**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained free of accident hazards for 1 of 11 residents (Resident #1) reviewed for accident hazards and supervision. CNA A failed to provide adequate supervision for Resident #1 in the shower resulting in Resident #1 falling and fracturing her hip and ankle. Resident #1 had to be hospitalized and required surgical intervention. On 11/03/23 at 7:15 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 11/04/23 at 12:04 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of harm and/or injury and contribute to avoidable accidents. Findings Included: Record review of Resident #1's face sheet, dated 11/03/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include hemiplegia (severe or complete loss of strength or paralysis) & hemiparesis (slight weakness or mild loss of strength in leg, arm or face) following cerebral infarction (stroke) affecting left non-dominate side (left side), reduced mobility, long term (current) use of anticoagulants (blood thinners), muscle wasting and atrophy (waste away), lack of coordination, abnormal posture (rigid body movements), muscle weakness, chronic pain, dorsalgia (back pain), chronic embolism (a clot, ft air bubble travels through the blood vessels)and thrombosis (blood clot forms in a blood vessel), conversion disorder (mental health issue disrupts how the brain works, also known as hysteria)with seizures or convulsions, Atherosclerotic heart disease of native coronary artery without angina pectoris [thickening or hardening of the arteries (blood vessels that carry oxygen-rich blood away from the heart to the body)caused by buildup of plaque], and cerebrovascular disease (a group of conditions that affect blood flow and blood vessels in the brain). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #1 understands (clear comprehends). The MDS revealed Resident #1 had a BIMS of 09 which indicated the resident's cognition was moderately impaired; Section G revealed the resident transfer required limit assistance (resident highly involved in the activity, staff provides guided maneuvering of limbs and other non-weight-bearing assistance) with support (two+ person physical assist); personal hygiene required limit assistance resident highly involved in the activity, staff provides guided maneuvering of limbs and other non-weight-bearing assistance) with support (one- person physical assist); bathing required total dependence with support (one- person physical assist). Record review of Resident #1's care plan dated 07/30/23 revealed a problem area dated 07/17/23 for falls as Resident #1 has a history of falls due to poor cognition and a diagnosis of hemiplegia (paralysis on one side). Resident approach dated 07/21/23 revealed have staff place brief on patient with two-person assist in shower room. The care plan further revealed a problem area dated 07/17/23 for ADL's Functional Status/Rehabilitation Potential related to diagnosis of hemiplegia (paralysis on one side). The approach area revealed one-person assist with transfers, bathing, and dressing. The approach area further revealed toileting amount of assist transfer assistance when able, most of the time incontinent. Record reviewed Resident #1's progress notes revealed the following: -07/21/23 at 2:06 PM, LVN P documented Notified by staff that resident (Resident #1) fell in the shower. Went to assess pt. States unable to move L leg due to severe pain to L hip. Called and notified doctor (MD Q). Received order to sent (send) to ER for x-rays. Eval and tx. Called and notified RP of new order. -07/21/23 at 5:24 PM, LVN P documented Call ER to check on resident. Was notified by ER staff that left hip was fracture. Called RP and notified of fracture and that ER wants to speak with family to decide further tx. -07/28/2023 at 1:35 PM, ADON documented Resident is expected to be discharged from hospital back to facility tomorrow. This nurse attempted to call RP to ensure that she is aware but was unable to reach her via phone call or voice mail. In a phone interview on 11/03/23 at 10:15 AM, Resident #1 stated there were two aides arguing over who was going to shower her. She stated CNA K took her into the shower room. After my shower she stood me up and told me to hold onto the rail. I told her I could not stand up and she just left me. She stated, I will be right back. Resident #1 stated she did not know why CNA K left her in the shower alone. She stated she could not hold on to the handrail and fell in shower room. She stated CNA K came back and then got the nurse. She stated she cannot even hold a piece of paper in her left hand. During interview Resident #1 became emotional stating she just left me there. In an interview on 11/02/23 at 05:08 PM, Resident #1's family member stated the facility called to let the family member know Resident #1 had fallen, and she was going to the hospital. She stated when they called her, they did not make it sound like it was bad, so she waited for Resident #1 to call her from the hospital before going to the hospital. Resident #1's family member stated another family member called and informed her that Resident #1 had a fractured hip. The doctor stated Resident #1 told him she tried to stand up in the shower and fell in the shower. She stated Resident #1 cannot stand up and has been paralyzed for 15 years. She stated she took care of Resident #1 in her home and the reason she put her in the nursing home was because she was no longer able to transfer her without assistance. She stated there was usually two people assisting her in the shower when she has witness them showering her. She