**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 as was possible and each resident received adequate supervision to prevent accidents for 1 of 1 resident (Resident #13) reviewed for accidents and hazards. The facility failed to ensure Resident #13 was provided with adequate supervision to prevent her from falling off the mechanical lift of the facility van on 02/28/24. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/28/24 and ended on 03/05/24. The facility corrected the non-compliance before survey began. This failure could place residents at risk of harm and serious injuries due to lack of supervision and failure to follow protocols. Findings included: Record review of Resident #13's Face sheet undated revealed she was admitted to the facility on [DATE]. Resident #13 was a [AGE] year-old female admitted with diagnosis of anemia (low red blood cells), end stage renal disease (kidneys cease to function), dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working). Record review of Resident #13's significant change in status MDS assessment dated [DATE] revealed she had a BIMS score of 13 indicating no cognitive impairment. The MDS Assessment indicated Resident #13 was dependent with chair/bed-to-chair transfers. The MDS Assessment indicated Resident #13's car transfer was not attempted. Record review of Resident #13's care plan dated 12/22/2023 and revised on 02/12/2024 revealed: Resident #13 was at risk for falls related to impaired mobility, incontinent status with interventions that included Mechanical lift x2 to assist with transfers. Resident #13 has limited physical mobility related to generalized weakness with interventions that included The resident requires x1 staff participation for mobility and the resident uses wheelchair for locomotion. Record review of incident report dated 02/28/2024 revealed: nurse was called outside to the facility van resident was lying on right side on ground just behind van. Head to toe assessment done resident was assisted back in the w/c and brought into building. 14. Initial treatment/New orders revealed: assessment done sent to hospital for further evaluation. 15. Resident Statement revealed: I tipped over backwards and fell. Record review of the facility's Provider Investigation report dated 02/28/2024 revealed the following: [Resident#13] was being unloaded in the van using the lift. The seatbelt came unfastened and [Resident #13's] wheelchair tipted backwards causing [Resident #13 to fall backward hitting her head on the pavement. No bruising cuts, abrasions were noted. [Resident #13] complained of head pain. V/S WNL, pupils reactive, [Resident #13] was alert and oriented x4. [Resident #13] was sent to ER via ambulance. Record review of hospital medical records dated 3/1/24 revealed Resident #13 was transferred from local hospital to higher level of care hospital via helicopter on 2/28/24 with multiple trauma injuries: right subdural hematoma with 3mm leftward shift, T1 (first bone in the spinal column) acute compression fracture and T4 (fourth bone of the spinal column) acute compression fracture. During an interview on 03/24/24 at 10:38 AM Resident # 13 said she was returning from dialysis on 02/28/2024 when Van Driver D pulled into the facility and drove around to the back of the facility which is not where she was normally unloaded. Resident #13 said she was normally unloaded at the front of the facility. She said Van Driver D was unloading her from the van and was not paying attention and did not click the seat belt to hold her in. Resident #13 said Van Driver D started lowering the van lift and about halfway down to the ground she heard Van Driver D say, uh oh and then she fell off the lift and hit the ground on her head. Resident #13 said after she fell staff had come outside and were debating on if they should send Resident #13 to the hospital. Resident #13 said staff picked her up and put her back in her w/c and took her inside the facility. She said once she was back in the facility that is when the facility decided to send her to the ER. Resident #13 said she went to the local hospital and was life flighted to another hospital. Resident #13 said the facility was blaming the incident on her bag that hangs on the back of her w/c for dialysis. Resident #13 said the dialysis bag had nothing to do with the fall and Van Driver D was just not paying attention to what she was doing. Resident #13 said Van Driver D admitted that it was her fault that Resident #13 had fallen. During an interview by phone on 03/24/24 at 11:56 AM Van Driver D said that on 2/28/24 she had parked the van at the end of 500 hall to unload residents off the van. Van Driver D said it was cold outside that day so she parked the van at the end of 500 hall so residents would be closer to their rooms when she unloaded them. She said Resident #13 was on the lift and was about halfway down about even with the van bumper when all of a sudden, Resident #13 fell off of the lift. Van Driver D said she