**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of policies and procedures, and staff interviews, the facility failed to protect the residents' right to be free from neglect, in that the facility failed to ensure staff who use mechanical lifts to transfer residents were trained, and competent to safely use the lifts. Resident #1 was dependent on staff for transfer and required the use of a mechanical lift. On 8/12/23 Resident #1 fell from the full body mechanical lift during transfer. Resident #1 was hospitalized and suffered spinal and pelvic fractures. There was no documentation the staff who transferred Resident #1 were trained and competent to safely use the mechanical lift. The facility's failure to provide the necessary structure and processes to prevent neglect placed other residents who require the use of mechanical lifts at a likelihood of avoidable accidents and falls which could result in serious injury, impairment, or death, and resulted in the determination of Immediate Jeopardy. On 8/24/23 at 12:55 p.m., the Administrator was notified of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. The facility census was 101 with 20 residents who were transferred with mechanical lifts. The facility used five different brands of mechanical lifts for transfers. The Immediate Jeopardy began on 8/12/23. On 8/25/23, after the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 8/24/23 and the scope and severity were reduced to no actual harm, with no more than minimal harm. The findings included: Cross reference to F689, F726, and F835. The facility's policy and procedure titled, Abuse, Neglect and Exploitation, with a date reviewed/revised of 10/1/2022 noted, The facility will develop and implement written policies and procedures that: Prohibit and prevent . neglect . The facility will make individual determinations in consideration of current staffing patterns, staff qualifications, competency and knowledge, clinical resources, physical environment, and equipment . Identifying, correcting, and intervening in situations in which . neglect is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual resident's care needs . Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors . The facility's policy and procedure titled, Safe Resident Handling/Transfers, with a date reviewed/revised of 1/2022 noted, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines . The staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly . Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur . Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device . Review of the clinical record for Resident #1 revealed an admission date of 10/7/22. Diagnoses included Arthritis, seizure disorder, and muscle weakness. The Quarterly Minimum Data Set (MDS) assessment with a reference date of 7/10/23 noted Resident #1 was totally dependent on the physical assistance of two persons for bed mobility and required extensive physical assistance of two persons for transfer. Resident #1 had functional limitation in range of motion of both lower extremities. The Physical Therapy Plan of Treatment for the period of 3/28/23 to 4/26/23 noted Resident #1 used a mechanical lift. Precautions included fall risk and (brand name) lift. Review of the progress notes revealed on 8/12/23 at 2:07 p.m., the Director of Nursing (DON) documented at 10:49 a.m., two Certified Nursing Assistants (CNAs) were transferring Resident #1 from bed to chair. There was a loud noise from the lift and then the resident was lowered to the floor. The CNAs tried to stop it but were unsuccessful. The Advanced Practice Registered Nurse (APRN) came to the room as the CNAs and the resident were screaming. The resident complained of back and hip pain. The APRN documented on 8/12/23 at 10:52 a.m., she examined Resident #1. The resident was alert and cooperative, had a fall after transfer using a mechanical lift. She went in the room, noted the resident on the floor on her back, yelling out, crying, c/o (complaining of) headache, right hip pain, back pain . The APRN recommended sending the resident to the emergency room for further evaluation. Resident #1 was transferred to the local hospital via EMS (Emergency Medical Services). Review of the hospital records revealed on 8/12/23 Resident #1 was admitted and suffered spinal and pelvic fractures. Review of the Nursing Home Federal Report to the Florida Agency for Health Care Administration (Florida state survey agency) revealed on 8/13/23 a representative of the Florida Department of Children and Families (Florida abuse investigation agency) visited the facility and reported an allegation of neglect related to the care provided to Resident #1, including fractures sustained during the transfer with the mechanical lift. The facility documented they completed a thorough investigation into the allegation of neglect and determined the allegation was not substantiated. The facility's investigative findings noted on 8/12/23, two CNAs used a mechanical lift to transfer Resident #1. Once the resident was lifted off the bed, and the lift moved to place Resident #1 in the chair, one loop of the sling came loose, and the resident fell to the floor. On 8/21/23 the facility provided witness statements from CNA Staff I and CNA Staff L who used the mechanical lift to transfer Resident #1. CNA Staff L provided a statement on 8/15/23 noting the bar of the lift was shaking. This lift is too light and not stable, but this resident was light (did not have too many pounds). Only one hook came loose but it was the loop at the resident's head on her left side. The other CNA opened the legs of the (brand name) lift and the resident then dropped to the floor. CNA Staff I provided a statement on 8/15/23 which included, Something was loose on the machine. One loop came loose, and the resident fell to the floor . The sling came off all by itself. The facility also provided a video re-enactment of the incident, using the same mechanical lift that was used to transfer Resident #1. The video showed the mechanical lift making a clicking noise as the boom, and cradle bars were lowered. The loops from the sling did not come loose, and did not detach from the lift during the re-enactment. The facility's incident investigation did not document a root cause for the loop detaching from the lift and removed the mechanical lift from service. Review of the user manufacturer's instruction manual for the lift used to transfer Resident #1 noted, Important safety information for hazards that might cause serious injury. The instructions included, before using the lift examine slings for fraying or other damage. Do not use if damaged or if the sling shows signs of wear. The investigation did not include documentation CNA Staff I or CNA Staff L inspected the lift or the sling before transferring Resident #1 per facility policy, or manufacturer's safety information. On 8/23/23 at 10:08 a.m., the Administrator provided the survey team with a picture of the sling used with the mechanical lift to transfer Resident #1 on 8/12/23. The sling was from a manufacturer different from the manufacturer of the mechanical lift it was used for. Review of the manufacturer's user guide for the mechanical lift used to transfer Resident #1 noted, WARNING. (company's name) RECOMMENDS THE USE OF GENUINE (brand name) PARTS. (Brand name) slings and lifters are not designed to be interchangeable with other manufacturer's products. Using other manufacturer's products on (brand name) products is potentially unsafe and could result in serious injury to patient and/or caregiver. The facility's investigation did not address the failure of staff to follow the manufacturer's user guide for slings. The facility provided staff education sign in sheets dated 8/12/23 and 8/14/23 for (brand name) lift use. The outline was, Staff member provided (brand name lift) instructions packet with diagram and demonstration of proper use provided. A total of 24 of 48 CNAs employed by the facility attended the training. The instructions provided included, To raise the consumer the base of the (brand name) Lifter must be spread to its widest possible position to maximize stability . Positioning the lift for use: With the legs of the base open and locked, use the steering handle to push the consumer lift into position . The education did not include a return demonstration to verify staff understood the education and were able to safely use the mechanical lifts. The education did not include a visual inspection of the lift and the slings before use as per the manufacturer's specifications. On 8/21/23 at 11:03 a.m., a sit-to-stand lift was observed in the central shower room of the North Unit. The adjustable knee pad was missing a large piece. An orange sticker with a handwritten date of 8/15/23 was observed on the lift. Photographic evidence obtained. A damp transfer sling was observed resting on the lift. The label was torn out. The strap appeared frayed. The buckle of the strap belt that goes around the resident's waist was secured to the belt with a knot. Photographic evidence obtained. Review of the manufacturer's instructions for the sling noted, Bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately. DO NOT alter slings. On 8/21/23 at 11:05 a.m., the Maintenance Assistant verified the sit-to-stand lift with the missing piece of the adjustable knee pad was inspected on 8/15/23 as per the orange sticker. The Maintenance Assistant said the sit-to-stand lift was one of the five lifts currently being used to transfer residents. On 8/21/23 at 11:30 a.m., CNA Staff E, and CNA Staff F said the buckle strap must be used to safely use the sling, and verified the buckle was secured to the strap belt with a knot. They said the buckle must have come loose and someone tied a knot to the strap to secure the buckle in place. They both said it would not be safe to transfer a resident with the defective sling. On 8/21/23 at 11:30 a.m., CNA Staff E and CNA Staff F who attended the in-service on 8/14/23 were observed using a full body mechanical lift to transfer Resident #18 from bed to chair. The CNAs positioned the base of the mechanical lift under the bed without spreading the legs of the base open. They placed the resident in the lift and guided the lift toward the chair without spreading the legs of the base open per the in-service of 8/14/23. On 8/21/23 at 1:34 p.m., a full body mechanical lift was observed in the hallway of the South Unit. One of the six hooks of the hanger bar was missing the locking clip. There was no sign on the lift to alert staff of the missing locking clip. Photographic evidence obtained. On 8/21/23 at 3:12 p.m., a sling was observed stored on a full body mechanical lift on the South Unit. A zip tie was observed around one of the loops (green loop) used to attach the sling to the mechanical lift. Photographic evidence obtained. On 8/21/23 at 3:25 p.m., the Maintenance Assistant verified the green loop of the strap had a zip tie around it. He said it shouldn't be on there and offered to cut it off. On 8/21/23 at 3:25 p.m., Occupational Therapist Staff M said she came from a facility where therapy would provide in-services to the staff on the correct use of the lifts. She said, They