**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure that one resident (R2) was free from abuse from her roommate (R3). This failure resulted in R2 being struck by R3 and sustaining a broken nose. Findings include: R2 is an [AGE] year old with diagnosis including but not limited to: unspecified dementia, unspecified severe protein-calorie malnutrition, age - related osteoporosis without chronic pathological fracture, chronic pain and cognitive communication deficit. R3 is a [AGE] year old with diagnosis including but not limited to: bipolar disorder, generalized anxiety disorder, major depressive disorder, type 2 diabetes mellitus, restlessness and agitation. R7 is a [AGE] year old with diagnosis including but not limited to: essential hypertension, chronic obstructive pulmonary disease with acute exacerbation, pain in left leg, major depressive disorder and anxiety disorder. R7 has a BIMS (Brief Interview of Mental Status) score of 14, which indicates cognitively intact. On 01/06/2025 at 10:15 AM, V1 (Administrator) said that R2 had been transferred out of the facility per family's wishes after R2 was hit by another resident. On 01/06/2025 at 12:39 PM, V2 (DON/Director of Nursing) said that R3 was no longer in the facility and that she was sent out for aggressive behavior and allegedly punching R2 in the nose. On 01/06/2025 at 3:12 PM, R7 (R2 and R3's former roommate) was observed lying in her bed. R7 was asked about the incident involving R2 and R3. On 01/06/2025 at 3:14 PM, R7 said, The night that R2 was hit, I was asleep, but I heard her (R2) yell out and when I woke up, R3 was wide awake and walking around the room. R3 would always yell at and intimidate R2. She (R3) once told R2 that she wished that she (R2) would die. R2 would cry out a lot and the nurse would come in and check on R2 then leave. R3 was abusive to everyone and the staff knew it. She (R3) would cuss at staff and was always angry and demanding. At night, R2 would talk a lot and that would set R3 off. R3 would become very upset with R2. I didn't say anything because I was afraid of R3 retaliating against me. One night, I opened my eyes and R3 was standing near my bed. R3 was very unpredictable and always targeted R2. On 01/06/2025 at 1:10 PM, V8 (CNA/Certified Nurse Assistant) said, I saw R2 at around 7:30 AM during breakfast, I went in to feed her. Her face was covered with a blanket and when I removed the blanket, she was bloody and her face was bruised. R2 had told me that the little lady hit her but did not say a name. R3 had recently moved from the first floor and was one of R2's roommates. R3 does not talk but she is a mean person. When R2 yells out, R3 yells and tells her to shut her mouth. R7 had told me that R3 was standing over her two months ago in the middle of the night. On 01/06/2025 at 1:26 PM, V9 (CNA) said that she was assigned to R2 on 12/16/24 and that the previous CNA did not mention anything about any injuries. On 01/07/2025 at 12:15 PM, V2 (DON) said that she was not aware of R3 allegedly targeting or being mean to R2 in the past and that she (V2) would expect for any possible signs of abuse to be reported. Surveyor inquired about the purpose of staff members reporting possible signs of abuse. On 01/07/2025 at 1:30 PM, V1 (Administrator) said that the purpose of the staff reporting any signs of possible abuse is to prevent the abuse from occurring. Resident statement by R2 on 12/16/24 documents, the little lady hit me. Resident statement by R7 on 12/16/24 documents, I heard her (R2) scream three times and my curtain was pulled. I did not see any individual come in my room. I didn't pull the call light because I've pulled the call light before and the nurse would come in to see and check on her (R2) and then say she's ok, so I didn't think that pulling the call light would make a difference. However last night was a different type of scream. Employee statement by V8 (CNA/Certified Nurse Assistant) on 12/16/24 documents, V8 was preparing to feed R2 and saw R2's right eye bruised and swollen; R2 said the lady hit me. Employee statement by V15 (Housekeeping Supervisor) on 12/18/24 documents the following: V15 was told by R7 that R3 physically abused R2 and that the CNA was notified; the CNA would come and check on R2, then would say that there are no bruises and would leave the room; R3 also verbally abused R2 and wished that she would die. Facility document titled Preliminary Incident Investigation Report dated 12/16/24 documents, R2 was found by staff at approximately 7:50 AM in bed with swelling, discoloration and a laceration to her left eye. Facility document titled Final Incident Investigation Report dated 12/18/24 documents the following: R2 identified as the abused; on 12/16/24, R2 was found by V8 (CNA) with laceration and visible blood on her right eye; R2 said, the little lady hit me; physical abuse was founded. Facility Census report dated 01/06/2025 excludes R2 and R3 as residents in the facility. Facility Abuse policy documents the following: Staff obligations to prevent and report abuse; Employees are required to report any incident, allegation or suspicion of potential abuse; any incidents or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation; residents who allegedly abused another resident will be removed from contact with other residents during the course of the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident (R3) was free from physical abuse. This failure resulted in R3 sustaining a bruise and skin tear to the left arm that required a dressing twice a day and R3 being afraid at the facility. Findings include: The facility's Preliminary Incident Investigation Report to the local state agency dated 11/22/24 completed by V1 (Administrator) shows a report of physical abuse with alleged individual V11 (CNA/Certified Nursing Assistant) and R3. The facility's Completed Incident Investigation Report to the local state agency dated 11/27/24 competed by V1 documents, in part On 11/24/24 (should be 11/22/24) at approximately 11:45 am, R3's CNA (V14) was making rounds. V14 stated, I (V14) saw bleeding on the left arm. I (V14) asked what happen and R3 said the night CNA did that to me. Based on the known facts, medical record review, and interviews, the following conclusion have (sic) been determined about the allegation: Abuse-Neglect Founded. Based on statements from R3 and staff an investigation was conducted by V1, and incident noted to be founded. R3 stated that V11 (CNA) was turning him over hard. R3's Brief Interview for Mental Status (BIMS) dated 11/22/24 shows that R3 has a BIMS of 15 which indicates that R3 is cognitively intact. On 12/16/24 at 11:52 am, V3 (Licensed Practical Nurse, LPN) stated that V3 is familiar with R3 at the facility. When V3 was asked regarding the event with R3 on 11/22/24, V3 stated that V3 recalls on 11/22/24 at around 7:15 am, V14 (Certified Nursing Assistant, CNA) informed V3 that R3 wanted to see V3 regarding R3's arm. V3 stated that when she (V3) went to R3's room, V3 observed R3's left forearm with