**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure the environment remained free of accident hazards and residents received adequate supervision to prevent accidents for 3 (R34, R29, and R50) of 5 residents reviewed for accidents. *R34 was given a handled cup of hot chocolate with the handle placed towards the right hand. R34 had limited movement of the right hand and, while transferring the cup from the right hand to the left hand, the scalding liquid spilled onto R34's left side/hip/buttock area causing a third degree burn that measured 34 cm x 30 cm. The facility staff did not place the cup in a safe manner for R34 to manage the cup independently and the water was at a temperature hot enough to cause a third degree burn. The facility did not investigate or monitor the temperature of the water used when making the hot chocolate to prevent other residents from potentially being burned if a spill occurred. *R29 had a fall on 2/17/2025 when being transferred. R29 was not being transferred per care plan. *R50 had a fall on 3/8/2025 that was not thoroughly investigated to determine a root cause and implement appropriate interventions to prevent future falls. Findings include: *R34 was admitted to the facility on [DATE] with diagnoses of cervical disc disorder with myelopathy (the spinal cord is compressed in the neck region that causes pain, loss of sensation, and problems with movement or fine motor skills), paraplegia (the inability to move the lower extremities), and dementia. R34's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R34 had mild cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 9 and had an active diagnosis of paraplegia. R34's Care Plan documented R34 could not complete cares independently and needed the assist of one staff to provide setup or clean-up with eating. R34 used a soft touch call light and needed adaptive equipment for eating. Surveyor noted R34's Care Plan did not address R34's limited movement of the right hand/arm and the need to have items placed for R34 to use the left hand. The State Operations Manual has the following chart: Time and Temperature Relationship to Serious Burns that shows the water temperature and the time required for a third degree burn to occur: 155 degrees F - 1 second 148 degrees F - 2 seconds 140 degrees F - 5 seconds 133 degrees F - 15 seconds 127 degrees F - 1 minute 124 degrees F - 3 minutes 120 degrees F - 5 minutes 100 degrees F - safe temperatures for bathing Note: burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. On 12/17/2024 at 11:25 PM in the progress notes, Licensed Practical Nurse (LPN)-H documented R34 spilled hot chocolate and has a reddened area on the left hip/side/buttock with a couple scattered blisters. LPN-H documented the Physician Assistant was contacted. LPN-H applied SSD (Silver Sulfadiazine) cream (a cream that is used to treat and prevent infection in second and third degree burns) to the affected area that measured 35 cm (centimeters) x 22 cm. On 12/18/2024 at 4:19 PM in the progress notes, Director of Nursing (DON)-B documented an assessment of R34's burn to the left posterior back. The burn was a partial thickness (second degree burn) reddened area measuring 34 cm x 30 cm with blistering in some places. The etiology of the wound was dropping hot chocolate onto the skin. DON-B documented R34's burn would be assessed by the wound physician. On 12/23/2024, R34 was seen by the wound physician for an initial assessment. The wound physician documented the full thickness (third degree) burn measured 30 cm x 28 cm x 0.1 cm with 70% thick adherent devitalized necrotic tissue, 20% dermis, and 10% intact skin. The wound physician surgically debrided the area to a depth of 0.2 cm and as a result of the procedure, the nonviable tissue in the wound bed decreased from 70% to 50%. The wound physician continued to assess and treat the burn on a weekly basis. The most recent assessment was on 5/5/2025; the wound physician documented the full thickness burn measured 17 cm x 2 cm x 0.1 cm with 50% granulation and 50% intact skin. The facility initiated an investigation on 12/18/2024 into R34's burn on 12/17/2024 and provided a recap of the investigation to Surveyor. R34 had been placed on the UTI (urinary tract infection) tracker due to R34's family member noticing R34 was more confused than normal with burning with urination and lower abdominal pain. The facility interviewed staff that were involved in R34's care on the second shift of 12/17/2024. Through those interviews it was discovered