**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 2 residents reviewed who required full assistance with repositioning while in bed due to not being able to ambulate. CNA A failed to use to proper techniques when repositioning Resident #1 to sit up in bed, which resulted in a fracture to the upper part of the arm. The failure placed residents at the facility who require assistance with ADLs at risk for pain or serious injuries. The failure resulted in actual harm to Resident #1 on 10/14/2022. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. Findings included: Record review of Resident #1's Face Sheet, dated 12/01/2022, revealed an [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses of Hemiplegia (one-sided paralysis) and Hemiparesis (weakness or inability to move one side of the body) following a Cerebral Infarction (occurred as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting the left non-dominant side and Personal History of (healed) Osteoporosis (bones become weak and brittle) Fractures. Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 11, which indicated moderate cognitive impairment. The record review revealed Resident #1 required total assistance with bed mobility and dressing with at least 2 staff providing physical assistance based on the functional status section of the assessment. Record review of Resident #1's Care Plan, dated 10/17/2022, revealed Resident #1 had Osteoporosis related to the disease process of Osteoarthritis with an acute (sudden) fracture of the left shoulder. The record review revealed the interventions included staff would ensure the immobilization device was in place as per MD orders to the left extremity, provide PRN analgesics (prescribed pain medication) for pain, stiffness, or weakness, provide pillows to help maintain a comfortable position, and educate on a rich in calcium diet. Resident #1 had an ADL Self-Care Performance Deficit related to a history of a cerebral vascular accident (interruption of blood to cells in the brain) with left sided Hemiparesis. Interventions include in part, Bed Mobility: The resident was extensive assistance with turning and repositioning in bed by 2 staff members. Record review of Resident #1's medical records from the emergency room, dated 10/14/2022, revealed Resident #1 was diagnosed with a 2-part non-displaced fracture of surgical neck (end) of the left humerus (bone of the upper arm). Recommendations included the use of an immobilizer, prescription pain medication, and follow-up with her PCP. During an interview on 12/01/2022 at 9:50 a.m., Resident #1's family member reported they witnessed two aids on the video camera set up in Resident #1's room, lean into Resident #1 to adjust her shirt while Resident #1 was sitting in bed. The family member said as the aids were assisting Resident #1 to sit up, one of the aids pulled Resident #1's left arm straight up and a pop was heard. Resident #1's family member said one aid was on the right side of the bed and the other was on the left side of the bed, parallel to Resident #1's torso. Resident #1's family member said the aid on the left side pulled Resident #1's left arm, which had a contracture and was weak, when the family member heard the pop. Resident #1's family said they immediately heard Resident #1 scream out in pain and told the aid to not touch her. Resident #1's family member said the other aid in the room told the aid who pulled Resident #1's arm to step back and then she called the nurse. Resident #1's family member said the nurse entered the room and the second aid told the nurse they were sitting Resident #1's up and misunderstood each other and Resident #1 had injured her left shoulder. Resident #1's family member said the aid told the nurse she was going to sit her up and the other was going to pull her back when Resident #1's arm was dislocated. Resident #1's family member said the facility took Resident #1's to ER and determined the left upper arm was broke. Resident #1's family member identified the aid who pulled Resident #1's arm by the first name but did not know the last name. Based on the first name provided during the interview, the aid was identified as CNA A. During an interview on 12/01/2022 at 10:24 a.m., Resident #1 said she remembered what happened the day her arm was broke. Resident #1 said the 2 aids was scooting her up in bed, and CNA A had pulled her by her arm and broke it. Resident #1 said the staff were lifting her up in bed and CNA A took her arm and lifted it straight up. Resident #1 said she told the aid she was breaking her arm when she lifted it straight up. Resident #1 said she told the CNA B to stop her and not let CNA A touch her because she had