Every finding on record at Liberty Healthcare Services of Golden Years Nursin

Based on medical record review and staff interviews, the facility failed to accurately code the Quarterly Minimum Data Set (MDS) assessment for 1 of 33 sampled residents reviewed for diagnosis of depression. (Resident #12)Findings included:Resident #12 was admitted to the facility on [DATE]. Cumulative diagnoses included hypertension, diabetes mellitus, depression and hyperlipidemia.Review of the August 2025 Medication Administration Record (MAR) revealed Resident #12 received the medication Sertraline (antidepressant medication) tablet 25 Milligram (MG) 1 tablet by mouth one time a day for depression.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12 was cognitively intact. MDS Section I5800 under the active diagnoses was documented as no for Resident #12 having an active diagnosis of depression.During an interview with the Director of Nursing (DON) on 11/20/2025 at 9:14 AM, she confirmed that the resident's MDS was inaccurate due to the resident having a diagnosis of depression and was receiving antidepressant medication. The DON further stated that it was her expectation that the MDS would be coded accurately.During an interview with the MDS Coordinator on 11/20/2025 at 10:15 AM, she confirmed Resident#12 had diagnosis of depression and the MDS was not coded accurately. MDS Coordinator added that she will be careful next time to make sure the MDS was coded accurately.During an interview with the Administrator on 11/20/2025 at 10:35 AM, she stated the MDS was not accurate because the resident had diagnosis of depression. She added her expectation was the MDS is coded accurately for the residents.

Based on record review, observations, and interviews of staff and residents, the facility failed to provide nail care for dependent residents (Resident #s 2, 3, 4, 6, and 7). This deficient practice affected 5 of 6 residents reviewed for activity of daily living. Findings included: 1. Resident #2 was admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease. Resident #2's care plan dated 2/3/25 documented the resident had an activity of living self-care performance deficit. The intervention was to check nail length and trim as necessary. There was no refusal of care in the plan. The quarterly Minimum Data Set, dated dated dated [DATE] for Resident #2 documented he had a severly impaired cognition. The resident was dependent on staff for personal hygiene. On 3/10/25 at 11:10 am an observation was done of Resident #2. He was sitting in his wheelchair in the dining room. The resident was clean and dressed. His nails were long, jagged, and clean. The nail length was approximately 1/4 of an inch. An interview was attempted with the resident which revealed he was aware of the situation and could make his needs known. The resident was able to state yes he would like his nails cut. On 3/10/25 at 12:05 pm an interview was conducted with Nursing Assistant (NA) #1. NA #1 stated she provided a resident's nail care during the bed bath or shower. NA #1 stated if the resident was a diabetic she would inform the nurse to cut the resident's nails. NA #1 stated she was assigned to Resident #2 and knew him well and was not aware his nails needed care. On 3/10/25 at 12:10 pm an interview was conducted with Nurse #1. She stated the NAs were responsible to cut the resident's nails and inform the nurse if unable to provide nail care. 2. Resident #3 was admitted to the facility on [DATE] with the diagnosis of diabetes. Resident #3's care plan dated 1/2/25 documented the resident had an activity of living self-care performance deficit. The intervention was for staff to assist with personal hygiene. There was no refusal of care in the plan. The quarterly Minimum Data Set, dated dated dated [DATE] for Resident #3 documented he had moderately impaired cognition. The resident required substantial/maximal assistance from staff for personal hygiene. On 3/10/25 at 11:15 am an observation was done of Resident #3. He was sitting in his wheelchair in the dining room. The resident was clean and dressed. His nails were long, jagged, and clean. His right hand first and second fingers were longer than the rest. The length of the nails were approximately 1/4 to 1/2 of an inch. The resident was interviewed and stated he would like his nails cut. He also commented that nails were cut on shower days but he had not received care. On 3/10/25 at 12:05 pm an interview was conducted with NA #1. NA #1 stated she provided resident's nail care during the bed bath or shower. NA #1 stated if the resident was a diabetic she would inform the nurse to cut the resident's nails. NA #1 stated she was not aware Resident #3's nails were long and that he wanted his nails cut. NA #1 stated she was assigned to the resident today and would inform the nurse if he was a diabetic. On 3/10/25 at 12:10 pm an interview was conducted with Nurse #1. She stated the NAs were responsible to cut the resident's nails and inform the nurse if unable to provide nail care. 3. Resident #4 was admitted to the facility on [DATE] with the diagnosis of Parkinson's disease. The quarterly Minimum Data Set, dated dated dated [DATE] for Resident #4 documented he had an intact cognition. The resident required maximal assistance from staff for personal hygiene. Resident #4's care plan dated 2/20/25 documented the resident had an activity of living self-care performance deficit. The intervention was to check nail length and trim and clean as necessary. There was no refusal of care in the plan. On 3/10/25 at 12:00 pm an observation was done of Resident #4. He was sitting on his bed in a gown. The resident was clean. His nails were long and jagged with minimal brown matter underneath. The length was approximately 1/4 to 1/2 of an inch. An interview with the resident revealed he would like his nails cut. The resident stated he was not offered nail care and had not asked the staff. On 3/10/25 at 12:05 pm an interview was conducted with NA #1. NA #1 stated she provided resident's nail care during the bed bath or shower. NA #1 observed Resident #4's nails and confirmed that they were long. NA #1 stated if the resident was a diabetic she would inform the nurse to cut the resident's nails. Nurse #1 was present in the resident's room and informed NA #1 that Resident #4 was not diabetic. NA #1 stated she was assigned and would cut the resident's nails. NA #1 had no further comments about resident's nail care and commented that she was usually assigned to this hall and resident on day shift. On 3/10/25 at 12:10 pm an interview was conducted with Nurse #1. She stated the NAs were responsible to cut the resident's nails and inform the nurse if unable to provide nail care. Nurse #1 stated Resident #4's nails were long and required care. 4. Resident #6 was admitted to the facility on [DATE] with the diagnosis of diabetes. Resident #6's care plan dated 2/7/25 documented the resident had an activity of living self-care performance deficit. The intervention was the resident required staff assistance for grooming and personal hygiene. There was no refusal of care included in the plan. The quarterly Minimum Data Set, dated dated dated [DATE] for Resident #6 documented he had an intact cognition. The resident was dependent on staff for personal hygiene. On 3/10/25 at 12:25 pm an observation was done of Resident #6. He was lying in his bed with family at the bedside. The resident was clean and dressed. His nails were long and jagged. The left hand was contracted, and the nails were pressing into the palm. There was no injury or redness noted. The family member commented the nails had been like this for a while. The length was approximately 1/4 to 1/2 of an inch. The resident was sleeping and a limited interview with the resident revealed he was aware of the situation and could make his needs known. The resident was not able to state he wanted his nails cut at this time. The family member requested the resident's nails be trimmed to prevent injury to his palm. On 3/10/25 at 12:30 pm an interview was conducted with Nurse #2. Nurse #2 stated the NAs were required to provide the residents nail care as needed unless the resident was a diabetic, were unable to, or the resident refused. Nurse #2 was not aware of Resident #6's long nails on the left contracted hand that was pressing on the palm. Nurse #2 stated she would address the need for nail care. The resident was a diabetic and would require a nurse to provide nail care because he had the diagnosis of diabetes. 5. Resident #7 was admitted to the facility on [DATE] with the diagnosis of diabetes. The annual Minimum Data Set, dated dated dated [DATE] for Resident #7 documented he had an intact cognition. The resident was dependent on staff for personal hygiene. Resident #7's care plan dated 3/7/25 documented the resident had an activity of living self-care performance deficit. The intervention was the resident required staff assistance for grooming and personal hygiene. There was no refusal of care in the plan. On 3/10/25 at 12:25 pm an observation was done of Resident #7. The resident was clean and dressed and was lying in his bed. His nails were long and jagged and approximately 1/4 inch long. An interview with the resident revealed he received his shower yesterday (3/9/25) but was not offered nail care. The resident stated he was unable to cut his own nails and had not asked staff to cut them. On 3/10/25 at 12:30 pm an interview was conducted with Nurse #2. Nurse #2 stated the NAs were required to provide the residents nail care as needed unless the resident had the diagnosis of diabetes, or the resident refused. Nurse #2 stated she would address the need for nail care since the resident had the diagnosis of diabetes. She had not received a report from the NA the resident required nail care. On 3/10/24 an interview was conducted with the Corporate Nurse. She stated the Director of Nursing position was open and corporate staff was covering. The Corporate Nurse was not aware of the residents that needed nail care and would follow up. The NAs were expected to provide nail care if not contraindicated (i.e. diabetic) on shower days or report to the nurse.

