**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to comprehensively assess each fall, identify causal factors to determine reason for falls, identify potential effective interventions to decrease the risk for falls, and failed to comprehensively evaluate and implement fall interventions for 3 of 3 residents (R1, R2, and R3) reviewed for resident safety. The facility's failures resulted in an immediate jeopardy (IJ) for R1 who sustained fractures after his first and second fall.The IJ began on 5/23/25, when the facility failed to complete a comprehensive fall assessment along with root cause analysis and implement appropriate interventions after R1 attempted to self-transfer, resulting in an unwitnessed fall requiring hospitalization with a right frontal sinus fracture. Upon return from the hospital, on 6/10/25, R1 again attempted to self-transfer resulting in an unwitnessed fall requiring hospitalization where R1 sustained two left pubic bone fractures with bleeding and hematoma formation surrounding the fractures. The vice president of success (VPS)-A, vice president of human resources (VPHR)-A and director of nursing (DON) were notified of the IJ on 7/24/25 at 5:51 p.m. The IJ was removed on 7/28/25 at 2:02 p.m. after it could be verified that the facility had implemented an acceptable removal plan, however, non-compliance remained at D isolated severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings include:R1's admission Evaluation dated 5/19/25 at 6:00 p.m., identified that R1 verbalized understanding of call light/bell and was unable to use devices so a soft touch call light was provided. R1's activity of daily living (ADL) care plan identified R1 required extensive assist of one staff with bed mobility and personal hygiene. R1 required extensive assist of two staff with transfers and toileting. R1 was alert to person and was aphasic (difficulty finding words, nonsensical speech). R1 had bladder incontinence one to two times daily during the day and evening. R1 exhibited, dizziness or lightheadedness, vertigo (feeling of spinning or whirling), impulsivity or poor safety awareness, and moved too quickly. R1 exhibited gait and balance problems.R1's care plan identified a focus date 5/19/25, at risk for falls related to Arteriovenous Malformation (AVM)-(a condition where an abnormal tangle of blood vessels connecting arteries and veins, bypassing the normal capillary network in the brain that can cause bleeding and a lack of oxygen to reach the tissues which can put the person at risk for hemorrhage or ruptures that can lead to a stroke), hydrocephalus-(-condition where cerebrospinal fluid (CSF) builds up in the brain's ventricles, leading to increased pressure on brain tissue that can cause headaches, nausea, vomiting, vision problems, and difficulty with walking and balance, and cognitive deficit following a brain bleed), and medications. Interventions dated 5/19/25, included to encourage to transfer and change positions slowly, reinforce wheelchair safety as needed such as locking brakes, report development of pain, bruises, change in mental status, ADL function, appetite, or neurological status post fall, reinforce need to call for assist and scoop mattress. On 5/22/25, interventions included anti-rollbacks to wheelchair, fall mat beside bed-left side toward door, medications as ordered, medication regiment review, soft touch call light and therapy to eval and treat as ordered.R1's medical doctor (MD) progress admission note dated 5/22/25, identified reason for admission was hydrocephalus and metabolic encephalopathy- (a condition that causes brain dysfunction that can cause confusion, memory problems, and changes in mood or behavior). COGNITION: R1 exhibited a severe to profound cognitive-communication impairment characterized by deficits in orientation, attention (focused, sustained, alternating, divided), memory (immediate, delayed), visual perceptual skills (L inattention), problem solving/reasoning (insight/awareness, safety), and significantly delayed processing speed. R1 was impulsive and motor restless, requiring consistent redirection. No vital signs were taken for this visit and R1 was drowsy, but arousable and largely unintelligible. Further identified R1 had a fall within the last year.R1's admission Minimum Data Set (MDS) dated [DATE], noted R1 had moderately impaired cognition. Further identified R1 needed substantial to maximal assist of one staff with bed mobility, transfers and toileting. R1 had one fall with no injury and was occasionally incontinent of bladder and bowel. R1's Unwitnessed Fall document dated 