Based on observation, record review, and interview, the facility failed to ensure staff followed care planned interventions requiring one staff member to perform transfers with gait belt to promote resident safety and prevent injury for 1 (Resident #2) of 3 sampled residents who required one-person transfers with a gait belt. This failed practice resulted in actual harm for Resident #2, who was transferred without the use of a gait belt and sustained a dislocation of the shoulder, proximal humerus fracture, ligamentous injury, and clavicle injury. The findings are: 1. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/26/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11 (8-12 indicated the resident had moderate cognitive impairment). Resident #2 had diagnoses of age-related osteoporosis, osteoarthritis of hip, other chronic pain, vitamin D deficiency, displaced fracture of surgical neck of left humerus, closed fracture. a. Resident #2 ' s Care Plan with a revision date of 12/20/2023, indicated, Focus: (Resident #2) has an ADL self-care performance deficit related to impaired mobility; Intervention: Transfer: (Resident #2) requires extensive assist of 1 staff and a gait belt for transfers between surfaces b. The Closet Care Plan Form dated 09/14/2023, for Resident #2 that was observed in Resident #2 ' s closet on 03/13/2025 indicated that resident needed assistance of one [staff member] and instructed staff to utilize a gait belt with all transfers. c. A form titled Witness Statement Form completed by Certified Nursing Assistant (CNA) #1 on 01/08/2025 at 5:55 PM, indicated Certified Nursing Assistant (CNA) #1 assisted Resident #2 to bed. Resident #2 was in [Resident #2] wheelchair beside the bed. CNA #1 did not use a gait belt and grasped Resident #2's left upper arm. CNA #1 lifted Resident #2 and transferred the resident to the bed supporting part of the resident ' s weight by their left arm and pivoted the resident to the bed. CNA #1 indicated that Resident #2's arm popped while transferring resident. CNA #1 indicated that Resident #2 complained a little about their arm hurting so she ran and got the nurse. d. A form titled Witness Statement Form completed by Licensed Practical Nurse (LPN) #1, on 01/08/2025 at 5:55 PM, indicated Licensed Practical Nurse (LPN) #1 was passing meds when CNA #1 alerted him that Resident #2 complained of shoulder pain after hearing a loud pop during transfer. LPN #1 assessed Resident #2 shoulder and determined that it was necessary to notify the on-call provider. LPN #1 indicated that Resident #2's shoulder popped when moving the arm and the movement caused the resident 7/10 pain, resident indicated that the pain was minimal when not moved. e. A form titled Witness Statement Form for Resident #2 was written by LPN #1 on 01/08/2025 at 10:00 PM, LPN #1 took Resident #2 ' s statement as to how resident ' s arm/shoulder was hurt. Resident #2 indicated that CNA #1 was helping me out of my wheelchair. Resident #2 indicated that CNA #1 was not going slow, but did not know how to explain it. Resident #2 indicated that ' it ' (shoulder) popped and began to hurt immediately. Resident #2 indicated that CNA #1 went to get help after that. f. A form titled Emergency Department [Named], date 01/08/2025, Medical Decision Making: Differential diagnosis includes dislocation of the shoulder, proximal humerus fracture, ligamentous injury, clavicle injury. X-ray of the shoulder is pending to further evaluate g. A form titled Emergency Department [Named] Imaging Services dated 01/08/2025, indicated findings: Mildly displaced transverse fracture through the surgical neck of the humerus. h. A form titled Academy: CARE Academy with a completion date 08/29/2024, For CNA #1 shows CNA #1's Skill Assessments were completed on 08/29/2024, Return demonstration - Transfers and Gait Belt, progress 100 percent. i. Undated Gail Belt, Use of Policy provided by the Administrator on 03/14/2025, indicated gait belts will be utilized for any resident transfers. j. The Undated Care Plan Policy provided by the Administrator on 03/14/2025, indicated, facility will develop and review the care plan of each resident. k. On 03/12/2025 at 12:03 PM, this surveyor spoke with Resident #2. Resident #2 indicated they could tell their shoulder was injured after the improper transfer. Resident #2 stated, The girl (CNA #1) was kind of rough with me and she does not work here anymore. Resident #2 indicated that [Resident #2] had heard they were having a lot of complaints about the CNA that hurt [Resident #2]. This surveyor asked Resident #2 where they were when CNA #1 helped the resident up and caused the injury. Resident #2 indicated [Resident #2] was