Based on observations, record review, residents and staff interviews, the facility failed to implement ongoing training, competencies and supervision of staff to ensure the safe use of manual and mechanical lifts to prevent avoidable accidents for 1 (Resident #48) of 29 residents care planned for manual or mechanical lift transfer. Resident #48's diagnoses included obesity, history of multiple strokes and functional limitation in range of motion of upper and lower extremities on one side. On 5/2/25 the nurse on duty documented the resident was crying and in a lot of pain. Her ankle was swollen with purple bruising. Resident #48 reported she sustained the injury to her foot the previous night when the lift was used wrong. Resident #48 was diagnosed with a fracture of the left heel bone. The facility had no documentation staff using manual and mechanical lifts to transfer Residents were trained and competent to safely use the lifts. This lack of knowledge and ability placed all 29 residents care planned for manual and mechanical lift transfers at a likelihood of serious harm, and serious injury from improper use of the lift and resulted in the determination of Immediate Jeopardy. The findings included: Cross reference to F726, F835. Review of the clinical record revealed Resident #48 had a date of admission of 10/18/21. Review of the Annual Minimum Data Set (MDS) assessment with a target date of 5/12/25 revealed Resident #48 scored 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognitive skills for daily decision making were intact. The resident had functional limitation in range of motion of the upper and lower extremities on one side of the body. Review of the care plan initiated on 11/10/21 and revised on 9/19/24 revealed Resident #48 was at risk for falls and/or fall related injury related to history of multiple strokes, generalized weakness, impaired balance, and unsteady gait. Resident #48 required staff assistance with transfers and ambulation. The interventions included to provide hands on assistance with transfers and utilize (brand name) manual standing aid as ordered. Review of the nursing progress notes revealed on 5/2/25 at 10:27 p.m., Licensed Practical Nurse (LPN) Staff O documented in a change in condition progress note, Nursing observations, evaluations, and recommendations are: Resident is crying in a lot of pain. Her left ankle is swollen and has purple bruising. She stated, We were using the (brand name) lift last night and it was used wrong. LPN Staff O documented the Advanced Practice Registered Nurse (APRN) was notified on 5/2/25 at 10:42 p.m. and ordered a STAT (Immediate) X-ray of the resident's left ankle. Review of the Radiology Results Report of the resident's left ankle X-ray revealed the STAT X-ray was not done until 5/3/25 at 10:24 a.m. The results reported on 5/3/25 at 2:20 p.m., read, Left calcaneal (heel bone) fracture. The age of the fracture is indeterminate. On 6/15/25 at 9:35 a.m., in an interview Resident #48 said she sustained a fracture of the left foot when her foot got stuck between the lift and the wheelchair during transfer. She said the Certified Nursing Assistant (CNA) did not place her feet correctly on the lift. Her left foot slipped off the lift and caused the injury. Resident #48 said she could not walk or stand. She tried but was not able to lift her feet or move her legs. She said, My foot was not on right. I told them that but they didn't fix it. My foot went between the lift and the floor. On 6/17/25 at 3:40 p.m., in an interview, the Director of Nursing (DON) said she was out of town on 5/2/25 and did not know about Resident #48's left calcaneal fracture from the manual lift. The DON looked in the facility's incident investigations and said there was no documentation the incident was investigated. On 6/17/25 at 4:30 p.m., in an interview Resident #48 said staff were still using the manual lift to transfer her. She said when she injured her left foot, 2 staff were transferring her with the lift. They were not paying attention. Her foot was not placed properly in the machine and moved. Her foot got stuck and twisted and caused the left heel bone fracture. On 6/17/25 at 4:45 p.m., in an interview the Administrator said no one called him on 5/2/25 to report the incident. When the nurse told him about it on 5/5/25, he started an investigation but could not locate it. He said they started re-educating staff on the lifts. When asked to see documentation of the training, he said, Like I said, I can't find anything. On 6/17/25 at 4:50 p.m., in an interview the Social Service Director said when there is an incident involving a resident, she is the one who interviews the affected resident. She said on 5/5/25 she became aware of Resident #48's left heel fracture and interviewed her. She said Resident #48 told her the injury happened when CNA staff G and another CNA transferred her with the (brand name) manual lift. She wrote the resident's statement but could not find it. On 6/17/25 at 5:40 p.m., the DON was interviewed about facility processes related to safe use of the manual and mechanical lifts to ensure residents' safety during transfer with manual and mechanical lifts and prevent avoidable accidents. The DON said as part of orientation all staff watch a video on the use of the different lifts used at the facility. The therapy department evaluates residents to determine the transfer status, including the type of lift appropriate for each resident as necessary. Requested documentation of training for CNA Staff G who was assigned to Resident #48 on 5/1/25. Review of the employee file for CNA Staff G revealed a date of hire of 8/29/2018. There was no documentation of manual or mechanical lift training on orientation. A Competency Assessment-Mechanical lift from a previous company dated 1/11/19 was in CNA Staff G employee file. The form was not signed by CNA Staff G or reviewer. The form contained several questions. A question mark was entered for: Able to demonstrate appropriate set up of mechanical lift. A 2 (supervision required) was documented for: Demonstrates ability to transfer from bed to chair and chair to bed using mechanical lift. Not done was entered for: Demonstrates ability to transfer from floor to bed or chair using mechanical lift and demonstrates ability to transfer from chair to toilet using mechanical lift. On 6/17/25 at 5:50 p.m., in an interview CNA Staff G said it has been 7 years since she's had training for mechanical lifts. On 6/17/25 at 6:00 p.m., in a telephone interview CNA Staff P said she took care of Resident #48 on 5/2/25 from 7:00 p.m. to 7:00 a.m. She said that day Resident #48 requested to put her to bed earlier than her usual time of 8:30 p.m. She said Resident #48 said her ankle got injured the previous night when they transferred her with the manual lift. Resident #48 told her the CNA who transferred her didn't know what she was doing. CNA Staff P said she immediately notified Licensed Practical Nurse (LPN) Staff O. The DON was present during the telephone interview conducted on speaker phone. On 6/18/25 at 8:19 a.m., CNA Staff E and CNA Staff F were observed using the (brand name) manual sit-to-stand lift to transfer Resident #48 from bed to chair. The CNAs brought the manual lift to the bed and helped the resident place her feet on the footrest of the lift. Resident #48 was not able to pull herself in a standing position without extensive assistance of both CNAs. The CNAs stood on opposite sides of the resident. Both CNAs pulled the resident to a standing position on the lift. Resident #48 was able to grab and hold onto the handlebar during the transfer with the lift. On 6/18/25 at 9:20 a.m., a joint interview was held with the Administrator and the DON about facility processes to investigate residents' incidents and accidents, and the lack of investigation related to Resident #48's incident during transfer with the manual sit-to-stand lift. The Administrator said he found the staff statements related to Resident #48's accident. He said, Her foot slipped, it was an accident. He provided employee statements related to the Resident #48's incident and said the statements were the investigation. He said based on what Resident #48 said he did not need to interview anyone else. Review of the statements revealed: On 5/5/25 the Social Services Director wrote on a signed statement, Visited resident regarding her foot (ankle) and she stated that when (CNA Staff G) and another CNA changed her briefs, her left foot slid and hit her ankle on the bar (to open and close) of the (brand name lift). She stated that this happened on Thursday May 1, 2025 @ (at) around 5 or 6 pm. On 5/5/25 LPN Staff Q wrote on a signed statement, I was the nurse assigned to the resident (Resident #48's name) on 5/5/25. She told me that when the CNA was transferring her to the bathroom using the (brand name manual lift) that she hit her left ankle on it. At the time she could not remember the name of the CNA. There was no documentation LPN Staff Q documented the interview with the resident or completed an incident report. On 5/5/25 CNA Staff G wrote on a signed statement, I did not take the resident to the bathroom on Thursday 5/1/25 and she did not hit her left ankle with me or reported anything to me about her ankle. The first time I'm hearing about it is today. On 5/5/25 LPN Staff R wrote on a signed statement, On 5-2-25, I was the nurse assigned to (Resident #48) 7A-7P (7:00 a.m. to 7:00 p.m.). During my shift resident did not complain of pain. One other CNA (CNA Staff S) signed a statement dated 5/5/25 noting she had not heard anything about Resident #48 hurting her foot. Review of the nursing staffing schedule for 5/1/25 revealed 4 CNAs worked on the unit where Resident #48 resides during the 7:00 a.m., to 7:00 p.m. shift. Only one of the 4 CNAs was interviewed. There was no statement from LPN Staff O. On 6/18/25 at 9:30 a.m., the Director of Rehab provided documentation of a discharge from therapy summary for Resident #48 dated 10/30/23, a Quarterly Physical/Occupational Therapy Screening form dated 9/17/24, a Quarterly Physical/Occupational Therapy Screening form dated 5/12/25, and Change of Status Physical/Occupational Therapy Screening form dated 6/18/25. Review of the discharge from therapy summary dated 10/30/23 revealed one of the therapy goals was to increase bilateral lower extremities strength to 4 minus out of 5 to facilitate patient's ability to perform sit to stand transfers with moderate assistance and 25% verbal cues with use of grab bars/manual standing aid (brand name sit-to-stand lift) while maintaining functional posture in order to decrease level of assistance from caregivers. The therapy discharge noted Resident #48 achieved a 3 minus out of 5 for the bilateral lower extremities strength and was total dependence for sit to stand. Review of the Quarterly Physical/Occupational Therapy screening form dated 9/17/24 noted Resident #48 was reviewed for changes in functional status. Resident #48 remained appropriate for the (brand name) sit-to-stand lift. The source for the screening information was staff interview. Review of the Quarterly Physical/Occupational Therapy screening form dated 5/12/25 noted no change in condition and No functional decline indicated. The source of the information was staff interview. Review of the Physical/Occupational Therapy screening form dated 6/18/25 noted the screen was done for a change in transfer status for Resident #48. The Physical Therapy Assistant documented, Observed nursing staff perform (brand name manual sit-to-stand lift) with patient for safety. For transfers and toileting. No information regarding Resident #48's ability to use the lift was documented. On 6/18/25 at 9:35 a.m., in an interview the Director of Rehab said a therapy screen did not necessarily involve an observation of the resident. She said, In that case it was talking with the staff. On 6/18/25 at 9:40 a.m., in an interview the Physical Therapy assistant who conducted the screening on 6/18/25 said he observed the Director of Nursing and a CNA transfer Resident #48 with the (brand name) sit-to-stand manual lift. He said they did a great job. He verified the screening did not reflect the resident's ability to use the lift but said Resident #48 was able to do it correctly. On 6/18/25 at 9:55 a.m., the DON provided a yearly performance appraisal for CNA Staff G dated 9/9/24. The form noted CNA Staff G scored 3 (average) in Personal Nursing Care Functions which included, Assist with lifting, turning, moving , positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc. The DON verified there was no competency evaluation for the use of the manual or mechanical lifts or how the rating of 3 listed on the form was determined. She said CNA Staff G trained new CNAs which includes showing them how to use the lifts. She said she considered this an evaluation of the CNA's ability to use the manual and mechanical lifts since CNA Staff G was evaluating new CNAs. On 6/18/25 at 2:22 p.m., in an interview LPN Staff T said she received training on the manual sit-to-stand lift 3 years ago. LPN Staff T was not able to explain or demonstrate how to use the manual sit-to-stand lift. She said, I don't know how to use the lift, I have never used it. On 6/19/25 at 11:21 a.m., CNA Staff E and CNA Staff V were observed using a (brand name manual sit-to-stand lift) to transfer Resident #32 from bed to the wheelchair. Resident #32 was wearing tennis shoes. He sat on the edge of the bed with his feet on the floor. CNA Staff E placed herself on the resident's right side and CNA Staff V placed herself on the resident's right side. The CNAs positioned the (brand name) manual sit-to-stand lift in front of the resident. The CNAs instructed the resident to place his feet on the footrest and his hands on the handlebar. The resident placed only the front part of his feet on the footrest of the lift with the heels hanging off the back of the footrest. The resident's feet were not completely supported by the footrest. Resident #32 stood up with his heels off hanging off the footrest. The CNAs rotated the half seats underneath the resident's buttocks and transported the resident in the manual sit-to-stand lift with his heels hanging off the footrest. The CNAs did not ensure the resident's feet were properly placed on the footrest before wheeling the resident to the wheelchair. CNA Staff E moved over to the wheelchair. CNA Staff V transferred Resident #32 with the heels hanging off the back of the footrest. Photographic evidence obtained. Review