**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 71 residents. The sample included 18 residents, with 12 reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide adequate supervision to ensure a safe environment for Resident (R) 10, after a fall while outside alone. As a result, R10 had a second fall while outside alone resulting in abrasions and a laceration (cut) to his right palm (the underside of the hand), that required sutures (stitches) as well as right rib fractures. The facility also failed to evaluate R17 for his ability to safely handle hot liquids to identify risk and implement interventions and education to prevent accidents. Subsequently, R17 spilled his coffee and sustained multiple burns including a second-degree burn (potentially painful burn that affects the first and second layer of the skin). These failures also placed the residents at risk for increased pain. Findings included: - The Electronic Medical Record (EMR) for R10 documented diagnoses of dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion), hemiplegia/hemiparesis (weakness and paralysis on one side of the body) affecting the right dominant side, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS), dated [DATE], documented R10 had intact cognition. R10 was independent with all activities of daily living (ADLs) and had no functional impairment. The MDS recorded R10 had one fall with injury since his prior assessment. The Quarterly MDS dated 07/17/24, documented R10 had intact cognition. R10 required substantial assistance with personal hygiene, supervision with dressing, and partial assistance with ambulation. R10 was independent with toileting and mobility and had no functional impairment. The MDS recorded R10 had one fall since his prior assessment. R10's Fall Assessment, dated 04/17/24 and 07/17/24 documented R10 was at high risk for falls. R10's Care Plan updated 04/18/24, documented R10 maintained functional range of motion through his ADLs including going outside per wheelchair to care for his garden when in season. The plan directed R10 transferred himself, and independently ambulated short distances in his room. The update dated 07/11/24 directed staff to do visual checks on R10 every 30 minutes if he was outside during the day and especially at night. The plan documented the resident had a call light pendent to use when going outdoors on the patio. The Fall Investigation, dated 04/15/24 at 08:56 AM, documented R10 self-propelled himself outside in his wheelchair heading to the facility's chicken [NAME] and was going too fast which caused him to fall forward onto his knees. The investigation further documented R10 sustained abrasions (scrapes) to his left knee which measured 1.5 centimeters (cm) by 1.5 cm, and to his right knee which measured 3 cm by 6 cm. Nursing staff assisted R10 to his wheelchair and took him to his room. The investigation documented R10 was alert with cognitive loss and had poor safety awareness and R10 voiced understanding of the need to go slower down the pathway to the chickens and was able to go up and down the sidewalk in his wheelchair safely. Staff were directed to gently guide R10 when he was observed being unsafe as he would often become angry when he felt staff told him what to do. Staff notified R10's physician and family of the fall. The Nurse's Note, dated 04/18/24 at 11:59 AM, documented R10 had right and left knee abrasions. The abrasions were covered with Telfa (a nonstick bandage) and secured with tape. The areas had a small amount of serosanguineous (semi-thick blood-tinged drainage) drainage but had no odor or redness around the wounds. The Nurse's Note, dated 04/18/24 at 11:59 AM, documented R10 had right and left knee abrasions. The abrasions were covered with Telfa (a nonstick bandage) and secured with tape. The areas had a small amount of serosanguineous (semi-thick blood-tinged drainage) drainage but had no odor or redness around the wounds. The Nurse's Note, dated 06/28/24 at 09:11 AM documented the nurse was notified by maintenance staff that R10 was lying on the ground. The nurse observed R10 lying still on his back near the chickens next to his wheelchair. The nurse along with multiple other staff ran to assist the resident. Staff called R10's name and he raised his head and stated yes? There was a large amount of blood noted on the sidewalk, and the resident's hands and clothing. R10's phone was on the ground next to him. Upon assessment the nurse noted a deep laceration across the palm of R10's right hand. The staff assisted R10 into his wheelchair. The resident denied hitting his head, but neurological evaluations were initiated anyway due to the resident was confused at times. The Fall