**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility policy review, and staff interviews, the facility failed to use safe transfer techniques when using a mechanical lift to transfer 2 of 3 (Resident #101 and Resident #102) which resulted in one resident incurring bilateral femur fractures. The facility failed to safely transfer 2 of 2 residents (Resident #101 and Resident #102) from the floor after a fall. The facility reported a census of 52 residents. Findings include:1. Review of the Minimum Data Set (MDS) assessment, dated 6/04/25, revealed Resident #101 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The list of diagnoses included type 1 diabetes, congestive heart failure, and neuromuscular dysfunction of the bladder (loss of control due to nerve damage). The MDS indicated Resident #101 dependent for all transfers, which included going from a seated to standing position. The MDS revealed the resident unable to walk and utilized a wheelchair. The MDS documented Resident #101 had no falls since the previous assessment. Review of the Care Plan, date initiated 9/26/23, revealed a Focus area to address I have limited physical mobility d/t (due to) physical weakness DM (diabetes), COPD (chronic obstructive pulmonary disease), ASHD (arteriosclerotic heart disease), HTN (high blood pressure), renal disease and medications. Interventions included, in part:a. Assess my functional ability with bed mobility, transfers, walking, and locomotion upon admission, quarterly, annually, with a significant change and as needed. Date initiated: 10/2/23.b. I wear Draco boot (boot with a hard sole) to left foot with all standing, and blue boot on at other times. Date initiated: 1/4/24.c. PT (Physical Therapy), OT (Occupational Therapy) referrals as ordered, PRN (as needed). Date Initiated: 3/17/25. d. TRANSFERS: I require assist of two with a mechanical full body lift and green sling. Date initiated: 9/26/23.Review of the Care Plan, date initiated 9/26/23, revealed a Focus area to address I am at risk for falls d/t physical weakness, history of falls, diabetes, COPD, ASHD, HTN, renal disease and medications. Interventions included, in part:a. Alert resident of changes to the environment. Date initiated: 9/26/23.b. Be sure my call light is within reach, and encourage her to use it for assistance as needed. Date initiated: 3/17/25. c. Complete a fall risk assessment/evaluation quarterly and as needed. Date initiated: 10/2/23.d. Ensure that I am wearing appropriate footwear. Date initiated: 3/17/25.e. Follow facility fall protocol. Date initiated: 10/2/23f. Give me my pain medication as ordered. Date initiated:10/2/23.g. Orient to new environment, routine, and caregivers. Date initiated: 9/26/23. h. Place call light within reach and answer it promptly. Date initiated: 9/26/23.i. PT (physical therapy) evaluate and treat PRN (as needed). Date initiated: 9/26/23. j. Review information on past falls and attempt to determine the cause of falls. Record possible root causes and alter or remove potential causes if possible. Date initiated: 3/17/25. Review of the clinical record revealed a General Note entered on 6/07/25 at 3:50 AM, which documented This nurse assisted the CNA (Certified Nurse Assistant) with transferring the resident (Resident #101) to the toilet by [NAME] flex (brand name of a sit to stand mechanical device) around 0350 (3:30 AM), resident encouraged to push her call light when finished. Call-light and cell phone in hand. Review of a facility Incident Report, dated 6/07/25 at 5:20 AM, completed by Staff F, Licensed Practical Nurse (LPN), revealed Resident #101 had a controlled landing fall from a mechanical stand lift, in the resident's bathroom, with injuries noted to both right and left knees. The Incident Report identified a causal factor that Resident #101 was unable to support herself with the stand lift due to becoming weak and sliding downwards in the lift. Staff F identified a suggested intervention for Physical/Occupational Therapy to evaluate Resident #101 for an updated transfer status. Review of a General Note entered on 6/07/25 at 5:20 AM, revealed The resident pushed her call-light around 0520 to get off the toilet. This nurse and CNA headed into the residents bedroom to assist her off the toilet and back to her bed. The CNA grabbed the [NAME] flex (lift) and pulled it into the residents bathroom. Before lifting the resident up, this nurse checked the positioning of the resident feet on the [NAME] flex, feet were correctly re-positioned in place on the foot plate. The resident had her orotho shoe and grippy sock on her left foot, and grippy socks on her right foot, residents yellow sling was correctly faceted with both straps and attached to lift, resident red rolled up blanket was positioned in-between her thighs and knees, residents pillow was placed where her knees were resting on the silicone leg support. The resident had her elastic green bands positioned on the handles of the flex. The resident was then lifted from the toilet by this nurse. The resident stated I want to be lifted all the way up in the air. The hoyer was raised all the way up. Wheels were locked in place on the flex and the CNA began peri-care on the resident. the resident was standing for a while and the CNA asked her if she would like to sit, the resident stated I'm okay. The CNA continued peri-care on the resident, the resident then vocalized she needed to sit. We tried to sit the resident down, but her knees had already began to buck and she ended up on her knees on the low footplate of the flex. The resident began having a bowel movement while on her knees. The resident began to yell out ‘My knees, my knees. This nurse told the resident that we needed to lower her off the flex onto the ground and the hoyer (a brand name of a full body mechanical lift, often used to refer to any type of full body mechanical lift) was the safest way to lift her up. The resident refused and began to yell I don't want to use the hoyer, please don't use the hoyer. I educated the resident that the safest way to her off the flex was to lower her down on th ground and that she needs to let of the handles so we can get her knees off the flex. The resident continued to hold onto the handles on the flex. The resident stated ‘she wanted us to lift her up and put her back on the toilet. I explained to the resident that at this time we are unable to lift her. The resident began pleading and screaming no I don't want the hoyer, to pick her up. We called for he [the] second CNA to come and assist with transferring the resident. The resident still wouldn't let go of the handles, we told the resident she had to so we can ger off her knees, when the second CNA entered her room we decided that we would all lift her up as she wasn't trying to get up. The resident finally let go and the CNA grabbed her torso, and this nurse, and the 1st CNA each grabbed her thigh and lifted her back into her bed. We re-positioned the resident back in bed with pillows and blankets. The