**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for one of six residents (Resident #1) reviewed for accidents and supervision. CNA A failed to transfer Resident #1 in accordance with her care plan and facility protocol when she independently transferred Resident #1 via mechanical lift (a mechanical device used to safely transfer individuals with limited mobility, typically those who are unable to bear weight or have difficulty moving independently, from one place to another, such as a bed, chair, or wheelchair). As a result, Resident #1 fell from the mechanical lift and sustained a head laceration that required staples. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 02/21/25 and ended on 03/04/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for serious accidents/injuries and/or death. Findings included: Review of Resident #1's Face Sheet, dated 03/12/25, reflected she was an [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including dementia in other diseases classified elsewhere (dementia is a general term for a decline in mental ability severe enough to interfere with daily life, encompassing memory loss, thinking, and behavioral changes), age-related physical disability (impairments in physical function that become more common with advancing age, often due to conditions like arthritis, hearing loss, or decreased mobility), and muscle weakness (a condition where muscles are unable to contract or move as easily as they used to, potentially due to various underlying causes). Review of Resident #1's MDS Assessment, dated 02/06/25, reflected she had moderate cognitive impairment. Resident #1 was identified as needing staff assistance for transfers. Review of Resident #1's Care Plan, dated 05/02/24, reflected she required the use of a mechanical lift for transfers, with two staff members to assist in the transfer. Review of the facility's Incident Report, dated 02/21/25, reflected LVN B was called to Resident #1's room. When she arrived, she noted Resident #1 was lying on the floor and bleeding from her head. LVN B immediately called 911 for assistance. It was noted that CNA A reported Resident #1 slid out of the mechanical lift sling as she was being transferred. Resident #1's family, physician, and HHSC were notified of the incident. The mechanical lift was inspected with no noted issues to the mechanical lift or the sling. Review of the facility's Provider Investigation Report, dated 02/21/25, reflected on 02/21/25 at around 11:00AM, CNA A attempted to independently transfer Resident #1 from her wheelchair and into her bed via mechanical lift. While Resident #1 was in a lifted position, she slid out of the mechanical sling. Resident #1 fell to the ground and sustained a head laceration. LVN B was called to the room, and upon seeing Resident #1's condition, immediately called 911 for assistance. Resident #1 was sent to the hospital for further evaluation and treatment, and she returned to the facility that same day with staples to her head. CNA A was suspended pending the outcome of the investigation. She admitted ly knew that two staff members were required when transferring residents via mechanical lift. Facility staff were in-serviced on mechanical lift transfer protocols; staff completed mechanical lift competency checks. CNA A was also in-serviced on mechanical lift transfer protocols and completed a competency check prior to returning to work. In addition, she received a final written warning for unsatisfactory conduct. Observation of Resident #1 on 03/12/25 at 11:40AM revealed she was clean, well-groomed, and appropriately dressed. She was free from any odors. There were no concerning marks or bruises noted on her person. The area of her head in which she previously sustained a laceration as a result of falling during a mechanical lift transfer had healed. Resident #1 displayed no obvious signs or symptoms of distress. During an interview with Resident #1 on 03/12/25 at 11:40AM, she stated she previously sustained an injury to her head when she was being transferred out of bed by facility staff. She was unable to recall any additional details to the incident. She denied any current presence of pain. She stated she believed two staff members were always present when they transferred her via mechanical lift. During an interview with CNA A on 03/12/25 at 12:44PM, she stated on the day of the incident (02/21/25), Resident #1's family member asked for Resident #1 to be transferred from her bed and into her wheelchair. CNA A stated she felt as though she was being rushed by Resident #1's family member, so she decided to transfer Resident #1 by herself via mechanical lift. CNA A stated she did not ask any other staff members to assist her, because she thought the other staff members were busy providing care for other residents. CNA A stated during the transfer, while Resident #1 was seated in the mechanical sling and was in a lifted position, she fell out of the sling and hit her head. CNA A stated Resident #1 sustained a laceration to her head. She immediately called for help, and LVN B promptly came to provide assistance and assess Resident #1. CNA A stated she had been in-serviced on mechanical lift transfers prior to the incident occurring, and she knew she needed two staff members to complete the mechanical lift transfer safely. CNA A stated she received a final written warning as a result of the