**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow two residents fall care plan and failed to transfer two residents (R1, R2) in a safe manner using a wheelchair and mechanical lift in a sample of three. These failures resulted in R1 sustaining an avoidable fall out of wheelchair and R2 sustaining a fall while using a mechanical lift resulting in R2 being sent to hospital due to constant headache, left hip, left elbow and left leg pain for three days. Findings include: R2 is a [AGE] year-old resident initially admitted to the facility on [DATE] with diagnoses including but not limited to quadriplegia cervical 1-cervical 4 complete, anxiety disorder and spinal stenosis cervical. R2's Minimum Data Set (MDS) section C0500 dated 4/4/2025 documents Brief Interview for Mental Status (BIMS) score = 15 which suggests cognition is intact. MDS section GG0130 dated 4/42025 documents resident is dependent on staff for the following: eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. R2's Fall Risk Observation form dated 4/7/2025 documents fall risk low with score of 9. On 6/16/2025, at 10:48 AM R2 stated I had a fall about 3 weeks ago it was a Friday. I was in the Mechanical lift and I ended up on the floor. The strap was not put right in the hook, I think. I hurt my elbow and my hip and my head. I went to the hospital Monday after the fall Friday due to the pain. They took x-rays and everything was ok. No injuries. I do not have any bruises any longer from it, but I did have. Only the left side unhooked. V6 CNA (Certified Nurse Assistant) and someone else (V8) were the CNAs that were here when it happened. They asked if I wanted to go to the hospital and I said not today. On 6/17/2025, at 10:49 AM R2 stated I had the fall with the Mechanical lift before Memorial Day that Friday. The lifts are not broken, they just did not hook it right that is what happened. I did have a lot of pain in my left elbow, left hip, and head. Pain level was 8/10 to head for 3 days. The elbow pain was about an 8/10. The hip did not have much pain at all. I had bruises to left elbow and left hip. The CNA name was (V6) the one that hooked up the loops to the machine. At 10:55AM as surveyor was speaking with R2, V10 CNA and V11 CNA entered R2's room to help move R2 from bath bed to chair. Surveyor observed both CNAs place Mechanical lift pad and place R2 in lift. R2 stated he wanted black loop on legs and green on the top. Bar placed across chest. Mechanical lift legs were not opened to wide base while lifting R2 with mechanical lift. Legs of Mechanical lift was then opened slightly to lower resident in chair. R2 noted to instruct CNAs on Mechanical lift use every step of the way. V11 stated we are supposed to widen the legs of the lift prior to lowering the patient. When asked if needed to widen the legs to lift patient V11 stated there is no need to widen the legs to lift the patient from bath bed if the lift fits it fits. V10 CNA stated I was only aware of widening the legs of the lift when getting in front of chair to lower resident. R2's care plan dated 4/4/2024 documents focus: The resident is at risk for falls related to Deconditioning, Gait/balance problems, Paralysis. Goals: The resident will be free of minor injury through the review date. o The resident will not sustain serious injury through the review date. Interventions: Anticipate and meet the resident's needs. o Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. o Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility o ensure even weight distribution, when using H**** lift/sling (mechanical lift) d/t (due to) patient's spasms/quadriplegia o Follow facility fall protocol. On 6/16/2025, at 12:53 PM, V5 Licensed Practical Nurse (LPN) stated I was here the day R2 had a fall from the Mechanical lift. The CNAs were V8, and the other person was a restorative aide V6. So, I was sitting at the nurse's station charting and V6 CNA came by the door and waved for me to come here and R2 was on the floor in between the Mechanical legs. R2 was completely out of the sling on the floor. The Mechanical lift was like halfway up/down like in the middle. I assessed R2. I helped get R2 back in the bed. I called V2 and the Doctor. The doctor asked if he was in pain. R2 had denied pain and did not want to be sent out to the hospital. A few days later I was R2's nurse again and he was complaining of pain, and I sent R2 out to hospital then and they did a full work up with no findings. I do not know how or why R2 fell out of the Mechanical lift. It makes no sense to me. R2's progress note dated 5/23/2025 documents: Note Text: Patient fell out of H**** lift (mechanical lift) during transfer. R2's incident report dated 5/23/2025 documents: witnessed fall. Resident description: resident stated they fell out of H**** lift (mechanical lift) during 2-person transfer. R2's skin assessments dated 5/27/2025, 5/30/2025 and 6/3/2025 show skin intact and no abnormalities marked. R2's hospital records dated 5/26/2025 document reason for visit: Fall. Imaging tests Computed Tomography (CT) cervical spine without contrast, CT head without contrast, X-ray elbow left 2 views, and x-ray hip left 2 views. CT head wo contrast results documents history: post traumatic headache. CT cervical spine wo contrast documents history: posttraumatic cervical spine pain. X-ray elbow left 2 views documents history: elbow pain. X-ray hip left 2 views results document history: posttraumatic left hip pain. ED (emergency department) triage notes documents: Patient comes to ED via EMS (emergency medical services) for a fall that occurred 3 days ago. Patient denies any LOC (loss of consciousness). Per patient, nursing staff was using a (mechanical lift) and dropped patient