resident continued to verbalize that [NAME] as in pain and her knees her. The resident facial expressions was grimacing in pain. The nurse offered the resident pain medication several times and she declined. I explained to the resident that I could see she was in a lot of pain, and the medication may take the edge off. The resident agreed. this nurse gave the resident a PRN hydrocodone and a PRN muscle relaxer. VS (vital signs) were taken and a Neuro assessment was completed see VS tab. The resident oxygen fluctuated between 83% - 93%. This nurse auscultated (listed to) the residents lungs and she was diminished in her lower bases. I asked the resident if she would like to go to the ER (emergency room) and she stated The hospital never does anything and I want to settle down for a bit. The resident was given her call-light and the side table was in reach. The CNA staff attempted to do peri-care and the resident declined. This nurse was going to call PCP (primary care provider) and update her on what occurred, will continue to monitor. Review of the clinical record revealed General Noted which documented Resident #101 encouraged to go to the ER on [DATE] at 7:30 AM, 7:50 AM, and 8:35 AM. A General Note entered on 6/07/25 at 11:18 AM, documented CNA called this nurse to the resident's room, the resident requesting to go to the ED (emergency department) as her knee pain is not getting better. Review of a General Note entered on 6/7/25 at 5:26 PM revealed, in part.[name redacted, Resident #101] had been admitted for at least tonight as she has bilateral femur fractures at the knees.Review of a Consult note, dated 6/8/25 at 9:17 AM revealed in part: Chief Complaint: Bilateral leg pain.X-rays of her right knee shows a significantly displaced supracondylar femur fracture. Her bone is extremely osteoporotic.X-rays of her left knee shows a mildly displaced supracondylar femur fracture. Her bone is extremely osteoporotic.Plan: I explained to the patient that her best treatment option for her right leg would be an above-the-knee amputation. She is adamant that she does not want to do that. I did explain to her that fixing this fracture is difficult and trying to get this to heal is difficult and then it would be a lengthy operation and are not sure that she is a surgical candidate with her heart.Review of the hospital Discharge summary, dated [DATE], revealed orders for comfort measures only, re-admission to Nursing Facility, and referral for hospice services. During an interview on 7/08/25 at 3:45 PM, Staff C, CNA, confirmed working on 6/07/25 and had assisted Resident #101 at 5:20 AM with sit to stand lift transfer from toilet. Staff C recalled that Resident #101 typically sat on the toilet for long periods of time and had been very particular about how she liked to transfer in the stand lift. Staff C stated Resident #101 would always use a rolled blanket between her knees and elastic bands on the lift handles and had always refused the leg secure strap (silicone strap used on the sit to stand lift, that goes around the back of legs, and holds lower legs in place). Staff C reported that Resident #101 had also begun using a pillow in front of knees to prevent her knees from touching the lift. Staff C stated that the rolled blanket, pillow in front of knees, elastic bands to handles, and orthopedic boot to left foot were all in place and leg strap was not used during transfer on 6/07/25. Staff C reported that Staff F, LPN, had run the lift controls and lifted resident up from toilet, while Staff C assisted resident with perineal cares following bowel movement. Staff C recalled that Resident #101 had been standing in lift for a long period while cares were performed and Resident #101 was asked if she needed to sit down, to which the resident replied she was okay. Staff C claimed Resident #101's legs then gave out and she slipped downwards, knees landing on the lift foot platform, resident's hands continued to hold onto handles, and sling slid up towards the resident's neck. Staff C explained that herself, and Staff F slowly moved the lift out of bathroom, with the resident still in lift, into the bedroom for more room to assist Resident #101 off the lift. She stated they then called Staff B, CNA into room for additional assistance. Staff C stated Resident #101 continued to refuse to let go of lift handles and was screaming in pain. She stated she and the other 2 staff were able to convince the resident to let go of handles. Staff C explained Staff B held her torso while she and Staff F, LPN removed the sling from lift and then they assisted the resident to the floor next to bed. Staff C stated she then left room and returned with a full body lift and sling to assist Resident #101 up off the floor. Staff C explained Resident #101 refused to use the full body lift. Staff C revealed that Staff F, LPN directed the CNAs to lift Resident #101 into bed without use of mechanical lift. Staff C revealed that Staff B again held Resident #101's torso, while she and Staff F each held a thigh and physically lifted the resident from the floor onto her bed, then repositioned the resident with pillows in bed before leaving the room. During an interview on 7/08/25 at 2:30 PM, Staff B, CNA confirmed working on 6/07/25 at 5:20 AM and was called in to Resident #101's room to assist with fall from mechanical lift. Staff B recalled that upon entering room, she observed that Resident #101 had slid downwards on the sit to stand lift, with sling still attached, resident holding onto the handles, and knees noted to be down on the foot platform. Staff B reported that a regular sized bed pillow also appeared to have slid down during transfer and was noted to be on the foot platform as well. Staff B stated Resident #101 was screaming in pain related to knees, and was holding on to the lift for dear life, afraid to let go of the handles. Staff B recalled she was able to get behind Resident #101 and placed resident's arm around Staff B's shoulder, while sling loops were removed, then all three staff guided Resident #101 down onto the floor next to her bed. Staff B stated Resident #101 had been refusing the full body lift and Staff F, LPN gave direction to physically pick the resident up off the floor. Staff B reported she had again assisted behind Resident #101's torso, Staff C, CNA and Staff F each held a thigh and lifted her into her bed from the floor, then repositioned Resident #101 with pillows where the resident liked before leaving the room. During an interview on 7/09/25 at 3:12 PM, Staff F, LPN, confirmed working as nurse on duty on 6/07/25 at 5:20 AM and assisted with Resident #101's transfer from the toilet using the sit to stand lift with Staff C, CNA. Staff F confirmed that a rolled blanket, hand grips, orthopedic boot to left foot, and pillow in front of knees were used during the sit to stand lift transfer and that leg strap had been omitted. Staff F stated no one had ever put the leg strap on Resident #101 when she transferred in stand