**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the safety of one resident (Resident #1), of seven sampled residents. While assisting the resident to transfer from the toilet to his/her new motorized chair, staff ran the motorized chair over the resident's left foot. The resident sustained a fractured toe. The facility census was 66. Review of the facility policy for Accidents and Supervision dated 07/2024 showed the following:-The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devises to prevent accidents. This includes identifying hazards(s) and risk(s); evaluating and analyzing hazards(s) and risk(s); implementing interventions to reduce hazards(s) and risk(s); monitoring for effectiveness and modifying interventions when necessary;-The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents;-All staff are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident;-Use specific interventions to try to reduce a resident's risks from hazards in the environment. This process includes in part: providing training as needed;-Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. 1.Review of Resident #1's face sheet showed the following:-admitted to the facility on [DATE];-Diagnoses of end stage renal disease (ESRD, a disease in which the kidneys do not function), with dialysis, type 1 diabetes, atrial fibrillation (irregular heartbeat) and Parkinson's disease (a progressive neurodegenerative disorder that primarily affects movement). Review of the resident's care plan for Activities of Daily Living (ADL) dated 6/23/25 showed the following:-The resident has alterations in ADL function secondary to ESRD, decreased mobility and decreased strength.-Assist in completing ADL tasks each day. Review of the resident's Care Plan showed no direction related to use of the resident's new motorized chair. Review of the resident's nurses note dated 6/25/25 at 10:23 A.M. signed by Assistant Director of Nursing (ADON)/Registered Nurse (RN) showed the certified nurse aide (CNA) reported the resident's right foot was accidently rolled over by resident's power chair. Nurse Practitioner (NP) notified and assessed resident. No signs of injury currently. Resident denies pain, no changes in range of motion (ROM) to Right foot or ankle. X-rays order and set up for 4:00 P.M. when resident returned from dialysis. During an interview on 7/15/25 at 3:55 P.M. Certified Nurse Aide (CNA) B said the following:-He/She and CNA C were transferring the resident from the electric wheelchair to the toilet on 6/25/25 in the morning;-CNA C moved the electric wheelchair out of the way, as he/she dressed the resident's lower body, then CNA C began to move the electric wheelchair closer to the resident when the resident said ouch and said the electric chair was on his/her foot. He/She and CNA C looked down and saw the electric chair was on top of the resident's toes; CNA C backed the chair off the resident's foot;-He/She reported this to the nurse and there was a nurse practitioner in the facility at the time;-The resident complained of pain in the foot, but could still move the foot;-They took the resident to the front lobby as he/she had to go to dialysis. During an interview on 7/28/25 at 2:40 P.M. CNA C said the following:-He/She did not receive any training on how to use this electric wheelchair;-CNA B helped him/her transfer the resident into the electric wheelchair, took the resident into the bathroom and transferred him/her out of the electric wheelchair onto the toilet;-He/She did not remember running over the resident's foot;-He/She reported what the resident said to the ADON and the Nurse Practitioner (NP). During an interview on 7/17/25 at 8:50 A.M. Resident #1 said the following:-The staff seemed like they were in a hurry when they came to get her up and take her to the bathroom;-When the CNA's stood him/her up off the toilet, one CNA moved the electric wheelchair over towards him/her and it rolled onto his/her left foot;-The aides left the electric wheelchair on top of his/her foot; he/she told them the chair was on his/her foot;-The aids moved the wheelchair, so it wasn't sitting on his/her foot, then helped him/her into the chair and took him/her to the front lobby to go to dialysis;-No one looked at his/her foot before he/she went to dialysis;-When he/she got to dialysis, he/she could not stand to transfer, his/her foot hurt bad;-Dialysis staff were unable to transfer the resident to the dialysis chair due to his/her painful right foot, so they sent him/her to the hospital;-Once he/she was at the hospital, they x-rayed the left foot and the toes and top on his/her foot was broken so they put a walking boot on the foot. Review of the resident's progress note dated 6/25/25 signed by NP A showed the following:-In the process of getting to the toilet from the motorized wheelchair, the resident's foot was hit by the wheel of the chair;-The resident denies pain, he/she is moving the foot. Order X-Ray to the right foot due to injury. Okay to wait until after dialysis per resident's request. (The right foot was not the