in [Resident #2 ' s] wheelchair in [Resident #2 ' s] room and wanted to go to bed. Resident #2 indicated that CNA #1 did not use a gait belt and grabbed [Resident #2] under the arm and then it popped and hurt. Resident #2 demonstrated that CNA #1 grabbed their upper arm (left) under the shoulder, and then stated, it got a little broke. Resident #2 stated She (CNA #1) was helping me from the wheelchair to the bed and she (CNA #1) was rough. If she would have been careful it would not have happened. l. On 03/13/2025 at 9:25 AM, CNA #4 was asked how they know a resident needs one person or two-person assistance with transfers. CNA #4 indicated staff utilized the closet care plan. CNA #4 was asked how often the closet care plan was checked. CNA #4 stated Every day, because it can change. CNA #4 was asked if she had been in-serviced on transfers. CNA #4 stated Yes, less than 6 months ago. CNA #4 was asked how a resident that needed one person assistance should be transferred. CNA #4 stated With a gait belt. m. On 03/13/2025 at 9:38 AM, CNA #5 was asked how they know what care a resident might need. CNA #5 stated, I check the closet care plan in the resident ' s closet. CNA #5 was asked how they would know if a person needed one or two-person assistance with transfers. CNA #5 stated, Closet care plan. CNA #5 was asked how often she checked the closet care plan. CNA #5 stated Every day, because it can change. CNA #5 was asked if she had been in-serviced on transfers. CNA #5 stated Yes, a few months ago. CNA #5 was asked how a resident who needs one person assistance should be transferred. CNA #5 stated, With a gait belt. n. On 03/13/2025 at 9:50 AM, CNA #6 was asked how they would know what care a resident might need. CNA #6 stated Check the closet care plan. CNA #6 was asked how they would know if a resident needed one or two-person assistance. CNA #6 stated, By their care plan. CNA #6 was asked how often they checked a resident's closet care plan. CNA #6 stated, Every day, because it may change. CNA #6 was asked how a resident who needed one person assistance should be transferred. CNA #6 stated With a gait belt. CNA #6 was asked if she had been in-serviced on transfers recently. CNA #6 stated Yes, I think it was within the last month. o. On 03/13/2025 at 10:10 AM, CNA #3 was asked how much assistance Resident #2 needed with transfers. CNA #3 stated two-person assistance due to [Resident #2 ' s] arm. CNA #3 was asked how they would know what care a resident may need. CNA #3 stated I check the closet care plan. CNA # 3 was asked how often she checked the closet care plan. CNA #3 stated Every time I go into the resident's room, at least once a day. CNA #3 was asked if she had received any training recently. CNA #3 indicated that she had just been in-serviced on transfers a few weeks ago. p. On 03/13/2025 at 10:20 AM, CNA #2 was asked how much assistance Resident #2 needed with transfers. CNA #2 stated Resident #2 ' s plan says one, but if the resident was weak that day I will ask for more help. CNA #2 was asked how you should transfer a resident that is one person assistance. CNA #2 stated, With a gait belt. CNA #2 was asked if she had been in-serviced on transfers recently. CNA #2 stated, Maybe a week or two ago. q. On 03/13/2025 at 1:21 PM, the Director of Nursing (DON) was interviewed and indicated she started on 01/27/2025. The DON was asked how staff know what care a resident needed. The DON indicated staff had the closet care plan in the room to refer to, they are in each resident room. The DON was asked how they [staff] find that out (to utilize the closet care plans). The DON indicated staff were trained when hired to always refer to closet care plan. The DON was asked who updated the closet care plans. The DON indicated that the Assistant Director of Nursing (ADON) did, anytime a change was made. The DON was asked when staff should check a closet care plan, and indicated before any care was given to a resident. The DON was asked how much assistance Resident #2 needed for transfers. The DON indicated that Resident #2 needed 1 person assistance, then indicated it was based on a resident ' s care plan. The DON also indicated that she had the department supervisors go around each day and check 5 closet care plans per day to audit and make sure the closet care plans were current and in place. The DON was asked who determined if a resident was a one person or two-person transfer. The DON indicated Physical Therapy. The DON indicated that she monitored ten transfers a day to make sure they are done correctly. r. On 03/13/2025 at 3:15 PM, the Administrator (AD) indicated that he was advised of the situation with Resident #2 by phone. The AD indicated that his on-call supervisor called him, but he could not remember who was on-call that night. The AD indicated that he was told a resident was hurt due to an improper transfer. The AD indicated that he called his consultant and then he went to the facility. The AD indicated that CNA #1 self-reported that she transferred Resident #2 without a gait belt. The AD indicated that he called the police and notified the family and the doctor. The AD indicated that he watched the cameras to see if he could observe anything. He indicated that cameras were in the halls but not in the rooms and that he did not see anything. The AD indicated that the DON started abuse and neglect in-services that night. The AD indicated that CNA #1 was suspended immediately that night, pending investigation. He indicated that there was no need to just suspend CNA #1, due to her self-reporting that she transferred resident improperly without using a gait belt, so she was terminated that night. s. On 03/13/2025 at 3:18 PM, the Nurse Consultant (NC), advised that the previous Director of Nursing (PDON) had started a monitoring program for transfers, right after this incident and she checked as of 03/11/2025, it was still in place with the current DON. The NC also indicated that they had done a QAPI (Quality Assurance and Performance Improvement) on the improper transfer and injury. The facility provided the following evidence of corrective actions that were initiated after the incident, but prior to the Complaint Survey: 1. Record of in-service dated 01/09/2025, titled Abuse, Neglect, Misappropriation and Exploitation with attached policy Abuse, Neglect, Misappropriation and Exploitation Investigation & Reporting Policy attached for staff to read. 2. Form titled Transfers provided by the DON, showing where transfers have been monitored since 01/09/2025 to make sure they are being done correctly. 01/08/25 - 01/23/25 30 transfers a day were observed. 01/24/35 - 02/06/25 20 transfers a day were observed. 02/07/25 - 03/14/25 10 transfers a day were observed. 3. Quality Assurance and Performance Improvement (QAPI) meeting minutes for 01/31/2025 were provided by the DON. It shows that the Reportable was discussed and monitoring system had begun for monitoring system of proper gait belt transfer with CNA's weekly. 4. Employee Timesheet for CNA #1 was provided by the Administrator to show that CNA #1 was not showing time after 01/08/2025. It shows CNA #1 clocked out at 10:15 PM on 01/08/25.

Based on observation, record review, and interview, the facility failed to implement interventions for previous falls as indicated from the care plan to decrease the potential for future falls with injuries which resulted in a fall with a fracture for 1 (Resident #53); This failed practices had the potential to affect 23 residents who were at risk for falls according to a list provided by the Assistant Director of Nursing on 12/21/23 at 10:39AM. The facility failed to ensure residents who were at risk for fluid aspiration had the correct thickened consistency per physician's orders for 2 of 2 (#85 and #89). The Findings are: 1a. Resident #53 had a fall on 08/02/23 resulted in a radius fracture, ulnar fracture, seventh and eight rib fractures. b. Resident #53 had a fall on 08/21/23 which resulted in a knot to the right side of her head. c. Resident #53 had a fall on 08/26/23 resulted in a right femur fracture. d. Resident #53 had a fall on 10/30/23 with no injuries. e. On 12/19/23 at 7:00 PM review of Resident #53's electronic showed Nursing-I&A Note Effective Date:8/26/2023 15:30:00 written by Licensed Practical Nurse Created Date: 8/26/2023 19:18:30: Advanced Practice Nurse (APN) contacted at 1541. Family contacted at 1559. Incident Description: This nurse was alerted to noise and then a resident yelling she fell. Stood up from nurses' station to see resident laying on her right side in foyer to courtyard. Approached resident and wheelchair was noted to be at end of her body near her feet. Asked resident what happened, and she said she got up to go pee and fell. Resident reported some tenderness to right leg but was able to move leg. Resident was assisted by two staff members out of floor and into wheelchair. CNA [Certified Nursing Assistant] educated that one CNA is to be in common area at all times to watch the residents. Immediate Intervention: Staff educated that an CNA is to be in common area watching resident at all times. Nursing Note on effective Date: 8/21/2023 10:39:00 created by Licensed Practical Nurse Date:8/21/2023 10:42:23 Physician Contacted and Family Contacted Resident went into another resident's room, and it appears that she went to the restroom by herself and