Health inspection·April 15, 2026

This citation includes two separate deficiency tags, F689 and F726, each based on a distinct violation of a specific regulatory requirement and supported by evidence demonstrating the facility's failure to meet that requirement. F689 42 CFR §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Based on observation, interview, medical record review, and facility P&P (policy and procedure) review, the facility failed to provide the necessary care and services to ensure Patient 4, who had a prior history of falls and left femur fracture, and who was at high risk for further fractures due to osteoporosis (chronic disease that weakens bones, making them fragile and highly susceptible to fractures, even from minor falls or daily activities), was free from accident hazards. 1. The facility failed to ensure the patient environment was free from accident hazards by allowing Patient 4 to be elevated in the sit-to-stand lift without the sling's waist belt applied, contrary to manufacturer instructions and the facility's Step-by-Step Guide, the staff positioned Patient 4 in the lift without securing the belt snugly at the mid-back and waist, and neither CNA (Certified Nursing Assistant) 6 nor CNA 7 provided hands-on support while the patient was elevated. These failures directly contributed to Patient 4 slipping from the sling and falling to the floor, sustaining left hip fracture. 2. The facility failed to provide adequate supervision and required two-person assistance during a mechanical lift transfer. Although the facility required two staff members (to operate the lift and to stand behind the resident for guidance and support) neither CNA 6 nor CNA 7 held or stabilized Patient 4 during the lift transfer. The staff allowed Patient 4 to be elevated unsupported, despite Patient 4 being dependent for transfer and at high fall risk, resulting in a preventable accident and injury. 3. The facility failed to maintain equipment readiness and proper use in accordance with manufacturer guidelines, including failure to ensure the correct sling type and size were selected and failure to require mandatory securement of the waist belt designed to prevent sliding from the sling. The staff confusion regarding required belt use, improper sling placement, and inconsistent application of equipment safety checks demonstrated the facility's failure to maintain mechanical lift equipment in operable and safe condition. 4. The facility failed to review, evaluate, and update Patient 4's care plan after a change in condition as evidenced by the facility's incomplete and inaccurate investigation of Patient 4's fall. The nursing staff did not verify critical safety elements of the lift transfer including whether the sling's waist belt had been applied, whether the staff provided the required hands-on support during elevation, or whether the correct sling size and components were used. The supervisory nurses, including LVN (Licensed Vocational Nurse) 9 , RN (Registered Nurse)1, and the DON (Director of Nursing), did not interview both CNAs involved to reconcile conflicting accounts, did not confirm sling and belt application with each staff member, and did not assess whether the required two-person assistance procedures were followed. Because the facility failed to conduct a complete and accurate investigation, the nursing staff cannot demonstrate Resident 4's care plan accurately reflected the transfer needs or required revision following a documented fall with injury. 5. The facility failed to ensure written policies and procedures were implemented as evidenced by: a. The facility's failure to follow its own established protocols for safe use of the sit-to-stand lift and for investigation of fall incidents. The facility's P&P required the staff to apply the sling's waist belt snugly around the patient's mid-back and waist, to provide two-person assistance for all mechanical lift transfers, and to ensure one staff member remained positioned behind the patient to provide support during elevation. These procedures were not implemented when neither CNA 6 nor CNA 7 applied the required waist belt and no other staff member provided hands-on- support while the patient was elevated, the patient was lifted without adherence to mandatory safety steps identified in the facility's Step-by-Step Guide and the manufacturer's instructions. b. The facility's failure to follow its fall management and incident-review P&P which required a complete investigation to include interviewing all staff involved, verifying equipment use, and identifying causal factors. Supervisor nursing staff did not verify whether the sling's waist belt had been applied, did not interview both CNAs to reconcile conflicting statements, and did not assess whether lift procedures were followed. The failure to implement the facility's own written policies and procedures contributed to unsafe transfer practices, an incomplete investigation, and the inability to prevent recurrence of similar incidents. As a result of these failures, Patient 4 had a witnessed fall incident on 10/18/25, resulting in a left hip fracture, hospitalization, surgery (hip hemiarthroplasty), and psychiatric morbidity including depression and anxiety relating to the fall and injury. Findings: Review of the facility's P&P titled Fall Management System revised 6/2018 showed the facility would provide each patient with an appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurred. The policy stated that when a patient sustained a fall, a physical assessment would be completed and documented in the patient's medical record; an attending physician and patient representative should be notified of the fall and patient's status; and a post-fall risk evaluation would be completed. In addition, review of the fall incident would include an investigation to identify the probable causal factors. Review of the Direct Supply Panacea owner's manual for the Atlas Sit-to-Stand Lift dated 2021 showed under the Safety Warnings & Cautions section, staff were required to check all sling attachments prior to each use to ensure proper connections. Additional safety precautions included a recommendation to use more than one assistant for all patient lift activities. Review of the Direct Supply Panacea owner's manual for Slings Multi-Brand Compatible dated 12/2023 showed under the Instructions for Sit-to-Stand Slings section, staff were to place the sit-to-stand sling around the patient, secure the buckle on the sling's safety belt, and to adjust the belt to fit comfortably but snugly around the patient's waist. The belt must fit snugly on the patient to prevent the Patient from sliding out of the sling during a transfer, which could cause injury. Review of the facility's Step-by-Step Guide for the Mechanical Stand-Assist Lift (Sit-to-Stand) (undated) showed the Sit-to-Stand Lift was indicated for patients who could bear partial weight, sit up independently, and follow simple commands. Instructions for sling placement included to place the sling around the patient's mid-back and to secure the waist belt snugly to prevent the sling from riding up. In addition, the safety checklist for skilled nursing facility staff included a two-person requirement for the use of mechanical lifts to ensure patient safety and proper positioning. 1. On 3/4/26 at 1315 hours, during the initial tour of the facility, an interview was conducted with Patient 4. Patient 4 stated she had a fall in the facility resulting in a left hip fracture. Patient 4 stated she fell while she was using a sit-to-stand lift to transfer from a shower chair to a wheelchair with the assistance of a CNA. Health record review for Patient 4 was initiated on 3/4/26. Patient 4 was admitted to the facility on 1/8/16 and readmitted on 10/23/24, with diagnoses including a closed fracture of the head and neck of the left femur (thighbone), history of falling, major depressive disorder, osteoporosis, and generalized muscle weakness. Review of Patient 4's MDS (Minimum Data Set- an assessment tool) assessment dated 8/21/25, showed Patient 4 was dependent on staff for chair-to-chair transfers. Further review of the MDS showed to code the patient as dependent, when the patient did not provide any effort to complete the activity or the assistance of two or more helpers were required for the patient to complete the activity. Review of Patient 4's N Adv - Fall Risk Evaluation dated 8/21/25, showed a score of 12, indicating a high fall risk. Review of Patient 4's eINTERACT (quality improvement program that focuses on the management of acute change in a patient condition) Change in Condition Evaluation - V 5.1 dated 10/18/25, showed Patient 4 had a fall incident. The clinician was notified and instructed the staff to contact 911 and perform a neurological assessment per facility protocol. Review of Patient 4's Nursing Progress Notes dated 10/18/25, showed the following: - at 1500 hours, a CNA notified LVN 9 Patient 4 fell on the floor. Patient 4 reported she was being transferred to a shower chair and slipped down to the floor. The clinician was notified and ordered a transfer to an acute care hospital for further evaluation; and - at 1553 hours, RN 2 entered Patient 4's room and observed Patient 4 seated on the floor and leaning against the bathroom door. Patient 4 was crying and with pain rated 8/10 (on the pain scale of 0 to 10 with 0 = no pain and 10 = worst) from her hip and bilateral (both) legs. CNAs were transferring Patient 4 from a wheelchair to a shower chair using a sit-to-stand lift machine and it was reported Patient 4 accidentally slipped from the shower chair and landed on the floor. Review of Patient 4's Incident Report dated 10/18/25, showed the following: - an interview was conducted with CNA 6. CNA 6 stated Patient 4 was using the sit-to-stand lift machine prior to the fall incident and Patient 4 let go of the handlebars of the sit-to-stand lift machine which led to her fall; - a written statement from CNA 6 stating CNAs 6 and 7 were transferring Patient 4 from a shower chair to a wheelchair by using the sit-to-stand lift machine. When the patient was being transferred, Patient 4 accidentally slipped from the sling when Patient 4 let go of the lift's handlebars; - a written statement from CNA 7 stating CNA 7 was helping CNA 6 transfer Patient 4 from a shower chair to a wheelchair, when Patient 4 accidentally slipped her hands outside of the sling, slipped, and fell. CNA 7 stated she went to get LVN 9 to assist Patient 4; and - a written statement from LVN 9 stating a CNA reported her Patient 4 was on the floor. LVN 9 found Patient 4 sitting on the floor and was unable to move her bilateral lower extremities due to severe pain. Review of Patient 4's Acute Care Hospital Record dated 10/23/25, showed Patient 4 fell onto her hips, which caused increased pain. Patient 4 remained on the floor until the paramedics transported her to the acute care hospital. The Left Hip X-Ray showed an impacted left subcapital femoral neck fracture (a fracture just below the femoral head (subcapital) where broken ends are wedged together, keeping the fracture relatively stable). Patient 4 had a left hip hemiarthroplasty (a surgical procedure that replaces half of a damaged hip joint) on 10/19/25. Review of Patient 4's H&P (History and Physical) examination dated 10/27/25, showed Patient 4 had the capacity to make decisions. On 3/5/26 at 1700 hours, a telephone interview was conducted with CNA 6. CNA 6 stated on 10/18/25, she was transferring Patient 4 from a shower chair to a wheelchair using a sit-to-stand lift machine. CNA 6 further stated Patient 4 fell next to the bathroom door inside Patient 4's room. CNA 6 stated Patient 4 fell because Patient 4 let go of the sit-to-stand lift machine's handlebars before CNA 6 instructed her to let go. CNA 6 stated she was operating the sit-to-stand lift machine, while CNA 7 was positioned behind the shower chair, behind Patient 4. CNA 6 stated neither CNAs 6 nor 7 were holding or supporting Patient 4 when Patient 4 was elevated in the sling. On 3/5/26 at 1717 hours, an interview was conducted with CNA 7. CNA 7 stated she was positioned behind Patient 4's shower chair while CNA 6 placed the sling on Patient 4 prior to using the sit-to-stand lift machine. CNA 7 stated CNA 6 was holding Patient 4 at the side of the sit-to-stand lift machine during the transfer. CNA 7 stated Patient 4 was not wearing the sling's waist belt while being lifted in the sling. CNA 7 further stated if Patient 4 had been properly strapped, the fall could have been prevented. CNA 7 explained the sling was required to be positioned under the patient's armpits and secured around the waist with the belt. On 3/9/26 at 1306 hours, an interview was conducted with CNA 8. CNA 8 stated the patients were not required to wear the sling's waist belt and stated the belt was applied for the patients who could not stand upright. On 3/9/26 at 1330 hours, an interview was conducted with CNA 9. CNA 9 stated the sling's waist belt should be applied every time the sit-to-stand lift was used for safety purposes. CNA 9 demonstrated the use of the sit-to-stand lift machine and stated one staff member operated the machine while a second staff member stood behind the patient to guide them. When asked whether a Patient could fall from the sling if they let go of the lift's handlebars, CNA 9 stated a fall would not occur if the waist belt was properly applied. On 3/9/26 at 1402 hours, an interview was conducted with the COTA (Certified Occupational Therapy Assistant). The COTA stated he in-serviced the facility's staff regarding the use of the sit-to-stand lift machine. The COTA further stated two staff members were required when using the lift: one staff member operated the lift, while the second staff member should be positioned behind the patient to guide and support them. The COTA stated the facility's expectation for the use of the sit-to-stand lift machine was to ensure the patients were secured with the sling's waist belt for safety. When asked whether a patient could fall from the sling if they let go of the lift's handlebars, the COTA stated a fall would not occur if the patient was properly secured in the sling. On 3/11/26 at 1446 hours, an interview was conducted with the DON. The DON stated Patient 4 should have been held or supported during the lift transfer by the staff members. On 3/11/26 at 1450 hours, a follow-up interview was conducted with CNA 7. CNA 7 stated neither CNAs 6 nor 7 were holding or supporting Patient 4 while she was elevated in the lift machine. On 3/11/26 at 1511 hours, an observation and concurrent interview was conducted with CNA 7, the COTA and the DON. CNA 7, the COTA and DON demonstrated how to operate the sit-to-stand lift. CNA 7 performed the transfer and one of the surveyors served as the example patient. CNA 7 applied the sling's waist belt to the surveyor, attached the sling to the lift machine, and instructed the surveyor to hold onto the lift's handlebars. During the demonstration, the surveyor was properly strapped into the sling. When the surveyor released her grip from the handlebars, she remained supported in the sling. The COTA stated a patient who was properly secured in the sling would not fall if they let go of the lift's handlebars. The COTA further stated one staff member should operate the lift while a second staff member should always remain behind the patient to provide support and guidance. During the demonstration, CNA 7 clarified that in her earlier statement, she meant Patient 4 was not wearing a gait belt at the time of the lift transfer. The COTA stated a gait belt was not required when using the sit-to-stand lift machine. b. On 3/10/26 at 1155 hours, an interview was conducted with Patient 4. Patient 4 stated she was not wearing the sling's waist belt when she was lifted using the sit