**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the hand sink in a resident's bathroom was inspected during daily rounds by the maintenance staff and/or the facility's administrative staff, to ensure it was mounted securely to the bathroom wall and did not detach and fall off the wall causing a resident to fall and sustain injuries for one of three sampled residents (Resident 1). This deficient practice resulted in the hand sink in Resident 1's bathroom detaching from the wall and falling to the floor when Resident 1 placed her hands on it while washing her face. Resident 1 fell to the floor and sustained a left hip fracture, a bump with discoloration to her left eye and a bump with discoloration to the left side of the back of her head. This deficient practice had the potential for Resident 1 to sustain more critical injuries including death. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including cerebral infarction [stroke] occurs when blood flow is disrupted to the brain) affecting Resident 1's left side, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), glaucoma (chronic, progressive eye disease), and a history of failing. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 12/28/2023, the MDS indicated Resident 1's cognitive (the ability to think, reason, and understood) skills for daily decision-making were severely impaired. The MDS indicated Resident 1 required moderate to maximal assistance for activities of daily living ([ADL] activities related to personal care that include, bathing, dressing, getting in/out of bed, walking, toileting and eating). The MDS indicated Resident 1 was 4'7' tall and weighed 100 pounds (lbs.) During a review of Resident 1's Change of Condition (COC) dated 3/10/2024 and timed at 8:29 a.m., the COC indicated Resident 1 sustained a fall and was noted with a bump and discoloration on her left eye and a bump and discoloration to the back left side of her head. During a review of the facility's Incident Investigation Summary, dated 3/10/2024 and timed at 5 a.m., the Incident Investigation Summary, indicated Resident 1 was washing up, while supervised by a Certified Nursing Assistant (CNA 1) when the toilet sink fell off the wall and Resident 1 lost her balance and slid on her left side. The Incident Investigation Summary indicated Resident 1 most likely hit her left orbital external side (the outer portion of the resident's left eye) on a paper towel dispenser, then hit her left mid upper parietal (back of her head) side on the wall, before she slid to the floor. The Incident Investigation Summary indicated at that time Resident 1 had no pain or injuries. On reassessment (time not indicated), Resident 1 was noted with red discoloration and bumps to her left exterior-lateral orbital region and left mid-upper parietal part of her head. Resident 1 complained of minimal tolerable pain on a scale of 3 out of 10 (an 11 point scale where pain is rated zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain). Later in the evening (time not indicated), Resident 1 complained of pain to her left hip when crossing her left leg above her right leg. During a review of Resident 1's Nursing Notes, dated 3/10/2024, the Nursing Notes indicated no documentation of Resident 1's fall or an assessment of Resident 1 after her fall. During a review of Resident 1's Nursing Note dated 3/10/2024 and timed at 2:31 p.m., the Nursing Note indicated Resident 1 verbalized pain to her left hip. The Nursing Note indicated Resident 1's physician was notified and an order for a Stat (immediate) X-ray (an imaging study that takes pictures of bones and soft tissues) was obtained. During a review of Resident 1's X-ray Results Report, dated 3/10/2024 and timed at 4:37 p.m., the X-ray Results Report indicated Resident 1 had an acute (a condition that is severe and has a sudden onset) left hip fracture. During a review of Resident 1's Physician's Order dated 3/10/2024 and timed at 5:16 p.m., the Physician's Order indicated to transfer Resident 1 to a General Acute Care Hospital (GACH) for evaluation related to her fall. During a review of Resident 1's GACH records dated 3/10/2024, the GACH records indicated Resident was admitted to the GACH on 3/10/2024 with a diagnosis of a left intertrochanteric femoral neck (region on top of the thigh bone that connects to the hip bone) fracture, secondary to a mechanical fall (a fall caused by an external force). During a review of the GACH's Hospital Course, dated 3/10/2024, the Hospital Course indicated given Resident 1's frailty, advanced age, poor baseline mobility, and dementia, Resident 1's Family Member (FM) and DPOA, requested conservative, nonoperative management. Resident 1 would return to custodial care for pain management and hospice consultation. Resident 1 was at high risk for mortality (death), either with surgery or without surgery. During a telephone interview on 3/27/2024 at 12 p.m., CNA 1 stated, she escorted Resident 1 to the bathroom (3/10/2024) in her wheelchair and placed her in front of the hand sink and stood her up so she (Resident 1) could wash her face. CNA 1 stated Resident 1 turned on the water in the sink and placed her hands on the sink when the sink fell to the ground. CNA 1 stated Resident 1 landed on her left hip and bumped the left side of her head. CNA 1 stated she could not recall if there was anything wrong with the hand sink prior to Resident 1 using it. During an interview on 3/27/2024 at 1:30 p.m., the Maintenance Supervisor stated it takes a lot of weight to force a sink off the wall and Resident 1 should not have been able to pull it from the wall. The Maintenance Supervisor stated the maintenance staff conducts daily rounds of the facility to identify any issues that the maintenance department needs to address. The Maintenance Supervisor stated he was not aware of any problems with the hand sink in Resident 1's bathroom. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 3/27/2024 at 2:56 p.m., LVN 1 stated she was summoned to Resident 1's room by CNA 1 and found Resident 1 on the floor, and the bathroom sink on the floor with water coming out of the pipes. LVN 1 stated she assessed Resident 1 and noticed discoloration to Resident 1's left eye and on the back of her head. During an interview with the Administrator (ADM) on 3/28/2024 at 12:44 p.m., the ADM stated, safety rounds are conducted daily by all staff to identify any hazards. The ADM stated he was not aware of any problems with the hand sink in Resident 1's bathroom and if there was a problem with the sink it should have been reported immediately to the maintenance department so it could have been repaired. During a review of the facility's policy and procedure (P/P) titled Safety and Supervision of Residents, revised 7/2017, the P/P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. During a review of the facility's P/P title Maintenance Service, revised 12/2009, the P/P indicated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of the maintenance personnel include but are not limited to: maintaining the building in good repair and free from hazards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident, who was walking 85 feet with moderate assistance (about 25-50 percent [%] physical assistance) with a platform walker ([PFW] a type of assistive device with forearm supports to provide extra support during walking), did not decline in walking and subsequently stopped walking, and failed to ensure the resident, who had limited ROM to both lower extremities received restorative nursing treatment to prevent potential decline in ROM for two of 15 sampled residents (Resident 3 and Resident 47). The facility failed to: 1. Assist Resident 47 with ambulation during Restorative Nursing Aide ([RNA] nursing aide program that help residents to maintain their function and joint mobility) treatment to maintain function and ability to move (walking) in accordance with the Physical Therapy ([PT], profession aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge Recommendation and Treatment Note dated 1/3/24. 2. Ensure Resident 47's physician (MD 1) was notified of the resident's decline in his function to walk and subsequently stopped walking. 3. Ensure RNAs notified nursing and physical therapy staff of Resident 47's decline in walking. 4. Ensure RNA 1 and RNA 2 followed the facility's Policy and Procedure (P&P) titled, Resident Mobility and Range of Motion, by ambulating Resident 47 as ordered to maintain or improve mobility. 5. Ensure RNAs 1 provided Resident 3 with ROM to minimize decline in range of motion and mobility. 6. Ensure RNA 1 provided Active Range of Motion ([AROM] a movement at a given joint when the person moves voluntarily) to Resident 3 to both upper extremities (BUE) including shoulder, elbow, wrist, and hand and to both lower extremities (BLE) including hip, knee, ankle, and feet, five (5) times a week in February 2024 as ordered by the physician. These deficient practices resulted in: 1. Resident 47's significant decline in mobility from being able to walk 85 feet with moderate assistance with a PFW to not being able to walk. 2. Resident 3's potential further decline in ROM and physical function such as rolling, dressing, walking, and transferring. Findings: A. During a review of Resident 47's admission Record, the record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (condition in which the body does not metabolize blood sugar correctly), chronic kidney disease (gradual loss of kidney function to filter waste and excess fluid from the blood), unilateral primary osteoarthritis (loss of protective cartilage that cushions the ends of your bones) right knee and left knee, difficulty in walking, and muscle weakness. During a review of Resident 47's Joint Mobility Assessment ([JMA] assessment of joints to monitor joint range of motion) dated 10/10/23, the Joint Mobility Assessment indicated Resident 47 had both upper extremities (BUE) and both lower extremities (BLE) within functional limits and had no impairment in upper or lower extremities. The Joint Mobility Assessment indicated, recommendation for Resident 47 to ambulate with RNA using a platform walker. During review of Resident 47's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 12/19/23 indicated Resident 47 had no impairment in cognitive skills (ability to think, understand, learn, and remember) for daily decision making and did not exhibit behavior of rejection of care. The MDS indicated Resident 47 did not have any functional limitations in range of motion ROM on either side of the upper or lower extremities. The MDS also indicated Resident 47 required partial or moderate assistance (helper does less than half the effort) from staff for eating, oral hygiene, upper and lower body dressing, and lying to sitting on side of the bed. The MDS indicated Resident 47 was dependent on two staff assistance (staff does all the effort or the assistance for the resident to complete the activity) to walk 10 feet, walk 50 feet with two turns and walking 150 feet was not attempted. During a review of Resident 47's care plan titled The Resident is at Risk for Injury, Pain and Discomfort related to right knee chondrocalcinosis (condition in which calcium crystals (mineral) deposit in joints causing pain), right knee osteoarthritis, back pain with bilateral sciatica (type of pain that radiates down both legs from the back), right knee joint effusion (extra fluid around the joint), left knee osteoarthritis, chronic midline low back pain with left sided sciatica, left great toe amputation (surgical removal of a limb), history of laminectomy (surgical procedure that remove a portion of the spinal bone to relieve pressure on nerves) dated 6/15/23 with target date of 3/18/24 indicated the goal for Resident 47 was to be able to participate in daily activities. The care plan's intervention included the following: 1. RNA to perform AROM exercises to BUE daily five times a week for four weeks (5x/wk for 4 wks.) as tolerated. 2. RNA to perform AROM to BLE daily 5x/wk for 4 weeks as tolerated. 3. Encourage exercise as well as rest periods, monitor medication (unspecified) effectiveness and for medication adverse effects (undesirable harmful effect resulting from medication). 4. Notify MD 1 as needed, monitor presence of pain during daily care, transfer, or positioning. During a review of Resident 47's care plan titled Resident Has Alteration in Physical Functioning Related to Disease Condition .at Risk for Decline in Joint Mobility .Decline in Activities of Daily Living ([ADL] basic activities such as eating, dressing, toileting), dated 6/15/23 with a target date of 3/18/24, indicated a goal for Resident 47 was to develop some area in physical function and achieve some degree of independence and be able to meet ADL needs with staff assistance. During a review of Resident 47's Physician's Order Summary Report dated 2/14/24 indicated an order dated 7/30/23 for RNA to perform AROM exercises to Resident 47's BUE once a day 5x/wk for 4 weeks as tolerated and an order dated 8/1/23 for RNA to perform BLE AROM daily 5x/wk for 4 weeks as tolerated. During a review of Resident 47's physician's order discontinued on 2/12/24, indicated an order for RNA program for assisted ambulation using platform walker once a day, five times a week for 4 weeks or as tolerated. This order was entered on 2/13/24 with no start date indicated. During a review of Resident 47's Physical Therapy (PT) Evaluation and Plan of Treatment dated 12/4/23 indicated Resident 47's prior level of function (before PT's evaluation on 12/4/23) was independent with rolling, sit to lying, lying to sitting on side of bed, supervision or touching assistance with sit to stand, bed to chair transfer, and walking 10 feet. The PT Evaluation and Plan of Treatment indicated Resident 47's discharge plan was to live at home with support from others. The PT Evaluation and Plan of Treatment indicated Resident 47 required substantial/maximal assistance to roll from left to right, sit to lying, lying to sitting on side of bed, sit to stand, bed to chair transfers, and walking was not attempted due to environmental limitations. During a review of Resident 47's PT Treatment Encounter Note dated 12/29/23 indicated Resident 47 required contact guard (physical steadying assistance) minimal assistance (less than 25% physical assistance) with bed mobility, moderate assistance for transfers and that the resident was able to ambulate 85 feet with moderate assistance and PFW. During a review of Resident 47's PT Treatment Encounter Note dated 1/2/24 indicated Resident 47 required contact guard/minimal assistance with bed mobility, moderate assistance for transfers, and that the resident was able to ambulate 85 feet with moderate assist with PFW. During a review of Resident 47's PT Treatment Encounter Note dated 1/3/24 (last PT treatment) indicated Resident 47 required moderate assistance for transfers, was able to ambulate 85 feet with two persons moderate assistance using PFW and with one person following with a wheelchair (WC) behind. The PT Treatment Encounter Note indicated Resident 47's gait (ambulation) training with RNA was completed using PFW with moderate assistance and required another person following with WC due to resident having episodes of knee buckling (knees feel weak) but resident was able to self-correct and maintain proper base of support (contact points beneath a person and supporting surface to provide balance when walking), step length (how far each step is), and continuity of steps. The PT Treatment Encounter Note indicated Resident 47 was very cooperative and tolerated the treatment session well. During a review of Resident 47's PT Discharge summary dated [DATE] indicated the discharge reason was the resident achieved highest practical level of functioning. The PT Discharge Summary indicated discharge recommendations to see RNA order. During a review of Resident 47's Joint Mobility assessment dated [DATE] indicated Resident 47's BUE and BLE were within functional limits without. The Joint Mobility Assessment indicated the recommendation for RNA for ambulation using platform walker. During a review of Resident 47's January 2024 Documentation Survey Report (record of nursing assistant tasks) for RNA, the report indicated for RNA to ambulate Resident 47's with PFW 5x/wk for 4 weeks as tolerated. Resident 47's January 2024 Documentation Survey Report indicated on 1/10/24 Resident 47 ambulated 20 feet for 15 minutes and on 1/12/24 Resident 47 ambulated 50 feet for 20 minutes. The January 2024 Documentation Survey Report indicated RNAs did not ambulate Resident 47 from 1/13/24 through 1/31/24, a total of 18 days. During a review of Resident 47's RNA Weekly Summary dated 1/11/24, the Weekly Summary indicated RNA walked Resident 47 five times a week from 1/3/24 to 1/10/24, used PFW as the assistive device and walked 25 feet. During a review of Resident 47's RNA Weekly Summary dated 1/18/24, the Weekly Summary indicated Resident 47 was seen by RNA five times the week of 1/11/24 to 1/17/24, and provided the resident with ambulation, AROM of BUE and BLE treatment, used a front-wheeled walker ([FWW] a device to assist with walking that has a wheel on each of the front legs) as the assistive device and walked zero feet. The RNA Weekly Summary also indicated Resident 47 Complains of pain. Not able to walk with the RNA after medicine (unspecified) given. During a review of Resident 47's RNA Weekly Summary dated 1/25/24, the Weekly Summary indicated Resident 47 was seen by RNA five times the week of 1/18/24 to 1/24/24, provided the resident with ambulation, AROM of BUE and BLE treatment, used FWW and walked zero feet. The RNA Weekly Summary also indicated the resident Complains of pain. Not able to walk with the RNA after medicine (unspecified) given. During a review of Resident 47's RNA Weekly Summary dated 2/1/24, the Weekly Summary indicated Resident 47 was seen by RNA five times the week of 1/25/24 to 1/31/24, provided the resident with ambulation, AROM of BUE and BLE treatment, used FWW platform and walked zero feet. The RNA Weekly Summary indicated the resident Complains of pain. Not able to walk with RNA. During a review of Resident 47's RNA Weekly Summary dated 2/8/24, the Weekly Summary indicated Resident 47 was seen by RNA five times the week of 2/1/24 to 2/7/24, provided the resident with ambulation, AROM of BUE and BLE RNA, used PFW as the assistive device and walked zero feet. The RNA Weekly Summary indicated the resident Complains of pain. Not able to walk after standing up. During a review of Resident 47's February 2024 Documentation Survey Report for RNA to perform Resident 47's ambulation with PFW, 5x/wk for 4 weeks as tolerated, the report indicated Resident 47 did not walk with any RNA from 2/1/24 to 2/14/24, a total of 14 days. During a review of Resident 47's medical record, the record indicate there were not any change of condition (COC) reports or reports of Resident 47's inability to ambulate with RNA, or any assessment of Resident 47's decline and interventions to address Resident 47's decline during January 2024 and February 2024. During a concurrent observation and interview on 2/13/24 at 10:15 a.m., in Resident 47's room, Resident 47 was in bed and was observed able to move a little bit both legs underneath the blankets. Resident 47 stated he was walking using a walker with PT, but it had been about a month since the last time he walked. Resident 47 stated no staff had been walking with him since physical therapy stopped on 1/3/2024. During a concurrent observation and interview on 2/14/24 at 10:06 a.m., in Resident 47's room, Resident 47 was in bed. Resident 47 stated he had not walked and wanted to walk again. Resident 47 stated he was walking before but now he was not walking. Resident 47 stated he had not done any walking with RNA and performed exercises (unspecified) on his own in the bed. During a concurrent observation and interview on 2/14/24 at 3:13 p.m., in Resident 47's room, Resident 47 was in bed on his back and stated he did not receive any RNA treatment today (2/14/24). During a concurrent observation and interview on 2/15/24 at 10:49 a.m., in Resident 47's room, RNA 1was observed to conduct treatment session to Resident 47. Resident 47 was observed sitting at the edge of the bed. RNA 1 was observed standing in front of the resident demonstrating the exercise movement to Resident 47 and the resident was following RNA 1's demonstration without any physical assistance from RNA 1. RNA 1 was observed counting the number of exercise repetition until Resident 47 