R34 had requested hot chocolate from the second shift staff and when R34's dinner tray was being removed from R34's room, the hot chocolate was found spilled on R34. R34 had a black mug at that time from the dinner tray. R34 has left hand contractures that needed adaptive equipment for silverware from a previous Occupational Therapy (OT) evaluation. R34 was interviewed and was able to tell what happened with the hot chocolate and how R34 dropped it when trying to move the cup from one hand to the other. R34 stated R34 had never spilled drinks before this incident nor had an issue with drinking independently. The Nurse Practitioner was consulted and agreed to have R34 evaluated by OT for different adaptive equipment. The Ad Hoc QAPI (Quality Assurance and Performance Improvement) team met on 12/18/2024 to discuss the isolated incident that occurred with R34. The discussion included R34 had been displaying symptoms of altered mental status based off R34's family member's observation, R34 could normally eat independently, and the OT screen that was ordered to determine different adaptive equipment. OT completed a screen and recommended Kennedy cups based off contractures and upper extremity movements. A Kennedy cup is a lightweight drinking cup with a spillproof lid designed for ease of use and accessibility for individuals that have difficulty gripping or manipulating standard cups. Kennedy cups were added to R34's meal ticket for communication between dietary staff and nursing. Surveyor noted the facility did not investigate the temperature of the hot chocolate that was served or address the placement of the cup handle so R34 could pick up the cup with the left hand and not have to pass the cup from the right to the left hand. R34's Significant Change MDS assessment dated [DATE] documented R34 was cognitively intact with a BIMS score of 14 and had impairment to one arm and both legs. Surveyor noted R34 had fluctuations in cognition with improvement from R34's Quarterly MDS assessment dated [DATE] with a BIMS score of 9. On 5/5/2025 at 9:27 AM, Surveyor asked R34 if R34 had any pain. R34 stated R34 had boiling hot chocolate spilled on R34's back that was still causing R34 pain. Surveyor asked R34 when did the spill happen and how did it happen. R34 stated the spill occurred maybe in November 2024 or sometime close to that. R34 stated R34 was switching the cup from one hand to the other when the hot cocoa spilled. R34 denied anyone else was present when the spill occurred. Surveyor noted R34's hands to be malformed and contracted. R34 showed Surveyor how the right hand cannot grasp while the left hand had slightly more mobility. R34 stated R34 can only use the left hand to pick things up or grasp them. On 5/7/2025 at 7:50 AM, Surveyor talked with R34 again to get a clearer picture of what happened on 12/17/2024 when the hot cocoa was spilled and R34 was burned. R34 stated R34 had to ask for the hot chocolate when the dinner tray was brought to R34's room. R34 stated R34 always eats in bed. R34 stated the aide put the cup down with the handle facing the right hand and R34 needed it facing the left hand, so R34 picked up the cup with the right hand and while switching it to the left hand, the hot chocolate spilled all over the left side of R34's body. R34 stated R34 yelled out and staff came fairly quickly. R34 denied pushing the call light because they heard R34 yelling. R34 stated the staff changed R34's clothes and bedding but could not recall if a cream was applied to the burned area. R34 stated R34 overheard staff questioning the person who brought in the hot cocoa, Why did you get it from there? R34 thought they got the hot chocolate from the boiler or something; it was very hot. R34 stated since then, the staff give R34 a Kennedy cup, and it does not spill. On 5/7/2025 at 8:39 AM, Surveyor went to the kitchen and requested a cup of hot chocolate. Food Service Manager (FSM)-J dispensed hot water from a coffee/hot water machine in the kitchen. The machine has three spigots. The spigots on the left and right dispense hot coffee and hot decaffeinated coffee. The middle spigot dispenses hot water. FSM-J took a surface temperature of the hot water after it was dispensed from the machine. The surface temperature ranged from 145-150 degrees F. FSM-J thought the water was 195 degrees F when it comes out of the machine, but did not know for sure because there was no gauge indicating the water temperature. Surveyor asked FSM-J who has access to the kitchen and the hot water dispenser. FSM-J