**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards and each resident received adequate supervision to prevent accidents for 1 (CR #100) of 1 resident reviewed for adequate supervision. -The facility failed to provide adequate supervision and training of the staff when they incorrectly identified CR #100 as having left the facility with a family member on 05/22/2023 but later identified him as eloped on 05/23/2023. This failure placed residents living in the facility at risk of harm due to avoidable accidents by inadequately monitoring and documenting resident whereabouts, with the potential of the residents eloping from the facility while still requiring care and treatment. This noncompliance was identified as Past Non-Compliant. The IJ began on 5/22/23 and ended on 5/24/23. The facility corrected the noncompliance by providing in-servicing and hands-on training regarding elopement for facility staff prior to state entrance. On 02/29/2024 at 10:54 a.m., facility administrator was notified of past noncompliance IJ. A plan of removal was not requested. An IJ template was provided to the administrator by email. Findings include: Record review of CR #100's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses include cerebral infarction with aphasia, dysphagia, lack of coordination, cognitive communication deficit, depression, and anxiety. Review of CR #100's MDS (Minimum Data Set) dated April 28, 2023, section C revealed a BIMS (Brief Interview for Mental Status) score of 7. Section G regarding resident's Activities of Daily Living (ADL) Assistance revealed resident needs supervision and one person assisting with bed mobility, transferring and toilet use. It also revealed resident requires limited, one-person assistance with dressing, eating and personal hygiene. Record review of CR #100's care plan dated 05/03/2023 revealed: 1. Focus: I have impaired cognitive function/dementia or impaired thought process r/t (related to) aphasia following acute CVA (cerebral vascular accident, a stroke) . -Goal: I will improve current level of cognitive function . -Interventions: 1. Keep my routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion .2. Ask yes/no questions in order to determine my needs. 2. I am at risk for discharge concerns r/t resident not able to stay at SNF (Skilled Nursing Facility) -Goal: Resident .will not experience AMA (this stands for against medical advice, used when a resident discharges from a health care institution against the advice of their doctor), or will not experience any negative outcomes as a result -Interventions: 1. Coordinate a care plan meeting as indicated. Include resident/patient and representative as indicated. 2. Refer to Social Services as needed. Record review of CR #100's progress notes dated 5/22/23 revealed RN B recorded resident as D/C (discharged ) home but no nurse progress notes or documentation detailing where the resident went to after he was last seen at the facility on 5/22/23. Record review of facility's grievance log from March 2023 to February 2024 revealed no concerns from CR #100 or family members. Record review of the facility's daily staffing sheet for May 22, 2023, when CR #100 eloped from the facility revealed that LVN C was working on resident's hall on day shift and RN B was working on resident's hall on night shift. Record review of LVN A's statement dated 5/23/23 revealed that she received a report from the day nurse LVN B that two residents had discharged , including CR #100, and when she walked the hall with the nurse both of them saw nobody in resident's room. LVN #1 said she never set her eyes on the resident and relied on LVN B's statement and discharged the resident in PCC, charting that he went home. Record review of CNA A's statement dated 5/23/23 revealed she last saw CR #100 around 6:50pm, as he was going towards the front of the building. When she asked where he was going, he said he was going to meet his wife. CNA A stated resident was acting normally. She saw him with a pullup in his hand. She told resident's nurse he was going to wait for his wife in the front lobby and she went to talk to him. Interview with CR #100's wife at 2/27/24 at 12:44pm, she said staff told her CR #100 informed them he was waiting for someone, but the wife told the staff she did not know anyone by the name CR #100 provided. She said she did not have transportation at the time so would not have been able to visit. She said CR #100's cognitive memory was 50% and he could not walk well. She said the police found CR #100 around a week and a half later sitting on his rollator, and that he was dirty and had lost his phone. The hospital informed resident's wife he had a diaper rash. She said the facility's told her their cameras face the front and did not capture him leaving. She said he never exhibited exit-seeking at his previous facilities. Interview with DON on 2/28/24 at 3:30pm, she last saw CR #100 sitting at the front entrance on 5/22/23 between 6-6:30pm. Resident #1 told her that his wife was coming to pick him up. DON said resident was pleasant and said he had eaten when asked. She didn't think nothing of it and trusted his nurse would sign him out on pass. When she came to work the following morning on 5/23/23, DON found out resident was marked as discharged in PCC. When she looked at his records, she