Based on interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from neglect when a Certified Nurse Aide (CNA) inappropriately transferred a dependent resident, resulting in a fractured femur for one (1) of two (2) residents reviewed for accidents, Resident #3. Based on the implementation of the facility's corrective actions on 4/24/25, the deficient practice was determined to be Past Non-Compliance (PNC) with measures put in place to correct the deficiency effective 4/25/25, prior to the State Agency (SA) entrance on 4/29/25. Findings include: Review of the facility's policy, Abuse, Neglect, and Exploitation, revised 10/10/2022, revealed, Policy: This facility's policy is to protect each resident's health, welfare, and rights by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect .Definitions .'Neglect' means the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . A record review of the facility's investigation, dated 4/23/25, revealed that during the 3-11 PM shift on 4/23/25, two Certified Nurse Aides (CNAs) noted Resident #3 had a swollen and painful left hip. The Registered Nurse (RN) supervisor assessed the resident and arranged for transfer to an acute care hospital. The facility was notified that Resident #3 had sustained a fracture. Upon reviewing security footage, the Administrator observed that Resident #3 was assisted with lunch, then later wheeled to her room by her daughter-in-law, who left the resident alone in the room in a geri-chair at 12:53 PM. The assigned CNA (CNA #1) later entered and exited the room between 1:13 PM and 1:18 PM. When questioned, the CNA admitted that no one assisted her with transferring Resident #3 and that she had transferred her by placing one arm under the legs and one under the arms. The CNA was immediately suspended pending the facility's investigation. A record review of the admission Record revealed the facility admitted Resident #3 on 9/29/17 with diagnoses including Sick Sinus Syndrome. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/25 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated her cognition was severely impaired. Further review revealed Resident #3 was dependent upon staff for assistance with mobility including rolling left to right, moving from sitting to lying position, and getting in and out of the shower. A record review of the Emergency Department's Provider Notes, dated 4/24/25, revealed, .History .Nursing home reports that they noted that patient's left upper leg was swollen and appeared to be painful when they were changing her this evening .Left upper leg is swollen .X-ray hip - complete 2 views LT (Left) .Left hip arthroplasty with significantly displaced angulated overriding comminuted periprosthetic fracture of the proximal femoral shaft along the mid to distal aspect of the femoral stem component. Severe osteopenia. Soft tissue swelling . On 4/30/25 at 1:05 PM, during an interview with the Director of Nursing (DON), she explained that an investigation was initiated after the night shift charge nurse notified her on 4/23/25 that the resident had a knot with bruising on the left hip and appeared to be in pain. The DON instructed staff to contact the nurse practitioner, who recommended sending the resident to the ED (Emergency Department). The DON stated the ED physician questioned the injury mechanism and referred the incident to the Attorney General's office. The DON and Administrator questioned CNA #1 on 4/24/25, and CNA #1 admitted to lifting the resident out of her chair and into bed by herself. The DON stated that CNA #1 should have either used the stand-and-pivot method or a mechanical lift with other staff assistance. She emphasized the expectation that staff follow safe transfer techniques to prevent resident injury. On 4/30/25 at 10:42 AM, during an interview with CNA #1, she stated that on 4/24/25 she lifted the resident from the chair to bed using one hand under the hips and the other under the back. She acknowledged that lifting the resident in that way was inappropriate but felt comfortable doing so because of the resident's small size and her own strength. CNA #1 acknowledged the risk of injury, including broken bones, from improper lifting. On 5/1/25 at 9:20 AM, during an interview with RN #1 (Care Plan/MDS Nurse), she explained CNAs are instructed to use a lift if they are uncomfortable transferring a resident. She confirmed that Resident #3 was recommended for one-person stand-and-pivot transfer at the time of the injury. On 5/1/25 at 9:39 AM, during an interview with the facility's Occupational Therapist, he stated that therapy last saw Resident #3 on 9/9/24 and recommended one-person maximal assistance with a stand-and-pivot method. He stated this method was safest and that improper lifting could result in residents having serious injuries or falls. On 5/1/25 at 10:26 AM, during an interview with the Administrator, she confirmed CNA #1 admitted to lifting the resident inappropriately. The Administrator stated she did not believe the act was malicious and CNA #1 had no prior disciplinary issues, but the CNA was placed on leave pending investigation and later terminated. On 5/1/25 at 12:40 PM, during an interview with Resident #3's Resident Representative (RR), she stated the resident had experienced a recent incident that resulted in a hip fracture. She stated the injury occurred when CNA #1 lifted the resident from a chair to bed. She added that on 4/30/25 at 9:35 AM, the Administrator informed her that CNA #1 admitted to lifting the resident inappropriately. On 5/8/25 at 9:50 AM, during a post-exit interview with the Administrator, she explained that at the time of the inappropriate transfer, Resident #3 had a lift pad under her in the geri-chair because staff earlier in the day had used a mechanical lift to transfer her. She stated that while the resident could typically perform a stand-and-pivot transfer with assistance, her condition varied day to day. The Administrator emphasized that the staff are expected to evaluate transfers and, if a resident appears too weak or unstable to complete a safe pivot, a mechanical lift must be used. She explained that this expectation was reinforced through immediate in-services and education following the incident, which applied not only to residents with established lift orders, but to any resident whose transfer needs may change based on their condition at the time. The facility submitted the following corrective action plan: 1. Address how corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Certified Nurse Aide (CNA) (CNA #1) in question was suspended on April 24, 2025, pending investigation completion. Certified Nurse Aide (CNA) to be terminated week of April 28, 2025, following completion of investigation. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents using the lifts have the potential to be affected. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. An Emergency Quality Assurance meeting was called at 9:20 a.m. on April 24, 2025, to discuss injury to Resident. Read and sign immediate education was placed in the In-Service Binder by the Staff Educator on April 24, 2025, regarding: i. Lift Education - Patient Lifts Safety Guide ii. Policy and Procedure for Safe Lifting Program iii. Step-by-step Instructions to find lift orders in the kiosk for residents. iv. Policy and Procedure for Abuse, Neglect, and Exploitation A 100% audit was conducted by the Minimum Data Set (MDS) Nurses of all residents using sit to stand or total lifts to verify sling sizes, care plans, lift evaluations, and orders were correct and accessible to staff through the Electronic Health Record kiosk. A 100% audit was conducted by the Minimum Data Set (MDS) Nurses of all residents diagnosed with osteopenia or osteoporosis to review care plans. All Nurses and Certified Nurse Aides (CNA) will complete one-on-one checkoffs on proper use of the lift beginning April 24, 2025, by Quality Assurance (QA) Nurse, Staff Educator, Registered Nurse Supervisors, or DON. All Nurses and CNAs will continue to complete skills checkoffs for sit to stand lift and total lift bi-annually and on hire. In addition to lift usage review in Quality Assurance and Performance Improvement (QAPI) committee, the committee will review any specific changes or needs for further education of staff beginning during the QAPI meeting on April 30, 2025, and continue for three months. Conducted a directed in-service on April 24, 2025, at 3:00 p.m. with consultant via Zoom on abuse, neglect, and exploitation. Recording of in-service was distributed by Remind to all staff unable to attend to watch prior to working next shift. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. QA Nurse began spot rounds regarding proper use of lifts on April 24, 2025, and will continue every week for four weeks, then every month for three months, and then quarterly. Audit results will be reviewed by the OAPI Committee on April 30, 2025, and monthly for three months until such time consistent substantial compliance has been achieved as determined by the committee. 5. Indicate the date(s) the corrective action(s) will be completed. The corrective action will be completed by April 24, 2025, with audits to continue until substantial compliance is reached. Validation: The State Agency (SA) validated on 5/1/2025, through interview and record review that all corrective actions had been implemented as of 4/24/25, and measures put in place to correct the deficiency effective 4/25/25, prior to the SA's entrance on 4/29/25.

Based on record reviews, interviews, and facility policy review, the facility failed to implement a comprehensive care plan intervention for a resident transfer with a stand mechanical lift, resulting in left ankle fractures for one (1) of three (3) resident care plans reviewed. Resident #1. Based on the implementation of the facility's corrective actions on 1/17/24, the deficient practice was determined to be Past Non-Compliance (PNC) and the facility was in compliance effective 1/18/24. Findings include: A review of the facility's policy, Comprehensive Plan of Care, revised 10/10/22, revealed POLICY: It is the policy of this facility to .implement a comprehensive person-centered care plan for each resident .Policy explanation and Compliance Guidelines .3. The comprehensive care plan will describe .a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . A record review of the Care Plan revealed Focus The resident has an ADL (Activities of Daily Living) self-care performance deficit .Interventions .TRANSFER: The resident requires STAND lift X (times) 2 staff for transfers. Date initiated 1/10/24 . A record review of