**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide a safe transfer using a mechanical lift resulting in a fall with fractures for one of eight residents in the survey sample (Resident #1).The findings include:Facility staff failed to attach a mechanical lift sling according to facility and manufacturer's recommendations during a transfer of Resident #1 from the bed to a wheelchair. Resident #1 slid out of the sling during the transfer causing fracture of the resident's shoulder (proximal left humerus) and left wrist (harm).Resident #1 (R1) was admitted to the facility with diagnoses that included cerebrovascular accident (stroke), left side hemiplegia, hypothyroidism, chronic pain, mood disorder, major depressive disorder, hearing loss, epilepsy, polyneuropathy, insomnia and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact and as totally dependent upon staff for bed mobility and transfers.R1's clinical record documented a nursing note dated 7/9/25 stating, .At approximately 1015 am [10:15 a.m.] CNA [certified nurse's aide] called out to staff that resident and CNA needed assistance that a resident was on the floor .as this writer opened the door resident [R1] noted lying on the floor in front of the door . Resident noted yelling out, when asked where she was hurting at resident told this writer that her left side was hurting .911 was called and EMS arrived shortly after call to transfer resident to the hospital .NP [nurse practitioner] and RP [responsible party] made aware of incident. A nursing note dated 7/10/25 documented on 7/9/25, the nurse arrived at R1's room and observed the resident on the floor. This note documented, .I asked what happened and was told that he [she] slid ot [out] of the hoyer lift onto the CNA .asked resident if she was in pain. She [R1] stated 10 on scale [0= no pain, 10 = worst pain] . (sic)R1's hospital discharge record dated 7/9/25 documented x-ray results diagnosing the resident with an acute minimally displaced fracture of the distal radius [wrist] and an acute displaced fracture of the proximal left humerus [shoulder]. R1 returned to the nursing facility on 7/9/25 with orders for immobilization of the left arm/wrist with a splint and sling, pain medication, ice with elevation of left upper extremity for 20 minutes four times per day and a follow up appointment with orthopedics. R1's clinical record documented pain in the left arm/wrist after the fall/fracture. Pain assessments prior to the fall from 7/1/25 through 7/8/25 documented daily pain ratings ranging from 0 to 2 (on scale of 0 = no pain, 10 = worst pain). Pain ratings after the injury from 7/10/25 through 7/26/25 ranged from 0 to 8 with pain medicine and ice/elevation documented as effective. R1 was assessed on 7/17/25 by an orthopedist. The orthopedist note dated 7/17/25 documented, .for evaluation of an acute left proximal humerus fracture and left distal radius fracture sustained when she fell off of a lift at the nursing home, and landed on the left side . The orthopedist assessed proper alignment of fractured areas and no current pain concerns. The orthopedist ordered continued use of the splint and sling and a 4-week follow-up. R1 was assessed on 8/22/25 by the orthopedist with swelling/bruising still present on left shoulder, proper shoulder alignment and excellent healing of the left wrist. The wrist splint was discontinued with orders to continue use of the left upper arm sling, and a 4-week follow-up appointment.R1's plan of care prior to the 7/9/25 injury (revised 11/1/24) documented the resident required total assistance with activities of daily living including transfers due to stroke with left side hemiplegia. R1's MDS assessment dated [DATE] documented the resident weighed 237 pounds and required total assistance of two people for bed mobility and transfers.The facility's investigation of R1's fall/fracture of 7/9/25 was reviewed. The investigation documented CNA #4 was assigned to R1 on 7/9/25 and was assisted during the lift transfer by CNA #1 and CNA #5. CNA #4's written statement dated 7/9/25 documented, I placed the hoyer lift pad under the resident + I had help to lift her up. As she [R1] was up in the air she said 'something isn't right' as me + the other coworker look at her, she was sliding out . (sic) CNA #4's statement documented that she had been educated on how to use the lift, and that she had the lift straps hooked correctly. CNA #1's written statement dated 7/9/25 documented the lift pad straps were already hooked when she went in to help with the transfer. CNA #1's statement documented, .i was lifting her up she [R1] said i'm not in this right, by the time i asked her whats wrong she fell down. (sic) CNA #5's statement documented that as CNA #1 was pulling the lift back to place the resident in the chair, R1 fell from the sling and that she immediately went to get help.The administrator and DON documented a re-enactment of the