Mn Veterans Home Fergus Falls

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide sufficient protection to other residents while the investigation was completed for 1 of 3 residents (R1) who was reviewed for accidents. This had the potential to affect all 9 residents who required staff assistance with total body lift transfers.Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified he was admitted to the facility on [DATE], from a skilled nursing facility. He had severely impaired cognition, disorganized thinking, and physical behavioral symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing). He was dependent upon staff for all transfers. Diagnoses included non-traumatic brain dysfunction, Alzheimer's (brain cells die over time, brain shrinks and causes dementia/memory loss), aphasia (a disorder that affects how you communicate, speech and as well as the way you write and understand both spoken and written language), seizure disorder, and muscle weakness. R1's care plan dated 12/1/25, identified impaired mobility/transfers due to generalized weakness and severely impaired cognition. Staff were directed on 10/28/25, transfer with one staff assist with ceiling lift. Use Basic Basic (all around sling) size large sling. May leave ceiling lift sling under when in wheelchair. Two staff assist with transfers when having increased behaviors. Care plan transfer section revised on 12/1/25, two staff assist with all transfers using ceiling lift and use Sit on Comfort size large sling.R1's progress notes from 11/30/25 through 12/2/25, identified:-On 11/30/25 at 3:55 p.m. Fall Note: Nursing assistant (NA) alerted nurse during a transfer from bed to wheelchair he fell from the ceiling lift, heard a pop and his left leg went up and fell backwards from the sling. He landed on his back, first hitting his buttocks on the floor mat. Called local medical center and verbal order received to send to ED. Hematoma noted to back left side of head, unable to check eyes. Assessed vitals and level of consciousness. Assisted up with ceiling lift and four staff. Ice applied to back of head. Kept by nursing staff until he could be transferred-On 11/30/25 at 3:55 p.m. Plan of Care note: Writer, registered nurse (RN)-B was called by NA to R1's room. Reported he fell during transfer via lift. He was on the floor with floormat behind. Neuro vital signs started. See contusion on the back of the head, ice pack applied. A bleeding wound was seen on the right posterior arm, applied Opti foam dressing. -On 11/30/25 at 4:50 p.m. he left facility via van and transported to ED. -On 11/30/25 at 10:53 p.m. he returned in wheelchair from ED. Assessed for injuries. Bruising to back of the head and skin tear to forearm. CT scan of head and neck showed no evidence of injuries. Possible mild concussion. Follow up with primary provider for reassessment in 3 to 5 days. -On 12/2/25 at 11:06 a.m. Interdisciplinary team (IDT) reviewed fall from ceiling lift in his room on 11/30/25 at 3:55 p.m. Two staff were present at time of fall and was believed that one of the sling straps came off during the transfer causing him to fall. He hit his head and sent to ED for evaluation. Computed tomography (CT) scan (an advanced imaging test that used x-rays and a computer to create detailed, cross section pictures of inside the body) indicated no internal injury. R1's sling was changed to a full body lift sling that did not require crossing of the leg straps and care plan updated to use two staff for all transfers. Staff involved were immediately retrained. -On 12/2/25 at 10:05 p.m. he had a bruise at the back of the head about 6 by 6 cm in diameter (approximately 2.36 inches), still swollen area surrounding it, wabbly and soft to touch. Skin tear on right forearm still present, cleansed and applied Opti foam dressing. R1's emergency department (ED) visit dated 11/30/25, identified he presented for assessment of injury sustained after he rolled backwards out a Hoyer lift falling approximately 12 to 18 inches striking the back of his head on the ground. Exam noted a large 5 mm contusion/hematoma to the occipital without evidence of depressed skull fracture and a small skin tear to the right forearm without evidence of active bleeding or repairable laceration with a possible mild concussion sustained. Fall was witnessed by nursing staff no loss of consciousness, nausea/vomiting, headache or appreciate and changes to his mental status considering his baseline dementia. Facility 5-day report dated 12/5/25, identified two NAs crossed the lift sling leg straps between R1's legs. NA-B stood on left side of the bed and hooked the Basic Basic lower leg sling strap onto the ceiling lift. NA-A stood on the right side of the bed and hooked up the sling straps (did not identify how many and which one(s)) onto the ceiling lift. NA-B walked away from the left side of bed and towards the wheelchair to assure it was ready to go. NA-B turned around to go back to bed and NA-A had initiated the lift, raised his 3 to 4 inches off the bed, and pulled him away from the bed and towards the chair. NA-A hear a hard snap, but nothing broke on the sling. NA-B approached the end of the bed and heard a pop/thud noise, and he quickly slipped through the sling, buttocks landing on the floor mat first, fell backwards, and right leg remained elevated in the sling strap. NA-A stated happened so fast, unsure what he hit his head on other than the floor mat and received a goose egg. NA-A was the staff member responsible for hooking up the sling loop that came off the ceiling lift hanger bar. RN-A evaluated R1, was responsive and appeared at baseline. RN-A noted nothing wrong with sling, motor or hanger bar of the ceiling lift after incident and completed immediate re-education and competency training on NA-A and NA-B the evening of the incident. R1 was sent to ED and head CT indicated no internal injury. Lift sling was changed to a fuller body lift sling that did not require any crossing of leg straps and care plan updated to use two staff for all transfers. Through interviews and reenactments of events it was substantiated that the incident took place as described. Staff did not assure the lift strap was secured. Review of a facility document written by director of nursing (DON) identified on 12/1/25, DON, RN-A, nurse educator, RN-C, and RN-D went into a vacant room and set up same as R1's room to recreate the incident that occurred on 11/30/25. Immediately noted due to ceiling lift strap being of a non-stiff material was hard to get the strap to stay on the hanger bar and not fall off or in the correct position to stay hooked. If tension was placed on the strap by pulling it into place or raising the lift, stayed in place but not in the correct position inside the hanger bar hook. Much manipulation was needed before being successful to keep it in place and elevate the ceiling lift enough to provide tension enough to get the sling strap to pull out of place crating the popping noise they heard. After all interviews and reenactments were attempted, it was substantiated the incident took place as described by NA-A and NA-B, there was no malice, just an unfortunate accident that may have been precipitated by the left leg sling strap not being fully hooked to the lift bar correctly. During an interview on 12/3/25 at 3:28 p.m. NA-A stated R1 laid in a low bed with fall mat positioned on floor next to bed. She stood on right side of bed, NA-B stood on left side between bed and wall and completed a check and change. His yellow basic sling was located underneath him, the sling loops were crossed between his legs and hooked the loops up to the ceiling lift machine. She was unsure as to which loops she attached to the ceiling lift. She had the remote, lifted him off the bed approximately 9 inches, high enough to swing legs off the bed, the straps seemed tight without slack in the loops, and attached to the ceiling lift bar. NA-B came around to the bottom of the bed prior to when she lifted him off the bed and stood on her left side. She transferred him off the bed and when moved towards the wheelchair heard a loud pop sound he fell from the sling onto the floor on his buttocks. The sling hung from the ceiling lift bar; the left lower leg loop came unhooked from the right side. He laid on his back, legs directly straight out in front of him, unable to recall if he had hit his head, stated ouch asked if he hurt and answered yes. He had a big bump on the back of his head and left inner wrist skin tear, slightly bleeding. The sling was inspected by the nurse, removed from his room. He was lifted off the floor and into the wheelchair with the same ceiling lift. She received education later that night after 10:00 p.m. from the staff nurse when R1 returned from the hospital was transferred back into bed with the ceiling lift. She had worked on the floor and transferred residents with lifts after the incident. Then, later completed education on the computer, read the education document and signed off on the sheet. During a follow-up interview on 12/4/25 at 12:26 p.m. NA-A stated RN-A and RN-B worked with her and NA-B and transferred R1 off the floor with the ceiling lift and into his wheelchair. She continued working her shift and transferred three to four residents after the incident with a ceiling lift, which included R1's roommate (used the same ceiling lift) with the assistance of NA-B, from recliner back to bed. Later in the shift at approximately10:30 p.m. RN-A completed the competency check off list while she transferred R1 from wheelchair to the bed after he returned from ED. The education document located in the staff break room was reviewed also. During an interview on 12/3/25 at 4:40 p.m. RN-B stated she received a message on 11/30/25 at 3:55 p.m. over the walkie and asked her immediately to come to R1's room. He laid on his back on the floor on top of the fall mat, head positioned halfway down from his bed. She asked both NA's what happened they informed her he fell, and they could not recall what really happened. The sling hung from the ceiling lift. He had sustained a skin tear on the right wrist, the back of his head was swollen, and a large bump could be seen when a new sling was placed underneath him. She informed the staff a Hoyer should be used to lift him off the floor. No inspection had been completed on the ceiling lift prior to when it was used again on the same resident. One of the NA's indicated they could use the ceiling lift. She was in the room when R1 was lifted off the floor and placed into his wheelchair. He was at his baseline, body ridged, and no pain. Education on lift transfers and sign off sheet were placed in the staff break room on 12/1/25. During an interview on 12/4/25 at 10:53 a.m. maintenance supervisor (MS) stated once a resident has fallen from a lift the lift should have been taken out of service to make sure there was not anything wrong with the lift and help prevent further falls if it was the lift. His ceiling lift remained in his room and unsure if the lift was used after the incident. He returned to work on 12/1/25, informed of a fall from the ceiling lift, removed the machine from the room and replaced it with one that had been inspected. On 12/4/25 at 11:39 a.m. director of nursing (DON) stated education will be provided today for staff on the policy to remove the lift and sling from service if there is any incident that occurred with a device.During an interview on 12/4/25 at 1:15 p.m. RN-A stated she arrived at R1's room approximately five minutes after the fall occurred. He laid on his back on the floor perpendicular to the bed. She assessed his head and noted a goose egg bruise on the back side of his head about the size of the palm of her hand approximately 5 cm in diameter and a couple dots of blood noted on right wrist/lower forearm from a superficial small abrasion. It was obvious he had hit his head; the bruise was instantly there. He was in pain stated ahhh ahhh ahhh when she cradled the back of his head, barely touching it with her hand. He was asked if it hurt and stated yes. Range of motion (ROM) of all 4 extremities and vitals were completed. The sling hung from the ceiling lift. She asked NA-A what happened and stated did not know it happened so fast. Loops should have been properly hooked up into the ceiling lift bar and double checked they were secure prior to the lift and transfer. The ceiling lift was not taken out of commission during my shift that ended at 10:30 p.m. The sling was removed immediately and placed in DON's office. Another sling was in his dresser drawer and used to same ceiling lift he fell from to transfer him from the floor to the wheelchair. She assisted NA-B with the ceiling lift transfer after the fall. The facility had a portable Hoyer lift and used to if a resident was on the floor due to a fall in hindsight, we should have opted for a better way to transfer him off the floor and used the Hoyer lift. Something went wrong, and R1 fell from the ceiling lift, unsure what and how it happened. Would have been important to have made sure it was not a mechanical error from the ceiling lift and/or lift sling. The nurses should have made that decision and in that moment tried to get him off the floor and made sure he was ok. There was a new intervention added to his care plan the next day, black sling (supported his bottom with no opening) instead of the yellow one. He was sent to ED approximately one hour after fall. The first one to two hours after he was sent in, she completed paper and tasks and the two NAs were not removed from the floor, continued to work with several residents that remained up and required assistance to bed. There were other residents that required the use of the ceiling lift on the [NAME] wing, both NAs worked together, unsure if they used ceiling lifts after incident, unsure if they were safe working together on the floor, and did not observe transfers until she completed her tasks, later in the shift. Towards the end of the shift the two NAs were taken to another resident's room, and the lift competency was completed, and a ceiling lift transfer was observed while they asked questions. The education documents placed in the staff break room was communicated through shift change and she had not read that document yet. During an interview on 12/4/25 at 3:15 p.m. NA-B stated she had pushed R1's bed out from the wall and positioned herself between the wall and the bed on the left side. He laid on top of a yellow lift sheet, Basic Basic. and [NAME] crossed the loops between his legs. She initially hooked up the right upper side, shorter green loop to the left side of the ceiling lift bar, then realized it should have been the longer gray loops, switched it, and tugged on it to make sure it was secure. NA-A hooked up the other three loops to the ceiling lift bar, two on top green shorter loops and the left lower gray loop hooked up to the right side of the ceiling lift bar. Usually, she completed a double check on all the loops of the sling to assure they were connected to the ceiling lift properly but did not do that this time and should have, instead pushed the bed back against the wall (positioned approximately 20 inches from floor) and walked over to the right side of the bed and moved the wheelchair. She walked back over to the end of R1's bed, without her nearby, NA-A had already lifted him up off the bed approximately 9 inches and his legs hung down at a slight angle. She had witnessed in the past, sling loops let go from the ceiling lift when not enough tension was on the strap prior to a transfer. She had noted prior to R1's transfer the left lower loop located on the right side of the ceiling lift bar did not have enough tension on the loop, the strap folded down and hung down, and when raised up the tension tightens up the strap. She did not check the loop again when he was raised off the bed, prior to the fall, and that side that let go. She heard a big thud, sounded like a sling loop came loose and seen the lower left loop became unhooked from the right side of the ceiling lift bar. The sling lift strap flew out between his legs, he slid out of the sling lift, fell onto the floor mat (1 1/2 inches thick), and his right leg hung from the sling still attached to the ceiling lift machine, while he laid on the floor. His upper body was shaking while he hung onto the straps, gave him more security, which made the transfer a bit more difficult. R1 was lifted off the floor with the same ceiling lift by her and RN-A and reviewed what happened at that time. The ceiling lift was used to transfer his roommate back to bed after the incident without difficulty. She reviewed the education sheet today, was her first day back to work. Unsure if she received education prior to when she completed other lifts that evening after R1's fall and anxious about using a lift after the incident. She did not know what caused R1's fall on 11/30/25. During an interview on 12/4/25 at 4:31 p.m. lift supplier representative stated he parented with the lift supplier company and completed annual ceiling lift inspections to assure everything was operating correctly and carry the proper load. The Basic Basic sling was gold colored with gray trim and had two different loops, green (shorter) used on top and gray (longer)used on bottom, located on all four ends. This sling should have been crossed between the legs prior to the transfer. If the loops of the sling were placed properly into the ceiling lift it would have taken a person to manipulate it using human force and worked it out of the steel bull horn located on the ceiling lift. Either it was not hooked up properly, loop tore, or carry bar snapped. Important to ensure the loops were hooked up properly for patient safety and help prevent a fall. Most likely was not hooked up into the carry bar properly and if that happened, they should have had a certified inspector look at the lift. Staff should have been trained properly before being allowed to lift/transfer another resident. Until they determined how and what happened the ceiling lift machine should have removed and sling from the room until the cause could have been determined and sling and ceiling lift inspected. During an interview on 12/4/25 at 5:43 p.m. DON stated She was called right after R1 fell from the ceiling lift during a transfer. The ceiling lift was still in position, sling had remained attached on three out of the four sides and his right leg had to be removed from the lift. RN-A assessed the ceiling lift, speculated it was not the lift that caused the fall, seemed more like the sling loops, hanger bar was not damaged, and used the same lift to transfer him from floor to wheelchair after the fall. She was contacted after they had used the ceiling lift and would have instructed them to take it out of service instead per facility policy for safety purposes for him and his roommate (used to transfer both after fall). Alternative option would have been the EZ way body lift machine. The expectation would be to follow facility policy. RN-A was informed to observe the lift transfer with R1 when he returned to facility. The two NAs involved in the incident were not taken off the floor that night, did not expect them to be, they did not do anything intentional. At 5:00 p.m. she talked with NA-A and then NA-B. NA-A worked with residents while NA-B was in dining room assisting residents. RN-A had informed her she had talked to both NAs, gave them the education on lift and straps, unaware of what time the education was completed. She had received conflicting information from the staff involved. There was always slack in the sling strap until tension was applied, for some reason there was enough tension on the tip of the hanger bar when resident was raised it snapped off the bar from the lift. She would have expected the staff to recheck the loops of the sling and if not hooked appropriately call it out and fix it. Staff should work as a team and was important for the safety of the resident. After a reenactment of the fall from the ceiling lift was completed on 12/1/25, it was identified more education was needed to make sure the staff placed the loop of the sling into the hanging bar. We planned on changing the competency check list, language was vague and should have had a required double check included, which was not included prior to the incident. The outcome was that staff did not hook up the loops properly to the ceiling lift and R1 fell out of sling onto the floor. Facility policy Vulnerable Adult-Resident Protection Plan dated 6/21/23, identified purpose: to establish policies and procedures that ensure that all residents that live at the facility were protected from any and all abuse, neglect, misappropriation of resident property, exploitation, and harm in accordance with federal law and state statute and that they maintain the highest practicable physical, mental and psychosocial well-being of each resident. Investigation protocol to consider: While the investigation is being conducted, suspected individuals will have their employment status reviewed and appropriate actions taken, after approval by the Administrator or designee. Provision of therapeutic misconduct which: An individual makes an error in the provision of therapeutic conduct to a Vulnerable Adult that results in injury or harm, which reasonably requires the care of a physician. Identify and take corrective action and implement measures designed to reduce the risk of further occurrence of this error and similar errors. Facility Demonstration/Return Demonstration for Equipment Ceiling lift last revised 1/2025, identified Strap- must check the lifting strap prior to each transfer for fraying, wear and damage before using the hoist. Any irregularities mean I SHOULD NOT use the hoist and fill out a work order. Lying Position- After sling was placed properly per sling type, place leg straps beneath the resident's thighs, bring them up between the legs and cross them over each other. Bring lifting hanger over the center of the resident to be lifted and place the hanger parallel to the resident's shoulders. All four lift straps are now ready to be attached, and the lifting sling can be mounted on the lifting hanger. The competency did not identify the sling loops should be doubled checked once the resident was ready to be lifted off the bed and/or again after slightly lifted off the bed to confirm they are securely fastened.Facility Demonstration/Return Demonstration for Equipment Ceiling lift last revised 1/2025, page 3 identified: I have been shown how to operate a ceiling lift and have been educated on the various types of slings. I have had the opportunity to ask questions. I understand how to properly use the lift and understand I will use the correct care planned type and size of sling for resident transfers. Both NA-A and NA-B signed this agreement on 11/30/25, time was not documented. Facility policy Standard of Work: Lift, Ceiling - Operating and Daily Maintenance instruction dated 1/7/25, identified all resident equipment should be used appropriately and according to manufacturer's direction. This will ensure that safe resident transfer is provided. Place the leg straps beneath the resident's thighs, bring them up between the legs and cross them over each other (unless using an hourglass or sit on sling). Attach the lifting hanger sling on the lifting hanger: place the lifting hanger parallel to the resident's chest. Attach the hooks that face the resident to the uppermost set of straps (from the back). Attach the lowermost set of straps (from the legs) to the hooks that face away from the user. Check that the straps are placed correctly in a horizontal position on the hooks and are secure on the hooks of the lifting hanger before starting to lift. During the lifting procedure make sure the leg supports do not slide towards the groin of the resident. The resident can now be transferred. Guldmann ceiling lifts allowed one staff to operate and transfer the resident unless care planned for additional staff support. Facility policy Mechanical Transfer Devices dated 2/10/25, identified if an adverse event occurs, the stand or lift involved and sling, if applicable, will be placed out of service immediately by facility staff. The items will be kept in a secure place pending inspection/investigation by designated staff. Facility staff will receive training for both the standing assist and the full body mechanical lifts during their orientation/probation period, as needed, and annually as appropriate. Training will be in accordance with the stand or lift manufacturer's recommendations and documented in staff members' education record. Staff will demonstrate competency in the use of any mechanical stand or lift before assisting/lifting a resident. Staff education document provided on 12/2/25, identified mechanical lift training with all nursing staff upon hire, annually, and as needed. The training includes nursing staff must check the lifting strap to each transfer for fraying, ware and damage before using the hoist. Any irregularity meant I SHOULD NOT use the hoist and fill out a work order. Attach the four appropriate sheet loops to the lifting hanger and use remote to lift resident. Caution! Be careful when attaching the lifting slings' straps on the hooks. Check that the straps have been completely placed in the lifting hanger's hooks. When pressing the buttons on the hand control, check again that all straps remain correctly placed in the lifting hanger and use remote to lift resident. REMINDER: Ensure ALL straps are secure on hanger hooks by slowly lifting resident up PIROR to moving resident from wheelchair/bed/toilet. Ready - ask the resident if they are ready for the transfer? Are the staff ready? Is the equipment ready? Set -Are the sling straps on the hanger bar? Does the resident have shoes on? GO- all parties are ready to go for the transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to implement standards of practice to ensure a safe transfer for 1 of 3 residents (R1) reviewed for accidents when staff failed to properly attach the lift sling to the ceiling lift bar. This resulted in actual harm when R1 fell from the lift during a staff assisted transfer, sustained a large 5 centimeter (cm) contusion (a severe injury caused by a direct blow to the head leading to bruising/swelling of the brain tissue)/hematoma (blood leaks from tiny brain vessels causing swelling) to the occipital scalp (rearmost portion of the head constitutes the posterior section of the brain and skull) and was sent to the emergency department (ED) requiring medical evaluation and pain that persisted requiring medication for discomfort. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was admitted to the facility on [DATE], from a skilled nursing facility.R1 had a moderate difficulty hearing, unclear speech (slurred or mumbled), highly impaired vision, sometimes understood simple direct communication, severely impaired cognition, disorganized thinking, and physical behavioral symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing). R1 was dependent upon staff for all activities of daily living (ADLs), transfers, and incontinent of bowel and bladder. Diagnoses included non-traumatic brain dysfunction, Alzheimer's (brain cells die over time, brain shrinks and causes dementia/memory loss), aphasia (a disorder that affects how you communicate, speech and as well as the way you write and understand both spoken and written language), seizure disorder, and muscle weakness. R1's care plan Kardex dated 12/1/25, identified transfers: two staff assist with ceiling lift to transfer use sit on comfort size large sling. May leave ceiling lift sling under when in wheelchair. Handwritten on the Kardex with a line drawn directly to the above information: Please note change two staff for all transfer and different sling type sit on comfort size large. R1's care plan dated 12/1/25, identified impaired mobility/transfers due to generalized weakness and impaired cognition and not understanding directions. Staff were directed on 10/28/25, transfer with one staff assist with ceiling lift. Use Basic Basic (all around sling) size large sling. May leave ceiling lift sling under when in wheelchair. Two staff assist with transfers when having increased behaviors. Care plan transfer section revised on 12/1/25, two staff assist with all transfers using ceiling lift. Use Sit on Comfort size large sling.R1 had severe cognitive impairment due to dementia with illogical or disorganized speech. R1 was frequently anxious and often resistive to cares related to dementia and Parkinson's (a movement disorder of the nervous system that causes tremors, stiffness, slowing of movement and trouble with balance that raises the risk for falls) with delusions (a type of psychotic disorder with an unshakable belief in something that was untrue). R1's progress notes from 11/30/25 through 12/2/25, identified:-On 11/30/25 at 3:55 p.m. Fall Note: Nursing assistants (NA) stated during a transfer from bed to wheelchair R1 fell from the ceiling lift, heard a pop and his left leg went up and fell backwards from the sling. He landed on his back, first hitting his buttocks on the floor mat. Called local medical center and verbal order received to send to ED. Hematoma noted to back left side of head, unable to check eyes. Assessed vitals and level of consciousness. Assisted up with ceiling lift and four staff. Ice applied to back of head. Kept by nursing staff until he could be transferred-On 11/30/25 at 3:55 p.m. Plan of Care note: Writer, registered nurse (RN)-B was called by NA to R1's room. Reported he fell during transfer via lift. He was on the floor with floormat behind. Neuro vital signs started. See contusion on the back of the head, ice pack applied. A bleeding wound was seen on the right posterior arm, applied Opti foam dressing. -On 11/30/25 at 4:50 p.m. he left facility via van and transported to ED. -On 11/30/25 at 10:53 p.m. he returned in wheelchair from ED. Assessed for injuries. Bruising to back of the head and skin tear to forearm. CT scan of head and neck showed no evidence of injuries. Possible mild concussion. Follow up with primary provider for reassessment in 3 to 5 days. -On 12/1/25 at 8:56 p.m. 24-hour follow-up from fall yesterday. He does not have any additional injuries noted. Pain to back of head due to fall, scheduled Tylenol and Tramadol which was helpful in management of discomfort. Continue to monitor for signs and symptoms of concussion which has not been noted. -On 12/1/25 at 10:33 p.m. NAs reported R1 fell from the ceiling lift during a transfer from bed to wheelchair. They heard a pop, and his left leg went up and he fell downwards to the floor with buttocks landed on fall mat, and upper half went backward from the sling. -On 12/2/25 at 11:06 a.m. Interdisciplinary team (IDT) reviewed fall from ceiling lift in his room on 11/30/25 at 3:55 p.m. Two staff were present at time of fall and was believed that one of the sling straps came off during the transfer causing him to fall. He hit his head and sent to ED for evaluation. Computed tomography (CT) scan (an advanced imaging test that used x-rays and a computer to create detailed, cross section pictures of inside the body) indicated no internal injury. R1's sling was changed to a full body lift sling that did not require crossing of the leg straps and care plan updated to use two staff for all transfers. Staff involved were immediately retrained. -On 12/2/25 at 10:05 p.m. he had a bruise at the back of the head about 6 by 6 cm in diameter (approximately 2.36 inches), still swollen area surrounding it, wabbly and soft to touch. Skin tear on right forearm still present, cleansed and applied Opti foam dressing. R1's emergency department (ED) visit dated 11/30/25, identified he presented for assessment of injury sustained after he rolled backwards out a Hoyer lift falling approximately 12 to 18 inches striking the back of his head on the ground. Exam noted a large 5 mm contusion/hematoma to the occipital without evidence of depressed skull fracture and a small skin tear to the right forearm without evidence of active bleeding or repairable laceration with a possible mild concussion sustained. Due to his advanced dementia, he is non-verbal at baseline and therefore the history and physical (HP) is primarily obtained by verbal report provided by nursing home staff prior to his arrival to ED. Fall was witnessed by nursing staff no loss of consciousness, nausea/vomiting, headache or appreciate and changes to his mental status considering his baseline dementia. Facility 5-day report dated 12/5/25, identified two NAs crossed the lift sling leg straps between R1's legs. NA-B stood on left side of the bed and hooked the Basic Basic lower leg sling strap onto the ceiling lift. NA-A stood on the right side of the bed and hooked up the sling straps (did not identify how many and which one(s)) onto the ceiling lift. NA-B walked away from the left side of bed and towards the wheelchair to assure it was ready to go. NA-B turned around to go back to bed and NA-A had initiated the lift, raised him 3 to 4 inches off the bed, and pulled him away from the bed and towards the chair. NA-A hear a hard snap, but nothing broke on the sling. NA-B approached the end of the bed and heard a pop/thud noise, and he quickly slipped through the sling, buttocks landing on the floor mat first, fell backwards, and right leg remained elevated in the sling strap. NA-A stated happened so fast, unsure what he hit his head on other than the floor mat and received a goose egg. NA-A was the staff member responsible for hooking up the sling loop that came off the ceiling lift hanger bar. Registered nurse (RN-A) evaluated R1, was responsive and appeared at baseline. RN-A noted nothing wrong with sling, motor or hanger bar of the ceiling lift after incident and completed immediate re-education and competency training on NA-A and NA-B the evening of the incident. R1 was sent to ED and head CT indicated no internal injury. Lift sling was changed to a fuller body lift sling that did not require any crossing of leg straps and care plan updated to use two staff for all transfers. Through interviews and reenactments of events it was substantiated that the incident took place as described. Staff did not assure the lift strap was secured. Review of a facility document written by director of nursing (DON) identified on 12/1/25, DON, RN-A, nurse educator, RN-C, and RN-D went into a vacant room and set up same as R1's room to recreate the incident that happened on 11/30/25 with R1. Immediately noted due to ceiling lift strap being of a non-stiff material was hard to get the strap to stay on the hanger bar and not fall off or in the correct position to stay hooked. If tension was placed on the strap by pulling it into place or raising the lift, stayed in place but not in the correct position inside the hanger bar hook. Much manipulation was needed before being successful to keep it in place and elevate the ceiling lift enough to provide tension enough to get the sling strap to pull out of place crating the popping noise they heard. They were unable to get the person in the lift very high off the mattress to start to move them away from the bed towards the chair before the strap would come off the lift. After all interviews and reenactments were attempted, it was substantiated the incident took place as described by NA-A and NA-B, there was no malice, just an unfortunate accident that may have been precipitated by the left leg sling strap not being fully hooked to the lift bar correctly. During an observation on 12/3/25 at 11:15 a.m. NA-C and NA-D entered R1's room, washed hands and applied gloves. NA-C pushed bed out from the wall and positioned herself on the left side of the bed and NA-D checked his pants and verified dry. NA-D moved the ceiling lift over to his bed and lowered it down in front of him. NA-C and NA-D connected the sling loops on their side to the ceiling lift bar. Lift sling was black, size large, and cover his buttocks. The upper and lower sling loops were hooked up to the ceiling lift bar by each NA. NA-D used the ceiling remote control to lift him off the bed slightly and rechecked loop connections to ceiling lift bar. Then continued to raise him off the bed, moved him over to above the wheelchair, lowered him down, and disconnected the loops from the ceiling lift. During an interview on 12/3/25 at 3:28 p.m. NA-A stated R1 laid in a low bed with fall mat positioned on floor next to bed. She stood on right side of bed, NA-B stood on left side between bed and wall and completed a check and change. His yellow basic sling was located underneath him, the sling loops were crossed between his legs and loops hooked up to the ceiling lift machine. She was unsure as to which loops she attached to the ceiling lift. She had the remote, lifted him off the bed approximately 9 inches, high enough to swing legs off the bed, the straps seemed tight without slack in the loops, and attached to the ceiling lift bar. NA-B came around to the bottom of the bed prior to when she lifted him off the bed and stood on her left side. She transferred him off the bed and moved towards the wheelchair then heard a loud pop sound and he fell from the sling onto the floor on his buttocks. The sling hung from the ceiling lift bar; the left lower leg loop came unhooked from the right side. He laid on his back, legs directly straight out in front of him, unable to recall if he had hit his head, stated ouuuuu, asked if he hurt and answered yes. He had a big bump on the back of his head and left inner wrist skin tear, slightly bleeding. The sling was inspected by the nurse, removed from his room. He was lifted off the floor and into the wheelchair with the same ceiling lift. She received education later that night after 10:00 p.m. from the staff nurse when R1 returned from the hospital was transferred back into bed with the ceiling lift. She had worked on the floor and transferred residents with lifts after the incident. Then, later completed education on the computer, read the education document and signed off on the sheet. During a follow-up interview on 12/4/25 at 12:26 p.m. NA-A stated the nurses working the day of the fall RN-A and RN-B worked with her and NA-B while R1 was transferred off the floor with the ceiling lift and into his wheelchair. She continued working her shift and transferred three to four residents after the incident with the ceiling lift, which included R1's roommate (used the same ceiling lift) and transferred him, with the assistance of NA-B, from recliner back to bed. Later in the shift at about 10:30 p.m. RN-A completed the competency check off list while she transferred R1 from wheelchair to the bed after he returned from ED. During an interview on 12/3/25 at 4:40 p.m. RN-B stated she received a message on 11/30/25 at 3:55 p.m. over the walkie and asked her immediately to come to R1's room. He laid on his back on the floor on top of the fall mat, head positioned halfway down from his bed. She asked both NA's what happened they informed her he fell, and they could not recall what really happened. The sling hung from the ceiling lift. He had sustained a skin tear on the right wrist, the back of his head was swollen, and a large bump could be seen when a new sling was placed underneath him. She informed the staff a Hoyer should be used to lift him off the floor. No inspection had been completed on the ceiling lift prior to when it was used again on the same resident. One of the NA's indicated they could use the ceiling lift. She was in the room when R1 was lifted off the floor with the ceiling lift and placed into his wheelchair. He was at his baseline, body ridged, and no pain. Education on lift transfers and sign off sheet were placed in the break room on 12/1/25. During an interview on 12/4/25 at 10:53 a.m. maintenance supervisor (MS) stated the ceiling lift inspection was completed last by a local medical company 12/3/25, on all ceiling lifts in facility and passed. Once a resident has fallen from a lift, the lift should have been taken out of service to make sure there was not anything wrong with the lift and help prevent further falls if it was the lift. His ceiling lift remained in his room and unsure if the lift was used after the incident. He returned to work on 12/1/25, informed of a fall from the ceiling lift, removed the machine from the room and replaced it with one that had been inspected. His ceiling lift was inspected and tested on [DATE], by the medical company and no concerns were noted. On 12/4/25 at 11:39 a.m. director of nursing (DON) stated education will be placed today for staff on the policy to remove the lift and sling from service if there is any incident that occurred with a device.During an interview on 12/4/25 at 1:15 p.m. RN-A stated she arrived at R1's room approximately five minutes after the fall occurred. He laid on his back on the floor perpendicular to the bed. She assessed his head and noted a goose egg bruise on the back side of his head about the size of the palm of her hand approximately 5 cm in diameter and a couple dots of blood noted on right wrist/lower forearm from a superficial small abrasion. It was obvious he had hit his head; the bruise was instantly there. He was in pain stated ahhh ahhh ahhh when she cradled the back of his head, barely touching it with her hand. He was asked if it hurt and stated yes. Range of motion (ROM) of all 4 extremities and vitals were completed. The sling hung from the ceiling lift. She asked NA-A what happened and NA-A stated did not know, it happened so fast. Loops should have been properly hooked up into the ceiling lift bar and double checked they were secure prior to the lift and transfer. The ceiling lift was not taken out of commission during her shift that ended at 10:30 p.m. The sling was removed immediately and placed in DON's office. Another sling was in his dresser drawer and used with the same ceiling lift he fell from to transfer him from the floor to the wheelchair. She assisted NA-B with the ceiling lift transfer after the fall. The facility had a portable Hoyer lift and used if a resident was on the floor due to a fall. In hindsight, we should have opted for a better way to transfer him off the floor and used the Hoyer lift. Something went wrong, and R1 fell from the ceiling lift, unsure what and how it happened. Would have been important to have made sure it was not a mechanical error from the ceiling lift and/or lift sling. The nurses should have made that decision and in the moment tried to get him off the floor and made sure he was ok. There was a new intervention added to his care plan the next day, black sling (supported his bottom with no opening) instead of the yellow one. He was sent to ED approximately one hour after fall. The first one to two hours after he was sent in, she completed paperwork and tasks. The two NAs were not removed from the floor, continued to work with several residents that remained up and required assistance to bed. There were other residents that required the use of the ceiling lift on the [NAME] wing, both NAs worked together. She was unsure if they used ceiling lifts after incident or if they were safe working together on the floor, and did not observe transfers until she completed her tasks, later in the shift. Towards the end of the shift the two NAs were taken to another resident's room, the lift competency was completed during ceiling lift transfer, and observed while they asked questions. The education documents placed in the staff break room was communicated through shift change and she had not read it yet. During an interview on 12/4/25 at 3:15 p.m. NA-B stated she had pushed R1's bed out from the wall and positioned herself between the wall and the bed on the left side. He laid on top of a yellow lift sheet, and crossed the loops between his legs. She initially hooked up the right lower side, shorter green loop to the left side of the ceiling lift bar, then realized it should have been the longer gray loop, switched it, and tugged on it to make sure it was secure. NA-A hooked up the other three loops to the ceiling lift bar, two on top green shorter loops and the left lower gray loop hooked up to the right side of the ceiling lift bar. Usually, she completed a double check on all the loops of the sling to assure they were connected to the ceiling lift properly but did not do that this time and should have, instead she pushed the bed back against the wall (positioned approximately 20 inches from floor), walked over to the right side of the bed and moved the wheelchair. She walked back over to the end of R1's bed, NA-A had already lifted him up off the bed approximately 9 inches and his legs hung down at a slight angle. She had witnessed in the past, sling loops let go from the ceiling lift when not enough tension was on the strap prior to a transfer. She had noted prior to R1's transfer the left lower loop located on the right side of the ceiling lift bar did not have enough tension on the loop, the strap folded and hung down, and when raised up the tension tightened up the strap. She did not check the loop again when he was raised off the bed, prior to the fall, and that side let go. She heard a big thud, sounded like a sling loop came loose and seen the lower left loop became unhooked from the right side of the ceiling lift bar. The sling lift strap flew out between his legs, he slide out of the sling lift, fell onto the floor mat (1 1/2 inches thick), and his right leg hung from the sling still attached to the ceiling lift machine, while he laid on the floor. His upper body was shaking while he hung onto the straps, gave him more security, which made the transfer a bit more difficult. R1 was lifted off the floor with the same ceiling lift by her and RN-A and we reviewed what happened at that time. The ceiling lift was used to transfer his roommate back to bed after the incident without difficulty. She reviewed the education sheet today, was her first day back to work. Unsure if she received education prior to when she completed other lifts that evening, and anxious about using a lift after the incident. She did not know what caused R1's fall on 11/30/25. During an interview on 12/4/25 at 4:31 p.m. lift supplier representative stated he parented with the lift supplier company and completed annual ceiling lift inspections to assure everything was operating correctly and carried the proper load. The Basic Basic sling was gold colored with gray trim and had two different loops, green (shorter) used on top and gray (longer)used on bottom, located on all four ends. This sling should have been crossed between the legs prior to the transfer. If the loops of the sling were placed properly into the ceiling lift it would have taken a person to manipulate it using human force and work it out of the steel bull horn located on the ceiling lift. Either it was not hooked up properly, loop tore, or carry bar snapped. Important to ensure the loops were hooked up properly for patient safety and help prevent a fall. Most likely was not hooked up into the carry bar properly and if that happened, they should have had a certified inspector look at the lift. The ceiling lift machine should have been taken out of service if there was a failure of the lift. Staff should have been trained properly before being allowed to lift/transfer another resident. Until they determined how and what happened they should have removed the machine and sling form the room until the cause could have been determined and inspect the sling and ceiling lift. During an interview on 12/4/25 at 5:43 p.m. DON stated the sling reference book according to the manufacture was used on 4/11/25, to determine the sling size and type use for R1. The sling used during R1's transfer and fall on 11/30/25 was appropriate. He had Parkinson's, ridged, and NAs requested he be reassessed for comfort reasons due the Basic Basic sling went up and crossed between the legs. He was reassessed after the fall and changed to the black full body lift sling, more comfortable and assist of one to two due to he grabbed and shook when stimulated. She was called right after R1 fell from the ceiling lift during a transfer. The ceiling lift was still in position, sling had remained attached on three out of the four sides and his right leg had to be removed from the lift. RN-A assessed the ceiling lift, speculated it was not the lift that caused the fall, seemed more like the sling loops, hanger bar was not damaged, and used the same lift to transfer him from floor to wheelchair after the fall. She was contacted after they had used the ceiling lift and would have instructed them to take it out of service instead per facility policy for safety purposes for him and his roommate (used to transfer both after fall). Alternative option would have been the EZ way body lift machine. The expectation would be to follow facility policy. RN-A was informed to observe the lift transfer with R1 when he returned to facility. The two NAs involved in the incident were not taken off the floor that night, did not expect them to be, they did not do anything intentional. At 5:00 p.m. she talked with NA-A and then NA-B. NA-A worked with residents while NA-B was in dining room assisting residents. RN-A had informed her she had talked to both NAs, gave them the education on lift and straps, unaware of what time the education was completed. She had received conflicting information from the staff involved. There was always slack in the sling strap until tension was applied, for some reason there was enough tension on the tip of the hanger bar when resident was raised it snapped off the bar from the lift. She would have expected the staff to recheck the loops of the sling and if not hooked appropriately call it out and fix it. Staff should work as a team and was important for the safety of the resident. We completed a reenactment of the fall from the ceiling lift and decided more education was needed to make sure the staff placed the loop of the sling into the hanging bar. We planned on changing the competency check list, language was vague and should have had a required double check included, which was not included prior to the incident. The outcome was that staff did not hook up the loops properly to the ceiling lift and R1 fell out of sling to the floor. Facility Demonstration/Return Demonstration for Equipment Ceiling lift last revised 1/2025, identified Strap- must check the lifting strap prior to each transfer for fraying, wear and damage before using the hoist. Any irregularities mean I SHOULD NOT use the hoist and fill out a work order. Lying Position- After sling was placed properly per sling type, place leg straps beneath the resident's thighs, bring them up between the legs and cross them over each other. Bring lifting hanger over the center of the resident to be lifted and place the hanger parallel to the resident's shoulders. All four lift straps are now ready to be attached, and the lifting sling can be mounted on the lifting hanger. The competency did not identify the sling loops should be doubled checked once the resident was ready to be lifted off the bed and/or again after slightly lifted off the bed to confirm they are securely fastened to ensure they will not unhook during the transfer. Facility Demonstration/Return Demonstration for Equipment Ceiling lift last revised 1/2025, page 3 identified I have been shown how to operate a ceiling lift and have been educated on the various types of slings. I have had the opportunity to ask questions. I understand how to properly use the lift and understand I will use the correct care planned type and size of sling for resident transfers. Both NA-A and NA-B signed this agreement on 11/30/25, time was not documented. Facility policy Standard of Work: Lift, Ceiling - Operating and Daily Maintenance instruction dated 1/7/25, identified all resident equipment should be used appropriately and according to manufacturer's direction. This will ensure that safe resident transfer is provided. Place the leg straps beneath the resident's thighs, bring them up between the legs and cross them over each other (unless using an hourglass or sit on sling). Attach the lifting hanger sling on the lifting hanger: place the lifting hanger parallel to the resident's chest. Attach the hooks that face the resident to the uppermost set of straps (from the back). Attach the lowermost set of straps (from the legs) to the hooks that face away from the user. Check that the straps are placed correctly in a horizontal position on the hooks and are secure on the hooks of the lifting hanger before starting to lift. During the lifting procedure make sure the leg supports do not slide towards the groin of the resident. The resident can now be transferred. Guldmann ceiling lifts allow for one staff to operate and transfer the resident unless care planned for additional staff support. Staff education provided on 12/2/25, identified mechanical lift training with all nursing staff upon hire, annually, and as needed. The training includes nursing staff must check the lifting strap to each transfer for fraying, ware and damage before using the hoist. Any irregularity meant I SHOULD NOT use the hoist and fill out a work order. Attach the four appropriate sheet loops to the lifting hanger and use remote to lift resident. Caution! Be careful when attaching the lifting slings' straps on the hooks. Check that the straps have been completely placed in the lifting hanger's hooks. When pressing the buttons on the hand control, check again that all straps remain correctly placed in the lifting hanger and use remote to lift resident. REMINDER: Ensure ALL straps are secure on hanger hooks by slowly lifting resident up PRIOR to moving resident from wheelchair/bed/toilet. Ready - ask the resident if they are ready for the transfer? Are the staff ready? Is the equipment ready? Set -Are the sling straps on the hanger bar? Does the resident have shoes on? GO- all parties are ready to go for the transfer. Facility policy Vulnerable Adult-Resident Protection Plan dated 6/21/23, identified purpose: to establish policies and procedures that ensure that all residents that live at the facility were protected from any and all abuse, neglect, misappropriation of resident property, exploitation, and harm in accordance with federal law and state statute and that they maintain the highest practicable physical, mental and psychosocial well-being of each resident. Investigation protocol to consider: While the investigation is being conducted, suspected individuals will have their employment status reviewed and appropriate actions taken, after approval by the Administrator or designee. Provision of therapeutic misconduct which: An individual makes an error in the provision of therapeutic conduct to a Vulnerable Adult that results in injury or harm, which reasonably requires the care of a physician. Identify and take corrective action and implement measures designed to reduce the risk of further occurrence of this error and similar errors. Facility policy Mechanical Transfer Devices dated 2/10/25, identified purpose was to identify standard guidelines for the safe operation of standing assist mechanical lifts and full body mechanical lifts and to ensure the safety of facility staff when transferring, lifting, and moving residents. The appropriate mechanical device will be used for a resident requiring more than minimal assistance to enable nursing staff to lift, transfer, position, and move the resident safely per the resident's care plan and the facility Safe Resident Handling Program, in accordance with the equipment manufacturer's recommendations and all State and Federal rules and regulations. If an adverse event occurs, the stand or lift involved and sling, if applicable, will be placed out of service immediately by facility staff. The items will be kept in a secure place pending inspection/investigation by designated staff. Facility staff will receive training for both the standing assist and the full body mechanical lifts during their orientation/probation period, as needed, and annually as appropriate. Training will be in accordance with the stand or lift manufacturer's recommendations and documented in staff members' education record. Staff will demonstrate competency in the use of any mechanical stand or lift before assisting/lifting a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to accurately assess and implement safe smoking interventions for 1 of 1 resident (R17) reviewed for smoking.
Findings include:
R17's quarterly Minimum Data Set (MDS) dated [DATE], indicated R17 had diagnoses which included chronic obstructive pulmonary disease (COPD) hypertension (elevated blood pressure), and stroke. Identified R17 had severe cognitive impairment and was independent with activities of daily living (ADL's) which included transfers and toileting. Identified R17 used tobacco.
R17's annual Care Area Assessment (CAA) dated 5/1//24, identified interventions were in place to address safety needs.
R17's care plan revised 4/27/21, identified the facility had determined R17 was a modified independent smoker. Care plan identified facility was to store R17's cigarettes and give R17 one cigarette at a time to smoke independently.
R17's smoking assessment dated [DATE], indicated R17 was safe to dispose of ashes and smoking material completely. Assessment indicated R17 did not have any visible burns on clothing or wheelchair cushion. Indicated R17 was safe to smoke independently without supervision and did not require a smoking apron.
R17's smoking assessment dated [DATE], indicated R17 was safe to dispose of ashes and smoking material completely. Assessment indicated R17 did not have any visible burns on clothing or wheelchair cushion. Indicated R17 was safe to smoke independently without supervision and did not require a smoking apron.
During an observation on 2/4/25 at 9:15 a.m., R17 was standing at the nurses station. R17 received one cigarette from registered nurse (RN)-A. R17 walked into the smoking room which was located about 40 feet from the nurse's station. R17 put the cigarette into the wall lighter. (a small hole within a metal box located on the wall) and lit the cigarette. R17 sat down in the chair and began smoking the cigarette and as R17 was smoking the cigarette ashes began falling on his lap. R17 had not made any effort to remove the cigarette ashes from his pants and continued smoking. R17 placed the cigarette which was still burning in an ashtray and walked back to the nurses station and received another cigarette from RN-A. R17 walked back into the smoking room and picked up his previous cigarette and used it to light the new cigarette then placed the first cigarette still burning into the ashtray. R17 smoked the second cigarette as ashes continued to fall onto his lap. R17 made no effort to remove the cigarette ashes from his lap and continued smoking. R17 then placed the second cigarette which was still burning into the ashtray. R17 made no effort to extinguish either of the two cigarettes. R17 then left the smoking room and went back to his room.
During an observation on 2/4/25 at 9:51 a.m., R17 came out of his room and walked to the nurse's station and received one cigarette from RN-A. R17 walked into the smoking room and used the wall lighter to light the cigarette. R17 sat down in the chair and had visible holes in the black sweatpants he was wearing. R17 began smoking the cigarette and ashes began falling onto his lap. R17 made no effort to remove the cigarette ashes from his pants and continued smoking R17 placed the cigarette which was still burning into the ashtray. R17 made no effort to extinguish the cigarette, got up from the chair, several ashes were noted on the floor as R17 left the smoking room and walked back to his room.
During an inventory of R17's clothing on 2/4/25 at 9:26 a.m., RN-A identified two pair of blue pants with large burn-holes, one pair of gray pants with burn-holes, and the black sweatpants R17 was wearing had several burn-holes in them.
During an interview on 2/4/25 at 10:02 a.m., laundry aide (LA)-A stated she was aware of the burn-holes in R17's pants. LA-A stated she was not sure how long the burn-holes had been on R17's pants.
During an interview on 2/4/25 at 11:00 a.m., nursing assistant (NA)-A stated R17 was a smoker and the nurses stored R17's cigarettes for him. NA-A stated R17 was able to smoke in the smoking room without supervision or a smoking apron. NA-A stated she was aware of the burn-holes in R17's pants however, was unsure how long the burn-holes have been there.
During an interview on 2/4/25 at 11:10 a.m., NA-B stated R17 was a smoker and the nurses stored R17's cigarettes for him. NA-A stated R17 was able to smoke in the smoking room without supervision or a smoking apron. NA-A stated she was aware of the burn-holes on R17's pants however, was unsure how long the burn-holes have been there.
During an interview on 2/4/25 at 11:36 a.m., RN-A stated she had completed smoking assessments on R17 by observing R17 smoke through the window however, had never gone into the smoking room while R17 was smoking. RN-A stated she was aware of the burn-holes on R17's pants however, was not sure how long the holes had been there. RN-A stated she was not sure why the smoking assessments stated there were no visible holes on R17's clothing. RN-A stated for safety reasons her expectation was that staff should have been offering a smoking apron or supervise R17 while smoking.
During an interview on 2/4/25 at 12:13 p.m., RN-B stated she had observed R17 smoking through the window however, had never gone into the smoking room while R17 was smoking. RN-B stated she was aware of the burn-holes present on R17's pants and was not sure how long the holes had been there. RN-B stated she had assumed R17 was safe to smoke unsupervised and did not require a smoking apron.
During an interview on 2/4/25 at 12:17 p.m., RN-C stated she had not visualized R17 smoking. RN-C stated when the nurses completed a visual smoking assessment on R17, it was usually by visualizing the window. RN-C stated she was aware of the burn-holes present on R17 clothing however, was unsure how long the holes had been there. RN-C stated another assessment was going to be completed to ensure R17's safety while smoking.
During an interview on 2/4/25 at 12:42, director of nursing (DON) stated she was aware of the burn-holes present on R17's clothing. DON stated she was unsure how long the holes have been on the clothing or if any of the burn-holes had happened recently. DON stated her expectation was that R17 was safe while smoking and that another smoking assessment was to be completed and that safety interventions would be implemented off of that new smoking assessment to ensure R17 was safe while smoking.
Review of a facility policy titled Smoking and Tobacco Policy revised 5/1/19 identified residents ho smoke would have a smoking assessment quarterly and upon change of condition. Identified smoking interventions were based on the individualized smoking assessment. Residents will follow the plan of care. Violations of the rules or agreed to interventions may result in the loss of the smoking privilege or may lead to smoking restrictions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure professional standards of practice were followed during medication set-up and administration of insulin with a Novolog insulin pen ( rapid-acting insulin, used to improve blood sugar control in people with diabetes mellitus) for 1 of 2 residents (R15) who received insulin without the pen primed according to manufacturer's recommendations.
Findings include:
R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 had intact cognition with diagnosis of type two diabetes (DM), and received injections of insulin.
R15's care plan revised 5/31/24, identified staff were to administer medications as prescribed.
R15's Medication Review Report signed 12/18/24, identified Semglee Pen-100 units/milliliter, inject 12 units Subcutaneously (an injection just under the skin into the fatty tissue) two times daily for DM.
During an observation of medication pass on 2/3/25 at 6:10 p.m., registered nurse (RN)-D prepared R15's medication which included her evening, Semglee insulin. RN-D removed the Semglee insulin pen from the medication cart, removed the tip, attached a needle to the end of the pen, dialed the dose to the ordered 12 units, picked up an alcohol wipe, went to R15's room and administered the 12 units of insulin to R15. RN-D then removed the needle from the end of the pen, placed it in the sharps container and sanitized his hands. RN-D did not prime the pen (waste 2 units of insulin to remove the air bubbles) per manufacturer's instructions prior to drawing up the 12 units of insulin.
During an interview on 2/5/25 at 9:33 a.m., RN-D verified he had not primed the insulin pen prior to dialing up the 12 units of Semglee for R15 per manufacturer's recommendations. RN-D stated he was aware the insulin pen should have been primed prior to dialing up the insulin to ensure the accurate dosage of insulin was administered.
During an interview on 2/5/25 at 9:35 a.m., consultant pharmacist (CP) stated it was important to always prime an insulin pen prior to drawing up the dosage to ensure the residents received the correct dosage of insulin.
During an interview on 2/5/25 at 10:27 a.m., director of nursing (DON) stated her expectation was that the insulin pen would have been primed prior to dialing up the insulin dose for R15 to ensure the proper dose of insulin was administered.
Review of the Semglee insulin manufacture's package insert dated 2021, identified the need to perform an airshot before each injection to ensure the any air bubbles were removed. The process directed: Attach a new needle, Select a dose of 2 units on the dosage selector, hold the pen with the needle pointing upward, tap the insulin reservoir to move any air bubbles to the top of the reservoir, press the injection button all the way in, and check to see if insulin comes out of the needle tip. Repeat if no insulin comes from the needle, then dial the selector to the ordered insulin dose and administer as ordered.
Review of a facility policy titled Medication Administration Standard revised 5/23, identified staff would follow appropriate standards and protocols when administering medications.