**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, record review, and staff interview it has been determined that the facility failed to ensure that the residents' environment remains as free from accident hazards as possible, for 1 of 1 resident reviewed who sustained a burn from a radiator, Resident ID #1. Findings are as follows: Review of a facility reported complaint submitted to the Rhode Island Department of Health on [DATE] revealed Resident ID #1 was found with half of his/her body out of the bed with his/her legs against the radiator. Further review revealed the resident sustained burns on his/her knees and legs. Review of the Brava Stelpro Electric Baseboard heating system owner's manual revealed in part, Important Instructions .This heater is hot when in use. To avoid burns, do not let bare skin touch hot surfaces . Record review revealed the resident was admitted to the facility in July of 2021 with diagnoses including, but not limited to, dementia, vision loss of the left eye, anxiety, and a history of falling. Additionally, the record reveals that the resident is a centenarian (a person who is between 100 and [AGE] years of age). Review of the Quarterly Minimum Data Set Assessment (MDS) dated [DATE], revealed a Brief Interview for Mental Status Score of 5 out of 15, indicating his/her cognition was severely impaired. Further review revealed the resident is dependent on staff for transfers and suffers from impairments of mobility with his/her upper and lower extremities. Record review of a progress note dated [DATE] at 5:40 AM revealed the resident was found with the bottom half of his/her body by the heating radiator with burns noted to both legs. Record review of a Wound Management Detail Report dated [DATE] revealed the resident sustained the following 3 burns with Partial thickness: redness, blistered, moist, painful: - Left knee measuring 20 centimeters (cm) in length by 16 cm in width - Right knee measuring 25 cm in length by 5 cm in width - Right ankle measuring 1.8 cm in length by 3 cm in width Record review revealed a physician's order dated [DATE] for Silvadene cream 1% (an antibacterial wound ointment typically used on second and third degree burns) to be applied to the wounds twice a day. Further review revealed the following physician's orders dated [DATE]: -Morphine Concentrate (a narcotic used to reduce severe pain) 100 mg/5 ml (milligrams per milliliter), give 0.25 ml orally every 4 hours and premedicate 30 minutes prior to dressing changes and every 1 hour as needed for pain. Record review revealed the resident received the above medication as ordered and several times as needed for severe pain. Record review revealed the resident was admitted to hospice care on [DATE]. Further review revealed the resident had not required the use of morphine for severe pain prior to the incident resulting in multiple burns to his/her lower extremities. Additional review revealed the resident expired at the facility on [DATE]. Surveyor observations of radiators in the facility on [DATE] revealed that they were very hot to touch and were painful if touched for more than a couple of seconds. Temperatures taken of the exposed top portion of the radiators on [DATE] at approximately 10:30 AM in the presence of the Environmental Director and the Administrator, revealed temperature readings of 133.5-153 degrees Fahrenheit. These temperatures were obtained using a laser thermometer provided by the facility. During a surveyor interview on [DATE] at approximately 10:00 AM with the facility's Environmental Director, he revealed that the heat in the facility has worked like this since he has been there, approximately 34 years. Additionally, he revealed that the electric radiators are used to heat most of the facility and resident rooms. During a surveyor interview on [DATE] at approximately 10:30 AM with the Administrator, he was unable to provide evidence of any safety measures in place to prevent residents from being burned by the radiators throughout most of the facility. Additionally, he was unable to provide evidence that the facility ensured the residents' environment remains as free from accident hazards as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined the facility failed to develop and implement a baseline care plan for each resident within 48 hours of a resident's admission, that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 4 of 8 residents reviewed relative to falls, Resident ID #s 243, 244, 433, and 126. Findings are as follows: Record review of a facility policy and procedure titled, Baseline Care Plan dated [DATE] states in part .POLICY: It is the policy of this facility to ensure that baseline care plans are developed and implemented within 48 hours of admission. The care plan is to be person centered and include instructions to provide effective care that meets professional standards of care . PROCEDURE: 4. Once the initial needs have been determined professional standards of care will be utilized to address the identified issues . 6. The base line care plan is to be completed within 48 hours of admission. 7. A summary of the base line care plan will include (but not limited to) .any services being provided to the resident either by the facility or other acting on behalf of the facility . Record review of a facility policy and procedure entitled: Fall Prevention Program dated [DATE] states in part; Policy: It is the policy of this facility to assess all residents upon admission and at least quarterly thereafter for the risk of falling: to establish a care plan that identifies the risk factors exhibited by the resident and which directs staff re: measures to be taken to mitigate or eliminate those risk factors . Procedure: . 2. Whenever a resident has a history of falls and/or scores high on the fall risk assessment, a care plan is to be developed which establishes preventative measures or interventions to be taken to lower or eliminate the risk . 5. All fall prevention interventions are to be added to the resident's care plan or baseline care plan if the comprehensive CP [care plan] is not established yet . During a surveyor interview with the Director of Nursing Services (DNS) on [DATE] at 10:20 AM, she revealed they provide 20 minute safety checks for 24 hours for all residents who are admitted to the facility to monitor the residents activity or behaviors. 1. Record review revealed Resident ID #243 was admitted from the hospital (Hospital A) on [DATE] with diagnoses to include, but are not limited to, falls, syncope (loss of consciousness resulting from insufficient blood flow to the brain; faint), metastatic cancer, and orthostatic hypotension (a sudden drop in blood pressure caused by a change in posture, such as when standing up from sitting or lying down). Additional record review of the hospital record Final Report dated [DATE], under History of Present Illness states in part, .presents to the hospital due to recurrent falls over the last 3 weeks. Estimates that [s/he] .fallen 6 times over this timeframe . Review of the CTA(Computed Tomography Angiography) of the brain during this hospitalization revealed that no significant abnormalities of the brain were present. Review of a Fall Risk assessment dated [DATE] reveals this resident had a score of 12, which indicates that s/he is at high risk for falls. The assessment indicates that the resident had a history of falls, balance problems while standing and required the use of assistive devices (i.e., cane, walker). Review of the Baseline Care Plan dated [DATE] indicates that s/he had a history of falls at home and required the assistance of 1 staff member for transfers, walking, toileting, locomotion, bathing and required the use of an assistive device. Record review revealed that the 20 minute safety checks were completed for 24 hours after admission, however the Baseline Care Plan failed to provide evidence of any additional interventions to prevent this resident from falling. Review of the Nursing Kardex revealed the resident has a primary diagnosis of falls and under precautions it states falls. Record review of the progress notes revealed the following; - [DATE] at 11:56 PM: .with intermittent confusion .is able to ambulate with 1 assist with walker . - [DATE] at 12:27 PM: .vc [verbal cues] to increase BOS [base of support] .unsteady at times .demonstrated confusion .demonstrated poor safety and poor carryover - [DATE] at 12:08 PM: .demonstrates poor safety and poor carryover - [DATE] at 11:31 AM: .Difficulty with following 2 step instructions - [DATE] at 1:16 PM: .intermittent confusion .gait unsteady . Record review of a nursing progress note dated [DATE] documented at 11:41 AM revealed .[resident] had a fall in shower at 10am. CNA [Certified Nursing Assistant] left room to get towels and patient stood up without assist. [S/he] sustained a 2inch superficial laceration to back of head. blood noted on floor .sent to [Emergency Department] for eval [evaluation] via 911 at 1020am . Review a document from the Emergency Department (Hospital A), titled Final Report dated [DATE] revealed the resident presented after a fall with a 3 cm (centimeter) superficial laceration to the back of the resident's head, repaired with staples. Further record review revealed a CT scan was obtained and showed bilateral subarachnoid hemorrhages (bleeding in the space surrounding the brain that can be caused by head trauma) and the resident was transferred to Hospital B, which is the Level 1 trauma center for Southern New England. Review of the Hospital B Discharge summary dated [DATE] revealed that the resident was transferred from Hospital A on [DATE] for neurosurgery evaluation. The record indicates .[resident] had an episode of vomiting and reports photophobia [extreme sensitivity to light]. Repeat CT scan [brain] with increased contusions [bruise] .