on his left side. Patient has a constant headache, left hip pain, and left leg pain. Pt denies any blood thinner at this time. ED (emergency department) provider notes documents: He experiences pain in his left elbow, hip and head following an incident where he was dropped from a (mechanical lift) at facility. the pain is localized to the left side, with specific mention of elbow and hip. He has difficulty with movement, expressing both ' I can move and 'I can't move' indicating some level of immobility or discomfort. No changes in leg color were noted, as he confirms it is normal for him. ED Provider notes also document Fifty male with history of present illness above, differential includes acute traumatic injury versus sequelae. On 6/16/2025, at 1:10 PM, V6 (Restorative Aide/CNA) stated I do recall working the day R2 had a fall from the Mechanical lift. So, I was going in there to assist the CNA (V8) to get R2 up. We did all of R2's ADL (activities of daily living) care, got R2 dressed and was getting R2 up to get in his chair and were using the Mechanical lift. R2 was very specific as to wanting the green straps (of Mechanical lift pad) at the top and the black straps at the bottom. This Mechanical lift we were using did not go up very high so the other CNA V8 (she no longer works here) was lowering the bed and holding R2's feet as I was pulling the Mechanical lift out. R2's body started tipping a little and when I was pulling R2 out V8 CNA had his feet and somehow some way the strap came out of the Mechanical lift, and I was able to grab it and lower R2 down to the floor so he did not hit so hard. R2 did hit his left elbow and left hip. We immediately asked him if he was ok he said yes. V8 CNA went and got the nurse V5 (LPN). V5 assessed R2 and asked if he was ok and he said yes and that he just hit his elbow on the Mechanical lift leg. R2 did not want to go out to the hospital and said he was fine. Myself, V8 CNA and V5 LPN got R2 back in bed. V5 LPN reported it to V2, Director of Nursing (DON). V2 came around and checked on R2 and he was fine. R2 wanted us to use the same Mechanical lift again to get him up and I told him I did not feel comfortable using that same Mechanical lift. It had to be a Mechanical lift malfunction. It seemed like one of the arms were loose or something. I am not sure if that same Mechanical lift is here or not. R2 did not get hurt because I was able to grab the Mechanical lift pad as it was going down so R2 did not hit as hard as he would have if I didn't. Surveyor went with V6 to look at Mechanical lifts in the building. Mechanical lift with outside company stickers and battery with no brand name has no safety clips but does not appear to initially have them. V6 stated the other Mechanical lift we used is similar to this one and I think the side hook was loose. Surveyor noted nut holding the side plate with hooks. Mechanical lift observed and did not have safety clips and area to put loops on was smaller. V6 stated I think they got rid of that Mechanical lift. V2 and upper management were looking at the Mechanical lifts after the incident and I think they tightened the bolt and got rid of that lift. On 6/16/2025, at 1:32 PM, V2 DON stated I was in my office with the ADON (Assistant DON) and restorative nurse having a meeting and V5 LPN came and said R2 had a fall from the Mechanical lift. We all went down there to see what had happened. So, I checked to see if R2 was ok. R2 said he was fine. I came back and spoke to R2 later that day when it was just him and R2 told me it was an accident, and I am fine. I called V15 Nurse Consultant and me, the 2 CNAs (V6 and V8) and V15 Nurse Consultant went back to R2's room and connected him up to the same Mechanical lift they said they used. The aides claimed the Mechanical lift arm was loose, but I didn't think the arms were that loose. So, I took it (Mechanical lift) out of use sent it back to the company. I did have V13 (Maintenance Assistant) tighten up the nut on the arm just in case it got used before it got picked up from the company. V13 said it didn't tighten much but it did tighten some. Those arms are made to swivel. R2 did say what color loops he wanted where, and they hooked it up the same way they did earlier, and it did not sway how the girls (V6 and V8) said it did. One of the hooks from the head area had come undone and that is how he had fallen out. It was not one of the legs. R2 did not tell me that the CNA's did not hook it all the way. R2 complained that the bar on top wasn't wide enough on that Mechanical lift and that is why he was swinging. R2 kept telling me it was an accident. I also talked to him separately when the staff was not there so R2 could tell me anything confidentially. We also did education on staff on what Mechanical lift pads to use with the correct machine. The pad they used that day was the correct one for the correct lift. The one Mechanical lift that has the missing clips is a rented Mechanical lift and I am waiting for the company to pick it up. I needed it to lift a larger resident. On 6/16/2025, at 2:37 PM, V2 stated for the fall with the Mechanical lift for R2 the CNAs were V6 and V8. V8 resigned the day after the incident. V8 was upset when we were asking questions, I don't know if it scared her or what. My expectation of staff regarding things out of the ordinary happening is it should be reported. Proper lifting techniques, proper transfer techniques, etc. Once R2 fell they reported it right away. We as upper management were just making sure we are following our procedures. That is why I got V15 Nurse Consultant because it did not compute in my head how he could have had a fall from a Mechanical lift. On 6/16/2025, at 2:50 PM, V1 