incident. She also received additional in-servicing with competency checks on mechanical lift transfers, and she continued to participate in random competency checks conduced by upper management. CNA A stated the risk of transferring a resident without the recommended/required number of staff was that residents could be injured. During an interview with LVN B on 03/12/25 at 11:57AM, she stated on the day of the incident (02/21/25), CNA A yelled for assistance from Resident #1's room. LVN B stated when she arrived to Resident #1's room, she noted Resident #1 to be on the floor, bleeding from her head. LVN B immediately called 911 for further assistance. EMS arrived and transferred Resident #1 to the hospital for further evaluation and treatment. LVN B stated CNA A conducted an improper transfer for Resident #1, in which CNA A transferred Resident #1 independently via a mechanical lift transfer. LVN B stated mechanical lift transfers required at least two staff members to help ensure resident safety. She stated CNA A never asked for assistance with the transfer, prior to transferring Resident #1. During an interview with the Administrator on 03/12/25 at 12:21PM, she stated on 02/21/25, she was notified that Resident #1 fell while being transferred via mechanical lift by CNA A, who attempted to transfer Resident #1 without the assistance of any other staff. Resident #1 sustained a head laceration, so she was sent to the hospital for further evaluation and treatment. CNA A admitted to transferring Resident #1 independently and said she felt as though she was being rushed by Resident #1's family member. CNA A was suspended pending the outcome of the investigation. CNA A was able to return to work upon being in-serviced on mechanical lift protocol. All other direct care staff were in-serviced on mechanical lift protocol, as well. The Administrator stated there had been no additional incidents since that time. She stated the facility was monitoring for compliance by completing random mechanical lift competency checks with staff members. The Administrator stated the risk of transferring a resident without the recommended/required number of staff was that residents and/or staff could be injured. The surveyor attempted to contact Resident #1's family member on 03/12/25 at 4:44PM. The telephone call was not returned prior to exit. Review of the manual for the mechanical lift used in the incident involving Resident #1 was requested; however, the Director of Nursing stated the facility did not have access to the manual. Review of the facility's Lifting Machine, Using a Mechanical policy, dated 07/2017, reflected, .The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device . and .At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift . This noncompliance was identified as past noncompliance (PNC). The noncompliance began on 02/21/25 and ended on 03/04/25. The facility had corrected the noncompliance before the investigation began. The facility took the following actions to correct the non-compliance: Review of in-service records, dated 02/21/25, reflected direct care staff were in-serviced on mechanical transfer protocols. Review of Manual Lift Competency Assessments, dated from 02/21/25 to 02/28/25, reflected facility staff were screened for competency in using mechanical lifts. Facility staff were documented to have demonstrated competency in this area via return demonstration. Review of a Final Warning document, dated 03/04/25, reflected CNA A received a final written warning for unsatisfactory conduct, related to transferring Resident #1 via mechanical lift without having another staff member present to assist. Verification of these actions by the HHSC surveyor included: Observations of three separate mechanical lift transfers for Resident #1 (conducted by CNA E and CNA F), Resident #2 (conducted by CNA C and CNA D), and Resident #3 (conducted by CNA A and CNA E) on 03/12/25 from 11:20AM to 1:15PM revealed the mechanical lift transfers were completed without incident. Facility staff were observed to follow the facility's policies and procedures related to mechanical lift transfers. During interviews with multiple sampled residents (Resident #2, Resident #4, and Resident #5) on 3/12/25 from 11:30AM to 2:40PM, they each reported they required transfers via mechanical lift. Each of these residents reported two staff members were always present and assisted during the mechanical lift transfers. These residents all denied any incidents and/or injuries had occurred as a result of the mechanical lift transfers. During interviews with multiple staff members (CNA A, LVN B, CNA C, CNA D, CNA E, CNA F, and LVN G) on 03/12/25 from 11:40AM to 2:40PM, they each reported being in-serviced on the facility's mechanical lift transfer protocol. These staff members were able to explain, in detail, how to complete a mechanical lift transfer (including the requirement of having at least two staff members present) per the facility's written policies and procedures. These staff members reported they had completed return demonstration competency checks to check for understanding. The Administrator was informed the of the past noncompliance at the Immediate Jeopardy level on 03/26/25 at 3:27PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive for 1 (Resident #71) of 10 residents reviewed for advanced directives. Resident #71 was administered CPR by LVN H on [DATE], in not honoring the resident's advance directives. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:48PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of more than minimal harm that is not immediate jeopardy and a severity level of isolated because the facility was continuing to implement their Plan of Removal. This failure could affect residents with an accessible DNR and could result in residents not getting their Do Not Resuscitate wishes honored. The findings included: Record review of Resident #71's admission Record, dated [DATE], revealed the resident was an [AGE] year-old female, who admitted to the facility on [DATE] with diagnoses including myocardial infarction (heart attack), congestive heart failure, heart disease, and atrial fibrillation. Resident #71's admission Record did not indicate her code status. Further review revealed the resident expired on [DATE]. Record Review of the Care Plan meeting, held on [DATE] at 10:30AM, with Resident #71 and Resident #71's Responsible Party, the Social Worker, and the Director of Rehabilitation. During that meeting, Resident #71, and Resident #71's Responsible Party voiced that they wanted Resident #71 to be Do-Not-Resuscitate (DNR) Code Status. This was reflected in Resident #71's progress notes. Record review of Resident#71's progress note, Effective Date: [DATE] 11:00, .Author: LVN H progress note revealed Resident#71 unable to breath in the middle of receiving care jointly provided by CNA and resident's family member. A ran to notify LVN H that Resident#71 is not breathing or possibly having seizure per resident's Responsible Party. LVN went to resident's room and saw resident gasping for air, LVN H rushed to get a crash cart to start CPR and informed resident's Responsible Party that 911 call will be activated, resident's Responsible Party objected to both initiating CPR and calling 911 paramedics that Resident #71 did not want to be resuscitated or revived LVN H advised resident's Responsible Party that DNR PAPERS ARE NOT IN FILE When resident's Responsible Party left the room and Resident #71 continue gasping for air, LVN H started CPR, activated 911 call, CPR in progress, AED applied, 911 paramedics arrived, and care was transferred to 911 paramedics, resident's Responsible Party had a heated argument with 911. paramedics for them to stop the ongoing CPR. Resident#71 was pronounced at 1215 by the paramedics, Resident #71's body left facility at [3:33PM] for [name of funeral home] Funeral Home . In an interview with the social worker on [DATE] at 12:53 PM revealed, during Care Plan meetings, it was standard for code status was discussed. The SW revealed usually a DNR can be completed same day. The SW revealed the care conference for Resident #71 was held on [DATE] at 10:30am that included Resident #71 and Resident #71's Responsible Party. The SW allowed the surveyor to review an email in her laptop showing the email that she scanned DNR to the physician at 5:05pm on [DATE]. The SW revealed she did receive the physician signed DNR (which was the official, signed DNR order) via email on [DATE] at 5:35pm but she had already left work. The SW revealed if a resident did not have accurate orders on file in the electronic health record, there was a risk that the resident could code and then anything can happen. In an interview with the Administrator on [DATE] at 12:58 PM revealed if a resident voices desire to be DNR, the SW gets involved and notifies family when completed. The Administrator revealed the SW was responsible for initiating and completing the DNR Form and submitting it to the physician for review and signature. The Administrator revealed usually DNRs were done quickly and could be as quick as next day. The Administrator revealed the DNR was done quickly to honor wishes of family. The Administrator revealed the risk of not completing DNR timely would mean families wishes were not honored. In an interview with the DON on [DATE] at 1:06 PM revealed if the resident does not have a DNR already they were a Full Code. The DON revealed within 3 days of admission, the facility had a care conference and discussed Code Status and guides the resident. The SW puts order in to EHR and upload the DNR. The DON revealed the DNR would be initiated soon, but not sure how quickly it can be done. The DON revealed the reason to do it right away was because condition can change quickly. The DON revealed the risk of not having DNR completed was if a resident codes, the nurse will do CPR- which would be a violation of their rights. The DON revealed the expectation was to have the DNR completed as soon as practicable. The DON revealed the physician emailed the completed DNR to the SW, but SW had left for the day and the nursing team were unaware of the signed and completed DNR. The DON revealed the nursing staff did not have access of the DNR. During an interview on [DATE] at 1:23 PM via telephone with Resident #71's Responsible Party began to cry saying this was a hard conversation. The Responsible Party said she does not feel the facility honored her wishes. The Responsible Party said the facility admitted they did wrong. The Responsible Party said during the Care Conference, the DNR form was filled out and facility staff indicated they would send it to the physician for signature. The Responsible Party said the Director of Therapy and the Social Worker guided the Responsible