**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, satellite imagery and measurements from Google Earth review, Historic Weather Data from the National Weather Service (NWS) review, Fire Department (FD) record review, Emergency Medical Services (EMS) records review, facility investigation review, hospital documentation reivew, and interviews the facility failed to prevent an elopement of 1 resident, (Resident #7) of 6 residents reviewed. The facility's failure resulted in Harm to Resident #7 when on the evening of 5/26/2024, Resident #7 exited the facility unbeknownst to staff, walked 0.25 miles away from the facility, down the street, fell over the curb into the yard of a private residence, and was found by an off duty law enforcement officer who was passing by. Resident #7 sustained a fractured Humerus (upper long bone of the arm) in the fall, required transportation by EMS to a local hospital for emergent treatment, then later required outpatient surgical treatment to repair the fracture. The facility was cited at F 689 at a Scope and Severity of G (Harm). The facility was cited as past non-compliance. Noncompliance began on 5/26/2024 and continued until 5/31/2024. Noncompliance ended on 6/1/2024. The facility is not required to submit a Plan of Correction. The findings include: Review of the facility policy titled, Elopements and Wandering Residents, dated 5/26/2024, revealed, .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering . Review of medical records revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Atherosclerotic Heart Disease, Hypertension, Pneumonia, Intracranial Injury with Loss of Consciousness, Urinary Tract Infection, Dementia, Mood Disturbance, Psychotic Disturbance, Anxiety, Seizures, Difficulty Walking, and Muscle Wasting with Atrophy. Review of the care plan for Resident #7 dated 5/17/2024, revealed interventions in place for cognitive impairment and fall risk. Continued review revelaed no documentation the resident was at risk for elopement. Review of the Elopement and Wandering Evaluation dated 5/17/2024 at 6:44 PM (time of admission), revealed Resident #7 was a low risk for elopement. The assessment was revised on 5/17/2024 at 7:32 PM and revealed Resident #7 was changed to at risk for elopement. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment which indicated severe cognitive impairment. Resident #7 used a rolling walker or wheelchair for ambulation and required moderate assistance of 1 person for activities of daily living (ADL). Review of the nursing notes dated 5/19/2024, revealed Resident #7 was placed in a room closer to the nursing station to address behaviors which included arising from bed unattended and pushing his bedside table around his room. Review of overhead satellite imagery and digital measurements taken from Google Earth, revealed the facility was situated atop a hilly terrain, in the rear of a large residential neighborhood, surrounded by homes and side streets on all sides. The road which led to the facility, was moderately sloped to the facility property line and campus entrance. Review of weather data from the National Weather Service (NWS) dated 5/26/2024 at 8:30 PM, revealed for the location of the incident, the temperature was 68 degrees Fahrenheit (F) with no rain. Review of the local Fire Department records dated 5/26/2024, revealed Resident #7 was located laying on the ground, in the yard of a private residence, near the edge of the street, approximately 0.25 miles from the facility near the base of the hillside around 30 meters (98.43 feet) from the intersection of the facility entrance road and an adjacent 2 lane secondary road. Continued review revealed First Responders were summoned by a law enforcement officer who found Resident #7 at approximately 8:24 PM and arrived on scene at 8:35 PM. Continued review revealed .responded to non-emergency to a fall call at the intersection of [named road] and [named road] .Arrived on scene .Found an off duty [Police] .officer standing with a male lying on the ground .Officer .advised he was driving by and saw the gentleman lying there and stopped to render aid .The gentleman seemed very unsure of his location [EMS service] arrived on scene and had primary patient care .The gentleman had a tote bag with him marked [Facility name] .Officer .contacted the facility to advise them of the gentleman's location and to let them know .[EMS] would be transporting to the hospital . Review of EMS records for Resident #7 dated 5/26/2024, revealed EMS arrived to the scene at 8:25 PM and an ambulance arrived at 8:33 PM. Resident #7 was transported to a local hospital at 8:48 PM. Continued review of the EMS record revealed .Dispatched to location for .male that had fallen .Upon arrival .[Resident #7] was found sitting on the ground, conscious, alert and disoriented . The resident was in care by .an off-duty law enforcement officer .