**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the environment was free of accident hazards and residents received adequate supervision to prevent accidents for one of five residents (Resident 1) when, nursing staff were aware of Resident 1's behavior to self-propel in a wheelchair equipped with foot pedals and did not adequately supervise Resident 1 while propelling in a wheelchair. Staff did not assess the safety of the wheelchair for Resident 1's physical size and abilities. Resident 1 was not assessed and fitted for a wheelchair for personal use and instead Resident 1 used wheelchairs available for general use in the facility. Staff did not identify declining mobility in Resident 1's upper and lower extremities as identified in the Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive (the mental processes of perception, thinking, learning, memory, reasoning, judgment and physical function).These failures resulted in Resident 1 experiencing an unwitnessed avoidable accident on 8/17/25 where an internal investigation determined Resident 1's legs became entangled in the wheelchair while Resident 1 was self-propelling. The unwitnessed avoidable accident resulted in pain and tenderness to Resident 1's right lower leg and was sent to the local acute care hospital for evaluation which required hospitalized from [DATE] to 8/21/25. Resident 1 was diagnosed with acute (sudden and unexpected) right tibial (the larger of the two bones in the lower leg) fracture (a break or discontinuity in a bone) with only minimal displacement (broken bone fragments move out of alignment) and proximal (closer to the point of attachment or origin) fibular (thinner, outer bone of the lower leg) fracture. As a result of Resident 1's accident and injury he has pain, does not have the capability to self-propel and is isolated to his room.Findings:During an interview on 8/27/25 at 1:35 p.m. with Registered Nurse (RN) 1, RN 1 stated she was notified that Resident 1 had pain to the right lower leg and did not want to move his leg by the Certified Nursing Assistant (CNA) 1 on 8/18/25 around 11:00 a.m. RN 1 stated she went to Resident 1's room and did a physical assessment which included palpation (medical examination technique that involves using the hands to assess the body to detect abnormalities such as; tenderness/pain, temperature, size and shape, etc.) to the right lower leg. RN 1 stated Resident 1 had severe pain in the right lower leg when it was palpated and grimaced when palpated. RN 1 stated, Resident 1 does not complain about pain, and this complaint was unusual and new for him. RN 1 stated there was no physical deformity (a condition in which something is distorted from the usual or typical shape), no swelling or bruising, just pain. RN 1 stated she reported the condition of Resident 1 to the Director of Nursing (DON), offered pain medication to Resident 1 and notified the physician of Resident 1's condition.During a concurrent interview and record review on 8/27/25, at 1:45 p.m. with RN1, Resident 1's Situation, Background, Assessment, and Recommendation Communication Form (SBAR-a standardized communication tool used to convey patient status updates when a change occurs from baseline), dated 8/18/25 was reviewed. The SBAR indicated, .Situation.Resident has severed pain 9/10 (Pain scale from 0 to 10 with 0 representing pain free and 10 representing unspeakable bedridden pain) in the right lower limb.decreased mobility.2. Functional Status Evaluation (compared to baseline; check all changes that you observe) Decreased mobility, Other (describe).severe pain on the [right] lower extremity (the body parts farthest from the center of the body).9. Pain Evaluation.Does the resident have pain: yes (describe below), is the pain new: yes. Description/location of pain: Right lower leg pain, Intensity of Pain (rate on scale of 1-10, with 10 being the highest): 9.Appearance, CNA notified [charge nurse] regarding resident has severe pain in right lower limb. There is no swelling or redness, he claim[ed] it happened yesterday evening like he twisted his leg while propelling his wheelchair. He denied he had a fall. RN 1 stated CNA 1 informed her that Resident 1 was having pain in his right lower leg and RN 1 completed an assessment and did not find any deformity of the leg. RN 1 stated she administered acetaminophen (a drug used to relieve mild or chronic pain), informed the Medical Doctor (MD) and received an order for an in-house X-ray (a medical imaging tool used for diagnosing various conditions including bone fractures). RN 1 stated after Resident 1 twisted his legs while propelling his wheelchair on 8/17/25 she believes Resident 1 is sad because Resident 1 cannot roll around to different areas in the facility using a wheelchair anymore and he just lays in his bed and does not get up.During a review of Resident 1's Medication Administration Record (MAR), dated 8/25, the MAR indicated, .