Based on record review, observation, and interview, the facility failed to initiate fall interventions, to reduce the risk of a fall with major injury, for one (#23) of five residents sampled for falls. The Resident Census and Condition of Residents, form documented 39 residents resided in the facility. Findings: A Fall Prevention Program policy, dated 2022, documented in parts, .Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls .The nurse will indicate on the (specify location) the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk .Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care .interventions will be monitored for effectiveness . The plan of care will be revised as needed .When any resident experiences a fall, the facility will .document all assessments and actions . Resident #23 had diagnoses which included traumatic subdural hemorrhage without loss of consciousness and a history of cerebral infarction An Significant Change MDS Assessment, dated 10/26/22, documented the resident did not require a mobility device and was independent with transfers and locomotion. A Care Plan for resident #23, dated 12/30/22, documented the resident had a fall and hit their head. The care plan documented a history of falls, with the most recent fall being August 2022, prior to the current fall on 12/30/22. The care plan documented neuro checks were initiated with 72 hour routine monitoring, to include complaints of pain, new bruises, change in mental status, and vital signs. There was no documentation of new fall interventions initiated for this fall. A Nurse Note, dated 12/30/22 at 1:40 p.m., documented the resident had a fall and hit his head on the wall. The note documented the resident stated, I went to grab the rail in the hallway with my hand and wasn't close enough so I couldn't reach it and fell and hit my head on the wall. The note documented vital signs were obtained and the resident was assisted from the floor. The note documented the resident complained of being dizzy while being assisted from the floor. An Incident Report, dated 12/30/22 at 1:40 p.m., documented resident #23 had a fall and hit their head. The report indicated the resident went to grab the rail in the hallway and was not close enough to reach the rail. The resident fell and hit their head. The report documented neuro checks were started, vital signs were obtained, and the resident was assessed and assisted from the floor. The physician was notified and neuro checks started. There were no new fall interventions documented on the incident report. The Incident Report, dated 12/30/22, had not incuded a root cause to determine the cause of dizziness and the report had not included interventions. A facility Post Fall 72 Hour Monitoring Report, dated 12/30/22 through 01/02/23, documented neuro checks were completed. The report contained no documentation related to monitoring for dizziness. A Fall Risk Assessment for resident #23, dated 12/30/22, documented the resident had a fall score of 7, indicating the resident was a moderate fall risk. An Incident Report, dated 01/02/23 at 10:35 a.m., documented the resident had a witnessed fall in the dining room. The report documeted the resident stated their knee gave out. The resident was assessed for injury, vital signs taken, and assisted from the floor. The report documented there were no new interventions initiated. There was no documentation to indicate a follow up root cause analysis was completed by staff to determine the cause of the fall. A Nurse Note, dated 01/02/23 at 11:03 a.m., documented a CMA witnessed resident #23 walking into the dining room. The CMA reported the resident began to lean forward and was unable to regain their balance and fell landing on their hands and knees. The note documented the resident denied hitting their head and witnesses also reported the resident did not hit their head. There was no injury documented related to this fall. There were no documented interventions after this fall. An Incident Report, dated 01/02/23 at 5:06 p.m., documented resident #23 had a witnessed fall in the dining room. The report documented the resident stated they were dizzy and fell. The resident was assessed, vital signs obtained, and a laceration was noted above the left eye with hematoma noted under the left eye. The resident was sent to the emergency room for evaluation and treatment. The Incident Report, dated 01/02/23, did not incuded a root cause to determine the cause of the fall and the report did not included interventions. A Nurse Note, dated 01/02/23 at 5:20 p.m., documented resident #23 was witnessed falling in the dining room where the resident hit their head. The resident reported feeling dizzy and losing their balance. The resident was assessed, vital signs were obtained, and a laceration was noted above the left eye with hematoma noted under the left eye. The resident was sent to the emergency room. A hospital record History of Present Illness, admission date 01/02/23, documented the resident had a syncopal episode, falling and hitting their head. The record documented the resident sustained a left superorbital laceration and skin tear to left elbow from falling. The record documented a CT scan of the resident's head was obtained and documented a left frontotemporoparietal subdural hemorrhage with 5 mm of left-to-right midline shift. The physician was consulted and recommended ICU admission for close monitoring and frequent neuro checks. and repeat CT scan in 6 hours. A follow up to the investigation of the incident, dated 01/04/23, documented the IDT met and discussed the resident's recent multiple falls. The resident was still in the hospital at that time. The IDT team addressed the resident's dizziness and impaired balance with falls. The IDT team planned to request hospital records and evaluate for appropriate interventions upon the resident's return from the hospital. A Significant Change MDS Assessment, dated 01/12/23, documented the resident was cognitively intact. The assessment documented the resident required mobility devices of a walker or wheelchair. On 02/21/23 at 1:33 p.m., resident #23 was interviewed and reported having a fall a couple of weeks ago. The resident stated they were walking, turned the corner, their leg did not come down, and