**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #3), whose comprehensive plan of care and Care [NAME] (a summary of the resident's care needs, utilized by Certified Nurse Aides) indicated he/she required staff assistance with ambulation, the Facility failed to ensure staff consistently implemented and followed interventions related to ambulation, per his/her plan of care. On 02/11/25, Certified Nurse Aide (CNA) #2 saw Resident #3 ambulating by him/herself, and although she thought he/she required staff supervision with ambulation, CNA #2 did not provide him/her with supervision or assistance (per the plan of care) with ambulation. Resident #3 ambulated unassisted to his/her room, fell, was found a short time afterward on the floor, and was bleeding from a cut on his/her left eyebrow. Resident #3 was transferred to the Hospital Emergency Department (ED) and required three sutures to close the wound. Findings include: The Facility Policy, titled Comprehensive Person-Centered Care Plans, dated as revised 03/2022, indicated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs would be developed and implemented for each resident. The Facility Policy, titled Managing Falls and Fall Risk, dated as revised 03/2018, indicated that based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling, and the staff would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk. Resident #3 was admitted to the Facility in February 2023, diagnoses included chronic kidney disease, anemia, depression, anxiety, and insomnia. Review of Resident #3's Annual Minimum Data Set (MDS) Assessment, dated 01/16/25, indicated he/she required partial to moderate assistance from staff with ambulation. Review of Resident #3's Activities of Daily Living Care Plan, reviewed and renewed with his/her January 2025 MDS, indicated interventions included Resident #3 required assistance of one staff member for ambulation. Review of Resident #3's CNA [NAME] Report, dated 02/11/25, indicated he/she required one staff member assistance with ambulation. Review of Resident #3's Nurse Progress Note, dated 02/11/25, indicated that at 02:45 P.M., Resident #3 was found by a physician on the floor in his/her room, he/she was complaining of neck pain, and was bleeding from a cut on the left side of his/her forehead. The Progress Note indicated Resident #3 was transferred to the Hospital ED for evaluation. Review of Resident #3's Hospital ED Discharge summary, dated [DATE], indicated Resident #3 was diagnosed with a left eyebrow laceration as a result of a fall at the Facility, and required three sutures to close the wound. During an interview on 03/10/25 at 02:37 P.M., Certified Nurse Aide (CNA) #2 said she was familiar with Resident #3 and had been his/her assigned CNA many times. CNA #2 said the CNAs accessed the residents' [NAME]'s via the computer, and said she had been trained to do so prior to caring for her assigned residents. CNA #2 said she had never reviewed Resident #3's [NAME]. CNA #2 said she thought Resident #3's ambulation status was that he/she was independent with just staff supervision. CNA #2 said she had seen Resident #3 ambulating without assistance in the past, so she had not checked his/her ambulation status on the [NAME]. CNA #2 said that on 02/11/25 at 02:40 P.M., she was monitoring the residents in the unit dining room while the Activities Aide was off the unit, when Resident #3 got up and left the dining room. CNA #2 said she asked Resident #3 to wait because she could not leave the other residents unsupervised, but Resident #3 said he/she wanted to go to his/her room, and left. CNA #2 said she called out to a nurse (exact name unknown) who was down the hall working at a medication cart that Resident #3 was ambulating, but the nurse did not respond. CNA #2 said five minutes later she was relieved from monitoring the Dining Room by the Activities Aide, so she went to check on Resident #3, but he/she had already fallen and nursing staff were attending to him/her. During an interview on 03/10/25 at 01:20 P.M., The Unit Manager said that on 02/11/25 at the time Resident #3 fell, she was in her office. During an interview on 03/11/25 at 08:15 A.M., Nurse #1 said she was normally Resident #3's nurse and that on 02/11/25 she was his/her nurse. Nurse #1 said she was not sure what Resident #3's Care Plan indicated his/her ambulation status was, and said he/she usually ambulated by his/herself. Nurse #1 said at the time Resident #3 fell, she was off the unit on her break. During an interview on 03/10/25 at 02:12 P.M., Nurse #5 said that on 02/11/25 between 02:30 P.M., and 02:40 P.M., she was preparing and administering medications to residents on the unit, said she did not see Resident #3 at that time and did not hear CNA #2 say anything about Resident #3 ambulating by him/herself. Nurse #5 said she was not familiar with Resident #3's ambulation status at all, and said she only knew him/her in passing as she had never been his/her assigned nurse. During an interview on 03/10/25 at 03:41 P.M., the Director of Nurses (DON) said Resident #3's Plan of Care and [NAME], indicated he/she required assistance from one staff member for ambulation, and it was expected that staff would follow the Plan of Care, but that on 2/11/25, staff had not done so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #3), who was assessed by nursing as being at risk for falls, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to prevent an incident resulting in an injury. On 02/11/25, Certified Nurse Aide #2, who was familiar with and had provided care to Resident #3, observed him/her ambulating alone, but did not provide or get another staff member to assist or supervise him/her. Resident #3 was found a short time later on the floor in his/her room, was bleeding from a cut on his/her left eyebrow, was transferred to the Hospital Emergency Department (ED) and required three sutures to close the head wound. Findings include: The Facility Policy, titled Managing Falls and Fall Risk, dated as revised 03/2018, indicated that based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling, and the staff would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk. Resident #3 was admitted to the Facility in February 2023, diagnoses included chronic kidney disease, anemia, depression, anxiety, and insomnia. Review of Resident #3's Fall Risk Evaluation, dated 10/11/24, indicated he/she was at risk for falls due to deconditioning and weakness. Review of Resident #3's Annual Minimum Data Set Assessment, dated 01/16/25, indicated he/she required partial to moderate assistance from staff with ambulation. Review of Resident #3's Activities of Daily Living Care Plan, reviewed and renewed with the January 2025 MDS, indicated interventions included Resident #3 required assistance of one staff member for ambulation. Review of Resident #3's [NAME] Report (a summary of the resident's care needs, utilized by Certified Nurse Aides), dated 02/11/25, indicated he/she required one staff member assistance with ambulation. Review of Resident #3's Nurse Progress Note, dated 02/11/25, indicated that at 02:45 P.M., Resident #3 was found by a physician on the floor in his/her room, he/she was complaining of neck pain, and was bleeding from a cut on the left side of his/her forehead. The Progress Note indicated Resident #3 was transferred to the Hospital ED for evaluation. Review of Resident #3's Hospital ED Discharge summary, dated [DATE], indicated Resident #3 was diagnosed with a left eyebrow laceration as a result of a fall at the Facility, and required three sutures to close the wound. During an interview on 03/10/25 at 02:37 P.M., Certified Nurse Aide (CNA) #2 said she was familiar with Resident #3 and had been his/her assigned CNA many times. CNA #2 said she thought Resident #3's ambulation status was for staff to supervise him/her. CNA #2 said she had seen him/her ambulating without assistance in the past. CNA #2 said that on 02/11/25 at 02:40 P.M., she was monitoring the residents in the unit dining room while the Activities Aide was off the unit, when Resident #3 got up and left the dining room. CNA #2 said she asked Resident #3 to wait because she could not leave the other residents unsupervised, but Resident #3 said he/she wanted to go to his/her room, and left. CNA #2 said she called out to a nurse (exact name unknown) who was down the hall working at a medication cart that Resident #3 was ambulating, but the nurse did not respond. CNA #2 said five minutes later she was relieved from monitoring the Dining Room by the Activities Aide, so she went to check on Resident #3, but he/she had already fallen and nursing staff were attending to him/her. During an interview on 03/10/25 at 01:20 P.M., The Unit Manager said that on 02/11/25 at the time Resident #3 fell, she was in her office. During an interview on 03/11/25 at 08:15 A.M., Nurse #1 said she was normally Resident #3's nurse and that on 02/11/25 she was his/her nurse. Nurse #1 said at the time Resident #3 fell, she was off the unit on her break. During an interview on 03/10/25 at 02:12 P.M., Nurse #5 said that on 02/11/25 between 02:30 P.M., and 02:40 P.M., she was preparing and administering medications to residents on the unit, and said she did not see Resident #3 at that time and did not hear CNA #2 say anything about Resident #3 ambulating by him/herself. During an interview on 03/10/25 at 03:41 P.M., the Director of Nurses (DON) said Resident #3 required assistance from one staff member for ambulation, and it was expected that staff would provide the necessary level of care and assistance to each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to keep one Resident (#1) free from abuse out of a total sample of 28 residents. Specifically, an allegation of abuse was made by Resident #95 and filed as a grievance, subsequently allowing the accused certified nursing aide to continue working, which led to the physical abuse of Resident #1. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation and Missapropriation Prevention Program, undated, indicated the following: - Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misapporopriation of resident property. - Investigate and report any allegations within timeframes required by federal requirements. - Establish and implement a QAPI review and analysis of reports, allegations or findings of abuse, neglect mistreatment or misappropriation of property. Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised September 2022, indicates the following: -All reports of resident abuse (including injuries of uknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. -All allegations are thoroughly investigated. The administrator initiates investigations. -The administrator is responsible for keeping the resident and his/her representative informed of the progress of the investigation. -Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. -The individual conducting the investigation as a minimum: * interviews the person(s) reporting the incident * interviews any witnesses to the incident * interviews the resident * interviews the resident's attending physician as needed to determine the resident's condition * interviews the reisdent's roommate * interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident * review all events leading up to the alleged incident * documents the investigation completely and thoroughly -The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. 