Administrator stated my expectation of staff regarding falls is to prevent falls as much as possible. Once a fall occurs is to call the nurse and have the nurse assess, ensure resident is ok and report to administration to investigate fall. My understanding of a reportable is that we report abuse, fall or injury especially an injury of unknown origin. I would not consider these two falls reportable. In R2's case in the initial reporting of the incident he was lowered to the floor when the sling was coming unloose. V6 said she got him and assisted to the floor, and he did not have any injuries. When R2 was interviewed R2 said they did not let me fall. Then later R2 said they dropped me. V15 Nurse Consultant stated it was not reportable. We still did the fall incident in the computer. We always report abuse and if we don't know how it happened. But if we know how it happened and no injury, we don't report it. When asked by surveyor if reporting includes unusual occurrences V1 stated I understand I can see that they could be considered unusual occurrences. I don't see how him being assisted to the floor is an unusual occurrence though. R2 calls the state on us when he does not get his way. If I thought, they willfully did something or negligent I would have reported it. I am not sure what to think of the Mechanical lift fall. To be totally honest the equipment here is completely different to what I am used to. We did not have all of this equipment and I am not familiar with how they work. On 6/17/2025, at 9:59 AM, V8 CNA stated I previously worked at facility for about 2 months. I quit working there the last week of May. I do remember working when R2 fell from the Mechanical lift. So basically, I was assigned to that set. R2 likes to get up like 10 am. I went to go get V6 CNA to help me because a Mechanical lift is a 2-person lift. We did all his ADLs changed him and got him dressed. I went to go get the regular Mechanical lift and could not find the one I usually use. I got the other one and R2 likes us to use a certain color loop on top and a certain color on bottom. I told him we needed to put on the different colors because it was a different Mechanical lift. The Mechanical lift was broke and it was not working properly. The things that you put the loops on was swinging and it can literally flip all the way around. I told him I did not want to use this Mechanical lift but he wanted to get up. There was another Mechanical lift in the building, but it would not charge, and we could not find the battery for that one. So, we ended up using the broken Mechanical lift. R2 likes green and black loops. R2 would not let us use the different color loops R2 wanted the green and black. We hooked R2 up and V6 CNA was holding his top half and pulling the Mechanical lift away from the bed and I was holding R2's feet. The Mechanical lift would not lift R2 completely off the bed. R2's buttocks was still touching the bed. So, I was lowering the bed. I am moving R2's legs and V6 CNA started pulling the Mechanical lift and V6 seen the loop come off of the hook because the thing was swinging. R2's weight was swinging. R2 was not in the normal sitting position. It was not the right way; I knew it was not the right way. V6 seen that and tried to catch R2 in the Mechanical lift pad before he went to the floor. V6 was able to kind of catch R2 but R2 hit his shoulder and his hip on the floor. R2 hit his head on V6's foot. So, R2 did not fall as hard as he could have but R2 did fall. That is not even the first time they had an incident with this Mechanical lift. After this happened, they magically found another Mechanical lift that worked. R2 told me that the facility told them several times that they were not going to fix the (mechanical lift). I had not ever reported that Mechanical lift not working. That was the first time I had used that Mechanical lift. I usually used the other one, and that one worked. That day the battery would not charge on the other one. We could not find a battery that worked. I did not tell management about that prior to using the broken (mechanical lift). We told V2 after the fact about the battery not charging so he knew. What would have prevented this from happening would be if we would have had a different Mechanical lift or if the arms weren't loose and if we would have paid more attention to the state of the Mechanical lift before using it. The last time I was trained on the Mechanical lift was when I got hired around March. I always knew it was a 2-person job. If we see a fall or know of a fall, we are to report to the nurse right away. On 6/17/2025, at 11: 26 AM, V6 Restorative Aide/CNA stated, regarding the Mechanical lift used the day R2 had a fall, the Mechanical lift that we used that day, I was not aware of it being broken prior to us using. We looked for the Mechanical lift we normally used for R2 and could not find it. I did not notice prior to using the Mechanical lift that the arm was swinging more than it should have until he was in the sling. I was the one that hooked R2 up to the Mechanical lift that day. I did not and do not recall V8 telling R2 not to use the black and green loops for the Hoyer that day. There were 2 other Mechanical lifts here that day but did not have batteries to charge them. The batteries were dead. We had to plug them in. I do not know how long it normally takes to charge the batteries. I think they were the Mechanical lifts that they are renting. I do not think they came with any battery exchange. So, they only had the one it came with. V8 CNA no longer works here. V8 is my daughter. I don't know if V8 knew the lift was broke before I came in to help her. I did not know that it was broken prior to using it. I