Based on review of a facility reported incident, review of administrative and medical records, and staff interviews, it was determined that the facility failed to ensure a resident was free of a significant medication error when a nurse incorrectly administered the medication Methadone to a resident instead of the prescribed medication Methylphenidate. This was evident for 1 of 1 resident (Resident #1) reviewed for unnecessary medications during a complaint survey. The failure of the facility to ensure that Resident #1 was free of a significant medication error resulted in the determination of an immediate jeopardy situation being identified on February 25, 2025, at 6 PM. The findings include: Resident #1 was admitted to the facility after a brief hospital stay on 01/26/25 with diagnoses that included but were not limited to Narcolepsy, muscle weakness and recurrent falls. On 01/28/25, the plan for Resident #1 was to be discharged home. Review of facility reported incident #MD00214721 revealed Resident #1 received 100 milligrams of Methadone on 02/15/25 between 12 noon and 1 PM. Resident #1 should have received 20 milligrams of Methylphenidate which was prescribed for Narcolepsy. A review of the facility investigation on 02/24/25 at 3 PM revealed that RN#1 was performing treatments and then stopped and began administering medications. When RN#1 saw the letters M-E-T-H on Resident #1's MAR (medication administration record) RN#1 assumed the medication name was Methadone and administered a dose to Resident #1. It was not until about an hour later that RN#1 realized that he had given the wrong medication to Resident #1. RN#1 reported that he immediately assessed Resident #1 and stated that Resident #1 was sleepy, and his/her vital signs were stable. RN#1 then informed the nursing supervisor, RN#2, of the medication error. RN#2 instructed RN#1 how to complete the Change in Condition documentation, contact the on-call physician provider, and notify Resident #1's family. The third party physician service was notified of the error at this time. Further review of the facility's investigation revealed that RN#1 indicated that he did not compare the medication pulled from the cart (Methadone) to Resident #1's medication administration record and did not confirm the medication. RN#1 stated in the investigation that I was moving too fast and that he made an honest mistake. RN#1 indicated he saw the METH and assumed it was Methadone and administered the medication to Resident #1. RN#1 also indicated that he did not look at the bottle to see if was for Resident #1. RN#1 indicated that he did not check to see if the medication was in the correct form. Methylphenidate is prepared in a tablet (pill) and the Methadone that was administered to Resident #1 was in a liquid form. RN#1 indicated that he assumed the medication to be administered to Resident #1 was to be Methadone. In an interview with the third party physician service provider, CRNP#1, on 02/25/25 at 10 AM, CRNP#1 stated that she was on-call from 1 PM to 3 PM on 02/15/25. CRNP#1 stated that she received a telephone call on 02/15/25 at 2:14 PM regarding a medication error regarding Resident #1. CRNP#1 stated that during the a video telephone call she asked for the name of Resident #1 the date of birth which RN#1 could not provide. CRNP#1 stated she was informed that Resident #1 received a dose of another resident's Methadone in error. RN#1 was unable to provide CRNP#1 the exact dose of Methadone administered. CRNP#1 stated she was also informed the Methadone was located in the medication cart for a resident who had not been admitted to the facility. CRNP#1 stated she continued to ask RN#1 for the dose that was administered to Resident #1 but RN#1 was unable to inform her. CRNP#1 stated that she educated RN#1 on Methadone overdose and withdrawal signs and symptoms. CRNP#1 stated she confirmed that the facility had a supply of Narcan in the facility with RN#1. CRNP#1 stated that RN#1 informed her that Resident #1 was stable, in no distress, and that RN#1 would not administer Narcan to Resident #1 because Resident #1 had no symptoms of overdose. CRNP#1 asked for RN#1 to take the phone to Resident #1's bedside and was told by RN#1 that Resident #1 did not want to be bothered. CRNP#1 asked RN#1 to hold up the bottle of Methadone that was administered to Resident #1. CRNP#1 stated that RN#1 could not find the discarded bottle of Methadone administered to Resident #1 and held up a sealed unused container of Methadone to the camera. The sealed unused dose of Methadone was listed as having 100 milligrams in the bottle. CRNP#1 again asked RN#1 what was the dose of Methadone administered to Resident #1 and RN#1 stated that he did not know because he did not measure the dose of Methadone. RN#1 indicated that he could not find the empty bottle of Methadone administered to Resident #1. CRNP#1 was asked if she had access and if she reviewed Resident #1's electronic clinical record. CRNP#1 stated that she did not have access to Resident #1's clinical record due to the software not being the same. CRNP#1 stated that she relied on RN#1's information at the time of the call. CRNP#1 stated that RN#1 again informed her that Resident #1 was not symptomatic and stable. CRNP#1 stated that she did not think Resident #1 needed to be sent to the hospital at that time based on the report from RN#1. When asked, CRNP#1 stated that she did not call the facility back to check on Resident #1, did not speak with Resident #1's attending physician, and did not inform the oncoming CRNP of Resident #1's medication error after the phone call from the facility. In an interview with RN #1 on 02/25/2025 at 2:22 PM, RN#1 stated that he was an agency nurse and that 02/15/25 day shift was the very first shift working in the facility. RN#1 stated that he became aware of administering Methadone to Resident #1 in error during the shift. RN#1 stated that he called the nursing supervisor and reported the medication error. The nursing supervisor instructed him to notify the medical provider and the family. RN#1 stated that he was not familiar with the facility procedure on how to notify the medical provider and had to go to the nursing office to receive assistance from the nursing supervisor to notify the medical provider. RN#1 stated that he received instructions to monitor Resident #1 frequently and notify the medical provider if there were any changes. When asked, RN#1 stated that he did not follow the 5 rights for administering medications to Resident #1 on 02/15/25. RN#1 stated that he was also heavily distracted during the medication pass on 02/15/25 when he incorrectly administered a dose of Methadone to Resident #1. Resident #1 was incorrectly administered a dose of Methadone at approximately 12 noon on 02/15/25. Resident #1 was found pulseless and without respirations by the nursing staff at approximately 9:50 PM on 02/15/25. Resident #1's death was reported to the Medical Examiners office. These failures resulted in an Immediate Jeopardy situation being identified on February 25, 2025 at 6 PM. The Maryland Office of Health Care Quality (OHCQ) determined that F 760 concerns, affecting Resident #1, met the Federal definition of Immediate Jeopardy and the facility was given the template and notified of this determination 02/25/25 at 6:00 PM. On 02/25/25 at 9:56 PM, the facility provided a plan to remove the immediacy while the surveyor was onsite. The removal plan was accepted by OHCQ at 9:56 PM on 02/25/25 and verified by the surveyor at that time. The abatement plan included: 1) Education of all nurses was initiated overnight on 02/15-02/16 on medication administration with focus on the six-rights medication administration, opioid management, and signs of opioid overdose, and in-house escalation protocol. All outstanding education will be completed prior to the next scheduled shift. 2) Medicine Pass evaluations and competencies will be completed for all licensed nurses. Each nurse will undergo a thorough assessment of their medication administration skills. Any identified areas for improvement will be addressed through additional training, and successful completion will be documented in the employee ' s personnel file. All medication evaluations will be completed prior to the next scheduled shift. 3) Staff will be quizzed on their understanding of the opioid overdose management policy post education. The quizzes will cover key topics, including recognizing the signs and symptoms of opioid overdose, appropriate response protocols, and steps for escalation. Results will be reviewed, and any areas of concern will be addressed through additional training or clarification. All quizzes will be completed prior to the next scheduled shift. 4) Nursing staff will be quizzed on their understanding of the medication administration policy post education. The quiz will focus on the rights of medication administration. Any knowledge gaps identified will be addressed through additional training and support. All quizzes will be completed prior to the next scheduled shift. 5) Ongoing monthly medication evaluations will be conducted for all licensed nurses and Certified Medicine Aides by DON/designee for the next 6 months. Each nurse will undergo a thorough assessment of their medication administration skills. Any identified areas for improvement will be addressed through additional training, and successful completion will be documented in the employee ' s personnel file. 6) The results will be reported by the DON to the Quality Assurance Performance Improvement Committee for at least six months or until 100% compliance is achieved. The alleged date of compliance is 02/25/2025. After removal of the immediacy, the deficient practice continued with a scope and severity of D with potential for more than minimal harm for the remaining residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) A review of Resident #144 's medical record on 07/11/23 revealed the resident was totally dependent for care. The review of the medical records on 08/18/23 at 12:30 PM revealed that on 12/15/18, the resident was admitted with a side rail order (no indication for the purpose of side rails). On 12/17/18 the side rails order was discontinued. On 12/17/18 at 11:49 AM, the half-side rails were reordered for turning and positioning. On 01/06/19, the side rails order was discontinued and no further physician orders for side rails were found in the medical record. Resident #144 was readmitted to the facility on [DATE] and the resident was re-evaluated for side rails. However, no written physician orders for the installation of side rails could be found in the medical record. A review of the Minimum Data Set (MDS), Section P for the time period of 12/15/21, revealed the resident did have side rails, not used as a restraint, had a left-hand contracture, and the resident was coded as a two-person assistance for activities of daily living. On 07/17/23 the review of attending medical doctor (MD) #23 ' s orders revealed Resident #144 was transferred to the hospital at 16:21(4:21 PM) on 12/9/2022 via ambulance due to injury to the right arm when it became stuck in the bed rail. The resident was treated for a fracture to the right ulna and humerus and discharged back to the facility on [DATE]. Review of the medical record on 07/11/23 revealed a change in condition progress note written by Staff # 61 on 12/09/22 at 12:30 PM regarding what occurred between the hours of 2:00 AM and 5:00 AM. The progress note stated that while the resident was receiving care on 12/09/22, the resident's right hand was found caught in between the right-side rail and the mattress per GNA # 56. GNA #56 removed the resident's arm and Resident #144 complained that his/her whole arm was painful, and refused to be moved, touched, or receive care. Staff #61 documented that passive range of motion was unable to be performed. No swelling or bruising was noted by Staff #61 and the resident was found with his/her arm resting on his/her chest when Staff #61 entered the room. Staff # 61 documented that the physician was notified and ordered an X-ray of the right arm to rule out a fracture. A progress note written by Staff # 58 on 12/09/22 at 12:43 PM titled change in condition documented Resident #144's right arm pain with swelling and bruising to the inner forearm present at 07:30 AM during the change of shift rounds. The Resident complained of pain with motion of the right arm. The resident was described as currently resting with arm on chest. Tylenol was given with effective results and Mobilex called for an estimated time of arrival for X-ray at 10:00 AM. A review of the medical record revealed that on 12/09/22 a bed evaluation was performed for installation of ¼ side rails on the left upper and right upper sides after Resident #144's injury was reported. On the bed evaluation document, the following check marks were selected under the section titled: with the final actions for bedrail use: 2. Obtain consent, 2a. Physician Order. The document was signed by LPN # 58. However, upon further review of the medical records the surveyor did not find a consent form signed by the resident ' s representative for 12/09/22 or any date thereafter. On 08/18/23 at 10:30 AM the review of the progress note dated 12/10/22 at 12:30 PM written by Staff #61 revealed that Resident #144 returned to the facility from the hospital at 12:20 PM on 12/10/22 via ambulance. Per the hospital discharge report, Resident #144 had a fracture of the right ulna and humerus bones and was treated with a Splint applied with a sling. On 08/18/22 at 2:20 PM, the surveyor interviewed Staff #1 and Staff # 49 regarding Resident # 144's right arm fracture injury on 12/9/22 that was a result of the right arm being caught in between the mattress and the side rail. Both admitted the incident occurred as described in the medical record. In an interview with the resident's family member/resident representative on 08/18/23 at 2:40 PM he/she stated that the resident's right arm was broken in two places. This family was present while the resident was treated in the emergency room. Additionally, the family member described the resident as unable to move around in the bed independently, so the resident did not do this on his/her own. The family member stated that, after talking with staff members, the facility Administrator and the Director of Nursing, the details are still unknown as to how it happened. During an interview on 08/21/23 at approximately 3:20 PM, the surveyor asked the Administrator to explain the bedrail evaluation and assessment process, and the specific events that occurred on the night of the injury to the resident's right arm. The administrative staff stated that the facility believed the injury was a result of the resident throwing his/her arm against the bedrail. The surveyor asked the administrative staff to provide evidence of the resident meeting the criteria for bed rails as an enabler. On 08/22/23 at approximately 3:20 PM the administrator provided a copy of the 12/18/18 consent form for bed rails signed by the resident representative. The administrator stated that there had been discussions with the resident's representative regarding the need for the side rails during the past three years. However, the administrative staff could not provide an explanation of why the consent form had not been updated each time the resident was discharged and readmitted to the facility or why the resident continued to have side rails without an active physician order. A discussion was held with the surveyor regarding the side rail policy compliance of the facility based on the lack of consistent and frequent reassessments during a three-year period. The administrator and Staff #49 acknowledged that no additional consent forms were signed by the resident's representative and/or power of attorney after 12/18/18. A review on 08/21/23 of the facility's Side Rail Use policy with the creation date of 11/2019, and a last reviewed date of 01/2021, stated the interdisciplinary care plan team would: On admission, readmission, with a significant change in condition or change of bed surface assess the resident for the need for side rails to assist in bed mobility. On 08/22/23 at 09:22 AM, the maintenance director, Staff # 29 presented a hard copy of the bed system measurement device test results worksheet dated 12/09/22, related to Resident #144's bed. This assessment was performed after the Resident's injury was discovered on 12/9/22. Staff #29 stated that on 12/09/22, Resident #144's bed did not pass the bed assessment secondary to the five-inch gap between the headboard and the side rail on the right side. Staff #29 stated that he replaced the entire bed on 12/09/22. Staff #29 stated and provided a written statement that on 12/09/22 he performed a whole house audit for all beds in the facility Also, Staff # 29 stated that he/she was unable to locate a bed rail assessment for all beds for the year 2021. Additionally, Staff #29 observed Resident #144 in the bed with the side rails up prior to completing the assessment on 12/09/22. The concerns related to the deficient practice of not providing an accident-free environment for Resident #144 were reviewed again with the DON, NHA, and the VP of Clinical Operations during the exit conference on 08/22/23 Based on observation, medical record reviews, staff, and family interviews, it was determined the facility failed to: 1.) correctly assess a resident for smoking independently to include an accurate account of incidents of past unsafe smoking behaviors; 2) provide increased supervision and safety interventions after multiple unsafe smoking incidents; 3) keep a resident who had multiple smoking-related incidents from igniting flammable materials and safe from self-harm. This was evident for 1 of 4 (#92) residents reviewed for smoking. As a result of the deficient practice, residents were placed at risk for harm/injury causing an immediate jeopardy. The facility also failed to protect a resident who was totally dependent on staff for all aspects of activities of daily living, from an accident with injury (Resident #144). The failure resulted in harm to the resident who sustained a right arm fracture. The facility also failed to utilize the correct transfer tool to transfer a resident back to bed (R#157). This was evident for 2 of 13 residents reviewed for accidents. The immediate jeopardy(IJ) template was provided to the facility and an IJ was called on August 10, 2023, at 9:25 AM. The initial plan of action was submitted on August 10, 2023, at 12:20 PM, and was rejected and returned. The final plan of action was received at 2:24 PM and accepted at 3:00 PM. The IJ was abated on 8/17/2023 at 11:30 AM. After removal of the immediacy, the deficient practice remained with a scope and severity of G. The findings include: 1.) Record review of Resident #92's medical record on 07/14/23 at 10:15 AM revealed the resident was admitted to the facility on [DATE]. A smoking care plan was initiated on 2/23/21 with the goal for the resident to smoke safely for 90 days with a target date of 3/10/21 with the resident being reminded of the location of smoking areas and times. Additionally, on 2/23/21 a behavioral contract was signed with the resident with smoking goals for the resident not to smoke in his/her room or other areas of the facility not designated for smoking and the resident would not pick up or handle used cigarette butts from the floor, ash tray and/or trash can. Further review on Resident #92's medical record on 07/14/23 at 2:03 PM revealed that on 04/07/22 Resident #92 was found smoking in the dining room by a security guard who also found 7 cigarette butts in a cup in the sink. No new interventions were added to the smoking care plan after this incident. A goal for the resident to only smoke in designated areas was added to the care plan on 04/07/22. The target date was updated to 5/23/22. On 07/25/23 10:04 AM a review of the smoking assessment dated [DATE], it was documented the resident was no longer a smoker and recently quit within a month which was incorrect information. During an interview with Resident #92, on 08/07/23 at 5:09 pm he/she stated that he/she enjoyed smoking, had always smoked, and had no desire to stop. DON #2 was present during the interview. Review of Resident #92's electronic medical record (EMR) on 08/03/23 at 10:15 AM revealed that on 6/12/22 Resident #92 sustained a partial thickness burn to the tip of the nose from lighting a cigarette. The burn was discovered on 6/13/22 by Licensed Practice Nurse (LPN) #66. A note written by Nurse Practitioner (NP) #47 on 6/13/22 indicated Resident #92's smoking privileges were revoked, however the record failed to reveal details regarding the length of the revoked smoking privileges. During an interview with LPN #66 on 08/07/23 at 4:23 pm he/she was unable to remember the incident when Resident #92 burned his/her nose. During an interview with the DON#2 on 08/03/23 at 12:44 PM, she revealed that after the incident when Resident #92 burned his/her nose, staff education and education with the resident was done, and staff made sure the resident did not have a lighter. She also revealed an updated smoking assessment should