**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews, facility policy review, and observations. The facility failed to provide adequate nursing supervision to prevent accidents and injuries for 3 out of 7 residents reviewed for falls. Resident #2 experienced a fall outside of the facility and was not receiving an appropriate level of assistance. Resident #4 and #37 had a fall from a mechanical stand. The facility failed to use the correct harness and provide the correct level of assistance with transfers. The facility reported a census of 43. Findings include: 1. Resident #2’s Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #2’s MDS included diagnoses of heart failure, hypertension (high blood pressure), diabetes mellitus, anxiety and depression. The MDS coded Resident #2 substantial/maximal assistance, meaning the helper does more than half the effort, the helper lifts or holds the trunk or limbs and provides more than half the effort for toileting transfers. The MDS described Resident #2 continent of urine. Interview with Resident #2 on 07/23/2025 at 10:43 a.m. he stated that he had an appointment in another town approximately an hour and forty minutes away from the facility and was riding in the front seat of the transport vehicle because it was more comfortable for that long of a drive. He stated he didn’t take his wheelchair or his cane per his choice. Resident #2 stated that he had this driver before and had no issues. Resident #2 stated that they had stopped at a gas station on the way because he didn’t think he could make it to the clinic where his appointment was before using the restroom. Resident #2 stated he had been having diarrhea over the last couple of days and thought this was taken care of. Resident #2 stated he was utilizing the rock wall outside of the gas station to walk to the restroom and stated the transport driver was helping him. Resident #2 stated he got dizzy and fell to the ground. Resident #2 stated he hit his head and scraped his right knee. Resident #2 stated they called the ambulance to come get him and take him to the emergency room. Resident #2 stated he never made it into the restroom. Resident #2 stated the facility knew about the diarrhea, he stated he had been taking medication to help with that. Resident #2’s Care Plan with an initiated date of 5/23/25 revealed Resident #2 was at risk for falls related to generalized weakness, dependent on staff for mobility. Resident #2 needed assistance with transfers and ambulation. Resident #2 needed contact guard assist for long distance ambulation, and to utilize a gait belt and cane. Staff to do set up assist and check for accuracy and cleanliness for toileting. Resident #2 needed assistance from one staff member for dressing. Review of the clinical Physician Order’s revealed Resident #2 takes Apixaban (blood thinner) 5mg twice daily by mouth. Review of the Medication Administration Record (MAR) for July 2025 revealed Resident #2 requested Loperamide (antidiarrheal) 2mg to help with diarrhea on 7/8/25 and 7/9/25. Review of the fall risk evaluation through the admission assessment dated [DATE] revealed Resident #2 had a history of falls. The facility Progress Notes dated 7/10/25 at 8:45 a.m. revealed Resident #2 left the facility for an appointment with a transport car to go to a doctor’s appointment. The Facility Incident Report (IR) documented in the Progress Notes on 7/10/25 at 10:33 a.m. revealed the facility received a call from a friend of Resident #2 informing the facility Resident #2 had a fall attempting to utilize a restroom at a gas station on the way to his appointment. Resident #2 was transported to the emergency room for further evaluation. The emergency room nurse reported Resident #2 was ambulating into a bathroom and felt dizzy leading to a fall. Per the Incident Report Resident #2 was to have contact guard assist (a therapist or caregiver provides occasional physical support, like light touch, to help a patient with balance or stability while they perform a task, but the patient is mostly doing the work themselves) with long distance ambulation, a gait belt and cane. The intervention documented is to have a staff member accompany Resident #2 to appointments. Review of the emergency department’s final report dated 7/10/25 revealed Resident #2 presented to the emergency room (ER) via Emergency Medical Services (EMS) for presyncopal (the sensation of lightheadedness, dizziness, or feeling faint without actually losing consciousness) episode, while ambulating in the bathroom had a bowel movement and became lightheaded. Resident #2 noted he had several loose stool bowel movements over the course the past couple days and had been having this paroxysmal (something that occurs suddenly and intensely, often in a recurring or periodic way) on and off diarrhea for the past few weeks which he had taken medication for however patient is unable to recall the medication. Resident #2 complained of acute, focal, persistent mild pain along the right chest, hip and leg. Resident #2 confirmed hitting his head. Resident #2 received a left posterior scalp dense subcutaneous hematoma (localized collection of clotted blood beneath the skin, often appearing as a raised, firm, and painful lump. It is a more significant form of bleeding than a typical bruise, involving larger blood vessels and a more substantial amount of pooled blood) measuring 2.1 x 1.4 x 0.7 centimeters (cm). Interview with the Administrator on 07/23/2025 at 11:19 a.m. revealed the nurses made the appointment for Resident #2, he utilized the medicaid transportation and the appointment is longer than 30 miles from the facility. The Administrator stated that they take into consideration the type of appointment, how long the resident will be gone and if they are going to need to utilize the restroom to determine if they need to send a staff member along. Review of the facility’s policy named Fall Occurrence revised 2/2024 revealed it is the policy of the facility to ensure that residents are evaluated for fall risks and implement interventions to minimize risk for falls and/or risk for injury from falls. A Fall Risk Assessment is completed by the nurse upon admission, readmission, and as necessary. Based on assessment, interventions are implemented and placed on a care plan. An incident report will be completed by the nurse each time a resident has a fall. Residents will be assessed by a licensed nurse prior to being moved after a fall. The nurse will notify the physician and resident representative. Additional intervention(s) will be implemented post fall. Interdisciplinary Team (IDT) may change the intervention(s) if IDT investigation identifies a more appropriate intervention for the individual fall. The resident’s care plan will be updated with any new or revised intervention(s). Neurological assessment will be initiated for unwitnessed falls and/or falls that are witnessed and resident hits their head (neuros completed as directed on neuro flowsheet) Documentation and monitoring to be completed for 72 hours post fall. The Administrator reported the facility does not have a transportation policy. Interview with the Administrator on 07/24/2025 at 1:13 p.m. revealed the only Incident Report is in the Progress Notes and the root cause is the driver broke procedure/protocol and stopped for Resident #2. The Administrator stated the drivers are not supposed to stop. The Administrator stated they do not have a contract with this company, it is all done through the Managed Care Organization (MCO). The Administrator stated the driver is a friend of Resident #2, so they will be sending a staff person with him from now on. The Administrator stated this fell back on the facility anyway even when the driver broke protocol. 2. According to the Minimum Date Set (MDS) assessment dated [DATE], Resident #1 scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident exhibited a functional limitation in Range of Motion of both lower extremities. The resident was dependent on staff for toileting, and required substantial/maximal assistance with rolling in bed, and transfers, and did not walk. The resident's diagnoses included a need for assistance with personal care, morbid obesity, and lymphedema. The resident had no falls since the previous assessment. The Care Plan with a goal target date of 8/17/25 identified the resident at risk for falls related to generalized weakness, and depending on staff for transfers. Interventions included the new sling for the sit to stand (lift)in house. The Care Plan identified the resident required assistance with activities of daily living (ADL's) related to weakness, and a history of falling. Interventions included transferring with substantial/maximal assist of 2 staff members. Sit to stand with assist of 2 per physical therapy (PT) 2-3-25. The Progress Notes dated 5/2/25 documented a CNA paged the Nurse to the resident's room where they noted the resident on the floor with the sit to stand lift in front of her, and the aide holding her back up. The CNA reported the resident slipped out of the sling by lifting her arms up. The Nurse noted the belt on the sling clasped together like it should be. The CNA reported the resident did not hit her head. The resident was incontinent of bowel at the time. They helped the resident off the floor by the Nurse and the CNA with the use of the gait belt, and placed in her recliner. Preliminary Recommendations for consideration as further preventative measures included use of the hip sling when using the sit to stand with the resident. During an observation on 7/22/25 at 9:40 a.m. Staff C, Licensed Practical Nurse (LPN) and Staff D, Certified Nursing Assistant (CNA) placed the sit to stand lift up to the resident, hooked the lift sling to the lift on the harness hooks, with no safety tabs. Staff hooked the safety strap in front of the resident and tightened. They had the resident hold onto the handles and lifted, and rolled to the recliner and sat down. During the transfer, staff used the gray sling. On 7/22/25 at 1:24 p.m. Staff E LPN stated she recalled the incident with the resident. She said when she got to the room, the resident was on the floor and the sling off. The CNA told her the resident slipped through when she raised her arms up. She said the waist belt was clasped together, but she didn't know if it had been tightened. She didn't know how she would have slipped through if it was snug. She said the new intervention was the use of a hip sling. She said no education was provided. She did not know of any other incidents with the lift, or any other incidents with the staff involved. On 07/22/25 at 3:03 p.m. Staff F CNA stated he was assisting the resident with the sit to stand lift from the commode. He cleaned her and pulled her pad up and tried to get the commode back under her because she was weak. She let go of the handles of the sling and put her arms up and slipped through the sling up to her head and neck. He said he lowered her with the sling. He thought he used the green sling. He said he received no education after the incident. They were to have 2 staff with transfers with the the lift for this resident. He did not know about a different sling to use with her after the incident. The sit to stand lift Operator's Instructions revised 3/11/09 documented: Attaching the harness to the sit to stand included with the lift arm in the lowest position, attach the harness to the hooks at the end of the sit to stand lift arm using the loops at the end of the harness. The manufacturer suggested the following components and operating points be scheduled for inspection at intervals not greater than a month. Any detected deficiency must be rectified before putting the stand back into service. Safety tabs need to be checked to make sure they were installed correctly, not missing or torn. 3. Resident #37 MDS dated [DATE] identified a BIMS score of 15, which indicated intact cognition. The MDS identified Resident #37 required substantial/maximal assistance with all transfers. The MDS documented Resident #37 was non-ambulatory. The MDS included diagnoses of cerebral palsy (abnormal development or damage to the area of the brain that controls movement, balance and posture), anxiety, depression and hypertension (high blood pressure). The Care Plan with a target date of 9/10/25 documented Resident #37 required assistance with activities of daily living (ADL’s) and was at risk for falls due to diagnosis of cerebral palsy. The Care Plan directed staff to use a sit to stand lift for all transfers. A Progress Note titled Incident Report dated 6/22/25 at 11:38 PM documented Staff C, Licensed Practical Nurse (LPN) was called into Resident #37’s room by Staff F, Certified Nursing Assistance (CNA). Upon entering the room Staff C observed Resident #37 lying on the floor on her left side with a pillow under her head next to the sit to stand lift. According to the note, the sit to stand lift sling belt was around Resident #37’s waist and the straps were disconnected. The note documented when Staff F lifted Resident #37 with the sit to stand lift, the first strap of the two straps that were connected slid causing the Resident #37’s left side to drop a few inches. Staff F then lowered Resident #37 to the ground and placed a pillow under her head. The note documented further preventive measures were to assess the sit to stand lift and use the gray sling. The green sling was placed at the nurses station to be assessed further. A Progress Note dated 7/1/25 at 8:51 AM documented Resident #37 was seen for a 60 day recertification visit by her Physician. The note documented Resident #37 reported she was lowered to the floor. Resident #37 complained of continued left thigh pain and pain when standing. The note documented new orders were received to obtain left hip/pelvis x-ray due to diagnosis of fall/pain. A Progress Note dated 7/6/25 at 2:14 PM documented the facility received signed x-ray results of Resident #37’s femur/pelvis with no acute abnormalities. On 7/21/2025 at 2:01 PM, Resident #37 reported a couple weeks ago she had a fall from the sit to stand lift. She reported she thought something had happened with the equipment and the sling had slipped off from the stopper. She said she was lowered to the floor. Resident #37 said she had x-rays done and there were no fractures. On 7/22/25 at 9:30 AM, observed a sit to stand lift in the hallway by Resident #37’s room with two different slings made by two different manufacturer’s lying on top of the machine (one sling was gray in color and the other sling was blue). Observations of the slings revealed they were not made by the same manufacturer as of the sit to stand lift. The tag on the gray sling was dated 6/13/25 and directed the sling only to be used with lifts that were made by the same manufacturer. The tag on the blue sling was not dated, worn and very hard to read. On 7/22/25 at 9:50 AM, observed Staff A, CNA and Staff B, CNA transfer Resident #37 with the sit to stand lift. They placed a gray sling behind Resident #37’s back and then fastened the safety belts around Resident #37’s waist and legs. They then hook the sling onto the harness hooks and raised the sit to stand lift up while Resident #37 held onto the handle with her left hand. The safety belts loosened around the waist and legs while Resident #37 was raised up and the CNAs did not adjust or tighten the belts. They positioned Resident #37 with the sit to stand lift in front of the commode, pulled down her pants, removed the incontinence brief and then lowered her onto the commode in a sitting position. Observation revealed the gray sling used during the transfer was not manufactured by the same company as the sit to stand lift. On 7/22/25 at 1:26 PM, Staff F, CNA reported he had put the sling under Resident #37's arms and hooked the sling to the sit to stand lift. He said the sit to stand lift had rubber boots on the handles. He said he thought the straps must have gotten stuck on the rubber boot. He said when he stood her up she started to fall as the straps on the left side of the lift became unhooked and came off the ring. He stated that he had not double checked the straps before standing the resident up. He said the belt around the waist was attached and pulled tight. He reported that he did not have the leg strap in place. He said he lowered Resident #37 to the floor using the sit to stand lift. He said he has never had any issues before using the sit to stand lift before. When asked what type of sling was being used during the incident, he said it was a gray sling with rubber grip and padding under the arms. He said it was one of the new slings that the facility had gotten in because the old slings were bad and not in good shape. On 7/22/25 at 2:30 PM, the Administrator reported after Resident #37 had a fall involving the sit to stand lift, she walked around the facility to make sure the staff knew how to use the sit to stand lift and she thought they did. The Administrator reported the facility had gotten new slings for the sit to stand lifts recently. When brought to the attention of the Administrator that the new slings were not the same manufacturer as the sit to stand lifts, she said that the slings worked with the machines. When asked what the facility expectation was with following the sit to stand operator’s manual, she said she would have to check with Corporate to see what they wanted her to do. She said she felt the sit to stand operator’s manual was a recommendation. On 7/22/25 at 2:48 PM, Staff G, Nurse Consultant reported the facility was going to order the correct slings for the sit to stand lifts. She said the staff would use the mechanical full body lifts for transfers until the new slings arrived. The sit to stand Operator’s Instructions revised 3/11/09 documented the manufacturer’s sling/harnesses are made specifically for the sit to sand lifts. The operator’s instructions documented for the safety of the resident and caregiver, only the slings/harness made by the same manufacturer as the sit to stand lift should be used. In addition, the operator’s instructions, directed when transferring a resident, for the safety of the resident, securely fasten the safety strap around the resident’s torso and pull the strap to tighten. As the resident is being raised, simultaneously tighten the safety strap buckled around their torso.