of the instructions for use for the manual sit-to-stand lift provided by the representative via email revealed, Patient/Resident Assessment . Before use, the caregiver should always consider the patient's/resident's medical condition as well as physical and mental capabilities. In addition, the patient/resident must: . Have the ability to stand unaided or stand with minimal assistance. Safety instructions . This mobile lift must be used by a caregiver trained with these instructions . Before transferring the Patient . Position the (brand name lift) so that the patient's feet are placed on the footrest with knees comfortably against kneepad. Review of the manufacturer's skills checklist and performance observation revealed, The patient's/resident's feet should be on the footrest with knees comfortably against kneepad during transfer On 6/19/25 at 12:19 p.m., in a telephone interview CNA Staff G said she was assigned to Resident #48 on 5/1/24 from 7:00 a.m. to 7:00 p.m. She said CNA Staff U assisted her to transfer Resident #48 with the manual sit-to-stand lift. She said Resident #48 was totally dependent on staff for everything. Staff G said, She cannot turn, reposition herself or assist with the transfer with the (brand name sit-to-stand lift). CNA Staff G said it takes 2 staff to hold the resident by her pants and lift her to place her in the lift. She said Resident #48 cannot assist with the transfer with the lift, she is not even able to place her hands on the handlebar and cannot sustain her weight. Staff has to make all the effort to get her in the lift. CNA Staff G said after the incident someone must have realized the resident was not appropriate to use the lift and they changed it to a full body mechanical lift. She said for some reason, they went back to the manual sit-to-stand lift. CNA Staff G said she did not remember Resident #48 complaining about her foot with the transfer. When asked if she notified her supervisor of the difficulty Resident #48 had with the use of the manual sit-to-stand lift, she said she did not. On 6/19/25 attempted to contact CNA Staff U via telephone and got an error message. On 6/19/25 at 1:40 p.m., in a telephone interview LPN Staff O said on 5/2/25 Resident #48 was crying and was in a lot of pain. Her left foot was swollen and bruised. The resident said the CNAs used the lift wrong the previous evening and hurt her foot. She said she immediately reported it to the evening supervisor, Registered Nurse (RN) Staff D who instructed her to call the physician. LPN Staff O said she did not think she had to write an incident report since the incident did not happen on her shift. On 6/19/25 at 2:58 p.m., a joint interview was held with the DON and the evening supervisor, RN Staff D. RN Staff D verified on 5/2/25 LPN Staff O told her about Resident #48's bruised and swollen left foot but did not tell her how the resident sustained the injury. She instructed LPN Staff O to call the resident's attending physician. Evening supervisor RN Staff D said she knew she was supposed to assess the resident but she already had her bag on her shoulder and was leaving. The DON said the expectation was for the evening supervisor, RN Staff D to go assess the resident and give directions to the LPN. Review of the personnel files for CNAs Staff C (date of hire 1/30/2008), Staff W (date of hire 3/12/2001), Staff S (Date of hire 3/4/2025) and Staff Y (Date of hire 4/1/25) failed to reveal documentation of training, in-service or competency evaluations on use of manual and mechanical lifts. On 6/21/25 at 1:40 p.m., CNA Staff W and CNA Staff X were observed transferring Resident #33 with a (brand name) full body mechanical lift. The Assistant Director of Nursing (ADON) was in the room observing the transfer. The sling was worn out and the label was missing. Two holes were observed in the sling's fabric. The sling straps showed signs of damage and were frayed. Photographic evidence obtained. On 6/21/25 at 1:50 p.m., the ADON observed the holes in the sling's fabric and verified the sling was worn out and the label was missing. She also verified the straps showed signs of damage and were frayed. The ADON offered no explanation for the continued use of the worn out sling. Review of the manufacturer's manual for use of the slings provided by a representative of the sling's manufacturer revealed, Before every use. WARNING. To avoid injury, always make sure to inspect the equipment prior to use. Check all parts of the sling . If any part is missing or damaged- Do NOT use the sling. Check for: Fraying, loose stitching, tears, fabric holes, soiled fabric, damaged clips, unreadable or damaged label. Review of the facility's policy and procedure titled Lifting Machine, Using a Mechanical with a revised date of July 2017 revealed, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. Sling care: discard any worn, frayed or ripped slings. On 6/21/25 the immediate actions implemented by the facility and verified by the survey team included: On 6/21/25 the survey team verified through record review and interview with the Director of Nursing that the two CNAs who assisted resident #48 with the use of the manual sit-to-stand lift were suspended. On 6/21/25 the survey team verified through record review the facility investigated the incident involving Resident #48 which included additional staff interviews, simulation of the incident with the resident describing how the injury occurred, review of the resident's medical record to identify underlying contributing factors, and root cause analysis. On 6/21/25 the survey team verified through record review and interview with the Administrator that on 6/18/25 the facility reported the incident to the required State and local authorities. On 6/21/25 the survey team verified through record review and interview with the Director of Nursing that on 6/20/25 the current residents were assessed. No injuries were noted. 45 residents were identified requiring a manual or mechanical lift for transfers. On 6/21/25 the survey team verified through review of education records that on 6/20/25 the DON and ADON educated 53 of 58 CNAs on proper use of all facility lifts. The remaining untrained staff will receive training prior to working their next shift. Any new hire will receive training during facility orientation. On 6/21/25 the survey team verified through review of education records that on 6/20/25 the DON and ADON educated 27 of 47 licensed nursing staff and 53 of 58 Certified Nursing Assistants on proper use of all facility lifts and demonstrated the use of the manual and mechanical lifts. The DON verified that the remaining untrained staff will receive training prior to working their next shift and any new hires would receive this training during facility orientation. On 6/21/25 the survey team verified through record review and interview with the DON and Administrator that on 6/19/25 the facility held an Ad Hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) meeting and discussed the system failures and processes that needed to be implemented to prevent these failures in the future. The plan was approved by all in attendance, the Administrator, DON, ADON, Medical Director, Activities Director, Social Services Director, Dietary Manager, admission Director, Housekeeping Supervisor, Minimum Data Set Coordinator, Infection Preventionist, Medical Records, Maintenance Director, Human Resources, Therapy, 2 Nursing Unit Managers, and the Nurse Consultant. On 6/21/25 the survey team verified through record review and interview with the DON that on 6/19/25 the competency evaluation forms for all facility lifts were revised to provide more specific instructions. On 6/21/25 the survey team verified through record review of 3 CNAs and staff interviews that the DON and ADON used the revised competency evaluation forms to verify the staff skills with the use of facility lifts. 3 CNAs, and 3 Licensed Nurses were interviewed. They all verified they have received the training and were required to demonstrate competency for all the lifts used at the facility. On 6/21/25 at 11:00 a.m., the ADON said she started employment at the facility on 6/10/25. She said every facility uses different lifts. She watched a video on the use of the lifts. She observes the CNAs use the lifts and whatever they did wrong I corrected them. On 6/21/25 the survey team verified through observation of staff on duty, review of the staffing schedule and interview with the DON that the facility does not use agency staff. The Facility alleged compliance with the removal plan as of 6/20/2025. On 6/21/25 the survey team determined the facility was in compliance with their removal plan as of 6/21/25 when the worn out sling with frayed straps and holes used to transfer Resident #33 was removed from use and no other damaged sling was observed in use with residents care planned for transfer with mechanical lifts.

Based on observations, record reviews, residents and staff interviews, the facility failed to ensure nursing staff had the appropriate training and competencies to prevent avoidable accidents during residents' transfer with manual and/or mechanical lifts for 1 (Resident #48) of 29 residents care planned for transfers with manual or mechanical lifts. Resident #48 diagnoses included a history of multiple strokes, obesity and unilateral functional limitation in range of motion of upper and lower extremities. Resident #48 was care planned for the use of a (brand name) manual sit-to-stand lift for transfers. On 5/2/25 the nurse on duty documented the resident was crying and in a lot of pain. Her ankle was swollen with purple bruising. Resident #48 reported she sustained the injury to her foot the previous night when the lift was used wrong. On 5/3/25, Resident #48 was diagnosed with a fracture of the left heel bone. Resident #48 suffered serious injury from the improper use of the manual sit-to-stand lift. The facility had no documentation staff using manual and mechanical lifts to transfer Residents were trained and competent to safely use the lifts. This lack of knowledge and ability placed all 29 residents care planned for manual and mechanical lift transfers at a likelihood of serious harm, and serious injury from improper use of the lift and resulted in the determination of Immediate Jeopardy. The findings included: Cross reference F689, F835. Review of the Center Facility Assessment-Tool- FORM revised 6/12/25 revealed, Upon hire staff attend orientation classroom orientation and floor orientation to review specific facility features and basic competencies, along with required federal and state requirements. Facility provides ongoing educational opportunities for staff related to patient centered items and staff competencies throughout the year . Potential data sources include . education, training, competency instruction, and testing policies. Review of the facility's policy and procedure titled, In-Service Training Program revised October 2017 revealed, All personnel are required to attend regularly scheduled in-service training classes. Annual in-services must: . Ensure the continuing competence of personnel . All training classes attended by the employee shall be entered on the respective employee's Record of In-Service by the department supervisor or other person(s) as designated by the supervisor. Records shall be filed in the employee's personnel file or shall be maintained by the department supervisor. Review of the facility's policy and procedure titled, Lifting Machines, Using a Mechanical revised July 2017 revealed, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions . Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility . On 6/15/25 at 9:35 a.m., in an interview Resident #48 said she could not stand or walk and staff transfer her with a lift. Resident #48 tried to lift her feet and move her legs during the interview and said she was not able to. She said she sustained a fracture of the left foot when her foot got stuck during transfer between the lift and the wheelchair. She said the Certified Nursing Assistant (CNA) did not place her feet correctly on the lift. Her left foot slipped off the lift and caused the injury. She said, My foot was not on right. I told them that but they didn't fix it. My foot went between the lift and the floor. Review of the clinical record revealed Resident #48 had a date of admission of 10/18/21. Review of the Annual Minimum Data Set (MDS) assessment with a target date of 5/12/25 revealed Resident #48 scored 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognitive skills for daily decision making were intact. The resident had functional limitation in range of motion of the upper and lower extremities on one side of the body. Review of the care plan initiated on 11/10/21 and revised on 9/19/24 revealed Resident #48 was at risk for falls and/or fall related injury related to history of multiple strokes, generalized weakness, impaired balance, and unsteady gait. Resident #48 required staff assistance with transfers and ambulation. The interventions included to provide hands on assistance with transfers and utilize (brand name) manual standing aid as ordered. Review of the nursing progress notes revealed on 5/2/25 at 10:27 p.m., Licensed Practical Nurse (LPN) Staff O documented in a change in condition progress note, Nursing observations, evaluations, and recommendations are: Resident is crying in a lot of pain. Her left ankle is swollen and has purple bruising. She stated, We were using the (brand name) lift last night and it was used wrong. LPN Staff O documented the Advanced Practice Registered Nurse (APRN) was notified on 5/2/25 at 10:42 p.m. and ordered a STAT (Immediate) X-ray of the resident's left ankle. Review of the Radiology Results Report of the resident's left ankle X-ray revealed the STAT X-ray was not done until 5/3/25 at 10:24 a.m. The results reported on 5/3/25 at 2:20 p.m., read, Left calcaneal (heel bone) fracture. The age of the fracture is indeterminate. On 6/17/25 at 4:30 p.m., during a follow up interview Resident #48 said staff were still transferring her with the (brand name) manual lift. She said when she injured her left foot, 2 staff were transferring her with the lift. She said they were not paying attention. Her foot was not placed properly in the machine and moved. Her foot got stuck and twisted and caused the left heel bone fracture. On 6/17/25 at 4:45 p.m., in an interview the Administrator said no one called him on 5/2/25 to report the incident. On 5/5/25 he started an investigation when the