know R2 was adamant to get out of the bed because he was in the bed for the 2 days prior from his preference. R2 still wanted to use the same Mechanical lift after the fall and I refused. We did end up finding the other Mechanical lift we normally use for him after the fact. In my opinion if they checked the Mechanical lift more often to see if they are working properly this would have not happened. And making sure they are charged pretty much that is it. I do not know how often they check the Mechanical lifts. If they are broken or not charging, we let V2 know and take down to maintenance door and they will look at it. On 6/17/2025, at 11:44 AM, V2 stated, on the floor we have four Mechanical lifts in the building. We had more but parts broke, they were old we had to pull them out. It costs less to buy a new Mechanical lift than to get them fixed. Regarding the CNA Mechanical lift transfer trainings they should be done annually. The records show the last Mechanical lift training was done for all CNAs on 12/6/2023. I started some trainings for the CNA's that were here on the day of the Nurses training fair on 4/3/2025. Schedule requested from V2 for 4/3/2025. The Mechanical lift competency training for most of CNA's is past due about 6 months. I have a skills fair I am planning for September for CNA's. Maintenance logs provided to surveyor for six pieces of equipment. V2 stated some may be sit-to-stands and some Mechanical lifts. I do not think they have maintenance logs for the rented Mechanical lift . Surveyor requested to go with V2 to go match up serial numbers from maintenance logs with Mechanical lifts in the building. On 6/17/2025, at 11:49 AM, Surveyor went with V2 to look at all Mechanical lifts and match up serial numbers with Mechanical lifts from maintenance logs. 2 Mechanical lift and 1 sit to stand lift noted on (hall) (3). Medicare area noted to have 2 Mechanical lifts in that area. V2 stated there are 4 Mechanical lifts in the whole building. The other two maintenance logs are for sit to stand lifts. Surveyor asked V2 to provide surveyor with a report showing how many residents need to use the Mechanical lift. On 6/17/2025, at 2:22 PM, Surveyor reviewed list of residents who are care planned to use mechanical lift with 2-person transfer or mechanical lift and there are 18-24 residents in the building who use this type of lift per provided list. On 6/17/2025, at 11:55 AM, V7 Maintenance Director stated we do not do maintenance on rented Mechanical lifts as they are rented. I think we have 3 Mechanical lifts in the building. I do not know how many residents use Mechanical lifts in the building. On 6/17/2025, at 12:44 PM, training records provided to surveyor for 18 CNA's showing annual competencies completed on 4/3/2025 including total body lift including V6 CNA and V8 CNA. On 6/18/2025, at 1:00 PM, Administrator provided surveyor a list of current CNA's showing a total of 48 CNA's currently employed. On 6/17/2025, at 1:16 PM, V7 stated, we currently have 4 Mechanical lifts in the building currently all owned by us. We do monthly checks on those lifts unless staff notified us that there is a problem then we check them whenever staff brings to us or tells us about it. V14 Scheduler/Ancillary Clerk lets me know when we have a rental Mechanical lift in the building. I do not do any type of maintenance on those lifts. If anything goes wrong with them, we call the company and they come out and service or replace them right away. The lift that R2 fell from I did not tighten any screws to that lift unless my assistant did that, we are not supposed to do any maintenance on these lifts or equipment. We are not even supposed to touch them lifts. When surveyor told V7 that the staff stated maintenance tightened the screws V7 stated I am going to have to get on V13 Maintenance Assistant about that then. Anything the other companies bring we call them for maintenance on that, we are not supposed to touch them. On 6/17/2025, at 1:30 PM, V13 stated the Mechanical lift that R2 fell out of staff did bring that Mechanical lift down to me to tighten the screws. I did tighten the screws on it. I did tighten the screws on it after the fall. This was a rental Mechanical lift . The screws were loose and it had more play in it than we would like. We normally do not work on the rental equipment that is why I suggested it to be sent back. I did not know if they were going to come with a new rental or not and wanted it to be operational and safe that is why I tightened the screws on that (mechanical lift). As soon as that happened, we took it off the floor. When asked why you tightened the screws if you pulled the lift off of the floor right away V13 stated when I tightened the screws I had not talked to V2 at that point, but my suggestion was to get it replaced. I spoke to V2 and that is when it got taken off the floor. V7 stated I am not sure how long it usually takes to pick up or service equipment that would be V14. The companies do not come out and service their equipment unless we call them. I am not sure if they have a contract to do upkeep on their equipment on a certain schedule. That would be a V14 question. I have not seen them come out and just check on equipment that does not have any problems. On 6/17/2025, at 1:40 PM, V14 stated I am in charge of ordering rental equipment and notifying companies when their equipment needs servicing. Usually, it takes about a day or two to come and pick up or service equipment. Unless we have a problem with the equipment, the companies do not come out and maintain the equipment like Mechanical lifts, beds, broda chairs, floor mats, etc. The companies that provided oxygen and CPAP machines do come out about every 2 months