ecchymosis (bruising), red and, bleeding. V3 then stated that V3 asked R3 what happened to R3's left arm and R3 stated that the 11:00 pm - 7:00 am, CNA (who has been identified as V11 [CNA]) pulled R3's arm roughly bruising and tearing the skin to R3's left forearm. V3 explained that V3 assessed R3's left forearm and informed V2 (Director of Nursing/DON) regarding R3's left forearm injury. V3 then stated that V2 asked R3 additional questions and V3 left R3's room to inform R3's physician and family of the event. V3 further explained that R3's physician gave treatment orders for R3's bleeding left forearm injury and for an X ray of R3's left forearm. On 12/16/24 at 12:02 pm, V5 (Certified Nursing Assistant, CNA) was asked regarding the event with R3 on 11/22/24, V5 stated that V5 recalled the event with R3 on 11/22/24. V5 explained that R3 told V5 that V11 (Certified Nursing Assistant, CNA) held R3 very hardly by R3's arm and caused bruising to R3's left arm. V5 stated that V5 observed R3's left arm with bruising. V5 stated that V5 did not recall the color of R3's left arm bruising on 11/22/24. V5 stated that V5 then reported R3's concern and injury regarding R3's left arm to V3 (Licensed Practical Nurse, LPN) (R3's nurse) on 11/22/24. On 12/17/24 at 11:04 am, V17 (Registered Nurse, RN) stated that V17 is familiar with R3 at the facility. V17 then stated that R3 is alert , oriented and able to make R3's needs known at the facility. V17 stated that V17 was R3's 11:00 pm to 7:00 am nurse on 11/22/24 and that V17 recalled being phoned and questioned by V2 (Director of Nursing, DON) and asked if V11 (CNA); (R3's CNA on 11/22/24) made any reports to V17 regarding R3 during V17 shift on 11/22/24. V17 stated that V17 informed V2 that V17 was not made aware of any incidents or reports with R3 during V17's shift on 11/22/24. V17 stated that R3 slept during V17's shift on 11/22/24 and that V17 last saw R3 in bed sleeping around 5:30 am, when V17 was administering medication to R3's roommate. V17 denied witnessing any neglect, abuse, or injury to R3 at the facility. On 12/17/24 at 11:36 am, V11 (Certified Nursing Assistant, CNA) stated that V11 has worked at the facility for over 1 year and is scheduled to work at the facility on Monday's, Tuesdays, Thursdays, and every other weekend. V11 also stated that V11 recalls R3 at the facility and that V11 hasn't worked with R3 since 11/22/24. V11 stated that on 11/22/24 V11 provided incontinence care to R3 around 6:20 am and left R3's room. V11 then explained that around 6:30 am, R3 pulled the call light for V11 to come back into R3's room. V11 further explained when V11 went back into R3's room, R3 showed V11 a skin tear to R3's left inner arm, that needed to be covered up. V11 then explained that R3 stated that the skin tear to R3's left arm happened while V11 provided care to R3 around 6:20 am on 11/22/24. V11 denied causing injury to R3's left arm. When V11 was asked to describe how V11 last saw R3's left arm, V11 described R3's left arm at 6:30 am on 11/22/24 as opened with skin pulled back that looked tender, bruise and red, but not bleeding. V11 further explained that V11 informed R3 that V11 did not see the injury to R3's left arm when V11 provided care to R3 at 6:20 am. When V11 was asked when was the last time V11 provided care to R3 prior to 6:20 am and V11 stated that V11 did not provide any incontinence care to R3 prior to 6:20 am and that V11 only completed the round book to check to make sure R3 was ok and breathing well. V11 stated that V11 did not see bruising to R3's left arm until R3 pointed out R3's injury at 6:30 am. When V11 was asked if V11 reported R3's injury to R3's nurse V11 stated that R3's nurse left the first-floor unit and went to the third-floor unit prior to V11 providing care to R3 and that V11 did not report R3's injury to R3's nurse or any other nurse at the facility. V11 further explained that around 7:00 am, V11 informed V14 (CNA) for the 7:00 am to 3:00 pm CNA, that R3 needed the nurse and to let the nurse who comes in for the morning shift know. When V11 was asked regarding when V11 was scheduled to return to work at the facility V11 stated, They have not put me on the schedule yet, I am still suspended. On 12/17/24 at 1:48 pm, V14 (Certified Nursing Assistant, CNA) stated that V14 provides care to R3 daily on the 7:00 am to 3:00 pm shift at the facility. When V14 was asked regarding R3's event on 11/22/24, V14 stated that on 11/22/24 around 7:00 am, V14 began rounding for V14's 7:00 am to 3:00 pm shift on the first-floor unit at the facility when R3 stated to V14 Look at what the night CNA (referring to V11) did to my (R3) left arm. V14 stated that V14 observed R3's left arm red, bruising and with visible red blood from R3's left lower arm extending to above R3's left elbow. V14 then explained that V11 (CNA) was still in the facility and, V14 went to V11 and asked V11 if she knew what R3 was saying about R3's left arm injury. V14 further explained that V11 stated that V11 didn't know how R3's left arm injury happen and that V11 then left the facility for the day. V14 then explained that the day shift nurse V3 (Licensed Practical Nurse, LPN) arrived at the facility around 7:15 am, and V14 reported to the day shift nurse V3 that R3 had left arm bruising that R3 stated V11 (CNA) caused. On 12/17/24 at 2:04 pm, Surveyor observed R3 in R3's room, in bed, awake, alert and oriented times four. Surveyor observed R3's left arm area with pink discoloration, and the skin intact. R3 stated that a few weeks ago around 6:15 am, a night shift CNA intentionally caused an injury to R3's left arm. R3 explained that on 11/22/24 the CNA from the night shift (referring to V11) came into to R3's room to assist R3 with changing R3's incontinent brief. R3 further explained that V11 dug V11's fingers into R3's left arm to reposition R3 onto R3's right side. R3 then stated that R3's left arm began to bleed. R3 further stated that R3 told V11 that R3's arm was bleeding and asked V11 to get the nurse. However, V11 didn't. R3 stated that R3 waited until a staff member from the morning shift placed a bandage onto R3's left arm. R3 stated that R3 felt that V11 purposely injured R3's left arm because V11 would often speak meanly to R3 at the facility. R3 finally explained that V2 (Director of Nursing, DON) questioned R3 regarding the incident with R3 and V11 and informed R3 that V11 would not be allowed to work on the first floor with R3 again. When R3 was asked if R3 felt safe at the facility R3 stated, No! I (R3) am afraid that she (V11) will come back during the night from another floor and hurt me again. On 12/18/24 at 9:46 am, V2 (Director of Nursing, DON) stated V2 is familiar with R3 and that R3 is an alert and oriented times 3-4 resident at the facility. When V2 was asked regarding R3's event on 11/22/24, V2 explained that on 11/22/24 around 9:00 am, V2 recalls V3 (Licensed Practical Nurse, LPN ) informing V2 that R3 had an injury to R3's left arm that was bleeding. V2 stated that V2 then went to assess R3's left