5/23/25 at 5:50 p.m., identified R1 was found sitting on the floor in an upright position with legs extended next to his wheelchair in his room. R1 was wearing shoes and had his tray table in front of him. Family member (FM)-A reported she left R1 for a moment to get water and when she came back R1 was sitting on the floor and staff were in the room. Immediate Action taken: R1 was assessed, initial blood pressure (B/P) was elevated, but after assisting into bed B/P was checked and was 128/78. Heart Rate (H/R) was 113, Respiratory Rate (RR) was 20. Temp was 98.1, oxygen (O2) saturations 96% on 3 liters per nasal canula (NC). R1 was able to move all extremities and denied hitting his head. Corresponding Post Fall Assessment document dated 5/23/25 at 5:50 p.m. revealed incomplete sections; it did not identify R1's fall history, physical, mental/behavioral status, or medications status of R1 prior to fall. New immediate intervention was R1 was reminded to call for assist when needing help and further identified R1 was last seen 2 minutes ago by FM-A., however, did not identify when R1 was last assisted by staff and/or what services were last provided prior to the fall. R1's progress note dated 5/23/25 at 5:50 p.m., identified R1 had an unwitnessed fall, was on heparin injections every eight hours, had a history of metabolic encephalopathy, was able to move all extremities, denied hitting his head, neuro at baseline, and no bruises noted on head. Skin tear to left elbow measured 3 centimeters (cm) x 2 cm x 0.5 cm. R1 was sent to the hospital for evaluation due to being on a blood thinner.In review of R1's fall record for 5/23/25, there was no indication R1's care plan was updated to include the new interventions nor was the care plan updated to include the reminders to use the call light for assistance. Further not evident a comprehensive analysis was completed that identified modifiable and non-modifiable risk factors that may have contributed to the fall so that appropriate individualized interventions could be developed and implemented to prevent and/or mitigate the risk for recurrent falls and/or falls with major injury. Additionally, according to R1's record there was no indication of interdisciplinary team (IDT) involvement. R1's Care Area Assessment (CAA) dated 5/28/25, identified section 11. Falls, actual problem. One fall noted since admission. Out to emergency room (ER) for assessment and admitted to the hospital. Care plan considerations identified an alteration in mobility with risk of falls related to recent cardio vascular accident (CVA) with aphasia- (can include difficulty finding words, speaking in short phrases, struggling to understand others, and problems with reading and writing, cognitive/communication deficit, safety awareness issues), metabolic encephalopathy, hydrocephalus, left side neglect, insomnia, ongoing need for percutaneous endoscopic gastrostomy (PEG) tube with tube feedings per order, medications with current need for assistance to complete ADL's, toileting, and mobility tasks. R1 continued to work with physical therapy/occupational therapy (PT/OT) for rehab. Discharge plans at this time are uncertain, dependent on his final abilities/status. Continued to need assist from staff to complete his transfers. No adverse issues noted with medications. Interventions noted to be ongoing per care plan.R1's Hospital Discharge summary dated [DATE], identified R1 was hospitalized from [DATE] to 6/9/25. Details of hospital stay identified reason for admission was initial head injury, history of falling and pneumonia. Hospital course identified R1unfortunately sustained a fall at his skilled nursing facility (SNF) on 5/23/25, related to his impulsiveness and weakness. CT scan of R1's head showed fracture lines extending through the frontal sinus with communication intracranially and new extra axial fluid collection adjacent to the fracture lines [indicates a serious injury involving the skull, where a break in the frontal bone has opened a path into the brain, leading to an accumulation of fluid outside the brain and within the skull].Decision was made to focus on keeping R1 comfortable with comfort focused care and will be discharged back to the skilled nursing facility.R1's MD Progress note, dated 6/10/25, identified a readmission visit, brief summary of hospitalization form 5/23/25 to 6/9/25, identified R1 suffered an unwitnessed fall at SNF on 5/23, subsequently readmitted to the hospital and the ED workup demonstrated frontal sinus fracture. Narrative history identified that FM-A cited R1's urinary and stool incontinence