Health inspection·July 2, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to thoroughly investigate and report an allegation of neglect and an injury of unknow origin resulting in serious bodily injury to the Agency for Healthcare Administration (AHCA). The facility failed to report the allegation to AHCA within the federally required 2-hour timeframe, and the 5-day investigation report lacked sufficient detail, as required under federal regulation, for 1 of 1 resident reviewed for neglect, of a total sample of 8 residents, (#1).Findings:Resident #1 was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 4/09/24. Her most recent diagnoses included speech and language deficits after a stroke, reduced mobility, history of falling, muscle weakness, fracture of upper end of right humerus, and osteoarthritis.Review of the Minimum Data Set Quarterly assessment with Assessment Reference Date 3/09/25 revealed resident #1's was nonverbal, and cognitively impaired with bilateral upper extremity impairments. The assessment indicated she was dependent on staff for all care and mobility. Review of resident #1's progress notes revealed she was found on 6/01/25 with unexplained bruising, swelling, and guarding of the right upper arm (RUA). Later that evening, X-rays confirmed a fracture of the proximal humerus. The resident was transferred to the hospital, where significant bruising was noted to the RUA, the fracture of the proximal humerus was confirmed and concern for possible elder abuse was documented by hospital staff. In a telephone interview on 6/29/25 at 1:16 PM, Certified Nursing Assistant (CNA) A stated she had worked in the facility for 10 months and was assigned to resident #1 on 6/01/25 during the 7:00 AM to 3:00 PM shift. She reported CNA B assisted her with transferring resident #1 to her wheelchair at approximately 9:00 AM. CNA A stated resident #1 ate breakfast and spent the remainder of the day in the day room. She denied observing any bruising or signs of pain during her shift. She shared later that day she received a call from a supervisor who inquired about swelling and bruising noted on resident #1's right arm by the next shift's CNA. She stated she consistently used two staff to transfer resident #1, who was dependent and unable to assist with transfers. CNA A indicated she always sought assistance for transfers due to resident #1's weight and contractures. She expressed concern that CNA B denied helping with the transfer of resident #1 on 6/01/25 and confirmed she demonstrated her transfer technique to management the day after the incident. On 6/29/25 at 2:16 PM, with translation assistance from CNA H, CNA B explained that on 6/01/25 she asked CNA A for equipment between 7:00 AM and 7:30 AM and later returned it during her break around 2:00 PM. CNA B denied assisting CNA A with any transfers that day. She stated she could not recall how transfers were conducted when she previously trained with CNA A. In a telephone interview on 6/29/25 at 3:19 PM, resident #1's son stated his mother was nonverbal and physically unable to inflict injury on herself. He expressed concern about the lack of clear information from the facility regarding the incident on 6/01/25. He reported the facility later informed the family that resident #1 was mishandled during a transfer and that the employee involved was terminated. He expressed skepticism with the facility's explanation, citing the Residents Affected - Few Page 1 of 22 105754 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hospital's suspicion of potential abuse. Resident #1's son emphasized his mother had always previously required a two-person assist, but staff were observed performing single-person transfers, despite repeated complaints from the family. On 6/29/25 at 3:59 PM, CNA C recounted resident #1 required total assistance and prior to the incident, was transferred by one person using a gait belt. She indicated she observed a purple bruise on resident #1's RUA while changing her clothes on 6/01/25. She shared she immediately informed the nurse who was unaware of the injury. CNA C stated resident #1 was nonverbal and guarded the injured arm during care. She described resident #1's upper extremities as contracted and difficult to assess for pain unless physical signs were present. She stated after the nurses assessed resident #1, she transferred her back to bed with caution. CNA C indicated a few days after the incident, she was called into the DON's office and gave a verbal report of what she had observed. She recalled receiving an in-service training on transfers but was not required to demonstrate how she actually performed them. A gait belt is a device used by caregivers to help stabilize and guide a patient who walks but is not steady on their feet. The belts help enable safe functional mobility and reduce patient falls as well as patient and staff injuries. Staff should know when and how to use the gait belt as an important part of safe patient handling, (retrieved on 7/16/25 from www.medline.com). On 6/29/25 at 5:02 PM, Registered Nurse (RN) D recounted she was the nurse assigned to resident #1 on 6/01/25 and was informed of the bruising by CNA C. She indicated she observed a large purple bruise extending from the resident's right shoulder to her elbow. RN D confirmed there were no prior fall reports and initiated a telehealth visit with the on-call provider, who ordered a STAT (immediate) X-ray. She stated she reported the incident to her supervisor and the physician. She acknowledged she did not administer pain medication and stated she was instructed to wait for imaging results before notifying the family. In a telephone interview on 6/30/25 at 6:49 AM, Licensed Practical Nurse (LPN) E stated she was called to resident #1's room by RN D after CNA C discovered the bruising. She indicated she observed resident #1 grimacing and guarding her RUA. She confirmed a telehealth consultation was initiated and a STAT X-ray was ordered. LPN E indicated she ended her shift before the X-ray was completed and was unsure if pain medication was administered. She stated she attempted to contact the 11:00 PM to 7:00 AM shift CNA without success and called CNA A, who reported no unusual findings during her shift. LPN E confirmed she contacted the Director of Nursing (DON) to report the incident and followed the facility's protocol. She stated shortly after the injury was discovered she spoke with the DON who instructed her to contact the physician and investigate further. On 6/30/25 at 2:36 PM, the Director of Rehabilitation (DOR) shared resident #1's incident was discussed during the clinical meeting on 6/02/25 and re-education on transfers was initiated. She stated resident #1 was previously a one-person assist for transfers, but after returning from the hospital, a mechanical lift was considered. On 7/01/25 at 10:53 AM, the DOR confirmed therapy was not involved in CNA A's reenactments of the transfer incident during the investigation into the incident, nor did therapy staff participate in the review of the incident's transfer mechanics for the investigation.On 6/30/25 at 12:43 PM, CNA I reported resident #1 required assistance from two to three staff for transfers prior to the injury due to whole-body contractures and rigidity. She noted a gait belt was not used when three CNAs transferred resident #1. On 7/01/25 at 10:53 AM, Physical Therapy Assistant F stated resident #1 required maximum assistance of one staff and transfers always required use of the gait belt. He described standard one-person and two-person pivot techniques. The DOR, present during the interview, stated resident #1 was not considered complex despite her inability to assist or communicate and acknowledged resident #1 had strength in her legs, but did not assist by pushing up during transfers. In a telephone interview on 7/01/25 at 2:33 PM, via a translator, CNA 105754 Page 2 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A confirmed she did not ever use a gait belt with resident #1 and did not recall seeing any except those used by therapy staff. She indicated she was never instructed to use a gait belt for transfers with resident #1, nor for transfers with any other resident. Step by step, she explained her stand pivot transfer method for resident #1, which involved lifting the resident by the waist and under the arms, despite the resident's contractures and nonverbal status. CNA A confirmed she had previously documented residents as a one-person assist even when a two-person assist was needed. She explained she only documented a two-person assist when using a mechanical lift. CNA A confirmed she demonstrated her transfer technique to facility management during a reenactment following the incident but was never asked if she utilized the gait belt. Review of the facility's five-day report submitted to the State Agency on 6/06/25 revealed the facility first reported the allegations on 6/02/25 at 5:41 PM, the day after resident #1's fracture was found. The facility's five-day report concluded the allegations had No supportive findings, and not verified. The Allegation Details section included, Resident identified to have a humeral fracture having occurred during transfer. Resident sent to the ER (emergency room) for evaluation and treatment, returned to the facility with a sling in place. Physician visited, pain assessed, and medication regimen adjusted. Met with resident's son and daughter in law in person; discussed resident's status and plan of care updates. Conversation productive, both appreciative of the facility actions. The Analysis section read, Investigation-summary of interview (alleged victim/resident representative): Resident is unable to provide information, and family offered no additional information. Investigation-summary of interview with witnesses: N/A no witnesses identified. Investigation-summary of interview with alleged perpetrators: Interview and recap of events with the identified staff member demonstrates that the resident's physician ordered plan of care was carried out as intended. Investigation-summary of interview with other residents in contact with alleged perpetrator: Interviews unremarkable, resident's roommate who is alert and oriented . reports no concerns. Investigation-summary of interview staff: Staff interviews unremarkable, no