**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During the medication pass and pour observation, physician orders were not followed for the administration of Propranolol (medication given for hypertension) for Resident #92. Diagnoses for Resident #92 included: Hemiplegia, dementia, Hypertension, and hyperlipidemia. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/7/22. Resident #92's cognitive score was a 6 indicating moderately cognitively intact. On 08/16/22 at 8:26 AM a medication pass and pour was conducted with license practical nurse (LPN #3 ). LPN #3 began pulling Resident #92 's medications from the medication cart and handing them to the surveyor for review. One of the medications (Propranolol) instructed to give two 10 Mg (milligrams) tablets equaling 20 Mg. After reviewing the medications the surveyor handed the medication back to LPN #3 , and LPN #3 began popping the medications out into a medication cup. LPN #3 picked up the Propranolol medication card and only popped one pill into the cup (equaling 10 MG). LPN #3 then put all the medication back into the medication cart, locked the cart, turned and started to go into Resident #92's room. Upon entering the resident's room, LPN #3 was asked to come back to the cart and review the instructions for the Propranolol. LPN #3 pulled the medication from the medication cart and reviewed the instructions on the medication with the instructions on the medication administration record (MAR) and was asked, what is the dosage of each Propranolol tablet and how much is supposed to be given. LPN #3 realized that 2 Propranolol pills should have been dispensed and said You're right I will get another. Review of the physician's orders for Propranolol read: Propranolol 10 MG tablet Give 20 mg orally two times a day [ .] On 8/17/22 at 4:45 PM the above information was presented to the administrator and nurse consultant. No other information was presented prior to exit conference on 8/18/22. 5. The facility staff failed to obtain physician orders for the care of a midline (an intravenous line inserted into the upper arm, usually used for the treatment of antibiotics) for Resident #20. Diagnoses for Resident #20 included: Sepsis, stenosis of left carotid artery, depression, and urinary tract infection. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/30/22. Resident #20's cognitive score was a 15 indicating cognitively intact. On 08/16/22 at 8:54 AM during an interview, Resident #20 was asked about the Midline inserted into the left upper arm. Resident # 20 verbalized that he recently had an infection and was being given a antibiotics, but is no longer on antibiotics. On 8/16/22 Resident #20's medical record was reviewed. An order to insert a midline was dated 7/25/22, however there were no orders placed for care of the Midline (such as flushing to ensure patency). On 8/17/22 at 8:36 AM nurse consultant (administrative staff, AS #2) was interviewed. AS #2 reviewed Resident #20's physician orders and verbalized orders should have been placed for the care of the Midline. On 8/17/22 at 4:45 PM the above information was presented to the administrator and nurse consultant. On 8/18/22 at 8:30 AM AS #2 was asked if there are any nursing protocals regarding the care and treatment of a Midline. AS #2 said there is a protocol and those orders should have been placed on the medical chart. No other information was presented prior to exit conference on 8/18/22. 3. The facility failed to obtain a physician's orders for the care and treatment of a midline (intravenous) catheter for Resident #136. Resident #136's diagnoses included, but were not limited to: muscle weakness, high blood pressure, diabetes mellitus, and osteomyelitis of the left ankle/foot with partial amputation of the left foot. Resident #136's most recent MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 14, indicating the resident was intact for daily decision making skills. The resident was also assessed as requiring extensive assistance with most ADL's (activities of daily living). Resident #136 was interviewed on 08/16/22 at approximately 10:00 AM. The resident stated that he had an infection in his foot and that staff were giving him IV (intravenous) medications for the treatment. An IV pump/pole was observed in the corner of the room. The resident had a midline catheter in the right upper arm, a clear occlusive dressing was covering the catheter. There was no date, no time and no initials on the dressing. The resident's clinical records were reviewed. The resident had an order to, Insert midline one time only for IV abx [antibiotics] .order date: 08/03/22 start date: 08/03/2022 . There were no other orders found for the care and/or of the midline IV catheter. The resident's CCP (comprehensive care plan) was then reviewed. The CCP documented, .care needs related to osteomyelitis .meds as ordered . There was no information on the resident's care plan regarding a midline or care interventions for an intravenous catheter. The resident's MARs/TARs (medication administration/treatment administration records) were reviewed for July and August 2022. There was no information regarding the care and/or treatment of a midline IV catheter for Resident #136. On 08/17/22 at approximately 1:30 PM, Resident #136 was again interviewed. The resident's midline IV catheter dressing was intact (as observed the day before) no date, no time, and no initials were on the dressing. The midline, single lumen IV catheter was observed without a protective cap. RN #4 was in the room at the time and was interviewed. The RN stated that it should have a cap on the lumen hub and further stated that resident was no longer getting medication through the midline. The RN was asked how do the nurse's know how to care for a midline. The RN stated that they follow the physician's orders. The RN was made aware that there were no orders for the care of the midline. The RN stated that there should be orders. On 08/17/22 at 2:19 PM, in a meeting with the survey team, the NP (nurse practitioner) and the administrator were interviewed regarding the residents midline catheter and made aware of concerns regarding no care orders and/or instructions on how to manage the midline. The NP stated, I don't think I have specific orders for a midline, I think there is a standard, flush every 7 days, they [nurses] do the dressing change. You flush it everyday, with normal saline. I don't put in those orders, the nurses put them in and I would sign. The NP stated, that she thought it was a common practice for nurses to care for a midline and that she does review her orders. The NP was made aware that this resident did not have any care orders. The NP stated that when she was in nursing school that they had protocols they could use without physician's orders in the hospital. The NP was made aware that this is not a hospital and that resident's have to have specific care orders. The administrator nodded her head in agreement. On 08/17/22 at approximately 4:30 PM, in a meeting with the survey team, the administrator and corporate consultants were again made aware of the concerns regarding the lack of physician's orders for the care and treatment of Resident #136's midline. No further information and/or documentation was presented prior to the exit conference on 08/19/22 at noon. Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to obtain and/or follow physician orders for five of thirty-seven residents in the survey sample. 1. Resident #78 was not administered the medication epoetin alfa-epbx (Epogen) as ordered by the physician for treatment of anemia. After missing eight consecutive doses of the medication over a period of eight weeks, Resident #78 experienced critically low hemoglobin levels of 6.8 g/dL (grams per deciliter) and 6.7 g/dL and required treatment with a blood transfusion. 2. Resident #46 did not have a dressing applied to a forehead lesion as prescribed by the physician. 3. The facility failed to obtain a physician's order for the care and treatment of a midline (intravenous) catheter for Resident #136. 4. During the medication pass and pour observation physician orders were not followed for the administration of Propranolol (medication given for hypertension) for Resident #92. 