**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, facility policy review and staff interviews the facility failed to ensure residents needing a mechanical lift were provided safe and appropriate transfers to prevent injuries for 1 of 1 residents reviewed (Resident #54). This failure resulted in the resident falling out of the mechanical lift during a transfer and obtaining injuries and therefore causing an Immediate Jeopardy to the health, safety, and security of the residents. The facility failed to prevent further falls by following the care plan and implemented interventions for 1 of 1 residents reviewed (Resident #70). The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of August 16, 2025 on August 28, 2025 at 10:32 a.m The Facility Staff removed the Immediate Jeopardy on August 28, 2025 through the following actions:Notification to Nursing Staff on private Facebook page. Reminder to staff that if a sling needs readjustment that they need to place the resident back into bed or the chair while making adjustments before proceeding with transfer. Completed on 8/16/2025Education: All nursing staff educated on Smart Lift Operating Instructions. Furnished instructions for review and acknowledgment of understanding by staff. Completed on 8/18/2025. Assessments: All residents utilizing a mechanical lift were re-sized to ensure properly sized slings are being used for each resident. All residents were correctly sized. Notice of correct sling sizing placed by each resident room via a magnet for staff notification. Sizing of slings completed by Unit Managers on 8/27/2025.EZ Lift Slings1.The EZ Lift Slings stay with the resident, and in the resident's room.2.The EZ Lift Slings will be labeled with the resident's name.3. Residents will be sized for correct sling usage according to the sizing guide.4. Re-sizing will occur when needed by the charge nurse/unit managers according to the sizing guide.5. Magnets with matching colors to the sizing guide will be placed outside the resident rooms to identify what size lift sheet to use. EZ Way Sling Sizing Charts placed at each nurses' station. 8/27/2025.Education: Assigned all staff to watch video via CE Solutions (EZ Way Smart Lift Training Video). Assigned on 8/27/2025.Notification to Nursing Staff on a private Facebook page to educate staff on not locking the brakes when lifting or transferring a resident. Those employees that don't have Facebook access education provided with in-person or one-one education. Completed on 8/28/2025 User/Operating Manuals attached to each lift for staff reference if needed along with a reminder to not lock the brakes during transfers. Completed on 8/28/2025Nursing management will randomly monitor staff competency for safe transfers.All PRN nursing staff will be required to watch Training Video before being allowed to work the next scheduled shift. The scope lowered from a J to G at the time of the survey after ensuring the facilityimplemented education and their policy and procedures. The facility identified a census of 68 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #54 documented diagnoses of Alzheimer's Disease, heart failure and anemia. The MDS showed a Brief Interview for Mental Status (BIMS) score was not completed as resident is rarely or never understood. Review of Progress Notes revealed the following: On 8/16/25 at 9:32 a.m., facility requesting patient to be seen in Emergency Department (ED) for evaluation due to fall from mechanical lift that was above that height. On 8/16/25 at 9:38 a.m., Certified Nursing Assistant (CNA) getting the resident out of bed with mechanical lift, they stated there was a kink in the sling that they tried to fix and she fell to the side onto the floor. She did not hit her head, but did hit her left shoulder. On 8/16/25 at 1:11 p.m., new orders received and noted 8/16/25 new diagnosis bilateral sacral body fractures. On 8/16/25 at 1:12 p.m., resident leaves facility via ambulance at 7:45 a.m., to go to the ED. Returns to the facility at 12:10 p.m., via facility van. Review of the medical chart revealed Resident #54's weight on 8/15/25 was 141 pounds. Review of the facility investigation dated 8/18/25 revealed the following information: Resident is dependent on the facility staff for all Activities of Daily Living (ADL's) and require the use of mechanical lift for transfers. On 8/16/25 two CNA's were getting ready to transfer Resident #54. Upon interview with both staff members, they had placed the sling under Resident #54. Attached the appropriate loop device to the hanger bar with the leg portion of the sling crossed and double looped (using the bigger loop as a safety net) in case the first loop failed. After beginning the transfer, they noticed that the hanger bar was not level and that the loop on the right side had moved and folded upon itself. The nurse aide stated that she fell before they could even do anything. The 2nd loop was also unattached. In review of the lift sheet itself it was in good condition with loops not fraying or thinned. The resident was using the appropriate size lift sheet (large) at the time. Resident was sent to the emergency room for