**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure 2 (R26 and R29) of 2 residents reviewed received adequate supervision, interventions to prevent accidents. * On 02/12/2025, R26 sustained an injury during a transfer resulting in a skin tear to left lower leg requiring R26 to go to the emergency room where Steri-Strips were applied to R26's wound. On 03/03/2025, R26 reinjured R26's left lower leg during a transfer which caused bleeding and R26 was prescribed an antibiotic for Cellulitis. On 03/26/2025, Surveyor observed staff improperly transfer R26. *There was no quarterly smoking assessment for R29 on a quarterly basis. Findings Include: The facility's policy, titled NSG-Safe Resident Handling and transfers, with a last reviewed date of 05/05/2022, documents: Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping employees safe in accordance with current standards and guidelines. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employee that assist them. While manual lifting techniques may be utilized dependent upon resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Compliance Guidelines: . 5. Handling aids may include gait belt, transfer boards and other devices. 6. The staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly . 14. Resident lifting and transferring will be preformed according to the resident's individual plan of care. 1.) R26 was admitted to the facility on [DATE] with diagnoses that include, Polyneuropathy, anxiety, and Chronic Pain Syndrome. R26's Annual Minimum Data Set (MDS), dated [DATE], documents R26 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R26 is cognitively intact. R26's Annual MDS documents R26 did not exhibit behaviors, has impairment in bilateral lower extremities, uses a walker and wheelchair for mobility, requires substantial/maximal assist with sit to stand, is a partial/moderate assist with chair/bed-to-chair transfer, receives pain management with scheduled pain medication regimen, does not receive as needed pain medication, receives non-medication interventions for pain, frequency of pain is occasional, pain rarely effects sleep, pain rarely or not at all interferes with day-to-day activities, rates pain a 5 out of 10 and no documented skin tears. R26's Quarterly Minimum Data Set (MDS), dated [DATE], documents R26 has a BIMS score of 14, indicating R26 is cognitively intact, no behaviors exhibited, has impairment in bilateral lower extremities, uses a walker and wheelchair for mobility, is on a scheduled pain medication regimen, received as needed pain medication, did not receive non-medication interventions for pain, frequent pain frequency, does not interfere with sleep, occasionally interferes with day-to-day activities, rates pain 10 out of 10 on the pain scale, and has skin tear(s). Surveyor reviewed the Facility provided document, titled Care Plan Report, which documents: R26 has limited physical mobility with an intervention of transfer with assist of two using 2-wheel walker and gait belt. On 03/25/2025, at 09:11 AM, Surveyor interviewed R26. R26 informed Surveyor that during a transfer, the helper bumped R26's leg on the bed frame and indicated to Surveyor that this occurred twice. R26 informed Surveyor that R26 has been experiencing so much pain and does not want to lay in bed, but indicated the pain is bad causing R26 to stay in bed. R26 stated that R26 receives Tylenol but needs something stronger and informed Surveyor that R26 would be speaking with the wound doctor regarding the pain. R26 indicated that R26 has expressed being in pain to multiple staff. R26 informed Surveyor that R26's current pain is 5 out of 10 throbbing pain and pointed to R26's lower left leg that was wrapped in a gauze bandage. R26 informed Surveyor that it is hard for R26 to propel in R26's wheelchair due to the pain. Surveyor reviewed the facility provided document titled, Injury of Known Cause, dated 02/12/2025, which documents that Certified Nursing Assistant (CNA) reported that upon entering R26's room, there was a sheet on the ground saturated with blood. R26 had a deep skin tear to the front of R26's left leg with visible tissue. R26 states they hit their leg on the side of their bed while trying to transfer. R26 stated R26's leg hit on bed frame and was in pain. Under the Immediate action taken section it documents: R26's leg was wrapped to stop the bleeding, Emergency Medical Services (EMS) was called and R26 was sent out for further evaluation and treatment. Predisposing environmental factors documents, Furniture. Predisposing physiological factors documents, Weakness. Predisposing situation factors, documents, During Transfer. Other information documents, Noted: cap missing from bed frame exposing sharp edges of the metal. R26's late entry progress note dated 02/12/2025, documents that the clinical review determined root cause of injury was due to a missing cap from the metal frame of the residents' bed exposing, shard edges of metal piping. Under the Interventions section it documents that maintenance obtained the missing part from another bed not in use and placed on R26's bed. Surveyor reviewed the facility provided document titled, Injury of Known Cause, dated 03/03/2025, which documents in part, R26's left lower extremity wound reopened transferring from wheelchair to bed with assistance. Lower left extremity made contact with metal bed frame. R26 states R26 hit leg on the bed. Immediate action taken documents, pressure applied to wound, leg elevated, nurses applied pressure dressing and called 911. Foam pool noodles applied to bed frame, R26 made a 2 assist for transfers. Predisposing environmental factors documents, None. Predisposing physiological factors documents, Gait Imbalance and Weakness. Predisposing situation factors, documents, During Transfer and Other. Other information documents, R26 has fragile, poor skin turgor and left lower extremity contacted metal bedframe during transfer from wheelchair to bed. Surveyor noted a progress noted as Late Entry, dated 03/03/2025, documents, root cause: R26's skin is very thin and fragile with area previously opened. R26's left lower extremity encountered metal bedframe re-opening existing skin injury. Intervention: replaced R26's bed frame with a rounded- frame design. Surveyor reviewed the After Visit Summary (AVS) for R26, dated 02/12/2025, Surveyor noted under Instructions documents, Please continue wound care at home. Please follow -up with your primary doctor. Return to ER for any worse concerning symptoms. Please change the dressing daily. The Steri-Strips will fall off on their own when the hound is healing. Surveyor reviewed the Facility provided wounds notes by VOHRA. Surveyor noted R26 was seen on 02/18/2025 by the wound doctor and was prescribed Doxcycline 100 mg for 14 days, for Cellulitis of skin tear to lower left extremity. On 03/26/2025, at 09:10 AM, Surveyor observed Licensed Practical Nurse (LPN)-E assisting R26 from R26's wheelchair to R26's bed. Surveyor noted, LPN-E did not use the use of R26's 2-wheel walker. During the transfer, R26 indicated R26 was too weak, and could not transfer. LPN-E then indicated LPN-E would go to get someone else to help. On 03/26/2025, at 09:26 AM, Surveyor observed Certified Nursing Assistant (CNA)-D and LPN-E assisted R26 into bed. Surveyor noted R26's 2-wheel walker was not utilized during the transfer. Surveyor asked CNA-D how R26 transfers. CNA-D indicated before R26's leg got hurt, R26 was a one assist, but now for safety, is an assist of 2. CNA-D and LPN-E indicated that R26's transfer status should be in care plan and indicates how R26 transfers. On 03/26/2025, at 11:17 AM, Surveyor interviewed NHA-A regarding R26's transfer injury. NHA-A indicated can't remember exactly when it occurred but stated there was a process in place before 3/12/25 for a new bed, and stated there were no issues getting the new bed for R26. NHA-A stated that pool noodles stayed in place until a new bed arrived for R26. On 03/26/2025, at 03:08 PM, Surveyor interviewed CNA-F. CNA-F indicated that CNA-F got R26 up this morning. CNA-F indicated that R26 is a 1 person assist and can bear weight. On 03/26/2025, at 02:30 PM, Surveyor informed the facility of the above concerns. On 03/27/2025, at 09:15 AM, Surveyor interviewed NHA-A and Director of Nursing (DON)-B. NHA-A indicated that on 02/12/2025, following R26's injury, an audit was conducted of how many beds had open metal, circular holes, that were missing the plastic piece where R26 had cut R26's leg. NHA-A provided Surveyor with a document with no title, dated 02/12/2025, which documents 45 missing plastic pieces between 31 beds. NHA-A indicated the replacements were ordered, but then had to order more due to being on back order. NHA-A provided Surveyor with another document, with no title, dated 03/03/2025, documents 3 beds with missing square hole covers. NHA-A indicated that after the 03/03/2025 incident, it was noticed that the bed also had square plastic pieces missing causing the metal to be exposed on R26's bed. The audit was completed, and the square hold covers were replaced. NHA-A indicated there are no current occupied beds with holes. DON-B informed Surveyor that DON-B started to distribute trainings, on safe transfers, last night after speaking with surveyor. DON-B informed Surveyor that therapy will be seeing R26 later today to re-evaluate transfer status but is currently a 2 assist, using a gait belt and two wheel walker. No additional information provided as to why R26 was not provided with assistant devices to prevent accidents. The facility's Smoking Policy implemented 5/2019 and last reviewed 9/10/24 documents: Policy: It is the policy of this facility to provide a safe and healthy environment for Residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking Residents. This center shall establish and maintain a safe environment, while maintaining Resident rights, smoking or nicotine use will be limited to designated areas and safety plans. Policy Explanation and Compliance Guidelines: 4. All Residents will be asked about tobacco/nicotine use during the admission process, and during each quarterly or comprehensive MDS assessment process. 5. Residents who smoke or use nicotine or e-cigarettes will be further assessed, using the Nicotine Assessment UDA, to determine whether supervision is required for smoking, or if Resident is safe to smoke at all. 2.) R29 was admitted to the facility on [DATE] with diagnoses of Paraplegia, Acquired Absence of Right Leg Above Knee, Polyneuropathy, Necrotizing Fasciitis, and Major Depressive Disorder. R29's Quarterly Minimum Data Set(MDS) completed 2/9/25 documents R29's Brief Interview for Mental Status(BIMS) score to be 15, indicating R29 is cognitively intact for daily decision making. R29's MDS documents no behaviors. R29 has no range of impairment on upper extremities and impairment on both sides of lower extremities. R29's admission MDS completed 5/21/24 documents no tobacco use is documented. On 3/25/25, at 9:32 AM, Surveyor observed that R29's right and left hands are significantly contracted. R29 informed Surveyor both hands have been contracted for a long time and does not prevent R29 from being independent with use of hands. R29's smoking care plan initiated 3/25/25 documents: At risk for smoking related injury due to independent smoking. Interventions initiated 3/25/25: -Allow R29 to smoke independently in designated area. -Completed nicotine assessment per facility policy -Observe R29 for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management of concerns -Review smoking policy with R29 -Storage of smoking materials per facility policy On 3/25/25, at 10:50 AM, Surveyor notes that R29's smoking assessment determining R29 to be independent with smoking was completed 11/8/24. On 3/25/25, at 1:56 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B stated that smoking assessments are completed on admission, quarterly, and as needed. On 3/26/25, at 9:40 AM, Surveyor notes that a new smoking assessment was completed on 3/25/25. On 3/26/25, at 2:45 PM, DON-B confirmed that R29's smoking assessment should have been completed on a quarterly basis since admission. DON-B confirmed that DON-B completed R29's smoking assessment on 3/25/25. Surveyor shared the concern with Administrator (NHA)-A and DON-B that R29's smoking assessment was not completed on a quarterly basis. No additional information was provided by the facility as to why R29 did not have a smoking assessment completed on a quarterly basis.