incident was conducted on 7/9/25. The administrator documented, .we have concluded that one of the three CNAs involved in the transfer [CNA #4] did not properly connect the sling to the Hoyer lift. [CNA #4] verbalized that she did not connect the sling correctly to the Hoyer lift. [R1] slid out of the Hoyer lift sling during the transfer from her bed to her wheel chair. Staff did respond by attempting to guide her to the floor and brace the fall . (sic)On 9/2/25 at 11:15 a.m., R1 was observed in bed with a sling noted to the left arm. R1 was interviewed at this time about the 7/9/25 fall/injury. R1 stated she slid out of the lift when the aides were getting her out of bed to the wheelchair. R1 stated there were several aides in the room at the time and that when the aides swung the lift around, she slid out of the bottom of the lift pad and eventually hit the floor. R1 stated, Something wasn't hooked right. R1 stated she had never had any problems with the lift or transfers prior to the 7/9/25 incident. R1 stated she broke her left shoulder and wrist and still used a sling. R1 stated she had increased pain from the injury, that her pain had been managed effectively and was now better.On 9/2/25 at 11:55 a.m., the licensed practical nurse unit manager (LPN #1) was interviewed about R1's fall/fracture. LPN #1 stated she was immediately notified on 7/9/25 about the incident and that she observed R1 on the floor. LPN #1 stated R1 was immediately assessed and sent to the emergency room. LPN #1 stated R1 had always required a mechanical lift and minimum of two people for transfers due to left-side paralysis. LPN #1 stated a process improvement plan had been implemented in response to the incident.On 9/2/25 at 12:55 p.m., the registered nurse clinical service specialist (RN #1) and the director of nursing (DON) were interviewed about R1's fall/fracture of 7/9/25. The DON stated she was immediately notified about the fall on the morning on 7/9/25 and investigation of the incident started immediately after the resident was transferred to the hospital. The DON stated the fall occurred as the CNAs were pulling the resident in the lift from the bed. RN #1 stated three CNAs were in the room with R1 at the time of the incident. RN #1 stated CNA #4 was assigned to R1 that day and was assisted by CNA #1 and CNA #5. RN #1 stated when R1 was moved from the bed in the lift, R1 slid out of the bottom of the lift sling and eventually went to the floor. RN #1 stated it was determined there was misuse of the lift sling. RN #1 stated CNA #4 failed to cross the bottom sling straps between the resident's legs which was required for safe positioning during the transfer. RN #1 stated when R1 started sliding out of the sling, she was lowered to the floor. RN #1 stated the jolt of going down and the pressure from the sling was thought to have caused fracture of the wrist and shoulder. RN #1 stated R1 had left-side paralysis due to a previous stroke and was dependent on staff for transfers. RN #1 stated the resident was sent to the emergency room, was diagnosed with fracture to the left shoulder and left wrist and was treated with immobilization, pain management and orthopedic follow up. RN #1 stated a Hoyer lift with a U-shaped lift sling was in use at the time of the incident with the sling found to be the proper size for R1. RN #1 stated it was determined after re-enactment of the incident, that CNA #4 did not cross the straps between the resident's legs and instead attached the lower straps directly to the hooks. RN #1 stated when the resident was moved in the lift, the resident slid out of the bottom of the lift pad because the straps were not connected properly. The DON stated the expectation was that the bottom straps on the U-shaped lift sling were to be crossed between the legs for safe positioning during the transfer. RN #1 stated crossing the bottom straps of the U-shaped lift sling had always been the expectation in the facility and per manufacturer's recommendation as it provided increased support to prevent resident movement during the transfer. RN #1 stated the U-shaped sling was typically used when moving a resident from bed to a sitting position such as a wheelchair.On 9/2/25 at 2:00 p.m., RN #1 was interviewed about CNA #4's training regarding mechanical lift safety. RN #1 stated all CNAs had competency training and were signed off during orientation regarding use of the mechanical lifts and pad use. RN #1 stated CNA #4 had been oriented with an assigned mentor during her first weeks in the facility and this included training on use of the mechanical lift and sling use. RN #1 presented CNA #4's skill checklist for using the mechanical lift with the competencies observed and signed off by a mentor/trainer on 6/17/25. This competency included demonstrated skills to Attach sling straps to sling bar, according to manufacturer's instructions .Make sure the sling is securely attached to the