F0689

D

Failure to Follow Care-Planned Transfer Assistance for Two Residents

Paramus, New Jersey Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement residents’ individualized transfer assistance as specified in their care plans, resulting in unsafe transfer practices for two residents. For Resident #1, who had diagnoses including Parkinson’s disease, depression, heart failure, and anxiety disorder and was cognitively intact with a BIMS score of 15, the quarterly MDS dated 1/12/26 showed dependence on staff for toileting hygiene and a need for maximal assistance with toilet and chair-to-bed transfers. The resident’s fall care plan, effective 1/14/26 and last revised 7/31/24, required one-person assistance for transfers from bed to wheelchair and two-person assistance for transfers from wheelchair to bed, and the Kardex instructed two-person assistance for transfers from toilet to wheelchair. Despite these documented requirements, a resident statement dated 9/22/25 indicated that CNA #1 transferred the resident from the wheelchair independently by lifting the resident to a standing position without another staff member, causing a near-fall.

Further documentation for Resident #1, including the facility’s Final Investigation, showed that the resident reported to the social worker that CNA #1 assisted them to stand in the bathroom using a grab bar and then assisted them to stand again for personal hygiene without a second staff member present. The Facility Reportable Event documented that the resident reported pain rated 5 out of 10, and a mobile lumbar spine x-ray indicated a fracture at L1, after which the resident was sent to the hospital; a subsequent hospital imaging report dated 12/16/25 indicated no definite acute fractures. In an interview, the resident stated they did not recall the specific incident but knew they required two-person assistance to transfer from wheelchair to bed and that two-person assistance was not consistently provided. Staff interviews confirmed that transfer requirements were available on the assignment sheet and care plan, and the DON stated that it was important for nursing staff to follow the care plan regarding transfer status for resident safety.

For Resident #2, who had diagnoses including primary osteoarthritis of the right hip and knee, right knee pain, diabetes, hearing loss, and a history of falls, the quarterly MDS dated 11/24/25 showed a BIMS score of 14, indicating cognitive intactness, and dependence on staff for bed-to-chair transfers. The resident’s care plan, effective 2/24/25, identified risk for falls related to a history of falls and required use of a Hoyer lift with two staff members for all transfers as a safety precaution, which was also reflected on the Kardex. Despite these instructions, Resident #2 reported that two staff members assisted them to the edge of the bed, counted “1, 2, 3,” and transferred them into a wheelchair without using the mechanical lift, stating that the staff “did what they wanted to do.” The social worker confirmed that the resident reported being transferred out of bed without a Hoyer lift, and the facility’s investigation substantiated an illegitimate transfer by agency staff based on the investigation and correlation with the resident’s initial interview. The facility’s ADL policy stated that assistance must be provided in accordance with each resident’s assessed needs, care plan, preferences, and applicable regulations, which was not followed in these instances.