**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff, Nurse Practitioner, Funeral Home Representative and Hospitalist interviews the facility failed to provide care in a safe manner. On [DATE] Nurse Aide (NA) #1 was performing incontinence care for Resident #195 who was resting on an air mattress raised to waist height and rolled Resident #195 on her side away from NA #1 who proceeded to walk around to the other side of the bed at which time the air mattress decompressed. Resident #195 rolled off the side of the bed to the floor and was wedged between the bed and the wall. Resident #195 was transferred to the hospital where she was diagnosed with a right femur fracture, right inferior and superior pubic rami (pelvic) fractures, questionable nondisplaced sacral alar (lower spine) fracture. Resident #195 was a poor surgical candidate and was admitted to the hospital for comfort care. Resident #195 died on [DATE]. The deficient practice affected 1 of 6 residents (Resident #195) reviewed for accidents. The findings included: Resident #195 was admitted to the facility on [DATE] with diagnoses which included dementia, acute respiratory failure, chronic respiratory failure, history of pulmonary embolism (PE, blood clot) and quadriplegia. Review of a care plan dated [DATE] revealed Resident #195 had impaired mobility and required assistance with activities of daily living (ADL). Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #195 was severely cognitively impaired with no behaviors, wandering, or rejections of care. Resident #195 was dependent for toileting, bathing, and personal hygiene. Resident #195 was dependent for bed mobility. Review of a nursing note dated [DATE] at 10:41 pm authored by Nurse #3 revealed at 6:15 am on [DATE], Nurse Aide (NA) #1 came to the nurse's station and stated Resident #195 was on the floor. Resident #195 was observed laying on her right side beside the bed. Resident #195 was yelling help me please. Nurse #3 advised NAs (names unknown) to get the mechanical lift and pad while Nurse #3 moved Resident #195's bed. The lift pad and mechanical lift were used to lift and raise Resident #195 back to the bed. Resident #195 was assessed for injury and there was no injury or bruising found on Resident #195's head. Resident #195 stated that her right leg hurt severely when touched and that her chest was hurting. Review of the [DATE] Medication Administration Record (MAR) revealed an order to send Resident #195 to the hospital. Review of an Emergency Medical Services (EMS) note dated [DATE] revealed EMS was dispatched, routine (non-emergent) to the facility in reference to a fall/blunt force injury and acute respiratory distress involving Resident #195 at 6:32 am. EMS arrived on scene at 6:43 am, departed the facility at 7:07 am, and transferred care to the Hospital at 7:11 am. Oxygen was applied to Resident #195 at 6:46 am at a rate of 15 liters per non-rebreather mask. EMS documented vital signs at 6:51 am as blood pressure of 136/74, heart rate of 106 beats per minute, respiration rate of 17 breaths per minute, an oxygen saturation of 84% on 15 liters of oxygen per minute via non-rebreather, and a pain score of 0 on a scale of 0-10. Review of the hospital record dated [DATE] revealed Resident #195 arrived in the Emergency Department (ED) via EMS from the facility for evaluation after Resident #195 had a fall from the bed when an NA was trying to get her up to go to the bathroom that resulted in right hip and right shoulder pain. The NA also noted Resident #195 to be slightly more hypoxic than usual. Resident #195's right lower extremity was shortened and rotated with no significant pain to palpation. A computed tomography (CT, radiology scan) of the chest, abdomen, and pelvis dated [DATE] revealed Resident #195 had pulmonary edema, right proximal femur fracture, right inferior/superior pubic rami (pelvis) fractures, and a questionable nondisplaced right sacral alar (lower spine) fracture, anasarca (generalized swelling), and chronic distal colonic distention (enlarge colon). Resident #195 was a poor surgical candidate due to her acute on chronic respiratory failure, urinary tract infection, and likely pneumonia. Resident #195 was placed on bilevel positive airway pressure (BiPAP, a non-invasive machine that helps with breathing). Resident #195 was admitted to the hospital under comfort care to manage symptoms. Resident #195 was given furosemide (medication used to treat fluid retention) and morphine (pain medication, also used to treat shortness of breath) for air hunger (gasping for air), and was ordered a morphine intravenous (IV, medication given through the vein) continuous drip and lorazepam (medication used to treat anxiety and agitation). Resident #195 expired on [DATE]. An interview was conducted on [DATE] at 2:27 pm with NA #1. NA #1 stated she usually worked second shift (2:00 pm to 10:00 pm) and stated she had worked a double shift (2:00 pm until 7:00 am). NA #1 stated Resident #195 required two-person assist for all care and used a mechanical lift for transfers. NA #1 stated Resident #195 was not able to stand or help with turning and repositioning. NA #1 stated she had asked the Night Shift Supervisor before she started her round where NA #4 was because she needed help with her two-person assist residents. NA #1 stated she was told by the Night