did not locate any discharge paperwork. When she interviewed the nurse who worked the day shift of 5/22/23 , she said she thought the resident was leaving on pass. When she talked to the night nurse who took over the shift, she reported the day nurse told her the resident had been discharged . The night nurse marked the resident as discharged in the system. The DON said when she found out the resident was missing, she called a Code Pink, and the staff members did a full search of the facility and surrounding area by foot and car. The search was unsuccessful, so the Administrator notified the police for assistance. The DON also called CR #100's wife, who said resident is upset at her for not letting him come home and won't take her calls. The wife told the DON he has eloped multiple times before, but that she never told anyone at this facility. The DON then called resident's doctor who said resident is alert and oriented and therefore able to make the decision to discharge AMA. The DON called nearby shelters and hospitals. The facility conducted interviews of staff who worked with the resident on 5/22/23, including LVNs, CNAs, and housekeeping regarding resident's behavior. The DON said that LVN B was an agency nurse and did not return to the facility after 5/22/23 so she was unable to collect a witness statement. The facility reviewed cameras but was not able to see the resident exit the building. Based on the doctor's conclusion resident left AMA , the facility ended the search since he was able to leave on his own. When asked what should have been done, the DON said the nurses should have checked the sign-out binder, called the DON to confirm and reviewed PCC for discharge orders. During another interview with the DON on 2/29/24 at 9:50am, she stated the facility has not used agency staff since September 2023. She said the facility conducted in-services after the resident left, including rounding and census count during shift change, signing out residents, codes and elopement drills, anticipating elopement risk and identifying exit-seeking behaviors. She also said discharges are discussed during morning daily clinical meetings and that nurses receive resident discharge packets for the day so that staff are kept in the loop. She also said after the incident, nurses are required to provide a full 24-hour report both written and verbal. Interview with [NAME] County Police Department on 2/28/24 at 8:00am, the representative stated that a formal request for the police report on CR#100's missing persons case would need to be filled out and submitted to the legal department. The form has been submitted and is pending as of 03/12/2024. Attempted interview with RN B on 2/28/24 at 4:20pm and a voicemail was left. Attempted interview with LVN C on 2/28/24 at 1:01pm, LVN C was the one of the last staff to see resident at the facility. LVN C hung up after introduction. LVN C did not answer during the second attempt at 1:03pm; a voicemail was left. Interview with CR #100's physician on 2/29/24 at 11:44am, he stated that he had 4 visits with the resident between April and May 2023. He stated the resident was pretty stable, medically stable and that his visits were uneventful but that he left AMA (against medical advice). After the resident eloped, the DON called him regarding resident's right to leave. The physician said he told her he thought the resident could make his own decisions and therefore felt he was competent enough to leave on his own. When asked what his visits with the resident was like, the physician said he felt the resident was lucid and oriented every time he talked to the resident. He said during the last two visits with physician's NP, the resident could ambulate 150 ft (feet) with supervision. Physician did mention towards the end of his stay the resident was refusing physical therapy. Interview with the SW on 2/28/24 at 2:12pm, she said she conducts the BIMS score for residents. She said that CR #100 had a cognitive deficit, and she documents her assessments in PCC. She said that the resident never expressed wanting to leave the facility. She said she conducted initial social services assessments mainly with resident's wife. Interview with RN A on 2/28/24 at 9:19am, she said she did not know the resident. She said residents are assessed for elopement during admission and if they exhibit exit-seeking behaviors, such as saying I don't belong here or I don't belong here. If that happens, RN A will conduct an assessment and tell the DON who will conduct her own assessment for residents. She said she had elopement and Code Pink training in February. If residents are missing, staff will search each hall. If residents have a wanderguard it will sound an alarm. If residents aren't found after the search, staff will tell the Administrator and DON. Interview with LVN A on 2/28/24 at 1:12pm, they stated they did not know Resident #1 since they work on a different hall. They said they have in-services on elopement and abuse neglect twice a week. They said they round on residents every 30 minutes. When residents exhibit exit-seeking, they are placed on 1-to-1 monitoring and the DON was informed. An assessment would then conducted and if they determine a wanderguard is needed resident's representative will sign the form and resident will be placed with one. Wanderguards