**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the recertification and abbreviated surveys (NY00350448, NY0035998, NY00343310, NY00351372) from 1/22/2025-1/29/2025, the facility failed to ensure that four (4) of six (6) residents' (Resident, #534 #70, #207, #65) environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance to prevent accidents. Specifically: 1. Resident #534 was not supervised to prevent a fall from a wheelchair, which resulted in three (3) fractured ribs and a fractured scapula (shoulder blade); 2. Resident #70 required a mechanical lift and two-person physical assist for transfers. Certified Nurse Aide #24 used a sit to stand assistance device and one person for the transfer, resulting in a painful bruise on the left side of the forehead; 3. Resident #207 required a two-person assist for bathing, toileting, and transfers as documented in their plan of care however the assigned aide provided a one-person assist for bathing and the resident was later found with a bruise on their forehead. 4. Resident #65 required a mechanical lift and two-person physical assist for transfer. The resident was transferred with only one (1) assistant and had to be lowered to the floor. This resulted in actual harm that was not Immediate Jeopardy to Residents #534, #70, and #207 when Resident #534 sustained fractured ribs and a fractured scapula, and Residents #70 and #207 both sustained painful bruising. Findings include: The policy and procedure titled Resident Incident/Accident Reporting and Investigation Process revised 8/31/2022, documented the facility is to effectively investigate potential and actual injuries to resident to maximize resident care and minimize adverse resident outcomes. The licensed nurse notifies the nursing supervisor on duty of the accident/incident. 1. Resident #534 had diagnoses including Parkinson's Disease (progressive neurodegenerative disorder that affects movement, balance, and coordination), dementia, diabetes and a history of falls. The admission Minimum Data Set (an assessment tool) dated 3/20/2024, documented the resident was cognitively intact, required tray set up for eating, moderate assistance for toileting and Activities of Daily Living. The resident used a wheelchair, did not have wandering behaviors, and had a history of falls. The Fall Risk tool dated 3/10/2024, documented the resident was at risk for falls. The Comprehensive Care Plan dated 3/16/2024, documented the resident needs a safe environment with even floors free from spills and or clutter, needs to be evaluated for and provided adaptive equipment (low bed and wheelchair), review information on past falls, attempt to determine cause of falls, and out of bed in common area while awake and restless. A psychiatry note dated 4/9/2024 documented Resident #534 had a history of dementia and was an unreliable historian. The resident was minimally verbal, and their short-term memory, fund of knowledge, insight and judgment were limited. During a review of the Accident and Incident Reports and nurses' notes, the resident experienced seven (7) falls between 4/5/2024 and 5/25/2024 and four (4) of these falls resulted in injury. On 5/24/2024 Resident #534 sustained fractured ribs at levels #4, 5 and 6 and a fractured inner scapula following a fall. The Accident/Incident Report dated 4/5/2024, documented a witnessed fall where the resident was observed in their wheelchair in the dining room, and while changing position, slipped off the wheelchair onto the floor. The resident reported they were tired and wanted to go back to bed. The Accident/Incident Report dated 4/21/2024, documented Resident #534 was found kneeling in front of the wheelchair in their room. The resident stated they were trying to go to the bathroom and wanted to go back to bed. There were no injuries. Fall care plan updates included anticipate and meet the resident's needs, remind resident to use call bell to get help. The Accident/Incident report dated 4/23/2024 documented Resident #534 was observed on the floor in their room lying on their right side with the wheelchair tilted onto the right side. The resident was alert, awake, and moving all extremities. There was an abrasion noted to their right elbow. The Accident/Incident Report dated 4/27/2024, documented Resident #534 was observed lying on the floor in the dining room with their head on the baseboard and wheelchair turned over on the side and situated under them. A hematoma (clotted blood from a broken blood vessel) was noted in the occipital (back of head) area. A cool compress was applied, and neuro checks were started. The resident denied pain. A new Fall Care Plan intervention included for no apparent injury, determine and address causative factors of the fall, monitor, document, and report for 72 hours signs and symptoms of pain, bruising, change in mental status, new onset of confusion, sleepiness, inability to maintain posture and agitation. Purposeful rounding was also added. The facility had no documentation that defines Purposeful rounding. The Accident/Incident Report dated 4/28/2024, documented Resident #534 was found in the hallway with a small laceration (cut) to their left eyebrow. The Accident/Incident Report dated 5/7/2024, documented Resident #534 was found on the floor by the door to their room. The