**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Care to Skin Issues> 1) Resident 53 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 06/19/2023, showed Resident 53 was moderately cognitively impaired, was able to answer yes/no questions and had a gastrostomy tube (g-tube, a tube surgically inserted through the abdomen that delivers nutrition, hydration, medication, etc. directly to the stomach). Resident 53's physician orders, dated 05/27/2023, documented to cleanse the gastrostomy tube site with soap and water and apply a T (tube) sponge (small dressing with a slit that is placed around a tube and used as barrier between and to absorb any discharge) daily and as needed. On 07/26/23 at 10:10 AM, Staff K, RCM and LPN, was observed providing wound care to Resident 53's g-tube site. Staff K utilized one pair of gloves for the entire procedure including removal of old dressing, cleaning of surgical site, and application of new dressing. Staff K placed all supplies on Resident 53's pillow. Strips of tape, to be used to secure the new dressing, were hung from Resident 53's wheelchair handle. Staff K disposed of the blood soiled dressing and cleaning supplies in Resident 53's garbage can which did not have a garbage can liner. On 07/28/2023 at 11:40 AM, Staff B said Resident 53's wound care supplies should have been placed on a clean barrier rather than on Resident 53's pillow. Staff B said the nurse should have changed their gloves after removing Resident 53's dressing, after cleaning their wound, and after putting on the new dressing. 2) Resident 4 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus I and right side below knee amputation. The quarterly MDS, dated [DATE], documented the resident was cognitively intact, required extensive assistance from 1-2 staff members for activities of daily living (toileting, transfers, mobility, dressing, etc.), and was at risk for development of a pressure injury. On 07/26/23 at 10:30 AM, Staff K was observed providing wound care to Resident 4's left ankle. Prior to beginning wound care, Staff K assisted a CNA providing care. The CNA pointed out a skin concern to Staff K, redness to Resident 4's coccyx. Staff K touched Resident 4's coccyx with a gloved hand and then assisted the CNA with straightening Resident 4's sheets and moving them up in bed. Wound care supplies were set on Resident 4's bed. Staff K did not change his gloves and utilized the same pair of gloves for all wound care provided. On 07/28/2023 at 10:08 AM Staff T, LPN, said during wound care gloves needed to be changed at least two to three times depending on the wound care being provided. Staff T said a clean barrier between wound care supplies and the surface they were setting on needed to be used to keep the wound care supplies clean. At 11:40 AM, Staff B said Resident 4's wound care supplies should have been placed on a clean barrier. Staff B said the nurse should have changed their gloves prior to starting wound care, after removing Resident 4's dressing, after cleaning their wound, and after putting on their new dressing. Reference WAC 388-97-1320 (1)(a)(c)(2)(a)(b)(3)(4)(5)(a)(c)(d)(e) Based on observation, interview and record review, the facility failed to: ensure their infection control and preventions practices were implemented to prevent the transmission of a highly transmissible disease Carbapenem-resistant Acinetobacter baumannii (CRAB, a bacteria resistant to nearly all antibiotics and difficult to remove from the environment, a multi-drug resistant organism [MDRO]); prevent the spread of CRAB within the facility for 6 of 6 sampled residents (61, 41, 42, 70, 37 & 39) reviewed for infection control prevention; utilize the proper types of disinfectant wipes against the Carbapenem-Resistant Organism (CRO); follow and implement Enhanced Barrier Precautions (EBP is a type of isolation for identified high risk residents to prevent the spread of disease from one person to another) for 15 of 65 facility residents (17, 5, 30, 53, 54, 35, 26, 16, 13, 102, 121, 108, 105, 110 & 124) reviewed for infection prevention and control; keep dispensers filled with alcohol rub or hand sanitizer in various locations throughout the facility (front entrance, Resident rooms [ROOM NUMBERS], two dirty utility rooms, a shower room and in various locations on the North Hall); ensure the laundry sanitizer was effective against CRAB; and use proper precautions while providing skin care to 2 of 3 sampled residents (4 & 53) reviewed for infection control related to wound care. This caused harm to Resident 37, Resident 39, Resident 42 and Resident 70 when they experienced a healthcare acquired infection (HAI) of CRO (CRAB). This failure placed all residents at risk of transmission of a highly transmissible disease and a diminished quality of life. On 07/25/2023 at 7:05 PM, the facility was notified of an immediate jeopardy (IJ) at CFR 483.80 (a)(1), F 880 Infection Prevention, related to the facility's failure to ensure infection control and prevention practices were implemented to prevent the transmission of CRAB. The facility removed the immediacy on 07/28/2023 at 2:07 PM with an on-site validation date of 07/28/2023 when a facility-wide sanitation of the building was completed, implemented EBP for all high risk residents, procured and made available to staff appropriate wipes to combat CRAB, and re-educated staff for infection control practices. Findings included . The facility policy entitled Infection Prevention and Control Program, revised 2018, documented, The infection prevention and control program is a facility-wide effort involving all disciplines and individuals . Elements of the infection prevention and control program consist of coordination/oversight . outbreak management, prevention of infection . Outbreak Management is a process that consists of . (2) managing the affected residents; (3) preventing the spread to other residents . (6) educating the staff and the public . Important facets of infection prevention include . (2) instituting measures to avoid complications or dissemination (spreading); (3) educating staff and ensuring that they adhere to proper techniques and procedures . (7) implementing appropriate isolation precautions when necessary; and (8) following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). The CDC web site https://www.cdc.gov/mmwr/volumes/69/wr/mm6948e1.htm documented, Carbapenem-resistant Acinetobacter baumannii (CRAB) causes health care-associated infections that are challenging to contain and often linked to infection prevention and control (IPC) breaches. Review of the facility's infection control binder showed the first identified case was on 02/20/2023 while the resident was at the local hospital. A second case was identified on 03/30/2023. Both residents were readmitted to the facility. Record review showed the facility participated in an Infection Control Assessment and Response (ICAR, a consulting inspection done by the state's Department of Health) on 03/14/2023. After the onsite visit, Department of Health (DOH) provided a printout of educational resources and facility specific guidance was provided. Included in the education were items the facility was doing well and areas where they could improve. The following was a list of infection control practices the facility was noted to be doing well during the 03/14/2023 ICAR but were identified as issues during the annual survey starting 07/23/2023: hand sanitizer dispensers located in and out of resident rooms, each resident had their own sling for Hoyer or Sit to Stand lift with a process in place to clean, appropriate personal protective equipment (PPE) storage bins (isolation carts) located out of the room for residents on precautions, the Infection Preventionist completed rounds to ensure PPE storage bins were well stocked and completed education with staff regarding infection control practices and the Director of Nursing Services or Infection Preventionist worked with central supply to ensure adequate levels of PPE were readily available. The areas identified on 03/14/2023 that the facility could improve on included fully implementing Enhanced Barrier Precautions, assessing the system for handling laundry especially for residents on isolation, staff education, and creating a system to identify who was responsible for cleaning items such as Hoyer lifts and shared resident equipment. <Positive CRAB Cases> 1) Resident 61 was admitted to the facility on [DATE] with a right thigh wound. The quarterly Minimum Data Set (MDS), an assessment tool, dated 05/19/2023, showed Resident 61 required extensive assistance with transfers and was dependent on helpers for safe mobility with moving from position to position. Review of facility Infection Control Binder showed on 02/14/2023 Resident 61 had a positive wound culture for CRAB. 2) Resident 41 was admitted to the facility on [DATE]. The discharge MDS, dated [DATE], showed Resident 41 required supervision with transfers and required moderate assistance from a helper for safe mobility with moving from position to position. Review of a hospital culture report showed on 02/15/2023 Resident 41 had a culture taken which was positive for CRAB. Review of the DOH culture report showed on 03/10/2023 a culture was taken during facility wide testing which was positive for CRAB. 3) Resident 42 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 42 required extensive assistance with transfers and required substantial assistance from a helper for safe mobility with moving from position to position. Review of facility Infection Control Binder showed on 03/15/2023, Resident 42 had a culture taken during facility wide testing, which was positive for CRAB. 4) Resident 70 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 70 required extensive assistance with transfers and was dependent on helpers for safe mobility with moving from position to position. Review of the infection control binder showed Resident 70 tested negative for CRAB in March 2023 during facility wide testing. Resident 70 was identified on 04/14/2023 as having a worsening of a wound infection with new or increased purulent drainage (pus) and tested positive for CRAB during the April 2023 facility wide testing. 5) Resident 37 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 37 required extensive assistance with transfers and required substantial assistance from a helper for safe mobility with moving from position to position. Review of facility infection control binder showed during the April 2023 facility wide testing, Resident 37 was negative for CRAB. During facility wide testing, on 05/16/2023, Resident 37 tested positive for CRAB. 6) Resident 39 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 39 required supervision with transfers and required supervision, cueing and steadying, from a helper for a safe mobility with moving from position to position. Review of the facility infection control binder showed on 05/16/2023, Resident 39 tested negative for CRAB during facility wide testing. Review of a DOH culture result showed on 05/22/2023 a culture was obtained and tested positive for CRAB for Resident 39. Review of the infection control binder, for the month of May 2023, showed an undated trend and analysis sheet that documented one resident tested positive for CRAB on 05/16/2023 and due to continued spread, the DOH had recommended positive residents be transitioned to contact precautions (contact precautions are a higher level of isolation than the required enhanced barrier precautions). On 07/26/2023 at 10:13 AM, Collateral Contact 1 (CC1), DOH staff, said during the outbreak, the facility did not have an onsite infection preventionist (IP) person. CC1 said Staff G, Regional Infection Preventionist, was traveling to other buildings and was only onsite a couple of days per month. CC1 said she was concerned for the lack of oversight with IP practices as things deteriorated when Staff G was not there. CC1 said the testing was too burdensome for the facility so the DOH sent two staff to help test residents and provide information/education to the facility. <Enhanced Barrier Precautions> On 07/25/2023 at 1:41 PM, room [ROOM NUMBER] was observed to be on EBP, used for high risk residents including identified but limited to open wounds, catheters, central lines, and respiratory issues. There were no disinfectant wipes in the isolation cart (cart that holds PPE and items necessary for infection control) or nearby for staff use. At 1:46 PM, room [ROOM NUMBER] was observed to be on EBP. There were no disinfectant wipes in the isolation cart or nearby for staff use. On 07/26/2023 at 8:32 AM, Staff J, Certified Nursing Assistant (CNA), was observed in Resident 39's room talking with the resident while Resident 39 was sitting in a wheelchair at the bedside. Staff J closed the door and transferred Resident 39 to bed without wearing a gown or gloves then left the room. When asked about precautions used when an EBP sign was posted, Staff J said the sign on Resident 39's room was new. When asked if gloves and a gown should have been worn, Staff J said he would have to ask about it. After looking over the sign, Staff J said he should have asked about the signs a few days ago. At 8:38 AM, the rooms of high-risk residents (17, 5, 30, 53, 54, 35, 26, 16, 13, 102, 121, 108, 105, 110 and 124) were observed without EBP available for use. The only EBP were for residents identified as being CRAB positive. <Disinfecting wipes> On 07/25/2023 at 1:43 PM, Staff J said he used bleach or purple top (hospital grade disinfectant wipes) on Hoyer lifts after use. Staff J said wipes were kept in the nurses' cart or the clean utility room. Staff J was observed looking for wipes then found a tub in a black file cabinet drawer. The wipes were a citric acid base wipe that was ineffective against CRAB. At 2:16 PM, Staff G, Infection Preventionist, said they had an ICAR with DOH regarding the CRAB outbreak. The biggest recommendation was to increase the amount of disinfectant wipes available to staff and they had to change the COVID (pandemic respiratory infection which can lead to serious health issues including death) wipes to an appropriate disinfectant to cover the new MDRO. Staff G said they got rid of the old and got all new. At 6:00 PM, Staff R, Licensed Practical Nurse (LPN), said Staff A, Administrator, came around at 2:00 PM that afternoon to lock up the wipes. Staff R said they were to only be locked in the nurse cart or in the medication room. The tub of citric acid based wipes were still observed in the file cabinet. On the North nurses station, there were yellow grocery store brand sanitizer wipes. On 07/26/2023 at 8:26 AM, room [ROOM NUMBER] was observed to be on EBP but did not have wipes on the isolation cart. At 8:27 AM, Staff W, LPN, said she had wipes in her cart but did not recall having staff come ask for them. Staff W said the staff used them but did not get them from her. Staff W said it was not their process to get wipes from the nurse cart. At 8:28 AM, there were no wipes observed on the South nurses station counters. The tub of citric acid based wipes was still in the file cabinet. room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] were on EBP but did not have wipes on the isolation carts. At 10:40 AM, Collateral Contact 2 (CC2), DOH staff, said when she was onsite in March 2023 for the ICAR, she noticed the facility had several different types of wipes. CC2 said she recommended the facility use just one type of wipe. CC2 said she made sure the facility staff understood how to read the disinfectant labels for effectiveness. CC2 said she recommended to have wipes in easily accessible places for equipment cleaning. When asked about the amount of wipes available, CC2 said they were not able to go into the supply room because Staff G was a regional staff who did not have access. CC2 said they did not get to see it. At 2:24 PM, Staff M, Central Supply Clerk, said if she did not get the items she requested or needed, she would go to Staff A. Staff M said the budget came from corporate and was based on the facility census. Staff M said the wipes could be found in utility closets. Staff M said a nurse came through and took them off the unit, and stated, I had them out last week. Staff M said the wipes were removed due to residents with dementia. Staff M said in stock at the time was four citric acid based wipes, one grocery store brand wipe, one purple top, and one orange top. Staff M said she was told by Staff G and Staff L, Maintenance Director, to not stock wipes on the isolation cart. The North Hall clean utility room was observed with Staff M and showed no wipes were stocked. At 2:40 PM, Staff X, Environmental Services, showed the housekeeping stock of disinfectant wipes and supplies. Observed were two purple top wipes that were almost empty, one small hydrogen peroxide wipe bottle and one citric acid based wipes tub (which was ineffective against CRAB). Staff X said the facility was getting away from foam hand sanitizer because it was too expensive and there were only three left. Staff X said the facility supply of hand soap was almost out because they needed the dispensers. They had soap but no way to use it. The facility had recently changed brands for soap and about two months prior had changed the main disinfectant cleaner away from Eco Labs. At 2:48 PM, Staff L, Maintenance Director, said she told her staff to not stock wipes on the isolation carts because she was a CNA and the residents could eat them. Staff L said the wipes should be kept locked in the nurses cart or at the nurses station. Staff L said if a CNA came out of a room, they need to ask a nurse or go to the nurses station to get the wipes. Staff L said if she saw the wipes out when she walked by, she took them away. Staff L said she thought they kept the wipes in the clean utility. On 07/27/2023 at 1:33 PM, Staff G said they put all the wipes out, and there were no more. Staff G said the DOH recommended to have wipes on every isolation cart. Staff G said when the supply came, they would add to the rest of the isolation carts. Staff G was observed seeing the grocery store brand wipes on the South Nurses station and tossed them away. Staff G said there should not be any other wipes, only purple top. At 2:09 PM, Staff M said there was a delivery of 12 boxes. When the delivery was observed, there was only 1 box and when opened, the box had 10 tubs of wipes instead of 12. Staff M said the box came from the corporate warehouse. A bottle of yellow grocery store wipes were on the table. On 07/28/2023 at 9:48 AM, CC1 said she told the facility to stop using mismatched wipes and use only one to prevent confusion among staff. CC1 said when she was onsite she looked up the Environmental Protection Agency (EPA) registration numbers and everything was good; and they had the purple top wipes. After being told the facility changed the disinfectant two months prior, CC1 said she was not aware and she informed the facility they needed to look up the EPA registration number for all disinfectants. <Disinfecting of Shared Resident Equipment> On 07/25/2023 at 1:09 PM, Staff V, Certified Nursing Assistant (CNA), and Staff U CNA were observed moving a Hoyer lift from the hallway into a resident room. Staff U and Staff V said they were supposed to wipe down the lifts after each use with the purple or gold top wipes (disinfecting wipes). Staff U said there should be a cage holder for the bottle on each lift. The North [NAME] Hall was observed to only have one cage holder on one of the two sit to stands and none on the Hoyer lift. Staff U went to get a bottle of wipes. Slings were observed hanging over each sit to stand. Staff V said they should use one sling per resident. When asked about the slings, Staff V stated, Yes. They are dirty. Staff U was observed looking around for wipes, and had to ask several staff to locate wipes. Staff U returned to the hall with a yellow bottle of grocery store brand wipes, not with the purple or gold top. At 1:17 PM, Staff F, Resident Care Manager (RCM), said staff should clean the lifts with wipes and the slings were to be washed. When asked about the dirty Sit to Stand slings on the North [NAME] Hall, Staff F said staff should take the slings to the laundry. Staff F said the lift had not been cleaned recently, and stated, We'll have to get those cleaned and do some education. At 1:21 PM, Staff B, Director of Nursing Services and Registered Nurse, said she expected the staff to clean the lifts with wipes. Staff B said if the sling portion was soiled, staff should send them to the laundry; and if not soiled, she would have to look up the facility policy. When asked if the slings could be used resident to resident, Staff B said she was not sure and would verify with the policy. Staff B said she expected the slings and lifts to be clean. At 1:41 PM, a Hoyer lift was observed in the South East Hall with a dirty cloth cover over the main handlebar. There were not any wipes or a cage holder for wipes on the lift. At 1:46 PM, a Sit to Stand lift was observed in the South [NAME] Hall with several layers of debris including white flakes that moved when blown on. There were not any wipes or a cage holder for wipes. At 1:53 PM, A Sit to Stand and Hoyer lift were observed outside the Resident Care Manager (RCM) office/TV room. The Sit to Stand was coated with debris and the Hoyer had an empty wipe cage holder. At 1:55 PM, Staff H, CNA, said she wiped down lifts with Antibacterial wipes, orange or purple top wipes (approved hospital grade disinfectant). Staff H said the wipes were normally on the lifts but she did not see them now. Staff H said she could find extra wipes in the clean utility. Staff H said the sling stayed in the residents' room and all residents had their own sling. When the lift came out of the room, it needed to be wiped down. Staff H said dirty slings would be sent to the laundry. At 1:59 PM, the North East Hall was observed with three Hoyers and two Sit to Stands (types of mechanical lifts). When asked if they were clean, Staff H stated, No. They were not clean. Staff I, CNA, said the purple wipes used to be there (in the holders), and stated, Yeah. Not there anymore. Staff I said the sit to stands were dirty. On 07/27/2023 at 1:07 PM, Staff J was observed pushing a Hoyer lift out of room into the South East Hall, parked the lift and walked off. Staff J did not wipe/sanitize the lift. Review of the electronic medical record (EMR) and infection control documentation, showed five of the six residents (Residents 61, 41, 42, 70 and 37), who had tested positive for CRAB, required the use of a mechanical lift for transfers. <Empty Alcohol-Based Sanitizer In and Out of Resident Rooms> On 07/24/2023 at 8:00 AM, the front entrance desk hand sanitizer, next to the visitor check in, was observed to be empty. On 07/25/2023 at 8:00 AM, on 07/26/2023 at 8:00 AM, and on 07/27/2023 at 8:00 AM, the hand sanitizer dispenser at the front entrance was checked daily at 8 AM. The dispenser remained empty until the afternoon of 07/27/2023. On 07/26/2023 at 9:56 AM, during wound treatment rounds with Staff K, LPN, the alcohol dispensers in room [ROOM NUMBER] and room [ROOM NUMBER] were observed to be empty in both the resident rooms. Staff K said maintenance was doing an audit and would fix it. The hand sanitizer dispensers were observed and were identified as being empty in both dirty utility rooms, the shower room, and several North Hall dispensers. <Laundry Services> On 07/28/2023 at 11:12 AM, when asked about retrieving soiled laundry process, Staff N, Laundry, said they picked the soiled laundry up from the soiled utility and shower rooms. Staff N said the staff were supposed to put isolation laundry in red bags but they had not done so in a long time. Staff N said the soiled laundry was all together. The laundry staff would not know if an item was from an isolation room. Staff N said a few weeks ago the ECO lab tech came out to fix the wash machine and reprogrammed the washers so they were not reaching the normal temps of 140-158. It was running in the 120s. Staff N said the sanitizer was automatically plumbed in, even during the week where they had low temps. Staff N said the ECO tech came back last week and increased the hot temperatures to back where they were used to seeing them. Staff N said the machine would not let the temperatures get too high, over 160 degrees, as a part of the programing. (Review of the EPA website for disinfectants showed the sanitizing solution used in the laundry was not effective against CRAB.).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview, observation and record review, the facility failed to ensure staff provided safe resident transfers using a hoyer (mechanical lift used to transfer residents) and were educated on hoyer use, and failed to implement fall risk interventions for four of five sampled residents (53, 3, 55 & 19) reviewed for accident hazards. This failure placed residents at risk for injury, falls and death. An Immediate Jeopardy was called on 05/03/2022 when the facility failed to ensure the safe use of mechanical lifts and slings when transferring three residents and failed to ensure facility staff had the competencies, skills and training needed for safe operation of Hoyer lifts and slings. The facility removed the immediacy on 05/05/2022 by training nurses and nursing assistants prior on proper use of the hoyer lift including sling placement, sling selection to support residents' head, resident positioning during transfer, stabilizing and locking the mechanical lift and/or wheelchair during transfers. Findings included . <Hoyer Lift Use> Review of Invacare Reliant 450 and 600 mechanical lift manual, undated, showed staff performing a transfer should be trained to perform the entire lift procedure several times with proper supervision. A resident's head should be supported by the sling and/or assistant. The lift legs should be always in the maximum open position, unless closing the legs to maneuver under a bed, then moved back into the maximum open position. Wheelchair brakes must be locked before lowering a resident into a wheelchair. Wheelchair brakes must be engaged to prevent movement of the chair. Divided leg slings should be removed once the resident is transferred into the wheelchair. 1) Resident 53 was admitted to the facility on [DATE] with diagnoses including a stroke with left side weakness, difficulty swallowing, and difficulty with verbal expression and communication. The quarterly Minimum Data Set, an assessment tool, dated 01/07/2022, showed the resident had moderate cognitive impairment and was able to make needs known. The care plan, dated 07/22/2021, showed Resident 53 required the use of a hoyer for transfers. On 05/03/2022 at 9:21 AM, Staff J, Certified Nursing Assistant (CNA), and Staff H, Registered Nurse (RN), were observed going to Resident 53 to transfer him from his wheelchair into his bed using a hoyer lift. The staff were not familiar with the type of sling under Resident 53, which was a divided leg sling. Staff J and Staff H made multiple attempts to adjust the sling under the resident although it was appropriately placed. At 9:28 AM, Staff J was observed returning to the resident's room with Staff K, CNA, who identified the cross-leg sling, and was able to pull the straps through Resident 53's legs as he was positioned. Staff K showed Staff J how to attach the straps to the hoyer lift multiple times as staff kept attaching the straps incorrectly. Resident 53 was lifted and lowered into the bed without the hoyer brakes locked. Staff J said she had a lot of residents who required hoyer transfers in her section. On 05/06/2022 at 1:22 PM, Staff T, CNA, was observed leaving a room with a Hoyer lift. Staff T said the hoyer lift was used on Resident 53. There were no other staff members observed in the room to assist with the transfer. Staff T said Staff M, Nursing Assistant Registered in training, was the second person but was unsure if she was allowed. Staff T said she did hoyer lift transfers by herself quite often because she could not find anyone to help. 2) Resident 3 was admitted on [DATE], had a moderate cognitive impairment and was able to make needs known. On 05/03/2022 at 1:59 PM, Staff N, CNA, and Staff K were observed assisting Resident 3 into her wheelchair with the use of a hoyer lift. The lift brakes were unlocked while under the bed during the process of hooking up the sling. Staff K moved the lift to adjust positioning while lifting up the resident. While the lift was lifting the resident, Staff K locked the brakes. Staff N positioned the wheelchair in front of the lift while the lift brakes remained unlocked. The back arm of the lift was positioned against another bed. The position of the lift locks, slightly under the bed, made it difficult to engage. Staff N did not make attempts to adjust the location of the lift or lock the brakes. Staff K was standing behind the wheelchair with his feet wedged behind each wheel. Staff K adjusted the resident as she was lowered into the wheelchair. During the lowering, Staff K reached down to ensure the right wheelchair brake was off. The wheelchair and the lift moved during the lower as Resident 3 was placed into her wheelchair. When asked if he locked the brakes, Staff K stated, Yeah, I keep my feet here so I can adjust. Staff K demonstrated how he wedged his feet behind the wheelchair wheels and said this was helpful to adjust the resident while being lowered into position. 3) Resident 55 was admitted on [DATE] and was alert and oriented. On 05/03/2022 at 2:14 PM, Staff S, CNA, and Staff Q, NAR, were using a hoyer lift to transfer Resident 55. While lifting the resident out of bed, the base legs of the Hoyer lift, were not spread out for stability. As Staff S and Staff Q began to lift the resident up, the resident's head was unsupported and was in an awkward position. On 05/03/2022 at 1:40 PM, Staff L, CNA, said her hoyer training was the 12 years of experience she had. Staff L said she completed a check-off list 12 years ago but had not completed any annual or on-line training. Staff M said she was a new hire and had been at the facility for about one week and did not work independently. Staff M said she did not have any formal hoyer training, no new hire training, and had only been shown by staff how to complete hoyer transfers. When asked what safety instructions Staff L had taught Staff M, Staff L said to always lock it and keep the legs wide when moving. On 05/03/2022 at 2:20 PM, Staff S, CNA, said she had worked here since September and been a CNA since January. Staff S said she felt like she did not get adequate hoyer training. Staff S said she had an average of three Hoyer lift residents on her load per shift. Staff S said it depended on who was working if it was difficult to find a second person to assist. Staff S said she never had a nurse help her with a hoyer lift transfer so she did not know if they know how to use a Hoyer lift. At 3:48 PM, Staff S said she did not know what kind of sling to use, and said she did not know there were different slings for different weight limits. On 05/04/2022 at 5:33 AM, Staff R, CNA, said she had trouble finding people to help with Hoyer lift transfers. Staff R said today we only had three aides on the floor right now and she had 30 residents to take care of. Staff R said if you would have been here on Sunday night you would have seen we had two aides for the entire building. Staff R said because she could not find help when she needed it, there had been several times when she had transferred a resident by herself. Staff R said it was not safe for the residents. At 5:44 AM, Staff O, LPN, said the care aids worked very hard. They just do not have enough help. There were times when there were only two aids for the entire building. Staff O said they must do Hoyer lift transfers by themselves. Staff O said it was not safe for the residents at all. At 8:02 AM, Staff N said wheelchair brakes should be locked before lowering a resident into a wheelchair. Staff N said her hoyer training was from her Certified Nursing Assistant (CNA) class. Staff N said slings were chosen based on the size of the resident, based on the amount of extra fabric around them. Staff N said if a resident required total care or could not move, they required a full body sling. Staff N said leg slings were not really used in the facility. They were for toileting and should only be used on residents that were smaller and had strong legs. Staff N said she knew which sling to choose because it was on the care plan. Staff N said physical therapy made the decision on what transfer and sling to use. On 05/05/2022 at 10:25 AM, Staff P, LPN and RCM, said she was not aware the aides were doing hoyer transfers by themselves. Staff P said her expectation was they follow the policy and use two certified staff members when doing a Hoyer lift transfer. At 11:07 AM, Staff B, Director of Nursing Services, said staff were trained by experienced CNAs for two days and then they were checked off to make sure they were doing the transfers correctly. The check off included a return demonstration. Staff B said if they needed help, they were to ask another aide, ask a nurse, or wait for someone to be available so they could do a safe transfer. Staff B said her expectation was that staff always did what was safe for the residents and followed policy. Staff B said if they were doing Hoyer lifts and transfers without another certified/licensed staff in the room, they should not have been doing it. <Fall Interventions> Resident 19 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident was cognitively intact. Resident 19's fall risk care plan, initiated 12/14/2021 and revised on 03/02/2022, documented the intervention to ensure mat appropriately placed next to bed when resident [was] in bed. On 05/02/2022 at 1:00 PM, Resident 19 was observed in his room in bed. A fall mat was in the room, leaning on the wall across from the bed. It was not in position near the bed to prevent injury in the event of a fall. At 2:57 PM, Resident 19 was observed in his bed. The fall mat was observed across the room from the resident's bed, leaning on the wall. At 3:06 PM, Staff U, Certified Nursing Assistant (CNA), said Resident 19 was a fall risk. Staff U said Resident 19's fall risk interventions included the bed in low position, making sure the resident was comfortable, and a fall mat near his bed. On 05/03/2022, Staff B said a fall mat should be in Resident 19's fall risk interventions. When asked about the observations of the fall mat not in place, Staff B stated, That's not good. He should have a fall mat [in place]. Reference WAC 388-97-1060 (3)(g) .