don't do that here. I tried to get a CNA to help me with a mechanical lift today, but she seemed uncomfortable, so I didn't push. She said they should not put zip ties on the loop strap. On 8/21/23 at 3:50 p.m., CNA Staff J and CNA Staff K (who attended the in-service on 8/14/23) were observed using a mechanical lift to transfer Resident #18 from chair to bed. They did not lock the wheels of the lift. The CNAs moved the lift back, closed the legs of the base and wheeled the lift to the bed. They transferred the resident to the bed without spreading the legs of the base or locking the lift as per the in-service provided on 8/14/23. On 8/21/23 at 4:05 p.m., CNA Staff K said, They tell us what to do, they don't show us what to do. They just tell us in words and have us sign a paper. There was no documentation CNA Staff J attended the in-service on 8/12/23 or 8/14/23. On 8/21/23 at 6:36 p.m., the Regional Maintenance Director verified the full body lift observed in the hallway of the South Unit was one of the five mechanical lifts currently in use. He verified one of the locking clips was missing, and said, They should not use it without the clip. I'm taking it out of service right now. The Regional Maintenance Director verified no one had notified him of the missing clip. On 8/21/23 at 6:30 p.m., the DON said after Resident #1 fell from the mechanical lift, he started educating the CNAs on the use of mechanical lifts. He said he only educated the CNAs on duty on 8/12/23 and 8/14/23. He educated approximately 24 CNAs who use mechanical lifts. The DON said he did not structure the education given to the CNAs like a competency. He said, I wanted to be sure they knew how to use the machine since we did not really know what happened when the resident fell. He said he only provided education to the CNAs even though the nurses also use the mechanical lifts and supervise the CNAs. The facility provided certificates showing on 8/15/23, and 8/17/23 after Resident #1 fell from the lift, CNA Staff I, and CNA Staff L who performed the transfer satisfactorily respectively completed a computer training on CNA- Safely Moving Residents- Lifting and Transferring for 30 minutes and Using a Hydraulic Lift for 15 minutes. The training did not include a competency evaluation. Review of the CNAs daily assignment for 8/21/23 for the 7:00 a.m., to 3:00 p.m., shift revealed two of the nine CNAs on duty assigned to residents who require the use of a mechanical lift for transfers did not attend the in-service on 8/12/23 or 8/14/23. Seven CNAs attended the in-service on 8/12/23 or 8/14/23 for use of the lift but had no competencies or return demonstration on the use of the lift. On 8/21/23 at 2:30 p.m., CNA Staff I said she has been employed at the facility since 2001 and had not received any training on using mechanical lifts. She said after Resident #1 fell from the lift the facility had her complete a mechanical lift device training on the computer, but no one observed her using the mechanical lift after the training. On 8/21/23 at 7:00 p.m., the Administrator said the facility currently did not have an education coordinator, the position has been opened since 1/20/23. A person was hired for a short time on 5/29/23 and stayed through June 2023. The Regional Nurse Consultant who was present during the interview said there was no documented staff competencies for the use of mechanical lifts but will be working on them. On 8/23/23 at 1:00 p.m., in a telephone interview, the DON confirmed he was responsible to ensure staff had appropriate competencies for the use of mechanical lifts. He said, We educate them, we audit them, we mentor them. We try to put measures in place like check lists. Making sure that they know how to safely do their jobs. It is about the safety of the patients. If we don't do evaluations and competencies, then how would we know if we are giving safe care? The DON verified he had not ensured all staff who used mechanical lifts were educated and competent to safely use the lifts after Resident #1 fell from the lift and sustained serious injuries. The immediate actions to remove the Immediate Jeopardy implemented by the facility and verified by the surveyor on 8/25/23 included: The lift that was in use on 8/12/23 was removed from service and disposed of on 8/15/23. The surveyor verified on 8/21/23 by observation of the discarded lift and interview with the Regional Nurse Consultant and Administrator. Immediate education was provided on-site on 8/12/23 to all working Nursing staff on mechanical lift safety by the Director of Nursing. Eleven (11) were educated which is 17.5% of total nursing staff. This mechanical lift education was continued through 8/14/23 with an additional 13 (thirteen) nursing staff which equals 38.09% of the total nursing staff. Total nursing staff are 63 (sixty-three). There are 19 nurses and 44 CNAs on staff. The above mechanical lift education represents 43% CNAs, and 26% nurses. The surveyor verified by review of education provided. Education for Abuse, Neglect was started on 8/14/23 and continued for all staff in the facility through today and facility is at 72.16% of all total staff (97) for compliance with this education. The surveyor verified by record review of completion of the education. The agency staff are educated on the shift they arrive prior to taking an assignment, and a roster is kept with their signatures. This is done according to the daily schedule provided by the staffing coordinator. The surveyor verified through record review and interview of two licensed nurses. The new staff and the staff returning from leave (FMLA (Family Medical Leave of Absence), vacation, etc.) are tracked on the master education roster and will not work until they have completed all applicable educations. The scheduler provides the daily roster. Administrator and a nurse or designee educate at the start of the shift prior to accepting their assignment. The surveyor verified through review of the education, Administrator and scheduler interview. Education competencies were initiated on 8/15/23 on the electronic training system and on 8/21/23 with return demonstration for use of mechanical lifts through today, 8/24/23 with 76.19% of total nursing staff completed. The surveyor verified by review of the training and competencies completed. The training for the slings and mechanical lift compatibility was initiated on 8/23/23; however, (brand name) slings that state they are recommended only to be used on (brand name) lifts were taken out of service on 8/24/23 to prevent this from occurring. The surveyor verified by review of attestation of sling removal signed by the housekeeping director. Documentation for the education for ANE (Abuse, Neglect, Exploitation) according to policy, and proper use of mechanical lifts with competencies and signatures is confirmed. The percentage for completion is 72% for ANE and 76% for mechanical lifts; 63.15% are nurses, and 81.81% of CNAs. The surveyor verified by review of the in-service and random staff interviews. Facility lifts were all inspected to verify functionality on the date of event 8/12/23 by the Director of Nursing and found to be safe and functional. This was done after DON was educated by Regional Nurse Consultant for basic functionality and safe use. The surveyor verified by review of the lifts inspection and review of attestation of completion completed by the Regional Nurse Consultant and the Director of Nursing (DON). Facility maintenance assistant inspected all facility lifts on 8/15/23 and all lifts were found to be safe and functional. These were inspected according to their manufacturer's guidelines. The surveyor verified through record review. Regional director of plant operations inspected all facility lifts on 8/16/23 and verified that they were found to be safe and functional. These were inspected according to manufacturer's guidelines. The surveyor verified through record review. Slings in the facility that are in use were all inspected starting on 8/12/23 and continued through 8/22/23 and continued daily. Slings that were found in disrepair or torn were discarded on 8/12/23, 8/21/23 and 8/22/23. The surveyor verified by record review and observation of slings. A mechanical sit-to-stand lift was removed from service on 8/22/23 as it needed battery backup. A mechanical lift was removed from service on 8/22/23 as it needed a U-spreader clip which was ordered. The surveyor verified by record review of attestation from the Administrator. Additional mechanical lifts with additional slings have been ordered on 8/24/23 that are appropriate to resident size needs. Sizing was completed utilizing weight and height to calculate need by therapy and nursing department. These lifts and slings ordered are all the same, uniform brand. The surveyor verified by record review of purchase orders, and review of sizing of slings documented in the electronic clinical records. Residents who require mechanical lifts have all been re-evaluated by the therapy department and nursing department and of 20 there were 4 that were found not to require lift assistance and due to admissions an additional two will require mechanical lifts for a total of 18 as of 8/22/23. The surveyor verified by record review documentation of evaluation in Point Click Care, electronic record. The 18 residents who require mechanical lifts have been assigned a corresponding size recommendation by nursing and therapy according to weights and this information has been communicated to the staff in the electronic record in the care plans and the [NAME] (provides instructions for care) for nursing staff. The surveyor verified by record review. Seven residents required small slings initially there were seven; after evaluation three did not need mechanical lifts at all, leaving four residents who were found to be able to be transferred using two persons pivot transfer and will utilize this method of transfer until the ordered slings are delivered. This education to staff is provided daily at the beginning of their shift and the information is also available in the [NAME] for all shifts to view. The surveyor verified through record review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility's policies and procedures, family and staff interviews, the facility failed to implement ongoing training, competencies, and supervision of staff to ensure the safe use of mechanical lifts and prevent avoidable accidents. On 8/12/23 Resident #1 fell from a mechanical lift during transfer, was hospitalized and suffered spinal and pelvic fractures. The Certified Nursing Assistants (CNAs) transferring the resident had no documentation of training, or competency for the proper use of the lift. The failure to ensure staff use safe transfer techniques during mechanical lift transfers created an unsafe environment of avoidable accidents or falls which could result in serious injury, impairment, or death of residents from improper use of the lift and resulted in the determination of Immediate Jeopardy. On 8/24/23 at 12:55 p.m., the Administrator was informed of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. The facility census was 101 with 20 residents who were transferred with mechanical lifts. The facility used five different brands of mechanical lifts for resident transfers. The Immediate Jeopardy started on 8/12/23. On 8/25/23, after the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 8/24/23 and the scope and severity were reduced to D no actual harm, with no more than minimal harm. The findings included: Cross reference F600, F726 and F835. The facility's policy titled, Safe Resident Handling/Transfers with date reviewed/revised of 1/2022 noted, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines . The staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly. Damaged, broken, or improperly functioning lift equipment will not be used and tagged out according to facility policy . Ensure that the sling designated for the lift is utilized with that specific lift . Resident lifting and transferring will be performed according to the resident's individual plan of care . Review of the clinical record for Resident #1 revealed an admission date of 10/7/22. Diagnoses included Arthritis, seizure disorder, and muscle weakness. The Quarterly Minimum Data Set (MDS) assessment with a reference date of 7/10/23 noted Resident #1's cognition was intact with a Brief Interview for Mental Status score of 15. Resident #1 was totally dependent on the physical assistance of two persons for bed mobility and required extensive physical assistance of two persons for transfer (how the resident moves between surfaces including to or from bed, chair, wheelchair). Resident #1 had functional limitation in range of motion of both lower extremities. The Physical Therapy Plan of Treatment for the period of 3/28/23 to 4/26/23, noted Resident #1's prior level of function included the use of a mechanical lift, and precautions included fall risk and (brand name) lift. On 8/21/23, review of the facility's accidents and incidents investigations revealed on 8/12/23 at approximately 10:49 a.m., CNA Staff I and CNA Staff L were transferring Resident #1 using a total body mechanical lift from bed to the chair. There was a loud noise from the lift. The bar of the mechanical lift was shaking. One loop from the sling came loose and the resident fell to the floor. Resident #1 complained of back and hip pain and was transferred to an acute care hospital. On 8/15/23 CNA Staff L provided a statement that read, We cleaned her up, changed her clothes and put the sling under the resident. We brought the (brand name) lift to the bed and each of us hooked the two sling straps on our side of the bed. The patient was lifted up off of the bed with no problem. She pulled the (brand name) lift back and the resident was ok. I went to get the wheelchair turned around and placed behind the patient. The bar was shaking. This lift is too light and not stable, but this resident was light (did not have too many pounds). Only one hook came loose but it was the loop at the resident's head on her left side. The other CNA opened the legs of the (brand name) lift and the resident then dropped to the floor. The resident's hand [sic] were across her stomach, she was not holding on to anything. The statement noted two CNAs were using the lift and used a shower mesh sling for the transfer. On 8/15/23 CNA Staff I provided a statement that read, I finished cleaning the resident. The nurse practitioner was standing at the nurses station speaking with the nurse, so I asked another CNA to assist me. I put on the resident's dress and sling under her. I placed the machine and we each hooked two loops on our side of the bed. We lifted the resident above the bed without a problem. I then pulled the machine back towards the door and opened the legs. The other CNA was placing the wheelchair for the resident to be placed. Something was loose on the machine. One loop came loose, and the resident fell to the floor. Each of us hooked two straps. The sling came off all by itself. The statement documented CNA staff I said, I've worked here for 20 years and this is the first time something has happened. There was no documentation in the investigation, CNA Staff I or CNA Staff L inspected the lift prior to use to ensure functionality. The Director of Nursing (DON) noted the mechanical lift was removed from service and labeled. On 8/21/23 at 10:53 a.m., the lift used to transfer Resident #1 was observed for manufacturer, make and model. On 8/23/23 at 10:08 a.m., the Administrator provided the survey team with a picture of the sling which was used with the mechanical lift to transfer Resident #1 on 8/12/23. The sling was from a manufacturer different from the mechanical lift manufacturer it was used for. Review of the manufacturer's user guide for the mechanical lift noted, WARNING. (company's name) RECOMMENDS THE USE OF GENUINE (brand name) PARTS. (Brand name) slings and lifters are not designed to be interchangeable with other manufacturer's products. Using other manufacturer's products on (brand name) products is potentially unsafe and could result in serious injury to patient and/or caregiver. On 8/22/23, review of the hospital records showed Resident #1 presented to the Emergency Department via Emergency Medical Services from the facility, following a mechanical fall . She states she fell from a (brand name) lift. She struck her head and right side of her body . She currently reports posterior head pain, neck pain, right arm, and right leg pain . Movement exacerbates her pain . Review of the Computerized Tomography (CT) scan results from the hospital dated August 12, 2023, at 4:47 p.m., showed Resident #1 suffered: Acute non-displaced fracture of right transverse process of the L5 (5th lumbar) vertebra (lower back bones in spinal column). Acute non-displaced fracture of the body of the sacrum on the right and right sacral ala (bone that is located at the base of the lumbar vertebrae and is connected to the pelvis). Acute non-displaced fracture of right superior pubic ramus (group of bones that make up part of the pelvis). On 8/21/23 the facility provided a staff education sign in sheets dated 8/12/23 and 8/14/23 for (brand name) lift use as part of their corrective actions. The outline was, Staff member provided instructions packet with diagram and demonstration of proper use provided. The education did not include a return demonstration to verify staff understood the instructions and were able to safely use the mechanical lifts. The in-service did not include instructions on slings, including manufacturer, type, or size of sling to use for each resident. A total of 24 of 48 CNAs employed by the facility attended the training. The instructions provided noted, To raise the consumer the base of the (brand name) Lifter must be spread to its widest possible position to maximize stability . Positioning the lift for use: With the legs of the base open and locked, use the steering handle to push the consumer lift into position . On 8/21/23 at 11:30 a.m., CNA Staff E and CNA Staff F were observed using a mechanical lift to transfer Resident #18 from bed to chair. The CNAs positioned the base of the mechanical lift under the bed without spreading the legs of the base open. They placed the resident in the lift and guided the lift toward the chair without spreading the legs of the base open. Review of the education sign-in sheet revealed CNA Staff E and CNA Staff F attended the in-service on 8/14/23. On 8/21/23 at 3:50 p.m., CNA Staff J and CNA Staff K were observed using a mechanical lift to transfer Resident #18 from chair to bed. The CNAs opened the base of the lift and placed the resident on the sling. They did not lock the wheels of the lift as per the in-service provided on 8/12/23 and 8/14/23. The CNAs moved the lift back, closed the legs of the base and wheeled the lift to the bed. They transferred the resident to the bed without spreading the legs of the base or locking the lift. Review of the manufacturer's operating instructions for the lift used by Staff J and K noted, Warning: Never perform a lift/transfer with the legs in the closed/transport position (front casters touching). The closed/transport position is for storage and transport only. On 8/21/23 at 4:00 p.m., CNA Staff J verified they did not lock the lift or spread the legs of the base to safely transfer Resident #18 to bed. She said since she's been employed at the facility (2019) she has not received training on mechanical lifts. She said last week they told her what to do but no one showed her or worked with her to make sure she uses the lifts correctly. On 8/21/23 at 4:05 p.m., CNA Staff K said, They tell us what to do, they don't show us what to do. They just tell us in words and have us sign a paper. Review of the in-service sign in sheet showed CNA Staff K attended the in-service on 8/14/23. There was no documentation CNA Staff J attended the in-service. On 8/21/23 at 2:30 p.m., CNA Staff I said she has worked at the facility since 2001 and had not received any training on using mechanical lifts. She said they lifted Resident #1 using the mechanical lift, the top hook by the resident's left shoulder came loose and the resident fell out and landed on the floor. She said she did a mechanical lift device training on the computer after the fall. CNA staff I said no one observed her using the mechanical lift after she completed the computer training. On 8/22/23 at 8:56 a.m., CNA Staff X, and Licensed Practical Nurse (LPN) Staff Y were observed transferring Resident #5 from the bed to the chair using a total body mechanical lift. They did not open the base of the lift when they wheeled the lift from the bed to the chair. On 8/22/23 at 9:05 a.m., CNA Staff X who signed she attended the in-service on 8/12/23 said she has not had any training on using the mechanical lifts in over a year. She said, We just know how to do it, depending on how big the people are. There was no documentation LPN Staff Y attended the in-service. On 8/23/23 at 1:00 p.m., in a telephone interview, the DON said he has been employed at the facility since May 29, 2023. He said his role includes, We educate them, we audit them, we mentor them. We try to put measures in place like check lists. Making sure that they know how to safely do their jobs. The DON confirmed he was responsible to ensure staff had appropriate competencies for the use of mechanical lifts. He said the training he started after Resident #1's fall from the lift was for the overall use of mechanical lifts, not specific to any lift or sling. He said, I was only reacting to the incident. I should have done both all along. He said he had not received any training on the different lifts the facility utilizes, and he had not personally monitored the staff using the mechanical lift. The DON added, It is about the safety of the patients. If we don't do evaluations and competencies, then how would we know if we are giving safe care? On 8/23/23 at 9:45 a.m., CNA Staff L said she has been employed at the facility since the year 2000 and had not received any training on using mechanical lifts since then. She said she just used the sling that was in the resident's room. Review of the manuals for slings used at the facility revealed: Manufacturer A instructions for use of sling noted, Check the patient's weight and the sling's maximum weight capacity. Ensure the patient's weight does not exceed the sling's maximum weight capacity. Manufacturer B instructions for use of sling noted, (Brand name) slings are made specifically for use with (brand name) lifts. For the safety of the patient, DO NOT intermix slings and lifts of different manufacturers . Selecting the most appropriate sling is crucial since it ensures a safe, dignified and comfortable patient transfer whilst reducing the risks associated with manual handling . Manufacturer B sling instruction manual included a Size & [and] Weight Range Guide (approx.) chart guide which noted, It is very important to use the correct sized sling and ensure it is properly fitted before attempting to lift. This will ensure the person being lifted feels safe, dignified and comfortable. It will also provide the carer with confidence that they can achieve the transfer required and that the procedure will be executed in an effective and safe manner. The sling size chart included: Extra Small: 16-45 kg (kilograms), 35 to 99.2 pounds (lbs.). Small: 34-68 kg, 74.9 to 128 lbs. Medium: 57-91 kg, 125.6 to 200.6 lbs. Large: 80-136 kg, 176.3 to 299.8 lbs. Extra Large: 125-284 kg, 265.5 to 626. 