[acetaminophen] tablet.Give 325 mg (milligrams-unit of measure) by mouth every 8 hours as needed for mild pain. The MAR indicated medication was administered 8/18/25 at 10:58 a.m. and 8/19/25 at 8:13 a.m. both were after Resident 1 twisted his legs while propelling his wheelchair on 8/17/25 while awaiting in-house imaging results. No documentation of the pain level was indicated in Resident 1's MAR.During a review of the facility's Radiology Report (RR) for Resident 1, dated 8/19/25 the RR indicated, .Results: Proximal tibia/fibula fractures with mild displacement. Mild soft tissue swelling (condition that occurs when fluids accumulate in the damaged tissues) Conclusion: Acute appearing proximal tibia/fibula fractures as noted.During a record review of the general acute care hospital's (GACH) Discharge Summary (DS-a medical document that provides a comprehensive overview of a patient's hospital stay) for Resident 1, dated 8/21/25, the DS indicated, Resident 1 was admitted to the GACH on 8/19/25 and discharged on 8/21/25. Resident 1's admission diagnosis was closed fracture (break in a bone that does not penetrate the skin) of the right tibia and fibula (two bones in the lower leg). The DS indicated, .Consults: Orders place this encounter: [inpatient] consult to [company name] Orthopedic Surgery (medical specialty focused on the surgical and non-surgical treatment of the musculoskeletal system, which includes bones, joints, ligaments, tendons, muscles, and nerves).Procedure (during this hospitalization): No surgery found. [X-ray] Tibia Fibula Right.Impression: Tibial and fibular fracture, [Computed Tomography] (medical imaging technique that uses X-rays to create detailed cross-sectional images of the body's internal structures, such as organs, bones, and blood vessels) Knee Right [without] Contrast (a special dye that is used to enhance the visibility of certain structures in the body during a CT scan).Impression: 1. Acute right tibial metaphyseal (the wider, growing part of a long bone) fracture with only minimal displacement. 2. Proximal fibular fracture.Received [acetaminophen], fentanyl (a synthetic opioid that is used to treat severe pain), ibuprofen (over the counter non-steroidal anti-inflammatory drug used to relieve pain), [ondansetron] (used to prevent nausea and vomiting).Assessment And Plan: [company name] Ortho consulted-non operative [management], orthopedics to sign off, ok for discharge from orthopedic perspective.pain control.Non-Weight bearing (medical instruction to avoid placing any weight on a specific body part, typically a limb) [right lower extremity], [physical therapy] [evaluation].return to clinic in 2 weeks.During a concurrent observation and interview on 8/27/25, at 11:00 a.m. with Resident 1 and Certified Nursing Assistant (CNA) 1, in Resident 1's room, Resident 1 was observed lying in bed looking out the window. Resident 1 was observed to have a cast on his right leg extending from his right foot to his mid-thigh. Resident 1's right leg was extended straight and immobile due to the cast. When asked about his legs, Resident 1 stated while using a facility wheelchair on 8/17/25 he tried to turn the wheelchair, and both legs got caught under the wheelchair. Resident 1 stated the wheelchair had foot pedals (footplates-where the user of the wheelchair rests their feet on a flat surface) and he uses the foot pedals sometimes. Resident 1 stated he did not fall, and he did not inform staff of the injury due to not being in pain at the time of the incident but had pain the following morning on 8/18/25. Resident 1 stated he has been using a wheelchair for a long time, even before he got to the current facility. Resident 1 appeared sad, talked in a low voice and responded to interview questions in short sentences even when asked to expand.During a concurrent observation and interview on 9/3/25 at 1:30 p.m. with Resident 1 in Resident 1's room, Resident 1 was observed lying in bed, looking out the window with both legs extended straight with a cast to his right leg extending from his foot to his mid-thigh rendering his leg immobile. Resident 1 stated he was not in pain at the moment. Resident 1 stated that he was sad he cannot use the wheelchair due to twisting his legs while propelling his wheelchair on 8/17/25. Resident 1 stated he likes to go to the activities room and self-propel himself in the facility and now, he just lies in his bed.During an interview on 8/27/25 at 11:15 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was familiar with the needs of Resident 1 and had cared for him in the past. CNA 1 stated before the accident and injury when Resident 1 twisted his legs while propelling his wheelchair on 8/17/25, she had observed Resident 1 propelling himself in a wheelchair that had foot pedals around the facility. CNA 1 stated she was unsure if the wheelchair was safe for use that Resident 1 used to self-propel himself. CNA 1 stated she noticed a difference in Resident 1's mood and level of activity after the accident and injury and that he seemed quieter now and doesn't get up and go to the activities room like before.During an interview on 8/27/25 at 12:00 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated she is currently assigned to Resident 1. CNA stated she knew Resident 1 has broken bones in his right leg through CNA-to-CNA handoff report (the formal transfer of patient care responsibility and relevant information