Health inspection·June 20, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to protect the residents' right to be free from neglect by failure to ensure staff used the appropriate mechanical lift, and failure to follow safety protocol when using a mechanical lift to transfer 2 (Residents #1 and #2) of 3 sampled residents who use mechanical lifts for transfers. The findings included: Review of the facility's policy and procedure for Transfer/Mobility Evaluation Low Lift with and effective date of 11/30/2014 and a revision date of 11/1/2019 read, Center will evaluate the transfer and lifting needs of the resident to safely and comfortably transfer according to their individual needs . Two staff members are required when using a mechanical lift. Lift status will be indicated on the resident's care plan and [NAME] [Provides instructions for care]. The completed evaluation will be filed in the medical record. Review of the facility's skills competency assessments for CNA (Certified Nursing Assistant) Staff noted, Skills competency is your ability to apply your skill, knowledge, and experience to perform a duty correctly . The Skills Competency Assessment for the Sit to Stand lift included the employee demonstrates skills and competencies in: 1. [NAME] [document that provides instructions for care]: Transfer status is verified prior to transferring. 2. Two staff members are used during transfer . 1. Review of the clinical record for Resident #1 revealed an admission date of 12/4/2019. Diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) of the left non-dominant side, morbid obesity and muscle weakness. The Quarterly Minimum data Set (MDS) with a target date of 4/11/24 noted Resident #1's cognition was intact with a Brief Interview for Mental Status score of 15. Resident #1 had functional limitation in range of motion of upper and lower extremities on one side. The resident was dependent (helper does all of the effort) for chair to bed or bed to chair transfer. The care plan initiated on 1/3/20 and revised on 11/16/23 noted the resident had self-care Page 1 of 12 105443 105443 06/20/2024 Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285

F 0600 Level of Harm - Actual harm Residents Affected - Few performance deficit in activities of daily living related to a history of CVA (cerebrovascular accident) with left hemiplegia, impaired balance, limited mobility. The interventions for transfer as of 1/3/2020 specified, The resident requires [brand name full body mechanical lift] by 2 staff to move between surfaces. Review of the facility's incident investigations showed on 6/4/24 the facility initiated an investigation for an allegation of neglect with serious bodily injury. The investigation noted on 6/4/24 Certified Nursing Assistant (CNA) Staff A transferred Resident #1 with a (Brand name) sit to stand mechanical lift in the shower room without assistance. CNA Staff A left the resident alone in the mechanical lift in the shower room to request assistance from CNA Staff B. When they both walked back into the shower room, Resident #1 was sliding out of the lift. He stated, My knee my knee. They transferred the resident in the shower chair and CNA Staff A showered him. When the resident was transferred to the bed, he complained of pain in the left knee with swelling assessed. The Advanced Practice Registered Nurse ordered an X-Ray which showed a fracture of the left femur. The resident was transferred to a local Emergency Room. Review of the hospital record dated 6/4/24 noted Resident #1 arrived at the hospital via ambulance with concerns for left lower extremity pain after slipping from his wheelchair onto his left knee at approximately 10:00 a.m. Resident #1 was admitted to the hospital and returned to the facility on 6/8/24. The hospital discharge summary noted imaging studies showed no evidence of fracture. The facility provided a typewritten document as part of their investigation which included statements from CNA Staff A, CNA Staff B and Resident #1. The statement from CNA Staff A read, I transferred him in the [brand name sit to stand lift] to wheelchair and he started to slide out. His left leg so we put his legs back in place. We transferred resident to the shower chair. I showered the resident then took him back to his room. I used the [brand name sit to stand] lift to transfer him back to bed. He c/o [complained of] pain with the transfer. States he always c/o pain even with brief pain. The statement did not note CNA Staff A verified the transfer status before using the (sit to stand) mechanical lift to transfer Resident #1. Review of skills competency assessments revealed on 4/23/24 CNA Staff A had an annual refresher skills competency assessment which noted the CNA demonstrated skills and competence in the use of the Sit to Stand lift. The statement from CNA Staff B read, [CNA Staff A] came to get me when I was in [room number]. She said that [Resident #1] was sliding and to come help her. She was by herself. He was in the [brand name sit to stand] lift, and he was holding onto the [brand name sit to stand] lift and sliding. He said, my knee my knee. I told [CNA Staff A] to get the shower chair and we used the [sit to stand] lift to transfer him into the shower chair. She showered him and came to me again to help her transfer him back to the wheelchair. I don't think she had the [brand name sit to stand lift] pad on correctly]. The statement from Resident #1 read, I heard a pop when I was being transferred in the [sit to 105443 Page 2 of 12 105443 06/20/2024 Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285

F 0600 stand] lift. Level of Harm - Actual harm The facility documented CNA Staff A was immediately suspended pending investigation. Residents Affected - Few Review of the facility's Ad Hoc (unplanned) Quality assurance and Performance Improvement Meeting dated 6/14/24 noted the following root cause analysis: CNA failure to use the correct mechanical lift and following policy for 2 person assist. Care plan and [NAME] did not have the updated transfer status. On 6/19/24 at 9:15 a.m., in an interview Resident #1 said CNA Staff A was not listening when he told her his foot needed to be on the step of the Sit to Stand mechanical lift. He said while he was in the mechanical lift, CNA Staff A left him in the shower room with Staff B. He told Staff B he was slipping out of the sling. Staff B said they knew what they were doing. Resident #1 said he slipped and hyperextended his knees and started having terrible pain. He was begging Staff B to let him down to the floor. When Staff A returned, they transferred him to the shower chair using the sit to stand mechanical lift. Staff A and B also used the sit to stand mechanical lift to transfer him back to bed after the shower. Resident #1 said since the incident, he's been experiencing on-going pain requiring the use of pain pills. The resident said he did not trust the staff to use the mechanical lift to transfer him. As a result, he has not taken a shower since the incident and only receives bed baths. Review of the clinical record from 3/3/24 through 6/3/24 showed documentation on one occasion (5/28/24) Resident #1 experienced a pain level of 5. A progress note dated 6/9/24 at 5:01 a.m. read, [Resident #1's] pain situation s/p [status post] fall in the shower before going to the hospital for eval from which he returned today-with no pain meds ordered despite his c/o [complains of] 10/10 pain, esp [especially] when moving. LLE [left lower extremity] is more swollen than at the start of the shift . The Medication Administration Record (MAR) for June 2024 showed a physician's order dated 6/9/2024 for Percocet 5-325 milligrams one tablet by mouth every eight hours as needed for moderate pain (Pain level of 4 to 10) for 14 days. The MAR showed the resident received 15 doses of the Percocet from 6/9/24 through 6/18/24. On 6/19/24 at 10:00 a.m., in an interview Physical Therapist (PT) Staff C said Resident #1 could not bear weight on his legs and was not a candidate to use a sit to stand (Stand up ) lift. He said prior to the incident, staff had come to him and said Resident #1 wanted to use the sit to stand lift. PT Staff C said he counseled the resident about only using a full body mechanical lift. Review of the sling reference guide for the stand up patient lift used by the facility showed, standing lift requirements include, Standing slings are for residents who are partially dependent, have at least 60% weight bearing capacity, have head and neck control, are cooperative, can sit up on the edge of the bed (with or without assistance), and are able to bend at the hip, knees and ankles. On 6/20/24 at 2:01 p.m., in a telephone interview CNA Staff B said on 6/4/24 he was in a room assisting a resident when CNA Staff A told him Resident #1 was sliding out of a sit to stand lift and 105443 Page 3 of 12 105443 06/20/2024 Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285

F 0600 Level of Harm - Actual harm Residents Affected - Few asked for his help. He said CNA Staff A was using the lift by herself. When he walked into the shower room, Resident #1 was sliding from the sit to stand lift and holding onto the lift. Resident #1 was saying, My knee, my knee. Staff B said Staff A brought the chair while he was holding Resident #1 from behind. Staff A used the sit to stand mechanical lift to lower the resident into the chair. He reported the incident to Registered Nurse (RN) Staff J and told her to remind staff never to use a mechanical lift alone. Review of RN Staff J statement dated 6/7/24 read, Around 1050 [10:50 a.m.] CNA [Certified Nursing Assistant] [Staff A] informed me [Resident #1] had pain in his knee D/T [due to] his shower. I went and assessed [Resident #1] and he was in 10/10 [10 of 10 Severe] pain and his Left knee was swollen. ARNP [Advanced Registered Nurse Practitioner] was contacted and a new order for stat [immediately] Xray of left knee was completed. When I assessed [Resident #1] he stated these idiots had him in the sling wrong and He was slipping out of it B/C [because] She left a pillow behind him. He said he was sliding down to the ground and heard his knee pop and was asking them to stop and just lay him on the ground B/C [because] it hurt so badly. 2. Review of the clinical record for Resident #2 revealed an admission date of 6/1/21. Diagnoses included muscle weakness, unsteadiness on feet, and seizures. Review of the Significant Change in Status MDS assessment with a target date of 6/7/24 noted the resident's cognition was moderately impaired with a BIMS score of 12. The assessment noted Resident #2 was dependent on staff (Helper does all of the effort) to move from sitting on the side of the bed to lying flat on the bed, and transfers (Chair/bed-to-chair). Review of the CNA [NAME], and the care plan (as of 11/14/23) revealed Resident #2 required two staff and a (brand name) full body mechanical lift to move between surfaces every day and as necessary. On 6/19/24 at 10:00 a.m., CNA Staff E was observed pushing a Sit to Stand Lift out of Resident #2's room. On 6/19/24 at 10:15 a.m., in an interview the Assistant Director of Nursing (ADON) said she had just counseled Staff E earlier that day that Resident #2 could not use a Stand-up Lift, and she needed to read the resident's [NAME] before transferring the resident. On 6/19/24 at 11:35 a.m., in an interview CNA Staff E said Resident #2 uses a Stand-up (sit to stand) Lift to transfer. An unlabeled stand-up lift sling was observed being brought out of Resident #2's room. The sling was observed to have frayed edges in which the cloth could be spread apart on the side of the sling. On 6/19/24 at 3:25 p.m., in an interview the ADON said when she spoke with Staff E that morning she asked her if she was aware Resident #2 was required to use a (brand name) full body mechanical lift. The ADON said the CNA's exact words were, No, but the standing lift works great. Review of the skills competency assessments revealed on 6/5/24 the DON assessed CNA Staff E's skills competency to use the Sit to Stand Lift. The DON documented 2 (fully meet standards) for the level of competency which included [NAME]: Transfer status is verified prior to transferring. On 6/20/24 at 9:45 a.m., Resident #2 said staff had not been using a full body mechanical lift to transfer him from the bed to the chair. He said staff used the stand-up lift to transfer him. 105443 Page 4 of 12 105443 06/20/2024 Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285

F 0600 Resident #2 said he could not bear complete weight on his legs, and he could not sit on the side of the bed by himself without tipping over. Level of Harm - Actual harm Residents Affected - Few 105443 Page 5 of 12 105443 06/20/2024 Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, residents and staff interviews, review of facility's policy and procedure, the facility failed to ensure ongoing monitoring of staff competency for use of mechanical lifts to ensure the safety of residents during transfers for 2 (Residents #1 and #2) of 3 sampled residents of 16 residents who use mechanical lifts for transfers. The findings included: The facility policy Transfer/Mobility Evaluation Low Lift, Document Name N-907, Effective Date 11/30/2014, Revised 11/1/2019 read, Center will evaluate the transfer and lifting needs of the resident to safely and comfortably transfer according to their individual needs . Two staff members are required when using a mechanical lift . Lift status will be indicated on the resident's care plan and [NAME] [provides instructions for care]. Review of the facility's Skills Competency Assessments for C.N.A [Certified Nursing Assistant] Staff revealed the facility utilizes Skills