1. Resident #95 was admitted in November 2023 with diagnoses including hypertension and osteoporosis. Review of the Minimum Data Set (MDS) assessment, dated 10/31/24, indicated Resident #95 scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. The MDS further indicated Resident #95 requires partial to moderate assistance with all activities of daily living. During review of a grievance filed on 11/27/24, written by the Administrator, it indicates Resident #95 reported to the Unit Manager that a C.N.A. (Certified Nursing Assistant #5) did not follow his/her preferences for transferring. The grievance also indicated Resident had reported that a CNA (CNA #5) pulled his/her arm too hard during a transfer. Resident said he/she felt safe and had no concerns and wants the Unit Manager to train her (CNA #5) on his/her (the Resident) preferences for transfer. During an interview on 1/15/25 at 11:48 A.M., Resident #95 told the surveyor that he/she clearly remembers the incident and told a staff member that CNA #5 was rough with him/her. Resident #95 said that CNA #5 was rough when transferring him/her to the toilet and Resident #95 said he/she requires an extra large brief, but CNA #5 only brought in a small one. Resident #95 said he/she told CNA #5 that he/she needs an extra large brief and CNA #5 said she was going to leave and started counting down 5, 4, 3, 2, 1 . to get Resident #95 to put on the small brief. Resident #95 said he/she forced the small brief on because he/she thought CNA #5 would leave him/her in the bathroom if he/she didn't put the brief on. Resident #95 said he/she felt like CNA #5 was purposeful in her actions. Resident #95 said he/she had never seen CNA #5 before and has not seen CNA #5 since the incident. Resident #95 said he/she does not remember if anyone came to check on him/her to see if he/she felt safe or follow up with him/her. During an interview on 1/15/25 at 12:28 P.M., the Administrator said that Resident #95 reported to the Unit Manager that CNA #5 was kind of rushed and the Resident was upset with the transfer because the CNA was not taking her time. The Administrator said that from what she remembers, the CNA was very fast and quick and she does not remember the Resident mentioning anything about the briefs. The Administrator said that she asks residents verbatim if they feel like they have been abused. The Administrator said that from her recollection, she believes it was a customer service issue and that is why she filed it as a grievance. The Administrator said the Resident initially reported to her that it was rough handling, but she honed down the interview and the Resident wanted the CNA to go slower with his/her care. During an interview on 1/15/25 at 12:57 P.M., the Director of Nursing said she asked the Resident if he/she felt it was malicious and the Resident said no. Review of the medical record failed to indicate any information regarding the incident. Shortly after the interview, the facility Administrator provided two written statements and a skin check, dated 11/27/24. The written statements were from the Director of Nursing and the Unit Manager. The facility could not provide a written statement for the CNA involved. There was no action taken to prevent CNA #5 from working on the unit or at the facility. 2. Resident #1 was admitted in September 2020 with diagnoses including depression and arthritis. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #1 scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. The MDS further indicated Resident #1 requires substantial/maximal assistance with upper body dressing, is dependent on staff for lower body dressing and toileting. During an interview on 1/14/25 at 7:46 A.M., Resident #1 told the surveyor that on 12/9/24, a female CNA hurt his/her arm during an interaction. Resident #1 said that his/her arm still hurts from the incident. Review of a facility reported incident, dated 12/10/24, indicated Resident #1 reported to facility staff that CNA #5 was rough with him/her during care. Resident #1 told staff that, on 12/9/24, CNA #5 forcefully pulled the laptop case handle from my arm, causing him/her left upper arm pain, 8 out of 10 pain and that CNA #5 forcefully pulled a brief off of Resident #1. Resident #1 reported that he/she asked for a diet cola and CNA #5 brought the soda, but would not pour it for Resident #1 and told Resident #1 to open the bottle him/herself or he/she won't get any. Resident #1 also told staff that CNA #5 asked Resident #1 if he/she was full of urine or feces because she didn't have time to change Resident #1. Review of the Resident/Witness Statement, dated 12/10/24, indicated Resident #1 told the Social Worker that Resident #1 was not moving fast enough so CNA #5 grabbed the bag and pulled it off my arm fast and it hurt. The Social Worker documented Resident #1 reports his/her arm is still sore. There are no marks on the arm, but Resident #1 winced when it was lightly touched . He/she states that he/she feels safe with the other staff, but did not feel safe with CNA #5. Review of the medical record indicated that an x-ray was obtained on 12/10/24 in the facility of Resident #1's arm and showed a fracture of the left ulna (the long bone of the forearm) with indeterminate age (time of fracture could not be determined). Review of the Employee Performance Improvement Notification, dated 12/16/24, indicated CNA #5 was suspended from the facility, 6 days after the alleged incident occurred. Review of the Employee Performance Improvement Notification, dated 12/27/24, indicated CNA #5 was terminated due to performance. During an interview on 1/15/24 at 8:37 A.M., the Director of Nursing said Resident #1 reported the event the day after it occurred to the Unit Manager. The Director of Nursing said that Resident #1 felt like CNA #5 pulled his/her bag abruptly off when CNA #5 was changing him/her and felt the CNA was rude. The Director of Nursing said CNA #5 was suspended and then let go. See F609, F610, and F867.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to 1a. investigate an allegation of potential abuse for one Resident (#95), which 1b. failed to keep Resident (#1) free from abuse, out of a total sample of 28 residents. Specifically, Resident #95 reported to staff having been rough handled by a certified nursing aide. The report was not thoroughly investigated, which allowed the accused certified nursing aide to continue working, and eventually abuse Resident #1. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised September 2022, indicates the following: -All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. -All allegations are thoroughly investigated. The administrator initiates investigations. -The administrator is responsible for keeping the resident and his/her representative informed of the progress of the investigation. -Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. -The individual conducting the investigation as a minimum: * interviews the person(s) reporting the incident * interviews any witnesses to the incident * interviews the resident * interviews the resident's attending physician as needed to determine the resident's condition * interviews the resident's roommate * documents the investigation completely and thoroughly -The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. 1a. Resident #95 was admitted in November 2023 with diagnoses including hypertension and osteoporosis. Review of the Minimum Data Set (MDS) assessment, dated 10/31/24, indicated Resident #95 scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Review of the MDS indicated Resident #95 requires partial to moderate assistance with all activities of daily living. Review of a grievance filed on 11/27/24, written by the Administrator, indicates Resident #95 reported to the Unit Manager that a C.N.A. (certified nursing aide #5) did not follow his/her preferences for transferring. The grievance also indicated Resident had reported that a CNA pulled his/her arm too hard during a transfer. Resident said he/she felt safe and had no concerns and wants the Unit Manager to train her (staff member) on his/her (the Resident) preferences for transfer. Review of the medical record failed to indicate any information regarding the incident. During an interview on 1/15/25 at 11:48 A.M., Resident #95 said that he/she clearly remembers the incident and told a staff member that a CNA (CNA #5) was rough with him/her. Resident #95 said that CNA #5 was rough when transferring him/her to the toilet and Resident #95 said he/she requires and extra large brief, but CNA #5 only brought in a small one. Resident #95 said he/she told the CNA that he/she needs an extra large brief and CNA #5 said she was going to leave and started counting down 5, 4, 3, 2, 1 . to get Resident #95 to put on the small brief. Resident #95 said he/she forced the small brief on because he/she thought CNA #5 would leave him/her in the bathroom if he/she didn't put the brief on. Resident #95 said she felt like CNA #5 was purposeful in her actions. Resident #95 said he/she had never seen CNA #5 before and has not seen CNA #5 since the incident. Resident #95 said he/she does not remember if anyone came to check on him/her to see if he/she felt safe or follow up with him/her. During an interview on 1/15/25 at 12:28 P.M., the Administrator said that Resident #95 reported to the Unit Manager that a CNA was kind of rushed and the Resident was upset with the transfer and that the CNA was not taking her time. The Administrator said that from what she remembers, the CNA was very fast and quick and she does not remember the Resident mentioning anything about the briefs. The Administrator said that she asks residents verbatim if they feel like they have been abused. The Administrator said that from her recollection, she believes it was a customer service issue and that is why she filed it as a grievance. The Administrator said the Resident initially reported to her that it was rough handling, but she honed down the interview and the Resident wanted the CNA to go slower with his/her care. During an interview on 1/15/25 at 12:57 P.M., the Director of Nursing said she asked the Resident if he/she felt it was malicious and the Resident said no. Shortly after the interview, the facility Administrator provided two written statements and a skin check, dated 11/27/24. The written statements were from the Director of Nursing and the Unit Manager. The facility could not provide a written statement from the CNA involved nor could she provide any written statements from other staff working on the unit that day. 1b. Resident #1 was admitted in September 2020 with diagnoses including depression and arthritis. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #1 scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. The MDS further indicated Resident #1 requires substantial/maximal assistance with upper body dressing, is dependent on staff for lower body dressing and toileting. On 12/10/24, an abuse incident report was filed through the healthcare facility reporting system detailing an incident that occurred with CNA #5 and Resident #1, who alleged that CNA #5 pulled a bag off of his/her shoulder roughly and hurt Resident #1's arm. Review of a facility reported incident, dated 12/10/24, indicated Resident #1 reported to facility staff that CNA #5 was rough with him/her during care. Resident #1 told staff that, on 12/9/24, CNA #5 forcefully pulled the laptop case handle from my arm, causing him/her left upper arm pain, 8 out of 10 pain and that CNA #5 forcefully pulled a brief off of Resident #1. Resident #1 reported that he/she asked for a diet cola and CNA #5 brought the soda, but would not pour it for Resident #1 and told Resident #1 to open the bottle him/herself or he/she won't get any. Resident #1 also told staff that CNA #5 asked Resident #1 if he/she was full of urine or feces because she didn't have time to change Resident #1. Review of the Resident/Witness Statement, dated 12/10/24, indicated Resident #1 told the Social Worker that Resident #1 was not moving fast enough so CNA #5 grabbed the bag and pulled it off my arm fast and it hurt. The