**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 6 (Residents #36, #39, #43, #15, #10, and #8) of 25 residents reviewed for care plans. A) The facility failed to ensure Residents #36, #39, and #43's care plans addressed the specific individualized method of transfer needed (etc. use of a gait belt, mechanical lift, stand aid) for resident transfers. An Immediate Jeopardy (IJ) was identified on 6/25/2025. The IJ template was provided to the facility on 6/25/2025 at 12:24pm. While the IJ was removed on 6/27/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. B) The facility failed to ensure Resident #15's comprehensive care plan reflected a plan of care for her left-hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM). C) The facility failed to ensure Resident #10's Comprehensive Care Plan reflected triggers and individualized interventions for her diagnosis of PTSD (condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashbacks, and avoidance of similar situations). D) The facility failed to ensure Resident #8 comprehensive care plan reflected a plan of care for Resident #8's recurrent UTI's and prophylactic antibiotic use. The failures placed resident at risk of harm, hospitalization, psychosocial distress, and care needs not being identified.Findings included: A) Review of Resident #43's admission MDS assessment dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included heart failure, osteoporosis (bone disease which causes weakened bones and increased fractures), depression (sadness), and mild cognitive impairment. In Section GG-Functional Abilities, for the tasks of sit to stand and chair/bed-to-chair transfer, she was coded as needing substantial/maximal assistance. Her BIMS score was a 10, indicating she had mildly impaired cognition. Review of Resident #43's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included heart failure, renal failure (where the kidney's lose their ability to filter waste), other fracture, unspecified fracture of fourth cervical vertebra, repeated falls, osteoporosis, depression, and mild cognitive impairment. In Section GG-Functional Abilities, for the tasks of sit to stand and chair/bed-to-chair transfer, she was coded as needing substantial/maximal assistance. Her BIMS was a 14, indicating she was cognitively intact. Review of Resident #43's comprehensive care plan dated last revised 4/3/2025 reflected the resident was care planned for falls and had been care planned for requiring extensive assistance by 1 staff to move between surfaces and as necessary but did not indicate if she needed a gait belt, stand aide machine, mechanical lift, or touch assistance. Review of an incident report dated 4/14/2025 documented by CNA Q revealed a statement, Was taking {Resident #43} to the restroom using the bedrails to stand up as I stood by the wheelchair to help guide her to her chair as she went to turn to sit her ankle twisted, I believe, and she fell over head first and hit the wall. I could not catch her and try to keep her from falling. Review of Resident #43's physical therapy evaluation dated 3/25/2025 revealed that she was a moderate assistance with transfers. In an interview on 6/24/2025 at 2:50pm with Resident #43, she stated that she had a fall a couple of months ago that resulted in her having to have surgery at the hospital. She stated that she required assistance for almost everything from staff and that during her fall CNA Q was helping her get out of bed, and was holding onto the back of her wheelchair, and she was getting herself into it. She stated that her shoe must have gotten stuck, and she fell straight forward into the wall/baseboard and there was blood everywhere (indicating a laceration). She stated that CNA Q did not have her hands on her during the transfer, and that prior to that fall she was able to get out of bed by herself most of the time. She stated that was how they always did transfers, meaning the staff would hold onto the chair for her. In an interview on 6/24/2025 at 3:15pm with CNA Q, she stated that Resident #43 was transferring from her wheelchair into bed, and she (CNA Q) was holding onto the resident's wheelchair while the resident transferred herself into bed. She stated she was not using a gait belt. She stated that the resident was pivoting from the chair toward the bed when her foot got caught on the floor and she fell straight ahead into the wall and CNA Q called for help. She stated that they were doing their transfer the way they always did it, where CNA Q was standing by, and not touching the resident for assistance. Review of Resident #36's comprehensive MDS assessment dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including heart failure, high blood pressure, benign prostatic hyperplasia (noncancerous enlargement of the prostate gland), arthritis (inflammation of the joints), hemiplegia (total or nearly complete paralysis on one side of the body), seizure disorder, neuropathy (nerves do not function normally), and amnesia (loss of memories). His BIMS score was a 14, indicating intact cognition. Review of Resident #36's care plan last revised 3/7/2025 indicated he was a high risk for falls related to balance problems and hemiplegia. He was care planned for using the stand aide assistive device to maximize independence with transferring, but it was not indicated if a gait belt was to be used or if staff were to provide touch assistance during transfers. During an interview and observation on 6/25/25 at 2:49 PM with Resident #36 and their family, the resident stated that CNA Q would not use a gait belt, and she would just grip under his arms when getting him off the shower chair, and when transferring him out of his recliner and into the stand-aid she would pull on his belt loop/belt on his pants. He stated that recently the CNAs would have a gait belt around their waists when they would enter his room, but would not always use it, and they would still pull on his belt loops to transfer him into the stand aide. During an observation on 6/25/25 at 3:17 PM with CNA V revealed she informed Resident #36 of what she was going to be doing. The aide washed her hands and put on gloves. She did not use a gait belt when transferring the resident out of his recliner and into the stand aid. In an interview on 6/25/25 at 3:20 PM with CNA V she stated they were to put a gait belt on the residents for transfers. She stated she should have gotten a gait belt for the transfer, but she did not. She pulled out a slip of paper which indicated what kind of assist the residents she was assigned to were to receive, but Resident #36 was not on her list. She stated a negative outcome could be that the resident could fall. CNA V stated she was handed a gait belt by her nursing supervisor but was provided no instruction on how to use it, nor was she asked if she knew how to use one. Record review of Resident #39's comprehensive MDS assessment dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including anemia (not having enough healthy red blood cells to carry oxygen to the body's tissues), high cholesterol, arthritis (swelling and tenderness of one or more joints), depression (sadness), cataracts (clouding of the lends in the eye), mild cognitive impairment, vitamin D deficiency, and legal blindness. Resident #39 had a BIMS score of 11 which indicated she had moderately impaired cognition. Review of Resident #39's care plan dated last revised 5/14/2024 revealed that the resident required limited assistance by 1 staff using a stand aid to move between surfaces as necessary but did not indicate if a gait belt was to be used or if staff were to provide touch assistance during transfers. In an observation on 06/25/25 at 10:34 AM CNA O was observed assisting Resident #39 to transfer using the stand aid to get into bed. CNA O was not using a gait belt to assist the resident during the transfer, nor was the resident wearing slip resistant footwear, she was wearing fuzzy socks. A gait belt was observed lying on the shelf of the resident's bookcase. In an interview on 06/25/25 at 11:19 AM with CNA O, she stated that she knew what kind of assistance Resident #39 required based on the CNA assignment sheet at the nurse's station. She stated that when using the stand aid, the CNAs were also supposed to be supporting the residents by using a gait belt, but she had forgotten to use the gait belt because she was answering the call light for one of her coworkers who was tending to another resident at that time. She stated without the use of a gait belt and slip resistant footwear the resident could fall and injure themselves. In an interview on 6/25/25 at 3:20 PM with CNA V she stated that they were basically to always put a gait belt on the residents for transfers. She stated that she should have gotten a gait belt for the transfer, but she did not. She pulled out a slip of paper which indicated what kind of assist the residents she was assigned to were, but Resident #36 was not on her list. She stated that a negative outcome could be that the resident could fall. During a follow-up interview with CNA V, she stated that she was handed a gait belt by her nursing supervisor but was provided no instruction on how to use it, nor was she asked if she knew how to use one. In an interview on 6/24/2025 at 3:28pm with the DOR he stated that Resident #43 was a contact guard assist at the time of her fall, meaning that a staff member was to have had a hand on her for assistance. In an interview on 6/24/2025 at 3:45pm with the DON she stated that Resident #43 needed moderate assistance with transfers and that meant they needed hands on assistance. Her expectation was that for all transfers with Resident #43 staff had hands on her for assistance. Review of Resident #15's face sheet dated 06/26/2025 reflected a [AGE] year-old female admitted on [DATE] with the following diagnoses: psychotic disorder with delusions (characterized by unshakable belief in something that is not true or based on reality), hemiplegia and hemiparesis (one-sided paralysis) following cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia).) Review of Resident #15's annual MDS assessment dated [DATE] reflected she was assessed to have a BIMS score 14 indicating she was cognitively intact. Resident #15 was assessed to have functional limitations in range of motion on one side for her upper and lower extremities. Review of Resident #15's comprehensive care plan reflected a focus area for ADL self-care performance deficit related to hemiplegia to left side initiated on 08/07/2023. Interventions included Contractures: The resident has contractures of the left upper extremity. Provide skin care on shower days and PRN (as needed). Further review of her care plan reflected no other entries or plans for her left-hand contracture. Observation on 06/24/2025 at 10:00 AM revealed Resident #15 up in wheelchair in room. Resident #15 was observed to have a left-hand contracture with her fingers fixed into a closed position toward her palm. No palm guard or device was observed in her left hand. Review of definition of contracture in the [NAME] dictionary reflected a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to restricted joint mobility. Observation and interview on 06/26 2025 at 1:00 PM revealed Resident #15 in her room. Resident #15 was observed to have two therapy carrots, one on the floor and the other on a shelf. (The therapy carrot is an inflatable cone-shaped orthosis used for hand contractures. It gradually reduces sever contractures and provides painless positioning for severely contracted hands.) Resident #15 stated she could not open her left hand and using her right hand tried to open her left hand. Resident #15's left hand opened slightly to reveal long fingernails on her contracted fingers (middle finger to pinky finger). Resident #15 stated they did not really help her with her hand or trim her fingernails. Resident #15 further stated the hand these things (pointing to a therapy carrot) that they were supposed to put in her hand, but the staff rarely got around to it. In an interview on 06/26/2025 at 1:23 PM the DOR stated that Resident #15 was currently on therapy services for strengthening and stated Resident #15 was not on services for contracture management. The DOR stated Resident #15 was discharged from services on 01/29/2025. He stated a contracture management plan was not given to restorative in writing. He stated they just discussed it verbally in the morning meetings. The DOR further stated he did not provide the nursing staff with discharge notes. In an interview on 06/26/2025 at 1:45 PM the DON stated, after handing the surveyor a restorative plan for Resident #15 dated 07/28/2024, that Resident #15 was not currently getting restorative care for her left-hand contracture and should be. She further stated her contracture management was not on her care plan, and it should be. The DON stated Resident #15 should not have come off of restorative care but stayed on for contracture management to ensure her contracture did not worsen. Review of Resident #15's Restorative: hand program dated 07/28/2024 reflected the plan was active and included Restorative: Hand Program for LUE 1) Hygiene to hand, dry well. File and Trim Nails; 2) PR0M/AR0M to each joint of finger, hand and wrist joint of hand; 3) Assist resident to place hand on flat surface and stretch fingers while lightly pressing down X 10 reps; 4) Assist resident to squeeze and release ball X 10 reps; 5) Apply soft splint to hand. In an interview on 06/26/2025 at 2:00 PM CNA R stated Resident #15's left hand was contracted, and she has a carrot to put in her hand and they use it when they think about it. She stated there was no plan in her medical record or anywhere to document the use of the carrot or when they are supposed to put it in her hand. She stated since Resident #15 was not diabetic that any staff can trim her fingernails and that fingernails are usually done on the weekends. In an interview on 06/27/2025 at 12:34 PM the Administrator stated it was her expectation that residents with contractures should be seen by therapy then sent to restorative for maintenance. She stated the resident should remain on restorative and if not being seen by restorative the resident should be getting treatment from floor staff and should have a plan of care for contracture management. She stated failure of staff not doing this could result in worsening of the contracture and other complications. Review of the undated facility policy Plan of care for contracture management reflected Goals: First you want to reduce the risk of development/progression of contractures of fingers, hands or wrist. Improve range of motion of fingers hands or wrist. Improve hand hygiene. Approaches: Hygiene to right/left hand. Dry hands well and file and trim nails as needed. PROM/AROM to each joint of finger hand and wrist joint of right/left hand. Assist resident to place hand on flat surface and stretch fingers while lightly pressing down. Assist resident to squeeze and release ball. Apply soft splint to right/left hand. Review of Resident #10's face sheet, printed on 06/27/25, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included acute respiratory failure with hypoxia (not enough oxygen in the blood), post-traumatic stress disorder (PTSD), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), and low back pain. Review of Resident #10's quarterly MDS assessment dated [DATE], reflected a BIMS score of 12 which indicated moderately impaired cognition. The MDS reflected Resident #10 had a diagnosis of PTSD. Review of Resident #10's comprehensive care plan, revised on 12/11/24, reflected in part, [Resident #10] has lived a long life and has potentially suffered a traumatic event as some time in her life. Goal - [Resident #10] will remail calm/stress free during their stay in the facility. Interventions - Always approach resident calmly and speak clearly by announcing what is happening prior to performing task; Do not sneak up behind and try not to startle resident; Get to know resident and his/her preferences or triggers; Given resident choices when possible . There were no triggers identified. Review of Resident #10's Psychiatric Subsequent Assessment, dated 06/13/25, reflected a previous mental health diagnosis included PTSD. During an observation and an attempted interview on 06/25/25 at 09:30 AM, Resident #10 was observed in her bed. She stated she was comfortable, but her feet hurt. When asked about trauma, she stated she just wanted to rest, and she closed her eyes. In an interview on 06/27/25 at 10:33 AM, the Social Worker stated she asked residents about trauma when she completed the resident's social history. She stated she completed the care plans for residents with trauma. She stated she did not remember if Resident #10 had a diagnosis of PTSD. After looking into the electronic medical record, she stated she did not have any information about PTSD or triggers on the social history from when the resident was admitted . She stated if triggers were not on the care plan, staff could do something to upset or scare the resident and put them back in the situation that caused their trauma. In an interview on 06/27/25 at 10:49 AM, the DON stated she expected care plans to be accurate, individualized, and completed timely. She stated the Social Worker was responsible for completing some care plans including trauma related care plans. She stated if triggers were identified, staff would be able to avoid retriggering the resident. The DON stated she tried to monitor the care plans, and the care plans were reviewed in the quarterly IDT meetings. The DON stated if the care plan was not accurate or individualized, the resident may not receive appropriate care or support. In an interview on 06/27/25 at 12:40 PM, the Assistant Administrator stated she expected the care plans to be individualized, accurate, and completed timely. She stated the residents may not have their needs met if care plans were inaccurate. D) Review of Resident #8 face sheet dated 06/27/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses acute pulmonary edema (fluid on the lungs), urinary tract infection (bladder infection) and congestive heart failure (heart failure). Review of Resident #8's quarterly MDS assessment dated [DATE] reflected Resident #8 was assessed to have a BIMS score of 11 indicating moderate cognitive impairment. Resident #8 was assessed to always be incontinent of urine. Resident #8 was assessed to not have any infections and was assessed to be on antibiotics. Review of Resident #8's consolidated physician's orders dated 06/26/2025 reflected an order dated 08/15/2024 Keflex 500mg give one capsule by mouth at bedtime for prevention. Review of Resident #8's UTI's from 08/15/2024 through 06/26/2025 reflected she was diagnosed with a UTI on three separate occasions: -01/10/2025 reflected an individual resident infection surveillance report dated 01/08/2025. Symptoms listed: AMS (altered mental status) Culture: Yes; Organism: Pseudomonas Aeruginosa >100,00 CFU/ml. Medication Cipro 500 mg BID x 7 days. Further review of the infection surveillance report reflected no other symptoms were documented. -04/25/2025 reflected an individual resident infection surveillance report dated 04/25/2025. Symptoms listed: increased confusion: Culture yes: organism Enterococcus faecium 50-100,00 CFU/ml. Medication: Amoxicillin 500 mg TID x 10 days. -05/29/2025 reflected an individual resident infection surveillance report dated 05/28/2025. Symptoms listed: Resident not feeling well. antibiotics orders for ciprofloxacin HCL 250 mg one tablet two times daily for 7 days. Review of Resident #8's culture report reflected Pseudomonas Aeruginosa >100,00 CFU/ml. Review of Resident #8's comprehensive care plan initiated on 12/20/2023 and last revised on 04/23/2025 reflected no entries related to urinary tract infections or antibiotic use. In an interview on 06/27/2025 at 11:00 am the DON stated residents should have care plans for all UTIs and if a resident was on routine antibiotics a care plan should be done with a plan for monitoring for SE. She stated the facility has been without a MDS coordinator and they have just hired one moving forward she stated they will ensure the development of care plans to ensure the residents receive appropriate care to resolve UTI's. Review of the facility's undated policy Resident Care Plan reflected 1. To develop a comprehensive care plan for each resident that includes measurable short-term and long-term objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment . 2. A comprehensive care plan should be oriented towards . 5) Applying current standards of practice in the care planning process. 6) Evaluating treatment of measurable objectives, timetables, and outcomes of care.7) Respecting the resident's right to decline treatment. 8) Offering alternative treatments, as applicable. 9) Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities. 10) Involving resident, resident's family, and other resident representatives as appropriate. 11) Assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs. 12) Involving the direct care staff with the care planning process relating to the resident's expected outcomes. 