Investigation, dated 06/28/24 at 07:59 AM, documented R10 reported he self-propelled outside to see the chickens when one of his wheels went off the sidewalk which caused him to fall out of his wheelchair. R10 sustained a deep, seven-inch laceration (cut) to his right palm, and pressure was applied. R10 stated he was going too fast when he went down the slight incline of the sidewalk by the chicken [NAME] and he veered off the sidewalk. Staff assisted R10 into his wheelchair and sent him to the hospital for an X-ray (a type of electromagnetic radiation that can pass through most objects to create images of its internal structure) and sutures for his hand. The investigation documented that maintenance would paint caution signs on the sidewalk at the slight incline to serve as a warning for R10 to take precautions when the wheelchair went down the incline or when someone walked on the sidewalk. The X-ray Report, dated 06/28/24, documented there was no fracture of the right hand but documented R10 had multiple chronic right rib fractures. The Physician's Order, dated 06/28/24, directed staff to administer hydrocodone (for moderately severe pain), 5-325 milligrams (mg), one tablet, every four hours for pain. The Nurse's Note, dated 06/29/24, documented R10's right hand was redressed with gauze, Telfa, and a non-stick bandage. The note recorded all 12 sutures were intact, and a moderate amount of bright red blood had seeped through. R10 had hydrocodone twice during the shift for rib and hand pain. The Nurse's Note, dated 06/30/24, documented R10's sutures were intact, and the edges were approximated (to place or bring closer) though his hand was swollen and oozing serosanguinous fluid. On 09/24/24 at 01:05 PM, observation revealed R10 in his wheelchair outside by the chicken [NAME]. The sidewalk by the chicken [NAME] had two yellow painted lines, one at the beginning of the slight incline and one after the incline. R10 propelled himself backward on the sidewalk around the corner to get to the patio. R10 continued to propel himself backward until he got right in front of the entrance door to his household. R10 continued to sit there and watch the chickens. Observation revealed there was no call light pendant visible on R10. On 09/24/24 at 01:00 PM, Certified Nurse Aide (CNA) N stated R10 often went outside to check on the chickens and said the resident was supposed to have a call light pendant with him when he went outside. CNA N then went outside to check R10 and came back and confirmed R10 did not have the pendant all light with him. On 09/24/24 at 01:10 PM, Licensed Nurse (LN) H stated there was always a pendent call light hanging at the entrance of the door to the household for any resident to use to come back inside. When asked how residents call for assistance when they are outside, away from the entrance, and fall if they do not have a call pendant with them, LN H responded That's a good question. On 09/25/24 at 09:00 AM, Administrative Nurse E said staff were to visualize R10 every 30 minutes when the resident was outside. Administrative Nurse E further stated R10 did know the code to get outside, and a pendant call light hung by the door outside so R10 could call for staff to help him back inside once he was outside. On 09/25/24 at 09:49 AM, Administrative Nurse E stated the facility had provided R10 a pendant call light to wear when he was outside and R10 was not happy about it, but agreed to wear it when he was outside. On 09/25/24 at 11:46 AM, Administrative Nurse D stated when R10 fell while he outside alone the first time, staff educated him to slow down when he propelled his wheelchair. Administrative Nurse D verified this was the only intervention implemented after the first non-injury fall outside. Administrative Nurse D said when R10 fell outside again, the staff painted yellow stripes on the sidewalk so he would know when the incline began and ended. Administrative Nurse D stated there was a pendant call light at the door for R10 to use to call staff to let him back into the building. Administrative Nurse D further stated R10 did not always tell staff when he went outside but when the door was opened it alerted to the staffs' radios. Administrative Nurse D said the 30-minute checks were not initially one of the fall interventions until they discussed it and decided to implement it. Administrative Nurse D verified R10 had not been educated on the risks should he decide to not use the pendant call light when he was outside, but stated he would discuss the risks with him and document the conversation in the medical record. The facility's Resident Falls/Accidents policy dated, 07/15, documented that a fall risk assessment would be