The Villas At New Brighton

During the transfer, one loop of the sling handle came off of the lift hook, R1's right leg slid out of the sling and R1 landed on the floor in a sitting position then ended on his back.

The administrator, director of nursing and on-call provider were notified. R1 was transported to the hospital for evaluation and had subsequent surgery for a left femur fracture.

During an interview on 9/9/2025 at 3:23 p.m., the administrator stated R1 falling from the lift was determined to not be the result of abuse, neglect, exploitation, or misappropriation so it was not reportable. It was an accident.

During an interview on 9/10/2025 at 12:14 p.m. after reviewing incident video, the director of nursing stated the nursing assistants were not following manufacturer's instructions when they attached the sling to the lift prior to transferring R1. R1 fell from the sling because the sling came off the lift hook.

Review of facility policy titled The abuse prohibition/Vulnerable Adult Policy dated 4/2025, instructed incidents to be reported including all serious injuries that were determined to be a result of abuse, neglect, exploitation, or misappropriation, even those considered accidental.

Examples of serious injury include but were not limited to falls with major injury (including fractures, closed head injury, internal bleeding and death), burns, medication errors with adverse effects or potential for adverse effects, or other resident incidents.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Villas at New Brighton

825 First Avenue Northwest New Brighton, MN 55112

SUMMARY STATEMENT OF DEFICIENCIES

jeopardy to resident health or safety

instructions for proper sling attachment during the transfer. DON confirmed the lower right sling loop was placed at the top of the hook instead of the lower part of the hook.

Two attempts were made to contact NA-B with no return phone call.The manufacturer full body sling instruction manual undated, identified the sling was correctly attached to the lift when the loops of the sling were placed at the bottom of the hooks.

The manual warnings include: if the sling is not properly applied, personal injury and damage to the sling could occur.The facility mechanical lift competency instructs: Attach the sling to the lift assuring that the loops are secured to the hooks.Review of facility policy titled The facility safe resident handling program policy undated, instructed when residents received care require assistance from facility to move, assistance was provided in a manner that was safe to both the resident and employee.

The facility implemented the following actions prior to the survey which were verified through interview and document review and therefore the IJ was issued at past non-compliance:Staff involved in the incident were immediately suspended pending investigation.The lift and sling were put out of use.Education included how to identify what size a sling was, where to find a resident's sling size, how to attach the sling to the lift, and what to do if a resident's care plan did not identify sling size or if the proper sling size was not available.

All nursing staff were competency tested on use of the full mechanical lift.Any staff that had not completed the education or competency test would be required to complete both at the start of their next scheduled shift.

Facility ID: