Health inspection·October 4, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained free of accident hazards for 3 of 3 residents (Resident #1, Resident #2 and Resident #3) reviewed for quality of care in that: CNA A failed to operate the Hoyer lift with 2 staff per facility policy when transferring Resident #1 from the wheelchair to the bed. As a result Resident #1 sustained a head injury and was sent to the hospital. Resident #2 stated that staff (unknown) lifted him majority of the time with 1 staff using the Hoyer lift. Uncertified Nurses aides (NA B and NA C) admitted to using the Hoyer lift to transfer residents. The Director of Nurses (DON) and the Director of Rehabilitation (DOR) did not ensure that staff were trained according to their lifting policy to use the Hoyer. The DOR and DON did not have a contingency plan in place if the only Hoyer lift was not operational. A confidential staff admitted to utilizing the Hoyer lift with one staff to transfer residents. The Agency Nurse failed to assess/ take vitals of Resident #1 after she sustained a head injury after being dropped out of the Hoyer lift on [DATE]. Observation of staff (CNA E, F, H & J) using the Hoyer lift to transfer residents (Resident# 1 and Resident #3) revealed that they did not inspect the Hoyer sling and lock the wheels during the process. On [DATE] at 5:12 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] at 3:50 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of harm or injury and contribute to avoidable accidents. Findings Included: Page 1 of 21 745002 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0689 Resident 01 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #01's face sheet, dated [DATE], revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia and need for assistance with personal care. Residents Affected - Some Record review of comprehensive MDS assessment dated [DATE] revealed Resident #01 usually understood (misses some part/intent of message but comprehends most conversations). The MDS revealed Resident #01 had a BIMS of 00 which indicated the resident's cognition was severely impaired. Section G revealed the resident transfer required (total dependence) with support (two+ person physical assist) Record review of a care plan, dated [DATE] for Resident #01 revealed: Focus: May use Hoyer lift as needed for transfers; Goal: Will have safe transfers through the review date; Interventions: Assisted transfers with 2 licensed staff. Record review of a care plan, dated [DATE] for Resident #01 revealed: Focus: This resident had a fall from the mechanical lift on [DATE] with a laceration to the back of the head r/t improper use of the mechanical lift by staff; The resident's laceration will be healed by the review date without complications; Interventions: Staff training for proper mechanical lift training. Record review of a care plan, dated [DATE] for Resident #01 revealed: Focus: The resident has an ADL self-care performance deficit r/t dementia, impaired balance, limited mobility, stroke; Goal: The resident will maintain current level of function in mobility and ADLs through the review date; Interventions: Transfer: the resident requires total assistance by 2 staff & Hoyer lift to move between surfaces. Record review of hospital records dated [DATE] revealed the following: 95 years female, trauma-dropped out of Hoyer lift Findings: Brain: Small acute left subdural hematoma measuring up to 5 mm in greatest transverse diameter. No abnormal right sided extra-axial fluid collections. Discharge Diagnosis: Fall, laceration of right side of scalp, subdural hematoma Record review of the transfer paperwork titled, SNF/NF to Hospital Transform Form, undated, revealed the following: Vital signs (blood pressure, heart rate, respiration rate, oxygen level) data dated 5 days before the incident ([DATE]) 745002 Page 2 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0689 The pain level data dated 2 days before the incident ([DATE]) Level of Harm - Immediate jeopardy to resident health or safety Form completed and reviewed by On Call Charge Nurse dated [DATE] at 7:20 PM. Residents Affected - Some Record review of Resident #02's face sheet, dated [DATE], revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dementia, difficulty walking, unsteadiness on feet, need for assistance with personal care and personal injury of traumatic brain injury. Resident 02 Record review of comprehensive MDS assessment dated [DATE] revealed Resident #02 was usually understood (misses some part/intent of message but comprehends most conversation). The MDS revealed Resident #02 had a BIMS of 07 which indicated the resident's cognition was severely impaired. Section G revealed the resident transfer required (Extensive Assistance) with support (two+ person physical assist) Record review of a care plan, dated [DATE] for Resident #02 revealed the following: Focus: The resident has an ADL self care performance deficit r/t history of traumatic brain injury, dementia, cognitive and low vision; Goal: The resident will maintain current level of function through the review date. Staff will meet his needs; Transfer: The resident requires limited to extensive assistance by 1-2 staff to move between surfaces as necessary. Resident 03 Record review of Resident #03's face sheet, dated [DATE], revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia and a history of falling. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #03 was rarely understood. The MDS revealed Resident #03 had a BIMS of 00 which indicated the resident's cognition was severely impaired. Section G revealed the resident transfer required (total dependence) with support (two+ person physical assist) Record review of a care plan, dated [DATE] for Resident #03 revealed: Focus: The resident has an ADL self care performance deficit; Goal: The resident will maintain current level of function through the review date; Interventions: The resident requires total dependence by Hoyer lift to move between surfaces. During an interview on [DATE] at 3:16 PM, CNA A stated Resident #1's roommate needed to go to the restroom. She said since Resident #1's roommate was on the toilet and was by herself, she moved the bed diagonally to observe both residents. She said she had the Hoyer, opened the legs, and slid the lift under Resident #1's wheelchair. She said she hooked the sling onto the Hoyer lift. She said she had checked everything. She said she remembered that she had the top strap on the blue loop, the middle strap on the green, and the bottom straps crossed on the green loop. She said she lifted the resident up to get tension on the straps. She said she guided her safely to the bed. She said she heard 745002 Page 3 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some a loud pop once she was over the bed. She said she saw Resident #1 hit her head on the headboard. She said she pushed the call light for help. She said she yelled for help. She said she left the resident, but not for long. She said she knew she was not supposed to leave the resident, but she went and got the nurse in charge. She said she was an agency nurse. She said she stayed with Resident #1 after she got the nurse. She said she placed a cold towel on Resident #1 head. She said she did not remember if the nurse took her vitals. She said the other CNA on shift that night was putting her residents down. She said they tried to put their residents at risk for falls down first. She said she would never transfer another resident with the Hoyer alone again. She said this was her first time doing this alone. She said she had been trained when she first started at the facility, but it had been a while. She said she has been at the facility for over a year. She said she has never had to demonstrate her ability to use the Hoyer lift. She said she had signed an in-service. During an interview on [DATE] at 10:45 AM, the Agency Nurse stated she arrived at work at 5:30 PM. She said around 6:30 PM was when the incident with Resident #1. She said CNA A came to her flabbergasted, as something bad had happened. She said that CNA A kept saying, It was an accident, and I did not mean for it to happen. The Agency Nurse said she was in the medication room and was unsure what she would need. She said she gathered gauze and wound cleanser. She said she went to Resident #1s room, and she was laid on her left side. She said Resident #1 was awake. She said CNA A had placed a damp towel on Resident #1 head. She said when she removed the towel, there was a mass of blood mixed in with Resident #1's hair. She said the bleeding stopped, and you could see the laceration. She said CNA A told her that she was transferring Resident #1 from the wheelchair to the bed with the Hoyer by herself, and the strap came loose. The Agency Nurse said she told CNA A that she was not supposed to operate the Hoyer by herself. She said CNA A said she knew she was not supposed to. She said she did not know who she was supposed to call or what the emergency procedure was for the facility. She said she called the on-call charge nurse, and she said she was in the facility. She said she went to the on-call nurse's office. She said the on-call nurse told her to call the nurse practitioner and then gave her the number for the sheriff's department. She said she was told to call the sheriff's department because EMS responds quicker. She said she called the NP at 6:40 PM. She said she called the sheriff's office at 6:42 PM. She said she called the ADM at 6:50 PM. She said the on-call charge nurse would contact the DON. She said she notified Resident #1s family member at 6:53 PM. She said EMS arrived at 7:00 PM. She said the on-call charge nurse helped her get the paperwork to give to the EMS. She said EMS left with the resident around 7:05 PM. She said she forgot to call the hospital and give a report verbally. She said she did not get Resident #1's vitals. She said she was so frantic she did think to do them. She said she was focused on getting Resident #1 out of the facility. She said the purpose of taking vital signs was to get a baseline. She said it was good because neuro checks are also done. Neurological checks could let one know if something was happening in the brain. She said she was not aware that old vital signs were submitted. She said the on-call charge nurse was the person who submitted the vitals. She said she printed off the face sheet and the medication administration record. She said not taking vitals could have caused staff to miss if something was severely wrong. She said vitals could have helped identify the resident's diagnosis (subdural hematoma). She said she could have looked at the resident pupils. She had a subdural hematoma, which was a serious diagnosis. She said it was a pocket of blood outside of the brain but not outside of the skull. She said she had not been oriented to the facility or their processes as an agency nurse. She said she did not receive a tour of the facility and was not oriented to any policies or what to do in an emergency according to the facility policy. During an interview on [DATE] at 11:11 AM, the On Call 745002 Page 4 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Charge Nurse stated she was working in her office when she received the call from the Agency Nurse. She said she told her to come to her office. She said CNA A was crying. She said CNA A told her she was putting Resident #1 in bed. She said she heard a popping noise when she pushed the Hoyer down. She said CNA A said the strap popped off. She said once she knew the resident was safe, she had CNA A write a statement and then ask her to leave. She said she had given The Agency nurse a list of things to do. She said she was not sure if the Agency nurse was frantic. She said she gave her the NP and sheriff's department numbers. She also said on the list she had that she needed to put the information in the computer about the incident and notify the family. She said she told The Agency Nurse to update the vitals. She said she did not notice that the vitals were not current until she later found out that the Agency nurse did not give report to the hospital. She said she was at the facility until 2:30 AM on [DATE] & [DATE]. She said Resident #1 was sent to the hospital and was diagnosed with a subdural hematoma. She said a subdural hematoma was a bleed on the brain, and if it continues to bleed, it can lead to death. She said the purpose of taking a resident vitals after a fall was to identify shock, stability, and a baseline for the residents. She said a person's pulse and neurological checks could have identified if there was a bleed on the brain. She said if there was any indication of neurological problems, then EMS would need to know this because that would change how they treat Resident #1. She said the EMS took time to clean the resident up, but if there was knowledge of potential head trauma or vitals that were abnormal, they would have been busy driving getting her to the hospital. She said she did orient the Agency Nurse to the facility procedures two days prior. She said she asked the Agency Nurse and said she did not have any questions. She said all nurses should know what to do in an emergency. She said the Agency Nurse was responsible for getting Resident #1 vitals. During an interview on [DATE] at 8:04 AM, the Hospital Nurse stated a subdural hematoma was a serious diagnosis. She said it was bleeding in the brain. She said a person could die from that diagnosis. She said she had worked with Resident #1 during her hospital visit on [DATE]. She said that Resident #1 came back in on 10/05 for fever and tachycardia (fast heartbeat). She said this diagnosis could be related to her fall on [DATE]. She said her brain may not be regulating properly with the Dx of subdural hematoma. For example, her brain may not properly tell her how to swallow. She said the hospital did have Hoyer lifts, and they use them. She said it should always be two staff. She said the fact they need a Hoyer indicates that it is a lift that cannot be done alone. She said the second person was vital because that ensures the sling is properly placed under the resident, helps with a safe transfer, and has someone there if anything happens. She said not having vitals could aggravate hospital staff because they cannot see the resident's progression or decline. She said it is common nursing sense to obtain vitals and neurological checks. She said having vitals from 5 days before ([DATE]) would not likely be the same at [DATE], especially if she had bleeding in her brain. During an interview on [DATE] at 2:04 PM, Resident #1 could not answer any questions regarding the incident on [DATE] and about past transfers with the Hoyer lift. During an interview on [DATE] at 10:30 AM, the ADM stated CNA A went to place Resident #1 to bed, and she required the Hoyer lift. CNA A went by herself without the second CNA. She said she was told by CNA A that one of the straps was not secure and came off. Resident #1 hit her head on the headboard. She said it caused a laceration to the back of the head. She said the strap did not break; it just came loose. She said she was unsure why CNA A did not have the 2nd CNA for help. She said CNA A told the charge nurse she knew better than using the Hoyer alone. She said this incident occurred Saturday ([DATE]) around 7:00 PM. She said she sent CNA A home around 7:15 PM. Record review of a care plan, dated [DATE] for Resident #01 revealed: 745002 Page 5 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Focus: This resident had a fall from the mechanical lift on [DATE] with a laceration to the back of the head r/t improper use of the mechanical lift by staff; The resident's laceration will be healed by the review date without complications; Interventions: Staff training for proper mechanical lift training. During an interview on [DATE] at 10:35 AM, the ADON stated the expectation of the use of the Hoyer was that it had to be 2 certified nurse aides. She said it could not be a nurse aide. She said the CNA A was certified. During a confidential interview, it was revealed that they (unidentified staff) used the Hoyer alone when short-staffed. They said they were often short-staffed when they came in. They said they recently used the Hoyer lift alone. They said they used the Hoyer last week to transfer a resident. They said they were not the only ones to use the Hoyer alone but that other staff members also used the Hoyer lift with one staff. They said that they had never received Hoyer training at the facility. They said they had never had to demonstrate their knowledge of the Hoyer to anyone. They said they did not know the facility staff oriented agency staff to policy and procedures. They said that they have observed agency staff come in and have to ask questions constantly to provide care to the residents. They said they were relieved that what happened to CNA A and Resident #1 did not happen to them because it could have. During an interview on [DATE] at 1:10 PM, NA B stated she had been an NA for 2 weeks. She said she had used the Hoyer lift with another certified CNA. She said she rolled the resident and paced the net under them. She said they then hooked them up to the Hoyer. She said she had never used the Hoyer alone. She said she had not had recent training from the facility. During an interview on [DATE] at 1:18 PM, NA C stated that she had used the Hoyer lift with the assistance of a certified CNA. She said they had placed a resident in bed and left the sling under them in case they needed to be changed. She said she had not had any formal training. During an interview on [DATE] at 3:05 PM, the Director of Rehabilitation stated they had Hoyer lift training several months ago. He said it was an orientation for everyone. He said during the Hoyer lift training, they discussed the use of the Hoyer, transfers, and gait belts. He said they talked about how to place the sling under the resident. He said they trained the staff to use two people. He said he did not have staff demonstrate the use of the Hoyer. He said the staff present watched him. He said he was not familiar with CNA A. He said he had seen Resident #1 and said the Hoyer lift was an appropriate transfer method for Resident #1 because she could not bear weight. He said that the Hoyer sling used to transfer Resident #1 was not damaged that he knew of and the facility only had one Hoyer lift; if it went out, they did not have a contingency plan. He said if they did have a contingency plan this would help the resident. During an interview on [DATE] at 11:30 AM, CNA E stated she had not been checked off on the use of the Hoyer lift. She said she has never had to demonstrate her knowledge and ability to use the Hoyer lift. She said she has not been trained on a contingency plan in what to do if the one Hoyer they have was to stop working. She said she could use a sheet or get another staff to grab an arm and leg. She said the potential negative outcome of not having a contingency plan would be residents could get hurt. 745002 Page 6 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview on [DATE] at 11:35 AM, CNA E stated that if Hoyer was not working, she would get the older one. She said they have a crank Hoyer that they can use. She said she does take vitals, but it was a nurse's duty. During an interview on [DATE] at 11:40 AM, CNA G stated she had been checked off to use the Hoyer lift. She said she has never had to demonstrate. She said if the Hoyer lift does not work, the facility has a manual Hoyer lift that they are supposed to use. She said she was agency staff and had never been oriented to the facility policy and procedures. She said she just used her prior knowledge. During an interview on [DATE] at 11:45 AM, CNA H stated she had training with a group while back at the facility but did not demonstrate it for competency. She said she was unaware of a contingency plan if the one Hoyer lift did not work. During an interview on [DATE] at 11:50 AM the DON stated improper use of the Hoyer lift can lead to serious injury even death. She said it could have been worse if CNA A had not been over the bed. She said not taking a resident's vitals after a fall would mean the staff do not know the status of the resident and they could be worse than what was physically seen. She said not having a contingency plan for the Hoyer could lead to the staff not having a way to transfer the resident. She said there was only one Hoyer because the older one had been decommissioned. She said the staff were no longer using the old Hoyer. She said she did not know where the Hoyer was. She said she was unaware that the staff had not demonstrated using the Hoyer. She said she knew that they went over how to use the Hoyer, but this was before she was hired. She said she was unaware that non-certified aides were using the Hoyer lift. She said she was unaware that there was staff using the Hoyer alone because of staffing. She said she was unaware that the Agency Nurse did not take the resident's vitals. She said she was also unaware that there was no formal contingency plan. Regarding systems in place to monitor the deficient practices, she said annual training should cover Hoyer's use. She said in her experience, she had to demonstrate her skills. She said regarding taking vitals, they have their accident policy. She said she did not have any additional support regarding a contingency plan to ensure things such as contingency plans were not missed. She said there was no system in place to monitor the staff using the Hoyer lift or taking vitals. She said she had to trust that they were doing their job. She said there was no documentation to support staff skill competency for the Hoyer lift. She said she had been trained on the use of the Hoyer when she worked at the hospital, but not at the facility. She said she had training regarding taking vitals after a resident had fallen. She said she had not received any training regarding a contingency plan. She said she expected staff to use the Hoyer with 2 staff. She said non-certified nurse aides should not use the Hoyer to transfer residents. She said they should not be a part of the 2 staff. She said non-certified nurse aides can observe. She said she expected the staff to be 100 percent trained and demonstrate their skills and use of the Hoyer. She said she expected agency staff to have all the skills and training before working in their facility. She expected additional staff to be used until they could secure a working lift. The DON did not specify what the staff would use to transfer. She said regarding Resident #1 and CNA A incident, she expected the CNA to use the Hoyer properly with two staff. She said she, as the DON, she was responsible for monitoring the use of the Hoyer lift. She said the policy said the ADON was responsible, but since she was over the ADON, it was her responsibility. She said orienting agency staff was the responsibility of the same disciplines. She said if it was a CNA, a facility CNA staff would orient the staff. She said if it was a nurse, then a facility nurse would orient the agency nurse. She said she and ADM were responsible for ensuring a contingency plan was in place for transferring residents if the one Hoyer they had was unavailable. She said vitals should have been done as a part of the assessments after a resident falls. She said she has seen staff use the Hoyer in the past but never watched CNA A. 745002 Page 7 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some She said a subdural hematoma was a serious diagnosis. She said it was a bleed under the subdural tissue. She said it was serious, so she was kept overnight. She said it was very important to take vitals because they could miss something, and with this diagnosis, a resident could rapidly deteriorate. During an interview on [DATE] at 12:00 AM, the ADM stated not training and ensuring that the staff know how to use the Hoyer lift would mean that they, as management, do not know if the staff truly know how to use it. She said staff not properly being trained can lead to injury or death. She said regarding the resident #1 incident, she could have died. She said it could have been much worse if Resident #1 had not been over her bed. She said non-certified nurse aides are not trained, and they could also hurt someone. She said that by not orienting the agency staff to facility policies and procedures or emergency response, the agency staff may not know what they are doing. She said agency staff may do things in a way that was not acceptable to the facility. She said not having a contingency plan could result in the staff breaking something on the residents. She said she was unaware that there were no physical competencies and that the staff did not demonstrate the use of the Hoyer back. She said she was unaware that her non-certified nurse aides were using the lift. She said she was unaware that the Agency Nurse did not take resident vitals. Regarding agency staff, she said she had never had to orient the agency staff. She said they should know what they were doing regarding their skills. She said she was unaware there was no contingency plan for if the Hoyer lift was to no longer work. She said she was unaware that CNA A was using the Hoyer alone. She said she had no system to monitor staff training for Hoyer use and demonstration. She said she did not have a system to monitor if the uncertified nurse's aides were using the Hoyer lift because they were not supposed to use the Hoyer because they had not been fully trained. She said there was no system in place to orient the agency staff. She said there was a book with emergency numbers. She said there was no system to monitor contingency plans for the Hoyer lift. She said she was not sure where the old Hoyer lift was. She said the staff should not be using it. She said there was a sit-to-stand lift, but no one knew. She said she was unaware that CNA A had used the Hoyer by herself but believed if she had done it once she had done it more than once. She said she was unaware that other staff were using the Hoyer lift alone without a second staff. She said she had been trained in using the Hoyer and understood that staff should have demonstrated their use of the Hoyer. She said she has not personally been trained in taking vitals but understands that it has to be done after a fall. She said having a contingency plan had never been brought up. She said she expected all clinical staff to have been trained on using the Hoyer and should have physical competencies. She said she expected all staff to demonstrate to the Director of Rehab or the DON that they could properly use the Hoyer lift. She said it was not her expectation for staff to be just shown how to use the Hoyer. She said it was her expectation that the nurse in the facility take vitals after a fall. She said although she had seen CNAs take vitals, she had not seen them take them at her current facility. She said she understood that the CNA was trained to take vitals, but she did not want them taking vitals at the facility. She said the agency staff should know what comes with their respective discipline. The ADM stated For example, if they are a nurse, they should know all the skills and duties of a nurse. She said she expected if the agency staff had questions, they should ask them. She said with having one Hoyer lift, there should be a contingency plan in place to avoid injury and accidents. Regarding Resident #1 and CNA A, she expected the CNA to have retrieved another staff to help her and keep the resident safe from injury and accident. She said the DOR and the DON were responsible for completing physical competencies and ensuring that clinical staff demonstrated the use of the Hoyer per their policy and procedures. She said it was the responsibility of the DON and charge nurse to ensure that the uncertified 745002 Page 8 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some nurse aides were not using the Hoyer lift and that other staff were not using the Hoyer lift alone. She said it was the responsibility of the charge nurse to ensure that vitals are taken after a resident falls or experiences any type of head trauma. She said not taking vitals after a potential head injury was unacceptable, especially with two nurses in the facility. She said the resident should not have been moved until assessed. She said overall, the DON was responsible for the activity of CNA A. The ADM confirmed that there were no records of physical competencies in the facility because they did not exist. She said Resident #1 Dx of subdural hematoma was serious because it was bleeding in the brain and Resident #1 could have bled out. She said taking vitals could have helped identify a serious issue with the resident neurologically. She said the staff may have had a chance to respond differently if vitals had been taken. During an observation that occurred on [DATE] at 1:37 PM CNA F and CNA I transferred Resident #3 from her wheelchair to the bed using the Hoyer lift. Prior to operation of the Hoyer neither staff inspected the sling to insure it was intact and safe for use. CNA F and CNA I did not lock the wheels of the Hoyer throughout the use of the Hoyer lift. During an observation that occurred on [DATE] at 1:52 PM CNA E and CNA J transferred Resident #1 from her wheelchair to her bed. Prior to operation of the Hoyer neither staff inspected the sling to insure it was intact and safe for use. Resident #1 was one sided in the sling and no adjustments was made to ensure that the sling was evenly under the resident. Neither staff locked the Hoyer lift prior to using it to lift the resident out of her wheelchair. During an interview on [DATE] at 8:04 AM, the Hospital Nurse stated a subdural hematoma was a serious diagnosis. She said it was bleeding in the brain. She said a person could die from that diagnosis. She said she had worked with the resident during her hospital visit on [DATE]. She said that Resident #1 came back in on 10/05 for fever and tachycardia (fast heartbeat). She said this diagnosis could be related to her fall on [DATE]. She said her brain may not be regulating properly with the Dx of subdural hematoma. For example, her brain may not properly tell her how to swallow. She said the hospital did have Hoyer lifts, and they use them. She said it should always be two staff. She said the fact they need a Hoyer indicates that it is a lift that cannot be done alone. She said the second person was vital because that ensures the sling is properly placed under the resident, helps with a safe transfer, and has someone there if anything happens. She said not having vitals could aggravate hospital staff because they cannot see the resident's progression or decline. She said it is common nursing sense to obtain vitals and neurological checks. She said having vitals from 5 days before ([DATE]) would not likely be the same at [DATE], especially if she had bleeding in her brain. During an interview on [DATE] at 8:15 AM, The Dispatcher stated they received their initial call at 6:41 PM. It was reported that they needed resident transport because of a head wound. She said at 6:51, the EMS workers were enroute and arrived at the facility. At 6:55 PM, they received a call from the EMS staff stating they needed to extend their time at the facility because the resident was not ready to pick up. At 7:23 PM, the EMS staff called in and said the resident was still not ready for pickup. She said she did not know why the resident was not ready. She said at 7:29, the EMS was enroute to the hospital. She said they arrived at the hospital at 7:50 PM. She said the medic on duty could give more information. During an interview on [DATE] at 8:27 AM, The Primary Care Physician stated he was not the doctor who was notified. He stated from the notes and his most recent dealings with Resident #1, he knew that The NP mainly took care of Resident #1, but he supervised her work. He said it was his understanding on [DATE] the staff at the facility lifted her with the Hoyer and dropped her. They spoke with 745002 Page 9 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0689 NP, and she instructed the st[TRUNCATED] Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 745002 Page 10 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

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 interview and record review the facility failed to ensure licensed nurses and certified nurses Aides had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 3 of 3 Residents (Resident #1, #2, and #3) reviewed for nursing services. In that: The facility failed to ensure all clinical staff had physical competencies showing they were capable of utilizing the Hoyer lift. CNA A operated the Hoyer lift with on staff transferring Resident #1 which resulted in Resident #1 sustaining a head injury and being sent to the hospital. Uncertified Nurse Aides (NA B and C) admitted to operating the Hoyer lift to transfer residents. Resident #3 said that staff transfer him using the Hoyer lift with one staff. The Agency Nurse failed to assess/ take vitals of Resident #1 after she sustained a head injury after being dropped out of the Hoyer lift on [DATE]. Confidential Staff admitted to operating the Hoyer with one staff. Observation of staff (CNA E, F, H & J) using the Hoyer lift to transfer residents (Resident# 1 and Resident #3) revealed that they did not inspect the Hoyer sling and lock the wheels during the process. This failure could place all residents in need of transfer via the Hoyer lift at risk of injury, falls, hospitalization and death. Findings Included: Resident 01 Record review of Resident #01's face sheet, dated [DATE], revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia and need for assistance with personal care. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #01 usually understood (misses some part/intent of message but comprehends most conversations). The MDS revealed Resident #01 had a BIMS of 00 which indicated the resident's cognition was severely impaired. Section G revealed the resident transfer required (total dependence) with support (two+ person physical assist) Record review of a care plan, dated [DATE] for Resident #01 revealed: Focus: May use Hoyer lift as needed for transfers; Goal: Will have safe transfers through the 745002 Page 11 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0726 review date; Interventions: Assisted transfers with 2 licensed staff. Level of Harm - Minimal harm or potential for actual harm Record review of a care plan, dated [DATE] for Resident #01 revealed: Residents Affected - Some Focus: This resident had a fall from the mechanical lift on [DATE] with a laceration to the back of the head r/t improper use of the mechanical lift by staff; The resident's laceration will be healed by the review date without complications; Interventions: Staff training for proper mechanical lift training. Record review of a care plan, dated [DATE] for Resident #01 revealed: Focus: The resident has an ADL self-care performance deficit r/t dementia, impaired balance, limited mobility, stroke; Goal: The resident will maintain current level of function in mobility and ADLs through the review date; Interventions: Transfer: the resident requires total assistance by 2 staff & Hoyer lift to move between surfaces. Record review of hospital records dated [DATE] revealed the following: 95 years female, trauma-dropped out of Hoyer lift Findings: Brain: Small acute left subdural hematoma measuring up to 5 mm in greatest transverse diameter. No abnormal right sided extra-axial fluid collections. Discharge Diagnosis: Fall, laceration of right side of scalp, subdural hematoma Record review of the transfer paperwork titled, SNF/NF to Hospital Transform Form, undated, revealed the following: Vital signs (blood pressure, heart rate, respiration rate, oxygen level) data dated 5 days before the incident ([DATE]) The pain level data dated 2 days before the incident ([DATE]) Form completed and reviewed by On Call Charge Nurse dated [DATE] at 7:20 PM. Resident 02 Record review of Resident #02's face sheet, dated [DATE], revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dementia, difficulty walking, unsteadiness on feet, need for assistance with personal care and personal injury of traumatic brain injury. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #02 was usually understood (misses some part/intent of message but comprehends most conversation). The MDS revealed Resident #02 had a BIMS of 07 which indicated the resident's cognition was severely impaired. Section G revealed the resident transfer required (Extensive Assistance) with support (two+ person physical assist) 745002 Page 12 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0726 Record review of a care plan, dated [DATE] for Resident #02 revealed the following: Level of Harm - Minimal harm or potential for actual harm Focus: The resident has an ADL self care performance deficit r/t history of traumatic brain injury, dementia, cognitive and low vision; Goal: The resident will maintain current level of function through the review date. Staff will meet his needs; Transfer: The resident requires limited to extensive assistance by 1-2 staff to move between surfaces as necessary. Residents Affected - Some Resident 03 Record review of Resident #03's face sheet, dated [DATE], revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia and a history of falling. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #03 was rarely understood. The MDS revealed Resident #03 had a BIMS of 00 which indicated the resident's cognition was severely impaired. Section G revealed the resident transfer required (total dependence) with support (two+ person physical assist) Record review of a care plan, dated [DATE] for Resident #03 revealed: Focus: The resident has an ADL self care performance deficit; Goal: The resident will maintain current level of function through the review date; Interventions: The resident requires total dependence by Hoyer lift to move between surfaces. During an interview on [DATE] at 10:30 AM, the ADM stated CNA A went to place Resident #1 to bed, and she required the Hoyer lift. CNA A went by herself without the second CNA. She said she was told by CNA A that one of the straps was not secure and came off. Resident #1 hit her head on the headboard. She said it caused a laceration to the back of the head. She said the strap did not break; it just came loose. She said she was unsure why CNA A did not have the 2nd CNA for help. She said CNA A told the charge nurse she knew better than using the Hoyer alone. She said this incident occurred Saturday ([DATE]) around 7:00 PM. She said she sent CNA A home around 7:15 PM. During an interview on [DATE] at 10:35 AM, the ADON stated the expectation of the use of the Hoyer was that it had to be 2 certified nurse aides. She said it could not be a nurse aide. She said the CAN A was certified. During a confidential interview, it was revealed that they (unidentified staff) used the Hoyer alone when short-staffed. They said they were often short-staffed when they came in. They said they recently used the Hoyer lift alone. They said they used the Hoyer last week to transfer a resident. They said they were not the only ones to use the Hoyer alone but that other staff members also used the Hoyer lift with one staff. They said that they had never received Hoyer training at the facility. They said they had never had to demonstrate their knowledge of the Hoyer to anyone. They said they did not know the facility staff oriented agency staff to policy and procedures. They said that they have observed agency staff come in and have to ask questions constantly to provide care to the residents. They said they were relieved that what happened to CNA A and Resident #1 did not happen to them because it could have. During an interview on [DATE] at 1:10 PM, NA B stated she had been an NA for 2 weeks. She said she 745002 Page 13 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had used the Hoyer lift with another certified CNA. She said she rolled the resident and paced the net under them. She said they then hooked them up to the Hoyer. She said she had never used the Hoyer alone. She said she had not had recent training from the facility. During an interview on [DATE] at 1:18 PM, NA C stated that she had used the Hoyer lift with the assistance of a certified CNA. She said they had placed a resident in bed and left the sling under them in case they needed to be changed. She said she had not had any formal training. During an interview on [DATE] at 3:05 PM, the Director of Rehabilitation stated they had Hoyer lift training several months ago. He said it was an orientation for everyone. He said during the Hoyer lift training, they discussed the use of the Hoyer, transfers, and gait belts. He said they talked about how to place the sling under the resident. He said they trained the staff to use two people. He said he did not have staff demonstrate the use of the Hoyer. He said the staff present watched him. He said he was not familiar with CNA A. He said he had seen Resident #1 and said the Hoyer lift was an appropriate transfer method for Resident #1 because she could not bear weight. He said that the Hoyer sling used to transfer Resident #1 was not damaged that he knew of and the facility only had one Hoyer lift; if it went out, they did not have a contingency plan. He said if they did have a contingency plan this would help the resident. During an interview on [DATE] at 3:16 PM, CNA A stated Resident #1's roommate needed to go to the restroom. She said since Resident #1's roommate was on the toilet and was by herself, she moved the bed diagonally to observe both residents. She said she had the Hoyer, opened the legs, and slid the lift under Resident #1's wheelchair. She said she hooked the sling onto the Hoyer lift. She said she had checked everything. She said she remembered that she had the top strap on the blue loop, the middle strap on the green, and the bottom straps crossed on the green loop. She said she lifted the resident up to get tension on the straps. She said she guided her safely to the bed. She said she heard a loud pop once she was over the bed. She said she saw Resident #1 hit her head on the headboard. She said she pushed the call light for help. She said she yelled for help. She said she left the resident, but not for long. She said she knew she was not supposed to leave the resident, but she went and got the nurse in charge. She said she was an agency nurse. She said she stayed with Resident #1 after she got the nurse. She said she placed a cold towel on Resident #1 head. She said she did not remember if the nurse took her vitals. She said the other CNA on shift that night was putting her residents down. She said they try to put their residents at risk for falls down first. She said she would never transfer another resident with the Hoyer alone again. She said this was her first time doing this alone. She said she had been trained when she first started at the facility, but it had been a while. She said she has been at the facility for over a year. She said she has never had to demonstrate her ability to use the Hoyer lift. She said she had signed an in-service. During an interview on [DATE] at 10:45 AM, the Agency Nurse said she had not been oriented to the facility or their processes as an agency nurse. She said she did not receive a tour of the facility and was not oriented to any policies or what to do in an emergency according to the facility policy. During an interview on [DATE] at 11:11 AM, the On Call Charge Nurse stated she did orient the Agency Nurse to the facility procedures two days prior. She said she asked the Agency Nurse and said she did not have any questions. She said all nurses should know what to do in an emergency. She said the Agency Nurse was responsible for getting Resident #1 vitals. During an interview on [DATE] at 11:30 AM, CNA E stated she had not been checked off on the use of the Hoyer lift. She said she has never had to demonstrate her knowledge and ability to use the Hoyer 745002 Page 14 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some lift. She said she has not been trained on a contingency plan in what to do if the one Hoyer they have was to stop working. She said she could use a sheet or get another staff to grab an arm and leg. She said the potential negative outcome of not having a contingency plan would be residents could get hurt. During an interview on [DATE] at 11:35 AM, CNA E stated that if Hoyer was not working, she would get the older one. She said they have a crank Hoyer that they can use. She said she does take vitals, but it was a nurse's duty. During an interview on [DATE] at 11:40 AM, CNA G stated she had been checked off to use the Hoyer lift. She said she has never had to demonstrate. She said if the Hoyer lift does not work, the facility has a manual Hoyer lift that they are supposed to use. She said she was agency staff and had never been oriented to the facility policy and procedures. She said she just used her prior knowledge. During an interview on [DATE] at 11:45 AM, CNA H stated she had training with a group while back at the facility but did not demonstrate it for competency. She said she was unaware of a contingency plan if the one Hoyer lift did not work. During an interview on [DATE] at 11:50 AM the DON stated improper use of the Hoyer lift can lead to serious injury even death. She said it could have been worse if CNA A had not been over the bed. She said not taking a resident's vitals after a fall would mean the staff do not know the status of the resident and they could be worse than what was physically seen. She said not having a contingency plan for the Hoyer could lead to the staff not having a way to transfer the resident. She said there was only one Hoyer because the older one had been decommissioned. She said the staff were no longer using the old Hoyer. She said she did not know where the Hoyer was. She said she was unaware that the staff had not demonstrated using the Hoyer. She said she knew that they went over how to use the Hoyer, but this was before she was hired. She said she was unaware that non-certified aides were using the Hoyer lift. She said she was unaware that there was staff using the Hoyer alone because of staffing. She said she was unaware that the Agency Nurse did not take the resident's vitals. She said she was also unaware that there was no formal contingency plan. Regarding systems in place to monitor the deficient practices, she said annual training should cover Hoyer's use. She said in her experience, she had to demonstrate her skills. She said regarding taking vitals, they have their accident policy. She said she did not have any additional support regarding a contingency plan to ensure things such as contingency plans were not missed. She said there was no system in place to monitor the staff using the Hoyer lift or taking vitals. She said she had to trust that they were doing their job. She said there was no documentation to support staff skill competency for the Hoyer lift. She said she had been trained on the use of the Hoyer when she worked at the hospital, but not at the facility. She said she had training regarding taking vitals after a resident had fallen. She said she had not received any training regarding a contingency plan. She said she expected staff to use the Hoyer with 2 staff. She said non-certified nurse aides should not use the Hoyer to transfer residents. She said they should not be a part of the 2 staff. She said non-certified nurse aides can observe. She said she expected the staff to be 100 percent trained and demonstrate their skills and use of the Hoyer. She said she expected agency staff to have all the skills and training before working in their facility. She expected additional staff to be used until they could secure a working lift. The DON did not specify what the staff would use to transfer. She said regarding Resident #1 and CNA A incident, she expected the CNA to use the Hoyer properly with two staff. She said she, as the DON, was responsible for monitoring the use of the Hoyer lift. She said the policy said the ADON was responsible, but since she was over the ADON, it was her responsibility. She said orienting agency staff was the responsibility of the same disciplines. She said if it was a CNA, a facility CNA staff would 745002 Page 15 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some orient the staff. She said if it was a nurse, then a facility nurse would orient the agency nurse. She said she and ADM were responsible for ensuring a contingency plan was in place for transferring residents if the one Hoyer they had was unavailable. She said vitals should have been done as a part of the assessments after a resident falls. She said she has seen staff use the Hoyer in the past but never watched CNA A. She said a subdural hematoma was a serious diagnosis. She said it was a bleed under the subdural tissue. She said it was serious, so she was kept overnight. She said it was very important to take vitals because they could miss something, and with this diagnosis, a resident could rapidly deteriorate. During an interview on [DATE] at 12:00 AM, the ADM stated not training and ensuring that the staff know how to use the Hoyer lift would mean that they, as management, do not know if the staff truly know how to use it. She said staff not properly being trained can lead to injury or death. She said regarding the resident #1 incident, she could have died. She said it could have been much worse if Resident #1 had not been over her bed. She said non-certified nurse aides are not trained, and they could also hurt someone. She said that by not orienting the agency staff to facility policies and procedures or emergency response, the agency staff may not know what they are doing. She said agency staff may do things in a way that was not acceptable to the facility. She said not having a contingency plan could result in the staff breaking something on the residents. She said she was unaware that there were no physical competencies and that the staff did not demonstrate the use of the Hoyer back. She said she was unaware that her non-certified nurse aides were using the lift. She said she was unaware that the Agency Nurse did not take resident vitals. Regarding agency staff, she said she had never had to orient the agency staff. She said they should know what they were doing regarding their skills. She said she was unaware there was no contingency plan for if the Hoyer lift was to no longer work. She said she was unaware that CNA A was using the Hoyer alone. She said she had no system to monitor staff training for Hoyer use and demonstration. She said she did not have a system to monitor if the uncertified nurse's aides were using the Hoyer lift because they were not supposed to use the Hoyer because they had not been fully trained. She said there was no system in place to orient the agency staff. She said there was a book with emergency numbers. She said there was no system to monitor contingency plans for the Hoyer lift. She said she was not sure where the old Hoyer lift was. She said the staff should not be using it. She said there was a sit-to-stand one, but no one knew. She said she was unaware that CNA A had used the Hoyer by herself but believed if she had done it once she had done it more than once. She said she was unaware that other staff were using the Hoyer lift alone without a second staff. She said she had been trained in using the Hoyer and understood that staff should have demonstrated their use of the Hoyer. She said she has not personally been trained in taking vitals but understands that it has to be done after a fall. She said having a contingency plan had never been brought up. She said she expected all clinical staff to have been trained on using the Hoyer and should have physical competencies. She said she expected all staff to demonstrate to the Director of Rehab or the DON that they could properly use the Hoyer lift. She said it was not her expectation for staff to be just shown how to use the Hoyer. She said it was her expectation that the nurse in the facility take vitals after a fall. She said although she had seen CNAs take vitals, she had not seen them take them at her current facility. She said she understood that the CNA was trained to take vitals, but she did not want them taking vitals at the facility. She said the agency staff should know what comes with their respective discipline. For example, if they are a nurse, they should know all the skills and duties of a nurse. She said she expected if the agency staff had questions, they should ask them. She said with having one Hoyer lift, there should be a contingency plan in place to avoid injury and accidents. Regarding Resident #1 745002 Page 16 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and CNA A, she expected the CNA to have retrieved another staff to help her and keep the resident safe from injury and accident. She said the DOR and the DON were responsible for completing physical competencies and ensuring that clinical staff demonstrated the use of the Hoyer per their policy and procedures. She said it was the responsibility of the DON and charge nurse to ensure that the uncertified nurse aides were not using the Hoyer lift and that other staff were not using the Hoyer lift alone. She said it was the responsibility of the charge nurse to ensure that vitals are taken after a resident falls or experiences any type of head trauma. She said not taking vitals after a potential head injury was unacceptable, especially with two nurses in the facility. She said the resident should not have been moved until assessed. She said overall, the DON was responsible for the activity of CNA A. The ADM confirmed that there were no physical competencies in the facility because they did not exist. She said Resident #1 Dx of subdural hematoma was serious because it was bleeding in the brain and Resident #1 could have bled out. She said taking vitals could have helped identify a serious issue with the resident neurologically. She said the staff may have had a chance to respond differently if vitals had been taken. During an observation that occurred on [DATE] at 1:37 PM CNA F and CNA I transferred Resident #3 from her wheelchair to the bed using the Hoyer lift. Prior to operation of the Hoyer neither staff inspected the sling to ensure it was intact and safe for use. CNA F & I did not lock the wheels of the Hoyer throughout the use of the Hoyer lift. During an observation that occurred on [DATE] at 1:52 PM CNA E and CNA J transferred Resident #1 from her wheelchair to her bed. Prior to operation of the Hoyer neither staff inspected the sling to ensure it was intact and safe for use. Resident #1 was one sided in the sling and no adjustments was made to ensure that the sling was evenly under the resident. Neither staff locked the Hoyer lift prior to using it to lift the resident out of her wheelchair. During an interview on [DATE] at 2:03 PM, Resident #3 stated that there was usually only one staff when staff transferred her. She was able to tell the surveyor her name but could not provide any information suggesting that she was oriented to time and place. During an interview on [DATE] at 2:04 PM, Resident #1 could not answer any questions regarding the incident on [DATE] and about past transfers with the Hoyer lift. During an interview on [DATE] at 2:10 PM, Resident #2 stated that staff used the Hoyer lift to transfer him, and most of the time, it was one staff. He was able to tell the surveyor his name and that he did not have any concerns. He said the staff were overall nice to him and that he was cold. During an interview on [DATE] at 2:18 PM, CNA K stated she had received training on [DATE]. She said they were shown by the DOR how to use the Hoyer. She said before [DATE], she had never had to demonstrate competency of the Hoyer lift. She said she did learn something new in the training. She said she never knew anything about the emergency release. She said if the battery had died or the resident was stuck in the air, she would have known how to release the Hoyer lift. She said that could have been very scary for the resident, but before her training on [DATE], she would have had to get help from a nurse or someone. During an interview on [DATE] at 2:31 PM, CNA E stated she had been trained on using the Hoyer lift on [DATE]. She said she had to demonstrate competence in using the machine but never had to prior to [DATE]. She said she was familiar with the machine but had not had training like the one she received at the facility on [DATE] in over 8 years. 745002 Page 17 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0726 Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 2:47 PM, LVN K stated she had only been back at the facility for a week. She said before her return, she never had to demonstrate her skills as a nurse or the use of the Hoyer lift. During an interview on [DATE] at 3:00 PM, RN M stated that she had been trained on the use of the Hoyer and was required to demonstrate the use of the Hoyer back to the DOR on [DATE]. Residents Affected - Some During an interview on [DATE] at 3:10 PM, CNA N stated that she had never had to demonstrate her knowledge and use of the Hoyer lift before at the facility. She said she had worked at the facility five times as an agency staff member and had been briefed on some things but nothing in detail. She said she would work at night; most of the administration staff was gone. During an interview on [DATE] at 3:16 PM, NA O stated that before the Hoyer lift training she received on 10/03.23, she had never had to demonstrate her knowledge and use of the machine. She said she learned today that there was a red button that would let the resident down if the machine stopped working. She said without the training, she would not know what to do. She said she would have called for help. During an interview on [DATE] at 3:36 PM, MA P stated that she was a medication aide. She said she was also a CNA and sometimes helped staff with resident transfers. She said she had been trained on the Hoyer lift 20 years ago when she first obtained her CNA certification. Record review of the facility policy, Accidents and Incidents-Investigating and Reporting, Revised [DATE], revealed the following: Policy Statement All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Policy Interpretation & Implementation a. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. b. The following data. as applicable, shall be included on the Report of Incident/Accident form: The condition of the injured person, including his/her vital signs; Record review of the facility policy, Fall Risk Assessment, Revised [DATE], revealed the following: Policy Statement The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a 745002 Page 18 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0726 resident centered falls prevention plan based on relevant assessment information. Level of Harm - Minimal harm or potential for actual harm Policy Interpretation and Implementation Residents Affected - Some The attending physician and nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions (such as those that cause dizziness or vertigo) or sensory impairments (such as decreased vision and peripheral neuropathy) that may predispose to falls. Record review of the facility policy, Safety Precaution, Lifting, Revised [DATE], revealed the following: Policy Statement All personnel shall follow safety precautions established by this facility when lifting or handling heavy objects. If the weight is too heavy or bulky for one (I) person to lift, seek assistance. Do not try to lift it alone. When lifting or moving residents, make sure that equipment is secure (i.e., wheelchair, beds, stretcher, etc.). If there are mechanical devices available to assist you in moving residents more safely, use them. Record review of the facility policy, Safe Lifting and Movement of Residents, Revised [DATE], revealed the following: Policy Statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being recharged. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: 745002 Page 19 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0726 o Level of Harm - Minimal harm or potential for actual harm Involves employees in identifying problem areas and implementing workplace safety and injury- prevention strategies; Residents Affected - Some o Provides training on safety. ergonomics and proper use of equipment; and o Continually evaluates the effectiveness of workplace safety and injury-prevention strategics. Record review of the Resident Hoyer lift inservice dated [DATE] revealed the following: 12 staff signed to include CNA A. Record review of the material accompanying the inservice dated [DATE] titled Patient Lifts Safety Guide, undated, revealed the following: Cover Page: This guide provides general safety recommendations and is not a replacement for the manufacturers instructions. Refer to manufacturer's instructions for specific use guidelines. Page 6: Prepare Environment, Determine number of caregivers needed: Most lifts require to or more caregivers to safely operate lift and handle patient. Page 7: Prepare Equipment: Ensure slings, hooks, chains, straps and supports are available, appropriate and correctly sized. Examine sling and attachment areas for tears, holes and frayed seams. Page 9: Perform Safety Check: Before lifting the patient, perform safety check: Examine all hooks and fasteners to ensure they will not unhook during use. Double check position and stability of straps and other equipment before lifting patient. Ensure clips, latches and bars are securely fastened and structurally sound. Record review of facility provided list, undated, revealed the following residents use the Hoyerlift: Resident #3 Hall 1 Resident #1 Hall 4 Resident #2 Hall 1 Record Review of the Employee Information Roster dated [DATE] revealed a total of 28 clinical staff that provide care for all residents in the facility. Record review of the facility provided list of agency staff workers included 7 agency clinical staff that provide care to all residents at the facility. 745002 Page 20 of 21 745002 10/04/2023 Kent County Nursing Home 1443 North Main Jayton, TX 79528

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record Review of the Hoyer lift User Instruction Manual, undated, but obtained on [DATE] ( https://www.joerns.com/wp-content/uploads/2020/03/Hoyer-HPL700-User-Manual.pdf ) revealed: Page 4: WARNING: Important safety information for hazards that might cause serious injury. CAUTION: Information for preventing damage to the product. NOTE: Information to which you should pay special attention. DO NOT lift a patient unless you are trained and competent to do so ALWAYS lock the wheels when lifting from the floor. Page 15: CAUTION Have someone assist you when attempting to transfer a patient. Page 16: WARNING: recommends that slings be checked regularly and particularly before use for signs of frayi[TRUNCATED] 745002 Page 21 of 21