**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent resident to resident abuse for 2 residents (Resident #46, & Resident #37) of 6 residents residents reviewed for abuse. This deficient practice resulted in Resident #30 twisting Resident #46's right wrist causing pain, fear and increased anxiety, and Resident #42 perpetrating physical abuse to Resident #37 and another resident unknown with the potential for further continued abuse of residents residing in the facility to go unrecognized and the potential for further harm. (All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted.) Findings include: Resident #46 Review of an admission Record revealed Resident #46, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: generalized anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #46, with a reference date of 6/20/23 revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated Resident #46 was mildly cognitively impaired. During an interview on 8/16/23 at 10:30 AM., Resident #46 reported Resident #30 has come into her room on multiple occasions. Resident #46 reported Resident #30 had come into her old room before she moved into this new room. Resident #46 reported that not that long ago, maybe a few weeks Resident #30 was in her room and fell asleep in her bed while Resident #46 was out with family. Resident #46 reported her (Family Member (FM) H) requested the bedding was changed after (Resident #30) slept in her bed. Resident #46 reported not long after that day, another day Resident #30 came back into her room while she was sitting in her (Resident #46's) recliner. Resident #46 reported both her and her roommate Resident #15 were yelling out for staff to come and get Resident #30 out of their room. Resident #46 reported when she went to stand up, she (Resident #46) grabbed onto her walker with her right hand. Resident #46 stated (Resident #30) grabbed onto my right arm/wrist twisting it and squeezing my wrist very hard. Resident #46 reported she started to holler out you are hurting me, stop you are hurting me. Resident #46 reported her right arm/wrist hurt for days afterwards and had some bruising. Resident #46 stated my wrist (right) hurt so bad because last year I fell and broke that arm, so it already had an injury . Resident #46 reported she is very afraid of (Resident #30) and has been for a while now . Resident #15 Review of an admission Record revealed Resident #15, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: generalized anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #15, with a reference date of 7/1/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #15 was cognitively intact. During an interview on 8/16/23 at 10:45 AM., Resident #15 reported a month or so ago Resident #30 entered her room and Resident #30 headed towards her (Resident #15's) roommate Resident #46. Resident #15 reported her roommate Resident #46 was sitting down in her own recliner. Resident #15 reported Resident #46 yelled for help and told Resident #30 to leave their (Resident #15 & Resident #46's) room. Resident #15 reported once Resident #46 started to yell out for staff help Resident #30 walked up to Resident #46 who was reaching for her walker attempting to stand up. Resident #15 reported she saw Resident #30 grabbing onto Resident #46's right wrist and twisting Resident #46's wrist while she (Resident #30) was squeezing Resident #46's right wrist. Resident #15 reported at that time both herself (Resident #15) & Resident #46 were yelling for staff's assistance. Resident #15 reported it took a few staff members to get Resident #30 out of their room and Resident #46 was crying during the incident and saying you are hurting me. Resident #15 reported after the incident Resident #46's right wrist was in a lot of pain, and she (Resident #15) could see bruises on Resident #46's right wrist the following day. Resident #15 reported Resident #30 continues to enters her room often, despite the stop sign on the doorway. During an interview on 8/16/23 at 4:35 PM., Nursing Home Administrator (NHA) A reported she was not aware of any incident of Resident #30 going into Resident #15 & #46's room and/or any concerns from Resident #15 & #46. NHA A reported she would look for any notes and or grievance forms regarding any incidents with these residents. NHA A reported she had just started as the new NHA at the facility and recalls a Care Conference meeting with family members of Resident #46 's towards the end of June/early July 2023. NHA A reported she does not recall the details of anything concerning from the care conference meeting with Resident #46's family member(s). Requested pertinent documentation on 8/16/23 at 4:45 PM., from NHA A including incident accident reports, concern/grievance forms, care conference notes and any information in regards to Resident #30's altercation with Resident #46. During a phone interview on 8/17/23 at 12:10 PM., FM H reported in late June 2023 another female resident (name omitted Resident #30) entered Resident #46's bedroom and grabbed her (Resident #46) by her right wrist/arm twisting and squeezing it. FM H reported it was very concerning that just anyone can walk in her (Resident #46's) room and do as they please. FM H reported Resident #46 suffers from anxiety, and when something triggers her (Resident #46), anxiety symptoms are panic attacks, tearfulness, stomach issues and at times Resident #46 needs a lot more reassurance from family members. FM H reported Resident #46 has changed rooms 3 times to get farther away from Resident #30. FM H reported Resident #30 has repeatedly entered Resident #46's room and has been found sleeping in Resident #46's bed. FM H reported Resident #46 has many family members that are in the facility often, and the family members are very involved with Resident #46's care. FM H reported there have been multiple calls from Resident #46 to family members about how afraid, and anxious Resident #30 makes Resident #46 feel. FM H reported she has been in the facility enough times along with other family members who have seen Resident #30's behaviors of going in and out of resident rooms, trying to get out of the doors, and lashing out at other residents and staff. FM H reported she had concerns about Resident #30 and wondered if staff are doing enough not only to protect Resident #46 and other residents, but also keeping Resident #30 safe from other residents who may lash out at Resident #30 when she goes into other rooms. FM 'H reported she requested a meeting after the incidents in June 2023. FM H reported a Care Conference was held and (NHA A) did not seem to be hearing my concerns. FM H stated (NHA A) and the other staff present told me my mom (Resident #46) was exaggerating the incident . FM H reported there was no exaggeration of the incident, everyone knows what Resident #30's behaviors are, and staff and management should be keeping a closer eye on Resident #30 for everyone's safety. FM H stated My mother (Resident #46) always says don't say anything because I (Resident #46) will get in trouble . It breaks my heart I had her put here (the facility) to be safe, and right now I don't feel it is very safe . FM H reported she and Resident #46 have requested many times the last few weeks from nurses and management a copy of the incident reports from Resident #30 sleeping in her (Resident #46's) bed, and grabbing her (Resident #46's) right wrist, and have not received the reports, let alone any communications about the incidents. FM H stated (Resident #46) is [AGE] years old, and was driving up until she (Resident #46) admitted here. I don't want my mom to live her last years in pain, fear and misery this has been a very difficult time for our family, we should not have to be this worried and fearful for (Resident #46) safety . Resident #30 Review of an admission Record revealed Resident #30, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: dementia, severe, with agitation. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 6/11/23 revealed a Brief Interview for Mental Status (BIMS) score of 00/15 which indicated Resident #30 was severely cognitively impaired. Further review of the MDS assessment Behavior Symptom - Presence & Frequency revealed Resident #30 coded for #1. Wandering - Presence & Frequency Has the resident wandered .#1. Behavior of this type occurred 1 to 3 days . In a 7 day look back period Review of Resident #30's Care Plans revealed: 1/26/21 Focus- I (Resident #30) am an elopement risk/wanderer r/t (related to) dx (diagnosis) of dementia. I have a hx (history) of wandering into other resident rooms which significantly intrudes on other residents' privacy or activities Interventions: Staff to redirect me (Resident #30) out of other resident rooms and to my room or common area-Date Initiated: 11/16/2022 Redirect me (Resident #30) to my room or a common area before I enter into other resident's rooms-Date Initiated: 07/25/2023 7/05/2021 Focus-I (Resident #30) have potential to demonstrate physical/verbal behaviors such as swearing at other residents, going through my roommates' belongings, unplugging my roommates TV and becoming combative and slapping other resident that may be making noise, walking next to me or the general area. I (Resident #30) am very impulsive and unpredictable. I (Resident #30) do not single out certain residents or staff. I (Resident #30) can become physically and verbally combative without escalations or warning signs r/t Dementia with behavioral disturbances. I (Resident #30) can also become possessive over certain chair or couches. per family I prefer to sleep on a couch . 3/28/2023 Focus-I (Resident #30) have a behavior problem r/t dementia. I (Resident #30) have hx of breaking items, pushing things off tables and on to the floor, taking food off of other resident plates, taking other resident snacks out of their hands. I (Resident #30) will state I didn't do anything if asked about behaviors During an interview on 8/23/23 at 1:51 PM., MDS-RN (MDS/RN) V reported she recalled a month or so ago there was an incident when Resident #30 had to be removed from Resident #46's room. MDS/RN V reported it was about Resident #30 grabbing Resident #46's wrist. MDS/RN V reported she could not remember all the details of the incident. In an observation on 8/23/23 at 3:01 PM., Resident #30 was in main dining room attempting to push on the exit door to go outside. Resident #30 began to walk around the dining area, and then sat down on a chair. Resident #30 was noted to be tearful. In an observation on 8/23/23 at 3:16 PM., Resident #30 was walking near the nurse's station attempting to get into the medication cart. Resident #30 was randomly touching items on the nursing station counter, medication cart and then proceeded to attempt to open doors for shower rooms, conference room, and service hall entry door. Resident #30 then started to touch and pull on the hand sanitizer dispenser on the wall. Certified Nurse Aide (CNA) O came out of dining area, walked around the nurses' station, and noticed Resident #30 at the hand sanitizer dispenser. CNA O attempted to redirect Resident #30 with some difficulty at first, after approximately 10 minutes Resident #30 complied with CNA O's attempts at redirection and Resident #30 agreed to sit down in a wheelchair. Resident #30 was noted to be tearful during this observation. During an interview on 8/23/23 at 4:04 PM., Registered Nurse (RN) L reported there was an incident with Resident #46 and another resident (RN L could not recall 2nd residents name) a few months ago. The other resident wandered into Resident #46's room and staff had to intervene once they heard Resident #46 hollering for help. RN L reported Resident #46 does not typically exhibit behaviors. RN L reported she thinks the incident had to do with the other resident grabbing and twisting Resident #46's arm. During an interview on 8/23/23 at 4:39 PM., Licensed Practical Nurse (LPN) S reported Resident #30 had entered Resident #46's room a few months back and fell asleep in Resident #46's bed. LPN S reported she did not recall all the details but does remember that Resident #46 was out of the facility with family, and when they (FM H and Resident #46) returned to the facility they were upset because they wanted the bedding changed after Resident #30 had fallen asleep in the bed. LPN S reported not long after that something else happened where Resident #30 went into Resident #46's room again, and some sort of altercation happened. LPN S reported Resident #46 does not exhibit many behaviors at all but does get anxious when Resident #30 gets near her (Resident #46). LPN S reported Resident #46 is afraid of Resident #30. During an interview on 8/24/23 at 9:11 AM., Certified Nurse Aide (CNA) J reported there was an incident that Resident #30 went into Resident #46 room and slept in her bed. CNA J reported Resident #30 has a lot of behaviors and has many altercations with other residents. CNA J reported Resident #30 often wanders into other residents' rooms, lashes out and hit other residents, and has hit family members visiting residents who reside in the facility. CNA J reported Resident #46 does not have many behaviors, if any at all. CNA J reported Resident #46 can be anxious at times, but typically because a wandering resident is close to her doorway or trying to get into her room. CNA J reported she has worked with Resident #46 since her admission in late 2022, and to her knowledge has never hit, or become combative with any staff or other residents. CNA J reported Resident #46 was very pleasant, had a lot of family involvement and often went out of the facility with family and her friends. During an interview on 8/24/23 at 9:20 AM., CNA/SS P reported she now works as the Social Services (SS) staff member. SS P reported in her first week of being in the role of Social Services it was brought to her attention that Resident #30 had grabbed Resident #46's wrist. SS P reported shortly after hearing of the incident a meeting was held with NHA A, Director of Nursing (DON) B and Resident #46's FM H. SS P reported FM H was concerned about Resident #46's safety, and the fact that Resident #46 was afraid of Resident #30 and wanted us to ensure safety for Resident #46. SS P reported she has not had any behaviors from Resident #46 besides at times anxiety is increased. SS P reported Resident #30 has had multiple incidents/altercations with residents including a family member. Review of Resident #46's Electronic Medical Record (EMR) revealed documentation of: Nurse Practitioner (NP) Q 6/27/2023 09:06 onsite note .Chief Complaint: Chief complaint: patient (Resident #46) is seen today for right wrist pain .This is a [AGE] year-old female patient (Resident #46) who is seen today per nurse request .Patient (Resident #46) is a very concerned about her right wrist and forearm as she states that she is continuing to have pain in the area. She (Resident #46) said that her wrist and arm were twisted and twisted hard, and she (Resident #46) is not able to use her fingers like she did prior to that incident During an interview on 8/24/23 at 11:20 AM., Nurse Practitioner (NP) Q reported on 6/27/23 she had completed an examination of Resident #46. NP Q reported she (Resident #46) told me on 6/27/23 that a resident came into her room recently and she (Resident #46) was asking her (the other resident) to leave and then the other resident