ensuring the continuity and safety of patient care during a transition, such as a shift change). CNA 2 stated before the accident and injury on 8/17/25 when Resident 1 twisted his legs while propelling in the wheelchair, she observed Resident 1 propelling himself around the facility in the wheelchair using his arms and feet. CNA 2 stated Resident 1 sometimes used the foot pedals to rest his feet on. CNA 2 stated Resident 1 requires assistance with transfers from the wheelchair to bed and vice versa and Resident 1 required a mechanical lift (device that uses a sling to help a caregiver safely lift and transfer a person between surfaces like beds, chairs, and wheelchairs) before and after the accident. CNA 2 stated she has not been informed of Resident 1's needs specific to assistive equipment like wheelchairs for mode of transportation. CNA 2 stated Resident 1 has always used a wheelchair, so staff just put him in it when he wanted. CNA 2 stated she does not know if the wheelchair was safe for Resident 1 to use or if he had ever been assessed for safety when using it. CNA 2 stated Resident 1 would comply if there were any safety concerns while propelling himself in the facility. CNA 2 stated Resident 1 seems sad after the accident and injury on 8/17/25 when Resident 1 twisted his legs while propelling his wheelchair. CNA 2 stated Resident 1 just looks out the window and has not gotten up to go to activities room which he liked to do before the accident and injury.During an interview on 8/28/25 at 9:15 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated before Resident 1's accident and injury on 8/17/25 where Resident 1 twisted his legs while propelling the wheelchair, she observed Resident 1's feet dragging on the floor while he used his hands to propel himself. CNA 3 stated Resident 1 had been doing this as long as she can remember. CNA 3 stated it was not communicated to her if a safety assessment for use of a facility wheelchair had been completed for Resident 1 and she was not told which wheelchair was safe to use for Resident 1. CNA 3 stated Resident 1 appears sad since the accident and injury because Resident 1 smiles less than he did before the injury and accident.During an interview on 9/3/25 at 1:50 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated she is currently assigned to Resident 1, and she noticed a difference in Resident 1's mood and activity level after the accident and injury and that he doesn't seem as bright and isn't getting up and going to the activities room or to the dining room. CNA 4 states she thinks Resident 1 is in pain because sometimes she sees Resident 1 grimace in pain when repositioning himself. CNA 4 stated before the injury and accident, only one of Resident 1's feet were functional, so he used the opposite foot and both hands to propel himself in the wheelchair around the facility. CNA 4 stated Resident 1 would comply if there were any safety concerns while propelling. CNA 4 stated before the injury and accident to Resident 1, she was not informed if Resident 1 had been cleared to use a wheelchair or if the wheelchair was safe for him to use.During an interview on 9/3/25 at 2:00 p.m. with the Activities Director (AD), the AD stated before the accident and injury on 8/17/25 where Resident 1 twisted his legs while propelling the wheelchair, Resident 1 used to hang out in the activities room all day. The AD stated but since the accident and injury on 8/17/25 where Resident 1 twisted his legs while propelling the wheelchair, the AD hasn't seen Resident 1 in the activities room. The AD stated Resident 1 seems more down and a little more quiet when she visits with him in his room since he cannot get up in the wheelchair since the accident and injury.During an interview on 8/27/25 at 3:30 p.m. with the Director of Nursing (DON), the DON stated an internal investigation was completed regarding the injury to Resident 1. The DON stated she was informed on 8/18/25 that Resident 1 had pain to his right lower leg and not wanting to get out of bed. The DON stated the physician was notified right away, medications were administered and an order for in-house X-ray was received with the results coming in the following day on 8/19/25. The DON stated the resident refused to go to the hospital on 8/18/25, pending results of the X-Ray. After the results of the X-Ray, Resident 1 was agreeable to be sent to the hospital. The DON stated Resident 1 was interviewed two different times by different staff members on two different days and Resident 1 responded the same way both times, that he had twisted his leg on his wheelchair the day prior 8/17/25. He said he didn't tell anyone because he was feeling OK. The DON stated she interviewed the night nurse on 8/17/25 and Resident 1 did not complain of pain or mention his legs getting caught in the wheelchair. The DON stated she also interviewed the CNA's Resident 1 had on 8/17/25, day before the incident on 8/18/25. The DON stated the interviews with the CNA's did not report Resident 1 complaining of pain or his legs getting caught in the wheelchair. The DON stated this was an unusual occurrence and was investigated thoroughly.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive (the mental processes of perception, thinking, learning, memory, reasoning, and judgment) and physical function) Assessment, dated 8/8/25, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS -an evaluation of attention, orientation and memory recall) score of 7, (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had severe cognitive impairment (a significant decline in mental functions like memory, thinking, and judgment, making it impossible for an individual to live independently and requiring significant assistance with daily tasks and self-care).During a review of Resident 1's admission Record (AR-document containing resident demographic information and medical diagnosis), dated 8/27/25, the AR indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included but was not limited to .ABNORMAL POSTURE (a deviation from the normal upright position of the body).OTHER MUSCLE SPASM (involuntary and forceful contractions of muscles).OTHER SPECIFIED ARTHRITIS, OTHER SITE (a group of conditions that cause inflammation and pain in the joints where the specific type of arthritis is known, but the affected joint location is not specified, or the arthritis affects multiple sites).OTHER ALZHEIMER'S DISEASE (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline). There was no documentation indicating Resident 1 used a wheelchair from the AR.During a concurrent interview and record review on 9/5/25 at 9:25 a.m. with the Minimum Data Set Coordinator (MDSC-person who evaluates the process of patients in long-term care facilities, where they're responsible for up-to-date assessments of the patient and oversee the interdisciplinary assessment for all nursing home patients), Resident 1's Transfer/Discharge Report (TDR-a document that health care providers complete when a patient/resident is moved from one level of care to another, or is leaving a healthcare facility to go home or to another setting for continued services), dated 4/27/22, was reviewed. The TDR stated, .Ambulation [the act of moving about freely, can be done with or without assistance from assistive devices like canes, walkers, and wheelchairs]: Bedfast (confined to bed, or bedridden)/ [wheelchair]. The MDSC stated she was not in the current position at that time of the admission of Resident 1. The MDSC stated it looks like the facility just allowed Resident 1 to use wheelchairs because the TDR indicated the need for a wheelchair for mobility. The MDSC stated the facility also continued to use a mechanical lift (a medical device that helps safely transfer patients with no/limited mobility between surfaces like a bed, chair, or toilet) for transfers without knowing what Resident 1 could or could not do. The MDSC stated the facility should have done a physical therapy (type of medical treatment to improve movement and function) referral for an assessment at the time of admission and did not. The MDSC stated the facility continued with what the TDR indicated as far as the wheelchair for mobility mechanical lift and did not assess into if Resident 1 could walk or not at the time. The MDSC stated the only way to determine if Resident 1 could walk was to do a physical therapy referral for an assessment and it was not completed at that time or since admission.During a concurrent interview and record review on 9/5/25 at 9:50 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 1's MDS was reviewed, dated 5/9/22, 8/9/22, 11/9/23, and 8/8/25. The MDS dated [DATE] indicated, .Section G-Functional Status.Surface-to-surface transfer (transfer between bed and chair or wheelchair) 2: Not steady, only able to stabilize with staff assistance. Functional Limitation in Range of Motion (the full movement available at a joint, determined by the joint's condition and the flexibility of surrounding muscles and connective tissues). Upper extremity (shoulder, elbow, wrist, hand): 0-no impairment, Lower extremity (hip, knee, ankle, foot): 0-no impairment.Functional Rehabilitation Protentional, Resident believes he or she is capable of increased independence in at least some ADL (Activities of Daily Living like bathing, eating and dressing): yes. Direct care staff believe resident is capable of increased independence in at least some ADL's: yes. The MDS dated [DATE] indicated, .Functional Limitation in Range of Motion.Upper extremity: 1-impairment on one side, Lower extremity: 0-No impairment.Mobility Devices: C-Wheelchair. The MDS dated [DATE] indicated, .Functional Limitation in Range of Motion.Upper extremity: 1-Impairment on one side, Lower extremity: 2-Impairment on both sides.Mobility Devices: C-Wheelchair. The MDS dated [DATE] indicated, .Functional Limitation in Range of Motion.Upper extremity: 2-Impairment on both sides, Lower extremity: 2-Impairment on both sides.Mobility Devices: C-Wheelchair. The MDSC stated there was a change in functional status for Resident 1 and he was admitted to current facility with no impairment in his upper extremity on 5/9/22 to an impairment to both upper and lower extremities on both sides on 8/8/25. The MDSC stated it appears if Resident 1 is declining and that is a reason to inform the physician