Based on clinical record review, interview and review of facility documentation as indicated, it was determined that for one (R9) out of two sampled residents reviewed for accidents, the facility failed to ensure the resident's environment remained as free of accident hazards as was possible. For R9, an unsafe transfer was performed using a Sit-to-Stand mechanical lift with only one CNA as opposed to a Hoyer Lift (full body mechanical lift) with two CNA's per R9's plan of care, resulting in a fracture of R9's left leg. The unsafe transfer caused R9 harm. Based on review of the facility's evidence to correct the non-compliance and the facility's substantial compliance at the time of the current survey for F689, the specific regulatory requirement, the deficiency was determined to be past non-compliance. Findings include: A facility policy entitled Lift/Transferring/Repositioning Resident Safely (last revised 12/2018), included: a. Adhere to the designated lifting / transferring / repositioning technique per assignment. b. CNA's may always choose to use more help than assigned, but never less. c. Report any unsafe acts . d. Two employees will always be available when using a lift for residents who have no weight bearing ability and cannot provide assistance or balance. The following was reviewed in R9's clinical record: 5/8/15 - R9 was admitted to the facility with dementia. 12/27/18 - Review of the physical therapy plan of care documentation recommended that since R9 remained dependent and was an assist of two facility staff for transfers, the physician's order must remain that R9 continue to be transferred by a Hoyer lift and for the resident's care plan intervention to reflect a Hoyer transfer as well. 9/29/19 and 12/29/19 - A quarterly and significant change MDS assessment (respectively prior to the 1/14/20 incident) documented that R9 was cognitively impaired, dependent with the assist of two staff for transfers and had not walked or moved from a seated to a standing position. R9's care plan reflected the MDS documentation to use a mechanical lift for transfers with the assist of two staff. 1/14/20 11:19 PM - A progress note documented Resident (R9) complain(ed) of pain on her left leg. Was medicated with as needed Tylenol. 1/17/20 8:00 AM - A nursing progress note documented c/o (complained of) left knee pain, swelling present, ice applied. 1/17/20 8:06 AM - A nursing progress note included, CNA reported to this nurse change of condition in resident. Swelling to left knee measuring 49 cm and right knee measuring 43 cm (centimeters) .waiting to notify provider for further assessment. 1/19/20 9:43 AM - A nursing progress note documented Bilateral (both) knees are swollen. Resident denies any pain or discomfort at present time. She is oob (out of bed) to wheelchair. For last 2 days her left leg has been 'floppy' below her left knee. NP (Nurse Practitioner) saw resident on Friday [1/17/20] and ordered ice. Will continue to monitor. 1/20/20 9:53 AM - A nursing progress note documented For the last 3 days her left leg has been floppy. E11 (MD) in to see her this morning. 1/20/20 10:19 AM - A nursing progress note documented [X-ray company] in to do x-ray to the left knee. 1/20/20 4:22 PM - A nursing progress note included, E11 (MD) called and made aware of the left knee XR (x-ray) and ordered for the resident to be sent to the ER (Emergency Room) for evaluation. 1/20/20 7:47 PM- A nursing progress note documented Received a call from ER (name of Emergency Nurse - SS1), resident will be sent back with DX (diagnosis of) left knee fracture. The facility's investigation report and supporting documents revealed the following: -1/21/20 11:33 AM - A complaint report to the State Agency included, The resident started on Thursday 1/16/20 with some swelling to knee. No pain or discoloration. The nurse practitioner examined on Friday 1/17/20 and ordered ice. Swelling increased over the weekend and the physician ordered an x-ray and lab work . X-ray shows .left knee fracture. - 1/21/20 (untimed) - E15's (CNA) initial statement stated, On Monday Jan (January) 13, I worked half of day for E31 (CNA) 11 AM - 3 PM. Noticed nothing on (R9). I worked Tuesday (1/14/21) 7 AM - 3 PM. I gave (R9) a shower. I did not work Jan. 15 or 16 th. I was back on the 17th of Jan., but we worked with six, so I didn't have her (R9) in my group. - 1/22/20 (untimed) - E16's (CNA) Statement stated, On Tuesday (1/14/21) we heard a call over the 'walkie' that someone needed help in the shower room. It was E15 (CNA). She had R9 on the sit to stand (lift) and R9 was coming down (about to fall), so (E15) asked me to help her get her (R9) in the chair. So I grabbed R9 by the seat of her pants and we pulled her back in her chair. E15 was saying at least she did not fall. - 1/23/20 - E15's (CNA) second statement (after E16's statement) stated, On Jan (January) 14, 2020 R9 was not in my group, but the aide on the end E18 (CNA) was struggling so I gave her a shower for her. I did Hoyer (a mechanical lift) her into shower chair and proceeded into shower to give her a shower. R9 had a large loose BM (bowel movement) so I was trying to clean her up. I couldn't get her bottom good, so I did use the sit to stand lift to clean her bottom well. While on the sit to stand, resident's foot slipped. I was holding on to her. I did not let her fall. I used my walkie-talkie to call for help. E16 (CNA) came and we got her back in her chair. I asked R9 if she had pain. She said no. I did not report this to the nurse because she did not fall or hit the floor. After the facility became aware of the witness statement (written by E16) and gained knowledge of the improper/unsafe transfer (using the wrong lift and being alone), E15 was immediately suspended pending the incident investigation. 1/28/20 - E15 was terminated from the facility based on results of the investigation for serious misconduct and neglect of a resident's safety. 11/3/21 10:35 AM - During an observation and interview of R9's transfer to her wheelchair, 2 CNA's completed the correct transfer for R9 and reported that they found the transfer status of all residents in the CNA documentation. 11/4/21 at approximately 2:30 PM - During an interview with E1 (NHA), findings were reviewed. The facility confirmed that an unsafe transfer with the improper lift was performed by E15 (CNA) resulting in a left leg fracture above the knee. E1 showed that the facility conducted a thorough investigation, identified the failure, and immediately initiated a Performance Improvement Plan with multiple interventions as evidenced by the facility referenced sign-in sheets, including the following: 1. A review of all resident transfer status' with therapy and nursing was completed by 1/30/20. 2. Education was provided and content was signed off by employees to ensure patient safety during mechanical lift transfers was completed by 1/30/20, as dated on the inservice sheets. 3. All resident's transfer status' were reviewed to ensure they were correct and available in the computer for nursing, including CNA documentation by 1/30/21. Based on review of the aforementioned facility corrective actions, it was determined that the facility regained substantial compliance with F689 on 1/30/20. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 11/5/21, beginning at 12:00 PM.