**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, Emergency Medical Services (EMS) run report review, hospital record review, Medicolegal Death Investigator email, and interview, the facility failed to protect the residents' right to be free from abuse for 2 of 9 (Resident #1 and Resident #13) sampled residents reviewed for abuse. On 8/21/2025, the medical record of Resident #1, a vulnerable and cognitively impaired resident, revealed a skin assessment that documented a knot (raised area) to the left and right side of Resident's #1's forehead. On 8/28/2025, the medical record revealed Resident #1's right hand was swollen, warm to the touch, and painful. On 8/29/2025, the medical record documented an opened reddened area to the left side of Resident's #1's abdomen and an abrasion to the Resident's neck, which was documented as a large area of injury from the front of the neck to the back of the neck. On 9/8/2025 at 5:08 AM, Resident #1 was transferred to a local hospital for difficulty breathing, diminished irregular lung sounds and elevated blood pressure, with critical vital signs. The Resident was unable to respond to the nurse. Review of the hospital documentation dated 9/8/2025, revealed an Acute Ischemic Stroke (when a blood clot blocks an artery in the brain cutting off blood flow), Acute Hemorrhagic Stroke (when a blood vessel in or near the brain ruptures, causing bleeding in the brain), Basilar Skull Fracture (a break in one of the bones at the base of the skull), Cervical Spine Injury (spinal cord in the neck is damaged), Epidural Hematoma ( blood accumulates in the skull), Hemothorax (blood accumulates between the lung and the chest wall) , Hemorrhage Shock (blood loss to the body's organs), Hollow Viscus Injury (a tear in the wall of a hollow organ in the gastrointestinal tract), Multiple Rib Fracture, Pneumothorax (air leaks into the space between the lungs and chest wall), Spinal Cord Injury, Splenic Laceration (injury/trauma of the spleen), Subarachnoid Hemorrhage (bleeding between the brain and the tissue covering the brain), Subdural Hematoma (a pool of blood between the brain and it's outermost covering). Facility staff failed to assess Resident #1's injuries and facility staff failed to document or investigate how each of the injuries occurred. Medicolegal Death Investigator email provided to the facility revealed Resident #1's time of death was 9/12/2025 at 4:32 AM. The facility failed to provide documentation of an occurrence report for each of Resident #1's injuries. The facility failed to document the Resident's falls. The facility staff failed to report and investigate injuries of unknown origin. Review of the medical record dated 12/27/2024, revealed Resident #13, who was a vulnerable, cognitively impaired resident, had red scratches on his face, a knot and bruising to the right side of his head, and a swollen left hand which resulted in a 5th proximal phalanx (finger bone) fracture. Nursing staff failed to assess Resident #13's injuries and failed to document and investigate how each of the injuries occurred. The facility failed to provide documentation of an assessment, or an occurrence report for Resident #13's injuries. The facility failed to notify the Physician at the time of occurrence. The facility failed to report and investigate injuries of unknown origin. Resident #13 no longer resides in the facility. The facility should ensure residents residing in the facility receive the needed services to prevent neglect, such as injuries of unknown origin, which can cause serious harm, impairment, or death. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to identify, assess, investigate, and report injuries of unknown origin related to Resident #1's and 13's injuries of unknown, placed all residents at risk. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-600 on 9/23/2025 at 4:01 PM, in the Conference Room.An amended template was presented the Administrator on 9/24/2025 at 4:12 PM. The facility was cited IJ at F-600 at a scope and severity of J, which is substandard quality of care. The Immediate Jeopardy for F-600 began on 8/21/2025 and was removed on 9/25/2025. A partial extended survey was conducted from 9/25/2025 - 9/29/2025. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-600 was received on 9/25/2025. The Removal Plan was validated on-site by the surveyor on 9/30/2025 by medical record review, monitoring log review, education record review, and staff interviews. The facility's noncompliance at F-600 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction. The findings include: 1. Review of the facility policy titled, Identifying Types of Abuse, dated 9/2022, revealed .As part of the abuse prevention strategy.employees.are expected to be able to identify the different types of abuse that may occur against residents.Abuse of any kind against residents is strictly prohibited.Abuse prevention includes recognizing and understanding the definitions and types of abuse that can occur.Abuse is defined as the willful infliction of injury.or punishment with resulting physical harm, pain or mental anguish.Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse.Abuse toward a resident can occur as resident- to- resident abuse.staff-to-resident abuse.visitor-to-resident abuse.Physical abuse includes, but is not limited to hitting, slapping, biting, punching or kicking.Corporal (physical) punishment used to control behavior is recognized as a form of abuse.Possible indicators of physical abuse include an injury that is suspicious because the source of the injury is not observed, the extent or location of the injury is unusual, or because of the number of injuries either at a single point in time or over time.Examples of injuries that could indicate physical abuse include, but are not limited to.injuries that are non-accidental or explained.fractures, sprains.scratches, skin tears, and lacerations with or without bleeding, including those that are in locations that would unlikely result from an incident.bruises, including those found in unusual locations such as the head, neck.posterior torso and trunk.facial injuries.facial fractures.bruising.or swelling of mouth or cheeks.Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, pain mental anguish or emotional distress.Neglect includes cases where the facility's indifference to or disregard for resident care, comfort or safety results in (or could have resulted in) physical harm, pain, mental anguish or emotional distress.Neglect may be a pattern of failures or may be the result of one or more failures involving one resident and one staff person. 2. Review of the medical record revealed Resident #1 was admitted on [DATE], with readmission on [DATE], with diagnoses including Paranoid Schizophrenia, Alzheimer's Disease, and Hypertension. Review of the Physician's Order dated 6/4/2025, revealed .Apply landing mat on floor to reduce impact and injury of fall while in bed.Bed in lowest position when in bed to lessen impact of fall. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #1's Brief Interview for Mental Status (BIMS) was 9, indicating Resident #1 was moderately cognitively impaired and had poor short term and long-term memory. Resident #1 required substantial/maximal assistance with toileting, shower/bathing, dressing, and bed mobility.No behaviors were coded during this review period.Resident #1 rarely makes self-understood and rarely understood others during this coded review period. Review of the Care Plan with a goal date of 6/12/2025, revealed .is a risk for falls/injuries r/t [related to] dementia, needs assistance with ADLs [activities of daily living].will be free from injuries related to fall through next review date.BED IN LOWEST POSITION WHEN IN BED TO LESSEN IMPACT OF FALL.LANDING MAT ON FLOOR TO REDUCE IMPACT AND INJURY OF FALL.MAINTAINED CLEAR PATHWAY, FREE OF OBSTACLES/CLUTTERS.ROOM IS CLOSE TO THE STATION TO OBSERVE RESIDENT CLOSELY TO PREVENT FALLS. Review of the Nurse Practitioner (NP) Progress Note dated 8/11/2025, revealed .Resident is awake and alert.no distress noted. However, he has fallen since the last visit. Review of the care plan with a goal date of 8/18/2025, revealed .has a behavior problem r/t crawling onto the floor.The resident will be safe within the facility through the review date.Document behaviors and residents' [resident's] response to interventions.Provide consistent routine care. Review of the medical record revealed no documentation of a fall since the NP last visit of 8/4/2025. The last documented fall for Resident #1 was in May 2025. Review of the medical record SKIN ASSESSMENT (NON-PRESSURE INJURY) dated 8/21/2025, revealed .knot to left and right side of forehead.Face.Other.Knot [raised area] (left & right) . Review of the Nurses Notes dated 8/21/2025, revealed .Resident forehead noted with knot of unknown origin to the left and right side of forehead.DON notified and aware of findings. Review of the Weekly Summary note dated 8/25/2025 revealed .resident continues to place himself on the floor.knot to left and right side of head.aggression both verbal and physical. An addendum was added by the DON to this Weekly Summary dated 9/18/2025 (during the onsite complaint investigation) which revealed .patient continues to have behaviors at least once a day every day of either physical or verbal aggression. patient can be easily redirected by offering food and music to calm him. patient continue [continues] to throw himself down on the floor in his room. mattresses on floor for safety. patient does have a knot on the left and right side of his head due to placing himself on the floor in his room for his behaviors. Review of the medical record SBAR, & INITIAL COC (communication tool that stands for Situation, Background, Assessment, and Recommendation] [and] [change of condition)/ALERT CHARTING & SKILLED DOCUMENTATION electronic form dated 8/28/2025, revealed .Right hand swelling noted with pain as expressed per resident.Not using/moving right hand as he usually does, especially when eating. Review of the medical record SBAR & INITIAL COC/ALERT CHARTING &SKILLED DOCUMENTATION electronic form dated 8/28/2025, revealed .Right hand swelling noted with pain as expressed per resident.Not using/moving right hand as he usually does, especially when eating. Review of the Nurse Practitioner (NP) Progress Notes dated 8/28/2025, revealed .he [Named Resident #1] is noted to have right hand swelling for the past few days.nursing states.no reports of falls or injury.an Xray [medical imaging test to create pictures inside the body] of the right hand will be ordered. Review of the Physician's Order dated 8/28/2025, revealed Hand RT [right] 3V [views].swelling/ [and] pain right hand. Review of Resident #1's Radiology Results dated 8/28/2025, revealed .No gross hand fracture. Review of the SKIN ASSESSMENT (NON-PRESSURE INJURY dated 8/29/2025, revealed .Date of onset 8/28/2025 neck front to back.abrasion.RUQ [right upper quadrant of abdomen] .Resident presents with an abrasion across the back of the neck to the front larynx. Resident has skin tear at RUQ. Review of the NP Progress Note dated 8/29/2025, revealed .nursing staff c/o [complained of] wound to neck.states it started as a skin tear and has progressed. Review of the Physician's order dated 8/29/2025, revealed .Cleanse left side of neck with NS [normal saline], apply mupirocin [topical antibiotic ointment used to treat bacterial skin infections].leave open to air QD [every day] and PRN [as needed].Cleanse RUQ with NS, pat dry, apply iodine [antiseptic] and leave open to air QD and PRN. Review of medical record progress notes dated 9/8/2025, revealed .Upon morning round Nurse was informed by CNA [Certified Nursing Assistant] that resident was breathing weirdly. When assessing resident, he was visually rapid breathing. Vital signs were taken 0443 [at 4:43 AM] as follows: BP [blood pressure] 196/126 HR [heart rate] 120 SpO2 [oxygen saturation of peripheral blood, normal is 95 - 100] 79% [percent] RR [respiratory rate] 30 Temp [temperature] 97.6. Contacted on call Physician [at] 0450 [4:50 AM] and orders were given to place resident on 2L [liters] 02 [oxygen] BNC [binasal cannula] and sent out via 911 [emergency]. Call 911 @0500 [5:00 AM] ambulance arrived @0505 [5:05 AM] to transport resident to [Named] Hospital. Review of Resident #1's [Named Fire Department] run report dated 9/8/2025 4:55 AM, revealed .Altered mental status Primary Symptom: Neuro - Altered mental status.Secondary Impressions: Shortness of breath.Other Symptoms: Shortness of breath.Medical Assessment.Left: Breath Sounds-Decreased; Lung Assessment - Right: Breath Sounds-Decreased; Mental Status Assessment: Combative.Neurological Assessment: Cerebellar Function-Abnormal.Arrived to find [age] male in bed in nursing home. Per staff approx.[approximately] 30 min [minutes] prior to EMS [emergency management services] arrival Pt [patient/Resident #1] was found to be altered. Per staff Pt can normally answer questions with mild confusion. Pt eyes open not responding to questions. Withdraw from pain. Respiration rapid and shallow. Lungs clear on auscultation. SP02 80% on room air. Placed on 02 15 lpm [liters per minute] NRB [non-rebreather mask] and nasal capnography [measures concentration of carbon dioxide in exhaled breath]. Unknow last known well. Unable to complete a stroke screen due to Pt not following commands. Pt moved to cot and secured. Cot to unit. Began transport. C/M [cardiac monitor] applied. 12-lead ECG placement records electrical activity of the heart] obtained and transmitted. BG [blood glucose] tested and IV [intravenous therapy] placed. Report called to ED [emergency department] Sp02 increased with 02, no other changes. Care turned over at ED with report given to ED staff.Summary of Events.dispatched to [age] [year old male] with difficulty breathing and altered mental status change per health care personnel. assumed all pt care and rode into hospital with Pt was secured to stretcher with straps and rails and moved to unit without incident or injury. Pt was transported to [Named local hospital] where nurse signed for pt and report was given, pt was taken to Ct [imaging technique to make images of the body] scan and offloaded in ER [emergency room] . Review of the (Named Hospital) Emergency Department record dated 9/8/2025, revealed Resident #1 arrived the ED at 5:30 AM. Resident #1 had altered mental status, decreased breath sounds, and was .cachectic [condition of physical wasting and muscle loss].ill-appearing.Scrotum [sac of skin and muscles that holds a man's testicles outside of the body] noted to be swollen.Substantial subcutaneous emphysema [rare condition that happens when air gets trapped under the skin, common causes are blunt force trauma, surgery, and infections] appreciated around the patient's neck, anterior chest and proximal lower extremities. Resident #1 was intubated (tube inserted in the trachea for ventilation) in the ED on 9/8/2025 at 6:30 AM and a chest tube was inserted at 7:15 AM for a pneumothorax (collapsed lung). The ED physician documented the following medical conditions, .Bilateral pneumothorax [both lungs collapsed].Closed fracture of manubrium [sternum bone located at the level of the third and fourth thoracic vertebrae].Closed fracture of multiple ribs of both sides.Closed fracture of transverse process of lumbar vertebra [the largest and thickest bones in the lower back].Dissection of cervical artery [tear in the inner layer of an artery in the neck].Laceration of spleen.Midline shift of brain [when the brain tissue moves away from the midline of the skull].Subdural hematoma. The previous diagnoses were each documented as a complicated acute illness or injury that poses a threat to life or bodily functions by the ED physician. The ER physician documented, .Upon my evaluation, this pt had a high probability of clinically significant imminent or life-threatening deterioration due to polytrauma [when a patient has sustained multiple injuries which may cause significant disability and may be life-threatening]. Continued review of the ED record revealed, .M [male] polytrauma w/.aSDH,[a subdural hemorrhage] bilateral pneumothoraces,[pneumothorax in both lungs] deviated trachea [windpipe shifted from the normal position in the center of the chest]. LKW [last known well] yesterday at his nursing home. Unknown mechanism of injury. Hypoxic [inadequate supply of oxygen to tissues and organs] and hypertensive [elevated blood pressure] on arrival. Intubated in ED. Resident #1 was transferred to (Named Hospital) which is a Level 1 trauma center (facility that provides the highest level of care for critically injured patient)] from the ED. Review of the Medicolegal Death Investigator email to the DON dated 9/18/2025, revealed . [Named Resident #1]'s date and time of death are 9/12/2025 at 4:32 AM The cause of death is pending and will be pending until all the investigative work is completed . After Resident #1's death, the following information was documented in the resident's medical record: A SBAR-FALLS electronic form dated 9/23/2025 which documented .Date &Time of FALL: 08/21/2025 00:00 [12:00 AM].location of injury: forehead.Note any injury to the head.Bump.Alert Charting Notes.found to have a knot to the left and right forehead.Date and time Physician was notified 09/23/2025 17:39 [5:39 PM]. A SBAR-FALLS form dated 9/23/2025, for knot on left and right side of head, was completed and documented by the DON,16 days after his discharge from the facility and 34 days after the injury of unknown origin was initially documented in the medical record. A SBAR & INITIAL COC/ALERT CHARTING & SKILLED DOCUMENTATION dated 9/23/2025, revealed .scratches to neck and RUQ [right upper quadrant].Date & Time 08/29/2025 14:25 [2:25 PM].Patient.scratching himself across the neck going from the back of neck extending down/around to the front of his neck, he was also scratching area to RUQ [right upper quadrant] .fingernails were long. A SBAR & INITIAL COC/ALERT CHARTING & SKILLED DOCUMENTATION form dated 9/23/2025 for Resident #1's left side of his stomach open reddened area and an abrasion noted to the Resident's neck, which was documented as a large area of injury from the front of the neck to the back of his neck, was completed and documented by the DON, 16 days after Resident #1 was discharged from the facility and 26 days after the initial occurrence was documented in the medical record. A SBAR-FALLS form dated 9/23/2025, for knot on left and right side of head, was completed and documented by the DON,16 days after his discharge from the facility and 34 days after the injury of unknown origin was initially documented in the medical record. 3. During an interview on 9/11/2025, the Medical Director (MD) was asked when he was notified of Resident #1's injuries. The Medical Director stated The NP was probably notified. The Medical Director was asked if he was aware of Resident #1's injuries from the hospital report on 9/8/2025. The Medical Director stated I'm not sure I have all the details yet. The Medical Director was asked if he would expect the facility to notify him and all State Agencies of injuries of unknown origin. The Medical Director said Yes. The Medical Director was asked if he had been notified of injuries of unknown origin. The Medical Director stated, No, not recently. The Medical Director was asked if he had concerns with the facility's abuse reporting system. The Medical Director stated, I had concerns with the former management team. The Medical Director was asked if the facility's Administrator or DON should identify, report and investigate any form of abuse. The Medical Director stated Yes, that would be my expectations. During an interview on 9/11/2025 at 1:50 PM, Licensed Practical Nurse (LPN) B was asked if Resident #1's condition had changed prior to going to the hospital. LPN B stated .yes, he started pocketing his food a couple of days before he was sent to the hospital, and seemed a little