Other·February 22, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflect the findings of the Department of Public Health during the investigation of a Facility Reported Incident (FRI). FRI No. CA00589467 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 38700 The inspection was limited to the specific FRI investigated and does not represent the findings of a full inspection of the facility. One deficiency was written for ERI No: CA00589467. Highest Severity and Scope = G

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 02/11/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, record review and interview, the facility failed to ensure one of one LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VM0011 Facility ID: CA92000011 If continuation sheet 1 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 01/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE sample resident (Resident 369) was free from accidents including a fall, during a transfer using a mechanical lift by: The facility failed to: 1. Failing to ensure a monitoring system was in place for the mechanical lift sling (resident care equipment/machine used to lift and move a resident into and out of bed or chair using a sling that fits under the person's body and connects with the machine's lift frame) to ensure the staff discarded immediately, bleached, cut, torn, frayed, or broken slings. 2. Failing to ensure there was a system in place for the staff to remove slings deemed unsafe for use or had been in circulation beyond the manufactures recommended time line. 3. Failing to ensure the staff labeled each sling with a number as indicated in the facility's policy and procedure, to ascertain when the sling must be removed from use. 4. Failing to ensure the facility's laundry staff and Certified Nursing Assistants were trained for how to inspect the mechanical lift sling to ensure the sling is safe prior to each use. These deficient practices resulted in part of the mechanical lift sling strap ripping in half during transfer, causing Resident 369 to fall to the floor, and sustain a hip fracture. Resident 369 required hospitalization for 4 days and underwent general anesthesia for a retrograde intramedullary rodding of the left femur fracture (a type of hip surgery to repair the broken bone). Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VM0011 Facility ID: CA92000011 If continuation sheet 2 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 01/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On June 18, 2018, an unannouced onsite inspection of the facility was made regarding a Facility Reported Incident regarding resident safety/falls. A review of the admission record indicated Resident 369 was admitted on January 20, 2017, with diagnoses including but not limited to cerebral infarction (stroke) and hemiplegia (paralysis on one of the body) and hemiparesis (weakness on one side of the body) affecting the right side of the body. A review of the Minimum Data Set (MDS - an assessment and care screening tool) dated March 28, 2017, indicated Resident 369's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions making were intact. The MDS indicated Resident 369 required extensive assistance from one person for moving in bed, transferring from bed to chair, dressing, eating, toilet use, and personal hygiene. A review of the care plan for Self Care Deficit initiated on December 4, 2017, and revised in April 2018, indicated Resident 369 had a selfcare deficit related to stroke and right side hemiplegia and hemiparesis. The care plan indicated Resident 369 transfers with a mechanical lift when the resident wishes to get out of bed. The interventions in the care plan did not address precautions to be taken when using the mechanical lift and the sling to ensure safe transfers. The Fall Risk Evaluation dated April 10, 2018, indicated Resident 369 was at high risk for falls. The Monthly Record of Vital Signs and Weight dated May 5, 2018, indicated Resident 369 weighed 139 pounds. A review of the Incident/Accident Report dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VM0011 Facility ID: CA92000011 If continuation sheet 3 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 01/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE June 2, 2018, indicated two certified nursing assistants (CNA) were trying to put (transfer) Resident 369 back to bed from the shower bed using the mechanical lift when the sling strap (attaches the sling to the lift) ripped off and the resident fell onto the floor. The report indicated Resident 369 complained of severe left leg and hip pain (pain level of 10 out 10 on the pain scale rating, with zero being no pain and 10 being the worst pain possible). The physician was notified and Resident 369 was transferred to a general acute care hospital (GACH) via emergency ambulance services. A review of the GACH emergency (ED) department notes dated June 2, 2018, indicated Resident 369 presented to the emergency room for evaluation of left thigh pain after falling. The ED notes indicated Resident 369 reported she was on a sling, it broke, and she fell approximately two feet to the ground. A review of the CT scan (computed tomography scan allows doctors to see inside your body. It uses a combination of X-rays and a computer to create pictures of your organs, bones, and other tissues) result from the GACH dated June 2, 2018, indicated Resident 369 had a displaced (pulled out of alignment) acute (new) fracture of the femoral diaphysis (hip bone was broken). 1. A review the surgery report from the GACH indicated Resident 369 had a left knee arthrotomy (the creation of an opening in a joint that may be used in drainage) and a retrograde intramedullary rodding of the left femur fracture on June 4, 2018. The report indicated Resident 369 lost 100 milliliters of blood during the surgery. Resident 369 laboratory results from GACH indicated the following hemoglobin (Hgb-red blood cell count. The normal range for hemoglobin for men is 13.5 to 17.5 grams per FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VM0011 Facility ID: CA92000011 If continuation sheet 4 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 01/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE deciliter- gm/dl, and women 12.0 to 15.5 gm/dl.) and hematocrit (Hct -the ratio of the volume of red blood cells to the total volume of blood levels, the normal range for Hct is 35.0 to 45.00 percent (%) levels: June 2, 2018: Hgb 14.4 gm/dl and Hct 43.5 % June 3, 2018: Hgb 12.1 gm/dl and Hct 35.9 % June 4, 2018: Hgb 11.4 gm/dl and Hct 33.8 % June 5, 2018: Hgb 10.3 gm/dl and Hct 30.0 % A review of GACH discharge summary indicated Resident 369 was discharged on June 6, 2018, with the pain medication hydrocodone-acetaminophen (an opioid pain medication used to treat moderate to severe pain) 5/325 milligram (mg) to take 1 to 2 tablets every 4 hours as needed. On June 18, 2018, at 1:40 p.m., during an interview Certified Nursing Assistant 1 (CNA 1) stated she did not check the sling before use and transfer of Resident 369 because the resident was not assigned to her and that she only assisting CNA 2. On January 11, 2019, at 8:32 a.m., during an interview Laundry Staff 1(LS 1) stated she checked the slings after washing them and before use by the licensed staff. LS 1 stated she checked to make sure nothing was ripped and the hooks are intact. The facility was unable to provide any documented evidence of LS 1 inspecting the slings. A review of the facility's policy and procedure for "Laundering of Slings and Heat or Chemical Sensitive Items" revised on October 25, 2016, indicated bleached, cut, torn, frayed, or broken slings are unsafe and could result in injury; discard immediately. The policy and procedure indicated before the item is put out for use visually inspect it for any discoloration, cuts, tears or frays; if you see any, notify your FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VM0011 Facility ID: CA92000011 If continuation sheet 5 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 01/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE manager immediately, document sling log and take the item to the facility administrator; Do not take any chances. On January 11, 2019, at 8:37 a.m., during an interview LS 2 stated she checked the slings before returning them to the nurses to make sure nothing was ripped and there was no possibility of the slings ripping when used by the licensed staff. The facility was unable to provide any documented evidence of LS 2 inspecting the slings. On January 11, 2019, at 9:15 a.m., during an interview, CNA 2 explained that on June 2, 2018, CNA 1 was helping her transfer Resident 369 back to bed from the shower bed when one of the loops of the sling ripped and the resident fell on the floor. CNA 2 stated she checked the sling before using it. CNA 2 stated she avoided using slings that have areas that are "faded, and have lose strings". The facility was unable to provide any documented evidence that the sling was inspected before use. On January 11, 2019, at 10:05 a.m., the sling that was used during the incident was provided by the Director of Nursing. The sling did not have any of the manufactures label and did not have a label or an identifying number from the facility, to determine the brand, type of sling, or the length of time the sling was in use, to ascertain when the sling must be removed from use. The loops on one of the straps was ripped completely in half. (Photos of the sling were taken on the same day of observation.) On January 11, 2019, at 2:01 p.m., during an interview, the Director of Nurses (DON) stated prior to the incident occurring on June 2, 2018, the facility did not have a documented monitoring system for the slings. The DON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VM0011 Facility ID: CA92000011 If continuation sheet 6 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 01/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated laundry staff checked the slings and removed those that were not safe for use. The DON stated the laundry staff would then notify nursing, and housekeeping supervisor so that new slings may be purchased/provided. The DON stated the facility did not have a log to keep track of how many slings were in circulation in the facility. The DON stated there was no documented system of monitoring the wear and tear of the slings and of keeping track how long a sling had been in circulation and when the sling should be removed (from use.) On January 11, 2019, at 2:15 p.m., during an interview the DON stated the CNAs inspect the sling before each use to ensure the sling was safe to use. The DON stated there was no documented evidence of the daily inspection of the slings by the CNAs. The DON stated the facility now has a monthly monitoring system and log for the sling (inspection) done by nursing, the Director of Staff Development (DSD), the housekeeping staff and the infection control nurse. The DON stated the system (for sling inspection) was not in place before Resident 369 fell. On January 11, 2019, at 3:19 p.m., during a concurrent interview and record review of the CNAs personnel files, the DSD stated the CNAs are trained on how to use the mechanical lift as well as the sling. A review of the employees files for CNA 5, CNA 6, CNA 7 and CNA 8 all indicated they had training on "Mechanical Lift Transferring" The checklist used during the training did not mention use of the sling and steps to take prior to transferring a resident. The DSD stated there was no lesson plan for this training prior to June 2, 2018, (before Resident 369 fell.) On January 11, 2019, at 3:09 p.m., during an interview, the Assistant Administrator (AADM) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VM0011 Facility ID: CA92000011 If continuation sheet 7 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 01/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated he was responsible for purchasing the slings and have always used the brand Proactive. The AADM stated the sling involved in the accident was a Proactive brand. The AADM provided the invoices for the purchase of the sling, but since the sling used during the incident did not have any label, it was not possible to determine when the sling was purchased. On January 11, 2019 at 3:40 p.m., a review of Proactive Medical Product Full Body Sling Instruction Manual provided by the facility indicated the useful life of this product is six months from the date of purchase under normal use, however heavy use or excessive washing may reduce the useful life of the product. The manual indicated to carefully inspect each sling before use for wear and damage to the seams, fabric, straps, and strap loops. The manual indicated torn, cut, frayed or broken slings can fail resulting in personal serious injury to the user. On January 11, 2019, at 4:19 p.m., during an interview and review of laundry staff employee files, the Housekeeping Supervisor (HS) provided evidence of training on sling laundry done in July 2018. The HS stated the laundry staff was trained upon hire regarding the care of the sling, but was not able to provide any documented evidence of the training. The HS was unable to provide any other documented evidence of in-services or training of the laundry staff prior to Resident 369 fall incident. A review of the facility's Mechanical Lift policy and procedure revised in November 2017, indicated the facility is to provide safe and effective mechanical lift transfers to all residents requiring them. The procedure did not include visual inspection of the sling before each use. The policy and procedure did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VM0011 Facility ID: CA92000011 If continuation sheet 8 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 01/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE include a system for monitoring the slings. A review of the facility's Mechanical Lift policy and procedure revised in November 2017, indicated the purpose was to enable health care workers to lift and move a resident safely and with as little physical effort as possible. The policy and procedure did not mention visual inspection of the sling prior to use. The policy and procedure did not include a system for monitoring the slings. On January 14, 2019, at 8:12 a.m., during an interview, the Housekeeping Supervisor stated he spoke to his supervisor and they were unable to find any documents indicating training or in-services of the laundry staff regarding care and monitoring of the slings, before Resident 369's fall occurred, in June 2018. On January 14, 2019, at 9:08 a.m. during an interview, a customer service representative of Proactive Medical products stated the company's products always came with a manufactures label including the slings. On January 14, 2019, at 9:47 a.m., during an interview the DON stated she was aware the sling used for the transfer of Resident 369, (on June 2, 2018), did not have any labels and stated "Maybe because it was old the label came off". On January 11, 2019, the DON provided a new policy and procedure titled "Patient Safety Lift and Transfer Program" that was released in July 2018, and to be presented in the facility's upcoming QAPI (Quality Assurance and Performance Improvement) meeting in January 2019. The policy indicated the following: Remove any sling from service that is worn, frayed, or has exceeded the manufacture's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VM0011 Facility ID: CA92000011 If continuation sheet 9 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ (X3) DATE SURVEY COMPLETED 01/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GOLDEN LEGACY CARE CENTER 12260 Foothill Blvd Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE maximum recommended time line. Any torn sling or unlabeled slings will be taken out of service. Training on the use and coordination of available lift/transferring equipment is essential for maximizing the benefit and the success of the program. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VM0011 Facility ID: CA92000011 If continuation sheet 10 of 10