**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility reported incident, review of facility policy, and staff interviews, the facility failed to ensure residents remained free from abuse from 1 of 1 sampled resident (Resident #1) with verbal, physical, and sexual behaviors towards other residents. Failure to assess, care plan, and operationalize a plan/process resulted in fear, anxiety, pain, and an unsafe environment for all residents residing in the memory care unit. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation Policy occurred on 09/05/24. This policy, revised August 2023, stated, . Abuse: the willful infliction of injury, unreasonable confinement, intimidation . with resulting physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse . Residents who mistreat, are aggressive towards . other residents . must have a care plan in place that addresses the behavior(s) in question and those residents that have had aggressive behavior directed at them . must be protected from further injury or mental anguish. Documentation must be in place to identify the steps taken to identify the problems, the corrective action taken, and follow-up monitoring. In a situation where there is an aggressive resident or a catastrophic event such as pushing, hitting, throwing objects, etc. the following steps should be taken . Re-direct resident and take to a quiet area if possible. Contact resident provider, follow provider's orders, and update family. Social Services to monitor for trends or patterns and update the residents Care Plan as needed. A facility reported incident, received by the state agency on 08/23/24, stated Resident #1 kicked a female resident in the stomach which cause her to fall. Review of Resident #1's medical record occurred on all days of survey. Diagnoses included anxiety, dementia, mood disturbance, and psychotic disturbance. The quarterly Minimum Data Set (MDS), dated [DATE], indicated severe cognitive deficits and behaviors. The progress notes identified the following: * 07/02/24 at 7:06 p.m., Resident [#1] is calling another resident a piece of [explicit word]. He then got into an altercation with another resident. * 07/07/24 at 5:32 p.m., Resident went down to end of hall and blocked another resident against the wall and was swearing at him. Other [sic] resident was begging him to just leave him alone. A cna [certified nurse aid] got them seperated [sic] . He then came up behind the other resident swearing at him and kicked him in the back. Got them seperated [sic] again and he went after him again and kicked his hand. The other resident then punched him [Resident #1] in the chest. * 07/07/24 at 11:20 p.m., Resident is growling at another resident and trying to get close to other resident to kick him. Residents kept seperated [sic]. * 07/09/24 at 11:44 p.m., Resident went up to another resident and grabbed her breasts. Both residents were separated and redirected immediately. * 07/11/24 at 7:21 p.m., The resident kicked another resident's wheelchair. He was taken to another room . * 07/14/24 at 4:54 p.m., Resident moving around dining room [NAME] [sic] other residents pieces of [explicit word]. * 07/18/24 at 12:45 a.m., Resident was blocking door from another resident, Did not verbal [sic] respond to resident when she was yelling at him. Resident did come with me to a different spot and had an HS [hour of sleep] snack. * 07/20/24 at 7:13 p.m., Resident kicked the back of another resident's wheelchair. He also yelled, 'You stupid [explicit word]' to a different resident. He was redirected each time to another area. * 07/22/24 at 5:55 p.m., Resident yelling and cursing at other residents. * 07/27/24 at 8:15 p.m., . Female residents afraid of going near resident. * 07/28/24 at 3:05 a.m., Resident [#1] grabbed another female resident by her arm. No injuries noted at this time. Resident is immediately redirected away from the other resident. * 07/29/24 at 10:37 p.m., Resident is trying to pinch resident [sic] breast after supper. Unable to redirect him away from the females. * 07/30/24 at 2:17 p.m., Resident was glaring at another resident. He was redirected away from her before anything happened. * 07/30/24 at 4:59 p.m., . He was grabbing female resident [sic] breast [sic] or talking sexual to them. He would not let a female resident go by him so staff had to get the resident by him . * 07/30/24 at 11:20 p.m., Resident sat at the main door after supper. Cussed at other residents. * 08/01/24 at 9:32 p.m., before supper started to get near female residents. Then he proceeded to kick another male resident [sic] wheelchair and call him '[explicit word].' when taking residents to the table for supper [Resident #1] would go and stare at the female resident and call her '[explicit word]' and stare at her . [Resident #1] would then try and quickly get near another female resident if staff looked away. Informed [Resident #1] that he needs to stay away from other residents especially the ladies. It is not appropriate for him to touch other residents or call them names. The minute we turned our back he was headed to a table with female residents. * 08/02/24 at 11:16 a.m., Nursing staff called Social Services last evening to report [Resident #1] was having a lot of behaviors. Some changes have been made to his psychotropic medications and he is being monitored closely. * 08/03/24 at 10:54 a.m., The resident would not let another resident's family leave by blocking the exit door. He also tried to grab one of their breast [sic] as they tried to leave. Staff redirected the resident to another area. * 08/03/24 at 9:49 p.m., resident kicked at female resident when she was walking past him after supper. * 08/04/24 at 1:59 p.m., CNA reported . she tried to redirect him [Resident #1] from hitting another resident. She directed him to another room. * 08/04/24 at 9:30 p.m., Resident going up to other female resident [sic], stares at them then calls them [explicit word]. Unable to redirect as he goes to another resident and tries to kick them [sic], grab them [sic] or call them [sic] names. Resident assisted to bed. * 08/07/24 at 11:01 a.m., Resident grabbed a female resident's left breast after breakfast. Female resident yelled at him and walked away and came to the nurses' desk. Resident's breast was red, no bruising. * 08/07/24 at 6:51 p.m., Resident was making faces at another resident in the dining room. Other resident told him to stop looking at her and then she threw her apple juice on him. Both residents were separated . * 08/08/24 at 6:53 p.m., The resident propels his wheelchair fast towards other residents and he changes the look on his face, which scares them. One resident threw food at him. Staff redirected him to his room . * 08/08/24 at 11:10 p.m., The nurse was walking up the hallways on the unit, when she observed resident stomping his feet as he was propelling fast in his wheelchair towards a female resident who was quietly sitting in her wheelchair in the hallways [sic]. There was no physical interaction. The female resident appeared frightened and the suggestion was made to go to her room and she complied and was taken to her room. As the nurse was prepared to leave, the resident stated, 'he is creepy.' * 08/11/24 at 3:48 a.m., Resident [#1] went up to a