**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 23 residents. The sample included 12 residents with seven residents reviewed for falls. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 4 remained free from a preventable accident during a sit-to-stand mechanical lift transfer. This deficient practice resulted in a fractured finger and placed R4 at risk for further complications. Findings included: - R4's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, low back pain, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest),dementia (a progressive mental disorder characterized by failing memory and confusion), paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented R4 had limited function in bilateral extremities. The MDS documented R4 was dependent on staff assistance for toileting, bathing, lower extremity dressing and transfers. The MDS documented R4 had no falls since the MDS dated [DATE]. R4's Falls Care Area Assessment (CAA) dated 08/15/24 documented he had a fall that resulted in a fractured finger. R4's fractured finger was noted two days after his fall. R4's Care Plan dated 07/24/22 documented staff would rearrange his current room to be exactly like his previous room to avoid falls and confusion. The plan of care dated 05/22/23 documented staff were educated on bed positioning. R4's plan of care dated 07/24/24 documented staff were educated on sling and lift placement with the sling. R4's EMR under the Clinical Documentation tab recorded a Note dated 07/24/24 at 06:30 AM that documented R4 had to be assisted to the floor during a transfer with a sit-to-stand mechanical lift. The sling had become unhooked from the sit-to-stand lift on the right side during the transfer. R4 complained of pain to his ring finger on his right hand. R4 was able to complete active range of motion to the finger on his right hand without difficulty. A Note dated 07/24/24 at 09:30 AM documented R4's ring finger on his right hand started to swell and bruise. A Note dated 07/24/24 at 05:49 PM documented R4 continued to complain of pain in his fourth digit on his right hand. That finger had been caught in the sling during the fall from the sit-to stand lift that morning. R4's finger was red and swollen. R4's finger was bruised on the inner part and was bruised and swollen greater than the other finger on his right hand. The licensed nurse decided R4 would need an X-ray to rule out a possible fracture of his finger on the right hand. A Note dated 7/24/24 at 11:44 PM documented R4 continued to complain of pain in his fourth digit on right hand. R4's finger remained bruised. A Note dated 07/25/24 at 10:13 AM documented R4's ring finger on his right hand remained swollen, bruised, and he continued to complain of pain. A Note dated 07/25/24 at 03:50 PM documented R4 returned from an appointment with the physician and was waiting for the results of an X-ray of R4's right hand. A Note dated 07/25/24 at 06:06 PM documented the physician recommended to tape R4's ring finger on his right hand to the next finger to prevent bending his finger till the x-ray results came back. R4 continued to complain of pain in his finger on his right hand. A Note dated 07/26/24 at 10:59 AM documented the physician's office called with x-ray results that revealed a fracture to the fourth digit of his right hand. The physician wanted R4 to return to the clinic and be fitted for the correct splint. An undated and untitled form provided by the facility documented the sling had come loose during a transfer with the sit-to-stand lift for R4 and that resulted in a fall. The form documented the root cause was one of the hooks of the sling gave way and that caused R4 to slide out of sling. The analysis noted that it was apparent that staff did not fully loop the hooks on the sling to the right-side causing the resident to fall. On 10/24/24 at 08:44 AM R4 sat in his wheelchair on the back patio smoking. On 10/24/24 at 09:13 AM, Certified Nurse Aide (CNA) M stated she had been trained on how to safely use the mechanical lifts by another CNA. CNA M stated a resident's weight determined the size of sling and placements of the sling loops on the mechanical lifts was determined by the comfort of the resident. CNA M stated the only way she could think the sling would come loose from the lift was if it was not placed on the lift correctly. On 10/24/24 at 09:35 AM, Licensed Nurse (LN) G stated all mechanical lift transfers are always completed with two staff members. LN G stated the facility provided in-services on lifts. LN G stated the staff train each other on the transfers for each resident. LN G stated the therapy department would determine the placement of sling loops on the mechanical lift. On 10/24/24 at 10:00 AM, Consultant Staff GG stated she would train the staff on safe transfers when a resident started to use a mechanical lift. Consultant Staff GG stated she believed the sling loop had not been placed on the sit-to-stand lift correctly and that is why it had slipped loose during R4's transfer on 07/24/24. On 10/24/24 at 10:44 AM, Administrative Nurse D stated the nursing staff had received yearly skills fair to go over the mechanical lift transfers. Administrative Nurse D stated the current nursing staff did train the new nursing staff members on the resident's transfers during their training. Administrative Nurse D stated the therapy department did provide education and training on safe transfers with the mechanical lifts. The facility's Safe lift, Transfer, and Repositioning Policy last revised 07/01/24 documented it was the policy of this facility to provide safe, appropriate and timely care to each elder in accordance with the eider's comprehensive care plan. All elders would be assessed by the Interdisciplinary Team (IDT) with regard to the need for assistance with transfer activities, mobility, or repositioning in accordance with the Resident Assessment Instrument (RAI) procedures and requirements. Subject to IDT determinations regarding rehabilitation, restoration, or maintenance of functional abilities, or medical contraindications or emergencies or other exceptional circumstances. Elders identified as totally dependent or extensive assistance would be transferred by means of mechanical lift equipment and/or other assistive devices rather than by manual lift. All mechanical lifting devices always required two-person assistance without exception. The nursing supervisors would ensure that mechanical lifting devices and other equipment/aids are accessible to staff. Nursing and environmental services supervisors would ensure that mechanical lifting devices and other equipment/aids are maintained regularly and kept in proper working order. All mechanical lifting devices would be checked on a weekly basis with findings documented on the maintenance log. Nursing supervisors and staff would ensure that mechanical lifting devices and other equipment/aids are stored conveniently and safely. The facility failed to ensure R4 remained free from a preventable accident during a sit-to-stand mechanical lift transfer. This deficient practice resulted in a fractured finger and placed R4 at risk for further complications. The facility completed the following corrections by 07/24/24: The facility updated R4's Care Plan on 07/24/24. Physical Therapy (PT) provided staff education for Safety Steps when using Patient lifts to CNA staff on 07/24/24. Because the facility implemented and completed the corrections prior to the onsite survey, this deficient practice was cited as past noncompliance at a G scope and severity.