**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one of seven residents (Resident #1) reviewed for abuse. The facility failed to protect Resident #1 from physical abuse by CNA A on 03/30/25, which resulted in Resident #1 sustaining a head injury and contusion to her forehead. The noncompliance was identified as Past Noncompliance IJ. The noncompliance began on 03/30/25 at 6:40 p.m. and ended on 03/31/25. The facility had corrected the noncompliance before the incident investigation began on 07/15/2025. This failure could place residents at risk of serious abuse, injury and harm. Findings included: Record review of Resident #1's face sheet, dated 07/15/25, reflected she was a [AGE] year-old female, admitted to the facility on [DATE] with the diagnoses of Alzheimer's and cognitive communication deficit (communication difficulties stemming from impairments in cognitive skills like attention, memory, and problem- solving). Record review of Resident #1's Quarterly comprehensive MDS, dated [DATE], reflected a BIMS of 4, had continuous behaviors of disorganized thinking, no physical or verbal behaviors toward others, was ambulatory without assistive devices and required stand by assistance for ADLs. Record review of Resident #1's care plan, revised on 02/03/25, reflected [Resident #1] has impaired cognitive function or impaired thought process related Alzheimer's/dementia, mental disorder.Interventions.Use the resident's preferred name. Identity yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions.The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated.Keep the residents routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Record review of Provider Investigation Report (Form 3613-A of Texas Health and Human Services) dated 04/04/2025 reflected, . on 03/30/25 at approximately 07:00 p.m. the DON notified the Administrator that CNA B alleged the CNA A pushed Resident #1 causing her to fall and bump her head. CNA A denied any such allegation claiming it was incidental contact. CNA A was immediately suspended pending investigation. There was no other known witness to the allegation. On 03/30/25 at 06:45 p.m. LVN C conducted a head-to-toe assessment of Resident #1, noting swelling to Resident #1's right forehead. On 03/30/25 Resident #1 was sent to the hospital where she received a CT scan which revealed no intracranial abnormalities (any deviation of typical structure or function of the brain). Resident #1 was returned to the facility later that evening. On 03/31/25 Resident #1 was seen by Psychiatric services that noted Resident #1 wasn't experiencing any emotional distress. On 03/31/25 The facility called the police and reported the incident to them. Officer D was the reporting officer, and the case number was [PHONE NUMBER]. On 03/31/25 Facility Social Worker conducted safe surveys with all Interviewalbe resident with no negative outcomes. On 03/31/25 The administrator visited Resident #1 who was asleep on the couch in the memory care unit. Resident #1 had a bruise and some swelling to her forehead.The investigation reveals through witness statements and resident statement that the allegation of abuse had been confirmed. The facility immediately suspended the alleged perpetrator once the allegation was made. The facility notified the family, physician, and ombudsman. The facility immediately sent Resident #1 out to the hospital to receive treatment which revealed no abnormalities of the intercranial space. The facility called and filed a report with the local police. The facility's social worker conducted safe surveys with all Interviewalbe residents with no negative outcomes. The facility terminated the alleged perpetrator. The facility conducted in-service with staff on abuse/neglect. Record review of CNA B's written statement dated 03/30/25 reflected, Resident #1 walked up to CNA A while she was sitting down eating a sandwich. [Resident #1] Was asking to call her son on the phone. CNA A told her that the phones were not working. [Resident #1] stated the was BS I know that they are working. CNA A stood up, got in [Resident #1's] face nose to nose and told [Resident #1] to get out of her face and she shoved her. [Resident #1] fell and hit her head on the floor. Record review of CNA A's written statement dated 03/30/25 reflected, I [CNA A] came to work on Sunday March 30th, 2025. I was sitting at table taking my daily meds I take every day after I get to work and eating a half of a sandwich before I get going. At that time, I was approached by [Resident #1] asking she could use the phone like she does every day, but today she was really aggressive and being really bossy and not trying to listen to our answers. She was yelling y'all are damn liars. I was just trying to calm her down and explain to her she can, we gotta [sic] clean up trays and all that and we will. I turned around in my chair she was standing at nurse desk. I get up and stood in front of her trying again to explain we will she got up on me put her face in my face and I said please give me my space. [Resident #1] was still talking and yelling at [Resident #2] She turned toward [Resident #2] and somehow, she lost her footing and I watched her leg cross over and she fell that fast. CNA B was sitting right there with us and witnessed it all. She immediately said I pushed her. I did not. I've been a CNA for 33 years. I would never hurt myself or anyone else. My job is to protect this resident. Record review of CNA A's clock in and out for pay period 03/23/25-04/05/25 reflected on 03/30/25 she had clocked in at 06:05 p.m. and clocked out 07:57 p.m. There were no other time entry's after 03/30/25 and she was listed as terminated. Record review of the Incident report for Resident #1 completed on 03/30/25 at 6:25 p.m. by LVN C reflected, Called to Memory care unit by CNA [B] stating resident was in the floor. Upon entering main room of memory care unit resident was observed to be sitting in the floor to the right of the nurse's station, with her legs straight out. She was noted to be wearing socks and tennis shoes with rubber soles. There is a large hematoma noted to the right forehead with no break in the skin. No loss of consciousness. Resident states she fell due to being pushed down by someone while pointing at CNA [A].VS obtained with assessment. No AMS noted. BP 140/51, P-89, R-20, T 97.9. DON of facility, MD and [family member] notified. Transferred to [hospital] ER via EMS for eval per MD recommendation. DON of facility notified administrator. Written statements obtained from both CNAs on memory care unit. Record review of Resident #1's hospital record dated 03/30/25 reflected an admission date of 03/30/25 at 7:29 p.m. and discharge back to the facility on [DATE] at 10:18 p.m. Resident #1 had a CT scan performed which revealed no intracranial hemorrhage (brain bleed). There was noted a small right frontal scalp hematoma (collection of blood underneath the skin of the forehead and scalp, often the resulting from trauma), No skull fracture. No acute intracranial abnormalities (any deviation from the typical structure or function of the brain or its surrounding structure). The discharge diagnosis was head injury and contusion (bruise) of scalp. Record review of the Police reported completed on 03/31/25 by Officer D, reflected he had attempted to interview Resident #1 who was not able to recall the events from the previous night, only that she had sustained an injury to her head. In addition, he spoke with Resident #1's family member who indicated he wished to press charges against CNA A. He interviewed CNA B, and her statement was consistent with the written statement she had made on 03/30/25. Officer D then made contact with CNA A which reflected, .contact was then made with [CNA A] via phone to gather her statement of what occurred the previous evening. [CNA A] advised that on the evening of March 30th, 2025, upon arrival to work the patients were sitting at their tables eating dinner. [CNA A] stated she takes a lot of medications that requires she eat food with, so with the patients busy, she decided to take her medication (did not state what medication) and sit down behind the nurse's desk to eat her food. [CNA A] had mentioned that there were four groups of women always wanted to use the phone to call family and causing issues and Resident #1 was the ringleader. [CNA A] had mentioned that the entire weekend [Resident #1] had been acting very aggressive, hitting people, and doing all kinds of crazy stuff. On this evening [CNA A] stated the [Resident #1] had come up to the desk asking to use the phone. [CNA A] stated that she informed [Resident #1] that once they get everyone settled that she would get the phone number from her nurse so she could make the call. Due to [Resident #1] being forgetful, [CNA A] stated that she had come up to the desk multiple times asking the same question. On roughly the fourth time, [CNA A] stated that [Resident #1] became agitated as she approached the nurse's desk with a large purse on her shoulder as she was followed by another patient only identified as [Resident #2]. [CNA A] stated, I then stood up to go wash my hands or do something. When she stood up, she stated that [Resident #1] was right there, but there was a taller desk in between the two of them. [CNA A] stated that [Resident #1] then leaned over the desk and began screaming in her face, calling her a damn liar and that she was holding them captive. [CNA A] stated that [Resident #1] then began turning back and forth between her and [Resident #2] stating they're not gonna let us out, [CNA A] stated as [Resident #1] turned back towards her, she observed her leg/foot twist and that is what caused her to fall to the ground and strike her head on the floor. [CNA A] stated that she tried to catch [Resident #1] as she was falling, but it happened to fast. [CNA A] stated she immediately got the nurse [LVN C]. [CNA A] had stated I've been an aid for 30 plus years, I don't do something like that. Those people are really aggressive. [CNA A] was advised that due to what had been informed to be up to this point and having a witness statement regarding the incident that the charge of Injury to a Child, Elderly Individual, or Disabled individual (PC 22.049f0) was going to be filed at large against her. She advised she understood. Record review of Resident #1's Psychiatric Subsequent Assessment note completed on 03/31/25 by NP F reflected, .Patient seen today for a new problem.Asked by facility DON to see patient via video telehealth for a recent altercation. Patient seen via telehealth with DON assisting. Pt is able to identify herself by her name and date of birth . Patient denies depressive and/or anxiety symptoms. Pt states I was pushed the other day however overall, I am okay. I know that it was not a resident who did it. It was an employee. I don't' know why they did that. I am not scare [sic] to be here and I feel very staff [sic] here. No overt psychosis detected.Mental Status examination.Short term memory: severely impaired.Long term memory.severely impaired. Observation of Resident #1 on 07/15/25 at 8:55 a.m. revealed her in her room in bed sleeping. In an interview with LVN E on 07/15/25 at 9:10 a.m. she stated she worked the 6 a.m. 6 p.m. shift on 04/01/25 following the incident with Resident #1 on 03/30/25. She stated the resident had a pretty good bruise and knot on her forehead which had also progressed to a black eye to her right eye. She stated the resident told her she had been pushed but was unable to identify who pushed her. She stated Resident #1 frequently request to use the phone and thinks her car is out in the parking lot and wants to call the police and report it stolen. She stated she was usually easily redirected, but at times can get very agitated. She stated they just keep reassuring her and re-directing and offering her another activity. Call placed to CNA A on 07/15/25 at 11:10 a.m. Message was left with a request for a return call. In an observation and interview with Resident #1 on 07/15/25 at 11:15 a.m. resident was observed ambulating in the hallway. Resident was asked if we could go to her room to talk, and resident stated yes. Resident #1 stated she was doing wonderful today. Resident was unable to recall any of the events that had occurred on 03/30/25 and stated she felt safe here and liked it here very much. Return call received from CNA A on 07/15/25 at 12:43 p.m. CNA A stated she had just come on duty on 03/30/25 for her 6 p.m. to 6 a.m. shift. She stated it was her 3rd day of her rotation. She stated it was a rough day. She stated Resident #1 had been aggressive all weekend. She stated she and the other residents all rushed the desk wanting to use the phone. She stated they usually kick in right after supper. She stated she was sitting behind the station eating her sandwich and taking her medications which was her usual routine when she came on duty. She stated Resident #1 kept coming up to the desk and asking to use the phone and she kept telling her to back up. She stated there was a resident behind Resident #1. She stated she stood up and Resident #1 was in her face, and she stated she told her again to back up and get out of her face. She stated Resident #1 went to turn around and got her feet tangled up and fell. She stated as soon as she fell, she yelled that I had pushed her. She stated she thinks in the resident's mind she thinks she pushed her. CNA A denied pushing the resident and denied putting her hands on the resident. CNA A stated CNA B went and got LVN C who came and assessed the resident and sent her to the hospital. She stated she was removed from the unit and asked to write a statement and was then sent home. She stated she tried to call the DON but was not able to reach her. She stated she had been terminated. She stated she was interviewed by the police and was told she would be getting a letter but stated she had not received anything yet. In an interview with Officer D on 07/15/25 at 1:05 p.m. he stated he did come to the facility on [DATE] to complete the report. He stated he spoke with the DON and met with Resident #1 and her family member. He stated Resident #1's family member wanted to press charges against CNA A. He stated he completed his investigation and handed it off to the District Attorney's office who will have the final say on what, if any charges were filed. In an interview with the DON on 07/15/25 at 1:10 p.m. stated she received a call from LVN C after the incident on 03/30/25 and was told about the fall and the allegation that Resident #1 had been pushed by CNA A. She stated she told LVN C to remove CNA A immediately from the unit, have her write her statement and then leave. She stated she then called the Administrator. She stated they also contacted the ADON who lives very close to the facility, to come and begin the investigation. She stated they started the Abuse and Neglect in-services that night and then on 03/31/25 they also in-serviced on Resident Rights, Dementia care, and recognizing and dealing with signs of burn out. She stated they sent the resident out to the hospital for evaluation, contacted the MD, family, police and reported the incident to the State. She stated they had NP F from Psychiatric services evaluate Resident #1 the next day and they monitored her for any changes in physical or emotional distress. She stated after they completed their investigation, they felt there was enough evidence to terminate CNA A. She stated she was very surprised at CNA A's action. She stated she had never had any complaints about her care toward the residents. She stated they try and keep consistent staff in the memory care, so they are familiar with the residents and familiar with what works with the resident for behavior management. She stated any time they place a new employee in the unit they go over each resident and review with them the interventions they had in place for re-direction. She stated asking for the phone and asking for her keys was Resident #1's normal behavior. She stated CNA A should have handed her the phone instead of putting her off, which only escalated the resident's behaviors. In an interview with LVN C on 07/15/25 at 4:19 p.m. she stated she had just come onto her 6 p.m. to 6 a.m. shift on 03/30/25. She stated she was responsible for hall 600 and hall 500 which is the locked unit. She stated she was still getting report from the off going nurse on hall 600 when she got a call from CNA B telling her she needed to come quick to the unit. She stated when she arrived on the unit, CNA B was on the floor by Resident #1 and CNA A was standing behind the resident. She stated CNA B was nervous. She stated CNA B was whispering to her that CNA A had pushed Resident #1. She stated Resident #1 was pointing to CNA A stating she had pushed her, and CNA A was stating she had not pushed her. She stated she evaluated the resident who had a large knot on her forehead. She stated she notified the MD who requested to send the resident out to the hospital for evaluation. She stated after she sent the resident out, she notified the DON about the situation. She stated the DON told her to send CNA A home after she completed her statement and to get a written statement from CNA B. She stated she took CNA A off the unit to the other nurse's station to complete her statement and then she went home. She stated she notified Resident #1's family member of the fall and her transport to the hospital. She stated she had worked with CNA A for several months and had not ever had any issues with her performance. She stated she could get a little overwhelmed at times, but stated she was very thorough with her work. She stated Resident #1 would often get close to you, but stated she thought it was because she was hard of hearing. She stated it was not unusual for her to want to use the phone, often stating she needed to call the police because someone had stolen her car. She stated they would re-direct her with activities or agree with her and she would often forget what she was wanting. She stated the facility started in-services on abuse and neglect that evening and the next day they had in-services on resident rights, dementia care and how to recognize burnout. In an interview on 07/15/25 at 4:36 p.m. with Resident #1's Family member, he said he had no concerns regarding the care of Resident #1. He stated the facility contacted him regarding the incident in March 2025 and that they had terminated the CNA. He stated when he saw Resident #1 the next day, she still had a big goose egg on her forehead and a black eye. He stated he regularly visited with Resident #1 and had not observed any change in behavior. He stated she still seemed to like it at the facility. He stated he does not hold the facility responsible for the actions of the CNA A, but stated he did hold her responsible and had told the police he wanted to press charges. He stated she had no business taking care of the elderly. In an interview with CNA B on 07/15/25 at 5:15 p.m. she stated she and CNA A had just come onto shift for their 6 p.m. to 6 a.m. shift on the memory care unit on 03/30/25. She stated the residents were finishing up with their supper. She stated the nurse's station sits in the middle of the large common/dining area and is L-shaped with the opening to the right side of the station. She stated behind the nurse's station was a small table against the wall. She stated she was sitting on the outside of the station at the L reviewing the assignment book and CNA A was sitting at the small table behind the nurse's station eating a sandwich. She stated Resident #1 had walked up behind CNA A requesting to use the phone and CNA A had told her the phone was not working. She stated Resident #1, again asked to use the phone. She stated when CNA A jumped up suddenly from her chair, was what caused her to look up. She stated CNA A turned around and put herself in Resident #1' face, nose to nose and screamed for her to back up and get out of her face and she stated all of sudden CNA A pushed the resident with both her hands open palmed. She stated Resident #1 stumbled backwards and tried to break her fall but could not and fell backwards outside of the nurse's station. She stated there was not another resident behind her. She stated CNA A did not try to catch the resident, but instead just put her hands down to her side. She stated she immediately jumped to run around the station to check on the resident. She stated she did not see her hit her head, but stated she heard the thump, which was very loud. She stated she took a very hard fall. She stated when she got to the resident, she could see the knot on her forehead. She stated she reached in her pocket to get her phone to call for the nurse. She stated she retrieved her phone, and CNA A reached down and grabbed her arm, which caused her phone to fly across the floor. She stated CNA A asked her what she was doing, and she stated she was calling the nurse, look at her head. She stated when CNA A grabbed her arm, Resident #1 flipped out yelling keep her away from me, she pushed me. She stated she retrieved her phone, called the nurse and stayed on the floor with the resident until LVN C got to the unit. She stated she informed LVN C about what she had witnessed. She stated LVN C assessed the resident and called 911. She stated she was asked to write a statement of what she witnessed, and CNA A was told to write her statement. She stated they removed CNA A from the unit immediately. She stated the ADON came to the facility shortly after the incident and she showed her what had happened. She stated the Administrator was on the phone listening to her describe what had occurred. She stated later that evening, maybe around 10:00 p.m. she received a call from CNA A. She stated she wanted her to write her statement that she witnessed the resident get her feet tangled up and that CNA A had tried to catch her. She stated she told CNA A, but you did not try and catch her, She stated CNA A wanted her to make sure she put in her statement the resident tripped over