stated the facility never called to check on Resident #1. She stated it was one nurse who showered Resident #1 because they were short staffed, and she needed two people. She stated her Resident #1 told the nurse she could not stand, and she needed two people to help her. She stated she was never put on high fall risk and she was high fall risk. She stated she was paralyzed on the left side from a stroke and required two people to assist resident. She stated one-person showering her puts her at risk for a fall. She stated Resident #1 had no movement on the left side for 15 years. She stated Resident #1 was strong on her right side and has no impairment. In a phone interview on 11/03/23 at 10:46 AM, CNA K stated she worked at the facility through facility's corporate agency, and she is no longer employed with the agency. She stated she was working the day Resident #1 had a fall in the shower. She stated she was the CNA helping Resident #1. I had showered the resident and she was dressed. I had her stand up and hold on to the rail so I could pull up her brief and pants. While she was standing, she started to lean and fell on the floor. She stated she had showered resident before, and she was a one-person assist. She stated she did transfers fairly good from the wheelchair, but she did have one leg she could not stand on. She stated she did not have a gait belt on resident because she was pulling up her brief and pants. She stated she did not leave the resident unattended in the shower. She stated when resident fell, she stepped out of the shower room and the nurse was in the hall and came to shower room and assessed resident. She stated Resident #1 was not moved until EMS got to the facility. She stated she could not remember if there was any other staff working with her that day. She stated she got her out of bed that morning and took her to the shower room. She stated she never argued with any other staff. She stated she does not remember the names of any other CNA's working that day. She stated LVN P assessed the resident and the DON also provided resident care and took vitals. She stated Resident #1 was alert and orientated and able to answer questions appropriately. She stated Resident #1 did not hit her head. She stated her fall was more like me assisting her to the floor. She stated Resident #1 kept changing her story. She stated Resident #1 was holding the rail and started slipping to the left. She stated it's a real small shower room. She stated Resident #1 fell towards the wall away from the door. She stated she moved the chair behind her. She stood up and I kind of pushed the chair back to get behind her to pull her pants up and then she just started to slide to the left like she's still holding on to the rail and then she just went down. She stated her back was towards the shower head and I had to turn her around to face the rail. She stated she turned her to the right. Her right side was towards the door. She stated the shower chair was behind me and I was between the resident and the chair. She stated she was not sure what caused her to fall. She stated, she felt the resident lost her balance. She stated one of her hands (right hand) had contractures and she had to help her grab the rail and hold with that one and the right hand she can control that one fairly good. Surveyor clarified which hand had contractures and she stated the right hand, yes, the right hand is contracted. She can grip stuff and I put her hand on it (the rail) and then she can grip it. She stated she dried the rail before she stood Resident #1 up. Surveyor asked if Resident was weak on right side or left side and she stated, right side I believe. She stated Resident #1 had something wrong with her ankle and could not bear weight but could not remember what side. She stated Resident #1 could not walk but she could bear weight to pivot transfer. She stated she had never had any training related to transfers while working for the facility. She stated I've never really had training, I was agency, so it wasn't like full time. I just went whenever they needed or when I could. Surveyor asked CNA K are you sure it's her right hand that was contracted and she stated, yeah because I remember having to pick it up and put it on handrail, but I don't remember what ankle was hurt, maybe right. When asked if she had any paralysis on one side or the other, she stated No I do not think so, because she used her hands and was able to stand. She just could not bear weight on that one leg. She stated Resident #1 never stated to CNA K they might need another CNA to help. CNA K stated Resident #1 did really good with transferring because it was morning and she had to ger her up and out of bed into wheelchair. She stated she took her to the shower room in her wheelchair. She stated once in the shower room she places wheelchair in front of grab bars and stood resident up and moved the wheelchair and place the shower chair behind Resident #1 and assisted her to sit on shower chair. She stated she gave Resident #1 a little push to assist her stand. She stated the resident could assist herself on her own. In an interview on 11/03/23 at 11:35 AM, the DON stated when she arrived at the shower room, Resident #1 was laying of the floor with her head towards the back wall complaining that her left leg hurt. The DON stated the resident was half dress and she wanted to be covered up. The DON stated she covered her with towels and put a pillow under head. The DON stated Resident #1 admitted to the facility with stroke affecting her left side, paralysis. The DON stated Resident #1 had fractured her hip, she was