stated the kitchen is always open and staff has access at any time. The hot chocolate was brought to the conference room and the temperature of the hot chocolate was 149 degrees. On 5/7/2025 at 8:49 AM, Surveyor observed R34 in bed, finishing eating breakfast. R34 had built up eating utensils and two Kennedy cups with beverages in them on the tray. The Kennedy cup had one handle and a tight fitting lid with a straw coming out of the center. Surveyor asked R34 if R34 had anything hot to drink in the Kennedy cup. R34 stated R34 did not have any hot drinks that day, but when R34 does have a hot drink, the staff uses the Kennedy cup. Surveyor stated to R34 that Surveyor would have thought the straw would melt if used with a hot beverage. R34 stated surprisingly the straw does not melt, because R34 thought the same, that it would melt. In an interview on 5/7/2025 at 9:52 AM, Surveyor asked Certified Nursing Assistant (CNA)-L where CNA-L would get hot chocolate for a resident if a resident made such a request. CNA-L stated CNA-L would go to the kitchen and ring the doorbell at the kitchen door. CNA-L stated the kitchen staff makes the hot chocolate and gives it to CNA-L to bring to the resident. In an interview on 5/7/2025 at 9:59 AM, Surveyor asked CNA-M where CNA-M would get hot chocolate for a resident if a resident requested hot chocolate. CNA-M stated the kitchen has the hot water and then CNA-M mixes the hot chocolate into the cup. Surveyor asked CNA-M if CNA-M ever tests the temperature of the hot beverage. CNA-M stated CNA-M feels the warmth of the cup and sometimes it is steaming so CNA-M warns the resident that it is hot. CNA-M stated sometimes CNA-M takes a straw and gets a little on CNA-M's wrist, but usually it is not scalding. In an interview on 5/7/2025 at 10:09 AM, LPN-I stated LPN-I was told it was a freak accident that R34 spilled hot chocolate on themselves. LPN-I stated LPN-I got the wound physician involved. Surveyor observed the burn to R34 at that time and the wound extended from the left iliac crest down to the left outer hip. The burn was consistent with hot liquid spilling and pooling on the left side while R34 was in bed. On 5/7/2025 at 10:28 AM, Surveyor attempted to call LPN-H. LPN-H was the nurse on duty at the time R34 sustained the third degree burn to the left side. A message was left to return the call. No return call was received. In an interview on 5/7/2025 at 10:42 AM, Surveyor asked DON-B to describe the events of 12/17/2024 regarding R34 sustaining a third degree burn from hot chocolate. DON-B stated DON-B was informed by the nurse the next day that at dinner time, R34 had asked for hot chocolate. DON-B stated the CNA went to the kitchen to get hot chocolate during the meal service. The CNA was given a black mug with the hot chocolate in it and the CNA gave it to R34. R34 switched the mug from hand to hand and spilled the hot chocolate. DON-B stated after dinner when the staff was collecting dinner trays, they found the hot chocolate had spilled onto R34 and found R34 had been burned. DON-B stated the Nurse Practitioner and family member were notified of the burn. Surveyor asked DON-B if R34 had been sent to the emergency room for evaluation and treatment. DON-B stated no, R34 was not sent out at all. Surveyor asked DON-B what the process was for residents who request hot chocolate. DON-B stated during dinner time, staff cannot go into the kitchen; they are given the hot water, and the CNA mixes the drink in the dining area. Surveyor asked DON-B if, during their investigation, they found out how hot the water was that was used to make the hot chocolate. DON-B stated no, DON-B did not know how hot the water was. DON-B stated they have not had any other complaints or burns from the water being too hot. DON-B stated since March 1, 2025, when they started using a different computer charting system, they now do a hot liquid beverage assessment on admission and quarterly. Surveyor asked DON-B if anyone since the incident in December 2024 has tested the temperature of the hot water. DON-B stated no one has tested the temperature of the hot water that DON-B was aware of. Surveyor shared with DON-B that Surveyor had tested the temperature of hot chocolate that was made that morning by FSM-J and the temperature was 145-150 degrees surface temperature. Surveyor asked to speak to the CNAs that were working on R34's unit when the incident happened. DON-B stated the CNA that delivered the hot chocolate is no longer employed at the facility, but CNA-K would