completed within 7 days of admission and would be reviewed at least every 90 days. A licensed Charge Nurse would investigate each fall, and a review or update in the plan of care would be implemented, all falls would be reviewed weekly by involved staff, and would review interventions, modify interventions, and evaluate the outcomes. The facility failed to provide adequate safety interventions and supervision for R10 in order to promote a safe environment free from accident hazards after R10 had a fall while outside. As a result, R10 had a second fall while outside which resulted in a palm laceration that required sutures as well as identification of multiple right rib fractures. This also placed the resident at risk for increased pain and decreased mobility. - The Electronic Medical Record (EMR) for R17 documented diagnoses of hemiplegia/hemiparesis (weakness and paralysis on one side of the body) affecting the right dominant side, and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) with nephropathy. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had intact cognition and was dependent upon staff for dressing, personal hygiene, mobility, transfers, and required set-up assistance for eating. R17 had upper and lower functional impairment on one side. The MDS recorded R17 had no skin issues. R17's Care Plan, dated 07/10/24 and initiated on 04/03/24, documented R17 was on a low concentrated sweet, mechanical-soft diet with cut-up meat. Staff were directed to offer R17 his favorite beverage and provide a plate guard at meals. The care plan lacked interventions related to R17's preference to not use a lid or related to R17's ability to manage hot liquids. R17's clinical record lacked evidence the facility assessed R17's ability to safely handle hot liquids. The Physician's Orders, dated 09/03/24, directed staff to administer hydromorphone (used for moderate to severe pain), 4 milligrams (mg), one tablet, by mouth, every 2 hours as needed for pain. The facility Investigation, dated 09/08/24 at 12:29 PM, documented the Certified Nurse Aide (CNA) gave R17 his coffee and walked out of the room. The CNA heard a noise, went back into the room, and noted R17 had spilled his coffee. Staff removed the covers and applied cold compresses to R17's left upper inner thigh and left groin area as both areas were red. R17's left upper thigh had five blisters; one was open, and the area was 17 centimeters (cm) long. Staff called the doctor who ordered a moisture barrier. R17 also had a 19.5 cm red area to his left palm and forearm with a width of 3 cm in the palm that tapered to 0.5 cm on the forearm. R17 had discoloration to his left thumb area of 1.5 cm by 1 cm. The investigation noted that R17 stated he had done it himself. A Physician's Orders, dated 09/08/24, directed staff to apply Z-Guard (topical barrier medication to treat burns), apply to the red and blistered areas on R17's upper leg, every day, for seven days until healed. This was discontinued on 09/09/24. The Investigation Follow Up, dated 09/09/24, documented R17 stated he had taken his coffee in his right hand and was going to put it to his lips when his elbow caught in the halo rail on his bed, and he spilled his coffee. R17 stated he tried to move the blanket away but was unable to get it moved fast enough. The investigation noted that R17 stated he drinks his coffee without a lid and wanted to have his coffee very hot despite the offer to provide cooler coffee. The investigation noted the facility implemented an intervention to place a Chux (an absorbent pad that protects furniture and bedding from leaks) on R17 to cover his body when he was drinking hot liquid in his room. The resident also agreed to use a lid on his coffee, however, he tended to dribble all over and wondered if there was a sippy cup or something to trial. The investigation documented that the dietary department evaluated the coffee coming out of the pot and it had a temperature of 145-149 degrees Fahrenheit which was not adjusted due to the resident's request for his coffee to remain at that temperature. The staff were directed to use a two-handled cup with a lid that had four tiny holes in it for hot liquids for R17. The Nurse's Notes, dated 09/09/24 at 10:17 AM, documented the facility called for an appointment with the physician for a follow-up on R17's burn. The Nurse's Note, dated 09/09/24 at 10:58 AM, documented that in the past R17 wished to drink his coffee from a cup without a lid but was willing to try a lid on it. The note documented R17 would use a Chux barrier when drinking hot liquids. The Nurse's Note, dated 09/09/24 at 11:00 AM, documented R17's upper left leg was assessed after his bath and had a