did not remember if the seat belt was latched or not. She said then she ran inside and got the nurse to come and assess Resident #13. She said Resident #13 was brought back inside the building and then sent to the ER. She said the facility had done education with her prior to the incident on how to properly load and unload a resident. Van Driver D said she had not driven the van since the incident. During an interview and observation on 3/24/2024 at 2:30 pm Van Driver E said he had worked at the facility for about 3 years and was the van driver prior to Van Driver D. Van Driver E said he had taken over transporting residents since the incident on 02/28/2024. Van Driver E demonstrated the process for unloading a resident using the wheelchair mechanical lift. Prior to placing the resident on the lift, the Van Driver E did a safety check of the safety belt by latching and pulling on belt to ensure it was fastened. He then stood on the lift to ensure it was secure. Van Driver E then placed resident on the lift by rolling the resident from the interior of the van onto the lift ramp. Van Driver E secured the wheelchair by locking the wheels, checked the safety belt again to ensure it was secured and fastened, placed the resident's hands on the bars and left all resident belongings or bags in the van until the resident was unloaded. Van Driver E stood behind the wheelchair with hands on the grips as he lowered the resident from the van. Van Driver E said the Maintenance Director had done all of the training with Van Driver D prior to her driving the van. Van Driver E said he rode with Van Driver D for her first week of transporting and did not have any concerns. During an interview on 03/26/24 at 10:25 AM Van Driver D said she had worked at the facility since 1/2024. She said on 2/28/24 she parked at the end of 500 hall to unload Resident #13. Van Driver D said she had two other residents on the van that she unloaded first without incident. She said she went to open the facility door for the first two residents that she had already unloaded and then came back to the van to unload Resident #13. She said the ramp was already down with the seat belt latched. She said she raised the lift back up and went to unbuckle Resident #13 from inside the van. Van Driver D said she rolled Resident #13 back on to the lift with Resident #13 facing the windshield and locked her wheelchair brakes. She said she had already latched the seat belt previously, so she did not latch it again. Van Driver D then said she is not a hundred percent sure she latched the seatbelt because it becomes like muscle memory and said she did not remember seeing if the seatbelt was latched. She said she was standing outside of the van and started lowering the lift. She said when the lift was about halfway down level with the van bumper, Resident #13 and her w/c fell off the back of the lift. Van Driver D said she tried to catch the resident but was not able to. She said she did not move Resident #13; she ran inside to get the nurse. Van Driver D said she stayed with Resident #13 until she was sent out to the hospital. Van Driver D said she had not driven the van since the incident. Van Driver D said she had been given a new job title of hospitality aide and would no longer be driving the van. During an interview and observation on 03/26/24 at 10:42 AM The Maintenance Director said he had worked at the facility since 2013. He said he did not witness the incident with Resident #13 on 02/28/2024. He said he inspected the van after the incident on 02/28/2024 and did not find any issues with the van. He said he inspects the van every Friday. He said the drivers were to inspect the van daily before transporting any residents. The Maintenance Director said prior to placing a resident on the lift, the Van Driver should do a safety check of the safety belt by latching and pulling on belt to ensure it was fastened. The Maintenance Director demonstrated the lift being raised and lowered to demonstrate the safety features of the lift. The Maintenance Director demonstrated that if anything touches the back ramp of the lift the lift will automatically stop moving. The Maintenance Director said he had completed Van Driver D's van training upon hire before transporting any residents and had no concerns. During an interview on 03/26/24 at 11:08 AM the DON said she had been the DON for 6-7 years. She said her expectation is for all residents to arrive timely and safely to appointments. She said she had not been trained on the facility van. She said she expects all van drivers to be trained and follow the policy and procedures when loading/unloading residents. During an interview on 03/26/24 at 11:11 AM the Regional Nurse Consultant said she expects van drivers to follow policy and procedures and protect the residents when transporting. During an interview on 03/26/24 at 11:11 AM the ADO said he expects van drivers to follow policy and procedures and protect the residents when transporting. During