**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of facility policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and implement a Comprehensive Care Plan (CCP) for each resident to meet a resident's medical, nursing, mental and psychosocial needs for one (1) of forty (40) sampled residents (Resident #44). Resident #44's Comprehensive Care Plan, dated [DATE], revealed the resident was at risk for injury related to mobility; however, the CCP was not developed with interventions for a Hoyer lift (mechanical lift) for transfers. On [DATE], Resident #44 was being assisted to bed from a wheelchair with the use of a Hoyer lift by Certified Nursing Assistant (CNA) #1 (orientee) and CNA #3. The resident slid from the lift sling and landed on the floor. Upon assessment, the resident was alert and oriented, able to answer questions, and was noted to have a raised area to the back of the head with no additional injuries noted. The resident was transferred back to bed using the lift. The physician was notified, and new orders were received for a Computed Tomography (CT) of the head, but later the resident experienced a change in level of consciousness (LOC). The Medical Emergency Response Team (MET) was called, and the resident was transferred to the hospital emergency room (ER) for evaluation and treatment. Resident #44 expired at the hospital on [DATE] at 10:22 PM. Refer to F689 The facility's failure to ensure the Comprehensive Care Plan (CCP) was developed and implemented for each resident to meet a resident's medical, nursing, mental and psychosocial needs has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] at 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), at the highest scope and severity (S/S) of a J; and 42 CFR 483.25 Quality of Care (F689), at the highest S/S of a J, which was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. In addition, Substandard Quality of Care (SQC) was identified at 42 CFR 483.25, Free of Accident Hazards/Supervision/Devices (F689). An acceptable Immediate Jeopardy Removal Plan was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency (SSA) validated Immediate Jeopardy was removed on [DATE], prior to exit on [DATE]. Non-compliance remained in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656) at a Scope and Severity (S/S) of a D; and 42 CFR 483.25 Quality of Care (F689) at a S/S of a D, while the facility monitors the effectiveness of systemic changes and quality assurance activities. The Findings include: Review of the facility policy titled, Care Plans, revised 11/2022, revealed a comprehensive care plan was developed consistent with the patient's (resident's)specific conditions, risks, needs, behaviors, preferences, and standards of practice. Care Plans should include measurable objectives, interventions/services, and timetables to meet the patient's (resident's) response to the interventions or changes in the patient's (resident's) condition. Further, Care Plans should reflect the patient's (resident's) needs and preferences and align with the patient's (resident's) cultural identity and if history of trauma, describe the corresponding interventions for care in accordance with professional standards of practice. The facility would provide or arrange these services by individuals who have the skills, experience, and knowledge to do a particular task or activity in accordance with the patient's (resident's) plan of care. Review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, dated [DATE], revealed the Comprehensive Care Plan was an interdisciplinary communication tool and must include measurable objectives and timeframe's and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental,and psychosocial wellbeing. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Resident #44's closed medical record revealed the facility admitted the resident on [DATE] with diagnoses including Acute and Chronic Respiratory Failure, and Muscle Weakness. Resident #44's Annual Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating intact cognition. Continued review revealed the facility assessed Resident #44 as totally dependent on staff for chair/bed to chair transfer. Further review revealed the facility assessed the resident as having no falls. Review of Resident #44's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating intact cognition. Continued review revealed the facility assessed Resident #44 as totally dependent on staff for chair/bed to chair transfer. Further review revealed the facility assessed the resident as having no falls. Resident #44's Comprehensive Care Plan (CCP), dated [DATE], revealed a focus of Activities of Daily Living (ADL) Self Care Performance Deficit related to Immobility, Activity Intolerance, Weakness, Ventilator Dependent, and Tracheostomy; and required assistance with transfers. The CCP goal stated ADL/Self care needs would be met on a daily basis through next review. However, there were no individualized interventions related to transfer technique nor how many staff was required to transfer the resident. Review of Resident #44's Comprehensive Care Plan, dated [DATE], revealed the resident was at risk for injury related to mobility impairment; use of psychotropic medication, and narcotic pain medication; and ADL/Self care Performance deficit related to immobility. The goal stated the resident would be free from falls and fall related injuries through next review. Interventions included: Anticipate and meet needs; provide assistance with mobility and transfers as needed; assist with mobility as needed, and if anxious or restless assess basic needs, or room temperature. However, there were no individualized interventions related to transfer technique. There was no intervention listed for a Hoyer lift. Further, there was no guidance as to how many staff members were required to transfer this resident. Review of the Resident Summary (Nurse Aide Care Plan), dated [DATE], revealed Resident #44 was care planned for Assist x two (2) with a Mechanical/Electrical Lift for transfers. However, this Resident Summary did not specify the type or size of sling to be used, nor did it specify a Hoyer lift was to be used. Review of the Nurse's Progress Note, dated [DATE] at 4:15 PM, entered by Licensed Practical Nurse (LPN) #4, revealed Resident #44 was being assisted to bed from the chair with the use of a mechanical lift. The resident slid from the lift sling landing on the floor, and the Nurse was notified immediately by the CNA. Upon assessment, the resident was alert and oriented and able to answer questions, and was noted to have a raised area to the back of his/her head with no additional injuries noted. Further, the resident was transferred back to bed using the lift. The physician was notified and new orders were received for a CT (Computerized Tomography Scan) of the head, but the resident experienced a change in LOC (level of consciousness). The MET Team (Medical Emergency Response Team) was called and the resident was transferred to the ER (Emergency Room) for evaluation and treatment. Resident #44's hospital Discharge summary, dated [DATE] at 10:22 PM, revealed the resident presented after a fall at the nursing home while attempting to move off his/her chair. The resident was found unresponsive and transferred to the hospital for further evaluation and treatment. The Computed Tomography Scan revealed a massive left convexity with a midline shift and signs of uncal herniation (occurs when rising intracranial pressure causes portions of the brain to move from one intracranial compartment to another). Further review of the Summary, revealed Resident #44's poor prognosis was explained to his/her family and