injured foot) Review of the local hospital X-ray report dated 6/25/25 showed x-ray of the left foot; possible fracture along the medical base of the second metatarsal (toe) concerning for mildly displaced age indeterminate fracture. Review of the resident's Orthopedic Physician progress noted dated 6/29/25 showed the following:-The resident sustained an injury recently, as scooter ran over his/her left foot. He/She has had mild to moderate amount of pain in the foot since the injury, and noticed bruising in the foot after the injury;-He/She has some bruising noted to the dorsum (the upper surface of the foot) in the left foot;-Interpretation of the residents' x-ray of the left foot: a new nondisplaced fracture at the base of the third metatarsal (toe);-This is the result of the scooter (motorize chair) rolling over his/her foot. During an interview on 7/15/25 at 4:00 P.M. the ADON said the following:-He/She was helping LPN A on 6/25/25 when CNA B and CNA C reported the electric wheelchair had been on the resident's foot;-He/She did not look at the resident's foot, NP A was in the facility, so he/she informed the NP so they could assess the resident;-The resident said that his/her foot hurt but he/she could move the foot;-The CNA incorrectly reported it was the resident's right foot. During an interview on 7/17/25 at 11:15 A.M. LPN A said the following:-He/She was aware of the accident involving Resident #1 and the electric chair, but he/she did not assess the resident, the ADON/RN took care of the assessment and notified the NP;-CNA C said the resident's foot was run over by the wheelchair, but he/she does not know which foot;-The resident went from his/her room after the incident to the front lobby for transport to dialysis. During an interview on 7/17/25 at 4:00 P.M. the Director of Nursing said the following:-Review of the resident's hospital records showed the resident sustained a fracture of the left foot;-She would expect the nurses to assess a resident after an accident, visualize the resident and document in the electronic medical record the assessment;-Staff should be shown how to operate the resident's electric wheelchair. During an interview on 7/17/25 at 4:00 P.M. the Administrator said the following:-He would expect nurses to assess a resident after an incident/accident occurred;-He would expect the staff to be trained on how to control an electric wheelchair. During an interview on 7/18/25 at 9:15 A.M. NP A said the following:-She was at the facility when the resident's right foot injured by the electric wheelchair;-The ADON/RN informed her of the incident;-The resident was in therapy when she was told of the incident;-She assessed the resident's right foot in therapy and did not see any sign of injury;-She wrote an order for an X-ray of the right foot to be done after the resident returned from dialysis;-The resident did not want to miss dialysis so he/she said that he/she could wait until he/she returned from dialysis in the afternoon. 1785365178536417853631785362

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete weekly skin assessments per facility policy for two residents, (Resident #1 and #2), of five sampled residents. Resident #1 admitted to the facility with no pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Staff failed to identify any issue with the resident's skin before the resident presented with a Stage III pressure ulcer on the resident's buttocks on 1/19/25 (Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue). Resident #2 was at risk for pressure ulcers and admitted to the facility without pressure ulcers. The resident was dependent on staff for cares, was not consistent in keeping pressure off his\her heels, and would slide down in bed so his/her feet touched the footboard. The facility had not addressed the resident's heels in his/her care plan and did not complete weekly skin assessments. According to staff, therapy discovered the wounds on the resident's feet on 2/28/25. The wounds included an unstageable pressure ulcer (wound is unstageable due to a covering of slough or eschar (dead tissue) to the right heel, an unstageable pressure ulcer on the left Achilles (ankle) area, and a suspected deep tissue injury (a localized area of discolored intact skin or a blood-filled blister caused by damage to underlying soft tissue from pressure and/or shear often appearing as a purple or maroon discoloration) on the right great toe. The facility census was 33. Review of the facility policy for Skin Assessment with a revision date of 1/2024 showed the following: -It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management; -A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury; -Documentation of skin assessment includes date and time of the assessment, your name and position title, document observations (e.g. skin condition, how the resident tolerated the procedure, etc); document type of wound; document wound (measurements, color, type of tissue in wound bed, drainage, odor, pain); document if resident refused assessment and why; document other