nurse reported the incident but could not locate the investigation. He said they also started re-educating the staff on using the lifts. When asked to see documentation of the re-education, he said, Like I said, I can't find anything. On 6/16/25 at 5:40 p.m., an interview was held with the Director of Nursing (DON) to discuss processes in place to ensure staff were educated, had the skills set and competencies on safe use of manual and mechanical lifts, in accordance with facility's policies and procedures and manufacturer's specifications. The DON said as part of orientation all staff are required to watch a video on the use of the 3 different kinds of lifts used at the facility (manual sit-to-stand lift, mechanical sit-to-stand lift and full body mechanical lift). The therapy department evaluates residents to determine their transfer status, including the type of lift appropriate for each resident as necessary. When asked for documentation of staff training and competencies for the safe use of the lifts, the DON said she made sure all staff watch the videos but had no documentation verifying the training or competence of staff related to safe use of the manual or mechanical lifts. On 6/17/25 at 5:50 p.m., in an interview CNA Staff G said it has been 7 years since she's had training for mechanical lifts. On 6/17/25 at 6:00 p.m., in a telephone interview CNA Staff P said she took care of Resident #48 on 5/2/25 from 7:00 p.m. to 7:00 a.m. She said that day Resident #48 requested to be put to bed earlier than her usual time of 8:30 p.m. Resident #48 said her ankle got injured the previous night when they transferred her with the manual lift. Resident #48 told her the CNA who transferred her didn't know what she was doing. CNA Staff P said she immediately notified the LPN Staff O. The DON was present during the interview conducted on speaker phone. On 6/18/25 at 8:19 a.m., CNA Staff E and CNA Staff F were observed using the (brand name) manual sit-to-stand lift to transfer Resident #48 from bed to chair. The CNAs brought the manual lift to the bed and helped the resident place her feet on the footrest of the lift. Resident #48 was not able to pull herself in a standing position without extensive assistance of both CNAs. The CNAs stood on opposite sides of the resident. Both CNAs pulled the resident to a standing position on the lift. On 6/18/25 at 9:20 a.m., the Administrator said he found the staff statements related to Resident #48's accident. He said, Her foot slipped, it was an accident. The Administrator did not provide staff education on safe use of the lifts. He said they did a reenactment yesterday on 6/17/25, did not document the re-enactment but would document if needed. Review of the statements revealed: On 5/5/25 the Social Services Director wrote on a signed statement, Visited resident regarding her foot (ankle) and she stated that when (CNA Staff G) and another CNA changed her briefs, her left foot slid and hit her ankle on the bar (to open and close) of the (brand name lift). She stated that this happened on Thursday May 1, 2025 @ (at) around 5 or 6 pm. On 5/5/25 CNA Staff G wrote on a signed statement, I did not take the resident to the bathroom on Thursday 5/1/25 and she did not hit her left ankle with me or reported anything to me about her ankle. The first time I'm hearing about it is today. On 5/5/25 LPN Staff Q wrote on a signed statement, I was the nurse assigned to the resident (Resident #48's name) on 5/5/25. She told me that when the CNA was transferring her to the bathroom using the (brand name manual lift) that she hit her left ankle on it. At the time she could not remember the name of the CNA. On 5/5/25 LPN Staff R wrote on a signed statement, On 5-2-25, I was the nurse assigned to (Resident #48) 7A-7P (7:00 a.m. to 7:00 p.m.). During my shift resident did not complain of pain. One other CNA (CNA Staff S) signed a statement dated 5/5/25 noting she had not heard anything about Resident #48 hurting her foot. Review of the nursing staffing schedule for 5/1/25 revealed 4 CNAs worked on the unit where Resident #48 resides during the 7:00 a.m., to 7:00 p.m. shift. Only one of the 4 CNAs was interviewed. On 6/18/25 at 9:55 a.m., the DON provided a yearly performance appraisal for CNA Staff G dated 9/9/24. The form noted CNA Staff G scored 3 (average) in Personal Nursing Care Functions which included, Assist with lifting, turning, moving , positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc. The DON verified there was no competency evaluation for the use of the manual or mechanical lifts or how the score of 3 listed on the form was determined. She said CNA Staff G trained new CNAs which includes showing them how to use the lifts. She said she considered this an evaluation of the CNA's ability to use the manual and mechanical lifts since CNA Staff G was evaluating new CNAs. Review of the personnel file for CNA Staff G revealed a date of hire of 8/29/2018. There was no documentation of manual or mechanical lift training on orientation. A Competency Assessment-Mechanical lift from a previous company dated 1/11/19 was in the CNA Staff G employee file. The form was not signed by the CNA Staff G or reviewer. The form contained several questions. A question mark was entered for: Able to demonstrate appropriate set up of mechanical lift. A 2 (supervision required) was documented for: Demonstrates ability to transfer from bed to chair and chair to bed using mechanical lift. Not done was entered for: Demonstrates ability to transfer from floor to bed or chair using mechanical lift and demonstrates ability to transfer from chair to toilet using mechanical lift. Review of the personnel files for CNAs Staff C, Staff W and Staff S revealed: CNA Staff C had a date of hire 1/30/2008. A Competency Assessment-Mechanical lift from a previous healthcare management company dated 1/15/19 noted the CNA was proficient to use a mechanical lift. The method of evaluation was return demonstration. There was no documentation of training or competency evaluation for the use of the (brand name) manual sit-to-stand lift. The most recent Performance Appraisal dated 2/11/25 noted CNA staff C scored above average in Personal Nursing Care Functions which included, Assist with lifting, turning, moving , positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc. The form did not include a competency evaluation for the use of the manual or mechanical lifts. CNA Staff Y had a date of hire of 3/12/2001. The personnel file did not contain documentation of competency evaluation on the safe use of manual and mechanical lifts. The employee's education log documented 15 minutes of education on (brand name) full body mechanical lift on 1/10/2007. CNA Staff S had a date of hire of 3/4/2025. The personnel file did not contain documentation of training or competency evaluation for the safe use of the manual or mechanical lifts used by the facility. On 6/18/25 at 2:22 p.m., in an interview LPN Staff T said she received training on the manual sit-to-stand lift 3 years ago. LPN Staff T was not able to explain or demonstrate how to use the sit-to-stand lift. She said, I don't know how to use the lift, I have never used it. LPN Staff T called a CNA over and said the CNA would be able to demonstrate how to use the lift. On 6/19/25 at 11:21 a.m., CNA Staff E and CNA Staff V were observed using a (brand name manual sit-to-stand lift) to transfer Resident #32 from bed to the wheelchair. Resident #32 was wearing tennis shoes. He sat on the edge of the bed with his feet down to the floor. CNA Staff E positioned herself to the resident's left side and CNA Staff V positioned herself to the resident's right side. The CNAs positioned the (brand name) manual sit-to-stand lift in front of the resident. The CNAs instructed the resident to place his feet on the footrest and place his hands on the handlebar. The resident placed only part of his feet on the footrest of the lift with the heels hanging off the back of the footrest. The resident's feet were not completely on the footrest. Resident #32 stood up with his heels off hanging off the footrest. The CNAs rotated the half seats underneath the resident's buttocks and transported the resident in the manual sit-to-stand lift with his heels hanging off the footrest. The CNAs did not ensure the resident's feet were properly placed on the footrest before wheeling the lift and transferring the resident to the wheelchair. CNA Staff E moved over to the wheelchair. CNA Staff V transferred Resident #32 with the heels hanging off the back of the footrest. Photographic evidence obtained. On 6/19/25 at approximately 12:00 p.m., in an interview the Director of Rehab reviewed the photographic evidence of the positioning of Resident #32's feet on the manual sit-to-stand lift and said the resident's feet were not positioned properly and it was not safe. Review of the manufacturer's instructions for use for the manual sit-to-stand lift provided by a manufacturer's representative of lift revealed, Patient/Resident Assessment . Before use, the caregiver should always consider the patient's/resident's medical condition as well as physical and mental capabilities. In addition, the patient/resident must: . Have the ability to stand unaided or stand with minimal assistance. Safety instructions . This mobile lift must be used by a caregiver trained with these instructions . Before transferring the Patient . Position the (brand name lift) so that the patient's feet are placed on the footrest with knees comfortably against kneepad. Review of the manufacturer's skills checklist and performance observation revealed, The patient's/resident's feet should be on the footrest with knees comfortably against kneepad during transfer On 6/19/25 at 12:19 p.m., in a telephone interview CNA Staff G said she was assigned to Resident #48 on 5/1/24 from 7:00 a.m. to 7:00 p.m. She said CNA Staff U assisted her to transfer Resident #48 with the manual sit-to-stand lift. She said Resident #48 was totally dependent on staff for everything. Staff G said, She cannot turn, reposition herself or assist with the transfer with the (brand name sit-to-stand lift). CNA Staff G said it takes 2 staff to hold the resident by her pants and lift her to place her in the lift. She said Resident #48 cannot assist with the transfer with the lift, she is not even able to place her hands on the handlebar and cannot sustain her weight. Staff has to make all the effort to get her in the lift. CNA Staff G said after the incident someone must have realized the resident was not appropriate to use the lift and they changed it to a full body mechanical lift. She said for some reason, they went back to the manual sit-to-stand lift. CNA Staff G said she did not remember Resident #48 complaining about her foot with the transfer. On 6/21/25 at 1:40 p.m., CNA Staff W and CNA Staff X were observed transferring Resident #33 with a (brand name) full body mechanical lift. The Assistant Director of Nursing (ADON) was in the room observing the transfer. The sling was worn out and the label was missing. Two holes were observed in the sling's fabric. The sling's straps showed signs of damage and were frayed. Photographic evidence obtained. On 6/21/25 at 1:50 p.m., the ADON observed the holes in the sling and verified the sling was worn out and the label was missing. She also verified the straps showed signs of damage and were frayed. The ADON offered no explanation for the continued use of the damaged sling. Review of the manufacturer's manual for use of the slings revealed, Before every use. WARNING. To avoid injury, always make sure to inspect the equipment prior to use. Check all parts of the sling . If any part is missing or damaged- Do NOT use the sling. Check for: Fraying, loose stitching, tears, fabric holes, soiled fabric, damaged clips, unreadable or damaged label. Review of the facility's policy and procedure titled Lifting Machine, Using a Mechanical with a revised date of July 2017 revealed, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. Sling care: discard any worn, frayed or ripped slings. On 6/21/25 the immediate actions implemented by the facility and verified by the survey team included: On 6/21/25 the survey team verified through record review and interview with the Director of Nursing that the two CNAs who assisted resident #48 with the use of the manual sit-to-stand lift were suspended. On 6/21/25 the survey team verified through review of residents' assessments and interview with the Director of Nursing that on 6/20/25 the current residents were assessed. No injuries were noted. 45 residents were identified requiring a manual or mechanical lift for transfers. On 6/21/25 the survey team verified through review of education records that on 6/20/25 the DON and ADON educated 53 of 58 CNAs on proper use of all facility lifts. The remaining untrained staff will receive training prior to working their next shift. Any new hire will receive training during facility orientation. 3 CNAs interviewed verified receipt of the training and were able to verbalize the content of the training. On 6/21/25 the survey team verified through review of education records that on 6/20/25 the DON and ADON educated 27 of 47 licensed nursing staff on proper use of all facility lifts and demonstrated the use of the manual and mechanical lifts. 3 Licensed nurses were interviewed and verified receipt of the training and were able to describe the content of the training. 