**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident interview and staff interviews, the facility failed to perform a transfer from the bed to wheelchair in a safe manner for 1 of 3 residents reviewed for accidents (Resident #26). Resident #26 had pain and sustained a skin tear (laceration) to midline shin (the front of the leg below the knee) with significant depth to left lower leg which required a visit to the emergency department and sutures. Findings included: Resident #26 was admitted to the facility on [DATE] with the diagnoses that included hypertension, hyperlipidemia, polyneuropathy and anemia. The admission Minimum Data Set Assessment (MDS) dated [DATE] revealed that Resident #26 was coded as cognitively intact, required wheelchair for mobility, required partial/moderate assistance for a chair-to-bed transfer. On the same assessment, she was also coded as requiring supervision or touching assistance with personal hygiene. Documentation on Resident #26's care plan initiated on 8/6/2025 revealed a focus area of Activities of Daily Living (ADL) self-care performance deficit due to impaired, limited mobility, limited Range of Motion (ROM), musculoskeletal impaired and pain. The care plan revealed Resident #26 required the intervention of 2-person assistance with transfers. Review of undated Kardex (a quick- reference tool that provides a concise summary of a patient's essential information and daily care needs for handoff between nursing shifts) report revealed Resident #26 require 2-person assistance with transfers. Review of the transfer status form for Resident #26 dated 08/08/2025 revealed her transfer status was maximum assistance with 2-person assist due to limited shoulder pain. Review of the August 2025 Medication Administration Record (MAR) revealed Resident #26 was not prescribed an anticoagulant medication. Review of the incident report dated 08/08/2025 documented Resident #26 sustained skin tear during transfer from bed to wheelchair. Resident #26 stated she told Nurse Aide (NA) #1 to stop when being transferred because she was hurting her and that she required assist of 2 however NA #1 continued to transfer her. It documented Resident # 26 was transferred to the emergency department for further evaluation. NA #1 was immediately suspended pending investigation. Review of NA #1's statement dated 08/08/2025 revealed she was getting the patient up out of bed, the resident was able to turn and sit on the side of bed, and the resident stated sometimes it took two people to get her up. NA #1 told the resident that she was able to do it alone. During a phone interview on 08/19/2025 at 11:55AM, NA #1 stated another staff told her several times to get Resident #26 up so she could go to therapy. NA #1 stated she proceeded to get the resident up without asking for assistance from another staff member. She stated during the transfer of the resident her lower leg bumped on the wheelchair, and the leg started bleeding. NA #1 stated she did not review the Kardex which indicated the resident needed 2-person assistance for transfer. She added that she realized the resident required 2-person assistance after the skin tear accident. NA #1 stated the resident appeared very fragile and she felt that she could transfer her without assistance from another staff member from bed to her wheelchair. Review of skin tear assessment for Resident #26 dated 08/08/2025 revealed the site of left lower leg (front). It documented skin tear laceration, heavy bleeding and pressure applied. Exact measurements could not be obtained. Resident #26 wound was dressed and cleansed for transport to emergency room (ER) per Medical Doctor's (MD) order for further evaluation. The review of the assessment revealed the resident was given Acetaminophen (pain medication) 325 milligrams (mg) 2 tablets for pain. During an interview on 08/19/2025 at 1:28PM, Nurse #2 stated she was notified about Resident #26's skin tear on 08/08/2025. She stated she observed the resident was bleeding with a deep cut. She added she applied pressure on the deep cut to stop bleeding. She reported the bleeding was heavy, the provider was notified, and he ordered the resident to be sent to the Emergency Department. Review of the Emergency Department (ED) note dated 08/08/2025 documented the chief complaint was the resident was taken to ED after getting small laceration to left shin due to hitting it on a wheelchair. The resident was given (pain medication) enroute to the ED. The note documented a skin tear- about 6 centimeters (cm) to left lower leg which was bleeding, had controlled distal pulses (a pulse felt in an artery located further away from heart) capillary refill and had no neurovascular (the interconnected of nerves and blood vessels) deficits. ED note also documented the medical decision described the resident as coming to the ED with skin tear and laceration to left lower leg, which was repaired using sutures, irrigated and dressed by the provider. Review of the Health Status note dated 08/11/2025 by Nurse #2 documented procedural notes post ED visit for laceration management obtained. Three sutures internal placement will dissolve. (Bandage) placed. Light amount serosanguinous drainage noted. Physician Assistant (PA) ordered dressing changes daily. During an interview on 08/19/2025 at 10:07 AM, Resident #26 stated that she informed NA #1 to transfer her using 2-person assist but NA #1 stated she could transfer her by herself. She reported during the transfer; her leg bumped into the wheelchair, and she felt a sharp pain coming from her left leg. The resident stated that she noticed the blood coming from her leg. She further added a nurse came and dressed the deep skin tear and then she was sent out to the ED. During an interview on 08/19/2025 at 9:48AM the Physical Therapist (PT) stated when the resident was admitted to the facility on [DATE], the resident was assessed as needing 2-person assistance for transfer due to limited shoulder pain. The PT stated the MDS Coordinator was informed about the resident's need for 2-person assistance, and it was added to the resident's care plan. During an interview on 08/19/2025 at 1:48 PM the MDS Coordinator stated the common practice at the facility was that they had weekly meetings to discuss the newly admitted resident's needs. She reported the Physical Therapist notified her about Resident #26 requiring 2-person assistance and the requirement was added in the resident's Kardex and the care plan. During an interview on 08/20/2025 at 10:53PM the Director of Nursing (DON) stated Resident #26 required 2-person assist and NA #1 transferred the resident by herself from the bed to the wheelchair. DON stated the expectation was NA #1 to have reviewed the Kardex before assisting Resident #26. The DON indicated Resident #26's Kardex indicated she required 2-person assistance. The DON further stated NA #1 was an agency staff and was suspended. The DON added agency staff and facility staff were all in serviced in reference to reviewing and following the care guide before transferring the residents. During an interview on 08/20/2025 at 11:45 AM the Administrator stated NA #1 should have reviewed the Kardex before transferring the resident from bed to the wheelchair. She reported the resident should have been transferred using 2-person assist but the NA #1 used one person assist. She stated the agency NAs and the facility NAs were in serviced in reference to reviewing Kardex so they can be aware of how many persons were required to transfer the residents. The facility provided the following corrective action plan with a completion date of 08/12/2025 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 8/8/2025 skin tear assessed by wound nurse and MD and pressure dressing applied. Head to toe assessment, wound assessment completed by the wound nurse.Resident was transferred to the emergency room (ER) for further evaluation.On 8/8/2025 the resident's wheelchair (w/c) was removed from service and inspected by the facility maintenance director.The results included: No concerns noted for wheelchair. 2. Address how the facility will identify other residents having the potential to be affected. On 8/8/2025 the DON identified residents that were potentially impacted by this practice by completing head to toe audits on all residents with a Brief Interview of Mental Status (BIMS) less than 13 (intact) and assessing for any skin integrity concerns to include skin tears/bruising or signs of potential injuries. The results included: No concerns identified.On 8/8/2025 all residents with a BIMS below 13 had a head-to-toe assessment completed by the assigned nurse with no concerns identified.On 8/8/2025 all w/c's were assessed by the facility maintenance director for any concerns to include areas that may be rough/cracked or malfunctioning. The results included: No concerns identified. On 8/08/2025 the DON/ Staff Development Coordinator (SDC) began direct observation of Nurses/NA's/Agency scheduled to work on that day (08/08/2025) and evening/night shift's ability to access the Kardex, to verbalize understanding of process of resident refusal/assuring resident safety and notification of the nurse of any refusal. The results included: 5 of 5 nursing staff/agency directly observed were able to access the Kardex prior to care, verbalize steps to take to assure resident rights/resident refusal were followed and understand the nurse notification process for any refusal of care/transfer etc.On 8/11/2025, residents with BIMS of 13 or above were interviewed by DON/Social Worker (SW) for any concerns related to care concerns/resident refusal concerns or transfer concerns. The results included: No concerns identified.On 8/ 11 /2025 the DON/ MDS nurse began auditing all resident care plans and transfer status to assure the transfer status was current and the care plan/Kardex were in compliance. The results included: All transfers current and in compliance. As of 8/11/2025 any above identified areas of concern were in compliance. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.On 08/8/2025, the DON/SDC began in-service of all nursing staff (including agency) on: Transfer Safety, Kardex Utilization, and for all staff and agency on Resident Rights/Refusal of Care/Treatment and Abuse/Neglect. To include Full Time(FT)/ Part Time (PT) and as needed (PRN) staff. Accessing the Kardex prior to care How to access the Kardex Using the correct transfer technique and always using 2 staff for all mechanical lift transfers. Assuring resident rights and refusal of care are honored by staff even if the resident is confused. Assuring resident rights are honored when a resident asks staff to stop a task. Assuring resident safety if a resident refuses care or is in the process of care or being transferred, Notification of the nurse of all resident refusals or requests you to stop care/transfer being provided. Reporting any incidents that occur while caring or transferring a resident to the assigned nurse. Abuse/Neglect- types, reporting and assuring resident safety.The Director of Nursing will ensure that any of the above identified staff who does not complete the in-service training by 8/11 /2025 will not be allowed to work until the training is completed. This in-service was incorporated into the new employee facility orientation for the above-mentioned staff.4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. - Monitoring plan was initiated on 08/08/2025. The DON/designee will monitor Transfer/ Kardex utilization/ Resident Rights Process weekly for 2 weeks and monthly for 3 months for compliance with assuring resident requests are honored and that the Kardex and transfer process are followed to assure resident safety. Reports will be presented to the monthly Quality Assurance (QA) committee by the Administrator or Director of Nursing to ensure corrective action is initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the monthly QA Meeting. The monthly QA Meeting is attended by the Administrator, DON, MDS Coordinator, Therapy, Health Information Management (HIM), and the Dietary Manager. Date of Compliance: 8/12/2025Validation of the corrective action plan was completed on 08/20/2025 by the following. The Quality Assessment and Performance Improvement Plan was reviewed with corresponding documentation to support the actions taken by the facility. Interviews were conducted with a sample of nurses and nurse aides from all nursing shifts to verify education was provided for licensed nurses and certified nursing assistants regarding assuring the staff were reviewing the Kardex before performing a transfer. The documentation for in-service records was reviewed. Social Worker #1 was interviewed to confirm all alert and oriented residents were interviewed to verify no other inappropriate transfers had occurred. During the investigation, NA#2 was observed transferring Resident #26 according to her plan of care. The MDS nurse was interviewed to confirm the Kardex, and care plans were up to date indicating how many people each resident required for the transfer from bed to wheelchair. The audits were verified as well as the ongoing monitoring audits to ensure residents were being transferred with appropriate person assistance.The corrective action plan completion date of 8/12/2025 was validated.