1 lbs. Manufacturer C instructions for slings noted (Brand name) slings and patient lift accessories are specifically designed to be used in conjunction with (Brand name) patient lifts. Slings and accessories designed by other manufacturers are not to be utilized as a component of (brand name) patient lift system . Use only genuine (brand name) slings and lift accessories to maintain patient safety and product utility. On 8/23/23 at 1:52 p.m., Resident #13 and Resident #14 were observed in a wheelchair with a sling from manufacturer A. CNA Staff CC said the lift (lift 3) she used to transfer the residents was not from manufacturer A. Review of the manufacturer's instruction manual for lift 3 noted, Warning! Using accessories, detachable parts, or materials not described in the instruction manual MAY RESULT IN SERIOUS INJURY OR DEATH . The list of slings compatible with mechanical lift 3 did not include slings from manufacturer A. On 8/25/23, the immediate actions to remove the Immediate Jeopardy implemented by the facility and verified by the surveyor included: Immediate education was provided on-site on 8/12/23 to all working Nursing staff on mechanical lift safety by the Director of Nursing. Eleven (11) were educated which is 17.5% of total nursing staff. This mechanical lift education was continued through 8/14/23 with an additional 13 (thirteen) nursing staff which equals 38.09% of the total nursing staff. Total nursing staff are 63 (sixty-three). There are 19 nurses and 44 CNAs on staff. The above mechanical lift education represents 43% CNAs, and 26% nurses. The surveyor verified through review of the education. Job Descriptions for the Administrator and Director of Nursing were reviewed on 8/23/23 with focus on supervision of staff, prevention of accidents, and the facility education program to ensure understanding of role responsibility. The surveyor verified through record review of newly signed job description for the Administrator and Director of Nursing, and interview with the Administrator. Education for Abuse, Neglect was started on 8/14/23 and continued for all staff in the facility through today and facility is at 72.16% of all total staff (97) for compliance with this education. Included in this education is neglect correlation to preventable accidents. The surveyor verified through record review. Mechanical lift trainings were initiated on 8/15/23 on the electronic training system and on 8/21/23 with return demonstration for use of mechanical lifts through today, 8/24/23 with 76.19% of total nursing staff completed; 63.15% are nurses, and 81.81% are CNAs. This included applicable sling sizes and use of [NAME] (provides instructions for care) to determine transfer status. The surveyor verified through record review, and observation of staff members transferring Resident #18 with a mechanical lift. Facility lift that was in use during event of 8/12/23 was removed from service and disposed of on 8/15/23. Surveyor verified through observation of discarded lift. Facility lifts were all inspected to verify functionality on the date of event 8/12/23 by the Director of Nursing and found to be safe and functional as to prevent avoidable accidents or falls. This was done after DON was educated by Regional Nurse Consultant for basic functionality and safe use. The surveyor verified through record review. Facility maintenance assistant inspected all facility lifts on 8/15/23 and all lifts were found to be safe and functional as to avoid accidents or falls. These were inspected according to their manufacturer's guidelines. The surveyor verified through record review. Regional director of plant operations inspected all facility lifts on 8/16/23 and verified that they were found to be safe and functional as to avoid accidents or falls. These were inspected according to their manufacturer's guidelines. The surveyor verified through record review. Slings in the facility that are in use were all inspected starting on 8/12/23 and continued through 8/22/23 and continue daily. Slings that were found in disrepair or torn were discarded on 8/12/23, 8/21/23 and 8/22/23. The surveyor verified through review of attestation documentation provided. The training for the slings and mechanical lift compatibility was initiated on 8/23/23; however, (brand name) slings that state they are recommended only to be used on (brand name) lifts were taken out of service on 8/24/23 to prevent this from occurring. The surveyor verified through record review, observation of transfer of Resident #18 using a mechanical lift, and review of attestation signed by the Regional Nurse Consultant. Two CNAs were interviewed and able to describe the process for safe use of mechanical lifts, including the correct size of slings. Observation of two CNAs transferring Resident #18 with a mechanical lift showed the sling was compatible with the lift used. Residents who require mechanical lifts have all been re-evaluated by the therapy department and nursing department and a total of 18 residents use mechanical lifts as of 8/22/23. The surveyor verified through residents record review and documentation on electronic clinical record. The 18 residents who require mechanical lifts have been assigned a corresponding size recommendation and this information has been communicated to the staff in the electronic record in the care plans and the [NAME] for nursing staff. The sling size has been determined by the therapy and nursing leadership team utilizing weight and height. The surveyor verified through record review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility's Administration failed to utilize resources effectively to protect the residents right to be free from neglect in that the Administration failed to ensure staff who use mechanical lifts were trained and competent in the safe use of the lift to transfer residents. On 8/12/23 Resident #1 sustained a fall during a transfer with a mechanical lift resulting in multiple fractures and transfer to the hospital. The CNAs using the lift were not trained and competent to use the mechanical lift. The facility's Administration failure to ensure the nursing staff had the appropriate skills and competency to safely transfer residents with a mechanical lift created a likelihood of avoidable falls and accidents which could result in serious injury, impairment, or death of residents, and resulted in the determination of Immediate Jeopardy. On 8/24/23 at 12:55 p.m., the facility's Administrator was informed of the Immediate Jeopardy (IJ) and provided the IJ Templates. On 8/21/23, the census was 101, with 20 residents who were transferred with mechanical lifts. The facility used five different brands of mechanical lifts for resident transfers. On 8/25/23, after the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 8/24/23 and the scope and severity were reduced to no actual harm, with no more than minimal harm. The findings included: Cross Reference to F600, F689, and F726. The facility policy titled Job Descriptions and Performance Evaluations revised September 2020 noted, The objectives of our job descriptions and performance evaluations are to: a. clarify who is responsible for particular duties; b. assist employees in understanding essential functions, responsibilities, working conditions, qualifications, and specific physical requirements of the positions; c. Prevent misunderstandings about job responsibilities and how each job is evaluated; d. Aid management in analyzing and improving the facility's services and structure of its organization; e. Provide a basis for job evaluation . and to improve quality of work performances . The signed Administrator Job Description dated 3/20/23 noted, Summary: Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Essential Duties and Responsibilities: Monitor each department's activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed . Responsible for QA (Quality Assurance) program. Maintain a working knowledge of and confirm compliance with all governmental regulations . Recognize employees for exceptional care and job performance on a regular basis and as part of their performance evaluations . Provide guidance and leadership throughout the survey process to ensure state and federal regulations are met and adhered to . The signed Director of Nursing Job Description dated 5/29/23 noted, Summary: To manage the overall operations of the Nursing Department in accordance with company policies, standards of nursing practices and governmental regulations to maintain excellent care of all residents' needs. Essential Duties and Responsibilities: Plan, develop, organize, implement, evaluate, and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, policies/procedures and guidelines that govern the long-term care facility. Assume administrative authority, responsibility and accountability for all functions, and activities of the nursing department . Ensure the provision of appropriate departmental in-service education programs in compliance with Corporate, State and Federal guidelines . Direct the performance and delivery of nursing services and resident care services in compliance with corporate policies and State and Federal regulations . Regularly inspect the facility and nursing practices for compliance with federal, state, and local standards and regulations . Participate in monthly QA. Participate in the Facility Assessment . Ensure all department employees have annual performance reviews and competencies timely . On 8/21/23, review of the facility's incidents and accidents logs revealed on 8/12/23 Resident #1 fell from a mechanical lift during transfer, was hospitalized and suffered spinal and pelvic fractures. Review of the employee files for Certified Nursing Assistants (CNAs) Staff I (date of hire of 4/1/2020) and L (date of hire of 8/29/2000) who used the total body mechanical lift to transfer Resident #1 failed to show documentation CNAs Staff I and L were trained and competent in the use of mechanical lifts at the time of the incident. Review of the SNF Clinic list of training for Staff I, and Staff L revealed on 8/15/23, and 8/17/23 respectively CNA Staff I, and CNA Staff L completed a 15 minute computer training on Using a Hydraulic Lift. There was no documentation of a competency evaluation following the computer training. On 8/21/23 through 8/23/23, observation revealed the facility utilizes five different brands of mechanical lifts. The facility provided staff education sign-in sheets dated 8/12/23 and 8/14/23 for (brand name) lift use as part of their corrective actions after Resident #1 fell from a lift. The outline of the in-service was, Staff member provided instructions packet with diagram and demonstration of proper use provided. The in-service was not specific to the different brands and models of mechanical lifts used at the facility with each manufacturer's specification. The in-service did not include the appropriate size of sling to use for each resident for comfort and safe transfer. A total of 24 of 48 CNAs employed by the facility attended the training. The in-service did not include a return demonstration to verify staff were able to safely use the different mechanical lifts. On 8/21/23 the facility provided a list of 20 current residents who require the use of a mechanical lift for transfers. Review of the CNAs assignment schedule for 8/21/23 for the 7:00 a.m., to 3:00 p.m. shift revealed nine CNAs, including CNAs Staff E, Staff F, Staff I, Staff K, Staff T, and Staff X were assigned to care for residents who require the use of a mechanical lift. Seven of the nine CNAs attended the in-service on 8/12/23 or 8/14/23 but lacked documentation of a competency evaluation. On 8/21/23 at 11:30 a.m., CNA Staff E and CNA Staff F who attended the in-service on 8/14/23 were observed using a mechanical lift to transfer Resident #18 from bed to chair. The CNAs positioned the base of the mechanical lift under the bed without spreading the base open. They placed the resident in the lift and guided the lift toward the chair without spreading the base open per the in-service of 8/14/23. On 8/21/23 at 3:50 p.m., CNA Staff J and CNA Staff K (who attended the in-service on 8/14/23) were observed using a mechanical lift to transfer Resident #18 from chair to bed. They did not lock the wheels of the lift. The CNAs moved the lift back, closed the base and wheeled the lift to the bed. They transferred the resident to the bed without spreading the base or locking the lift as per the in-service provided on 8/14/23. On 8/21/23 at 4:05 p.m., CNA Staff K said, They tell us what to do, they don't show us what to do. They just tell us in words and have us sign a paper. There was no documentation CNA Staff J attended the in-service on 8/12/23 or 8/14/23. On 8/21/23 at 10:10 a.m., CNA Staff X said she had two residents in her assignment who require the use of a mechanical lift to get up to their chairs. The CNA denied receiving any recent education on the use of mechanical lifts, even though she signed the in-service attendance for the use of mechanical lifts on 8/12/23. On 8/21/23 at 10:43 a.m., CNA Staff G with a date of hire of 2/24/14 said she had not received any training on the use of mechanical lifts at the facility. There was no documentation CNA Staff G attended the in-service on 8/12/23 or 8/14/23. On 8/21/23 at 5:45 p.m., CNA Staff T said she has worked at the facility for 25 years. She said she has not received any recent training on the use of mechanical lifts even though on 8/12/23 she signed she attended the in-service on the use of mechanical lifts. She said, I know what I am doing. On 8/21/23 at 6:55 p.m., the Director of Nursing (DON) said he did not structure the education on 8/12/23 and 8/14/23 like a competency but since he had them return demonstration of the use of the mechanical lift, he felt it perhaps could count as a competency. The DON said, I would not consider it an annual competency. I wanted to be sure they knew how to use the machine since we did not really know what happened when the resident (Resident #1) fell. The DON confirmed he did not educate the nurses and did not document any competency for the CNAs who participated. On 8/22/23 at 8:56 a.m., CNA Staff X, and Licensed Practical Nurse (LPN) Staff Y were observed transferring Resident #5 from the bed to the chair using a total body mechanical lift. They did not open the legs of the base of the lift when they wheeled the lift from the bed to the chair. On 8/22/23 at 9:05 a.m., CNA Staff X said she has not had any training on using the mechanical lifts in over a year. She said, We just know how to do it, depending on how big the people are. There was no documentation LPN Staff Y attended the in-service. Review of the employee list revealed Unit Manager, LPN Staff O had a permanent hire date of 5/22/23. Review of the job description for the LPN Unit Manager position showed LPN Staff O signed the job description on 8/23/23 (three months after the hire date). The position summary noted, Twenty-four-hour responsibility for supervision and the delivery of care and services to residents on their assigned unit . Essential duties & [and] Responsibilities: . Supervise nursing staff on assigned unit(s). Make round to monitor resident care and status of residents . Ensure nursing policies and procedures are implemented and followed, educating nursing support staff as necessary and according to facility guidelines . On 8/23/23 at 10:27 a.m., LPN Staff O said he has been a Unit Manager for about three months. He said he did not receive a full orientation to the manager's role and had to hit the ground running. The Unit Manager said he ensures safe care is being provided by monitoring his staff all of the time but does not maintain a log or audit for the monitoring. He said the majority of his staff speak English as a second language. He said, It is a challenge to communicate with the staff overall. He said the facility does not have a staff development coordinator, so they have not scheduled any skills fairs or competency fairs as far as he knew. The Unit Manager said, I know we need to do them. This is my first job as a manager, so I am doing my best. He said he has not participated or heard anything related to staff evaluations since he started employment at the facility. The Unit Manager said he had not received any formal training for the mechanical lifts used at this facility. He said, I have been everywhere and anywhere. I don't do direct patient care, so I wasn't and don't need to be trained here. These are the same lifts I have used at many different places I have worked. On 8/23/23 at 11:15 a.m., LPN Staff P said she became a Unit Manager at the facility four months ago after working as a staff nurse through an agency for over a year. She said she did not get a full orientation to her new role. She was not aware of a skill checklist or competency for staff. She said most of the staff speak Creole primarily. She has been used as a translator, but hand outs are in English. She said it was a challenge for the leadership to communicate with the staff and she reminds them they need to try to understand when education is being done. She said she received education on monitoring staff, but nothing related to the use of mechanical lifts. She said, I wasn't trained here. I was trained in 15 facilities in the last three years, and I feel comfortable using the different types of lifts. On 8/23/23 at 11:40 a.m., the Administrator provided an annual education calendar for 2023 which listed Mechanical lift skills for February 2023 but said she could not confirm the Mechanical lift skills check was done. Review of employee files with the Administrator for seven randomly selected direct care staff who use mechanical lifts, including, CNA Staff I (Date of hire 7/3/2001), CNA Staff L (Date of hire 8/29/2000), CNA Staff S (Date of hire 4/17/2013), CNA Staff T (Date of hire 8/28/2003), CNA Staff U (Date of hire 7/28/1992), Registered Nurse (RN) Staff V (Date of hire 3/7/2023) and LPN Staff W (Date of hire 7/2/2019) revealed the most recent evaluations and competencies were completed in February 2021, and did not include the use of mechanical lifts. The Administrator said, The Staff Development Coordinator (SDC) is the position that is tasked with that responsibility. Currently, we do not have an SDC, so it falls to the DON and then me after him. Ultimately, I am responsible for ensuring the DON is ensuring staff are properly trained. The administrator confirmed there were risks for not completing staff evaluations and competencies. She said, We would be unaware of the staff skills and level of competence since we do not have the return demonstrations. It would be unsafe for the residents. On 8/23/23 at 1:00 p.m., in a telephone interview, the DON said he was unaware of an education calendar at the facility. He was also unaware direct care staff had not had evaluations or competencies documented. The DON confirmed he was responsible for ensuring staff had appropriate competencies documented including safely using mechanical lifts. He said, It is about the safety of the patients. If we don't do evals and competencies then how would we know if we are giving safe care? He said prior to Resident #1's fall during transfer with a lift, he assumed staff had been trained on the mechanical lifts, so there had been no education or monitoring of the lift use. The DON said, Ultimately it is my responsibility to ensure they have their competencies done and are providing safe care. The immediate actions to remove the Immediate Jeopardy implemented by the facility and verified on 8/25/23 by the surveyor included: Facility Administrator was re-educated on Abuse, Neglect and Exploitation on 8/21/23 by Regional Nurse Consultant with specific regard to mechanical lifts, CNAs comprehension of ANE as it pertains to reporting and the event that occurred on 8/12/23. The surveyor verified through reviewed documentation of reeducation for DON and administrator. Facility Administrator and Director of Nursing were re-educated on Failure to Prevent Incidents and Accidents regarding Supervision, preventing avoidable accidents and oversight of the education program, calendar, and competencies on 8/23/23 by Regional Nurse Consultant. The surveyor verified through review of the Administrator and DON signed attestations for education. Facility Administrator and Director of Nursing were re-educated on 8/21/23 by Regional Nurse Consultant on developing a process to validate education, training and competencies with initial focus on mechanical lift safety. The surveyor verified through review of the education. On 8/23/23, Administrator job description was reviewed by Regional Nurse Consultant, including understanding supervision and adherence to the training and education of staff. Administrator was re-educated on role and responsibilities of this position. The surveyor verified through review and signature of newly signed job description. On 8/23/23, Director of Nursing job description was reviewed by Regional Nurse Consultant, including supervision and adherence to the training and education of staff. DON was re-educated on role and responsibilities of this position. The surveyor verified through review of the signed job description. Education calendar has been reviewed. Validation completed for the education program. An electronic system for delivering and tracking education and in-services has been implemented. Training and competencies that were previously planned and not completed have been rescheduled in accordance with administration utilizing effective resources to ensure staff are trained and competent. The surveyor verified through reviewed of scheduled education assignments in SNF clinic for staff meetings. The DON, Regional Nurse Consultant and Administrator trained additional leaders to utilize a Train the [NAME] system to ensure all shifts are educated and able to perform return demonstrations. The surveyor verified through review of the attestation signed by administrator of the train the trainer education. Administrator was educated by Regional Nurse Consultant regarding ensuring staff are educated and competent to safely use mechanical lifts. The surveyor verified through review of the Administrator's signed attestation of education. DON was educated by Regional Nurse Consultant regarding ensuring staff are educated and competent to safely use mechanical lifts. The surveyor verified through record review of the education. Immediate education was provided on-site on 8/12/23 to all working Nursing staff on mechanical lift safety by the Director of Nursing. Eleven (11) were educated which is 17.5% of total nursing staff. This mechanical lift education was continued through 8/14/23 with an additional 13 (thirteen) nursing staff which equals 38.09% of the total nursing staff. Total nursing staff are 63 (sixty-three). 8/25/23 reviewed sign in sheets and electronic education records with checklist completion attestation. The surveyor verified through record review of education. There are 19 nurses and 44 CNAs on staff. The above mechanical lift education represents 43% CNAs, and 26% nurses. The surveyor verified through record review of education. Training and competencies for mechanical lift safety has continued through 8/24/23 with 100% of working staff in compliance. The percentage for completion is 76% total nursing staff for mechanical lifts; 63.15% are nurses, and 81.81% are CNAs. The surveyor verified through review of documented process in place for capturing staff as they work their next shift. The agency staff are educated on the shift they arrive prior to taking an assignment, and a roster is kept with their signatures. This is done according to the daily schedule provided by the staffing coordinator. The surveyor verified through record review of the process in place for capturing staff as they work their next shift. The new staff and the staff returning from leave (FMLA (Family Medical Leave of Absence), vacation, etc.) are tracked on the master education roster and will not work until they have completed all applicable educations. The scheduler provides the daily roster. NHA and a nurse or designee educate at the start of the shift prior to accepting their assignment. The surveyor verified through record review of the process in place for capturing staff as they work their next shift. Additional mechanical lifts with additional slings have been ordered on 8/24/23 that are appropriate to resident size needs. These lifts and slings ordered are all the same, uniform brand. The nurse leaders and therapy staff selected appropriate sizes according to weight and height. The surveyor verified through review of purchasing orders. Once the new mechanical lifts and slings arrive, all of the previous slings and lifts will be disposed of to prevent and incompatibility. The surveyor verified through review of the attestation statement from the Administrator. Regional Nurse Consultant educated Administrator and Director of Nursing on QA&A (Quality Assessment and Assurance) and QAPI (Quality Assurance and Performance Improvement) processes with focus on how to effectively utilize resources to ensure staff are trained and competent. The IDT (Interdisciplinary) team also attended and are in agreement. The surveyor verified through review of the education completed 8/24/23, and interview with the Administrator. An Ad-hoc (impromptu) QAA meeting was held on 8/24/23 to review the IJ templates and gather input for suggestions. There were no additional suggestions at this time. The surveyor verified through review of the content of the meeting held on 8/24/23 addressing the Immediate Jeopardy, and interview with the Administrator. The manufacturer was contacted and message left for reporting this equipment failure concern on 8/23/23. An email will follow. The surveyor verified through review of the attestation signed by the Administrator. FDA (Food and Drug Administration) form Medical Device Reporting (MDR) How to report medical device problems/FDA form: MedWatch form 3500A was submitted on 8/25/23 as the initial form used was incorrect. The surveyor verified through review of the attestation statement by administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of facility's policies and procedures, and staff interviews, review the facility failed to have processes in place to ensure nursing staff were trained and competent to safely use mechanical lifts for resident transfers. On 8/12/23 Resident #1 sustained a fall during transfer with a mechanical lift resulting in a transfer to the hospital. Resident #1 suffered spinal and pelvic fractures. The Certified Nursing Assistants (CNAs) transferring the resident had no documentation of training and competency in the use of the mechanical lift. The failure to ensure the nursing staff have the necessary training, skills set and competency to safely transfer residents using a mechanical lift created an unsafe environment of avoidable accidents and falls which could result in serious injury, impairment, or death of residents, and resulted in the determination of Immediate Jeopardy. On 8/24/23 at 12:55 p.m., the facility's Administrator was informed of the Immediate Jeopardy (IJ) and provided the IJ Templates. The facility census was 101 with 20 residents who were transferred with mechanical lifts. The facility used five different brands of mechanical lifts for resident transfers. The Immediate Jeopardy began on 8/12/23. On 8/25/23, after the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 8/24/23, and the scope and severity were reduced to no actual harm, with no more than minimal harm. The findings included: Cross Reference to F600, F689, and F835 The facility's policy and procedure titled, Safe Resident Handling/Transfers with a date reviewed/revised of 1/2022 noted, Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur . Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device . The job description for the position for the nurse educator noted, Responsible for the development, coordination and implementation of facility wide training, education, and development program . Essential Duties & Responsibilities: . Works cooperatively with the Administrator, Director of Nursing, and other facility leadership in assessing educational needs and plan programs to meet these needs. Develops, coordinates, and maintains in-service education records and files related to attendance and content of all programs scheduled and presented to facility employees . Conduct new hire and annual orientation programs. Conduct competency skills review on hire and annually for all applicable personnel . The facility did not have a nurse educator at the time of the survey. The Certified Nursing Assistant (CNA) job description dated April 2020 noted, Summary: Perform direct resident care duties under the supervision of licensed nursing personnel. Assist with promoting a compassionate physical and psychosocial environment for the residents . Essential Duties and Responsibilities: . Ambulate and transfer residents, utilizing appropriate assistive devices and body mechanics . 1. Review of the clinical record for Resident #1 revealed an admission date of 10/7/22. Diagnoses included Arthritis, seizure disorder, and muscle weakness. The Quarterly Minimum Data Set (MDS) assessment with a reference date of 7/10/23 noted Resident #1's cognition was intact with a Brief Interview for Mental Status of 15. Resident #1 was totally dependent on the physical assistance of two persons for bed mobility and required extensive physical assistance of two persons for transfer (How the resident moves between surfaces including to or from bed, chair, wheelchair). Resident #1 had functional limitation in range of motion of both lower extremities. On 8/21/23, review of the facility's accidents and incidents investigations revealed on 8/12/23 at approximately 10:49 a.m., CNA Staff I and CNA Staff L were transferring Resident #1 using a total body lift from bed to the chair. There was a loud noise from the lift. The bar of the mechanical lift was shaking. One loop from the sling came loose and the resident fell to the floor. Resident #1 complained of back and hip pain and was transferred to an acute care hospital. Review of the hospital records showed on 8/12/23 Resident #1 presented to the Emergency Department via Emergency Medical Services from the facility, following a mechanical fall . She states she fell from a (brand name) lift. She struck her head and right side of her body . She currently reports posterior head pain, neck pain, right arm, and right leg pain . Movement exacerbates her pain . The hospital record documented Resident #1 suffered spinal and pelvic fractures. 2. Review of the facility's incident investigation into Resident #1's fall from the mechanical lift showed: On 8/15/23 CNA Staff L provided a statement that read, We cleaned her up, changed her clothes and put the sling under the resident. We brought the (brand name) lift to the bed and each of us hooked the two sling straps on our side of the bed. The patient was lifted up off of the bed with no problem. She pulled the (brand name) lift back and the resident was ok. I went to get the wheelchair turned around and placed behind the patient. The bar was shaking. This lift is too light and not stable, but this resident was light (did not have too many pounds). Only one hook came loose but it was the loop at the resident's head on her left side. The other CNA opened the legs of the (brand name) lift and the resident then dropped to the floor. The resident's hand [sic] were across her stomach, she was not holding on to anything. The statement noted two CNAs were using the lift and used a shower mesh sling for the transfer. On 8/15/23 CNA Staff I provided a statement that read, I finished cleaning the resident. The nurse practitioner was standing at the nurses station speaking with the nurse, so I asked another CNA to assist me. I put on the resident's dress and sling under her. I placed the machine and we each hooked two loops on our side of the bed. We lifted the resident above the bed without a problem. I then pulled the machine back towards the door and opened the legs. The other CNA was placing the wheelchair for the resident to be placed. Something was loose on the machine. One loop came loose, and the resident fell to the floor. Each of us hooked two straps. The sling came off all by itself. The statement documented CNA staff I said, I've worked here for 20 years, and this is the first time something has happened. Review of the personnel file for CNA Staff I revealed a date of hire of 4/1/2020. The employee file lacked documentation of education, and competency in use of mechanical lifts. On 8/21/23 at 2:30 p.m., CNA Staff I said she has worked at the facility since 2001 and had not received any training on using mechanical lifts. She said they lifted Resident #1 using the mechanical lift, the top hook by the resident's left shoulder came loose and the resident fell out and landed on the floor. She said she did a mechanical lift device training on the computer after the fall. CNA staff I said no one observed her using the mechanical lift after she completed the computer training. Review of the SNF Clinic (computer based) list of training for CNA Staff I revealed on 8/15/23 (Three days after Resident #1 fell from the mechanical lift), CNA Staff I completed a 15 minute computer training on Using a Hydraulic Lift. There was no documentation of a competency evaluation following the computer training. On 8/23/23 at 9:45 a.m., CNA Staff L said she has been employed at the facility since the year 2000 and had not received any training on using mechanical lifts. She said she just used the sling that was in the resident's room. Review of the personnel file for CNA Staff L revealed a date of hire of 8/29/2000. The employee file lacked documentation of education, and competency in use of mechanical lifts. Review of the SNF Clinic list of training for CNA Staff L revealed on 8/17/23 (Three days after Resident #1 fell from the mechanical lift), CNA Staff L completed a 15 minute computer training on Using a Hydraulic Lift. There was no documentation of a competency following the computer training. 3. On 8/21/23 at 10:53 a.m., the lift used to transfer Resident #1 was observed for manufacturer, make and model. On 8/23/23 at 10:08 a.m., the Administrator provided the survey team with a picture of the sling which was used with the mechanical lift to transfer Resident #1 on 8/12/23. The sling was from a manufacturer different from the mechanical lift. Review of the manufacturer's user guide for the mechanical lift used to transfer Resident #1 noted, WARNING. (company's name) RECOMMENDS THE USE OF GENUINE (brand name) PARTS. (Brand name) slings and lifters are not designed to be interchangeable with other manufacturer's products. Using other manufacturer's products on (brand name) products is potentially unsafe and could result in serious injury to patient and/or caregiver. The facility provided sign-in sheets dated 8/12/23 and 8/14/23 for an in-service for (brand name) lift use, as part of their corrective actions. The outline of the in-service was, Staff member provided instructions packet with diagram and demonstration of proper use provided. The in-service was not specific to the different brands and models of mechanical lifts used at the facility with each manufacturer's specification. The in-service did not include the appropriate sling, including manufacturer, and size to use for each resident for comfort and safe transfer. The in-service did not include a return demonstration to verify staff were able to safely use the different mechanical lifts. A total of 24 of 48 CNAs employed by the facility attended the training. The instructions provided noted, To raise the consumer the base of the (brand name) Lifter must be spread to its widest possible position to maximize stability . Positioning the lift for use: With the legs of the base open and locked, use the steering handle to push the consumer lift into position . 4. On 8/21/23 at 11:30 a.m., CNA Staff E and CNA Staff F were observed using a mechanical lift to transfer Resident #18 from bed to chair. The CNAs positioned the base of the mechanical lift under the bed without spreading the legs of the base open. They placed the resident in the lift and guided the lift toward the chair without spreading the legs of the base open. Review of the education sign-in sheet revealed CNA Staff E and CNA Staff F attended the in-service on 8/14/23. There was no competency evaluation documented after the in-service for CNA Staff E and CNA Staff F. On 8/21/23 at 3:50 p.m., CNA Staff J and CNA Staff K were observed using a mechanical lift to transfer Resident #18 from chair to bed. The CNAs opened the legs of the base of the lift and placed the resident on the sling. They did not lock the wheels of the lift as per the in-service provided on 8/12/23 and 8/14/23. The CNAs moved the lift back, closed the legs of the base and wheeled the lift to the bed. They transferred the resident to the bed without spreading the base or locking the lift. On 8/21/23 at 4:00 p.m., CNA Staff J verified they did not lock the lift or spread the legs of the base to safely transfer Resident #18 to bed. She said since she's been employed at the facility in 2019, she has not received training on mechanical lifts. She said last week they told her what to do but no one showed her or worked with her to make sure she uses the lifts correctly. On 8/21/23 at 4:05 p.m., CNA Staff K said, They tell us what to do, they don't show us what to do. They just tell us in words and have us sign a paper. Review of the sign in sheet showed CNA Staff K attended the use of the lift in-service on 8/14/23. There was no documentation of a competency evaluation after the in-service for CNA Staff K. There was no documentation CNA Staff J attended the in-service. On 8/21/23 at 10:10 a.m., CNA Staff X said her current assignment included two residents who require a mechanical lift for transfers. Review of the in-service on use of the lifts revealed CNA Staff X attended the in-service on 8/14/23. There was no documentation of competency evaluation following the in-service. On 8/21/23 at 10:43 a.m., CNA Staff G said she did not recall receiving mechanical lift training at the facility. She said, The machines we have here are old. I don't recall any training here. Most places have specific slings and the loops on the sling represent different weights like blue is for patient that weighs 300 to 400 pounds. All the slings are mixed up and the person using the sling might not use the one with the correct fit. If that happens you can see the sling does not fit the patient. If the patient does not have enough space in the middle of the sling, then the patient will be uncomfortable. A new person will just use the sling, they don't know how to use good judgement to use the sling. If they don't have the correct size, they just take whatever is available. If we don't have one that's the correct size, we try to tie them to make it the smaller size. I know we are not to use it that way, but we explain that we can't leave the patient out of bed. On 8/21/23 at 5:30 p.m., CNA Staff Z said she has been working at the facility since 2001. She said she was trained on using a (brand name) mechanical lift, a long time ago. She said she did not have any recent training; she just knows what to do. The CNA said she just knew which colored loops to use when positioning a resident in a sling for mechanical lift transfer. When asked how she knew which loops to use CNA Staff Z said, I don't know, I just know. She was unable to explain the process to ensure the correct size of sling, or which colored loop to use to secure the sling to the lift during transfers. She said she received a recent in-service on 8/12/23 related on use of the mechanical lifts but no competency evaluation. She said she had not had a skills evaluation, for many years. Review of in-service on mechanical lifts conducted by the Director of Nursing showed CNA Staff Z attended the in-service on 8/12/23. There was no documentation of a competency evaluation following the in-service for Staff Z. On 8/21/23 at 5:45 p.m., CNA Staff T said she has worked at the facility for 25 years. She said she has not received any recent training on the use of mechanical lifts but, I know what I am doing. Review of the in-service on mechanical lifts dated 8/12/23 conducted by the Director of Nursing showed Staff T attended the in-service. There was no documentation of a competency evaluation following the in-service for Staff T. On 8/22/23 at 8:56 a.m., CNA Staff X, and Licensed Practical Nurse (LPN) Staff Y were observed transferring Resident #5 from the bed to the chair using a total body mechanical lift. They did not open the legs of the base of the lift when they wheeled the lift from the bed to the chair. On 8/22/23 at 9:05 a.m., CNA Staff X said she has not had any training on using the mechanical lifts in over a year. She said, We just know how to do it, depending on how big the people are. Review of the sign-in sheet for the in-service on use of the mechanical lift showed CNA Staff X attended the in-service on 8/12/23. There was no documentation of a competency evaluation following the in-service for Staff X. There was no documentation LPN Staff Y attended the in-service. On 8/21/23 at 6:43 p.m., LPN Staff C said the management did not do any training about mechanical lifts for nurses. On 8/21/23 at 6:52 p.m., agency LPN Staff D said she has been working at facility since July 2023. She said there had been no training for using mechanical lifts, and no competency evaluation done since coming to this facility. On 8/21/23 at 6:55 p.m., the Director of Nursing (DON) said he did not structure the education on 8/12/23 and 8/14/23 like a competency but since he had them return demonstration of the use of the mechanical lift, he felt it perhaps could count as a competency. The DON added, I would not consider it an annual competency. I wanted to be sure they knew how to use the machine since we did not really know what happened when the resident (Resident #1) fell. The DON confirmed he did not educate the nurses and did not document any competency for the CNAs who participated. 5. On 8/22/23 at 9:20 a.m., the Regional Nurse Consultant verified 20 current residents require the use of a mechanical lift. She said all residents using a mechanical lift should have it listed on their [NAME] (provides instructions for care) and their care plan. She confirmed it was not the case for the 20 current residents requiring mechanical lifts for transfer. She said the colored loops on the slings were for positioning of the resident during transfer and the CNAs were responsible for owning which loops to use. When asked how CNAs were educated on which loops to use when transferring, the Regional Nurse Consultant said they were not addressing the loops, just the size of the sling at this time. On 8/22/23 at 9:45 a.m., CNA Staff L confirmed she was shown how to use the mechanical lift when she was hired in 2000 but has not received any education since then, until the incident with Resident #1. The CNA said the facility has not done annual competencies for years saying, They used to do them but not anymore. On 8/22/23 at 9:50 a.m., the DON said when he did the staff training on 8/12/23 and 8/14/23, he did not address how to use the various colored loops to secure the sling to the mechanical lift. The DON said, I don't remember the exact words, but the staff need to use the loops that keep the resident in the sitting position. The CNAs determine that. On 8/22/23 at 12:30 p.m., CNA, Staff I who was transferring Resident #1 at time of incident said she only opens the legs of the base when the base does not fit under the chair or bed. When asked if she uses the brakes on the chairs or lifts when transferring residents, she said, sometimes but not always. Only if I need to. 6. On 8/23/23 at 10:27 a.m., LPN Staff O said he has been a Unit Manager for about three months. He said he did not receive a full orientation to the manager's role and had to hit the ground running. The Unit Manager said he ensures safe care is being provided by monitoring his staff all of the time but does not maintain a log or audit for the monitoring. He said the majority of his staff speak English as a second language. He said, It is a challenge to communicate with the staff overall. He said the facility does not have a staff development coordinator, so they have not scheduled any skills fairs or competency fairs as far as he knew. The Unit Manager said, I know we need to do them. This is my first job as a manager, so I am doing my best. He said he has not participated or heard anything related to staff evaluations since he started employment at the facility. When asked if he had been trained on the use of mechanical lifts at the facility, he replied, I have been everywhere and anywhere. I don't do direct patient care, so I wasn't and don't need to be trained here. These are the same lifts I have used at many different places I have worked. He confirmed he had no formal training for the mechanical lifts used at this facility. On 8/23/23 at 11:15 a.m., LPN Staff P said she became a Unit Manager at the facility four months ago after working as a staff nurse through an agency for over a year. She said she did not get a full orientation to her new role. She was not aware of a skill checklist or competency for staff. She said most of the staff speak Creole primarily. She has been used as a translator, but hand outs are in English. She said it was a challenge for the leadership to communicate with the staff and she reminds them they need to try to understand when education is being done. She said she received education on monitoring staff, but nothing related to the use of mechanical lifts. She said, I wasn't trained here. I was trained in 15 facilities in the last three years, and I feel comfortable using the different types of lifts. LPN Staff P said she had no audits of staff using the mechanical lifts. 7. On 8/23/23 at 11:40 a.m., the Facility Administrator provided an annual education calendar for 2023 which listed Mechanical lift skills for February 2023 but said she could not confirm the Mechanical lift skills check was done. The Administrator said, The Staff Development Coordinator (SDC) is the position that is tasked with that responsibility. Currently, we do not have an SDC, so it falls to the DON and then me after him. Ultimately, I am responsible for ensuring the DON is ensuring staff are properly trained. The Administrator confirmed annual performance evaluations should be completed for the staff and annual competencies were needed as well. 8. Review of employee files with the Administrator for seven randomly selected direct care staff who use mechanical lifts, including, CNA Staff I, CNA Staff L, CNA Staff S, CNA Staff T, CNA Staff U, Registered Nurse (RN) Staff V and LPN Staff W revealed the most recent evaluations and competencies were completed in February 2021, and did not include the use of mechanical lifts. The administrator confirmed there were risks for not completing staff evaluations and competencies. She said, We would be unaware of the staff skills and level of competence since we do not have the return demonstrations. It would be unsafe for the residents. The administrator had no explanation for the lack of evaluations for direct care staff. She said she has been employed at the facility since February 2023 but has not looked for evaluations until now. On 8/23/23 at 1:00 p.m., in a telephone interview, the DON said he was unaware of an education calendar at the facility. He was also unaware direct care staff had not had evaluations or competencies documented. The DON confirmed he was responsible for ensuring staff had appropriate competencies documented including safely using mechanical lifts. He said, It is about the safety of the patients if we don't do evals and competencies then how would we know if we are giving safe care. He said prior to Resident #1's fall during transfer with a lift, he assumed staff had been trained on the mechanical lifts, so there had been no education or monitoring of the lift use. The DON said, Ultimately it is my responsibility to ensure they have their competencies done and are providing safe care. On 8/24/23 at 11:05 a.m. in a telephone interview the DON said on 8/12/23 and 8/14/23, he educated the staff step by step as the handout he used. The observation of CNA Staff J, CNA Staff K, CNA Staff E, and CNA Staff F, using the mechanical lift to transfer Resident #18 without opening the legs of the base, and the observation of CNA Staff X, and Licensed Practical Nurse (LPN) Staff Y, using the mechanical lift to transfer Resident #5 without opening the legs of the base as per the manufacturer's instructions was shared with the DON. The DON said, I'm not surprised. We have such a bad language barrier but if I need to educate six times I will, to be sure that the CNAs understand and provide safe care. On 8/25/23, the immediate actions to remove the Immediate Jeopardy implemented by the facility and verified by the surveyor included: Facility Administrator and Director of Nursing were re-educated on 8/21/23 by Regional Nurse Consultant on developing a process to validate education, training and competencies with initial focus on mechanical lift safety. The surveyor verified through record review. An electronic training system for providing, tracking and documenting training and education was added as an additional resource on 8/15/23. The surveyor verified through review of education records. Immediate education was provided on-site on 8/12/23 to all working Nursing staff on mechanical lift safety by the Director of Nursing. Eleven (11) were educated, which is 17.5% of total nursing staff. This mechanical lift education was continued through 8/14/23 with an additional 13 (thirteen) nursing staff which equals 38.09% of the total nursing staff. Total nursing staff are 63 (sixty-three). There are 19 nurses and 44 CNAs on staff. The above mechanical lift education represents 43% CNAs, and 26% nurses. The surveyor verified through record review. This was done after DON was educated by Regional Nurse Consultant for basic functionality and safe use. The surveyor verified through record review. Education with return demonstration competencies started on 8/21/23 and continued for use of mechanical lifts through today, 8/24/23 with all working staff in compliance. 76% of nursing staff have been trained as of this date, 63.15% are nurses, and 81.81% are CNAs. This training includes the sizes indicated for each resident and where to find this information on the [NAME]. The surveyor verified through record review. A documented checklist for personnel education files was initiated that includes all recommended competencies and education for CNAs and Nurses. The surveyor verified through record review. Audit of personnel files that started on 8/22/23 did not show documented proof of training and competency for staff that utilize mechanical lifts and education was initiated immediately. The surveyor verified through record review. Documentation for the education provided along with competencies is now organized by staff names and includes title and all applicable annual education. A process was initiated to continue this to ensure compliance. The surveyor verified through record review. Facility lifts were all inspected to verify functionality on the date of event 8/12/23 by the Director of Nursing and found to be safe and functional. This was done after DON was educated by Regional Nurse Consultant for basic functionality and safe use. The surveyor verified through record review. Facility maintenance assistant inspected all facility lifts on 8/15/23 and all lifts were found to be safe and functional. These were inspected according to their manufacturer's guidelines. The surveyor verified through record review. Regional director of plant operations inspected all facility lifts on 8/16/23 and verified that they were found to be safe and functional. These were inspected according to their manufacturer's guidelines. The surveyor verified through review of the inspection forms. Slings in the facility that are in use were all inspected starting on 8/12/23 and continued through 8/22/23 and continued daily. Slings that were found in disrepair or torn were discarded on 8/12/23, 8/21/23 and 8/22/23. The surveyor verified through record review. A mechanical sit to stand lift was removed from service on 8/22/23 as it needed battery backup. A mechanical lift was removed from service on 8/22/23 as it needs a U-spreader clip which was ordered. The surveyor verified through documentation provided. Additional mechanical lifts with additional slings have been ordered by the Administrator on 8/24/23 that are appropriate to resident size needs. These lifts and slings ordered are all the same, uniform brand. The sizes were determined by the nursing and therapy team leaders according to residents' weight and height. (Brand name) slings that state they are recommended only to be used on (brand name) lifts were taken out of service on 8/24/23 to prevent incompatible use. The surveyor verified through review of purchase orders. After the new mechanical lifts are received, the previous lifts will all be taken out of service and disposed of, as well as the slings that are in service. The surveyor verified through record review. Residents who require mechanical lifts have all been re-evaluated by the therapy department and nursing department as of 8/22/23. The surveyor verified through review of clinical documentation for residents who use mechanical lifts. As of 8/22/23 the residents who require mechanical lifts have been assigned a corresponding sling size recommendation as evaluated by nursing and therapy, and this information has been communicated to the staff in the electronic record in the care plans and the [NAME]. The surveyor verified through review of clinical documentation in the electronic clinical records, and observation of CNAs transferring Resident #18 with a mechanical lift. Residents who require extensive assistance will be transferred using two-person pivot transfer if needed if their sling size is temporarily unavailable. This education to staff is provided daily at the beginning of their shift and the information is also available in the [NAME] for all shifts to view. Of the residents who require small slings (initially there were seven) after evaluation three did not need mechanical lifts at all, leaving four. These four will utilize this method of transfer until the ordered slings are delivered. The surveyor verified through review of staff education sign-in sheets identifying residents appropriately.