13) Addressing additional care planning areas that are relevant to meeting the resident's need in the long-term care setting . The assistant ADM and DON were notified on 6/25/2025 at 12:15pm that an Immediate Jeopardy had been identified due to the above failure and an IJ template was provided. The following POR was accepted on 6/26/2025 at 12:35pm: On 06/25/2025 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 the Immediate Threat states as follows: F656- The facility must develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The facility failed to ensure Resident #43's care plan addressed the specific individualized method of transfer needed (etc. use of a gait belt, mechanical lift, stand aid) for resident transfers. Action: All resident care plans will be updated and individualized with specific patient care needs. MDS Coordinator will review all care plans and individualize. Director of Nursing will monitor and assist as needed, and update with 72 hours. Care Plans will be individualized to the resident's specific needs. Start Date: 06-25-2025 Completion Date: 06-25-2025 Responsible: Director of Nursing Action: Assistant Administrator In-Serviced Director of Nursing and MDS Coordinator on the importance of updating and individualizing the care plans within 72 hours. Informed them this would be discussed during morning meeting and if there were any status changes or new orders, the care plan would need to be updated within 72 hours. Assistant Administrator or Administrator will do a visible audit to ensure care plans are being updated, once a week for four weeks, then monthly for 6 weeks, then quarterly thereafter. Care Plan policy will be updated to reflect all new practices adopted. Start Date: 06-25-2025 Completion Date: 06-25-2025 Responsible: Administrator Action: The MDS Coordinator will be responsible for reviewing the most recent comprehensive assessments to ensure they match the individualized resident care plan. The DON or ADON will monitor for accuracy. Start Date: 06-25-2025 Completion Date: 06-25-2025 Responsible: Director of Nursing The surveyor monitored the POR on 6/27/2025 as follows: Review of Resident #36's care plan last updated on 6/25/2025 revealed that his care plan was changed to The resident uses stand aide assistive device with gait belt to maximize independence with transferring. Review of Resident #39's care plan last updated on 6/25/25 revealed that her care plan was changed to The resident requires assistance by 1 staff using stand aid and gait belt to move between surfaces as necessary. Review of Resident #43's care plan last updated on 6/25/25 revealed that her care plan was changed to The resident requires extensive assistance by 1 staff with stand aide and gait belt to move between surfaces and as necessary. Review of a list of residents was provided to the state surveyors on 6/27/25, revealing that all residents had their care plans reviewed and updated if applicable. Review of the facility's updated policy titled; Resident Care Plan revealed the following updates: Addressing additional care planning areas that are relevant to meeting the resident's need in the long-term care setting. Any changes in condition that are reported by the nursing staff will be updated within 72 hours of notification. Review of an in-service titled Care Plan Updates In-Service conducted by the ADM on 6/25/25, revealed that the DON and MDS coordinator were counseled on the timely updates of care plans to be individualized, the importance of recognizing when a resident had a change in their specific care needs and method of transfer had changed. It reflected those things would be discussed during each morning meeting held and that care plans needed to be updated accordingly and timely, if needed. The signatures of the ADM, DON, and MDS were reflected. In an interview on 6/27/2025 at 12:29 PM with the DON she stated she had the nursing supervisors to pass out the gait belts to all staff and placed them at nurses' station to ensure a gait belt was available to each CNA. She stated the IDT would bring up any issues in morning meetings to ensure access to gait belts. She stated she had the nursing supervisors print out current transfer status and had each resident assessed and care plans were updated to reflect resident specific transfers. She stated that she would be responsible for monitoring the accuracy of resident assessments and care plans. In an interview on 6/27/2025 at 12:40 PM with the ADM she stated that she in-serviced the DON and MDS Coordinator on the importance of updating and individualizing resident care plans within 72 hours. She informed them it would be discussed during morning meetings and if there were any status changes or new orders, the care plan would need to be updated within 72 hours. She stated she would do a visible audit to ensure care plans were being updated once a week for four weeks, then monthly for 6 weeks, then quarterly thereafter. She further stated the care plan policy was updated to reflect the new procedures. In an interview on 6/27/2025 at 12:47 PM with the MDS Coordinator she stated that she was going to be responsible for reviewing all resident's most recent comprehensive MDS assessments and would ensure that the comprehensive care plan would reflect the same. She stated that she recently received in-service training from the ADM regarding this. Review of the facility's updated on 6/27/2025 Care Plan policy revealed, A comprehensive care plan should be oriented towards managing risk factors to the extent possible or indicating the limits of such interventions. Involving the direct care staff with the care planning process relating to the resident's need in the long-term care setting. The ADM and DON were notified the IJ was removed on 06/27/25 at 3:30PM. However, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 4 (Residents #19, #36, #39, and #43) of 24 residents reviewed for accidents and hazards. A) The facility failed on [DATE] to ensure Resident #43 was provided contact guard assistance during sit to stand transfers which resulted in an actual fall which resulted in 9th, 10th and 11th right rib fractures, C4 spinous process fracture, T10 compression fracture, and a frontal scalp hematoma/laceration. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 6:00pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. B) The facility failed to on [DATE] and [DATE] ensure there was appropriate assistance provided to Residents #19, #36, and #39 while utilizing the stand aide (mechanical lift to assist the resident into a standing position). These failures could place residents at risk for falls, injuries, hospitalization, or death. Findings include: A) Resident #43 Review of Resident #43's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included other fracture, unspecified fracture of fourth cervical vertebra, repeated falls, osteoporosis, and mild cognitive impairment. In Section GG-Functional Abilities, for the tasks of sit to stand and chair/bed-to-chair transfer, she was coded as needing substantial/maximal assistance. Her BIMS was a 14, indicating she was cognitively intact. Review of Resident #43's comprehensive care plan dated last revised [DATE] reflected the resident was care planned for falls and had been care planned for requiring extensive assistance by 1 staff to move between surfaces and as necessary. Review of Resident #43's physical therapy evaluation dated [DATE] revealed that she was a moderate assistance with transfers. Review of an incident report dated [DATE] documented by CNA Q revealed a