**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, administrative record review, and staff interview; it was determined that the facility failed to protect a cognitively impaired resident (resident #900) from physical abuse from a facility staff member. This was evident for 1 of 5 residents reviewed during a complaint survey. After the incident, the facility implemented effective and thorough corrective measures.The facility's plan and action were verified during this survey; therefore, this deficiency will be cited as past noncompliance. The date of correction is 2/20/23 The following terms are defined for comprehension of the investigative findings: Minimum Data Set (MDS): The Minimum Data Set (MDS) is a comprehensive assessment of a resident completed by facility staff. The MDS is a multi-discipline tool that allows many facets of the resident's care [cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain, and medications to name a few] to be addressed. The MDS assessment is part of the broader Resident Assessment Instrument (RAI) process. The RAI process ties the assessment and care plan to the delivery of care to meet the needs of the resident. The findings include: Medical record review on 8/7/24 at 9:25am revealed resident #900 was a memory-impaired long-term care resident as documented in the quarterly MDS assessment dated [DATE]. On 8/7/24 at 9:25am, surveyor review of facility reported incident intake MD#00189249, dated 2/19/23, revealed that on 2/19/23 resident #900 reported to facility nursing staff that I don't want to be hit anymore. On 8/7/24 at 9:30am, surveyor review of the facility investigation dated 2/19/23 revealed a witness statement by LPN #304 which stated that on 2/19/23, resident #900 reported that he/she did not want to be hit anymore. LPN #304 assessed the resident and observed that the resident had purple/red bruises on his/her right temple, right eyebrow, right hand, and left hand. LPN#304 also stated that he/she spoke to GNA #302 regarding the bruising on resident #900's body. GNA#302 admitted that he/she bumped the resident when he/she was attempting to clean barrier cream from the resident ' s face. On 8/8/24 at 9:00am, surveyor interview with the Director of Nursing (DON) revealed he/she interviewed GNA #302 on 2/19/23 at approximately 12:30am, and he/she confirmed that he/she bumped resident #900 when he/she was taking a tube of barrier cream from the resident. The DON also stated that he/she interviewed LPN #304 on 2/19/23 at approximately 12:15 am and was told that he/she spoke to resident #900 and the resident stated, I don't want be hit anymore. LPN #304 observed that the resident was covered with thick, white barrier cream on the right side of his/her face/ hair and bruises on the resident's right temple. LPN #304 escorted the resident to his/her bathroom where the resident was assessed and additional bruises were found on the resident's right eyebrow, top of left hand, and between the 4th and 5th finger on the right hand. The DON stated that LPN #304 also observed that the bruises were purple/red in color. The DON stated that he/she was also able to observe the bruises reported by LPN #304 and he/she agreed with the assessment. The DON stated that he/she took GNA #302 from the unit by 12:30am on 2/19/23 and escorted GNA #302 from the property by 1:30am. On 8/8/24 at 10:40am, the surveyor interviewed Human Resource Director #305. HR Director #305 was able to confirm that GNA #302 last day of pay was on 2/19/23 and GNA#302 worked until 1:30am. On 8/9/24 at 9:31am, surveyor interview with LPN #304 confirmed the details gathered from the DON. The surveyor asked LPN #304 how he/she made initial contact with resident #900. LPN #304 stated that he/she was preparing medications at the medicine cart on 2/19/23 at approximately 12:00am. The resident approached LPN #304 and stated, I don ' t want to be hit anymore. LPN #304 initially thought the resident was involved in a resident-to-resident altercation. LPN#304 stated that when he/she continued to question the resident about his/her statement, the resident was unable to tell him/her any information. LPN #304 then realized the resident had barrier cream all over his/her hair, face and hands. LPN #304 then took the resident to his/her bathroom to clean him/her up and then observed the bruises on the resident ' s face and hands. While LPN #304 was assisting resident#900, GNA #302 came into resident ' s room to speak to LPN #304 about other residents. LPN #304 stated that he/she told GNA #302 that he/she was unable to speak to him/her because the resident was injured in an altercation. LPN#304 stated that GNA#302 told him/her that not one hit the