5. There were no physician orders obtained for the care of a midline (an intravenous line inserted into the upper arm, usually used for the treatment of antibiotics) for Resident #20. The findings include: 1. Resident #78 was admitted to the facility with diagnoses that included anemia in chronic kidney disease, diabetes, osteomyelitis, multiple myeloma in remission, peripheral vascular disease, dysphagia, cerebrovascular disease, COPD (chronic obstructive pulmonary disease), hypertension, hyperlipidemia, major depressive disorder, gout and urinary retention. The minimum data set (MDS) date 6/27/22 assessed Resident #78 as cognitively intact. Resident #78's clinical record documented a physician's order dated 1/18/22 for epoetin alfa-epbx 4000 units/milliliter with instructions to administer 1 ml (milliliter) intramuscularly once every 7 days for treatment of anemia. Resident #78's medication administration record (MAR) documented no administration of the epoetin alfa-epbx during the next eight weeks following the order. The MAR documented doses of epoetin alfa-epbx were scheduled but not administered on 1/27/22, 2/3/22, 2/10/22, 2/17/22, 2/24/22, 3/3/22, 3/10/22 and 3/14/22. Nursing notes documented the epoetin alfa-epbx was not administered because the medication was not available from the pharmacy. Nursing notes documented the following regarding missed doses of the epoetin alfa-epbx. 2/3/22 - .med [medication] is not available Epoetin Alfa-epbx Solution 4000 unit/ml . 2/10/22 - .non available labs to be faxed to pharmacy . 2/17/22 - Waiting for pharmacy to deliver Epoetin Alfa-epbx Solution 4000 unit/ml . 2/24/22 - non available 3/10/22 - awaiting delivery 3/14/22 - no available labs faxed . (sic) 3/15/22 - .Hg [hemoglobin] 6.8. Epoetin Alfa-epbx Solution 4000 unit/ml and order fax to pharmacy waiting for med . Prior to and during the weeks of missed epoetin alfa-epbx, Resident #78's hemoglobin was tested and documented as follows. The resident was identified with critically low hemoglobin on 3/14/22 after missing the ordered epoetin alfa-epbx injections for two months. Lab reports listed the hemoglobin in g/dL and documented a reference/normal range of 11.0 to 15.3 g/dL. 11/19/21 - 8.6 (low) 12/16/21 - 11.2 (in range) 1/31/22 - 8.6 (low) 2/28/22 - 7.1 (low) 3/3/22 - 7.3 (low) 3/7/22 - 7.4 (low) 3/14/22 - 6.8 (critically low) A nurse practitioner (other staff #4) assessed Resident #78 two times prior to the critically low hemoglobin level of 3/14/22. The NP notes listed the resident was receiving epoetin alfa-epbx as treatment for anemia and made no mention of the resident not receiving the injections as ordered or that the medication was not available. The NP (other staff #4) documented the following assessments of Resident #78. 1/24/22 - .Pt asked to be seen per nursing request for abnormal lab review .Assessment and Plan .Anemia Epoetin 1 ml IM [intramuscularly] inj [injection] Q 7D [every 7 days] . 3/2/22 - .Pt asked to be seen per nursing request for blood streaks in foley catheter, fever, and tachycardia .Assessment and Plan .Anemia Epoetin 1 ml IM inj Q 7D . A different NP (other staff #13) assessed the resident on 3/11/22 and diagnosed a urinary tract infection, started antibiotics and increased the frequency of the epoetin alfa-epbx from once per week to three times per week. There was no mention in the note that the resident had not received prescribed weekly doses of epoetin alfa-epbx or that the medicine had not been provided by the pharmacy. The lab report listing the critically low hemoglobin of 6.8 on 3/14/22 documented the physician was notified of the abnormal value on 3/15/22. A nursing note dated 3/15/22 documented, .Lab result received Hg [hemoglobin] 6.8. Epoetin Alfa-epbx 4000 unit/ml and order fax to pharmacy waiting for med. NP .notified. Continue Cefuroxime Axetil Tablet 500 mg .for UTI [urinary tract infection] . An additional dose of epoetin alfa-epbx scheduled for Wednesday 3/16/22 was not administered as ordered. A nursing note dated 3/16/22 at 10:22 a.m. documented, Pending pharmacy delivery and another note dated 3/16/22 at 10:55 p.m. documented, Waiting for med Epoetin Alfa-epbx Solution 4000 unit/ml . There was no documented notification to the physician or NP about the unavailable epoetin alfa-epbx until 3/17/22. A nursing note dated 3/17/22 documented, NP [nurse practitioner] .was notified of Epogen still pending deliver from pharmacy . (sic) The NP ordered a repeat lab test for 3/18/22. The resident's hemoglobin was checked on 3/18/22 with results reported on 3/19/22 indicating another critically low value at 6.7 g/dL. A nursing note dated 3/19/22 documented, .NP Notified of critical labs and order received to send pt [patient] out to . [hospital] for blood transfusion . The emergency department report dated 3/19/22 documented, .presents from .nursing facility, after being found to have severe anemia, hemoglobin of 6.7. She reports no significant symptoms .upon being informed of her decreased hemoglobin, she was sent to the ER [emergency room] for