grabbed her (Resident #46's) wrist hard and twisted it. NP Q reported she did not know who the other resident was, but she (NP Q) did report to upper management. NP 'Q reported she has not heard of any behaviors from Resident #46 but at times has increased anxiety especially when residents who wander get close to her doorway or try to get in her room. NP Q stated she (Resident #46) was anxious just talking about it . that day she told me she (Resident #46) was fearful and anxious, she looked anxious about it NP Q reported she made sure the nurse (did not recall what nurse) knew about her (Resident #46's) anxiety at the time of her (NP Q's) visit and then ordered an x-ray of (Resident 46's) wrist. During an interview on 8/24/23 at 12:16 PM., MDS-RN V was re-interviewed and reported she was in attendance of a meeting with a few members (NHA A, CNA/SS, and FM H). MDS-RN V reported the meeting was regarding Resident #30 entering Resident #46's on multiple occasions, once falling asleep in her bed, and another time when Resident #30 entered and grabbed Resident #46's wrist. MDS-RN V stated I (MDS-RN V) know (NHA A) had spoken to Resident #46 and Resident #46 explained what happened to her wrist. MDS-RN V reported Resident #46 told (NHA A) that it was Resident #30 who grabbed and hurt her wrist. Resident #37 Review of an admission Record revealed Resident #37, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: autistic disorder. Review of a Minimum Data Set (MDS) assessment for Resident #37, with a reference date of 6/24/23 revealed a Brief Interview for Mental Status (BIMS) score of 04/15 which indicated Resident #37 was severely cognitively impaired. Review of an Incident/accident for Resident #37 revealed: 6/7/2023 Writer was in nursing office and heard yelling coming from the nurses desk/dining room entrance area r/t (related to) an altercation happening between two residents. Writer and fellow nurse ran to the dining room (both arriving at the same time) and observed .(Resident #42) holding (Resident#37's) right arm telling him (Resident #37) to stop yelling like that Resident Description: (Resident #37) .He pinched me . Resident #42 Review of an admission Record revealed Resident #42, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia, severe with psychotic disturbance. Review of a Minimum Data Set (MDS) assessment for Resident #42, with a reference date of 5/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 03/15 which indicated Resident #42 was severely cognitively impaired. Review of an Incident/accident for Resident #42 revealed: 6/7/2023 Writer was in nursing office and heard yelling coming from the nurses desk/dining room entrance area r/t an altercation happening between two residents. Writer and fellow nurse ran to the dining room (both arriving at the same time) and observed (Resident #42) holding (Resident#37's) right arm telling him to stop yelling like that Resident Description: The only comment resident (Resident #42) gave writer at the time of the incident was this guy (Resident #37) shouldn't be in here yelling at people like that . Review of an Incident/accident for Resident #42 revealed: On 6/22/23 About 0730 CNA called for assist 100 hallway outside of room [ROOM NUMBER]. Writer observed resident (Resident #42) intertwined with CNA and resident 1435 (unknown resident). CNA states they were inside room assisting when they heard (Resident #42) state I'm gonna punch you in the gut .CNA opened door and saw (Resident #42's) hand make contact with 1435 (unknown resident) stomach (surveyor noted discrepancy on the incident/accident report with resident identifier 1435, unable to locate resident 1435 in facility electronic medical record (EMR) .). During an interview on 8/23/23 at 3:30 PM., Certified Nurse Aide (CNA) N reported Resident #42 had a lot of behaviors, was difficult to redirect, and at times he has struck out at other residents and staff. CNA N reported the staff had to keep a very close eye on Resident #42 along with quite a few other residents such as Resident #30 who were known to wander and roam into to other residents personal space. CNA N reported both Resident #30 and Resident #42 have had multiple resident to resident altercations with other residents, and both Resident #30 and Resident #42 sometimes just randomly would lash out. Review of the policy, Abuse and Neglect, reviewed 07/11/23, revealed: It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The term abuse (abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation) will be used throughout this policy unless specifically indicated .Reporting .It is the policy of this facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility .Serious Bodily injury: The term serious bodily injury is defined as an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization, or physical rehabilitation .Serious Bodily Injury reporting - 2 Hour Limit: If the events that cause reasonable suspicion and allegation involve abuse or result in serious bodily injury to a resident, the covered individual shall report the suspicion immediately, but not later than 2 hours after forming the suspicion .All other injury reporting - Within 24 Hours: If the events that cause the reasonable suspicion do not result in serious bodily injury to a resident, the covered individual shall report the suspicion not later than 24 hours after forming the suspicion .Harm is a negative outcome that has compromised the resident's ability to maintain or reach the highest practicable physical, mental, or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficiency is related to Complaint Intakes MI00131768 and MI00136585. Based on observation, interview, and record review, the facility failed to provide care to prevent skin breakdown, promote healing, and prevent infection related to pressure injuries for two Residents (R104 and R155) out of two residents reviewed for pressure injuries. This deficient practice resulted in harm to R104 when their pressure ulcer wound infection progressed to organ failure, and the development of facility acquired pressure injuries for both R104 and R155. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. Resident R104 Review of R104's MDS assessment, dated [DATE], revealed R104 was re-admitted to the facility on [DATE] with active diagnoses that included: stroke, heart failure, coronary artery disease (CAD), hemiplegia (paralysis of one side of the body), malnutrition, depression, and chronic obstructive pulmonary disease (COPD). R104 scored 9 of 15 on the BIMS, reflective of moderate cognitive impairment. Skin conditions identified in Section M - Skin Conditions of the MDS assessment revealed R104 had one Stage II, and one Unstageable pressure injury. Section E0800. Rejection of Care - Present & Frequency was documented on the [DATE] MDS assessment as 0. Behavior not exhibited. R104 required extensive, one-person physical assistance with bed mobility. During a telephone interview on [DATE] at 5:44 p.m., Family Member (FM) EE reported the facility Nurse Practitioner (NP) Q had told FM EE that R104 had gone septic (when an infection-fighting process turns on the body, causing the organs to work poorly) from (infected) pressure injuries. FM EE stated, [NP Q] acknowledged that [R104's] rapid decline was due to the wounds (infected pressure injuries). FM EE said she was unaware that [R104] had significant wounds (pressure injuries). FM EE, also an advanced practice medical clinician, stated, I assumed and put my trust in them that they would do the right thing in putting a barrier on the wound and change (R104's) position. FM EE stated, We (family members) were the ones that ended up turning (repositioning) him, because