are checked for function every shift. When asked what they would do if they can't find a resident, they said they would check that the resident didn't go out on pass or an appointment and check all the rooms. If resident can't be located, they will notify staff to assist. If they still cannot locate resident, they will tell the DON, Administrator and the resident's physician. Interview with CNA B on 2/28/24 at 1:30pm, she stated that she did not know the resident and did not work on his floor. When asked what she would do if a resident said they want to go home, she would check to see if they have any appointments. If not, she would redirect the resident and inform her Charge Nurse or DON of resident's behavior. If a resident cannot be located, she would search the building; if unsuccessful she would go to the nurse's station and call a Code Pink. If that is unsuccessful, someone would call the DON. CNA B had an in-service on abuse and neglect two weeks ago. She said they have elopement in-services and drills every few months. Interview with Staff A on 2/29/23 at 10:00am, they stated that CR #100 had cognitive impairment. They said he had orientation, memory, reasoning, and safety awareness deficits. Resident was verbal and never mentioned wanting to leave. Interview with Staff B on 2/29/23 at 10:10am, they stated that CR #100 was very cooperative. He was in rehab for endurance and strengthening so he could achieve his goal of living alone. Staff B was surprised and never thought the resident would leave and he never had any discussion or complaints about leaving facility. Interview with Staff C on 3/1/24 at 9:30am, she stated that she did not know the resident. She said if a resident was missing, she would look in all the rooms on her hall. If unsuccessful, she would call a Code Pink and have all staff search the building. If resident is still missing, someone will let the Administrator and DON know. Since resident eloped, she has not heard of another elopement that she's aware of. Interview with the facility receptionist on 3/1/24 at 9:16am, she stated that when she sees residents walking towards the door, she makes sure they have signed the on-pass binder (on-pass was when the resident has received permission to leave the facility) at the nurse's station. She said if residents leave with family they are expected to electronically check in, then go to the nurse's station to sign the on-pass binder before residents can leave. Observation on 3/1/24 at 11:45am, a sign near guest check-in stated that guests should sign check-in binder at the nurse's station before leaving with residents. Record review of facility's Elopement policy dated January 2023 revealed the guideline on facility response to being unable to locate a resident as follows: 1. .immediately initiate a search of the entire community both inside and outside premises 2. Search all rooms within the community . 3. Conduct a complete head count of all residents . 4. If the resident is not located .notify the Administrator/DNS immediately 5. Confirm all doors and windows are secured. Check all door locking systems, door alarms .exit seeking alarm devices . Further review of the facility's Elopement policy stated that the facility is supposed to review sign out logs and confirm with family, notify the MD (resident's physician), Administrator/DON, medical director and initiate an investigation and implement and develop a 4-step response plan. Additional steps are to assess current residents for elopement and provide services such as wanderguards (which are bracelets that activate an alarm when residents get close to any exit doors) and/or placing residents on Memory Unit if needed, and to refer residents to psychiatric/psychological services. Record review of facility's Resident's Rights policy dated October 2022 states that resident rights include: all care necessary for them to have the highest possible level of health .to discharge themselves from the community unless they have been adjudicated mentally incompetent. Record review of the facility's Admissions Packet dated 10/12/2020 states that residents may leave the facility for therapeutic home visits called out-on-pass, with permission of resident's attending physician and RP (responsible party). Administration will be notified of all passes in advance and the resident will be signed in and out at the nurse's office. The The facility corrected the noncompliance by providing in-servicing and hands-on training regarding elopement for facility staff prior to state entrance, as evidenced below: Record review of facility's Discharge Assessment in-service acknowledgement dated 5/22/23 revealed charge nurses received training for how to discharge a resident in the online portal. Record review of the facility's daily staffing sheet for May 22, 2023, when CR #100 eloped from the facility revealed that LVN C was working on resident's hall on day shift and RN B was working on resident's hall on night shift. Record review of facility's Residents leaving AMA in-service acknowledgement dated 5/23/23 revealed nursing staff receiving training on the process for when a resident requests AMA. The steps included: notify the doctor, notify the DON, notify the responsible party, have the resident fill out the release form, and writing a process note stating the resident choosing to leave AMA, the time they left and how they left. Record review of facility's Discharge and Residents Leaving Facility in-service acknowledgement dated 5/23/23 revealed nursing staff receiving education on documenting resident leaving the facility, including how the resident left and where the resident was in route to, and a note after resident return, if applicable. The signature page included RN B the nurse who marked Resident #1 as discharged without verifying physician orders. Record review of facility's Shift Change Rounds/Resident Count in-service acknowledgement dated 5/23/23 revealed nursing staff receiving education on being expected to perform room to room rounds during shift change and checking the census for their hall. Residents who are not accounted or not discharged from PCC (Point Click Care, electronic medical record system) are treated as a missing person/elopement and that the DON and Administrator must be notified immediately. The signature page included LVN A, the nurse who marked CR #100 as discharged without verifying physician orders. Record review of facility's Calling a Code: Elopement/Missing Resident in-service acknowledgement dated 5/24/23 revealed facility staff receiving education what to do when a resident is unaccounted for at a facility. Record review of facility's Code Pink Drill in-service acknowledgement dated 5/24/23 revealed nursing staff receiving education on what to do when a resident was missing or eloped.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 2 out of 2 residents (Resident #1 and CR #2) reviewed for adequate supervision. 1. The facility failed to ensure the Hoyer lift being used to transfer Resident #1 was in good condition, the sling broke and Resident #1 fell on the floor, resulting in injuries while being transferred, Resident #1 sustained head and hip injuries and pain from the fall requiring transfer to hospital for further evaluation and higher level of care. 2. The facility failed to ensure CR #2 was assisted by 2 persons during incontinent care. CR #2 fell off the bed during incontinent care while being assisted by one staff and Sustained deep laceration and bleeding from her legs requiring transfer to hospital for higher level of care for the injuries and surgical intervention. The resident expired from complications post surgical treatment at the hospital. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 9:52 AM. While the IJ was removed on [DATE] at 12:10 PM, the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of harm, injury, and hospitalization. Findings include: Review of Resident #1's face sheet revealed a [AGE] year old woman admitted to the facility [DATE] with diagnoses of Hemiplegia and hemiparesis, Type 2 diabetes, muscle wasting, lack of coordination, Chronic obstructive pulmonary disease, heart failure, contusion of scalp, and hypertension. Review of Resident #1's Kardex record revealed, she currently required Hoyer lift for transfer from bed to chair and from chair to bed. Review of Resident #1's progress note documented by LVN C at [DATE] at 08:08am revealed Res noted on floor in room lying on back next to bed. Golf ball-sized hematoma noted to back of head on right side. CNAs were resent x 2. Incident happened while attempting to transfer from bed to w/c via Hoyer. Res c/o pain to back of head. MD notified. Order given to send to ER via911. RP informed of status. Res able to move left extremities and head without difficulty. In an interview on [DATE] at 12:50 p.m. with Resident #1, she stated she saw that the straps on the Hoyer lift sling were rotting, she stated she could tell the difference in the color of the straps of the sling, and she told them (the two CNAs who transferred her) it was rotten. Resident #1 stated when she was being lifted up with the Hoyer lift the slings broke loose, and she fell and hit her head on the floor. She stated 4 staff members helped her and she was sent to the hospital. She stated she had an injury on top of her head, and it had not gone away yet because the top of her head was still sore. Resident #1 stated her head hurt for 2 or 3 days and then her head was spinning. She stated her vision had been blurry since the incident. Resident #1 stated the doctor came by one day and he did examine her. He looked at her head. In an interview on [DATE] at 1:48 PM Resident #1 stated she was still having pain at her hip and head due to the fall. She said the nurse gave her pain medication. In an interview on [DATE] at 1:46 PM with CNA K on 100 hall, stated he had been working with the facility for three months; he started working in [DATE]. The Surveyor asked to know what training regarding a Hoyer lift he received during hiring. He stated they watched video. Further interview with CNA K revealed there was no hands on training, return demonstration on Hoyer lift operation, and safety check observation for him during hiring. Observation and interview on [DATE] at 2:03 PM revealed in room [ROOM NUMBER]A the Surveyor observed Resident #1 being transferred with Hoyer lift by two CNAs (CNA J and CNA L). Both CNAs failed to observe or inspect the Hoyer lift and the sling for safety, to make sure both the sling and the Hoyer lift were in a good working condition before they transferred Resident #1. In an interview with CNA J, she stated she