**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to protect the resident(s') right to be free from neglect when it failed: 1) to provide a hazard free environment and supervision for three residents (#3, #8, and #12) of three reviewed for falls with injuries; 2) to provide follow-up notification for critical radiology results for one resident (#9) of one reviewed for imaging; 3) to provide proper wound care to prevent the development of complications for four residents (#19, #21, #22, and #20) of four reviewed for wound care; 4) to provide medication administration per physician orders for three residents (#1, #13, #15) of three reviewed for medications; 5) to provide assistance with Activities of Daily Living (ADL's) related to showers, incontinence care, and assistance with meals for six resident (#16, #18, #7, #17, #24, and #25) out of six reviewed for Activities of Daily Living; 6) to provide laboratory services as ordered for three residents (#14, #13, and #10) out of three reviewed for laboratory orders. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #3, #8, #12, #9, #19, #21, #22, #20, #1, #13, #15, #16, #18, #7, #17, #24, #25 #14, and #10 and resulted in the determination of Immediate Jeopardy on 6/22/24. The findings of Immediate Jeopardy were determined to be removed on 10/28/2024 and the severity and scope was reduced to an E. Findings included: 1. Review of Resident #3's progress note, dated 6/22/24 at 9:48 a.m., authored by Staff M, Licensed Practical Nurse (LPN) showed the following: Upon arriving on the unit and doing rounds the resident was observed sitting in wheelchair by resident's room door chanting but not outside of her normal behavior. Another nurse came and informed the nurse that the resident posture was not looking normal and if I would assess her. Upon walking up to the resident, the posture was abnormal, and her leg was twisted. When approaching the resident to touch her she begin screaming. Wheelchair was in locked position. The resident admitted to pain and responded to yes or no type questions. The nurse asked if she was in pain she stated 'yes'. The nurse asked was her leg bothering her and she stated 'yes'. The nurse asked did she fall, and she stated, 'yes'. When asked can the nurse look at her leg she stated, 'no don't'. PRN [as needed] offered to resident for pain but resident was not eating or drinking breakfast tray in front of her. EMS [Emergency Management Services] arrived and took resident to [Hospital Name]. Supervisor notified [family member] of resident's transfer. [Physician] office notified. Review of Resident #3's progress note, dated 6/22/24 at 2:45 p.m., authored by Staff M, LPN showed the following: The nurse spoke with ER [Emergency Room] at [Hospital Name] and was notified that the resident was admitted for UTI [Urinary Tract Infection] and hip fracture. Review of admission Records showed Resident #3 was admitted on [DATE] with diagnoses including pacemaker placement, weakness, low back pain, Alzheimer's disease, and other co-morbidities. Review of Resident #3's Quarterly Minimum Data Set (MDS), dated [DATE], showed the resident required maximum assistance with all Activities of Daily Living (ADL) care, the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months, and the resident had not had any falls since admission/entry or reentry prior to the assessment. Review of Resident #3's Comprehensive Care Plan, 7/31/23, showed the following: Focus: Resident needed assistance with activities of daily living because of a diagnosis of dementia with memory impairment, pain, and weakness. Goals included: -Caregivers will be able to perform a safe transfer using proper body mechanics with 100% carryover by the next review date. -Resident will perform self-feeding tasks with supervision or touching assistance by next review date. -Staff will help me with all my ADL needs so that I appear neat and tidy with absence of foul body odor through next review. Interventions included: -Anticipate resident's needs. -Assist me with hygiene, bathing, dressing, toileting and transfers. -Assist me with toileting promptly when requested. -Assist with all ADL care to ensure daily needs are met. Check nails, trim and clean on bath day and as necessary. -Encourage/allow me to do as much for self as possible with feeding self, provide assistance with ADLs that I am unable to do for myself as indicated. -Keep call bell within reach and remind/encourage me to use it to call for assistance. -Skin inspections twice a week on shower days and with ADL care: Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Review of the facility's Incident Log, from April 2024 to October 2024, did not reveal any incidents related to Resident #3 suffering an injury of unknown origin. Review of the facility's Abuse and Neglect Log, from April 2024 to October 2024, did not reveal any allegations/incidents of abuse or neglect for Resident #3 had occurred or been reported. Review of Resident #3's progress note, dated 6/22/24 at 3:20 p.m., authored by the Nursing Home Administrator (NHA) showed: Writer spoke to [family member] who stated that she was with [Resident #3] at the hospital and [Resident #3] was admitted with a hip fracture and UTI. I notified [family member] that we were working on the root cause investigation, and she was satisfied and understood. Review of Emergency Department (ED) records for Resident #3, dated 6/22/24, showed per EMS she had a possible trip and fall it was unwitnessed, but she does slip out of her wheelchair multiple times per the facility has a history of hip fracture falls . It showed prior to arrival in the ED the resident had 70 mcg (micrograms) of Fentanyl for pain, and she endorsed pain when pressing on her right hip. The extremities physical assessment showed, no deformity, moderate trauma. Difficult to examine the patient's right leg patient is curled up in bed she usually is in a wheelchair moderately confused and not following direction with palpitation of the patient's right thigh/right hip she does scream in excruciating pain . Review of the hospital History and Physical for Resident #3, dated 6/22/24, showed the resident was brought to the emergency department after she was found on the floor .patient found to have right periprosthetic proximal fracture with significant angulation . Review of the hospital Operative Reports for Resident #3, dated 6/24/24, showed the resident underwent an open reduction and internal fixation of right periprosthetic proximal femur fracture. The surgeon noted, The rationale for surgery would be for palliative measures. I do not anticipate this fracture will heal to the point where she will be more functional than she was before the injury, which was bedbound, wheelchair dependent, non-weight bearing. My hope is that the incision heals, and she does not develop any perioperative complications arising, such as blood clots, infections, wound healing problems, fractures, dislocations, or risks of the medications and anesthesia. Review of Resident #3's progress note, dated 6/24/24 at 3:36 p.m., authored by the Director of Nursing (DON) showed: Investigation and statements stated that fx [fracture] happened during transfer of resident from bed to chair. Resident at no time had a fall. Daughter made aware of findings of investigation. An interview was conducted on 10/22/24 at 4:43 p.m. with the DON and Risk Manager (RM). The DON stated during an investigation it was determined Resident #3's fracture occurred during a transfer. The DON said she had been notified the resident was transferred out with a potential fracture on 6/22/24. She stated an investigation was started to see how the possible fracture happened. She said a report was not filed for abuse or neglect as the fracture occurred during transfer. An interview was conducted on 10/22/24 at 5:08 p.m. with the Nursing Home Administrator (NHA) and the Administrator in Training (AIT). The NHA said he became aware of Resident #3's fracture during a morning meeting on 6/22/24 when a nurse's note was read that stated Resident #3 had a fall. He said the management team reviewed the statements from the staff who worked, and everyone stated there was no fall. He said the management team did not complete interviews, they just read the written statements received. The NHA explained the Department of Children and Families (DCF) came in later that same morning (6/22/24) as the hospital had contacted them regarding the fracture. The NHA said the management team investigated and determined Resident #3 did not have a fall, therefore they did not file a reportable event. The NHA said the investigation they did, did not indicate how the resident was transferred to the wheelchair. During a follow-up interview on 10/23/24 at 9:38 a.m. with the NHA. The NHA stated he did not know how the fracture occurred, he stated, I went off the DCF investigation. An interview was conducted on 10/22/24 at 5:35 p.m. with Staff M, LPN. Staff M stated being familiar with Resident #3 and recalled the event on 6/22/24. She said upon arrival to the unit on 6/22/24, Resident #3 was up in the wheelchair. Staff M said Resident #3 was usually self-propelling around the unit and talked nonsensically. She said on the morning on 6/22/24 Resident #3 was not self-propelling nor speaking as usual. Staff M said she did not think much of it, she thought maybe Resident #3 was just tired from the night before. She said another nurse came to her and asked if she thought Resident #3 looked funny. She stated, I then noted the angle of Resident #3's leg was not right. Staff M said she went to assess the resident's leg and as soon as she reached for her leg, Resident #3 started screaming. Staff M said the resident answered yes to being in pain when asked. She said Resident #3 was not able to be touched therefore they contacted 911. Staff M said when she was on the phone with 911, the DON told her to cancel the call, because the x-rays could be conducted in the facility. Staff M said she did not cancel the call and when 911 arrived, they had to sedate Resident #3 so she could be moved from the wheelchair to stretcher. An interview was conducted on 10/25/24 at 12:00 p.m. with Staff O, Certified Nursing Assistant (CNA). Staff O said she recalled Resident #3 and the shift when the fracture occurred. She said she worked 6/21/24 for the 3 p.m. to 11 p.m. shift and the 11 p.m. to 7 a.m. shift ending 6/22/24. Staff O said she was not assigned to Resident #3. She said Staff P, CNA asked her to help transfer Resident #3. Staff O explained she overheard Resident #3 scream multiple times during the night, which is normal for her, so she did not think much about it. Staff O said when she entered the room to assist Staff P, Resident #3 screams were different, painful almost. She said she helped Staff P place Resident #3 in the wheelchair. Staff O explained for the transfer of Resident #3, she placed her arm under the resident's, to assist with standing. She said the two CNAs had the resident pivot and they assisted the resident to sit in the wheelchair. Staff O said she does not recall if the resident scream out or just took a deep breath during the transfer, but it was very quick. Staff O said Staff P was rushing and wanted to get off shift. Staff O said typically when Resident #3 was in the wheelchair, she self-propelled throughout the unit but she did not go anywhere. She said she thought Resident #3 was just tired from being up most of the night. Staff O said later that same morning she observed blood on the arm of Resident #3 and informed the nurse. Staff O stated no skin tears occurred during the transfer. Staff O stated no one ever spoke with her regarding the fracture until the next day when the supervisor asked her to write a statement as Resident #3 had a fracture. She stated she did not hear anything else regarding the subject. An interview was conducted on 10/28/24 at 11:38 a.m. with Staff Q, CNA. Staff Q recalled working 6/21/24 on the 11 p.m. to 7 a.m. shift into 6/22/24 and stated Resident #3 was on the morning list to get up early. She said Staff P, CNA was assigned to Resident #3 and would have been the one to transfer the resident. She said she did not recall anyone mentioning anything throughout the shift, it was a normal night until she noticed Resident #3 had blood on her hand and was gripping her hip. Staff Q said she brought this to the attention of Staff M, LPN and Staff G, LPN. She said the nurses commented about the resident's leg looking odd. She said she didn't notice the resident's leg at the time as she was looking at the blood on her hand. She said Staff M, LPN called 911 and while Staff M was on the phone, the DON told her to hang up because we could take care of the resident here. She said the nurse didn't hang up the phone. Staff Q said she was surprised that no one asked her about the incident. An interview was conducted on 10/25/24 at 11:18 a.m. with Staff G, LPN. Staff G confirmed he worked the evening of 6/21/24 into the morning of 6/22/24 and said he was the one that saw Resident #3 sitting in her wheelchair and her leg bent awkwardly. Staff G said he informed Staff M, LPN and told her to look at Resident #3 and Staff M immediately said, Oh her leg is broken. Staff G said they were not able to touch the leg because the resident would scream. Staff G said no one looked into how the fracture occurred. Staff G said they didn't know if Resident #3 fell and just got put back in the wheelchair. He said Resident #3 didn't ever try to walk or get out of bed and to his knowledge had never fallen before. Staff G said management did not know what happened, they got statements from a couple of CNAs then moved Staff P, CNA, who was assigned Resident #3, to a different floor. An interview was conducted on 10/28/24 at 2:35 p.m. with Staff P, CNA. Staff P stated she recalled Resident #3 and worked with on the 11p (6/21/24) to 7a (6/22/24) shift. Staff P said, I don't know anything about a fracture. Staff P said she arrived at the unit and Resident #3 was in the bed sleeping. Staff P said around 2:00 a.m. she completed incontinence care for Resident #3 while the resident slept. Staff P added Resident #3 was a squealing person, Resident #3 squeals all the time. She said Resident #3 was on the get up list so she got Resident #3 dressed and requested assistance from another CNA with the transfer to the wheelchair. Staff P could not recall how the transfer of Resident #3 occurred and denied any knowledge of a fracture or skin tear. Staff P said, If something happened maybe on her [Staff O, CNA]. Staff P, CNA stated, I didn't do anything wrong, DCF and the NHA said so. Staff P then disconnected the phone call. Review of Resident #3's primary care provider (PCP) note, dated 7/1/24, showed Patient was readmitted to [facility] on 06/25/24. Patient was sent to ER for right hip pain that she sustain during a fall per hospital records. Review of Resident #3's Social Service note, dated 7/10/24 showed Resident will be hospice resident as of tomorrow, 7/11/24 . A progress note, dated 7/13/24, showed Resident without vital signs. Family made aware. Hospice was also notified. An interview was conducted on 10/24/24 at 4:37 p.m. with Staff N, (CNA). Staff N said she had taken care of Resident #3 several times and did hear about the fracture. She said she was not working at the time of the incident but heard the CNA tried to transfer Resident #3 and dropped her. Staff N said, Sad, resident was perfectly fine before the fall, when she came back, she just went downhill medically, never the same. An interview was conducted on 10/28/24 at 2:37 p.m. with Resident #3's primary care provider (PCP). He said he remembered the incident with Resident #3 and recalled that Staff H, Nurse Practitioner (NP) was upset neither