**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to use a Hoyer lift, as determined necessary by the resident's comprehensive care plan, during a transfer from the resident's bed to wheelchair for 1 (#1) of 3 (#1, #2, #3) sampled residents which resulted in a right humeral neck fracture.The deficient practice resulted in harm for Resident #1 on 07/14/2025 at approximately 10:30 a.m. when S6 agency CNA (Certified Nursing Assistant) transferred Resident #1 from the bed to a wheelchair with a stand and pivot method without utilization of a Hoyer lift. Resident #1 had an onset of acute pain to her right arm/shoulder and reported her right arm hit the wheelchair armrest during transfer. Resident #1 was care planned for activities of daily living self-care deficit with intervention of dependent in transferring with the use of Hoyer lift. S7 agency LPN (Licensed Practical Nurse), Hospice and Resident #1's Responsible Party were notified. Resident #1's right shoulder x-ray results dated 07/14/2025 revealed an acute complex impacted fracture involving the right humeral neck. Resident #1 was sent to the emergency room for further evaluation and treatment and returned to the facility with a right upper arm sling in place. Findings:Review of Resident #1's record revealed an admit date of 09/14/2023 with a re-admit on 12/13/2023 with diagnoses that included in part other sequelae of cerebral infarction, rheumatoid arthritis, generalized muscle weakness, muscle wasting and atrophy bilateral shoulders, and generalized osteoarthritis. Resident #1 was admitted to hospice for cerebral infarction on 12/16/2023 and passed away on 07/28/2025 in the facility.Review of Resident #1's Minimum Data Set assessment dated [DATE] revealed a Brief Mental Status of 8 which indicated moderately impaired cognition. Resident #1 had impaired functional range of motion in bilateral upper extremities and was dependent on staff for bed mobility and transfer.Review of Resident #1's Comprehensive Care Plan revealed the following problems with interventions: At risk for falls with intervention of transfer with Hoyer lift initiated on 11/23/2023.Activities of daily living self-care deficit with intervention of totally dependent in transferring with the use of Hoyer lift initiated on 01/01/2024. At risk for pain initiated 01/24/2024 with an update on 07/14/2025 for intervention right arm sling due to fracture of proximal end of right humerus.Review of the facility's Incident Report dated 07/14/2025 created by S7 agency LPN included in part S6 agency CNA was assisting Resident #1 into the wheelchair. Resident #1 reported during transfer she hit her right arm on the right wheelchair armrest and had an acute onset of pain rated 10 out of 10 to her right arm and more defined in right shoulder. Resident #1 was assessed and Resident #1 was able to move her hand but refused to perform range of motion to her right upper arm and shoulder due to pain. Resident #1's Hospice and Responsible Party were notified.Review of Resident #1's three view right shoulder x-ray results dated 07/14/2025 revealed an acute complex impacted fracture involving the right humeral neck.Review of Resident #1's Nurses Notes revealed in part Resident #1 was sent to the a local emergency room and returned to the facility the same day with a sling in place to her right arm.Review of the facilities training records revealed an Agency Facility Orientation sheet signed by S6 agency CNA on 04/14/2025. S6 agency CNA was oriented on locating CNA care guides including each resident's individual plan of care at CNA stations.Review of _______Staffing Agency records for staff in the facility July 2025 indicated S6 agency CNA worked at the facility on the following dates:07/01/2025; 07/05/2025; 07/06/2025; 07/08/2025; 07/13/2025; and 07/14/2025.During an interview on 08/26/2025 at 1:40 p.m. S8 agency CNA reported Resident #1 was able to make her needs known and was a two person assist with the Hoyer lift for transfers.During an interview on 08/26/2025 at 1:52 p.m. S9 LPN reported Resident #1 was able to make her needs known and was a two person assist with the Hoyer lift for transfers. S9 LPN reported a list of resident's activities of daily living needs was kept at the nurses' station and if the resident required a Hoyer lift for transfer there would be a sign over the resident's bed. During a telephone interview on 08/27/2025 at 1:40 p.m. S7 agency LPN reported on 07/14/2025 S6 agency CNA transferred Resident #1 using a turn pivot method. S7 agency LPN reported residents who required the Hoyer lift for transfer had signs over their bed and Resident #1 did not on 07/14/2025. S7 agency LPN reported S6 agency CNA did not ask her about Resident #1's transfer abilities prior to using a turn pivot method. S7 agency LPN reported Resident #1 complained of shoulder pain and reported