the facility's investigation, dated 1/18/24, revealed that on 1/17/2024, Resident #1 reported she had pain in her left foot and that her foot had hit something while she was being transferred from the wheelchair to the bed the prior afternoon (1/16/24). The resident received x-rays and upon obtaining the images, the Nurse Practitioner gave an order to transfer the resident to an acute hospital. Additional x-rays were obtained which revealed she had fractures. An investigation was completed, and it was found that CNA #4 was transferring Resident #1 and did not use a stand lift, which was what the resident required per her care plan. A record review of the admission Record revealed the facility admitted Resident #1 on 12/28/2011 with current diagnoses including Chronic Obstructive Pulmonary Disease and Muscle Weakness. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/2023 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. A record review of the Physician's Order Sheet, revealed Resident #1 had a Physician's Order, dated 1/10/24, for Stand lift x (times) 2 persons for transfers. A record review of the local hospital report, dated 1/17/24, revealed Resident #1 had an acute spiral fracture lateral malleolus (outside ankle) and an acute avulsion fracture medial malleolus (inner side of ankle). During an interview on 02/15/2024 at 09:25 AM, Resident #1 revealed a CNA came into the room and assisted her from the wheelchair to her bed and did not use any type of mechanical lift. During an interview on 02/15/2024 at 12:15 PM, with the Director of Nursing (DON), revealed CNA #4 did not use the stand lift as was required per the Physician's Order and plan of care for Resident #1. He stated that he expected the staff to review the resident's care plan to ensure the resident was properly transferred. During an interview on 02/15/2024 at 12:30 PM, with the Administrator, she revealed the resident was not transferred appropriately per the care plan and Physician's Order. She stated that the facility conducted a thorough investigation and reported the fracture to the authorities as required. CNA #4 was placed on leave pending the investigation on 1/17/24 and was terminated on 1/18/24 because she did not come to Human Resources for a meeting as requested. The Administrator said that residents and other staff were interviewed and there were no other instances in which a resident was inappropriately transferred. The facility had an emergency Quality Assurance Performance Improvement (QAPI) meeting on 1/17/24 at 2:40 PM to discuss the injury to the resident. The facility's policies regarding mechanical lifts were reviewed during the QAPI meeting and there were no changes recommended to the current policy. The facility provided immediate education beginning 1/17/24 on Lift Education, Policy and Procedure for Safe Lifting Program, Step by step instruction to find lift orders in the kiosk for residents, and policy and procedure for Abuse, Neglect and Exploitation. She explained that a 100% audit was conducted of all residents using the stand and full body lifts to verify sling sizes, care plans and Physician Orders to ensure all were correct and accessible to staff through the electronic health records. All nurses and CNAs completed one-on-one checkoffs on the proper use of the lift beginning 1/17/24 and no staff were allowed to work until in-service training was completed. Lift skills checkoffs for nurses and CNAs will be completed bi-annually and upon hire. The QAPI committee will review lift usage and the need for further education of staff for the next three months. Based on implementation of the facility's corrective actions on 1/17/24, the deficient practice was determined to be Past Non-Compliance (PNC) and the facility was in compliance effective 1/18/24. Validation: On 2/15/24, the State Agency (SA) validated the following: The SA validated through interviews and record review that the facility completed a thorough investigation and reported the event to the SA and the Attorney General's Office. The SA validated through staff interview and record review CNA #4 was suspended on 1/17/24 pending the facility's investigation and was terminated on 1/18/24. The SA validated through interviews and review of the QAPI sign in sheet the facility held a Quality Assurance Performance Improvement (QAPI) meeting on 1/17/24 at 2:40 PM and the facility's policies regarding mechanical lifts were reviewed. The SA validated through staff interview and in-service sign in sheets that the facility provided immediate education beginning 1/17/24 on Lift Education, Policy and Procedure for Safe Lifting Program, Step by step instruction to find lift orders in the kiosk for residents, and policy and procedure for Abuse, Neglect and Exploitation. The SA validated through staff interview and record review the facility conducted a 100% audit of all residents using the stand and full body lifts to verify sling sizes, care plans and Physician Orders to ensure all were correct and accessible to staff through the electronic health records. The SA validated through staff interview and record review of competency checkoffs, that all nurses and CNAs completed one-on-one checkoffs on the proper use of the lift beginning 1/17/24 and no staff were allowed to work until in-service training was completed.