[Resident #7] .was able to give his name and date of birth but was disoriented to location and recent events leading up to him being on the ground. He complained only of left arm pain .It was discovered by the officer he was a resident at [the facility] .Upon assessment of the left arm, deformity .was noted .[The facility] was notified by the officer of the situation and that .[Resident #7] . would be transferred to [hospital] .The left arm was stabilized with .splint .transferred to hospital Review of Hospital documentation for Resident #7 dated 5/26/2024, revealed .History of Present Illness .This is a [AGE] year-old male .who lost his balance and fell while walking on the road. EMS was called [Resident #7] with significant deformity to his left elbow and left arm .does have a history of dementia and is slightly confused but states he did not lose consciousness Denies striking his head .denies neck pain .denies any other injury .complaining of pain to left elbow as well as left mid humerus .symptoms moderate intensity . Continued review revealed X ray results as follows: .Findings .Angulated and distracted fracture deformity distal diaphyseal segment left humerus involves the distal component of the operative fixation .with a fixation plate and multiple screws mid diaphyseal segment . [broken bone in the lower part of the upper arm, where the fracture fragments are not only bent at an angle but also pulled apart from each other] distal diaphyseal segment [lower, cylindrical part of the humerus bone, just before it flares out to form the joint surfaces of the elbow] . Further review revealed .[Resident #7] .did receive X rays which showed a previous plating [surgical procedure that involves attaching a plate to the fractured humerus to stabilize it] of the midshaft humerus .Family states this was done 20 years ago .also noted was significantly angulated displaced fracture of the distal portion of the humerus .elbow joint appears intact with no signs of fracture to the elbow itself .Discussed case with [orthopedist] .[Resident #7] .was placed in .splint .given a prescription for hydrocodone [opioid medication for pain] and discharged back to his skilled nursing facility in stable condition .follow up with orthopedic surgery in 2 to 3 days .Clinical impression, Acute Fall, Acute left distal humerus fracture . Review of staffing data dated 5/26/2024, revealed there were 13 residents present on Resident #1's unit at the time of the elopement with a Licensed Practical Nurse (LPN) and a Certified Nurse Aide (CNA) assigned full time to the unit. Review of the facility investigation, witness statements, and Interdisciplinary Team Notes dated 5/26/2024 - 5/28/2024, revealed on 5/26/2024 Resident #7 was last seen on the clinical unit, in his room seated in his wheelchair around 7:45 PM prior to the elopement. Resident #7 had not exhibited wandering or exit seeking behaviors prior to the incident. Continued review of the investigation revealed the facility was advised of Resident #7's elopement around 8:40 PM by way of a telephone call from first responders at the scene. Resident #7 returned to the facility from the hospital on 5/27/2024 at 12:44 AM and was transferred to the facility's secure memory care unit. Review of the elopement risk assessment dated [DATE] at 2:42 AM, revealed Resident #7 was considered at high risk for an elopement. Review of the care plan for Resident #7 dated 5/27/2024, revealed additional interventions to monitor behaviors, the resident's injuries, and prevent elopement were added to the care plan. Review of Orthopedic Surgeon Notes and Operative Reports dated 5/30/2024 revealed Resident #7 underwent surgical repair of the fracture without complications. Resident #7 was admitted to the hospital post operatively for monitoring and returned to the facility on 6/3/2024. During an interview on 2/14/2024 at 1:29 PM, the Police Officer who found Resident #7 on 5/26/2024, stated he lived in the area near the facility. The Police Officer stated he was off duty, and was driving by when he observed Resident #7 lying on his side, face down in the grass of a private residence, with his feet dangling over the curb, and he stopped to render aid. The Police Officer stated Resident #7 was profoundly confused and stated he was walking to a store. The Police Officer stated he observed obvious deformity in Resident #7's left upper arm and elbow and immediately called 911. The Police Officer stated he obtained an air splint from his personal first aid kit, splinted Resident #7's arm and awaited arrival of EMS and the Fire Department. The Police Officer stated he identified Resident #7 as a resident of the facility by a tote bag with the facility name that was on the ground beside Resident #7. The Police Officer stated Resident #7 could only give his name and date of birth . The Police Officer stated he telephoned the facility, advised the staff of the situation, and confirmed Resident #7 was a resident of the facility. The Police Officer stated the facility was not aware of the elopement until his notification. The Police Officer stated he advised the facility Resident #7 was injured and would be transported to the hospital by EMS. The Police Officer stated Resident #7 was dressed in blue jeans, a t-shirt, socks, and tennis shoes, During an interview on 2/18/2025 at 1:30 PM, the Director of Nursing (DON) stated the facility investigation determined at the time of the elopement Resident #7 exited the facility with visitors who did not realize he was a resident. The DON stated at the time of the incident, multiple family members of another resident had entered and left the facility in groups several times per hour throughout the day and evening of 5/26/2024. The DON stated at the time of the elopement a digital keypad was located at the front door and the entry code was posted in view above the door itself, in order to allow visitors to access the front lobby independently. The DON stated Resident #7 was not seen wandering about the facility or in the lobby prior to the incident and was carrying a tote bag given to visitors. The DON stated the facility investigation concluded it was likely a visitor mistook Resident #7 for another visitor and permitted him outdoors via the main entrance door. The DON confirmed the facility failed to prevent elopement of Resident #7 and he was harmed as a consequence. In Response to the incident, the facility implemented corrective actions which were validated onsite by the surveyor between 2/12/2025 and 2/18/2025. 1. On 5/26/2024 around 8:40 PM the facility launched an investigation which included interviews of all staff present in the facility prior to holding an ad hoc Quality Assurance Meeting between the DON, Administrator, and Nursing Supervisors. 2. On 5/26/2024 Resident #7's family along with the medical director were notified of the situation when the facility became aware of the elopement. 3. On 5/26/2024 The facility checked all entry and exit doors to ensure they were operational with no negative findings. The facility implemented door checks every 8 hours with logs on each unit. The door codes posted near the front door were removed. The door code at the front door was changed to a new code. Ad Hoc Quality Assurance review of the incident was initiated at 11:20 PM and included the medical director and corporate consultants. 4. On 5/26-27/2024 immediately upon return to the facility from the hospital, Resident #7 was transferred to a locked secure unit inside the facility for continued care. 5. ON 5/27/2024 staff education began related to the incident which included education that no visitors were permitted door codes, and all visitors were to be escorted in and out via the front door only. Additional education on the facility elopement policies and procedures were provided with attestations required by staff. Staff education was completed by 5/31/2024 with all remaining staff off duty at the time given notice education would be required prior to the next shift. 6. ON 5/27/2024 through 5/28/2024 the facility conducted elopement risk assessments on all residents, and identified increased risk for one elder, whose care plan was adjusted with new interventions and teaching to all staff on those (Resident #15). The facility held additional Quality Assurance (QA) Meetings related to the incident on 5/28/2024 and discussed facility conclusions of its investigation and root cause analysis of the incident, measures being implemented in response to findings, and added the incident to the QA agenda for monthly review to supplement weekly reviews to be performed by the DON, Administrator and ADON (assistant director of nursing). QA oversight of the incident response was monitored by the facility administrator, medical director and DON. The door codes on all doors at the facility were changed 5/28/2024. 7. ON 5/27/2024 Resident #7 was evaluated by the physician and Interdisciplinary team which included mental health services to address his changes in condition. 8. The facility began elopement drills on 5/29/2024 on every shift conducted 5 times weekly for 4 weeks. Then reduced at intervals to 3 times weekly for 4 weeks, then once weekly for 4 weeks. The drills were documented with no negative findings. Random elopement drills continued at the time of the facility investigation and were observed on the afternoon of 2/18/2025 during the onsite survey with no negative findings. Staff located a simulated missing resident in less than 3 minutes when the missing resident code (code pink) was called overhead. The test was initiated by the DON with assistance of a resident who served as the subject of the search at the request of the surveyor with no advance notice to other facility leadership or staff members before the drill began. 9. On 5/30/2024 the administrator completed notifications to all families and responsible parties via phone messages (168 total calls) and a voice mail left on the facility answering machine which advised callers of the new policy related to changed door codes which would no longer be provided them and safe entry and exit to the building via the front lobby entrance only. The facility placed a placard on the front door on both sides, which cautioned visitors to not allow others to follow them out, along with a phone number to call for entry after hours or if the lobby reception desk was unmanned. 10. Additional staff education on the incident and review of all prior education given and all staff attestations were logged into the facility investigation documents contained in a large binder on 5/30/2024. This documentation was preserved for State Agency (SA) review by the DON and presented as requested on 2/10/2024 after the entrance conference. The facility documentation was reviewed throughout the survey with no additions, deletions, or evidence of changes found in it at anytime during the survey as it was reviewed. (the binder was returned to the facility at the conclusion of each survey day 2/10/2025 -2/18/2025) and final copies obtained at conclusion of the survey on 2/18/2025 showed no alterations evident. 11. Monthly QA of the incident, elopement risks for residents, and effectiveness of the interventions continued throughout 2024 and January 2025 with no recurrent elopements or similar incidents. The surveyor validated the corrective actions via observations of the entry and exit procedures throughout the survey which were in place as reported. All door alarms were tested and were functional. 5 families were interviewed and reported they did not have access to door codes and had to be let in and out of the facility by staff. The surveyor was not provided door codes to enter the facility either. In total 10 staff interviews conducted on both shifts on all units which included day and night shift personnel showed all staff were knowledgeable of the elopement policy, facility safeguards to prevent elopement and actions to take to initiate a code pink drill, and steps to take during the drill in their assigned areas. The surveyor executed an unannounced nighttime entry to the facility on the evening of 2/13/2025 at 11:00 PM and remained onsite on 2/14/2024 until 2:30 AM with no breaches in the facility security measures observed. All signage was in place on the front entrance as reported and the phone number used to access the facility after hours was effective. A code pink drill was initiated by the DON at directive of the surveyor on the afternoon of 2/18/2025 with no negative findings. Resident #7 was observed throughout the survey on the secure unit. Resident #7 had fully recovered from his injuries but had no recall of the incident. Resident #7 was observed to be free of exit-seeking on the secure unit and appeared well adjusted to the environment. The surveyor validated all logs of staff training by review of the facility record of it and selected staff for interview from the logs observed. Additionally, the surveyor selected employees hired after the incident for interviews, which showed new hires had been trained on the facility elopement prevention policy and safeguards on hire. The Surveyor also reviewed QA sign in sheets for the period June 2024 to January 2025 and verified monthly QA of the incident remained ongoing at the time of the investigation. Medical record review for Resident #7 showed no recurrent serious behaviors or elopement attempts after the incident and the resident had successfully completed rehabilitation with occupational, physical and speech therapy. Review of facility incident logs showed no similar incidents in the prior year. The incident was appropriately documented in the incident logs and clinical records. The facility report of the incident to required authorities was completed timely in compliance with state and federal law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, document review, observation, and interviews, the facility failed to ensure 1 resident (Resident #10) of 3 residents was safely transferred using a mechanical lift. Specifically, Resident #1 had paralysis and weakness to the left side of the body. The facility failed to assess Resident #10 for the appropriate type of mechanical sling/lift pad to prevent the resident from leaning to the left side. On 11/30/2022 and 01/14/2023, while utilizing a bariatric sized four-point sling, Resident #10 began to lean toward the left side and fell to the floor from the sling. This failure resulted in a left shoulder fracture as a result of the 11/30/2022 fall, a left elbow fracture as a result of the fall on 01/14/2023, and resulted in Resident #10 being