female resident and said 'your [sic] a [explicit word].' He was calling . residents 'pieces of shit' and saying '[explicit word] you.' Resident very difficult to redirect. * 08/11/24 at 1:50 p.m., Resident was wandering around the halls most of shift. He was in a confrontation with another resident. * 08/12/24 at 6:59 p.m., [Physician] here for rounds. Updated her on the residents' behaviors. Called pharmacy requesting medication combination side effects. Carbidopa-levodopa [Parkinson's medication] can cause increased labito [sic] [sexual drive]. * 08/12/24 at 11:14 p.m., Resident pedaled himself quickly toward another resident at the door. Tried to grab the resident. [Resident #1] moved away from the door, then turned and went right back to the door. Other resident left the dining room. [Resident #1] kicked and attempted to hit at another resident in the dining room. [Resident #1] taken to his room . [Family Nurse Practitioner] called. Update given on behaviors. New orders received. Will update family in the morning. * 08/13/24 at 1:35 p.m., Resident was blocking the hall not letting other residents go by. * 08/13/24 at 9:36 p.m., [Sic] was calling another resident inappropriate names after supper. * 08/18/24 at 6:45 p.m., Resident propelling towards a resident and grabbed both her breast [sic]. He was taken to his room where [sic] sat peacefully. * 08/22/24 at 1:00 p.m., The CNA called out for this nurse at [1:00 p.m.] She said she witnessed the resident propelling quickly down the hall towards another resident. The other resident was moving towards the wall to move out of his way. Everywhere the other resident moved he would block her. Then he kicked her in the stomach. The other resident fell to the ground. This nurse and CNA took him to his room . * 08/25/24 at 9:16 p.m., After supper resident [#1] was kicking another resident's wheelchair and saying '[explicit word] you.' able to redirect. Then went to another resident and called him an [explicit word]. Told resident if he continued to kick other residents wheelchairs and call people names then he would need to go to bed. * 08/27/24 at 6:25 a.m., . Resident is very agitated and aggressive towards . residents tonight. He pinched another resident on her face, no injuries noted. He ran into the back of another resident's heels, no injuries noted at this time. He is going up to . residents growling at them and calling them '[explicit words].' He is trying to kick . resident. He is blocking people so they can't get by him. Resident followed this nurse into a female resident's room and refused to leave. Tylenol was given and ice cream for a snack. This nurse called the social worker about his behaviors. [Physician] was notified about resident's behaviors and a one time order for Ativan was given. * 08/30/24 at 1:18 p.m., Resident was following female . resident around, hard to redirect, resident removed from common area from other residents . * 08/31/24 at 12:38 a.m., Resident was kicking other resident [sic] wheelchair after supper. Also calling other resident [sic] '[explicit word].' . * 08/31/24 at 2:22 p.m., Resident propelling his wheelchair fast towards other residents and telling them to move. * 08/31/24 at 9:18 p.m., Resident continue to move his wheelchair fast around the dining room. Stops at different residents and calls them '[explicit word]' or says '[explicit word] You.' Also kicked a couple wheelchairs of different residents. * 09/01/24 at 2:03 p.m., Resident propelled quickly towards other residents. CNA . tried to redirect . * 09/04/24 at 6:04 a.m., Resident is going up to residents and saying '[explicit word] You.' Attempts made to redirect . Resident #1's care plan stated, . At times becomes physically and verbally abusive when he can't communicate his need. If [Resident #1] is upset, allow time for him to calm down, then re-approach. Distract him from behaviors by offering food, beverage or activity. Remove [Resident #1] from area if he is calling other residents names, growling, or if agitated. Assess any changes in . behavior and report to . Social Services. [Resident #1] receives psychotropic medication . Monitor for changes in . behaviors and report to MD [medical doctor]/NP [nurse practitioner] as needed. The current care card also stated, . Observe and report any changes in mental status caused by situational stressor . Provide opportunities for expression of feelings related to situational stressor . The care plan failed to identify the situational stressors affecting Resident #1 and failed to address his sexually abusive behaviors towards the female residents. During an interview on 09/04/24 at 4:50 p.m., a managerial nurse (#2) indicated staff remove Resident #1 from the area whenever he behaves aggressively towards other residents. During an interview of 09/04/24 at 5:15 p.m., an administrative staff member (#1) reported the memory care unit staff failed notify her when Resident #1 grabbed the breasts of female residents. The facility failed to assess and monitor patterns and trends of behaviors in an effort to protect other residents from abuse and minimize Resident #1's physical aggression towards other residents. The facility failed to ensure Resident #1 did not infringe upon the rights of other residents to be free from verbal, mental, physical, and/or sexual abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and staff interviews, the facility failed to provide adequate dementia care and services for 1 of 1 sampled resident (Resident #1) with dementia and verbal, physical, and sexual abusive behaviors. Failure to adequately assess for necessary care and services and implement effective behavior management interventions resulted in a decreased level of psychosocial well-being for Resident #1 and had a negative impact on other residents. Findings include: The facility failed to provide a policy on dementia care. Review of the facility policy titled Abuse, Neglect and Exploitation Policy occurred on 09/05/24. This policy, revised August 2023, stated,. Residents who mistreat, are aggressive towards . other residents . must have a care plan in place that addresses the behavior(s) in question . In a situation where there is an aggressive resident or a catastrophic event such as pushing, hitting, throwing objects, etc. the following steps should be taken . Social Services to monitor for trends or patterns and update the residents Care Plan as needed. Review of Resident #1's medical record occurred on all days of survey. Diagnoses included anxiety, dementia, mood disturbance, and psychotic disturbance. The current physician's orders included: * Two 125 milligram (mg) Depakote Sprinkles capsules daily for mood stabilization started 08/31/23, * 20 mg Escitalopram Oxalate daily for major depressive disorder started 08/06/24, * 25 mg Hydroxyzine HCI daily for anxiety started 07/27/24, and * 0.5 mg Risperdal twice daily for agitation started 08/23/24. The current care plan stated, . At times becomes physically and verbally abusive when he can't communicate his need. Exit seeking. Calls other residents and staff vulgar names. Growls at . other residents. If [Resident #1] is upset, allow time for him to calm down, then re-approach. Distract him from behaviors by offering food, beverage or activity. He used to like to sort cards, work jigsaw puzzles and play with dominos. Remove [Resident #1] from area if he is calling other residents names, growling, or if agitated. Assess any changes in his mood or behavior and report to nurse and Social Services. [Resident #1] receives psychotropic medication . Monitor for changes in mood/behaviors and report to MD [medical doctor]/NP [nurse practitioner] as needed. The care card also stated, . Observe and report any changes in mental status caused by situational stressor . Provide opportunities for expression of feelings related to situational stressor . The care plan failed to identify the situational stressors affecting Resident #1 and failed to address his sexually abusive behaviors towards female residents. The progress notes identified the following: * 07/02/24 at 7:06 p.m., Resident [#1] is calling another resident a piece of [explicit word]. He then got into an altercation with another resident. * 07/07/24 at 5:32 p.m., Resident went down to end of hall and blocked another resident against the wall and was swearing at him. Other [sic] resident was begging him to just leave him alone. A cna [certified nurse aid] got them seperated [sic] . He then came up behind the other resident swearing at him and kicked him in the back. Got them seperated [sic] again and he went after him again and kicked his hand. The other resident then punched him [Resident #1] in the chest. * 07/07/24 at 11:20 p.m., Resident is growling at another resident and trying to get close to other resident to kick him. Residents kept seperated [sic]. * 07/09/24 at 11:44 p.m., Resident went up to another resident and grabbed her breasts. Both residents were separated and redirected immediately. * 07/11/24 at 7:21 p.m., The resident kicked another resident's wheelchair. He was taken to another room . * 07/14/24 at 4:54 p.m., Resident moving around dining room [NAME] [sic] other residents pieces of [explicit word]. * 07/18/24 at 12:45 a.m., Resident was blocking door from another resident, Did not verbal [sic] respond to resident when she was yelling at him. Resident did come with me to a different spot and had an HS [hour of sleep] snack. * 07/20/24 at 7:13 p.m., Resident kicked the back of another resident's wheelchair. He also yelled, 'You stupid [explicit word]' to a different resident. He was redirected each time to another area. * 07/22/24 at 5:55 p.m., Resident yelling and cursing at other residents. * 07/27/24 at 8:15 p.m., . Female residents afraid of going near resident. * 07/28/24 at 3:05 a.m., Resident [#1] grabbed another female resident by her arm. No injuries noted at this time. Resident is immediately redirected away from the other resident. * 07/29/24 at 10:37 p.m., Resident is trying to pinch resident [sic] breast after supper. Unable to redirect him away from the females. * 07/30/24 at 2:17 p.m., Resident was glaring at another resident. He was redirected away from her before anything happened. * 07/30/24 at 4:59 p.m., . He was grabbing female resident [sic] breast [sic] or talking sexual to them. He would not let a female resident go by him so staff had to get the resident by him . * 07/30/24 at 11:20 p.m., Resident sat at the main door after supper. Cussed at other residents. * 08/01/24 at 9:32 p.m., before supper started to get near female residents. Then he proceeded to kick another male resident [sic] wheelchair and call him '[explicit word].' when taking residents to the table for supper [Resident #1] would go and stare at the female resident and call her '[explicit word]' and stare at her . [Resident #1] would then try and quickly get near another female resident if staff looked away. Informed [Resident #1] that he needs to stay away from other residents especially the ladies. It is not appropriate for him to touch other residents or call them names. The minute we turned our back he was headed to a table with female residents. * 08/02/24 at 11:16 a.m., Nursing staff called Social Services last evening to report [Resident #1] was having a lot of behaviors. Some changes have been made to his psychotropic medications and he is being monitored closely. * 08/03/24 at 10:54 a.m., The resident would not let another resident's family leave by blocking the exit door. He also tried to grab one of their breast [sic] as they tried to leave. Staff redirected the resident to another area. * 08/03/24 at 9:49 p.m., resident kicked at female resident when she was walking past him after supper. * 08/04/24 at 1:59 p.m., CNA reported . she tried to redirect him [Resident #1] from hitting another resident. She directed him to another room. * 08/04/24 at 9:30 p.m., Resident going up to other female resident [sic], stares at them then calls them [explicit word]. Unable to redirect as he goes to another resident and tries to kick them [sic], grab them [sic] or call them [sic] names. Resident assisted to bed. * 08/07/24 at 11:01 a.m., Resident grabbed a female resident's left breast after breakfast. Female resident yelled at him and walked away and came to the nurses' desk. Resident's breast was red, no bruising. * 08/07/24 at 6:51 p.m., Resident was making faces at another resident in the dining room. Other resident told him to stop looking at her and then she threw her apple juice on him. Both residents were separated . * 08/08/24 at 6:53 p.m., The resident propels his wheelchair fast towards other residents and he changes the look on his face, which scares them. One resident threw food at him. Staff redirected him to his room . * 08/08/24 at 11:10 p.m., The nurse was walking up the hallways on the unit, when she observed resident stomping his feet as he was propelling fast in his wheelchair towards a female resident who was quietly sitting in her wheelchair in the hallways [sic]. There was no physical interaction. The female resident appeared frightened and the suggestion was made to go to her room and she complied and was taken to her room. As the nurse was prepared to leave, the resident stated, 'he is creepy.' * 08/11/24 at 3:48 a.m., Resident [#1] went up to a female resident and said 'your [sic] a [explicit word].' He was calling . residents 'pieces of shit' and saying '[explicit word] you.' Resident very difficult to redirect. * 08/11/24 at 1:50 p.m., Resident was wandering around the halls most of shift. He was in a confrontation with another resident. * 08/12/24 at 6:59 p.m., [Physician] here for rounds. Updated her on the residents' behaviors. Called pharmacy requesting medication combination side effects. Carbidopa-levodopa [Parkinson's medication] can cause increased labito [sic] [sexual drive]. * 08/12/24 at 11:14 p.m., Resident pedaled himself quickly toward another resident at the door. Tried to grab the resident. [Resident #1] moved away from the door, then turned and went right back to the door. Other resident left the dining room. [Resident #1] kicked and attempted to hit at another resident in the dining room. [Resident #1] taken to his room . [Family Nurse Practitioner] called. Update given on behaviors. New orders received. Will update family in the morning. * 08/13/24 at 1:35 p.m., Resident was blocking the hall not letting other residents go by. * 08/13/24 at 9:36 p.m., [Sic] was calling another resident inappropriate names after supper. * 