§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.
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Observations:
Based on facility policy reviews, clinical record reviews, facility provided documentation, manufacturer equipment manual review, and resident and staff interviews, it was determined that the facility failed to complete a thorough investigation into resident incidents for two of five residents reviewed (Residents 2, and 3); and failed to provide adequate assistance and supervision to prevent accidents, which resulted in actual harm as evidenced by bilateral upper arm fractures requiring hospital transfer and surgical intervention for one of five residents reviewed (Resident 1).
Findings include:
Review of facility policy, titled "Incident Investigation and Follow-Up," with a last revised date of April 2026, revealed, in part, "It is the policy in Messiah Lifeways Skilled Nursing to complete a thorough and prompt investigation of all resident incidents and provide related documentation to further clarify the events surrounding the incident. 1) Upon identifying an incident, clinical staff will take action immediately to protect the resident' s safety and report to the appropriate personnel (Clinical Manager, Supervisor, Nursing Administration). 2) Complete the Incident Investigation promptly following the incident with resident and team members involved. 2c) Obtain written statement from staff (see attached) that found or witnessed the event and any other necessary statements. "
Review of facility policy, titled "Fall Management," revealed, in part, "It is the policy of the facility to provide for the safest possible resident care environment while providing for the independence and highest practical level of function for each resident in the nursing care facility ... "
Review of facility policy, titled "Lift-Sara," with a last revised date of May 2026, revealed, in part, "The Sara lift provides an alternative method for safe transfer of patients who can bear weight on their extremities and can hold onto handles of the Sara Lift ..... Encourage the patient to assist all he/she can to achieve a standing position. Operate the handset control to raise the support arms, this will elevate the patient into a near standing position - their feet being supported on the footrest. 12. Be careful not to raise the patient too high as this could cause unnecessary pressure under the arms."
Review of the Sara Flex lift manual revealed, in part, "Sara Flex is a mobile standing and raising aid, with a Safe Working Load of 200kg [kilograms] (440 lb-pounds), intended to assist caregivers in hospitals, long-term care, nursing homes and home care environments, including private homes, to lift and transfer patients/residents from one place to another e.g. to and/or from a chair, wheelchair, bed side, bath, shower/commode chair or toilet. Patient/Resident Assessment: It is recommended that facilities establish regular assessment routines to make sure caregivers are assessing each patients/residents prior to use. Before use the caregiver should always consider the patients/residents medical condition, physical and mental capabilities. Safety Instructions: Warning-To avoid injury, a full clinical assessment of the patient's condition, and suitability must be carried out by qualified personnel, before attempting to use Sara Flex. Raise a Patient to Standing Position-Warning-To avoid injury make sure the patient is participating. If not, consider to end the transfer, return the patient to a sitting position and reevaluate the choice of equipment."
Review of Resident 1's clinical record revealed that the Resident was originally admitted to the facility on June 20, 2026, with diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), vitamin D deficiency, muscle weakness, and a periprosthetic fracture (a break in bone that occurs around or very close to an implanted orthopedic prosthesis [medical devices designed to replace missing body parts or support weakened or unstable joints and limbs]) in the left hip joint.
Further review of Resident 1 ' s clinical record revealed that she was admitted to the facility for short-term rehab, to include physical therapy (PT) and occupational therapy (OT), with a plan to discharge back to her home with caregiver support.
Review of Resident 1 ' s care plan revealed that upon her admission to the facility, she was to be transferred using a maxi-lift (a full body mechanical lift).
Review of Resident 1's PT Treatment Encounter Note dated July 13, 2026, revealed: "Attempted SARA lift with res[ident] this day but res[ident] unable to complete safely due to LLE [left lower extremity] ROM [range of motion] deficits."
Review of Resident 1's OT Treatment Encounter note dated July 13, 2026, revealed: "Skilled interventions focused on transfer training using hoyer lift/saralift (2A) [two assist] with MAX[imum] VCS [Verbal Communication Strategies] and 2 person A[ssist] for positioning properly on Sara lift to increase functional task performance. Pt unable to complete safely this date. "
Review of Resident 1's care plan revisions provided by the facility revealed that she was changed from a maxi-lift (full body mechanical lift) to a two-person assist with wheeled walker on August 7, 2026.
Review of Resident 1's clinical record revealed a nurse's note by Employee 6 (Registered Nurse Supervisor) dated August 16, 2026, at 8:00 PM, that indicated Resident 1 "was being transferred in sara lift this evening when she had pain in her bilateral arms. Transferred back to bed and noted bruise to left upper arm. resident unable to lift arms off bed. has severe pain with any movement. Given PRN [as needed] Tylenol and ice Suspected Cause of Incident : injured during transfer with sara lift Approach to Prevent Recurrence : Intervention maxi lift until further notice. Provider/Resident Representative Notification: Provider updated and ordered x-rays of bilateral arms (humerus [bone located in upper arm], clavicle [collarbone] and shoulder) POA aware."
Review of Resident 1's facility provided incident report dated August 16, 2026, at 6:03 PM, revealed Resident 1 "was being transferred in sara lift this evening when she had pain in her bilateral arms. Transferred back to bed and noted bruise to left upper arm." Resident description section indicated that Resident 1 reported "I heard a crack and have pain in both my arms."
Review of witness statements revealed a witness statement by Employee 1 (Nurse Aide) that indicated she was helping Employee 2 (Nurse Aide) "with transferring the resident, but the resident could not stand so they decided to use the Sara lift. When we stood her up, we heard a snap and the resident yelled so we hurried up and put her down. She said her arm hurts I told the other aide to get the nurse."
Review of the witness statement by Employee 2 revealed she was "putting the resident to bed with the help of another CNA. Resident could not bend her knee, so we used the Sara lift. When we lifted her up, we heard a snap and the resident yelled out in pain. We put her down on the bed safely and got the nurse."
Review of Resident 1's clinical record progress notes revealed a nurse's note by Employee 6 dated August 16, 2026, at 9:29 PM, that indicated she was alerted by staff nurse that Resident 1 "was in pain status post transfer via sara lift. upon eval resident unable to move either arm off the bed. severe pain noted with movement. less upon resting. provider notified and new order for stat [immediate] x-ray of bilateral clavicle and humerus. x-rays of humerus noted to be positive for fractures. provider updated and given order to send to hospital for eval. POA aware of injury and notified of provider order to send to hospital. left for [hospital] at 2125 [9:25 PM]."
Review of Resident 1's x-ray reports dated August 21, 2026, that were obtained at the facility revealed an acute comminuted, displaced, and distracted fracture of the mid to distal shaft of the left humerus; and presence of an acute comminuted, angulated, displaced fracture of the distal supracondylar aspect of the right humerus. These x-rays did not indicate any findings of osteoporosis or bone demineralization.
A comminuted fracture occurs when a bone breaks into three or more pieces due to high-energy trauma, such as a severe fall, car accident, or impact injury. A displaced fracture is when the bone fragments have moved out of their normal anatomical alignment after a break in the bone.
A distracted fracture (also called a separated fracture) is a type of fracture where the bone ends are pushed apart from each other.
An angulated fracture is a type of bone break in which the two fragments are no longer aligned and instead meet at a distinct angle, creating an angular deformity
Review of Resident 1's hospital history and physical dated August 17, 2026, at 5:13 AM, revealed the following: " Imaging redemonstrated comminuted displaced fractures of the bilateral humeral diaphyses [the shaft or long part of the bone]. Orthopedic surgery was consulted who put the patient in splints with tentative plans for operative repair in the morning. Internal medicine now consulted for admission."
Review of Resident 1's hospital X-ray reports dated August 17, 2026, revealed the following:
"Right humerus: The acute spiral fracture of the midshaft right humerus [the bone in the upper arm] has been stabilized with a plaster splint. Alignment is unchanged from prior exam. The bones are diffusely demineralized. There is posttraumatic deformity and secondary osteoarthritis [a degeneration of joint cartilage and the underlying bone, causing pain and stiffness] of the right humeral head. Left humerus: Acute spiral fracture of the mid shaft left humerus has been stabilized with a plaster splint. Alignment is unchanged from prior exam. The bones are diffusely demineralized. There is severe osteoarthritis of the left shoulder."
Spiral fractures are a type of broken bone that occurs when a bone is broken with a twisting motion. They create a fracture line that wraps around your bone and looks like a corkscrew.
Further review of Resident 1's hospital records revealed that she had surgical repair of her bilateral humeral fractures on August 19, 2026, and remained hospitalized until August 24, 2026, at which time she returned to the facility.
Review of Resident 1's current care plan revealed that she was made a maxi-lift upon her return to the facility on August 24, 2026.
Review of facility provided documentation revealed that Employee 1 last completed mechanical lift training on May 8, 2025, and Employee 2 last completed lift training on June 13, 2026.
Email communication from the Director of Nursing (DON) on September 1, 2026, at 1:03 PM, indicated that Employee 1 was unable to attend in person annual training for 2026 due to a Medical Leave of Absence. Make-Up education has been assigned to her to complete.
During a staff interview with Employee 1 on September 1, 2026, at 3:12 PM, Employee 1 indicated that she knew Resident 1 was two-person assist with wheeled walker, but the aide assigned to the Resident (Employee 2) came and got her to help her with the stand-lift because the Resident could not stand up because her leg sticks out straight. Employee 1 indicated that she told Employee 2 that they should not use the lift. Employee 1 said that they attached the Resident to the lift and that she was holding on to the Resident ' s left leg to help keep it from sliding off of the base of the Sara lift. She said that because of her position of being down at Resident 1's feet, she could not see what Employee 2 was doing specifically but she could tell the Resident was being lifted and that was when she heard a "crack" and the Resident began yelling "my arms" and they immediately lowered the Resident onto her bed and got the nurse. Employee 1 said that this was the first time she had assisted in using a stand-lift with Resident 1. She said that she only works two days a week. Employee 1 said that she believes Employee 2 raised Resident 1 up too high in the lift and indicated that Resident 1 was almost completely up. Employee 1 also indicated that she believed that therapy should have kept the Resident on a maxi lift for transfers. Employee 1 showed the surveyor which lift was used for the transfer, which was a Sara Flex.
During a staff interview with Employee 3 (Physical Therapy Assistant), Employee 4 (Physical Therapist), and Employee 5 (Certified Occupational Therapy Assistant/ Director of Rehab) on September 1, 2026, at 3:25 PM, Employee 3 indicated that on August 16, 2026, she had worked with Resident 1 in using a splint to treat the contracture of her left lower leg. Employee 4 further indicated that PT and OT had trialed the Sara stand lift with the Resident on July 13, 2026, and agreed that she was not safe to use the stand lift because of her limited upper body strength and her lower body limited range of motion deficits.
Employee 5 indicated that given Resident 1's cognitive deficits, her not participating with the walker transfer for the aides may have been behavioral and that staff could have walked away and reapproached later to see if that helped.
When Employees 3, 4, and 5 were asked based on their professional opinion if Employees 1 and 2 should have been utilizing the Sara stand lift with the Resident, they all stated absolutely not because she could not safely participate with a Sara lift transfer because of her limited upper body strength and limited range of motion to her left lower extremity.
During a staff interview with Employee 2 on September 1, 2026, at 4:23 PM, via phone, Employee 2 indicated that she had performed Resident 1's care and was ready to put her to bed. She said that she knew she could not transfer the Resident using the stand-aid without two-person assist, so she went and got Employee 1. Employee 2 said that they put Resident 1 correctly into the lift and then she began to raise Resident 1 up and that was when she heard something "snap." Employee 2 said that she operated the lift while Employee 1 was holding the Resident's foot in place because it was slanted outwards. Employee 2 said that she did not raise her to a complete standing position, but maybe half-way. Employee 2 said that they then transferred Resident 1 over to the bed and that was when Resident 1 began complaining of pain in her arms, so she went and got the nurse. When asked why she did not transfer with two-person assist and a wheeled walker as she was care planned, she said, "Oh. I was told by another aide that she was a stand lift transfer because she could not bend her knee on the one side." When Employee 2 was asked who told her this, she indicated that Employee 1 had told her. Employee 2 further indicated that the date of the incident was the first time she had ever provided care for Resident 1.
