**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed and care planned to be totally dependent on two staff members for bed mobility, incontinence care and turning and repositioning in bed, the Facility failed to ensure nursing staff consistently implemented and followed interventions from his/her Plan of Care while meeting his/her care needs, when on the 11:00 P.M. to 7:00 A.M. shift on 11/24/23 into 11/25/23, Nurse Aide #1 provided Resident #1 with incontinence care and repositioning in bed, without the assistance of another staff member. On 11/25/23 on the 7:00 A.M. to 3:00 P.M. shift, Resident #1 was found with a new area of bruising of unknown origin to his/her left upper arm. Resident #1 was transferred to the Hospital Emergency Department, where he/she was diagnosed with an acute left humeral (upper arm bone) fracture. Findings include: Review of the Facility Policy, titled Care Planning, dated as last revised 11/28/18, indicated that the Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Review of the Resident Assessment Instrument (RAI) Manual, dated as last revised 2019, indicated that the comprehensive care plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services that are to be provided by staff to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. Resident #1 was admitted to the Facility in April 2023, diagnoses included advanced dementia, malnutrition, anxiety, depression, and multiple contractures (shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints). Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 10/03/23, indicated he/she had both long-and short-term memory loss, severely impaired decision-making abilities, rarely/never unable to make his/her needs known, or rarely/never able to understand others. The MDS further indicated he/she was totally dependent on staff for bed mobility, turning and repositioning, transfers, and incontinence care. The MDS indicated he/she had bilateral contractures to his/her lower extremities and contractures to his/her upper extremity. Review of Resident #1's Care Plan, titled Activities of Daily Living, dated as last revised 10/18/23, indicated he/she required total assistance of two staff members to turn and reposition every two hours and as needed (PRN), incontinence care and weight shift in bed or chair every two hours, and totally dependent of two staff members with transfers while utilizing a mechanical lift. Review of Resident #1's Resident Profile, dated as last revised 10/18/23, indicated he/she required total assistance of two staff members to turn and reposition every two hours and PRN, incontinence care or weight shift in bed or wheelchair every two hours, and totally dependent of two staff members with transfers while utilizing a mechanical lift. Review of the report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 12/06/23, indicated that staff discovered a large bruise on Resident #1 left upper arm of unknown origin, however, after the Facility investigation, the nurse aide (later identified as Nurse Aide #1) on the 11:00 P.M. to 7:00 A.M. (night shift) informed the Director of Nurses (DON) that she had provided incontinence care twice during the shift to Resident #1 and had not asked another staff member for any assistance. Review of the Facility Incident Report, dated 11/25/23, indicated Resident #1 was found with a large irregularly formed ecchymotic area, measuring 14 centimeters (cm) by 8 cm to his/her left upper arm and required transfer to the Hospital Emergency Department for evaluation. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she was diagnosed with an acute comminuted displaced fracture through the left humeral surgical neck with the involvement of the greater tuberosity, non-displaced fracture of the proximal end of the left humerus. Review of Nurse Aide (NA) #1's, Written Witness Statement, dated 11/25/23, and review of NA #1's telephone interview with the DON, dated 11/28/23 at 4:00 P.M., indicated that Resident #1 was on her assignment from 11:00 P.M. on 11/24/23 through 7:00 A.M. on 11/25/23. NA #1 said that she checked on him/her when she first arrived and said she provided incontinence care to him/her twice during the night. The DON asked NA #1 if she got help from any other staff and NA #1 said no. The DON explained to NA #1 that Resident #1 should have been a two person assist for care. During a telephone interview on 1/24/24 at 12:00 P.M., Nurse Aide (NA) #1 said she was aware that Resident #1 needed the assistance of two staff to transfer and to change his/her position when he/she was in bed and said she had not asked any other staff member for assistance that night. During a telephone interview on 01/18/24 at 2:01 P.M., the Director of Nurses (DON) said that when she specifically asked NA #1 if she knew Resident #1 was a 2 person assist, she said NA #1 was very vague and did not answer her question. During a telephone interview on 01/25/24 at 10:28 A.M., CNA #8 said she had worked on 11/25/23 at 7:00 A.M. and said Resident #1 was on her assignment. CNA #8 said she and CNA #2 were beginning to get Resident #1 ready for the day and said when she removed his/her night gown they noticed a large red area to his/her left arm (between the shoulder and elbow). CNA #8 said she immediately called the nurses (Nurse #1 and Nurse #2) to see the area. During a telephone interview on 01/23/24 at 1:27 P.M., Nurse #1 said she was working from 11:00 P.M. on 11/24/23 through 7:00 A.M. on 11/25/23 and said that she had explained to NA #1 in the past that Resident #1 was very contracted, fragile and required two assists with all care. Nurse #1 said NA #1 had not asked for any assistance during that shift. Review of CNA # 7's Written Witness Statement, dated 11/25/23, indicated he had no interaction with Resident #1 at all during that night shift. During a telephone interview on 01/25/24 at 2:39 P.M., CNA #5 said she had trained NA #1 on the night shift for some of her orientation and said the first thing she always did was go around and ensure that NA #1 was aware of each resident's level of care on their assignment. CNA #5 said Resident #1 had been on their assignment in the past when NA #1 was in training. During an interview on 01/17/24 at 1:54 P.M., the Director of Rehabilitation Services said Resident #1 requires total care of two nursing staff members at all times, except for eating and oral hygiene. During a telephone interview on 1/18/24, the Nurse Manager said that back in October 2023, Resident #1's Family Member had some concerns with his/her care, considering how fragile and contracted Resident #1's was, and said since then, Resident #1 was care planned to have two nursing staff for all care, except for eating and brushing his/her teeth (that only required one nursing staff member). The Nurse Manager said that was when his/her Care Plan and Resident Profile were updated. The Nurse Manager said it is the Facility's expectation that all CNA's are aware of each resident's functional level prior to actually providing physical care and should be utilizing the Resident Profile for guidance. During a telephone interview on 01/18/24 at 2:01 P.M., the Director of Nurses said it is the expectation of the Facility that all nursing staff are familiar with each resident's care needs prior to providing them with physical assistance. The DON said all nursing staff are expected to follow each resident care plan and care areas are located on each Resident profile for CNA's to access and are expected to ask questions if they are uncertain of how to care for a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed to be totally dependent on two staff members with bed mobility, turning and repositioning, and incontinence care, the Facility failed to ensure his/her plan of care was followed to maintain his/her safety and prevent an incident or accident resulting in a major injury, when on the 11:00 P.M. to 7:00 A.M. shift on 11/24/23 into 11/25/23, Nurse Aide #1 provided Resident #1 with incontinence care and repositioning in bed, without the assistance of another staff member. On 11/25/23, on the 7:00 A.M. to 3:00 P.M. shift, Resident #1 was found with a new area of bruising of unknown origin to his/her left upper arm. Resident #1 was transferred to the Hospital Emergency Department, where he/she was diagnosed with an acute left humeral (upper arm bone) fracture. Findings include: Review of the Facility's Policy, titled Safe Lifting and Movement Policy, dated as last revised 08/01/18, indicated that employees use safe methods for lifting and moving elders in the nursing facility in order to prevent injury to both the employees and elders. The Policy further indicated that all elders/residents who have any degree of dependency for transfer or movement will be assessed to determine the extent of assistance required and the safest method of assistance. Resident #1 was admitted to the Facility in April 2023, diagnoses included advanced dementia, malnutrition, anxiety, depression, and multiple contractures (shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints). Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 10/03/23, indicated he/she had both long and short-term memory loss, severely impaired decision-making abilities, rarely/never unable to make his/her needs known, or rarely/never able to understand others. The MDS further indicated he/she was totally dependent on staff for bed mobility, turning and repositioning, incontinence care, and transfers. The MDS indicated he/she had bilateral contractures to his/her lower extremities and contractures to his/her upper extremity. Review of Resident #1's Care Plan, titled Activities of Daily Living, dated as last revised 10/18/23, indicated he/she required total assistance of two staff members to turn and reposition every two hours and as needed (PRN), incontinence care and weight shift in bed or chair every two hours, and totally dependent of two staff members with transfers while utilizing a mechanical lift. Review of Resident #1's Resident Profile, dated as last revised 10/18/23, indicated he/she required total assistance of two staff members to turn and reposition every two hours and PRN, incontinence care or weight shift in bed or wheelchair every two hours, and totally dependent of two staff members with transfers while utilizing a mechanical lift. Review of Occupational Therapy Progress Note, dated 10/31/23, indicated Resident #1 had bilateral (both left and right side) contractures to his/her shoulders, elbows, hips, and knees. Review of the report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 12/06/23, indicated that staff discovered a large bruise on Resident #1 left upper arm of unknown origin, however, after the Facility investigation, the nurse aide (later identified as Nurse Aide #1) on the 11:00 P.M. to 7:00 A.M. (night shift) informed the Director of Nurses (DON) that she had provided incontinence care twice during the shift to Resident #1 and had not asked another staff member for any assistance. Review of the Facility Incident Report, dated 11/25/23, indicated Resident #1 was found with a large irregularly formed ecchymotic area, measuring 14 centimeters (cm) by 8 cm to his/her left upper arm and required transfer to the Hospital Emergency Department for evaluation. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she was diagnosed with an acute comminuted displaced fracture through the left humeral surgical neck with the involvement of the greater tuberosity, non-displaced fracture of the proximal end of the left humerus. Review of Nurse Aide (NA) #1's, Written Witness Statement, dated 11/25/23, and review of NA #1's telephone interview with the DON, dated 11/28/23 at 4:00 P.M., indicated that Resident #1 was on her assignment from 11:00 P.M. on 11/24/23 through 7:00 A.M. on 11/25/23. NA #1 said that she checked on him/her when she first arrived and said she provided incontinence care to him/her twice during the night. The DON asked NA #1 if she got help from any other staff and NA #1 said no. The DON explained to NA #1 that Resident #1 should have been a two person assist for care. During a telephone interview on 1/24/24 at 12:00 P.M., Nurse Aide (NA) #1 said she was aware that Resident #1 needed the assistance of two staff to transfer and to change his/her position when he/she was in bed and said she had not asked any other staff member for assistance that night. During a telephone interview on 01/18/24 at 2:01 P.M., The Director of Nurses (DON) said that when she specifically asked NA #1 if she knew Resident #1 was a 2 person assist, she said NA #1 was very vague and did not answer her question. During a telephone interview on 01/25/24 at 10:28 A.M., CNA #8 said she worked on 11/25/23 at 7:00 A.M. and said Resident #1 was on her assignment. CNA #8 said she and CNA #2 were beginning to get Resident #1 ready for the day and when she removed his/her night gown, they noticed a large red area to his/her left arm (between the shoulder and elbow). CNA #8 said she immediately called the nurses (Nurse #1 and Nurse #2) to see the area. During a telephone interview on 01/23/24 at 1:27 P.M., Nurse #1 said she was working from 11:00 P.M. on 11/24/23 through 7:00 A.M. on 11/25/23 and said that she had explained to NA #1 in the past that Resident #1 was very contracted, fragile and required two assists with all care. Nurse #1 said NA #1 had not asked for any assistance during that shift. Review of CNA # 7's Written Witness Statement, dated 11/25/23, indicated he had no interaction with Resident #1 at all during that night shift. During a telephone interview on 01/25/24 at 2:39 P.M., CNA #5 said she had trained NA #1 on the night shift for some of her orientation and said the first thing she always did was go around and ensure that NA #1 was aware of each resident's level of care on their assignment. CNA #5 said Resident #1 had been on their assignment in the past when NA #1 was in training. During a telephone interview on 01/18/24, the Nurse Manager said that back in October 2023, Resident #1's Family Member had some concerns with his/her care, considering how fragile and contracted Resident #1's was. The Nurse Manager said since then, Resident #1 was care planned for two nursing staff for all care, except for eating and brushing his/her teeth (that only requires one nursing staff member). The Nurse Manager said that was when his/her Care Plan and Resident Profile were updated. The Nurse Manager said it is the Facility's expectation that all CNA's are aware of each resident's functional level prior to actually providing physical care and should be utilizing the Resident Profile for guidance. During a telephone interview on 01/18/24 at 2:01 P.M., the Director of Nurses said it is the expectation of the Facility that all nursing staff are familiar with each resident's care needs prior to providing them with physical assistance. The DON said all nursing staff are expected to follow each resident care plan and care areas are located on each Resident profile for CNA's to access and are expected to ask questions if they are uncertain of how to care for a resident.