Party in completion of the DNR. The Responsible Party said the physician emailed the signed copy back the same day, but the social worker had already left for the day and no-one else had access to the signed DNR. The Responsible Party said the facility told her this would not occur again, as they will ensure others have access to the fax. The Responsible Party said the paramedics worked on Resident #71 for 30 minutes. In an interview with the Administrator - Executive Director (who was the interim Administrator at the time of the incident) on [DATE] at 1:36 PM revealed he remembered Resident #71. The said he was the Manager on Duty on the day of the death. He revealed one of the facility customer service staff alerted him a family was upset. He told the family he would follow up on the fully executed DNR the physician. The Administrator - Executive Director expectation of completing the DNR was that it be completed fully, quickly and put into the system. The Administrator Executive director revealed the facility must have the completed DNR, or the resident was Full Code. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:00 PM. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 4:48 PM. The facility's Plan of Removal included: [Facility Name] Immediate Jeopardy Plan of Removal Resident Code Status - DNR Status [DATE] All residents desiring to be DNR status without a current DNR order are at risk to receive CPR. Actions to correct and remove IJ: 1. Verify code status for all residents. The social worker will complete this by noon [DATE]. 2. Any resident/resident POA wanting to be DNR status will have the DNR election form completed, and the physician will be contacted for the DNR order. The Social Worker and support staff will complete this for current residents by end of day on [DATE] per the DNR Order policy. The staff member (Social worker, Weekend Nurse Supervisor or designee) completing the DNR Election form will: a. upload the completed form into the Electronic Health Record (EHR) under the Code Status category b. enter the physician order for the In House DNR into the EHR, c. make a progress note in the EHR to show on the shift report when form is completed, d. make a progress note in the EHR when the DNR order has been received and resident/family notified been completed 3. Residents also wanting an Out of Hospital DNR will be contacted by the Social Worker on the process for completing this form, witnesses and other requirements. An appointment to complete the documents will be completed at their earliest convenience. The Social Worker or designee completing the OOH-DNR form will: a. upload the completed OOH-DNR form into the Electronic Health Record (EHR) under the Code Status category b. enter the physician order for the OOH-DNR into the EHR, c. make a progress note in the EHR to show on the shift report that the OOH-DNR has been completed and orders are on the chart, d. Completion of this will be based on the residents/responsible parties' response and availability to complete. 4. Resident Care Plans on advanced directives will be updated to reflect any change in code status by the staff member ((Social Worker, Weekend Nurse Supervisor, Charge Nurse, or designee) obtaining the Physicians Order. Complete implementation of the current DNR Order policy will be completed by [DATE]. This includes: 1. Identification of Code Status by completion of the DNR Election form will be initiated prior to admission or the day of admission - this will be completed by the admissions team (Admissions Coordinator, PAC Admin Assistance, Care Transitions Nurse, or Clinical Liaisons). a. The admission team will send the form to the patient or their responsible party prior to admission through the electronic document signature system. The admission team will call patient or Responsible Party if response is not received within 24 hours prior to admission. b. Any admission that does not have the DNR Election form completed by the time the charge nurse completes the admission assessment will have the form completed by the admitting nurse. The admitting nurse will make sure DNRs are completed updated for admissions or DNR changes requested after hours and on the weekends. i. If the patient is not able to make a decision and not accompanied by a Responsible Party, a nurse can obtain the consent via phone as long as another witness is present, and the Responsible Party has a copy of the CPR election form and document this in the EHR. c. Once consent for DNR is obtained from the patient or RP, the nurse will get the DNR order from the patient's primary physician. If the primary physician is not available, the nurse will call the medical director to obtain the order. 2. Social Worker will initiate OOH-DNR process if requested on the DNR Election form. Completion of the OOH-DNR form will be based on the residents/responsible parties' response and availability to complete. 3. Re-Education of the Director of Nursing was conducted by the Corporate Compliance Director on [DATE]. Re-education of all nursing staff, the social worker, administrator, physicians, admissions personnel and medical directors on the DNR Order policy at all-staff meetings to be held on [DATE] and [DATE]. Reeducation conducted by the Director of Nursing and Administrator at all staff meetings. 