arm and observed a skin tear that was approximately 4.0 cm (centimeters) in length by 4.0 cm width, red, open skin, and slightly bleeding. V2 then stated that V2 asked R3 what happened to R3's left arm and R3 stated The nightshift CNA (referring to V11) was cleaning me (R3) up, grabbed my arm and dug into it. Then she (V11) flipped me over to change me and when I (R3) looked at my (R3) arm it was all bloody. V2 further explained that R3 stated that R3 asked V11 if she would tell the nurse and V11 said that she would. R3 then stated that V11 had been mean to R3 for a while and that R3 didn't tell anyone because R3 thought V11 was going to change. V2 then stated that V2 immediately reported R3's allegations against V11 to V1 (Administrator) and that V1 immediately started an investigation. V2 further explained that V1 and V2 phoned V11 and informed V11 of R3's statement regarding V11 injuring R3's left arm. V2 stated that when V2 initially spoke with V11, V11 stated that nothing happened to R3's left arm, then after V2 told V11 that R3 had a skin tear to R3's left arm and asked V11 if V11 knew anything regarding R3's left arm injury again, V11 was quiet and denied R3's arm was bleeding and refused to acknowledge seeing R3's left arm injury during V11's shift. V2 further explained that V11 did not acknowledge R3's left arm injury until V2 explained to V11 that V2 had spoken with V14 (CNA) who stated that he (V14) spoke with V11 regarding R3's left arm injury on 11/22/24 prior to V11 leaving the facility. V2 then stated that V11 finally acknowledged R3's left arm injury and stated I (V11) saw it, but it wasn't bleeding. I (V11) couldn't tell the nurse because the nurse was working another floor, but I told CNA (referring to V14). V2 stated after V11 changed her (V11's) story she (V11) was suspended until further investigation and then terminated by V1 (Administrator) and V2, after V1 concluded V1's investigation regarding R3's left arm injury. V2 then stated that V2 informed R3 that V11 would not be working with R3 anymore at the facility. When V2 was asked regarding what could happen if a staff grabs a residents' arm, digs into the resident's arm, and flips the resident over and V2 stated, They (referring to staff) can cause an injury, break the skin, cause a sore or an infection to the resident. Residents who have fragile skin can be harmed, possibly have psychological problems, and not feel safe. On 12/18/24 at 10:43 am, V18 (R3's physician) stated that V18 is familiar with R3. V18 explained that R3 is alert, oriented, able to make needs known, and ambulatory with the use of a cane with a history of falls. V18 explained that V18 last saw R3 a few weeks ago after R3 was sent out to the local hospital for something that happened to R3 at the facility (V18 could not recall). When V18 was asked regarding R3's incident on 11/22/24, V18 stated that V18 received a call from R3's nurse at the facility who stated that the staff was changing R3 when R3 acquired a skin tear on the arm that was superficial. V18 stated that V18 could not remember what orders were given regarding the incident. When V18 was asked regarding what could happen if a staff member digs their nail in R3's arm and flips R3 over onto R3's side and V18 stated that staff should not dig into a resident arm and flip a resident over because the staff can scratch and injure the skin. V18 then explained that R3 has fragile skin from receiving chemotherapy and staff should not be using their nails to reposition R3 or any resident because it can cause a nail mark or abrasion or injury to the resident. V18 stated, Repositioning should not be done with someone using their nails. Who is doing that? I (V18) was not informed that happened. On 12/18/24 at 11:19 am, V1 (Administrator) stated that V1 is the facility's abuse coordinator. V1 stated that V1 has been the Administrator at the facility for about one month. V1 then stated that V1 is familiar with R3 at the facility. V1 stated that V1 is alert, oriented, articulate, and able to make needs known. V1 explained on 11/22/24 V1 was called to R3's room and observed a reddish skin tear to R3's left forearm area that looked fresh and had a little blood to it. V1 explained that V1 asked R3 what happened and R3 stated that (the night shift CNA on 11/22/24) (referring to V11 (CNA)), had been treating R3 roughly for a long time and that R3 did not say anything because R3 thought It would get better. V1 further explained that R3 did not identify the CNA by name however, R3 stated that he was referring to the overnight CNA that had left the morning of 11/22/24. V1 then explained that V1 looked at the nursing schedule to identify the night shift CNA that left the morning of 11/22/24 and determine the CNA was V11. V1 further stated that V1 immediately suspended and removed V11 from schedule and notified the police. V11 then explained that the Police came to the facility, interviewed R3, observed R3's arm, gave a report number and left the facility. V1 stated that during V1's investigation, V1 found that V11 did not report R3's injury to the nurse on 11/22/24. V1 further explained that V11 stated, that V11 informed V14 (CNA) regarding R3's left arm on 11/22/24. V1 then explained that V1 suspended V11 then terminated V11 for improper reporting of abuse and resident injury. V1 stated that V11 denied ever abusing R3 and that V11 was not aware that R3 had a skin tear to R3's arm when V1 asked V11 regarding R3's left arm injury on 11/22/24. V1 stated that V11 was suspected of abusing R3 because R3 stated that V11 was the staff who injured R3's arm. When V1 was asked regarding what can happen if a staff handles a resident roughly and dig their nails into the residents skin and V1 stated, That is physical abuse. That is not tolerated by the facility. R3's progress note dated 11/22/24 at 12:59 pm, authored by V3 (Licensed Practical Nurse, LPN) documents, in part: Resident received alert and oriented at the beginning of the shift. At about 8.00 am the CNA notified the writer that the resident was found with ecchymosis in the lower left forearm. R3 said he got the bruises early in the morning when the CNA was cleaning him. The wound was cleaned with normal saline, and bacitracin was applied and properly dressed. He (R3) voiced no pain at that time and all due medication was administered and he is stable. V/S (vital signs) b/p (blood pressure) -130/69, PR (pulse rate)-75, RR (respiratory rate)-18, 02 Sat -(oxygen saturation) 97%, T (temperature)-96.9*F (Fahrenheit). R3's physician was notified with the order to carry out x-ray to rule out fracture's. The administrator and DON made aware. The resident was notified. R3's Physician Order Sheet (POS) dated 11/22/2024 shows an order for R3 to cleanse left arm with normal saline and apply bacitracin ointment and cover with dry gauze BID (twice a day) till (until) healed. R3's X-ray report dated 11/22/24 at 3:39 pm and titled Left Forearm 2V (view) documents, in part: left radius and ulna have normal ossification pattern. No fracture or dislocation reviewed. The facility's document titled Employee Report documents, in part: The above stated employee after an investigation was done allegedly caused an injury to a resident R3 and failed to report it properly as a result the employee is terminated. The facility's document dated 11/22/2024 and titled Victim Information Notice/Police Department documents, in part: Incident number JH517396: Incident: Aggravated (aff) Battery ([NAME]) Senior Citizen. Name of victim/complainant R3. The facility document dated 18 November 16 and titled Abuse Prevention Program Facility Procedure documents, in part: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish . III Orientation and Training of Employees: During orientation of new employees, the facility will cover at least the following topics: . Staff obligation to prevent and report abuse, neglect, exploitation, mistreatment, and misappropriation of resident property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent a resident's fall from the bed to the floor, who was assessed as a two person assist for bed mobility. This failure affected 1 (R44) of 28 residents reviewed for falls. R44 was emergently transferred to the hospital with increased pain and experiences psychosocial harm, feeling scared and afraid while being turned in bed by staff. Findings include: On 5/20/24 at 11:13am, R44 stated that R44 has been in the facility for almost 2 years, and I (R44) don't walk. R44 stated, I fell out of bed about 2 months ago. I had moved to (another floor) because they needed my room as an isolation room. R44 stated that in R44's current room, R44's bed is up against the wall and that the room on the other floor (where R44 had been temporarily transferred on 2/13/24) didn't have a wall next to R44's bed, so R44's bed was open on both sides. R44 stated, (V20 Certified Nursing Assistant/CNA) was on the same (one) side and pushed me over to change me. I was holding onto the end table. When (V20) pushed my (incontinence brief), (V20) pushed it under my buttock, and I fell face first on the floor. I had bruises on my right knee and feet and my toes and elbow hurt. There was no side rail. When asked if one or two CNAs assisted R44 with turning in bed for incontinence or activities of daily living (ADL) care, R44 stated that there was one CNA, but now, a majority of the time, there's 2 people. When asked if the staff move the bed away from the wall to stand on one side (with other CNA on the other side), R44 stated, No. I roll to the side and hang onto the wall. My body hits against the wall to keep me propped up. R44 said that both CNAs stay on the one side for R44's care. R44 stated, I am not over it. I still have issues of getting too close to the side. When asked how does this make R44 feel, R44 stated, I feel afraid on the inside. I talked to my psychiatrist (V24) about it. R44 said that R44 even asked V24 if it was R44's fault that R44 fell, and V24 said, You have nothing to do with it. It's not your fault. They had one aide there. It was their mistake. R44 stated that V24 said to get it out of R44's head and to not think about it. R44 stated that R44 talked to V24 shortly after the fall happened on 2/23/24 with V2 (Director of Nursing/DON). On 5/22/24 at 9:38 am, R44 was reinterviewed and stated that it was at 8:30pm on 2/23/24 when R44 fell from the bed to the floor. When asked if R44 has expressed R44's feelings after R44's fall, R44 stated, I told (V2), and I had talked to (V24) after I had fallen. I still have a phobia to falling off the side of my bed. R44 stated, (V2) was in the room with (V24) when I said that I am scared about rolling off the bed. I told (V2) the other day too. R44 stated that before this fall on 2/23/24, I have never fallen before. When asked about a fall mat as a fall precaution, R44 stated that there was one in the room but that there was problem with the bedside table not rolling on it. R44 stated, I rely on that table. I tried it, and it wouldn't roll at all. R44 stated, since I am larger, it's harder for me to move in bed. I can't move my legs. I have so much pain. R44 stated, I can pull with my arms. They had even talked about a trapeze, but that didn't come to be. R44's Face Sheet documents, in part, diagnoses of idiopathic peripheral autonomic neuropathy; chronic obstructive pulmonary disease with (acute) exacerbation; asthma, uncomplicated; acute embolism and thrombosis of other specified deep vein of right lower extremity; pain in left leg; anxiety disorder due to known physiological condition; arthropathy; obesity; essential (primary) hypertension; heart failure, unspecified; cramp and spasm; hypoparathyroidism; localized edema; major depressive disorder; hyperlipidemia; presence of left artificial knee joint; non-pressure chronic ulcer of unspecified part of left lower leg limited to breakdown of skin; body mass index [BMI] 34.0-34.9, adult; and bacterial pneumonia. R44's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 15 which indicates that R44 is cognitively intact. R44's bed mobility of rolling left and right is indicated as substantial/maximal assistance. R44's MDS, dated [DATE] and 4/17/24, indicate no side rails in use. R44's Care Plan, active effective date of 1/13/24, documents, in part, a focus of (R44) is at risk for falls related to impaired mobility, pain on right lower extremity, unable to stand without staff assistance, use of psychotropic medication with a goal of R44 being free from falls until next review and interventions of anticipate resident needs in relation to present ADL function and provide education on safety techniques. R44's Fall Risk Assessment, dated 1/12/24, documents, in part, a score of 10 which is a high fall risk. R44's Census Activity, documents, in part, that R44 was transferred to another room on another floor on 2/13/24. On 5/22/24 at 2:43pm, V20 (CNA) stated that R44 is alert, and (R44) is bed bound. When asked about R44's fall incident on 2/23/24, V20 stated that V20 was taking care of R44 in R44's new room on the 3:00pm to 11:00pm shift, and it was about 8:30pm. V20 stated, I (V20) was changing (R44's) (incontinence brief), cleaning (R44) on the bed. There's no bed rail. (R44's) bed was not against the wall. I turned (R44) by myself. (R44) usually holds onto the side of the bed frame with (R44's) hand on that side. I was just ready to bring (R44) back to me when I realized that (R44) fell. I hollered help. No one came. I had to come out the room. I said to (V27, Security), 'Please call the nurse (V18, Registered Nurse/RN). I need help'. V20 stated that V18 then came into R44's room, assessed R44, and then 911 emergency services were called. When asking V20 about what action in R44's care was V20 performing when R44 fell off the bed, V20 stated, I was putting (incontinence brief) on (R44). I (V20) had rolled (R44) away from me. I was behind (R44), and I pull (R44) back to put clean (incontinence brief) under (R44's) hip. I just slid it (clean incontinence brief) under hips, and R44 fall out of bed. When asked how high the