resident and he/she must have bumped the resident ' s glasses with my arm or hand when I was taking the barrier cream from her. LPN#304 then realized that the facial bruises were in the shape of the resident ' s glasses. LPN #304 realized at that moment that GNA #302 may have hurt the resident so he/she did not let the resident out of his/her sight until the DON came to the unit to take GNA#302 off the unit. On 8/9/24 at 11:00am, the surveyor then expressed concern to the Administrator and the DON that the facility failed to protect a cognitively impaired resident (resident #900) from physical abuse from a facility staff member. The DON stated that the facility self-initiated the following actions to correct and re-enforce facility abuse policy as of 2/19/23: 1.) The DON terminated GNA #302 from facility employment on 2/20/23. 2.) The facility reported GNA #302 to the State of Maryland ' s Board of Nursing after termination. 3.) All facility nursing staff were re-educated on abuse prohibition and neglect policies on 2/20/23 and any staff not educated on 2/21/23 were not allowed to work in the facility until re-educated on abuse prohibition and neglect policies.

Based on medical record review, administrative record review, and staff interview; the facility failed to protect a vulnerable resident (resident #901) from a fall with major injury when facility nursing staff failed to delete an incorrect order for sleep medication (Ambien) from the resident ' s medical record. This was evident for 1 of 4 residents reviewed during a complaint survey. The findings include: Surveyor review of resident #901's medical record on 8/8/24 at 12:00pm revealed resident #901 was admitted to the facility for rehabilitation after orthopedic surgery. Further review of the resident ' s medical record on 8/8/24 at 12:05pm revealed the resident had a witnessed fall on 9/11/22 at 8:30am. The resident was transferred to a local hospital and was diagnosed with a fracture of the bones near the left eye. Surveyor review of the fall incident report on 8/8/24 at 12:34pm revealed resident #901 fell while being assisted by his/her assigned GNA to the bathroom. The resident was ambulating with a rolling walker when the resident lost his/her balance and fell toward his/her left side, bruising the left side of the resident's forehead. The resident was assessed and ordered to be sent to a local hospital for evaluation by the primary provider. Surveyor review of a self-report (MD00190723) on 8/8/24 at 12:45pm, dated on 9/15/22, revealed the facility completed an investigation of the resident's fall and discovered the root cause of the resident's fall was over-administration of the resident's prescribed sleep medication (Ambien) on 9/10/22. The facility further discovered in the investigation that the facility nursing staff that over-administered the resident's sleep medication was following provider orders transcribed by facility nursing staff on 9/8/22 at 5:38pm. Surveyor review of a medication error report on 8/8/24 at 1:15pm revealed the document, dated 9/11/22, reported that RN #307 transcribed a provider order for a one-time dose of Ambien for 12.5mg on 9/8/22 at 5:38pm. RN #307 administered the one-time dose of Ambien and failed to discontinue the medication after administration. On 9/10/22 at 9:38pm, RN #308 administered the resident's standing dose of Ambien of 6.25mg and the one-time dose 12.5mg of Ambien. Surveyor interview with the RN #310 on 8/8/24 at 2:08 pm revealed RN #310 assessed resident #901 after the 9/11/22 fall incident. RN #310 observed a red bump/bruise on the resident's left side of his/her head. RN #310 contacted the provider and was ordered to have the resident sent to the local hospital. The resident's family was also contacted. RN#310 started a medication review after the resident's fall because GNA #309, the facility nursing staff member who assisted the resident when he/she fell, noticed the resident was lethargic when he/she assisted the resident to the bathroom. RN #310 discovered that RN#308 administered a higher dose of the resident's sleep medication when he/she gave the resident the standing dose and a one-time dose of the sleep medication on 9/10/11 at 9:38pm. RN #310 also discovered that RN #307 transcribed a one-time dose of sleep medication from a provider phone order. RN #307 administered the one-time dose of the sleep medication on 9/8/22 and failed to discontinue the one-time dose after administration of the medication. Surveyor interview with the Director of Nursing (DON) on 8/9/24 at 8:30am confirmed the statements made by RN #310 and the fall incident report. The DON also stated the facility added steps to the order reconciliation