**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop and revise comprehensive care plans for each resident that included the instructions needed to provide effective and person-centered care for one (#10) of four residents out of 30 sample residents. Specifically, the facility failed to: -Update and personalize care plans for Resident #10 who was at high risk for falls; -Update Resident #10's dementia care plan documenting interventions; -Initiate a care plan for Resident #10's refusals to wear oxygen; -Personalize Resident #10's behavioral care plan with interventions to deter his verbal aggression; and, -Personalize Resident #10's care plan for his refusals of care. Findings include: I. Resident status Resident #10, age over 65, was admitted on [DATE]. According to the February 2024 computerized physician order (CPO) diagnoses included injury of the brachial plexus (nerves in the shoulder), chronic respiratory failure with hypoxia (not enough oxygen in the tissues of the body), heart failure, chronic diastolic heart failure (congestive heart failure) and unspecified dementia without behavioral disturbances. According to the 12/12/23 minimum data set (MDS) assessment Resident #10 declined to complete a brief interview for mental status (BIMS). Staff completed an assessment for mental status on behalf of Resident #10 and documented he did not have a memory problem, no issues with inattention, disorganized thinking or altered level of consciousness. During the assessment, Resident #10 was documented as having displayed physical and verbal behavioral symptoms directed toward others. II. Care plan failures A. Dementia and behavior care plan 1. Progress notes A progress note entered on 3/6/23 documented Resident #10 was inappropriate at 9:45 a.m. during a shower. He attempted to spray the nurse with the handheld showerhead. The resident was angry, belittled the nurse and was condescending to her because she stayed behind the shower curtain to keep dry. The nurse asked the resident to stop spraying the water toward her and the resident asked the nurse Why? Do you not want to play? You can just go change after this. The nurse told Resident #10 that she did not bring extra clothes and preferred to stay dry and comfortable while performing her job for the rest of the day. Resident #10 continued yelling at the nurse after the encounter with the water. The resident told the nurse to hurry up and demanded she scrub his back. The nurse offered to let the resident direct her actions instead of the nurse showering him in the order he normally showered. The resident said Are you going to scrub my back? How long does it take to put soap on my back? As the nurse scrubbed his back from top to bottom the resident yelled at her Are you not going to wash my legs? The nurse agreed and asked if she could put the handheld shower back on the holder so she did not accidentally get wet. The resident argued again and said, It was just a game. He told the nurse Smile if you want me to hand you the shower head three times before eventually handing it to the nurse. During the rest of the shower, the resident was equally demanding and rude to the nurse. He did not joke around with the nurse like he usually did. While the nurse assisted the resident with getting dressed the resident threatened to turn the water back on in order to drench the nurse. A progress note entered on 3/17/23 documented Resident #10 reported to a certified nurse aide (CNA) he was realizing his memory was worsening and that he either did not remember things or could not remember the next word he wanted to say. A message was left with social services to check in with the resident. A progress note entered on 3/31/23 documented Resident #10 was assisted to the toilet by the nurse. The resident became agitated when he refused proper peri-care. The nurse provided education about preventing skin breakdown. He started talking loudly and called the nurse a rude name and told the nurse she did not know how to do her job. The nurse told Resident #10 he was being rude and disrespectful and it was not being nice to the nurse. The nurse swapped out with the CNA who finished providing care to the resident. Later in the evening Resident #10 requested to speak with the nurse. The CNA walked in with the nurse and the resident asked the CNA to leave. The CNA left the resident's line of sight but stayed in the doorway to witness the conversation. Resident #10 apologized to the nurse and said he was not serious and meant it as a joke. The resident said he did not understand why the nurse took it seriously. The nurse told the resident she did not appreciate the way the resident teased her and not to do it again. The resident verbalized his understanding. Another progress note entered on 4/18/23 documented Resident #10 had a behavior on 4/16/23 and the progress note was a late entry. Resident #10 told the CNA to shut up while yelling profanities at the CNA. The CNA reported this incident to the nurse at the end of the shift. The CNA said the behavior occurred while the CNA assisted the resident with a transfer to his bed. The nurse told the CNA to tell the resident his behavior was inappropriate and to report the behaviors as soon as they occurred. The resident said he did not remember the incident. Another progress note entered on 4/18/23 documented Resident #10 used his call light and asked the nurse to turn on his television. The resident placed the television remote on his lap. The nurse told the resident she was not grabbing the remote from his groin. Resident #10 laughed and asked the nurse why she would not grab the remote. The nurse told the resident he was being nasty. The resident laughed as the nurse left his room. Another progress note entered on 4/18/23 documented Resident #10 used his call light and when the nurse responded a CNA waited in the doorway to be a witness to the conversation. The resident asked the nurse to turn on his television again. The resident was covered with a blanket and the remote was placed on his chest. The nurse asked the resident to hand her the remote. The resident said Oh come on. The nurse told the resident he placed the remote on his groin and then moved it to his chest so he could place the remote in her hand. The resident picked up the remote and the nurse took it from his hand. The nurse turned on the television and asked the resident what he wanted to watch. The resident asked the nurse to call someone else to assist him and the nurse informed the CNA. A progress note entered on 5/6/23 documented Resident #10 was in his doorway when another resident passed by Resident #10's door. Resident #10 started joking around, raised his voice and made aggressive hand gestures. The other resident told Resident #10 to stop multiple times and Resident #10 continued to escalate. Resident #10 believed it was all in fun. The staff intervened and the other resident continued down the hallway. Resident #10 finally understood the other resident was not joking around and did not appreciate Resident #10's behaviors. Resident #10 expressed remorse for his actions. A progress note entered on 5/12/23 documented Resident #10 was screaming profanities while yelling Where is it. The nurse heard a loud crash in the resident's room. The nurse entered the resident's room and he triggered his call light. The resident escalated and said he was mad at his hand because he spent two hours working on getting his hand to work. Resident #10 spilled a cup of juice and threw his cup at the door of his room and broke it. A progress note entered on 6/21/23 documented Resident #10 had been reported to the nurse as being disrespectful to the staff. The nurse talked with the resident and asked him to be respectful when he interacted with staff. A progress note entered on 8/3/23 documented Resident #10 was excessively sleepy. The CNA entered his room and told the resident he was there to recheck his vital signs. The CNA told Resident #10 he would fix the resident's messy hair and reached over to assist. Resident #10 intentionally struck the CNA in the stomach. The CNA stopped for a moment to see if it was an accident. Resident #10 did not say anything. The CNA attempted to fix the resident's hair again and the resident struck the CNA in the stomach even harder. The CNA left his room and told the nurse. The nurse checked on Resident #10 to see what was going on and he refused to talk to the nurse. The resident was asked if he hit the CNA and he said no. The nurse said hitting was not an acceptable behavior and left Resident #10's room. A progress note entered on 8/10/23 documented Resident #10 did not listen to the CNA's instructions when the resident was helped to the bathroom. The resident continued to turn before he sat down on the toilet. The resident refused to follow instructions or help the CNA in any way when he was getting off the toilet. The CNA told the resident she needed to get another CNA for assistance and the resident yelled profanities at the CNA. He demanded the CNA stay in the bathroom. The CNA told the resident he was safe sitting on the toilet and to wait for her to return. The resident ignored the CNA when she told Resident #10 to be nice. A progress note entered on 9/22/23 documented Resident #10 had a good day for the most part. Resident #10 cursed at staff and called staff derogatory names. He was offered to shower numerous times throughout the day and refused all offers. The resident said he did not want a shower and did not need one. A progress note entered on 10/25/23 documented Resident #10 was reported to yell at a CNA that he did not like her and demanded her to leave his room on 10/24/23. A progress note entered on 12/4/23 documented Resident #10 called the CNA names in a degrading manner. Resident #10 yelled for the CNA to get out of his room because he did not like her. The resident yelled profanities at the CNA to get out of his. Resident #10's representative was informed of the incident and said she did not believe the incident occurred and said the CNA was too sensitive. A progress note entered on 12/16/23 documented Resident #10 was sitting in his wheelchair for a few hours and refused offers to lie back in bed. After the resident ate lunch he yelled for help instead of using his call light. He yelled profanities while demanding the staff to get him into his bed because he had sat on his buttocks too long which caused some discomfort. The staff told the resident they needed to get the Hoyer (mechanical) lift. Resident #10 yelled profanities at the staff and demanded they push his wheelchair next to the bed so he was able to transfer himself because he felt he did not need the Hoyer lift. 2. Care plan failure Resident #10's dementia care plan, reviewed 9/18/23, documented the resident would maintain mental and psychological function as long as possible and behaviors would be reversed when possible. -Interventions were not documented on the care plan. Resident #10's behaviors were documented he was at risk for self-harm which referred to inappropriate behavior. Resident #10 lashed out at others, made inappropriate verbal and sexual comments and gestures toward caregivers, had irritability, refused to participate in therapy and refused care and medications. Resident #10 often made comments or used humor that he stated were harmless and he meant well but sometimes the staff took offense and he never meant it in a malicious way. Interventions were documented as: Assess ability to cope; Inform the resident of the care being provided; Maintain a regular daily schedule; Set the expectations for behavior; Document behaviors; Notify social services of decline in mood; Notify the medical director (MD) of any significant changes as needed; Observe for signs of agitation; Approach the resident in a friendly and calm manner; Do not ask why, question or argue with the resident; and, Assure the resident's safety and approach at a later time if necessary. -However, the facility failed to update the care plan with person-centered interventions to provide staff members with guidance to assist with Resident #10's verbal aggression and sexually inappropriate comments toward others. B. Fall care plan 1. Progress notes A progress note entered on 2/14/23 documented Resident #10 yelled out for help around 6:40 p.m. The CNA found the resident on the floor. He was on his back parallel to his bed. His head was at the foot of his bed and his feet were at the head of his bed, near the opened bathroom door. The resident said he was trying to find his cell phone while it was ringing. He said he stood up and was reaching around on his bed when he lost his balance, slipped on the floor, hitting his right hip and landed on his back. A progress note entered on 2/16/23 documented Resident #10 attempted to transfer three times throughout the shift without notifying staff. A progress note entered on 3/10/23 documented Resident #10 transferred himself four times during the shift without calling for assistance. The resident was reminded each time to call for assistance. A progress note entered on 3/18/23 documented the nurse was sitting at the nurses' station and heard a loud bang. The nurse looked over and saw Resident #10 was on the floor. When the nurse entered his room he was lying prone with his head and upper body lying next to the wall. The resident said he tried to get up by himself and lost his balance, fell and hit his head. The call light was near the resident and his pendent was around his neck. He was wearing shoes and had his oxygen on. Resident #10 had a hematoma (clotted blood under the skin) on the left side of his forehead near his hairline. The resident was sent to the emergency room and returned on 3/18/23. A note entered on 3/21/23 documented Resident #10 was reminded several times daily not to reach for items that had fallen on the floor. A progress note entered on 3/23/23 documented the nurse was at the nurses' station for over 10 minutes within sight of Resident #10. Resident #10 was seen standing unassisted in his room. The nurse reminded the resident that his behavior was unsafe. She said all he needed to do was push his call light and she would have happily assisted him to stand in a safe manner. The resident nodded his understanding. Another progress note entered on 3/23/23 documented Resident #10 was being monitored for a fall on 3/20/23 and began an antibiotic for a UTI. Resident #10 was impulsive by standing up without locking his wheelchair or calling for assistance. The resident was reminded to call for assistance. The resident nodded his understanding. A progress note entered on 3/26/23 documented the CNA at the nurses' station noticed Resident #10 was standing up from his wheelchair and attempting to walk across his room to get his walker. The CNA and nurse assisted the resident with his walker to the bathroom. Resident #10 was unsteady with two-person assistance. He was unable