as well as impulsivity and safety concerns as barriers to returning home. Regarding stool incontinence, R1 has significant diarrhea and cannot seem to get up and go to the bathroom on time. FM-A described R1's impulsivity and that he does not realize that he isn't safe to walk and often tries to get up and go on his own. FM-A has noticed more cognitive decline in the last few weeks.Although R1's physician note dated 6/10/25 identified safety concerns with impulsivity, indicated R1 had an unawareness of his limitations in ability to walk, tried to self-transfer, and had urinary and bowel incontinence with significant diarrhea, there was no indication of comprehensive bowel and bladder assessment that would determine an individualized toileting program nor an assessment that determined R1's required level of supervision to mitigate risk of falls related to impulsivity, self-transfers, and incontinence. R1's Unwitnessed Fall document dated 6/10/25 at 4:00 p.m., identified R1 was found lying on his right side with his head facing the bed. R1 said yes when asked if he hit his head, stated he was trying to get up. R1 complained of right hip pain 9/10, PRN (ad needed) Tylenol 500 mg was administered, pain was still 9 out of 10 thirty (30) minutes later and was not able to bear weight on his right side. R1 was sent to the hospital for further evaluation. Further identified R1 was confused, room had poor lighting, was transferring self. Lacked mental status assessment. Corresponding Post Fall assessment dated [DATE] at 4:00 p.m., did not list date and time of most recent falls, indicated R1 was last seen at 5:00 p.m., (even though documentation identified the fall occurred at 4:00 p.m.) by registered nurse (RN)-B. Further identified R1 was wearing socks/stockings and was getting up from a chair at the time of the fall. Care plan portion identified the new immediate intervention was shoes put on and call light within reach, however care plan was not updated.R1's progress note dated 6/11/25 documented approximately 8.0 hours after the fall at 12:04 a.m., identified R1 had a fall at around 4:00 p.m., [6/10/25] complained of 9/10 pain, was given Tylenol 500 milligrams (mg), was still in pain and unable to bear weight on right side and was sent to the hospital. In review of R1's 6/10/25 fall record did not in include a comprehensive analysis; the record did not include physical status, medication(s) administered, when R1 was last assisted, and which services were provided prior to the fall.R1's emergency room (ER) progress note dated 6/10/25, identified the chief complaint was at approximately 2:00 p.m. (time conflicted with the facility documentation that identified 4:00 p.m.), R1 suffered an unwitnessed ground level fall at SNF. He was amnestic to the events of the fall, was found by nursing staff and emergency medical services (EMS) was called. History identified R1 had a fall at SNF on 5/23/25, his workup demonstrated a frontal sinus fracture with right frontal complex fluid collection. On arrival to the emergency department (ED), computed tomography (CT) scans demonstrated R1 had an acute nondisplaced left superior and inferior pubic rami fractures-(cracks in the bones of the pelvic ring on the left side), acute intramuscular left obturator hematomas- (blood collected in the muscles of the left obturator region, indicating bleeding), acute bleeding from peri vesicular space adjacent to pubic ramus-(blood loss into the space around the bladder, located next to the broken pubic bone). R1 was admitted to medicine floor.R1's IDT Clinical review progress note dated 6/11/25 at 10:05 a.m., identified R1 had a fall on 6/10/25, root cause analysis was impulsivity, and intervention was to do frequent purposeful rounding.R1's care plan had an added intervention dated 6/11/25, to do frequent purposeful rounding, however, did not specify the intervals of frequent rounding R1 required nor address what type of footwear needed. During a phone interview on 7/23/25 at 1:09 p.m., FM-A stated R1 could not safely get up by himself that's why he was at the facility to work with therapy. Since the day R1 was admitted FM-A told the facility R1 needed constant supervision because he was so impulsive, but did not feel like anyone listened to her. FM-A was at the facility in his room every day from about 9:00 a.m. to around 5:00 p.m. and then another family member would come for a couple hours in the morning and a couple hours in the evening after she left until R1 was asleep. Family thought this was necessary because they had noticed no staff would ever come into R1's room to check on R1 or offer toileting; family were the ones that had to put on the call light when R1 needed help. R1 was very impulsive, a typical day, no matter where he was or what he was doing, he would try to get up. FM-A told the facility R1 needed more than a low bed and a floor mat to keep him from falling, she told staff he needed supervision to which staff responded- they would do the best they can do. On 5/23/25, R1 was in his wheelchair, his tray table was in front of him with food on it. FM-A had told him she would go refresh his ice water, don't move, and would be right back. FM-A explained on her way back she heard a ruckus and heard a nursing assistant yelling someone help me we have a fall. FM-A indicated R1 sustained a skin tear which was bleeding and he was sent to the hospital where he was found to have some kind of a sinus fracture. FM-A stated I knew he was going to fall he did not have enough supervision or safety interventions in place. R1 came back from the hospital on 6/9/25, a day later he fell again fractured his pelvis and broke his hip. R1 was sitting in his recliner on 6/10/25, between 1:00 p.m. and 1:30 p.m., he was covered in a blanket, and was dozing off so she thought it would be a good time to go to the store. FM-A told staff she would be back in an hour; she wasn't gone 30 minutes when the facility called to inform her R1 had fallen and was now complaining of a sore left hip. FM-A asked the staff what happened, and they told her they didn't know. The ER doctors said he broke his left hip and pelvis, and they really couldn't do anything for his type of injury and the only choice was comfort care. FM-A stated R1 needed more supervision but felt this was not provided by the facility and now he [R1] was gone. During an interview on 7/28/25 at 11:53 a.m., registered nurse (RN)-A stated she was the one who admitted R1. He was very impulsive and slightly aphasic; he would climb out of his wheelchair without saying what he was doing. R1's family was here all the time they were always afraid he was going to fall because he was so impulsive. RN-A was unaware R1 had a fracture after his first fall. RN-A was asked at what point they would do increased supervision for a fall prevention intervention. RN-A indicated R1 probably required one-to-one supervision but did not think the facility provided that level of care. During an interview on 7/29/25 at 2:33 p.m., RN-B indicated when R1 was first admitted the family was toileting him not the facility staff. The family was worried about him falling because R1 was so impulsive, so they were here a lot. RN-B was working when R1 fell on 6/10/25. RN-B stated she could not remember how he was found on the floor and that the documentation in his medical records did not identify that. When RN-B walked into R1's room to assess him, he was on the floor lying on his right side in front of his recliner without his shoes on and only regular socks. RN-B did not investigate the fall to determine if R1's basic needs were met such as the last time he was assisted with toileting or if he was incontinent at the time of the fall. R1 was having severe pain, and they decided to send him to the hospital for further evaluation. RN-B stated she documented the root cause of the fall as not wearing shoes but stated she did not update the care plan to reflect that. During an interview on 7/23/25 at 2:56 p.m., nurse manager (NM)-A described R1 as complex, cognition varied, was incontinent of bladder, required extensive assist with ADLs and was very impulsive with his movements. NM-A further indicated R1's family spent a great deal of time with R1 because they were afraid R1 was going to fall due to his impulsivity. NM-A explained when a resident falls, the floor nurse should first assess the resident for injury, notify physician and family, document findings in risk management, in progress note, and on the post fall assessment. The nurse was supposed to put an immediate fall prevention intervention in place and that would be documented in the post fall assessment. The interdisciplinary team (IDT) would then meet Monday through Friday at 9:00 a.m., where falls would be reviewed to ensure each resident had a root causal analysis with an appropriate intervention added to the care plan. NM-A was unsure who was responsible to ensure each resident's care plan was updated. NM-A stated R1 had a fall on 5/23/25, the fall was not comprehensively assessed to determine a root cause and there was no new intervention developed/implemented to his care plan for future fall prevention. NM-A stated R1 was sent to the hospital on 5/23/25 and did not return to the facility until 6/9/25, he was hospitalized for pneumonia. R1then fell on 6/10/25; that fall was not comprehensively analyzed either. NM-A stated IDT met on 6/11/25, to discuss root cause and they came up with R1 fell due to impulsivity and put an intervention in place to do purposeful frequent rounding. However, identified that intervention would not be measurable and was not able to articulate how staff would know when to round on R1 or how to document. NM-A stated at the very least the care plan should have been developed/implemented to ensure appropriate footwear was on since R1 had regular socks on. R1 was a resident who needed frequent supervision due to his impulsivity. During an interview on 7/24/25 at 3:20 p.m., director of nursing (DON) explained the process for a resident with an unwitnessed fall included the nurse completed a full body assessment for injury and start neuro checks. After it was determined the resident was safe staff were to notify the physician and family. The nurse should then document the fall in risk management which included completing the incident report and post fall assessment along with making a progress note. The floor nurse should then put an immediate intervention in place. DON indicated IDT met Monday through Friday and discussed each fall in real time except for falls that happened on the weekends to ensure there was a root cause and prevention intervention documented in the resident care plan. If IDT met about a residents fall there would be an IDT note in the resident's progress notes. R1 had a complex medical history and came to facility with neurological problems and had impulsivity and R1's family stayed with R1 most of the day because they were scared, he would fall. DON indicated they tried to put several interventions in place to prevent his falls but did not consider increased supervision as one of the interventions. R1 had an unwitnessed fall four days after his admission on [DATE]. The facility did not ensure R1's basic needs were met indicating the fall assessment was not comprehensive. DON was unable to articulate why IDT never met to try and find a root cause and appropriate fall prevention intervention to prevent future falls and indicated it may have been because R1 was hospitalized from [DATE] to 6/9/25. DON was unaware that R1 sustained a right frontal sinus fracture from R1's fall and stated NM-A would have been responsible to thoroughly read through the hospital record upon readmission to determine that. DON stated R1 fell on 6/10/25, and IDT met the following day and determined the root cause to be impulsivity with a prevention intervention to do frequent purposeful rounding that was updated on R1's care plan. DON stated the intervention would not be measurable and was not able to articulate how staff would know when to round on R1 or how to document said intervention. R1's care plan should have been developed/implemented to ensure R1 was wearing appropriate footwear and should have had increased supervision due to his impulsivity.The immediate jeopardy for R1 was removed on 7/28/25, at 2:02 p.m., when it was verified, the facility developed and implemented the following:-Reviewed falls policy and remained current -Completed comprehensive fall risk assessments on all residents, reviewed/revised/implemented care plan with appropriate interventions.-Identified like residents who were at high risk for falls with falls since 5/23/25 and reviewed/revised care plans with appropriate fall interventions in place.-All staff were provided education on the fall program policy, comprehensive fall assessments, root cause analysis and ensuring fall prevention interventions are care planned and implemented as it pertained to their scope of practice. R2R2's admission Evaluation dated 5/2/25, identified R2 required limited assist of one staff for transfers, bed mobility, toileting and personal hygiene. Level of consciousness not assessed. R2 was continent of bladder and on diuretics. Balance identified R2 was impulsive and had poor safety awareness. Fall history of one to two falls within the last 30 days. Agitated behavior that occurred less than daily in the last seven days. R2 was at risk for falls. Care plan portion identified goals to minimize risk for falls and injury related to falls. Interventions included bed in low position and encourage to transfer and change positions slowly.R2's care plan identified a focus dated 5/2/25, at risk for falls related to right sided hemiplegia (paralysis on one side of the body) and right sided hemiparesis (weakness on one side of the body) secondary to a cerebral vascular infarction (stroke). Interventions dated 5/2/25, was to encourage to transfer and change positions slowly. On 5/9/25, included to have commonly used articles within easy reach, therapy eval and treat as ordered and use wheelchair for independent locomotion and walker with gait belt and assist of one for ambulation.R2's admission MDS dated [DATE], identified R2 had severely impaired cognition, diagnoses of ischemic stroke with hemiplegia affecting right dominant side, dysarthria-(a motor speech disorder that makes it difficult to speak clearly due to impaired muscle control in the face, mouth, or respiratory system that can impact articulation, voice quality, and speech rhythm), diabetic neuropathy-(nerve damage caused by diabetes, often leading to numbness, tingling, and pain in the extremities, particularly the hands and feet), osteoarthritis of right knee, pain in right shoulder and right foot, and urinary retention. R2 required partial to moderate assist with hygiene and transfers and required substantial to maximal assist with dressing and donning and doffing footwear. In addition, R2 had a fall within the last 30 days prior to admission.R2's CAA dated 5/9/25, identified Falls as an actual problem. No falls noted since admission. Care plan considerations identified R2 had alteration in mobility with risk for falls following hospital stay for pneumonia, underlying hemiplegia, diabetes mellitus (DM), acute kidney injury (AKI), chronic kidney disease (CKD), right foot pain, and medications that could affect his overall mobility status. R2 continues to work with PT/OT for rehab. Currently needs assist with completing ADL's, toileting, and mobility tasks. Lived with family with plan to return back to that living situation, pain management continues to be ongoing, noted to have right foot and shoulder pain. Staff will continue with ongoing assistance. Interventions remain ongoing per care plan to assist with preventing any future falls.R2's Unwitnessed Fall document dated 5/11/25 at 1:00 p.m., identified R2 was found sitting between the leg rests of the wheelchair. R2's shoe Velcro was caught in leg rest. R2 stated, he was trying to go to the bathroom. R2 denied hitting his head. Further identified R2 had improper footwear and was transferring self. The form was not completed; did not address mental status, predisposing environmental and physiological factors. Corresponding Post Fall assessment dated [DATE] at 1:00 p.m., identified R2 did not have a fall history, indicated R2 was last seen at 3:00 p.m., by registered nurse (RN)-B. Further identified R2 was going to the bathroom at the time of the fall and that R2 had unsteady gait. Mental status prior to the fall and after the fall identified that R2 was confused some of the time. Care plan portion identified the new immediate intervention was to ensure the call light was within reach, however review of R1's care plan revealed the care plan was not updated.R2's progress note dated 5/11/25 at 3:11 p.m., identified R2 was found sitting between the leg rest of the wheelchair, R2's shoe Velcro was caught in leg rest. R2 stated he was trying to go to the bathroom and denied hitting head.R2's IDT Clinical Review progress note dated 5/12/25 at 9:41 a.m., identified root cause of R2's fall was to catch Velcro on the wheelchair. Intervention was to make sure Velcro was trimmed and remove the foot pedals.In review of R2's 5/11/25 fall record identified no indication a comprehensive fall analysis had been completed to determine appropriate individualized interventions were developed and implemented. Further, even though the fall record identified R2 fell trying to get to the bathroom, R2's care plan did not include a toileting schedule when R1 required assist of one staff with toileting.R2's Unwitnessed Fall document dated 6/4/25 at 3:10 p.m., identified activity manager reported that R2 was on the floor. Was trying to get up and his wheelchair wheels did not lock. Upon assessment writer found R2 lying on his back on the floor, denied hitting head. R2 did not sustain any injuries from the fall, DON on duty notified along with family. R2's progress note dated 6/4/25 at 3:56 p.m., identified that activity manager reported that R2 was on the floor, upon assessment writer found R2 lying on his back on the floor, denied hitting head. R2 did not sustain any injuries from the fall. Although R2's care plan was updated on 6/6/25, to have R2 evaluated by therapy as needed to assist for safe transfers and walking. Review of R2's OT and PT notes identified he had been receiving both therapy services since 5/5/25. In review of R2's 6/4/25 fall documentation revealed no indication of IDT involvement. Further the records did not include a comprehensive analysis to determine modifiable and non-modifiable risk factors so that individualized interventions could be developed and implemented to prevent and/or mitigate R2's risk of re-current falls. R2's quarterly MDS dated [DATE], identified R2 had severely impaired cognition, required limited assist with bed mobility, transfers and toileting and had two or more falls without injury.R2's Unwitnessed Fall document dated 6/9/25 at 4:50 p.m., identified an aide found R2 sitting on the floor next to his bed and stated, I was trying to clean the floor. R2 denied hitting head and pain form falling. R2 was alert and oriented to the event. DON and family notified. Document was not completed- lacked predisposing physiological factors. Corresponding Post Fall assessment dated [DATE] at 4:50 p.m., identified the aforementioned information and included the following additional information; R2 had one to two falls in the last 30 days but lacked dates and times of falls; safety check (record does not address why R2 was on 15-minute checks) was provided 15 minutes prior to the fall at 4:20 p.m. he was sitting in his wheelchair but did not identify when he was last assisted. R2 had a behaviors that occurred daily or more: wandering, verbally abusive, physically abusive, calls out, socially inappropriate, noisy, screams, disrobes, self-abusive, rummages hoards etc.Identified R2 had call light within reach and bed locked. Care plan portion identified R2 was educated to call for help before getting up, R2 was on 15-minute safety checks by writer to prevent falling. Writer an aide needs to check on resident. Care plan was not updated. R2's progress note dated 6/9/25 at 5:31 p.m., identified aide found R2 sitting on the floor in room.R2's IDT Clinical Review progress note dated 6/10/25 at 12:30 p.m., identified root cause of fall was R2 continued to walk with wheelchair, prevention intervention was to educate R2 on need not to use wheelchair as a walker.In review of R2's 6/9/25 fall record there was no indication of a comprehensive fall analysis that identified root cause, and the care plan was not updated to reflect the15-minute checks. During an interview on 7/28/25 at 11:10 a.m., nursing assistant (NA)-B stated she was the aide responsible for R2. R2 did walk but he was very unsteady and did try and get up frequently. NA-B thought he was independent with toileting and ADLs and was unaware he had falls. NA-B indicated R2 was incontinent at times and stated she would look at the Kardex to determine how often to offer toileting or any safety checks. During an interview on 7/23/25 at 3:35 p.m., NM-A stated after reviewing falls on 5/11/25, 6/4/25, and 6/9/25, they were not comprehensively assessed to determine if R2's basic needs were met as he needed staff assist with ADLs. R2's fall on 5/11/25, should have addressed his toileting routine/needs but it did not. The fall on 6/4/25, should have addressed his wheelchair brakes and it did not. The fall on 6/9/25, was not root caused and the intervention to the care plan was not updated until 6/24/25. During an interview on 7/24/25 at 3:18 p.m., DON indicated R2's falls on 5/11/25, 6/4/25, and 6/9/25 were not comprehensively assessed and interventions were not always implemented or related to the root cause. DON stated R2's fall on 5/11/25 had to do with toileting, R2 has incontinence, and the care plan should have addressed that. In relation to the fall that occurred on 6/9/25, she was unaware the unaware the nurse had him on 15-minute checks or why, the fall should have been comprehensively assessed to determine if his basic needs were met so we could figure out a more appropriate fall preventions intervention.R3R3's admission Evaluation dated 6/2/25 at 12:00 p.m., identified that R3 required extensive assist of one staff with bed mobility, transfers and toileting. R3 was alert to person, place and time, had bladder incontinence one to two times daily during the day and evening once or more a shift and had difficulty initiating urine flow. R3 had a history of falls: one to two falls in the last 30 days, last two months and last six months. R3 was at risk for falls with a goal to minimize the risk for falls. No fall interventions identified.R3's care plan identified a focus date 6/2/25, at risk for falls due to: Parkinsonism, dementia with cognitive losses, restless leg syndrome, bladder incontinence, constipation, decline in mobility status. In