**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility procedure review, medical record review, facility investigation review, and interviews the facility failed to implement the comprehensive care plan for 1 resident (Resident #3) which resulted in actual Harm, of 5 residents reviewed for care plans for accidents. The facility was cited as past non-compliance and the facility is not required to submit a Plan of Correction for F-656. Non-compliance began on 9/26/2022 and ended on 8/28/2023. The findings include: Review of the facility's policy titled, Comprehensive Care Plans and Revisions, dated 3/2/2022, showed .Procedure .The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery .Additional interventions on existing problems . Review of a facility procedure titled, Transfer with a Mechanical Lift [device that holds the patient in a hammock-type sling to lift them completely between surfaces] Long-Term Care, dated 5/20/2022, showed .The facility will ensure that two associates should be present during the transfer of residents who require a mechanical lift . Resident #3 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Hemiparesis, Lack of Coordination, and Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #3 scored 13 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact and required total 2-person assistance with transfers. Review of Resident #3's comprehensive care plan revised 8/17/2023, showed the resident was at risk for falls secondary to impaired mobility from left sided weakness due to a Cerebral Vascular Accident (CVA), impaired balance, episodes of incontinence, and required 1-2 staff assistance with transfers. The comprehensive care plan was revised to include the sit to stand lift on 9/17/2022 and Hoyer lift with all transfers on 12/28/2022. Review of a post fall investigation report dated 9/17/2022, showed Resident #3 had transferred himself to the toilet without assistance. Certified Nursing Assistant (CNA) #5 entered his room and attempted to assist the resident from the commode back into the wheelchair. During the transfer from the toilet to the wheelchair the resident's hand slipped off the safety bar and the resident fell forward out of the wheelchair. The resident was assessed for injury with none observed. The facility implemented the intervention of a sit to stand lift for transfers and the care plan was updated. Review of a post fall investigation report dated 9/26/2022, showed Resident #3 sustained a fall when CNA #6 was transferring the resident from the bed to the wheelchair using a slide board (device used to aid as a bridge in between 2 surfaces so a patient can slide across to transfer). During the transfer the slide board slipped out of the wheelchair and CNA #6 lowered the resident to the floor. The comprehensive care plan indicated Resident #3 was to be transferred with a sit to stand mechanical lift, the resident sustained a fracture of the left femur and required surgical intervention which resulted in actual Harm to Resident #3. Review of a post fall investigation dated 12/27/2022, showed Resident #3 was being transferred by CNA #7 from the wheelchair to the bed with the use of a sit to stand lift (2 staff had not assisted the resident according to the facility procedure guide), the resident became weak, and was lowered to the floor. The resident was assessed for injury with none observed, the facility discontinued the use of the sit to stand lift for transfers, and implemented a new intervention to use a mechanical hoyer lift for all transfers and the care plan was revised. Review of a transfer injury investigation report dated 5/1/2023, showed Resident #3 was transferred by 2 CNAs, #1 and #8 from the bed to the wheelchair using the sit to stand lift (care planned to use hoyer lift only for transfers). The resident complained of pain to his left arm during the transfer. An x-ray was ordered, and the resident received an acute and impacted humeral neck fracture (left upper arm fracture) and was transported to the emergency room for further evaluation. The facility failed to implement the comprehensive Care Plan intervention for use of a hoyer lift with all transfers which resulted in actual harm to Resident #3 when the resident sustained a left humeral fracture following transfer with the sit to stand lift. During an interview on 2/27/2022 at 9:00 AM, the Director of Nursing (DON) confirmed CNA #6 should have used a sit to stand mechanical lift for the transfer on 9/26/2022, the CNA failed to follow the care planned intervention and Resident #3 was harmed. During an interview on 2/27/2024 at 9:45 AM, the DON confirmed the facility failed to follow Resident #3's comprehensive care plan related to fall interventions. The failure caused the resident harm from the falls on 9/26/2022 and 5/1/2023. During a telephone interview on 2/27/2024 at 6:00 PM, CNA #6 stated on 9/26/2022 she transferred Resident #3 from the bed to the wheelchair using a slide board. During the transfer the slide board slipped out of the wheelchair and CNA #6 lowered the resident to the floor. Continued interview showed CNA #6 always transferred the resident with a slide board. CNA #6 failed to use the sit to stand mechanical lift to transfer Resident #3 and confirmed the care plan had not been followed. Review of an Ad hoc (when necessary or needed/for this situation) Quality Assurance Performance Improvement (QAPI) meeting dated 5/3/2023, showed the facility initiated and conducted a root cause analysis and developed a corrective action plan which was verified by the surveyor on 2/28/2024. The corrective action plan included the following: 1. Conduct staff education to ensure all staff are aware Resident #3 was to be hoyer lift transfer only with 2-person assist. The education included how to transfer current residents list (located at the nurse station), and re-education on the location of special instructions for each resident. The education had been completed by 5/31/2023. 2. An Audit of all residents that required the use of a mechanical lift for transfers and verified the information was correct on the individual care plan. The audits had been completed on 5/10/2023. 3. All CNAs were educated on the following: A. Limited Lift Program (Safe Patient Handling) policy B. Using a Sit to Stand Lift - Skills Checklist C. Transfer using a Sit to Stand Mechanical Lift-Procedure D. Transfer with a mechanical lift, long-term care-Skills checklist E. Transfer with a mechanical lift, long term care - Procedure All CNA education had been completed on 6/9/2023. 4. All licensed nurses Registered Nurse and Licensed Practical Nurse were educated on the following: A. Limited Lift Program (Safe Patient Handling) policy B. Using a Sit to Stand Lift - Skills Checklist C. Transfer using a Sit to Stand Mechanical Lift -Procedure D. Transfer with a mechanical lift, long-term care - Skills checklist E. Transfer with a mechanical lift, long term care - Procedure F. Bedside Mobility Assessment Tool - Procedure G. Bedside Mobility Assessment Tool - Checklist All licensed nurse education had been completed on 6/30/2023. 5. Clinical observation audits were conducted for residents that required the use of a mechanical lift for transfers to ensure residents are transferred properly, 5 residents per week for 12 weeks. Observations were conducted on 2/29/2024 to ensure proper lift usage was completed. 6. Audit of incidents to ensure if a transfer injury occurred, and the correct mechanical lift was utilized if applicable, weekly for 12 weeks. Audits were verified for completion. 7. Audit of all new admissions/readmissions to ensure the level of assistance/type of mechanical lift is reflected in the resident's medical record, weekly for 12 weeks. Audits were verified for completion. Review of the QAPI sign-in sheets dated 5/2023, 6/2023, 7/2023, and 8/2023, and interview with the Administrator on 2/28/2024, confirmed the corrective action audits/observations were completed and discussed in the QAPI meetings. The Performance Improvement Plan (PIP) was considered resolved with the date of compliance effective on 8/28/2023. Non-Compliance began on 9/26/2022 and ended on 8/28/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility procedure review, medical record review, review of facility investigation documentation, and interviews the facility failed to prevent falls with major injury for 1 resident (Resident #3) of 5 residents reviewed for accidents. The facility was cited as past non-compliance and the facility is not required to submit a Plan of Correction for F-689. Non-compliance began on 9/26/2022 and ended on 8/28/2023. The findings include: Review of the facility's policy titled, Fall Management, dated 4/7/2022, showed .Accident .Refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident .Avoidable Accident .an accident occurred because the facility failed to .Evaluate/analyze the hazards and risks and eliminate them, if possible .if not possible .identify and implement measures to reduce the hazards/risks as much as possible .Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan .reduce the risk of an accident .Monitor the effectiveness of the interventions and modify the care plan as necessary . Review of a facility procedure titled, Transfer with a Mechanical Lift, Long-Term Care, dated 5/20/2022, showed .The facility will ensure that two associates should be present during the transfer of residents who require a mechanical lift . Resident #3 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Hemiparesis, Lack of Coordination, and Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #3 scored 13 on the Brief Interview of Mental Status (BIMS) assessment, which indicated the resident was cognitively intact and required total, 2-person assistance with transfers. Review of a post fall investigation report dated 9/17/2022, showed Resident #3 had transferred himself to the toilet without assistance. Certified Nursing Assistant (CNA) #5 entered his room and attempted to assist the resident from the commode back into his wheelchair. During the transfer from the toilet to the wheelchair the resident's hand slipped off the safety bar and the resident fell forward out of his wheelchair. The resident was assessed for injury with none observed. The facility implemented the intervention of a sit to stand lift for transfers. Review of Resident #3's comprehensive care plan revised 9/17/2022, showed the resident had left sided weakness due to a Cerebral Vascular Accident (CVA) and impaired balance and a sit to stand lift for transfers was implemented after a fall. Review of a post fall investigation report dated 9/26/2022, showed Resident #3 sustained a fall when Certified Nursing Assistant (CNA) #6 was transferring the resident from