to grab his walker with his left hand and was swinging it around his right hand and leaned forward because he was unable to stand upright with one hand. He was assisted back to bed. The nurse provided education to the resident to use his call light before he self-transferred next time. He verbalized his understanding. Rounding was implemented for safety checks for Resident #10. A progress note entered on 4/28/23 documented Resident #10 transferred himself and had difficulty cooperating with staff. A progress note entered on 4/30/23 documented Resident #10 transferred himself twice during the shift. The first self-transfer was during from morning from his bed to his wheelchair. The second self-transfer was in the afternoon from his wheelchair to his bed. The staff overheard the resident's representative encouraging the resident to transfer himself without staff assistance. The staff educated the resident and his representative the importance of staff supervision during transfers. Another progress note entered on 5/6/23 documented Resident #10 transferred himself to the toilet without staff assistance or notifying staff. When the resident was done on the toilet he called staff to assist him. The resident told the staff What? You would have helped me? Resident #10 was reminded of the safety interventions and the potential consequences if he fell. The resident was angry toward the staff who assisted him in the bathroom and was yelling and disrespectful to the staff. A progress note entered on 6/30/23 documented Resident #10 had transferred himself from his wheelchair to his bed without calling for assistance. He was educated to call for assistance and nodded his understanding. A progress note entered on 9/24/23 documented Resident #10 was discovered on the floor by a CNA. The resident was on his knees at his bedside in a praying position. Resident #10 said he was trying to get into bed by himself. No injuries were noted. The resident was instructed not to get out of bed and to use his call light or pendant for staff assistance. A progress note entered on 11/12/23 documented Resident #10 was in a standing position with his walker and wanted to sit down. The wheelchair was in his bathroom and the resident was on the floor approximately three feet away from his wheelchair. Resident #10 did not use his call light. He was trying to straighten his waistband and he lost his balance and fell. The resident's representative witnessed the fall but did not remember what happened. A progress note entered on 12/5/23 documented Resident #10 insisted on ambulating from his bed to the bathroom. The resident refused to allow staff to use the Hoyer lift to transfer the resident to his wheelchair. Resident #10 said he had to use the restroom too badly to use the lift. He agreed to use the gait belt and his walker. A progress note entered on 1/21/24 documented Resident #10 sustained a fall at approximately 11:00 a.m. The resident had requested his phone to be charged before it started ringing. The resident said he heard his phone ringing and tried to answer his phone but it was not within his reach. Resident #10 stood up from his wheelchair, lost his balance, fell backwards and his head on the front wheel of his wheelchair. The resident said his head was hurting but refused to go to the emergency room. A progress note entered on 1/23/23 documented Resident #10 sustained a fall at approximately 6:20 p.m. The resident had fallen out of his wheelchair to the floor and was found in a prone (face down) position with his head on a pillow. Resident #10 said he was sitting in his wheelchair and tried to pick up something off the floor when he fell forward onto the floor and landed on his head. 2. Care plan failures Resident #10's care plan, reviewed 9/18/23, documented he was at risk for falls. Interventions were documented as: Assess the environment for safety risks; Modify the environment to eliminate risks; Keep the bed in the lowest possible position; Non-skid socks or shoes during transfers or ambulation; Assure position and possessions in reach; Call light within reach before leaving; Anticipate the resident's needs; Wall signage; Remind the resident to use his call light; Medication reviews; Fall leaf posted outside his door; Lipped mattress; Anti-rollbacks on his wheelchair; Motion sensor pad; Provide adaptive devices as needed; Offer to lay the resident down; Therapy will screen; and, Continue working with therapy. -However, the facility failed to revise the care plan when the resident had falls and document person-centered interventions to provide staff members with guidance to assist with Resident #10's refusal to use the Hoyer lift and his insistence on walking or self-transferring. C. Bowel and bladder care plan 1. Progress notes A progress note entered on 2/5/23 documented Resident #10 continued to be incontinent of urine at most of his three hours checks. His brief was changed and peri-care was provided as needed. He does not call to use the urinal or toilet, he often told staff he did not have to use the bathroom. A progress note entered on 2/15/23 documented Resident #10 refused toileting offered twice during the shift. A progress note entered on 3/11/23 documented Resident #10 was offered to use the toilet before lunch by a CNA. The resident yelled profanities at the CNA to stop asking him about being toileted. Another progress note entered on 3/11/23 documented Resident #10 refused to use the toilet multiple times during the shift even though the staff saw the resident's clothes and brief were visibly wet with a strong odor of urine. A progress note entered on 3/20/23 documented Resident #10 refused to be toileted. The resident reluctantly allowed a brief check and the brief was clean, dry and intact. The nurse asked multiple times and encouraged the resident to toilet before soiling his briefs. The resident refused because he wanted to sleep. A progress note entered on 3/21/23 documented Resident #10 refused a urinary tract infection (UTI) drink (cranberry) and refused any intake of water besides a small amount of water to swallow his medications. The nurse educated the resident on increased fluid intake and the benefits of cranberry on the bladder. The nurse explained it would flush out the bacteria and the resident groaned No I am just going to push it out. I am not taking any more of that (and pointed at the fluids offered). The resident continued on an antibiotic for UTI. A progress note entered on 3/23/23 documented Resident #10 had not agreed to any encouragement about increasing his fluid intake, despite the nurse's education provided. A progress note entered on 3/31/23 documented Resident #10 was assisted to the toilet by the nurse. The resident became agitated when he refused proper peri-care. The nurse provided education about preventing skin breakdown. A progress note entered on 4/28/23 documented Resident #10 refused each toileting offered throughout the shift. The resident agreed around 4:00 p.m. His brief, wheelchair, and clothes were soaked in urine. A progress note entered on 5/19/23 documented Resident #10 refused offers of toileting assistance. His clothes and the floor were wet with urine. A progress note entered on 10/25/23 documented Resident #10 refused assistance to the bathroom and refused to allow staff to change his briefs. Later in the shift two CNAs assisted Resident #10 to the bathroom. One of the CNAs noticed the resident's gait belt was loosening and the CNA saw the resident was trying to take off his gait belt. The CNA told the resident to stop taking off his gait belt. Resident #10 yelled at the CNA but stopped taking off the gait belt. 2. Care plan failures Resident #10's care plan, reviewed 9/18/23, documented he had bowel and bladder incontinence. Interventions were documented as: Apply moisture barrier ointment; Perineal care; Urology appointment as needed; Toileting assistance every three hours while awake; Incontinence education as needed; Assess his ability to communicate toileting needs; Assist with changing after an incontinence episode; Provide pull-ups or depends; Toilet frame in bathroom; and, Assist bars in the bathroom. -However, the facility failed to implement person-centered interventions to provide staff members with guidance to assist with Resident #10's refusals of toileting. D. Activities of daily living (ADLs) care plan 1. Progress notes A progress note entered on 3/21/23 documented Resident #10 had a dressing on his left hip. He was assisted to bed and demanded the nurse remove the dressing. The nurse educated the resident about the bandage. Resident #10 cursed at the nurse and said Take this thing off and just put some lotion on it. The nurse applied a skin barrier cream and he still refused to have a new dressing placed. A progress note entered on 12/19/23 documented Resident #10 was monitored for having two teeth extracted on 12/18/23. The resident had orders to not use straws and avoid carbonated beverages. Resident #10 insisted on using straws. The staff educated Resident #10 on the importance of not using straws but the resident demanded to use a straw. A progress note entered on 12/20/23 documented Resident #10 was monitored for having two teeth extracted on 12/18/23. Resident #10 kept insisting on using straws. The resident was educated on the importance of not using straws. A progress note entered on 12/21/23 documented Resident #10 was monitored for having two teeth extracted on 12/18/23. Resident #10 kept insisting on using straws. The resident was educated on the importance of not using straws. 2. Care plan failures Resident #10's care plan, reviewed 9/18/23, documented he was at risk for alterations in ADLs. Interventions were documented as: ADL support; Assure position and possessions were within his reach; Preferred bathing in the early morning in the bathtub or the shower with a shower bench; Call light within reach before leaving; and, Daily routine preferences. -However, the facility failed to revise the care plan with person-centered interventions to provide staff members with guidance to assist with Resident #10's refusals of ADL care. E. Nutritional care plan 1. Progress notes A progress note entered on 3/19/23 documented Resident #10 ate breakfast with a good appetite and was not interested in lunch or dinner. A progress note entered on 6/22/23 documented Resident #10 refused lunch and dinner during the shift on 6/21/23. Resident #10 requested and ate two sandwiches after day shift left. The resident requested another sandwich at 2:00 a.m. A progress note entered on 8/16/23 documented Resident #10 refused to get out of bed for dinner. His meal and snack were saved for later. Another progress note entered on 8/16/23 documented Resident #10 ate a late breakfast and had two servings. The resident refused lunch but accepted two servings of dessert at lunch time. Resident #10 stayed in bed during dinner. His meal and snack were saved for later. A progress note entered on 8/25/23 documented Resident #10 continued to be provided education on nutrition directly related to his health and strength. The resident continued to eat large portions, have second helpings of meals, snack throughout the night and had sandwiches or toast at night. He had gained 22 pounds since February 2023. Resident #10's care plan, reviewed 9/18/23, documented the resident was at risk for nutritional deficits and was on a dietitian-led weight loss program. Interventions were documented as: Consistent carbohydrate; Regular texture; Monitor weight and reassess as needed; Monitor laboratory values; Monitor intake as needed; Monitor frequency and type of bowel movement; Thin liquids as ordered; Provide the resident with his adaptive cups and silverware; Supervised meal assistance; Cut up meats as needed; and, Obtain, honor, and update food preferences as needed. -However, the facility failed to document person-centered interventions to provide staff members with guidance to assist with Resident #10's refusals of meals and his weight loss regimen. F. Continuous positive airway pressure (CPAP) and oxygen therapy care plan 1. Progress notes A progress note entered on 4/14/23 documented Resident #10 refused to wear his oxygen multiple times throughout the night. The resident woke up nauseous and with shortness of breath. The nurse checked his oxygen saturation and it registered at 89% on room air. The resident refused his oxygen and insisted he just needed some crackers. The nurse provided the resident with cracks and helped the resident to the toilet. After toileting, the resident appeared very out of breath and finally accepted his nasal cannula. His oxygen saturation was checked again and was at 93% while on two liters of oxygen through a nasal cannula. Resident #10 continued to complain of nausea but refused to stay in his wheelchair. Resident #10 started to wheeze and loudly said he had been doing this for his entire life and that he knew what was best for himself. Once Resident #10 calmed down the nurse assisted with his repositioning and the resident said he felt stable. Another progress note entered on 4/14/23 documented Resident #10's oxygen saturation was 89% while he was on two liters of oxygen via nasal cannula. The resident refused to allow staff to raise the head of the bed. The oxygen concentrator was increased to four liters and his oxygen saturation increased to 93%. A progress note entered on 4/17/23 documented Resident #10 was lethargic when breakfast was served. Resident #10 refused to wear his oxygen all night on 4/16/23 and the morning of 4/17/23. His oxygen saturation was 86% on room air. The nurse applied the resident's nasal cannula and his oxygen saturation increased to 94%. Resident #10 was agitated and scowled at the nurse because he did not want to wear his oxygen. The nurse told the resident it was an emergency situation if his oxygen saturation was that low and he was symptomatic and kept his oxygen on. A progress note entered on 4/18/23 documented Resident #10 refused to wear his oxygen during the night. His oxygen saturation was 86% on room air. The nurse applied the resident's nasal cannula and his oxygen saturation increased to 92%. A progress note entered on 4/24/23 documented Resident #10 often requested to have his oxygen removed. The resident said he did not need his oxygen anymore and told the nurse to check his oxygen saturation. The resident's oxygen saturation was at 88% on room air. When his nasal cannula was applied his oxygen saturation increased to 94%. A progress note entered on 5/12/23 documented Resident #10 refused to wear his compression stockings and oxygen. His oxygen saturation was at 88% on room air. The resident was educated on the need for oxygen therapy. The resident expressed his understanding but continued to refuse his oxygen. A progress note entered on 11/12/23 documented Resident #10's oxygen saturation was 84% on room air. A progress note entered on 11/22/23 documented Resident #10 refused to where his continuous positive airway pressure (CPAP) with oxygen during the night. 