**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from accidents for one of three residents (Resident (R) 2) sampled for falls and one of one resident (R1) sampled for accident hazards. 1) The facility failed to ensure two trained staff members operated a mechanical lift and upon analysis, indicated human error, which lead to R2's fall from the lift. During transfer with use of a mechanical lift, the left side lift sling straps slipped off the hanger bar as R2 was lifted causing R2 to fall. As a result, R2 was hospitalized with left side rib fractures with pneumothorax (collapsed lung) requiring a pigtail chest tube placement. 2) The facility failed to ensure R1 received care consistent with her physician orders. As a result, R1's safety was compromised, and she was placed at risk of an avoidable injury and/or adverse outcome in the event of a respiratory emergency. Findings Include:1) R2 was admitted to the facility on [DATE] with diagnoses, not limited to, resolved right pneumothorax, acute respiratory failure with hypoxia, pneumonia due to Hemophilus influenza, shortness of breath, muscle weakness, and unspecified abnormalities of gait and mobility. Review of R2’s admission comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/18/25, R2 scored a 14 out of 15 (cognitively intact) during the brief interview for mental status (BIMS). In section GG, Functional Abilities and Goal, R2 is dependent in chair/bed-to-chair transfer. Review of R2’s comprehensive care plan documented “I need dependent assist (2 staff with Maxi lift) during chair/bed-to-chair transfer,” created on 06/18/25. Review of R2’s nursing notes documented on 07/25/25, “Charge nurse alerted by CNA [Certified Nurse Aide] that the patient had a fall. Immediately went to the site of incident and noted patient lying on his back to the floor…Patient [R2] described pain with movement on posterior Left rib cage…The patient moved all extremities within limits. Questioned the patient on the incident. Patient landed on left side, making contact with the metal component of the lift machine. Although the patient did not strike his head, the initial impact to his left side caused his head to bounce and hit a surface.” Review of the completed event report provided to State Agency (SA) on 07/29/25 documented the 07/25/25 incident, “On the day of the incident, the resident [R2] was initially transferred from wheelchair to bed at the start of the shift. Later in the afternoon, just before dinner, the resident’s spouse requested that he be transferred back to his wheelchair in anticipation of a visitor. 2 staff members assisted with the transfer using a mechanical lift…During the lift and while maneuvering the resident toward the wheelchair, the sling supporting the upper left side of the resident’s body suddenly detached. This caused the resident to fall from the lift, landing on his left side and striking his left ribcage on the metal portion of the Maxi Lift. The resident’s right food remained partially attached to the sling, contributing to the awkward fall…The following day, the resident continued to report left-sided rib pain aggravated by movement. The physician subsequently gave an order to transfer the resident to the hospital for further evaluation…The conclusion from the maxi lift representative was the hook probably shifted out of position due to rigidity of the strap combined with resident movement upon lifting. He advised staff to pay attention to the positioning of strap at all times.” On 08/13/25 at 10:34 AM, an interview with Nurse Aide (NA) 23 was done. NA23 reported her first day of work was the day before the incident on 07/24/25. NA23 stated 07/25/25 was her second day orientating on the job and was not allowed to provide care to the residents but helped and followed orders from the CNAs training her. NA23 confirmed she was in R2’s room when he fell from the mechanical lift. CNA62 was reportedly training her on how to use the lift, NA23 was at the end of the bed, on the side, and CNA62 was hooking the sling straps onto the lift with R2 positioned in the sling. NA23 reportedly remembers CNA62 tell her that she checks and double checks everything, pulled down the straps to make sure it was strong, then asked her to hold the remote and press the up button. R2 went up and NA23 stated, “I went blank and then saw him go on the floor.” NA23 confirmed, CNA62 and her were the only staff in the room operating the lift, she was orientating and only there to observe and not position or provide care. On 08/13/25 at 12:06 PM, an interview with CNA62 was done. CNA62 confirmed with NA23 present, she attempted to transfer R2 from bed to wheelchair with the mechanical lift. CNA62 reported, at approximately 05:00 PM, R2’s wife asked staff to get resident up from bed