her feet and she wanted her to send her a screenshot of her statement. She stated she told CNA A OK so she could get her off the phone. She stated once she hung up, she immediately blocked her number. She stated she did not send her a screen shot of her statement. She stated she had no doubt CNA A pushed Resident #1 down. She stated she was interviewed by the police and told them the same thing. She stated she had worked with CNA A for a long time and never witnessed her being abusive toward any of the residents but stated she could be a bit explosive with staff at times. She stated the facility in-serviced them on Abuse and neglect that evening and the next day they were in-serviced on resident rights, dementia care and burn out. She stated she did not hesitate in reporting what she saw. In an interview with the ADON on 07/16/25 at 8:55 a.m. she stated the DON had called her on 03/30/25 after the incident with Resident #1. She stated she only lived about 10 minutes away from the facility, so she arrived probably around 8:00 p.m. She stated CNA A had already left the building. She stated CNA B was very distraught over the incident. She stated she did re-enact the incident with her and was very certain she saw CNA A push Resident #1. She stated she spoke with Resident #1 who was also adamant that she did not fall, but instead was pushed. She stated the resident could not name the person who pushed her. She stated she started in servicing the staff on Abuse and Neglect that evening and then onto to the next day. She stated they also in serviced on dementia care, resident rights, and signs of burnout and how to prevent it. She stated they do abuse and neglect in- services monthly or more frequently if an incident occurs. She stated she had not received any complaints or concerns about CNA A's performance before this incident. In an interview on 07/16/25 at 10:47 a.m. with the Social Worker she stated she was responsible for the safe surveys conducted after the incident with Resident #1. She stated none of the residents had abuse concerns. She stated she was familiar with Resident #1, and did not observe any psychosocial impacts such as change in emotional patterns or behavior since the incident. The Social Worker stated that the facility in-serviced on abuse routinely, was able to name types of abuse and who the abuse coordinator was including reporting requirements. In an interview with the Administrator on 07/16/25 at 11:15 a.m. he stated he was the abuse coordinator, and staff were in-serviced on abuse and neglect monthly and sometimes more often. He stated he was notified by the DON on 03/30/25 of the incident involving Resident #1. He stated they suspended CNA A immediately. He stated Resident #1 was assessed and sent to the hospital for further evaluation. He stated she was returned to the facility later the same day. He stated they immediately began in services on Abuse and neglect, Resident rights, dementia care and signs and symptoms of burn out. He stated he reported the incident to the State within 2 hours. He stated the family was notified as well as the MD. He stated they completed their investigation and determined abuse had occurred at the hands of CNA A. He stated they terminated her. He stated in his conversation with CNA A she did not show any remorse or concern for Resident #1, she just kept repeating how many years she had been a CNA and adamantly denied she had pushed her. He stated they held a QAPI meeting on 04/01/25 and put monitoring into place. He stated they interviewed and tested 3-5 random staff members on abuse and neglect, did skin assessments on 3 residents in the memory care unit, the DON reviewed all the weekly skin assessment, and randomly did 3 safe surveys on Interviewalbe residents weekly for 4 weeks and then monthly until June 2025. He stated in addition they were reviewing grievances daily with a resolution within 72 hours. He stated he also communicated frequently with the families, especially the families on the memory care unit. He stated he felt his staff had acted quickly and appropriately during this unfortunate incident and they had done everything in their power to prevent this from occurring. Interviews on 07/15/25 and 07/16/25 across both 12 hour shifts with various staff members, as well as new staff and agency staff (ADON, CNA B LVN C, LVN E, CNA G, CNA H, Staffing Coordinator, CNA I, Agency CNA J, LVN K, RN L, MA M, Agency CNA N, LVN O, CNA P, LVN Q, CNA R, Social Worker and the DON) revealed the facility had conducted abuse and neglect in-services immediately after the incident on 03/30/25 and on a routine basis. The above-mentioned staff members were able to verbalize abuse and different forms of abuse and neglect including reporting to the Administrator who was the facility's abuse coordinator. In addition, the facility had conducted training on Resident rights, dementia care and signs of burnout on 03/31/25. Staff were knowledgeable in re-direction, offering activities, snacks and residents centered activities to assist in behavior management as well as resident rights for refusal a care. Record review of CNA A's personnel file revealed she was hired on 04/01/24 with a last worked date of 03/30/25 and terminated from employment on 04/01/25. The facility had conducted Texas Department of Public Safety Criminal History verification and Employee Misconduct Registry Employability status checks as required and found no bars to employment. Record Review of abuse and neglect in-services conducted by the facility on 03/30/25 revealed that the facility staff was trained on abuse and neglect, types of abuse, who was the abuse coordinator and when abuse should be reported. Record Review of in-services on Resident rights, Dementia Care and Recognizing Burn out reflected the staff were in-serviced on the facility's protocols on 03/31/25. Record review of the facility policy titled, Abuse and Neglect-Clinical Protocol dated October 2022, reflected, The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect resident from abuse.Staff to Resident Abuse of any Types.The facility assumes the responsibility upon admission of ensuring safety and well-being of the resident.Education fro all staff will be ensured in how to react and reason appropriately to resident behaviors.Staff are expected to be in control of their behavior and behave professionally.The facility will not accept from an employee to claim his/her action was reflexive or knee-jerk reaction' and was not intended to cause harm.Definition.Abuse.the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Willful.the individual mush have acted deliberately, not that the individual mush have intended to inflict injury or harm. Record review of the facility's policy titled, Resident Rights, dated October 2022, reflected, Employee's will treat residents with kindness, respect, and dignity.be free from abuse.be supported by the facility in exercising his or her rights. Record review of the facility's policy titled, Dementia- Clinical Protocol, dated November 2018, reflected, .For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of [NAME] with interventions that are resident specific. Record review of the facility's policy titled, Recognizing and Dealing with Signs of Burnout, Frustration and Stress that May lead Abuse, dated December 2022, reflected, The facility will make every effort to prevent abuse.Training will be included on these topics in orientation of new employees and at least annually for education and awareness.Behaviors to avoid being accuse of abuse.Never get caught in a shouting match or shoving contest with a resident or staff that would be considered inappropriate.stay calm-maintain a soothing tone of voice.If necessary ask another person to intervene.Always report an incident to your supervisor.Understand resident with Cognitive deficits or Dementia for episode of action out and why they do this. The noncompliance was identified as PNC. The IJ began on 03/30/25 at 6:40 p.m. and ended on 03/31/25. The facility had corrected the noncompliance before the survey began. CNA A was terminated from employment and Resident #1 had no other incidents or signs of harm. The facility staff were reeducated regarding Abuse and Neglect on 03/30/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure the resident environment was free of accidents and hazards as was possible for one resident (Resident #33) of four residents reviewed for accidents and hazards, in that: CNA A, CNA B, CNA C and LVN D failed to lift Resident #33 with a mechanical lift twice on 01/05/23, which resulted in the resident having a broken leg. The noncompliance was identified as PNC. The IJ began on 01/05/23, and ended on 07/26/23. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of severe injury. Findings include: Review of Resident #33's face sheet, dated 11/15/23, reflected Resident #33 was a [AGE] year-old female, admitted on [DATE], and had a primary admitting diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right-sided weakness and paralysis following stroke), as well as stroke, generalized muscle weakness, and dysarthria following cerebral infarction (difficulty speaking following a stroke.) Review of Resident #33's annual MDS, dated [DATE], reflected Resident #33 was able to speak clearly, be understood by others, and was able to understand others. The resident had a BIMs of 12, indicating possible moderate cognitive impairment. The document reflected no behavioral issues or indicators of psychosis. The document reflected functionally Resident #33 used a wheelchair and required extensive two-person assistance for bed mobility (moving herself around in her bed), transfer, dressing, and toilet use. She was totally dependent on staff for bathing but was able to feed herself. Review of Resident #33's admission MDS, dated [DATE], reflected she required extensive two-person assistance with bed mobility, dressing, bathing, and toilet use, and was only transferred once or twice with one-person physical assist. Review of Resident #33's care plan, dated 11/20/22, reflected Transfers total assist x 2 with Mechanical lift . An interview on 11/07/23 at 3:27 PM with Resident #33 revealed that on her birthday this year, 01/05/23, the aide did not want to use the mechanical lift, and she and the other aide who assisted dropped her, and the nurse on duty, whose name she did not know, did not seem very worried about it. She said she had been visiting with her family member, and after shift change he noticed that her leg was swelling and said it looked like she had two knees on one leg. She said the nurse who had come on duty (LVN A) was alarmed and got X-rays for her and she had a broken leg. She said her leg had a knot which was discolored and as large as a fist. She said they fired a nurse and an aide over the incident. She was unable to identify the staff members by name. An interview on 11/09/23 at 11:01 AM with Asst. Administrator revealed she had been employed at the facility for about a week when the Administrator discovered the incident with Resident #33's leg during a mock survey. She said they immediately put a PIP in place and started doing training with staff on related issues. She said they did skills check-offs for all of the nurses and CNAs. She said at the time they discovered it, in July, the people involved in the transfer were not working at the facility. She had been told that day (11/09/23) initially that the staff involved in the incident were not working at the facility at the current time, and when she learned that they actually were still employees, she knew that was bad. An interview on 11/09/23 at 11:05 AM with the DON revealed the former DON had been terminated for not performing her job duties, which included not reporting things that should have been reported. She said the former DON was very avoidant of reporting and some other aspects of her job, and when she was at the facility she created a culture of similar attitudes among the staff, and they had worked very hard to change that since she had been there, including terminating some staff and hiring new, and a lot of training. She said their QAPI process included many PIPs due to the former DON's lack of performance, and the incident with Resident #33 was one of the things they QAPI'd. She said in July 2023, when they discovered the issue, the former DON (at that time the active DON) told them the staff involved were no longer employed at the facility. She said the Administrator had been at the facility for less than a week when they discovered the issue with Resident #33 and they felt absolutely sick about it and immediately began to re-train the direct care staff. An interview and record review on 11/09/23 at 3:18 PM with the ADON revealed she started around the time that they did the mock survey and discovered the incident with Resident #33. At that time she was not able to find skills check-offs for the direct care staff left by the former administrative staff, so she initiated new ones. She said she did them with all of the already existing staff, and when they hired new staff they had seven days to get all of their check-offs completed. At the time of this interview, she provided a binder with all of the skills check-offs she had done, organized by hallway, and including full time and PRN employees. An interview on 11/09/23 at 4:08 PM with CNA D revealed she had been the CNA who had an incident with Resident #33 during a transfer, but there had been one on the shift before hers, as well. She said she had come in for her 6PM to 6AM shift, and Resident #33 was complaining about pain in her leg when she got there. She said the resident was in her wheelchair, visiting with her when she got to work, and there was no sling under her, so she and LVN A attempted to transfer her with a gait belt. She said that they stood the resident up and when she went to push the wheelchair out of the way something was wrong, and it would not move. At that time Resident #33 started to drop, and she tried to stop her with the belt, but the way her arm was extended she was not able to, so she yelled at the nurse that she was falling, and she fell with the resident. She said she landed on the floor, partially on the leg of the wheelchair, and Resident #33 landed on top of her. She said LVN A also went down on the side, while slowing the fall. She said the fall happened very slowly and she cushioned Resident #33 from the floor and wheelchair, but it was scary. She said the nurse assessed Resident #33 and they got a sling and got the resident back into her bed. She said after that the resident was still complaining about pain in her leg, so she told LVN E, who said the CNAs had to set her on the floor earlier that day too, and that she had normal pain for her when she checked on her. She then told LVN A, because the resident kept complaining, and LVN A sent Resident #33 out to the hospital right away . CNA D said Resident #33 was new to her at that time, and she did not know the resident was lift, but had been trained since on how to know. She said she would look at the [NAME] (information regarding care in the electronic chart) and talk to the nurse, and if there was not a sling under the resident, she would put one under them and use the mechanical lift to transfer them. She said the two CNAs who had the fall with the resident earlier that day did not work there anymore, and she thought she remembered their first names, but did not know their last names, and they had not worked there for a long time. An interview on 11/10/23 at 10:04 AM with the DON revealed there was a disciplinary notice for LVN E back in January, when this incident happened for not reporting the first of two incidents to administrative staff. At the time of this interview she provided an incident report for the second of the two falls the resident had that day, but said there was no incident report for the other one. An interview on 11/10/23 at 10:50 AM with Resident #33 revealed she had been a mechanical lift for years, before she even came to this facility. She said she only remembered one fall, and it was with a CNA and nurse who still worked at the facility. She said they did send her to the hospital after it happened, and she only remembered falling one time. She said she thought she remembered that the aide had not used the mechanical lift because there was something wrong with it, but she could not remember what. She said since that happened all the staff had done a good job transferring her with the mechanical lift. An observation on 11/10/23 at 11:34 AM of Resident #27 being transferred by mechanical lift ed by CNA I and CNA J. Correct procedures were followed by the CNAs and no concerns were noted. A telephone interview on 11/10/23 at 1:09 PM with LVN E revealed two CNAs (CNA B and CNA C) had lifted Resident #33 with a gait belt on her shift, but she talked to the CNAs at the time, and they said they had looked at the [NAME] and it said to use a gait belt. She did not check at that time to see if the [NAME] said the resident was a gait belt transfer. She said the resident did not really fall, but was slowly sat down on the floor by the CNAs and she assessed the resident. She was not in the room during that transfer, so she did not see it, but the resident was able to talk to her and tell her what happened. She said Resident #33 always had pain, to the point where you could touch her and she would say it hurt, and her pain was at her baseline when she assessed her . LVN E said there was no indication of injury at that time, and she told the resident's that if she started to have increased pain to let her know and she could contact the physician and get Xray orders, and he seemed like he was fine with that. After she assessed her, she and the CNAs put her back in her wheelchair using the gait belt, with no problems. She said after the incident the resident and her were outside talking and laughing, and she does not remember her acting like or saying she was in additional pain. She said she and the two CNAs involved were suspended related to the incident, and then terminated. Review of an incident report for Resident #33, dated 01/05/23, by LVN A, reflected Nursing Description: Pt was being transferred to bed from w/c using gait belt when her body became flaccid. CNA and this nurse low [missing text] floor. Resident Description: Pt stated that her leg was hurting and she wanted to sit. Description: Pt lowered to floor into seated position. VS taken at that time and WNL; Pt c/o pain in LLE; Mechanical lift and sling gathered and [missing text] from floor; EMS called and transported to (name of hospital); Family/DON/ADON/PCP notified of event. The report reflected bruising on the front of the resident's left lower leg, that the resident was alert and oriented, and had pain of eight on a scale from one to ten. Review of a nursing progress note for Resident #33, by LVN E, dated 01/05/23 at 4:00 PM, reflected resident wanted to get up in w/c chair, CNA;s was [sic] getting resident up using gait belt. had to assist resident to floor. this nurse assessed resident. No injuries are [sic] bruising noted at this time. resident stated she had little pain to left LLE asked her resident if pain was different from her normal pain stated no. gave resident pain pill. resident up there told him if she states pain is worse i will notify DR to get x ray. Review of a nursing progress note for Resident #33, by LVN A, dated 01/05/23 at 8:52 PM, reflected Pt lowered into floor after attempting to transfer her from the w/c to the bed; Gait belt in use; C/o pain in LLE prior to transfer; Bruise noted at site of pain after transfer; EMS contacted and transported to TMC for eval; Appropriate parties notified. Review of a nursing progress note for Resident #33, by LVN O, dated 11/07/23, reflected Resident #33's return to the facility from the hospital. Resident is readmitted from TMC ( .) Resident is happy to be back home, alert and oriented though feeling bad about her L tibia fracture that is nonsurgical. The patient is post fall, history of CVA, and left hemiparesis. The left leg is immobilized and in a non-weight bearing status. Interviews beginning at 8:00 AM on 11/09/23, and concluding at 4:00 PM on 11/10/23 with the following staff (covering all shifts and halls) revealed staff had been trained, and was knowledgeable about all aspects involved in the incident with Resident #33, including what to do if the mechanical lift did not work properly, what to do if a mechanical lift resident does not have a sling underneath them, where to find transfer information about a resident, how to do a proper mechanical lift transfer, and reporting incidents, accidents, or concerns. Interviewed staff were: CNA D, LVN E, ADON, LVN F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, CNA N, LVN P, CNA Q, CNA R, LVN Y, LVN Z, and CNA AA. The Former DON and LVN A were not available for interview on 11/10/23. Review of QAPI documents for a Performance Improvement Plan, dated 07/26/23, reflected plans which included training of all staff due to concerns regarding mechanical lift transfers and reporting incidents. Review of the binder of skills check-offs, which included all full time and PRN staff, reflected completed, correct skills check-offs and competency quizzes which included mechanical lift transfers, for a sample of CNAs covering all halls and all shifts (CNA D, CNA G, CNA I, CNA J, CNA K, CNA L, CNA M, and CNA N). Review of the policy Safe Lifting and Moving of Residents, revised 07/2017, reflected the following: Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. ( .) 2. Manual lifting of residents shall be eliminated when feasible. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. 7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. 8. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being recharged. 9. Enough slings, in the sizes required by residents in need, will be available at all times. As an alternative, residents with lifting and movement needs will be provided with single-resident use disposable slings.