lethargic, with a slight cough. LPN B was asked if Resident #1 had behaviors. LPN B stated Yes, he was resistant to care at times, and we would leave him at the nurse's station in his geri-chair [geriatric chair for limited mobility, for comfort and support] most days, since he would slide out of the chair and roll out of his bed. LPN B was asked if the staff would tell the nurses each time Resident #1 was on the floor. LPN B stated, No, he was care planned to be in the floor. LPN B was asked did the nurses do a head-to-toe assessment each time the resident was on the floor. LPN B stated No, he was allowed on the floor. LPN B was asked if he crawled in other residents' rooms. LPN B stated, Yes, but he was care planned for that. LPN B was asked if the nurses document an occurrence report and start an investigation for resident falls. LPN B stated No, but we will try to do an SBAR for falls. LPN B was asked when Resident #1 had a fall was a SBAR completed. LPN B stated, He is care planned for being in the floor so he wouldn't have one. During an interview on 9/16/2025 at 8:51 AM, LPN A was asked if she completed an occurrence report or an investigation regarding Resident #1's injuries of unknown origin and what was the Knot to left and right side of the resident's forehead. LPN A stated, .[Named Resident #1] had a large, raised area to his left and right forehead that should not be there.there was bluish bruising to the areas . LPN A was asked if she was trained to do an occurrence report or start an investigation when a resident is injured. LPN A stated, No, I wasn't aware to do that, and I did not do an occurrence or investigation, but I did notify the DON. LPN A was asked what the DON said to her after notifying her of the injuries to [Named Resident #1]'s head. LPN A stated, She [DON] just said ‘thank you for notifying me.' LPN A was asked if she completed neuro-checks. LPN A stated, No. LPN A was asked should she have completed neuro-checks. LPN A stated, Yes I should have. LPN A was asked if an injury of unknown origin was considered as an allegation of abuse. LPN A stated, .yes, I suppose so. LPN A was asked if she was asked to write a statement or obtain witness statements from the staff the night the head injury was observed. LPN A stated No. LPN A was asked if Resident #1 could tell her what happened to his head. LPN A stated, .mentally he couldn't explain, he was active, and we had to keep an eye on him.he was a high fall risk.his bed was low to the floor with a floor mat beside his bed, but the floor mat would move away from the side of the bed. LPN A was asked if Resident #1 was on the floor during the night of the occurrence. LPN A stated, .he was in the floor or crawling around almost every night, no one told me when he was in the floor and I didn't ask, but he was care planned for that and he could be in the floor, but as a dignity thing they would just pick him up and put him back to bed.I wasn't told each time he was in the floor. LPN A was asked what her conclusion was of how the injury occurred and if she notified the Physician. LPN A stated, .I cannot answer that question, I did notify the Director of Nursing. LPN A was asked should she have notified the Physician. LPN A stated, Yes. During an interview on 9/16/2025 at 11:45 AM, the DON was asked if an injury of unknown origin for Resident #1 was reported to the State Agencies. The DON stated, No, the [Named Resident #1] did not receive those injuries listed from the hospital report here at this facility. The DON was asked when she was told about Resident #1's injuries and if she started an investigation on that day. The DON stated, I was notified on 9/8/2025. The DON was asked if she started an investigation. The DON stated, No, the injuries didn't occur here. During an interview on 9/18/2025 at 10:45 AM, the Nurse Practitioner (NP) was asked when she was notified Resident #1 had sustained head injuries. The NP stated, I would have to look at my notes.I don't see it documented. The NP was asked would you expect to be notified of a resident's injuries. The NP stated, Yes. The NP was asked when Resident #1 had a fall. The NP stated .I don't recall. The NP was asked if a resident has a fall or is observed on the floor, should that constitute a fall investigation and should the resident be assessed after each fall. The NP stated, Yes. The NP was asked how Resident #1 injured his right hand. The NP stated, I'm not sure.but the Xray was negative for fracture. The NP was asked how he sustained injuries to his neck and abdomen. The NP stated, That's not certain. The NP was asked should these injuries have been investigated. The NP stated, Yes. The NP was asked if bruising was evidenced around his neck. The NP stated, I believe so. There was no documentation in the resident's medical record of a detailed description of Resident #1's neck or abdomen injuries. During an interview on 9/22/2025 at 11:50 AM, the MDS Coordinator was asked if Resident #1 was observed on the floor, would that be considered