resident had a swollen raised area on the top, left side of their head which was bleeding. The resident to be placed by nurses' station for safety monitoring. The care plan updated 5/8/2024, documented the resident's room was changed so they would be closer to the nurse's station for observation. The Accident/Incident Report dated 5/25/2024, documented at 6:00 AM Licensed Practical Nurse #40 was informed by Certified Nurse Aide #41 of a bruise on the resident's back which was painful to the touch and was discovered while turning the resident on their side. There was no documented evidence of a recent fall. The Nursing Supervisor, Physician, and family were notified, and the resident was transferred to the hospital. During the facility investigation, it was determined there was an unwitnessed fall on 5/24/2024 while the resident was left unattended in the Southwest dining room. It was determined Certified Nurse Aide #43 and Food Service Worker #42 picked up Resident #534 from the floor without a Registered Nurse assessment. Licensed Practical Nurse #44 was aware the resident fell but did not notify the Nursing Supervisor, physician, or family about the fall. Resident #534 was returned to their room until a large bruise was identified during morning rounds on 5/25/2024 by Certified Nurse Aide #41, who in turn notified the nurse. On 5/28/2024, Food Service Worker #42 documented in their statement that on 5/24/2024 after 6:00 PM, they were coming from the bathroom and saw the resident on the floor in the Southwest dining room area and called out for someone to come and help. Certified Nurse Aide #43 asked Food Service Worker #42 to help them get Resident #534 off the floor and into the chair. Certified Nurse Aide #43 then wheeled the resident out of the dining room. During an interview with Food Service Worker #42 on 1/27/2025 at 10:15 AM, they stated they came out from the bathroom and saw resident #534 on floor, laying on their side and the wheelchair was on its side next to the resident. Certified Nurse Aide #43 came to the dining room and asked them (Food Service Worker #42) if they would help them get the resident into the wheelchair. Food Service Worker #42 stated they grabbed the resident by their pants and their arm and got the resident into the chair. They stated there was no other staff present in the dining room at that time. During an interview on 1/27/2025 at 11:08 AM, Certified Nurse Aide #43 stated they were on the facility computer and was told by Licensed Practical Nurse #44 that Resident #534 was on the floor and to go and get them off the floor. They further stated they were only doing what they were told. They stated they went to the dining room and picked up the resident with Licensed Practical Nurse #44. During an interview with Licensed Practical Nurse #44 on 1/27/2025 at 1:05 PM, they stated they were passing medications on the unit and knew there was something going on in the dining room but did not know what. They asked Certified Nurse Aide #43 to go in the dining room to see what was going on. The next thing they saw was Certified Nurse Aide #43 wheeling the resident out of the dining room in a wheelchair. Licensed Practical Nurse #44 stated they went to the resident's room and the resident was already in bed. They stated they did not know if the resident fell or slid to the floor, but they should have called the Supervisor to assess the resident. During an interview with the Director of Nursing on 1/28/2025 at 12:07 PM, they stated the fall on 5/24/2024 was investigated and they did not know why Food Service Worker #42 and Certified Nurse Aide #43 lifted the resident off the floor. Resident #534 was not assessed by a nurse, which delayed required treatment. They stated there were no vital signs obtained, and the physician and family were not notified until the next morning when the bruise was found by the Certified Nurse Aide. During an interview on 1/29/2025 at 4:33 PM, Registered Nurse #3 stated they would not expect residents who needed closer supervision to be left in the dining room. Registered Nurse #3 stated they were surprised Resident #534 was left unattended and they should not have been left alone. During a follow-up interview with the Director of Nursing on 1/29/2025 at 3:46 PM, they stated after dinner, staff take residents out of the dining room and no staff were in the dining room when the resident fell. Resident #534 was at risk for falls and should have been supervised. The Director of Nursing stated they did not know why Resident #534 was left in the dining room alone, but Certified Nurse Aides were bringing residents out of the dining room and putting them to bed instead of waiting until all the residents were cleared from the dining room. The Director of Nursing reviewed the care plan and stated the care plans should have been updated, after each fall, with clear guidance for supervision and the interventions would have transferred to the [NAME] (care instructions) for the Certified Nurse Aides to follow. During an interview on 1/29/2025 at 4:53 PM, Attending Physician #47 stated Resident #534 had a history of falls and would stand up unassisted. Physician #47 stated the staff should have provided close monitoring and the resident should not have been left in the dining room alone. There should have been