**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #40) reviewed for accidents. The transportation driver failed to ensure Resident #40 was safely transferred onto the transportation van on 06/21/24 when he was picked up for dialysis. The resident sprained his foot when it got caught in the van gap where the ramp met the van. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life. Findings included: Record review of Resident #40's MDS, dated [DATE], reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included end stage renal disease (kidney failure), diabetes, osteoporosis, stroke, and seizure disorder. The MDS further Resident #40 had a BIMS of 14, which indicated his cognition was intact. Resident #40 used a manual wheelchair. Record review of Resident #40's care plan, dated 08/29/23, reflected he had osteoporosis and interventions included to protect the resident from injury avoiding sudden bumps, jarring with transfers. The care plan further reflected Resident #40 attended dialysis Mondays, Wednesdays, and Fridays. Record review of Resident #40's progress note, dated 06/21/24, documented by LVN A, reflected the following: Notified by 1st floor nurse that resident had an incident getting onto the transportation bus. This nurse went down to the 1st floor to assess the resident noted resident sitting in wheelchair, leaned over holding onto right foot, when assessed the right foot noted swelling to the right ankle, very sensitive to touch, able to wiggle toes and pedal pulse 3+. Took resident to his room, assisted him to bed, resident cannot bare weight on right foot .Resident stated 'driver of the van was pushing me onto the ramp but had to push me a little fast because there's a little bump to get over on the ramp when my foot got caught in the ramp and pushed my foot all the way back.' MD notified ordered STAT x-ray to right foot .Asked resident pain level from 0-10 resident stated a 10, administered Acetaminophen-Codeine Tablet 300-30MG per resident request for pain. Record review of radiology results, dated 06/21/24, reflected there were no fractures and no new orders given. Record review of the Transportation Company's Accident/Incident Report Form, dated 06/21/24, reflected the following: .Incident Information Incident Description [Resident #40] right ankle was injured while being rolled into the rear ramp of the wheelchair van by driver, [Driver]. As [Resident #40] crested the top of the ramp to enter the van, his right foot was not high enough, which caused his foot to roll under the leg. Driver took [Resident #40] back into the facility for examination by a nurse to determine the severity of his injury. Observation and interview with Resident #40 on 06/25/24 at 11:23 AM revealed when he was picked up for dialysis last Friday, 06/21/24, the transportation driver pushed him into the transportation van too fast and his foot got caught where the lift and the van connected. The resident said he immediately felt pain because it sprained his ankle. The facility ordered x-rays to ensure it was not broken due to the swelling. Observation of Resident #40's ankle revealed there was some swelling but there was no bruising noted at the time, but there was a pain patch on his ankle. The resident said he got some pain relief with the pain medications and pain patch. Resident #40 said the same transportation driver took him to dialysis on Monday, 06/24/24. Interview on 06/26/24 at 4:04 PM with LVN B revealed the transportation van had arrived to pick up Resident #40 to take him to dialysis on, 06/21/24, and they were loading the resident into the van. Shortly after, the transportation driver brought Resident #40 back into the facility and said as he was pushing the resident into the van, his foot had gotten caught and twisted up on the ramp and Resident #40 had immediately expressed pain. LVN B said she looked at the resident's ankle and noticed swelling on the outer side so she called to let his nurse, LVN A, know what had occurred. Interview on 06/26/24 at 2:51 PM with LVN A revealed she got a call from LVN B on, 06/21/24, and said Resident #40 had hurt his ankle when the transportation driver was pushing him up the ramp into the van. When she was downstairs she asked the resident what had occurred and he said the transportation had pushed him faster to get onto the van, causing his foot to get stuck in the gap where the ramp meets the van and his foot had bent back. LVN A said she assessed the resident's ankle and noted swelling around it. Resident #40 told LVN A he was having pain to his ankle and he was medicated and they ordered x-rays to ensure it was not fractured. Interview with the DON on 06/26/24 at 3:20 PM revealed she was told about Resident #40's incident and they had called the doctor for x-rays to ensure his ankle was not broken. The DON stated she called the transportation company to find out what happened but said she had not heard back but would be calling them again for a statement. Record review of the facility's policy titled Transportation to and from an off-site certified dialysis facility revised November 2017 reflected the following: POLICY: It is the policy of this facility to assist residents in arranging transportation to/from an off-site dialysis facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to the ensure the resident received assistance devices to prevent accidents and the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance for 2 of 5 Residents (Resident #1 & Resident #2) whose records were reviewed for falls. 1. Resident #1 had 4 falls within 24 hours upon admission related to nursing staff not providing Resident #1's fall history through report, lack of staffing and staff not initiating appropriate safety interventions to keep Resident #1 as safe as possible. As a result, he sustained multiple fractures. 2. Resident #2 had a history of falling out of his wheelchair. Nursing staff failed to ensure his wheelchair was in the locked position and placed away from his bed to prevent further falls. These deficient practices could affect any resident and potentially contributed to avoidable falls and injuries. The findings were: 1. Review of Resident #1's face sheet, dated 1/19/23, revealed he was admitted to the facility on [DATE] with diagnoses including unspecified Dementia and Chronic Systolic (congestive) Heart Failure. Review of Resident #1's admission assessment, dated 12/30/22 at 3:49 PM, revealed Resident #1 was alert 1-2, understood had memory loss which caused agitation and impulsiveness, complained of dizziness in past 3 days, wore glasses, had moderate hearing impairment, no use of assuasive device noted, history of falls, unable to determine weight bearing limitations and it was noted he had limited range of motion on both legs and feet. Further review revealed LVN F completed the assessment. Review of Resident #1's 5-day MDS, dated [DATE], revealed he had vision impairment; his BIMS was 00 (out of 15) indicative of severe cognitive impairment; he exhibited inattention and disorganized thinking; transfers only happened once or twice by 1 person; he was not steady moving from seated to standing position, moving off and on the toilet and surface to surface transfer; he used a wheelchair for mobility; was incontinent of urine; he had a fall in the last month, 2-6 months, fracture related to a fall in the last 6 months prior to admission and he had a fall since admission; he had one fall with no injury and one fall with a major injury. Review of Resident #1's 48-hour Care Plan, dated 12/30/22, revealed he was a risk for falls related to history of falls, generalized weakness, poor safety awareness and impulsiveness and the intervention implemented was to keep needed items water, etc., in reach. Review of Resident #1's incident log revealed he had a fall on 12/30/22 at 19:51 (7:51 PM), at 12/31/22 at 0:00 (!2 PM) and on 12/31/22 at 10:03 AM. Review of incident report for Resident #1, dated 12/30/22 at 7:51 PM revealed, This writer was called due to roommate hollering. Upon entering the room resident was one foot away from mattress, head pointed towards the wall and feet over by the privacy curtain and laying on the floor on stomach but favoring the right side. Right arm was folded under the resident. Resident still has red slip grip socks from hospital and the roommates bedside table was pulled away from the wall and the small refrigerator was knocked over on the floor. This writer and CNA attempted to assist the resident up but stated that he wanted a moment to lay on the floor because he was in a great deal of pain. Does attempt to explain what he was trying to do but gets lost in thought and cannot recall the right words so he stops explaining and sighs heavily. Immediate action taken: Resident stood himself up and walked himself back to bed and laid down, covered himself and keeps saying, there was something I was going to do. Injury Type: Unable to Determine. Injury Location: Right hand palm. Level of pain based on observing the resident was a 5. Mental Status: Oriented to Person. Notes: Resident has history of falls due to impulsivity. Further review revealed LVN F completed this report. Review of Resident #1's order summary for December 2022 revealed an order dated 12/30/22 for an x-ray to the right shoulder and right hand due to fall and complaint to pain one time only until 12/31/22. Review of an X-ray report for Resident #1, dated 12/30/22, revealed no acute fracture or dislocation of right shoulder and no acute fracture or dislocation of right hand. Interview on 1/19/23 at 11:30 AM with Resident #1's RP revealed she was not happy with the fact Resident #1 fell within 2 hours upon admission and then fell again later. She stated Resident #1 had a history of falling at home because he could not walk on his own and he had severe Dementia. She stated she let nursing staff know about his history of falling. The RP stated she did not believe they took care of him the way he needed. Furthermore, she did not believe he would be safe if he returned to the facility so she secured alternative placement. Interview on 1/19/23 at 1:15 PM with LVN F revealed she admitted Resident #1 on a Friday and no one was with him upon admission from the hospital. He did not have any visitors. A family member called about a visit and she let him know Resident #1's roommate went to bed early and told the son if he visited it would have to be a quick visit or he could visit early next morning. LVN F stated Resident #1 had a communication deficit (lack of expressive language) and would get agitated. She stated the bed was in the lowest position and the urinal was at bedside within reach. She demonstrated how to use the call light; had it pinned to his gown and provided the bed remote. LVN F stated Resident #1 was a 2 person assist and not able bare weight; he could not stand for long without his knees buckling. She stated Resident #1 was thin but tall. He could follow commands and seemed to understand. LVN F stated Resident #1 fell within 2 hours after admission before dinnertime. She had put him to bed about 2 hours prior to the fall and he was talking on the phone. LVN F stated Assistant MS saw Resident #1 on the floor and told her. LVN F stated she talked with Resident #1's RP about the fall and she stated Resident #1 had fallen at home. LVN F stated Resident #1 was sleeping by the time she left at 10 PM. She stated Resident #1 requested that she leave the overhead light on. LVN F stated she asked the MS about fall mats and he told her she could find them in central supply. She stated she did not implement fall mats. Interview on 1/19/23 at 2:13 PM with CNA G revealed she was on duty on 12/30/22 from 2 PM to 10 PM when Resident #1 fell. She stated LVN F told her he was a fall risk. She stated fall protocol usually required the use of a low bed in the lowest position, fall mat, call within reach and more frequent visual checks. She stated she was not sure if the bed was in the lowest position and there was not a fall mat in place. She stated the call light was clipped to Resident #1's gown ad he had 2 urinals by the bedside. CNA B stated Resident #1 got up twice during the shift and did not seem to understand what he was doing. She stated the first time she caught Resident #1 up and she put him back to bed. CNA G stated she thought Resident #1 fell after dinner between 6 PM to 7 PM and had checked on him about an hour before he fell. Resident #1 was found on the floor and he did not say how he fell. He seemed confused. She stated she alerted LVN F who came right away. CNA G stated she thought Resident #1 sustained an injury but could not remember what type of injury. Interview on 1/19/23 at 2:35 PM with LVN F revealed she did not get a fall mat from central supply and did not have the CNA get a fall mat because they were the only ones on duty. She stated she did not implement a fall mat. She stated typically there were 2 aides on duty but was not sure if someone called in or what happened. She stated there were three or four other residents who were a fall risk so it made it difficult for her and the 1 aide to complete tasks and do as many visual checks as required on the residents who were a fall risk. Interview on 1/19/23 at 6:10 PM with LVN F revealed she did not know Resident #1 was a fall risk until he fell. She stated she knew she would be getting a new admission but nursing staff including the AM nurse did not provide any descriptive information about Resident #1. She stated the hospital nurse also did not tell her in report that Resident #1 was a fall risk. She clarified that she asked the MS about the mats to ensure they were available as needed. She stated she did not know enough about Resident #1 to determine whether the use of a fall mat was beneficial or a safety hazard. LVN F confirmed Resident #1 was not able to bare weight and was unsteady on his feet. However, stated he continued to try and walk on his own and was concerned a mat would be more of a safety hazard. LVN F further stated that she believed Resident #1 was going to fall no matter what because he was so unsteady on his feet and could not bare weight for long. Review of incident report for Resident #1, dated 12/31/22 at 0:00 (12 PM) revealed CNA found resident sitting on floor. Immediate action taken: Assessed had small abrasion to forehead. Cleansed with normal saline and pat dried. Bleeding stopped. Vital signs 103/66, 76, 18, 98.2, 97 RM air, Assisted back to bed. Neuros started again. Mental Status: Oriented to Person. Further review revealed the family representative, the resident physician and DON were notified of the incident. Further review revealed LVN D completed this report. Review of Fall Risk Evaluation dated 12/31/22 0:00 (12 PM) revealed Resident #1 was a high risk for falls with a score of 18. He was noted to be disoriented x 2, had poor vision with or without glasses, history of 3 or more falls in the past 3 months and he had balance problems while standing/walking. Review of incident reports for Resident #1 did not reveal an incident report dated 12/31/22 at 2:05 AM. Review of Fall Risk Evaluation dated 12/31/22 2:05 AM revealed Resident #1 was a high risk for falls with a score of 18. He was noted to be disoriented x 2, had poor vision with or without glasses, history of 3 or more falls in the past 3 months, he had balance problems while standing/walking and requires use of assistive devices (i.e., cane, walker or wheelchair). Review of incident report for Resident #1, dated 12/31/22 at 4:30 AM revealed Resident #1's roommate came yelling down hall that resident was on his side and going to fall again. Resident observed holding onto wheelchair very unsteady gait. 'I immediately ran to his side. Resident stated, hurry up get me to bed. Immediate action taken: Resident had to be eased to sitting position too heavy to try continuing to walk to bed as he was not following direction, please slow down and let go of wheelchair. Abrasion to back observed/scratch. Has swelling to head in between eyebrows. Redness to right hip observed. Injury Type: Abrasion. Injury Location: scapula. Mental Status: Oriented to Person. Notes: Abrasion noted to right hip and abrasion to upper back/scratch, swelling now in between eyebrows. NP notified, requested X-RAY to head and Right hip. Further review revealed the family representative, the resident physician and DON were notified of the incident. Further review revealed LVN D completed this report. Review of Fall Risk Evaluation dated 12/31/22 4:30 AM revealed Resident #1 was a high risk for falls with a score of 15. He was noted to be disoriented x 3, had adequate vision, history of 3 or more falls in the past 3 months and he had balance problems while standing/walking. Review of Resident #1's order summary for December 2022 revealed an order dated 12/31/22 for STAT X-RAY to right hand, digits, wrist and forearm. Review of an X-ray report for Resident #1, dated 12/31/22, revealed acute fracture of distal radius of the right forearm; acute fracture of distal radius of the right wrist and of the 5th digit at the PIP joint. Review of hospital transfer form dated 12/31/22 revealed Resident #1 was transferred to the hospital at 2:44 PM. Interview on 1/20/23 at 8:10 AM with LVN D revealed she worked at the overnight shift and worked on 12/30/22 and 12/31/22. She stated Resident #1 was extremely confused, impulsive and did not retain instruction. She stated Resident #1 was difficult to redirect based on impulsiveness. He also seemed anxious and she suspected it was because he was in a new environment. LVN D stated Resident #1 had his first fall during her shift around midnight. She stated the CNA on duty reported Resident #1 was sitting next to his bed. She assessed Resident #1, started neurochecks and transferred him back into bed. LVN D stated the bed was in the lowest position and she educated Resident #1 about using the call light to ask for assistance. She encouraged Resident #1 to allow them to help him so he would not fall. LVN D stated she changed Resident #1 and continued to encourage him to use the call light before getting up. She stated later on in the shift the roommate came out into the hallway yelling that Resident #1 was up and was going to fall. She ran to the room and saw Resident #1 using the roommate's wheelchair to ambulate. He was walking towards his bed but was extremely wobbly. LVN D stated she walked up beside Resident #1 and held on to his arm. He was clinching on to the wheelchair and she attempted to lock the wheelchair cut could not reach to secure the lock. LVN D stated it was not a good situation and was afraid they were both going to fall. She was able to get Resident #1 to release the wheelchair and she eased him down to the floor. The roommate reported that Resident #1 darted up from the bed and fell trying to get to the restroom and hit his head prior to her entering the room. LVN D stated upon assessment she noted redness to his right hip and ordered x-rays. She passed on the events that took place during her shift, in report, to the morning nurse, LVN E LVN D stated she notified the RP about the falls and she stated he fell at the hospital. The RP said Resident #1 had really bad Dementia. LVN D stated Resident #1 required 1 on 1 supervision and was probably a good candidate for a memory care unit. LVN D stated LVN F told her in report she did not use a fall mat because it would be a tripping hazard. She stated based on her experience with Resident #1 the one night she believed he was going to fall no matter what. She also thought a fall mat would probably have been more of a safety/trip hazard because he was on a mission to get up and go. Although, she stated it might have cushioned his fall. LVN D stated she talked with the ADON and DON both and they did not instruct her to implement any other interventions than were already in place: bed to the lowest position, clipped the call light to his gown, continue to instruct to use it and increase visual checks. Interview on 1/20/23 at 9:21 AM with the ADM revealed the Admissions Coordinator would round on the residents in the hospital and get as much information as possible prior to admission. He stated it became obvious very quickly that they were not going to be able to meet his needs in the facility due to Resident #1's impulsivity and not following directives. Interview on 1/20/23 at 10:41 AM with the Admissions Coordinator (AC) revealed he started working for the facility during October 2022. He stated he was also an LVN. The AC stated he would get a referral from the hospital, review the clinical documents, visit the patient at the hospital, talk to the aide, nurse and doctor per availability to determine any special needs/equipment the patient might need. He would also talk with family. The AC stated he would present the patient information to the IDT team (department heads) including ADON, DON, ADM, Rehab Director, MDS Coordinator and the SW. The AC stated Resident #1 was referred for skilled nursing for PT/OT with the plan to return home. He had a history of falls at home and had fallen in the hospital 3 times. The hospital had him on 1 on 1 supervision for a period of time but when he visited Resident #1 he was not on 1 to 1 supervision any longer. The AC stated he talked to the nurse who stated Resident #1 was no longer trying to get out of bed. He also spoke with the case manager, with Resident #1 and the RP around 12/22/22 to 12/23/22. He stated he was in contact with the case manager off and on until Resident #1 was ready to be released to determine his discharge plan. The AC stated Resident #1 seemed really nice, able to answer questions, was always in bed, calm and progressing in therapy at the hospital. Resident #1 did not display any agitation or behavior issues and was compliant with treatments per report from nursing. He stated the case manager stated Resident #1 had been on 1 on 1 supervision and it was discontinued on 12/22/23. The AC stated he was not sure if the supervision was continuous but the nurse told him they would be taking him off 1 to 1 supervision. The AC stated per his own experience the Resident would need to be off 1 to 1 supervision 24 hours prior to placement. The AC stated there was not a facility policy that he knew of regarding the supervision and he had not received direction from the nursing facility. The AC stated he presented Resident #1's information to the IDT team on 12/23/22 or 12/24/22. He stated he did not remember everyone who attended the IDT meeting but again stated it was usually the department heads. The IDT reached a consensus that they would accept Resident #1 but stated the admission took place at the end of the month after they secured the contract with Resident #1's insurance provider. Interview on 1/20/23 at 1:06 PM with LVN H revealed she worked on 12/30/22 from 6 AM to 2 PM. She stated she knew Resident #1 was admitted on 12/3022 but it was not on her shift. LVN H stated she was not provided any information about Resident #1 including that he had a history of falling. Interview on 1/20/23 at 1:43 PM with the Interim DON stated she knew Resident #1 was being admitted but was not sure if she was part of the IDT meeting when staff discussed his appropriateness for placement. She stated the day of admission the floor nurse would receive an admission packet. The first shift nurse would pass on in report that they were expecting a new admission if the resident did not arrive during the first shift and so on. The admitting nurse would document the resident's admission in the 24- hour report and any significant information. Interview on 1/20/23 at 2:10 PM with the ADON revealed she was part of the IDT meeting when they discussed Resident #1's placement. She stated she was not sure who all attended but usually it included the DON, SW, therapy, ADM and the BOM. The ADON stated she told LVN H know about Resident #1's admission on [DATE]. LVN H worked the 6 AM to 2 PM shift. The ADON stated she would have provided specifics about Resident #1 including that he was a fall risk. LVN H should have passed the information on in report to LVN F. The ADON stated LVN F asked about implementing a fall mat after Resident #1 fell the first time but she advised her to wait until therapy assessed him. She stated Resident #1 was referred for therapy services with the focused areas being strength and mobility. The ADON stated nursing staff would have to get clearance from management before implementing a floor mat. She stated the interventions in place for Resident #1 included clipping the call light to his gown and increasing rounding on him. She stated they did not put the bed in the lowest position because he was a tall man and would often get up on his own. She stated Resident #1 did not have the strength to get up from the bed in the lowest position and it would be considered a restraint. Interview on 1/20/23 at 3:10 PM with the ADM revealed they conducted a fall management in-service on 12/31/22 for the nurses. He stated they had not provided another in-service since to include the CNA's or other staff. Interview on 1/20/23 at 3:15 PM with the SC revealed a CNA called in 12/30/22 for the 2 PM to 10 PM shift. He stated they had to make some changes to the assignments and LVN F and CNA G were the only two staff working the hall from 2 PM to 10 PM shift. The SC stated it would have made it difficult to complete normal tasks and to provide the level of supervision Resident #1 required in addition to the 3 or 4 other residents on the hall that were also a fall risk. He stated the census was probably like over 30 residents. Interview on 1/20/23 at 4 PM with the Interim DON revealed a fall risk assessment was completed for every resident upon admission and after any fall. She stated nursing staff were to gather information to determine the root cause of the fall. Nursing staff was supposed to ask the who, what, when, where and why and implement interventions according to the root cause analysis. Interview on 1/20/23 at 4:09 PM with the Staffing Coordinator (SC) revealed he worked the second floor from 10 PM to 6 AM as a CNA on 12/31/22. He stated upon beginning his shift he would usually make a sweep of all residents, checking on residents to ensure they were in their room, in bed and were ok. He remembered Resident #1 talking to himself and fidgeting with his gown. He asked the Resident if he was ok and the Resident said yes. The SC stated he completed his sweep and then started with incontinent care. He stated Resident #1's roommate came out and asked for help while he was in another resident room by the nurse's station. The SC stated Resident #1 was lying on the floor on his right side by the roommate's bed . Resident #1 said I'm hurting but could not say what happened. The SC stated there was not a fall mat in place. The bed was in the lowest position about 1 foot off the floor. He stated the nurse responded and assessed Resident #1 while on the floor. He and the nurse transferred Resident #1 to bed and the Resident complained of pain to his wrist. The SC stated after the second fall he answered the call light. The roommate was out in the hallway yelling for help. The SC stated when he entered the room he saw Resident #1 crawling on the floor. He stepped out of the room to get the nurse to help and when they returned Resident #1 had put himself back to bed. The SC stated Resident #1 was very confused. The roommate reported he saw Resident #1 crawling on the floor when he woke up. The SC stated he had checked in on Resident #1 about an hour before he was observed crawling on the floor. He stated Resident #1 was wide awake and restless. The SC stated he would round on residents every two hours and in between changing residents. He stated the nurse would also make her own rounds. The SC could not remember if the nurse told him Resident #1 was a fall risk. He stated the fall protocol required they put the resident bed to the lowest position, ensure the environment was clutter free and a fall mat was used if it was not a safety hazard. The SC further stated Resident #1 had the call light clipped to his gown and his overhead light was on. The SC stated Resident #1 was not able to walk and during transfer he was able to bare weight for a short time. He stated the nurse did not implement the use of the fall mat after the additional 2 falls. Interview on 1/20/23 at 4:40 PM with the Interim DON revealed she assumed her position on 12/27/22 or 12/28/22. She stated she reviewed Resident #1's hospital documentation after it was faxed to the facility and stated Resident #1 had 3 falls while at the hospital related to impulsivity. She stated Resident #1 had heart failure and his heart was operating at 30 %. The Interim DON stated LVN F called her late in the evening after Resident #1 had his first fall. She understood Resident #1 was using his bedside table to walk and he fell into the roommate's mini refrigerator. The nurse educated Resident #1 on the use of the call light. She stated X-rays were ordered and they were negative for any fractures. The Interim DON stated staff found Resident #1 sitting next to his bed after his 2nd fall and LVN D reported she guided Resident #1 to the floor which was considered to be his 3rd fall. LVN D stated Resident #1 was using his roommate's wheelchair/ to ambulate and was very unsteady. Interim DON stated the last two falls took place during the overnight shift. She stated Resident #1 had 3 falls altogether while at the facility. The Interim DON stated a 2nd set of X-rays were positive for a fracture but was not sure about the exact location. She stated the interventions in place for Resident #1 included: call light was clipped to his gown; he had 2 urinals at bedside and his overnight light was on. She stated nursing staff believed Resident #1 required 1 to 1 supervision because he was determined to get up and walk. He was able to ambulate somewhat; not safely but he could walk. Interim DON stated they obviously could not provide 1 to 1 supervision. Furthermore, nursing staff was not convinced using a fall mat was a safe intervention which she discussed with nursing staff. The Interim DON stated she did not know who received Resident #1's clinical's to determine whether he was appropriate for placement. Interview on 1/23/23 at 1:39 PM with the SC revealed he confirmed that on Saturday, 12/31/22, he found Resident #1 on the floor after the first fall during the night shift; later he observed Resident #1 crawling on the floor and then LVN D called him over to Resident #1's room to help transfer Resident #1 to bed after reporting she had lowered him to the floor. The SC stated technically Resident #1 had 3 falls during the night shift. Interview on 1/23/23 at 1:42 PM with Resident #4 revealed he remembered Resident #1 after cueing. He stated Resident #1 kept falling. He would get out of bed and would hold on to everything to keep from falling but he fell anyway. Resident #4 stated Resident #1 was not steady and could not walk very good. He stated Resident #1 knocked his mini refrigerator over from on top of his dresser. Resident #4 stated Resident #1 did not want to be in bed. Resident #4 stated he kept calling staff for help because it usually took staff over an hour to respond when he used the call light. He stated the staff responded to his call for help. 2. Review of Resident #2's face sheet, dated 1/23/23, revealed he was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy and repeated falls. Review of Resident #2's admission quarterly MDS, dated [DATE], revealed his BIMS was 8 (out of 15) indicative of severe cognitive impairment; he required extensive assistance by 1 person for bed mobility and transfers; he was unsteady moving from sitting to standing position, on and off the toilet and surface to surface transfer and only able to stabilize with staff assistance. Review of Resident #2's Care Plan, revised 11/8/22, revealed he required extensive assistance by 2 persons for bed mobility and transfers. Resident #2 was identified as being a fall risk and interventions included: anticipate and meet needs, avoid rearranging furniture, be sure the call light is within reach and encourage to use it to call for assistance as needed, educate resident and caregivers about safety reminders and what to do if a fall occurs, maintain a clear pathway, free of obstacles. Further review revealed Resident #2 had a fall on 1/13/23 and the interventions included: Call don't fall signs next to bed, check range of motion, monitor/document /report to MD for s/sx: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, neuro-checks as ordered and vital signs as ordered. Review of an incident report, dated 1/13/23, revealed LVN E heard Resident #2 yelling out for nurse at 6:30 AM. She found him on the floor laying on his left side with wheelchair beside him. The wheelchair brakes were not locked. The Resident was wearing non-skid socks. Resident #2 was able to make his needs known and stated he hit his head on the floor. Resident #2's description: I don't know, I just fell. Immediate Action Taken: assessed Resident #2 and observed bump on left side of forehead and purple discoloration to left knee upon sitting Resident #2 up. Resident #2 denied pain. He was assisted to the wheelchair by 2 persons and neurochecks initiated. It was noted he did not have any injuries. Further review revealed LVN E notified Resident #2's physician, family member and the DON about the incident. Observation on 1/18/23 at 2:05 PM revealed Resident #2 sitting in a wheelchair by the nurse's station. Further observation revealed he had bruising over his left eye. Interview with Resident #2's family member revealed Resident #3 had a fall. Observation and interview on 1/20/23 at 11:40 AM revealed Resident #2 was lying in bed on his left side with eyes closed and his bed in a low position. The wheelchair was a couple of feet from the bedside. Interview with CNA I revealed she worked Monday through Friday from 8 AM to 5 PM. She stated she noted bruising over Resident #2's left eye on Monday, 1/17/23, and did not know if he had a fall. She stated the nurse did not say anything to her. CNA I stated Resident #2 was able to make his needs known, would use his call light to ask for assistance, was a 1 or 2 person assist with transfers. She stated the following interventions were used when a resident was identified as being a fall risk: call light within reach, low bed to lowest position and talk to nurse about using a fall mat. LVN I stated she would think Resident #2 was a fall risk because she had seen him try to self-transfer without assistance. She stated he was unsteady on his feet. Further observation revealed Resident #2's bed was not in the lowest position. She stated Resident #2 would sit up and the bed was in the position which allowed him to sit up and place his feet on the floor. CNA I stated there was no fall mat and his call light (touch pad) was placed underneath his left hand. Observation and interview on 1/20/23 at 1:06 PM revealed Resident #2 was lying in bed on his left side with eyes closed and his bed in a low position. The wheelchair was a couple of feet from the bedside. Interview with LVN H revealed Resident #2 was a fall risk per nursing report. He required assistance with transfers and stated he was able to pivot at one point but not so much anymore. LVN H stated she was aware Resident #2 had bruising over his left eye but did not talk to CNA I about his fall history because it took place earlier in the month. She stated the information would be available in Resident #2's POC. She stated this was the program the aides documented on which provided them with resident ADL information and any special circumstances. LVN H stated the aides should report any change of condition to them when they noted any changes. She stated CNA I should have reported the bruising over Resident #2's left eye if she had not noted the bruising during her previous shift. LVN H stated she understood LVN E found Resident #2 on the floor by the bed but was not sure if he fell out of the bed or the wheelchair. She did not know all of the details and had not looked at his chart. LVN H stated a low bed to the lowest position would be utilized if Resident #2 fell from the bed and if he fell from the wheelchair then it should be positioned out of the reach/sight from Resident #2 and in the locked position. Further observation revealed Resident #2's bed was not in the lowest position, his wheelchair was by his bedside in front of the night stand, his call light was under his left hand and the bed remote was on the floor. LVN H further stated the wheelchair was not in the locked position and a safety hazard if Resident attempted to transfer to the wheelchair. Interview on 1/20/23 at 1:20 PM with CNA J revealed she and CNA I were working together on the same hall. She stated she did not know Resident #2 had fallen and had not noted the bruising to his forehead. She stated she would ask the nurse on duty of any new resident changes upon returning from her days off. CNA J review[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review failed to ensure resident receive treatment and care in accordance with professional standards of practice, based on the comprehensive assessment of a resident, the comprehensive person-centered care plan, and the resident's choices for 1 of 10 residents (Resident #2) reviewed for quality of care, in that: 1. The facility did not identify 2 shearing wounds on Resident #2 buttocks prior to surveyor intervention. 2. LVN D did not immediately notify the physician and receive treatment orders for Resident #2 upon identification of open areas on her buttocks. 3. The facility did not implement interventions to prevent further breakdown for Resident #2 after identifying wounds on her buttocks. 4. The facility did not identify 4 more open areas to Resident #2 ' s buttocks 2 days later and prior to surveyor intervention. These deficient practices could result in pressure ulcer development and decline in the resident's physical condition. The findings included: Record review of Resident #2's electronic face sheet with an admission date of 10/28/2022 and diagnosis which included cerebral criptococcosis(Cryptococcosis is a disease caused by fungi from the [NAME] Cryptococcus that infect humans and animals, usually by inhalation of the fungus, which results in lung infection that may spread to the brain), rheumatoid arthritis(a chronic inflammatory disorder that can affect more than just your joints.),metabolic encephalopathy(abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function.), and dysphagia(A condition with difficulty in swallowing food or liquid. This may interfere in a person ' s ability to eat and drink.) Review of Resident #2's admission MDS, dated [DATE] revealed a BIMS score of 8 indicating cognitive impairment. Record review of Resident #2's Care Plan, dated 11/2/2022, revealed, Focus: Has pressure ulcer or for potential pressure ulcer development. Goal: Will have intact skin, free of redness blisters or discoloration through review date. Interventions: Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration during bath or daily care. Weekly head to toe skin assessment. Record review of Resident #2's electronic medical record nursing progress notes dated 11/1, 11/2, 11/4, 11/6,11/7,11/8/2022, documented as: overall skin description is: skin intact with no breakdown noted. There are no active symptoms effecting the integumentary system observed. Record reveiw of Resident #2's Skin evaluation-prn weekly dated 11/2/2022, documented as new admit skin assessment. no redness noted to bilateral heels. Wearing pressure reducing boots. Remaining skin intact. No indication of presure wounds. Record review of Resident #2's electronic medical nursing progress notes from Registered Dietician on 11/9/2022, documented as: No pressure wounds, though with skin tears to bilateral buttocks. Record reveiw of Resident #2's Skin evaluation-prn weekly dated 11/10/2022, documented as groin abdomen, and left front thigh with bruising. No indication of buttock wounds. Record review of wound record provided by DON on 11/9/2022 at 11:30 a.m. revealed no documentation regarding Resident #2 having any wounds. Record review of Resident #2's score on the Braden Scale for predicating pressure risk, dated 10/28/2022 revealed a score of 17, which indicated a low risk. During an interview on 11/8/2022 at 2:15 p.m. with Resident #2 she stated she had sores on her bottom and that they hurt and no one was helping her. When asked how long she had the sores, Resident #2 stated, I do not know, I just know it hurts. Permission was asked by surveyor to see the sores and Resident #2 stated yes. Informed her this surveyor would have staff present. During an observation on 11/8/2022 at 2:24 p.m., Resident #2 had two, 2cm (centimeters) long by 1/2 cm wide oblong open areas to her right upper buttock and one, 2cm long by 1/2cm wide oblong open area to her left buttock. LVN D was present with surveyor during observation of skin on Resident #2. LVN D stated yes