information related as indicated or appropriate. Review of the facility's Pressure Injury Prevention and Management policy with a revision date of 7/2024 showed the following: -This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries; -Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device; -Avoidable means the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice, monitor and evaluate the impact of the interventions; or revise the interventions as appropriate; -The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate; -Assessment of Pressure Injury Risk: licensed nurses conduct a pressure injury risk assessment, using the (fill in blank for designated tool) on all residents upon admission/re-admission, weekly for four weeks, then quarterly or whenever the resident's condition changes significantly; the tool will be used in conjunction with other risk factors not captured by the risk assessment tool. Examples of risk factors include, but are not limited to: impaired/decreased mobility and decreased functional ability; co-morbid conditions, such as end stage renal disease, thyroid disease, or diabetes mellitus; -Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be document in the medical record; -Nursing assistants will inspect skin during a bath and will report any concerns to the resident's nurse immediately after the task; -Interventions for Prevention and to Promote Healing; after completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions; -Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: redistribute pressure (such as repositioning, protecting and /or offloading heels, etc.); minimize exposure to moisture and keep skin clean, especially of fecal contamination; provide appropriate, pressure-redistributing, support surfaces; provide non-irritating surfaces; and maintain or improve nutrition and hydration status, where feasible; -Interventions will be documented in the care plan and communicated to all relevant staff. 1. Review of Resident #1's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of parainfluenza virus with pneumonia, Parkinson's disease (a movement disorder of the nervous system that worsens over time), diabetes, heart disease, and generalized weakness. Review of the admission skilled nurses note dated 12/6/24 showed the resident's skin was clean and dry with no alterations in skin integrity. Review of the resident's comprehensive Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 12/12/24, showed the following: -Able to make self understood and able to understand others; -Alert and oriented with some difficulty making decisions; -Dependent upon staff for activities of daily living (ADLs), transfers and walking; -Occasional incontinent of bowel and bladder; -At risk for pressure ulcers. Review of the resident's Care Plan for skin integrity dated 12/8/24 showed the following: The resident was at risk for alteration to skin integrity secondary to mobility deficits; -Goal: the resident will have no unaddressed alteration of skin integrity; -Approaches: provide skin and incontinence care assistance as needed; standard facility pressure reduction mattress; weekly skin checks per facility schedule; notify the physician for prompt/proper interventions. Review of the resident's weekly skilled charting nurses notes showed the following: -On 1/9/25 the area for assessment of the skin was blank with no documentation; -On 1/16/25 the area for assessment of the skin was blank with no documentation; Review of the resident's Weekly Wound Rounds dated 1/19/25 signed by Registered Nurse (RN) D showed the resident had an open area to the left buttock, that measured 2 cm by 1.5 cm by 0.2 depth, Stage III, found upon assessment. During an interview on 3/24/25 at 2:45 P.M. RN D said the following: -He/She was working as the RN supervisor when a staff member asked him/her look at Resident #2's bottom on 1/19/25; -He/She assessed the area, the area was open and deep. He/She documented the findings on the weekly wound rounds and notified management. During an interview on 3/24/25 at 1:04 P.M. RN B said the following: -He/She was the wound nurse and measured the wounds when found and then weekly; -Staff found the resident with a Stage III pressure ulcer on his/her left buttock on 1/19/25; -He/She had not assessed the resident's skin prior to 1/19/25; -The resident was seen by the contracted wound care company on 1/22/25. During an interview on 3/19/25 at 2:00 P.M. the Director of Nurses (DON) said the following: -Resident #1 did not have any identified issues with his/her skin until 1/19/25; -The resident had a toilet riser and may have developed the ulcer due to sitting on the toilet for a long period of time; -Staff did not find the area until it was open and at a Stage III level. During an interview on 3/24/25 at 2:00 P.M. the Nurse Practitioner for the contracted wound care company said the following: -The resident had been referred to him/her on 1/22/25 for a wound on his/her left buttock; -He/She assessed the wound to be quarter size, open with slough and was a Stage