be in for the second shift that day and DON-B would have CNA-K talk to Surveyor. On 5/7/2025 at 11:16 AM, Surveyor went to the kitchen to test the water temperature from the hot water dispenser with an immersion thermometer, rather than the surface temperature thermometer that was used earlier. FSM-J greeted Surveyor in the kitchen and stated someone had been in the kitchen earlier to get the phone number off of the hot water machine to have it serviced because the facility does not own the machine and therefore cannot change the settings. Surveyor requested FSM-J make a cup of hot chocolate and we would get temperatures throughout the process to determine what the temperature of the hot chocolate could have been at the time R34 spilled the hot chocolate. FSM-J dispensed the hot water into a plastic mug. The water was steaming as it was coming out of the dispenser. FSM-J measured the temperature of the hot water right after it was dispensed from the machine into a plastic mug with an immersion thermometer. The water was 170 degrees F. FSM-J mixed the hot chocolate packet into the hot water and put a plastic lid on it. We walked down to R34's room, took off the lid, and FSM-J measured the hot chocolate temperature. The beverage measured 160 degrees F. FSM-J put the lid back on the mug and we walked back to the kitchen. We waited five minutes and had FSM-J measure the temperature of beverage. When FSM-J removed the lid, the beverage was still steaming. FSM-J measured the temperature, and the beverage was 150 degrees F. On 5/7/2025 at 11:35 AM, Nursing Home Administrator (NHA)-A stated NHA-A called the company that services the coffee/hot water dispenser to turn down the temperature of the machine. NHA-A stated for lunch, the kitchen staff will be temping the hot beverages and adding ice to the hot beverages. NHA in training-C stated maintenance was done about a year ago on that machine where they had to turn up the temperature because it was not warm enough. In an interview on 5/7/2025 at 2:32 PM, CNA-K stated another CNA had given R34 hot chocolate that caused R34 to get burned. CNA-K stated after all the dinner trays had been collected that day, R34 complained that R34's side hurt. CNA-K stated CNA-K was not involved with caring for R34 that day but had thought the CNA heated up a cup of hot chocolate in one of the microwaves in the kitchen. CNA-K did not have any other information about the incident. Surveyor noted this was the only report of the use of microwave to heat up the hot chocolate. On 5/7/2025 at 4:00 PM, Surveyor shared with NHA-A, DON-B, and NHA in training-C the concern R34 did not have in the Care Plan to place items to the left because of R34's inability to use the right hand and the Care Plan was not revised after the incident to address this. R34 was served hot chocolate on 12/17/2024 and staff did not turn the handle towards the left hand causing R34 to have to use the right hand get the cup into the left hand. R34 spilled scalding liquid onto the left side while trying to transfer the cup from one hand to the other causing a third degree burn that to the left side. Surveyor shared the concern the facility did not do any investigation into the temperature of the water that was dispensed by the machine in the kitchen and the staff continued to use the hot water without any regulating or monitoring of the temperature of water until Surveyor brought it to the facility's attention during survey, potentially causing harm to any other resident that accidentally spills a hot beverage. 2) R50 was admitted to the facility on [DATE] and has diagnoses that include moderate protein-calorie malnutrition, moderate dementia with other behavioral disturbance, peripheral vascular disease, mood affective disorder, macular degeneration, muscle weakness, and rhabdomyolysis. R50's quarterly minimum data set (MDS) dated [DATE] indicated R50 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 4 and the facility assessed R50 needing maximal assist with one staff member for repositioning, and total assist with one staff member for toileting hygiene, upper and lower body dressing. R50 transferred with assist of two staff and a gait belt to move between surfaces. R50 is incontinent of bowel and bladder and wears adult briefs for protection. R50's care plan documents risk for injury, have the potential to fall down and hurt self -care plan initiated on 2/5/2025 with the following interventions: I (R50) need my nurses to: - Request a therapy screen if needed and collaborate with