**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for three (Resident #1, and Resident #2) of five residents reviewed for accidents and hazards. Hospitality Aide A and CNA C observed the sling prior to entering Resident #1 room and determined at this time the sling was not safe to use. Hospitality Aide A and CNA C did not report this to anyone and used the unsafe sling on the Mechanical lift during transfer of Resident #1. Hospitality Aide A and CNA C observed the loops on the sling to be frayed. There were four green loops on the sling and three of the four green loops broke during the transfer. The bottom four blue loops were already torn and unable to use prior to hooking the sling to Mechanical lift. There were three of four purple loops frayed and was beginning to tear and these loops were used on the Mechanical lift during transfer of Resident #1. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 6:27 PM. While the IJ was removed on [DATE] at 7:50 PM, the facility remained out of compliance at a severity of no actual harm that is not immediate and a scope of isolated. This failure could result in residents experience accidents, injuries, unrelieved pain, and diminished quality of life. Findings included: Record review of Resident #1's face sheet, dated [DATE], reflected Resident #1 was a [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses of: nontraumatic intracerebral hemorrhage in cerebellum (primary, admission - a devastating condition whereby a hematoma ( swelling or clotted blood) is formed within the brain parenchyma ( functional part of an organ) with or without blood extension into the ventricles (cavities in the brain)- this is a new diagnosis after return from hospital on [DATE], the following are diagnosis prior to being admitted to hospital on [DATE]: hemiplegia and hemiparesis following cerebral infarction left non-dominant side ( paralysis or partial or total body function on one side of the body, whereas hemiparesis is characterized by one-sided weakness, but without complete paralysis), lack of coordination (not able to move different parts of the body together easily), muscle wasting and atrophy ( thinning of the muscle mass), and type 2 diabetes mellitus with diabetic neuropathy, unspecified ( nerve damage caused by high blood sugars levels over time, leading to various complications in different parts of the body). Record review of Resident #1's Annual MDS Assessment, dated [DATE], reflected Resident #1 had a BIMS score of 15 indicated her cognition was intact. Resident #1 was assessed to have limited range of motion with upper and lower extremity on one side (left side). She required assistance with ADLs such as eating, all hygiene, upper and lower dressing including assist with footwear, toileting, all transfers, and repositioning in bed. Record review of Residents #1 Comprehensive Care Plan revised on [DATE], reflected Resident #1 had impaired physical mobility related to decreased in muscle strength and recent clavicle fracture (broken collar bone). Resident #1 required two person Mechanical lift transfer assistance. Intervention dated [DATE]: staff to provide a safe environment during transfers and will use a Mechanical lift with two-person assistance. Resident #1 had impaired physical mobility related to hemiplegia and hemiparesis following cerebral infarction affecting left-dominant side. Intervention: Assess need for an provide as indicated adaptive devices, furniture, and clothing. She was assessed to be at risk for unstable blood glucose level related to Type 2 diabetes mellitus with diabetic neuropathy. Intervention: Assess blood glucose levels as ordered. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Resident #1 was assessed to be at risk for falls related to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Intervention dated [DATE]: Encourage to keep bed in low position. Keep call light in reach. Keep personal belongings in reach. Increased staff supervision with intensity based on resident need. Resident # 1 had ADL self-care performance deficit. Interventions: She was total dependent on staff for bathing/showering, toileting, transfers and required extensive assistance with personal hygiene and oral care. Record review of Resident #1's Nurses Note dated [DATE] at 9:10 AM reflected DON was called to the room at 0901 (9:01 AM), upon arrival to the room, resident was laying in supine position, stating 'help me'. Noted blood and skin tear to LUE and LLE. OTA with resident on the floor. CNA's present in the room. Statements received from 3 CNA's. ADON present and at resident's head holding steady and asking resident not to move. DON conducted partial assessment for visible injuries without moving resident. Resident complaining of neck pain. Resident alert and oriented to self only. Baseline is A&O X 4. Pupils reactive to light. Right cheek bone noted to be swollen along with orbital swelling around right eye. Petechiae( a small red or purple spot caused by bleeding into the skin) noted to right cheek bone and right bicep area. Top of right shoulder with abrasion and blue bruising noted. Blue discoloration and bruising noted to top right middle knuckle. Resident breathing WNL. Vitals obtained (did not see vital entered in documentation). ADON states she will kept resident calm and talking until EMS comes and has the situation under control. DON left room with ADON and 2 aides present in room. Floor RN was on phone with 911attempting to get EMS on the way. Signed by Director of Nurses. Record review of Resident #1's Nurses Note dated [DATE] at 9:49 AM reflected, called to room by CNA- upon entering room client in prone position with face and lower extremities laying across Mechanical legs non responsive during course of log roll to supine client started groaning started neuro checks pupils non responsive client groaning and grunting- sent CNA to get DON left OTA and two other CNAs in room started process to send out to hospital-unable to reach ( she named two persons names question of these people are at the time of reading the nurses note when in the facility determined after reviewing face sheet she was referring to two family members) One family member called back as EMS was entering room-report given to them along with transfer paperwork - spoke to family member concerning the incident: client being transferred by Mechanical, Mechanical sling broke client fell to floor informed of clients condition, other family member called also given same information and updated him on where they would be taking her. Signed by RN E. Record review of Hospital Records, dated [DATE], reflected Resident #1 had new diagnosis after her CT scans. New diagnosis: back pain, brain bleed (bleeding between the brain tissue and the skull or inside the brain tissue), cerebellar hemorrhage (where the bleeding is located in a small space in the skull, found near the brainstem and cerebellum. The cerebellum is the part of the brain responsible for balance and coordinated movements. The brainstem is responsible for controlling vital body functions, such as breathing), closed head injury (rotational forces when the head twists or turns side to side or from the brain moving forward or backward inside of the skull), facial contusion (a bruise appears on your face after an injury), fall (to drop or descend under the force of gravity, as to a lower place through loss or lack of support), intraventricular hemorrhage (bleeding inside or around the ventricles-spaces in the brain that contain the cerebral spinal fluid. Bleeding in the brain can put pressure on the nerve cells and damage them. If the nerve cells are severely damaged, it can result in irreversible brain injury), right clavicle fracture (broken collar bone), right hip pain (injuries to your hip), subarachnoid hemorrhage (bleeding in the space between your brain and the membrane that covers it), traumatic intraventricular hemorrhage (an uncommon but important condition that may be a marker of severe injury in patients with blunt head trauma), traumatic subarachnoid hemorrhage (there is bleeding in the space that surrounds the brain), and traumatic subdural hemorrhage ( type of brain hemorrhage happens when blood is leaking out of a torn blood vessel and below the space of the brain and skull. This prevents the brain from getting enough oxygen). Record review of Resident #1's facility investigation dated ,[DATE], reflected skin tear to left forearm and left upper thigh, bruising noted to right middle knuckle, right side of face on cheek bone with petechiae (round spots that form on the skin), along with petechiae on right upper extremity. Resident #1 complaining of neck pain. Resident #1 kept still on ground by ADON for prevention of further injury since complaining of neck pain. The sling to Mechanical lift ripped and caused the resident to fall to the ground. The investigation findings were confirmed. Signed by DON. Record review of written statement by CNA C, dated [DATE] reflected I was working halls 500 and 600, Hospitality Aide A and I went into Resident #1's room to get her up for a shower, to get her ready to go and see religious service., we put the sling underneath it, we noticed the blue hook was already ripped so we put it on the green hook, we got her ready her arms were on her chest like she always did. CNA D walked into the room because she needed the Mechanical lift for another resident. Hospitality Aide A was on one side of the bed and I was on the other side of the bed, as Hospitality Aide A began to move the Mechanical, I began my way by the shower chair because I was going to grab Resident #1, from behind to make sure that she was sitting properly in the shower chair, and as I got by the shower chair, that was when I saw her fall, the sling broke from under her. CNA D did not sign her statement. Record review of written statement by Hospitality Aide A , dated [DATE], reflected I went into Resident #1's room to give her a shower. We (does not specify who assisted Hospitality Aide A) prepared the water to the shower, her clean clothes on the chair, I went to her bed. CNA C and I put the sling under her (Resident #1). We went to hook the sling to the Mechanical. The blue hooks were ripped. We used the green hooks. At this point, I did not report the ripped blue hooks. I would have reported the sling to RN E. The green hooks looked good. We did look for other slings but were unable to locate one. I was using the remote for the sling. On the way up, everything looked and went well. When I went to move Resident #1 to the shower chair, I heard the sling rip. It was really fast. Both hooks ripped. Resident #1 was holding her left arm, she flipped and landed face down on the Mechanical legs. CNA D went to call for help. I was trying to get Resident #1 to respond to me, but she was not responding at all. RN D came into the room with the therapy guy, and they took over care for Resident #1. Signed by Hospitality Aide A Record review of written statement by CNA D, not dated, reflected I walked into Resident #1's room [ROOM NUMBER] around 9:00 AM on [DATE] (no year documented). When I walked in Resident #1's room I saw Hospitality Aide A had the Mechanical controller in her hand and Resident #1 was on the bed. CNA C was at the foot of the bed with the shower chair in front of her. I came in and shut the door. Hospitality Aide A moved it (did not specify in her statement) out to put in front of the shower chair. The back strap broke which cuz (do not know the meaning of cuz) Resident #1 to fall and hit the floor. She hit her eye/cheek on the leg of the Mechanical. She was on her stomach. I ran out in the hallway looking for RN E. There was not a signature of CNA D or a date when she wrote the statement. Record review of written statement by DON, dated [DATE], reflected the same information from nurses note dated [DATE] by they DON was documented on the top paragraph of the statement. The second paragraph reflected DON spoke with 3 CNAs to gather information on how incident occurred. 3 CNAs were standing near restroom with Mechanical lift in resident's room. DON asked each CNA to explain what occurred in exact details. Group statement received was that CNA C was standing on the window side of the bed, Hospitality Aide A was on the opposite side of the bed with the Mechanical lift and controls. CNA C was walking around the bed and as they began to move Resident #1 by a Mechanical lift to the shower chair, the sling ripped, resident fell to the ground landing with her face on the legs of the Mechanical lift. They (did not specify in statement of who she was referring to as they) then called for help. CNA D was standing in the resident's room observing the transfer and witnessed the incident. CNAs called for help and floor RN E came. CNA (don't know which CNA did not specify) called for DON, Medical Records Coordinator F and the Receptionist G came to the conference room and informed DON and ADON that we were needed on hall 500. The sling was located by the door in the Resident #1's room. Upon inspection, the 3 green hooks and 4 blue hooks were ripped and tore. Signed by the DON. Record review on [DATE] of Hospitality Aide personnel file reflected she was a Hospitality Aide. She did receive one-on- one in-service by the DON of hospitality aide job description on [DATE] and was given a copy of the job description. She signed the original Hospitality Aide job description on [DATE]. She did not have another job description or any indication she was a CNA in her personnel file. The hospitality aide job description reflected the following: 1. Answer call lights in a timely manner; determine if request does not involve direct care and then carry out request. 2. Examples of non-direct care: helping with television, telephone, getting a personal item for a resident, giving a blanket or a pillow. 3. Be alert to resident's comfort and needs. Answer their requests promptly and report to nurse any need that exceeds your ability. 4. Uses tactful, appropriate communications in sensitive and emotional situations. 5. Observe all residents and report anything unusual or abnormal to Charge Nurse. 6. Offer fluids and encourage residents to drink (check with nurse for a list of residents with fluid restrictions or on thickened liquids). 7. Pass out meal trays and labeled snacks to residents 8. Clean and pick up rooms. 9. Stock gloves in rooms and notify housekeeping/maintenance if paper towels running low. 10. Pass ice and pick up meal trays from resident's room. 11. Empty bedside commodes. 12. Take laundry barrels to laundry room, get linens for beds, make unoccupied beds. 13. Bring residents to and from daily activities. 14. Perform other duties as assigned. 15. Treat all residents, visitors, and staff with courtesy. What you cannot do: 1. You cannot help feed residents (unless you have received training to be a feeding assistant). 2. No direct care (including changing, showering, transfers, shaving) 3. Cannot cut nails. 