because he will have a visitor over to eat with him at the lanai. CNA62 stated they put the lift straps on the hook and started with the straps closest to the head and ended with the straps closest to the legs. While putting the straps on, CNA62 reportedly explained to NA23 where to hook the straps, to double check, and to never operate the lift alone because “…something can happen.” Then they started lifting R2 up and off the bed, his position looked good, and he was straight, then when they were ready to set up the wheelchair, R2 slipped off the sling and “…fell down from the Hoyer lift…I noticed the red plastic stopper part flipped outward…” CNA62 reported after the incident she received training from Vendor 1 (V1) and he demonstrated the straps in the right position, it was correctly put on, but the straps came off, V1 reportedly “… said we are supposed to hold the strap down…” before lifting the residents. On 08/13/25 at 01:08 PM, an interview with Maintenance Manager (MM) was done. MM reported the mechanical lift vendors came to the facility after the incident and inspected the lifts, including the one used by R2 when he fell, and found nothing wrong with the equipment. MM reported he did not keep a log that the lifts were periodically inspected but just did visual checks. On 08/13/25 at 01:13 PM, an interview with V1 was done. V1 confirmed he came to the facility on [DATE] along with V2, re-training staff on using the lift and proper sling strap placement and inspected the lift that was used and found it to be in working condition, no visual damage, and no mechanical failure. For the red plastic tab/clip to invert, it would require a lot of weight, and the red tabs were not meant to hold weight. V1 described the incident to be a “user error” versus “mechanical error.” V1 reported, while providing training, the facility described to him what happened when R2 fell, he attempted to replicate what was described and stated “I don’t know if she [CNA62] wasn’t aware and not paying attention, but the plastic clip doesn’t pop on its own…no one noticed it was not fully seated in the hook…I think they attached it correctly…” but when R2 was seated not putting pressure to the straps the straps would have slack and “…sometime in between the slack was pulled and moved out of place while R2 was lifted, it pulled on the red tab and came off the carry bar.” V1 stressed the importance of paying attention when lifting a resident during the training to ensure the straps do not move out of place. Review of a letter sent to the facility by V1 regarding R2's incident on 07/25/25, dated 07/28/25. “Per staff, the resident was being moved from bed to wheelchair with an… [mechanical lift] …and loop-style sling on 7/25/25. Two staff members assisted with the transfer using the lift. Staff reported that the sling strap inverted the hanger strap lock---a non-load-bearing component---resulting in the strap detaching from the hanger bar hook. This caused the resident to fall onto his left side, striking the base of the lift, with his right leg partially remaining in the sling. The lift was promptly removed for inspection. Upon inspection on 7/28/25 by…[V1] … (authorized distributor representative) and…[V2] …(distributor service manager) the lift was found to be in proper working condition. The hanger bar and hanger strap locks were intact without any visual defects. Following the incident, staff received re-education on proper sling strap placement, including reminders: 1. The hanger strap locked is not load-bearing 2. Ensure straps are fully seated in hooks 3. Best practice is to attach shoulder straps before leg straps. 4. Straps may shift until the sling is fully loaded and slack is eliminated. Pay attention to strap position during transfer.” On 08/13/25 at 02:06 PM, an interview with Director of Nursing (DON) was done. DON stated after the incident they called the vendor to find out what could have happened and were told “…the strap might have shifted during the lifting which caused the straps to snap out…” DON reported, after the incident, chest x-ray was done at the facility and results were negative. R2 was sent to the emergency room (ER) and hospitalized the next day, on 07/26/25, after complaining of pain to left side. At the ER, R2’s x-rays found fracture to left ribs. Review of R2’s ER physician notes documented, “Patient is at nursing home after prolong battle with pneumonia…He states he was being lifted in a .