they expressed their decision to start comfort measures only. Resident #44 was terminally disconnected from the ventilator and then passed away shortly. Time and date of death was [DATE] at 10:22 PM. Resident #44's Incident/Accident Report, dated [DATE], entered by the Executive Director (ED), revealed the facility determined due to the resident's contracted stature and limited range of motion (ROM), the divided leg sling posed an increased risk of shifting out of proper position during mechanical transfer. Two (2) CNAs were present and reported when the resident began slipping they were not able to get to him/her in time. In an interview with Certified Nursing Assistant (CNA) #1, on [DATE] at 8:30 AM, he stated, on [DATE], he was in orientation at the facility and was with his preceptor, CNA #3, when the transfer occurred with Resident #44. He further stated during observation of the use of the Hoyer lift on Resident #44, he noted the sling had what appeared to be an opening made into the lower part of the sling. CNA #1 stated Resident #44 slid out of the sling as it was being used to transfer him/her from the wheelchair to the bed and the resident's head hit the floor. He further stated CNA #3 yelled for staff to help and LPN #4 arrived and assessed the resident. In further interview, he stated immediately after the fall the resident did not appear to have any injuries, but a few minutes later the resident started to have changes and he/she was transferred to the hospital. He stated the resident's care plan was where the information related to transfer technique should be located, but he did not recall checking Resident #44's care plan prior to the transfer. During interview with CNA #3, on [DATE] at 12:27 PM, she stated she had worked at the facility since [DATE]. She further stated she had been assigned to Resident #44 and provided care for the resident in the past and was aware the resident was to be transferred per Hoyer Lift with the assist of two (2) staff without checking the care plan. Further, she stated, on [DATE], she assisted Resident #44 onto the Hoyer lift sling while CNA #1 who was an orientee in training, assisted with putting the loops of the sling onto the sling hooks of the Hoyer lift. She further stated she then locked the wheels of the Hoyer Lift, and began to lift the resident off the wheelchair. CNA #3 stated she then stopped for a brief moment to check the resident for stability, and everything appeared to look good; so she unlocked the wheels and proceeded with moving the resident towards the bed. During continued interview with CNA #3, on [DATE] at 12:27 PM, she stated Resident #44 began to slide out of the sling from the opening that was built into the bottom of the sling. CNA #4 stated Resident #44 fell hitting his/her head on something, as he/she fell to the floor. She further stated she thought the resident had hit his/her head on the bed side dresser as he/she fell. Further, she stated at this point the resident was partially in the sling and partially on the floor with one (1) of his/her legs sticking out of the lift pad. In continued interview she called for help and the shower aide (CNA #4) arrived first and helped her lower Resident #44's leg from the lift. Per interview, CNA #4 then informed LPN #4 of the fall and the nurse immediately assessed the resident. During interview with LPN #4, on [DATE] at 9:28 AM, she stated Resident #44 sustained the fall while being transferred to the bed with a Hoyer lift by CNA #1 (orientee) and CNA #3. LPN #4 stated to her knowledge, CNA #1 had been checked off as being certified to use the mechanical lift prior to assisting CNA #3 with the transfer. Further, she stated upon being notified of the resident's fall, she immediately went to his/her room and noted he/she was lying on the floor. She stated she assessed Resident #44 and noted him/her to be alert and oriented, and to have a knot on the back of his/her head. LPN #4 further stated she initiated neurological checks every fifteen (15) minutes, notified the Medical Doctor and obtained an order for a CT Scan of the head. However, LPN #4 further stated the CT Scan was not obtained because the resident became unstable and had a change in level of consciousness about an hour after the event. She stated the Medical Emergency Response Team (MET) was called, and the resident was subsequently transferred to the hospital. In an interview with RN #4, on [DATE] at 11:49 AM, she stated the MDS Nurse was responsible for developing and revising care plans. Further, it was important for staff to implement the care plan for the safety of the residents. In an interview with the Staff Development Coordinator on [DATE] at 11:00 AM, he stated the floor nurses did not develop care plans, as that was the responsibility of the MDS Nurse. Further, he stated the floor nurses did not revise the care plans, but could initiate interventions after conferring with either the On-Call Manager or the Director of Nursing. He stated it ultimately was the MDS Nurse and Manager's responsibility to update the care plans. Continued interview revealed it was important for residents who were at risk for falls to have individualized fall interventions for staff to implement. During interview with the MDS Nurse, on [DATE] at 4:47 PM, he stated the Comprehensive Care Plan was generated from the MDS Assessments. He further stated he completed MDS Assessments on residents upon admission, quarterly, annually and with a significant change. The MDS Nurse stated it was his responsibility to develop the Comprehensive Care Plan (CCP) and revise them with each MDS Assessment, and he also revised the CCP with any changes in the resident's condition or with any changes necessary. The MDS nurse stated he was responsible for updating the Resident Summary which served as the CNA care plan. In continued interview, he stated human error was the reason he failed to develop/update Resident #44's CCP with interventions to include the type of lift to be used for transfers, as well as, how many staff was required for the transfer. He stated it was important to have all fall interventions on the CCP in order to prevent falls. In an interview with the Interim Director of Nursing (DON), on [DATE] at 11:30 AM, she stated it was the MDS Nurse's responsibility to develop the care plans from the MDS Assessments. Further, she stated the MDS Nurse was also to revise the care plans with necessary information. In continued interview, she stated it was her expectation for the comprehensive care plans to be person-centered and reflect the needs of the resident. The Interim DON stated in order to prevent accidents and falls, it would be important to ensure fall interventions were available to staff on both the CCP and the Resident Summary and to ensure the interventions were implemented. In an interview with the Executive Director on [DATE] at 10:23 AM, he stated it was his expectation the CCP and Nurse Aide Care Plan included specific information to guide staff for safe resident transfers in order to prevent falls. Further, he stated it was his expectation staff implement the interventions. In continued interview he stated it was his expectation the facility followed the Centers for Medicare/Medicaid Services (CMS) regulations and requirements regarding care plans and making updates to care plans. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #44 expired on [DATE] after being transferred to the hospital Emergency Room. 2. On [DATE], the Executive Director removed the lift and sling used during Resident #44's transfer from service. A visual inspection was performed. No issues were identified. The Executive Director interviewed both CNA #1 and CNA #3, who were present during the transfer of Resident #44 and walked through the event details. 3. On [DATE], a technician from the facility's service department, completed a safety check of the lift and noted no safety issues. 4. On [DATE], as part of the Root Cause Analysis, an event re-enactment was conducted by the District Director of Operations, Executive Director, Interim Director of Nursing, Staff Development Coordinator, Wound Care Nurse, Shower CNA, and one of the CNAs who was present during the event, to gather details of how the event occurred. 5. On [DATE], an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the QAPI Team which included the Executive Director, Interim Director of Nursing, Wound Care Nurse, Registered Dietician, Social Services, Case Manager, Respiratory Therapy Manager, Activity Coordinator, Staff Development Coordinator, Infection Control Preventionist, and the facility Medical Director via telephone. The QAPI team, after reviewing the reenactment information, recommended changing the type of sling that the facility was using from a split leg sling to a full body sling that was more appropriate for their specific resident population. The QAPI team also approved the education plan for licensed nurses, CNAs, and Physical and Occupational Therapists who utilized the mechanical lifts and sling pads. 6. On [DATE], the Interim Director of Nursing completed a room-to-room audit to obtain the type and size of the lift sling that each resident was currently using. 7. On [DATE], all split leg slings were removed from residents' rooms and supply rooms by the Interim Director of Nursing, Wound Care Nurse, Executive Director, and the Nurse Managers. 8. On [DATE], the Wound Care Nurse reviewed the weight of each resident that utilized the mechanical lift for transfers to ensure the correct size full body sling was ordered. 9. On [DATE], staff was informed by the Executive Director of the discontinuation and the removal of all split leg slings, and the plan to replace them with full body slings. 10. Beginning [DATE], routine rounding was completed by administration including the Executive Director and other members of the QA team during daily morning huddles which occurred five (5) times per week, Monday through Friday. On weekends this was conducted by the charge nurses to ensure no split leg slings were being utilized on the unit and to provide ongoing communication to staff regarding the plan. 11. Beginning [DATE], Licensed Nurses, CNAs, and Physical and Occupational Therapy Staff completed education and a lift competency related to proper mechanical lift usage, the new universal full body slings, proper response to a resident fall/accident, supervision of residents and comprehensive care planning. The education was conducted by the Interim Director of Nursing, Licensed Nurse Managers, Staff Development Coordinator, and Wound Care Nurse. The education was followed by a post-test to ensure understanding of the information. The facility did employ agency staff, who were included in the education, competency, and post testing. New hires will receive the education. After the alleged date of removal of immediacy, no staff would be allowed to work without having received the education, competency, and completion of the post-test. A score of one hundred percent (100%) was required on the post test. If anyone did not achieve 100% on the first attempt, additional education would be provided and a retest would occur, until 100% was achieved. After three (3) unsuccessful attempts, the Human Resources Performance Improvement process would be executed by the employee's manager. 12. On [DATE], the Executive Director placed an order for the new, appropriately sized, full body slings. Slings were shipped and arrived by Friday, [DATE]. 13. On [DATE], the facility's monthly QAPI meeting was held, and the committee was updated regarding the education progress, full body sling implementation plan, and care plan audit results. 14. On [DATE], an Ad Hoc meeting was held with the QAPI committee. The meeting consisted of the Executive Director, Interim Director of Nursing, Wound Care Nurse, Registered Dietician, Social Services, Case Manager, Respiratory Therapy Manager, Activity Coordinator, Licensed Staff Development Coordinator, Licensed Infection Preventionist, and the Medical Director (via Telephone). The purpose of the meeting was to discuss the purchase of the new slings, which had arrived, the completion of staff education, and the plan for ongoing monitoring which would include observation of staff utilizing the new universal full body slings when transferring a resident with the lift. The plan was approved and scheduled to start the same day and occur daily for one (1) week, then decrease to five (5) times a week for one (1) week, then decrease to twice weekly for two (2) weeks, then decrease to monthly for four (4) months. The State Survey Agency validated the facility had taken the following actions: 1. Review of the Progress Note, dated [DATE] at 4:15 PM, entered by LPN #4, revealed Resident #44 was discharged from the facility on [DATE] at 4:15 PM and transferred to the hospital emergency room for evaluation and treatment. Review of the hospital Discharge summary, dated [DATE] at 10:22 PM, revealed Resident #44 was admitted to the hospital emergency room on [DATE] at 6:48 PM and expired on [DATE] at 10:22 PM. 2. In an interview with the Executive Director on [DATE] at 10:00 AM, he stated he had the Hoyer Lift and sling used during the transfer of Resident #44 removed from service and visually inspected the lift and sling and noted no issues. He further stated he had CNA #1 and CNA #3 give him an account of the event and write out statements regarding what happened. In an interview with CNA #3, on [DATE] at 12:27 PM, she stated she was interviewed about the transfer involving Resident #44 and gave a written statement to the Executive Director. Review of the Incident Binder, revealed documentation of written statements from CNA #1 and CNA #3 related to Resident #44's fall incident. 3. Review of the Incident Binder, revealed a work order dated [DATE] at 2:00 PM, detailing the inspection of the lift and verifying it to be operational. In an interview with the Technician from the service department within the facility, on [DATE] at 12:06 PM, he stated he performed a safety check of the lift that was used during the incident on [DATE] and found no issues. He further stated the lifts were inspected annually and per his records, that particular lift had an annual inspection on 05/2023 with no issues noted. 4. Review of the Incident Binder, revealed documentation of the re-enactment of Resident #44's fall on [DATE]. In an interview with the Executive Director, on [DATE] at 4:55 PM, he stated an event re-enactment was performed by Administration along with some nursing staff members including one of the CNA's that was directly involved in Resident #44's fall incident. He stated this was to gather additional information related to the event. During an interview with CNA #4, on [DATE] at 3:31 PM, she stated she participated in the re- enactment of the event. In an interview with the District Director of Operations, on [DATE] at 5:15 PM, she stated she assisted with the re-enactment of the fall event. 