4. Cannot do vitals. Observation/Interview on [DATE] at 9:15 AM CNA B opened utility room door and reached for a Mechanical lift sling. Did not observe her inspecting the Mechanical lift sling. She began to walk down the hall with the staff coordinator was walking with her. Upon observation of his name tag noticed it stated staff coordinator. Asked the staffing coordinator to get two CNAs for observation of a Mechanical lift transfer. He stated he trained staff on how to transfer using Mechanical lift with the therapy department and he was qualified to do Mechanical lift transfers. It was explained to the staff coordinator preferred two CNAs to observe and not the training staff. The Staff Coordinator agreed and stated he would find another CNA. Observed someone walking down the hall and it was the same Hospitality Aide who was observed in [DATE] assisting with Mechanical lifts. Hospitality Aide A was walking toward CNA B. They entered Resident #2's room and Hospitality Aide A rolled Resident toward CNA B and placed the sling underneath Resident #2. CNA B rolled Resident #2 toward Hospitality Aide A and reached for the sling and pulled it under Resident #2. CNA B hooked the loops onto the sling and began to move resident. Hospitality Aide moved to Resident's wheelchair and assisted resident from behind as she was being lowered into the wheelchair. The legs of the Mechanical lift were widened, and the wheelchair was locked. The Hospitality Aide A and the CNA B did not inspect the sling prior to using it on the Mechanical lift. In an interview on [DATE] at 9:15 AM Hospitality Aide A stated she did not inspect the sling on the Mechanical lift, and she did not witness CNA B inspect the sling prior to using it on the Mechanical Lift. She stated her name tag was correct she was a Hospitality Aide and not a CNA. She stated she had taken written CNA test and past . Hospitality Aide A also stated she told everyone that she was nervous when she took the clinicals. Hospitality Aide A also stated she was not nervous she did not know how to do some of the clinicals, and she did not pass. She stated on most of the clinicals she guessed on how to the tasks including using Mechanical lift and transfers. She stated she does get confused on some of the slings especially which hooks to use to place on the Mechanical lift. She stated it depended on the resident which color to use and she does gets this confused sometimes. She also stated that she and CNA B obtained the sling from the closet they noticed the sling was ragged and did not look safe to use. Hospitality Aide A stated she had concern about using the sling, however, she did check the storage closet on 500 and 600 hall and did not see any more slings. She stated she did not report this to the nurse or to anyone. She stated on that particular day ([DATE]) with the incident with Resident #1 she asked CNA C and they discussed which color to use because the blue hooks were broken the purple hooks was tattered and a little torn. She stated the only option was the green hooks and she had never used the green hooks before until that day. She also stated she was not qualified to do any type of transfers including Mechanical lifts. She stated she needed to do something and asked if she could finish this interview later today. In an interview on [DATE] at 9:35AM CNA B stated she did not inspect the sling prior to using it on the Mechanical lift to transfer Resident #2. She stated she had been in-service to inspect the sling prior to placing under the resident. CNA B stated she was in serviced in July the day of incident with Resident #1. She stated She was not aware that Hospitality Aide A was not allowed to do Mechanical Lift transfers. She stated Hospitality Aide A has been doing Mechanical lift transfers over 5 months. She agreed she remembered the incident when she was observed assisting with Mechanical lift during an investigation with a surveyor U in [DATE] and she continued to do Mechanical lift transfers after the surveyor U left the facility. She stated Hospitality Aide passed her written test and did not pass her clinicals. CNA B stated the staff coordinator H was aware she was completing Mechanical lift transfers and did not say it was not ok for her to bed completing this task. In an interview on [DATE] at 9:50 AM Staff Coordinator H stated he was aware Hospitality Aide A was doing Mechanical Lift transfers and did not believe it was a problem. He stated she passed her written test but did not pass her clinicals. He stated he believed since she had passed her written test, she was a Certified CNA. He stated he was aware of the incident with this same Hospitality Aide using Mechanical Lifts during an investigation in [DATE]. He stated she did continue to use Mechanical lift after [DATE]. He stated she had been trained by CNAs and also went through training with him and the therapy department after the investigation in [DATE]. He stated he did have her on the schedule but did not put what her duties would be on the schedule. He stated only CNAs were required to use Mechanical lift and if she did not pass her clinicals she was not a Certified Nursing Assistant. He also stated prior to entering a resident room with a sling the staff was expected to check the sling and if it was torn or looked unsafe the staff was to report this to their charge nurse and the charge nurse would obtain a new sling for the staff. In an interview on [DATE] at 10:15 AM CNA C stated she was aware Hospitality Aide A was not a certified nursing assistant. She stated she was not aware Hospitality Aide A was not to assist with any type of transfers. CNA C stated she did not recall who informed her of this information. She stated the Hospitality Aide A has been doing CNA work over 4 months. She also stated she had continued to assist CNAs with Mechanical lifts and also had been performing care on residents such as: showers, peri care, assisting residents to the bathroom and everything a CNA would do without another CNA with her doing these tasks except for Mechanical Lift transfers. She stated she did not report this to anyone. CNA C also stated she thought everyone knew it especially the floor nurses. She stated the day of the incident on [DATE] Resident #1 was wanting a shower to go to a religious activity. She stated she was working with Hospitality Aide A on [DATE]. She stated she walked with Hospitality Aide to the linen closet to get obtain a sling. She stated both of them looked at the sling and saw where the blue hooks were torn. She stated they noticed the purple hooks was a little torn and tattered. She stated she did not recall if they looked at the green hooks. CNA C also stated they had concerns of the safety of the sling and went to other linen closets trying to find another sling to use due to the one they had did not look safe. She stated they did not find another sling and did not report it to the nurse on duty (RN E). She stated they were in a hurry and decided to use the sling they did not believe was safe to use. CNA C stated she entered Resident #1 room with the Hospitality Aide A. She stated she went by the window and the Hospitality Aide A was behind the Mechanical lift. She stated during the time of the transfer prior to Resident #1 being lifted off the bed CNA C entered the room to wait for the Mechanical lift to be used on another resident. She stated the blue hoops were torn and was unable to use them and the some of the purple hooks was tearing and was tattered and they discussed if the green hooks were the appropriate hooks to use. She stated they did not look closely at the green hooks and used the green ones to hook to the Mechanical lift. She stated they placed the sling under Resident #1 and Hospitality Aide began to lift her off the bed and this is when I moved from the window area to the shower chair. She stated when she placed herself by the shower chair to assist with the transfer, she heard a noise and saw Resident #1 fall to the floor hitting her face on the legs of the Mechanical lift. CNA C stated CNA D left the room to find the nurse. She also stated the RN E entered the room and began to assess the resident and within 3 minutes the DON, OTA and ADON entered the room. She stated that particular sling was not safe to use due to some of the hooks being torn and some tattered and was tearing. She also stated the sling overall was worn and beginning to tear. should have never been used on Resident #1. She stated it was not safe to use and they (Her and Hospitality Aide A) should have reported it to RN D or to the DON. She stated they knew for a fact the sling was not safe and because they did not see another one, they decided to use the unsafe sling. She stated Resident #1 was not responsive when she fell and hit her head on the legs of the Mechanical lift. CNA C stated they did have an in-service in March after the investigation by surveyor U of the hospitality aides job description. She stated in the in-service it was discussed the hospitality aide could only pass out ice, make beds, answer call lights, and never do hands on care with a resident including Mechanical lift and any type of care to a resident with a CNA or alone. In an interview on [DATE] at 10:45 AM Hospitality Aide A stated she was in serviced in March after surveyor U had left completing investigation where she was observed using a Mechanical lift. She stated she was in-serviced one on one and within a group. She stated her job description of being a hospitality aide was reviewed with her. She stated she was informed by the DON to only pass out water, answer call lights, make up beds, assist residents to the dining room in their wheelchairs and she stated it was a lot more but could not recall the rest of it at this time. She stated she was also informed during the in-service never do any type of hands-on care such as Mechanical lift, any type of care that was hands on with a resident by herself or with a CNA present. She stated she had been doing everything the CNAs does during ADL care with the residents since before [DATE] but was in-serviced in [DATE] about only doing her job description of being Hospitality Aide. She stated she continued to do Mechanical lifts and gave care to residents after being in-service in [DATE]. She stated she gave the following care without any other staff with her such as: peri-care, assisting resident to the shower and giving showers, transfer residents to the toilet, transfer residents from their bed to wheelchair and to the shower chair, feeding residents, assisted CNAs using Mechanical lifts. She stated she had been doing everything the CNAs does during ADL care with the residents since before [DATE] but was in-serviced in [DATE] about only doing her job description of being Hospitality Aide. She stated she knew she was not qualified on [DATE] and any other time she assisted to do Mechanical lifts. Hospitality Aide A stated she knew the sling was not safe and it was tearing and ripped. She stated she did not look at the green hooks prior to placing them on the Mechanical lift when transferring Resident #1. Hospitality Aide A stated she was not qualified to perform a lot of skills a CNA performed. She stated she realized this when she took her skills test and failed. Hospitality Aide A stated she told staff that she became nervous but that was not the truth. She stated she guessed at a lot of the skills tasks during the test and passed but it was not because she knew what she was doing it was just luck. She stated she did not feel she was qualified to do any of the CNA ADL care. Hospitality Aide A stated she did it because she felt she could learn if she continued to do care with the residents. She stated she did not consider the residents safety when she was giving ADL care. Hospitality Aide A stated a resident may had a serious injury due to her lack of ability and knowledge on how to operate a Mechanical lift. She also stated she should not had been the one to operate the Mechanical lift the day of [DATE] due to not knowing what to do about the sling. She stated she did not know how to use that particular sling and was confused with the hooks torn and she always used the purple hooks and was afraid to use them because they were tattered and beginning to tear. She stated she discussed it with CNA C and they decided to go with the green hooks but they did not look at the green loops to determine if they were in good condition. She stated she did not request to be removed from the Mechanical lift when they used it on Resident #1 she did not want others to know she did not know what she was doing because she was afraid that she may be asked to resign from her job until she became a CNA. Hospitality Aide A stated the Staff Coordinator was aware she had continued to assist with Mechanical Lifts over the past 4 or 5 months. She stated he had observed her go into residents' rooms and ask if she was going to assist the CNA with Mechanical lift transfer and did not say she could not do this task. She stated when she and CNA B obtained the sling from the closet, they noticed the sling was ragged and did not look safe to use. Hospitality Aide A stated she had concern about using the sling, however, she did check the storage closet on 500 and 600 hall and did not see any more slings. She stated she did not report this to the nurse or to anyone. She stated she walked with CNA B into Resident #1's room with the sling and the Mechanical lift was already in the room. Hospitality Aide A stated CNA B was by the window, and she was using the Mechanical lift. She also stated she had never used this type of sling before and one the blue hooks was broken, and they couldn't use them, and the purple hooks looked old and was frailed such as slightly tearing apart. She stated she discussed with CNA B of which hooks to use on the Mechanical lift. She also stated they had to use the purple that was frail and the green hooks. She stated she did not notice if the green hooks were tearing /frail looking like the purple hooks. Hospitality Aide A stated she placed the hooks on one side and CNA B placed hooks on the other side of Mechanical lift. She stated when she began to lift Resident #1 from the bed and was pulling the Mechanical lift away from the bed, she heard a snap and Resident #1 fell to the floor when she was in the air on the Mechanical lift. She stated the green hooks broke. Hospitality Aide A stated she was aware it was not in her job description to do Mechanical lift transfers and she had been doing them for 5 months. She stated she did not know if the director of nurses knew she was doing the Mechanical lift transfers. She stated she had been in serviced on her job description when the facility got into trouble about her using Mechanical lift in March. She stated she did CNA care thinking she was helping the staff. She stated now she realizes without being qualified she caused a resident serious injury from not knowing how to properly use a Mechanical lift with a defected sling and she had never used that type of sling before until [DATE]. She stated a resident fell and had serious injuries as a result of her not being a CNA and not being qualified to use a Mechanical lift. She stated Resident #1 could have died or any resident could have been seriously injured or died with me not being qualified to give any type of hands-on care to the residents. She stated she should have followed the Hospitality Aide job description and never completed any type of CNA care to a resident she was placing all residents she assisted in danger of being harmed. Observation and interview on [DATE] at 11: 20 AM with Resident #1. She was lying in bed. Resident #1 had bruises on her face and her shoulder. Resident #1 had burrowed eyebrows and a frown on her face. She stated she was afraid to get on that lift again. She stated she never wanted to be dropped again. Resident #1 had difficulty finishing her sentences but was able to when given time. This was not abnormal to her per staff and her medical records. Resident #1 stated she was sadder and more depressed. Resident #1 did not feel like talking about the incident and wanted to go to sleep. In an interview on [DATE] at 12:04 PM CNA D stated she entered Resident #1's room (did not recall the time) and was waiting for Hospitality Aide A and CNA C to transfer Resident #1 because she needed to use the Mechanical lift on another resident. She stated when she entered Resident #1 room the resident lying on the bed and the Hospitality Aide A had the controller in her hand to maneuver Resident #1 in the air to transfer her to the shower chair. She stated CNA C was standing behind the shower chair. When Resident #1 was being assisted in the air and Hospitality Aide A was beginning to maneuver her away from the bed this is wh[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #1 and Resident #2 .reviewed for Mechanical lift transfers. The facility failed to ensure Resident #1 was transferred with qualified staff. Hospitality Aide A knew the sling was not safe to use by observing the bottom loops were broken and three of the four top purple loops was frayed and beginning to tear. Hospitality Aide A did not report the unsafe sling to nurse prior to using the sling. Hospitality Aides were allowed to assist with resident transfers outside of the scope of their job description. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 6:27 PM. While the IJ was removed on [DATE] at 7:50 PM, the facility remained out of compliance at a severity of no actual harm that is not immediate and a scope of isolated. This failure could place residents at risk for serious injury, serious harm, serious impairment, or death. Findings included : Record review of Resident #1's face sheet, dated [DATE], reflected Resident #1 was a [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses of: nontraumatic intracerebral hemorrhage in cerebellum (primary, admission - a devastating condition whereby a hematoma ( swelling or clotted blood) is formed within the brain parenchyma ( functional part of an organ) with or without blood extension into the ventricles (cavities in the brain)- this is a new diagnosis after return from hospital on [DATE], the following are diagnosis prior to being admitted to hospital on [DATE]: hemiplegia and hemiparesis following cerebral infarction left non-dominant side ( paralysis or partial or total body function on one side of the body, whereas hemiparesis is characterized by one-sided weakness, but without complete paralysis), lack of coordination (not able to move different parts of the body together easily), muscle wasting and atrophy ( thinning of the muscle mass), and type 2 diabetes mellitus with diabetic neuropathy, unspecified ( nerve damage caused by high blood sugars levels over time, leading to various complications in different parts of the body). Record review of Resident #1's Annual MDS Assessment, dated [DATE], reflected Resident #1 had a BIMS score of 15 indicated her cognition was intact. Resident #1 was assessed to have limited range of motion with upper and lower extremity on one side (left side). She required assistance with ADLs such as eating, all hygiene, upper and lower dressing including assist with footwear, toileting, all transfers, and repositioning in bed. Record review of Residents #1 Comprehensive Care Plan revised on [DATE], reflected Resident #1 had impaired physical mobility related to decreased in muscle strength and recent clavicle fracture (broken collar bone). Resident #1 required two person Mechanical lift transfer assistance. Intervention dated [DATE]: staff to provide a safe environment during transfers and will use a Mechanical lift with two-person assistance. Resident #1 had impaired physical mobility related to hemiplegia and hemiparesis following cerebral infarction affecting left-dominant side. Intervention: Assess need for an provide as indicated adaptive devices, furniture, and clothing. She was assessed to be at risk for unstable blood glucose level related to Type 2 diabetes mellitus with diabetic neuropathy. Intervention: Assess blood glucose levels as ordered. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Resident #1 was assessed to be at risk for falls related to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Intervention dated [DATE]: Encourage to keep bed in low position. Keep call light in reach. Keep personal belongings in reach. Increased staff supervision with intensity based on resident need. Resident #1 had ADL self-care performance deficit. Interventions: She was total dependent on staff for bathing/showering, toileting, transfers and required extensive assistance with personal hygiene and oral care. Record review of Resident #1's Nurses Note dated [DATE] at 9:10 AM reflected DON was called to the room at 0901 (9:01 AM), upon arrival to the room, resident was laying in supine position, stating 'help me'. Noted blood and skin tear to LUE and LLE. OTA with resident on the floor. CNA's present in the room. Statements received from 3 CNA's. ADON present and at resident's head holding steady and asking resident not to move. DON conducted partial assessment for visible injuries without moving resident. Resident complaining of neck pain. Resident alert and oriented to self only. Baseline is A&O X 4. Pupils reactive to light. Right cheek bone noted to be swollen along with orbital swelling around right eye. Petechiae( a small red or purple spot caused by bleeding into the skin) noted to right cheek bone and right bicep area. Top of right shoulder with abrasion and blue bruising noted. Blue discoloration and bruising noted to top right middle knuckle. Resident breathing WNL. Vitals obtained (did not see vital entered in documentation). ADON states she will kept resident calm and talking until EMS comes and has the situation under control. DON left room with ADON and 2 aides present in room. Floor RN was on phone with 911 attempting to get EMS on the way. Signed by Director of Nurses. Record review on [DATE] of Hospitality Aide personnel file reflected she was a Hospitality Aide. She did receive one-on- one in-service by the DON of hospitality aide job description on [DATE] and was given a copy of the job description. She signed the original Hospitality Aide job description on [DATE]. She did not have another job description or any indication she was a CNA in her personnel file. The hospitality aide job description reflected the following: 1. Answer call lights in a timely manner; determine if request does not involve direct care and then carry out request. 2. Examples of non-direct care: helping with television, telephone, getting a personal item for a resident, giving a blanket or a pillow. 3. Be alert to resident's comfort and needs. Answer their requests promptly and report to nurse any need that exceeds your ability. 4. Uses tactful, appropriate communications in sensitive and emotional situations. 5. Observe all residents and report anything unusual or abnormal to Charge Nurse. 6. Offer fluids and encourage residents to drink (check with nurse for a list of residents with fluid restrictions or on thickened liquids). 7. Pass out meal trays and labeled snacks to residents 8. Clean and pick up rooms. 9. Stock gloves in rooms and notify housekeeping/maintenance if paper towels running low. 10. Pass ice and pick up meal trays from resident's room. 11. Empty bedside commodes. 12. Take laundry barrels to laundry room, get linens for beds, make unoccupied beds. 13. Bring residents to and from daily activities. 14. Perform other duties as assigned. 15. Treat all residents, visitors, and staff with courtesy. What you cannot do: 1. You cannot help feed residents (unless you have received training to be a feeding assistant). 2. No direct care (including changing, showering, transfers, shaving) 3. Cannot cut nails. 4. Cannot do vitals. Record review on [DATE] of one-on one Inservice with the Hospitality Aide, dated [DATE] reflected Hospitality Aide A was aware and knowledgeable with which skills she was able to perform and which skills she was not to perform. Record review on [DATE] of the Inservice on the Hospitality Aide Job description given to the staff on [DATE] reflected the hospitality aides job description was reviewed with the staff. CNA B, CNA C and RN E signed the in-service. Observation/Interview on [DATE] at 9:15 AM CNA B opened utility room door and reached for a Mechanical lift sling. Did not observe her inspecting the Mechanical lift sling. She began to walk down the hall with the staff coordinator was walking with her. Upon observation of his name tag noticed it stated staff coordinator. Asked the staffing coordinator to get two CNAs for observation of a Mechanical lift transfer. He stated he trained staff on how to transfer using Mechanical lift with the therapy department and he was qualified to do Mechanical lift transfers. It was explained to the staff coordinator preferred two CNAs to observe and not the training staff. The Staff Coordinator agreed and stated he would find another CNA. Observed someone walking down the hall and it was the same Hospitality Aide who was observed in [DATE] assisting with Mechanical lifts. Hospitality Aide A was walking toward CNA B. They entered Resident #2's room and Hospitality Aide A rolled Resident toward CNA B and placed the sling underneath Resident #2. CNA B rolled Resident #2 toward Hospitality Aide A and reached for the sling and pulled it under Resident #2. CNA B hooked the loops onto the sling and began to move resident. Hospitality Aide moved to Resident's wheelchair and assisted resident from behind as she was being lowered into the wheelchair. The legs of the Mechanical lift were widened, and the wheelchair was locked. The Hospitality Aide A and the CNA B did not inspect the sling prior to using it on the Mechanical lift. In an interview on [DATE] at 9:15 AM Hospitality Aide A stated she did not inspect the sling on the Mechanical lift and she did not witness CNA B inspect the sling prior to using it on the Mechanical Lift. She stated her name tag was correct she was a Hospitality Aide and not a CNA. She stated she had taken CNA written test and past . Hospitality Aide A also stated she told everyone that she was nervous when she took the clinicals. Hospitality Aide A also stated she was not nervous she did not know how to do some of the clinicals, and she did not pass. She stated on most of the clinicals she guessed on how to the tasks including using Mechanical lift and transfers. She stated she does get confused on some of the slings especially which hooks to use to place on the Mechanical lift. She stated it depended on the resident which color to use and she does gets this confused sometimes. She also stated that she and CNA B obtained the sling from the closet they noticed the sling was ragged and did not look safe to use. Hospitality Aide A stated she had concern about using the sling, however, she did check the storage closet on 500 and 600 hall and did not see any more slings. She stated she did not report this to the nurse or to anyone. She stated on that particular day ([DATE]) with the incident with Resident #1 she asked CNA C and they discussed which color to use because the blue hooks were broken the purple hooks was tattered and a little torn. She stated the only option was the green hooks and she had never used the green hooks before until that day. She also stated she was not qualified to do any type of transfers including Mechanical lifts. She stated she needed to do something and asked if she could finish this interview later today. In an interview on [DATE] at 9:35AM CNA B stated she did not inspect the sling prior to using it on the Mechanical lift to transfer Resident #2. She stated she had been in-service to inspect the sling prior to placing under the resident. CNA B stated she was in serviced in July the day of incident with Resident #1. She stated She was not aware that Hospitality Aide A was not allowed to do Mechanical Lift transfers. She stated Hospitality Aide A has been doing Mechanical lift transfers over 5 months. She agreed she remembered the incident when she was observed assisting with Mechanical lift during an investigation with a surveyor U in [DATE] and she continued to do Mechanical lift transfers after the surveyor U left the facility. She stated Hospitality Aide passed her written test and did not pass her clinicals. CNA B stated the staff coordinator H was aware she was completing Mechanical lift transfers and did not say it was not ok for her to bed completing this task. In an interview on [DATE] at 9:50 AM Staff Coordinator H stated he was aware Hospitality Aide A was doing Mechanical Lift transfers and did not believe it was a problem. He stated she passed her written test but did not pass her clinicals. He stated he believed since she had passed her written test she was a Certified CNA. He stated he was aware of the incident with this same Hospitality Aide using Mechanical Lifts during an investigation in [DATE]. He stated she did continue to use Mechanical lift after [DATE]. He stated she had been trained by CNAs and also went through training with him and the therapy department after the investigation in [DATE]. He stated he did have her on the schedule but did not put what her duties would be on the schedule. He stated only CNAs were required to use Mechanical lift and if she did not pass her clinicals she was not a Certified Nursing Assistant. He also stated prior to entering a resident room with a sling the staff was expected to check the sling and if it was torn or looked unsafe the staff was to report this to their charge nurse and the charge nurse would obtain a new sling for the staff. In an interview on [DATE] at 10:15 AM CNA C stated she was aware Hospitality Aide A was not a certified nursing assistant. She stated she was not aware Hospitality Aide A was not to assist with any type of transfers. CNA C stated she did not recall who informed her of this information. She stated the Hospitality Aide A has been doing CNA work over 4 months. She also stated she had continued to assist CNAs with Mechanical lifts and also had been performing care on residents such as: showers, peri care, assisting residents to the bathroom and everything a CNA would do without another CNA with her doing these tasks except for Mechanical Lift transfers. She stated she did not report this to anyone. CNA C also stated she thought everyone knew it especially the floor nurses. She stated the day of the incident on [DATE] Resident #1 was wanting a shower to go to a religious activity. She stated she was working with Hospitality Aide A on [DATE]. She stated she walked with Hospitality Aide to the linen closet to get obtain a sling. She stated both of them looked at the sling and saw where the blue hooks were torn. She stated they noticed the purple hooks was a little torn and tattered. She stated she did not recall if they looked at the green hooks. CNA C also stated they had concerns of the safety of the sling and went to other linen closets trying to find another sling to use due to the one they had did not look safe. She stated they did not find another sling and did not report it to the nurse on duty RN E. She stated they were in a hurry and decided to use the sling they did not believe was safe to use. CNA C stated she entered Resident #1 room with the Hospitality Aide A. She stated she went by the window and the Hospitality Aide A was behind the Mechanical lift. She stated during the time of the transfer prior to Resident #1 being lifted off the bed CNA C entered the room to wait for the Mechanical lift to be used on another resident. She stated the blue hoops were torn and was unable to use them and the some of the purple hooks was tearing and was tattered and they discussed if the green hooks were the appropriate hooks to use. She stated they did not look closely at the green hooks and used the green ones to hook to the Mechanical lift. She stated they placed the sling under Resident #1 and Hospitality Aide began to lift her off the bed and this is when I moved from the window area to the shower chair. She stated when she placed herself by the shower chair to assist with the transfer she heard a noise and saw Resident #1 fall to the floor hitting her face on the legs of the Mechanical lift. CNA C stated CNA D left the room to find the nurse. She also stated the RN E entered the room and began to assess the resident and within 3 minutes the DON, OTA and ADON entered the room. She stated that particular sling was not safe to use due to some of the hooks being torn and some tattered and was tearing. She also stated the sling overall was worn and beginning to tear. should have never been used on Resident #1. She stated it was not safe to use and they (Her and Hospitality Aide A) should have reported it to RN D or to the DON. She stated they knew for a fact the sling was not safe and because they did not see another one they decided to use the unsafe sling. She stated Resident #1 was not responsive when she fell and hit her head on the legs of the Mechanical lift. CNA C stated they did have an in-service in March after the investigation by surveyor U of the hospitality aides job description. She stated in the in-service it was discussed the hospitality aide could only pass out ice, make beds, answer call lights, and never do hands on care with a resident including Mechanical lift and any type of care to a resident with a CNA or alone. In an interview on [DATE] at 10:45 AM Hospitality Aide A stated she was in serviced in March after surveyor U had left completing investigation where she was observed using a Mechanical lift. She stated she was in-serviced one on one and within a group. She stated her job description of being a hospitality aide was reviewed with her. She stated she was informed by the DON to only pass out water, answer call lights, make up beds, assist residents to the dining room in their wheelchairs and she stated it was a lot more but could not recall the rest of it at this time. She stated she was also informed during the in-service never do any type of hands-on care such as Mechanical lift, any type of care that was hands on with a resident by herself or with a CNA present. She stated she had been doing everything the CNAs does during ADL care with the residents since before [DATE] but was in-serviced in [DATE] about only doing her job description of being Hospitality Aide. She stated she continued to do Mechanical lifts and gave care to residents after being in-service in [DATE]. She stated she gave the following care without any other staff with her such as: peri-care, assisting resident to the shower and giving showers, transfer residents to the toilet, transfer residents from their bed to wheelchair and to the shower chair, feeding residents, assisted CNAs using Mechanical lifts. She stated she had been doing everything the CNAs does during ADL care with the residents since before [DATE] but was in-serviced in [DATE] about only doing her job description of being Hospitality Aide. She stated she knew she was not qualified on [DATE] and any other time she assisted to do Mechanical lifts. Hospitality Aide A stated she knew the sling was not safe and it was tearing and ripped. She stated she did not look at the green hooks prior to placing them on the Mechanical lift when transferring Resident #1. Hospitality Aide A stated she was not qualified to perform a lot of skills a CNA performed. She stated she realized this when she took her skills test and failed. Hospitality Aide A stated she told staff that she became nervous but that was not the truth. She stated she guessed at a lot of the skills tasks during the test and passed but it was not because she knew what she was doing it was just luck. She stated she did not feel she was qualified to do any of the CNA ADL care. Hospitality Aide A stated she did it because she felt she could learn if she continued to do care with the residents. She stated she did not consider the residents safety when she was giving ADL care. Hospitality Aide A stated a resident may had a serious injury due to her lack of ability and knowledge on how to operate a Mechanical lift. She also stated she should not had been the one to operate the Mechanical lift the day of [DATE] due to not knowing what to do about the sling. She stated she did not know how to use that particular sling and was confused with the hooks torn and she always used the purple hooks and was afraid to use them because they were tattered and beginning to tear. She stated she discussed it with CNA C and they decided to go with the green hooks but they did not look at the green loops to determine if they were in good condition. She stated she did not request to be removed from the Mechanical lift when they used it on Resident #1 she did not want others to know she did not know what she was doing because she was afraid that she may be asked to resign from her job until she became a CNA. Hospitality Aide A stated the Staff Coordinator was aware she had continued to assist with Mechanical Lifts over the past 4 or 5 months. She stated he had observed her go into residents' rooms and ask if she was going to assist the CNA with Mechanical lift transfer and did not say she could not do this task. She stated when she and CNA B obtained the sling from the closet they noticed the sling was ragged and did not look safe to use. Hospitality Aide A stated she had concern about using the sling, however, she did check the storage closet on 500 and 600 hall and did not see any more slings. She stated she did not report this to the nurse or to anyone. She stated she walked with CNA B into Resident #1's room with the sling and the Mechanical lift was already in the room. Hospitality Aide A stated CNA B was by the window and she was using the Mechanical lift. She also stated she had never used this type of sling before and one the blue hooks was broken and they couldn't use them and the purple hooks looked old and was frayed such as slightly tearing apart. She stated she discussed with CNA B of which hooks to use on the Mechanical lift. She also stated they had to use the purple that was frail and the green hooks. She stated she did not notice if the green hooks were tearing /frail looking like the purple hooks. Hospitality Aide A stated she placed the hooks on one side and CNA B placed hooks on the other side of Mechanical lift. She stated when she began to lift Resident #1 from the bed and was pulling the Mechanical lift away from the bed she heard a snap and Resident #1 fell to the floor when she was in the air on the Mechanical lift. She stated the green hooks broke. Hospitality Aide A stated she was aware it was not in her job description to do Mechanical lift transfers and she had been doing them for 5 months. She stated she did not know if the director of nurses knew she was doing the Mechanical lift transfers. She stated she had been in serviced on her job description when the facility got into trouble about her using Mechanical lift in March. She stated she did CNA care thinking she was helping the staff. She stated now she realizes without being qualified she caused a resident serious injury from not knowing how to properly use a Mechanical lift with a defected sling and she had never used that type of sling before until [DATE]. She stated a resident fell and had serious injuries as a result of her not being a CNA and not being qualified to use a Mechanical lift. She stated Resident #1 could have died or any resident could have been seriously injured or died with me not being qualified to give any type of hands-on care to the residents. She stated she should have followed the Hospitality Aide job description and never completed any type of CNA care to a resident she was placing all residents she assisted in danger of being harmed. In an interview on [DATE] at 12:04 PM CNA D stated she entered Resident #1's room (did not recall the time) and was waiting for Hospitality Aide A and CNA C to transfer Resident #1 because she needed to use the Mechanical lift on another resident. She stated when she entered Resident #1 room the resident lying on the bed and the Hospitality Aide A had the controller in her hand to maneuver Resident #1 in the air to transfer her to the shower chair. She stated CNA C was standing behind the shower chair. When Resident #1 was being assisted in the air and Hospitality Aide A was beginning to maneuver her away from the bed this is when Resident #1 fell to the floor and hit her head on the legs of the Mechanical lift. She stated she immediately left the room to find RN E or any nurse. She stated Hospitality Aide A has been using Mechanical lifts before [DATE]. She stated she was not aware of any in-service being given of the Hospitality Aide job description. CNA D stated someone told her but she did not recall who told her it was ok for Hospitality Aide A to do any type of ADL care including Mechanical lifts on residents since she passed her written test. She stated you do have to past written and skills test to be a CNA. She stated she did know Hospitality Aide A did not pass her skills test. CNA D stated she was not to touch the residents and give any type of care including Mechanical lift if she did not have her CNA certification. She also stated she is not qualified to do Mechanical lifts or any ADL care but she had been doing this before [DATE]. CNA D stated she did not report any concerns about qualifications of Hospitality Aide A to anyone. She stated she knew of two nurse supervisors knowing Hospitality Aide A was assisting with Mechanical lift and doing ADL care. She did not give any names of the nurse supervisors and stated they were not working today ([DATE]). In an interview on [DATE] at 1:10 PM RN E stated Hospitality A and CNA C did not report to her about their concerns of the safety of the sling used on Resident #1. She stated if she had known the staff felt the sling was unsafe, she had new slings she could have given them. She stated she knew Hospitality Aide A was not to use a Mechanical lift. She stated she was not aware when she worked on the hall, she was assigned to that she was assisting with transfer via Mechanical lift or doing any CNA tasks without a CNA assisting her. RN E stated she has worked with Hospitality Aide A several times but did not recall how many times a week or a month. She stated Hospitality Aide A was not qualified to use Mechanical lift or to do any type of care on a resident. RN E stated on the day Resident #1 fell CNA D came out of the room and found me and immediately went to Resident #1's room. She stated Resident #1 was not responsive and within 3 minutes DON, ADON and OTA entered the room and took over while I went to make phone calls to 911, physician, and family. She stated it was her responsibility to monitor the nursing staff working under her on the floor she was assigned to. RN E also stated she knew Hospitality Aide A was working helping CNA C on [DATE] and she did not monitor Hospitality Aide A to ensure she was not doing hands on care. RN E stated Hospitality Aide A was only to pass out ice, answer call lights, assist residents to the dining room and make up beds and this was discussed in an in-service in [DATE]. She also stated she expected all staff to check the slings prior to entering the resident's room for safety of the sling. She stated if the sling was not safe the staff was to report to nurse supervisor and if the nurse supervisor was busy the staff was to go to the ADON or DON and report the sling was not safe to use. In an interview on [DATE] at 1:35 PM LVN I stated she was aware Hospitality Aide A was doing Mechanical lifts over 6 months. She stated she was also doing CNA care alone such as: peri care, showers, grooming, feeding residents, and transfer residents to the bathroom. LVN I stated Hospitality Aide A had been doing everything a CNA does and has been doing these tasks alone except for Mechanical lifts. She stated she was informed that the Hospitality Aide A could do anything that CNAs could do due to recently she passed her written test but failed her skilled test. She stated this does not make her a CNA if she did not pass the clinicals. LVN I stated she was the nurse supervisor and had been a supervisor when Hospitality Aide A worked on her hall. She stated she did not feel she was responsible for monitoring the staff as much as the ADON and DON. She also stated the correct proper chain of command with the CNAs was the nurse supervisor, the ADON and the DON. LVN I stated she did not report Hospitality Aide A was doing Mechanical lift transfers or any other hands-on care to the residents. She stated she assumed everyone knew since the Hospitality Aide had continued to do these tasks after the incident when surveyor U came in the facility around March. She stated the Hospitality Aide A never quit doing Mechanical lifts or any CNA care. She stated she realize after the incident with Resident #1 she should have reported it to upper management. LVN I also stated they had an in-service in [DATE] related to the Hospitality Aides job description. She stated the DON read the job description and explained that Hospitality Aides are only to pass out water, answer call lights, make up beds, can push residents in wheelchairs to activities and to the dining room. The Hospitality Aide was never to do hands on care with any resident. She also stated the staff was required to check the slings before entering the resident's room to ensure they were safe to use. She stated she received in-service on the checking the slings the day of the incident with Resident #1 on [DATE]. In an interview on [DATE] at 2:00 PM the DON stated there were three CNAs in Resident #1's room on [DATE] the day of the incident with Resident #1 was not correct . DON stated in her statement she put there were 3 CNAs in the room and this was not correct. There were 2 CNAs in the room and one Hospitality Aide. She stated there were two CNAs present (CNA C and CNA D). She also stated the other staff was present was Hospitality Aide A. She stated there were never 3 CNAs in Resident #1's room and she did interview the staff that was in the room at the time of Resident #1 falling from the Mechanical lift and she interviewed Hospitality Aide A, CNA C, and CNA D). She stated she in-service Hospitality Aide A after the state investigation in [DATE]. She stated she reviewed the Hospitality Aide job description and explained to Hospitality Aide A not to give any type of direct care including Mechanical lifts to any resident. Her job description was only to pass out ice, make beds, answer call lights, assist residents to the dining room in their wheelchairs, etc. She stated Hospitality Aide A signed the in-service. DON stated she was not aware Hospitality Aide was continuing to perform Mechanical lifts on residents or giving ADL care without another CNA assisting her. She stated no one had reported this to her. She stated the nurse supervisor was to monitor the staff on their halls. The DON also stated she did not follow up on monitoring or designate anyone to monitor Hospitality Aide A after the state investigation of Hospitality Aide A using Mechanical lift in [DATE] and this was part of the facilities plan of correction. She stated if someone had been monitoring Hospitality Aide A the incident with Resident #1 may not have occurred if there was another CNA using the Mechanical lift and reported to someone the sling was damaged. She also stated the sling should not have been used on Resident #1. The DON stated it was not a safe sling and should have been thrown away by staff. She stated that she and another administrator from sister facility completed a facility wide check on all slings. The staff had slings to use that was safe and the facility ordered more new slings on [DATE]. She stated in service began on [DATE] on how to inspect slings for any imperfections prior to every use. Who purchases new slings (DON or Medical supply), what to do if a sling is not in working condition-repot sling, the concerns of chain of command (floor nurse, DON, and then the Administrator), laundry to inspect slings each wash and all remaining slings in the facility was inspected by the DON. There were no further defected slings found in the facility. The DON stated it was not in the facility policy or protocol for Hospitality Aide to give direct care to any residents. She stated the investigation was confirmed that Hospitality Aide A was not qualified to do any Mechanical lift [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in a safe operating condition for 1 of 6 residents (Resident #1) reviewed for safe requirements. The facility failed to provide a safe sling to be used for Resident #1 on [DATE]. On [DATE], Resident #1 was being transferred by Mechanical lift and the sling broke while Resident #1 was in the air, and she fell and hit her face on the legs of the Mechanical lift. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious injury, serious impairment, or death. Findings included: Record review of Resident #1's face sheet, dated [DATE], reflected Resident #1 was a [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses of nontraumatic intracerebral hemorrhage in cerebellum (primary, admission - a devastating condition whereby a hematoma ( swelling or clotted blood) is formed within the brain parenchyma ( functional part of an organ) with or without blood extension into the ventricles (cavities in the brain)- this is a new diagnosis after return from hospital on [DATE], the following are diagnosis prior to being admitted to hospital on [DATE]: hemiplegia and hemiparesis following cerebral infarction left non-dominant side ( paralysis or partial or total body function on one side of the body, whereas hemiparesis is characterized by one-sided weakness, but without complete paralysis), lack of coordination (not able to move different parts of the body together easily), muscle wasting and atrophy ( thinning of the muscle mass), and type 2 diabetes mellitus with diabetic neuropathy, unspecified ( nerve damage caused by high blood sugars levels over time, leading to various complications in different parts of the body). Record review of Resident #1's Annual MDS Assessment, dated [DATE], reflected Resident #1 had a BIMS score of 15 indicated her cognition was intact. Resident #1 was assessed to have limited range of motion with upper and lower extremity on one side (left side). She required assistance with ADLs such as eating, all hygiene, upper and lower dressing including assist with footwear, toileting, all transfers, and repositioning in bed. Record review of Residents #1 Comprehensive Care Plan revised on [DATE], reflected Resident #1 had impaired physical mobility related to decreased in muscle strength and recent clavicle fracture (broken collar bone). Resident #1 required two person Mechanical lift transfer assistance. Intervention dated [DATE]: staff to provide a safe environment during transfers and will use a Mechanical lift with two assistance. Resident #1 had impaired physical mobility related to hemiplegia and hemiparesis following cerebral infarction affecting left-dominant side. Intervention: Assess need for an provide as indicated adaptive devices, furniture, and clothing. She was assessed to be at risk for unstable blood glucose level related to Type 2 diabetes mellitus with diabetic neuropathy. Intervention: Assess blood glucose levels as ordered. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Resident #1 was assessed to be at risk for falls related to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Intervention dated [DATE]: Encourage to keep bed in low position. Keep call light in reach. Keep personal belongings in reach. Increased staff supervision with intensity based on resident need. Resident # 1 had ADL self-care performance deficit. Interventions: She was total dependent on staff for bathing/showering, toileting, transfers and required extensive assistance with personal hygiene and oral care. Record review of Resident #1's Nurses Note dated [DATE] at 9:10 AM reflected DON was called to the room at 0901 (9:01 AM), upon arrival to the room, resident was laying in supine position, stating 'help me'. Noted blood and skin tear to LUE and LLE. OTA with resident on the floor. CNA's present in the room. Statements received from 3 CNA's. ADON present and at resident's head holding steady and asking resident not to move. DON conducted partial assessment for visible injuries without moving resident. Resident complaining of neck pain. Resident alert and oriented to self only. Baseline is A&O X 4. Pupils reactive to light. Right cheek bone noted to be swollen along with orbital swelling around right eye. Petechiae ( small red or purple spot caused by bleeding into the skin) noted to right cheek bone and right bicep area. Top of right shoulder with abrasion and blue bruising noted. Blue discoloration and bruising noted to top right middle knuckle. Resident breathing WNL. Vitals obtained (did not see vital entered in documentation). ADON stated she would kept resident calm and talking until EMS comes and has the situation under control. DON left room with ADON and 2 aides present in room. Floor RN was on phone with 911 attempting to get EMS on the way. Signed by Director of Nurses. Record review of Resident #1's Nurses Note dated [DATE] at 9:49 AM reflected, called to room by CNA- upon entering room client in prone position with face and lower extremities laying across Mechanical legs non responsive during course of log roll to supine client started groaning started neuro checks pupils non responsive client groaning and grunting- sent CNA to get DON left OTA and two other CNAs in room started process to send out to hospital-unable to reach ( she named two persons names question of these people are at the time of reading the nurses note when in the facility determined after reviewing face sheet she was referring to two family members) One family member called back as EMS was entering room-report given to them along with transfer paperwork - spoke to family member concerning the incident: client being transferred by Mechanical, Mechanical sling broke client fell to floor informed of clients condition, other family member called also given same information and updated him on where they would be taking her. Signed by RN E. Record review of Hospital Records, dated [DATE], reflected Resident #1 had new diagnosis after her Computed Tomography scans. New diagnosis: back pain, brain bleed (bleeding between the brain tissue and the skull or inside the brain tissue), cerebellar hemorrhage (where the bleeding is located in a small space in the skull, found near the brainstem and cerebellum. The cerebellum is the part of the brain responsible for balance and coordinated movements. The brainstem is responsible for controlling vital body functions, such as breathing), closed head injury (rotational forces when the head twists or turns side to side or from the brain moving forward or backward inside of the skull), facial contusion (a bruise appears on your face after an injury), fall (to drop or descend under the force of gravity, as to a lower place through loss or lack of support), intraventricular hemorrhage (bleeding inside or around the ventricles-spaces in the brain that contain the cerebral spinal fluid. Bleeding in the brain can put pressure on the nerve cells and damage them. If the nerve cells are severely damaged, it