**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 6 (Residents #1, 11, 6, 8, 10, and 7) of 6 residents reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan that included transfer goals and interventions for Residents #1, 11, 6, 8, 10, and 7. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/31/24. The IJ template was provided to the Administrator. The IJ was removed on 02/01/24, but the facility remained out of compliance. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings include: Resident #1 Record review of Resident #1's face sheet dated 12/30/12 revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of vascular dementia, unsteadiness to feet, other abnormalities of gait and mobility, difficulty in walking, hemiplegia (paralysis of one side of the body), hemiparesis (one-sided muscle weakness), muscle weakness, age-related osteoporosis, and other lack of coordination. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score 08, which indicated she was moderately cognitive impaired and required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for chair/bed to chair transfer. Record review of Resident #1's care plan dated 12/13/2023 revealed a focus area for resident requires assist with ADLs but did not have interventions for level of assistance needed for transfers. Review of Resident #1's facility note dated 12/26/23 at 10:11 p.m. Change of Condition -Describe Change - Pain in Left Elbow. Nursing Interventions: notified Nurse Practitioner, got orders to give pain medication. Response: Elbow x-ray new order acetaminophen #3 by mouth every 6 hours as needed. Family aware, DON aware. Review of Resident #1's facility note dated 12/27/23 at 6:28 p.m. Change of Condition -Describe Change- resident has pain to left arm, purplish bruising to arm. Nursing Interventions- attempted in-house x-ray. Physician Notified. Physician Response: send to emergency room for evaluation due to unable to complete in-house x-ray. Family and DON notified. Review of Resident #1's facility note dated 12/27/23 at 7:23 p.m. Transfer Out - Clinical Condition/Reason for Transfer Complain of pain to her left elbow. Interventions attempted prior to discharge? If linked to Change of Condition? X-ray unable to be done in facility. Time left facility 7:18 p.m. Family, physician, and DON notified. Record review of Resident #1's local hospital diagnostic radiology report dated 12/27/2023 revealed reason for exam was pain and impression was acute fracture of the surgical neck of the left humerus (a bony constriction at the proximal end of shaft of humerus). Record review of Resident #1's local hospital discharge instructions dated 12/27/2023 revealed diagnoses of left humeral fracture and left elbow pain. Review of the Incident/Accident Report dated 12/28/23 documented: Incident- Resident stated that upon transferring in shower, she was lifted up under both arms and it hurt her left arm. Actions taken - was put back to bed, administered as needed pain medication, was checked on in approximately one hour and was resting comfortably and stated she was ok. During an interview on 01/29/2024 at 6:47 pm, CNA B stated she was assigned to Resident #1 on the day of the incident (12/27/2023). CNA B stated Resident #1 required a one person assist transfer and Resident #1 was able to assist with her good side. CNA B stated she had assisted Resident #6 to the shower, during the transfer from the wheelchair to the shower chair, she had attempted to assist Resident #1 to a standing position in which Resident #1 told her she needed to ask for help because she felt weak. CNA B stated she assisted Resident #1 to sit down on her wheelchair and called CNA A for help. CNA B stated her and CNA A assisted Resident #1 to a standing position and she left CNA A holding Resident #1 alone while she just turned to grab the shower chair that was not placed at a 90-degree angle as required. CNA B stated she let go of Resident #1, she slid down and landed on CNA A's feet. CNA B stated CNA C heard Resident #1 scream and went in the shower room to ask if they needed help and then assisted with lifting Resident #1 by herself off CNA A's feet to place her on the shower chair. CNA B stated she did not check Resident #1's care plan to check for the level of assistance she required for transfers. CNA B stated they (CNAs) would ask other CNAs and charge nurses about the type of transfers a resident may need. CNA B stated if comfortable they would decide to do a one person transfer and would only ask for help if they felt they needed it. CNA B stated there were no risk due to them receiving training on transfer technique. During an interview on 01/30/2024 at 9:30 am, Resident #1 was alert and oriented to person, place, and event. Resident #1 stated she did not remember the date of the fall but stated it had occurred in the shower room. Resident #1 stated she did not remember if she slipped but had ended up on the floor. Resident #1 stated there were 3 CNAs in the shower room and only one had assisted her off the floor. Resident #1 could not remember their names and further details. Resident #1 stated she had a lot of pain to her left arm and was sent out to the hospital the following day. Resident #1 stated staff usually transfer her either 1 or 2 people at a time. During an interview on 01/30/2024 at 9:39 am, RN H stated Resident #1 required a 2-person assist with a gait belt for transfers. RN H stated normally the CNAs had access to the residents' care on their electronic records under POC (plan of care). RN H stated CNAs also received verbal report from the charge nurse. RN H stated she was not aware of CNAs conducting one person assist for transfers. RN H stated she was not aware if therapy had given specific instructions on the level of care Resident #1 required for transfers. Resident #11 Record review of Resident #11's face sheet dated 1/30/14 revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of legal blindness, anxiety, muscle weakness, hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), osteoarthritis of knee (causes the cartilage in your knee joint to thin and the surfaces of the joint to become rougher, which means that the knee doesn't move as smoothly as it should, and it might feel painful and stiff), and low back pain. Record review of Resident #11's annual MDS assessment dated [DATE] revealed a BIMS score of 08, which indicated he was moderate cognitive impaired and required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half). Record review of Resident #11's care plan last revised on 01/15/2024 revealed a focus area for resident requires assist with ADLs with interventions of Hoyer lift (mobility tool used to help seniors with mobility challenges get out of