08/18/24 at 6:45 p.m., Resident propelling towards a resident and grabbed both her breast [sic]. He was taken to his room where [sic] sat peacefully. * 08/22/24 at 1:00 p.m., The CNA called out for this nurse at [1:00 p.m.] She said she witnessed the resident propelling quickly down the hall towards another resident. The other resident was moving towards the wall to move out of his way. Everywhere the other resident moved he would block her. Then he kicked her in the stomach. The other resident fell to the ground. This nurse and CNA took him to his room . * 08/25/24 at 9:16 p.m., After supper resident [#1] was kicking another resident's wheelchair and saying '[explicit word] you.' able to redirect. Then went to another resident and called him an [explicit word]. Told resident if he continued to kick other residents wheelchairs and call people names then he would need to go to bed. * 08/27/24 at 6:25 a.m., . Resident is very agitated and aggressive towards . residents tonight. He pinched another resident on her face, no injuries noted. He ran into the back of another resident's heels, no injuries noted at this time. He is going up to . residents growling at them and calling them '[explicit words].' He is trying to kick . resident. He is blocking people so they can't get by him. Resident followed this nurse into a female resident's room and refused to leave. Tylenol was given and ice cream for a snack. This nurse called the social worker about his behaviors. [Physician] was notified about resident's behaviors and a one time order for Ativan was given. * 08/30/24 at 1:18 p.m., Resident was following female . resident around, hard to redirect, resident removed from common area from other residents . * 08/31/24 at 12:38 a.m., Resident was kicking other resident [sic] wheelchair after supper. Also calling other resident [sic] '[explicit word].' . * 08/31/24 at 2:22 p.m., Resident propelling his wheelchair fast towards other residents and telling them to move. * 08/31/24 at 9:18 p.m., Resident continue to move his wheelchair fast around the dining room. Stops at different residents and calls them '[explicit word]' or says '[explicit word] You.' Also kicked a couple wheelchairs of different residents. * 09/01/24 at 2:03 p.m., Resident propelled quickly towards other residents. CNA . tried to redirect . * 09/04/24 at 6:04 a.m., Resident is going up to residents and saying '[explicit word] You.' Attempts made to redirect . The Behavioral Health Clinic Notes stated the following: * 07/26/24, . one day he was grabbing breasts and arms of female staff . He has been telling other residents that they are pieces of [explicit word] . Staff noted he had been watching the door . it was reported by staff that they have been taking him outside and that he enjoys this. He does say yes to watching the door hoping to go outside. * 08/09/24, . I did speak with staff who reported . one day . he was pretty rude in the evening to staff and other residents but that otherwise he has been doing ok. Staff noted that he does still enjoy going outside and that they noticed improvement in his mood when he is able to go outside. * 08/23/24, . patient [Resident #1] was in his wheelchair in front of the door when I arrived I did have to ask him to move in order to open the door enough to get in. Received a call from the nurses at the nursing home regarding behavior of [Resident #1]. Cornering staff, sexually inappropriate, mean comments and door watching he did just have a dose of Sinemet 25-100 added which can cause increase in sexual attention, this dose was added as well as adding Seroquel 50 mg in the am. Documentation failed to show staff reported Resident #1's intimidating and verbally, physically, and sexually abusive behaviors towards other residents on the unit. During an interview on 09/04/24 at 4:50 p.m., when asked if staff attempted to identify the situational stressors/triggers that lead to Resident #1's aggressive/abusive behaviors towards other residents, a managerial nurse (#2) responded, No. During an interview of 09/04/24 at 5:15 p.m., an administrative staff member (#1) acknowledged staff failed to notify her of Resident #1's behaviors towards female residents, such as grabbing their breasts. The facility failed to assess and monitor patterns and trends of behaviors in an effort to minimize these behaviors, recognize unmet needs, and prevent situations/triggers which may lead to behaviors and verbal, physical, or sexual abuse toward other residents. The facility failed to develop an effective behavior management program, consistently implement purposeful and meaningful activities, such as going outside, in an attempt to manage the behaviors exhibited by Resident #1, evaluate the behavior management program on an on-going basis, and modify interventions as needed. The facility failed to ensure Resident #1 did not infringe upon the rights of others while still allowing him to achieve his highest level of well-being. These failures resulted in verbal, physical, and sexual abuse from Resident #1 towards other residents and residents experiencing fear and anxiety related to Resident #1's abusive behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide appropriate treatment and services to prevent the development of a pressure ulcer for 1 of 5 sampled residents (Resident #68) with pressure ulcers. Failure to implement interventions as ordered, and ensure adequate monitoring/assessment resulted in an avoidable facility acquired pressure ulcer. Findings include: Review of the facility policy titled Skin Management -[NAME] Homes occurred on 08/08/24. This policy revised, December 2022, stated, . Nursing will follow the skin care procedures outlined below to . 2. Maintain the integrity of the resident's skin through monitoring and timely interventional skin care management . 8. Braden Scale will be repeated upon resident changes in condition . The resident's care plan will be updated by the nurse to include goals for prevention and management of pressure injuries with appropriate interventions. The care plan will be reviewed . at change of condition . Appropriate pressure reduction/relief devices: 1. Turn and positioning system 2. Heel protectors, therapeutic boots, or items ordered by provider . Floor nurse will observe wound daily . If dressing is soiled or not intact at any point . the dressing will be replaced . Review of Resident #68's medical record occurred on all days of survey. Diagnoses included end stage renal disease, diabetes mellitus, peripheral vascular disease, a Stage 2 pressure ulcer on the left heel. An admission Minimum Data Set (MDS), dated [DATE], identified moderate to maximum assistance with activities of daily living, dependent for transfers, a Stage 1 pressure ulcer. The current care plan stated, . is at risk for skin break down and for developing a pressure ulcer due to impaired mobility, diabetes, ESRD [end stage renal disease], CHF [congestive heart failure] . will have intact skin, free of redness, blisters, or discoloration . Pressure Ulcer Care/Prevention: Pressure relieving mattress & [and] pressure relieving wheelchair cushion. Notify nurse of new or changes in skin breakdown, redness, blisters, bruises, discoloration. Turn and reposition every 2 to 4 hours and prn [as needed]. Float heels off mattress. refuses to wear prevalon boots [pressure reducing boots] . The care plan failed to include the left heel pressure ulcer. Review of nurse's notes identified the following: * 04/23/24 at 11:20 p.m., . Dressing changed on her toes on both feet, noticed a foul smell with greenish discharge on the old dressing, complained too that her left heel is sore, on assessment they are red, intact, blanchable, applied calmoseptine [skin protectant]. Updated [provider name] by fax about the wound and the left heel. * 05/30/24 at 9:58 a.m., Resident stated to PT [physical therapist], the CNA [certified nurse aide] says 'my left heel is black'. PT removed ace wrap and found that resident has what appears to be a deep tissue injury on the left heel. PT encouraged resident to wear prevalon boots day and night. Resident . she is not doing any standing or walking, and prevalon boots would be better. PT informed nurse of this . PT also suggested perhaps a mepilex [protective dressing] over the left heel. * 07/18/24 at 2:47 p.m., . she is to be NWB [non-weight bearing] on her L [left] foot for fear of wound and bone damage. [Resident] will be a hoyer [full-body mechanical] lift for transfers until her next follow up. Review of podiatry progress notes/consultation form identified the following: * 06/14/24 . This patient is high risk for other potential complications and infections. She needs to continue with offloading to protect her heels from decubitus (injury to skin and underlying tissue resulting from prolonged pressure on the skin) ulcerations. * 07/16/24 . She has decubitus ulceration on the left heel . She apparently is not doing [sic] enough pressure off her left foot . she will need to be protected at the nursing home otherwise she will lose her legs. * 07/16/24 podiatry consult form, . new decub (decubitus) stage 3 . KEEP on Prevalon boots BIL (bilateral) . Review of wound management documentation/Braden Skin Risk Assessments (scale to determine pressure ulcer risk)/Focused Skin Observations identified the following: * 05/05/24 . Focused observation skin - left heel red and sore . * 05/09/24 . Focused observation skin - left heel, red, sore . * 06/07/24 . Braden Skin Risk Score 15 at risk [of developing pressure ulcers]. * 07/16/24 . Wound Location Left heel . Length . 1.3 cm [centimeter] Width . 1.3 cm . * 07/29/24 . Wound Location Left heel . Length . 1 cm Width . 1 cm . * 08/04/24 . Wound Location Left heel . Length . 1 cm Width . 1 cm . Exudate Amount . light . Exudate color and consistency . serosanguinous (pale red to pink, thin and watery [drainage]) . A physician's order dated 07/16/24, stated, Prevalon Boots to bilateral feet @ [at] all times. Daily Betadine [skin disinfectant] and bandages to all wounds. Observations of Resident #68 showed the following: * 08/05/24 at 2:49 p.m., Seated in a recliner in her room with the foot rest elevated and wearing ankle socks, and the Prevalon boots in a chair across the room. * 08/06/24 at 7:56 a.m., Out of facility for dialysis, and the Prevalon boots in a chair in her room. * 08/06/24 at 2:00 p.m. and 4:47 p.m., Seated in a wheelchair in her room, feet on the foot pedals, ankle socks on, and not wearing Prevalon boots. * 08/07/24 at 7:53 a.m., Laying in bed, feet directly on the mattress, and the Prevalon boots in a chair across the room. The resident stated she wore Prevalon boots during the night but takes them off when she wakes up because I just can't function with them. * 08/07/24 at 8:11 a.m., Two certified nurse aides (CNAs) (#25 and #28) transferred the resident from bed to the wheelchair with a full-body mechanical lift. The resident wore no socks or shoes, no dressing to the left heel. The CNAs failed to apply the Prevalon boots to the resident's feet. The resident's bare feet with open wound to the left heel rested directly on the carpeted floor. The CNA (#25) stated the resident doesn't wear the Prevalon boots during the day. The CNA (#25) spoke to the nurse but failed to inform her of the absence of Resident #68's dressing to her left heel. * 08/07/24 at 11:11 a.m. and 2:22 p.m., Seated in the wheelchair in her room with her bare feet directly on the carpeted floor. * 08/07/24 at 2:22 p.m., The nurse (#24) applied a dressing to the ulcer but failed to apply Prevalon boots. During an interview on 08/07/24 at 1:54 p.m., an administrative nurse (#1) stated Resident #68 intermittently refused to wear the Prevalon boots, confirmed he expected staff to document patient refusals of care or treatments, to follow infection control measures during wound care, and to cover open wounds. The facility failed to follow through after the development of a pressure injury to Resident #68's left heel. The facility lacked regular assessments of the size and condition of the wound including care planning interventions to aid in healing. observation showed staff failed to implement the use of preventative devices and document the resident's refusal. Due to the resident's risk factors which can cause a delay in healing and this resident to develop a pressure injury and may cause future complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of Resident #36's medical record occurred on all days of survey. Diagnoses included muscle weakness and difficulty walking. The current care plan stated, . [Resident] is not able to do his own ADL's or activities of daily living due to weakness . Power wheelchair for locomotion. [Resident] is at risk for bleeding and bruising related to blood thinner medication. [Resident] is at risk for falls due to weakness. Edited: 08/05/2024 When going out for an appointment, communicate with transport to only use lift system and not ramp when getting in/out the van. During an interview on 08/05/24 at 12:46 p.m., when asked about the large bruises on right arm, Resident #36 stated, I was coming back from a doctor's appointment and the transportation van had a ramp instead of a lift. The ramp was too steep, and my power wheelchair doesn't have brakes. I started going down too fast, and I tipped over and fell out. The resident indicated bruises on his legs and knees. Review of Resident #36's progress notes showed the following: *07/29/24 at 1:55 p.m. Resident states he was coming down the ramp in his electric scooter, off of the bus after returning from his appointment. Resident states the entire wheelchair tipped over and fell off the ramp. Resident states he hit his head, his right elbow, has a small abrasion, and his right outer calf has a large hematoma. Provider and care giver were notified. *07/29/24 at 11:29 p.m. Resident has bruise on the right elbow due to fall. No new bruise observed, no complain of pain, alert and oriented. *07/30/24 at 8:11 a.m. [Resident] requested PRN [as needed] Tylenol last night for c/o [complaints of] being sore and his right hamstring and leg were hurting him from the fall. He also requested some ice to put on his hamstring. He showed staff all his bruises on his right elbow and sore areas. He slept all night and this morning after 0630 [6:30 a.m.] he said that he was 'very sore' this morning and he was slower because of it. He told staff all about what happened and about using a ramp to get off the bus and how he had no brakes with his electric wheelchair and everything that happened after that. *7/30/24 at 9:36 a.m. Resident alert, no changes noted in mentation. Hematoma [swollen bruise] to R [right] leg appears stable, but tender to the touch. Bruising to R arm also stable. All skin areas are intact. *07/31/24 at 11:58 p.m. Continues on fall monitoring r/t [related to] recent fall with multicolored bruising to right upper arm / elbow and right outer shin. *08/05/24 at 8:14 a.m. Falls committee meeting on 7/30/24. Recommendation: communicate with transport to only use lift system and not ramp when getting in/out [sic] the van. Care plan has been reviewed. No other concerns/issues raised. During an interview on 08/07/24 at 10:00 a.m., two administrative staff mambers (#1 and #11) confirmed Resident #36 fell out of his wheelchair when exiting a transport van, the transport company completed an incident report, and the facility did not complete an incident report or investigation. The facility failed to evaluate the transfer requirements and safety needs of Resident #36 during van transportation. 1. Based on observation, record review, review of facility investigation, and resident and staff interview the facility failed to provide adequate supervision to prevent accidents for 1 of 1 sampled resident (Resident #61) who required surgical intervention for an injury. Failure to provide adequate supervision during a transfer from the shower resulted in Resident #61 experiencing severe pain, a hematoma (collection of blood in a tissue) which required three hospitalizations and surgical intervention, cellulitis (infection of the skin), and increased anxiety and depression. Findings include: Review of the facility reported incident form occurred on 08/05/24. The form, dated 07/25/24, stated, . On 07/16/24 at 5:00 p.m. after [Resident #61's] shower was complete, [certified nurse aide name] [CNA] (#27) went to pull her out in the shower chair and [Resident #61's] left leg hit the shower wall . [Resident #61] immediately complained of pain to the area . Review of Resident #61's medical record occurred on all days of survey. Diagnoses include atrial fibrillation, anemia, long term use of anticoagulants, cellulitis of left lower limb, and contusion of left lower leg. A quarterly Minimum Data Set (MDS), dated [DATE], identified intact cognition, and dependent on staff for shower transfers. Observation on 08/05/24 at 11:33 a.m. showed Resident #61 resting in bed with a wound VAC (vacuum-assisted closure device) to her lower left leg. During an interview at this time, the resident indicated the wound vac is for the injury that occurred when the CNA transferred her from the shower room and hit her leg on the wall. The resident stated her leg immediately started hurting after it hit the wall, the pain continued to get worse. The resident indicated during the week between the injury and her final hospitalization her leg worsened, and it was horrendously painful. She stated she went to the hospital three times, underwent surgery to debride [remove damaged tissue] my leg, and resulted in the need for a the wound vac. She indicated being frustrated with the incident and results because she was progressing in her therapy prior to the injury and now is unable to stand. She stated her blood thinners had been stopped and now every time I feel a flutter or twinge in my, chest I worry about a heart attack or a stroke. Review of nurse's notes identified the following: * 07/16/24 at 5:00 p.m., . The attention of this nurse was called because according to her the resident is in severe pain due to a bump on her lateral lower leg, on assessment noticed a hematoma measuring about 4cm [centimeter] x [by] 4 cm in diameter. Asked what happened and she and the CNA relayed that she bumped her leg on the wall when they were wheeling her out of the shower room. Applied ice, elevated her leg, and gave PRN [as needed] Tyl;enol [sic] [pain relieving medication] 1000 mg [milligram]. After supper around 1800 [6:00 p.m.], she was crying and said she's still in a lot of pain, her hematoma became bigger with the surrounding area red. Paged [provider name] the on call and gave an order to sent [sic] her to the ER [emergency room]. * 07/17/24 at 3:13 a.m., Received resident from EMT [emergency medical technician]; Alert and oriented complaining of Left leg pain; with new Doctor's order for pain. Left leg with ace wrap and swollen with hematoma noted. * 07/17/24 at 3:53 p.m., Resident complained of having pain on the left leg with ace wrap and swollen with hematoma, PRN tab Tramadol [narcotic pain medication] 50mg was given with good effect . * 07/18/24 at 11:34 a.m., I visited with [Resident #61] about the hematoma to her left lower leg. She explained to me that when she was in the shower chair on 7-16-24 the CNA pulled her sideways and her left lower leg hit the corner of the shower wall. [Resident #61] is not able to bend her legs completely. * 07/20/24 at 2:15 p.m., Resident insisted she go to the emergency room today for her left lower leg hematoma. She states was previously at the ER, however, states her condition has changed and hasn't been assessed. I did inform her I spoke with the on-call provider who declined to send the patient to the emergency and recommended that the patient take her pain medication. * 07/20/24 at 10:23 p.m., The NP [nurse practitioner] went to see the resident and measured the swollen left leg with hematoma and still intact at 10X12 cm; ordered to send the resident to E.R. for treatment and further evaluation. After 10 mins [minutes] resident was calling and that she is scarred [sic] that her left left [sic] is draining fluids and dried blood. Resident was sent to E.R. immediately. * 07/24/24 at 3:00 p.m., Resident was brought back to the facility by the ambulance, alert, oriented, responsive, and not in pain. Left leg still swollen and with purplish discoloration, wound kept open and with ace wrap from left ankle to left foot. * 07/26/24 at 1:53 p.m.,. OT [occupational therapist] expressed concern for hematoma to L [left] lower leg is now open and draining . After observing hematoma . contacted NP . * 07/26/24 at 3:19 p.m., . Pt [physical therapist] notified this nurse of open area to posterior Lt [left]leg, stated large amount eschar [dead tissue] to area, looked at wound, hematoma open with a large amount coagulated [clotted] dark blood escaping, call to NP [name], stated she would stop and look at area and speak with resident, remains on antibiotic without adverse reaction. * 07/26/24 at 8:08 p.m., NP [name] came to review the resident and ordered that Resident should be sent to ER for Evaluation of worsening left lower extremity hematoma with necrotic tissue. Resident was taken to ER by EMT at 7pm. * 07/31/24 at 3:30 p.m., Resident was brought back to this facility by ambulance . wound back [sic] intact draining bloody discharge . *08/06/24 at 11:51 p.m., Writer visited with resident on Monday afternoon. She is worried about her bill . She owns a home and wants to be able to return to it. We had a good discussion about how she is holding up mentally. She was hoping to be home by now and now feels like she is starting over. [Resident #61] verbalized being depressed and having a lot on her mind that makes it hard to sleep, she stopped her