there are open areas to her buttocks, she further revealed she was not aware of any open areas to Resident #2's buttocks. She stated I see barrier cream on the areas to the buttocks that the nurse aides must have put on them. LVN D stated she was not told by any nurse aides that Resident #2 had a need for a treatment to her buttocks. She stated the treatment nurse would be in facility tomorrow and would get an order for a treatment. When asked what the charge nurse would do if the treatment nurse was not available, LVN D stated we would call the doctor and do the treatment ourselves. When asked why she did not want to call the doctor today, she said because the resident has barrier cream now and the treatment nurse will be here tomorrow. During an interview on 11/8/2022 at 3:35 p.m. with LVN F she revealed she was aware that Resident #2 had red areas on her buttocks but not aware if they were open. She further revealed she was not aware of any treatment orders for her buttocks . She stated she had not seen Resident #2 on 11/8/2022. During an interview on 11/8/2022 at 3:55 pm CNA I stated the sores on Resident #2 's buttocks were not open when she first came in(admission [DATE]). She further revealed they were only red. She stated I told the LVN D and CNA I put barrier cream until the treatment nurse could assess the resident. CNA I revealed she was aware of Resident #2 had blisters type on her right and left buttock . She stated she was to place barrier cream on her, she was told to do this by LVN F. She further revealed we are to turn and change her every 2 hours and as needed. When asked how long the areas have been open to Resident #2's buttocks , CNA I stated, I am not sure exactly but several days. During an interview on 11/10/2022 at 11:01am, Treatment Nurse C stated he worked Monday through Friday 8am to 5 pm normally. He further revealed the Wound Doctor comes every Thursday. He stated he was off work Friday, 11/5//22 and returned to the facility on [DATE]. Treatment Nurse C stated, the nurses do the skin and wound treatments when I am off. The aides have shower sheets that they do on bath days for the residents, and they give those to the charge nurse and then that is given to the DON. He further stated, If I am not here the nurse should call the Dr. and get a treatment for the Residents whenever a skin issue is identified. During an observation on 11/10/2022 at 11:15 am, Resident #2 was in bed. Treatment Nurse and surveyor asked permission to see wounds on the buttocks. Resident #2 agreed. Resident #2 complained of pain during the observation. Observation of Resident #2's buttocks revealed a 2cm long by 1/2 cm wide oblong open areas to her right upper buttock and one, 2cm long by 1/2cm wide oblong open area to her left buttock. There were also 4 new areas open to the buttocks that were not there on initial assessment of 11/8/2022. Treatment Nurse stated he was not aware and had not been told that Resident #2 had any skin issues. He stated he was going to call the Doctor now and get a treatment plan for Resident #2. During an interview on 11/10/2022 at 2:30 p.m. with DON revealed she was not aware that Resident #2 had any open areas to her buttocks. The DON stated nurses should check residents' skin weekly and document in weekly skin report or progress notes in the electronic medical record. She further revealed if there is a treatment nurse on staff then they would document the assessment and call the physician for any orders for the residents. She stated it is her expectation that staff including nurses and nurse aides should notify their superior of any skin changes in residents. The facility DON stated our team of department heads discuss any skin issues in our morning meetings daily, Monday through Friday. Review of facility policy titled Infection Control Policy/Procedure, Section: Resident Care, Subject: Wound Care and Treatment Guidelines: Policy: It is the policy of this facility to provide excellent wound care to promote healing. Procedures: A weekly assessment should be done on all wounds requiring treatment. The careplan should reflect the current status of the wound and appropriate goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 5 residents (Resident #4) reviewed for abuse. 1. The facility failed to protect Resident #4 from being hit by Resident #5 with a walking stick on his right hand on 10/31/22. 2. The facility failed to protect Resident #4 from being fearful (psychosocial harm) of Resident #5 from 10/31/22 through 11/10/22 when Resident #4 filed a grievance. These failures could place residents at risk for continued abuse, undetected abuse, neglect and/or decline in feelings of safety and well-being; and psychosocial harm. Findings were: 1. Record review of Resident # 4's face sheet dated 11/08/2022 revealed a [AGE] year old male with an admission date of 7/20/2022 with diagnoses which included: chronic kidney disease stage 3, type 2 diabetes mellitus and major depressive disorder recurrent mild Record review of Resident #4's revised admission MD'S dated 7/31/2022 revealed a BIMs score of 14 (scale of 0-15) which indicated the resident was cognitively intact. As for ADLs: bed mobility was extensive with two staff assistance; transfer was extensive two staff assistance; resident unable to walk. Range of motion: resident had contractures to both legs. Record review of Resident #4's CP, dated 07/26/22, revealed the goal and intervention for a resident to resident incident on 10/31/22 read: Roommate [Resident #5] was moved to different room after alleged altercation on [10/31/22] . Referral to an appropriate psychiatric provider as needed .[no documented referral in the clinical record to deal with Resident #4's fear or psychosocial harm] . Stop and talk with resident when passing by . [CP dated 10/31/22 revealed that no thorough investigation was completed and no new interventions were put in place to protect R#4 from further abuse from R#5]. Record review of Resident #4's Physician Progress Note dated 11/20/22 revealed: no diagnoses of paranoia. The resident was described as pleasant and cooperative, flat affect. Record review of Resident #4's Nurse Progress Notes from 10/31/22 (date of incident) to 12/02/22 (survey exit date) revealed: no documented referral for Psych services or mental status examination focused on the resident's fear (psychosocial harm) and anxiety involving Resident #5. Record review Resident #4's MAR, dated November 2022, revealed the resident received the psychotropic medication fluoxetine 20 mgs daily at bedtime for depression. Record review of a local police report dated 10/31/2022 revealed a call was received on 10/31/2022 at 11:11 p.m. from Resident #4 who stated his male roommate [Resident #5] had been threatening to him and assaulted him with a cane. Resident #4 stated he wanted the incident documented in case something happened later. The local police notified both parties that the light can stay on if one party wants it on and the other party can leave the room if they do not like it. Record review of TULIP (Texas Unified Licensure Information Portal) a computerized program facilities utilize to report incidents to HHSC revealed an allegation of abuse occurred on 10/31/2022 at 1:00 p.m. involving Residents #5 and #4 was reported to HHSC on 11/01/2022 at 11:00 p.m. The incident involved Resident #5 who wanted to go to sleep and asked Resident #4 to turn off the light on his side of the bed. Resident #4 did not want to turn it off and they began arguing about it. Resident #5 were both egging each other on. Resident #4 stated that Resident #5 poked him with his cane in his stomach and hit his hand. Resident #4 called the police, and the police came [to the facility].[Record review of incident report did not reveal effective interventions put in place to deal with mental health referral for R#4 and psychosocial harm]. Record review of Resident #4's grievance filed on 11/10/22 revealed: he was fearful and felt that Resident #5 was sitting outside his room. Facility's actions were: to speak to Resident #5 and to instruct Resident #5 not to visit Resident #4. Resident #4 was informed that Resident #5 did not sit or would not sit outside his door; grievance was recorded as resolved. During an interview on 11/8/2022 at 1:00 p.m., Resident #4 stated Resident #5 had hit him with his cane. He stated he was in his room in bed and [Resident #5] got mad at him because he would not turn his light off. Resident #4 stated the nurses moved Resident #5 to another room. During an interview on 11/8/2022 at 1:30 p.m., Resident #5 stated he did hit Resident #4 with his cane because he wanted the light turned off in his room. During an interview on 11/10/2022 at 12:45 p.m., the Administrator confirmed the abuse incident was not reported within 2 hours. During an observation and interview on 12/01/22 at 10:25 a.m., Resident #4 was in bed with a cellophane. Resident was bedbound. Resident #4 had contractures to both legs. The resident was alert and oriented; no bruises, wounds or skin tears were present. The resident stated that he still did not feel safe because Resident # 5 still roamed the hallway on the first floor of the facility. Resident #4 stated that there have been no incidents with Resident #5 since the 10/31/22 incident of physical abuse. Resident #4 stated he was thinking about moving to another nursing home because the facility was short staff and could not be assured that Resident #5 would not again strike him. Resident #5 had not physically abused him (Resident #4) since 10/31/22, but he was fearful that (R#5) might enter his room at night. His (R#4) medications were not changed after the 10/31/22 incident; and R#4 did not want to see a psychiatrist or psychologist. Likewise, R#4 did not want this room changed. During an interview on 12/01/22 at 12:25 p.m., the SW stated: prior to the incident on 10/31/22, R#5 and R#4 were roommates. According to the SW, the incident of physical abuse was not predicted. After the incident, preventative measures put in placed included: R# 5 was moved to the second floor; a Guardian Angel was posted outside R#4's room during the day Monday through Friday; staff were alerted to monitor R#4's movements; and there had been no other incidents. The SW intended on exploring a discharge plan for R#4 if he continued to remain fearful of R#5; and would explore with him a discharge plan. [SW plan was to explore discharging Resident #4 and keeping Resident #5 in the facility]. During a joint interview on 12/01/22 at 2:20 PM, the DON revealed: preventative measures after the Incident on 10/31/22 included: Resident #5 was moved to another floor; the wooden stick (tall walking stick) used in the incident belonged to Resident #5 and was voluntarily given to the Administrator by Resident #5; close monitoring of the first floor was put in place; when Resident #5 smoked outside near the first floor a staff member was present in the smoking area. As for Resident #4, the facility attempted a Psych referral around the day of the incident but the resident refused. No new medications were added to deal with any signs of paranoia or fear/anxiety exhibited by Resident #4. The DON commented, the Police only investigated a verbal argument over the back light of the room and the sound from the TV or radio. She stated no evidence surfaced that Resident #4 was struck by Resident #5. Resident #4's Skin assessment done on 11/01/22 was negative; and Resident #4 was not sent to ER on [DATE]. [Skin assessment was done one day after the incident-reason not given by the DON] From 11/15/22 to 12/01/22, staff have visited Resident #4 and reports he never expressed fear of Resident #5. The Administrator responded that he would make a referral to Psych services to check on Resident #4's fear of Resident #5 and to rule-out paranoia. During an interview on 12/01/22 at 4:40 PM, the facility MD revealed she saw Resident #4 on 11/20/22 and the resident did not express any paranoia or fear of other residents or raised the 10/31/22 incident with her. In the past the resident refused psychiatric evaluations because he stated nothing was wrong with him. The MD said Resident #4) had not expressed any desires for discharge. The intervention the facility put in place was to separate the residents and move Resident #5 to a separate floor. The MD added that the resident was not prescribed medications to control anxiety or his fears because, he did not want to see a psychiatrist. During an interview on 12/01/22 at 4:45 p.m., the Business Office Manager said she made ambassador rounds on Resident #4 (to check on concerns) and he never expressed any fears about other residents or Resident #5. She participated in the discussion on the grievance Resident #4 filed against Resident #5 and the resident revealed he felt safe. She said she spoke to Resident #4 on 11/10/22 about the grievance and on 12/01/22 (day of surveyor's entrance into the facility) as a follow-up on any concerns. She said she did not document her follow-up on 12/1/22, but Resident #4 said he felt safe and did not want to be referred to psychiatric services. She said he did not want any resident wondering into his room; he does not have a roommate. The Business Office Manager stated, given the Responsible Party was the resident and he did not consent to a psychiatric referral we have made none .and there was no special Care Plan meeting to discuss the 10/31/22 incident and possible interventions other than those that were in place. During an interview on 12/01/22 at 4:53 p.m., the SW said she visited Resident #4 as needed from the day of the incident 10/31/22 to the present 12/01/22 to check on concerns and safety; but did not document the encounters with the resident or psychosocial harm. [The SW was trained to document but did not give a reason for not documenting her encounters with Resident #4.] During a joint interview on 12/02/22 at 10:30 a.m., the DON stated a referral was not made for Resident #4 for Psych services because resident rights, she said Resident #4 refused Psych services verbally, but no documentation of refusal was documented in the clinical record. The Administrator stated Resident #4 did not want a Psych referral and he left it up to the clinical staff to document and follow-up on any Psych referral. During an observation and interview on 12/02/22 at 2:50 PM, Resident #4 was in bed trying to fall asleep. Resident #4 revealed that he was still afraid of Resident #5 and that he had been told by other residents that Resident #5 comes down to the first floor. Resident #4 said he does not want his room changed. He said he is weighing whether a transfer to another nursing home was the best option for his fear. He stated, in the best of [NAME], my desire is that Resident #5 would go away . Resident #4 said he will give the facility a chance to see whether they keep him safe before making a final decision on a transfer. During an interview on 12/2/22 at 5:30 PM, the DON said the Elder Care Program was a mental health community provider that visited the facility weekly to provide mental health services to residents. She said Resident #4 and Resident #5 were not provided mental health services because, they refused Psych services. When asked whether a documented referral was made for mental health services to the Elder Care Program, or any other community mental health provider, the DON revealed that no written documentation existed. Record review of Resident #4's wound care physician email dated 12/02/22 at 8:01 AM (after surveyor's entrance) revealed: weekly wound care visits were done and Resident #4 had not expressed any fears of other residents [not documented in the clinical record] to the Wound Care Physician. Record review of Resident #4's grievance filed on 11/10/22 revealed: he was fearful and felt that Resident #5 was sitting outside his room. Facility's actions were: to speak to Resident #5 and to instruct Resident #5 not to visit Resident #4. Resident #4 was informed that Resident #5 did not sit or would not sit outside his door; grievance was recorded as resolved. Record review of the Administrators written note dated 11/01/22 in reference to Resident #4 and incident on 10/31/22 revealed: Resident #4 accused Resident #5 of hitting him in the hand .with a cane the previous night (10/31/22). The DON assessed resident and did not see anything on the hand any redness, swelling, or discoloration . [written statement dated 11/01/22 was not documented in the clinical record.] 