lift. Staff F recalled running the lift controls and lifted Resident #101 into a standing position, all the way upright (highest position of handles), while Staff C completed cares on Resident #101. Staff F reported that while Staff C performed cares, Resident #101 denied the need to sit down, then her knees started to go down and she ended up with her knees resting on the lift foot plate. Staff F reported the resident did not want to let go of the lift handles and said that her knees hurt. Staff F stated she called another staff member, Staff B, CNA into the room to assist in getting resident off the lift. Staff F recalled that Staff B stood behind Resident #101 and assisted with holding resident's torso as she and Staff C, CNA removed the sling from lift, and then all three staff members guided Resident #101 onto the floor, laid her on her side. Staff F reported that Resident #101 refused to use the full body lift to assist with getting her up from the floor and into bed, due to knee pain, Staff F stated she decided she and the other two staff members would instead physically lift the resident from the floor to her bed without the full body lift. Staff F, LPN recalled that Staff B, CNA assisted Resident #101 behind her torso while she and Staff C, CNA held each thigh and lifted her from the floor onto the bed. Staff F stated she offered Resident #101 pain medication and hospitalization which were initially both refused. Staff F stated that the resident did decide to accept pain medication but continued to refuse to go to the hospital. Staff F stated a fall assessment was completed after Resident #101 was removed from lift, picked up from the floor, and then put into bed, due to the fall being witnessed and knowing that the resident had not hit her head. Staff F stated that she believed Resident #101 should have been a full body lift for all transfers due to previous transfers in which knees gave out, but resident had refused full body lift and was changed back to sit to stand lift following a prior fall from the lift. During an interview on 7/09/25 at 3:00 PM, the Director of Rehabilitation (DOR), reported therapy had completed a transfer assessment on 12/27/24 and confirmed Resident #101 was able to transfer with a sit to stand lift, with the use of 2 staff and yellow (medium) sized sling. The DOR stated at the time of the assessment, therapy had worked with Resident #101 on standing endurance and maintaining position when mechanical lift is moved. The DOR stated Resident #101 had been assessed and utilized a rolled blanket between knees, an orthopedic boot to left foot, and grips on lift handles. The DOR denied knowledge of Resident #101 using a pillow in front of knees or refusal to use leg strap when transferring with sit to stand lift. The DOR revealed they would expect a new therapy transfer assessment to be completed when modifications are added or removed related to a mechanical lift transfer. The DOR stated therapy had not assessed the use of a pillow in front of knees or omission of leg strap. The DOR stated the use of pillow in front of knees on stand lift might increase her posterior lean but did not believe the pillow would affect her leg position. During an interview on 7/10/25 at 9:30 AM, Staff G, CNA, stated she worked with and transferred Resident #101 several times in the past month. Staff G stated staff had been placing a pillow in front of the resident's knees and did not hook the leg straps when transferring the resident. She stated she had reported a concern regarding the residents' knees not being up against the knee rest due to the use of the pillow, and her concern with the leg strap not being used. Staff G stated she reported these concerns to Staff F, LPN. Staff G reported that Staff F informed her that Resident #101 had requested the modifications to the stand lift and had been transferring like that. Staff G stated that Resident #101's transfers did not look safe and she requested to work on a different floor due to her concerns. Review of the employee files revealed Staff B, CNA; Staff C, CNA; and Staff F, LPN did not have training on the use of a mechanical lift prior to the use of the devices. During an interview on 7/09/25 at 5:00 PM, the Administrator stated the facility identified prior to 5/19/25 the facility had not provided training on the use of mechanical lift training with direct care staff. She stated a mandatory training was held on 5/19/25 to check staff off on the use of both the full body lift and the sit to stand lift. The Administrator stated that Staff B, CNA and Staff C, CNA had been on suspension pending investigation, and would require mechanical lift training prior to returning to work. During an interview on 7/10/25 at 3:30 PM, the Director of Nursing (DON) stated she had been notified on 6/07/25 around 11:00 AM that Resident #101 would be transferred to the hospital due to bilateral lower extremity pain. She stated around 5:00 PM she had been notified of the femur fractures following the fall from the mechanical lift when the resident's knees gave out. The DON reported that she was unaware of modifications (the rolled blanket between legs, elastic bands on handles, pillow in front of knees, or omission of the leg strap) being used on the stand lift when transferring Resident #101. The DON stated she would expect staff to notify her of items added or removed from the lift. The DON stated she would want to know why each item was in place, get therapy involved for an evaluation to make sure transfers were safe, and then get any approved modifications Care Planned. When queried the modifications, the DON stated that no modifications to the stand lift were included in the Care Plan related to transfers for Resident #101. The DON stated that if Resident #101 refused the leg safety strap, the sit to stand lift should not be used, and stated she would provide Resident #101 with a lot of education on the safety purposes of ensuring leg strap was in place during transfers. The DON stated mechanical lift training should be completed during staff orientation, before new hires begin working with residents. The DON reported that Staff F, LPN had been terminated due to failure to appropriately assess Resident #101 when on the floor and failed to utilize a full body lift to pick Resident #101 up from the floor. At 3:40 PM, the DON added the facility had a no lift policy in reference to picking residents up from the floor and expected that a full body lift would be used to assist residents up from the floor following a fall. Review of the undated facility policy titled, Skill Competency: [Brand name redacted] [NAME] Flex Lift, revealed a step to ask or assist the resident to place his or her feet on the foot plate, push the sit to stand lift towards the resident until it gently touches the resident's shin and explained that the leg support is silicone and would adjust itself based on pressure applied by the resident's knees. The document also included a step, prior to transfer, to attach the leg straps and explained that the leg strap was to be attached around the resident's legs, and to ensure the strap was not twisted. 2. Review of the MDS assessment dated [DATE], revealed Resident #102 had both short term and long-term memory problems and cognitive skills for daily decision making were severely impaired. The MDS identified Resident #102 had behaviors such as hallucinations, delusions, physical and verbal symptoms directed towards others which would interfere with resident's care and put resident at risk for physical illness or injury. The MDS revealed that Resident #102 utilized a wheelchair for mobility, was unable to ambulate (walk), and dependent on staff with all transfers. The MDS indicated Resident #102 had two falls without injury, and one fall with injury since the previous assessment. The list of diagnoses included Alzheimer's disease, osteoporosis, and anxiety disorder. Review of the Care Plan, revised date 6/28/25, revealed a Focus area to address I have limited physical mobility, weakness/impaired mobility/self-care abilities, Alz disease/Dementia with mood disturbance/hallucinations/delusions, anxiety, impaired hearing, radiculopathy of lumbar/pain, s/p (post status) fx (fracture) to distal end of left femur (immobilizer prn). Interventions included, in part:a. AMBULATION: I do NOT ambulate. Date initiated: 11/21/23, revised: 6/6/25. b. TRANSFERS: I use a full body lift with assist of 2 and medium (yellow) sling. May have sling under resident. Resident becomes combative when attempting to remove or place. Date initiated: 5/31/24, revised: 6/27/25. The Care Plan also included a Focus area, date initiated 11/23/23, revised 3/27/25 to address I am risk for falls. Cognitive impairment, hearing problems, repeated falls, chronic disease processes/med side effects, hallucinations/delusions. Interventions included, in part:a. Alert resident of changes to environment. Date initiated: 11/21/23.b. I have a non-skid (dycem - name brand of a non-skid material) in my wheelchair. Date initiated: 4/07/25. c. Monitor resident for side effects of medications per policy. Date initiated: 12/08/23. d. Orient to new environment, routine, and caregivers. Date initiated: 11/21/23. e. Place call light within reach and answer promptly. Date initiated: 11/21/23. f. PT evaluate and treat PRN. Date initiated 11/21/23.Review of a Resident Occurrence Report, dated 2/26/25 at 7:15 AM, revealed, in part: a. Location of Occurrence: Bathroomb. Type of Occurrence: Witnessed Fall, Other: assisted fall.c. Nature of injury: None. Medical Attention Required: No. First Aid Required: No.d. Witness/es: Yes. Name: [Redacted, Staff H]. Relationship to resident: CNAe. Analysis as to cause of Occurrence: CNA did not use maxi move with assistance as it was updated yesterday. f. Action to Minimize Reoccurence: update CNA on status change.During an interview on 7/10/25 at 9:45 AM, Staff H, CNA confirmed working with Resident #102 on 2/26/25. Staff H reported that Resident #102 transferred with a mechanical stand lift prior to a hospitalization in February. Staff H stated she was unaware that when the resident returned her transfer status changed. Staff H recalled transferring Resident #102 with stand lift to the bathroom and resident had let go of the lift just before reaching the toilet. Staff H stated Resident #102 slid down to the floor from the stand lift in front of the toilet. Staff H stated that after the fall the nurse informed her Resident #102 was changed to a full body lift. Staff H stated she did not check the Care Plan sheet prior to transferring Resident #102. She added the stand lift sling remained in Resident #102's room.Review of a Resident Occurrence Report, dated 3/13/25 at 3:15 AM, revealed, in part: a. Location of Occurrence: Roomb. Type of Occurrence: Witnessed Fall c. Nature of injury: None. d. Witness/es: Yes. Name: [Redacted, Staff G]. Relationship to resident: CNAe. Analysis as to cause of Occurrence: [no statement on report]f. Action to Minimize Reoccurence: [no statement on report]g. What suggestions do you have to prevent this from occurring again? CNA should read updated Care Plan of the residents every day, start of shift to be updated. During an interview on 7/10/25 at 9:25 AM, Staff G, CNA, confirmed working with Resident #102 on 3/13/25. Staff G reported that she transferred Resident #102 from her bed to a recliner using the mechanical stand lift. She explained upon reaching edge of recliner Resident #102 was unable to sit and instead slid down the front of the recliner onto the floor. Staff G recalled that in shift to shift report she was told that Resident #102 used the stand lift to transfer, and the stand lift sling remained the resident's room. Staff G stated after the fall, the nurse told her Resident #102 was a fully body sling. When queried about Care Plan changes, Staff G reported that the Care Plan sheets were kept at nurse's station and were not always updated timely. During an interview on 7/08/25 at 2:20 PM, Staff I, Clinical Coordinator, stated Care Plan sheets for staff reference are kept at the nurse's station. She explained she would update the sheets with any changes in a resident's care. Review of the electronic health record revealed Resident #102 had the following falls:a. A Resident Occurrence dated 2/11/25 at 4:35 AM, documented an unwitnessed fall out of wheelchair, found in Resident #102's room without injury. Intervention to frequently check on resident and complete a medication review. A Nursing Note entered on 2/11/25 at 6:24 AM, documented Resident b. A Nursing note entered on 4/15/25 at 5:59 AM, documented Resident #102 had unwitnessed fall in her room and was picked up from the floor, physically by a CNA and a Nurse, and transferred to her bed.During an observation on 7/08/25 at 1:45 PM, Resident #102 sat in her wheelchair in the first-floor lounge area with eyes closed and head falling forward. Nursing staff in and out of the area. On 7/10/25 at 9:28 AM, Resident #102 sat in wheelchair in the first-floor lounge area with eyes closed and head falling forward. Nursing staff in and out of the area. At 9:58 AM, a staff member greeted Resident #102 and stated she looked so tired. The resident remained in her wheelchair. During an observation on 7/10/25 at 2:28 PM, Resident #102 sat in wheelchair in the first-floor lounge area with arms forward and head bowed forward, resident's hair at cheeks in front of her face. Nursing staff in and out of the area.During an interview on 7/10/25 at 3:30 PM, the DON stated Resident #102 changed from requiring a one staff assist with a mechanical stand lift transfer to a two staff assist with the mechanical full body lift in February. The DON explained the change had been made due to increased agitation and combative behavior during transfers. When queried about CNA staff not knowing the change in transfer status, The DON stated Care Plan sheets are available at the nurse's station for staff. She added a new system had recently been implemented to electronically update staff of changes made to the Care Plans. The DON stated interventions in place for Resident #102's falls from her wheelchair included non-slip pad to wheelchair, assist her to bed when resident is sleepy, and looked into use of anti-tip bars on wheelchair. 