**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, facility investigation review, and interview, the facility failed to protect the resident's right to be free from neglect for 1 of 22 (Resident #319) sampled residents reviewed for abuse. The facility's failure to provide the necessary structure and processes to meet the care needs of Resident #319 resulted in actual HARM when Resident #319 fell from the bed and sustained a left hip fracture. Staff failed to provide 2-person assistance during incontinent care, for a cognitively impaired resident with contractures (a permanent tightening of muscle, tendons, skin, and surrounding tissue that causes the joints to shorten and stiffen) and hemiparesis (paralysis and partial weakness of one side of the body). Staff failed to ensure Resident #319 was monitored for adverse outcomes related to the witnessed fall. Resident #319 remained in the facility with a major injury for 1 day before receiving treatment. On [DATE], Resident #319 was sent out to the Emergency Department (ED) for evaluation of neurological symptoms and the facility failed to report information related to the fall that occurred on [DATE] to the receiving facility and ensure safe transition of care. The facility also failed to ensure 2 of 22 (Resident #56 and Resident #81) residents reviewed for abuse were free from verbal abuse when Certified Nursing Assistant (CNA) #11 made verbal threats and derogatory statements to them on [DATE]. The failure of the facility to prevent resident abuse resulted in psychosocial HARM for Resident #56 and Resident #81. The findings include: Review of the facility's policy titled, .Fall Management, revised 7/2017 revealed, .The facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs, as appropriate, to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risk. A care plan is developed and implemented, based on this evaluation, with ongoing review .Care Plan updated as appropriate .Fall Event .When a fall occurs, the resident is assessed for injuries by the nurse .Complete an Incident/Accident Report .Complete .Progress Note .Add the fall event to 24-Hour Report .Initiate the Interdisciplinary Post-Fall Review .communicates resident falls to the attending physician .will discuss recommended interventions to reduce the potential for falls for the resident .IDT reviews all falls within 24-72 hours .IDT designee will discuss recommended significant changes .care plan will be reviewed and/or revised as indicated . Review of the policy titled, MDS [MDS Assessment] revised 12/2020 revealed, .The Purpose of the Assessment .Is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity, as well as medical, cognitive, and emotional needs .The information derived from the MDS assessment is then used to assist the staff to care plan for the resident, so the resident may achieve/maintain their highest level of daily function . Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, with revision date 4/2021, revealed, .Residents have the right to be free from abuse, neglect .Protect residents from abuse, neglect .by anyone including, but not necessarily limited to .facility staff .staff from other agencies .Develop and implement policies and protocols to prevent and identify .abuse or mistreatment of residents .neglect of residents .Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems .Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting or abuse, stress management, and handling verbally or physically aggressive resident behavior .Identify and investigate all possible incidents of abuse, mistreatment .Investigate and report any allegations within timeframes required by federal requirements .Protect residents from any further harm during investigations . Review of the CMS RAI Version 3.0 Manual dated 10/2018 revealed, . Section G0110: Activities of Daily Living Assistance dated 10/2018 revealed, .How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of Toileting . Review of the medical record revealed Resident #319 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Other Sequelae of Cerebral Infarction (late effects of stroke), Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Speech and Language Deficits following Cerebrovascular Disease and Seizures. Review of the care plan for Resident #319 revealed, XXX[DATE] .at risk for falls r/t [related/to] stroke XXX[DATE] .on an platelet inhibitor XXX[DATE] .communicate best with yes/no questions post-stroke XXX[DATE] .chronic pain r/t Chronic Physical Disability XXX[DATE] .contractures XXX[DATE] .require assist with activities of daily living XXX[DATE] air mattress monitor placement and function XXX[DATE] Patient to wear LLE [Lower Left Extremity] knee extension [device to allow extension of lower extremity] daily as tolerated XXX[DATE] .Bed Mobility .Total Assist x [times] 2 Staff XXX[DATE] .Toilet Use .Total Dependence x 1 Staff XXX[DATE] Transfers .Totally Dependent x 2 Staff (Mechanical Lift) XXX[DATE] Remove air mattress . Continued review revealed there was no focus or interventions for Seizure diagnosis and no focus or interventions for risks associated with behaviors of jerking motions or spasms during care.There were no safety interventions for the air mattress included in the care plan. Review of Resident #319's Order Summary revealed, XXX[DATE] .Air Mattress-Monitor QShift [every shift] for Placement and Function XXX[DATE] .levETIRActam [anticonvulsant medication] Tablet 500 MG [milligram] two times a day for seizures . Review of the Quarterly MDS assessment dated [DATE] revealed Resident #319 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Resident #319 required extensive assistance with two persons physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture and hygiene), total dependence with two persons physical assist for transfer (how resident moves between surfaces including to or from the bed, chair, wheelchair, or standing position (excludes to/from bath/toilet), total dependence with one-person physical assist for toilet use (how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes) and required extensive assistance with two person physical assist for personal hygiene (how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers). Continued review revealed Resident #319 was always incontinent of bowel and bladder. Resident #319 had active diagnoses which included Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke, Hemiplegia or Hemiparesis, Seizure Disorder or Epilepsy, Muscle Weakness, and Other Lack of Coordination. Resident #319 had a pressure reducing device to the bed. Review of the facility document (event/incident report) titled, Fall: Witnessed, dated [DATE] at 10:18 AM, revealed, .Incident Description: Resident was lying on side receiving patient care per CNA .to remove fecal matter .Resident grunted and moved his body like he was in pain and forcefully projected himself off of bed. Lower body was tense and appeared to be spasming .Level of Pain .5 .Mental Status .Lack of Safety Awareness .Predisposing Physiological Factors .Cognitive Impairment .Extremity Weakness-Upper .Communication Deficit .Extremity Weakness-Lower .Incontinent .Predisposing Situation Factors .History of Falls .Side Rails Up .No Witnesses found . Resident 319's fall was witnessed by the roommate and CNA#6. Review of the nursing progress notes for Resident #319 dated [DATE] through [DATE], revealed no documentation of monitoring/assessment for changes related to Resident #319's witnessed fall on [DATE] at 10:18 AM. Review of the facility eINTERACT [facility documentation tool] Transfer Form , dated [DATE] at 4:47 PM, revealed Resident #319 was sent to Hospital #2 for numbness on left side of head. Resident Representative and Medical Director (MD) were notified. Director of Nursing [Former DON #1] completed the transfer form and Licensed Practical Nurse [LPN] #36 called report to Hospital #2 at 4:34 PM. There was no documentation related to Resident #319's fall on [DATE] on the transfer form. Review of Hospital #2's Emergency Department [ED]records for Resident #319 dated [DATE] revealed, .CHIEF COMPLAINT .came by ems [Emergency Medical Service] from snf [Skilled Nursing Facility] #1 for numbness on the top of his head for 3 days .possible stroke .HISTORY OF PRESENT ILLNESS .He states that yesterday, he was pushed off of his bed by a CNA. He hurt his left hip, low back, and hit his head .XR[Xray] Hip 2 or 3 Views Left with Pelvis .IMPRESSION: Comminuted [bone broken into more than two pieces] fracture LEFT femoral neck extending to the lesser trochanter [left hip fracture] .Impressions the patient has a left femoral neck fracture from his fall . Review of the employee record for CNA #6 revealed no documented training for Activities of Daily Living (ADL) Care (DON #1 stated CNA #6 received training on ADLs with return demonstration). Review of the facility investigation statement dated [DATE], revealed, .Interview with [Resident #319]: Admin [Administration] and Social Services Director (SSD) #1 asked [Resident #319] to recall the incident he had spoken to [Named Family Member FM #14] about .[Resident #319] was asked to show how this incident occurred .SSD #1 turned her back to [Resident #319] and he placed both of his hands in a cupping motion underneath SSD #1's armpits and made a pushing motion away from [Resident #319]'s body . Review of the facility investigation statement dated [DATE], revealed, .Interview with [Resident #47] dated [DATE] .Admin and Social Services spoke to [Resident #47] concerning the incident. [Resident #47] said that he had witnessed his roommate fall to the floor with the staff member. He relayed that no pushing happened and that the lady [CNA#6] was changing him and he fell . Review of facility investigation statement dated [DATE] revealed, .[CNA #6] was asked by Admin and Social Services to recall the incident from yesterday [[DATE]]. She stated that she was performing patient care to [Named Resident #319]. She said that [Resident #319] was lying horizontal on his side on the bed when she was attempting to wipe [Resident #319]. She stated that [Resident #319] had jumped a little bit, enough to cause [Resident #319]'s legs to swing out of the bed. Review of the progress notes for Resident #319 dated [DATE] at 4:47 PM revealed, Registered Nurse (RN) #6 documented, .pt [patient] sent out due to family request. pt c/o [complained of] numbness on left side of head . During an interview on [DATE] at 3:35 PM, the Former DON #1 stated she went to Resident #319's room and completed a head-to-toe assessment when notified about the fall on [DATE]. (During interview with LPN #4 and CNA #6, they both denied the Former DON #1 was present in the room after Resident #319's fall.) The Former DON #1 stated, .When I entered the room, [Resident #319] was in a sitting position or maybe propped up against something .[Resident #319] rated his pain 5 of 10 to his left knee .[Resident #319] told me to just put him back in bed . The Former DON was asked if Resident #319 was provided an intervention for pain rated 5 of 10. The Former DON #1 replied, .[Resident #319] refused pain medication for pain in his knee and just wanted to be put back in bed . the Former DON #1 stated CNA #6 and LPN #4 were in the room and used a mechanical lift to place Resident #319 back in the bed. (During interview, LPN #4 and CNA #6 denied the use of a mechanical lift.) The Former DON #1 stated CNA #6 was performing incontinence care when Resident #319 slid off the bed. The Former DON was asked which way CNA #6 had Resident #319 turned for incontinence. The Former DON #1 replied, [Resident #319] was turned away from [CNA #6] and when [Resident #319] started to fall, I guess [CNA #6] came around to catch him. The Former DON #1 stated the CNAs are able to look at the Kardex for information involving residents' care plans. DON #1 was asked if nursing documented Resident 319's continuing assessment for changes post fall in the progress notes for Resident #319. She responded No, I am not sure what the policy is for follow up charting. During an interview on [DATE] at 10:17 AM, CNA #16 stated Resident #319 was incontinent and required a 2 person assist with a lift for transfers. CNA #16 stated, [Resident #319] would push back against you when he was rolled over and that's why I always used 2 people for his care, because it was safer. During an interview on [DATE] at 2:00 PM, the Rehab Director was asked what was included in assessment for bed mobility. He responded bed mobility included side to side, and sit to supine. The Rehab Director stated when a patient/resident is coded for 2-person assist for bed mobility, it would require a 2-person assist for incontinence care provided in bed. During a telephone interview on [DATE] at 9:05 AM, LPN #4 stated she was Resident #319's nurse on [DATE]. LPN #4 stated, .I was notified by [CNA #6] that [Resident #319] had fallen off the bed .the tech [CNA #6] stated [Resident #319] was turned on his side .His body tensed up and he threw his body onto the floor .This is not the first time he had the jerking movements during care .[Resident #319] said I don't know why I do this .LPN #4 stated, When I walked in the room, he was lying on the floor .It took several of us to get him up . LPN #4 was asked if she assessed Resident #319 on the floor. She responded, He had on a gown. I did not see any deformities. I tried to do what I could of a head-to-toe assessment while he was on the floor. When asked if a lift was used to put Resident #319 back in bed, LPN #4 replied, No. Three of us picked him up and placed him back in bed. LPN #4 stated DON #1 did not come to the room after the fall and complete an assessment. LPN #4 was asked ; have you received training to provide care of a patient on an air mattress. LPN #4 replied, No. LPN #4 was asked did Resident #319 require seizure precautions. LPN#4 responded, I don't think so. LPN #4 was asked if Resident #319 was care planned for jerking movements . LPN #4 replied, Yes, keep bed in lowest position. No interventions in place for jerking behaviors on current care plan. LPN #4 stated CNA #6 should have requested help when [Resident #319] clinched up (became stiff). LPN #4 was asked if there had been 2 CNAs providing incontinence care for Resident #319, would that have prevented the fall . LPN #4 replied, Yes. During a telephone interview on [DATE] at 11:02 AM, CNA #6 stated, .I was giving patient care and [Resident #319] was turned away from me .He jumped when I was cleaning his bottom .He has jumped before related to pain . CNA #6 stated, .I reached back to get some cream with one hand and kept the other hand on [Resident #319] and that's when he fell .[Resident #319] stiffened up and threw his legs off the bed .I jumped across the bed and grabbed him under his arms .[Resident #319] had jerking movements during care, that wasn't unusual. CNA #6 was asked if another CNA [2-person assist] had been present while performing incontinence care on Resident #319, would that have prevented Resident #319 from falling . CNA #6 replied, Yes, two people could have stopped him from falling .His care plan said 1 person assist . CNA #6 was asked if she was one of the 3 people that picked Resident #319 up from the floor ? CNA #6 responded, Yes, we did pick him up and he was groaning from pain. Further interview revealed CNA#6 received no training on ADL care of residents on an air mattress at SNF #1. During an interview on [DATE] at 11:16 AM, FM #14 stated, .[Resident #319] is paralyzed on the left side. FM #14 was asked if she had Resident #319 sent out to the hospital for symptoms of a stroke . FM #14 responded, .No, when I walked in that room, he started crying .He was in so much pain .I asked them then, are y'all going to send him out for Xray .The nurse said he doesn't have any broken bones .That's when I demanded [Resident #319] to be sent to the emergency room [ER] .He had not had another stroke; he had a broken hip .I talked to his roommate [Resident #47], he was in his right mind .[Named Resident #47] said [Resident #319] hit the floor .[SNF #1] said he never hit the floor . During a telephone interview on [DATE] at 4:15 PM, the SSD #1 stated, .During an interview on [DATE], I asked [Named Resident #319] to demonstrate how the CNA lowered him to the floor .I backed up to the bed and [Resident #319] extended his arms and reached under my arms like he was catching me . During an interview on [DATE] at 12:45 PM, the Former DON #1 stated the Interdisciplinary Team (IDT) investigated Resident #319's fall on [DATE] and determined the air mattress on his bed had contributed to him sliding off the bed due to him moving around and an air mattress being slick. The Former DON #1 stated residents on an air mattress should have a care plan with interventions in place. When asked what type of interventions would need to be implemented, Former DON #1 replied, .check placement and functioning, and do not use fitted sheets . When asked what is meant by placement and functioning of an air mattress, Former DON #1 replied, Placement is making sure the resident actually has the air mattress, the resident could have moved rooms and the mattress did not follow .Functioning means is the air mattress turned on, is it inflated. When asked if sheets should be used on an air mattress, the Former DON #1 replied, No, fitted sheets would prevent the mattress from properly inflating and could possibly turn off the CPR [Cardiopulmonary Resuscitation] function [This allows for a proper hard surface needed in which to initiate chest compressions and intubation]. The Former DON #1 stated she could not think of any safety interventions that would need to be implemented for use of an air mattress. Continued interview revealed the Former DON #1 stated she was not aware of Resident #319 having a diagnosis for seizures. The Former DON #1 stated she would expect his care plan to reflect a diagnosis for seizures with