5. Review of QAPI minutes from [DATE], revealed the Root Cause Analysis was completed and the Re-enactment of Resident #44's transfer was reviewed. A recommendation for full body slings was made by the team. Additionally, staff education was discussed related to mechanical lifts. In an interview with the Medical Director, on [DATE] at 5:00 PM, he stated due to illness, he attended this meeting by phone, and they discussed the event and reviewed the re-enactment information. He further stated the QAPI team decided at that time they would change the sling type to full body slings. During interviews with the District Director of Clinical Operations on [DATE] at 5:15 PM, Dietician on [DATE] at 11:01 AM, and the Staff Development Coordinator on [DATE] at 11:17 AM, they verified attendance at the QAPI meeting on [DATE]. Further, they verified reviewing the reenactment information, and discussion related to changing the type of sling that the facility was using from a split leg sling to a full body sling. Additionally, they verified discussing staff education related to utilization of the mechanical lifts and slings. 6. Review of the Incident binder, on [DATE] at 9:55 AM, revealed documentation of room-to-room audits of sling sizes for each resident on [DATE]. In an interview with the Interim Director of Nursing, on [DATE] at 10:49 AM, she stated she performed the audit of sling sizes for the residents. 7. Observation on [DATE] at 2:23 PM, revealed there were no split leg slings in any of the resident rooms or supply rooms. In an interview with the Executive Director, on [DATE] at 10:00 AM, he stated all split leg slings were removed from resident rooms and supply rooms. He stated this was because the Root Cause Analysis related to Resident #44's fall determined the type of sling used for the transfer posed a risk. During interviews with the Interim Director of Nursing, on [DATE] at 10:49 AM, and the Wound Care Nurse, on [DATE] at 12:12 PM, both stated they assisted in removing the split leg slings from all resident rooms. 8. Review of the Incident Binder, revealed documentation of resident weights and sling size documented on [DATE]. In an interview with the Wound Care Nurse, on [DATE] at 11:47 AM, she stated she reviewed each resident's weight to ensure the correct size was ordered for the full-size body sling. 9. Review of the Incident binder, revealed the information sheet, dated [DATE], verified staff was informed of the discontinuation and removal of the split leg sling. Also, lifts were not to be used except for shower transfers until the full body slings arrived. In an interview with the Executive Director, on [DATE] at 10:00 AM, he stated he informed staff on [DATE], they would no longer be using the split leg slings as they were being replaced with full body slings. Further, he stated he informed staff the lifts were not to be used except for shower transfers until the full body slings arrived. In an interview with CNA #1, on [DATE] at 8:30 AM, he stated he was informed by the Executive Director about the slings being removed and not being allowed to use the lift for transfers until the new slings came in. In an interview with CNA #4, on [DATE] at 3:31 PM, she stated she was informed by the Executive Director about the slings being removed and not using the lifts until the new ones arrived. 10. Review of the Incident binder, revealed routine rounding starting [DATE] during daily morning huddles to ensure no split leg slings were being utilized on the unit and to provide ongoing communication to staff regarding the plan. In an interview with the Executive Director, on [DATE] at 4:55 PM, he stated he participated in rounding during daily huddle meetings to ensure no split leg slings were being used on the unit. In an interview with the Staff Development Coordinator, on [DATE] at 11:17 AM, he stated observations were being done to ensure correct usage of the mechanical lifts. In an interview with the Interim Director of Nursing, on [DATE] at 10:49 AM, she stated she participated in the daily huddles and ensured no split leg slings were being used on the unit and also ensured proper usage of the lifts. In an interview with RN #2, on [DATE] at 2:20 PM, she stated there were daily huddle meetings to ensure no split leg slings were being utilized on the unit and to see if staff had any questions related to the lift usage. 11. Review of the Incident binder, revealed verification, that before [DATE], Licensed Nurses, CNAs, and Physical and Occupational Therapy Staff completed education and a lift competency related to proper mechanical lift usage, the new universal full body slings, proper response to a resident fall/accident, supervision of residents and comprehensive care planning. In an interview with the Staff Development Coordinator, on [DATE] at 11:17 AM, he stated he trained the Wound Care Nurse, Nursing Managers, and some nursing staff regarding proper lift usage with new full body slings, proper response to a fall or accident, supervision of residents, and care plan education. During an interview, on [DATE] at 2:20 PM, Registered Nurse (RN) #2 stated she received education regarding proper lift usage with new full body slings and performed a return demonstration on the proper use of a mechanical lift. Further, she verified she received education on proper response to a fall or accident, supervision of residents, and care plan education. RN #2 stated she took a post-test. Review of the Incident Binder revealed documentation of RN# 2's education. In an interview with CNA #2, on [DATE] at 11:05 AM, she stated she received education on usage of the mechanical lift with new full body slings, and performed a return demonstration on the proper use of the mechanical lift. Additionally, she verified she received education on proper response to a fall or accident, supervision of residents, and care plans. She stated she took a post test, which was given to her by the Staff Development Coordinator. Review of the Incident Binder revealed documentation of CNA #2's education. 12. Review of the Incident Binder, revealed documentation of order invoices for the full body slings that were ordered and confirmation of receipt. In an interview with the Executive Director, on [DATE] at 10:00 AM, he stated he ordered the new full body slings. 13. Review of QA minutes from the [DATE] meeting, revealed it was attended by the Executive Director, Respiratory Therapy Manager, Medical Director, Director of Therapy, Infection Control Preventionist, Case Manager, Activities Director, Registered Dietician, MDS Nurse, Clinical Pharmacy Manager, and Staff Nurse. During the meeting discussion included the fall event on [DATE]; the education progress; full body sling implementation plan and care plan audit results. In an interview with the Executive Director, on [DATE] at 4:55 PM, he stated another QAPI meeting was held on [DATE] and the QA team went over the results of the care plan audits and education process. In an interview with the MDS Nurse, on [DATE] at 10:04 AM, he stated he printed off a census sheet and created an audit tool for the transfer status of residents, made corrections if any discrepancies were found, and presented the data to the QAPI Team at the meeting on [DATE]. 