raw, open area to his inner thigh near the scrotum that measured 3 cm by 3.5 cm, with a small amount of serosanguineous (semi-thick blood-tinged drainage) drainage. The area above it had a T-shaped intact blister which measured 5 cm by 3.5cm, and the surrounding area was difficult to assess as there was Z-Guard ointment on it. The Physician's Order, dated 09/10/24, directed staff to apply Z-Guard to the red and blistered areas on R17's upper leg, daily for seven days, and chart measurements of the wound on Mondays and Thursdays after his bath. This was discontinued on 09/15/24. The Physician's Order, dated 09/11/24, directed staff to apply Silvadene External Cream (topical antimicrobial cream used for the prevention and treatment of second and third-degree burns), apply topically, every 12 hours, as needed for red areas with blisters. The Nurse's Note, dated 09/17/24 at 01:39 PM, documented R17's burn to the inside of his left palm measured 2 cm by 1 cm, and the top of his thumb had a 1 cm scabbed area. The left leg area continued to measure the same and had no drainage, and staff would continue to monitor. On 09/24/24 at 08:15 AM, observation revealed a two-handled cup with a lid on R17's bedside table to the right of him. Continued observation at 08:27 AM, revealed R17 sat in a Broda chair (a special chair with the ability to tilt and recline), his left arm rested on a pillow. Licensed Nurse (LN) G, with a gloved hand, pulled down R17's pants, which revealed a healing, darkened area approximately six inches long and two to three inches wide at the widest part on his left upper thigh. R17 also had a scabbed area on his thumb that covered the entire area on the outer portion of his thigh. R17 stated he had been in his bed and went to reach for his coffee from the bedside table and his elbow hit the halo rail which caused his coffee to spill. R17 stated it was his fault, not the facility's and he had removed the lid. R17 stated he liked his coffee very hot and did not like to have a lid on his cup. On 09/24/24 at 08:30 AM, LN G stated R17 liked to remove the lid from his coffee cup but stated he would not remove the lids anymore since he was burned and has started to use cups with lids. On 09/24/24 at 01:10 PM, CNA M stated R17 always removed the lid from his cups but since he was burned, he used a cup with a lid and a barrier on his lap. On 09/24/24 at 03:15 PM, Administrative Nurse F stated R17's Care Plan had not been updated yet, but staff were provided communication cards that informed them to use cups with lids and to use the Chux for R17. Administrative Nurse F said the facility's policy was that the communication cards were part of the resident's medical record and at that time did not know when the care plan would be updated with interventions to prevent further injury or burns. Administrative Nurse F verified the facility did not assess any residents for safe abilities to handle hot liquids. On 09/24/24 at 03:20 PM, Administrative Nurse D stated that the facility had not documented the risks of R17 drinking hot coffee without the lid because R17 was capable of drinking without spilling. Administrative Nurse D said the event was an accident and the coffee would have spilled even if a lid was on the cup. Administrative Nurse D further stated Dietary BB stated when R17's coffee was brought to him, there was a lid on it strictly for transport from the kitchen to the room but R17 would remove the lid because he liked to drink without a lid getting in the way. Administrative Nurse D stated R17 liked his coffee very hot and the coffee from the pot was temped at 145-149 degrees Fahrenheit after the incident. Administrative Nurse D stated R17 wanted to continue to receive very hot coffee but the facility had not discussed and documented any risks or hazards of injury should he remove the lid from the coffee cup and spill it on himself. Administrative Nurse D stated R17 was cognitively intact and was capable of knowing that he could spill the coffee therefore staff did not feel it was necessary to discuss identify risks and implement anything or educate R17; the resident would know it was a possibility if he removed the lid. The facility's Resident Falls/Accidents policy, dated 07/15, documented the facility provides a safe environment and monitors, evaluates, and modifies interventions. A licensed Charge Nurse would investigate each fall or accident, and a review or update in the plan of care would be implemented, all falls, and accidents would be reviewed weekly by involved staff, and would review interventions, modify interventions, and evaluate the outcomes. The facility failed to assess R17's ability to handle hot liquids to identity risks and implement safety intervention including education for the resident regarding potential hazards. As a result, R17 spilled his coffee and sustained second degree burns. This also placed R17 at risk for increased pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 78 residents. The sample included 18 residents, with five reviewed for accidents. Based on observation, record review, and interviews, the facility failed to prevent an avoidable accident when staff failed to ensure Resident (R) 20 was secured in the whirlpool seat and failed to provide adequate assistance and/or supervision. As a result of the failures, R20 fell out of the whirlpool chair and sustained facial injuries which required emergency treatment and sutures (stitches.) The facility further failed to follow R31's plan of care, resulting in two falls. The deficient practice placed R31 at risk for further falls and avoidable injuries. Findings included: - R20's Electronic Medical Record (EMR) recorded diagnoses of Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), hypotension (low blood pressure), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness, and hopelessness. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R20 had severely impaired cognition and was dependent on two staff for bed mobility, transfers, ambulation, toileting, personal hygiene, and bathing. The MDS further documented R20 had unsteady balance and two or more non-injury falls. R20's Quarterly MDS, dated 03/01/23, documented R20 had long and short-term memory problems, moderately impaired decision-making skills, and was dependent upon two staff for transfers, bathing, and required extensive assistance of two staff for bed mobility, toileting, and personal hygiene. The MDS further documented R20 had unsteady balance, and two or more non-injury falls. The Fall Care Area Assessment [CAA], dated 06/01/22, documented R20 had diagnoses of Parkinson's disease, depression, osteoarthritis, and hypotension which predisposed him to falls. The CAA further stated R20 no longer ambulated, and he used a Broda chair (special positioning wheelchair) for locomotion. The Fall Assessments, dated 06/08/22, 09/07/22, 11/30/22, and 03/01/23, all documented R20 was a high risk for falls. The Care Plan, dated 06/08/22, documented R20 had balance problems when standing and transferring. He had a bed alarm, low bed, wedge cushion, and floor mat, and he sat in Broda chair with a reclining back. R20 had a pressure reducing seat, both side supports, and foot supports for out of bed positioning. The care plan further documented R20 required assistance with whirlpool baths. The update dated 08/10/22 documented R20 received bed baths. The Fall Investigation, dated 08/10/22 at 08:50 AM, documented the bath aide was getting ready to dry R20. R20 leaned forward and fell to the floor. The investigation further documented the whirlpool belt was placed around the resident. The investigation documented R20 received a laceration (cut) to his left forehead that measured 4.8 centimeters (cm) by 2.3 cm, a laceration under his left eye which measured 2.4 cm, and an abrasion (scrape) to his left knee that measured 3.5 cm by 2.5 cm. The resident was assessed and sent to the emergency room for evaluation. The Nurse's Note, dated 08/10/22 at 02:47 PM, documented at 08:50 AM the nurse was summoned to the whirlpool room, and observed R20 lying on his left side, bleeding from his head. The noted further documented R20 would not respond when asked questions related to the fall. Staff assisted R20 to a seated position and noted his range of motion to all extremities was intact as well as his limbs could passively be moved. The note documented staff transferred R20 to his Broda chair with a full mechanical lift and staff applied pressure to his facial injuries as well as an ice pack. The note documented R20 was sent to the emergency room via van. R20's family was notified. The Physician Orders, dated 08/10/22, documented R20 received sutures to his left forehead, and directed staff to follow up in 14 days for suture removal. The order directed staff to wash the lacerations gently with soap and water twice daily, and pat dry. R20 should not tub bathe until after the sutures were removed. Apply a cold pack for 20-30 minutes and remove it for at least 30 minutes. The Nurse's Note, dated 08/10/22 at 04:16 PM, documented R20 had a bruise to his left eye that circled the eye and was mostly red with some purple. R20's stitches were intact without drainage and were covered with a nonstick dressing, as R20 picked at the wound. The Charge Nurse Treatment Record, dated August 2022 documented staff monitored R20's lacerations to the left forehead, beneath his