3. During an interview on 7/08/25 at 1:30 PM, Staff A, CNA recalled on 3/08/25 between 6:45 PM and 7:00 PM, Resident #102 needed to use the bathroom. Staff A stated she followed after Staff J, CNA and Staff K, Certified Medication Assistant (CMA) to assist the resident. Staff A explained Resident #102 required a hoyer lift. Staff A stated that when she informed the Staff J and Staff K that she was going to go grab the lift, Staff K stated they didn't have time for that. Staff A stated Staff K then picked Resident #102 up from her wheelchair in a bear hug type hold, with his arms wrapped around the resident's mid-section. Staff A explained neither she or Staff J knew how to react initially and assisted with adjusting Resident #102's clothing for toileting task. Staff A stated that Staff K again assisted Resident #102 off the toilet in a bear hug type hold to transfer her back to the wheelchair as Staff A and Staff J assisted with clothing management. Staff A denied Resident #102 having injury during this transfer. Staff A stated she reported the incident to Charge Nurse, Staff F, LPN. She stated she also wrote a statement of the incident and gave it to DON, as well as a Human Resources staff. Staff A stated she received no follow up. During an interview on 7/10/25 at 2:26 PM, Staff J, CNA stated on 3/08/25, Staff A, CNA asked Staff J to get Resident #102 hooked up to the mechanical lift for transfer to the toilet. Staff J stated that Staff K, CMA, had gone with her into Resident #102's room and Staff A entered the room after. Staff J recalled that Staff K had stated he didn't have time for Staff A to get the mechanical lift and picked Resident #102 up from the wheelchair in a bear hug type hold, with his arms wrapped around the resident's mid-section. Staff J stated Staff K did not use a gait belt or the mechanical lift as required. Staff J stated that she assisted with Resident #102's clothing management as Staff K physically lifted the resident on to and off the toilet. Staff J stated she reported the incident the Charge Nurse, Staff F, wrote a statement of the incident and gave it to the DON, and emailed Human Resources but received no follow up. During an interview on 7/09/25 at 3:12 PM, Staff F, LPN, stated she worked on 3/08/25 and received a report from Staff A, CNA and Staff J, CNA that Staff K, CMA incorrectly transferred Resident #102 by physically lifting her without the use of a mechanical lift when Resident #102 required full body lift. Staff F stated that she confronted Staff K about the transfer of Resident #102 and he responded by saying, they're snitching on me. Staff F stated she wrote a statement of the incident and gave it to the DON but received no follow up. During an interview on 7/10/25 at 12:10 PM, Staff K, CMA confirmed working with Resident #102 approximately 3 months ago. Staff K stated communication related to resident transfer status was through stand-up meetings at the beginning of 1st and 2nd shift or reported verbally between staff. Staff K denied knowledge of resident Care Plan posted at the nurse's station. Staff K revealed that a full body mechanical lift transfer required 2 staff, and a sit to stand mechanical lift transfer would only require 1 staff. Staff K stated he followed Resident #102's transfer status and had not heard of any staff transferring Resident #102 incorrectly. When queried about mechanical lift training, Staff K denied attending any lift training but recalled there may have been a training set up for CNA staff to attend. During an interview on 7/10/25 at 3:12 PM, the DON stated she had a nurse tell her that Staff K, CMA transferred a resident without use of mechanical lift but when queried, Staff K denied such transfer. DON denied having any concerns with Staff K.Review of Staff K, Certified Medication Aide (CMA), employee file lacked documentation of mechanical lift training. Review of the facility policy titled, CC (Care Center) Resident Transfer Assessment Policy, dated April 2025, revealed a Policy statement which declared, in part: The residents.will be properly assessed to assure resi

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, employee record review, staff and resident interviews, and facility policy review, the facility failed to provide adequate supervision for residents who occupied a 14 room shift assignment. This resulted in harm to Resident #3 due to her walker being left out of reach when she was put to bed, leading to a fall with injury. Staff failed to perform safety rounds and the resident was not found by staff for a significant amount of time after the fall. Additionally, other residents of the shift assignment were left without call lights in reach and others with call lights going unanswered. The facility reported a census of 50 residents. Findings include: The Minimum Data Set of Resident #3 dated 12/3/24 identified a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. The MDS indicated the resident had not had any falls since the prior assessment. The Care Plan documented that on 9/6/24 the resident was deemed to be independent in her room with her walker. The General Note dated 1/5/25 at 6:20 am, authored by Staff D, Licensed Practical Nurse (LPN) noted the resident was found lying on the floor with blood all over the carpet, resident lying on her left side. The Note documented the resident's walker was tipped on its side by the dresser and the call light was secured to the side rail of the bed. The resident was bleeding from a wound to her head. Emergency services were called and the resident was transferred to the hospital. On 1/21/25 at 1:21 pm, the Administrator stated the staff on duty for the night shift of 1/4/25 was Staff D, LPN, and Staff A, Certified Nurse Aide (CNA). On 1/21/25 at 3:20 pm, Resident #3 stated that on the night she fell, the person who put her to bed put her walker out of reach. She stated when she went to get up, she tried to reach the walker but it was by her dresser and when she attempted to walk to obtain it, she fell and hit her head. She stated it was dark in the room and she could not see her clock. She said she remembered around 1:00 in the morning, staff had been in the room bringing fresh ice water. She thought it might have been around 2:00 in the morning when she fell. She said her normal routine is to use the toilet every two hours or so. She said she stayed on the floor until she heard footsteps in the hallway and then she called out for help. She stated Staff B, CNA was the first person who found her after she called for help. She thought it was around 6:00 in the morning when she was found. On 1/21/25 at 4:36 pm, Staff B, CNA stated he had arrived for work at 6:00 am on 1/5/25. He was not assigned