[resident] was admitted to NCCU [neurological critical care unit] for close Neurological monitoring. On [DATE] [his/her] family opted to transition [him/her] to comfort measures only . Further record review revealed that the resident was discharged to an inpatient hospice facility on [DATE] with a diagnosis of traumatic brain injury, for end of life care, and s/he later expired on [DATE]. During a surveyor interview with Nursing Assistant, Staff A on [DATE] at 1:21 PM, she revealed that she assisted Resident ID #243 with a shower the morning of [DATE]. She indicated that this was the first time she had been assigned to provide care to the resident. She stated that during morning report she was not informed that the resident was at risk for falls. She further revealed that she gave a basin to Resident ID #243's roommate when she saw Resident ID #243 stand up. The NA indicated that the resident wanted to take a shower, so she followed him/her to the shower. She indicated that she assisted him/her with the shower and that after the shower was completed, she needed more towels. She further indicated that she told the resident to sit and wait while she went to get the towels from the linen closet. Staff A further indicated that while she was at the linen closet, she heard a loud bang. When she came back to the room the resident was on the floor of the shower bleeding from his/her head. Additionally, Staff A stated, if I knew [the resident] was at risk for falls, I would not have left [him/her] alone. 2. Record review revealed that Resident ID #244 was admitted to the facility for respite care (provides short term relief for primary caregivers) in July of 2022 with diagnoses which include, but are not limited to, heart failure and muscle weakness. Review of a Fall Risk assessment dated [DATE] revealed the resident had a score of 11, which indicated that s/he was at a high risk for falls. The Fall Risk Assessment also indicated that the resident had intermittent confusion and required the use of an assistive device. Review of the Baseline Care Plan dated [DATE] indicated that s/he was forgetful and had a memory decline in the last 2 weeks. The Baseline Care Plan also indicated that the resident required assistance of 1 staff member for bed mobility, transfers, walking, toileting, locomotion, grooming/hygiene, and bathing. Further record review failed to reveal that the 20 minute safety checks were completed for 24 hours after his/her admission. The record also failed to reveal evidence that the Baseline Care Plan had any interventions relative to fall prevention for this resident. Record review of the nursing progress notes revealed the following: - [DATE] at 10:07 PM: .RESIDENT WAS FOUND ON THE FLOOR, AT ABOUT 730PM, ABRASION LEFT INNER ELBOW . - [DATE] at 2:47 AM: .attempting to get up without calling for help, sliding down out of bed, staff .help to sit .down to the floor . - [DATE] at 11:07 PM: .sent out via rescue to [hospital] at 1040pm .found [resident] on the floor bleeding profusely from posterior head and top of head . Record review revealed a hospital document titled, ED [Emergency Department] Provider Notes, dated [DATE] and [DATE] which revealed that the resident required laceration repair and .remains in severe back pain, requiring multiple rounds of narcotic pain control . Additional record review revealed that the resident was hospitalized until [DATE] until s/he returned to the facility for long term placement, initiation of hospice services and pain management. Additionally, the record revealed that s/he expired on [DATE] at 5:11 PM. 3. Record review revealed that Resident ID #433 was admitted to the facility from the hospital in August of 2022 with a diagnosis to include, but not limited to, status post fall with brain injury. Review of a physician's progress note dated [DATE] revealed that prior to admission to the facility, the resident was found unresponsive at home and sent to the hospital. The note further revealed CT brain scan showed ICH [Intracerebral hemorrhage, when blood suddenly bursts into brain tissue, causing damage to the brain] and SDH [A subdural hemorrhage, bleeding in the area between the brain and the skull]. Review of the Fall Risk assessment dated [DATE] revealed the resident had a score of 10 which indicated s/he is at high risk for falls. The Fall Risk Assessment also indicates the resident has balance problems while standing, decreased muscular coordination, jerking or instability when making turns and requires the use of an assistive device. Record review failed to reveal evidence that the 20 minute safety checks for 24 hours after admission were completed on [DATE] between 7:00 AM and 2:00 PM. Review of the Baseline Care Plan dated [DATE] indicates that s/he has a history of falls with injury and requires the assistance of 1 staff member for bed mobility, transfers, walking, toileting, locomotion, grooming/hygiene and bathing and requires the use of an assistive device. The Baseline Care Plan failed to provide evidence of any interventions to prevent this resident from falls. During a surveyor interview with the DNS on [DATE] at 1:45 PM, she was unable to provide evidence that the Baseline Care Plans included interventions to prevent Resident ID #'s 243, 244, and 433 from falls. 