Failure to Provide Safe Mechanical Lift Transfers, Adequate Supervision, and Sufficient Staffing to Prevent Falls
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible and to provide adequate supervision and assistive devices to prevent accidents for multiple residents at risk for falls. One resident with dementia, severe cognitive impairment, and a care plan requiring two staff for mechanical lift transfers was routinely transferred by a single aide using a mechanical lift. On one morning, the resident reported being dropped to the floor during a mechanical lift transfer performed by one nurse aide, who then pulled her back into the wheelchair and instructed her not to tell anyone. The resident later complained of pain in her left hip, leg, and foot, with internal rotation, redness, swelling, and inability to move the lower leg/foot, and was subsequently diagnosed with a distal femur fracture requiring surgery. The resident’s roommate, who had moderate cognitive impairment, stated she observed the aide alone transferring the resident with the mechanical lift, heard the aide exclaim, and saw both the resident and the lift on the floor, and further stated she had never seen two staff assist with that resident’s mechanical lift transfers. The facility’s own records and staff interviews showed that the resident’s care plan required assistance by two staff for transfers using a mechanical lift, and the facility’s mechanical lift policy required at least two nursing assistants for safe use. The nurse aide involved stated she had never been trained by the facility on mechanical lift transfers, although she knew two staff were required, and the facility could not locate her orientation/evaluation checklist or any documented training regarding resident care. Another nurse aide on the same shift reported she had not received training on mechanical lift use and did not recall assisting with the transfer, while the LVN on duty denied assisting and reported having previously voiced concerns about aides transferring residents alone. The ADON stated that nurse aides could not perform transfers without a CNA or nurse and that nurses were supposed to supervise aides to ensure they did not perform tasks they were not trained in, but there was no evidence this supervision or training occurred for the aide involved. The deficiency also includes failures related to supervision and staffing for two other residents at high risk for falls. One resident with heart failure, kidney disease, moderate cognitive impairment, and a care plan identifying high fall risk and the need for prompt call light response fell after using the call light for toileting assistance, waiting, then attempting to go to the bathroom alone, urinating on herself, slipping, and falling. At the time of this fall, timecards showed only one nurse aide was on duty as direct care staff; during observation, no staff were present in the hall or at the nurses’ station while the resident was on the floor with the call light activated, and a hospice aide not employed by the facility ultimately located staff. The aide on duty stated she was the only aide working, had difficulty getting everything done when working alone, and that being short staffed could lead to residents not getting the care they needed and could be considered neglect. Another resident with colon cancer, muscle weakness, moderate cognitive impairment, and a care plan identifying high fall risk related to weakness experienced multiple falls over a period of time, including several without injury and two with injury, one resulting in multiple rib fractures and hospitalization. The care plan for this resident had not been updated with new fall interventions since several months prior, despite repeated falls documented in the incident log. Progress notes described falls in the bathroom and between the bathroom and room, with the resident attempting to get on the commode or reaching down to pick up a phone and losing balance. The resident’s family representative reported the resident was anxious and tried to get up on her own. Timecards showed that at the time of two of this resident’s falls on the same day, only one nurse aide was on shift as direct care staff. The ADON later stated that interventions had been implemented for this resident but acknowledged they were not updated in the care plan or medical record.
Removal Plan
- Define direct care staff as any trained individual who demonstrates competency per the facility aide competency checklist (including NA enrolled in CNA class employed, CNA, LVN, RN) for providing direct care/ADL assistance.
- Ensure at least two direct care staff on the floor at all times in addition to one LVN/RN charge nurse.
- Ensure a total of one LVN/RN and two direct care staff are in the building at all times if there are any mechanical lift residents.
- Assess staffing requirements based on census and resident needs.
- Maintain two direct care staff whenever the facility has any residents who use a mechanical lift or are a two-person transfer.
- Ensure DON/ADON verify all agency or temporary direct care staff have documented training prior to working a shift.
- Obtain access to the current temporary agency portal to check staff credentials.
- Require the sister facility to send CNA credentials prior to staff working a shift.
- For Resident #1, assess immediately upon discovery, send to hospital, follow discharge orders, notify physician/ADON/administrator/responsible party, initiate neuro checks/monitoring, remove NA-A from resident care pending investigation, and terminate NA-A.
- For Resident #5, assess and send to hospital, place reminder posters to use call light, educate resident on call light use, and work with hospice and follow hospice physician orders.
- For Resident #3, assess, notify hospice/doctor/family/administrator, transfer to hospital for evaluation, and continue monitoring for post-fall outcomes (pain, emotional distress, injury).
- Complete a 100% audit of all residents requiring mechanical lift transfers and display the list at the nurses station.
- Notify all staff of the mechanical lift resident list and include it in shift report and in the shower sheet book for aides.
- Send a text message to all direct care staff about the locations of the mechanical lift list.
- Have the ADON review the mechanical lift transfer list during shift report.
- Continue monitoring Residents #3 and #5 related to incidents and staffing comparison.
- Educate Residents #3 and #5 on call light usage on the same day as their respective falls.
- Educate staff on call light response expectations via informational handout at the nurses station with signature confirmation prior to starting first shift.
- Provide call light education at an in-service with an in-service signature sheet.
- Provide nursing staff education about call light usage and falls (DON via phone calls) and track completion; prevent staff from starting next shift until educated.
- Require all direct care nursing staff to take a quiz prior to working as direct care staff; grade prior to shift; re-educate and retest failures; remove from care if they fail the subsequent quiz.
- Re-educate all RNs/LVNs/CNAs/NAs on mechanical lift policy including two-staff requirement via protocol handout with staff signatures.
- Conduct follow-up in-service with return demonstration of mechanical lift use (COTA).
- Add proper mechanical lift use to new hire packets and competency checklists for direct care staff.
- Provide agency and sister-facility direct care staff an educational handout prior to starting shift (abuse/neglect, call light usage, mechanical lift transfer, falls) directed by charge nurse; verify competency via verbal return and staff signature.
- Re-educate staff on falls and post-fall procedures with documented signatures prior to start of first shift.
- Train new direct care staff on call light expectations during on-the-floor training before providing resident care; verify competency via verbal return and orientation sheet initials.
- Conduct an audit of in-services (mechanical lift use, incident reporting, abuse/neglect, falls, call lights) to ensure all staff trained; restrict work until training completed with verbal return; complete audits and report to IDT/QAPI.
- Complete competency validations for mechanical lift use for 100% of direct care staff (COTA/ADON) with signature validation.
- Conduct regular random observations of lift transfers by charge nurses and DON/designee; document in a log; suspend/remove staff from care until correct return demonstration if noncompliance occurs.
- Post signage above mechanical lift resident beds to remind staff which residents require mechanical lift use.
- Reinforce mechanical lift policy with clear disciplinary consequences for non-compliance; require staff to sign in-service sheet acknowledging review prior to working first shift.
- Have charge nurse/designee monitor transfers on each shift for compliance; track checks in a log at the nurses station; review by ADON in QAPI.
- Monitor a mechanical lift transfer once per shift with charge nurse initials; if noncompliance noted, immediately re-educate and remove staff from duty until proper return demonstration completed.
- If non-compliance is noted during monitoring, terminate staff who performed mechanical lift improperly and assess the resident for pain or injury.
- Report monitoring results at monthly QAPI.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that the facility failed to keep the environment free of accident hazards when a resident’s room contained an unattended shaving razor on the sink and additional razors in a nightstand, despite leadership stating razors were not permitted in resident rooms. An LPN disposed of unused lancets in regular trash instead of a sharps container, contrary to acknowledged policy. On two occasions, an unattended housekeeping cart on an upper floor had germicidal wipes left on top and easily accessible, even though housekeeping leadership and staff stated that chemicals and disinfectant wipes were to be kept locked in the cart for safety.
A resident with severe cognitive impairment, dementia with behavioral disturbances, and fall risk interventions in place was transferred by staff using methods that did not match the care plan and Kardex. Staff used a transfer belt for some transfers, then later used a Hoyer lift from mattresses on the floor to a wheelchair, but used a green sling even though the resident required a yellow sling based on weight. The RN, LPN, DON, and PT verified the resident’s transfer status and sling instructions were not updated to reflect current needs.
A resident with severe cognitive impairment, dementia, a history of falls, and dependence on staff for transfers was observed using a lift reclining chair even though the care plan and physical device review did not identify that device. Therapy staff lowered the chair and placed the remote next to the call light on the resident’s lap, and staff stated they were not aware of any formal assessment for safe use of the lift chair. The DON stated the resident should have had an assessment to determine whether she was safe to have the lift chair.
A resident with nicotine dependence was care planned as a smoker who could go out to smoke at designated times or with family, with an intervention that a smoking evaluation be completed quarterly. The last documented smoking safety evaluation showed the resident could safely smoke with supervision, but no additional evaluations were completed for several months, contrary to facility policy requiring smoking assessments at admission, readmission, with significant change, and quarterly by a licensed nurse, even though the resident continued to smoke under staff and family supervision in the courtyard.
Failure to supervise smokers and secure smoking materials. Surveyors found that 27 smokers were not adequately monitored and that residents were able to keep cigarettes and lighters in their possession despite care plan directions to return them after smoking. One resident with severe cognitive impairment, dementia, schizophrenia, and continuous oxygen use was observed with cigarettes and a lighter while on oxygen, and staff confirmed she was an unsafe smoker requiring direct supervision.
Code Alert System Failed to Prevent Resident Elopement: The facility failed to keep the code alert system functioning as intended and did not follow the manufacturer’s weekly testing and inspection guidance. Two residents with significant cognitive impairment were able to get through the main doors, and one resident exited the building before staff followed outside. The report also states that multiple residents with code alert devices did not have adequate elopement or wandering assessments and care plan interventions, and several attempts to leave were not documented in the record.
Failure to Control Razors, Sharps, and Chemical Wipes Creating Accident Hazards
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision and safe handling of potentially hazardous items. On one floor, a shaving razor was observed on the sink in a resident’s room. When questioned, the resident stated the razor on the sink was not his and showed the surveyor separate razors he kept in his nightstand. The resident’s record showed admission with malignant neoplasm of overlapping sites of the bladder and care plans for ADL self-care deficits related to activity intolerance, generalized muscle weakness, bladder cancer, and a history of gross hematuria, with interventions including encouraging and assisting with bathing, personal hygiene, and oral care. Facility leadership, including the ADON, Administrator/Risk Manager, and DON, stated that residents were not allowed to keep shaving razors in their rooms and that razors were to be kept in the supply room. Additional observations showed that staff did not consistently follow safe disposal practices for sharps and did not secure chemical products as required by facility policy. An LPN performing a blood glucose check discarded unused lancets into the medication cart trash instead of a sharps container, despite acknowledging that lancets were to be disposed of in a sharps-resistant container. On two separate observations, a housekeeping cart on the second floor was left unattended with a container of germicidal wipes placed on top of the cart and easily accessible. Corporate housekeeping staff and the Housekeeping Director stated that all chemicals that could harm residents should be locked in the cart’s compartment, and housekeeping staff reported that disinfectant wipes and cleaning supplies were to be kept locked in the cart for resident safety. The facility’s written “Nursing Home Accident Prevention and Safety Policy” stated a commitment to maintaining a safe, hazard-free environment and identifying and correcting safety risks promptly.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. The facility continues to ensure that the resident environment remains free of accident hazards as possible. IMMEDIATE CORRECTIVE ACTION Resident #29 was not adversely affected by the alleged deficient practice. Razor was immediately removed and disposed of from resident's room by nurse on 5/11/26. Germicidal wipes were immediately secured in a locked housekeeping cart on 5/11/26. Staff E was provided with 1:1 education by the Director of Nursing regarding the importance of providing an environment free from hazards and accidents with emphasis on keeping hazardous items like razor secured on 5/11/26. Staff G was provided with 1 to 1 education by House Keeping Director regarding ensuring that all housekeeping chemical products are secured in a locked housekeeping cart when not in use on 5/12/2026. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED All active residents in the facility can potentially be affected by the alleged deficient practice. The Director of Nursing and/ designee conducted a facility-wide observation audit to ensure that hazardous items are locked and secured and that staff are disposing of Sharps in a Sharp Resistant Container on 05/15/2026. The Housekeeping Director conducted a facility-wide observation on 5/15/2026 to ensure that all housekeeping chemical products were secured and locked inside the housekeeping cart when not in use. No residents were adversely affected by the alleged deficient practice. SYSTEMATIC CHANGES Director of Nursing initiated ongoing in-service education with staff on standards of maintaining an environment free from hazards/accidents with emphasis on keeping hazardous items like razor secured and properly disposing of sharps in sharps resistant container on 5/20/26. The Housekeeping Director and/or designee initiated ongoing in-service education on standards of maintaining an environment free from hazards/accidents with emphasis on keeping housekeeping chemical products secured and locked in a housekeeping cart when not in use on 5/20/2026. MONITORING The Director of Nursing and/or designee will conduct random observation audits to ensure that hazardous items are locked and secured and sharps are disposed in sharps resistant container weekly for 3 months. The Housekeeping Director and/or designee will conduct random observation audits to ensure that housekeeping chemical products are secured and locked in a housekeeping cart weekly for 3 months. The Director of Nursing, Housekeeping Director and/or designee will report findings of observation/audits to the quality assurance committee monthly for 3 months to ensure continued substantial compliance is achieved and maintained.
Failure to Follow Transfer and Sling Size Interventions
Penalty
Summary
The facility failed to ensure staff followed fall risk interventions for one resident identified as at risk for falls. The resident had severe cognitive impairment, delusions, behaviors directed at others, dementia with behavioral disturbances, anxiety, an affective disorder, diabetes, and hearing loss. The resident’s care plan and Kardex identified the resident as a fall risk and stated the resident was independent for transfers, while also noting that if a Hoyer transfer was required, a yellow/medium sling was to be used. During observation, nursing assistants transferred the resident from a wheelchair to the toilet using a transfer belt, then later transferred the resident from the wheelchair to mattresses on the floor using a transfer belt and two staff members. Staff stated they normally used a Hoyer lift to lift the resident from the mattresses on the floor, but the resident’s Kardex did not identify the mattresses on the floor or clarify when a Hoyer should be used for transfers. Staff also stated the resident was not independent with transfers and required one to two staff for wheelchair-to-toilet transfers and two staff with a Hoyer for transfers to and from the mattresses on the floor. On a later observation, two nursing assistants used a Hoyer lift to transfer the resident from the mattresses on the floor to a wheelchair, but used a green sling even though the resident weighed 155 pounds and the manufacturer’s chart indicated a yellow sling was required. Staff stated the green sling was too big for the resident and that the correct sling size was important for safety. The RN, LPN, DON, and PT all verified that the resident’s care plan and Kardex were not revised to reflect the resident’s current transfer abilities and the correct sling size and transfer method for the resident’s current setup.
Failure to Assess Safe Use of Lift Reclining Chair
Penalty
Summary
The facility failed to ensure a resident was safe to have a lift reclining chair. The resident had severe cognitive impairment, lower extremity impairment on one side of the body, a history of falls, dependence on staff for transfers, and diagnoses including dementia, disorientation, anxiety, muscle weakness, and a right pubis fracture. The resident’s care plan identified high fall risk related to impaired mobility, confusion, and dementia, and directed staff to keep the call light within reach and encourage use of it. The care plan also stated the resident required two staff to assist with transfers using a standing lift as needed, but it did not identify use of a lift reclining chair. The physical device review also did not identify an electric recliner chair or other lift type reclining chair. During observation, the resident was transferred into the lift chair by therapy staff, who lowered it from an upright position to a seated and then reclining position. The remote for the lift chair and the call light were both placed on the resident’s lap next to each other. The PTA stated she was not aware of any assessment for safe use of the lift chairs, and nursing and therapy staff stated they were not aware of any formal lift chair assessment for the resident. The DON stated therapy worked with residents who had lift chairs and was not aware of any formal assessment, and later stated the resident should have had an assessment completed to determine if she was safe to have a lift chair. The DON also stated the resident was cognitively impaired and could accidentally use the lift chair remote when intending to push the call light.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
The facility failed to ensure resident safety related to smoking by not completing required smoking safety assessments at the prescribed frequency for one resident. A resident with a diagnosis that included nicotine dependence was observed smoking in the courtyard with his daughter present, and later in the presence of Activities staff who remained outside with the residents while they smoked. The resident’s care plan, dated 2/4/25, identified him as a smoker who could go out to smoke at designated times or with family and specified that a smoking evaluation would be completed quarterly. Record review showed the most recent Smoking Safety Evaluation had been completed on 11/6/24 and indicated the resident could safely smoke with supervision, but no further evaluations were completed until 4/30/26, despite facility policy requiring smoking assessments upon admission, readmission, with significant change, and quarterly by a licensed nurse.
Failure to Supervise Smokers and Secure Smoking Materials
Penalty
Summary
The facility failed to adequately supervise 27 identified smokers and failed to secure resident smoking materials, including lighters and cigarettes. Surveyors found that the facility’s smoking policy required smoking-related privileges, restrictions, and concerns to be documented in the care plan and communicated to personnel, and required residents with restricted smoking privileges to be monitored under direct supervision while smoking. Resident #15 was observed sitting up in bed with oxygen in use, and later was observed on the smoking patio sitting in a wheelchair with a plastic bag containing cigarettes and a lighter in her lap. Staff confirmed she was identified as an unsafe smoker and required a smoking apron while smoking. Her record showed severe cognitive impairment with a BIMS score of 6, diagnoses including dementia and schizophrenia, and continuous oxygen at 2 liters per minute via nasal cannula for COPD. Review of the records for all 27 smokers showed care plan interventions requiring them to return smoking materials to the Activities Department after re-entering the building from the smoking patio. Interviews with the Activity Director, LPN, MDS staff, CNA, DON, Administrator, and Medical Director showed conflicting descriptions of where smoking materials were kept, but multiple staff acknowledged that residents kept cigarettes and lighters in their possession and that residents were expected to turn them in after smoking. The Medical Director stated residents were not permitted to keep cigarettes or lighters and that residents with low BIMS scores or those receiving oxygen should not have access to smoking materials.
Code Alert System Failed to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure the code alert system used for residents at risk for elopement was functioning properly and failed to follow the manufacturer’s recommendations for weekly testing and inspection. The report states that the immediate jeopardy began when R12 was able to exit the building after the main entrance code alert system malfunctioned, and that R19 was also able to get through the main doors because the doors did not lock as required by the system. The manufacturer’s binder in the facility called for weekly testing of the code alert units, regular testing of each detection zone, and quarterly service inspections, but the facility’s logs showed the doors were being tested monthly instead of weekly. R19 was severely cognitively impaired with Alzheimer’s disease. The resident’s assessment identified low elopement risk, and the care plan lacked interventions for elopement and wandering. During observation, R19 wheeled to the main entrance, went through the first door into the vestibule, and the alarm sounded, but the door did not lock. A nursing assistant responded and redirected R19 back to the central TV area. The resident’s progress note did not include the attempt to leave the building. R12 was severely cognitively impaired with non-Alzheimer’s dementia and anxiety. The resident had repeated attempts to leave the facility, but the care plan lacked elopement and wandering interventions, and the most recent assessment also identified low elopement risk with the door alarm band not selected. During observations, R12 repeatedly approached the main entrance, triggered the alarm, and was able to get through the first door into the vestibule; on one occasion R12 exited the building before being followed outside by staff. The report also states that R12’s record lacked documentation of the successful exit and other attempts to leave. In addition, the facility failed to adequately assess and develop care plans for multiple other residents assigned code alert devices, including residents with severe or moderate cognitive impairment and diagnoses such as dementia and Alzheimer’s disease, whose care plans did not include elopement or wandering interventions or, in some cases, the location of the device.
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