evaluation out of precaution. She was not exhibiting any signs of pain or injury at the time of the fall. She did wince with the left arm movement. A CT scan was performed and found to have severe osteopenic disease and closed fracture of sacrum. Review of facility provided report dated 8/16/25 at 7:10 a.m., revealed the following information: Injuries rule out left shoulder sent to hospital for evaluation following fall Under notes witness statement on 8/19/25 at 10:02 a.m., Staff G, CNA and Staff H, CNA revealed the following: We noticed the hoyer was slanted weird at the top, Staff H reached up to fix it and it slipped off the machine. As a result Resident #54 slid out of the hoyer lift and fell to the floor on her left side. We called for the nurse immediately. Review of hospital Discharge Plan dated 8/16/25 at 11:24 a.m., revealed resident had a fall from a mechanical lift at the facility and fell approximately four feet. Following CT imaging revealed bilateral sacral body fractures as suspected. Recommendations based on orthopedic consultation revealed conservative management as the patient is not a surgical candidate. Pain management with existing morphine regimen from nursing home. Review of Major Injury Form dated and signed by the physician 8/18/25 revealed the following information: Resident up in hoyer, kink in sling causing loop to slide off, staff attempted to fix sling. Resident fell out of the side onto the floor. X was marked in front of after reviewing the circumstances, injury, and prognosis of the patient, I believe the injury sustained is a major injury. Interview on 8/26/2025 at 10:15 a.m., with Resident #54's family member revealed the resident had a fall from the mechanical lift. Resident #54's family revealed they had spoken to the CNA that was in the room when the fall happened. Resident #54's family member revealed the CNA was transferring resident with mechanical lift and the other staff was supposed to use a clip for safety before transferring her to her bed and the staff didn't use it and that is what caused the resident to fall from the lift. Resident #54's family revealed the resident went to the ED and the resident had fractures in her lower region but was unsure of exactly where. Interview on 8/26/2025 at 10:56 a.m., with Staff H revealed her and Staff G were assisting resident #54 with the mechanical lift transfer. Staff H explained that they were getting resident up and when they hooked up the hooks to the mechanical lift they hooked up all four hooks onto the lift. Staff H stated the one strap on the front did not get hooked all the way and when noticed that she was going to put the lift back down and it went the opposite way and came unhooked and the resident fell to the floor. Staff H revealed she should have lowered her right back down onto the bed and fixed the hook and re-lifted her up. Staff H revealed the staff do not use a particular size lift sheet size and it was our fault. Staff H explained she had learned her lesson and didn't want this to ever happen again. Interview on 8/26/2025 at 1:08 p.m., with Staff G revealed her and Staff H were assisting Resident #54 with a mechanical lift. Staff G stated she lifted the resident in the mechanical and noticed there was a kink in the sheet. Staff H went to straighten it out and it fell off and the resident fell to the floor. She further revealed the resident was sent to the hospital for an evaluation. Staff G explained she used a large lift sheet underneath her but was unsure of what was under her when they lifted her that day. Staff G explained if a large was not available then she would use a medium lift sheet. She explained the sheets go by dimensions and weight of the person. Observation on 8/27/2025 at 9:57 a.m., of Staff A, CNA and Staff B, CNA assisting resident #54 with transfer from wheelchair to bed. Staff A and Staff B assisted the resident to place the sling underneath her in the wheelchair. Staff locked the wheels on the mechanical lift and hooked up the sling to the mechanical lift. With the mechanical lift wheels still locked, staff lifted resident out of the wheelchair and moved over to the bed and lowered down until comfortable onto the bed. Interview with Staff A and Staff B revealed the staff just picks a sling that fits the resident. Staff A explained the staff just pick a sling that fits the resident and they use a size medium or a size large for Resident #54. Staff B explained the aides usually just try and pick a sling that fits around the resident's shoulder and that's not too big. There isn't a size assigned to the resident that she is aware of. Staff A confirmed there is no book that she is aware of that has a chart to help the staff pick a lift sheet for the resident. Observation on 8/27/2025 at 12:43 p.m., with Staff C, CNA and Staff D, CNA transfer Resident #11 into bed. Staff D told Staff C to lock the wheels on the mechanical lift. Staff C locked the wheels on the mechanical lift and hooked the resident's lift sheet to the mechanical lift. Staff D with mechanical lift wheels still locked raised Resident #11 up and unlocked the wheels and placed him onto this bed. Staff D explained