had received in service training in the past week on how to use the Hoyer lift. CNA J did not state the reason why she did not perform a safety check on the Hoyer lift and the sling before they transferred Resident #1. In an interview with CNA L, she stated she was trained about using a Hoyer lift before she came to the facility. She also said she received training a few weeks ago around February 2023. In an interview on [DATE] at 2:55 PM with CNA P, working in the building as an agency staff, she stated it's been about eight months since she started coming to the building which she was off and on about 8 months ago. She said she just came back working at the building and today ([DATE]) was her first day coming back. She said she did not receive any training about how to use Hoyer lift in the building, she said I know how to use it because she had been using a Hoyer lift for a long time. She said, They know I know how to use it. The Surveyor asked how the facility knew that she could use a Hoyer lift, she said I told them I know how to use it. CNA P stated she did not go through any formal training on the use of Hoyer lifts and there was no return demonstration oh check off done for her before she started taking care of the residents in the building. In an interview on [DATE] at 3:08 PM with CNA A, she said she started working at the facility [DATE]. She said she had been working as a CNA for 11 years. She said CNA M was the primacy caregiver for Resident #1. She stated she was called to assist her, and they were transferring the resident as they usually did for all residents during a transfer. She also said she believed the Hoyer lift was okay before they used it because that was what they used all the time. However, she stated they hooked up Resident #1 on the sling but it split on us. She said the sling split at the top side of the sling. The Surveyor asked if she inspected the sling or noticed if the sling was ripping fore they did the transfer. She stated, Not the part that it split. She stated At the bottom part, the blue part looked like it was [NAME]. She said they only used the black part (the loop) at the bottom of the sling. She said the top part appeared okay but the top was the part that broke. She stated it never occurred to her that the sling could break because the part of the sling loop that broke was okay, however she did not take the time to inspect other parts of the sling altogether. She stated when the sling broke, the resident fell on the floor. She said the resident said she had no pain, but she had a little swelling on her head. She said the nurse came to assess the Resident #1 and was transferred to hospital for further check up. She said the same day the incident happened the Director of Clinical Education took her to another resident to observe how they did the transfer on Resident #1. CNA A did not state specifically if they performed safety checks/inspections on the sling before they used it. She stated there was no previous training observation and/or return demonstration on safety inspection of Hoyer lifts and slings at the time of her hiring at the facility. In an interview on [DATE] at 3:27 PM CNA M stated she started working with the facility on [DATE]. She stated Resident #1 fell when they (CNA A and CNA M) were transferring her from bed to wheelchair, because the sling broke. She stated she was trained on how to use Hoyer lift after the incident. She stated however, she did not have any return demonstration training or check off on Hoyer lift transfers and/or safety inspection of Hoyer lifts during her hiring process. CNA M stated the training she got at the facility was on video. She stated also that she had been using a Hoyer lift for up to 2 years before she became a CNA and she told them at the facility that she knew how to use it. In an interview on [DATE] at 4:02 PM with the DON, the Surveyor asked about their training for nursing staff for Hoyer lifts, and she stated they usually trained their staff during hiring with 15 minutes video. She said all their new staff watched the video before they let them take care of residents. The Surveyor asked if there was any checklist/observation of return demonstration from the staff using a Hoyer lift, and she stated they had a checklist and return demonstration which they used for in servicing their staff. She stated she was not sure if there was any before she got to the facility. However, further interview with the DON revealed that since she became the DON at the facility, there was no return demonstration observed for the nursing staff during the hiring process training and there was no checklist in place prior to the occurrence of the incident. She stated further that they had, since the incident occurred, been training every staff, and making sure they got the in service before they got to work with the residents. She stated the Director of Clinical Education was the one who always handled training with staff during the hiring process and the tool she used was the 15 minutes video. The DON stated further that when the incident happened, the company who made the Hoyer lift was called to come in and train them (facility staff). When asked about how often the company trained them, she stated she did not know the last time the company came to train the facility, and they never