5 different CNAs were observed transferring 3 residents using the manual sit-to-stand lift and full body mechanical lift. On 6/21/25 the survey team verified through review of the education, sign-in sheets and interview with 3 CNAs and 3 Licensed Nurses that on 6/20/25 the DON and ADON educated 79 of 145 facility staff regarding the proper reporting of all incidents and/or changes in condition. The training included what to report, who to report incidents to, when and how to report. On 6/21/25 the survey team verified through record review and interview with the DON and Administrator that on 6/19/25 the facility held an Ad Hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) meeting and discussed the system failures and processes that needed to be implemented to prevent these failures in the future. The plan was approved by all in attendance, the Administrator, DON, ADON, Medical Director, Activities Director, Social Services Director, Dietary Manager, admission Director, Housekeeping Supervisor, Minimum Data Set Coordinator, Infection Preventionist, Medical Records, Maintenance Director, Human Resources, Therapy, 2 Nursing Unit Managers, and the Nurse Consultant. On 6/21/25 the survey team verified through record review and interview with the DON that on 6/19/25 the competency evaluation forms for all facility lifts were revised to provide more specific instructions. The facility has a separate competency evaluation form for each type of lift used by the facility. The survey team verified through review of 5 random competency evaluations that the new forms were used to verify staff competency on safe use of the lifts. On 6/21/25 the survey team verified through review of licensed nurses education and interview with the DON that as of 6/20/25 26 of 47 licensed nurses were educated on the new electronic incident reporting system. The incidents are also monitored and reviewed by an outside contracted consulting service. On 6/21/25 at 3:20 p.m., The DON demonstrated the use of the new electronic incident reporting system. The DON verified that all remaining untrained staff will not be permitted to work until the training has been completed. On 6/21/25 the survey team verified through review of education content and sign-in sheets, interview with 3 licensed nurses, the DON and the evening supervisor that on 6/20/25 14 of 47 licensed nurses were educated on proper supervision of the Certified Nursing Assistants. The DON verified that all untrained nurses would receive the education prior to their next scheduled shift. Each nurse interviewed said they are now required to supervise all transfers with lifts to ensure the safety of residents. They are the CNAs direct supervisors. Training included ADL (activities of daily living), transfers, meals delivery and feeding . Provide redirection, instructions, guidance as needed according to the resident's plan of care. Report any need for education or concerns to the management team. The Facility alleged compliance with the removal plan as of 6/20/2025. On 6/21/25 the survey team determined the facility was in compliance with their removal plan as of 6/21/25 when the worn out sling with frayed straps and holes used to transfer Resident #33 was removed from use and no other damaged sling was observed in use with residents care planned for transfer with mechanical lifts.

Based on observations, record review, residents and staff interviews, the facility's Administration failed to utilize its resources effectively to maintain oversight and ensure staff were trained and competent in the safe use of manual and mechanical lifts to transfer residents and appropriately respond to residents' incidents for 1 (Resident #48) of 29 residents care planned for manual or mechanical lifts for transfers. Resident #48 diagnoses included a history of multiple strokes, obesity and unilateral functional limitation in range of motion of upper and lower extremities. Resident #48 was care planned for the use of a manual sit-to-stand lift for transfers. On 5/2/25 the nurse on duty documented the resident was crying and in a lot of pain. Her ankle was swollen with purple bruising. Resident #48 reported she sustained the injury to her foot the previous night when the lift was used wrong. On 5/3/25, Resident #48 was diagnosed with a fracture of the left heel bone. Resident #48 suffered serious injury from the improper use of the manual sit-to-stand lift. The facility administration failed to investigate the incident, failed to have documentation staff using manual and mechanical lifts to transfer residents were trained and competent to safely use the lifts, and failed to ensure nursing staff implemented the facility's policies and procedures and immediately reported the allegation of improper use of the lift resulting in serious injury to Resident #48. The facility administration failure to provide oversight, monitoring, and staff training to ensure the safe delivery of nursing care and related services placed all 29 residents care planned for manual and mechanical lift transfers at a likelihood of serious harm, and serious injury, or death from improper use of the lift and resulted in the determination of Immediate Jeopardy. The findings included: Cross reference F689 and F726 Review of the signed Administrator's job description dated 9/19/2024 revealed, The primary purpose of your position is to direct the day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times . Duties and responsibilities . Review accident and incident reports . Monitor to determine the effectiveness of the Facility's risk management program . Review of the signed Director of Nursing's job description dated 4/16/2020 revealed, General description. Responsible for planning, coordination, implementation, evaluation and supervision of the nursing services. The Director of Nursing is responsible for maintaining consistent, safe and effective nursing practices and the management of the overall operation of the Nursing Department in accordance with policies, standards of nursing practices and regulatory requirements. Establish processes that are outcome focused as to maintain the highest possible level of care and services for each resident . Essential job functions: . Responsible for . orientation, training, evaluation . of nursing personnel. Provides leadership to the nursing department in accordance with guidelines and regulations concerning the delivery of care to assure appropriate nursing services are delivered . Nursing care and documentation function. Establish and maintain systems including chart audits for . incident reports, etc., regarding patient services. Instruct nursing staff on appropriate required action. Resident comfort and safety . Ensure equipment . are safe . and any hazardous conditions are addressed. Review of the clinical record for Resident #48 revealed an admission date of 10/18/21. The care plan initiated on 11/102021 and revised on 9/19/24 noted Resident #48 was at risk for falls and/or fall related injury due to generalized weakness, impaired balance, unsteady gait and required staff assistance with transfers and ambulation. The care plan noted the resident had a history of multiple strokes. The interventions included to provide hands on assistance with transfers and utilize (brand name) manual standing aid (manual sit-to-stand lift) as ordered. Review of the nursing progress notes revealed on 5/2/25 at 10:27 p.m., Licensed Practical Nurse (LPN) Staff O documented in a change in condition progress note, Nursing observations, evaluations, and recommendations are: Resident is crying in a lot of pain. Her left ankle is swollen and has purple bruising. She stated, We were using the (brand name) lift last night and it was used wrong. LPN Staff O documented the Advanced Practice Registered Nurse (APRN) was notified on 5/2/25 at 10:42 p.m. and ordered a STAT (Immediate) X-ray of the resident's left ankle. Review of the Radiology Results Report of the resident's left ankle X-ray revealed the STAT X-ray was not done until 5/3/25 at 10:24 a.m. The results reported on 5/3/25 at 2:20 p.m., read, Left calcaneal (heel bone) fracture. The age of the fracture is indeterminate. On 6/15/25 at 9:35 a.m., in an interview Resident #48 said she sustained a fracture of the left foot when her foot got stuck between the lift and the wheelchair during transfer. She said the Certified Nursing Assistant (CNA) did not place her feet correctly on the lift. Her left foot slipped off the lift and caused the injury. Resident #48 said she could not walk or stand. She tried but was not able to lift her feet or move her legs. She said, My foot was not on right. I told them that but they didn't fix it. My foot went between the lift and the floor. The facility's Incident by incident type list from 1/1/25 through 6/14/25 was reviewed and did not include the improper transfer of Resident #48 on 5/1/25 with the manual sit-to-stand lift that resulted in Resident #48's serious injury to the left foot. On 6/17/25 at 3:40 p.m., an interview was held with the Director of Nursing (DON) to review the incident, including immediate reporting, investigation, root cause and measures implemented to prevent further avoidable incidents when using manual or mechanical lifts to transfer residents. The DON reviewed the facility's incidents and verified Resident #48's injury sustained on 5/1/25 during transfer with the manual sit-to-stand lift was not listed on the incidents log. She said there was no documentation the incident was investigated. The DON said she was out of town and the facility Administrator would have been responsible for the investigation. On 6/17/25 at 4:30 p.m., in an interview Resident #48 said staff were still using the manual lift for all transfers. She said when she injured her left foot, 2 staff were transferring her with the lift. Resident #48 said they were not paying attention. Her foot was not placed properly in the machine and moved. Her foot got stuck and twisted and caused the left heel bone fracture. On 6/17/25 at 4:45 p.m., in an interview the Administrator said on 5/2/25, when Resident #48 reported she was injured during transfer with a lift, no one notified him. The nurse on duty reported the incident to him on 5/5/25. The Administrator said he started an investigation on 5/5/25 but could not locate it. He said they also started re-educating staff on the lifts. When asked to see documentation of the training, he said, Like I said, I can't find anything. On 6/17/25 at 4:50 p.m., in an interview the Social Service Director said when there is an incident involving a resident, she is the one who interviews the affected resident. She said on 5/5/25 she became aware of Resident #48's left heel fracture and interviewed her. She said Resident #48 told her the injury happened when Certified Nursing Assistant (CNA) staff G and another CNA transferred her with the (brand name) manual lift. She wrote the resident's statement but could not find it. On 6/17/25 at 5:40 p.m., an interview was held with the DON to review facility's processes to ensure staff were trained and competent to safely transfer residents with manual and mechanical lifts. The DON said as part of orientation, all staff watch a video on the use of the different lifts used at the facility (manual sit-to-stand lift, mechanical sit-to-stand lift and full body mechanical lift). She said the therapy department evaluates residents to determine their transfer status, including the type of lift appropriate for each resident as necessary. Review of the facility's policy titled, Resident Safe Handling Policy revised 8/3/2015 revealed, In order to provide a safe environment for our residents and Clinical team, this facility has adopted a Safe Resident Handling philosophy. Clinical team(s) responsible for the transferring or repositioning of residents will receive instruction on the safe operation of mechanical lifts, the non-mechanical standing aid, and assistive transfer/repositioning devices . The Clinical Educators will be responsible for the training of current Lateral slide/repositioning devices, and the policy of Safe Resident handling. Clinical Educators will also coordinate with Physical Therapy for training employees on the use of all Safe Resident Handling devices. Training will be conducted upon hire with re-instruction as needed. Nursing Leadership will monitor the appropriate use of all Safe Resident Handling devices by the Clinical team and provide instructions as deemed necessary and appropriate .The Administrative team and Nursing leadership will support and enforce this retraining for the safety of the Clinical team and Residents. The policy noted the (brand name) sit-to-stand manual lift was an example of a non-mechanical standing aid device. When asked for documentation of staff training and competencies for the safe use of the lifts for Certified Nursing Assistant (CNA) Staff G and other CNAs, the DON said she made sure all staff watch the videos but had no documentation verifying the training or competency of staff related to safe use of the manual or mechanical lifts. Review of the personnel file for CNA Staff G revealed a date of hire of 8/29/2018. There was no documentation of manual or mechanical lift training on orientation. A Competency Assessment-Mechanical lift from a previous company dated 1/11/19 was in CNA Staff G employee file. The form was not signed by CNA Staff G or the reviewer. The form contained several questions. A question mark was entered for: Able to demonstrate appropriate set up of mechanical lift. A 2 (supervision required) was documented for: Demonstrates ability to transfer from bed to chair and chair to bed using mechanical lift. Not done was entered for: Demonstrates ability to transfer from floor to bed or chair using mechanical lift and for, demonstrates ability to transfer from chair to toilet using mechanical lift. The personnel file did not contain training or competency evaluation for the use of the (brand name) sit-to-stand lift used on 5/1/25 to transfer Resident #48. CNA Staff G's personnel file contained a Safe Resident Handling Policy Acknowledgement form dated 1/1/19. The form noted, I acknowledge that I have received the information concerning this policy and agree to work within the guidelines set forth. The date of employee training was 1/11/19. The form was not signed by CNA Staff G and did not contain the Clinical Educator Signature. Review of the personnel files for CNAs Staff C (date of hire 1/30/2008), Staff W (date of hire 3/12/2001), Staff S (Date of hire 3/4/2025) and Staff Y (Date of hire 4/1/25) failed to reveal documentation of training, in-service or competency evaluations on use of manual sit-to-stand lifts. On 6/17/25 at 5:50 p.m., in an interview CNA Staff G said it has been 7 years since she's had training for mechanical lifts. On 6/17/25 at 6:00 p.m., in a telephone interview CNA Staff P said she took care of Resident #48 on 5/2/25 from 7:00 p.m. to 7:00 a.m. She said that day Resident #48 requested to be put to bed earlier than her usual time of 8:30 p.m. Resident #48 said her ankle got injured the previous night when they transferred her with the manual lift. Resident #48 told her the CNA who transferred her didn't know what she was doing. The DON was present during the interview done on speaker phone. On 6/18/25 at 8:19 a.m., CNA Staff E and CNA Staff F were observed using the (brand name) manual sit-to-stand lift to transfer Resident #48 from bed to chair. The CNAs brought the manual lift to the bed and helped the resident place her feet on the footrest of the lift. Resident #48 was not able to pull herself in a standing position without extensive