then somehow fell backwards, hitting her head on the wall on the way down. She has a knot on the right side of her head and states its sore. I tried calling Power of Attorney, but no answer so I left a voice nail. I spoke with [physician contact: name] and we started neuro checks, assessed for other injuries, helped her back to her wheelchair. Immediate Intervention: non-slip socks wheelchair alarm Nursing Note on Effective Date: 8/2/2023 05:40:00 Created Date: 8/2/2023 05:43:43 physician at 4:30 AM multiple attempts have been made to reach family but she still has not answered as of 5:45 AM. Incident Description: Resident found lying in her bathroom floor on her right side. Her head was sticking out of the bathroom doorway and could be seen from the common area. Resident was partially dressed and barefooted. Immediate Intervention: Resident assessed for injury. Resident's left arm appeared deformed, and Resident was guarding it in pain. ROM [range of motion] performed on other 3 extremities. Resident assisted out of floor and into w/c [wheel chair] with gait belt x 3 people. Telehealth call performed with on call and n/o [no orders] received to send resident to ER [Emergency Room] for possible arm fx [fracture] with uncontrollable pain. h. On 12/20/23 at 9:08 AM after being observed for 3 days the Surveyor asked Licensed Practical Nurse (LPN) #3 if she could locate the following interventions from previous falls, shoes with back closures, rear tilted wheelchair seat, (measured front and back of wheel chair seat to the ground and noted 17 inches observed by LPN#3 and Certified nurse aide # 3), a seat belt, high back broad, anti-rollbacks. LPN #3 confirmed that none of the planned interventions were in place. During interview, the Surveyor asked LPN #3 was asked if the interventions should have been in place. LPN #3 stated, yes. The Surveyor asked LPN #3 was asked how the Certified Nursing Assistant (CAN)s knew how to care for the residents. LPN #3 stated, They have a closet care plan (CCP). The Surveyor asked show the surveyor the CCP. On the CCP were interventions that were not implemented. i. On 12/20/23 at 9:39 AM, the Director of Nursing (DON) was asked if she expected her staff to follow the interventions explicitly Resident # 53. The DON stated Yes, they should be in place every day. 3.a On 11/03/23 at 3:00PM, Resident #85 had orders for thickened liquids. Nectar Thick Liquids every shift. b. A care plan dated 11/3/23 documented change to mech soft, diet changed to puree, nectar thick liquids, date Initiated: 12/20/2021 with a revision date on 11/13/23. c. On 12/21/23 at 8:56AM the Surveyor asked CNA #3 to observe the thickened liquids and explain what was wrong. CNA #3 stated, I'm not sure. The Surveyor asked CNA #3 if there was a possibility Resident #85 could get any kind of liquids that the Resident might ingest that she shouldn't. CNA #3 stated, Oh yes, she can drink the melted ice. CNA #3 stated, She can aspirate and that can cause death. d. An order dated 09/13/23 at 3:00 PM an order for Honey Thick Liquids Every shift was documented in the Physicians Orders. e. On 08/02/23 the Care plan documented Diet changed to mech soft, honey thick liquids. f. On 12/18/23 at10:13 AM Resident #89's honey thick liquids were sitting at bedside in ice in a face pan. The ice was melting. g. On 12/19/23 at 9:15 AM, a warm ice pack with a small amount of thin water in pan at bedside with honey thick liquids floating in the water was observed. h. On 12/19/23 at 2:43 PM Resident # 89's thickened liquids from yesterday were in a pan of small amount of water with a warm ice pack on top of them at bedside. i. On 12/20/23 at 08:40 AM resident #89s thickened liquids were sitting in a pan of ice from Monday. The ice was melting and was 1/3 full of water. j. On 12/21/23 at 9:05AM, LPN #3 was asked to observe the thickened liquids and explain what was wrong. LPN #3 stated, The ice is melting, and she can drink it, aspirate fluids in her lungs and die. 4.a. On 12/18/23 at10:13 AM, Resident #89's honey thick liquids were sitting at bedside in ice in a face pan. The ice was melting. b. On 12/19/23 at 9:15 AM, a warm ice pack with a small amount of thin water in pan at bedside with honey thick liquids floating in the water was observed. c. On 12/19/23 at 2:43 PM Resident # 89's thickened liquids from yesterday were in a pan of small amount of water with a warm ice pack on top of them at bedside. d. On 12/20/23 at 8:40 AM, Resident #89's thickened liquids were sitting in a pan of ice from Monday. The ice was melting and was 1/3 full of water. e. On 12/21/23 at 9:05AM, LPN #3 was asked to observe the thickened liquids and explain what was wrong. LPN #3 stated, The ice is melting, and she can drink it, aspirate fluids in her lungs and die. g. On 12/20/23 at 4:26 the Assistant Director of Nurses (ADON) provided a form titled, Incident and Accident Policy. This policy isn't pertinent to the concern. h. On 12/21/23 at 10:39 AM, the Assistant Director of Nursing was asked to observe the thickened liquids sitting in thin water and explain what she observed. The ADON stated, The ice should be changed out more often to keep the consistency per physicians orders because if they drink the thin liquid they could aspirate and possibly die.