**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement interventions to prevent the development of pressure ulcers for 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 7. This failure resulted in R1 developing facility acquired moisture associated skin damage to the buttocks, a stage 2 pressure ulcer to the Left Ischium, a stage 3 pressure ulcer to the Right Ischium, and a stage 3 pressure ulcer to the Sacrum. Findings include: R1's admission Record documented an initial admission Date of 12/8/22 and a readmission date of 10/5/24. Diagnoses listed include Hemiplegia and Hemiparesis following Cerebral Infarction Affecting the Right Dominant Side, Type 2 Diabetes, Chronic Kidney Disease Stage 4 (Severe), Morbid Obesity, Epilepsy, and Aphasia. R1's 12/11/24 Braden Scale for Predicting Pressure Ulcer Risk documented a score of 11, indicating R1 is at high risk for the development of pressure ulcers. R1's Minimum Data Set, dated [DATE] documented that R1 is severely cognitively impaired to the extent that a Brief Mental Status Score could not be performed, was always incontinent of bowel and bladder, required substantial/maximal staff assistance for bed mobility, and was totally dependent on staff for transfers. The same MDS documents in Section M, Skin Conditions, that R1 is at risk for pressure ulcers/injuries and that R1 did not have any pressure ulcers/injuries. R1's Care Plan dated 12/8/24 documented a Focus area of, Pressure Ulcers, sites: Left Ischium, Right Ischium, Coccyx, with corresponding interventions, Repositioning every 2 hours and PRN (as needed). The same Care Plan also documents a Focus area of Potential for impaired skin integrity related to: Cognitive deficits, Decreased sensation, PVD (Peripheral Vascular Disease), DM (Diabetes Mellitus), hemiplegia right side, Impaired mobility, Incontinence. Documented interventions include Monitor Incontinence and provide pericare. R1's Wound Assessment and Plan Notes, authored by V6, Wound Care Nurse Practitioner, documented the following: 12/1/24: Wound location: Bilateral Buttocks, MASD (Moisture Associated Skin Damage) Wound onset date, 11/28/24. Irritant Contact Dermatitis due to dual incontinence. Coccyx, pressure injury, stage 3. Wound onset date, 11/28/24. 12/10/24:Wound location: Sacrum, pressure injury, stage 3. Declined. Wound onset date 11/28/24. Location changed (from Coccyx) to more accurately reflect current wound. Wound location: Bilateral Buttocks: Healed. Wound location: Left Ischium, pressure injury, stage 2. Onset date 12/10/24. Wound location: Right Ischium, pressure injury, stage 3. Onset date 12/10/24. R1's Nurses Notes dated 12/11/24 at 10:30pm stated, Resident not responding during care, lethargic. Resident had blood in urine and fever of 101.2. Sending resident to ER (Emergency Room) for evaluation and treatment. Power of Attorney and MD (Medical Doctor) aware. R1's (local hospital) ED (Emergency Department) Note, Physician, dated 12/11/24 documented, It was brought to my attention that the family wanted the patient to stay locally. However, after reviewing the patients chart, the patient is noted to have elevated [NAME] (Blood Cell) Count of 19.3 and continues, And white (blood) cells in the urine which may indicate sepsis with abnormality in other organs. I ordered Ceftriaxone and the family was informed that the patient willing to be transferred for a higher level of care (at a regional hospital). Assessment: Dehydration, severe. Hypernatremia. UTI (Urinary Tract infection). A (Regional Hospital) Admitting Physician History and Physical Examination dated 12/12/24 documented, [AGE] year old female with a past history significant for Diabetes Type 2, Bilateral Carotid Stenosis, Hypertension, Seizure Disorder, PVD (Peripheral Vascular Disease) presented to (Regional Hospital) on 12/12/24 with Altered Mental Status. Assessment/Plan: Altered Mental Status,Hypernatremia, UTI, Sepsis present outside facility with respiratory rate of 25, Altered Mental Status, elevated [NAME] (Blood Cell) Count of 19.3, Sacral Decubitus Ulcer present on admission, AKI (Acute Kidney Injury) on CKD (Chronic Kidney Disease). On 12/26/24 at 9:20am, V4, R1's Power of Attorney, stated on 12/11/24, V2, Director of Nurses, calledV4 to state R1 had recently developed pressure areas, had experienced a deterioration in status, and the facility was sending R1 to hospital for treatment, where R1 was found to have a UTI. V4 stated she was told by V2 that R1's pressure wounds were [NAME] Ulcers, and V2 stated these were as a result of R1 being near the end of her life. V4 stated she does not believe this is accurate as R1 has since improved and has not been under hospice care. V4 stated V4 believed R1 developed pressure wounds due to not being repositioned and changed often enough, based on V4's history of working many years as a CNA (Certified Nursing Assistant). V4 stated as an example, V4 informed staff she wanted R1 get up to the wheelchair for meals, but when V4 visited, R1 often ate meals in bed. V4 stated staff told V4 that R1, Was a fall risk, had to be transferred with a mechanical lift, and they did not have enough staff to be able to supervise her while up. V4 stated she felt the facility was leaving R1 in bed all day for staff convenience. V4 stated after R1 was discharged from the hospital on [DATE], V4 had R1 sent to a different facility, where R1's wounds and overall condition have improved. On 12/27/24 at 9:35am, V9, CNA, stated she primarily works the 6am to 6pm shift. V9 stated incontinent residents on the 6:00pm to 6:00am shift are not being changed and repositioned often enough. V9 stated most mornings when V9 arrives, including the morning of 12/27/24, incontinent, confused residents are urine soaked, with dried brown rings on bed linens, and dried feces. V9 stated although there are supposed to be at least 3 CNAs and one nurse on the 6:00pm shift, at times there are 2 CNAs and one nurse, and such was the case the previous night. V9 stated when she has verbalized concern about care and staffing to Administration, she was told to call the corporate hotline to complain. On 12/27/24 at 10:15am, V8, CNA, stated she primarily works the 6am to 6pm shift. V8 stated the facility definitely does not have enough CNAs on the 6pm to 6am shift. V8 stated when she begins her shift at 6:00am, confused incontinent residents are frequently urine soaked, with brown rings on linens, and dried feces. V8 stated R1 was always incontinent of both bowel and bladder and was unable to reposition herself. When asked about R1 developing pressure wounds, V8 stated, She probably got them from not being turned and changed enough. V8 stated in regard to R1, They just tried to turn her as best they could when they remembered and tried to keep her clean and dry. On 1/2/25 at 11:40am, V12, CNA, stated she generally works the 6am shift but has also worked the 6pm shift as well. V12 stated both shifts are often short of CNAs. V12 stated when she started her shift that morning (1/2/25), several incontinent residents were soaked with urine and had odor and brown rings on linens due to the 6:00pm shift not changing them. V12 stated, There are definitely issues with people not getting turned and changed every 2 hours. V12 stated on the 6:00pm shift, They don't do bed checks like they are supposed to. Everybody is in bed by 8:00pm or 9:00pm, then they are to do bed checks at 11:00pm, 1:00am, 3:00am, and 5:00am. They always skip the 11:00pm bed check, they do a bed check at 1:00am, then they start getting people up at 4:30am, so technically there is only one bed check, at 1am. V12 said there are times when perineal care is not done when changing incontinent residents due to time constraints, incontinence briefs are changed but the perineal area is not cleansed. This is happening a lot, mostly to confused residents who can't tell anybody what is going on. In regard to R1, V12 stated, She for sure did not get turned every two hours. She (urinated) a lot, but we did try to keep her dry, although she may not have got her perineal area cleaned. V12 stated R1's family wanted her to get up to the wheelchair for meals, and when she (V12) worked with R1, she got her up. V12 stated complaints to Administration about staffing and care, Go nowhere. Nothing ever changes. On 1/2/25 at 2:25pm, V2, Director of Nurses, stated as far as she is aware, all dependent incontinent residents are being changed, receive perineal care, and are repositioned every two hours, including on the 6:00pm shift, and she has not heard otherwise. V2 stated R1's family would not have been told R1 couldn't be gotten up due to being a fall risk or not having enough staff to supervise her as those statements would not be accurate. V2 stated R1 developed MASD (Moisture Associated Skin Damage) to both buttocks and a stage 3 pressure wound to the Coccyx on 11/28/24 and was therefore referred to V6. V2 stated R1 went on to develop a stage 3 pressure area to the Right Ischial Tuberosity and a stage 2 pressure area to the Left Ischial Tuberosity, both acquired on 12/10/24. V2 stated she assumed all of these pressure areas were [NAME] Ulcers, associated with tissue breakdown at the end of life. V2 stated R1's condition continued to deteriorate and she was sent to the hospital on [DATE] due to nausea and vomiting and change in mental status. V2 stated a Urinalysis obtained prior to the hospital admission showed evidence of UTI. V2 stated at some point in December 2024, V4 had told V1, Administrator, that R1 would not be returning to the facility after hospitalization. On 1/3/24 at 10:15am, V1, Administrator, stated V4 came to the facility in December 2024, date unknown, to state that V4 did not believe that R1's wounds could have occurred that quickly and to that extent unless R1 was not being turned and changed frequently. V1 stated V4 said R1 would therefore not be returning to the facility. V1 stated as far as she knew, R1 was being changed and turned. V1 stated she told V4 that her understanding was that R1's areas were [NAME] Ulcers. On 1/3/24 at 11:05am, V6, Wound Care Nurse Practitioner, stated she evaluated R1 on 12/1/24 for facility acquired MASD to both buttocks, and a facility acquired stage 3 pressure wound to the Coccyx, both acquired 11/28/24. V6 stated she evaluated R1 again on 12/10/24, and found the MASD to the buttocks had resolved but R1 had a facility acquired stage 2 pressure area to the Left Ischium and a facility acquired stage 3 pressure area to the Right Ischium, both acquired 12/10/24. V6 stated on 12/10/24 the Coccyx wound had deteriorated to involve the entire Sacrum at a stage 3. V6 stated within December 2024, following R1's hospitalization, she resumed treating R1, at a different facility, and last evaluated R1 on 12/31/24. V6 stated all the pressure areas are now healing and R1's overall condition has improved. V6 stated she does not endorse the use of the term [NAME] Ulcers, and would not say R1 is currently at the end of life. V6 stated overall at the time the pressure areas developed, R1's overall health was in decline. V6 stated residents should be repositioned frequently to improve blood flow, but not necessarily every two hours, the time to reposition residents varies with each individual. V6 stated not being changed frequently and the perineum not being cleansed of urine and feces would be very damaging to the skin, probably more so than not being frequently repositioned. An Incontinence Care Policy dated 5/16/22 documented, All incontinent residents will receive incontinence care in order to keep skin clean, dry, and free of irritation and/or odor. Incontinence care will be provided as required. 8. Wash all soiled skin areas and dry very well, especially between skin folds. 11. Change linen as needed. The facility policy titled Skin Integrity Protocol (undated) documents Preventative Measures: 1. Turning, positioning and pressure redistribution {off-loading) will be utilized for all residents who have been identified of being at risk for developing pressure ulcers . 3. Minimizing exposure to moisture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and manage pain for 1 (R198) of 2 residents reviewed for pain management in the sample of 34. This failure resulted in R198 experiencing severe pain and anxiety, resulting in a transfer to the ER (Emergency Room). Findings include: 1. R198's admission Record documented an admission Date of 9/21/24 and listed diagnoses including Chronic Obstructive Pulmonary Disease and Anxiety Disorder. R198's Minimum Data Set, dated [DATE] documented that R198 has no deficit in cognition A Hospice Center Discharge Instructions Sheet dated 9/21/24 documented, Medications: Ativan 2mg. (milligrams) per ml. (milliliter), give 0.5ml by mouth every hour prn (as needed) for anxiety. Morphine Sulfate 20mg./ml. give 0.5ml by mouth every hour prn for pain/SOB (Shortness of Breath). R198's September 2024 Physician's Orders documented an order, Pain assessment every shift using 1-10 scale with a start date of 9/21/24. There were no medications documented to be started on 9/21/24. A September 2024 Medication Administration Record (MAR) contained no documentation that Ativan or Morphine were administered in that month. The same MAR documented that R198's pain was not assessed until 9/23/24 on the 6pm to 6am shift, at which time it was 2 on a scale of zero to ten. R198's Nursing Progress Notes documented the following: 9/21/24, 11:00am: Report received from hospice nurse. Nurse states that the resident is not eating any food but will occasionally sip on water or tea. She has a (name of indwelling urine catheter) in place. 2L NC (Oxygen at 2 liters, per nasal canula) for comfort. A&O x2 (Alert and oriented to person and place) intermittent confusion. Taking morphine for pain and ativan for agitation round the clock. Nurse states that the resident is being discharged from hospice and all orders will need to come from the admitting physician. 9/21/2024, 1:33pm: The resident arrived (to the facility) via EMS (Emergency Medical Services). 9/24/24, 5:30pm: Resident and family request to go to the ER for pain control. There was no documentation in the Progress Notes between 9/21/24 and 9/24/24 referencing R198's pain or anxiety. R198's Emergency Department (ED) Note dated 9/24/24 documented, (R198) presented to the Emergency Department for evaluation of lower abdominal pain that has been going on intermittently for the last few days. The pain is dull, 8 out of ten. Under Assessment/Plan it documents Abdominal pain, acute; acute cystitis; hypokalemia; Diagnosis: Cystitis (Urinary Tract Infection); abdominal pain; generalized weakness. Under Medication Reconciliation it documents Cephalexin 500mg.