening of the wound on R1's left upper thigh/buttock area. During a phone interview on 2/19/25 at 3:52 p.m., licensed practical nurse (LPN)-B stated she did not notice the wound was bad and maybe she had been looking at the wrong spot. During a phone interview on 2/19/25 at 9:56 a.m., LPN-A stated R1's wound dressing was mainly completed on day shift. LPN-A recalled an agency staff member questioned the wound at one point during a shift and thought the wound was a stage 1-2 pressure ulcer. Any wound would have to be assessed, measured and the resident should have interventions that included repositioning off the area in question. other interventions could include an air mattress. Nurses usually reported changes in wounds to the nurse managers and then the nurse managers would notify the doctor. LPN-A stated the physician was not notified of the changes, The ball was dropped. During a phone interview on 2/19/25 at 10:48 a.m., LPN-C stated she first noticed the wound bed was beefy red with a small area of white and gray/black with no odor on 1/16/25. The next time she saw the wound there was green drainage on 1/23/25. The process for wound management was the floor staff put in a progress note about a wound and notify and/or update the clinical managers and ADON as needed. The clinical manager would notify the medical provider. The floor staff did not report to the physician. During an interview on 2/19/25 at 1:20 p.m., LPN-D stated she was aware of the blister on R1's left upper thigh. LPN-D stated she did not look at the wound and staff did not inform her that it had worsened. LPN-D was unsure how the communication breakdown occurred. During an interview on 2/19/25 at 8:10 a.m., RN-A stated wounds were measured weekly with the first showers. Residents with pressure ulcers would have more frequent repositioning. When a blister ruptured, the wound would be considered worse. The physician should be contacted when a blister opens. RN-A thought a different treatment should have been put in place for R1; having the wrong type of dressing could make the wound worse but would defer to the physician for appropriate treatments. RN-A explained he failed to notify R1's medical doctor or the nurse manager of the changes to R1's blistered area. RN-A should have notified the provider. RN-A explained the facility recently designated the ADON to lead the wound management program; ADON was the person completely weekly wound rounds. Prior wound changes would be reported to the nurse managers however did think the nurse managers were addressing the wounds because of time constraints. During an interview on 2/19/25 at 11:13 a.m., clinical nurse manager RN-B reviewed R1's record and explained on 12/17/24, the IDT reviewed the presence of the new blister which was determined to be a result of R1's personal wheelchair being tight, and friction/shearing occurred while placing the mechanical lift sling under her. The facility got R1 a better fitting wheelchair and IDT determined a mepilex placed over the blister for treatment. The provider was not notified by RN-B or LPN-D. Then on 12/21/24 the blister opened but RN-B and LPN-D were not notified until 12/24/25. The physician again should have been notified, however, was not. 12/29/25, RN-B completed the dressing change to R1 and noted green drainage, slough tissue, purple discoloration, and the wound had irregular borders. The wound had changed significantly since RN-B had seen it. The physician was not notified, and the orders were not changed. On 1/13/25, when the wound measured 3.5cm x 4.0cm x 0.5cm depth, certified nurse practitioner (CNP)-A was at the facility and had an appointment with R1. CNP-A did not review the wound and did not have knowledge of the wound at this time. R1's care plan had not been revised to reflect the wound; care plans should be updated when a new issue is discovered with new interventions to prevent the wound from worsening such as air mattress, repositioning schedule, and diet changes. RN-B indicated there had been a breakdown in communication, however, the facility has a different process in place and one person, ADON, designated for wound management. ADON completes the weekly wound rounds. New skin issues were now reported on a communication board or in the risk management tab, which was new to the facility and communicate any concerns to herself, ADON, or LPN-D. Between wound rounds nurses were expected to complete the dressing change as ordered, assess the wound, document findings, and immediately notify if any changes. During a phone interview on 2/19/25 at 9:56 a.m., R1's CNP-A stated she came to facility to complete R1's discharge paperwork on 1/23/25. CNP-A was told R1 had a blister on her left upper thigh/buttock region and looked at it. CNP-A stated she was quite surprised by what she saw. The area measured 8cm x 5cm with an undetermined depth that she would stage at least at a stage 3 or more and the wound required some debridement (removal or dead or infected tissue from a wound to promote healing). CNP-A expected to be notified when the wound occurred. CNP-A would have prescribed something more than just a mepilex (foam dressing) to cover the wound. The facility did not explain why she was not informed of the wound. Left untreated the wound could have certainly worsened and could lead to an infection. During an interview on 2/19/25 at 11:41 a.m., ADON stated she had taken over wound care very recently. ADON would expect the physicians to be notified of wounds and of wound changes. On 12/29/24, R1's blistered area would be considered a pressure ulcer, and the physician should have been notified. ADON was unsure why the first notification to the physician occurred on 1/23/25 and not prior. There has been a lot of revamping to the wound program at the facility since she took over the wounds. ADON has been completing 1:1 wound care with floor nurses, education on wound documentation, how to assess a wound, how to properly measure a wound, and auditing the floor staff with wound rounds weekly the last few weeks. Education with floor staff was also completed by an outside agency for wound care on 2/11/25. ADON had implemented a flow sheet that is sent weekly to the nurse managers, DON, MDS coordinator, nurse practitioner, wound supplier, hospice, and dietary manager that included. The flow sheet included resident identifier, who provides wound supplies, where the wound was located, what the wound measurements are, date identified, current treatments, current interventions in place, brief assessment in the comments of what is going on with the wound, along with color coding the measurements green if it is smaller and red if it is changing. The ADON stated, wounds have gotten a lot better and communication and documentation have come together. Floor staff were comprehending and understanding what was needed from them with all the recent and continuing education on wound care. During an interview on 2/19/25 at 1:31 p.m., DON stated R1's wound was initially a minor blister and the medical provider would not need to be notified. As the wound progressed the physician should have been notified. The area should have been care planned and proper interventions put into place. DON stated wound care had been an issue that was recognized as a problem and the facility had been working on correcting it. The following corrective actions were verfied as implemented prior to the survey: On 1/8/25, ADON implemented weekly wound rounds with nursing staff providing 1:1 education and started an auditing system for wound monitoring and documenation. The facility reviewed and revised the wound managment policy and protocals on 1/22/25. The afternoon of 1/22/25, education was provided to staff pertaining to wound monitoring, documentation, physician notification, communication, and comprehensive assessments. R1's record was reviewed by the CNP which resulted in appropriate treatments and interventions were developed and implemented on 1/23/25. R1 was discharged from the facility on 1/24/25. Sampled resident records were reviewed from 1/23/25 through 2/19/25 did not identify deficient practices pertaining to pressure ulcer management. The facility Skin Issues and Wounds policy dated 2/13/23, identified body audits are completed within 24 hours of admission and on shower days. Evaluation of risk factors and Braden scale is done on admission and once per week x 4 weeks and then quarterly or with any new pressure injuries. Tissue tolerance evaluation is done within the first 24 hours of admission and an individualized repositioning program is devised and re-evaluated annually and as needed. When a skin issue is noted licensed staff fill out an incident report or ulcer of unknown origin report, each clinical nurse manager is notified of the skin issue. Wound rounds are done by designated nurse or clinical nurse manager. The are is measured and using nursing judgement, staff initiate appropriate treatment. Medical doctor notified if needed. IDT to review skin issues as needed. Progress notes from IDT are written weekly. The facility Pressure Ulcers/Vascular Ulcers policy dated 1/25, identified pressure ulcers/vascular ulcers will be evaluated weekly by an RN delegated to wound rounds. Weekly documentation by RN will include: measurement of length, width, and depth of wound, odor, drainage including color and amount, skin temperature and color, appearance of wound bed, current treatment including supplements. When an ulcer/pressure area is noted, licensed staff fill out an incident report/risk management and the RN is notified of the skin issue. Staff initiate appropriate treatment and medical providers notified as needed. Medical providers will review all skin conditions on rounds. IDT review new skin conditions at morning meeting. When pressure ulcers have resolved, area will be monitored by RN for two additional weeks. If area remains clear, tissue tolerance will be evaluated to determine repositioning schedule. The facility Care