14. Review of the QAPI Binder, revealed signatures for all parties listed and documentation of meeting minutes. Per the minutes, discussion included lift audit forms and documentation of the audits. Review of the incident binder, revealed starting [DATE], there was observation of staff utilizing the new universal full body slings when transferring a resident with the lift daily for one (1) week, then five (5) times a week for one (1) week, then twice weekly for two (2) weeks, then to be completed monthly for four (4) months. During interviews with the Interim Direct[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents. Additionally, the facility failed to ensure staff were properly trained and knowledgeable of how to safely use the Hoyer lift (mechanical lift) for resident transfers. This affected two (2) of forty (40) sampled residents (Residents #10 and #44). On [DATE], Certified Nursing Assistant (CNA) #1 (orientee) and CNA #3 assisted Resident #44 to the bed from his/her wheelchair with the use of a Hoyer lift. The resident slid from the sling and landed on the floor. Resident #44 experienced a change in his/her level of consciousness (LOC). The Medical Emergency Response Team (MERT) was called. The facility transferred Resident #44 to the hospital emergency room (ER) for evaluation and treatment. Resident #44 expired at the hospital on [DATE] at 10:22 PM. Further observation on [DATE] at 10:30 AM, revealed CNA #2 and CNA #4, positioned Resident #10 on the lift sling while the resident was in the bed. The CNAs pushed the Hoyer lift over to the bed. However, they failed to lock the lift wheels prior to hooking the lift sling to the lift, and raising the resident off the bed. The facility's failure to ensure each resident received adequate supervision and assistance devices to prevent accidents has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] at 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), at the highest scope and severity (S/S) of a J; and at 42 CFR 483.25 Quality of Care (F689), at the highest S/S of a J, which was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. In addition, Substandard Quality of Care (SQC) was identified at 42 CFR 483.25, Free of Accident Hazards/Supervision/Devices (F689). An acceptable Immediate Jeopardy Removal Plan was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency (SSA) validated Immediate Jeopardy was removed on [DATE], prior to exit on [DATE]. Non-compliance remained in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656) at a Scope and Severity (S/S) of a D; and 42 CFR 483.25 Quality of Care (F689) at a S/S of a D, while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: In an interview with the Executive Director on [DATE] at 10:23 AM, he stated the facility did not have a policy regarding the Hoyer Lift and slings. Review of the Manufacturer's Instructions for the Hoyer Lift, revealed staff must receive training and practice before operating a lift. Staff should check a resident's physical capabilities, medical condition, and mental status before using the lift with them; using the appropriate size lift pad (sling) specifically designed for the lift. Continue review revealed instructions to lock both rear wheels on the back of the lift before attempting to lift the resident. Review of the facility's policy titled, Accidents and Supervision to Prevent Accidents, revised 11/2022, revealed the Subacute Unit (SAU) was to provide an environment free from accident hazards over which the SAU has control, and provide supervision and assistive devices to each patient to prevent avoidable accidents. Review of the facility's policy titled, Fall Response and Management, revised 10/2022, revealed the staff in the Subacute Unit (SAU), will attempt to break the resident's fall and take appropriate actions post fall including evaluating the resident for injury, noting any deviations from the resident's baseline condition and notifying the physician of changes immediately. Continued review revealed staff should determine if the resident experienced any head trauma, monitor neurological assessments per physician's orders, and evaluate the resident's limb strength. Further review of the policy, revealed the facility was to investigate the cause after the resident had been stabilized, revise the care plan if necessary, and notify the physician and family. 1. Review of Resident #44's closed medical record revealed the facility admitted the resident on [DATE] with diagnoses which included acute and chronic respiratory failure, and muscle weakness. Review of Resident #44's Falls Risk Assessment, dated [DATE] revealed the legend stated the resident was to be assessed by using the eight (8) criteria listed on this tool which included: mental status, incidence of falls, ambulation/elimination status, vision, mobility, medications, and predisposing diseases. Per the Assessment, if there was a score of ten (10) or above, the resident would be considered high risk for falls. However, there was no fall's score for this resident listed on the Assessment. Per the Assessment, this resident was not a fall's risk and no interventions were required at this time. Review of Resident #44's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), which indicated intact cognition. Continued review revealed the facility assessed Resident #44 as totally dependent on staff for chair/bed to chair transfer. Further review revealed the facility assessed the resident as having no falls. Review of Resident #44's Comprehensive Care Plan (CCP), dated [DATE], revealed a focus of Activities of Daily Living (ADL) Self Care Performance Deficit related to Immobility, Activity Intolerance, Weakness, Ventilator Dependent, and Tracheostomy; and required assistance with transfers. The CCP goal stated ADL/Self Care needs would be met on a daily basis through next review. However, there were no individualized interventions related to transfer technique nor was there an intervention to indicate how many staff were required to transfer the resident. Review of the Comprehensive Care Plan, dated [DATE], revealed Resident #44 was at risk for injury related to mobility impairment; use of psychotropic medication, and narcotic pain medication; and ADL/Self Care Performance deficit related to immobility. The goal revealed the resident would be free from falls and fall related injuries through next review. Interventions included: Anticipate and meet resident's needs; provide assistance with mobility and transfers as needed; assist with mobility as needed, and if anxious or restless assess basic needs, or room temperature. However, there were no individualized interventions related to transfer technique. Additionally, there was no intervention listed for a Hoyer lift, nor was there guidance as to how many staff members were required to transfer this resident. Review of the Resident Summary (Nurse Aide Care Plan), dated [DATE] revealed the facility care planned Resident #44 for the assist of two (2) with a mechanical/electrical lift for transfers. However, this Resident Summary did not specify the type or size of sling to be used. Additionally, it did not specify if a Hoyer lift was to be used. Review of Resident #44's Nursing Progress Note, dated [DATE], at 4:15 PM, entered by Licensed Practical Nurse (LPN) #4, revealed the resident was being assisted to bed from the chair with the use of a mechanical lift. The resident slid from the lift sling landing on the floor. The Nurse was notified immediately by the Certified Nursing Assistant (CNA). Upon assessment the resident was alert and oriented and able to answer questions, and had a raised area to the back of the head. No additional injuries were noted. Further review of the Note, revealed the resident was transferred back to bed using the lift. The Physician was notified and new orders were received for a Computerized Tomography (CT) of the head, but the resident experienced a change in level of consciousness (LOC) and the Medical Emergency Response Team (MET) was called. Per the Note, the resident was transferred to the emergency room (ER) for evaluation and treatment. Review of Resident #44's hospital Discharge summary, dated [DATE] at 10:22 PM, revealed the resident presented after a fall at the nursing home. He/she was found unresponsive and sent to the hospital for further evaluation and treatment. The Computerized Tomography Scan (CT scan) revealed a massive left convexity with a midline shift and signs of uncal herniation (occurs when rising intracranial pressure causes portions of the brain to move from one intracranial compartment to another). Additional review of the Summary, revealed Resident #44's poor prognosis was explained to his/her family and they expressed their decision to start comfort measures only. Resident #44 was terminally disconnected from the ventilator and passed away shortly. Time and date of death was [DATE] at 10:22 PM. Review of Resident #44's Death Certificate, revealed the cause of death listed was Blunt Force Head Trauma sustained from a fall. Review of the facility's Incident/Accident Report, dated [DATE], entered by the Executive Director, revealed the facility determined due to Resident #44's contracted stature and limited range of motion (ROM), the divided leg sling posed an increased risk of shifting out of proper position during the mechanical transfer. Two (2) CNAs were present and reported when Resident #44 began slipping they were not able to get to him/her in time. Immediate action items put in place included: removal of the lift and sling from service pending the service technician review; removal of all divided leg slings from service and transition to full body slings prior to any more transfers occurring; and begin education and competency training of sling change with plan of one hundred percent (100%) of staff to participate prior to transferring. Per the Report, the service technician review and inspection of the sling used for Resident #44 revealed both in good repair. In an interview with Certified Nursing Assistant (CNA) #1, on [DATE] at 8:30 AM, he stated, on [DATE], he was in orientation with his preceptor, CNA #3, who was training him. He further stated he had not been checked off on the lift (demonstrated proper usage of the lift) and therefore was just observing the use of the Hoyer lift and did not assist with the transfer of Resident #44. He stated the sling being used for the transfer had what appeared to be an opening made into the lower part of the sling. CNA #1 further stated Resident #44 slid out of the sling as it was being used to transfer him/her from the wheelchair to the bed from a high position and the resident's head hit the floor. He stated CNA #3 stopped and yelled for staff help and asked Resident #44 if he/she was okay and the resident responded, Yes. CNA #1 further stated immediately after the fall the resident didn't appear to have any injuries, but a few minutes later the resident started to have changes and he/she was transferred to the hospital. In an interview with CNA #3, on [DATE] at 12:27 PM, she stated she had worked at the facility since [DATE]. She further stated she had provided care for Resident #44 in the past and was aware without checking the care plan the resident was to be transferred per Hoyer Lift with the assist of two (2) staff. Per interview, she stated, on [DATE], she asked Resident #44 if he/she was ready for bed and he/she stated, Yes. CNA #3 stated CNA #1 was in training with her and she was to show him how to use the lift. She stated she assisted Resident #44 onto the sling while CNA #1 assisted with putting the loops of the sling onto the sling hooks of the Hoyer lift. She stated she then locked the wheels of the Hoyer Lift, and began to lift the resident off the wheelchair. CNA #3 further stated she stopped for a brief moment to check the resident for stability, and everything appeared to look good; then she unlocked the wheels and proceeded with moving the resident towards the bed. In continued interview with CNA #3, she stated Resident #44 began to slide out of the sling from the opening that was built into the bottom of the sling lift pad. She further stated Resident #44 fell hitting his/her head on something, which she thought was the bedside dresser as he/she fell to the floor. Further, she stated at this point the resident was partially in the sling and partially on the floor with one (1) of his/her legs sticking out of the lift pad. CNA #3 stated she and CNA #1 tried to break the fall, but were unable to prevent the fall in time. During continued interview with CNA #3, on [DATE] at 12:27 PM, she verified she was the only other person in the room assisting with the transfer besides CNA #1. CNA #3 stated she called for help from additional staff members, and the shower aide (CNA #4) arrived first and helped her lower Resident #44's leg from the lift. CNA #3 stated she then asked CNA #4 to get the nurse and CNA #4 came back with Licensed Practical Nurse (LPN) #4. CNA #3 stated CNA #4 told her (CNA #3), it appeared Resident #44 was placed in the sling incorrectly and the correct way to place the lift pad on the resident was with the lower part of the sling criss-crossed around the resident's legs. CNA #3 stated she used the mesh sling that was already underneath Resident #44 when he/she was sitting in the chair prior to the transfer and did not criss-cross the lower part of the sling around the resident's legs. CNA #3 further stated she was never trained on how to make sure the residents had the correct type or size sling. Additionally, she did not recall being trained on the use of the Hoyer lift and slings in orientation and was unaware of sling size for residents being posted anywhere or care planned. Review of education/training records revealed CNA #3 did receive Hoyer lift training on [DATE] which included type of sling and sling size to be used for residents. Further, the training revealed CNA #3 performed a return demonstration during the training. In an interview with Shower Aide, (CNA #4) , on [DATE] at 3:31 PM, she stated , she was in the hall when she heard the fall happen. Upon opening the door to Resident #44's room, she saw the resident sitting up straight on the floor, with the sling still underneath him/her. She further stated she asked CNA #3 what happened and CNA #3 stated to her, I was just trying to to get [him/her] up from the chair and into bed and [he/she] just fell. CNA #4 stated when she asked Resident #44 if he/she was ok, the resident stated, Yes, but my head hurts. She further stated after LPN #4 evaluated the resident, she (CNA #4) assisted with getting the resident back in bed and she (CNA #4) briefly educated CNA #3 on how to correctly place the sling underneath the resident. She further stated she could tell the sling was incorrectly placed under Resident #44 by the way it was wrapped around his/her legs. CNA #4 stated she had received training on the mechanical lifts when she was hired, but she could not recall if she received any annual training. She further stated there was a chart in the shower room that listed each resident and their weight and it specified which size sling each resident needed. However, she stated she was not aware of the CNAs using this chart to choose slings for the residents. During interview with LPN #4, on [DATE] at 9:28 AM, she stated she had only been employed at the facility for a little more than one (1) month when Resident #44's fall occurred. LPN #4 stated the resident sustained the fall while being transferred to bed with a Hoyer lift by CNAs #1 and #3. She further stated CNA #1 was in orientation and to her knowledge, had been checked off as being certified to use the mechanical lift prior to assisting CNA #3 with the transfer. In further interview, she stated CNA #4 notified her Resident #44 sustained a fall and when she arrived to the resident's room, he/she was lying on the floor swearing at CNA #1 and CNA #3. She further stated she assessed Resident #44 and noted the resident was alert and oriented, and had a knot on the back of the head. LPN #4 stated she initiated neurological checks for every fifteen (15) minutes, notified the Medical Doctor and obtained an order for a CT Scan of the head. LPN #4 further stated the CT Scan was not obtained because the resident became unstable and had a change in level of consciousness about an hour after the event. She stated the Medical Emergency Response Team (MERT) was called, and upon arrival advised her Resident #44 needed to go to the hospital. LPN #4 stated Emergency Medical Services (EMS) and the Fire Department were called and the resident was transferred to the hospital. During interview with Respiratory Therapist (RT) #5, on [DATE] at 11:06 AM, she stated she went to Resident #44's room after the the resident sustained the fall on [DATE]. She further stated when she arrived the resident was awake, alert and oriented, and requested to be suctioned. RT #5 stated she performed suctioning, and LPN #4 was performing fifteen (15) minute checks on the resident. She further stated about thirty (30) minutes later when she returned to check on Resident #44, she found him/her to have agonal breathing (gasping for air), head bobbing up and down, and eyes rolling around. RT #5 stated the Medical Emergency Response Team was called, and they realized it was a neurological issue. RT #5 further stated Resident #44 was transferred to the hospital ER for further evaluation. During an interview with the Respiratory Therapy (RT) Manager, on [DATE] at 4:47 PM, she stated on [DATE], she was sitting at the nurse's station when a nurse (she could not recall the nurse's name), came down the hall and told another staff member, Resident #44 was unresponsive. The RT Manager stated she questioned the nurse about Resident #44 being unresponsive, and the nurse informed her the resident had sustained a fall earlier. The RT Manager stated she entered Resident #44's room and noted the resident was back in bed, but didn't look well so she had another staff member call MERT to assist. In continued interview, she stated EMS and the Fire Department came to transfer the resident to the hospital and she assisted with providing ventilation to Resident #44 while enroute. She stated the primary role of respiratory during resident transfers was to provide protection and assistance with the resident's airway. During interview with the Interim Director of Nursing, on [DATE] at 10:49 AM, she stated she was the Interim DON from [DATE] to [DATE]. She further stated on [DATE] at approximately 5:15 PM, she was notified of Resident #44's fall by the Staff Development Coordinator (SDC). She explained after notification she went to the unit and spoke with LPN #4, who informed her Resident #44 was awake and alert after the fall and then began to decline. The Interim DON further stated she assessed Resident #44 and found the resident to be breathing really hard and at that time the Respiratory Therapist was trying to check the positioning of the resident's tracheostomy tube because of his/her past history of difficulty breathing. The Interim Director of Nursing stated MERT was called and eventually EMS transported Resident #44 to the hospital for further evaluation and treatment once they realized it was more of a neurological issue. She stated the family was notified at the time of transfer of the resident's change in condition. In an interview with the MDS Nurse, on [DATE] at 4:47 PM, he stated MDS Assessments were completed on residents upon admission, quarterly, annually and with a significant change in the resident. In continued interview, he stated it was his responsibility to develop the Comprehensive Care Plan (CCP) and revise them with each MDS Assessment, and he was also to revise the CCP if there were any changes in the resident. Further, he was also to update the Resident Summary which served as a CNA care plan. In continued interview, he stated human error was the reason he failed to develop/update Resident #44's CCP with transfer status and interventions to ensure a safe transfer. In an interview with the Staff Development Coordinator (SDC), on [DATE] at 11:00 AM, he stated he provided annual check offs on Hoyer lifts, and safe lifting ergonomics, with online education yearly and after an event. He stated during the education related to Hoyer lifts, he trained staff on how they were to select the proper size sling according to resident's size and weight. He stated the bindings of the slings were different colors depending on the size of the sling. The SDC further stated orientees were given lift check off training once they hit the floor by their preceptors. The SDC stated the orientees then had to perform another demonstration for him with the Hoyer lift in order to get checked off. During further interview with the SDC, on [DATE] at 11:00 AM, he stated the orientees could be a second assist person, but would not be permitted to operate the lift until they had demonstrated proper use of the lift in front of him and he checked them off. The SDC further stated CNA #1 had been educated on the Hoyer lift prior to the incident involving Resident #44, and was the second assist person during the transfer. However, he stated CNA #1 could not operate the lift as he was observing use of the lift, so that he could be checked off. He further stated prior to the incident the facility did not have any manufacturer's instructions or user manuals on the Hoyer lifts available' However, after deficient practice was identified, they had obtained copies of the instructions and staff had access to them at all times in the orange Education Binder. He also stated there was a copy of the instructions on the computer network drive that staff could utilize. During further interview with the Interim DON, on [DATE] at 10:49 AM, she stated it was her expectation staff was knowledgeable of the proper transfer technique, and proper equipment to be used during a transfer for the safety of the residents. She stated in order to prevent accidents and falls, it would be important to ensure this information was available to staff on the CCP and the Resident Summary. Continued interview revealed the SDC provided training for new orientees on hire related to the Hoyer lifts and also provided this training annually. She stated before the incident involving Resident #44, the facility did not have a clear written process of how to assess residents for the appropriate size sling. She stated the shower aide was initially doing the assessment for size on admission. She stated after the incident, the wound nurses assessed residents for the correct type of sling. In additional interview, the DON stated the facility had completed an investigation related to Resident #44's fall, and the root cause analysis revealed staff was using the wrong type of sling. In an interview with the Medical Director, on [DATE] at 5:00 PM, he stated he was notified of Resident #44's fall on the day it occurred by the Executive Director (ED). He further stated the Quality Assurance Performance Improvement (QAPI) team met the next day to discuss the incident and had been discussing the incident each meeting. In an interview with the Executive Director (ED), on [DATE] at 10:00 AM, and [DATE] at 10:23 AM, he stated he was notified of Resident #44's fall on the same day of the incident and then he notified the Medical Director. He further stated an investigation began immediately and there was an Ad hoc QAPI meeting the next day during which a re- enactment of the event was performed. The ED stated the Root Cause of Resident #44's fall was the split leg sling used with the Hoyer lift and the fact that the resident had contractures that caused him/her to slide out onto the floor. The ED stated it was concluded the split leg slings would be discontinued and replaced with full body slings. He stated prior to Resident #44's fall, the facility had ensured the orientees received education related to Hoyer lifts and demonstrated proper usage of the lifts. The ED stated staff received annual training related to the Hoyer lift usage. However, he stated there was not a quality assurance audit to observe for proper Hoyer lift usage before Resident #44's fall occurred. The ED stated the lift that was used for Resident #44 was put out of service and sent to the facility's service department for inspection. He further stated they removed all the split leg slings from residents' rooms and replaced them with full body slings. The ED explained it was his expectation that staff was knowledgeable and proficient in the proper usage of the Hoyer lift for the safety of the residents. 