Every finding on record at Maple Manor Care Center

Based on observation, record review, review of professional reference, and resident and staff interview, the facility failed to develop and provide an effective pain management regimen to meet resident needs for 2 of 14 sampled residents (Resident #4 and #5) reviewed for pain management. Failure to develop, implement, and provide an effective pain management plan resulted in unresolved pain and discomfort and decreased quality of life. Findings include:Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, pages 625-626, stated, . pain is a physical and emotional experience . Pain interferes with functional abilities and quality of life. Severe and persistent pain affects all body systems, causing potentially serious health problems while increasing the risk of complications and delays in healing. Pain management is the alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the client. Page 631 stated, . the nurse must act to promote optimal and appropriate pain control. and page 645 stated, . A preventive approach to pain management involves the provision of measures to treat the pain before it occurs or before it becomes severe . - Review of Resident #4's medical record occurred on all days of survey. The record identified on hospice services for a terminal illness. The care plan stated, I am at risk for pain. My pain will be well controlled . Give medications as ordered . The physician's orders included the following:* Baclofen (muscle relaxant) tablet 20 milligrams (mg) four times a day, start date 12/15/23.* Morphine Sulfate (opioid for severe pain) Oral Concentrate 0.3 milliliters (ml) every 4 hours, start date 07/30/25.* Morphine Sulfate Oral Concentrate 0.3 ml every 1 hour as needed (PRN), start date 07/30/25.Observation on 09/09/25 at 10:16 a.m. showed Resident #4 in bed, contractures to both legs, and two certified nurse aides (CNAs) (#9 and #10) provided morning cares. When the CNAs rolled the resident from side to side and moved/spread his legs, the resident repeatedly stated, It's bad. It's bad. Oh, it's bad and Oh that hurts really bad. It hurts really bad though. The CNAs asked the resident multiple times to relax. The resident stated, I'm trying to relax. When asked if the resident received any pain medication prior to the start of cares, the CNA (#9) stated, He gets morphine round [sic] the clock. He gets it in 45 minutes.Observation on 09/10/25 at 10:42 a.m. showed Resident #4 in bed and a CNA (#6) provided morning cares. When the CNA moved the resident's legs to apply a clean brief, the resident stated, Ouch. Hurts really bad.Review of Resident #4's medication and treatment administration records (MAR/TARs) for September 1-9, 2025, identified scheduled morphine administered every four hours and the PRN morphine administered only once on 09/03/25 at 10:00 a.m.The nursing staff failed to effectively utilize the PRN morphine to promote optimal pain control before providing cares to Resident #4. - Review of Resident #5's medical record occurred on all days of survey. Diagnoses included diabetic neuropathy [nerve pain] and a left foot ulcer. The care plan stated, . I have chronic pain r/t [related to] osteoarthritis and Diabetic neuropathy . Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results . Notify MD [medical doctor]/NP [nurse practitioner] of an increase of pain levels. The physician's orders included the following:* Left diabetic foot ulcer dressing changes twice a day in the morning and at bedtime. * Gabapentin tablet 600 mg three times a day for diabetic neuropathy, start date 04/25/25* Oxycodone-Acetaminophen tablet 10-325 mg every 4 hours as needed for pain, start date 06/12/25.Review of the quarterly Minimum Data Set (MDS), dated [DATE], identified intact cognition and a pain rating of 8 out of 10 (10 being the worst pain) and pain almost constantly which frequently affected sleep and day-to-day activities. Observation of 09/09/25 at 1:41 p.m. showed a nurse (#4) completed Resident #5's dressing change to the left foot. The resident displayed facial grimacing, muscle tension, under-the-breath vocal sounds, and moved her head back and forth throughout the entire dressing change procedure. During an interview on the afternoon of 09/09/25, Resident #5 stated, I've been on the same pain med [medication (the resident referred to oxycodone)] since 2014. I keep asking for a different family [drug class] to see if that helps, and I wish it was like when I was in the hospital. They would give me morphine with dressing changes.Review of Resident #5's MAR/TARs for September 1-9, 2025 related to morning dressing changes identified the following:* 09/02/25, no PRN oxycodone administered. * 09/03/25, the PRN oxycodone administered 1 hour and 37 minutes after the dressing change.* 09/04/25, the PRN oxycodone administered at 6:57 a.m., the same time the dressing change signed out.* 09/08/25, the PRN oxycodone administered 3 hours and 37 minutes before the dressing change.The facility failed to implement measures to prevent and/or treat Resident #5's pain before it occurred to promote optimal pain control before dressing changes. The medical record lacked evidence the facility notified Resident #5's provider related to increased pain with dressing changes or consider scheduled pain medications.During an interview on 09/10/25 at 3:51 p.m., an administrative nurse (#1) stated, We could do more [to help control Resident #4 and #5's pain].

Based on review of a facility job description and staff interview, the facility failed to ensure 1 of 1 dietary manager (#11) obtained the proper qualifications to serve as the dietary manager. Failure to ensure staff have the qualifications to carry out the functions of a manager in the dietary department has the potential to result in foodborne illness to residents, staff, and visitors.Findings include: Review of the facility job description titled Dietary Manager occurred on 09/10/25. This undated job description stated, . Minimum requirements include one of the following . Certification as a dietary manager . Certification as a food service manager . Has similar national certification for food service management and safety from a national certifying body . Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, but no later than October 1, 2023 . During an interview on 09/08/25 at 3:00 p.m., the dietary manager (#11) confirmed she had not completed the certified dietary manager course. The facility failed to ensure the dietary manager (#11) completed the required education for a certified dietary manager, certified food service manager, or a national certification for food services management and safety from a national certifying body.