Competency Assessments to ensure you are able to fulfill your duties as required by state and federal regulations. We follow the minimal regulatory requirements for assessment of competency. Our practice is a Tell, Show, Do, Practice, Review training method followed by: Direct observations of your performance while conducting the tasks . Monitoring and recording of your Skills Competency Assessment results. All employees have the responsibility to sustain the competencies represented in the assessments and any other procedures/responsibilities for performing their job. 1. Review of the facility's incident investigations showed on 6/4/24 the facility initiated an investigation for an allegation of neglect with serious bodily injury involving Resident #1. The investigation noted on 6/4/24 Certified Nursing Assistant (CNA) Staff A transferred Resident #1 with a (Brand name) Sit to Stand mechanical lift in the shower room without assistance. CNA Staff A left the resident alone in the mechanical lift in the shower room to request assistance from CNA Staff B. When they both walked back into the shower room, Resident #1 was sliding out of the lift. He stated, My knee my knee. They transferred the resident in the shower chair and CNA Staff A showered him. When the resident was transferred to the bed, he complained of pain in the left knee with swelling assessed. The Advanced Practice Registered Nurse ordered an X-Ray which showed a fracture of the left femur. The resident was transferred to a local emergency room for evaluation. Review of the hospital record dated 6/4/24 noted Resident #1 arrived at the hospital via ambulance with concerns for left lower extremity pain after slipping from his wheelchair onto his left knee at approximately 10:00 a.m. Resident #1 was admitted to the hospital and returned to the facility on 6/8/24. The hospital discharge summary noted imaging studies showed no evidence of fracture. Review of the clinical record for Resident #1 revealed an admission date of 12/4/2019. Diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) of the left non-dominant side, morbid 105443 Page 6 of 12 105443 06/20/2024 Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285

F 0689 obesity and muscle weakness. Level of Harm - Actual harm The care plan initiated on 1/3/20 and revised on 11/16/23 noted the resident had self-care performance deficit in activities of daily living related to a history of CVA (cerebrovascular accident) with left hemiplegia, impaired balance, limited mobility. The interventions for transfer as of 1/3/2020 specified, The resident requires [brand name full body mechanical lift] by 2 staff to move between surfaces. Residents Affected - Few The facility provided a typewritten document as part of their investigation which included statements from CNA Staff A, CNA Staff B and Resident #1. The statement from CNA Staff A read, I transferred him in the [brand name Sit to Stand lift] to wheelchair and he started to slide out. His left leg so we put his legs back in place. We transferred resident to the shower chair. I showered the resident then took him back to his room. I used the [brand name Sit to Stand] lift to transfer him back to bed. He c/o [complained of] pain with the transfer. States he always c/o pain even with brief pain. Review of skills competency assessments revealed on 4/23/24 CNA Staff A had an annual refresher skills competency assessment which noted the CNA demonstrated skills and competency in the use of the Sit to Stand lift. The skills competencies for CNA Staff A noted on 4/23/24 Staff A demonstrated skills and competencies in use of the Sit to Stand mechanical lift which included, [NAME]: Transfer status is verified prior to transferring. Two staff members are used during transfer. The statement from CNA Staff B read, [CNA Staff A] came to get me when I was in [room number]. She said that [Resident #1] was sliding and to come help her. She was by herself. He was in the [brand name sit to stand] lift, and he was holding onto the [brand name sit to stand] lift and sliding. He said, my knee my knee. I told [CNA Staff A] to get the shower chair and we used the [sit to stand] lift to transfer him into the shower chair. She showered him and came to me again to help her transfer him back to the wheelchair. I don't think she had the [brand name sit to stand lift] pad on correctly. The statement from Resident #1 read, I heard a pop when I was being transferred in the [Sit to Stand] mechanical lift. On 6/19/24 at 9:15 a.m., in an interview Resident #1 said CNA Staff A was not listening when he told her his foot needed to be on the step of the Sit to Stand mechanical lift. He said while he was in the mechanical lift, CNA Staff A left him in the shower room with Staff B. He told Staff B he was slipping out of the sling. Staff B said they knew what they were doing. Resident #1 said he slipped and hyperextended his knees and started having terrible pain. He was begging Staff B to let him down to the floor. When Staff A returned, they transferred him to the shower chair using the sit to stand mechanical lift. Staff A and B also used the sit to stand mechanical lift to transfer him back to bed after the shower. Resident #1 said since the incident, he's been experiencing on-going pain requiring the use of pain pills. On 6/19/24 at 10:00 a.m., in an interview Physical Therapist (PT) Staff C said Resident #1 could not bear weight on his legs and was not a candidate to use a sit to stand (Stand up ) lift. He said prior to the incident, staff had come to him and said Resident #1 wanted to use the sit to stand lift. 105443 Page 7 of 12 105443 06/20/2024 Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285

F 0689 PT Staff C said he counseled the resident about only using a full body mechanical lift. Level of Harm - Actual harm On 6/20/24 at approximately 3:00 p.m., in a joint interview the Director of Nursing and the Regional Nurse said PT Staff C did not report to them Resident #1 requested to use the Stand up lift. Residents Affected - Few Review of all discontinued and current electronic physician's orders in the electronic record shows Resident #1 had not used Opioid pain medications since being admitted to the facility until 6/9/24. Review of the clinical record from 3/3/24 through 6/3/24 showed documentation on one occasion (5/28/24) Resident #1 experienced a pain level of 5. A progress note dated 6/9/24 at 5:01 a.m. read, [Resident #1's] pain situation s/p [status post] fall in the shower before going to the hospital for eval from which he returned today-with no pain meds ordered despite his c/o [complains of] 10/10 pain, esp [especially] when moving. LLE [left lower extremity] is more swollen than at the start of the shift . The Medication Administration Record (MAR) for June 2024 showed a physician's order dated 6/9/2024 for Percocet 5-325 milligrams one tablet by mouth every eight hours as needed for moderate pain (Pain level of 4 to 10) for 14 days. The MAR showed the resident received 15 doses of the Percocet from 6/9/24 through 6/18/24. Review of the facility's Ad Hoc (unplanned) Quality assurance and Performance Improvement Meeting dated 6/14/24 noted the following root cause analysis: CNA failure to use the correct mechanical lift and following policy for 2 person assist. Care plan and [NAME] did not have the updated transfer status. The Plan included CNA education regarding proper techniques when utilizing mechanical lift along with competencies. 2. Review of the list of residents who use a mechanical lift for transfer revealed Resident #2 used a full body mechanical lift for transfer. On 6/19/24 at 10:00 a.m., CNA Staff E was observed pushing a Sit to Stand Lift out of Resident #2's room. On 6/19/24 at 10:15 a.m., in an interview the Assistant Director of Nursing (ADON) said she had just counseled Staff E earlier that day that Resident #2 could not use a Stand-up Lift, and she needed to read the resident's [NAME] before transferring the resident. On 6/19/24 at 11:35 a.m., in an interview CNA Staff E said Resident #2 uses a Stand-up (sit to stand) Lift to transfer. An unlabeled stand-up lift sling was observed being brought out of Resident #2's room. The sling was observed to have frayed edges in which the cloth could be spread apart on the side of the sling. On 6/19/24 at 3:25 p.m., in an interview the ADON said when she spoke with Staff E that morning she asked her if she was aware Resident #2 was required to use a (brand name) full body mechanical 105443 Page 8 of 12 105443 06/20/2024 Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285

F 0689 lift. The ADON said the CNA's exact words were, No, but the standing lift works great. Level of Harm - Actual harm Review of the skills competency assessments revealed on 6/5/24 the DON assessed CNA Staff E's skills competency to use the Sit to Stand Lift. The DON documented 2 (fully meet standards) for the level of competency which included [NAME]: Transfer status is verified prior to transferring. Residents Affected - Few On 6/20/24 at 9:45 a.m., Resident #2 said staff had not been using a full body mechanical lift to transfer him from the bed to the chair. He said staff used the stand-up lift to transfer him. Resident #2 said he could not bear complete weight on his legs, and he could not sit on the side of the bed by himself without tipping over. 105443 Page 9 of 12 105443 06/20/2024 Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure 4 (Staff A, Staff E, Staff F, Staff G) of 4 sampled Certified Nursing Assistants (CNAs) were knowledgeable and competent to ensure the safe use of mechanical lifts to transfer residents. The findings included: The facility policy Transfer/Mobility Evaluation Low Lift, Document Name N-907, Effective Date 11/30/2014, Revised 11/1/2019 read, Center will evaluate the transfer and lifting needs of the resident to safely and comfortably transfer according to their individual needs . Two staff members are required when using a mechanical lift . Lift status will be indicated on the resident's care plan and [NAME] [provides instructions for care]. Review of the facility's Skills Competency Assessments for C.N.A [Certified Nursing Assistant] Staff revealed the facility utilizes Skills Competency Assessments to ensure you are able to fulfill your duties as required by state and federal regulations. We follow the minimal regulatory requirements for assessment of competency. Our practice is a Tell, Show, Do, Practice, Review training method followed by: Direct observations of your performance while conducting the tasks . Monitoring and recording of your Skills Competency Assessment results. All employees have the responsibility to sustain the competencies represented in the assessments and any other procedures/responsibilities for performing their job. The Skills Competency Assessment for the Sit to Stand lift included the employee demonstrates skills and competencies in: 1. [NAME] [document that provides instructions for care]: Transfer status is verified prior to transferring. 2. Two staff members are used during transfer . 1. Review of the facility's incident investigations showed on 6/4/24 the facility initiated an investigation for an allegation of neglect with serious bodily injury involving Resident #1. The investigation noted on 6/4/24 Certified Nursing Assistant (CNA) Staff A transferred Resident #1 with a (Brand name) Sit to Stand mechanical lift in the shower room without assistance. CNA Staff A left the resident alone in the mechanical lift in the shower room to request assistance from CNA Staff B. When they both walked back into the shower room, Resident #1 was sliding out of the lift. He stated, My knee my knee. They transferred the resident in the shower chair and CNA Staff A showered him. When the resident was transferred to the bed, he complained of pain in the left knee with swelling assessed. The Advanced Practice Registered Nurse ordered an X-Ray which showed a fracture of the left femur. The resident was transferred to a local emergency room for evaluation. The facility provided a typewritten document as part of their investigation which included statements from CNA Staff A, CNA Staff B and Resident #1. 105443 Page 10 of 12 105443 06/20/2024 Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285

F 0726 Level of Harm - Minimal harm or potential for actual harm The statement from CNA Staff A read, I transferred him in the [brand name Sit to Stand lift] to wheelchair and he started to slide out. His left leg so we put his legs back in place. We transferred resident to the shower chair. I showered the resident then took him back to his room. I used the [brand name Sit to Stand] lift to transfer him back to bed. He c/o [complained of] pain with the transfer. States he always c/o pain even with brief pain. Residents Affected - Some Review of skills competency assessments revealed on 4/23/24 CNA Staff A had an annual refresher skills competency assessment which noted the CNA demonstrated skills and competency in the use of the Sit to Stand lift. The skills competencies for CNA Staff A noted on 4/23/24 Staff A demonstrated skills and competencies in use of the Sit to Stand mechanical lift which included, [NAME]: Transfer status is verified prior to transferring. Two staff members are used during transfer. Review of the clinical record for Resident #1 revealed an admission date of 12/4/2019. Diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) of the left non-dominant side, morbid obesity and muscle weakness. The care plan initiated on 1/3/20 and revised on 11/16/23 noted the resident had self-care performance deficit in activities of daily living related to a history of CVA (cerebrovascular accident) with left hemiplegia, impaired balance, limited mobility. The interventions for transfer as of 1/3/2020 specified, The resident requires [brand name full body mechanical lift] by 2 staff to move between surfaces. Review of the facility's Ad Hoc (unplanned) Quality assurance and Performance Improvement Meeting dated 6/14/24 noted the following root cause analysis: CNA failure to use the correct mechanical lift and following policy for 2 person assist. Care plan and [NAME] did not have the updated transfer status. The Plan included CNA education regarding proper techniques when utilizing mechanical lift along with competencies. 2. On 6/19/24 at 10:00 a.m., CNA Staff E was observed pushing a Sit to Stand Lift out of Resident #2's room. Review of the CNA [NAME], and the care plan (as of 11/14/23) revealed Resident #2 required two staff and a (brand name) full body mechanical lift to move between surfaces every day and as necessary. Review of the skills competency assessments revealed on 6/5/24 the DON assessed CNA Staff E's skills competency to use the Sit to Stand Lift. The DON documented 2 (fully meet standards) for the level of competency which included [NAME]: Transfer status is verified prior to transferring. On 6/19/24 at 10:15 a.m., in an interview the Assistant Director of Nursing (ADON) said she had just counseled Staff E earlier that day that Resident #2 could not use a Stand-up Lift, and she needed to read the resident's [NAME] before transferring the resident. On 6/19/24 at 11:35 a.m., in an interview CNA Staff E said Resident #2 uses a Stand-up (sit to 105443 Page 11 of 12 105443 06/20/2024 Aviata at Venice 1026 Albee Farm Rd Venice, FL 34285

F 0726 stand) Lift to transfer. Level of Harm - Minimal harm or potential for actual harm On 6/19/24 at 3:25 p.m., in an interview the ADON said when she spoke with Staff E that morning she asked her if she was aware Resident #2 was required to use a (brand name) full body mechanical lift. The ADON said the CNA's exact words were, No, but the standing lift works great. Residents Affected - Some 3. Review of the user manual for the Stand up lift used by the facility revealed, Warning: The legs of the stand up lift MUST be in the maximum open position for optimum stability and safety. If it is necessary to close the legs to maneuver the stand up lift under a bed, close the legs only as long as it takes to position the stand up lift over the patient and lift the patient off the surface of the bed. When the legs of the stand up lift are no longer under the bed, return the legs to the maximum open position. [Manufacturer name] does not recommend locking the rear casters of the stand up lift when lifting and transferring an individual. Doing so could cause the lift to tip and endanger the patient and assistants. [Manufacturer name] recommends that the rear casters be left unlocked during lifting and transferring procedures to allow the stand up lift to stabilize itself when the patient is initially lifted from and transferred to a chair, bed or any stationary object. Review of the skills competency assessment for CNAs for the Sit to Stand (Stand up) mechanical lift revealed, Lock the rear swivel casters only when positioning or removing the stand assist sling from the patient. Unlock the rear casters while lifting/transferring the resident . On 6/19/24 at 12:43 p.m., CNAs Staff F, and Staff G were observed transferring Staff H with a Stand up mechanical lift to demonstrate the proper use of the mechanical lift. The Assistant Director of Nursing (ADON) was present during the observation. After placing the transfer sling around Staff H, Staff F was observed to place the lift next to the chair without completely opening the base of the lift. Staff F locked the rear casters and attempted to lift Staff H with the Stand Up mechanical lift. The lift did not respond. Staff changed the battery twice and lifted Staff H off the chair. The lift stopped in the middle of the lift and would not respond. Staff F was observed trying to wiggle the wires on the bottom of the lift to get the lift to respond. When the lift would not respond Staff F and G were observed transferring Staff H to the chair without ensuring Staff H was fully standing. Staff F was observed to unlock the casters and move Staff H without fully extending the base of the lift. Staff F then locked the rear casters before lowering Staff H. On 6/19/24 at 1:45 p.m., in an interview the ADON verified she instructed all staff both verbally and by observation on the use of the facility's mechanical lifts after the incident on 6/4/24. 105443 Page 12 of 12