Shift Supervisor that NA #4 had been in and out of the building all night. NA #1 stated she proceeded to start her care rounds before shift change. NA #1 stated she should have waited for NA #4 to help her change Resident #195 but was not able to locate NA #4. NA #1 stated Resident #195 had had an incontinence episode and required a full bed change. NA #1 stated she rolled Resident #195 on her left side and had gone to the opposite side of the bed when the air mattress shifted, and Resident #195 rolled out of bed. NA #1 stated Resident #195's bed was approximately waist high, 2 foot off the ground. NA #1 stated she immediately left the room and alerted Nurse #3, who was passing medications on 100 hall and the Night Shift Supervisor, who was at the nurse's station. NA #1 stated Nurse #3 and the Night Shift Supervisor went to Resident #195's room and assessed her. NA #1 stated she observed Resident #195 to be in pain but could not specify where. NA #1 stated the Night Shift Supervisor left the room to call EMS and Nurse #3 instructed her to get the mechanical lift and transfer Resident #195 into bed. NA #1 stated after she helped get Resident #195 back into bed, she finished her morning rounds while Nurse #3 remained with Resident #195. An interview was conducted on [DATE] at 8:36 am with NA #4. NA #4 stated that she worked on [DATE] and was a floater (went between 100 and 300 halls). NA #4 stated she had worked with Resident #195 and stated she required two-person assistance, was bedridden, and not able to assist with any care. NA #4 stated she offered at the beginning of her shift to help NA #1 with her rounds, and NA #1 stated she did not need any assistance. NA #4 stated NA #1 stated, I can do it myself with my eyes closed. An interview was conducted on [DATE] at 4:23 pm with Nurse #3. Nurse #3 stated she worked third shift (11:00 pm to 7:00 am) on [DATE] and was assigned Resident #195. Nurse #3 stated Resident #195 required total care, was not able to do anything on her own, and required two-person assistance with all care. Nurse #3 stated NA #1 had approached the nurse's station close to shift change, around 6:15 am, on [DATE] and stated Resident #195 was in the floor. Nurse #3 stated she took off running down the hall and when she arrived at Resident #195's room, Resident #195 was lying on her right side with her back facing the bathroom. Nurse #3 stated Resident #195's head and shoulders were underneath the bed. Nurse #3 stated she crawled under the bed where she was eye-to-eye with Resident #195 and assessed her head for any obvious trauma and did not see any external rotation or shortening of the right leg. Nurse #3 stated she assessed Resident #195 for bleeding, bruising, and deformities. Nurse #3 stated she obtained vital signs while Resident #195 was on the floor and noted Resident #195's oxygen saturation to be 82% at which time she increased Resident #195's supplemental oxygen from 2 to 3 liter per minute and was instructed by the Night Shift Charge Nurse to transfer Resident #195 back to bed utilizing the mechanical lift. Nurse #3 stated after Resident #195 was transferred to bed, she began to gasp for air. Nurse #3 stated she continued to monitor Resident #195 until EMS arrived. Nurse #3 stated NA #1 reported she was not able to find the NA#4 to help her and had tried to change Resident #195 by herself. An interview was conducted on [DATE] at 1:35 pm with the Night Shift Supervisor. The Night Shift Supervisor stated she was able to recall the incident with Resident #195 on [DATE]. The Night Shift Supervisor stated, close to shift change around 6:15 am, NA #1 approached the nurse's station and reported Resident #195 was on the floor. The Night Shift Supervisor stated she observed Resident #195 to be laying on her side between the wall and the bed. The Night Shift Supervisor stated she felt Resident 195's hips and felt no deformities. The Night Shift Supervisor stated she had not noticed any shortening or external rotation. The Night Shift Supervisor stated Nurse #3 instructed the NAs to transfer Resident #195 to bed and she left the room to call EMS. An interview was conducted on [DATE] at 10:32 am with the Hospitalist. The Hospitalist stated she cared for Resident #195 on [DATE] after she arrived in the Emergency Department. The Hospitalist stated she had only been told Resident #195 had been found in the floor and no additional details about the fall. The Hospitalist stated Resident #195 had a femur fracture and pelvic fractures but was a poor surgical candidate. The Hospitalist stated Resident #195's family opted for comfort care and Resident #195 was admitted , and later expired on [DATE]. The Hospitalist stated Resident #195 had a history of chronic respiratory failure and her cause of death was respiratory failure. The Hospitalist stated the fall on [DATE] could have been a contributing factor because the pain associated with the fall could have led to worsening respiratory failure. An interview was conducted on [DATE] at 1:15 pm with the Funeral Home Representative. The Funeral Home Representative stated Resident #195's death certificate revealed she expired on [DATE] at 9:25 am with the cause of death as respiratory failure. An interview was conducted on [DATE] at 4:53 pm with the Director of Nursing (DON). The DON stated NA #1 tried to change Resident #195 by herself. The DON stated after NA #1 had turned Resident #195 on her side, she walked around to the other side of the bed, at which time Resident #195 rolled out of bed. The DON stated Resident #195 was a two-person assist and NA #1 had tried to change Resident #195 on her own. An interview was conducted on [DATE] at 4:37 pm with the Administrator. The Administrator stated he had been notified NA #1 had tried to perform two-person assist incontinence care on her own, had positioned Resident #195 on her left side facing the sink, went around Resident #195's bed to change the linens, and Resident #195 rolled off the bed. The Administrator stated staff reported she was screaming and demanded to be gotten up. The Administrator stated NA #1 should have gotten help before attempting to provide incontinence care for Resident #195. The Administrator was notified of immediate jeopardy on [DATE] at 6:15 pm. The facility provided the following corrective action plan with a completion date of [DATE]: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On [DATE] at approximately 6:15 am resident # 195, rolled from the bed onto the floor as Nurse Aide (NA)#1 was providing incontinent care. NA#1 was providing care to the resident without the assistance of another NA and walked to the other side of the bed after cleaning the resident and positioning resident on their side on an air mattress. When NA #1 reached the other side of the bed to finish changing the soiled linen, the weight of the resident depressed the air mattress and the resident rolled onto the floor in a face down position. The resident, who requires a mechanical lift for transfers, was yelling help me, get me out of the floor. The resident was positioned partially under the bed so the nursing staff utilized a mechanical lift pad to slide her from under the bed and then a mechanical lift to get her back into the bed to assess and provide care. Prior to lifting the resident from the floor, the nurse #3 observed no injuries including external rotation of legs or leg length difference. The resident was transferred to the emergency room (ER). Physician was notified of fall by the charge nurse at 6:30 am on [DATE]. EMS was called and resident was transferred to ER at approximately 6:30 am on [DATE]. Resident's first contact was called at approximately 6:20 with no answer on [DATE]. Nurse #2 called the second contact after the resident was transferred and they indicated they were in the hospital, for an unrelated reason, and saw the resident being brought in. Upon investigation by the DON on [DATE], the following was determined: NA#1 did not follow resident care guide of having 2 people assist although there were two other CNAs working the hall. A root-cause analysis completed by the DON on [DATE] revealed the cause of the fall to be NA #1 not having assistance with providing resident incontinent care for a resident on an air mattress and dependent for bed mobility. Address how the facility will identify other residents that have the potential to be affected by the same deficient practice: All residents who are dependent for bed mobility, and those on air mattresses, have the potential to be affected. The DON and designee completed an audit of all resident's orders, mechanical lift use, progress notes, and air mattress user list and determined that those who are dependent for bed mobility and those on air mattresses, have the potential to be affected. Completed [DATE] Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice: NA #1 was suspended by the DON from [DATE], after the incident, until [DATE]. NA #1 met with the DON on [DATE] and was given a final warning for failure to follow facility practice/use of care guide. NA #1 was re-educated on [DATE] by the DON. Re-education included: checking care guide at the beginning of each shift to determine level of assistance required, requesting assistance when appropriate, notifying charge nurse if another NA refuses to assist, not positioning a resident on their side on edge of bed and going to other side without another staff member present to keep the resident from rolling to floor, use of two people assistance with air mattresses, and that two person assistance must always be used for mechanical lifts. On [DATE], the SDC had NA #1 return to the facility. NA#1 completed a demonstration of competency on providing care to a resident who is dependent for bed mobility. A skills competency sheet was also completed with employee on [DATE] by SDC. NA#1 was not allowed to return to work until completed. Completed [DATE] by DON and SDC. 100% of NAs and Nurses were in-serviced on facility practice regarding use of the care guide for determining level of assistance with ADLS. Staff were instructed that they must check the care guide in the closet of each resident room to determine how many staff members needed to assist and ask for that assistance. If for any reason assistance was not available or refused the NAs were to report to the charge nurse who would assist or direct another staff member to assist. Staff were educated that they must never leave a resident lying on their side on the edge of the bed without a second staff present to prevent a fall from the bed. Staff were in-serviced that an air mattress might collapse if the resident was positioned on the edge of the mattress and therefore