2. Review of Resident #10's medical record revealed the facility admitted the resident on [DATE] with diagnoses to include Quadriplegia and History of Transient Ischemic Attack. Observation on [DATE] at 10:30 AM, revealed CNA #2 and CNA #4 positioned Resident #10 on the lift sling while the resident was in the bed. The CNAs pushed the Hoyer lift over to the bed. However, they failed to lock the lift wheels prior to hooking the lift sling to the lift, and raising the resident off the bed with the lift. In an interview with CNA #2, on [DATE] at 11:05 AM, she stated she realized she should have locked the wheels on the Hoyer Lift after she positioned the lift over the resident's bed, and prior to hooking the resident's sling to the lift and raising the resident up with the lift. She stated she then should have unlocked the wheels in order to move the resident to the shower bed. In an interview with CNA #4, on [DATE] at 11:10 AM, she stated she did not realize CNA #2 neglected to lock the wheels of the lift prior to raising Resident #10 up with the lift as she was on the other side of resident's bed assisting. During further interview with the SDC, on [DATE] at 11:00 AM, and the Executive Director (ED), on [DATE], they stated monitoring of Hoyer lift usage was ongoing. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #44 expired on [DATE] after being transferred to the hospital Emergency Room. 2. On [DATE], the Executive Director removed the lift and sling used during Resident #44's transfer from service. A visual inspection was performed. No issues were identified. The Executive Director interviewed both CNA #1 and CNA #3, who were present during the transfer of Resident #44 and walked through the event details. 3. On [DATE], a technician from the facility's service department, completed a safety check of the lift and noted no safety issues. 4. On [DATE], as part of the Root Cause Analysis, an event re-enactment was conducted by the District Director of Operations, Executive Director, Interim Director of Nursing, Staff Development Coordinator, Wound Care Nurse, Shower CNA, and one of the CNAs who was present during the event, to gather details of how the event occurred. 5. On [DATE], an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the QAPI Team which included the Executive Director, Interim Director of Nursing, Wound Care Nurse, Registered Dietician, Social Services, Case Manager, Respiratory Therapy Manager, Activity Coordinator, Staff Development Coordinator, Infection Control Preventionist, and the facility Medical Director via telephone. The QAPI team, after reviewing the reenactment information, recommended changing the type of sling that the facility was using from a split leg sling to a full body sling that was more appropriate for their specific resident population. The QAPI team also approved the education plan for licensed nurses, CNAs, and Physical and Occupational Therapists who utilized the mechanical lifts and sling pads. 6. On [DATE], the Interim Director of Nursing completed a room-to-room audit to obtain the type and size of the lift sling that each resident was currently using. 7. On [DATE], all split leg slings were removed from residents' rooms and supply rooms by the Interim Director of Nursing, Wound Care Nurse, Executive Director, and the Nurse Managers. 8. On [DATE], the Wound Care Nurse reviewed the weight of each resident that utilized the mechanical lift for transfers to ensure the correct size full body sling was ordered. 9. On [DATE], staff was informed by the Executive Director of the discontinuation and the removal of all split leg slings, and the plan to replace them with full body slings. 10. Beginning [DATE], routine rounding was completed by administration including the Executive Director and other members of the QA team during daily morning huddles which occurred five (5) times per week, Monday through Friday. On weekends this was conducted by the charge nurses to ensure no split leg slings were being utilized on the unit and to provide ongoing communication to staff regarding the plan. 11. Beginning [DATE], Licensed Nurses, CNAs, and Physical and Occupational Therapy Staff completed education and a lift competency related to proper mechanical lift usage, the new universal full body slings, proper response to a resident fall/accident, supervision of residents and comprehensive care planning. The education was conducted by the Interim Director of Nursing, Licensed Nurse Managers, Staff Development Coordinator, and Wound Care Nurse. The education was followed by a post-test to ensure understanding of the information. The facility did employ agency staff, who were included in the education, competency, and post testing. New hires will receive the education. After the alleged date of removal of immediacy, no staff would be allowed to work without having received the education, competency, and completion of the post-test. A score of one hundred percent (100%) was required on the post test. If anyone did not achieve 100% on the first attempt, additional education would be provided and a retest would occur, until 100% was achieved. After three (3) unsuccessful attempts, the Human Resources Performance Improvement process would be executed by the employee's manager. 12. On [DATE], the Executive Director placed an order for the new, appropriately sized, full body slings. Slings were shipped and arrived by Friday, [DATE]. 13. On [DATE], the facility's monthly QAPI meeting was held, and the committee was updated regarding the education progress, full body sling implementation plan, and care plan audit results. 14. On [DATE], an Ad Hoc meeting was held with the QAPI committee. The meeting consisted of the Executive Director, Interim Director of Nursing, Wound Care Nurse, Registered Dietician, Social Services, Case Manager, Respiratory Therapy Manager, Activity Coordinator, Licensed Staff Development Coordinator, Licensed Infection Preventionist, and the Medical Director (via Telephone). The purpose of the meeting was to discuss the purchase of the new slings, which had arrived, the completion of staff education, and the plan for ongoing monitoring which would include observation of staff utilizing the new universal full body slings when transferring a resident with the lift. The plan was approved and scheduled to start the same day and occur daily for one (1) week, then decrease to five (5) times a week for one (1) week, then decrease to twice weekly for two (2) weeks, then decrease to monthly for four (4) months. The State Survey Agency validated the facility had taken the following actions: 1. Review of the Progress Note, dated [DATE] at 4:15 PM, entered by LPN #4, revealed Resident #44 was discharged from the facility on [DATE] at 4:15 PM and transferred to the hospital emergency room for evaluation and treatment. Review of the hospital Discharge S[TRUNCATED]