Email communication from the DON on September 2, 2026, at 9:26 AM, indicated "Regarding staff use of Sara Lift: per the lift manual, residents must be able to bear weight on at least one leg, which [Resident 1] was capable of. Additionally, we [the facility] attempt to use the least restrictive means in order to promote as much independence and maintain movement as we can, which would have been the sit to stand lift vs a maxi/Hoyer lift. Additionally, given that she was having difficulty standing on her own with staff assisting, it likely would have been more difficult and potentially dangerous to attempt to place a Hoyer sling safely under her. "
Email communication from the DON on September 2, 2026, at 11:51 AM, indicated the following: "We do encourage our team members to reach out to their nurse and/or supervisor if they have questions but also understand that they are able to determine if a transfer is not going well/unsafe and may downgrade to the next least restrictive (if possible) level of transfer.
Email communication received from the NHA on September 3, 2026, at 3:04 PM, revealed that, "Our downgrade for lift use in this scenario occurred as I would have expected. ... The CNAs acted as I would have expected based on our policies. They attempted to follow the resident ' s care plan, noted that she was not capable of safely transferring in that manner and utilized the next least restrictive method of transfer with a mechanical lift. After the incident, they immediately reported concerns to the nurse and the resident was assessed and treated as per policy. "
The facility failed to provide adequate assistance devices to prevent accidents, which resulted in actual harm to Resident 1. The facility failed to adhere to safety warnings in the manufacturer manual for the Sara lift that stated, "Safety Instructions: Warning-To avoid injury, a full clinical assessment of the patient's condition, and suitability must be carried out by qualified personnel, before attempting to use Sara Flex[lift]." At the time of the event, Resident 1 had not been determined to be safe for the use of the Sara lift by qualified personnel, Resident 1 had never been transferred with the Sara lift, and Resident 1 had known cognitive impairments which could also impact her safety in a new, unfamiliar situation. In addition, it was known by the facility at the time of Resident 1's admission that she had osteoporosis and was being treated for a post-surgical repair of a hip fracture. Employees 1 and 2 failed to seek guidance from a nurse when they were having trouble standing/transferring her and made the decision to use the sara lift. These failures resulted in Resident 1 suffering bilateral upper arm fractures and being hospitalized for surgical repair of the fractures.
Review of Resident 2's clinical record revealed diagnoses that included muscle weakness and cerebral infarction (a stroke-damage to the brain from interruption of its blood supply).
Review of Resident 2's facility provided incident report and investigation for an injury of known cause dated August 17, 2026, at 8:45 AM, revealed Resident 2 was being transferred from bed to chair using the Sara lift. The Sara lift caused an abrasion to right shin. Resident description section indicated that Resident 2 said "my foot was way forward and felt something when I was standing " .
Further review of the investigation revealed only one witness statement by Employee 8 (Nurse Aide), which stated, "I noticed the abrasion after using the Sara lift to transfer the resident from bed to wheelchair."
During a staff interview with the NHA and DON on September 1, 2026, between 2:40 PM and 3:05 PM, the DON indicated that for injuries of known origin, the facility practice was to only get a witness statement from the assigned staff member and that was why there would not be a second statement for Resident 2's incident on August 17, 2026. When questioned how they would know that the plan of care was followed and a two-person assist was provided with the lift transfer, the NHA said, "because it is our policy."
During a final interview with the NHA, DON, and Employee 9 on September 3, 2026, at 3:47 PM, they were made aware of the concern of a lack of a thorough investigation to ensure that the Resident was being transferred with 2-person assist at the time he sustained an abrasion from the stand lift during a transfer. The NHA and DON indicated that they had no additional information to provide.