2. Care plan failures Resident #10's care plan, reviewed 9/18/23, documented he had complications which referred to sleep apnea. The intervention was documented as CPAP with oxygen while sleeping. -However, the facility failed to document person-centered interventions to provide staff members with guidance to assist with Resident #10's refusals to wear his oxygen throughout the day and CPAP while he slept. III. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 2/7/24 at 5:20 p.m. She said she used humor with Resident #10 when he was inappropriate toward her and the humor worked. She said some staff told him not to talk inappropriately but she used humor because the resident responded to it well. LPN #2 said at times the resident showed symptoms of a cognitive deficit and Resident #10 fell a lot because he still thought he could walk. She said when Resident #10 needed assistance two staff were required to provide the assistance because the physical therapist said he could not walk and needed the Hoyer lift for transfers. She said when the resident had urinary tract infections (UTIs) or a fall he showed less cognition. She said Resident #10's room was next to the nurses' station so the staff could keep a closer eye on him. The social services director (SSD) was interviewed on 2/8/24 at 9:00 a.m. She said Resident #10 had some memory forgetfulness but was able to make his own decisions. She said the staff explained things to him and he verbalized his understanding. The SSD said Resident #10 had not had [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for one (#27) of four residents reviewed for accident hazards out of 30 sample residents. Specifically, the facility failed to ensure timely, effective and properly communicated interventions were in place to prevent skin injuries and the recurrence of skin injuries to Resident #27. Findings include: I. Facility policy The Assisted lift Program policy, reviewed 1/30/23, was provided by the assistant director of nursing (ADON) on 2/7/24 at 2:39 p.m. The policy read in part: (The facility) wants to ensure that its (residents) are cared for safely, while maintaining a safe work environment for its employees. All patients and residents will be assessed with regard to the need for assistance with transfer activities, mobility or repositioning in accordance with (the facility) procedures and requirements. The patients/residents care plan will be established through the use of (the facility's) assisted lift policy and algorithms in determining and identifying the means for providing transfer and mobility assistance. Patients/residents identified as total dependent or needing more than minimal assistance will be transferred by means of mechanical lift equipment and or other assistive devices instead of a manual lift. Lifting equipment and other approved patient/resident assist devices will be operated in accordance with instruction and training. Staff will report to their supervisor all injury claims involving patient/resident-handling and movement. Staff will complete and document training initially, annually and as required to correct improper use/understanding of safe patient/resident handling and equipment training. The General Safety policy, reviewed 5/15/23, read most accidents were due to carelessness or lack of concentration. Staff should plan ahead of any possible hazards to help prevent the occurrence of an accident. The Positioning, Transfers, and Ambulation procedure, undated, read in part: Nursing assistants should not use equipment they have not been trained to use, as doing this could cause injury. II. Resident status Resident #27, age over 65, was admitted on [DATE]. The 10/24/23 minimum data assessment (MDS) assessment identified Resident #27 had medically complex conditions. Her diagnoses included dementia, heart failure, depression, asthma, chronic obstructive pulmonary disease (COPD) or chronic lung disease. The 10/24/23 MDS assessment indicated Resident #27 had severe cognitive impairment with a brief interview of mental status (BIMS) score of zero out of 15. The resident was dependent on staff for personal hygiene, dressing, toileting and transferring. The MDS assessment identified the staff did all the effort during a sit to stand transfer, a chair to bed transfer and a tub/shower transfer. III. Observations A. Protective geriatric (geri) sleeve use On 2/6/24 at 2:57 p.m. and again 4:38 p.m. Resident #27 wore long sleeves but she did wear geri-sleeves on her arms as indicated as an intervention for when she obtained skin tears (see below). On 2/7/24 between 9:38 a.m. and 5:39 p.m. Resident #27 was not observed to wear protective geri-sleeves. -At 9:38 a.m. Resident #27 was observed to be transferred by use of the sit to stand lift with the occupation therapy assistant (OTA). The resident wore long sleeves but she did not wear geri-sleeves as additional protection to her arms. The OTA did not offer geri-sleeves to the residents arms before the lift transfer. On 2/8/24 between 9:20 a.m. and 1:19 p.m. Resident #27 did not wear protective geri-sleeves. -At 9:20 a.m. Resident #27 was in the dining room. The resident's arms wear observed with CNA #1. The CNA identified the resident was not wearing geri-sleeves. She said Resident #27 did not wear geri-sleeves. She said if the resident needed the geri-sleeves, the sleeves would be available in the unit's supply closet. B. Mechanical lift observations On 2/7/24 at 9:44 a.m. Resident #27 was observed to be transferred with a sit to stand lift with the OTA. The OTA removed the lift from the resident's bathroom. The OTA identified the resident could not hear her so she replaced the resident's hearing aid batteries. Resident #27 was in her wheelchair in her room. The OTA removed the resident's non-skid socks from her feet and put slippers with a tread on the resident's feet. The OTA placed the sit to stand lift in front of the resident. The OTA placed a sling around the back of the resident and under the resident's arms. Resident #27 told the OTA Not too tight. The OTA placed the resident's feet on the footrests of the lift and placed her knees up against the knee/shin pads. The pads had standard manufacturing padding. -There was no additional padding to the knee/shin pads during the observation that was added once identified on survey from the resident obtaining injury (see investigations below). The OTA had the resident lean forward and attached the sling to the right and left side clip. The resident moaned slightly as the sling was attached to the lift. The resident's legs were not secured to the lift with straps or belt. The resident's hands were placed on the hand handles of the lift. The OTA unlocked the lift breaks and rolled the resident over to her bed. The OTA raised the bed and lowered the resident onto the bed and removed the sling. The resident was repositioned on her bed as she laid down with some manual assistance and cueing. A bedside table with the resident's cup with lid was placed next to the resident and a western show was turned on the television for the resident. -Observations did not identify additional padding covering the lift knee/shin pad. -Observations did not identify the resident's legs were secured to the lift with straps/belt. The sit to stand lift was observed with CNA #1 on 2/8/24 at 1:41 p.m.The CNA said she was shown how to use the lift when she was hired in December 2023. The review of the lift identified newly placed lamb wool padding covering the knee/shin pads on the lift. The safety belts/straps rested on top of the wool padding. The CNA said the belts buckle near the resident's feet. CNA #1 said the lambs wool padding was not there this morning (2/8/24). She said therapy must have just put it on the lift because the resident's skin was so fragile. IV. Skin injuries to Resident #27 during care with staff. A. 1/1/24 skin injury The 1/1/24 incident report was provided by the ADON on 2/8/24 at 12:37 p.m. The incident report read Resident #27 acquired a skin tear in the tub room on 1/1/24 at 7:40 a.m. A certified nurse aide (CNA) notified LPN #1 her name badge caused a skin tear to the resident's right lateral (outer side) of wrist. The skin tear measured 0.9 centimeters (cm) by 0.1 cm. The CNA staff was educated to use caution when working with the undressed resident and relocate name badge to prevent a recurrence. The 1/1/24 incident report identified the CNA who was involved in the incident and identified the CNA was educated. The 1/5/24 interdisciplinary team (IDT) review note read the resident was reported to have sustained a new skin tear to the right wrist during her bath to the right wrist. It was reported by staff a CNA had caused the skin tear. The wrist was exposed during bathing and the name badge brushed up against the resident. The resident typically wore geri-sleeves and long sleeves to prevent skin injuries due to her fragile skin integrity. The nurse on shift provided wound care per guidelines and staff education to CNAs on shift to tuck their name badge in the garment or move to another location on their person. -However, according to the observations (see above) the geri-sleeves were not offered. B. 1/17/24 skin injury The 1/17/24 at 8:00 p.m. skin assessment read a new skin issue was identified. The 1/17/24 incident report was provided by the DON on 2/7/24 at 5:15 p.m. The incident report read Resident #27 acquired a bruise in the resident's room on 1/17/24 at 10:20 p.m. During a weekly skin check, the resident was noted to have a bruise on her right lower extremity (RLE). The bruise was approximately 3.0 cm in diameter, dark purple in color and flush to the skin. The note indicated the bruise was caused during a transfer from the sit to stand lift and her wheelchair. The resident's leg was bumped. The resident did not voice or exhibit complaints of pain or discomfort. The staff would take precautions of placement of the lift and the wheelchair to prevent further injury or future events so extremities were not in jeopardy of bumping. -The incident report did not identify staff members involved or a witness when the bruising incident occurred. The 1/22/24 IDT review note read a bruise identified during the resident's weekly skin check was possibly caused from a transfer with the sit to stand lift. The resident's leg could have been bumped which caused the bruise. The interventions included 72 hour monitoring, continued weekly skin checks, staff reminders to monitor placement of extremities when assisting the resident onto the sit to stand lift and a discussion with therapy to determine if padding was needed to protect the resident's fragile skin. -However, therapy did not address additional padding on the lift until during the survey (see addendum note below). A 2/8/24 at 1:32 p.m. (during the survey) late entry note form the director of rehabilitation (DOR) was added as an addendum to the above 1/22/24 IDT note. Resident #27's sit to stand lift was assessed. The shin pads on the lift were padded, however, the shin pads were wrapped with lambs wool for increased protection of the resident's sensitive skin. The resident verbalized agreement to adding the lambs wool to the shin pad. C. 2/5/24 skin injury The 2/5/24 incident report was provided by the DON on 2/7/24 at 5:15 p.m. The incident report read Resident #27 acquired a skin tear on 2/5/23 at 8:15 a.m. in the tub room. The incident report read the resident bumped her left wrist on the clip bolts on the sit to stand lift which caused a skin tear measuring 1.1 cm by 0.2 cm. There was a scant amount of bleeding. The area was cleansed and dressing was applied. Staff was to ensure proper hand placement to prevent a recurrence. CNA #5 witnessed the incident. The 2/7/24 IDT review note read Resident #27 had sustained a skin tear to her left wrist during lift use. The left wrist was reported to have been bumped on clip bolts of the lift. The resident was dependent on staff with the lift which placed her at an increased risk for skin injury. Resident #27 had long sleeve clothing at the time of the incident and was care planned for both long sleeves and geri-sleeves. The interventions read to educate staff on the importance of proper hand placement during lift use and continue to encourage use of long sleeves and geri-sleeves. -However, this was a previous intervention added and according to observations (see above) the resident was not wearing geri-sleeves. V. Record review The 9/23/2020 risk for alterations in activities of daily living (ADLs) care plan read Resident #27 was at risk due to overall decline, deconditioning and generalized weakness. The care plan directed staff to use a sit to stand lift with one person assistance. The 2/23/22 computerized physician orders (CPO) directed staff to offer protective sleeves to upper extremities at 8:00 a.m. and 8:00 p.m. The 3/1/22 skin care plan identified Resident #27 was at risk for skin breakdown. The care plan intervention directed staff to offer long sleeves or protective (geri) sleeves to upper extremities as tolerated by the resident. According to the care plan the resident would often decline to wear these (sleeves). -The care plan did not identify other interventions to try when the resident refused the geri-sleeves. -The care plan was not updated after 3/1/22 to direct staff to encourage long sleeves and geri-sleeves as identified in the IDT note on 1/1/24 and 2/5/24. A 1/18/24 email was provided by the ADON on 2/8/24 at approximately 3:30 p.m. According to the email from the ADON, he asked the nurse filing an incident report to investigate the root cause of the injury at the time of the report. He reminded the nursing staff to provide more details and a description of the incident when documenting the incident reports. The ADON identified the CNAs were often the ones to first identify or report concerns. The ADON requested the CNAs take mental notes on what they observed, what staff/residents were doing at the time of the incident and any suspected causes. -The email did not remind staff of proper body placement during transfers (see interviews below.) VI. Staff interviews The OTA was interviewed on 2/7/24 at 9:55 a.m. The OTA identified the precautions she took when using a sit to stand lift with Resident #27. The OTA said the resident was able to bear weight and understand basic directions. She said it was important the resident was able to understand her so the resident could follow the OTA's instructions as much as possible. The OTA said she made sure the lift sling was under the resident's arms, around her chest and under her breasts so nothing was pinching the resident. The OTA said she would make sure the resident's hands were clear of the lift and the resident had her hands on the lift handles. The DON and the ADON were interviewed on 