Based on staff interviews and record reviews the facility failed to apply for an updated level I Preadmission Screening and Resident Review (PASRR) for a resident admitted with mental health diagnoses for 1 of 3 residents reviewed for PASRR (Resident #36). The findings included: A review of the medical record for Resident #36 was admitted into the facility on [DATE] with diagnoses that included major depression and psychotic disorder. A review of Resident #36's most recent PASRR Level I screen was dated 11/16/21 and marked no to the question is there a Mental Health diagnosis. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #36 was cognitively intact and was taking antipsychotic medication. An interview with the Administrator on 8/29/24 at 9:26 AM revealed there was not a Social Worker in the building since the last Social Worker resigned. He stated that the Social Worker duties were supposed to be split between the administrative staff which included reviewing the PASRR. He further stated that Resident #36 should have been screened for a PASRR when admitted into the facility.

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of discharge location (Resident #42) and tracheostomy care (Resident #145) for 2 of 12 residents reviewed for MDS accuracy. The findings included: 1. Resident #145 was admitted to the facility on [DATE] with diagnoses that inclued laryngectomy (surgical removal of the larnyx) and tracheostomy (a breathing tube). The 5-day Minimum Data Set (MDS) dated [DATE] had Resident #145 was moderately cognitively. He was coded for suctioning and as not having a tracheostomy. The care plan dated 10/11/2022 had a focus of laryngectomy, tracheal suctioning as needed (PRN) for congestion or unable to clear secretions, change tracheostomy ties weekly and PRN. Monitor skin and document concerns in nursing notes as needed for laryngectomy stoma, and laryngectomy care everyday shift and PRN. An interview with the MDS Coordinator was conducted on 08/01/2023 at 10:11 AM. The MDS Coordinator stated she completed Resident #145's MDS and he did have a tracheostomy. The MDS also stated the MDS was coded incorrectly due to oversite. An interview with the Director of Nursing was conducted on 08/01/2023 at 12:03 PM. The DON stated Resident #145 did have a tracheostomy and it was coded incorrectly on the MDS due to oversite. 36573 2. Resident #42 was admitted to the facility on [DATE]. Review of Nursing Progress Note written by Nurse #1 on 6/28/23 read: Resident discharged home with daughter. The Discharge MDS dated [DATE] was coded in Section A as discharge to hospital. An interview with the Director of Nursing was conducted on 08/02/2023 at 12:35 PM. The DON stated Resident #42 discharged to home on 6/28/23 and the Discharge MDS was coded incorrectly due to oversite. An interview with the MDS Coordinator was conducted on 08/02/2023 at 1:23 PM. The MDS Coordinator verified Resident #42 was discharged home on 6/28/23. She stated she completed Resident #42's Discharge MDS and it was coded incorrectly due to oversite.

Based on staff interviews, and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place following the 3/18/22 recertification survey. This was for a recited deficiency in the area of Accuracy of Assessments (F641). This deficiency was cited again on the current recertification survey of 8/3/23. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F641: Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of discharge location (Resident #42) and tracheostomy care (Resident #145) for 2 of 12 residents reviewed for MDS accuracy. During the recertification survey of 3/18/22, the facility was cited at F641 for failing to accurately code the MDS in the areas of Preadmission Screening and Resident Review level II and personal hygiene. During an interview on 8/3/23 at 12:00 PM, the Director of Nursing (DON) revealed she completed chart audits monthly to review for accuracy of MDS assessments. She addressed findings in QAA meetings monthly. She had not found any issues with accuracy of MDS assessments. During an interview on 8/3/23 at 12:05 PM, the Administrator revealed that monitoring for accuracy of assessments was an ongoing project. He was not aware of any issues with MDS coding accuracy but will be working with a corporate consultant to address the issues found.

Based on staff and resident interviews and record review, the facility failed to provide a written notice of transfer/discharge to the hospital to the resident and regional ombudsman for 1 of 1 resident (Resident #18) reviewed for hospitalization . Findings included: Resident #18 was initially admitted to the facility on [DATE]. Her quarterly Minimum Data Set (MDS) dated [DATE] indicated she was cognitively intact. A nursing progress note dated 7/15/23 completed by Nurse #2 indicated Resident #18 was complaining of abdominal pain and was sent to the hospital for evaluation. The progress note did not indicate if Resident #18 was provided written notice of reason for transfer. A nursing progress note dated 7/19/23 indicated Resident #18 returned to the facility from the hospital. During an interview on 8/1/23 at 2:25 PM, Nurse #1 revealed when a resident was discharged to the hospital an Interact Transfer Form was filled out and sent to hospital staff but not provided to the resident. During an interview on 7/31/23 at 2:10 PM, Resident #18 revealed she was not provided written notice that included the reason for transfer to the hospital. During an interview on 8/2/23 at 10:20 AM, the Director of Nursing (DON) revealed written notice of reason for transfer to the hospital was not provided because they were anticipated to return. The DON revealed the regional ombudsman was not notified of transfers or discharges because the facility did not have a social worker, and no one had taken over submitting since she started three months ago. During an interview on 8/3/23 at 10:00 AM, the Administrator revealed he was not aware of the requirement to provide a resident a written notice that included reason for transfer to the hospital. He was not aware no one was contacting the ombudsman of discharges and transfers.