4. Staff who are not present during the in-services will be in-serviced individually before they can begin their next shift at work. 5. New admission code status is reviewed during the daily start up meeting and Code Status is discussed in each care plan meeting and care plan updated as needed. 6. A DNR is considered complete when the physician/medical director signs the order to support the request. 7. In the event a code incident occurs while awaiting the DNR completion, the in-house DNR form will be used, and the physician or medical director will be called for consent via phone as long as another witness is present. When completed, the DNR will be honored. Reviews: 1. Weekly the Social Worker will pull all orders from the EHR for Code Status and review for accuracy. The administrator will meet with the Social Worker weekly to audit and verify this review has been completed. This will be ongoing for the next two months. 2. Reports to the QAPI committee on the number of DNRs, OOH-DNRs and those with full code status will include those identified outside the current DNR Order policy for discussion and revision of plan 3. A Corporate Designee will audit the Facility Code Status compliance weekly until stable and monthly for the next six months, quarterly thereafter if stable and report findings to the governing body. The new policy on DNR order and form is attached. The facility's Plan of Removal was accepted on [DATE] at 3:13 PM. The following actions were taken: 1. Review of the facility's code status printed report from the minimum data set in the health records for all residents reflected code statuses were up-to-date and current. 2. Review of the facility's DNR orders and the Care Plan report revealed 1 family/resident requested to complete a DNR election form. The physician order was entered into the EHR under the Code Status category. A progress note that was entered in the EHR that showed on the shift report for each resident when completed. A progress notes in the EHR when the DNR order was received, and the resident/family notified it was completed. 3. Two residents/families met with the Social Worker to complete the OOH DNR. The Social Worker uploaded the completed OOH DNR into the EHR under the Code Status category. The Social Worker entered the physician order for the OOH DNR into the EHR. Social Worker made a progress note in the EHR that showed up on the shift report when the form was completed. Social Worker made a progress note in the EHR when the OOH DNR order had been received and received and the resident/family was notified it had been completed. Review of these documents were conducted and verified by the survey team. 4. Resident care plans showed advanced directives were updated to reflect any change in code status by the staff member (social worker, admissions nurse, weekend supervisor, charge nurse or designee) obtaining the physician's order. Review of all resident care plan updates were conducted and verified by the survey team. Review of an in-service conducted on [DATE] and [DATE], titled CPR Election Form, Policy and Procedure reflected staff (with signatures) had been educated on the facility's DNR Election Form. On [DATE] interviews with multiple staff members across various departments and shifts revealed the staff members were recently in-serviced properly on DNR Election Form Policy and Procedure. Each staff member was aware of the steps of completion of the DNR Election Form. No concerns were noted from these interviews. [DATE] at 9:21 AM Admissions Coordinator- was able to verbalize the new process for the DNR election form and policy. [DATE] at 9:26 AM Care Transitional Nurse works in the admission dept. was able to verbalize the new process for the DNR election form and policy. [DATE] at 9:34 AM (PAC) Administrative Assistant- was able to verbalize the new process for the DNR election form and policy. [DATE] at 9:58 AM LVN F works Monday through Friday 7a-3p weekdays was able to verbalize the new process for the DNR election form and policy. [DATE] at 10:05 AM LVN E 7a-3p was able to verbalize the new process for the DNR election form and policy. [DATE] at 10:11 AM LVN H 7a-3p weekdays was able to verbalize the new process for the DNR election form and policy. [DATE] at 10:30 AM LVN I 7a-3p weekdays was able to verbalize the new process for the DNR election form and policy. [DATE] at 10:42 AM LVN A 7a-3p weekdays was able to verbalize the new process for the DNR election form and policy. [DATE] at 11:06 AM Clinical Liaison was able to verbalize the new process for the DNR election form and policy. [DATE] at 11:09 AM RN J 3p-11p was able to verbalize the new process for the DNR election form and policy. [DATE] at 11:39 AM 11p-7a was able to verbalize the new process for the DNR election form and policy. [DATE] at 11:14 AM Weekend Nurse Supervisor was able to verbalize the new process for the DNR election form and policy. [DATE] at 12:07 PM called back was able to verbalize the new process for the DNR election form and policy. Re-education of medical director on the DNR Order policy at all-staff meetings held on [DATE] and [DATE]. Reeducation conducted by the Director of Nursing and Administrator at all staff meetings. Review of these in-services was conducted and verified by the survey team. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 2:00PM. The facility remained out of compliance at a severity level of more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.