[mechanical lift] .yesterday when part of it malfunctioned and he landed on his left posterior ribs and hit his head. He has noted significant rib pain since and notes that he has mild shortness of breath and feels his ribs moving. He had an x-ray last night and was told everything was fine but he feels something is wrong. Pain is significant…” R2’s history and physical documented “Patient presents from nursing home complaining of left rib pain. Patient was being lifted in the Hoyer lift one of the straps was not connected properly and the patient fell 3 feet landing on mostly left side.” Review of R2’s ER x-ray results on 07/26/25, found “Acute appearing fractures of the lateral left sixth. Four, and second ribs. Worsening lower lung opacities. Small left apical pneumothorax.” Further review of R2’s physician notes dated 08/20/25, documented R2 was admitted to the hospital on [DATE] due to closed traumatic facture of ribs of left side with pneumothorax. R2’s pneumothorax worsened on 07/29/25 requiring pigtail chest tube placement from 07/29/25 to 08/10/25. Review of the facility’s policy and procedure “Hoyer Lift Safe Use Policy” dated 07/28/25, documented “A minimum of two trained staff members is required for all mechanical lift transfers.” On 08/13/25 at 03:15 PM, an interview with CNA Supervisor, CNA57 was done. CNA57 was not able to provide documentation that NA23 was trained to use the mechanical lift to meet the facility’s policy requiring a minimum of two trained staff. The facility uses a checklist that the CNA or NA orientee signs after a trainer goes over what is included in the checklist and CNA57 confirmed NA23 did not sign it. 2) R1 is an [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation. Her admitting diagnoses include, but are not limited to, a history of stroke, gastrostomy (a surgical opening into the stomach for the introduction of nutrition and/or medication), and dysphagia (difficulty swallowing foods or liquids). On 08/11/25 at 11:47 AM, observations were made at the bedside of R1. R1 was lying in bed sleeping connected to oxygen via nasal cannula (indicating respiratory issues), with a suction machine at the bedside without any suction tubing, suction canister, or yankauer (rigid, curved, suction tip connected to suction tubing). On 08/11/25 at 11:51 AM, an interview was done with Registered Nurse (RN) 3. RN3 validated that due to R1’s dysphagia, she is to have nothing by mouth, however the suction machine is kept at the bedside “just in case it is needed.” RN3 agreed that the suction machine at the bedside was no good without the suction canister, suction tubing, and yankauer, stating, it should definitely be there. During a concurrent review of R1’s physician orders, the following order was revealed: Suction PRN [as needed] for oral secretions. When asked why it was important to have the suction machine set-up and ready to use at any time, RN3 answered “to prevent an accident.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, record review, the facility failed to provide adequate supervision to one Resident (R)2. On 09/21/2024, R2 fell while in the Physical Therapy gym which resulted in harm. He was hospitalized with a subdural hematoma (bleeding near the brain) which required immediate surgical intervention. In addition, the facility failed to conduct a thorough investigation, document findings, and interventions taken to reduce the likelihood of a similar event. This deficient practice could affect any resident if the appropriate level of supervision is not provided. Findings include: 1) On 09/23/2024, the Office of Healthcare Assurance (OHCA) received an facility reported incident (ACTs # 11218) regarding a witnessed fall with injury. The report included: Resident is a [AGE] year-old-male who was admitted . on 09/12/2024 for PT/OT (physical/occupational services) after being hospitalized . following right foot necrotizing fasciitis status post angiogram and balloon angioplasty on 8/29/24, then right knee above amputation on 9/5/24. He is A&Ox4 to person, time, place, and situation. He is on hemodialysis three times a week, mostly incontinent to bowel and bladder. He is only able to walk 10 feet with use of parallel bars with contact guard assistance from therapist. On 09/21/2024 at approximately 10:15 AM, resident had a witnessed fall in therapy gym. Resident was receiving physical therapy service with PTA (physical therapy assistant). He propelled himself to the parallel bars, quickly attempted to go up the ramp to parallel bars. Resident's wheelchair tipped and he slid backwards out of it and fell to the ground. Resident was assisted to lying on the floor with comfortable position and a pillow was placed under his head. No changes of level of consciousness or visible injuries were noted. The therapist called a licensed nurse immediately. Resident verbalized that he moved too quickly to attempt standing in parallel bars. Head to toe assessment performed after the fall. Resident was able to answer questions appropriately. He reported pain to the back of head. No bump or lump on his head was noted. Pupil