a broken arm. Resident #1 said CNA A had not worked with her since the day of the incident. During an interview on 12/01/2022 at 10:54 a.m., the DON said she had been working at the facility for approximately one year. The DON said on the date of the incident, she received a call from LVN A that Resident #1 was injured when staff were assisting her with dressing. The DON said she was told Resident #1's left arm was injured, and Resident #1 was transported to the ER and diagnosed with a fracture to her left upper arm. The DON said CNA A was no longer employed with the facility due to the fact that several allegations were made after the incident with Resident #1, of CNA A after several residents complained CNA A rushed through patient care and quickly rolled a resident over during patient care and grabbing a resident by the arm and tugging. The review revealed these incidents were after the incident on 10/14/2022 that involved Resident #1. Interview on 12/01/2022 at 11:19 a.m., CNA B stated she had worked at the facility for two years. CNA B stated she was present the day Resident #1 sustained her injury. CNA B stated around 5:00 p.m., Resident #1's call light went off and she entered the room of Resident #1 and Resident #1 asked her to assist her with personal care. CNA B stated she asked CNA A to help her and together they the changed Resident #1 and performed peri care together. CNA B stated they had scooted Resident #1 up in the bed with the use of a repositioning pad and CNA B was verbally instructing CNA A step-by-step as they put Resident #1's shirt on. CNA B stated every time they scooted Resident #1 up in bed, they would lift her up into a sitting position by lifting up on her torso to a sitting position and then pulled her shirt down in the back. CNA B stated as they went to sit her up and verbally agreed based on Resident #1's request. CNA B stated she witnessed CNA A pull Resident #1's arm in an upper ward motion straight up as if she was scooting her up in the bed by grabbing her by the arm and pulling. CNA B stated when this occurred, she heard a pop and Resident #1 immediately started screaming and stated to CNA A, do not touch me. During an interview on 12/01/2022 at 11:35 a.m., LVN A said she had been at the facility for approximately five months. LVN A said she was called into Resident #1's room by CNA B on 10/14/2022 at approximately 6:00 p.m. and observed CNA A on the on right side of the bed and CNA B on the left side about level with Resident #1's chest. LVN A said she was told by CNA B, who was on the right side of the bed, that she was assisting Resident #1 to sit up and CNA A pulled Resident #1's arm in an upper ward motion, and she heard a pop. Resident #1's left arm was observed to be in a twisted position, and she was holding the left arm, screaming in pain. LVN A said she asked the aids to cover Resident #1 up with blankets and she called 911 and had her transported to the emergency room. LVN A said she contacted the nurse practitioner, the DON, and the family. LVN A said she thought there was a miscommunication between the CNA A and CNA B who was assisting Resident #1 by the statements that were made when she entered Resident #1's room immediately after the incident. LVN A said CNA A kept saying she did not know Resident #1's arm was fragile, and she was not aware of the extreme care needed to assist this resident. CNA B had said they were going to sit Resident #1 in a sitting position, but CNA A had pulled her arm up over her head instead of lifting Resident #1 up by her torso. LVN A said once Resident #1 screamed out in pain, the facility quickly acted and got her medical attention. LVN A said she had not received a complaint from Resident #1 or had any knowledge of CNA A being rough with Resident #1 prior to the incident on 10/14/2022. During an interview on 12/01/2022 at 1:09 p.m., the DON said she was unsure why the CNA A pulled Resident #1 left arm in the manner she did. The DON said she determined the manner which CNA A demonstrated how she repositioned Resident #1 was incorrect, and she suspended CNA A for three days without pay on 10/17/2022. The DON stated CNA A demonstrated the chicken wing technique and pulled straight up on the shoulder to reposition Resident #1, causing the fracture to the upper left arm. The DON said she also instructed CNA A that she was no longer allowed to assist Resident #1 in the future. The DON stated based on results of her investigation, physical therapy retrained CNA A on proper body mechanics, transfers, and repositioning using another employee as a model. The DON said it was her expectation the diagnosis of Osteoporosis should be include in care plan and stated the information was added 10/17/2022. Record review of a progress note, dated 10/14/2022, revealed the nurse who responded to the call for assistance was identified as LVN A. The record review documented, CNA A and CNA B reported that while in Resident #1's room assisting Resident #1 with changing her shirt, they assisted Resident #1's torso up to help with pulling shirt down in the back when they heard a loud pop coming from the left shoulder. Resident #1 then started crying and holding her left shoulder. LVN A notified Resident #1's family, the DON and ADON notified as well, NP notified, and new order received to send Resident #1 to the ER for further evaluation and treatment. Resident #1 left via stretcher and taken to ER by staff. Record review of the DON's Investigation Progress Note, dated 10/17/2022, revealed the DON received information from Resident #1's family members during an interview on 10/17/2022 that they witnessed CNA A improperly reposition Resident #1 by pulling her arm while attempting to set Resident #1 up in bed to change her shirt. Record review revealed the DON then interviewed Resident #1, who stated, CNA A pulled her arm while attempted to sit her up in the bed to get her shirt on. Resident #1 stated, she pulled her arm from the front causing a loud pop and pain. Record review revealed the DON interviewed CNA A and had her demonstrate the manner in which she repositioned Resident #1 to put her shirt on and determined the manner to be incorrect. The DON documented CNA A demonstrated the chicken wing technique and pulled straight up on the shoulder to reposition Resident #1 causing the fracture. Record review revealed CNA A was suspended for 3 days without pay and would no longer be able to care for Resident #1. DON documented, the manner which Resident #1 was repositioned, DON determined improper technique and further education required. Record review of the facility's policy Recognizing and Reporting Elder Abuse/Neglect, not dated, revealed neglect was defined as the failure to fulfill any part of a person's obligation or duties to the elder. Record review of the facility's policy Safe Resident Handling Program, not dated review all appropriate staff shall be trained on the safe handling of residents at hire, annually, and as needed thereafter. The DON shall have overall responsibility for the safe lifting program, including training, in-serving, evaluating and competency. The review revealed the resident needs shall be reassessed as the resident condition changes or upon request of the resident or family. On 12/01/2022, attempts were made to contact CNA A by phone at 11:50 a.m. and 2:10 p.m , but CNA A did not respond. During an observation on 12/01/2022 at 2:30 p.m., CNA B and CNA C were observed to reposition Resident #2 by raising the bed up off the floor. CNA C stood on the left side and CNA B on the right of the bed. Both staff were observed as they rolled Resident #2 to his side and repositioned the pad under him and then barrel rolled his body to the other side and pulled the pad straight. Once Resident #2 was straight, the staff grabbed the pad on each side and communicate to ensure each was ready and pulled Resident #2 up in the bed. Noted at no time did the staff touch or pull-on Resident #1's arms. During an interview on 12/01/2022, at 2:35 p.m., CNA C said she had learned to reposition residents the way she demonstrated with Resident #2 when she was trained to become a CNA and when she came to work at the facility. CNA C said she had been a CNA for over 10 years, and she would never pull-on Resident #2's arms or his hands. CNA C said she knew Resident #2's required 2-staff assistance based on training she had received. During an interview on 12/01/2022, at 2:45 p.m., CNA B said she had learned to reposition residents the way she demonstrated with Resident #2 when she was trained to become a CNA. CNA B said she knew not to touch Resident #2's arms and his hands. On 12/01/2022 at 3:10 p.m., the surveyor determined the facility was in non-compliance from 10/14/2022 - 11/14/2022 due to all CNA staff not being trained after the incident on 10/14/2022. The facility only retrained CNA A. The facility completed the following corrective actions to address the non-compliance after the incident occurred but prior to the surveyor entering: Record review of the Employee Counseling Form for CNA A dated 10/17/2022 - 11/14/2022, revealed CNA A received a counseling and disciplinary action of suspension for 3 days on 10/17/2022 for improper repositioning of a resident causing a left shoulder fracture. CNA A was offered retraining with the Physical Therapy department in body mechanics, repositioning, and transfers. Review revealed the training was completed on 10/24/2022 by the PT/OT staff. PT/OT was the department of the nursing facility that provides physical therapy (improving the Resident's ability to move the body) and occupational therapy (improving the Resident's ability to perform activities of daily living)Record review of the attached staff statements revealed rough was described as quickly rolling a resident over during patient care and grabbing a resident by the arm and tugging. Record review revealed a resident made a complaint to staff that CNA A had tugged on her on 10/29/2022 and another resident made a complaint on 10/29/2022 that CNA A had tugged on her and rushed her through patient care. The review revealed these incidents occurred after the incident on 10/14/2022 that involved Resident #1. CNA A was terminated 11/14/2022. Record review of the in-service agenda and signature sheet, dated 11/30/2022, revealed staff were in-serviced. The bullet point on the itinerary stated, Multiple complaints from residents about the staff being too rough and rushing through patient care. The staff meeting notes stated, this is a blanket verbal counseling for all CNA staff - 1. This taken very seriously, 2. Will lead to immediate disciplinary action. During interviews on 12/01/2022 between 3:22pm and 3:35pm with CNAs revealed there was additional verbally discussion during the in-service that included specific information regarding the incident with Resident #1, how to properly reposition a resident who had limited bed mobility, and what Osteoporosis was and how to properly care for a resident who had this condition. During an interview on 12/01/2022 at 3:15 p.m., CNA C said she knew what Osteoporosis meant, which was brittle bones that could easily break. CNA C said when a resident had a diagnosis of Osteoporosis, she would be extra careful when providing care. CNA C said she attended the in-service on 11/30/2022 when the topic of being rough with residents was not allowed and she was aware the topic was covered due to the incident with Resident #1. CNA C said the incident with Resident #1 was caused by the staff pulling on her arm when she had a contracture, and the staff used the improper technique. CNA C said the in-service covered the correct way to reposition a resident who had fragile bones and contractures. Observed her signature on the sign-in sheet corresponding with the in-service dated 11/30/2022 which was evidence she attended. During an interview on 12/01/2022 at 3:22 p.m., CNA B said Osteoporosis was brittle bones and when a resident had this, their bones could break easily. CNA B said the resident bones were fragile and she was trained to be extra [NAME] with residents who have Osteoporosis. CNA B said she did her recertification in June 2022 by retraining at the with facility staff. CNA B clarified the training was her annual training for employment at the facility. CNA B said she was present at the in-service where staff were reminded not to be rough with residents. CNA B she was aware the in-service was held because of the incident with Resident #1 and other complaints of staff rushing through patient care. CNA B said there was discussion during the in-service on how to reposition residents who needed gentle care due to contracture of their arms or legs. Observed her signature on the sign-in sheet corresponding with the in-service dated 11/30/2022 which was evidence she attended. During an interview on 12/01/2022 at 3:26 p.m., CNA D said Osteoporosis meant someone's bones were fragile. CNA D said when this happens, their bones could break more easily, and she had to be more cautious when bathing or transferring the person. CNA D said attended the in-service training on 11/30/2022 when the DON covered the issue of rushing through caring for the residents. CNA D said she was familiar with Resident #1's care needs after she had a fracture in her left arm and was aware had Osteoporosis because she reviewed her care plan when it was updated after she broke her arm. CNA D said during the in-service, staff discussed the specific incident with Resident #1 and to properly reposition her. Observed her signature on the sign-in sheet corresponding with the in-service dated 11/30/2022 which was evidence she attended. During an interview on 12/01/2022 at 3:30 p.m., CNA E said he knew Osteoporosis meant brittle bones and when old people have this, their bones could easily break. CNA E said he was present at the in-service where the topic of rushing and being rough with the residents' during care was not allowed. CNA E said he was aware the DON was reminding staff due to the incident with Resident #1 when she broke her arm after staff had pulled on her incorrectly. CNA E said during the in-service, the DON demonstrated how to properly reposition a resident with a two staff. Observed hir signature on the sign-in sheet corresponding with the in-service dated 11/30/2022 which was evidence he attended. During an interview on 12/01/2022 at 3:35 p.m., CNA F said she had been a CNA for many years and knew that Osteoporosis was when a patient had brittle bones and she needed to be very careful with the patients. CNA F said she was aware Resident #1 had Osteoporosis and required gentle care based on the information in her care plan. CNA F said she was present at the in-service when the topic of being rough with the residents was reviewed. CNA F said the information included in Resident #1's care plan was reviewed during the in-service held on 11/30/2022. Observed her signature on the sign-in sheet corresponding with the in-service dated 11/30/2022 which was evidence she attended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care to prevent a fracture while repositioning 1 (Resident #1) of 2 residents reviewed for bed mobility due to inability to ambulate. CNA A failed to use the proper technique when repositioning Resident #1 to sit up in bed, which resulted in a fracture to the upper part of the arm. The failure placed residents at risk for serious injuries who require assistance with ADLs. The failure resulted in actual harm to Resident #1 on 10/14/2022. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. Findings included: Record review of Resident #1's Face Sheet, dated 12/01/2022, revealed an [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses of Hemiplegia (one-sided paralysis) and Hemiparesis (weakness or inability to move one side of the body) following a Cerebral Infarction (occurred as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting the left non-dominant side and Personal History of (healed) Osteoporosis (bones become weak and brittle) Fractures. Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 11, which indicated moderate cognitive impairment. The record review revealed Resident #1 required total assistance with bed mobility and dressing with at least 2 staff providing physical assistance based on the functional status section of the assessment. Record review of Resident #1's Care Plan, dated 10/17/2022, revealed Resident #1 had Osteoporosis related to the disease process of Osteoarthritis with an acute (sudden) fracture of the left shoulder. The record review revealed the interventions related Osteoporosis included staff would ensure the immobilization device was in place per MD orders to the left extremity, provide PRN analgesics for pain, stiffness, or weakness, provide pillows to help maintain a comfortable position, and educate on a rich in calcium diet. Resident #1 had an ADL Self-Care Performance Deficit related to a history of a cerebral vascular accident (interruption of blood to cells in the brain) with left sided Hemiparesis. Interventions include in part, Bed Mobility: The resident was extensive assistance with turning and repositioning in bed by 2 staff members. Record review of Resident #1's medical records from the emergency room, dated 10/14/2022, revealed Resident #1 was diagnosed with a 2-part non-displaced fracture of surgical neck (end) of the left humerus. Recommendations included the use of an immobilizer, prescription pain medication, and follow-up with her PCP. During an interview on 12/01/2022 at 9:50 a.m., Resident #1's family member reported they witnessed two aids on the video camera set up in Resident #1's room, lean into Resident #1 to adjust her shirt while Resident #1 was sitting in bed. The family member said as the aids were assisting Resident #1 to sit up, one of the aids pulled Resident #1's left arm straight up and a pop was heard. Resident #1's family member said one aid was on the right side of the bed and the other was on the left side of the bed, parallel to Resident #1's torso. Resident #1's family member said the aid on the left side pulled Resident #1's left arm, which had a contracture and was weak, when the family member heard the pop. Resident #1's family said they immediately heard Resident #1's scream out in pain and told the aid to not touch her. Resident #1's family member said the other aid in the room told the aid who pulled Resident #1's arm to step back and then she called the nurse. Resident #1's family member said the nurse entered the room and the second aid told the nurse they were sitting Resident #1's up and misunderstood each other and Resident #1 had injured her left shoulder. Resident #1's family member said the aid told the nurse she was going to sit her up and the other was going to pull her back when Resident #1's arm was dislocated. Resident #1's family member said the facility took Resident #1's to ER and determined the left upper arm was broke. Resident #1's family member identify the aid who pulled Resident #1's arm by the first name but did not know the last name. Based on the first name provided the interview, the aid was identified as CNA A. During an interview on 12/01/2022 at 10:24 a.m., Resident #1 said she remembered what happened the day her arm was broke. Resident #1 said the 2 aids was scooting her up in bed, and CNA A had pulled her by her arm and broke it. Resident #1 said the staff were lifting her up in bed and CNA A took her arm and lifted it straight up. Resident #1 said she told the aid she was breaking her arm when she lifted it straight up. Resident #1 said she told the CNA B to stop her and not let CNA A touch her because she had a broken arm. Resident #1 said CNA A had not worked with her since the day of the incident. During an interview on 12/01/2022 at 10:54 a.m., the DON said she had been working at the facility for approximately one year. The DON said on the date of the incident, she received a call from LVN A that Resident #1 was injured when staff were assisting her with dressing. The DON said she was told Resident #1's left arm was injured, and Resident #1 was transported to the ER and diagnosed with a fracture to her left upper arm. The DON said CNA A was no longer employed with the facility due to the fact that several allegations were made after the incident with Resident #1, of CNA A after several residents complained CNA A rushed through patient care. Interview on 12/01/2022 at 11:19 a.m., CNA B stated she had worked at the facility for two years. CNA B stated she was present the day Resident #1 sustained her injury. CNA B stated around 5:00 p.m., Resident #1's call light went off and she entered the room of Resident #1 and Resident #1 asked her to assist her with personal care. CNA B stated she asked CNA A to help her and together they the changed Resident #1 and performed peri care together. CNA B stated they had scooted Resident #1 up in the bed with the use of a repositioning pad and CNA B was verbally instructing CNA A step-by-step as they put Resident #1's shirt on. CNA B stated every time they scooted Resident #1 up in bed, they would lift her up into a sitting position by lifting up on her torso to a sitting position and then pulled her shirt down in the back. CNA B stated as they went to sit her up and verbally agreed based on Resident #1's request. CNA B stated she witnessed CNA A pull Resident #1's arm in an upper ward motion straight up as if she was scooting her up in the bed by grabbing her by the arm and pulling. CNA B stated when this occurred, she heard a pop and Resident #1 immediately started screaming and stated to CNA A, do not touch me. During an interview on 12/01/2022 at 11:35 a.m., LVN A said she had been at the facility for approximately five months. LVN A said she was called into Resident #1's by CNA B on 10/14/2022 at approximately 6:00 p.m. and observed CNA A on the on right side of the bed and CNA B on the left side about parallel level with Resident #1's chest. LVN A said Resident #1's left arm was observed to be in a twisted position, and she was holding the left arm, screaming in pain. LVN A said she suspected the bone might be broken due to the arm's position. LVN A said she was told by CNA B, who was on the right side of the bed, they were assisting Resident #1 to sit up and CNA A pulled Resident #1's arm in an upper ward motion, and she heard a pop. LVN A said she asked the aids to cover Resident #1 up with blankets and she called 911 and had her transported to the emergency room. LVN A said she thought there was a miscommunication between the CNA A and CNA B who was assisting Resident #1 by the statements that were made when she entered Resident #1's room immediately after the incident. LVN A said CNA A kept saying she did not know Resident #1's arm was fragile, and she was not aware of the extreme care needed to assist this resident. CNA B had said they were going to sit Resident #1 in a sitting position, but CNA A had pulled her arm up over her head instead of lifting Resident #1 up by her torso. During an interview on 12/01/2022 at 1:09 p.m., the DON said in the past there was not a standardized training on repositioning and the method used was hands-on training and modeling or demonstrating. The DON said the facility had realized the training in place in the area of transfers and bed mobility was insufficient and she was in the process of updating the training documentation and would implement the new information in January 2023. The DON said when new staff were hired, the employee was provided a check list that documented all the skills the employee would need to be competent in to complete the job description of CNA. The DON said staff are observed by another seasoned staff or the ADON/DON and the employee was responsible for checking off each skill as he/she completed the list. Record review of a progress note, dated 10/14/2022, revealed the nurse who responded to the call for assistance was identified as LVN A. The record review documented, CNA A and CNA B reported that while in Resident #1's room assisting Resident #1 with changing her shirt, they assisted Resident #1's torso up to help with pulling shirt down in the back when they heard a loud pop coming from the left shoulder. Resident #1 then started crying and holding her left shoulder. LVN A notified Resident #1's family, the DON and ADON notified as well, NP notified, and new order received to send Resident #1 to the ER for further evaluation and treatment. Resident #1 left via stretcher and taken to ER by staff. Record review of CNA A's Certified Nurse Aid Competency Checklist, located in her employee file in the new employee section revealed the form was not completed by the employee or the staff that performed observation as the form was blank in all columns required to be initialed. The form contained no information to determine CNA A was competent in the skills required to provide patient care tasks with competency and safety. Record review of CNA A's Departmental Orientation and Initial Competency Assessment, dated 8/10/2022, located in her employee file in the new employee section revealed the form was not signed by CNA A. On 12/01/2022, attempts were made to contact CNA A by phone at 11:50 a.m. and 2:10 p.m , but CNA A did not respond. During an observation on 12/01/2022 at 2:30 p.m., CNA B and CNA C were observed to reposition Resident #2 by raising the bed up off the floor. CNA C stood on the left side and CNA B on the right of the bed. Both staff were observed as they rolled Resident #2 to his side and repositioned the pad under him and then barrel rolled his body to the other side and pulled the pad straight. Once Resident #2 was straight, the staff grabbed the pad on each side and communicate to ensure each was ready and pulled Resident #2 up in the bed. Noted at no time did the staff touch or pull-on Resident #2's arms. During an interview on 12/01/2022, at 2:35 p.m., CNA C said she had learned to reposition residents the way she demonstrated with Resident #2 when she was trained to become a CNA and when she came to work at the facility. CNA C said she had been a CNA for over 10 years, and she would never pull-on Resident #2's arms or his hands. CNA C said she knew Resident #2's required 2-staff assistance based on training she had received. During an interview on 12/01/2022, at 2:45 p.m., CNA B said she had learned to reposition residents the way she demonstrated with Resident #2 when she was trained to become a CNA. CNA B said she knew not to touch Resident #2's arms and his hands. On 12/01/2022 at 3:10 p.m., the surveyor determined the facility was in non-compliance from 10/14/2022 - 10/24/2022 when CNA A was retrained by PT/OT staff. The facility completed the following corrective actions to address the non-compliance after the incident occurred but prior to the surveyor entering: Record review of the Employee Counseling Form for CNA A dated 10/17/2022 - 11/14/2022, revealed CNA A received a counseling and disciplinary action of suspension for 3 days on 10/17/2022 for improper repositioning of a resident causing a left shoulder fracture. CNA A was offered retraining with the Physical Therapy department in body mechanics, repositioning, and transfers. Review revealed the training was completed on 10/24/2022 by the PT/OT staff. PT/OT was the department of the nursing facility that provides physical therapy (improving the Resident's ability to move the body) and occupational therapy (improving the Resident's ability to perform activities of daily living)Record review of the attached staff statements revealed rough was described as quickly rolling a resident over during patient care and grabbing a resident by the arm and tugging. Record review revealed a resident made a complaint to staff that CNA A had tugged on her on 10/29/2022 and another resident made a complaint on 10/29/2022 that CNA A had tugged on her and rushed her through patient care. The review revealed these incidents occurred after the incident on 10/14/2022 that involved Resident #1. CNA A was terminated 11/14/2022. Record review of the in-service agenda and signature sheet, dated 11/30/2022, revealed staff were in-serviced. The bullet point on the itinerary stated, Multiple complaints from residents about the staff being too rough and rushing through patient care. The staff meeting notes stated, this is a blanket verbal counseling for all CNA staff - 1. This taken very seriously, 2. Will lead to immediate disciplinary action. During interviews on 12/01/2022 between 3:22pm and 3:35pm with CNAs revealed there was additional verbally discussion during the in-service that included specific information regarding the incident with Resident #1, how to properly reposition a resident who had limited bed mobility, and what Osteoporosis was and how to properly care for a resident who had this condition. During an interview on 12/01/2022 at 3:15 p.m., CNA C said she knew what Osteoporosis meant, which was brittle bones that could easily break. CNA C said when a resident had a diagnosis of Osteoporosis, she would be extra careful when providing care. CNA C said she attended the in-service on 11/30/2022 when the topic of being rough with residents was not allowed and she was aware the topic was covered due to the incident with Resident #1. CNA C said the incident with Resident #1 was caused by the staff pulling on her arm when she had a contracture, and the staff used the improper technique. CNA C said the in-service covered the correct way to reposition a resident who had fragile bones and contractures. Observed her signature on the sign-in sheet corresponding with the in-service dated 11/30/2022 which was evidence she attended. During an interview on 12/01/2022 at 3:22 p.m., CNA B said Osteoporosis was brittle bones and when a resident had this, their bones could break easily. CNA B said the resident bones were fragile and she was trained to be extra [NAME] with residents who have Osteoporosis. CNA B said she did her recertification in June 2022 by retraining at the with facility staff. CNA B clarified the training was her annual training for employment at the facility. CNA B said she was present at the in-service where staff were reminded not to be rough with residents. CNA B she was aware the in-service was held because of the incident with Resident #1 and other complaints of staff rushing through patient care. CNA B said there was discussion during the in-service on how to reposition residents who needed gentle care due to contracture of their arms or legs. Observed her signature on the sign-in sheet corresponding with the in-service dated 11/30/2022 which was evidence she attended. During an interview on 12/01/2022 at 3:26 p.m., CNA D said Osteoporosis meant someone's bones were fragile. CNA D said when this happens, their bones could break more easily, and she had to be more cautious when bathing or transferring the person. CNA D said attended the in-service training on 11/30/2022 when the DON covered the issue of rushing through caring for the residents. CNA D said she was familiar with Resident #1's care needs after she had a fracture in her left arm and was aware had Osteoporosis because she reviewed her care plan when it was updated after she broke her arm. CNA D said during the in-service, staff discussed the specific incident with Resident #1 and to properly reposition her. Observed her signature on the sign-in sheet corresponding with the in-service dated 11/30/2022 which was evidence she attended. During an interview on 12/01/2022 at 3:30 p.m., CNA E said he knew Osteoporosis meant brittle bones and when old people have this, their bones could easily break. CNA E said he was present at the in-service where the topic of rushing and being rough with the residents' during care was not allowed. CNA E said he was aware the DON was reminding staff due to the incident with Resident #1 when she broke her arm after staff had pulled on her incorrectly. CNA E said during the in-service, the DON demonstrated how to properly reposition a resident with a two staff. Observed hir signature on the sign-in sheet corresponding with the in-service dated 11/30/2022 which was evidence he attended. During an interview on 12/01/2022 at 3:35 p.m., CNA F said she had been a CNA for many years and knew that Osteoporosis was when a patient had brittle bones and she needed to be very careful with the patients. CNA F said she was aware Resident #1 had Osteoporosis and required gentle care based on the information in her care plan. CNA F said she was present at the in-service when the topic of being rough with the residents was reviewed. CNA F said the information included in Resident #1's care plan was reviewed during the in-service held on 11/30/2022. Observed her signature on the sign-in sheet corresponding with the in-service dated 11/30/2022 which was evidence she attended.