bed was during R44's care on 2/23/24 at 8:30pm, V20 stated that V20 had raised to the height of R44's bed to about V20's waist for V20 to provide R44's care. When asked if R44 was in the middle of the bed when turning R44, V20 said that V20 usually makes sure that residents are in the middle but didn't with R44. V20 stated that R44 landed on the floor, and I run around the bed and look at (R44) on the floor. That's the first thing I did, run around and see (R44). Then I hollered for help. No one. Then I run out by the room door and holler to (V27) to send in (V18). V20 stated that after V18 responded, V18 informed V20 that two staff members usually turn R44 in bed. V20 stated that V20 told V18, I never had a problem with (R44) before, but (R44) was in a room with bed against the wall. This bed was open on both sides. I didn't think something like this was going to happen. Can (R44) have a bed rail? I cared for (R44) before with one person. Bed was against the wall, I did it before. When asked, how does V20 know how many staff persons it takes to assist residents with bed mobility, V20 stated, I look at their size. I had been able to do (R44) with one before, but I know now that I need two. If it's a large person, common sense tells you, you need two. When asked if V20 looks in the chart for assistance level, V20 stated yes, but couldn't tell where to this surveyor. On 2/23/24, V20 was asked if R44 needed two staff persons for assistance with turning, V20 stated, At that time, no. Not need two people. (sic) When asked if R44 moves R44's legs in bed, (V20 shaking V20's head no) and stated, (R44) does not move (R44) legs. On 5/21/24 at 2:19pm, V18 (RN) stated that R44 is alert, oriented, stays in the bed and is almost bed bound. When asked about R44's fall incident on 2/23/24, V18 stated that V18 was made aware of R44's fall when V20 (CNA) came to V18 and said that R44's on the floor. V18 stated that V18 went to the room, and R44 was laying, face down on the floor and that R44 said R44 fell when V20 was taking care of R44. When asked if V18 had performed incontinence care with R44 prior to the fall on 2/23/24, V18 stated that V18 had an admission that day. V18 stated that when R44 fell, I (V18) called 911. (R44) is very big (weight). There was one CNA (V20) on the floor. (V20) was elderly. (R44) stayed on the floor. When asked about R44's position, V18 stated that R44's bed was open on both side with no side rails, and R44's position on floor was face first. V18 stated that R44's body on the floor was parallel with the bed and was in between the wall and nightstand (end table) where there was a wall near R44's head. V18 stated that R44 was alert and said that R44 bumped R44's head on the wall. When asked if R44 complained of pain after the fall on 2/23/24 at 8:30pm, V18 stated, Yes, (R44) had pain. I gave (R44) pain meds a few hours before the fall. I gave (R44) all (R44's) meds. When asked about where R44 was complaining of pain, V18 stated, (R44) didn't talk much due to position (laying face down on floor). I just moved (R44's) head to put pillow and and use sheet to cover (R44). (R44) was naked. V18 stated that (R44) did have redness to right side of R44's face. V18 stated that V18 did not medicate R44 with any pain medication due to already giving R44's pain medication prior to R44's fall. V18 stated that when V18 gave R44 the medications before R44's fall, R44's bed was in the low position; however, when V18 went in with V20 (CNA) after the fall, (R44's) bed was high. (V20) was taking care of (R44). In R44's Progress Note, dated 2/23/24 at 9:09pm, V18 (RN) documents, in part, At 8:40pm, writer was informed by (V20, CNA) that resident fell off the bed while giving care. Writer immediately went to resident room and found (R44) on the floor facing down, initials assessment done, noted with redness on right-side of the face, no bleeding noted, voiced 5/10 on pain scale, resident states 'I hit my head on the wall'. R44's February 2024 MAR (Medication Administration Record) shows that on 2/23/24 from 3:00pm to 11:00pm, there is no documentation of Hydrocodone 5 milligram (mg)/Acetaminophen 325 mg tablet oral every 6 hours PRN (whenever needed) was noted. Facility document, titled CNA Assignment Sheet and dated 2/23/24 for 3:00pm to 11:00pm shift (on R44's new floor from transfer date of 2/13/24), documents, in part, that V18 is the nurse assigned, and V20 is the one CNA assigned to the floor. R44's emergency hospital records, dated 2/23/24, document, in part, that R44 was being changed at the nursing home and fell off of the bed. (R44) with head strike and pain to right arm, bilateral feet, and that R44's pain to right arm and bilateral ankles is exacerbated from baseline. On 5/22/24 at 10:16am, V4 (Restorative Nurse, Licensed Practical Nurse/LPN) stated that R44 was receiving bed mobility for restorative therapy because R44 had reached R44's maximum potential with transfers in skilled therapy. V22 stated that with standing, (R44) could not do it. (R44) can't with left leg. When asked about bed mobility for R44, V4 stated that it's how (R44) can maneuver left to right in bed and repositioning. V4 stated that it's done with the CNA staff and also with the restorative aide (V5). When asked what R44's bed mobility staff assistance level for turning left to right in bed is, V4 stated, Substantial maximum assist with 2 persons. It needs to be 2 persons. It's for safety purposes. (R44) has no side rails. One person is on one side of the bed and the other person is on the other side of the bed to avoid falls. When asked how this is done when one side of R44's bed is up against the wall, V4 stated that the aides will move the bed from the wall, so that one person is on one side and the other person is on the opposite side. When asked about side rails as an option for R44, V4 stated that it's our facility policy of no side rails. We don't have side rails. V4 stated, That's why at all times for R44's changes (incontinence care), it has to be 2 persons. When asked about R44's fall on 2/23/24, V4 stated, (V20) tried doing (R44's) care alone. It caused the fall. There was no other CNA on the floor. That was the problem. When this surveyor informed V4 that R44 stated R44 is utilizing the end table next to R44's bed for support when there is one CNA turning R44 in bed, V4 stated, That's not acceptable. (R44) should not be holding that. There should be someone there. The nightstand is used for (R44's) personal things. V4 stated, (R44) has pain all the time with legs causing decreased mobility in bed which is why R44 is a two person assist for bed mobility. R44's Restorative Program Notes, dated 1/15/24, documents, in part, that R44 is receiving bed mobility restorative therapy with (R44) is working towards set bed mobility goal of turning onto left side with substantial maximal assist from staff, goal ongoing and that R44 has presence of left artificial knee joint, weakness, other lack of coordination and pain in left leg, and has decreased ROM (range of motion) to BLE (bilateral