and check on their equipment. We are not supposed to do any maintenance on outside company equipment. Surveyor asked is there anything that could have been done to prevent R2's fall from Mechanical lift. V14 stated in my opinion me being a CNA for umpteen years I would have noticed the arm being loose. Maybe a newer CNA would not have noticed that. R1 is a [AGE] year-old resident initially admitted to facility on 4/25/2023 with diagnoses including but not limited to: transient cerebral ischemic attack, vascular dementia unspecified severity with behavioral disturbance and major depressive disorder. R1's Minimum Data Set (MDS) section C0500 dated 4/30/2025 documents Brief Interview for Mental Status (BIMS) score = 06 which suggests severe cognitive impairment. MDS section GG0130 dated 4/30/2025 documents resident needs set up or clean up assistance with eating. Resident needs substantial/maximal assistance with lower body dressing, putting on/taking off footwear, and personal hygiene. Resident is dependent on staff for oral hygiene, toileting hygiene, shower/bathe self, and upper body dressing. R1's Fall risk assessment dated [DATE] documents resident is a high falls risk with score of 15. R1's Progress note dated 6/6/2025 documents: Note Text: Staff brought resident while in his wheelchair to the nurses cart and stated that the resident almost fell, (V4) CNA (certified nursing assistant) states that resident was standing while holding onto the side rails of the wall and as an attempt was made to sit down in his wheelchair resident missed the wheelchair and V4 CNA assisted resident to the floor with no injuries, no injuries noted. Resident assessed, vitals WNL, denies pain, no further actions required at this time. On 6/16/2025, at 10:55 AM, R1 noted to be sitting in wheelchair in front of nursing station. Surveyor asked staff to see if R1 would talk to surveyor in his room. R1 agreed to talk to surveyor in his room. R1 noted to be sleepy sitting in wheelchair with eyes opening and closing during wheelchair transfer to room by staff. R1 stated he was ok. R1 stated he did not have a fall recently. Everyone treats me ok. When asked if anyone pulled the wheelchair out from underneath R1 he stated yes and stated the first name of V4 when asked who did that. When R1 was asked if he fell when the wheelchair was pulled from underneath R1 he stated yes. I do not remember what day she (V4) pulled the wheelchair from underneath me. Resident could not answer why V4 pulled the chair from underneath of R1 or if it was an accident or on purpose. R1 clean and well groomed. No foul odors noted. On 6/17/2025, at 10:42 AM, R1 was in dining room alone at a table close to doors by nursing station. R1 stated I did not fall out of my wheelchair recently. Someone pulled the chair out from underneath of me. It was the nurse. R1 stated her name was the first name of V4. When asked how it happened R1 stated I was sitting down. She (V4) was trying to push me out of the dining room. She (V4) was pushing me backwards in the wheelchair. I fell to the ground. She (V4) helped me back up. I did not get hurt. I did not have any pain or bruises. On 6/16/2025, at 11:58 AM, V4 stated I do recall an incident with R1 almost falling out of the wheelchair. I do not recall the exact date. I think it was a Thursday about a week and a half ago. I am pretty sure it was a Thursday. All that happened was that R1 was trying to stand up and was trying to grab on to a door handle and R1 is a high fall risk. So, I went over to R1 and tried to sit him down and he grabbed on to the handrailing and was holding on really tight and so I went to move the chair because the chair was stuck. R1 was standing up at that point, and I went to move the chair and R1 started wobbling and he lowered himself to the floor as I was standing by him. R1 was taken to the nurse (V3) Registered Nurse (RN) and I let her know R1 had an assisted fall to the floor and everything was witnessed. No one else that I am aware of witnessed the fall besides me. I was already guiding R1 to sit down when this happened, so it was an assisted lowered to the floor. R1 landed on one of his knees. There were no visible injuries. R1 was acting normal. No complaints of pain. R1 was taken straight to the nurse. The nurse was V3. R1 is a high fall risk. R1 constantly tries to stand up and we have to assist him or redirect him to sit down. R1 was close to the nurse's station but by the corner. R1 is usually at the nurse's station for higher visibility. But R1 can wander around a little bit, but he does not go too far. We all keep an eye and watch closely the high fall risk residents. R1 was my resident that day. That is my normal assignment. I have had R1 every day I have worked for like a year and a half, so I know him very well. On 6/16/2025, at 1:32 PM, V2 Director of Nursing (DON) stated my expectation of staff regarding documentation is that staff should document incidents before their shift is over. Obviously patient care comes first. There should not be an incident that is documented the next day. For R1, I got a note under my door that a staff member seen resident on the floor, but no incident was reported. I went and talked to all staff members noted in the area that day. My investigation revealed there was a CNA (V4) that was caring for R1 and was rolling him backwards through the door and he grabbed the door frame, and he slid out of the chair. V4 picked him up and put him back in the chair but did not report. The CNA V4 told the nurse V3, get your resident he almost fell. So now I am interviewing everyone and trying to investigate and see what happened. The CNA V4 did not want to get in trouble and did not report so we opened up the incident