**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide adequate supervision to prevent accidents for 1 of 17 residents (Resident #8) in the survey sample, which constituted harm. The findings included: The facility staff failed to provide adequate supervision to ensure Resident #8 was safe from falling while ambulating, which constituted harm. Resident #8 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #8 was admitted to the facility on [DATE] after a hospital stay. The resident's diagnoses included unspecified nondisplaced fracture of the second cervical vertebra, nondisplaced intertrochanteric fracture of the right femur, vascular dementia, and muscle weakness. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/6/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 03 out of a possible 15. This indicated Resident #8’s cognitive abilities for daily decision making were severely impaired. A review of section “GG” (Functional Abilities and Goals) dated 11/6/24 of Resident #8’s Minimum Data Set (MDS) coded the resident as partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for Walk 10 feet (once standing, the ability to walk at least 10 feet in a room, corridor, or similar space), partial/moderate assistance for Walk 50 feet with two turns, and partial/moderate assistance for Walk 150 feet. A care plan problem dated 1/14/24 read, risk for falls. The goal read, resident will be free of falls. The interventions included assist resident with ambulation and transfers, utilizing therapy recommendations. Determine Residents ability to transfer. If fall occurs, alert provider. If fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol. If Resident is a fall risk, initiate fall risk precautions. A synopsis of an event dated 12/20/24 revealed that Resident #8 had an unwitnessed fall in another resident's room. The resident was lying in the corner of the room with his head against the heater and his walker on top of him. The resident was sent to the emergency room and was diagnosed with a closed nondisplaced fracture of the second cervical vertebra and a closed nondisplaced intertrochanteric fracture of the right femur. On 8/22/25 at 10:46 AM, an interview was conducted with Licensed Practical Nurse (LPN) #5. LPN #5 stated that Resident #8 had an unwitnessed fall on 12/20/24 in another resident's room and was not being supervised by facility staff. LPN #5 also stated that she was the only Nurse working with two Certified Nursing Assistants (CNA) in the memory unit during this shift. LPN #5 further said that there was not enough staff to provide care for the residents on the memory care unit. LPN #5 lastly stated, “We have asked, asked, and asked, and they would never give us 3 (three) CNAs on the memory care unit. With only three staff members working, residents are unable to be supervised as they should be. This could have absolutely prevented falls such as (Resident name).” On 8/22/25 at 12:30 PM, an interview was conducted with the MDS (Minimum Data Set) Coordinator. The MDS Coordinator stated that Resident #8 was coded in section “GG” (Functional Abilities and Goals) dated 11/6/24 as requiring partial/moderate assistance for ambulating. The MDS Coordinator also stated that partial/moderate assistance means that the staff should lay hands on the resident such as on the elbow, hand, arm, the walker, or even using a gait belt while the resident is ambulating. The MDS Coordinator further stated that the staff should have been assisting and supervising Resident #8 with ambulation. On 8/22/25 at 1:36 PM, an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA #1 stated that Resident #8 was not being supervised when he had an unwitnessed fall with injuries. CNA #1 also stated that the staff did not know that Resident #8 required partial/moderate assistance for ambulating. CNA #1 further stated that information such as this is not communicated to the CNAs. On 8/22/25 at 2:10 PM, an interview was conducted with the Certified Occupational Therapy Assistant. The Certified Occupational Therapy Assistant stated that Resident #8 was a fall risk and required supervision for functional transfers and ambulation on the memory care unit. The Certified Occupational Therapy Assistant also stated that Resident #8 required supervision using his front-wheeled walker and needed occasional verbal cues while using his front-wheeled walker. The Certified Occupational Therapy Assistant further stated that Resident #8 required supervision for safety while ambulating to prevent a fall. A review of Resident #8's Interdisciplinary Therapy Screen dated 11/24/24 at 12:04 PM read: Ambulation: Comments: supervision using FWW with occasional VC to use walker. Safety/Restraint Issues: fall risk Additional Comments: Per Nursing and Chart review: Patient is at baseline and continues to require Minimal assistance with all ADLs and supervision for functional transfers and ambulation on the unit. No change in functional status. No therapy needs at this time. A review of Resident #8's nurse's note dated 12/20/24 at 6:22 PM read: Resident was observed lying on the floor in room [ROOM NUMBER]. Resident was lying in the corner of the room with his head against the heater and his walker on top of him. Resident complaining of right leg and hip pain. Skin tear noted to his right elbow. Pillow placed behind residents head and RN supervisor called to assess resident. Resident calling out in pain when right leg manipulated. Per RN supervisor Send resident to ER Emergency transfer . RP called and notified. Resident transported via EMS stretcher at 1800. On call provider notified of transfer. A review of Resident #8's nurse's note dated 12/20/24 at 6:47 PM read: Fall Details: Date / Time of Fall: 12/20/2024 5:15 PM Fall was not witnessed. Fall occurred elsewhere. Other fall location: another resident's room. Activity at the time of fall: unknown. Reason for the fall was evident. Reason for fall: resident was stuck between the dresser and the wall. Did an injury occur as a result of the fall: Yes. Injury details: skin tear to right elbow and right hip pain Did fall result in an ER visit/hospitalization: Yes. ER Visit/Hospitalization Details: sent to ER for eval Provider: message left for on call provider. and in communication book Time notified: 12/20/2024 Notified of: fall with possible injury to right hip Fall Details Note: Resident was observed lying on the floor in room [ROOM NUMBER]. Resident was lying in the corner of the room with his head against the heater and his walker on top of him. Resident complaining of right leg and hip pain. Skin tear noted to his right elbow. Pillow placed behind residents head and RN supervisor called to assess resident. Resident calling out in pain when right leg manipulated. Per RN supervisor Send resident to ER Emergency transfer . RP called and notified. Resident transported via EMS. A review of Resident #8’s General Hospital Discharge summary dated [DATE] read: Assessment and Plan: closed nondisplaced fracture of second cervical vertebra, and closed nondisplaced intertrochanteric fracture of right femur. (Resident name) is a [AGE] year-old Caucasian gentlemen with a history of dementia who presented to the emergency department after sustaining an unwitnessed fall at his memory care unit where he resides. The patient sustained multiple traumatic injuries. For this reason the Trauma service was contacted regarding admission. On 8/25/25 at approximately 1:05 PM, a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, Assistant Chief Nursing Officer, and Director of Clinical Education. An opportunity was offered to the facility’s staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, family interview, clinical record review and facility document review the facility staff failed to prevent an avoidable fall for 1 of 59 residents in the survey sample, Resident #121. During the provision of care by staff, the resident fell off the bed and sustained left hip and left femur fractures. Following the fall, the facility staff did a root cause analysis and implemented a plan of correction with a completion date of 1/15/2020. No other falls during provision of care was identified after the completion date. The deficiency is cited as a level 3 isolated, past non-compliance. The findings included: Resident #121 was admitted to the facility on [DATE] with a readmission date of 1/1/20 following a hospitalization for surgical intervention to the left hip and proximal femur fractures resulting from a fall from the bed on 12/25/19 at the facility. The resident's other diagnoses included, but were not limited to chronic pain syndrome, Alzheimer's dementia with behavioral disturbance, and left below the knee amputation. The MDS (Minimum Data Set) prior to the fall was a quarterly with an Assessment Reference Date of 12/11/19. The resident was coded as scoring an 11 out of a possible 15 on the Brief Interview for Mental Status indicating the resident had moderately impaired daily decision making skills. The resident was dependent on two staff for transfers, dependent on one staff for bathing, and extensive assistance of one staff for bed mobility, dressing, toileting and personal hygiene. The resident was frequently incontinent of bladder and always incontinent of bowels. The physician orders dated 7/24/17 included an air mattress with perimeter cover for pressure relief, check function and inflation every shift. The person-centered plan of care effective date of 3/3/17-present identified the resident was at risk for falls and/or history of falls related to, unsteady gait, loss of balance, poor sitting balance/ poor trunk control, short-term memory loss, requires reminders to call for assistance, requires staff assistance for transfers, pain, impaired sensation, unstable/ fluctuating health conditions, diabetes, high blood pressure, use of narcotic analgesia , incontinence and history of falls. The goal was that the resident will not experience significant injury (i.e., requiring ER visit or hospitalization) through next review. During each of the survey days 2/18/20, 2/19/20, 2/20/20 and 2/21/20 the resident was observed in bed on a bariatric low air loss mattress. There was no defined perimeter mattress in place; there was no physician's order after readmission for a perimeter cover. A review of the clinical record and facility event report evidenced the resident had a witnessed fall from the bed during ADL (activities of daily living) care on 12/25/19. As a result of the fall the resident sustained an acute fracture of the left proximal femur per the mobile x-ray report dated 12/26/19. The resident was transferred to the emergency room for evaluation and admitted . The clinical notes by Licensed Practical Nurse (LPN) #9 dated 12/25/19 read in part: Resident fell out of bed @11:15. CNA (certified nursing assistant) reported to nurse while turning the resident the resident slid to the floor. Left leg in pain 10/10 (intensity of pain 1-10, 10 being the worst) and has 4 abrasions below the L (left) knee and 1 abrasion below the R (right) knee . The facility incident report also documented, Resident fell out of bed @11:15. CNA reported to nurse while turning the resident the resident slid to the floor. CNA#2 who was providing care at the time of the fall was interviewed on 2/21/20 at 12:30 p.m. CNA#2 stated that she was giving the resident a bed bath that morning, she had completed the top part of the resident's body and asked the resident to turn on her left side. She stated after the resident was turned to her side she completed washing her back and rolled the chux pad under the resident's bottom to change it, at this time the resident started scooting her bottom towards the edge of the bed to see something out the window. The resident then slid off the bed feet first. Immediately after the fall the resident began hollering in pain. When asked if the resident was re-admitted back to the same room and same bed after hospitalization she stated, Yes. On 2/21/20 at 1:12 p.m., the daughter of the resident was interviewed. She stated she received a phone call from LPN #9 informing her of the fall. She was told that, When the aide (CNA) turned her she was too close to the edge. The hospital discharge summary documentation dated 1/1/20 indicated the resident had a fall while being given a bath per the daughter. The patient had been non-ambulatory for years and was bed-bound. The CT scan showed intramedullary hip fracture and proximal femur fracture. The patient was seen in consultation by Orthopedics and underwent cephalomedullary nail replacement of the left hip. On 2/21/20 at 2:30 p.m., the durable medical equipment specialist was interviewed on site. He stated the defined perimeter mattress is an added safety feature to prevent falls from low air loss mattresses. He further stated that the contract with the facility specifically calls for all low air mattresses rented to the facility must have the added safety feature of a defined perimeter mattress. The specialist was asked if Resident # 121 was on a perimeter mattress, after pulling up the order in his system he stated, Yes, since 2017. The specialist was asked to go into the resident's room to ensure the low air loss mattress that the resident was on included the defined perimeter mattress cover. Several minutes later he reported to this inspector that the resident's low air loss mattress did not include the defined perimeter mattress cover. He stated he called his company and one was on it's way. Per the manufacture the Defined Perimeter Mattress Cover creates a raised rail, defined perimeter for enhanced fall prevention, without using patient restraints. The 10 deep static perimeters surround the length of the mattress. On 2/21/20 at 3:02 p.m., the above findings was shared with the Director of Nursing (DON). She stated she was not aware that the resident was not on the perimeter mattress as ordered. When asked what is the purpose of the perimeter mattress she stated, I would suppose an added protection from falls. When asked what the root cause of the fall, she stated, I believe at the time the resident got distracted, she was not paying attention to what she was doing .I think the perimeter mattress would have helped her. A root cause analysis and plan of correction was completed and included resident assessments and staff education. No additional falls during provision of care was identified. The compliance completion date was documented as 1/15/20. The above findings was shared with the Administrator and the Director of Nursing (DON) during the pre-exit meeting conducted on 2/21/20. The facility was afforded ample time to present any additional information prior to exit. No additional information was presented. Past non-compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and family interviews, the facility staff failed to ensure the residents environment remained as free of accident hazards and receive adequate supervision and assistive devices to prevent accidents for two residents (Resident #87 and #47) in the survey sample of 52 residents. 1. The facility identified Resident #87 was a high fall risk. The facility developed a plan of care to prevent avoidable injuries, which included the use of a Hoyer lift with two staff assistance for transfer. The resident was transferred on 02/16/18 by one staff member doing a stand pivot transfer instead of using a Hoyer lift. As a result, Resident #87 sustained an avoidable Right Femur Fracture resulting in harm. 2. The facility staff failed to ensure the assistive device, total lift, was utilized appropriately to prevent Resident #47 from an avoidable fall during a transfer. The findings included: 1. Resident #87 was admitted to the facility on [DATE]. Diagnosis for Resident #87 included but not limited to *Muscle weakness, *Anxiety disorder and *Dementia without disturbance and *Osteoporosis. *Osteoporosis is a disease that thins and weakens the bones. Your bones become fragile and break easily, especially the bones in the hip, spine, and wrist (https://medlineplus.gov/ency/patientinstructions/000685.htm). *Muscle weakness is reduced strength in one or more muscles (https://medlineplus.gov/ency/article/007365.htm). *Anxiety disorder is a mental condition in which you are frequently worried or anxious about many things. Even when there is no clear cause, you are still not able to control your anxiety (https://medlineplus.gov/ency/patientinstructions/000685.htm). *Dementia is the name for a group of symptoms caused by disorders that affect the brain. People with dementia may not be able to think well enough to do normal activities, such as getting dressed or eating. They may lose their ability to solve problems or control their emotions. Their personalities may change. They may become agitated or see things that are not there (https://medlineplus.gov/ency/article/007365.htm). The most recent Minimum Data Set (MDS) a comprehensive assessment with an Assessment Reference Date (ARD) of 6/12/18 coded the resident with a 02 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. In addition, the MDS coded Resident #87 total dependent of two with bathing, personal hygiene, toilet use, dressing and transfers, extensive assistance of one two with bed mobility and extensive assistance of one with eating for Activities of Daily Living. Under section G0400 (Functional Limitation in Range of Motion) was coded for impairment on both side for lower extremity (hip, knee, ankle, foot). The MDS prior to Resident #87's Right Femur Fracture was an Annual Assessment with an ARD date of 1/2/18 coded Resident #87 dependent of two with transfers. Under section G0400 (Functional Limitation in Range of Motion) was coded for impairment on both side for lower extremity (hip, knee, ankle, foot). The review of Resident #87's comprehensive care plan documented Resident #87 is at risk for/has impaired skin integrity due to impaired mobility requires extensive assistance or is dependent in bed mobility and/or transfers. Some of the intervention/approaches to manage goal included use assistance devices for transfer as needed (i.e. *Hoyer lift, sliding board, 2-person assist, etc.). *Mechanical lift (Hoyer lift) used for transfers when a person requires 90-100% assistance to get into and out of bed. A pad fits under the person's body in the bed and connects with chains to the Hoyer lift frame (free-foundation.org/hoyer-lifts). A Fall Risk Assessment was completed on 02-08-18; a resident is determined high risk if score of 10 or above, Resident #87 score was 16. The review of clinical record revealed a Physical Therapy note dated 2/2/17 for the use of a Hoyer lift at this for Resident #87. Review of the clinical nurse's notes evidenced an entry dated 2/17/18 at 6:00 p.m. The nurse documented Resident #87's daughter requested pain medication for resident right leg. Daughter reported resident leg was not elevated; just hanging. Routine pain medication given. Resident placed in bed noted right thigh appear larger than the left, no redness or bruising , heat noted and resident denies pain. Will continue to monitor. Review of the clinical nurse's notes evidenced an entry dated 2/18/18 at 6:20 a.m. The nurse documented Resident #87's right thigh appears bigger in size in comparison to the left. Warm to touch. Resident is in grimacing pain when right leg is moved lightly, MD notified. Review of the clinical nurse's notes evidenced an entry dated 2/19/18 at 12:22 a.m. The nurse documented Resident #87's right thigh remained bigger than the left for day 2. Resident on bedrest during this shift. Pain noted during patient care. Review of the clinical record revealed a Progress Note HPI documented the following on 2/19/18: Patient is seen today in follow up evaluation and management of acute medical problem identified by nursing. Patient had discrete onset Saturday of pain in her right thigh and knee after she was transferred by nurse's aide. Apparently, she was requested to pivot around for positioning. Patient has been screaming out in pain with all passive movement by the staff. Other than the pivot incident, I did not receive any information regarding known accidental injuries or falls. Review of Systems: -Cardiovascular Positive for leg swelling -Musculoskeletal: Positive for gait problem and joint swelling -Musculoskeletal: She exhibits edema and tenderness. There is moderate soft tissue swelling from just above the right knee laterally, to the ankle. There is more swelling in the knee area, consistent with a 3+ joint effusion. Sensate to light touch. Plan: -We will get an x-ray of the right hip and femur today. -We will get a venous duplex of the right lower extremity today. -Patient is currently on Noro daily. I will change that to Noro 1-2 every 6 hours as needed -Primary diagnosis: Lower extremity pain, diffuse, right -Reason for Visit: Right lower extremity pain The x-ray report exam dated 2/19/18 impression was an acute nondisplaced fracture of the *right distal femur seen. *Femur fracture (the femur is the thighbone, which extends from the pelvis to the knee. It is the largest and strongest bone in the body). A fracture is a traumatic injury to the bone in which the continuity of the bone tissue is broken (Mosby's Dictionary of Medicine, Nursing & Health Professions 7th Edition.) Review of the clinical notes revealed a Progress note from [NAME] Roads Ortho/Sports Medicine dated 2/20/18 at 7:43 a.m. The noted documented she (Resident #87) apparently had some event happen at the nursing home where they tried to stand and turn her. Since then, she has had pain around her right knee. We did just complete care of her in the last year or two for nondisplaced fractures of her contralateral distal femur and her right proximal tibia. X-rays ordered and reviewed today of her right distal femur and showed an impacted distal femoral condylar fracture. Assessment: Right distal femur fracture. This should do well with conservative treatment. We will get her into a knee immobilizer. She (Resident #87) is to be strictly nonweightbearing. A phone interview was conducted with Certified Nursing Assistant (CNA) #16 on 8/4/18 at approximately 11:45 a.m., who stated, On the morning of 2/16/18, I transferred Resident #87 by myself. The surveyor asked, Tell me how did you transfer Resident #87 from the bed to the wheel chair (w/c). The CNA stated, I positioned the resident on the edge of the bed, she sat for a few seconds, then I instructed the resident to grab me around my neck and then on the count of 3 we did a stand pivot transfer into the wheel chair. The CNA also said she placed the wheel chair close to the bed before the transfer. The surveyor asked if she know Resident #87 was a Hoyer lift transfer, she replied, Yes. The CNA stated, When I first started here, we would use the Hoyer lift often but now she does better with the pivot/stand transfer and this really works for her. An interview was conducted with CNA #19 on 8/2/18 at approximately 4:40 p.m. The surveyor asked, How was Resident #87 transferred from the w/c to the bed on 2/17/18 she replied, Resident #87's leg was swollen and she was in pain so we had to do a two person transfer. The surveyor asked, How did you do a two person transfer she replied, One person grabbed her under her armpits and the other person under her legs. The CNA said when she went to lay resident down; she was crying in pain while rubbing her right leg. The CNA said Resident #87's right leg was swollen and she reported it to the nurse. On 08/2/18 at approximately 4:45 p.m., a phone interview was conducted with License Practical Nurse (LPN) #18 via phone. She (LPN) stated on 2/17/18, Resident #87's daughter approached her because Resident #87 was having right leg pain and her leg rest was not on her wheelchair. The LPN said she assessed the resident's right leg; noticed the right leg was larger than the left so she administered pain medication and notified the physician. An employee statement written by CNA #33 dated 2/18/19 documented in part the following: On 2/17/18, I was given an assignment, which included Resident #87. A staff member walked through the assignment with me about each resident around 7:30 a.m. The staff instructed me that resident in room (number) (Resident #87) could be transferred via one person using stand pivot method transfer. CNA stated she proceeded to give resident patient care and upon bathing, she turned right to her right side, the resident started complaining of pain in her right knee. On 08/03/18 at approximately 4:30 p.m., an interview was conducted with CNA #17. The CNA stated she transferred Resident back to bed on 2/16/18 and noticed her right leg was larger than the left and tender to touch; her skin is very fragile so we could not use the Hoyer lift. The CNA said she has never used a Hoyer lift on Resident #87 because as I said, her skin in very fragile and it tears easily. The surveyor asked, How did you transfer Resident #87 back to bed from the w/c on 2/16/18, she replied, We transferred her like a baby, one person got her under her arms and the other under legs, removed the w/c arms and lifted her over to the bed; just like a baby. The surveyor asked, Do you use any type of assistive device doing the transfer, she replied, No. The surveyor asked if she was aware that Resident #87 was a Hoyer lift transfer, she replied, Yes, but transferring her this way works better. The surveyor asked, How are you transferring Resident #87 now, she replied, The same way, one person grabs her under her arms while the other under the legs/thighs, remove the w/c arm and just lift her into the bed. The surveyor asked, Do you use a sheet or lift pad she replied, No, we put the bed in lowest position, place the w/c close to the bed, remove the w/c arm rest and on the count of 3 we lift resident into the bed. An interview was conducted with CNA #36 on 08/3/18 at approximately 4:45 p.m., who stated, I was putting (Resident #87) back to bed with 2 people assist - not using a mechanical lift. The CNA stated the resident kept getting bruises because I skin was breaking. He (CNA) stated, I was told by a nurse that Resident was a lift for transfers but could not recall who told me. The surveyor asked, When resident was transferred manually with two people, how was she being transferred back to bed from the wheel chair he replied, One person grabbed (Resident #87) under her lower thighs and someone else would grab under her armpits and just put her in the bed. The surveyor asked, Was a draw sheet or lift pad being used to assist with the transfer he replied, No; we did not use a draw sheet or anything. The CNA stated, He used the Hoyer lift today to put Resident #87 back to bed. An interview was conducted with the Assistant Director of Nursing (ADON) on 08/03/18 at approximately 5:20 p.m., two surveyors present. The surveyor asked, How is Resident #87 being transferred she (ADON) replied, With a Hoyer lift; this is the safest way. The surveyor informed the ADON; Resident #87 was always being transferred by a Hoyer lift but one-person grabbing Resident #87 under her armpits and the other person under the knees. The surveyor asked is that an appropriate transfer for Resident #87 she replied, Absolutely not, you do not transfer anyone that way; Resident #87 is a mechanical lift with 2 people. The ADON stated, We have an issue- we did not follow safe best practice in the recommendation in transfers for this resident and that a problem - we should have clearly used a mechanical lift - that is our expectations for the CNA's. The ADON stated, We will start immediate education. The ADON also said, I did not do a very good job investigation this incident, I should have done a better job. The review of Resident #87's Certified Nursing Assistant (CNA) care plan documented the following on 8/3/18 at approximately 4:28 p.m., under Transfer/Mobility required assist x 2. The surveyor and ADON reviewed Resident #87's CNA care plan. The surveyor asked, How does the staff know how to transfer Resident #87 correctly by looking at the CNA's Care plan she replied, They do not, it should say to use Hoyer Lift with two assist with transfer/mobility. The review of Resident #87's Transfer/Mobility Status Criteria Form dated for 2/8/18 and 8/15/17 revealed the following: -Lifting to be used; Total lift with fully body sling. -Comments: patient requires two person transfer with Hoyer lift for patient and staff safely d/t fragile skin and inability to demonstrate adequate strength to assist with transfer. The review of Resident #87's Transfer/Mobility Status Criteria Form dated 6/7/18 revealed the following; lifting to be used; total lift with full body sling. The review of Physical Therapy Discharge summary dated [DATE] revealed the following: -Analysis of Functional Outcomes/Clinical Impressions: -Patient (Resident #87) has made limited progress with therapy as a result of extreme anxiety and fearful of falling especially in standing position. -Recommendations: recommend nursing continue to use Hoyer lift for out of bed. Resident #87's ADL verification worksheet was reviewed with the ADON on 08/03/8 at approximately 5:20 p.m., two surveyors present. The ADON stated, The transfer should be a 4/3 for total assistance of two with transfers and not 4/2 for total assistance of one with transfers. An interview was conducted with the Rehab Director on 8/3/18 at 10:25 a.m. She said, (Resident #87) was seen on 4/12/18 for evaluation after her femur fracture with a nonweightbearing status to lower bilateral lower extremities. The surveyor asked, What is the proper technique for transfers with a mechanical lift, she replied, Max assist of 2 for Hoyer lifts; it gives safety for the resident as well as the staff. She proceeded to say that Resident #87 has a history of falls with fractures so a Hoyer lift transfer was recommended for her. The Rehab Director was made aware that Resident #87 was being transferred prior to her fracture doing a stand pivot transfer by the CNA for getting out of bed. She was also made aware that when putting Resident #87 back to bed the two staff members would grab her under her armpits and under knees, place the wheel chair next to the bed, remove the wheel chair arm rest then manually put her in the bed. The Rehab Director stated, The expectation is for the staff to follow the resident Plan of Care for Resident #87 and that is to use the Hoyer lift for all her transfers to and from the bed. The facility's administration was informed of the findings during a briefing on 08/3/18 at approximately 5:35 p.m. The facility did not present any further information about the findings. The facility's Policy titled Transfer Using the Mechanical Lift (Revision 11/15). Policy: Mechanical lifts will be utilized by nursing staff to transfer residents who cannot help themselves, residents who fall, and residents who need repositioning that requires a mechanical lift. The number of staff assisting will transfer using the mechanical lift is dependent on: Conditions that may require more than one person to assist during transfer and will be addressed in the Resident Care Plan. 2. Resident #47 was originally admitted to the facility 7/12/13 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; kidney failure, chronic pain, stroke with left hemiplegia, breathing difficulties an anxiety disorder and a psychotic disorder with delusions. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/17/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #47's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 1 person with bed mobility, transfers, toileting, personal hygiene, locomotion, and dressing, total care with bathing. The comprehensive care plan dated 2/10/17 read; Resident has a risk for falls and/or a history of falls related to poor sitting balance, requires staff assistance for transfers, pain, impaired sensation (paralysis, paresis), unsafe behaviors; prefers bed in the high position, unstable fluctuating health conditions, diabetes, hypertension, anemia, psychotropic medication usage, incontinence and history of falls. The goal read; Resident will not experience significant injury (i.e. requiring an emergency room visit or hospitalization through the next review. The interventions included; Keep bed in lowest position for safe transfers, keep bed wheels locked. Keep frequently used items within reach and/or close proximity (i.e. telephone, TV remote, books, water, etc.), If diabetic, monitor blood sugars and treat. Keep call bell within reach, Provided assistive mobility devices as recommended by therapy; report unsafe use to therapy. Use of manual wheel chair and reacher, trapeze to bed. Resident # 47 was observed in bed 7/31/18 at approximately 2:24 p.m. Resident #47 stated she rarely gets out of bed anymore because the last time she got up the staff injured her paralyzed left foot during the transfer and it had been very painful since the event. The resident also stated I've been dropped multiple times and the most recent drop was from the total lift. Resident #47 began crying and stated if they drop me again I may die before my kidneys give out. Review of the clinical record revealed a note dated 7/13/18, which read; resident states that during a lift transfer she felt a pinch on her left leg on 7/11/18. Staff reports no complaints made during the transfer. Area assessed and there is no bruising or broken skin to the left leg. Another clinical note revealed on 12/23/17, the resident was assisted to the floor by Certified Nursing Assistant (CNA) #15 while transferring the resident from the wheelchair to bed. CNA stated resident started slipping out of the hoyer sling. Upon Assessment, noted resident sitting on the floor with her back against the bed. No visible injuries noted. Resident denied any pain or discomfort. Assisted resident up via hoyer lift times 3. Resident remains alert, verbal and able to make her needs known. Will continue to monitor. A telephone interview was conducted with the resident's mother 8/2/18 at approximately 10:30 a.m. The resident's mother stated the facility notifies her of falls and other events but when she desires to discuss falls, or other concerns with the staff during the care plan meeting she is told they will not discussing that in this meeting. An interview was conducted on 8/3/18 at approximately 3:30 p.m., with Certified Nursing Assistant (CNA) #15. CNA #15 stated on 12/23/17 she was transferring the resident alone from the wheel chair to the bed, when the resident began slipping out of the total lift pad. CNA #15 stated it was a frightening experience but she was able to assist the resident to the floor without injuring the resident or herself. CNA #15 also stated she hadn't worked with Resident #47 before and she hadn't been trained in use of the total lift except by watching others. The safety precautions put in place based on the incident report read; educated CNA #15 on the importance of having 2 CNA's present when using the lift. An interview was conducted on 8/3/18, with the Assistant Director of Nursing (ADON) at approximately 4:05 p.m. The Assistant Director of Nursing was able to to present documentation that CNA #15 was educated during orientation on use of the total lift but here was no documentation indicating safety instructions were given to CNA #15 after the 12/23/17 fall. The ADON stated the total lift requires 2 persons to utilize it. The facility's policy titled Transfers using the Mechanical Lift with a review date of 8/17 read; Mechanical lifts will be utilized by nursing staff to transfer residents who cannot help themselves, residents who fall, and residents who need repositioning that requires a mechanical lift. The type of sling used depends on the resident's size, condition and needs, Slings must be washed per facility policy, before using a lift, it must be checked if it is in good working condition. The resident's weight must not exceed the lift's capacity. The number of staff assisting with the transfer using the mechanical lift is dependent on: the manufacturer guidelines - Facility must review guidelines prior to use. Conditions that may require more than one person to assist during transfer and will be addressed in the Resident Care Plan (i.e. bariatric need, uncontrolled body movements, etc.). On 8/3/18 at approximately 6:00 p.m., the above findings were shared with the Administrator and Director of Nursing. An opportunity was given for the facility to present additional information but none was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interviews, clinical record review, and review of the facility's policy, the facility staff failed to ensure that pain management was provided for 1 of 52 residents (Resident #136), in the survey sample. The facility staff failed to provide effective pain management to Resident #136, by not having the ordered narcotic analgesic (Hydrocodone/APAP tablet 5/325 milligrams) readily available for administration, resulting in periods of unnecessary and excruciating pain, constituting harm. The findings included: Resident #136 was originally admitted to the facility 8/1/03 and readmitted [DATE], after an acute care hospital stay. The current diagnoses included; spasmodic torticollis. Cervical dystonia, also called spasmodic torticollis, is a painful condition in which your neck muscles contract involuntarily, causing your head to twist or turn to one side. Cervical dystonia can also cause your head to uncontrollably tilt forward or backward. A rare disorder that can occur at any age, cervical dystonia most often occurs in middle-aged people, women more than men. Symptoms generally begin gradually and then reach a point where they don't get substantially worse. There is no cure for cervical dystonia. The disorder sometimes resolves without treatment, but sustained remissions are uncommon. Injecting botulinum toxin into the affected muscles often reduces the signs and symptoms of cervical dystonia. Surgery may be appropriate in a few cases. (https://www.mayoclinic.org/diseases-conditions/cervical-dystonia/symptoms-causes/syc-20354123) The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/21/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #136's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring limited assistance of 1 with dressing and wheel chair locomotion, extensive assistance of 2 people with transfers and personal hygiene, extensive assistance of 1 person with bed mobility and toilet use, and total care with bathing. The resident navigates the facility via an electric scooter. In section J Resident #136 completed the pain interview which revealed she experienced frequent pain rated at a level of 8 out of 10. The resident also stated during the pain interview that the pain affects her daily activities and ability to sleep. The clinical record review revealed, Resident #136 had physician's orders dated 2/20/18 for Hydrocod/APAP tablet 5/325 milligrams (mg) 1 tablet by mouth every six hours as needed for pain scale 1- 4 and dated 2/21/18 for Hydrocodone/APAP tablet 5/325 milligrams (mg) 2 tablet by mouth every six hours as needed for pain greater than 5. Review of the clinical record also revealed; Resident #136 also receives services from a neurologist every 3 months for treatment of spasmodic torticollis and botulinum injections are administered. The active care plan dated 1/4/17 had a problem which read; Resident has a potential for expressed/demonstrated pain/discomfort related to neuropathy, spasmodic torticollis, cervical dystonia, muscle spasm, neck pain. History of bloating and cramping. The goal read; Resident will express or demonstrate that interventions are effectively controlling and/or relieving pain or discomfort. The interventions included; Encourage and assist resident to identify intensity, quality and location of pain. Encourage resident to tell the nurse when pain interventions are not effective. Report to physician when pain interventions are not effective. When as needed medications are being used with consistency; request a review by the physician or pharmacist for benefit of scheduled medication or change in medication or dosage. Assist the resident as needed to position in a manner that is most comfortable, use pillows or other devices as necessary. Offer psychological consult and spiritual support as appropriate and desired by resident and/or family. Offer activities that may refocus resident such as; music, conversation, etc. Review of the Medication Administration Record (MAR) revealed non-pharmacological interventions were initiated prior to each administration of Hydrocodone/APAP. They included repositioning, food/hydration and redirecting with effectiveness but; the medication was still administered. On 7/31/18 at approximately 2:15 p.m. Resident #136 was observed in bed. Resident #136 was barely opening her eyes and holding her head. The resident stated, I'm not getting out of bed for chapel or activities because she I have an excruciating headache and didn't slept all night because my pain medication Norco (Hydrocodone/APAP) wasn't available last evening, this morning or currently, 2:15 p.m. Resident #136, further stated when the pain medication Norco (Hydrocodone/APAP) is available for me to receive at least 3 doses per day the regime is effective but; frequently 9 out of 10 times I experience excruciating pain for the medication isn't available because the nursing staff doesn't order another supply prior to the current supply exhausting. The resident also stated that, the nurses tell me when there is no Norco (Hydrocodone/APAP tablet) available, I can have Tylenol, which is never effective. Prior to the surveyor completing the interview, Resident #136 stated; this is my home and I like it here, pleases help the nurses get my new supply of pain medication in before the current supply runs out. That was the only request she made. Review of the Controlled Drug Receipt/Record/Disposition Form revealed; on 7/26/18, twenty-five Hydrocodone/APAP tablets were delivered and the supply was exhausted at 4:30 a.m., on 7/31/18 and the next supply wasn't delivered to the facility until approximately 4:30 a.m., 8/1/18. Only one dose was withdrawn from the stat box over the 24 hours the supply was exhausted; that was on 7/31/18, at 2:42 p.m. At 10:46 a.m. Tylenol was administered when the resident requested Hydrocodone/APAP tablets. On 7/20/18, twenty-five Hydrocodone/APAP tablets were delivered and the supply was exhausted at 4:46 a.m., on 7/26/18. The next supply wasn't delivered until 9:30 p.m., (16.75 hour later) on 7/26/18. No doses were obtained from the stat box but Tylenol was administered upon the resident's request for Hydrocodone/APAP tablet on 7/26/18. On 6/28/18, thirty Hydrocodone/APAP tablets were delivered and the supply was exhausted at 10:19 a.m., on 7/6/18. The next supply arrived to the facility at 7/7/18 at 4:45 a.m. Tylenol was administered 7/6/18 at 5:02 p.m., for pain because Hydrocodone/APAP tablets were not available in the medication cart. The resident's pain level was 5/10. No doses were obtained from the stat box. On 6/18/18 Tylenol was administered upon the resident's request for Hydrocodone/APAP tablets for pain at a level 4/10 at 4:29 p.m. On 6/19/18, thirty Hydrocodone/APAP tablets were delivered. The time of the delivery is unknown but the resident was not administered any of the medication delivered on 6/19/18 until 8:50 a.m., and the supply was exhausted at 9:00 p.m., on 6/25/18. On 5/27/18 twenty-five tablets were delivered and the supply exhausted 6/4/18 at 11:00 p.m. On 6/5/18 a dose was obtained from the stat box at 4:46 a.m. The Hydrocodone/APAP tablets had not been delivered by 6:15 p.m. therefore; for pain rated 7/10 Tylenol was administered. At 6:26 a.m. on 6/6/18 the medication still had not arrived and Tylenol was again administered for pain rated 8/10. The next supply was delivered 6/6/18. But the exact time is unknown, but the resident received a dose of Hydrocodone/APAP tablets at 9:38 a.m. An interview was conducted on 8/3/18, at approximately 4:00 p.m., with Licensed Practical Nurse (LPN) #29. LPN #29 stated whenever Resident #136 didn't have the Hydrocodone/APAP tablets available to be administered the nurses offered Tylenol or Flexeril until the Flexeril was discontinued because the resident wouldn't accept it. LPN #29 was asked if scheduling the Hydrocodone/APAP tablets had been considered since a care plan intervention was reviewing use and effectiveness of the medication and following up with the physician. LPN #29 stated they had talked with the resident about scheduling the pain medication 8/2/18, and she was going to think about it and give the staff her answer. An interview was conducted with on 8/3/18, at approximately 4:30 p.m., with the Assistant Director of Nursing (ADON). The ADON stated the facility has 1 Hydrocodone/APAP 5/325 mg tablet available in the Omnicell (medication storage system), 8 Hydrocodone/APAP 5/325 mg tablets available most days in stat box 2 and (7.5/325 and 10/325) other doses are available if ordered by the physician. The ADON stated when Resident #136's personal Hydrocodone/APAP tablets were exhausted the nurse should have obtained the medication from the stat box. The process requires the nurse to call the pharmacy, who will review the prescription and give the nurse a code, the nurse will document the authorization code and obtain the medication from the stat box to administer to the resident. The ADON stated a resident should never be in pain because the pain medication isn't available in their personal medication when it is available in the stat boxes. The facility's policy titled Controlled Substances date 6/21/17 read; (name of pharmacy) will not dispense a controlled medication or approve its removal from an onsite store supplied by the pharmacy, until a valid prescription has been received by the pharmacy from the prescriber. Under procedure #2 the policy stated; the prescriber must always provide a complete and valid prescription prior to dispensing of controlled substance medications. It is the facility and prescriber's responsibility to obtain the required prescription needed to meet the needs of the resident. On 8/3/18 at approximately 6:00 p.m., the above findings were shared with the Administrator and Director of Nursing. An opportunity was given for the facility to present additional information but none was provided.