the bed to wheelchair using a slide board (device used to aid as a bridge in between 2 surfaces so a patient can slide across to transfer). During the transfer the slide board slipped out of the wheelchair and CNA #6 lowered the resident to the floor. Resident #3 complained of pain, the Nurse Practitioner was notified and ordered an x-ray of the resident's bilateral hips and pelvis. Resident #3 had sustained a left hip fracture as a result from the fall. Continued review of the medical record and care plan showed the appropriate device for transfers was a sit to stand lift which had been implemented on 9/17/2022. Review of an x-ray report dated 9/26/2022 for Resident #3, showed . acute displaced .fracture of the proximal left femoral diaphysis [long bone in leg] . Review of a hospital summary dated 9/29/2022, showed Resident #3 underwent a surgical procedure on 9/27/2022 to repair the fracture of the left femur. Review of a Physical Therapy (PT) Evaluation dated 9/30/2022 showed Resident #3 was assessed for transfers and continued the use of the sit to stand lift for transfers. Review of a post fall investigation dated 12/27/2022, showed Resident #3 was being transferred by CNA #7 from the wheelchair to the bed with the use of a sit to stand lift, the resident became weak, and was lowered to the floor. The resident was assessed for injury with none observed and the facility discontinued the use of a sit to stand lift for transfers and implemented the use of mechanical Hoyer lift for all transfers. CNA #7 failed to have assistance of a 2nd staff member transfer of the resident using the sit to stand lift per facility procedure. Review of Resident #3's comprehensive care plan revised 12/28/2022, showed the resident was at risk for falls secondary to impaired mobility from left sided weakness due to a Cerebral Vascular Accident (CVA), impaired balance, episodes of incontinence, and required 1-2 staff assistance with transfers. The comprehensive care plan was revised to include and Hoyer lift with all transfers. Review of a post fall investigation report dated 2/21/2023, showed CNA #2 and Licensed Practical Nurse (LPN) #2 attempted to transfer Resident #3 from his wheelchair to bed using the sit to stand lift. The resident became weak on his left side and was lowered to the floor with no injury. The floor staff were re-educated the resident should be transferred with a mechanical Hoyer lift and the only time he should use the sit to stand lift was during training with restorative nursing staff. Continued review of the medical record and care plan showed the Hoyer lift was the appropriate device to be used during the transfers which had been implemented on 12/28/2022. Review of a transfer injury investigation report dated 5/1/2023, showed Resident #3 was transferred by 2 CNAs from the bed to his wheelchair using the sit to stand lift. The resident complained of pain to his left arm during the transfer. The CNA's reported resident's complaint of pain to LPN #1. The LPN assessed the resident, and he reported his left arm just hurt a little. The resident remained in his wheelchair throughout the day with no reported increased pain. During transfer from the wheelchair back to the bed the resident complained of left arm pain, the NP was notified, and an x-ray of his left shoulder and chest was obtained. Continued review of the medical record and care plan showed the Hoyer lift was the appropriate device to be used during the transfers which had been implemented on 12/28/2022. Review of an X-Ray report dated 5/2/2023, showed Resident #3 had an .acute and impacted humeral neck fracture [left upper arm fracture] . The NP was notified, and the resident was sent to the Emergency Department for evaluation and treatment. Review of Emergency Department documentation dated 5/2/2023, showed .patient [Resident #3] was placed in a shoulder immobilizer and discharged back to the nursing facility with instructions to follow-up with orthopedics with the next week .Patient is stable and in no acute distress . Review of an orthopedic follow-up visit documentation dated 5/12/2023, showed Resident #3 should remain non-weight bearing to left upper extremity, continue with the shoulder immobilizer, and return for a follow-up visit in approximately 3 weeks. During an interview on 2/27/2024 at 9:00 AM, the Director of Nursing (DON) confirmed Resident #3 suffered a left arm fracture during a transfer on 5/1/2023. The facility had failed to use the Hoyer lift which had been implemented and used a sit to stand lift during the transfer which resulted in an injury. During a telephone interview on 2/27/2024 at 9:00 AM, the DON confirmed CNA #6 failed to use the sit to stand lift during a transfer on 9/26/2022. The DON also confirmed Resident #3 sustained a fracture of the left femur, required surgical intervention, and the resident was harmed due to the inappropriate transfer. The facility had failed to use a sit to stand lift which had been implemented and used a slide board during the transfer which resulted in an injury. During an interview on 2/27/2024 at 12:37 PM, the Restorative Certified Nursing Assistant (R-CNA) stated Resident #3 had been resistant to care and mechanical lift usage. R-CNA stated the resident would demand the staff to use the sit to stand lift (device that helps lift a patient into a supported, standing position to move them