2/8/24 at 11:17 a.m. The skin injuries and related documentation were reviewed with the DON and the ADON. The skin injury on 1/1/24 was caused when a staff's name tag brushed up against the resident causing a skin tear. The staff member was verbally educated at the time of the incident on the placement of the name tag during bathing. The ADON said the resident had a 2/22/23 physician's order for protective sleeves. She was care planned for the protective sleeves and she would often refuse them. The DON said after the 1/17/24 bruise she went to staff who worked on the unit and verbally did a one-to-one education with them to be mindful of resident body placement when using a mechanical lift. The staff should make sure the resident's legs were against the knee pad on the sit to stand and secured with straps behind her legs. She said the nurse who found the injury would be expected to do an education with staff on duty at the time of the incident. The ADON said staff were to follow up with therapy. The ADON said the height of the padded shin rest of the sit to stand lift matched up to the location of the bruise. The ADON said the bruise could have been avoided if proper leg placement was used. The DON said the bruise was found during weekly skin checks. She said she was not sure when exactly the bruise was caused or by which staff member. The DON said staff was reminded of proper body positioning of the resident when use of a lift. The ADON said an email was sent out to the nursing and CNA staff (see above). The ADON said the skin injury on 2/5/24 was caused when Resident #27 bumped the attachment clips of the sit to stand. There was no way to properly cover the clips and attempts could create concerns with infection control. Proper body placement was the one thing staff had control over. Staff was verbally educated on proper hand placement. The resident's arms needed to be on the inside of the lift and her hands placed on the handles. The DON said the incident was after the resident was bathed and getting into her wheelchair. The resident wore long sleeves at the time but not the geri-sleeves. The DON said licensed practical nurse (LPN) #1 documented the 2/5/24 injury. The DON said the staff member involved in the incident was either CNA #5 or CNA #6. The DON confirmed the CNA involved was not included in the incident report. She said she would contact LPN #1 to find out which CNA was involved in the 2/5/24 incident. The ADON said to prevent recurrence of a skin injury, staff would have continued education to promote long sleeves and geri-sleeves. He said they would also have therapy to screen the resident. The DON said there would be a lift training on 2/15/24 because of identified incidents and a need to review the mechanical lift process. The DON said the facility has had new nursing management since November 2023 and she had been looking at the improvement process as a whole. The DON said starting in this month (February 2024) in a couple of weeks, all new nursing/CNA staff would have on boarding training that would include mechanical lift training. The DON said the new hires would have exposure to the mechanical lifts before working the floor. The DON and the ADON said all staff education after Resident #27's incidents on 1/1/24, 1/17/24 skin injury incidents were completed verbally and were not documented. CNA #2 was interviewed on 2/8/24 at 1:25 p.m. CNA #2 said she was the CNA for Resident #27 this morning (2/8/24). She said the resident had a bath today and then went to therapy. She said if the resident needed geri-sleeves, they would be in the supply closet but she thought she had seen some in her drawer in her room. CNA #2 entered the resident's room and found the geri-sleeves in the dresser drawer. She said she did not ask the resident if she could put on the geri-sleeves because she had heard from another CNA that when the resident had on long sleeves, she did not need the geri-sleeves. She said in the CNA electronic charting showed there was nothing that she was aware of to direct her to offer the geri-sleeves to the resident. CNA #1 joined the interview with CNA #2. CNA #1 opened Resident #27 the electronic medical record task flow sheet and said the resident was only scheduled to be offered at 8:00 p.m. CNA #1 said Resident #27 had told her she did not want to wear the geri-sleeve but she (CNA #1) worked in the morning so the geri-sleeves were never brought up to her to have the resident wear the geri-sleeves. CNA #1 said the resident always wore long sleeved outfits. CNA #1 said the geri-sleeves were also set up as a nursing task so the nurse would be the one to put on the geri-sleeves. -CNA #1 and CNA #2 were not aware geri-sleeves should be offered during the day. The DON was interviewed on 2/8/24 at 2:29 p.m. The DON said geri-sleeves/protective sleeves for Resident #27 was scheduled as a task at 8:00 a.m. and 8:00 p.m. The DON said there was no way in our electronic medical record task flow sheet to identify if the resident refused. The task flow sheet just identified if the task was completed. The DOR was interviewed on 2/8/24 at 3:18 p.m. She said Resident #27 had very fragile skin. The DOR said the IDT requested therapy to provide extra padding to the resident's sit to stand lift. She said she was out of the facility at the time of the 1/17/24 skin injury incident and did not know of the request. The DOR said the communication was lost. She said she reviewed the lift and added lambs wool to the sit to stand lift pad. She said any of the therapists could have added the lambs wool if the therapists were made aware. She said the current system was not set up for direct notification to the therapy department when there was a request after an incident. She said moving forward she would request the IDT to email all the staff in the therapy department so any of the therapists could follow up with a request. The DOR said she was not involved in the interventions related to the 2/5/24 skin injury. The DON was interviewed again on 2/8/24 at 3:34 p.m. The DON said LPN #1 would have done a verbal training with the staff involved on 2/5/24. The DON said she had not been able to get a hold of LPN #1, CNA #5 or CNA #6 to find out who was involved in the incident. The DON said it would be beneficial to know who was involved in the 2/5/24 skin injury incident so she could provide additional education to that individual and learn more of what happened during the incident. Registered nurse (RN) #1 was interviewed on 2/8/24 at 4:07 p.m. RN #1 said she worked two days a week as the nurse for Resident #27. The RN said it was her understanding that the CNAs would offer Resident #27 geri-sleeves if the resident was wearing short sleeves but the resident usually wore short sleeves. The RN said the long sleeves count as protective sleeves. She said she was not aware of the resident's refusal to wear protective sleeves. -The RN was not aware the resident should be encouraged to wear both the long sleeves and the geri-sleeves as an intervention to protect the residents skin. -RN #1, CNA #1 and CNA #2 (above interviews) were not aware of who should offer the geri-sleeves. The DON was interviewed on 2/8/24 at 4:11 p.m. The staff training records were reviewed. The DON said CNA #6 was hired in March 2023. The CNA did not have mechanical lift training. The DON said she was not the DON when CNA #6 was hired so she did not know why the CNA had not received lift training yet. The nursing home administrator (NHA), the DON and the ADON were interviewed on 2/8/24 at 4:30 p.m. Accident hazards have been reviewed as part of the facility's quality assurance and improvement process. The facility was reviewing how to improve training and overall employee education in the coming year. The facility initiated a 1/4/24 improvement plan. The plan included a skills checklist for new hire employees during orientation and an ongoing audit of current employees who were due for annual educations. The new hire orientation would also include hands-on training with equipment to include the mechanical lifts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident who upon admission displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct an assessed problem and/or to attain the highest practicable mental and psychosocial well-being for one (#50) of four residents reviewed out of 30 sample residents. Specifically, the facility failed to: -Initiated therapy as recommended by preadmission screening and resident review (PASRR) Level II until four weeks later and after Resident #50 was experiencing mental health concerns: -Identify the Resident #50 triggers and past trauma to minimize being retraumatized; and, -Allow Resident #50 to have the bed of her preference due to a past traumatizing experience to minimize her trouble sleeping and night terrors. Findings include: I. Facility policy The Behavioral Health Care process and procedure, undated, provided by the nursing home administrator (NHA) on 2/8/24 at 1:06 p.m. read in pertinent: The Care Center social service team will reach out to the behavioral health liaison and request a meeting either via phone or in-person to discuss the support needed and coordinate with them appropriately to ensure that the resident receives adequate support to ensure that the behavioral health needs are met. The need is initiated either through staff observations, clinical documentation, or physician notes or a combination of all three as well as by resident and/or family request. II. Resident status Resident #50, age over 65, was admitted on [DATE]. According to the February 2024 computerized physician order (CPO), diagnoses were recurrent and moderate major depressive disorder, insomnia, unspecified depression, amnesia and unspecified dementia. According to the 1/10/24 minimum data set (MDS) assessment Resident #50 had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #50's patient health questionnaire (PHQ-9) score was zero out of 27 indicating no depression. III. Resident interview Resident #50 was interviewed on 2/5/24 at 2:29 p.m. She said she was not happy at the facility. She said she was having a rough time sleeping and was terrified of hospital beds. She said she had her own mattress and thought it would help but since the mattress was on a hospital bed it did not help. She said she was attacked in a hospital bed in the past and being in a hospital bed triggered her trauma. She said she had night terrors when she slept in the hospital bed. She said before she was admitted she measured the room she would be in and bought a bed frame and mattress that would fit with her other items. She said the facility told her she could not have the bed frame and it was in storage at the facility. Resident #50 said the facility told her she needed to sleep on a hospital bed. She said she tried to sleep on the floor with her pillow and blanket but she was not sleeping well. She said the thought of sleeping in the hospital bed triggered her trauma and caused her to sleep poorly. She said she woke up screaming numerous times when she slept in the hospital bed and she felt terrible if she woke up other residents from her night terrors. She said if she was unable to walk she would graciously give in and sleep in the hospital bed but she was still independent in most of her activities of daily living (ADLs) and should be allowed to use her bed frame. She said she knew it was an inanimate object but it did not matter because it was hard to get over it. Resident #50 said she had a lot of therapy sessions and they were helpful. She said she thought the trauma and triggers were taken care of until she was told she needed to use the hospital bed. She said she started sleeping during the day and stayed up all night because she felt safer sleeping in the hospital bed during the daytime. She said she missed out on some activities she wanted to attend because she needed sleep. She said the nursing staff were aware of her other triggers. She said she was triggered by people coming up behind her and touching her or speaking to her from directly behind her. She said another trigger was anyone coming into her room while she slept and she woke up to people in her room. She said staff would announce themselves when they were behind her from a distance and they knocked hard on her door but did not enter if she did not respond to the knocking. She said she was confused the staff worked on those triggers but she needed to sleep in a hospital bed which triggered her the worst. She said she enjoyed it when staff came into her room as long as she was awake because it scared her to wake up and find staff in her room. Resident #50 was interviewed again on 2/7/24 at 4:56 p.m. She said her traumatic experience was a physical and sexual assault at a hospital. She said she was diagnosed with chronic post-traumatic stress disorder. She said when someone approached her from behind and talked she went ballistic and freaked out on the person who triggered her. She said she had not slept at all during the night and was trying to sleep during the day because she was exhausted. She said she was tired of missing out on activities because she slept during the day but she did not know what else to do. IV. Record review Resident #50 was admitted on [DATE] with a PASRR II for her recurrent, moderate major depressive disorder. The recommended treatment was documented to provide individual therapy. Resident #50's care plan, revised 1/3/24, documented she suffered from complications of depression. Interventions were documented as the following: Depression screening as needed; Monitor for signs or symptoms of depression; Notify social services of a decline in mood; Allow time to express her feelings; Provide validation therapy; Administer medications as ordered; Document behaviors for psychotropic medications; and, Psychiatric services as needed. Resident #50's care plan documented she preferred no one enter her room until she answered the door and she slept late in the morning. A welcome email about Resident #50 was sent to the staff who worked the hall where her room was on 1/3/24 and read in pertinent part, Please welcome Resident #50. She is here for long-term care. She can be independent in the facility and her room. She startles easily, please approach from the side. -However, the facility failed to inform staff about her depression. A progress note from 1/12/24 documented a referral was sent per Resident #50's request for counseling. Resident #50 reported she had a long history of attending counseling and found it beneficial. A progress note from 1/31/24 documented that Resident #50 told the nurse she was afraid to sleep the night before (1/30/24). Resident #50 said she was worried she would scream again from her night terrors. She said she did not want to scare other residents with her screaming. She told the nurse she slept part of the night on her floor by putting her pillow on the floor, lying down and covering up with her blanket. The resident spoke several times about a situation in her past. Resident #50 said she was assaulted in a hospital bed in the past and did not want to sleep on her own mattress because it was on the hospital bed. The nurse asked the nurse practitioner (NP) who was at the facility to join the conversation. Resident #50 told the NP the same thing she told the nurse. Resident #50 said she was open to mental health counseling sessions and a behavioral consult was ordered by the NP. A counseling session was scheduled for 3/25/24 and an appointment with a behavioral health NP was pending for 2/12/24 in an effort to have the resident seen sooner. A progress note from 2/2/24 documented that a counseling session was scheduled for Resident #50 on 3/25/24 and a behavioral health appointment was scheduled for 2/12/24 to have the resident seen sooner. It documented these appointments were scheduled due to a past traumatic encounter that may have caused the resident night terrors and sleepless nights. V. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 2/7/24 at 5:20 p.m. She said the facility provided some training in the past for dementia care and trauma-informed care but the training was not in-depth. She said more training for Resident #50 would have benefitted the staff and Resident #50. She said after Resident #50 was admitted the certified nurse aides (CNAs) and nurses talked about trauma and how to help the resident but it was not enough. LPN #2 said Resident #50 was triggered by people walking up behind her and the staff talked about it but only with the staff that worked on Resident #50's hall. She said she knew Resident #50 asked for staff not to enter her room while she slept. LPN #2 did not know why Resident #50 did not want staff to enter her room while she slept. She said the staff on other halls would not know what Resident #50's triggers were because they were not documented except for waiting until the resident responded before the staff entered her room, but she thought it was just the resident's preference. The social services director (SSD) was interviewed on 2/8/24 at 9:00 a.m. She said once she received the recommendations, from a resident's PASRR II, she documented them in the care plan and offered the resident the recommended services. She said she updated leadership during morning meetings and asked leadership to inform their CNAs and nurses. The SSD said the facility required staff to attend at least 80% of all-staff training which included trauma-informed care and triggers. She said if staff members were unable to attend the training they watched them at a later date because the trainings were recorded. She said she completed hand-outs and emails to make sure the staff were informed of the resident's trauma and triggers. The SSD said she was unaware Resident #50 had any trauma or triggers because Resident #50 did not talk to the staff about anything in depth. She said she knew the resident had a personal mattress on the hospital bed but was unsure why. She said if Resident #50 was assaulted in a hospital bed then she was being traumatized and it was something that needed to be fixed. She said Resident #50 requested counseling and it was scheduled for 3/24/24 because that was the earliest appointment that was available. The SSD said she did not know there was a progress note which documented Resident #50's trauma, night terrors and she was not sleeping at night. She said Resident #50 did not like staff checking in on her if her door was closed. -However, according to Resident #50's interview (see above) she did not want staff entering her room if she was asleep. Resident #50 enjoyed staff checking in on her and talking with her if she was awake in her room. The SSD was interviewed again on 2/8/24 at 11:03 a.m. She said she was confused when she received Resident #50's PASRR II at admission. The SSD said she completed another PASRR II and she was told the resident already had an active PASRR II and the recommendations were still to provide individual therapy. She said she followed up with Resident #50 at her two-week care conference and Resident #50 asked to go to counseling and the referral was sent by the SSD for the facility's appointment scheduler to set the resident up with a therapy appointment. She said she was unsure why Resident #50's appointment for counseling was not scheduled until 1/31/24. The NHA was interviewed on 2/8/24 at 11:27 a.m. He said residents were not required to use a hospital bed but the facility was concerned about infection control and fall risk issues. He said upon admission she only requested her mattress and mentioned nothing about the bed frame. He said he was not informed the resident slept on the floor and asked if the staff confirmed it because Resident #50 had dementia and was often confused. He said he would have heard if the resident slept on the floor. Registered nurse (RN) #2 was interviewed on 2/8/24 at 12:48 p.m. She said she was unsure how to provide trauma-informed care to residents. She said she respected their boundaries and attempted to figure out what was wrong. She said she believed the facility provided online training for trauma-informed care annually but she felt the facility needed to provide more training for the staff. The assistant director of nursing (ADON) was interviewed on 2/8/24 at 1:15 p.m. He said the PASRR II came with recommendations that were recommendations for the facility to provide, not required. -However, PASRR II recommendations were required to be implemented in the resident's plan of care to address their mental condition. He said Resident #50 made some objective statements to her nurse and the NP was informed and assessed the resident. He said her appointment with behavioral health was scheduled for 2/12/24. He said the facility offered one-on-one therapy or talk sessions and emotional support. He said the resident had a BIMS of 15 and her PHQ-9 was zero. He said the resident was able to make her needs known if she needed more support. The ADON said the staff members were told not to enter the resident's room before she responded to them knocking on her door and he said that was implemented because it was her preference. He said she preferred that staff members did not come up behind her. He said the nurses documented any statements or incidents and that was how the facility managed her depression until she attended her appointments. The ADON was not sure where Resident #50's triggers were documented or what interventions were provided when she experienced triggers or depression. The SSD was interviewed again on 2/8/24 at 2:19 p.m. She said Resident #50's care plan only documented that she had depression (noted above). She said the resident's major depressive disorder was documented in the care plan as the resident has a PASRR II diagnosis. She said the care plan had nothing in it for her triggers or what staff needed to do to provide support for her major depressive disorder. VI. Facility follow-up On 2/8/24 at 2:00 p.m. Resident #50 received her bed frame from storage during the survey. She said she felt safe to sleep and was able to sleep at night so she would not miss out on activities or appointments during the day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the facility medication administration observation error rate was 7.32% or three errors out of 41 opportunities. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 2/12/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication. II. Facility policy and procedure The Medication Administration and Documentation policy, revised 11/3/21, was provided by the director of nursing (DON) on 2/7/24 at 8:49 a.m. It read in the pertinent part, Patient Safety is demonstrated by the use of the Five Rights: Right Medication, Right Patient, Right Dose, Right Route, Right Time. Verify that medication is being administered at the correct time, in the correct dose and by the correct route to the correct patient. III. Observations On 2/7/24 at 9:56 a.m. registered nurse (RN) #1 was observed preparing and administering medications to Resident #3: -Diclofenac Sodium, one application topical. Apply to bilateral hands three times a day before meals for pain. Scheduled for 7:00 a.m., 11:00 a.m. and 4:00 p.m. -Furosemide 40 milligram (mg) tablet for essential hypertension. Scheduled for 7:00 a.m. -Spironolactone 100 mg tablet for heart failure. Scheduled for 7:00 a.m. III. Staff interviews RN #1 was interviewed on 2/7/24 at 10:17 a.m. She said she was aware the three medications showed late but she was allowed to adjust the administration times for the three medications because the resident was sleeping and then had a scheduled shower. -However, she was not able to show where the allowance was ordered. The DON was interviewed on 2/7/24 at 12:48 p.m. She said the nurses should follow the seven rights of medication administration when administering medications. She said the facility followed a two-hour window on either side of the physician-ordered time for medication administration. -However, the 7:00 a.m. medications were not administered within the two-hour window (see observation above). She said when they noticed a resident was routinely sleeping in and not getting their medications at the prescribed time or within the two-hour window they would contact the physician and get an order to change the administration time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for one out of three units at the facility. Specifically, the facility failed to ensure housekeeping staff: -Following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (remote controls, light switches, door handles and drawer pulls); -Performed hand hygiene when appropriate; -Cleaning the toilet bowl appropriately; -Cleaned a resident's room from cleaner areas to dirtier areas to avoid spreading dirt and microorganisms; and, -Adhered to disinfectant cleaning guidelines. Finding include: I Professional reference Assadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. The Journal of Hospital Infection. 2021 Jul;113:104-114 was retrieved on 2/13/24 revealed, in pertinent part: High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 2/13/24 read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails -IV (intravenous) poles -sink handles -bedside tables -counters -edges of privacy curtains -patient monitoring equipment (keyboards, control panels) -call bells -door knobs Proceed From Cleaner To Dirtier Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: -During terminal cleaning, clean low-touch surfaces before high-touch surfaces. -Clean patient areas (patient zones) before patient toilets. -Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone. -Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. II. Facility policy and procedure The Patient Room Cleaning policy and procedure, revised on 5/10/23, was provided by the assistant director of nursing (ADON) on 2/7/24 at 12:05 p.m. It read in pertinent part, Remove liners from waste cans, remove soiled linen, remove everything from nightstands and over-bed table except the phone book, cafe menu, smoking cessation, Dispose of all trash in the normal trash cart, empty normal trash cart into the compactor prior to the end of the work shift. Check sharps container and install new container if full, [NAME] bio hazard waste take it to bio-hazard storage room. -Use Super HDQ solution, (10-minute disinfectant contact time). -Check cubicle curtain. If soiled, remove and send to laundry. -Check walls, and spot clean as indicated. -Check window and clean interior as indicated. -Check supply/exhaust vents and surrounding ceiling tile. -Wipe down the over-bed lights, over-the-bed table, nightstands, TV, chairs, trash cans, sink, mirror, paper towel holder, and soap dispenser. -Clean all surfaces of the bed(s), including both sides of head and foot boards, bed frame, lower bed frame, and control pendant. Make sure beds are centered under the lights. -Leave porcelain wet. Clean inside and outside of closets. Clean all doors, light switches, telephones and wall outlets. Use germicidal solution for all items, let the disinfectant work into all surface areas for the recommended contact disinfect time. -Dust mop floor. Damp mop floor using germicidal solution, rinsing mop after half the room. Change water and mop head after every three rooms, (change the water every room if the room had bodily human fluid). -Check all features of the room including over-bed lights (up and down lighting), TV, telephone, all lights, plumbing features, window blinds, bed controls, over-bed tables, etc. Check walls, floors, and ceiling for defects and report any deficiencies to Maintenance immediately. Bathroom: -Wash shower walls, sinks, disinfect mirrors, check soap dispensers, paper towel dispensers, toilet paper dispensers. Allow the disinfectant solution work on all surfaces for the recommended contact disinfect time. -Make a toilet cleaning solution using one full stroke of Super HDQ. Pour into toilet and swab all inside surfaces using a 'Johnny mop.' Use this cleaning solution to clean all exterior surfaces of the toilet including chrome plumbing fixtures and seat, Flush the toilet, let the disinfectant solution work in all the surfaces for the recommended contact disinfect time. -Clean exhaust vent as indicated. -Clean light switch and door handle with germicidal solution. -Check walls and spot clean as needed. -Damp mop floor with germicidal solution. Daily Cleaning of Occupied Room: -Introduce yourself to the patient and family members and ask permission to clean the room. -Do not clean the TV if it is on. If the TV is off, clean the TV. -Remove trash liners and soiled linen, making sure all wastebaskets are clean. Wash and spray if needed. Dispose of normal trash in the normal trash cart. Empty normal trash cart into the compactor prior to the end of the work shift, send all the soiled linen to the Laundry, check sharps containers, and bio-hazard waste and take it to the bio-hazard storage room. -Wipe down sink, paper towel holder, soap dispenser, towel rack, and mirror. Wipe down bedside tables and over the bed tables. Use germicidal solution described above. Do not move any personal items unless it is necessary, and put items back in the same place. -Dust mop and damp mop the floor, including the underneath of the bed. Rinse mop after half of the room has been mopped. Change mop water and mop head after every three rooms. -Clean the bathroom as described above. III. Disinfectant used in the facility The disinfectant used in the residential bathrooms in the facility was Peroxy II FBC antibacterial surface cleaner, the guidelines read: The antibacterial cleaning power of Peroxy II fbc kills 99.9% of household bacteria (Staphylococcus aureus and Enterobacter aerogenes) in 2 minutes. To Clean and Deodorize: Spray product on surface and wipe clean. Rinse