nursing care was not there. That is when we discovered how bad the wounds were. I don't believe they even had dressings . The one on his hip was necrotic (covered with black eschar). The tissue was black and dead and there was a foul odor. He was laying directing on the sacral wound . They told us to wear gloves when we touched him . I would have expected the wounds to have dressings (applied to them) and the wounds to have been debrided . seeing how severe it was, it was concerning . Observation of undated photographs provided by Complainant FF showed the following: Photo 1: appeared to be a large right trochanter (hip) pressure injury covered with blackish eschar, making the wound unstageable. Photo 2: a small heel pressure injury, scabbed over with residual yellow colored topical ointment/liquid similar to iodine color on the wound. Photo 3: a large, coccyx/sacral pressure injury with black eschar, yellowish slough, and irregular wound edges. Wound was bordered by pink, inflamed skin with apparent infectious process. No dressing was visible on the wound, and the bedding underneath the R104 was partially saturated with bloody, and brownish puss. This wound appeared to be unstageable. Photo 4: a picture of the large coccyx/sacral pressure injury from the side view, showing the tissue swelling and discoloration around the area of the wound. Review of a [DATE] Incident Reported related to development of multiple Stage II pressure injuries, one to coccyx and one under the right gluteal fold, revealed the following, in part: [RN V] assessed the area and documented in the Skin and Wound application the presence of the two (new) pressure injuries. During an interview on [DATE] at 1:58 p.m., the DON was asked to review R104's last six months of nursing progress notes for any documentation from the nursing staff that R104 had refused turning and repositioning. The DON reviewed progress notes from [DATE] through [DATE], and following her review said that no documentation of [R104's] refusal to turn or reposition was found in any of the six months of nursing notes.). When asked what nursing staff would be expected to do if a CNA reported [R104] had refused turning and repositioning, the DON stated, I would expect the nurses to make a progress note. When asked if it would also have been documented as a refusal in the Certified Nurse Aide (CNA) documentation on turning and repositioning, the DON stated, Honestly, I don't know if they can document a refusal on turning and repositioning. The DON confirmed the CNA Task to document on resident repositioning was not set up for documentation. When asked how I would know [R104] refused repositioning, or was just not repositioned by facility staff, the DON looked at me silently, and after a silent delay stated, I get what you are saying. When asked what documentation was available as evidence to show R104's refusal to turn and reposition, the DON remained silent and did not answer. At this same time the DON was asked to review R104's coccyx/sacral wound where there were two separate openings, one below the sacral wound that showed a depth was present but was not documented on the Skin and Wound documentation. The DON agreed there were two wounds visible on this picture, one above and one below. When a copy of the wound documentation was requested, the DON stated, I really don't know about wounds because I don't do the wounds. I honestly don't know how to print this. During an interview on [DATE] at 2:18 p.m., the DON was asked for what physician orders were in place at the time of identification of R104's greater trochanter (right hip) wound. The DON reviewed R104's physician orders, prior to his expiration in the facility on [DATE], and when the review was completed, the DON stated, I don't see one (physician order for greater trochanter pressure injury treatment). Review of R104's Physician Orders between [DATE] and [DATE], provided by the facility on [DATE], revealed the following, in part: 1. Apply betadine to pressure ulcer on medial aspect of left heel. Cover with 4x4 and wrap with gauze every day shift for wound care. Start Date [DATE], End Date [DATE]. 2. Apply Butt Paste to open areas surrounding coccyx BID (twice daily), every day and evening shift for Pressure ulcers. Start Date [DATE], End Date [DATE]. 3. Coccyx Ulcer: Cleanse with wound wash, Apply skin prep around wound. Apply Medi honey to yellow necrotic area. Cover with 4x4 and change QD every day shift. Start Date [DATE], End Date [DATE]. 4. Dolphin (Specialty pressure reduction mattress), Order Date [DATE], NO Start Date, End Date [DATE]. 5. Dressing change to unstageable pressure ulcer Right hip. Cleanse with NS (normal saline), apply skin prep over area, cover with an Allevyn. Change every 48 hours every day shift every other day for pressure ulcer. Start Date [DATE], End Date [DATE]. 6. Dressing change to unstageable pressure ulcer right hip. Cleanse with NS, apply skin prep around wound bed, cover wound bed with Medi honey and 4x4 gauze every day shift for pressure ulcer. Start Date [DATE], End Date [DATE]. 7. HOSPITALIZATION FOR ACUTE TREATMENT IF DEEMED NECESSARY BY THE PHYSICIAN. Start Date [DATE], End Date [DATE]. 8. NO intravenous hydration. YES, to IV antibiotic Therapy. Order Date [DATE], NO Start Date, End Date [DATE]. Review of R104's Pressure Injury Timeline, provided by the Nursing Home Administrator (NHA) on [DATE] at 12:15 p.m. [Central Daylight Savings Times (CDST)] revealed the following information: [DATE], Coccyx Pressure - Kennedy terminal ulcer Unstageable (Note: Photo observation of two separate wound areas: coccyx with visible depth, and sacral enlarged with slough and eschar.) [DATE], Coccyx Pressure - Kennedy terminal ulcer Unstageable 3.91 cm 2.16 cm (Note: Two wounds present in photo, coccyx pressure injury and sacral pressure injury.) [DATE], Coccyx Pressure Stage 2 0.51 cm 0.39 cm (Note: photo shows dressing covering sacral area previously reddened and coccyx pressure injury.) [DATE], Coccyx Pressure Stage 2 0.81 cm 0.59 cm [DATE], Coccyx Pressure Stage 2 0.39 cm 0.39 cm [DATE], Coccyx Pressure Stage 2 0.77 cm 0.55 cm [DATE], Coccyx Pressure Stage 2 0.71 cm 0.63 cm [DATE], Coccyx Pressure Stage 2 0.9 cm 0.73 cm Re-opened Sep 19, 2022, Coccyx Pressure Stage 2 0 cm 0 cm Resolved. [DATE], Coccyx Pressure Stage 2 0.79 cm 0.39 cm [DATE], Coccyx Pressure Stage 2 0.92 cm 0.43 cm [DATE], Coccyx Pressure Stage 2 0.61 cm 0.3 cm [DATE], Coccyx Pressure Stage 2 0.46 cm 0.79 cm [DATE], Right Trochanter Pressure Unstageable 2.25 cm 4.08 cm (Note: Photo observation shows wound bed all necrotic with dark eschar.) [DATE], Right Trochanter Pressure Unstageable 3.34 cm 5.74 cm [DATE], Right Trochanter Pressure Unstageable 5.35 cm 4.22 cm [DATE], Right Trochanter Pressure Unstageable 3.33 cm 2.44 cm [DATE], Right Trochanter Pressure Unstageable 4.53 cm 5.67 cm [DATE], Right Trochanter Pressure Deep Tissue Injury 5.67 cm 7.21 cm New (Note: showed a photo of R104's right trochanter with a deep purple bruise inside a much larger reddened and abraded right hip. Appears to have resulted from a fall or trauma injury to the right hip. The dimensions as listed on the Wound Evaluation revealed an area of 29.96 centimeters (cm), length of 5.67 cm and with of 7.21 cm.) Review of R104's right trochanter Wound Evaluations revealed the following, in part: 1. [DATE] showed a photo of an open wound, covered with yellowish slough, with an apparent depth to the wound that was not measured. 2. [DATE], showed a photo of the right trochanter with two separate wound areas on the right hip partially covered in slough. 