**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to comprehensively assess environmental hazards and/or ensure the environment was free from accident hazards for 1 of 3 residents (R1) reviewed for falls. The facility's failures caused actual harm when R1 tripped and fell on a mechanical lift which resulted R1 suffering multiple rib fractures with hemothorax, unstable T11 fracture, and a large laceration to her elbow. Findings include: R1's admission Record dated 4/17/24, identified R1's diagnoses included dementia with other behavioral disturbance, Hospice care, muscle weakness, unsteady gait, impaired safety awareness, and history of falls. R1's admission Minimum Data Set (MDS) dated [DATE], R1 required limited assistance for activities of daily living (ADLs), and mobility and had severe cognitive impairment. R1's care plan initiated 4/1/25, indicated R1 had a history of falls, impaired safety awareness, and unsteady gait. Staff interventions included providing assistance with mobility/ADLs. R1's fall risk assessment completed 4/1/25, indicated R1 is a high risk for falls related to muscle weakness, cognitive impairment, unsteady gait, and impaired safety awareness. R1's progress note dated 5/20/25 at 10:50 p.m. indicated R1 appeared to trip on a mechanical lift parked against a wall outside of her room as she turned the corner out of her room with her walker, attempting to ambulate independently. The note indicated R1 fell on her left side sustaining a large skin tear to her elbow, upper arm, and part of forearm with left side. R1 complained about ribs pain. R1's emergency department (ED) note dated 5/20/25 at 11:47 p.m. indicated R1 presented to ED for ground level fall with trauma, multiple or serious injuries. The note stated exam revealed laceration of left elbow, which was not amenable to repair, chest wall tenderness and left sided rib fractures. R1's progress note dated 5/21/25 at 2:21 a.m., indicated R1 was admitted at the hospital with multiple ribs fracture to her left side, hemothorax ( a condition where blood accumulates in the space between the lung and the chest wall) to her right side and an unstable spinal fracture to T11. During an interview on 6/17/25 at 10:51 a.m., a family member (FM)-A stated she turned and saw R1 when she was falling down just outside her room. FM-A stated R1 had a walker, and her back hit part of the mechanical lift parked a foot or two from her doorway against the wall. During an interview on 6/17/25 at 11:09 a.m., FM-B stated R1 walked right outside of her room and her walker got caught by the mechanical lift parked right outside her room against the wall a foot from her doorway when she fell on the lift. During an interview on 6/17/25 at 12:52 p.m., nursing assistant (NA)-D stated she witnessed R1's fall and stated R1 landed with her left side on the mechanical lift which was one or two feet from her doorway. NA-D stated nursing staff did not have a designated spot to park the lifts and she did not recall receiving any education about environmental safety hazards. During an interview on 6/17/25 at 2:54 p.m., licensed practical nurse (LPN)-A stated on 5/20/25 R1 fell on the legs of the mechanical lift with her left side and started bleeding heavily. LPN-A stated R1 was one person assist with mobility and supervision. LPN-A did not recall receiving any education about environmental safety hazards after the incident. During an observation on 6/16/2025 11:37 a.m., a mechanical lift was observed parked against the wall less than a foot just outside of R5's doorway. During continuous observation, another mechanical lift was parked against the wall of R4's room with two wheels visible in R4's doorway. At 11:45 a.m., an unknown nursing staff member was noted to be in the hallway moving back and forth from the nursing station walking by the lifts. During an interview on 6/16/25 at 1:32 p.m., NA-A stated nursing staff have been trained on how to use the mechanical lift during their orientation. NA-A stated she was educated to put the mechanical lift on the right side of the hallway, against the wall between residents' rooms during her orientation. NA-A stated she did not receive any education about a designated spot to park the mechanical lifts. NA-A stated nursing staff had to use their own judgment to put the lift in the middle against the wall to prevent any accident. NA-A did not identify the lift parked against the walls in the hallway as a safety and/or tripping hazard. During an interview on 6/16/25 at 2:17 p.m., NA-B indicated sometime between new employee orientation but before R1's accident, she was trained only to park the mechanical lift on the right side of the hallway against the wall facing one way. That training did not address any specific spot the lifts should parked other than the right side of the hallway. NA-B explained after R1's fall nursing staff did not receive any education pertaining to the storage of lifts and/or where in the hallway they should be parked and did not identify the lifts in the hallway a safety hazard for residents. During an interview on 6/17/25 at 10:23 a.m., NA-C stated she was directed to put the mechanical lift locked against the wall on the right side, using common sense not to put it on the resident's doorway. NA-C stated she did not receive any environmental safety hazard