promptly with water. For tougher jobs, allow product to penetrate dirt and/or soap scum before wiping. For best results, use regularly to prevent dirt and soap scum build-up. To Sanitize: To sanitize pre-cleaned non-food contact surfaces spray until thoroughly wet. Let stand for 2 minutes. Then wipe and rinse promptly with water. IV. Observations On 2/7/24 housekeeper (HK) #1 was continuously observed in a room on the Birch unit from 10:40 a.m. to 11:13 a.m. HK #1 sprayed the antibacterial surface cleaner on the shower walls and floor, the walls around the toilet and the top of the toilet. She removed the roll of toilet paper from the holder to the basket in the bathroom. She scrubbed the floor of the shower with a brush. She did not wipe the walls or toilet before spraying them down with the shower head. No high-frequency touch areas (door knobs, light switches or lower drawer handles) were disinfected. HK #1 left the bathroom and changed her gloves before getting the toilet brush from a red bucket with one inch of bleach in it. The toilet brush was not completely submerged in the bleach. She then returned to the bathroom with the toilet brush to clean the interior of the toilet. HK #1 finished cleaning the interior of the toilet and then put the roll of toilet paper back on the holder before she returned the toilet brush to the red bucket. She then got the mop and began mopping the floors. -She did not wipe the disinfectant over the surfaces (see above) before rinsing with water. -She did not use the toilet bowl disinfectant the facility used and there was not enough of the disinfectant that was used to cover the toilet brush. -She did not change her gloves after cleaning the interior of the toilet bowl before she mopped the floors. While mopping the floor HK #1 knocked the remote control that operated the recliner onto the floor. She did not clean the remote before placing it back on the recliner. She returned the mop to the bucket and began making the bed. She finished cleaning the room at 11:13 a.m. -She cleaned the resident's bathroom first (dirtier area) instead of cleaning the room first (cleaner). -She did not perform hand hygiene after touching the remote for the recliner that was on the floor. -She did not wipe any high-touch areas such as door knobs, light switches or lower drawer handles. V. Staff interviews HK #1 was interviewed on 2/7/24 at 11:13 a.m. HK #1 said she was trained by a coworker when she was hired. She said the liquid in the red bucket holding the toilet brush was bleach and it was not diluted. The housekeeping supervisor (HKS) was interviewed on 2/8/24 at 9:34 a.m. The HKS said housekeeping staff were trained by current workers. She said staff were instructed what solutions to use for particular areas and that bleach should not be used. She said they should use Comet for the toilet bowl. The HKS said housekeepers could clean the room in any pattern they wanted and there was no set direction (starting in the bedroom and moving to the bathroom). She said the staff should change their gloves between each room and after each time in the bathroom. She said if a device was on the floor it should be cleaned before moving it onto a clean surface.

Based on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner for two out of four kitchens. Specifically, the facility failed to ensure: -Staff used adequate hand hygiene while serving meals and touched ready-to-eat food appropriately; and, -Residents were offered and encouraged hand hygiene prior to meals. Findings include I. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved 12/27/23 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, Food employees shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a handwashing sink. II. Facility policy A. The Food Preparation and Service policy, revised 10/2/23, provided by the dietary manager (DM) on 2/8/24 at 3:00 p.m. read in pertinent: Food service staff, including nursing services personnel, will wash their hands before serving food to residents. Employees also will wash their hands after collecting soiled plates and food waste prior to handling food trays. Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed in between tasks. Disposable gloves are single-use items and shall be discarded after each use. Dietary staff shall wear hair restraints (hair net, hat, beard restraint) so that hair does not contact food. B. The Hang Hygiene policy, revised 3/30/2020, provided by the nursing home administrator (NHA) on 2/7/24 read in pertinent: Employees should perform hand hygiene by using alcohol-based hand rub with 60 to 95% alcohol or washing hands with soap and water for at least 20 seconds. Turn on the water to the desired temperature; Wet hands and forearms and apply one to three milliliters of soap (size of a quarter in palm); Rub hands vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. During washing and rinsing, keep hands lower than forearms, so water and soap drip off with gravity; Rinse hands completely (hands and fingers lower than wrist and forearm); Dry hands thoroughly with a paper towel; and Use a clean paper towel to turn off the water (unless an automatic sink). Use a clean paper towel to open the door if in a closed room. III. Observations on 2/5/24 At 11:45 a.m. no residents were offered hand hygiene prior to lunch in the dining room. At 11:53 a.m. dietary aide (DA) #4 prepared plates for lunch in Cedar hall while training DA #1. At 12:00 p.m. the DM entered Cedar's kitchenette and washed her hands for five seconds. At 12:10 p.m. DA #4 served a plate to the dining room and washed her hands for eight seconds before she made another resident's tray. DA #1 did not wash his hands upon returning to the kitchenette. At 12:13 p.m. DA #4 and DA #1 served a resident their lunch in their room using a meal cart. The DAs returned to the kitchenette and DA #4 carried dirty breakfast dishes to the pantry room where the dishwasher was located. DA #4 washed her hands for five seconds and DA #1 did not wash his hands. DA #1 prepared drinks for the residents and put the lids on to their cups without washing his hands. DA #1 touched the cabinet drawers and refrigerator doors as he prepared the drinks. At 12:17 p.m. the DAs went to see what a resident wanted for lunch. DA #4 washed her hands for five seconds and DA #1 did not wash his hands after leaving the resident's room. DA #1 prepared drinks for residents while DA #4 prepared their plates. DA #1 touched meal tickets, cups, pitchers, lids to the pitchers and the meal cart that was used to deliver meal trays. At 12:22 p.m. the DAs went to another resident's room to see what they wanted for lunch. DA #4 washed her hands for three seconds after leaving the resident's room. DA #1 washed his hands for four seconds and turned the water off with his hands instead of a paper towel. At 12:27 p.m. the DAs delivered another room tray. DA #4 washed her hands for three seconds and DA #1 did not wash his hands. The assistant director of nursing (ADON) pulled DA #1 aside and reminded him to wash his hands any time he changed environments (resident rooms, dining room, kitchen). DA #1 washed his hands for six seconds and turned the water off with his hands instead of a paper towel after he spoke to the ADON. At 12:33 p.m. DA #4 went to a resident's room and when she came back to the kitchenette she did not wash her hands. DA #4 put on a pair of gloves and grabbed a bowl of food out of the refrigerator and placed it on a meal tray. DA #4 removed her gloves and delivered the tray to the resident's room. DA #1 went to the main kitchen to get an alternative meal for a resident. At 12:36 p.m. DA #1 returned from the main kitchen with a sandwich covered on a plate and served it to a resident in the dining room. DA #1 entered the kitchenette and washed his hands for seven seconds and turned the water off with his hands instead of a paper towel. At 12:40 p.m. DA #4 returned from talking with the residents in the dining room and washed her hands for eight seconds. She prepared another meal and delivered it to a resident's room. At 12:45 p.m. DA #4 washed her hands for five seconds and DA #1 washed his hands for seven seconds and turned the water off with his hands instead of a paper towel. DA #4 served another room tray on the meal cart. At 12:50 p.m. DA #4 returned to the kitchenette and did not wash her hands. She grabbed a resident's adaptive silverware to deliver another room tray. At 12:52 p.m. the DAs delivered a room tray and returned to the kitchenette with dirty dishes. They placed the dirty dishes in the pantry. DA #1 washed his hands for six seconds and turned the water off with his hands instead of a paper towel. DA #4 did not wash her hands. DA #4 began cleaning the kitchenette. At 12:59 p.m. DA #1 washed his hands for six seconds and turned the water off with his hands instead of a paper towel. DA #4 washed her hands for five seconds before returning the hot and cold box to the main kitchen. IV. Observations on 2/6/24 At 11:32 a.m. DA #5 prepared plates for Cedar hall and was training DA #1. At 11:34 a.m. DA #5 went into the pantry. At 11:35 a.m. DA #5 returned to the kitchenette and washed her hands for 10 seconds. She opened kitchen drawers, removed serving ware and put on gloves. At 11:37 a.m. the DM entered the kitchenette and washed her hands for six seconds. At 11:38 a.m. DA #5 plated stuffed peppers as DA #1 filled drinks for the residents. DA #5 brought lunch to a resident in the dining room and a resident's guest asked for cream and sugar for his coffee. DA #5 removed her gloves before serving a resident in the dining room. At 11:40 a.m. DA #5 washed her hands for four seconds and brought the resident's visitor items for his coffee. DA #5 returned to the kitchenette and put on gloves while DA #1 washed his hands for five seconds and turned the water off with his hands instead of a paper towel. At 11:42 a.m. DA #5 put on gloves to prepare another resident's plate. DA #5 grabbed the meal cart used to deliver room trays with her gloves. She grabbed a plate with her thumb in the middle of the plate then plated a stuffed pepper where she was holding the plate with her gloves. DA #5 removed her gloves and out on another pair without washing her hands in between glove changes. DA #5 removed her gloves after she finished plating and took DA #1 to serve a resident in the dining room using the meal cart. At 11:45 a.m. DA #1 helped a resident put on a clothing protector in the dining room. DA #1 grabbed the handle of the meal cart and returned to the kitchenette. DA #1 washed his hands for five seconds and turned the water off with his hands instead of a paper towel. DA #1 filled drinks. DA #5 finished talking with residents in the dining room and returned to the kitchenette. She washed her hands for eight seconds. At 11:47 a.m. DA #1 began scratching his left arm with his right hand then grabbed more cups to fill for the residents. DA #5 reached across the steam table to grab silverware and her hoodie string drug across the serving utensils on the steam tray. DA #5 then used the serving utensil to plate a resident's meal. At 11:50 a.m. DA #5 served three residents in the dining room and assisted them with putting on clothing protectors. She brought the meal cart back to the kitchenette. At 11:52 a.m. DA #5 washed her hands for eight seconds. DA #5 grabbed the meal cart and moved it closer to put completed plates on it. DA #5 grabbed two plates from the drawer with the same hand she used to pull the meal cart closer. DA #5 put on gloves, touched two steam table covers, grabbed two dinner rolls and cut them open before buttering the rolls. At 11:56 a.m. DA #1 placed dirty dishes in the pantry and washed his hands for seven seconds and turned the water off with his hands instead of a paper towel. At 11:58 a.m. DA #5 served two more residents in the dining room with the meal cart and returned to the kitchenette. DA #5 washed her hands for 12 seconds. At 12:00 p.m. an unidentified certified nurse aide (CNA) entered the kitchenette and washed her hands for five seconds. DA #1 returned to the kitchenette and washed his hands for four seconds and turned the water off with his hands instead of a paper towel. At 12:02 p.m. DA #5 took a room tray to a resident and DA #1 entered the pantry. At 12:03 p.m. DA #1 washed his hands for five seconds and turned the water off with his hands instead of a paper towel. DA #1 grabbed a rag out of the cleaning solution and wiped down the counters in the kitchenette. At 12:04 p.m. DA #5 returned to the kitchenette and washed her hands for eight seconds and DA #1 went back into the pantry with dirty dishes. At 12:06 p.m. DA #5 put a glove on her right hands but then touched the silverware, cabinets, drawers, and serving utensils. DA #5 then touched the resident's clean plate with the gloved hand before she plated the food. At 12:07 p.m. an unidentified CNA assisted a resident with his lunch. The CNA used the back of her right hand and knuckles to itch her tailbone area under her scrubs before she continued to assist the resident his lunch. At 12:08 p.m. DA #5 served a resident in the dining room and washed her hands for eight seconds. She then grabbed the handle of the meal cart and pulled it closer. DA #5 used the same hand to grab a clean plate and touched the center of the plate before putting food on it. At 12:11 p.m. DA #1 returned from the pantry with a clean adaptive cup for a resident and had not washed his hands before he put the lid on the cup touching the spout. At 12:12 p.m. DA #1 washed his hands for four seconds and turned the water off with his hands instead of a paper towel. V. Observations on 2/6/24 Hand hygiene was not offered or provided to the residents in the dining room prior to lunch. At 11:34 a.m. a resident self-propelled her wheelchair into the dining room and was not offered or provided hand hygiene. At 12:06 p.m. another resident self-propelled her wheelchair into the dining room after she visited with her family and was not offered or provided hand hygiene. At 12:12 p.m. a resident was sitting at a table in the dining room and touched the table and other residents and was not offered or provided hand hygiene. V. Observations on 2/7/24 At 11:30 a.m. eight residents in the dining room were not offered or provided hand hygiene before lunch. At 11:45 a.m. DA #2 entered the kitchenette on Aspen and did not wash her hands. She sorted through the meal tickets. DA #2 grabbed the meal cart and pulled it closer before she plated lunch, she pulled silverware out of the cabinet and touched the countertops. She put a glove on her right hand and grabbed a dinner roll, however, when she went to cut the roll open she used her gloved hand to hold the knife and her ungloved hand to touch the roll. DA #2 plated another resident's lunch the same way. DA #2 served the two residents. At 11:51 a.m. DA #2 entered the kitchenette and washed her hands. She applied soap to her hands and immediately placed her hands under the water and scrubbed for 10 seconds. She prepared lunch for a resident. DA #2 cut open the resident's dinner roll with a knife but used her bare hand to hold the roll. DA #2 plated Resident another resident's lunch and used her bare hand to hold the roll while she cut it. At 11:55 a.m. chef #2 entered the kitchenette to help DA #2 serve lunch. Chef #2 washed her hands for five seconds. Chef #2 served both residents' plates DA #2 had prepared. At 12:00 p.m. DA #2 plated a resident's lunch and used her bare hand to hold the roll while she cut it. At 12:06 p.m. CNA #7 entered the kitchenette and washed her hands for eight seconds. At 12:07 p.m. Chef #2 washed her hands for six seconds and DA #2 applied soap to her hands and immediately placed her hands under the water and scrubbed for five seconds. At 12:08 p.m. a resident self-propelled her wheelchair to the dining room. The resident used her actual wheels to self-propel versus the handles on the wheels. A CNA offered the resident a clothing protector and was not offered or provided hand hygiene. She used her left hand to hold and eat ready-to-eat food while using her right hand to hold utensils. The resident was coughing all over her hands. At 12:10 p.m. DA #2 moved the meal cart with her bare hands after chef #2 returned the cart to the kitchenette after she served a resident's room tray. DA #2 cut open a roll for another resident's lunch. Chef #2 did not wash her hands when she returned from a resident's room. At 12:11 p.m. DA #2 applied soap to her hands and immediately placed her hands under the water and scrubbed for eight seconds. At 12:14 p.m. a resident was assisted into the dining room with her walker and was not offered or provided hand hygiene. At 12:15 p.m. chef #2 washed her hands for eight seconds. At 12:18 p.m. DA #2 plated a residents lunch. Some of the pasta was hanging over the edge of the plate and DA #2 used her bare hand to push the pasta back onto the plate. DA #2 then grabbed and cut the resident's roll with her bare hands. At 12:19 p.m. DA #2 served the resident's lunch and returned to the kitchenette without washing her hands. At 12:20 p.m. DA #2 plated a resident's lunch and used her bare hands to grab and cut her roll. She served the resident's lunch and assisted the resident with buttering her but did not put on any gloves before doing so. At 12:21 p.m. a resident was served lunch and was not offered or provided hand hygiene as he dipped his finger into the pie and licked his finger. At 12:22 p.m. DA #2 entered the kitchenette after assisting a resident in the dining room with her lunch and failed to wash her hands. She plated another resident's lunch. Chef #2 entered the kitchenette and used alcohol-based hand sanitizer instead of washing her hands. At 12:23 p.m. CNA #7 entered the kitchenette and put on a pair of gloves without washing her hands. She then grabbed a rag from a cooler of cleaning solution. At 12:24 p.m. DA #2 grabbed a dinner roll with her bare hands and cut it up into bite-sized pieces and delivered a plate to the dining room. At 12:25 p.m. DA #2 entered the kitchenette and applied soap to her hands and immediately placed her hands under the water and scrubbed for seven seconds. At 12:27 p.m. a lunch test tray was requested. At 12:28 p.m. DA #2 returned from the dining room and did not wash her hands. She grabbed a roll for the test tray with her bare hands and put it back down to go into the pantry. She returned and said her knife was dirty so she could not cut open the roll. She failed to wash her hands after leaving the pantry and grabbed the roll again with her bare hands and put it on the plate. At 12:30 p.m. DA #2 applied soap to her hands and immediately placed her hands under the water and scrubbed for five seconds. Chef #2 entered the kitchenette and failed to wash her hands. VI. Staff interviews The director of nursing (DON) was interviewed on 2/7/24 at 4:35 p.m. She said staff needed to offer hand washing or hand sanitizer before each meal, even for residents who were independent. She said it was especially important for the residents who self-propelled in their wheelchairs. Licensed practical nurse (LPN) # 2 was interviewed on 2/7/24 at 5:20 p.m. She said she was a CNA trainer for the facility. She said she turned on the faucet, wet her hands, applied soap, lathered for at least 20 seconds, rinsed with her fingers down without splashing, dry hands with a clean paper towel, threw the paper towel away and grabbed a clean paper towel to turn off the water. She said hand washing from start to finish was 60 seconds and staff should not put soap on their hands and immediately put them under the water to scrub. She said doing that caused the soap to wash away before the germs were taken care of. She said not all staff washed their hands accurately but it was something the facility was working on. The assistant director was nursing (ADON) was interviewed on 2/8/24 at 10:07 a.m. He said he was the infection control preventionist. He said when staff washed their hands they were trained to turn on the water, get their hands wet, apply soap, scrub for 15 to 20 seconds while scrubbing between fingers and under nails, rinse hands, dry hands with a clean paper towel and get a clean paper towel to turn off the water. He said there was some hand hygiene training provided in 2023 and he thought there was training provided in the annual competencies that the staff had each year but he was not sure. He said his plan for 2024 was to have more routine hand hygiene audits with the facility. The ADON said the staff were to use hand sanitizer when their hands were not visibly soiled and for staff to use soap and water if their hands were visibly soiled. He said if he saw a staff not washing their hands or not washing them appropriately he provided verbal reminders in the moment. He said he saw DA #1 failed to wash his hands on 1/5/24 when he changed settings so reminded DA #1 he needed to wash his hands. The ADON said he was working on having staff complete all of their training before they worked the floor but it was a work in progress for 2024. CNA #3 was interviewed on 2/8/24 at 12:42 p.m. She said she turned on the water, applied soap to her hands, lathered for 20 seconds and got under the nails and in between the fingers, rinsed off all of the soap, dried her hands with a clean paper towel and used another clean paper towel to turn off the water. Registered nurse (RN) #2 was interviewed on 2/8/24 at 12:48 p.m. She said when she washed her hands she sang Happy Birthday song to herself twice to know she washed her hands for enough time. She said she turned on the water, wet her hands, applied soap, lathered the soap for 20 to 30 seconds outside of the water, rinsed all of the soap off, dried her hands with a clean paper towel and used a clean paper towel to turn off the water. CNA #4 was interviewed on 2/8/24 at 1:00 p.m. She said the CNAs offered or suggested hand sanitizer or hand washing to all residents before each meal and after using the restroom. The DM was interviewed on 2/8/24 at 2:50 p.m. She said she turned on the hot water, wet her hands, scrubbed with soap for 20 seconds including the front and back of her hands and her fingernails, rinsed her hands to get all of the soap off, used a clean paper towel to dry her hands and used a clean paper towel to turn off the water. She said the staff members were not allowed to touch ready-to-eat food with their bare hands. She said staff needed to use utensils or gloves to touch ready-to-eat food. She said she provided training to the dietary staff regarding hand hygiene. -However, the facility failed to ensure staff washed their hands appropriately even though they were able to describe how to wash their hands. VII. Record review Copies of the training provided to the dietary staff were provided by the DM on 2/8/24 at 3:00 p.m. as follows: On 5/24/23 the DM completed a mock survey preparation training with the dietary staff which covered hand hygiene, sanitizing hands and hand hygiene. On 7/12/23 the DM completed training for ordering and reviewed the mock survey results with the dietary staff. Issues for the dietary department identified in the mock survey included hand hygiene between resident tray delivery at meal times. On 8/9/23 the DM completed a review of the mock survey results with the dietary staff. Issues for the dietary department were identified as hand hygiene and handling ready-to-eat food. On 9/13/23 the DM completed a review of the mock survey results with the dietary staff. Issues for the dietary department were identified as hand hygiene, sanitizing their hands after staff left a resident's room and handling ready-to-eat food. On 10/11/23 the DM completed a training with staff to be ready for their state survey with the window being open and covered hand hygiene, hand sanitizer, and proper glove use. On 11/17/24 the DM completed a training for cleaning dish machines and went over hand hygiene, gloves and handling ready-to-eat food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide an environment as free from accident hazards and risks as possible for one (#21) out of two residents reviewed for accidents out of 23 sample residents. Specifically, the facility failed to: -Ensure Resident #21 was safely transferred without risk of resident or staff injury; -Assess and communicate clearly the changing transfer expectations and needs of Resident #21; -Ensure consistent facility training for all staff who conducted resident transfers; and, -Instill Resident #21's security and confidence in staff's ability to safely and consistently transfer her without additional pain or risk of additional injury. Findings include: I. Facility policy and procedure The Resident-Patient Declining the Use of Lifts Policy, dated 5/1/07, was provided by the facility on 7/8/21. According to the policy, the facility would work towards consensus with the staff, the residents and their families on the safest method of transferring. The staff would evaluate and identify the resident's needs to determine if there was a need for a mechanical lift. The resident's needs would be identified in their chart and identified through a magnet on their door frame indicating specific mechanical lift requirements. II. Resident #21 A. Resident status Resident #21, age [AGE], was admitted on [DATE]. According to the July 2021 computerized physician orders (CPO), diagnoses included osteoarthritis, intention tremor, neuropathy, closed fracture of the pubic ramus, congestive heart failure and anxiety. The 5/18/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. According to the May 2021, the resident required extensive assistance from one person for bed mobility, transfers and toileting. B. Resident interview Resident #21 was interviewed on 7/7/21 at 9:32 a.m. According to the resident, she was having difficulty using the sit-to-stand (mechanical) lift. She said the lift had been implemented a couple of weeks ago. She said it was very hard for her to try to reach for the bars on the lift as she tried to fully pull herself up. She said she was [AGE] year old and did not always have the strength. She said a certified nursing aides (CNA) back was injured the day before the interview, when she was transferring the resident by herself. She said she was afraid that she may not always have the strength to keep herself up and did not want to get hurt or hurt another person. She said she had a fear of falling when only one person helped her transfer with the lift. The resident said she did not like the way the staff used the belts on her during the transfers. She said a staff member had bruised her a few weeks ago using the gait belt. Resident #21 was interviewed on 7/7/21 at 3:55 p.m. She said she cried because she was going to have to continue to use the lift and gait belt. She said she did not want another accident. Resident #21 was interviewed again on 7/8/21 at 1:45 p.m. She said on occasion, staff would have two CNAs transfer her with the sit-to-stand lift but it was usually just one CNA. She said the lift was hard for her to do both day and night. Resident #21 said she would feel much more confident in the lift if she consistently had two staff helping her. She said one staff member could help lift up her bottom while the other staff member could support her top with a gait belt. She said the CNA would not have to pull up so hard on the gait belt if she had assistance. She said she did not want to be bruised again by the belt and did not want them to use it on her. C. Facility incidents The 4/7/21 facility reported incident investigation was provided by the facility on 7/6/21. According to the report Resident #21 the resident felt she was slammed down on the toilet during a manual transfer from her wheelchair. The facility investigation revealed the resident was difficult to transfer and the CNA was unable to fully support the resident when she was lowered down. The facility therapy team evaluated the resident for transfers and the resident agreed to utilizing an assistive device during transfers to prevent recurrence. The 6/5/21 incident report was provided by the facility on 7/13/21 via email. The incident confirmed Resident #21's statement of a bruise acquired by a gait belt during a transfer. According to the report, the resident had a dark purple bruise under her left breast. Initial probable cause of the bruise was from the gait belt or a staff transfer assist resulting in hand or finger print. The resident was placed on 72 hour monitoring, staff was educated on proper transfer and gait belt use, informed therapy and recommended a padded gait belt. The report read that the resident refused the use of the gait belt. The investigation outcome summary read the bruise was consistent with a gait belt and a guiding hard. The summary did not indicate which staff received the training or when. The manager's investigation report was provided on 7/8/21 at 12:48 p.m. via email. According to the initial report, CNA #3 assisted Resident #21 to transfer from her lounge chair with use of a gait belt and the sit-to-stand lift. According to the report, the resident was not able to assist much during the transfer so CNA #3 had to pull her up with a gait belt and strained the right side of her upper back. The CNA attempted the transfer alone. The report read the CNA had annual lift training. The report indicated the resident would be re-evaluated with the lift. D. Observations On 7/7/21 at 4:10 p.m. was transferred with one CNA by use of the sit-to-stand lift and a gait belt. The resident's legs began to shake as she pulled herself up with the bars. The resident was lowered to her lounge chair with an approximate six inch drop without the lift seat under her. She said the drop between the lift and the chair also hurt her bottom. She said it just kills me. On 7/7/21 at 8:38 p.m. Resident #21 call light was placed on. CNA #1 entered the room. After a couple of minutes a second CNA entered the room after CNA #1 said she needed a second person with the lift. The door was shut behind the CNAs. A magnet on the resident's door indicating the specific mechanical lift requirements was not observed. On 7/8/21 at approximately 12:30 p.m. CNA #5 was observed entering Resident #21's room alone with the sit-to-stand lift to transfer the resident. The CNA did not have a second staff member assist her in the lift transfer. E. Staff interviews CNA #5 was interviewed on 7/7/21 at 4:00 p.m. She said Resident #21 was usually mad or sad when she used the sit-to-stand lift with her but reminded her it was for her and the staff's safety. She said she had to help pull her up with the gait belt because the resident's legs were not strong enough to completely lift herself up even with the sit-to-stand lift assist. Registered nurse (RN) #1 was interviewed on 7/7/21 at 4:27 p.m. He identified himself as a charge nurse. RN #1 said he was aware of an incident last month regarding the use of a gait belt and bruising but he did not know all the details. He said Resident #21 has had more difficulty transferring lately, mainly associated with her refusal of the gait belt. RN #1 said she has had a general complaint of pain in her knees. The rehabilitation supervisor (RS) was interviewed on 7/7/21 at 4:39 p.m. She said Resident #21 remained on skilled therapy because of the continued concerns with transfers. The RS said the therapists provided staff training during the on boarding (orientation) of the staff member but she revealed that they were not able to get to all the CNAs. She said the nursing department provided a on teach back training with demonstration if we think something with a lift could cause an injury. She said CNAs were using max assistance with transferring with the gait belt alone so a lift was incorporated. The resident ordinally screened well for a pivot assistive device and was not identified to need a hoyer lift. She said the resident was currently using the sit-to-stand lift until the pivot assistive device parts arrived (see explanation below in RS second interview). The nursing home administrator (NHA) was interviewed on 7/7/21 at 4:46 p.m. The NHA referenced the April (2021) incident where the resident said she was slammed down during a transfer. He said it was determined that the resident lost leg stability and the CNA was not able to fully support her. A pivot device was implemented which the resident was satisfied with but it was later determined that the resident needed more assistance so therapy recommended the sit-to-stand lift. He said Resident #21 had been tearful with use of the lift but acknowledged she needed more help transferring in the last week or two since the use of the sit-to-stand lift. The NHA said he asked the resident to follow the therapy recommendations for safe transfers. He said staff were not allowed or asked to do anything that would be deemed as unsafe. The NHA said she had been encouraged to continue the use of lift to maintain her mobility. CNA #1 was interviewed on 7/7/21 at 8:38 p.m. CNA #1 said she always used two staff when she used the lift. CNA #1 said they had transfer training two months ago. CNA #4 was interviewed on 7/7/21 at 8:40 p.m. She said she had not received transfer or lift training from the facility but felt she knew how to use all the lifts. RN#2 was interviewed on 7/7/21 at 9:10 p.m. She said she had been at the facility for three weeks but had not had lift training but had helped with transferring residents with the lifts. RN #3 was interviewed on 7/8/21 at 9:14 a.m. RN #3 said she had helped residents with the sit-to-stand lift but did not have training at the facility for use. CNA #5 was interviewed again on 7/8/21 at 12:42 p.m. She said Resident #21 was usually a one person transfer assist with the sit-to-stand lift but she probably needed to be a two person transfer because sometimes her knees would go out. CNA #6 was interviewed on 7/8/21 at 1:39 p.m. The CNA said the resident was limited assistance with a gait belt but she was getting weak in one knee so she now used the sit-to-stand lift. The CNA said she was comfortable transferring Resident #21 transferring her by herself with the sit-to-stand, even though Resident #21 sometimes liked to let go of the bars. CNA #7 was interviewed on 7/8/21 at 9:23 a.m. She said when residents need a change on how much assistance they need during a lift transfer, therapy usually would put out a communication email to staff informing them of the resident's needs. She said the transfer status of a resident was probably in the resident's electronic records but she did not think she had access to them. The director of nursing (DON) was interviewed on 7/8/21 at 10:14 a.m. The DON reference the CNA injury when transferring Resident #21. She said CNA #3 was transferring the resident during the night by herself with a sit-to-stand lift. Resident #21 was not able to pull herself up so CNA #3 pulled on the belt staining her shoulder muscle. The DON said the resident has had more difficulty transferring from her lounge chair because it was lower than the bed. According to the DON, the CNA had been at the facility for eight years and had been transfer trained with the lifts. The RS was interviewed again on 7/8/21 at 12:52 p.m. She said Resident #21 was referred to therapy in April 2021. The RS said the resident would participate in therapy but in May and June 2021 started to refuse more and then she started to decline in her ability to transfer. Staff informed therapy that Resident #21 was required for maximum assistance with transfers. The resident acquired bruising from her gait belt during a manual transfer. The RS said therapy wanted to have safe transfer while providing her with a sense of control and independence. The RS said the sit-to-stand lift had a platform which raised the resident's feet, raising the resident's knees and tilting her hips back. The RS said in this position it would be harder for the resident to lift her bottom up and reach for the pull bars. She said the resident was evaluated for the Etac [NAME] Pro pivot device. The device was trialed successfully with the resident but the facility only had one device located on the other side of the facility and the resident who used it relied on it heavily. On 6/7/21, the RS requested approval for the order and the device arrived on 6/14/21.The sit-to-stand lift was then recommended so she still could pull herself up intll the new device was in place. She said after a series of emails, the device arrived on 7/1/21 but was not complete since it was missing parts. She said she continued to request the rest of the parts or a replacement. The RS said the resident would continue to use the sit-to-stand lift till the new device was available. The RS said the pivot device would meet Resident #21's needs to pull herself up but still pose a risk to the resident if her legs gave out. According to the RS, the resident had poor trunk control and had not been observed by therapy on her ability to use the sit-to-stand lift at night. The RS said she spoke to several CNAs who worked with her at night. She said one male CNA said he was able to transfer fine at night. The other female CNAs said they had struggled at night transferring with Resident #21. The RS said she was aware that a CNA was recently hurt transferring the resident. The RS said two transfers with the sit-to-stand would have been her recommendation because the resident's strength and abilities were variable. She said she assumed staff were providing a two person transfer with Resident #21 when using the sit-to-stand because staff was safety minded. The RS said she always recommended two person transfers when incorporating a new lift to assess how well and safe the resident does with the new lift. She said she was surprised to hear some staff including the injured CNA, transferred Resident #21 without a second person. The RS confirmed she normally communicated residents' transfer needs via email to the nursing staff. She said she did inform the staff that a sit-to-stand lift was recommended for Resident #21. The RS said the email directed staff to lower her slowly when transferring with the lift. According to the RS, the email directed staff to use minimal assistance with sit-to-stand. She said she did not clarify to the staff if the resident required a one or two person transfer assistance and should have made it clear on the email. She said it was a missing piece of information. The RS identified another area of concern. She said the therapists had done some on the spot transfer training with staff but had not documented that training. She said the facility had conducted teach back demonstrations but it had been a few months. She said the nursing staff would all eventually have the training. She said trainings had not been as often as it used to be related to COVID-19 and the facility moved into a new facility less than a year ago. She said the facility used to have a once a month training before all the changes. She said she was in the process of working with nursing to incorporate a routine twice a month transfer training for staff. Physical therapist (PT) #1 was interviewed on 7/8/21 at 1:29 p.m. She said she had competed undocumended sit to stand demonstration training with staff but as a one person assistance. PT #1 said it was appropriate for a one person transfer with the sit to stand lift if the resident had the strength to pull themself up with minimal assistance. She said if a resident was not strong enough then a two transfer would be appropriate. PT#1 said she was Resident #21's physical therapist and had heard that transfers were not going well at night with Resident #21. She could add it to the care plan for the resident to be a two person transfer with the sit to stand. The DON was interviewed again on 7/8/21 at 4:05 p.m. The DON said she spoke to CNA #3 for follow-up on her injury during the resident transfer. The CNA confirmed the resident had been weaker at night and the CNA was having to do most of the resident transfer herself, creating the strain. The DON said CNA #3 should have had a second CNA help her when she determined the resident was not able to physically assist more in the transfer. The CNA should not have attempted the lift alone. The DON said during the injury investigation, she learned that the resident required more assistance than a one person transfer with sit-to-stand during the night. She said CNAs were interviewed after the incident and had informed her that they had also noticed the resident was weaker at times and not able to fully assist with transfer. She said the staff should have communicated their concern so the resident could be re-evaluated for a two person transfer with the sit-to-stand lift for resident and staff safety. The DON said she would have done a change of condition assessment and requested therapy to re-evaluate her lift needs. The DON said she could only produce a limited amount of transfer training records because the lead CNA kept those records. She said she was still trying to contact the CNA. -The facility did not provide additional transfer records other than a April 2021 inservice by exit on 7/9/21. The DON was interviewed with the NHA on 7/8/21 at 5:25 p.m. They said they wanted all staff trained by the facility on transfers and lift use to ensure staff competence and resident and staff safety. F. Record review The July 2021 care plan revealed the Resident #21 had potential for pain and required activities of daily living (ADL) support. According to the care plan for alteration in comfort, the resident was at risk for pain associated with the disease process, indicating neuropathy and arthritis. Other potential factors identified on the care plan included musculoskeletal and surgical pain. Interventions to alleviate the pain included staff to anticipate and assist with activities of daily living (ADLs). The ADL specific care plan directed staff to offer the manual sit-to-stand lifting device for one to two persons. A physical therapy inservice was conducted on 4/14/21 for lifts according to the staff education agenda on 4/14/21 in Resident #21's incident folder. The following emails were provided by the medical record director via email on 7/8/21 identifying the most recent and documented staff transfer training in 2021: A lift training was conducted on 1/25/21 for use of the hoyer, sit-to-stand and the [NAME] lift. According to the January 2021 attendance sheet, 31 staff total were anticipated to attend the inservice. Out of the 31 staff, nine staff did not participate. The lift training attendance sheet did not identify if the training was open to both CNAs and nurses. The lift training sheet did not indicate a second training was offered for staff who missed the 1/25/21 lift training. -Not all nursing staff attended the training. A 3/9/21 and 6/18/21 RS communication email with a youtube link and simple instruction, informed staff of use new transfer devices to include the Etec lift and a pivot device for two individual residents, not Resident #21. Review of the therapy notes indicated the resident was evaluated for physical therapy on 4/8/21 for balance, difficulty walking, difficulty with daily activities, fatigue/poor endurance and weakness. Physical therapy also identified her as a fall risk. A 6/29/21 communication email sent out by the RS was provided on 7/8/21 at 3:27 p.m. The email was sent to the nursing and therapy staff. The email read in part: I know (Resident #21's) transfers have been a big concern, and everyone is unsafe transferring her the way it had been happening According to the email, the resident did well with sit-to-stand and recommended its use with minimal assistance and the fur lined gait belt. The email read the manual sit-to-stand was the safest and best way to transfer her. The RS wrote that the resident said she would refuse the use of the lift and the belt. A 7/2/21 email revealed the RS identified a need for increased staff training on lifts, transfer equipment and techniques. According to the CNAs in the past would spend an hour with therapy for these onboarding orientation trainings. The RS requested therapy refreshers'' for the staff to go over body mechanics and the transfers. She offered to set up times to offer the training twice a month to also include night shifts. III. Facility follow up A 7/8/21 communication email sent out by the RS was provided on 7/8/21 at 3:44 p.m. The email was sent to the nursing and therapy staff. According to the communication email, therapy requested staff to provide assistance of the two persons for all transfers on the manual sit-to-stand lift for Resident #21. The email indicated staff could use either the fur lined or regular gait during the lift transfer.