III pressure ulcer; -This was the first time he/she had seen the resident's skin. Review of the resident's weekly skilled charting nurses notes showed the following: -On 1/23/25 the area for assessment of the skin was blank with no documentation; -On 1/30/25 the area for assessment of the skin was blank with no documentation; -On 1/31/25 the area for assessment of the skin was blank with no documentation. (The resident had a pressure ulcer on his/her buttock that was identified on 1/19/25) 2. Review of Resident #2's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of low back pain, weakness, pneumonia, and diabetes. Review of the resident's admission skin assessment dated [DATE], showed no skin issues, buttocks red but not open. Review of the resident's Care Plan for Alteration in Skin Integrity Risk dated 1/24/25, showed the following: -Resident was at risk for skin alteration due to incontinence of bladder; -Encourage and assist with frequent repositioning to alleviate areas of pressure; provide skin and incontinence care assistance as needed. -The care plan did not address any interventions to address pressure relief specific to the resident's heels, including refusals to use devices for pressure relief or or sliding down in the bed. Review of the resident's Care Plan for Actual Skin Impairment/Wound dated 1/28/25 showed the following: -The resident had a skin tear to the right upper extremity; -Enhanced barrier precautions (a type of isolation to prevent the spread of multi resistant organisms); in house wound care provider to assess and treat; registered dietician to evaluate as needed; treatments as prescribed; resident was being followed by outside wound care provider; -The care plan did not address any interventions to address pressure relief or wounds on the resident's heels. Review of the resident's comprehensive MDS dated [DATE], showed the following: -Able to make self understood and able to understand others; -Alert and oriented able to make some decisions; -Dependent upon staff for Activities of Daily Living (ADLs), dependent upon staff to come from a sitting to a standing position and standing to sitting position, dependent upon staff for toileting transfers; -Incontinent of bowel and bladder; -At risk for the development of pressure ulcers, no pressure ulcers present. Review of the resident's Treatment Administration Record dated 2/1/25 through 2/28/25 showed no treatment orders or interventions to the resident's heels including pressure relieving boots or application of skin prep. Review of the resident's skilled nursing notes dated 1/26/25, 2/6/25, 2/14/25, 2/15/25, 2/19/25, 2/25/25 and 2/26/25 showed the section in the notes for skin assessment was left blank, with no documentation of an assessment. Review of the resident's daily skilled nursing notes dated 2/28/25 showed the following: -Right heel Issue type: Pressure ulcer/injury. Length 2.5 centimeters(cm): Width 2.5 (cm): Depth 0.003 (cm): , skin issue had not been evaluated. Location: Left Achilles (heel bone) scabbed over area. Length 2.5 (cm): Width 1.25 (cm): Depth 0 (cm). Skin note: soft boots to bilateral feet, heels floated. Review of the resident's Wound Rounds dated 2/28/25 showed the following: -Wound acquired in house. Right heel, pressure ulcer 3.3 cm by 3.0 cm. Depth unable to determine, unstageable (a full-thickness skin and tissue loss where the base of the ulcer was obscured by slough (dead fibrous tissue usually yellow in color), and eschar (dead tissue forming a crust on the surface making it impossible to determine the true depth or stage of the ulcer); -Left Achilles, pressure, 0.7 cm by 1.5 cm, unable to determine depth, unstageable; -Right great toe, pressure, 0.7 by 0.7 by 1.3, suspected deep tissue injury (a localized area of discolored intact skin or a blood-filled blister caused by damage to underlying soft tissue from pressure and/or shear often appearing as a purple or maroon discoloration). Review of the resident's care plans dated 2/28/25 showed no care plan to address the resident's pressure ulcers to the resident's heel, Achilles area, or right great toe. Review of the resident's nurses notes dated 3/2/25, showed the resident started having acute on chronic left knee pain. The resident had called Family Member (FM) A several times throughout the night after 4:00 A.M. regarding the pain; family demanded 911 be called for evaluation. Resident sent out (to the hospital) per request. During an interview on 3/21/25 at 11:18 A.M., the resident's FM A said the following: -The resident would complain about pain in his/her feet and legs; -The night before the resident was sent to the hospital, the resident called him/her crying with the pain in his/her feet and legs; -On 3/1/25 when he/she went to the facility, he/she took pictures of the sore/open area on the resident's right foot. Review of photographs supplied by FM A ( photographs taken on 3/1/25), on 3/21/25, showed a wound to the resident's right heel the size of a quarter that had yellow slough with dried, flaky skin around the wound. During an interview on 3/19/25 at 3:55 P.M. Certified Nurse Aide (CNA) A said the following: -The resident spent a lot of time in bed and was incontinent of bladder; -The resident had complained about heel pain since admission and the resident's heels felt a little soft and were red; -The nurses put skin prep (a medication that reduces friction, protecting sensitive skin) on the resident's heels; -The resident had protective boots, but refused to wear them; -The heels did open up to a sore; -He/She thought nurses were aware of the skin on the heels opening; -On 3/1/25, the resident was in a lot of pain and the family requested that the resident be sent to the hospital. During an interview on 3/24/25 at 1:04 P.M. Registered Nurse (RN) B said the following: -He/She did weekly wound rounds with the contracted wound care nurse practitioner and measured wounds; -Nurses will notify him/her of any new wounds and he/she will measure the wounds and document in the electronic medical record in the weekly wound assessment; -The resident was not admitted with any skin issues on his/her feet, the resident did have a large skin tear on an arm that was being treated and followed by the contracted wound care nurse practitioner; -On 2/28/25, he/she was notified by therapy of the wounds on the bottom of the resident's right heel, the Achilles area of the left heel, and the right great toe; -The Achilles area of the left heel was open with slough with the wound bed was yellow, the bottom right heel was open and the wound bed covered with yellow slough and the right great toe was dark purple in color; -The resident spent a lot of time in bed with the head of the bed elevated and he/she would slide to the end of the bed with his/her feet pressed on the foot board. The resident had foot protectors, but he/she would not leave them on; -The resident went to the hospital before the outside contracted wound care provider could see the wounds. During an interview on 3/24/25 at 2:50 P.M. RN C said the following: -He/She was not aware of any wounds on the resident's feet; -He/She worked the day shift on 3/1/25 and sent the resident to the hospital due to extreme pain in his/her knee; -He/She did not look at the resident's feet before he/she sent the resident to the hospital; -The nurses would do skin checks and document the skin checks in the skilled nurses notes; -He/She did not remember any staff member telling him/her about any sores on the resident's feet. During an interview on 3/19/25 at 2:00 P.M. and 3:00 P.M. the Director of Nurses (DON) said the following: -Resident #2 was very sick upon admission; -Resident #2 had a low air loss mattress on his/her bed and had heel protectors on both heels that he/she would refuse to wear; -CNAs are to inspect the resident's skin with cares and bathing at least two times a week and inform the nurses of any concerns; -If the CNAs notice a problem with a resident's skin, they are to notify the nurses verbally of the concern and the nurses are to check the resident's skin; -Nurses should document on a wound assessment if there was a wound and notify the physician and responsible party; -The nurses are to assess the resident's skin weekly and document the results on their weekly skilled nursing note; -Resident #1 and Resident #2's weekly skilled nurses notes does not always address the resident's skin; -She would expect nurses to complete the weekly skin checks per the facility policy and thoroughly assess the resident's skin. During an interview on 3/19/25 at 3:00 P.M., the Administrator said he would expect the nursing staff to follow their policy for skin and pressure ulcers. During an interview on 3/24/25 at 9:00 A.M. facility Medical Director/Physician A said the following: -He would expect the facility nurses to follow their policy to assess the resident's skin at least weekly and document the results and if there are any skin issues or concerns to notify the physician and the contracted wound care company for orders and treatments; -The facility staff should have identified these pressure ulcers before they were a Stage III and the unstageable on the resident's heel; -Generally, the skin would have shown some type of changes, such as being discolored, reddened or a blister, before the wounds opened. MO249791 and MO250792

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the safety of one resident (Resident #1), of four sampled residents, who was dependent upon staff for transfers and at risk for falls. The facility failed to ensure staff followed facility policy for using a sit to stand lift. Certified Nurse Aide (CNA) A transferred Resident #1 using the sit to stand lift without assistance of an additional staff to transfer the resident. The resident sustained significant pain and bruising from the improper transfer. The facility census was 36. The administrator was notified on 9/30/24 at 3:00 P.M , of the Past Non-Compliance which occurred on 9/24/24. On 9/24/24, the administrator became aware of the injury to Resident #1 which resulted in a staff member failing to follow the facility