and to do a physical therapy referral for assessment and neither of those things were done at the time of the MDS assessment or since then. The MDSC stated a physical therapy referral should have been completed to see what he was capable of doing regarding his range of motion and strength and if he was able to use the wheelchair safely. The MDSC stated no documentation could be provided indicating physician was notified and no documentation for a physical therapy referral could be provided. During a concurrent interview and record review on 8/27/25 at 12:15 p.m. with the Rehabilitation Coordinator (RC), Resident 1's Electronic Chart (EC-a digital version of a patient's medical information, encompassing their comprehensive health history, including medications, diagnoses, test results, and treatment plans). The RC confirmed Resident 1 had not had any referrals to physical therapy for consultation and/or assessment. The RC stated physical therapy cannot evaluate a resident unless there is a referral for physical therapy. The RC stated that any resident can have a wheelchair, but to have a custom wheelchair (personalized mobility device by taking detailed individual measurements and preferences to meet the unique medical, physical, and psychosocial needs of the user, that generic wheelchairs cannot provide), they would need a Medical Doctors (MD) order, which is preceded by a referral for consultation and assessment from physical therapy. The RC stated the physical therapy staff must do a complete assessment and evaluation of a resident for the resident to get a custom wheelchair. The RC stated the physical therapy staff do not give out wheelchairs to just any resident. The RC confirmed Resident 1 used a wheelchair in the facility and did not have a wheelchair assigned to him by physical therapy staff.During a concurrent interview and record review on 9/3/25 at 3:15 p.m. with the Physical Therapist (PT), the PT verified Resident 1 never had a physical therapy evaluation from his admission to the facility on 5/9/22 to present day. The PT stated that she does not know if it is safe or appropriate for Resident 1 to be using a wheelchair. The PT stated the only way to know if a resident is safe to use any Durable Medical Equipment (DME-reusable medical devices, equipment, and supplies prescribed by a healthcare provider for a resident to manage a medical condition or disability. Examples include walkers, wheelchairs, hospital beds, and crutches) is to do an evaluation to determine strength, range of motion, and potential for improvement. The PT confirmed Resident 1 did not have an evaluation by physical therapy.During a concurrent interview and record review on 8/27/25 at 2:58 p.m. with the Assistant Director of Nursing (ADON), Resident 1's EC, undated was reviewed. The ADON confirmed Resident 1 had an accident with an injury on 8/17/25 that resulted in 2 broken bones in the lower right leg to Resident 1. The ADON confirmed there was not a physical therapy referral in the E-Chart for Resident 1. The ADON also confirmed there was no wheelchair component to the Care Plan (a dynamic, patient-centered document to outline their specific health needs, goals, preferences, and the necessary treatments, services, and support to achieve them) for Resident 1. The ADON stated there is no way of knowing if Resident 1 is safe or capable of using a wheelchair since there was no physical therapy assessment. The ADON stated Resident 1 seems sadder to me because before the accident and injury, he would wheel himself around the facility and now he just lays in his bed and doesn't get up.During a concurrent interview and record review on 8/27/25, at 1:30 p.m. with Registered Nurse (RN) 1, Resident 1's Care Plan (CP-a personalized, detailed document created to outline the specific medical, physical, and psychosocial needs of an individual receiving care by comprehensive assessments and includes identified risks, goals, treatments, and preferences to ensure the resident receives consistent, individualized, high-quality care to achieve their highest practicable well-being), dated August 2025, was reviewed. The CP did not have a component for the use of a wheelchair for Resident 1. RN 1 stated if Resident 1 was using a wheelchair, he should have a CP. RN 1 stated she did not know if Resident 1 needed the wheelchair for ambulation due to disability and does not know if the wheelchair is appropriate for the resident. RN 1 stated she did not know if the resident was assessed by physical therapy for safety or appropriateness of wheelchair use.During a concurrent interview and review on 8/27/25 at 3:10 p.m. with the Assistant Director of Nursing (ADON), the facility's policy and procedure (P&P) titled, Assistive Devices and Equipment, dated February 2021 was reviewed. The P&P indicated, Our facility maintains and supervises the use of assistive devices and equipment for residents.1. Certain devices and equipment that assist with resident mobility, safety and independence are provided. c. mobility devices (wheelchairs).3. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the residents' care plan. 6. The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment. a. Appropriateness for resident condition-the resident is assessed for lower extremity strength, range of motion, balance and cognitive abilities when determining the safest use of devices and equipment. b. Personal fit-the equipment or device is used only according to its intended purpose and is measured to fit the resident's size and weight. The ADON stated the facility did not follow the P&P and did not make sure Resident 1 was safe with his wheelchair.During a review of the facility's document titled, MDS Coordinator Job Description, dated 2/19/25, the MDS Coordinator Job Description indicated, .Job Responsibilities: .Responsible for insuring that the MDS reflect a true picture of the resident.Meeting with staff and residents to gather any information that may have changed on the MDS.During a review of the facility's document titled, RN (Registered Nurse) Charge Nurse, dated 1/23/25, the RN Charge Nurse indicated, . Job Summary: The charge nurse is to ensure that effective, efficient and comprehensive resident care is provided.Job Responsibilities: . 5. Is responsible for maintaining an acceptable standard of nursing practice. 6. Is responsible for accurate observations, evaluations, and multi-system assessment of residents in an accurate and timely manner. 9. Is responsible for supervising the CNA's (Certified Nursing Assistant) during the care they provide to residents-ensuring resident safety. 11. Is responsible for correlating resident care with other departments. 15. Is responsible for. care planning as needed.During a review of the facility's document titled, Assistant Director of Nursing Job Description, dated 7/12/24, the Assistant Director of Nursing Job Description indicated, .The primary purpose of the job position is to assist.in managing overall operation of the Nursing Services Department in accordance with current Federal, State and local.regulations that govern this facility.to ensure that the highest degree of quality care is maintained at all times.Essential Job Functions:. Monitor unit activities, communicate policies.Conduct regular rounds to monitor resident activity and ensure resident quality care. Assess residents' physical and psychosocial status. Monitor care activities and documentation to ensure the delivery of nursing care according to the physician's orders, care plans and established standards and facility policies.Plan, organize and direct.effective administration of nursing unit and patient care given based on the establish goals and objectives, standards, policies and procedures of this facility. Regularly inspect the facility and nursing practices for compliance with federal, state and local standards and regulations. Assure residents of.safe environment. Assist in development of Patient Care Plans for individual residents including rehabilitative and restorative activities. Assist in.scheduling of rounds to see all residents.During a review of the facility's policy and procedure (P&P) titled, Hazardous Areas, Devices and Equipment, dated July 2017, the P&P indicated, .All hazardous areas, devices and equipment in the facility will be identified and address appropriately to ensure resident safety and mitigate accident hazards to the extent possible.1. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed. Identification of Hazards: 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness. b. Devices and equipment that are improperly used. Assessment and Analysis of Hazards: 1. Assessment and analysis of hazardous areas and equipment will include resident-specific information including identification of vulnerable residents. 2. Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous. 3. Resident vulnerability is based on risk factors including the individual resident's functional status, medical condition, cognitive abilities, mood, and health treatments. 4. Resident vulnerability to hazards may change over time. Ongoing assessment helps identify when elements in the environment pose hazards to a particular resident. 5. Improper or inappropriate use of equipment and devices will be identified as part of the hazard assessment and analysis.During a review of the facility's policy and procedure (P&P) titled Assistive Devices and Equipment, dated February 2021, the P&P indicated, Our facility maintains and supervises the use of assistive devices and equipment for residents.1. Certain devices and equipment that assist with resident mobility, safety and independence are provided. c. mobility devices (wheelchairs).3. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the residents' care plan. 6. The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment. a. Appropriateness for resident condition-the resident is assessed for lower extremity strength, range of motion, balance and cognitive abilities when determining the safest use of devices and equipment. b. Personal fit-the equipment or device is used only according to its intended purpose and is measured to fit the resident's size and weight.During a review of a professional reference titled, Topics in geriatric rehabilitation, dated 2015, retrieved from https://doi.org/10.1097/TGR.0000000000000042, indicated, .e