Based on observation, interview, record review, and document review, the facility failed to ensure staff transferred a resident, who was at risk for falls, with the use of a mechanical lift and two-person staff assistance. Specifically, on 06/11/2024, failed to follow the resident's care plan and daily care guide when she assisted the resident with a transfer from their wheelchair to the bed. During the transfer, Resident #6 fell to the floor and sustained a right femur fracture. This deficient practice affected 1 (Resident #6) of 4 sampled residents reviewed for accidents. Findings included: An admission Record revealed the facility admitted Resident #6 on 04/10/2024. According to the admission Record, the resident had a medical history that included diagnoses of autistic disorder, cerebral palsy, age-related osteoporosis, a history of falling, and morbid obesity. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/17/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required partial/moderate assistance with roll left to right, sit to lying, lying to sitting on side of bed and sit to stand and was dependent on staff for chair/bed-to chair transfers and toilet transfers. Resident #6's Care Plan included a problem statement initiated 04/19/2024, that indicated the resident had a potential for future falls due to a history of falls, weakness, impaired mobility, cognitive deficit, and unawareness of safety boundaries. Interventions directed the staff to provide a two person assist with mechanical lift for transfers. The undated Daily Care Guide, indicated Resident #6 was a 2 person assist with transfers using mechanical lift. Resident #6's progress note signed by Licensed Practical Nurse (LPN) #2 and dated 06/11/2024 at 3:29 PM, indicated LPN #2 was informed by a certified nursing assistant (CNA) that the resident fell to the floor while being transferred from a wheelchair to their bed. The progress note revealed the resident initially complained of left lower extremity pain and had a reddened area on their left lower extremity. Per the progress note, the physician was notified and gave an order to x-ray the resident's left and right tibia, fibula, and foot, The progress noted indicated the x-ray revealed the resident had a fractured right femur and orders were received to send the resident to the emergency room (ER) for further evaluation and treatment. Resident #6's x-ray report dated 06/11/2024 indicated the resident was found to have an oblique mildly displaced, apex ventro-lateral angulated mid-diaphyseal fracture of the right femur noted. A handwritten statement written by CNA #32 and dated 06/11/2024, indicated after Resident #6 got dressed, CNA #32 brought the mechanical lift pad to the resident's room and Resident #6 began to panic and stated they did not want to use the mechanical lift that they could stand to get in their wheelchair. According to the handwritten statement, CNA #32 indicated the first time the resident stood, the resident sat back down by their bed, but when the resident stood the second time, the resident pivoted a little bit, tried to turn then fell. Per the handwritten statement, CNA #32 stated she held onto the back of Resident #6's pants. During an interview on 06/05/2025 at 5:05 PM, LPN #2 stated Resident #6 was a two-person assist and did not like the mechanical lift. LPN #2 stated there should have been two people to assist the resident with the transfer on 06/11/2024 with the mechanical lift. During an interview on 06/06/2025 at 9:57 AM, the Quality Assurance/Infection Preventionist (QA/IP) stated Resident #6 required the use of a mechanical lift with a two-person assist for transfers at the time of the incident on 06/11/2024. The QA/IP stated to her knowledge Resident #6 was not capable to stand by themselves. Per the QA/IP, there should have been another person with CNA #32 when she attempted to transfer the resident on 06/11/2024. On 06/07/2025 at 9:08 AM, 06/07/2025 at 6:08 PM, and 06/08/2025 at 8:20 AM, the surveyor attempted to conduct a telephone interview with CNA #32; each time the surveyor left a voicemail message and no return call was received. During a follow-up interview on 06/07/2025 at 9:46 AM, the QA/IP stated during the course of the investigation into Resident #6's fall on 06/11/2024, CNA #32 informed her that it was just her in the resident's room at the time of the fall. The QA/IP stated CNA #32 was terminated because she did not follow the resident's care guide, which indicated the resident was a two-person transfer with a mechanical lift. The QA/IP stated as the result of the incident, education was done with the staff, staff were observed to ensure they followed the resident's care plan/guide, and Resident #6's care plan was updated to reflect that if the resident refused to be transferred with the mechanical lift, the staff should notify the nurse. The QA/IP stated it was poor judgement and understanding by CNA #32 that led to the resident's fall. During an interview on 06/07/2025 at 12:03 PM, the Director of Nursing Services (DNS) stated CNA #32 was terminated for failure to follow protocol. During an interview on 06/07/2025 at 1:49 PM, the Executive Director (ED) stated he was made of the incident and the DNS informed him that CNA #32 did not follow the process. The ED stated the DNS addressed the issue with CNA #32, training was done with the staff and observation/monitoring of resident transfers were implemented. Per the ED, since the incident on 06/11/2024, there had not been another incident in which staff did not follow a resident's care plan during transfers, so the facility felt the retraining/education and monitoring worked. During a follow-up interview on 06/08/2025 at 12:19 PM, the DNS stated she expected the CNAs to follow the pocket care guide when they provided care to the residents. During a follow-up interview on 06/08/2025 at 1:48 PM, the ED stated he expected the staff to follow the resident's pocket care guide. The facility's actions to correct the identified deficient practice related to falls during a transfer with a mechanical lift revealed: - The facility terminated CNA #32's employment on 06/13/2024. - The facility revised the care plan for Resident #6. - The facility completed in-service education with the nursing staff, to include all CNAs on resident transfers. - The facility reviewed the resident incident during their weekly risk management meeting. - The facility monitored resident transfers and interventions implemented and determined no other falls occurred in the facility related to a resident transfer. Verification of corrective actions taken by the facility revealed the following: - The personnel file for CNA #32 revealed a hire date 04/1/2024 and a termination date of 06/13/2024 for failure to follow policy and procedure. - Resident #6's revised care plan interventions included the resident was a two-person assist with transfers using a mechanical lift, and if the resident refused to transfer with the lift the certified nursing assistant was to notify a nurse and not attempt to transfer without using the lift. - Training of 100% of nursing staff and competencies were conducted for 100% of the CNAs between 06/12/2024 and 06/17/2024. - Observation of transfers for two residents including Resident #6 on 06/08/2025 with no concerns noted. - Multiple interviews with staff revealed their knowledge to utilize the pocket care guide for daily care instructions for each resident, including whether a resident was a two person assist. All staff interviewed stated if a mechanical lift was to be used for a resident that it required two people. - Observation of the pocket care guide for Resident #6 revealed the resident was a two-person assist with a mechanical lift. - Multiple interviews with staff revealed monitoring was in place of the CNAs for transfers utilizing a mechanical lift. - Interview with the Executive Director revealed ongoing discussion of falls and transfers during the weekly risk management calls and monthly quality assurance meetings. - Review of the incident log revealed no other falls with a fracture related to a transfer utilizing a mechanical lift since 06/11/2024. Based on verification of the facility's corrective action, the severity of harm was determined to be past noncompliance.