of them were notified. The PCP reviewed Resident #3's medical records. He said the hospital records showed the resident had a fall and another note said there were no falls. He said, I would assume the facility has protocols in place if a resident had a fracture and they don't know where it came from. He said there should be a protocol and procedure for falls/injuries. An interview was conducted on 10/28/24 at 2:47 p.m. with Staff H, Nurse Practitioner (NP). She said she was a provider for Resident #3. She said she had not been notified when Resident #3 had a fall. She said facility staff should have called when something happened to a resident. She said she did not know until the resident returned from the hospital and she saw the fall in the hospital record. Staff H said the resident was having pain but was stable after she returned. She said, For sure, they should look into that if it is not known where the fracture came. Staff H said the resident's fracture was fixed for comfort, not really to be able to walk on it. 2. Review of the facility's Admission/Discharge To/From Report, dated 7/1/24 to 10/21/24, revealed Resident #8 was discharged to an acute care hospital on 9/23/24. Review of the facility's Incident Log, dated 4/24 to 11/24, revealed Resident #8 had a fall on 9/23/24. Review of a progress note for Resident #8, dated 09/23/24 at 11:35 p.m., by Staff S, LPN showed, This writer noticed other nurses and cna's running down the hall, I went to see what was going on and witnessed other nurses assisting the resident and speaking to keep to keep [sic] him awake. A focus assessment was performed on the resident. Resident Vital signs, kept residents on his Rt [right] side to prevent aspiration, held gauze and applied pressure to eyebrow area. 911 was called and stayed with the patient until EMS [Emergency Management Service] arrived. A message was left with the PCP [Primary Care Provider] answering service. Family was called and voicemail was left, shift supervisor was notified. Review of admission Records showed Resident #8 was admitted on [DATE] with diagnoses including Cerebrovascular Accident (stroke) with right hemiparesis, sepsis, dysphagia, wounds, and other co-morbidities. Review of Resident #8's admission MDS, dated [DATE], showed the resident was dependent with all activities of daily living care (ADL), had impairments in both upper and lower extremities preventing movement, and the resident had not had any falls since admission/entry or reentry prior to assessment. An interview was conducted on 10/23/24 at 3:31 p.m. with Staff S, LPN. Staff S, LPN confirmed working with Resident #8 on 9/23/24 and recalled the incident. Staff S recalled coming out of another resident's room seeing all these employees going to Resident #8's room. Staff S said she immediately followed, as she was the assigned nurse. She said upon arrival, she noted Resident #8 on the floor with blood on his head. Staff S said the CNA responsible for the resident (Staff T, CNA) stated she turned the resident, and he rolled out of the bed. She stated Resident #8 had an air mattress with collapsable sides. Staff S stated she was not sure how this happened as Resident #8 was tall, thin, and did not move. An interview was conducted on 10/23/24 at 5:13 p.m. with Staff T, CNA. Staff T confirmed she cared for Resident #8 on the night of 9/23/24. She said he often had behaviors and yelled. She said she went in and talked to him, and he was calm. She said since the resident was calm, she thought she could clean him up on her own. She said she cleaned up his front and rolled him away from her to clean up his back side. She said the resident was on an air mattress and they are slippery. She said he was not really on a sheet. She said when she rolled him away from her, he slipped off the other side. She said she tried to catch him by his shirt, but he fell off and hit the floor. She said as that happened, she had to let go of his shirt and go search for someone to help. She said she went outside and got the nurse assigned to him. She said she didn't really know his injuries, but he was bleeding, and the nurse started working on him. The CNA said she had previously assisted with Resident #8 being cleaned and changed because he was sometimes combative. She said she was only worried about his behavior and thought since he was calm, she could change him herself. She said the CNAs do not know if a resident is a one-person or a two-person assist because it is not in the computer or on their Kardex. She said they have to go off of personal judgement and it is sometimes passed down from the previous shift's CNA. Staff T explained if shift to shift report was not completed, then you just go off your experience. She said the facility had not done any training on turning/positioning residents before or after the incident with Resident #8. Review of Resident #8's Comprehensive Care Plan, 8/2/24, showed the following: -Focus: Resident needed assistance with activities of daily living because of weakness. The goal showed: I will improve my ability to transfer, dress, toilet, ambulate by next review. The interventions included: Anticipate resident's needs; Assist me with all oral intake of food and fluids; Assist me with hygiene, bathing, dressing, toileting and transfers; Assist me with toileting promptly when requested; Assist with all ADL care to ensure daily needs are met. -Focus: The staff have identified that I am at risk for falls because of these risk factors: Unaware of safety needs. The goal showed: I will have minimized injury due to a fall through next review. The interventions included: Anticipate resident's needs; I should have sneakers, shoes, slippers with rubber soles or non-slip socks when I am out of bed; Keep frequently used items within reach: TV remote, tissues, water glass over bed stand and my water glass (unless I need thickened liquids or can't have anything by mouth); Keep my call light within reach so I can call for assistance; Maintain bed in lowest locked position. -Focus: At times I can agitated, combative, continuous outburst. The goal showed: I will show a decrease in my episodes of being resistant thru next review. The interventions included: Allow choices when able to give resident feeling of control; Converse with during care about topic of interest to redirect; Monitor for effectiveness of medication prescribed to limit behavior; Report to Dr if not effective or behavior continues to decline; Psych eval and follow up per order. An interview was conducted on 10/24/24 at 1:10 p.m. with Staff Z, LPN UM (Unit Manager). Staff Z said residents were evaluated by therapy and those results were sent to the MDS team. She said MDS then enters the information about the functional level of the resident and that populates to the Kardex. She said it usually says dependent or max assist, something like that. She said dependent means two-person assist and maximum assist means 1-2. When asked how the CNAs would know which to use since they cannot assess residents she said, That is all I know about the process. An interview was conducted on 10/25/24 at 12:48 p.m. with Staff Y, CNA. She said the facility had not done any training on turning, positioning, or transferring residents. She said the CNAs do not know if a resident is a one or two-person assist or if they need a lift. She said the CNAs have To figure it out. Interviews were conducted from 10/22/24 to 10/28/24 at various times with the following staff: Staff U, D, W, X, V, N, O, Q, CNA's. During these interviews staff stated the computer system does not indicate specific directions for what level of care (i.e Assist of one, mechanical lift) is needed for residents' ADL needs. The staff stated usually they just know how to care for residents based on our experience. The CNAs said they try to complete shift to shift report to inform other CNAs of care needs, but it does not always happen with staffing patterns and time constraints. An interview was conducted on 10/24/24 at 2:23 p.m. with the MDS Coordinator. She said approximately a year ago, when the Minimum Data Set (MDS) changed from section G to section GG, it quit having an assist of 1 or two option. She stated related to the care plan not indicating a level of assistance needed, That is not a directive I have been given here. She said the CNAs would just know the level of care from passing it down in report. She doesn't know how else they would know. The MDS Coordinator confirmed CNAs cannot assess residents. Review of hospital records for Resident #8, dated 9/24/24, showed the resident presented to the emergency department and underwent a head and maxillofacial CT (computed tomography) scan which revealed an 8 millimeter (mm) subdural hemorrhage layering along the right frontotemporal convexity, with no significant midline shift, interval development of large right frontotemporal infarct is noted compared to February 2022, and possible acute/subacute. The resident was noted to have a right front scalp hematoma which was a laceration, and sutures were applied. Upon arrival the resident was noted to have a forehead laceration with a dressing in place that was blood soaked. The resident was unable to answer questions correctly although he was attempting to. The CT scan results, dated 9/23/24, showed the following: Calvarium/Scalp: large right frontal scalp hematoma calvaria fracture evaluation limited by motion artifact. CT Maxillofacial: comminuted right greater than left nasal bone fractures moderate overlying soft tissue swelling. Review Resident #8's ER record showed the resident received 12 sutures to right eyebrow laceration. Resident #8 was admitted to the ICU (intensive care unit). No other documentation is available at this time. An interview was conducted on 10/23/2024 at 4:10 p.m. with the NHA and DON. The NHA stated the facility was following Resident #8's plan of care with one-person assist. The NHA confirmed the care plan did not have assist requirements as an intervention. The NHA stated, I thought it was there. The NHA stated no investigation was needed. The NHA stated after comparing statements from staff he decided to eventually find the CNA neglected to utilize proper positioning techniques and the facility had no control over this. The NHA stated this was based on the DCF investigation. After the NHA spoke with the investigator, the NHA decided to start a neglect report. The NHA stated the report was filed and the nursing assistant was reported to the board. The NHA and DON stated no other actions needed to be taken. They stated they did not do any in-services, review their policies, or interview other residents. They stated no education was provided to staff post-incident. An interview was conducted on 10/23/24 at 4:38 p.m. with the Director of Rehabilitation (DOR). He said Resident #8 had severe safety awareness concerns and had decreased coordination. He said Resident #8 was totally dependent and in therapy that means they would use two people to assist. He said nursing decides if two people should be used for transfers and care on the unit. He said the Resident #8 had rigid tone so Everything is total dependent, and he needs a lot of help. He said the resident having rigid tone means staff would have to hold him because he cannot hold himself while turning. He said if the resident was being turned, he would need a person on each side of him. The DOR stated, To roll him he still needs a lot of help. He said if the resident didn't have control, it is dangerous for a CNA to roll the resident away from them because they can roll off the bed if no one is on the other side. The DOR said for therapy, Total dependent means max assist; two people and lifts. Review of the facility's Abuse and Neglect Log, dated 4/24 to 10/24, did not reveal any reports after 8/28/24 of any incidents of abuse or neglect. An interview was conducted on 10/22/24 at 10:33 a.m. with the DON. The DON stated she had validated with the NHA, no other reports or allegations of abuse or neglect had been made since 8/28/24. 3. Review of the facility's Admission/Discharge To/From Report, for dates 7/1/2024 to 10/21/24, revealed Resident #12 was discharged to an acute care hospital on 9/26/24. Review of Resident #12's progress notes, dated 9/26/2024 at 3:31 p.m., authored by the DON showed: Resident had a fall blood pressure is 159/86 pulses 85. We're sending her to the hospital. Review of Resident #12's progress notes, dated 9/26/2024 at 3:44 p.m., authored by Staff AA, Registered Nurse (RN) showed: Pt [patient] found on the floor at evacuation site. VSS [Vital Signs Stable]. EMS [Emergency Medical Services] on site. Pt sent to hospital. Family called. Message left. Review of admission Records showed Resident #12 was admitted on [DATE] with diagnoses including hypertension, weakness, dementia, Huntington's disease, and other co-morbidities. Review of Resident #12's admission MDS, dated [DATE], Section C, Cognitive Patterns, revealed a BIMS score of 8, indicated the resident had moderate cognitive impairment, Section J, Health Conditions showed no pain and no falls. Review of Resident #12's Physical Therapy Discharge summary, dated [DATE], showed: Resident #12 was able to perform sitting to standing with the use of an assistive device; was able to transfer with supervision only, and was able to walk 150 feet with a front wheeled walker with contact guard assistance. Review of Resident #12 Comprehensive Care Plan, 7/19/24, shows: -Focus: The staff have identified that I am at risk for falls because of these risk factors: Dementia, use of anti-psychotic medication, use of antidepressant medication. The care plan interventions showed: Anticipate resident's needs; I should have sneakers, shoes, slippers with rubber soles or non-slip socks when I am out of bed; Keep frequently used items within reach: TV remote, tissues, water glass over bed stand and my water glass (unless I need thickened liquids or can't have anything by mouth); Keep my call light within reach so I can call for assistance; Maintain bed in lowest locked position. -Focus: I need assistance with activities of daily living because of weakness. The care plan intervention showed: Anticipate resident's needs; Assist me with all oral intake of food and fluids; Assist me with hygiene, bathing, dressing, toileting and transfers; Assist me with toileting promptly when requested; Assist with all ADL care to ensure daily needs are met. -Focus: The resident has an ADL Self Care Performance Deficit r/t Activity Intolerance, r/t cognitive deficits. The interventions showed: Encourage the resident to participate to the fullest extent possible with each interaction; Encourage the resident to use bell to call for assistance; Anticipate needs not verbalized as resident does not always clearly make needs Nursing known. Keep call bell within reach, encourage use, answer promptly. An interview was conducted on 10/21/2024 at 3:15 p.m. with the NHA and AIT. They stated the facility needed to prepare for evacuation to a church on 9/24/24. The NHA said at the church the County Emergency Management showed up and stated the facility should move their residents to a county shelter. The NHA and AIT stated no one was seriously injured, no one died, and no one eloped. They said there may have been a skin tear. The NHA stated, We did the best we could. The NHA confirmed they did not comple a post-storm assessment, as they did not have time; they needed to get ready for the next storm. An interview was conducted on 10/24/24 at 11:50 a.m. with Staff V, CNA. Staff V sta[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide a hazard free environment and adequate supervision for three residents (#3, #8, and #12) of three reviewed for falls with injuries, resulting in the need for transfer to a higher level of care for evaluation and treatment. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Residents #3, #8, and #12 and resulted in the determination of Immediate Jeopardy on 6/22/24. The findings of Immediate Jeopardy were determined to be removed on 10/28/04 and the severity and scope was reduced to a E. Findings included: 1. Review of Resident #3's progress note, dated 6/22/24 at 9:48 a.m., authored by Staff M, Licensed Practical Nurse (LPN) showed the following: Upon arriving on the unit and doing rounds the resident was observed sitting in wheelchair by resident's room door chanting but not outside of her normal behavior. Another nurse came and informed the nurse that the resident posture was not looking normal and if I would assess her. Upon walking up to the resident, the posture was abnormal, and her leg was twisted. When approaching the resident to touch her she begin screaming. Wheelchair was in locked position. The resident admitted to pain and responded to yes or no type questions. The nurse asked if she was in pain she stated 'yes'. The nurse asked was her leg bothering her and she stated 'yes'. The nurse asked did she fall, and she stated, 'yes'. When asked can the nurse look at her leg she stated, 'no don't'. PRN [as needed] offered to resident for pain but resident was not eating or drinking breakfast tray in front of her. EMS [Emergency Management Services] arrived and took resident to [Hospital Name]. Supervisor notified [family member] of resident's transfer. [Physician] office notified. Review of Resident #3's progress note, dated 6/22/24 at 2:45 p.m., authored by Staff M, LPN showed the following: The nurse spoke with ER [Emergency Room] at [Hospital Name] and was notified that the resident was admitted for UTI [Urinary Tract Infection] and hip fracture. Review of admission Records showed Resident #3 was admitted on [DATE] with diagnoses including pacemaker placement, weakness, low back pain, Alzheimer's disease, and other co-morbidities. Review of Resident #3's Quarterly Minimum Data Set (MDS), dated [DATE], showed the resident required maximum assistance with all ADL care, the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months, and the resident had not had any falls since admission/entry or reentry prior to the assessment. Review of Resident #3's Comprehensive Care Plan, 7/31/23, showed the following: Focus: Resident needed assistance with activities of daily living because of a diagnosis of dementia with memory impairment, pain, and weakness. Goals included: -Caregivers will be able to perform a safe transfer using proper body mechanics with 100% carryover by the next review date. -Resident will perform self-feeding tasks with supervision or touching assistance by next review date. -Staff will help me with all my ADL needs so that I appear neat and tidy with absence of foul body odor through next review. Interventions included: -Anticipate resident's needs. -Assist me with hygiene, bathing, dressing, toileting and transfers. -Assist me with toileting promptly when requested. -Assist with all ADL care to ensure daily needs are met. Check nails, trim and clean on bath day and as necessary. -Encourage/allow me to do as much for self as possible with feeding self, provide assistance with ADLs that I am unable to do for myself as indicated. -Keep call bell within reach and remind/encourage me to use it to call for assistance. -Skin inspections twice a week on shower days and with ADL care: Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Review of the facility's Incident Log, from April 2024 to October 2024, did not reveal any incidents related to Resident #3 suffering an injury of unknown origin. Review of the facility's Abuse and Neglect Log, from April 2024 to October 2024, did not reveal any allegations/incidents of abuse or neglect for Resident #3 had occurred or been reported. Review of Resident #3's progress note, dated 6/22/24 at 3:20 p.m., authored by the Nursing Home Administrator (NHA) showed: Writer spoke to [family member] who stated that she was with [Resident #3] at the hospital and [Resident #3] was admitted with a hip fracture and UTI. I notified [family member] that we were working on the root cause investigation, and she was satisfied and understood. Review of Emergency Department (ED) records for Resident #3, dated 6/22/24, showed per EMS she had a possible trip and fall it was unwitnessed, but she does slip out of her wheelchair multiple times per the facility has a history of hip fracture falls . It showed prior to arrival in the ED the resident had 70 mcg (micrograms) of Fentanyl for pain, and she endorsed pain when pressing on her right hip. The extremities physical assessment showed, no deformity, moderate trauma. Difficult to examine the patient's right leg patient is curled up in bed she usually is in a wheelchair moderately confused and not following direction with palpitation of the patient's right thigh/right hip she does scream in excruciating pain . Review of the hospital History and Physical for Resident #3, dated 6/22/24, showed the resident was brought to the emergency department after she was found on the floor .patient found to have right periprosthetic proximal fracture with significant angulation . Review of the hospital Operative Reports for Resident #3, dated 6/24/24, showed the resident underwent an open reduction and internal fixation of right periprosthetic proximal femur fracture. The surgeon noted, The rationale for surgery would be for palliative measures. I do not anticipate this fracture will heal to the point where she will be more functional than she was before the injury, which was bedbound, wheelchair dependent, non-weight bearing. My hope is that the incision heals, and she does not develop any perioperative complications arising, such as blood clots, infections, wound healing problems, fractures, dislocations, or risks of the medications and anesthesia. Review of Resident #3's progress note, dated 6/24/24 at 3:36 p.m., authored by the Director of Nursing (DON) showed: Investigation and statements stated that fx [fracture] happened during transfer of resident from bed to chair. Resident at no time had a fall. Daughter made aware of findings of investigation. An interview was conducted on 10/22/24 at 4:43 p.m. with the DON and Risk Manager (RM). The DON stated during an investigation it was determined Resident #3's fracture occurred during a transfer. The DON said she had been notified the resident was transferred out with a potential fracture on 6/22/24. She stated an investigation was started to see how the possible fracture happened. She said a report was not filed for abuse or neglect as the fracture occurred during transfer. An interview was conducted on 10/22/24 at 5:08 p.m. with the Nursing Home Administrator (NHA) and the Administrator in Training (AIT). The NHA said he became aware of Resident #3's fracture during a morning meeting on 6/22/24 when a nurse's note was read that stated Resident #3 had a fall. He said the management team reviewed the statements from the staff who worked, and everyone stated there was no fall. He said the management team did not complete interviews, they just read the written statements received. The NHA explained the Department of Children and Families (DCF) came in later that same morning (6/22/24) as the hospital had contacted them regarding the fracture. The NHA said the management team investigated and determined Resident #3 did not have a fall, therefore they did not file a reportable event. The NHA said the investigation they did, did not indicate how the resident was transferred to the wheelchair. During a follow-up interview on 10/23/24 at 9:38 a.m. with the NHA. The NHA stated he did not know how the fracture occurred, he stated, I went off the DCF investigation. An interview was conducted on 10/22/24 at 5:35 p.m. with Staff M, LPN. Staff M stated being familiar with Resident #3 and recalled the event on 6/22/24. She said upon arrival to the unit on 6/22/24, Resident #3 was up in the wheelchair. Staff M said Resident #3 was usually self-propelling around the unit and talked nonsensically. She said on the morning on 6/22/24 Resident #3 was not self-propelling nor speaking as usual. Staff M said she did not think much of it, she thought maybe Resident #3 was just tired from the night before. She said another nurse came to her and asked if she thought Resident #3 looked funny. She stated, I then noted the angle of Resident #3's leg was not right. Staff M said she went to assess the resident's leg and as soon as she reached for her leg, Resident #3 started screaming. Staff M said the resident answered yes to being in pain when asked. She said Resident #3 was not able to be touched therefore they contacted 911. Staff M said when she was on the phone with 911, the DON told her to cancel the call, because the x-rays could be conducted in the facility. Staff M said she did not cancel the call and when 911 arrived, they had to sedate Resident #3 so she could be moved from the wheelchair to stretcher. An interview was conducted on 10/25/24 at 12:00 p.m. with Staff O, Certified Nursing Assistant (CNA). Staff O said she recalled Resident #3 and the shift when the fracture occurred. She said she worked 6/21/24 for the 3 p.m. to 11 p.m. shift and the 11 p.m. to 7 a.m. shift ending 6/22/24. Staff O said she was not assigned to Resident #3. She said Staff P, CNA asked her to help transfer Resident #3. Staff O explained she overheard Resident #3 scream multiple times during the night, which is normal for her, so she did not think much about it. Staff O said when she entered the room to assist Staff P, Resident #3 screams were different, painful almost. She said she helped Staff P place Resident #3 in the wheelchair. Staff O explained for the transfer of Resident #3, she placed her arm under the resident's, to assist with standing. She said the two CNAs had the resident pivot and they assisted the resident to sit in the wheelchair. Staff O said she does not recall if the resident scream out or just took a deep breath during the transfer, but it was very quick. Staff O said Staff P was rushing and wanted to get off shift. Staff O said typically when Resident #3 was in the wheelchair, she self-propelled throughout the unit but she did not go anywhere. She said she thought Resident #3 was just tired from being up most of the night. Staff O said later that same morning she observed blood on the arm of Resident #3 and informed the nurse. Staff O stated no skin tears occurred during the transfer. Staff O stated no one ever spoke with her regarding the fracture until the next day when the supervisor asked her to write a statement as Resident #3 had a fracture. She stated she did not hear anything else regarding the subject. An interview was conducted on 10/28/24 at 11:38 a.m. with Staff Q, CNA. Staff Q recalled working 6/21/24 on the 11 p.m. to 7 a.m. shift into 6/22/24 and stated Resident #3 was on the morning list to get up early. She said Staff P, CNA was assigned to Resident #3 and would have been the one to transfer the resident. She said she did not recall anyone mentioning anything throughout the shift, it was a normal night until she noticed Resident #3 had blood on her hand and was gripping her hip. Staff Q said she brought this to the attention of Staff M, LPN and Staff G, LPN. She said the nurses commented about the resident's leg looking odd. She said she didn't notice the resident's leg at the time as she was looking at the blood on her hand. She said Staff M, LPN called 911 and while Staff M was on the phone, the DON told her to hang up because we could take care of the resident here. She said the nurse didn't hang up the phone. Staff Q said she was surprised that no one asked her about the incident. An interview was conducted on 10/25/24 at 11:18 a.m. with Staff G, LPN. Staff G confirmed he worked the evening of 6/21/24 into the morning of 6/22/24 and said he was the one that saw Resident #3 sitting in her wheelchair and her leg bent awkwardly. Staff G said he informed Staff M, LPN and told her to look at Resident #3 and Staff M immediately said, Oh her leg is broken. Staff G said they were not able to touch the leg because the resident would scream. Staff G said no one looked into how the fracture occurred. Staff G said they didn't know if Resident #3 fell and just got put back in the wheelchair. He said Resident #3 didn't ever try to walk or get out of bed and to his knowledge had never fallen before. Staff G said management did not know what happened, they got statements from a couple of CNAs then moved Staff P, CNA, who was assigned Resident #3, to a different floor. Staff G said, there were Many incidences of neglect that could have been prevented. He said, It is my belief she died from it, speaking of Resident #3's hip fracture. Review of the facility's staff roster did not list Staff R, LPN. The AIT stated Staff R, LPN is no longer employed at the facility but gave the last known phone number. On 10/24/24 at 4:00 p.m. the number was called, and a message was heard stating the number had been disconnected. An interview was conducted on 10/28/24 at 2:35 p.m. with Staff P, CNA. Staff P stated she recalled Resident #3 and worked with on the 11p (6/21/24) to 7a (6/22/24) shift. Staff P said, I don't know anything about a fracture. Staff P said she arrived at the unit and Resident #3 was in the bed sleeping. Staff P said around 2:00 a.m. she completed incontinence care for Resident #3 while the resident slept. Staff P added Resident #3 was a squealing person, Resident #3 squeals all the time. She said Resident #3 was on the get up list so she got Resident #3 dressed and requested assistance from another CNA with the transfer to the wheelchair. Staff P could not recall how the transfer of Resident #3 occurred and denied any knowledge of a fracture or skin tear. Staff P said, If something happened maybe on her [Staff O, CNA]. Staff P, CNA stated, I didn't do anything wrong, DCF and the NHA said so. Staff P then disconnected the phone call. Review of Resident #3's primary care provider (PCP) note, dated 7/1/24, showed Patient was readmitted to [facility] on 06/25/24. Patient was sent to ER for right hip pain that she sustain during a fall per hospital records. Review of Resident #3's Social Service note, dated 7/10/24 showed Resident will be hospice resident as of tomorrow, 7/11/24 . A progress note, dated 7/13/24, showed Resident without vital signs. Family made aware. Hospice was also notified. An interview was conducted on 10/24/24 at 4:37 p.m. with Staff N, (CNA). Staff N said she had taken care of Resident #3 several times and did hear about the fracture. She said she was not working at the time of the incident but heard the CNA tried to transfer Resident #3 and dropped her. Staff N said, Sad, resident was perfectly fine before the fall, when she came back, she just went downhill medically, never the same. An interview was conducted on 10/28/24 at 2:37 p.m. with Resident #3's primary care provider (PCP). He said he remembered the incident with Resident #3 and recalled that Staff H, Nurse Practitioner (NP) was upset neither of them were notified. The PCP reviewed Resident #3's medical records. He said the hospital records showed the resident had a fall and another note said there were no falls. He said, I would assume the facility has protocols in place if a resident had a fracture and they don't know where it came from. He said there should be a protocol and procedure for falls/injuries. An interview was conducted on 10/28/24 at 2:47 p.m. with Staff H, Nurse Practitioner (NP). She said she was a provider for Resident #3. She said she had not been notified when Resident #3 had a fall. She said facility staff should have called when