**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 41 residents with one resident sampled for accidents. Based on observation, interview, and record review, the facility failed to provide adequate supervision and ensure a safe and secure environment as free from accident hazards as possible when Housekeeping/Laundry Staff C failed to report a malfunctioning basement door. About six weeks later, on 07/01/24, cognitively impaired Resident (R)1 opened the same malfunctioning, key coded basement door and fell down seven steps to the landing, in her wheelchair. R1 sustained major injuries including a lump to the back of her head and three fractured ribs. This deficient practice placed R1 in immediate jeopardy and at risk for personal injury. (R1) Findings included: - R1's electronic medical record (EMR) included the following diagnoses that included cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and cognitive impairment (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The Significant Change in Status Minimum Data Set (MDS) dated [DATE], revealed R1 had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. The MDS documented the resident wandered daily. The Behavioral Symptoms Care Area Assessment (CAA) dated 03/27/24 revealed R1 wandered around the facility and went into other residents rooms due to her confusion. The Quarterly MDS dated 06/17/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The MDS documented the resident wandered daily. R1' s Care Plan revised 02/23/24, revealed R1 required a wheelchair for mobility. Staff were to monitor the resident and document/report to R1's physician of any changes in cognitive function, specifically changes in decision making ability, memory, recall, general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. R1 was at risk for falls related to confusion, muscle weakness, and cerebral infarction. The Care Plan included a 06/16/24 revision for staff to encourage the resident to remain in the common area until staff could assist her to bed. On 07/01/24 at 11:15 AM, a fall note revealed Licensed Nurse (LN) B was looking for R1 when a housekeeper notified the nurse the resident fell down the stairs. Upon entering the staircase, the resident was on the landing of the basement stairs on the floor with her wheelchair near her. The resident had her shoes on and a stack of kitchen napkins beside her. LN B asked the resident if she hit her head and R1 stated yes. Three staff assisted R1 into her wheelchair. When asked what she was doing R1 reported, I was walking down the stairs. Staff transported R1 upstairs via a basement elevator. R1 could follow commands and answer most questions. R1 had a bump to the back, left side of her head. R1 reported pain to her upper left back and stated it hurts when staff palpated (touched) her head. LN B provided Tylenol (pain medication), 650 milligrams (mg), as needed (PRN) at 11:23 PM. Review of the facility investigation dated 07/01/24, revealed R1 went through a door with a keylock and fell down the basement stairs (7 stairs). R1 told staff she was walking down the stairs and lost her balance and fell. The resident had a bump to the back, left side of her head and pain to her left upper back. No other injuries found. Staff initiated neuro checks (an assessment to monitor for neurological functions, motor and sensory response and level of consciousness). Staff notified R1's physician and the physician advised staff to apply an ice pack to the affected area. Immediately after the accident, the resident had complaints of pain and the staff administered PRN Tylenol. Later in the day, (untimed) the resident complained of left-sided pain. The nursing staff contacted the physician a second time and received orders for an X-ray of her ribs to the left side. The X-ray revealed three minimally displaced fractures of the left fifth, sixth, and seventh ribs. The Progress Notes dated 07/01/24 at 04:18 PM, revealed the resident complained of pain to her left ribs when staff transferred her from a recliner to a wheelchair. Staff contacted Physician F's office to request an X-ray. On 07/02/2024 at 02:04 PM, the x-ray results revealed R1 ha Minimally displaced fractures of the posterior left 5th, 6th, and 7th ribs. The witness statement by Housekeeping Staff C revealed on 07/02/24 Housekeeping Staff C reported the [malfunctioning basement door] door was not completely shut. The statement revealed if staff let it shut slowly, the door would not latch. Housekeeping Staff C documented it was approximately a month and a half ago, the door did not latch effectively. Housekeeping Staff C documented she told another housekeeper about it but did not report it to maintenance because she did not feel the door was broken, but it was just not latching. Review of the maintenance door logs from 06/03/24 through 07/18/24 showed no malfunction of the doors or the locks. Observation on 07/15/24 at 11:45 AM, revealed the resident in her wheelchair and able to propel her wheelchair without assistance. Observation on 07/15/24 at 01:40 PM, revealed the resident sat in a recliner in the commons area with the TV on. Observation on 07/15/24 at 02:40 PM, revealed Certified Nurse Aide (CNA) D transferred R1 from a recliner in the commons area to a wheelchair. R1 wheeled herself independently to her room with staff walking beside her. Once in her room, CNA D assisted the resident to the toilet. R1 could stand while she held onto the grab bar to transfer to the toilet. On 07/15/24 at 11:10 AM, Administrative Staff A stated staff were not sure how the resident got the door open. Administrative Staff A reported she knew laundry staff noted the door was not all the way latched about six weeks