interventions implemented. DON #1 was unable to provide documentation related to a root cause analysis and investigation related to Resident #319's [DATE] fall. The Former DON #1 reviewed the transfer form dated [DATE] for Resident #319 and stated.The fall was not documented on the transfer form because [Resident #319] was not sent out for symptoms related to the fall . When asked if the information related to the fall on [DATE] was relevant information due to Resident #319 being transferred to the ER for symptoms of numbness of the scalp. The Former DON #1 replied, No. During an interview on [DATE] at 10:40 AM, the MDS Coordinator was asked to review Resident #319's quarterly assessment dated [DATE]. The MDS Coordinator was asked how she determined Resident #319 required extensive assistance of 2 persons for bed mobility, total dependence for toileting one person assist, and extensive assist of 2 persons for personal hygiene. The MDS Coordinator stated, .I would review the staffing documentation and make visual observations. If I code a resident as total assistance, then the CNA documentation must say the resident required total assistance all the time during the 7 day look back period . The MDS Coordinator was asked how Resident #319 could require 2 person assist for personal hygiene and only require 1 person assist for toileting. The MDS Coordinator stated, .I am not the CNA that cared for him so I can't tell you that . The MDS Coordinator was asked if the CNA documentation was always correct. The MDS Coordinator stated, No. During an interview on [DATE] at 2:50 PM, The MDS Coordinator was asked if seizures were checked on Resident #319's Care Area Assessment (CAA) and Resident #319 was on seizure medication twice a day, should Resident #319 have been care planned for seizures. The MDS Coordinator responded, .Seizures should have been care planned since he was on seizure medication . The MDS Coordinator was then asked if a resident was on an air mattress, should safety measures be care planned. The MDS Coordinator stated, .I don't usually put safety measures in for an air mattress . During a telephone interview on [DATE] at 3:34 PM, LPN #36 stated he was the Unit Manager for 3rd floor on [DATE]. LPN #36 was unable to recall sending Resident #319 to the ER on [DATE] and stated, .I always assisted the nurse during a transfer by calling report to the receiving facility .I used the Interact transfer form as a guide when calling report, and sent a copy of the form with the resident to the ER . The surveyor asked LPN #36 if information related to a fall the previous day would be included in the report to the receiving facility . LPN #36 replied, Yes. LPN #36 stated if he had known about Resident #319's fall on [DATE], he would have included it on the transfer form and in the call for report. LPN #36 stated if the information about the fall was not noted on the transfer form for Resident #319, then he was unaware of the fall. During an interview on [DATE] at 12:13 PM, Nurse Practitioner (NP) #3 stated she had no record that she or any other of the NP's at the facility had assessed Resident #319 after the fall on [DATE] . The facility failed to provide 2 person assistance during incontinence care that resulted Resident 319's fall with hip fracture. The facility failed to perform a thorough assessment after the fall, that led to Resident 319's delay of treatment until the following day. The facility failed to notify the receiving facility of Resident 319's fall with injury. ________________________________ Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cerebral Infarction, Hemiplegia, Osteomyelitis, and Type 2 Diabetes Mellitus. Review of the comprehensive care plan dated [DATE] Resident #56 revealed, .Focus Resident requires assist with activities of daily living .Interventions/Tasks .Roll left and right .Substantial/maximal assistance X 1 staff .Shower/Bathe self .Substantial/maximal assistance x 1 staff .Toileting hygiene .Substantial/maximal assistance required x 1 staff .Focus Mood/Behavior: I'm at risk of a change in my mood and behavior due to my diagnosis of MDD [Major Depressive Disorder] and anxiety disorder .Goal My behavior will not cause distress to myself and others .Interventions/Tasks .Encourage me to voice my feelings, fears, and concerns .Observe me for changes in my mood that may put me at risk for behaviors to occur .Provide me supportive listening and communication . Review of the Psychological Diagnostic Interview for Resident #56 dated [DATE] revealed, .[Named Resident #56] is being seen today for follow-up regarding any emotional needs since he reportedly observed verbal abuse of his roommate from a CNA, who is no longer in the facility .He was able to describe the events that occurred recently . Review of the Quarterly MDS dated [DATE] revealed Resident #56 had a BIMS score of 15, which indicated no cognitive impairment. Continued review of the MDS revealed Resident #56 was dependent for toileting, personal hygiene, and bathing which required extensive assistance of one person. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses which included Encounter for Orthopedic Aftercare following surgical amputation, Type 2 Diabetes Mellitus, and Congestive Heart Failure (CHF). Review of the Psychological Diagnostic Interview for Resident #81 dated [DATE] revealed, .[Resident #81] related events related to the abuse, saying that he didn't sleep the night of the event, saying he was fearful for his safety . Review of the comprehensive care plan dated [DATE] Resident #81 revealed, .Focus Abuse/Neglect: I'm at risk for actual/potential abuse/neglect related to my dependence on others for ADL care .Goal I will not experience any form of abuse or neglect through review date .Interventions/Tasks Provide assistance with ADL's as needed .Provide support and ensure resident is free from abuse and/or neglect . Review of the Quarterly MDS assessment dated [DATE] revealed Resident #81 had a BIMS score of 15, which indicated no cognitive impairment. Continued review of the MDS revealed Resident #81 was dependent for toileting, supervision related to personal hygiene, and substantial/maximum assistance with rolling left and right, sit to lying, and lying to sitting on side of bed. Review of the facility investigation dated [DATE] revealed, .Date/Time/Name of when staff became aware of this incident XXX[DATE] at 2:15 PM .Date/Time administrator was notified of the incident XXX[DATE] 2:35 PM .Date and time when the alleged incident occurred [DATE] 11:00 PM .[Named Resident #81] (BIM Brief Interview for Mental Status - 15) reported to the Unit Manager that he had a confrontation with his night shift [7:00 PM-7:00 AM [DATE]] CNA. Resident reported that the confrontation had arisen during a periodic check around midnight by the alleged perpetrator. Resident stated that he was upset with the frequency in which the same [CNA ] had made rounds to check on him. Resident stated that the CNA was very argumentative and made a threatening remark when exiting the room. Resident has displayed no signs of psychosocial distress or harm .Residents roommate [Named Resident #56 BIM-15] corroborated [Named Resident #81 BIM - 15] allegation against CNA when questioned by administration .Administrator conducted a phone interview with the alleged perpetrator, [Named CNA #11], on [DATE] regarding the alleged incident. [Named CNA #11] stated that she mistakenly had thought that the Resident was independent with ADLs. [Named CNA #11] stated that when she checked on [Named Resident #81] around midnight he became very upset. [Named CNA #11] states [Named Resident #81] started cursing her out so she exited the room. [Named CNA #11] denied making any threatening statement to the Resident during the interaction . Continued review of the facility investigation revealed a written statement completed by Unit Manager [LPN #19] which stated, .Tech [CNA #11] came @ [at] 11[11:00 PM] - told them they were independent, told [Named Resident #81] she was brand new, he told her she still had to check them. She said 'you don't tell me what to do' 'I'll kick your ass, slamed [slammed] the bathroom door he sadi [said] '[expletive] you try it' She said '[expletive] you mother [expletive]', you can suck my ass' after confrontation She never came back 12 pm-7 am .She called [Resident #56] a'mfer' [expletive] . Review of the facility investigation revealed the allegation of abuse occurred on [DATE] around 11:00 PM - 12:00 AM [midnight] and was not reported to the Administrator until [DATE] at 2:35 PM. Review of CNA #11's employee clock in and clock out for [DATE] revealed the employee clocked in at 7:04 PM on [DATE] and clocked out at 7:03 AM on [DATE]. The allegation of abuse reported by Resident #81 revealed the interaction with the employee occurred around 11:00 PM - 12:00 AM on [DATE]. The employee clock in and clock out revealed CNA #11 worked the remainder of the shift past the time of the allegation of the verbal abuse. Review of Police Department #1's Incident Report dated [DATE] revealed, Dispatched .Report Date [DATE] .Victim [Named Resident #81] .Victim to Suspect Number 1 [Named CNA #11] .Complainant .