therapy. - Remind to ask for help. - Anticipate fall times. - Ensure proper positioning. I (R50) need my aides to: - Remind to ask for help. - Soft touch call light within reach. - Offer to get up between 0600 - 0745 (600 AM-7:45 AM) . - Ensure grippy socks are on when in bed. - Place fall mat on floor next to bed. - Offer to toilet between 2030 - 2230 (8:30 PM - 10:30 PM), then offer assistance to bed. - Ensure grippy socks or shoes are on at all times . - Soft touch call light within reach. On 3/10/2025, at 11:00 AM, in the progress notes nursing documented medical doctor (MD) and physician assistant (PA) updated on R50's fall with no injury on 3/8/2025, no new orders. Surveyor noted there was no documentation in R50's progress notes on 3/8/2025 regarding R50 falling. Surveyor requested the fall investigation for R50's fall on 3/8/2025. Surveyor reviewed the facility's fall investigation completed on 5/8/2025 at 20:58 (8:58 PM) which documented R50 was found sitting on the fall mat next to R50's bed with an aide by R50's side when nursing entered R50's bedroom. R50 was unable to describe what happened. Surveyor noted no staff statements were documented. There is no documentation as to when staff last observed or assisted R50 to the bathroom or what R50 was doing prior to R50's fall. An interdisciplinary team (IDT) note dated 3/10/2025 documents root cause analysis determined by IDT team using fall report and staff statements. R50 was lying in bed and then observed sitting on fall mat next to bed. R50 denies hitting head and no injuries noted at time of fall. Intervention: bolster cover over mattress to define edge of bed for resident. On 5/7/2025, at 9:37 AM, Surveyor asked Director of Nursing (DON)-B if all the information from R50's fall on 3/8/2025 was provided. DON-B stated all the information was provided. Surveyor asked what expectations were of staff if a resident fell. DON-B stated staff should assess the resident, complete a fall report, fall assessments, initiate neurological check if unwitnessed, update administration, medical providers, and emergency contacts, put on 24 hour board for monitoring. Surveyor shared the concern there was no documentation in R50's medical record regarding R50's fall, no indication if medical providers were notified, and no staff statements indicating when R50 was last observed or toileted or what R50 was doing prior to R50 falling on 3/8/2025. DON-B stated medical providers, emergency contacts, and administration was contacted but noted it was not documented in progress notes or the fall investigation so when the IDT reviewed the fall on 3/10/2025, a progress noted was documented. DON-B understood concern there was not documentation or staff statements indicating when R50 was last observed, checked on, or toileted or what R50 was doing prior to R50's fall on 3/8/2025 to indicate if R50's fall could have been prevented. 3) R29 requires extensive assistance by 2 staff using a gait belt and non-mechanical transfer device to move between surfaces. On 2/17/25, 2 staff members were transferring R29 and did not use the non-mechanical transfer device correctly. R29 fell. The facility did not thoroughly investigate the fall to identify an accurate root cause for R29's fall. The facility implemented a new fall intervention of educating staff on correct use of the transfer device. The facility did not educate all staff members involved in R29's fall. The facility policy revised 5/2024, titled Fall prevention and Management Program, documents, in part: . The goal of this program is to enhance each resident's mobility and encourage independence by removing the risk of falls where possible and reducing both the incidence of falls and the injuries that may occur. It is the policy of this facility to provide the highest quality care in the safest environment for the residents residing in the facility. The program identifies the factors that place residents at risk for falls, promotes proactive healthcare practices for resident care planning using the least restrictive method possible to keep the resident safe and identifies the main components of an effective fall prevention program. These components include fall risk assessment, identifying risk factors, implementing interventions, documentation, evaluation, regular reassessment and re-evaluation . The Fall prevention and management program identifies staff participation and accountability to include . Expectation of all caregivers to observe resident transfer status, environmental hazards, and any other