statement, Was taking {Resident #43} to the restroom using the bedrails to stand up as I stood by the wheelchair to help guide her to her chair as she went to turn to sit her ankle twisted, I believe and she fell over head first and hit the wall. I could not catch her and try to keep her from falling. Review of Resident #43's hospital record dated [DATE] revealed: 9th, 10th and 11th right rib fractures, C4 spinous process fracture, T10 compression fracture, and a frontal scalp hematoma/laceration. In an interview on [DATE] at 2:50pm with Resident #43 she stated she had a fall a couple of months ago that resulted in her having to have surgery at the hospital. She stated that she required assistance for almost everything from staff and that during her fall CNA Q was helping her get out of bed, and was holding onto the back of her wheelchair, and she was getting herself into it. She stated that her shoe must have gotten stuck, and she fell straight forward into the wall/baseboard and there was blood everywhere. She stated that CNA Q did not have her hands on her during the transfer, and that prior to that fall she was able to get out of bed by herself most of the time. She stated that was how they always did transfers, meaning the staff would hold onto the chair for her. In an interview on [DATE] at 3:15pm with CNA Q she stated that Resident #43 was transferring from her wheelchair into bed, and she (CNA Q) was holding onto the resident's wheelchair while the resident transferred herself into bed. She stated she was not using a gait belt. She stated that the resident was pivoting from the chair toward the bed when her foot got caught on the floor and she fell straight ahead into the wall and CNA Q called for help, the nurse assessed the resident, began neurological checks, and called the EMS. She stated that they were doing their transfer the way they always did it, where CNA Q was standing by, and not touching the resident for assistance. In an interview on [DATE] at 3:28pm with the DOR he stated that Resident #43 was a contact guard assist at the time of her fall, meaning that a staff member was to have a hand on her for assistance. In an interview on [DATE] at 3:45pm with the DON she stated that Resident #43 needed moderate assistance with transfers and that meant they need hands on assistance. Her expectation was that for all transfers with Resident #43 staff have hands on her for assistance. Review of CNA Q's in-service record revealed she was last in-serviced on resident fall prevention on [DATE]. B) Resident #19 Record review of Resident #19's comprehensive MDS assessment dated [DATE] reflected an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including osteoporosis (bone disease which causes weakened bones and increased fractures), muscle weakness, lack of coordination, and a history of falling. In Section GG-Functional Abilities, for the tasks of sit to stand and chair/bed-to-chair transfer, she was coded as needing supervision or touching assistance. She had a BIMS score of 12, which indicated she had moderately impaired cognition. Review of Resident #19's care plan revealed she had limited physical mobility due to weakness. She was care planned for being on diuretic therapy and had an intervention for being monitored for an increased risk of falls. She was care planned for being a moderate risk for falls related to mobility abnormality, lack of coordination, muscle weakness, falls. Interventions included to make sure the resident's call light was within reach, follow facility fall protocol. Review of Resident #19's weekly skin assessment dated [DATE] revealed a note that stated, Resident has multiple purple bruises to bilateral arms. Review of Resident #19's weekly skin assessment dated [DATE] revealed the answer to question 1. Skin intact with no visible injury, discoloration, or change from previous assessment was marked as (a. Yes). Further review revealed there were no notes indicating the resident still had bruising. In an observation and interview on [DATE] at 1:34 PM with Resident # 19 she stated the large bruises on her arm near her left elbow crease was from the metal nut that held the bars together on the stand aid. She stated her arm hit the nut on the stand aid and bruised her and she told her CNA, (CNA D), and sometimes a nurse would look at it. She stated sometimes the CNA's used a gait belt but not all the time. She stated the RN had looked at the bruises but there was not much they could do about it. In an interview on [DATE] at 1:45 PM with CNA M she stated that Resident # 19 had told her the bruising on her arm was from the stand aid and she (CNA M) had verbally told her charge RN, but at that time she was unable to say which charge RN it was, just that it was whichever one was working at the time of the report. In an observation on [DATE] at 1:10pm of the 2 of 2 stand aides in the shower room of station 2 revealed 3 of the 4 nuts/bolts that protruded from the outsides of the stand aide machine (where a resident would reach up to begin grabbing onto the bars) were missing their plastic caps. In an interview on [DATE] at 1:47 PM with Nurse Supervisor A she stated that Resident # 19 took a blood thinner and bruised easily and that she had not been informed that the resident was being bruised by the stand aid. When shown the stand aid nut cover on 1 of the 4 nuts, she stated that they could put in a maintenance request for them to order more covers to prevent more residents from being bruised or cut. In an interview on [DATE] at 1:49PM with the MS he stated he would get the handwritten maintenance requests from the nurses' stations but that no one had ever requested the plastic caps to be replaced before. He stated it was maintenances responsibility to inspect the stand aid machines to look for wear and tear on the kneepads, seat pads, and they would replace the bolts, but it was not their practice to look at the plastic caps. Resident #36 Review of Resident #36's comprehensive MDS assessment dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses arthritis (inflammation of the joints), hemiplegia (total or nearly complete paralysis on one side of the body neuropathy (nerves do not function normally), and amnesia (loss of memories). His BIMS score was a 14, indicating intact cognition. Review of Resident #36's care plan indicated he was a high risk for falls related to balance problems and hemiplegia. He was care planned for using the stand aide assistive device to maximize independence with transferring. During an interview an observation on [DATE] at 2:49 PM with Resident #36 and their family, the resident stated that CNA Q would not use a gait belt and she would just grip under his arms when getting him off the shower chair, and when transferring him out of his recliner and into the stand-aid she would pull on his belt loop/belt on his pants. He stated that recently the CNA's would have a gait belt around their waists when they would enter his room, but would not always use it, and would still pull on his belt loops to transfer him into the stand aid. During an observation on [DATE] at 3:17 PM with CNA V she informed the resident of what she was going to be doing, washed her hands, and put