Based on record reviews, interviews, and facility policy review, the facility failed to ensure a resident was free of accidents and/or hazards during a transfer when a Certified Nurse Aide (CNA) transferred Resident #1 from the wheelchair to the bed without using the required stand mechanical lift, resulting in left ankle fractures for one (1) of three (3) residents reviewed for accident/hazards. Resident #1. Based on the implementation of the facility's corrective actions on 1/17/24, the deficient practice was determined to be Past Non-Compliance (PNC) and the facility was in compliance effective 1/18/24. Findings include: A review of the facility's policy Safe Lifting Program, revised 09/22/2022 revealed, POLICY: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury . Compliance Guidelines .3. Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs .10. Two staff members must be utilized when transferring residents with a mechanical lift .13. Staff members are expected to maintain compliance with safe handling/transfer practices . A record review of the facility's investigation, dated 1/18/24, revealed that on 1/17/2024, Resident #1 reported she had pain in her left foot and that her foot had hit something while she was being transferred from the wheelchair to the bed the prior afternoon (1/16/24). The resident received x-rays and upon obtaining the images, the Nurse Practitioner gave an order to transfer the resident to an acute hospital. Additional x-rays were obtained which revealed she had fractures. An investigation was completed, and it was found that CNA #4 was transferring Resident #1 and did not use a stand lift, which was what the resident required per her care plan. A record review of the local hospital report, dated 1/17/24, revealed Resident #1 had an acute spiral fracture lateral malleolus (outside ankle) and an acute avulsion fracture medial malleolus (inner side of ankle). A record review of the Physician's Order Sheet, revealed Resident #1 had a Physician's Order, dated 1/10/24, for Stand lift x (times) 2 persons for transfers. A record review of the admission Record revealed the facility admitted Resident #1 on 12/28/2011 with current diagnoses including Chronic Obstructive Pulmonary Disease and Muscle Weakness. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/2023 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. On 02/15/2024 at 09:25 AM, an interview with Resident #1 revealed a CNA came into the room and assisted her from the wheelchair to her bed. She stated that she bumped her leg on something, but she did not report that her foot was hurt until the next morning. She said the nurse came and looked at her foot and then she was sent to the hospital. She confirmed the CNA transferred her by helping her to stand and did not use any type of mechanical lift. On 02/15/2024 at 10:30 AM, an interview with CNA #1 revealed there was information on the kiosk that indicated how a resident was to be transferred, including if a mechanical lift was required or how many staff were required to complete the transfer. On 02/15/2024 at 12:15 PM, an interview with the Director of Nursing (DON) revealed he assisted with the investigation in which CNA #4 transferred Resident #1 to the bed without using the mechanical lift. He acknowledged that CNA #4 did not use the stand lift as was required per the Physician's Order and plan of care for Resident #1. He stated that he expected the staff to review the resident's care plan to ensure the resident was properly transferred. On 02/15/2024 at 12:30 PM, an interview with the Administrator revealed the resident was not transferred appropriately per the care plan and Physician's Order. She stated that the facility conducted a thorough investigation and reported the fracture to the authorities as required. CNA #4 was placed on leave pending the investigation on 1/17/24 and was terminated on 1/18/24 because she did not come to Human Resources for a meeting as requested. The Administrator said that residents and other staff were interviewed and there were no other instances in which a resident was inappropriately transferred. The facility had an emergency Quality Assurance Performance Improvement (QAPI) meeting on 1/17/24 at 2:40 PM to discuss the injury to the resident. The facility's policies regarding mechanical lifts were reviewed during the QAPI meeting and there were no changes recommended to the current policy. The facility provided immediate education beginning 1/17/24 on Lift Education, Policy and Procedure for Safe Lifting Program, Step by step instruction to find lift orders in the kiosk for residents, and policy and procedure for Abuse, Neglect and Exploitation. She explained that a 100% audit was conducted of all residents using the stand and full body lifts to verify sling sizes, care plans and Physician Orders to ensure all were correct and accessible to staff through the electronic health records. All nurses and CNAs completed one-on-one checkoffs on the proper use of the lift beginning 1/17/24 and no staff were allowed to work until in-service training was completed. Lift skills checkoffs for nurses and CNAs will be completed bi-annually and upon hire. The QAPI committee will review lift usage and the need for further education of staff for the next three months. Based on implementation of the facility's corrective actions on 1/17/24, the deficient practice was determined to be Past Non-Compliance (PNC) and the facility was in compliance effective 1/18/24. Validation: On 2/15/24, the State Agency (SA) validated the following: The SA validated through interviews and record review that the facility completed a thorough investigation and reported the event to the SA and the Attorney General's Office. The SA validated through staff interview and record review CNA #4 was suspended on 1/17/24 pending the facility's investigation and was terminated on 1/18/24. The SA validated through interviews and review of the QAPI sign in sheet the facility held a Quality Assurance Performance Improvement (QAPI) meeting on 1/17/24 at 2:40 PM and the facility's policies regarding mechanical lifts were reviewed. The SA validated through staff interview and in-service sign in sheets that the facility provided immediate education beginning 1/17/24 on Lift Education, Policy and Procedure for Safe Lifting Program, Step by step instruction to find lift orders in the kiosk for residents, and policy and procedure for Abuse, Neglect and Exploitation. The SA validated through staff interview and record review the facility conducted a 100% audit of all residents using the stand and full body lifts to verify sling sizes, care plans and Physician Orders to ensure all were correct and accessible to staff through the electronic health records. The SA validated through staff interview and record review of competency checkoffs, that all nurses and CNAs completed one-on-one checkoffs on the proper use of the lift beginning 1/17/24 and no staff were allowed to work until in-service training was completed.