**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #138 was admitted to the facility on [DATE] with diagnoses which included hypertension, muscle weakness and Alzheimer's disease. Review of Resident #138's most recent significant change Minimum Data Set (MDS) assessment revealed the resident was severely cognitively impaired and was dependent on staff for all activities of daily living (ADL). Review of Resident #138's Care Area Assessment summary dated 01/14/25 revealed she was at risk for falls related to unsteady gait and muscle weakness. Staff will provide transfers as needed. The resident is at risk of a decline in activities of daily living (ADL) related to acute illness and muscle weakness. Nursing staff will provide assistance with ADL as needed. The resident is at risk of altered communication related to cognitive impairment. Staff will anticipate needs and provide assistance as needed. Staff will continue to monitor and anticipate needs in effort to prevent further declines and treat/manage current conditions. Review of Resident #138's care plan dated 01/14/25 revealed a focus area for ADL/mobility related to requiring assistance related to impaired mobility. The goal was for the resident to improve current level of function in ADL. The interventions included in part: Total lift for transfers with 2 staff. A continuous observation on 02/26/25 from 4:38 PM until 4:43 PM revealed Resident #138 screaming out and when walked in the room, Nurse Aide (NA) #2 was lifting Resident #138 to bed in a mechanical lift without the assistance of a second staff member. NA #2 was operating the lift mechanism and there was no one holding onto the resident in the lift pad and directing her onto the bed. Resident #138 was placed in bed with the lift pad and continued to scream until she was adjusted in the bed by NA #2 An interview on 02/26/25 at 4:44 PM with NA #2 revealed she had gotten Resident #138 up with the mechanical lift by herself because she stated the resident was sliding out of her wheelchair and she didn't want her to fall. NA #2 stated she had yelled for help but didn't feel like she could wait so she went ahead and got her up in the lift by herself. NA #2 further stated she had had education on mechanical lifts and knew she was not supposed to get a resident up in the mechanical lift without a second staff member to assist. She indicated she had been provided with education on new equipment and lifts and other equipment throughout the year. A telephone interview on 02/26/25 at 8:19 PM with NA #1 who was working with NA #2 on the hall revealed NA #1 had not asked her to assist her with getting Resident #138 up with the mechanical lift. NA #1 stated she had been available to assist with getting Resident #138 up with the mechanical lift but had not been asked by NA #2 for assistance. A telephone interview on 02/26/25 at 8:29 PM with Nurse #1 who was assigned to care for Resident #138 from 7:00 AM to 7:00 PM revealed she had not been asked to assist NA #2 in getting Resident #138 up in the mechanical lift. Nurse #1 stated she was a new nurse and had only been working for 3 weeks and was not familiar with the facility's protocols for mechanical lifts. She further stated she was not sure if mechanical lifts required 2 staff members when transferring residents. An interview on 02/27/25 at 3:57 PM with the Director of Nursing (DON) revealed mechanical lifts required 2 staff members when transferring residents. She stated NA #2 should have gotten assistance prior to getting Resident #138 up in the mechanical lift and transferring her to bed. An interview on 02/27/25 at 4:31 PM with the Administrator revealed he felt NA #2 did the best she could have given the resident was sliding from her wheelchair. He stated although NA #2 did not follow the facility's policy for mechanical lifts he thought it was admirable that she prevented Resident #138 from falling. Based on record review, observation, staff interview, Nurse Practitioner and Medical Director interview, the facility failed to ensure the necessary supervision was provided to a cognitively impaired resident to prevent an avoidable accident. On 06/25/24 Resident #79, who was known to have poor safety awareness, returned from an outing on the facility's transportation bus and was left unattended on the bus by three staff members. The front door of the bus was left open. Resident #79 unbuckled her seatbelt and ambulated to the front of the bus exiting at the front stairs. The resident was wearing slip on shoes that came off, the resident lost her footing and experienced a fall from the bus steps, hitting her head and landing on her right side on the asphalt. On initial assessment, the resident sustained multiple injuries that included a right shoulder bone dislocation, skin tears to the upper and lower extremities, abrasions to the lower extremities and forehead, a bruise to the inner right back, a right tongue hematoma (collection of blood formed under the tongue), a cracked right front tooth, and a lump/hematoma to the right side of her head. Following the incident the resident experienced dizziness and vomited multiple times. She was assessed at the hospital with a left temporal subarachnoid hemorrhage (bleeding in the space below one of the thin layers that cover and protect the brain), right clavicle (collarbone) fracture, right humeral (long bone that runs from the shoulder to elbow) fracture and bilateral rib fractures. At a lower scope and severity of D, the facility failed to ensure a safe transfer in a mechanical lift for a resident (Resident #138) when Nurse Aide (NA) #2 transferred Resident #138 in a mechanical lift in an unsafe manner. The deficient practice affected 2 of 11 residents reviewed for supervision to prevent accidents (Resident #79 and Resident #138). Immediate jeopardy began on 06/25/24 when Resident #79 was left unattended on a transportation bus. She unbuckled herself and ambulated to the front of the bus exiting the stairs resulting in a fall. Immediate jeopardy was removed on 07/03/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Example #2 is being cited a scope and severity of D. The findings included: 1. Resident #79 was admitted to the facility on [DATE] with diagnoses of cerebrovascular accident (CVA), Non-Alzheimer's dementia and hemiplegia (paralysis or weakness on one side of the body) affecting the right dominant side. A fall risk evaluation dated 11/01/23 revealed Resident #79 scored a level 8, indicating she was at moderate risk for potential falls. The resident was noted to have a balance problem while standing and required the use of assistive devices such as a wheelchair. Resident #79's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired and required extensive assistance of one staff member for sit to stand transfers and chair to bed transfers. Resident #79 was coded under walking 10 feet as not applicable. Resident #79 used a wheelchair as an assistive device and had no functional impairments with range of motion to the upper or lower extremities. She did not receive an anticoagulant during the assessment period. An interview conducted on 03/03/25 at 11:26 AM with the MDS Coordinator revealed under Resident #79's annual MDS assessment the wording not applicable meant the resident was unable to ambulate with assistance during the assessment period. A care plan initiated on 11/29/2022 and revised on 04/10/24 revealed a focus area related to Resident #79 being at risk for falls related to gait/balance problems and psychotropic medication use. The goal was for Resident #79's falls to be minimized with staff intervention through the next review date. Interventions included reminding the resident to use a wheelchair for mobility, ensuring the resident was wearing appropriate footwear while out of bed and to anticipate the needs of the resident. On 02/25/25 at 1:00 PM an observation was conducted of the facility transportation bus. The transportation bus had a total of 2 seating rows on the passenger side, and 3 rows of seats on the driver's side. On the passenger side of the bus at the rear tire area was a large ramp that lowered down and was used to bring residents onto the bus using their wheelchairs. There were three steps leading onto the bus from the front entrance at the drivers steering wheel. A nursing note dated 06/25/24 at 12:30 PM written by the Director of Nursing revealed Resident #79 left the facility at approximately 10:30 AM for an outing with other residents and three facility staff members via the facility transportation bus. Upon return at 12:10 PM, per staff statement, staff informed all residents not to unbuckle their seat belts or to rise until the staff went to assist the residents from their seats. Resident #79 was sitting in the second row of seats, per staff Resident #79 unbuckled her seatbelt and attempted to exit the facility bus without assistance while staff were preparing to assist residents to exit the bus. The resident was wearing fleece lined shoes. Resident #79 slid out of her shoe and tumbled down the steps landing on her right side in the parking lot. A STAT (immediate) response was called, and Resident #79 was immediately assessed by the facility Nurse Practitioner and nursing staff. A raised abrasive area was noted to the resident's right scalp, she complained of pain to her right shoulder. Resident #79 was taken to her room for a full body assessment noting multiple abrasive areas. During the time of the assessment Resident #79 complained of dizziness and nausea, vomiting four times with diarrhea noted during incontinent care. The Nurse Practitioner was notified and gave orders to send the resident to the Emergency Department for an evaluation. Resident #79's Responsible Party (RP) was notified of the resident's condition, incident and need to send to the Emergency Department. The RP stated the resident was impulsive and attempted to get up without assistance all of the time. Emergency Medical Services (EMS) arrived at the facility at approximately 12:50 PM to transport the resident to the hospital. On 02/25/25 at 12:23 PM an interview was conducted with the Activities Director. During the interview she stated on 06/25/24 she had taken Resident #79 on an outing for ice cream via the transportation bus with two other staff members and a volunteer. Four residents were on the bus and she was familiar with each of the residents prior to going on the outing. Upon arrival back to the facility after Transportation Driver #1 had parked the bus and got off to go to the rear of the bus to open the ramp. She (the Activities Director) gathered the trash and exited via the front entrance along with the Volunteer. She stated when she exited the bus all residents were still buckled in their seats. The Activities Assistant was behind her getting off of the bus and stated to the residents to stay in their seats, they would be assisting them in a minute. The interview revealed Resident #79 was confused at times but she did not think the resident would get out of her seat to ambulate without assistance. The Activities Director stated she was in the sunroom of the facility directly in front of where the bus was parked throwing away the trash with the Volunteer. She stated after throwing away the trash she exited the sunroom and that was when she heard a loud thump and Resident #79 yelled out. She ran over to see Resident #79 on the asphalt at the bottom of the steps. The Activities Director then ran back in the facility and paged for assistance to the parking lot as the Activities Assistant and Transportation Driver #1 stayed with Resident #79. The Director of Nursing and Nurse Practitioner came and assessed Resident #79 along with other staff members. Resident #79's slipper was found on the top step of the bus. She stated when the incident happened nobody had seen Resident #79 get up and out of her seat on the bus. The Activities Director stated looking back on the incident a staff member should have stayed on the bus with the residents and not left them unattended. On 02/25/25 at 12:35 PM an interview was conducted with the Activities Assistant. During the interview she stated she, the Activities Director, Transportation Driver #1 and a Volunteer had taken Resident #79 on an outing to get ice cream on 06/25/24. There were four residents in total on the outing and she was familiar with Resident #79 prior to the outing. Upon returning to the facility, Transportation Driver #1 opened the front door and got off of the bus. Next, the Activities Director and Volunteer exited the bus to throw trash away. She stated before exiting the bus herself she told the residents to remain seated, that her and Transportation Driver #1 would start unloading the residents from the back of the bus. All residents were buckled and secure when she exited the bus via the front entrance. She stated she did not think Resident #79 would unbuckle her seat belt and stand up without assistance. She stated when she walked down the steps, the front door was left open. She went to the back of the bus to lower the wheelchair lift to help Transportation Driver #1. All of the residents onboard required the use of the wheelchair ramp to exit. She stated shortly after she got to the rear of the bus Resident #79 had unbuckled herself, lost her footing and fell down the bus steps out of the front entrance. The Activities Assistant did not witness Resident #79 unbuckle her seat belt or stand up but assumed that was what happened by the sequence of events leading to the fall. The interview revealed it happened quickly after she exited the bus. The Activities Assistant stated she ran to her and immediately put her hands under the resident's head because it was a hot day and the asphalt was hot. The Activities Director ran into the building to get help. The Director of Nursing, nurses and Nurse Practitioner went to the resident to assess her injuries. The Nurse Practitioner stated to the staff she wanted to get the resident up off of the ground because of the hot pavement. The Activities Assistant stated she backed up from the situation at that time because she was not clinically trained, and she let the other staff handle the situation. The Activities Assistant stated no staff members were on the bus when Resident #79 stood up and ambulated to the front entrance and fell down the steps. She stated she could not see Resident #79 stand up from where she was positioned at the rear of the bus. The interview revealed she felt a staff member should have remained on the bus at the time of the incident with the residents. She stated she felt like she was very close to the residents being at the rear ramp but it was too far away to have seen Resident #79 unbuckle herself and get up. On 02/25/25 at 4:00 PM an interview was conducted with Transportation Driver #1. During the interview she stated on 06/25/24 she had taken Resident #79 on an outing with the Activities Director, Activities Assistant and a Volunteer. She stated when they returned to the facility, she parked the transportation bus and put the vehicle's breaks on. She left the bus running to keep the residents cool because it was a hot day. Transportation Driver #1 stated she exited through the front entrance first, and when she exited there were two staff members (the Activities Director and Activities Assistant) and the Volunteer still on the bus. The interview revealed the residents, including Resident #79, were placed onto the transportation bus via a rear wheelchair ramp. The residents were wheeled onto the ramp in their wheelchairs and placed in the row seating by the staff members. The wheelchairs were stored at the rear of the bus during transport. She stated she was at the rear of the bus opening the door when she heard Resident #79 screaming. When she looked, Resident #79 was lying on the asphalt outside the front of the bus. She stated she did not know where the other staff members were at the time of the fall but she did remember one of the Activities staff members was the first to get to Resident #79. The interview revealed she assumed Resident #79 had fallen from the three steps located at the front entrance of the bus but she did not witness the resident fall. Transportation Driver #1 stated she never left a resident unattended on the bus and the only reason she got off and left the residents was because other staff members were on board. She stated she did not know at the time that everyone had exited the bus and left the residents unattended. The interview revealed someone should have remained with the residents and all staff members should not have exited the bus. On 02/25/25 at 12:08 PM an interview was conducted with Wound Nurse #1. Wound Nurse #1 stated on 06/25/24 she was notified by a staff member (name she could not recall) that Resident #79 had fallen out of the transportation bus, and she needed to go outside to the parking lot. She stated when she got to the bus Resident #79 was lying on the pavement with her feet toward the bus at an angle on her right side. The Nurse Practitioner assessed Resident #79 and said it was okay for staff to transfer her into a wheelchair because she was concerned about the ground being hot. She stated the staff rolled Resident #79 onto a sheet then sat her up using a gait belt to get her into the wheelchair. Resident #79 was responsive and alert but never oriented. Wound Nurse #1 stated Resident #79 was confused at baseline and there seemed to be no change in her cognition at the time of the incident. Wound Nurse #1 stated Resident #79 did not say she was in pain when they transported her to her room and got her into bed. The resident began vomiting once she was in bed and she notified the DON who said to send the resident to the hospital for an evaluation. An undated/untimed evaluation written by Wound Nurse #1 following the incident on 06/25/24 revealed Resident #79 had the following injuries : right inner back bruise, two skin tears on the right elbow, three closed raised areas on the right hand, right shoulder burn open, right shoulder bone dislocated, left hand two open skin tears, complaints of right ankle pain, quarter size abrasion to the right knee, left great toe abrasion, left second toe abrasion, left top of foot skin tear, complaints of back pain, right forehead raised abrasion, left forehead raised abrasion, Resident #79 could not turn her head all of the way to the right side, right tongue hematoma, right front tooth cracked and right side of head goose egg. Resident #79 had stated during the assessment that nobody told her not to move and she did not know where she was going. She did not remember falling and did not have a headache. Resident #79's vital signs were blood pressure 143/77 (normal range 120/80), pulse 80 (normal range 60-90), respirations 16 (normal range 12-20) and oxygen saturation level 90% (normal range 90% or greater). On 02/25/25 at 11:46 AM an interview was conducted with the Director of Nursing (DON). During the interview she stated, based on her investigation on 06/25/24, three staff members (Activities Director, Activities Assistant and Transportation Driver #1) had taken Resident #79 on an outing to get ice cream along with three other residents. When they returned from the outing and parked the transportation bus, Transportation Driver #1 got off of the bus. The Activities Director and a Volunteer that was on the bus got off to throw away trash. The Activities Assistant got off of the bus to assist Transportation Driver #1 and told the residents to stay seated prior to getting off. The DON stated based on the sequence of events the facility had put together, that Resident #79 unbuckled herself and attempted to ambulate without assistance getting to the first step of the bus. When she reached the first step, she was wearing slippers that came off and she then fell down the steps out onto the pavement of the parking lot. The Activities Assistant and Transportation Driver #1 stayed with Resident #79 while the Activities Director ran inside of the building to get help. The Nurse Practitioner was in the building that day and went out to the parking lot to assess the resident and obtain vital signs. Resident #79 had multiple abrasions that were visible. Resident #79 had a knot on the back of her head, but no open areas. The DON stated the staff used a gait belt and Resident #79 was able to stand up with staff assist to get into the wheelchair. Resident #79 was then taken to her room and assisted to the bed via a gait belt and staff assistance. The Wound Nurse assessed the resident, and the DON went to obtain a vital sign machine. The Wound Nurse called the DON on the phone and stated Resident #79 was vomiting a lot, and she (the DON) stated to them to send the resident to the hospital for an evaluation. The DON stated Resident #79 seemed alert after the incident however wasn't as, feisty as she normally acted. She stated Resident #79 was unstable and unable to ambulate without assistance from staff at her baseline and had poor safety awareness. EMS arrived to the facility and transported the resident to the hospital for an evaluation. Nurse Practitioner note dated 06/25/24 revealed staff reported Resident #79 with a fall getting off of the transportation bus. On arrival to the resident she was noted laying on the ground outside. Resident #79 was noted to be alert at baseline and stated she was having right shoulder pain. The resident was examined while lying on the ground. She was noted to have a small lump/hematoma to her scalp, abrasion noted to her left shoulder with mild deformity. No spine tenderness was reported. Staff were cleared to assist the resident to her wheelchair due to elevated temperature and hot grounding to decrease the risk of a burn. A mild deformity was noted to the right shoulder with mild crepitus (crackling, popping, or grinding sound) as well, however Resident #79 was noted to have a history of an old fracture reported to the arm with chronic mild deformity. Initial plans were to obtain x-rays of left arm/shoulder/chest and initiate neurological checks but once the resident returned to her room and was repositioned, staff reported 2-3 episodes of vomiting. Therefore, orders were given to send the resident to the hospital for an evaluation. Resident #79 was noted with chronic/progressive dementia. She was documented as being alert and able to make needs known however was forgetful with a short term memory. On 02/25/25 at 12:41 PM an interview was conducted with the Nurse Practitioner (NP). During the interview she stated she received a call that Resident #79 had experienced a fall from the transportation bus in the parking lot. The NP immediately went outside to see Resident #79 lying on the ground and noticed her shoes were on the steps of the bus. She stated she did a quick assessment and observed no spine tenderness or obvious deformities. She stated Resident #79 was stable enough to move her from the ground because it was hot that day and she worried the resident would get burned from the asphalt. The staff obtained vital signs and got the resident up in a wheelchair. She stated she asked baseline questions and Resident #79 complained of a little arm pain, so she ordered a radiology exam based on her complaints and physical assessment. She told the staff to start neurological assessments and monitor Resident #79 during the first hour, however, after she was transported to her room she began vomiting and was sent to the hospital. The NP stated she did not go to the resident's room to reassess her she just gave the orders to send her out. The NP stated Resident #79 had returned to baseline since the incident. An Emergency Department (ED) report dated 06/25/24 at 2:17 PM revealed Resident #79 had experienced a fall coming off of a bus. She was noted to hit her head and right shoulder during the fall and had a hematoma to the right side of her head. Resident #79 did not remember the event and stated she was experiencing pain in her right shoulder, pointing to the back of her shoulder. Neurosurgery, trauma service and orthopedic surgery were consulted. A hospital Discharge summary dated [DATE] revealed Resident #79 was evaluated for a mechanical fall resulting in a left temporal subarachnoid hemorrhage, right clavicle fracture, right humeral fracture and bilateral rib fractures. Resident #79 was admitted into the hospital on [DATE] where she received services from the neurology team along with the trauma surgery team. Resident #79 was found to be stable with orders to remain non-weight bearing to the right upper extremity. She was treated for aspiration pneumonia with intravenous antibiotics during the hospital stay and discharged back to the facility on [DATE]. On 02/25/25 at 4:30 PM a follow up interview was conducted with the Nurse Practitioner. The NP stated while in the hospital Resident #79 was also treated for aspiration pneumonia. The NP stated the aspiration pneumonia could have possibly come from the resident vomiting however there would be no way of definitively knowing. She stated the facility staff would not have been able to tell the resident aspirated immediately, symptoms would have been seen later into her hospitalization. On 02/25/25 at 2:40 PM an interview was conducted with the Medical Director (MD). During the interview he stated the Nurse Practitioner was in the building at the time of the incident and assessed Resident #79. The resident had a diagnosis of dementia with episodes of confusion. She attempted to ambulate without assistance from staff and had a fall from the facility transportation bus. On 02/27/25 at 5:00 PM an interview was conducted with the Administrator. The Administrator stated that he felt it was an imperfect day. He stated he would not change anything about the day or how his staff reacted because it was an unavoidable fall. The Administrator stated the facility had no indication Resident #79 was going to unbuckle herself and attempt to ambulate off of the transportation bus. The Administrator was notified of the immediate jeopardy on 02/25/25 at 5:05 PM. The facility provided the following immediate jeopardy removal plan: 1. Address how corrective actions will be accomplished for those residents who have been affected by the deficient practice: On 06/25/24 the facility van returned to the facility following an outing with 4 residents, 3 staff and a volunteer. When the van returned to the facility, the Activities Director and volunteer exited the van to discard the waste. The Van Driver who is the only one trained to operate the lift exited the van to begin the unloading process in the lift area. The Activities Assistant remained in the van and instructed residents to remain seated and they would be unloaded starting at the back. The Activities Assistant then exited the van to assist the Van Driver who had opened the door. No staff were in the van, but the Van Driver and Activities Assistant were at the lift and within 60 inches of the resident. Resident #79 was seated closest to the staff, unbuckled herself, ambulated to the steps of the van and fell to the asphalt after being reminded by staff to stay seated. There were no staff members in the van at the time of the event, but staff were in speaking distance at the rear of the van. After being assessed, one of the resident's slippers were noted on the top step and the other was lower on the steps indicating she stepped on the back of her slipper which caused the fall. On 6/25/24, the affected resident, Resident # 79, was immediately assessed by the onsite nurse practitioner prior to her being moved. Upon the initial assessment, it was deemed the resident was safe to be transported into the facility where she was placed in bed and continued to be assessed. Emergency Medical Services (EMS) was notified to transport the resident to the hospital for additional tests and exams. On 7-5-2024, Resident #79 was readmitted to the facility. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice: On 06/25/24 during her initial interview with the Van Driver, the Director of Nursing inquired if any other resident had fallen or had any other near miss on the van. No other residents were identified. On 6/26/24 the Interdisciplinary Team consisting of all department managers, Administrator and Director of Nursing met to review residents with outside appointments. They met to identify residents scheduled for transport through 7/6/24 using the medical record to identify residents that were unable to make their needs known, appropriately respond to direction, had a BIMS score less than 10, and those unable to comply with standard safety precautions. Identified residents will have increased supervision on their transport to and from the facility as well as proper footwear. Moving forward, the facility will conduct weekly reviews of all residents scheduled for transportation to ensure ongoing compliance with this protocol. In addition, residents must have safe and appropriate footwear on at the time of the transfer. On 7/3/24 the Administrator, Director of Nursing, Social Services Director and Activities Director, inspected 100% of the residents to ensure all residents had appropriate footwear for any potential transport, whether scheduled or not. Only one resident did not have appropriate shoes for their given shoe size. The Director of Nursing purchased him a pair of lace up shoes for outings and medical appointments. Given there was only one resident, transportation was notified by the Director of Nursing not to transport him until the new shoes arrived. They were ordered once edema was resolved and the facility could find size 20 shoes to accommodate his physical structure. No transports for this resident were impacted. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur: On 6/25/2024, the Director of Nursing will ensure adequate supervision is provided by determining the need of each resident being transported. This will be conveyed to the Van Driver to ensure compliance with the level of supervision required. This measure was initiated on 6/25/24. All residents will be required to have appropriate footwear which, at the minimum, must have closed toes, a closed heel and non-skid soles. Slippers and other slide on footwear will be strictly prohibited in order to be transported by the facility van or approved vendor. Residents with confusion and poor safety awareness will require a staff person or trained volunteer to increase basic supervision during transport. Beginning on 6/26/24, the weekly transportation schedule will be reviewed in morning meeting prior to any transport and if a resident needs increased supervision, the Director of Nursing will ensure it is available at the time. Increased supervision will be assigned by the Transportation Coordinator after notification by the Director of Nursing on 7/1/2024. Those individuals assigned for increase supervision , will be trained verbally by the Administrator or Director of Nursing prior to service and will include how to encourage the resident to remain seated and fastened until the van driver can safely help them off the transport vehicle. Those selected will have proper training on keeping residents safe. If utilizing a trained volunteer, the training will include how to encourage the resident to remain seated and fastened until facility staff can assist them off the transport. This training will be provided by the Administrator during volunteer orientation before their service begins. Volunteers will be instructed on identifying unsafe situations-such as when a resident might unbuckle a seatbelt while the van is in motion, or when a resident is at risk of f[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and family, resident, physician, physical therapist, and staff interviews, the facility failed to ensure a safe transfer for 1 of 3 residents reviewed for accidents (Resident #8). An agency nurse aide (NA #1) transferred Resident #8 without the use of a mechanical lift from the bed to the wheelchair. NA #1 lifted Resident #8 under his arms and the Resident's left lower leg made contact with the side rail during the transfer. Resident #8 reported pain which worsened as a 10 centimeter (cm) by 6 cm hematoma (a collection of blood under the surface of the skin) developed rapidly on his left lower leg between the knee and the ankle. He was prescribed two medications that can cause bleeding prior to the incident. Resident #8 was transferred to the hospital for evaluation and was diagnosed with blood loss anemia. The findings included: Resident #8 was admitted to the facility 2/10/2023. Diagnoses for Resident #8 included peripheral vascular disease, right above the knee amputation, contracture of left leg, history of strokes, anemia, and muscle wasting. The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #8 to be moderately cognitively impaired (a score of 9 out of 15 on the Brief Interview for Mental Status). The MDS documented Resident #8 required the extensive assistance of 2 people to transfer and he was not stable to perform surface to surface transfers without assistance. The MDS documented limited range of motion of one lower extremity. Resident #8's weight on admission was 127 pounds and he was 61 inches tall (5 feet 1 inch). Physician orders for Resident #8 were reviewed. Resident #8 was prescribed Clopidogrel (an antiplatelet medication that acts as a blood thinner) 75 milligrams (mg) daily on 2/11/2023 and aspirin 81 mg daily on 2/11/2023. A baseline physical therapy assessment performed by PT #2 dated 2/27/2023 assessed Resident #8's ability to transfer from bed to wheelchair with the use of a slide board and one person assistance and Resident #8 required maximum assistance to use the slide board. This intervention was discontinued on 3/25/2023 due to the risk of skin shearing and breakdown. A mechanical lift for transfers was recommended by physical therapy. Additionally, the baseline physical therapy assessment assessed Resident #8's ability to stand and pivot to transfer and at baseline on 2/27/2023 Resident #8 was unable to perform due to weakness and muscle tightness. This intervention was discontinued on 3/10/2023. The [NAME] (information about the care needs of a resident, used by NAs to provide resident specific care) dated 3/21/2023 was reviewed and an intervention addressed transfer needs for Resident #8, which included the use of the mechanical lift for transfers. The physical therapy discharge recommendations dated 3/25/2023 and written by PT #1 included total dependence for transfers. Physical Therapist (PT) #1 was interviewed on 5/10/2023 at 2:36 PM. PT #1 reported she provided therapy services to Resident #8 and after working with him and the slide board, he told her that the slide board was hurting him, and it was difficult for him to use. PT #1 explained on 3/22/2023 Resident #8 was reevaluated for transfers and he expressed he was most comfortable with a mechanical lift. PT #1 informed the nursing staff to initiate mechanical lift with the understanding the nursing staff would change the intervention on the [NAME]. PT #1 concluded by reporting that Resident #8 was dead weight and could not help with a transfer by bearing weight on his left leg. A nursing note written by Nurse #1 dated 3/26/2023 at 6:25 PM documented that at 3:00 PM Nurse #1 arrived at the facility to begin her shift and was getting shift change report when Resident #8's family member approached her and reported Resident #8 hit his left leg during a transfer. The note documented Resident #8 was out on the smoking patio and the family member wanted Nurse #1 to come and assess his left lower leg. Nurse #1 documented that she went to the smoking patio and assessed Resident #8's left lower leg and did not see any swelling. The note documented the family member brought Resident #8 back to his room and stated she was going to call an ambulance to transfer Resident #8 to the hospital for evaluation. Nurse #1 reassessed Resident #8's left lower leg and noted there was some swelling. Nurse #1 documented that Resident #8 reported he had pain in his left lower leg that increased by the time medics arrived to transport Resident #8 to the hospital. Nurse #1 documented Resident #8 left the facility at 3:45 PM. An interview was conducted by phone with Nurse #1 on 5/11/2023 at 10:04 AM. Nurse #1 reported she was receiving change of shift report on 3/26/2023 when Resident #8's family member came to her and asked her to look at Resident #8's leg. Nurse #1 reported she went out to the smoking patio and assessed Resident #8's leg but didn't see anything wrong with it. Nurse #1 explained she told Resident #8 and the family member she would get him some pain medication if his leg was hurting. This was the first time Nurse #1 had met Resident #8, and Nurse #1 explained she did not know his baseline (normal state). The family member brought in Resident #8 from smoking and said she was going to call EMS to take him to the hospital because of his leg. Nurse #1 reported she looked at his left leg again and she was able to see an area that was bruised and appeared swollen. Nurse #1 explained that when she looked at Resident #8's leg outside on the smoking patio, there was no area of bruising or swelling and she offered to get him pain medication. When she looked at the leg in his room, Nurse #1 said that the area on the leg appeared to be swelling up as they were watching and EMS was on their way, so there was nothing else for her to do for Resident #8. Nurse #1 said that by the time EMS arrived, Resident #8 was yelling in pain from his left leg. NA #1 was interviewed by phone on 5/10/2023 at 5:39 PM. NA #1 reported that she was assigned to Resident #8 on 3/26/2023. NA #1 explained that Resident #8 wanted to go outside to smoke, and his family was there to take him outside. NA #1 said that she transferred Resident #8 to the wheelchair by lifting him under his arms. NA #1 reported she had not used the mechanical lift because she had observed another NA transfer Resident #8 the day before by lifting him under his arms. NA #1 reported she lifted Resident #8 to the wheelchair, and he never mentioned he had hit his leg. NA #1 reported she thought everything was fine. Resident #8 was interviewed by phone on 5/11/2023 at 4:39 PM. Resident #8 reported that his family member had arrived to visit and was going to take him outside to smoke. Resident #8 said that NA #1 lifted him under his arms to transfer to the wheelchair, and when she moved him off the bed, his left lower leg hit the top side rail. Resident #8 explained that the side rail was in the lowered position so that the NA could get the wheelchair closer to the bed. Resident #8 said he had told NA #1 my leg hit the side rail and she had replied Ok, but nothing more was said about it. Resident #8 reported when his leg was hit, it was tender, but it wasn't a sharp pain. He then explained that after he went outside to smoke, his leg started to get very painful, and he could feel it swelling. Resident #8 said by the time he finished his cigarette, his leg was getting very swollen and very painful, and his family member said she would call EMS to take him to the hospital. Resident #8 reported he was unable to remember exactly when Nurse #1 looked at his leg, but he knew she looked at it when he was smoking and then later when he returned to his room. The family member for Resident #8 was interviewed by phone on 5/10/2023 at 9:33 AM. The family member reported she had arrived on 3/26/2023 to visit Resident #8 and was in the room when he was transferred to the wheelchair from the bed by NA #1. The family member reported NA #1 did not use a mechanical lift, but instead lifted Resident #8 under his arms from the bed to his wheelchair. The family member explained that during the transfer, she had observed Resident #8's left lower leg hit the side rail of the bed. The family member reported that Resident #8 had not cried out when his leg hit the side rail, and NA #1 did not seem to be aware that his leg hit the side rail. When she took Resident #8 outside to smoke, he told her that his left leg was hurting, and the family member went inside the facility to get Nurse #1 to assess the leg. The family member said that the nurse came out to the smoking patio and said that she did not see anything wrong with the left lower leg, but the family member could see an area that was swelling and appeared bruised. Resident #8 continued to report lower leg pain. The family member reported Resident #10 was outside smoking at the same time and observed Resident #8's leg and the interaction with Nurse #1. When Resident #8 finished smoking, he said the left lower leg was very painful and the family member decided to call for an ambulance to transfer him to the hospital for evaluation. An Emergency Department evaluation dated 3/26/2023 at 4:19 PM was reviewed. The note documented that Resident #8 was transferred from the facility for a rapidly expanding hematoma after hitting his leg during a transfer from the bed to the wheelchair and hit his leg on a metal object during the transfer. The note documented that the hematoma spontaneously ruptured and started leaking blood upon arrival to the emergency room and the resident reported relief from pain. The hematoma measured 10 cm by 6 cm and was located on his left lateral (outer) lower leg between the knee and the ankle. A non-adherent absorbent dressing was applied over the hematoma and the lower left leg was wrapped with an elastic bandage. The hospital history and physical examination noted Resident #8 had a contracture (a condition that causes hardening of muscle, tendon, and other tissue leading to deformity and rigidity of a joint) of the left leg. Emergency Department labs drawn on 3/26/2023 at 4:31 PM revealed Resident #8's hemoglobin (red blood cells in the blood that carry oxygen to organs) was 9.9 (normal 12.1 to 17.4) and hematocrit (the percentage of volume of red blood cells in the blood) measured 31% (normal 36-52%) which was at baseline for resident. According to the emergency department note, the plan was to repeat hemoglobin and hematocrit to evaluate if there was a significant drop. Resident #8's repeat hemoglobin and hematocrit drawn on 3/26/2023 at 8:39 PM showed significant drop from 9.9 to 8 and 31% to 25%. The labs were ordered to be obtained every 4 hours for 8 hours to monitor the hemoglobin and hematocrit, and the next lab results on 3/28/2023 at 1:25 AM resulted in a hemoglobin of 7.2 and hematocrit of 22%. Resident #8 was admitted to the hospital for hematoma to left lower extremity and a diagnosis of blood loss anemia. The facility physician (MD) was interviewed on 5/11/2023 at 10:24 AM. The MD reported he had provided care to Resident #8 since his admission and Resident #8 had a low pain tolerance due to his medical conditions. The MD explained that he was not certain what happened to the left leg of Resident #8 because if he had hit it on the bed, Resident #8 would have let the staff know by calling out in pain, or telling someone he was hurt. The MD concluded by explaining that he was unable to determine if the injury was a traumatic injury or if the hematoma had spontaneously occurred. An interview was conducted with the Administrator, the Chief Nursing Officer, and the Director of Nursing (DON) on 5/11/2023 at 9:15 AM. The Administrator reported she began her position on 4/11/2023 and this incident occurred prior to her arrival at the facility. The Administrator reported that upon her arrival, the plan of correction was in place and the staff were monitoring and performing audits as the plan of correction directed. The Chief Nursing Officer reported that she was contacted on 3/26/2023 by the DON after the incident with Resident #8 and she arrived at the facility to initiate an investigation. During the investigation, the Chief Nursing Officer reported she was able to determine the root cause of the incident had to do with NA #1 not following the activity orders on the [NAME]. The Chief Nursing Officer reported the DON obtained statements from all the involved staff members, interviewed the residents who observed Resident #8 after the incident and started working on the plan of correction. The DON reported she was called on 3/26/2023 after the incident and she called the Chief Nursing Officer to notify her of the incident. The DON reported she talked to staff and residents to determine a timeline and get statements from the staff and residents. The DON reported that once that investigation was completed, they determined that the incident did not need to be reported, nor an incident reported needed to be completed, however, there were gaps in training, and they needed to monitor to prevent further incidents of transferring a resident incorrectly. The Administrator was notified of Immediate Jeopardy on 5/12/2023 at 1:25 PM. The facility provided the following corrective action plan with a compliance date of 4/3/2023: How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 3/26/2023, the (family member) of resident #8 who had a history of Peripheral Vascular disease, right above the knee amputation, aneurysm of the iliac artery, and moderate impaired cognition reported to Nurse #2 that Resident #8's left leg had been hit during transfer and wanted someone to come look at it while they were out at the smoking area. Nurse #1 evaluation documented no swelling was present. After returning from the smoking area, the family member stated she was calling Emergency Medical Services (EMS). Nurse #1 re-examined the leg at this time and noted some swelling but did not document any discoloration. Resident #8 was sent to the hospital at that time related to pain and swelling in the left lower extremity. According to hospital records, Resident#8 was evaluated at the hospital on 3/26/2023 and found to have a 10 centimeter (cm) by 6 cm hematoma of the left lateral aspect of the left lower leg distal to the knee. Resident #8 had complaints of severe pain until the hematoma spontaneously ruptured when he arrived in the emergency department. The resident did not return to the facility. Nursing Assistant (NA) #1 who had transferred Resident#8 on 3/26/2023, denied hitting Resident #8's leg during any transfers. NA #1 transferred him twice, from the wheelchair to the bed and then from the bed to the wheelchair. NA #1 was interviewed on 3/27/2023 and was asked if the resident ever complained of pain during the transfers, she stated no. NA #1 confirmed she did not utilize the [NAME] prior to transferring the resident using a stand pivot technique. She stated she was aware that the resident was a mechanical lift transfer but did not use it because she had asked the resident prior to each transfer how he wanted to be transferred and he expressed that he was ok with the stand pivot method. NA #1 did re-enact how she transferred the resident stating that she put his arms around her neck and placed her arms under his arms and locked her hands around his back. She demonstrated moving the resident as he pivoted on his left leg from the bed to the wheelchair. NA #1 was asked if she had been educated on how to care for residents utilizing the [NAME] prior to providing care, she replied yes. After a thorough review it was found that NA #1 did not review the [NAME] prior to caring for Resident#8 but knew that the resident was transferred via a mechanical lift. Immediately following, a [NAME] training and monitoring tool was put in place to assure all nursing assistant staff were aware of the importance of reviewing the [NAME] prior to caring for residents. After interviewing NA #1 on 3/27/2023, the decision was made at that time to no longer have her work at Five Oaks due to her deliberate disregard of reviewing and implementing care according to Resident#8's [NAME] as it relates to his/her transfers. Based on record review, interviews, and re-enactment, we were unable to establish a point of contact during transfer and therefore were unable to confirm that the resident hit his leg during transfer as alleged by the family member. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All resident Activities of Daily Living (ADL) care are guided by the [NAME] and therefore all residents are at risk for the deficient practice. The [NAME] competency tools would be reviewed by the DON and or Unit Coordinators prior to the morning meeting with any identified [NAME] education discussed at the meeting Monday through Friday to include weekends. There were no identified competency issues regarding the [NAME] reported. NA#1 received [NAME] education 2/24/2023, and the competency tool was completed 3/5/2023. 3/30/2023 Education to the nursing assistants for the [NAME] was verbally reviewed and verified by the DON, Unit Coordinators, and other nursing designee using the same education provided on 2/24/2023: o rounding with off-going nursing assistants o review of the [NAME] o report from shift nurse o reporting to shift nurse if resident refuses care as indicated on the [NAME] Nursing assistants who were not educated by 3/30/2023 were not allowed to care for residents until the education had been received. This included newly hired nursing assistants and agency nursing assistants. The unit nurse coordinator that does staffing is responsible for tracking new staff and agency staff. New staff or agency staff that work Monday through Friday are educated by the Unit Coordinators and the new or agency staff that work weekends are educated by the weekend RN Supervisor. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not occur. An ADHOC Quality Assurance Process Improvement (QAPI) meeting was held on 3/30/2023 by the Medical Director, the DON, the unit coordinators, the social worker, maintenance director, housekeeping, medical records (CNA) and administrator to review the plan of correction for Resident #8 discharged 3.26.2023. Results of The Safety: Room Round Observation Tools and [NAME] competency tools completed prior to this date were discussed. There were no findings related to unsafe issues involving transfers and no findings indicating that the nursing assistants did not know that the [NAME] is used to care for the resident. The new [NAME] education monitoring tool developed by the Director of Nursing, Chief Nursing officer and Unit Coordinators and was introduced and explained to the QAPI committee at that time. The new [NAME] observation tool requires unit coordinators and RN weekend supervisor and other nursing staff (Nurse Consultant, RN Staff) as designated by the DON to select a minimum of three residents' [NAME] weekly to review and then observe the assigned nursing assistant providing care. Increased observations would be based on finding and or at the request of the QAPI committee. The unannounced observations are for the designated staff to validate that nursing assistants are providing care according to the resident's [NAME]. Observations include transfers, bathing, repositioning, ambulating, eating, etc. all care reflected on a resident's [NAME]. The new [NAME] education monitoring tool results will be reviewed daily in the morning meeting Monday through Friday. This tool is ongoing. Incident logs are reviewed daily Monday through Friday in morning meetings by the unit coordinators and or the DON. The information from the incident logs are tracked and trended and presented by the Director of Nursing in the monthly QAPI meetings and at times (if needed) in ADHOC QAPI meetings. There have not been any findings related to unsafe issues involving transfers or issues indicating [NAME]'s were not being reviewed prior to care or issues or that indicated nursing assistants did not know where or how to get report on their assigned residents. This process is ongoing. The [NAME] observation tool began 4/3/2023 and will remain in place. The audits were reviewed in the morning meeting by the unit coordinators and or the Director of Nursing. The results of the tool as of 4/20/2023 revealed no findings indicating [NAME]'s were not being reviewed prior to care or issues that indicated nursing assistants did not know where or how to get report on their assigned resident in morning meeting daily. A QAPI meeting was held on 4/20/2023 and a summary of 15 nursing assistants who were observed using the new [NAME] education observation tool revealed there were no findings indicating [NAME]'s were not being reviewed prior to care or any issues with transfers. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The Safety Room Round observation tool information is tracked and trended monthly by the administrator and or the Director of Nursing and monitored in the QAPI committee ongoingly as determined by the QAPI Committee. Incident log information will continue to be tracked and trended monthly and reported by the Director of Nursing ongoingly in QAPI unless determined otherwise by the QAPI Committee. The [NAME] education has been added to the new hire orientation. The [NAME] competency tool remains ongoing for newly hired, prn and agency nursing assistant staff. The information is tracked and trended by the Director of Nursing and or Nurse designee in her absence and monitored monthly and ongoingly as determined by the QAPI Committee. Information from the new [NAME] education and monitoring tool will be tracked and trended by the Director of nursing for 3 months and presented ongoingly as determined by the QAPI committee. The date of compliance is 4/3/2023. The corrective action plan was reviewed on-site and validated on 5/11/2023: interviewing nursing staff, NAs and confirming they had monitoring of provision of care to residents. Education for the nursing staff and NA staff was reviewed. The audits of the incident reports and [NAME] reviews were reviewed, and they were completed three times per week. The Administrator reported there was no end date planned for this intervention and it would continue indefinitely. The ad-hoc QAPI meeting minutes were reviewed and the incident with Resident #8 was discussed, the plan for corrective action was discussed and ongoing audits were being conducted. A transfer of a resident was observed, and no issues were identified. NA staff were able to identify the transfer needs of residents in the [NAME] and perform the correct resident transfer. The compliance date of 4/3/2023 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A review of the Invacare User Manual for CS7 Series Beds revealed bed controls (pendant) were only to be placed in three ways: 1. on the pendant holster that is positioned between the top side rail bars 2. attached to the back of either side of the head end 3. attached to the bed linen via a pendant clip. The User Manual further revealed improper installation and improper use of the bed control could cause harm. Extra cable should be routed and secured to the bed to prevent tripping hazards. Otherwise, injury may occur. 2 a. Resident #5 was admitted to the facility on [DATE] with diagnoses that included dementia. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #5 with severe cognitive impairment. She required extensive assistance with bed mobility, and total dependence with transfers and toileting. Resident #5 was a fall risk, non-ambulatory and required a wheelchair for mobility. Resident #5's care plan dated 1/17/23 indicated she was a fall risk due to use of prescribed psychotropic medication and required fall precautions with interventions that included assistance with transfers, wheelchair cushion, concave mattress, keep call bell within reach, monitor for side effects to medication and notify the physician as needed. Resident #5 had an Activities of Daily Care (ADL) deficit related to decreased mobility and difficulty processing needs. Interventions included use of bilateral side rails to aid in turning and positioning. An observation on 1/27/23 at 4:48 PM revealed Resident #5 lying in bed. The bed control cord was wrapped around the side rail with the pendant dangling over the side rail. The pendant was not attached to the Velcro located on the side of the bed frame, or the pendant holder or head end. 2 b. Resident #6 was admitted on [DATE] with diagnoses that included receptive expressive language disorder, gout, and acid reflux. The quarterly MDS dated [DATE] indicated Resident #6 had moderate cognitive impairment, required extensive assistance with bed mobility, transfers, and required total assistance with toileting. A care plan dated 9/8/22 revealed Resident #6 was a fall risk due to weakness and need for assist with transfers for safety. Psychotropics and pain management had the potential for side effects that included the potential for a fall. The goal to minimize a fall risk through interventions that included anticipate and meet needs, two-person assist with transfers, be sure call light was within reach and call bell use was encouraged for assistance as needed. Resident #6 needed prompt response to all requests for assistance. An observation on 1/27/23 at 4:50 PM of Resident #6's bed control pendant which was attached to it cord revealed the bed control cord was wrapped around side rail several times, then tucked between the mattress and side rail, which allowed the bed control pendant to hang over the side rail. An interview with the Maintenance Director on 1/27/23 at 4:50 PM indicated Resident #6's bed control cord was tucked under her mattress and looped through the bed rail. He further indicated bed control cords were not to be wrapped around side rails according to the manufacturer's user manual because it was a hazard. An interview with the Administrator on 1/27/23 at 5:20 PM indicated he was unaware bed control cords were being wrapped around side rails. He educated staff on how to position the bed controls and how to remind residents that bed control cords could not be wrapped around side rails, according to the user manual. He further indicated he instructed staff to perform additional observations of resident rooms to assure bed control pendants were not wrapped around the side rails. Based on interviews with staff, Medical Director, Mental Health Nurse Practitioner (NP) and record review, the facility failed to provide close supervision of Resident #1 who was assessed as confused, impulsive, unsafe, with a history of falls and at risk for further falls. The facility failed to observe the condition of Resident #1 after an unwitnessed fall, report the observation to a nurse with any urgency, provide continuous monitoring after Resident #1 was found with his neck entrapped by a bed control cord and observed that his face was blue. Resident #1 was found on 1/13/23 after 7:00 PM by Nurse Aide (NA) #3 prone with his feet on the floor, but she did not enter the room to see his condition. Nurse #1 entered the room and found Resident #1 with his right side against his bed. His neck was entrapped by the bed control cord that was attached to the bed and the siderail. Resident #1 was left in this condition when Nurse #1 left the room to get help. Emergency Medical Services (EMS) was called on 1/13/23 and pronounced his death in the facility at 7:39 PM. This failure occurred for 1 of 8 sampled residents reviewed for supervision to prevent accidents (Resident #1). Additionally, the facility failed to store bed control cords per manufacturer recommendations for the prevention of tripping hazards for 2 of 8 sampled residents reviewed for supervision to prevent accidents (Residents #5 and #6). Residents #5 and #6 are cited at scope and severity level of D (no actual harm with the potential for minimum harm that is not immediate jeopardy). Immediate jeopardy began on 1/13/23 when NA #3 failed to observe the condition of Resident #1 when she saw his feet on the floor in a prone position after an unwitnessed fall. Immediate jeopardy was removed on 1/26/23 when the facility provided an acceptable credible allegation of an immediate jeopardy removal plan. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with the potential for minimum harm that is not immediate jeopardy) to ensure the monitoring of systems put in place and to complete facility employee and agency staff in-services, orientation, and training. Findings included: A phone interview with the Mental Health NP on 1/26/23 at 2:29 PM revealed he provided mental health services once to Resident #1 on 12/15/22 due to a referral from the Medical Director for impulsivity and medication management while Resident #1 lived at an assisted living facility (ALF). He planned to see Resident #1 again on 1/16/23 but Resident #1 was discharged from the ALF at the time of this scheduled appointment. The NP stated that Resident #1 previously lived with family, then was admitted to the hospital and then to an ALF where he had been for about 1 week before the NP assessed him on 12/15/22. The NP stated Resident #1 had a sitter because of impulsivity, agitation and a history of frequent falls associated with his diagnoses of Parkinson's disease and dementia with Lewy Bodies characteristics. The NP stated that based on his assessment, he increased the dosage of Citalopram (antidepressant) from 20 mg daily to 30 mg daily for increased anxiety/impulsivity and auditory/visual hallucinations noted at the time of the assessment. The NP further stated that his hallucinations had the potential to increase his agitation due to fluctuations in his cognitive status. The NP stated that due to the Parkinson's disease and dementia, his response to medication was not predictable, unlike other psychiatric conditions. The NP stated that medication adjustments were made to help reduce the hallucinations, but often a side effect of this disease process is the inability to move, or freeze and the meds will only manage these symptoms, not treat the disease. He stated the response to medication was person specific, very unpredictable, and difficult to manage. A 12/31/22 hospital Health & Physical recorded that Resident #1 did not walk, was wheelchair bound and had a history of falls. A 1/12/23 hospital discharge summary recorded Resident #1 presented to the Emergency Department with altered mental status, and a reported syncope (unconscious) episode. He was diagnosed with aspiration pneumonia, and acute toxic/metabolic encephalopathy with a component of delirium (delirium and acute confusion). Resident #1 was admitted to the facility on [DATE] from the hospital. Diagnoses included Parkinson's disease, advanced dementia, psychotic disturbance, mood disturbance, anxiety disorder, metabolic encephalopathy, paroxysmal atrial fibrillation, and syncope with collapse (unconscious), among others. A 1/12/23 Fall Risk Evaluation, assessed Resident #1 at risk for falls due to intermittent confusion, history of falls, and balance problems while standing. The evaluation suggested fall risk interventions to include rubber soled shoes or non-skid slippers for ambulation. A phone interview with Nurse #3 occurred on 1/31/23 at 1:17 PM. Nurse #3 stated she worked on 1/12/23 on the 7:00 AM to 7:00 PM shift when Resident #1 admitted from the hospital to the facility sometime before 6:00 PM. Nurse #3 stated on admission, Resident #1 was weak, alert with confusion and that she was told by the hospital that he had a history of falls, atrial fibrillation, and Parkinson's disease. Nurse #3 stated on admission, Resident #1 tried to call his son by using the bed control remote because he thought it was a phone. Nurse #3 stated his family arrived and fed him his dinner meal and assisted him to use the urinal due to weakness, and he made several attempts to get up from his wheelchair unassisted. A 1/13/23 5-Day MDS assessed Resident #1 with adequate hearing, adequate vision, usually understood by others, usually understands other, clear speech, no corrective lenses or hearing aids, and moderately impaired cognition. His mood was assessed as feeling down, depressed, hopeless, fidgety, restless, and moving around a lot more than usual. He required the physical assistance of 1 staff person for bed mobility and transfers, he did not walk, his balance during transitions was not steady but he was able to stabilize without staff assistance. It also recorded a fall in the last month prior to entry to the facility. On 1/26/23 at 1:14 PM, Nurse Aide (NA) #1 stated in interview that she met Resident #1 on Friday 1/13/23 for the first time when she came to work at 6:45 AM. NA #1 stated that when she received a shift report all she was told was that Resident #1 was a new admission, he was at risk for falls and that he kept taking his clothes off. NA #1 stated she went to his room to meet him; he was in bed with his night gown and bed cover on the floor. NA #1 asked Resident #1 if she could get him dressed, he said yes and so she assisted him. NA #1 said when she came back to check on him before breakfast, he had taken his clothes off again, so she dressed him again. NA #1 stated she brought him a breakfast tray, assisted him with his breakfast meal and placed him in his wheelchair. NA #1 stated throughout the morning Resident #1 made several attempts to get out of his wheelchair unassisted. NA #1 said Resident #1 received occupational therapy (OT) and physical therapy (PT) that morning and she asked the PT if he was safe to walk. NA #1 said the PT told her that Resident #1 was not safe to walk by himself because he was unsteady on his feet and at risk for falling. NA #1 said she observed Resident #1 in his wheelchair at the nurse's station before lunch, fed him lunch in the dining room, assisted him with toileting in his room, placed him back in his wheelchair and returned him to the nurse's station around 2:20 PM. NA #1 stated she passed him several times while he was seated at the nurse's station until she left her shift at 3:00 PM. NA #1 stated she left Resident #1 at the nurse's station at 3:00 PM with Nurse #2 because NA #3 (3:00 PM - 11:00 PM NA) had not yet arrived. A 1/13/23 NP progress note documented Resident #1 was hospitalized for altered mental status on 12/31/22 and discharged to the facility on 1/12/23 for rehabilitation and chronic disease management. Resident #1 was assessed as forgetful, confused, oriented to person only, with decreased mobility, and poor strength. A 1/13/23 OT evaluation assessed Resident #1 with fall risk precautions related to combativeness, agitation, confusion, and reduced cognition. A 1/13/23 PT evaluation assessed Resident #1 with fall risk precautions related to decreased balance, impulsiveness, and Parkinson's disease. During an interview with PT #1 and OT #1 on 1/27/23 at 1:30 PM, both staff stated that they worked together with Resident #1 on 1/13/23 to evaluate and treat him sometime after 10:00 AM until about 11:30 AM. They described him as confused, able to state basic needs, like I have to go to the bathroom, I want to get into my wheelchair, I want to get dressed, and I can do it by myself. He was described with unsteady balance and gait and had difficulty staying upright. They said when he toileted he leaned while he faced the toilet, and had to be held upright, as he did not realize he was unsafe. They described his movements as frozen, fidgety and that he had trouble with reciprocal movement, retropulsion (a tendency to walk backwards) and balance because of Parkinson's disease. They stated he could not perform functional cycling because his feet acted more like brakes, and he could not make them work. During the interview, they said he had problems with motor planning, he could understand what was said to him, but that he had difficulty performing tasks. They described him as unable to get out of bed independently, he used the side rail to pull himself up, but because he leaned, he could not independently perform the task of getting himself out of bed. PT #1 and OT #1 both said they told the Unit Coordinator, Nurse #2, and NA #1 on 1/13/23 that he needed assistance out of bed and assistance to walk, but that he was still being assessed for other needs. They stated after PT/OT treatment on 1/13/23 he was left at the nurse's station with Nurse #2. On 1/27/23 at 8:30 AM NA #3 was interviewed by phone. NA #3 stated she was assigned to care for Resident #1 on 1/13/23 from 3:00 PM to 7:00 PM. NA #3 stated when she came on shift, Resident #1 was seated at the nurse's station in his wheelchair. NA #3 said she did not receive shift report from NA #1 because she got to her assignment after NA #1 had already left. NA #3 said the only thing Nurse #2 told her was that Resident #1 was a new admission and at risk for falls. NA #3 said Resident #1 kept trying to get up from his wheelchair at the nurse's station, but each time she asked him to sit back down he complied. NA #3 said she started her rounds and at about 4:30 PM she saw Resident #1 in bed in his room dressed and wearing non-slip socks. Then between 5:15 PM and 5:30 PM, NA #3 said she took him a dinner tray and fed him dinner in bed. NA #3 said after she fed him dinner, she left him in bed, bilateral helper side rails in the up position, and his call light and bed control cords lying across his stomach. NA #3 stated on her last round, at about 6:30 PM, she walked past his room and saw he was in bed with his upper body positioned to the left of the bed and his lower body was positioned to the right. NA #3 said she repositioned him straight in bed, left his bed at regular height and placed his call light and bed control cords across his stomach. NA #3 then said sometime between 7:00 PM and 7:30 PM, she was walking towards the nurse's station, passed his room and she did not see him in bed. She said she peeked in his room and saw his feet were on the floor, with his feet facing down and his toes were touching the floor. NA #3 said she did not look to see where his upper body was, but rather went to the nurse's station and told Nurse #1 and NA #2 that Resident #1 was on the floor, then she left to go to another unit in the facility to finish her shift. NA #3 said she was suspended because she did not go into the room when she saw Resident #1 on the floor and that she did not stay to help Nurse #1 get Resident #1 off the floor. A 1/14/23, late entry progress note, completed by Nurse #1 (7:00 PM - 7:00 AM Nurse) recorded that NA #3 notified Nurse #1 around 7:15 PM on 1/13/23 that Resident #1 was on the floor. The progress note recorded that Nurse #1 grabbed a neuro-assessment sheet and the vital sign (VS) machine to go assess Resident #1. Nurse #1 observed Resident #1 on the floor in a prone (faced down) position with his head and upper trunk raised up, appearing as if he was propped up on his right arm against the bed. Upon further inspection, Nurse #1 noted Resident #1's head was caught in the cord of the bed remote control, and the left side of his face was blue. Nurse #1 attempted to sit Resident #1 up to pull his head out of the cord with no success. Nurse #1 then ran to nurse's station to ask for help, get a stethoscope, and Resident #1's code status. Nurse #2 (7:00 AM -7:00 PM Nurse) said Resident #1's code status was full code. Nurse #1 told Nurse #2 to call 911 and Nurse #1 ran back to Resident #1's room with NA #2 (7:00 PM - 7:00 AM NA) following to assist. After placing Resident #1 on his back, no pulse was palpable, and Nurse #2 came into the room and said Resident #1's code status was DNR. EMS arrived and was able to find a pulse, but CPR (cardiopulmonary resuscitation) was not started due to DNR code status. Time of death was called by EMS at 7:39 PM. A phone interview with Nurse #1 occurred on 1/26/23 at 4:49 PM and a follow-up interview on 1/31/23 at 10:20 AM. Nurse #1 stated she came to work on 1/13/23 before 7:00 PM and all she was told when she received shift report from Nurse #2 was that Resident #1 was a new admission and at risk for falls. Nurse #1 stated that NA #3 came to the nurse's station after 7:00 PM, while she was counting narcotics with Nurse #2 and said Resident #1 was on the floor. NA #3 then said, it was after 7:00 PM and she had to go to another unit to finish her shift and then she left the unit. Nurse #1 said the fall was not communicated to her with any sense of urgency, and when she was told by Nurse #2 that he was at risk for falls, Nurse #1 said she did not know if falling was routine for him and since she was about midway through the narcotic count with Nurse #2, she completed the count, obtained a neuro-assessment sheet, the VS machine and then went to Resident #1's room. Nurse #1 said this took about 2 - 3 minutes. Nurse #1 said as soon as she approached the room, she could see from the doorway that his legs and feet were on the floor in a prone position. Nurse #1 said she entered the room and saw Resident #1 on the floor with the right side of his body against the bed. Nurse #1 said as she got closer, she spoke to him, but he did not respond, so she touched him and he was warm, but she could not find his pulse. Nurse #1 said as she got closer, she saw that his face was blue, and his head was held upward by the bed control cord that was wrapped several times around the left side rail which was in the up position. Nurse #1 said his body weight was on the cord that appeared to be cutting off his air supply. Nurse #1 said she tried to lift Resident #1 off the cord, but she could not lift him off the cord alone, so she stated, I gently put him back and ran to the nurse's station to get help, a stethoscope and to get his code status. Nurse #1 said she told Nurse #2 how she found Resident #1, to get his code status, call 911, asked NA #2 to come help her and then she returned to the room. Nurse #1 said she and NA #2 arrived at his room and NA #2 held Resident #1 up while Nurse #1 removed his head off the bed control cord and laid him on his back on the floor. Then Nurse #2 came to his room and said his code status was DNR. EMS arrived, found a thready pulse that faded and EMS pronounced his death at 7:39 PM. Nurse #1 said she did not use the call light in his room or bathroom to get help, but rather left his room to get help because in her experience working at the facility sometimes the response to call lights was not fast enough, as staff may be in other resident rooms helping other residents. Nurse #1 said she did not want to go to the hallway to yell out because she did not want to alert visitors of the urgency of the situation, so she made a judgement call to go get help because she did not want other residents/visitors to hear her hollering and feel unsafe about the facility. Nurse #2 stated in interview on 1/26/23 at 12:40 PM and in a follow up interview on 1/27/23 at 11:02 AM that she cared for Resident #1 on 1/13/23 from 7:00 AM - 7:00 PM. Nurse #2 stated Resident #1 was admitted to the facility on [DATE] and that during the nurse shift report all she was told was that he was at risk for falls and took his medications crushed in pudding. Nurse #2 described Resident #1 as confused, but able to follow simple commands. Nurse #2 stated Resident #1 was at the nurse's station most of the 7:00 AM - 7:00 PM shift because during the shift he required frequent verbal ques and redirection to remind him not to attempt to stand from his wheelchair unassisted and walk. Nurse #2 further stated that day (1/13/23) he was still while he was eating and that he could be easily redirected with food/drink, but when he was not eating, he was very busy reaching for, touching and pointing at things with his hands. Nurse #2 said she last saw Resident #1 between 6:00 PM and 6:30 PM when she administered his medication while he was in bed. He had completed his dinner meal which was fed to him by NA #3. Nurse #2 stated that around 7:00 PM she completed a med count with Nurse #1 and gave her the keys to the med cart. Then just after 7:00 PM, NA #3 came to the nurse's station and told Nurse #1 that Resident #1 was on the floor. NA #3 said she had to go finish her shift on another unit and then she left. Then Nurse #1 got the neuro-assessment and fall report sheets and went to the room. After a few minutes, Nurse #1 came back to the nurse's station and said she found Resident #1 face down with his neck lying on the cord and she could not find a pulse. Nurse #1 asked what his code status was, and asked NA #2 to come help her. Nurse #2 stated that Nurse #1 asked her to call 911, she gave Nurse #1 Resident #1's code status and then Nurse #1 returned to the room. Nurse #2 said she called 911, told the EMS dispatcher that Nurse #1 could not find a pulse for Resident #1 and that his code status was DNR. The EMS dispatcher asked Nurse #2 if he was still breathing, she yelled out to Nurse #1, but did not get an answer. Nurse #2 stated she then ran to Resident #1's room to find out if he was breathing. Nurse #2 stated when she got to Resident #1's room she saw him lying on his back on the floor on the right side of the bed, he was not wearing a shirt and there was a red mark on the right side of his neck from the Adam's apple to the right ear. He was not breathing, and his face was blue. Nurse #2 stated then EMS arrived, found a pulse for Resident #1, took over his care and Nurse #2 left the room. NA #2 stated in an interview on 1/26/23 at 4:16 PM that when she came to work on 1/13/23 for the 7:00 PM to 7:00 AM shift all she was told during shift report from NA #3 was that Resident #1 was a new admission and he was at risk for falls. NA #2 further stated that about 7:20 PM or 7:25 PM, NA #3 came to the nurse's station and told Nurse #1 and NA #2 that the Resident in room [ROOM NUMBER] is on the floor. NA #3 then said that it was 7:30 PM and she had to go to another unit to finish her shift. NA #2 stated Nurse #1 gathered some papers, her stethoscope and went to the room. NA #2 stated, then Nurse #1 came back to the nurse station and asked Nurse #2 to call EMS, what his code status was, and asked for some help because his neck was caught on a cord and she could not lift him off the cord, then Nurse #1 ran back to his room. NA #2 said she went to the room with Nurse #1 to help her. NA #2 said when she walked in the room, Nurse #1 was on the floor on her knees next to Resident #1 who was also on the floor with his neck caught on the call light cord. She said he was wearing clothes, yellow non-skid socks, his arms were behind him, palms facing up and he was lying directly on his face. Nurse #1 than asked NA #2 to hold him up so she could remove the cord from his neck. NA #2 said Resident #1 was lying on the floor with the cord underneath his neck, and it looked like the cord had cut off his air supply because his face was blue, and he was not talking. NA #2 said she held him up and Nurse #1 removed the cord; they laid him on his back and placed his head on a pillow. NA #2 said the call light and bed control cords were both wrapped tightly to the side rail, but that she could not recall if the side rail was raised or not. Nurse #2 then came to the room and said his code status was DNR, so Nurse #1 did not do CPR. Then EMS arrived and NA #2 said she left the room. The Unit Coordinator was interviewed on 1/26/23 at 11:37 AM and stated that she saw Resident #1 on 1/12/23 when he arrived at the facility around 5:40 PM. She stated that she did not talk to him and left her shift around 7:00 PM. The Unit Coordinator said on 1/13/23, she arrived at the facility around 12:30 PM, saw him seated in his wheelchair at the nurse's station and asked him several times to sit in his wheelchair because he kept trying to stand and walk. She described him as pleasant, verbal, easily redirected and kept saying that he needed to stand up to look right there, I want to look at the board. She said she asked PT if he was safe to walk, and she was told that he was not safe. The Unit Coordinator further stated she left shift on 1/13/23 around 7:00 PM and then received a call from the Director of Nursing (DON) after she left asking her to return to the facility because Resident #1 was found deceased when the nurse entered his room. The Unit Coordinator said when she arrived at the facility, the Administrator informed her that the police were in the room and that staff were not allowed to enter Resident #1's room. A 1/13/23 Emergency Medical Service (EMS) Patient Care Record documented that EMS responded to a 911 cardiac arrest call on 1/13/23 at 7:26 PM from the facility for Resident #1. The EMS Patient Care Record recorded that EMS arrived at the facility on 1/13/23 at 7:31 PM and found Resident #1 unresponsive, apneic (not breathing), and with a faint pulse. Staff reported to EMS that Resident #1 was found on the ground belly down with his neck held up by the coiled cord on the remote to bed control. Staff also reported to EMS that NA #3 helped scoot Resident #1 back on the bed at approximately 7:15 PM on 1/13/23. When staff returned at 7:30 PM Resident #1 was found with his neck held up by the bed control cord. Staff pulled the cord from the neck of Resident #1, laid him on the floor and called 911. When EMS personnel arrived Resident #1 had a faint carotid pulse, but was apneic (not breathing). EMS attempted to pace (controlled pulses delivered to mimic a normal heart rhythm) Resident #1, but he remained with pulseless electrical activity and apneic. Due to Resident #1's advanced directive for DNR, EMS pronounced his death at 7:39 PM. A phone interview with the Lead Paramedic on 1/28/23 at 8:45 AM, revealed she completed the EMS Patient Care Record for Resident #1. She stated EMS dispatcher received a cardiac arrest call from the facility on 1/13/23 and was advised the patient had a DNR code status which meant chest compressions could not be performed to sustain life. She stated when EMS arrived, she observed Resident #1 face up on the floor next to the bed, he had a big bruise on his neck that looked like the bed control cord which extended from his left ear lobe to the midline of his neck, but the mark was not on the right side. He had a thready pulse, so EMS put defibrillator pads on his chest to check his heart rate. His heart rate (HR) was low, he was [NAME] (slow hear rate), and he was not breathing. EMS attempted to pace him with the defibrillator pads to diffuse the HR but was unsuccessful as he was in respiratory failure with pulseless electrical activity. She stated chest compressions were not performed due to the DNR code status, so his death was pronounced by EMS at 7:39 PM. The Lead Paramedic stated she did not see the bed control cord on him because when EMS arrived, he was off the cord lying on the floor on his back. The Lead Paramedic stated EMS called the police to come and investigate, because staff said they scooted him up in bed at 7:15 PM and then about 7:26 PM or 7:27 PM staff said they found him lying on his belly on the floor on the bed control cord and called EMS due to cardiac arrest. Resident #1's death certificate recorded that Resident #1 expired on 1/13/23 at 7:39 PM after a fall from bed with his neck caught on the call light cord. His primary cause of death was arteriosclerotic cardiovascular disease due to positional asphyxiation and ligature strangulation. A 1/14/23 24-hour Initial Report signed by the Administrator recorded the reason for the report was reasonable suspicion of a crime, with serious bodily injury. The 24-hour Initial Report recorded Resident #1 was suspected to have an unwitnessed fall and loss of consciousness on 1/13/23 at approximately 7:00 PM which resulted in his death. The incident was reported to law enforcement on 1/13/23 at 7:55 PM and investigated. The facility's 5-day Investigation Report and summary of findings signed by the Administrator on 1/20/23 recorded that on 1/13/23, Resident #1 was suspected of having an unwitnessed fall and subsequent cardiac arrest resulting in his death. At approximately 7:05 PM Nurse #1 received a report from the NA #3 who had been caring for Resident #1 that he had a fall. Nurse #1 stated she grabbed the VS machine and went to the room where she observed Resident #1. She described his upper body was somewhat propped up next to the bed which was in a low position to the floor and the lower part of the body on the floor. Resident #1's head/upper body were in an upright position not touching the floor and he was laying on a cord. Nurse #1 attempted to remove Resident #1 from laying on the cord, but stated she physically was unable to do so and so she had to exit the room to get assistance. Nurse #1 returned to the room with the NA #2 and was able to remove Resident #1 from laying on the cord. EMS arrived while Resident #1 was being evaluated by Nurse #1. EMS was able to obtain a pulse for Resident #1 described as thready. During the evaluation of the event EMS determined Resident #1 was without a pulse at 7:39 PM and due to his DNR code status, EMS pronounced his death. The facility's 5-day Investigation Report and summary of findings also indicated that based on the initial reports provided to EMS by facility staff, law enforcement was contacted to assess the situation. It recorded that the investigation did not reveal criminal activity but did provide opportunity to enhance staff education on safety responding to incidents/accidents, assistive devices, admissions/UDAs (assessments), abuse and neglect, and documentation. The Assistant Director of Nursing (ADON) stated in an interview on 1/31/23 at 12:35 PM that she was in the facility on 1/13/23 getting ready to leave the facility when Nurse #1 called her and said to tell NA #3 to come back to Resident #1's room. She stated she was informed by Nurse #1 that Resident #1 had expired. The ADON stated she went to Resident #1's room and saw him on the floor on his back away from the bed with EMS in the room trying to get his pulse. The ADON said she saw a red mark on his neck from mid neck to the left side of his neck that looked to her that it came from the bed control cord. EMS said the police would have to be called for a crime scene investigation. The ADON then said she sent a text message to the DON advising her of the incident. During an interview with the DON on 1/27/23 at 11:14 AM, she stated she only saw Resident #1 once on 1/13/23 after 5:00 PM while he was in the facility and at that time he was reaching for things while seated in his wheelchair at the nurse's station. The DON stated she was notified via a text message from the ADON on 1/13/23 at 7:35 PM that Resident #1 was in cardiac arrest after a fall in the facility, EMS was in the facility and his code status was DNR. The DON stated she contacted the ADON[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interview with staff, Medical Director and the Nurse Practitioner the facility failed to increase supervision of Resident #57, knowing he had a history of removing his wanderguard (a device that triggers alarms and can lock monitored doors to prevent a resident from leaving unattended) device and failed to monitor the placement of Resident #57's wanderguard. On 3/17/22, he exited the facility without staff's knowledge and was found at the end of the parking lot near the road. Resident #57 was lying on the ground with his wheelchair behind him. He was not injured. 1 of 2 residents were reviewed for wandering behaviors (Resident #57). Immediate jeopardy began 3/17/22 when Resident #57 exited the facility unsupervised and sustained an unwitnessed fall. Immediate jeopardy was removed on 5/16/22 when the facility provided an acceptable credible allegation of Immediate Jeopardy removal plan. The facility will remain out of compliance at lower scope and security of D (no actual harm with the potential for minimum harm that is not immediate jeopardy) to ensure the monitoring of systems put in place and to complete facility employee and agency staff in-services, orientation and training. Findings included: Resident #57 was readmitted to the facility on [DATE] with diagnoses that included psychosis, insomnia, bilateral below knee amputations, fall history, depression, dementia and bipolar disorder. On 7/14/20 a care plan was initiated and last reviewed on 4/22/22 for Resident #57 revealed, in part, that Resident #57 had exit seeking behaviors and stated he was leaving to live in the community. Resident #57 had increased confusion and constantly removed his wanderguard by cutting the band with a butter knife. The goal was that Resident #57 would remain safe in the facility unless accompanied by staff or family. Interventions were to notify staff of elopement (leaving an area without permission or supervision), redirect and allow time to verbalize feelings, check wanderguard placement every shift (located on the back of his wheelchair), monitor his room for butter knives. Physician (MD) orders dated 09/27/21 included to check Resident #57's wanderguard for placement and location every shift. A progress note by the Doctor of Osteopathy (Osteopathy defined as the use of a whole person approach to help prevent illness and injury) note dated 3/4/22 included that Resident #57 was a poor historian due to cognitive and psychiatric impairment. Resident #57 had impaired insight and delusions, he was forgetful and stated I gotta get out of here. Resident #57 was independent in the wheelchair. Resident #57 was followed by mental health for poor decision making capacity and persistent delusions with suspected vascular dementia. Nursing was to continue safety measures. A Psychiatry progress note dated 3/4/22 revealed, in part, Resident #57 had major neurocognitive disorder of unknown etiology no reported disruptive behaviors or moods reported at that time. An Elopement Evaluation form dated 3/09/22 at 7:18 AM included that Resident #57 had verbally expressed the desire to go home and packed his belongings and he stayed near the exit door with his belongings. Resident #57 exhibited patterned wandering which did not affect the safety or well- being of other or to himself. Staff was educated that Resident #57 was an elopement risk, to monitor his location frequently and monitor that Resident #57 always had a personal alarm in place. This evaluation was complete by Nurse #2. On 5/10/22 at 2:35 PM a phone interview was conducted with Nurse #2. Nurse #2 explained she worked mainly weekends and she had completed the Elopement Evaluation form for Resident #57 on 3/13/22 because the electronic medical record (EMR) notified her that it was due that day. Nurse #2 revealed Resident #57 had a risk for elopement and had the risk for a few years. Resident #57 wore a wanderguard bracelet on his wrist or it was attached to his wheelchair at various times and that Resident #57 always seemed to locate his wanderguard and removed it no matter where it was located on his body or his wheelchair. Nurse #2 also revealed that Resident #57 had sometimes used a butter knife and cut the straps to get the alarm off which was the reason he was served only plastic utensils but Resident #57 still wandered into the dining room and seemed to locate a metal butter knife and cut the strap when no one was looking. Nurse #2 explained the wanderguard door alarm and personal wanderguard bracelet were checked at least once daily and recorded in the EMR. Nurse #2 explained that the nurse staff had a small battery-operated machine to test the resident alarms for function and the box flashed an indicator message when it was held near a resident with a wanderguard it flashed if the alarm was present and functioning or not. Nurse #2 revealed that Resident #57 had never eloped from the facility before or after the elopement on 3/17/22, but that he did wheel himself toward exit doors sounding the alarm and staff would direct him away from the door and coded the door alarm to go off and reset. Nurse #2 reported that Resident #57 would tell her he needed to leave to go home to get supplies to load onto his spaceship. Nurse #2 explained that if it was determined that a resident was missing that the nurse or other staff used the intercom and announced a Code Silver that alerted all facility staff to start to look for a particular resident and that the facility also maintained Code Silver books at each nurse station that included a resident photo, a copy of the resident's face sheet and any other material deemed necessary to locate and identify residents. Nurse #2 revealed she did not receive any new education or that the process had changed after Resident #57 eloped on 3/17/22. A social worker (SW) progress note dated 3/9/22 at 1:21 PM included Resident #57 continued to have delusions and told the SW he had a great escape plan to get back to his businesses and his farmland was abandoned and he needed to attend to it. Resident #57 was redirected as needed. A review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed in part that Resident #57 had clear speech, was usually understood and sometimes understood. Resident #57 rejected care 1 to 3 days of the review period and required 1 staff assist with bed mobility, he did not require staff set up assist to transfers, locomotion. Resident #57 was steady with no assist to move from sit to stand and surface to surface transfers. He used a wheelchair and prosthetics for mobility. Resident #57 had one fall without injury and one fall without major injury during the review period. No active discharge plans were in place. A review of multiple MDS assessments for Resident #57 dated from 10/03/20 through 3/10/22 revealed that Resident #57 had fluctuating cognition patterns. A Nurse Practitioner (NP) note dated 03/16/22 included, in part, that Resident #57 was a poor historian due to cognitive and psychiatric impairment and received psychiatric and psychological services with minimal ability to provide his history. The NP recorded on examination Resident #57 had impaired insight, was delusional and forgetful. A review of the medication administration record dated for3/17/22 revealed that Resident #57's wanderguard was checked on the day shift and the evening shift and functioned appropriately and was located directly under the wheelchair seat as high up on the cross bars as it would fit. Nurse #3 was interviewed via phone on 5/11/22 at 3:31 PM. Nurse #3 revealed she worked from 7:00 PM on 3/17/22 until 7:00 AM on 3/18/22 and was the assigned to the rehab unit. Nurse #3 revealed she believed Resident #57 exited the facility about 8:30 PM because it was dark outside and she had just finished her medication pass when the pharmacy delivery driver from the pharmacy informed Nurse #3 that there might be a resident outside in a wheelchair going toward the street at the end of the side parking lot. Nurse #3 and the pharmacy delivery driver exited the facility to look for a resident and realized that a Code Silver (used for actual or potentially missing residents) had not been announced. Nurse #3 and the pharmacy delivery driver just ran out of the facility toward the road and observed Resident #57 lying in the dirt at the side of the road with his wheelchair right behind him. The traffic had stopped in both directions. Nurse #3 confirmed that neither Resident #57 nor his wheelchair were in the road. Resident #57 had both of his leg prosthetics on. Nurse #3 did not observe any injury to Resident #57 who also reported that he was not injured. Nurse #3 explained she and the pharmacy delivery driver tried to pick Resident #57 up off the side of the road but he was too heavy then a gentleman got out of his vehicle and came over and assisted them to place Resident #57 back into his wheelchair and it was then that Nurse #4 and Nursing Assistant (NA) #1 came running out of the facility and explained they were assigned to Resident #57 and were looking for him because they had not seen him for the last 15 to 20 minutes. Nurse #3 explained that Nurse #4 assessed and confirmed that Resident #57 had no injury and then Nurse #4 and the NA #1 wheeled Resident #57 back into the facility. Nurse #3 returned to her assigned unit. Nurse #3 explained that if a resident elopes from the facility a Code Silver was to be announced and all staff available were to begin searching the entire facility and proceed to search outside of the facility for the resident. Nurse #3 revealed that an unsupervised exit from the facility by a resident was to be reported to the Director of Nursing (DON) immediately and notification made to the MD and family of the resident even if the resident was listed as their own responsible party. Nurse #3 explained that complete vital signs, neurological checks and a full body assessment were to be completed, then an incident and/or accident report completed and a detailed progress note written and try to obtain written statements from any staff involved. Nurse #3 revealed that she had been assigned to Resident #57 a few times before 3/17/22 and she was aware he wore a wanderguard, but he had not exhibited any wandering or exit seeking behaviors when she was assigned to him. Nurse #3 reported that Resident #57 had shorts on when he eloped from the facility on 3/17/22 but she was not sure of the type of shirt he wore and that it was cool outside but not very cold or raining. Nurse #3 revealed that she completed and signed a statement that described what she observed on 3/17/22 directed by the nurse supervisor before she left the facility the morning of 3/18/22. On 5/12/22 at 7:05 AM a follow up phone interview conducted with Nurse #3. Nurse #3 clarified that neither Resident #57 nor his wheelchair were in the road on 3/17/22 when he eloped and that he was observed approximately 15 feet from the end of the parking lot driveway on the facility side of the road. Nurse #3 confirmed that it was getting very dark outside and she believed the time was near 8:30 PM and the weather was mild. On 5/10/22 at 3:35 PM a phone interview was conducted with NA #1. NA #1 revealed worked from 3:00 PM until 11:00PM on 3/17/22 and it was the first time she was assigned to Resident #57 so she did not know he wandered or had a wanderguard. NA #1 revealed that on 3/17/22 she was on her break sitting in her vehicle in the parking lot and when she exited her vehicle to return to the facility at about 8:00 PM she observed someone with their head down moving away from the 100 hall sunroom door in the back parking lot of the facility. NA #1 explained she was not sure if it was a resident or visitor or anyone else because she was in a different parking lot and it was dark outside and could just make out the top of a head. NA #1 went into the facility and Nurse #4 approached her and explained that Resident #57 was missing when the nurse was taking him his medicine. NA #1 revealed she informed Nurse #4 that she might have seen Resident #57 leaving the facility a few minutes ago when she was returning from her vehicle. NA #1 revealed both she and Nurse #4 proceeded to leave the facility at the 100 hall sunroom door where NA #1 had observed someone outside and when they got outside, they saw 2 staff and a man placing Resident #57 into his wheelchair. NA #1 revealed that Nurse #1 examined Resident #57 and asked him if he was injured and he told her he was fine. NA #1 revealed that she did not see any cuts or scratches on Resident #57. Then, NA #1 stated that she and Nurse #1 wheeled Resident #57 into the facility and to his room and placed him in his bed. Resident #57 told Nurse #4 and NA #1 that he was angry and would only leave the facility again. Resident #57 also reported to the nurse staff that he cut his alarm bracelet off so Nurse #4 went and got another wanderguard alarm and attached it under the chair cushion on his wheelchair. NA #1 revealed she had not been aware the Resident #57 cut the straps of the wanderguard off and that was likely why the alarm never sounded at the door. NA #1 revealed that she had been assigned to sit in the doorway of Resident #57's room after that and for the rest of the 3:00 PM to 11:00 PM shift. Resident #57 remained asleep in his bed reported NA #1 and she was able to recall that Resident #57 wore shorts and his prosthetic legs when he was outside. Nurse #1 was interviewed on 5/09/22 at 4:26 PM and revealed she worked from 7:00 AM until 7:00 PM the on 3/18/22 and was assigned to Resident #57 and he always wore a wanderguard. Nurse #1 revealed the current wanderguard was under the cushion of his wheelchair and the wanderguard was checked daily or more frequent if needed because Resident #57 removed the attachment strap and removed the alarm if he was able to by cutting the strap with a butter knife. Nurse #1 obtained the wheelchair from the room of Resident #57 as he slept in his bed and she wheeled the chair to the exit door at the end of the 100 hall and was approximately 10 feet from the door when the alarm sounded. Nurse #1 explained that the alarm automatically locked the door and needed a code entered the keypad to the left side of the door to silence the alarm and unlock the door after the wheelchair was moved back approximately 10 to 12 feet from the door alarm. A review of a nurse note dated 3/18/22 at 1:10 AM by Nurse #4 revealed that at approximately 8:40 PM on 3/17/22 Resident #57 was not in his room when she went to administer his bedtime medications. The nurse began looking for him and an NA told the nurse that she (the NA) thought she saw someone in the parking lot matching the description of Resident #57. Resident #57 was found outside just off the property near the road. He was assessed for injury and was not injured his skin was intact. Resident #57 reported that he just wanted to go home. Resident #57 was educated on the proper procedure to sign out of the facility correctly and about giving notice to set up transportation and escort him safely. Resident #57 stated understanding of the proper procedure. Resident #57 was his own responsible party. Multiple attempts were made to contact Nurse #4 during the survey but were unsuccessful. A review of a late entry nurse progress note completed by Nurse #4 on 3/18/22 at 7:52 AM included that the DON was notified at 8:51 PM on 3/17/22 that Resident #57 got out of the facility near the street. An observation and interview of Resident #57 conducted on 5/09/22 at 4:02 PM revealed Resident #57 seated in his wheelchair in his room, wearing bilateral lower leg prosthesis. Resident #57 was awake and alert to himself his speech was clear but nonsensible. He reported that the date was Tuesday in March of 1944. Resident #57 revealed he did not live here very long and the name of the place was 104 in Concord. Resident #57 also revealed he remembered he fell outside but was not certain exactly when, but he went outside one of the doors and his wheelchair got caught on the edge of the door and he fell, but he did not get hurt. Resident #57 added he was going outside because the lady with the menus told him to come outside quickly and that was why he fell. On 5/11/22 at 6:35 AM a weather search conducted on wunderground.com recorded the temperature during the late evening of 3/17/22 in Concord, NC as partly cloudy and 61 degrees Fahrenheit. An interview conducted with the registered dietician (RD) on 5/11/22 at 11:27 AM revealed that Resident #57 received plastic utensils with his meal trays because he sometimes used the metal butter knives to cut the strap of his wanderguard alarm. The RD was not able to recall when the plastic silverware use had been initiated but he was care planned at one time for the use of plastic silverware but the RD had no idea what happened to that care plan because it remained current. The RD explained that after meals the meal carts were brought to the dining room to be taken into the kitchen to be washed and sometimes Resident #57 had been observed coming into the dining room and attempting to remove silver butter knives from the dirty meal trays. The RD revealed when she observed this behavior, she stopped Resident #57 and retrieved the knife or knives from him and redirected him to exit the dining room. On 5/11/22 at 1:00 PM an interview and observation of the wanderguard door alarms was conducted with the Maintenance Director. The Maintenance Director revealed that the facility had 18 doors that had alarms that were activated by wanderguard bracelets. The Maintenance Director explained that he checked all door alarms every morning and he used a test stick to activate each alarm that automatically sounded the alarm and locked the doors. The Maintenance Director explained that he was not at work when Resident #57 eloped from the facility, but that nurse Unit Manager (UM #1) had been assigned to test the door alarms when he was not present. The 18 doors of the facility were observed as they were tested and no concerns were identified. The Maintenance Director then obtained the wheelchair that belonged to Resident #57 and pushed it close to the door at the end of the 100 hall and it alarmed and the door locked. The Maintenance Director explained that when the door alarmed it automatically locked as the alarm sounded and could only be disarmed and unlocked when a staff member entered the correct code into the keypad located on the wall to left of each alarmed door. The Maintenance Director stated that he had been informed that Resident #57 exited the facility at the door of the sunroom near room [ROOM NUMBER] and that from the sunroom to the roadway measured 65 feet to 70 feet. The speed limit sign on the road next to the facility revealed the speed limit was 35 miles per hour. The Maintenance Director reviewed his daily logbook that contained daily door alarm checks from 1/2020 until 5/11/21 and the log dated 3/17/22 revealed that UM #1 signed that all the door alarms functioned as required. An interview conducted with the NP on 5/11/22 at 2:40 PM revealed that she was aware that Resident #57 had an elopement on 3/17/22, but never prior to that date. The NP explained that Resident #57 had become more delusional over the past few years with more verbalizations of wanting to go home. The NP revealed that she was made aware that Resident #57 eloped on 3/17/22 because she received notification from the on-call service and then had received more details when she came to the facility on 3/23/22 at which time she examined Resident #57 , found no injury and Resident #57 acted no different and spent most of the day seated in his wheelchair in the doorway of his room. The NP revealed that in her medical opinion Resident #57 was not able to make medical care decisions for himself. An interview conducted on 5/11/22 at 4:00 PM with UM #1. UM #1 revealed that she usually worked weekdays until about 5:00 PM and she was responsible to check the 18 door alarms and locks daily when the Maintenance Director was out at the facility and she did check the door alarms on 3/17/22 and all doors functioned appropriately. UM #1 revealed that on 3/17/22 she had not observed any concerns that Resident #57 experienced any changes in his status and she was leaving the facility for the day at about 6:30 PM. She was not certain of the exact time, but she had just went out to her vehicle in the front parking lot when she received a phone call from an unknown visitor at the facility who informed her that a resident in a room on the 100 hall about half way had been observed seated in his bed and he had is wheelchair turned upside down and was fiddling with something. UM #1 then called the facility to speak to the nurse assigned to that 100 hall but the nurse was not available and UM #1 told the NA that answered the phone to tell the nurse what was reported by the visitor and that someone needed to check on Resident #57 because UM #1 believed it was Resident #57. UM #1 revealed she was about to leave the parking lot driveway when she received a phone call from Nurse #3 and was informed that Resident #57 had been found outside lying on the side of the road with his wheelchair behind him and that at one point traffic stopped on both sides of the road. Nurse #3 explained that she and another staff member went out of the facility together and that a man had gotten out of his car to assist lifting Resident #57 back into his wheelchair. Nurse #3 revealed that Resident #57 had no visible injury and stated he was not injured and 2 other staff came out of the facility ( 1 was a nurse) and the nurse assessed Resident #57 and then the nurse and NA rolled Resident #57 back into the facility. UM #1 revealed that she returned to the facility and spoke to Nurse #4 assigned to Resident #57 and Nurse #4 explained she had been taking bedtime medications to Resident #57 in his room and he was not there and the NAs helped to look for him inside the facility and then NA #1 reported to Nurse #3 that she may have observed Resident #57 outside and both Nurse #3 and NA #1 went outside and saw 2 other staff and a man lifting Resident #57 back into his wheelchair and he had no injuries and she and NA #1 wheeled him back to his room and assisted him to bed. UM #1 revealed she instructed Nurse #3 to document what happened and to notify the DON, MD and family as well. UM #1 explained that she then went to Resident #57's room and observed him in bed with his prosthetics removed. Resident #57 told UM #1 that he was angry and that he would only leave again. UM #1 revealed when she asked Resident #57 where the wanderguard bracelet that had been attached to his wheelchair earlier that day was and Resident #57 pointed to the top drawer under his closet. When she opened it, she found 2 wanderguard battery pieces and 1 rubbery bracelet used to attach the wanderguard to a resident or wheelchair along with 2 silver butter knives in the drawer which she removed from the room. UM #1 reported that the NA present in Resident #57's room at that time explained that she was going to stay with him for the rest of her shift at 11:00 PM and replaced the wanderguard. UM #1 revealed that she then left the facility after Nurse #3 confirmed that the DON had been notified. UM #1 revealed that based on the information she received, Resident #57 was outside for no more than 15 minutes to 20 minutes and he was not injured. UM #1 revealed that Resident #57 had a history of removing his wanderguards from any place the staff attached them and in the recent past he removed wanderguards attached to his wrist, from the bars on the bottom of his wheelchair and even tucked under the chair cushion on his wheelchair. UM #1 explained that he only received plastic silverware because he used the knives to cut the bracelets, but he somehow managed to get the metal knives and used them. UM #1 obtained the personal alarm test box and was observed standing at the back of Resident #57's wheelchair and the code flashed that the wanderguard alarm was present and functioning. UM #1 went on to explain that if a resident exited or eloped from the facility unsupervised then the staff was to call a Code Silver to alert all present staff that a resident was missing and that all staff was expected to search inside and outside the facility. UM #1 added that the nurse was to notify the DON, MD and family of the episode and to obtain full vital signs and neurological checks as part of the resident assessment required and the to write a detailed nurses note and complete an incident and/ or accident report. UM #1 revealed that she had not viewed an incident and/ or accident report or investigation completed for Resident #57 dated 3/17/22.UM #1 revealed that Resident #57 was confused most of the time but more confused over the past few months. UM #1 added that the facility did not implement any new interventions to the care plan of Resident #57 related to the elopement or fall on 3/17/22. A form titled wanderguard Residents dated from 3/01/22 through 3/31/22 was reviewed and the form listed each resident's name, room number and verified the placement and function of each resident and their wanderguard daily and was signed by the person responsible to check residents and their wanderguards. The form included Resident #57 had a functional wanderguard in place daily. On 5/12/22 at 10:13 AM an interview was conducted with the facility MD. The MD explained that Resident #57 had experienced a decline in his cognition over the last few years and Resident #57 had experienced more delusions and even hallucinations over the past year or more and was not capable making his own care decisions. Resident #57's cognition and behaviors change daily per the MD. On 5/10/22 at 5:28 PM a brief interview conducted with the DON revealed that she completed an investigation for the elopement and fall of Resident #57 beginning 3/18/22 through about 3/23/22. The DON confirmed that on 3/17/22 after Resident #57 was safely returned to the facility no other safety interventions were put in place to prevent future elopements because at the time of the unsupervised exit from the facility, Resident #57 was his own responsible party and based on the most recent MDS date 3/10/22 Resident #57 had no cognitive impairment. The DON confirmed that Resident #57 had fluctuations in cognitive status but as his own responsible party he could not be prevented from leaving the facility if that was the decision he made. The DON revealed that Resident #57 was not a prisoner and could not be made to stay at the facility if he did not want to. The DON did not reply when asked what the purpose of the wanderguard was in that case. On 5/12/22 at 3:56 PM the DON was interviewed and revealed that when a resident eloped, she expected the licensed nurse to contact her and the nurse did call her on 3/17/22 about Resident #57 being found lying next to the street between 8:30 PM and 9:00 PM. The DON revealed that she expected all residents always be accounted for. The DON also revealed that Resident #57 had verbalized exit seeking behaviors in the past and that he still does. The nurses revealed the DON were to also notify the MD and family of any incident and/ or accident and were to complete all documentation needed for the exact episode. The DON believed that the nurse staff and facility followed up as required and expected on 3/17/22 related to Resident #57. The DON revealed that Resident #57 was not outside for longer than 15 to 20 minutes. Administrator was notified of immediate jeopardy on 5/12/22 at 4:39 PM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered or are likely to suffer a serious adverse outcome as a result of noncompliance. Resident #57 left the facility unsupervised after cutting off his wanderguard on 3/17/22. Residents wearing wanderguards were determined to have the potential to remove wanderguards and exit the facility unsupervised. Resident #57 was placed on one-to-one monitoring on 5/12/22 and will remain on one -to- one supervision until the Interdisciplinary team determines he is no longer at risk of removing his wanderguard or another plan is determined to be appropriate by the interdisciplinary team. Resident #57's care plan was updated by the DON to reflect current wandering and elopement risk and one-to -one supervision on 5/12/22. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring. The Elopement and Wandering residents policy was reviewed on 5/12/22 by the DON and Administrator; no changes were made. All exits and wanderguard alarms were checked and functional on 3/18/22 by maintenance. They continue to be functional as evidenced by check completed on 5/12/22 by maintenance. Functional checks will continue weekly by maintenance. Education of all facility staff on wandering and elopement with a post-test was initiated by the DON on 5/12/22 with all facility staff working at that time. Any facility staff not present at that time will receive the education with post-test on their next scheduled workday. The DON or designee will use the staff roster to verify that all staff have received the education with post-test. The DON or designee will review new admissions for potential elopement risk and ensure appropriate interventions are added to the care plan, the [NAME] reflects the care plan and is accessible to direct care staff. Residents with elopement potential will be listed y the DON or designee in the Code Silver binders at each nurses station with each resident's face sheet and picture. The binders are accessible to all facility staff. Starting 5/13/22 residents identified as having a change in condition to include elopement potential by the interdisciplinary team will be placed on one-to-one until appropriate interventions to decrease the potential of elopement are care planned, implemented and the resident has been added to the Code Silver binders. The wandering and elopement education with post-test was added to the orientation materials on 5/12/22 by the DON. Date alleged Immediate Jeopardy removal: 5/16/22. The facility's credible allegation of compliance was validated through an on-site review process which included record review, observations, interviews with staff and observations. Date of IJ removal was validated as of 5/16/22. The validation of the credible allegation conducted on 5/16/22 included that 97 staff had completed in-service education and a post test of the policy and procedure related to elopement and wandering residents. Random staff were interviewed and were able to explain the facility policy related to elopement and the use of the Code Silver binders located at each nurse station. Resident #57's care plan was updated to include one to one supervision at all times and the placement and function of his wanderguard was recorded every shift by the nurses. Resident #57 was observed with an NA providing direct one to one supervision at all times. Audits completed by the DON included an audit of each resident with a wanderguard that confirmed the placement and function of each wanderguard, a wanderguard assessment and a copy of each resident care plan updated to reflect use of the wanderguard.