had any issue with the Hoyer lift before the incident happened. In an interview on [DATE] at 5:25 PM with Laundry Staff A, who had been working with the facility since [DATE], she stated she had been working as a laundry staff up to 7 years and she had been laundering the sling same way washing and drying in low heat. She stated no one ever told her not to dry the sling in the dryer. She said she followed the manufacturer's recommendation to dry on low heat. She stated since she had been working at the facility, she had been using the dryer on low heat to dry the sling and no one ever instructed her not to do so even including her supervisor. She said the same day the incident happened with Resident #1, she was written up after the incident occurred, and her supervisor told her never to use the dryer to dry the sling. She said the facility brought rack the next day and installed it on the wall at the back of the door for her to hang the slings on whenever she washed them. When asked Laundry Staff A stated she never used bleach to wash the sling since after COVID 19 protocol changed. She said during the outbreak of COVID 19 the guideline was to wash everything in the yellow bag twice with bleach and dry them twice. She said that was the only situation where she washed the sling with bleach, and it was the only the sling they used for residents in isolation for COVID 19, because she was trying to follow COVID 19 protocol. She said after the COVID 19 protocol changed she did not use bleach on the sling anymore. In an interview on [DATE] at 5:23 PM with Regional Director of Clinical Operation, she stated, as of the day that the Hoyer lift incident occurred, they did the 100% training for all staffs in the facility, and the training still continued. Review of CR #2's face sheet undated, revealed a [AGE] year old female, admitted into the facility on [DATE] with diagnoses of respiratory failure, heart disease, heart failure, kidney disease, morbid obesity, abnormalities of gait and mobility, and muscle wasting. Review of CR #2's care plan revealed she was a two person assist for bathing/shower, bed mobility, dressing/ grooming, hygiene, toileting/incontinent care, transfers, and turning/repositioning. s In an interview on [DATE] at 2:55 PM with CNA P, working in the building as an agency staff, the Surveyor asked how she would know if a resident required two person assist. She said she would hear from other CNAs because they would get report at the beginning of their shift. She said she did not know which record to review to see if any resident was a two person assist. She also stated she was not sure if it was documented in residents' profiles. CNA P stated the only way she knew if any resident was a two person assist was through the report from other CNAs. Review of hospital record for CR#2 revealed reason for visit was Laceration without foreign body left knee, initial encounter. and admit diagnosis was sepsis, unspecified organism Review of hospital record titled 'hospital course' dated [DATE] and electronically signed by MD at 10:06 a.m. revealed CR #2 has large laceration involving the deep subcutaneous tissue on both legs, right deeper than left. There is mild oozing on the right and a vein was ligated and the wound packed . The patient has difficulty talking due to shortness of breath . imaging was done without any fracture, but the wounds were extensive, so trauma surgery was consulted . 2 deep lacerations to the anterior aspect of both legs s/p fall . The right laceration was deep to the subcutaneous tissue approximately 16 centimeters in length and 5 6 centimeters deep. The left anterior lower leg laceration was superficial at 7.5 centimeter in length . postoperatively, patient had worsening shock and [NAME] (Acute Blood Loss Anemia) resulting in a AKI (Acute Kidney Injury) necessitating CRRT (Continuous Renal Replacement Therapy) and intubation for intensive mechanical ventilation. Patient ultimately made DNR (Do Not Resuscitate) comfort after being placed on three pressors and not tolerating CRRT. In an interview on [DATE] at 3:27 PM with CNA M, she stated resident CR #2 was a two person assist for all ADLs such as bed mobility, incontinent care, bathing/ shower, and transfer. In an interview on [DATE] at 5:10 PM with CNA B, who was providing incontinent care at the time CR #2 fell out of bed, he stated he assisted CR #2 reposition on her side, so he could clean her and change her diaper. He stated suddenly the patient fell from bed to the floor before he could intervene to hold her back in bed. He stated it was a surprise for him the night that the CR #2 fell. He stated he had been taking care (incontinent care) of the CR #2 all by himself in the past. He stated he knew the CR #2 very well and took care of the CR #2 often. He stated I was never really told that CR #2 required 2 people and had to be assisted by two people. He stated CR #2 sometimes would lay on her side to hold the side rail when turned, so he had taken care of CR #2 without any issues in the past. He stated his supervisors had always told him to call for help if he needed help, but no one had ever specifically instructed him to always use two person assist with the CR #2, neither was he trained or shown where to locate information in the resident's record. CNA B said he only used his