Based on observation, record review, and interviews, the facility's Administration failed to utilize resources effectively to protect the residents right to be free from neglect by failing to ensure staff competency in the areas of inspecting, identifying, and removing unsafe resident equipment from use, and safe transfer techniques with mechanical lifts. On 1/22/24 Staff used a full body mechanical lift to transfer Resident #1. The motor of the lift had been removed since July 2023 causing the legs of the base to not lock to ensure a safe transfer. Resident #1 fell from the mechanical lift, sustained cuts, complained of head trauma and generalized pain requiring an emergent transfer to an acute care hospital. The facility's administration failure to ensure effective use of resources to ensure residents safety and prevent neglect created a likelihood of avoidable falls and accidents from mechanical lifts with a likelihood of serious injury, impairment or death of residents and resulted in the determination of Immediate Jeopardy. On 2/15/24 at 6:58 p.m., the facility's Administrator was informed of the Immediate Jeopardy (IJ) and provided the IJ Templates. The Immediate Jeopardy began on 1/22/24. The facility census was 113 with 19 residents who were transferred with full body mechanical lifts. The facility used three different brands of mechanical lifts. On 2/16/24, after the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/16/24. The scope and severity were reduced to no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross Reference to F600, F689, and F908. The Nursing Home Administrator job description signed on 7/8/22 noted, Nursing Home Administrator . is responsible and accountable for . all aspects of the Facility including but not limited to establishing and implementing policies and procedures, quality of care, quality of life, regulatory compliance . Provides supervision either directly or indirectly to all facility employees including the selection, hiring, orientation, training, and coaching of employees. Identifies facility needs or issues and obtains consulting assistance, as needed in the root-cause analysis, recommendation for improvement, education assistance or monitoring . The Director of Nursing job description signed on 8/14/23 noted, The Director of Nursing as a member of The Board of Managers of Operator is responsible for developing, organizing, evaluating, and administering patient care programs and services of the Center. The DON (Director of Nursing) has twenty-four (24) hour responsibility for the overall delivery of nursing services and ensures the implementation of all clinical policies and procedures . Makes daily patient rounds with the appropriate manager/supervisor(s) to note resident/patient conditions and to ensure nursing personnel are performing their work assignments in accordance with acceptable nursing standards. Accountable for adherence by staff to policies, procedures and standards; delivery and proper documentation of patient care. 1. On 2/12/24, review of facility incident and accident log revealed on 1/22/24 Resident #1 was being transferred with a total body mechanical lift which tipped over resulting in the resident falling to the floor. Resident #1 was transferred via Emergency Medical Services to an acute care hospital. Review of the Emergency Medical Services Patient Care record dated 1/22/24 noted, Medic two arrived on scene to a skilled nursing facility where (Resident #1) was found lying on the floor. Staff explained that they were using a [brand name] mechanical lift to move the patient which he then fell out of and hit the floor. Patient was found lying on his right side in his room. Patient was complaining of pain all over that he could not pinpoint. A cervical collar was used to immobilize the patient's neck . Review of the emergency room Physician's progress note dated 1/23/24 at 1:35 a.m., noted, Today, while at rehab (rehabilitation), patient sustained a fall from a (brand name) lift onto the ground. Patient endorses head trauma but denies loss of consciousness . Review of the clinical record for Resident #1 revealed an admission date of 1/19/24. Diagnoses included morbid obesity; muscle wasting and atrophy; need for assistance with personal care; and difficulty in walking. The care plan initiated on 1/20/24 noted Resident #1 had an activities of daily living (ADL) self-care performance deficit. The interventions included the use of a, total mechanical lift to chair. Review of the progress notes revealed on 1/22/24 at 8:40 p.m., Registered Nurse (RN) Staff K documented, Rental bed arrives at the facility. Upon arrival, 3 CNA (Certified Nursing Assistant) and nurse assist resident with transferring from old bed to new bed. Upon transfer, resident began moving, twisting, flailing his arms and grabbing bed causing the lift to tip to the side and resident to attain [sic] skin tear. Staff attempt to calm and reassure resident with no resolve. Staff brace resident and lower resident to the ground. Assessment finds resident alert, denies pain, denies being hurt or hitting his head. No other injuries or skin alterations noted. MD (Physician) notified with orders to send to ER (Emergency Room) for evaluation . On 1/22/24 CNA Staff B signed a witness statement written by Unit Manager Registered Nurse (RN) Staff J which noted, . The resident started shaking the straps attached to the lift. We tried to calm him down. He said he was afraid and continued to shake the straps. We got him close to the bed. He twist [sic] in the lift, that is when he went to the floor. As he was going down to the floor he grabbed the side rail he scraped his arm on the wall causing a skin tear. The nurse (RN Staff K) was present in the room at that time. On 2/12/24 at 4:35 p.m., in an interview CNA Staff B confirmed on 1/22/24 she was operating the full body mechanical lift to transfer Resident #1 to a new bed. CNA Staff A, CNA Staff C, and Registered Nurse (RN) Staff K assisted with the transfer. CNA Staff B said Resident #1 kept shaking and saying, I'm going to fall. She said, When we were moving to the bed he turned and twisted, the machine tipped over but did not fall over. The machine did not fall on him. The other CNAs grabbed him and held him while I lowered him to the floor. The bottom of the lift is always open. We open it with our feet but sometimes it closes again. I know I opened it, but it might have closed on its own, I don't know for sure. CNA Staff B did not say she verified the lift was in safe operating condition before the transfer. On 2/13/24 at 8:30 a.m., in an interview the Maintenance Director said he started employment at the facility on 7/5/23. He said on 1/22/24 when Resident #1 fell from the lift, he came in to check the lift. He said the lift was not broken but it was removed from service due to the incident and possible investigation. The Maintenance Director said he did not have the owner's operator and maintenance manual for the three brands of lifts used at the facility. The Maintenance Director said he followed the checklist on their maintenance computer system but the checklist was not specific to each brand or model of mechanical lift. Review of the electronic checklist for mechanical lifts noted to, Conduct mobile lift safety inspection 2. Inspect the shifter handle; ensure that shifter operates smoothly; verify that base is locked when handle is engaged. On 2/15/24 at 8:50 a.m., in a follow up telephone interview CNA Staff B said on 1/22/24 she opened the base wide with the foot control when transferring Resident #1 with the full body mechanical lift. She confirmed the legs of the base closed on their own when the machine tilted over and she reported it to the Administrator. On 2/15/24 at 10:30 a.m., in an interview the Administrator said the CNA did not tell her the legs of the base closed on their own when the fall occurred. She said, The statement that I took was that the legs were open. We removed the lift, and an outside company is coming next week to check the lift. The Administrator said she did not have documentation of the reenactment or the Maintenance Director assessing the lift after the incident. The Administrator verified the facility's investigation did not consider the failure of the legs of the base to lock into place as a contributing factor of Resident #1's fall on 1/22/24. On 2/15/24 at 10:45 a.m., mechanical lift (Brand A) used on 1/22/24 to transfer Resident #1 was observed with the Maintenance Director. The motor of the lift was missing. The Maintenance Director said the motor has been missing since he started employment at the facility on 7/5/24. He demonstrated how staff opened the legs of the base by kicking the frame of the legs. The legs of the base did not lock into place. The Maintenance Director said it was possible for the legs to move easily during transfer if the base was bumped. He said the motor was connected to the legs and would lock them in place. He said since the motor has been removed, there was no locking feature. He said he has been checking the lift monthly since 7/2023 and did not realize it should have had a brake handle or a motor to ensure the legs of the base stayed open while in use. On 2/15/24 at 11:00 a.m., the mechanical lift used to transfer Resident #1 on 1/22/24 was observed with the Administrator, the Maintenance Director, and the DON. The Maintenance Director opened the legs of the base by kicking them with his foot. The DON demonstrated and verified the legs of the base closed easily and did not lock into position. When asked if this was the condition of the lift on 1/22/24 when Resident #1 fell from the lift, the Administrator said, Yes it is. When asked if staff kicked open the legs of the base during the reenactment she conducted on 1/22/24, the Administrator said, I don't remember. I can only go by the witness statements I obtained where she said the base was open. When asked if the lift was safe to use she said, No it's not. On 2/15/24 at 11:15 a.m., the DON verified the mechanical lift used to transfer Resident #1 on 1/22/24 did not have a motor and the legs of the base did not lock into place. He said it was unacceptable and unsafe for resident use. He said he was not aware the lift was broken and didn't know how unsafe it was. He said, The staff should never have been using it. On 2/15/24 at 12:35 p.m., in an interview the Administrator said she was the Risk Manager for the facility and participated in the interviewing and hiring process of the Maintenance Director. On 2/15/24 at 12:40 p.m., the Regional Physical Plant Consultant said he took over the facility in December 2023 and did not hire the Maintenance Director. He said the Administrator was the Maintenance Director's supervisor. He said the process for checking the lifts is that the equipment should be working to manufacturer's recommendations. If not, it needs to be removed from service. The Regional Physical Plant Consultant said the electronic maintenance checklist said to check the bar on the mechanical lift. He would have expected the Maintenance Director to notice the missing part and identify the lift should not have been in use. He said, I was unaware, I would have pulled it myself if I was aware. He said he was surprised the Maintenance Director did not have more experience with medical equipment. On 2/15/24 at 12:50 p.m., in an interview the Maintenance Director said he previously worked at an Assisted Living Facility and they do not use mechanical lifts. He said when he started employment at the facility, There was no orientation. The person who hired him filled out a list by asking him if he knew about different systems like fire alarms and HVAC (Heating, Ventilation, Air Conditioning). I don't think it comprised any medical equipment. He said he was told to review the electronic maintenance system and follow the checklists. He said he did not know the lift used to transfer Resident #1 had motor at one time. The first time he inspected the lift, he asked a CNA how it worked. The CNA demonstrated by using her feet to open the legs of the base. The Maintenance Director said, I thought it was okay since the staff showed me and did not tell me it was wrong. I did not have enough knowledge to safely assess the lifts. The Maintenance Director job description noted, The Maintenance Director is responsible for the overall maintenance of the Facility . ensures the facility, equipment and utilities are maintained in good working order . Ensure equipment . are clean, safe, and orderly . Maintain and repair specialized equipment and machinery . Coordinates maintenance services with all other departments and services . The job description was not signed. On 2/15/24 the Administrator provided a letter dated 2/15/24 that noted, Maintenance Director Job Description was not located signed in Employee File. On 2/15/24 at 1:40 p.m., the Risk Consultant said he was not part of the hiring process for the Maintenance Director. He said when he became aware of the incident he instructed the facility to remove and replace the lift immediately. He said overall it seemed reasonable there would have been a concern if he had seen the lift as described. He said, I would have investigated further. On 2/15/24 at 2:00 p.m., the Administrator verified she did not have any documentation that the Maintenance Director was oriented and knowledgeable to perform his job duties. Said she was unaware that the Maintenance Director didn't have experience checking some of the medical equipment. The Administrator said, Ultimately it is my responsibility as the facility administrator. She stated the facility has initiated an investigation into the event of 1/22/24 and submitted a report to the State Survey Agency as required. 2. Review of the manufacturer's guidelines for full body mechanical lift (Brand A) used to transfer Resident #1 noted under operation section, The legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position. On 2/12/24 at 2:02 p.m., in an interview, when asked about the process to transfer residents with a full body mechanical lift, CNA Staff E said, I start raising the lift, I put chair in good spot after pulling out from under bed, pull out, go over to the chair and then open legs so I can fit under chair. When asked to clarify when to open the legs of the base, CNA Staff E confirmed she only opens the legs of the base when she has stopped moving the lift and is placing the resident in bed or chair. On 2/12/24 at 4:00 p.m., in an interview CNA Staff A said on 2/1/24 she was assisting transferring Resident #1 to a new bed with a full body mechanical lift. She said there were people on all sides. There were three people because, he was so big. When he was very close to the bed, Resident #1 grabbed the straps and twisted himself. The lift started to tip to the left and he tried to grab the bed. CNA Staff A said, Yes, he fell to the floor because he was twisting. We tried to catch and guide him but we can do nothing. She said CNA Staff B held the machine to control him to the ground and the machine tilted over. CNA Staff A simulated the process to transfer residents with a full body mechanical lift. She did not inspect the lift or the sling before simulating the transfer. She did not open the legs of the base when simulating placing and lifting a resident in the lift and wheeling the lift. She only opened the legs of the base when simulating lowering the resident in the chair. CNA Staff A said, We open (the legs of the base) when we stop moving before we put the resident in the bed or chair. It will tip if the bottom (legs of the base) is open when moving. On 2/13/24 at 9:10 a.m., in an interview RN Staff K verified on 2/1/24 she was in the room when Resident #1 was being transferred with the mechanical lift. RN Staff K said, I went with three care givers. Everything was fine until the last part when moving him to the new bed. He got upset; he fell. RN Staff K said she did not receive too much training on mechanical lifts. She said she never participate in the actual lift. She helps placing the sling but the CNAs do all the work. On 2/13/24 at 9:41 a.m., CNA Staff H and CNA Staff I were observed using a full body mechanical lift (Brand A) to transfer Resident #20 from bed to wheelchair with a size large sling with visible green trim. Staff H placed the legs of the base under the resident's bed and lifted the resident in the sling. The CNA did not open the legs of the base. She pulled the legs of the base from under the bed, turned the lift to the right and wheeled the resident in the lift approximately three feet without opening the legs of the base. She opened the legs of the base when she lowered Resident #20 into the wheelchair. On 2/13/24 at approximately 10:00 a.m., CNA Staff H verified she did not open the legs of the base when transferring Resident #20 with the full body mechanical lift. She said, If I try to move her with the legs open it could tip over. We only open them when we are placing the resident in the bed or the chair. Review of employee files of staff using the mechanical lift on 1/22/24 when Resident #1 fell during transfer documented: Certified Nursing Assistant (CNA) Staff A date of hire 9/6/2021and computer-based training for mechanical lifts and transfers completed 9/5/2023. Most recent mechanical lift skills competency documented on 10/23/23. CNA Staff B employee files documented a hire date 4/27/2010 and computer-based training for mechanical lifts and transfers completed 12/11/2023. Most recent skills competency demonstrated on 10/22/23. CNA Staff C employee files documented a hire date 5/4/21 and computer-based training for mechanical lifts and transfers completed on 11/9/2023. Most recent skills competency demonstrated on 10/22/23. Registered Nurse (RN) Staff K documented a hire date of 9/6/22 and required nurse competency for mechanical lift use completed on 9/2/23. On 2/14/24 at 1:50 p.m., in a telephone interview the Assistant Director of Nursing (ADON) said on 1/22/24 after the fall involving Resident #1, We got called in, we had them reenact the situation in both the conference room and in the resident's room with (Brand A) mechanical lift and sling and all four staff members. I saw no concerns in the reenactments. The resident became anxious and fearful and grabbed onto bed. That is when it tipped towards staff. They were in the process of spreading out the base, is what they told me. She confirmed she did not document the reenactments or any additional post fall staff education. On 2/16/24 at 2:45 p.m., the DON said the nurses were responsible to supervise the CNAs and nursing leadership was responsible to ensure care is provided safely. He verified the lift used to transfer Resident #1 on 1/22/24 was broken and should not have been in use. When asked how the facility monitored to ensure the CNAs followed safety precautions when using mechanical lifts, the DON said, We only do the skills check, but we have not done any spot check or observe them. 3. On 2/12/24 observation showed the facility uses three different brands of mechanical lifts. On 2/14/24 the facility provided a list of 19 residents who used full body mechanical lifts Brand A, Brand B, or Brand C with manufacturer's Brand A slings assigned to them. Review of the manufacturer's instructions for slings for full body mechanical lift (Brand A) noted, (Brand A) slings are made specifically for use with (Brand A) lifts. For the safety of the patient, DO NOT intermix slings and lifts of different manufacturers. The instructions noted, Sling size and fit can vary significantly depending on patient weight and girth. These are general guidelines. Consult physician before sling selection. Review of the manufacturer's instructions of (Brand B) mechanical lift for slings noted, Specific slings are made for the Electric Patient Lifts. For the safety of the patient, DO NOT intermix slings and patient lifts of different manufacturers . Warranty will be voided. Review of the manufacturer's instructions of (Brand C) mechanical lift for slings noted, Use ONLY (Brand C) branded slings. DO NOT use a sling unless it is recommended for use with the lift. On 2/12/24 at 11:15 a.m., in an interview Unit Manager RN Staff G said the CNAs choose the sling based on the resident's size. The slings are left in the room. If soiled, they are sent to laundry and returned. On 2/12/24 at 1:30 p.m., CNA Staff D said the CNAs decide what size sling to use for each resident. She said, We just look at the resident. She said the facility uses all different types of slings. On 2/12/24 at 2:02 p.m., in an interview CNA Staff E said the CNAs decide what sling to use for each resident. She said, When I am looking at them [residents], I see them, so I know what size to get. On 2/12/24 at 2:35 p.m., in an interview CNA Staff F said the CNAs choose the sling size for the residents. She said, Large is the best, I always use large. You can't go wrong. On 2/12/24 at 3:25 p.m., in an interview about mechanical lifts, and choosing sling sizes, CNA Staff C said, We know if a person can't move, they we know they are a total mechanical lift. The slings are in the laundry room, I know the sizes. I just look at the resident and hold up to see if the sling will fit. I know the slings and how they will fit. From experience I know how to pick the right size. On 2/12/24 at 4:00 p.m., in an interview about sling sizes, CNA Staff A said she knew the sling size since they were in the residents' rooms. She said if there is no sling in the room, she gets one from the laundry. She said, We just know what will fit. On 2/13/24 at 9:10 a.m., in an interview RN Staff K said she did not receive too much training on mechanical lifts. She said she never participates in the actual lift. She helps placing the sling but the CNAs do all the work. On 2/13/24 at 9:41 a.m., CNA Staff H and CNA Staff I were observed using a full body mechanical lift (Brand A) to transfer Resident #20 from bed to wheelchair with a size large sling with visible green trim. On 2/13/24 at approximately 10:00 a.m., CNA Staff H verified she used a (Manufacturer A) large sling to transfer Resident #20 and said the CNAs choose the sling based on the resident's weight. Review of the clinical record for Resident #20 revealed the resident's current weight was 163.8 lbs. Review of Manufacturer A's Full Body & Stand-Up Lift Sling Sizing Chart noted sling size and fit can vary significantly depending on patient weight and girth. Consult physician before sling selection. The sling sizing chart noted a medium sling was for weight range of 90 to 200 lbs. On 2/13/24 at 9:30 a.m., in an interview the Director of Nursing (DON) said the CNAs choose the size of the sling based on weight. He said, I noticed they go by color coding on the slings themselves. On 2/15/24 at 9:45 a.m., the Regional Nurse Consultant said, All of the slings can hold up to 450 lbs. They are not going to break. The different sizes are more about comfort than safety. On 2/15/24 the Administrator provided a letter from (Brand B) lift Manufacturer dated 2/15/24 that read, Please be advised that (Brand B) Patient lifts are versatile and compatible with slings from other manufacturers, as well as being suitable for use with our own slings. The Administrator also provided a letter from (Brand C) lift manufacturer which documented, Most manufacturers recommend the use of their own slings with their lifts. While this may reduce risk of non-compatibility it also reduces health care professionals' flexibility in meeting the needs of their clients. (Brand C) floor and sit to stand patient lifts are compatible with most other manufacturer's slings with loop style attachments . On 2/16/24 at approximately 4:00 p.m., in an interview the Administrator said she contacted (Brand A) manufacturer. They would not give her a letter stating manufacturer (Brand A) slings were compatible with other brands of lift. The immediate actions implemented by the facility to remove the Immediate Jeopardy, and verified by the surveyor on 2/26/24 included: Lift identified from the 1/22/24 event was removed from service 1/22/24. On 2/15/24 the surveyor verified through observation. The lift used to transfer Resident #1 on 1/22/24 was removed from service. Resident involved in identified transfer 1/22/24 no longer resides in facility. On 2/12/24 the surveyor verified through record review. Resident #1 was transferred to an acute care hospital on 1/22/24 and has not returned to the facility. The facility utilized the lift companies resource guideline to establish the standard for sling sizing and lift usage. On 2/16/24 the surveyor verified through review of training provided using the manufacturer's resource guideline for standard for sling sizing and lift usage. The Administrator and Director of Nursing reviewed the events for the last 30 days to identify any other issues with lift transfers. No events related to lift transfers. On 2/16/24 the surveyor verified through record review and interview with the Administrator. The Physical Plant Consultant reviewed each lift to ensure they were in a safe operating condition on 2/14/24. On 2/16/24 the surveyor verified through review of the lift inspections to ensure each lift was in safe operating condition. Risk Management Consultant completed directed in-service with the Nursing Home Administrator and Director of Nursing related to the Abuse prevention Program 2/16/24. On 2/16/24 the surveyor verified through review of the in-service and interview with the Administrator and Director of Nursing. The Administrator and Director of Nursing were educated by the Physical Plant Consultant related to the requirement to educate staff regarding the reporting of faulty equipment, removal from service, and activating the lock-out Tag-out process through maintenance. 2/16/24. On 2/16/24 the surveyor verified through review of the education and interview with the Administrator and Director of Nursing. The Nurse Consultant educated the Facility Administrator and the Director of Nursing related to ensuring staff were educated related to use of the correct brand and sling size as specified by the individual manufacturer to ensure the safety of residents during transfer with the lifts. 2/14/24. On 2/16/24 the surveyor verified through review of the education and interview with the Administrator.

Based on observations, record review, review of policies and procedures, and staff interviews, the facility failed to protect the residents' right to be free from neglect by failing to ensure full body mechanical lifts were in safe operating condition, failing to ensure staff followed safety protocol when using mechanical lifts, and failure to ensure staff responsible for the inspection and maintenance of mechanical lifts was knowledgeable and competent to perform the job duties. Resident #1 was dependent on staff and required the use of a mechanical lift for transfer. On 1/22/24 Resident #1 fell from the full body mechanical lift during transfer. The motor of the lift used to transfer Resident #1 had been removed since July 2023, preventing the legs of the base to remain locked into position during the transfer. Resident #1 sustained cuts to the left arm, complained of pain and head trauma requiring an emergent transfer to an acute care hospital for evaluation and treatment. The facility's failure to ensure necessary structure and processes to prevent neglect placed other residents who require the use of mechanical lifts at a likelihood of avoidable accidents and falls which could result in serious injury, impairment, or death, and resulted in the determination of Immediate Jeopardy. On 2/15/24 at 6:58 p.m., the Administrator was notified of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. The Immediate Jeopardy began on 1/22/24. The facility census was 113 with 19 residents who were transferred with full body mechanical lifts. The facility used three different brands of mechanical lifts. On 2/16/24, after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/16/24. The scope and severity were reduced to no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference to F689, F835 and F908. 1. The facility's policy and procedure titled, Abuse Prevention Program, with a date reviewed/revised August 2022 noted, The facility has designated and implemented processes, which strive to reduce the risk of . neglect . These policies guide the identification, management, and reporting of suspected, or alleged . neglect . It is expected that these policies will assist the facility with reducing the risk of . neglect . through education of staff and residents . Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Procedure: The facility has implemented the following processes in an effort to provide residents . with a safe and comfortable environment . Prevention . Facility leadership will identify situations in which . neglect . may be more likely to occur . The facility policy and procedure titled, Back Injury and Body Mechanics effective March 2022 noted, Mechanical Lifts for Residents . Complete Mechanical Lift competency (Appendix B) at orientation and annually . The facility's Skills Check for Total Lift included to, Identify correct lift and sling size by matching the color-coded sticker to the color of the piping on the sling. Inspect lift and sling for condition . The facility's policy and procedure titled, Lock Out/ Tag out Policy effective March 2022 noted, The facility will use the Lock Out/ Tag Out practices to secure inoperable equipment . Other Physical Equipment . Mechanical lifts .When an issue is identified, remove the equipment from use . Review of the manufacturer's guidelines for full body mechanical lift (Brand A) used to transfer Resident #1 noted under operation section, The legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position. Review of the clinical record for Resident #1 revealed an admission date 1/19/2024. Diagnoses included morbid obesity; muscle wasting and atrophy; need for assistance with personal care; and difficulty in walking. The admission Minimum Data Set (MDS) assessment with a reference date of 1/22/24 noted Resident #1 was totally dependent on the physical assistance of two persons for bed mobility and required extensive physical assistance of two persons for transfer. The care plan initiated on 1/20/24 noted Resident #1 had an activities of daily living (ADL) self-care performance deficit. The interventions included the use of a, total mechanical lift to chair. The Physical Therapy Plan of Care with a start of care date of 1/20/24 noted Resident #1 was currently unable to ambulate and performed all functional transfers with total assist/dependent. Review of the progress notes revealed on 1/22/24 at 8:40 p.m., Registered Nurse (RN) Staff K documented, Rental bed arrives at the facility. Upon arrival, 3 CNA (Certified Nursing Assistant) and nurse assist resident with transferring from old bed to new bed. Upon transfer, resident began moving, twisting, flailing his arms and grabbing bed causing the lift to tip to the side and resident to attain [sic] skin tear. Staff attempt to calm and reassure resident with no resolve. Staff brace resident and lower resident to the ground. Assessment finds resident alert, denies pain, denies being hurt or hitting his head. No other injuries or skin alterations noted. MD (Physician) notified with orders to send to ER (Emergency Room) for evaluation . The facility's fall incident dated 1/22/24 at 10:24 p.m., noted the resident did not hit his head during the transfer. The incident noted, Resident attempts to grab and self-position side to side during transfer causing lift to tip to side. Review of the EMS (Emergency Medical Services) Patient Care record dated 1/22/24 noted, Medic two arrived on scene to a skilled nursing facility where (Resident #1) was found lying on the floor. Staff explained that they were using a [brand name] mechanical lift to move the patient which he then fell out of and hit the floor. Patient was found lying on his right side in his room. Patient was complaining of pain all over that he could not pinpoint. A cervical collar was used to immobilize the patient's neck . Review of the emergency room Physician's progress note dated 1/23/24 at 1:35 a.m., noted, Today, while at rehab, patient sustained a fall from a (brand name) lift onto the ground. Patient endorses head trauma but denies loss of consciousness . On 2/12/24 the facility provided the following witness statements from staff as part of their investigation: On 1/22/24 CNA Staff B signed a witness statement written by Unit Manager Registered Nurse (RN) Staff J which noted, . The resident started shaking the straps attached to the lift. We tried to calm him down. He said he was afraid and continued to shake the straps. We got him close to the bed. He twist [sic] in the lift, that is when he went to the floor. As he was going down to the floor he grabbed the side rail he scraped his arm on the wall causing a skin tear. The nurse (RN Staff K) was present in the room at that time. On 1/22/24 CNA Staff A documented in a statement Resident #1 was connected to the mechanical lift with three person assist to go to the new bed. The resident was moving and shaking and the mechanical lift tipped over to the side, the resident was twisting. Staff A wrote, Resident did not fall, lowered to ground inside sling. She noted Resident #1 was positioned on the floor with pillows and had no acute pain complaint. On 1/22/24 the Administrator documented an interview with CNA Staff C. The statement noted CNA Staff C went in the room to assist CNA Staff A and CNA Staff B to transfer Resident #1. They used a mechanical lift to transfer the resident. During the transfer Resident #1 began twisting and flaying his arms and the lift started to fall to the one side. The legs of the lift were spread but because resident was twisting and moving his arms around, the lift fell to the side. The statement noted CNA Staff B guided the resident and he then went on down slowly to the floor. On 1/22/24 at 8:40 p.m., RN Staff K documented in a statement Resident #1 was transferred from the wheelchair to the mechanical lift in an extra-large sling and three person assist. While positioning the mechanical lift on the side of the new bed, the resident became anxious. The resident was moving his arms and grabbing the side of the bed. The resident continued to shake and pull himself aside. RN Staff K wrote the mechanical lift tips to left side. [Brand name] lift did not tip over. Resident #1 was lowered to the floor by the mechanical lift, in sling. The statement noted Resident #1 sustained a skin tear to the left arm where he attempted to grab the bed bar. RN Staff K wrote the resident did not hit his head or complained of pain. The investigation did not include documentation CNA Staff A, CNA Staff B, CNA Staff C, or RN Staff K inspected the mechanical lift and the sling for condition as per the facility's Skills Check for Total Lift to ensure the mechanical lift was in safe operating condition. The investigation did not include verification that staff used safe transfer technique per manufacturer's guidelines when using the mechanical lift. On 2/12/24 at 10:00 a.m., in an interview the Administrator said Resident #1's fall was witnessed. The documented root cause of the fall was, The resident was self-positioning, twisting, moving and grabbing during transfer. She said Resident #1's fall did not meet criteria of an alleged violation and was not reportable to the Florida State Survey Agency. On 2/12/2024 at 3:25 p.m., in an interview CNA Staff C said on 2/1/24 she assisted with the transfer of Resident #1 with the mechanical lift. CNA Staff C said the resident was getting a new bed. She said, We tried to turn the lift to put him in the bed. He started twisting, and he started to tip over. He did not fall out. We grabbed him in the sling. I grabbed him and the other CNA grabbed him, the CNA used the machine and lowered to floor with the lift. He was frightened and grabbed onto the bed. He had a scrape on his left arm was his only injury. CNA Staff C said, we know if a person can't move, then we know they are a total mechanical lift. When asked about selecting the size of the sling, CNA Staff C said, Slings are in the laundry room, I know the sizes. I just look at the resident and hold up to see if the sling will fit. I know the slings and how they will fit. From experience I know how to pick the right size. When asked, CNA Staff C described the process for mechanical lift transfers as, I put the sling under resident with a second person on the other side of the bed. I put the lift with the base closed under the bed and then open the legs. Under the bed it is wide then when I pull out the lift from under the bed, I close the base so we can turn and move. CNA Staff C said she did not know if the legs of the base were opened or close when Resident #1 fell on 2/1/24. She said she was not operating the lift and, I just know it started to tilt over. Review of the employee file for CNA Staff C revealed a date of hire of 5/4/21. A computer based training for mechanical lift and transfers was dated 11/9/2023. The most recent skills competency was dated 10/22/23. On 2/12/24 at 4:00 p.m., in an interview CNA Staff A said on 2/1/24 she was assisting transferring Resident #1 to a new bed with a full body mechanical lift. She said there were people on all sides. There were three people because, he was so big. When he was very close to the bed, Resident #1 grabbed the straps and twisted himself. The lift started to tip to the left and he tried to grab the bed. CNA Staff A said, Yes, he fell to the floor because he was twisting. We tried to catch and guide him but we can do nothing. She said CNA Staff B held the machine to control him to the ground and the machine tilted over. CNA Staff A said she knew the size of sling for each resident since the sling was already in the room. If there is no sling, she'll get one from the laundry room, We just know what will fit. CNA Staff A demonstrated the process to transfer residents with a Brand C full body mechanical lift. She did not open the legs of the base when simulating placing and lifting a resident in the lift and wheeling the lift. She only opened the legs of the base when simulating lowering the resident in the chair. CNA Staff A said, We open (the legs of the base) when we stop moving before we put the resident in the bed or chair. It will tip if the bottom (legs of the base) is open when moving. On 2/12/24, review of CNA Staff A's employee file revealed a date of hire of 9/6/21. The most recent computer based training for mechanical lifts and transfers was completed on 9/5/23, and a competency completed on 10/23/23. On 2/12/24 at 4:35 p.m., in an interview CNA Staff B confirmed on 1/22/24 she was operating the full body mechanical lift to transfer Resident #1. CNA Staff B said Resident #1 kept shaking and saying, I'm going to fall. She said, When we were moving to the bed he turned and twisted, the machine tipped over but did not fall over. The machine did not fall on him. The other CNAs grabbed him and held him while I lowered him to the floor. The bottom of the lift is always open. We open it with our feet but sometimes it closes again. I know I opened it, but it might have closed on its own, I don't know for sure. When asked how to select the sling for each resident, she replied, We find them in the room, just what fits right. On 2/12/24, review of CNA Staff B's employee file revealed a date of hire of 4/27/2010. The most recent computer based training for mechanical lifts and transfers was completed on 12/11/23. The last competency skill for mechanical lifts was dated 10/22/23. On 2/13/24 at 9:10 a.m., in an interview RN Staff K verified on 2/1/24 she was in the room when Resident #1 was being transferred with the mechanical lift. RN Staff K said, I went with three care givers. Everything was fine until the last part when moving him to the new bed. He got upset; he fell. The CNA in the corner tried to carry the man's weight on her. Unfortunately, we had to put him on the floor. I assessed the resident, and I stayed in the room. I had one nurse text the ARNP (Advanced Registered Nurse Practitioner) and one call 911. RN Staff K said she did not receive too much training on mechanical lifts. She said she never participate in the actual lift. She helps placing the sling but the CNAs do all the work. RN Staff K said she did not know the size of the sling used to transfer Resident #1 but she never tells the CNAs what size of sling to use. She said, They all know, they know what to use, they are very smart. On 2/12/24 review of RN Staff K's employee file revealed a date of hire of 9/6/22 and a competency for mechanical lift use dated 9/2/23. On 2/13/24 at 9:30 a.m., in an interview the Director of Nursing (DON) said the expectation was to widen the legs of the base for patient safety. He said as they clear the lift from under the bed, the legs of the base need to be open. It is very important so that it leveled and weight distribution is even, and a wide center of gravity. The DON said, correct base widening decreases the tipping potential. On 2/13/24 at 9:41 a.m., CNA Staff H and CNA Staff I were observed using a Brand A full body mechanical lift to transfer Resident #20 from bed to wheelchair with a size large Brand A sling with visible green trim. Staff H placed the legs of the base under the resident's bed and lifted the resident in the sling. The CNA did not open the legs of the base. She pulled the legs of the base from under the bed, turned the lift to the right and wheeled the resident in the lift approximately three feet without opening the legs of the base. She opened the legs of the base when she lowered Resident #20 into the wheelchair. On 2/13/24 at approximately 10:00 a.m., CNA Staff H verified she did not open the legs of the base when transferring Resident #20 with the full body mechanical lift. She said, If I try to move her with the legs open it could tip over. We only open them when we are placing the resident in the bed or the chair. CNA Staff H verified she used a (Manufacturer A) large sling to transfer Resident #20 and said the CNAs choose the sling based on the resident's weight. Review of the clinical record for Resident #20 revealed the resident's current weight was 163.8 lbs. Review of Manufacturer A's Full Body & Stand-Up Lift Sling Sizing Chart noted sling size and fit can vary significantly depending on patient weight and girth. Consult physician before sling selection. The sling sizing chart noted a medium sling was for weight range of 90 t0 200 lbs. The Owner's Operator and Maintenance Manual for Brand A Patient Slings noted under warning, [Brand A] slings are made specifically for use with [Brand A] lifts. For the safety of the patient, DO NOT intermix slings and lifts of different manufacturers. Review of Brand C mechanical lift owner manual noted to use only Manufacturer Brand C branded slings. On 2/13/24 at 12:50 p.m., the DON said the facility ordered standard medium and large slings. He said the CNAs evaluate the residents to determine the size of sling to use. He verified the sling size was not on the CNA Kardex (provides instructions for care) and the lack of documentation the CNAs were trained and competent to determine the size of sling to use in accordance with manufacturer's instructions. On 2/15/24 at 9:20 a.m., in an interview Unit Manager RN Staff J said on 1/22/24 she was working when Resident #1 fell from the lift. She said, I was sitting at the desk on 300 hall, and I heard a noise. We jumped up and ran into the room where he was sitting against the wall; the [brand name] lift was tilted over and was leaning on his wheelchair. The sling was still under him, and the loops were still attached. They told me they got him up, weighed him because they got him a new, wider bed, and air mattress with the little side rails. The staff said that the resident grabbed side rail and that is how he scratched his arm. Unit Manager RN Staff J said she did not remember the color of the sling used. Said she notified the administrator of the fall. The Administrator came in with the maintenance man. They took the lift into the conference room and had the staff demonstrate how they did the procedure. Unit manager RN Staff J confirmed the staff demonstrated that the legs in the lift base were closed when they were moving the resident in the lift, the lift tilted over and leaned against wheelchair. RN Staff J said, He did not fall. I know technically it was a fall since he was on the floor, but it was controlled. RN Staff J said when she entered the room after the event, the base was straight because that is the way they have it when they are moving to the bed. Unit Manager Staff J confirmed the legs of the base were closed, and straight, and the mechanical lift was tilted against the resident's wheelchair. She said, The CNA was half under him trying to hold up the resident, so we moved him to the floor. He was a big man. On 2/15/24 at 8:50 a.m., in a follow up telephone interview CNA Staff B said on 1/22/24 she opened the base wide with the foot control when transferring Resident #1 with the full body mechanical lift. She said it (legs of the base) is supposed to stay open but when they turned the machine it closed on its own. CNA Staff B said, The resident was upset and moving. He was grabbing at the bed and the machine tilted over. We did everything we could but could not stop it. She confirmed the legs of the base closed on their own when the machine tilted over and she reported it to the Administrator. On 2/15/24 at 10:30 a.m., in an interview the Administrator said the CNA did not tell her the legs of the base closed on their own when the fall occurred. She said, The statement that I took was that the legs were open. We removed the lift, and an outside company is coming next week to check the lift. The Administrator said after the incident on 1/22/24 they did a reenactment with the lift used to transfer Resident #2. She said she did not have documentation of the reenactment or the Maintenance Director assessing the lift after the incident. The Administrator verified the facility did not identify the failure of the legs of the base to lock into place as a contributing factor of Resident #1's fall on 1/22/24. On 2/15/24 at 10:45 a.m., mechanical lift (Brand A) used on 1/22/24 to transfer Resident #1 was observed with the Maintenance Director. The Maintenance Director verified on 1/22/24 he inspected the mechanical lift used to transfer Resident #1 and did not think it was broken. He verified the motor of the lift was missing. The Maintenance Director said the motor had been missing since he started employment at the facility on 7/5/23. He demonstrated how staff opened the legs of the base by kicking the frame of the legs. The legs of the base did not lock into place. The Maintenance Director said it was possible for the legs to move easily during transfer if the base was bumped. He said the motor was connected to the legs and would lock them in place. He said since the motor has been removed, there was no locking feature. He said he has been checking the lift monthly since 7/2023 and did not realize it should have had a brake handle or a motor to ensure the legs of the base stayed open while in use. On 2/15/24 at 11:00 a.m., the mechanical lift used to transfer Resident #1 on 1/22/24 was observed with the Administrator, the Maintenance Director, and the DON. The Maintenance Director opened the legs of the base by kicking them with his foot. The DON demonstrated and verified the legs of the base closed easily and did not lock into position. When asked if this was the condition of the lift on 1/22/24 when Resident #1 fell from the lift, the Administrator said, Yes it is. When asked if staff kicked open the legs of the base during the reenactment she conducted on 1/22/24, the Administrator said, I don't remember. I can only go by the witness statements I obtained where she said the base was open. When asked if the lift was safe to use she said, No it's not. On 2/15/24 at 11:15 a.m., the DON verified the mechanical lift used to transfer Resident #1 on 1/22/24 did not have a motor and the legs of the base did not lock into place. He said it was unacceptable and unsafe for resident use. He said he was not aware the lift was broken and didn't know how unsafe it was. He said, The staff should never have been using it. On 2/15/24 at 12:50 p.m., in an interview the Maintenance Director said he previously worked at an Assisted Living Facility and they did not use mechanical lifts. He said when he started employment at the facility, There was no orientation. He said the person who hired him filled out a list by asking him if he knew about different systems like fire alarms and HVAC (Heating, Ventilation, Air Conditioning) but, I don't think it comprised any medical equipment. He said he was told to review the electronic maintenance system and follow the checklists for the inspection and maintenance of the mechanical lifts. He said he did not know the lift used to transfer Resident #1 had a motor at one time. The first time he inspected the lift, he asked a CNA how it worked. The CNA demonstrated by using her feet to open the legs of the base. The Maintenance Director said, I thought it was okay since the staff showed me and did not tell me it was wrong. I did not have enough knowledge to safely assess the