3. [DATE], showed a photo of the right trochanter, significantly enlarged (measurements: area: 16.38 cm2, Length 5.35 cm, Width 4.22 cm) with two separate areas open, with visible in the photo with an unmeasured depth. 4. [DATE], showed a photo of the entire greater trochanter area with dark, necrotic eschar covering the entire, previously multiple wound areas. Measurements of: Area 13.25 cm2, Length 3.34, Width 5.74. Significant worsening of wound visibly apparent in the photo. Review of Physician visits for R104 between 10/2023 and 4/2023 revealed physician visits were performed on [DATE] and [DATE] for R104. Review of R104's Care Plans revealed the following: 1. Focus: I have had a Cerebral Vascular Accident (Stroke), Date Initiated: [DATE] . Interventions . Turn and Reposition q (every) 2 hours and PRN (as needed), Keep body in good alignment. Date Initiated: [DATE], Canceled Date: [DATE] (date of expiration). 2. Focus: Bowel/Bladder . I am only to wear blue incontinence pads, no underwear, briefs, or pullups as they can cause pressure injuries. Date Initiated: [DATE], Cancelled Date: [DATE]. 3. Focus: Hx of reoccurring pressure injury to my coccyx and heels r/t hx of pressure injury, immobility, poor nutrition, and failure to thrive. I have unavoidable pressure injury to left heel and coccyx r/t refusal to eat refusal of medications and noncompliance with turning and repositioning program. Date Initiated: [DATE], Cancelled Date: [DATE] . Interventions/Tasks: Avoid positioning me on my coccyx area. I am often noncompliant with reposition wedge. Remind me the importance of keeping pressure off coccyx. Date Initiated: [DATE], Cancelled [DATE] . Follow facility policies/protocols for the prevention/treatment of my skin breakdown. Date Initiated [DATE], Cancelled Date [DATE]. 4. Focus: Comfort Measures Only . Date Initiated [DATE], Date Cancelled: [DATE]. 5. Focus: ADLs (Activities of Daily Living . BED MOBILITY: I am an Assist x 1, Date Initiated: [DATE], Cancelled Date: [DATE]. During an interview on [DATE] at 2:44 p.m., RN V was asked for any evidence to show R104 refused turning and repositioning by facility staff. RN V said there was no task for turning and repositioning that was documented by the CNAs. When asked how a CNA would document that R104 did refused turning and repositioning, RN V said they (CNAs) would have to tell their nurse who would do a progress note. RN V stated, Apparently they (CNAs) do not document turning and repositioning at all . During an interview on [DATE] at 11:35 a.m., CNAs CC and N confirmed they had provided direct care to R104 when he was in the facility. When asked how they had documented R104's refusal to turn and reposition, CNA CC and N looked puzzled, individually, and then looked at each other with a questioning look, eyes raised. CNA N stated, He didn't refuse. CNA CC also said he never refused. When asked if CNA CC and CNA N believed R104 was consistently repositioned by facility staff, both said they did not think he was always repositioned. During an interview on [DATE] at 2:46 p.m., NP Q was asked what she had told the family regarding R104's sudden decline prior to his death on [DATE]. NP Q said they would need to review notes related to R104. NP Q said R104 had the pressure injuries four, five, and six months prior to his death. NP Q said R104 refused a lot of turning, which had been reported to her by the nursing staff she rounded with. NP Q stated, I was very open and honest with the family that the infected pressure ulcers were the cause of the decline (R104's rapid decline) . it developed rather quickly. NP Q said it looked like a terminal Kennedy ulcer to her, and agreed the right great trochanter, and coccyx/sacral wound were all unstageable. NP Q stated, There was thought about antibiotics. There was discussion about going to the wound clinic. When asked if those discussions were documented, NP Q turned her head from side to side, and stated, I hope I documented that. When asked if the pressure ulcer wound infections were a factor in R104's organ failure (including renal and heart failure), NP Q paused and stated, It is a combination of all three (pressure ulcer infection, renal and heart failure). One (the pressure ulcer infection) led to the other two (renal and heart failure). When asked to clarify that the pressure ulcer wound infections lead to R104's organ failure, NP Q acknowledged that was her belief. Resident #155 During an observation on [DATE] at 12:06 p.m., Licensed Practical Nurse (LPN) D assisted R155 to stand for an observation of a potential pressure injury following a staff transfer. A pressure ulcer dressing was applied to the coccyx area this morning by [NP Q]. Observation of the coccyx area revealed a small, circular Stage II pressure injury on R155's left, interior buttock cheek. The pressure injury had no drainage, and no slough was present on the wound. R155 stated, It was really killing me back there (left buttock) . After repositioning it really hurt. During an interview on [DATE] at approximately 12:15 p.m., NP Q confirmed she had examined R155 that day and applied a dressing to a Stage II pressure injury on R155's left inner buttock. NP Q confirmed it was not a sacral or coccyx wound but would be considered a left inner buttock pressure injury. Review of R155's Care Plans, with the following interventions all updated [DATE], revealed the following, in part: - I have pressure injury to buttock. Date Initiated: [DATE]. - Interventions will be put in place to prevent decline in wound and maintain my comfort. - Administer treatments as ordered and monitor for effectiveness. - Assess me and attempt to determine underlying cause of wound, alleviate causes if possible. - Assess/record/monitor wound healing per facility policy. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. - Educate me/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. - Encourage fluids with each interaction. Review of R155's Physician Orders revealed the following, in part: Foot cradle for end of bed at all times, every shift for skin integrity. -Order Date: [DATE] 19:29 (7:29 p.m. CDST) Cleanse coccyx wound with wound wash, apply skin prep around area, apply Lidocaine 4% cream to wound, cover with Allevyn. every day shift every 2 day(s) for coccyx wound until healed. Start Date: [DATE] 0600 (6:00 a.m., CDST) Cleanse coccyx wound with wound wash, apply skin prep around area, cover with Allevyn. every day shift every 2 day(s) for coccyx wound until healed. -Start Date: [DATE] -D/C (discontinue) Date: [DATE] During an interview on [DATE] at 9:42 a.m., Resident #155 reported they sustained a pressure ulcer (on [DATE]), shortly after their admission to the facility, when they were positioned in bed incorrectly with the bed pad, causing shearing of their buttocks skin. Resident #155 described the incident as follows: I could feel the [skin] tear after they [nursing staff] lifted the edges of the [bed] pad, and it felt like a knife going in. They were going to roll me to the center of the bed, and [when] they pulled on the pad, I said, 'Oh my goodness,' and after that they started using a [wound treatment] cream. Resident #155 reported the new pressure ulcer was still present, and was located a bit lower than the tailbone, and clarified, It hurts. As soon as I move the wrong way, then I feel it again. My son and daughter know. They [family] were very disappointed in it [the development of the pressure ulcer]. During an interview on [DATE] at 12:55 p.m., R155 was sitting in a recliner, with bilateral feet elevated on the recliner footrest. When asked about any sores on her bottom, R155 stated, Well I talked to the Doctor (NP Q) who said that they were going to try lidocaine on a patch to help with the pain from the pressure injury. R155 said they had not