**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, document review, and facility policy review, the facility failed to develop a comprehensive care plan for two of 57 sampled residents (R#12 and R#120). A review of the care plan for R#12 revealed a care plan was not developed to address the resident's needs related to transferring and the use of a mechanical lift to include the sling size that was needed. During observations of a transfer of R#12 utilizing a mechanical lift on 5/3/24, the resident voiced discomfort and concern that the resident was going to fall during the transfer using the lift. Further observations revealed the resident was not properly placed in the sling and the resident was not properly supported by the sling during the transfer. As a result, the resident was placed in a wheelchair and could not be properly positioned in the wheelchair and the resident slid from the wheelchair onto the floor sustaining no injuries. Also, the facility failed to include care plan objectives and interventions for indwelling urinary catheter care for R#120. On 5/4/23, determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 5/4/23 at 6:10 p.m. The noncompliance related to the IJ was identified to have existed on 5/3/23. An Acceptable Removal Plan was received on 5/6/23. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 5/6/23. Findings included: A review of the facility's policy titled, Comprehensive Care Plans, revised 9/12/22, indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy also revealed, The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. A review of R#12's admission Record revealed the resident's original admission date was 1/30/23 with a readmission on [DATE]. R#12's diagnoses included metabolic encephalopathy, peripheral vascular disease, acquired absence of the right lower leg below the knee, hemiplegia and hemiparesis following a cerebrovascular accident affecting the left dominant side, and vascular dementia with behavioral disturbance. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/2/23 revealed R#12 had a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had moderately impaired cognition. The MDS further indicated R#12 required the extensive assistance of one person for activities of daily living including dressing, eating, and personal hygiene. The MDS indicated for transferring, the activity only occurred once or twice, and no setup or physical help was required from staff. A review of the five-day MDS with an ARD of 2/23/23 revealed R#12 was totally dependent on physical assistance from two-persons for transfers. The MDS further indicated the resident used a wheelchair. The use of a mechanical lift was not checked as used for R#12. A review of R#12's Care Plan, last reviewed on 2/6/23, indicated the resident had an activity of daily living (ADL) self-care deficit related to dementia, generalized muscle weakness, cardiovascular accident with left sided weakness, and a right below the knee amputation. The care plan interventions, initiated on 2/6/23, directed staff to encourage the resident to participate to the fullest extent possible with each interaction, encourage the resident to use the call bell to call for assistance, and for physical therapy and occupational therapy to evaluate and treat the resident as ordered by the physician. The care plan did not include interventions that directed staff how to provide assistance to the resident for transfers or equipment that was needed for transfers. Observations on 5/3/23 from 10:13 a.m. to 10:27 a.m. revealed Certified Nursing Assistant (CNA) RR and CNA TT transferred R#12 from the bed to a wheelchair using a mechanical lift. The CNAs did not ensure the sling for the lift was appropriately placed to support the resident during the transfer and the resident's buttocks were unsupported during the transfer. Observations revealed the staff continued to transfer the resident despite the resident voicing concerns that they were falling and were having pain during the transfer while in the lift sling. After the resident was placed in the wheelchair, the resident could not be repositioned in the wheelchair because the sling was not positioned correctly and as a result the resident slid from the wheelchair onto the floor. The resident did not sustain any injuries as a result of the fall. During an interview with CNA UU on 5/4/23 at 11:13 a.m., she stated she had worked at the facility for two weeks. She stated she had been a CNA for 12 years, and her mechanical lift knowledge came from her experience. CNA UU stated the care plans should be at the nurse's station and available for CNAs to review. She stated the care plans told the nursing staff what to do regarding care requirements, behaviors, and diet orders. She stated a resident's transfer needs and requirements should be included in the care plan as well. She stated she was not sure of the size of sling R#12 needed for transfers using the mechanical lift, but would go ask the nurse before providing transfer assistance. During an interview with Licensed Practical Nurse (LPN) ZZZ on 5/4/23 at 10:23 a.m., she stated she had worked at the facility for two weeks. LPN ZZZ stated she would expect to see mechanical lift transfer needs on the care plan so nursing staff would know what to do for a resident. She stated she had access to the care plans, and it should include how many staff were required for a safe transfer, the type of lift needed for the transfer, fall interventions, diet orders, and any other risks to the resident. She stated she was working with R#12 that day and upon review of the care plan, could not find the resident's transfer needs to include if a mechanical lift was needed or the size sling the resident needed documented on the care plan. During an interview with the Director of Rehabilitation (DOR) on 5/4/23 at 10:43 a.m., she stated she had been the DOR for one year. She stated the mechanical lift transfer status of a resident was based on evaluation. She stated if the resident was totally dependent and maximum assistance for transfers was required, the therapy department recommended the mechanical lift transfers for resident safety. She stated the therapy department completed the mechanical lift evaluations and communicated their recommendations to the nursing staff. The DOR stated she did not update the resident care plans. She stated the care plans should include fall risk, behaviors, transfer needs, and other care needs. She stated any recommendations from the therapy department were discussed in the interdisciplinary team (IDT) meetings and forwarded to the nursing department. During an interview with MDS Coordinator EEE on 5/5/23 at 12:43 p.m., she stated she had been the MDS Coordinator for nine years at the facility. She stated she completed the comprehensive care plans and updated them during the resident's quarterly review. She stated the purpose of the resident's care plan was to help relay care needs to nursing staff. She stated the care plan should include fall risk and transfer assistance requirements under the ADL objectives. She stated mechanical lift transfer status and therapy recommendations were discussed in the IDT meetings. She stated if she was made aware of the resident's use of a mechanical lift for transfers, she would include it in the comprehensive care plan, but she did not include the specific transfer needs on the comprehensive care plan. MDS Coordinator EEE stated she did not know how to include bed mobility and transfer needs on the residents' care plans. She stated the resident's transfer information should be on the [NAME] Care Cards (a file used for overviews of residents' care in a facility) available to the CNAs at the nurse's station and that was where the CNAs should be referring for resident care needs. The MDS Coordinator stated Resident #12 had been discussed during IDT meetings related to behaviors and discharge planning but never about transfer requirements. During an interview with the Administrator on 5/5/23 at 4:33 p.m., he stated he had been the Administrator at the facility since 2/1/12. He stated the resident care plans should be updated by the department that monitored them. He stated nurses would update the nursing tasks, and activities would update the activity tasks. He stated the CNA [NAME] and the electronic health record (EHR) should communicate the transfer status of the residents to the nursing staff. He stated he did not believe the resident's mechanical lift transfer needs or required sling size needed to be included on the resident's care plans. The Administrator stated the purpose of a care plan was to inform the staff of resident care needs, and acknowledged, in hindsight, that mechanical lift transfer requirements and sling size were a care need and should be included in the care plan so nursing staff had access to the information. During an interview with the Director of Nursing (DON) on 5/6/23 at 1:02 p.m., she stated she had worked for the facility since 2017, taking over as DON in the spring of 2020. She stated she expected nursing staff to be aware of resident transfer needs, where mechanical lift and sling requirements were documented on the [NAME], and on the care plan. The DON stated the resident care plans were updated during IDT meetings and were initially compiled by MDS Coordinator EEE, noting all nurses could make updates to the care plan. She stated interventions should be added timely, especially for safety concerns. She stated the IDT met daily to review events and put things in place for the residents. 