Resident #1 had bumped her arm on the wheelchair when transferring from the bed to the wheelchair. S7 agency LPN reported she notified Hospice and an x-ray was ordered. S7 agency LPN reported the x-ray indicated a fracture and Resident #1 was sent to the emergency room for further evaluation and treatment.During an attempted telephone interview on 08/27/2025 at 2:25 p.m. with S6 agency CNA there was no answer. Surveyor immediately received a call back from S6 agency CNA's telephone number. During this interview, S6 agency CNA reported she had worked agency throughout the facility wherever she was assigned. S6 agency CNA reported she had training at the facility, reported a resident's level of care could be checked in the computer, and if a resident required a Hoyer lift for transfer there would be a sign over the resident's bed. During interview on 08/27/2025 at 3:34 p.m. S3 DON reported Resident #1 had been on hospice for about 2 years, was able to make her needs known, and was a two person assist with the Hoyer lift for transfers. When asked about Resident #1's incident on 07/14/2025 S3 DON reported Resident #1 told her she hit her elbow on the arm of the wheelchair when the CNA transferred her to the wheelchair. S3 DON reported Resident #1 was assessed and indicated it appeared as though Resident #1's shoulder had possibly come out of socket. S3 DON reported Resident #1 reported pain and guarded her arm and shoulder. S3 DON reported Resident #1's Hospice and Responsible Party were notified and an x-ray was ordered. S3 DON reported the x-ray indicated a fracture and Resident #1 was sent to the emergency room and returned that evening with a sling in place to her arm. During a telephone interview with S11 agency CNA on 09/02/2025 at 8:18 a.m. S11 agency CNA reported she did not recall having cared for Resident #1. S11 agency CNA reported she learned of resident's transfer abilities from report or in the resident's chart. S11 agency CNA reported she recalled a resident being hurt during transfer. S11 agency CNA reported she recalled S6 agency CNA crying and telling her she had transferred a resident and did not know she was supposed to use the Hoyer lift. S11 agency CNA reported there was not a sign over the resident's bed.During an attempted phone interview with Resident #1's Responsible Party on 09/02/2025 at 9:13 a.m. there was no answer.During an interview on 09/02/2025 at 10:05 a.m. S12 agency LPN reported Resident #1 was not able to move on her own, and was not able to make her needs known all the time. S12 agency LPN reported when she provided care to Resident #1 there was a sign over her bed that indicated Resident #1 was transferred with a Hoyer lift.During an interview on 09/02/2025 at 10:45 a.m. S13 CNA reported Resident #1 was transferred with a Hoyer lift and had a sign over her bed that indicated Resident #1 was transferred with a Hoyer lift.During an attempted telephone interview with Resident #1's Responsible Party on 09/02/2025 at 12:59 p.m. there was no answer.During an interview on 09/02/2025 at 1:10 p.m. S3 DON and S4 ADON reported new staff and agency CNA staff were oriented to the facility, given access to the CNA charting record, and trained on how to locate things in a resident's CNA charting including transfer abilities prior to working. S3 DON and S4 ADON reported the agency CNAs sign on the Agency Facility Orientation sheet indicating they were oriented to the facility CNA charting system.During an interview on 09/02/2025 at 1:24 p.m. S1 Quality Improvement Nurse and S2 Quality Improvement Nurse confirmed new staff and agency CNA staff were oriented to the facility, given access to the CNA charting record, and trained on how to locate things in a resident's CNA charting including transfer abilities. S1 Quality Improvement Nurse and S2 Quality Improvement Nurse confirmed the agency CNAs sign on the Agency Facility Orientation sheet indicating they were oriented to the facility CNA charting system.During an interview on 09/02/2025 at 2:20 p.m. S5 ADON confirmed new staff and agency CNA staff were oriented to the facility, given access to the CNA charting record, and trained on how to locate things in a resident's CNA charting including transfer abilities prior to working. S5 ADON confirmed the agency CNAs sign on the Agency Facility Orientation sheet indicating they were oriented to the facility CNA charting system. S5 ADON reported she had scheduled staff for Resident #1's hall. S5 ADON reported on 07/14/2025 S6 agency CNA arrived late to the facility because she had to call the agency to cover staff due to a late call in. S5 ADON reported she was called to go with S3 DON when the incident with Resident #1 occurred on 07/14/2025. S5 ADON reported she was told Resident #1 was transferred using a lift and pivot method. S5 ADON reported she did not recall Resident #1's transfer abilities without reviewing Resident #1's record.During an interview on 09/03/2025 at 10:15 a.m. S14 RN (Registered Nurse)/Wound Care Nurse reported Resident #1 could not do anything on her own and required the Hoyer lift for transfers. S14 RN/Wound Care Nurse reported there should have been a sign over Resident #1's door indicating she required a Hoyer lift for transfers.During an interview on 09/03/2025 at 11:00 a.m. S6 agency CNA reported on 07/14/2025 she came late and was given access to the CNA charting record and her assigned residents. S6 agency CNA reported she transferred Resident #1 with a stand and pivot method and Resident #1 told her she hit her arm on the wheelchair and complained of pain. S6 agency CNA reported she notified the nurse and DON and they assessed Resident #1, an x-ray was done, and Resident #1 had a fracture. S6 agency CNA reported she did not know Resident #1 was to be transferred with a Hoyer lift until after the incident. S6 agency CNA reported she did not know how to look up a resident's transfer abilities until after the incident. When asked if she had worked at the facility before S6 agency CNA reported she had worked at the facility once before that date and had not come back until recently. S6 agency CNA reported she was in-serviced regarding obtaining information regarding proper transfer after the incident with Resident #1.During an interview on 09/03/2025 at 12:30 p.m. S2 Quality Improvement Nurse reviewed S6 agency CNA's work history in the facility and reported S6 agency CNA first worked at the facility on 04/14/2025 and did not work again at the facility until 07/01/2025. S2 Quality Improvement Nurse confirmed S6 agency CNA had worked at the facility on 07/01/2025; 07/05/2025; 07/06/2025; 07/08/2025; 07/13/2025; and 07/14/2025 and confirmed documentation of S6 agency CNA's charting record entries for the dates worked in July 2025 which indicated proficient use by the CNA of resident's care guides.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to use a two-person transfer, as determined necessary by the comprehensive care plan, during a transfer from the resident's wheelchair to bed for 1 (#1) of 5 (#1, #2, #3, #4, and #5) sampled residents who required two-person assist with transfers. The deficient practice resulted in actual harm for resident #5 on 8/3/2022 when the resident was being transferred from a wheelchair to her bed. Resident #5 required two plus person physical assistance for bed mobility and transfers. Resident # 5 was being transferred by only one person when her left leg was hit on the bed rails and injured. On the morning of 8/4/2022 after resident #5 left leg was hit on the bedrail she complained of pain and discomfort. Resident #5 was assessed by a facility nurse, an x-ray was ordered and it was confirmed resident #5 had a left tibia/fibula fracture. Resident #5 was sent to a local hospital with at diagnosis of proximal fibula fracture with mid shaft comminuted spiral tibia fracture with non-displaced fracture of medical malleolus. Findings: Review of the facility's Safety and Supervision of Residents Policy revealed in part: Revised July 2017 Policy Statement: Our facility strives to make environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation Individualized, Resident - Centered Approach to Safety 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring the interventions are implemented correctly and consistently. Resident Risks and Environmental Hazards 1. B. Safe Lifting and Movement of Residents Review of resident #5's clinical records revealed an admit date of 7/8/2022 to this facility and a discharge date of 8/9/2022. Diagnoses include hemiplegia following a cerebral infraction affecting right dominant side, diabetes, arthritis, aphasia, Non-Alzheimer's dementia and muscle wasting and weakness. Review of resident #5's MDS (Minimum Data Set) with ARD (Assessment Reference Date) 7/15/2022 revealed the resident required two plus persons physical assistance for bed mobility and transfers. Review of resident #5's Comprehensive Plan of Care revealed she required staff assistance for all activities of daily living. Resident #5 needs included extensive assist with bed mobility, transfers, and toileting. Some of the approaches are staff will provide assistance with transfers using two people. 7/13/2022 May use sliding board for transfers. 