they fell. The resident stated the facility responded by sending them to the emergency room. On 02/22/23 at 2:13 p.m., the DON stated she understood there were no new interventions initiated following resident #23's falls on 12/30/22 and 01/02/23. The DON reported monitoring of the resident and neuro checks had been initiated. The DON reported the resident had not been the same since their last fall. The Corporate RN reported there was an IDT meeting while the resident was still hospitalized , with plans to implement interventions upon the resident's return to the facility. She stated the facility started therapy when the resident returned from the hospital. The RN stated with the first two falls, the facility followed physician orders to monitor the resident and complete neuro checks. On 02/22/23 at 3:42 p.m., CMA #1 stated she witnessed the fall the afternoon of 01/02/23. The CMA reported the resident got up to get a glass of tea on their own. The CMA reported she believed the resident walked too fast, lost their balance and fell, hitting their head on the ground. The CMA stated staff called a nurse, the nurse assessed the resident, and the resident was sent to the ER. The CMA reported she was not aware the resident had experienced two or more falls prior to the fall with injury the afternoon of 01/02/23. On 02/22/23 at 4:00 p.m., CNA #1 reported she was not aware resident #23 was a fall risk and had not witnessed previous falls. She stated if she sees the resident go to their room, she follows the resident because they use a wheelchair and has been known to self-transfer from the wheelchair to the bed. The CNA stated it would be helpful to know when a resident was a fall risk. The CNA reported she charts in the EMR and the resident did not have any fall charting interventions. On 02/22/23 at 4:43 p.m., LPN #1 reported being aware resident #23 was a fall risk. The LPN stated the resident had changed cognitively since their fall with injury. The LPN reported the resident would get up and forget they could not walk independently. The LPN stated on the day of the fall with injury, the resident was leaning forward more than usual and walking faster, causing them to be unsteady on their feet. The LPN stated after the fall on the morning of 01/02/23, she walked the resident back to their room and encouraged them to use the call light for assistance. She stated the resident was not using a wheelchair or walker at that time. The LPN stated she spoke with the CNAs about providing the resident extra help with transfers and ambulation, but reported these interventions were not documented. On 02/23/23 at 9:33 a.m., resident #23 was observed using a wheelchair to ambulate in the hall to their room. During the survey process, the resident was not observed to ambulate or get out of their wheelchair on their own. On 02/23/23 at 11:20 a.m., LPN #2 stated the first fall on 01/02/23 was right after breakfast. The LPN reported she was entering the dining room and witnessed the resident on their hands and knees. She stated she assisted with getting the resident up and the resident voiced no complaints of pain. The LPN stated when the resident tried to stand, they were wobbly and unsure on their feet. She stated a wheelchair was offered to take the resident back to their room but the resident refused the wheelchair and insisted they could ambulate. The LPN reported the resident was assessed and one of the aides walked the resident back to their room. The LPN reported she did not document the wheelchair being offered and had not documented the resident's refusal. The LPN reported when the resident fell the second time, the resident was observed getting a drink. She stated when the resident turned around, the resident was observed to walk on their toes, leaning forward, and fell. The LPN stated she moved toward the resident, but the resident fell over before she could get to them. She stated the nurse immediately contacted the physician and sent the resident to the ER. On 02/23/23 at 11:39 a.m., the DON discussed the facility's policy and procedure for addressing falls. She stated it would be the nurse's responsibility to determine the cause of the fall and implement interventions to try and prevent additional falls. The DON stated the nurse should provide communication through the incident report with the IDT team, as to interventions initiated, and provide documentation regarding the incident. She stated the intervention should be appropriate for the individual resident related to the cognition of the resident. The DON reported there were no new interventions initiated for resident #23 for the falls which occurred on 12/30/22 and 01/02/23. The DON stated she had re-educated nursing staff reguarding incident reports and the importance of including immediate action taken, as well as providing the immediate interventions initiated. On 02/23/23 at 12:01 p.m., the Administrator reported he was aware of the incidents with resident #23 and the fall with major injury. The Administrator stated the staff would be working to improve the process for identifying and initiating interventions to prevent falls. On 02/24/23 at 12:59 p.m., the ADON reported the nurse should put an intervention in place when a fall occurs. The ADON stated when the IDT team follows up on the incident, they will look at the incident report and ensure the nurse followed the process and the interventions were appropriate for the individual resident. The ADON reported the investigation would be documented in the IDT note on the IR report. The ADON stated the root cause from resident #23's first fall was found to be the resident reaching for the hand rail and missing the rail. She stated she did not recall if the IDT team discussed the resident's complaints of dizziness. The ADON stated when resident #23 fell the second time, the morning of 01/02/23, she talked through the events with the nurses. She stated she asked if the resident was offered a walker or wheelchair, and stated she instructed staff to continue offering the resident assistance with ambulation. The ADON reported staff stated the resident continued to refuse help at that time. The ADON stated her investigation was not documented and the resident's refusal of a walker or wheelchair was not documented.