reactions were equal and brisk to light. He was able to move both upper and lower extremities. Resident remained alert with no loss of consciousness or change in mental status. VS 174/71, 68, SPO2 99% on RA. Resident was assisted back to wheelchair via mechanical lift with two staff transfer. Neurocheck were initiated every 15 min. for 1hr., every 30 min. for 2 hrs. per facility protocol. Resident reported pain level 5/10 to back of his head when he transferred to his bed around 10:45 am. Physician (MD)1 was notified and he ordered to send resident to emergency room for further evaluation. POA1(power of attorney/daughter) was notified. Note: Emergency Medical Service (EMS) responded that it would take proximately 20 minutes because they had a lot of calls, and if resident ' s condition changes to call back. While awaiting arrival of EMS the licensed nurse noted resident ' s change of mental status and increased pain. The nurse immediately re-alerted 911 to respond immediately. Resident left with EMS at approximately 11:57 AM . Completed report was dated and received on 09/23/2024. The report included R2 would not be returning to the facility, and will be discharge to the community. 2) Request made for the investigation notes. Reviewed the notes provided by the Director of Nursing (DON), which included: DON notes dated 09/25/2024: Resident is baseline A&O x3. However, occasional episodes of confusion and disorientation noted since SNF admission. The therapy reports stated that resident was displaying anxiety, disorientation, suspicions, and depression, and SLUMS scored 11/30 (questionnaire that measures cognitive function. Higher scores indicate better cognitive function) Verbal and tactile cues required for safe transfer technique during therapy sessions. Cognitive deficit, complex medical conditions with easy fatigue, impaired physical function with recent right AKA ambulation also increased risk of fall and injury. This fall happened due to resident moved too quickly to get to the parallel bars before therapist could provide verbal cue for safety. Due to right above knee amputation, he might not be able to hold himself without sliding from the wc. Unit Manager (UM)2 notes dated 9/30/2024: Per interview with therapist who worked with resident at the time of incident, they were working on wheelchair propulsion up to parallel bars for next activity to attempt ambulate in parallel bars. Resident self propelled to therapist on the left side. Resident propelled too fast to ramp and posteriorly tipped out of wheelchair. Therapist attempted to catch the resident but was too late and bumped occipital area of head. Reviewed the Corporation Resident/patient Incident Report completed by PTA1 dated 09/22/2024. The report included, but not limited to the following: On 21 [DATE] at 1015 with daughter and grandson present, R2 and PTA were working on wheelchair propulsion to parallel bars for next activity to attempt to ambulation in parallel bars. Resident self-propelled to parallel bars, with Therapist 6 ft. to the left side. Resident propelled to [sic] fast to ramp and posteriorly tipped out of the chair. Therapist attempted to catch resident however to [sic] late and resident bumped occipital region of head. BP documented to be 174/74. 3) Review of R2's medical records revealed R2 had a past pertinent history of diabetes, hypertension, and end stage renal disease. He was incontinent of urine, had a urostomy (urinary bladder removed and opening in belly created to drain urine ), and had dialysis three times a week. R2 has some memory issues at baseline and prior to hospitalization was dependant on his daughter for care. He was hospitalized on [DATE], for sepsis due to cellulitis (bacterial infection) of the right lower extremity. His hospitalization was complicated by delirium. The goal was for R2 to return home. Reviewed R2's Fall Risk Evaluation completed on admission, which deemed R2 to be a high risk with a score of 18. Score 10 or higher indicates the resident is at high risk of fall. Reviewed Physical Therapy Treatment Encounter Note date of Service 09/21/2024 by PTA1. The note included, but not limited to the following: .Pt (R2) is able to stand with CGA (contact guard assist-the therapist is close and not more than several steps away in case resident loses their balance, strength, etc) performed x1 with gait belt (safety device used to help someone move or walk) for assistance for 2 mins (minutes). .Wheelchair navigation and transfer training in and out of wheelchair x2 from mat table to wheelchair with CGA/SBA (standby assist-both require no immediate assistance from the therapist, however, the therapist would intervene as needed) with gait belt for safety. Wheelchair management training self propelling in therapy gym