**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, review of facility documentation, review of facility policy, and interviews, for two of six sampled residents (Residents #13 and #47) reviewed for accidents, the facility failed to ensure the required staff assistance was utilized during the use of the mechanical lift, and for one of six sampled residents (Resident #33) the facility failed to ensure the required staff assistance was in place during a mechanical lift transfer and failed to ensure the resident was attached to the lift correctly, which resulted in an accident and injury. The findings include: 1. Resident #13 was admitted to the facility in January 2025 with diagnoses that included metabolic encephalopathy, dementia, and renal failure. The admission MDS assessment dated [DATE] identified Resident #13 had intact cognition, functional limitation in range of motion of the bilateral upper extremities, utilized a wheelchair for mobility, was dependent on staff for toileting hygiene, toileting and transfers from the bed to the wheelchair, and was always incontinent of bowel and bladder. The physician's order dated 3/17/25 directed Resident #13 be transferred with the assistance of two staff members. The care plan dated 1/31/25 identified Resident #13 had a deficit in Self Care Function with interventions that direct 2 staff for bathing/showering, 2 staff for dressing, and 2 staff for toileting. Observation on 4/9/25 at 9:40 AM identified NA#7 and NA#6 utilizing the mechanical lift to transfer Resident #13 from the bed (a seated position) to the bathroom, to be seated on the toilet. Both NA#6 and NA#7 completed the transfer. Resident #13 was seated on the toilet and disconnected from the lift. NA#7 directed NA#6 to call him when she was finished with care and left the room. NA#6 completed care and dressed the resident in the bathroom with the door closed. Observation on 4/9/25 at 9:55 AM identified NA#6 operating the mechanical lift independently without assistance to transfer Resident #13 out of the bathroom and into the wheelchair which was located in the room next to the bed. Interview on 4/9/25 at 10:04 AM with NA#6 identified she has worked at the facility since 9/2024 and identified she is a full-time employee. NA#6 further identified that she looks at the care card to identify what type of care the resident needs and indicated that all residents required two staff members when utilizing the sit to stand mechanical lift. Interview on 4/9/25 at 10:24 AM with RN#1 identified that all of the staff is aware that mechanical lift transfers require the assistance of two staff members. Interview on 4/9/25 at 12:39 PM with the ADNS identified that NA competencies are done annually and as needed and that all nurses' aides are aware that two staff members are required when utilizing the mechanical lift. Interview on 4/9/25 at 2:15 PM with the Administrator and RN#4 identified that the facility policy identifies that mechanical lift transfers require the assistance of 2 staff members. The policy on use of the mechanical lifts identified that two staff members must be involved in the transfer of a resident with the mechanical lift. 2. Resident #33's diagnoses included Alzheimer's disease, aphasia, muscle weakness and chronic kidney disease. The annual MDS assessment dated [DATE] identified Resident #33 had intact cognition (BIMS of 13), required maximal assistance with bed mobility, and upper body dressing, required total assistance with lower body dressing and toileting hygiene. The assessment further identified Resident #33 did not ambulate, utilized a wheelchair and was dependent on staff for mobility. The care plan dated 8/21/24 identified Resident #33 had an activities of daily living (ADL) self-care performance deficit due to Alzheimer's/dementia. The care plan interventions directed: transfer status of [NAME] (which is a sit to stand mechanical lift) or Hoyer lift (which is a total mechanical lift) with assist of two (staff), back to bed with Hoyer at night, and toilet transfer status of Sara lift assist of two if able otherwise back to bed with the Hoyer lift. The care plan also identified Resident #33 had limited physical mobility related to Alzheimer's dementia and osteoarthritis. Review of the Nurse Aide care card instructions in effect for the month of October 2024 identified the need for two staff with the use of the Sara lift and the Hoyer lift. The physician's orders for the month of October 2024 directed Acetaminophen (Tylenol) tablet 650 milligrams (mg), administer two tablets orally in the morning for pain. Review of the medication administration record identified that on 10/8/24, the resident was administered Tylenol 650 mg at 10:07 AM for complaint of discomfort in addition to his/her regularly scheduled Tylenol. The nurse's note dated 10/8/24 at 10:46 AM written by RN #5 identified Resident #33 had pain in the left knee, tibia and fibula area with some increased warmth and swelling. The note further identified that APRN #1 was notified, and an x-ray was ordered. APRN 1's progress note/assessment via telehealth visit dated 10/8/24 identified Resident #33 reported left knee pain and the inability to help with Sara lift transfer as usual. The note further identified that per nursing the left knee had slight edema, a negative [NAME] sign, was warm to the touch without erythema and an x-ray of the knee was ordered. The x-ray results dated 10/8/24 identified the resident had a fracture of the left tibia and fibula. It further noted that the resident had mild degenerative changes and diffuse osseous demineralization. The nurse's note dated 10/9/24 at 12:30 AM identified the x-ray results were positive for fracture of the left tibia/fibula and that an order was obtained to send the resident to the hospital emergency department. Review of the hospital discharge paperwork dated 10/9/2024 identified bruising and tenderness in the left proximal tibia and an x-ray was performed in the emergency department which showed an oblique left proximal tibia fracture. The leg was splinted with instructions to follow up with orthopedic surgery. The facility's reportable event report and investigation dated 10/9/24 at 9:30 AM identified Resident #33 complained of having pain in the left leg, with increased warmth and swelling to the area. In addition, an order was received to have an x-ray performed which indicated a left lower leg fracture involving the proximal tibia and fibula with minimal callus and mild displacement, and an order was received to send the resident to the emergency department for further evaluation. The report further identified the hospital identified a fracture of the left tibia, placed a long leg splint, and noted the resident a status of non-weight bearing until follow-up with orthopedic surgery. The facility submitted the report to the state survey agency with the classification as an injury of unknown origin, the reportable event report did not acknowledge the incident with the Sara lift that occurred on 10/7/25. The reportable event report identified a written statement by NA #2 dated 10/9/24 that identified she washed and got Resident #33 prepared for the transfer to his/her wheelchair, she placed the straps around the resident's torso, and attached the straps to the lift, placed the resident's feet on the lift platform, The statement further identified that during the transfer from the bed to the wheelchair, she noticed one of the resident's feet fell off the lift, and the resident told her that his/her leg was weak. The documentation further noted NA #2 lowered the resident down and went to get the nurse. The reportable event report investigation further identified that on 10/15/24 The DNS (former) spoke to NA #2 who identified that Resident #33's left foot slipped off the lift platform, causing the resident to kneel on the left knee. Interview with NA #2 on 4/3/25 at 2:20 PM identified that in the morning she assisted Resident #33 to sit on the edge of the bed to transfer him/her using the Sara lift to the wheelchair. She further identified that while the resident was attached to the Sara lift via the straps and in the process of transferring the resident she noticed that the resident's left foot slipped off the Sara lift platform. She noted that she locked the Sara lift and went in the hallway to get the nurse (LPN #2). LPN #2 came and asked the resident if she had any pain and assisted NA #2 in transferring the resident to the bed with the Sara lift. She further noted that they used the Hoyer lift to transfer the resident from the bed to the wheelchair. NA #2 identified that she was aware that Resident #33 required assistance from two staff to use the Sara lift, however, she transferred the resident by herself because there was nobody available to assist with the transfer. LPN #2's written statement dated 10/9/24 identified on 10/7/24 around 9:30 AM she was called by NA #2 to Resident #33's room. She noted that on arrival to the room she observed Resident #33 hooked up on the Sara lift and noted the left leg was bent behind the resident and was not on the lift platform (where the feet should be placed). She further identified that immediately the resident was safely transferred back to bed with assistance of two and noted Resident #33 appeared calm, denied pain or discomfort, had no visible bruises, lacerations or swelling and was able to move extremities without pain. Interview with the Charge Nurse (LPN #2) on 4/3/25 at 2:35 PM identified she was the nurse on duty on 10/7/24 for the 7:00 AM to 3:PM shift. LPN #2 identified she was taking care of another resident in a nearby room when NA #2 called her to come to Resident #33's room. She identified that when she entered the room, Resident #33 had the lift pad around her upper torso with the straps attached to the lift, but the resident was hanging freely from the lift with the knees not touching the padding on the lift where the knees are supposed to touch to support the resident, her left leg was also bent back and was not on the lift platform. LPN #2 further noted that NA #2 was in the process of transferring the resident from the bed to the wheelchair. LPN #2 identified that the leg straps (supports) were not in place (as they should be) around the resident's lower legs. LPN #2 further identified that the resident required two staff to assistance with the transfer and that NA #2 had not requested assistance. Additionally, LPN #2 identified that she notified the nursing supervisor of the incident. Interview with LPN #2 on 4/8/25 at 1:44 PM identified that on 10/8/24 Resident #33 complained of pain in the left lower extremity. LPN #2 noted that the left lower extremity was noted with swelling and redness. She identified that she notified the nursing supervisor on duty and x-rays were ordered. LPN #2 further identified Resident #33 should absolutely have the lift leg support straps in place when using the Sara lift. The physical therapy (PT) note dated 10/9/24 at 2:44 PM by PT #2 identified Resident #33 was referred to PT due to significant decline in his/her transfer abilities that was noted on 10/8/24, and the resident was found to have a deformity of the left lower extremity with increased edema to the left lower extremity and was sent out for x-rays which revealed a fracture of the left fibula/tibia. Interview with MD #1 (Orthopedic Surgeon) on 4/9/25 at 9:26 AM identified Resident #33 was seen in the office due to a fracture and based on the x-ray results, and his examination of the resident, he identified Resident #33 had an acute fracture. He further noted that the accident with the Sara lift could definitely have caused the fracture, and because of the resident's dementia, the response to pain may be atypical and the resident may not remember what occurred. Interview with the Physical Therapist (PT #1) on 4/8/25 at 8:33 AM identified that if the resident transfer status fluctuates between the use of a Sara lift and Hoyer lift then the leg straps should be utilized. PT #1 further identified if the leg straps on the Sara lift are not used as indicated and secured it can cause injuries to the resident. PT #1 further identified that if the leg straps on the Sara lift are used and secured properly, a resident's leg would not slip off the platform/foot support. PT #1 added that when using the Sara lift with Resident #33, two staff members are needed to prevent the resident from getting hurt and for safety. PT #1 added that two staff members are needed in Sara lift transfers as one staff would aid in positioning residents who are unable to position themselves in a seated position to be connected to the Sara lift and guide the resident during the transfer while the other staff manages the Sara lift. Interview with the Staff Development Nurse (RN #2) on 4/7/25 at 10:56 AM identified that two staff members are required when using the mechanical lift as one staff operates the machine/lift and the other staff guides the resident, and legs support straps are to be utilized during the transfers as it is a part of the training. Interview with the current DNS and the Administrator on 4/9/25 at 1:39 PM identified that NA #2 was an agency staff and was provided with education following the incident. Review of the [NAME] 3000 (Sara lift) instructions for use manual identified that the foot support is used for positioning before and supporting the resident's feet during raising and transferring. In addition, the lower leg straps accessory is used to ensure that the lower parts of the resident's legs stay close to the knee support as they pass around the knee supports, then around the resident's lower calves. Also to ensure that the straps are firm but comfortable for the resident. In addition, the manual further identified in the warning section that the residents' feet shall always remain in full contact with the foot support and when raising, check to ensure that the resident's feet do not lift from the foot support. Review of the policy and procedure for Sara lift (partial weight bearing/standing lift) identified a mechanical lifting device is utilized to safely move a patient/resident from bed to chair or to the commode/bathroom and two staff are utilized to perform the procedure unless it is specified by physical therapy that the transfer can be completed with one person assisting. The policy and procedure for using the Sara lift in part, identify to place the resident's feet onto the foot support, adjust the resident's leg so that they are in full contact with the knee support of the lift, attach sling to the lift at the designated spots and attach the support strap to the resident's legs for safety. 3. Resident #47's diagnoses included dementia, type 2 diabetes, anemia and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. The quarterly MDS assessment dated [DATE] identified Resident #47 had severe cognitive impairment, had no behaviors, was dependent for hygiene, lower body dressing, and bed mobility. The assessment further identified Resident #47 did not ambulate, utilized a wheelchair and was dependent on staff for mobility. The care plan dated 2/9/25 identified Resident #47 had an ADL self-care performance deficit related to cognitive impairment /history of CVA with left sided hemiplegia. Care plan interventions included transfer with two staff assist using the Sara lift (sit to stand lift). The Nurse Aide care card instruction for April 2025 identified Resident #47 required the assistance of two 2 staff members when using the Sara lift. Observation on 4/2/25 at 12:19 PM identified Resident #47 seated in his/her adaptive wheelchair located on the right-side of the resident's bed. NA #5 wheeled the resident to the end of the bed facing the entrance door of the room. NA #5 positioned the Sara lift in front of the resident, then applied the sling to Resident #47 followed by attaching the sling to the Sara lift followed by applying the leg support straps and she ensured the resident placed his/hand on the support grips. NA #5 then utilized the control to raise the resident up, then transferred the resident to the bathroom and lowered the resident to the toilet seat. Interview with NA #5 on 4/2/25 at 1:06 PM identified the care card indicated Resident #47 required two staff members for transfers with the Sara lift. NA #5 further identified that she should have had a second staff member with her during the transfer, but she transferred the resident by herself. She added that when she first started orientation on the unit, she was trained and told by staff that Resident #47 only needed one person to use the Sara lift for transfers. Interview with the DNS on 4/2/25 at 3:10 PM identified that two staff members are required to use the Sara lift. The DNS reviewed Resident #47's care plan and indicated that he/she required two people when utilizing the Sara lift. Interview with the Staff Development Nurse (RN #2) on 4/7/25 at 10:56 AM identified that staff are trained to use two staff members when using the Sara lift. RN #2 further identified she provided education and/competency to the nurses' aides including NA #5 in December of 2024. She noted that during the transfer, one staff member operates the lift, and one staff member provides hands on guidance to the resident. Interview with the Physical Therapist (PT #1) on 4/8/25 at 8:25 AM identified Resident #47 requires two staff members for transfers using the Sara lift. PT #1 noted that when using the Sara lift for this resident that two staff members are needed to prevent the resident from getting hurt and for safety, as one staff member operates the Sara lift, and the other staff member guides the resident and ensures the resident is positioned properly. The Mechanical Lift policy identified two staff members must be involved in the transfer of a resident with the Mechanical Lift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy, and interviews for one (2) of six (6) residents reviewed for (Resident #204), the facility failed to ensure a resident had appropriate supervision while in the bathroom, and that leg rests were removed from the wheelchair prior to a transfer, resulting in an injury and for accidents for (Resident # 31), the facility failed to ensure staff remove the plastic covering from a hot beverage within accordance to facility practice to prevent a burn and . The findings included : 1. Resident #204 had diagnoses that included Alzheimer's disease, and weakness of right dominant side following a stroke. The admission nursing assessment dated [DATE] at 5:30 PM identified Resident #204 was alert only to person, had problems with his/her memory, and had fallen within the last month. The fall risk assessment dated [DATE] identified Resident #204 had a fall within the previous six (6) months and was identified as a fall risk. The baseline care plan dated 10/14/21 at 5:45 PM identified Resident #204 was confused, and had impaired vision which required glasses and further identified that Resident #204 had a history of falls and fall related injuries with interventions that included flat bells (flat pad a resident presses for assistance) and transfer, walking and toileting assist of one staff. A Physical Therapy plan of care dated 10/15/21 identified Resident #204 was referred for short term rehab due to recently being diagnosed with vertebrae compression fractures due to a fall at home. It further identified Resident #204 was orientated to person and had severely impaired safety awareness/judgement. An Occupational Therapy plan of care dated 10/15/21 identified Resident #204 was very forgetful and required one assist for transfers and toilet use, with recommended supervision and assistance for safety awareness and judgement. A Social worker admission assessment dated [DATE] identified Resident #204 was alert and pleasantly confused. She further identified Resident #204 was very forgetful and relied on his/her husband to answer much of the intake questions. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #204 had severely impaired cognition, required extensive assistance with transfers and toilet use, balance to move on and off the toilet was impaired and the resident was only able to stabilize self with staff assistance. A nurse's note dated 10/21/21 at 8:42 PM identified Resident #204 was alert and pleasantly confused. It further identified Resident #204 had poor safety awareness and had self-transferred at times. A progress note written by Registered Nurse (RN) #1 dated 10/24/21 at 7:49 PM identified she was called to Resident #204's room by Nurse Aide (NA) #1. Resident #204 was noted with a 6.5 centimeter (cm) in length by 1 cm in width cut to the Right lower leg. First aid was rendered, the cut was cleansed with normal saline and a dressing applied. The physician and spouse were notified and 911 was alerted. An Accident & Incident (A&I) report dated 10/24/21 at 7:15 PM identified that the resident had obtained a laceration to the right lower leg. A statement written by NA #1 dated 10/24/22 identified she assisted Resident #204 into the bathroom and after placing the resident on the toilet, asked the resident to pull the cord when finished, and Resident #204 replied h/she would. She then went to another resident's room to assist the nurse with another resident. A statement written by NA#2 identified that he heard Resident # 204 calling for help, he saw blood on the floor and called for the nurse. The record of conversation form dated 10/24/22 for NA #1 identified that the RN supervisor discussed with NA#1 that a patient with dementia who required an assist of one staff member for toileting, transfers, and ambulation should not be left unattended in the bathroom. Review of the hospital emergency room encounter dated 10/24/21 identified Resident #204 had a laceration to his/her right lower leg that required a repair with eight (8) sutures. A Nurse's note dated 10/25/21 at 4:24 AM identified Resident #204 returned to the facility after emergency department visit for laceration of right lower extremity. Resident #204 received 8 sutures at the hospital. Multiple attempts made to contact NA #1, however attempts were unsuccessful. Interview with the Director of Nursing Services (DNS) on 4/5/23 at 2:00 PM and 4/6/23 at 11:28 AM identified that Resident # 204 had attempted to independently transfer from the toilet, and Resident #204's injury was caused by the wheelchair footrest's. The NA had failed to remove the footrests prior to the transfer but had positioned Resident #204's wheelchair footrests to the side for the transfer to the toilet. The DNS further identified that the resident should not have been left in the bathroom unattended because of cognitive impairment and risk for falls, further identified that the facility policy directs for footrests to be removed prior to a transfer, however the resident was left unattended and the footrests were not removed prior to the transfer. She further identified Resident #204's care plan was updated to have staff present with Resident #204 while in the bathroom. Review of the transfer of resident policy directed, in part, footrests should be off the wheelchair prior to transfer to reduce tripping or injury. 2. Resident # 31's diagnoses included dementia, anxiety, chronic kidney disease stage 3, hypothyroid and hypertension. A physician's order dated 1/25/22 directed to every 15 minutes check due to wandering in and out of resident's room. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident # 31 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicative of severe cognitive impairment and noted the resident required supervision to limited assist of 1 person with bed mobility, transfer, ambulation, hygiene and toileting. Resident #31 was independent with eating and only required set-up during meal time. The Resident Care Plan (RCP) dated 2/14/22 identified Resident # 31 required assistance with Activity Daily Living (ADL) related to impaired cognition, dementia and osteopenia. Interventions directed to assist with dressing, bathing, hygiene and grooming, to maintain privacy and dignity, Occupational Therapy (OT) screen as needed and to provide verbal cuing for safety. Review of temperature log dated 3/3/22 identified that the hot beverage at dinner time was 181 degree. The facility Accident and Incident Report dated 3/3/22 at 5:30 PM identified Resident #31 had an accident that cause a second-degree burn on his/her bilateral thighs. The report also indicated the nursing staff did not removed the lid cover from the hot water cup per facility practice causing the resident to spill hot water on his/her lap when he/she tried to remove the lid cover from the cup independently. The nurse's note dated 3/3/22 at 5:38 PM identified Resident # 31 was yelling from her/his room and dinner tray was on the floor. A cup of hot tea had fallen on Resident # 31's lap. The RN assessment at the time of the incident identified redness with a raised area to the resident's bilateral inner thigh, groin and posterior thigh. The nurse's note dated 3/4/22 at 4:23 AM identified Resident #31 was awake and located at the nursing desk at 1:00 AM with a little teary eye. The inner right thigh with large fluid filled blister developed and measure 1.5 inches x 2.0 inches surrounded with deep pink skin and several tiny fluids filled areas. The left inner thigh with 1 inch's fluid filled blister area surrounded with multiple smaller fluid filled blister. Silvadene 1% cream arrived from the pharmacy was applied to the burn area and Resident # 31 expressed relief. A physician's order dated 3/4/22 directed to administered 1 gram of Silvadene 1% cream to each thigh twice a day for 7 days then re-evaluate. A physician's order dated 3/7/22 directed to monitor burn to bilateral thighs daily for 7 days. A physician's order dated 3/11/22 directed to administered 1 gram of Silvadene 1% cream to each thigh twice a day for 14 days then re-evaluate. A physician's order dated 3/22/22 directed to monitor inner thighs with dried scab for on-going healing daily. Interview with Dietary Director on 4/4/23 at 1:55 PM identified the kitchen staff log the temperature of hot beverage water daily. She identified that the hot water beverage would have a temperature between 180 to 200 degrees from the kitchen. She also indicated the water would cool down about 10 to 20 degree when the nursing staff started passing the tray. Interview with RN # 3 on 4/5/23 at 10:55 AM identified Resident # 31 could eat independently and required set-up during mealtime. RN # 3 indicated the nursing staff would open the food packaging, open container and removing the lid from a cup prior to leaving the resident's room. She also indicated Resident # 31 had been receiving hot tea beverage in the facility. Interview with (NA # 5) on 4/5/23 at 11:10 AM identified that Resident #31 was independent with eating and required set-up assist during mealtime. He/she indicated that she/he would open the food packaging, open container and remove the lid from a cup prior to leaving the resident's room. NA # 5 also indicated Resident #31 had been getting a hot tea beverage. Interview with RN # 2 on 4/5/23 at 1:25PM identified Resident #31 was yelling from his/her room and the food tray was on the floor. She identified Resident # 31 had a pre-pour hot water included in his/her meal tray. She further indicated that the hot water spilled on Resident #31's lap. She identified Resident #31 was independent with eating and required set-up with his/her meal. She further indicated that the hot water had a lid cover on the cup Resident #31 tried to take it off independently. She was not sure why the plastic lid cover on the hot water cup was not removed. She further indicated the plastic lid cover should had been removed. Interview with DNS on 4/6/23 at 1:10 PM identified Resident #31 required set-up with his/her meal. She expected the nursing staff to open all food packaging and remove the plastic lid cover from the cup before the staff would leave the resident room. She indicated that she was aware of Resident #31 hot water accident that cause the second-degree burn to the bilateral thighs. The DNS also identified the accident and incident report indicated the NA # 4 did not removed the plastic lid cover from the cup that cause the second-degree burn on his/her bilateral thighs when the hot water cup spilled on his/her lap. The DNS also indicated that she updated the hot water policy to prevent the accident from happening to all residents. Observation on 4/6/23 at 12:00 PM identified Resident #31 received food prior to receiving the hot beverage. Resident #31 received a 120 ml cranberry juice and 240 ml of hot tea with plastic lid removed from the cup. Observation on 4/6/23 at 12:10 PM in the dining room identified the nursing staff prepared the utensil, open food packages and removing all the plastic cover lid from the cup. Attempted to interview NA # 4 was unsuccessful during the survey. Review of policy titled Hot Water for Beverages Policy dated 3/22 and revised on 4/22 and 5/22 directs to provide beverages at a temperature that is both acceptable for resident's enjoyment and safety. The policy indicated that water for tea or hot beverages would be dispensed from the coffee machine in the main kitchen into carafes and placed on the dietary cart at each meal.