to Resident #3's room. He said he found Staff A, CNA and received a report on his assigned residents. He then began his morning routine and after assisting another resident, he was transporting soiled linens down the hall when he heard Resident #3 calling for help. He stated he did not immediately know which room the call was coming from and he entered a couple of other rooms trying to locate who was calling out. When he entered the room of Resident #3, he noticed her lying on the floor with blood, and could tell she had been moving around due to the trail of blood on the carpet. He checked on her, found her to be alert, and immediately went to find the nurse for assistance. Staff B stated it was around 6:20 am when he found the resident on the floor. He said that the resident told him she thought she had been on the floor since approximately 4:00 am. He stated he did not see Staff A at any time after he received report from her and he did not know when she had left the building. On 1/22/25 at 7:32 am, the Household Coordinator stated Staff A was investigated following Resident #3's fall. He stated she had been terminated due to conduct. He said in the investigation of the fall, it was reported to him that the resident believed she had fallen in the time frame of 4:00 am. He said the night shift is to make rounds every two hours, and the shift begins at 10:00 pm. He said he would expect first rounds to be around 11:00 pm and then every 2 hours but there is flexibility on that with how long shift exchange takes. He stated the off going and on coming shifts are to do walking rounds together in each room. On 1/22/25 at 9:36 am, Staff C, CNA stated she was assigned to Resident #3 on the morning shift of 1/5/25. She stated she and Staff A began to do walking rounds with Resident #5, in room [ROOM NUMBER]. Resident #3 was in room [ROOM NUMBER]. She stated Staff A told her she had not checked on Resident #5 the entire night because she had not rung her call light. She said she immediately told Staff A all residents had to be rounded on, not only when call lights were rang and instructed her to go and check on Resident #5. She said she then turned back down the hall to wait for Staff A to finish so they could continue report but then started hearing someone calling for help. She said she entered the room of Resident #3 shortly after Staff B had entered. She said when they found Resident #3, Staff A had already left. She did not know when she left and never obtained a report from her on any other residents. Staff C stated that even for residents who are independent in their rooms, staff were still supposed to check on them, verify they have their call light and anything they need. She stated Resident #3 often still calls for help for going to the restroom or assistance with her shoes and other things. On 1/22/25 at 10:00 am, an attempt to reach Staff A by phone was made. The phone number had been disconnected. On 1/22/25 at 10:55 am, Staff D, LPN stated on 1/5/25 around 4:00 or 4:30 am, she had found Staff A sleeping in the lounge. She said for the last hour or so she had been on the other part of the hall, rounding with the other CNA on duty and assisting residents on that side of the hall. She said when she returned to the nurses station, she saw the call light monitor and noted there was a call light that had been ringing for over an hour. She said she went looking for Staff A and found her sleeping in the lounge area of the second floor. Staff D explained she had been the staff member who had assisted Resident #3 to bed the night before. She described she had administered the resident's bedtime insulin and eye drops and helped her to bed. She was unable to recall where the resident's walker had been left when she assisted her to bed. She said at night the CNAs normally do rounds at 1:00 am and 4:00 am. She said prior to 1:00 am, Staff A had told her she was going to go do rounds and Staff D told her to get her if she needed assistance but Staff A never asked for assistance that night. She said when day shift arrived, she instructed them to do walking rounds with Staff A and they stated they would but she was unaware of when Staff A left. Staff D recalled that prior to Resident #3 being found on the floor that morning, she was down the hall with the medication cart administering morning medications. She said she was coming down the hall and the CNAs came and got her explaining they had heard someone calling for help. She stated when she entered the room, the resident was lying on her left side, looking across the room. She described there being blood everywhere from the dresser to where the resident was lying by the bed. She stated she was not sure what the resident had hit her head on and could not recall seeing the walker. She stated she instructed the CNA to apply pressure to the wound, she went to get a second nurse and to call for an ambulance. Staff D commented when she had worked with Staff A on prior shifts, she had never caught her sleeping before. However, she said day shift staff often reported that several residents would be heavily wet with incontinence following shifts that Staff A was on duty on the night shift. On 1/22/25 at 12:39 pm, the Clinical Administrator stated she had spoken to Staff D regarding Resident #3's fall. She stated the conversation was via text and Staff D had notified her about finding Staff A sleeping in the lounge. She said Staff A was immediately suspended pending the outcome of the investigation. She said after reviewing the call light log, their main concern outside of Resident #3's fall was one call light that was on for over an hour prior to Staff D finding and waking up Staff A. The Clinical Administrator also said that Staff D had told her that she didn't think Staff A had ever rounded at all during the entire shift because two of the residents on the hallway required a 2 person assistance for rounds and Staff A never asked for help the entire shift. The Clinical Administrator stated the night shift is to round every 2 hours, which included checking all residents, changing residents who are incontinent, and repositioning those who need assistance to reposition. She stated that while Resident #3 was independent in her room, she would still expect her to be checked on for safety every 2 hours. Review of Staff A's employee file revealed a Notice of Termination. The Notice stated During the NOC (night) shift on 1/4/2025, the charge nurse reported that you were found sleeping in the lounge on the second floor. The charge nurse had to wake you to answer call lights. The Note further documented during a phone call with Human Resources, Staff A stated she was not originally planning to work that night due to low census but ended up picking up the shift for a coworker who asked her to work for her. Staff A reported she was not feeling well and she had an off day. The Notice also documented, after further investigation, that various residents assigned to Staff A were found to not have their