bed) for all transfers. Record review of Resident #11's fall investigation sheet dated 12/12/23 revealed section B.1 CNA was transferring resident from shower chair to bed. [Resident #11] slipped down to floor. No changes were identified. Correct level of assist provided during transfers was extensive: lifted manually or mechanically. Analysis facts section revealed [Resident #11] slipped on floor post shower, was not wearing any shoes or non-slip socks. Educated staff to ensure proper footwear, and transfers per directions and educated [Resident #11] to voice if lower extremities feel weak. No injuries identified and pain level of 0/10 was noted. During an interview on 01/31/2024 at 11:07 am, CNA B stated she was Resident #11's assigned CNA the day of the incident. CNA B stated Resident #11 had slid to the floor when she was assisting him with a transfer from the shower chair to the bed. CNA B stated she assisted Resident #11 alone, used a gait belt to do a one-person assistance transfer. CNA B stated Resident #11 had voiced he felt weak and slipped to the floor. CNA B stated she did not look at Resident #11's care plan, did have access to care plan and forgot to look. CNA B stated she was new to the hall and had asked an unidentified CNA about the type of transfer Resident #11 was and was told he was able to assist with a one-person assistance. During an interview in 1/31/2024 at 11:50 am, Resident #11 was alert and oriented to person and event. Resident #11 sated a CNA whose name he can't remember had assisted him to transfer from the chair to the bed and during the transfer he fell. Resident #11 stated staff had always transferred him alone but recently they had started using the lift and had felt safe since then. Resident #11 stated staff had been assisted with transfers alone (one-person transfer) prior to the incident. Resident #6 Record review of Resident #6's face sheet dated 01/31/2024 revealed an [AGE] year-old male who was admitted on [DATE] with diagnoses of abnormalities of gait and mobility, muscle wasting atrophy, lack of coordination, arthritis to right knee, Alzheimer's, muscle weakness, unsteadiness to feet. Record review of Resident #6's other payment MDS assessment dated [DATE] revealed a BIMS score of 11, which indicated he was cognitively intact and required extensive assistance with 2-person physical assist for transfers. Record review of Resident #6's care plan last reviewed on 12/28/2023 revealed no interventions addressing 2-person physical assist for transfers. During an observation and interview on 01/29/2024 at 3:39 pm, revealed Resident #6 was alert and oriented to person, place, and event. Resident #6 was in his room, bed at the lowest position (ankle high) with the call light within reach. Resident #6 denied needing any assistance from staff to do anything including transfers and stated he was very independent. Resident #8 Record review of Resident #8's face sheet dated 01/31/2024 revealed a [AGE] year old male who was admitted on [DATE] with diagnoses of dementia, muscle weakness, muscle spasm, lack of coordination, multiple fractures of ribs, right side, and subsequent encounter for fracture with routine healing, displaced bicondylar fracture of left tibia(significant soft tissue swelling precluding arthroscopic or open repair of soft tissues), unspecified fracture of shaft of right tibia (tibia is the big bone between your knee and ankle, shaft is the middle of that bone), unspecified fracture of unspecified talus (large bone in the ankle that articulates with the tibia of the leg and the calcaneum and navicular bone of the foot), pain due to internal orthopedic prosthetic devices, implants and grafts, pedestrian on foot injured in collision with car in traffic accident. Record review of Resident #8's other payment assessment dated [DATE] revealed a BIMS score of 09, which indicated he was moderately cognitively impaired and required extensive assistance with 2-person physical assist with transfers. Record review of Resident #8's care plan last reviewed on 11/01/2023 revealed a focus area for resident requires assist with ADLs with interventions of two-person assist in room at all times per request. The care plan did not address level of care needed for transfer. During an observation and interview on 01/29/2024 at 3:50 pm, revealed Resident #8 was alert and oriented to person and event. Resident #8 had a brace to his left foot. Resident #8 stated he was involved in a car accident and broke his foot but did not remember how long ago it happened. Resident #8 stated he did not need assist with getting in and out of bed. Resident #8 stated he was able to get out of bed alone and attempted to demonstrate. During an interview on 01/30/2024 at 10:49 am, CNA I stated Resident #8 could put some weight on his left foot with the brace and was normally good about assisting with the transfers. CNA I stated they do not have a care plan to reference for level of care residents may need with transfers. CNA I stated they would ask other CNAs who had worked with a resident and were familiar with their care, charge nurse and therapy were good about teaching them on the transfer they needed. CNA I stated the residents electronic record under POC only reflected the services they provided for the day, it did not give guidance on the level of assistance a resident needed for transfers. CNA I stated depending on a resident they would decide on the type of transfer they would do, for example Resident #8 required one person assist and if he felt weak they would go ask for another CNA's help to complete the transfer. CNA I stated the level of assistance was done by their judgement not per special instructions because they did not have anything to refer to. During an interview on 01/30/2024 at 11:14 am, CNA J stated she was not familiar with Resident #8 as much. CNA J stated she had asked other CNAs who were more familiar with him about n his transfer status. CNA J stated she would also ask the residents if they were able to talk, and what they needed assistance with. CNA J stated electronic records only gave them a little bit of information but no special instructions on transfers. CNA J stated the POC was to document what was done for them that day but did not give instructions on transfers. CNA J stated the level of assistance was done by their judgement, based on verbal report gathered and not per special instructions because they did not have any to refer to. Resident #10 Record review of Resident #10's face sheet dated 01/31/2024 revealed a [AGE] year-old female who was re-admitted on [DATE] with diagnoses of localized edema (swelling), hearing loss, unspecified osteoarthritis, muscle weakness, age related osteoporosis, difficulty in walking, other lack of coordination, pain due to internal orthopedic prosthetic devices, and unspecified fall. Record review of Resident #10's admission MDS assessment dated [DATE] revealed a BIMS score of 04, she was severely cognitive impaired and was dependent on chair/bed to chair transfer. Record review of Resident #10's care plan last reviewed 01/19/2024 revealed a focus area for resident requires assist with ADLs with no interventions on level of care needed for transfers. Resident #7 Record review of Resident #7's face sheet dated 01/31/2024 revealed a [AGE] year-old female who was admitted on [DATE] with diagnoses of lack of coordination, unsteadiness to feet, abnormalities of gait and mobility, age related physical debility, muscle weakness, difficulty in walking, restless leg syndrome. Record review of Resident #7's other payment MDS assessment dated [DATE] revealed a BIMS score of 01, which indicated she was severely cognitively impaired and required extensive assistance with two-person physical assist for transfers. Record review of Resident #7's care plan last reviewed on 1/17/24 revealed a focus area for resident requires assist with ADLs with no interventions on level of care needed for transfers. During an interview on 01/30/2024 at 11:32 am, MDS Nurse L stated anything that was mentioned on a resident's physician's orders would be included in their care plans. MDS Nurse L stated after she completed a MDS assessment the DON was the person responsible to review it. MDS Nurse L stated transfers with special instructions would typically be included on a resident's electronic record profile bar. MDS Nurse L stated if there were no special instructions on their electronic record profile it was assumed that they did not require special instruction, or a specified level of care needed for transfers. MDS Nurse L stated if no special instructions were documented for reference on the resident's electronic record profile, the transfer used for the resident was left to the CNAs discretion to decide. MDS L Nurse stated the reason for transfers not being included was due to the residents' care frequently changing and they would have to be changing and updating all the time. CNAs did have access to care plans but level of care for transfers were not implemented for guidance. During an interview on 01/30/2024 at 1:53 pm, CNA K stated she worked the night shift. CNA K stated for transfers she would ask other CNAs, charge nurses, and even the resident about what type of transfer they required. CNA K stated the level of assistance was done by their judgement not per special instructions because they did not have anything to refer to. During an interview on 01/30/2024 at 4:28 pm, the DON stated transfers were not included in the residents' care plans due to the residents' level of care changing from day to day. The DON explained that a resident one day might be a 2 person transfer and the following day they might be OK and only require a one-person transfer. The DON stated CNAs made the judgement on what level of assistance to provide during a transfer based on asking and seeing how much a resident could assist with the transfer. The DON explained and gave an example: if a resident's MDS assessment reflected they were a 2 person transfer and she felt she could do a one person transfer because she felt she had the strength to do so, she would do a one person transfer and not follow the MDS assessment. The DON stated the example was what the facility system was when determining the level of assistance a resident needed. Record review of Comprehensive Person-Centered Resident Care Planning policy undated reflected in part VI. 5- The facility will develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. VI.7- Each resident's plan of care shall be periodically reviewed and revised by and interdisciplinary team after each MDS assessment, including both the comprehensive and quarterly review assessments to reflect the resident's current care needs. The services provided or arranged by the facility, as outlined in the comprehensive care plan, must meet professional standards of quality; be provided by qualified persons in accordance with each residents written plan of care. VII.2- Based on the comprehensive assessment of a resident and consistent with the resident's needs and choice, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individuals clinical condition demonstrate that such diminution was unavoidable. The facility will provide care and services for the following activities: hygiene, mobility (transfer and ambulation, including walking), elimination, dining, and communication. The Administrator and DON were informed on 01/31/24 at 6:00 PM that Immediate jeopardy (IJ) had been identified and copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested. The Plan of Removal was accepted on 01/01/2024 at 1:14 pm. The Plan of Removal revealed the facility took the following actions: 1- Every resident (108 Census) was assessed for transfer status with a transfer proficiency assessment by nurse management to include the DON and ADONs and it was documented under resident care profile in PCC. Completed on 1/31/24. 2- All assessments were reviewed by the DOR of resident transfer status to include Resident #1 and Resident #11; agreed to all resident assessments (108 Census) but one. This resident was changed from 2 person to one person on 1/31/24. 3- The comprehensive care plans were updated to reflect the appropriate transfer status i.e. One person, two-person, Hoyer lift for all residents (108 census) on 1/31/24. The MDS Nurse will monitor transfer status and update as needed completed on 1/31/24. 4- The CNA Care Profile was updated to reflect transfer status to allow the CNAs to review transfer requirement for all residents on 1/31/24 on the facility room roster. The Care profile updates will occur during daily stand-up meetings and updates to be reflected on their care profile. The ADONs will be responsible for updating the care profile and any changes in transfer status. This was completed on 1/31/24. The CNAs will have to acknowledge any changes in transfer status in the task tab. Completed on 1/31/24. 5-All direct care staff were in-serviced by the Staffing Coordinator on where to look for transfer status. Return demonstration required by the CNAs. This will be included in the orientation process for newly hired staff and all current staff cannot return to the floor until complete. The Staffing Coordinator will be responsible for all continuing education upon annual competencies in regard to this moving forward. Inservice started on 1/30/24 all direct care staff 1/31/2024-ongoing. 