education to address [sic] STG (short term goal) of wheelchair mobility tolerance and to improve independence with mobility and ensure safety within home. Other Status Update Report: Patient had minor fall in therapy gym while attempting to navigate parallel bars. Transfers .Sit to stand = CGA Safety Awareness = impaired Response to Session Interventions: Patient was responsive to therapeutic [sic] interventions, completed all strengthening, transfer training, and mobility training well, however while working on STG of self propelling in wheelchair patient moved too quickly up to parallel bars. Once patient hit the ramp with wheelchair his wheelchair tipped and he fell backwards, therapist jumped to try to assist descent however patient fell back to quickly hit back side of head, patient was assessed rapidly, given pillow underneath head . Reviewed the Fall Nursing Note, dated 9/21/2024 at 04:43 PM, which included, but not limited to: - pt (R2) wasn't on the unit until after 10:44 am. - Between 10:45 am and 11:15 am MD and 911 called due to pt complaining of headache MD gave instructions to call 911. - Called 911 immediately and they said that because of pt's LOC (level of consciousness (Showed no signs of confusion)) they would come in approximately 20 minutes because they had a lot of calls today; they said to call back if pt (R2) condition changes; pt was showing no signs of confusion initially - after reassessing pt he had some confusion (could not remember where he was, who the nurse was, etc) I immediately called 911 again to report the update in pt condition and they said that they would be there in a few minutes. - continued to monitor pt until EMT [sic] arrived sometime between 11:30 am to 11:45 am. - Left for hospital around 11:57 am. Reviewed the Neurological Assessment form, that included the following documentation following after P2's fall 09/21/2024 at approximately 10: : 10:15 AM (in PT gym: Blood pressure (BP) 174/71, oriented, speech clear, headache 10:30 AM: Not taken. (Arrive on unit after 10:44 AM). 10:45 AM: (Back on unit) BP 172/72, oriented, speech clear, headache 10:49 AM: BP 169/80, oriented, speech clear, headache 11:00 AM: BP 171/70, oriented, speech clear, headache 11:30 AM: BP 184/83, disoriented, drowsiness, speech garbled 11:51 AM: Pt (patient/R2) sent to ER (emergency room) with EMT' Review of R2's vitals summary revealed is BP baseline was lower prior to the fall, and recorded as: 09/21/2024 at 08:27 AM: 138/67 09/20/2024 at 06:32 PM: 139/71 09/20/2024 at 02:26 PM: 145/78 09/19/2024 at 07:28 PM: 138/75 09/19/2024 at 0:542 PM: 166/66 09/19/2024 at 09:21 AM: 165/72 09/19 2024 at 00:32 AM: 135/69 Review of R2's Medication Administration Record (MAR) for behavioral monitoring every shift, revealed the following behaviors: 09/14/2024 1st shift - 3 (key agitation) 09/15/2024 2nd shift - 3 09/19/2024 3rd shift - 2 (keyRestless, attempting to get out of bed) Reviewed R2's MDS (Minimum Data Set-clinical assessment) dated 09/19/2024, documented his Functional Status (Section G) for transfers was total dependence. Reviewed R2's active care plan, which included: -Risk for fall, due to recent right above the knee amputation. Intervention 09/13/2024 Provide me safety reminder as needed. -I need assist during ADL (activities of daily living) daily due to right above the knee amputation .I am here for short term rehabilitation to improve ADL function . Interventions 09/13/2024: Provide me simple verbal or physical cues as needed for my maximum participation and safety, .I need 1 or 2 staff substantial/maximum assist to dependent assist during sit to stand .I am not walking with nursing at this time. PT will direct nursing staff when is appropriate. Reviewed EMS Patient Care Record) dated 09/21/2024, which included .The pt. opened his eyes briefly to painful stimuli and moaned in response to verbal commands, with no purposeful movements of his arms.Clinical impression: Closed head injury, Intracranial Bleed. Reviewed R2's Emergency Department (ER) Provider (MD)2 notes 09/21/2024 that revealed the following: - Full trauma team activation (team page for immediate response to ER) on arrival. -EMS reports fall backwards out of wheelchair .Patient experienced head strike and then sudden onset of worst headache of life. Reviewed the Trauma History and Physical by (MD)3, dated 09/21/2024 included .patient found to have large acute on chronic SDH (Subdural hematoma-dangerous bleeding that puts pressure on the brain) with midline shift, neurosurgery to take for emergent craniotomy (surgery to relieve pressure on the brain). On 09/25/2024, R2 had a complication of a large rebleed and required a second surgery. 