an assessment by the nurse after the fall. Physician #47 stated rib fractures could cause extreme pain and difficulty breathing, and the resident would have been in pain all evening and night. During an interview on 1/30/2025 at 11:11 AM, Physician #46 stated they were covering for Attending Physician #47 and saw Resident #534 on the day the bruise was found. They stated it was a large painful bruise and the resident had facial grimaces when touched. They stated the resident was possibly in pain all night and if they were made aware sooner, the resident would have been transported to the hospital sooner. Physician #46 stated their expectation was that the nurse would assess the resident and call the physician as there was always a physician on call. During an interview on 1/30/2025 at 12:17 PM, Registered Nurse Unit Manager #9 stated the resident was care planned for purposeful rounding, and to be in the common area when out of bed. They stated purposeful monitoring was keeping an eye on the resident, providing closer supervision. A Certified Nurse Aide was assigned, on a rotating basis, throughout the shift to the supervised area. Registered Nurse Unit Manager #9 was unable to provide documented evidence of purposeful monitoring. They also stated all staff knew that if someone fell, a Registered Nurse needed to assess before getting the resident off the floor. 2. Resident #70 was admitted with diagnoses of Schizophrenia (mental illness that affects how a person thinks, feels, and behaves), cerebrovascular accident (stroke) and depression. The 6/21/2024 Annual Minimum Data Set (an assessment tool) documented the resident's cognition was intact and the resident was dependent on staff for transfer. The Physical Therapy assessment dated [DATE], documented Resident #70 was total dependence for transfers. The physician order dated 4/16/2024, documented to transfer the resident with a mechanical lift. The mechanical lift competency dated 6/14/2024, documented Certified Nurse Aide #24's signature. The Certified Nurse Aide Care Guide dated 8/2024, documented the resident was dependent on staff for transfers. The Comprehensive Care Plan for Activity of Daily Living, last updated 7/8/2024, documented Resident # 70 required the use of a mechanical lift with staff assistance. The facility incident report dated 8/6/2024, documented on 8/5/2024 Resident #70 was transferred by Certified Nurse Aide #24 using a sit to stand assistance device instead of a mechanical lift. During the transfer, Resident #70 struck their head on the handle of the sit to stand assistance device. Certified Nurse Aide #24 stated that using the sit to stand assistance device instead of the mechanical lift was easier for transferring the resident to the shower. Certified Nurse Aide #24 reported the incident to the nurse on duty that day. Nursing Supervisor #9 stated the incident was not reported to them until 8/6/2024. The resident transfer order is mechanical lift and staff was aware. Certified Nurse Aide #24 did not seek assistance from another staff member to facilitate the resident transfer and use the mechanical lift. A skin assessment dated [DATE] documented Resident #70 had a bruise on the left frontal lobe of the head, measuring 1 centimeter by 2 centimeter. No swelling was noted at the time of the assessment. A physician note dated 8/8/2024, documented an area of ecchymosis (discoloration of the skin) on the left forehead with mild tenderness. During an observation on 1/22/2025 at 10:00 AM, Resident #70 was in the doorway of the bathroom, sitting in their wheelchair on a pad used with the mechanical lift. During an interview on 1/23/2025 at 10:27 AM, Resident # 70 stated a transfer to the shower was conducted using a sit to stand assistance device. During the transfer, they struck their head on the handle of the sit to stand assistance device causing significant pain, and the nurse on duty looked at their head. During an interview 01/27/2025 at 9:27 PM, Certified Nurse Aide #24 stated on 8/5/2024, Resident #70 was transferred to the shower using a sit to stand assistance device. During the transfer, Resident #70 moved forward and struck their head on the handle of the sit to stand assistance device. They stated the transfer should have been performed with the assist of two (2) staff members and the mechanical lift as documented in the care guide. Following the incident, a report was made to Licensed Practical Nurse #25 and no bruising was observed at the time of the incident. However, bruising became apparent the following day. During an interview on 1/24/2025 at 1:15 PM, Licensed Practical Nurse #25 stated Certified Nurse Aide #24 reported that during a transfer, Resident #70 struck their head on the handle of the sit to stand assistance device. An examination of the resident's head was conducted, and no bruising or discoloration was observed at that time. Documentation of the incident was not completed, and the supervisor was not informed. The following day it was revealed that the incorrect lift and only one (1) staff member was involved in the transfer. During an interview on 1/24/2025 at 1:03 PM, Licensed Practical Nurse #26 stated Resident #70 told them that they hit their head the previous day (8/5/2024) while taking a shower. Licensed Practical Nurse #26 stated they