Based on record review and staff interview, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 5 of 90 days reviewed (dates 1/07/23, 1/08/23, 2/18/23, 3/04/23, and 3/05/23). The findings included: A review of the facility's Daily Schedules and the Daily Nursing staff posting dated January 2023 through March 2023 was conducted on 8/03/23. The Daily Schedules and the Nursing Staff Postings indicated a Registered Nurse (RN) was not scheduled for at least 8 consecutive hours a day on the following dates: 1/07/23, 1/08/23, 2/18/23, 3/04/23, and 3/05/23. A review of the Payroll Based Journal Report dated Quarter 2 (January 1-March 2023). It triggered no RN hours for four or more days withing the quarter. Those dates included 1/07/23, 1/08/23, 2/18/23, 3/04/23 and 3/05/23. An interview was conducted on 8/03/23 at 10:45 AM with the Director of Nursing (DON). During the interview, the DON stated that she was not employed at the facility during that time. She confirmed with the facility human resource staff there was no RN on shift during 1/07/23, 1/08/23, 2/18/23, 3/04/23, and 3/05/23. She stated there should have been RN coverage for at least 8 consecutive hours 7 days a week. An interview was conducted on 8/03/23 at 11:15 AM with the Administrator. He explained he had been made aware of the Payroll Based Journal Report (PBJ Report) and the staffing issues when he took over as Administrator in late April 2023. He stated he did not know what happened prior to his employment. He stated his expectations are for the current DON to cover if there are any call outs.

Based on record review, staff interview, Consultant Pharmacist interview, and Physician interview the facility failed to assure the Consultant Pharmacist reported to the physician there were no finger stick blood sugars being done for an insulin dependent diabetic. This was for one (Resident # 2) of two sampled insulin dependent residents. The findings included. Resident # 2 was last admitted to the facility on [DATE]. The resident had a diagnosis of Type 2 diabetes. Resident # 2 had a current order, which had been in effect since 1/27/22, for 40 units of [MEDICATION(S)] 70/30 to be administered every morning. ([MEDICATION(S)] insulin contains 30% short acting insulin and 70% long acting insulin). Review of Resident # 2's record since 3/19/22 revealed there were no finger stick blood sugars being done. Non-fasting chemistry labs drawn on 3/20/22 and 3/21/22 revealed glucose levels of 178 and 214 respectively. A Hemoglobin AIC lab was drawn on 4/28/22 and registered a result of 8.4. (This is a test to reflect the average blood sugar levels for the past two to three months. An interview with the facility's Medical Director on 5/25/22 at 11:10 AM revealed the goal for diabetics would be a Hemoglobin AIC value between 7 and 8). On 4/28/22 a fasting blood sugar was also completed with a result of 236. Review of the Consultant Pharmacist notes revealed a drug regimen review on 3/24/22 with no mention or recommendations regarding Resident # 2's diabetic mediations or monitoring. On 4/28/22 the Consultant Pharmacist noted in the drug regimen review Resident # 2 had a HbgAIC but made no mention of the result or forwarded any recommendations to the physician related to monitoring of blood sugars. The Nurse Practitioner (NP), who had initiated Resident # 2's last insulin orders, was interviewed on 5/24/22 at 3:19 PM and reported she thought daily finger stick blood sugars were being done on Resident # 2. She thought she had put the order into the electronic orders. The Director of Nursing (DON) was interviewed on 5/24/22 at 2:50 PM. The DON reviewed the record back to 3/19/22 and could find no record of finger stick blood sugars. According to the DON, when a resident was ordered insulin there are additional steps needed in entering the order for accompanying finger stick blood sugars to be ordered and then populate on the electronic Medication Administration Record, and the Nurse Practitioner may not have realized her intended order did not go through. The Consultant Pharmacist was interviewed on 5/24/22 at 3:27 PM and reported she usually looked at diabetic residents' blood sugars during her monthly drug regimen review but had not caught Resident # 2's finger stick blood sugars were not being done. She was interviewed regarding recommended frequency of checking blood sugars for residents who were receiving 70/30 insulin, and reported it was resident specific. Interview with the Administrator on 5/24/22 at 4:55 PM revealed she felt the facility staff were providing monitoring of the insulin via way of the Hemoglobin AIC and fasting blood sugar. Resident # 2's physician, who also serves as the facility's Medical Director, was interviewed on 5/25/22 at 11:10 AM and reported the following. Although some insulin dependent individuals do not have their blood sugar checked daily, the intent of the NP was that Resident # 2's finger stick blood sugar be checked when the last insulin order had been initiated but an error had been made because of how the order was entered in the system. The physician stated that was not the facility staff's fault, but it was the fault of the NP, and therefore he would make sure in the future he and the NP did it correctly. He felt the facility had been doing some monitoring by way of their standing orders to do labs, but he felt the Consultant Pharmacist should have called it to his attention that there were no finger stick blood sugars being done. The physician reported a resident on [MEDICATION(S)] 70/30 did typically have some finger stick blood sugars done and the frequency would have been determined and clarified if the Consultant Pharmacist had brought it to their attention.

Based on observations, staff interviews, and record review, the facility failed to have a medication error rate of less than 5 percent as evidenced by 3 medication errors out of 26 opportunities, resulting in a medication error rate of 11.5 percent for 2 of 5 residents (Resident #4 and Resident #6) observed during medication pass. The findings included: 1. On 4/26/2022 at 8:01 A.M., Medication Aide (MA) #1 was observed as she prepared and administered medication to Resident #4. The administered medications included one tablet of acetaminophen 650 milligrams (mg). The medication was obtained from a house stock bottle stored on the medication cart. A review of Resident #4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 4/26/2022 at 10:00 A.M. with MA #1. During the interview the stock bottle of acetaminophen was reviewed and compared with Physician Orders. MA #1 confirmed the order stated to give two tablets of acetaminophen and she had administered one tablet of acetaminophen to Resident #4. MA #1 stated the physician usually ordered acetaminophen 650 mg and she thought Resident #4's order was for a total dose of 650 mg. An interview conducted on 4/26/2022 at 10:24 A.M. with the Administrator and the Director of Nursing revealed during the medication administration pass, staff were responsible to follow the five rights of medication administrations to ensure the correct medication, correct dose and correct time were followed during medication administration. An interview conducted on 4/26/2022 at 12:26 P.M. with the Physician revealed staff needed to administer medications as ordered. The Physician stated Resident #4 was not harmed with the omission of one acetaminophen tablet. 2. On 4/26/2022 at 8:25 A.M., Nurse #1 was observed as she prepared and administered medication to Resident #6. The administered medications included one capsule of Cranberry 500 mg. The medication was obtained from a house stock bottle stored on the medication cart. Nurse #1 removed [MEDICATION(S)] 0.01% solution eye drops (used to reduce eye pressure in patent's with [CONDITION(S)]) from the top drawer of the medication cart. A review of Resident #6's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 4/26/2022 at 10:00 A.M. with Nurse #1. During the interview the stock bottle of cranberry capsules was reviewed and compared with Physician Orders. Nurse #1 confirmed the order stated to give two tablets of Cranberry 200 mg and Nurse #1 administered one tablet of Cranberry 500 mg to Resident #6. During the interview Nurse #1 stated Resident #6 had run out of her prescription cranberry tablets and Nurse #1 substituted the missing medication with house stock one cranberry tablet 500 mg. During the interview Nurse #1 confirmed the [MEDICATION(S)] 0.01% solution eye drops were administered during the morning medication pass and the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview conducted on 4/26/2022 at 10:24 A.M. with the Administrator and the Director of Nursing revealed during the medication administration pass, staff were responsible to follow the five rights of medication administrations to ensure the correct medication, correct dose and correct time were followed during medication administration. An interview conducted on 4/26/2022 at 12:26 P.M. with the Physician revealed staff needed to administer medications and eye drops as ordered. During the interview the Physician stated there was no harm to Resident #6 with the increase in the cranberry dose and the eye drops being received in the morning instead of at bedtime.