factor that may lead to falls during the daily provision of the resident's personal care . Post fall assessment: .Transfer resident per safe patient handling policy. Utilize lift unless the resident is able to rise independently . A comprehensive Post fall Nursing Report must be completed in [name of electronic medical record] . Care plans must be reviewed and revised at the time of the fall. A new intervention must be added to prevent further falls The [Interdisciplinary Team (IDT)] will complete a post-fall evaluation as soon as possible to assure that appropriate measures are in place in order to prevent falls. The post-fall evaluation should include factors specific to the resident. General factors affecting the resident's falls will be considered . The facility policy reviewed/updated 2/2024, titled Safe Patient Handling, documents, in part: . Goals: Reduce the injury potential for both the resident and caregiver . Ensure staff competency in the safe use of transfer and mobility-related equipment. Outline roles and responsibility of staff members. New resident's transfer status will be determined by therapy. Stand Aid with gait belt- A stand Aid may be used with one or two caregivers as care planned. The resident must be able to bear weight and pull themselves into a standing position. Resident must be able to hold on with at least one hand during the entire transfer. Each caregiver participating in a transfer will be required to abide by this policy. It is the responsible of all nurses and management to ensure this policy is followed. Non-compliance with the policy will result in disciplinary action (this includes employment termination) and retraining. Training specific to the safe patient handling policy and all equipment will be provided before employee uses any equipment to transfer resident. All caregivers will receive training on all transfer status and use of mechanical lifts . It is required that the safe patient handling policy will be followed at all times. If this policy is not followed, disciplinary action, including termination of employment, will be taken. The undated manufacturer's operation manual for [name brand] non-mechanical stand assist device documents, in part: . The [name brand] stand assist is a manual standing aid that requires patients to assist themselves in preparation for transport. Functionally, the Stand Assist is positioned between a traditional walker and a battery powered sit-to-stand lift. The Stand Assist is a convenient toileting alternative to a wheelchair. Once the resident has positioned themselves on board, the split seat can be positioned to allow the resident to sit comfortably while a caregiver performs the transport. The [name brand] Stand Assist's intended use is as a transport assistance unit. R29 was admitted to the facility on [DATE] with diagnosis that includes acquired absence of right leg below knee, Type 2 Diabetes with foot ulcer and chronic peripheral venous insufficiency. R29's admission Minimum Data Set assessment dated [DATE] documents R29 is cognitively intact. R29 has a lower extremity impairment on one side. R29 requires substantial/maximal assistance for toileting hygiene, shower/bathing, and dressing. R29 is dependent in the ability to come to a standing position from a sitting position. R29 is dependent for transfers. R29 is frequently incontinent of bladder and always incontinent of bowel. R29 has not had a fall in the last 6 months prior to admission. R29's fall risk assessment completed on 12/10/24 documents a score of 17 which indicates R29 is at risk for falls. R29's potential to fall care plan dated 12/10/24, documents the following pertinent interventions: remind me to ask for help, frequently check on me, assist me with transfers, remind me to get up and move slowly, encourage me to use assistance. My goal is to stay safe while I'm moving about to avoid injury. R29's Certified Nursing Assistant (CNA) Kardex documents: The resident requires extensive assistance by 2 staff using a gait belt and [non-mechanical transfer device] to move between surfaces as necessary. Keep a Hoyer sling in resident chair in case resident refuses [non-mechanical transfer device] transfer. R29's fall report dated 2/17/25, at 3:01 PM, documents, in part: Date of fall: 2/17/25. Time of fall: 1:15 PM. Location of Fall: Resident's Room . While transferring resident from bathroom to wheelchair via [non-mechanical transfer device], resident's legs gave out causing resident to be assisted to the floor. No injury noted. Mobility