Social Worker documented Resident #1 reports his/her arm is still sore. There are no marks on the arm, but Resident #1 winced when it was lightly touched . He/she states that he/she feels safe with the other staff, but did not feel safe with CNA #5. Review of the medical record indicated that an x-ray was obtained on 12/10/24 in the facility of Resident #1's arm and showed a fracture of the left ulner (the long bone of the forearm) with indeterminate age (time of fracture could not be determined). Review of the Employee Performance Improvement Notification, dated 12/16/24, 6 days after the alleged incident, indicated CNA #5 was suspended from the facility pending investigation of the incident that occurred with Resident #1. Review of the Employee Performance Improvement Notification, dated 12/27/24, indicated CNA #5 was terminated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #92 was admitted to the facility in May 2023 with diagnoses including type 2 diabetes mellitus, atherosclerosis, and legal blindness. Review of Resident #92's most recent Minimum Data Set Assessment (MDS) indicated the Resident had a Brief Interview for Mental Status score of 15 out of a possible 15 indicating that the Resident is cognitively intact. The MDS further indicated Resident #92 required assistance with all activities of daily living. On 1/24/24 at 11:45 A.M., the surveyor observed Resident #92 lying in his/her bed with his/her feet exposed. Resident #92's feet were observed to have large, fluid filled blisters on them. Review of Resident #92's nursing progress notes indicated the following: *Dated 12/16/23 at 3:15 P.M. written by Nurse #1: [Resident #92] was sitting in his/her w/c (wheelchair) with his/her feet resting on the room heater wrapped in blankets. He/she was then assisted back to bed. *Dated 12/18/23 at 12:19 P.M.: It was brought to this UM's (Unit Manager) attention that (Resident #92) has burns on his/her feet from sleeping with his/her feet on the heater. When asking the Resident why he/she sleeps with his/her feet on the heater he/she states that he/she is very cold. He/she also stated that he/she doesn't feel the burns so he/she will continue to do this. We have offered resident more blankets and he/she said that might help. Resident seen by wound MD (medical doctor) and NP (nurse practitioner). Notified DON (director of Nursing) and administrator. *Dated 1/2/24: At 10:20 A.M. resident noted to have increased lethargy. Resident noted to have left sides weakness. NP made aware and new order to send resident to hospital for Evaluation. Review of Resident #92's care plan for resistive care (refusing care, treatment) related to ineffective coping skills, dated 11/22/23 indicated the following interventions: *Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care. Review of Resident #92's skin breakdown care plan dated 5/20/23 was updated after the Resident received burns on his/her feet from putting his/her feet on the heater despite staff being aware of the Resident's behaviors. Review of Resident #92's nursing progress notes from 12/16/23 through 12/18/23 failed to indicate any education or refusal of care was documented regarding the Resident putting his/her feet on the heater. Review of Resident #92's medical record indicated safety interventions to prevent injury were only put into place after the Resident burned his/her feet despite staff knowing of Resident #92's behaviors prior to being burned. Review of a wound evaluation and management summary from the wound doctor written on 12/18/23 indicated Resident #92 had a burn on his/her left, lateral foot; a burn on his/her right, medial foot; a burn of the right lateral foot. Review of Resident #92's hospital Discharge summary dated [DATE] indicated the following: *Hospitalist course: Sepsis from cellulitis. LE (lower extremity) wounds seem likely entry point, continue wound care. *Wound care: Bilateral feet and left heel burns Review of a General Medicine Progress Note from the Hospital dated 1/2/2024 indicated the following: *Cellulitis of lower extremities *Sepsis from cellulitis During an interview on 1/24/24 at 12:41 P.M., Nurse #2 said Resident #92 had burns on his/her feet from putting them on the heater. She continued to say that the Resident is diabetic and has neuropathy (numbness from nerve damage) in his/her feet so he/she did not feel them burning. She said the Resident would often turn the heat so he/she could feel warmer. She then said since his/her injury we switched his/her room so he/she would not be on the side where the heater is. During an interview on 1/24/24 at 12:53 P.M., Resident #92 said he/she would put his/her feet on the heater all the time but he/she did not feel his/her feet burning. When asked if staff members have ever seen the Resident put his/her feet on the heater, the Resident responded with I am sure staff have seen me with my feet up there before. During an interview on 1/24/24 at 1:54 P.M., Nurse #1 said she does not normally work on the B unit (where Resident #92 resides), it was her first time on that unit. She said she saw Resident #92's feet wrapped in blankets and on the heater and she told the resident to take his/her feet off the heater so he/she would not burn his/her feet. Nurse #1 then said she was told by nurses who normally work on that unit that Resident #92 has been putting his/her feet on the heater. During an interview on 1/24/24 at 2:18 P.M., Certified Nursing Assistant (CNA) #1 said Resident #92 likes to be warm so he/she would put his/her feet on the heater. He continued to say the Resident has little to no feeling in his/her feet so he/she did not know they were burning. During an interview on 1/24/24 at 2:19 P.M., Unit Manager #1 said she did not know Resident #92 had a pattern of putting his/her feet on the heater. She thought he/she only did it once on 12/18/23. She was not aware of the nursing progress note written two days before the Resident burned his/her feet mentioning this behavior. She said the progress note written two days before the incident was written by the 11-7 shift and they never told her that the Resident was putting his/her feet on the heater, she said she would have expected someone to tell her. She continued to say if she knew about Resident #92's behavior of putting his/her feet on the heater she would have moved his/her room right away to prevent an accident from happening. Unit Manager #1 then said Resident #92 ended up going to the hospital with sepsis resulting from the burns on his/her feet. During an interview on 1/24/24 at 2:31 P.M., the Director of Nursing (DON) said if a resident sustains a burn in the facility, it should be reported and investigated right away. When asked about Resident #92's feet, the DON initially said she was not aware he/she burned his/her feet. The surveyor and the DON looked though Resident #92's incident/accident reports for December 2023 and did not see a report mentioning the burns on his/her feet. She said she would have the wound doctor assess Resident #92's feet and she would do it herself as well, she said she did not assess his/her feet. She continued to say if she knew that Resident #92 was putting his/her feet on the heater she would have expected that preventative interventions to be put in place right away. Based on observation, record review, policy review and interview, the facility failed to provide adequate supervision and ensure an environment free from accidents and hazards, for two Residents (#99 and #92) out of a total sample of 34 Residents. Specifically: 1.) For Resident #99, who was assessed by nursing to be a high risk for falls, the facility failed to ensure he/she received adequate supervision to prevent accidents when he/she experienced 13 falls over a span of 51 days, with two of those falls resulting in injuries which required 6 staples (12/16/23) and 12 sutures (12/29/23). 2.) For Resident #92, the facility failed to implement preventative interventions for accidents in a timely manner resulting in the Resident burning his/her feet on the heater, subsequently causing hospitalization. Findings include: Review of the facility policy titled Accidents and Incidents - Investigating and Reporting, dated and revised July 2017 indicated the following: All accidents or incidents involving residents occurring on the facility's premises shall be investigated and reported to the administrator. Policy Interpretation and Implementation 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable shall be included in the report of the incident/accident: a. The date and time the accident or incident took place b. The nature of the injury c. The circumstances surrounding the accident or incident d. Where the accident or incident took place f. The injured person's account of the accident or incident g. The time the injured person's attending physician was notified i. The condition of the injured person, including his/her vital signs j. The disposition of the injured k. Any corrective action taken 5. The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. 6. The director of nursing service shall ensure that the administrator received a copy of the Report of Incident/Accident for each occurrence. Review of the facility policy titled, Assessing Falls and Their Causes, dated as revised March 2018, indicated: 1. Review the resident's care plan to assess for any special needs of the resident. 1.) For Resident #99 who was assessed to be a high risk for falls the facility failed to ensure he/she received adequate supervision to prevent accidents when he/she experienced 13 falls over a span of 51 days, with two of those falls resulting in injuries which required 6 staples (12/16/23) and 12 sutures (12/29/23). Resident #99 was admitted to the facility in November 2023 with diagnoses including dementia, hemiplegia, dysphagia and cerebral infraction. Review of the Minimum Data Set (MDS) assessment, dated 12/30/23, indicated Resident #99 had a memory problem and indicated he/she had a history of falls. Review of the nursing note, dated 11/2/23, indicated: - Resident was found in the bathroom alone. Review of the nursing note, dated 11/6/23, indicated: - Pt (patient) kept getting off wheel chair without assistance. Poor safety awareness redirected with minimal effects. 1. Review of the incident report, dated 11/8/23 at 12:00 A.M., indicated Resident #99 had a fall in his/her room while ambulating, unwitnessed. He/she sustained an abrasion to his/her left knee. I wanted a cup of juice, then I lost my balance. 2. Review of the incident report, dated 11/8/23 4:58 P.M., indicated Resident #99 had a fall in his/her room while sitting, witnessed by his/her roommate. He/she sustained a bruise to mid center back and right rear thigh. Review of the nursing note dated 11/8/23, indicated: -At 4:58 P.M. Certified Nurse Assistant (CNA) reported to writer that the pt was on the floor. Writer observed him/her on his knees trying to get himself back up. Roommate reported that he/she had an unwitnessed fall. By the time writer entered the room pt was transferring himself/herself to wheelchair. Writer didn't get an opportunity to do a full assessment on the floor because of this. Writer did an assessment with him/her in chair and observes two bruises mid back. Pt brought to the nursing station for close monitoring. Review of the nursing note, dated 11/12/23 at 10:00 P.M., indicated: -Patient has poor safety awareness, he/she keeps getting up from wheelchair. Pt was moved closer to nursing station for close monitoring. Patient was redirected when he/she stood up without help. 3. Review of the incident report, dated 11/13/23 at 12:00 A.M., indicated Resident #99 had a fall in his/her room while transferring, unwitnessed. I just fell, that's it. Review of the health status note, dated 11/13/23, indicated: -At 00:00, writer and CNA heard someone yelling out. CNA responded to Resident #99 room first and observed him/her on the floor. CNA then alerted writer Resident #99 was on the floor. Writer entered the room to find Resident #99 laying supine on the floor, parallel next to his/her bed, with his/her brief removed, and his/her arms crossed behind his/her head. A new brief was applied, and he/she was put into his/her wheelchair and brought to the nurses station. Writer then asked Resident #99 what happened, I fell. Writer asked the question a few different ways and pt would not or could not elaborate further. Resident #99 was unable to say if he/she was doing anything, how the fall happened or any information about the fall. Writer believes he/she was trying to change himself/herself. His/her brief had a very small spot of stool on it, and it seems like Resident #99 took the brief off and lost his/her balance. Writer had yet to do rounds yet, and writer had not seen him/her yet this shift, prior to the fall. However, the previous shift 3-11 nurse did report to writer that Resident #99 was asked to not sit on the very edge of the bed, to either lay down or get in his/her wheelchair, but he/she denied their request and continued on with his/her behavior. Resident #99 sat with writer or CNA at the nurse's station up until 03:30. Resident #99 is still not tired. Writer keeps asking periodically if he/she is tired and wants to go to bed, however, he/she is still not ready yet. Care is ongoing. 4. Review of the incident report, dated 11/24/23 at 4:15 P.M., indicated Resident #99 had a fall in a common area, unwitnessed. Complaint of right rib pain Review of the health status note, dated 11/24/23, indicated: - S/P fall with complaints of right rib pain 9/10 and a noted abrasion, new order obtained to send to the ER for further evaluation and treatment by NP. Resident #99 is on Eliquis with a history of a stroke and right sided hemi-paresis. Resident was transferred out to Holy Family Hospital by EMS-assisted off of the floor with 2 assist by EMS. BP noted to be Hypotensive on initial Vital sign check, unable to obtain further vital signs secondary to Resident moving his/her arm with increased pain. Review of the health status note, dated 11/24/23, indicated: - Resident admitted to pneumothorax (collapsed lung). Review of the health status note, dated 12/1/23, indicated: - Resident readmitted . 5. Review of the health status note, dated 12/3/23, indicated: - Patient with unwitnessed fall @12:40 P. M. in day room. Staff heard loud noise coming from dayroom, this writer at med cart by room [ROOM NUMBER] at the time, also heard loud noise, and ran to day room at the time. Patient found by sink lying on floor on L side. Denied hitting head, stated I walked over to get some soda. Stated my chest hurts while guarding R side of body. On call provider notified of findings, new order to send to ED for evaluation. 6. Review of the incident report, dated 12/6/23 at 8:20 A.M., indicated Resident #99 had a fall in a common area, unwitnessed. I was just moving in my seat, and I slipped Review of the health status note, dated 12/6/23, indicated: - Patient with unwitnessed fall this AM @8:20 A, found sitting on floor in front of wheelchair, with slipper socks on, liner clean, no fluids noted on floor. Patient stated he/she slid to the floor on my ass. Patient attempting to reposition himself/herself per conversation, intervention; [NAME] [sic] (dycem a non-slip, rubber-like plastic material used to stabilize surfaces) to wheelchair cushion. Review of the health status note, dated 12/8/23, indicated: - falls reviewed at risk. Patient intervention for fall was to monitor in common areas while awake and [NAME] to wheelchair in place 7. Review of the incident report, dated 12/9/23 at 1:45 P.M., indicated Resident #99 had a fall in a common area, witnessed by a staff member. Review of the health status note dated 12/9/23, indicated: - At around 1:45 pm Resident was sitting next to nurse station; he/she was trying to stand up lost balance and fell to the floor. 8. Review of the incident report, dated 12/16/23 at 4:03 P.M., indicated Resident #99 had a fall in a common area, unwitnessed. Resident #99 had head trauma to the back of the head. Review of the health status note, dated 12/16/23, indicated: -Nurse heard loud noise near nurses' station, noted patient was on the floor, bleeding from his/her head. Pt unable to verbalize what he/she was trying to do and why he/she got up unattended. 911 called and transferred to hospital. Review of the health status noted, dated 12/17/23, indicated: - returning from hospital, 6 staples to head laceration. 9. Review of the incident report, dated 12/18/23 at 7:30 P.M., indicated Resident #99 had a fall in the dining room, unwitnessed. Review of the health status note, dated 12/18/23, indicated: -Patient having a fall in the dining room next to dining room table. Review of the physician's order, dated 11/30/23, indicated: - Supervision at meals with meals 10. Review of the incident report, dated 12/19/23 at 4:45 P.M., indicated Resident #99 has a fall in the common area, unwitnessed. Resident #99 sustained a skin a skin tear on the left elbow. Review of the health status note, dated 12/19/23, indicated: - Resident was noted on the floor in the dining Room at 4:45 pm. Left elbow old skin tear is reopened. 11. Review of the incident report, dated 12/20/23 at 5:20 P.M., indicated Resident #99 had a fall in the dining room, unwitnessed. Resident #99 sustained a skin tear on the lower center back. Review of the health status note, dated 12/20/23, indicated: - Patient fell today at 5:20 pm. He/she was attempting to get up from his wheelchair in the day room and lost his/her balance. He/she rated his/her pain a 6/10. I put him/her in bed to do a skin check and found a small superficial scrape on the center of his/her lower back. 12. Review of the incident report, dated 12/24/23 at 3:30 P.M., indicated Resident #99 had a fall in the common area, unwitnessed. Resident #99 sustained a skin tear on left elbow and an abrasion to the right elbow. Review of the health status note, dated 12/24/23, indicated: - Patient fell today in the common room at 1730. Patient fell facing forward and used his/her elbows to brace his/her fall. He/she got a scrape on each one of his/her elbows. Review of the health status note, dated 12/26/23, indicated: - Patient awake and attempting out of bed at 2 am. Patient remains out of bed near nurses station for safety. Review of the health status note, dated 12/27/23, indicated: - Patient was up all night. 13. Review of the incident report, dated 12/29/23 at 10:49 P.M., indicated Resident #99 had a fall in his/her room, unwitnessed. Resident #99 sustained a laceration to his/her left upper arm. Review of the health status note, dated 12/29/23, indicated: - Heard loud bang and patient yell out. Patient found on floor bleeding profusely from left arm. awake and alert. EMS called. pressure applied to site with ice. ambulance arrived and transferred patient to hospital. Review of the hospital paperwork, dated 12/30/23, indicated: - There is a 15-centimeter flap laceration that is deep into the subcutaneous tissue. Review of the incident report, dated 1/5/24, indicated: - Resident #99 had 12 sutures. Review of the MQS: Fall Risk Evaluation - V 2 assessment indicated the following: 11/13/23 Fall Risk score of 23, indicating he/she is a high fall risk. 11/21/23 Fall Risk score of 23, indicating he/she is a high fall risk. 11/24/23 Fall Risk score of 32, indicating he/she is a high fall risk. 12/18/23 Fall Risk score of 24, indicating he/she is a high fall risk. Review of the plan of care related to falls indicated the following interventions: - 11/2/23 Keep personal items and frequently used items within reach. Create a safe environment; floors clear of clutter, clean up spills, adequate lighting. Be sure the call light is within reach and provide reminders to use call for assistance as needed. Assist and/or remind me to change position and get up from sitting or lying slowly due to orthostatic blood pressure problems. - 11/9/23 Urinal at bedside - 11/13/23 Low bed in lowest position, except during care. Assist with incontinent care at the beginning of the 11-7 shift. Encourage resident, involved family members, and caregivers about safety reminders, fall prevention, and what to do if a fall occurs. - 11/24/23 Send to ER for evaluation, Medication Review of Cardiac Medications, Antibiotic for urinary tract infection. Resident has poor impaired vision. Make sure that the room has adequate lighting. Consult optometry as needed. Resident receives sedatives/ hypnotics at night for sleep. Monitor safety throughout the night. - 12/6/23 Non-skid socks at all times. - 12/9/23 Offer Toileting every 2 hours. - 12/16/23 Dycem to seat of chairs when out of bed, monitor scalp laceration. - 12/18/23 Toilet Resident first rounds 3-11, Staple removal. - 1/3/24 Mats on floor next to bed and anti-rollbacks (prevents a wheelchair from rolling backward and helps prevent falls. As the wheelchair resident begins to stand, the device grabs the tires to prevent the chair from rolling backward. When the resident is seated, the device is in standby mode and the chair can be easily moved in all directions) on wheel chair. On 1/23/24 at 12:09 P.M., Resident #99 was in his/her wheelchair in a common area unsupervised by staff, the antiroll backs were not engaged (the brake arms were not positioned over the tires and the lift lever was not in the functioning position) and Resident #99 was not seated on dycem. On 1/23/24 at 5:25 P.M., Resident #99 was in his/her wheelchair in a common area, the antiroll backs were not engaged and Resident #99 was not seated on dycem. On 1/24/24 at 12:12 P.M., Resident #99 was in his/her wheelchair in a common area, the antiroll backs were not engaged, and Resident #99 was not seated on dycem. On 1/24/24 at 2:46 P.M., the surveyor observed Resident #99 transfer to bed with Certified Nurse Assistant (CNA) #6. When CNA #6 stood Resident #99 up and out of his/her wheelchair the chair began to roll back. CNA #6 said the antiroll backs were broken. There was no dycem under Resident #99. On 1/25/24 at 10:09 A.M., CNA #6 transferred Resident #99 from the bed to the wheelchair, there was no dycem on the chair and when Resident #99 sat in the wheelchair the anti-rollbacks did not engage. CNA #6 said the antiroll backs were still broken. On 1/25/24 at 11:08 A.M., CNA #6 and CNA #8 transferred Resident #99 into the bathroom. When CNA #6 and CNA #8 stood Resident #99 up the wheelchair slid back and the anti-rollbacks were not engaged. There was no dycem on the wheelchair. On 1/25/24 at 11:16 A.M., CNA #6 and CNA #8 transferred Resident back into the wheelchair. There was no dycem in the chair and CNA #6 and CNA #8 said they were not aware that Resident #99 required dycem. CNA #6 and CNA #8 tried to adjust the anti-rollback and said that they were broken and not working. During an interview on 1/24/24 at 1:50 P.M., CNA #7 said that Resident #99 has a history of falls. CNA #7 said Resident #99 uses a standard cushion and is not aware he/she needs dycem. During an interview on 1/24/24 at 2:24 P.M., CNA #6 said Resident #99 has a history of falls. CNA #6 said that Resident #99 uses the bathroom and does not use a urinal. During an interview on 1/25/24 at 8:22 A.M., Nurse #6 said Resident #99 has a history of falls. Resident #99 uses antiroll backs to his/her wheelchair. During an interview on 1/25/24 at 12:21 P.M., the Director of Nursing (DON) said she was aware that Resident #99 did not have dycem on his/her wheelchair. The DON said that Resident #99 has a fall history and nursing should implement the interventions to prevent falls.