2. A review of an admission Record indicated the facility admitted Resident #120 on 02/24/2023 with diagnoses that included hydronephrosis with renal and ureteral calculous obstruction (excess urine accumulation in the kidneys as a result of an obstruction to urine flow). An admission MDS, with an ARD date of 2/27/23, revealed Resident #120 had a BIMS score of 15, which indicated the resident was cognitively intact. The resident required extensive assistance with their ADLs, including toilet use and personal hygiene. The MDS indicated the resident had an indwelling catheter. A review of a Nursing Comprehensive Assessment, dated 2/25/23, indicated R#120 had an indwelling urinary catheter. A review of an Order Summary Report for active orders as of 5/5/23 indicated R#120 had an order, dated 4/6/23, for staff to perform catheter care every day and evening shift and as needed. Additional orders were added on 5/3/23 to specify the size of the catheter and indicate bedside straight drainage for a diagnosis of bilateral hydronephrosis, to change the catheter when occluded or leaking as needed, and to replace the drainage system if disconnection or leakage occurred every 30 days and as needed. A review of R#120's Care Plan revealed a focus area addressing the indwelling catheter, initiated on 5/3/23. This was during the survey and after the surveyor requested information regarding the resident's use of the catheter. Prior to this, R#120's Care Plan did not address the use of an indwelling catheter or interventions for the care of the catheter. During an interview on 5/4/23 at 10:58 a.m., Unit Manager (UM) LLL stated the use of a catheter should be care planned. She stated the Care Plan should include fall and skin risks and medications based on the assessment. She stated the Care Plan was updated by the interdisciplinary team (IDT) when needed, such as after falls and with medication changes, and the nurse should update the Care Plan with any changes. During an interview on 5/4/23 at 2:03 p.m., Registered Nurse (RN) NNN stated the use of a catheter should be care planned. During an interview on 5/4/23 at 2:20 p.m., Licensed Practical Nurse (LPN) OOO stated the use of a catheter should be care planned. During an interview on 5/5/23 at 4:32 p.m., the Administrator stated he thought the use of a catheter should be care planned. He stated the Care Plan should include items from the nursing assessment including medication reviews. He stated updating the comprehensive Care Plan was done by the nursing department, if nursing related, or according to the proper discipline. During an interview on 5/6/23 at 12:24 p.m., the DON acknowledged R#120's Care Plan did not address the resident's use and care of the indwelling urinary catheter. The DON stated the use of a catheter should be care planned, and R#120 now had a Care Plan in place for the use of their catheter. The DON stated the Baseline Care Plan should include everything the staff needed to know to care for a resident. Per the DON, any items on the Baseline Care Plan should be included on the comprehensive Care Plan unless there was an area that needed to be changed because it was determined to not be appropriate. She stated the Care Plan was initiated by the MDS staff and any nurse or IDT member could update the Care Plan. The facility implemented the following actions to remove the IJ: 1. Ad hoc meeting held on 5/4/23 at 7:00 pm with Medical Director, center Nurse Practitioner, Administrator, Director of Nursing, Assistant Director of Nursing, center Educator (SDC), Director of Operations for Georgia, Regional Director of Clinical Operations, and other center management team members to address concerns identified during the survey process related to accidents and incidents, staff competency, and comprehensive care plans to review the findings for IJs and plan for removal of IJs issues. 2. A care plan was developed for RI R#12 and the resident was further assessed by the NP on 5/3/23 in which no injuries or adverse effects were identified. The resident was assessed for pain by a licensed nurse and the resident did not complain of pain above [the resident's] usual pain level. In addition, [R#12] stated [R#12] was not hurt. 3. On 5/4/23 the Center Administrator, Director of Operations, Director of Nursing, and Regional Director of Clinical Operations reviewed the center policy on Comprehensive Care Plan. No process changes or recommendations were made because of this review. 4. On 5/4/23, to identify other residents that may be affected by this practice, 100% of residents of the total census (census 136-136 residents out of 136) received a current transfer assessment which included the 37 residents who required the use of a mechanical lift were reassessed by a licensed nurse to ensure the appropriate transfer techniques and appropriate sling sizing would be used to successfully transfer residents. The licensed nurse did not note any injuries or harm to any resident. 5. On 5/4/23, the Staff Development Coordinator began to re-educate licensed nurses and CNAs on the importance of ensuring that the type of transfer techniques needed for the resident to safely transfer to the use of a mechanical lift and the number of staff needed to safely transfer a resident, documenting the sling size on the [NAME] to ensure communication are care planned. Currently there are 27 certified nursing assistants, 22 Licensed Practical Nurses, and 10 Registered Nurses of which currently 100% of current RNs, 100% of current LPNs, and 88% of current CNAs have been re-educated. Four LPNs and Four RNs were educated over the phone and will complete education in person at next scheduled shift. 6. Those clinical staff members who did not attend the re-education on the importance of the development and on following the comprehensive care plan received the re-education via telephone conference. Currently, there are no staff members on FLMA [sic; FMLA; Family and Medical Leave Act] or LOA [leave of absence]. Any clinical staff members who were not re-educated due to Vacation, PRN [pro ne nata; as needed] Status, etc., will be re-educated prior to resuming their duties on their designated shift by the Unit Nurse Manager, Shift Supervisor or Charge Nurse. Newly hired clinical staff such as Agency or PRNs will be re-educated during orientation or prior to assuming the responsibilities of their designated shift by the Staff Development Coordinator (SDC) or Nurse Manager. 7. On 5/4/23 the Registered Nurse MDS Coordinator conducted a 100% review of care plans for residents' transfer needs to ensure those requiring the use of a mechanical lift care plans were updated to reflect their need for a mechanical lift for transfers and to ensure the number of staff needed to ensure a safe transfer. Revision of care plans was completed on 5/4/23. 8. The Regional Director of Clinical Services re-educated the center Staff Development Coordinator, DON, ADON, and MDS team on Person-Centered Care Plan to include development, implementation, and revision of care plans related to mechanical lift use and risk reduction related to accidents and injuries on 5/4/23. 9. ADL care plans will be reviewed by the MDS Coordinator(s) (licensed nurses) to ensure mechanical lift use, the number of staff members needed to safely transfer a resident, and appropriate sling size is documented on the [NAME] to ensure a safe transfer related to residents requiring the use of a mechanical lift are reflective on the resident plan of care weekly for four weeks; then monthly for two months. 