[Named Administrator] .Narrative .[Named SNF #1] administrator .reported the following incident at the facility. [Resident #81] stated that on [DATE] at approximately 11:00pm [PM] he got into an argument with employee [CNA #11] employed at the facility. During the argument [Named CNA #11] allegedly said to [Named Resident #81] 'I'll kick your ass' . During an interview on [DATE] at 11:34 AM , Former DON #1 and Administrator confirmed they were notified of the allegation of verbal abuse on [DATE]. The Former DON #1 stated, .The written statement in the investigation was the Unit Manager's [LPN #19] statement of what [Named Resident #81] reported . The Administrator was asked if Resident #81's roommate (Resident #56) or any other employees that worked that shift were interviewed . The Administrator replied, If I had interviewed the roommate, it would be in the investigation. I didn't ask anyone else because they were not in ear shot, I would have thought the roommate would have been interviewed. I think the roommate was interviewed by the SSD. When I called [Named CNA #11] she had an attitude with me. I just had what [Named Resident #81] reported and it was conflicted with what [Named CNA #11] said happened. I was not aware [Named Resident #81] said he didn't sleep the night of the event and was fearful for his safety. The supervisor [LPN #26] for [DATE] denied knowing anything about it . During an interview on [DATE] at 12:20 PM, Resident #81 stated, . [Named CNA #11] threatened us, slammed the door, [Named CNA #2] another tech took care of me and my roommate the rest of the night. [Named CNA #11] never came in our room to check on us until 11:00 PM that night [[DATE]]. When [named CNA #11] came in the room I said 'are you not supposed to check on us every 2 hours.' The CNA told me to shut up and threatened to kick my ass. I did tell her [expletive] you and then [Named CNA #11] said suck my ass, no one wants to take care of you, she slammed the door so hard the clock almost fell off the wall. I told the supervisor that night, I can't remember the supervisor's name, but the [CNA #11] wasn't sent home. I saw [CNA #11] in the hallway about 12:00 AM and 1:00 AM . The night nurse was an agency nurse, she knew about what happened. I stayed up all night because I was scared, and my roommate was scared. I never seen anybody get that angry, they should have sent her home. I am pretty sure she worked all night. The supervisor on night shift didn't [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, review of the facility incident report, facility investigation, review of Hospital #2's Emergency Department (ED) records, medical record review, and interview, the facility failed to ensure a person-centered care plan was developed and implemented for 1 of 11 (Resident #319) sampled residents reviewed using an air mattress. The facility's failure to develop and implement a person-centered care plan for Resident #319 resulted in actual harm when he fell from the bed during incontinence care and sustained a left hip fracture. The findings include: Review of the policy titled, MDS [Minimum Data Set] Assessment revised 12/2020 revealed .The Purpose of the Assessment .Is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity, as well as medical, cognitive, and emotional needs .The information derived from the MDS assessment is then used to assist the staff to care plan for the resident, so the resident may achieve/maintain their highest level of daily function . The facility was unable to provide the facility policy titled Care Plans, Comprehensive Person-Centered dated 2022 . Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated [DATE], revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Review of the CMS RAI Version 3.0 Manual dated 10/2018 revealed, .Section G0110: Activities of Daily Living (ADL) Assistance .How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of Toileting . Review of the medical record revealed Resident #319 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Other Sequelae of Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Speech and Language Deficits following Cerebrovascular Disease and Other Seizures. Review of an Order Summary revealed, XXX[DATE] .Air Mattress-Monitor QShift [every shift] for Placement and Function XXX[DATE] .levETIRActam [anticonvulsant medication] Tablet 500 MG [milligram] two times a day for seizures . Review of the Annual MDS dated [DATE] revealed Resident #319 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Resident #319 required extensive assistance with two persons physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture and hygiene), total dependence with two persons physical assist for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). Resident #319 was coded always incontinent of bowel and bladder. Resident #319 had active diagnoses which included Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke, Hemiplegia or Hemiparesis, Seizure Disorder or Epilepsy, Muscle Weakness, Other Lack of Coordination. Resident #319 had a pressure reducing device to the bed. Review of the care plan for Resident #319 revealed, XXX[DATE] .require assist with activities of daily living XXX[DATE] .at risk for falls r/t [related to] stroke XXX[DATE] .communicate best with yes/no questions post-stroke XXX[DATE] .chronic pain r/t Chronic Physical Disability XXX[DATE] .on an platelet inhibitor XXX[DATE] .contractures XXX[DATE] Patient to wear LLE [Left Lower Extremity] knee extension daily as tolerated XXX[DATE] air mattress monitor placement and function [no safety interventions implemented] XXX[DATE] .Bed Mobility .Total Assist x [times] 2 Staff .Transfers .Totally Dependent x 2 Staff (Mechanical Lift) XXX[DATE] Remove air mattress . Continued review revealed there was no focus or interventions for the Seizure diagnosis and no focus or interventions for risks associated with behaviors of jerking motions or spasms during care. Review of the Quarterly MDS dated [DATE] revealed Resident #319 had an unchanged BIMS score of 3, which indicated severe cognitive impairment. Resident #319 required extensive assistance with two persons physical assist for bed mobility, total dependence with two persons physical assist for transfer. Resident #319 was coded always incontinent of bowel and bladder. Review of the facility document (event/incident report) titled, Fall: Witnessed, dated [DATE] at 10:18 AM revealed, .Incident Description: Resident was lying on side receiving patient care per Certified Nursing Assistant [CNA] .to remove fecal matter .Resident grunted and moved his body like he was in pain and forcefully projected himself off of bed. Lower body was tense and appeared to be spasming .did not hit his head and denies pain anywhere other than his left knee .No injuries observed at time of incident .Level of Pain .5 .Mental Status .Lack of Safety Awareness .Predisposing Physiological Factors .Cognitive Impairment .Extremity Weakness-Upper .Communication Deficit .Extremity Weakness-Lower .Incontinent .Predisposing Situation Factors .History of Falls .Side Rails Up .No Witnesses found . The facility event incident report incorrectly stated no witnesses were found. There were two witnesses to the fall, CNA#6 and Resident 319's roommate witnessed the fall. Review of Hospital #2's ED Records for Resident #319 dated [DATE] , revealed, .CHIEF COMPLAINT .came by ems [Emergency Medical Service] from snf [Skilled Nursing Facility #1] for numbness on the top of his head for 3 days .possible stroke .HISTORY OF PRESENT ILLNESS .He states that yesterday, he was pushed off of his bed by a CNA. He hurt his left hip, low back, and hit his head .XR [Xray] Hip 2 or 3 Views Left with Pelvis .IMPRESSION: Comminuted [bone broken into more than two pieces] fracture LEFT femoral neck extending to the lesser trochanter [left hip fracture] .Impressions: the patient has a left femoral neck fracture from his fall . Review of a facility investigation statement dated [DATE] revealed, .Interview with Resident #47 dated [DATE], revealed, Admin [Administration] and Social Services spoke to [Resident #47] concerning the incident. [Resident #47] said that he had witnessed his roommate fall to the floor. Resident #47 stated, .the lady [CNA#6] was changing him, and he fell . Review of a facility investigation statement dated [DATE] revealed, . [CNA #6] was asked by Admin [Administration] and Social Services to recall the incident from yesterday [[DATE]]. She stated that she was performing patient care to [Resident #319]. She said that [Resident #319] was lying horizontal on his side on the air mattress when she was attempting to wipe [bowel incontinent care]. She stated that [Resident #319] had 'jumped a little bit', enough to cause [Resident #319]'s 'legs to swing out of the bed'. During an interview on [DATE] at 3:35 PM, Former Director of Nursing (DON) #1 stated she went to Resident #319's room and completed a head-to-toe assessment when notified about the fall on [DATE]. Former DON #1 stated CNA #6 was performing incontinence care after Resident #319 had an incontinent episode, when Resident #319 slid off the bed. When asked which way CNA #6 had Resident #319 turned for incontinent care, Former DON #1 replied, [Resident #319] was turned away from [CNA #6] and when [Resident #319] started to fall, I guess [CNA #6] came around to catch him. During an interview on [DATE] at 10:17 AM, CNA #16 stated Resident #319 was incontinent and required a 2 person assist with a lift for transfers. CNA #16 stated, [Resident #319] would push back against you when he was rolled over and that's why I always used 2 people for his care, because it was safer. During an interview on [DATE] at 11:13 AM, the Occupational Therapist (OT) stated Resident #319 was on and off therapy from 2019 through 2022 and fluctuated frequently with his care. When asked about bed mobility, the OT stated this would include supine [lying face upward] to sit, which would require 2 persons assist During an interview on [DATE] at 2:00 PM, the Rehab Director was asked what was included in an assessment for bed mobility . He responded bed mobility included side to side, and sit to supine. The Rehab Director stated when a patient/resident is coded for 2-person assist for bed mobility, it would require a 2-person assist for incontinence care provided in bed. During a telephone interview on [DATE] at 9:05 AM, Licensed Practical Nurse (LPN ) #4 stated she was Resident #319's nurse on [DATE]. LPN #4 stated, .I was notified by [CNA #6] that [Resident #319] had fallen off the bed .the tech (CNA #6) stated [Resident #319] was turned on his side .His body tensed up and he threw his body onto the floor .This is not the first time he had the jerking movements during care .LPN #4 stated, When I walked in the room, he was lying on the floor .It took several of us to get him up . LPN #4 was asked, did you assess [Resident #319] on the floor. She responded, He had on a gown. I did not see any deformities. I tried to do what I could of a head-to-toe assessment while he was on the floor. When asked if a lift was used to put Resident #319 back in bed, LPN #4 replied, No, three of us picked him up and placed him back in bed. LPN #4 stated, The [Former DON #1] did not come to the room after the fall and complete an assessment. LPN #4 was asked if she had been trained on providing patient care for a patient on an air mattress. LPN #4 replied, No. LPN #4 was asked if Resident #319 required seizure precautions. She responded, I don't think so. LPN #4 was asked if Resident #319 was care planned for jerking movements. LPN #4 replied, Yes, keep bed in lowest position. LPN #4 further stated, [CNA #6] should have requested help when [Resident #319] clinched [stiffened] up. LPN #4 was asked if there had been 2 CNAs providing incontinence care for Resident #319, would that have prevented the fall. LPN #4 replied, Yes. There were no interventions in place for jerking behaviors on the current care plan. A mechanical lift was not used to transfer Resident #319 from the floor to the bed. During a telephone interview on [DATE] at 11:02 AM, CNA #6 stated, .I was giving patient care and [Resident #319] was turned away from me .He jumped when I was cleaning his bottom .He has jumped before related to pain . CNA #6 stated, .I reached back to get some cream with one hand and kept the other hand on [Resident #319] and that's when he fell .[Resident #319] stiffened up and threw his legs off the bed .I jumped across the bed and grabbed him .[Resident #319] had jerking movements during care, that wasn't unusual. CNA #6 was asked if there had been another CNA with her while performing incontinence care on Resident #319, would that have prevented Resident #319 from falling out of the bed. CNA #6 replied, Yes, two people could have stopped him from falling .His care plan said 1 person assist . CNA #6 was asked if she was one of the 3 people that picked Resident #319 up off the floor. CNA #6 responded, Yes, we did pick him up and he was groaning from pain. During an interview on [DATE] at 12:45 PM, Former DON #1 stated the Interdisciplinary Team (IDT) investigated Resident #319's fall on [DATE] and determined the air mattress on his bed had contributed to him sliding off the bed due to him moving around and an air mattress being slick. Former DON #1 stated residents on an air mattress should have a care plan with interventions in place. When asked what type of interventions would need to be implemented, Former DON #1 replied, .check placement and functioning, and do not use fitted sheets . When asked what is meant by placement and functioning of an air mattress, the Former DON #1 replied, Placement is making sure the resident actually has the air mattress, the resident could have moved rooms and the mattress did not follow .Functioning means is the air mattress turned on, is it inflated. When asked if sheets should be used on an air mattress, the Former DON #1 replied, No, fitted sheets would prevent the mattress from properly inflating and could possibly turn off the CPR [Cardiopulmonary Resuscitation] function [This function allows for an instant deflation providing a hard surface needed for chest compressions and intubation]. Former DON #1 stated she could not think of any safety interventions that would need to be implemented for use of an air mattress. The Former DON #1 was asked if [Resident #319] had seizure precautions in place. Former DON #1 stated she was not aware of Resident #319 having a diagnosis for seizures. Former DON #1 stated she would expect his care plan to reflect a diagnosis for seizures with interventions implemented. During an interview on [DATE] at 10:40 AM and [DATE] at 2:50 PM, the MDS Coordinator was asked to review Resident #319's quarterly assessment dated [DATE]. The MDS Coordinator was asked how she determined Resident #319 required extensive assistance of 2 persons for bed mobility, total dependence for toileting one person assist, and extensive assist of 2 persons for personal hygiene. The MDS Coordinator stated, .I would review the staffing documentation and make visual observations. If I code a resident as total assistance, then the CNA documentation must say the resident required total assistance all the time during the 7 day look back period . The MDS Coordinator was asked how Resident #319 could require 2 person assist for personal hygiene and only require 1 person assist for toileting. The MDS Coordinator stated, .I am not the CNA that cared for him so I can't tell you that . The MDS Coordinator was asked if the CNA documentation was always correct. The MDS Coordinator stated, No. The MDS Coordinator was asked if seizures were checked on Resident #319's Care Area Assessment (CAA) and Resident #319 was on seizure medication twice a day, should Resident #319 have been care planned for seizures. The MDS Coordinator responded, .Seizures should have been care planned since he was on seizure medication . The MDS Coordinator was then asked if a resident was on an air mattress, should safety measures be care planned. The MDS Coordinator stated, .I don't usually put safety measures in for an air mattress . The facility failed to implement the plan of care (2 person assistance for bed mobility/incontinent care) that resulted in Resident #319's fall out of the bed and sustained a hip fracture. The facility failed to establish interventions for the Seizure diagnosis or for risks associated with behaviors of jerking motions or spasms during care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, facility eINTERACT Transfer Form review, medical record review, facility investigation review, and interview, the facility failed to provide an environment that is free from accident hazards over which the facility has control and provide supervision for 1 of 11 (Resident #319) sampled residents reviewed for assistance with Activities of Daily Living (ADL)s and air mattress use. The facility's failure to provide a safe environment during care resulted in actual harm when Resident #319 fell from bed and sustained a left hip fracture on [DATE] while receiving incontinence care with use of 1 person assist. The findings include: Review of the facility's policy titled, .Fall Management revised 7/2017 revealed, .The facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs, as appropriate, to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risk. A care plan is developed and implemented, based on this evaluation, with ongoing review .When a fall occurs, the resident is assessed for injuries by the nurse .Complete an Incident/Accident Report .Complete SBAR [Situation, Background, Assessment, and Recommendation] Communication Form & Progress Note .Add the fall event to 24-Hour Report .Initiate the Interdisciplinary Post-Fall Review .communicates resident falls to the attending physician .will discuss recommended interventions to reduce the potential for falls for the resident .IDT reviews all falls within 24-72 hours .IDT designee will discuss recommended significant changes .care plan will be reviewed and/or revised as indicated . Review of the CMS RAI Version 3.0 Manual dated 10/2018 revealed, .Section G0110: Activities of Daily Living (ADL) Assistance .How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of Toileting . Review of the facility's policy titled MDS [Minimum Data Set] Assessment, revised 12/2020 revealed, .The Purpose of the Assessment .Is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity, as well as medical, cognitive, and emotional needs .The information derived from the MDS assessment is then used to assist the staff to care plan for the resident, so the resident may achieve/maintain their highest level of daily function . Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated [DATE], revealed .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Review of the facility's policy titled, Accidents Incidents Investigating, dated [DATE] revealed, .All accidents or incidents involving residents .occurring on our premises shall be investigated and reported to the administrator .b. The nature of the injury/illness .c. The circumstances surrounding the accident or incident .k. Any corrective action taken . Review of the medical record revealed Resident #319 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Other Sequelae of Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Speech and Language Deficits following Cerebrovascular Disease and Other Seizures. Review of the Physician's Orders revealed, XXX[DATE] .Air Mattress-Monitor QShift [every shift] for Placement and Function XXX[DATE] .levETIRActam [anticonvulsant medication] Tablet 500 MG [milligram] two times a day for seizures . Review of the Fall Risk Evaluation dated [DATE], revealed Resident #319 was scored high risk for falls. Review of the Quarterly MDS dated [DATE] revealed Resident #319 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Resident #319 required extensive assistance with two persons physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture and hygiene), total dependence with two persons physical assist for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). Continued review revealed Resident #319 was always incontinent of bowel and bladder. Review of Resident #319's Fall Risk Evaluation dated [DATE], revealed, Former DON #1 documented, .Reason for Assessment Request .Recent Falls .Gait Analysis .Unable to independently come to a standing position .Exhibits loss of balance while standing .Requires hands on assistance to move from place to place .Decrease in muscle coordination . Review of the care plan revealed, XXX[DATE] .at risk for falls r/t [related to] stroke XXX[DATE] .on an platelet inhibitor XXX[DATE] .communicate best with yes/no questions post-stroke XXX[DATE] .chronic pain r/t Chronic Physical Disability XXX[DATE] .contractures XXX[DATE] .require assist with activities of daily living XXX[DATE] air mattress monitor placement and function XXX[DATE] Patient to wear LLE [left lower extremity] knee extension daily as tolerated XXX[DATE] .Bed Mobility .Total Assist x [times] 2 Staff XXX[DATE] Transfers .Totally Dependent x 2 Staff (Mechanical Lift) . Continued review revealed there was no Focus/Interventions for a seizure diagnosis, no focus for risks associated with involuntary jerking motions and/or spasms during care, and no safety interventions related to use of an air mattress. Review of the facility document (event/incident report) titled, Fall: Witnessed, dated [DATE] at 10:18 AM, revealed, .Incident Description: Resident was lying on side receiving patient care per Certified Nursing Assistant (CNA) .to remove fecal matter .Resident grunted and moved his body like he was in pain and forcefully projected himself off of bed .Lower body was tense and appeared to be spasming .did not hit his head and denies pain anywhere other than his left knee .No injuries observed at time of incident .Level of Pain .5 .Mental Status .Lack of Safety Awareness .Predisposing Physiological Factors .Cognitive Impairment .Extremity Weakness-Upper .Communication Deficit .Extremity Weakness-Lower .Incontinent .Predisposing Situation Factors .History of Falls .Side Rails Up .No Witnesses found . The incident description described above was incorrect. There were two witnesses present in the room at the time of the fall. Review of the facility eINTERACT Transfer Form, dated [DATE] at 4:47 PM revealed, Resident #319 was sent to Hospital #2 for numbness on left side of head. Resident Representative (Family Member-FM #14) and Medical Director (MD) were notified. Former DON #1 completed the transfer form and Licensed Practical Nurse (LPN) #36 called report to Hospital #2 at 4:34 PM. There was no documentation on the transfer form related to Resident #319's fall on [DATE]. Review of Hospital #2's Emergency Department (ED) Records for Resident #319 dated [DATE] revealed, .CHIEF COMPLAINT .came by ems [Emergency Medical Services] from snf [Skilled Nursing Facility #1] for numbness on the top of his head for 3 days .possible stroke .HISTORY OF PRESENT ILLNESS .He states that yesterday, he was pushed off of his bed by a CNA. He hurt his left hip, low back, and hit his head .XR [Xray] Hip 2 or 3 Views Left with Pelvis .IMPRESSION: Comminuted [bone broken into more than two pieces] fracture LEFT femoral neck extending to the lesser trochanter [left hip fracture] .Impressions the patient has a left femoral neck fracture from his fall . Review of the employee record for CNA #6 revealed no documented training for Activities of Daily Living (ADL) Care. Review of a facility investigation statement dated [DATE] revealed, .Interview with [Named Resident #319]: Admin [Administrator] and Social Services asked [Resident #319] to recall the incident he had spoken to [FM-Family Member #14] about. He [Resident #319] recounted that the day prior he was sitting upright on the side of his bed when a tech came in and pushed him from behind off the side of the bed and he fell to the floor. Patient [Resident #319] could not recall why the tech was in his room but stated that he felt like it was an intentional act .[Resident #319] was asked to show how this incident occurred. Social Services [SSD #1] turned her back to [Resident #319] and [Resident #319] placed both of his hands in a cupping motion underneath Social Service's armpits and made a pushing motion away from [Resident #319]'s body . Resident #319 had a BIMS score of 3, which indicated severe cognitive impairment. Resident #319 had hemiparesis to his left extremities and his left hand was contracted. The two witnesses in the room at the time of incident, reported conflicting accounts related to the fall. The facility provided no documentation to substantiate the details provided in the above facility investigation statement. Review of a facility investigation statement dated [DATE] revealed, .Interview .Admin [Administrator] and Social Services spoke to [Named Resident #47] concerning the incident .[Resident #47] said that he had witnessed his roommate fall to the floor with the staff member .He relayed that no pushing happened and that the lady was changing him and he fell . Review of a facility investigation statement dated [DATE] revealed, .[CNA #6] was asked by Admin and Social Services to recall the incident from yesterday .She stated that she was performing patient care to [Named Resident #319] .She said that [Resident #319] was lying horizontal on his side on the bed when she was attempting to wipe [Resident #319] .She stated that [Resident #319] had jumped a little bit, enough to cause [Resident #319]'s legs to swing out of the bed. She said that she could see that [Resident #319] was going to fall off the bed so she put her arms underneath his and assisted him to the floor. During an interview on [DATE] at 4:05 PM, FM #14 (Resident #319's significant other) stated, .[Named Resident #319] can't walk or sit up .[SNF #1] called me and said [Resident #319] fell. They said the CNA caught him .I asked his roommate [Resident #47] if [Resident #319] had hit the floor and [Resident #47] said 'yes he did' .I asked [SNF #1] if [Resident #319] had any broken bones and did they do X-rays .[SNF #1] said 'no' .I went to see [Resident #319] the next day and he was crying because he was in so much pain .I called the paramedic to take him to [Hospital #2] ER .[Resident #319] had a broken hip .[Hospital #2] did surgery on his hip the next day . During an interview on [DATE] at 3:35 PM, Former DON #1 stated she went to Resident #319's room and completed a head-to-toe assessment when notified about the fall on [DATE]. Former DON #1 stated, .When I entered the room, [Resident #319] was in a sitting position or maybe propped up against something .