3) On 10/16/2024 at 12:45 PM, interviewed RN3. She said R2 had some hospital delirium with some residual behaviors. RN3 went to the PT gym to assist the day R2 fell. She said the PTA relayed R2 quickly rolled his wheelchair toward the parallel bars and when he reached the incline the w/c flipped backwards and he struck his head. She said daughter had been present at the time of the fall but had her back turned as she was watching her son. On 10/16/2024 at 12:00 PM, conducted telephone interview with R2's Power of Attorney (POA/daughter). She shared that she was present with her young son when her dad was getting PT. The POA said she heard the tech ask Are you OK? The whole wheelchair fell backward. She felt there was a delay getting additional help, approximately 15-20 minutes. The POA said she heard the therapist say, I should have been behind him instead of next to him. She said it was then over an hour before EMS was called. The POA felt the therapist should have known R2 was a high risk, and not able to stand on own. She went on to say R2 had neuropathy (nerve damage) in his good leg, and can't feel it all the time. The POA said R2 he is not able to walk on his own, and totally dependent. On 10/16/2024 at 02:30 PM, interviewed the UM2. She said when there is a fall, nursing does a root cause analysis (RCA), that includes looking at how the fall happened, identify contributing factors, and interview staff. Inquired if there were opportunities identified during this RCA, and she said the only question that came up was why the therapist was at R2's side, instead of behind the w/c. UM2 said [NAME] from PT participated in these, and she did not discuss the concern with the PT Director She said she was not aware of any changes that had been implemented as a result of the incident. On 10/16/2024 at 03:00 PM, interviewed the Director of Rehab (DPT). She said from what she had been told, PTA1 and R2 went up to the gym, and the daughter and young son were present. She went on to say they were doing exercises and w/c mobility, then going to work on the bars (parallel) for standing. When transitioning, R2 went up to the bar, pulled up to bars, got into bars. guess too forceful and went back. The DPT said there is a very small incline, little ramp to get into bars. She said it was PTA1's first time with R2, and it was on a Saturday, so he was alone. Inquired if the incident was analyzed for any opportunities, and she replied to make sure precautions are in place, specific to the resident and to follow current levels of supervision, and weight bearing. Asked if anything specific related to positioning of the PTA1 to Resident, and she said she didn't really identify anything. PTD said she called PTA1 the next day, but it was difficult to understand him at the time. She said he was very sad and upset the fall occurred. Inquired specifically if PTA1 talked about any opportunities or ideas to prevent similar fall, and she said no. On 10/16/2024. at 03:30 PM, toured the rehab room with the PTD, and observed the parallel bar equipment. At each end of the bars is a small ramp with a skid strip to enter the bars to the level plane. The PTD did not know any specifics of the fall. such as which end of the ramp the fall occurred, placement of the wheelchair, position of therapist, and had not reenacted the event to identify opportunities. On 10/17/2024, at 09:45 AM, interviewed the DON. She said she became aware of the incident that Saturday, and had a conversation with the PTD and there needed to be investigation and inservices to the rehab team. She went on to say on Monday (09/23/2024), she went to a meeting with the therapists, and they briefly went over what happened on Saturday. Inquired if any opportunities were identified or changes made based on review of the incident, and she said just how to prevent incidents and need to know each resident and follow PT recommendations. She went on to say they identified a need to be able to obtain assistance quicker, and that staff need to always stay with the resident. The DON said it was agreed therapists shouldn't use the rehab gym unless there is another staff present. She did not think there were minutes to the meeting or attendance recorded. The DON stated I should have written more in my summary. On 10/17/2024 at 02:00 PM, interviewed the Physical Therapy Assistant Director (PTAD). He explained they are a contracted group. The PTAD confirmed they discussed the fall that Monday, and that PTA was alone in the gym at the time. There was further discussion in the future, they want to have other staff around. He said the meeting emphasis was on fall prevention, to be attentive and present. On 10/18/2024 at:915 AM, conducted a phone interview with the VP of Operations for the PT vendor. She said the corporate office provides operational and clinical support to the staff working at the different facilities. The