10. The Director of Nursing, or Assistant Director of Nursing, will complete random audits of 20% of mechanical transfers care plans weekly for four consecutive weeks: then monthly for two months. The Regional Director of Clinical Services will conduct random care plan audits to ensure that comprehensive care plans are developed and updated for residents requiring the use of a mechanical lift for a safe transfer monthly for the next two months. 11. On 5/4/23, 37 of 37 residents' [NAME] (which is an extension of the care plan) were reviewed and revised to specifically include the appropriate sling size for each resident requiring the use of a mechanical lift. Any [NAME] found to be without documentation of the appropriate sling size was updated and communicated with the Center's CNAs, licensed nurses, and physical therapy department. 12. The administrator [Administrator] reviewed the results of the audits and shared the findings with the Ad Hoc Quality Assurance Performance Improvement Committee on 5/5/23. The administrator will share the findings of audits related to care plans and mechanical lifts with the QAPI Committee weekly for four weeks then monthly for two months to ensure compliance is achieved and sustained with care planning mechanical lifts, sling size, and number of people needed to support a safe transfer. The administrator will sign and communicate the results of the audit review with the Medical Director and the members of the QAPI committee. Subsequent plans of corrections will be implemented as necessary. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Action verified on 5/6/23 through review of the Ad Hoc QAPI minutes dated 5/4/23 and 5/6/23 and interview with the DON, SDC, and Medical Director on 5/6/23 and interview with the Administrator on 5/7/23 as the Administrator was not available for interview on 5/6/23. 2. Action verified 5/6/223 through review of the record for R#12 and review of the care plan. 3. Action verified through interviews with the Administrator on 5/7/23 who was unavailable on 5/6/23. 4. Action verified through interview with the DON, and Administrator (on 5/7/23) and review of the 37 residents' charts requiring mechanical lifts on 5/6/23. 5. Action verification completed on5/6/223. Interviews with 12 CNAs, five LPNs, one RN, and the Director of Rehabilitation present in the facility on 5/6/23 revealed the re-education of updating care plan interventions had been provided by the SDC and DON. Telephone interviews with 19 CNAs, 10 LPNs, and four RNs across day, evening, and night shifts revealed the re-education revealed the re-education of updating care plan interventions had been provided by the SDC and DON. 6. Action verified through interview with the DON and SDC on 5/6/23. 7. Action verified through interviews with the DON and review of the records of the 37 residents who required a transfer with a mechanical lift and review of the [NAME] Care Cards on 5/6/23. 8. Action verified through training record document review and interviews with the SDC, ADON, and DON on 5/6/23. 9. Action verified through review of care plans and interview with the MDS Coordinator, SDC, and DON on 5/6/23. 10. Action verified via interview with DON on 5/6/23. 11. Action verified on 5/6/23 through review of the [NAME] for the residents on each unit. 12. Action verified through interview with the DON on 5/6/23 and the Administrator on 5/7/23.

Based on observations, interviews, record review, document review, and facility policy review, the facility failed to ensure two of four sampled residents (R) (R#12 and R#69) for accidents received adequate supervision to prevent accidents. Observations of a mechanical lift transfer of R#12 on 5/3/23 revealed the resident voiced discomfort and concern that they were falling during the transfer and the observation revealed the mechanical lift sling was not positioned properly to support the resident during the transfer. The Certified Nursing Assistants (CNAs), CNA RR and CNA TT, who were performing the transfer failed to appropriately supervise the transfer and intervene to properly position the resident in the sling when the resident verbalized discomfort. As a result, once the resident was moved to the wheelchair, the staff were unable to effectively position the resident in the chair, and the resident slid from the wheelchair onto the floor. In addition, interviews with nursing staff revealed CNAs who lacked the minimum training and oversight to ensure correct sling sizes and safe practices were utilized during mechanical lift transfers. Additionally, R#69 had a syncopal episode and staff left the resident sitting in a wheelchair unattended. The resident fell and sustained a laceration to the forehead and rib fractures. On 5/4/23, determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 5/4/23 at 6:10 p.m. The noncompliance related to the IJ was identified to have existed on 5/3/23. An Acceptable Removal Plan was received on 5/6/23. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 5/6/23. Findings included: 1. A review of an undated facility policy titled, Safe Resident Handling/Transfers, revealed, 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 a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The policy also revealed, 8. The facility will ensure that there are appropriate amounts of varying sizes of slings to accommodate residents and that residents will be measured correctly as per manufacturer's instructions on proper sling sizing. The policy also indicated, 11. 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. 12. The staff must demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file. 13. Staff members are expected to maintain compliance with safe handling/transfer practices. A review of R#12's admission Record revealed the facility admitted the resident on 1/30/23 with diagnoses that included metabolic encephalopathy (abnormalities of water, electrolytes, vitamins, and other chemicals that adversely affect brain function), peripheral vascular disease (a disorder of the circulatory system outside the brain and heart), acquired absence of right lower leg below the knee, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease affecting the left dominant side, vascular dementia with behavioral disturbance, anxiety disorder, and depression. A review of a five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/23/23, revealed R#12 had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severe cognitive impairment. The MDS indicated the resident was totally dependent on two or more people for transfer. The MDS indicated the resident used a wheelchair and weighed 186 pounds. A review of R#12's Care Plan, revised on 2/27/23, indicated R#12 had an activity of daily living (ADL) self-care performance deficit related to dementia, generalized muscle weakness, and a stroke. The interventions directed staff to encourage the resident to participate to the fullest extent possible with each interaction. The care plan did not address the resident's need for assistance with transfers or the use of a mechanical lift for transfers. A review of a Lift Transfer Reposition assessment, dated 2/20/23, revealed R#12 was unable to transfer independently or with supervision without using a device, was able to bear 50% of their weight on one or both legs, was unable to perform a stand-pivot transfer with limited assistance, and a gait/transfer belt was not required. The assessment indicated the resident did not require a total lift but required two-staff assistance with repositioning in bed. The area of the assessment regarding care planning was not checked 'yes' or 'no' to indicate whether the care plan for repositioning/transferring was completed or updated. Observations on 5/3/23 from 10:13 a.m. to 10:27 a.m. revealed CNA RR and CNA TT performing a mechanical lift transfer of R#12. Both CNAs communicated to the resident that they were going to transfer the resident from the bed to the wheelchair. The resident acknowledged the CNAs and was already lying on a mechanical lift sling in their bed. The sling appeared very large underneath the resident. CNA RR positioned the lift for transfer of the resident, attached the sling loops to the corresponding hooks, and pulled on them, checking for secure placement. CNA RR confirmed the hooks were securely attached and asked if CNA TT was ready. CNA TT nodded and prepared to spot the resident's head and shoulders. CNA RR was operating the lift and spotting the resident's feet and buttocks during the transfer. CNA RR then communicated with the resident before she began to lift the resident from the bed. As the resident was being lifted from the bed, the resident's buttocks were observed to be hanging off the edge of the sling, unsupported. The resident asked twice for the CNAs to reposition them in the sling due to their leg hurting. CNA RR acknowledged the resident's discomfort and reassured the resident of their safety but continued to transfer the resident and lowered the resident into the seat of the wheelchair. After the resident was lowered into the wheelchair, CNA TT attempted to reposition the resident from behind by pulling on the sling, but verbalized the sling was not underneath the resident. R#12 began complaining of pain and, as CNA RR placed the resident's foot in the foot support, the resident complained of sliding from the seat cushion in their wheelchair and voiced a fear of falling. CNA TT and CNA RR continued their attempts to reposition the resident using the sling. CNA RR stopped the attempted repositioning and stated the wheelchair was too small for the resident and that the CNAs needed to put the resident back into bed. CNA RR quickly stripped the bed linens and left to retrieve clean ones. CNA TT stayed with the resident. R#12 was slumped down in the wheelchair with their chin tucked against their chest and continued to voice that they were sliding in the wheelchair and felt like they were choking and needed to be pulled up. CNA RR returned with clean sheets and quickly made the bed before assisting CNA TT. CNA TT stated CNA RR should go get a third staff member to assist them with the resident, due to how badly the resident was positioned in the wheelchair. The resident still complained they were slipping and afraid of falling. CNA RR continued to attempt the repositioning of the resident, and when CNA RR leaned the resident forward to attempt to get the sling back underneath the resident, R#12 slid from the wheelchair onto the floor, landing with their left leg folded underneath them. CNA RR went out into the hallway to retrieve a third staff member. CNA RR returned moments later with a male staff member. CNA RR, CNA TT, and the male staff member attempted to lift R#12 from the floor using the sling, which had become stuck on the wheelchair, inhibiting the manual lift. CNA SS entered the room and asked what had happened. CNA RR stated the sling had been improperly placed underneath the resident during transfer. CNA SS instructed the staff to lay the resident down flat to reposition them correctly on the sling for transfer from the floor to their bed and provided the resident with a pillow. The sling was positioned correctly underneath the resident, who was then safely transferred back into bed for a nursing assessment. During an observation with the Central Supply Manager on 5/4/23 at 12:49 p.m., the sling in R#12's room was observed to be an extra-large. The Central Supply Manager stated the extra-large sling was too big and not the correct size for R#12. She stated the large sling, color-coded yellow, was the most secure fit for R#12. She stated if the CNAs had questions about the sling size required for R#12, they should have come to ask her about the appropriate size. During a follow-up interview with the Central Supply Manager on 5/5/23 at 3:19 p.m., she stated she used the sling sizing guide and confirmed R#12 needed a size large for a weight range between 154-264 pounds. She stated the resident's weight had not fluctuated since admission, so the resident did not require evaluation for a different size sling. During an interview with CNA SS on 5/3/23 at 10:31 a.m., she stated she was an internal agency CNA who had been working at the facility for three months. She stated the sling should be positioned to cover the resident's bottom and be lined up with the resident's shoulders. She stated the resident's shoulders should also line up with the safety hooks of the lift. She stated the bottom straps should be underneath the resident's legs to support the resident and keep them from hanging in the lift. She stated the resident's bottom should not be hanging out, and the sling the resident required should cover the resident's entire backside, buttocks to shoulders, for support. CNA SS stated she had received mechanical lift training a couple of months ago and completed the in-service training and demonstration. She stated the Staff Development Coordinator (SDC) led the training and covered how to position the sling and operate the mechanical lift for a safe transfer. During an interview with CNA TT on 5/3/23 at 10:38 a.m., she stated she had been working at the facility for a little over a month. She stated as the spotting CNA for a transfer with a mechanical lift, she would make sure the resident's head was supported by the sling and not slumping back. She stated she completed the mechanical lift training and demonstration during orientation. She stated the sling should be positioned under the resident's buttocks and around the resident's shoulders, and she would watch the resident's head and limbs for safety during transfer. She stated if the resident was not securely in the sling, the resident could slide out during transfer. She stated the sling had been positioned underneath Resident #12 and crossed in between their legs, with their arms crossed over their chest during the lift. She stated she did not notice any issues with the sling placement until the resident was in the wheelchair, at which point it was too high up on the resident. She stated that due to the improper placement of the sling underneath the resident, the CNAs could not correctly reposition the resident to prevent the slide from the wheelchair. During an interview with CNA RR on 5/3/23 at 1:14 p.m., she stated she was an internal agency CNA who had worked frequently at the facility for the past two years. She stated the last mechanical lift training she received was about three weeks ago, and it covered how to get the residents ready for a lift and the procedure for a safe transfer using a mechanical lift. She stated she completed the in-service and accompanying demonstration. She stated the sling should be placed below the resident's buttocks and even with their shoulders so the lift could hold them. She stated she had positioned the resident on the sling appropriately on the bed before the lift, so it should have supported their buttocks throughout the lift. She stated she did not notice if the resident's buttocks were supported during the transfer and only noticed an issue when the resident was in the wheelchair. She stated when the resident was in the wheelchair, she noticed the sling had come up too high above the resident's shoulders, making it difficult to reposition the resident. She stated R#12 had requested to get out of bed to relieve the pain in their leg. She stated R#12 stayed in bed most of the time but had insisted on getting up this morning. She stated she informed the unit manager, who confirmed the resident could get out of bed. At the time of the survey, there were 27 CNAs employed by the facility, according to the facility's Removal Plan. A review of the facility's training information revealed a document titled, Employee Education/In-service dated 3/27/23, that indicated 32 employees attended a training that covered lifts and transfers, 15 of whom were CNAs. The lift training was provided and overseen by the SDC. Further review of the training documents revealed CNA RR completed a Total Mechanical Lift Competency Checklist on 3/28/23, and No was indicated next to five of the 17 steps including: demonstrates ability to lower resident after lift has failed, locate emergency stop button and its purpose, verbally prepares resident for transfer, gently raises resident minimally from surface, unweight resident from bed, performs a safety check,, and removes sling from under resident, only leaves sling on resident if Care Planned. Handwritten entries next to the five No responses indicated, education provided; however, there was no documentation of the specific re-education that was provided, nor was there a competency checklist that indicated CNA RR had successfully completed a return demonstration. Further review of the training information revealed CNA TT completed a Total Mechanical Lift Competency Checklist on 3/29/23, and No was indicated by one of the 17 steps, adjust bed to height that promotes good body mechanics. There was no evidence that CNA TT was retrained in the area that was checked No. During an interview with Licensed Practical Nurse (LPN) ZZZ on 5/3/23 at 2:18 p.m., she stated she had worked at the facility for two weeks. She stated she assessed R#12 after the incident and found no visible injury and had notified the medical director and family member. She stated the resident reported no pain following the incident. During an interview with LPN YYY on 5/3/23 at 3:34 p.m., she stated mechanical lift transfers were always done with two staff members. She stated the sling should be above the shoulders and below the buttocks, before being crisscrossed in between the resident's legs, and securely attached to the lift. She stated if the CNAs saw any safety concerns during a transfer, they were to stop transferring the resident and return them to bed, reposition the sling, and attempt the transfer again. She stated Resident #12 had no complaints of pain or injury after the incident that morning. She stated the CNAs reported to her the resident was sliding from the wheelchair during repositioning but did not mention anything to her about the sling position not being safe during the transfer. She stated the resident had no previous slides out of the wheelchair or falls. During an interview with the SDC on 5/4/22 at 12:24 p.m., she stated she had worked at the facility since 2/1/23. She stated she provided in-service training to all nursing staff regarding safe mechanical lift transfers and sling placement. She stated the training included how to operate the mechanical lifts, safe sling placement for a transfer, and a satisfactorily completed demonstration with the nursing staff before approving their competencies to perform a mechanical lift transfer on the Total Mechanical Lift Competency Checklist. She stated mechanical lift transfer training was completed upon hire, annually, and if the need was identified for one-to-one training. The SDC stated if the skills check off was done correctly during floor observations, it was outlined on the comprehensive check-off sheet. She stated if the CNA forgot a step during the demonstration, the CNA was immediately provided one-to-one education privately. She stated if retraining was needed, the CNAs would demonstrate a lift on the facility manikin to ensure safety during a mechanical lift transfer. She stated a CNA competency checklist that had four or five No indications did not meet the requirements for a satisfactory skills demonstration. She stated retraining would be provided until the CNA completed a demonstration with all Yes indications, demonstrating the comprehension needed for a safe mechanical lift transfer. The SDC stated CNA RR had completed the mechanical lift transfer training and completed the skills demonstration during a mechanical lift transfer of a resident. She stated she oversaw the training and skills demonstration with CNA RR. She stated she re-educated CNA RR after the five No indications were revealed on the comprehensive skills check-off sheet. She stated that aside from the documentation of education provided on the original skills check-off sheet, she had no further documentation of CNA RR's re-education or successful return demonstration of a safe mechanical lift transfer. The SDC stated during a transfer, if the resident's buttocks were unsupported by the sling, the CNAs should lay the resident back down and reposition the sling for a safe transfer. She stated sling safety and correct positioning should be checked after the resident had been slightly lifted from the surface upon which they had been resting, before continuing the transfer. She stated if the resident was hanging out of the sling, it was an unsafe transfer. She stated if the resident was complaining of pain, discomfort, or fear of falling, the CNAs should stop the transfer and re-evaluate the sling placement and transfer technique. During an interview with R#12 on 5/4/23 at 12:49 p.m., the resident stated they were fine, in no pain, and sustained no injury from the incident the previous day. During an interview with CNA II on 5/4/23 at 1:47 p.m., she stated she was an agency CNA who had worked at the facility off and on for two years. She stated the green slings did not indicate a size and she would just eyeball them, and if the sling was too big or too small, it should not be used for the resident. She stated she received training about how to operate, clean, and raise and lower residents in the mechanical lift. She stated the residents' buttocks should not be hanging out of the sling. She stated the resident's arms should be in the sling and the resident should be comfortable. She stated that before beginning the transfer, the resident should be slightly lifted from the bed to make sure the sling was placed correctly. She stated she had to search for the slings she needed for mechanical lifts, and if she could not find one, a transfer using the mechanical lift was not provided. During an interview with CNA MM on 5/4/23 at 1:47 p.m., she stated she had received training for mechanical lift transfers from the facility. She stated the sling size a resident required was determined by weight and was color coded on the sling. She stated the sizing chart for the sling was located on the lift and indicated the size correlation to color on the sling. She stated this chart was not always what was used when retrieving a sling for a resident. She stated that at times, she could not find a sling, and when this occurred, she would let the Assistant Director of Nursing (ADON) know. During an interview with CNA JJ on 5/4/23 at 1:51 p.m., she stated she had been a CNA at the facility for three years. She stated the sling size was determined by weight. She stated the facility did not have enough slings for everyone that required a mechanical lift. She stated CNAs had to check the slings for holes or tears and inspect the lift before providing a mechanical lift transfer to make sure everything was safe for use. She stated all mechanical lift transfers required two staff for assistance. She stated the SDC provided the mechanical lift training about two weeks ago and made sure everyone could do it. During an interview with CNA PP on 5/4/23 at 1:52 p.m., she stated she had never received mechanical lift training from the facility or been told how to find the sling size required for a resident. During an interview with CNA QQ on 5/4/23 at 2:01 p.m., she stated she had never received mechanical lift training from the facility. She stated she received mechanical lift training from the agency she worked for and knew how to do it from her 13 years of experience as a CNA. During an interview with the Assistant Director of Nursing (ADON) on 5/5/23 at 11:40 a.m., she explained the color sizing guide on the mechanical lift used for R#12's transfer. She stated the color chart on the lift indicated the size of sling the resident required for a safe transfer. She stated the color corresponded to size, but the weight guidelines were not included on the lift itself. She stated the CNAs could find the appropriate color by checking the sling size documented on the KARDEX Care Cards (a summary or overview of residents' care needs). On 5/5/23 at 11:45 a.m., the ADON retrieved the KARDEX Care Card for R#12, and it indicated R#12 utilized an extra-large sling and was transferred via mechanical lift with the assistance of two staff. A copy of R#12's KARDEX Care Card was requested from the facility but was not received. During an interview with the Administrator on 5/5/23 at 4:33 p.m., he stated he had been the Administrator of the facility since 2/1/12 and the CNA Kardex and the electronic health record (EHR) should communicate the transfer requirements of the residents to the nursing staff. He stated he did not believe the resident's mechanical lift transfer needs or the sling size needed for transfers should be included on the residents' care plans. The Administrator stated he expected nursing staff to provide safe mechanical lift transfers to residents per the procedures of the facility. The Administrator stated he expected the CNA competencies to be accompanied by a satisfactory demonstration skills check-off. He stated the SDC completed the CNA competency skills check-off, and if the CNAs could not demonstrate a safe mechanical transfer, retraining and another demonstration should be conducted with the CNA before the staff performed another mechanical lift transfer for a resident. The Administrator stated that as far as he knew, the facility had enough lift slings so that each resident had the appropriate size. The Administrator stated that after a resident sustained a fall, an investigation would be initiated, and the resident assessed for injury and safety. During an interview with the DON on 5/6/23 at 1:02 p.m., she stated she had worked for the facility since 2017, taking over as the DON in the spring of 2020. She stated she expected the CNAs to be trained and demonstrate competency with safe mechanical lift procedures and expected nursing staff to be aware of residents' transfer needs, know where mechanical lift and sling requirements were documented on the KARDEX and care plan, and know how to determine the size of sling required by each resident for a mechanical lift transfer. She stated all CNAs were provided mechanical lift training and completed a demonstration with the SDC during new hire orientation. She stated if any issues arose regarding mechanical lift transfers, the CNA would be pulled aside and provided one-to-one re-education. She stated mechanical lift transfers were also a part of the annual training provided to all nursing staff. She stated if a CNA had four or five No indications during the demonstration of a mechanical lift transfer, it would be deemed an unsafe transfer and re-education would be provided immediately with the facility manikin. She stated a follow-up should be completed a few days after re-education to make sure the staff person retained the information. The DON stated she expected the sling to be positioned safely underneath the resident, supporting their coccyx. She stated the sling placement and hooks should be checked for secure placement as a part of the visual safety inspection before the lift was initiated. She stated all mechanical lift transfers should be completed after the resident was slightly lifted from the surface. She stated if the CNAs had any doubts about safety or the resident voiced discomfort or fear during a mechanical lift transfer, the transfer should be stopped, the resident returned to the original surface, and the nurse consulted. She stated she expected the CNAs to watch the resident constantly during the lift procedure to ensure the sling was positioned safely. She stated she expected any concerns with the mechanical lifts or availability of sling sizes to be reported to management and if needed, the lift would be removed from service. She stated all equipment was inspected before use. She stated the resident's weight determined the sling size to use for a mechanical lift transfer. She stated the CNAs should compare the KARDEX to the documented weight and color of the sling (which indicated the size of the sling) to ensure the correct sling was used before a transfer. 2. A review of a facility policy titled, Fall Prevention Program, implemented October 2022, revealed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The policy also indicated, Monitor for changes in resident's condition, gait, ability to rise/sit, and balance. Additionally, the policy indicated, The risk assessment categorizes residents according to low, moderate, or high risk, and defined specific protocols for low/moderate risk and high risk. A review of R#69's admission Record revealed the facility admitted R#69 on 10/31/22 with diagnoses that included unspecified abnormalities of gait and mobility, lack of coordination, repeated falls, unsteadiness on feet, laceration without foreign body, hypertension, and fracture of one rib on the left side sequela. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/22/23, revealed R#69 had a Brief Interview for Mental Status (BIMS) score of three, indicating the resident was severely cognitively impaired. The MDS also indicated R#69 did not experience falls since the prior assessment and required extensive assistance with bed mobility, transfers, and locomotion on the unit. A review of R#69's Fall Risk Assessment, dated 10/31/22, revealed the resident had a score of 12. The assessment revealed a score greater than 10 indicated the resident was considered at risk for falls. The Fall Risk Assessment did not indicate if R#69's score was considered low, moderate, or high risk. A review of R#69's Care Plan revealed a focus area initiated on 11/1/22 that indicated the resident had fall, gait, and balance problems, including a fall on 11/1/22. The resident was at risk for falls and had syncope. A planned intervention directed staff to follow the facility's fall protocol (initiated 11/2/22). The Care Plan did not specify whether staff should follow the fall protocols for low/moderate fall risk or high fall risk. A review of R#69's Order Summary Report, which included active orders as of 5/4/23, revealed no orders addressing fall prevention or fall protocols. A review of R#69's Progress Notes, dated 12/10/22 at 3:05 p.m., revealed R#69 was found sitting in their wheelchair unresponsive but breathing and had a pulse rate of 90 beats per minute. Within a minute of Licensed Practical Nurse (LPN) XXX continuously calling the resident's name and performing sternal rubs, the resident became alert but was trembling. LPN XXX contacted R#69's physician and obtained orders to send the resident to the hospital. While calling 911, LPN XXX heard a loud noise, and R#69 was found lying face down on the floor, with a visible laceration to the top right eyebrow. R#69 was lifted off the floor back into the wheelchair and sent to the hospital. A review of R#69's Change in Condition Follow Up, dated 12/10/22, revealed R#69 fell out of their wheelchair due to a syncopal (fainting) episode. R#69 suffered a laceration above their right eye. The plan was to send the resident to the emergency room (ER) for evaluation and treatment. A review of R#69's Full QA [Quality Assurance] Report, with an incident date of 12/10/22, revealed the date and time of the incident involving R#69 was 12/10/22 at 10:31 a.m. The resident was found unresponsive and slumped over in their wheelchair. The resident's physician was notified and gave orders to send the resident to the hospital. While calling 911, a loud sound was heard, and the resident was found face down in front of the nurse's station with a visible laceration to the top right eyebrow. According to the form, the Director of Nursing (DON) and the Administrator were both notified of the incident in person on 12/10/22 at 10:31 a.m. The Administrator electronically signed the form on 12/29/22 at 9:47 a.m. A review of R#69's hospital record, dated 12/10/22, revealed R#69 had a syncopal episode and an unwitnessed fall. R#69 had a laceration to the right side of the forehead above the eyebrow. Additionally, the After Visit Summary indicated X-rays and a computed tomography (CT) scan revealed a non-displaced rib fracture on the right side. A review of R#69's medical record revealed no evidence the resident's fall was evaluated for causative factors. In an interview on 5/3/23 at 11:31 a.m., R#69 stated they fell out of their wheelchair and bumped their head. During an interview on 5/4/23 at 11:14 a.m., the DON stated when a fall occurs, a licensed nurse should assess the resident for injury/pain and, if safe to do so, transfer the resident to a safe position. She stated staff would need to complete fall documentation and notifications to the physician and family. She indicated if it was not safe to transfer a resident then they should call emergency medical services (EMS). She stated that after a fall, the facility needed to find out the cause of the fall to mitigate the risk of future falls and injury. She indicated that after the cause was determined, the staff should implement interventions, communicate the interventions during their huddles, and the resident's care plan should be updated by the nurses to include the interventions as soon as possible. The DON indicated the facility reviewed falls Monday through Friday as an interdisciplinary team (IDT). She revealed the supervisors were expected to call her if a fall occurred and she would direct them to interview staff to find out the cause. She indicated that while interviews were conducted following R#69's fall, they may not have made it into the record. She stated her understanding was that R#69 had a syncopal episode, the nurse left them in the wheelchair, and the resident fell out. She stated LPN III, the weekend supervisor, interviewed LPN XXX, who was an agency nurse and no longer worked at the facility. She indicated she did not know if LPN