completed the exercise. Resident 47 was observed able to move the right arm up and down to the resident's ear, bend and straighten the right elbow, roll both shoulders backward, touch the left shoulder with right hand, and open and close the right fingers without limitation. Resident 47 was able to lift the left arm to below shoulder level, touch the right shoulder with left hand, able to bend and straight left elbow, and open and close left fingers. Resident 47 was able to bend and straighten right knee but could not fully straighten the right knee, move the right ankle up and down. Resident 47 was able to bend and straighten the left knee but could not fully straighten the left knee and able to move left ankle up and down. RNA 1's was observed not ambulating Redesign 47 during observed treatment session on 2/15/24 at 10:49 a.m. During a concurrent interview and record review on 2/15/24 at 11:01 a.m. with RNA 1, the RNA's January 2024 and February 2024 treatment records and RNA's Weekly Summary were reviewed. RNA 1 stated Resident 47 currently had orders for RNA to provide AROM exercises to BUE and BLE and did not have an order for ambulation with RNA. RNA 1 stated she was not sure when the RNA's ambulation order was discontinued but it was recent. RNA 1 stated Resident 47 was previously on physical therapy and was transferred to RNA program for walking, but Resident 47 was not able to walk much. RNA 1 stated Resident 47 has to walk with a platform walker with two staff next to him on either side and one staff walking behind with a wheelchair. RNA 1 stated Resident 47 had not been walking with RNAs. RNA 1 reviewed the RNAs Weekly Summary dated 1/25/24, 2/1/24, 2/8/24, and stated Resident 47 did not walk with RNA due to pain (location not specified). RNA 1 stated she did not remember the last time she was able to walk with Resident 47. RNA 1 stated there were errors on the January 2024 RNA task documentation and confirmed Resident 47 had not walked for a while. During a concurrent interview and record review on 2/15/24 at 11:59 a.m. with PT 1, Resident 47's PT's records were reviewed. PT 1 stated if residents were discharged from PT with recommendations for RNA program, then orders for RNA were completed and RNAs were trained on how much assistance to provide during transfers, average distance for walking, and how to monitor ambulation. PT 1 reviewed Resident 47's PT's Treatment Notes and Discharge summary and stated, on 1/3/24 Resident 47 was able to ambulate 85 feet with moderate assistance and PFW. PT 1 stated there should have been an order for RNA for ambulation with PFW and leg (BLE) exercises. PT 1 stated Resident 47 should be able to walk 85 feet with moderate assistance, PFW and RNA, because that was the distance Resident 47 was able to walk upon discharge from PT therapy on 1/3/2024. PT 1 stated if Resident 47 could walk and did not receive ambulation exercises, then Resident 47 would decline in walking. PT 1 stated RNAs or nurses would report to physical therapy if a resident stopped walking with RNA or if a resident refused RNA. PT 1 stated PT would try to reassess the resident to see if they could benefit from therapy or assess if the resident really did not want to do any RNA. PT 1 stated walking 85 feet was a functional distance and a good distance so it would not be good if the resident was no longer able to walk this distance anymore. PT 1 stated that if a resident, who could previously ambulate, was no longer ambulating, the resident was at risk for getting weaker which may affect his ability to transfer. PT 1 stated Resident 47 would need to be reassessed by PT. PT 1 stated she was not aware Resident 47 was no longer walking with RNA. During a concurrent interview and record review on 2/15/24 at 1:51 p.m. the Director of Staff Development (DSD) stated she was the RNAs supervisor. DSD reviewed Resident 47's medical records and stated there was an order dated 11/15/23 for RNA program for assisted ambulation using PFW once a day 5x/wk for 4 weeks or as tolerated and she discontinued the RNA ambulation order on 2/12/24. DSD stated she discontinued the order due to Resident 47 was not able to ambulate. DSD stated Resident 47 was doing well with ambulation with RNA, then had a slow decline and complained of pain. DSD stated Resident 47 was walking a little less and then he did not walk at all. DSD stated if Resident 47, who was able to walk when discharged from physical therapy on 1/3/24, no longer able to walk, it considered a change of condition, and a COC should have been completed immediately so that nursing staff could notify the MD to see if there were any interventions or new orders to address the issue. DSD stated if the resident refused to walk with RNA, then RNAs should attempt treatments three times, and then complete a COC. DSD stated she reviewed Resident 47's medical records and there was no documentation indicating RNA staff or DSD reported the decline in ambulation with RNA to nursing staff, therapy staff, or the resident's physician. DSD stated there were no interventions or assessment completed by nursing or physical therapy to address Resident 47's significant decline in mobility. DSD stated if the MD was notified earlier and Resident 47 received an assessment and interventions to address the reason(s) for Resident 47's inability to walk, Resident 47's current inability to walk could have been avoided. During a phone interview on 2/15/24 at 3:07 p.m., with Medical Doctor (MD 1) stated he did not receive any notification from the facility regarding Resident 47's decline in mobility and inability to ambulate with RNA. During a concurrent interview and record review on 2/15/24 at 3:16 p.m. with DSD, the RNA Weekly Summaries was reviewed. DSD stated on 1/11/24 RNA's Weekly Summary indicated Resident 47 ambulated 25 feet with RNA assistance. DSD stated Resident 47 ambulated zero feet as indicated on RNA's Weekly Summaries dated 1/18/24, 1/25/24, 2/1/24, and 2/8/14. DSD stated she reviewed Resident 47's medical record again and confirmed there were no documented evidence of RNAs reporting to nursing, physical therapy, or MD 1 of Resident 47's inability to walk. DSD stated there were no nursing assessment, interventions, or COCs completed for Resident 47 to address the resident's decline in functional mobility and inability to ambulate. During a concurrent observation and interview on 2/16/24 at 9:20 a.m. with Resident 47, in Resident 47's room, the resident was observed in bed on his back. Resident 47 stated he would love to walk. Resident 47 stated he felt great and stronger when he walked and felt like he could move his body more when he walked. Resident 47 stated now he was in bed and felt like it took a lot of time for his body to get going to do anything since he had not walked. Resident 47 stated he felt like he could not walk right now and would have to get stronger to be able to walk again. During a phone interview on 2/16/24 at 10:53 a.m. RNA 2, stated Resident 47 did not walk that much with RNAs. RNA 2 stated Resident 47 did not walk 50 feet with RNA 2 on 1/13/24 and 1/14/24 (as documented by RNA 2) and it must have been an error. During an interview on 2/16/24 at 11:41 a.m., the Director of Nursing (DON) stated a COC was a form of communication about any alteration in a resident's condition and would include a decline in function. The DON stated a COC includes notification of a resident's MD, family, or responsible party, and interventions to improve a resident's condition. The DON stated the nurses must complete a COC. The DON stated if Resident 47 was walking while on RNA program and declined in mobility, and then stop walking, it should have been reported. The DON stated the nurses had to complete an assessment and refer Resident 47 to a higher level of care such as physical therapy to reassess the resident. During an interview on 2/16/24 at 2:38 p.m., the Registered Nurse Supervisor (RN 1) stated the licensed nurses were supposed to complete a COC as soon as possible when there was a decline in Resident 47's physical functioning. RN 1 stated waiting two weeks or four weeks was too long to complete a COC. RN 1 stated it was important to complete a COC immediately or the function of the resident would get worse, and the resident could decline and have contractures. RN 1 reviewed Resident 47's medical record and confirmed Resident 47 was previously able to ambulate and that there was no COC completed for Resident 47's decline in ambulation. RN 1 stated she was not notified about Resident 47 not being able to ambulate. During a concurrent interview and record review on 2/16/24 at 2:54 p.m., with the DON, Resident 47's medical record was reviewed. The DON stated no one from the facility's staff informed about Resident 47's had not been walking with RNAs. The DON stated walking 10 feet and taking a few steps with nursing staff considered a decline from walking 85 feet with moderate assistance. The DON stated Resident 47 should continue to walk 85 feet with RNAs because that was the distance the resident was walking with PT. The DON stated there was no documentation regarding RNAs reporting Resident 47 was not walking with RNAs. The DON stated RNAs should have reported to the licensed nurses and PT about Resident 47 was not walking. B. During a review of Resident 3's admission Record indicated Resident 3 originally was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cellulitis (infection of the skin) of left lower limb and right lower limb, acute respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) with hypoxia (low oxygen level in tissues), and muscle weakness. During a review of Resident 3's MDS dated [DATE] indicated Resident 3 had the ability to express ideas and wants and had the ability to understand others. The MDS also indicated Resident 3 had no functional limitations in range of motion in both upper extremities and had impairments on both sides of the lower extremities. The MDS indicated Resident 3 was dependent on staff for position from sit to lying, lying to sitting on side of a bed, and chair to bed transfers. The MDS indicated Resident 3 required substantial/maximal assistance from staff with eating, oral hygiene, and upper body dressing. During a review of Resident 3's Joint Mobility Assessment (JMA) dated 1/7/24 