freely between seated surfaces) instead of the hoyer lift (device that holds the patient in a hammock-type sling to lift them completely between surfaces) and would often refuse to transfer if the sit to stand lift was not used. R-CNA stated she would notify the nurse assigned to his care when he refused usage of the lift. During an interview on 2/27/2024 at 12:48 PM, CNA #2 stated Resident #3 had been resistant to care and lift usage at times. She stated she notified the nurse assigned the residents care when he refused. She also stated during one of the falls [could not recall date] the resident refused to use to the hoyer lift to go to bed and stated the sit to stand lift was used. During an interview on 2/27/2024 at 2:13 PM, Registered Nurse (RN) #1 stated Resident #3 was resistant to transfers which included hoyer lift usage. During an interview on 2/27/2024 at 2:31 PM, Licensed Practical Nurse (LPN) #1 stated multiple CNAs had reported Resident #3 had refused hoyer lift transfers and had been resistant to care. During a telephone interview on 2/27/2024 at 6:00 PM, CNA #6 stated on 9/26/2022 she transferred Resident #3 from the bed to wheelchair using a slide board. During the transfer the slide board slipped out of the wheelchair and CNA #6 lowered the resident to the floor. Continued interview showed CNA #6 always transferred the resident with a slide board. CNA #6 failed to use the sit to stand lift to transfer Resident #3 as indicated on the care plan. During an interview on 2/28/2024 at 11:10 AM, the DON confirmed CNA #7 failed to follow the facility procedure of having 2 staff members present during the use of a sit to stand lift during the 12/27/2022 fall. Review of an Ad hoc (when necessary or needed/for this situation) Quality Assurance Performance Improvement (QAPI) meeting dated 5/3/2023, showed the facility initiated and conducted a root cause analysis and developed a corrective action plan which was verified by the surveyor on 2/28/2024. The corrective action plan included the following: 1. Conduct staff education to ensure all staff are aware Resident #3 was to be hoyer lift transfer only with 2-person assist. The education included how to transfer current residents list (located at the nurse station), and re-education on the location of special instructions for each resident. The education had been completed by 5/31/2023. 2. An Audit of all residents that required the use of a mechanical lift for transfers and verified the information was correct on the individual care plan. The audits had been completed on 5/10/2023. 3. All CNAs were educated on the following: A. Limited Lift Program (Safe Patient Handling) policy B. Using a Sit to Stand Lift - Skills Checklist C. Transfer using a Sit to Stand Mechanical Lift-Procedure D. Transfer with a mechanical lift, long-term care-Skills checklist E. Transfer with a mechanical lift, long term care - Procedure All CNA education had been completed on 6/9/2023. 4. All licensed nurses Registered Nurse and Licensed Practical Nurse were educated on the following: A. Limited Lift Program (Safe Patient Handling) policy B. Using a Sit to Stand Lift - Skills Checklist C. Transfer using a Sit to Stand Mechanical Lift -Procedure D. Transfer with a mechanical lift, long-term care - Skills checklist E. Transfer with a mechanical lift, long term care - Procedure F. Bedside Mobility Assessment Tool - Procedure G. Bedside Mobility Assessment Tool - Checklist All licensed nurse education had been completed on 6/30/2023. 5. Clinical observation audits were conducted for residents that required the use of a mechanical lift for transfers to ensure residents are transferred properly, 5 residents per week for 12 weeks. Observations were conducted on 2/29/2024 to ensure proper lift usage was completed. 6. Audit of incidents to ensure if a transfer injury occurred, and the correct mechanical lift was utilized if applicable, weekly for 12 weeks. Audits were verified for completion. 7. Audit of all new admissions/readmissions to ensure the level of assistance/type of mechanical lift is reflected in the resident's medical record, weekly for 12 weeks. Audits were verified for completion. Review of the QAPI sign-in sheets dated 5/2023, 6/2023, 7/2023, and 8/2023, and interview with the Administrator on 2/28/2024, confirmed the corrective action audits/observations were completed and discussed in the QAPI meetings. The PIP was considered resolved with the date of compliance effective on 8/28/2023. Non-Compliance began on 9/26/2022 and ended on 8/28/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of facility documentation, and interview, the facility's Administration failed to provide effective oversight and follow the facility's corporate notification protocol for falls with major injury which resulted in actual Harm of Resident #3 of 5 residents reviewed for falls and had the potential to affect all 86 residents residing in the facility. The facility was cited as past non-compliance and the facility is not required to submit a Plan of Correction for F-835. Non-compliance began on 9/26/2022 and ended on 8/28/2023. The findings include: Review of the facility's policy titled, Incident and Reportable Event Management, dated 9/14/2023, .each resident receives adequate supervision .to prevent accidents .facility has identified the following events as being Never Event [fall that results