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) to reflect the Preadmission Screening and Resident Review (PASRR) Level II status for 3 of 4 residents (Resident #16, #19, and #29) and to correctly code a resident's personal hygiene on a quarterly minimum data set assessent (Resident #23) for 4 of 4 residents reviewed for MDS accuracy. Finding included: 1. The North Carolina Department of Health and Human Services PASRR Level II determination notification dated 08/10/2021 revealed the nursing facility placement was appropriate. Resident #16 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #16 coded as cognitively intact and needed extensive assistance with activities of daily living (ADL). The MDS was also coded 7 days for antidepressant use during the 7-day look back period. Resident #16's MDS was coded, No for having been considered by the state PASRR Level II process to have serious mental illness and/or intellectual disability or a related condition. The care plan dated 01/05/2022 had focus' of having had episodes of displaying the following inappropriate behaviors: cursing, yelling at staff, wandering, & violence/aggression towards staff/other residents, and a focus of having a PASRR Level II related to severe mental illness, use anti-anxiety medications with risk for adverse side effects. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the MDS nurse was conducted on 03/15/2022 at 3:47 PM. The nurse stated she was responsible for coding the resident's MDS and the annual MDS was coded as no when it asked if Resident #16 was considered for a PASRR Level II, and it should have been checked, Yes. The nurse also stated the wrong coding was due to human error. An interview with the Administrator was conducted on 03/15/2022 at 3:52 PM. The Administrator stated the MDS nurse is responsible for coding the screening for the PASRR's and they are expected to be coded accurately. 2. Resident #19 was initially admitted to the facility on [DATE] with the last readmission on 1/5/2022. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The North Carolina Department of Health and Human Services PASRR level II determination notification dated 4/23/20 revealed a Level II PASRR for Resident #19. Nursing facility placement was appropriate. The most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #19 did not currently have a Level II PASRR. An interview was conducted on 03/16/22 at 08:50 AM with the MDS Nurse. She indicated it was an error and Resident # 19's MDS should have been coded as having a Level II PSARR screening since a Level II PSARR had been submitted to the state agency and received back. An interview was conducted on 03/16/22 at 09:44 AM with the facility Administrator. The Administrator stated the annual MDS should have been coded to indicated Resident #19 had a Level II PSARR. 3. Resident #29 was initially admitted to the facility on [DATE] with the last readmission on 6/26/2020. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The North Carolina Department of Health and Human Services PASRR level II determination notification dated 9/2/21 revealed a Level II PASRR for Resident #29. Nursing facility placement was appropriate. The most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #29 did not currently have a Level II PASRR. An interview was conducted on 03/16/22 at 08:50 AM with the MDS Nurse. She indicated it was an error and Resident # 29's MDS should have been coded as having Level II PSARR screening since a Level II PSARR had been submitted to the state agency and received back. An interview was conducted on 03/16/22 at 09:44 AM with the facility Administrator. The administrator stated the annual MDS should have been coded to indicated Resident #29 had a Level II PSARR. 4. Resident #23 was admitted to the facility on [DATE] with most recent readmission on 12/23/21. Her active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23 quarterly minimum data set (MDS) assessment dated [DATE] revealed in section G - personal hygiene was coded as total dependence. A review of her most recent MDS assessment dated [DATE] revealed in section G - personal hygiene was coded as needing supervision. The care plan dated 1/17/22 had focus area to include having activities of daily living self-care performance deficit related to [CONDITION(S)]. Interventions included tasks to assist with total dependence for dressing and requiring staff assistance with grooming and personal hygiene. During an interview on 3/14/22 at 4:00 PM Nurse Aide #1 stated that Resident #23 required total dependence with personal hygiene and with one-person physical assist. She further stated Resident #23 had always been total dependent to her knowledge. An interview was conducted on 3/16/22 at 3:05 PM with the MDS Nurse. She stated she was responsible for coding Resident #23 activities of daily living. She continued and stated Resident #23 should not have been coded as supervision. An interview was conducted on 3/18/22 at 8:13 AM with the Administrator. She explained Resident #23 coding for the quarterly MDS dated [DATE] was coded incorrectly. She also stated Minimum Data Set assessments should be entered correctly on each assessment.

Based on observation and staff interviews, the facility failed to protect private health information for 1 of 1 resident (Resident #10) by leaving confidential medical information unattended and exposed in an area visible and accessible to the public on 1 of 2 medication cart computers. The findings included: A continuous observation of an unattended medication cart in unit 1 hall was made on 3/16/22 from 8:27 AM to 8:30 AM. Nurse #1 left the medication cart with the computer screen visible outside of room [ROOM NUMBER] while she administered medications to Resident #10 who also resided on unit 1 hall. Resident #10's medical information was visible on the screen. Other residents, staff and visitors were present in the hallway. During an interview on 3/16/22 at 8:30 AM with Nurse #1, she indicated she had left the computer screen unattended in the hallway while she went to administer medications to Resident #10. Nurse #1 explained she should have locked the screen and not left Resident #10's medical information in an area visible to others in the hallway. An interview was conducted on 3/16/22 at 9:35 AM with the Director of Nursing (DON). He indicated Nurse #1 should not have left the computer screen unlocked when she went into Resident #10's room to administer medications. He stated nurses were responsible for protecting Residents' medical information from others' visibility. During an interview on 3/16/22 at 9:40 AM with the facility Administrator, she indicated Nurse #1 should not have left the computer screen unattended while she went into residents' rooms. The Administrator further stated private health information should never be left on the computer screen where it is visible to the public.

Based on staff interview and record review, the facility failed to obtain a Preadmission Screening and Resident Review (PASRR) Level II for a resident with an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident #4) The findings included: The North Carolina Department of Health and Human Services PASRR screening tool dated 03/14/2022 at 2:32 PM revealed a PASRR Level II screening was completed for Resident #4. Resident #4 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #4 coded as cognitively intact and needing total dependence on staff with activities of daily living (ADL). The MDS was also coded for an anxiety disorder and [CONDITION(S)] and used an antipsychotic and an antidepressant for 7 days of the 7-day look back period. The annual MDS dated [DATE] had Resident #4 coded as, No for having been considered by the state PASRR Level II process to have serious mental illness and/or intellectual disability or a related condition. The comprehensive care plan dated 01/17/2022 had focus' of have episodes of displaying the following inappropriate behaviors: cursing, yelling at staff, potential to demonstrate verbally abusive behaviors related to (r/t) ineffective coping skills, mental/emotional illness, poor impulse control. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the Social Worker (SW) was conducted on 03/15/2022 at 3:49 PM. The SW stated she was familiar with the resident. He was submitted for a PASRR level II on 03/14/2022. He had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The SW also stated she had been going through the charts in August to get PASRR screening up to date and will continue to update all residents. An interview with the Administrator was conducted on 03/16/2022 at 11:34 AM. The Administrator stated she was new to PASRR's, but she and the social worker was working on the PASRR screening. The Administrator also stated residents with a new mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, observations, staff and physician interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 1 resident (Resident #34) reviewed for respiratory care. The findings included: Resident #34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #34 was moderately impaired and received oxygen therapy. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #34's care plan revised 2/8/22 indicated focus areas of chronic heart failure, shortness of breath and continuous oxygen therapy. Interventions included administer oxygen per physician orders. Observation on 03/14/22 at 12:50 PM revealed Resident #34's oxygen regulator on the concentrator was set at 3.5 liters/minute when viewed horizontally at eye level. Observation on 03/15/22 at 9:36 AM revealed Resident #34's oxygen regulator on the concentrator was set at 3.5 liters/minute when viewed horizontally at eye level. Observation on 03/15/22 at 3:00 PM revealed Resident #34's oxygen regulator on the concentrator was set at 3.5 liters/minute when viewed horizontally at eye level. During an interview on 03/15/22 3:02 PM with Medication Aide #1, she stated Resident #34 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #34's oxygen regulator was verified with Medication Aide #1 to be set at 3.5 liters/minute. Medication Aide #1 stated she had not adjusted the oxygen levels during her shift and probably the night shift nurse had adjusted the settings. During an interview on 3/15/22 at 3:08 PM with Medication Aide #2, she revealed she had cared for Resident #34 on 3/14/21 night shift. Medication Aide #2 indicated she had noticed Resident #34's oxygen regulator was set at 3.5 liters/minute during her shift but forgot to adjust the setting to the ordered flow rate. She verbalized Resident #34 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted 03/15/22 3:15 PM with the Director of nursing (DON). He stated Resident #34 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . He further stated nurses were to call the physician if they needed to titrate the oxygen rate. During an interview on 03/15/22 at 3:32 PM with the facility Administrator, she indicated Medication Aide #1 should have ensured Resident #34's oxygen regulator was set at the physician ordered rate. The Administrator explained she expected nursing staff to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 03/16/22 at 2:49 PM with the facility Physician. He stated he expected nursing staff to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation and staff interviews, the facility failed to secure 1 of 2 medication carts (unit 1 medication cart) when left unattended in the hallway. The findings included: A continuous observation of an unattended medication cart on the Unit 1 hall was made on 3/16/22 from 8:27 AM to 8:30 AM. The medication cart was noted to be unlocked with the push in lock in the out position. The medication cart was outside room [ROOM NUMBER] and was not visible to Nurse #1 when she was in room [ROOM NUMBER]. Other residents, staff and visitors were present in the hallway. The medication cart was verified to be unlocked with Nurse #1 at 8:30 AM. During an interview on 3/16/22 at 8:30 AM with Nurse #1, she indicated she had left the medication cart unlocked in the hallway while she went into room [ROOM NUMBER] to administer medications. Nurse #1 explained she should have locked the medication cart when she walked away from the cart. An interview was conducted on 3/16/22 at 9:35 AM with the Director of Nursing (DON). He indicated Nurse #1 should not have left the medication cart unlocked while unattended. He stated nurses were responsible for securing the contents of the carts they were assigned. During an interview on 3/16/22 at 9:40 AM with the facility Administrator, she indicated Nurse #1 should not have left the medication cart unlocked and unattended.

Based on observation and staff interviews the facility failed to maintain ceiling tiles and ceiling vents clean and in good repair. This was evident in 10 (Rooms 12, 14, 20, 22, 24, 26, 29, 32, 33, 34) of 27 rooms observed. Findings included: On 3/15/22 at 8:10 AM a tour of hallways and ceilings was conducted. Observations were made of the ceiling and the overhead ceiling vents in all rooms. -a. An observation in room 12 revealed the ceiling vent at the entrance of the room was heavily covered in dust. -b. An observation in room 14 revealed the ceiling vent at the entrance of the room was heavily covered in dust. -c. An observation in room 20 revealed the ceiling vent at the entrance of the room was heavily covered in dust. -d. An observation in room 22 revealed the ceiling vent at the entrance of the room was heavily covered in dust. -e. An observation in room 24 revealed the ceiling vent at the entrance of the room was heavily covered in dust. -f. An observation in room 26 revealed the ceiling vent at the entrance of the room was heavily covered in dust. The ceiling also had darkened discolored areas near the bathroom door. -g. An observation in room 29 revealed the ceiling vent at the entrance of the room was heavily covered in dust. The ceiling also had a large darken area the ceiling vent. -h. An observation in room 32 revealed the ceiling vent at the entrance of the room was heavily covered in dust. The ceiling also had an irregular shaped discolored areas over the head of the resident ' s bed. -i. An observation in room 33 revealed the ceiling vent at the entrance of the room was heavily covered in dust. The ceiling also had discolorations along the back corner of the room. -j. An observation in room 34 revealed the ceiling vent at the entrance of the room was heavily covered in dust. The ceiling also had large discoloration of irregular shapes in the center of the room. On 3/15/22 at 1:59 PM an interview was conducted with the Housekeeping/Maintenance Supervisor. He acknowledged the dust and stated it was the responsibility of housekeeping to dust and clean the ceiling vents. He explained he was planning to clean the vents and complete some facility repairs in the near future. He discussed having a new filter system to help improve the air circulation. He also stated painting repairs were to be done soon. On 3/15/22 at 5:30 PM a tour of the rooms was conducted with the Administrator. She acknowledged the dust hanging from the overhead vents as soon as you enter each room. The Administrator stated there had been a plan from the corporate office for future improvements. Upon sharing the plan of Golden Year EVS (environmental services) Site Visit dated 3/03/22 listed life safety priority items, general maintenance/housekeeping tasks and projects. The list included vent cleaning, filter changes, and ceiling repairs and paint. The Administrator admitted the list had not been started prior to the survey for vent cleaning or ceiling repairs. Observations of Rooms 12, 14, 20, 22, 24, 26, 29, 32, 33, and 34 on 3/16/22 at 9:00 AM was conducted. The overhead vents at the room entry had been dusted. Some of the dust had been removed from the first grid; but there was dust still hanging on the second grid. On 3/18/22 at 8:13 AM a telephone interview was conducted with the Administrator. The Administrator stated that the facility had completed the dusting of the identified rooms on 3/15/22 and housekeeping/maintenance would be doing a deep cleaning according to the proposed corporate schedule. The Administrator acknowledged her expectation was the facility environment would be maintained in a healthy, clean, and safe manner.

