Windsor House At Champion

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident #88's granddaughter via telephone on 10/16/25 at 10:40 A.M. revealed her concerns that the Resident suffered two injuries at the facility in such a short time and she stated her hope that this doesn't happen to anyone else. Resident's granddaughter also stated her desire to advocate for the Resident who was cognitively impaired and couldn't speak on her own behalf. Review of the facility's policy titled Hoyer Lift - One Piece Sling with Straps revised November 2024 revealed Hoyer slings are to be placed half-way under the resident so the lower edge is slightly below the knees and the resident should be centered on the sling with the lower edge right behind the resident's knees. The deficient practice was corrected on 10/13/25 when the facility implemented the following corrective actions: The facility completed an audit to

review all current facility residents to determine if leg rests were in place/available for residents that require assistance with wheelchair mobility. This quality assurance (QA) audit was completed on 09/01/25 by the facility QA nurse. Leg rests that were identified as needed through the audit were provided and this added to the Kardex /care plan by the facility MDS nurse by 09/05/25. On 09/02/25, a new order was obtained for Resident #88 to be up in a Broda chair (tilt-in-space positioning chair) with elevating leg rests. Her care plan was updated on 09/03/25 to reflect this change. An ad-hoc quality assurance and performance improvement (QAPI) meeting was held on 09/02/25 to review wheelchair transport on 08/30/25 for Resident #88. A plan of action was discussed and developed to include actions already taken by the facility. The medical director was also notified of the incident with Resident #88 by the facility DON on 09/02/25.

Re-education was initiated with all CNA's on making sure leg rests are in place on wheelchairs for residents that require assistance with wheelchair mobility or determined to need leg rests for transport. The re-education was provided by the facility QA nurse and CNA supervisor and was started on 09/02/25 and completed by 10/12/25. Observation audits were initiated on 09/08/25 and were done by the facility QA nurse. Observation audits of 10 residents three times a week. Any issues identified during the audits will be immediately addressed with the individual responsible. Audits will be reviewed by the QAPI at the next three QAPI meetings. Immediate inspection of the Hoyer lift was completed by the charge nurse on 10/03/25, and no issues with the Hoyer lift were found. On 10/03/25, CNAs #578 and #571 were immediately in serviced by charge nurse on the Hoyer Lift policy. On 10/06/25, all Hoyer lifts and slings were inspected by the facility QA nurse with no issues noted. An ad-hoc QAPI meeting was held on 10/06/25 by the facility DON and QA nurse. The medical director was notified by the facility corporate nurse on 10/06/25. All clinical staff were educated on the Hoyer lift transfer policy by the QA Nurse and CNA supervisor. The education began on 10/03/25 and was completed by 10/13/23. All CNAs had a Hoyer lift competency completed by the facility QA nurse or CNA supervisor and follow up Hoyer lift Quiz. All residents that require a Hoyer lift trans-fer were assessed for appropriate size lift pad on 10/06/25 by the facility QA nurse. Hoyer lift observation audits were completed by the QA Nurse four times a week for four weeks. All observation audits will be reviewed by the QAPI committee at the next three QAPI meetings. This violation represents non-compliance investigated under Complaint Number 2640382.

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