in serious injury or fracture] and when these type of events occur the Director or Nursing and/or Executive Director should contact their Regional and Divisional team to review the Never Event and determine based on the Never Event the cause of the event, implement corrective actions to prevent future events, and conduct monitoring to ensure desired outcomes are achieved and .through the development of a performance improvement plan (PIP) .identified Never Events are .fall that results in serious injury .fracture . Review of the facility's policy titled, Resident Rights, dated 9/25/2023, showed .The resident has the right to receive the services and/or items included in the plan of care .The resident has the right to reside and receive services in the facility with reasonable accommodation of resident and preferences except when to do so would endanger the health or safety of the resident . Review of the facility's policy titled, Quality Assurance and Performance Improvement Plan [QAPI], dated 10/19/2023, showed .Performance Improvement (PIP) .is the continuous study and improvement of processes with the intent to improve services or outcomes, and prevent or decrease the likelihood of problems, by identifying opportunities for improvement .PI aims to improve facility processes involved in care delivery and enhanced resident quality of life . Review of the facility's policy titled, QAPI - Feedback, Data Systems, and Monitoring, dated 10/19/2023, showed .This facility will establish systems and processes to monitor care and services, utilizing data from multiple sources .This facility will also establish systems to track, investigate, and monitor adverse events to prevent recurrences .The facility will obtain feedback from direct care staff, other staff, residents and resident representatives, as well as other sources, and be used to identify problems that are high-risk, high-volume, and/or problem-prone . Resident #3 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Hemiparesis, Lack of Coordination, and Muscle Weakness. Review of a post fall investigation report dated 9/26/2022, showed Resident #3 had a fall when staff transferred him from the bed to wheelchair using a slide board (device used to aid as a bridge in between 2 surfaces so a patient can slide across to transfer). Resident #3 had been care planned for staff to transfer him with a sit to stand lift (device that helps lift a patient into a supported, standing position to move them freely between seated surfaces) and the Certified Nursing Assistant (CNA) #6 had not followed the care plan. Resident #3 sustained a left hip fracture as a result from the fall on 9/26/2022. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #3 scored 13 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact and required total 2-person assistance with transfers. Review of Resident #3's comprehensive care plan revised 8/17/2023, showed .resident has an ADL [Activities of Daily Living] self-care performance .limited physical mobility r/t [related to] impaired mobility, limited endurance, and poor balance .assist resident in identifying outcomes of refusal of care . Continued review showed showed the resident was at risk for falls secondary to impaired mobility from left sided weakness due to a Cerebral Vascular Accident (CVA), impaired balance, episodes of incontinence, and required 1-2 staff assistance with transfers. The comprehensive care plan was revised to include the sit to stand mechanical lift on 9/17/2022 and the Hoyer mechanical lift with all transfers on 12/28/2022. Record review showed Resident #3 had repeated fall occurrences on 12/27/2022, 2/21/2023, and a transfer injury on 5/1/2023. Review of a transfer injury investigation report dated 5/1/2023, showed Resident #3 had a transfer injury when staff transferred him from bed to wheelchair using a sit to stand lift. Resident #3 was care planned for staff to transfer him with a Hoyer lift and the CNA #1 had not followed the care plan due to resident refusal. Resident #3 sustained a left humerus fracture as a result from the improper transfer. The facility immediately implemented an intervention and corrective actions post Resident #3's injury on 5/1/2023. During an interview on 2/27/2024 at 2:13 PM, Registered Nurse (RN) #1 stated Resident #3 was resistant to transfers which included hoyer lift usage. RN #1 confirmed she had not documented Resident #3's refusal with resistance to transfers in the medical record. During an interview on 2/27/2024 at 2:31 PM, Licensed Practical Nurse (LPN) #1 stated multiple CNAs had reported Resident #3 had refused hoyer lift transfers and had been resistant to care. LPN #1 confirmed she had not documented Resident #3's refusal of transfers and resistance to care in the medical record. During an interview on 2/28/2024 at 11:56 AM, the Director of Nursing (DON) confirmed the medical record for Resident #3 did not reflect his refusals of lift usage or non-compliance with transfers. During an interview on 2/28/2024 at 3:45 PM, the Regional Director of Clinical Services (RDCS) stated the facility had a notification protocol for Never Events (falls with major injury) and the fall on 9/26/2022 for Resident #3 would qualify as a Never Event. The RDCS stated the former Director of Nursing (DON) had not contacted him when the fall with fracture occurred on 9/26/2022 with Resident #3. The RDCS stated it was the facility's expectation when a resident had a fall with major injury and continued non-compliance with safety interventions, the corporate staff would be notified so appropriate oversight and interventions could occur. The RDCS confirmed the former DON did not follow the notification protocol so the corporate team could initiate the appropriate oversight/intervention in response to Resident #3's fall with major injury on 9/26/2022. The RDCS further confirmed this failure to follow the notification process for Never Events resulted in ineffective administration oversight which had the potential to affect all residents residing in the facility. The RDCS stated when the corporate team became aware of Resident #3's multiple falls with major injury, a Performance Improvement Plan (PIP) was initiated, and immediate education was given to the former DON and the former Administrator. Review of an Ad hoc (when necessary or needed/for this situation) Quality Assurance Performance Improvement (QAPI) meeting dated 5/3/2023, showed the facility became aware, initiated and conducted a root cause analysis and developed a corrective action plan on 5/3/2023, which was verified by the surveyor on 2/28/2024. The corrective action plan included the following: 1. Conduct staff education to ensure all staff are aware Resident #3 was to be hoyer lift transfer only with 2-person assist. The education included how to transfer current residents list (located at the nurse station), and re-education on the location of special instructions for each resident. The education was completed by 5/31/2023. 2. An Audit of all residents that required the use of a mechanical lift for transfers and verified the information was correct on the individual care plan. The audits were completed on 5/10/2023. 3. All CNAs were educated on the following: A. Limited Lift Program (Safe Patient Handling) policy B. Using a Sit to Stand Lift - Skills Checklist C. Transfer using a Sit to Stand Mechanical Lift-Procedure D. Transfer with a mechanical lift, long-term care-Skills checklist E. Transfer with a mechanical lift, long term care - Procedure All CNA education was completed on 6/9/2023. 4. All licensed nurses Registered Nurse and Licensed Practical Nurse were educated on the following: A. Limited Lift Program (Safe Patient Handling) policy B. Using a Sit to Stand Lift - Skills Checklist C. Transfer using a Sit to Stand Mechanical Lift -Procedure D. Transfer with a mechanical lift, long-term care - Skills checklist E. Transfer with a mechanical lift, long term care - Procedure F. Bedside Mobility Assessment Tool - Procedure G. Bedside Mobility Assessment Tool - Checklist All licensed nurse education was completed on 6/30/2023. 5. Clinical observation audits were conducted for residents that required the use of a mechanical lift for transfers to ensure residents are transferred properly, 5 residents per week for 12 weeks. Observations were conducted on 2/29/2024 to ensure proper lift usage was completed. 6. Audit of incidents to ensure if a transfer injury occurred, and the correct mechanical lift was utilized if applicable, weekly for 12 weeks. Audits were verified for completion. 7. Audit of all new admissions/readmissions to ensure the level of assistance/type of mechanical lift is reflected in the resident's medical record, weekly for 12 weeks. Audits were verified for completion. Review of the QAPI sign-in sheets dated 5/2023, 6/2023, 7/2023, and 8/2023, and interview with the Administrator on 2/28/2024, confirmed the corrective action audits/observations were completed and discussed in the QAPI meetings. The Performance Improvement Plan (PIP) was considered resolved with the date of compliance effective on 8/28/2023. Non-Compliance began on 9/26/2022 and ended on 8/28/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to follow professional standards of practice per the comprehensive care plan for pain management for 1 resident (#87) of 3 residents reviewed for pain management of 21 sampled residents. The facility's failure to follow professional standards of practice for pain management resulted in actual HARM to Resident #87. The findings include: Review of the facility policy Pain Management dated 11/2016 revealed, .Purpose .To promote patient well-being by reducing their pain .Based on comprehensive assessment [of] the patient, the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences . Medical record review revealed Resident #87 was admitted to the facility on [DATE] with diagnoses including Acquired Absence of Right Leg Below Knee, End Stage Renal Disease, Muscle Wasting and Atrophy, Restless Leg Syndrome, Peripheral Vascular Disease, and Dependence on Renal Dialysis. Medical record review of the Physician's Order Summary Report dated 7/10/19 revealed a physician's order for acetaminophen (non-narcotic pain reliever) 325 milligram (mg) give 2 tablets every 4 hours as needed for pain (not to exceed 3 grams in 24 hours), and oxycodone-acetaminophen (narcotic pain reliever) 5/325 mg give 1 tablet every 4 hours as needed for pain. Medical record review of the comprehensive care plan dated 7/11/19 revealed the resident was at risk for pain related to post-operative pain of recent below the knee amputation of right leg .Evaluate the effectiveness of pain interventions .Pain meds [medications] as ordered . Continued review revealed