assistance of both CNAs. The CNAs stood on opposite sides of the resident. Both CNAs pulled the resident to a standing position on the lift. Review of the documentation for 6/18/25 for the task: Transfer: Self Performance (How resident moves between surfaces including to or from bed, chair, wheelchair, standing position) revealed the CNA placed a check mark on Limited assistance. Resident highly involved in activity, staff provides guided maneuvering of limbs or other non-weight-bearing assistance. Review of the manufacturer's instructions for use for the manual sit-to-stand lift provided by a manufacturer's representative of the lift revealed, Patient/Resident Assessment . Before use, the caregiver should always consider the patient's/resident's medical condition as well as physical and mental capabilities. In addition, the patient/resident must: . Have the ability to stand unaided or stand with minimal assistance. Safety instructions . This mobile lift must be used by a caregiver trained with these instructions . Before transferring the Patient . Position the (brand name lift) so that the patient's feet are placed on the footrest with knees comfortably against kneepad. Review of the manufacturer's skills checklist and performance observation revealed, The patient's/resident's feet should be on the footrest with knees comfortably against kneepad during transfer. On 6/18/25 at 9:20 a.m., the Administrator said he found the staff statements related to Resident #48's accident. He said, Her foot slipped, it was an accident. The Administrator did not provide staff education on safe use of the lifts. He said they did a reenactment yesterday on 6/17/25 but did not document the reenactment. He said if needed he would document. When asked about the incident investigation, the Administrator said the staff statements were the investigation. The staff statements did not include a statement from LPN Staff O. The Administrator said he did not interview anyone else after reading the resident's interview. The DON who was present during the interview said she had a call out to LPN Staff O who documented Resident #48's change in condition but did not report it to anyone. She said, Staff know they are supposed to fill out an incident report and nothing was done. Review of the staff statements revealed: On 5/5/25 the Social Services Director wrote on a signed statement, Visited resident regarding her foot (ankle) and she stated that when (CNA Staff G) and another CNA changed her briefs, her left foot slid and hit her ankle on the bar (to open and close) of the (brand name lift). She stated that this happened on Thursday May 1, 2025 @ (at) around 5 or 6 pm. On 5/5/25 CNA Staff G wrote on a signed statement, I did not take the resident to the bathroom on Thursday 5/1/25 and she did not hit her left ankle with me or reported anything to me about her ankle. The first time I'm hearing about it is today. On 5/5/25 LPN Staff Q wrote on a signed statement, I was the nurse assigned to the resident (Resident #48's name) on 5/5/25. She told me that when the CNA was transferring her to the bathroom using the (brand name manual lift) that she hit her left ankle on it. At the time she could not remember the name of the CNA. On 5/5/25 LPN Staff R wrote on a signed statement, On 5-2-25, I was the nurse assigned to (Resident #48) 7A-7P (7:00 a.m. to 7:00 p.m.). During my shift resident did not complain of pain. One other CNA (CNA Staff S) signed a statement dated 5/5/25 noting she had not heard anything about Resident #48 hurting her foot. Review of the nursing staffing schedule for 5/1/25 revealed 4 CNAs worked on the unit where Resident #48 resides during the 7:00 a.m., to 7:00 p.m. shift. Only one of the 4 CNAs was interviewed. On 6/18/25 at 9:55 a.m., the DON provided a yearly performance appraisal for CNA Staff G dated 9/9/24. The form noted CNA Staff G scored 3 (average) in Personal Nursing Care Functions which included, Assist with lifting, turning, moving , positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc. The DON verified there was no competency evaluation for the use of the manual or mechanical lifts or how the rating of 3 listed on the form was determined. She said CNA Staff G trained new CNAs which includes showing them how to use the lifts. She said she considered this an evaluation of the CNA's ability to use the manual and mechanical lifts since CNA Staff G was evaluating new CNAs. On 6/18/25 at 2:22 p.m., in an interview LPN Staff T said she received training on the manual sit-to-stand lift 3 years ago. LPN Staff T was not able to explain or demonstrate how to use the manual sit-to-stand lift. She said, I don't know how to use the lift, I have never used it. LPN Staff T called a CNA over and said she would be able to demonstrate how to use the lift. On 6/19/25 at 11:21 a.m., CNA Staff E and CNA Staff V were observed using a (brand name manual sit-to-stand lift) to transfer Resident #32 from bed to the wheelchair. Resident #32 was wearing tennis shoes. He sat on the edge of the bed with both feet on the floor. CNA Staff E positioned herself to the resident's left side and CNA Staff V positioned herself to the resident's right side. The CNAs positioned the (brand name) manual sit-to-stand lift in front of the resident. The CNAs instructed the resident to place his feet on the footrest and his hands on the handlebar. The resident placed only part of his feet on the footrest of the lift with the heels hanging off the back of the footrest. The resident's feet were not completely on the footrest. Resident #32 stood up with his heels hanging off the footrest. The CNAs rotated the half seats underneath the resident's buttocks and transported the resident in the manual sit-to-stand lift with his heels hanging off the footrest. The CNAs did not ensure the resident's feet were properly placed on the footrest before wheeling the lift and transferring the resident to the wheelchair. CNA Staff E moved over to the wheelchair. CNA Staff V transferred Resident #32 with the heels hanging off the back of the footrest. Photographic evidence obtained. On 6/19/25 at approximately 12:00 p.m., during an interview the Director of Rehab reviewed the photographic evidence of the positioning of Resident #32's feet on the manual sit-to-stand lift. She said the resident's feet were not positioned properly and it was not safe. The Director of Rehab said the therapy department did not conduct staff training on the use of the manual or mechanical lifts. On 6/19/25 at 12:19 p.m., in a telephone interview CNA Staff G said she was assigned to Resident #48 on 5/1/24 from 7:00 a.m. to 7:00 p.m. She said CNA Staff U assisted her to transfer Resident #48 with the manual sit-to-stand lift. She said Resident #48 was totally dependent on staff for everything. Staff G said, She cannot turn, reposition herself or assist with the transfer with the (brand name sit-to-stand lift). CNA Staff G said it takes 2 staff to hold the resident by her pants and lift her to place her in the lift. She said Resident #48 cannot assist with the transfer with the lift, she is not even able to place her hands on the handlebar and cannot sustain her weight. Staff has to make all the effort to get her in the lift. CNA Staff G said after the incident someone must have realized the resident was not appropriate to use the lift and they changed it to a full body mechanical lift. She said for some reason, they went back to the manual sit-to-stand lift. CNA Staff G said she did not remember Resident #48 complaining about her foot with the transfer. On 6/19/25 at 1:40 p.m., in a telephone interview LPN Staff O said on 5/2/25 Resident #48 was crying and was in a lot of pain. Her left foot was swollen and bruised. The resident said the CNAs used the lift wrong the previous evening and hurt her foot. She said she immediately reported the incident to the evening supervisor, Registered Nurse (RN) Staff D who instructed her to call the physician. LPN Staff O said she did not think she had to write an incident report since the incident did not happen on her shift. On 6/19/25 at 2:58 p.m., a joint interview was held with the DON and the evening supervisor, RN Staff D to discuss processes in place to address residents' incidents, including post-incident assessment, DON and Administrator immediate notification. RN Staff D verified that on 5/2/25 LPN Staff O told her about Resident #48's bruised and swollen left foot but did not tell her how the resident sustained the injury. She instructed LPN Staff O to call the attending physician. Evening Supervisor RN Staff D said she knew she was supposed to assess the resident but she already had her bag on her shoulder and was leaving. She verified she did not follow up to ensure an incident report was completed and the incident was reported to the DON or Administrator. The DON said the expectation was for the Evening Supervisor, RN Staff D to go assess the resident and give directions to the LPN. She said LPN Staff O should have notified her or the Administrator. The expectation was for LPN Staff O to complete an incident report and she did not. The DON said she started educating the licensed nurses and CNAs on incident reporting and investigation. She said the facility began training the licensed nurses on a new electronic incident reporting system. The DON provided a sign-in sheet dated 5/21/25 for an in-service on Incident Reporting/Grievance new portal. The content was, All incidents/Grievances must be completed in the (electronic incident reporting system) portal timely. The instructions included to contact their supervisors with any questions and noted, Not completing an incident during your shift is not an option. 22 of 37 Licensed Nurses hired prior to 5/21/25, including LPN Staff O and Evening Supervisor RN Staff D attended the in-service. On 6/21/25 the DON provided documentation that on 6/20/25, 53 of 58 Certified Nursing Assistants were educated regarding the proper use of all facility lifts. On 6/21/25 at 1:40 p.m., CNA Staff W and CNA Staff X were observed transferring Resident #33 with a (brand name) full body mechanical lift. The Assistant Director of Nursing (ADON) was in the room observing the transfer. The sling's label was missing. Two holes were observed in the fabric of the sling. The sling's straps showed signs of damage and were frayed. Photographic evidence obtained. On 6/21/25 at 1:50 p.m., the Assistant Director of Nursing (ADON) observed the holes in the sling and verified the sling's label was missing. She also verified the straps showed signs of damage and were frayed. The ADON offered no explanation for the continued use of the damaged sling. Review of the manufacturer's manual for use of the slings provided by a representant of the slings manufacturer revealed, Before every use. WARNING. To avoid injury, always make sure to inspect the equipment prior to use. Check all parts of the sling . If any part is missing or damaged- Do NOT use the sling. Check for: Fraying, loose stitching, tears, fabric holes, soiled fabric, damaged clips, unreadable or damaged label. Review of the facility's policy and procedure titled Lifting Machine, Using a Mechanical with a revised date of July 2017 revealed, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. Sling care: discard any worn, frayed or ripped slings. On 6/21/25 the immediate actions implemented by the facility and verified by the survey team included: On 6/21/25 the survey team verified through review of the education and interview with the DON and Administrator that on 6/20/25, the Regional Nurse reviewed the reporting process and job descriptions with the Administrator and Director of Nursing to ensure oversight and effective monitoring are maintained on facility processes to include reporting requirements, conducting investigations and completing root cause analysis. On 6/21/25 the survey team verified through review of education and interview with the DON and ADON that on 6/19/25 the Regional Nurse educated the Administrator and department heads regarding reporting and incident investigations. On 6/21/25 at 11:25 a.m., in an interview evening supervisor RN Staff D said the situation with Resident #48 opened my eyes to me thorough with her assessments and stopping to see what staff is doing. She said she was educated and knows that if someone comes to her with a problem, she must go and assess the resident. She must call the DON and if not able to reach the DON she must call the Administrator. If staff call her, she has to go immediately. As a supervisor, she makes rounds and ask staff what they need help with. She also said she was trained on the use of the lifts this week. On 6/21/25 at 11:45 a.m., in an interview RN Staff AA said she started employment at the facility approximately 3 months ago. She said the training of the usage of the lifts was a good idea. After she was trained, she helped trained the CNAs. She had to tell them that the residents' feet have to be completely inside the footboard platform of the lift. She said the training started on 6/19/25 and she's had to correct at least 2 CNAs who were not using the lift correctly. She said for now they are observing every single transfer with a lift and they keep training and educating. On 6/21/25 the survey team verified through review of residents' assessment that on 6/20/25 all residents requiring use of facility lifts were identified and assessed with no injuries noted. On 6/21/25 the survey team verified through review of the education and interview with 3 licensed nurses, 3 CNAs and the ADON that on 6/20/25 the DON and ADON educated 79 of 145 facility staff regarding the proper reporting of all incidents. All remaining staff will be required to complete this education prior to working in the facility. On 6/21/25 the survey team verified through record review and interview with the Administrator and DON that on 6/19/25 the facility conducted an Ad Hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) meeting to review the system failures and processes that need to be implemented to prevent these failures in the future. This Plan was approved by all in attendance including the Medical Director. On 6/21/25 the survey team verified through review of the education and interview with the Administrator and DON that a new electronic incident reporting system was implemented. On 6/21/25 the DON demonstrated the use of the new system. She verified that all incidents are reviewed internally by the DON, ADON, Nurse Consultant, and Administrator. These same incident reports are also monitored and reviewed by their contracted outside consulting service. She verified that as of 6/20/25, 26 of 47 full time licensed nurses have completed the training. The remaining untrained nurses will not be permitted to work until training has been completed. On 6/21/25 the survey team verified through review of the schedule and interview with the DON that the facility does not use agency staff. On 6/21/25 the survey team verified through review of additional staff statements and facility investigation the Administrator conducted a more thorough investigation to include additional staff interviews, simulation of incident with resident describing how the injury occurred with the manual sit-to-stand lift, review of medical record to identify any underlying contributing factors, and root cause analysis. The Administrator provided documentation that on 6/19/25 a Federal reporting was initiated and submitted. The Facility alleged compliance with the removal plan as of 6/20/2025. On 6/21/25 the survey team determined the facility was in compliance with their removal plan as of 6/21/25 when the sling with frayed straps and holes used to transfer Resident #33 was removed from use and no other damaged sling was observed in use with residents care planned for transfer with mechanical lifts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility policies and procedures, resident representative and staff interviews, the facility failed to protect the residents' right to be free from neglect. The facility failed to re-evaluate the risk for elopement and implement adequate supervision to prevent unsafe wandering and elopement for 1 (Resident #1) of 3 sampled residents reviewed with severe cognitive impairment, confusion, and decreased safety awareness. Resident #1 was a vulnerable adult admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, cognitive communication deficit, and generalized muscle weakness. On 8/16/24, documentation in the nursing progress notes indicated Resident #1 was confused, wandering and said he wanted to go down the street to his house. The facility neglected to re-evaluate the risk for elopement and adequately supervise Resident #1. On 8/16/24 at approximately 7:30 p.m., Resident #1 was sitting in the front lobby with a bag of clothes on his shoulder. The receptionist neglected to verify the resident's identity. She unlocked the front door and allowed him to leave. The facility staff were not aware of the resident's exit until 8/16/24 at approximately 8:45 p.m. Resident #1 walked approximately 75 feet to a busy six lane road, got on a bus to Fort [NAME] located approximately 16 miles from the facility. Resident #1 could have been hit by a car while crossing the busy six lane road. He could have wandered into an unsafe area, get assaulted, causing serious injury or death. The facility's failure to provide the necessary care and services to prevent neglect created a likelihood of serious harm, serious injury, or death of Resident #1 and other cognitively impaired residents from unsafe wandering. This failure resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of Isolated (J) starting on 8/16/24. On 8/24/24, after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 8/24/24. The scope and severity were reduced to no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference F689. The facility's Standards and Guidelines for Abuse, Neglect and Exploitation revised on 11/1/2017 noted, It will be the standard of this facility [sic] honor residents' rights and to address with employees the seven (7) components regarding . neglect . Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Training will focus on the following topics: Recognizing . neglect . The facility environment will be monitored to prevent any potential ANE [Abuse, Neglect, Exploitation] through: . Monitoring of residents with needs and behaviors that might lead to conflict . The facility's elopement policy revised August 2014 noted, The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement . The staff will identify residents who are at risk for harm because of unsafe wandering or exit seeking (including elopement). Staff will utilize the admission Nursing Comprehensive Evaluation to determine the residents risk for elopement . After the time of admission staff will utilize the Elopement evaluation as needed to determine the residents risk for elopement. The following are behaviors or changes in behavior that would require staff to re-evaluate a resident to determine their risk of Elopement. i. Resident expressing, he/she is looking to leave the facility . iii. Loitering around exit doors . The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate whether the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included . Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] from an acute care hospital. Diagnoses included Alzheimer's disease and Dementia. The admission Nursing Comprehensive evaluation dated 8/7/24 at 6:56 p.m., noted Resident #1 scored a 6 on the elopement risk evaluation indicating the resident was not at risk for elopement. The Licensed Nurse completing the assessment noted in History of elopement/wandering, Wanders, but has NEVER eloped. Resident #1 was totally or mostly dependent in locomotion, was discontent but agreeable to facility placement. The baseline care plan initiated on 8/8/24 documented Resident #1 had decreased cognitive skills related to cognitive/linguistic deficits and a potential for alteration in thought process related to diagnosis of dementia, Alzheimer's disease and altered mental status. The baseline care plan specified to observe Resident #1 for changes in cognitive function and notify the physician if noted. On 8/8/24 the Speech Language Pathologist checked the boxes in a therapy screen form indicating Resident #1 had a change in cognitive function, and a change in safety awareness/judgement in the section for The following changes in condition have been observed/reported. The Speech Language Pathologist documented Resident #1 scored a 03 on the Brief Interview for Mental Status assessment (used to evaluate a resident's cognition, behavior and mood), indicative of severe cognitive impairment. On 8/8/24 the Physical Therapist documented in an evaluation Resident #1 was able to ambulate 150 feet with minimal assistance. Resident #1's goal was, I want to go home. The Therapist documented the potential for achieving the goal was fair, limited by the resident's impaired cognition and safety awareness. Review of the progress notes revealed the Attending Physician assessed Resident #1 on 8/8/24, 8/9/24, 8/15/24, and 8/16/24. The physician documented during each visit, Cognitive impairment. Monitor for worsening symptoms or changes in mental status. On 8/15/24 the Psychiatrist documented Resident #1 had impaired cognition, confusion, restlessness, excessive worry, oriented to person only, poor insight, poor judgment, poor short term and long term memory. The Psychiatrist documented to monitor for mood and behavior. On 8/16/24 at 3:50 a.m., Licensed Practical Nurse (LPN) Staff A documented in a progress note, Pt [Patient] is alert with confusion. Pt wanders and doesn't know where he is, stated I am going down the street to my house. The clinical record lacked documentation the facility reevaluated the resident's risk for elopement and initiated adequate supervision to ensure the safety of the resident. On 8/16/24 at 10:00 p.m., LPN Staff B documented in a progress note Resident #1, was last seen sitting in the lobby at approximately 7:25 p.m. We [sic] was asked to go back to his room but he declined stating that he was fine where he was. Resident was calm and not agitated so he was left to lounge in the lobby. Elopement protocol followed; room search, 911 called, family notified, hospitals called to search for resident, facility searched. Review of the facility's investigation report dated 8/17/24 showed documentation Resident #1 was, his own person with no advance directives and no incapacity. On 8/16/24 at around 7:15 [p.m.] he was at the front lobby fully dressed and with a bag of clothes around his shoulder and then proceeded to walk out the front door when it opened and when asked by the receptionist if he was a visitor or resident/patient he stated he was a visitor and kept on going. Review of staff statements obtained as part of the investigation revealed: On 8/16/24 LPN Staff B said at approximately 7:20 p.m., she observed Resident #1 walking toward the lobby. She was receiving report from the morning nurse. She told Certified Nursing Assistant (CNA) Staff C to ask Resident #1 to return to his room and continued to get report. On 8/16/24 at 7:30 p.m., CNA Staff D asked her in reference to resident. She advised the CNA that Resident #1 was walking in the hallway near his room. On 8/16/24 at 8:45 p.m., CNA Staff D informed her that Resident #1 was not in his room. They started to search for the resident and he, wasn't easily found. They notified the Nurse Manager. On 8/16/24 CNA Staff D wrote she was doing her rounds at 7:30 p.m. and notified the nurse that Resident #1 was not in his room. The nurse said, He is walking around. She continued to do her work. On 8/16/24 at 8:45 p.m., she went back to see if Resident #1 was in his room. She told the nurse the resident was not in his room, or in any room she was assigned to. She went outside the facility to look for the resident near a discount department store by the hospital. The receptionist wrote in an undated statement that on 8/16/24 at around 7:10 p.m., she noticed a gentleman taking a seat in the lobby. He was neatly dressed and had a bag over his shoulder that appeared to have clothes in it. She was tending to another gentleman who was signing out from visiting his mother. After about five minutes the gentleman (Resident #1) that was sitting in the chair casually got up and walked to the exit door with his bag over his shoulder. She had not seen this individual before. The way he was dressed, he looked like a visitor. As Resident #1 approached the door, she asked him if he was a resident or a visitor. He was not wearing any name band. He said he was a visitor and proceeded to walk out the door. She tried to get his attention to sign out. He kept walking and she did not call him to come back and sign out. She locked the door at 7:30 p.m. at the end of her shift. She received a call at approximately 9:00 p.m., to 9:30 p.m. asking about Resident #1. She told the facility she saw him go out and he stated he was a visitor. On 8/22/24 at 3:02 p.m., in a telephone interview the receptionist said she was working on the day Resident #1 eloped. She said around 7:20 p.m., she made the announcement for visitors to come to the front lobby since visiting hours were over at 7:30 p.m. She said at approximately 7:10 p.m., Resident #1 came and sat on a chair in the lobby. He looked like a visitor and had a large bag, the kind you would put clothes in. He looked like he was watching people leaving. She thought he was waiting for a ride. Resident #1 told her he was a visitor which she thought was kind of strange. He did not have a wrist band on. He got up slowly and walked toward the door. He exited the facility when she let another visitor out. The receptionist said they used to give visitors an orange sticker but it stopped during COVID. They started it again after Resident #1 eloped. On 8/22/24 at 3:33 p.m., in a telephone interview Resident #1's daughter said the case manager at the hospital told her the facility had a memory care unit. She found out when her father got to the facility that they did not. She wanted him safe in a memory unit. She voiced her concern to the nurse who told her they monitor their residents all the time. She said her father took a bus and got dropped off in a downtown area (approximately 16 miles from the facility) and was found sitting outside of a bar. He had no identification on and would not know his address. She said Resident #1 was currently at a different skilled nursing facility in a secured memory unit. On 8/22/24 at 5:30 p.m., in an interview the Administrator said on 8/16/24 Resident #1's family was with him the whole day on 8/16/24 and he did not display unsafe wandering or exit seeking behaviors. On 8/23/24 at 10:22 a.m., in a telephone interview LPN Staff A said on 8/15/24 she worked from 7:00 p.m., to 7:00 a.m., on 8/16/24. She said that night Resident #1 was very confused. She documented in a progress note that he was wandering and he walked pretty well. When he got into bed, he did not remove his shoes. She told the oncoming nurse about the resident's wandering and expressing desire to leave the facility to go down the street to his house. He did not know where he was so she didn't think he really knew if he lived down the street. LPN Staff A said Resident #1 was not safe to leave the facility unsupervised. She said she should have placed a wander alarm band (alerts staff when a resident leaves a safe area) on him. She said if she had done that, the alarm would have gone off and Resident #1 would not have left. She said on 8/16/24 at 7:00 a.m., when she gave report to the oncoming nurse, Resident #1 was again sitting in the front lobby. On 8/23/24 at 11:05 a.m., in an interview the Speech Language Pathologist (SLP) said he evaluated Resident #1 on 8/8/24 and saw him three times during his stay. He clearly was cognitively impaired. His orientation was pretty bad, His BIMS was 03. He was not safe to leave the facility unsupervised. He was a lot better physically than cognitively. His orientation, decision making, and short term memory were severely impaired. He would not trust him to go to the convenience store nearby by himself because he would not come back. The SLP said Resident #1 kept saying he wanted to go home. He said, What made this resident's situation unsafe is the fact that he was very confused but very mobile. On 8/23/24 at 11:07 a.m., in a telephone interview the Psychiatrist said on 8/15/24 when she assessed Resident #1, he was very depressed, crying and confused. He could not give much information. The information was obtained from the daughter and hospital notes. He did not know where he was and was very confused. He was cognitively impaired. He was not safe to walk out, he was not safe to catch the bus and was not able to make his own decisions. She saw the consent for treatment form that was signed by the wife and thought Resident #1 had an existing incapacity. She thought the wife was the power of attorney. The facility did not ask her to write an incapacity statement. The psychiatrist repeated Resident #1 could not be out on his own. On 8/23/24 at 11:49 a.m., in an interview the Physical Therapy Assistant said Resident #1 was confused but hid it well. He said he was almost afraid to make the resident better physically due to his severe cognitive impairment. That would predispose Resident #1 to get into dangerous situations. He could leave the facility, go into the wrong building, and get into dangerous situations. He would not be able to make the right decision for anything such as walking in the middle of the street, going into the wrong building. Resident #1 kept saying he wanted to go home. He was not safe to leave the facility unsupervised. On 8/23/24 at 2:00 p.m., in an interview the Attending Physician said anything bad could have happened to the resident. He was not safe the leave the facility unsupervised and could have been seriously harmed. She said it was a blessing that his defibrillator (implanted device that sends electric shock to the heart to restore normal rhythm) went off and he went to the hospital. Review of the emergency room (ER) Physician's progress note dated 8/17/24 showed documentation Resident #1 was at the nursing facility in [NAME] when he eloped from the nursing facility, got on a bus and went to a bar. He was a silver alert (Public notification system to help locate missing people 60 or older). They were in the process of trying to find him with helicopters, police dogs, personnel search when his defibrillator fired. EMS was called for his chest pain which is when they located him. The physician wrote, On bedside physical exam he is awake he follows commands he is confused he knows the year not the month or time of year. He believes he is in Maine. He cannot remember what state he currently lives in. In the medical decision making of the progress note the ER Physician documented, Medical hold was placed on his chart as he is a flight risk and he did try to elope from the emergency department. After verification of implementation of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 8/24/24. The Immediate actions implemented by the facility and verified by the survey team included: On 8/17/2024 an ad hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) meeting was held, and a root cause analysis of the incident was done. Attendees of the QAPI included the Medical Director, Director of Nursing, Administrator, Human Resources, Social Service, Activities, Therapy Director, Minimum Data Set nurse, Nurse, CNA. The Licensed Nurses neglected to assess Resident #1 with severe cognitive impairment, confusion and decreased safety awareness to prevent unsafe wandering and elopement. The receptionist neglected to verify the identity of Resident #1 before allowing him to leave the facility. On 8/24/24 the surveyor verified through review of the QAPI meeting. On 8/17/2024 the DON completed an audit of all 119 current residents to ensure each resident is receiving the appropriate care and services to prevent neglect focusing on adequate assessment and supervision of residents with severe cognitive impairments, confusion and decrease safety awareness to prevent unsafe wandering and elopement. 43 residents were identified with a BIMs score below 13. All 43 residents were reviewed to ensure each resident is receiving appropriate care and services to prevent neglect. On 8/24/24 the surveyor verified through review of the audits completed and review of two randomly selected residents with impaired cognition for evidence of adequate assessment and supervision. One resident was identified to be at risk of unsafe wandering and elopement. The care plan was updated to ensure the safety of the residents. Resident was placed in the elopement binder and elopement binder was updated to reflect current elopement risk residents. There are 4 binders in the facility. One is at the receptionist desk and one on each of the three nursing stations in the facility. On 8/24/24 the surveyor verified through observation and content of the four binders with one resident identified at risk for unsafe wandering and elopement. On 8/17/2024 the DON initiated education of all staff on abuse, neglect and exploitation, focusing on adequate supervision to ensure the safety of cognitively impaired residents to prevent unsafe wandering and elopement. As of 8/24/2024, 45 of 53 Licensed nurses, 49 of 54 Certified Nursing Assistants, 17 of 17 Therapists, 3 of 3 receptionists and 42 of 47 staff from other departments completed their education. Knowledge verification was done through a posttest. Any staff who has not completed the education will be required to complete the required training prior to the start of their next shift. On 8/24/24 the surveyor verified through review of the training provided. On 8/24/24, one receptionist, six licensed nurses and three CNAs were interviewed. They were able to verbalize content of training and process to identify and ensure adequate supervision of cognitively impaired residents to prevent unsafe wandering and elopement. On 8/23/24 the DON initiated the education with the Licensed Nurses on prevention of neglect of cognitively impaired residents by ensuring accurate assessment and adequate supervision to prevent unsafe wandering and elopement. As of 8/24/24, 28 of the 53 Licensed Nurses received education. The remaining 25 Licensed Nurses will be educated before their next shift begins. On 8/24/24 the surveyor verified through review of the content of education provided and interview with six licensed nurses. Each nurse was able to verbalize the content of the education on neglect prevention by ensuring accurate assessment and adequate supervision to prevent unsafe wandering and elopement. The DON/Designee will audit the clinical record of new admissions and random residents to ensure appropriate care and services are provided to prevent neglect. On 8/24/24 the surveyor verified through interview with the DON and review of audits completed, and review of two random residents records to ensure accurate assessment and interventions to prevent neglect related to unsafe wandering and elopement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility's policies and procedures, resident representative and staff interviews the facility failed to recognize risk factors for elopement and adequately supervise 1 (Resident #1) of 3 sampled residents with severe cognitive impairment, confusion, wandering behavior and poor safety awareness who expressed desire to leave the facility. On 8/16/24 at approximately 7:30 p.m., Resident #1 who was confused, wandered, and voiced desire to leave the facility sat in the front lobby with a bag of clothes. The receptionist unlocked the door to the front lobby and allowed the resident to leave the facility without verifying his identity. The facility staff were not aware of the resident's exit until 8/16/24 at approximately 8:45 p.m. Resident #1 walked approximately 75 feet to a busy six lane road, got on a bus to Fort [NAME] located approximately 16 miles from the facility. Resident #1 was at a bar, complained of chest pain and was transported to a local emergency room via Emergency Medical Services and admitted to the hospital. The facility failure to implement adequate supervision to prevent unsafe wandering and elopement of cognitively impaired, and confused residents created a likelihood of avoidable accidents for Resident #1 and other cognitively impaired and confused residents at risk for elopement which could result in serious harm, serious injury, serious impairment or death of the residents. This failure resulted in the determination of Immediate Jeopardy. On 8/24/24 after verification of an acceptable removal plan, the immediate Jeopardy was removed as of 8/24/24. The scope and severity were reduced to no actual harm with potential for more than minimal harm (D) that is not Immediate Jeopardy. The findings included: Cross reference to F600. The facility's elopement policy revised August 2014 noted, The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement . The staff will identify residents who are at risk for harm because of unsafe wandering or exit seeking (including elopement). Staff will utilize the admission Nursing Comprehensive Evaluation to determine the residents risk for elopement . After the time of admission staff will utilize the Elopement evaluation as needed to determine the residents risk for elopement. The following are behaviors or changes in behavior that would require staff to re-evaluate a resident to determine their risk of Elopement. i. Resident expressing, he/she is looking to leave the facility . iii. Loitering around exit doors . The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate whether the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included . Review of the clinical record revealed Resident #1 was a vulnerable [AGE] year-old male admitted to the facility from an acute care hospital on 8/7/24. Diagnoses included Dementia and Alzheimer's disease. On 8/7/24 the Licensed Practical Nurse documented in an elopement risk evaluation Resident #1 scored a 6 on the elopement risk evaluation indicating he was not at risk for elopement. The resident was alert and oriented X 1 (Oriented to person) or had periodic confusion. Resident #1 wandered but has never eloped. Resident #1 was discontent but agreeable to facility placement. The admission Comprehensive Nursing Evaluation with an effective date of 8/7/24 noted Resident #1 was alert with some confusion. The resident's balance while standing, sitting and during transitions was not steady but Resident #1 was able to stabilize self without assistance. The baseline care plan initiated on 8/8/24 documented Resident #1 had decreased cognitive skills related to cognitive/linguistic deficits and a potential for alteration in thought process related to diagnosis of dementia, Alzheimer's disease and altered mental status. The baseline care plan specified to observe Resident #1 for changes in cognitive function and notify the physician if noted. On 8/8/24 the Speech Language Pathologist (SLP) checked the boxes in a therapy screen form indicating Resident #1 had a change in cognitive function, and safety awareness/judgment. The SLP noted the resident's cognition was severely impaired with a score of 03 on the Brief Interview for Mental Status assessment (used to evaluate a resident's cognition, behavior and mood). On 8/8/24 the Physical Therapist (PT) documented in an evaluation Resident #1 was able to ambulate 150 feet with minimal assistance. Resident #1's goal was, I want to go home. The PT documented the potential for achieving the goal was fair, limited by the resident's impaired cognition and safety awareness. Review of the progress notes revealed the Attending Physician assessed Resident #1 on 8/8/24, 8/9/24, 8/15/24, and 8/16/24. The physician documented during each visit the resident's cognition was impaired and, Monitor for worsening symptoms or changes in mental status. On 8/15/24 the Psychiatrist documented Resident #1 was referred for an evaluation for Depression and anxiety. The resident's daughter reported he has been showing sundowning behavior (confusion that occurs in the late afternoon and lasts into the night) with more anxiety specially at nighttime. The psychiatrist documented, Cognitive impairment, Confusion. Resident #1's insight, judgment, short-term, and long-term memory were poor. The treatment plan noted to monitor for changes in mood or behaviors. On 8/16/24 at 3:50 a.m., Licensed Practical Nurse (LPN) Staff A documented in a progress note, Pt [Patient] is alert with confusion. Pt wanders and doesn't know where he is, stated, I am going down the street to my house. Patient in bed with call light within reach and bed in lowest position. Care ongoing. The clinical record lacked documentation LPN Staff A communicated the change in behavior to the interdisciplinary team, reevaluated the resident's risk for elopement and initiated adequate supervision to ensure the safety of the resident. Review of the Medication Administration Record for August 2024 showed documentation on 8/16/24 Resident #1 received his scheduled 5:00 p.m. medications. Review of the Certified Nursing Assistant (CNA) documentation for 8/16/24 showed the last entry was at 5:22 p.m., for eating. No other progress note was found in the clinical record for 8/16/24 addressing the resident's confusion with wandering behavior and voiced desire to leave the facility. On 8/16/24 at 10:00 p.m., LPN Staff B documented in a progress note Resident #1, was last seen sitting in the lobby at approximately 7:25 p.m. We [sic] was asked to go back to his room but he declined stating that he was fine where he was. Resident was calm and not agitated so he was left to lounge in the lobby. Elopement protocol followed; room search, 911 called, family notified, hospitals called to search for resident, facility searched. The clinical record lacked documentation Resident #1 was adequately supervised to prevent unsafe wandering and elopement while sitting in the lobby. Review of the facility's investigation report dated 8/17/24 showed documentation Resident #1 was, his own person with no advance directives and no incapacity. On 8/16/24 at around 7:15 [p.m.] he was at the front lobby fully dressed and with a bag of clothes around his shoulder and then proceeded to walk out the front door when it opened and when asked by the receptionist if he was a visitor or resident/patient he stated he was a visitor and kept on going. On 8/16/24 LPN Staff B documented in a statement at approximately 7:20 p.m., she observed Resident #1 walking toward the lobby. She was receiving report from the morning nurse. She told Certified Nursing Assistant (CNA) Staff C to ask Resident #1 to return to his room and continued to get report. On 8/16/24 at 7:30 p.m., CNA Staff D asked her in reference to resident. She advised the CNA that Resident #1 was walking in the hallway near his room. On 8/16/24 at 8:45 p.m., CNA Staff D informed her that Resident #1 was not in his room. They started to search for the resident and he, wasn't easily found. They notified the Nurse Manager. The clinical record lacked documentation staff coordinated with the receptionist and adequately supervised Resident #1while he was sitting in the front lobby. A review of the undated statement by the receptionist documented that on 8/16/24 at around 7:10 p.m., she noticed a gentleman taking a seat in the lobby. He was neatly dressed and had a bag over his shoulder that appeared to have clothes in it. She was tending to another gentleman who was signing out from visiting his mother. After about five minutes the gentleman (Resident #1) that was sitting in the chair casually got up and walked to the exit door with his bag over his shoulder. She had not seen this individual before. The way he was dressed, he looked like a visitor. As Resident #1 approached the door, she asked him if he was a resident or a visitor. He was not wearing any name band. He said he was a visitor and proceeded to walk out the door. She tried to get his attention to sign out. He kept walking and she did not call him to come back and sign out. She locked the door at 7:30 p.m. at the end of her shift. She received a call at approximately 9:00 p.m., to 9:30 p.m. asking about Resident #1. She told the facility she saw him go out and he stated he was a visitor. On 8/22/24 at 3:02 p.m., in a telephone interview the receptionist said she was working on the day Resident #1 eloped. She said around 7:20 p.m., she made the announcement for visitors to come to the front lobby since visiting hours were over at 7:30 p.m. She said at approximately 7:10 p.m., Resident #1 came and sat on a chair in the lobby. He looked like a visitor and had a large bag, the kind you would put clothes in. He looked like he was watching people leaving. She thought he was waiting for a ride. Resident #1 told her he was a visitor which she thought was kind of strange. He did not have a wrist band on. He got up slowly and walked toward the door. He exited the facility when she let another visitor out. On 8/22/24 at 3:33 p.m., in a telephone interview Resident #1's daughter said the case manager at the hospital told her the facility had a memory care unit. She found out when her father got to the facility that they did not. She wanted him safe in a memory unit. She voiced her concern to the nurse who told her they monitor their residents all the time. She said her father took a bus and got dropped off in a downtown area (approximately 16 miles from the facility) and was found sitting outside of a bar. He had no identification on and would not know his address. She said Resident #1 was currently at a different skilled nursing facility in a secured memory unit. On 8/23/24 at 10:22 a.m., in a telephone interview LPN Staff A said on 8/15/24 she worked from 7:00 p.m., to 7:00 a.m. She said that night Resident #1 was very confused. She documented in a progress note that he was wandering and he walked pretty well. When he got into bed, he did not remove his shoes. He did not know where he was so she didn't think he really knew if he lived down the street. LPN Staff A said Resident #1 was not safe to leave the facility unsupervised. She said she should have placed a wander alarm band (alerts staff when a resident leaves a safe area) on him. She said if she had done that, the alarm would have gone off and Resident #1 would not have left. She said on 8/16/24 at 7:00 a.m., she gave report to the oncoming nurse and told her about the resident's exit seeking behavior during the night. She said Resident #1 was already sitting in the front lobby while she gave report to the oncoming nurse. On 8/23/24 at 11:05 a.m., in an interview the SLP said he evaluated Resident #1 on 8/8/24 and saw him three times during his stay. He clearly was cognitively impaired. His orientation was pretty bad. He was not safe to leave the facility unsupervised. He was a lot better physically than cognitively. His orientation, decision making, and short term memory were severely impaired. He would not trust him to go to the convenience store nearby by himself because he would not come back. The SLP said Resident #1 kept saying he wanted to go home. He said, What made this resident's situation unsafe is the fact that he was very confused but very mobile. On 8/23/24 at 11:07 a.m., in a telephone interview the Psychiatrist said on 8/15/24 when she assessed Resident #1, he was very depressed, crying and confused. He could not give much information. The information was obtained from the daughter and hospital notes. He did not know where he was and was very confused. He was cognitively impaired. He was not safe to walk out, he was not safe to catch the bus and was not able to make his own decisions. She saw the consent for treatment form that was signed by the wife and thought Resident #1 had an existing incapacity. She thought the wife was the power of attorney. The facility did not ask her to write an incapacity statement. The psychiatrist repeated Resident #1 could not be out on his own. On 8/23/24 at 11:49 a.m., in an interview the Physical Therapy Assistant said Resident #1 was confused but hid it well, he was in his own world. He said he was almost afraid to make the resident better physically due to his severe cognitive impairment. That would predispose Resident #1 to get into dangerous situations. He could leave the facility, go into the wrong building, and get into dangerous situations. He would not be able to make the right decision for anything such as walking in the middle of the street, going into the wrong building. Resident #1 kept saying he wanted to go home. He was not safe to leave the facility unsupervised. The therapist said Resident #1 was definitely able to walk about 300 feet. He said when he got tired, he would start staggering and go back onto his heels and that would put him at risk for falls. On 8/23/24 at 1:15 p.m., in an interview the Administrator said the SLP and the PTA did not report their concerns to him. He said he was not aware the PTA was almost afraid to make him physically better due to his severe cognitive impairment. On 8/23/24 at 2:00 p.m., in an interview the Attending Physician said anything bad could have happened to the resident. He was not safe the leave the facility unsupervised and could have been seriously harmed. She said it was a blessing that his defibrillator (implanted device that sends electric shock to the heart to restore normal rhythm) went off and he went to the hospital. After verification of implementation of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 8/24/24. The Immediate actions implemented by the facility and verified by the survey team included: On 8/16/2024 Resident #1 was admitted to the hospital and has not returned to the facility. On 8/24/24 the surveyor verified through review of the facility census, and review of Resident #1's clinical record On 8/17/2024 an ad hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) meeting was done, and a root cause analysis of the incident was conducted. Attendees of the QAPI meeting included the medical director, Director of Nursing, Administrator, Human Resources, Social Service, Activities, Therapy director, MDS (Minimum Data Set) coordinator, Nurse, and CNA. The receptionist did not follow facility protocol and failed to verify the identity of Resident #1, opened the door and allowed the resident to leave On 8/16/2024 Resident #1 was confused, wandering and voiced desire to leave the facility. The Licensed Nurse failed to implement adequate supervision to ensure the safety of the resident. On 8/24/24 the surveyor verified through review of the Ad Hoc QAPI meeting and root cause analysis. On 8/17/2024 the DON (Director of Nursing) completed an audit with 119 current residents, focusing on accuracy of elopement risk. One resident was identified as at risk of elopement and the care plan was updated to ensure their safety. Resident was placed in the elopement binder and elopement binder was updated to reflect current elopement risk residents. There are 4 binders in the facility. One is at the receptionist desk and one on each of the three nursing stations in the facility. On 8/24/24 the surveyor verified through review of the audit and review of the audit completed, and review of two randomly selected residents with impaired cognition for evidence of accurate elopement risk assessment, care plan and adequate supervision. The surveyor verified the location and information in the four elopement binders. On 8/17/2024 the facility initiated a new process for visitors: The front lobby door of the facility will remain locked. On 8/23/24 and 8/24/24 random observations showed the front lobby door of the facility remained locked. Visitors must press the doorbell and receptionist unlocks the door. All visitors will sign the visitor log and will be provided with a visitor badge. On 8/23/24 and 8/24/24 random observation of visitors entering the facility showed the receptionist provided each visitor with a visitor's badge and made sure each visitor signed the visitor's log. All visitors will be required to sign out and turn in visitors' identification before exiting. On 8/23/24 and 8/24/24 random observation of visitors leaving the facility showed the receptionist made sure each visitor signed out and returned the visitor's badge before unlocking the door. The identity of any person without a visitors' badge will be verified prior to leaving the facility. On 8/24/24 at 6:15 p.m., in an interview the receptionist on duty was able to verbalize the process to verify the identity of anyone leaving the facility who did not have a visitor's badge. The receptionist had a resident's list which is updated with new admissions daily. She would ask for an identification and compare with the resident's list. She also said she would call the nurse in charge before allowing anyone without a badge to leave. On 8/24/24 at approximately 6:18 p.m., LPN Staff C and Unit Manager, Registered Nurse (RN) Staff D were able to describe the new visitation process. RN Staff D said one of the attending physicians also requires staff to call him before any of his residents leave the facility. On 8/24/24 five additional licensed nurses and three CNAs were interviewed and able to describe the process for visitors. All CNAs said they do not open the door for anyone who wishes to leave the facility after 7:30 p.m. when the receptionist leaves. They would call the nurse. The nurse would make sure the visitor signs out and returns the badge. On 8/17/2024 the Administrator started education with the three receptionists on the new process for visitors. As of 8/19/2024, all three receptionists were educated before their shifts began. Competency was verified through observation of the three receptionists implementing the new procedures for signing visitors in and out of the facility. On 8/24/24 the surveyor verified through review of the education provided by the Administrator. On 8/24/24 at 6:15 p.m., the receptionist on duty confirmed she received education related to the updated visitation policy and was able to describe the process. The receptionist was observed following the process to let visitors in and out of the facility. The receptionists leave at 7:30 p.m After 7:30 p.m., the licensed nurses are responsible for letting visitors in and out of the facility. Starting on 8/17/2024 the DON/Designee educated the licensed nurses on the new process for visitors. As of 8/23/2024 45 of the 53 licensed nurses received education on the new process, including all 14 licensed nurses who work the night shift (7:00 pm to 7:00 am). Competency was verified through verbalization of the process and written post education questionnaire. On 8/24/24 the surveyor verified through review of the education provided. On 8/24/24 six licensed nurses were interviewed. All six nurses verified they received training on the updated visitation policy and were able to describe the process. The DON/Designee will educate the remaining 8 nurses on the new visitors' process prior to the start of their shift. On 8/24/24 the surveyor verified through interview with the Director of Nursing. As of 8/17/2024, the Administrator or designee will conduct an audit of the visitors log to ensure staff (Receptionist and Licensed nurses) are following the processes. On 8/24/24 the surveyor verified through review of the audit completed and observation of the visitor's log. As of 8/17/2024 each visitor received a copy of the new process for visitor badge and signing in and out of the facility. On 8/24/24 at 6:15 p.m., the surveyor verified through interview of the receptionist on duty. The receptionist was observed providing visitors a memo signed by the Administrator describing the name badge process. The instructions included, You must turn in your Visitor Badge when you sign out prior to exiting the facility. If you do not have a Visitor Badge when you are exiting the facility staff will not be allowed to open the exit door until they have verified that you are a Visitor and not a resident of the facility. As of 8/17/2024 the Licensed Nurses, Certified Nursing Assistants, and Therapists were assigned a comprehensive online training module that covered elopement prevention, elopement evaluation, identifying change in behavior, including wandering, verbalization of wanting to leave the facility and immediate interventions to ensure the safety of the residents. The understanding of the training was verified through a posttest evaluation. Upon completion of the training and passing the posttest a certificate was issued. As of 8/23/2024 45 of the 53 Licensed nurses, 49 of the 54 Certified Nursing Assistants and 17 of the 17 Therapists completed the training and received the certificate. The remaining licensed personnel will receive the training and complete the posttest before their next shift begins. On 8/24/24 the surveyor verified through review of the training provided. On 8/24/24 six licensed nurses and three CNAs were interviewed and were able to describe the content of the training. On 8/23/2024, the DON initiated additional training for the licensed nurse on identifying changes in cognition, recognizing behaviors that may lead to elopement, unsafe wandering, and need to complete an elopement evaluation, and update the care plan in the electronic health record to ensure the safety of the resident. As of 8/24/2024, 28 of 53 Licensed Nurses were educated. The remaining Licensed nurses will be educated before their next shift starts. On 8/24/24 six licensed nurses were interviewed and were able to verbalize content of the training and immediate actions to ensure the safety of cognitively impaired residents with behaviors that may lead to elopement. Elopement Drills are conducted at least once per shift every month. Post incident Elopement drill was conducted on 8/24/2024 to ensure process is followed and will continue until all staff have participated. On 8/24/24 the surveyor verified through review of the elopement drill completed on 8/24/24.