the next day because we now knew R1 actually fell. V4 was the CNA, and she was terminated after the investigation. Once I got everyone's statements, I suspended V4 for 3 days pending investigation and then terminated her the following Wednesday. We looked at the camera and it doesn't show the area. You can see everyone going over there but cannot see the incident. That is when I started getting statements from everyone I seen in the camera. So, R1 did have a fall, it was not assisted to the floor. V4 was pulling him backwards and R1 put his arms on both sides of door jambs, and R1 braced himself on the door and fell out of wheelchair. R1 was not standing up, V4 was bringing him out of the dining room. I don't think it was intentional, if V4 would have just reported it we would not have a problem. Surveyor asked to see cameras and to see the termination paperwork. V2 DON provided discipline form recommending termination dated 6/10/2025 signed by V4 CNA. V2 DON stated we brought V4 back from suspension and the same day terminated her. On 6/16/2025, at 2:06 PM, V2 DON stated the camera only records for 24 hours and it cycles so we do not have the footage unless maintenance can pull it up. When I looked at it, it was still in the 24 hours. V2 showed surveyor the live footage of the area and where R1 was, which is out of screen view but just to give you an idea of where he was and where it happened. I will go see if maintenance can pull it up for you. On 6/16/2025, at 2:11 PM, V2 DON and V7 Maintenance Director. V7 stated the cameras only loop for 24 hours. After 24 hours there is no access that we can get. Surveyor asked what happens if something happens on the weekend and now you do not have access to check the cameras. V2 DON stated I think it is the package they bought for the cloud I have been asking them to upgrade it for that reason. On 6/17/2025, at 12:18 PM, V3 Registered Nurse (RN) stated I was working when R1 had his fall. I did not witness it. It (fall) was on a Thursday. I charted on 6/6/2025. I was notified of an incident that he almost fell, and they brought R1 to me on 6/5/2025. On 6/6/2025 I was notified that R1 did have a fall on 6/5/2025 and told to put in my progress note and open an incident on it. R1's Care plan dated 3/3/2024 documents focus: Resident is at risk for falls and injury related to falls due to history of falls, decreased safety awareness due to altered mental status and Dementia. He also has weakness, decreased mobility, and utilizes psychotropic medications. Goals: The resident will not sustain serious injury through the review date. Interventions: Ask the resident every one to two hours if he needs to use the bathroom. o Dycem in place o Ensure the transfer path is clear and\or resident is not grabbing stationary objects during transfer. o Give resident verbal reminders not to ambulate/transfer without assistance. o Keep bed in lowest position with brakes locked. o Keep call light in reach at all times. o Keep personal items and frequently used items within reach. o Keep wheelchair out of reach of resident. o Monitor for proper positioning when in bed o Monitor pt closely when in wheelchair. o Observe frequently o Orient [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions to prevent pressure ulcer/pressure injury (PU/PI) development for residents who were admitted without PU/PIs and totally dependent on staff for care and assessed to be at increased risk for PU/PI development; the facility also failed to provide ongoing skin assessments for these residents. This failure affected three (R4, R5 and R7) of four residents reviewed for pressure ulcers and resulted in R4 developing a stage 4 facility acquired wound to the right buttock, R5 developed a stage 3 facility acquired wound to the coccyx, and R7 developed a stage 3 facility acquired wound to the sacrum. Findings include: R4 is an [AGE] year-old male who was admitted to the facility August 4, 2022 with diagnoses that include malignant neoplasm of the prostate pressure ulcer of right lower back stage for retention of urine other core compression, secondary malignant neoplasm of bone, atherosclerotic, heart disease, paraplegia, spinal stenosis, hyperlipidemia, history of falling, anemia, neuromuscular dysfunction of the bladder gastroesophageal, reflux disease, essential, hypertension, osteoarthritis, and weakness. MDS (minimum data set) dated March 8, 2023, indicates R4 requires extensive two person staff assist with bed mobility and toileting, extensive one person staff assist with dressing and personal hygiene. 5/17/23 3:36 PM R4 stated, I got a bedsore on my butt, and it healed about this month, the last month I got it while I was here. I think they weren't cleaning me properly. The staff doesn't come and reposition me when they come to change me. That's the only time I get repositioned and that's only about two or three times a day because I have the catheter. Braden score assessment dated [DATE] scored R4 as 12.0 high risk, initial skin assessment dated [DATE] documented no skin issues. 5/22/23 3:24 PM V19 (RN Wound Care) said that R4 was admitted in August he will sit up in his chair for long periods of time. He did have a chair cushion, but he can't feel anything from the waist down. The woman started as a deep tissue injury. He was already at risk for pressure ulcer development because, he is paralyzed a DT high is considered a pressure injury and he developed it about a month after he was admitted every once in a while I spot check residence just to make sure their skin is OK I'm the one who discovered the wounds according to my notes, it was 90% read 10% scan with some bleeding it was identified September 5, 2022 and we marked it as an unstageable wound November 28th, 2022 the wound opened and it was stage IV. It was covered with yellow or gray slough. DTIs can sometimes heal without opening and sometimes it will soften up, and the tissue will slowly deteriorate meaning the necrotic tissue starts to come off and granulation tissue forms. Granulation tissue is beefy red, healthy tissue, and is an indication of healing if there were other increases of redness surrounding the wound and increased tissue necrosis would mean that the wound is deteriorating. This wound eventually healed and it was a very slow process. I can't explain why the wound developed if we had interventions put in place to prevent this. Whenever they were changing him, they should have been repositioning to take off pressure. He also had a skin tear on the tip of his penis where the catheter laid up against the skin, and when we saw that we told the nurses that they have to make sure that the anchor is in place so that it is not causing pressure he's still at risk for developing pressure ulcers even though the side has healed right now, he has a protective dressing on the sacrum and Ischium, where the scar is The doctor said the strength of the tissue is never going to be 100% so he can re-open quite easily residence with pressure. Ulcers are susceptible to more pain in the open wound and makes the resident at risk for infection. I would expect the nurses and CNA's to conduct daily skin checks, regular repositioning, air mattress and heel protectors to remain in place as interventions. I checked his skin this morning and he didn't have his heel protectors on, but I didn't notice any new openings. R5 is a an [AGE] year-old female who was admitted to the facility on [DATE] with medical history including, but not limited to Unspecified dementia, unspecified severity with other behavioral disturbance, hypertensive heart disease without heart failure, weakness, fibromyalgia, anxiety disorder, hyperlipidemia, history of falling, etc. 5/17/2023 at 9:30AM, R5 was observed in her room, awake and alert with some confusion. Resident was noted with lots of redness and bruising on her legs and arms, staff is not sure if resident is on a blood thinner. At 9:38AM, observed wound care for resident with V6 (LPN/Wound care) and noted a quarter size opening on the resident's sacrum, V6 stated that the wound is facility acquired, and has been documented as stage 3, they always stage wounds as stage 3 until it is healed. admission progress note dated 1/21/2023 documented the following skin issues; Skin tear to Rt forearm 0.5x1.5cm, 100% red, small amt. bleeding, no odor, peri wound intact. Skin tear to Rt lateral shin, 2.0x2.0cm, 100% red, small amt. bleeding, no odor serous drainage and intact. Braden score dated 1/20/2023 coded R5 as 16, mild risk for skin breakdown. R5 has an active order for Skin assessment daily, turn and reposition q 2hrs, q shift, & PRN, and was assessed as requiring staff assistance for all Activities of daily living (ADLs). Review of shower sheets for the month of May for R5 did not show any documentation of resident receiving a shower, and no documented skin assessments. Wound management report for R5 documented a facility acquired pressure ulcer to the coccyx, identified on 3/21/2023, measuring 0.6x0.6 with a depth of 0.1, moderate serous exudate, and was described as a stage 3. R7 is a [AGE] year-old female who have resided at the facility since 2018, with past medical history of type 2 diabetes mellitus with diabetic neuropathy, unspecified psychosis not due to a substance or known physiological condition, sepsis, gastritis, dementia, dysphagia oral phase, anxiety, etc. Review of resident's record showed a Braden score assessment dated [DATE] with a score of 11, high risk for alteration in skin impairment, skin assessment dated [DATE] documented no bruises and no open areas. R7 also has an order for daily skin assessment and to be turned and repositioned every 2 hours and as needed. Review of shower sheet for the month of May did not show a documentation of any showers given or skin assessment done as ordered. 5/17/2023 at 9:38AM during wound care observation, V5 (LPN/Wound care) was asked if she has any wound treatment for R7 and she said that the resident just got a pressure ulcer to her right buttocks that was identified last night. At 9:55AM, surveyor did a skin check for R7 with V5 and noted with a nickel size open area to her sacrum, V5 said that she classified it as a stage 3 pressure ulcer with slough in the wound bed. V5 added that the wound doctor will see resident on Friday, when asked if resident gets out of bed, V5 said that she does not know, she is not familiar with the resident. R7's care plan dated 8/17/2019 states Resident is at risk for further skin breakdown R/T impaired mobility, incontinence, potential problem for friction and shear, Hx. (history) healed wound, interventions include Avoid shearing resident's skin during positioning, transferring, and turning, Conduct a systematic skin inspection weekly. Pay particular attention to the bony prominences, Provide incontinence care after each incontinent episode, etc. 5/17/2023 at 2:47PM, V3 (RN Supervisor) said that skin assessment should be done during showers, everyone has a scheduled shower date, showers should be documented in the shower sheets. If a shower sheet is empty and nothing is documented, then it is not done. If residents do get their scheduled showers, they will not be clean and that will be an indication of poor hygiene and could lead to skin breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide supervision and assistance for a resident assessed to require assistance with toileting. This failure applied to one (R3) of one resident reviewed for accidents and supervision and resulted in R3 having a laceration to her back and being sent to local hospital for evaluation and treatment. Findings include: R3 is an [AGE] year-old-female who was admitted to the facility on [DATE] for skilled nursing/24 hours observation, with past medical history of Nontraumatic subarachnoid hemorrhage unspecified, insomnia, anxiety disorder, weakness, difficulty walking, chronic kidney disease stage 3, history of falling, primary pulmonary hypertension, etc. Minimum Data Set (MDS) assessment dated [DATE] section C (cognitive) scored R3 with a BIMS of 12 (moderate cognitive impairment), section G (functional) coded R3 as requiring extensive assistance with 2-person physical assist for bed mobility and transfer, and extensive assistance with one-person physical assist for toileting and personal hygiene. Section H (bowel and bladder) of the same assessment indicated that R3 is frequently incontinent of bowel and bladder. 2/17/2023 11:55AM, While conducting rounds in the unit, observed the paramedics in the unit stating that they are here to transport a resident to the hospital. They spoke to V3 (LPN) who is the assigned nurse for the resident, V3 stated that resident had an unwitnessed fall in her room last night and sustained a laceration to her back, was sent to the hospital for further evaluation and the hospital sent her right back without doing anything. The wound care team assessed resident and the doctor ordered for the resident to be sent back to the hospital. At 12:00PM, R3 was observed in her room in bed, alert and awake, R3 said that she is not doing well. She stated that she is hungry and tired, she fell last night while trying to go to the bathroom, R3 was asked if her call light was on and she said yes, no one came. R3 said, you turn that thing on for a long time and no one comes, I just got up and tried to do it by myself. When the paramedics pulled up resident's clothes to assess the wound, resident was noted with a large area on her back covered with a dressing, one of the paramedics pulled back the dressing and resident had some steri strips under the dressing, area still actively bleeding. Progress not documented by V6 (LPN) dated 2/17/2023 at 7:01AM reads: Writer heard resident calling out and went to resident's room writer note the resident's bed side table was hold open bathroom door writer noted that resident was sitting on floor of bathroom next to toilet writer asked resident what happened resident stated that she got out of and used bed side table to walk to bathroom and once in the bathroom side tried to turn around and lost her balance and slid to the floor writer also state that she hit her back on something resident was transferred to wheelchair resident was assessed and writer that resident has laceration to mid back area resident cleaned up and dressing place to laceration son called and voice mail was full Resident sent to the hospital ER for further evaluation and treatment. Facility fall log provided by V2 (Director of Nursing) documented the time of the fall as 4:04AM. 2/17/23 at 3:46PM, V6 (LPN) said that R3 called out, she went to the room and noticed that the bedside table was propping the bathroom door open and the resident was on the floor. R3 does not go to the bathroom by herself, she is a fall risk and staff are supposed to be monitoring her very often and remind her to use her call light. V6 said that she last saw the resident at 12:15AM, the C.N.A saw her at 12:00AM and she was toileted at that time. Resident was put in bed at 9:00PM, she wears incontinence brief and not able to use the bathroom by herself. 2/17/2023 at 4:10PM, V9 (C.N.A) said that she usually sits with R3 in her room, she was sitting with her till she fell asleep and then she left her around 11:30AM to 12:00AM. V9 said that the nurse saw the resident when she fell, V9 was in another room assisting another resident, she saw R3 last around 2:15AM when she walked past the room and resident was still in bed sleeping. V9 said she has worked with resident for about one year, she has fallen before, resident knows how to put on the call light and will put it on sometimes, R3 is a fall risk and the only intervention she is aware of is frequent checks, maybe every 30 minutes. Progress note dated 4/4/2022 states: Certified Nurse Assistant (C.N.A) notified nurse that resident slid on floor from bed. Resident stated to writer she was sitting on side of the bed and slid out of bed to the floor. IDT (Interdisciplinary Team) Fall Review: Resident fell on 4/4/22 states I needed to go to the bathroom. Per resident she states she does not always need to go to the bathroom at night or in the morning. Resident states she did put the call light on. Fall care plan dated 3/10/2022 states in part, resident is at risk for falling. Interventions include observe frequently and place in supervised area when out of bed, give resident verbal reminders not to ambulate/transfer without assistance, keep bed in lowest position with brakes on, etc. 2/17/2023 at 3:26PM, V2 (DON) said that residents who are at risk for falls are supposed to have their bed to the lowest position, call light within reach, and fall care plans are individualized according to resident needs. For R3, V2 said that she is supposed to be frequently monitored by staff. A document presented by V2 (DON) titled falls-clinical protocol (undated) states that as part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. The same document states in part under treatment and management that based on preceding assessment, the staff and physician will identify pertinent interventions to try and prevent subsequent falls and to address risk of serious consequences of falling.