the resident had Peripheral Vascular Disease with the intervention .Give medications as ordered .Observe and report PRN [as needed] any s/sx [signs and symptoms] of complications of extremities .pain . Medical record review of a 14 day Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Continued review revealed the resident required the extensive assist of 1 staff for bed mobility, dressing, toileting, and hygiene. Further review revealed the resident had a surgical site of the right lower extremity due to recent amputation. Continued review revealed Resident #87 was assessed as having frequent pain which impacts the resident's daily activities and made it difficult to sleep at night. Further review revealed Resident #87 rated her pain as a '9' on a 1 to 10 scale (0 being no pain, and 10 being worst pain possible). Interview with Resident #87 on 7/30/19 at 9:47 AM, in the resident's room, revealed the resident complained of severe bilateral lower extremity (BLE) pain on 7/29/19 at 9:00 PM, and on 7/30/19 at 12:00 AM and 3:30 AM. Further interview revealed Licensed Practical Nurse (LPN) Charge Nurse #1 advised the resident .it was not time . for another dose of the PRN oxycodone/acetaminophen. Continued interview revealed the resident was not offered a PRN dose of acetaminophen at the time of the resident's complaint of pain. Further interview revealed the resident again complained of continued pain at 12:00 AM (3 hours later) and was told it was not yet time for the PRN dose of oxycodone/acetaminophen. Continued interview revealed .I had my right leg amputated about 3 weeks ago and I have neuropathy in both my legs .and they hurt so bad .I could hardly stand it .I asked her [Charge Nurse #1] to please bring me one [PRN oxycodone/acetaminophen] as soon as I could have it Further interview revealed Resident #87 was not administered the PRN oxycodone/acetaminophen 5/325 mg until 3:30 AM, after the 3rd request on 7/30/19. Interview with the Licensed Practical Nurse (LPN) Charge Nurse #1 by phone on 7/30/19 at 7:23 PM, revealed the LPN thought she had administered the oxycodone/acetaminophen to Resident #87 with her 9:00 PM medications and therefore was not time for another PRN dose. Continued interview with LPN Charge Nurse #1 confirmed the LPN also failed to give the resident the PRN acetaminophen after Resident #87 continued to complain of severe pain. Further interview confirmed the LPN had not administered the PRN dose of oxycodone until 3:30 AM on 7/30/19. Interview with the Director of Nursing (DON) and Unit Supervisor #1 on 7/31/19 at 11:15 AM, in the DON's office, confirmed the resident was not administered the PRN dose of oxycodone/acetaminophen 5/325 mg or acetaminophen 325 mg at 9:00 PM on 7/29/19 or 12:00 AM on 7/30/19 for Resident #87's complaints of severe pain. Further interview confirmed the PRN dose of oxycodone/acetaminophen was not administered until 3:30 AM on 7/30/19 (6.5 hours after the initial request). Continued interview confirmed the facility failed to follow Resident #87's pain management care plan which resulted in severe, unrelieved pain and actual HARM to Resident #87. Refer to F-697

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to provide effective pain management for 1 resident (#87) of 3 residents reviewed for pain of 21 sampled residents. The facility's failure to implement an effective pain management program for Resident #87 resulted in an increase in severe pain and actual HARM to Resident #87. The findings include: Review of the facility policy, Pain Management, dated 11/2016, revealed, .Purpose .To promote patient well-being by reducing their pain .Based on .assessment .the facility must ensure that pain management is provided to residents who require such services .Recognition and Management of Pain: In order to help a patient attain or maintain his or her highest practicable level of well-being and to prevent or manage pain, the facility .Recognizes when the patient is experiencing pain .Evaluates the existing pain .Manages or prevents pain . Medical record review revealed Resident #87 was admitted to the facility on [DATE] with diagnoses including Acquired Absence of Right Leg Below Knee, End Stage Renal Disease, Muscle Wasting and Atrophy, Restless Leg Syndrome, Peripheral Vascular Disease, and Dependence on Renal Dialysis. Medical record review of the comprehensive care plan dated 7/11/19 revealed the resident was at risk for post-operative pain related to below the knee amputation of right leg. Continued review revealed pain managment interventions to include evaluating the effectiveness of pain interventions and administer pain medications as ordered. Medical record review of a 14 day Minimum Data Set (MDS) dated [DATE] revealed the resident scored a 13 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Continued review revealed the resident required the extensive assist of 1 staff for bed mobility, dressing, toileting, and hygiene. Further review revealed the resident had a surgical site of the right lower extremity due to recent amputation. Continued review revealed Resident #87 frequently experienced pain which limited daily activities and made it difficult for the resident to sleep at night. Further review revealed the resident rated her pain as a '9' on a 1 to 10 scale (0 = no pain, 10 = worst pain possible). Medical record review of the Physician's Order