transfusion . The ER report documented the resident's hemoglobin at 6.8. The resident was administered one unit of packed red blood cells and transferred back to the facility on 3/20/22. NP (other staff #4) assessed Resident #78 on 3/21/22 after the blood transfusion. The NP note dated 3/21/22 documented, .Assessment and Plan .Anemia critical lab hemoglobin 6.7, send out non-emergent for transfusion, 1 unit PRBCs [packed red blood cells] c/w [continue with] Epo [Epogen] 1 ml mon, wed, fri x 5 weeks . After receiving the blood transfusion, Resident #78's hemoglobin on 3/21/22 was assessed at 8.0 g/dL. The resident continued to miss doses of the epoetin alfa-epbx following the blood transfusion because the medication was not available. Scheduled doses on 3/23/22, 3/25/22 and 3/28/22 were not administered because the medication was not provided by the pharmacy. The first dose documented as administered was on 3/30/22. The record documented no notification to the physician regarding the missed doses of epoetin alfa-epbx from 1/24/22 until 3/17/22. There were no documented attempts to determine the reason for the undelivered medicine, no communication to/from the provider or pharmacy about the medication or of any alternative treatments attempted to prevent the critically low hemoglobin that resulted in a blood transfusion. The resident was prescribed Vitron-C (iron-vitamin C) for anemia starting on 1/21/22 and this supplement was ongoing during the time with the critically low hemoglobin values. Nurse practitioner assessments on 1/24/22 and 3/2/22 listed the epoetin alfa-epbx as treatment for anemia and made no mention the medication was not administered to the resident as ordered. Another NP assessment on 3/11/22 made no mention of missed/unavailable epoetin alfa-epbx and increased the frequency of the medication from once per week to three times per week. Monthly medication regimen reviews conducted by the consultant pharmacist on 2/22/22 and 3/20/22 documented no new irregularities with Resident #28's medicines and made no mention of the weeks of missed epoetin alfa-epbx injections. On 8/17/22 at 10:06 a.m., the licensed practical nurse unit manager (LPN #1) was interviewed about Resident #78's missed doses of epoetin alfa-epbx. LPN #1 stated he did not work on Resident #78's unit until May 2022 and he did not know anything about the missed epoetin alfa-epbx or the critically low hemoglobin. On 8/17/22 at 11:10 a.m., the regional director of clinical services (other staff #3) stated she reviewed Resident #78's medication records and the epoetin alfa-epbx was not administered as ordered and nursing should have notified the physician regarding the missed medication. The regional director stated nursing notes listed the medication had not been supplied by the pharmacy. On 8/17/22 at 11:10 a.m., the unit manager (LPN #1) was interviewed again about the protocol when medications were not available. LPN #1 stated if medications were not available, the nurse should call pharmacy requesting delivery, notify the physician and seek alternate treatments if appropriate. On 8/17/22 at 2:08 a.m., the nurse practitioner (other staff #4) that routinely cared for Resident #78 was interviewed about epoetin alfa-epbx and the missed doses prior to critically low hemoglobin values. The NP stated the Epogen (epoetin alfa-epbx) was a medication used to stimulate production of red blood cells for patients with anemia. The NP stated Resident #79 had anemia due to chronic kidney disease. The NP stated the resident's baseline hemoglobin was low and ran in the high 7's. The NP stated she got a couple of contacts from nursing about the medication not available but she did not recall specific dates of the notifications. The NP stated patients with chronic kidney disease may have low hemoglobin readings even when taking Epogen. The NP stated sometimes there was no reason why something triggered a drop in hemoglobin. The NP stated her colleague (NP - other staff #13) increased the Epogen to three times per day so she was unable to comment on the increased dosage. The NP stated she had no information about why the epoetin alfa-epbx was not provided by the pharmacy and she had experienced problems getting Epogen for other residents in the facility. The NP stated there could be other reasons for the drop in hemoglobin such as dehydration or infection. When asked about any interventions implemented other than the