2. Record review of Resident #5's face sheet dated 11/09/2022 revealed a [AGE] year-old male with an admission date of 7/23/2022 with diagnoses which included: acute pancreatitis without necrosis or infection (inflammation of the pancreas), Chronic obstructive pulmonary disease (persistent respiratory symptoms like progressive breathlessness and cough), diaphragmatic hernia without obstruction or gangrene (hernia in the muscle that separates the lungs from the abdominal cavity) and unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (dementia without behaviors). Record review of Resident #5's revised admission MDS dated [DATE] revealed a BIMs of 11 (scale of 0-15) which indicated a moderate cognitive impairment. As for ADLs: Resident #5 required only supervision for ambulation and transfer. Record review of R#5's CP dated 11/01/22 revealed the goal and intervention around resident-to-resident altercation read: Psychiatric consult as indicated Resident moved to different room r/t (related to) resident to resident on 11/1/22. [record review of CP did not reveal that a thorough investigation was conducted and the interventions put in place to prevent R#5 for wanting to harm R#4; also the CP did not document that a mental health referral was made for R#5 afer the incident on 10/31/22.] Record review of R#5's PT (physical Therapy) certification dated 12/02/22 revealed: resident required a single point cane for ambulation and to prevent falls. Record review of R#5's PT Evaluation and Plan of treatment dated 7/26/22 read: Patient will safely ambulate on level surfaces 100 feet using SPC (single point cane) with Partial/Moderate Assistance . Record review of R#5's SW notes revealed the last SW entry was made on 10/30/22. [no notes documented to evaluate any safety concerns towards R#4 or any referral to Psych services]. Record review of R#5's incident record for falls past 90 days ( 09/1/22 to 12/2/22) revealed the resident had no falls from the use of a walking cane or wheelchair ambulation. Record review of R#5's Wound Care Physician email dated 12/02/22 at 8:01 AM revealed: R#5 used a cane to get out of his wheelchair. Record review of facility's weekly behavior meetings revealed meetings were held in the month of November 2022. Record review of facility's standard of care sign-in sheet (same as weekly behavior meeting) revealed a meeting was held on 11/17/22. [the tracking of residents with behaviors started 11/16/22] R#5 was listed on the Behavior sheet with the comments: hx (history) of physical aggression, does not like to be challenged .interventions: leave him alone when upset .refuses psych services . [The behavior monitoring meeting did not specifically deal with the incident on 10/31/22 and the need for a mental health referral; and protective measures put in placed to protect R#4 from harm from R#5]. Record review of the Administrators written note dated 11/01/22 in reference to R#5 and incident on 10/31/22 revealed: R#5 said that R#4 was a liar. During an interview on 11/08/2022 at 4:00 p.m., CNA I stated that Resident #5 moves around the facility with his wheelchair. He carries a walking single point cane with him. [The cane was used for mobility when the resident was out of the wheelchair. CNA I did not witness Resident #5 striking Resident #4; and she had received training on abuse and neglect.] During an interview on 11/09/2022 at 12:21 p.m. the Administrator acknowledged he was the abuse coordinator. During an observation and interview on 12/01/22 at 10:51 a.m., Resident # 5 was attending bingo. Resident #5 was sitting in a W/C with a walking cane, he spoke in Spanish, was alert and oriented to person and place. Resident #5 had no wounds, bruises or skin tears, he stated that he was treated well, had no fears and denied being struck by other residents. Resident #5 stated that he had no intentions of harming other residents. He recalled the incident with Resident #4 because he was bothering me .I hit him with my cane . He added his room was changed and he has not bothered the other resident (R#4) who was his [former] roommate. He said he only goes down to the first floor to the smoking area and had not had any altercations with other residents. He (R#5) does not hate other residents. He stated that the walking cane helped him with mobility especially when he wanted to get out of the wheelchair. The resident added that he tried to control his anger; and he did not feel unsafe in the facility. [Resident #5 did not want to see a mental health provider because he had no mental health concerns.] During an interview on 12/01/22 at 11:05 AM, LVN E revealed R#5 carried a walking cane while sitting in his wheelchair; the walking cane was used for ambulation. LVN E said interventions the facility put in place for the safety of residents from R#5 included: close monitoring, being aware when he wanted to get a smoke break and staff supervised him at the smoke area; no changes in medications [resident room is at the end of the hall]; hall cameras were present monitored from the DON's office. According to LVN E, R#5 has had no altercations in Hall 200 with other residents. During an interview on 12/01/22 at 12:33 PM, the SW revealed: R#4 and R#5 were roommates; an un-expected incident of resident-to-resident altercation occurred on 10/31/22. After the incident, R# 5 was moved to another floor; no other incidents occurred after the room change. During an interview on 12/01/22 at 5:05 PM, the SW revealed she had not documented in the clinical record (from 10/31/22 to 12/01/22 (entrance date of surveyor) her encounters with R#5 involving safety and any encounters with R#4. During a joint interview on 12/02/22 at 10:50 a.m. , the Director of Rehab and PT O revealed: R#5 had a wheelchair based on a physician's order and a physical therapy assessment. R#4 was ambulatory and had instability when standing; and had impaired endurance. Physical Therapy department had assessed R#5 for the single point cane. The single point cane was necessary for assisting R#5 with ambulation. R#5 did not require physical assistance to transfer out of the W/C. The cane helped the resident avoid falls which he had none in 90 days (September, October, and November 2022). During an observation and interview on 12/02/22 at 3:10 p.m., R#5 was participating in a bingo activity sitting in his wheelchair and holding his walking cane. R#5 agreed to briefly speak to the surveyor. R#5 revealed that he was fine and had no anger towards anyone. He had no complaints and ended the interview and returned to the bingo activity. Record review of grievance log from 11/01/22 to 12/01/22 revealed: only one grievance filed by R#4 on 11/10/22 against R#5 revealing that he (R#4) was afraid that R#5 was sitting outside his room; Resolution: no evidence surfaced that R#4 was not outside the room; and R#5 educated not to visit R#4. Also, staff sat outside R#4's room during the day [Surveyor observed on 12/02/22 a staff member sitting outside of Resident #4's room.] Record review of Incident log from 11/05/22-12/01/22 revealed no incidents involving Resident #4 and #5 after 10/31/22. Record review of facility's Reliance Computer courses on the topics of: behaviors, resident-to Resident, de-escalation revealed 100% of the staff (Total paid staff of 89 (time frame 11/05/22-11/12/22 ) received the training prior to surveyor's entry on 12/01/22. Record review of weekly behavior meetings revealed meetings were held in the month of November 2022. Record review of facility's standard of care sign-in sheet (same as weekly behavior meeting) revealed a meeting was held on 11/17/22. [the tracking of residents with behaviors started on 11/16/22]. Record review of a facility policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment dated 11/28/2017 revealed: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents .Procedures: In response to allegations of abuse, neglect, exploitation or mistreatment, the Facility will: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately but not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury. Ensure that all alleged violation involving abuse .are reported to the State Survey Agency.