started the lidocaine and the pressure injury was still painful. R155 said they had not been in to do the dressing changes, since the dressing was changed last week. R155 said she had asked if they could take the foam dressing off at night and that is what they had been doing. R155 said they had not put any lidocaine on her dressing as she had not had pain relief. R155 said when the staff sat her straight up in bed or in the chair, she sits right on the pressure injury, and it is really painful then. The resident said she knew they were not supposed to sit her straight up, but all the staff didn't know that. Review of R155's Physician Visit Progress Notes revealed the following: [DATE] Physician Visit - review of integumentary - no mention of any pressure injuries. [DATE] Physician Visit NP - Asked to see pressure injury HPI: This is a [age] female with a history of COPD and heart failure is seen today per nurse request to assess open area on the left buttocks. The area was originally a shearing wound of unknown etiology. Over the past 24 hours staff report that the wound has become larger. Patient states that she is having pain in the area where the wound is present. She states that she has a hard time staying off of the area when she is up in her wheelchair and reclining chair. She states that she needs the head of the bed elevated at 45 degrees in order to breathe at night and it is very uncomfortable for her to lay on her side . The nurses were applying butt paste to the area bid and prn, but the wound has increased in size and depth and requires a different treatment . NP .Integumentary: Stage 2 pressure ulcer on left buttocks. Measured by nurses using the PCC wound app - (0.63 x 0.59 cm) x 0.1 cm, wound with 90% granulation tissue and 10% yellow slough, no drainage noted, no warmth or evidence of infection noted .1.: Pressure ulcer of left buttock, stage 2. Abrasion left buttocks with no stage II pressure ulcer. Wound was being treated with butt paste, but it has increased in size . Staff instructed to report any change in status of the wound to this provider . Review of R155's Treatment Administration Record (TAR) on [DATE] 01:04 p.m., revealed the left inner buttock cheek pressure injury was described as a coccyx wound. The sacral bruising was identified as a Stage II sacral pressure injury on [DATE] by NP Q. During an interview on [DATE] at 2:22 p.m., the DON asked to review Skin and Wound Documentation and provide date of First development of R155's left buttock wound. The DON reviewed the computer screen silently, as she tried to determine when the wound originated for R155. The DON stated, No, I do not see a skin and wound documentation for [DATE]) . I guess I can't be sure when this started. Review of the Wound History Screen on the DON computer showed R155's left inner buttock wound was initially assessed by RN V 14 days ago, on [DATE]. [Regulatory Compliance Officer G] updated 155's Wound Evaluation 5 days previous on [DATE]. Measurements were 0.31 area, 0.76 cm length, and 0.55 cm width. The Photo taken on [DATE] showed an abrasion pressure injury with top layer of skin off R155's left interior buttock cheek. The photo taken on [DATE] included measurements of 0.63 cm length x 0.59 cm width. R155's right interior buttock pressure injury was listed as new on [DATE]. When asked when the wound started, the DON stated, It appeared that it started on the 8th, when that (the initial wound) was found. During an interview on [DATE] at 2:35 p.m., RN V said R155's right interior buttock cheek wound started as an abrasion. RN V confirmed the second, [DATE] photo of the wound appeared more like a pressure injury. RN V confirmed that the CNAs are responsible to report any new skin changes. RN V stated, I think that they (CNAs) interpret that if it (wound) was there (already), they would not have to report any changes in a previously identified skin concern. During an observation on [DATE] at 3:34 p.m., Resident R155 was laying on her right side in bed. The old dressing, which was not dated or initialed was removed from R155's right buttock. Licensed Practical Nurse (LPN) S confirmed there was no date or dressing on the dressing removed from R155.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation relates to Intake #MI00138093. Based on interview and record review, the facility failed to provide effective safety interventions to prevent two falls with major injury (a hip fracture with surgical fixation, and a non-operable femur fracture) for one Residents (#154) of six residents reviewed for falls. This deficient practice resulted in surgical intervention, hospitalization, functional and medical decline, and increased pain requiring additional opioid pain medication. Findings include: All times are noted in Eastern Daylight Time unless otherwise noted. Review of Resident #154's Emergency Department transfer report, dated 05/20/23 at 2309 [11:09 p.m. report time] revealed, [Hospital EMS] is dispatched to [facility] to transport a female patient [Resident #154] with possible broken hip to [hospital] . Upon immediate response arrived to find the patient [Resident #154] lying supine in bed on 3L [Liters] O2 [Oxygen] via NC [nasal cannula]. Patient states she was walking without her walker when she fell , landing into a wall and then falling to the ground. Patient hit head on a radiator, denies loss of consciousness, blurred vision, or headache. Patient states she got up and was unable to bear weight on the right side Staff heard pt fall in bedroom. Stated she fell while trying to open her window without using her walker . Review of Resident #154's emergency room History and Physical report, dated 05/20/23 at 2302 [11:02 p.m.], revealed, Patient [Resident #154] presents to emergency department via EMS [ambulance] after she had a mechanical fall. [Resident #154] states that she could not find her walker and 1 of the nurses was looking for when she tried to get up and go ahead walking. She tripped and fell injuring her right hip and also hit the right side of her scalp .Medical Decision Making: Closed nondisplaced [properly aligned] intertrochanteric fracture of right femur, initial encounter, acute illness or injury. Contusion of scalp. Going to [higher acuity hospital for surgery] hospital emergency department .X-ray hip and pelvis shows a right hip fracture. CT head is read negative . Review of Resident #154's Emergency Department transfer report, dated 05/20/23 at 2309 [11:09 p.m. report time] revealed, [Hospital EMS] is dispatched to [facility] to transport a female patient [Resident #154] with possible broken hip to [hospital] . Upon immediate response arrived to find the patient [Resident #154] lying supine in bed on 3L [Liters] O2 [Oxygen] via NC [nasal cannula]. Patient states she was walking without her walker when she fell , landing into a wall and then falling to the ground. Patient hit head on a radiator, denies loss of consciousness, blurred vision, or headache. Patient states she got up and was unable to bear weight on the right side Staff heard pt fall in bedroom. Stated she fell while trying to open her window without using her walker . Review of Resident #154's acute hospital stay Discharge summary, dated [DATE], revealed Resident #154 had a discharge diagnosis of Fall with right intertrochanteric hip fracture, status post short intramedullary nail placement [internal fixation to repair the fracture], metastatic lung cancer .COPD without exacerbation, oxygen dependent, chronic atrial fibrillation [heart rhythm irregularity] . Anticipated discharge date was noted as 05/26/23. During a phone interview on 8/11/23 at 4:33 p.m., Family Member (FM) BB reported Resident #154 had a fall with