**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R1) of 5 sampled residents when staff used a mechanical lift without ensuring a safety latch was in place prior to transferring R1.On 7/30/25 at 11:00 AM, Certified Nursing Assistant (CNA)-C and CNA-D transferred R1 from bed to Broda chair via a Liko Golvo 7007ES full body lift. CNA-C and CNA-D positioned the sling under R1 and hooked all 4 sling loops onto 2 hooks on either end of the sling bar. During the transfer, a sling loop slid down the sling bar, which caused the bar to go vertical. A safety latch that should have been attached to the sling bar hook was missing which caused a sling loop to detach from the lift. CNA-C and CNA-D were aware the safety latch was missing prior to the transfer. R1 fell out of the sling upper body first and hit R1's head on the leg of the lift. CNA-C stayed with R1 while CNA-D notified the nurse. R1 was bleeding from the back of the head and was transferred to the hospital. A computed tomography (CT) scan indicated R1 had a large right-sided acute subdural hematoma, a right scalp laceration, a small scalp hematoma, and a fracture of the C7 spinous process. R1 was admitted to the hospital and passed away on 8/2/25.The failure to identify and correct a known hazard related to the use of a mechanical lift created a finding of immediate jeopardy that began on 7/30/25. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 8/11/25 at 3:18 PM. The immediate jeopardy was corrected and removed on 7/31/25. The immediate jeopardy is being cited at past non-compliance. Findings include:The facility's Fall Risk Assessment and Management policy, dated January 2025, indicates it is the policy of the facility to provide as safe of an environment for our residents as possible .High-risk fall prevention interventions .are designed to reduce the severity of injuries due to falls as well as prevent falls from reoccurring, supplementing standard fall prevention interventions, including .Make sure supportive devices are applied properly before leaving the room for any reason.The facility's Safe Resident Handling policy, dated January 2025, indicates: .1. Protect the health and safety of residents and staff; 2. Maintain a high level of resident dignity and a positive resident experience during transfers; 3. Improve quality of care; 4. Maintain the resident's right to be as independent as possible based on their physical and psychological abilities; .6. Standardize resident lifting procedures. The policy also indicates mechanical equipment will be re-evaluated annually to ensure the equipment is adequate to meet the needs of the resident population .Caregivers will do visual inspections of lifts prior to use to ensure they are properly functioning. If equipment is in need of repair, it will not be used and maintenance staff will be contacted. Maintenance staff will complete an inspection of equipment as necessary to ensure it is properly functioning.On 8/11/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, epilepsy, and anxiety disorder. R1's Minimum Data Set (MDS) assessment, dated 6/18/25, indicated R1 was rarely to never understood and R1's cognition was severely impaired. The MDS also indicated R1 was dependent on staff for mobility and transfers. R1 had an activated Power of Attorney for Healthcare (POAHC). A progress note, dated 7/30/25, indicated at approximately 11:00 AM, a CNA approached the nurse and indicated R1 fell out of a full body lift during a transfer and hit the back of R1's head. The nurse assessed R1 and noted R1 was bleeding from the back of the head. The nurse also noted a safety latch on the lift may have been faulty. The nurse called 911 and R1 was transferred to the hospital. A Hospital History and Physical (H&P), dated 7/30/25, indicated R1's CT scan showed a large right-sided acute subdural hematoma up to 2.3 centimeters (cm) thick with localized mass effect and an approximate 7 millimeters (mm) midline shift, as well as a right posterior lateral scalp laceration and a small underlying scalp hematoma. The cervical CT showed a mild displaced acute fracture of the C7 spinous process. The H&P indicated R1's POAHC opted for Hospice services and comfort measures. A Hospital Discharge summary, dated [DATE], indicated R1 passed away on Hospice services on 8/2/25. The primary cause of death was listed as a subdural hematoma with contributing illness of severe dementia. On 8/11/25 at 10:17 AM, Surveyor interviewed Deputy Medical Examiner (DME)-F via phone who stated R1's death certificate indicated the cause of death was an accident resulting in a closed head injury as a result of a fall. On 8/11/25 at 11:12 AM, Surveyor interviewed Maintenance Technician (MT)-E who stated MT-E completes monthly equipment checks on safety latches and other features of the lifts. MT-E stated if there is a concern, the lift is removed from the floor until maintenance repairs it. MT-E stated MT-E checked the lift with the missing safety latch 2 weeks prior to the incident and the latch was in place. MT-E stated MT-E carries extra latches because MT-E has had to replace the latches on other full body lifts in the past. On 8/11/25 at 11:18 AM, Surveyor interviewed CNA-D via phone who confirmed CNA-D assisted with R1's transfer on 7/30/25. CNA-D confirmed a sling loop detached which caused R1 to fall out of the sling and hit R1's head on the lift. CNA-D stated the sling loop became loose because one of the safety latches for the hook was missing. CNA-D stated CNA-D was aware the latch was missing prior to the transfer on 7/30/25 but was unsure how long the latch was missing CNA-D confirmed CNA-D had used the lift to transfer R1 prior to 7/30/25 with a missing latch. CNA-D indicated CNA-D did not think about the risk prior to the transfers. On 8/11/25 at 1:03 PM, Surveyor interviewed CNA-C who confirmed CNA-C assisted with transferring R1 on 7/30/25. CNA-C indicated a safety latch was missing from the sling bar hook which resulted in R1's fall. CNA-C confirmed CNA-C was aware the latch was missing prior to the transfer but was unsure how long the latch was missing. CNA-C was unable to state for certain if CNA-C had transferred R1 or any other residents with the lift prior to R1's fall on 7/30/25. The Liko Golvo instruction guide for model number 7007ES states for safe operation, a few procedures should be performed every day the lift is used including checking that the latches work properly.Surveyor reviewed the facility's monthly lifting device inspection audits for the facility's 24 mechanical lifts which included the following: Inspect each lift monthly with attention to specific operating points according to manufacturer; Check for accuracy of scale using 50 (pound) weight as needed; Check brakes and wheels, clean and lubricate wheels; Check for loose parts, bolts and nuts; Lubricate lift; Check voltage of all lift batteries; Remove lift from service if repairs are needed.A monthly lift inspection, due date 8/4/25, indicated the Liko Golvo 7007ES full body lift (T013) was last inspected by MT-E on 7/14/25. Surveyor also reviewed lift inspections dating back to March 2025 and noted inspections were completed monthly for all 24 of the facility's mechanicals lifts, including the T013 lift.On 8/11/25 at 9:31 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed CNA-C and CNA-D transferred R1 knowing that a safety latch was missing from the lift. DON-B stated CNA-C and CNA-D were suspended immediately, completed in-person hands on education related to equipment safety as well as abuse and neglect, and completed retraining on appropriate and safe transfer techniques, including demonstrations, before they returned to work. DON-B verified the lift in question was immediately removed from the unit. A full inspection was completed and the safety latch was replaced before the lift was returned to the floor. DON-B stated all staff received equipment safety education, which was completed on 7/31/25, and indicated all staff who transfer residents attended one of two transfer safety workshops to demonstrate competency. DON-B acknowledged CNA-C and CNA-D should not have transferred R1 knowing that the latch was missing.The failure to keep R1 free from a fall by identifying and eliminating a known hazard for a mechanical lift created a finding of immediate jeopardy. The facility removed and corrected the jeopardy on 7/31/25 when it had completed the following:Immediately removed the lift from resident use, completed a full maintenance inspection, and replaced the safety latch before the lift was returned to the floor. The facility also completed audits on all other mechanical lifts.Removed the staff from resident care pending the outcome of the investigation and hands-on education.Educated staff on equipment safety, gait belt, stand lift, and full body lift transfers, and abuse/neglect related to equipment safety. Randomly audited 8 lifts per month for 3 months to ensure there are no maintenance concerns with lifts and slings.Audited 10 lift transfers per month for 3 months to ensure proper transfer techniques as well as proper pre-lift review of the equipment to ensure there are no safety concerns.