Based on record review, review of the facility reported incident (FRI) investigation, and review of facility policy, the facility failed to properly utilize assistive devices necessary to prevent accidents for 1 of 1 sampled resident (Resident #150) who fell during a staff assisted transfer. Failure to utilize the gait belt resulted in Resident #150's fall/fracture and placed all residents transferred with a gait belt at risk for injury. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 02/26/25. The facility implemented corrective action immediately, completed corrective action on 03/03/25, and continues with staff education and monitoring. Review of the facility policy titled Gait Belt Use occurred on 06/19/25. This policy, revised August 2023, stated, . Use an underhand grasp to hold on to the gait belt . Review of Resident #150's medical record occurred on all days of survey. Diagnoses included right femur fracture. The care plan stated, . TRANSFER: assist by 1 staff with gait belt . I am at risk for falls r/t [relate to] cognitive impairments, gait/balance problems, deconditioning . I have parkinsonism affecting my balance and mobility. A FRI investigation, dated 03/03/25, stated, . [Resident #150] was being assisted by [CNA [#3] in her room. [The] Resident is care planned as assist of one with [a] gait belt for transfers and ambulation. [CNA #3] had the gait belt in place and had assisted [the] resident from the bathroom to the sink in her room. LBSW [Licensed Baccalaureate Social Worker #4] came into the room and was talking to resident [#150]. At that time, [CNA #3] let go of the gait belt to throw trash in the bathroom. LBSW [#4] noted [the] resident starting to tip backward and yelled to notify [CNA [#3]. [The] Resident then fell backwards, hitting her head on the sink and fell to the ground. Resident [#150] complained of pain, was transferred to the ER [emergency room], and subsequently diagnosed with a displaced, right femur fracture. She required surgical repair. The facility failed to ensure staff utilized the gait belt while assisting Resident #150. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented the following corrective actions to ensure all residents affected by the deficient practice were transferred in an appropriate manner: * Completed an investigation into Resident #150's fall/right femur fracture. * Suspended CNA (#3) following the incident and terminated him/her after completing the investigation. * Provided staff education regarding staff-assisted transfers/gait belt use via electronic messages and/or posted memos. * Completed competency testing to ensure staff met the requirements for staff-assisted transfers/gait belt use. * Updated resident care plans as necessary. * Updated policies and procedures addressing staff-assisted transfer/gait belt use. * Initiated a four-stage (plan-do-study-act) quality improvement plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision necessary to prevent accidents for 1 of 1 sampled resident (Resident #165) who required one to one supervision with meals. Failure to stay with the resident while eating as care planned places the resident at risk for choking. Findings include: Review of the facility policy titled Care Plan, Comprehensive Interdisciplinary occurred on 05/16/24. This policy, dated March 2017, stated, . The services provided or arranged by the facility will meet professional standards of quality, be provided by qualified persons, and be culturally-competent and trauma-informed. Review of Resident #165's medical record occurred on all days of survey. The current care plan stated, . EATING: I am to eat all my meals out of bed in the upright position. Encourage me to go to the family room. I require 1:1 assist for meals d/t [due to] hx [history of] coughing with meals. I am at increased nutrition risk r/t [related to] h/o [history of] CVA [cerebrovascular accident/stroke], aphasia, dysphasia [language disorder that affects speech production and comprehension], and FTT [failure to thrive]. Provide and serve Regular diet with regular texture/thin liquids, breads and straws are ok per SLP [speech language pathology] 12/8/23. Resident does require assistance/observance at meals h/o of choking. I have a history of swallowing problems. Report to the dietitian if I have any difficulty with chewing/swallowing my food. A task that is completed by care staff stated NUTRITION - Snacks PM [afternoon] -encourage high calorie item; HS [bedtime] -choc milk or ice cream *needs 1:1 supervision-high choking risk. During an observation on 05/14/24 at 10:55 a.m., the certified nurse aide (CNA) (#7) placed a supplement shake with a straw on the resident's bedside table and left the resident unattended. During an interview on 05/15/24 at 1:51 p.m., the nurse (#5) stated the resident could reach the protein shake independently but would expect the CNA who gave the shake to stay with the resident. 1. Based on record review and review of facility reported incident documents, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 1 closed record (Resident #285) reviewed for a fall. Failure to use a gait belt and to provide adequate supervision resulted Resident #285 sustaining a fracture. Findings include: Review of Resident #285's medical record occured on 05/16/24. The care plan identified the following: . Focus: I have an ADL [activities of daily living] self-care performance deficit r/t [related to] Activity intolerance following a hospital stay for weekend, near syncope . and chronic back pain r/t degenerative disc disease (Initiated on 07/12/23). Interventions: AMBULATION: I am able to ambulate with assist of 1 staff with gait belt and FWW [front wheeled walker] . PERSONAL HYGIENE: I require assistance by 1 staff with person hygiene, perineal and oral care. TOILET USE: I need assist of 1 with toileting. TRANSFER: I am able to transfer with assist of 1 with gait belt and my FWW. Focus: I am at risk for falls r/t Deconditioning, incontinence, near syncope . Goal: I will not sustain serious injury . Interventions: Be sure my call light is in reach and encourage me to use it for assistance as needed. I need a safe environment with even floors free from the spills and /or clutter, adequate reduced glare lighting . Review of Resident #285's nurses notes identified the following: * 11/29/24 at 9:03 p.m.; Resident was transferring to bed and lost balance fell and hit top of head. No injuries noted. Denies pain. Neuro [neurological] checks initiated. * 11/29/23 at 11:32 p.m.; . Resident fell at 2016 [8:16 p.m.] . [Name of physician] notified of fall and aware resident hit head. Neuro checks initiated. No injuries noted. Resident Alert and Oriented. Primary decision maker . notified of fall. * 11/30/23 at 2:30 a.m.; . Resident got up to go to the bathroom around 1:30am. Reported pain 10 out of 10. When resident sat in wheelchair she started gagging and spitting up thick sputum. Reported of feeling funny but couldn't explain. Action: Gave Tylenol 500 mg [milligrams] PRN [as needed]. Called [Name of physician] and notified of change in status. Resident primary decision maker [name] was notified. Resident sent to ER [emergency room] via wheelchair at 0208 [2:08 a.m.] . Response: [Name of physician] stated, Send her in. [name of primary decision maker] stated, 'I'll go to the ER.' '' * 11/30/23 at 7:23 a.m.; . Resident returned from ER at this time. Per report from ER resident has TLSO [thoracic-lumbo-sacral orthosis] brace. * 11/30/23 at 11:22 a.m.; Resident Concern Progress Note . Resident had fall in room last evening and did not have gait belt on as care planned. Resident and CNA [certified nurse aide] reported that resident hit her head. No visible injury noted. At 1:30AM, resident woke up and vomited, provider updated and resident was sent to ER. RN [registered nurse] notified daughter of fall and notified her of change in status when she went to the ER. Daughter met resident in ER. Initial findings regarding Resident concern: CNA did not follow care plan for transfer/ambulation. Resident was assessed in ER, CT scan showed compression fracture of T-9. Resident returned to [nursing home]. Review of the Facility Reported Incident investigation identified a staff member assisted resident to the bathroom and the resident put the call light on when done. The staff member returned and assisted to pull her brief and pants up, then walked behind the resident to the sink where she was removed her dentures and put them away. The staff member left resident at the sink and moved to open the covers on resident's bed and set up her pillows. As the staff member turned around, the resident started to lean back and fell before he/she could get to her. The staff member did not have a gait belt on resident and reports that he/she didn't think the resident needed it. The facility failed to ensure staff followed Resident #285's plan of care by utilizing a gait belt and this failure resulted in a fall and fracture.