8/5/2022 Transfer with mechanical lift. Review of a hand written statement dated 8/3/2022 by S4 Agency CNA (Certified Nursing Assistance) revealed: upon putting resident #5 in the bed during the transfer I heard her leg pop as we were putting her in the bed on yesterday and after I heard it pop I asked her was she okay. She said she was, but her legs always hurt like that and she was rubbing the left one saying that if you have it just right it'll go back right. When I was transferring her we started out using the sliding board but as we were using it she was having difficulty getting on it right so I turned her around towards the bed to put her in it so it would be more helpful for her to get in the bed. We did not use the sliding board because it was easier for her without it. Review of S14 LPN Charge Nurse Hand written statement, documented on 8/3/2022 she was scheduled to work on the same hall with S4 Agency CNA. I noticed S4 Agency CNA transferring resident #5 from her wheelchair to her bed by himself. Review of S10 CNA hand written statement dated 8/9/2022 documented, the day resident #5's had her incident I witnessed almost the ending I was in the process of putting resident ____ in the bed and I heard something like a loud yell. S4 Agency CNA was putting resident #5 in the bed by himself. Resident #5 said her leg hurt he continued to adjust her in the bed. As far as anyone helping S4 Agency CNA put resident #5 in bed there was no one helping him. Review of S2 DON (Director of Nursing) notes dated 8/4/2022 revealed the following documentation: 10:00 a.m. resident #5 was found to have pain by daytime nurse S13 LPN. S13 LPN assessed resident #5 left lower leg. Left lower leg noted swollen, warm to touch, and with bruising to medial aspect of leg. Left leg was noted to be turned in an outward position towards the patient's left side. Resident voiced the person who put her to bed from the wheelchair, the night before, bumped her leg on the bed frame, but he did not use the sliding board. Dr._____ was notified of the above findings and new orders were notified for x-ray and Doppler ultrasound of left leg. 3:40 p.m. x-ray tech arrived and completed x-ray indicating possible fracture. NP (Nurse Practitioner) aware of x-ray results and referred resident to ER (emergency room) for evaluation. 4:13 p.m. resident transport to ER for evaluation per____ stretcher prior to being able to do a Doppler ultrasound. 8/5/2022 at 11:00 a.m. Administrator and I spoke with resident #5's RP (responsible party) related to resident's incident on 8/3/2022. Informed resident #5's RP the CNA who performed the transfer from the wheelchair to the bed 8/3/2022 did not use proper procedure in placing resident in the bed with a slide board, even after resident stated to him to use it. CNA stated to me that he felt he could do the transfer without it. CNA will no longer be working at this facility because of the lack of proper transferring technique resulting in a resident's injury. Review of resident #5's Nurse Notes revealed: Nurse's notes dated 8/4/2022 at 10:00 a.m. S13 LPN (Licensed Practical Nurse) documented writer called to resident #5's room by PT (physical therapist) for resident complaint of pain to left lower leg. Examined and noted purple bruise to left lower leg, swollen, warm to touch and painful. Resident able to flex foot but notable to rotate inward. Resident reported she bumped her leg on bed frame when they were putting her to bed last night. Call to Dr. _____ notified new order for x-ray and Doppler study. Resident given APAP (Tylenol) 650mg (milligram) by mouth for pain. Review of nurse's notes dated 8/4/2022 at 11:30 a.m. S16 LPN documented late entry writer received report from floor nurse that resident has swelling and bruising to her left lower leg. Writer went to resident's room to evaluate resident left lower extremity, swollen, warm to touch with bruising noted to medial aspect of leg. Resident left foot is also turned outward. Resident stated that she is experiencing intense pain when writer touched her leg. When trying to lift resident's leg she screamed in pain. Floor nurse administered resident prn pain meds and contacted doctor for new orders Review of nurse's notes dated 8/4/2022 at 4:34 p.m. S16 LPN documented __ Imaging arrived to perform x-ray of resident's left leg at 3:40 p.m. Upon completion of x-ray tech showed NP (Nurse Practitioner) resident's imaging and NP stated that resident needs to be sent to the ER(Emergency Room) due to possible bone fracture. EMS (emergency medical services) was called and they arrived to facility at 4:13 pm to transport resident. Resident #5 left facility in stable condition. Vital signs 96% - 97.3-130/80-78-18. Resident #5 stated that she was still having intense leg pain. Review of the hospital emergency room notes dated 8/4/2022 at 4:55 p.m. revealed the chief complaint, leg injury. [AGE] year old female presents to the emergency department with complaint of left lower leg injury. Patient states she was being moved into bed when her lower leg hit the bed. Content: other (hit on side of bed). Extremity/Vascular: Left lower extremity: Knee joint (swelling noted), lower leg left; Lower leg: Inspection (bruising from mid to distal left anterior shin) and palpation (tenderness of mid left anterior shin distally to left ankle) and ankle joint (ankle deformity with left foot rotated laterally. Imaging Data Attestation imaging: X-ray left tib-fib (tibia-fibula) and left ankle: Proximal fibula fracture with mid shaft comminuted spiral tibia fracture with non-displaced fracture of medical malleolus, mortise appears intact. Impression: Fractured tibia and fibula as described. 2. Fracture medial malleolus. Attempted to interview S4 Agency CNA (Certified Nursing Assistant) by phone on 11/21/2022 at 1:34 p.m. and 6:04 p.m., with no answer. During an interview on 11/21/2022 at 9:36 a.m. S2 DON reported she had notified the Staffing Agency, S4 Agency CNA is not to return to work at this facility again. S2 DON reported S4 Agency CNA did not follow the resident plan of care. S2 DON reported S4 Agency CNA admitted he did not use the resident sliding board, he thought he could get her into bed by himself. S2 DON reported resident #5 did not complain of pain or anything until the next day. S15 Physical therapist reported to S13 LPN resident #5 complained of pain and discomfort to her left leg. At this time S13 LPN assessed resident #5 and found her left leg red, warm, painful and swollen. During an interview on 11/21/2022 at 10:15 a.m. S13 LPN reported she was notified by S15 PT (Physical Therapist) on 8/4/2022 at 10:00 a.m. that resident #5 was complaining of pain to her left lower extremity. S13 LPN reported she assessed resident #5 and found her left lower extremity to be swollen, red, warm, rotated outward and hurting. S13 LPN reported she notified S2 DON and she assessed resident #5 herself. S13 LPN reported she administered Tylenol for pain, she reported it was effective. S13 LPN reported the Unit Manager notified the family. S13 LPN reported resident #5's physician was notified. X-rays was ordered and it showed resident #5 had a fracture. S13 LPN reported resident #5 requires maximum assistance with 2 persons for transfer and bed mobility. S13 LPN reported resident #5 can use the sliding board with assistance. S13 LPN reported resident #5 is alert and able to make her needs know. During an interview on 11/21/2022 at 12:55 pm S21 Corporate Nurse reported they have a contract with _______ Staffing Agency that they are provided trained and competent staff. She further reported an agency CNA has a sign in code where they have access to all resident's plans of care. During an interview on 11/21/2022 at 1:51 p.m. S10 CNA reported she and another CNA were working on the hall with S4 Agency CNA on 8/3/2022. S10 CNA reported they passed resident #5's room in route to help put another resident to bed. S10 CNA reported she asked S4 Agency CNA if he need some help to put resident #5 in bed and he declined help. S10 CNA reported she knew he needed assistance because resident #5 requires 2 person assistance with transfers. She reported S4 Agency CNA refused any help. During an interview 11/21/2022 at 2:16 p.m. S14 LPN reported she works 2 days a week at this facility for ____ Staffing Agency. S14 LPN reported on 8/3/2022 she was in the room across from resident #5 room when she noticed S4 Agency CNA helping resident #5 from her wheelchair to the bed. S4 Agency CNA was in the process of transferring resident #5. S14 LPN reported before she could remove her PPE's (personal protective equipment) S4 Agency CNA had transferred resident #5 to her bed without any assistance. She reported S4 Agency CNA did not wait for any assistance, did not use a sliding board or the mechanical lift. S14 LPN reported the reason she was concerned about S4 Agency CNA moving resident #5 by himself is because he is a small man and she is a large woman. S14 LPN reported that entire night resident #5 never complained of foot or leg pain. S14 LPN reported she was aware resident #5 required extensive assistance, 2 plus assistance for transfers and bed mobility. During an interview on 11/21/2022 at 6:58 p.m. resident #5's RP (Responsible Party) reported her mother was not available for an interview. She reported her mother confirmed she tried to tell S4 Agency CNA he could not get her up by himself but he would not listen. She acknowledged her mother is over 6 feet tall and weighs over 200 pounds and S4 Agency CNA was a small guy. During an interview on 11/22/20222 at 9:10 a.m. S15 PT (Physical Therapist) reported he was performing side board training with resident #5. S15 PT reported the morning of 8/4/2022 he arrived in the resident's room and she complained of not feeling very good. She complained of pain to her left leg, so I said let's just do the training in the bed this morning. S15 PT reported resident #5's left leg was swollen, red and tender. S15 PT reported he notified the floor nurse, S13 LPN about resident #5 complaint about her left leg. S15 PT reported resident #5 required 2 plus person assistance with transfers and bed mobility.