**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the residents' environment remained as free from accident hazards as possible and prevent falls with major injury for two (#46 and #76) of four residents reviewed for falls out of 53 sample residents. Resident #46, who had a known history of falls, had a diagnosis of obesity which required the use of a bariatric (to support substantial weight) bed with extensions to enable the bed frame to be made larger. On 1/29/24, the resident sustained a witnessed fall from her bed when she was being rolled on her side with the assistance of staff during a bed bath. Resident #46 was sent to the hospital for evaluation of left knee pain following the fall where she was discovered to have a fracture of her left femur (thigh bone), which was surgically repaired on 1/30/24. The resident returned to the facility on 2/1/24 and was placed in the same bed she fell from on 1/29/24. The facility did not inspect the bed to ensure the extensions were pulled out appropriately and the mattress fit correctly prior to placing the resident back in the bed. On 2/5/24 (4 days after Resident #46's readmission to the facility), a rental supply company came to the facility to install bed canes (a device which can be utilized to assist a person to reposition themselves in bed). The rental supply company's personnel discovered the extensions on Resident #46's bed had not been pulled out prior to the resident's fall from the bed and the facility had failed to pull the extensions out prior to the resident's readmission to the facility. Additionally, Resident #76, who had diagnoses of muscle weakness and unsteadiness on her feet, was admitted to the facility on [DATE]. The resident had a history of falls with injuries in the 12 months prior to her admission to the facility. She required partial assistance with her toileting, bathing and moving from a sitting position to a standing position. The facility failed to implement appropriate person-centered fall interventions for the resident upon her admission to the facility. On 10/20/23, Resident #76 sustained a fall after tripping while she was attempting to get clothes from her closet. The resident complained of pain in her right wrist and x-rays were obtained which revealed she sustained a fracture to her right pinky finger and right thumb. The facility put an intervention in place to educate the resident to remember to turn on the overhead light before moving around in her room, however, the resident sustained five more falls following the 10/20/23 fall. The facility failed to put new and effective interventions into place after each fall to prevent the resident from sustaining further falls. Due to the facility's failure to properly evaluate Resident #46's bed frame and mattress for appropriate functionality and fit and the failure to implement timely and effective person-centered fall interventions for Resident #76, both residents sustained falls with major injury and experienced pain. I. Findings include A. Policy and procedure The Fall Management policy and procedure, reviewed 11/30/22, was provided by the nursing home administrator (NHA) on 2/26/24 at 2:19 p.m. It read in pertinent part: To promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indications. The facility must ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Residents will be assessed for fall indications upon admission, readmission, quarterly, change in condition, and with any fall utilizing the Fall Risk Assessment. II. Resident #46 A. Resident status Resident #46, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses include chronic respiratory failure, insomnia, chronic pain, bed confinement, colostomy, low back pain, muscle weakness, lack of coordination, history of falling and body mass index of 45.0 to 49.9 (obesity). The 2/2/24 minimum data set (MDS) assessment revealed the resident had normal cognition with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required two person assistance with dressing, toileting, bathing/showering, bed mobility and use of a mechanical lift with two staff members for transfers. The resident required one person assistance with personal hygiene and was independent for eating. B. Resident interview Resident #46 was interviewed on 2/21/24 at 11:26 a.m. The resident said she had fallen out of bed on 1/29/24. The resident said the problem was the bed. She said she felt as if she were sliding out of the bed when being turned onto her side. She said the staff had not pulled the slide outs/extensions out so the mattress fit correctly. She said she had been in the center of the bed, had started slipping and was unable to catch herself before falling to the floor. She said when she returned from the hospital the bed rental company