status: Resident is an assist of two via [non-mechanical transfer device], non-ambulatory. What was the resident wearing? Personal well-fitting clothes, prosthesis to right lower extremity. Gait belt used? N/A. Lift used correctly: Yes . Care plan followed: Yes . Intervention: Therapy to re-assess transfer status, using Hoyer for safety at this time. Surveyor noted R29's fall report documents the fall occurred because R29's legs gave out. The fall report does not document that a gait belt was used according to R29's care plan. The fall report documents the lift was used correctly. R29's post-fall evaluation note dated 2/18/25, at 10:00 AM, documents, in part: Location of fall: Resident's room/bathroom . Equipment issues: none noted . Contributing factors: none identified . Appliance used correctly: Yes . Cause: Became weak during transfer with staff using [non-mechanical transfer device] . Root cause analysis determined by IDT team using fall report and staff statements. Resident being transferred with staff from [non-mechanical transfer device] to wheelchair when resident became weak/legs gave out and resident was lowered to the floor by staff. No injury noted at time of fall. New intervention: Floor nurse intervention discontinued. New intervention: staff education on correct use of [non-mechanical transfer device] and therapy to work with resident on [non-mechanical transfer device] transfers. Surveyor noted R29's post-fall evaluation documented there were no contributing factors, the appliance was used correctly and there were not any equipment issues. This contradicts the new intervention of staff education on correct use of transfer device. Surveyor noted the root cause analysis identifies R29 became weak but does not identify or document what staff did incorrectly with the transfer device and why staff needed education. Surveyor noted staff statements were not included in the post-fall evaluation. R29's potential to fall care plan dated 2/17/24 documents, in part: I have fallen .I need my nurses to have therapy re-assess transfer status, use Hoyer for safety at this time. On 3/3/25, at 9:40 AM, Surveyor interviewed R29 about the fall. R29 stated R29 fell while 2 staff members were transferring R29 from the toilet to R29's wheelchair. R29 was on the transfer device when a staff member was pushing the device to get over the thresh hold bump from the bathroom to the resident's room where R29's wheelchair was located. R29 stated both seats of the transfer device were not down as they should have been. R29 stated R29 was not wearing a gait belt. R29 stated the staff member pushing the transfer device could not get the transfer device over the little bump. R29 stated the staff member pushed hard to get over the bump. That is when R29's leg gave out and R29 fell off the device on the side the seat was not down. Surveyor noted R29 is cognitively intact and R29's account of the fall was not included in the facilities fall report or post fall evaluation. Surveyor noted R29 indicated the non-mechanical transfer device was not used correctly and noted R29 was not wearing a gait belt as care planned. On 5/6/25, at 12:56 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D, who was the nurse assisting R29 with the transfer on 2/17/25. LPN-D stated LPN-D and a Certified Nursing Assistant (CNA) were helping R29 from the bathroom to the wheelchair located right outside of the bathroom when R29 lost R29's balance and fell. LPN-D stated LPN-D was at the lift and the CNA was getting the wheelchair to put it in the correct position. LPN-D stated LPN-D did not remember which CNA was helping. LPN-D indicated the seats of the non-mechanical transfer device were being lifted while the wheelchair was being placed. That is when R29 lost balance and LPN-D, and the CNA assisted R29 to the floor. Surveyor asked if any education was completed after this incident. LPN-D stated LPN-D did not recall any education provided after this incident. On 5/6/25, at 1:18 PM, Surveyor interviewed CNA-F, who was the other staff member helping LPN-D transfer R29 on 2/17/25. CNA-F indicated CNA-F and LPN-D were moving the non-mechanical transfer device from the bathroom to right outside of the bathroom where R29's wheelchair was located. CNA-F stated as they were turning the device to position it in front of the wheelchair, R29 let go of the device and both staff members assisted R29 to the floor. Surveyor asked if both sides of the seat to the transfer device were down as R29 was being transferred. CNA-F s[TRUNCATED]