an interview on 03/26/24 at 11:11 AM the Administrator said she expects van drivers to follow policy and procedures of loading/unloading residents and protect the residents when transporting. Record review of employee disciplinary report revealed: Van Driver D was placed on investigatory suspension pending an investigation into allegations of resident treatment on 02/28/2024. Record review of witness statement provided by Van Driver D on 02/28/2024 at 3:30 PM revealed: [Resident #13] was in the van, and I had unlocked her straps and seatbelt. I pushed her back onto the ramp, and locked her wheels. Coming halfway down, the seatbelt popped off, and her chair went back. Her wheels were locked. She then fell backward and landed on her side and hit the back of her head. I didn't want to risk moving her, so I ran inside and got a nurse and aides. They checked her and got her up. She didn't have any obvious injuries other than a bump on her head. They brought her inside and sent her to the hospital. Signed by Van Driver D. Record review of witness statement provided by the Maintenance Director undated revealed: February 28, 2024. I [Maintenance Director] did investigate with a wheelchair on the lift in the van it flipping over. I tried using my legs and hands pushing back against it trying to flip the wheelchair to flip over. The wheelchair never flipped over. I tried this using the seatbelt and not using the seatbelt. Both actions produced the same thing of not flipping over. Signed by the Maintenance Director. Record review of a witness statement provided by the DON undated revealed: On Saturday 03/02/2024, I was working as a CNA covering 500 hall. Myself and the ADON, was making rounds and went into [Resident #13's] room to check on her. We spoke to her regarding the incident on the van .I then asked if she remember the van driver locking her wheels and securing the seatbelt behind her, she replied yes, but they must have come undone, because when she started lowering me down, I started rolling back and flipped out of my chair backwards and landed on the ground. Signed by the DON. Record review of vehicle inspection report dated 02/23/2024 revealed: 1. Seat belts clean and in good working condition was marked acceptable. 2. Wheelchair tie-downs inspected and working properly was marked acceptable. Vehicle inspector: Van Driver E/Maintenance Director. Record review of personnel file for Van Driver D revealed, Van Driver D had completed all employee auto training on 01/05/2024. Record review of the facility Employee Auto Training Handbook undated revealed: Wheelchair lifts make it possible to load wheelchairs of all weights in an efficient and safe manner. However, lifts are potentially hazardous equipment. They must be maintained and operated properly. Considerable caution and awareness is needed when operating a lift. Unloading: 4. Staff will stand behind wheelchair and will pull the resident onto the lift, lock brakes, place seatbelt around the rider (if available) and encourage the rider to hold handrails (if available). Staff will then lower the lift to ground until completely on the ground before unloading resident from the lift. Record review of QAPI notes dated 02/28/2024 indicated that the meeting was attended by the following members: Administrator, DON, ADON, Medical Director, Social Services, Dietary, MDS nurse, Activity Director, Assistant Business Office Manager, Human Resources Coordinator, Therapy, Maintenance Director and Medical Records. The interventions and plan for correction included: 1. Self report to HHSC. 2. The facility van was removed from service on 2/28/24. 3. On 2/28/24 & 2/29/24 the Maintenance Director and Administrator tested the lift with a staff member in a wheelchair to ensure that nothing was causing the wheelchair to tip. 4. No resident transport in the facility van until it has been assessed by maintenance staff for proper functioning of all safety devices/equipment. 5. Suspend known perpetrators immediately pending investigation. 6. Take statements from everyone involved or with potential knowledge/involvement. 7. Begin Abuse/Neglect in-service and/or assign course regarding abuse/neglect for all staff who transport or assist with transporting residents in the van. 8. The Maintenance Director and/or designee verified that all resident's wheelchair locks are functioning properly. 9. Inservice staff who transport or assist with transporting resident in the van on the following (with return demonstration): Staff members not inserviced will not transport residents. a. How to safely load and unload resident in the van using the lift. b. Insure when lift safety belt is buckled you hear an audible click. Once clicked, pull the belt as to try and pull it out of the buckle. If no click heard or the belt pulls loose from the buckle, notify the administrator and maintenance director immediately and do not attempt to lift or lower resident. c. When loading or unloading a resident, make sure the vehicle is parked on as flat a surface as possible. d. Properly securing a resident in the van. 10. Inservice all nursing staff to report immediately to the maintenance director if a resident's wheels do not lock once engaged . 11. Maintain a list of staff who have completed training and provided return demonstration regarding transporting a resident in the van. Staff not listed will not transport residents. 12. Complete risk management entry as other in Point Click Care. Record review of sign in sheets for in-service dated 2/28/24 through 3/5/24 indicated that 64 staff members had signed the sign in sheet for the in-service on Abuse & Neglect P&P. Record review of sign in sheets for in-service dated 2/28/24 indicated that 58 staff members had signed the sign in sheet for the in-service on Report immediately to the Maintenance Director any loose, broken, missing brakes on w/c that do not engage. Record review of sign in sheets for in-service dated 2/28/24 indicated that 3 staff members had signed the sign in sheet for the in-service on Securing Residents in Van. Record review of sign in sheets for in-service dated 2/28/24 indicated that 3 staff members had signed the sign in sheet for the in-service on When loading or unloading a resident make sure the vehicle is parked on as flat a surface as possible. Record review of sign in sheets for in-service dated 2/28/24 indicated that 3 staff members had signed the sign in sheet for the in-service on Ensure when the lift safety belt is buckled you hear an audible click. Record review of sign in sheets for in-service dated 2/28/24 indicated that 3 staff members had signed the sign in sheet for the in-service on No Bags, Luggage or other storage containers are to be on w/c during loading and unloading residents. Record Review of Van Driver D re-education on Employee Auto Training Handbook completed dated 2/28/24. Record review of Van Incident Monitoring dated 2/29/24 through 3/22/24 revealed 5 resident wheel chairs each week were checked to ensure brakes are functioning properly, and 5 instances a week of loading/unloading of a resident using the van lift to ensure the lift was used correctly. On 3/25/24 at 9:32 am the Administrator, and DON were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 2/28/24 and ended on 3/5/24. The facility had corrected the noncompliance before the investigation began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the residents environment remained free from accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 3 of 5 residents (Residents #4, #8, and #9) reviewed for accidents, hazards, and supervision. 1.The facility failed to adequately supervise Resident #4 when being transferred. Resident #4 sustained a fracture of the proximal tibia (broken bone below the knee) when the Hoyer lift tipped over while being transferred with a Hoyer lift device (a mobility device with a U-shaped base and an overhead horizontal bar with hooks on top. A sling suspended by loops or metal clips attached to the overhead bar with hooks. The lift is used to lift and transport people who cannot safely walk or put weight on either leg) by CNA A on 09/07/23. 2. The facility failed to ensure that on 9/26/23 at 10:26 am CNA B and CNA C opened the legs to stabilize base of Hoyer lift during transfer of Resident #9 from geri-chair to bed. 3. The facility failed to ensure that on 9/26/23 at 11:36 am CNA D and CNA E opened the legs to stabilize base of Hoyer lift during transfer of Resident #8 from shower bed to geri-chair. An Immediate Jeopardy (IJ) was identified on 9/26/23 at 2:50 pm. The IJ template was provided to the facility on 9/26/23 at 3:01 pm. While the IJ was removed on 9/27/23, the facility remained out of compliance at a severity level of actual harm that is not an immediate jeopardy and scope of isolated due to the facility's need evaluate and monitor the effectiveness of corrective systems. These failures placed residents at risk of falls, fractures, and death. Findings include: 1. Record review of a face sheet dated 9/26/23 for Resident #4 indicated that he was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: nondisplaced fracture of right tibial tuberosity (fractures that occur in the bony prominence on the front of the tibia (shin bone) near the knee), Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), and multiple sclerosis (a potentially disabling disease of the brain and spinal cord (central nervous system). Record review of Resident #4's Annual Comprehensive MDS, dated [DATE], indicated that he had a BIMS score of 15, which indicated no cognitive impairment. The MDS further indicated the resident's functional status was a 3 for transfers which indicated he required extensive assistance and a 3 for support in transfers which indicated he required two or more persons assist. Record review of a care plan for Resident #4 with revision date of 10/9/20 read .requires total assist X 2 staff with use of Hoyer lift . Record review of a facility in-service sheet dated 8/17/23, titled read CNAs - get a gait belt and keep one on you. You must use a gait belt for transfers you assist with other than Hoyer lifts. Hoyer lift transfer requires 2 people indicated that CNA A had signed the in-service sheet. Record review of a nurses note for Resident #4 dated 9/7/23 at 10:45 am read Summoned to shower room by ADON [name] stating that resident was on the floor. This nurse entered shower room and observed resident lying on the floor in the middle of the shower room on his back. Resident assessed for injuries no apparent injuries noted. Resident c/o slight pain to right hip 3-10 and pain 7-10 to right knee. Resident refused to go to ER stating that he did not think he needed to go. Resident requested to be put back into his bed. This nurse 2 other nurses and shower tech assisted resident off the floor and back into his bed via mechanical lift. Report to [name], PA for Dr. [name] residents fall and refusal to go to ER. [Name] gave orders for mobile X-ray, 2 view of right knee and 2 view of right hip. [Name] imaging called, and orders placed for x-rays. RP and DON aware of incident and orders received. Signed by LVN G. Record review of a witness statement dated 9/7/23 and signed by CNA A, read I, [name], CNA tried to transfer [name (Resident #4)] to his chair from the shower bed with the Hoyer lift. The Hoyer lift leg hit the shower bed leg and caused it to flip. I hurry hold the lift pad and put [name (Resident #4)] down on the floor to prevent from get hurt. I asked him if he hit his head, he said no. The accident was report. Record review of a nurses note for Resident #4 dated 9/7/23 at 2:10 pm read received x-ray results and impressions indicate possible Fx [fracture] to the left femur. Right knee is negative for any acute fractures this nurse reported findings to [name] PA for Dr. [name] and received new orders for 2 view x-ray of the left hip and femur. Resident continues to deny pain to bilateral hips and reports pain 5/10 to right knee. Signed by LVN G. Record review of a nurses note for Resident #4 dated 9/7/23 at 9:08 pm read Impression to left hip negative for Fx, [family member] and [name] PA notified of results signed by LVN H. Record review of a nurses note for Resident #4 dated 9/8/23 at 7:30 pm read Resident's RP [name] in facility, stated resident continued to have pain to RLE (right lower extremity). Noted slight swelling to leg, no redness or warmth noted. No bruising noted. Per RP request, resident to be sent to ER for eval and tx on 9/9/23 at 11 am. Refused transportation at this time, stated not this late. Transportation set up. Signed by LVN J. Record review of a nurses note for Resident #4 dated 9/9/23 at 11:00 am indicated that resident was transferred to ER at that time for MRI related to recent fall. Record review of hospital records for Resident #4 indicated that resident was admitted to the hospital on [DATE] at 2:46 pm with diagnosis of Impacted Fracture of proximal right tibia (A break in the shinbone just below the knee). Hospital course read .Patient was admitted with right knee pain. X-ray of the leg did not show any acute fractures although osteopenia was seen. He continued to have significant knee pain and MRI was done which showed impacted fracture of the proximal tibia which appears late acute/subacute. Orthopedics was consulted and did not recommend any acute surgical interventions. Non weight bearing, no range of motion and knee immobilizer was recommended for the next 4 to 6 weeks . Record review of a nurses note for Resident #4 dated 9/13/23 at 5:20 pm indicated that resident returned to facility at this time via ambulance transfer. 2. Record review of a face sheet dated 9/26/23 for Resident # 9 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: seizures (sudden, uncontrolled movements), hypokalemia (low potassium levels in the blood), diabetes (uncontrolled blood sugars), and hypertension (high blood pressure). Record review of Resident #9's Comprehensive MDS dated [DATE] indicated that she was unable to complete the interview for a BIMS score, and she was severely cognitively impaired. The MDS further indicated the resident's functional status was a 3 for transfers which indicated she required extensive assistance and a 3 for support in transfers which indicated she required two or more persons assist. Record review of a care plan for Resident #9 with date of 10/26/22 read .mechanical lift with staff X 2 to assist with transfers . 3. Record review of a face sheet dated 9/26/23 for Resident #8 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: epilepsy (seizures), cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), and bradycardia (low heart rate). Record review of Resident #8's Comprehensive MDS dated [DATE] indicated that she was unable to complete the interview for a BIMS score, and she was severely cognitively impaired. The MDS further indicated the resident's functional status was a 3 for transfers which indicated she required extensive assistance and a 3 for support in transfers which indicated she required two or more persons assist. Record review of a care plan for Resident #8 with revision date of 9/8/23 read .requires X 2 staff participation with transfers via mechanical lift . During an observation on 9/26/23 at 10:26 am, Resident #9 was observed being transferred from Geri-chair to bed by CNA B and CNA C. CNA B pushed the lift under the resident's Geri chair and both CNAs placed the sling on the red straps in the lift. Resident was lifted out of the chair and rolled over to the bed with the lift legs closed. The lift legs were rolled under the bed and the resident was lowered to the bed. During a joint observation and interview on 9/26/23 at 11:10 am, the Administrator and DON both said that Resident #4 was not actually in the shower when he fell, but in the common area of the room where transfers occurred. Observation of the shower room showed that there were multiple showers off one common open room for residents to transfer from shower beds or shower chairs to their regular chairs or beds. DON said that resident was found on floor in this common room after the fall while being transferred from the shower bed to his chair. During an observation on 9/26/23 at 11:36 am, Resident#8 was observed being transferred in the shower room from shower bed to Geri chair by CNA D and CNA E. CNA D moved the lift under the shower bed, the sling was attached at the green strap. Resident was lifted off the bed and CNA D pulled the lift back with resident in the air. Resident was pushed across the room with the lift. CNA D was in the process of pushing the lift under the Geri chair when LVN F opened the door to ask the CNA a question and said, make sure the legs are open. CNA D then opened the legs on the lift to the widest position. The resident was then lowered into the Geri chair. During an observation and interview on 9/26/23 at 1:20 pm, Resident #4 was observed up in a mechanical wheelchair with a Hoyer lift sling underneath him. Knee immobilizer was in place on right knee, with obvious swelling noted. He said that on the day that he fell, he was being transferred from the shower bed to his wheelchair and something went wrong with the leg on the lift, he was unsure what occurred, but the lift tilted over, and the bars were on his stomach and his leg/knee. He said that he believed that was how the fracture occurred. He said that the bars were very heavy and uncomfortable until they got them off him and got him up. He said he was immediately put back to bed with a lift and there were several staff members using the lift at the time they put him to bed after the fall. He said that the nurses looked over him well and tried to get him to go to the ER, but he did not think he needed to go at that time. He said he continued hurting despite pain medications and he did go to the ER a couple of days later. He said that CNA A had been caring for him for years and had always done the transfers by herself. He said that he did not know to tell her to get another staff member to transfer him. He said that he had an appointment tomorrow with an orthopedic doctor. He said that he would never allow any staff to transfer him without 2 people anymore because he was too nervous and afraid that something else might happen. During an interview with Resident #4's family member on 9/25/23 at 3:45 pm, she said that she was notified of the fall from the Hoyer lift on the day it occurred. She said that she could not remember what time she was notified, but that she had no issues with the way the facility handled it. She said that he seemed fine after the fall, but the next day started complaining of knee pain. She said that she did not want him sent out that day because it was too late but had him sent to the ER on Saturday 9/9/23. She said that the ER went back and forth over whether his leg was broken, but he ended up being admitted for a UTI. After admission, she said that they did tell her it was broken. A knee immobilizer was placed, and he would see an orthopedic doctor in the next couple of days. She said that it was her understanding that the employee was suspended pending investigation due to the accident and that she understood that the employee no longer worked here. She said that Resident #4 had multiple sclerosis and had been there about 7 years. During an interview on 9/26/23 at 9:20 am, the Administrator said that CNA A had been suspended and terminated after the incident with Resident #4 and was no longer employed by the facility. She said that CNA A and all other nursing staff had been in-serviced regarding using 2 people for Hoyer lift transfers immediately after the fall. During an attempted telephone interview on 9/26/23 at 10:36 am with CNA A, phone went to message that said not accepting calls at this time and there was no option to leave voicemail. During an interview on 9/26/23 at 10:38 am, CNA C said that she had been in-serviced on mechanical lift transfers but was not sure when. She said she got distracted by the other resident in the room yelling out cuss words while they were transferring Resident #9 and was just nervous and forgot to open the legs of the lift. She said the purpose of opening the legs on the lift was to allow more room to put the resident in the chair or bed. She said there must always be 2 people in the room to do a transfer with the lift. She said that she had been working as a CNA at the facility for about 3 years. During an interview on 9/26/23 at 10:40 am, CNA B said that she had been in serviced about doing transfers with a lift about a month ago. She said she was always supposed to have two people. She said she forgot to open the legs on the lift because the other resident in the room had said a cuss word that had distracted her while they were transferring Resident #9. She said she knew the legs were supposed to be open to help balance the lift. During an interview on 9/26/23 at 10:58 am, CNA K said that she was in serviced on Hoyer lifts upon hire, and she was hired 1 ½ years ago. She said there was always supposed to be 2 people for all Hoyer lift transfers. During an interview on 9/26/23 at 11:05 am, the Administrator said that she did not have another telephone number for CNA A. During an interview on 9/26/23 at 11:38 am, CNA E said she was in serviced about a month ago. She said she normally opened the legs of the lift and does not know why CNA D didn't open the legs. She said the purpose of opening the legs was for easier access to get the legs around the Geri chair. During an interview on 9/26/23 at 11:42 am, CNA D said she had worked at the facility for 1 year. She said she was in serviced on Hoyer lifts about a week ago. She said they were always supposed to have 2 people in the room for a Hoyer lift transfer. She said she did not open the legs on the lift all the way because the way things were arranged in the shower room, she couldn't maneuver the lift with the legs open. She said when she got the resident over the Geri chair that was when she opened the legs on the lift to fit around the Geri chair properly. During an interview on 9/26/23 at 1:05 pm, LVN F said when she walked into the shower room, from where she was standing it did not look like the legs to the lift were open. She said that was why she told CNA D to make sure the legs of the lift were open. She said they had just received an in-service about a week ago regarding Hoyer lifts. During an interview on 9/27/23 at 3:30 pm, the DON said that the legs of the Hoyer lift should be opened to provide stability to the lift to prevent it from tipping over. She said that the CNAs should have opened the legs on the base of the lift while moving resident. She said that she would be in-servicing staff and expected her staff to always use at least 2 people for Hoyer transfers and to have the legs open for stability. She said that improper Hoyer transfers could put residents at risk for injury, falls, and fractures. She said she had in-serviced staff after the fall with Resident #4, and she was ultimately responsible for training CNAs on proper transfers. She said that CNAs were supposed to check the [NAME] for proper methods to transfer residents and she would be doing more in-services with them. Record review of a facility policy titled Hydraulic Lift, undated read .8. Prepare the lift by setting the adjustable base to its widest position . This was determined to be an Immediate Jeopardy (IJ) on 9/26/23 at 2:50 pm. The Administrator and DON were notified. The Administrator was provided with the IJ template at 3:01 pm. The following Plan of Removal submitted by the facility was accepted on 9/27/23 at 8:11 am and included the following: Interventions: * Suspend and terminate CNA A, 9-7-23. * Disciplinary action given for CNA B,C,D,E 9-26-23 by Administrator/HR * 1on1 Hoyer transfer training with return demonstration given to CNA B,C,D,E by DON/ADON/Therapy on 9-26-23 3:15pm * MD notified of IJ 9-26-23 at 3:15pm * Ad hoc QAPI held with Medical Director 9-26-23 4:30pm * All residents were assessed and evaluated for transfer assistance by DON/ADON/MDS/Therapy 9-26-23 4pm * All resident care plans reviewed for accuracy of transfer assistance by MDS 9-26-23 4pm. * All nursing staff checked off on mechanical lift transfers by DON/ADON/Therapy 9-26-23 6:05pm Any staff member not present or in-serviced will not be allowed to assume their duties in providing Hoyer transfer until in-serviced. The following in-services were initiated by Admin/DON on .9/26/23 at 3:15pm. Any direct care staff not present or in-serviced will not be allowed to assume their duties until in-serviced. * Hoyer transfer x 2 staff, prepare lift by setting base to widest position to transfer by DON/ADON/Therapy/MDS 9-26-23 4pm, any staff member not present or in-serviced will not be allowed to assume their duties in providing Hoyer transfer until in-serviced. * How to use the [NAME] in PCC to determine the transfer