personnel came to install bed canes and discovered the extensions had not been pulled out. C. Record review A nursing note dated 1/29/2024 at 6:51 p.m. documented a witnessed fall. A certified nurses aide (CNA) had yelled for help due to a resident falling from her bed while receiving a bed bath. Upon entering the room the resident was found on the left side of the bed on the ground. The resident was screaming in pain. The resident had swelling and a scrape on her left knee and was not able to move it. The resident was sent to the hospital for evaluation of her left knee. An emergency department (ED) note, dated 1/29/24, documented the resident fell out of bed during a bed bath landing on her left knee which was bruised with joint effusion (swelling). A diagnostic radiology (x-ray) note, dated 1/29/24, documented Resident #46 sustained a comminuted (broken in three or more places) mildly displaced and impacted (a break where the ends are driven into each other) distal (near the knee) femoral fracture. The operative report, dated 1/30/24, documented the operation/procedure of an open reduction (repositioning of pieces of fractured bone) and nailing of the femur fracture. A [NAME] 13 by 1340 millimeter (mm) nail locked the knee with three advanced locking screws and locked proximally (nearer the body) with one screw. Hospital discharge documentation, dated 2/1/24, documented the resident was discharged back to the facility. A facility readmission note, dated 2/1/24, at 3:35 p.m. documented the resident returned to the facility by stretcher. A bed rental company report, dated 2/5/24, documented the service to Resident #46's bed for placement of assist bars (bed canes). D. Staff interviews Licenced practice nurse (LPN) #2 was interviewed on 2/26/24 at 1:21 p.m. LPN #2 said the staff should check the bed before residents were admitted to ensure the bed was working properly and the mattress fit correctly. LPN #1 was interviewed on 2/26/24 at 2:06 p.m. LPN #1 said the bariatric (large size) beds, which was the type of bed Resident #46 used, had extensions to make the bed frame larger. She said the bariatric beds with the extensions were delivered to the residents' rooms from the facility's central supply (CS). She said CS personnel were supposed to check the bed to ensure the bed was working properly and the extensions were pulled out to accommodate the mattress. She said the mattress should fit inside the bed frame. LPN #1 said the extensions could be adjusted while the resident was in the bed, however, she said it was better to adjust them before the resident got into the bed. She said if a resident felt something was wrong with the bed, nursing staff should call maintenance to check the bed. The central supply director (CSD) was interviewed on 2/26/24 at 3:03 p.m. The CSD said Resident #46's bed had not been checked due to the resident being readmitted on [DATE] to the facility after she had left work for the day. She said the nursing staff should check the frame if the CSD was not available. She said the bed rental personnel had reported the extension bars were not all the way out on one side on 2/5/24 when they came to install the bed canes. The CSD said the extensions were not hard to pull out. She said the staff should report if the mattress was too small for the bed. She said there was no report of problems with the bed until the bed canes were put on by the service provider on 2/5/24. The director of nursing (DON) was interviewed on 2/27/24 at 11:33 a.m. The DON said if a resident was reporting a feeling of slipping in the bed it should be reported and the facility should look into the cause. He said the admissions staff and the CSD ensured the resident had the correct size bed. He said nursing staff was responsible for ensuring the extensions on the bed frame were pulled out and the mattress fit the bed appropriately. He said nurses should look at the frame. He said Resident #46 slipping from the bed could have been a bed frame problem.III. Resident #76 A. Resident Status Resident #76, age [AGE], was admitted on [DATE] and readmitted [DATE]. According to the February 2024 CPO, diagnoses included fracture of the sacrum, fracture of the left pubis (pelvis), multiple fractures of the ribs, history of falling, muscle weakness, unsteadiness on feet, fracture of the fifth metacarpal bone (pinky) and thumb on the right hand, depression, and anxiety. The 12/29/24 MDS assessment revealed, the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. She had impairment to both sides of her lower extremities. She used a walker and wheelchair. She had falls prior to admission as well as falls in the facility. She had a fall with a fracture. She required partial assistance with toileting, bathing, and sitting to standing. B. Resident interview Resident #76 was interviewed on 2/21/24 at 11:15 a.m. She said she had many falls. She said she fell and broke her thumb and pinky when she tripped over the wheel on her wheelchair. She said she also slid off the mattress and asked staff for a different one. She said staff told her all the mattresses were the same. She said when she stood up, she had nothing to hold onto. She asked staff if she could have a side rail and was told facilities were not allowed to put side rails on a resident's bed. C. Record review A physician's order, dated 10/20/23, instructed staff to send the resident to the hospital for abnormal x-ray results. A physician's order, dated 10/27/23, documented a fractured right fifth digit (pinky finger). Put the fourth digit together with the fifth digit as a guardian, apply a long cast from the fifth digit to the forearm, secure with ace wrap from finger to forearm. Let the thumb, middle, and ring finger be free from the ace wrap. Leave in place at all times every shift for a right fifth digit fracture. A physician's order, dated 10/27/23, documented a right thumb fracture. Apply an aluminum cast, U shaped and secure with coban. Leave in place at all times for thumb fracture. The hospitalization care plan, initiated 10/16/23, revealed Resident #76 was at risk for rehospitalization due to a history of injurious falls in the past 12 months. The interventions included labs as ordered, provide medications as ordered, registered dietician to evaluate and staff to provide timely communication to the physician regarding any change in resident condition. The fall risk care plan, initiated on 9/30/23 and revised on 10/16/23 revealed Resident #76 had a history of falls with injuries. Interventions included: -Assess if the resident wanted her bed made frequently and place the bed against the wall, initiated 2/12/24; -Assess toileting needs frequently, initiated 1/2/24; -Assist with activities of daily living as needed, initiated 9/30/23; -Bathroom lights to remain on at all times and remind resident to turn overhead light on when walking around the room, initiated 10/20/23; -Keep call light, reacher, and frequently used items within reach, initiated 9/30/23; -Complete a fall risk assessment, initiated 9/30/23; -Provide appropriate footwear/non-skid socks when ambulating, initiated 1/19/24; and, -Physical therapy to evaluate and treat, initiated 1/19/24. Review of Resident #76's falls were reviewed from 10/20/23 to 2/9/24. 1. 10/20/23 fall An event progress note, dated 10/20/23 at 11:15 a.m., revealed Resident #76 was found lying on her right side next to her bed. Her call light was within reach but not activated. The room had poor lighting and the resident did not turn on the light. The resident stated she was trying to get clothes from her closet and tripped. The resident expressed pain to her right wrist and bruising was noted to the left wrist. The physician was notified and x-rays of both wrists were ordered. The intervention was to educate the resident to remember to turn the overhead light on before movement in the room. -There was no fall investigation provided for the 10/20/23 fall. 2. 11/17/23 fall A health status progress note, dated 11/17/23 at 7:45 p.m., revealed the registered nurse (RN) supervisor was called to the unit because Resident #76 was on the floor. She required maximum assistance of two staff members to be lifted off the floor. An abrasion was found to the resident's mid lower back. The fall investigation dated 11/17/23 revealed the resident was found sitting on the floor after losing her balance at bedside. The resident stated she was reaching for an item near her bedside night stand. The intervention was to place frequently used items in reach of the resident. 3. 12/1/23 fall A health status progress note, dated 12/1/23 at 7:08 p.m., revealed Resident #76 had a fall. She was found while eating her dinner. She was sitting in a chair. There was no complaint of pain. The fall investigation dated 12/1/23 revealed the resident's roommate was able to activate the call light and call the nurses station from her cell phone. Resident #76 said she was seated in front of her bedside table and stood up to retrieve her purse. She said she felt she might fall and backed up to her bed. The resident assisted herself up from the floor. She had no injuries. -The intervention was to continue to remind the resident to use her call light to get items at a distance, which was the same intervention implemented for the fall on 11/17/23. -There were no new fall interventions put into place. 4. 