4. Record review revealed that Resident ID #126 was admitted from the hospital in July of 2022 with diagnoses which include, but are not limited to, hip surgery and arthritis. Review of the Fall Risk assessment dated [DATE], revealed the resident had a score of 16 which indicates s/he is at a high risk for falls. The Fall Risk Assessment also indicates the resident has had a history of 1-2 falls in past 3 months, has balance problem while standing, decreased muscular coordination, jerking or instability while making turns and requires the use of an assistive device. Review of the Baseline Care Plan dated [DATE] indicates that s/he has a history of fall related injury (right hip dislocation). The Baseline Care Plan also indicates the resident requires assistance of 1 staff member for bed mobility, transfers, walking, toileting, locomotion, grooming/hygiene, bathing and requires the use of a walker. Record review revealed that the 20 minute safety checks for 24 hours after admission were completed, however the Baseline Care Plan failed to provide evidence of additional interventions to prevent this resident from falling. During a surveyor interview with the DNS on [DATE] at approximately 12:00 PM, she was unable to provide evidence that the Baseline Care Plan included the instructions needed to provide effective and person centered care for Resident ID #126. As a result of the facility's failure to develop and implement a Baseline Care Plan for each resident within 48 hours of the resident's admission, that includes instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care, Resident ID #243 sustained a fall and had a laceration to the back of his/her head with severe brain injury and subsequently expired. Resident ID #244 sustained a fall and had a laceration to the back of his/her head, with severe back pain and subsequently expired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide adequate supervision to prevent accidents for 6 of 11 residents reviewed for falls, Resident ID #'s 243, 244, 431, 233, 482 and 107. Findings are as follows: Record review of a facility policy and procedure titled Safe Resident Handling dated [DATE] states in part; .POLICY: It is the policy of this facility to ensure that our residents are cared for safely, while maintaining a safe work environment for our employees .Direct resident care staff members are to assess all resident handling tasks in advance to determine the safest way to accomplish them. Additionally, mechanical lifting equipment and/or other approved resident handling aids are to be used to prevent manual lifting and handling of residents except when medically contraindicated or in medical emergency . Record review of a community reported complaint sent to The [NAME] Department of Health on [DATE] alleges that Resident ID #243 was sent to the hospital after s/he sustained a fall in the shower after being left unattended. The resident had a large laceration and is receiving care at the Neuro Critical Care Unit. During a surveyor interview on [DATE] at approximately 1:15 PM with Registered Nurse, Staff V she indicated that when giving verbal daily report to the Nursing Assistant's (NA) the nurses utilize the Nursing [NAME], the Safe Patient Handling Assessment and the Treatment Administration Record. Staff V indicated that the nurse should communicate to the NA's the resident's ambulatory, fall risk, continence and skin status. 1. Record review revealed that Resident ID #243 was admitted to the facility in July of 2022 with diagnoses to include, but are not limited to; falls, syncope (loss of consciousness resulting from insufficient blood flow to the brain; faint), metastatic cancer, and orthostatic hypotension (a sudden drop in blood pressure caused by a change in posture, such as when standing up from sitting or lying down). Additional record review of the hospital record Final Report dated [DATE], under History of Present Illness states in part, .presents to the hospital due to recurrent falls over the last 3 weeks. Estimates that [s/he] .fallen 6 times over this timeframe . Review of the CTA (Computed Tomography Angiography) of the brain during this hospitalization revealed that no significant abnormalities of the brain were present. Review of the Fall Risk assessment dated [DATE] revealed the resident had a score of 12, which indicated that s/he is at a high risk for falls. The assessment indicated that the resident had a history of falls, balance problems while standing and required the use of assistive devices (i.e., cane, walker). Record review of a document titled, ASSESSMENT CRITERIA AND CARE PLAN FOR SAFE PATIENT HANDLING AND MOVEMENT revealed that the assessment was incomplete relative to equipment/assistive devices and the number of