lower extremity). R44's Restorative Functional Assessment, dated 1/17/24, documents, in part, that R44 was noted with decreased bed mobility skills, total to substantial maximal assist from staff was provided to resident when performing bed mobility maneuvering and repositioning and that R44 is non-ambulatory/wheelchair/bedbound. On 5/22/24 at 11:20am, V2 (DON) stated that V2 was notified by V18 (RN) on 2/23/24 about R44's fall. When asked if V2 inquired about details of the fall incident, V2 stated, I (V2) asked what happened and (V18) said that (V2) was repositioning (R44) and (R44) fell. I (V2) asked (V18) if (V20) asked (V18) for help because (R44) is a two person assist. (V18) said no. When asked about R44's fall on 2/23/24, V2 stated that (R44) had never fallen before, and that since R44 had surgery on left leg with a pin inserted, R44 cannot bend the left knee. V2 stated that R44 has received multiple skilled therapy sessions to strengthen R44's legs, but R44 has reached the maximum potential. V2 stated that R44 sees V24 (Psychiatrist) for depression. When asked if V2 was with V24 (Psychiatrist) on 3/7/24, when V24 was talking to R44 after the fall on 2/23/24, Yes, I did rounds with (V24) after the fall. (R44) said that (R44) was scared and apprehensive with (staff) turning her. I assured (R44) that we will make sure proper staff provide R44's care. When asked if V2 has spoken to R44 about still feeling scared with receiving care in bed, V2 said that V2 hasn't and will make sure that V2 supervises R44's care. V2 stated, I understand that (R44's) kind of scared but will have to overcome that gradually. V2 stated that two persons are there during care so R44 should not have that feeling of being scared. This surveyor informed V2 that R44 said that when staff turn R44 now, R44 uses the wall as a support device, and V2 stated, That should never be. That's inappropriate. It should be two persons. V2 stated, It's never appropriate to use the wall like that. It should never happen. V2 stated, (R44's) care planned for two people to assist. When asked if using two persons for turning R44 in bed is ensuring that R44 is feeling safe and not scared, V2 stated, Yes. On 5/23/24 at 4:46pm, V24 (Psychiatrist) stated that V24 sees R44 in the facility for depression and anxiety. This surveyor explained to V24 about the review of R44's fall incident on 2/23/24 in the facility. When asked if R44 and V24 had a conversation about R44's fall after it occurred, Yes. V24 stated, It was the caregiver (V20) turning (R44) too fast or positioning. I provided (R44) more comfort. I told (R44) not to feel anxious about this one caregiver (V20) and try not to generalize it to all staff. When asked if R44 stated to V24 that R44 was still feeling afraid and scared after the fall when R44 is having care rendered by staff, V24 stated, Correct. V24 stated that R44 has a fear of falling from this fall incident on 2/23/24. When asked if V24 has visited R44 since having this conversation, V24 stated that V24 couldn't recall but doesn't think so. In R44's Progress Notes, dated 3/14/23 at 9:03pm, V24 documents, in part, that R44's last date seen was 3/7/24. Facility policy (undated) titled Fall Prevention Policy documents, in part, It is the policy of (Facility) to identify residents at risk for falls and to implement a fall prevention approach to reduce the risk of falls and possible injury . Every resident will be evaluated for falls upon admission and subsequently thereafter when the resident's condition changes or at least quarterly. The care plan will state the goals, interventions and approaches to every resident who was identified as being at risk for falls. Staff will be trained to be alert to risk and hazards for falls in the environment. Facility policy (undated) titled Facility Policy Regarding Resident Falls documents, in part, Overview: This facility is committed to minimizing resident falls so as to maximize each resident's physical, mental and psychosocial well-being. While preventing all resident falls is not possible, it is this facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible. Facility policy (undated) titled Personal Care Services documents, in part, Policy: Each resident shall receive nursing care and supervision based on individual needs. Each resident shall show evidence of good personal hygiene. A patient care plan for each resident is developed based on the nature of the illness, treatment prescribed, long and short term goals, and other pertinent information. The nursing care plan is a personalized plan of care for individual residents. It indicates what nursing care is needed, how it can be accomplished for each resident, how the resident likes things done, what methods and approaches are most Successful; and what modifications are necessary t (to) insure (ensure) best results. Nursing care plans are available to all nursing personnel assigned to a resident. Procedure: . Incontinent residents: Incontinent residents shall have partial baths and clean linen each time the bed or clothing is soiled. Facility job description, dated May 2003 and titled Certified Nursing Assistant, documents, in part, Purpose of the Position: The primary purpose of the position is to provide your assigned residents with routine daily nursing care in accordance with our established nursing care procedures, and as may be directed by your supervisors. Duties and Responsibilities: . Nursing Care Functions: . 25. Perform ADL programming in accordance with each resident's individual care plan goal . Safety and Sanitation: . 8. Follow established safety precautions in the performance of all duties.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of records, the facility failed to protect the residents' right to be free from physical abuse by resident (R2) against another resident (R1). The facility failed to follow their abuse policy by not having preventative measures in place for a resident with a history of physical, verbal, and sexually inappropriate behavior. The facility failed to have preventative measures in residents (R1) care plan before and after a resident (R1) was physically abused. These failures led to a resident (R2) physically assaulting another resident (R1) causing multiple injuries. Findings include: Facility reportable dated 8/1/2023 between R1 and R2: Per report facility substantiated the incident of physical abuse between R1 and R2 did occur, and that due to the incident R1 sustained injuries. Per hospital records dated 8/2/2023 R1 sustained multiple bruises to the right side of her face, under her right eye, right upper arm and forearm, left shoulder, and scratches to her left forearm. R1 is [AGE] years old, initially admitted in the facility on 9/6/2022. R1's medical diagnosis includes atherosclerotic heart disease of native coronary artery. R1's cognition is intact with a brief interview of mental status (BIMS) dated 2/12/2024 with a score of 15. On 4/23/2024 at 12:40 PM, R1 was seen sitting on her bed inside her room. R1 was alert, verbally responsive, and