have been done as the resident was care planned prior to the smoking incident and that the resident had been a smoker since he had been in the facility. Review of the EMR on 08/03/23 at 12:25 PM revealed a smoking assessment dated [DATE] that documented that the resident did not have a history of smoking-related incidents which was incorrect. The assessment also noted the staff reviewed the policy related to smoking times and storage materials with the resident. The section for care plan initiated/updated was documented as N/A for not applicable. Further review of the EMR revealed that on 10/12/22 Resident #92 was found smoking in the bathroom and refused to give the cigarettes and lighter to staff. Staff reminded the resident of the smoking times and areas and educated about safety and the resident stated, I don't care. Six days later 10/18/22 a smoking assessment was completed on Resident #92 and indicated the resident did not have a history of smoking-related incidents which was incorrect. Again, the section for care plan initiated/updated was documented as N/A. On 1/19/23 a smoking assessment was completed for Resident #92 and categorized the resident as an independent smoker and that the resident did not have a history of smoking-related incidents which was incorrect. The section for listing previous assessments was documented as N/A. The section for care plan initiated/updated was documented as yes, however, none of the interventions on the form were checked off. On 07/14/23 while reviewing Resident #92's EMR it was documented that on 4/8/2023 Resident #92 was found with a lit cigarette butt along with 7-8 cigarette butts wrapped around a towel on his/her wheelchair cushion. The towel and part of the wheelchair cushion had burned, and staff put the fire out. The smoking assessment completed on 04/08/23 indicated the resident was an assisted smoker with a history of smoking-related incidents that included: burning clothing, burning furniture, disposing of lighted products in trash, smoking in bed, dropping ashes on self, and smoking in a non-smoking area. It was also documented the resident did not have the ability to extinguish a cigarette safely. Continued review of Resident #92's EMR revealed that on 07/05/23 a smoking assessment was completed on Resident #92 and categorized the resident as an independent smoker and that the resident did not have a history of smoking-related incidents which was incorrect. Under the smoking care plan focus section, the following was documented: the resident had been found smoking in the bathroom and leaving lit cigarette butts on a wheelchair or other places. The goal was documented as resident will smoke in designated smoking areas during smoking times with interventions listed as; instruct resident about smoking risks/hazards and about smoking cessation aids that are available. Instruct resident about the facility policy on smoking: locations, times, and safety concerns. Provide cigarettes and lighters to the resident only at facility smoking times at facility-designated smoking areas. The resident requires supervision while smoking. On 7/13/23 a smoking assessment was completed on Resident #92 and categorized the resident as an Assisted Smoker and failed to document the resident's history of smoking-related incidents as that section on the assessment had nothing checked off. The section for care plan initiated/updated was documented as yes but the only intervention checked off was the resident requires supervision while smoking. On 7/13/23 Resident #92 had two goals initiated to a care plan dated 04/08/23 and revised on 07/17/23. The care plan did not have any goals or interventions documented prior to 07/13/23. The focus was the resident was a smoker and had been found smoking in the bathroom and left lit cigarette butts on the wheelchair or other places. The goals added on 07/13/23 were: the resident will not smoke without supervision through the review date, and the resident will not suffer injury from unsafe smoking practices through the review date which was documented as 08/13/23. The intervention dated 07/13/23 read: notify the charge nurse immediately if it is suspected the resident has violated the facility smoking policy. The interventions added on 07/17/23 were listed as: instruct resident about the facility policy on smoking: times, safety, and concerns; the resident requires a smoking apron while smoking, and the resident requires assistance when smoking. During a follow-up interview with the DON#2 on 08/07/23 at 05:12 PM she revealed a smoking assessment is completed on admission and when changes occur and every time Resident # 92 had an incident. She indicated she was not sure if the smoking assessment triggered a care plan and stated the care plan is updated any time an incident happens and if there is a change in the assessment. She also indicated an independent smoker doesn't need supervision and independent smokers are allowed to have their cigarettes, but no one is allowed to have a lighter. She continued that a designated staff assists an assisted smoker depending on their need and that one staff member lights everybody's cigarettes. The facility plan of correction to remove the IJ immediacy was as follows: a) An updated smoking assessment was completed on Resident #92 on 7/13/23 which