lifts. The Maintenance Director job description noted, The Maintenance Director is responsible for the overall maintenance of the Facility . ensures the facility, equipment and utilities are maintained in good working order . Ensure equipment . are clean, safe, and orderly . Maintain and repair specialized equipment and machinery . Coordinates maintenance services with all other departments and services . The job description was not signed. On 2/15/24 at 2:00 p.m., the Administrator verified she did not have any documentation that the Maintenance Director was oriented and knowledgeable to perform his job duties. Said she was unaware that the Maintenance Director didn't have experience checking some of the medical equipment. The Administrator said, Ultimately it is my responsibility as the facility administrator. On 2/16/24 at 2:45 p.m., the DON said the nurses were responsible to supervise the CNAs and nursing leadership was responsible to ensure care is provided safely. He verified the lift used to transfer Resident #1 on 1/22/24 was broken and should not have been in use. 2. On 2/12/24 observation showed the facility used three different brands of mechanical lifts. Review of the manufacturer's instructions for slings for full body mechanical lift (Brand A) noted, (Brand A) slings are made specifically for use with (Brand A) lifts. For the safety of the patient, DO NOT intermix slings and lifts of different manufacturers. Review of the manufacturer's instructions of (Brand B) mechanical lift for slings noted, For safety of the patient, DO NOT intermix slings and patient lifts of different manufacturers . Review of the manufacturer's instructions of (Brand C) mechanical lift for slings noted, Use ONLY (Brand C) branded slings. DO NOT use a sling unless it is recommended for use with the lift. On 2/13/24 at 12:05 p.m., during a tour with Unit Manager RN Staff G, three of the 19 residents who use full body mechanical lifts had manufacturer's (Brand A) slings in their rooms. The other 16 residents did not have a sling. Review of (Brand A) manufacturer's Full Body & Stand-Up Lift Sling sizing Chart noted, Sling size and fit can vary significantly depending on patient weight and girth. These are general guidelines. Consult physician before sling selection. Small: 55 to 100 pounds (lbs.) Medium: 90 to 200 lbs. Large: 175 to 285 lbs. Extra-large: 265 to 500 lbs. Extra-Extra Large: 265 to 600 lbs. On 2/14/24 the facility provided a list of 19 residents who used Brand A, Brand B, and Brand C full body mechanical lifts with manufacturer's Brand A slings assigned to them. 13 of the 19 residents had the incorrect size of slings. Resident #2's current weight was 133.2 lbs. and assigned a size large sling by facility. Resident #3's current weight was 167 lbs. and assigned a size large sling by facility. Resident #4's current weight was 157.4 lbs. and assigned a size large sling by the facility. Resident #5's current weight was 160.4 lbs. and assigned a size large sling by facility. Resident #7's current weight was 208 lbs. and assigned an extra- large sling by facility. Resident #8's current weight was 169 lbs. and assigned a size large sling by facility. Resident #9's current weight was 170 lbs. and assigned a size large sling by facility. Resident #11's current weight was 146 lbs. and assigned a size large sling by facility. Resident #14's current weight was 101 lbs. and assigned size large sling by facility. Resident #17's current weight was 204 lbs. and assigned an extra-large sling by facility. Resident #18's current weight was 224 lbs. and assigned an extra-large sling by facility. Resident #19's current weight was 168.4 lbs. and assigned size large sling by facility. Resident #20's current weight was 163.8 lbs. and assigned a size large sling by facility. On 2/14/24 at 12:25 p.m., the Administrator said she was not aware each manufacturer specified to only use their brand of slings with their mechanical lifts. She said, That's not what the rental company told me. They said the slings were universal. She verified the facility only had (Brand A) slings available. On 2/15/24 at 9:45 a.m., the Regional Nurse Consultant said, All of the slings can hold up to 450 lbs. They are not going to break. The different sizes are more about comfort than safety. On 2/15/24 the Administrator provided a letter from (Brand B) lift Manufacturer dated 2/15/24 that read, Please be advised that (Brand B) Patient lifts are versatile and compatible with slings from other manufacturers, as well as being suitable for use with our own slings. The Administrator also provided a letter from (Brand C) lift manufacturer which documented, Most manufacturers recommend the use of their own slings with their lifts. While this may reduce risk of non-compatibility it also reduces health care professionals' flexibility in meeting the needs of their clients. (Brand C) floor and sit to stand patient lifts are compatible with most other manufacturer's slings with loop style attachments . On 2/16/24 at approximately 4:00 p.m., in an interview the Administrator said she contacted (Brand A) manufacturer. They would not give her a letter stating their slings were compatible with other brands of lift. The immediate actions implemented by the facility to remove the Immediate Jeopardy, and verified by the surveyor on 2/26/24 included: To protect the residents that require mechanical lift transfers the lift Identified was removed from services and Maintenance activated the Lock-out Tag-out process and sequestered the lift 1/22/24 in a locked storage room to prevent reintroduction into care areas. On 2/15/24 the surveyor verified through observation of the lift which was removed from patient care area. A Federal immediate report was completed and submitted 2/15/24. On 2/16/24 the surveyor verified through review of the Federal Immediate Report submitted to the State Survey Agency on 2/15/24. A comprehensive facility investigation has been reopened. On 2/16/24 the surveyor verified through review of documentation of facility's investigation and interview with the Administrator. Resident #1 involved in identified transfer 1/22/24 no longer resides in facility. On 2/12/24 the surveyor verified through record review Resident #1 was admitted to the acute care hospital on 2/1/24 and has not returned to the facility. Director of Nursing/Designee educated CNAs identified from lift transfer 2/13/24 using checklist for total lift transfer. On 2/16/24 the surveyor verified through review of the education provided using the checklist for total lift transfer. The surveyor interviewed four CNAs, two Licensed Practical Nurses and one Unit Manager. All were able to describe the process for transfer using a full body mechanical lift. The nurse identified as being a participant in the 1/22/24 transfer was suspended pending investigation. On 2/16/24 the surveyor verified through record review, and interview with the Administrator. The three CNAs identified performing the transfer 1/22/24 were educated regarding proper mechanical lift transfer and suspended pending investigation outc[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility's policies and procedures, and staff interviews, the facility failed to implement processes to prevent accidents by failing to ensure staff followed manufacturer's safety recommendations during transfer with mechanical lift, and failing to ensure mechanical lifts were in safe operating condition. On 1/22/24 staff used a full body mechanical lift to transfer Resident #1. The motor of the lift had been removed making the locking mechanism inoperable. Resident #1 fell from the lift, sustained cuts to the left arm, complained of head trauma and pain all over. Resident #1 required an emergent transfer to an acute care hospital for evaluation and treatment. The failure of staff to follow manufacturer's safety recommendations for transfer with mechanical lifts created an unsafe environment of avoidable accidents or falls which has a likelihood to result in serious injury (i.e. Fractures, head injuries), impairment, or death of residents from avoidable accidents, and resulted in the determination of Immediate Jeopardy. On 2/15/24 at 6:58 p.m., the Administrator was notified of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. The Immediate Jeopardy began on 1/22/24. The facility census was 113 with 19 residents who were transferred with full body mechanical lifts. The facility used three different brands of mechanical lifts. On 2/16/24, after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/16/24. The scope and severity were reduced to no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference to F600, F835 and F908. 1. Review of the clinical record for Resident #1 revealed an admission date 1/19/2024. Diagnoses included morbid obesity; muscle wasting and atrophy; need for assistance with personal care; and difficulty in walking. The care plan initiated on 1/20/24 noted Resident #1 had an activities of daily living (ADL) self-care performance deficit. The interventions included the use of a, total mechanical lift to chair. Review of the progress notes revealed on 1/22/24 at 8:40 p.m., Registered Nurse (RN) Staff K documented Resident #1 was being transferred with a mechanical lift to a new bed with three staff members. The resident was moving, twisting, flailing his arms and grabbing the bed, causing the lift to tip to the side. Staff lowered the resident to the floor. The fall investigation dated 1/22/24 at 10:24 p.m., noted Resident #1 was oriented to person, place, time, and situation at the time of the incident. The investigation did not list any predisposing environmental factors, and noted, Resident attempts to grab and self-position side to side during transfer causing lift to tip to side. Resident #1 was transferred to an acute care hospital via Emergency Medical Services (EMS). The facility's internal investigation of the fall included staff statements but did not include documentation Certified Nursing Assistant (CNA) Staff A, CNA Staff B, CNA Staff C, or RN Staff K inspected the mechanical lift and the sling for condition as per the facility's Skills Check for Total Lift to ensure the mechanical lift was in safe operating condition. The investigation did not include verification that staff used safe transfer technique per manufacturer's guidelines. Review of the manufacturer's guidelines for full body mechanical lift (Brand A) used to transfer Resident #1 noted under operation section, The legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position. The facility's policy and procedure titled, Lock Out/ Tag out Policy effective March 2022 noted, The facility will use the Lock Out/ Tag Out practices to secure inoperable equipment . Other Physical Equipment . Mechanical lifts .When an issue is identified, remove the equipment from use . The facility's Skills Check for Total Lift included to, Identify correct lift and sling size by matching the color-coded sticker to the color of the piping on the sling. Inspect lift and sling for condition . On 1/22/24 the Administrator documented an interview with CNA Staff C. The statement noted CNA Staff C went in the room to assist CNA Staff A and CNA Staff B to transfer Resident #1. They used a mechanical lift to transfer the resident. During the transfer Resident #1 began twisting and flaying his arms and the lift started to fall to the one side. The legs of the lift were spread but because resident was twisting and moving his arms around, the lift fell to the side. The statement noted CNA Staff B guided the resident and he then went on down slowly to the floor. CNA Staff C's statement did not include documentation staff verified the lift was in safe operating condition before the transfer. On 2/12/2024 at 3:25 p.m., in an interview CNA Staff C said on 2/1/24 she assisted with the transfer of Resident #1 with the mechanical lift. CNA Staff C said the resident was getting a new bed. She said, We tried to turn the lift to put him in the bed. He started twisting, and he started to tip over. He did not fall out. We grabbed him in the sling. I grabbed him and the other CNA grabbed him, the CNA used the machine and lowered to floor with the lift. He was frightened and grabbed onto the bed. He had a scrape on his left arm was his only injury. When asked to describe the process for mechanical lift transfers, CNA Staff C said, I put the sling under resident with a second person on the other side of the bed. I put the lift with the base closed under the bed and then open the legs. Under the bed it is wide then when I pull out the lift from under the bed I close the base so we can turn and move. CNA Staff C did not say if the lift was inspected prior to use or if the legs of the base were opened during the transfer. She said, I don't know, I was not the one who was controlling the lift itself I was just there to help. I don't know if his base was open or closed when we were moving to put resident #1 back into the bed. I just know it started to tilt over. On 1/22/24 CNA Staff A documented in a statement Resident #1 was connected to the mechanical lift with three person assist to go to the new bed. The resident was moving and shaking and the mechanical lift tipped over to the side, the resident was twisting. Staff A wrote, Resident did not fall, lowered to ground inside sling. She noted Resident #1 was positioned on the floor with pillows and had no acute pain complaint. CNA Staff A statement did not include verification that the lift was inspected before the transfer. On 2/12/24 at 4:00 p.m., in an interview CNA Staff A said on 2/1/24 she was assisting transferring Resident #1 to a new bed with a full body mechanical lift. She said there were people on all sides. There were three people because, he was so big. When he was very close to the bed, Resident #1 grabbed the straps and twisted himself. The lift started to tip to the left and he tried to grab the bed. CNA Staff A said, Yes, he fell to the floor because he was twisting. We tried to catch and guide him but we can do nothing. She said CNA Staff B held the machine to control him to the ground and the machine tilted over. CNA Staff A simulated the process to transfer residents with a brand C full body mechanical lift. She did not inspect the lift before simulating the transfer. She did not open the legs of the base when simulating placing and lifting a resident in the lift and wheeling the lift. She only opened the legs of the base when simulating lowering the resident in the chair. CNA Staff A said, We open (the legs of the base) when we stop moving before we put the resident in the bed or chair. It will tip if the bottom (legs of the base) is open when moving. On 1/22/24 CNA Staff B signed a witness statement written by Unit Manager Registered Nurse (RN) Staff J which noted, . The resident started shaking the straps attached to the lift. We tried to calm him down. He said he was afraid and continued to shake the straps. We got him close to the bed. He twist [sic] in the lift, that is when he went to the floor. As he was going down to the floor he grabbed the side rail he scraped his arm on the wall causing a skin tear. The nurse (RN Staff K) was present in the room at that time. The statement did not include CNA Staff B verified the lift was in safe operating condition before the transfer. On 2/12/24 at 4:35 p.m., in an interview CNA Staff B confirmed on 1/22/24 she was operating the full body mechanical lift to transfer Resident #1. CNA Staff B said Resident #1 kept shaking and saying, I'm going to fall. She said, When we were moving to the bed he turned and twisted, the machine tipped over but did not fall over. The machine did not fall on him. The other CNAs grabbed him and held him while I lowered him to the floor. The bottom of the lift is always open. We open it with our feet but sometimes it closes again. I know I opened it, but it might have closed on its own, I don't know for sure. When asked how to select the sling for each resident, she replied, We find them in the room, just what fits right. On 1/22/24 at 8:40 p.m., RN Staff K documented in a statement Resident #1 was transferred from the wheelchair to the mechanical lift in an extra-large sling and three person assist. While positioning the mechanical lift on the side of the new bed, the resident became anxious. The resident was moving his arms and grabbing the side of the bed. Staff attempted to calm and reassure the resident of safe transfer. The resident continued to shake and pull himself aside. RN Staff K wrote the mechanical lift tips to left side. [Brand name] lift did not tip over. Resident #1 was lowered to the floor by the mechanical lift, in sling. The statement noted Resident #1 sustained a skin tear to the left arm where he attempted to grab the bed bar. RN Staff K wrote the resident did not hit his head or complained of pain. RN Staff K's statement did not include staff verified the lift was in safe working condition before the transfer. RN Staff K's statement did not include verification staff used safe transfer technique and ensure the legs of the base were opened when the lift tipped to the side. On 2/13/24 at 9:10 a.m., in an interview RN Staff K verified on 2/1/24 she was in the room when Resident #1 was being transferred with the mechanical lift. RN Staff K said, I went with three care givers. Everything was fine until the last part when moving him to the new bed. He got upset; he fell. The CNA in the corner tried to carry the man's weight on her. Unfortunately, we had to put him on the floor. I assessed the resident, and I stayed in the room. I had one nurse text the ARNP (Advanced Registered Nurse Practitioner) and one call 911. RN Staff K said she did not receive too much training on mechanical lifts. She said she never participate in the actual lift. She helps placing the sling but the CNAs do all the work. On 2/13/24 at 8:30 a.m., in an interview the Maintenance Director said he started employment at the facility on 7/5/23. He said on 1/22/24 when Resident #1 fell from the lift, he came in to inspect the lift. He said the lift was not broken but it was removed from service due to the incident and possible investigation. The Maintenance Director said he did not have the owner's operator and maintenance manual for the three brands of lifts used at the facility. The Maintenance Director said he followed the checklist on their maintenance computer system but the checklist was not specific to each brand or model of mechanical lift. Requested the Maintenance Director obtained the owner's operator and maintenance manual for each brand of lift used at the facility. On 2/13/24 at 9:41 a.m., CNA Staff H and CNA Staff I were observed using a Brand A full body mechanical lift to transfer Resident #20 from bed to wheelchair with a size large Brand A sling with visible green trim. Staff H placed the legs of the base under the resident's bed and lifted the resident in the sling. The CNA did not open the legs of the base. She pulled the legs of the base from under the bed, turned the lift to the right and wheeled the resident in the lift approximately three feet without opening the legs of the base. She opened the legs of the base when she lowered Resident #20 into the wheelchair. On 2/13/24 at approximately 10:00 a.m., CNA Staff H verified she did not open the legs of the base when transferring Resident #20 with the full body mechanical lift. She said, If I try to move her with the legs open it could tip over. We only open them when we are placing the resident in the bed or the chair. CNA Staff H verified she used a (Manufacturer A) large sling to transfer Resident #20 and said the CNAs choose the sling based on the resident's weight. Review of the clinical record for Resident #20 revealed the resident's current weight was 163.8 lbs. Review of Manufacturer A's Full Body & Stand-Up Lift Sling Sizing Chart noted sling size and fit can vary significantly depending on patient weight and girth. Consult physician before sling selection. The sling sizing chart noted a medium sling was for weight range of 90 to 200 lbs. On 2/15/24 at 8:50 a.m., in a follow up telephone interview CNA Staff B said on 1/22/24 she opened the base wide with the foot control when transferring Resident #1 with the full body mechanical lift. She confirmed the legs of the base closed on their own when the machine tilted over and she reported it to the Administrator. On 2/15/24 at 10:30 a.m., in an interview the Administrator said the CNA did not tell her the legs of the base closed on their own when the fall occurred. She said, The statement that I took was that the legs were open. We removed the lift, and an outside company is coming next week to check the lift. The Administrator said she did not have documentation of the reenactment or the Maintenance Director assessing the lift after the incident. The Administrator verified the facility's investigation did not consider the failure of the legs of the base to lock into place as a contributing factor of Resident #1's fall on 1/22/24. On 2/15/24 at 10:45 a.m., mechanical lift (Brand A) used on 1/22/24 to transfer Resident #1 was observed with the Maintenance Director. The motor of the lift was missing. The Maintenance Director said the motor has been missing since he started employment at the facility on 7/5/24. He demonstrated how staff opened the legs of the base by kicking the frame of the legs. The legs of the base did not lock into place. The Maintenance Director said it was possible for the legs to move easily during transfer if the base was bumped. He said the motor was connected to the legs and would lock them in place. He said since the motor has been removed, there was no locking feature. He said he has been checking the lift monthly since 7/2023 and did not realize it should have had a brake handle or a motor to ensure the legs of the base stayed open while in use. On 2/15/24 at 11:00 a.m., the mechanical lift used to transfer Resident #1 on 1/22/24 was observed with the Administrator, the Maintenance Director, and the DON. The Maintenance Director opened the legs of the base by kicking them with his foot. The DON demonstrated and verified the legs of the base closed easily and did not lock into position. When asked if this was the condition of the lift on 1/22/24 when Resident #1 fell from the lift, the Administrator said, Yes it is. When asked if staff kicked open the legs of the base during the reenactment she conducted on 1/22/24, the Administrator said, I don't remember. I can only go by the witness statements I obtained where she said the base was open. When asked if the lift was safe to use she said, No it's not. On 2/15/24 at 11:15 a.m., the DON verified the mechanical lift used to transfer Resident #1 on 1/22/24 did not have a motor and the legs of the base did not lock into place. He said it was unacceptable and unsafe for resident use. He said he was not aware the lift was broken and didn't know how unsafe it was. He said, The staff should never have been using it. 2. On 2/12/24 observation showed the facility uses three different brands of mechanical lifts. Review of the manufacturer's instructions for slings for full body mechanical lift (Brand A) noted, (Brand A) slings are made specifically for use with (Brand A) lifts. For the safety of the patient, DO NOT intermix slings and lifts of different manufacturers. The instructions noted, Sling size and fit can vary significantly depending on patient weight and girth. These are general guidelines. Consult physician before sling selection. Review of the manufacturer's instructions of (Brand B) mechanical lift for slings noted, Specific slings are made for the Electric Patient Lifts. For the safety of the patient, DO NOT intermix slings and patient lifts of different manufacturers . Warranty will be voided. Review of the manufacturer's instructions of (Brand C) mechanical lift for slings noted, Use ONLY (Brand C) branded slings. DO NOT use a sling unless it is recommended for use with the lift. On 2/12/24 at 11:15 a.m., in an interview Unit Manager RN Staff G said the CNAs choose the sling based on the resident's size. The slings are left in the room. If soiled, they are sent to laundry and returned. On 2/12/24 at 1:30 p.m., in an interview CNA Staff D said the CNAs decide what size sling to use for each resident. She said, We just look at the resident. She said the facility uses all different types of slings. On 2/12/24 at 2:02 p.m., in an interview CNA Staff E said the CNAs decide what sling to use for each resident. She said, When I am looking at them [residents], I see them, so I know what size to get. When asked about the process to transfer residents with a full body mechanical lift, CNA Staff E said, I start raising the lift, I put chair in good spot after pulling out from under bed, pull out, go over to the chair and then open legs so I can fit under chair. When asked to clarify when to open the legs of the base, CNA Staff E confirmed she only opens the legs of the base when she has stopped moving the lift and is placing the resident in bed or chair. On 2/12/24 at 2:35 p.m., in an interview CNA Staff F said the CNAs choose the sling size for the residents. She said, Large is the best, I always use large. You can't go wrong. On 2/12/24 at 3:25 p.m., in an interview about mechanical lifts, and choosing sling sizes, CNA Staff C said, We know if a person can't move, they we know they are a total mechanical lift. The slings are in the laundry room, I know the sizes. I just look at the resident and hold up to see if the sling will fit. I know the slings and how they will fit. From experience I know how to pick the right size. On 2/12/24 at 4:00 p.m., in an interview about sling sizes, CNA Staff A said she knew the sling size since they were in the residents' rooms. She said if there is no sling in the room, she gets one from the laundry. She said, We just know what will fit. On 2/12/24 at 4:35 p.m., in an interview about choosing the right sling size, CNA Staff B said, We find them in the room, just what fits right. On 2/13/24 at 9:10 a.m., in an interview RN Staff K verified on 2/1/24 she was in the room when Resident #1 was being transferred with the mechanical lift. RN Staff K said she did not know the size of the sling used to transfer Resident #1 but she never tells the CNAs what size of sling to use. She said, They all know, they know what to use, they are very smart. On 2/13/24 at 9:30 a.m., in an interview the Director of Nursing (DON) said the CNAs choose the size of the sling based on weight. He said, I noticed they go by color coding on the slings themselves. On 2/13/24 at 12:05 p.m., during a tour with Unit Manager RN Staff G, three of the 19 residents who use full body mechanical lifts had manufacturer's (Brand A) slings in their rooms. The other 16 residents did not have a sling. On 2/14/24 at 12:25 p.m., the Administrator said she was not aware each manufacturer specified to only use their brand of slings with their mechanical lifts. She said, That's not what the rental company told me. They said the slings were universal. She verified the facility only had (Brand A) slings available. Review of (Brand A) manufacturer's Full Body & Stand-Up Lift Sling sizing Chart noted, Sling size and fit can vary significantly depending on patient weight and girth. These are general guidelines. Consult physician before sling selection. Small: 55 to 100 pounds (lbs.) Medium: 90 to 200 lbs. Large: 175 to 285 lbs. Extra-large: 265 to 500 lbs. Extra-Extra Large: 265 to 600 lbs. On 2/14/24 the facility provided a list of 19 residents who used full body mechanical lifts with manufacturer's Brand A slings assigned to them. 13 of the 19 residents had the incorrect size of slings. Resident #2's current weight was 133.2 lbs. and assigned a size large sling. Resident #3's current weight was 167 lbs. and assigned a size large sling. Resident #4's current weight was 157.4 lbs. and assigned a size large sling. Resident #5's current weight was 160.4 lbs. and assigned a size large sling. Resident #7's current weight was 208 lbs. and assigned an extra- large sling. Resident #8's current weight was 169 lbs. and assigned a size large sling. Resident #9's current weight was 170 lbs. and assigned a size large sling. Resident #11's current weight was 146 lbs. and assigned a size large sling. Resident #14's current weight was 101 lbs. and assigned size large sling. Resident #17's current weight was 204 lbs. and assigned an extra-large sling. Resident #18's current weight was 224 lbs. and assigned an extra-large sling. Resident #19's current weight was 168.4 lbs. and assigned size large sling. Resident #20's current weight was 163.8 lbs. and assigned a size large sling. On 2/15/24 the Administrator provided a letter from (Brand B) lift Manufacturer dated 2/15/24 that read, Please be advised that (Brand B) Patient lifts are versatile and compatible with slings from other manufacturers, as well as being suitable for use with our own slings. The Administrator provided a letter from (Brand C) lift manufacturer which documented, Most manufacturers recommend the use of their own slings with their lifts. While this may reduce risk of non-compatibility it also reduces health care professionals' flexibility in meeting the needs of their clients. (Brand C) floor and sit to stand patient lifts are compatible with most other manufacturer's slings with loop style attachments . On 2/16/24 at approximately 4:00 p.m., in an interview the Administrator said she contacted (Brand A) manufacturer. They would not give her a letter stating manufacturer their slings were compatible with other brands of lift. The immediate actions implemented by the facility to remove the Immediate Jeopardy, and verified by the surveyor on 2/26/24 included: Lift identified from the 1/22/24 event was removed from service on 1/22/24 through the lock-out Tag-out process. On 2/15/24 the surveyor verified through observation of the lift used on 1/22/24 to transfer Resident #1. Resident #1 involved in the identified transfer 1/22/24 no longer resides in the facility. On 2/12/24 the surveyor verified through record review. Resident #1 was transferred to an acute care hospital on 1/22/24 and has not returned to the facility. CNAs identified performing transfer 1/22/24 were educated regarding proper mechanical lift transfer and suspended 2/14/24 pending investigation. On 2/16/24 the surveyor verified through record review and interview with the Administrator. The Administrator and Director of Nursing reviewed the events for the last 30 days to identify any other issues with lift transfers. No events related to lift transfers were identified. On 2/16/24 the surveyor verified through record review and interview with the Administrator. The facility utilized the Manufacturers guidance to reevaluate sizing for each resident requiring mechanical lift transfer for each brand of mechanical lift as specified by the individual manufacturer to ensure the safety of the residents during transfers with the mechanical lift. On 2/16/24 the surveyor verified through review of residents reevaluation of sizing as specified by individual manufacturer to ensure the safety of the residents during transfers with the mechanical lift. Residents requiring the total lift were reevaluated using the Manufactures' sizing guidelines to determine the correct sling size. On 2/16/24 the surveyor verified through review of residents reevaluation of sizing as specified by individual manufacturer to ensure the safety of the residents during transfers with the mechanical lift. The Nurse Consultant provided education for the facility administration related to utilizing the Manufacturers' resources effectively for mechanical lifts 2/16/24. On 2/16/24 the surveyor verified through review of the education provided to the facility administration and interview with the Administrator and DON. The Physical Plant Consultant provided education to administrative staff related to the Lock-out, Tag-out process 2/16/24. On 2/16/24 the surveyor verified through review of the education provided and interview with the Administrator. The Facility Plant Consultant educated the Director of Maintenance related to the Monthly inspection process for Mechanical Lifts 2/16/24. On 2/16/24 the surveyor verified through review of the education provided to the Maintenance Director and interview with the Maintenance Director. The Facility Director of Nursing/Designee provided education to facility staff related to the Lock-Out Tag-out process and reporting & removing faulty equipment from service. Percentage of education completed as of 2/16/24 is 77%. The remaining staff will not work until the education is completed. On 2/16/24 the surveyor verified through review of the education provided to facility staff. Four CNAs, two Licensed Practical Nurses and one Unit Manager were interviewed and able to verbalize the content of the education. Sling selection sizing guidelines were placed at each nursing station in the resource binder 2/15/24. On 2/16/24 the surveyor verified through observation of the sizing guidelines at each nursing station. The sizing results from the individual resident evaluation have been scribed into the plan of care and into the [NAME] (Provides instructions for care) for Certified Nursing Assistant use. 2/15/24. On 2/16/24 the surveyor verified through review of individual resident evaluation and [NAME]. The facility implemented a mechanical lift monitor to oversee sling selection and observation of lift use for transfer technique. 2/16/24. On 2/16/24 the surveyor verified through record review and interview with the Administrator. The Nurse Consultant provided education to the facility Director of Nursing related to sling sizing per manufacturer guidelines and mechanical lift transfer techniques on 2/14/24. On 2/16/24 the surveyor verified through review of the education provided and interview with the Director of Nursing. The Director of Nursing/Designee initiated education with licensed nurses on proper mechanical lift transfer procedures to provide Certified Nursing Assistants supervision on 2/16/24. On 2/16/24 the surveyor verified through review of the education with the licensed nurses. Two Licensed Practical Nurses and one Unit Manager were interviewed and able to verbalize understanding of education provided. The Director of Nursing/Designee educated Facility Certified Nursing Assistants on proper mechanical lift transfer procedures using the Checklist for Total Lift Transfer which was initiated 2/14/24. The percentage completed is 93%. The 4 remaining certified nursing assistants will not work until the education is completed. On 2/16/24 the surveyor verified through review of the education provided and interview with four CNAs. The Director of Nursing/Designee completed education with licensed staff regarding sling sizing 2/15/24. The percentage of education completed is 91%. The remaining three licensed staff members will not work until the education is completed. On 2/16/24 the surveyor verified through review of the education, and interview with two Licensed Practical Nurses and one Unit Manager. The MDS (Minimum Data Set) nurse to evaluate resident using total lift and place sling size on [NAME] (provides instructions for care). Completed 2/14/24. On 2/16/24 the surveyor verified through review of education provided and review of [NAME].

Based on observation, record review, and staff interviews, the facility failed to implement processes to ensure resident equipment was in safe operating condition. On 1/22/24 Staff used a full body mechanical lift to transfer Resident #1. Resident #1 fell from the mechanical lift, sustained cuts, complained of head trauma and generalized pain requiring an emergent transfer to an acute care hospital. The motor of the lift had been removed since July 2023 causing the legs of the base to not lock to ensure a safe transfer. Staff responsible for the inspection and maintenance of the mechanical lifts did not have the training and competency to ensure the mechanical lifts were in safe operating condition. The facility failure to implement processes and ensure resident care equipment were in safe operating condition created an unsafe environment of avoidable falls and accidents with a likelihood of serious harm, impairment or death of residents who use a mechanical lift for transfers and resulted in the determination of Immediate Jeopardy (IJ). On 2/15/24 at 6:58 p.m., the Administrator was informed of the determination of Immediate Jeopardy and provided the IJ templates. The facility census was 113 with 19 residents who were transferred with mechanical lifts. The facility used three different brands of mechanical lifts for transfers. The Immediate Jeopardy began on 1/22/24. On 2/16/24, after the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/16/24 and the scope and severity were reduced to no actual harm, with no more than minimal harm. The findings included: Cross reference to F600, F689, and F835 On 2/12/24, review of facility incident and accident log revealed on 1/22/24 Resident #1 was being transferred with a total body mechanical lift which tipped over resulting in the resident falling to the floor. Resident #1 was transferred via Emergency Medical Services to an acute care hospital. The fall investigation dated 1/22/24 at 10:24 p.m., noted Resident #1 was oriented to person, place, time, and situation at the time of the incident. The investigation did not list any predisposing environmental factors, and noted, Resident attempts to grab and self-position side to side during transfer causing lift to tip to side. The investigation included statements of staff who used the mechanical lift to transfer Resident #1 and did not include a lift inspection to ensure the full body mechanical lift was in safe operating condition at the time of the fall. On 2/12/24 at 4:35 p.m., in an interview Certified Nursing Assistant (CNA) Staff B confirmed on 1/22/24 she was operating the full body mechanical lift to transfer Resident #1to a new bed. CNA Staff A, CNA Staff C, and Registered Nurse (RN) Staff K assisted with the transfer. CNA Staff B said Resident #1 kept shaking and saying, I'm going to fall. She said, When we were moving to the bed he turned and twisted, the machine tipped over but did not fall over. The machine did not fall on him. The other CNAs grabbed him and held him while I lowered him to the floor. The bottom of the lift is always open. We open it with our feet but sometimes it closes again. I know I opened it, but it might have closed on its own, I don't know for sure. The facility's policy and procedure titled, Lock Out/ Tag out Policy effective March 2022 noted, The facility will use the Lock Out/ Tag Out practices to secure inoperable equipment . Other Physical Equipment . Mechanical lifts .When an issue is identified, remove the equipment from use . On 2/13/24 at 8:30 a.m., in an interview the Maintenance Director said he started employment at the facility on 7/5/23. He said on 1/22/24 when Resident #1 fell from the lift, he came in to check the lift. He said the lift was not broken but it was removed from service due to the incident and possible investigation. The Maintenance Director said he did not have the owner's operator and maintenance manual for the three brands of lifts used at the facility, he followed the checklist on their maintenance computer system. He said the checklist was not specific to each brand or model of mechanical lift. The Maintenance Director provided a copy of the electronic form with steps to conduct the mechanical lifts safety inspection. Review of the electronic checklist for mechanical lifts noted to conduct mobile lift safety inspection and inspect all that apply. The tasks included, Inspect the caster base, check for missing hardware . Inspect the shifter handle: Ensure that shifter operates smoothly. Verify that base is locked when handle is engaged . Inspect the brakes . Ensure that the brakes engage when pressure is applied . The Maintenance Director provided documentation he inspected the mechanical lifts on 7/25/23, 8/16/23, 10/5/23, 11/7/23, 12/5/23, and 1/22/24. On 2/14/24 at 1:50 p.m., in a telephone interview the Assistant Director of Nursing (ADON) said on 1/22/24 after the fall involving Resident #1, We got called in, we had them reenact the situation in both the conference room and in the resident's room with (Brand A) mechanical lift and sling and all four staff members. I saw no concerns in the reenactments. The resident became anxious and fearful and grabbed onto bed. That is when it tipped towards staff. They were in the process of spreading out the base, is what they told me. She confirmed she did not document the reenactments or any additional post fall staff education. On 2/15/24 at 8:50 a.m., in a follow up telephone interview CNA Staff B said on 1/22/24 she opened the base wide with the foot control when transferring Resident #1 with the full body mechanical lift. She confirmed the legs of the base closed on their own when the machine tilted over and she reported it to the Administrator. On 2/15/24 at 10:30 a.m., in an interview the Administrator said the CNA did not tell her the legs of the base closed on their own when the fall occurred. She said, The statement that I took was that the legs were open. We removed the lift, and an outside company is coming next week to check the lift. The Administrator said she did not have documentation of the reenactment or the Maintenance Director assessing the lift after the incident. On 2/15/24 at 10:45 a.m., mechanical lift (Brand A) used on 1/22/24 to transfer Resident #1 was observed with the Maintenance Director. The motor of the lift was missing. The Maintenance Director said the motor has been missing since he started employment at the facility on 7/5/24. He demonstrated how staff opened the legs of the base by kicking the frame of the legs. The legs of the base did not lock into place. The Maintenance Director said it was possible for the legs to move easily during transfer if the base was bumped. He said the motor was connected to the legs and would lock them in place. He said since the motor has been removed, there was no locking feature. He said he has been checking the lift monthly since 7/2023 and did not realize it should have had a brake handle or a motor to ensure the legs of the base stayed open while in use. Photographic evidence obtained. On 2/15/24 at 11:00 a.m., the mechanical lift used to transfer Resident #1 on 1/22/24 was observed with the Administrator, the Maintenance Director, and the Director of Nursing (DON). The Maintenance Director opened the legs of the base by kicking them with his foot. The DON demonstrated and verified the legs of the base closed easily and did not lock into position. When asked if this was the condition of the lift on 1/22/24 when Resident #1 fell from the lift, the Administrator said, Yes it is. When asked if staff kicked open the legs of the base during the reenactment she conducted on 1/22/24, the Administrator said, I don't remember. I can only go by the witness statements I obtained where she said the base was open. When asked if the lift was safe to use she said, No it's not. On 2/15/24 at 11:15 a.m., the DON verified the mechanical lift used to transfer Resident #1 on 1/22/24 did not have a motor and the legs of the base did not lock into place. He said it was unacceptable and unsafe for resident use. He said he was not aware the lift was broken and didn't know how unsafe it was. He said, The staff should never have been using it. On 2/15/24 at 12:35 p.m., in an interview the Administrator said she was the Risk Manager for the facility and participated in the interviewing and hiring process of the Maintenance Director. The Maintenance Director job description noted, The Maintenance Director is responsible for the overall maintenance of the Facility . ensures the facility, equipment and utilities are maintained in good working order . Ensure equipment . are clean, safe, and orderly . Maintain and repair specialized equipment and machinery . Coordinates maintenance services with all other departments and services . The job description was not signed. On 2/15/24 at 12:40 p.m., the Regional Physical Plant Consultant said the process for checking the lifts is that the equipment should be working to manufacturer's recommendations. If not, it needs to be removed from service. The Regional Physical Plant Consultant said the electronic maintenance checklist said to check the bar on the mechanical lift. He would have expected the Maintenance Director to notice the missing part and identify the lift should not have been in use. He said he was surprised the Maintenance Director did not have more experience with medical equipment. On 2/15/24 at 12:50 p.m., in an interview the Maintenance Director said he previously worked at an Assisted Living Facility and they did not use mechanical lifts. He said when he started employment at the facility, There was no orientation. He said the person who hired him filled out a list by asking him if he knew about different systems like fire alarms and HVAC (Heating, Ventilation, Air Conditioning) but, I don't think it comprised any medical equipment. He said he was told to review the electronic maintenance system and follow the checklists for the inspection and maintenance of the mechanical lifts. He said he did not know the lift used to transfer Resident #1 had a motor at one time. The first time he inspected the lift, he asked a CNA how it worked. The CNA demonstrated by using her feet to open the legs of the base. The Maintenance Director said, I thought it was okay since the staff showed me and did not tell me it was wrong. I did not have enough knowledge to safely assess the lifts. On 2/15/24 at 2:00 p.m., the Administrator verified she did not have any documentation that the Maintenance Director was oriented and knowledgeable to perform his job duties. Said she was unaware that the Maintenance Director didn't have experience checking some of the medical equipment. The Administrator said, Ultimately it is my responsibility as the facility administrator. On 2/16/24 at 2:45 p.m., the DON said the nurses were responsible to supervise the CNAs and nursing leadership was responsible to ensure care is provided safely. He verified the lift used to transfer Resident #1 on 1/22/24 was broken and should not have been in use. He said on 1/22/24 the ADON should have identified the mechanical lift was broken and should not have been in use. When asked how the facility monitored to ensure the CNAs followed safety precautions when using mechanical lifts, the DON said, We only do the skills check, but we have not done any spot check or observe them. The immediate actions implemented by the facility to remove the Immediate Jeopardy, and verified by the surveyor on 2/26/24 included: The Facility obtained the Manufacturers manuals for the three types of lifts utilized at the facility. On 2/16/24 the surveyor verified by review of the manufacturer's manuals for the three types of lifts utilized by the facility. Lift identified from the 1/22/24 event was removed from service 1/22/24. On 2/15/24 the surveyor verified the mechanical lift used on 1/22/24 to transfer Resident #1 was removed from service. The Physical Plant Consultant provided education with the maintenance director related to the maintenance of the mechanical lifts, and the monthly maintenance of mechanical lifts 2/16/24. On 2/26/24 the surveyor verified by review of the education provided to the Maintenance Director and interview with the Maintenance Director. The Physical Plant Consultant provided education to the Facility Maintenance Director related to the removal of faulty equipment from services and implementation of the lock-out Tag-out process 2/16/24. On 2/26/24 the surveyor verified by review of the education provided to the Maintenance Director and interview with the Maintenance Director. The Physical Plant Consultant Educated the Facility Maintenance Director on maintaining mechanical lifts in a safe operating condition 2/16/24. On 2/26/24 the surveyor verified by review of the education provided to the Maintenance Director and interview with the Maintenance Director. The Physical Plant Consultant Inspected the lifts currently in service and determined they were in safe operating condition on 2/14/24. On 2/26/24 the surveyor verified through review of the inspection of the lifts currently in service. The Physical Plant Consultant educated the Director of Maintenance related to the Monthly inspection process for Mechanical Lifts on 2/16/24. On 2/16/24 the surveyor verified through review of the education provided to the Maintenance Director and interview with the Maintenance Director. The Facility Director of Nursing/Designee will provide education to facility staff related to the Lock-out, Tag-out process regarding the removal of faulty equipment and sequestering from the patient care areas which was initiated 2/15/24 and the percentage is 77%. The remaining staff will not work until the education is completed. On 2/16/24 the surveyor verified through review of the education provided to the facility staff using the mechanical lifts. A total of four CNAs, two Licensed Practical Nurses, one Unit Manager and the DON were interviewed. All were able to verbalize understanding of the content of education provided and the process to identify, report and remove faulty equipment from patient care areas.