can result in irreversible brain injury), right clavicle fracture (broken collar bone), right hip pain (injuries to your hip), subarachnoid hemorrhage (bleeding in the space between your brain and the membrane that covers it), traumatic intraventricular hemorrhage (an uncommon but important condition that may be a marker of severe injury in patients with blunt head trauma), traumatic subarachnoid hemorrhage (there is bleeding in the space that surrounds the brain), and traumatic subdural hemorrhage ( type of brain hemorrhage happens when blood is leaking out of a torn blood vessel and below the space of the brain and skull. This prevents the brain from getting enough oxygen). Record review of Resident #1's facility investigation dated ,[DATE], reflected a skin tear to left forearm and left upper thigh, bruising noted to right middle knuckle, right side of face on cheek bone with petechiae (round spots that form on the skin), along with petechiae on right upper extremity. Resident #1 complaining of neck pain. Resident #1 kept still on ground by ADON for prevention of further injury since complaining of neck pain . The sling to Mechanical lift ripped and caused the resident to fall to the ground. The investigation findings were confirmed. Signed by DON. Record review of written statement by CNA C, dated [DATE] reflected I was working halls 500 and 600, Hospitality Aide A and I went into Resident #1's room to get her up for a shower, to get her ready to go and see religious service., we put the sling underneath it, we noticed the blue hook was already ripped so we put it on the green hook, we got her ready her arms were on her chest like she always did. CNA D walked into the room because she needed the Mechanical lift for another resident. Hospitality Aide A was on one side of the bed and I was on the other side of the bed, as Hospitality Aide A began to move the Mechanical, I began my way by the shower chair because I was going to grab Resident #1, from behind to make sure that she was sitting properly in the shower chair, and as I got by the shower chair, that is when I saw her fall, the sling broke from under her. CNA D did not sign her statement. Record review of written statement by Hospitality Aide A, dated [DATE], reflected I went into Resident #1's room to give her a shower. We (does not specify who assisted Hospitality Aide A) prepared the water to the shower, her clean clothes on the chair, I went to her bed. CNA C and I put the sling under her (Resident #1). We went to hook the sling to the Mechanical. The blue hooks were ripped. We used the green hooks. At this point, I did not report the ripped blue hooks. I would have reported the sling to RN E. The green hooks looked good. We did look for other slings but were unable to locate one. I was using the remote for the sling. On the way up, everything looked went well. When I went to move Resident #1 to the shower chair, I heard the sling rip. It was really fast. Both hooks ripped. Resident #1 was holding her left arm, she flipped and landed face down on the Mechanical legs. CNA D went to call for help. I was trying to get Resident #1 to respond to me, but she was not responding at all. RN D came into the room with the therapy guy and they took over care for Resident #1. Signed by Hospitality Aide A Record review of written statement by CNA D, not dated, reflected I walked into Resident #1's around 9:00 AM on [DATE] (no year documented). When I walked in Resident #1's room I saw Hospitality Aide A had the Mechanical controller in her hand and Resident #1 was on the bed . CNA C was at the foot of the bed with the shower chair in front of her. I came in and shut the door. Hospitality Aide A moved it (did not specify in her statement) out to put in front of the shower chair. The back strap broke which cuz (do not know the meaning of cuz) Resident #1 to fall and hit the floor. She hit her eye/cheek on the leg of the Mechanical. She was on her stomach. I ran out in the hallway looking for RN E. There was not a signature of CNA D or a date when she wrote the statement. Record review of written statement by DON, dated [DATE], reflected the same information from nurses note dated [DATE] by the DON was documented on the top paragraph of the statement. The second paragraph reflected DON spoke with 3 CNAs to gather information on how incident occurred. 3 CNAs were standing near restroom with Mechanical lift in resident's room. DON asked each CNA to explain what occurred and exact details. Group statement received was that CNA C was standing on the window side of the bed, Hospitality Aide A was on the opposite side of the bed with the Mechanical lift and controls. CNA C was walking around the bed and as they began to move Resident #1 via Mechanical lift to the shower chair, the sling ripped, resident fell to the ground landing with her face on the legs of the Mechanical lift. They (did not specify in statement of who she was referring to as they) then called for help. CNA D was standing in the resident's room observing the transfer and witnessed the incident. CNAs called for help and floor RN E came. CNA (don't know which CNA did not specify) called for DON, Medical Records Coordinator F and the Receptionist G came to the conference room and informed DON and ADON that we were needed on hall 500. The sling was located by the door in Resident #1's room. Upon inspection, the 3 green hooks and 4 blue hooks were ripped and tore. Signed by the DON. Record review of maintenance of slings from the Mechanical lift manual reflected to check sling for wear; discard if worn. and to Ensure sling hardware is in good condition before each use. Observation on [DATE] at 3:30 PM of the sling used to transfer Resident #1 on [DATE] revealed there were four green loops, and three of the four green loops broke during the transfer. The bottom loops had already broken prior to using the sling. There were three out of four top purple loops frayed and was beginning to tear when the sling was used for Resident #1 transfer. In an interview on [DATE] at 10:45 AM Hospitality Aide A stated she knew the sling used on Resident #1 was not safe and it was tearing and ripped. She stated she did not look at the green hooks prior to placing them on the Mechanical lift when transferring Resident #1. Hospitality Aide A stated she was not qualified to perform a lot of skills a CNA performed. She stated she realized this when she took her skills test and failed. Hospitality Aide A stated she told staff that she became nervous but that was not the truth. She stated she guessed at a lot of the skills tasks during the test and passed but it was not because she knew what she was doing it was just luck. She stated she did not feel she was qualified to do any of the CNA ADL care. Hospitality Aide A stated she did it because she felt she could learn if she continued to do care with the residents. She stated she did not consider the residents safety when she was giving ADL care. Hospitality Aide A stated a resident may had a serious injury due to her lack of ability and knowledge on how to operate a Mechanical lift. She also stated she should not had been the one to operate the Mechanical lift the day of [DATE] due to not knowing what to do about the sling. She stated she did not know how to use that particular sling and was confused with the hooks torn and she always used the purple hooks and was afraid to use them because they were tattered and beginning to tear. She stated she discussed it with CNA C and they decided to go with the green hooks but they did not look at the green loops to determine if they were in good condition. She stated she did not request to be removed from the Mechanical lift. She stated when she and CNA B obtained the sling from the closet they noticed the sling was ragged and did not look safe to use. Hospitality Aide A stated she had concern about using the sling, however, she did check the storage closet on 500 and 600 hall and did not see any more slings. She stated she did not report this to the nurse or to anyone. She stated she walked with CNA B into Resident #1's room with the sling and the Mechanical lift was already in the room. Hospitality Aide A stated CNA B was by the window and she was using the Mechanical lift. She also stated she had never used this type of sling before and one the blue hooks was broken and they couldn't use them and the purple hooks looked old and was frayed such as slightly tearing apart. She stated she discussed with CNA B of which hooks to use on the Mechanical lift. She also stated they had to use the purple that was frail and the green hooks. She stated she did not notice if the green hooks were tearing /frail looking like the purple hooks. Hospitality Aide A stated she placed the hooks on one side and CNA B placed hooks on the other side of Mechanical lift. She stated when she began to lift Resident #1 from the bed and was pulling the Mechanical lift away from the bed she heard a snap and Resident #1 fell to the floor when she was in the air on the Mechanical lift. She stated the green hooks broke. Hospitality Aide A stated she was aware it was not in her job description to do Mechanical lift transfers and she had been doing them for 5 months. She stated she did not know if the director of nurses knew she was doing the Mechanical lift transfers. She stated she had been in serviced on her job description when the facility got into trouble about her using Mechanical lift in March. She stated she did CNA care thinking she was helping the staff. She stated now she realizes without being qualified she caused a resident serious injury from not knowing how to properly use a Mechanical lift with a defected sling and she had never used that type of sling before until [DATE]. She stated a resident fell and had serious injuries as a result of her not being a CNA and not being qualified to use a Mechanical lift. She stated Resident #1 could have died or any resident could have been seriously injured or died with me not being qualified to give any type of hands-on care to the residents. She stated she should have followed the Hospitality Aide job description and never completed any type of CNA care to a resident. Hospitality Aide A stated she was placing all residents she assisted in danger of being harmed. In an interview on [DATE] at 12:04 PM CNA D stated she entered Resident #1's room (did not recall the time) and was waiting for Hospitality Aide A and CNA C to transfer Resident #1 because she needed to use the Mechanical lift on another resident. She stated when she entered Resident #1 room the resident lying on the bed and the Hospitality Aide A had the controller in her hand to maneuver Resident #1 in the air with the Mechanical lift to transfer her to the shower chair. She stated CNA C was standing behind the shower chair. When Resident #1 was being assisted in the air and Hospitality Aide A was beginning to maneuver her away from the bed this is when Resident #1 fell to the floor and hit her head on the legs of the Mechanical lift. She stated she immediately left the room to find RN E or any nurse. She stated Hospitality Aide A has been using Mechanical lifts before [DATE]. She stated she was not aware of any in-service being given of the Hospitality Aide job description. CNA D stated someone told her, but she did not recall who told her it was ok for Hospitality Aide A to do any type of ADL care including Mechanical lifts on residents since she passed her written test. She stated you do have to past written and skills test to be a CNA. She stated she did know Hospitality Aide A did not pass her skills test. CNA D stated she was not to touch the residents and give any type of care including Mechanical lift if she did not have her CNA certification. She also stated she is not qualified to do Mechanical lifts or any ADL care, but she had been doing this before [DATE]. CNA D stated she did not report any concerns about qualifications of Hospitality Aide A to anyone. She stated she knew of two nurse supervisors knowing Hospitality Aide A was assisting with Mechanical lift and doing ADL care. She did not give any names of the nurse supervisors and stated they were not working today ([DATE]). In an interview on [DATE] at 1:10 PM RN E stated Hospitality A and CNA C did not report to her about their concerns of the safety of the sling used on Resident #1. She stated if she had known the staff felt the sling was unsafe, she had new slings she could have given them. She stated she knew Hospitality Aide A was not to use a Mechanical lift. She stated she was not aware when she worked on the hall, she was assigned to that she was assisting with transfer via Mechanical lift or doing any CNA tasks without a CNA assisting her. RN E stated she has worked with Hospitality Aide A several times but did not recall how many times a week or a month. She stated Hospitality Aide A was not qualified to use Mechanical lift or to do any type of care on a resident. RN E stated on the day Resident #1 fell CNA D came out of the room and found me and immediately went to Resident #1's room. RN E stated Resident #1 was not responsive and within 3 minutes DON, ADON and OTA entered the room and took over while I went to make phone calls to 911, physician, and family. She stated it was her responsibility to monitor the nursing staff working under her on the floor she was assigned to. RN E also stated she knew Hospitality Aide A was working helping CNA C on [DATE] and she did not monitor Hospitality Aide A to ensure she was not doing hands on care. RN E stated Hospitality Aide A was only to pass out ice, answer call lights, assist residents to the dining room and make up beds and this was discussed in an in-service in [DATE]. She also stated she expected all staff to check the slings prior to entering the resident's room for safety of the sling. She stated if the sling was not safe the staff was to report to nurse supervisor and if the nurse supervisor was busy the staff was to go to the ADON or DON and report the sling was not safe to use. In an interview on [DATE] at 1:35 PM LVN I stated no one reported to her of sling not being safe to use on [DATE] when Hospitality Aide A and CNA C transferred Resident #1 via Mechanical lift and the sling broke, and Resident #1 fell to the floor hitting her face on the legs of the Mechanical lift. She stated if the Hospitality Aide A or the CNA C reported their concern safety of the sling, she could have given them a new sling. In an interview on [DATE] at 2:00 PM the DON stated there were three CNAs in Resident #1's room on [DATE] the day of the incident with Resident #1 was not correct . She stated there were two CNAs present (CNA C and CAN D). She also stated the other staff was present was Hospitality Aide A. She stated there were never 3 CNAs in Resident #1's room and she did interview the staff that was in the room at the time of Resident #1 falling from the Mechanical lift and she interviewed Hospitality Aide A, CNA C, and CNA D). She also stated after she inspected the sling the Hospitality Aide A and CNA C used on Resident #1 date of [DATE] she did confirm the sling was unsafe to use for the transfer of Resident #1. She stated the sling was tattered and the purple hooks was beginning to tear. She stated the sling was not in safe condition to use on any resident. The DON stated no one was inspecting the Mechanical lift slings used for mechanical transfer of residents and did not have a way of ensuring worn out slings were not in use. She also stated the maintenance supervisor did check the Mechanical lifts weekly, but no one was assigned to inspect the slings. She stated she in-service Hospitality Aide A after the state investigation in [DATE]. She stated she reviewed the Hospitality Aide job description and explained to Hospitality Aide A not to give any type of direct care including Mechanical lifts to any resident. Her job description was only to pass out ice, make beds, answer call lights, assist residents to the dining room in their wheelchairs, etc. She stated Hospitality Aide A signed the in-service. DON stated she was not aware Hospitality Aide was continuing to perform Mechanical lifts on residents or giving ADL care without another CNA assisting her. She stated no one had reported this to her. She stated the nurse supervisor was to monitor the staff on their halls. The DON also stated she did not follow up on monitoring or designate anyone to monitor Hospitality Aide A after the state investigation of Hospitality Aide A using Mechanical lift in [DATE] and this was part of the facilities plan of correction. She stated if someone had been monitoring Hospitality Aide A the incident with Resident #1 may not have occurred if there was another CNA using the Mechanical lift and reported to someone the sling was damaged. She also stated the sling should not have been used on Resident #1. The DON stated it was not a safe sling and should have been thrown away by staff. She stated that she and another administrator from sister facility completed a facility wide check on all slings. The staff had slings to use that was safe and the facility ordered more new slings on [DATE]. She stated in service began on [DATE] on how to inspect slings for any imperfections prior to every use. Who purchases new slings (DON or Medical supply), what to do if a sling is not in working condition-repot sling, the concerns of chain of command (floor nurse, DON, and then the Administrator), laundry to inspect slings each wash and all remaining slings in the facility was inspected by the DON. There were no further defected slings found in the facility. The DON stated it was not in the facility policy or protocol for Hospitality Aide to give direct care to any residents. She stated the investigation was confirmed that Hospitality Aide A was not qualified to do any Mechanical lift transfers. She also stated the staff coordinator did not report to her the Hospitality Aide A was using Mechanical lifts with another CNA or completing any type of ADL care without a CNA assistance. Record review of Sling inspection protocol, not dated, reflected inspect slings prior to each use. Report sling concerns to chain of command (floor nurse, DON, and then Administrator). Action: Record review on [DATE] of documentation of the investigation reflected on [DATE], the sling that was used on failed transfer was immediately removed from employee access by the DON at the time of the incident. The hall was delivered a new sling to begin using from this point forward. Record review on [DATE] of inspecting sling in-service dated [DATE] reflected the DON was in-serviced by sister facility DON and Administrator via zoom conference call regarding manufacturer recommendations on signs of deterioration for slings such as: sling faded, illegible tags, extreme curling or permanent wrinkles or creases, strap brittleness, stiffness, surface, and edge abrasions, decomposition of edge binding, surface abrasion and color loss. Record review on [DATE] of in-service regarding inspecting slings dated on [DATE] reflected the employees were educated one-on-one by the DON or designee, this in-service included a guideline for identifying signs of deterioration which include a guideline for identifying signs of deterioration which include completely faded, missing, illegible tags, extreme curling or permanent wrinkles or creases, strap brittleness, stiffness, surface, and edge abrasions, decomposition of edge binding, surface abrasion and color loss. She stated the staff was in serviced on chain of command the floor nurse was first in command, then DON and then the Administrator and how to report faulty equipment to appropriate supervisor. All resident care staff was informed new slings were readily available in the facility for replacement of unsafe or compromised equipment. The noncompliance was identified as PNC. The IJ began on [DATE] and ended [DATE]. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff did not use physical abuse or corporal punishment on a resident for one of three residents (Resident #1) reviewed for abuse. CNA C pulled Resident #1's hands and refused to stop when Resident #1 repeatedly stated to stop and there was a bruise on Resident #1's right hand after CNA C pulled on her hand. Resident #1 stated CNA C was hurting her while attempted to transfer her from lying position in bed to sitting position on the side of bed. Resident #1 was afraid of CNA C and isolated self in room after the incident. An Immediate Jeopardy (IJ) situation was identified on 06/03/2024 at 8:19 PM. While the IJ was removed on 06/06/2024 at 6:50 PM, the facility remained out of compliance at a severity of no actual harm that is not immediate and a scope of isolated. This failure placed residents at risk for injury, harm, psychosocial harm, and a decreased quality of life. Findings included: Record review of Resident #1's face sheet, dated 06/03/2024, reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of rheumatoid arthritis with rheumatoid factor, unspecified (a chronic inflammatory disorder that affects more than just your joints), polyosteoarthritis, unspecified (have arthritis in five or more joints at the same time), and scoliosis, unspecified (spine deformity). Record review of Resident #1's BIMS assessment, dated 05/16/2024, reflected Resident #1 had a BIMS score of 15 which indicated her cognition was intact. Record review of Resident #1's admission Assessment, dated 05/22/2024, reflected Resident #1 had a BIMS score of 11 which indicated her cognitive status was moderately impaired. She required assistance with ADLs such as: bathing, dressing, hygiene, bed to chair transfer, sit to stand transfer, toilet transfer and shower transfer. Resident #1 was assessed to need PRN pain medication. She also had diagnosis of arthritis (joint inflammation) and medically complex conditions (usually involve multiple body systems and are often chronic in nature). Record review of Resident #1's Baseline Care Plan, dated 05/17/2024, reflected Resident #1 was alert and oriented to time, place, and person. She was at risk for pain related to scoliosis and other diagnosis. Her bed mobility, dressing, transfers, and toileting required one staff person assist. Record review of Resident #1's Comprehensive Care Plan, dated 05/22/2024, reflected Resident #1 was at risk for injury from decrease in ADLs. Intervention: Administer medication as ordered per the physician. Assess and document pain level. She had impaired physical mobility related to rheumatoid arthritis, and polyarthritis. Intervention: Encourage participation in range of motion exercises and praise accomplishments. Evaluate and treat underlying causes. PT and OT evaluations as needed. Resident is at risk for falls due to impaired mobility. Interventions: Increased staff supervision with intensity based on resident need. Monitor resident's use of side rails when repositioning and resident's ability to safely enter/exit bed. Monitor resident's use / need of side rails per protocol. Record review of Resident #1's Nurses Notes, dated 05/15/2024 at 9:24 PM reflected Resident #1 was admitted to the facility. She had a bruise on top of her right-hand brown in color. (there was not a skin assessment completed on 05/15/2024). Signed by LVN F. Record review of Resident #1's facility admission Record, dated 05/16/2024, reflected Resident #1 responded to commands. She was alert and oriented to person, place, time, and situation. Resident #1's right and left-hand grasp were weak. Her left and right foot press strength was also weak. Record review of Resident #1's facility investigation report reflected the incident occurred on 05/16/2024 at 4:00 AM Resident #1 was interviewable and had capacity to make informed decisions. She had diagnosis of rheumatoid arthritis and polyosteoarthritis. CNA C was described as the perpetrator. Description of the allegation CNA C entered Resident #1's room to change her, CNA C was telling her to sit up, he grabbed Resident #1 by her hands and was assisting her up. Resident #1 asked him (CNA C) to stop because he was hurting her. Staff member (CNA C) kept pulling her up. Assessment of Resident #1 completed by the Director of Nurses reflected there were purple discoloration to the top of right hand between the thumb and index finger. The size of the bruise on Resident #1 right hand was 5.5 cm x 3.0 cm and was tender to touch. There was not treatment provided. The investigation reflected the investigation findings was confirmed. NP, DON, and Administrator was notified. CNA C received one-on-one counseling (date counseling was completed not indicated on the facility investigation report) and was to return to facility and reassigned to work on another hall where Resident #1 was not residing. CNA C was reeducated on resident rights, abuse, and neglect. Resident wanted to notify her family. Investigation was completed by the Administrator and Director of Nurses. Record review on 06/03/2024 of Resident #1's nurses note dated 05/16/2024 at 4:24 AM reflected Resident #1 was in bed resting with eyes closed, unlabored breathing with no facial grimacing noted and arouses without difficulty. Resident #1 is alert and oriented. She is capable of verbalizing her needs. (has numbers for vitals but does not describe what type of vitals was completed). Unable to assess skin integrity at this time related to Resident #1 refusal. Signed by LVN D Record review of Resident #1's MAR reflected on 5/16/2024 LVN D administered PRN pain medication a 6:43 AM. Resident #1 pain was at an eight (on 1 being the lowest pain and 10 being highest in pain). Record review of Resident #1's nurses notes dated 05/16/2024 at 9:15 AM (recorded as a late entry on 05/22/2024 at 6:32 PM) reflected DON called to room for assessment. Resident voiced concerns with aide on previous shift. DON conducted assessment and found purple discoloration to top of right hand between the thumb and index finger. 5.5 cm x 3.0 cm. Tender to touch. Declined pain medication. NP notified of findings on exam. Signed by Director of Nurses. Record review of Resident #1's statement to the Director of Nurses on 05/16/2024 at 9:25 AM reflected he walked in and I've (Resident #1) had never done this before. He asked what do you need? Resident #1 stated she could probably go to the bathroom. He asked me if my clothes needed to be changed. Resident #1 stated if they need to. She also stated he changed my pants and got another pair of pants out of the closet. He was going to change my pants He stated to get up. He was very rude. Resident #1 stated her right wrist was sore. Resident #1 stated the CNA told her if I don't hurt you, I will hurt myself. She asked for someone else, the CNA stated he was the only one here. Record review of CNA C's written statement dated 05/16/2024 at 5:01 PM reflected CNA C went in Resident #1 room during normal rounds. She stated she wanted to get up for the day. She was trying to find her call light but was unable to locate the call light. He stated it was attached to her right-side rail and was within reach. He stated he asked her are you sure you want to get up and she stated yes. CNA C stated he picked out a pair of pants and a shirt. He stated her brief was wet and he changed her brief. He stated he was putting on her socks and she stated Owe. CNA C also stated he was putting her pants on her and rolled her to her side and she stated, 'Owe like something hurt. He stated this was his first time working with Resident #1 and he did not know if she was in actual pain. He stated he asked her if she still wanted to get up and she said yes. He stated he assisted her in sitting position on the side of the bed. Resident #1 stated she needed something to hold on to in order to sit up on her own. Resident #1 decided she did not want to get up and I assisted her to lay back down on the bed. CNA C stated he was in her room over 20 minutes and he ensured call light was within reach and he left the room. Record review of Resident #1's nurses note dated 05/16/2024 at 9:05 PM reflected Resident #1 continued to follow up for new admission from the assisted living. She is very pleasant and alert and oriented x 3 (person, place, and time). She is cooperative with care. Resident #1 had a small open area to her upper back with a band aid covering the area. When the band aid was removed prior to giving her a shower and a new band aid was applied to residents back after her shower. There was very minimal drainage noted to the area on her back. Resident #1 required extensive assistance of one staff for transfers. Resident's care remains ongoing. Written by LVN E. Record review of Resident #1's electronic medical record reflected incident/ accident report, pain assessment, skin assessment or nurses' notes was not completed on 5/16/2024 after the incident was first reported to LVN A by CNA I LVN A did document Resident #1's vital signs on 05/16/2024 at 10:03 AM. Record review of Resident #1's nurses note on 05/17/2024 at 1:56 PM reflected Resident #1 was a new admit. Resident #1 was assisted by one staff with transfers and toileting (incontinent of bladder). She was having difficulty adjusting to new environment and the need to ask for help. Resident #1 refused to come out of her room for activities and to eat in the dining room. Record review of Resident #1's nurses note from 05/17/2024 through 06/04/2024 did not mention her bruise or if she was in pain, having depression, or change in her emotional status from the incident on 05/16/2024. There were no follow-up notes to the incident with bruising on her hand on 05/16/2024. Record review of Resident #1's nurses note on 06/04/2024 at 1:24 PM reflected there was a referral for supportive care for emotional distress. Supportive services in the facility today and will visit the resident and will obtain consent for visits. Signed by LVN H. In an interview on 06/03/2024 at 8:45 AM the Director of Nurses stated she needed to ensure CNA C gave a more descriptive interview. She stated she did not want to use leading questions. The Director of Nurses stated she needed to have asked more questions to understand in detail how he assisted her from laying position to a sitting position. Record review of LVN A's written statement (not dated) reflected LVN A received a report from Resident #1 stated CNA C was rude and rough with her. Resident #1 stated CNA C entered her room to assist with toileting and dressing early this AM. (no date on the statement). Resident #1 stated during CNA C assisting her he was pulling on her hands and arms and telling her to get up. Resident #1 stated she expressed several times he was hurting her and CNA C stated he did not want to hurt his back. Resident #1 requested to be assisted by another staff and CNA C stated he would get someone for her and he left the room and did not get anyone else to come to my room at assist me. Resident #1 stated she had bruising on her hand and the bruise was not present last night when she fell asleep. Resident #1 requested a male aide not enter her room. LVN A stated she received a verbal report from LVN D. LVN A stated in the report LVN D stated Resident #1 voiced aide was moving too fast and was rough. LVN D stated she spoke to CNA C to be mindful of how he was providing assistance. In an interview on 06/03/2024 at 9:15 AM Resident #1 stated she was admitted to this facility from assisted living center owned by the same company. She stated she was admitted late afternoon on 05/15/2024. She stated during the early morning on 5/16/24 between around 3:00AM- 4:00 AM a male staff came into her room and asked her if she needed to be changed. She stated she explained to him she thought she needed to be changed but she would rather be changed later. Resident #1 stated he would not stop asking her and she finally told him to go ahead and change her. She stated he was standing at an angle by her bed and grabbed her hands and began pulling her from a laying position and attempted to pull her to sit on the side of the bed. Resident #1 stated she began to tell him he was hurting her and to stop. She stated she kept explaining to him he was hurting her and to stop. Resident #1 stated he continued to pull her hands attempting to sit her up on the side of the bed. She also stated when she kept saying you are hurting me please stop the CNA stated, I rather for you to hurt than for me to get hurt. She stated later he stated again I rather for you to hurt than for me to hurt my back. Resident #1 stated she was afraid of him. She stated she thought he was going to hurt her. Resident #1 stated she believed he was going to pull her arm out of socket he was pulling on her that hard. She also stated she was afraid he was going to break her wrist or bones in her hands or arm. Resident #1 stated she had been in hospitals and in nursing facilities but she had never experienced any type of treatment the CNA gave me. She stated she requested another aide to assist her and he explained he was the only one on duty. Resident #1 also stated he left her room and never sent anyone else in her room to assist her. She stated she described him to the Director of Nurses and another nurse worked the morning on 05/16/2024. She stated she found out CNA C was the one who hurt me. Resident #1 stated she had a bruise on her right hand and it was not there when she went to bed when she was admitted to the facility the day before. She also stated it was a new bruise and it was painful in the area where the bruise was located. Resident #1 stated a nurse came in before 7:00 AM and gave her some medication for pain. She stated the nurse who gave her the medication was the nurse that worked with CNA C. Resident #1 stated the nurse never came in her room until after the incident and wanted to see my skin. She stated she asked her why she needed to see her skin. She stated the nurse that worked the same time with CNA C stated it was something she did with everyone. Resident #1 stated she asked her about her furniture in her room. She also stated the nurse never looked at her hands. She was wanting to see her legs for something and I told her I did not have any of that on my legs. Resident #1 stated it had something to do with cells or something like that. She stated I never understood what she was wanting to look at my skin and not my hands where he had pulled on my hands. She stated she was not very clear of what she wanted to look at on her and she was afraid to let anyone touch her at that time due to being hurt by the aide. She stated she was not going to allow anyone that morning to touch her until she saw someone in charge. Resident #1 stated she was afraid to go to sleep and she did not know what the aide may do to her if he decided to move her again. She also stated she did not appreciate the tone of voice he used and making a statement he rather for me to hurt than for him to get hurt. Resident #1 stated that made me mad and she did not want to be around him. Resident #1 stated he is working on another hall and came back to work the very night this all happened to me. She stated she was afraid if she did see him in the hall and was afraid he would do something to her for reporting him. Resident #1 also stated she was so worried about the women he was taking care of on the other halls. She stated what if they cannot speak up for themselves and he hurts someone else. Resident #1 stated someone like him did not need to be taking care of anyone in a nursing home. She stated it has taken her 2 weeks or more to trust anyone in this facility. She stated when anyone comes in her room to give her care she begs them not to hurt her. She stated she asks them a lot of questions before she will agree for them to give her care. Resident #1 stated there were 2 or 3 staff that takes care of her now and she trusts them and one is a male. She said he was so gentle with her and was so good to her. She stated she did not trust not one person in the facility because she felt since they let him come back in that facility the management did not take this abuse seriously and she stated she did consider she was abused by the male aide that worked on her hall morning of 05/16/2024 and she stated his name was (she stated his name) and it was CNA C. In an interview on 06/03/2024 at 9:57 CNA J stated she had given care to Resident #1. CNA J stated Resident #1 did not trust anyone and would ask staff to please don't hurt her or give her a bruise (Resident #1). CNA J stated Resident # 1 would talk to the staff and ask the staff questions before she would allow any staff to give her care. CNA J also stated Resident #1 trusted most staff but it was approximately 2 weeks after she was admitted to the facility before she trusted anyone. She stated Resident #1 would state the male aide hurt my hands and gave me a bruise and don't hurt me like hurt me. In an interview on 06/03/2024 at 10:40 LVN A stated LVN D gave her verbal report at the change of shift the morning of 05/16/2024. She stated during the morning report LVN D stated Resident #1 stated CNA C was rough with her and moved too fast. LVN D stated if a staff is being rough with a resident during care that would be potential abuse. LVN D stated CNA I came to her and reported Resident #1 was making accusations of an aide hurting her hands and there were bruises on her hand. LVN A stated she went to Resident #1's room and observed a new bruise on top of her right hand between the thumb and index finger. She stated Resident #1 reported to her that the male aide worked last night and early this morning (05/16/2024) came into her room between 3:00 AM and 4:00 AM and asked her if she needed to be changed. She stated Resident #1 informed her CNA C grabbed her hands and attempted to transfer her from lying position to a sitting position by grabbing her hands and pulling on her hands. LVN A stated during interview with Resident #1 of what created the bruise on her hand, she stated CNA C would not stop when she asked him to stop pulling her hands because he was hurting her. She stated Resident #1 repeatedly stated you are hurting me and stop. LVN A also stated Resident #1 informed her CNA C stated, I rather for you to hurt than for me to get hurt. LVN A stated she did consider this physical and verbal abuse. She stated Resident #1 was afraid and stated she did not want any males in her room to give her care. LVN A also stated she was alert and oriented to person, place, time, and situation on the morning of 05/16/2024. She also stated Resident #1 did not trust staff in giving her care or come out of her room approximately 1-2 weeks after the incident with CNA C on 05/16/2024. LVN A stated Resident #1 would ask each staff who entered her room not to hurt her or give her a bruise. LVN A stated she did not trust anyone and would talk to the staff and question them before she would allow anyone to do any type of care for her. In an interivew with Resident #1's R/P on 06/03/2024 at 11:30 AM she stated Resident #1 was afraid of CNA C and she repeated the same report of what occurred when CNA C pulled on her hands the early morning of 05/16/2024. She stated her mother (Resident #1) had been in the facility less than 24 hours. She also stated Resident #1 would not come out of her room approximately 1 week or more due to being afraid of CNA C and was afraid he may retaliate against her for reporting the incident of abuse. In an interview on 06/03/2024 at 11:50 AM LVN D stated she was not aware any incident occurred with Resident #1 during her shift on 05/15/2024-05/16/2024. She stated CNA C did not report anything to her. LVN D stated she went to Resident #1 during her shift sometime after midnight to check on her. LVN D stated she could not remember her nurses note documented on 05/16/2024 at 4:24 AM. She stated (after her nurses note read to her) she went in Resident #1's room to check Resident #1's skin. LVN D stated she is expected to check residents' skin before 4:00 AM if it is required to be checked. She stated Resident #1 had diagnosis of cellulitis (a common skin infection caused by bacteria), and was ordered medication for the cellulitis. LVN D stated she was required to check the area of cellulitis. She stated this is what she meant in her note when it stated to assess skin integrity. She stated she went in Resident #1's room to check the area of cellulitis. She stated Resident #1 did refuse and she did not go back to her room to check her skin. LVN D stated she did not recall why she spoke to CNA C related to being mindful of the care he was giving to Resident #1. She stated later in the morning (05/16/2024) around 6:00 AM she spoke with Resident #1 about if she had been abused. She stated she did not know the reason she asked her that question and that was something they ask new admission residents. LVN D stated Resident #1 denied being abused and they talked about her personal items in her room. LVN D stated she did not ask Resident #1 if anything happened to her earlier in the morning. She stated she did not believe there was a reason to ask Resident #1 any questions about if anything occurred with her and CNA C due to nothing had been reported to her of any type of incident. LVN D stated she did give a verbal report to LVN A at the change of shift but did not recall what she reported to LVN A. She also stated she did not know why Resident #1 was in pain around 6:45 AM on 05/16/2024. She stated she did remember giving her a pill for pain but did not recall why Resident #1 was in pain. Record review of Resident #1's medical diagnosis in the electronic medical record revealed she does not have a diagnosis of cellulitis. In an interview on 06/03/2024 at 12:50 PM CNA I stated she was taking care of Resident #1 the day shift on 05/16/2024. She stated on 05/16/2024 when she entered Resident #1's room, she was not smiling and had a grimace expression on her face and immediately stated don't hurt me. CNA I stated when she spoke to Resident #1 she began saying please don't give me a bruise and hurt me. CNA I also stated Resident #1 expressed to her that she did not trust anyone in the facility. CNA I stated Resident #1 explained to her a male CNA was in her room between 3:00 AM-4:00 AM early in the morning (on 5/16/2024) and asked her if she needed assistance. CNA I stated Resident #1 kept rubbing her hands and explained the male CNA pulled on her hands when he tried to pull her up from lying in the bed to sit on the side of the bed. CNA I stated Resident #1 informed her she told the male aide to stop and he was hurting her and he would not stop pulling her hands. CNA I also stated Resident #1 explained the male aide told her I rather for you to hurt than for me to get hurt. CNA I stated she observed a bruise on her right hand on top of hand near her thumb and the finger beside the thumb. She stated Resident #1 told her it was hurting but she got something for pain. CNA I stated she reassured Resident #1 she would not hurt her and would be very slow giving her care. CNA I stated she found LVN A and reported to her what Resident #1 told her and LVN A went to Resident #1 and assessed her. CNA I stated for approximately 2 weeks after the incident on 05/16/2024 with Resident #1, she would state to every staff who entered her room please don't hurt me and give me a bruise and would repeat please don't hurt me. CNA I stated Resident #1 would talk with staff before she would allow them to do anything for her. She also stated Resident #1 did not come out of her room or interact with anyone but her family approximately 1-2 weeks after the incident on 05/16/2024. In an attempted interview with CNA C on 06/03/2024 at 1:20 PM attempted to call CNA C and left voice message. In an attempted interview with CNA C on 06/03/2024 at 3:00 PM attempted to call CNA C and left a voice message. In an interview on 06/03/2024 at 3:10 PM the Director of Nurses stated she completed the investigation of the incident with Resident #1 and CNA C. She stated abuse was confirmed during the investigation. She stated Resident #1 had a BIMS score of 15 which indicated her cognitive status was intact. She also stated Resident #1 reported the same event that occurred with CNA C each time she had spoke to her. The Director of Nurses stated Resident #1 did have difficulty trusting staff and would talk to the staff before she agreed for any type of care given to her. She also stated LVN A reported the incident to her after LVN A assessed Resident #1. She stated she completed investigation on 05/16/2024 and it was confirmed abuse did occur when CNA C pulled on Resident #1's hands when Resident #1 asked CNA C to stop numerous times. She stated Resident #1 was afraid CNA C was going to harm her such as: break her hand or pull her shoulder out of socket. Director of Nurses stated Resident #1 did not come out of her room approximately 1-2 weeks after the incident 05/16/2024. She stated she would speak to each staff who entered her room and would not allow them to give her care until she felt safe and the staff reassured her they would not hurt her. She stated she agreed Resident #1 was reporting exactly what happened early morning of 05/16/2024 and she was physically and verbally abused by CNA C. In an interview on 06/03/2024 at 3:45 PM The Administrator stated he did sign the investigation report and it was confirmed Resident #1 was abused by CNA C. He stated he did speak to Resident #1. The Administrator did not elaborate on the details of their conversation. He stated he was not aware of CNA C making a statement he rather for Resident #1 to hurt than for him to hurt. He stated he was not aware of this statement until 06/03/2024. Record review of the Facility's Resident Abuse/ Neglect Policy (not dated) reflected This facility will not tolerate resident abuse and neglect. Any reported of suspected abuse or neglect will be thoroughly investigated by administrative staff. The residents in this facility have the right to be free of verbal, sexual, physical, or mental abuse, corporal punishment, involuntary seclusion, and/ or injury of unknown source. Definitions: 1. Abuse- Any act, failure to act, or incitement to act done willingly, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. 2. Physical Abuse- Physical action within the definition of abuse including, but not limited to, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. 3. Verbal Abuse- The use of any oral, written, or gesture language that includes disparaging or derogatory terms to the resident or within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. The Administrator was notified on 06/03/2024 at 8:19 PM, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 06/05/2024 at 06:01 PM: On 06/03/2024, an abbreviated survey was initiated at the facility. On 06/03/2024, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. Plan of Removal for F600 The facility failed to ensure that the resident was free from Abuse. CNA C attempted to transfer Resident #1 from her bed by pulling her by her arms and hands causing bruising to the resident. The facility failed to assess and document the injuries of Resident #1 after advising staff her hand was tender to touch. The facility failed to immediately assess Resident #1 after the allegation of physical abuse was made to LVN A. Action: On 6/04/2024, the DON designated an LVN to make a referral to Psychological Care, and Resident #1 was evaluated by their psychologist. The psychologist reported to the DON on 06/04/2024 that resident was doing great. The psychologist will continue to visit with the resident until she discharges her from psychological services. On 06/04/2024, the DON assessed the resident's hands where injuries occurred during transfer. DON stated that the resident has no more pain and that the injuries are in the final stages of healing. No follow-up will be needed for the bruises on the resident's hands. Starting 06/04/2024, The DON or designee will in-service and retrain nursing staff on policy and procedures of transfers. Safe transfers must be performed by all staff who work in patient care areas. All CNA's and nurses are required to follow transfer procedures. Education will include stand by, one person assists, 2 person assist, sliding board, sit to stand (Sara lift), Hoyer lift, and the stand and pivot. Return demonstration will be provided by the trainee to confirm understanding. The ADON or designee will monitor 4-5 transfers per week for 3 months to verify company policies and procedures are followed thoroughly and report findings to the DON and/or administrator weekly. Starting 06/04/2024, The DON or designee will in-service and re-educate all nursing staff on when resident physical assessments should be completed, and appropriate documentation made. If a resident makes any type of physical abuse allegation, then a complete head-to-toe physical assessment must be completed by the charge nurse. If injuries are found on assessment, appropriate documentation in observations and progress notes should be made as well as documentation of provider informed. Progress notes should be made on each shift by the charge nurse stating a detailed update on the injury site. Staff will be educated on when families should be informed of injuries or findings in a timely manner. The DON and administrator will be reeducated on pain and skin assessments and following proper policies & procedures by outside DON on 06/05/2024. Starting 06/04/2024, The Director of Nursing (DON) or designee will reeducate all nursing staff on triggers to notice when a resident is in pain and what steps need to be taken. If a C.N.A. observes a resident grimacing in pain, then he/she must notify the charge nurse immediately. The charge nurse should evaluate the resident for pain and take appropriate measures. If the resident has orders in place for pain management, then the charge nurse is to follow orders and follow-up an hour after treatment is provided to determine if treatment was successful. If current orders do not seem to be effective, then the charge nurse is to call the attending physician for further treatment/recommendations. If a resident makes an allegation of physical abuse, then the charge nurse is to immediately complete a head-to-toe assessment on the resident and document his/her findings on the resident's skin. The ADON or designee will monitor all reported pain assessments, via the 24-hour reports 4-5 days per week, to ensure that policies and procedures are being followed appropriately by the nursing staff. The ADON will report her findings to the DON and/or administrator weekly unless she finds noncompliance. If noncompliance is found, she will report immediately to the DON and/or administrator. Start Date: 06/04/2024. Completion Date: The above will be completed by 06/07/2024. Responsible: Administrator, DON and ADON Monitoring: Record review on 06/06/2024 of the in-service on abuse/neglect reflected the Administrator and the Director of Nurses was in serviced by Administrator M and DON/RN K from a facility owned by the same company. They were in serviced on the following: 1. Types of Abuse and Neglect such as verbal, physical, mental, emotional, sexual, exploitation, and neglect. 2. Procedure for suspected abuse and/or

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent the abuse of residents for one (Resident #1) of three residents reviewed for abuse. The facility did not implement the Abuse and Neglect Policy when CNA C abused Resident #1 and CNA C was not immediately relieved of duty. This failure could place residents at risk of abuse, neglect, physical harm, pain, mental anguish, emotional distress, and serious harm. An Immediate Jeopardy (IJ) situation was identified on 06/03/2024 at 8:19 PM. While the IJ was removed on 06/06/2024 at 6:50 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: Record review of the Facility Policy of Resident Abuse/ Neglect, (not dated), reflected This facility will not tolerate resident abuse and neglect. Any reported of suspected abuse or neglect will be thoroughly investigated by administrative staff. The residents in this facility have the right to be free of verbal, sexual, physical, or mental abuse, corporal punishment, involuntary seclusion, and/ or injury of unknown source. Definitions: 1. Allegations of Abuse/Neglect (Employees): After investigation is completed, and there is reason to believe that abuse, neglect, or mistreatment of a resident has occurred, the administrator or his/her designee will notify the family, attending physician, medical director, ombudsman, and the licensing agency. The administrator will relieve the employee of duty immediately. 2.Abuse- Any act, failure to act, or incitement to act done willingly, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. 3. Physical Abuse- Physical action within the definition of abuse including, but not limited to, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. 3. Verbal Abuse- The use of any oral, written, or gesture language that includes disparaging or derogatory terms to the resident or within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. Record review of Resident #1's face sheet, dated 06/03/2024, reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of rheumatoid arthritis with rheumatoid factor, unspecified (a chronic inflammatory disorder that affect more than just your joints), polyosteoarthritis, unspecified (have arthritis in five or more joints at the same time), and scoliosis, unspecified (spine deformity). Record review of Resident #1's BIMS assessment, dated 05/16/2024, reflected Resident #1 had a BIMS score of 15 which indicated her cognition was intact. Record review of Resident #1's admission MDS Assessment, dated 05/22/2024, reflected Resident #1 had a BIMS score of 11 which indicated her cognitive status was moderately impaired. She required assistance with ADLs such as: bathing, dressing, hygiene, bed to chair transfer, sit to stand transfer, toilet transfer and shower transfer. Resident #1 was assessed to need PRN pain medication. She also had diagnosis of arthritis (joint inflammation) and medically complex conditions (usually involve multiple body systems and are often chronic in nature). Record review of Resident #1's Baseline Care Plan, dated 05/17/2024, reflected Resident #1 was alert and oriented to time, place, and person. She was risk for pain related to scoliosis and other diagnosis. Her bed mobility, dressing, transfers, and toileting required one staff person assist. Record review of Resident #1's Comprehensive Care Plan, dated 05/22/2024, reflected Resident #1 was at risk for injury from decrease in ADLs. Intervention: Administer medication as ordered per the physician. Assess and document pain level. She had impaired physical mobility related to rheumatoid arthritis, and polyarthritis. Intervention: Encourage participation in range of motion exercises and praise accomplishments. Evaluate and treat underlying causes. PT and OT evaluations as needed. Resident is at risk for falls due to impaired mobility. Interventions: Increased staff supervision with intensity based on resident need. Monitor resident's use of side rails when repositioning and resident's ability to safely enter/exit bed. Monitor resident's use / need of side rails per protocol. Record review of Resident #1's facility investigation report reflected the incident occurred on 05/16/2024 at 4:00 AM Resident #1 was interviewable and had capacity to make informed decisions. She had diagnosis of rheumatoid arthritis and polyosteoarthritis. CNA C was described as the perpetrator. Description of the allegation CNA C entered Resident #1's room to change her, CNA C was telling her to sit up, he grabbed Resident #1 by her hands and was assisting her up. Resident #1 asked him (CNA C) to stop because he was hurting her. Staff member (CNA C) kept pulling her up. Assessment of Resident #1 completed by the Director of Nurses reflected there were purple discoloration to the top of right hand between the thumb and index finger. The size of the bruise on Resident #1 right hand was 5.5 cm x 3.0 cm and was tender to touch. There was not treatment provided. The investigation reflected the investigation findings was confirmed. NP, DON, and Administrator was notified. CNA C received one-on-one counseling (date counseling was completed not indicated on the facility investigation report) and was to return to facility and reassigned to work on another hall where Resident #1 was not residing. CNA C was reeducated on resident rights, abuse, and neglect. Resident wanted to notify her family. Investigation was completed by the Administrator and Director of Nurses. Record review of CNA C's time sheet reflected he was allowed to return to work the night of 05/16/2024. Record review of CNA C's disciplinary action dated 05/22/2024 reflected CNA C had a final written warning for performance and policy violation. Details of the incident: see self-report (gave the intake number of this investigation). Methods by which the employee can correct the unsatisfactory behavior: No further C/O abuse by residents. Consequences: Termination. Time frame for improvement: Remaining Employment. Employee Signature: Via Phone date: -5/22/2024. Preparer's signature: Director of Nurses date: 05/22/2024. In an interview on 06/03/2024 at 2:00 PM Resident #1 stated she was happy someone was here to investigate what happened to her when she was admitted to this facility. She stated she had not seen CNA C and she hoped she never saw him for the rest of her life. Resident #1 stated if she saw him she did not know what she would do but try to get away from him. She also stated she was afraid that morning when he was pulling her hands and she kept asking him to stop. She stated her hand did hurt and she asked for a pain pill for her hand. She stated the nurse worked the same time as CNA C did not ask her anything what happened. She stated she wanted to look at her skin and did not understand what she was wanting to look at. She did not ask to look at her hands. Resident #1 stated if the nurse (LVN D) asked her to look at her hands she would have let her. Resident #1 stated she did not understand why the CNA C did not stop when she told him to stop he was hurting her hands. She stated she interviewed staff and asked them questions before she allows anyone to touch her. Resident #1 stated she was lying in bed asleep when CNA C came in the room and kept on wanting her to sit up on the bed and be changed. She stated she did not trust him by the way he talked to her in a loud tone and was not treating her like a human. Resident #1 stated he kept pulling on her hands and then told me he rather for me to hurt than from him to get hurt. She stated no one had ever treated me so bad like he did early that morning. She stated she had only been in the facility less than 24 hours. Resident #1 also stated when CNA C said to her he rather for her to hurt than for him to get hurt, she stated she felt he was the meanest person to say something like that to an elderly lady who could not care for herself. She stated it made her mad and she became more afraid of CNA C after he said he did not care if she hurt as long as he did not hurt. Resident #1 stated she did not see him again after that night he pulled on her hands. In an interview on 06/03/2024 at 3:10 PM the Director of Nurses stated she completed the investigation of the incident with Resident #1 and CNA G. She stated abuse was confirmed during the investigation. The Director of Nurses stated Resident #1 did have difficulty trusting staff and would talk to the staff before she agreed for any type of care given to her. She also stated LVN A reported the incident to her after LVN A assessed Resident #1. She stated she completed investigation on 05/16/2024 and determined abuse did occur with Resident #1 from CNA C. She stated Resident #1 was afraid CNA C was going to harm her such as: break her hand or pull her shoulder out of socket. Director of Nurses stated Resident #1 did not come out of her room approximately 1-2 weeks after the incident 05/16/2024. She stated she would speak to each staff who entered her room and would not allow them to give her care until she felt safe and the staff reassured her they would not hurt her. The Director of Nurses stated CNA C was counseled via phone on 05/22/2024. She stated the investigation was completed on 05/16/2024 and she did not counsel with him and give him a written disciplinary action until 05/22/2024 via phone. She stated she should have spoken to him face to face when she gave him the disciplinary action. The Director of Nurses stated she did not recall the reason the disciplinary action was not completed on 05/16/2024 after the investigation. She stated according to the facility policy he should have been terminated immediately and the abuse was violation of their abuse and neglect policy. In an interview on 06/03/2024 at 3:45 PM The Administrator stated he did sign the investigation report and it was confirmed Resident #1 was abused by CNA C. He stated CNA C had not been accused of abusing anyone in the facility until now. The Administrator also stated he believed CNA C had only been confirmed abuse one time and the Administrator did not agree with terminating him at that particular time. He stated according to the policy the facility was required to terminate CNA C immediately. The Administrator was notified on 06/03/2024 at 8:19 PM, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 06/05/2024 at 06:01 PM: On 06/03/2024, an abbreviated survey was initiated at the facility. On 06/03/2024, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: F607 The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents. CNA A- attempted to transfer Resident #1 from her bed by pulling her by her arms and hands causing bruising to the resident. The facility failed to follow their policy when physical abuse was confirmed. Action: On 6/04/2024, the DON designated an LVN to make a referral to Psychological Care, and Resident #1 was evaluated by their psychologist. The psychologist reported to the DON on 6/04/2024 that resident was doing great. The psychologist will continue to visit with resident until she discharges her from psychological services. On 6/04/2024, the DON assessed the resident's hands where injuries occurred during transfer. DON stated that the resident has no more pain and that the injuries are in the final stages of healing. No follow-up will be needed for the bruises on the resident's hands. The DON and administrator will be reeducated on pain and skin assessments and following proper policies & procedures by outside DON on 6/05/2024. Starting 6/04/2024, The Director of Nursing (DON) or designee will reeducate all nursing staff on triggers to notice when a resident is in pain and what steps need to be taken. C.N.A.'s will be trained by the DON or designee on how to observe a resident that is grimacing in pain. The C.N.A. must notify the charge nurse immediately. The charge nurse should evaluate the resident for pain and take appropriate measures including documenting under pain assessment. If the resident has orders in place for pain management, then the charge nurse is to follow orders and follow-up an hour after treatment is provided to determine if treatment was successful. If current orders do not seem to be effective, then the charge nurse is to call the attending physician for further treatment/recommendations. All of this will be documented in the resident's progress notes and chart reports. The ADON or designee will monitor all reported pain assessments, via the 24-hour reports 4-5 days per week, to ensure that policies and procedures are being followed appropriately by the nursing staff. The ADON will report her findings to the DON and/or administrator weekly unless she finds noncompliance. If noncompliance is found, she will report immediately to the DON and/or administrator. Starting 6/04/2024, The DON or designee will in-service all nursing staff on when providing a thorough skin assessment is necessary and expected, such as upon admission, if a bruise or skin tear is noticed for the first time on a resident, if resident complains of roughness or states they were abused. The charge nurse will be responsible for completing and documenting a thorough skin assessment, incident report and calling the physician for orders, if necessary. Along with a skin assessment, a pain assessment must always be performed to determine the pain level of the resident. If it is determined that the resident is in pain, then the procedures for pain treatment must be followed by the charge nurse. The ADON or designee will monitor all reported bruises / skin tears to ensure company policies and procedures are followed thoroughly. Findings will be reported weekly to the DON and/or administrator unless she discovers violation of policy. If violation of company policy is found, then she will report immediately to the DON and/or administrator. Starting 06/04/2024, The DON or designee will in-service and retrain staff on policy and procedures of transfers. Safe transfers must be performed by all staff who work in patient care areas. All CNA's and nurses are required to follow transfer procedures. Education will include stand by, one person assists, 2 person assist, sliding board, sit to stand (Sara lift), Hoyer lift, and the stand and pivot. Return demonstration will be provided by the trainee to confirm understanding. The ADON or designee will monitor 4-5 transfers per week for 3 months to verify company policies and procedures are followed thoroughly. Findings will be reported to the DON and/or administrator weekly unless noncompliance is observed. If noncompliance is observed, then she will report immediately to the DON and/or administrator. The facility administrator and DON will be reeducated by outside administrator on company policies and procedures regarding resident abuse. The administrator, who is the abuse coordinator, or designee will in-service all facility staff on company policies and procedures regarding resident abuse/neglect. Administrator and DON will thoroughly review company policy and procedures regarding resident abuse and neglect for retraining purposes. If an employee witnesses an abuse allegation or if an employee is told that a resident is abused/neglected by a resident/family member or visitor, the employee will be trained by the administrator or designee to report the allegation, immediately to the administrator. If the administrator is unavailable, then the employee is to report the allegation to their immediate supervisor. It is then the supervisor's responsibility to notify the administrator. It is then the administrator's responsibility to ensure that all of the proper steps are completed, and a thorough investigation is completed, after reporting the allegation(s) to HHSC. The administrator or designee are responsible for completing the investigation and sending in the final report to HHSC in accordance with state regulatory requirements. If any of the staff are unavailable for training sessions by 6/7/2024, then each employee, including agency staff will not be able to work on the floor until they have gone through the appropriate training. C.N.A. A has been terminated from employment by the administrator, effective 6/04/2024. Start Date: 06/04/2024. Completion Date: The above will be completed by 6/7/2024. Responsible: Administrator, DON and ADON Record review on 06/06/2024 of the inservice on Resident Abuse/Neglect Policy, dated 06/04/2024, reflected 67 staff was inserviced on the abuse and neglect policy by the Administrator and DON. Record review on 06/06/2024 of CNA C personnel record reflected he was terminated on 06/04/2024. Interview on 06/06/2024 at 11:03 am the DON stated she was reeducated on pain and skin assessments and the proper policies and procedures by DON K from a sister facility. She stated she was inserviced when pain and skin assessments were to be completed after an incident with a resident. The DON stated a pain and or skin assessment should be reported when any new skin findings or abnormalities are discovered, or resident has new complaints of pain or if resident falls. The DON stated if this occurred, a skin and pain assessment should be completed, and resident should be evaluated head to toe including any report of abuse or neglect. She also stated nurses were to evaluate pain, look at non-verbal grimacing, verbal screaming, the nurses had a scale of 0 - 10 to use on residents who are verbal. She also stated reporting should be completed when there was bruises from an unexplained injury within 2 hours of discovery. The DON also stated the nurses was expected to document in the chart any administration of pain medication as ordered or needed and to notify the physician. She also stated the CNAs was expected to immediately report any abuse/neglect, change of condition or pain to the charge nurse. She stated she was in-serviced on abuse and neglect and read over the policy. She stated she learned the facility had five days to complete investigation and send in the report to HHSC. She stated if anyone reported abuse or neglect to her or the Administrator they had 2 hours to resport it to HHSC. She sated the Administrator was the abuse and neglect coordinator. The DON also stated the staff was expected and had been in serviced to report any signs of abuse or neglect to the Abuse Coordinator, the Administrator. On 6/6/2024 at 1:57 am the Administrator revealed he was reeducated on pain and skin assessments and the proper policies and procedures by RN K DON and Administer M at a sister facility. He learned pain and skin assessment should be complete anytime anything is noticed on a resident that has not been seen before. If it is noticed by the CNA, it should be report to the nurse immediately. If the CNA sees something that is red on the resident's body, and it is new it needs to be reported to the charge nurse. The charge nurse should then do a head-to-toe assessment and a pain assessment. He was also in-serviced in abuse and neglect. If someone is dismissed for abuse or neglect, the facility needs to report it to the licensing authority within 5 days. He will report abuse and neglect to HHSC as soon as possible as soon as he can get his computer up and running. On 06/06/2024 at 6:50 PM, the Administrator was notified the IJ was removed on 06/06/2024 at 6:50 PM, the facility remained at a level of with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.