Summary Report dated 7/10/19 revealed a physician's order for acetaminophen (non-narcotic pain reliever) 325 milligram (mg) give 2 tablets every 4 hours as needed (PRN) for pain (not to exceed 3 grams in 24 hours), and oxycodone-acetaminophen (narcotic pain reliever) 5/325 mg give 1 tablet every 4 hours PRN for pain. Medical record review of the Medication Administration Record (MAR) dated 7/2019 revealed the resident received a PRN oxycodone-acetaminophen 5/325 mg 1 tablet on 7/29/19 at 1:00 AM and on 7/30/19 at 7:16 AM and on 7/30/19 at 3:30 AM. Continued review revealed the PRN acetaminophen 325 mg 2 tablets was not administered on 7/29/19 or 7/30/19. Medical record review of the Controlled Drug Record revealed 1 tablet of the PRN oxycodone-acetaminophen 5/325 mg was removed and signed by the Licensed Practical (LPN) Charge Nurse #1 from the narcotic packet on 7/30/19 at 3:30 AM. Observation and interview with Resident #87 on 7/30/19 at 9:47 AM, in the resident's room, revealed the resident complained of severe bilateral lower extremity (BLE) pain on 7/29/19 at 9:00 PM. Continued interview revealed LPN Charge Nurse #1 instructed Resident #87 the pain medication was included and administered with her night time medications at 9:00 PM on 7/30/19. Further interview revealed the resident's pain was not relieved after the medication was administered. Continued interview revealed the resident continued to have severe pain of the bilateral lower extremities and again requested pain medication at 12:00 AM. Continued interview revealed LPN Charge Nurse #1 advised the resident .it was not time . Further interview revealed, .I had my right leg amputated about 3 weeks ago and I have neuropathy in both my legs .and they hurt so bad last night I could hardly stand it .I knew it might not be due but the pain medicine she gave me at 9:00 [PM] was not working .and I asked her [Charge Nurse #1] to please bring me one as soon as I could have it . Continued interview revealed the resident's pain on 7/29/19 at 9:00 PM through 7/30/19 at 3:30 AM was a 9 on a pain scale of 0-10 (0-No pain, 10-severe pain). Further interview revealed Resident #87 was not administered the PRN pain medication until 3:30 AM, after the resident's 3rd request. Continued interview revealed after Resident #87 received the 3:30 AM PRN dose of medication her pain was relieved. Interview with the LPN Charge Nurse #1 by phone on 7/30/19 at 7:23 PM, confirmed Resident #87 complained of bilateral lower extremity pain at 9:00 PM on 7/29/19, and on 7/30/19 at 12:00 AM, and 3:30 AM. Continued interview revealed after the resident had requested a PRN dose of the oxycodone/acetaminophen on 7/30/19 at 12:00 AM .I talked to her [Resident #87] and told her it wasn't [was not] time, she was not due .because I thought I gave it [oxycodone/acetaminophen] to her [Resident #87] . at 9:00 PM .I thought I gave it to her .but I guess I didn't [did not] because the count was right this morning, and I signed out for the one at 3:30 [3:30 AM dose of oxycodone/acetaminophen] . Further interview confirmed Charge Nurse #1 did not administer the PRN dose of oxycodone/acetaminophen 5/325 mg nor the PRN dose of acetaminophen at 9:00 PM on 7/29/19 or at 12:00 AM on 7/30/19. Further interview confirmed Resident #87 complained of pain again at 3:30 AM, and the PRN oxycodone/acetaminophen 5/325 mg was administered at that time, 6.5 hours after the initial request. Interview with Certified Nursing Assistant (CNA) #2 on 7/31/19 at 7:20 AM, in the conference room, confirmed Resident #87 complained of pain at 12:00 AM on 7/30/19. Continued interview revealed CNA #2 reported the pain and the request for a .pain pill . to Charge Nurse #1. Further interview revealed Charge Nurse #1 instructed CNA #2 the pain medication was not due to be administered. Further interview revealed Charge Nurse #1 entered Resident #87's room and instructed the resident the PRN oxycodone/acetaminophen pain medication was not due at that time. Continued interview revealed Resident #87 advised CNA #2 .my legs are hurting so bad .I can't [cannot] hardly stand it .I need my pain medicine as soon as I can have it . Continued interview revealed CNA #2 applied a blanket to the resident's bilateral lower extremities, adjusted the room temperature, and offered to reposition the resident to aid in comfort. Further interview revealed the interventions to aid the resident's comfort were not successful and the resident continued to complain of pain. Continued interview revealed the resident again reported the continued pain at 3:30 AM. Further interview revealed CNA #2 reported Resident #87's pain and request for pain medication to Charge Nurse #1. Observation and interview with Resident #87 on 7/31/19 at 7:25 AM, in the resident's room, revealed the resident received pain medication .last night . and the resident was free from pain. Interview with the Director of Nursing (DON) and Unit Supervisor #1 on 7/31/19 at 11:15 AM, in the DON's office, confirmed the resident was not administered the PRN pain medication when first requested by the resident at 9:00 PM on 7/29/19 or at 12:00 AM when the resident continued to complain of unrelieved pain. Further interview confirmed the facility failed to implement an effective pain management program for Resident #87 resulting in severe, unrelieved pain for 6.5 hours and actual HARM to Resident #87.