prior to the incident and did not know if the resident just shook the door handle until it opened or how she opened the door. Administrative Staff A stated the resident was confused but told staff she was walking down the stairs and lost her balance, so staff do not know how she got out the door. Her wheelchair was on the landing next to her when a housekeeping staff saw her on the floor. On 07/15/24 at 11:20 AM, Maintenance Staff H reported the door had a manual lock on it, but it worked fine when he checked the doors. He reported he checked all doors and door locks to make sure they were functioning and documented those on a daily log. He reported the whole locking mechanism was changed and switched it to an electronic lock pad to assure it did not open except with the code. On 07/15/24 at 01:30 PM, Licensed Nurse B reported she did not know how the resident got the door open. LN B said the door had a keypad on it and if a person did not have the code, it should not open. She reported it was about lunch time and the resident had been outside at an activity and as she was coming back in, R1 went through the dining room and picked up a big stack of napkins. LN B saw R1 go by the nurses' station holding onto the napkins. LN B said she watched her go by and was going to finish her charting and then take the resident to the dining room for lunch, but when she looked down the hall, she could not find R1, so she went to look for her. LN B said she looked on in every room, including the chapel and the restrooms, and had all the aides looking as well. LN B said Housekeeping Staff C took LN B to the basement door and LN B saw the resident on the landing of the stairs, going to the basement. LN B said her wheelchair was upright and next to the resident. LN B did range of motion (ROM) and asked R1 if she hit her head the resident reported yes, she hit her head. LN B said R1 had a bump to the back of her head. Several CNAs lifted the resident back into her wheelchair and staff carried her in her wheelchair down the stairs to the basement, then brought her upstairs in the elevator. LN B said she notified Administrative Nurse G, faxed the physician, then put an ice pack on the resident's head. The resident was placed in recliner in the commons area and was there a couple of hours. Staff then went to take her to the bathroom and when they transferred R1, the resident complained of pain in her left side by her ribs. LN B said she notified the physician for an order to get an x ray of her ribs. The physician ordered the X-ray the next day, which revealed three rib fractures. The physician ordered Tramadol (pain pill) and ice for pain. LN B said the maintenance department changed the locks on the door so it could not come open again and said the door is heavy and difficult for staff to open. On 07/15/24 at 02:30 PM, CNA D said they did know how R1 could open the heavy door. CNA D said a housekeeping staff saw R1 and notified the nurse. Review of the undated facility Maintenance policy for doors, documented all doors were to be checked daily for proper function and documented on the door log. On 07/15/24 at 05:20 PM, the IJ template was provided to Administrative Staff A and notified the facility of the failure to ensure a safe and secure environment as free from accident hazards as possible when a housekeeping/laundry staff failed to report a malfunctioning basement door, and about six weeks later, on 07/01/24, cognitively impaired R1 opened the key coded basement door and fell down seven steps to the landing, in her wheelchair and sustained major injuries that included a lump to the back of her head and three fractured ribs, placed the resident in immediate jeopardy. The immediate jeopardy was determined to first exist on 07/01/24. The facility identified and implemented the following corrective actions, completed on 07/03/24: 1. Doorknob/lock changed, and door closure changed on 07/02/24. 2. All staff received education on Reporting malfunction or equipment not working appropriately immediately to Administration Team. 3. Charge Nurses received education If there is a substantial fall (stairwell, out of transportation vehicle, fall face first out of wheelchair) and Director of Nursing/ Assistant Director of Nursing is present in the building, notify them and have them assess, too; if not present and another Charge Nurse present in the facility have the assess, also. If a resident sustains a substantial fall notify physician via phone, not a fax. 4. The Medical Director notified on 07/03/24. 5. Staff members who have not had education will be educated prior to working their next assigned shift. 6. An ad-hoc QAA meeting held to review this area of concern and the action plan created to ensure system is corrected and sustained 07/03/24. The surveyor verified the above implemented and completed corrective actions while onsite 07/15/24. Due to corrective actions the facility completed prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J scope and severity.

The facility reported a census of 41 residents with three residents sampled for safety related to transportation outside the facility. Based on observation, interview, and record review, the facility failed to ensure staff provided a safe environment as free of accident hazards as possible, when Social Services Designee (SSD) C failed to ensure the lap belt was snug on Resident (R)1 prior to transport in the facility van while traveling on the highway. R1 fell out of the wheelchair onto the floor of the facility van, landing on his knees. SSD C failed to notify 911 or activate EMS for assistance. SSD C assisted R1 to lay on the floor of the van and then drove R1 back to the facility (approximately 20 miles), unsecured, and laying on the floor of the wheelchair van. Upon arrival to the facility R1 required emergency medical transport to a local hospital for evaluation and treatment of a left femur (thigh bone) fracture (broken bone). This deficient practice placed R1 in immediate jeopardy. Findings included: - Review of the Electronic Health Record (EHR) documented R1 had diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one side of the body) following cerebrovascular disease (CVA or stroke - a sudden death of brain cells due to the lack of oxygen caused by impaired blood flow to the brain), end stage renal disease (ESRD - a terminal disease of the kidneys due to irreversible damage), dependence on renal dialysis (a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to - a treatment procedure that is usually performed three to four times per week), diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin) and disorders of bone density (disorders of altered bone density), and osteopenia (loss of bone density which weakens the bone). The 05/18/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required extensive assistance of two staff for all cares except eating, which was independent. R1 had no falls in the facility since admission. The 05/18/23 Falls Care Area Assessment (CAA) documented R1 was at increased potential for falls related to the requirement of a full body mechanical lift, incontinence (loss of bowel or bladder function), use of psychotropic medications (classes of medications that affect the mind, mood or mental processes), and hemiplegia. The 11/08/23 Quarterly MDS documented a BIMS score of 13, which indicated intact cognition. R1 required the assistance of two or more staff for all cares except eating, which was independent. The MDS documented no falls since admission. The Care Plan documented R1 was at risk for falls related to hemiplegia, history of CVA, chronic diffuse osteopenia, muscle weakness, bone demineralization, and history of a fall prior to admission that resulted in a femur fracture. The Care Plan lacked interventions specific to the mitigation of fall risk during transportation in facility owned vehicles. The Care Plan documented an intervention on 02/01/24 at 10:00 AM for R1 to have a pummel cushion (a cushion added to a wheelchair seat to prevent sliding) in place and to add use of vehicle's factory installed shoulder/lap seat belt for all transportations. The Fall Risk Score Assessments revealed the following for R1: 1. On 11/02/23, a fall score of 16, which indicated high risk for falls. 2. On 01/29/24, a fall score of 19 which indicated high risk for falls. The Progress Notes documented the following: On 02/01/24 at 06:45 AM, SSD C was providing transportation in the facility van when a small herd of deer crossed the road in front of the vehicle. SSD C swerved the vehicle to miss the deer and heard R1 yell her name. SSD C stopped the vehicle on the side of the road and saw R1 on his knees on the floor with the seatbelt intact on the wheelchair. On 02/01/24 at 07:36 AM, Licensed Nurse (LN) D documented at approximately 07:00 AM, SSD C reported to her that SSD C swerved to avoid hitting deer on the road and R1 fell out of his wheelchair. SSD C laid R1 down on the floor of the van and drove the resident back to the facility. R1 complained of left leg pain. LN D assessed R1 for injuries and called 911 to activate EMS (Emergency Medical Services) at 07:06 AM and R1 was transported to the ED (Emergency Department) for further evaluation of his injuries. On 02/01/24 at 12:00 PM, Administrative Nurse B informed LN D that R1 was going to be returning to the facility via EMS with a left leg splint (a rigid device used to prevent motion of a joint or the ends of a fractured bone) due to a distal femur fracture and R1 was not a candidate for surgery. On 02/01/24 at 12:45 PM, R1 returned to the facility via EMS from the ED and R1 complained of pain to his left leg and required pain medication. Review of the facility's undated investigation revealed on 02/01/24 at 06:45 AM, R1 was being transported to an appointment out of town in the facility van. The van traveled on the highway approximately 20 miles from the facility when a herd of deer crossed the highway. SSD C performed an emergency stop and swerve to avoid colliding with the deer and heard R1 call her name. R1 was observed by SSD C to have slipped out of his seatbelt and was on his knees on the floor. SSD C observed the seat belt and other safety belts were still in their proper position/placements. SSD C then assisted the resident off his knees and into a laying position on the floor of the van and returned to the facility. Upon the return to the facility, LN D assessed R1 and called 911 to activate EMS to transport R1 to the ED for further evaluation of his injuries. The ED staff assessed R1 and diagnosed a left distal femur fracture with slight displacement and placed a left leg splint due to R1 not being a candidate for surgical repair and opioid (a class of medications for severe pain) medication for pain management. On 02/07/24 at 09:41 AM, R1 observed laying in his bed on his left side. The resident wore a left leg splint. R1 stated that some deer ran out in front of the facility owned transport van and SSD C slammed on the brakes and swerved to avoid the deer. R1 stated that he slid out of his wheelchair and landed on his knees on the floor of the transport van. R1 further stated that he did not think the seatbelt was appropriately fastened to the wheelchair and only recalled use of the lap belt. On 02/07/24 at 10:45 AM, SSD C stated when staff transport residents in the van, a resident is wheeled into the transport van, there are four hook straps that secure the wheelchair to the van floor, then a seatbelt is placed through the arms of the wheelchair and positioned as low as possible on the resident's abdomen/pelvis. Further stated that at the time of the incident, deer were beginning to cross the roadway and she performed an emergency braking maneuver and swerved to the right to avoid the collision with the wildlife. Stated after the incident, the resident called out her name and she pulled completely off the road to the right to assess what had happened. R1 knelt on the floor of the transport van with the wheelchair and the seatbelt still fastened/secured to the van. She assisted R1 to a laying position while telling the resident that she was going to call 911. Once R1 was laying on the floor of the transport van with the wheelchair and seatbelts moved out of the way, she transported the resident back to the facility without the resident being secured in any way. Confirmed that she failed to call 911 from the side of the road, and that she failed to call the licensed nurse on duty for instructions. On 02/07/24 at 10:50 AM, Transportation Aide E revealed when staff propel a resident into the transportation van, the wheelchair should be secured to the transportation van with four hook straps then a seatbelt is snugly placed as low as possible across the resident's abdomen/pelvis. In the event a resident fell from the wheelchair, staff were to check the resident for injuries, then call 911 to activate EMS for further assistance. On 02/07/24 at 11:15 AM, Licensed Nurse D revealed that on 02/01/24 at approximately 07:00 AM, SSD C revealed an incident occurred to R1 in the transport van and R1 had been injured. 911 was called to activate EMS response for further assistance. R1 was laying on the floor of the transport van on his right side. On 02/07/24 at 11:30 AM, Certified Nurse Aide (CNA) F revealed when a resident was wheeled into the transportation van, the wheelchair should be secured with four hook straps and then a lap belt snugly placed as low as possible around the resident's abdomen/pelvis. In the event of a resident falling from the wheelchair, staff were to check the resident to make sure they were OK and then call 911 to activate EMS for further assistance, then call the charge nurse and/or Administrative Nurse B. On 02/07/24 at 11:42 AM, Administrative Nurse B revealed in the event of an incident in the transportation van, the expectation is for staff to call 911 to activate EMS to evaluate the resident for injuries. Further stated that she was unsure of what the policy directed in that situation. Further confirmed R1 was transported unsecured on the floor of the transportation van approximately 20 miles back to the facility. On-the-spot reeducation was provided to SSD C. On 02/07/24 at 12:00 PM, Administrative Staff A revealed in the event of an incident in the transportation van, the expectation is that staff should not move the resident and call 911 to activate EMS to evaluate the resident for injuries. Further, confirmed that SSD C did not follow procedure to call 911 to activate EMS. The facility's undated Assessing Falls and Their Causes policy lacked guidance related to incidents that occurred during transport to and from the facility in facility owned vehicles. On 02/07/24 at 03:43 PM, Administrative Staff A was provided a copy of the immediate jeopardy (IJ) template and informed of the IJ when SSD C failed to ensure the lap belt was snug on R1 prior to transport in the facility van while traveling on the highway. R1 fell out of the wheelchair onto the floor of the facility van, landing on his knees. SSD C failed to notify 911 or activate EMS for assistance. SSD C assisted R1 to lay on the floor of the van and then drove R1 back to the facility (approximately 20 miles), unsecured, and laying on the floor of the wheelchair van. Upon arrival to the facility R1 required emergency medical transport to a local hospital for evaluation and treatment of a left femur fracture. This deficient practice placed R1 in immediate jeopardy. The deficient practice was cited as past non-compliance as the facility implemented the following corrective actions beginning on 02/01/24: The facility implemented education for all transportation staff on the proper securing methods for securing residents into transportation vans and the use of the new seatbelt that was initiated on 02/01/24 at 01:00 PM and completed on 02/05/24 at 02:00 PM. The facility implemented education for all transportation staff on the need to call 911 to activate EMS response during an emergency event during transportation, initiated on 02/01/24 at 01:00 PM, and completed on 02/05/24 at 02:00 PM. The facility completed on-the-spot education to SSD C on the necessity of calling 911 to activate EMS response during any emergent event initiated on 02/01/24 at 11:00 AM and completed on 02/01/24 at 11:00 AM. The facility updated R1's care plan to include the use of a pummel cushion and use of transportation van's factory installed shoulder/lap belt for all resident transports initiated on 02/01/24 at 10:00 AM and completed on 02/01/24 at 10:00 AM. The facility ordered shoulder straps that attach to the resident's wheelchair for added protection in addition to implementation of a seatbelt device that allows for integration of the transportation van's factory installed shoulder/lap belt and was initiated on 02/02/24 at 01:00 PM and completed on 02/02/24 at 01:00 PM. Due to the correction measures implemented by the facility prior to the onsite complaint investigation on 02/07/24, the deficient practice was deemed past non-compliance. The deficient practice remained at a J scope and severity.