a hip fracture at the facility on 5/20/23, when there was no walker at Resident #154's bedside, and the nursing aide left. Resident #154 was left unattended when they went to get find a walker. FM BB reported they observed Resident #154 could not stand up properly on admission to the facility on 5/18/23 and had been given a walker by physical therapy to transfer, due to leg weakness and debility from pneumonia, malnutrition and other medical conditions. FM BB clarified they knew Resident #154 was at high risk for falls, and her room was hot and Resident #154 got up and tried to open the window, and slipped and hit her head on the radiator, and sustained had a hip fracture, which required surgical intervention. FM BB reported during their visits, Resident #154 often waited up to 30 minutes for their call light to be answered. FM BB stated staff would complain about Resident #154 having their call light on, and Resident #154 would call her spouse in the night, as her call light wasn't being answered. FM BB added Resident #154 had a second fall on 6/3/23 out of bed, without injury, and a third fall on 6/6/23, when she fractured her femur, which was non-operable due to Resident #154's medical frailty. FM BB explained Resident #154 required five stiches to her head after the fall on 6/5/23, was hospitalized , and did not return to the facility. FM BB conveyed they were unclear how this third fall occurred out of bed, as they did not believe Resident #154 was strong enough to get out of bed herself. FM BB reported all of Resident #154's falls occurred when she was left alone, without a walker, and had inadequate supervision. FM BB reported they had asked for additional fall interventions, such as bedrails or an alternative mattress but none were provided, although reportedly promised to them by the facility management. Review of Resident #154's Minimum Data Set (MDS) assessment, dated 5/20/23, revealed Resident #154 was admitted to the facility on [DATE], with diagnoses including respiratory failure with hypoxia (low oxygen), lung disease, heart failure, depression, and malnutrition. The assessment revealed Resident #154 was 65 tall and weighed 84# upon admission. The assessment showed Resident #154 required supervision for bed mobility, transfers, walking, and toileting. Resident #154 was admitted on opioid [narcotic, controlled classification] pain medication. Review of #154's MDS assessment, dated 5/29/23, revealed Resident #154 was readmitted to the facility on [DATE], with a new diagnoses of hip fracture and surgical repair with fixation [securing of joint]. The assessment revealed Resident #154 required extensive two-person assistance with bed mobility and toileting, and was unable to perform transfers or walking, and showed Resident #154 was occasionally incontinent of urine, and was incontinent of bowel. The assessment revealed Resident #154 required additional days of opioid pain medications. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 10/15, which showed Resident #154 had moderate cognitive impairment. The assessment showed Resident #154 required use of a walker for functional mobility. Review of Resident #154's Accident and Incident Report, dated 5/20/23 at 19:50 p.m. (7:50 p.m.), revealed Resident #154 was found lying on the floor on their right hip at the end of their bed in front of the window, facing the window. Resident complained of right hip pain 10/10 pain (with 10 being the highest), and reported she hit her head on the heater vent. Her right leg was described as shorter than the left, and she was unable to move her right leg without severe pain. She was wearing regular socks and was ambulating without her front wheeled walker. Resident #154 stated she was trying to open the window and lost her balance. The staff named as present was Certified Nurse Aide (CNA) X. Review of Resident #154's progress note, dated 05/20/23 at 22:20 (10:20 p.m.), by Registered Nurse (RN) V, revealed Resident #154 was ambulating without assistance and fell and hit her head and her right hip while trying to open the window in her room, and was sent to the Emergency Department. The note revealed Resident #154's spouse was notified, along with physician and the Administrator. Review of facility documentation provided related to this incident via emails and multiple requests from the team leader showed no interviews or witness statements by CNA X or RN V related to this fall/incident on 05/20/23. Review of Resident #154's progress noted, dated 05/26/23 at 18:44 [6:44 p.m.], revealed, Resident [#154] was a return admit to our facility after surgical repair of a right hip fracture at 1430 [2:30 p.m.] today via ambulance .Resident [#154] has two surgical wounds covered with bandages to right thigh, uses bed pan .husband visiting at this time . Review of Resident #154's Fall Care Plan, accessed 7/24/23, revealed, I am at risk for falls at home with injury, rt [related to] fx [fracture] with surgical repair, weakness, SOB [short of breath] overestimation of ability Ensure that I am wearing appropriate footwear (non-skid socks] when ambulating or mobilizing in w/c .I utilize a FWW [front wheeled walker] for ambulation; ensure it is placed near my bed to prompt me to use it and ask for assistance . Review of Resident #154's Mobility (activities of daily living) Care Plan, accessed 7/24/23, revealed, Mobility. 05/18/23 .Ambulation: assist with FWW. Date initiated: 05/18/23 .Mobility device: Walker. Date initiated: 05/18/23. Transfers: Physical Assist x 1. Date initiated: 05/18/23 . Review of Resident #154's fall assessment report, dated 5/20/23 at 22:22 [10:22 p.m.] revealed a score of 80, which showed Resident #154 was deemed a high fall risk, given any score above 45 was designated as high fall risk. Review of Resident #154's pain assessment, dated 5/20/23 at 20:00 [8:00 p.m.], revealed pain at the right trochanter (hip) at sharp pain with movement and 10/10 pain [with 10 as the highest pain]. Review of Resident #154's Accident and Incident Report, dated 6/5/23 at 01:51 a.m by RN W, revealed, .We [nursing staff] were at the nurse's station and heard a 'thump'. Resident [#145] was sitting on the floor in her room in front of the closet, facing the window. She had a 3 cm [centimeter] laceration above her right eye. She complained of pain [radiating] from her right hip to right knee. [Resident #145 was] unable to bear weight on right leg. [Resident #145 was] Assisted to bed. Cleansed and applied ice pack to laceration above eye .Orders to send to ED [emergency department] for evaluation. Report called to ED 911 called and resident out with ambulance .[Resident #145] was wearing grippy socks and a hospital gown at the time of the fall .Resident [#145] stated she was attempting to toilet herself but later stated she was going [walking] to the closet] . Pain level was 2/10. The intervention in this fall report was: 06/05/23: I utilize a FWW [front wheeled walker] for ambulation; ensure it is placed near my bed to prompt me to use it when ambulating independently. This intervention revealed Resident #145 did not have their walker designated on the Care Plan until 06/05/23, after their third fall, although physical therapy designated use of the walker for transfers and mobility at the time of therapy evaluations on 05/18/23 and 05/26/23 and during subsequent sessions per their documentation, interviews, and therapy progress notes. Review of RN W's witness statement, dated 06/05/23, revealed, Staff [nursing staff] heard a 'thump' and went to investigate. Resident [#154] was sitting on the floor in front of her closet, facing the window. There were no additional witness statements provided, and no additional description of incident, per request. During a phone interview on 08/22/23 at 8:34 a.m., Resident #154's Power of Attorney (POA) Y, was asked about Resident #154's falls at the facility. POA Y reported the first time Resident #154 fell at the facility (on 5/20/23) and fractured her hip, she did not have a walker in her room, which concerned them. POA Y reported the staff were not answering the call light timely, and just prior to the fall (the same day) Resident #154 called him because she had waited 45 minutes for assistance. POA Y stated, [Resident #154] should have been supervised more and had her walker with her. POA Y reported [Resident #154] had been given a walker upon arrival to the facility by physical therapy, on 5/18/23, and should have been wearing gripper socks during one of the falls (on 05/20/23) and required use of a walker for transfers and ambulation during her stay. During an interview on 8/23/23 at 9:34 a.m., the Rehabilitation Director, Physical Therapy Assistant U, was asked about Resident #154's falls, and when the walker was provided. PTA U reported Resident #154 was evaluated by Physical Therapy on 5/18/23, and confirmed they treated her frequently during therapy. PTA U recalled a walker being provided to Resident #154 in their room upon evaluation on 5/18/23, as they had reviewed the physical therapy evaluation and had treated Resident #154 before their fall on 5/20/23. PTA U stated, Every day we came to transfer [Resident #154] she had a walker in her room. When asked if Resident #154 should have been wearing gripper socks when she fell on 5/20/23, PTA U affirmed Resident #154 should have always had on gripper socks, as her gait was unsteady at times. Review of Resident #154's Physical Therapy progress note, dated 05/19/23, and reviewed with PTA U, showed Resident #154 was using a FWW during the treatment, and PTA U confirmed they should have always had a walker during transfers in their room. PTA U reported Resident #154 was very unsafe without the walker, and staff had been instructed to transfer Resident #154 with the walker, including during their entire stay, for functional transfers with staff assistance. Review of Resident #154's nursing progress note, dated 5/18/23, at 20:15 [8:15 p.m.] revealed, Resident [#154] arrived with husband from [hospital]. [Resident #154] ambulates with SBA [stand by assistance] and walker .Stage 1 pressure area to coccyx. A & O x 3 [alert and oriented x three spheres], able to verbalize. Continent of B & B [bowel and bladder]. Further review of Resident #154's Care Plan revealed there was no Care Plan intervention added for Resident #154 to have their walker available for transfers until 6/5/23, after the second fall with major injury (femur fracture, non-operable). A telephone call was placed on 8/23/23 at 11:27 AM to interview RN W regarding Resident #154's falls on 5/20/23 and on 6/5/23, however no call was returned by the end of the survey. A telephone call was placed on 08/23/23 at 11:32 a.m. to interview CNA X regarding Resident #154's fall on 5/20/23. No call was returned by survey exit on 08/24/23. Surveyor reviewed schedule of staff working on 06/05/23 night shift at the time of Resident #154's fall on 6/5/23. RN V verified this was the shift the fall occurred, which was verified by the incident report time. The schedule showed CNA P, CNA J, and CNA Z were working on the night shift on 6/5/23 when the second fall with major injury occurred for Resident #154. A telephone call was placed on 8/24/23 at 07:57 a.m. to interview CNA Z regarding the incident (as they worked the night shift on 8/24/23), with no call returned by the end of the survey. During an interview on 8/24/23 at 9:04 a.m., CNA J was asked about Resident #154's fall with major injury on 6/5/23 and had no recollection of the incident. During an interview on 8/24/23 at 9:10 a.m., the nursing aide schedule dated 6/5/23 for the night shift was reviewed with CNA P. CNA P acknowledged they were working on 6/5/23 on the shift when the incident occurred but had absolutely no recall of the details of Resident #154's fall. CNA P verified they were working in the building as a CNA and on shift (6/5/23) when the fall occurred. The schedule on 6/5/23 did not specifically designate who was assigned to Resident #154's hall. CNA P reported all staff shared resident responsibilities, and this was why the schedule did not designate who was working on Resident #154's hall (the 300 hall). During an interview on 8/24/23 at 10:12 a.m., RN V was asked about Resident #154's fall on 5/20/23. RN V reported they were on shift doing medication pass when one of the aides heard yelling and a thump and went into [Resident #154's] room and notified them Resident #154 was on the ground by the window. RN V confirmed Resident #154 reported they were trying to open the window and CNA X was working when the incident occurred. RN V clarified CNA X reported they had left Resident #154 alone, as they went to look for Resident #154's walker, and thus the fall was unwitnessed. RN V confirmed Resident #154 should have had her walker by the bedside, as she used a walker for mobility at that time, since admission, and understood the concern with Resident #154 not having the walker readily available and not wearing gripper socks. RN V denied any abuse occurred and reported Resident #154 did not have a roommate at that time. RN V reported no abuse concerns were discovered or reported to them by family or staff. RN V denied any staffing concerns when the fall occurred. Surveyor requested documentation of Resident #154's daily pain levels during this interview and did not receive this information by time of survey exit. RN V reported they did know the details of Resident #154's fall on 06/05/23, as RN W was the nurse who worked on 6/5/23, and they no longer worked at the facility. During an interview on 8/24/23 at 11:52 a.m., Nurse Practitioner (NP) Q was asked about Resident #154's falls, and not having the walker at the bedside. NP Q reported they knew the walker was supposed to be at the bedside for Resident #154 and understood the concerns, as they understood Resident #154 required a walker during their stay for safe transfers and assisted ambulation. Review of the policy, Fall Prevention Program, revised 8/1/2022, revealed, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individual level of risk to minimize the likelihood of falls .1. The facility utilizes a standardized assessment for determining a resident's fall risk . The nurse will .initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk .5 a. Implement universal environmental interventions that decrease the risk of resident falling .b. Implement routine rounding schedule. c. Monitor for changes in resident's cognition, gait, ability to rise/sit, and balance. d. Encourage residents to wear shoes or slippers with non-slip soles [such as gripper socks] .High risk protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan .Provide interventions that address unique risk factors measured by the risk assessment toll: medication, psychological, cognitive status, or recent change in functional status. Provide additional interventions as directed by the resident's assessment, including but not limited to: i. Assistive devices. ii. Increased frequency of rounds (supervision). iii. Sitter [1:1 supervision], if indicated. iv. Medication regimen review. v. Low bed. vi. Scheduled ambulation or toileting assistance . Review of the policy, Abuse and Neglect, reviewed 7/11/23, revealed: .Harm is a negative outcome that has compromised the resident's ability to maintain or reach the highest practicable physical, mental, or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services .