sent to a hospital in a larger city to have surgery. She stated Resident #1 did not return back to the facility. The DON stated Resident #1 admitted with paralysis on the left side due from a stroke. She stated Resident #1 could stand while holding on to the handrail with one hand. The DON continued to state, Resident #1 could tell the staff if she was having a bad day and she needed extra help. The DON stated, in her investigation of the incident, Resident #1 lost grip of the handrail and started sliding down the handrail and CNA K assisted her to the ground. In a telephone interview on 11/03/23 at 03:00 PM, TDOT stated she had staff come to the therapy room two at a time and instructed them on the proper ways to transfer and the staff did a return demonstration; she stated she did not have any documentation except the sign in sheet. She stated Resident #1 was on therapy services and her fall on 07/21/23 happened a day after she was discharged from therapy. She stated Resident #1 had paralysis on left side. She stated gait belts should be used with stand pivot transfers. She stated staff should not use residents under arms to assist them to standing. She stated not using a gait belt with stand pivot transfers would be an improper transfer. In an interview on 11/03/23 at 12:31 PM, CNA L stated she was working the day Resident #1 fell. She stated the facility had been using a lot of agency staff. She stated she had transferred Resident #1 before, and she was a two-person transfer. She stated she knew how to transfer residents by using her knowledge from the past. She stated she just knows how to transfer residents and all residents should be transferred with a gait belt regardless of weight or the resident's ability to assist. She stated therapy tells them how to transfer a resident by the resident's assessment and trains them on how to transfer the resident. She stated Resident #1 was a two-person transfer and when she transferred her, she always used two people. She stated Resident #1 would tell you how to transfer her, whether one staff or two staff was needed. In an interview on 11/03/23 at 04:11 PM, LVN N stated she was not involved in Resident #1 fall. She stated the staff knew there was a book at the nurse's station with cheat sheets with resident information. She stated she had always told staff if they need help to ask the charge nurse. She stated she never would transfer Resident #1 by herself, she would always get help. She stated Resident #1 could bear weight, but legs would give out on her. She stated staff should be able to find how each resident was transferred in the care plan. In an interview on 11/03/23 at 9:30 AM, CNA G (agency) stated this was her second day at the facility and she did not know where to locate the assistance a resident need, like transferring. CNA G continued to state depending on the size of the person if she needs another person or not. In an observation on 11/03/23 at 09:34 AM, ADON C at the nurse's station educating staff on how to find the care plan information for each resident. In an interview on 11/03/23 at 9:44 AM, CNA H (agency) stated she had been coming to the facility off and on for about five months. She stated when she arrived at the building, during report, the CNA told her she was relieving who was continent and incontinent and which residents need transferring assistance. CNA H stated since she had been coming to this facility so often and worked the same hall, she knew the residents and their ADL help. She stated she had about two mechanical lifts and needed another staff to assist; a few of the residents could stand and pivot with one-person assist. CNA H stated she would assist them by placing her arms under the resident's arms and transfer them. In an interview on 11/03/23 at 9:50 AM, CNA G stated, when I arrived this morning, they (the facility) showed me a book at the nurses' station that tells me how a person was transferred, one-person, two-persons or Hoyer Lift. She stated she had not received any training or skills test when she started yesterday. Record review of an information book at the nurse's station revealed cheat sheet for Hall 1, 2,3 and 4. Information on cheat sheet revealed residents who used oxygen, bowel/bladder status, Hoyer lift, dining room placement and dialysis. In an interview on 11/03/23 at 9:59 AM, CNA I stated she had been with the facility for three and half years. She stated she received training when she arrived this morning on how to transfer residents and where to find the information on transfer assist by referring to the resident care plan. She stated she does not look at care plans in the EMR. She stated she knows the residents. CNA I stated Resident #1 was sometimes a one-person transfer and other times a two-person transfer, depending on how she was feeling that day. CNA I continued to state, Resident #1 could help more with transferring when she would tell you she was having a good day. And if she said she was not having a good day, she would tell you, she needed another aide. CNA I stated she does not look at care plans in the EMR. She stated she knows the residents and their ADLs. She stated Resident #1 could not use her left side and her hand was contracted. In an interview on 11/03/23 at 10:03 AM, CNA J stated she had been working at the facility for about a month, prior to working full time she stated she was an agency CNA. She stated she had been educated on transfers a long time ago. She stated the ADON in-serviced her today on transfers and how to locate a resident's information in the EMR. Record review of an In-Service titled transfer dated 07/24/23 revealed in-service on transfer training, stand pivot, and slide board for 6 staff CNA. In an interview on 11/03/23 at 02:46 PM, CNA H stated she had not received any training on transfers or how to find information on how a resident was assisted for transfers. In an interview on 11/03/23 at 3:57 PM, LVN R stated she does not show agency staff how to get into the EMR. In an interview on 11/03/23 at 04:00 PM, CNA H stated she has been coming to the facility for about 5 months. She stated she had no orientation to the building. She stated other facilities require her employer to train any staff going into their building, but she does not recall having to do any special training to go into this facility. In an interview on 11/03/23 at 4:30 PM, the DON stated she does not have documentation for competencies for agency staff. She stated the proper transfer was to use a gait belt and staff are provided with gait belts and if they need one the gait belts are in the therapy room. The DON stated the gait belt should be on their person and should be used for all transfers. She stated therapy has trained staff on proper transfers and they must use a gait belt. She stated her expectations were for all staff to use gait belts with stand/pivot transfers. In an interview on 11/03/23 at 4:44 PM, the Admin stated they do in-service/trainings but when they have certification, they do not do a check since they are certified nursing assistants. In an interview on 11/03/23 at 05:15 PM, the Admin stated they have no training for staff on falls, transfers, or restraints. In an interview on 11/03/23 at 6:01 PM, CNA J stated her gait belt is on her cart on the hall. She stated if she cannot find her gait belt, she can ask the ADON for one. She stated she had been trained to use a gait belt with all transfers. She stated she had not been trained on how to find residents care plan in the EMR since she came back to work for the facility. In an interview on 11/03/23 at 06:15 PM, CNA O stated she had worked for the facility 31 years. She stated she had therapy trained them on transfer a couple of months ago. She stated the residents care plans tell you if the resident is a 1 or 2 person assist. She stated if a resident is heavy, she is going to get help. She stated she goes by how the resident feels that day. She stated she used her gait belt on some of the transfers. She stated she has her gait belt in her bag. Record review Safe Lifting and Movement of Residents dated 03/31/23 revealed the following: Policy Statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation 1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3.Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. Resident's preference for assistance; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status; f. Whether that resident is usually cooperative with staff; and g. The resident's goals for rehabilitation, including restoring or maintaining functional abilities. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving residents when necessary. 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. 7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques . 12. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies; b. Addresses reports of workplace injuries; c. Provides training on safety, ergonomics, and proper use of equipment; d. Continually evaluates the effectiveness of workplace safety and injury-prevention strategies . The ADM, DON and ADON were notified on 11/03/23 at 7:05 PM an IJ situation was identified due to the above failures and the IJ template was provided. The Plan of Removal submitted by the facility and was accepted on 11/04/23 at 12:04 PM and included: Plan of Removal: F-689: Free of Accidents, Hazards, Supervision, Devices Action: All resident's care plans have been reviewed to ensure correct transfer information is available for staff that may transfer a resident. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/4/2023 Action: Staff (including facility staff and temporary staff- agency and/or mobile clinical) that may transfer a resident have been educated in all aspects for safe transfers related to gait belt transfers (at minimum x1 staff assist), Hoyer transfers (at minimum x2 person assist), sliding board (at minimum x1 assist), stand by assist (at minimum x1 assist), and any of the other applicable transfer techniques that apply to [NAME] Oaks Nursing and Rehabilitation's residents. Applicable staff's education will also include the minimum number of staff required for each resident centered transfer, this may vary by resident, staff will know the number of staff members needed to assist for transfers through the below action item. All staff, facility and/or temporary, that this action item applies to will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/4/2023 Action: Staff (including facility staff and temporary staff- agency and/or mobile clinical) that may transfer a resident have been educated on where to pull transfer information/what avenue of transfer a resident is/how many staff members will be needed to assist the resident with their transfer. This information is available on the care assist/POC/resident chart. All staff, facility and/or temporary, that this action item applies to will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/4/2023 Action: The Director of Nursing, Assistant Director of Nursing, and/or designee will observe a minimum of 5 transfers a week x4 weeks to ensure the staff responsible for the transfer have: checked the appropriate number of staff required for the transfer (per the residents plan of care), that the appropriate amount of staff are assisting with the transfer (per the residents care plan), and that the transfer is completed safely and appropriately. Any concerns with the process will be addressed immediately and retraining will occur. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/4/2023 Action: Ad Hoc QAPI performed with Medical Director regarding the Immediate Jeopardy template F-689 and the facility's plan of removal. Person(s) Responsible: Administrator and Director of Nursing Date: 11/4/2023 On 11/04/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: In an observation on 11/04/23 at 1:10 - 3:30 PM, the DON and the TDOT were educating staff on transferring by stand-pivot with gait belt, sliding board and mechanical lift and staff were demonstrating all three methods of transferring. In an interview on 11/04/23 at 2:15 PM, the DON stated improper transferring of a resident could result in falls, broken limbs, and skin tears. She continued to state improper transferring could result into the staff person getting hurt as well. She stated all nursing staff whether facility or agency staff are receiving training and performing competency skill test. In an interview on 11/04/23 at 4:00 PM, the DON stated when night shift comes in, they will repeat the training with all the night shift staff. She stated night shift begins at 6:00 PM. Record reviewed the following documents revealed the following: (not dated) Clinical Skills Checklist and Competency Evaluation for the following skills: Transfer from Bed to Wheelchair Using Transfer Belt Assists to Ambulate Using Transfer Belt Slider Board and Slider Sheet (lateral transfer) Competency Assessment Lifting Machine, Using a Mechanical Agency Orientation (not dated) To ensure the safety of our residents, all Agency Certified Personal are to be orientated to facility by using guidelines below. This should approximately take 60 minutes. All agencies C.N.A.'s will take 60 minutes. All agencies C.N.A.'s will provide signature indicating understanding of below guideline. AGENCY ORIENTATION GUIDELINES Facility Tour-Halls Emergency Cart-Located at nurses station Oxygen/concentrators/tanks location-Located on hall 3 supply room Central Supply - Located on hall 3 Emergency Firebox/location/procedure /reset-Located between hall 3 & 4 Emergency Disaster Plan/Emergency numbers - Located at nurse station/red binder Dept. Head Phone number location - Located at the nurse station in staffing book Telephone use /paging system Eye wash Stations - Located in employee break room Abuse/Neglect Prevention Matrix Care Matrixcare Login POC Documentation Resident Profile Identification of residents/Pictures on Mars may be used by aides-Lic. Nurse to assist Advance Directive System/DNR/FULL CODE Resident Rights Care plan location Reporting Change/referring questions to Charge Nurse Residents with special needs Pocket Worksheet/Cardex/Nurse Aide Care Plans Fall Prevention Signature of Agency Aide and Date Signature of Person conducting Orientation/Date. In-service for Resident Profile dated 11/04/2023 revealed the following: How to view the resident profile to meet resident's needs (transferring, eating, dressing, etc.) CNA: When you are in the POC look under Resident Profile then open Profile Care Plan Approaches LVN: It can be viewed the same way as the CNA, or from resident chart click on resident then resident profile. In an interview on 11/04/23 at 3:50 PM, LVN R stated she had received training on properly transferring residents with a gait belt, Hoyer lift, sliding board and where to locate in the EMR for resident's information regarding ADLs. In an interview and observation on 11/04/23 at 3:55 PM, CNA M stated she had received training on transferring residents with a sliding board, Hoyer lift and using the gait belt. Observed CNA M with gait belt on her person, around her waist and able to locate a resident's information in the EMR program. In an interview and observation on 11/04/23 at 4:01 PM, AD/CNA S stated she had been re-trained on transferring residents with a sliding board, Hoyer lift, using the gait belt and one-person and two-person transfer. Observed AD/CNA S wearing her gait belt on her person, around her waist. AD/CNA S stated since she too was the activity director, she was completely familiar with the EMR and how to locate information. In an interview and observation on 11/04/23 at 6:30 PM, CNA T (agency) stated she had received training on properly transferring residents with gait belt, Hoyer lift, sliding board and where to locate in the EMR for resident's information regarding ADLs. She stated she was given the orientation for agency staff. Observed CNA T with a gait belt around her waist and able to locate resident's information in the EMR program. In an interview and observation on 11/04/23 at 6:37 PM, CNA U (agency) stated she had received training on properly transferring residents with gait belt, Hoyer lift, sliding board and where to locate in the EMR for resident's information regarding ADLs. She stated she was given the orientation for agency staff. Observed CNA T with a gait belt around her waist and able to locate resident's information in the EMR program. In an interview on 11/04/23 at 7:08 PM, LVN V stated he had been in-serviced on the sliding board, gait belt and the Hoyer lift. He stated he was familiar with getting resident information from the EMR. The administrator was notified the IJ was removed on 11/04/2023 at 12:04 PM, however the facility remained out of compliance, at a scope of a pattern and a severity level of actual harm that is not immediate jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure training and competency skills demonstrations for contracted certified nurse aides who provided activities of daily living services to residents for five of five contracted certified nurse aides (CNA G, CNA H, CNA K, CNA T, and CNA U) competency skills. 