left eye, and the abrasion to his left knee daily. This was discontinued 08/31/22. The Nurse's Note, dated 08/19/22, documented R20 had his sutures removed and the laceration below his eye was completely healed. On 03/14/23 at 08:15 AM, observation revealed R20 slept in his Broda chair. Certified Nurse Aide (CNA) H woke the resident to tell him staff were going to transfer him into bed. Further observation revealed CNA H and CNA I attached the lift sling onto the full mechanical lift, raised R20, and transferred him to his bed. Continued observation revealed CNA H and CNA I removed the lift sling, changed R20's incontinence brief, and positioned him on his left side. The staff lowered R20's to the ground, placed a positioning wedge behind his back, under the sheet, and a pillow between his legs. CNA, I made sure R20 had his call light and the fall matt was placed beside the bed. On 03/14/23 at 08:20 AM, CNA H stated R20 used to try to get out of bed unassisted and would fall, but R20 had not done so in quite a while. CNA H further stated R20 did not try to get out of bed anymore as his Parkinson's had progressed and he was on comfort care. On 03/14/23 at 03:44 PM, Administrative Nurse E stated R20 was in the whirlpool chair (on 08/10/22) and CNA M applied the whirlpool belt like a transfer belt but did not realize that because there were not teeth on the whirlpool belt buckle, it did not hold the belt in place. Administrative Nurse E stated he educated all bath aides and had them demonstrate back to him the proper way to attach the belt. Administrative Nurse E said he hung pictures for demonstration in the whirlpool room. On 03/15/23 at 07:45 AM, CNA M stated she finished giving R20 a whirlpool bath and went to the towel warmer to get towels. When CNA M turned around, she saw R20 slowly fall forward through the belt. CNA M stated she did not get to him quick enough before he fell to the floor. CNA M stated R20 had been leaning to the left in the chair prior to his fall. CNA M stated she had two days of orientation in the spa room and had not had specific training on how to secure the belt but right after the incident, they demonstrated how to properly secure the belt and provided pictures in the spa room to make sure it was done correctly. She said she had to demonstrate how to secure the belt. CNA M stated she felt horrible that this happened to R20. On 03/15/23 at 01:00 PM, Licensed Nurse (LN) G stated R20 fell from the whirlpool chair and received sutures at the emergency room but could not remember how many sutures he had. LN G stated staff monitored R20 daily for infection and stated it was double layered with sutures and glue and was not a very large laceration. On 03/15/23 at 01:30 PM, Administrative Nurse D stated they had debated on whether to send R20 to the emergency room after the fall because the family did not feel it was necessary to do so, but she felt he needed to be assessed and treated. Administrative Nurse D stated CNA M was new when the incident happened and anyone that worked as a bath aide received training. Administrative Nurse D provided two pages of documentation of the bath aide training, which did state to make sure the seat belt was secure to get the resident out of the whirlpool tub. The facility's Bathing Protocol for Cascade Aqua-Aire Bath System dated March 2019, documented make sure the seat pad is securely latched in position onto the chair frame, lock the caster brakes before the resident sits in the transfer lift chair, secure the belt around the resident's torso, the strap may be loosened during the whirlpool if you deem the resident safe, The protocol further documented do not leave resident unattended during the whirlpool or while on the chair with belt secured and use the call button to ask for help. Make sure the seat belt is secure to get the resident out of the tub. The facility failed to ensure R20 was properly secured and adequately supervised in the whirlpool spa chair. As a result, R20 fell out of the whirlpool chair to the floor and sustained facial injuries, which required sutures. - The Electronic Medical Record (EMR) documented R31 had diagnoses of low back pain, edema (swelling), heat failure (a chronic condition in which the heart doesn't pump blood as well as it should), and cerebrovascular accident (CVA-loss of blood flow to part of the brain, which damage brain tissue). The Quarterly Minimum Data Set (MDS), date 01/04/23, documented R31 had intact cognition and required extensive assistance of one staff for bed mobility, transfers, ambulation, dressing, toileting, and personal hygiene. The MDS further documented R31 had unsteady balance, no functional impairment, and no falls. The Fall