(miligram) oral every 12 hours for 10 days and Acetaminophen/Hydrocodone (Norco) 325mg-5mg, one tablet as needed every 6 hours for pain. Buspar 5mg. one tablet 3 times daily as needed for anxiety. On 10/08/24 at 12:01 PM, R198 was alert and oriented. R198 stated she was admitted on Saturday 9/21/24. R198 stated she was transferred from a hospice facility and was on round the clock medications for pain and anxiety. R198 stated she was told by facility staff that they would not be able to get these medications over the weekend. R198 stated shortly after her admission, she began to experience, Terrible pain in my abdomen, and anxiety, which exacerbated her breathing problems. R198 stated finally on 9/24/24 her family asked that she be sent to the ER to get the pain and anxiety under control. R198 stated the ER physician put her on new medications for pain and anxiety. On 10/09/24 at 9:18 AM, V2, Director of Nurses, stated when R198 was admitted on Saturday 9/21/24, she was transferred from a hospice program. V2 stated R198 had been on round the clock Ativan and Morphine, but came without medications. V2 stated normally when they get a new resident on the weekend they make sure they have the residents medication by Friday, but in this case, they were told R198 would be there on Friday, but she did not show up. V2 stated she was called the next day to say that R198 had arrived without medication. V2 stated she called the Medical Director on 9/21/24 to get medication orders for R198, but hard copy prescriptions were needed to get the medications and there was no way to obtain them. V2 further stated the pharmacy was closed, and even to take the medications out of the emergency kit, a written script was needed. V2 stated she is not sure why she did not document this call to the Medical Director. V2 stated on Monday 9/24/24, R198 was sent to the ED at the request of her family, where she was given orders for the Norco and Buspar. V2 stated every resident should have their pain assessed at least once every 12 hour shift. A Management of Pain Policy dated 5/16/22 documented, Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. A Medication Administration Policy dated 9/27/22 stated, Medications will be administered safely to residents within the facility by licensed nurses at the specified time/timeframe, following the recommended administration method and will be documented as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician in a timely manner for 1 (R2) of 3 residents reviewed for physician notification. This failure resulted in the hospitalization of R2 for 2 days with a diagnosis of cellulitis of the right abdominal pannus and left lower extremity cellulitis, and insertion of a Peripherally Inserted Central Catheter (PICC) line for intravenous (IV) antibiotic therapy. The findings include: R2 ' s face sheet documents that R2 was admitted to the facility on [DATE] with a primary diagnosis of Morbid (Severe) Obesity due to excess calories. R2 ' s Minimum Data Set (MDS) dated [DATE] documents in Section C, a Brief Interview for Mental Status (BIMS) score of 15, indicating that R2 is cognitively intact. Section GG of the same MDS, Functional Abilities and Goals, documents that R2 is independent with eating, setup/clean-up assistance with oral hygiene, dependent with toileting hygiene, showering, lower body dressing, bed mobility, transfers, and partial/moderate assistance with upper body dressing. R2's Progress Notes dated 1/07/2024 documents in part . R2 reports she has a mass on her lower right side that has been constantly growing . Mass upon examination is hard, tender to palpation, warm to touch, and appears over twice the size of her left side .Nurse will reassess area tomorrow and call primary physician to determine the next steps. R2's Progress Notes has no further documentation that the primary physician was notified regarding R2's change in condition from 1/07/2024 - 1/09/2024. R2's Progress Notes dated 1/9/2024 documents in part .spoke with primary physician related to red, warm area to R2's right lower quadrant .New order to start Levaquin 500 milligrams (mg) twice daily x 10 days and probiotic x 10 days and add R2 to primary physician's rounding list of patients to see. R2's Progress Notes dated 1/11/2024 documents in part .Primary physician in house to examine R2 .New order for Clindamycin 300mg three times daily related to cellulitis to right lower quadrant. R2's Medication Administration Record (MAR) dated 1/12/2024 - 1/25/2024 documents R2 receiving ordered Clindamycin 300mg three times daily. R2's Progress Notes dated 1/11/2024 - 1/24/2024 reviewed with no further documentation after ordered Clindamycin was administered on 1/12/2024 assessing improvement of right lower abdominal pannus. R2's Progress Notes dated 1/25/2024 documents in part .R2's cellulitis to right trunk and left lower extremity persists with no improvement .R2 would like to go to the emergency department and get assessed as it is not improving .R2 is own responsible party and agreeable. Primary physician notified and aware. On 1/25/2024 at 11:00 AM, R2 was observed lying in her bed wearing a nightgown. R2's right lower abdomen and left posterior thigh has redness. R2 stated that her right side is warm to touch, and she has been taking antibiotics for two weeks now. R2 stated that her left thigh is red, warm to touch and hard to touch. R2's Progress Notes dated 1/25/2024 at 12:44 PM by V2 (Director of Nursing) documents Resident started with area to RLQ (Right Lower Quadrant) cellulitis, PO (by mouth) ATB (antibiotic) initiated. No improvement occurred; area began to grow. A new area was noted on right posterior calf as well. The same note further documents Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Send to ED (Emergency Department) for evaluation R/T (related to) failed outpatient PO ATB therapy for cellulitis to RLQ and new right calf cellulitis. R2's Hospital Record dated 1/25/2024 documents in part . presenting to the ED on 1/25/24 with complaints of worsening cellulitis of the right abdominal pannus and left lower extremity cellulitis. R2 reports she has been on antibiotics 3 times a day since 1/11/2024 (14 days). She reports worsening pain of the right lower abdomen with thickening of the skin . As patient failed oral antibiotic therapy for treatment of her cellulitis, she will need to continue IV antibiotic therapy for total of 10 days. PICC line was placed, and she was subsequently transitioned to IV antibiotics 24 hours prior to discharge. R2's Progress Notes dated 1/27/2024 documents in part .R2 returned from local hospital via ambulance with new orders for IV antibiotic to treat cellulitis to right pannus and left lower extremity .dual lumen PICC to right upper extremity. On 1/29/2024, at 1:20 PM, V2 (DON) stated that antibiotic monitoring is documented in the resident's progress notes. The facility's Antibiotic Stewardship Program Policy dated 12/13/2023 documents in part .4. Antibiotic Stewardship Actions .iv. Antibiotic time-out. At 72 hours of antibiotic initiation or first dose in the facility, each resident will be reassessed for consideration of antibiotic need, duration, selection, and de-escalation potential .Completion of antibiotic time-out must be recorded in the resident record. On 1/30/2024, at 1:30 PM, V11 (Primary Physician) stated that if R2 was assessed on 1/07/2024 and was found to have a mass that was hard to touch, red, warm to touch, and appeared twice the size as the other side, I should have been notified on 1/07/2024, not wait until 1/09/2024. V11 stated that if an antibiotic is not improving, I should be notified right away so that a different treatment can be determined. The facility's Change of Condition Policy dated 10/07/2022 documents in part .Policy - The resident's physician and responsible party will be notified of any changes that occur in the resident's condition by licensed personnel as warranted. These changes are to include but are not limited to: Symptoms of infectious process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review, the facility failed to follow fall interventions for 1 (R1) of 3 residents reviewed for falls. This failure resulted in R1 experiencing a fall and receiving a broken rib. Findings: 1. R1's face sheet documents that R1 admitted to the facility on [DATE] with a diagnosis of Other Idiopathic Peripheral Autonomic Neuropathy. R1's Minimum Data Set (MDS) dated [DATE] documents in Section C, a Brief Interview for Mental Status (BIMS) score is 13, indicating that R1 is cognitively intact. Section GG, Functional Abilities and Goals, documents that R1 is independent with eating, dependent with oral hygiene, partial/moderate assistance with toileting hygiene, showering, upper/lower body dressing, bed mobility, sit to stand, chair/bed/chair transfer, toilet transfer, supervision/touching assistance with walking 50 feet with two turns. Section GG, dated 12/22/2023 documents that R1 requires set-up/clean-up assistance with eating, dependent with oral hygiene, substantial/maximal assistance with toileting hygiene, showering, partial/moderate assistance with upper/lower body dressing, personal hygiene, bed mobility, sit to stand, chair/bed/chair transfer, toilet transfer, tub/shower transfer, walk 10 feet/50 feet with two turns. R1's Care Plan documents in part . R1 is at risk for