categorized the resident as an assisted smoker with a history of smoking-related incidents. Resident's care plan was updated on 7/17/23 to include the use of a smoking apron for safety. Resident #92 was discharged to another facility on 8/8/23. b) On 8/10/23, smoking assessments for all current residents were audited by the nursing management team to ensure no further inaccuracies. Nursing Managers, DON, and Regional Clinical Consultant reviewed the medical records of all current residents in the facility who smoke to ensure that all current smokers have an updated, accurate smoking assessment and an updated, accurate care plan which includes appropriate interventions to prevent smoking-related injury. On 8/10/23, recreation staff verified via direct observation that smoking supervision was provided, and care plan interventions related to smoking safety are being carried out appropriately for current residents who smoke. Residents who fail to comply with the rules of the facility's smoking contract, which is signed on admission by the resident, or with safety interventions as outlined in their care plan, will be issued a behavioral contract. Continued noncompliance after issuance of behavioral contract may result in involuntary discharge notice. This was reviewed with current smokers by NHA during an ad hoc meeting on 8/10/23 and was added to the facility's smoking contract. c) Unit Managers and Nurse Practice Educator were educated via speakerphone while in the NHA office by Director of Nursing on 8/10/23 on smoking assessment accuracy, timeliness of smoking assessment, care plan intervention updates and accuracy related to smoking. Education of all licensed nurses working 7-3 shift on 8/10/23 was immediately performed by Nurse Practice Educator (NPE) and NPE will continue to educate all other licensed nurses on smoking assessment accuracy, timelines of smoking assessment, and care plan intervention updates and accuracy related to smoking. Education of all licensed nurses will be completed by 8/14/23. NHA educated Department Heads on 8/10/23 regarding safe smoking practices while supervising smoking. Department Heads began educating their staff on safe smoking practices on 8/10/23 and will continue to educate all staff within their department. Education of all facility staff will be completed by 8/14/23. NHA educated recreation staff on 8/10/23 to verify via direct observation that smoking supervision was provided, and that care plan interventions related to smoking safety are being carried out appropriately for current residents who smoke. Any facility staff member or agency staff member unable to be reached by 8/14/23 (i.e., call-out, vacation) will be educated upon arrival at the facility; NHA will ensure that education has been provided to them prior to beginning their shift. Education will be validated by quizzes performed randomly by Nurse Practice Educator with 10% of staff weekly for a period of 3 months. d) DON, Unit Managers, and Nursing Supervisors will conduct audits on smoking assessments and care plan updates (related to smoking) weekly x 3 months to determine compliance with smoking assessment accuracy, timeliness of smoking assessments, and care plan updates related to smoking. Recreation staff will conduct daily audits to verify that smoking supervision was provided, and care plan interventions related to smoking safety are being carried out appropriately for current residents who smoke. Findings will be reported by the DON at the monthly Quality Assurance Performance Improvement (QAPI) meeting for a period of 3 months to monitor progress towards improvement and recommendation 3) On 08/03/23 10:08 AM, facility incident MD00190558 was reviewed and revealed that Resident #157 was transferred to bed without using the mechanical lift causing a bruise on the resident's shoulder blade. Review of the medical record on 8/3/23 at 10:15 AM revealed the resident was admitted to the facility for rehabilitation and with diagnoses that include generalized muscle weakness, and difficulty walking. Further review of the lift transfer repositions assessment revealed the following: the resident is not able to transfer independently, full body sling the resident is not able to bear weight, a total lift is required ( indicating a hoyer lift to be used.) Further review of the assessment revealed that the resident was documented as needing a 1 person assist for bed mobility. A hoyer lift requires a 2 person assist with the correct sling for lifting. Further review of the facility investigation revealed that on 3/23/23 the resident had asked the Geriatric Nursing Assistant (GNA) # 96 to put him back in bed. When GNA#96 came to the resident's room he picked the resident up by himself placing Resident #157 in bed bruising his/her back. During an interview with the DON on 8/3/21 at 10:30 AM, the surveyor asked about the incident with Resident #157 and she reported that GNA #96 was employed through a nursing staffing agency who was notified the GNA should not return to the facility for failing to follow the resident treatment plan on transfer causing a bruise. The concern regarding the failure to ensure the resident was transferred via Hoyer lift with the assist of two persons was reviewed with the DON and the Administrator on 8/22/23 during the survey exit.