fearful of getting out of bed with a mechanical lift. The facility's failure resulted in actual Harm to Resident #10. Findings included: A review of the [Name of the Mechanical Lift] User Manual with a copyright date of 2014 revealed WARNING Visibly inspect sling prior to each use to ensure sling is the correct type, size and design to handle lifting. The manual indicated Most accidents occur from wrong sling size or type. Make certain you understand how to select, attach, inspect and test slings. According to the manual, In addition, ensure slings are sized appropriately and attached correctly to the patient and lift. Failure to follow these instructions could result in serious injury. A review of the facility's policy, titled, Safe Resident Handling/Transfers, initiated on 01/02/2020, indicated, 8. The facility will ensure that there are appropriate amounts of varying slings to accommodate residents and that residents will be measured correctly as per the manufacturer's instructions on proper sling sizing. 9. Ensure that an appropriate sling is utilized. The policy further indicated 14. Resident lifting and transferring will be performed according to the resident's individual plan of care. A review of an undated document titled, Choosing the Proper Sling for Your Residents revealed Sling size and fit can vary significantly depending on resident weight, girth and shape. Ensure sling is properly fitted before performing any lift. - Resident being lifted will feel safe, dignified and comfortable - Will increase caregiver confidence and lift efficiency - Maximize resident and caregiver safety As prescribed by company policy, a therapist or nurse should provide sling sizing and style selection. A review of a Resident Face Sheet for Resident #10 revealed the facility admitted the resident on 06/11/2019 with diagnoses to include Hemiplegia(paralysis) and Hemiparesis (muscle weakness) following a stroke affecting the left non-dominant side, Morbid Obesity, Muscle Weakness, Generalized Anxiety Disorder, and Unspecified Intellectual Disabilities. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/01/2022, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The MDS indicated Resident #10 required extensive assistance of two plus persons for transfers, which occurred only once or twice during the assessment period. The MDS indicated Resident #10's height was 66 inches tall. A review of Resident #10's Weights and Vitals Summary, revealed on 11/01/2022, the resident weighed 326 pounds. A review of Resident #10's care plan initiated on 05/09/2018 and revised on 06/30/2022, indicated Resident #10 was at risk for falls related to decreased mobility. A review of Resident #10's care plan initiated on 05/09/2018, indicated the resident had a activities of daily living self-care performance. An intervention revised on 10/14/2021, instructed the staff that Resident #10 required total assistance of two people for transfers using a mechanical lift. A review of a Kardex Report [a care guide for Certified Nursing Assistants (CNAs)] as of 11/10/2022, revealed Resident #10 required total assistance of two people for transfers using a mechanical lift. During an observation on 08/10/2023 at 10:00 AM, the surveyor observed the available facility mechanical lift sling pads were medium with a maximum weight of 450 pounds, large with maximum weight of 600 pounds and bariatric size with a maximum weight of 700 pounds. During an interview on 08/11/2023 at 9:32 AM, the Director of Nursing (DON) stated all the facility slings could accommodate up to 450 pounds and they had no residents that were greater than 450 pounds. The DON stated the CNAs used their judgement based on resident girth and shape for sizing. A review of the facility Incidents by Incident Type report revealed Resident #10 sustained a fall on 11/14/2022. A review of Resident #10's Progress Notes, dated 11/14/2022 at 4:40 PM, revealed while being transferred from a shower chair to bed by way of a bariatric mechanical lift, the lift pad underneath the resident tilted to the left side and the resident slipped/assisted by staff to the floor landing on their back and the back of the head. The note indicated the resident had left shoulder and left hip pain and a physician's order was obtained for x-rays of the left shoulder and left hip. The Progress Notes indicated an immediate intervention put in place was to use a bariatric lift pad during transfers. A review of Resident #10's Radiology Report dated 11/15/2022, revealed the resident had an acute, comminuted (broken in at least two places) fracture of the proximal left humerus (shoulder). A review of Resident #10's ED [Emergency Department] General Adult Worksheet with an admit date of 11/15/2022, revealed the resident presented to the ED with complaints of left shoulder pain status post fall. The document revealed, the resident was