Based on record review and staff interviews, the facility failed to provide written notification of discharge or transfer to the resident representative of the reason for discharge to the hospital for 1 of 1 sampled resident (Resident #25) reviewed for hospitalization . This deficient practice had the potential to affect other residents. The findings included: Resident #25 was initially admitted to the facility on [DATE] with the last readmission on 3/10/22. The most recent quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #25 was cognitively impaired. Resident #25's medical records revealed hospital stays from 11/27/21 through 12/4/21, 1/3/22 through 1/10/22 and 3/5/22 through 3/10/22. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 03/18/22 at 1:16 PM with facility Social Worker (SW). The SW stated she was not aware she was supposed to provide a written notice of the reason for transfer to resident/ resident representative (RR). She indicated going forward she would send a written notice of the reason for transfer to RR. During an interview on 03/18/22 at 11:05 AM with the facility Administrator, she stated nursing staff usually notified RR of resident's transfer by telephone call and documented in resident's record. She indicated the facility had not been providing RR with written notifications of the reason for transfers. She explained going forward she would ensure Social Worker sent a written notice of the reason for transfer to RR.

Based on record review and staff interview the facility failed to schedule a Registered Nurse (RN) eight consecutive hours on 16 of 94 days during the weekends, holidays and week days. The findings included: Review of the daily nursing staffing sheets from (MONTH) (YEAR) to (MONTH) 2019 revealed the following days during the weekend when there was no RN coverage as working on the following days: (MONTH) 16, (YEAR) - Sunday - census - 45; (MONTH) 22, (YEAR) - Saturday - census 48; (MONTH) 23, (YEAR) - Sunday - census - 47; (MONTH) 29, (YEAR) - Saturday - census - 47; (MONTH) 30, (YEAR) - Sunday - census - 47; (MONTH) 5, (YEAR) - Friday - census - 49; (MONTH) 10, (YEAR) - Wednesday - census - 49; (MONTH) 20, (YEAR) - Saturday - census 52; (MONTH) 21, (YEAR) - Sunday - census - 51; (MONTH) 03, (YEAR) - Sunday - census - 51; (MONTH) 4, (YEAR) - Sunday - census - 51; (MONTH) 22, (YEAR) - Thursday (Thanksgiving) - census - 49; (MONTH) 15, (YEAR) - Saturday - census - 50; (MONTH) 16, (YEAR) - Sunday - census - 50; (MONTH) 25, (YEAR) - Tuesday (Christmas) - census - 48; (MONTH) 24, 2019 - Sunday - census - 48. During an interview with the Administrator on 04/03/19 at 2:05 PM, she stated that it is her expectation that RN coverage is in the building 8 hours a day, 7 days a week. The Administrator stated that they have struggled in this remote area to employ RN's they have reached out staffing agencies and offered a sign on bonus. The Administrator stated that she is an RN and have worked on the weekends when an RN has called out and on the above weekends she may been out of town and was not sure why the Director of Nursing was not in the building. She further stated that on the two days during the week the DON had paid time off and the two holidays had no RN coverage. She further stated that sometimes the when an RN calls out at the last minute they could not cover the RN position.

Based on record review and staff interviews the facility failed to accurately code information correctly for 1 of 2 sampled closed records (Resident #46) whose Minimum Data Set (MDS) assessments were reviewed. The findings included: Resident #46 was admitted to the facility on [DATE] and discharged home on[DATE]. Cumulative [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set assessment dated on 03/21/19 revealed that section O (special treatments, procedures and programs) was coded inaccurately. The following areas were check yes while a resident [MEDICAL CONDITIONS], oxygen, suctioning, [MEDICAL CONDITION] care, invasive mechanical ventilator, IV medications, [MEDICAL CONDITION], [MEDICAL TREATMENT], hospice and isolate/quarantine. Record review revealed that the resident had none of these areas. During an interview with the MDS Licensed Practical Nurse on 04/01/19 at 3:00 PM, stated that she was must have been distracted to make these errors and the resident did not have any of those conditions. During an interview with the MDS Consultant Nurse on 04/02/19 at 1:30 PM who signs off on the MDS stated that she typically looks at section H, G, O & P. She further stated that it was an oversight that she did not catch the errors and is her expectation that the MDS be coded accurately. During an interview with the Administrator on 04/03/19 at 2:05 PM, she stated that it is her expectation that the MDS be coded accurately according to the Resident Assessment Instrument (RAI) Manual.

Based on record review and staff interviews the facility's Quality Assessment and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place following the recertification survey of 05/18/18. This was for the deficiency originally cited in (MONTH) (YEAR) and subsequently recited on the current recertification survey of 04/03/19 in the area of Accuracy of Assessments (F641). The continued failure of the facility during two federal surveys of records show a pattern of the facility's inability to sustain an effective Quality Assurance (QA Program. The findings included: This tag is crossed-reference to: F641 Accuracy of Assessments - Based on record review and staff interviews the facility failed to accurately code information correctly for 1 of 2 sampled closed records (Resident #46) whose Minimum Data Set (MDS) assessments were reviewed. During the previous recertification survey of 05/18/18, the facility failed to accurately code MDS assessment for active [DIAGNOSES REDACTED]. During an interview with the Administrator on 04/03/19 at 3:34 PM, she stated that it is her expectation that the MDS assessments are accurately completed by conducting QAA to follow up on any failure to code the MDS accurately. The Administrator further stated moving forward Director of Nursing will be signing off all the Minimum Data Set (MDS) to make sure they were coded accurately.

Based on record review, observation, and staff interviews, the facility failed to follow established infection control guidelines for hand hygiene and changing gloves while [MEDICAL CONDITION] care was provided for 1 of 1 residents (Resident #31) when a nurse failed to perform hand hygiene between contaminated and sterile procedures. Findings Included: A review of the facility's Hand Hygiene Policy and Procedures, last revised (MONTH) 2010, indicated it was the policy of the facility that hand hygiene be regarded as the single most important means of preventing the spread of infections. The policy indicated if gloves were worn for a procedure, hand hygiene was to be completed before putting on gloves and after the removal of gloves. During an observation of [MEDICAL CONDITION] care for Resident #31 on 04/03/19 at 11:13 a.m., Nurse #1 was observed to wash her hands, apply non-sterile gloves and suction tracheal secretions (mucous) from the resident's [MEDICAL CONDITION] site. Nurse #1 removed her gloves and did not wash her hands. Nurse #1 then opened the [MEDICAL CONDITION] care kit and removed the sterile drape and placed it on the over-bed table. When asked if she had washed her hands after she had performed suctioning and had removed her non-sterile gloves, Nurse #1 stated she had not. Nurse #1 stated she had been nervous and over-thinking the procedure and had forgotten to wash her hands. During an interview with the Director of Nursing (DON) on 04/03/19 at 11:52 a.m., the DON stated it was her expectation nursing staff follow the facility's infection control policy. During an interview with the Administrator on 04/03/19 at 2:00 p.m., the Administrator stated it was her expectation nursing staff follow infection control policies and procedures.

Based on observations, resident, staff and physician interviews and record review: the facility left a resident sitting alone on the side of the bed resulting in a fall with left tibia/fibula fracture, failed to determine cause of the fall and the facility failed to have two staff present during a full sling transfer for 1 (Resident #11) of 4 reviewed for accidents. Findings included Resident #11 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. A review of Resident #11 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated he was cognitively intact with no behaviors, required extensive assistance of one person for bed mobility, and extensive assistance of two staff for transfers. The MDS also indicated impairment of mobility to both lower extremities and one upper extremity. His annual MDS assessment dated [DATE] indicated Resident #11 remained cognitively intact with verbal behaviors toward staff, extensive assistance of two staff for bed mobility and total dependence of two staff for transfers. The 5/23/16 MDS also indicated impairment mobility to both lower extremities and one upper extremity. His annual MDS assessment was also coded for one fall with major injury. A review of the Care Area Assessment (CAA) dated 5/31/16 indicated Resident #11 triggered for activities of daily living (ADLs), behaviors and falls. The CAA read Resident #11 was alert and oriented and able to make his needs known. He required extensive assistance from staff for his activities of daily living (ADLs), non-ambulatory and currently required to use of a full sling lift for transfers due to a left tibia/fibula fracture requiring a soft cast. He displayed periods of agitation and verbally abusive toward staff. Resident #11 ' s most recent MDS assessment dated [DATE] indicated he was cognitively intact with verbal behaviors towards staff. He required extensive assistance of two staff with bed mobility and total assistance of two staff for transfers. A review of Resident #11 ' s quarterly care plan dated 2/23/16 did not include a care concern related to his falls risk, actual falls or transfer needs until 4/18/16 when those areas were added to Resident #11 ' s care plan. The care plan dated 4/18/16 included the following intervention: Resident #11 was to be transferred using the full sling lift with two staff assistance. Resident #11 was receiving therapy services starting on 4/6/16 due to expressed desire to increase his independence with transfers and ambulation. The physical therapy plan of care dated 4/6/16 indicated Resident #11 had not ambulated in two years but had a strong desire to stand and ambulate. The long term goals indicated Resident #11 would complete a basic transfer from sit to stand to chair safely requiring contact guard assist (contact with resident due to unsteadiness.) The goal date was set for 5/3/16. A review of the last daily note dated 4/13/16 indicated Resident #11 was moderate to maximum assistance to perform a stand pivot transfer from the edge of the bed to the wheelchair to the mat table with the physical therapy assistant. (PTA). The PTA documented Resident #11 did not have postural control to stand completely upright. He was discharged from services on 4/13/16 due to a fall resulting in a left tibia/fibula fracture. In an interview on 9/12/16 at 4:15 PM, Resident #11 recalled being left on the side of bed unattended by an aide about four months ago. He stated he slipped off the edge of the bed and fell to the floor breaking his left tibia/fibula. He stated it sounded like a gunshot went off when it popped. A review of a nursing note dated 4/14/16 and timed 4:45 PM read the aide reported Resident #11 was sitting on the side of the and slid off. He complained of left knee pain and was sent to the hospital for an evaluation. A review of the incident report dated 4/14/16 indicated at 4:35 PM, Resident #11 was sitting on the side of his bed and his knees gave away and fell to the floor hurting his left knee and hip. The report indicated nursing assistant (NA #1) was present at the time of the fall and tried to prevent him from sliding off the side of the bed. NA #1 stated Resident #11 was sitting on the side of the bed waiting to be transferred to the wheelchair. The aide stated she put his shoes on and his feet were planted on the floor and the bed was low and that Resident #11 raised the bed. A review of the emergency room record dated 4/14/16 indicated Resident #11 presented with left knee and hip pain after falling out of a full sling lift at the nursing home. He was diagnosed with [REDACTED]. An orthopedic follow up 5/10/16 indicated Resident #11 was non-ambulatory from severe [DIAGNOSES REDACTED] and ordered the continued use of the immobilizer for six to eight more weeks for healing. In an interview on 9/13/16 at 9:55 AM, NA #2 stated before Resident #11 ' s fall, staff were using the sit to stand lift to get him up out of the bed. She stated Resident #11 was no longer able to get himself up to the side of the bed without staff assistance and he was not steady to be left unattended at the bedside. She stated she had not known Resident #11 to adjust his bed height because he rarely got up out of the bed. NA #2 stated the Kardex (quick reference guide) was what the aides followed to know how much assistance a resident needed and the facility put a picture in a resident ' s room of what type of lift they needed for transfers. A review of an undated Kardex indicated Resident #11 required two staff for assistance with transfers using the full sling lift and he was totally dependent on staff for repositioning and turning in bed. A Kardex indicating the previous staff instructions was requested on 9/13/16. The Administrator stated that due to the computer limitations, she could not provide a Kardex with previous staff instructions since only the date the Kardex was printed would populate on the copy. In another interview with Resident #11 on 9/13/16 at 3:50 PM, he stated he was working with therapy and the PTA came to his room to get him every day around 4:00 PM. He stated NA #1 got him up in preparation for therapy and NA #1 left him sitting on the side of the bed while she did something for another resident. Resident #11 stated he recalled he had the urge to urinate so he yelled out to NA #1 and she went to get the sit to stand lift since therapy had not arrived yet. When NA #1 got to the room with the sit to stand lift, she tried to stop the fall by grabbing his pants but she was not able to hold him up (weight at time of the 5/23/16 MDS assessment was 259 pounds). Resident #11 stated he preferred his bed up in the high position while in bed but NA #1 lowered his bed so his feet would be flat on the floor while he waited on the PTA to come get him for therapy the day of the fall. There was a picture of a full sling lift taped to the outside of Resident #11 ' s closet door observed. In an interview on 9/13/16 at 4:50 PM, the PTA stated Resident #11 had been non-ambulatory since his admission but he had expressed a desire to attempt ambulation so he was being treated by physical therapy in April 2016. The PTA stated he was not present on 4/14/16 at the time of the fall. He recalled the medication aide (MA) came and got him because Resident #11 raised his bed too high. The PTA stated Resident #11 was able to sit unsupported on the mat table during therapy while supervised and he was working on transfers with Resident #11 using the standing and pivot method. In an interview on 9/14/16 at 8:30 AM, Nurse #1 stated Resident #11 only had the one fall in April since his admission and that he was unable to move himself from the lying position to sitting up on the side of the bed unassisted. Nurse #1 stated she had never known Resident #11 to sit on the side of his bed unsupervised and he preferred to stay in bed and watch television or play on his phone. In an interview on 9/14//16 at 9:10 AM, the Administrator stated she did not do an investigation regarding the fall on Resident #11 because she was under the impression that Resident #11 adjusted the bed height resulting in his fall. The Administrator stated she was aware therapy was working with Resident #11 and therapy informed her that he was able to support himself sitting on the side of his bed unattended. In a telephone interview on 9/14/16 at 9: 40 AM, medication aide (MA) #1 stated she was working on 4/14/16 and NA #1 was assigned to Resident #11. MA #1 recalled Resident #11 wanting to urinate before going to therapy. MA #1 stated she was told Resident #11 raised his bed while NA #1 was in the room with the sit to stand lift. MA #1 stated staff were instructed that one person can use a sit to stand for transfers of a resident and two staff must be present to use the full sling lift. She stated NA #1 must have assisted Resident #11 to the side of the bed because next she heard NA #1 yelling for help. She ran to the room and saw NA #1 holding onto Resident #11 ' s pants trying to prevent him from falling off the side of the bed. MA#1 stated she did not stop to assist NA #1 but rather went and got the PTA to assist since he was strong and Resident #11 was so large. MA #1 stated when they got to the room, Resident #11 was on the floor complaining of left leg pain. MA #1 stated the Administrator questioned her about the fall after it happened. In a telephone interview on 9/14/16 at 9:50 AM NA #1 stated she was assigned Resident #11 on 4/14/16 but she had never gotten him up out of the bed before. She assisted Resident #11 in getting his pants and ready for therapy. She stated she always had trouble getting Resident #11 shoes on so she asked NA #3 to help her put his shoes on and left him sitting on the side of the bed. NA #1 stated his feet were flat on the floor. She stated she left the room and went into another resident ' s room to work with another resident. NA #1 stated she was not aware that Resident #1 could not use his legs. NA #1 stated she left Resident #11 sitting there waiting on the PTA to come get him for therapy. She stated she heard Resident #11 yelling for help so she ran and got the sit to stand lift but when she got to the room, Resident #11 was already sliding from the side of the bed so she grabbed him by his pants. She stated she called for help but Resident #11 fell to the floor. In an observation on 9/14/16 at 10:30 AM, NA #4 performed a transfer on Resident #11. NA #4 had to physically roll Resident #11 over onto his sides to get the lift pad underneath him then was able to hold himself onto each side using the side rail and roll back onto his back. He had no range of motion in his legs. Prior to the transfer, Nurse #1 asked NA #4 if she needed any assistance performing the transfer. NA #4 stated she did not. Using the full sling lift to transfer Resident #11 from the bed to the shower chair, NA #4 did not employ a second staff member for assistance. When asked if it was the facility ' s practice to only use one person during a full sling lift transfer, she stated it was not. NA #4 stated two staff should be present during full sling lift transfers. When questioned as to why she did no employ the offered assistance of Nurse #1, NA #4 stated she thought the surveyors presence counted as the second person. Once he was sitting up into the shower chair, Resident #11 was asked to demonstrate any range of motion he had in his legs. He was unable to bend his left leg and his right knee only was able to bend approximately 10 degrees. NA #4 stated she had been working at the facility for about 8 months and she had never knew Resident #11 to have any falls and he always needed assistance of a lift for transfers. She stated she would not leave Resident #11 unsupervised to sit on the side of bed because he was not steady and he could not hold himself upright without help. In an interview on 9/14/16 at 10:42 AM, the Administrator stated Resident #11 ' s fall occurred at a time when several nurses were out of work and she had to work on the halls. The Administrator stated it was the facility policy and her expectation for two staff members to be present during a full sling lift transfer. A review of Resident #11 current weight as of 9/1/16 was 287 pounds. In a second transfer observation on 9/14/16 at 11:00 AM, NA #4 and Nurse #1 were both present during the transfer from the shower chair back to the bed using the full sling lift. In an interview on 9/14/16 at 11:17 AM, Nurse #2 stated she was summoned to Resident #11 ' s room and NA #1 was standing outside his room complaining of back pain. Nurse #2 entered the room to see Resident #11 lying on the floor. The previous MDS nurse was assessing Resident #11 for injuries and she could not remember if the sit to stand lift was in the room at the time she entered. Nurse #2 stated she had never known Resident #11 to sit on the side of the bed unsupervised and it was unsafe to leave him that way because of poor judgment and advanced deconditioning. In another interview on 9/14/16 at 2:00 PM, the PTA stated he had been working with Resident #11 on his upright sitting posture because his abdominal muscles were weak and that made it difficult for him to lean in preparation for transfers. The PTA stated Resident #11 was not able to sit on the side of the bed unassisted and it was not safe to leave Resident #11 alone sitting on the side of the bed. He stated he did not instruct the staff to leave him sitting on the side of the bed in an effort to strengthen his abdominal muscles or to leave him sitting on the side of the bed while Resident #11 waited for him to come and get him for therapy. In an interview on 9/14 at 2:28 PM, NA #3 stated when he entered the room to help NA #1 put Resident #11 ' s shoes on, he was already dressed and sitting on the side of the bed with his legs extended outward touching the floor. NA #3 stated he would have never left Resident #11 alone sitting on the side of the bed to wait for therapy to come get him. He stated if therapy wasn ' t there after he got Resident #11 ready, he would have laid him back down and engaged his side rail. In a telephone interview with the Medical Director (MD) on 9/14/16 at 2:40 PM, he stated he thought he had an old tibia/fibula fracture and he recalled ordering him to see an orthopedic. The Medical Director stated it was his expectation Resident #11 not be left alone sitting on side of bed unattended due to Resident #11 ' s inability to ambulate, inability to his move legs and due to his obesity. He stated it was not safe.