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a cognitively impaired resident was adequately supervised when drinking hot liquids which resulted in an injury for 1 (Resident #5) and failed to supervise a cognitively impaired resident who got a hot curling iron from behind the nurses station for 1 (Resident #4) of 5 (Residents #1, #2, #3, #4 and #5) sampled residents who resided on the Secure Unit. This failed practice had the potential to affect all 23 residents residing on the Secure Unit as documented on the Census provided by the Administrator on 11/28/22 at 10:18 a.m. The findings are: 1. Resident #5 had diagnosis of Vascular Dementia. The Quarterly MDS with an ARD of 09/06/22 documented the resident scored 2 (0-7 indicates severely cognitively impaired) on a BIMS and required supervision and set up help with eating. a. The Care Plan with an initiated date of 09/02/22 documented, .is at risk for burns from hot liquids due to confusion and frequently attempts to dump her coffee or other hot liquids into her oatmeal, or into her plate. Also had a spill today of her coffee into her lap . b. The Incident and Accident Report (I&A) dated 09/03/22 documented, .Incident Description Nursing Description: Resident was at the dining room table and was drinking a cup of coffee and dropped it in her lap. Resident Description: Oops, I dropped it . Immediate Action Taken Description: Resident taken to her room and cold water was applied. Skin assessment performed with slight redness to the skin on the thighs radiating between the inside of the legs. 0 [no] blistering noted at this time . c. The Hot Liquid assessment dated [DATE] at 2:48 PM documented, .Hot Liquids Material Management History 1. Can the resident manage coffee cup on their own? No. 2. Does the resident require cup with a lid? No. 3. Does the resident require a cup with two handles? No. 4. Does the resident require a weighted cup No. 5. Does resident have a history of hot liquid spills? Yes. 6. Has resident experienced burn from spills? Yes . 2. Resident #4 had a diagnosis of Cognitive Communication Deficit. The Quarterly MDS with an ARD of 10/11/22 documented the resident scored 1 (0-7 indicates severely cognitively impaired) on a BIMS and required extensive physical assistance of two plus persons with transfers, limited physical assistance of one person with locomotion on and off the unit and extensive physical assistance of one person with personal hygiene. a. The Incident and Accident Report dated 11/03/22 documented, .Incident Description Nursing Description: resident was found behind nursing station holding in her hand a warm curling iron. No injuries . Resident Description: she said she didn't know that it was warm, she just wanted to take it to her room . Immediate Action Taken Description: NO curling irons left behind the nurses station. Immediate Intervention: items not be left where resident have access to them. b. The Progress Note dated 11/04/22 at 2:49 AM documented, .Hot Rack Charting: Resident was holding a warm curling iron on previous shift. 0 c/o [complaints of] pain or discomfort to residents hands. 0 s/s [signs and or symptoms] of burns, redness, or swelling noted at this time. Resident in bed resting with eyes closed. Call light, fluids and bedside table within reach . 3. On 11/29/22 at 9:41 a.m., the Surveyor asked Certified Nursing Assistant (CNA) #3 How did [Resident #4] obtain a hot curling iron on the Secure Unit? CNA #3 stated, I don't know anything about it. The Surveyor asked, Who is responsible for ensuring a hot curling iron isn't available? She stated, Each staff member who uses them should replace them in the shower room cabinet. The nurse should check behind. 4. On 11/30/22 at 8:20 a.m., the Surveyor asked the Director of Nursing (DON), When did you start? The DON stated, I began after Labor Day. The Surveyor asked the DON to review the I&A for Resident #5. The Surveyor asked, Did the spilled coffee result in an injury as documented? The DON stated, Slight redness not a burn, but just in case she treated it with cool water to proactively treat the area in case a burn came up.