being lifted with a mechanical lift and fell onto their left shoulder. Resident #10 was informed of the results which demonstrated a nonoperative, proximal humerus fracture. Resident #10's arm was placed in a sling and the resident was discharged back to the facility. A review of CNA #9's handwritten statement dated 11/15/2022, revealed she assisted CNA #17 with the transfer of Resident #10. According to CNA #9's statement, she was on Resident #10's right side and CNA #17 was on the resident's left, paralyzed side. CNA #9 indicated she turned around and noticed Resident #10 was about to fall. CNA #9 reached for the resident to catch the resident and lowered the resident to the ground on their back. During an interview on 08/10/2023 at 9:41 AM, CNA #9 stated she, CNA #17, and LPN #10 transferred Resident #10 into bed with the mechanical lift when the resident fell. CNA #9 stated she was on one side and CNA #17 was on the other side of the resident. CNA #9 stated they instructed Resident #10 to hold on to their left paralyzed arm with the right arm, but Resident #10 released the left arm, but when the resident dropped their arm, all their weight went to one side. CNA #9 stated she was on the left side of Resident #10 but could not hold the resident up due to the resident's weight. CNA #9 stated she and the resident both fell to the ground. CNA #9 stated the slings could hold up to 450 pounds, but some were wider than others and they used the wider, bariatric one for Resident #10. CNA #9 further stated Resident #10 no longer wanted to get out of bed. A review of CNA #17's handwritten statement dated 11/15/2022, revealed on 11/14/2022, CNA #17 got assistance from CNA #9 to transfer Resident #10 back to bed. CNA #17 indicated as the staff were about to lift the resident, she noticed the resident was crooked, so the resident was placed back down into the shower chair to reposition Resident #10. According to CNA #17's handwritten statement, Licensed Practical Nurse (LPN) #10 helped the CNAs by moving the chair, while CNA #9 operated the controls. CNA #17 indicated as the staff were about to place Resident #10 in bed, the resident slipped from the mechanical lift pad and fell to the floor. During a telephone interview on 08/10/2023 at 10:28 AM, CNA #17 stated she and CNA #9 positioned Resident #10 on the sling but then Resident #10 started to lean to one side and they could not keep the resident from falling. CNA #17 stated she had training on the proper use of the mechanical lift and slings and stated they used a bariatric sling and lift for Resident #10. CNA #17 stated she thought the sling just was not positioned correctly on the resident. During an interview on 08/10/2023 at 12:30 PM, LPN #10 stated she was present when Resident #10 fell in November 2022. LPN #10 stated the CNAs had gotten the resident up for a shower without incident, but then upon transferring the resident back to bed, the resident started leaning to one side and fell. During an interview on 08/09/2023 at 2:31 PM, the Occupational Therapist (OT)/Director of Rehabilitation (DOR) stated Resident #10 had used a mechanical lift since admission to the facility. The OT/DOR stated she evaluated Resident #10 following the fall in November 2022 for proper positioning and a shoulder immobilizer but did not assess the type of sling after the November fall. The DOR stated Resident #10 had used a 4-point sling since admission without any incidents, but due to Resident #10's weight and hemiparesis, if the resident was not perfectly aligned in the sling, the resident could lean to the left, causing the sling to be off balance. A review of the Facility Event Summary Report revealed Resident #10 had a fall on 01/30/2023. A review of Resident #10's Resident Progress Notes dated 01/30/2023 at 11:55 AM revealed LPN #19 documented she observed the resident lying face down on the floor next to the bathroom door. The note indicated CNAs had used a bariatric lift and bariatric lift pad. The resident had a bruise to the right arm above the elbow and a slight raised area on the left cheek that was pink in color. The note indicated the facility notified the family and the nurse practitioner. On 01/30/2023 at 1:07 PM, the note indicated a new order was received to x-ray to the resident's left shoulder, left forehead, left wrist, left hand, and left facial with attention to the nose and left maxilla (jaw). A review of an Event Report for Resident #10 dated 02/10/2023, revealed the resident had a fall on 01/30/2023. The report indicated the resident was lowered to the ground from a mechanical lift as the resident was sliding out. The facility's intervention to prevent further falls was to provide a six-point lift pad and therapy to educate staff on usage. A review of Resident #10's Radiology Report dated 02/10/2023, revealed the resident had a minimally displaced and angulated fracture of the left elbow that was not included on the prior field of view (dated 01/30/2023). During an interview on 08/10/2023 at 1:13 PM, LPN #19 stated she worked when Resident #10 fell on [DATE]. LPN #19 stated Resident #10 was on the floor when she came in, and she did not witness the fall. LPN #19 stated the sling with the resident's name on it was underneath the resident on the floor. LPN #19 stated the resident was large and flaccid on the left side. LPN #19 stated the staff would remind the resident to hold their left paralyzed arm with the right arm during transfers, but sometimes the resident would release the left arm, causing the resident to lean to the left. During an interview on 08/10/2023 at 2:38 PM, CNA #20 stated she and CNA #21 got Resident #10 up in a bariatric mechanical lift with the bariatric sling for a shower. CNA #20 stated Resident #10 leaned to the left, so they tried to hold up that side. CNA #20 stated she assisted Resident #10 with transfers multiple times without incident. CNA #20 stated she knew to use the bariatric lift and sling and had crossed it under the resident's legs, but it did not keep the resident from leaning to the left, and Resident #10 fell. During an interview on 08/10/2023 at 2:49 PM, CNA #21 stated she and CNA #20 got Resident #10 up with the large bariatric lift. CNA #21 stated Resident #10 was weak on the left side and started leaning to the left. CNA #21 stated both she and CNA #20 tried to keep Resident #10 from falling but the resident was too heavy. CNA #21 stated the sling was already under Resident #10 when she came in the room to assist. During an interview on 08/09/2023 at 2:31 PM, the OT/DOR stated after the second fall in January 2023, nursing realized the problem had not been resolved and reached out to therapy to evaluate the sling. The OT/DOR stated at that time she recommended the six-point harness sling because it provided additional lateral support (more support to each side of the resident). During an interview on 08/08/2023 at 2:34 PM, Resident #10 stated they did not get out of bed because of a broken elbow and did not want to fall out of the lift. Resident #10 stated their left arm was heavy and caused them to lean that way, which caused them to fall. Resident #10 pointed to a six-point bariatric sling in the room with the resident's name on it. During a follow-up interview on 08/11/2023 at 7:02 PM, Resident #10 stated they did not want to use the mechanical lift. Resident #10 stated they used to get up for showers and sometimes for bingo prior to the falls. Resident #10 stated they would prefer to get a shower over a bed bath. Resident #10 stated they would like to get up again but did not trust the CNAs and had not allowed anyone to work with the resident on getting up. During an interview on 08/10/2023 at 12:00 PM, the Assistant Director of Nursing (ADON) stated Resident #10's fall in January 2023 had been discussed in the weekly Interdisciplinary Team (IDT) Clinical At-Risk meetings (CAR). The ADON stated Resident #10 tended to lean to one side. The ADON stated if a resident was above 450 pounds or wider staff should use a bariatric sling. During an interview on 08/11/2023 at 9:32 AM, the DON stated during the facility's IDT meeting regarding Resident #10's November 2022 fall, they discussed the root cause and felt it may have been caregiver error, as the resident had recently moved halls, so they did in-service training with the staff. The DON also stated even though Resident #10 was not technically heavy enough to require a bariatric sling, given the resident's girth and short height, Resident #10 was appropriate for a bariatric sling. Per the DON, the facility ordered a bariatric sling with the resident's name on it to keep in the resident's room. The DON stated Resident #10 had never gotten up much but did get up for showers. The DON confirmed the facility had not consulted with therapy to assess the sling at that time. According to the DON, after the second fall in January 2023, the staff reached out to therapy to assess the sling and therapy determined it was not the size of the sling, but the resident needed more lateral support. During a follow-up interview on 08/11/2023 at 2:58 PM, the DON stated after a fall, the IDT met and discussed what happened and put appropriate interventions in place. The DON stated the facility provided staff training following Resident #10's fall on 11/14/2022. However, it was not specific to Resident #10 and was a general training and staff demonstration on proper use of mechanical lifts. The DON stated her expectation was that staff would follow the care plan to ensure safety when transferring residents. During an interview on 08/11/2023 at 3:51 PM, the Executive Director (ED) stated she expected staff to know how a resident was supposed to be transferred and follow the resident's plan of care.