12/22/23 fall An event progress note, dated 12/22/23 at 1:14 p.m,. revealed Resident #76 was found on the floor next to her bed in a sitting position. The resident stated she had tried to reach for her grabber and slid off the bed. The fall investigation dated 12/22/23 revealed the resident had no injuries. The intervention was to make sure her grabber and belongings were within reach. All the staff were aware to check the resident regularly. The resident was reminded to use her call light. -Despite the fall investigation documenting that all staff were aware to check the resident regularly, frequent checks were not implemented as a fall intervention on the resident's care plan. 5. 1/2/24 fall An event progress note, dated 1/2/24 at 12:33 a.m., revealed Resident #76 was found on the floor by a certified nurse aide (CNA). The resident was lying prone (face down) between the bathroom and the foot of her bed. She had pillows beneath her face. The call light was not activated. The resident's walker was approximately one foot away from her. The bed was soaked with urine. She had a small scratch to her left knee and complained of pain to her left leg and buttocks. The resident stated she exited the bathroom and her weakened hands led to a fall. She was assisted back to bed by three staff members. The fall investigation dated 1/2/24 revealed the resident fell after exiting the bathroom. The intervention was to assess the residents' toileting needs frequently. -The intervention did not document how frequently the resident should be offered toileting. 6. 2/9/24 fall An event progress note, dated 2/9/24 at 8:50 p.m., revealed Resident #76 was found on the floor at her bedside. She acknowledged she fell while trying to reach the call button as she was making her bed. There were no injuries noted. The fall investigation dated 2/9/24 revealed the resident was found on the floor and initially denied falling. The intervention was to have staff offer to make her bed when it was untidy or upon the resident's request. She was currently working with therapy to improve strength. D. Staff interviews CNA #1 was interviewed on 2/26/24 at 1:55 p.m. CNA #1 said Resident #76 was a stand by assist (SBA) for transfers and ambulation. She said the resident used her call light when she needed help. She said she did not know what interventions were put into place to help her from falling. LPN #2 was interviewed on 2/26/24 at 2:07 p.m. LPN #2 said she had worked with Resident #76 a couple weeks ago but was not told what fall interventions were put into place. She said if a resident had a fall, a new intervention should be put into place for each fall. The DON was interviewed on 2/26/24 at 2:29 p.m. The DON said Resident #76 liked to be independent. He said interventions that had been put into place were making sure the bathroom light was on, making her bed regularly, and making sure her grabber was in reach. He said he had thought about placing a bed cane on her bed but was afraid she would hit her head. He said he had not thought about placing a transfer pole at her bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, document review, and facility policy review, the facility failed to ensure a resident was provided with an environment that was free of accident hazards and adequate supervision/assistance to prevent an accident for 1 (Resident #56) of 3 sampled residents reviewed for accidents. Specifically, Certified Nursing Assistant (CNA) #4 transferred Resident #56 on 12/09/2021 using a sit-to-stand lift (a mechanical device utilized to assist a person from a sitting to a standing position) when Resident #56 had not been assessed for the use of the lift. Additionally, CNA #4 performed the transfer without the assistance of a second staff member, when two staff were required for the transfer. Further, the facility failed to complete a thorough investigation to determine the root cause of the incident. As a result of the improper transfer, Resident #56 slipped from the sling of the lift and sustained an avulsion injury (skin avulsion - a wound that occurs when skin is torn from the body during an accident or other injury) to the left wrist, the resident expressed fear of transfers since the incident, and staff reported the resident preferred to stay in bed. Findings included: Review of a facility policy titled, Mechanical Lift Use, revised 07/22/2021, revealed, The facility will provide mechanical lifts for transfers of residents who are determined to need this type of transfer to meet their needs. The facility will ensure that two associates should be present during the transfer of residents who require a mechanical lift, and at least one of the two associates must be over the age of 18. Review of a facility policy titled, Fall Management, revised 04/07/2022, revealed, Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs. The policy also defined an avoidable accident as an accident that occurred because the facility failed to, 3. Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and if not, reduce the risk of an accident. Review of an admission Record revealed Resident #56 had diagnoses that included atrial fibrillation (disorder of the heart characterized by an irregular and often faster heartbeat), dependence on supplemental oxygen, shortness of breath, muscle weakness, and difficulty in walking. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance of two or more staff with bed mobility and transfers. Review of a care plan, dated as initiated on 11/03/2020 and revised 10/14/2021, revealed Resident #56 had an activities of daily living (ADL) self-care performance deficit related to activity intolerance, fatigue, impaired balance, limited mobility, and pain. The interventions/tasks indicated that for transfers, the resident required the assistance of two staff with the use of a transfer belt and a front-wheeled walker (FWW) to move between surfaces as necessary. The care plan did not indicate any type of mechanical lift was to be utilized to transfer the resident. Review of an Occupational Therapy (OT) Evaluation & Plan of Treatment, dated as initiated 12/08/2021, revealed Resident #56 received OT services from 12/08/2021 through 01/04/2022 to assess safety and independence with self-care and functional tasks of choice. The goals included for the resident to complete transfers with moderate assistance to decrease dependence on caregivers and increase independence with functional tasks. There was no evidence on the OT evaluation that indicated Resident #56 was assessed for the use of a sit-to-stand mechanical lift. Review of Progress Notes, dated 12/09/2021 at 5:25 PM, revealed a health status note that indicated Resident #56 was assisted from the bed to the toilet in preparation for a shower. The note indicated that after the resident was momentarily placed on the toilet, the resident was being transferred to the shower chair utilizing a mechanical lift when the resident slipped from the sling support. The note indicated the CNA performing the transfer attempted to support Resident #56 during the fall; however, Resident #56 sustained a large skin tear to the left forearm near the lower part of the arm, and an, irregular skin lump tissue swelling to left forearm and right lower leg. The note indicated staff provided first aid and notified the family and physician. According to the note, the resident was transported to the hospital via ambulance at 4:50 PM. Review of an incident report, dated 12/09/2021, revealed Resident #56 was assisted from the bed to the toilet preparing for a shower and, while the resident was being assisted from the toilet using a mechanical lift, the resident slipped from the sling support. The report indicated the CNA attempted to support the resident during the fall. Resident #56 sustained a large skin tear to the left forearm near the lower part of the arm and left forearm/LLE [left lower extremity] irregular lump in tissue or swelling. The report indicated that Resident #56 stated, All I know is I was being lifted from the toilet and then I ended up down here. The report indicated first aid was provided to the left forearm skin tear. Review of the hospital ED [Emergency Department] Provider Note, dated 12/09/2021, revealed Resident #56 was brought to the ED from the nursing home after a fall during a mechanical lift transfer from the toilet. The note indicated that Resident #56 presented with an avulsion to the left wrist, which was bandaged on scene with the bleeding mostly controlled. The note indicated the resident complained of pain in the left wrist and both legs. Further review of the ED records revealed x-rays were completed of the bilateral lower extremities as well as the left wrist, and there was no evidence of fractures. The notes indicated the avulsion wound was dressed with Xeroform gauze (a fine mesh gauze impregnated with petrolatum to maintain a moist wound bed and prevent the gauze from adhering to the wound). Review of Progress Notes, dated 12/09/2021 at 10:55 PM, revealed Resident #56 returned from the hospital at approximately 10:30 PM. The note indicated the resident's x-rays were negative for fractures and the resident had a soft tissue bruise to the left forehead and left lateral calf with swelling. Review of a Wound Observation Tool, dated 12/14/2021, revealed the left arm wound was measured as 10 centimeters (cm) long by (x) 10 cm wide x 0.1 cm deep. Review of Risk Management Meeting notes, dated 12/16/2021, revealed Resident #56 fell on [DATE] during staff assistance and sustained a skin tear to the left forearm. The notes indicated the CNA was transferring the resident off the toilet with a sit-to-stand lift when the resident slipped from the sling and injured the left