XXX was provided education on ensuring the resident was sa[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, document review, and facility policy review, the facility failed to ensure certified nursing assistants (CNAs) demonstrated competency in skills and techniques necessary to care for residents' needs related to transfers using a mechanical lift for two of 15 CNA competency documents that were provided. During observations of a transfer of R#12 by way of a mechanical lift, the resident voiced discomfort and concern of falling during the transfer. Observations revealed the resident was not appropriately positioned in the mechanical lift sling and as a result, after the resident was transferred to the wheelchair, R#12 slid from the wheelchair into the floor because the resident could not be appropriately positioned in the chair. A review of training records revealed the competency evaluations for the CNAs that performed the transfer (CNA RR and CNA TT) indicated they had not met all the requirements to demonstrate competence and there was no evidence that the CNAs were retrained to ensure competence. On 5/4/23, determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 5/4/23 at 6:10 p.m. The noncompliance related to the IJ was identified to have existed on 5/3/23. An Acceptable Removal Plan was received on 5/6/23. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 5/6/23. Findings included: The facility's undated policy, titled, Safe Resident Handling/Transfers, indicated, 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 a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The policy also revealed, 11. 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 in changes in equipment occur. 12. The staff must demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file. 13. Staff members are expected to maintain compliance with safe handling/transfer practices. A review of R#12's admission Record revealed the facility admitted the resident on 1/30/23 with diagnoses that included metabolic encephalopathy, peripheral vascular disease, acquired absence of right lower leg below the knee, hemiplegia and hemiparesis following a cerebrovascular disease affecting left dominant side, muscle weakness, and vascular dementia with behavioral disturbance. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/2/23 revealed R#12 had a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had moderately impaired cognition. The MDS further indicated R#12 required the extensive assistance of one person for activities of daily living including dressing, eating, and personal hygiene. The MDS indicated for transferring, the activity only occurred once or twice, and no setup or physical help was required from staff. A review of R#12's Care Plan, last reviewed on 2/6/23, indicated the resident had an activity of daily living (ADL) self-care deficit related to dementia, generalized muscle weakness, cardiovascular accident with left sided weakness, and a right below the knee amputation. The care plan interventions, initiated on 2/6/23, directed staff to encourage the resident to participate to the fullest extent possible with each interaction, encourage the resident to use the call bell to call for assistance, and for physical therapy and occupational therapy to evaluate and treat the resident as ordered by the physician. The care plan did not include interventions that directed staff how to provide assistance to the resident for transfers or equipment that was needed for transfers. Observations on 5/3/23 from 10:13 a.m. to 10:27 a.m. revealed Certified Nursing Assistant (CNA) RR and CNA TT transferred R#12 from the bed to a wheelchair using a mechanical lift. The CNAs did not ensure the sling for the lift was appropriately placed to support the resident during the transfer and the resident's buttocks were unsupported during the transfer. Observations revealed the staff continued to transfer the resident despite the resident voicing concerns that they were falling and were having pain during the transfer while in the lift sling. After the resident was placed in the wheelchair, the resident could not be repositioned in the wheelchair because the sling was not positioned correctly and as a result the resident slid from the wheelchair onto the floor. The resident did not sustain any injuries as a result of the fall. A review of an Employee Education/In-service sheet, dated 3/27/23, revealed 32 employees attended lift and transfer training provided by the Staff Development Coordinator (SDC), 16 of which were certified nursing assistants (CNAs). During an interview with CNA RR on 5/3/23 at 1:14 p.m., she stated she was an internal agency CNA who had worked frequently at the facility for the past two years. She stated the last mechanical lift training she received was about three weeks ago, and the training, which was an in-service and demonstration, covered how to get the residents ready for a lift and the procedure for a safe mechanical transfer. A review of a Total Mechanical Lift Competency Checklist for CNA RR dated 3/28/23, revealed the SDC observed the CNA's competency and checked No for five of the 17 steps. The steps the CNA did not meet were: Demonstrates ability to lower resident after lift has failed, Locate emergency stop button and its purpose, Verbally prepares resident for safe transfer, Gently raises resident minimally from surface. Unweight resident from bed. Performs a safety check, and Removes sling from under resident. Only leaves sling on resident if Care Planned. The SDC did not provide documentation that education was provided to ensure CNA RR was competent in all aspects of how to transfer a resident by way of a mechanical lift. During an interview with CNA TT on 5/3/23 at 10:38 a.m., she stated she had worked at the facility for a little over a month. Per CNA TT, she completed the mechanical lift training and demonstration during orientation. A review of CNA TT's Total Mechanical Lift Competency Checklist dated 3/29/23 revealed the CNA did not meet the criteria for one of the 17 steps, Adjust bed to height that promotes good body mechanics. During an interview with the Staff Development Coordinator (SDC) on 5/4/23 at 12:24 p.m., she stated she provided in-service training to all nursing staff on safe mechanical lift transfers and sling placement. She stated the training included how to operate the mechanical lifts, safe sling placement for a transfer, and a satisfactorily completed demonstration with the nursing staff before she approved the staff's competency to perform a mechanical lift transfer on the Total Mechanical Lift Competency Checklist. She stated mechanical lift transfer training was completed upon hire, annually, and if the need was identified for one-to-one training. The SDC stated if the skills check off was done correctly during floor observations, it was outlined on the comprehensive check-off sheet. She stated if the CNA forgot a step during the demonstration, the CNA was immediately provided one-to-one education privately, away from the earshot of the residents. She stated if retraining was needed, the CNAs would demonstrate a lift on the facility manikin to ensure safety during a mechanical lift transfer. She stated a competency checklist that had four or five No responses indicated the staff was not competent in the skills to perform a safe mechanical lift transfer. She stated retraining would be provided until the CNA completed a demonstration with all Yes indications, which demonstrated the competency needed for a safe mechanical lift transfer. She stated education would be provided until the deficit in training was identified and corrected with the CNA. The SDC stated CNA RR had completed the mechanical lift transfer training and completed the skills demonstration during a mechanical transfer of a resident. She stated she oversaw the training and skills demonstration with CNA RR. She stated she re-educated CNA RR after the five No indications were revealed on the comprehensive skills check-off sheet. She stated that aside from the documentation on the check-off sheet that specified education provided, there was no other documentation to indicate how re-education was provided to ensure CNA RR was competent to perform a mechanical lift transfer. She stated that since CNA RR was an internal agency CNA, the facility training was only provided because an issue was identified. During an interview with the Administrator on 5/5/23 at 4:33 p.m., he stated he expected the CNA competencies