Based on observation, clinical record review, staff interview, and facility policy review, the facility failed to ensure the safety for 1 of 5 residents (Resident #2) reviewed. This failure caused harm when Resident #2 was improperly transferred and needed to be lowered to the floor. This transfer resulted in a ligament injury. The facility reported a census of 72 residents. Findings include: The Annual Minimum Data Set (MDS) of Resident #2, dated 11/18/24, identified a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. The MDS revealed the resident required substantial/maximal assistance for sit to stand, chair/bed-to-chair transfers and toilet transfer. The MDS documented diagnoses that included osteoporosis and Alzheimer's Disease. The MDS recorded the resident had not received any scheduled or as needed pain medication during the prior five days, and denied having any pain. The resident denied having had any pain during the prior 5 days of the look back period. The following Significant Change MDS Assessment for Resident #2, dated 1/23/25, revealed the resident was now totally dependent on staff for sit to stand, chair/bed-to-chair transfers and toilet transfer. The MDS documented the resident received scheduled pain medication and non-medication interventions for pain. The resident reported she had pain during the prior 5 days of the look back period. The Care Plan of Resident #2 identified a problem area needing assistance with daily needs. It directed staff the resident required two staff members for transfers, dated 8/12/24. On 1/6/25, the Care Plan was updated to require the resident to transfer with a standing mechanical lift from her bed to her wheelchair only. The Care Plan was updated again on 2/7/25 directing the staff to use two staff members using a full body mechanical lift for transfers. The resident was receiving Physical Therapy at the facility and was seen on 11/18/24. The Physical Therapy Treatment Encounter note documented the following; Patient completes sit to stand transfers from wheelchair to four wheeled walker with minimal to moderate assist each time. Patient requires extensive cues for upright posture and full bilateral knee extension. The note did not detail the resident experiencing any pain in either leg. The Progress Note dated 11/19/24 documented staff reported to the Registered Nurse the resident had fallen. Upon assessment, the resident was found to be in a sitting position on the floor with her legs stretched. Staff reported the resident had started to fall and was lowered to the floor, and during the lowering, her right knee had bent. The resident was complaining of severe pain, and was unable to move or bend her right leg. The medical provider was notified and the facility received orders to send the resident to the emergency room (ER) for evaluation. The ER notes documented the following: Musculoskeletal exam: Swelling, tenderness, and signs of injury present. Right upper knee: Swelling and bony tenderness present. Decreased range of motion. Tenderness present over the medial joint line. Right upper leg: Tenderness present. No swelling, deformity or bony tenderness. Comments: Limited range of motion right lower extremity. - Findings: Ligamentous injury versus knee sprain. Knee immobilizer was avoided due to risk of pressure induced soft tissue injury due to age and lack of subcutaneous tissue. Placed in an ACE wrap. Non weight bearing at baseline. The Event Report dated 11/19/24 documented the resident received an injury to her right lower extremity, experiencing painful/limited range of motion. Her left lower extremity was documented as strong movement, and her right lower extremity was documented as weak movement. The Report documented the operational factors which led to the fall as Students transferred resident without gait belt and proper transfer. Lowered to floor. The written statement from Student #1 documented the Student went to answer the resident's call light and the resident stated she needed to use the restroom. The student retrieved the wheelchair and moved it next to the recliner. The statement documented the resident told the student that she could do it (stand up) on her own, but the student offered help by holding her hands, then moving into a hug position to lift the resident but she was unable to lift her alone. The student documented that she then called for a second person (Student #2). She wrote they tried to move the resident to her wheelchair but the resident had started calling out about her leg, so she attempted to move the resident back to her recliner and for extra help. She documented the resident was still complaining of her leg and she then noticed the resident's right leg was caught by the wheel of the wheelchair. At that time, the students lowered the resident to the ground, writing that because of the position of her right leg behind her bent at the knee, they were not able to lower her fully to the ground. Staff A, Certified Nurse Aide (CNA) entered the room to help support the resident to a safe position. The statement ended with noting the resident was complaining of right knee pain. The written statement from Student #2 documented she was in the hallway and heard Student #1 calling for help. Her statement noted the resident was unbalanced and leaning forward almost off of the recliner, so she and Student #1 attempted to move the resident to the wheelchair. The resident's right foot was caught on the wheelchair wheel and she was unable to stand. She wrote they then lowered her to the ground and her right knee was under the resident's buttocks. The two students called for help and Staff A, CNA came to assist. The written statement from Staff A, CNA documented she was alerted by students of needing help in Resident #2's room, and heard Resident #2 calling out before she got to the room. She wrote the students had attempted to transfer Resident #2 and had not used a gait belt. The students were attempting to hold the resident up and she instructed them to lower her to the floor. She stated when she asked the students what happened, they told her the resident needed to use the restroom, and they had positioned the wheelchair close to the resident and attempted to assist her due to the resident stating she could do it herself. The Medication Administration Record (MAR) of Resident #2 for November of 2024 documented an order for Hydrocodone-Acetaminophen 5/325 mg (a narcotic pain reliever mixed with acetaminophen/Tylenol) ordered to be given one tablet three times a day beginning 11/20/24. The MAR reflected the order was changed on 11/25/24 to a half tablet three times a day. The MAR reflected additional orders for an ice pack to the right knee for 20 minutes at a time as a non pharmacological pain intervention. The MAR for March of 2025 revealed the current pain medication order to be Hydrocodone-Acetaminophen 5/325 mg, half a tablet, four times a day. Review of Progress Notes of Resident #2 identified the following: 11/20/24: Returned to facility on a stretcher via ambulance accompanied by two male staff. Transferred into her bed with assist x 4 without difficulty. Resident wakened during transfer from stretcher to bed and began crying out: Please leave me alone, please don't touch my leg it hurts. 11/20/24: Lying in bed resting soundly with eyes closed, no further crying out in pain after PRN Tramadol. She did refuse the scheduled ice pack to right knee yelling: stop it, no, I don't want it, leave me alone! 11/21/24: Resident has been resting quietly this shift without complaints voiced when lying still. Nurse placed pillow under legs to float heels which resident did wince at. Routine Norco (Hydrocodone/Acetaminophen) initiated with resident sleepy. 11/21/24: Patient has been in bed all shift again today. Did drink and eat better and her pain seems to be in better control. Cold pack applied several times to her right knee, patient tolerated well. Therapy was in and stated to use the Hoyer (full body mechanical) lift for resident when she gets up. 11/26/24: Removed ace wrap and floated heels on pillow. Ice three times a day continues. Right lower extremity remains edematous and resident has pain with movement and repositioning. 11/27/24: Continues to use Hoyer lift assist of two for transfers 11/30/24: Resident up in wheelchair this evening. Voiced no complaints of pain but did show symptoms during transfer to bed via Hoyer lift. 12/2/24: Hospice referral sent. 12/5/24: Resident denies complaints of pain unless she is moving. Assist of two with Hoyer lift for transfers. Ice, norco and ace wrap continue for swelling and pain issues. 12/13/24: Family requested decrease in pain medication due to resident being too sleepy 12/15/24: Edema remains to bilateral lower extremities, right greater than left. Assist of two via Hoyer lift for transfers 12/16/24: Staff requested to reinstate order for ice pack as an as needed order. Resident remains on scheduled narcotic pain medication four times a day which appears to manage pain at this time. Remains as a two person assist with a full body mechanical lift for transfers. Resident #2 was observed on 3/4/25 at 12:17 being transferred from her bed to her wheelchair by Staff B, CNA and Staff C, CNA. The full body mechanical lift sling was in place under the resident as she laid in bed. Staff B and Staff C secured the loops of the sling to the mechanical lift, verified placement and safety, and appropriately transferred Resident #2 from the bed to her wheelchair. Resident #2 stated during the transfer this leg hurts and indicated with her hand it was her right leg hurting. Observation ended after the resident was safely in her wheelchair, foot pedals were put in place, and staff was fixing her hair prior to taking her to lunch. On 3/4/25 at 4:57 pm, the Administrator stated the CNA students had been provided with pocket care guides. She said the students were eager to help and the resident told them it was fine. The Administrator verified the resident was care planned as a two staff assist but the students failed to use a gait belt. On 3/5/25 at 8:42 am, the Assistant Director of Nursing stated the resident only had the single injury to her knee in November of 2024 but has always had pain in her knee. On 3/5/25 at 9:29 am, the Physician Assistant from the facility stated the injury was a potential ligament injury. She stated due to the resident continuing to complain of pain, she did order a second x-ray (results were negative for any fractures). She stated the family ultimately chose to pursue hospice care as she had been declining prior to the injury related to advanced age and her diagnosis of Alzheimer's Disease. She stated she feels the resident's right leg pain will always be chronic and they are treating it as much as possible to keep her comfortable. Her pain management regimen has changed a couple of times to try to give the most pain relief without causing sedation or other side effects. On 3/5/25 at 1:17 pm, Staff A stated when she entered the room, the resident was not yet lowered to the floor. She described the resident's left leg as being extended forward and her right leg was bent. Staff A stated she instructed the students the resident needed to be lowered to the floor. When she was lowered, due to her leg being bent, her right leg was going out to the side but underneath the resident as she was gently lowered. She stated the resident was either wearing tennis shoes or slippers with non slip grippers on them. She stated the students were not using a gait belt during the transfer. The facility policy Transfer/ambulation assist using gait/transfer belt, review date 3/25/24 documented the following: Policy: Gait/transfer belts will be used for all residents who require physical support for mobility or safety in transfers. The residents will be assessed for appropriate transfer status by PT, OT, or a nurse. Gait/transfer belt will be removed upon completion of transfer/ambulation. Follow care plan for number of staff assistance required. Procedure: Assist to stand 1. Identify resident. 2. Verify in care plan the number of staff required for transfer assistance. 3. Explain procedure as needed. 4. Provide privacy as needed. 5. Apply the gait/transfer belt snugly around the waist, over the clothing. Apply the belt snugly enough so it will not ride up or down on the resident's body. 6. Fasten the safety buckle in the front, slightly off center. 7. Bring the resident to a standing position, using one or two hands on the gait/transfer belt. Do not lift resident under their arms during transfers. If the belt loosens, tighten it again after the resident is standing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on direct observation, clinical record review, staff interviews, family interviews, and policy review, the facility failed to provide sufficient amount of properly trained staff to implement care plan interventions for 1 of 1 residents with self-injurious behavior. (Resident#37). The facility staff also failed to intervene when the resident displayed behaviors. This resulted in harm to the resident in the form of three occurrences of cellulitis and loss of the distal portion of the left index finger - the tip of the left index finger to the first finger joint. She was placed on antibiotics for the treatment of the cellulitis. The facility reported a census of 75. Findings include: Record review of Resident #37's Minimum Data Set (MDS) assessment dated [DATE] documented that a Brief Interview of Mental Status (BIMS) could not be completed due to the resident being rarely or never understood. The MDS also documented the need for significant assistance for transfers, dressing and toileting, supervision at meals with set up assistance, and assistance for bed mobility. The resident's diagnoses included, non-traumatic brain dysfunction, Alzheimer's disease, Non-Alzheimer's Dementia, diabetes, anxiety, depression, and pain. Record review of Resident #37's Care Plan last revised on 05/17/24 indicated staff should redirect self-harm behaviors by handing Resident #37 something to eat or giving her a stuffed dog. It indicated dependent care for oral hygiene. Review of oral hygiene charting revealed that oral cares were only recorded as completed on the following dates and times: 1. 04/29/24 at 10:52 AM 2. 04/30/24 at 12:24 AM 3. 05/07/24 at 02:48 PM 4. 05/08/24 at 09:23 AM 5. 05/09/24 at 04:25 AM 6. 05/10/24 at 12:35 PM 7. 05/11/24 at 03:55 PM 8. 05/12/24 at 10:21 AM 9. 05/13/24 at an undocumented time. Review of a Physician's Progress Note dated 04/15/24 revealed the following: 1. Resident #37 had a diagnosed history of advanced dementia. 2. She was placed on hospice services. 3. She had been persistently biting at her nails and fingers, ongoing for approximately two months as of the date of this progress note. 4. It began as minor wounds, but the patient had now chewed off the distal part of the left index finger near the distal interphalangeal (DIP) joint. 5. She had dementia related agitation, anxiety, and hallucinations. 6. The care team added Divalproex Sprinkles 125mg twice daily on 03/25/24. 7. This was reported to have slowed her behaviors, but staff reported finger chewing worsened as of the writing of this progress note. 8. Other measures have failed to stop chewing, included bandages and gloves. The Progress Notes for the resident documented the following: a. On 02/07/24 at 05:24 AM the resident was agitated, yelling, and biting an open area on the middle finger of the left hand. The area appeared swollen, red, and painful. The area was cleansed and covered. b.On 02/07/24 at 12:45 PM the resident was seen by the physician's assistant (PA) for an acute visit in which the resident presented with a swollen finger. The resident was prescribed Keflex 500mg two times daily for ten days, the wound to be covered, and triple antibiotic ointment to be applied to the left middle finger. c.On 02/12/24 at 07:31 AM the resident remained on antibiotics for cellulitis of the left middle finger. Resident #37 continued to bite at the area, and had removed the bandages, but fresh bandages were applied. It noted a scant amount of serosanguinous drainage present on the dressing. d.On 02/24/24 at 05:48 PM The resident continued to bite at her left index finger. e.On 02/25/24 at 06:23 AM The resident bit her left index finger nail causing mild bleeding. f.On 02/25/24 at 03:48 PM The resident had new wounds on left index and middle fingers. It noted the resident had been chewing on fingers, staff covered wounds with dressings, and resident continued to remove dressings and chew on fingers. g.On 02/29/24 at 01:45 PM Nursing staff dressed the left index finger and lower left extremities, at this time it was noted the left index finger nail had nearly fallen off. h.On 03/01/24 at 05:10 PM The resident continued to chew on her fingers. i.On 03/04/24 at 02:37 PM noted the resident had gloves added as an intervention which successfully prevented chewing behavior. j.On 03/05/24 at 06:19 AM the resident continued biting behavior and refused to allow staff to apply gloves or dressing. k.On 03/10/24 at 06:28 AM Noted the resident had bitten off nails on left index and middle fingers. A geri sleeve was placed over the dressing as a deterrent, which proved effective. l.On 03/15/24 at 03:13 PM The resident removed the dressing from her fingers. Nursing staff noted the fingers were red and warm to the touch. At 05:13 PM an order for Augmentin was clarified and changed to Doxycycline 100mg two times a day for ten days related to a second occurrence of cellulitis in the left fingers. m.On 04/12/2024 at 05:56 AM Noted that the resident had bitten her left index finger down to the distal interphalangeal joint and had bitten the fingernail off of her left middle finger. n.On 04/19/2024 at 03:43 PM Noted resident was placed on Bactrim for ten days due to another occurrence of cellulitis in the left finger. o.On 04/28/2024 at 10:42 AM Noted the resident continued to chew on fingers and is quickly removing bandages and dressings. Review of a Provider Progress Note dated 04/15/24 recorded Resident #37 had been persistently biting at her nails and fingers; ongoing for approximately two months. These began has minor wounds, but patient had since chewed off distal part of the left index finger, nearly to the distal interphalangeal joint. Divalproex sprinkles 125mg twice daily was added at 03/25/24, which first appeared to have slowed the chewing behavior, but was reported to have failed as of the writing of this note. A direct observation on 05/28/24 at 01:00 PM revealed wounds on Resident #37's legs and bandages on her left hand with no blood visible on the bandages at the time of this observation. A continuous direct observation on 05/29/24 from 12:12 PM to 12:40 PM revealed the following: 1. At 12:12 PM, Resident #37 in the dining room attempting to free herself from her wheelchair. When attempts failed to free herself from her wheelchair she began to bite the bandage on her left middle finger. A red mark on the bandage was present. 2. At 12:14 PM, Staff B, Therapeutic Activities Coordinator, walked past Resident #37. No attempts were made at redirection and the nurse was not notified. Resident continued to chew the bandage on her left middle finger. 3. At 12:17 PM, Staff C, CNA, seated another resident next to Resident #37, then placed a clothing protector on Resident #37. No attempts were made to redirect the resident from chewing. Nurse was not notified. Resident continued to chew on the bandage on her left middle finger. 