policy on a sit to stand transfer when the staff member did not use two staff to transfer the resident. The facility began an investigation and determined that the staff did not follow the facility policy for a sit to stand transfer. The facility began in-servicing all staff on safety, the facility policy to use two staff members for all mechanical lift transfers, and competencies for staff on the use of the sit to stand lift. The G grid deficiency was removed and corrected on 9/25/24. Review of the facility policy for Safe Resident Handling Transfers revised on 7/2024 showed the following: -It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines; -All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them; -The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs; -Two staff members must be utilized when transferring residents with a mechanical lift; -Mechanical lifts may include equipment such as fully body lifts and sit to stands lifts. 1. Review of Resident #1's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of coronary heart disease (a condition that occurs when the heart's blood vessels narrow due to plaque buildup), atrial fibrillation (irregular heart beat), diabetes and peripheral vascular disease (PVD is a circulatory condition that occurs when blood vessels outside of the brain and heart narrow, spasm, or become blocked. This can lead to reduced blood flow and tissue damage. PVD can affect any blood vessel outside of the heart, including arteries, veins, and lymphatic vessels. The legs and feet are most often affected). Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 9/22/24 showed the following: -Able to make self understood and able to understand others; -Brief Interview for Mental Status (BIMS-a cognitive screening tool used to identify cognitive impairment in patients in long-term care facilities and skilled nursing facilities:) of 10 (Indicates moderate impairment); -Impairments of both lower extremities, required total staff assistance with transfers, toilet hygiene and partial to maximum assistance with Activities of Daily Living (ADL's); -Frequent pain at a level of 10 (0 being no pain, 10 being excruciating pain). Review of the resident's Physical Therapy Treatment Notes dated 9/24/24 showed the following: -Transfers with sit to stand with use of lift with staff and resident raining with maximum assist of one, with another staff member to operate the machine and complete safe transfer to the wheelchair; -Resident and caregiver training: the resident and the staff member training in safe transfer technique with use of the sit to stand lift from the bed to the wheelchair and proper positioning in the wheelchair. Review of the resident's nurses notes dated 9/24/24 at 6:30 P.M., signed by the Director of Nursing (DON) showed the following: -Resident is alert and oriented. The resident reported earlier in the shift the day shift CNA came into the room to assist the resident to bed. The CNA used the sit to stand lift to transfer the resident from the chair to the bed. The resident said he/she started to scream as his/her arms were too high and he/she felt a pop in the right shoulder when he/she was raised to a standing position. The CNA continued to raise him/her then used force to put him/her into bed. The resident said he/she was screaming in pain. His/Her right shoulder was painful with a pain level of a 10 (on a scale of 1-10 with 10 being the worst pain possible). Review of the resident's nurses notes dated 9/25/24 at 12:39 P.M. signed by the DON showed the following: -X-rays to the right shoulder negative but does show a potential rotator cuff tear. The resident complains of chronic pain with movement to the right shoulder. Nurse Practitioner here to see the resident and orders to send to orthopaedic outpatient clinic. There was no fracture or rotator injuries. Possible right pectoral muscle (a group of muscles in the upper chest that connect the upper limbs to the chest wall) stain and new orders for Voltaren gel ( topical pain relieve medication). The resident continues receiving physical and occupational therapy with their recommendation to continue to use the sit to stand lift or the full mechanical lift. Review of the resident's nurses notes dated 9/29/24 at 10:07 A.M. showed staff informed the resident's the resident had a bruise to the right breast. Area was assessed and noted large purple bruising with yellowish shadowing to the right lateral (outer aspect) of the breast. This area was previously noted on 9/26/24 and DON aware. Orders received for bilateral rib X-rays. During an interview on 9/30/24 at 9:38 A.M. Resident #1 said the following: -A few days ago a staff member came into the room and told him/her that he/she was going to put him/her to bed; -The staff member brought in the sit to stand lift, he/she questioned the staff member on getting another staff member to help, and this staff member said the he/she knew how to work the sit to stand and everything was going to be okay; -The staff member put the sit to stand belt around his/her waist and began to lift him/her up. As he/she was being lifted up, the belt felt like it was cutting into his/her body, he/she began to scream out as it hurt under his/her right arm; -The staff member continued to lift him/her up and then pushed him/her into the bed and lowered him/her down onto the bed; -The staff member put his/her legs onto the bed and without positioning him/her and left the room; -Another staff member came in and positioned him/her in bed; -His/Her right side under the arm pit still hurt and caused him/her pain. Observation of the resident on 9/30/24 at 11:13 A.M. showed the following: -A large dark purple with yellow edges located on the lateral aspect of the resident's right breast; -The resident said it was tender when touched. During an interview on 9/30/24 at 2:00 P.M. the DON said the following: -She was notified on 9/24/24 that CNA A had transferred Resident #1 by him/herself using a sit to stand lift; -It is the facility policy that two staff members are required when using any mechanical lift to transfer a resident; -Therapy had assessed the resident on 9/24/24 and determined that the sit to stand lift was appropriate. Therapy then will educate the staff on how to use the sit to stand with the resident. This was done on 9/24/24 with CNA A; -The employee was an agency aide and signed that he/she was aware of the facility policy that two staff members were to be used when using the sit to stand lift; -CNA A will not be working at the facility again; -She would expect staff to follow the facility policy for using two staff members with any mechanical lift transfer. During an interview on 10/1/24 at 3:50 P.M. CNA A said the following: -He/She worked the day shift on 9/24/24. He/She had never cared for Resident #1 before; -He/She was a agency employee and did not get any report from the off going staff member, so he/she was unsure how the resident transferred; -Therapy evaluated the resident on 9/24/24 and educated the resident and staff on how to use the sit to stand for transfers with the resident; -Toward the end of the shift, the resident asked to go to bed so he/she brought the sit to stand machine to the resident, placed the belt around the resident and began to transfer the resident from the wheelchair to the bed. The resident yelled out in pain as he/she put the resident in the bed; -He/She knew that there should have been two people to use the sit to stand machine, but he/she could not find any help and the resident begged to lay down; -He/She knew how to operate the machine. The belt did not slid up under the resident's arm pits; -He/She finished care on the resident and left the room. During an interview on 10/4/24 at 8:45 A.M. the Director of Therapy said the following: -Physical Therapy had assessed the resident on 9/24/24 for the safest method of transfer which was the sit to stand lift; -Once therapy evaluates for the safest mode of transfer, they will train the staff, including agency staff, on that method. This was done with the assigned caregivers on 9/24/24; -Staff should use two staff members when using any mechanical lift including the sit to stand lift. MO242605

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one resident (Resident #1) in a review of three sampled residents, was free from abuse when Certified Nurse Aide (CNA) A picked the resident up out of bed with his/her arms and aggressively transferred the resident from the wheelchair to the toilet, causing the resident to hit his/her back and head. The resident reported pain at the time and continued pain after the incident. The resident reported feeling helpless and was afraid of CNA A. The facility census was 29. Review of the facility policy for Abuse, Neglect and Exploitation dated 10/22 showed: -It is the policy of this facility to provide protections fro the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Definition: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercation. Abuse also includes the deprivation by an individual, including a caretaker, of good or services that are necessary to attain or maintain physician, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; -Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment; -Neglect means failure to the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 1. Review of Resident #1's baseline care plan dated 6/6/23 showed: -The resident requires physical assistance of one staff member for toileting; -Requires extensive assistance of two staff members for transferring. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 6/8/23 showed: -Resident was admitted to the facility on [DATE]; -Alert and able to answer questions appropriately; -Able to make self understood and understand others; -Diagnoses of periprosthetic fracture (A periprosthetic hip fracture is a broken bone that occurs around the implants of a total hip replacement); -Requires extensive assistance of one staff person for bed mobility, dressing and personal hygiene; -Requires extensive assistance of two staff persons for transfers and toilet use; -Balance is not steady moving from a seated to standing position, transfer between the bed and chair to wheelchair; -Has an impairment of the lower extremities on one side; -Uses a wheelchair and walker for mobility; -Has severe pain and requires medication. During an interview on 6/14/23 at 10:30 A.M. the resident said the following: -Sometime during the evening on 6/9/23, between 7:00 P.M. and 10:00 P.M. or so, he/she rang his/her call light to go to the bathroom. CNA A came into his/her room and seemed rushed and angry and was mumbling under his/her breath; -When CNA A moved him/her from the bed to the wheelchair, CNA A wrapped his/her arms around his/her shoulders, picked him/her up and sat him/her hard down into the wheelchair; -CNA A took him/her into the bathroom and put his/her hand on his/her upper arm area, picked him/her up and threw him/her onto the toilet; -As a result, he/she hit his/her back and the back of his/her head; -He/She still has some pain in his/her back from this; -When CNA A threw him on the toilet, he/she called out in pain and said You are too rough!, the aide just shrugged his/her shoulders and said Oops and walked out the room; -He/She rang his/her call light to get off the toilet, CNA A came back into the room and picked him/her up by his/her arms and put him/her in the wheelchair, then picked him/her up by the arms and put him/her back in bed; -He/She has a lot of pain in his/her leg due to a broken bone in the hip that cannot be repaired; -CNA A hurt his/her arms and back; -CNA A did not use a gait belt to transfer him/her, he/she grabbed him/her by the arms; -He/She does not want CNA A back in his/her room and is afraid of CNA A; -He/She did not say anything when it happened, as he/she was afraid of CNA A and does not want any retaliation against him/her or his/her family; -On 6/10/23 when CNA B came in and said he/she was going to take care of him/her, he/she was relieved and told CNA B that he/she was glad CNA A was not working; -He/She told CNA B that CNA A had been rough with him/her the night before and hurt him/her. During an interview on 6/14/23 at 10:30 A.M. the resident's Family Member A said: -Resident #1 called him/her on 6/9/23 after the incident happened; -The resident was very upset and said that he/she was afraid of CNA A and did not want him/her to take care of him/her again; -He/She and the resident reported the incident on 6/10/23 to CNA C, who told him/her that he/she needed to file a report with management and that he/she had received several complaints about CNA A being rough with other residents; -On 6/11/23 the Director of Nurses (DON) came to see them and talk with them about what happened on 6/9/23. During an interview on 6/14/23 at 1:30 P.M. CNA B said the following: -On 6/10/23 the resident said he/she did not want CNA A to take care of him/her again; -The resident said CNA A was very rough with him the night before, the aide had transferred him/her very aggressively and slammed him/her into the toilet and hit his/her back. During an interview on 6/15/23 at 11:15 A.M. Licensed Practical Nurse (LPN) A said the following: -On 6/10/23 CNA B told him/her that Resident #1 did not want CNA A taking care of him/her; -The resident said CNA A had manhandled him/her, threw him/her onto the toilet and hurt him/her; -When LPN A went to the resident' room to make a report, the resident was sitting on the side of the bed and said he/she felt helpless and did not want CNA A to take care of him/her again; -LPN A considered what the resident told him/her described abuse. During an interview on 6/14/23 at 10:00 A.M. the DON said the following: -She had come in to relieve LPN A from duty on 6/11/23 around 7:00 A.M.; -LPN A told him/her Resident #1 told CNA B on 6/10/23 on the evening shift CNA A had thrown him/her onto the toilet on 6/9/23; -She interviewed the resident who said that sometime after 7:00 P.M. and before midnight, he/she had rang his/her call light to ask for assistance from the bed to the bathroom. CNA A came into him/her room to assist the resident. CNA A seemed rushed and angry, CNA A roughly transferred the resident into the wheelchair without using a gait belt, then threw the resident onto the toilet causing the resident to hit his/her back and the back of his/her head. The resident said CNA A said whoops and left the bathroom. The resident put his/her call light on when he/she was finished. CNA A returned and in a rushed manner put the resident back to bed. When she asked the resident what he/she meant by throw onto the toilet, the resident said CNA A bear hugged him/her and threw him/her onto the toilet; -At the time that the incident was reported, she felt this was a customer service concern. She was unaware that the resident said he/she was afraid of CNA A. During an interview on 6/14/23 at 9:36 A.M. the Administrator said the following: -Resident #1 alleged CNA A threw him/her onto the toilet; -The incident occurred on the night shift on 6/9/23; -He would have expected the staff to report the incident to the DON or himself immediately. MO219823