call lights in reach, and were not checked and changed, resulting in residents being left in soiled clothing. The Notice documented Resident #3 being found on the floor suffering a head wound by the oncoming shift, and that the oncoming shift reported walking rounds were not completed at shift exchange. Staff A was notified on 1/9/25 via telephone that her employment was terminated. The Device Activity Report (Call Light Report) for the overnight shift on 1/4/25 for Staff A's room assignment revealed room [ROOM NUMBER] call light was triggered at 3:43 am and was answered at 4:44 am. The report revealed three other call lights during the shift were answered greater than 15 minutes after being rang. The Resident Assistant (CNA) Position Description and Performance Review directed the Resident Assistant is responsible for the provision of high-quality care and services to residents to support the choices of the residents, while maintaining consistency with regulations and established best practices. The Supervisor/Manager Coaching Note revealed Staff A had received coaching on 11/3/24 on the importance of rounding on all assigned patients, in addition to removing trash and soiled linens from the rooms. The Role Orientation Checklist of Staff A documented Staff A had received training on 11/12/2023 of maintaining resident room order including call lights and personal items to be kept in reach. The facility policy Call Light Policy, modified November 2022 documented the following: Point 1: All facility personnel must be aware of call lights at all times. Point 2: Answer all call lights promptly, whether or not you are assigned to the resident. Point 4: Answer all call lights in a prompt, calm, courteous manner, turn off the call light as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview, resident interview, and family interview the facility staff failed to properly insert a catheter for 1 of 3 residents reviewed which resulted in hospitalization (Resident #3). The facility identified a census of 33 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 3.27.24 indicated Resident #3 had diagnoses that included Parkinson's Disease, End Stage Renal Disease (ESRD), Benign Prostatic Hyperplasia with Lower Urinary Tract symptoms, Bladder Neck Obstruction, Urinary Tract Infection (UTI), and Diabetes Mellitus (DM). The assessment indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 (moderately impaired cognitive status), with the ability to understand others and make himself understood. The assessment indicated the Resident required maximum/substantial assistance to dependent on staff with activities of daily living (ADL's) and had a catheter. A Care Plan identified a Focus area of a catheter (revised 1.8.24). A Treatment Administration Record (TAR) form dated 5.1.24 thru 5.30.24 indicated the Resident's catheter as changed on 5.25.24 by Staff B, Registered Nurse (RN). During an interview 7.3.24 at 9:17 a.m. Staff D, Certified Nursing Assistant (CNA) indicated Staff B requested assistance with the resident's catheter change. Staff B removed the old catheter as Staff D observed thick, cloudy mucus discharge that followed the removal. Staff B used sterile technique with the re-insertion of the new catheter however the process had not appeared correct as the resident grimaced, shook, started sweating, and verbalized pain. Staff B met resistance during insertion so pulled catheter out a bit and pushed the catheter up more at which time there had been yellow urine return without blood in the catheter tubing. Staff B attempted to inflate the balloon but for some reason she met resistance and the fluid returned to the syringe. Staff B again re-adjusted the catheter a bit and pulled it back far enough that it protruded approximately 10 inches from the end of his penis. Staff D knew the catheter had not been placed properly at that point because too much of the catheter appeared exposed. Again, Staff B attempted to inflate the balloon but the fluid returned into the syringe. Staff B stated she had not known what had been going on. At that point Staff B requested Staff D to get Staff C, Licensed Practical Nurse (LPN). Staff C arrived and told Staff B the catheter had not been properly placed as Staff B continued to attempt to manipulate the catheter further into the penis with no urine return. Staff D reiterated the only urine return in the catheter tubing and/or bag had been with the original insertion. At that point Staff B re-inflated the balloon and put all 30 cc into the balloon and that had been the time the resident started continuously dripping, bright red blood from the end of his penis. The resident shook profusely because of the pain. Staff B asked the resident if he wanted something for pain which he agreed too. When Staff B left to retrieve the pain pill Staff D cleaned up the resident, placed a barrier under the resident, covered him up, turned the lights down and told him if he needed anything to use the call button. During an interview 7.2.24 at 4:45 p.m. Staff B, RN indicated on 5.25.24 she changed the resident's catheter with sterile technique. During the process she inserted the catheter to the bifurcation (where the catheter split into two (2) channels) of the catheter tubing, received a slug return followed by clear yellow urine so she inflated the balloon. Following the inflation of the balloon she pulled the catheter back gently to assure placement. The resident complained of pain and spasms so the staff member went and retrieved a pain medication. When she returned to the room she reassessed the resident's pain and catheter at which time she observed blood at the end of his penis. Staff B went and asked Staff C if the resident had ever bled for her during a catheter change. Both staff members returned to the resident's room again and noted the bleeding. Staff B had not been sure of the opinion of Staff C because she had been an LPN so she asked Staff A for another opinion. Staff A arrived in the resident's room with Staff B and at that time there had been a lot of bright red blood around the end of his penis with hematuria in the catheter tubing and bag. Staff A flushed the catheter line which flushed but with no return/back flow back into the catheter tubing. Staff A then removed the catheter. Staff A stayed with the resident as Staff B called the Physician, family, ambulance, and prepared for transport to the hospital. During an interview 7.2.24 at 4:07 p.m. Staff C indicated on 5.25.24 Staff B requested assistance after she changed the resident's catheter. Both nurses entered the resident's room and Staff B asked Staff C if the resident ever bled after she changed his catheter to which she answered no. Staff C indicated she had only been a nurse since July 2023 and the resident had been her 1st male catheter change but she had no problems with the insertion process. At that point they pulled back the resident's covers and noted bright red blood which came out of the tip of the resident's penis and around the catheter itself . Staff C noted the catheter protruded from the end of the resident's penis approximately 10 inches which made it obvious the catheter had not been properly placed. Staff C also noted blood in the catheter bag but could not tell if there had been urine present along with the blood. Staff C informed Staff B she felt the catheter had not been properly placed and she needed to deflate the balloon in the catheter which would have allowed her to guide the catheter into the resident's bladder however Staff B requested another opinion and that she planned to wait for a time to see if the bleeding subsided. Approximately 45 minutes later Staff B approached Staff C again and requested her assistance. Both nurses returned while Staff C deflated the catheter balloon, advanced the catheter close to the bifurcation of the catheter tubing until she observed urine return and re-inflated the balloon without difficulty however the resident continued to express severe pain as noted by his rapid breathing, pale skin, diaphoresis and stating oh, oh, oh through the process. Staff C exited the room and requested the assistance of Staff A. During an interview 7.3.24 at 10:54 a.m. Staff A confirmed on 5.25.24 she got wind of the catheter change situation so she asked Staff B what happened. Both nurses proceeded to the resident's room and when they pulled back the covers a blood clot approximately an inch wide and several inches long presented at the end of the resident's penis. Staff A assessed the catheter tubing and noted blood in tubing but no urine. Staff A also looked at the catheter bag and noted 10-20 milliliters (ml) of bright red blood present with no urine. Staff A then pushed 60 cubic centimeters (cc) of sterile water into the catheter tubing which went right into the tubing with no return however the process had been painful to the resident as noted by his facial expressions and his moaning. Staff A then removed the catheter and immediately after removal a continual flow of bright red blood drained from the resident's penis. At that point Staff A informed Staff B the resident required hospitalization. When the ambulance crew arrived they estimated the amount of blood loss at 100 ml of bright red blood. Staff A indicated she changed the resident's catheter in the past and it inserted without difficulty. A Transfer/Discharge Report form dated 5.25.24 confirmed the resident as transferred to the hospital related to excessive bleeding after a catheter change with complaints of pain. The resident experienced bleeding from the tip of his penis, around the catheter, and in the bag. The staff member deflated and advanced the catheter however the complaints of discomfort continued with no urine output. The catheter had been flushed with no return so staff removed the catheter. Upon removal the tip of the resident's penis became full of clots with a large fluid discharge that followed a stream of blood. The resident's blood pressure measured 117/109, pulse 116, blood sugar 203 and he experienced sweaty/clammy skin. The resident had been alert and oriented times (x) 4 (person, place, time and event). A Pre-hospital Care Report Summary Area Ambulance Service report form dated 5.25.24 with an in-route time of 4:46 p.m. included the following documentation: The patient alert as he laid in bed. The patient's airway patent, breathing rapid and labored with his skin pale, cool, and diaphoretic. Report received from the facility RN who stated that they changed out the patient's permanent catheter. Initial insertion of the catheter went fine. However, no output had been noticed after insertion. The catheter was flushed and the patient reported excruciating pain. No output was noted after flushing saline but the catheter flushed without problem. The catheter was pulled followed by 200 ml of bloody urine per the facility RN. A clot then formed at the end of the penis that stopped the blood flow. Vitals: Blood pressure: 175/91, pulse 129, respirations 36 and labored and pain a 9 on a scale of 0-10 with 10 having been the highest. A hospital Emergency Department Note dated 5.25.24 at 5:32 p.m. included the following: Presented with acute gross hematuria after a catheter had been exchanged at the nursing facility. Catheter no longer in place and currently had only minimal amount of bleeding at the meatus. However, given that he had gross hematuria the Physician had concerns that he may eventually form clots and became obstructed so discussed Lidocaine Uro-Jet (anesthetic) followed by three-way catheter placement which patient agreed upon. A Urology Consultation form dated 5.26.24 at 11:04 a.m. included the following: The patient had been well-known in urology with a chronic indwelling catheter and history of renal cell carcinoma. His catheter had been exchanged 5.25.24 however there had been difficulty. When the nurse called the Physician it sounded as though the catheter had been only advanced as far as the prostate and then inflated there which caused trauma. The patient began to have hematuria at that time as well. The patient had been admitted to the hospital and started on continuous and extensive bladder irrigation with additional hand irrigation 2 times for clot retention. During an interview 7.2.24 at 1:40 p.m. the resident and family indicated on 5.25.24 the family received a telephone call from Staff A, who reported there had been a bad catheter change by Staff B which ultimately resulted in hospitalization. One family member reported she arrived on 5.25.24 at approximately 5 p.m. at which time she found the resident in such pain he presented as diaphoretic (sweating) and shaking to the point when the ambulance crew arrived they asked her if someone had poured water on the resident. The family members also indicated Staff B had a similar incident with the resident when he resided at the previous location of the same nursing facility which also resulted in Physician intervention. On 5.27.24 the areas within the resident's urinary tract which continued to bleed had been cauterized. The family indicated the last traumatic change from Staff B had been on 6.15.23. 2. A Progress Note entry dated 6.10.23 at 2:58 p.m. included the following documentation from Staff B: Catheter replaced today per order. Tolerated the insertion but there had been mild bleeding coming from the Urethra. Good urine output and no clots noted in the urinary bag. Patient complained of penile pain. Physician Progress Notes dated 6.16.23 at 2 p.m. included the following documentation from a Urology Clinic: A [AGE] year old man came in today for an urgent visit as he had been catheter dependent from chronic bladder outlet obstruction. His catheter had been changed out last Saturday with worsening spasms and some hematuria which ultimately had been exchanged two (2) days ago. The Physician suspected a traumatic catheter placement with either the catheter itself caused the trauma during insertion or the balloon had been partially inflated in the bladder neck.