Based on medical record review, review of the facility investigation report, and staff interview, the facility failed to ensure a safe transfer was provided for 1 of 7 sample residents (#1) reviewed for falls. This failure resulted in actual harm to resident #1 who was unable to keep his/her balance during a transfer. The resident suffered a comminuted [bone breaks in 3 or more places usually occurring after a forceful event] fracture involving the distal femoral diametaphysis above the femoral component of the left knee prosthesis. The facility implemented corrective action prior to the survey and was determined to be in substantial compliance as of 3/7/25. The findings were: 1. Review of the 2/14/25 quarterly MDS assessment showed resident #1 had a BIMS score of 8 out of 15 (moderate cognitive impairment); required substantial to maximal assistance with all mobility ADLs; and had diagnoses which included Alzheimer's disease and bipolar disease. Review of the resident's care plan showed the resident had a fall on 3/7/23 and 2 staff were to assist the resident with transfers. Review of the Occupational Therapy Recertification Progress Report and Updated Therapy Plan Report for the certification period of 1/28/25 to 2/26/25 showed the resident required maximal assistance with toilet transfers. The following concerns were identified: a. Review of a 2/20/25 nurse's note showed resident #1 was up to the restroom with assistance x [times] 1. Resident lost balance and CNA unable to lower resident to floor. Resident did hit head. Neuros were initiated. Further review of the incident showed the fall occurred at approximately 2:45 PM on 2/20/25. The nursing assessment showed no signs of injury, the resident did not exhibit pain, and had resumed his/her normal activities. b. Review of a nurse's note, dated 2/21/25 and timed 1:34 AM, showed the resident had started to yell and complain of severe pain to his/her knee. The resident was sent for imaging and diagnosed with an acute nondisplaced oblique spiral type fracture through the distal left femoral metaphysis superior to the knee arthroplasty. The injury was inoperable and the resident was placed on non-weight bearing status and was prescribed 5 milligrams of oxycodone every 4 hours as needed, 1000 milligrams of Tylenol 3 times per day, and a lidocaine patch to the knee. c. Review of a 2/24/25 nurse's note showed Notified physician of resident discomfort/pain. Order received to increase from 5 milligrams to 10 milligrams oxycodone every 4 hours as needed. 2. Interview with the NHA on 3/19/25 at 9:52 AM confirmed CNA #1 did not follow the resident's care plan which resulted in the resident falling and subsequent injury. The NHA stated the CNA received disciplinary action, had been educated, and audits of the CNA's skills continued to be evaluated. Further, an ad hoc Quality Improvement/Performance Improvement (QAPI) meeting was conducted on 2/27/25. 3. Review of the 2/27/25 QAPI minutes showed falls which occurred on 2/19 and 2/20 were reviewed; education to all staff doing mobility tasks was scheduled; an audit tool was created for the CNA involved; an audit tool was created for all staff doing mobility tasks; and an audit of all care plans for those assessed as needing 2-person assist or were a fall risk was planned. 4. Review of the facility's investigation showed interviews with staff were conducted and it was determined CNA #1 was independently toileting the resident when the resident fell. Education was provided to the CNA, an ongoing audit, which was started on 3/1/25, of the CNA's adherence to care plans and providing safe assistance to residents was reviewed. An audit of all residents currently listed as a 2-person assist was conducted and education was provided to all staff providing assistance with transfers by the therapy department on 3/7/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, facility incident review, and policy and procedure review, the facility failed to protect the residents' right to be free from verbal abuse by a staff member for 1 of 6 sample residents (#4). This failure resulted in actual psychosocial harm to resident #4. The findings were: The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 9/5/24. 1. Review of the quarterly Minimum Data Set assessment dated [DATE] showed resident #4 had a brief interview for mental status score of 9 out 15, which indicated moderate cognitive impairment, and diagnoses which included cerebrovascular accident, hemiplegia or hemiparesis, and depression. Further review showed the resident did not exhibit physical or verbal behavioral symptoms or rejection of care. The following concerns were identified: a. Review of an incident report dated 8/31/24 showed CNA #1 and CNA #2 were assisting the resident with care. The resident called CNA #1 a bitch and told the CNA to get out of his/her room while using expletives. The CNA responded by calling the resident a cunt. The incident was reported by CNA #2 to the nurse and the nurse notified administration. CNA #1 was placed on suspension pending an investigation. During the investigation, resident #4, who has difficulty with communication, reported CNA #1 was making fun of him/her, grabbed [him/her] and told the resident to knock it off, and s/he totally lost her mind. The resident was emotional during the interview, said CNA #2 was good and nice, and acknowledged s/he had been swearing, yelling, or using foul language with staff that day. The investigation showed resident #4's representative reported the resident had called after the incident to report CNA #1 was mocking the resident due to his/her difficulty speaking and the resident was embarrassed and belittled. The resident's representative reported CNA #1 had been one of the resident's favorites in the past. The Investigation showed CNA #2 reported the resident had been cursing at staff and CNA #1 called the resident a F-ing Cunt and may have been a bit rough. CNA #2 described the resident as a bit stunned after the incident. Further review showed CNA #1 admitted to calling the resident the name and was terminated from the facility. b. Interview with resident #4 on 9/17/24 at 5:24 PM revealed the CNA #1 entered the room and was speaking to him/her in a way s/he felt was making fun of him/her. CNA #1 forced the resident to roll over in bed and it made the resident mad. Following the incident, the resident revealed s/he called his/her daughter while crying, because s/he was upset. c. Interview with CNA #2 on 9/18/24 at 9:21 AM revealed on the day of the incident, she had asked CNA #1 to assist with providing care to the resident. She revealed CNA #1 forcefully repositioned the resident and the resident called the CNA a fucking bitch and CNA #1 responded by calling the resident a fucking cunt. Further interview revealed CNA #1probably made fun of resident #4 during the incident; however, she does not recall it. d. Attempted interview with CNA #1 on 9/18/24 at 9:15 AM was unsuccessful. A message was left and no return call was received. e. Interview with the administrator on 9/18/24 at 10:45 AM confirmed CNA #1 was terminated from the facility. The administrator revealed although the resident curses often, s/he did not normally get upset which made the facility believe the resident was affected by the incident. The administrator revealed resident #4 had previously refused counseling services offered by the facility; however, s/he accepted counseling following the incident. Further interview revealed as a result of the incident, the facility completed abuse training for staff, interviewed residents, performed ongoing customer satisfaction surveys, and were reviewing abuse in during their quality assurance meeting. f. Interview with licensed clinical social worker #1 on 9/18/24 at 11:05 AM confirmed resident #4 began counseling services and the incident was an area to address. g. Review of the facility policy titled Abuse, Neglect, and Exploitation last revised 6/2023 showed .1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of resident and misappropriation of resident property . 2. The following plan of correction was implemented by the facility on 9/5/24: a. CNA #1 was terminated from the facility. b. Residents were interviewed related to abuse and neglect. c. Counseling services were offered, accepted, and implemented with resident #4. d. Staff completed training related to the Dos and dont's of managing a client who is angry or aggressive and Techniques for managing cognitive impairment. e. Customer Satisfaction Surveys. f. Quality Assurance review of abuse.