arm. The planned intervention to address the incident was, Hoyer mechanical lift only for transfers. Review of Resident #56's most recent quarterly MDS, dated [DATE], revealed Resident #56 had a BIMS score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required the extensive assistance of two or more staff with bed mobility and transfers. Observations on 11/29/2022 at 10:20 AM and 11/30/2022 at 3:24 PM revealed Resident #56 lying in bed watching television. During an interview on 11/30/2022 at 9:29 AM, Resident #56 stated CNA #4 was getting the resident off the toilet using the lift, and when CNA #4 rolled Resident #56 out of the bathroom on the lift, the resident did not recall whether the resident's legs gave out or their hands slipped. Resident #56 indicated that before the incident, they were walking with a walker with physical therapy. Resident #56 said that since the incident, they were scared to go to the shower and preferred a bed bath. During an interview on 11/29/2022 at 2:01 PM, CNA #1 indicated she obtained information on how to care for the residents by going to the computer to review the care plans and/or from verbal reports. CNA #1 indicated two staff were required for any mechanical lift transfer. During an interview on 11/29/2022 at 2:11 PM, CNA #2 indicated she went to the computer to review the care plans or received information from verbal reports regarding how to take care of the residents. CNA #2 indicated she did not witness the incident on 12/09/2021. CNA #2 stated that when using any mechanical lift, two staff were required. During an interview on 11/29/2022 at 3:26 PM, CNA #3 indicated Resident #56 required the assistance of two people with a mechanical lift for transfers. She revealed most of the time, Resident #56 did not want to get out of bed, but a mechanical lift was used when the resident had to be weighed. CNA #3 stated she did not witness the incident on 12/09/2021. She indicated she went to the computer to review care plans and received information from verbal reports regarding how to take care of the residents. CNA #3 stated when using any mechanical lift, two staff were required. During an interview on 11/29/2022 at 3:38 PM, Licensed Practical Nurse (LPN) #5 indicated Resident #56 was bedbound and required a mechanical lift with at least two staff for transfers. LPN #5 indicated the CNAs used the computer system or received a verbal report to know how to take care of the resident. LPN #5 indicated Resident #56 did not trust staff due to a fear of falling and the resident would choose staff they felt safer with for transfers. LPN #5 stated CNA #4 transferred Resident #56 during the 12/09/2021 incident and that the sit-to-stand lift was used for the transfer. LPN #5 indicated that to the best of her knowledge, there was only one CNA that transferred the resident with the sit-to-stand lift, and that was CNA #4. LPN #5 stated two CNAs should always be used when transferring a resident with any mechanical lift. LPN #5 revealed she was called to Resident #56's room after the 12/09/2021 incident, and Resident #56 was on the floor and the shower chair was in the room. LPN #5 indicated a registered nurse (RN) assessed the resident and applied a dressing to the resident's arm. The LPN stated she completed the incident report, and the Director of Nursing (DON) evaluated the incident reports and recommended therapy if needed. LPN #5 indicated education was provided to CNA #4 that two CNAs should be used during a transfer utilizing a sit-to-stand lift. The LPN indicated she had no prior knowledge that CNA #4 was using the sit-to-stand lift and did not know of any other time the sit-to-stand lift was used on Resident #56. During a follow-up interview with LPN #5 on 11/30/2022 at 5:08 PM, LPN #5 stated CNA #4 was made aware that two people were required for any transfer utilizing a lift. During an interview on 11/30/2022 at 8:38 AM, the Interim DON/Staff Development Coordinator indicated she was the Staff Development Coordinator on 12/09/2021 and was not working as the DON at the time. The Interim DON indicated that Resident #56 was in bed most of the time and required a lot of assistance with transfers. She indicated Resident #56 spent a lot of time in bed prior to the fall on 12/09/2021. The Interim DON stated a total-body mechanical lift was put into place as an intervention for transfers for Resident #56 after the 12/09/2021 incident. She indicated that complete investigations with a root-cause analysis were only completed for falls with major injury. During an interview on 11/30/2022 at 9:51 AM, the Rehabilitation (Rehab) Director indicated the therapy department provided guidance on how a resident should be transferred through skilled assessment during admission. The Rehab Director indicated the nurse could also make clinical judgements and look at the assessment and see how they were transferring the resident in the hospital. The Rehab Director indicated there should be at least two staff assisting when operating any mechanical lift. The Rehab Director indicated the resident should be provided the highest functional and safest transfer. The Rehab Director indicated OT was initiated for Resident #56 on 12/08/2021 and 12/13/2021. The Rehab Director indicated Resident #56 required moderate assistance with transfers before the incident on 12/09/2021 and maximum assistance after the incident. The Rehab Director indicated the therapy department did not assess Resident #56 for the use of a sit-to-stand lift. During a telephone interview on 11/30/2022 at 4:44 PM, the previous DON, who was the DON at the time of the 12/09/2021 incident, revealed staff notified the DON of all falls, and the DON reviewed the incident report, observed the resident, updated the care plan, and put in an interdisciplinary team note. The previous DON indicated she did not remember the incident with Resident #56. She indicated physical therapy evaluated and decided which lift was appropriate for a resident. The previous DON indicated all the mechanical lifts in the facility required two staff and stated the CNAs were trained on that requirement. During a telephone interview on 11/30/2022 at 5:18 PM, CNA #4 indicated she transferred Resident #56 during the incident on 12/09/2021 utilizing the sit-to-stand lift and the resident fell during the transfer. CNA #4 indicated she was oriented by another CNA that used the sit-to-stand lift for Resident #56. CNA #4 indicated the incident was her fault because she was trained that two staff were required to operate any mechanical lift but stated there was no help available to assist her with transferring Resident #56. (Review of staffing for 12/09/2021 revealed the facility was adequately staffed). CNA #4 stated that when she checked the computer on a later date, there was no information on which mechanical lift to use for Resident #56. During a follow-up telephone interview on 12/01/2022 at 2:32 PM, CNA #4 revealed she provided the previous DON with a written statement on the 12/09/2021 incident. CNA #4 indicated Resident #56 let go of the handles during the transfer and she lowered Resident #56 to the floor. CNA #4 indicated she normally transferred the resident with the sit-to-stand lift with another staff and knew that the procedure should involve at least two staff. The CNA indicated the facility provided training every other month on how to use the mechanical lifts and stated she had knowledge of how to transfer the resident using the stand-to-sit lift. CNA #4 indicated she saw Resident #56 bleeding but did not know how the skin tear happened. CNA #4 indicated she really felt bad that Resident #56 got hurt, and she knew that two staff should have been used with all mechanical lifts. CNA #4 indicated she had training in September 2022 on the mechanical lifts by the therapy department. CNA #4 indicated the full-body mechanical lift was put into place for Resident #56 after the 12/09/2021 incident. CNA #4 indicated Resident #56 did not like any of the lifts and preferred to take bed baths after the incident on 12/09/2021. During a follow-up interview on 12/01/2022 at 11:31 AM, the Interim DON/Staff Development Coordinator indicated Resident #56 had pain and was sent out to the hospital, and this incident should have been considered a significant injury for which an adverse event packet would have been completed. The Interim DON/Staff Development Coordinator indicated no root-cause analysis would be investigated for incidents that did not result in significant injury. The Interim DON/Staff Development Coordinator indicated that if the facility policy stated that two people should be used to operate the sit-to-stand lift, it was her expectation that the facility staff use two staff and follow the facility's policy. During an interview on 12/01/2022 at 12:18 PM, the Administrator indicated adverse event packets should be completed, to include a full investigation with root-cause analysis for incidents of abuse, falls/fall with major injury, or head injuries. The Administrator stated an adverse event packet should have been completed for the 12/09/2021 incident, due to the resident's injury, the staff involved, and the fact that a piece of equipment was involved. The Administrator indicated she was not employed at the facility at the time of the 12/09/2021 incident and could not answer why an adverse event packet was not completed. The Administrator indicated it was her expectation that the staff follow the facility's policy on mechanical lifts when transferring residents.