to be accompanied by satisfactory demonstration skills check off. He stated the SDC completed the CNA competency skills check off, and if the CNAs could not demonstrate a safe mechanical lift transfer, retraining and another demonstration should be conducted with the CNA before another mechanical lift transfer was performed for a resident. During an interview with the DON on 5/6/23 at 1:02 p.m., she stated she expected the CNAs to be trained and demonstrate competency of safe mechanical lift procedures. She stated all CNAs were provided mechanical lift training and completed a demonstration with the SDC during new hire orientation. She stated if any issues arose on the floor around mechanical lift transfers, the CNA would be pulled aside and provided one-to-one re-education. She stated mechanical lift transfers were also a part of the annual training provided to all nursing staff. She stated if a CNA had four or five No answers that indicated they were not competent to perform a mechanical lift transfer, it would be deemed an unsafe transfer and re-education would be provided immediately using the facility manikin. She stated a follow-up check should be completed a few days after re-education to make sure the staff member retained the training. The facility implemented the following actions to remove the IJ: 1. Ad hoc meeting held on 5/4/23 at 7:00 p.m. with Medical Director, center Nurse Practitioner, Administrator, Director of Nursing, Assistant Director of Nursing, center Educator (SDC), Director of Operations for Georgia, Regional Director of Clinical Operations, and other center management team members to address concerns identified during the survey process related to accidents and incidents, staff competency, and comprehensive care plans to review the findings for IJs and plan for removal of IJs issues. 2. On 5/3/23, R#12 was assessed by the NP and determined to be without injuries or adverse effects. The resident was assessed for pain by a licensed nurse and the resident did not complain of pain above her usual pain level. In addition, she stated she was not hurt. 3. On 5/4/23, the Regional Director of Clinical Operations educated the Director of Nursing, ADON, and Staff Development Coordinator on the facility's Safe-Resident-Handling Transfer (Mechanical lift) process for residents requiring the use of a mechanical lift to ensure licensed nurses and certified nursing assistants can demonstrate competencies through return demonstration as evidenced by both visual and skilled competency checklist for safe transfer.? 4. On 5/4/23, the Staff Development Coordinator provided education with return demonstration competency to certified nursing assistants (both facility hired and contracted CNAs) on safe transfers of residents requiring the use of a mechanical lift. Education included: Ensuring the resident's care plan included the type of transfer the resident needed for a safe transfer to include the use of a mechanical lift, use and communication of the appropriate sling size, care planning the number of staff needed for a transfer, documenting the sling size on the [NAME], assessing/determining if the sling has been placed on the resident correctly before using the mechanical lift, and communicating with the nurse if the resident is in pain. 5. As of 5/5/23, Currently there are 27 certified nursing assistants, 22 Licensed Practical Nurses, and 10 Registered Nurses of which currently 100% of current RNs, 100% of current LPNs, and 88% of current CNAs have been re-educated by the Staff Development Coordinator (SDC) on importance of using the proper sling sizes when transferring residents using a mechanical lift; assessing the resident on admission, annually, and quarterly for lift assessment; using the manufacturer's guidelines to measure for appropriate sling size when needed (manufacturer's guidelines will be kept at the nurses' station); ensuring that the slings placement has been checked/assessed before using the mechanical lift; and the ongoing importance safe transfer education along with competency validation Four LPNs and Four RNs were educated over the phone and will complete education in person at next scheduled shift. 6. The Director of Nursing and nursing management team (consisting of Unit Managers, ADON, MDS, and SDC) using a tool labeled Mechanical Lift Observation will conduct a 10% random observation audit daily (Monday through Friday) for two weeks of residents' transfers of those requiring the use of a mechanical lift and then weekly times four weeks and monthly times two months to ensure ongoing and sustained competency related to ensure ongoing and sustained compliance with mechanical lift usage, appropriate sling size, documentation of sling size on the [NAME], appropriate placement of the sling for the resident use. 7. Newly hired CNAs (contracted and or agency) as well as newly hired will receive education upon hire will receive ongoing education as needed on Transfer assessments, safe transfer, mechanical lift use, and appropriate sling size and use. CNAs will be required to perform return demonstrations on mechanical lift use upon hire, annually, and as needed. Those current CNAs who did not attend the re-education on the importance of Safe-Resident-Handling Transfer (Mechanical lift) process received the re-education via telephone conference. Currently, there are no staff members on FLMA or LOA. Any clinical staff who were not re-educated due to Vacation, PRN Status, etc., will be re-educated prior to resuming their duties on their designated shift by the Nurse Manager, Shift Supervisor or Charge Nurse. Newly hired stakeholders, Agency or PRNs will be re-educated during orientation or prior to assuming the responsibilities of their designated shift by the Staff Development Coordinator (SDC) or Director of Nursing. 8. The Center administrator will review results from the Mechanical Lift Observation audits in the Quality Assurance Performance Improvement Committee meeting for four weeks then monthly times two months to ensure compliance is achieved and sustained. QAPI team will continue to monitor and the SDC will conduct 1:1 reeducation as areas identified as non-compliance and report results to QAPI committee. The administrator will sign and communicate the results of the audit review with the Medical Director and the members of the committee. Subsequent plans of corrections will be implemented as necessary. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Action verified through interview with the DON, SDC, and the Medical Director and review of the Ad Hoc QAPI minutes dated 5/4/23 on 5/6/23 and with the Administrator on 5/7/23 who was unavailable on 5/6/23. 2. Action verified through interview with the Medical Director and DON and review of facility fall investigation on 5/6/23. 3. Action verified through interview with the DON, ADON, and SDC and a review of training records and demonstration competencies on 5/6/23. 4. Action verification completed through staff interviews and a review of training records and demonstration competencies on 5/6/23. Interviews with 12 CNAs, five LPNs, one RN, and the Director of Rehabilitation present in the facility on 5/6/23 revealed the re-education regarding mechanical lifts and sling sizes had been provided by the SDC and DON. Telephone interviews with 19 CNAs, 10 LPNs, and four RNs across day, evening, and night shifts revealed the re-education regarding mechanical lifts and sling size had been provided by the SDC and DON. 5. Action verification completed through staff interviews and a review of training records and demonstration competencies on 5/6/23. Interviews with 12 CNAs, five LPNs, one RN, and the Director of Rehabilitation present in the facility on 5/6/23 revealed the re-education regarding mechanical lifts and sling sizes had been provided by the SDC and DON. Telephone interviews with 19 CNAs, 10 LPNs, and four RNs across day, evening, and night shifts revealed the re-education regarding mechanical lifts and sling size had been provided by the SDC and DON. 6. Action verified through interview with the DON, a review of the Mechanical Lift Observation tool, and a demonstration of its use on 5/6/23. 7. Action verified through interview with the DON and SDC on 5/6/23. 8. Actions verified through interview with the Administrator on 5/7/23, as he was not available on 5/6/23. Action also verified through interview with the DON on 5/6/23, a review of the Mechanical Lift Observation tool, and a demonstration of its use on 5/6/23.