something happened to a resident. She said she did not know until the resident returned from the hospital and she saw the fall in the hospital record. Staff H said the resident was having pain but was stable after she returned. She said, For sure, they should look into that if it is not known where the fracture came. Staff H said the resident's fracture was fixed for comfort, not really to be able to walk on it. 2. Review of the facility's Admission/Discharge To/From Report, dated 7/1/24 to 10/21/24, revealed Resident #8 was discharged to an acute care hospital on 9/23/24. Review of the facility's Incident Log, dated 4/24 to 11/24, revealed Resident #8 had a fall on 9/23/24. Review of a progress note for Resident #8, dated 09/23/24 at 11:35 p.m., by Staff S, LPN showed, This writer noticed other nurses and cna's running down the hall, I went to see what was going on and witnessed other nurses assisting the resident and speaking to keep to keep [sic] him awake. A focus assessment was performed on the resident. Resident Vital signs, kept residents on his Rt [right] side to prevent aspiration, held gauze and applied pressure to eyebrow area. 911 was called and stayed with the patient until EMS [Emergency Management Service] arrived. A message was left with the PCP [Primary Care Provider] answering service. Family was called and voicemail was left, shift supervisor was notified. Review of admission Records showed Resident #8 was admitted on [DATE] with diagnoses including Cerebrovascular Accident (stroke) with right hemiparesis, sepsis, dysphagia, wounds, and other co-morbidities. Review of Resident #8's admission MDS, dated [DATE], showed the resident was dependent with all activities of daily living care (ADL), had impairments in both upper and lower extremities preventing movement, and the resident had not had any falls since admission/entry or reentry prior to assessment. An interview was conducted on 10/23/24 at 3:31 p.m. with Staff S, LPN. Staff S, LPN confirmed working with Resident #8 on 9/23/24 and recalled the incident. Staff S recalled coming out of another resident's room seeing all these employees going to Resident #8's room. Staff S said she immediately followed, as she was the assigned nurse. She said upon arrival, she noted Resident #8 on the floor with blood on his head. Staff S said the CNA responsible for the resident (Staff T, CNA) stated she turned the resident, and he rolled out of the bed. She stated Resident #8 had an air mattress with collapsable sides. Staff S stated she was not sure how this happened as Resident #8 was tall, thin, and did not move. An interview was conducted on 10/23/24 at 5:13 p.m. with Staff T, CNA. Staff T confirmed she cared for Resident #8 on the night of 9/23/24. She said he often had behaviors and yelled. She said she went in and talked to him, and he was calm. She said since the resident was calm, she thought she could clean him up on her own. She said she cleaned up his front and rolled him away from her to clean up his back side. She said the resident was on an air mattress and they are slippery. She said he was not really on a sheet. She said when she rolled him away from her, he slipped off the other side. She said she tried to catch him by his shirt, but he fell off and hit the floor. She said as that happened, she had to let go of his shirt and go search for someone to help. She said she went outside and got the nurse assigned to him. She said she didn't really know his injuries, but he was bleeding, and the nurse started working on him. The CNA said she had previously assisted with Resident #8 being cleaned and changed because he was sometimes combative. She said she was only worried about his behavior and thought since he was calm, she could change him herself. She said the CNAs do not know if a resident is a one-person or a two-person assist because it is not in the computer or on their Kardex. She said they have to go off of personal judgement and it is sometimes passed down from the previous shift's CNA. Staff T explained if shift to shift report was not completed, then you just go off your experience. She said the facility had not done any training on turning/positioning residents before or after the incident with Resident #8. Review of Resident #8's Comprehensive Care Plan, 8/2/24, showed the following: -Focus: Resident needed assistance with activities of daily living because of weakness. The goal showed: I will improve my ability to transfer, dress, toilet, ambulate by next review. The interventions included: Anticipate resident's needs; Assist me with all oral intake of food and fluids; Assist me with hygiene, bathing, dressing, toileting and transfers; Assist me with toileting promptly when requested; Assist with all ADL care to ensure daily needs are met. -Focus: The staff have identified that I am at risk for falls because of these risk factors: Unaware of safety needs. The goal showed: I will have minimized injury due to a fall through next review. The interventions included: Anticipate resident's needs; I should have sneakers, shoes, slippers with rubber soles or non-slip socks when I am out of bed; Keep frequently used items within reach: TV remote, tissues, water glass over bed stand and my water glass (unless I need thickened liquids or can't have anything by mouth); Keep my call light within reach so I can call for assistance; Maintain bed in lowest locked position. -Focus: At times I can agitated, combative, continuous outburst. The goal showed: I will show a decrease in my episodes of being resistant thru next review. The interventions included: Allow choices when able to give resident feeling of control; Converse with during care about topic of interest to redirect; Monitor for effectiveness of medication prescribed to limit behavior; Report to Dr if not effective or behavior continues to decline; Psych eval and follow up per order. An interview was conducted on 10/24/24 at 1:10 p.m. with Staff Z, LPN UM (Unit Manager). Staff Z said residents were evaluated by therapy and those results were sent to the MDS team. She said MDS then enters the information about the functional level of the resident and that populates to the Kardex. She said it usually says dependent or max assist, something like that. She said dependent means two-person assist and maximum assist means 1-2. When asked how the CNAs would know which to use since they cannot assess residents she said, That is all I know about the process. An interview was conducted on 10/25/24 at 12:48 p.m. with Staff Y, CNA. She said the facility had not done any training on turning, positioning, or transferring residents. She said the CNAs do not know if a resident is a one or two-person assist or if they need a lift. She said the CNAs have To figure it out. Interviews were conducted from 10/22/24 to 10/28/24 at various times with the following staff: Staff U, D, W, X, V, N, O, Q, CNA's. During these interviews staff stated the computer system does not indicate specific directions for what level of care (i.e Assist of one, mechanical lift) is needed for residents' ADL needs. The staff stated usually they just know how to care for residents based on our experience. The CNAs said they try to complete shift to shift report to inform other CNAs of care needs, but it does not always happen with staffing patterns and time constraints. An interview was conducted on 10/24/24 at 2:23 p.m. with the MDS Coordinator. She said approximately a year ago, when the MDS changed from section G to section GG, it quit having an assist of 1 or two option. She stated related to the care plan not indicating a level of assistance needed, That is not a directive I have been given here. She said the CNAs would just know the level of care from passing it down in report. She doesn't know how else they would know. The MDS Coordinator confirmed CNAs cannot assess residents. Review of hospital records for Resident #8, dated 9/24/24, showed the resident presented to the emergency department and underwent a head and maxillofacial CT (computed tomography) scan which revealed an 8 millimeter (mm) subdural hemorrhage layering along the right frontotemporal convexity, with no significant midline shift, interval development of large right frontotemporal infarct is noted compared to February 2022, and possible acute/subacute. The resident was also noted to have a right front scalp hematoma which was a laceration, and sutures were applied. Upon arrival the resident was noted to have a forehead laceration with a dressing in place that was blood soaked. The resident was unable to answer questions correctly although he was attempting to. The CT scan results, dated 9/23/24, showed the following: Calvarium/Scalp: large right frontal scalp hematoma calvaria fracture evaluation limited by motion artifact. CT Maxillofacial: comminuted right greater than left nasal bone fractures moderate overlying soft tissue swelling. Review Resident #8's ER record showed the resident received 12 sutures to right eyebrow laceration. Resident #8 was admitted to the ICU (intensive care unit). No other documentation is available at this time. An interview was conducted on 10/23/2024 at 4:10 p.m. with the NHA and DON. The NHA stated the facility was following Resident #8's plan of care with one-person assist. The NHA confirmed the care plan did not have assist requirements as an intervention. The NHA stated, I thought it was there. The NHA stated no investigation was needed. The NHA stated after comparing statements from staff he decided to eventually find the CNA neglected to utilize proper positioning techniques and the facility had no control over this. The NHA stated this was based on the DCF investigation. After the NHA spoke with the investigator, the NHA decided to start a neglect report. The NHA stated the report was filed and the nursing assistant was reported to the board. The NHA and DON stated no other actions needed to be taken. They stated they did not do any in-services, review their policies, or interview other residents. They stated no education was provided to staff post-incident. An interview was conducted on 10/23/24 at 4:38 p.m. with the Director of Rehabilitation (DOR). He said Resident #8 had severe safety awareness concerns and had decreased coordination. He said Resident #8 was totally dependent and in therapy that means they would use two people to assist. He said nursing decides if two people should be used for transfers and care on the unit. He said the Resident #8 had rigid tone so Everything is total dependent, and he needs a lot of help. He said the resident having rigid tone means staff would have to hold him because he cannot hold himself while turning. He said if the resident was being turned, he would need a person on each side of him. The DOR stated, To roll him he still needs a lot of help. He said if the resident didn't have control, it is dangerous for a CNA to roll the resident away from them because they can roll off the bed if no one is on the other side. The DOR said for therapy, Total dependent means max assist; two people and lifts. Review of the facility's Abuse and Neglect Log, dated 4/24 to 10/24, did not reveal any reports after 8/28/24 of any incidents of abuse or neglect. An interview was conducted on 10/22/24 at 10:33 a.m. with the DON. The DON stated she had validated with the NHA, no other reports or allegations of abuse or neglect had been made since 8/28/24. 3. Review of the facility's Admission/Discharge To/From Report, for dates 7/1/2024 to 10/21/24, revealed Resident #12 was discharged to an acute care hospital on 9/26/24. Review of Resident #12's progress notes, dated 9/26/2024 at 3:31 p.m., authored by the DON showed: Resident had a fall blood pressure is 159/86 pulses 85. We're sending her to the hospital. Review of Resident #12's progress notes, dated 9/26/2024 at 3:44 p.m., authored by Staff AA, Registered Nurse (RN) showed: Pt [patient] found on the floor at evacuation site. VSS [Vital Signs Stable]. EMS [Emergency Medical Services] on site. Pt sent to hospital. Family called. Message left. Review of admission Records showed Resident #12 was admitted on [DATE] with diagnoses including hypertension, weakness, dementia, Huntington's disease, and other co-morbidities. Review of Resident #12's admission MDS, dated [DATE], Section C, Cognitive Patterns, revealed a BIMS score of 8, indicated the resident had moderate cognitive impairment, Section J, Health Conditions showed no pain and no falls. Review of Resident #12's Physical Therapy Discharge summary, dated [DATE], showed: Resident #12 was able to perform sitting to standing with the use of an assistive device; was able to transfer with supervision only, and was able to walk 150 feet with a front wheeled walker with contact guard assistance. Review of Resident #12 Comprehensive Care Plan, 7/19/24, shows: -Focus: The staff have identified that I am at risk for falls because of these risk factors: Dementia, use of anti-psychotic medication, use of antidepressant medication. The care plan interventions showed: Anticipate resident's needs; I should have sneakers, shoes, slippers with rubber soles or non-slip socks when I am out of bed; Keep frequently used items within reach: TV remote, tissues, water glass over bed stand and my water glass (unless I need thickened liquids or can't have anything by mouth); Keep my call light within reach so I can call for assistance; Maintain bed in lowest locked position. -Focus: I need assistance with activities of daily living because of weakness. The care plan intervention showed: Anticipate resident's needs; Assist me with all oral intake of food and fluids; Assist me with hygiene, bathing, dressing, toileting and transfers; Assist me with toileting promptly when requested; Assist with all ADL care to ensure daily needs are met. -Focus: The resident has an ADL Self Care Performance Deficit r/t Activity Intolerance, r/t cognitive deficits. The interventions showed: Encourage the resident to participate to the fullest extent possible with each interaction; Encourage the resident to use bell to call for assistance; Anticipate needs not verbalized as resident does not always clearly make needs Nursing known. Keep call bell within reach, encourage use, answer promptly. An interview was conducted on 10/21/2024 at 3:15 p.m. with the NHA and AIT. They stated the facility needed to prepare for evacuation to a church on 9/24/24. The NHA said at the church the County Emergency Management showed up and stated the facility should move their residents to a county shelter. The NHA and AIT stated no one was seriously injured, no one died, and no one eloped. They said there may have been a skin tear. The NHA stated, We did the best we could. The NHA confirmed they did not compile a post-storm assessment, as they did not have time; they needed to get ready for the next storm. An interview was conducted on 10/24/24 at 11:50 a.m. with Staff V, CNA. Staff V stated, During the evacuation things happened. Staff V stated, Yes there was a fall. I was in the gym where [Resident #12] was assigned. The management did not leave out assignments for CNAs, so I am not sure who was responsible for [Resident #12]. Staff V said, I was in a doorway and heard a loud thud. I turned and noted [Resident #12[ on the floor, it looked bad, no one was near. [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, facility policies, interviews with facility staff, the resident's physician, Medical Director and family members, the facility failed to provide supervision, education and corrective action in response to incidents in order to prevent falls with injury for 1 resident (#3 ) out of 12 residents sampled for falls. Resident #3 was a long-term nursing care resident who was at risk for falls admitted to the facility