Marlborough Hills Rehabilitation & Health Care Cen

During an interview of 09/17/25 at 3:15 P.M., the Director of Nursing (DON) said Facility staff had not transferred Resident #1 utilizing a Hoyer lift in accordance with his/her plan of care, as required. On 10/14/25, the Facility was found to be in Past Non-Compliance effective 09/24/25, and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A) The Facility discussed the area of concern at Quality Assurance Performance Improvement Committee meeting in September 2025 and initiated a Quality Improvement Plan. B) 09/17/25, the Facility implemented disciplinary actions for CNA#1 and CNA #2. C) 09/17/25, the Assistant Director of Nursing (ADON) conducted audits of all residents utilizing mechanical lift for compliance with transfer status, and skin condition to identify inconsistencies against observed head to toe assessments. D) 09/17/25, the Staff Development Coordinator (SDC) initiated education to facility CNAs on providing safe transfers. E) 09/18/25, the SDC initiated education to facility CNAs on the importance of adherence to information on the individual resident Care Cards and upholding safe transfers. F) 09/23/25, the SDC conducted clinical competency assessments on transferring Residents using a mechanical lift for CNA #1 and CNA #2. G) The SDC will conduct follow up audits consisting of random visual observations of mechanical lift transfers three times a week for three months. H) The Facility will continue to monitor compliance at monthly and quarterly Quality Assurance Meetings. I) The Director of Nurses and/or designee are responsible for overall compliance.

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