**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff, Nurse Practitioner and the Medical Director's interviews, the facility failed to use the mechanical lift to transfer a non-weight bearing resident from a chair to the bed and instead used the stand and pivot method for transferring (A technique for moving where a resident stands with assistance and pivots on their feet then sits. This technique requires the ability to bear most of their body weight.) which resulted in a comminuted (the bone is broken into multiple small pieces) mildly displaced (bone fragments are slightly out of alignment) fracture of the distal tibia (large bone of the lower leg near the ankle) and proximal fibula (upper section of smaller bone in the lower leg just below the knee). This occurred for 1 of 3 residents reviewed for accidents (Resident #77). Findings included: Resident #77 was admitted to the facility on [DATE]. Diagnoses included osteoarthritis of the knee (a breakdown of the protective cartilage that lines the bones and joints), osteopenia (a loss of bone density causing the bone to weaken and an increased risk of fractures) and dementia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #77 was severely cognitively impaired and required extensive two-person assistance with transfers, and activities of daily living (ADLs). Resident #77 had no falls, a weight of 127 pounds, and received blood thinning medication. She was on Hospice services. The care plan dated 6/15/25 revealed Resident #77 had an ADL self-care deficit related to weakness, poor endurance, and poor cognition. Interventions included in part; total dependence with transfers using the mechanical lift with two-person assistance. A progress note dated 8/4/25 at 10:30 AM documented by the Hospice nurse revealed in part; this writer received notification today from the Hospice aide that Resident #77's right lower leg was noted to be bruised, swollen, and painful to touch this morning. Upon arrival Resident #77 was resting in bed with her eyes closed and aroused easily with verbal and tactile stimuli. She was oriented to person and unable to make her needs known and appeared weak and frail. Her right lower leg was bruised, bluish purple in color, swollen, and painful to touch She yelled out it hurts, it hurts when the area was touched and randomly when the area was not touched. Resident #77 was unable to state what happened to her right leg. The facility staff nurse (Nurse #2) was made aware of the right leg status. Resident #77 was medicated with Tylenol 650 milligrams during this visit for pain. Nurse Practitioner #1 is making rounds at the facility today and was notified. Resident #77 requires total assistance with all activities of daily living. A progress note dated 8/4/25 at 3:19 PM documented by Nurse #2 revealed Resident #77's x-ray impression revealed an acute nondisplaced oblique fracture of the proximal fibula, and distal tibia. Nurse Practitioner #1 was made aware. A progress note dated 8/4/25 at 6:32 PM documented by Nurse Practitioner #1 revealed in part; Resident #77 currently received hospice care. Nursing staff reported the presence of bruising on her right leg. Upon assessment, the right lower extremity exhibited mild swelling, and bluish discoloration consistent with bruising, and tenderness upon palpation. There was no active bleeding. The x-ray findings revealed an acute nondisplaced oblique fracture of the proximal fibula, and distal tibia. An orthopedic consult was ordered along with Tramadol 50 milligrams every 12 hours for pain. On 8/5/25 at 3:45 PM Resident #77 was transported by emergency medical services (EMS) to the hospital. A hospital note dated 8/5/25 at 10:56 PM revealed Resident #77 was seen in the emergency department, and vital signs were stable. X-rays showed oblique comminuted mildly displaced fracture of the distal tibial and proximal fibula. Orthopedics was consulted and recommended admission for pain control, there is no anticipated surgical intervention. A hospital orthopedic note dated 8/7/25 at 1:17 PM revealed Resident #77 was evaluated for a mildly displaced fracture of the distal tibial diaphysis and proximal fibular diaphysis. Impressions revealed fracture and osteoarthritis of the knee and osteopenia. Resident #77's Responsible Party stated Resident #77 had been non-ambulatory for several years, using a wheelchair and a slide board. She developed a urinary tract infection six months ago and has been bed bound since that time. The plan of care was to keep the splint in place and remain non-weight bearing. No orthopedic intervention was warranted at this time. Resident #77 returned to the facility. A facility investigation report on 8/5/25 revealed interviews were conducted with Nurse Aide #9 and #10 and concluded that the improper transfer of Resident #77 resulted in the fracture of the tibia and fibula. The Kardex audits concluded that several of the Kardex's needed to be updated and were updated today 8/5/25 by the Director of Nursing and the MDS nurse. Both Nurse Aide #9 and #10 were suspended until the investigation was complete. The timeline of events revealed:On 8/3/25 Resident #77 was up in her Geri chair most of the day at the nurses station. At approximately 7:00 PM Nurse Aide #9 and #10 went in to transfer Resident #77 back to bed. The lift sling was not positioned properly. They tried to reposition the sling, but Resident #77 resisted. Nurse Aide #9 and #10 got on each side and stood Resident #77 up and pivoted her a few steps to the bed from the chair. On 8/3/25 through 8/4/25 the night shift nurse and nurse aides (7:00 PM through 7:00 AM) reported Resident #77 rested well during the night. On 8/4/25 approximately 8:30 AM the nurse aide found a bruise to the outer right leg (shin) and notified Nurse #2. Nurse #2 notified the Nurse Practitioner and an x-ray was ordered. The x-ray resulted with a non-displaced fracture of the right lower leg.The root cause analysis determined Nurse Aide #9 and #10 did not follow the policy, or Resident #77's Kardex on the proper transfer which led to Resident #77 sustaining the injury. During an interview on 09/05/25 at 3:08 PM Nurse Aide #9 stated she had been a nurse aide for many years and was distraught when she learned that Resident #77 had fractured her leg after she and Nurse Aide #10 transferred Resident #77 back to bed on Sunday evening (8/3/25). Nurse Aide #9 stated they initially tried to transfer Resident #77 from the chair back to her bed using the mechanical lift, but the lift sling was not positioned right and kept sliding up her back because Resident #77 was agitated and flailing her arms. They decided since there were two of them and Resident #77 was small enough that they could get on each side of her and have her stand and pivot over to the bed. Nurse Aide #9 stated she was not aware that Resident #77 was non weight bearing and it never occurred to her that having Resident #77 stand and pivot could cause a fracture. She stated Resident #77 did not have any signs of an injury and no symptoms of pain or discomfort after being put back to bed or during the night. Nurse Aide #9 stated she was not aware of any injury until the following day (8/4/25) when she talked with the DON. She received education on 8/4/25 and was suspended from work. Nurse Aide #9 stated Resident #77's transfer status was listed on the Kardex which was located in her electronic medical record. Nurse Aide #9 indicated she did not review the Kardex that evening before attempting to transfer Resident #77. She stated she knew how to use the sling but due to Resident #77 becoming agitated they decided to stand and pivot her to the bed. Nurse Aide #9 stated she had provided care to Resident #77 many times and thought she would be safe to stand and pivot with two-person assistance, but she should not have done that. During a phone interview on 9/5/25 at 3:45 PM Nurse Aide #10 stated she and Nurse Aide #9 attempted to transfer Resident #77 back to bed that evening (8/3/25) with the mechanical lift, but the lift sling moved out of position. Resident #77 was yelling and agitated, so they decided not to use the lift and instead have her stand and pivot to her bed and thought that would be safe. Nurse Aide #10 stated she did not observe any injuries on Resident #77 after the transfer, and Resident #77 was not complaining of pain or discomfort once they got her back in the bed. She stated she did not review the Kardex which was located in the electronic medical record prior to transferring Resident #77. Nurse Aide #10 stated she was educated the following day (8/4/25) on properly transferring residents and reviewing the Kardex and was suspended from work. During an interview on 09/04/25 at 12:40 PM Nurse #2 stated she was the assigned nurse on Sunday 8/3/25 from 7:00 AM through 7:00 PM. Resident #77 was at her baseline and was up in her Geri chair at the nurses station for a while. She had dementia but no pain, no distress, and was talkative. When she returned to work the next morning (8/4/25) a nurse aide whose name she could not recall, asked her to come check Resident #77 because she noticed discoloration on one side of her lower leg and the area was painful to touch. Upon assessment Resident #77 would say no don't touch it. The Nurse Practitioner was in the facility at the time and came in to evaluate her. An x-ray was ordered which showed a right lower leg fracture. Resident #77 was administered pain medication. Nurse #2 stated the night shift nurse did not report any concerns regarding Resident #77 having pain or discomfort during the night. Nurse #2 indicated she was not sure of what the final determination was that caused the fracture and that Resident #77 had been on Hospice care. She stated Resident #77 was dependent on staff for care and required the use of the mechanical lift for transfers currently and prior to her fracture. An observation on 9/2/25 at 12:45 PM revealed Resident #77 was sitting up in bed being fed lunch by a staff member. She was oriented to person only and was smiling and talkative but could not engage in meaningful dialogue. A splint was in place on her right lower leg. There were no visible indicators of pain or discomfort. During an interview on 9/4/25 at 1:00 PM the Director of Nursing (DON) indicated Resident #77 was observed by Nurse #2 to have pain, swelling, and discoloration on the morning of 8/4/25. An x-ray was ordered and showed a lower leg fracture. An investigation on 8/4/25 determined Resident #77 was transferred inappropriately by the two nurse aides (Nurse Aide #9 and Nurse Aide #10) who worked the evening shift the previous night (8/3/25). The DON stated the nurse aides transferred Resident #77 back to bed without using the mechanical lift and instead had her stand and pivot. She stated initially Nurse Aide #9 and #10 attempted to transfer Resident #77 using the mechanical lift but the lift sling was not positioned properly underneath her. The nurse aides tried to reposition her, but Resident #77 resisted. The nurse aides then decided to get on each side of Resident #77 and have her stand and pivot to get into the bed. The DON stated Resident #77 had been non weight bearing for a while and required the use of the mechanical lift. She stated Nurse Aide #9 and Nurse Aide #10 were educated on 8/4/25 on the importance of following the Kardex (a resident care guide that shows essential information including transfer status) and correctly transferring residents, then were suspended until the investigation was completed. A phone interview was conducted on 9/16/25 at 3:00 PM with Nurse Practitioner #1. She stated she was notified on 8/4/25 of the bruising and swelling on Resident #77's lower leg. Nurse Practitioner #1 stated she ordered an x-ray which showed a hairline nondisplaced fracture of the tibia and fibula. During her evaluation of Resident #77 on 8/4/25 there were no deformities of the leg observed, and Resident #77 was not complaining of pain during that time. The decision was then made for conservative management due to being on Hospice care, having multiple comorbidities, and not being a surgical candidate. She discussed this plan of care with the Hospice nurse and Resident #77's Responsible Party who were in agreement. Nurse Practitioner #1 stated the following day the family decided to go ahead and send her to the hospital so that she could be seen by orthopedics sooner and she wrote the order on 8/5/25 to send Resident #77 out to the hospital. During an interview on 9/4/25 at 2:30 PM the Medical Director indicated she was made aware on 8/4/25 that Resident #77 had fractured her lower leg during a transfer. She stated Resident #77 had been non weight bearing for months and required the mechanical lift for transfers and was on Hospice services prior to the incident. The Medical Director indicted Resident #77 was able to continue to get up into the Geri chair, and she had no significant decline following the injury. During an interview on 9/5/25 at 3:00 PM the Administrator along with the Director of Nursing, and the Corporate Compliance Nurse each stated an investigation was initiated on 8/4/25 following the transfer that occurred on 8/3/25 which resulted in the injury. The root cause analysis determined the injury resulted when the two nurse aides (Nurse Aide #9 and #10) did not follow the policy or the Kardex on the proper transfer which led to Resident #77 sustaining the tibia- fibula fracture. The DON stated in-service training started with Nurse Aide #9 and #10 on 8/4/25, and Kardex audits began on 8/5/25 to ensure each residents transfer status was correct. The Administrator stated they made the decision to monitor residents for safe transfers and put it in their Quality Assurance (QA) program. The facility provided the following corrective action plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 8/4/25 at approximately 8:30 AM the nurse aide found a bruise to the outer right leg (shin) and notified Nurse #2. Nurse #2 notified the Nurse Practitioner and an x-ray was ordered. The x-ray resulted with a non-displaced fracture of the right lower leg. Resident #77 was assessed by Nurse Practitioner #1 on 8/4/25 and new orders were placed for an orthopedic consult and pain medications. On 8/4/25 the facility investigation of the injury revealed on 8/3/25 at approximately 7:00 PM Nurse Aide #9 and #10 went in to transfer Resident #77 back to bed. The lift sling was not positioned properly. They tried to reposition the sling, but Resident #77 resisted. Nurse Aide #9 and #10 stood Resident #77 up and pivoted her a few steps to the bed from the chair. On 8/4/25 Nurse Aide #9 and Nurse Aide #10 were given one-to-one education on the importance of following the Kardex and correctly transferring each resident to prevent injuries. The nurse aides were suspended until the investigation was completed. On 8/5/25 at 3:45 PM Resident #77 was sent to the emergency department per the family request for a quicker orthopedic consult. The Administrator and the DON completed a root cause analysis which determined Nurse Aide #9 and #10 did not follow the policy, or Resident #77's Kardex on the proper transfer which led to Resident #77 sustaining the injury. Address how the facility will identify other residents having the potential to be affected. On 8/5/25 the Director of Nursing along with the MDS nurse identified residents potentially impacted by the practice by completing Kardex audits on all current residents. The audit revealed 66 of 84 Kardex's had the correct transfer status. On 8/5/25 the Director of Nursing along with the MDS nurse interviewed the nurse aides and nurses on the halls for the correct transfer status of every resident and updated each Kardex. All Kardex's were updated by 8:00 PM on 8/5/25. Direct care staff were notified by the DON and the MDS nurse verbally in the facility on 8/5/25 and through in-service training conducted from 8/5/25 through 8/8/25 that the resident Kardex's had been updated and staff were to check the Kardex for all residents for accurate transfer status prior to transfers. On 8/5/25 the MDS nurse was informed she would be responsible for keeping the Kardex's updated to reflect the current transfer status of all residents. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.On 8/5/25 the Director of Nursing along with the Staff Development Coordinator in-serviced all staff including agency personnel on transfer safety, following the Kardex, and the facility transfer policy.All in-service training will be completed by 8/8/25. Any staff who had not completed education by 8/8/25 would not be allowed to work until training was completed. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.On 8/5/25 the decision was made by the Administrator to monitor the plan to ensure safe resident transfers and will be presented to the Quality Assurance Performance Improvement (QAPI) committee to include the Administrator, the Director of Nursing, MDS coordinator, therapist, and dietary manager. The Director of Nursing will monitor safe resident transfers through observations conducted on all shifts, along with reviewing resident care plans and auditing Kardex accuracy to ensure they reflect the correct transfer status using the quality assurance tool. This will be completed weekly for 2 weeks and monthly for three months to ensure compliance. Quality Assurance (QA) monitoring will begin the week of 8/11/25. Reports will be presented in the monthly QA committee by the Administrator or the Director of Nursing. Compliance will be monitored and the ongoing auditing program reviewed at the monthly QA meetings.The monthly QA meeting was held on 8/25/25 where the results of the audits and ongoing monitoring were discussed. The facility's alleged compliance date of the corrective action plan was 8/9/25. The corrective action plan was validated on 9/5/25. The following documentation was reviewed along with staff interviews and observations:Validation included staff interviews regarding the incident and in-service training that was received to ensure understanding and knowledge of the training provided. All of the staff members interviewed stated they had received training. In-service training included safe resident transfers, and the importance of reviewing the residents Kardex. Inservice logs were verified, and the initial and ongoing audits were verified. A resident transfer using the mechanical lift was observed. There were no concerns identified. The compliance date of 8/9/25 was validated.