initiative when taking care of all his residents including CR #2. He said he would call for help when trying to adjust resident's up in bed because the resident's was a big woman and he needed help to scoot her up. He said on the day when the CR #2 fell, he called on the nurse (LVN A) after which the CR #2 was transferred to hospital. In an interview on [DATE] at 4:47 PM with LVN A (the night nurse who assessed CR #2 after she fell out of bed), he stated he was called to the room after the resident fell out of bed. He said there was a CNA with the resident who was changing CR #2's brief. LVN A said he assessed the resident and observed a laceration on resident's lower extremities and bleeding. He said he tried to stop the bleeding by applying compression to the wound, and called 911 immediately, and he notified the DON, the resident's doctor, and family member. He stated he had to call 911 immediately because what he saw was a major thing. The Surveyor asked if CR #2 was usually a two person assist and the nurse stated the resident was usually assisted by 2 staff because CR #2 weighed more than 300 pounds. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 9:52 AM. The IJ template and the plan of removal was provided to the Administrator. The plan of removal was accepted on [DATE]. The plan of removal reflected the following: Immediate Jeopardy [DATE] 9:50 a.m.F689 Accidents and Supervision Imediate Response related to Accidents and Supervision 1. Resident # 1 Assessed immediately on [DATE] at 8:08 a.m. by LVN A resident alert, answers questions appropriately, gets up in w/c and propels self around and participates in activities back to baseline. 2. CR #2 discharged [DATE] at 8:30 a.m. to hospital via EMS. o All Team Members providing care to residents where re education/re training was provided regarding: o Transfers utilizing mechanical lifts and slings process and procedures by the DON/Designee. o Preventing Accidents/Fall Prevention/Promoting a Safe: identifying risk, reducing risks, and promoting an accident free environment and transferring as per indicated in the plan of care by DON/Designee. o Proper inspection of all mechanical lift devices and mechanical lift slings to validate that the equipment is in good repair and safe to use prior to patient use as per manufacturer's recommendation by Admin/DON/Designee. o Safe Lift and Transfer Program by the DON/Designee o Prevention of Abuse & Neglect as well as preventing, identifying, and reporting all suspicions or allegations of abuse by the DON/Designee o 1:1 skills observation DNS/Designee to validate competency on safe lift and transfers utilizing mechanical lift device to be completed prior to reassuming patient care. All staff to be educated prior to working the floor/shift by DON/Designee. o The DON/Designee provided immediate education on use of the Kardex (record that gives a brief overview of each patient care and is updated every shift). o The DON/Designee reviewed policy and procedure. No revisions were needed at this time. o Root cause analysis conducted for both incidents is: failure to thoroughly inspect the Hoyer pad and failure to review the Kardex prior to providing care to the resident. o Visual inspection of all Hoyer slings was conducted by the Administrator to determine if any slings were in use that should not be in use completed by the admin on [DATE]. o Community evaluated the process for cleaning and drying of slings and determine that the process the community is using is in accordance with the manufacturer specifications. The process was re evaluated on [DATE] and [DATE]. o Laundry staff and the Supervisor will be in serviced on washing and drying of the hoyer sling per manufacturer instructions: Sling is to be washed in warm water. Hoyer slings are to be dried utilizing the follow method: cool tumble dry, air dry or dry at a very low temperature. Date commenced: [DATE] Completion date: [DATE] Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. Risk Response: Residents who currently reside in community, noted as a fall risk, assistance with transfers may potentially be affected by the alleged deficient practice. o DNS/IDT/Designee reviewed/assessed other residents who require assistance with transfers. All residents Kardex/plan of care to assure it is an accurate reflection of current patient needs and/or complete the care plan review and update as indicated. Direct care staff was educated on the use of Kardex, including how and where to access the Kardex. o Proper inspection of all mechanical lift devices and mechanical lift slings to validate that the equipment is in good repair and safe to use prior to patient use as per manufacturer's recommendation by Admin/DON/Designee. o Validating transfer assessment are complete and accurate by DON/Designee. Date commenced: [DATE] Date of completion: [DATE] Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in service/education prior team members working their assigned shift. Systemic Response: o All team members will receive re education on Prevention of Abuse & Neglect identifying and reporting all suspicions or allegations of abuse. All staff will receive the education on Abuse and Neglect prevention, identifying and reporting before assuming next shift. Effective as of [DATE]. o All direct care staff will receive additional training