blood thinner so now whenever she feels something strange, she worries it may be a stroke or heart attack. [Resident #61] said she does not want to die and has no plans to harm herself but feels like she is going to die in here. I asked [Resident #61] if she is interested in speaking to someone and she is, she has an order for a psych consult and is on the list to see the psychiatrist. Review of provider notes identified the following: * 07/16/24 at 9:09 p.m., . presents because of pain and swelling of her left lower leg. She was being brought out of the shower room in a wheelchair when the aide ran her leg into the door frame. She had immediate pain and it began swelling right away . There is a raised 7 x 6 cm x 2 cm raised ecchymotic [bruised] soft/fluctuant [unstable] area on the . left lower leg. she states that after the third dose of morphine [narcotic pain medication] she has finally get [sic] pain relief . * 07/20/24 at 5:00 p.m., . being seen today for evaluation of worsening swelling and pain to left lower extremity. Skin: Measured 12 cm x 10 cm . Surrounding skin appears to have swelling, mild erythema [redness], warmth, and tenderness. Assessment and plan 1. Worsening pain and swelling to LLE [left lower extremity] due to recent trauma. Large intact fluid filled blister with hematoma noted. There is concern for cellulitis - send to ER for evaluation and treatment. * 07/24/24 at 12:00 a.m., . HPI [history of present illness] presented back to the emergency room . with worsening pain swelling and acute drainage from the hematoma. In the emergency room she had a CT scan [computerized tomography] which showed enlarging hematoma measuring 16 cm x 25 cm x 4.7 cm. * 07/26/24 at 5:23 p.m., . evaluated at bedside today for concerns by nursing staff today for worsening left lower extremity hematoma and cellulitis. She was recently sent to the ER and admitted from 7/20/2024 to 7/24/2024 for acute traumatic enlarging left lower extremity hematoma, left lower extremity cellulitis, and acute blood loss anemia [not enough healthy red blood cells to carry oxygen]. She was treated with antibiotics and given blood transfusions. SKIN: large area of necrotic tissue to posterior [back] left lower extremity with large open area and covered with clotted blood. Hematoma measures 25.5 cm x 25 cm. Assessment and plan Hematoma with necrotic skin tissue - There is a concern for developing large necrotic tissue, and worsening cellulitis send to ER for evaluation and treatment. * 07/31/24 at 11:00 a.m., . presented to . hospital 07/26/24 due to large left lower extremity hematoma. Underwent debridement of wound, lower lateral left hematoma 20 cm x 20 cm on 07/28/24 . Wound vac to LLE . wound bed measures approximately 19 cm x 20 cm x 0.3 cm . positive cultures obtained in OR [operating room]. Placed on oral abx [antibiotics] . Review of the facility investigation contained a written statement from the CNA (#27), dated 07/22/24, and stated I, [CNA #27] was giving [Resident #61] a shower on 7/16/24. When we was [sic] finished I had pushed her sideways out the shower door due to her showering in a bari [bariatric] chair, which was a small area, and opening the door at the same time. As I was pushing her out the shower door I didn't realize she had put her leg out & her leg hit the corner of the wall. The facility failed to ensure the CNA (#27) provided a safe transfer for Resident #61 from the shower room which resulted in an injury to the resident's lower leg and lead to a hematoma, increased pain, three hospitalizations, surgical debridement, and placement of a wound vac. 2. Based on observation, record review, review of facility policy, review of manufacturer's instructions, and staff interview, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 2 of 3 sampled residents (Resident #4) observed during a sit-to-stand lift transfer and (Resident #36) observed with bruises. Failure to use a mechanical lift properly and/or re-evaluate the suitability of a mechanical lift transfer, and monitor/ensure safe transfer methods placed Residents #4 and #36 at risk for injury. Findings include: Review of the EZ Way Smart Stand [type of sit-to-stand mechanical lift] 400, 500 & 800 lb [pound] Capacities Operator's Instructions, revised 09/29/23, pages 2-6, stated, . As patients do vary in size, shape, weight and temperament, these conditions must be taken in to [sic] consideration when deciding if the EZ Way Smart Stand is suitable for their needs. Patients should be able to bear some weight, have upper body strength and be able to follow simple commands. Attach harness 1) Position the harness around the upper body of the patient so the sides of the harness are between the patient's torso and arm, resting 2-3 inches below the underarm. 2) For the safety of the patient, securely fasten the safety strap around the patient's torso. 3) Secure the buckle and pull the strap to tighten. Raise the patient . As the patient is being raised, simultaneously tighten the safety strap buckled around their torso. Stop lifting when the patient is in a standing position. Review of the facility policy titled Transporting Resident For Care Outside The Facility occurred on 08/08/24. This policy, revised February 2023, stated . If there is no family available for transport [NAME] Home will provide a transporter [employee that accompanies residents]. Arrangements can be made with [name of transport company for transportation by bus or van with wheelchair lift. If [transport company] is not available, contact Plan Operations and complete a work order . Notify nursing staff on the Unit of transport. Documentation in Nurses' Notes includes the date, time, who is accompanying the resident, the time of their return and any changes noted upon return. The facility failed to provide a policy for transportation via ambulance van. - Review of Resident #4's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, muscle weakness, and repeated falls. The quarterly Minimum Data Set (MDS), dated [DATE], identified moderate cognitive impairment, verbal and other behaviors, functional limitation in range of motion to bilateral lower extremities, dependent with chair-to-bed-to-chair transfers and toilet transfers. The care plan, revised 11/17/23, stated, . Toileting: . Staff assist of 2 and PAL [Portable Aquatic Lift - type of sit-to-stand mechanical lift] to transfer to toilet. Transferring: Assist of 2 and PAL . Resident #4's nurses' notes stated the following: * 01/19/24 at 1:24 p.m., [Resident #4] seen 1/18/24 for re-evaluation for RNP [restorative nursing program]. [Resident #4] requires training with standing and transfers. She is transferring with PAL and 2 staff. Upper body exercises continue as tolerated as well as XBOX [type of workout game]. * 02/26/24 at 1:21 p.m., [Resident #4] was discontinued from the RNP. She will continue to transfer via PAL and 2 staff. Observation on 08/05/24 at 4:56 p.m. showed two certified nurse aides (CNAs) (#6 and #7) transferred Resident #4 with an EZ Way sit-to-stand mechanical lift from the bed to her wheelchair, to the bathroom toilet, and back to her wheelchair. The resident yelled loudly as the CNAs assisted her to sit at the edge of the bed, then placed the lift harness, safety strap, and shin strap, and