Review of facility provided information failed to reveal a second witness statement for Resident 2 ' s fall. Therefore, it cannot be confirmed that two staff were present when Resident 2 sustained an abrasion from the stand lift during a transfer.
Review of Resident 3's clinical record revealed diagnoses that included vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults) and Vitamin D deficiency.
Review of Resident 3's facility provided incident report and investigation for a witnessed fall dated July 27, 2026, at 5:50 PM, revealed that "resident was assisted to the floor gently by his CNA [Employee 7]. She found him at edge of his wheelchair cushion, intervened when wasn't able to assist him back in his wheelchair safely." Resident description section indicated that Resident 3 was unable to give a description.
The new intervention was for dycem (an anti-slip material) to be placed under his wheelchair cushion.
Review of Employee 7's witness statement related to the fall indicated that she "saw several times during my previous shift that he was sliding down the wheelchair, and I noticed it was the same today. Today, he made it to the doorway of his room. He was sitting to close to the edge of the wheelchair. I was alone and cried for help. While I was waiting for help, he slid further down until it was not safe for his shoulder, so I lowered him to the floor." Employee 7 and the nurse who responded to help used the maxi-lift to get the Resident up and placed him in bed.
During a staff interview with the NHA and DON on September 1, 2026, between 2:40 PM and 3:05 PM, the surveyor discussed the witnessed fall incident for Resident 3 and Employee 7's statement indicating that she had observed him sliding to the front of his wheelchair several times on her previous shift. The surveyor questioned whether there was any investigation into that statement or action taken.
Email received from the DON on September 2, 2026, at 9:26 AM, the DON indicated that Employee 7 is a part-time team member and works 4 days a pay period on the neighborhood where Resident 3 resides. The DON further indicated "we have planned in-person education for our Skills Fair in October to cover change in conditions that will review reporting changes in your residents and how to navigate those changes " . In addition, the DON shared that Resident 3 was actively participating in restorative nursing programs during that time.
During a final interview with the NHA, DON, and Employee 9 on September 3, 2026, at 3:47 PM, the NHA and DON acknowledged the above surveyor concerns. No new information was provided.
Employee 7 failed to report her repeated observations of Resident 3 sliding off of the chair on July 23, 2026. Facility staff failed to thoroughly investigate Employee 7's witness statement and failed to provide appropriate action/ education for Employee 7 on July 27, 2026, when the statement for Resident 3's incident was provided. Employee 7 was educated on September 3, 2026; 38 days after Resident 3's incident occurred.
201.14(a) Responsibility of licensee.
201.18(b)(1)(3) Management.
201.20(a)(1) Staff development.
211.10(d) Resident care policies.
211.12(d)(1)(2)(3) Nursing services.
| | Plan of Correction - To be completed: 09/27/2026
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice, administrative proceedings or other court proceedings.
1. For all affected residents, incident investigations were reopened and reviewed to ensure all available information was completed and appropriate corrective actions were implemented.
2. A whole-house audit was completed for all residents requiring stand lift transfers to verify transfer assessment is completed and transfer instructions are appropriately reflected in the care plan. Any identified concerns will be addressed.
3. The facility revised its procedures to include that staff will downgrade to maxi-lift and not stand lift until the resident is assessed by therapy and approved for stand lift. The facility also revised its incident investigation process to require two witness statements for all mechanical lift incidents are obtained and reviewed, follow-up interviews are completed when indicated, and appropriate corrective action and education are documented. The facility will re-educate licensed nurses and CNAs on updated policies, adhering to resident-specific transfer requirements, reporting and documenting incidents appropriately.
4. Nursing administration or designee will complete audits of 4 mechanical stand lift transfers 2x per week for 4 weeks then weekly for 4 weeks to verify transfer assessment is completed, transfer instructions are appropriately reflected in the care plan, and required number of staff are present. Nursing administration or designee will complete audits of all transfer-related incident investigations weekly for 2 months to ensure investigations are completed thoroughly and include appropriate follow-up. Results of the audits will be reported to the QAPI committee.
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