Based on review of the facility Quality Assurance and Performance Improvement (QAPI) program, review of the facility policy, and staff interview, the facility failed to ensure the Medical Director (physician) actively participated on the Quality Assurance (QA) committee for 3 of 4 quarters (July-September 2024, October-December 2024, and April-June 2025). Failure to ensure the medical director participates in the facility's QA activities deprived the committee of the physician's unique contribution for analyzing and correcting problems with identified resident care areas.Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership occurred on 09/10/25. This policy, revised January 2025, stated, . The following individuals serve on the committee . Medical director . The committee meets at least quarterly (or more often as necessary). Committee members are reminded of meeting day, time and location via e-mail at least two business days prior to the meeting. Review of the QA committee attendance records from July 2024 to June 2025 showed the medical director attended one meeting, in January 2025. During an interview on 09/10/25 at 10:00 a.m., an administrative staff member (#11) reviewed the QA committee meeting minutes and indicated the medical director attended the January 2025 meeting via telephone, but was unable to attend the October 2024 and May 2025 meetings. She added, He did not attend, but read the notes on rounds. She failed to address the 3rd quarter of 2024.

Based on observations and review of facility policy, the facility failed to serve food in accordance with professional standards for food safety in 1 of 2 dining rooms (north dining room). Failure to ensure no bare-hand contact with ready-to-eat food has the potential to result in a food borne illness. Findings include: Review of the facility policy titled Kitchen and Service Kitchen Safe Practice Guidelines occurred on 09/10/25. This policy, dated 07/14/25, stated, . When handling clean dishes care will be taken to minimize hand contact with food surfaces. plates [will be touched] on the outside rim . Review of the facility policy titled Serving Meals occurred on 09/10/25. This policy, dated 07/13/25, stated, . Staff will serve meal without touching prepared food. Review of the facility policy titled Dietary Infection Control and Glove Usage occurred on 09/10/25. This policy, dated 07/14/25, stated, . Change Gloves after . touching hair or face with gloved hands. -Observations of food service showed the following:*On 09/09/25 at 7:45 a.m., a dietary staff member (#13) placed a plate with a breakfast sandwich on it in the microwave, touching the top of the plate with her bare right thumb. The staff member then removed the heated sandwich/plate from the microwave, placed grapes on the plate, touching them with her bare hand, and touched the top of the plate with her bare right thumb as she handed the plate to another staff member.*On 09/09/25 at 12:17 p.m., two dietary staff members (#13 and #14) touched the top of dished and/or reheated plates with their bare thumbs. The dietary staff member (#13) also touched her face and face mask with her bare hand as she dished and passed plates.

Based on observation, record review, review of professional reference, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 14 sampled residents (Residents #4 and #5) observed during personal cares. Failure to practice infection control standards during medication administration and resident cares has the potential to spread infection throughout the facility. Findings include:Review of the Centers for Disease Control (CDC) Frequently Asked Questions (FAQS) about Enhanced Barrier Precautions in Nursing Homes at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html, dated 06/28/24, stated, 1 . Enhanced Barrier Precautions [EBP] involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [multidrug-resistant organism] as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 9 . Adherence to other recommended infection prevention practices including performing hand hygiene, cleaning and disinfection of environmental surfaces . proper handling of indwelling medical devices, and care of wounds is also critical.Review of the CDC Clinical Safety: Hand Hygiene for Healthcare Workers at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, dated 02/27/24, stated, . Know when to clean your hands . after touching a patient or patient's surroundings. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal. Know when to wear (and change) gloves. Gloves are not a substitute for hand hygiene. When to change gloves and clean hands . If gloves become soiled with blood or body fluids after a task. If moving from work on a soiled body site to a clean body site on the same patient or if clinical indication for hand hygiene occurs.- Review of Resident #5's medical record occurred on all days of survey and identified EBP related to an open left foot wound.Observation on 09/09/25 at 8:49 a.m. showed a nurse (#4) prepared Resident #5's oral medications, insulin pens, and eye drops for administration. The nurse (#4) applied personal protective equipment (PPE) outside the resident's room, entered the room, and placed the medications onto the resident's overbed table without placing a barrier or disinfecting the table. After administration, the nurse (#4) removed the PPE, carried the insulin pens and the container that held one of the eye drop bottles out of the room, and without sanitizing the pens and the eye drop bottle/container, placed them back into the medication cart. - Review of Resident #4's medical record occurred on all days of survey and identified EBP for multiple open wounds, an indwelling catheter, and MDROs.Observation of Resident #4's cares showed the following:* 09/09/25 at 10:16 a.m., two certified nurse aides (CNAs) (#9 and #10) provided perineal cares. The CNA (#10) failed to remove the soiled gloves prior to opening the resident's nightstand to remove and apply a skin barrier cream. With the same gloves, the CNA (#9) repeatedly reached into her pocket to answer calls from a walkie talkie and placed it back into her pocket. The CNA (#9) failed to sanitize the walkie talkie prior to exiting the room.* The afternoon on 09/09/25, a CNA (#10) emptied the catheter bag into a container. The CNA poured the urine into the toilet, obtained water from the bathroom sink, and poured the water into the toilet. When asked if she ever uses the sprayer located beside the toilet, the CNA stated never and I don't think it works. Observation on 09/10/25 at 12:03 p.m. showed a CNA (#11) emptied the urine from the catheter bag into a container, poured the urine into the toilet, and utilized the sprayer to rinse out the container. * 09/10/25 at 10:56 a.m., a CNA (#6) assisted with positioning Resident #4 while two nurses (#7 and #8) performed multiple dressing changes. Throughout the observation, the CNA (#6) removed soiled dressings from the resident's ankle, shin, toe, and foot. When the CNA (#6) removed the soiled dressing from the foot, the CNA stated, It smells, folded the dressing in half, and handed it to the nurse. The CNA failed to remove the soiled gloves, perform hand hygiene, and apply clean gloves before adjusting the resident's clothing and bedding. After the observation, when asked if CNAs typically remove Resident #4's dressings, a nurse (#7) stated, She [CNA #6] normally does not do that [remove dressings]. I didn't say anything as she already touched them.During an interview on the afternoon of 09/10/25, an administrative staff member (#2) stated she expected staff to place medications on a clean surface, sanitize items after use and before placing them back into the medication cart, change gloves and perform hand hygiene between clean and dirty tasks, and nurses to remove dressings from resident wounds.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 3 of 14 sampled residents (Resident #3, #11, and #32). Failure to review and revise the care plan as the needs change for the resident limited the ability of staff to communicate care needs and ensure continuity of care for each resident.Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered occurred on 09/10/25. The revised policy, dated March 2025, stated, . Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. -Observation on the afternoon of 09/08/25 showed facility staff changed Resident #32's brief and left his/her pants down and around the ankles and covered with a blanket. On 09/09/25 at 3:39 p.m., observation showed the resident lying in bed without pants and covered with a blanket. Review of Resident #32's medical record occurred on all days of survey. The current care plan failed to identify no pants while in bed. During an interview on 09/10/25 at 8:41 a.m., an administrative nurse (#1) confirmed the care plan lacked Resident #32's choice of having pants removed while lying in bed. -Review of Resident #3's medical record occurred on all days of survey. A code status form, signed and dated by the resident on 03/22/25, showed do not resuscitate (DNR). A physician's order, dated 05/30/25, and the resident's electronic health record (EHR) identification ribbon identified DNR. The current care plan identified a full code status. During an interview on 09/09/25 at 3:18 p.m., an administrative staff member (#2) confirmed facility staff failed to revise Resident #3's care plan when the code status changed to DNR. - Review of Resident #11's medical record occurred on all days of survey. The physician's orders included Seroquel (an antipsychotic medication) started on 05/09/25. The care plan lacked a problem, goal, or interventions related to the use of an antipsychotic medication. During an interview on 09/10/2025 at 11:55 a.m. an administrative nurse (#1) confirmed staff failed to revise Resident #11's care plan to reflect the use of an antipsychotic medication.

Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 2 of 3 sampled residents (Residents #3 and #5) observed during medication pass. Failure to disinfect the rubber seal of insulin pens increases the risk of infection to residents and failure to follow manufacturer instructions for eye drop administration may impede the effectiveness of the eye drops. Findings include: Review of the facility policy titled Insulin Administration occurred on 09/10/25. This policy, dated May 2025, stated, . Pull off the pen cap. Wipe the rubber seal with an alcohol swab. Information found at https://www.drugs.com/pro/pataday-once-daily-relief.html, revised 08/14/25, stated, . Pataday (treatment for dry eyes) . Package Insert/Prescribing Info [information] . if using other ophthalmic products while using this product, wait at least 5 minutes between each product . -Observation on 09/09/25 at 9:14 a.m. showed a nurse (#4) administered Pataday eye drops to both of Resident #5's eyes. At 9:16 a.m. (two minutes later) the nurse administered Xiidra eyedrops (treatment for dry eyes) to both eyes. The nurse (#4) failed to wait at least five minutes between administering two different eye products. During an interview on 09/10/25 at 12:45 p.m., an administrative staff member (#2) agreed the nurse should wait at least five minutes between administration of two eye drops. -Observation on 09/10/25 at 8:09 a.m. showed a nurse (#3) prepared an insulin pen for Resident #3. The nurse failed to wipe the rubber seal with an alcohol swab before applying the needle to the insulin pen. During an interview on the afternoon of 09/10/25, an administrative nurse (#1) confirmed she expected staff to wipe the rubber seal of an insulin pen with an alcohol swab before applying the needle.

Based on observation, record review, and staff interviews, the facility failed to ensure 1 of 1 sampled resident (Resident #29) with contractures received the necessary devices. Failure to consistently provide a rolled washcloth to the resident's right hand may result in worsening of the contracture, pain, and further skin breakdown. Findings include:Review of Resident #29's medical record occurred on all days of survey. Diagnosis included hemiplegia and hemiparesis [weakness or paralysis] following cerebral infraction [stroke] affecting the right side. The care plan stated, I require assist for all ADL's [Activity of Daily Living] . Please ensure that a rolled-up washcloth to [sic] placed to her right hand while at night and when she is in bed during the day. Observation occurred on all days of survey and showed Resident #29's right hand contracted in a gripped position. On the afternoon of 09/09/25 and 09/10/25, observation showed Resident #29 in bed without a rolled-up wash cloth in her right hand.During an interview on the afternoon of 09/10/2025, a CNA (#5) stated staff are able to open Resident #29's right hand, but it hurts her. When asked about the rolled-up wash cloth, the CNA stated forgot to put it in. The CNA (#5) returned to Resident #29's room, opened the resident's right hand, and the resident grimaced in pain. The CNA (#5) placed a rolled-up washcloth into Resident #29's right hand and noticed a small open area on her palm. During an interview on the afternoon of 09/10/25, an administrative nurse (#1) stated she expected staff to place the rolled-up wash cloth in Resident #29's hand whenever they assisted her to bed.

Based on observation, record review, and staff interview, the facility failed to properly utilize assistive devices for 1 of 4 sampled residents (Resident #16) reviewed for falls. Failure to properly use a bed and chair alarm placed the resident at risk for falls. Findings include:Review of Resident #16's medical record occurred on all days of survey. Diagnosis included dementia and anxiety. The current care plan stated, . I am at risk for falls . Silent fall alarms on chair and bed. A Quarterly Minimum Data Set (MDS) dated [DATE] identified a bed and chair alarm used daily. A Fall Risk Evaluation, completed 08/23/24 identified a Fall Risk Score of 18 (High Risk of falls). Observations on all days of survey showed Resident #16's chair and bed alarm unplugged and not functioning. During an interview on 09/10/2025 at 8:44 a.m., an administrative nurse (#1) confirmed Resident #16's bed and chair alarm were unplugged, was not aware if the resident was able to unplug the alarms, and expected staff to ensure the alarms are functional.

Based on observation, review of facility policy, and resident and staff interviews, the facility failed to serve foods at palatable temperatures on 2 of 3 days of survey (July 8-9, 2024). Failure to serve foods at a temperature acceptable to residents may result in decreased intake, weight loss, and inadequate nutrition. Findings include: Review of the facility policy titled Food Temperatures occurred on 07/10/24. This policy, dated 07/13/23, stated, . Foods will be served at the appropriate temperatures to ensure good flavor and to prevent food borne illnesses. All hot food items will be served to the resident at the temperature of at least 140 degrees. During an interview on 07/08/24, Resident A stated, The food is always cold. Observation of the noon meal occurred on 07/08/24 at 12:25 p.m. in dining room [ROOM NUMBER]-3 and showed a cook (#5) dished the final resident tray. A temperature of the three-bean vegetable showed a reading of 72.5 degrees Fahrenheit (F). Observation of the evening meal occurred on 07/09/24 at 5:35 p.m. in dining room [ROOM NUMBER]-3. The surveyors asked for a meal tray after all the residents had received their meals. Temperatures were obtained and showed the following: *Macaroni and Cheese at 132 degrees F *Mashed Potatoes at 139 degrees F *Green Peas at 95 degrees F During an interview on 07/10/24 at 11:45 a.m., an administrative staff member (#4) agreed she expected staff to serve food to residents at an acceptable temperature.

Based on observation, review of facility policy, and staff interview, the facility failed to store food in a sanitary manner in 1 of 1 main kitchen. Failure to apply an identifying label to food and add an open date has the potential to affect food quality/preparation and may result in the spread of foodborne illness to residents, staff, and visitors. Findings include: Review of the facility policy titled Storage and Cooking of Food occurred on 07/10/24. This policy, dated July 2023, stated, . Food Storage . Foods which have been opened or prepared will be placed in an enclosed container, dated and labeled. If food is ever found undated these will be thrown without exception. Observation of the main kitchen occurred on 07/08/24 at 11:20 a.m. with a dietary manager (#6) and showed the following: Walk-in Refrigerator: *Four individually dished containers identified as taco sauce by a dietary staff member with no identifying label or prepared date. *One brick of a white substance identified as cream cheese but not sure, by a dietary staff member with an unidentifiable date and no identifying label. *Two disposable bowls of a pudding like dessert and a crumble type dessert covered with unsealed plastic wrap with no identifying label or date. *One 1/2 full gallon size zip top plastic bag of sliced strawberries with no identifying label or date. *Three 1/2 full bags of shredded cheese with no open date. *One 1/4 full open jar of peach preserves with no open date. *A tray holding an onion, apples, and oranges with one orange soft and showing dark spots. *A tray with four containers of fruit juice sitting in spilled juice, with dark, sticky spots. Walk-in Freezer: *Three 1/2 full bags of frozen potato tots and french fries with no open dates. *A zip top plastic bag with what dietary staff identified as omelet patties, with no identifying label or open date. *An open bag of sausage patties and an open bag of sausage links inside their respective boxes which showed an open date of the box, but not the individual bags. Walk In Cooler: *One box of oranges, one of the oranges soft and black. Dry Storage: *Four open bags of pudding mix within a zip top plastic bag, with no open date. *One open bag of croutons wrapped in plastic wrap with no open date. During an interview on 07/10/24 at 11:45 a.m., an administrative staff member (#4) confirmed she expected staff to label and date food items when opened and throw away food items if not identifiabe.

Based on observation, record review, review of facility policy, confidential interview, and staff interview, the facility failed to provide resident care for 2 of 11 sampled residents (Resident #8 and #14) requiring assistance with activities of daily living in a manner that promotes, maintains, or enhances their quality of life. Failure to cover a urinary catheter leg bag (Resident #8) and failure to clean and shave resident's face and change the soiled shirt (Resident #14) has the potential to affect the resident's psychosocial well being and personal dignity. Findings include: Review of the facility policy titled Dignity occurred on 07/10/24. This policy, revised February 2024, stated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. Staff are expected to promote dignity and assist residents: for example: helping the resident to keep urinary catheter bags covered. Review of the facility policy titled Activities of Daily Living (ADLs), Supporting occurred on 07/10/24. This policy, revised March 2024, stated, . Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. - Review of #8's medical record occurred on all days of survey. The current care plan stated, . I require assist of one for most ADL's . Observations throughout the day on 07/08/24 showed Resident #8's urinary catheter leg bag (containing urine) exposed below the resident's pant leg and uncovered. Observations on 07/09/24 at 12:09 p.m. and 5:20 p.m., and on 07/10/24 at 7:53 a.m. showed Resident #8 seated at the dining room table with the urinary catheter leg bag (containing urine) exposed below the resident's pant leg and uncovered. During an interview on 07/10/24 at 11:21 a.m., and administrative nurse (#1) stated staff are expected to cover resident's urine catheter leg bag at all times. -Review of Resident #14's medical record occurred on all days of survey. The current care plan stated, . I require assist. of 1 for all ADL's. I have an ADL self-care performance deficit r/t [related to] cognition/mobility. PERSONAL HYGIENE/ORAL CARE: I am an assist of one. DRESSING: I am an assist of one. An interview occurred 07/08/24 at 5:12 p.m. with Individual A. This individual stated Resident #14 is frequently unshaven and has a dirty face and clothing. Observations on 07/08/24 at 11:15 to 11:53 a.m.showed Resident #14 seated in a wheelchair in the front lobby or the dining room wtih an unshaven face, a soiled shirt, and food debris on his face. Observations on 07/09/24 from 8:34 a.m. to 12:12 p.m. showed Resident #14 seated in a wheelchair in the front lobby or in the dining room with an unshaven face, a soiled shirt, and food debris on his face. At 1:12 p.m., a progress note stated Resident #14 allowed a certified nurse aide (CNA) to wash his face but refused to have his shirt changed. Resident #14 remained unshaven and in the same soiled shirt the rest of the observation day. Observation on 07/10/24 at 9:00 a.m. showed Resident #14 seated in a wheelchair in the front lobby with his shirt and face soiled with food. The above observations showed facility staff had multiple encounters with Resident #14, but failed to change his soiled shirt, shave and wash his face. During an interview on 07/10/24 at 11:19 a.m., an administrative nurse (#1) confirmed Resident #14 frequently has a soiled shirt or dirty face and staff are expected staff to change his shirt and wash his face.

1. Based on record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 sampled residents (Resident #15) reviewed with orders for specific parameters for blood glucose levels. Failure to notify the physician of high blood glucose levels as ordered placed the resident at risk for delayed treatment and adverse health events. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, Nurses are expected to analyze procedures and medications ordered by the physician or primary care provider. Review of the facility policy titled Physician, Physician Assistant, Nurse Practitioner or Clincal Nurse Specialist Lab Notification occurred on 07/10/24. This policy, revised 03/11/24, stated, . The physician . will determine parameters for 'immediate' and 'non-immediate' lab results. Notification parameters for 'immediate' lab results will be included in lab order. Immediate notifications. Call physician. with lab result and resident current condition. Review of Resident #15's medical record occurred on all days of survey. Diagnoses included Type 2 Diabetes Mellitus. A physician's order, dated 10/11/22, stated, Notify provider if blood glucose [sugar] is above 400 or below 70. Review of Resident #15's blood glucose levels from 05/10/24 through 07/10/24 showed the following: * 05/23/24: 445.0 mg/dL [milligrams per deciliter]. * 05/28/24: 436.0 mg/dL The medical record lacked documentation the facility notified Resident #15's provider of the elevated blood glucose levels. During an interview on 07/10/24 at 12:30 p.m., an administrative nurse (#1) confirmed the staff failed to notify the provider of Resident #15's elevated blood glucose levels. 45873 2. Based on observation and review of facility policy, the facility failed to follow professional standards of practice for 1 of 1 supplemental resident (Resident #34) observed for insulin preparation and administration. Failure to prime the insulin pen and administer the insulin over the required length of time may result in the resident receiving an inaccurate dose. Findings include: Review of the facility policy titled Insulin Administration occurred on 07/10/24. This policy, dated 06/14/24, stated, Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes. Steps in the procedure for (insulin pen) administration . Prime the insulin pen. Priming means removing air bubbles from the needle. You must prime the pen before each injection. To prime the insulin pen, turn the dosage knob to the 2 units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. Depress the plunger and remove the needle after approximately five (5) seconds. Observation on 07/08/24 at 5:20 p.m. showed a medication aide (MA) (#2) prepared Resident #34's Novolog insulin pen for administration. The MA (#2), without priming the insulin pen, dialed the insulin pen to the prescribed units, inserted the needle into the resident's abdomen, depressed the plunger and removed the needle without waiting the required length of time. During an interview on 07/10/24 at 11:35 a.m., an administrative staff member (#1) confirmed she expected staff to follow the policy for priming insulin pens and administering insulin.

Based on observation, record review, review of professional reference, and staff interviews, the facility failed to provide supervision to prevent accidents for 1 of 2 sampled residents (Resident #33) observed during a gait belt transfer. Failure to provide supervision of certified nurse aides (CNAs) by a licensed nurse regarding resident transfer assistance may result in unnecessary pain, falls and/or injury for residents. Findings included: Review of the North Dakota Administration Code (NDAC) online at www.ndlegis.gov/information/acdata/pdf/33-43-01.pdf stated, . 33-43-01-12. Supervision and delegation of nursing interventions. An individual on the department's nurse aide registry [CNA] may perform nursing interventions which have been delegated by a licensed nurse. An individual on the departments nurse aide registry as delegated and supervised by a licensed nurse . Review of Resident #33's medical record occurred on all days of survey and included diagnoses of weakness and dementia. The current care plan stated, . TRANSFER: Resident is transfer of 1-2 depending on pt [patient] tolerance. If resident is shakier, will assist of 2 PRN [as needed]. A physical therapy note, dated 06/05/24, stated, Transfer of 1-2 depending on pt tolerance. If [Resident #13] is more shaky, use assist of 2 as needed. PT [physical therapy] observed transfer attempt with assist of 1 today and was safer with assist of 2. Observation on 07/08/24 at 4:01 p.m. showed Resident #33 seated in the wheelchair. A CNA (#8) placed the gait belt on Resident #33, placed a front wheeled walker (FWW) in front of the resident and assisted the resident to a standing position. As the resident attempted to stand, she was shaky, unsteady, and leaned backwards as she placed her left hand on the FWW and her right hand on the wall. The CNA (#8) continued to assist the resident to ambulate to the bathroom. During an interview on 07/10/24 at 12:35 p.m., when asked if Resident #33 is transferred with one or two assist, a CNA (#8) stated, I always just use one assist because that's what they told me to do. Observation on 07/10/24 at 11:28 a.m., showed a CNA (#7) attempted to assist Resident #33 from the bed to the wheelchair. The resident refused to get out of the bed. When asked how the CNA (#7) would have transferred the resident out of bed the CNA stated, She's a pivot transfer with one person. When asked if the CNA ever used two staff to transfer the resident, the CNA stated, She [Resident #33] had a fall a few months ago and then we started to use two staff sometimes. It depends on the kind of day she (Resident #33) is having. I can decide if I should use one or two assist to transfer her. During an interview on 07/10/24 at 1:26 p.m., an administrative nurse (#1) stated she expected the nurse to assess Resident #33 to make the decision if the resident needed to be transferred with two staff.

Based on observation, record review, review of a professional reference, and staff interview, the facility failed to provide appropriate toileting for 1 of 6 sampled residents (Resident #33) who required staff assistance with toileting. Failure to provide toileting may result in a loss of dignity and placed the resident at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and risk for fall and/or injuries. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 892, stated, Fecal and Urinary Incontinence: Moisture from incontinence promotes skin maceration [tissue softened by prolonged wetting or soaking] and makes the epidermis [skin] more easily eroded and susceptible to injury. Digestive enzymes in feces, urea in urine . also contribute to skin excoriation [area of loss of the superficial layers of the skin] . Any accumulation of secretions . is irritating to the skin, harbors microorganisms, and makes an individual prone to skin breakdown and infection. Page 1221 stated, Managing Urinary Incontinence . Habit training, also referred to as timed or prompted voiding and scheduled toileting, attempts to keep clients dry by having them void at regular intervals, such as every 2 to 4 hours. The goal is to keep the client dry . Review of Resident #33's medical record occurred on all days of survey and included a diagnosis of dementia. The care plan stated, . TOILET USE: The resident is an assist of 1 . Observation on 07/08/24 at 4:01 p.m. showed a certified nurse aide (CNA) (#8) assisted Resident #33 to the bathroom. The resident's saturated incontinent product leaked urine through the resident's jeans. Observation on 07/10/24 at 11:29 a.m. showed a CNA (#7) changed resident #33's incontinent product and showed it saturated with urine. Review of Resident #33's toileting record, dated June 9th through July 9th, 2024, identified 56 occasions where staff failed to assist the resident with toileting every three hours. The log showed gaps of approximately 3.5 to 12 hours between staff assistance with toileting. During an interview on 07/10/24 at 1:26 p.m., an administrative staff member (#1) stated she expected staff to assist residents with toileting every 2-3 hours.

Based on review of Medicare Part A letters/notices, Centers for Medicare and Medicaid Services instructions, and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) form and Notice of Medicare Non-coverage (NOMNC) form two days in advance of discharge for 2 of 3 residents (Resident #23 and #38) discharged from Medicare Part A services. Failure to provide Medicare Part A letters/notices within the required time frame has the potential to limit the residents' right to an expedited review of service termination (NOMNC) and/or to exercise their rights to Medicare Part A services (SNFABN). Findings include: Review of [Medicare Advantage/Health Plan] Expedited Determination Notices (MA) webpage on 08/09/23, at https://www.cms.gov/medicare/medicare-general-information/bni/downloads/instructions-for-notice-of-medicare-non-coverage-nomnc.pdf, stated, . The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Review of the Medicare notices provided by the facility on occurred on 08/09/23, and showed facility staff failed to provide the forms two calendar days before Resident #23's services ended on 06/30/23, and before Resident #38's services ended on 04/04/23. During an interview on 08/09/23 at 10:05 a.m., an administrative staff member (#2) confirmed she expected staff to provide termination of Medicare Part A services letters/notices to residents or resident representatives two days prior to the end of the resident's Medicare Part A services.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident or their representative and/or the State Long Term Care Ombudsman written notice of transfer for 1 of 4 residents (Resident #30) with a recent hospital transfer. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights or inform the Ombudsman of the transfer. Findings include: Review of the facility policy titled Transfer or Discharge Notice occurred on 08/09/23. This policy, revised March 2021, stated, . Under the following circumstances, the notice is given as soon as it is practicable but before the transfer . the resident and representative are notified in writing . A copy is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Review of Resident #30's medical record occurred on all days of survey and identified a hospital transfer on 07/23/23. The resident's medical record lacked evidence the resident/representative received a copy of the transfer notice and the facility informed the State Ombudsman of the hospital transfer. During an interview on 08/09/23 at 12:35 p.m., administrative member (#1) stated, We are unable to produce a copy of [Resident #30's name] transfer form.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 15 sampled residents (Resident #8 and #9). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION H: BLADDER AND BOWEL The Long-Term Care Facility RAI User's Manual, revised October 2019, page H-2 states, . Suprapubic catheters and nephrostomy tubes should be coded as an indwelling catheter (H0100A) only and not as an ostomy (H0100C) . Review of Resident #8's medical record occurred on all days of survey. A physician's order, dated 05/18/23, identified the resident as having a suprapubic catheter. The annual MDS, dated [DATE], identified the resident as having an ostomy. During an interview on the afternoon of 08/09/23, two administrative staff members (#2 and #3) confirmed staff coded Resident #8's MDS incorrectly. SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS The Long-Term Care Facility RAI User's Manual, revised October 2019, page O-5 states, . Code residents identified as being in a hospice program . Review of Resident #9's medical record occurred on all days of survey. A physician's order, dated 12/30/22, identified the resident admitted to hospice. The significant change MDS, dated [DATE], failed to reflect the resident received hospice services. During an interview on 08/09/23 at 3:35 p.m., an administrative staff member (#2) agreed staff coded Resident #9's MDS incorrectly. 46259

Based on record review, review of the North Dakota Provider Manual for Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 1 sampled resident (Resident #28) with a newly diagnosed mental illness. Failure to complete a change in status assessment may result in the delivery of care and services that are inconsistent with residents' needs. Findings include: The North Dakota PASARR Provider Manual, revised 12/29/20, page 13 states, . Change in Status Process . Whenever the following events occur, nursing facility staff must contact Maximus to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC (mental illness, intellectual disability, and conditions related to intellectual disability [referred to in regulatory language as related conditions or RC]) was not identified at the Level I screen process, and that condition later emerged or was discovered. Review of Resident #28's medical record occurred on all days of survey. The record showed an initial PASARR completed November 2022, prior to the resident's admission to the facility, and identified a diagnosis of dementia and no mental illness. The resident's current diagnosis list identifies a diagnosis of anxiety disorder and schizophrenia as of admission to the facility. The record lacked evidence the facility completed a Level I screening/change in status assessment with the addition of the two diagnoses upon admission. During an interview on 08/09/23 at 3:52 p.m., two administrative staff members (#2 and #3) confirmed the facility failed to contact Maximus to update the Level I screen with the addition of the new diagnoses.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the current status for 3 of 15 sampled residents (Resident #8, #17, and #35). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered occurred on 08/09/23. This policy, revised March 2022, stated, . care plans are revised as information about the resident and the resident's condition change. -Review of Resident #8's medical record occurred on all days of survey. A progress note, dated 07/13/23, stated, . does have positioning wedges, but continually rolls himself to different position . Observations on 08/08/23 and 08/09/23 showed the resident utilized positioning devices (positioning wedges and leg spacer). The current care plan lacked information related to Resident #8's use of positioning devices. During an interview on 08/09/23 at 2:38 p.m., an administrative nurse (#3) confirmed the current care plan failed to reflect the resident's need for positioning devices. - Review of Resident #17's medical record occurred on all days of survey. Review of nursing progress notes showed the following: * 07/31/23 at 1:26 p.m., . Resident is COVID-19 positive. Resident moved to an empty household at this time to quarantine. * 08/07/23 at 2:30 p.m., . Resident remains on isolation precautions. - Review of Resident #35's medical record occurred on all days of survey. Review of nursing progress notes showed the following: * 07/31/23 at 10:30 a.m., . Binax covid test completed, positive result . * 08/07/23 at 2:46 p.m., . Resident remains on isolation precautions . Observation on 08/07/23 at 2:16 p.m., showed an isolation cart in the hall outside of Resident #35's room, and a sign on the door which stated, airborne precautions. During an interview on 08/09/23 at 10:20 a.m., two administrative nurses (#3 and #4) agreed Resident #17 and #35's care plans lacked problems, goals, and interventions related to COVID-19 and transmission based precautions. 46259

Based on record review, review of the facility reported incident investigation, review of facility policies, review of personnel records, and staff interview, the facility failed to perform Cardiopulmonary Resuscitation (CPR) on 1 of 1 resident (Resident #1) who requested CPR in the event of absence of pulse or respirations. Failure to perform CPR contributed to Resident #1's death. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: Review of the facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation occurred on [DATE]. This policy, revised [DATE], stated, . Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. there are obvious signs of irreversible death (e.g., rigor mortis, decapitation or decomposition). Emergency Procedure-Cardiopulmonary Resuscitation . If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: Instruct a staff member to activate the emergency response system (code) and call 911. Instruct a staff member to retrieve the automatic external defibrillator. Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic life support (BLS) sequence of events. Review of Resident #1's medical record occurred on [DATE] and identified medical diagnoses of atherosclerotic heart disease, coronary artery disease, heart failure, and hypertension. Resident #1's DO NOT RESUSCITATE (DNR) REQUEST FORM signed by Resident #1 and Resident #1's physician on [DATE] stated, I understand the 'Do Not Resuscitate' order. (Check one). The resident placed a check mark by I want to be resuscitated. Physician's rounds/orders review, dated [DATE], showed, FULL CODE . order status active, order date [DATE] . Resident #1's most recent care plan stated . Advanced Directives Full Code . Review of progress notes identified the following: * [DATE] at 2:23 p.m. Care conference was held. Those in attendance was Interdisciplinary Team [IDT] and [resident name]. Family declined invite. Advanced directives were discussed and will remain as full code. * [DATE] at 4:20 a.m. Resident was found at this time to have cold lips, blue, eyes fixed and no reaction to light, no pulse, no heartbeat or respirations, [name] power of attorney [POA] was contacted and gave the ok to release the body to [name of funeral home] upon medical doctor [MD's] order. * [DATE] at 5:00 a.m. [family] arrived to see resident and did have priest come and deliver residents last rights. * [DATE] at 6:41 a.m. Signed fax back [from physician] at this time in regards to residents time of death and ok to release body to [name of funeral home]. The facility's investigation report dated [DATE] included the following documentation: * Staff #2 interview [DATE] I received an for your information [FYI] call from [Nurse #3] during the night shift notifying me that she had found an unresponsive resident with no pulse. [Nurse #3] stated that the resident was cold, lips were blue, eyes fixed, and she wasn't sure how long he had been like this. [Nurse #3] stated that she was going to call the resident's POA and the funeral home. Upon hanging up the phone with [Nurse #3] I became worried that the resident she had called about was a full code. I immediately texted and call her back, which she did not immediately answer as she was on the phone with the POA. She quickly returned my call. I stated that I thought the resident was a full code, so I asked if they started CPR and called 911. She confirmed that he was a full code but stated that the resident was cold, blue, and pupils were fixed. I stated that I still thought that CPR needed to be started and 911 called. [Nurse #3] stated to me again that he looked like he had been gone for some time and the body was cold. She repeated that he was blue/pale and pupils were fixed with no pulse or breath sounds. She also stated that the POA had already been called for permission to release the body. I stated that she needed to call the on-call physician for more guidance as I was under the impression that we needed to start CPR. I instructed [Nurse #3] to call me back when she found out. Shortly thereafter, [Nurse #3] called me back and reported that the physician told her that she did not have to do CPR since the POA gave approval to release the body. During an interview on [DATE] at 4:35 p.m., two administrative staff members (#1 and #2) stated they expected staff to initiate CPR on Resident #1. Based on the following information, non-compliance at F678 is considered past non-compliance. The facility implemented corrective actions for the deficient practice by: *Completing an investigation with interviews of staff who were present on [DATE]. *Determining the investigation showed staff failed to follow CPR policy and resulted in a resident's death. *Providing 1 on 1 education immediately after the incident with involved staff regarding the facility's emergency procedure for cardiopulmonary resuscitation. *Suspending (Nurse #3) for three days pending investigation and notifying the appropriate state agency. The facility addressed measures put in place and implemented systemic changes to ensure the deficient practice does not recur by: *Providing education to all nursing staff on the facility's emergency procedure for cardiopulmonary resuscitation and providing staff with copies of the policy beginning on [DATE] through the weekend of [DATE]. *Informing the Quality Assurance committee on [DATE] and determining what audits will be implemented. The surveyor determined a deficient practice existed on [DATE]. The facility implemented corrective action on [DATE] and completed nursing education by [DATE].

Based on record review, review of facility policy, resident interview, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 1 of 1 sampled resident (Resident #21) who utilized a slide board for transfers. Failure to reassess Resident #21's ability to utilize a slide board and failure to ensure staff are consistent on the use of a slide board resulted in an avoidable fall and fracture. Findings include: Review of the facility policy titled Slide Board Policy, dated (MONTH) (YEAR), stated, Policy/Procedure: 1. A sliding board is a piece of equipment that can be used if a person is not able to use their legs to complete a transfer between surfaces or if a standing transfer is not safe to perform or if the person refused the use of a full lift. The board is used to make a solid 'bridge' between the two surfaces that a person can slide across to transfer between them, with or without assistance. 2. A screening from occupational or physical therapy is advisable. Be aware the resident may not always be cooperative with the most safe method of transferring so deciding between quality of life, his wishes and safety of all involved must be determined. 3. The slide board transfer involves either transferring a paraplegic resident from the wheelchair to a bed, or from a bed to a wheelchair utilizing a board, and often with the use of a gait belt. You may still need assist of two. 5. Your resident should have the physical upper body strength to help get onto the board as you transfer them from the chair to the bed, or back. 6. Encourage proper transfer technics (sic) with repeated instructions. An interview with Resident #21 occurred on 06/12/19 at 12:18 p.m. The resident indicated he fell from bed during a transfer a couple of weeks ago because the certified nursing assistant (CNA) didn't know how to use the slide board. He stated once the slide board is in place, the CNAs have to pull him by the waistband of his pants over the bump (back wheel) of the wheelchair, but on the day of the fall, the CNA pushed him instead. When the CNA pushed, the wheelchair moved, he fell to the floor, and his foot caught under the nightstand. Review of Resident #21's medical record occurred on (MONTH) 12-13, 2019 and identified a fall on 06/01/19 and a closed [MEDICAL CONDITION] tibia and fibula on 06/03/19. The care plan (prior to 06/03/19) stated, Transfers: Requires staff assistance with sliding board . Transfers: One person extensive assistance PER RESIDENT REQUEST . Resident demands a step by step way of transferring him with sliding board. Resident has been educated about proper transfer process but refuses to allow staff to perform skill correctly. The current care plan (after the fall/fracture) stated, Transfer: Hoyer Lift (full body mechanical lift) with Assist x 2 (with 2 staff). Review of Resident #21's Minimum Data Sets (MDSs) dated 10/22/18, 01/26/19, and 04/19/19, all identified extensive assistance of two more staff members required for transfers. Resident #21's progress notes identified the following: * 06/01/19 at 7:27 a.m.: Writer called to resident room at 630 am (6:30 a.m.). Resident was found sitting on floor beside bed with WC (wheelchair) behind resident. Writer asked what happened and resident chuckled and said 'I fell on to the floor.' . CNA explained to writer that the sliding board was three quarters on the WC per resident request. CNA states that she told resident it would not work. Resident replied 'This is how I do it all the time.' CNA assisted with transfers and resident was on the edge of the WC and slid off cushion . * 06/03/19 at 6:51 a.m.: Writer called to resident's room at 6 AM by CNA. CNA stated resident has a large bruise to right lower leg and when resident lifted up his leg his ankle 'gave out' Resident had a fall on Friday (sic) (fall occurred Saturday) morning while transferring from his bed to wheelchair. Resident told writer that he twisted his right leg and landed on his buttocks. Writer assessed right lower leg and it is very unstable to which a possible fracture could be present . * 06/03/19 at 4:30 p.m.: . Resident has a fracture to the tbial (sic) and fibia (sic) . An occupational therapy (OT) evaluation, dated 03/26/18, stated, . Clinical Impression: Patient lying in bed and refusing to get up for OT. OT explained that OT needed to assess transfers and it would only take a short time. Patient states that his transfers are going fine and doesn't need to be changed and he refused to get up. OT continued to encourage patient but he continued to refuse. OT spoke with CNAs in regards to his transfer and a slide board has been appropriate use of transfer method. Patient does not want the transfer method changed. At this time, slideboard will continue to be used due to patient not cooperative with OT at this time. The facility failed to make additional attempts to evaluate Resident #21's use of the slide board and failed to educate the resident of the possible risks of injury if the slide board is not used properly. The facility failed to document the resident's refusals, if any, of any other forms of transfer. The next OT evaluation occurred on 06/06/19, five days after the fall/fracture. The evaluation stated, . total assist to use sliding board to w/c (wheelchair). encouraged patient to complete as I'ly (independently) as possible. w/c to EOB (edge of bed) completed very unsafely (with patient completing 1/2 of transfer & falling onto bed total A (assist) of 2 to advance body into bed. Patient upset with staff stating they did it wrong. Recommend cont. (continued) use of hoyer for safety of patient & staff. During an interview on the afternoon of 06/12/19, an administrative staff member (#5) stated Resident #21 chooses how many CNAs he will allow to transfer him with the slide board and he prefers just one. During an interview on 06/13/19 at 8:55 a.m., a CNA (#3) indicated Resident #21 is difficult to transfer with the slide board because he is not involved at all. Staff need to do everything . pulling and pushing him onto the board and then over the wheel. The CNA stated it's hard to transfer him alone but she knows some staff do. During an interview on 06/13/19 at 10:44 a.m., an OT staff member (#4) stated she completed a screening for Resident #21's use of the slide board on 06/06/19. Two CNAs totally assisted the resident with the transfers, both from bed to the wheelchair and back to bed. Resident #21 kept repeating staff were doing it wrong but, in her opinion, the CNAs completed the transfers correctly. The facility failed to reassess Resident #21 ability to utilize a slide board after he refused the assessment in (MONTH) of (YEAR) and failed to assess the staff's safety and the safety of the resident while utilizing the slide board. These failures resulted in Resident #21's avoidable fall and fracture.