Plan policy dated 12/15/23, identified facility will develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet a residents medical, nursing, mental and psychosocial needs. The care plan will reflect intermediate steps for each outcome objective if identification of those steps will enhance the residents ability to meet objectives. The care is evaluated and revised as the residents status changes. The care plan is oriented toward preventing avoidable declines in functioning and functional levels, attempts to manage risk factors, build on resident strengths, and reflects standards of current professional practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to complete a thorough analysis of resident falls to determine root cause, failed to implement appropriate patient-centered interventions, and evaluate the effectiveness of those interventions to minimize and/or prevent future falls with injury for 2 of 2 residents (R1 and R2) reviewed for falls. The facility's failure resulted in harm to R1 when after 3 prior falls R1 fell a fourth time and sustained a cervical (neck) fracture. Findings include: R1's 12/20/22, admission Minimum Date Set (MDS) assessment identified R1 had severe cognitive impairment, and exhibited behaviors which included physical behavior 1-3 days, verbal behaviors 1-3 days, other behaviors 1-3 days, rejection of care 1-3 days, and wandering 1-3 days. R1 had diagnosis of multiple myeloma, congestive heart failure, hypertension, cerebral vascular accident, urinary tract infection and arthritis. R1's record review of Fall Incident reports from admission on [DATE] through 1/22/23 included 4 falls with the fourth resulting in a significant injury requiring hospitalization. 1.) R1's fall incident report dated 1/2/23, at 3:00 p.m., indicated R1 had fallen out of his wheelchair while in the living room and was found sitting on his buttocks in front of his wheelchair (w/c). Nursing assessment identified no injuries and the Root Cause Analysis completed by the nurse on duty was listed as impulsive. Immediate interventions were listed as assessed for injuries, returned to wheelchair. R1's medical record lacked additional review to determine a cause for the fall and the 1/3/23, at 11:24 a.m., interdisciplinary team (IDT) meeting note listed the Root Cause Analysis: confused and attempted to self-transfer. No new interventions were implemented or the care plan updated following the fall. 2.) R1's fall incident report dated 1/4/23, at 3:45 a.m., indicated R1 had been found sitting on the floor of his room in front of his recliner. The report identified R1's call light was on with time documented as 4:45 a.m. When an unidentified nursing assistant (NA) found R1, he had been incontinent, and the footrest of the recliner chair was extended. The incident report listed the conclusion as R1 had slid off the footrest of the recliner causing the chair to tip forward. There was no injury noted and the immediate intervention was R1 was not to use the electric recliner unless the family was in attendance. The root cause completed by the nurse completing the report of the fall listed R1 had attempted to self-transfer from the recliner with the chair reclined. (R1 had been sleeping in his recliner according to interviews). The 1/4/23, at 10:50 a.m., IDT note listed the cause of the fall as R1 was attempting to self-toilet and the intervention was to assist R1 to bed after checking and to use the captain's chair instead of the recliner in his room. There was no further investigation or discussion documented as to the cause of R1's fall and no interventions were added to R1's plan of care. 3.) R1's fall incident report dated 1/20/23, at 1:45 p.m., identified R1 had been found sitting on the floor of his room with his back against the wall by an unidentified therapy staff who passed by R1's room. The report identified R1 had been more confused and had chronic Clostridium difficile (C-diff) (inflammation of the colon caused by bacteria and often caused by use of antibiotics. It can be transmitted from person to person by spores and can cause severe damage to the colon and even be fatal). The medical record contained no documentation on either the incident report or medical record as to what R1 had been doing prior to fall. R1's medical record lacked documentation of a IDT meeting review of the fall and the root cause listed by the nurse completing the report was confusion with a urinary tract infection (UTI). There were no further investigation documented or interventions added to R1's plan of care. 4.) R1's fall incident report dated 1/22/23, at 8:40 p.m., identified R1 was observed lying on the floor at the foot of his bed with an abrasion to his forehead, a second abrasion above the first one, a bruise to his right knee, a laceration on the top of his left thumb, and a laceration on the bridge of his nose. R1 refused to allow vital signs (VS) and became combative when staff went to assist him. The root cause documented on the incident report by the nurse was self-transfer, and attempt to ambulate without a walker. Notification was listed as completed but no time was documented as when family members were notified of R1's fall and that R1 needed to be sent to Emergency department for evaluation. The incident report identified R1 had been resistive and did not want staff to touch him as they were attempting to stop the bleeding. The report identified R1 was lifted from the floor with a Hoyer sling after checking his extremities (no additional assessment, or precautions for a potential head/neck injury were identified). R1 was seated in a wheelchair when family members and the ambulance arrived, and he was transferred to the ambulance and to the emergency department. R1 was assessed at the emergency department and had diagnosis of left- sided frontal sinus and inferior wall of the right maxillary sinus fracture, small left anterior parafalcine subdural hematoma, (brain bleed), and acute fracture of the ring of his first cervical vertebrae. R1 was admitted to the acute care hospital from the emergency department. R1's medical record lacked documentation of an IDT meeting review of the incident, potential cause of the fall, review of interventions in place to keep R1 safe, and a review of actions taken by facility staff following discovery of R1 with a head injury. R1's current undated care plan identified R1 had been admitted from an acute care hospital following a change in mental status and Clostridium Difficile. R1's goal was for a short term stay with therapy for strengthening and conditioning and return to his previous living situation. R1 had also been diagnosed with Vancomycin-resistant Enterococci (VRE) and placed on contract isolation with cares. R1 was identified as at risk for falls with the intervention to remind to use his call light when he needed assistance and had been moved to a room closer to the nursing station following his 1/22/23 fall with fracture. The care plan failed to include safety measures that had been put into place which included the need for increased supervision, not to be in his room unattended, and use of his wingback chair if he wanted to transfer from his wheelchair. The care plan failed to identify R1's desire to return to an independent status with ambulation and lack of understanding of the need for assistance. R1 returned to the facility on 1/31/23 with signed physician orders for a cervical collar to be worn at all times and a shower collar to be used when showering. Must have 2 staff persons present when going into his room every shift. R1's nursing assistant (NA) care sheet identified 2 staff were to be present when going into his room, he required the assist of 2 staff with a four wheeled walker and gait belt for all transfers and ambulation, he was to be repositioned every (Q) 3 hours. R1 had a cervical collar that was to be worn at all times, unless showering and then a shower collar was to be used. The NA care sheet identified R1 was to use the wing back chair in his room when he wanted to be out of his wheelchair and not the electric recliner. R1's 1/23/23 at 12:25 a.m., emergency room (ED) report identified he had orders for aspirin and Plavix (a medication that decreases blood clots), had a history of stroke, recent urinary tract infection treated with Macrobid, C-diff treated with oral Vancomycin and he had been transferred to the ED after a fall with altered mental status. The record identified it was not known if R1 had lost consciousness, but he had hit his head. R1 had discoloration beneath his left eye, and multiple abrasions of his face. Evaluation in the ED identified R1 had a left- sided frontal sinus and inferior wall of the right maxillary sinus fracture, small left anterior parafalcine subdural hematoma, (brain bleed), and acute fracture of the ring of his first cervical vertebrae. R1 was admitted to acute care following the ED evaluation. Interview on 2/7/23 at 9:00 a.m., with NA- A reported R1 had been hospitalized following a fall on 1/22/23 at 8:40 p.m. and returned to the facility on 1/31/23. She reported R1 required 2 staff persons to assist with personal cares and activities of daily living (ADL's). NA-A reported R1 required supervision due to attempts to self-transfer and was not supposed to be in his room without staff or family in attendance. NA-A reported R1 was positioned in the living room area to allow for close supervision by staff and was encouraged to attend activities to keep him busy. NA-A reported R1 had behaviors of hitting out, yelling and became agitated when staff attempted to redirect him when he attempted to self-transfer. She reported R1 did not understand he needed to have assistance for transfers and prior to his last fall R1 had been able to walk with therapy and the assistance of one staff person in his room. Interview on 2/7/23 at 11:36 a.m. with family members (FM)-A and B, reported R1 had fallen 4 times since his admission to the facility. FM-A reported the first fall on 1/2/23 had occurred due to R1 being left unattended in the living room area, and he had needed to go to the bathroom. The second fall took place on 1/4/23 and was due to R1 being left in his recliner with the footrest elevated, and he had attempted to climb out of the chair without the footrest lowered and had fallen. The third fall occurred on 1/20/23 when R1 was discovered seated on the floor of his room by therapy and he had been attempting to get something from his nightstand and could not reach it. The fourth fall was 1/22/23 and they were told R1 had fallen out of bed and had injuries to his face, arm, and hand. FM-A reported she was told R1 was being transferred to the ED for evaluation, and upon her arrival he was seated in his wheelchair in the living room area. Both FM-A and B reported they were concerned R1 had been transferred from the floor with a sling lift after his fall and no immobilization of his head and neck had been implemented. In addition, when the ambulance arrived, they also failed to provide head and neck immobilization for R1, and he had been transferred from his wheelchair to the ambulance stretcher. FM-A and B reported when R1 had arrived at the ED the doctor had also expressed concern that R1 had been transferred with no head and neck immobilization when he had an obvious head injury. Interview on 2/7/23 at 4:25 p.m., with the medical director (MD) reported his expectation for a resident that experienced a fall with a suspected head injury the provider would be notified, and the resident would not be moved until the ambulance arrived and immobilized the resident to prevent the risk of further injury prior to transfer to the ED. He also reported his expectation for the facility to investigate the potential root cause analysis of a fall and develop appropriate patient specific interventions which were included in the care plan. The MD reported he was not aware the facility was not following through with appropriate investigation into the potential cause of a fall and adding resident specific interventions to address the areas identified. R2's 11/11/22, admission MDS identified moderate cognitive impairment, extensive physical assistance of 1 staff for transfers, locomotion on/off the unit, dressing and toileting. R2 required limited physical assistance of one staff for bed mobility, ambulation in his room, and personal hygiene. R2 was occasionally incontinent of bladder and frequently incontinent of bowel. R2 had a history of falls prior to admission and diagnosis of type 1 diabetes, hemiplegia, and hemiparesis (paralysis of left side) following a cerebral infarction (stroke), hypertension, epilepsy, major depressive disorder, and history of a Myocardial infarction (heart attack). R2's record review of fall incident reports dated 1/1/23 through 2/6/23 identified R2 had experienced 6 falls during that period with minor injuries. 1.) R2's fall incident report dated 1/1/23 at 7:45 p.m., identified R2 had attempted to self-transfer and was found on his back on the floor. The root cause listed on the incident report by the nurse was impulsive and self-transferred. R2's medical record lacked documentation of IDT review and analysis of the fall and the only intervention was signage posted in his room to use his call light as a reminder. 2.) R2's fall incident report dated 1/4/23 at 4:30 a.m., identified R2 had reported he had fallen, but it was not able to be determined if the fall occurred in his bedroom or the bathroom. The report noted R2 had been incontinent of stool and had scraped his knee which R2 reported had occurred when he had climbed into his recliner. The medical record lacked documentation of a root cause analysis or an IDT meeting review of his fall. There were no interventions added to the care plan. 3.) R2's fall incident report dated 1/9/23 at 8:30 a.m., identified R2 had fallen in the bathroom, the fall was unwitnessed and he was found sitting on the bathroom floor. The report identified R2 reported he had walked into the bathroom with his walker and fell. R2 had no injuries identified and the root cause analysis reported by the nurse completing the report was listed as self-transfer and weakness. No new interventions were added and the medical record lacked documentation of IDT review and analysis of R2's fall. 4.) R2's fall incident report dated 1/13/23 at 9:00 a.m., identified R2 was found leaning over Bed A and the call light was on, (R2 used Bed B). The report identified R2 had reported he was reaching for the call light and fell out of his wheelchair. The immediate intervention was listed as Dycem (non-slip surface) placed in his wheelchair. The IDT meeting note in the medical record dated 1/16/23 listed the intervention of Dycem in wheelchair, to offer to move to a room closer to the nursing station, but R2 declined, and no root was cause identified. 5.) R2's fall incident report dated 2/6/23 at 9:50 a.m., identified R2 had been found lying on the floor by his bed, and reported he had self-transferred from his recliner, attempted to walk behind his wheelchair to the bathroom, had fallen and then crawled to his room to turn on the call light. R2 reported he had turned on his call light prior to his fall but no light was on according to the report. The medical record lacked documentation of a root cause analysis or an IDT meeting review of his fall. 6.) R2's fall incident report dated 2/6/23 at 5:30 p.m., identified R2 was found lying on floor on his belly. The root cause listed by the nurse completing the report noted the resident wants to go home and thinks he can self-transfer. The medical record identified the fall was discussed on 2/7/23 at the IDT meeting with the note that R2 had forgotten he had 2 falls on 2/6/23, and no injury was noted. The intervention was for the nurse practitioner to be updated on the two recent falls and the plan to perform a medication reconciliation on her visit on 2/8/23. There was no interventions added to provide for R2's safety in the care plan. Observation on 2/7/23 at 12:30 p.m., following his return from an appointment outside the facility. R2 was in a room located at the end of the hall next to a lounge area and farthest from the nursing station. R2 was seated in his wheelchair, in a darkened room watching TV. His lower body was positioned toward the front of his chair and upper body leaned back against the back of his chair. An over bed table was positioned in front of R2 with personal items within reach. R2 was noted to have his call light within reach and a sign posted in his room which was a reminder to use his call light. Interview on 2/7/23 at 1:58 p.m., with the director of nursing (DON) who reviewed the fall incident reports for both R1 and R2, identified the charge nurse on duty at the time of the fall was expected to complete the incident report and include the root cause analysis, and any immediate interventions were put into place. The DON reported the incident reports for R1 and R2 had missing details regarding the falls and actions had been implemented. During the interview the DON was uncertain of events or actions that had taken place and referred to the electronic documentation, but reported she was not able to explain or provide information other than what had been documented on the incident report. The DON reported R1 should not have been transferred following his fall on 1/22/23, until the ambulance arrived and provided immobilization of his head and neck due to the potential of head and neck injury. She reported would need to provide additional education and review of the facility policy and procedure. The DON reported when staff went to check on R2 he became frustrated and didn't want staff to assist him because he believed he could do his own cares, including self -transfer and ambulation and did not need assistance. She reported R2 believed he was able to return home and resume his previous lifestyle which was not possible. The DON reported there needed to be ongoing discussion with the doctor and family members to determine a plan to provide for R2's safety and the development of reasonable goals for short and long term needs. Following review of the incidents for R2 the DON identified the incident reports did not contain complete information, appropriate root cause analysis of the potential cause of R2's falls, or individualized interventions implemented to keep R2 safe. The DON reported review and analysis of falls needed to be discussed at IDT meetings with the developed interventions included in the care plan. Interview on 2/8/23 at 6:30 p.m., with the DON reported in other facilities where she had worked previously, the process followed was for the initial incident report completed by the nurse on duty at the time of the fall, a follow up meeting/discussion was held with the IDT or management team on the following business day, and a Fall Committee was in place to review and determine any additional education or measures indicated. The DON reported this process was not currently in place in the facility and needed to be developed to better determine the root cause of a fall and any appropriate interventions which could be added to the individualized care plan. Review of the 2/1/23, Resident Fall policy and procedure identified a nurse was to assess a resident before they were gotten up off the floor and if there was evidence of a significant injury and/or significant facial or head injury the provider was to be notified for guidance on steps to implement, and if the resident was to be moved from the floor or wait for the ambulance to arrive. Documentation of the fall was to include time the fall occurred, location of the fall, what the resident was doing prior to the fall, any environmental information that might have affected the fall, completion of pertinent information on the Fall Scene Investigation form with root cause of fall and immediate intervention. Document any injury and if the resident was receiving a blood thinning medication.