Assessments, dated 12/22/22 and 01/04/23, documented R31 was a high risk for falls. R31's Care Plan, dated 10/13/22, documented R31 was a high risk for falls due to her unawareness of personal safety. She was on the falling star program, had a pressure alarm on the bed, wheelchair and her recliner. R31's Care Plan directed staff to keep her door open, check on her frequently, ensure her call light was within reach, assist with activities of daily living, transfer and ambulate with a gait belt, front wheeled walker and assistance of one staff. The update, dated 11/01/22, documented R31 ambulated to and from meals as tolerated per assistance of one staff using a gait belt, a front wheeled walker, and directed staff to bring along her wheelchair. The update, dated 01/14/23, directed staff to place a tabs alarm to her clothing when R31 was in the bathroom. The Fall Investigation, dated 01/07/23 at 03:10 PM, documented a Certified Nurse Aide (CNA) was with the resident in her room, and the resident was lying on her left side on the floor in her bathroom doorway. R31 told staff she was washing her hands, turned to place the towel in the trash, and lost her balance. The investigation further documented R31 received a superficial skin tear which measured 2 centimeters (cm) c 2 cm to her right lower extremity and a purple raised area to the top of her hand which measured 2 cm x 4 cm. The investigation documented R31 was care planned to use a gait belt with transfers, pressure alarm in place to all surfaces, a tabs alarm when the resident was in the bathroom. There was a reminder in the communication book to use a gait belt for all transfers and to stay with the resident when she was at the bathroom sink or anytime she was not in her chair as she was a high all risk. The Nurse's Note, dated 01/07/23 at 03:10 PM, documented the CNA stated she was in R31's room to assist her to the bathroom and asked the resident if she needed a gait belt, in which R31 replied No so no gait belt was used. The CNA further stated that she assisted R31 with personal care and R31 stated she needed to wash her hands. The CNA was in the resident's room, near the bathroom when the resident fell. R31 was assisted by three staff and a gait belt to her chair and stated she did not hit her head. The Fall Investigation, dated 02/01/23 at 01:55 PM, documented staff transferred R31 from her wheelchair to her recliner without a gait belt. R31 lost her balance and fell over on her left side. The investigation further documented R31 was assisted by two staff and a gait belt to her chair. The investigation documented R31 was care planned to use the gait belt for transfers and ambulation and this was not being followed. A reminder note was placed in the CNA communication book to use a gait belt for all transfers and if the resident refused, kindly remind her the gait belt was needed for safety. On 03/14/23 at 11:25 AM, observation revealed CNA I placed a gait belt around R31's waist, cued R31 to stand slowly, turn and R31 sat down in the wheelchair. On 03/14/23 at 07:55 AM, CNA H stated R31 had falls and staff used the gait belt to transfer and ambulate her. CNA H further stated R31 had alarms for her bed, chairs and in the bathroom. On 03/14/23 at 09:38 AM, Licensed Nurse (LN) J stated R31 just wanted to get up by herself so staff checked on her frequently; R31had an alarm. LN J further stated R31 had intact cognition but had problems remembering to call for help. On 03/14/21 at 11:25 AM, R31 stated she had a dumb brain and stated she did dumb things. R31 stated staff knew how she was, laughed and said it was nothing to worry about. On 03/ 14/23 at 03:00 PM, Administrative Nurse D stated staff did not follow the care plan and were given reminders to make sure they use the gait belt with R31 as she was a high fall risk. The facility Fall Precautions policy, dated July 2015, documented the facility ensures safe practices and environment for prevention of falls and interventions to reduce falls/injuries. The facility identify residents at risk for falls on admission and every 90 days, supervise and check on residents routinely, practice wheelchair safety, gait belts will be used for residents when needed, and would be assessed for appropriate fall prevention methods, The Falls and incidents would be monitored for frequency, time of day, reason, and appropriate interventions implemented, All falls, accidents and incidents would be reviewed weekly at risk management committee with follow up of interventions. The facility failed to follow R31's care plan of using a gait belt during transfers and ambulation, resulting in non-injury falls. This placed the resident at risk for avoidable injury.