indicated Resident 3 was within functional limits (variance due to normal aging) for BUE and both ankle flexion (bend). The JMA indicated Resident 3 had minimal limitations (75 percent [%] to 100%) in both hip flexion and both knee flexion. During a review of Resident 3's Physician's Order Summary Report dated 2/14/24 indicated an order dated 7/26/23 for RNA to perform AROM exercises to BUE once a day five (5) times a week for four (4) weeks (5x/wk for 4 wks) as tolerated and an order dated 7/26/23 for RNA to perform BLE AROM (5x/wk for 4 wks) once a day as tolerated. During a review of Resident 3's care plan titled Alteration in Physical Functioning dated 3/10/23, the care plan indicated Resident 3 was at risk for decline in joint mobility and ADL decline. During a review of Resident 3's the February 2024 RNA Task Documentation Survey Report, the Survey Report indicated RNA provided to Resident 3 AROM exercises to BUE and BLE daily on 2/8/24, 2/9/24, 2/10/24, 2/11/24, 2/12/24, 2/13/24. During a concurrent observation and interview on 2/13/24 at 3:59 p.m., in Resident 3's room, observed Resident 3 was lying in bed on her back and wearing a hospital gown. Resident 3 stated she had not started doing any exercises with facility staff due to having an infection. Resident 3 was observed able to move both arms with minimal limitations and able to move a little both lower extremities underneath the blankets. During a concurrent observation and interview on 2/14/24 at 3:16 p.m., in Resident 3's room, Resident 3 was observed lying in bed with eyes closed and arousable to verbal cues. Resident 3 stated no staff came on 2/14/24 to do any exercises with her. During a concurrent interview and record review on 2/15/24 at 11:30 a.m., of Resident 3's February 2024 RNA Documentation Survey Report for RNA tasks, RNA 1 stated she did not provided ROM exercises to Resident 3. RNA 1 stated she has helped a Certified Nursing Assistants (CNA) to complete Resident 3's activity of daily living care and counted those encounters as RNA's treatment. RNA 1 stated the RNAs documented that Resident 3 completed RNA treatment when performed ADL care and not specific RNA ROM exercises to BUE and BLE. RNA 1 stated she should not have counted ADL care as RNA treatment because ROM exercises were different and that during ADL care provided to Resident 3, the resident did not move her arms and legs through a full range of motion. During an interview on 2/15/24 at 11:59 a.m., PT 1 stated joint mobility helps with function such as rolling, dressing, walking, transfers. PT 1 stated it was important to maintain Resident 3's joint mobility. During a concurrent interview and record review on 2/15/24 at 1:16 p.m., the DSD stated she was the RNA supervisor. DSD stated RNA orders for treatments were different than CNA or ADL care. DSD stated RNA orders for ROM was more intentional, more purposeful than just ADL care. DSD stated ADL care was not considered an RNA treatment. During an interview on 2/15/24 at 11:24 a.m., the DON stated an RNA program was a restorative program to maintain or improve a resident's ROM ability because residents could have ROM decline without the RNA program. The DON stated the facility should provide the RNA program to resident so that the residents maintained their function and quality of life. The DON stated RNA was different than CNA, because RNA was a special program that provides exercises to residents as recommended by PT and ordered by a resident physician. During a review of the facility's policies and procedures (P&P) revised 7/2017 titled, Resident Mobility and Range of Motion, indicated residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility. The policy indicated, documentation of the resident's progress toward the goals and objectives will include attempts to address any changes or decline in the resident's condition or needs. During a review of the facility's P&P revised 7/2017 titled, Restorative Nursing Services, indicated restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services. During a review of the facility's P&P revised 10/2020 titled, Range of Motion Exercises, indicated, the purpose of this procedure is to exercise the resident's joints and muscles .move each joint through its range of motion three (3) times unless otherwise instructed. Cross reference F580, F842

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a history of multiple falls, was supervised, monitored, and provided with a Mat alarm (an alarm used on top of a mattress or in a wheelchair to help monitor residents when they rise from the bed or wheelchair to reduce falls and unnecessary injury) in his wheelchair as recommended the Interdisciplinary Team ([IDT] a group of health care professionals with various areas of expertise who work together toward the goals of a resident) to prevent Resident 1 from falling and sustaining an injury. The facility failed to: 1. Ensure Resident 1's care plan was revised to include IDT's recommendations made after Resident 1's fall on 11/13/2023 that included continued use of the Mat alarm, frequent visual checks, and placing Resident 1 in front of or close to the nursing station. 2. Ensure Resident 1's care observation was endorsed to the nursing staff at the nursing station when Resident 1 was placed next to a nursing station on 12/12/2023 and was left unsupervised. Resident 1 without staff knowledge self-propelled himself in his wheelchair to the facility's dining/activity room where there was no staff present, stood up from his wheelchair unassisted and fell. 3. Ensure licensed staff followed the facility's P&P titled, Care Plans, Goals and Objectives, that indicated care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. 4. Ensure the licensed nurses and the IDT followed the facility's P&P, titled, Safety and Supervision of Residents in implementing interventions to reduce Resident 1's accident risks and hazards by communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions and ensuring interventions are implemented and documented. These deficient practices resulted in: Resident 1 sustaining seven falls on 4/16/2023, 5/9/2023, 5/12/2023, 5/30/2023, 11/13/2023 and twice on 12/12/2023. On 12/12/2023 at 8:45 p.m., Resident 1 was taken to a nursing station by CNA 6 without alerting nursing staff that she was leaving Resident 1 there and to watch him. Resident 1 left the nursing station without staff knowledge and entered the facility's dining/activity room where he stood up from his wheelchair unassisted and unsupervised, and fell. After the fall at the dinning/activity room, Resident 1 was taken to the nursing station and approximately 20 minutes later, in the presence of Licensed Vocational Nurse (LVN 1), Resident 1 stood up from his wheelchair unassisted and unsupervised, and fell to the floor again. Resident 1 sustained fracture (break) to his distal coccygeal (tailbone). Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (progressive loss of memory and impaired ability to remember or make decisions) and difficulty walking. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 3/10/2023, the MDS indicated Resident 1's cognitive skills for daily decision-making were severely impaired. The MDS indicated Resident 1 was not steady when moving from a seated to a standing position and could only stabilize with staff assistance. The MDS indicated Resident 1 required extensive one-person physical assist to move on/off the unit. During a review of Resident 1's Morse Fall Scale (a method for determining a resident's likelihood of falling) Reports for 2023, the reports indicated Resident 1 had falls on 4/16/2023, 5/9/2023, 5/12/2023, 5/30/2023, 11/13/2023 and 12/12/2023. During a review of Resident 1's IDT meeting note, dated 11/14/2023, the IDT note indicated Resident 1 had poor safety awareness, forgetfulness, and disorientation. The IDT note indicated Resident 1 needed constant redirection and reorientation of location. The IDT's recommendations were to continue the Mat alarm, frequent visual checks, and place Resident 1 in front of or close to the nursing station. During a review of Resident 1's Care Plan dated 11/13/2023, the Care Plan indicated the IDT's recommended interventions, to continue the use the Mat alarm, frequent visual checks, or to place Resident 1 in front of or near the nursing station, were not included. During a review of Resident 1's Tracking Record for Improving Patient Safety Report, dated 12/14/2023, the Tracking report indicated on 12/12/2023 at 8:21 p.m., Resident 1 wheeled himself to the dining room. The Tracking report indicated Resident 4, who was in the dining room, witnessed Resident 1 get out of his wheelchair and fall to the floor. The Tracking report indicated Resident 4 called for assistance and LVN 1, a certified nursing assistant (CNA 2) and CNA 3 arrived to find Resident 1 on the floor. The Tracking report indicated Resident 1's fall was unwitnessed by staff and Resident 1's wheelchair alarm was not in use. During a review of Resident 1's Tracking Record for Improving Patient Safety Report, dated 12/14/2023, the Tracking report indicated on 12/12/2023 at 8:45 p.m., after Resident 1 experienced an unwitnessed fall a few minutes prior (8:21 p.m.) and was taken in his wheelchair to the nursing station. The Tracking report indicated while LVN 1 was on the phone, Resident 1 got up from his wheelchair and fell again. During a review of Resident 1's Health Status Note dated 12/13/2023, the Health Status Note indicated Resident 1's physician ordered a STAT (urgent) X-ray of Resident 1's sacrum (triangular bone near buttocks). During a review of Resident 1's Radiology (X-ray) Report dated 12/13/2023, the Radiology Report indicated Resident 1 sustained a distal coccygeal fracture. During an interview on 12/29/2023, at 1 p.m., LVN 1 stated, on 12/12/2023, CNA 2 called her to attend to Resident 1. LVN 1 stated she went to the activity room to see what was going on and observed Resident 1 lying on the floor outside the activity room. LVN 1 stated, she, CNA 2, and CNA 3 assisted Resident 1 back into his wheelchair. LVN 1 stated, 15 minutes after she assisted Resident 1 back into his wheelchair, she (LVN 1) observed Resident 1, at the nursing station, getting up from his wheelchair and falling onto the floor on his buttocks. LVN 1 stated Resident 1 needed to be closely supervised. During a concurrent interview and record review on 1/2/2024 at 2:05 p.m., with the Director of Staff Development (DSD), Resident 1's Morse Fall Score Reports dated 3/4/2023, 4/16/2023, 5/9/2023, 5/12/2023 and 11/13/2023 were reviewed. The Morse Fall scores indicated Resident 1 scored between 55-75 indicating Resident 1 was at high risk for falls. The Morse Fall Score Report indicated Resident 1 would overestimate or forget limits of his ability to ambulate safely. The DSD stated the purpose of the Morse Fall Scale Report was to determine Resident 1's risk for falls and to develop a care plan with interventions to prevent falls and injuries. The DSD stated Resident 1's Morse Fall Score Report indicated Resident 1 was at high risk for falls due to his diagnosis of dementia and poor safety awareness and his care plans should be revised to reflect effective goals and interventions after each fall. During an interview on 1/12/2023 at 11a.m., CNA 6 stated she was assigned to Resident 1 on 12/12/2023 during the evening shift (3 p.m. - 11 p.m.). CNA 6 stated on 12/12/2023 at approximately 8 p.m., she wheeled Resident 1 to the nursing station. CNA 6 stated during that time there were staff present in the hallway and at the nursing station, so she thought Resident 1 was being supervised. CNA 6 stated she did not tell anyone that Resident 1 was there or to watch him as she left him there. CNA 6 stated Resident 1 propels himself in a wheelchair independently and often tries to get out of the wheelchair unassisted. During an interview on 1/12/2023 at 4:35 p.m., the DON stated she reviewed Resident 1's care plan dated 11/13/2023 and confirmed Resident 1's care plan was not revised to reflect specific interventions such as conducting frequent visual checks and placing a w/c alarm in Resident 1's wheelchair as discussed during the IDT meeting held after Resident 1's fall on 11/13/2023. During a review of the facility's P/P titled, Safety and Supervision of Residents dated 7/2017, the P/P indicated Resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. The P/P indicated the IDT care team shall analyze information obtained from assessments and observation to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The P/P indicated the facility will implement interventions to reduce accident risks and hazards including the following: Communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as needed, ensuring that interventions are implemented and documented. The P/P indicated how the facility will monitor the effectiveness of interventions to include ensuring interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying, or replacing interventions as needed, and evaluating the effectiveness of new or revised interventions. During a review of the facility's P/P, titled Care Plans, Goals and Objectives, revised 4/2009, the P/P indicated care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plan goals and objectives are defined as desired outcome for a specific resident problem. When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident, who was a high risk for falls, was transferred from a wheelchair to the bed by two persons for one of two sampled residents (Resident 1). The facility failed to: 1. Ensure a certified nursing assistant (CNA 1) and CNA 4 did not transfer Resident 1 from a wheelchair to bed without another staff assistance as indicated in the resident ' s untitled care plan. 2. Ensure CNA 1, CNA 4, and CNA 5 followed the facility ' s policy and procedure (P/P) titled Falls and Fall Risk, Managing by trying to prevent Resident 1 from falling during transfer from a wheelchair to bed by implementing the care plan intervention to have two person physical assistance for the resident ' s transfer. These deficient practices resulted in Resident 1 falling during transfer from a wheelchair to bed and sustaining a right femur (thighbone) fracture (broken bone) requiring transfer to a general acute care hospital (GACH) for right hip repair surgery. Findings: During a review of Resident 1 ' s admission Records the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility 11/19/2023 with diagnoses including unspecified fracture of the right femur, aftercare following right hip replacement surgery, difficulty walking, muscle weakness and hemiplegia (paralysis [loss of the ability to move] on one side of the body). During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care-screening tool) dated 10/11/2023, the MDS indicated Resident 1 was able to make herself understood and understood others. The MDS indicated Resident 1 was not experiencing any pain or hurting during the time of assessment (5 day look back period (period of time within which the resident ' s condition is captured by the MDS assessment). The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort of activities for the resident) on staff for assistance with bathing, dressing, and using the toilet. During a review of Resident 1 ' s Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated Resident 1 was rated 75 indicating a high fall risk (0-24 low fall risk, 25-44 moderate fall risk, above 45 a high fall risk). During a review of Resident 1 ' s Health Status Note dated 3/25/2023, the Health Status Note indicated Resident 1 had an assisted fall on 3/25/2023 while CNA 4 attempted to transfer the resident to a wheelchair. The Health Status Note indicated Resident 1 was being assisted by CNA 4 into her wheelchair and Resident 1 ' s knee gave out. Resident 1 was assisted to the floor, landing on her buttocks. During a review of Resident 1 ' s untitled care plan dated 3/25/2023 (initiated after the witnessed fall), the care plan indicated Resident 1 had an assisted fall by CNA 4 with a goal for Resident 1 to not have any injuries status post (s/p) fall. Resident 1 ' s care plan interventions included assessing for the root cause and risk factors that may have resulted in Resident 1 ' s fall and facility staff to utilize two-person physical assistance for Resident 1 ' s transfers between surfaces and bed mobility. This care plan was active when Resident 1 sustained a fall on 11/15/2023. During a review of Resident 1 ' s Joint Mobility Assessment, dated 7/12/2023, the Joint Mobility Assessment indicated Resident 1 had functional impairment to both lower extremities including hip, knee, ankle, foot. During a review of Resident 1 ' s History and Physical report (H&P) dated 9/26/2023, the H&P indicated Resident 1 required assistance with walking, had right sided hemiplegia, and was able to exercise her rights regarding care (able to understand and be involved in care). During a review of Resident 1 ' s Health Status Note dated 10/4/2023, the Health Status Note indicated Resident 1 was assessed and required extensive two-person assistance for activities of daily living (ADL) and had limited mobility. During a review of Resident 1 ' s Health Status Note written by the licensed vocational nurse (LVN 1) dated 11/15/2023 and timed at 7:09 p.m., the Health Status Note indicated at approximately 3 p.m., Resident 1 sustained a sprain (twist of connective tissue that connects two bones of a joint) on right thigh during incontinence brief change. The Health Status Note indicated LVN 1 applied Rest, Ice, Compression, and Elevation (RICE). During a review of the Change of Condition ([COC] documentation of vital medical information when a resident experiences a change from their normal state of being) evaluation dated 11/16/2023 at 9 a.m., the COC indicated Resident 1 was experiencing right knee and right hip pain rated a nine out of 10. The COC indicated Resident 1 had a witnessed fall on 11/15/2023 (the second fall in 2023 while being assisted by one person). The COC indicated the pain was acute (new) musculoskeletal (involving both muscles and bones) pain. The COC indicated Resident 1 reported the following: 1. Right hip pain was acute, intolerable (unable to endure), sharp, throbbing pain rated nine out of10. 2. Right thigh pain was acute, intolerable, sharp, throbbing pain rated eight out of 10. 3. Right knee pain was acute intolerable, sharp, throbbing pain rated seven out of 10. The COC indicated the movement of the right leg made the pain worse and immobilization (the process of stopping something from moving) that was applied by the registered nurse supervisor (RN 1), made the pain better. During a review of Resident 1 ' s Health Status Note dated 11/16/2023 (the day after the fall) at 9 a.m., the Health Status Note indicated at approximately 9 a.m. Resident 1 complained of right hip and right knee pain. The Health Status Note indicated Resident 1 was assessed by RN 1 and LVN 2, who was a charge nurse. Resident 1 ' s physician (MD1) was notified of Resident 1 ' s severe pain. The Health Status Note indicated MD1 ordered the following: 1. Obtain an X-ray (a photographic or digital image of the internal composition of a part of the body) of the right hip and knee. 2. Administer Ultracet (a combination of Tramadol [pain medication] 37.5 ([mg] unit of weight measurement) and 325 mg Tylenol (a pain medication ) for pain level of six out of 10. 3. Administer Norco (narcotic pain medication) 10/325mg for a pain scale of seven out of 10. 4. Apply an ice pack to the right knee for swelling and pain. During a review of Resident 1 ' s COC dated 11/16/2023 and timed at 9:15 a.m., the COC indicated Resident 1 ' s change of condition was a fall, and Resident 1 had a decline in function and mobility, with uncontrollable pain. The COC indicated Resident 1 had a fall that was associated with a suspected serious injury (e.g., fracture) and hip pain. During a review of Resident 1 ' s X-ray results report dated 11/16/2023 and timed at 12:14 p.m., the X-ray report indicated the following: An acute interochanteric fracture (upper portion of femur, a type of hip fracture or broken hip) of the right femur with superior (top) and medial (middle) displacement (femur bone was forced out of alignment) without dislocation (bones separated where they meet at the joint). During a review of Resident 1 ' s Health Status Note dated 11/16/2023 at 2:47 p.m., the Health Status Note indicated Resident 1 was transferred to GACH via ambulance at 2:45 p.m. on 11/16/2023. During a review of Resident 1 ' s H&P report from the GACH dated 11/16/2023, Resident 1 was admitted to the GACH due to a right hip fracture after sustaining a fall at the facility the day prior (11/15/2023). The GACH record indicated Resident 1 was to undergo an Open Reduction Internal Fixation ([ORIF], a type of surgery used to stabilize and heal a broken bone) for the right hip fracture. During an interview on 11/30/2023 at 11 a.m., Resident 1 stated on 11/15/2023 around 4 p.m. CNA 1 was assisting her to go to the bathroom. Upon returning from the bathroom CNA1 was assisting her (Resident 1) to get back to bed by transferring her from a wheelchair to bed. CNA 1 was transferring her alone without the assistance of another staff. Resident 1 stated when she stood up to initiate the transfer her leg gave out and she (Resident 1) fell to the floor straight on her knees. Resident 1 stated she immediately felt excruciating pain and began yelling and screaming in pain. Resident 1 stated CNA 1 and CNA 2 got her (Resident 1) off the floor and back into bed. Resident 1 stated she was having excruciating pain. Resident 1 stated the next day (11/16/2023) the X-ray was done which showed a fracture and she was sent to the GACH for surgery. During an interview on 11/30/2023 at 1 p.m., a restorative nursing assistant ([RNA 1] a trained CNA that interacts with the resident and provides skilled practice and exercises with walking and mobility) stated Resident 1 could be very unsteady on her feet and her legs were shaky. RNA 1 stated when RNAs walk Resident 1 they would use a front wheeled walker (a mobility device with two front wheels that offers stability and support while walking) and have two to three RNAs for assistance, one on the left side, one on the right side, and one walking behind Resident 1 with a wheelchair in case Resident 1 ' s legs gave out or she became tired. During an interview on 12/1/2023 at 12:21 p.m., CNA 1 stated on 11/15/2023 around 4 p.m. she was helping Resident 1 to transfer from a wheelchair back to bed. When Resident 1 stood up from the wheelchair to get transfer, her leg gave out so she fell on her right side, hitting the mattress with the right side of the body then slid down to her knees. CNA1 stated, Resident 1 immediately started screaming in pain, so she called CNA 2 for help and her (CNA 1) and CNA 2 placed Resident 1 back to bed. CNA1 stated after dinner time (between 5 p.m. to 6 p.m.) she (CNA 1) went to check on Resident 1 and change her incontinence briefs. CNA1 stated Resident 1 was okay when she was just lying in bed but as soon as she (Resident 1) was moved to be changed or repositioned, Resident 1 was yelling and screaming in pain. CNA 1 stated Resident 1 had her face scrunched up and was grimacing (a facial expression of pain) due to the amount of pain she was in. During an interview on 12/1/2023 at 12:58 p.m., LVN 1 stated on 11/15/2023 CNA 1 reported Resident 1 was in pain, she did not mention that Resident 1 fell. During an interview on 12/1/2023 at 1:15 p.m., Resident 1 ' s Family Member (FM1) stated on 11/15/2023 around 7 p.m. Resident 1 called her and was hysterically crying due to having pain in her leg. FM1 stated Resident 1 informed her of the fall. FM1 stated she was frustrated to learn that only one CNA was helping Resident 1 with the transfer from a wheelchair to bed leading to Resident 1 ' s fall. FM1 stated Resident 1 had a history of falls at the facility. FM1 stated she had a meeting with the facility after previous falls, and she was assured that two people would be assisting Resident 1 during care and transfer. FM1 stated she visited Resident 1 frequently and Resident 1 was unsteady on her feet so it was unbelievable to her the facility would have one CNA transferring Resident 1 alone. During an interview on 12/1/2023 at 5:08 p.m., the Director of Nursing (DON) stated when a fall occurs, the facility staff were to follow the facility ' s Falls and Fall Risk policy. The DON stated the licensed nurses must immediately assess the resident prior to moving the resident incase the resident has injuries that can get worse with movement. The DON stated the resident ' s physician should have been notified immediately so the physician could give timely orders for tests to treatment. The DON stated it was important for the facility staff to carry out interventions outlined in Resident 1 ' s untitled care plan for falls, dated 3/25/2023, because the care plan was a guideline for Resident centered care and Resident 1 ' s fall prevention. During an interview on 12/7/2023 at 10:15 a.m., RN 1 stated that on the morning of 11/16/2023, she first learned of Resident 1 ' s right hip pain at around 9 a.m. from LVN 2. RN 1 stated when she went to assess Resident 1, the resident was lying comfortably in bed but as soon as she (RN 1) touched the resident ' s right leg, the resident screamed in pain. RN 1 stated Resident 1 informed her that she had fallen the night prior (11/15/2023) on her right side. RN 1 stated she placed an immobilizer on Resident 1 ' s right leg to relieve Resident 1 ' s pain. RN 1 stated MD1 was notified of Resident 1 fall and right hip pain for the first time on 11/16/2023 around 9 a.m. During a review of the facility ' s P/P titled Falls and Fall Risk, Managing dated 3/2018, the P/P indicated the facility staff was to identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P/P indicated facility staff was to implement a resident-centered fall prevention care plan to reduce the specific risk factors of falls for each resident at risk or with history of falls. The P/P indicated if falling recurs despite initial interventions, staff will implement additional or different interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to manage pain for one of two sampled residents (Resident 1). The facility failed to: 1. Ensure the licensed vocational nurse (LVN 1) did not let Resident 1 experience excruciating pain without receiving pain medication for 17 and half hours after a fall. 2. Ensure LVN 1 notified Resident 1's physician of Resident 1 experiencing excruciating pain in the right leg after the resident fell; and obtain orders for pain medication. 3. Ensure LVN 1 assessed Resident 1 for pain location and pain severity when Resident 1 complained of pain after a fall. 4. Ensure Resident 1's physician was notified of the resident's fall for the physician to provide orders for timely treatment and transfer to a general acute care hospital (GACH). These deficient practices resulted in Resident 1 experiencing excruciating pain without receiving pain medication for 17 and half hours after the fall. Resident 1 was sent to the GACH on 11/16/2023 where the resident was diagnosed with right femur (thighbone) fracture and underwent an Open Reduction Internal Fixation ([ORIF] a type of surgery used to stabilize and heal a broken bone) surgery of the right hip fracture. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including fracture of the right femur, aftercare following right hip joint replacement surgery, difficulty walking, muscle weakness, and hemiplegia (paralysis [loss of the ability to move] on one side of the body). During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care-screening tool) dated 10/11/2023, the MDS indicated Resident 1 was able to make herself understood and understood others. The MDS indicated Resident 1 was not experiencing any pain or hurting during the time of assessment (5 day look back period (period of time within which the resident's condition is captured by the MDS assessment). The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort of activities for the resident) on staff for assistance with bathing, dressing, and using the toilet. During a review of Resident 1's Care Plan initiated on 8/24/2018, and last revised on 1/11/2023, the Care Plan focus indicated Resident 1 was at risk for pain. The Care Plan goal was for Resident 1 to maintain her comfort level and to be free from pain with interventions that included assessing Resident 1 for changes in pain that may have indicated new pain, assessing Resident 1's characteristics of pain, and administer as needed pain medication as ordered. During a review of Resident 1's Health Status Note, written by licensed vocational nurse (LVN 1) dated 11/15/2023 and timed at 7:09 p.m., the Health Status Note indicated that at approximately 3 p.m., Resident 1 sustained a sprain (a twist of the ligaments [connective tissue that connects two bones] such as in the ankle, the wrist, or other joint violently as to cause pain and swelling) on a left thigh. (however, it was Residetn 1's right leg). The Health Status Note documentation indicated that per a certified nursing assistant (CNA 1), Resident 1 was experiencing pain in the right leg during incontinence brief change . The note indicated the Rest, Ice, Compression, and Elevation (RICE, a method of self-care to care for an injury, usually for soft tissue injuries [sprains, strains, and bruising]) protocol was initiated. During a review of Resident 1's Medication Administration Report (MAR) for the month of 11/2023, the MAR indicated Resident 1 was not given any medication for pain on 11/15/2023 (the day of the fall). During a review of Resident 1's Change of Condition ([COC] documentation of vital medical information when a resident experiences a change from their normal state of being) Evaluation form dated 11/16/2023 and timed at 9 a.m., the COC indicated Resident 1 had a witnessed fall (Resident 1 fell while CNA1 was assisting her from the wheelchair back to bed) on 11/15/2023. The COC indicated the resident had acute (new) musculoskeletal (involving both muscles and bones) pain. The COC indicated Resident 1 complained of right hip pain described as intolerable (unable to endure), sharp and throbbing. Resident 1 rated pain as nine out of 10 on a pain scale from zero to 10 (a tool used to assess a person's pain where zero is no pain, 1-4 was mild pain, 5-7 was moderate pain, and 8-10 was severe pain). The COC indicated that Resident 1 also complained of acute right thigh pain which was described as intolerable, sharp, throbbing, and rated eight out of 10 on the pain scale. The resident also complained of acute right knee pain, which was described as intolerable, sharp, throbbing pain and rated a seven out of 10 on a pain scale. The COC indicated movement of Resident 1's right leg made the pain worse and not moving Resident 1's leg made the pain better. During a review of Resident 1's Health Status Note dated 11/16/2023 (the day after the fall) and timed at 9 a.m., the Health Status Note indicated at approximately 9 a.m. on 11/16/2023 Resident 1's physician (MD 1) was notified of Resident 1's severe pain. MD 1 ordered the following: 1. Obtain an X-ray (a photographic or digital image of the internal composition of a part of the body) of the right hip and knee. 2. Administer Ultracet (a combination of Tramadol [pain medication] 37.5 ([mg] unit of weight measurement) with 325 mg Tylenol for pain level of six out of 10. 3. Administer Norco (narcotic pain medication) 10/325mg for a pain scale of seven out of 10. 4. Apply an ice pack to the right knee for swelling and pain. A review of Resident 1's order summary report dated 11/2023, indicated MD 1 placed an order on 10/31/19 for Tylenol 325 mg, two tablets by mouth every four hours as needed for joint pain scale level one out of 10. During a review of the MAR dated 11/2023, the MAR indicated on 11/16/2023, Resident 1 received Tylenol 650 mg at 9:30 a.m. for pain level of six out of 10 and again at 1 p.m. for pain level of six out of 10. The MAR indicated Resident 1 did not receive Ultracet for a pain level of six out of 10 as ordered. During a review of Resident 1's X-ray results report dated 11/16/2023 and timed at 12:14 p.m., the X-ray report indicated the following: 1. No acute fracture or dislocation of the right knee. 2. Acute interochanteric fracture (upper portion of femur, a type of hip fracture or broken hip) of the right femur with superior (top) and medial (middle) displacement (femur bone was forced out of alignment) without dislocation (bones separated where they meet at the joint). During a review of Resident 1's Health Status Note dated 11/16/2023 and timed at 2:47 p.m., the Health Status Note indicated Resident 1 was transferred to the GACH via ambulance at 2:45 p.m. (22 hours and 45 minutes after Resident 1's fall). During a review of Resident 1's History and Physical (H&P) report from the GACH dated 11/16/2023, the H&P indicated Resident 1 was admitted to the GACH due to a right hip fracture after sustaining a fall at the facility the day prior (11/15/2023). During a review of Resident 1's Discharge Summary report from the GACH dated 11/19/2023, the Discharge Summary indicated Resident 1 underwent ORIF surgery for a right hip fracture. During an interview on 11/30/2023 at 11 a.m., Resident 1 stated on 11/15/2023 around 4 p.m. CNA 1 was assisting her to go to the bathroom. Upon returning from the bathroom CNA1 was assisting her (Resident 1) to get back to bed by transferring her from a wheelchair to bed. CNA 1 was transferring her alone without the assistance of another staff. Resident 1 stated when she stood up to initiate the transfer her leg 'gave out' and she fell straight to the floor on her knees. Resident 1 stated she immediately felt excruciating pain and started yelling and screaming in pain. Resident 1 stated CNA 1 and CNA 2 got her off the floor and placed her back into bed. Resident 1 stated she was having excruciating pain, but LVN 1 just applied an ice pack on her leg. Resident 1 stated she was in excruciating pain all night every time the CNAs tried to change her incontinence briefs. Resident 1 stated she uses incontinence briefs at night. Resident 1 stated around 7 p.m. on 11/15/2023 she was in so much pain she called a family member (FM 1) crying that she could not tolerate the pain and kept begging the facility's staff for medication, but all she got was an ice pack. Resident 1 stated she felt pissed off that she had fallen, and staff was not taking her pain complaints seriously. Resident 1 stated she was waiting for pain medication until the next day. During an interview on 12/1/2023 at 12:21 p.m., CNA 1 stated on 11/15/2023 around 4 p.m. she was helping Resident 1 transfer from a wheelchair back to bed and when Resident 1 stood up to get transferred she fell to her side, hitting the mattress with the right side of her body and then slid down to the floor on her knees. CNA1 stated Resident 1 immediately started screaming in pain. CNA 1 stated she called CNA 2 for help and together they lifted Resident 1 from the floor and placed the resident back into the bed. CNA1 stated she immediately reported to LVN 1 what had happened. CNA 1 stated LVN 1 went to check Resident 1 and told the resident she (LVN 1) would get an ice pack for her (Resident 1's) pain. CNA1 stated after dinner time (between 5 p.m. and 6 p.m.), she (CNA1) went to check on Resident 1 and change her incontinence briefs. CNA1 stated Resident 1 was okay when she was just lying in bed but as soon as she (Resident 1) was moved to be changed or repositioned, Resident 1 was yelling and screaming in pain. CNA 1 stated Resident 1 had her face scrunched up and was grimacing (a facial expression of pain) due to the amount of pain she was in. CNA 1 stated she informed LVN 1 again about Resident 1 having pain and LVN 1 brought more ice to apply on Resident 1's leg. CNA 1 stated she informed LVN 1 three times that day that Resident 1 was screaming in pain. During an interview on 12/1/2023 at 12:58 p.m., LVN 1 stated on 11/15/2023 CNA 1 reported that Resident 1 was in pain, but not that Resident 1 had a fall. LVN 1 stated Resident 1 informed her it was a leg sprain, therefore she treated it as a leg sprain and performed RICE. LVN 1 stated she gave Resident 1 an ice pack and elevated the leg. LVN 1 stated she did not call the physician on 11/15/2023 to report Resident 1's change of condition after the resident complained of pain. During a review of Resident 1's Pain Tool Evaluation form for the month of 11/2023, the Pain Tool Evaluation form indicated LVN 1 did not assess Resident 1's pain location and characteristics on 11/15/2023 (the day of Resident 1 fall) as care planned. During an interview on 12/1/2023 at 1:15 p.m., FM 1 stated on 11/15/2023 at around 7 p.m. Resident 1 called her hysterically crying where she could barely even make out what Resident 1 was saying but she could understand that her leg was hurting her. FM 1 stated she called the facility and spoke to LVN 1 who informed her everything was going to be okay and Resident 1 just sprained her leg. FM1 stated she found it odd that LVN 1 was calling it a sprain just by looking at it without an X-ray, but she was the nurse, so I did not question it. FM 1 stated LVN 1 informed her she did a knee massage for Resident 1 and gave the resident some ice and the resident was okay. FM 1 stated she was worried about Resident 1 and her pain, but the nurse assured her the resident was okay, so she (FM 1) tried not to worry about her that night. FM 1 stated she was very upset and believed the facility downright neglected Resident 1 because they left her in pain all night and did not address the resident's fall or pain until the next day. FM 1 stated Resident 1 was in bad pain all night. FM 1 stated Resident 1 was a very strong lady and does not complain often so the nurses should have known something was seriously wrong when Resident 1 was crying in pain. During an interview on 12/1/2023 at 5:08 p.m., the director of nursing (DON) stated when a fall occurs, the facility staff must follow the facility's policy on Incidents and report the fall, and the resident must immediately be assessed by a licensed nurse prior to moving the resident incase the resident has injuries that can get worse with movement. The DON stated staff cannot make medical diagnoses because it is not within their scope of practice and LVN 1 should not have assumed Resident 1 just had a sprain. The DON stated the physician should have been notified immediately so the physician could give orders for tests and treatment for the resident and get a true medical diagnosis, and to treat the pain. The DON stated LVN1 failed to document a pain assessment (including pain location, intensity, and other characteristics of pain) for Resident 1 on 11/15/2023. The DON stated appropriate pain assessment and management was important because pain affects the resident's quality of life and pain is an indicator that something is wrong with the resident. The DON stated it was important for the facility staff to carry out interventions outlined in Resident 1's untitled care plan for falls, dated 3/25/2023, because the care plan was a guideline for Resident centered care and Resident 1's fall prevention. During an interview on 12/7/2023 at 10:15 a.m., Registered Nurse supervisor (RN 1) stated on the morning of 11/16/2023, she first learned of Resident 1's pain at around 9 a.m. from LVN 2. RN 1 stated when she went to assess Resident 1 on 11/16/2023, the resident was lying comfortably in bed but as soon as she (RN 1) touched the resident's right leg, Resident 1 complained of pain. RN 1 stated Resident 1 informed her that she (Resident 1) had fallen the night prior and had a sprain on her leg. RN 1 stated LVN 2 gave Resident 1 Tylenol 650 mg for pain on 11/16/2023 at around 9:30 a.m., because that was what was available. During an interview and concurrent record review on 12/7/2023 at 10:24 a.m., the DON reviewed Resident 1's MAR record for 11/15/2023 and 11/16/2023. The DON stated that on 11/15/2023 (the day of Resident 1's fall), Resident 1 did not receive any pain medications. The DON stated Tylenol was documented as given on 11/16/2023 at around 9:30 a.m. (17.5 hours after the fall). The DON stated Resident 1 was requesting more powerful pain medications than Tylenol on the morning of 11/16/2023 but by time they received the new orders from MD 1 and the stronger pain medications were authorized, Resident 1 had already been sent out to the GACH. During a review of the facility's policy and procedure (P/P) titled Incidents dated 12/2007, the P/P provided guidelines for facility staff to follow in the case of an actual fall. The P/P indicated to prevent further injury, do not move the resident after fall until complete range of motion (ROM) was done. The P/P indicated a complete head to toe check was required and the physician and responsible party was to be notified of the fall. During a review of the facility's P/P titled Pain Assessment and Management dated 10/2022, the P/P indicated acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. The P/P indicated facility staff was to monitor the resident for the presence of pain and the need for further assistance when there was a change of condition. The P/P indicated the physician was to be notified immediately if the resident's pain was not adequately controlled the physician needed to be notified for significant changes in the level of the resident's pain. The P/P indicated the documentation regarding the resident's pain should be documented with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA 1) did not physically and verbally abuse a resident (Resident 1) when Resident 1 refused to have her wet adult brief changed and peri-care (cleaning the private area) performed by CNA 1 for one out of two sampled residents (Resident 1). As a result of this deficient practice, Resident 1 felt helpless, useless, and like CNA 1 was going to kill her, following CNA 1's disparaging (words meant to belittle the value or importance of someone or something) comments about her that is why you are blind, you cannot walk, and you are going to be in that bed for the rest of your life, and when CNA 1 physically assaulted Resident 1 by grabbing her wrist tightly, pulling and pushing her from side to side in her bed, hitting and smashing her face on the bed rail, then using a threatening tone when she told Resident 1's (Resident 2) not to use the call light again. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), type 2 diabetes ([DM] a condition that affects how the body processes sugar), and hypertension ([HTN] high blood pressure). During a review of Resident 1's History and Physical (H&P), dated 11/15/2022, the H&P indicated, Resident 1 was alert and oriented (aware of) to person, place, time, and event, was cooperative and had an appropriate mood and affect (the outward expression of emotion). During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 2/4/2023, the MDS indicated, Resident 1 had the ability to express ideas and wants, had clear comprehension (capability of understanding something), required extensive one-person physical assist to complete toileting, personal hygiene, dressing, and was totally dependent and required a two-person physical assist with transfers and bed mobility. During a review of Resident 1's Care Plan (CP), dated 8/23/2019, the CP indicated, Resident 1 preferred to be changed at specific times by certain CNAs. The CP's goal was to meet Resident 1's needs through the next CP review date, 5/26/2023. The CP's interventions included always respecting Resident 1's rights and letting Resident 1 make choices regarding what time she wanted to be changed instead of staff telling the resident what to do. During a review of a Report of Abuse and Neglect of an Elder or Dependent Adult (SOC 341), dated 3/10/2023, the SOC 341 indicated Resident 1 reported that CNA 1 was physically and verbally abusive. The SOC 341 indicated Resident 1 did not want her buttocks cleaned and CNA 1 ignored Resident 1's preference. The SOC 341 indicated CNA 1 grabbed Resident 1's arm very strongly and forced Resident 1 to have her buttocks cleaned after the resident refused. During a review of Resident 1's Health Status Note (HSN), dated, 3/10/2023, the HSN indicated Resident 1 had episodes of screaming during incontinence (involuntary voiding of urine and stool) care. The HSN indicated Resident 1 did not like her assigned CNA (CNA 1) and after a moment of exchanging words, managed to change the bottom sheet with a dry sheet, but Resident 1 was still upset. It took a while to calm Resident 1 down. During an interview on 3/15/2023 at 2:05 p.m., with the Social Services Director (SSD), the SSD stated on 3/10/2023, she (the SSD), the Administrator (ADM), and the Director of Nursing (DON) interviewed Resident 1, who reported she had been physically and verbally abused on the night shift (3/10/2023), by CNA 1, who was from a registry (a nurse who works on a temporary basis through an agency in a variety of settings rather than a permanent role or in one fixed place). During a concurrent observation and interview on 3/15/2023, at 2:50 p.m., with Resident 1, Resident 1 stated when she refused to allow CNA 1 to change her wet brief, CNA 1 insisted on changing her anyway. Resident 1 stated she asked her roommate (Resident 2) to put on her (Resident 2's) call light, but CNA 1 responded in a loud and aggressive tone of voice, you better not turn on the call light. Resident 1 stated, CNA 1 said to her, that is why you are blind, you cannot walk, and you are going to be in that bed for the rest of your life. Resident 1 stated, she continued to refuse to have her brief changed several times and CNA 1 grabbed her wrist tightly, pulled and pushed her from side to side and hit and smashed her face on the bed rail. Resident 1 stated, she yelled and screamed for help and Licensed Vocational Nurse 1 (LVN 1) came running into her room and she immediately informed LVN 1, that CNA 1 was abusing her. Resident 1 stated she felt helpless and useless, and thought CNA 1 was going to kill her. Resident 1 was observed with glossy eyes, her voice crackled and between long pauses stated, she wished her son had been there to protect her. During an interview on 3/15/2023 at 3:10 p.m., with Resident 2, Resident 2 stated, she was awake and witnessed the incident with Resident 1 and CNA 1. Resident 2 stated, she did not see the physical stuff, but stated she heard CNA 1 tell Resident 1 that she (Resident 1) was blind and could not walk. Resident 2 stated, she heard Resident 1 tell CNA 1 that she (Resident 1) did not want to be changed, then she heard Resident 1 yell, stop treating me so rough! Resident 2 confirmed, Resident 1 asked her (Resident 2) to put on her call light, then stated she heard CNA 1 say in a loud aggressive tone, do not put on that call light again! that was when Resident 1 started screaming for help. Resident 2 stated, CNA 1's statement about not putting the call light on again, made her (Resident 2) afraid to turn on the call light for the rest of the night. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses including heart failure and major depression (persistent feeling of sadness and loss of interest). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had adequate hearing, clear speech, was usually able to understand and make herself understood by others. During an interview on 3/15/2023 at 4:30 p.m., with the Director of Staff Development (DSD), the DSD stated, on 3/10/2023, Resident 1 reported she had been physically and verbally abused by a night shift CNA (CNA 1) The DSD stated, she did not investigate the allegation of abuse made by Resident 1 but reported the allegation of abuse to the Administrator (ADM). The DSD stated, CNA 1 was a registry staff, and worked on 3/9/2023 from 10:30 p.m.,., to 3/10/2023 at 7 a.m. During a telephone interview on 3/15/2023 at 4:45 p.m., with LVN 1, LVN 1 stated, on 3/10/2023 around 4 a.m., to 5 a.m., he was at the other end of the facility when he heard Resident 1 was screaming for help. LVN 1 stated, when he entered Resident 1's room he heard a heated discussion between Resident 1 and CNA 1, but he could not remember what was said. LVN 1 stated, Resident 1 reported that CNA 1 abused her by grabbing her arm tight, pushing, and pulling her and smashing her face against the bed rail. LVN 1 stated, Resident 1 reported that she told CNA 1 she did not want to be changed, but CNA 1 changed her anyway and handled her roughly. During an interview on 3/15/2023 at 5:10 p.m., with the Director of Nursing (DON), the DON stated, on 3/10/2023 the ADM informed her of Resident 1's allegation of abuse. The DON stated, she, the ADM, and the SSD interviewed Resident 1. The DON stated, Resident 1 reported she was physically and verbally abused by her night shift CNA (CNA 1). The DON stated, Resident 1 reported that CNA 1 grabbed her arm and squeeze her tight, hurting her arm. The DON stated the nursing registry was notified of the abuse allegation and CNA 1 was put on the do not return list. During an interview on 3/15/2023 at 5:25 p.m., with the ADM, the ADM stated, on 3/10/2023 she was informed of Resident 1's allegation of abuse. The ADM stated, Resident 1 reported she was handled roughly by the CNA 1 on the night shift. The ADM stated the investigation of the alleged abuse was ongoing. During an interview on 3/16/2023 at 12:43 p.m., with CNA 1, CNA 1 stated, on 3/10/2023 at 4 a.m., she entered Resident 1's room and explained to Resident 1 that she was there to change her wet brief. CNA 1 stated, Resident 1 started arguing with her and refused to be changed. CNA 1 stated, Resident 1 initially told her several times she did not want to be changed but stated eventually Resident 1 agreed to be changed. CNA 1 stated, while changing Resident 1 she (Resident 1) began to scream and would not allow her to finish changing her (Resident 1). CNA 1 stated, LVN 1 came into the room and Resident 1 told LVN 1 that she (CNA 1), was abusing her (Resident 1). CNA 1 stated, Resident 1's sheets and brief were wet, and she could not leave Resident 1 like that even though Resident 1 refused to be changed. CNA 1 acknowledged and stated, Resident 1 had the right to refuse, and staff must honor residents' rights. CNA 1 stated, she did not physically or verbally abuse Resident 1. During an interview on 3/16/2023 at 2:30 p.m., with CNA 2, CNA 2 stated, on the morning of 3/10/2023, Resident 1 was quiet, she was not happy, or talkative, and social like she normally was. CNA 2 stated, she asked Resident 1 if she was ok and Resident 1 told her, she had a rough night and stated, that CNA 1 on the night shift handled her roughly, squeezed her arm, pushed her hard against the bed rail, and was verbally abusive towards her and then told her roommate (Resident 2), in an intimidating manner she better not turn on the call light again. CNA 2 stated she reported the allegation to the DSD. During a review of the facility's policy and procedure (P/P) titled, Abuse Prevention Program, dated 12/2016, the P/P indicated, residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. As part of the resident abuse prevention, the administration will protect residents from abuse by anyone including, but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.