clips and that it is properly balanced .On 9/2/25 at 2:17 p.m., CNA #5 that assisted with R1's transfer on 7/9/25 was interviewed. CNA #5 stated R1 required a mechanical lift and that two staff members were always required with a lift transfer. CNA #5 stated when she entered R1's room to help with the transfer, CNA #4 had already positioned and attached the sling to the lift. CNA #5 stated CNA #1 was operating the lift, CNA #4 was behind the wheelchair and that she was guiding the resident. CNA #5 stated as the lift was pulling back from the bed, R1 started sliding out the bottom of the lift pad and then went to the floor. CNA #5 stated she then left the room to get help. CNA #5 stated she did not look at the sling straps prior to the lift as they were already attached. CNA #5 stated after the incident, she noted that the bottom straps on the sling were not crossed between the resident's legs. CNA #5 stated it was required for the bottom straps to crisscross to hold the resident in a seated position and prevent sliding.On 9/2/25 at 2:50 p.m., the administrator and DON were interviewed about R1's fall/fracture of 7/9/25. The DON stated CNA #4 initially wrote in a statement that she had the sling straps crossed properly. The DON stated when the re-enactment was done, CNA #4 stated the bottom sling straps were not crossed as required. The DON stated CNA #4 did not provide a reason for not following the lift protocol. The administrator stated the lift was immediately taken out of service and inspected by maintenance with no malfunction identified. The administrator stated when the re-enactment was done, that CNA #4 had an aha moment and realized she did not cross the sling straps as required. The administrator stated there was no concern of neglect or willful actions by CNA #4. The administrator stated CNA #4 thought she had hooked the straps correctly and when the re-enactment was done, realized and voiced that she did not have the straps crossed.On 9/3/25 at 9:06 a.m., CNA #1 that assisted with R1's transfer on 7/9/25 was interviewed. CNA #1 stated she assisted CNA #4 and CNA #5 with R1's transfer and that she was operating the lift. CNA #1 stated as she lifted the resident from the bed, R1 started sliding out the bottom of the lift pad. CNA #1 stated R1 partially came out of the lift sling as she lowered the resident to the floor. CNA #1 stated, The lift pad was already hooked up when I came in. CNA #1 stated she did not pay attention to how the lift sling straps were attached. CNA #1 stated after the fall, she observed the sling straps were attached straight to the hooks and were not crossed as required. CNA #1 stated with the U-shaped lift sling, the bottom straps were required to cross between the legs to prevent the resident from sliding out. CNA #1 stated the lift and sling use were reviewed and checked off during orientation. CNA #1 stated she tried to break the fall but was not able to keep the resident from falling. CNA #1 stated there were three CNAs in the room at the time of the incident but that the sling was hooked up wrong.On 9/3/25 at 10:15 a.m., CNA #3, that was the assigned mentor to CNA #4 in May 2025, was interviewed. CNA #3 stated she provided direct supervision of CNA #4 during resident care for three weeks after CNA #4's hire date before she was approved to provide care independently. CNA #3 stated she had no issues or concerns with care demonstrated by CNA #4. CNA #3 stated she went over and observed CNA #4 operate the mechanical lift multiple times, including crossing the U-shaped sling straps, without any concerns. CNA #3 stated she had explained to CNA #4 about why the straps were crossed and what could happen if the straps were not crossed or hooked as required. CNA #3 stated she had never seen CNA #4 hook the sling straps incorrectly prior to the accident.CNA #4 assigned to R1 at the time of the 7/9/25 fall/fracture was not available for interview as she no longer worked at the facility.The manufacturer's instructions titled U-Shaped Seated Slings (2023 Medline Industries) documented regarding strap positioning, .apply the leg straps under the patient's thighs, making sure the material is flat and reaches entirely underneath the thigh .Place straps under each leg, cross straps in middle and attach to the lift . The facility's policy titled Nursing Care and Services Statement (revised 3/13/25) documented nursing personnel will provide care and services following accepted standards of practice guidelines as recognized by the state board of nursing and national nursing organizations. This policy referred to Mosby's Textbook for Long-term Care Nursing Assistants for procedures related to proper use of a mechanical lift. The protocol titled Body Mechanics and Safe Resident Handling, Position, and Transfers (Mosby's Textbook for Long-Term Care Nursing Assistants 8th edition) documented on pages 207and 208, .Always follow the manufacturer