on [DATE] and discharged on 2/14/23 to an acute care hospital for a fall with injury. On 2/14/23 at 1:45 pm a Certified Nursing Assistant (CNA) did not follow facility policy and independently used the sit to stand lift for Resident #3. The CNA did not use the appropriate size waist belt during the transfer even after Resident #3, who was assessed to have no cognitive deficits, told the CNA she was using the incorrect sling [waist belt] and that the blue sling was the right one for her not the red one. The CNA continued to use the wrong supportive waist belt and continued to use the sit to stand lift independently which resulted in Resident #3 sustaining a fracture of both bones of the lower leg which required surgical repairment. Resident #3 suffered multiple complications after the surgery, required intensive care and remained hospitalized on [DATE]. The facility was unable to provide documentation of the CNA's training on the lift during orientation. The facility's response to the incident did not address communicating individual resident sling size with staff. Additionally, based on observation, interview and record review the facility failed to provide supervision to prevent multiple falls in the facility's secured unit. A review of the facility's incident list revealed on 2/25/23, 2/26/23 and 2/27/23, 16 falls occurred in the facility. Ten of the 16 falls were unwitnessed and occurred on the secured unit to Residents #8, #9, #19, #11, #12, #13, #14, #15, #16 and #17. The residents who resided on the secured unit due to severe cognitive impairment, were observed unattended in the common area or with limited supervision on 4 of 4 days of the survey, (2/27/23, 2/28/23, 3/01/23 and 3/02/23). This placed them at risk for falls, accidents, and potentially injurious interactions between residents. The actual serious physical harm to Resident #3, likelihood of death to Resident #3, likelihood of serious harm to residents who require mechanical lifts, and very likely risk of serious harm, injury or death from a fall to the facility's residents who are at risk for falls resulted in the finding of on-going immediate jeopardy starting on 2/14/23. Findings included: An interview was conducted on 2/27/23 at 5:31 p.m. with Staff Q, Registered Nurse (RN) who said . [Resident #3] room was in a quad room [four person room, with 2 residents on the left side of an entrance hallway and 2 residents on the right side of an entrance hallway], and I was in one of the rooms taking care of another resident when I heard the resident yelling my leg! my leg! my leg! The CNA [Staff P, CNA] was also screaming [Staff Q, RN]! [Staff Q, RN]! Come help! The resident was in the hallway of the quad, I think [Staff P, CNA] was trying to transfer her to the bathroom, the bathroom is also in the hallway of the quad, I heard her screaming and I came out saw the resident and yelled for help because she was about to hit the floor, she was suspended on the lift. Her left leg was out past the foot plate towards the shift bar of the mechanical lift. The resident was in the strap that goes on like a belt around her waist and the straps were still hooked onto the sit to stand machine. Her two arms were still holding on to the handles of the machine. Both sides of the belt straps were still attached to the sit to stand. Her right leg was on the foot plate. She was slipping off of the belt I don't know if it was tight enough or what but she never touched the ground at this point. I think when [Staff P, CNA] noticed [Resident #3] was going to hit the ground that's when she started to call out. The hallway door was closed, I opened it and called out for help. The CNA was not touching the resident, the CNA was holding onto the remote of the machine with one hand and reaching for the wheelchair with the other and telling me to get the wheelchair to put the resident back into the wheelchair but I told her the resident was too low to put her back into her chair we need to lower her to the ground so I got behind the resident and supported her head and guided her to the floor and the CNA pressed the remote to lower the sit to stand which lowers the resident. We lowered the resident completely to the ground, the CNA removed the lift from the area and that's when I noticed her leg is facing an asymmetrical position and now, she was yelling, and the pain is too much and at that point 911 was called. Because of the pain, we couldn't touch her, and other people came to help, and we put pillows under her head and stayed with her until the paramedics came. I did not see the sit to stand on the resident. I don't think it fell on her, It is a very heavy machine and I don't think if it fell on the resident the CNA would not have been able to pick it up and get the resident back into the position I found her in. It's just my opinion but what I think might have happened was her leg got caught under the foot plate and when she was lifted up it could have broke but like I said that is just my opinion because her break was just above her ankle. But that is why we are supposed to have 2 people when they use the mechanical lifts, one to operate it and one to guide the resident. The CNA did not do that, that day. I don't know why she didn't use two people. She floats around all the units but she has worked with this resident before so she cannot say she doesn't know how she was supposed to be transferred. The CNA told me she was taking the resident to the bathroom. The resident did have a brief on, but she told me she was taking her to the toilet. And usually that's what they do when they take someone to the toilet they transfer them from the wheelchair onto the sit to stand with two people, wheel them into the bathroom, one person pulls down their clothes and the other lowers them onto the toilet while the other person guides them onto the toilet, the resident uses the bathroom, the staff member cleans them up, puts their clothes back up and then they wheel the resident back to the wheelchair and lowers them back onto the wheelchair. The resident never comes off of the lift they are strapped to it the entire time. The resident did not have a strap around her legs to stabilize her legs against the padded cushion of the sit to stand, no A phone interview was conducted on 2/28/23 at 2:11 p.m. with Staff P, CNA, who operated the mechanical lift at the time of Resident #3's fall. She stated I know when I wrote my initial letter about [Resident #3] I was emotional and all over the place. But, when I put her in the machine and we went up she kind of slipped, she did not hit the floor and once the nurse came, she told me to put her on the floor. My first instinct was to not let her touch the floor. I just didn't want her to touch the floor at all. I was holding the resident on her side she was still attached to the machine and then [Staff Q, RN] said let's put her on the floor [Staff Q, RN] said we aren't getting her back onto the wheelchair so I took the controller and lowered her down with the machine as low as it possibly could, unhooked her and we lowered her to the floor. The belt was Velcro'd on pretty decently .I was never told there was different sizes or different colored slings and belts .That day I was just getting off my 30-minute break and [Staff Q, RN] was saying my lights were on and people were waiting for me to take them to the restroom . so I was trying to prioritize who I saw first. I had one person in bed with a call light on, I had one person who was continent and then [Resident #3]. I went and saw the resident who was in their bed, they told me that they had already been helped so I turned off their light and then I heard the two women arguing about who has been waiting longer to go to the bathroom. [Resident #3] had her wipes and her brief in her lap and the other resident had her towels and I knew she was continent and she said she had been holding it for 30 minutes, so I put her on the sit-to-stand lift and took her to the bathroom, I came back out and put her back in her chair. Then I was going to take [Resident #3] to the bathroom and she had already soiled herself and as I was strapping her waist belt on and hooking her onto the machine, just as I did earlier that morning when I got her out of bed, I was talking to her apologizing to her for her wait and telling her I understand her frustration I didn't mean to frustrate her because when I was taking the other lady to the bathroom I could hear her arguing, well not arguing she was just expressing how she felt. But I don't want to use me talking to her as an excuse that I was distracted. As I was strapping the belt on her she was trying to strap it on herself, and she was trying to tell me how other people do it and I told her that I'm not the other CNA's I feel more comfortable doing it my way and then I told her I am going to lift you up and as I was lifting her up I was explaining to her you're wet let me take you to your room to change you and she said she said no I want to get changed right here and then everything happened so fast the resident was slipping, I grabbed her because I didn't want her to hit the floor, I called out for [Staff Q, RN] and [Staff Q, RN] came and that's when we lowered her to the floor. When I got back from break there was no one on the floor, everyone was doing their own thing except [Staff Q, RN] because she was the one who told me about my lights. I did not have another staff member right there with me because everyone was doing their own thing and when I got off break there was no one in the hallways and I just felt this sense of urgency because people needed to use the toilet and people are yelling at each other and I just wanted to help the residents. I did not have two people with me either time I used the sit to stand for both of them. So, the way the room worked is there is a door off the hallway and then there is a bathroom in the corridor of the hallway and 4 rooms that branch off that corridor; I was in the corridor with [Resident #3] and the other lady that is in one of the other rooms in [Resident #3's] hallway. [Staff Q, RN] was in one of the other residents' rooms in that hallway, but she was not right next to me when I used the lift. I had worked there for about 2 months before this happened . Review of Resident #3's admission record revealed she was an [AGE] year-old female resident admitted to the facility on [DATE] from an acute care hospital and discharged on 2/14/23 back to an acute care hospital. Resident #3 had diagnoses that included congestive heart failure, muscle weakness, dysphagia, type 2 diabetes with chronic kidney disease, type 2 diabetes with diabetic peripheral angiopathy without gangrene, diabetic neuropathy, dementia, pulmonary hypertension, anemia, hyperlipidemia, atherosclerosis, bipolar disorder current episode hypomanic, disorder of bone density and structure of right lower leg, primary osteoarthritis left hip and right knee, sciatica left side, localized edema, chronic kidney disease stage 3A, age related osteoporosis without current pathological fracture, generalized anxiety disorder, nonrheumatic mitral valve insufficiency, atrial fibrillation, other specified disorders of bone density and structure of the left forearm, pharyngoesophageal phase and vitreous degeneration, bilaterally. Review of Resident #3's progress note dated 2/14/23 at 13:45 p.m. revealed Resident had a fall incident. 2/14/23 1:45 PM resident is alert and oriented. Resident was Transferring at time of incident. Pain is noted. Resident sent to emergency room for evaluation. Neuro Checks immediate after. Physician notified Responsible party notified. Guardian Notified. Supervisor notified. Review of Resident #3's quarterly minimal data set (MDS) dated [DATE] section C, cognitive patterns, revealed she had a brief interview for mental status (BIMS) score of 15 out of 15 indicating no cognitive deficits. Section G, functional status, revealed Resident #3 had impairment on both sides of her lower extremities. For transfers Resident #3 required extensive assistance with two plus person's physical assist. Toilet use revealed Resident #3 required extensive assistance with two plus person's physical assist. Section H, bowel and bladder, revealed Resident #3 was frequently incontinent of bowel and bladder. Review of Resident #3's Task List Report revealed a task with an initiated date of 4/21/2022 and a resolved/cancelled date of 2/14/2023. The position(s) indicated the task was for Certified Nursing Aide. to Transfers: Sit to stand lift, Assist x2 [times 2] Everyday. Qshift [every shift]: Day (7-3), Night (11-7), Evening (3-11). Everyday, Qshift Night (7-7). Further review of February's task documentation revealed Staff P, CNA signed off Transfers: Sit to Stand lift, assist X2 on 2/14/23 at 8:59 a.m. Review of Resident #3's care plan initiated on 2/14/2019 revealed a focus of The staff have identified that I am at risk for falls because of these risk factors: weakness, impaired mobility, dementia, History of falls, Incontinence, use of opioid medication, dizziness, DM [diabetes mellitus] with neuropathy; Dx [diagnosis] of Osteoporosis with increased risk for pathological fractures. The goal revealed I will be free of major injury due to a fall through next review. Interventions included but are not limited to, .I will notify staff my need for assistance when I have a bowel or bladder accident. Toilet me upon rising before and after meals at hs [hours of sleep] and when needed . Assist of 2 staff with transfers using sit-to-stand lift. Further care plan review revealed a care plan with an initiated date of 2/14/2019 revealed a focus of I need assistance with activities of daily living because of muscle weakness, pain, dizziness, impaired mobility. The goal revealed I like to maintain a neat and tidy appearance. Staff will assist as needed to help maintain that goal through next review. Interventions included but are not limited to, 2 female staff to be present when caring for resident Assist of 2 staff using sit-to-stand for transfers . Review of Resident #3's Clinical Physician Orders revealed a physician's order with a start date of 2/14/2023 TRANSFER TO ER [EMERGENCY ROOM] HOSPITAL FOE [sic] EVALUATION AND TREATMENT FOR POSSIBLE TIBIA FRACTURE OF THE LEFT LEG. Review of Resident #3's Change in Condition Evaluation with an effective date of 2/14/23 at 1:45 p.m. revealed 1. The change in condition, symptoms or signs I am calling about is/are: Falls 2. This started on: 2/14/23 3. What time of day did this start: Afternoon 1. The resident is in the nursing home for: Long Term Care .4. Is the resident on warfarin/coumadin? No 4c. is the resident on another anticoagulant drug? (e.g. Aspirin, Plavix, Dabigatran, Rivaroxaban, Apixaban) Yes .Skin Evaluation 16. describe skin changes: No changes observed 16n. document location and details: Site: Left lower leg (front) Description: possible tibia fracture . Pain Evaluation 17. Is the resident cognitively able to rate their pain scale? Yes 17a. Rate pain on a scale of 0 to 10 (0=no pain, 4-5=moderate pain, 10=excruciating pain): 10 17b. Is the pain: acute 17c. Pain location: Musculoskeletal pain 17h. Describe musculoskeletal pain: Marked localized bruising, swelling, or pain over joint or bone, with or without recent fall. 17k. Specify exact location of pain: Site: Left lower leg (front) Description: possible tibia fracture .20. Since the change in condition occurred have the symptoms or sign gotten: Worse 21. Things that make the condition or symptoms worse are: activity 22. Things that make the condition of symptoms better are: pain medication .25. Summarize your observations and evaluation: Transfer to ER Hospital for treatment .2. Reported to primary care clinician: [Resident #3's physician] 3. Date and time of clinician notification: 2/14/23 2:08 p.m. 4. Orders obtained from the clinician: Other 4a. Specify other: Transfer to ER Hospital. 5. Name of Family/healthcare agent notified: [Resident #3's family member] 6. Date and time of family notification: 2/14/23 2:06 p.m. A phone interview was conducted on 2/27/23 at 3:13 p.m. with Resident #3's family member, she said It wasn't a fall it was a drop; my mother was in her room she needed a diaper change so she could go to activities this is a routine for her, she required a sit to stand, the CNA wheeled her out of the room into the hallway to change her diaper. I spoke to some of the nurses and that is supposably their new way of doing diaper changes is out in the hall. The CNA gets my mother, wheels her into the hallway, my mother tells her that's the wrong strap to the machine, the CNA said don't worry about it it'll be fine. My mother said no I am worried about it, that's the wrong strap. The CNA said it'll be fine and proceeded to use the strap and lift my mother up using the machine, The strap breaks, my mother falls to the floor, the machine flipped in the air and hit my mother's leg breaking her leg in two places. The ambulance was called this all happened on 2/14/23. She is still in the hospital. She is not doing good because of her other problems which they warned us about an [AGE] year-old women needing surgery is a risk. And every problem they warned us about she had. Her heart stopped twice, they had her on a respirator then they took her off the respirator and now she's on oxygen. Her Blood pressure tanked to 58/30, Her kidney's stops working no urine output at all. Her A-fib [Atrial Fibrillation] starts acting up. I'm in the ICU [intensive care unit] with her on 2/16/23 and she starts bleeding internally. They could not get her into surgery, they had to come to her. A tube went down her throat and into her stomach. Then she's back on the respirator and then taken off the respirator for the second time and back on oxygen. Then she got a tube through her nose down into her stomach for 5 days. Then that came out on Saturday. They did surgery on her leg, there was 2 breaks, she now has rods, screws all inserted in her leg permanently. My mother told me this whole story when I came to the hospital in between all her screaming because of the pain she was in. She told the same story to all the doctors and paramedics. The paramedics found her with the machine on her in the hallway, they even came back to the hospital to see my mom because they said it was such a horrific accident. When the administrator called me about what happened she said I feel so bad your mom was like my mom and I said to her well my mom did not give birth to you so yeah. A CNA is a Certified Nurse assistance that is someone who is trained on how to use these machines. The Sunday prior to the accident my brother was visiting my mom and the CNA said she does not know how to use the machine my brother asked her how is it you don't know how to work the machine and she said I don't know how to work it. My mother said here I will show you. [The NHA] said she was currently in the process training the staff on how to use the machine. I said what do you mean you are training them now. They are supposed to have training on this before they even get hired and she's telling me they are using real life people as practice dummies. The Director told me I understand you are very upset, and I want to assure you that the staff are being trained but they should already be trained she shouldn't just now be training them. Since then, the director called me back saying they have suspended her [Staff P, CNA] pending investigation and then they called me again and have since fired her and reported her licenses. A phone interview was conducted on 3/1/23 at 3:31 p.m. with Resident #3's physician. She stated I am very familiar with [Resident #3] I have worked with her for the last 3 years. I was immediately notified about the fall from someone, I'm not sure who called me, but I was notified that she had fallen, and it was suspected that her leg was broken. She was in a lot of pain, and I believe we had her sent out versus us getting X-rays. The hospitalist [hospital physician] will call me once the resident is done with their hospital stay to give an update, but I have not talked to anyone from the hospital. But middle to end of last week my Nurse Practitioner talked to someone and let me know that she {Resident #3] was not doing well, she had a really bad fracture and was having complications. The resident has severe lumbosacral disease which leaves her unable to use her legs which could lead to brittle bones, but I don't think we have any sort of osteoporosis on her. My understanding is that the resident had a fall from the lift, and the lift fell on the resident. I also heard another story regarding the lift so it's hard to say exactly what happen but the more reliable source I heard was the aid used a lift inappropriately, she used the wrong sling, the resident told her it was the wrong sling and the resident fell from the machine and the machine tipped and fell on the resident. I will say other than this event she was well taken care of . A phone interview was conducted on 3/1/23 at 3:34 P.M. with Staff P, CNA she stated, oh no the machine did not fall on the resident that would have meant we would've had to pick it back up off the resident and we did not have to do that. Review of Resident #3's hospital records revealed she sustained an acute displaced (bone breaks into two or more pieces and moves out of alignment) markedly comminuted (bone broken into three or more pieces) fracture involving the mid to proximal (near the knee) tibia (larger bone of the lower leg, also called the shin bone) . as well as an acute comminuted mildly displaced proximal fibular (outer smaller bone of the lower leg) fracture. Review of the hospital physician's notes dated 2/23/23 revealed [Resident #3] is an [AGE] year-old female with severe tricuspid regurgitation [heart valve does not close properly], moderate mitral regurgitation [heart valve does not close properly], suspected underlying heart failure with preserved ejection fraction [the heart pumps normally but too stiff to fill properly] on diuretics chronically, A-fib [atrial fibrillation, an irregular heart rhythm] on Eliquis, history of CVA[cerebral vascular accident], hypertension, DM 2 [diabetes mellitus 2] with peripheral neuropathy, hyperlipidemia [high levels of fat in the blood] who was admitted to [Hospital] following fall with tibia and fibula fracture. She is status post intramedullary nailing [permanent rod placed in the cavity of a bone to treat a fracture] 2/15. She developed gaseous distention concerning for ileus [when the intestines stop moving correctly and cannot push food through] versus obstruction/pseudoobstruction, CT [computerized tomography scan] abdomen pelvis showed marked gastric distention, possible transition and duodenum. NG [nasal gastric] tube was placed for decompression. She had acute anemia requiring transfer to the ICU [intensive care unit] with hypotension/shock. Echocardiogram showed EF [ejection fraction] 60 to 65%, severely dilated left and right atria [heart valve], severe pulmonary hypertension, severe tricuspid regurgitation. She received transfusions, EGD [esophagogastroduodenoscopy] revealed erosive esophagitis, adherent blood and edema with erosions and erythema, PPI [proton pump inhibitor] started, last transfusion 2/21. Additional issues have included but are not limited to hypernatremia [high concentration of sodium in the blood. Further hospital physician note review dated 2/23/23 revealed Plan - I reviewed the different disease trajectories for patients with multiple medical comorbidities, advanced age, acute event and introduced the idea of refocusing hopes and life goals as the timeline progresses and modifying what the expectations are for levels of functional ability and daily quality of life targets. Reviewed high possibility of development of cycle of frailty including more frequent hospitalizations and decline in overall performance status if she is not well able to participate with physical therapy and regain mobility. Daughter voiced agreement and stated she had discussed this previously with another physician prior to the surgery. --In light of possibility of further progressive decline offered outpatient palliative medicine referral for ongoing goals of care conversations following this hospitalization and trial of SNF [Skilled Nursing Facility]/rehab. Family declines at this time. --Reviewed what-ifs and family had questions about prognosis and including DIL[dangerous illness list] inquiring about possibility of hospice down the line. Reviewed mod-high [moderate to high] of 6mo-1yr mortality [6 month to 1 year mortality], particularly if mobility is not regained in light of multiple medical comorbidities. Review of Resident #3's Post Fall Review by IDT [interdisciplinary team] Team dated 2/15/23 revealed 1. In Attendance, Unit Manager, Risk Manager, DON [Director of Nursing], Social Services, Therapy, PT [Physical Therapy], OT [Occupational Therapy], ST [Speech Therapy], Reviewed details of resident's recent fall, .4. Comments, IDT meeting. Sent to ED [Emergency Department] for Eval and treatment, Staff educated re: staffing for mechanical lift, determining proper sling size for mechanical lift. Inventory all mechanical lift slings; invite [Medical Equipment Company]. Review of Resident #3's Incident Report dated Tuesday February 14, 2023, at 1:45 p.m. revealed, General Information, Type: Fall, Incident Location: Hallway/Corridor, Activity: Transfer, Reported by: [Staff Q, RN], Witness(es): [Staff P, CNA], .Cognition Prior to Incident: Oriented X3, Cognition after Incident: Oriented x3, Injuries, Type: R/O [rule out] Fracture, Location: Left Lower Leg, Date/Time: 2/14/23 1:45 p.m., Details: Left lower leg-external curvature and rotated, Actions, Skin assessment completed, Pain Assessment, Investigative Statements, Resident: [Resident #3] stated that she told the CNA she was using the incorrect sling and that the blue sling was the right one for her not the red one. And the CNA continued to use the red sling for the transfer., Staff interviews, No Staff Interviews. Review of facility's Sit-to-Stand Lift (Brand Name) Usage Procedure undated, revealed a sizing chart which indicated the red sling was a size medium and the blue sling was a size large. An interview was conducted on 3/1/23 at 1:15 p.m. with Staff T, Educator, she stated, on orientation I do lift education and lift competency check off. We also have a mentor check off sheet which also indicates the staff are competent in the use of lifts. The week [Staff P, CNA] was in orientation I was not here so the competencies did not get done and her mentor check offs, she didn't turn that in. Review of the facility's Transfer Equipment 2 people education dated 2/7/23 revealed 13 employes were present for the education but [Staff P, CNA] was not located on the sign in education sheet indicating she did not receive the training. Review of Staff P, CNA's employee file revealed she was hired on 12/12/2022 and was terminated on 2/24/23 for transferring a resident in a sit to stand lift, with her last day of work being 2/14/23. The resident started slipping from the sling and was lowered to the floor. She sustained a fracture of the left tibia and fibula during the procedure. [Staff P, CNA] disregarded the following facility protocols for mechanical lift transfers. 1. 2 staff members must be present when transferring a resident with a mechanical lift. 2. The proper size sling must be used. An interview was conducted on 2/28/23 at 12:04 p.m. with the Director of Therapy he said, No we don't have anything to do with lifts. In rehab we want them off the lifts and gaining more function. Usually nursing makes the decision if the residents need a lift or not. Once we do our assessment on the resident then we tell them why this person is one person assist or two person assist, but that's later on in the admission. Once the resident comes into the building that's when nursing decides if they need a lift or not. We are not the ones who make the decision on the lifts. Unless they have specific stuff like the resident has a broken hip then we will tell nursing that they cannot use a lift. [Resident #3] was on case load from 1/20/23-2/14/23 there is nothing in our notes regarding lifts for her. They [Therapists] did mention and recommend a sit to stand lift on her evaluation. Transfer to wheelchair via sit-to-stand lift, that's all they mentioned, which indicates that is how she transfers. She is a long-term resident who utilized a sit to stand for transfers since before January 20th, 2023. That was not something that changed she has always been using that. I cannot see any lift assessment for her. An interview was conducted with the DON on 2/28/23 at 12:21 p.m. she said So, after [Resident #3's] fall we actually assessed all the residents who are using lifts maybe ten days ago, after [Resident #3's] to make sure that we have the appropriate lift for everyone. [Staff S, Informatics Specialist] and [Staff R, RN] did the assessment. [Staff S, Informatics Specialist] is an LPN [Licensed Practical Nurse] and [Staff R. RN] is an RN. They determined what type of lift and slings or belts they needed for all the residents who are needing a lift. The criteria to use a sit to stand lift if they can bear partial weight and can't be an amputee. For the [complete body lift] the criteria is they are not able to bear weight at all they can use the Complete body lift. There are sizes for the sling for the Complete body lift and there is a Velcro belt for the sit to stand lift that comes in small, medium, large, and extra-large and [Staff R. RN] and [Staff S, Informatics Specialist] determined what size sling and belt those residents needed. They based their measurements on the manufacture's recommendations they measured the residents from mid shoulder to gluteal fold and based on that measurement they were able to ascertain what size sling they needed. The waist belt we had an in-service from the vendor they said the waist belt has to have at least a 2-inch overlap on the belt. This information is in the Kardex that the CNA's have access to in the [Electronic Medical Record]. The new residents who are admitted if they can't bear weight or partial weight bearing the nurses have been educated on how to determine the sling and belt sizes and have been checked off on their competency. To be honest with you the residents that were transferred with lifts before we put everything in place, I'm not sure what the process was the staff just knew what lift and what color band around the sling the residents needed and that band around the sling determines what size it is. For the waist belts the staff just knew what color each resident needed. I'm new I just started in October. There was no formal process before this, this is what we discovered they would just ask a nurse or another CNA or the CNA that was on shift before them would tell them what they used. An interview was conducted with [Staff R. RN] on 2/28/23 at 12:41 p.m. she said I worked with therapy and staff we identified who used a mechanical lift then I entered that information on the Kardex so all staff could see how a resident could transfer. I participated in the training on how to do the measuring of slings and belts, but I did not measure anyone. All I did[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, facility policies, interviews with facility staff, the resident's physician, Medical Director and family members, the facility failed to provide supervision, education and corrective action in response to incidents in order to prevent falls with injury for 1 resident (#3 ) out of 12 residents sampled for falls. Resident #3 was a long-term nursing care resident who was at risk for falls admitted to the facility on [DATE] and discharged on 2/14/23 to an acute care hospital for a fall with injury. On 2/14/23 at 1:45 pm a Certified Nursing Assistant (CNA) did not follow facility policy and independently used the sit to stand lift for Resident #3. The CNA did not use the appropriate size waist belt during the transfer even after Resident #3, who was assessed to have no cognitive deficits, told the CNA she was using the incorrect sling [waist belt] and that the blue sling was the right one for her not the red one. The CNA continued to use the wrong supportive waist belt and continued to use the sit to stand lift independently which resulted in Resident #3 sustaining a fracture of both bones of the lower leg which required surgical repairment. Resident #3 suffered multiple complications after the surgery, required intensive care and remained hospitalized on [DATE]. The facility was unable to provide documentation of the CNA's training on the lift during orientation. The facility's response to the incident did not address communicating individual resident sling size with staff. Additionally, based on observation, interview and record review the facility failed to provide supervision to prevent multiple falls in the facility's secured unit. A review of the facility's incident list revealed on 2/25/23, 2/26/23 and 2/27/23, 16 falls occurred in the facility. Ten of the 16 falls were unwitnessed and occurred on the secured unit to Residents #8, #9, #19, #11, #12, #13, #14, #15, #16 and #17. The residents who resided on the secured unit due to severe cognitive impairment, were observed unattended in the common area or with limited supervision on 4 of 4 days of the survey, (2/27/23, 2/28/23, 3/01/23 and 3/02/23). This placed them at risk for falls, accidents, and potentially injurious interactions between residents. The actual serious physical harm to Resident #3, likelihood of death to Resident #3, likelihood of serious harm to residents who require mechanical lifts, and very likely risk of serious harm, injury or death from a fall to the facility's residents who are at risk for falls resulted in the finding of on-going immediate jeopardy starting on 2/14/23. Findings included: An interview was conducted on 2/27/23 at 5:31 p.m. with Staff Q, Registered Nurse (RN) who said . [Resident #3] room was in a quad room [four person room, with 2 residents on the left side of an entrance hallway and 2 residents on the right side of an entrance hallway], and I was in one of the rooms taking care of another resident when I heard the resident yelling my leg! my leg! my leg! The CNA [Staff P, CNA] was also screaming [Staff Q, RN]! [Staff Q, RN]! Come help! The resident was in the hallway of the quad, I think [Staff P, CNA] was trying to transfer her to the bathroom, the bathroom is also in the hallway of the quad, I heard her screaming and I came out saw the resident and yelled for help because she was about to hit the floor, she was suspended on the lift. Her left leg was out past the foot plate towards the shift bar of the mechanical lift. The resident was in the strap that goes on like a belt around her waist and the straps were still hooked onto the sit to stand machine. Her two arms were still holding on to the handles of the machine. Both sides of the belt straps were still attached to the sit to stand. Her right leg was on the foot plate. She was slipping off of the belt I don't know if it was tight enough or what but she never touched the ground at this point. I think when [Staff P, CNA] noticed [Resident #3] was going to hit the ground that's when she started to call out. The hallway door was closed, I opened it and called out for help. The CNA was not touching the resident, the CNA was holding onto the remote of the machine with one hand and reaching for the wheelchair with the other and telling me to get the wheelchair to put the resident back into the wheelchair but I told her the resident was too low to put her back into her chair we need to lower her to the ground so I got behind the resident and supported her head and guided her to the floor and the CNA pressed the remote to lower the sit to stand which lowers the resident. We lowered the resident completely to the ground, the CNA removed the lift from the area and that's when I noticed her leg is facing an asymmetrical position and now, she was yelling, and the pain is too much and at that point 911 was called. Because of the pain, we couldn't touch her, and other people came to help, and we put pillows under her head and stayed with her until the paramedics came. I did not see the sit to stand on the resident. I don't think it fell on her, It is a very heavy machine and I don't think if it fell on the resident the CNA would not have been able to pick it up and get the resident back into the position I found her in. It's just my opinion but what I think might have happened was her leg got caught under the foot plate and when she was lifted up it could have broke but like I said that is just my opinion because her break was just above her ankle. But that is why we are supposed to have 2 people when they use the mechanical lifts, one to operate it and one to guide the resident. The CNA did not do that, that day. I don't know why she didn't use two people. She floats around all the units but she has worked with this resident before so she cannot say she doesn't know how she was supposed to be transferred. The CNA told me she was taking the resident to the bathroom. The resident did have a brief on, but she told me she was taking her to the toilet. And usually that's what they do when they take someone to the toilet they transfer them from the wheelchair onto the sit to stand with two people, wheel them into the bathroom, one person pulls down their clothes and the other lowers them onto the toilet while the other person guides them onto the toilet, the resident uses the bathroom, the staff member cleans them up, puts their clothes back up and then they wheel the resident back to the wheelchair and lowers them back onto the wheelchair. The resident never comes off of the lift they are strapped to it the entire time. The resident did not have a strap around her legs to stabilize her legs against the padded cushion of the sit to stand, no A phone interview was conducted on 2/28/23 at 2:11 p.m. with Staff P, CNA, who operated the mechanical lift at the time of Resident #3's fall. She stated I know when I wrote my initial letter about [Resident #3] I was emotional and all over the place. But, when I put her in the machine and we went up she kind of slipped, she did not hit the floor and once the nurse came, she told me to put her on the floor. My first instinct was to not let her touch the floor. I just didn't want her to touch the floor at all. I was holding the resident on her side she was still attached to the machine and then [Staff Q, RN] said let's put her on the floor [Staff Q, RN] said we aren't getting her back onto the wheelchair so I took the controller and lowered her down with the machine as low as it possibly could, unhooked her and we lowered her to the floor. The belt was Velcro'd on pretty decently .I was never told there was different sizes or different colored slings and belts .That day I was just getting off my 30-minute break and [Staff Q, RN] was saying my lights were on and people were waiting for me to take them to the restroom . so I was trying to prioritize who I saw first. I had one person in bed with a call light on, I had one person who was continent and then [Resident #3]. I went and saw the resident who was in their bed, they told me that they had already been helped so I turned off their light and then I heard the two women arguing about who has been waiting longer to go to the bathroom. [Resident #3] had her wipes and her brief in her lap and the other resident had her towels and I knew she was continent and she said she had been holding it for 30 minutes, so I put her on the sit-to-stand lift and took her to the bathroom, I came back out and put her back in her chair. Then I was going to take [Resident #3] to the bathroom and she had already soiled herself and as I was strapping her waist belt on and hooking her onto the machine, just as I did earlier that morning when I got her out of bed, I was talking to her apologizing to her for her wait and telling her I understand her frustration I didn't mean to frustrate her because when I was taking the other lady to the bathroom I could hear her arguing, well not arguing she was just expressing how she felt. But I don't want to use me talking to her as an excuse that I was distracted. As I was strapping the belt on her she was trying to strap it on herself, and she was trying to tell me how other people do it and I told her that I'm not the other CNA's I feel more comfortable doing it my way and then I told her I am going to lift you up and as I was lifting her up I was explaining to her you're wet let me take you to your room to change you and she said she said no I want to get changed right here and then everything happened so fast the resident was slipping, I grabbed her because I didn't want her to hit the floor, I called out for [Staff Q, RN] and [Staff Q, RN] came and that's when we lowered her to the floor. When I got back from break there was no one on the floor, everyone was doing their own thing except [Staff Q, RN] because she was the one who told me about my lights. I did not have another staff member right there with me because everyone was doing their own thing and when I got off break there was no one in the hallways and I just felt this sense of urgency because people needed to use the toilet and people are yelling at each other and I just wanted to help the residents. I did not have two people with me either time I used the sit to stand for both of them. So, the way the room worked is there is a door off the hallway and then there is a bathroom in the corridor of the hallway and 4 rooms that branch off that corridor; I was in the corridor with [Resident #3] and the other lady that is in one of the other rooms in [Resident #3's] hallway. [Staff Q, RN] was in one of the other residents' rooms in that hallway, but she was not right next to me when I used the lift. I had worked there for about 2 months before this happened . Review of Resident #3's admission record revealed she was an [AGE] year-old female resident admitted to the facility on [DATE] from an acute care hospital and discharged on 2/14/23 back to an acute care hospital. Resident #3 had diagnoses that included congestive heart failure, muscle weakness, dysphagia, type 2 diabetes with chronic kidney disease, type 2 diabetes with diabetic peripheral angiopathy without gangrene, diabetic neuropathy, dementia, pulmonary hypertension, anemia, hyperlipidemia, atherosclerosis, bipolar disorder current episode hypomanic, disorder of bone density and structure of right lower leg, primary osteoarthritis left hip and right knee, sciatica left side, localized edema, chronic kidney disease stage 3A, age related osteoporosis without current pathological fracture, generalized anxiety disorder, nonrheumatic mitral valve insufficiency, atrial fibrillation, other specified disorders of bone density and structure of the left forearm, pharyngoesophageal phase and vitreous degeneration, bilaterally. Review of Resident #3's progress note dated 2/14/23 at 13:45 p.m. revealed Resident had a fall incident. 2/14/23 1:45 PM resident is alert and oriented. Resident was Transferring at time of incident. Pain is noted. Resident sent to emergency room for evaluation. Neuro Checks immediate after. Physician notified Responsible party notified. Guardian Notified. Supervisor notified. Review of Resident #3's quarterly minimal data set (MDS) dated [DATE] section C, cognitive patterns, revealed she had a brief interview for mental status (BIMS) score of 15 out of 15 indicating no cognitive deficits. Section G, functional status, revealed Resident #3 had impairment on both sides of her lower extremities. For transfers Resident #3 required extensive assistance with two plus person's physical assist. Toilet use revealed Resident #3 required extensive assistance with two plus person's physical assist. Section H, bowel and bladder, revealed Resident #3 was frequently incontinent of bowel and bladder. Review of Resident #3's Task List Report revealed a task with an initiated date of 4/21/2022 and a resolved/cancelled date of 2/14/2023. The position(s) indicated the task was for Certified Nursing Aide. to Transfers: Sit to stand lift, Assist x2 [times 2] Everyday. Qshift [every shift]: Day (7-3), Night (11-7), Evening (3-11). Everyday, Qshift Night (7-7). Further review of February's task documentation revealed Staff P, CNA signed off Transfers: Sit to Stand lift, assist X2 on 2/14/23 at 8:59 a.m. Review of Resident #3's care plan initiated on 2/14/2019 revealed a focus of The staff have identified that I am at risk for falls because of these risk factors: weakness, impaired mobility, dementia, History of falls, Incontinence, use of opioid medication, dizziness, DM [diabetes mellitus] with neuropathy; Dx [diagnosis] of Osteoporosis with increased risk for pathological fractures. The goal revealed I will be free of major injury due to a fall through next review. Interventions included but are not limited to, .I will notify staff my need for assistance when I have a bowel or bladder accident. Toilet me upon rising before and after meals at hs [hours of sleep] and when needed . Assist of 2 staff with transfers using sit-to-stand lift. Further care plan review revealed a care plan with an initiated date of 2/14/2019 revealed a focus of I need assistance with activities of daily living because of muscle weakness, pain, dizziness, impaired mobility. The goal revealed I like to maintain a neat and tidy appearance. Staff will assist as needed to help maintain that goal through next review. Interventions included but are not limited to, 2 female staff to be present when caring for resident Assist of 2 staff using sit-to-stand for transfers . Review of Resident #3's Clinical Physician Orders revealed a physician's order with a start date of 2/14/2023 TRANSFER TO ER [EMERGENCY ROOM] HOSPITAL FOE [sic] EVALUATION AND TREATMENT FOR POSSIBLE TIBIA FRACTURE OF THE LEFT LEG. Review of Resident #3's Change in Condition Evaluation with an effective date of 2/14/23 at 1:45 p.m. revealed 1. The change in condition, symptoms or signs I am calling about is/are: Falls 2. This started on: 2/14/23 3. What time of day did this start: Afternoon 1. The resident is in the nursing home for: Long Term Care .4. Is the resident on warfarin/coumadin? No 4c. is the resident on another anticoagulant drug? (e.g. Aspirin, Plavix, Dabigatran, Rivaroxaban, Apixaban) Yes .Skin Evaluation 16. describe skin changes: No changes observed 16n. document location and details: Site: Left lower leg (front) Description: possible tibia fracture . Pain Evaluation 17. Is the resident cognitively able to rate their pain scale? Yes 17a. Rate pain on a scale of 0 to 10 (0=no pain, 4-5=moderate pain, 10=excruciating pain): 10 17b. Is the pain: acute 17c. Pain location: Musculoskeletal pain 17h. Describe musculoskeletal pain: Marked localized bruising, swelling, or pain over joint or bone, with or without recent fall. 17k. Specify exact location of pain: Site: Left lower leg (front) Description: possible tibia fracture .20. Since the change in condition occurred have the symptoms or sign gotten: Worse 21. Things that make the condition or symptoms worse are: activity 22. Things that make the condition of symptoms better are: pain medication .25. Summarize your observations and evaluation: Transfer to ER Hospital for treatment .2. Reported to primary care clinician: [Resident #3's physician] 3. Date and time of clinician notification: 2/14/23 2:08 p.m. 4. Orders obtained from the clinician: Other 4a. Specify other: Transfer to ER Hospital. 5. Name of Family/healthcare agent notified: [Resident #3's family member] 6. Date and time of family notification: 2/14/23 2:06 p.m. A phone interview was conducted on 2/27/23 at 3:13 p.m. with Resident #3's family member, she said It wasn't a fall it was a drop; my mother was in her room she needed a diaper change so she could go to activities this is a routine for her, she required a sit to stand, the CNA wheeled her out of the room into the hallway to change her diaper. I spoke to some of the nurses and that is supposably their new way of doing diaper changes is out in the hall. The CNA gets my mother, wheels her into the hallway, my mother tells her that's the wrong strap to the machine, the CNA said don't worry about it it'll be fine. My mother said no I am worried about it, that's the wrong strap. The CNA said it'll be fine and proceeded to use the strap and lift my mother up using the machine, The strap breaks, my mother falls to the floor, the machine flipped in the air and hit my mother's leg breaking her leg in two places. The ambulance was called this all happened on 2/14/23. She is still in the hospital. She is not doing good because of her other problems which they warned us about an [AGE] year-old women needing surgery is a risk. And every problem they warned us about she had. Her heart stopped twice, they had her on a respirator then they took her off the respirator and now she's on oxygen. Her Blood pressure tanked to 58/30, Her kidney's stops working no urine output at all. Her A-fib [Atrial Fibrillation] starts acting up. I'm in the ICU [intensive care unit] with her on 2/16/23 and she starts bleeding internally. They could not get her into surgery, they had to come to her. A tube went down her throat and into her stomach. Then she's back on the respirator and then taken off the respirator for the second time and back on oxygen. Then she got a tube through her nose down into her stomach for 5 days. Then that came out on Saturday. They did surgery on her leg, there was 2 breaks, she now has rods, screws all inserted in her leg permanently. My mother told me this whole story when I came to the hospital in between all her screaming because of the pain she was in. She told the same story to all the doctors and paramedics. The paramedics found her with the machine on her in the hallway, they even came back to the hospital to see my mom because they said it was such a horrific accident. When the administrator called me about what happened she said I feel so bad your mom was like my mom and I said to her well my mom did not give birth to you so yeah. A CNA is a Certified Nurse assistance that is someone who is trained on how to use these machines. The Sunday prior to the accident my brother was visiting my mom and the CNA said she does not know how to use the machine my brother asked her how is it you don't know how to work the machine and she said I don't know how to work it. My mother said here I will show you. [The NHA] said she was currently in the process training the staff on how to use the machine. I said what do you mean you are training them now. They are supposed to have training on this before they even get hired and she's telling me they are using real life people as practice dummies. The Director told me I understand you are very upset, and I want to assure you that the staff are being trained but they should already be trained she shouldn't just now be training them. Since then, the director called me back saying they have suspended her [Staff P, CNA] pending investigation and then they called me again and have since fired her and reported her licenses. A phone interview was conducted on 3/1/23 at 3:31 p.m. with Resident #3's physician. She stated I am very familiar with [Resident #3] I have worked with her for the last 3 years. I was immediately notified about the fall from someone, I'm not sure who called me, but I was notified that she had fallen, and it was suspected that her leg was broken. She was in a lot of pain, and I believe we had her sent out versus us getting X-rays. The hospitalist [hospital physician] will call me once the resident is done with their hospital stay to give an update, but I have not talked to anyone from the hospital. But middle to end of last week my Nurse Practitioner talked to someone and let me know that she {Resident #3] was not doing well, she had a really bad fracture and was having complications. The resident has severe lumbosacral disease which leaves her unable to use her legs which could lead to brittle bones, but I don't think we have any sort of osteoporosis on her. My understanding is that the resident had a fall from the lift, and the lift fell on the resident. I also heard another story regarding the lift so it's hard to say exactly what happen but the more reliable source I heard was the aid used a lift inappropriately, she used the wrong sling, the resident told her it was the wrong sling and the resident fell from the machine and the machine tipped and fell on the resident. I will say other than this event she was well taken care of . A phone interview was conducted on 3/1/23 at 3:34 P.M. with Staff P, CNA she stated, oh no the machine did not fall on the resident that would have meant we would've had to pick it back up off the resident and we did not have to do that. Review of Resident #3's hospital records revealed she sustained an acute displaced (bone breaks into two or more pieces and moves out of alignment) markedly comminuted (bone broken into three or more pieces) fracture involving the mid to proximal (near the knee) tibia (larger bone of the lower leg, also called the shin bone) . as well as an acute comminuted mildly displaced proximal fibular (outer smaller bone of the lower leg) fracture. Review of the hospital physician's notes dated 2/23/23 revealed [Resident #3] is an [AGE] year-old female with severe tricuspid regurgitation [heart valve does not close properly], moderate mitral regurgitation [heart valve does not close properly], suspected underlying heart failure with preserved ejection fraction [the heart pumps normally but too stiff to fill properly] on diuretics chronically, A-fib [atrial fibrillation, an irregular heart rhythm] on Eliquis, history of CVA[cerebral vascular accident], hypertension, DM 2 [diabetes mellitus 2] with peripheral neuropathy, hyperlipidemia [high levels of fat in the blood] who was admitted to [Hospital] following fall with tibia and fibula fracture. She is status post intramedullary nailing [permanent rod placed in the cavity of a bone to treat a fracture] 2/15. She developed gaseous distention concerning for ileus [when the intestines stop moving correctly and cannot push food through] versus obstruction/pseudoobstruction, CT [computerized tomography scan] abdomen pelvis showed marked gastric distention, possible transition and duodenum. NG [nasal gastric] tube was placed for decompression. She had acute anemia requiring transfer to the ICU [intensive care unit] with hypotension/shock. Echocardiogram showed EF [ejection fraction] 60 to 65%, severely dilated left and right atria [heart valve], severe pulmonary hypertension, severe tricuspid regurgitation. She received transfusions, EGD [esophagogastroduodenoscopy] revealed erosive esophagitis, adherent blood and edema with erosions and erythema, PPI [proton pump inhibitor] started, last transfusion 2/21. Additional issues have included but are not limited to hypernatremia [high concentration of sodium in the blood. Further hospital physician note review dated 2/23/23 revealed Plan - I reviewed the different disease trajectories for patients with multiple medical comorbidities, advanced age, acute event and introduced the idea of refocusing hopes and life goals as the timeline progresses and modifying what the expectations are for levels of functional ability and daily quality of life targets. Reviewed high possibility of development of cycle of frailty including more frequent hospitalizations and decline in overall performance status if she is not well able to participate with physical therapy and regain mobility. Daughter voiced agreement and stated she had discussed this previously with another physician prior to the surgery. --In light of possibility of further progressive decline offered outpatient palliative medicine referral for ongoing goals of care conversations following this hospitalization and trial of SNF [Skilled Nursing Facility]/rehab. Family declines at this time. --Reviewed what-ifs and family had questions about prognosis and including DIL[dangerous illness list] inquiring about possibility of hospice down the line. Reviewed mod-high [moderate to high] of 6mo-1yr mortality [6 month to 1 year mortality], particularly if mobility is not regained in light of multiple medical comorbidities. Review of Resident #3's Post Fall Review by IDT [interdisciplinary team] Team dated 2/15/23 revealed 1. In Attendance, Unit Manager, Risk Manager, DON [Director of Nursing], Social Services, Therapy, PT [Physical Therapy], OT [Occupational Therapy], ST [Speech Therapy], Reviewed details of resident's recent fall, .4. Comments, IDT meeting. Sent to ED [Emergency Department] for Eval and treatment, Staff educated re: staffing for mechanical lift, determining proper sling size for mechanical lift. Inventory all mechanical lift slings; invite [Medical Equipment Company]. Review of Resident #3's Incident Report dated Tuesday February 14, 2023, at 1:45 p.m. revealed, General Information, Type: Fall, Incident Location: Hallway/Corridor, Activity: Transfer, Reported by: [Staff Q, RN], Witness(es): [Staff P, CNA], .Cognition Prior to Incident: Oriented X3, Cognition after Incident: Oriented x3, Injuries, Type: R/O [rule out] Fracture, Location: Left Lower Leg, Date/Time: 2/14/23 1:45 p.m., Details: Left lower leg-external curvature and rotated, Actions, Skin assessment completed, Pain Assessment, Investigative Statements, Resident: [Resident #3] stated that she told the CNA she was using the incorrect sling and that the blue sling was the right one for her not the red one. And the CNA continued to use the red sling for the transfer., Staff interviews, No Staff Interviews. Review of facility's Sit-to-Stand Lift (Brand Name) Usage Procedure undated, revealed a sizing chart which indicated the red sling was a size medium and the blue sling was a size large. An interview was conducted on 3/1/23 at 1:15 p.m. with Staff T, Educator, she stated, on orientation I do lift education and lift competency check off. We also have a mentor check off sheet which also indicates the staff are competent in the use of lifts. The week [Staff P, CNA] was in orientation I was not here so the competencies did not get done and her mentor check offs, she didn't turn that in. Review of the facility's Transfer Equipment 2 people education dated 2/7/23 revealed 13 employes were present for the education but [Staff P, CNA] was not located on the sign in education sheet indicating she did not receive the training. Review of Staff P, CNA's employee file revealed she was hired on 12/12/2022 and was terminated on 2/24/23 for transferring a resident in a sit to stand lift, with her last day of work being 2/14/23. The resident started slipping from the sling and was lowered to the floor. She sustained a fracture of the left tibia and fibula during the procedure. [Staff P, CNA] disregarded the following facility protocols for mechanical lift transfers. 1. 2 staff members must be present when transferring a resident with a mechanical lift. 2. The proper size sling must be used. An interview was conducted on 2/28/23 at 12:04 p.m. with the Director of Therapy he said, No we don't have anything to do with lifts. In rehab we want them off the lifts and gaining more function. Usually nursing makes the decision if the residents need a lift or not. Once we do our assessment on the resident then we tell them why this person is one person assist or two person assist, but that's later on in the admission. Once the resident comes into the building that's when nursing decides if they need a lift or not. We are not the ones who make the decision on the lifts. Unless they have specific stuff like the resident has a broken hip then we will tell nursing that they cannot use a lift. [Resident #3] was on case load from 1/20/23-2/14/23 there is nothing in our notes regarding lifts for her. They [Therapists] did mention and recommend a sit to stand lift on her evaluation. Transfer to wheelchair via sit-to-stand lift, that's all they mentioned, which indicates that is how she transfers. She is a long-term resident who utilized a sit to stand for transfers since before January 20th, 2023. That was not something that changed she has always been using that. I cannot see any lift assessment for her. An interview was conducted with the DON on 2/28/23 at 12:21 p.m. she said So, after [Resident #3's] fall we actually assessed all the residents who are using lifts maybe ten days ago, after [Resident #3's] to make sure that we have the appropriate lift for everyone. [Staff S, Informatics Specialist] and [Staff R, RN] did the assessment. [Staff S, Informatics Specialist] is an LPN [Licensed Practical Nurse] and [Staff R. RN] is an RN. They determined what type of lift and slings or belts they needed for all the residents who are needing a lift. The criteria to use a sit to stand lift if they can bear partial weight and can't be an amputee. For the [complete body lift] the criteria is they are not able to bear weight at all they can use the Complete body lift. There are sizes for the sling for the Complete body lift and there is a Velcro belt for the sit to stand lift that comes in small, medium, large, and extra-large and [Staff R. RN] and [Staff S, Informatics Specialist] determined what size sling and belt those residents needed. They based their measurements on the manufacture's recommendations they measured the residents from mid shoulder to gluteal fold and based on that measurement they were able to ascertain what size sling they needed. The waist belt we had an in-service from the vendor they said the waist belt has to have at least a 2-inch overlap on the belt. This information is in the Kardex that the CNA's have access to in the [Electronic Medical Record]. The new residents who are admitted if they can't bear weight or partial weight bearing the nurses have been educated on how to determine the sling and belt sizes and have been checked off on their competency. To be honest with you the residents that were transferred with lifts before we put everything in place, I'm not sure what the process was the staff just knew what lift and what color band around the sling the residents needed and that band around the sling determines what size it is. For the waist belts the staff just knew what color each resident needed. I'm new I just started in October. There was no formal process before this, this is what we discovered they would just ask a nurse or another CNA or the CNA that was on shift before them would tell them what they used. An interview was conducted with [Staff R. RN] on 2/28/23 at 12:41 p.m. she said I worked with therapy and staff we identified who used a mechanical lift then I entered that information on the Kardex so all staff could see how a resident could transfer. I participated in the training on how to do the measuring of slings and belts, but I did not measure anyone. All I did[TRUNCATED]