4. At 12:19 PM, Staff D, CNA, walked past Resident #37 as she freed her finger from the bandage. Staff D commented That didn't last long and continued to seat residents at the dining tables. No attempts were made to redirect at this time. The nurse was not notified. Resident #37 began to chew on the proximal interphalangeal joint of her left middle finger - the middle joint of her middle finger. 5. At 12:25 PM, Resident #37 continued to chew on the proximal interphalangeal joint of her middle finger, but asked for help from Staff F, Culinary Assistant. Staff F did not acknowledge Resident #37. Staff F left the dining room without informing nursing staff. 6. At 12:27 PM, The Director of Food and Nutrition Services offered Resident #37 a glass of water. Resident #37 accepted the drink and stopped chewing. The chewing did not resume until the glass of water had been consumed. At 12:32 PM Resident #37 resumed chewing on the proximal interphalangeal joint of her left middle finger. Redness is noted on the finger at this time. 7. At 12:32 PM, Resident #37 had a dessert placed just out of her reach by the Director of Food and Nutrition Services. She continued chewing behavior in clear sight of Staff C and Staff D. No attempts to redirect were made. 8. At 12:40 PM, Staff G, RN noted resident was actively engaged in chewing behavior. Staff G placed the dessert in reach of Resident #37. Resident immediately ceased chewing behavior and began eating the dessert. In an interview on 05/29/24 at 03:23, PM Staff C stated they do not feel they have enough staff to handle the needs of residents in the Memory Care unit. She noted that several residents require a mechanical lift with an assist of two, leaving only on person on the floor to monitor all residents in Memory Care. She acknowledged the biting behavior but noted it happens so frequently it fades into the background. She acknowledged that staff should attempt to redirect when they notice. In an interview on 05/30/24 at 09:28 AM, Staff D noted staff are to attempt to redirect Resident #37 when they notice her biting or attempting to free herself from her wheelchair. She noted that interventions are not always successful, but staff are still supposed to attempt to distract or redirect the resident. She stated she feels they need more staff in Memory Care. She stated that it is hard to tend to resident needs when they are dealing with a two person assist. She noted it leaves only one staff member to monitor the rest of the floor. In an interview on 05/30/24 at 09:06 AM A family member of Resident #37 stated he feels the facility does not have enough staff to adequately care for all of the residents in the Memory Care Unit. He noted when a resident is being assisted it often leaves only one person to watch the entire floor. He noted he visits every morning and most evenings. The family member gave permission to take pictures of Resident #37's fingers. These pictures were taken on 05/30/24 at 01:05 PM. They revealed scabs on the distal phalangeal joint, with a finger missing above that point on the left index finger. The fingernail of the middle left finger had been removed and there was an open wound with a small white area protruding from the nail bed. There was recent trauma to the proximal phalangeal joint present with some scabbing noted. In an interview on 05/29/24 at 4:46 PM The Director of Nursing (DON) acknowledged the expectation is for nursing staff to attempt redirection as soon as they witnessed the self-injurious behavior. She noted kitchen and activities staff are expected to say something to nursing staff when they witness the behavior so that nursing staff can attempt to implement interventions in accordance with Resident #37's care plan. She stated she did not believe the facility could provide one on one care for Resident #37 at this time. Review of a visual body inspection dated 05/24/24 documented that the resident had no new injuries or damaged skin present. Review of a facility document titled Behavioral Health Services last reviewed on 03/18/24, documented the facility's interdisciplinary team (IDT) will evaluate behavior health symptoms to determine the degree of severity, distress and potential safety risk to the resident and effectiveness of interventions. If necessary, safety strategies will be implemented immediately to protect the resident or others from harm. If a resident is having behaviors that are not responding to current interventions, staff will complete a behavioral expression-elevated event and this will be reviewed by the IDT. Facility staff will receive education to ensure competency in meeting the behavioral health needs of residents. Review of a facility document titled Dementia Care last reviewed on 03/28/24, documented the facility will use consulting psychologists as needed for assessment and intervention, and should it be deemed necessary for the well-being of the resident, safety of other residents, and/or staff, the use of geriatric inpatient mental health units. The facility did not provide evidence that this occurred.