instructions. Knowing how to use one lift does not mean that you know how to use others. If you have questions, ask the nurse .Center the sling under the person .To position the sling, turn the person from side to side .Position the sling according to the manufacturer instructions .The facility's policy titled Care and Treatment of Bariatric Patients (revised 3/13/25) documented, .Mechanical devices, including lifts will be utilized to promote the safety of the patient and caregiver .Employees are responsible for following established policies and procedures regarding the care and treatment of bariatric patients, and the appropriate use of mechanical devices for safe patient handling .The administrator stated corrective actions were immediately initiated on 7/9/25 in response to R1's fall/fracture and presented the following plan of correction.The correction plan included the following:R1 sustained fractures as the result of the fall on 7/9/25 during transfer with a mechanical lift. Through investigation, it was determined that with the assistance of three CNAs, improper technique was utilized and discrepancies in competencies determined. All residents were identified as at risk of injury during transfer if the plan of care and proper mechanical lift procedures were not followed. The following actions were implemented in response to the 7/9/25 fall/fracture.7/9/25 - R1 assessed and sent to the emergency room after the fall with complaints of pain in left shoulder and wrist. Notifications made to family and physician. R1 returned to the facility with diagnosed fracture of left shoulder and wrist. Orders were implemented for wrist splint, immobilization with sling, ice/elevation, pain management and orthopedic referral. 7/9/25 - The mechanical lift used at the time of the incident was removed from service and inspected by maintenance with no malfunctions identified. All mechanical lifts in the facility were inspected by maintenance with no identified problems. All lift slings were inspected with five removed from use.7/9/25 - Statements were obtained from staff involved. A re-enactment of the incident was conducted with CNAs involved with the incident. Re-enactment of the incident revealed that the lift sling straps were not crossed as required for safety. Education was immediately provided to the CNAs involved with the incident including procedure for crossing sling straps between the resident's legs. CNA #4 went home after the incident due to being upset about the incident. Care plans were reviewed for all residents with need for 2-person assistance for accuracy and current competencies were reviewed for accuracy.7/10/25 - 7/12/25 - CNA competencies regarding proper use of the mechanical lift, sling straps and plans of care for transfers were conducted with all CNAs. This was documented on a form titled Skills Checklist Using a Mechanical Lift with observations and sign-off of demonstrated proper procedures.7/16/25 - DON conducted in-service education with all CNAs and nurses regarding residents' transfer status and following the plan of care/kardex for proper transfer status.7/21/25 - DON or designee began random observations of five mechanical lift transfers weekly for four weeks with report of findings presented to the quality assurance committee. Weekly audits were ongoing and to be reviewed by the quality assurance committee.Date of compliance was listed as 8/5/25.The education, competency checklists and lift transfer monitoring were documented as listed with weekly monitoring of lift transfers continuing during the current survey. The audits since 8/5/25 indicated compliance with proper lift procedures including proper sling strap positioning. There were no falls/incidents involving a mechanical lift since the correction date of 8/5/25. There were six residents that had experienced a fall in the facility since 8/5/25. These residents (R3, R4, R5, R6, R7 and R8) were included in the survey sample with no deficiencies identified related to falls/accidents. On 9/3/25 at 8:00 a.m., accompanied by CNA #2 and CNA #3, a mechanical lift/transfer with use of the U-shaped sling was observed with Resident #2. Proper sling and strap positioning was observed along with proper lift operation for a safe transfer. Twelve CNAs were interviewed on different shifts regarding education and competencies with all interviewed verifying the education provided and verbalizing knowledge about crossing the bottom straps when using the U-shaped sling. The plan of correction was deemed acceptable and implemented as listed with no non-compliance identified regarding falls/accidents since the correction date of 8/5/25.This finding was reviewed with the administrator, DON, clinical service specialist and director of quality assurance on 9/2/25 at 2:50 p.m. and on 9/3/25 at 11:40 a.m. with no further information presented prior to the end of the survey.This deficiency was cited as past non-compliance.