on gloves. She did not use a gait belt when transferring the resident out of his recliner and into the stand aid. In an interview on [DATE] at 3:20 PM with CNA V she stated they were to put a gait belt on the residents for transfers. She stated she should have gotten a gait belt for the transfer, but she did not. She pulled out a slip of paper which indicated what kind of assist the residents she was assigned to were to receive, but Resident #36 was not on her list. She stated a negative outcome could be that the resident could fall. CNA V stated she was handed a gait belt by her nursing supervisor but was provided no instruction on how to use it, nor was she asked if she knew how to use one. Resident #39 Record review of Resident #39's comprehensive MDS assessment dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including arthritis (swelling and tenderness of one or more joints), , cataracts (clouding of the lends in the eye), mild cognitive impairment, and legal blindness. Resident #39 had a BIMS score of 11 which indicated she had moderately impaired cognition. Review of Resident #39's care plan revealed the resident required limited assistance by 1 staff using stand aid to move between surfaces as necessary. During an observation on [DATE] at 10:34 AM CNA O was observed assisting Resident #39 transfer using the stand aide to get into bed. CNA O was not using a gait belt to assist the resident during the transfer, nor was the resident wearing slip resistant footwear, she was wearing fuzzy socks. A gait belt was observed lying on the shelf of the resident's bookcase. In an interview on [DATE] at 11:19 AM with CNA O, she stated she knew what kind of assistance Resident #39 required based on the CNA assignment sheet at the nurse's station. She stated when using the stand aid, the CNAs are also supposed to be supporting the resident's by using a gait belt, she had forgotten to use the gait belt because she was answering the call light for one of her coworkers who was tending to another resident at that time. She stated without the use of a gait belt and slip resistant footwear the resident could fall and injure themselves. Review of the Stand Assist Assembly and Operation Manual dated [DATE] revealed that plastic caps were a part of the pictured fasteners and tools that came with the machine. Review of the facility's undated Transfer Activities Assisting Resident to Transfer to Chair or Wheelchair policy reflected under 'Purpose': To assist the resident to transfer from bed to chair, toilet, or other surface safely or without trauma or avoidable pain. Review of the facility's undated Resident Falls Protocol policy reflected under 'Fall Prevention': Assist residents with ADLs as needed. Inservice staff as needed over Fall Prevention. The assistant ADM and DON were notified on [DATE] at 5:45pm that an Immediate Jeopardy had been identified due to the above failure and an IJ template was provided. The following POR was accepted on [DATE] at 4:44pm: On [DATE] an abbreviated survey was initiated at facility. On [DATE] 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 Threat states as follows: F689 - The facility must ensure each resident receives adequate supervision and assistant devices to prevent accidents. The facility failed to ensure Resident #43 was provided contact guard assistance during sit to stand transfers with resulted in an actual fall with injuries including multiple rib fractures, a closed nondisplaced fracture of the fourth cervical vertebrae, and a frontal scalp laceration that required sutures on [DATE]. Action: All nursing staff verbally and by in-service were made aware of how to find a resident's transfer status and level of assistance needed. Start Date: 06-25-2025 Completion Date: 06-26-2025 Responsible: Administrative Nursing and Training Coordinator Action: Nursing Administration ensured there are adequate gait belts available on each station for each CNA. Charge nurses will show CNAs at the beginning of each shift where they can locate a gait belt and when to properly use one. Nursing Supervisors distributed a gait belt to each nursing staff member on duty to use and showed them on their group assignment how to locate a resident's transfer status. The Training Coordinator in-serviced all nursing staff on proper transfers and the use of all transfer devices in the facility. Training will be completed upon hire, yearly and as needed for retention to ensure ongoing proper use of equipment and in-services will be provided to all nursing staff. Charge nurses will be responsible for educating/in-servicing agency staff to ensure they are aware of a resident's level of assistance and will ensure proper transfers and use of all transfer devices in the facility. A test will be required at the end of each in-service for proof of retention. Start Date: 06-25-2025 Completion Date: 06-26-2025 Responsible: Administrative Nursing and Training Coordinator Action: In-Service on proper transfers for nursing staff and neglect for all staff. Training coordinator is a Licensed Vocational Nurse as well as a NATCEP Instructor, as well as 40 years as a LVN at our facility. Her NATCEP was completed on 02-14-2024 and skills review was completed on 05-10-2024. In-service will be completed quarterly and as needed for retention; a test will be required at the end of each in-service for proof of retention. Upon hire, quarterly and as needed for retention, to ensure ongoing proper transfers and education on neglect in-services will be provided to all staff; a test will be required at the end of each in-service for proof of retention. All staff, including agency will be required to attend all in-services and will be checked off quarterly for retention, a test will be required at the end of each in-service for proof of retention. Start Date: 06-25-2025 Completion Date: 06-26-2025 Responsible: Training Coordinator Action: New protocol in place to complete an interdisciplinary post fall investigation within 72 hours on each fall in this facility. Form will be completed by nursing supervisor and kept electronically on our shared computer drive that is accessible on any computer in our facility. The Interdisciplinary post fall investigation will be reviewed at the following QAPI meeting. Administrative nursing will follow up on all interdisciplinary post fall investigations every 6 months. Administrator will monitor investigation is being performed within 72 hours. Pending outcome of investigation will warrant if further action is needed. Start Date: 06-25-2025 Completion Date: 06-25-2025 Responsible: Director of Nursing Action: QAPI Committee met to discuss new implementations and new QAPI processes of reviewal of the interdisciplinary post fall investigation monthly at each meeting. All members agreed form was a good addition and to implement. DOR suggested that someone from therapy coordinate with the training coordinator and when we hire a new CNA, a therapist would demonstrate on the proper use transfer aides. Attendees of QAPI: Assistant Administrator, Director of Nursing, Assistant Director of Nursing, Director of Rehab, MDS, Business Office Manager, Dietary Manager, Social Services, Environmental Services Manager