1. The facility failed to ensure contacted agency staff CNA G, CNA H, CNA K, CNA T, and CNA U received proper training. 2. CNA K failed to properly assist Resident 1 in the shower resulting in a fall where Resident 1 fractured her hip and required hip surgery. On 11/03/23 at 7:15 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 11/04/23 at 12:04 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The facility failed to train all contracted certified nurses aides showing they were capable of caring for residents. Findings included: In an interview on 11/03/23 at 9:30 AM, CNA G (agency) stated this was her second day at the facility and she did not know where to locate the assistance a resident's needs, like transferring. CNA G continued to state depending on the size of the person if she needs another person or not. In an observation on 11/03/23 at 09:34 AM ADON at the nurse's station educating staff on how to find care plan information for each resident. In an interview on 11/03/23 at 9:44 AM, CNA H (agency) stated she has been coming to the facility off and on for about five months. She stated when she arrived at the building, during report, she was told by the CNA she was relieving who was continent and incontinent and which residents need transferring assistance. CNA H stated since she had been coming to this facility so often and worked the same hall, she knew the residents and their ADL help. She stated she had about two mechanical lifts and needed another staff to assist; a few of the residents could stand and pivot with one-person assist. CNA H stated she would assist them by placing her arms under the resident's arms and transfer them. In an interview on 11/03/23 at 9:50 AM, CNA G stated, when I arrived this morning, they (the facility) showed me a book at the nurses' station that tells me how a person was transferred, one-person, two-persons or Hoyer Lift. She stated she had not received any training or skills test when she started yesterday. In an interview on 11/03/23 at 10:03 AM, CNA J stated she had been working at the facility for about a month, prior to working full time she stated she was an agency CNA. She stated she had education on transfers a long time ago. She stated the ADON in-serviced her today on transfers and how to locate a resident's information in the EMR. In a phone interview on 11/03/23 at 10:46 AM, CNA K stated she worked at the facility through facility's corporate agency, and she is no longer employed with the that agency. She states she had never had any training related to transfers while working for the facility. She stated I've never really had training, I was agency, so it wasn't like full time. I just went whenever they needed or when I could. In an interview on 11/03/23 at 02:46 PM, CNA H stated she had not received any training on transfers or how to find information on how a resident was assisted for transfers. In an interview on 11/03/23 at 3:14 PM, MD stated he was not involved in the training of staff, but safety comes first. He stated the facility should have something in place to show staff which residents are at high risk of falls. He stated if a resident who admits to the facility who has had a stroke, especially with paralysis, should be considered a high risk for falls. MD stated he expects that training for all staff including agency staff; there should be a protocol in place for all nursing staff including agency. No staff should be transferring residents without being trained. In an interview on 11/03/23 at 3:57 PM, LVN R stated she does not show agency staff how to get into the EMR. In an interview on 11/03/23 at 04:00 PM, CNA H stated she has been coming to the facility for about 5 months. She stated she had no orientation to the building. She stated other facilities require her employer to train any staff going into their building, but she does not recall having to do any special training to go into this facility. In an interview on 11/03/23 at 04:11 PM, LVN N stated the staff knew there was a book at the nurse's station with cheat sheets with resident information. She stated staff should be able to find how each resident was transferred in the care plan. In an interview on 11/03/23 at 4:30 PM, DON stated she does not have documentation for competencies for agency staff. She stated the proper transfer was to use a gait belt and staff are provided with gait belts and they need one the gait belts are in the therapy room. DON stated the gait belt should be on their person. She stated when the CNA came from an agency, it was assumed the CNA was trained by the agency. In an interview on 11/03/23 at 05:15 PM, Admin stated they have no training for staff on falls, transfers, or restraints. In an interview on 11/03/23 at 6:01 PM, CNA J stated she has not been trained on how to find residents care plan in the EMR since she came back to work for the facility. In an interview on 11/03/23 at 06:15 PM with CNA O stated she has worked for the facility 31 years. She stated if a resident is heavy, she is going to get help. She stated she goes by how the resident feels that day. She stated she used her gait belt on some transfers. She stated she has her gait belt in her bag. Record review of the Facility Assessment date 12/13/22 revealed; .Part 3: Facility Resourced Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies .Staffing training/education