6- The Director of Clinical Services in serviced DON regarding the proper transfer techniques using the proper amount of assistance and the MDS/Care plan updating process. Completed 2/1/24 and monitor ongoing. Action plan to be incorporated to ensure systems are in place to monitor corrections. -The Administrator/designee to monitor of these processes during the morning meeting daily 1/31/24 ongoing -The DON/designee to monitor during SOC weekly. 1/31/24 ongoing -The DON and or designee to monitor 10 random staff members for 8 weeks on how to demonstrate how to find the transfer status on the C.N.A. Care Profile. 1/31/24 -The DON/designee to monitor 10 random staff members for 8 weeks to ensure they can demonstrate proper transfer techniques utilizing the recommended amount of assistance 1/31/24 -The facility Medical Director and attending physicians of the SQC/IJ have received a copy of this plan 1/31/24 -The QAAC committee will review and evaluate this system for effectiveness to prevent any reoccurrence of this deficient practice. 1/31/24 ongoing. - The Director of Clinical Services to monitor the facility DON's understanding/compliance with the following 2/1/24 ongoing a. Transfer proficiencies b. Resident transfer status c. Transfer status updates d. CNA care profile updates e. Annual Competencies Interviews, observations, and record review to confirm implementation of the Plan of Removal were conducted as follows: Observations on 02/01/2024: 1:32 pm, CNA M logged into Resident #12's electronic profile and located special instructions and the POC transfer task and stated Resident #12 required a one person assist. CNA M proceeded to complete a one person assist transfer. No concerns were identified. 1:37 pm, CNA N and CNA O logged into Resident #13's electronic profile and located special instructions and the POC transfer task and stated Resident #13 required a 2-person physical assist with a Hoyer lift transfer. CNA N and CNA O proceeded to complete a 2-person physical assist transfer with a Hoyer lift. No concerns were identified. 1:48 pm, CNA A and CNA P logged into Resident #14's electronic profile and located special instructions and the POC transfer task and stated Resident # required a 2-person physical assist with a Hoyer lift transfer. CNA A and CNA P proceeded to complete a 2-person physical assist transfer with a Hoyer lift. No concerns were identified. 1:55 pm, CNA Q and CNA R logged into Resident #15's electronic profile and located special instructions and the POC transfer task and stated Resident #15 required a 2-person physical assist transfer. CNA Q and CNA R proceeded to complete a 2-person physical assist transfer. No concerns were identified. Interviews: 1:32 pm - 1:55 pm (interviews were conducted with observations), CNA A, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S confirmed in-services provided regarding residents' transfer status and weight bearing status located in the special needs instructions in PCC; task in PCC to complete every shift regarding each residents' transfer status; if not sure of any resident's transfer status they will ask the assigned nurse or check with therapy; pay attention to each resident's transfer status; if there was a change in transfers, ADLs, mobility, or residents complain of pain/discomfort notify the nurse immediately. 1:45 pm, the MD confirmed receiving copies of the IJ templates. 2:47 pm, MDS Nurse T and MDS Nurse U both stated they had already updated all care plans to reflect the residents' current level of assistance required. Both stated they will continue to update as needed on admission, quarterly, significant change and annually. 2:55 pm, the DON confirmed in-services provided regarding care plans needed to be updated to reflect transfer status, transfer technique to be decided by nurses, MDS and a therapy evaluation if needed, transfer status should reflect on the POC to be available for CNAs. The DON stated she or ADON X will review the standard of care in daily morning meetings. The DON stated she will monitor at random different staff to ensure they can properly demonstrate transfer and locate level of care needed for transfers and will document on the monitoring tool for 8 weeks. The DON stated she had already started the monitoring as of 1/31/24. 3:05 pm, the Administrator stated he will be overseeing the QAAC meeting and ensure all topics are being discussed any address any new concerns. 3:15 pm, The DOR stated she in-serviced the DON on updating and including transfers on the care plan. The DOR stated she in-serviced DON on resident assessment for level of care needed to be completed by nurses, a therapy evaluation if needed and to ensure level of care for transfers were available in PCC for CNAs to have access to. The DOR stated she reviewed all 108 residents with the nurses and DON to ensure the residents' care plans reflected their current level of care needed for transfers and signed the forms after each review. The DOR stated they will be discussing in morning meetings for new admission transfers and refer to the DON to ensure the PCC and care plans matched. Record review: Record review of the in-service training report dated 1/30/24 revealed it addressed the following: residents' transfer status and weight bearing is located in the special needs instructions on PCC; there is also a task in PCC to complete every shift regarding each residents transfer status; if staff was not sure of any resident's transfer status to please ask the nurse or check with therapy; pay attention to each resident's transfer status; if staff noticed a change in transfers, ADLs, mobility, or residents complained of pain/discomfort the staff was to notify their nurse immediately; it is the nurse's responsibility to notify the physician, therapy and document changes. Record review of Residents #1, 6, 7, 8, 10, 11, 12, 13, 14, and 15's electronic medical records reflected: a special instructions bar included level of assistance each resident required; POC tasks for transfers had the level of assistance needed for transfers and care plans were updated on 1/30/24. Record review of the transfer assessments for 108 residents (census) revealed they were completed with the DOR signature of review. The IJ was removed on 02/1/24, but the facility remained out of compliance at a scope of actual harm and severity level of isolated because the facility failed to have documented plans of care in place to provide guidance to the CNAs when performing resident transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure residents were provided supervision and assistive devices to prevent accidents for 6 of 6 (Residents #1, 11, 6, 8, 10, and 7) residents reviewed for accidents. The facility allowed CNAs to determine the amount of assistance to provide to each resident and determine if they could transfer residents alone or ask for assistance. Resident #1 had a fall on 12/7/23 during transfer and was injured with acute fracture of the surgical neck of the left humerus. Resident #11 had slipped and landed on floor on 12/12/23 during a transfer with no injuries. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/31/24. The IJ template was provided to the Administrator. The IJ was removed on 02/01/24, but the facility remained out of compliance. These deficient practices have the potential to affect residents who require extensive assistance with transfers, which could result in residents having pain, falls or injuries including fractures. Findings include: Resident #1 Record review of Resident #1's face sheet dated 12/30/12 revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of vascular dementia, unsteadiness to feet, other abnormalities of gait and mobility, difficulty in walking, hemiplegia (paralysis of one side of the body), hemiparesis (one-sided muscle weakness), muscle weakness, age-related osteoporosis, and other lack of coordination. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score 08, which indicated she was moderately cognitive impaired and required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for chair/bed to chair transfer. Record review of Resident #1's care plan dated 12/13/2023 revealed a focus area for resident requires assist with ADLs but did not have interventions for level of assistance needed for transfers. Review of Resident #1's facility note dated 12/26/23 at 10:11 p.m. Change of Condition -Describe Change - Pain in Left Elbow. Nursing Interventions: notified Nurse Practitioner, got orders to give pain medication. Response: Elbow x-ray new order acetaminophen #3 by mouth every 6 hours as needed. Family aware, DON aware. Review of Resident #1's facility note dated 12/27/23 at 6:28 p.m. Change of Condition -Describe Change- resident has pain to left arm, purplish bruising to arm. Nursing Interventions- attempted in-house x-ray. Physician Notified. Physician Response: send to emergency room for evaluation due to unable to complete in-house x-ray. Family and DON notified. Review of Resident #1's facility note dated 12/27/23 at 7:23 p.m. Transfer Out - Clinical Condition/Reason for Transfer Complain of pain to her left elbow. Interventions attempted prior to discharge? If linked to Change of Condition? X-ray unable to be done in facility. Time left facility 7:18 p.m. Family, physician, and DON notified. Record review of Resident #1's local hospital diagnostic radiology report dated 12/27/2023 revealed reason for exam was pain and impression was acute fracture of the surgical neck of the left humerus (a bony constriction at the proximal end of shaft of humerus). Record review of Resident #1's local hospital discharge instructions dated 12/27/2023 revealed diagnoses of left humeral fracture and left elbow pain. Review of the Incident/Accident Report dated 12/28/23 documented: Incident- Resident stated that upon transferring in shower, she was lifted up under both arms and it hurt her left arm. Actions taken - was put back to bed, administered as needed pain medication, was checked on in approximately one hour and was resting comfortably and stated she was ok. During an interview on 01/29/2024 at 6:47 pm, CNA B stated she was assigned to Resident #1 on the day of the incident (12/27/2023). CNA B stated Resident #1 required a one person assist transfer and Resident #1 was able to assist with her good side. CNA B stated she had assisted Resident #6 to the shower, during the transfer from the wheelchair to the shower chair, she had attempted to assist Resident #1 to a standing position in which Resident #1 told her she needed to ask for help because she felt weak. CNA B stated she assisted Resident #1 to sit down on her wheelchair and called CNA A for help. CNA B stated her and CNA A assisted Resident #1 to a standing position and she left CNA A holding Resident #1 alone while she just turned to grab the shower chair that was not placed at a 90-degree angle as required. CNA B stated she let go of Resident #1, she slid down and landed on CNA A's feet. CNA B stated CNA C heard Resident #1 scream and went in the shower room to ask if they needed help and then assisted with lifting Resident #1 by herself off CNA A's feet to place her on the shower chair. CNA B stated she did not check Resident #1's care plan to check for the level of assistance she required for transfers. CNA B stated they (CNAs) would ask other CNAs and charge nurses about the type of transfers a resident may need. CNA B stated if comfortable they would decide to do a one person transfer and would only ask for help if they felt they needed it. CNA B stated there were no risk due to them receiving training on transfer technique. During an interview on 01/30/2024 at 9:30 am, Resident #1 was alert and oriented to person, place, and event. Resident #1 stated she did not remember the date of the fall but stated it had occurred in the shower room. Resident #1 stated she did not remember if she slipped but had ended up on the floor. Resident #1 stated there were 3 CNAs in the shower room and only one had assisted her off the floor. Resident #1 could not remember their names and further details. Resident #1 stated she had a lot of pain to her left arm and was sent out to the hospital the following day. Resident #1 stated staff usually transfer her either 1 or 2 people at a time. During an interview on 01/30/2024 at 9:39 am, RN H stated Resident #1 required a 2-person assist with a gait belt for transfers. RN H stated normally the CNAs had access to the residents' care on their electronic records under POC (plan of care). RN H stated CNAs also received verbal report from the charge nurse. RN H stated she was not aware of CNAs conducting one person assist for transfers. RN H stated she was not aware if therapy had given specific instructions on the level of care Resident #1 required for transfers. Resident #11 Record review of Resident #11's face sheet dated 1/30/14 revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of legal blindness, anxiety, muscle weakness, hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), osteoarthritis of knee (causes the cartilage in your knee joint to thin and the surfaces of the joint to become rougher, which means that the knee doesn't move as smoothly as it should, and it might feel painful and stiff), and low back pain. Record review of Resident #11's annual MDS assessment dated [DATE] revealed a BIMS score of 08, which indicated he was moderate cognitive impaired and required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half). Record review of Resident #11's care plan last revised on 01/15/2024 revealed a focus area for resident requires assist with ADLs with interventions of Hoyer lift (mobility tool used to help seniors with mobility challenges get out of bed) for all transfers. Record review of Resident #11's fall investigation sheet dated 12/12/23 revealed section B.1 CNA was transferring resident from shower chair to bed. [Resident #11] slipped down to floor. No changes were identified. Correct level of assist provided during transfers was extensive: lifted manually or mechanically. Analysis facts section revealed [Resident #11] slipped on floor post shower, was not wearing any shoes or non-slip socks. Educated staff to ensure proper footwear, and transfers per directions and educated [Resident #11] to voice if lower extremities feel weak. No injuries identified and pain level of 0/10 was noted. During an interview on 01/31/2024 at 11:07 am, CNA B stated she was Resident #11's assigned CNA the day of the incident. CNA B stated Resident #11 had slid to the floor when she was assisting him with a transfer from the shower chair to the bed. CNA B stated she assisted Resident #11 alone, used a gait belt to do a one-person assistance transfer. CNA B stated Resident #11 had voiced he felt weak and slipped to the floor. CNA B stated she did not look at Resident #11's care plan, did have access to care plan and forgot to look. CNA B stated she was new to the hall and had asked an unidentified CNA about the type of transfer Resident #11 was and was told he was able to assist with a one-person assistance. During an interview in 1/31/2024 at 11:50 am, Resident #11 was alert and oriented to person and event. Resident #11 sated a CNA whose name he can't remember had assisted him to transfer from the chair to the bed and during the transfer he fell. Resident #11 stated staff had always transferred him alone but recently they had started using the lift and had felt safe since then. Resident #11 stated staff had been assisted with transfers alone (one-person transfer) prior to the incident. Resident #6 Record review of Resident #6's face sheet dated 01/31/2024 revealed an [AGE] year-old male who was admitted on [DATE] with diagnoses of abnormalities of gait and mobility, muscle wasting atrophy, lack of coordination, arthritis to right knee, Alzheimer's, muscle weakness, unsteadiness to feet. Record review of Resident #6's other payment MDS assessment dated [DATE] revealed a BIMS score of 11, which indicated he was cognitively intact and required extensive assistance with 2-person physical assist for transfers. Record review of Resident #6's care plan last reviewed on 12/28/2023 revealed no interventions addressing 2-person physical assist for transfers. During an observation and interview on 01/29/2024 at 3:39 pm, revealed Resident #6 was alert and oriented to person, place, and event. Resident #6 was in his room, bed at the lowest position (ankle high) with the call light within reach. Resident #6 denied needing any assistance from staff to do anything including transfers and stated he was very independent. Resident #8 Record review of Resident #8's face sheet dated 01/31/2024 revealed a [AGE] year old male who was admitted on [DATE] with diagnoses of dementia, muscle weakness, muscle spasm, lack of coordination, multiple fractures of ribs, right side, and subsequent encounter for fracture with routine healing, displaced bicondylar fracture of left tibia(significant soft tissue swelling precluding arthroscopic or open repair of soft tissues), unspecified fracture of shaft of right tibia (tibia is the big bone between your knee and ankle, shaft is the middle of that bone), unspecified fracture of unspecified talus (large bone in the ankle that articulates with the tibia of the leg and the calcaneum and navicular bone of the foot), pain due to internal orthopedic prosthetic devices, implants and grafts, pedestrian on foot injured in collision with car in traffic accident. Record review of Resident #8's other payment assessment dated [DATE] revealed a BIMS score of 09, which indicated he was moderately cognitively impaired and required extensive assistance with 2-person physical assist with transfers. Record review of Resident #8's care plan last reviewed on 11/01/2023 revealed a focus area for resident requires assist with ADLs with interventions of two-person assist in room at all times per request. The care plan did not address level of care needed for transfer. During an observation and interview on 01/29/2024 at 3:50 pm, revealed Resident #8 was alert and oriented to person and event. Resident #8 had a brace to his left foot. Resident #8 stated he was involved in a car accident and broke his foot but did not remember how long ago it happened. Resident #8 stated he did not need assist with getting in and out of bed. Resident #8 stated he was able to get out of bed alone and attempted to demonstrate. During an interview on 01/30/2024 at 10:49 am, CNA I stated Resident #8 could put some weight on his left foot with the brace and was normally good about assisting with the transfers. CNA I stated they do not have a care plan to reference for level of care residents may need with transfers. CNA I stated they would ask other CNAs who had worked with a resident and were familiar with their care, charge nurse and therapy were good about teaching them on the transfer they needed. CNA I stated the residents electronic record under POC only reflected the services they provided for the day, it did not give guidance on the level of assistance a resident needed for transfers. CNA I stated depending on a resident they would decide on the type of transfer they would do, for example Resident #8 required one person assist and if he felt weak they would go ask for another CNA's help to complete the transfer. CNA I stated the level of assistance was done by their judgement not per special instructions because they did not have anything to refer to. During an interview on 01/30/2024 at 11:14 am, CNA J stated she was not familiar with Resident #8 as much. CNA J stated she had asked other CNAs who were more familiar with him about n his transfer status. CNA J stated she would also ask the residents if they were able to talk, and what they needed assistance with. CNA J stated electronic records only gave them a little bit of information but no special instructions on transfers. CNA J stated the POC was to document what was done for them that day but did not give instructions on transfers. CNA J stated the level of assistance was done by their judgement, based on verbal report gathered and not per special instructions because they did not have any to refer to. Resident #10 Record review of Resident #10's face sheet dated 01/31/2024 revealed a [AGE] year-old female who was re-admitted on [DATE] with diagnoses of localized edema (swelling), hearing loss, unspecified osteoarthritis, muscle weakness, age related osteoporosis, difficulty in walking, other lack of coordination, pain due to internal orthopedic prosthetic devices, and unspecified fall. Record review of Resident #10's admission MDS assessment dated [DATE] revealed a BIMS score of 04, she was severely cognitive impaired and was dependent on chair/bed to chair transfer. Record review of Resident #10's care plan last reviewed 01/19/2024 revealed a focus area for resident requires assist with ADLs with no interventions on level of care needed for transfers. Resident #7 Record review of Resident #7's face sheet dated 01/31/2024 revealed a [AGE] year-old female who was admitted on [DATE] with diagnoses of lack of coordination, unsteadiness to feet, abnormalities of gait and mobility, age related physical debility, muscle weakness, difficulty in walking, restless leg syndrome. Record review of Resident #7's other payment MDS assessment dated [DATE] revealed a BIMS score of 01, which indicated she was severely cognitively impaired and required extensive assistance with two-person physical assist for transfers. Record review of Resident #7's care plan last reviewed on 1/17/24 revealed a focus area for resident requires assist with ADLs with no interventions on level of care needed for transfers. During an interview on 01/30/2024 at 11:32 am, MDS Nurse L stated anything that was mentioned on a resident's physician's orders would be included in their care plans. MDS Nurse L stated after she completed a MDS assessment the DON was the person responsible to review it. MDS Nurse L stated transfers with special instructions would typically be included on a resident's electronic record profile bar. MDS Nurse L stated if there were no special instructions on their electronic record profile it was assumed that they did not require special instruction, or a specified level of care needed for transfers. MDS Nurse L stated if no special instructions were documented for reference on the resident's electronic record profile, the transfer used for the resident was left to the CNAs discretion to decide. MDS L Nurse stated the reason for transfers not being included was due to the residents' care frequently changing and they would have to be changing and updating all the time. CNAs did have access to care plans but level of care for transfers were not implemented for guidance. During an interview on 01/30/2024 at 1:53 pm, CNA K stated she worked the night shift. CNA K stated for transfers she would ask other CNAs, charge nurses, and even the resident about what type of transfer they required. CNA K stated the level of assistance was done by their judgement not per special instructions because they did not have anything to refer to. During an interview on 01/30/2024 at 4:28 pm, the DON stated transfers were not included in the residents' care plans due to the residents' level of care changing from day to day. The DON explained that a resident one day might be a 2 person transfer and the following day they might be OK and only require a one-person transfer. The DON stated CNAs made the judgement on what level of assistance to provide during a transfer based on asking and seeing how much a resident could assist with the transfer. The DON explained and gave an example: if a resident's MDS assessment reflected they were a 2 person transfer and she felt she could do a one person transfer because she felt she had the strength to do so, she would do a one person transfer and not follow the MDS assessment. The DON stated the example was what the facility system was when determining the level of assistance a resident needed. Transfer policy was not obtained. Record review of Comprehensive Person-Centered Resident Care Planning policy undated reflected in part VI. 5- The facility will develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. VI.7- Each resident's plan of care shall be periodically reviewed and revised by and interdisciplinary team after each MDS assessment, including both the comprehensive and quarterly review assessments to reflect the resident's current care needs. The services provided or arranged by the facility, as outlined in the comprehensive care plan, must meet professional standards of quality; be provided by qualified persons in accordance with each residents written plan of care. VII.2- Based on the comprehensive assessment of a resident and consistent with the resident's needs and choice, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individuals clinical condition demonstrate that such diminution was unavoidable. The facility will provide care and services for the following activities: hygiene, mobility (transfer and ambulation, including walking), elimination, dining, and communication. The Administrator and DON were informed on 01/31/24 at 6:00 PM that Immediate jeopardy (IJ) had been identified and copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested. The Plan of Removal was accepted on 01/01/2024 at 1:14 pm. The Plan of Removal revealed the facility took the following actions: 1- Every resident (108 Census) was assessed for transfer status with a transfer proficiency assessment by nurse management to include the DON and ADONs and it was documented under resident care profile in PCC. Completed on 1/31/24. 2- All assessments were reviewed by the DOR of resident transfer status to include Resident #1 and Resident #11; agreed to all resident assessments (108 Census) but one. This resident was changed from 2 person to one person on 1/31/24. 3- The comprehensive care plans were updated to reflect the appropriate transfer status i.e. One person, two-person, Hoyer lift for all residents (108 census) on 1/31/24. The MDS Nurse will monitor transfer status and update as needed completed on 1/31/24. 4- The CNA Care Profile was updated to reflect transfer status to allow the CNAs to review transfer requirement for all residents on 1/31/24 on the facility room roster. The Care profile updates will occur during daily stand-up meetings and updates to be reflected on their care profile. The ADONs will be responsible for updating the care profile and any changes in transfer status. This was completed on 1/31/24. The CNAs will have to acknowledge any changes in transfer status in the task tab. Completed on 1/31/24. 5-All direct care staff were in-serviced by the Staffing Coordinator on where to look for transfer status. Return demonstration required by the CNAs. This will be included in the orientation process for newly hired staff and all current staff cannot return to the floor until complete. The Staffing Coordinator will be responsible for all continuing education upon annual competencies in regard to this moving forward. Inservice started on 1/30/24 all direct care staff 1/31/2024-ongoing. 6- The Director of Clinical Services in serviced DON regarding the proper transfer techniques using the proper amount of assistance and the MDS/Care plan updating process. Completed 2/1/24 and monitor ongoing. Action plan to be incorporated to ensure systems are in place to monitor corrections. -The Administrator/designee to monitor of these processes during the morning meeting daily 1/31/24 ongoing -The DON/designee to monitor during SOC weekly. 1/31/24 ongoing -The DON and or designee to monitor 10 random staff members for 8 weeks on how to demonstrate how to find the transfer status on the C.N.A. Care Profile. 1/31/24 -The DON/designee to monitor 10 random staff members for 8 weeks to ensure they can demonstrate proper transfer techniques utilizing the recommended amount of assistance 1/31/24 -The facility Medical Director and attending physicians of the SQC/IJ have received a copy of this plan 1/31/24 -The QAAC committee will review and evaluate this system for effectiveness to prevent any reoccurrence of this deficient practice. 1/31/24 ongoing. - The Director of Clinical Services to monitor the facility DON's understanding/compliance with the following 2/1/24 ongoing a. Transfer proficiencies b. Resident transfer status c. Transfer status updates d. CNA care profile updates e. Annual Competencies Interviews, observations, and record review to confirm implementation of the Plan of Removal were conducted as follows: Observations on 02/01/2024: 1:32 pm, CNA M logged into Resident #12's electronic profile and located special instructions and the POC transfer task and stated Resident #12 required a one person assist. CNA M proceeded to complete a one person assist transfer. No concerns were identified. 1:37 pm, CNA N and CNA O logged into Resident #13's electronic profile and located special instructions and the POC transfer task and stated Resident #13 required a 2-person physical assist with a Hoyer lift transfer. CNA N and CNA O proceeded to complete a 2-person physical assist transfer with a Hoyer lift. No concerns were identified. 1:48 pm, CNA A and CNA P logged into Resident #14's electronic profile and located special instructions and the POC transfer task and stated Resident # required a 2-person physical assist with a Hoyer lift transfer. CNA A and CNA P proceeded to complete a 2-person physical assist transfer with a Hoyer lift. No concerns were identified. 1:55 pm, CNA Q and CNA R logged into Resident #15's electronic profile and located special instructions and the POC transfer task and stated Resident #15 required a 2-person physical assist transfer. CNA Q and CNA R proceeded to complete a 2-person physical assist transfer. No concerns were identified. Interviews: 1:32 pm - 1:55 pm (interviews were conducted with observations), CNA A, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S confirmed in-services provided regarding residents' transfer status and weight bearing status located in the special needs instructions in PCC; task in PCC to complete every shift regarding each residents' transfer status; if not sure of any resident's transfer status they will ask the assigned nurse or check with therapy; pay attention to each resident's transfer status; if there was a change in transfers, ADLs, mobility, or residents complain of pain/discomfort notify the nurse immediately. 1:45 pm, the MD confirmed receiving copies of the IJ templates. 2:47 pm, MDS Nurse T and MDS Nurse U both stated they had already updated all care plans to reflect the residents' current level of assistance required. Both stated they will continue to update as needed on admission, quarterly, significant change and annually. 2:55 pm, the DON confirmed in-services provided regarding care plans needed to be updated to reflect transfer status, transfer technique to be decided by nurses, MDS and a therapy evaluation if needed, transfer status should reflect on the POC to be available for CNAs. The DON stated she or ADON X will review the standard of care in daily morning meetings. The DON stated she will monitor at random different staff to ensure they can properly demonstrate transfer and locate level of care needed for transfers and will document on the monitoring tool for 8 weeks. The DON stated she had already started the monitoring as of 1/31/24. 3:05 pm, the Administrator stated he will be overseeing the QAAC meeting and ensure all topics are being discussed any address any new concerns. 3:15 pm, The DOR stated she in-serviced the DON on updating and including transfers on the care plan. The DOR stated she in-serviced DON on resident assessment for level of care needed to be completed by nurses, a therapy evaluation if needed and to ensure level of care for transfers were available in PCC for CNAs to have access to. The DOR stated she reviewed all 108 residents with the nurses and DON to ensure the residents' care plans reflected their current level of care needed for transfers and signed the forms after each review. The DOR stated they will be discussing in morning meetings for new admission transfers and refer to the DON to ensure the PCC and care plans matched. Record review: Record review of the in-service training report dated 1/30/24 revealed it addressed the following: residents' transfer status and weight bearing is located in the special needs instructions on PCC; there is also a task in PCC to complete every shift regarding each residents transfer status; if staff was not sure of any resident's transfer status to please ask the nurse or check with therapy; pay attention to each resident's transfer status; if staff noticed a change in transfers, ADLs, mobility, or residents complained of pain/discomfort the staff was to notify their nurse immediately; it is the nurse's responsibility to notify the physician, therapy and document changes. Record review of Residents #1, 6, 7, 8, 10, 11, 12, 13, 14, and 15's electronic medical records reflected: a special instructions bar included level of assistance each resident required; POC tasks for transfers had the level of assistance needed for transfers and care plans were updated on 1/30/24. Record review of the transfer assessments for 108 residents (census) revealed they were completed with the DOR signature of review. The IJ was removed on 02/1/24, but the facility remained out of compliance at a scope of actual harm and severity level of isolated because the facility failed to have documented plans of care in place to provide guidance to the CNAs when performing resident transfers.