and Activity Director. Dr. [name] met with Assistant Administrator and Director of Nursing separately due to not being able to attend the QAPI meeting to go over his expectations of the importance of recognizing neglect and investigating falls appropriately. Start Date: 06-25-2025 Completion Date: 06-25-2025 Responsible: Administrator Action: Director of Rehab will coordinate with Training Coordinator on all new hires for CNAs to train for proper use of transfer aides. To ensure completion added to Nurse Aide performance record check off list for new hires. A therapist from the therapy department will demonstrate the proper use of transfer aides with the new hires. The new hire will then demonstrate back the proper use of transfer aides. This will be checked off in their new hire packet. Start Date: 06-25-2025 Completion Date: 06-25-2025 Responsible: Training Coordinator Action: Charge Nurse will be responsible for ensuring agency staff will be made aware of the resident's level of assistance and proper use of transfer devices. Form will be signed off showing they have been educated on the different levels of assistance and proper use of transfer devices. We will in-service agency quarterly and as needed for retention. All care plans will be updated to be individualized with their specific transfer needs and levels of assistance needed. A detailed legend that describes the definition of each level of care will be posted explaining different levels of assistance required at all CNA monitors and nursing monitors at all stations. Start Date: 06-25-2025 Completion Date: 06-25-2025 Responsible: Nursing Supervisors The surveyor monitored the POR on [DATE] as follows: An observation on [DATE] at 9:15 AM nurses' station #2 was observed to have multiple gait belts lying on the countertop, and majority of the nursing staff were observed wearing a gait belt draped around them or on their person. A CNA assignment sheet dated [DATE] revealed what type of assistance the residents on the halls required and if a gait belt was required for their transfers. An observation on [DATE] at 11:04 AM CNA M assisted Resident #43 out of her bed and onto the stand aid. She washed her hands and then applied gloves to her hands. The CNA put shoes on the resident. CNA M put a gait belt around the resident's waistline and tightened it, she checked with the resident to make sure it was not too tight. She informed the resident where to grab the stand aid and lifted the resident's bed to help her into the stand aid, they then helped lower her into her wheelchair. The resident's knees were not buckling, there were no signs of stress, and she assisted the aide in getting herself into the stand aid. An observation on [DATE] at 11:55 AM PTA was assisting Resident #36 into his w/c from his recliner. PTA was using a gait belt that was placed at the resident's waistline, and the PTA assisted the resident out of his recliner and the resident pivoted to sit down into his wheelchair. The resident appeared steady with no weakness in his knees and was wearing tennis shoes. An observation on [DATE] at 1:25 PM revealed CNA K and CNA L transferred Resident # 100 from the wheelchair to the bed using the mechanical lift. The CNAs explained the procedure to the resident before they initiated the transfer and throughout the transfer. The CNAs adjusted the lift in front of the resident and connected the purple loops on the sling to the lift. CNA L pushed the buttons to raise the resident and CNA K held the handle on the back of the sling and steadied the resident. When the resident was at the proper height, the CNAs adjusted the position of the lift until the resident was properly centered over the bed. They lowered the resident on to the bed then disconnected the sling from the lift. The CNAs moved the lift away from the bed and positioned the resident for comfort. In an interview on [DATE] at 11:17 AM with CNA M she stated that she was in-serviced on using a gait belt during all transfers for residents who were indicated as needing a gait belt on their CNA assignment sheet. They report ANE to the ADM or charge RN or the DON. She stated they could locate a gait belt at the nurse's station at the beginning of each shift. In an interview on [DATE] at 11:18 AM with Nurse Supervisor A she stated that she was taught how to implement gait belts during transfers for patient safety, during the in-services they went over types of ANE and to report it to their ADM, or their assistant ADM, or the DON. She stated that the CNA's were to pick up a gait belt at the RN station at the beginning of their shifts and the CNAs were to have the gait belt on their person during their shift and what kind of assistance a resident needed was mentioned on the assignment sheet at the nurse's station. In an interview on [DATE] at 11:25 AM with Agency LVN Y she stated she worked at the facility a lot. She stated on [DATE] they were given an in-service to sign, and a book was left at the nurse's station that she signed to acknowledge that she understood safe resident transfer devices, when to use a gait belt, who required the use of gait belts, and what method of transfer to use for which residents. In an interview on [DATE] at 11:30 AM with CNA P she stated he had 2 - 3 in-services in the last 2 days on safe transfers and preventing and reporting ANE. She was told that at the beginning of her shift she should go to the nurse's station and obtain a gait belt to keep on her for resident transfers. She stated if a gait belt was not available, she would ask the charge nurse or supervisor to get one for her. She stated she was in-serviced on ANE and provided examples to the state surveyor. She stated she was in-serviced on proper transfers to include gait belt, mechanical lifts and stand aide. In an interview on [DATE] at 11:58 AM with PTA he stated that he was recently in-serviced, a situation of ANE was when lights are ignored, therapy always uses gait belts for standing, transfers, anything pertaining to standing, he stated they will start showing new employees how to use gait belts. They report ANE to ADM or DON. In an interview on [DATE] at 11:59 AM with CNA N she stated she recently received in-servicing where she was informed they always had to have the stand aid and wheelchairs locked, then put the gait belts on residents who require them (indicated on the CNA assignment sheet), if the resident was a 2 person assist, 2 people must assist. The only time they do not use a gait belt was during a mechanical lift or for a resident who was independent. She stated that a gait belt was a part of their uniform to assist with the resident. She stated the training coordinator provided training on how to properly put the gait belt on the residents. She took a posttest after doing receiving the in-service. In an interview on [DATE] at 12:01 PM with CNA I she stated she had been trained [DATE] on proper transfers. She stated she was told to ensure the resident had shoes on and to make sure the gait belt was on the resident and fitted properly before a transfer. She stated she was told to use her leg to block or steady the resident's legs then she would hold the gait belt to assist the resident to stand. She stated she had received training on the stand aid and the mechanical lift. She was told if the resident required assistance of two staff for transfers, there had to be two staff there for the transfer. She stated she was told that ANE had to be reported immediately to the ADM who is the abuse coordinator. She stated she was told to report to the nurse if the ADM was not available. In an interview on [DATE] at 12:05 PM with CNA L stated she had been trained this morning on transfers and she took a test. She stated she was told their daily assignment sheets had the information on the type of assist each resident required. She had a copy of the assignment sheet in her pocket. She stated she was told that the gait belts were located behind the nurse's station. She stated she was told if a resident required two staff for transfers, two staff had to do the transfer. She stated she had training on how to use the stand aid and the mechanical lift and was told were they were located. She stated she was told to immediately report any ANE to the ADM who was the abuse coordinator. In an interview on [DATE] at 12:08 PM with LVN G he stated that he had received training on transfers [DATE]. He stated the transfer information was located on the assignment sheets at the nurses station. He stated he learned the gait belts were kept behind the nurse's station and that gait belts were used for all transfers except for mechanical lift transfers or independently ambulatory residents. He stated he was told any suspected ANE was to be reported immediately to the ADM. In an interview on [DATE] at 12:12 PM, with CNA K she stated on [DATE], she was trained on proper transfers. She stated she learned how and when to use a gait belt for transfers. She stated the gait belts were kept behind the nurse's station and that the daily assignment sheet told her what type of assistance each resident required. She stated she learned two staff were required to perform a mechanical lift transfer. She stated in the training she learned all ANE was reported to the abuse coordinator who was the ADM. In an interview on [DATE] at 12:20 PM with the Restorative Aide, she stated that she was trained by the training coordinator on how to identify what kind of assistance a resident required, and she was in-serviced on ANE and provided examples to the state surveyor. In an interview on [DATE] at 12:29 PM with the DON she stated she instructed the nursing supervisors to pass out gait belts to all staff and placed them at nurses' station to ensure a gait belt was available to each CNA. She stated the IDT will bring up any issues in the morning meetings to ensure access to gait belts. She stated she had the nursing supervisors print out current transfer status and had each resident assessed and care plan updated. In an interview on [DATE] at 12: 32 PM with HK X she stated that she was in-serviced recently on ANE being that anything like not answering call lights, raising her voice or and talking ugly was not meeting resident's needs, and should report to the Administrator immediately. In an interview on [DATE] at 12:45 PM with CNA Z. She stated she was in-serviced on ANE recently, and on the different transfer devices to include mechanical lift and stand aide. She stated the assignment sheets were located at the nursing station and it indicated if a resident was independent, or required 2-person transfer, stand aid with gait belt or mechanical lift. She stated gave examples of ANE and that she would report any ANE to her ADM or designee. In an interview on [DATE] at 1:47 PM with Nurse Supervisor A she stated she had just been trained on the new post fall protocol and was given a copy of the fall protocol form. She stated she was told the form must be completed within 72 hours of any fall, witnessed and unwitnessed and that the completed forms were to be given to the DON. She stated she was told the forms would be reviewed at the QAPI meetings. In an interview on [DATE] at 01:48 PM with Nurse Supervisor B. She stated that she was in-serviced by the DON, informing her that she was going to be responsible for the newly implemented post fall forms. She stated she would be notified by the nurse of a fall, and she would have up to 72 hours. to complete the post fall form and turn it into the DON or ADON so it could be discussed in their QAPI. She stated if she was off or if the fall happened during the weekend, another nurse supervisor would complete the post fall form and ensure it was turned in within 72 hours. In an interview on [DATE] at 02:27 PM with the DOR he stated that rehab would coordinate with the Training Coordinator on all new hires for CNAs to receive training on proper use of transfer assistive devices (mechanical lifts, stand aide, gait belts). He stated that a therapist from the therapy department would demonstrate the proper use of transfer aides and that the new hire would return demonstration. Observation on [DATE] at 9:25 AM and 9:37 AM of the 2 nurses stations revealed CNA assignment sheets revealed what kinds of assistance each resident required. Review of Resident #43's care plan last updated on [DATE] revealed that her care plan was changed to The resident requires extensive assistance by 1 staff with stand aide and gait belt to move between surfaces and as necessary. Review of a list of residents was provided to the state surveyors on [DATE], revealing that all residents had their care plans reviewed and updated if applicable. Review of the facility's updated policy titled; Resident Care Plan revealed the following updates: Addressing additional care planning areas that are relevant to meeting the resident's need in the long-term care setting. Any changes in condition that are reported by the nursing staff will be updated within 72 hours of notification. Review of an in-service titled Care Plan Updates In-Service conducted by the ADM on [DATE], revealed that the DON and MDS coordinator were counseled on the timely updates of care plans to be individualized, the importance of recognizing when a resident had a change in their specific care needs and method of transfer had changed. It reflected those things would be discussed during each morning meeting held and that care plans needed to be updated accordingly and timely, if needed. The signatures of the ADM, DON, and MDS were reflected. Review of the Resident Transfer in-service dated [DATE] reflected the in-service covered before beginning work, make sure you have a resident assignment sheet to see how each resident transfers. This is provided in a notebook at the nurses station if you need further assistance, see charge nurse. The in-service covered the Mechanical lift transfer, stand aide transfer and the procedural guideline for assisting resident to transfer to chair or wheelchair. The signatures of CNA's I, K, L, M, N, O, P, PTA, LVN G, LVN H, Agency LVN Y, Nurse Supervisor A and B, restorative aide, HK X, and the DOR were observed. Review of in-service posttests revealed tests for CNA's I, K, L, M, N, O, P, PTA, LVN G, LVN H, Agency LVN Y, Nurse Supervisor A and B, restorative aide, HK X, and the DOR. Review of an Employee Status Report dated [DATE] revealed that CNA Q was terminated[TRUNCATED]