on the below topics and will not assume next shift until education has been received. o Proper inspection of all mechanical lift devices and mechanical lift slings to validate that the equipment is in good repair and safe to use prior to patient use as per manufacturer's recommendation. o Inspection of all mechanical lift slings to ensure that they are in good repair and safe to use as per manufacturer's recommendation. o Validating transfer assessment are completed and accurate on all residents. o Reviewing the Kardex/plan of care specifically regarding transfer status/needs, prior to transfer care being provided. Reporting any concerns or inaccuracies to the charge nurse/licensed nurse for additional direction prior to care provided. o Validate competencies of care givers regarding safe lift and transfers process for utilizing mechanical lift devices. o Education on review of the Kardex prior to providing care in response to CR #2 incident. o DON/Designee conducted a 100% audit onall residents transfer status on [DATE]. Date commenced by DON/Designee: [DATE] Date of completion: [DATE] Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in service/education prior team members working their assigned shift. Monitoring Response: The Administrator/ DNS/ designee will conduct weekly rounds to validate that transfer policies are followed to ensure the safety and wellbeing of our residents. Additional education will take place based on needs observed during this process. All findings will be reported to the QAPI committee during monthly meeting until there is 100% compliance observed during observations Adhoc QAPI was conducted on [DATE] with Medical Director All team members included in Resident #1 incident were educated with validation of mechanical lift device conducted on [DATE]. The team member involved with the incident for CR #2 was educated on [DATE] by phone and in person on [DATE] by the DON on providing care to residents per Kardex, what is the Kardex, How/where to access Kardex and when to access Kardex. Surveyor monitored IJ from [DATE] through [DATE]. IJ was removed on [DATE] at 12:10PM. In an interview on [DATE] at 4:02 PM with LVN B working at the facility since [DATE]th she said she received training yesterday [DATE]on how to use Hoyer lift, and she was also trained sometime in the past weeks. When asked, she stated further that the training involved inspecting the lift and the sling to make sure both were in good condition. In an interview on [DATE] at 4:39 PM with CNA C working 2 years at the facility, she said she was trained yesterday ([DATE]) about Hoyer lift transfer and to inspect it before they use it to make sure it is safe In an interview on [DATE] at 4:42PM with CMA A about a year, she stated she was trained to check the color, make sure they were 2 people when using Hoyer lift, inspect the sling and make sure they were okay. In an interview on [DATE] at 4:44 PM with CMA B started working February 1st 2023. She said she was trained this morning the correct way to put patient in the Hoyer lift, to check the lift and the sling and to make sure it is not torn, and they must be 2 people to use Hoyer lift on residents. In an interview on [DATE] at 4:46pm with CNA D working at the facility for the 1st day. She stated she was trained today ([DATE]) about how to use Hoyer lift correctly she stated she was trained to inspect the Hoyer lift, make sure the Hoyer lift worked properly and to make sure it has no rip. Record review of Hoyer lift competency assessment training revealed training had been provided to the two CNAs (CNA A and CNA M) involved with Resident #1 transfer. Record review of Hoyer lift competency assessment training revealed training had been provided to the CNA B who provided incontinent car for CR #2 In an interview on [DATE] at 8:50 AM interview with RN A, she said she had been working at the facility two years. she stated she received training on Hoyer lift transfer 2 days ago ([DATE]), she stated she was trained on how to transfer resident from the bed to chair and chair to bed, to make sure the lift and sling was working well and safe, and to also make sure they were two person assisting the resident during Hoyer lift transfer. She said they were taught to look in the PCC (point Click care) under Kardex tab to see patients' ADL needs for them to know if patient required two person assist and/or if the patient required Hoyer lift for transfer. In an interview on [DATE] at 9:03 AM interview with CNA E an agency staff who stated she had been working for the facility in and out for a while. She stated she was trained on how to use Hoyer lift couple of times in the past days. She said she was taught to make sure no holes, no rips, no tears, on both the sling and the Hoyer lift machine. She also said she was taught to check the computer in the PCC Kardex to know if a resident required two person assistance with ADLs. Record review of Transfer Audit tool included date of audit, resident number, compliance met or not, and intervention implemented if compliance was not met during the audit. In an observation on [DATE] at 9:18 AM Surveyor observed Hoyer lift transfer with CNA F and CNA G in room [ROOM NUMBER] B Resident #3. The two CNAs inspected the Hoyer lift and sling for safety before they hook the resident up on the Hoyer lift [NAME]