process to avoid the mistake made in resident #901's medication order record. The facility now requires a nurse on the 11-7 shift on each floor of the facility to reconcile all resident orders for that floor daily. Any new orders must be written in an order book. This step is in addition to the nurse printing out all orders and reconciling all orders to the electronic record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, administrative record review, policy review and staff interview; the facility failed to protect vulnerable residents (resident #901 & #174) from a significant medication error. This was evident for 2 of 30 residents reviewed during the survey. This deficient practice resulted in harm to resident # 901 who had a fall incident (accident) with major injury. The findings include: 1.) Surveyor review of resident #901's medical record on 8/8/24 at 12:00pm revealed resident #901 was admitted to the facility for rehabilitation after orthopedic surgery. Further review of the resident's medical record on 8/8/24 at 12:05pm revealed the resident had a witnessed fall on 9/11/22 at 8:30am. The resident was transferred to a local hospital and was diagnosed with a fracture of the bones near the left eye. Surveyor review of the fall incident report on 8/8/24 at 12:34pm revealed resident #901 fell while being assisted by his/her assigned GNA to the bathroom. The resident was ambulating with a rolling walker when the resident lost his/her balance and fell toward his/her left side, bruising the left side of the resident's forehead. The resident was assessed and ordered to be sent to a local hospital for evaluation by the primary provider. Surveyor review of a self-report (MD00190723) dated 9/15/23 revealed the facility completed an investigation of the resident ' s fall and discovered the root cause of the resident ' s fall was over-administration of the resident ' s prescribed sleep medication (Ambien) on 9/10/22. The facility further discovered in the investigation that the facility nursing staff that over-administered the resident ' s sleep medication was following provider orders transcribed by facility nursing staff on 9/8/22 at 5:38pm. Surveyor review of a medication error report on 8/8/24 at 1:15pm revealed the document, dated 9/11/22, reported that RN #307 transcribed a provider order for a one-time dose of Ambien for 12.5mg on 9/8/22 at 5:38pm. RN #307 administered the one-time dose of Ambien and failed to discontinue the medication after administration. On 9/10/22 at 9:38pm, RN #308 administered the resident's standing dose of Ambien of 6.25mg and the one-time dose 12.5mg of Ambien. Surveyor interview with the RN #310 on 8/8/24 at 2:08 pm revealed RN #310 assessed resident #901 after the 9/11/22 fall incident. RN #310 observed a red bump/bruise on the resident's left side of his/her head. RN #310 contacted the provider and was ordered to have the resident sent to the local hospital. The resident ' s family was also contacted. RN #310 started a medication review after the resident ' s fall because GNA #309, the facility nursing staff member who assisted the resident when he/she fell, noticed the resident was lethargic when he/she assisted the resident to the bathroom. RN #310 discovered that RN#308 administered a higher dose of the resident's sleep medication when he/she gave the resident the standing dose and a one-time dose of the sleep medication on 9/10/11 at 9:38pm. RN #310 also discovered that RN #307 transcribed a one-time dose of sleep medication from a provider phone order. RN #307 administered the one-time dose of the sleep medication on 9/8/22 and failed to discontinue the one-time dose after administration of the medication. 2.) Review of R174's undated Face Sheet, located in the electronic medical record (EMR) under the Dashboard tab, revealed R174 was admitted to the facility on [DATE] with diagnoses that included disorder of bone and other cervical disc degeneration. R174 had the following drug allergies: Penicillin's, Avelox, Bactrim, and cephalosporins. Review of R174's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/21/22, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R174 was cognitively intact. It was recorded R174 had experienced occasional pain the last five days and had received opioids in the preceding seven days. Review of R174's Physician's Orders, dated 04/15/22 and located in the EMR under the Physician Orders tab, revealed an order for Oxycodone 5 mg [milligrams] tablet 0.5 tab (2.5 mg) by mouth every 8 hours for pain. Review of R173's Physician's Orders, dated 04/29/22 and located under the Physician Orders tab of the EMR, revealed an order for Oxycodone 5 mg tablet one by mouth every 4 hours as needed for moderate to severe pain. Review of R173's facility provided Controlled Substance Record, dated 05/09/22, revealed 26 medications noted at 11:00 PM on 05/09/22 count; resident on leave of absence (LOA) pulled in error. Review of the facility's investigative documents revealed the following nursing staff statements written on 05/10/22: Certified Medicine Aide (CMA) 1: On 05/09/22 at 1:00 PM, she pulled R173's medication card from the medication cart and administered R174 the wrong pain medication (Oxycodone 5.0 MG instead of Oxycodone 2.5 MG). Licensed Practical Nurse (LPN) 7: On 05/09/22 at 11:00 PM, during the change of shift count, she noticed R173's medication card was missing one Oxycodone which was not correct because he was out of the facility. During an interview on 08/08/24 at 2:49 PM, CMA1 confirmed she pulled R173's Oxycodone medication card from the medication cart and administered the pain medication to R174 in error. CMA1 stated she should have checked the medication card to ensure she had the right resident and correct medication, but she was distracted by coworkers at the time. LPN7 was unavailable for interview. During an interview on 08/08/24 at 3:36 PM, Director of Nursing (DON) 1 stated she was notified by LPN7 on 05/09/22 at 11:00 PM that one of R173's Oxycodone pills was missing from the medication card and R173 was in the hospital. DON 1 stated she completed the investigation on 05/10/22 and determined CMA1 pulled the wrong medication card from the cart in error and administered R174 Oxycodone 5 MG which was double the dose he/she was supposed to receive per the physician order. DON1 indicated R174 was assessed with no adverse reaction or change of condition and the physician was notified on 05/10/22. DON1 indicated she expected nursing staff to administer medications to the right resident. Review of the facility's policy titled, Administering Medications, revised April 2019 ad provided by the facility, revealed policy medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; b. the dosage; c. the route of administration; d. the injection site (if applicable); e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug .

Based on facility report review, medical record review, and staff interview, it was determined that the facility staff failed to ensure that safety interventions were followed and that the physician was provided sufficient notification regarding a recent fall with injury This is evident for 1 (#272) of 2 residents reviewed for provision of quality of care. These failures resulted in a finding of actual harm for Resident #272. The findings include: Review of the facility's investigation report MD#00139351 revealed that, on 4/12/19 at 8:30 AM, Charge Nurse and Unit Manager observed Resident #272 on the floor, blood on the head and a bruised rug burn noted on forehead. Review of the investigation revealed that the resident's floor mat was not in place at the time of the fall. Review of the progress note, written by Licensed Practical Nurse (LPN) #2 on 4/12/19 at 10:05 AM, revealed that Resident #272 was found on the floor in a pool of blood that had come from his/her nose. At 10:56 AM, LPN #2 noted a bruise to the resident's right eye during a follow up assessment. At 11:09 AM, LPN #2 documented that she faxed physician #13 (the on-call physician) about the fall. However, review of the document faxed at 10:26 AM failed to indicate that the resident had bled or was noted with a bruise, or sustained a carpet burn injury or that the fall mat was not in place. Further review revealed that the notification did not require a return call from the physician to the facility. A progress note, written by LPN #2 on 4/12/19 at 1:06 PM, revealed that the resident was found unresponsive and sent to an acute care hospital for evaluation. A record review on 6/24/19 at 1:10 PM, revealed a summary of Resident #272's emergency room visit, dated 4/12/19. Resident #272 had a Computed Tomography (CT Scan) of the head on 4/12/19, which revealed a fracture of the frontal bone (the forehead) with a hematoma (which is collection of blood out the blood vessel) and swelling in the brain and evidence that the brain shifted from one side to the other. A second CT scan was done of the sinuses on 4/12/19 that revealed the fracture in the frontal bone extended to the sinus cavity and included the bone around the right eye. Further review of the summary documented that the neurosurgeon felt that surgery could not be done and the resident was placed in hospice (end of life) care. A progress note, written on 4/13/19 at 8:30 AM by LPN #11, documented that Resident #272 passed away on 4/12/19 at 11:50 PM. A