**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility's Administration failed to utilize resources effectively to protect the residents' right to be free from neglect by failing to ensure staff were competent to safely use full body mechanical lifts and follow manufacturers safety instructions for the brand and size of slings. On 2/1/24 a dependent resident (Resident #1) fell during transfer using a mechanical lift and required transfer via EMS to the emergency room (ER) for evaluation and treatment for a head laceration. The facility's administration failure to ensure effective use of resources to ensure residents safety and prevent neglect created a likelihood of avoidable falls and accidents from mechanical lifts with a likelihood of serious injury, impairment or death of residents who use mechanical lifts and resulted in the determination of Immediate Jeopardy. On 2/23/24 at 5:35 p.m., the Executive Director was informed of the determination of immediate Jeopardy (IJ) and provided the IJ templates. The Immediate Jeopardy began on 2/1/24. On 2/25/24 at 3:45 p.m., after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/25/24. The scope and severity were reduced to no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference F600, F689, and F726 The Administrator job description signed on 2/15/24 noted essential duties and responsibilities included to, Supervise assigned department directors . Monitor in-service education for employees . Ensure compliance with State and Federal regulations . The Director of Clinical Services (Director of Nursing) job description signed on 7/10/23 noted, The Director of Clinical Services is responsible for the overall supervision, provision, and quality of nursing care in the Health Center . He/she is responsible for the selection, training, discipline, and supervision for all nursing related Health Center personnel . Oversees completion of written orientation and annual evaluations of all nursing staff . Coordinates required and supplemental in-service education programs appropriate for nursing staff and acts as a resource for Facility staff to increase knowledge of competence and job skills for the benefit of staff and residents . The facility policy Safe Lifting and Movement of Residents revised in 2017, read, In order to protect the safety and wellbeing of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents . Staff responsible for direct resident care will be trained in the use of . mechanical lifts . Only staff with documented training in the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policy and procedures regarding use of equipment and the safe techniques . The policy Lifting Machine, Using a mechanical revised 2017, read, Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using specific machines or devices utilized in the facility. 1. On 2/21/24 at approximately 11:00 a.m., during a tour of the facility a Brand A full body mechanical lift was observed in use on the third floor and a Brand B full body mechanical lift was observed in use on the second floor. Review of the facility's investigations of allegations of neglect showed on 2/1/24 at 11:15 a.m., Certified Nursing Assistant (CNA) Staff B and CNA Staff C were transferring Resident #1 from bed to wheelchair with a mechanical lift (a device used to assist with transfers and movement of individuals who required support for mobility beyond the manual support provide by caregivers alone). Midway through the transfer Resident #1 slid out of the sling. One of the CNAs tried to grab Resident #1 as she saw her sliding out. The resident potentially hit her head on the side of the bed and potentially on the carpeted floor. The resident sustained a laceration to the top area on the right side of her head. Resident #1 remained conscious during emergency treatment and evaluation. The facility's investigation summary noted neglect was not substantiated. Resident #1 slid to the right side between the top and bottom sling rope toward the floor. The resident landed on the right side between the mechanical lift legs with the resident's left leg still in the sling which was attached to the lift. The mechanical lift and the sling used to transfer Resident #1 were inspected with no abnormalities found. The facility's investigation summary noted neglect was not substantiated. Resident #1 slid to the right side between the top and bottom sling rope toward the floor. The resident landed on the right side between the mechanical lift legs with the resident's left leg still in the sling which was attached to the lift. The mechanical lift and the sling used to transfer Resident #1 were inspected with no abnormalities found. The investigation did not document the brand of the mechanical lift or the brand and size of sling used to transfer Resident #1. On 2/21/24 at 2:15 p.m., the mechanical lift and sling used to transfer Resident #1 on 2/1/24 were observed with the Assistant Director of Nursing (ADON). The mechanical lift was a Brand A full body mechanical lift and the sling was a Brand C size small four-point sling. The ADON verified on 2/1/24 a Brand A full body mechanical lift was used with a Brand C sling to transfer Resident #1. The ADON said the Certified Nursing Assistants undergo an annual competency which includes the use of mechanical lifts. She said on 2/1/24 the nursing staff was re-educated on transfers with mechanical lifts since the facility's investigation determined staff used the wrong size of sling to transfer Resident #1 causing her to fall. The facility's investigation did not include a review of the Brand A operating manual to ensure the Brand C sling was compatible to be used with the Brand A full body mechanical lift. Review of the operating manual for mechanical lift Brand A provided by the facility noted, ONLY (Brand A) slings must be used on (Brand A) mechanical lifts. The use of non-company (Brand A) slings could be unsafe and may result in injury to the patient or caregiver. Review of the Brand C manufacturer operating manual revealed under warning, [Brand C] slings may be used with [Brand C] lift only. Using other manufacturer's patients lifts with [Brand C] slings is also prohibited. Review of the competency evaluations for CNA Staff B and CNA Staff C revealed: On 1/26/24 Licensed Practical Nurse (LPN) Staff A validated CNA Staff B satisfactorily demonstrated the use of a mechanical lift. On 1/10/24 LPN Staff A validated CNA Staff C satisfactorily demonstrated the use of a mechanical lift. The skills checklist did not include a step-by-step demonstration of transfer with the mechanical lifts, or ensuring staff used the right size and brand of slings in accordance with each mechanical lift's operating manual. Review of LPN Staff A's training record showed an Annual Nurse Competency form dated 12/20/23. The competency form did not include the use of mechanical lifts. On 2/22/24 at 3:00 p.m., in an interview LPN Staff A verified she signed the skills checklist for CNAs Staff B and Staff C certifying the CNAs satisfactorily demonstrated the proper use of mechanical lifts. When asked to describe the process to verify competency, LPN Staff A said first she demonstrates the transfer with a mechanical lift for the CNA, then she has the CNA complete the task. LPN Staff A said she would only open the legs of the base when lowering the resident on the wheelchair. She said she would not open the base of the lift when it was placed under the bed. LPN Staff A was not able to describe how to select the correct brand or size of sling for each resident. She said she would use the weight of the resident. Review of Brand A mechanical lift operating manual instructions provided by the facility showed, ALWAYS, (except when lifting a patient from the floor) while lifting or lowering a patient, maintain the base unit legs spread to the widest position and ensure that the casters are unlocked. On 2/23/24 at 8:15 a.m., in an interview the Director of Nursing (DON) said she was not able to find documentation LPN Staff A was trained on the safe use of mechanical lifts and had the necessary skills set to teach and administer competency evaluations on the safe use of mechanical lifts. 2. Review of the in-service for Mechanical lift use dated 2/1/24 showed the facility used the policy and procedure Lifting Machine, Using a Mechanical for the in-service. The policy noted the purpose of the procedure was to establish the general principles of safe lifting using a mechanical lifting device and was not a substitute for manufacturer's training or instructions. The policy or the in-service did not include the manufacturer's safety specifications for the mechanical lifts (Brand A and Brand B) used at the facility. The in-service was not followed by a competency evaluation to verify staff understood the training and were competent to use the mechanical lifts and follow each manufacturer's safety protocol. On 2/21/24 at 1:30 p.m., CNAs Staff E and Staff C were observed transferring Resident #2 with a Brand A full body mechanical lift. The Director of Nursing (DON) and Unit Manager Staff D were present during the observation. The sling used to transfer the resident did not have a label, making it impossible to determine the brand or the size of the sling. A label affixed to the mechanical lift specified, Danger . Read the Lift User Manual and the sling instruction sheet before operating. Staff E was observed operating the lift. She closed the legs of the base and placed them under the bed. CNA Staff E did not open the legs of the base lift after placing them under the bed. CNAs Staff E and Staff C placed the resident in the sling. CNA Staff E pulled out the lift from under the bed. She did not open the legs of the base and wheeled the resident approximately three feet to the wheelchair. CNA Staff C tilted the wheelchair on its back wheels as CNA Staff E lowered the resident with the mechanical lift. While observing the CNAs transferring Resident #2 with the mechanical lift, Unit Manager Staff D said the sling used to transfer Resident #2 was not labeled making it impossible to tell the brand or the size of the sling. Unit Manager Staff D, and the DON did not intervene and did not correct the CNAs to ensure a safe transfer, and used the appropriate brand and size of sling to protect Resident #2 from avoidable fall or accident. Photographic evidence obtained. On 2/21/24 at 2:30 p.m., in an interview CNA Staff E verified she did not open the legs of the base as per the manufacturer's safety instructions. She said on 2/1/24 after Resident #1 fell from the lift, she was given a paper to read regarding mechanical lifts. Review of the In-Servicing Program log showed Staff E and Staff C both attended the in-service on 2/1/24. 