Health inspection·June 18, 2025

F 0689 to total lift (Hoyer)(device used to transfer individuals who can bear little to no weight) x2 staff members. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's consolidated physician's orders, dated 6/17/25, reflected in part the following: -May use mechanical lift device- as needed. Start date: 1/27/25. Residents Affected - Few -May use specialized wheelchair-as needed for posturing and comfort. Start date: 1/28/25. -Acetaminophen tablet 325 mg-give 1 tablet by mouth two times a day for pain. Do not exceed 3 grams in 24 hours. Start date: 6/12/25. -Tramadol HCL oral tablet 50 mg-give 1 tablet by mouth every 12 hours for pain. Start date: 1/28/25. -X-ray of left femur in two weeks 6/27/25-one time only for verbal check fracture healing. Start date: 6/13/25; End date: 6/27/25. Record review of Resident #1's progress notes, dated 6/12/25 at 9:00 AM by LVN A, reflected the following: [Resident #1] c/o left leg pain while up for breakfast. Tramadol and routine Tylenol given for pain. [MD] here and assessed leg and new order given for left leg x-ray from hip to ankle. [Resident #1] was returned to bed and a skin tear was observed on left lower leg. Dressing applied. Record review of Resident #1's progress notes, dated 6/12/25 at 9:50 AM by LVN A, reflected the following: [Hospice RN] here to see [Resident #1]. [Hospice RN] said areas on right buttock and gluteal fold were looking much better. [Hospice RN] is going to order [Resident #1] a new hospital bed with air mattress and another overbed table. [Hospice RN] has seen [Resident #1's] left leg and was informed of new order for left leg x-ray. [Hospice RN] will call [Resident #1's] [RP]and let him know about x-ray order. [Hospice RN] changed routine Tylenol order from one 325 mg Tylenol BIB [sic] to two 325 mg Tylenol BID. A PRN Tylenol 325 mg one tab every 6 hours as needed for pain was added to orders. Record review of Resident #1's progress notes, dated 6/12/25 at 2:36 PM by LVN A, reflected the following: [MD] notified of spiral fracture (a complete bone break that spirals around the bone) of left femur. [MD] ask that [LVN A] call [Resident #1's] [RP] to see if he wanted [Resident #1] sent out to the hospital, or if [Resident #1] would continue to be monitored here by [Hospice]. [Resident #1's] [RP] notified and he said that he would speak to hospice and make a decision. Record review of Resident #1's progress notes, dated 6/12/25 at 4:33 PM by the MD, reflected the following: [Resident #1] seen this am for left lower extremity pain Xray report acute spiral fracture of left femur with displacement (bone moved out of normal position) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455617 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Christian Care Communities and Services Mesquite 1000 Wiggins Pkwy Mesquite, TX 75150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety No falls reported. Skin tear to left shin noted during visit. [Resident #1] usually transferred using sit to stand lift. Xray positive for acute spiral fracture of left femur with displacement. Spoke to [Resident #1's] [RP], pain is currently controlled on APAP and Tramadol. Residents Affected - Few [RP] to decide: continue palliative care in facility on hospice, manage pain and add Lovenox for DVT prophylaxis (action taken to prevent disease). or Revoke hospice and transfer to hospital for management, due to overall condition surgery not recommended, possible bracing if indicated. Record review of Resident #1's progress notes, dated 6/12/25 at 8:48 PM by LVN M, reflected the following: [RP] called facility. Stated do not send [Resident #1] to hospital re: Fx of left femur. Provide care/comfort at facility, [Hospice]. [Resident#1] sleeping no complaints or s/s of pain or discomfort. Cont on routine pain management of Tramadol/APAP. Record review of Resident #1's Xray, dated 6/12/25, reflected in part the following: . LEFT FEMUR X-Ray - 2 view: Findings: AP (front to back) and lateral (one side of the body to the other) views of the left femur demonstrate a diffuse osteoporosis. There is a distal femoral metaphyseal (area of the thigh bone located just above the knee) spiral fracture with mild displacement. No bony erosion or destruction is present. The soft tissues are unremarkable. There is no radiopaque foreign body (white or bright objects). IMPRESSION: The bones are osteoporotic. The posteriorly (position at the back, or towards the rear) displaced distal femoral metaphyseal spiral fracture is present. Record review of a statement, dated 6/12/25, submitted by MA B reflected in part the following: When I went to get [Resident #1] up, at first she was saying leave me alone I went to another resident then came back. When I came back to get [Resident #1] up for breakfast, I used the sit to stand lift and put her on the chair. [Resident #1] was stating, leave me alone, leave me alone. [Resident #1] was then complaining of pain when she got in the chair, I thought it was regular pain, because I know she gets pain pill. I went and told the nurse that [Resident #1] was complaining of pain and the nurse went to give her medicine. When was [sic] transferring with the sit to stand lift [Resident #1] did not bump her legs or any part of her body she was ok when I transferred her with the lift. In an interview on 6/17/25 at 9:20 AM with the Administrator and DON, the DON stated on 6/12/25 it was reported to her that Resident #1 complained of pain to MA B while she was preparing her for breakfast. The DON stated MA B notified LVN A, who notified the DON and MD. The DON stated Resident #1 was given pain medication and had an Xray that revealed an acute spiral fracture of the femur. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455617 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Christian Care Communities and Services Mesquite 1000 Wiggins Pkwy Mesquite, TX 75150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated Resident #1 was on hospice and her RP chose not to have her sent out to the hospital since hospice was able to adjust her pain medication and keep her comfortable. The DON stated the lab was able to determine that the fracture was acute after comparing the Xray to a previous image. The DON stated this was her first time dealing with a spiral fracture and she could not use her clinical experience to state likely causes of that type of fracture. The DON stated Resident #1 was diagnosed with generalized pain and a hx of a hip fracture, so when she complained of pain, MA B thought it was her usual pain. The DON stated Resident #1 had a hx of falls but was currently non-ambulatory and was not considered a fall risk. The DON stated Resident #1 depended on staff for mobility and required a sit-to-stand mechanical lift to be transferred out of bed. The DON stated there had been no reported incidents or changes in Resident #1's condition in the days leading up to the injury. The DON stated she took statements from staff who worked with Resident #1, and no one stated any incidents or changes with the resident. The DON stated if Resident #1 had fallen out of bed she would have needed assistance getting up, so staff would have been aware if the injury was caused from a fall. The Administrator stated an investigation was conducted and the cause of injury was unfounded. The Administrator stated an emergent QAPI meeting was held, and interventions were put in place that included all staff being in-serviced and completing skills checkoffs on mechanical lift transfers. In an interview on 6/17/25 at 10:05 AM, LVN A stated she worked at the facility for about 9 years. She stated she worked with Resident #1 on 6/12/25. She stated they were passing breakfast trays when Resident #1 looked at her and said [LVN A] my leg hurts. LVN A stated she was shocked that Resident #1 knew her name and was able to be specific about where her pain was because Resident #1 was diagnosed with advanced dementia and was normally confused. LVN A stated Resident #1 was able to express when something was wrong, but she was very specific that day and was able to point to her left leg. LVN A stated she assessed Resident #1 and only found a faint skin tear to her lower left leg. LVN A stated Resident #1 was on routine Tylenol and Tramadol that had already been administered. LVN A stated the MD was already at the facility doing rounds and was notified that Resident #1 was complaining of pain. LVN A stated hospice and Resident #1's RP was also notified. LVN A stated the MD assessed Resident #1 and ordered a STAT Xray. LVN A stated hospice increased Resident #1's pain medication. LVN A stated Resident #1's Xray was positive for a spiral fracture to her hip bone and that was considered a more serious type of fracture. LVN A stated in her experience that type of fracture could be caused by the leg being bent all the way back or a forceful movement. LVN A stated when she arrived on shift that morning, the off-going nurse did not report any incidents or changes in Resident #1's condition. LVN A stated the day started as normal. LVN A stated the usual CNA for that hall did not work that day and MA B was filling in. LVN A stated there were some staff openings on the unit and it was not unusual for staff from other halls to help. LVN A stated Resident #1 was total care and required a sit-to-stand mechanical lift for transfers. LVN A stated MA B did not report any accidents or injuries while transferring Resident #1 to her wheelchair that morning. In an interview on 6/17/25 at 10:05 AM, MA B stated she worked at the facility for about a year. She stated she was a MA but also helped as a CNA when needed. MA B stated she worked on the memory care unit for the past two weeks and was familiar with Resident #1, who complained of pain often. She stated she worked with Resident #1 on 6/12/25 when the injury was found. MA B stated when she entered Resident #1's room to get her out of bed for breakfast, she complained of pain which she thought was her normal pain. MA B stated Resident #1 was complaining of pain before she moved her; however, she proceeded to use the sit-to-stand mechanical lift to get her into the wheelchair. MA B stated mechanical lift transfers were supposed to be done with 2 staff but there was no one else available to help so she did it alone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455617 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Christian Care Communities and Services Mesquite 1000 Wiggins Pkwy Mesquite, TX 75150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety MA B stated Resident #1 was able to assist some, which made it easier. MA B stated there was not an accident during the transfer. MA B stated once she got Resident # in the wheelchair, she reported to LVN A that Resident #1 was complaining of pain. MA B stated she had been trained on abuse and neglect. She was able to provide examples of abuse and stated she would report any concerns to the Administrator. MA B stated she had also been trained on safe repositioning, mechanical lift transfers, and notifying the nurse if a resident complained of pain before completing any care. Residents Affected - Few In an interview on 6/17/25 at 11:01 AM, Resident #1's RP stated the facility notified him on 6/12/25 that Resident #1 complained of pain in her leg and an Xray showed a spiral fracture of the left femur. The RP stated he did not have any concerns that Resident #1 was abused or neglected, and the facility always notified him of any incidents or changes with the resident. He stated he was not present, but he could see how maybe during a transfer Resident #1's foot was not planted correctly when staff went to transfer her, and the bone twisted. He stated Resident #1 had multiple fractures in the past and had fragile bones. The RP stated he was pleased with the care Resident #1 was receiving at the facility; however, he understood why the State Agency needed to investigate the injury. In an interview and observation on 6/17/25 at 12:00 PM, Resident #1 was observed lying comfortably in bed. The bed was in the lowest position with a fall mat on the floor. Resident #1 was dressed in her gown and was well-groomed with no visible marks or bruises. Resident #1 stated she was fine and denied being in any pain. Resident #1 stated something happened to her hip, but she was not able to recall what happened. Resident #1 stated she did not fall, and no one hurt her. Resident #1 was not a good historian due to her dementia and was not able to complete the interview. In an interview on 6/17/25 at 1:20 PM, CNA C stated she worked at the facility for 8 years. She stated she normally worked on the memory care unit with Resident #1; however, she called out on 6/12/25 and staff who normally did not work with Resident #1 filled in for her that day. CNA C stated she received a call informing her that Resident #1 had a fractured hip and was on bedrest. CNA C stated Resident #1 required a sit-to-stand mechanical lift for transfers but when she returned to work, she received an in-service and was told that Resident #1 now required a total lift for transfers. CNA C stated she was also informed that all mechanical lift transfers had to be performed with 2 staff. CNA C stated they always used 2 staff with total lift transfers, but they would sometimes do sit-to-stand lift transfers alone because the residents could bear some of their weight and assist some. CNA C stated when Resident #1 was transferred, staff had to know to be patient with her and remind her to keep her legs bent. CNA C stated on 6/13/25 she had to do an in-service and skills check-off for mechanical lift transfers. She stated shewas also in-serviced on notifying the nurse of any complaints of pain or change in condition before proceeding with care, and abuse and neglect. CNA C denied having concerns that any residents were being abused or neglected in the facility . In an interview on 6/17/25 at 1:45 PM, the DON stated MA B informed the DON that she used a sit-to-stand mechanical lift to transfer Resident #1 without a second staff. The DON stated Resident #1 required a 2-person assist with transfers and it was also the facility's protocol to use 2 staff during mechanical lift transfers. The DON stated it was important to use 2 staff during mechanical lift transfers to ensure the safety of residents and prevent injuries. Further interview on 6/17/25 at 3:32 PM with the Administrator and DON, the DON stated the expectation was for the aides to notify the nurse if a resident complained of pain before proceeding with any type of care so the resident could be assessed and provided pain management and staff were re-educated on this during in-services regarding the incident. The Administrator stated the aides were not qualified to assess residents or make any determinations, which was why the nurse had to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455617 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Christian Care Communities and Services Mesquite 1000 Wiggins Pkwy Mesquite, TX 75150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few notified. The DON stated providing care after a resident expressed being in pain, without notifying the nurse, could place the resident at risk of increased pain. The Administrator added that it could place the resident at risk of further injury or cause an injury. In an interview on 6/18/25 at 12:49 PM, the MD stated on 6/12/25, she was making rounds at the facility when LVN A notified her that Resident #1 was complaining of pain in her left leg. The MD stated she went in the room to assess Resident #1 and ordered an Xray of the leg. The MD stated the Xray was positive for an acute spiral fracture of the left femur/hip. The MD stated Resident #1 had memory loss due to dementia; however, she was able to express when she was in pain, she just could not state what caused it. The MD stated Resident #1 was on hospice for terminal diagnoses of dementia and was also diagnosed with osteopenia, which meant that the resident's bones were very fragile. The MD stated a spiral fracture was an injury that would make one think; however, in Resident #1's case it would only take minor trauma to obtain due to her bones being so fragile. The MD stated there were no reports of a fall or other incidents. The MD stated Resident #1's bed was always low to the ground and staff used a sit-to-stand mechanical lift to transfer her. The MD stated she believed the sit-to-stand lift was in the room when she assessed her on 6/12/25. The MD stated Resident #1's injury could have happened during a transfer. Review of the facility's policy titled Lifting Machine, Using a Mechanical, revised July 2017, revealed in part the following: Purpose: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. General Guidelines: 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. . Steps in the Procedure: 1. Before using a lifting device, assess the resident's current condition, including: a. Physical: (1) Can the resident assist with transfer? (2) Is the resident's weight and medical condition appropriate for the use of a lift? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455617 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Christian Care Communities and Services Mesquite 1000 Wiggins Pkwy Mesquite, TX 75150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 b. Level of Harm - Immediate jeopardy to resident health or safety Cognitive/Emotional: Residents Affected - Few Can the resident understand and follow instructions? (1) (2) Does the resident express fear or appear anxious about the use of a lift? (3) Is the resident agitated, resistant, or combative? . The non-compliance was identified as past non-compliance (PNC). The Administrator and DON were notified of the PNC on 06/18/25 at 1:00 PM. The Immediate Jeopardy began on 06/12/25 and ended on 06/16/25. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review on 6/17/25 of a document provided by the Administrator titled Emergent Quality Assurance (QA) Form 10, dated 6/13/25, reflected a QAPI meeting was held to discuss failure and interventions put in place to prevent failure from occurring again, which included: assessment and STAT treatment of Resident #1, notifying MD, hospice, family, and ombudsman of incident, in-servicing all staff, skills checkoffs with all staff, skin assessments, chart review and updated care plan. Follow-up included: continued monitoring of pain, two weeks of bedrest, and transfer status changed from sit-to-stand lift to complete lift (Hoyer) for Resident #1, and monitoring of CNAs weekly for proper lift transfers for 4 weeks, then twice monthly, then times 3 quarterly with results of audits provided to QAPI and recommendations reviewed. Record review on 6/17/25 of a document provided by the Administrator titled Teammate Corrective Action Form, dated 6/13/25, reflected CMA B received corrective action via Coachable Moment. CMA B received one on one education regarding proper use of mechanical lifts and notifying the nurse immediately when assistance is needed. Record review on 6/17/25 of documents provided by the DON titled Skin Monitoring Assessment Sheet, dated 6/13/25-6/14/25, reflected 18 residents on the unit received head-to toe- skin assessments with no negative findings. Record review on 6/17/25 of documents provided by the DON titled Competency Assessment: Lifting Machine,, dated 6/14/25-6/17/25 (overnight 6/16-6/17), reflected 28 staff completed skills checkoffs for mechanical lift transfers, which included assessing the resident's current physical and emotional condition before performing the lift and general principles of safe lifting. Record review on 6/17/25 of in-service titled Use of Sit to Stand and Hoyer lifts, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455617 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455617 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Christian Care Communities and Services Mesquite 1000 Wiggins Pkwy Mesquite, TX 75150 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 6/13/25-6/15/25, reflected 36 staff were educated by the DON on ensuring that all mechanical lifts be performed with a 2-person assist always. Record review on 6/17/25 of in-service titled Abuse, Neglect, Exploitation Policy, dated 6/13/25, reflected 34 staff were educated by the DON regarding the facility's abuse, neglect, and exploitation policy. Record review on 6/17/25 of in-service titled Safety with turning and repositioning, dated 6/14/25, reflected 28 staff were educated by the DON on safe protocol when turning and repositioning residents. Record review on 6/17/25-6/18/25 of Residents #1, #2, #3, #4, #5, #6, #7, and #8, who all required transfer assistance, EHRs revealed their care plans included interventions to address ADL needs and appropriate transfer requirements. Resident #1's care plan was revised on 6/13/25 with transfer status updated to Hoyer Lift X 2 staff members, Observations on 6/17/25 from 12:00 PM-1:15 PM; 4:00 PM-4:35 PM, with Residents #1, #2, #3, #4, #5, #6, #7, and #8, who all required transfer assistance, revealed no s/sx of pain or visible marks or bruises. Observation of mechanical lift transfers revealed they were safely completed, following protocol with 2-person assist. Interviews on 6/17/25 from 12:00 PM-1:15 PM; 4:40 PM-5:05 PM, with the RPs and Residents #1, #2, #3, #4, #5, #6, #7, and #8, who all required transfer assistance, revealed no concerns for accidents/injuries during mechanical lift transfers, abuse, or neglect of residents. Interviews from 6/17/25 (varied times between 10:05 AM-5:22 PM) - 6/18/25 (9:40 AM-11:35 AM), conducted with the Administrator, DON, nurses and CMA/CNAs: LVN A (1st shift/weekdays), CMA B (1st shift/rotating days), CNA C (1st shift/rotating days), CNA D (1st shift/rotating days), RN E (2nd shift/weekdays), CNA F (2nd shift/rotating days), CNA G (2nd shift/ rotating days), CNA H (2nd shift/ rotating days), CNA I (2nd shift/ rotating days), LVN J (1st shift/weekdays), CNA K (1st shift/rotating days), CNA L (1st shift/rotating days), LVN M (3rd shift/weekdays), CNA N (3rd shift/rotating days), LVN O (1st/2nd shift/double weekends), CNA P (3rd shift/ rotating days), RN Q (3rd shift/weekends), and CNA R (3rd shift/ rotating days), indicated they all participated in in-services and skill checkoffs prior to starting their shifts. All staff were able to state that the facility used two different type of mechanical lifts (sit-to-stand and total mechanical lift) and transfers with both lifts required a 2-person assist at all times. All staff were able to state that using a draw sheet and pillow would reduce the risk of injuries when turning and repositioning residents. All CMA/CNAs were able to state that the nurses must be notified immediately if a resident had any changes in condition or c/o pain before proceeding with care or transfers . All nurses were able to state they were responsible for assessing any c/o of pain or changes in a resident's condition, report to the MD, and follow any new orders. All nurses were able to state they would be aware of all mechanical lift transfers and would be available to assist if needed. All staff were able to state in their own words the facility's abuse, neglect, and exploitation policy. All staff were able to describe abuse, neglect, and exploitation, when to report it, and who to report it to. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455617 If continuation sheet Page 8 of 8