RVP was notified of the incident by the onsite PTD. She went on to say she was on site at the facility October 1, 2024, the week after the incident for follow up education with staff. As a result of that, they determined and put in action plan as follows: 1) there will be two people in the space at all times 2) to expedite response and assist staff were trained to use the 500 page, and 3) emphasize staff will review the chart to familiarize self with resident and adhere to functional recommendations. The VPO said she did not interview or speak with PTA1, but reviewed the records and conclusion was that R1 was not doing a transfer from sit to stand, and R2 propelled himself to the ramp. She went on to say the facility does the investigation after the report is made. Request was made regarding the documentation of the incident review, recommendations and action plan. At the time of exit, this documentation was not provided. On 10/18/2024 at 10:30 AM conducted a second interview with PTD by phone. At that time the RTD said the staff meet every morning, and that Monday after the incident, the DON was present to discuss what could be done to prevent another incident. She said about a week later, the RVP met with them. Inquired if there were any changes or actions taken as a result of the two meetings, and she said they would call Code 500 if assistance was needed, for quicker response. She said they emphasized knowing what level of assistance the resident needs for fall prevention. The RTD said there were no minutes to the meeting. Inquired if there would be any policy changes, and she said we don't want any therapist alone in the gym. Inquired if that policy had been implemented, and she said yes. The RTD said she usually gets information to the on call staff by texting them. She said not all of the on call staff had been notified of the changes. Inquired why she did not mention the action plans during the initial interview, and she said she misunderstood the question. When inquired if PTA1 had received an orientation, she said she did a phone orientation with him the Friday before he worked, but did not have any documentation regarding the orientation or content. On 10/18/2024 at approximately 10:30 AM, interviewed PTA2, who works part time. She said they discussed the fall at one of their meetings Asked it she had any ideas how to prevent this type of fall and she said some of the wheelchairs have stoppers, but did not know if the w/c used that day had them or not. PTA2 went on to say, its all about staying close to the patient, always contact guard. always use safety belt, hold the wheel chair and gotta be behind. She said most of the residents are high risk. On 10/18/2024 11:56 AM, conducted a phone interview with PTA1. He said it had been his first time at the facility and confirmed the orientation he received was on the phone. RTA1 said after the fall occurred, he assessed R2, checked neuro signs and he was alert and oriented. He said R2's daughter was there, so he ran downstairs to get help. PTA1 said they did some exercises on the unit before going upstairs (to the PT gym). He went on to say he reviewed R2's chart and noted he needed work with wheelchair mobility, standing and a few steps in the parallel bars. He said he instructed R2 to wheel over to the parallel bars, and turned to pick up some equipment. He said R2 wheeled too quickly, and he witnessed the fall, but could not get to him. Inquired if anyone had discussed the specifics of the fall with him, and he said he was asked to write a statement, about [NAME] had discussed details, or reenacted the event. Inquired if he had any suggestions to prevent a similar fall, and he said after the incident, he looked at the w/c with nursing, and it was noted that w/c did not have the longer antitip bars. He went on to say the antitip bars on the chair used that day were the short ones, and would buffer a fall, but not stop it. He said R2 had been following directions well and trusted him to be safe with the w/c mobility. PTA1 said it was his first time at the facility and was not oriented to the gym, layout of the facility, or how to summons help. 4 ) Reviewed the facility policy titled Fall Management, revised date 08/04/2024. The purpose of the policy read The fall management program are interventions developed to prevent falls and injury. The procedure included 2. When a fall occurs, an incident report investigation will be initiated immediately, including .A root cause analysis as to the reason a fell occurred and strategies to minimize reoccurrence 5) Requested documentation of PTA1's orientation, and was provided validation that PTA1 completed the required training from the contracted vendor, but there was no orientation specific to the facility documented.