3. On 2/21/24 at 2:15 p.m., The ADON said Central Supply Staff H was responsible for ensuring the correct sling was used for each resident. The ADON said Central Supply Staff H was currently on vacation and not available for a telephone interview. On 2/22/24 at 11:15 a.m., a joint interview was conducted with the Director of Rehabilitation, the Registered Nurse Senior Clinical Specialist, and the DON. The DON verified the facility used a Brand A full body mechanical lift to transfer Residents #1, #2, #3, and #4 who reside on the third floor and a Brand B full body mechanical lift to transfer Resident #5 who resides on the second floor. When asked if Resident #1 was reassessed after the fall on 2/1/24 for transfers using a full body mechanical lift, the Director of Rehabilitation said she would have to check her paperwork. On 2/22/24 at 12:30 p.m., a brand D medium size sling was observed in Resident #1's room (Third floor). In an interview, Resident #1's daughter said since the fall from the mechanical lift on 2/1/24 the facility has been using the Brand D medium size sling for transfers. Photographic evidence obtained. On 2/22/24 at 1:10 p.m., Resident #5, who resides on the third floor, was observed in bed. A Brand C, size large mesh sling was observed over the resident's wheelchair. In an interview Resident #5 said she had a smaller sling that did not fit between her legs. She said, They brought me this sling and it is too big. Resident #5 said, They don't know what they are doing, I was never measured for a sling. They were going by weight alone. On 2/22/24 at approximately 3:05 p.m., upon request the DON provided a list of Central Supply Staff H trainings. The training included one hour online in-service titled Transferring, Repositioning, and Lifting Residents safely. The training was dated 5/1/2016. The DON said she could not locate documentation Resident #1 was reassessed after the fall on 2/1/24 to ensure transfer with a full body mechanical lift was appropriate for the resident. She said the facility reassessed Resident #1 on 3/22/24 and provided the surveyor an evaluation dated 3/22/24. The DON did not provide the content of the in-service or a competency evaluation verifying Central Supply Staff H was trained and competent to evaluate each resident for the correct brand and size of sling according to each manufacturer's specification. The DON could not provide documentation Residents #1(Date of admission [DATE]), #2 (Date of admission 5/23/23), #3 (Date of admission 5/17/23) , #4 (Date of admission 8/29/22), and #5 (Date of admission [DATE]) were assessed for the correct brand and size of slings before or after Resident #1's fall from the mechanical lift on 2/1/24. On 2/23/24 at 11:00 a.m., in an interview the Medical Director said he attends all QAPI (Quality Assurance and Performance Improvement) meetings when available. He said he was told about the incident that occurred with the Mechanical lift roughly about the time it occurred but has not been updated as to what is being done since the incident. The Medical Director said he was not involved in determining the size of slings, the nurses were responsible to make sure the correct size of sling is used. On 2/23/24 at 1:30 p.m., in an interview the Administrator said he started employment at the facility on 2/15/24 and knew very little about Resident #1's fall from the mechanical lift. He said he just knew what the DON and Executive Director told him. He said he was aware a Federal Report was made because Resident #1 bumped her head, required sutures, and had to be sent to the hospital. He said, I do not know the root cause of the incident. On 2/25/24 at 3:45 p.m., the immediate actions implemented by the facility and verified by the surveyor included: On 2/22/24 the Clinical Equipment Repair company was contacted by Facility administrative Assistant to schedule monthly inspections of community Mechanical Lifts. On 2/25/24 the surveyor verified by documentation of the contract and interviews with administration. On 2/22/24 Interim Administrator instructed Maintenance Supervisor to obtain Brand F Lifts and Brand F slings from an additional resource a sister community and remove Brand A mechanical lift from service. On 2/25/24 the surveyor verified by observation and interviews with staff Brand F mechanical lift with appropriate slings was in use on the third floor of the facility. On 2/22/2024 Interim administrator instructed Maintenance Supervisor to inspect the Brand F lift and the Director of Nursing and RN manager to inspect Brand F slings upon arrival and before use per manufacture guidelines. The Clinical Equipment Repair company was contacted by Facility administrative Assistant to schedule monthly inspections of community Mechanical Lifts. On 2/25/24 the surveyor verified by observations and review of the contract with the Clinical Equipment company. A sticker was observed on the Brand F lift showing the date of the inspection. On 2/22/24 Nursing staff were educated and demonstrated competency, on the safety and proper use of mechanical lifts and slings in accordance with the facility policy Safe Lifting Movement of Resident, Brand F Lift/Sling manufacturer guidelines, and Brand B Sling guidelines by the Director of Nursing, Assistant Director of Nursing and RN Manager. On 2/25/24 the surveyor verified by observations of the slings on the lifts on the second and the third floor and interviews with the facility direct care staff. On 2/22/24 Resident #1 use of a mechanical lift for transfers was assessed for the correct size and brand of slings. Sizing completed by Director of Nursing and RN Nurse Manager in the presence of the Occupational Therapist. On 2/25/24 the surveyor verified by observation of Resident #1's sling and transfer using the mechanical lift, and review of assessment for correct size of sling. On 2/22/24 the four remaining residents who utilize the mechanical lifts were assessed for the correct size and brand of sling compatible with lift. Sizing/Measuring of slings was completed by Director of Nursing, Family Nurse Practitioner, Assistant Director of Nursing per manufacturer guidelines. Appropriate Slings were labeled and placed in resident rooms. On 2/25/24 the surveyor verified by review of documentation showing Residents on the third floor were sized to ensure the appropriate sling was in use to transfer each resident. This documentation was kept in a folder at the nurse's station with the lift operating manual. On 2/22/24 Ad-[NAME] (unplanned) QAPI (Quality Assurance and Performance Improvement) meeting held with Executive Director, Interim Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, RN Manager, AL/MC (Assisted Living/Memory Care) Director, Maintenance Director, HR (Human Resources) and Facility Administrator Assistant. An audit plan for following manufacture guidelines for mechanical lifts to prevent injury to residents was developed and approved by the committee. In addition, the meeting included the responsibility of the facility's administration to ensure safe practices for resident health and safety including the safe use of mechanical lifts. On 2/25/24 the surveyor verified through review of the Ad-hoc meeting documentation and review of audit forms for the mechanical lifts on the second and third floor. On 2/22/24 An observation/audit of mechanical lifts to compatibility of slings utilized and sling sizing for all residents who utilize lifts were completed by the Director of Nursing, ADON and RN manager on 2/22/24 and is ongoing to ensure the proper sling is utilized with the compatible lift, that the transfer of resident using the mechanical lift meets the lift competency demonstrated by staff. Audits have a goal of 100% compliance. Audits are completed weekly for three months then monthly for nine months. On 2/25/24 the surveyor verified by review of the audits completed and residents evaluation for the correct brand and size of slings. On 2/23/24 and 2-24-2024 the Corporate Senior Clinical Specialist provided education to the Executive Director, Interim Administrator, Director of Nursing and ADON on Abuse, Neglect and Resident Rights Policies with a focus on ensuring goods and services are provided to the residents that are necessary to avoid physical harm, pain, mental anguish or emotional distress. This included the importance of ensuring resident health and safety including the use of mechanical lift devices. On 2/25/24 the surveyor verified through review of the education, observations of staff using mechanical lifts and interviews with direct care staff. On 2/23/24 the Medical Director notified of four area of deficiency by the Director of Nursing. On 2/25/24 the surveyor verified by interviews with administrative staff. On 2/23/24 Mechanical Lift and Sling Competencies have been added to the general orientation packet for all nursing staff and will be completed upon hire prior to resident care and then completed quarterly. Competencies to be completed by Director of Nursing/qualified designee. On 2/25/24 the surveyor verified by reviewing the documentation created by administration and the 95% competencies completed with facility direct care staff. On 2/23/24 The Clinical Equipment Repair company inspected and found Brand F lift to function per manufacture guidelines. On 2/25/24 The surveyor verified by observation of the sticker applied to the lift by the clinical repair company. On 2/23/2024 Director of Nursing informed the Medical Director of the removal plan. On 2/25/24 the surveyor verified by an interview with the Director of Nursing. On 2/24/24 the Corporate Senior Clinical Specialist reviewed job descriptions with the Executive Director, Interim Administrator, Director of Nursing and ADON with the importance of following guidelines set forth by the regulations of the Federal and State requirements. On 2/25/24 the surveyor verified by reviewing of the Job descriptions. No changes noted. On 2/24/24 Brand F lift was received and inspected by Maintenance Tech and replaced the temporary sister facility lift on third floor. On 2/25/24 the surveyor verified by observation of the lifts. On 2/24/24 Executive Director contacted corporate purchasing and secured the order for two new Brand F mechanical lifts and manufacturer specified slings. On 2/25/24 the surveyor verified by interviews with the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, Policy reviews, and interviews, the facility failed to protect the residents' right to be free from neglect by failing to ensure staff were competent to safely use full body mechanical lifts and by failing to ensure staff followed the manufacturer's safety instructions for the brand and size of slings and transfer techniques. Resident #1 was dependent on staff and used a mechanical lift for transfer. On 2/1/24, staff did not follow the manufacturer's instructions for the appropriate brand and size of sling during transfer with a mechanical lift. Resident #1 fell from the sling, struck her head on the bed and the floor. Resident #1 sustained a laceration to the right temporal area requiring an emergent transfer to an acute care hospital for evaluation and treatment. The facility's failure to ensure necessary structure and processes to prevent neglect placed other residents who use mechanical lifts for transfer 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 2/23/24 at 5:35 p.m., the facility's Executive Director was informed of the determination of immediate Jeopardy (IJ) and provided the IJ templates. The Immediate Jeopardy began on 2/1/24. On 2/25/24 at 3:45 p.m., after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/25/24. The scope and severity were reduced to no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference F689, F726 and F835. The facility's policy and procedure titled, Abuse Prevention Program dated February 2020 noted, Neglect is defined as failure of the facility, its employees or service providers, to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress . This community desires to prevent . neglect . by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach including the following . Environmental assessment: At least annually, an interdepartmental team will both tour the community assessing the safety of the community environment . Staff supervision: On a regular basis, supervisors will monitor the ability of the staff to meet the needs of the residents, staff understanding of individual resident care needs . Any incident or allegation involving . neglect . will result in an abuse investigation . The facility's policy titled, Lifting Machine, Using a mechanical revised 2017, read, . Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using specific machines or devices utilized in the facility . 1. Review of the clinical record for Resident #1 revealed an admission date of 10/1/21. Resident #1 scored 00 on the Brief Interview for Mental Status dated 1/5/24 indicating severe cognitive impairment. Resident #1's diagnoses included Alzheimer's disease, stiffness of the right hip, left hip, and the left knee. Resident #1 was dependent on staff for transfers with a full body mechanical lift. Review of the progress notes revealed on 2/1/24 at 11:40 a.m., Licensed Practical Nurse (LPN) Staff A documented, CNA Staff C informed her Resident #1 fell out of the sling while she was in a mechanical lift (a device used to assist with transfers and movement of individuals who required support for mobility beyond the manual support provide by caregivers alone). When she went in the room the resident was still in the sling and, her head was bleeding from the top right side. LPN Staff A documented CNA Staff C and CNA Staff B reported the sling did not come unattached from the lift. LPN Staff A wrote Resident #1's arms and legs were permanently contracted (fixed deformity of joints). The resident had a laceration to the right 10:00 a.m. laceration. Resident #1 was transferred to the hospital via EMS (Emergency Medical Services). Review of the facility's accidents and incidents investigations showed on 2/1/24 at 11:15 a.m., Certified Nursing Assistant (CNA) Staff B and CNA Staff C were transferring Resident #1 from bed to wheelchair with a mechanical lift. Midway through the transfer Resident #1 slid out of the sling. One of the CNAs tried to grab Resident #1 as she saw her sliding out. The resident potentially hit her head on the side of the bed and potentially on the carpeted floor. The resident sustained a laceration to the top area on the right side of her head. Resident #1 remained conscious during emergency treatment and evaluation. Resident #1 was transferred to the hospital via EMS (Emergency Medical Services). The facility's investigation summary noted Resident #1 slid to the right side between the top and bottom sling rope toward the floor. The resident landed on the right side between the mechanical lift legs with the resident's left leg still in the sling which was attached to the lift. The mechanical lift and the sling used to transfer Resident #1 were inspected with no abnormalities found. As part of their investigation, the facility obtained statements from CNA Staff B, and CNA Staff C who transferred the resident with the mechanical lift, and Licensed Practical Nurse (LPN) Staff A who evaluated Resident #1 after the fall. On 2/1/24 CNA Staff B wrote in a statement Resident #1, slid off and came out from the sling on one side. My coworker (CNA Staff C) catch her but resident hit the floor. We called the nurse. On 2/1/24 CNA Staff C wrote in a statement, While transferring the resident from the bed to the wheelchair she slide [sic] out of the sling and her head hit the carpet floor. I tried to catch her but the action was so quick I couldn't. On 2/1/24 LPN Staff A wrote in a statement, The resident fell out of the [brand name] sling while being transferred to her wheelchair. The facility's conclusion noted, After a thorough investigation and review of the lifting machine policy & [and] procedure the facility could not substantiate neglect. As a precautionary measure each lift will be checked by an outside licensed contractor. Each staff member in the nursing department will get additional training on mechanical lift transfer. The facility's investigation did not include a review of the operating manual for each brand of mechanical lifts to staff followed the manufacturer's safety precautions when using the lift. On 2/21/23 at 10:00 a.m., CNA Staff C was interviewed with the assistance of Unit Manager Staff D translating in CNA Staff C's native language. CNA Staff C said on 2/1/24 she was on the opposite side of the bed when Resident #1 fell from the lift before she could get to the other side of the bed after the resident was lifted. She said CNA, Staff B had already moved the lift away from the bed and had started turning the resident. She stated the resident slid from the top of the sling and hit her head on the bed and the floor. CNA Staff C did not say the brand or size of sling used to transfer Resident #1. On 2/21/24 at 10:15 a.m., CNA Staff B was interviewed with the assistance of Minimum Data Set Staff I in CNA Staff B's native language. CNA Staff B said Staff C was coming around the bed and tried to catch the resident as she fell but the incident occurred to quickly. Staff B said Staff C threw her hands in the air and said she did not do it; she never touched the resident and it was not her fault. CNA Staff B did not say the brand or size of sling used to transfer Resident #1. On 2/21/24 at 2:15 p.m., an observation was made, in the presence of the Assistant Director of Nursing (ADON), of the lift and sling used to transfer resident #1 on 2/1/24. Observed were the lift (Brand A) and the sling (Brand C), at this time the ADON verified these were the lift and sling used to transfer Resident #1 on 2/1/24. The ADON reported that the facility's investigation determined that the wrong size sling had been used to transfer the resident which caused her to fall from the sling. She stated that on 2/1/24 after Resident #1 fell from the lift, the facility contacted Brand A mechanical lift manufacturer and found out some of the slings they were using were not the correct size slings. A review was conducted of the facility provided operating manual for mechanical lifts. Brand A revealed that ONLY (Brand A) slings must be used on (Brand A) mechanical lifts. The manual goes on to state that the use of non-company (Brand A) slings could be unsafe and may result in injury to the patient or caregiver. Review of the Brand C manufacturer operating manual revealed under warning, [Brand C] slings may be used with [Brand C] lift only. Using other manufacturer's patients lifts with [Brand A] slings is also prohibited. On 2/21/24 at 2:15 p.m., in an interview the ADON reported she went over the facility's policy titled, Lifting Machine, Using a Mechanical as part of the facility's investigation's corrective actions. The policy Lifting Machine, Using a Mechanical noted the purpose of the policy was to establish the general principles of safe lifting using a mechanical lifting device and was not a substitute for manufacturer's training or instructions. The in-service did not include the operating instructions, and safety warnings for the full body mechanical lifts (Brand A and B) used at the facility and did not include a competency evaluation. 2. Review of Brand A operating manual instructions showed, ALWAYS, (except when lifting a patient from the floor) while lifting or lowering a patient, maintain the base unit legs spread to the widest position and ensure that the casters are unlocked. On 2/21/24 at 1:30 p.m., CNAs Staff E and Staff C were observed transferring Resident #2 with a Brand A full body mechanical lift. The Director of Nursing (DON) and Unit Manager Staff D were present during the observation. The sling used to transfer the resident did not have a label, making it impossible to determine the brand or size. A label affixed to the mechanical lift specified, Danger . Read the Lift User Manual and the sling instruction sheet before operating. Staff E was observed operating the lift. She closed the legs of the base and placed them under the bed. CNA Staff E did not open the legs of the base after placing them under the bed. CNAs Staff E and Staff C placed the resident in the sling. CNA Staff E pulled out the lift from under the bed. She wheeled the resident in the lift approximately three feet to the wheelchair with the legs of the base closed. CNA Staff C tilted the wheelchair on its back wheels as CNA Staff E lowered the resident with the mechanical lift. While observing the CNAs transferring Resident #2 with the mechanical lift, Unit Manager Staff D said the sling used to transfer Resident #2 was not labeled making it impossible to tell the brand or the size of the sling. Unit Manager Staff D and the DON did not intervene, and did not correct the CNAs to ensure Resident #2's safety. Photographic evidence obtained. Review of the attendance log for the Mechanical Lift In-service conducted on 2/1/24 showed CNAs Staff C and Staff E both had attended the in-service. On 2/21/24 at 2:30 p.m., in an interview CNA Staff E verified she did not open the legs of the base as per the manufacturer's safety instructions. She said on 2/1/24 she was given a paper to read regarding mechanical lifts. 3. On 2/21/24 at approximately 11:00 a.m., during a tour of the facility a Brand A mechanical lift was observed in use on the third floor of the facility and a Brand B mechanical lift was observed in use on the second floor of the facility. On 2/21/24 at 2:15 p.m., The ADON said Central Supply Staff H was responsible for ensuring the correct sling was used for each resident. The ADON said Central Supply Staff H was currently on vacation and not available for a telephone interview. On 2/22/24 at 11:15 a.m., a joint interview was conducted with the Director of Rehabilitation, the Registered Nurse Senior Clinical Specialist, and the DON. The DON verified the facility used a Brand A full body mechanical lift on the third floor to transfer Residents #1, #2, #3, and #4, and a Brand B full body mechanical lift to transfer Resident #5 who resides on the second floor. On 2/22/24 at 12:30 p.m., a brand D medium size sling was observed in Resident #1's room on the third floor. In an interview, Resident #1's daughter said since the fall from the mechanical lift on 2/1/24 the facility has been using the Brand D medium size sling for transfers. Photographic evidence obtained. On 2/22/24 at 1:10 p.m., Resident #5 was observed in bed in her room on the third floor. A Brand C, size large mesh sling was observed over the resident's wheelchair. In an interview Resident #5 said she had a smaller sling that did not fit between her legs. She said, They brought me this sling and it is too big. Resident #5 said, They don't know what they are doing, I was never measured for a sling. They were going by weight alone. On 2/22/24 at approximately 3:05 p.m., upon request the DON provided a list of Central Supply Staff H trainings. The training included one hour online in-service titled Transferring, Repositioning, and Lifting Residents safely. The training was dated 5/1/2016. The DON did not provide the content of the in-service or a competency evaluation showing Central Supply Staff H was trained, competent and had the skills set to evaluate residents for the correct brand and size of sling according to each manufacturer's specification. The DON could not provide documentation Residents #1(Date of admission [DATE]), #2 (Date of admission 5/23/23), #3 (Date of admission 5/17/23) , #4 (Date of admission 8/29/22), and #5 (Date of admission [DATE]) were assessed for the correct brand and size of slings before or after Resident #1's fall from the mechanical lift on 2/1/24. On 2/23/24 at 11:00 a.m., in an interview the Medical Director said he attends all QAPI (Quality Assurance and Performance Improvement) meetings when available. He said he was told about the incident that occurred with the Mechanical lift roughly about the time it occurred but has not been updated as to what is being done since the incident. The Medical Director said he was not involved in determining the size of slings, the nurses were responsible to make sure the correct size of sling is used. On 2/25/24 at 3:45 p.m., the immediate actions implemented by the facility and verified by the surveyor included: On 2/2224 Brand F Lift and Brand F compatible slings were obtained from a sister community. The Maintenance Director inspected the Brand F lift. The Director of Nursing and Registered Nurse Manager examined slings per manufacture guidelines. On 2/25/24 the surveyor verified through observation of the Brand F mechanical lift and compatible Brand F slings, and interview with the Director of Nursing. On 2/22/24 Brand A mechanical lift was removed from service. On 2/25/24 the surveyor verified through observation of Brand A mechanical lift was removed from service. On 2/22/24 Resident #1 was sized with appropriate size of sling in accordance with manufacturer's instructions by Director of Nursing, RN Manager in the presence of the Occupational Therapist. On 2/25/24 the surveyor verified through observation of Resident #1's sling for proper size and brand. On 2/22/24 it was determined by the Director of Nursing, RN Manager and Occupational Therapist that the Brand F Large sling fit the resident the best utilizing the measurements and observation of the residents' positioning in the sling. On 2/25/24 the surveyor verified through observation of Resident #1's sling for adequate size and brand of sling. On 2/22/24 All current residents utilizing mechanical lifts were evaluated by the Director of Nursing and RN for appropriate Brand F sling to utilize with Brand F lift and Brand B sling and compatible slings to utilize with Brand B lift in accordance with manufacture guidelines by measurements, weight, and observation. Appropriate Slings were labeled with resident name and placed in resident rooms. On 2/25/24 the surveyor verified through observation of the slings for Residents #1, #2, #3, #4 and #5. On 2/22/24 nursing staff were educated on the safety and proper use of mechanical lifts and slings in accordance with the facility policy Safe Lifting Movement of Resident and Brand F Lift and Sling manufacture guidelines and Brand B manufacturer guidelines by Director of Nursing, ADON, RN Nurse Manager and FNP (Family Nurse Practitioner). Nursing Staff were notified by the Director of Nursing and ADON that they were not to utilize the mechanical lift until they have completed the Mechanical Lift Competencies with 100% compliance to competency. On 2/25/24 the surveyor verified through review of the in-service education, competencies, and interview with four licensed Nurses and eight CNAs. All staff interviewed were able to verbalize the content of the in-service. On 2/22/24 Ad-hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) meeting held with Executive Director, Interim Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, RN Manager, AL/MC (Assisted Living/Memory Care) Director, Maintenance Director, Director of Human Resources and Facility Administrative Assistant. An audit and direct care observation plan was developed and approved by the committee. On 2/25/24 the surveyor verified through review of the QAPI meeting and audit care observation plan implemented. On 2/22/24 Audits/Observation for all residents who utilize Brand F and Brand B Lift were by completed by the Director of Nursing, ADON, RN Manager to ensure the proper sling is utilized for the compatible lift and that the staff competency was completed per manufacture guidelines. Audits have a goal of 100% compliance. Audits continue weekly for 3 months then monthly for 9 months. On 2/25/24 the surveyor verified through review of the audit tool and interview with the DON and Executive Director. On 2/23/24 the Executive Director, Interim Nursing Home Administrator, Director of Nursing and Assistant Director of Nursing were educated regarding Abuse, Neglect, and Resident Rights by Corporate Senior Clinical Specialist. On 2/25/24 the surveyor verified through review of the education and interview with the DON. On 2/23/24 the Director of Nursing and ADON educated Licensed Nurses and Certified Nursing Assistants on the Abuse, Neglect, and Resident Rights policies. On 2/23/24 a Root cause analysis completed by the Director of Nursing and reviewed by the Interim Administrator regarding Resident #1 incident. On 2/25/24 the surveyor verified through review of the education and root cause. Four Licensed Nurses and eight CNAs were interviewed. All staff interviewed were able to verbalize the content of the in-service received. On 2/22/24 a Clinical Equipment Repair company was contacted by Facility administrative Assistant to schedule monthly inspections of community Mechanical Lifts. On 2/25/24 the surveyor reviewed the documentation provided to schedule monthly inspections of mechanical lifts. On 2/23/24 the Director of Nursing and Assistant Director of Nursing provided education to staff regarding Abuse, Neglect and Resident Rights. Director of Nursing and ADON notified staff to contact nursing administration prior to providing direct care of resident to receive Abuse, Neglect and Resident Rights education. On 2/25/24 the surveyor verified through review of education provided. On 2/23/24 the Director of Nursing verified model numbers of lifts and slings and obtained manufacture guidelines for equipment. Nursing staff were educated on location of Brand F Lift/slings manufacture guidelines located exclusively on the third floor and location of the Brand A Lift/slings manufacturer guidelines located exclusively on the second floor for staff to reference. Nursing Staff were notified by the Director of Nursing and ADON that they were not to utilize the mechanical lift until they have completed the Mechanical Lift Competencies which includes the location of the manufacture guidelines with 100% compliance to competency. On 2/25/24 the surveyor verified through review of the education provided, and interview with four licensed Nurses and eight CNAs. All staff interviewed were able to verbalize the content of the in-service. On 2/24/24 the Maintenance Technician inspected Brand F lift. On 2/25/24 the surveyor verified through review of documentation of Mechanical Lift brand F inspection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policies and procedures, staff, resident, and resident representative interviews, the facility failed to implement processes to prevent accidents by failing to ensure staff followed manufacturer's safety recommendations for transfer with mechanical lifts. On 2/1/24 Staff used a full body mechanical lift to transfer Resident #1. Staff did not follow manufacturer's safety recommendations for the size and brand of sling used. Resident #1 fell from the lift, struck her head on the bed and on the floor. Resident #1 sustained a laceration to the right temporal area requiring an emergent transfer to an acute care hospital. The facility failure to ensure staff follow manufacturer's safety recommendations for brand and size of slings and safe transfer technique when using mechanical lifts created an unsafe environment of avoidable accidents or falls of residents who use mechanical lifts with a likelihood to result in serious injury (i.e. fracture, head injury), impairment or death and resulted in the determination of Immediate Jeopardy. On 2/23/24 at 5:35 p.m., the Executive Director was notified of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. The Immediate Jeopardy began on 2/1/24. On 2/25/24 at 3:45 p.m., after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/25/24. The scope and severity were reduced to no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference to F600, F726, and F835. Review of the clinical record for Resident #1 revealed an admission date of 10/1/21. Diagnoses included Alzheimer's disease, stiffness of the right hip, left hip, right knee, and left knee. The Quarterly Minimum Data Set (MDS) assessment with a target date of 1/5/24 noted the resident's cognition was severely impaired. Resident #1 was dependent on staff for chair to bed transfer (Helper does all of the effort. Resident does none of the effort to complete the activity). The care plan initiated on 1/23/23 noted the resident was at risk for falls related to Dementia/Alzheimer's, gait, and balance problems. The goal was for the resident not to sustain serious injury through the review date. Interventions as of 1/23/23 included to educate the family and care givers about safety reminders and what to do if a fall occurs, be sure the call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt responses to all requests for assistance. The care plan dated 1/23/23 did not include the use of a mechanical lift for transfer. Review of the progress notes revealed on 2/1/24 at 11:40 a.m., Licensed Practical Nurse (LPN) Staff A documented, CNA Staff C informed her Resident #1 fell out of the sling while she was in a mechanical lift (a device used to assist with transfers and movement of individuals who required support for mobility beyond the manual support provide by caregivers alone). When she went in the room the resident was still in the sling and, her head was bleeding from the top right side. LPN Staff A documented CNA Staff C and CNA Staff B reported the sling did not come unattached from the lift. LPN Staff A wrote Resident #1's arms and legs were permanently contracted (fixed deformity of joints). The resident had a laceration to the right side of the head with moderate amount of bleeding from the laceration. Resident #1 was transferred to the hospital via EMS (Emergency Medical Services). Review of the facility's accidents and incidents investigations showed on 2/1/24 at 11:15 a.m., Certified Nursing Assistant (CNA) Staff B and CNA Staff C were transferring Resident #1 from bed to wheelchair with a mechanical lift. Midway through the transfer Resident #1 slid out of the sling. One of the CNAs tried to grab Resident #1 as she saw her sliding out. The resident potentially hit her head on the side of the bed and potentially on the carpeted floor. The resident sustained a laceration to the top area on the right side of her head. Resident #1 remained conscious during emergency treatment and evaluation. The facility's investigation summary noted Resident #1 slid to the right side between the top and bottom sling rope toward the floor. The resident landed on the right side between the mechanical lift legs with the resident's left leg still in the sling which was attached to the lift. The mechanical lift and the sling used to transfer Resident #1 were inspected with no abnormalities found. As part of their investigation, the facility obtained statements from CNA Staff B, and CNA Staff C who transferred the resident with the mechanical lift, and Licensed Practical Nurse (LPN) Staff A who evaluated Resident #1 after the fall. On 2/1/24 CNA Staff B wrote in a statement Resident #1, slid off and came out from the sling on one side. My coworker (CNA Staff C) catch her but resident hit the floor. We called the nurse. On 2/1/24 CNA Staff C wrote in a statement, While transferring the resident from the bed to the wheelchair she slide [sic] out of the sling and her head hit the carpet floor. I tried to catch her but the action was so quick I couldn't. On 2/1/24 LPN Staff A wrote in a statement, The resident fell out of the [brand name] sling while being transferred to her wheelchair. The facility's conclusion noted, After a thorough investigation and review of the lifting machine policy & [and] procedure the facility could not substantiate neglect. As a precautionary measure each lift will be checked by an outside licensed contractor. Each staff member in the nursing department will get additional training on mechanical lift transfer. The facility's investigation did not include a review of the operating manual for each brand of mechanical lifts to staff followed the manufacturer's safety precautions when using the lift. On 2/2/24 the facility updated Resident #1's care plan to include the use of a mechanical lift for transfers. The facility policy Safe Lifting and Movement of Residents revised in 2017, read, In order to protect the safety and wellbeing of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents . Staff responsible for direct resident care will be trained in the use of . mechanical lifts . Only staff with documented training in the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policy and procedures regarding use of equipment and the safe techniques . The policy Lifting Machine, Using a mechanical revised 2017, read, Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using specific machines or devices utilized in the facility. On 2/21/24 at 2:15 p.m., the mechanical lift and sling used to transfer Resident #1 on 2/1/24 were observed with the Assistant Director of Nursing (ADON). The mechanical lift was a Brand A full body mechanical lift and the sling was a Brand C size small four-point sling. The ADON verified on 2/1/24 a Brand A full body mechanical lift was used with a Brand C sling to transfer Resident #1. Review of the operating manual for mechanical lift Brand A provided by the facility noted, ONLY (Brand A) slings must be used on (Brand A) mechanical lifts. The use of non-company (Brand A) slings could be unsafe and may result in injury to the patient or caregiver. Review of the Brand C manufacturer operating manual revealed under warning, [Brand C] slings may be used with [Brand C] lift only. Using other manufacturer's patients lifts with [Brand A] slings is also prohibited. The ADON said after a full investigation, the facility determined the wrong size of sling was used to transfer the resident which caused her to fall from the sling. The ADON said the CNAs undergo an annual competency which includes the use of mechanical lifts. Review of CNA Staff B's employee file revealed a Certified Nursing Assistant Training Program Skilled Checklist dated 1/26/24. The checklist included, Mechanical Lift in the skills satisfactorily demonstrated. Review of CNA Staff C's employee file revealed on 1/10/24 she satisfactorily demonstrated the use of a Mechanical lift. The skills checklist did not include a step by step demonstration of safe transfer with the mechanical lifts, including the right size and brand of slings in accordance with each mechanical lift's operating manual. Licensed Practical Nurse (LPN) Staff A signed the forms verifying the CNAs successfully demonstrated the skills for Mechanical lifts. On 2/22/24 at 3:00 p.m., in an interview LPN Staff A verified she signed the skills checklist for CNAs Staff B and Staff C. When asked about the process to verify competency, LPN Staff A said she demonstrates the transfer with a mechanical lift for the CNA, then she has the CNA complete the task. When asked to describe the step by step process, LPN Staff A said she would only open the legs of the base when lowering the resident on the wheelchair. She said she would not open the base of the lift when it was placed under the bed. LPN Staff A was not able to describe how to select the correct brand or size of sling for each resident. She said she would use the weight of the resident. Review of Brand A mechanical lift operating manual instructions showed, ALWAYS, (except when lifting a patient from the floor) while lifting or lowering a patient, maintain the base unit legs spread to the widest position and ensure that the casters are unlocked. Review of LPN Staff A's training record showed an Annual Nurse Competency form dated 12/20/23. The competency form did not include the use of mechanical lifts. On 2/23/24 at 8:15 a.m., in an interview the Director of Nursing (DON) said she was not able to find documentation LPN Staff A was trained on the safe use of mechanical lifts and was competent to teach and administer a competency evaluation on safe use of mechanical lifts. 2. On 2/21/24 at 1:30 p.m., CNAs Staff E and Staff C were observed transferring Resident #2 with a Brand A full body mechanical lift. The Director of Nursing (DON) and Unit Manager Staff D were present during the observation. The sling used to transfer the resident did not have a label, making it impossible to determine the brand or the size of the sling. A label affixed to the mechanical lift warned to read the user manual before operating the lift. Photographic evidence obtained. Staff E was observed operating the lift. She closed the legs of the base and placed them under the bed. CNA Staff E did not open the legs of the base lift after placing them under the bed. CNAs Staff E and Staff C placed the resident in the sling. CNA Staff E pulled out the lift from under the bed. She did not open the legs of the base and wheeled the resident approximately three feet to the wheelchair. CNA Staff C tilted the wheelchair on its back wheels as CNA Staff E lowered the resident with the mechanical lift. While observing the CNAs transferring Resident #2 with the mechanical lift, Unit Manager Staff D said the sling used to transfer Resident #2 was not labeled making it impossible to tell the brand of the sling or the size of the sling. Unit Manager Staff D and the DON did not intervene to ensure the resident's safety from avoidable fall and accident from using the wrong sling and not following the mechanical lifts safety instructions for use. On 2/21/24 at 2:30 p.m., in an interview CNA Staff E verified she did not open the legs of the base as per the manufacturer's safety instructions. She said on 2/1/24 after Resident #1 fell from the lift, she was given a paper to read regarding mechanical lifts. Review of the in-services showed on 2/1/24 CNA Staff E and CNA Staff C attended the in-service for Mechanical lift use. On 2/21/24 at 2:15 p.m., the ADON said she used the facility's policy titled, Lifting Machine, Using a Mechanical. for the in-service on 2/1/24. The facility's policy and procedure Lifting Machine, Using a Mechanical. noted the purpose of the procedure was to establish the general principles of safe lifting using a mechanical lifting device, and was not a substitute for manufacturer's training or instructions. The in-service did not include the operating instructions, and safety warnings for manufacturer Brand A or B. There was no documentation that the in-service was followed by a competency evaluation. 3. On 2/21/24 at approximately 11:00 a.m., during a tour of the facility a Brand A mechanical lift was observed in use on the third floor of the facility and a Brand B mechanical lift was observed in use on the second floor of the facility. On 2/21/24 at approximately 1:35 p.m., Unit Manager Staff D said Central Supply Staff H places the slings in the residents' rooms. On 2/21/24 at 2:15 p.m., The ADON said Central Supply Staff H was responsible for ensuring the correct sling was used for each resident. The ADON said Central Supply Staff H was currently on vacation and not available for a telephone interview. On 2/22/24 at 11:15 a.m., a joint interview was conducted with the Director of Rehab, the Registered Nurse Senior Clinical Specialist, and the DON. The DON verified the facility used a Brand A full body mechanical lift on the third floor to transfer Residents # 1, #2, #3, and #4 who reside on the third floor. She said a Brand B full body mechanical lift is used on the second floor to transfer Resident #5 who resides on the second floor. On 2/22/24 at 12:30 p.m., a brand D medium size sling was observed in Resident #1's room. In an interview, Resident #1's daughter said since the fall from the mechanical lift on 2/1/24 the facility has been using the Brand D medium size sling for transfers. Photographic evidence obtained. On 2/22/24 at 1:10 p.m., Resident #5 was observed in bed. A Brand C, size large mesh sling was observed over the resident's wheelchair. In an interview Resident #5 said she had a smaller sling that did not fit between her legs. She said, They brought me this sling and it is too big. Resident #5 said, They don't know what they are doing, I was never measured for a sling. They were going by weight alone. On 2/22/24 at approximately 3:05 p.m., the DON provided a list of Central Supply Staff H trainings. The training included one hour online in-service titled Transferring, Repositioning, and Lifting Residents safely. The training was dated 5/1/2016. The DON did not provide the content of the in-service or a competency evaluation showing Central Supply Staff H was competent to assess and ensure each resident had the correct brand and size of sling according to each manufacturer's specification. The DON could not provide documentation Residents #1(Date of admission [DATE]), #2 (Date of admission 5/23/23), #3 (Date of admission 5/17/23), #4 (Date of admission 8/29/22), and #5 (Date of admission [DATE]) were assessed for the correct brand and size of slings before or after Resident #1's fall from the mechanical lift on 2/1/24. On 2/25/24 at 3:45 p.m., the immediate actions implemented by the facility and verified by the surveyor included: On 2/22/24 Brand A mechanical lift was removed from service. On 2/25/24 this was verified by interviews with staff and observations of the lifts on the second and third floors. On 2/22/24 The facility system for the Brand F and Brand B mechanical Lift maintenance was Repair company by the Facility Administrative Assistant. On 2/25/24 the surveyor verified this with an interview with the DON and documentation of the repair company bill. On 2/22/24 Brand F Lift and Brand F compatible slings were obtained from a sister community. The Maintenance Director inspected the Brand F lift. Director of Nursing and RN Manager examined slings per manufacture guidelines. On 2/25/24 the surveyor verified through observation of the Brand F mechanical lift and compatible Brand F slings, and interview with the Director of Nursing. On 2/22/24 Resident #1 currently resides in the facility. Director of Nursing and RN Manager performed resident measurements for the Brand F lift sling to determine proper sizing per the Brand F manufacturer guidelines. This was observed by the Occupational Therapist. It was determined that the Brand F Large sling fit resident #1 the best utilizing the measurements and observation of the residents' positioning in the sling. On 2/25/24 it was verified by the surveyor that Resident #1 is now using a large size sling from Company F and is using Company F's mechanical lift on the third floor though observation, interview and record review. On 2/22/24 the nursing staff were educated by the Director of Nursing, ADON, RN Manager and FNP (Family Nurse Practitioner) on the safety and proper use of mechanical lifts and slings in accordance with the facility policy Safe Lifting Movement of Resident and Brand F Lift and Sling manufacture guidelines. Utilizing the Competency Assessment Lifting Machine, using a Mechanical Brand F Lift the DON, ADON, RN Manager and FNP educated nursing staff with return demonstration on use of the mechanical lift and slings according to manufacturer guidelines. Nursing Staff were notified by the Director of Nursing and ADON that they were not to utilize the mechanical lift until they have completed the Mechanical Lift Competencies with 100% compliance to competency. On 2/25/24 the surveyor verified through review of the education and root cause. Four Licensed Nurses and eight CNAs were interviewed. All staff interviewed were able to verbalize the content of the in-service received. On 2/22/24 The Director of Nursing, ADON, RN Manager and FNP conducted a 100% audit of remaining residents who utilize the Brand F mechanical lift. These residents were evaluated and measured for appropriate size of Brand F Slings per manufacturer guidelines. Once measurement and sizing was determined the slings were labeled and placed in the resident rooms for use. On 2/25/24 the surveyor verified by observation of the mechanical lift manuals and folders at the nursing stations on the first and second floor. On 2/22/24, the Director of Nursing, ADON, RN Manager and FNP conducted a 100% audit of remaining residents who utilize Brand B mechanical lift. These residents were evaluated and measured per Brand A sling guidelines for accurate sizing and slings were labeled and placed in the residents' rooms. On 2/25/24 the surveyor verified by observation of the mechanical lift manuals and folders at the nursing stations on the first and second floor. Audits were reviewed and staff were interviewed. On 2/22/24, the nursing staff were educated by the Director of Nursing, ADON, RN Nurse Manager and FNP on the safety and proper use of mechanical lifts and slings in accordance with the facility policy Safe Lifting Movement of Resident and Brand F Lift and Brand B lift and sling manufacturer guidelines. Nursing Staff were notified by the Director of Nursing and ADON that they were not to utilize the mechanical lift until they have completed the Mechanical Lift Competencies with 100% compliance to competency. On 2/25/24 the surveyor verified through review of education documentation and interviews with all direct care staff on duty. On 2/22/24 the DON, ADON, RN Manager and FNP provided education to nursing staff Utilizing the Competency Assessment Lifting Machine, using a Mechanical Brand F Lift and the Brand B Mechanical Lift Competency with return demonstration on use of the mechanical lift and slings according to manufacturer recommendations 100% compliance to the competency. Nursing Staff were notified by the Director of Nursing and ADON that they were not to utilize the mechanical lifts until they have completed the Mechanical Lifts Competencies with 100% compliance to competency. On 2/25/24 two CNAs from the second floor and two CNAs from the third floor were observed by the surveyor demonstrating the appropriate use of the full body lift using Brand B and Brand F mechanical lifts. On 2/23/24 The Brand F Lift is used exclusively on the third floor. The manufacturer guidelines were placed at the third floor nurses station. The Brand B lift is used exclusively on the second floor. The manufacturer guidelines were placed at the second floor nurses station. On 2/25/24 the surveyor verified by observations of the lifts being used on the second and third floors. On 2/23/24 A Root Cause analysis was completed by the Director of Nursing on the accident related to the mechanical lift due to the failure to ensure that Lifts and Slings manufacturer guidelines were followed. On 2/25/24 the surveyor verified by review of documentation of the root cause and interview with the Director of Nursing. On 2/23/24 Mechanical Lift and Sling Competencies have been added to the general orientation packet for all nursing staff and are being completed upon hire prior to resident care and completed quarterly and observed periodically thereafter per policy. On 2/25/24 the surveyor verified by record review and interview with the Director of Nursing. On 2/22/24 The facility policy Safe Lifting Movement of Residents was reviewed by the Director of Nursing and found to meet professional standards. On 2/25/24 the surveyor verified through review of the policy. On 2/22/24 Ad-hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) meeting held with Executive Director, Interim Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, RN Manager, AL/MC (Assisted Living/Memory Care) Director, Maintenance Director, Director of Human Resources and Facility Administrative Assistant. An audit plan was developed and approved by committee and audit processes were initiated and will continue. On 2/25/24 the surveyor verified through review of the Ad-hoc QAPI meeting and interviews with the Director of Nursing. On 2/22/24 Audits/Observation for all residents who utilize the Brand F and Brand B Lift was initiated by the Director of Nursing, ADON, RN Manager to ensure the proper sling is utilized for the compatible lift and that the resident was transferred by staff per manufacture guidelines. Audits have a goal of 100% compliance. Audits will be completed weekly for three months then monthly for nine months. On 2/25/24 the surveyor verified by observations of staff demonstrating the use of mechanical lifts according to manufacturer's operating manual, and observation of the manuals located at the nurse's station on the second and third floor. On 2/23/24 the Director of Nursing informed the Medical Director of the IJ and the removal plan. On 2/25/24 the surveyor verified through review of the communication with the Medical Director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, facility's policies and procedures review, the facility failed to ensure the nursing staff had the appropriate competencies and skills set to ensure residents' safety during transfers with mechanical lifts. Resident #1 was dependent on staff and used a mechanical lift for transfer. On 2/1/24 Resident #1 fell from the lift during transfer, struck her head on the bed and the floor. Resident #1 sustained a laceration to the right temporal area requiring an emergent transfer to an acute care hospital for evaluation and treatment. The failure to ensure staff had the appropriate training, competencies, and skills sets to safely use the mechanical lift created an unsafe environment of avoidable accidents or falls with a likelihood to result in serious injury (i.e. fracture, head injury), impairment or death of residents who use mechanical lifts for transfers and resulted in the determination of Immediate Jeopardy. On 2/23/24 at 5:35 p.m., the Executive Director was notified of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. The Immediate Jeopardy began on 2/1/24. On 2/25/24 at 3:45 p.m., after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/25/24. The scope and severity were reduced to no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference to F600, F689, and F835. Review of the facility's accidents and incidents investigations showed on 2/1/24 at 11:15 a.m., Certified Nursing Assistant (CNA) Staff B and CNA Staff C were transferring Resident #1 from bed to wheelchair with a mechanical lift. Midway through the transfer Resident #1 slid out of the sling. One of the CNAs tried to grab Resident #1 as she saw her sliding out. The resident potentially hit her head on the side of the bed and potentially on the carpeted floor. The resident sustained a laceration to the top area on the right side of her head. Resident #1 remained conscious during emergency treatment and evaluation. Resident #1 was transferred to the hospital via EMS (Emergency Medical Services). The facility's investigation summary noted Resident #1 slid to the right side between the top and bottom sling rope toward the floor. The resident landed on the right side between the mechanical lift legs with the resident's left leg still in the sling which was attached to the lift. The mechanical lift and the sling used to transfer Resident #1 were inspected with no abnormalities found. The facility's investigation conclusion noted, After a thorough investigation and review of the lifting machine policy & [and] procedure the facility could not substantiate neglect. As a precautionary measure each lift will be checked by an outside licensed contractor. Each staff member in the nursing department will get additional training on mechanical lift transfer. The investigation did not include verification staff used safe transfer techniques, or the right brand and size of sling to transfer Resident #1 with the mechanical lift. As part of their investigation, the facility obtained statements from CNA Staff B, and CNA Staff C, and Licensed Practical Nurse (LPN) Staff A who evaluated Resident #1 after the fall. On 2/1/24 CNA Staff B wrote in a statement Resident #1, slid off and came out from the sling on one side. My coworker (CNA Staff C) catch her but resident hit the floor. We called the nurse. On 2/1/24 CNA Staff C wrote in a statement, While transferring the resident from the bed to the wheelchair she slide [sic] out of the sling and her head hit the carpet floor. I tried to catch her but the action was so quick I couldn't. On 2/1/24 LPN Staff A wrote in a statement, The resident fell out of the [brand name] sling while being transferred to her wheelchair. On 2/21/23 at 10:00 a.m., CNA Staff C was interviewed with the assistance of Unit Manager Staff D translating in CNA Staff C's native language. CNA Staff C said on 2/1/24 she was on the opposite side of the bed when Resident #1 fell from the lift before she could get to the other side of the bed after the resident was lifted. She said CNA, Staff B had already moved the lift away from the bed and had started turning the resident. She stated the resident slid from the top of the sling and hit her head on the bed and the floor. CNA Staff C did not say the brand or size of sling used to transfer Resident #1. On 2/21/24 at 10:15 a.m., CNA Staff B was interviewed with the assistance of Minimum Data Set Staff I in CNA Staff B's native language. CNA Staff B said Staff C was coming around the bed and tried to catch the resident as she fell but the incident occurred to quickly. Staff B said Staff C threw her hands in the air and said she did not do it; she never touched the resident and it was not her fault. CNA Staff B did not say the brand or size of sling used to transfer Resident #1. On 2/21/24 at approximately 11:00 a.m., during a tour of the facility a Brand A mechanical lift was observed in use on the third floor of the facility and a Brand B mechanical lift was observed in use on the second floor of the facility. On 2/21/24 at 2:15 p.m., the mechanical lift and sling used to transfer Resident #1 on 2/1/24 were observed with the Assistant Director of Nursing (ADON). The mechanical lift was a Brand A full body mechanical lift and the sling was a Brand C size small four-point sling. The ADON verified on 2/1/24 a Brand A full body mechanical lift was used with a Brand C sling to transfer Resident #1. The ADON said the CNAs undergo an annual competency which includes the use of mechanical lifts. The ADON said after a full investigation, the facility determined the wrong size of sling had been used to transfer Resident #1 which caused her to fall from the sling, and on 2/1/24 the facility reeducated the nursing staff on the use of mechanical lifts, using the facility's policy titled, Lifting Machine, Using a Mechanical. The in-service did not include the manufacturer's safety specifications for Brand A mechanical lift even though the policy and procedure for Lifting Machine, Using a Mechanical specified the purpose of the procedure was to establish the general principles of safe lifting using a mechanical lifting device, and was not a substitute for manufacturer's training or instructions. The facility provided the manufacturer's operating manual for Brand A mechanical lift. The operating manual noted, ONLY (Brand A) slings must be used on (Brand A) mechanical lifts. The use of non-company (Brand A) slings could be unsafe and may result in injury to the patient or caregiver. The facility provided the manufacturer's manual for the Brand C sling used to transfer Resident #1 with the Brand A mechanical lift. The operating manual noted under warning, [Brand C] slings may be used with [Brand C] lift only. Using other manufacturer's patients lifts with [Brand C] slings is also prohibited. Review of the Operating Manual for Brand B mechanical lift noted, Warning! Using other manufacturers patient lifts with (Brand B) slings is prohibited. Review of CNA Staff B's employee file revealed a Certified Nursing Assistant Training Program Skilled Checklist dated 1/26/24. The checklist included, Mechanical Lift in the skills satisfactorily demonstrated. Review of CNA Staff C's employee file revealed on 1/10/24 she satisfactorily demonstrated the use of a Mechanical lift. The skills checklist did not include a step-by-step demonstration of safe transfer with the mechanical lifts, including the right size and brand of slings in accordance with each mechanical lift's operating manual. LPN Staff A signed the forms verifying the CNAs successfully demonstrated the skills for Mechanical lifts. On 2/22/24 at 3:00 p.m., in an interview LPN Staff A verified she signed the skills checklist for CNAs Staff B and Staff C. When asked about the process to verify competency, LPN Staff A said she demonstrates the transfer with a mechanical lift for the CNAs, then she has the CNA complete the task. When asked to describe the step-by- step process, LPN Staff A said she would only open the legs of the base when lowering the resident on the wheelchair. She said she would not open the base of the lift when it was placed under the bed. LPN Staff A was not able to describe how to select the correct brand or size of sling for each resident. She said she would use the weight of the resident. Review of Brand A mechanical lift operating manual instructions showed, ALWAYS, (except when lifting a patient from the floor) while lifting or lowering a patient, maintain the base unit legs spread to the widest position and ensure that the casters are unlocked. 2. On 2/21/24 at 1:30 p.m., CNAs Staff E and Staff C were observed transferring Resident #2 with a Brand A full body mechanical lift. The Director of Nursing (DON) and Unit Manager Staff D were present during the observation. The sling used to transfer the resident did not have a label, making it impossible to determine the brand or the size of the sling. A label affixed to the mechanical lift specified, Operating Instructions . Read User manual before operating. Staff E was observed operating the lift. She closed the legs of the base and placed them under the bed. CNA Staff E did not open the legs of the base lift after placing them under the bed. CNAs Staff E and Staff C placed the resident in the sling. CNA Staff E pulled out the lift from under the bed. She did not open the legs of the base and wheeled the resident approximately three feet to the wheelchair. CNA Staff C tilted the wheelchair on its back wheels as CNA Staff E lowered the resident with the mechanical lift. While observing the CNAs transferring Resident #2 with the mechanical lift, Unit Manager Staff D said the sling used to transfer Resident #2 was not labeled making it impossible to tell the brand of the sling or the size of the sling. Unit Manager Staff D did not intervene to ensure the CNAs used the right brand and size of sling or followed the manufacturer's safety instructions during the transfer. The DON did not intervene to ensure staff followed safe transfer technique according to the manufacturer's safety instructions. On 2/21/24 at 2:30 p.m., in an interview CNA Staff E verified she did not open the legs of the base as per the manufacturer's safety instructions. She said on 2/1/24 after Resident #1 fell from the lift, she was given a paper to read regarding mechanical lifts. Review of the in-service for Mechanical lift use showed CNA Staff E and CNA Staff C attended the in-service on 2/1/24. The facility's policy and procedure Lifting Machine, Using a Mechanical used for the in-service did not include the manufacturer's safety specifications for Brand A mechanical lift or Brand B mechanical lift and was not followed by a competency evaluation. 3. On 2/21/24 at approximately 11:00 a.m., during a tour of the facility a Brand A mechanical lift was observed in use on the third floor of the facility and a Brand B mechanical lift was observed in use on the second floor of the facility. On 2/21/24 at approximately 1:35 p.m., Unit Manager Staff D said Central Supply Staff H places the slings in the residents' rooms. On 2/21/24 at 2:15 p.m., The ADON said Central Supply Staff H was responsible for ensuring the correct sling was used for each resident. The ADON said Central Supply Staff H was currently on vacation and not available for a telephone interview. On 2/22/24 at 11:15 a.m., a joint interview was conducted with the Director of Rehabilitation, the Registered Nurse Senior Clinical Specialist, and the DON. The DON verified the facility used a Brand A full body mechanical lift on the third floor to transfer Residents # 1, #2, #3, and #4. She said a Brand B full body mechanical lift is used on the second floor to transfer Resident #5. On 2/22/24 at 12:30 p.m., a brand D medium size sling was observed in Resident #1's room (Third floor). In an interview, Resident #1's daughter said since the fall from the mechanical lift on 2/1/24 the facility has been using the Brand D medium size sling for transfers. Photographic evidence obtained. On 2/22/24 at 1:10 p.m., Resident #5 was observed in bed in her room on the third floor. A Brand C, size large mesh sling was observed over the resident's wheelchair. In an interview Resident #5 said she had a smaller sling that did not fit between her legs. She said, They brought me this sling and it is too big. Resident #5 said, They don't know what they are doing, I was never measured for a sling. They were going by weight alone. On 2/22/24 at approximately 3:05 p.m., the DON provided a list of Central Supply Staff H trainings. The training included one hour online in-service titled Transferring, Repositioning, and Lifting Residents safely. The training was dated 5/1/2016. The DON did not provide the content of the in-service or a competency evaluation showing Central Supply Staff H was trained, competent and had the skills set to evaluate each resident and determine the correct brand and size of sling according to each manufacturer's specification. The DON could not provide documentation Residents #1(Date of admission [DATE]), #2 (Date of admission 5/23/23), #3 (Date of admission 5/17/23), #4 (Date of admission 8/29/22), and #5 (Date of admission [DATE]) were assessed for the correct brand and size of slings before or after Resident #1's fall from the mechanical lift on 2/1/24. On 2/25/24 at 3:45 p.m., the immediate actions implemented by the facility and verified by the surveyor included: On 2/22/24 Brand F Lift and compatible slings were obtained from a sister community; Maintenance Director inspected The Brand F lift. Director of Nursing and RN Manager examined slings per manufacture guidelines. On 2/25/24 the surveyor observed Brand B lift was used by facility staff on the second floor, and Brand F on the third floor. On 2/22/24 Brand A mechanical lift used to transfer Resident #1 was removed from service. On 2/25/24 the surveyor verified through observation. On 2/22/24 Resident #1 currently resides in the facility. The Director of Nursing and RN Manager in the presence of the Occupational Therapist performed resident measurements for the Brand F lift sling to determine proper sizing per the Brand F manufacturer guidelines to utilize with the Brand F Lift. On 2/25/24 the surveyor verified documentation of the evaluation for the right brand and size of sling for Resident #1 and observation of the sling in the resident's room. On 2/22/24, the Director of Nursing and Registered Nurse (RN) Management determined that Brand F large sling fit resident #1 the best utilizing the measurements and observation of the residents' positioning in the sling. On 2/25/24 the surveyor verified by observation of the sling in the resident's room. On 2/22/24 The Director of Nursing, ADON, RN Manager and FNP (Family Nurse Practitioner) conducted a 100% audit of remaining residents who utilize the Brand F mechanical lift. These residents were evaluated and measured for appropriate size of Brand F slings per manufacturer guidelines. Once measurement and sizing were determined the slings were labeled and placed in the resident rooms for use. On 2/25/24 the surveyor verified through review of the audits and evaluation of the residents for the right brand and size of sling. On 2/22/24, the Director of Nursing, ADON, RN Manager and FNP conducted a 100% audit of remaining residents who utilize Brand B mechanical lift. These residents were evaluated and measured for appropriate size of Brand B sling guidelines for accurate sizing and slings were labeled and placed in the residents' rooms. On 2/25/24 the surveyor verified through review of the audits and evaluation of the residents for the right brand and size of sling. On 2/22/24, for the Brand F lift and slings that are exclusively utilized on the third floor and in the accordance with the facility policy Safe Lifting Movement of Resident and Brand F lift and sling manufacturer guidelines, the Director of Nursing, ADON, RN Manager and FNP conducting training to the nursing staff utilizing the Competency Assessment Lifting Machine, using a Mechanical Brand F Lift which included a return demonstration on use of the mechanical lift and slings according to manufacturer recommendations. Nursing Staff were notified by the Director of Nursing and ADON that staff are required to complete the training and competencies before their next shift. On 2/25/24 the surveyor verified through review of education and observation of staff using mechanical lifts in accordance with manufacturer's safety instructions. On 2/22/24 For the Brand B lift and slings that are exclusively utilized on the second floor and in accordance with the facility policy Safe Lifting Movement of Residents the DON, ADON, RN Manager and FNP provided education to nursing staff Utilizing the Competency Assessment Lifting Machine for the Brand B Mechanical Lift Competency with return demonstration on use of the mechanical lift and slings according to manufacturer recommendations. Nursing Staff were notified by the Director of Nursing and ADON that staff are required to complete the training and competencies before their next shift. On 2/25/24 the surveyor verified through review of the competencies and observation of staff using mechanical lifts in accordance with manufacurer's safety instructions. On 2/22/24, the DON revised the mechanical lift competency training guide to include a more extensive step by step training which was reviewed and approved by the Administrator. On 2/25/24 the surveyor verified through review of the competency training guide, step by step training and interview with the DON. On 2/22/24, a Root Cause analysis was completed on the accident by the Director of Nursing related to the mechanical lift due to the failure to ensure that Lifts and Slings manufacturer guidelines were followed. On 2/25/24 the surveyor verified through review of the root cause analysis. On 2/22/24 Updated Mechanical Lift and Sling Competencies have been added to the general orientation packet for all nursing staff for completion upon hire prior to resident care, completed quarterly and observed periodically thereafter per policy. On 2/25/24 the surveyor verified thorugh review of general orientation packet. The facility policy Safe Lifting Movement of Residents was reviewed by the Director of Nursing. The policy includes competency training of nursing personnel. On 2/25/24 the surveyor verified through review of the facility's policy. On 2/22/24 Brand F Lift/Sling and Brand B Lift/Sling competency training tools were reviewed and updated by the Director of Nursing and ADON and approved by the Administrator. On 2/25/24 the surveyor verified through review of the competency training tools. On 2/22/24, an Ad-hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) meeting held with Executive Director, Interim Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, RN Manager, AL/MC (Assisted Living/Memory Care) Director, Maintenance Director, Director of Human Resources, and Facility Administrative Assistant on Mechanical Lift Competency Training. An audit and direct care observation plan was developed and approved by the committee. On 2/25/24 the surveyor verified through review of the Ad-Hoc QAPI meeting and review of the audit forms. On 2/23/24, the Director of Nursing informed the Medical Director of the removal plan. On 2/25/24 the surveyor verified through interview with the DON. On 2/23/24, an observation of all residents who require a mechanical lift for transfer assistance is ongoing and will be completed by the Director of Nursing, ADON and RN manager to ensure the proper sling is utilized with the compatible lift, that the transfer of resident using the mechanical lift meets the lift competency demonstrated by staff. Audits have a goal of 100% compliance. Audits are completed weekly for three months then monthly for nine months. On 2/25/24 the surveyor verified through review of the audits and competency evaluations completed.