able to express her thoughts during conversation. R1 stated that 8/1/2023 was the day when R2 hit her on her face. R1 stated that when R2 was first admitted it became clear that R2 has changes in behavior and becomes darker and darker, violent, and bullies her. R1 said that she is afraid that R2 will hurt another person in another facility. R1 said that R2 was very violent and that R2 was even physically aggressive with a social worker staff in the facility. R2 is [AGE] years old, initially admitted in the facility on 4/28/2023. R2's medical diagnosis includes psychosis, schizophrenia, restlessness, auditory hallucination (threatening to harm himself and others), and agitation. R2's cognition is intact with a brief interview of mental status (BIMS) dated 5/4/2023 with a score of 15. Per census record, R2 was discharged from the facility against medical advice on 8/18/2023. Identified Offender Report of R2 recorded the following: Armed habitual criminal, unlawful use of weapon, multiple aggravated battery, multiple domestic battery, multiple aggravated robbery, home invasion, resisting peace officer. Per R2's progress notes, R2 has multiple incidents of physical, verbal, and sexually inappropriate behavior to both staff and residents in the facility. Progress notes of R2 are as follows: On 5/2/2023, V22 (Activity Aide) documents: R2's diagnosis includes depression with psychosis, auditory hallucination, hearing voices, threatening to harm self and others, seeing dead bodies, non-compliant with medication. On 6/8/2023, V23 (Social Worker) documents: R2 yelling and angry said barely got sleep due to his roommate being loud and calling his name. 6/13/2023 R2 was horse playing with another resident, R2 was being too rough with that resident. On 6/13/2023, V19 (Registered Nurse) documents: R2 was raising voice towards staff and co-resident because of co-resident's complaint of disturbing his sleep due to female resident present in his room. On 6/15/2023, V9 (Registered Nurse) documents that R2 was under suspicion of drinking ETOH or alcoholic drinks. On 7/5/2023, V20 (Licensed Practical Nurse) documents: R2 started playing loud music at 10:30 PM and was verbally inappropriate toward staff and residents. On 7/2/2023, V19 (Registered Nurse) documents that R2 was agitated and verbally aggressive towards staff and refused to let female resident leave the room. 7/3/2023 documents: R2 was ordered by V16 (Psychiatrist/Physician) via involuntary petition due to aggressive behavior. Police intervention was needed prior to transfer to the hospital. On 7/27/2023, V9 (Registered Nurse) documents: R2 was reported to attempt to touch on another staff buttocks while the staff was getting the food cart. On 7/31/2023, V21 (Director of Nursing) documents: dietary staff reported that R2 touched her inappropriately by brushing against her. On 8/1/2023, V9 (Registered Nurse) documents that R2 was physically aggressive to R1 resulting in multiple injuries. On 8/2/2023, V8 (Licensed Practical Nurse) documents that R2 was admitted for aggressive behavior to the hospital. On 8/15/23, V9 (Registered Nurse) R2 was readmitted back to the facility. On 8/18/2023, V11 (Social Worker) documents: R2 assaulted writer (V11), hit her in the head three times, once in the ear and twice on the neck. On 4/24/2024 at 12:38 PM, V11 (Former Social Worker) stated that since the start of her employment in the facility around July 2023, R2's behavior was making her feel uncomfortable. R2 was very aggressive and violent. He (R2) punched another Social Worker (V10) very hard on his face. V11 stated when she saw R1's face after the incident that happened on 8/1/2023 it was hurt badly. V11 confirmed that R1 and R2 are in a relationship. V11 stated that there was no determination or assessment as to R1 and R2's safety in their relationship with R2's behavioral concerns. On 4/24/2023 at 1:08 PM, V10 (Former Social Worker) stated that R2 assaulted him and V11. R2 was abusive to staff members and also directed his abuse to residents. R2 targets certain residents, including R1 even before the incident on 8/1/2023 happened. V10 stated R1 and R2 were separated and that he told R2 that he was restricted to go to a specific floor. V10 did a care plan on his (R2) behavior. Abuse Prevention Program Facility Procedures dated November 18, 2016, reads: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain, or mental anguish. Under pre-admission screening of potential residents. The facility shall check the criminal history background on any resident seeking admission to the facility in order to identify previous criminal conviction. While the background or fingerprint check, and/or Identified Offender Report and Recommendation are pending, the facility shall take steps necessary to ensure safety. Under resident assessment, as part of the resident social history evaluation and MDS (Minimum Data Set) assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or misappropriation of resident property or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis. For residents who are identified offenders, the facility shall incorporate the Identified Offender Report and Recommendations Report into the identified offenders plan of care including the security measures listed. Abuse policy of the facility clearly instruct for facility staff to identify residents with increased vulnerability of abuse or who have behavior that might lead to conflict. R2's care plan does not address any of the incidents on R2's progress notes to address his physical, verbal, and sexually inappropriate behavior. No psychiatric notes or any medical notes by physician(s) were documented on R2's progress notes that addresses R2's inappropriate behavior. On 4/24/2024 at 2:48 PM, V1 (Nurse Consultant) was informed about R2's lack of documentation and that he wasn't seen by a psychiatrist or any physician on his progress notes. After V1 reviewed R2's electronic record, V1 stated that she cannot find any documentation. V1 stated that there should be a sit down and facility staff should work together to determine that residents are safe and that R2 needs to be seen by a psychiatric or medical doctor when initially admitted and readmitted within 72-hours after admission. V1 said, I don't know why there is no documentation that R2 was not seen by any doctor. As to R1's care plan, it does not address potential abuse prior to and actual abuse after the physical abuse incident happened on 8/1/2023. On 4/24/2024 at 11:45 AM, V7 (Social Service Director) stated that currently she is in-charge of the whole facility and all residents since she is the only social worker in the facility. V7 was asked about R1 being a victim of abuse and if there is a need for this to be care planned. V7 said, I am new to this position. I don't know that an abuse incident should be care planned for the resident that experienced abuse. For me, I will talk to the admin for best practices. V7 was asked if there is a need to determine safety of both residents for residents that are couple. V7 