[Resident #319] rated his pain 5 of 10 his left knee hurt but that was his bad knee. [Resident #319] told me to just put him back in bed . When asked if Resident #319 was provided an intervention for pain rated 5 of 10, Former DON #1 replied, .[Resident #319] refused pain medication for pain in his knee and just wanted to be put back in bed . Former DON #1 stated CNA #6 and LPN #4 were in the room and used a mechanical lift to place Resident #319 back in the bed. Former DON #1 stated CNA #6 was performing incontinence care after Resident #319 had an incontinent episode when Resident #319 slid off the bed. When asked which way CNA #6 had Resident #319 turned for incontinence care, Former DON #1 replied, [Resident #319] was turned away from [CNA #6] and when [Resident #319] started to fall, I guess [CNA #6] came around to catch him. Former DON #1 stated the CNAs are able to look at the [NAME] for information involving residents' care plans. Former DON #1 was asked if nursing had documented Resident #319's continuing assessment for changes post fall in the progress notes for Resident #319. She responded No. During interview with LPN #4 and CNA #6, they both denied Former DON #1 was present in the room after Resident #319's fall. LPN #4 and CNA #6 stated no lift was used to place Resident #319 back in bed. During an interview on [DATE] at 10:17 AM, CNA #16 stated Resident #319 was incontinent and required a 2 person assist with a lift for transfers. CNA #16 stated, [Named Resident #319] would push back against you when he was rolled over and that's why I always used 2 people for his care, because it was safer. During an interview on [DATE] at 2:00 PM, the Rehab Director was asked what was included in assessment for bed mobility. He responded bed mobility had a wide range which included side to side and sit to supine. The Rehab Director stated when a patient/resident is coded for 2-person assist for bed mobility, it would require a 2-person assist for incontinence care provided in bed. During a telephone interview on [DATE] at 9:05 AM, LPN #4 stated she was Resident #319's nurse on [DATE]. LPN #4 stated, .I was notified by [CNA #6] that [Named Resident #319] had fallen off the bed .the tech [CNA #6] stated [Resident #319] was turned on his side .His body tensed up and he threw his body onto the floor .This is not the first time he had the jerking movements during care .[Resident #319] said I don't know why I do this .LPN #4 stated, When I walked in the room, he was lying on the floor .It took several of us to get him up . LPN #4 was asked, did she assess Resident #319 on the floor. She responded, He had on a gown. I did not see any deformities. I tried to do what I could of a head-to-toe assessment while he was on the floor. When asked if a lift was used to put Resident #319 back in bed. LPN #4 replied, No, three of us picked him up and placed him back in bed. LPN #4 stated the DON #1 did not come to the room after the fall and complete an assessment. LPN #4 was asked if she had been trained on providing patient care on an air mattress. LPN #4 replied, No. LPN #4 was asked if Resident #319 required seizure precautions. She responded, I don't think so. LPN #4 was asked was Resident #319 care planned for jerking movements. LPN #4 replied, Yes, keep bed in lowest position. LPN #4 stated [CNA #6] should have requested help when Named Resident #319] clinched [stiffened] up. LPN #4 was asked if there had been 2 CNAs providing incontinence care for Resident #319, would that have prevented the fall. LPN #4 replied, Yes. The facility was unable to provide documentation of any assessments performed related to Resident #319's fall on [DATE]. During a telephone interview on [DATE] at 11:02 AM, CNA #6 stated, .I was giving patient care .[Named Resident #319] was turned away from me .He jumped when I was cleaning his bottom .He has jumped before related to pain .I reached back to get some cream with one hand and kept the other hand on [Resident #319] and that's when he fell .[Resident #319] stiffened up and threw his legs off the bed .I jumped across the bed and grabbed him under his arms and lowered him to the floor .[Resident #319] had jerking movements during care, that wasn't unusual. CNA #6 was asked if she had another CNA [2-person assist] with her while performing incontinence care on Resident #319, would that have prevented Resident #319 from falling out of the bed. CNA #6 replied, Yes, two people could have stopped him from falling .His care plan said 1 person assist . CNA #6 was asked if she was one of the three people that picked Resident #319 off the floor. CNA #6 responded, Yes, we did pick him up and he was groaning from pain. During an interview on [DATE] at 11:16 AM, FM #14 stated, .[Resident #319] is paralyzed on the left side. FM #14 was asked if she had Resident #319 sent out to the hospital for symptoms of a stroke. FM #14 responded, .No, When I walked in that room, he started crying .He was in so much pain .I asked them then, are y'all going to send him out for Xrays .The nurse said he doesn't have any broken bones .That's when I demanded [Resident #319] to be sent to the ER .He had not had another stroke, he had a broken hip .I talked to his roommate and [Resident #47] was in his right mind .[Resident #47] said [Resident #319] hit the floor .they [SNF #1] said he never hit the floor . During a telephone interview on [DATE] at 4:15 PM, Former SSD #1 stated, .I asked [Resident #319] to demonstrate how the CNA lowered him to the floor .I backed up to the bed and [Resident #319] extended his arms and reached under my arms like he was catching me . During an interview on [DATE] at 12:45 PM, Former DON #1 stated the Interdisciplinary Team (IDT) investigated Resident #319's fall on [DATE] and determined the air mattress on his bed had contributed to him sliding off the bed due to him moving around and an air mattress being slick. Former DON #1 stated residents on an air mattress should have a care plan with interventions in place. When asked what type of interventions would need to be implemented. Former DON #1 replied, .check placement and functioning, and do not use fitted sheets . When asked what is meant by placement and functioning of an air mattress, Former DON #1 replied, Placement is making sure the resident actually has the air mattress, the resident could have moved rooms and the mattress did not follow .Functioning means is the air mattress turned on, is it inflated. When asked if sheets should be used on an air mattress. Former DON #1 replied, No, fitted sheets would prevent the mattress from properly inflating and could possibly turn off the CPR [Cardiopulmonary Resuscitation] function [This function allows for an instant deflation providing a hard surface needed for chest compressions and intubation]. Former DON #1 stated she could not think of any safety interventions that would need to be implemented for use of an air mattress. Former DON #1 was asked if Resident #319 had seizure precautions in place. Former DON #1 stated she was not aware of Resident #319 having a diagnosis for seizures. Former DON #1 stated she would expect his care plan to reflect a diagnosis for seizures with interventions implemented. During an interview on [DATE] at 10:40 AM, the MDS Coordinator was asked to review Resident #319's quarterly assessment dated [DATE]. The MDS Coordinator was asked how she determined Resident #319 required extensive assistance of 2 persons for bed mobility, total dependence for toileting one person assist, and extensive assist of 2 persons for personal hygiene. The MDS Coordinator stated, .I would review the staffing documentation and make visual observations. If I code a resident as total assistance, then the CNA documentation must say the resident required total assistance all the time during the 7 day look back period . The MDS Coordinator was asked how Resident #319 could require 2 person assist for personal hygiene and only require 1 person assist for toileting. The MDS Coordinator stated, .I am not the CNA that cared for him so I can't tell you that . The MDS Coordinator was asked if the CNA documentation was always correct. The MDS Coordinator stated, No. During an interview on [DATE] at 2:50 PM, The MDS Coordinator was asked if seizures were checked on Resident #319's Care Area Assessment (CAA) and Resident #319 was on seizure medication twice a day, should Resident #319 have been care planned for seizures. The MDS Coordinator responded, .Seizures should have been care planned since he was on seizure medication . The MDS Coordinator was then asked if a resident was on an air mattress, should safety measures be care planned. The MDS Coordinator stated, .I don't usually put safety measures in for an air mattress . During an interview on [DATE] at 12:13 PM, Nurse Practitioner (NP) #3 stated she had no record that she or any other of the NP's at the facility had assessed Resident #319 after the fall on [DATE]. The facility's failure to provide a safe environment during care resulted in actual harm when Resident #319 fell from bed and sustained a left hip fracture on [DATE] while receiving incontinence care with use of 1 person assist.

**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 2 (Resident #221 and #224) of 5 residents reviewed for pain. The facility's failure to implement an effective pain management program for Resident #221 and Resident #224 resulted in an increase in pain and actual HARM to Resident #221 and Resident #224. The findings include: Review of the facility policy titled, Pain Assessment and Management, dated 5/19/2023 revealed, .The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain .1. Observe the resident [during rest and movement] for physiologic .signs of pain. 2. Possible Behavioral Signs of Pain .a. negative verbalizations and vocalizations such as groaning .b. facial expressions such as grimacing, frowning .4. Ask the resident if he/she is experiencing pain .Identifying the Causes of Pain .1. Residents may experience pain from several different causes simultaneously. 2. In addition, common procedures such as moving the resident, physical therapies .3. Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including .fractures .end of life/hospice care .Establish a treatment regimen that is specific to the resident based on consideration of the following: a. The resident's medical condition .b. Current medication regimen .f. treatment goals .Administering medications around the clock rather than PRN [as needed] . Review of the medical record revealed Resident #221 was admitted to the facility on [DATE] with diagnoses which included Unspecified Trochanteric Fracture of Left Femur, and Type 2 Diabetes Mellitus. Review of baseline care plan dated 1/26/2024 for Resident #221 revealed, .The resident has greater trochanter left femur fracture r/t [related/to] fall .Goal The resident will remain free of complications related to hip fracture, such as contracture formation .Interventions/Tasks .Anticipate and meet needs .Follow MD [Medical Doctor] orders for weight bearing status. See MD and/or PT [Physical Therapy] treatment plan .impaired mobility, Unrelieved pain .PT/OT [Occupational Therapy] evaluation and treatment per orders .Focus At risk for pain related to Acute Illness, Recent Change in Condition-Requiring Skilled Nursing Home Placement, Recent Hospitalization .Goal The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain .Interventions/Tasks .Monitor/record/report to Nurse any s/sx (signs/symptoms) of non-verbal pain .Vocalizations (grunting, moans, yelling out . Review of the Medication Administration (Admin) Audit Report dated January 2024 for Resident #221 revealed an order for Oxycodone Hydrochloride (HCL) (opioid medication used medically for treatment of moderate to severe pain) Oral Tablet 5 milligram (mg) give 5 mg by mouth four times a day for Chronic Pain and Acetaminophen 500 mg give 1 tablet by mouth three times a day for pain with a scheduled time for 1/30/2024 at 9:00 AM. Further review of the Medication Admin Audit Report revealed on 1/30/2024 Oxycodone HCL 5 mg tablet and Acetaminophen 500 mg tablet was administered at 11:34 AM by Licensed Practical Nurse (LPN) #44. The audit report revealed Resident #221's pain medications were administered 1 hour and 34 minutes late. During an observation on the 200 hall on 1/30/2023 at 11:00 AM, Resident #221 was observed walking with his walker with assistance of OT #2 back to his room. Resident #221 requested his pain medication in the hall. OT #2 assisted Resident #221 to the side of his bed to sit down. Resident #221 with a facial grimace, groaned loudly when he sat down on the side of his bed. During an interview on 1/30/2024 at 11:10 AM, OT #2 was asked if Resident #221 received his pain medication prior to his therapy this morning. OT #2 stated, No. OT #2 was asked if Resident #221 was able to complete his therapy session. OT #2 stated, .he was unable to complete all the transfer training. He did complain of pain during his therapy session . During an interview on 1/30/2024 at 11:15 AM with Licensed Practical Nurse (LPN) #44, she was asked why Resident #221 was unable to receive his pain medication prior to his therapy. LPN #44 stated, .this is my first day to be at the facility .I work for agency .I was unable to sign on to the computer to be able to start my medications this morning . LPN #44 stated, .basically all my medications were late this morning . LPN #44 was asked if any manager or other nurse stepped in to help her with the medication pass. LPN #44 stated, No. During an interview on 1/30/2024 at 1:00 PM, Resident #221 was asked about his care at the facility. Resident #221 stated, .my pain meds are late didn't get them this morning and its due again at 1:00 PM . I need my pain medication . The facility failed to provide agency staff with login information to the electronic medical record in a timely manner, therefore pain medication was not administered as ordered, which resulted in actual harm for Resident #221. Review of the medical record revealed Resident #224 was admitted to the facility on [DATE] with diagnoses which included Unspecified Cord Compression, Collapse Vertebra subsequent encounter for Fracture, Malignant Neoplasm of Unspecified Bronchus or Lung, Encounter for Palliative Care, Malignant Neoplasm of Spinal Cord, and Neoplasm related Pain (acute) (chronic). Review of the admission MDS dated [DATE] for Resident #224 revealed a BIMS score of 14, which indicated no cognitive impairment. Continued review of the MDS revealed Resident #224 received scheduled pain medication and PRN pain medication over the last 5 days. Further review of the MDS revealed a pain assessment interview with a pain frequency of almost constantly. Review of the comprehensive care plan dated 1/12/2024 for Resident #224 revealed, .Focus Resident is at risk for neoplastic disorders Cancer of Lung and spinal cord .Interventions/Tasks .Monitor pain levels and administration pain meds .per MD [Medical Doctor] order .Focus At risk for pain related to .Chronic Illness .Interventions/Tasks .Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment . Review of the Medication Admin Audit Report for Resident #224 revealed an order for Morphine Sulfate (opioid pain reliever) ER (extended release) 30 mg (milligram) give 1 tablet by mouth every 12 hours for pain with a scheduled time for 1/30/2024 at 8:00 AM. Continued review of the Medication Admin Audit Report revealed an order for Methocarbamol (muscle relaxant) 500 mg give 1.5 tablet by mouth four times a day for muscle spasm with a scheduled time for 1/30/2024 at 9:00 AM. Further review of the Medication Admin Audit Report revealed on 1/30/2024 Morphine Sulfate ER was administered at 13:05 PM by LPN #44 and Methocarbamol was administered at 13:06 PM. The audit report revealed Resident #224's pain medication was administered 4 hours and 5 minutes late and muscle relaxer was administered 3 hours and 6 minutes late. During an observation on the 200 halls on 1/30/2024 at 11:25 AM, Resident #224's call light was on. A housekeeper answered the call light and came out in the hall and told the Unit Manager (LPN #2) Resident #224 wanted her pain medication. During an observation on the 200 halls on 1/30/2024 at 11:30 PM, the Unit Manager (LPN #2) walked by this surveyor smiled and stated, The nurse is behind on her medications, but she is trying to get caught up. During an interview on 1/30/2024 at 12:00 PM, Resident #224 was asked why she had her call light turned on. Resident #224 stated, .My morning pain medication was late .I have Cancer I need my pain meds . Resident #224 was asked what her pain scale was on a scale from 1-10. Resident #224 stated, .It is a 9 but the medications help when I get them . During an interview on 2/6/2024 at 3:35 PM, Former DON #1 was asked if she received a text on 1/30/2024 that an agency nurse needed assistance with a login to the computer system. Former DON #1 looked at her cell phone and stated, .I received a text on 1/30/2024 at 8:28 AM, from the Unit Manager [LPN #2] saying the nurse needed the sign on stuff. I got the login for the nurse, and it usually is ready after 5 minutes . Former DON #1 was asked if it was normal for an agency nurse not to have her login information prior to her starting her shift. Former DON #1 stated, It would depend on who the on-call person was, if I were on call, I would look at the schedule and see if I needed to get one for a nurse. During an interview on 2/6/2024 at 7:55 AM, LPN #9 was asked if she was an agency nurse for the facility. LPN #9 stated, .I use to be an agency nurse but not now. I wasn't given any training prior to starting as an agency nurse. I had to wait to get a login for the computer system which makes it hard to start your medications . The facility failed to administer pain medications as ordered, which resulted in actual harm for Resident #224.