staff members required for transfers and repositioning. Further record review revealed that the 20-minute safety checks for 24 hours after admission were completed, however the record failed to provide evidence of any further interventions in place to prevent this resident from falls after 24 hours of admission. Review of the documents titled, NURSING [NAME] and the Treatment Administration Records for July and [DATE], failed to reveal evidence of interventions for fall prevention. Record review of the progress notes revealed the following: - [DATE] at 11:56 PM: .intermittent confusion .is able to ambulate with 1 assist with walker . - [DATE] at 12:27 PM: .unsteady at times .demonstrated confusion .demonstrated poor safety and poor carryover. - [DATE] at 2:15 PM: .increased confusion this date .difficulty following commands at times and poor safety . - [DATE] at 11:31 AM: .Difficulty following 2 step instructions. - [DATE] at 1:16 PM: .intermittent confusion .Gait unsteady . Record review of a nursing progress note dated [DATE] at 11:41 AM states in part, Patient had a fall in shower at 10am. CNA [Certified Nursing Assistant] left room to get towels and patient stood up without assist. [S/he] sustained a 2inch superficial laceration to back of head. blood noted on floor .sent to [emergency room, Hospital A] for eval via 911 at 1020am . During a surveyor interview with Nursing Assistant, Staff A on [DATE] at 1:21 PM, she revealed that she assisted Resident ID #243 with a shower the morning of [DATE]. She indicated that this was the first time she had been assigned to provide care to the resident. She stated that during morning report she was not informed that the resident was at risk for falls. She further revealed that she gave a basin to Resident ID #243's roommate when she saw Resident ID #243 stand up. The NA indicated that the resident wanted to take a shower, so she followed him/her to the shower. She indicated that she assisted him/her with the shower and that after the shower was completed, she needed more towels. She further indicated that she told the resident to sit and wait while she went to get the towels from the linen closet. Staff A further indicated that while she was at the linen closet, she heard a loud bang. When she came back to the room the resident was on the floor of the shower bleeding from his/her head. Additionally, Staff A stated, if I knew [the resident] was at risk for falls, I would not have left [him/her] alone. During a surveyor interview with Licensed Practical Nurse, Staff I on [DATE] at 10:07 AM, she revealed that she was the nurse on the unit the day of Resident ID #243's fall. She indicated that when she entered the room the resident was on the floor bleeding from a laceration to the back of his/her head. It appeared to Staff I that the resident stood up and fell. She indicated that there was a radiator in the bathroom in close proximity to the shower that had blood on it. She indicated she assessed the resident and sent him/her out to the hospital via rescue. She further revealed the resident was admitted to the facility with change of mental status, syncope and falls. She stated, [s/he] fell 6 times at home and 1 time at the hospital. Additionally, Staff I indicated the resident's family informed her of safety concerns at home relative to the resident's poor safety decisions. She also revealed that the resident would call for assist at times and other times would not and that s/he had an unsteady gait. Review of the Emergency Physician's Final Report (Hospital A) following the resident's fall on the morning of [DATE] revealed the resident presented after a fall with a 3 cm (centimeter) superficial laceration to the back of the resident's head and that was repaired with staples. Further record review revealed a head CT scan was obtained and showed bilateral subarachnoid hemorrhages (a life-threatening stroke caused by bleeding in the space surrounding the brain that can be caused by head trauma) and the resident was transferred to Hospital B, a level one trauma center for Southern New England. Review of the Hospital B Discharge summary dated [DATE] revealed that the resident was transferred from Hospital A on [DATE] for a neurosurgery evaluation. The record revealed a discharge summary which states in part, .[resident] had an episode of vomiting and reports photophobia. Repeat CT scan with increased contusions .[resident] was admitted to NCCU [Neurological Critical Care Unit] for close Neurological monitoring. On [DATE] [his/her] family opted to transition [him/her] to comfort measures only . Further record review of the above-mentioned discharge summary revealed that the resident's discharge diagnoses included but we not limited to; traumatic brain injury, cerebral hemorrhage (bleeding within the brain), cerebral edema (brain swelling), and compression of the brain. The resident was discharged from Hospital B to an inpatient hospice facility on [DATE] for end-of-life care where s/he later expired on [DATE]. During a surveyor interview with the Director of Nursing (DNS) on [DATE] at 1:45 PM, she was unable to provide evidence that the facility communicated the resident's daily needs to the NA and that Resident ID #243 was not provided with adequate supervision to prevent a fall. As a result of the facility's failure to communicate Resident ID #243's daily needs to the NA's s/he failed to have adequate supervision while in the shower sustaining a laceration to the back of his/her head with severe brain injury and subsequently expired. 