looked at Resident #70's head and found bruising to the left frontal lobe and called the supervisor. During an interview on 1/28/2025 at 9:55 AM, Registered Nurse Supervisor #9 stated they were made aware of the incident the following day (8/6/2024) and Resident #70 sustained a bruise to the left forehead. Certified Nurse Aide #24 did not follow the care plan and used a sit to stand assistance device instead of a mechanical lift for the transfer, resulting in the resident having a head injury. During an interview conducted on 01/28/2025 at 9:59 AM, the Director of Nursing stated that Certified Nurse Aide #24 used a sit to stand assistance device instead of a mechanical lift for a transfer. During the transfer, Resident #70 bent forward and struck their head on the handle of the lift, resulting in an injury. Certified Nurse Aide #24 reported the incident to the nurse; however, the supervisor was not informed in a timely manner. 3. Resident #207 had diagnoses including neurocognitive disorder with Lewy bodies (a progressive brain disorder), non-Alzheimer's dementia, and malignant neoplasm (cancer). The quarterly Minimum Data Set (an assessment tool) dated 6/24/2024 documented Resident #207 had severe cognitive impairment and was dependent on two (2) staff for bed mobility, transfer, toileting, and bathing. The 9/28/2023 Behavior Care Plan documented behaviors included spitting and hitting staff during care. Interventions included to administer medications as ordered, psych follow up; ensure safety of resident and others, explain procedure prior to start; monitor for emotional factors that may contribute to new behaviors; provide towel in residents hand to hold prior to the start of care; and provide emotional support regarding new onset of repetitive behaviors. The 10/16/2023 Activities of Daily Living care plan documented Resident #207 required extensive assist of one (1) person for eating, extensive assist of two (2) person for bed mobility and total assist of two (2) persons for transfer and toileting. The 8/13/2024 at 5:51 PM Registered Nurse progress note documented they were notified of an injury of unknown origin and Resident #207 was observed with an abrasion on the right side of their forehead. The abrasion with mild swelling measured 3 centimeters by 2 centimeters. The resident was not able to report occurrence and grimaced when a cold pack was applied to the area. The 8/13/2024 Investigation Summary for Injury of Unknown Origin documented the resident was observed with redness and swelling to their forehead at approximately 5:30 PM. The resident was returned to their bed using the mechanical lift for transfer without incident. Resident #207 required total assistance with Activities of Daily Living, however Certified Nurse Aide #31 completed the resident care alone without the assistance of a second certified nurse aide. The investigation conclusion documented Resident #207 sustained an injury due to care plan violation. When interviewed on 1/28/2025 at 10:29 AM, Certified Nurse Aide #32 stated they assisted Certified Nurse Aide #31 to put the resident in bed. Certified Nurse Aide #32 stated Certified Nurse Aide #31 told them they could leave, and they would finish washing up the resident alone. Certified Nurse Aide #32 stated they went to the dining room during dinner to feed another resident. After dinner, Certified Nurse Aide #31 asked them to go look at Resident #207. When they went to see Resident #207, they observed a red mark on resident's forehead and stated it was reported to the nurse immediately and that they had a safe transfer because the resident had their towel, and they were calm during the transfer. They did not know what happened after they left the room and later when they returned, they noticed a red mark on the resident's forehead. Certified Nurse Aide #32 stated Resident #207 was a two (2) person assist for all Activities of Daily Living. When interviewed on 1/28/2025 at 12:52 PM, Register Nurse Supervisor #29 stated the resident was a two (2) person assist and did not know why Certified Nurse Aide #31 would provide care alone. Register Nurse Supervisor #29 stated Certified Nurse Aide #31 should not have provided care alone when resident was planned for a two (2) person assist and had a history of combative behavior. When interviewed on 1/28/2025 at 2:04 PM, the Director of Nursing stated Certified Nurse Aide #31 reported Resident #207 was not combative and did not fight during care that day. The Director of Nursing stated Certified Nurse Aide #31 was not able to explain why they provided care alone when the resident required a two (2) person assist. The Director of Nursing stated they were unable to really figure out what happened and when they attempted to touch the resident or provide care the resident would not allow them to touch them and immediately had behaviors. When interviewed on 1/29/2025 at 3:23 PM, Certified Nurse Aide #31 stated Certified Nurse Aide #32 helped with a mechanical lift transfer to put the resident in bed. Certified Nurse Aide #31 stated they did not know why Certified Nurse Aide #32 left the room and they washed up the resident alone. Certified Nurse Aide #31 stated the resident was very combative at times and required a two (2) person assist for transfers with a mechanical lift 415.12(h)(2)