a fall. MDS Coordinator stated, Yes, it is considered a fall, he had a behavior problem of crawling on the floor, but that wasn't an intervention for a fall. MDS Coordinator was asked how Resident #1 received injuries to the left and right side of his head. MDS Coordinator stated, .I don't remember that. MDS Coordinator was asked if a resident has an injury to the head what should be documented. MDS Coordinator stated, .I would think a skull series. MDS Coordinator was asked what the nurse should document. MDS Coordinator stated, .they should do a head-to-toe assessment and figure out how it happened.if a fall occurred, they should document where it was, how it happened and ask for a witness statements then tell the DON.he [Named Resident #1] had impaired mobility and required staff for transfers and bed mobility. The MDS Coordinator was asked when Resident #1 had his last fall. The MDS Coordinator stated, .[Named Resident #1]'s last falls were in May 2025. His [Named Resident #1] falls occurred 5/10/2025, 5/12/2025, 5/14/2025 and 5/20/2025.there's no documented falls in the medical record since May 2025. The MDS Coordinator was asked what interventions were put into place to prevent falls. The MDS Coordinator stated, .interventions included a landing mat on the floor and for his room to be close to the nurse's station. The MDS Coordinator was asked was his room close to the nurse's station. The MDS Coordinator stated, No, it wasn't.it was at the end of 200 hall. During an interview on 9/22/2025 at 1:40 PM, CNA N was asked if she observed Resident #1's neck wound and RUQ abdomen wound. CNA N stated, .yes, I observed the neck, and it appeared as blue bruising with redness that looked raw, it stretched from one side of his neck to the other side. His stomach injury appeared as a round half dollar size area that was open with white in it like a big pimple with dried blood inside of it. I told my nurse as soon as I found it. CNA N was asked if she knew how it happened. CNA N stated, I was assuming it was a fall.he would crawl from room to room too. CNA N was asked if his fingernails were long. CNA N stated, No, I don't think so, they were okay. CNA N was asked if he had several falls. CNA N stated, No, he was care planned to be on the floor.we would just put him back to bed. CNA N was asked if she told the nurse when he was on the floor. CNA N stated, No not every time, but they [nurses] know he rolls out of bed.he would get between the bed and the air conditioner at times, and we would just pick him up and put him back in bed. CNA N was asked if Resident #1 could say if he was hurt. CNA N stated, Not really. During an interview on 9/22/2025 at 2:23 PM, the Wound Nurse was asked how the injury occurred to the Resident #1's neck and right upper abdomen and asked if she could describe the appearance of the wounds on the day they were assessed. The Wound Nurse stated, .I was told it was from a fall.the neck was worse than an abrasion.it was a big long bruise.looked like a deep tissue injury.it was bruising all around the neck except not on the back of the neck, it appeared as a new blue bruise.they said he had a fall that morning.the resident's right upper quadrant of his abdomen was an open area. The Wound Nurse was asked if either site could have been considered as an injury of unknown origin. The Wound Nurse stated possibly. The Wound Nurse was asked where she documented the description of the injuries. The Wound Nurse stated, I should have charted that. During an interview on 9/22/2025 at 3:45 PM, CNA L was asked about Resident #1‘s behavior the day before he went to the hospital. CNA L stated, .he was up in his Geri chair for a few hours, but we laid him down because he was tired and sleepy. CNA L was asked if he had fallen that day. CNA L stated, Yes, he rolled off the bed between the bed and the air conditioner, the mat would slide away from the bed, he would get on the side of the wall, but he was asleep, so we just put him back in bed. CNA L was asked if she told the nurse. CNA L stated, No, he was care planned for being in the floor. CNA L was asked if Resident#1 acted like he was hurt. CNA L stated, No he was asleep face down when we put him back in bed. CNA L was asked why the nurse wasn't notified. CNA L stated, .they usually just tell us to put him back in the bed. During an interview on 9/23/2025 at 1:55 PM, the DON was asked when Resident #1 was throwing himself in the floor, where was the documentation of an occurrence report or head head-to-toe assessment, documentation the MD was notified, follow up documentation for his behaviors, and the interventions put into place were all documented in the medical record. The DON stated I don't see any documentation of that in his [Resident #1] medical record. The DON was asked if the facility provided adequate monitoring, supervision, adequate assessment and adequate interventions to keep Resident #1 safe in the facility. The DON stated Yes.those type injuries he sustained couldn't have happ