said, If both can give consent. I don't know if I need to check on the safety of residents that are a couple even when a resident has a record of domestic violence. Hypothetically, I don't really know the guidelines on how to protect the victim from the perpetrator. These are all new to me. V7 then stated that room changes and coordination of outside services for domestic violence are possible interventions. After request for behavioral services, policies, and procedures V7 said, I don't know what are those (sic) behavioral services that the facility offers. The facility's Behavioral Management Protocol and Guidelines for Handling Behavioral Emergencies and Reducing Hospitalization dated January 2019, reads: Staff need to decide how likely a resident is to lose control by determine (sic) if there is a history of aggressive and /or unpredictable behavior. If a resident is the person making delusional (untrue) statements. If a resident behavior is illogical. The facility's Abuse Prevention Program Facility Procedures dated November 18, 2016, reads: Through the care planning process, staff will identify any problems, goals and approaches which would reduce the changes of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident receives adequate supervision and assistance devices to prevent accidents in 1 (R1) of three residents (R1, R3 and R4) included in the sample. This failure resulted in R1 sustaining a closed fracture of phalanx of right fourth toe with laceration requiring 3 sutures. Findings include: R1 is a [AGE] year-old male with a diagnosis including COPD, Schizophrenia, and Parkinson's Disease. R1 has a Brief Interview for Mental Status of 11/15. R1 requires 1-person physical assistance for transfer and walking in room. R1 uses a wheelchair to ambulate. R1 wanders and has an electric monitoring device on ankle to help prevent elopement. Incident report sent to Illinois Department of Public Health shows on 6/11/23 at 6:45AM resident accidentally ran over by staff with his wheelchair, resulting in R1 sustaining a laceration to his right 4th toe, first aid rendered. Resident transferred to hospital and returned the same day. Received 3 sutures to his laceration on the 4th toe. Facility document titled Accident includes statement on 6/12/2023 6AM CNA observed bleeding from his socks and informed the nurse on duty. Nurse on duty assessed and notes with bleeding under the 4th toe, initiate first aid treatment by cleaning with saline and applied gauze and tape. Resident went out to hospital and returned with 3 sutures. Resident has a diagnosis of Parkinson's and he became restless during the night and was attempting to get out of the bed. Night CNA assisted him out of bed and he has tremors, she mistakenly hit his foot with the wheelchair. Hospital record dated 6/11/23 shows laceration of fourth toe of right foot, initial encounter. Closed fracture of phalanx of right fourth toe, initial encounter. On 8/7/23 at 11:00 AM R1 was observed in his room in bed. R1 was clean, odor free and appropriately dressed. Attempt was made to interview him. R1 could only respond, I don't know and I don't remember. R1's wheelchair did not have footrests attached to wheelchair during this interview. R1's footrests were not in his room when surveyor searched. A second attempt to interview R1 was made on 8/7/23 at 11:07 AM. R1 stated, I don't know how I cut my toe. I may have bumped it while in my wheelchair. The nurse saw it and I had to go to hospital. I am ok now. On 8/7/23 V4 (Physician) stated R1 could have gotten the cut injury by hitting his foot while in the wheelchair. It was not by being run over by the wheelchair. R1 is very restless and resistive to care. Due to his cognition, it is hard to interview him so we could not get him to tell us what happened himself. On 8/7/23 at 12PM R1 was observed in the dining room eating lunch. R1 was in wheelchair. R1 did not have footrest attached or in the immediate area for staff to use while transporting. R1 had on socks. R1's feet were in contact with the floor. On 8/7/23 at 12:05PM V2 (DON) stated R1's footrest are supposed to be attached to wheel chair. V2 stated, I don't know why they are not. I am also the restorative nurse. The CNA involved in this incident was identified as V3 (CNA). During interview with surveyor on 8/7/23 at 10:42AM V3 denied allegation she injured R1 per following interview. V3 (CNA) stated, That day I put (R1) in the chair. I pushed the chair to the nurse station. There was no injury at that time. I came back to (R1) ten minutes later and there was blood from his toe. I told the nurse. Nurse came and looked at it. She treated it. I had nothing to do with injury. I did not see the injury until I came back to him. He did not move from the location I pushed him to in front of the nurses station. On 8/8/23 at 1:33PM V6 (RN) stated, I was called to the floor at nurses station by the CNA (V3). (R1) was in his wheelchair. His foot was bleeding. There was a cut between the 4th and pinky toe. I assessed, cleaned and wrapped in gauze. I notified the physician and (R1) was sent out. That is all I remember. He did not say how he did it. The CNA did not say how it happened. On 8/7/23 at 11:58AM V2 (DON) stated, I was told that a (V3 CNA) ran over his foot during transfer. (R1) did not have any footrest on his wheelchair. I don't know why (R1) is missing footrest on his chair. I was told it was a mistake by (V3) herself. This was reported to Public Health. We re-educated (V3) on proper transfer to wheelchair and transport. I do not know why (V3) admitted to me running over (R1's) foot and then telling you she didn't. On the day he got hurt, (V3) told me he didn't have his footrest for his wheelchair. On 8/7/23 at 12:05PM V4 (CNA/ Restorative Aid) stated R1 is supposed to have his footrest attached to his wheelchair when being transported. On the day he was injured he did not have footrest attached. V4 stated, I do not know where his footrest are at this time. They are not on his chair or his room. He could easily hit his feet without the footrest in place on his wheelchair. On 8/7/23 at 12:15PM V4 (CNA/ Restorative Aid) stated, I was able to locate the footrest of (R1). Another CNA borrowed (R1's) footrest to use on another resident. The CNA never brought them back. On 8/10/23 at 10:09 AM V2 (DON) on inquiry as to whether there is a policy for staff transporting a resident in a wheelchair and the use of footrest, stated we do not have a specific policy on the use of footrests for wheelchair transfer and transport of resident. The CNAs are taught that when in school. Facility policy titled Lifting and Transferring Residents include statements: Standard: Residents are lifted and transferred safely in all instances. Policy: Residents are assessed and determinations made for lifting and transfer requirements and the procedure for each resident. All members of the nursing staff, nurses, nursing assistant are responsible for using good body mechanics, knowing the proper procedures, and properly operating assistive devices.