concerns noted. A follow-up request made by the State Agency on 6/10/25 cited the lack of detail, failure to describe the transfer method, staff involvement, protection plans for resident #1 and others, and failure to identify staff status. The facility did not update or correct the report as directed.In a joint interview on 6/30/25 at 3:27 PM, with the Nursing Home Administrator (NHA) and the DON, the NHA indicated he was the Abuse Coordinator, and the DON was the Risk Manager. The DON stated she was informed of resident #1's bruising by the Weekend Supervisor on 6/01/25 and that a STAT X-ray had been ordered by the physician. The DON continued, that after imaging confirmed a fracture, resident #1 was transferred to the hospital, and she began collecting data regarding the incident the following morning. She reported she spoke with all staff who worked the Sunday shift, including those assigned to resident #1 and those who were not. The DON stated no staff were able to provide information about how the injury occurred at that time. She stated she interviewed the Weekend Supervisor, assigned nurse and assigned CNAs but no one reported witnessing a fall or other injury. The DON indicated she interviewed resident #1's roommate but she did not see or hear anything. She stated she interviewed CNA A in person that morning. The DON explained CNA A demonstrated how she transferred resident #1 in resident #1's room. The DON recalled CNA A reported that at approximately 10:00 AM, CNA B assisted her to transfer resident #1 from bed to her wheelchair. CNA A demonstrated how she held resident #1 under her right arm but and confirmed she did not mention the use of a gait belt. The DON recalled CNA B told her she did not assist CNA A to transfer anyone. The DON stated she and the NHA called CNA A to his office, but CNA A was adamant that CNA B assisted her to transfer resident #1. The DON shared CNA B re-confirmed she had not helped CNA A with the transfer. The DON stated CNA B 105754 Page 3 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reported that CNA A had told her to say she helped her, to cover for her, but CNA B refused. The DON stated due to the reported inconsistencies they decided to watch the video footage of the hallway outside resident #1's room from the previous day. The DON shared that based on CNA A's reenactment, which was observed by the DON, NHA, the Unit Manager and a fourth person the DON could not recall, it was determined the fracture likely occurred due to the transfer technique used. The DON described CNA A's technique as involving a lift under the resident's right upper side and mentioned the upward jerking during the maneuver may have caused the injury. The DON related that how CNA A executed the transfer, was a bit aggressive for a resident being contracted. The DON said, You do not pull someone who is contracted like CNA demonstrated. The DON acknowledged CNA A never mentioned the use of a gait belt and they did not inquire as to whether she used one. The DON concluded, The upward jerking motion under resident #1's arm may have caused the fracture. The DON stated the mechanism of the transfer was correct but the CNA's motion under resident #1's arm may have caused the fracture. The DON confirmed CNA A told them that was how she always transferred resident #1. The NHA explained the harm was unintentional. The DON confirmed the facility did not address the additional information requested by the State Agency for complete investigation and reporting. She stated she was under the impression the reports were to give a rough synopsis of what the investigation showed. They confirmed no witness statements or specific details of their investigation were included in the report.On 7/01/25 at 11:28 AM, the DON reported observing three reenactments of CNA A's transfer technique. Later at 1:28PM, the NHA and DON validated during the three reenactments no one ever inquired if CNA A used a gait belt to transfer resident #1 according to facility procedure for transfers. They both acknowledged CNA A did not indicate whether she used a gait belt in her demonstrations of stand to pivot transfer. They did not say how the investigation could be complete without knowing all of the pertinent details of CNA A's transfer of resident #1. A contracture is a medical condition characterized by fixed tightening of the muscles, tendons, ligaments or skin which can prevent normal movement of the affected body part leading to joint deformity and rigidity. This can limit the range of motion and cause pain, (retrieved on 7/17/25 from www.mountsinai.org).In a telephone interview on 7/02/25 at 3:52 PM, resident #1's primary care physician (PCP) described resident #1 as one of the most vulnerable residents in the facility due to her physical and cognitive deficits. She stated the injury significantly impacted the resident's quality of life and pain medication was required. The PCP affirmed the lack of firsthand accounts in the investigation and the resident's communication status complicated it. She noted if two-person assistance was needed, it should have been clearly communicated and documented. The PCP expected staff to follow any facility policies and protocols regarding the care of the residents. During a telephone interview on 7/02/25 at 4:25 PM, the Medical Director stated he was informed the injury occurred due to transfer conducted by a single CNA without assistance. He reported the transfer technique used by the CNA was improper and emphasized all staff should be trained with hands-on demonstrations, not just checklists to ensure their understanding and compliance. He expressed concern that therapy staff was not involved in reviewing the incident to complete a thorough investigation.Review of the Administrator job description signed by the NHA on 2/20/25 revealed duties included to ensure quality resident care was provided in accordance with state and federal laws, rules and regulations. The form listed Essential Job Duties of this position to include, Ensures quality resident care is provided to meet and exceed company expectations and in accordance with state and federal laws, rules and regulations. Responsible for the compliance of legal, regulatory, accreditation and reimbursement laws, regulations and expectations. Oversees the completion of forms and documents to ensure compliance with company guidelines and other laws and regulations. 105754 Page 4 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensures accurate and timely reporting of incidents related to resident rights or abuse to the appropriate state agency; reports any findings of internal investigations. Actively participates in investigations related to resident or employee matters. Review of the DON job description signed by the DON on 7/02/25 revealed she was Responsible for developing, directing and managing the nursing services department to ensure the delivery of high-quality nursing care and services in accordance with all laws, regulations and facility guidelines. The form listed Essential Job Duties of this position included, Appointed as facility Risk Manager and is responsible for overseeing investigations related to resident events. Review of the policy and procedure titled Risk Management Incident Guidelines, dated 2015, revealed all incidents that occurred in the facility would be documented, investigated and recorded in their electronic tracking system. The form indicated the Incident Report & Investigation was to develop initiatives for the improvement of care and quality of life for residents. The policy indicated the investigation was completed by the DON, charge nurse, or Nursing Supervisor and the Risk Manager with a goal to identify the underlying cause, referred to as root cause analysis. The policy further detailed that the Federal 2 Hour/Immediate/5-Day Allegation Investigation Worksheet should be completed for all incidents categorized as allegations of mistreatment, abuse, neglect, injury of unknow origin, and submit the appropriate Federal and State reports as required. Review of the facility policy and procedure titled Resident Mistreatment, Abuse and Neglect Prohibition, dated 2017, indicated the facility was required to identify, correct, and intervene in suspected situations of abuse, or neglect. The policy detailed that the facility should regularly monitor staff to determine whether inappropriate behaviors occurred; assess care plans and monitor residents with needs or behaviors which may lead to abuse or neglect. The document also indicated that the facility would thoroughly investigate injuries of unknow origin and any suspected or alleged abuse or neglect in accordance with federal and state regulations. 105754 Page 5 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop, implement, and revise a person-centered, comprehensive care plan to address communication needs for 1 of 4 residents reviewed for care planning, of a total sample of 8 residents, (#1).Findings: Cross Reference F689 Review of the medical record revealed resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. Her most recent diagnoses included stroke with residual speech and language deficits, impaired mobility, right humerus fracture, type 2 diabetes, and osteoarthritis. Review of the Minimum Data Set (MDS) signification change in condition assessment with Assessment Reference Date (ARD) of 6/10/25 revealed resident #1's preferred language was Spanish. Resident #1 had bilateral upper extremities impairment and was dependent on staff for all Activities of Daily Living, mobility and transfers. The MDS quarterly assessment with ARD of 3/09/25 showed resident #1's preferred language was Spanish. In a telephone interview on 6/29/25 at 3:19 PM, resident #1's son stated after his mother suffered two strokes, she could no longer speak but she only spoke Spanish. He explained he posted a note with reminders for staff which included she only understood Spanish. On 7/01/25 at 8:03 AM, resident #1's son described how his mother became frightened and withdrawn due to her inability to understand staff. He shared he contacted the facility leadership about his concerns and provided a copy of an email he sent to the former Director of Nursing (DON) dated 9/10/23 stating, in part, . Between her weight and her immobility, we know she is not easy to maneuver. Especially if they are not speaking Spanish to her, she will not understand a word they are saying. A review of an undated sign observed posted in resident #1's room on 6/30/25 at 11:20 AM read: Reminders: -NOT ABLE TO SPEAK -ONLY UNDERSTANDS SPANISH . Review of resident #1's care plan for communication problems related to weak or absent voice, language barrier, and impaired cognition, revised on 12/13/24, did not reflect the resident's preferred language or outline individualized communication strategies for addressing the language barrier. Review of the Kardex (Certified Nursing Assistant care plan) revealed a Communication section which read, Use task segmentation to support short term deficits. Break tasks into one step at a time. The document did not reference resident #1's language preference. On 6/29/25 at 3:59 PM Certified Nursing Assistant (CNA) C stated she explained what she would be doing with resident #1 in English, even though the resident only Speaks Spanish. On 7/01/25 at 12:18 PM, CNA G indicated resident #1 understood some English, but she only knew a few words in Spanish. CNA G stated resident #1 was totally dependent and could not do anything for herself.On 7/02/25 at 11:56 AM, the East Wing Unit Manager (UM) acknowledged the sign posted in resident #1's room, which included the resident only understood Spanish. She explained the facility could not always accommodate language preferences. She mentioned no formal Spanish-speaking staff assignments were in place for resident #1. She then shared they had some nursing or therapy staff who spoke Spanish and staff could ask one of them to translate when needed. She validated resident's preferred language should be included in the care plan but was unsure if resident #1's reflected it. She stated every nurse had the ability to update the care plan if needed. On 6/30/25 at 1:30 PM, the MDS Coordinator stated the care plan should be person-centered and reflect a clear picture of the resident's status across all disciplines. She explained her role in updating care plans during clinical meetings. On 7/02/25 at 10:43, the MDS Coordinator validated the resident's primary language should have been included in the care plan so staff would know. She stated she did not recall if this was discussed during any of the care plan meetings she attended. Review of the Facility assessment dated [DATE] showed the facility identified the presence of Hispanic residents and that care would be 105754 Page 6 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0656 directed as culturally appropriate. The assessment also referred to the use of a Cultural Competency and the goal of ensuring staff could meet the cultural and linguistic needs of residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105754 Page 7 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) followed facility protocol when transferring a physically and cognitively impaired vulnerable resident from bed to wheelchair; and failed to ensure staff transferred residents safely for 1 of 4 resident reviewed for accidents, of a total sample of 8 residents, (#1). On 6/01/25 at approximately 10:40 AM, resident #1, vulnerable and dependent on staff for all Activities of Daily Living (ADLs), mobility and transfers, sustained a displaced fracture of the right humerus when the 7:00 AM to 3:00 PM shift CNA transferred the resident by herself without the use of a gait belt. After CNA A transferred resident #1 from her bed to the wheelchair she transported her to the dayroom. Hours later, when resident #1 was taken back to her room by the next shift CNA, she noticed a bruise on the resident's right upper arm (RUA) and notified the nurse. Resident #1 was assessed by her assigned Registered Nurse (RN) and via telehealth by a medical provider who ordered a STAT (immediately) X-ray of the right shoulder. At approximately 8:00 PM, an X-ray revealed an acute displaced proximal humerus fracture. Resident #1 was transferred to the hospital for evaluation, where it was determined surgical repair was not recommended due to comorbidities and age. Findings:Cross Reference F726Resident #1, a [AGE] year-old female, was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 4/09/24. Her most recent diagnoses included speech and language deficits after a stroke, reduced mobility, history of falling, muscle weakness, fracture of upper end of right humerus (upper arm bone), type 2 diabetes, and osteoarthritis.Review of the Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date 3/09/25 revealed resident #1's Brief Interview for Mental Status was not obtained because the resident was rarely or never understood. Instead, a Staff Assessment for Mental Status was conducted, and short and long-term memory were selected. The MDS assessment indicated resident #1 had severely impaired cognitive skills for daily decision making. The MDS assessment noted no behavioral issues or rejection of care during the lookback period. Resident #1 had bilateral upper extremity impairment and no lower extremity impairment. She was dependent on staff for all ADLs, mobility, transfers and locomotion on and off the unit. A sit-to-stand test was Not attempted due to medical condition or safety concerns.Review of resident #1's care plan for ADL self-care performance deficit related to generalized weakness, impaired mobility, impaired cognition, revised on 12/13/24, revealed resident #1 required the assistance of one staff for transfers until 6/02/25. An intervention dated 5/16/23 directed staff to report changes in ADL self-performance to the nurse.Resident #1 had a care plan for risk for falls related to confusion, impaired mobility, and incontinence. Another care plan was for communication problems related to weak or absent voice, language barrier, and impaired cognition; both revised on 12/13/24.Review of the Nursing Quarterly Evaluation dated 4/21/25 revealed resident #1 was always disoriented to person, place, and time. The evaluation indicated resident #1 had a balance problem while standing/sitting/walking and required the use of a wheelchair. Review of resident #1's medical record revealed a progress note by the on-call provider on 6/01/25 at 5:12 PM, which detailed, Nurse notified clinician that new bruising was noted to the patient's RUA, and she is guarding with touch and attempted movement. She is nonverbal so unable to verbalize any possible injuries. Per the nurse, there are no recent documented falls. She is a total care patient. Will obtain STAT (immediate) X-rays of right shoulder and humerus. The note revealed a physical exam per nurse and video observation showed skin bruising to RUA, guarding right shoulder with touch and range of motion (ROM), and pain in RUA. Review of a progress note dated 6/01/25 at 5:38 PM, by Licensed Practical Nurse (LPN) E indicated, she was called into the 105754 Page 8 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's room by the evening shift CNA after she found right shoulder bruising, and left bloodshot eye was also noted. The nurse documented that the patient was noted to be grimacing and guarding upon movement of the extremity. She noted the physician was notified, and a STAT X-ray was ordered.Review of a progress noted by the on-call provider on 6/01/2025 at 8:29 PM, revealed the Xray showed a visible fracture at the upper end of the humerus. The note detailed that due to the location of the fracture and possible dislocation the resident would be sent to the hospital emergency department (ED) for orthopedic evaluation.Review of resident #1's Change in Condition & Transfer form dated 6/01/25 at 9:58 PM, revealed the change of condition was an abnormal X-ray finding which occurred on 6/01/25 at 7:45 PM which resulted in a transfer to an acute care hospital. The narrative summary identified that at 7:00 PM the evening shift CNA notified the nurse of bruising on the right shoulder. In conflict with the nurse's progress note from 5:38 PM, the form indicated resident #1 did not show signs of pain.Review of an Emergency Department Provider Note dated 6/01/25 revealed, Emergency Medical Services (EMS) reported resident #1 was found to have bruising of the right arm and an X-ray showed a proximal humerus fracture. EMS noted there was no reported falls or trauma at the facility. The ED provider note included, Significant bruising noted to the right upper arm. X-rays confirmed proximal humerus fracture. Had long discussion with family about concern for possible elder abuse at the nursing home. Offered admission if family wants patient transferred to a different facility. The provider indicated a report was to be initiated with Adult Protective Services concerning the possible abuse.Review of a Progress Note from resident #1's primary care provider dated 6/05/25 revealed a sling was in place to resident #1's right shoulder, and the resident had pain present secondary to the humeral head fracture. The note detailed that ED notes including imaging were reviewed, and the plan was for non-operative management.In a telephone interview on 6/29/25 at 1:16 PM, CNA A explained she held this position for about 10 months which was her first as a CNA in the nursing home setting. She indicated she was familiar with resident #1 and had cared for her often before Sunday 6/01/25 on the 7:00 AM to 3:00 PM shift. CNA A recalled on 6/01/25, she asked CNA B to help transfer resident #1 to her wheelchair. She stated they both went into the resident's room and CNA B assisted with the transfer at approximately 9:00 AM. CNA A remembered resident #1 ate half of her breakfast in the wheelchair and was later wheeled to the day room, where she spent the rest of the day. CNA A mentioned she observed resident #1 had a red eye but could not recall on which side, and she notified the nurse. CNA A stated the nurse checked resident #1's eye and asked her to retake the blood pressure which she reported as normal. She shared later that day she received a call from the supervisor who inquired whether she had noticed anything unusual with resident #1 because the next shift CNA had noted bruising and swelling to the right arm. CNA A stated she observed redness on resident #1's arm the following day. She explained resident #1 was never transferred using a mechanical lift but instead was a two-person transfer. The CNA indicated she demonstrated to management how she transferred resident #1 from the bed to her wheelchair. She said, The problem is the other CNA is saying she did not help me. CNA A reiterated resident #1 was a two-person transfer and conveyed she always had someone to assist because resident #1 was heavy. She emphasized resident #1 was dependent and unable to assist herself. CNA A explained she held up resident #1 by the right shoulder and assisted her by lifting her to a sitting position, and both CNAs then helped her transfer into the wheelchair. She stated she had received training on transfers and was very familiar with transfer techniques. On 6/29/25 at 2:16 PM, with English to Creole translation CNA B recalled on Sunday 6/01/25 she was scheduled to be assigned to a team independently for the first time, as she was new to the facility at that time. She recalled between 7:00 and 7:30 AM, she approached CNA A and asked to borrow her blood 105754 Page 9 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pressure cuff and pulse oximeter to complete her morning vital signs. CNA B reported after collecting the supplies she needed, she returned to her assigned wing. CNA B stated CNA A never asked her for assistance with transferring any residents, including resident #1. CNA B stated she later returned the borrowed supplies to CNA A in the breakroom around 2:00 PM, during her scheduled break. CNA B shared she had trained with CNA A the prior Sunday but did not recall if or how resident #1 was transferred at that time. She confirmed the day after the incident; she told her supervisor she had not helped CNA A with the transfer. In a telephone interview conducted on 6/29/25 at 3:19 PM, resident #1's son shared his mother had suffered two strokes, was nonverbal, and unable to move independently. He said there was no way she could hurt herself this badly on her own. He mentioned he and his wife could only guess what had occurred, as the facility had not provided them with full details about the incident. He shared the facility recently completed an internal investigation and informed the family that his mom had been mishandled during a transfer and the involved employee had been terminated. The son expressed frustration, stating the facility tried to make it appear as though the injury was accidental or mishandling instead of mistreatment. He explained, To get her socket where it is at, there would have had to have some major force against it. He mentioned resident #1 had always required a two-person assist, but there were multiple instances when the family observed his mother being transferred by just one staff member. He shared that each time they had brought the concerns to the attention of facility leadership, but the issue continued, so the family started placing signs in the room to instruct staff on what to do in hopes it would help. The son stated the former Director of Nursing (DON) repeatedly told them staff would be retrained to ensure two-person transfers were utilized. He mentioned he felt that due to high staff turnover this issue continued to occur. Resident #1's son further explained many staff members had difficulty communicating with his mother because she only spoke and understood Spanish and would become frightened or withdrawn when she could not understand what was happening. He lamented, My poor mom, her last few years, living in pain, and scared. He indicated he felt like he had to supervise the staff himself. He added staff often failed to read or follow the reminders he had placed in her room. He shared he had placed full trust in the facility to care for his mother with humanity and respect. The son expressed sadness his mother would now require long term pain management, as the Orthopedic surgeon had advised surgical repair was not an option for her fractured shoulder.On 6/30/25 at 11:20 AM, in resident #1's room one of various undated signs posted on the wall indicated: Reminders: -NOT ABLE TO SPEAK -ONLY UNDERSTANDS SPANISH -DO NOT GRAB HER BY HER HANDS, WRISTS OR ARMS WHEN TRANSFERRING.On 7/01/25 at 8:03 AM, resident #1's son shared an instance when he contacted facility leadership about his concerns over the handling of his mother during transfers. He provided a copy of an email he sent to the former Director of Nursing (DON) on 9/10/23. The email read, Since significant bruising has shown up a couple of times, we are concerned that maybe the nurse that's assigned is having a hard time handling my mother when it comes to transferring or showering. Between her weight and her immobility, we know she is not easy to maneuver. Especially if they are not speaking Spanish to her she will not understand a word they are saying. A second email he sent to the Unit Manager (UM) with copy to the former DON dated 6/21/24 read, Two Person Transfer - it concerns us that when we see someone getting her ready that there is always just one person; she has always been a two-person transfer. The response from the DON on 6/25/24 indicated, I have received the email, will meet with the team, and will get back to you regarding the plan of action.On 6/29/25 at 3:59 PM, CNA C recalled on Sunday 6/01/25 she was assigned to provide care and was going change resident #1 into a gown as the resident had spent the day in the facility's day room. CNA C stated upon removing the resident's top, she noticed a purple bruise and 105754 Page 10 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few swelling on her right upper arm. She indicated she immediately informed the nurse, who was not aware of any prior injury. CNA C noted resident #1's left arm was more contracted than the right, and the bruised arm was considered her good arm. She recalled resident #1 required total assistance with her care and prior to the incident on 6/01/25, the resident was a one-person assist for transfers. CNA C reported when she transferred resident #1, she used a gait belt, ensured the wheelchair was locked, and pivoted the resident from chair to bed. CNA C further described resident #1 was nonverbal and did not express pain verbally, but when she removed the resident's clothing, she moved her arm as if protecting the area. She shared she did not observe obvious signs of pain or discomfort while providing care, adding, You cannot tell when she is in pain. She is always protecting herself. Unless you see a bruise or swelling, you would not know. CNA C stated she transferred the resident back to bed, carefully with one person assist during the transfer. She said, As soon as I saw the bruise I knew not to touch that area.A contracture is a medical condition characterized by fixed tightening of the muscles, tendons, ligaments or skin which can prevent normal movement of the affected body part leading to joint deformity and rigidity. This can limit the range of motion and cause pain, (retrieved on 7/17/25 from www.mountsinai.org).A gait belt is a device used by caregivers to help stabilize and guide a patient who walks but is not steady on their feet. The belts help enable safe functional mobility and reduce patient falls as well as patient and staff injuries. Staff should know when and how to use the gait belt as an important part of safe patient handling, (retrieved on 7/16/25 from www.medline.com). On 6/29/25 at 5:02 PM, RN D stated she was the assigned nurse for resident #1 on 6/01/25. She explained she routinely worked double shifts on Saturdays and Sundays, and this had been her second time caring for the resident. RN D reported the 7:00 to 3:00 shift CNA did not mention anything unusual that occurred with resident #1 at the beginning of her shift. She explained while administering medications later that day, the evening shift CNA C asked her to assess resident #1 due to a concern. She stated upon her assessment; she noted a large purple bruise that extended from resident #1's right shoulder/mid-clavicle down to her elbow. She indicated she immediately left the room, notified her supervisor, and reviewed resident #1's medical record to check for any recent falls. She recalled CNA A had earlier mentioned some redness on the resident's eye, which she had evaluated and described like a little dot. RN D stated she reported the bruising to her supervisor and the physician. She shared a head-to-toe assessment was completed by her and LPN E with no other areas of concern identified. She indicated a telehealth provider visit was initiated. She stated the provider saw the bruise and ordered a STAT X-ray of the right shoulder. She stated the X-ray was completed a few hours later and the provider directed resident #1 to be transferred to the hospital. She recalled she administered resident #1's scheduled medications but did not give any pain medication at the time. She stated she had asked resident #1 if she was in pain, but the resident did not respond and showed no obvious signs of discomfort. RN D indicated she was unaware of how many staff were required to assist with transfers for resident #1 and did not recall any CNAs calling for additional help during transfers that day. She explained she was instructed not to contact the family upon discovery of the bruise and, instead, wait for the X-ray results to have something to tell them. RN D indicated another nurse on the evening shift later contacted resident #1's family and informed them of the bruise, imaging results, and hospital transfer. In a telephone interview on 6/30/25 at 6:49 AM, LPN E stated she was working on the [NAME] Wing when she received a call from RN D asking her to come to resident #1's room. LPN E indicated she was informed CNA C was changing resident #1's clothes when the bruise was discovered. She indicated she observed resident #1 grimacing and guarding her RUA. She recalled the on-call provider was contacted and a STAT X-ray was ordered after the provider was 105754 Page 11 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few informed of the bruising, guarding behavior and pain indicators. She noted her shift had ended when the X-ray technician arrived at the facility. LPN E recalled when they tried to assess resident #1's right arm, she squinted her eyes. She stated she was not sure if RN D administered pain medication. She recalled a head-to-toe assessment was completed but did not recall assisting CNA C in transferring the resident back to bed. She shared she attempted to reach the 11:00 PM to 7:00 AM CNA to gather more information but was unsuccessful. She stated she also contacted CNA A who stated she did not observe anything unusual with resident #1 during her shift. LPN E stated she reported the incident to the DON and followed facility protocol. She stated the DON instructed her to notify the physician, determine what had occurred and keep leadership informed. She indicated they did notify the family immediately as the team was waiting for X-rays to be completed in order to provide accurate information. She stated she learned of resident #1's fracture only after leaving her shift. On 6/30/25 at 2:36 PM, the Director of Rehabilitation (DOR) stated resident #1's incident was discussed during a clinical meeting on 6/02/25, and nursing staff were involved in the investigation. The DOR said after the incident she was asked to clarify resident #1's transfer status, including how resident #1 got out of bed. She indicated the investigation revealed deficiencies in transfer technique, prompting staff re-education. She confirmed resident #1 returned from the hospital with a sling. The Director indicated prior to the incident, resident #1 had been on therapy caseload and was noted to be an extensive assist of one. She clarified this meant only one staff member was needed to transfer the resident, even though resident #1 did not actively participate in transfers. She explained after resident #1 went to the orthopedic appointment, the facility contacted the family to discuss the potential need for a mechanical lift going forward. She shared resident #1 would become anxious during the use of the lift, even though it would have been the safer option. The DOR indicated the mechanical lift was not used before this because resident #1 would get anxious and was nonverbal. She stated previous lift attempts had resulted in her holding her breath and becoming visibly distressed, which the DOR described as her face got red, it stressed her out a lot. She was unable to say when prior attempts to use the mechanical lift occurred and stated she would have to follow up with others for that information. She reviewed Physical Therapy (PT) and Occupational Therapy (OT) notes during 2025 but was unable to find documentation of recent use or attempts to transfer the resident with a mechanical lift. The DOR did not explain why another plan for transfer of resident #1 was not put into place when the facility felt a mechanical lift was needed but not able to implement successfully. On 6/30/25 at 12:43 PM, CNA I stated she was familiar with resident #1's care. She conveyed resident #1 currently required a mechanical lift but prior to the incident on 6/01/25, two or three CNAs were needed to transfer her. She explained additional CNAs were needed because resident #1 had contractures of her whole body and when you touched her, she moved her hands towards her body and was stiff. On 7/01/25 at 12:18 PM, CNA G shared she was a Restorative CNA for over 10 years and said resident #1 had always needed help. She recalled resident #1 had been in the restorative program for over a year, was totally dependent and could not do anything for herself. She remembered helping CNAs numerous times in the past with resident #1's transfers. She indicated it was always safer to have two staff assist for transfers when the resident was rigid and pushed back like resident #1. She said she felt another person should help, for safety reasons. On 7/1/25 at 10:53 AM, in a joint interview with Physical Therapist Assistant (PTA) F and the DOR, they explained residents were evaluated by therapy to determine the type of transfer and by how many staff which should be used. This information and any needed training were passed along to the nursing staff by the therapy department. PTA F stated resident #1 was always documented as a maximum assist of one and transfers always required the use of a 105754 Page 12 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few gait belt. He explained for a stand pivot transfer there were typically two approaches: one involving one person at the front holding the gait belt and another behind to guide, or two CNAs in front holding the gait belt together. The DOR stated resident #1 did not use her arms during transfers due to contractures and was not able to communicate verbally. The DOR indicated although resident #1 had strength in her legs, she still required staff use of a gait belt for all stand pivot transfers. Both the DOR and PTA F confirmed they had not received any requests from staff for additional gait belt instruction related to resident #1. The DOR stated she was not present for CNA A's re-enactment of the transfer and was unsure if any therapy staff had been involved. She also noted if CNAs had concerns or questions about safe transfers, she expected they could refer to therapy staff who were available for guidance.In a telephone interview conducted on 7/01/25 at 2:33 PM, with a Creole to English translator, CNA A stated she never used a gait belt to transfer resident #1 or any other resident during her time working at the facility. She did not recall ever seeing a gait belt used by CNAs in the facility, only by therapy staff. CNA A shared she received gait belt training in CNA school but none from the facility. She stated while CNAs were permitted to use gait belts, they were stored in the therapy room, not in resident care areas. CNA A emphasized she had not received instruction to use a gait belt when transferring resident #1, or any other resident. CNA A described her typical transfer technique, which involved rolling resident #1 to a seated position at the edge of the bed, placing her feet between the resident's feet, using one arm around the resident's waist and the other behind her to assist the pivot from bed to wheelchair. CNA A clarified a gait belt was not used for a two-person transfer, instead the second CNA would be on the opposite side, mirroring her actions, as resident #1 could not hold on to anything due to her upper extremity contractures. CNA A explained she had documented one-person assist in the medical record, even though resident #1 was a two-person assist. She said this was because she was not using a mechanical lift, which required two people. She stated no one had informed her she was required to document a two-person assist for other types of transfers using two staff. CNA A repeated she knew resident #1 was completely dependent, could not assist with transfers, and was fully aware of the resident's contractures when she transferred resident #1 without a gait belt. CNA A confirmed she demonstrated her transfer technique to facility management during a reenactment following the incident but was never asked if she utilized the gait belt.The facility had a security system, and the video footage was reviewed to provide this timeline:*On 6/01/25 at 7:24 AM, RN D entered and exited resident #1's room.*On 6/01/25 at 7:31 AM, CNA A entered resident #1's room and exited at 7:33 AM.*On 6/01/25 at 7:48 AM, both CNAs A and B entered resident #1's room to retrieve equipment and exited room at 7:49 AM.*On 6/01/25 at 8:03 AM, CNA A entered the room carrying a food tray and exited the room at 8:04 AM.*On 6/01/25 at 8:26 AM, CNA A walked into resident's room and exited the room carrying a food tray at 8:35 AM.*On 6/01/25 at 10:40 AM, CNA A walked into resident's room and closed the door.*On 6/01/25 at 11:06 AM, CNA A exited resident #1's room with soiled bag.*On 6/01/25 at 11:08 AM, CNA A reentered resident #1's room and exited the room with resident #1 in the wheelchair at 11:08 AM. CNA A proceeded down the hall and was stopped by RN D. RN D kneeled in front of resident #1 then stood back up and CNA A continued to walk resident in wheelchair to the day room. Resident #1 remained in the day room with others for the afternoon, which is her typical routine.*On 6/01/25 at approximately 3:45-4:00 PM, CNA C reported new bruising to RN D and LPN E. Resident #1 was evaluated and bruising was confirmed. Facial grimacing noted.On 6/30/25 at 6:21 PM, the Administrator (NHA) reported that upon reviewing video footage, the correct time resident #1 was returned to her room was approximately 4:45 PM on 6/01/25. The DON stated she was initially contacted by LPN E at 4:56 PM and later received an update from LPN E at 6:52 PM 105754 Page 13 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few regarding interviews she had conducted. The DON mentioned the next communication from LPN E occurred around 7:59 PM, likely following receipt of the X-ray results. On 7/01/25 at 11:28 AM, in a joint interview with the DON and NHA the DON explained she observed multiple reenactments by CNA A demonstrating the transfer of resident #1, all occurring the Monday following the incident. She indicated the first reenactment was performed in resident #1's room in the presence of the DON, the Unit Manager (UM), and the Advanced Practice Registered Nurse (APRN). The DON stated during the demonstration, CNA A showed how she placed her left hand on the back of resident #1 and her right arm under the resident's right armpit, assisting her from a seated position. The DON stated the second reenactment occurred with the DON and the NHA in his office. The NHA noted when resident #1 was moved forward from the bed, by default she extends and retro-pulses. The DON indicated the third reenactment was conducted in front of the facility's legal counsel and the DON. The NHA stated prior to the incident, there were no documented issues with resident #1's transfers. The NHA surmised discrepancies in documentation of the number of CNAs utilized to transfer resident #1 could be due to inaccurate documentation, CNAs may have had bad days or sought assistance when resident #1's condition varied. The NHA acknowledged new staff unfamiliar with the resident's needs may have contributed to inconsistent transfer practices. The NHA explained the lack of pain management documentation by RN D, when she had noted resident #1 was grimacing in pain, was that pain was subjective, or it may have been missed or misinterpreted due to RN D's focus on doing the right thing. Later at 1:28 PM, the NHA and DON validated during their investigation neither one of them asked CNA A if she used a gait belt during resident #1's transfer. They acknowledged CNA A did not indicate gait belt use during her demonstration.In a telephone interview on 7/02/25 at 3:52 PM, resident #1's primary care physician (PCP) shared she had been the resident's physician for approximately two years and saw her monthly and as needed. She stated resident #1 had been pretty much stable, with no major changes until recently. She recalled she was informed about resident #1's fracture on the evening of the event. She indicated at that time the facility launched an internal investigation as it was difficult to ascertain the circumstances around incident as resident #1 was nonverbal and the facility did not have much information at the time. She explained resident #1 was one of the more vulnerable patients, thus a potential for things to happen. She shared they had many care plan meetings with the family and therapy, and she deferred the assessments concerning assistance to therapy. She indicated she was aware resident #1 required a transfer by one person. She stated she was unaware resident #1 required two person transfers at times. She did not feel as that was communicated to her but said it was a very important piece of information. She stated she could only speculate if they communicated among themselves in the facility but said if CNAs were requiring two staff then the facility should have communicated that. The PCP confirmed resident #1's pain from the fracture should have been addressed by nurses as she was nonverbal, and said, Yes, certainly pain should have been addressed after the bruise was noted and the suspicion of fracture. The PCP pointed out she was not the provider on call, and she did not know the specifics but typically they would want to medicate the resident for pain. She shared she was not sure if it was overlooked by the on-call provider or the facility nurse, but based on the documentation, it would have made sense to dispense pain medication for this case. She mentioned the fracture and dislocation would affect resident #1's quality of life going forward. She validated resident #1 was now required to be transferred by mechanical lift and needed pain medication daily. She said it would probably be a few more months for resident #1's right shoulder to heal.During a telephone interview on 7/02/25 at 4:25 PM, the Medical Director stated he was not the attending physician for resident #1 but he was made aware of resident #1's incident shortly after it occurred. He shared he had 105754 Page 14 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few discussions with the facility staff about how the injury happened. The Medical Director reported he was told there was an error in lifting and there was no second person who was present to assist during the transfer. He shared he learned the CNA did not use the proper transfer technique with resident #1. He indicated he attended an Ad Hoc meeting regarding the incident in which he emphasized to leadership that transfer education must include hands on demonstration and validation, not just a checklist. He stated he was not aware therapy was not involved in the reenactments by CNA A and said, That's crazy, they should have been. He reiterated gait belt use and proper staffing during transfers should be non-negotiable expectations and noted multiple opportunities to prevent this incident were missed.Review of a Progress Note dated 6/23/25 from the Orthopedic Surgeon indicated, . her family shared that she was pulled by her right arm by a health aide when transferring from the wheelchair to the bed which resulted in her current injury. DCF (Department of Children and Families) is managing this case. The patient is nonverbal, uses a wheelchair, and has limited functional abilities. Her family shares that she expresses pain of the right arm by grimacing. Patient is currently utilizing a right arm sling. The note included, Two views of the right shoulder demonstrate a right proximal humerus fracture dislocation. There is significant displacement.Review of the policy and procedure titled Resident Transfers, dated 2008, revealed the purpose, To increase or maintain a resident's activity level. To improve and/or maintain highest optimum level of function, both mentally and physically. The document indicated, Always choose the safest transfer method for the resident and you. The resident's ability to follow directions and cooperate during transfer needs to be considered before choosing the method of transfer.Review of the Facility Assessment updated in May 2025 revealed the facility was able to assist residents with mobility and transfers based on resid[T 105754 Page 15 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the appropriate level of transfer assistance for a cognitively and physically impaired vulnerable resident and failed to ensure nursing staff demonstrated competency in all aspects of the transfer process. The facility failed to validate staff retained education provided and monitor Certified Nursing Assistants (CNAs) for adherence to facility transfer processes for 1 of 4 resident reviewed for accidents, of a total sample of 8 residents, (#1). On 6/01/25 at approximately 10:40 AM, resident #1, vulnerable and dependent on staff for all Activities of Daily Living (ADLs), mobility and transfers, sustained a displaced fracture of the right humerus when the 7 AM to 3 PM shift CNA transferred the resident by herself without the use of a gait belt. After CNA A transferred resident #1 from her bed to the wheelchair, she spent approximately six hours in the dayroom. Resident #1 was taken back to her room by the 3 to 11 PM shift CNA, who noticed a bruise on the right upper arm (RUA) and notified the nurse. Resident #1 was assessed by her assigned Registered Nurse (RN) and via telehealth by a medical provider who ordered a STAT (immediately) X-ray of the right shoulder. At approximately 8:00 PM, an X-ray revealed an acute displaced proximal humerus fracture. Resident #1 was transferred to the hospital for evaluation. The hospital determined surgical repair was not recommended due to comorbidities and age. Findings:Cross Reference F689Review of the medical record revealed resident #1, a [AGE] year-old female, was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 4/09/24. Her most recent diagnoses included speech and language deficits after a stroke, reduced mobility, history of falling, muscle weakness, fracture of upper end of right humerus, and osteoarthritis. Review of the Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date of 3/09/25 revealed resident #1 had severely impaired cognitive skills for daily decision making. Resident #1 had bilateral upper extremity impairment and no lower extremity impairment. She was dependent on staff for all Activities of Daily Living, mobility and transfers. Review of resident #1's care plan for ADL self-care performance deficit related to generalized weakness, impaired mobility, impaired cognition, revised on 12/13/24, revealed resident #1 required the assistance of one staff for transfers until 6/02/25, when it was revised to the assistance of two. An intervention dated 5/16/23 directed staff to report changes in ADL self-performance to the nurse. Resident #1 had care plans for risk for falls related to confusion, impaired mobility, and incontinence and for communication problems related to weak or absent voice, language barrier, and impaired cognition. Both care plans were revised on 12/13/24. Review of resident #1's medical record revealed a progress note by the on-call provider on 6/01/25 at 5:12 PM, which detailed, Nurse notified clinician that new bruising was noted to the patient's RUA, and she is guarding with touch and attempted movement. She is nonverbal so unable to verbalize any possible injuries. Per the nurse, there are no recent documented falls. She is a total care patient. Will obtain STAT X-rays of right shoulder and humerus. The note revealed a physical exam per nurse and video observation showed skin bruising to RUA, guarding right shoulder with touch and range of motion (ROM), and pain in RUA.Review of a progress note dated 6/01/25 at 5:38 PM, by Licensed Practical Nurse (LPN) E indicated, she was called into the resident's room by the evening shift CNA after she found right shoulder bruising, and left bloodshot eye was also noted. The nurse documented the patient was noted to be grimacing and guarding upon movement of the extremity. She noted the physician was notified, and a STAT X-ray was ordered.Review of a progress noted by the on-call provider on 6/01/2025 at 8:29 PM, revealed the Xray showed a visible fracture at the upper end of the humerus (upper arm bone) The note detailed that due to the 105754 Page 16 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few location of the fracture and possible dislocation the resident would be sent to the hospital emergency department (ED) for orthopedic evaluation. A Change in Condition & Transfer form dated 6/01/25 at 9:58 PM, revealed the change of condition was an abnormal X-ray finding which occurred on 6/01/25 at 7:45 PM which resulted in a transfer to an acute care hospital. The narrative summary identified that at 7:00 PM the evening shift CNA notified the nurse of bruising on the right shoulder. In conflict with the nurse's progress note from 5:38 PM, the form indicated resident #1 did not show signs of pain. Review of an Emergency Department Provider Note dated 6/01/25 revealed, Emergency Medical Services (EMS) reported resident #1 was found to have bruising of the right arm and an X-ray showed a proximal humerus fracture. EMS noted there was no reported falls or trauma at the facility. The ED provider note included, Significant bruising noted to the right upper arm. X-rays confirmed proximal humerus fracture. In a telephone interview on 6/29/25 at 1:16 PM, CNA A explained she held this position for about 10 months which was her first as a CNA in the nursing home setting. She indicated she was familiar with resident #1 and had cared for her often before Sunday 6/01/25 on the 7:00 AM to 3:00 PM shift. CNA A recalled on 6/01/25, she asked CNA B to help transfer resident #1 to her wheelchair. She stated they both went into the resident's room and CNA B assisted with the transfer at approximately 9:00 AM. CNA A remembered resident #1 ate half of her breakfast in the wheelchair and was later wheeled to the day room, where she spent the rest of the day. CNA A mentioned she observed resident #1 had a red eye but could not recall on which side, and she notified the nurse. CNA A stated the nurse checked resident #1's eye and asked her to retake the blood pressure which she reported as normal. She shared later that day she received a call from the supervisor who inquired whether she had noticed anything unusual with resident #1 because the next shift CNA had noted bruising and swelling to the right arm. CNA A stated she observed redness on resident #1's arm the following day. She explained resident #1 was never transferred using a mechanical lift but instead was a two-person transfer. The CNA indicated she demonstrated to management how she transferred resident #1 from the bed to her wheelchair. She said, The problem is the other CNA is saying she did not help me. CNA A reiterated resident #1 was a two-person transfer and conveyed she always had someone to assist because resident #1 was heavy. She emphasized resident #1 was dependent and unable to assist herself. CNA A explained she held up resident #1 by the right shoulder and assisted her by lifting her to a sitting position, and both CNAs then helped her transfer into the wheelchair. She stated she had received training on transfers and was very familiar with transfer techniques. In a subsequent telephone interview conducted on 7/01/25 at 2:33 PM, with a Creole to English translator, CNA A stated she never used a gait belt to transfer resident #1 or any other resident during her time working at the facility. She said she did not recall ever seeing a gait belt used by CNAs in the facility, only by therapy staff. CNA A shared she received gait belt training in CNA school but none from the facility. She stated while CNAs were permitted to use gait belts, they were stored in the therapy room, not in resident care areas. CNA A emphasized she had not received instruction to use a gait belt when transferring resident #1. CNA A described her typical transfer technique, which involved rolling resident #1 to a seated position at the edge of the bed, placing her feet between the resident's feet, using one arm around the resident's waist and the other behind her to assist the pivot from bed to wheelchair. CNA A clarified for a two-person transfer, the second CNA would be on the opposite side, mirroring her actions, as resident #1 could not hold on to anything due to her upper extremity contractures. CNA A explained she had documented one-person assist in the medical record, even though resident #1 was a two-person assist. She said this was because she was not using a mechanical lift, which required two people. She stated no one had informed her she was required to document a two-person 105754 Page 17 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assist for other types of transfers using two staff. CNA A repeated she knew resident #1 was completely dependent, could not assist with transfers, and was fully aware of the resident's contractures when she transferred resident #1 without a gait belt. CNA A confirmed she demonstrated her transfer technique to facility management during a reenactment following the incident but was never asked if she utilized the gait belt.A gait belt is a device used by caregivers to help stabilize and guide a patient who walks but is not steady on their feet. The belts help enable safe functional mobility and reduce patient falls as well as patient and staff injuries. Staff should know when and how to use the gait belt as an important part of safe patient handling, (retrieved on 7/16/25 from www.medline.com). On 6/29/25 at 2:16 PM, with English to Creole translation CNA B recalled on Sunday 6/01/25 she was scheduled to be assigned to a team independently for the first time, as she was new to the facility. CNA B expressed CNA A never asked her for assistance with transferring any residents, including resident #1. She confirmed the day after the incident; she told her supervisor she had not helped CNA A with the transfer. In a telephone interview conducted on 6/29/25 at 3:19 PM, resident #1's son shared his mother had suffered two strokes, was nonverbal, and unable to move independently. He shared the facility recently completed an internal investigation and informed the family that his mom had been mishandled during a transfer and the involved employee had been terminated. He said he felt for her arm to be displaced as it was, there would have had to have some major force against it. He mentioned resident #1 had always required a two-person assist, but there were multiple instances when the family observed his mother being transferred by just one staff member. He shared that each time the concerns were brought to the attention of facility leadership, but the issue continued. The son explained the family resorted to placing signs in the room to instruct staff on what to do in hopes it would help. Resident #1's son stated the former Director of Nursing (DON) repeatedly told them staff would be retrained to ensure two-person transfers were utilized. He mentioned he felt that due to high staff turnover this issue continued. He lamented, My poor mom, her last few years, living in pain, and scared. He indicated he felt like he had to supervise the staff himself. The son added staff often failed to read or follow the reminders he had placed in her room. The son expressed sadness his mother would now require long term pain management, as the Orthopedic surgeon had advised surgical repair was not an option for her fractured shoulder.On 6/30/25 at 11:20 AM, in resident #1's room one of various undated signs posted on the wall indicated: Reminders: -NOT ABLE TO SPEAK -ONLY UNDERSTANDS SPANISH -DO NOT GRAB HER BY HER HANDS, WRISTS OR ARMS WHEN TRANSFERRING.On 6/29/25 at 3:59 PM, CNA C stated resident #1 required total assistance with her care. She recalled on Sunday 6/01/25 while changing resident #1 into a gown, she noticed a purple bruise and swelling on her RUA. She indicated she immediately informed the nurse. CNA C noted resident #1's left arm was more contracted than the right, and the bruised arm was considered her good arm. CNA C stated she transferred the resident back to bed carefully and one assisted her during the transfer. CNA C recalled she received an in-service training on transfers but was not required to demonstrate how she performed them. On 6/29/25 at 5:02 PM, RN D stated she was the assigned nurse for resident #1 on 6/01/25, which was her second time caring for her. RN D indicated she was unaware of how many staff were required to assist with transfers for resident #1 and did not recall any CNAs calling for additional help during transfers that day. On 6/30/25 at 2:36 PM, the Director of Rehabilitation (DOR) stated resident #1's incident was discussed during a clinical meeting on 6/02/25, and the nursing staff was involved in the investigation. The DOR said she was asked to clarify resident #1's transfer status, including how resident #1 got out of bed. She indicated the investigation revealed deficiencies in transfer technique, prompting staff re-education. She indicated prior to the incident, resident #1 had been on 105754 Page 18 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few therapy caseload and was noted to be an extensive assist of one. She clarified this meant only one staff was assigned to transfer the resident, even though resident #1 did not actively participate in transfers. On 6/30/25 at 12:43 PM, CNA I stated she had worked at the facility for seven months and was familiar with resident #1 care needs. She reported resident #1 required a mechanical lift now but prior to the incident on 6/01/25, it would typically take two to three CNAs to complete a safe transfer of resident #1. She indicated the need for additional staff was attributed to resident #1's contractures, and said, when you touched her, she moved her hands towards her body and was stiff. CNA I emphasized before the incident resident #1 would require one to two additional staff, depending on staff availability and resident response. She indicated a gait belt was not used even when 3 CNAs helped with the transfer. On 7/01/25 at 12:18 PM, CNA G shared she was a Restorative CNA for over 10 years and said resident #1 had always needed help. She recalled resident #1 had been in the restorative program for over a year, was totally dependent and could not do anything for herself. She remembered helping CNAs numerous times in the past with resident #1's transfers. She indicated it was always safer to have two staff assist for transfers when the resident was rigid and pushed back like resident #1. She said she felt another person should help, for safety reasons. On 7/1/25 at 10:53 AM, in a joint interview with Physical Therapist Assistant (PTA) F and the DOR, PTA F stated resident #1 was always documented as a maximum assistance of one and transfers always required the use of a gait belt. He explained for a stand pivot transfer there were typically two approaches: one involving one person at the front holding the gait belt and another behind to guide, or two CNAs in front holding the gait belt together. The DOR stated resident #1 did not use her arms during transfers due to contractures and was not able to communicate verbally. The DOR indicated although resident #1 had strength in her legs, she still required staff use of a gait belt for all stand pivot transfers. Both the DOR and PTA F confirmed they had not received any requests from staff for additional gait belt instruction related to resident #1. The DOR stated she was not present for CNA A's re-enactment of the transfer and was unsure if any therapy staff had been involved. She also noted if CNAs had concerns or questions about safe transfers, she expected they could refer to therapy staff who were available for guidance. On 7/01/25 at 11:28 AM, the DON and NHA explained she observed multiple reenactments by CNA A demonstrating the transfer of resident #1, all occurring the Monday following the incident. She indicated the first reenactment was performed in resident #1's room in the presence of the DON, the Unit Manager (UM), and the Advanced Practice Registered Nurse (APRN). The DON stated during the demonstration, CNA A showed how she placed her left hand on the back of resident #1 and her right arm under the resident's right armpit, assisting her from a seated position. The DON stated the second reenactment occurred with the DON and the NHA in his office. The NHA noted when resident #1 was moved forward from the bed, by default she extends and retro-pulses. The DON indicated the third reenactment was conducted in front of the facility's legal counsel and the DON. The NHA stated prior to the incident, there were no documented issues with resident #1's transfers. The NHA surmised discrepancies in documentation of the number of CNAs utilized to transfer resident #1 could be due to inaccurate documentation, CNAs may have had bad days or sought assistance when resident #1's condition varied. The NHA acknowledged new staff unfamiliar with the resident's needs may have contributed to inconsistent transfer practices. Later at 1:28 PM, the NHA and DON validated during their investigation neither of them asked CNA A if she used a gait belt during resident #1's transfer. They acknowledged CNA A did not indicate gait belt use during her demonstration, as was indicated by therapy for all non-mechanical lift transfers.In a telephone interview on 7/02/25 at 3:52 PM, resident #1's primary care physician (PCP) stated she deferred the assessment for resident #1's transfer needs and 105754 Page 19 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few mobility status to therapy. The PCP stated if resident #1 required a two person assist for transfers, it should have been communicated to everyone. She validated the injury would have a significant impact on resident #1's quality of life given her age, contractures, and current dependence on pain medication. The PCP estimated several months of recovery would be required for resident #1's right shoulder to heal. During a telephone interview on 7/02/25 at 4:25 PM, the Medical Director stated he had discussions with the facility staff about how the injury happened. The Medical Director reported he was told there was an error in lifting and there was no second person present to assist during the transfer. He shared he learned the CNA did not use the proper transfer technique with resident #1. He indicated he attended an Ad Hoc meeting regarding the incident in which he emphasized to leadership that transfer education must include hands on demonstration and validation, not just a checklist that a task was completed. He reiterated gait belt use and proper staffing during transfers should be non-negotiable expectations and noted multiple opportunities to prevent this incident were missed. Review of the policy and procedure titled Resident Transfers, dated 2008, revealed the purpose To increase or maintain a resident's activity level. To improve and/or maintain highest optimum level of function, both mentally and physically. The document indicated, Always choose the safest transfer method for the resident and you. The resident's ability to follow directions and cooperate during transfer needs to be considered before choosing the method of transfer. Review of the Facility Assessment updated in May 2025 revealed the facility was able to assist residents with mobility and transfers based on resident's needs. The assessment indicated staff were educated and knowledgeable to provide residents with needed care and services. Review of the Administrator job description signed by the NHA on 2/20/25 revealed Competencies of the Position which read, Safety Awareness: Follows safety program guidelines; ensures the immediately reporting of accidents and incidents based on company guidelines; identifies unsafe working areas; promotes safety by working as safely and efficiently as possible; . identifies and corrects hazardous conditions; . Review of the Director of Nursing job description signed by the DON on 7/02/25 revealed Competencies of the Position which detailed, Safety Awareness: Follows safety program guidelines; immediately reports accidents and incidents to supervisors; identifies unsafe working areas and promptly reports to supervisors; promotes safety by working as safely and efficiently as possible; . identifies and corrects or reports hazardous conditions to supervisors; . Undated job description for RNs, LPNs, and CNAs included the same competency. Review of the CNA Competency Skills Checklist dated 9/24/24 revealed CNA A was deemed competent for transfers and demonstrated proper transfer technique with the assist of one, two, and a mechanical lift.Review of the Safe Patient/Resident Transfers Competency dated 9/24/24 included the following instructions, 1) Complete with each CNA/Licensed nurse 2) Complete upon HIRE/ANNUALLY/& or as indicated. 3) Complete ALL sections with return demonstration 4) Record any additional comments as indicated 5) Employee and facilitator to sign and date. The form revealed the steps to perform a stand pivot transfer and indicated, 8. Position the patient/resident so his/her strong side is closest to the surface her or she is transferring onto. Scoot the patient out of the edge of the bed or chair sliding hips forward. If the patent/resident has strength in his her/her legs, have him or her move hips toward the edge of the sitting surface (bed, chair or toilet). Keep the upper body straight and steady. Patient/resident may be able to move forward in the chair by pushing his/her shoulder into the back of the chair and sliding his/her hips outward toward the edge of the chair.9. Put the gait belt around the person's waist.10. Ask the patient/resident to place or help place his/her feet flat on the floor. Have his/her stronger foot slightly behind the weaker foot. Have the patient/resident shift his/her body weight forward, keeping trunk up and straight.11. Place your hands on the backside of 105754 Page 20 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the gait belt around the patient/resident's waist.12. To perform a safe transfer and to give stability to the patient's legs, block the legs by placing your feet and knees outside of the patient/resident's feet and knees. This prevents the patient/resident's knees from buckling.13. The patient/places his/her arms around your upper back or elbows. This provides control of the patient/resident's upper body.14. Assist the patient to lean his/her trunk forward over his/her knees. The patient/resident is to have a straight trunk. Give the patient/resident the cue to [NAME] on a count of three. Count 1 and 2 while rocking forward on each number to build up momentum. Come to a standing position on the number 3, as you straighten your legs and lift the patient/resident from the chair or bed. Allow the patient/resident's knees to come forward during the first part of standing. You should be careful to maintain a straight back and trunk and bend your knees for proper posture in order not to injure yourself. Keep your balance as you stand.15. Pivot your feet toward the transfer surface, rotating the patient/resident to the proper position for sitting on the transfer surface. Do not pivot until the patient/resident is upright and under control.16. Slowly lower the patient/resident's body onto the transfer surface. Have the patient/resident reach back to the armrest or surface to help lower himself/herself down.17. Hold on to the patient until he/she is in a position that he/she can maintain by himself/herself.18. If the transfer was to a chair, the patient/resident should try to scoot his/her hips back to the back of the chair. This will support his/her back in the best position possible.All steps were checked off on CNA A's competency as, Yes, except #9. Step #9 read, Put the gait belt around the person's waist.Review of a Safe Patient/Resident Transfers posttest form revealed it was not completed by CNA A. 105754 Page 21 of 22 105754 07/02/2025 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview, and record review, the facility failed to ensure effective implementation of policies, including thorough monitoring of previously identified areas of concern and adequate tracking of performance to verify improvement measures were realized and sustained. Findings: Review of the facility's policy titled QAPI (Quality Assurance and Performance Improvement)/Risk Management Program, dated 2017, read, The purpose of QAPI is to take a proactive approach to continual improvement of the care is given to residents, . The policy also referenced the QAPI Guiding Principles, stating, . QAPI focuses on systems and processes in order to examine and improve care or services in areas that are identified through the performance improvement plan (PIP) teams, as needing attention and setting priorities for action based on the information gathered. Data is obtained through the QAPI process from caregivers, residents, healthcare practitioners, families and others in the community, in order to systematically clarify areas of concentration focusing on root cause to determine proper interventions for improvement and to prevent future events and promote sustained improvement.The facility was previously cited for deficiencies under F689 and F610 on the complaint survey of 2/01/25. During the current survey, repeat deficiencies under F689 and F610 were again identified, indicating prior corrective actions were not adequately monitored or sustained. This demonstrated a lack of sufficient auditing and oversight in addressing the cited concerns.During an interview conducted on 7/02/25 at 6:16 PM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON), the NHA reported that upon assuming his role as Administrator, the facility had recently submitted a Plan of Correction for deficiencies cited under F689 and F610, which included two Immediate Jeopardy situations. The NHA stated audits were conducted and environmental modifications were implemented as required. He explained the facility received significant support from corporate leadership since that time. He acknowledged they were unaware of issues related to residents' transfers. The DON shared regional leadership was involved in reviewing all reports prior to submission to the State Survey Agency. The NHA added although efforts were being made to address the concerns, the process remained a work in progress, and there was still need for cultural change and continued improvement in QAPI practices. 105754 Page 22 of 22