medical record review on 6/24/19 at 1:35 PM, revealed a physician's order for floor mats at the bedside. Further review revealed a care plan as of 4/12/19, with a focus of, I (Resident #272) am at risk for falls related to poor safety awareness I have a history of falls. With a goal, I (Resident #272) would like to be free of falls at my next 90 day review. Interventions included a fall mat for safety and a bed alarm. Interview with the Unit Manager (UM) staff #1 on 6/25/19 11:21 AM revealed that, after the resident was found on the floor that morning, she provided the initial assessment then stayed and closely monitored the resident. She went on to say that she was aware of the development of the bruised right eye, nose, and forehead. However, further review of the medical record failed to indicate that the UM re-assessed the resident until 1:06 pm or tried to contact the physician personally that day. During an interview with the LPN #2, on 6/25/19 at 12:00 PM, she indicated that she would have called the physician after the fax was sent. However, she was unable to submit documentation to support that this was done. An interview with the Director of Nursing (DON) , on 6/25/19 at 3:48 PM, revealed her expectations would be that the physician be notified by phone regarding a resident's fall with details of the fall and the extent of the injuries. The DON acknowledged that this incident should have been reported to regulatory agencies and then investigated. Although LPN #2 indicated that the physician was updated at 1:52 PM, an interview with Physician #13 on 7/18/19 at 3:22 pm indicated that she was not made aware of the fall or the injuries, at the time of receipt of the resident's transfer to the hospital. In addition, she stated that, based upon the circumstances surrounding the fall and injuries sustained, she would have probably sent the resident to the hospital right away if notified of this information at the time of fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview, it was determined that the facility staff failed to protect a resident from an accident with injury. The failure of staff to follow the standard of care while turning a resident in bed resulted in the resident rolling out of bed and sustaining a knee and femur fracture. The facility staff also failed to follow a second resident's plan of care during a transfer which resulted in a fall without injury. This was evident for 2 (#23, #40) of 8 residents reviewed for falls. The findings include: 1) Review of the medical record for Resident #23, on 1/18/18 at 8:13 AM, revealed that Resident #23 had a diagnosis of CVA (cerebral vascular accident) with left hemiplegia (paralysis of one side of the body) following a stroke. The left hand also had a contracture. A contracture is an abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching which can lead to permanent disability. It can be caused by inadequate exercising of the joint in patients with paralysis. Resident #23 was recently in the hospital, from 12/31/17 to 1/7/18, due to acute hypoxemic respiratory failure, pneumonia, reactive airway disease, SIRS (systemic inflammatory response syndrome), along with other chronic diagnosis. After the resident returned from the hospital, the attending physician documented in Resident #23's medical record that the resident was Incapable due to cognitive dysfunction as of 1/11/18. During an interview with Resident #23 ,on 1/17/18 at 10:49 AM, Resident #23 stated he/she was just in the hospital due to a fall. The resident was observed with bruising to the right arm and on top of the right hand. The resident stated, my body hurts from the fall. Review of the medical record revealed that Resident #23 had a fall on 1/16/18 at 4:15 A.M while a Geriatric Nursing Assistant (GNA) was rendering care. This was 5 days after returning to the facility following hospitalization as stated above. Nursing documentation stated the resident was using the enabler bar and was holding on when the enabler bar moved. It was noted that the resident had a 3 cm (centimeter) purple bruise to the right hip. The resident was transferred to the hospital on 1/16/18 at 4:33 AM. A second note, written on 1/16/18 at 6:20 AM, stated GNA had turned the resident and resident grabbed the enabler and it was unsteady and he/she rolled off the side of the bed to the floor. Documentation revealed that the resident complained of right leg and knee pain. Review of the emergency room documentation, dated 1/16/18 at 13:20, revealed the clinical impression for Resident #23 was 1. Right distal femur fracture and 2. Right knee fracture. A splint device was applied to the resident's right leg and the resident was transferred back to the facility where the resident was to follow-up with orthopedics. A Fall's risk assessment was done, on 1/16/18 at 6:39 AM, after the fall by Staff #3 who documented the resident had intermittent confusion/poor safety awareness/impulsive. The assessment also documented the resident was chair bound, balance was decreased due to muscular coordination and was deemed a low risk for falls. An interview was conducted with the DON on 1/18/18 at 10:37 AM. The DON stated I didn't feel the enabler was involved at all. I had the GNA come in and I got a statement and we reenacted what happened and the GNA indicated the leg had come off the bed, had slid down and the resident indicated the bar was wobbly. I believe the legs got off the bed, were heavy and took him/her off the bed. The DON continued the GNA received education because I indicated to the supervisor if he/she was in the room alone, he/she needed to turn the resident towards him/her instead of away from him/her. We started education in house. Review of the in-house education given to the surveyor revealed 20 of the 46 GNAs had been in-serviced. The in-service education stated when you are assisting a resident in bed with care by yourself ALWAYS turn them toward you. This decreases the risk of the resident rolling OOB (out of bed). If you are ever uncomfortable providing care to a resident, you are encouraged to get a second person. An enabler is not to help the resident stay in bed. The sole purpose of the enabler is to assist the resident with mobility, increasing their independence. If you have questions, please ask your unit manager or shift supervisor. On 1/18/18 at 12:38 PM, Staff #3 was interviewed about the fall and stated that Staff #2 was turning and positioning the resident with no assistance and that the resident was usually a 1 assist. Staff #3 stated the resident will help with turning but is pretty much paralyzed on the left side. Staff #3 stated the resident said the enabler bar moved back and forth slightly. Staff #3 stated that he/she personally checked the enabler bar and it moved back and forth slightly. I thought it was the resident's perception of how loose the grab bar was and that the resident wasn't comfortable with the grip. Staff #3 also stated that after the resident came back from the hospitalization for pneumonia that the resident was more confused than normal and the night of the fall had baseline confusion and had issues with comprehension. On 1/19/18 at 7:45 AM, Staff #2 was interviewed regarding the fall. Staff #2 stated I was changing his/her Attends and linen pad. At 4:20 AM, the resident was wet so I got everything ready before I rolled him/her. I rolled him/her towards the enabler because his/her right side was the stronger side and he/she can hold on and he/she said the enabler was shaky and wobbly and I was trying to get everything under him/her. I wanted to roll him/her back towards me and he/she let go of the enabler and his/her feet went over the edge of the bed. The surveyor inspected the enabler bar and the bar was 4 inches wide and was located near the head of the bed on the left side of the bed. There were no side rails attached to the bed. The interview continued; normally I do him/her by myself because in the computer they have him/her as a 1 person assist. I wanted to get him/her changed and grab someone to help me pull him/her up in bed and he/she let go and his/her legs went and he/she fell on the floor. They said the enablers are not there to prevent someone from falling out of bed and it is for their bed mobility. They said that I should have rolled him/her toward my way instead of away from myself. The way I was taught in school they still had the side rails and that is not the same as enabler and I was taught to have them use their stronger side. I normally have 17 residents assigned to me. On Maplewood, I have to turn, position and change about 9 or 10 residents. About 5 or 6 of the residents, I need assistance with, and it would be easier to do rounds with 2 people. The surveyor asked if Staff #2 didn't feel comfortable doing a resident alone would Staff #2 get help. The response was In some cases I need to make a decision if I need help or not. I usually go by what's in the system. Review of Resident #23's MDS with an assessment reference date (ARD) of 11/19/17, Section G, Functional Status indicated that the resident was coded a (3) extensive assistance with the support (3) which meant a 2 plus person assist with bed mobility. The resident was also coded as having functional limitation for the upper extremity and no functional limitation for the lower extremity (which was an error - Cross Reference F641) as the resident had paralysis on the entire left side of the body, upper and lower. The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and-or Medicaid-certified long-term care facility. The MDS contains items that measure physical, psychological and psychosocial functioning. The items in the MDS give a multidimensional view of the patient's functional capacities and helps staff to identify health problems and develop a plan of care to meet the resident's needs. Review of Resident #23's Activities of Daily Living (ADL) functional care plan dated 1/8/18 documented enabler x 1 for bed mobility. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Review of the GNA Resident Care Guide, that was initiated on 1/7/18, documented transfers and ambulation/mobility: Hoyer for all transfers with 2 staff. Uses w/c (wheelchair). Has left sided paralysis, left hand contracted, left foot turns inward. Bathing/hygiene/dressing: one assist d/t (due to) left sided paralysis, left hand contracture, and left foot turned inward. Left hand splint when OOB, remove splint q shift when worn. Safety, enabler x 1 for bed mobility due to increased congestion - keep out of bed as much as possible. Review of the GNA care log for January 8-16, 2018 documented bed mobility as extensive assistance with 1 person. Review of the GNA care log for the month of December 2017 had varied documentation from 1 person assist to 2 person assist for bed mobility. Out of the 31 days for day shift, 15 of the days, the resident required 2 or more staff for bed mobility, which was 48% of the time. Out of the 30 days for evening shift, (resident was discharged to hospital on [DATE] in the afternoon) 22 of the evenings the resident required 2 or more staff for bed mobility which was 73% of the time. The night shift documented 0 nights that the resident required 2 or more staff members for bed mobility. There was no clarity or rationale on a day to day basis as to how the decision was made to determine the level of assistance Resident #23 required for bed mobility. The MDS assessment should drive the care the resident is to receive and the MDS assessment documented that the resident was a 2 person assist for bed mobility. In addition, a functional pathway assessment that was in the paper medical record, which was completed on 10/26/17 documented bed mobility as a 3/3 which was extensive assist with 2 person, transfer 4/3 which was total dependence with 2 person. On 8/4/17 bed mobility was documented again as 3/3 and on 5/23/17 the resident also was an extensive assist with 2 plus person assistance. The DON and MDS Coordinator advised the surveyor on 1/18/19 at 2:15 PM that the functional pathway assessment was an MDS work tool. When the resident was re-admitted from the hospital on 1/7/17 after pneumonia a physical therapy (PT) evaluation was done. PT documented on 1/8/18 that the resident was at baseline with dependence for transfers with Hoyer lift and was non-ambulatory. Nursing, GNA, PT and spouse did not feel PT was indicated as no changes in status existed for PT to address. On 1/19/17 at 2:00 PM the Physical Therapist was interviewed and asked how the resident should have been turned while in bed. The Physical Therapist stated the GNA should have turned towards them self, especially for this resident. 2) Review of the medical record for Resident #40 revealed documentation that the resident had a fall on 10/16/17 while being transferred by a GNA from the chair to the wheelchair. The GNA statement on the incident form stated went into resident room to transfer him/her to bathroom. When I helped him/her stand up (with gait belt on) to transfer him/her to w/c and help him/her to BR, his/her knees buckled on him/her. The resident was not hurt. The incident report only had 1 GNA in the room with the resident. Review of the MDS with an ARD of 9/117 and 12/1/17 coded the resident as a 3 which was extensive assist with 3 which was 2 person physical assistance. Review of GNA daily charting for October 2017 documented the resident was extensive assistance (3) with 2 person assist (3). Review of the care plan I have Parkinson's disease and I am dependent on staff for the completion of my ADLS bathing, dressing and personal hygiene needs. My mobility is limited due to my Parkinson's and OA (osteoarthritis). I am able to feed myself but at times I need staff to assist me due to tremors of my hands. The care plan evaluation documented transfer/ambulate with 2 assist walker. The 12/14/17 evaluation stated transfers and ambulates with 2 assist and use of walker. The potential for fall care plan stated transfer/ambulate with gait belt/walker/2 assist. Facility staff failed to follow the care plan.