Epogen to maintain the resident's hemoglobin, the NP stated the resident was already taking Vitron-C (iron-vitamin C). On 8/17/22 at 5:10 p.m., these findings were discussed with the administrator, regional director of clinical services and the corporate nursing consultant. The administrator stated at this time that nursing should contact the pharmacy when medicines were not available and notify the physician about any missed medicines. On 8/18/22 at 10:00 a.m., the regional nurse consultant (other staff #2) stated there was no notification documented regarding the unavailable Epogen for Resident #78. The nurse consultant stated she talked with the nurses and they reported some communication back and forth about the issue but there was nothing documented. The nurse consultant stated it was protocol to send a resident out for transfusion/treatment when hemoglobin dropped below 7.0. On 8/18/22 at 10:03 a.m., the NP (other staff #13) that assessed Resident #78 on 3/11/22 and increased the Epogen dose to three times per week was interviewed. This NP stated she was on-call and nursing notified her about abnormal labs. This NP stated she was not aware the resident was not getting the prescribed weekly doses of Epogen. This NP stated she increased the dose to three times per week because, based on her calculations, the previous dose was not adequate for the resident's condition and weight. This NP stated again she was not aware the resident had missed weeks of the Epogen injections. This NP stated she provided on-call coverage on 3/11/22 and did not assess the resident again after this visit. On 8/17/22 at 3:46 p.m., the registered pharmacist/director of quality (other staff #5) was interviewed about why Resident #78's Epogen was not provided. The pharmacist director stated the order was received by the pharmacy on 1/18/22 with a start date assigned as 1/24/22. The pharmacist director stated at this time that Epogen required permission to send and an email was sent to a facility distribution on 1/20/22 requesting this permission/approval from the provider. The pharmacist director stated no response was received to the email so the medication was never released. The pharmacist director stated a second email was sent on 1/24/22 with no response received from the facility so the medication was not dispensed. The pharmacist director stated Epogen (epoetin alfa-epbx) was a medication that stimulated production of red blood cells and helped maintain and/or increase hemoglobin levels for patients with anemia. The pharmacist director stated Epogen typically took two to six weeks for effect and was not used for immediate treatment of low hemoglobin. On 8/18/22 at 10:56 a.m., the consultant pharmacist (other staff #14) was interviewed about Resident #78's missed doses of Epogen due to unavailability from the pharmacy. The consultant pharmacist stated she performed spot checks of medications administered when she completed monthly medication reviews. The consultant pharmacist stated she did not pick up that Resident #78 missed the weekly Epogen during February and March (2022) reviews. The consultant pharmacist stated nobody from the facility notified her that the Epogen had not administered and/or provided. The consultant pharmacist stated Epogen was a medication that required additional approval before being dispensed. The director of nursing was out on leave and not available for interview during the survey. Resident #78's plan of care (revised 2/15/22) documented the resident had care needs and weakness due to conditions that included kidney failure, anemia and end stage kidney disease. Interventions to prevent complications included, Monitor and notify MD/RP [responsible party] of any critical Lab .Notify MD/RP of any changes in condition .Administer medications as ordered . The Lippincott Manual of Nursing Practice 11th edition on pages 757 and 758 describes anemia as, .the lack of sufficient circulating hemoglobin to deliver oxygen to tissues .Treatments for anemia include nutritional counseling, supplements, RBC [red blood cell] transfusions, and, for some patients, administration of exogenous erythropoietin (epoetin alfa or darbepoetin alfa), a growth factor stimulating production and maturation of erythrocytes .Severe compromise of the oxygen-carrying capacity of the blood may predispose to ischemic organ damage, such as myocardial infarction or stroke . (1) The Nursing 2022 Drug Handbook on page 49 describes epoetin alfa-epbx as a hematopoietic agent used for the treatment of anemia associated with chronic renal failure and cancer chemotherapy by stimulating red blood cell production in the bone marrow. Page 528 of this reference documents concerning epoetin alfa-epbx prescribed for anemia caused by chronic renal disease, .Maintenance dosage is highly individualized. Give the lowest effective dose to gradually increase Hb [hemoglobin] to a level at which blood transfusion isn't necessary . (2) These findings were reviewed with the administrator, regional director of clinical services and corporate nursing consultant during a meeting on 8/17/22 at 4:15 p.m. (1) [NAME], [NAME] M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/[NAME] & [NAME], 2019. (2) Woods, [NAME] Dabrow. Nursing 2022 Drug Handbook. Philadelphia: Wolters Kluwer, 2022. 2. Resident #46 was admitted to the facility with diagnoses that included atypical lesion of left eyebrow, hypertension, rheumatoid arthritis, chronic deep vein embolism, hyperlipidemia, cellulitis, peripheral vascular disease, major depressive disorder and GERD (gastroesophageal reflux disease). The minimum data set (MDS) dated [DATE] assessed Resident #46 as cognitively intact. On 8/16/22 at 10:00 a.m., Resident #46 was observed in bed. The resident had an irregular shaped growth over the left eyebrow. The surface of the growth was red and moist with the lesion hanging partially over the upper portion of the left eyelid. When asked about any concerns with her care, Resident #46 stated a dressing was supposed to be over the growth on her eyebrow. Resident #46 stated the dressing fell off earlier in the morning and she reported this to her nurse around 7:30 a.m. or 8:00 a.m. Resident #46 stated her nurse had been in the room and still had not replaced the dressing. Resident #46 stated she did not like having the lesion exposed to air. On 8/16/22 at 11:08 a.m., Resident #46 was observed in bed with no dressing in place over the eyebrow growth. Resident #46 stated the nurse had not returned to replace the dressing yet. On 8/16/22 at 12:00 p.m., Resident #46 was observed with a dressing in place over the eyebrow growth. Resident #46 stated a nurse had just applied the dressing. Resident #46 stated she was concerned that the dressing had been off all morning. Resident #46's clinical record documented a physician's order dated 7/3/22 to cleanse the atypical lesion on the left eyebrow with wound cleanser, apply Xeroform, calcium alginate and cover with a border gauze every day shift and as needed for loose dressing. On 8/16/22 at 12:03 p.m., the registered nurse (RN #3) caring for Resident #46 was interviewed about the eyebrow lesion without a dressing. RN #3 stated he was assigned to Resident #46 today and she told him earlier in the shift that the dressing was off. RN #3 stated he reported the missing dressing to the unit manager. RN #3 stated he did not know why the unit manager did not replace the dressing earlier. On 8/16/22 at 12:05 p.m., the licensed practical nurse (LPN #1) unit manager was interviewed about Resident #46's lesion without a dressing. LPN #1 stated he had just reapplied the dressing to Resident #46's eyebrow growth. LPN #1 stated it had not been reported to him earlier that the dressing was off. LPN #1 stated, No one told me the dressing was off. LPN #1 stated the lesion was supposed to have a dressing in place as ordered. This finding was reviewed with the administrator, regional director of clinical services and corporate nursing consultant during a meeting on 8/17/22 at 4:15 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, the facility staff failed to provide a safe transfer for one of 36 residents in the survey sample. Resident #90 was transferred to bed with the assistance of one person when her plan of care required two-person assistance for safe transfers, resulting in a fracture of the left femur. The findings include: Resident #90 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #90 included diabetes, high blood pressure, right hand contracture, history of bilateral knee replacements, chronic total knee dislocation, dysphagia, Alzheimer's, chronic pain, neuropathy, depression, atrial fibrillation and fractured left femur. The minimum data set (MDS) dated [DATE] assessed Resident #90 with severely impaired cognitive skills and as totally dependent upon two people for bed mobility. Resident #90's clinical record documented a nursing note dated 3/13/19 at 11:09 p.m. stating the resident complained of left knee pain and was administered Tylenol for pain rated 6 out of 10 (on scale of 0 = no pain, 10 = worst pain) with notification to the physician of the left knee pain. A nursing assessment dated [DATE] documented, .left knee is warm to touch, swollen and c/o [complaint of] pain .Tylenol 650 mg [milligrams] given .MD [physician] order for x-ray of left knee . The physician assessed the resident on 3/14/19 and documented, .Has had bilateral knee replacements. Left knee is warm and swollen. This seems acute . The x-ray report dated 3/14/19 documented the resident was diagnosed with an acute fracture of the distal left femur with 3 cm [centimeter] displacement of the fracture fragments. The physician was notified of the x-ray results and the resident sent to the hospital for treatment of the fractured femur. Resident #90 was hospitalized for three days for treatment of the left femur fracture. The hospital Discharge summary dated [DATE] documented, .was sent to the emergency room from the nursing home due to left knee pain and swelling. X-rays was performed earlier today and showed left distal femur fracture .has been nonambulatory for the last several years . (Sic) The emergency room physician's exam documented, The skin is intact about the left leg. There is mild swelling about the left distal femur. There is mild tenderness on palpation of the distal femur. There is motion at the fracture site .She [Resident #90] is unable to give a history or an account of how the leg was injured .X-rays of the left femur which reveal a displaced left long oblique periprosthetic femur fracture .There is significant lateral displacement of the distal fracture fragment . The resident was not a candidate for surgical repair, was treated conservatively with a knee immobilizer and discharged back to the nursing home. Resident #90 was re-admitted to the facility following hospitalization for the fracture 3/17/19. The resident was prescribed bedrest, a left knee immobilizer and Percocet 5/325 milligrams every 6 hours as needed for pain. The resident's medication administration record from 3/18/19 through 3/31/19 documented the resident was medicated with Percocet sixteen times for left leg pain rated from 4 to 9 on the pain scale. The resident was treated by orthopedics with the knee immobilizer and pain medications. A physician's note dated 12/19/19 documented, .Left femoral fracture is healing but it's not completely healed . A facility reported incident form dated 3/14/19 documented Resident #90 was transferred on the evening of 3/13/19 with the assistance of one person instead of two-person assistance as required in the plan of care, resulting in the fracture femur. The incident form dated 3/14/19 documented, Resident has chronic intermittent pain on left leg, but complained of severe pain during ADL [activities of daily living] care this morning around 7:30 am. X-ray was ordered and results came as an acute fracture of the distal left femur. The facility's internal investigation of Resident #90's femur fracture documented, .On the evening March 13, 2019, [Resident #90] expressed she was in pain. Her Charge Nurse asked her CNA [certified nurses' aide] to assist [Resident #90] back to bed in an attempt to alleviate her pain. Her pain worsened after the transfer to bed. She was offered acetaminophen which relieved her pain and she was able to sleep without incident. The morning of March 14, 2019, [Resident #90] complained of pain to her leg. Upon assessment, an X-ray was ordered and the fracture was identified. It is concluded that the fracture inadvertently occurred during her transfer to bed on the evening of March 13, 2019 unknown to the CNA that was performing the task. The facility's investigation dated 3/18/19 documented Resident #90 required two people for safe transfer and that CNA #1 transferred the resident on the evening of 3/13/19 without assistance of a second person. An employee corrective action form dated 3/18/19 documented, Failure to follow patient [Resident #90's] plan of care during transfer. [CNA #1] transferred the patient without a second staff assist on 3/13/19 and that cause possible injury to the patient . (Sic) CNA #1's written statement dated 3/13/19 documented, I worked with [Resident#90] on the 13th of March at 3 - 11 pm shift at about 8:00 [p.m.] after dinner she started complaining pain on the leg. She was saying 'my leg my leg' I took her from the dinning [dining] room to the nurses station for observation and told the nurse about the pain. The nurse asked me to put her in bed. When I undress her she showed me where she is hurting. I called the nurse for observation later the nurse told me she gave her medicine for the pain . (Sic) The MDS dated [DATE] documented the resident was 68 inches tall, weighed 165 pounds and was totally dependent upon two people for bed mobility and transfers. The resident's plan of care in place prior to the fracture (revised 10/23/18) documented the resident was dependent upon staff for all activities of daily living including transfers. Included in interventions for safe transfers was The resident requires 2 staff assistance for transfers. On 1/28/20 at 3:20 p.m., CNA #1 that transferred Resident #90 to bed on the evening of 3/13/19 was interviewed. CNA #1 stated on 3/13/19 around 8:00 p.m., Resident #90 was in a wheelchair in the dining room and complained of leg pain. CNA #1 stated she pushed the resident to the nursing station and told the nurse. CNA #1 stated the nurse told her to put Resident #90 to bed. CNA #1 stated, I just hurried up and put her to bed. CNA #1 stated she lifted the resident by herself and did not get assistance from another person when transferring her from the wheelchair to bed. CNA #1 stated, I lifted her myself, was in a hurry. The nurse said hurry up. CNA #1 stated the resident did not require a mechanical lift but required two people for transfers. When asked how she transferred her alone, CNA #1 stated she put her arms around the resident and just lifted her. CNA #1 stated the nurses were busy giving medications and she did not ask for assistance from the other aides on the floor. CNA #1 stated the resident complained of pain frequently when transferred and she did not realize the resident was hurt when she transferred her. CNA #1 stated the resident did indicate her left knee was hurting after she put her to bed on the evening of 3/13/19. CNA #1 stated she reported this to the nurse and the nurse told her she medicated the resident. On 1/29/20 at 11:30 a.m., the administrator and director of nursing (DON) were interviewed about Resident #90's improper transfer and resulting femur fracture. The administrator stated their investigation revealed that CNA #1 did not follow the protocol requiring a two-person transfer for Resident #90 that resulted in the resident's femur fracture. The DON stated prior to the incident the resident was totally dependent upon staff and required two-person assistance for all transfers. The administrator stated CNA #1 was initially suspended until the investigation was complete and was re-educated about proper transfer assistance prior to her return to work. The administrator stated audits and education were broadened to include all aides with correction date of 5/2/19. The administrator presented a plan of correction regarding the failure to provide required transfer assistance. The plan of correction documented an audit by unit managers dated 3/19/19 verifying each resident's transfer requirements and that care plans documented accurate transfer assistance requirements. A list of residents documented as two-person assistance was provided to each nursing manager. The plan documented education by the staff development coordinator to all certified nurses' aides on 3/19/19 identifying all residents requiring two-person transfer assistance and proper protocols for a two-person transfer. The plan documented education to CNA #1 on 3/20/19 regarding how to reference information about required transfer assistance, education about following the plan of care and online education with a passing test grade regarding safe transfers and positioning. The training also documented a return demonstration by CNA #1 regarding safe transfer techniques. The plan documented audits by the unit managers and/or DON of 10% of current residents on each floor requiring two-person transfer assistance. The audits were documented weekly for four weeks, monthly for two months and then once quarterly following the in-service education on 3/19/19. The date of completion/compliance was 5/2/19. The survey team reviewed and accepted the plan of correction as no new deficiencies were identified regarding accidents since the correction date of 5/2/19. This deficiency was past non-compliance.