no resident could be left unattended to go to the other side. Staff were specifically educated by the DON that they must use two-person assistance for anyone using an air mattress. Staff were also educated that two-person assistance is always required on any type of mechanical lifts. Any staff member that was not able to be in-serviced on this date will not be allowed to return to work until they have received the education. DON and SDC taught in small groups. Completed [DATE] Address what measure will be put into place or systemic changes made to ensure that the deficient practice will not recur: SDC or designee will ensure that new hires and agency staff receive training upon hire on utilizing the care guide to determine level of assistance, not leaving a resident unassisted on their side on the opposite side of the bed from where they are working and using two- person assistance for all residents who are dependent for bed mobility, on air mattresses and using mechanical lifts. Completed [DATE] 100% of NA's and Nurses were in-serviced on facility practice regarding use of the care guide for determining level of assistance with ADLS. Staff were instructed that they must check the care guide in the closet of each resident room to determine how many staff members needed to assist and ask for that assistance. If for any reason assistance was not available, or refused, the NAs were to report to the charge nurse who would assist or direct another staff member to assist. Staff were educated that they must never leave a resident lying on their side on the edge of the bed without a second staff present to prevent a fall from the bed. Staff were in-serviced that an air mattress might collapse if the resident was positioned on the edge of the mattress and therefore no resident could be left unattended to go to the other side. Staff were specifically educated that they must use two- person assistance for anyone using an air mattress. Staff were also educated that two-person assistance is always required on any type of mechanical lifts. Any staff member that was not able to be in-serviced on this date will not be allowed to return to work until they have received the education. By the SDC and DON using small groups. Completed [DATE] During orientation, new hires and agency will be trained by the SDC or designee regarding use of the care guide for determining level of assistance with ADLS, never leaving a resident lying on their side on the edge of the bed without a second staff present to prevent a fall from the bed, that an air mattress might collapse if the resident is positioned on the edge of the mattress and therefore no resident could be left unattended to go to the other side. Staff will be specifically educated that they must use two-person assistance for anyone using an air mattress or any type of mechanical lifts. Completed [DATE]. Care guides are present in the closet of each resident to communicate special needs between staff to promote continuity of care. Care guides should be reviewed before a staff member begins to work with a resident each day as care areas could change from day to day. Items on the care guide include assistance with ADLs, special devices for positioning including air mattress, splints, etc. They are updated by the administrative assistant after the review of all new orders, 24-hour report, and notes from the past 24 hours. This facility practice continues to be that the DON or designee notifies the administrative assistant of changes to make on the care guide on business days and as needed. This is a longstanding and ongoing process. Indicate how the facility plans to monitor its performance to make sure that the solutions are sustained and include dates when corrective action plan will be completed: Nursing Admin will conduct skills checks on 10% of CNAs for proper use of two-person assistance for bed mobility and those on air mattresses weekly x4 weeks, monthly x 2 months, and quarterly x3 or until such time as no incidents of failure to comply with Facility policy are noted. Monitoring ongoing. Plan completed [DATE]. The QA committee will review results monthly and modify actions as need. Monitoring ongoing. Plan completed [DATE]. IJ removal date: [DATE] On onsite validation was conducted on [DATE]. The facility's investigation was reviewed along with the root cause analysis. The initial audit of potentially affected other residents was reviewed with no concerns identified. The care guides in rooms of residents on the initial audit including residents on air mattress were verified to have the correct information posted in each resident room. Interviews with NAs and Nurses revealed that they had education in [DATE] and again [DATE] regarding safe bed mobility practices, how to turn a resident, how much staff each resident required, where the information was posted, and how often to review the information. Observations were conducted and revealed staff used two-people for incontinence care of dependent residents that utilized air mattresses. The interviews also revealed that staff were able to verbalize that if a staff member refused to assist with a two-person assistance resident that it should be reported and another staff member requested to assist with the care. The QA minutes were reviewed and included the plan put into place. The removal date of [DATE] was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to verify that a Nurse Aide (NA) was competent in providing care for a dependent resident. Resident #195 rolled out of bed and sustained a right femur (long bone of the upper leg), right inferior and superior pubic rami (pelvic) fractures and questionable nondisplaced sacral alar (lower spine) fracture during care. Resident #195 was a poor surgical candidate and was admitted to the hospital for comfort care. Resident #195 died on [DATE]. The deficient practice occurred for 1 of 6 NAs (NA #1) reviewed for competencies. Immediate jeopardy began on [DATE] when NA #1 performed care without competencies being verified Resident #195 rolled off the side of the bed. Immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems put into place are effective. The findings included: This tag is cross-referred to: F689: Based on observations, record review, staff, Nurse Practitioner, Funeral Home Representative and Hospitalist interviews the facility failed to provide care in a safe manner. On [DATE] Nurse Aide (NA) #1 was performing incontinence care for Resident #195 who was resting on an air mattress raised to waist height and rolled Resident #195 on her side away from NA #1 who proceeded to walk around to the other side of the bed at which time the air mattress decompressed. Resident #195 rolled off the side of the bed to the floor and was wedged between the bed and the wall. Resident #195 was transferred to the hospital where she was diagnosed with a right femur fracture, right inferior and superior pubic rami (pelvic) fractures, questionable nondisplaced sacral alar (lower spine) fracture. Resident #195 was a poor surgical candidate and was admitted to the hospital for comfort care. Resident #195 died on [DATE]. The deficient practice affected 1 of 6 residents (Resident #195) reviewed for accidents. Review of Nurse Aide (NA) #1's employee file revealed she had been hired on [DATE]. There was no evidence of a completed Nurse Aide Competency Checklist prior to [DATE]. Review of a Nurse Aide Competency Checklist dated [DATE] revealed NA #1 had completed all NA competencies. An interview was conducted on [DATE] at 2:27 pm with NA #1. NA #1 stated she was not able to recall what specific training or competencies she had completed upon hire. An interview was conducted on [DATE] at 10:43 am with the Staff Development Coordinator (SDC). The SDC stated when an employee was hired, they were required to attend orientation and completed 3 days on the floor with a preceptor at which time the preceptor would sign off on skills completed on the Nurse Aide Competency Checklist. The SDC stated NAs should have completed all competencies prior to taking an assignment by themselves. The SDC stated she or the Scheduler reviewed the competencies before new staff were taken off orientation to ensure that all the skills on the Nurse Aide Competency Checklist had been completed. The SDC stated she had no record of NA #1's competencies and stated she did not think that NA #1 had ever turned them back in. The SDC stated she was not sure how she had overlooked it. The SDC stated NA #1 should have completed all competencies after she was hired, prior to taking a resident assignment on her own. The SDC stated she was newer in her role and had not had any official training for the SDC position. The SDC stated she had NA #1 complete all NA competencies on [DATE] after the incident with Resident #195. An interview was conducted on [DATE] at 4:11 pm with the Director of Nursing (DON). The DON stated competencies should be completed during orientation for new employees. The DON stated the SDC should ensure that all items on the Nurse Aide Competency Checklist were completed and signed off on by a preceptor. The DON stated she was not sure why NA #1's competencies had not been completed before the incident with Resident #195 and stated she should have had her competencies verified prior to taking an assignment on her own. The Administrator was notified of immediate jeopardy on [DATE] at 6:15 pm. The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: NA #1, who was hired on [DATE], had skills competency completed on hire and signed off by mentors, but the employee misplaced the checklist before returning it to the SDC for filing. The Staff Development Coordinator (SDC) did not ensure that the skills checklist was placed in the file for NA #1. An audit of nursing staff employee files was initiated by the Director of Nursing (DON) who recalled, and confirmed through observation during her audit, that the previous owner had taken all personnel files during the change of ownership. The facility is unable to reach or request records from the previous owner. The ownership change was in 2005 and there are 23 employees who have been there longer than 2005. The audit further revealed that due to turnover of four SDCs in the past four years, and a change of offices, that an appropriate filing system had not been maintained for the On Hire Skills Checklist. Audit completed [DATE] All residents have the potential to be affected. All nursing staff have the potential to be affected. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: NA #1 was counseled and re-educated on [DATE] by the DON. Re-education included: checking care guide at the beginning of each shift to determine level of assistance required, requesting assistance when appropriate, notifying charge nurse if another NA refuses to assist, not positioning a resident on their side on the edge of the bed and going to other side without another staff member present to keep the resident from rolling to floor, use of two people assistance with air mattresses, and that two-person assistance must always be used for mechanical lifts. Completed [DATE] 100% of NAs and Nurses were in-serviced on facility practice regarding use other care guide for determining level of assistance with ADLS. Staff were instructed that they must check the care guide in the closet of each resident room to determine how many staff members needed to assist and ask for that assistance. If for any reason assistance was not available, or refused, the NAs were to report to the charge nurse who would assist or direct another staff member to assist. Staff were educated that they must never leave a resident lying on their side on the edge of the bed without a second staff present to prevent a fall from the bed. Staff were in-serviced that an air mattress might collapse If the resident was positioned on the edge of the mattress and therefore no resident could be left unattended to go to the other side. Staff were specifically educated that they must use two-person assistance for anyone using an air mattress. Staff were also educated that two-person assistance is always required on any type of mechanical lifts. Any staff member that was not able to be in-serviced on this date will not be allowed to return to work until they have received the education. By the SDC and DON using small groups. Completed [DATE] On [DATE] he SDC took NA#1 to a room and had her complete a return demonstration on providing care to a dependent resident in the bed. NA#1 was not allowed to return to work until all of this was completed. Completed [DATE] by SDC. A skills checklist was completed with NA#1 on [DATE] with the SDC. NA#1 was not allowed to return to work until this was completed. She returned to work on [DATE]. Completed [DATE] On [DATE] the DON asked the SDC about the On Hire skills checklist for NA#1. The SDC informed there was not one in the file and that NA #1 stated she had misplaced it before turning it in. The DON educated the SDC there must be a skills checklist on file for all new hires from that date forward. From [DATE] to present there have been 2 hires. Both have On Hire Skills Checklists in their file. No new hire will be allowed to begin work without a completed skills checklist. Completed [DATE] Due to the removal of On Hire Skills Checklist by the previous owner, and files being misfiled by turnover in SDC position, the facility will redo on hire skills checklists for all employees beginning [DATE] and ending [DATE]. No CNA or nurse will be allowed to return to work after [DATE] if they have not completed the on hire skills checklist. This will be completed by DON, SDC or designee. Completion [DATE] The categories of skills on the checklist are infection control, pressure ulcer prevention, nutrition, ADLs, documentation, patient satisfaction, safety (which includes use of lifts, two-person assistance for air mattress, total dependence, turning resident toward oneself for care). The Director of Nursing (DON) had the SDC sign an in-service form documenting that she was told on [DATE] that she must make sure that the On Hire Skills Checklist is completed and filed on hire for all nursing staff. Training completed [DATE]. Form signed [DATE]. The SDC will place, for all new hires, the On Hire Skills Checklist in an employee file with the employee's name and date of hire. This will be maintained in the SDC office. No employee will be allowed to begin work unless completed. Completed [DATE] A monitoring tool checklist, created by the Administrator, was implemented to track that the On Hire Skill Checklist was filed on hire and that annual training was provided with the date note. The checklist will be maintained by the SDC. Completed [DATE] The Administrator is responsible for the plan. Date of IJ removal: [DATE] An onsite validation was conducted on [DATE]. A review of documentation revealed skills checklists for all employees from [DATE] through [DATE] had been updated/completed that included the following: infection control, pressure ulcer prevention, nutrition, activities of daily living (ADL), documentation, resident satisfaction, safety, totally dependent resident care, turning and repositioning a resident towards oneself for care, and the use of the care guide for determining the level of assistance a resident required and that if a staff member refused to assist with a two-person assistance resident that it should be reported and another staff member requested to assist with the care. A review of an in-service revealed the Staff Development Coordinator (SDC) had been educated about ensuring the On Hire Skills Checklist had been completed and filed for all nursing staff, an employee file will be maintained in the SDC office, and staff would not be allowed to work until the checklist had been completed. The facility completed On Hire Skills Checklists for all staff. The facility's monitoring tool checklist was reviewed and had been implemented and was being maintained by the SDC. The IJ removal date of [DATE] was validated.