status of a resident 9-26-23 4pm By DON/MDS/ADON/Designee * Following the care plan interventions including how much staff and the proper equipment required for transfers by DON/MDS/ADON/Designee 9-26-23 4pm * If unable to provide the required staff or equipment to perform a transfer, do not perform until staff are available by DON/ADON/MDS/Designee 9-26-23 4pm * If the required number of staff or equipment is not listed for transfers, contact the Charge Nurse, ADON, and or DON immediately by DON/ADON/MDS/designee 9-26-23 4pm Observations, interviews, and record reviews were conducted on 9/27/23 from 2:00 pm to 4:20 pm and included (Administrator, DON, ADON, 3 LVN's, 3 MA's, and 8 CNA's) to ensure these interventions had been completed. Record review of an employee disciplinary report dated 9/15/23 indicated that CNA A was terminated on 9/15/23. Record review of 4 employee disciplinary action request forms dated 9/26/23 indicated that CNAs B, C, D, and E were disciplined with written counseling on 9/26/23 for failure to follow hydraulic lift policy and procedure. Record review of an in-service training sheet with check off sheets indicated that CNAs B, C, D, and E were trained on Hydraulic Lift policy and procedure and were checked off on 9/26/23. Record review of the ad hoc QAPI form indicated that MD was notified of IJ on 9/26/23 at 3:15 pm. Record review of a sign in sheet indicated that ad hoc QAPI was held with Medical Director on 9/26/23 at 4:30 pm. Record review of the attestation form dated 9/26/23 indicated that all residents were assessed and evaluated for transfer assistance by DON/ADON/MDS/Therapy on 9/26/23 at 4:00 pm. Record review of the attestation form dated 9/26/23 indicated that all resident care plans had been reviewed for accuracy of transfer assistance by MDS on 9/26/23 at 4:00 pm. Record review of the skills check off sheets indicated that 60 staff members had been checked off with return demonstration on mechanical lift transfers on 9/27/23 at 4:00 pm. Record review of a facility in-service sign-in sheet titled Hydraulic Lift policy and procedure x 2 staff; prepare lift base to widest position indicated that 49 staff members had been in-serviced as of 9/27/23 at 4:00 pm. Record review of a facility in-service sign-in sheet titled [NAME] training for CNAs. Instructed how to access the [NAME] through POC Kiosk for every resident. [NAME] has to be accessed for every resident to determine the requirements of staff when performing care including transfers, bed mobility, dressing, toileting, bathing, eating. The [NAME] also provides information on the method the resident requires for transfers indicated that 45 staff members had been in-serviced as of 9/27/23 at 4:00 pm. Record review of a facility in-service sign-in sheet titled Accessing CP, CP information pulls the [NAME]. [NAME] training for CNAs. Instructed how to access [NAME] for each resident. [NAME] has to be assessed for every resident to determine the requirement for staff when performing care including transfers, bed mobility, dressing, toileting, bathing, and eating The [NAME] also provides information on the method the resident requires for transfers indicated that 14 CNAs had been in-serviced as of 9/27/23 at 4:00 pm. Record review of a facility in-service sign-in sheet titled if unable to provide the required staff or equipment to perform tasks/transfer, do not perform until staff x 2 are available. DO NOT RUSH indicated that 45 staff members had been in-serviced as of 9/27/23 at 4:00 pm. Record review of a facility in-service sign-in sheet titled if the required number of staff or equipment is not listed for transfers, contact charge nurse, ADON, or DON immediately indicated that 46 staff members had been in-serviced as of 9/27/23 at 4:00 pm. Nursing staff were able to appropriately indicate they would only transfer residents using a Hoyer lift if there were at least 2 persons to assist and would only transfer residents with the base open to its widest position. Nursing staff were able to identify resident's care plans, the [NAME] system and how to find required level of resident care. CNAs and MAs were able to demonstrate the use of the Kiosk system to find resident care needs. The following staff from day and evening shift were able to verbalize and demonstrate understanding of all in-services given: MA S on 9/27/23 at 2:00 pm CNA O on 9/27/23 at 2:00 pm CNA N on 9/27/23 at 2:05 pm CNA K on 9/27/23 at 2:15 pm LVN J on 9/27/23 at 2:20 pm ADON on 9/27/23 at 2:22 pm MA L on 9/27/23 at 2:25 pm MA M on 9/27/23 at 2:30 pm LVN H on 9/27/23 at 2:30 pm CNA P on 9/27/23 at 2:40 pm CNA Q on 9/27/23 at 2:45 pm CNA U on 9/27/23 at 3:10 pm CNA R on 9/27/23 at 3:15 pm CNA T on 9/27/23 at 3:20 pm The Administrator was informed that the Immediate Jeopardy was removed on 9/27/23 at 4:20 pm. The facility remained out of compliance at a severity level of actual harm that is not an immediate jeopardy and scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.