and competencies 3.4 Describe the staff training/education and competencies that are necessary to provide the level and types of support and care needed for your resident population. Include staff certification requirements as applicable. Potential data sources include hiring, education, training, competency instruction, and testing policies. List all staff training and competencies needed by type of staff. Consider if it would be helpful to indicate with competencies are reviewed at the time the staff member is hired, and how often they are reviewed after that. Consider the following training topics (this is not an inclusive list): Communication-effective communication for direct care staff Resident's rights and facility responsibilities-ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents Required in-service training for nurse aides. In-service training must: oBe sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year. oInclude dementia management training and resident abuse prevention training. oAddress areas of weakness are determined in nurse aides' performance reviews and facility assessment and may address the special needs of resident as determined by the facility staff. o For nurse aides providing services to individuals with cognitive impairments, also address care of the cognitively impaired. Identification of resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life . Activities of daily living-bathing (e.g., tub, shower, sitz bed) bed making (occupied and unoccupied), bed pan, dressing, feeding, nail and hair care, perineal care (female and male), mouth care (brush teeth or dentures), providing resident privacy, range of motion (upper and lower extremity), transfers, using gait belt, using mechanical lifts . Record review Safe Lifting and Movement of Residents dated 03/31/23 revealed, Policy Statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation 1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. Resident's preference for assistance; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status; f. Whether that resident is usually cooperative with staff; and g. The resident's goals for rehabilitation, including restoring or maintaining functional abilities. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving residents when necessary. 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. 7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques . 12. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies; b. Addresses reports of workplace injuries; c. Provides training on safety, ergonomics, and proper use of equipment; d. Continually evaluates the effectiveness of workplace safety and injury-prevention strategies . The ADM, DON and ADON were notified on 11/03/23 at 7:15 PM an IJ situation was identified due to the above failures and the ID template was provided. The Plan of Removal submitted by the facility was accepted on 11/04/23 at 12:04 PM and included: Plan of Removal: F-947: Training Requirements- General Action: All resident's care plans have been reviewed to ensure correct transfer information is available for staff that may transfer a resident. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/4/2023 Action: Staff (including facility staff and temporary staff- agency and/or mobile clinical) that may transfer a resident have been educated in all aspects for safe transfers related to gait belt transfers (at minimum x1 staff assist), Hoyer transfers (at minimum x2 person assist), sliding board (at minimum x1 assist), stand by assist (at minimum x1 assist), and any of the other applicable transfer techniques that apply to [NAME] Oaks Nursing and Rehabilitation's residents. Applicable staff's education will also include the minimum number of staff required for each resident centered transfer, this may vary by resident, staff will know the number of staff members needed to assist for transfers through the below action item. All staff, facility and/or temporary, that this action item applies to will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/4/2023 Action: Staff (including facility staff and temporary staff- agency and/or mobile clinical) that may transfer a resident have been educated on where to pull transfer information/what avenue of transfer a resident is/how many staff members will be needed to assist the resident with their transfer. This information is available on the care assist/POC/resident chart. All staff, facility and/or temporary, that this action item applies to will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/4/2023 Action: The Director of Nursing, Assistant Director of Nursing, and/or designee will observe a minimum of 5 transfers a week x4 weeks to ensure the staff responsible for the transfer have: checked the appropriate number of staff required for the transfer (per the residents plan of care), that the appropriate amount of staff are assisting with the transfer (per the residents care plan), and that the transfer is completed safely and appropriately. Any concerns with the process will be addressed immediately and retraining will occur. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/4/2023 Action: Agency/temporary staff packet created to distribute to temporary staff (agency/mobile clinical), prior to working their first/next shift, to ensure they are aware of how to pull resident transfer information from the electronic medical record and our policy information on transfer techniques. All temporary staff (agency and mobile clinical) will receive prior to working their first/next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/4/2023 Action: Ad Hoc QAPI performed with Medical Director regarding the Immediate Jeopardy template F-947 and the facility's plan of removal. Person(s) Responsible: Administrator and Director of Nursing Date: 11/4/2023 On 11/04/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: In an observation on 11/04/23 at 1:10 - 3:30 PM, DON and TDOT F were educating staff on transferring by stand-pivot with gait belt, sliding board and mechanical lift and staff were demonstrating all three methods of transferring. In an interview on 11/04/23 at 2:15 PM, DON stated improper transferring of a resident could result in falls, broken limbs, and skin tears. She continued to state improper transferring could result into the staff person getting hurt as well. She stated all nursing staff whether facility or agency staff are receiving training and performing competency skill test. In an interview on 11/04/23 at 4:00 PM, DON stated when night shift comes in, they will repeat the training with all the night shift staff. She stated night shift begins at 6:00 PM. Record reviewed the following documents: *Clinical Skills Checklist and Competency Evaluation for the following skills (not dated): Transfer from Bed to Wheelchair Using Transfer Belt Assists to Ambulate Using Transfer Belt Slider Board and Slider Sheet (lateral transfer) Competency Assessment Lifting Machine, Using a Mechanical *Agency Orientation (not dated) To ensure the safety of our residents, all Agency Certified Personal are to be orientated to facility by using guidelines below. This should approximately take 60 minutes. All agencies C.N.A.'s will take 60 minutes. All agencies C.N.A.'s will provide signature indicating understanding of below guideline. AGENCY ORIENTATION GUIDELINES (not dated) 1. Facility Tour-Halls a.Emergency Cart-Located at nurses station b.Oxygen/concentrators/tanks location-Located on hall 3 supply room c.Central Supply - Located on hall 3 d. Emergency Firebox/location/procedure /reset-Located between hall 3 & 4 e. Emergency Disaster Plan/Emergency numbers - Located at nurse station/red binder f. Dept. Head Phone number location - Located at the nurse station in staffing book g. Telephone use /paging system h. Eye wash Stations - Located in employee break room 2. Abuse/Neglect Prevention 3. Matrix Care a. Matrixcare Login b. POC Documentation c. Resident Profile d. Identification of residents/Pictures on Mars may be used by aides-Lic. Nurse to assist 4. Advance Directive System/DNR/FULL CODE 5. Resident Rights 6. Care plan location 7. Reporting Change/referring questions to Charge Nurse 8. Residents with special needs 9. Pocket Worksheet/Cardex/Nurse Aide Care Plans 10. Fall Prevention Signature of Agency Aide and Date Signature of Person conducting Orientation/Date *In-service for Resident Profile dated 11/04/2023 revealed. How to view the resident profile to meet resident's needs (transferring, eating, dressing, etc.) CNA: When you are in the POC look under Resident Profile then open Profile Care Plan Approaches LVN: It can be viewed the same way as the CNA, or from resident chart click on resident then resident profile. In an interview on 11/04/23 at 3:50 PM, LVN R stated she had received training on properly transferring residents with a gait belt, Hoyer lift, sliding board and where to locate in the EMR for resident's information regarding ADLs. In an interview and observation on 11/04/23 at 3:55 PM, CNA M stated she had received training on transferring residents with a sliding board, Hoyer lift and using the gait belt. Observed CNA M with gait belt on her person, around her waist and able to locate a resident's information in the EMR program. In an interview and observation on 11/04/23 at 4:01 PM, AD/CNA S stated she had been re-trained on transferring residents with a sliding board, Hoyer lift, using the gait belt and one-person and two-person transfer. Observed AD/CNA S wearing her gait belt on her person, around her waist. AD/CNA S stated since she too was the activity director, she was completely familiar with the EMR and how to locate information. In an interview and observation on 11/04/23 at 6:30 PM, CNA T (agency) stated she had received training on properly transferring residents with gait belt, Hoyer lift, sliding board and where to locate in the EMR for resident's information regarding ADLs. She stated she was given the facility orientation for agency staff today. She stated before today, she had been training during her nurse aide certification classes. Observed CNA T with a gait belt around her waist and able to locate resident's information in the EMR program. In an interview and observation on 11/04/23 at 6:37 PM, CNA U (agency) stated she had received training on properly transferring residents with gait belt, Hoyer lift, sliding board and where to locate in the EMR for resident's information regarding ADLs. She stated she was given the facility orientation for agency staff today. She stated she had not been given any of training at this facility; her training was when she went through her nurse aide certification classes. Observed CNA U with a gait belt around her waist and able to locate resident's information in the EMR program. In an interview on 11/04/23 at 7:08 PM, LVN V stated he had been in-serviced on the sliding board, gait belt and the Hoyer lift. He stated he was familiar with getting resident information from the EMR. The administrator was notified the IJ was removed on 11/04/23 at 12:04 PM., however the facility remained out of compliance, at a scope of a pattern and a severity level of actual harm that is not immediate jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems.