**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (CR #1) reviewed for accidents and supervision, in that: CR #1 eloped from the facility on 6/21/25 after being let out of the building by the Receptionist. CR #1 was found by another staff member on the sidewalk near the carwash which was next door to the facility. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 06/21/25 and ended on 06/21/25. The facility corrected the non-compliance before the survey and investigation began on 06/24/25. The IJ template was sent to Administrator on 06/26/25 at 11:40a.m. This failure could place the residents with exit seeking behaviors at risk for injury or death. Findings included: Record review of CR #1 face sheet dated 06/25/35 revealed a [AGE] year-old male who admitted to the facility on [DATE] and discharged to a secure facility on 6/21/25. His diagnosis included: hemiplegia (severe weakness on side of the body) and hemiparesis (weakness affecting one side of the body, often the arm, leg, and sometimes the face) following cerebral infarction (part of the brain dies because it did not get enough blood or oxygen) affecting right dominant side, major depressive disorder(mood disorder that causes a feeling of sadness or loss of interest), atrial fibrillation(upper chambers of the heart beats very fast), and hypertension(when the pressure in the blood vessels is too high). Record review of CR #1 99 MDS assessment dated [DATE] revealed CR #1 was admitted to the facility on [DATE]. CR #1 was a admit. Record review of CR #'s initial baseline/advanced care plan dated 06/20/25 read in part . CR #1 required assistance with ADLs, and he was not at risk for elopement . Record review of CR #1's initial nursing evaluation dated 06/19/25 indicated he was alert to person and place and had difficulty expressing/pronouncing words. Record review of CR#1 BIMS assessment conducted twice on 06/21/25 revealed results were 0 out of 15 which indicated severe cognitive impairment. Record review of CR#1's BIMS assessment conducted on 06/21/25 result was 2 out of 15 which indicated severe cognition impairment. Record review of CR#1 initial wandering dated 06/19/25 25 indicated he was not a wandering risk. He used a manual wheelchair for ambulation. Record review of CR #1's nursing note dated 6/21/25 indicated the resident was noted outside the building by staff who was let out by the receptionist. The nurse brought the resident back in the facility and a head-to-toe assessment was done. There were no skin issues, and the facility started 1:1 monitoring. A new order was received from the MD to transfer resident to a secure facility. During an interview on 06/25/25 at 2:24 p.m., CNA B said she was across the street from the facility on break and saw CR# 1 outside of the facility gate by himself near the carwash. CNA B said CR #1 resisted returning to the facility. CNA B said she called the Weekend Supervisor and RN C for assistance in bringing CR # 1 back to the facility. CNA B said if she had not been at the store across the street on break, no one would have known that CR #1 had left the premises. During an interview on 06/25/25 at 3:05p.m., RN C said she was CR#'s1 nurse on the day of the incident, and it was her first day working with CR # 1 on 6/21/25. RN C said she received a report from the previous nurse that CR #1 was a fall risk, chair-bound, and confused. RN C said CR#1 was sitting in his wheelchair by the nursing station, facing the front door of the facility, when she went down the 100 hall to check on another resident. RN C said the Weekend Supervisor called and told her that CR #1 was outside the facility premises, by the car wash. RN C said she went out to the car wash with the weekend supervisor and assisted CR #1 back to the facility. RN C said she did head to assessment, and CR #1 had no injuries. RN C said CR #1 could not be outside by himself because he was cognitively impaired, and he could have gotten kidnapped or gone into the road. During an interview on 06/25/25 at 4:07 p.m., R N said CR# 1 approached the front door and made sounds, but she did not understand him. R N said she assumed CR #1 wanted to go outside, and she opened the door for him and let him out unattended. She said she did not know if CR #1 could go out by himself and did not ask other staff members. She said he might have exited the parking lot gate when a car entered the facility. R N said she was not aware of the wandering/elopement binder at the reception desk until after the elopement when the administrator brought the wandering and elopement binder to the reception desk. R N said she was under the assumption that residents sign out when they want to leave the facility premises, not when they want to sit outside the front door of the facility. That was why she let CR #1 out the door without him signing out. R N said she no longer work for the facility and her last day was on 06/21/25. During an interview on 06/25/25 at 4:47 p.m., the Administrator said R N told her she let CR #1 out the front door without checking the elopement binder or asking the nurse to make sure CR #1 could go outside by himself. The Administrator stated that R N said she let CR #1 out of the facility through the front door around 9:15 a.m. but was unsure of the exact time. The Administrator said the DON called her and notified her about CR#1 elopement and she came to the facility about 9:45 a.m. When the surveyor asked the Administrator what could have happened to CR #1 when he went outside the facility premises, the Administrator responded that CR #1 could have seen his loved ones while at the care wash. During an interview on 06/25/25 at 4:50 p.m., The DON said CR #1's BIMS score was 2 out of 15 (which indicated severe cognitive impairment). She said he should not have gone outside to sit by himself because he was cognitively impaired. The DON said residents who leave the building must sign out, but it would not have been appropriate for CR #1 to sign out because he had an impaired memory. The DON said R N should have asked a nurse or checked the wandering and elopement binder at the receptionist's desk before letting CR# I out of the building. The DON said anything could have happened to CR #1 when he was by the car wash. During an interview on 06/25/25 at 6:10 p.m., CR #1's RP said the facility called and notified her that CR #1 had left the facility premises, and the staff assisted him back to the facility. CR #1's RP stated that CR #1 was anxious and confused due to his new environment, and the facility should not have allowed him outside the door. Record review of the facility incident and accident dated 08/15/22 read in part incident is defined as an occurrence or situation that was not consistent with the routine care of a resident . Record review of the facility elopement and wandering resident read in part . elopement occurs when a resident leaves the premises or a safe area without authorization .#4. Monitoring and managing residents at risk for elopement or unsafe wandering .4a. resident will be assessed for risk for elopement or unsafe wandering upon admission and throughout their stay by interdisciplinary care team .4c. interventions to increase staff awareness of the resident's risk, modify the resident's behavior 4d. adequate supervision will be provided to help prevent accidents or elopements. Record review of the corrective actions' facility implemented facility beginning on 06/21/25. The facility had AdHoc QAPI Meeting was held on 06/21/25 and it was attendees were the Medical Direction, The Administrator, and DON. The summary and plan: indicated CR #1 observed on the side work outside the facility gate. Staff member who went on break a t a store across the street from the facility approached CR #1 and attempted to redirect him back to the facility. One of the CNAs called ADON who then sent additional staff to assist with redirecting CR #1 back inside the facility. Plan: The facility has an elopement book with resident pictures and resident consent forms for resident who are able to sign out the facility. All new residents will receive BIMS assessment and elopement/wandering assessment. All current facility staff have been in serviced on wandering resident and elopement. All new staff will be in serviced upon hire regarding wandering and elopement. Performance Improvement Plan: Issue: CR#1 left the facility premises and was outside the gate of the facility, by facility staff and brought back without incidence. The following was completed on 06/21/25: CR #1 was returned to the facility with 15 minutes by staff. Head count. No concerns identified Medical Director notified MD and RP notified Head to toe evaluation assessment completed for CR #1 CR #1 transferred to a facility with secured unit Immediate interventions on 06/21/25 and 06/22/25 Wandering evaluations completed for all facility residents to identify other residents at risk for elopement Elopement/wandering binder reviewed and updated as indicated Resident current BIMS score reviewed to confirm residents able to leave the facility unsupervised. Book reviewed and updated as indicated Exit doors checked for securement and function of alarms Exit gate checked for proper function Elopement drills completed all shifts Reeducation on 06/21/25: : (In service on elopement) The Administrator and/ or designee reeducated facility staff on the facility's Elopement and Wandering procedures, as well as Abuse and Neglect. Reeducation included identification of current residents who are elopement/ wandering risk and methods of identifying new elopement/ wandering risk, as well as identifying residents who can sign themselves out and leave the facility unsupervised. Pre and posttest were completed by staff to validate their understanding of the processes. Systemic Changes: 06/22/25, Education on Elopement and Wandering, to include pre/ posttest on first day of hire/ rehire for facility staff. Monitoring Outcomes: Effective 06/22/25, the Administrator and/ or designee will validate staff's understanding of elopement procedures by quizzing staff and completing questionnaires for random staff from all disciplines, all shifts including receptionist weekly for four weeks, then monthly for two months. The Administrator and/ or designee will conduct elopement drills on all shifts monthly for three months. Record review of the facility in-service dated 06/21/25 revealed staff were in serviced on resident leaving facility/elopement and wandering. Residents have the right to sign themselves out of the facility on pass for up to 72 hours at a time. Residents must sign out using the sign out book. There is a sign out book and an elopement book located at the receptionist desk and the nurse's station. In the elopement book there are pictures of residents who are a wandering risk and if they are going towards a door nursing staff must be notified immediately to redirect the resident. The Administrator and DON must be notified as well for any elopement risks. There are also consent forms located in the elopement book for all residents who are able to sign themselves out. If the resident does NOT have a signed consent form located in the book, you must make sure the resident stays within eyesight during the entire exit attempt and notify any facility staff currently working to assist also the DON and Administrator must be notified. Failure to follow the company protocol will result in disciplinary action, up to and including termination. record review of the facility elopement [NAME] revealed the facility completed wandering evaluation on CR #1 and all the resident in the facility after the elopement on 06/21/25. Record review of the facility incident binder revealed the facility completed BIMS for CR #1 and all the resident in the facility on 06/21/25. During an interview on 06/27/25 between 10:25 a.m. and 10:45 a.m., Resident #51 stated that the facility staff did not allow him to go out the front door by himself, but he could go through the back door, which required a code. Resident #51 said the staff would let him out because it was fenced in. Residents #25, #72, #77, #80, and #298 said they could sign out and go out through the front door and sit on the porch or leave the facility, but they have to sign out and sign back in when they entered the facility. During interview on 06/ 25/25 between 2:02 p.m. through 5:56 p.m. LVN R, R N, R G, RN C, CNA L, LVN U, CNA S, CNA B and on 06/26/25 between 9:58 a.m., and 4:30 p.m., LVN N, LVNK, LVN M, CNA K, CNA I, CNA J, CNA P, ADON, Office Manager, and HR were able to state they had a service on wandering and elopement. They said the facility had two binders: one for residents who could sign out and the other for those who could not sign out by themselves (the wandering/elopement binder). They said all residents must sign out before leaving from the front door. They said if a staff member was unsure whether a resident could leave through the front door, then the staff member must review the binders and ask the nurse before letting any resident out the front door. They said they had to lay eyes on their residents during rounds and monitor any residents who wander. They said if the staff could not find any resident, they had to report to the nurse, and the nurse would call Code Pink and notify management. The staff would start by searching all parts of the building and outside the building. The administrator would be the contact person for the facility. During an interview on 06/25/25 at 5:10 p.m., the Administrator said the DON notified her, and when she came to the facility, they (the medical director and DON) had QAPI. At the same time, RN C assessed CR #1 and placed him on 1:1 care until he was transferred to another facility around 4:30 p.m. on 06/21/25. The Administrator stated that the staff received in-person training on wandering and elopement, and electronic training was sent to all staff. No staff member was allowed to work unless they had completed the in-person training on wandering and elopement. The Administrator stated that the in-service was based on the facility's policy regarding accidents, supervision, and wandering/elopement. The Administrator stated that they had updated the two binders: one for elopement/wandering, which included pictures of the resident, and the other binder for residents who could sign out, containing the necessary consent forms. She said the binders are kept at the nursing station and the receptionist's desk. She also said R N(receptionist) no longer works for the facility. During an interview on 06/25/26 at 5:30 p.m., the DON said the weekend supervisor notified that CR #1 had left the facility premises, and she notified the administrator. The DON said she came to the facility on [DATE] and had a QAPI meeting, and then she started head count for all the residents in the facility. She said CR #1 was assessed and placed on 1:1 until he was transferred to a secured facility. The DON stated that the IDT team assisted with reviewing all resident BIMS and elopement risk assessments and updated the elopement binder and sign-out binder accordingly. The DON said she placed One set of binders at the nursing station while the other at the receptionist's desk. The DON stated that she notified CR #1's RP, CR #1's physician and risk management. Observation on 07/27/ at 2:30 p.m., revealed the alarm on the door would go off, the receptionist had the remote control for the door. Observation on 07/27 at 2:45 p.m., revealed regular wheelchair would not trigger the electronic gate to open.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure the resident environment remained free of accidents hazards and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents hazards. The facility failed to ensure that Resident #1, who was a two-person transfer using the mechanical lift . was transferred using the mechanical lift instead of a one-person manual lift. Resident #1 sustained a tibial plateau fracture to the right knee (a break at the top of the shinbone involving the cartilage surface of the knee joint). An Immediate Jeopardy (IJ) was identified on 03/18/2024 at 2:30PM. The Administrator was notified. The Administrator was provided with the IJ template on 03/18/2024 at 2:30PM. While the immediacy was removed on 03/21/2024 at 6:18PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure resulted in Resident #1 sustaining a fracture to the leg and could place other residents at risk of pain, injuries, and hospitalization. Findings included: Record review of Resident #1's electronic face sheet dated 03/16/2024 revealed a [AGE] year-old who was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (a disease in which the immune system attacks the protective layers of the nerve fibers and causes inflammation and lesion making it difficult for the brain to send signals to the rest of the body); paralysis affecting the right and left side of the body; contractures to the left elbow; muscle contractures to multiple sites; disorders of bone density and structure; vitamin D deficiency; bipolar disorder (mental illness characterized by extreme mood swings); Hypertension (elevated blood pressure); anxiety disorder, dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities) and seizure disorders. Record review of Resident #1's undated admission packet revealed she was originally admitted to the facility on [DATE]. Record review of Resident #1 annual MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 indicating intact cognition. Resident #1 had functional limitation in range of motion and had impairment to the upper and lower extremities. She used a wheelchair for mobility. Resident #1 was dependent on helpers when transferring to and from a bed to a chair. Resident #1 provided none of the effort to complete transfer activity. Record review of Resident #1's undated care plan revealed: Focus - Resident #1 had ADL self-care performance and mobility deficit r/t dementia, multiple sclerosis, limited mobility, limited range of motion. Date initiated was 04/03/2017. Interventions included - resident unable to ambulate with or without assistance, resident requires total assistance by 2 staff for transfers with mechanical lift. Date initiated was 04/13/2017 and revised on 07/26/2022. Focus - Resident #1 was at increased risk for stress fractures, pain, falls, impaired mobility secondary to diagnosis of osteoarthritis (inflammation of one or more joints). Date initiated was 05/02/2022. Record review of Resident #1's undated active physician orders revealed an order for mechanical lift for transfers with 2 staff, every shift with the start date of 01/10/2024. Record review of Resident #1's Hospital Discharge Summary with the encounter start date of 03/14/2024 read in part: .Chief Compplaint, Patient presens with Trample/strike injury, complained of right knee pain during transfer at facility from wheelchair to bed, patient's right knee got twisted . Further review revealed a CT scan (computer processing to create cross-sectional images of the bones) result of an acute tibial fracture to the right knee. Further review revealed the resident also complained of pain to the left lower extremity. An x-ray of the left lower leg showed mild soft tissue swelling around the ankle. Resident #1 was admitted to the hospital on [DATE] then released to the facility on 3/16/2024 with a right knee immobilizer. Record review of Resident #1's progress note dated 03/13/2024 at 10:39 PM, written by LVN A, revealed the resident sustained pain to the right leg and swelling to the knee when she was transferred from the wheelchair to the bed. Her pain level was 7 out of 10 and was administered routine pain medication and Tylenol was ordered at 6:30 PM. Later, her right knee was swelling. The resident complained of pain when the knee was touched. RP and MD were notified. Record review of Resident #1's progress note dated 03/15/2024 at 4:19 PM, written by LVN B revealed the resident returned from the hospital, x-rays were done at the hospital and the resident had a fracture to the right leg below the knee, closed splint in place. Record review of the facility's investigation report revealed CNA B transferred Resident #1 due to not being able to locate the mechanical lift. Further review revealed per LVN A, no one reported any issues with locating the mechanical lifts. Observation and Interview on 03/16/2024 at 11:20 AM, Resident #1 was lying in bed on her back and awake. She had a soft leg splint to the right leg that extended from above the knee to the ankle. Resident #1 stated that on Wednesday 3/13/24 at around 4:15 PM, she was transferred from the motorized wheelchair to the bed by CNA A and CNA B. She stated she was told by the CNAs that they could not find the mechanical lift. Resident #1 stated CNA B kept saying, I can transfer her from the chair, I got this, and CNA A kept saying that it was not the right way to transfer her, but CNA B was saying I got this. Resident #1 stated her feet were still on the footrests of the wheelchair and CNA B transferred her by grabbing and lifting under both arms. Resident #1 said she wore shoes on her feet. Resident #1 stated then her right knee would not move, that was when CNA A moved her right leg off the footrest. Resident #1 stated if her feet were on the floor she could have turned. Resident #1 stated she was supposed to be transferred using only the mechanical lift. She stated she felt pain immediately after she was transferred. She stated CNA A told LVN A about her pain and LVN A gave her pain medication. Resident #1 stated she was sent to the hospital and the doctor told her she had a fracture below the right knee and that she did not need surgery, just a splint. Resident #1 stated she was very angry that this happened. She stated she already had anxieties especially after they dropped her once from the mechanical lift in 2021 and she had to go to the hospital. Resident #1 stated she knows there were more mechanical lifts, but some lifts were not good, they did not turn or go all the way down. Resident #1 currently stated her pain level was 7 out of 10 and that the pain meds she had been receiving had not taken away the pain completely. She stated she may not have the use of her legs, but she could definitely still feel pain. Observation on 03/16/2024 at 1:45 PM revealed there was a mechanical lift being used on a resident on the 200 Hall. Observation and interview on 03/16/2024 at 4:25 PM, the Maintenance Assistant demonstrated that two other mechanical lifts were functioning. The Maintenance Assistant said one was found in the shower room on 500 Hall and the second mechanical was on the 100 Hall. Interview on 03/16/2024 at 4:08 PM, the Maintenance Assistant stated there were 3 working mechanical lifts and 2 that were not working. He stated that on 03/13/2024, he found 5 batteries and only one was not charging. He stated the repair service company was scheduled to come to the facility on 3/19/2024. Interview on 03/16/2024 at 6:00 PM, the Administrator stated she was in the process of conducting the accident investigation involving Resident #1 and that there were 3 mechanical lifts working and available the day of the incident (3/13/2024). In a telephone interview on 3/17/2024 at 9:42AM, CNA A stated she started her shift at 2:00 PM on 3/13/2024 and Resident #1 was already in her wheelchair. CNA A stated at around 4:30PM Resident #1 wanted to get back into bed as she had been up all day and her brief was wet. So CNA A searched for the mechanical lift. CNA A stated she always used the mechanical lift to transfer Resident #1. CNA A stated she found one, but it did not have a battery, so she decided to transfer another way but needed help. She stated CNA B told Resident #1 that they could not find the mechanical lift and that she would transfer her. CNA A stated Resident #1 said OK but to watch her legs because they were fragile. CNA A said her plan was to back the wheelchair up to the head of the bed and two people would lift/slide the resident onto the bed by using the mechanical lift sling and pad that the resident was sitting on and this was the safe way to transfer. CNA A said she told CNA B about the plan, so she moved to the other side of the bed waiting to grab the sling and pad. CNA A said CNA B said no, she could transfer the resident herself. CNA A stated she tried to help but CNA B kept saying she got this. CNA A stated she saw that the resident's feet were still on the footrest and that was a mistake, her feet should have been on the ground. CNA A said CNA B was fast and grabbed Resident #1 under both arms and as she was moved, Resident #1 started hollering and said ow, ow! Resident #1's legs were caught between the bed and wheelchair. CNA A stated she lifted both legs and pushed the wheelchair out of the way. CNA A said after CNA B put the resident into the bed, she left the room. CNA A stated, as she was changing Resident #1's brief, the resident was mad and told her that CNA A did offer to help CNA B. CNA A stated she notified the nurse who then gave the resident some Tylenol. CNA A stated she checked on Resident #1 later and noticed her right knee was swollen and she notified the nurse. CNA A stated that during her last round for the evening she decided to search again for the mechanical lift and with the help of another staff, she found one in a bathroom that was locked and needed a code to get in. CNA A stated since she started training at the beginning of March 2024, she was told there was only one mechanical lift. CNA A stated she recalled during orientation receiving papers to read and that information about the mechanical lift was included but did not recall if she had one-on-one training. CNA A stated that where she worked before, if the mechanical lift was unavailable, she would transfer using the pads to slide the resident onto the bed. On 03/17/24 at 11:48AM, an attempt was made to contact CNA B via telephone for an interview. Unable to leave a message. In a telephone interview on 3/17/2024 at 11:05AM, LVN A stated that on 03/13/2024 at 6:00 PM, the caregiver notified him that Resident #1 had complaints of pain to her right leg and he went to the resident's room to assess her. LVN A stated the CNA (he did not recall the name of CNA) told him the resident was transferred to the bed and that they carried her because they could not find the mechanical lift. LVN A stated the CNA told him there were 2 CNAs (he did not know the names of the two CNAs) and she wanted to transfer the resident together, but the other CNA did not want to and transferred the resident by herself instead. LVN A stated he asked both the CNAs why they did not tell him, and they did not reply. LVN A stated he gave Resident #1 Tylenol for pain and at 6:30 PM she denied any pain. LVN A stated at 8:00 PM he gave the resident the scheduled Tramadol and resident denied pain. LVN A stated then the CNA notified him that the resident's leg was swollen. LVN A stated the right knee was swollen, and she screamed when he touched the knee. LVN A stated he placed a call out to the MD, notified the family, and the DON. LVN A stated the DON asked what happened and he stated the aides did a manual transfer. LVN A stated Resident #1 was supposed to be transferred using the mechanical lift because she had MS, was immobile, was total dependent care and was only able to talk and eat. LVN A stated he had only known of one mechanical lift that was on 200 Hall because this was what he saw all the time and aides from other halls would come to 200 Hall and take it when needed LVN A stated the CNAs should have reported to him that they could not find the mechanical lift and that if they had, he would have said not to transfer her that he would find another plan to get the resident to bed safely such as call for more staff to help. Interview on 03/18/2024 at 12:18 PM, CNA C stated there had been issues with the mechanical lifts for about 2 weeks and it started before 03/13/2024. CNA C stated the batteries would die, the feet on the mechanical lifts did not work but she understood they were being repaired. CNA C stated it would take her 45 minutes to find a mechanical lift because everyone needed them. Interview on 03/18/2024 at 12:30PM, Resident #1 stated she had never been transferred manually before this incident since she got the motorized wheelchair 4 years ago. Resident #1 stated she had not been evaluated by Therapy for transfers in the past 4 years. Interview on 3/18/24 at 12:45 PM, the DOR stated that Resident #1 had always been a mechanical lift transfer since she was first admitted due to her medical conditions. The DOR stated the resident would often make her own rehab appointments for offsite therapy and that the only evaluations the facility had for Resident #1 was for splints to the elbows. The DOR stated the facility changed from using PCC (healthcare software provider) to Matrix and it was unknown where, if any, therapy evaluations for transfers would be located for Resident #1. Interview on 3/18/24 at 1:00PM, the Administrator stated she could not recall exactly but thought it was about 2 weeks ago when she was made aware there were issues with the mechanical lifts and did not recall who told her about the issues. The Administrator stated it was during a meeting when it was discussed that new mechanical lifts may need to be purchased The and that there were 2 quotes for new mechanical lifts but needed a 3rd quote. The Administrator stated she was also waiting for Corporate to make the decisions on whether to purchase or make repairs. Interview on 3/18/24 at 1:30PM, the Central Supply Coordinator stated she got 2 quotes for mechanical lifts on 2/8/2024 and was asked by Administrator to get a third which she received the quote on 3/18/2024. Interview on 03/20/2024 at 9:30 AM, the DON stated she was notified that Resident #1 had pain to her leg after being transferred. The DON stated CNA B told her that she was asked to assist with the transfer and that both CNA B and CNA A did the transfer. The DON stated that CNA B was not aware of Resident #1's leg pain. The DON stated CNA A told her she could not locate the mechanica lift and that CNA B decided to transfer Resident #1 herself after CNA A told her she was a 2-person transfer. The DON stated the CNAs should have used the mechanical lift per the resident's care plan and that CNA A should have notified the nurse if she could not find the mechanical lift. The DON stated the risk to the resident if not transferred properly was injury, fall and injury to the employee. The DON stated action was taken to suspend CNA A, CNA B and LVN A pending the investigation. Interview on 3/21/2024 at 2:00 PM, the Administrator stated she was getting another quote because the third quote for mechanical lifts came in high and this was part of the delay in decisions regarding the mechanical lifts when the monthly inspections came up. She stated she was not notified of any issues with the mechanical lifts then the incident with Resident #1 happened. The Administrator stated the incident involving Resident #1 had less to do with the mechanical lifts but more to do with the CNA who did the manual transfer. The Administrator stated she would terminate CNA B. Record review of the facility's mechanical lift service invoice dated 2/21/24 revealed there were 5 of 5 mechanical lifts that were inspected. Two of the 5 mechanical lifts required repairs. Record review of the facility's policy and procedure for Safe Lifting and Movement of Residents, revised on July 2017, read in part: In order to protect the safety and well-being of staff and residents, and to promote quality care, the facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation, 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible .8. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being recharged . Record review of the facility policy and procedure for Activities of Daily Living, Supporting, revised March 2018, read in part: .Policy Interpretation and Implementation .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .b. mobility (transfer and ambulation, including walking) . On 03/18/2204 at 2:30 PM, an Immediate Jeopardy (IJ) was identified. The Administrator was notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested ant the time. The following Plan of Removal submitted by the facility was accepted on 3/19/2024 at 6:00 PM. Immediate interventions: Plan of Removal: All direct care nursing staff will be in-serviced on the following- o DON and designees In-serviced direct care clinical staff on Mechanical Lift Transfers (Who requires ML, how many staff assistance is needed, how to use the ML, Resident Profiles to determine residents needs POC), Mechanical Lift Location/Passcodes for shower rooms where/battery stations are located (where to locate and store ML when not in use, where the charging stations are located, the passcodes to shower rooms where charger stations are located). Completion Date: 3/19/2024 o DON and designees audited employee roster to ensure 100% of direct care clinical staff are in serviced regarding Hoyer Transfers, Hoyer Location, Passcodes for shower rooms where battery stations are located. Completion Date: 3/19/2024 o DON and designees in-serviced regarding Abuse/Neglect/Exploitation/Reporting to the Abuse Coordinator (What is abuse, who to report to, reporting immediately), Resident Rights (Review of resident rights), Maintenance Binder to log areas of concerns prompting follow-up (Where binder is located, how to complete log for all issues). Completion Date: 3/19/2024 o DON and designees audited employee roster to ensure 100% of staff are in-serviced regarding Abuse/Neglect/Exploitation and the Reporting of to the Abuse Coordinator, Resident Rights, Maintenance Binder to log areas of concerns prompting follow-up. 3/19/2024 o DON and Designee completed competencies for all direct care clinical staff through Skills Check-Off for Mechanical Lifts. Completion Date: 3/19/2024 o DON and Designee audited employee roster to ensure 100% of direct care clinical staff complete Skills Check-Off for Mechanical Lifts. Completion Date: 3/19/2024 o Administrator/Designee conducted an assessment of working Mechanical Lifts (3 Mechanical Lifts) and total number of residents requiring Mechanical Lift (48 residents) to determine sufficient amount of equipment. Completion Date: 3/19/2024 o Administrator/designee audited and serviced all Mechanical lifts to ensure sufficient number of Mechanical Lifts (3 working Mechanical Lifts) are available. Completion Date: 3/19/2024. o Through observations nurses validated CNAs are utilizing Mechanical Lifts for all residents requiring Mechanical Lifts for transfers. Completion 3/19/2024. o Acknowledgement sheets signed by all direct care staff acknowledging their understanding of the importance of and expectations of how to identify and utilize resident's requiring mechanical lifts, how to use the mechanical lifts, where the mechanical lifts are located, how to charge a mechanical lift, what the codes are for each Shower room, and how and where to report concerns surrounding Mechanical Lifts maintenance issues. Completion Date: 3/19/2024 Demonstration of and acknowledgement that all direct care nursing staff are aware of the above- o DON/ DON Designee will contact all direct care nursing staff to obtain signature and return demonstration on site or via Facetime with demonstration and acknowledgment, however, if unable to obtain face to face or visual presentation a verbal acknowledgement will be obtained along with 2 signatures by DON/DON Designee to serve as a return demonstration of understanding that- o they are aware of how to identify and utilize resident's requiring mecq.anical lifts, how to use the mechanical lifts, where the mechanical lifts are located, how to charge a mechanical lift, what the codes are for each Shower room, and how and where to report concerns surrounding Mechanical Lifts maintenance issues. Completion Date: 3/19/2024 o DON/ DON Designee will remove all direct care staff from schedules and will not be allowed to provide direct resident care until all training has been completed. Items discussed were: IJ (Immediate Jeopardy) was cited on 3/18/2024 as evidenced by facility's failure to: F689 Free of Accident Hazard/Supervision The facility failed to use the mechanical lift device as determined necessary by physician orders during a transfer from Resident #1's wheelchair to the bed resulting in the resident sustaining a fracture to the right tibia below the knee requiring hospitalization. Training for all direct care nursing staff will include: o In-serviced all direct care clinical staff on Hoyer Transfers, Hoyer Location, Passcodes for shower rooms where battery stations are located and Maintenance Logs. o All direct care clinical staff are in-serviced regarding Hoyer Transfers, Hoyer Location, Passcodes for shower rooms where battery stations are located. o All direct care clinical staff complete Skills Check-Off for Mechanical Lifts. o DON/designee will randomly observe direct care nursing staff demonstrate how to locate and utilize the Mechanical Lift. o All direct care nursing staff were contacted in person or by phone and verbally in-serviced. o All direct care nursing staff in-services will be completed by 2pm 03/19/2024. Results of all observations will be reviewed by the Interdisciplinary Team to ensure that proper adherence to this process is met. Any deviations or omissions will be addressed immediately with staff member. Monitoring of the POR included the following: On 03/20/2024 at 8:45 AM to 3:00 PM and on 03/21/2024 at 11:30 AM to 5:30 PM, observations were made, records were reviewed, and direct care nursing staff were interviewed. During an observation on 03/21/2024 at 1:00 PM, there was a mechanical lift at the end of 300 Hall, a second at the end of 500 Hall and a third at the end of 100 Hall. Battery charging stations were located at all shower rooms in the 100 Hall, 300 Hall, 400 Hall and 500 Hall. There was no battery charging station at the 200 Hall shower room. Observed the codes to the shower rooms were on the doors to the shower rooms. During an observation on 03/21/2024 at 1:30 PM in the 100 Hall, CNA D and CNA E were using a mechanical lift to transfer a resident from the wheelchair to the bed without any issues. During an observation on 03/21/2024 at 5:15 PM, the Maintenance Logbook was located at the nurse station. Direct care nursing staff who worked days, evenings and night shift were interviewed. A total of 15 nursing staff were interviewed: 1 RN, 4 LVNs and 10 CNAs. Nurses and CNAs were able to verbalize their understanding on the use of Mechanical lifts and that 2 staff members were required to operate the lift when transferring. Nursing staff were able to explain where to find the Resident Profiles to determine residents needs on the plan of care. Nursing staff stated they knew there were at least 3 mechanical lifts were functioning and available and that they were stored in the back of each hall. Nursing staff stated they knew the battery charging stations were currently in hall shower rooms. Nursing staff stated they knew the codes to the shower rooms were written on the doors and that the other charging boxes were being repaired. The Nursing staff were able to verbalize their understanding of what to do if the mechanical lifts needed repair and to log the work order promptly into the Maintenance Logbook which was located at the nursing station. The Nursing staff were able to state the inservices for mechanical lift transfers, abuse and neglect, resident rights, abuse reporting procedures were conducted over the last few days and that the mechanical lift inservice was conducted by the DOR and Nurses. The nursing staff were able to state the inservices consisted of verbal, written, and demonstrations with return demonstrations for mechanical lift transfers and manual transfers. On 03/21/2024 at 4:00 PM the DOR stated in person demonstrations and return demonstrations on the use of mechanical lifts and manual transfers were conducted with staff on site. The DOR started the nurse would be able to observe the halls and see when the CNAs were bringing the mechanical lifts into resident rooms. On 03/21/2024 at 4:15 PM the DON stated staff who worked PRN or worked infrequently were inserviced via facetime and videos and were sent inservices and quizzes. The DON stated upon their return to work they would conduct the one-on-one trainings. The staff would double sign by their names when completed. The DON stated if staff were on leave or were absent during the inservices that they would have to do the skills check list before they would be put on the schedule. The DON stated there were currently 4 staff members out on leave. On 03/21/2024 at 4:25 PM The Administrator stated 24 of the 48 residents rarely got out of bed or preferred to remain in bed. The Administrator stated when the Mechanical Lift Assessment Analysis was conducted, the use of mechanical lifts was observed and timed and that was how she knew it would take 15 minutes to transfer a resident. The Administrator stated with the calculation it was determined that 3 mechanical lifts would be enough. On 03/21/2024 at 5:15 PM, LVN C stated he ensures CNAs on his hall were up to date on the residents transfer type needs by communicating with them frequently and throughout the shift. Record review of the undated Mechanical Lift Assessment Analysis revealed it would take 15 minutes to transfer a resident and with 48 residents and 3 mechanical lifts, it would take 4 hours' time to transfer all residents who required the use of a mechanical lift. In an 8-hour shift there would be ample time with 3 mechanical lifts. Record review of the inservice records for Mechanical Lift use, location, passcodes, Resident profiles, Maintenance logbook, Abuse/Neglect/Exploitation, Reporting to the Abuse Coordinator, Resident Rights and skills competency check lists for mechanical lifts were completed by 03/19/2024 and were signed by the staff. Record review of a service invoice dated 3/21/2024 reflected one of the mechanical lifts was removed with plans to be replaced, two other lifts had parts replaced and one mechanical lift had parts that were on order. The 5th and last mechanical lift did not indicate any repairs were needed per the invoice. Record review of the facility's Employee Counseling Report for CNA B dated 03/20/2024 and completed by the Administrator, read in part: .incident description: Improper transfer: Employee did not transfer resident's per resident's care plan . Record review of the sign in sheet, signed by department heads reflected an IDT meeting was held for the IJ F689 on date 03/19/2024. The Administrator was informed the immediate Jeopardy was removed on 03/21/2024 at 6:18 PM. The facility remained out of compliance at a scope of isolated at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated with serious injury due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #4) of 5 residents reviewed for resident rights. -The facility failed to notify and document notification of physician when LVN K rounded on Resident #4 and found oxygen saturation to be 85%. On [DATE] at 2:00 p.m an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] at 6:17 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could place residents at risk for receiving inadequate or untimely care. Findings include: Record review of Resident#4's face sheet dated [DATE] revealed he was an [AGE] year-old male admitted on [DATE] and readmitted from the hospital on [DATE]. The face sheet listed relevant diagnoses which included: Acute and Chronic Respiratory failure (condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), Hemiplegia (paralysis on one side of the body) following stroke (damage to brain from interruption of blood supply), Presence of a Cardiac Pacemaker (a small, battery-powered device that prevents the heart from beating too slowly), Atherosclerotic heart disease of native coronary artery (plaque buildup in the wall of the arteries that supply blood to the heart), Atrial Fibrillation (condition in which the heart's upper chambers beat chaotically and irregularly), and Hypertension (elevated blood pressure). Record review of Resident #4's Quarterly MDS assessment dated [DATE] revealed he had a BIMS score of 4, indicating severe cognitive impairment. Record review of Acknowledgement of Advance Care Planning dated [DATE] revealed Resident [#4] was full code status. Record review of Care Plan (undated) read in part .[Resident #4] was full code [[DATE]] . Approach: Monitor for changes in condition and status and promptly report to the MD . [Resident #4] was on oxygen therapy related to shortness of breath, dyspnea, and heart failure ,,, Goal: [Resident #4] will have no signs and symptoms of poor oxygen absorption through the review period . Approach: Monitor, document, and report signs and symptoms of respiratory distress such as; (r)espirations, pulse oximetry, increased heart rate, restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (collapse of part or all of lung), hemoptysis (coughing up blood), cough, accessory muscle usage, and skin color . Record review of vitals [last documented]: [DATE] [7:11 am] Pulse: 81 [DATE] [7:11 am] BP: 110/80 mmHg [DATE] [9:03 am] Respiration: 18 per minute [DATE] [9:03 am] Oxygen Saturation: 92% Record review of progress note dated [DATE] [6:20 am] revealed: Upon nursing rounds patient noted with abnormal breathing. Checked sats at this time and noted to be 85%. NC in place, no kinks observed, O2 water bottle, and NC replaced. Patient repositioned, HOB elevated. Floor nurse at bedside monitoring O2 level. Level up to 92% with O2 at this time. Patient breathing pattern stabilized. Call light in reach, bed in low position. CNA staff informed by floor nurse to monitor/check on patient regularly. Will continue to monitor. Interview on [DATE] at 12:13pm with the DON , she said a change in condition is a change from resident's normal or baseline. She said nurses are expected to report changes in condition to the primary provider (doctor) in case the doctor would need to make changes to an order or has another recommendation. She said failure to notify can cause a delay or inadequate treatment . Interview on [DATE] at 1:03pm with MD Z, he said he was unaware that Resident #4 was having difficulty with his oxygen levels the morning of [DATE]. He said the only call that he remembered from nursing staff was to tell him that they had to call 911 for Resident #4 . Interview with LVN K on [DATE] at 1:12 pm, she said she never had a set % oxygen saturation level to which she was instructed to call the doctor if it reached that level. She said the morning of [DATE], she was in and out of the room every 15 minutes checking on the resident after his morning episode of low oxygen. She said she could not recall whether or not she called the doctor to notify him of resident's low oxygen experienced that morning [[DATE] at 6:20am Oxygen sat 85%]. She said she called EMS around 9:00 am because he just didn't look good, and she contacted the resident's doctor, and RP at that time. She said the doctor should be notified of change in conditions so they know what it is happening and can adjust treatment or make a recommendation. She said in this instance, she was closely monitoring the resident and the resident seemed to be doing okay . Interview on [DATE] at 1:40 pm with the Administrator, she said that she started at the facility on [DATE] and had no prior knowledge of the circumstances surrounding the death of Resident #4. She said her expectation would be for nursing staff to, at minimum, document by exception meaning that anything that is outside of a resident's normal should be documented and the physician notified. She said the failure to notify physician of change in condition can result in the resident not getting the appropriate care and possible decline. Record review of Change in Resident's Condition or Status Policy (2021) revealed: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): . d. significant change in the resident's physical/emotional/mental condition . i. specific instruction to notify the physician of changes in the resident's condition . 2. A significant change of condition is a major decline or improvement in the resident's status that: . q. will not normally resolve itself without intervention by staff . 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the interact SBAR communication Form. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 2:00 pm The Administrator, the DON, the Assisting Administrator, and the CNC were notified. The administrator was provided with the IJ template via email on [DATE] at 2:17 pm. The following Plan of Removal submitted by the facility was accepted on [DATE] at 12:55 pm: The Texas Department of Health and Human Services entered Windsor Houston on [DATE], for a follow up on a Complaint Survey on a P1 that initiated on [DATE]. During the survey process an IJ (Immediate Jeopardy) was cited on [DATE] regarding - F580 as stated below: In-which resident #4 was transferred from facility to ER via EMS where he expired. Plan of Removal: F580 All direct care nursing staff will be in-serviced on the following- The expectation for all direct care nursing staff is to identify and document all change of conditions with the proper notifications to the MD, the RP, the DON, and the Administrator. The facility DON/ADON/Designee notified all direct care nursing staff of facility's policies regarding notifications, change of condition, reporting, and abuse and neglect. All direct care nursing staff will demonstrate and acknowledge that they are aware of how to identify a change of condition, how to complete an SBAR, and how to initiate the proper notifications. Specifically, where to locate the resident's medical history, to ensure they are capturing and can identify a change of condition to then have the proper documentation, and notifications in place. To access the employee will log into MatrixCare, select resident, then search resident by name, then select resident progress notes, residents face sheet for medical diagnosis, residents care plan, residents' orders, resident's vitals, and resident's observations/events, and residents' orders, to ensure the nursing staff member is familiar with the resident's baseline and level of care. The DON and designees audited employee roster to ensure 100% of direct care nursing staff are in-serviced regarding documentation, notifications, change in condition, and abuse and neglect. The training regarding identification of change of conditions and proper notifications will be an ongoing continuous training to be conducted quarterly with the first training completed [DATE]. Training will also be included in the new hire process for all direct care nursing staff which will include a skills competency. The DON/ADON during morning start-up will ensure that all change of conditions are captured with an SBAR along with the proper notifications. The training confirmations will be stored with their employee file in the Human Resources department. This is to include all direct care nursing staff and those with CPR certifications to cover the topics of: Importance of/and expectation that all licensed nursing staff will identify, and document all change of conditions with the proper notifications to the MD, the RP, the DON, and the Administrator promptly. The DON/ DON Designee will contact all direct care nursing staff to obtain signatures on site or via Facetime with acknowledgment, however, if unable to obtain face to face a verbal acknowledgement will be obtained along with 2 signatures by the DON/DON Designee to serve as an understanding of what the expectation is for all direct care nursing staff to identify and document all change of conditions with the proper notifications to the MD, the RP, the DON, and the Administrator promptly. On [DATE], the facility Administrator and the Director of Nursing notified Medical Director via phone. Items discussed were: IJ (Immediate Jeopardy) was cited on [DATE] as evidenced by facility's failure to: F580- Effective [DATE] the DON/ ADON/ designee will randomly observe direct care nursing staff demonstrate how to identify change of condition and when to do the proper notifications to the MD, the RP, the DON, and the Administrator. The DON/ADON/designee will conduct random observations with all direct care nursing staff of their ability to identify a change of condition and when to do the proper notifications to the MD, the RP, the DON, and the Administrator. All direct care nursing staff were contacted in person or by phone and verbally in-serviced. All direct care nursing staff in-services will be completed by 10:30AM on [DATE]. All direct care nursing staff will be made aware and provided with a copy of the facility's policies regarding change of condition, notifications, reporting, and abuse and neglect. The DON/ADON/designee completed a 100% audit of all Change of Conditions since [DATE] to ensure that the MD/RP was notified and documentation was in the resident's medical records . Monitoring: Record review of CPR certifications on [DATE] for all nursing staff listed, reflected all CPR certifications for nursing staff in report to be current. Record review of in-service trainings provided to direct care staff (licensed nurses) and other facility staff in contact with residents as part of the Plan of Removal. The following policies and protocols were reviewed: CPR on soft surfaces; Emergency Cart Checklist; AED, CPR, SBAR, Documentation, Notifying the MD, the RP, the DON, and the Admin; Stop & Watch, Abuse, Neglect, Exploitation, and Residents' Rights, Matrixcare Information, Mock Demonstration of Code Blue (CPR); Vital Signs return demonstration; CPR, Crash cart/Backboard. Interviewed 10 nurses across the three shifts who were able to verbally demonstrate knowledge gained from in-services. Interviewed 7 CNAs, 2 housekeepers, and 1 therapist who were able to verbally demonstrate knowledge gained from in-services. The Administrator, assisting Administrator, DON, and CNC were informed the Immediate Jeopardy was removed on [DATE] at 6:17 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate threat and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care and subject to related physician orders and the resident's advance directives for 1 of 1 resident (Resident #4) reviewed for basic life support, including CPR. -The facility failed to retrieve the automatic external defibrillator (AED) and initiate the basic life support sequence of events (chest compressions, airway, breathing) per the facility's Emergency Procedure- Cardiopulmonary Resuscitation Policy (CPR) for Resident #4. On [DATE] at 2:00 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] at 6:12 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place all residents who requested a full code status at risk of not receiving necessary life-saving measures, declining health, and death. Findings include: Record review of Resident#4's face sheet dated [DATE] revealed he was an [AGE] year-old male admitted on [DATE] and readmitted from the hospital on [DATE]. The face sheet listed relevant diagnoses which included: Acute and Chronic Respiratory failure (condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), Hemiplegia (paralysis on one side of the body) following stroke (damage to brain from interruption of blood supply), Presence of a Cardiac Pacemaker (a small, battery-powered device that prevents the heart from beating too slowly), Atherosclerotic heart disease of native coronary artery (plaque buildup in the wall of the arteries that supply blood to the heart), Atrial Fibrillation (condition in which the heart's upper chambers beat chaotically and irregularly), and Hypertension (elevated blood pressure). Record review of Resident #4's Quarterly MDS assessment dated [DATE] revealed he had a BIMS score of4, indicating severe cognitive impairment. Record review of Acknowledgement of Advance Care Planning dated [DATE] revealed Resident [#4] was full code status. Record review of Care Plan (undated) revealed: . [Resident #4] was full code [[DATE]] . Approach: Ensure order entered under advanced directive; Discuss code status and options with resident and family members at routine intervals as needed; Monitor for changes in condition and status and promptly report to MD . Emergency transport to hospital as indicated; Have crash cart ready; If resident found without a pulse, have someone call 911, send other nursing staff to assist with code, send crash cart to location of code, and notify the MD and the DON or designee of code being performed. Record review of vitals [last documented]: [DATE] [7:11 am] Pulse: 81 [DATE] [7:11 am] BP: 110/80 mmHg [DATE] [9:03 am] Respiration: 18 per minute [DATE] [9:03 am] Oxygen Saturation: 92% Record review of progress note dated [DATE] [9:10am] by LVN K revealed that Resident #4 was nonresponsive with oxygen saturation of 82%. The resident did not respond to sternal rub. Portable oxygen tank was brought into the room and patient placed on non-rebreather mask at 15 liters. 911 notified. The MD notified and the RP contacted. Floor nurse [LVN K] remained with resident until 911 arrived. Eyes fluttered. Record review of progress note dated [DATE] [9:18 am] by LVN K revealed 911 here. Patient unable to arouse. CPR initiated by 911 staff. Floor nurse notified (family member) of what's going on. Patient FULL CODE. Record review of EMS Unit Incident Details revealed the call to 911 was received on [DATE] at 9:11 am. EMS arrived to the facility at 9:30am and arrived to the patient [Resident #4] at 9:32 am. EMS left the facility at 9:56 am and arrived at the hospital at 10:08am. The Clinical Info Narrative section revealed: [Resident #4} was found by nurse lying in bed unresponsive and contacted for EMS assistance. [EMS] arrived to find pt unresponsive with absent pulses and absent respirations and no bystander CPR. Pt was moved to the floor and AED protocol administered, I-gel (a medical devices that facilitate oxygenation and ventilation without endotracheal intubation) was established and CPR administered . Pt [Resident #4] was transported to hospital and transferred to ER nurse and pronounced dead. The Special Circumstances revealed date and time of cardiac arrest: [DATE] at 9:06 am. Arrest witnessed by: Other Healthcare Provider. AED use Prior to EMS arrival: Yes, without defibrillation. First monitored Arrest Rhythm of Patient: Unknown AED Shockable Rhythm, Date and Time Last Known Well: [DATE] at 9:03am. Any return of spontaneous circulation: No, Who Initiated CPR: HFD First Responder . Who first applied the AED: HFD First Responder (Eng/Lad). [Resident #4 Pronounced Dead in ED ]. Record review of Hospital ED report revealed CPR in progress upon arrival [[DATE] at 10:08am]. Patient sent from nursing facility, found by nursing staff unresponsive without oxygen. No bystander CPR. EMS unit began CPR at 9:08am. 7 shocks 3 epi (drug used to reverse cardiac arrest) given by EMS. Time of death called at 10:21 am. Record review of Resident #4's certificate of death dated [DATE] revealed immediate cause of death was complications from chronic respiratory failure. Interview on [DATE] at 8:22 am with LVN K, she said she came to check on the resident around 9am on [DATE]. He had been having breathing difficulty that morning, and she said she and an aide were doing 15-minute rounds [no documentation]. She said around 9:00 am, Resident #4 just started to look unwell, and she called 911. She said oxygen levels decreased to 82%. She said resident's doctor and RP was notified. She said Resident #4 was still responsive with a pulse at this time, so she did not initiate CPR. She said EMS arrived in approximately 5-10 minutes. LVN K said she was unsure exactly of when Resident #4's vitals started to decline, but it happened between the time she called 911 and when they arrived. She said that Resident #4 was a large man and she and an aide were in the process of getting him to the floor when EMS arrived. She said that EMS immediately took over upon arrival and started CPR . Observed on [DATE] at 1:05 pm, the facility crash cart and AED machine located near the nursing station, adjacent to the dining room. Observed no back board on the crash cart, however, the DON found it between the wall and a different cart parked adjacent to the crash cart [not immediately visible]. Interview on [DATE] at 1:12 pm with LVN K, she said she called EMS because he just did not look good, however, Resident #4 did have a pulse which was why CPR was not initiated at that moment. She said she does not know when he ceased to have a pulse. She said she and CNA H were preparing to lower Resident #4 to the floor in case they had to do CPR. She said by the time they had gotten him down; EMS came in and took over. They immediately started CPR. She said CPR could not be done in the bed because it was not a firm surface . Interview on [DATE] at 1:23 pm with CNA H, she said that on [DATE] she witnessed LVN K frequently checking on Resident #4 through the morning. She said around 9am, LVN K called the ambulance for Resident #4 because he was not looking too good. CNA H said the paramedics arrived quickly. She said Resident #4 was a big man, and it took her and LVN K about 10 minutes to lower the bed and get the resident down to the floor in preparation to begin CPR. She said by the time he was down, the paramedics had already arrived and they took over. CNA H said that she could not say anything about Resident #4's vitals at the time because she did not recall. She said the resident had an air mattress which was why CPR could not be done in the bed. She said she was not familiar with a backboard and did not know the facility had one . Interview on [DATE] at 12:13pm with the DON, she said when a resident codes, whoever was with the resident should call for help and stay with the resident. If the resident was a full code, the resident should be placed on a hard, flat surface while someone else brings the crash cart and AED. Once on, the AED would give instructions and staff would continue CPR until there was a pulse, or 911 arrived, or if the doctor called it and says to stop. She said if the resident was in bed they should be placed on a hard, flat surface. The policy did not specify surface type. She said if the resident were of large stature and in bed, then the resident should have been placed on a backboard. She said failure to implement basic life saving measures could possibly cause harm or death. Interview on [DATE] at 1:03pm with MD Z, he said he was unaware that Resident #4 was having difficulty with his oxygen levels the morning of [DATE]. He said the only call that he remembered from nursing staff was to tell him that they had to call 911 for Resident #4. He said CPR was appropriate if the resident was unresponsive and had no pulse. He was not aware of who implemented CPR for Resident #4. He said he could not say whether or not CPR would have made a difference for Resident #4, but failure to provide CPR in a timely manner could increase likelihood of death. MD Z said the resident has had similar episodes before, a week prior in fact, for which he was sent out to the hospital and returned to the facility. He said that he cannot say what happened differently that lead to Resident #4's death because it could have been that his heart gave out. Interview on [DATE] at 1:40 pm with the Administrator, she said that she started at the facility on [DATE] and had no prior knowledge of the circumstances surrounding the death of Resident #4. She said her expectation would be for nursing staff to, at minimum, document by exception meaning that anything that was outside of a resident's normal should be documented and physician notified. She said if a resident was found unresponsive and without a pulse, a code should be called, and basic life saving measures implemented if the resident was full code. The Administrator said that she spoke to LVN K who told her that she did not start CPR because Resident #4 had a pulse, but there was no documentation, nor could the nurse say when the resident transitioned. She said failure to initiate CPR in a timely manner could be detrimental to the resident. Record review of Emergency Procedure- Cardiopulmonary Resuscitation (2018) revealed: . 6. If the individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR immediately unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or . b. there are obvious signs of irreversible death (e.g., rigor mortis) Record review of Automatic External Defibrillator, Use and Care of Policy (2015) revealed: . 3. The automatic external defibrillator (AED) will be used to try to restore normal cardiac rhythm when arrhythmia is strongly suspected. Recognizing the signs and symptoms of arrhythmia (and when to use the AE) is part of the CPR/BLS training .4. In general, sudden cardiac arrest should be suspected if: a. the victim's symptoms appeared very suddenly; b. he or she is unresponsive; c. his or her breathing has stopped . 5. If an individual is found unconscious and SCA is suspected, begin the AED protocol . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 2:00 pm. The Administrator, the DON, the Assisting Administrator, and the CNC were notified. The Administrator was provided with the IJ template via email on [DATE] at 2:17 pm. The following Plan of Removal submitted by the facility was accepted on [DATE] at 12:55 pm: The Texas Department of Health and Human Services entered Windsor Houston on [DATE], for a follow up on a Complaint Survey on a P1 that initiated on [DATE]. During the survey process an IJ (Immediate Jeopardy) was cited on [DATE] regarding - F678 as stated below- In-which resident #4 was transferred from facility to ER via EMS where he expired. Immediate Interventions: Plan of Removal: F678 All direct care nursing staff and those with CPR certifications will be in-serviced on the following- The expectation for all direct care nursing staff is to identify and utilize the crash cart, backboard, AED, how to perform CPR and when to initiate CPR; in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare . In serviced all floor nurses, administrative nurses, CNAs, CMAs, PTs, OTs, and STs on ensuring the resident is on a hard surface if and when CPR is initiated. If the resident is on an air mattress, the air mattress is to be deflated with backboard in place beneath the resident unless the resident is able to be safely be transferred to the floor. All direct care nursing staff will demonstrate and acknowledge that they are aware of how to identify and utilize the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR; in the event a resident is unresponsive with no pulse. Specifically, to locate the code status binder, which is accessible by all direct care nursing staff and indirect care staff in the facility. All direct care nursing staff will demonstrate and acknowledge how to access code status in Matrix. The employee will log into MatrixCare, select resident, d then search resident by name, resident facesheet, resident identifiers and banners, and resident code status. To validate DNR status, the employee will select resident documents, advance directives tab, and look for the advance directive. The DON and designees audited employee roster to ensure 100% of direct care nursing staff are in-serviced regarding identification and utilization of the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR; in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare. The training regarding identification and utilization of the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR; in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare will be an ongoing continuous training to be conducted quarterly with first training completed [DATE]. Training will also be included in new hire process for all direct care nursing staff and staff with CPR certification which will include a skills competency. The DON/ADON or Designees during morning start-up will ensure that the backboard is with the crash cart and during the weekends and holidays a designee will ensure that the backboard is with the crash cart. (Backboard is now attached to the crash cart). 100/200 hall nurses will do walking rounds, each shift (6am-2pm, 2pm-10pm, 10pm-6am), to ensure the backboard is in place prior to shift hand-off and will witness on change of shift log that backboard is in place. Nursing to notify the DON for all change of conditions along with MD/RPs. The facility DON/ADON/Designee notified all direct care nursing staff of facility's policies regarding AED, CPR, emergency nursing response, notifications, reporting, and abuse and neglect. The training confirmations will be stored with their employee file in the Human Resources department. On [DATE], the Director of Nursing initiated an addendum to the original in-service initiated on [DATE] to include visual aids and questions to assist staff with identification of the location of the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR in the event a resident is unresponsive without a pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare. This is to include all direct care nursing staff and those with CPR certifications to cover the topics of: Importance of/and expectation that all licensed nursing staff and those with CPR certifications will demonstrate and acknowledge that they are aware of where to locate the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare. The DON/DON Designee will contact all direct care nursing staff and those with CPR certificate to obtain signature on site or via Facetime with return demonstration and acknowledgment signed off on prior to start of next shift. However, if unable to obtain face to face or visual presentation a verbal acknowledgement will be obtained along with 2 signatures by the DON/DON Designee to serve as a understanding of what the expectations are for all floor nurses, administrative nurses, CNAs, CMAs, PTs, OTs, and STs to identify and utilize the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare. F678-Effective [DATE] the DON/ADON/designee will randomly observe direct care nursing staff demonstrate how to identify and utilize the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare. The DON/ADON/designee will conduct random observations with all direct care nursing staff of their ability to identify and utilize the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare. All direct care nursing staff and those with CPR certifications were contacted in person or by phone and verbally in-serviced. All direct care nursing staff and those with CPR certifications in-services will be completed by 10:30AM [DATE]. All direct care nursing staff and those with CPR certifications will be made aware and provided with a copy of the facility's policies regarding AED, CPR, emergency nursing response, notifications, and reporting, and abuse and neglect. Results of all observations will be reviewed by the Interdisciplinary Team to ensure that proper adherence to this process is met. Any deviations or omissions will be addressed immediately with staff member. This will be reviewed monthly in QAPI until compliance is met. Monitoring: Record review of CPR certifications on [DATE] for all nursing staff listed, reflected all CPR certifications for nursing staff in report to be current. Record review of in-service trainings provided to direct care staff (licensed nurses) and other facility staff in contact with residents as part of the Plan of Removal. The following policies and protocols were reviewed: CPR on soft surfaces; Emergency Cart Checklist; AED, CPR, SBAR, Documentation, Notifying the MD, the RP, the DON, and the Admin; Stop & Watch, Abuse, Neglect, Exploitation, and Residents' Rights, Matrixcare Information, Mock Demonstration of Code Blue (CPR); Vital Signs return demonstration; CPR, Crash cart/Backboard. Interviewed 10 nurses across the three shifts who were able to verbally demonstrate knowledge gained from in-services. Interviewed 7 CNAs, 2 housekeepers, and 1 therapist who were able to verbally demonstrate knowledge gained from in-services. The Administrator, assisting Administrator, DON, and CNC were informed the Immediate Jeopardy was removed on [DATE] at 6:17 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.