2. Record review revealed that Resident ID #244 was admitted to the facility for respite care (a form of short-term substitute care that provides temporary relief for caregivers) in July of 2022 with diagnoses to include but are not limited to, heart failure, atrial fibrillation (irregular or quivering heartbeat), and hypertension. Review of the Fall Risk assessment dated [DATE] revealed the resident had a score of 11, which indicates a high risk for falls. The assessment indicates that the resident had intermittent confusion and required the use of an assistive device. Review of a Baseline Care Plan dated [DATE] indicated s/he had a history of falls and required the assistance of 1 staff member for bed mobility, transfers, walking and toileting. Additionally, the Baseline Care Plan revealed that the resident was forgetful and had a memory decline over the last two weeks. Additional record review failed to reveal evidence that a Safe Patient Handling Assessment or that the 20-minute safety checks for 24 hours after admission were completed. Record review failed to reveal evidence that a Nursing [NAME] existed for this resident prior to [DATE]. Review of the nursing progress notes revealed the following: - [DATE] at 10:07 PM: .RESIDENT WAS FOUND ON THE FLOOR .ABRASION LEFT INNER ELBOW . - [DATE] at 2:47 AM: .attempting to get up without calling for help, sliding down out of bed .help to sit [him/her] down to the floor . - [DATE] at 11:07 PM: .sent out via rescue to [hospital] at 1040pm .had an unwitnessed fall in bedroom .found [resident] on the floor bleeding profusely from posterior head and top of head .laceration . Record review revealed a hospital document titled ED [Emergency Department] Provider Notes, dated [DATE] and [DATE] which revealed that the resident required laceration repair and remains in severe back pain, requiring multiple rounds of narcotic pain control . Additional record review revealed that the resident returned to the facility on [DATE] for long term placement, hospice services and pain management. Additionally, the record revealed that s/he expired on [DATE] at 5:11 PM. During a surveyor interview with the DNS on [DATE] at 1:45 PM, she was unable to provide evidence that Resident ID #244 was provided with adequate supervision to prevent a fall. 3. Record review for Resident ID #431 revealed that s/he was admitted to the facility in July of 2022 with diagnoses to include but are not limited to, cognitive impairment, insomnia, and cerebral infarction (stroke). Review of a Falls Risk Assessment completed [DATE] revealed the resident had a score of 16 indicating s/he was a high risk for falls. The assessment indicates the resident has intermittent confusion, balance problems while walking and requires the use of an assistive device. Additional record review revealed that the Safe Patient Handling Assessment was not completed. Although the resident had a history of falls and scored high on the Fall Risk Assessment, record review failed to reveal evidence that interventions were developed as preventative measures taken to lower or eliminate the risk of falling for this resident. During a surveyor interview with the DNS on [DATE] at approximately 2:54 PM, she was unable to provide evidence of interventions in place to prevent this resident from falls. 4. Record review of a facility document titled Assessment/Algorithm Document, revised on [DATE], states in part Algorithm 1: Transfer to and From: Bed to Chair .During any patient transferring task, if any caregiver is required to lift more than 35 lbs. [pounds] of a patient's weight, then the patient should be considered to be fully dependent and assistive devices should be used for the transfer. Record review for Resident ID #233 revealed that s/he was an emergency admission to shelter in place. S/he was admitted in July of 2022 with diagnoses to include, but are not limited to, dementia, seizures, and cancer (breast, bladder and kidney). Record review of the admission assessment dated [DATE] revealed that the resident's weight was 133.6 pounds. Record review of the Fall Risk Assessment completed [DATE] revealed the resident had a score of 17 which indicates s/he is at high risk for falls. Additionally, the assessment indicates the resident is disoriented times three at all times, has decreased muscular coordination, and had two or more falls in the past three months. Review of a nursing progress note dated [DATE] at 11:54 AM states in part, spoke with .nurse from .hospice regarding resident ambulation and transfer status stated resident has not ambulated in approx 2 months assist of 2 transfers. Further record review failed to reveal evidence that the Safe Patient Handling Assessment or 20 minute safety checks for 24 hours after admission were completed. During a surveyor observation on [DATE] at 9:54 AM revealed Registered Nurse Staff J and NA, Staff K, transfer Resident ID #233 from bed to chair. The staff members were observed lifting the resident from the bed to the chair while holding the resident under his/her arms while simultaneously pulling the resident by the back of his/her pants. Additionally, the observation revealed that the resident was unable to bear weight and staff did not utilize a gait belt or mechanical device during the transfer. During a surveyor interview with the Physical Therapist, Staff L, on [DATE] at 10:51 AM, he revealed that a gait belt should be used if a resident requires minimum or maximum assistance of one to two staff members and is able to bear weight. Additionally, he revealed that a mechanical device should be used if staff are required to lift greater than 30 pounds during a transfer. During a surveyor interview with the DNS on [DATE] at 11:03 AM, she revealed that she was unaware that Resident ID #233 was unable to bear weight. She further revealed that the resident was assessed in the afternoon on [DATE] and it was decided at that time a mechanical device should be used for the resident for all transfers. Additionally, she revealed that staff are expected to use a gait belt for residents who require assistance with transfers. During a surveyor interview with Staff J on [DATE] at 11:35 AM, she acknowledged that the gait belt should have been used during the resident's transfer on [DATE] in the morning. During a surveyor interview with Staff K on [DATE] at 11:40 AM, she revealed that she has been taking care of the resident since his/her admission to the facility. Additionally, she revealed the resident has been transferring in and out of bed with the assistance of two staff members and and no gait belt is being used. 5. Record review for Resident ID #482 revealed that s/he was an emergency admission to shelter in place. S/he was admitted in July of 2022 with diagnoses to include, but are not limited to, diagnoses which include, but are not limited to, Alzheimer's disease, and CVA (stroke). Review of the Fall Risk Assessment completed on [DATE] revealed the resident had a score of 19 which indicates the resident is at high risk for falls. The assessment further indicates the resident has intermittent confusion, balance problem while standing, decreased muscular coordination and requires the use of an assistive device. Review of the progress notes revealed the following: - [DATE] at 5:08 PM: .found on [his/her] back .on the floor . - [DATE] at 4:33 AM: .found .lying on the ground with brief on and blanket over [him/her] . - [DATE] at 5:04 AM .calling out on and off . - [DATE] at 10:58 AM: .had unwitnessed fall in [his/her] room .small scratch on [his/her] back . Although the resident had a history of falls and scored high on the Fall Risk Assessment, record review failed to reveal evidence that interventions were implemented as preventative measures taken to lower or eliminate the risk of falling prior to the resident's falls on [DATE], [DATE] and [DATE]. During a surveyor interview with the DNS on [DATE] at 11:15 AM, she was unable to provide evidence that Resident ID #243 was provided with adequate supervision to prevent a fall. 6. Record review for Resident ID #107 revealed that s/he was admitted from the hospital in July of 2022 with diagnoses which include but are not limited to, abdominal pain, urinary tract infection, and right ankle surgery. Review of the Fall Risk Assessment completed [DATE] revealed the resident had a score of 12 which indicates high risk for falls. The assessment further indicated the resident had intermittent confusion, balance problems while standing and required the use of an assistive device. Review of the Baseline Careplan revealed the resident had history of falls, diagnosis of hallucinations and delirium in the hospital. Additionally, the Baseline Careplan revealed the resident required assistance of 2 staff members for bed mobility, total dependence for transfers and locomotion. Review of the progress notes revealed the following: - [DATE] at 3:47 AM: .calling out .found .legs out of bed leaning right . During a surveyor interview with the DNS on [DATE] at 11:15 AM, revealed she was unable to provide evidence that interventions were implemented to prevent the resident from falls. Although the resident had a history of falls and scored high on the Fall Risk Assessment, record review failed to reveal that interventions were developed as preventative measures taken to lower or eliminate the risk of falling for this resident.