falls related to confusion, impaired mobility, incontinence, medications, osteoporosis, arthritis, and narcolepsy with a revision date of 10/23/2023; Goal: Decrease risk of fall and/or minimize injuries from falls x 90 days with a target date of 12/28/2023; Interventions: 2/01/2023 - Staff re-educated on importance of gait belt usage; 12/08/2023 - R1 is to be a two assist with all transfers until therapy is able to evaluate; 12/11/2023 - Transfer status changed to two assist until physical therapy is able to evaluate; 12/22/2021 - Educate to use walker with all transfers; 7/3/2022 - Educate staff to stay with her .Encourage use of call light; Give medications as ordered; Keep call light within reach; Keep environment free of clutter; Keep personal belongings within reach; Observe for side effects of medications; Observe for unsteady gait and balance; OT evaluate and treat if indicated; Provide adequate lighting; PT evaluate and treat if indicated. The facility's final fall investigation report dated 12/08/2023 documents A comprehensive investigation was completed and found on 12/08/2023, at approximately 4:40 PM, (R1) sustained a witnessed ground level fall in her bathroom. (R1) was being assisted by 1 staff member with her walker when her knees gave out. Licensed nursing staff immediately assessed (R1). Upon initial assessment, (R1) noted to have skin tears to right elbow, right hand, and right great toe. (R1) initially had no complaints of pain. On 12/11/2023, (R1) voiced complaint of pain to right knee and right side. Power of Attorney and Primary Physician were notified with an order obtained to complete an x-ray of right knee and right ribs. Results of the x-ray showed right lateral 9th rib fracture. The facility has completed a root cause analysis, which showed (R1) had become weak during transfer and was lowered to the ground. An appropriate intervention has been put into place in which (R1) was changed from a 1 person assist to a 2 person assist with a gait belt and walker to rest room. R1's X-ray report dated 12/11/2023 documents in part .1. Acute fracture right lateral ninth rib. R1's Fall Risk Assessment (Admission) dated 12/20/2021, documents fall risk score of 3 (low risk). R1's Fall Risk assessment dated [DATE], documents a fall risk score is 14 (high risk) and further documents that if the total score is 10 or greater, the resident should be considered at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. On 1/25/2024, at 10:45 AM, R1 stated that she had a fall last month and broke one of her ribs. R1 stated that the nursing staff was helping her roommate and told her to take herself to the bathroom. R1 stated that she walked to the bathroom with her walker by herself and when she got to the sink and turned around, she fell to the floor. R1 stated that she yelled and the nursing staff came to help her off the floor. R1 stated that she was wearing non-skid footwear when she had her fall. R1 stated that she did not have any pain after the fall. R1 stated that the pain came later. R1 stated that she started having pain on her right side and an x-ray was taken that revealed a broken rib. R1 stated that she did not have a gait belt on and walked to the bathroom by herself. R1 stated that she feels that she can walk to and from the bathroom with no problem even before the fall. R1 stated that she has walked to the bathroom by herself before her fall. R1 stated that she is working with therapy now. On 1/25/2024, at 11:58 AM, V3 (Certified Nurse Aide), stated that she and V9 (Certified Nurse Aide), were in R1's room assisting R1's roommate in getting up and observed R1 take herself to the bathroom. V3 stated that R1 attempted to turn herself, fell and her arm got stuck in walker/sink and R1's foot got stuck causing a skin tear to her toe. V3 stated that R1 did not have a gait belt on. On 1/25/2024, at 9:20 AM, attempted to contact V9, left message to return call back with no call back during this survey. R1's Witnessed Fall Report dated 12/8/23 documents a witness statement from V9 stating Residents knee gave out. fell on walker into sink. Got right arm stuck in between sink and walker. Feet bent still holding walker with left hand. On 1/29/2024, at 12:00 PM, V5 (Therapy Director) stated that the last time R1 was discharged from therapy was on 4/28/2023 and it was recommended at that time R1 would be an assist of 1 person with a gait belt & walker for transferring and ambulating. V5 stated that R1 is currently in therapy at this time since her fall on 12/8/2023. V5 stated that she is currently an assist x 2 with a gait belt and walker for transferring and ambulating. On 1/29/2024, at 12:45 PM, V7 (Certified Nurse Aide), & V8 (Certified Nurse Aide), were observed assisting R1 without the use of a gait belt, and walker to ambulate R1 to her bathroom.