they use a medium lift for this resident as he is not a giant man and it goes around his shoulders nice. Interview on 8/27/2025 at 1:54 p.m., with the Director of Nursing (DON) revealed she understood the situation to have happened as Staff G and Staff H were transferring Resident #54 and the lift sheet came loose and was coming off the mechanical lift and they wanted to push it back down and the sheet came off and the resident fell to the floor. The DON revealed the lift sheets stay with the residents in the facility. The DON confirmed she felt the resident was in the right lift sheet size during the transfer. The DON explained after the fall the facility changed the sling size for Resident #54 to a medium sling as that was a better fit for her. The DON revealed the Business Office Manager (BOM) does the sling sizing for the residents. The DON explained the BOM was a CNA for twenty plus years and she did the sizing but has not had any education regarding how to size the lift sheets. When asking the DON how do the CNA's and other staff members know the appropriate size lift sheet to use for the mechanical list she replied I don't know as there was nothing in writing for them to refer to. Review of the mechanical lift instruction manual with a revision date of 5/5/25 revealed the following information: The wheels of the mechanical lift should never be locked when lifting or lowering a patient. Sling sizing chart within the manual revealed the sling size large weight of the patient range is 190-320 pounds. Review of facility provided policy titled Safe Lifting and Movement of Residents with a revised date of February 2014 revealed the following information: Staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. Enough slings, in the sizes required by residents in need, will be available at all times. Interview on 8/27/2025 at 1:54 p.m., with the DON revealed she felt the facility did everything they could to prevent the fall and she has been doing education since the fall occurred. 2. Resident #70's MDS assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 3, indicating severely impaired cognition. The MDS documented Resident #70 required supervision or touching assistance with toileting (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity). The MDS included diagnoses of dementia, Parkinson's disease and anxiety disorder. Resident #70's fall investigation dated 5/31/25 documented the staff left Resident #70 unattended by staff in the bathroom. When staff returned to Resident #70's room, she was ambulating unattended and fell. The intervention put in place at the time of the fall documented staff to not leave Resident #70 unattended in the bathroom. Resident #70's Care Plan under safety date 5/31/25 directed staff to not leave her unattended and alone in my bathroom. Resident #70's fall investigation dated 7/31/25 documented the resident fell in the bathroom when washing her hands. The Fall Scene Investigation Report completed by Staff G, Certified Nurses Aide documented she left Resident #70 unattended at the bathroom sink to go into the room to get her wheelchair and the resident fell. It further documented the root cause was the resident was left unattended and staff not using a gait belt. On 8/28/2025 at 9:52 AM, the Director of Nursing reported staff are made aware of care plan changes with a care plan alert and it is at the nurses station to follow. Staff should not have left Resident #70 unattended in the bathroom. The facility policy titled Falls-Clinical Protocol dated 8/10/2008 documented staff and physicians will identify pertinent interventions to try to prevent subsequent falls. It lacked documentation of follow up to ensure interventions are being done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, video and record review, the facility failed to account for the whereabouts of 1 of 1 resident reviewed (Resident #16), and failed to ensure that the door alarms were activated. The facility failed to transfer correctly 1 of 1 resident reviewed for a transfer with a sit to stand lift, (Resident #23). On the evening of 5/7/24, Resident #16 used the handicap button, that did not trigger an alarm, to exit through the front door at 7:20 PM. A staff member from the assisted living facility returned him to the nursing home at 10:10 PM. Nursing home staff were unaware that he had been gone for over 2 hours and that he had fallen during his time outside. Staff later found that the alarm to the front door had been turned off earlier that evening. This failure caused an Immediate Jeopardy to the health, safety and security of the residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of May 7, 2024 on August 21, 2024 at 2:15 PM. The facility staff removed the Immediate Jeopardy on August 21, 2024 through the following actions: a. Contractor Knight Protection called to install new alarm system at front door with a key pad and code for anyone exiting the facility. b. Wanderguard System (WGS) was always in working order for those residents assessed to be at risk for elopement. c. Education: Wandering and Elopement in Long-Term Care was assigned to employees. d. Color placard placed at alarm panels at both Nurses' Stations regarding shutting off alarms. e. Employee that turned off the alarm on date of incident was disciplined. f. Director of Nursing had a private message via private FaceBook to nursing employees regarding elopement. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 67 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #16 had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive deficit). He was independent with eating, toileting, dressing, hygiene and walking with the use of a walker. His diagnosis included; seizure disorder, traumatic brain injury, anxiety disorder, and bradycardia. The Care Plan updated on 7/23/24, showed Resident #16 preferred to spend time in his room. Staff were to offer to take him outside to tend to the garden when appropriate. The resident had a history of a traumatic brain injury and had periods of confusion and difficulty organizing his thoughts and communicating needs. Resident #16 had the potential to fall down and get hurt, staff were directed to remind him to ask for help. He tended to lose his balance and would fall or bump into things. On 5/7/24 he had a WG placed to his right ankle and it was removed on 6/19/24. Staff were to monitor for attempts to leave facility and replace if needed. Encourage him to ask for staff assistance if he wants to go outside. Encourage to let staff know when leaving facility with family or friends not to leave facility on his own without staff knowledge. On 8/19/24 at 12:41 PM, Resident #16 was sitting in a recliner in his room. He pointed out at the bird feeder outside his window, and talked about migration of different birds. He said that the staff treat him well, but got in trouble when he went outside without them knowing. He said he wanted to put seed in the bird feeder but nobody wanted to go with him. It was 7:00 at night I sat out there and listened to the birds. He said that he was outside for about 2 hours and then he decided that he better come in because it was getting dark. He said that he was able to leave through the front entrance undetected by hitting the button so the alarm wouldn't go off. A facility investigation showed that on 5/7/24, Staff C Licensed Practical Nurse (LPN) reported that she gave Resident #16 medication at 7:04 PM and he asked her to fill up his bird feeder outside his window. She said she would put in a maintenance request to have that done in the morning. At 10:10 PM, Staff G, Personal Assistant (PA) from the Assisted Living (AL) building brought Resident #16 back to nursing home. He had entered the front door of AL and told Staff G that he needed help finding his room. She then walked him back to the nursing home. At 10:15 PM, Staff C noted that he did not have his walker and he commented to the staff that he went to fix his bird feeder. He was found to have an abrasion to left face, left wrist and both of his knees. At 11:00 PM Staff C went around the nursing home and checked exits and alarms and noted that the front door alarm was bypassed. The resident's walker was found by the front door. A Nursing Note dated 5/8/24 at 2:06 AM, showed that, initially, Resident #16 told the nurse that he hadn't fallen while he was outside. Later, when the nurse noticed a small abrasion to the left side of his face, under his glasses frame, he admitted that he had fallen and had a difficult time getting back up. He also had small abrasions to the left wrist, left knee above and below the knee cap and one to the right knee. An Elopement Risk assessment dated [DATE], showed Resident #16 was not at risk for elopement. An intervention was later added to the document reading: resident did have a WG in place after he went out of the facility without notifying staff, it was intentional that he went outside, and staff is aware to keep track of his whereabouts, WG had been removed. The following signed, written staff statements were included in the facility investigation of the incident from the evening of 5/7/24: a. Staff V, Certified Nurse Aide (CNA) was working that night, giving baths and putting residents to bed. She did not see the resident before he left the building and did not hear any alarms. b. Staff U, CNA did not see the resident or hear alarms. c. Staff W, RN did not see the resident or hear alarms. d. Staff X, Certified Med Aide (CMA) did not hear an alarm or see the resident before he left the building. Further investigation revealed that a family had left the facility around 8:00 PM, and the front door alarm went off. Staff E, CNA, indicated to Staff A that it was all clear and it was okay to turn the alarm off so she switched it off. Staff A thought she had turned it back on. Staff were educated and reminded that door alarms were to be turned on at all times, and hourly rounding was to be completed on resident per facility policy. On 8/20/24 at 6:05 PM, Staff G Personal Assistant (PA) in the AL building said that she was just starting her shift (10p-7a) when Resident #16 came to the South door. She said that it was dark outside, he was able to enter by pushing the handicap button. She asked him if he needed help and he said that he needed help finding his room so she walked him over to the nursing home. The only thing he said to her was it's buggy out there. He didn't say that he fell or what he was doing outside. It was chilly, and he was wearing a short-sleeved shirt, pants and shoes. One of his shoes was untied so she tied it for him. He had glasses on, and seemed to be walking okay without assistance. In an observation on 8/21/24 at 8:49 AM, it was found that the outside area from the front door of the nursing home to the assisted living door was about 500 feet through the grass. There were a couple of hills and a valley with rough, uneven ground. A review of a video from the front door of the facility revealed that on 5/7/24 at 7:20 PM Resident #16 walked to the door with his walker, pushed the handicap button and exited the building. On 8/19/24 at 7:20 PM Staff F LPN said that Resident #16 knew that he could just hit the handicap button and the front door would not alarm. He would go out with family quite often so he knew the routine. He wasn't a risk before, didn't wander or check doors, and he was pretty independent around the facility. On 8/20/24 at 8:45 AM, Staff C, LPN said she didn't know how long Resident #16 may have been outside or where he actually went during that time. She didn't think he ever made it to the bird feeder. When Staff G brought him over from Assisted Living, he said that he hadn't fallen. She took him to his room and helped him into the recliner. That's when she noticed he had a scratch near his eye, it was difficult to see behind his glasses. She noticed his knees were dirty and that's when he admitted that he had fallen. Staff C did not remember hearing an alarm. When the resident had been brought back to the facility, she called the supervisor on duty, and she directed her to go around and check all of the alarms. The northeast nurse station alarm for the front door had been turned off. She did not know how long it could have been off, someone cleared it and didn't turn the switch back on. On 8/21/24 at 5:50 AM, Staff A, CNA, said that she worked the night that Resident #16 got out. She did not see him leave or know that he was gone. Earlier in the evening, the alarm had gone off and another employee had told her it was clear so she shut the alarm off. I thought I turned it back on but apparently not. The other staff member could see the front door and the nurses' station where Staff A was standing, and she gave her the okay to turn it off. On 8/21/24 at 4:30 PM, the Director of Nursing (DON) said that after the incident with Resident #16, she reinstituted the hourly rounding. This was a process where the staff document that all residents are accounted for on an hourly basis. She said that they had used in the past, but most recently, it hadn't been followed. On 8/22/24 at 6:58 AM, the DON said that they had a process for residents and families to sign out so they know where they are, but it wasn't being used and they needed to reeducate staff and families about using that. On 8/21/24 at 3:49 PM Staff Z CNA works PRN. she has worked some evening shifts and from 6-9 PM, most of their time is spent getting residents to bed and it's a very busy time. They try to get to the rounding but sometimes there was just one CNA per hallway and one floater. On 8/21/24 at 3:45 PM, Staff X said that on the overnight/evening shift is a very busy time with getting residents too and from meals, and then getting them ready for bed. From 7 PM-10 PM was the busiest time for resident cares. According to a facility policy titled: Wanderguard System/Door Alarm System, Revised on 8/20/24. The front door was alarmed and you must push the red button to get into the facility. When exiting a code must be punched in before exiting. All door alarms need to physically be checked when sounding to assure that a resident was not leaving and not just turned off at the nurses' station. The policy indicated that staff would perform hourly rounding on residents. 2) According to the MDS dated [DATE], Resident #23 had a BIMS score of 14 (intact cognitive ability). She required substantial assistance with dressing, toileting hygiene, sit to stand and toilet transfers. Diagnosis included diabetes mellitus, anxiety disorder, muscle weakness and chronic pain. The Pare plan updated on 2/7/24, showed Resident #23 used a power scooter for mobility and an EZ stand mechanical lift for transfers. On 8/19/24 at 12:54 PM, Staff Y, CNA prepared to transfer Resident #23 from the wheel chair to the recliner with the Sit to Stand mechanical lift. She attached the sling and strapped the resident's legs to the platform. Several times, she reminded the resident to stand up straight. Once she was in the standing position, Staff Y failed to tighten the belt around the torso. On 8/21/24 at 10:12 AM, the DON said that the staff were taught upon orientation on safe transfers. She acknowledged the risks if/when the buckle on the Sit to Stand was not tightened, especially with a weaker resident. According to the user [NAME] for the Sit to Stand mechanical lift, page 6; as the patient is being raised, simultaneously tighten the safety strap buckled around the torso.