instructed the resident to hold the handles. As the CNAs (#6 and #7) lifted Resident #4 to a semi-standing position, she yelled loudly as the safety strap slid up her torso, and the CNAs lowered her back to the bed to adjust the safety strap. As the CNAs raised Resident #4 from the bed and encouraged her to stand up straight, her right arm/elbow rose to a nearly horizontal position. The resident whined, moaned, and/or yelled throughout the transfer to the toilet and again while the CNAs raised her from the toilet, provided perineal cares, and changed her brief. Resident #4's right shoulder, upper arm, and elbow rose above a horizontal position and the left arm/elbow nearly to a horizontal position as the CNAs transferred her from the bathroom to her wheelchair. The CNAs (#6 and #7) instructed the resident throughout the transfer to stand up straight as she sagged against the harness and safety strap, with the harness pushing up into her axilla. One CNA (#7) stated Resident #4 is declining with how she stands in the stand lift. Observation on 08/06/24 at 09:08 a.m. showed two CNAs (#8 and #9) transferred Resident #4 from her wheelchair to the bathroom toilet, back to her wheelchair and then to bed. The CNAs placed the EZ Way harness, safety strap (loosely around her torso), and shin strap, then cued the resident to hold the lift handles and stand up straight as she sagged against the harness which pulled up on her axilla. As the CNAs (#8 and #9) raised Resident #4 with the lift, her right arm/elbow moved up and away from her body in a horizontal position, throughout the transfer. Observation on 08/07/24 at 4:41 p.m. showed two CNAs (#6 and #7) applied the EZ Way stand harness, safety strap, and shin strap, while the resident frequently hollered oh boy, ouwwhh. The CNAs cued Resident #4 to hold the lift handles and placed her feet on the foot plate. A CNA (#6) tightened the safety strap as they raised the resident up, and the resident hollered [Explicit word], ouwwhh, do you have to have that so damn tight? Resident #4 failed to bear weight as the CNAs transferred her into the bathroom. During the transfer, the resident's right arm/elbow rose to a horizontal position and her left arm/elbow close to a horizontal position. As the CNAs (#6 and #7) lowered Resident #4 on the toilet, she hollered loudly ouch, that hurts indicating her breast. A CNA (#6) removed the safety strap which had pulled up under her breast. Upon standing the resident from the toilet to provide perineal cares, the CNAs attached the safety strap loosely with the resident's right upper arm/elbow in a horizontal position and the left arm/elbow nearly horizontal. The CNAs failed to tighten the safety strap during the transfer. The CNAs watched the resident's elbows which stuck out and upward, as they exited the bathroom to prevent the resident's elbows from hitting the door frame. When asked about elbow position during transfers, the CNA (#6) stated, I would want my arms down at my sides. A CNA (#7) stated she believed the resident used the stand lift about six months and doesn't feel like she bears her weight in the lift. When asked, a CNA (#6) stated staff should tell the nurse if concerns noted with a transfer, and the nurse would have physical therapy evaluate the use of the lift. During an interview on 08/08/24 at 12:01 p.m., a staff nurse (#20) agreed a resident's arms should not be in a horizontal position during a sit-to-stand mechanical lift transfer. Staff failed to provide safe transfers with the mechanical sit-to-stand lift. The facility failed to monitor Resident #4's upper/lower body strength and appropriate use of the stand lift and failed to periodically monitor and re-evaluate the suitability of the stand lift to meet Resident #4's needs and ensure safe transfers.

Based on record review, review of facility investigation, and review of facility policy, the facility failed to ensure adequate supervision and assistance for 1 of 2 sampled residents (Resident #68) who required staff assistance with transfers and experienced a fall with fracture injury. Findings include: Review of the facility policy titled Fall prevention policy occurred on 08/23/23. This policy, dated May 2022, stated, . residents will be assessed for risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls . provide additional interventions as directed by the resident's assessment . rounding to be performed hourly . ambulation and toileting assistance . the plan of care will be revised and updated as needed . Review of Resident #68's medical record occurred on all days of survey. The care plan at the time of the fall showed Resident #68 transferred and ambulated with the assist of one. Nursing progress notes identified the following: *06/28/2023 at 11:39 p.m., . was on the other other side of the hall, when this nurse heard someone calling 'help' from the other side of the hall, asked one of the CNAs [certified nurse aide] to see where the yell was coming from . found resident lying on her right side on the floor in her room . asked what happened . resident stated she went to get her shirt from her closet and when she was going back to her bed she fell . *06/29/2023 at 01:15 a.m., Resident continuously complaining of severe left shoulder pain after the fall . stated she fell and landed on her left side . On call provider notified with order to send the resident to the ER [emergency room] for evaluation . *06/29/2023 at 6:58 a.m., Resident back to facility at 5:35 a.m. has a fracture on left upper arm . wearing a splint on the affected arm . Physician Progress Notes, dated 07/06/23, stated, . had a fall one week prior and found to have displaced left humeral shaft fracture . having quite a bit of pain . medications for pain . Review of the facility's investigation of the incident identified the following: * . [Resident #68] suffered a fall last night around 11:30 p.m., was sent to the ER, and returned early this morning with a diagnosis of a fractured left upper arm. When the day staff were asking [Resident #68] about her fall this morning, after she woke up, she said she got up alone, to get a shirt out of her closet and fell on her way back to bed. She reported that she asked the CNA [#7] to assist her to get a clean shirt and CNA [#7] told her she didn't need a clean shirt and didn't assist her. That is when [Resident #68] did it herself. She had an accident and wanted her PJ's [pajamas] to match . * The facility investigative team completed the following summary, dated 06/29/23, with a CNA [#7], a witness to the incident. The CNA stated, . [Resident #68] requested to change her shirt so it matched her pajama pants . [CNA #7] admitted saying, 'it is not going to kill you to wear the shirt you have on.' . [CNA #7] said she had to go and left [Resident #68] standing at her dresser. [Resident #68] fell right after [CNA #7] left the room. During an interview on 08/24/23 at 11:43 a.m., an administrative staff (#1) confirmed Resident #68 required the assistance of one staff member for transfers/ambulating and stated she expected staff to follow the care plan. The facility failed to ensure Resident #68 received care and services necessary to attain the highest degree of safety possible during cares to prevent a fall with injury.