education recently. During an interview on 6/16/25 at 4:10 p.m., LPN-A stated nursing staff were supposed to park the mechanical lift on the right side of the hallway against the wall without blocking or inside the egress of the resident's doorway. LPN-A stated night shift should put them in the tub room if they were not using them, but nurses have to use their own judgment about putting the lift on the hallway. During an interview on 6/17/25 at 10:43 a.m., LPN-B stated they did not have a specific spot to put the mechanical lift as long as it was not blocking the doorway. LPN-B stated she did not recall receiving any environmental safety hazard education recently. During an interview on 6/17/25 at 9:46 a.m., a registered nurse (RN)-A stated after using the lifts, nursing staff have to put it at a safe location not blocking the hallway. RN-A stated he did not receive any direction about parking the lift at a designated location. During an interview on 6/17/25 at 1:25 p.m., RN-B stated she was responsible for training nursing assistants upon hire and she was part of the safety committee. RN-B stated she did provide training at the facility skills fair last week including how to use the mechanical lift, however she did not provide environmental safety hazard education to the nursing staff recently. Nursing staff were directed to park the mechanical lift on the right side of the hallway against the wall. No specific education pertaining to R1's incident had been provided, and no audits regarding how lifts have been parked properly in the hallway was conducted. During an interview on 6/17/25 at 3:19 p.m., the director of nursing (DON) stated R1 was a high risk for falls and was having increased confusion due to her dementia condition. The interdisciplinary team (IDT) did root cause analysis after the incident but did not consider the placement of the mechanical lift as a contributing factor in the incident. DON stated she did not do anything to address the mechanical lift parked in the hallway as a potential fall hazards or try to figure out a different safe location to store them after its used. DON explained she had not provided any environmental safety hazards education to the staff or audits regarding the residents' ability to safely maneuver around the mechanical lift in the environment for ambulatory residents who independently used assistive devices. During an interview on 6/17/25 at 3:52 p.m., the administrator stated during the IDT meeting they discussed R1's fall incident and determined it was related to R1 increased weakness and confusion but did not consider the lift as contributing factor to her injuries. The administrator stated R1 sustained injuries when she fell on the lift. The administrator stated the facility procedure was to park the mechanical lift on the right side of hallway against the wall because of a lack of storage. The administrator stated they met every morning with IDT and discussed many items including falls and their Quality Assurance and Performance Improvement (QAPI) meeting was scheduled for 6/20/25. The facility Environmental Hazards Policy dated January 2012 and revised in November 2020, indicated the facility shall maintain a safe, clean and orderly interior and directed staff to survey their assigned work area routinely to ensure a properly maintained, safe clean and orderly environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure fall interventions were implemented as care planned to prevent falls for 1 of 2 residents (R1) reviewed for accidents. This resulted in actual harm when R1 fell from a toileting sling and was diagnosed with a left shoulder fracture. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had hemiplegia and anxiety. The MDS indicated R1 was cognitively impaired, did not reject care, transferred with extensive assist of two, was always incontinent of bladder and frequently incontinent of bowel. The MDS further indicated R1 had occasional pain and had one fall with major injury since admission. R1's Care Plan dated 10/3/22 , indicated R1 was at moderate risk for falls related to weakness, needed assistance with mobility, diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side. The care plan indicated R1 used a bed pan for toileting until toileting sling use was re-assessed for proper fit. A Resident Abuse/Neglect Investigation Report Form completed by the facility on 10/03/22, indicated on 10/03/22, at 3:30 p.m. R1 was being transferred from commode to wheelchair using Hoyer lift and toileting sling when R1 started to slide out of sling and fell to the floor. The report indicated R1 had left shoulder pain with movement and denied other pain. The report indicated no neglect or abuse was found and care plan, policies and procedures were followed and facility was re-evaluating type of sling used, but sling in place was correct for lift and toileting. A Fax Form from the facility dated 10/03/22, at 4:23 p.m. to R1's physician indicated, at 3:50 p.m. R1 was being lifted with the hoyer lift using the toileting sling. When they were getting ready to lower her back to her wheelchair the NARs noticed R1 was slipping and before they could get the chair under her, she fell to the ground. R1 was assessed and stated her back, shoulder and head hit the ground. After being assessed, R1 was lifted to her bed using a hoyer lift and full body sling with compliants of pain in left shoulder with movement. She also complained of level 4 pain in left lateral thigh/lower flank area. There was a L shaped bruise in that area. Review of physician response fax was to monitor and update. An Office Visit note dated 10/06/22, indicated R1 was seen, had x-rays and was found to have a fracture of the left humeral neck (shoulder fracture). The note indicated an order for an arm splint and follow up in a week. Increased Tylenol to 1,000 milligrams (mg) TID (three times a day) for the next week and resume current dose. A CentraCare Clinic fax dated 10/07/22, indicated R1 continued to have increased left shoulder pain and Tramadol (used to treat pain) 50 mg one tablet every 6 hours as need. Review of Occupational Therapy (OT) and Certified Occupational Therapy Assistant (COTA)-A notes dated 8/19/22 through 10/04/22, indicated the following: On 8/19/22, OT indicated patient was educated on benefit of trial with toilet sling for toileting. On 8/22/22, staff CNA (certified nursing assistant) training to continue use hoyer transfers with toilet sling during use of commode. Patient completes transfers with assist of two. Occupational therapy (OT) updates toilet sling transfers, criss crossing leg straps for improved bilateral lower extremity stability. On 9/07/22, OT indicated concerns from staff over the weekend with patient use of toileting sling. Consulted with licensed practical nurse (LPN)-A and NA-K regarding incident, [FM]-A present reporting staff were not using the toileting sling. The note indicated social services was informed of FM-A concern. In addition the note indicated the director of nursing (DON) was looking into larger slings for R1. On 9/12/22, COTA-A indicated writer collaborates with nursing regarding toilet transfers. Writer provided staff training to use toilet sling crossing leg straps for improved security. On 9/21/22, COTA -A indicated writer consulted with NA-K and night staff concerns of poor safety using toileting sling. NA-K reported concerned with R1's posture in toilet sling during the night with increased fatigue. The note then indicated R1 was able to maintain posture in toilet sling during the night and OT will upgrade Functional Maintenance Plan (FMP) and RN education and collaboration regarding toileting task using the bed pan. R1's Rehab Visions Occupational Therapy report also known as Functional Maintenance Plan (FMP) dated 9/26/22, indicated R1 toileted with assist of two, toileting sling, and bedside commode. Use of bed pan as need (PRN). During observation and interview on 1/03/23, at 9:35 a.m. R1 was lying in bed and stated she had no pain. R1 stated she preferred to use the bedpan instead of the toileting sling. R1 then wanted to have her family member involved in the conversation so R1 used her [NAME] device (virtual assistant technology) and called (FM)-A. FM-A stated he was informed the facility felt the cause of the fall on 10/03/22, was due to R1's left arm slipped through the toileting sling and then fell to the floor. FM-A stated he was upset because after the fall R1 no longer received therapy and she became private pay. FM-A stated he wanted R1 to use the commode and hoped she would eventually be able to come home. FM-A stated he was not informed R1 was experiencing fatigue in the evening, but some of the staff would not want to use the sling. He encouraged them to use it since he felt it was painful for R1 to use the bed pain. During interview on 1/03/23, at 12:20 p.m. COTA-A stated she assessed R1 during the day and had no concerns with transfers using the toileting sling, but did not look at R1 later in the day or evening when staff expressed concerns with fatigue. COTA-A stated she was aware R1 had weakness later in the day and added to R1's functional maintenance plan (FMP) to use the bed pan as needed (PRN) instead of toileting sling and commode for safety. In addition, COTA-A stated she trained the staff on the floor on how to use the toileting sling on R1 if they communicated they had concerns. When asked if there was any training documentation, COTA-A stated she did not record the individual training's. During interview on 1/03/23, at 2:00 p.m. nursing assistant (NA)-A stated she had been working at the facility for over two years and always used the bed pan for R1's toileting needs and was never aware R1 used the toileting sling. During interview on 1/03/23, at 2:06 p.m. registered nurse manager (RN)-A stated she was aware the staff were reporting they were uncomfortable with using the toileting sling with R1 so she referred the concerns to the therapy department and felt if they assessed R1 to be safe using the toileting sling, then she felt it was safe. RN-A stated after R1 fell on [DATE], they were no longer using the toileting sling. RN-A confirmed, previous to the fall, she was not aware of PRN order to use bed pan if R1 was fatigued. During interview on 1/03/23, at 8:13 p.m. NA-B stated prior to R1's fall they used the toileting sling and felt it was small and R1's arms would go into the air. In addition, NA-B stated R1 would get tired in the evening and this had been reported to the nurses working. NA-B added, even though he voiced concerns of safety with the sling, he had not received any training on using the toileting sling with R1 and so would try to avoid the sling at any cost and just use the bed pan. NA-B stated he was not aware of the order to use the bed pan PRN if R1 was fatigued. During interview on 1/03/23, at 8:44 p.m. NA-C stated I would not transfer [R1] using the toileting sling, it would pinch at the wrong angles and was not a big fan of the sling. During interview on 1/03/23, at 8:45 a.m. NA-D stated she was the NA working when R1 slipped out of the sling. NA-D stated the sling was too small and R1's legs started to slide out, even though the straps around the legs were criss-crossed, her bottom was sliding down. NA-D stated she thought they used the biggest toileting sling they had and was never told it was too small until after the incident. NA-D stated when the incident occurred she was new to working at the facility and was trained on the B-wing not the A-wing where R1 was on. During interview on 1/04/23, at 9:40 a.m. DON stated, they checked the sling and R1's weight and according to the chart the toileting sling was appropriate for R1. The DON stated she felt the incident occurred because R1 pulled her arm in and out of the sling, slid out, and fell. Since the incident they have been using the bed pan. During interview on 1/04/23, 12:32 p.m. NA-F stated to be honest I was never aware [R1] used a toileting sling and was never trained. NA-F stated she worked evenings and they had a lot of new staff and there had been no formal training on how to use the sling on R1. During interview on 1/04/23, at 1:24 p.m. NA-G indicated she worked evening shifts and had been at the facility for over two years and never used the toileting sling on R1. NA-G stated she had heard staff state they were uncomfortable using the toileting sling. During interview on 1/04/23, at 1:33 p.m. NA-H stated she worked the evening shift and when she would use the toileting sling R1's arms and body would sink into the sling. It didn't look right and was too small. NA-H stated she reported to the nurses, but therapy wanted us to use the toileting sling and it was on our Nursing Assistant Care Sheet to use the toileting sling. NA-H stated she was not surprised after a short leave and then returning to find out that R1 had slid out of her sling. In addition RA-H stated even though she reported her concerns to the nurses she never received any training or direction on transfers for R1 when she became fatigued and felt the new staff should all be trained on the proper way to complete transfers so the residents were safe. During interview on 1/04/23, at 5:00 p.m. NA-I stated she worked the evening shift. When she transferred R1, the sling around her back did not fit her and she would just leave the leg straps un-crossed because she did not want to pinch her legs. NA-H further stated they communicated concerns to FM-A and nursing staff, but FM-A insisted they use the toileting sling for R1 and not the bed pan. During interview on 1/04/23, at 6:08 p.m. NA-D stated when she was transferring R1 she was not aware she could have used the commode (PRN when fatigued) and R1 probably slid through her toileting sling because she was tired and weak. During interview on 1/04/23, at 6:18 p.m. NA-J stated her and NA-D were the ones that transferred R1 when she slid out of her toileting sling adding, they knew her left arm had weakness and that when her arm slid through the sling, R1 could not hang on and fell to the floor. NA-J stated R1's weakness could have been the cause of her fall. NA-J added that they no longer used the toileting sling and used the bed pan for safety. During interview on 1/05/23, at 9:38 a.m. DON stated the COTA-A would train the staff working on the shift when she was there but not all 79 staff. In addition, DON stated she did not understand why the two staff working with R1 did not know they could have used the bedpan the day of her incident since it was listed on her resident care sheet and they should be looking at that every day. In addition she was unaware who the COTA-A discussed the use of the bed pan with when R1 was weak according to the therapy note on 9/21/22, since she spoke to her nurse manager and the nurse manager was never informed of the collaboration that was listed in the COTA's documentation. In addition, the DON stated the FMP and care plan should have addressed the reason for using the bed pan for weakness and not just stating it was used PRN. The facility was unable to provide documentation of communication or education provided to staff regarding changes to R1 care plan. Although therapy had recommend using the bed pan when R1 was weak or tired and revised care plan treatment on 10/03/22, the facility staff were unaware of the intervention and transferred R1 using the toileting sling which resulted in a left humorous fracture. A facility policy Fall Protocol dated 9/2022, indicated Realizing that not all falls can be prevented that the elderly population have multiple predispositions to falling and will fall, preventive measures shall be initiated when deemed appropriate to decrease the number of falls whenever possible. The policy further indicated if an assessment finds the resident at risk the RN case manager will implement appropriate interventions and/or precautions on the care plan as an attempt to reduce the risk of falls or the risk of injury due to falls.