**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, staff interview and observation, the facility failed to ensure a resident did not develop avoidable pressure ulcers. Resident #8 returned from the emergency room with bilateral leg immobilizes. The facility failed to implement a plan to prevent Resident #8 from developing pressure ulcers because of the leg immobilizers. Resident #8 developed bilateral unstageable pressure ulcers to both calves. The wounds have worsened and required the resident to be hospitalized and undergo debridement procedures on each of the wounds. The resident has voiced concerns and fears that his right leg will need an amputation because of the wound. The state agency (SA) determined the failures related to Resident #8 placed him and any other residents with medical devices such as leg braces in an immediate jeopardy (IJ) situation. The SA notified the facility of the IJ at 6:30 PM on 11/19/24. The SA accepted the facility's plan of correction (POC) at 8:09 PM on 11/19/24. After the SA observed for implementation of the POC which included staff interviews, resident interviews and record reviews of the required audits and training the SA abated the IJ at 5:10 PM on 11/20/24. After the immediacy was removed a deficient practice remained for Resident #4 and Resident #40. A deficient practice remains for Resident #4 who developed a blister to his lower leg because of a leg immobilizer. The facility identified it as an edema blister instead of a pressure ulcer. The facility also failed to perform a wound evaluation on the wound when it was discovered and weekly there after until it was resolved. A deficient practice was also present for Resident #40 because the facility failed to provide wound care consistent with current standards of practice. This was true for three (3) of four (4) residents reviewed for the care area of pressure ulcers during the long-term care survey process. Resident Identifiers: #8, #4, and #40. Facility Census: 54. Findings Included: a) Resident #8 Resident #8 was admitted on [DATE] and has the following diagnoses MS, DM, paraplegia lower extremities, Bipolar, PTSD, osteoporosis, HTN, Depression, GERD, Neurogenic bladder, MDRO, and fractures of both lower extremities and arthritis. Scored 15 on the Brief Interview for Mental Status (BIMS) which indicates cognitively intact. 1) Resident Interview During an interview with Resident #8 at 2:26 PM on 11/18/24 the resident stated, I fell and broke my legs on 09/17/24 and came back with a brace on each leg. He continued to state, They did not know what to do with the braces when I came back, and they did not take them off for a week. He stated, after a week they took them off to give him a shower and said, Oh Sh(x)t. He stated, it was then that the wounds were identified. He indicated he had been to the hospital because of the wounds, and he was scared he was going to lose his right leg. He indicated the leg he was talking about by tapping his right leg. The surveyor asked Resident #8, They never removed the brace or looked at your skin for seven (7) days? He stated, No the first time was after a week when they gave me a shower. 2) Record Review A review of Resident #8's medical record found a hospital history and physical dated 09/20/24 which indicated the resident was to wear bilateral immobilizers during transfers and as tolerated related to bilateral tibia fractures. A review of the resident's skin only evaluation dated 09/20/24 completed at 4:42 PM found the answer to question #2. External device(s) (cast, prosthetic, brace) present was answered with No. A further review of Resident #8's care plan found no care plan focus, goal, or intervention related to the removal of the braces for checking skin integrity. The treatment administration record (TAR) for the month of September 2024 was reviewed and found the following, Bilateral Knee immobilizers as resident tolerates. CMS(Circulation, motion and sensation) and skin observations/hygiene QS while in place every day and night shift. This was initialed on the TAR as being done on the night of 09/23/24, and the day and night of the 24, 25, and 26. However, Resident #8 who is completely cognitively intact denies them doing this. He stated, No the first time was after a week when they gave me a shower. It should also be noted Resident #8 has a diagnosis of paraplegia which was entered into his medical record on 09/15/19. Paraplegia is defined as a chronic condition that results in the loss of motor or sensory function in the lower half of the body, including the legs, feet, and sometimes the abdomen. Resident #8 confirmed in an interview on the afternoon of 11/18/24 that he had no sensation or motion in his legs or feet at all. 3) Left Calf The following are the wound assessments completed by the facility for the left medial calf. The facility refers to the wound being on the left lateral calf and the left medial calf, however this is the same wound. -- Wound was evaluated on 09/26/24 at 4:25 PM by RN #41 the wound care nurse. The wound was classified as a deep tissue injury. It was indicated the wound was a pressure injury caused by a medical device. The wound is located on the left medial calf. It was classified as a new wound and was an in-house acquired pressure ulcer. There was no PUSH score included in this assessment. Pressure Ulcer Scale for Healing (PUSH) was developed by the National Pressure Ulcer Advisory Panel (NPUAP) to categorize the ulcer with respect to surface area, exudate, and type of wound tissue. There is no depth measurement with this tool. Scores can range from 0 (healed) to 17 most serious. The Dimensions of the wound are as follows: The area was 9.93 cm² (Centimeter). The length was 4.2 cm. The width was 3.12 cm. There was no depth recorded with this assessment. The wound bed was not described in this assessment. There was no exudate present. The edges of the wound were attached, and the surrounding tissue was described as fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The goal for the wound is to be healable. The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The following was noted as education provided to the resident, Educated resident on ways to maintain good skin health; keeping skin clean and dry, moisturizer as needed, frequent position changes, including off-loading heels, adequate hydration and nutrition. Resident verbalized understanding and provided accurate teach back. This assessment was not signed by RN #41 until 09/27/24 at 1:19 PM. -- The wound was assessed on 09/30/24 at 11:23 AM by RN #41 the wound care nurse. The wound was classified as a Stage III pressure ulcer related to a medical device and was in house acquired. The wound age was identified as being four (4) days old. There was no PUSH score included in this assessment. The Dimensions of the wound were as follows: The area was 5.85 cm² (Centimeter) a decrease of 41 % since the previous assessment. The length was 2.42 cm a decrease of 42 % since the previous assessment. The width was 3.02 cm a decrease of 3 % since the previous assessment. There was no depth recorded with this assessment despite the fact the staging was changed from a deep tissue injury to a stage III pressure ulcer. In order for the wound to be a Stage III pressure ulcer there has to full thickness tissue loss therefore the wound would have a depth measurement. In addition, the medical record contained a picture of the wound at the time of the assessment. In the picture the full thickness tissue loss is noticeable, and the wound has a noticeable depth which was not measured by RN # 41 when completing this assessment. The wound bed was not described in this assessment, other than noting there was no signs of infection. There was a light amount of serous exudate present. There was no odor from the wound. The edges of the wound were attached, and the surrounding tissue was described as erythema and fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The wound was described as improving and the goal was healable. The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The following was noted as education provided to the resident, Educated resident on ways to maintain good skin health; keeping skin clean and dry, moisturizer as needed, frequent position changes, including off-loading heels, adequate hydration and nutrition. Resident verbalized understanding and provided accurate teach back. This assessment was not signed by RN #41 until 10/01/24 at 12:02 PM. -- The wound was evaluated on 10/08/24 at 2:41 PM by RN #41 the wound care nurse. The wound was classified as a Stage III pressure ulcer related to medical device. The wound is located on the left medial calf. It was assessed as deteriorating with a wound age of 12 days and was noted to be in-house acquired. The residents' PUSH score was 12 at the time of this assessment. The Dimensions of the wound were as follows: The area was 8.66 cm² (Centimeter) an increase of 48 % from the previous assessment. The length was 3.69 cm, an increase of 52 % from the previous assessment. The width was 3.01 cm and remained the same as the previous assessment. The deepest point was recorded at 0.3 cm, which was an increase of 100 % from the previous assessment. The wound bed was described as having no granulation, 50 % Slough, and no eschar. There was no evidence of an infection. The wound was noted to be bleeding. There was a light amount of Serosanguineous exudate and there was a faint odor noted after cleansing the wound. The edges of the wound were attached, and the surrounding tissue was described as fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The wound was described as Deteriorating and the goal was healable. The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The following was noted as education provided to the resident, Educated resident on ways to maintain good skin health; keeping skin clean and dry, moisturizer as needed, frequent position changes, including off-loading heels, adequate hydration and nutrition. Resident lethargic and does not acknowledge understanding on education provided. This assessment was signed by RN #41 the wound nurse on 10/09/24 at 8:28 AM. -- The wound was evaluated on 10/13/24 at 8:29 PM by RN #41 the wound care nurse. The wound was classified as an unstageable pressure ulcer related to Slough and/or eschar. The wound is located on the left medial calf. It was assessed as stable with a wound age of 25 days and was noted to be present on admission (It should be noted the resident was hospitalized from [DATE] to 10/11/24 and upon his return the facility changed the wound from in-house acquired to present on admission despite it being the same wound). The residents' PUSH score was 16 at the time of this assessment. The Dimensions of the wound are as follows: The area was 37.35 cm² (Centimeter). No comparison noted since this is the first assessment since his return from the hospital. The length was 11.51 cm No comparison noted since this is the first assessment since his return from the hospital. The width was 5.08 cm No comparison noted since this is the first assessment since his return from the hospital. There was no depth recorded with this assessment. The wound bed was described as having no granulation, 40 % Slough, and 60 % eschar. There was no evidence of an infection. There was a moderate amount of serous exudate and there was a faint odor noted after cleansing the wound. The edges of the wound were attached, and the surrounding tissue was described as fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The wound was described as stable, and the goal was healable. The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The following was noted as education provided to the resident, Educated resident on ways to maintain good skin health; keeping skin clean and dry, moisturizer as needed, frequent position changes, including off-loading heels, adequate hydration and nutrition. Resident verbalized understanding and provided accurate teach back. This assessment was signed by RN #41 the wound nurse on 10/16/24 at 12:22 PM. -- The wound was evaluated on 10/21/24 at 11:08 AM by RN #41 the wound care nurse. The wound was classified as an unstageable pressure ulcer related to slough and/or eschar. The wound is located on the left medial calf. It was assessed as stable with a wound age of 18 days and was noted to be present on admission. The residents' PUSH score was 16 at the time of this assessment. The Dimensions of the wound are as follows: The area was 18.01 cm² (Centimeter) a decrease of 52 % from the previous assessment. The length was 6.11 cm, a decrease of 47 % from the previous assessment. The width was 4.03 cm, a decrease of 21 % from the previous assessment. The deepest point was recorded at .1 cm which was an increase of 100 % from the previous assessment. The wound bed was described as having no granulation, 10 % Slough, and 90 % eschar. There was no evidence of an infection. There was a moderate amount of serous exudate and there was a faint odor noted after cleansing the wound. The edges of the wound were attached, and the surrounding tissue was described as eczematous and fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The wound was described as stable, and the goal was healable. The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The following was noted as education provided to the resident, Educated resident on ways to maintain good skin health; keeping skin clean and dry, moisturizer as needed, frequent position changes, including off-loading heels, adequate hydration and nutrition. Resident verbalized understanding and provided accurate teach back. This assessment was signed by RN #41 the wound nurse on 10/22/24 at 1:57 PM. --The wound was evaluated on 10/28/24 at 10:57 AM. This evaluation was completed by the Director of Nursing. The wound was classified as an unstageable pressure ulcer related to Slough and/or eschar. The wound is located on the left medial calf. It was assessed as stalled with a wound age of one month and was noted to be present on admission. The residents' PUSH score was 15 at the time of this assessment. The Dimensions of the wound were as follows: The area was 12.49 cm² (Centimeter) a decrease of 31 % from the previous assessment. The length was 6.1 cm which was the same value as the previous assessment. The width was 2.61 cm, a decrease of 35 % from the previous assessment. There was no depth recorded, which was a decrease of 100 % from the previous assessment. The wound bed was described as having no granulation, 10 % Slough, and 20 % eschar. There was no evidence of an infection. It was noted the wound was bleeding. There was a moderate amount of Serosanguineous/bloody exudate and there was a faint odor noted after cleansing the wound. The edges of the wound were not attached, and the surrounding tissue was described as fragile. There was no induration or edema noted. The peri wound temperature was normal. The dressing was described as intact. The goal of care was noted to be healable, and the progress of the wound was noted as stalled. No other information was contained in this wound assessment. -- The wound was evaluated on 11/08/24 at 3:03 PM. This wound evaluation was completed by LPN # 9. The wound was classified as a Stage 4 pressure ulcer. The wound was located on the left lateral calf. It was assessed as a new wound with an unknown age and was noted to be present on admission. The residents' PUSH score was 15 at the time of this assessment. The wound bed was described as having 50 % granulation and 50 % eschar. There was no evidence of an infection. Under the section titled other the nurse noted the wound was bleeding and the tendon was exposed. There was a moderate amount of Serosanguineous exudate and there was a faint odor noted after cleansing the wound. The edges of the wound were attached, and the surrounding tissue was described as fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The wound was described as slow to heal, and the progress was noted as new (indicating the wound is a new wound). The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The following was noted as education provided to the resident, Educated resident on ways to maintain good skin health; keeping skin clean and dry, moisturizer as needed, frequent position changes, including off-loading heels, adequate hydration and nutrition. Resident verbalized understanding but is non-compliant with turning and repositioning. This assessment was not signed by RN #41 the wound nurse until 11/14/24 at 10:57 AM. -- The wound was evaluated on 11/14/24 at 2:53 PM by Licensed Practical Nurse (LPN) #9. The wound was classified as an unstageable pressure ulcer related to slough and/or eschar. The wound is located on the left medial calf. It was assessed as improving with a wound age of two (2) months and was noted to be present on admission. The residents' PUSH score was 16 at the time of this assessment. The Dimensions of the wound are as follows: The area was 14.43 cm² (Centimeter) an increase of 16 % from the previous assessment. The length was 9.36 cm, an increase of 54 % from the previous assessment. The width was 3.09 cm, an increase of 19 % from the previous assessment. The wound bed was described as having 50 % granulation, 10 % Slough, and 40 % eschar. There was no evidence of an infection. There was a moderate amount of Serosanguineous exudate and there was a faint odor noted after cleansing the wound. The edges of the wound were attached, and the surrounding tissue was described as erythema. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The wound was described as healable, and the progress was noted as improving. The following note was entered, Wound assessment completed per (Facility Corporate Initials) policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. This assessment was signed by wound care nurse #41 on 11/15/24 at 4:58 AM. 4) Right Calf The following are the wound assessments completed by the facility for the right calf. The facility referred to the wound as being on the right medial calf and the right lateral calf, however it is the same wound. -- The wound was evaluated on 09/27/24 at 11:23 AM. This assessment was completed by RN #41 the wound care nurse. The wound was classified as a medical device related to pressure deep tissue injury. This wound was located on the right medial calf and is a new pressure area. The wound was in-house acquired. There was no PUSH score included with this assessment. The Dimensions of the wound were as follows: The area was 9.48 cm². The length was 3.97 cm. The width was 2.63 cm. The depth was not recorded on this assessment because there is no depth to the wound on this date. The wound bed was not described in this assessment other than stating there were no signs of infection. There was no exudate from the wound on this date. The edges of the wound were attached, and the surrounding tissue was described as fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The goal for the wound is healable. The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The following was noted as education provided to the resident, Educated resident on ways to maintain good skin health; keeping skin clean and dry, moisturizer as needed, frequent position changes, including off-loading heels, adequate hydration and nutrition. Resident verbalized understanding and provided accurate teach back. This assessment was signed by RN #41 on 09/27/24 at 2:45 PM. -- The wound was evaluated on 09/30/24 at 11:19 AM by RN #41 the wound care nurse. The wound was classified as a deep tissue injury related to a medical device. The wound was located on the right lateral calf. It was assessed as being three (3) days old and was in-house acquired. This assessment did not contain a PUSH score. The Dimensions of the wound were as follows: The area was 9.31 cm² a decrease of 2 % since the previous assessment. The length was 4.13 cm, an increase of 4 % since the previous assessment. The width was 2.27 cm, a decrease of 14 % since the previous assessment. The wound had no depth. The wound bed was not described other than noting there was no sign of infection. There was no exudate or odor noted. The edges of the wound were attached, and the surrounding tissue was described as fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The goal for the wound is healable. The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The following was noted as education provided to the resident, Educated resident on ways to maintain good skin health; keeping skin clean and dry, moisturizer as needed, frequent position changes, including off-loading heels, adequate hydration and nutrition. Resident verbalized understanding and provided accurate teach back. This assessment was not signed by RN #41 until 10/01/24 at 12:14 PM. -- The wound was assessed on 10/08/24 at 2:37 PM by RN #41 the wound care nurse. The wound was classified as a Stage III pressure ulcer related to a medical device and was in-house acquired. The wound age was identified as being 11 days old. There was no PUSH score included in this assessment. The Dimensions of the wound were as follows: The area was 29.91 cm² (Centimeter) an increase of 221% since the previous assessment. The length was 6.29 cm, an increase of 52 % since the previous assessment. The width was 5.99 cm, an increase of 164 % since the previous assessment. There was no depth recorded with this assessment despite the fact the staging was changed from a deep tissue injury to a stage III pressure ulcer. In order for the wound to be a Stage III pressure ulcer there has to full thickness tissue loss therefore the wound would have a depth measurement. In addition, the medical record contained a picture of the wound at the time of the assessment. In the picture the full thickness tissue loss is noticeable, and the wound has a noticeable depth which was not measured by RN # 41 when completing this assessment. The wound bed was not described in this assessment except for noting there were no signs of infection, and the wound was bleeding. There was a light amount of Serosanguineous exudate, and the wound had no odor. The edges of the wound were attached, and the surrounding tissue was described as fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The wound was described as deteriorating and the treatment goal was healable. The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The following education was noted as given to the resident, Educated resident on ways to maintain good skin health; keeping skin clean and dry, moisturizer as needed, frequent position changes, including off-loading heels, adequate hydration and nutrition. Resident lethargic and does not verbalize understanding. This assessment was not signed by RN #41 the wound nurse until 10/09/24 at 12:50 PM. -- The wound was assessed on 10/28/24 at 10:49 AM by the Director of Nursing. The wound was classified as an unstageable pressure ulcer related to slough and/or eschar. The wound is located on the right lateral calf. It was assessed as being one (1) month old and being present on admission (It should be noted the resident was hospitalized from [DATE] to 10/11/24 and upon his return the facility changed the wound from in house acquired to present on admission despite it being the same wound). There was no push score included in this assessment. The Dimensions of the wound were as follows: The area was 59.1 cm². The length was 13.6 cm. The width was 5.6 cm. The wound bed was described as having no granulation, slough was checked as being present, but a percentage was not identified, and 90 % eschar. There was no evidence of an infection. Under the section titled, other, the nurse noted, bleeding indicating the wound was bleeding. There was a moderate amount of Serosanguineous/bloody exudate and there was a moderate odor noted after cleansing the wound. The edges of the wound were not assessed, and the surrounding tissue was described as fragile. There was no induration or edema noted. The peri wound temperature was warm. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The dressing was described as intact, and Dakin's solution was used for cleaning. The wound was described as deteriorating and the goal was healable. It was noted that the wound had a suspected infection. -- The wound was evaluated on 11/08/24 at 3:02 PM. The wound evaluation was completed by RN #41 who was the wound nurse. The wound was classified as an unstageable pressure ulcer related to slough and/or eschar. The wound is located on the right lateral calf. It was assessed as being a new wound which was present on admission. The residents' PUSH score was 16 at the time of this assessment. The Dimensions of the wound are as follows: The area was 115.99 cm². The length was 27.53 cm. The width was 6.11 cm. The deepest point was recorded as 1 cm. The wound bed was described as having 10% granulation and 90% eschar. There was no evidence of an infection. Under the section titled, other the nurse noted, bleeding and tendon indicating the wound was bleeding and the tendon was exposed. There was a moderate amount of Serosanguineous exudate and there was a faint odor noted after cleansing the wound. The edges of the wound were attached, and the surrounding tissue was described as erythema and fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The wound was described as slow to heal and was identified as a new wound. The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain [TRUNCATED]

Based on record review, resident interview and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #8 requested the facility transport him to the bank in the facility van. The facility had decided prior to Resident #8's request to go to the bank that power wheelchairs could not be used on the facility van any longer. As a result of this decision the resident requested his manual wheelchair and chose to use the manual wheelchair in the van to go to the bank. The resident had not been in his manual wheelchair for at least a year prior to this. Since then, he had lost use of his legs and was paralyzed in both lower extremities. The resident slid from the wheelchair while on the van. A nurse aide was with him and another nurse aide responded to the scene where the van had pulled over after the resident slid from the wheelchair. The resident denied pain (please note the resident is a paraplegic and cannot feel his legs.) He stated he did not want to go to the hospital. The two (2) Nurse Aides who were on site lifted the resident back into his wheelchair and he was transported back to the facility. The facility policy indicates a resident should not be moved after a fall until a physician/advanced practice provider (APP), nurse or emergency medical services has evaluated them for possible injuries. Once evaluated and if the individual has no physical or verbal indication of injury, the patient can be moved to a safe and comfortable place when applicable. The resident was found to have bilateral tibia and fibula fractures. Based on the failure to ensure the resident was safe to be transferred in a manual wheelchair and the facility's failure to follow their policy after the fall it was determined this was an Immediate Jeopardy (IJ) situation. The facility was notified of the IJ on 11/19/24 at 5:45 PM. The State Agency (SA) accepted the facility's plan of correction (POC) at 6:10 PM. After observation of implementation of the POC which included staff interviews and record review of the required audits and education the IJ was abated at 5:10 PM on 11/20/24. This was true for one (1) of three (3) residents reviewed for the care area of accidents during the long term care survey process. Resident Identifier: #8. Facility Census: 54. Findings Included: a) Resident #8 On 09/17/24 Resident #8 asked the facility to transport him to the bank in the facility van. A decision was made some time back by the Nursing Home Administrator (NHA) that power wheelchairs would no longer be used in the facility van for transport due to safety concerns. An interview with the NHA on 11/19/24 at 12:27 PM confirmed that sometime back (exact time frame is unknown) that due to the VA and (Name of Local ambulance company) a decision was made to no longer allow power chairs on the van. When asked if the two (2) residents who have power chairs were notified of this decision at the time, he indicated they had not been notified because they had not requested to go anywhere since the decision was made. The NHA stated that on this date Resident #8 had demanded to go to the bank and asked for his manual chair so he would be able to ride in the van to the bank. The NHA stated, therapy and nursing tried to convince him to wait but he was insistent and wanted to go no matter what. The NHA stated he was not in the facility on this date because he was at a meeting. An interview with The Director of Rehab # 59 at 2:00 PM on 11/19/24 found on 09/17/24 Resident #8 had come to the rehab door and was beating on the door demanding his manual wheelchair from the therapy shed because he wanted to go to the bank. She stated, she tried to convince him to wait until the NHA returned to the facility tomorrow and give them time to find a safe way for him to go but he was insistent and did not want to wait. She stated, I told him I did not think it was safe. I feel it wasn't safe because he had not been in that wheelchair for quite some time and was not sure if he had enough trunk control to hold himself in the chair. I have been working with him for 10 years, but just had not had him in that wheelchair for a while. I was not ready to say he was safe in it The Director of Rehab #59 further stated, He came to the door demanding that wheelchair. He was with nursing and activities and I told them all that I did not feel he was safe in that wheelchair. The surveyor also asked the Director of Rehab if she felt the power wheelchair could safely be strapped in the van? She replied, Yes. An interview with the Activity Director at 2:18 PM on 11/19/24 found that when Resident #8 slid from his chair in the van the activity assistant had called her and she left the facility to go and assist the resident. When she arrived, she indicated the resident was sitting with his legs crossed between his wheelchair and the back of the seat in front of him. She indicated she asked him if he was hurt and he stated No. When asked if the lift pad was under the resident or in the wheelchair, she stated it was still in the wheelchair. She stated, There was no room to get the lift into the van to get him out of the floor so she and the activity assistant (who are both nurse aides) two armed the resident, lifted him up while the driver slid the wheelchair under him. She stated, before we lifted him up I straightened his legs out. She stated, The resident did not want us to call 911. He wanted to go to the bank, but we took him back to the facility. An interview with the Activity Assistant on 11/19/24 at 2:30 PM found she was in the van while the resident was being transported to the bank. She stated, the resident started saying I'm sliding I'm sliding. She continued to state, When I looked back he was sitting on the floor with his back against his wheelchair and his legs were crossed. She stated while they were waiting for the Activity Director, she moved the resident's wheelchair and laid him on his back with his head on a towel so he would be comfortable. She stated his legs remained crossed when she laid him back. She stated that she and the activity director then lifted him up and the driver slid the chair under him. She stated they asked if he wanted to go to the ER and he said no he wanted to go to the bank, but they returned him to the facility instead. The NHA provided the following typed document (Typed as written), Resident (Initials of Resident #8) was evaluated by the licensed nurse upon return to the facility, orders received to obtain x-rays of bilateral lower extremities (BLE) from the physician on 09/17/24. On 09/17/24 the Director of Nursing (DON) interviewed the van driver, the nurse aide assisting with transport and the resident who is alert and orientated to identify if the van was traveling too fast, if driver hit the brakes to hard or negotiated a turn too fast causing residents to slide out of the wheelchair onto floor of the facility van. All staff interviewed indicated No to the above questions. The NHA interviewed the Director of Rehab (DOR) who was present when (Initials of Resident #8) requested his manual wheelchair for transport to the bank in the facility van. The Director of Rehab,(Initials of Resident #8) was demanding his manual wheelchair and did not want to wait. (Initials of Resident #8 was secured with the facility van seatbelt and wheelchair was locked into place in the van with securing straps per van protocol. All residents have the potential to be affected. The Director of Rehab (DOR)/designee initiated an audit on 09/23/24 for all residents in wheelchairs that utilize the facility van to determine safety for transport. Corrective action implemented immediately upon discovery. The Director of Rehab (DOR)/designee will reeducate all interdisciplinary team, medical records/resident appointment scheduling and van driver with a posttest to validate understanding regarding: appropriateness of van utilization for transportation, positioning/devices in wheelchairs . The Director of Nursing (DON)/designee will reeducate all Certified Nursing Assistants on removal of lift sling prior to transport in facility van on or before 10/04/24. Medical Records/resident appointment scheduling will bring the upcoming week's transportation schedule to IDT on Thursdays for review to ensure the appropriateness of the van for transportation. Any appointments added after the review must be discussed with the IDT team prior to transporting the Resident. An interview with Resident #8 on 11/18/24 at 2:26 PM found that on 09/17/24 he wanted to go to the bank because he had finalized the sale of his house, and he needed to go to the bank. He stated the administrator had told him he could not take his power wheelchair in the van, and he would have to use his manual chair. He stated that he had not been in his manual chair for three (3) years and in that he did not know he could take his power chair on the van, he had to get to the bank that day. He stated, It was one of the highest points I have had lately because I was finalizing the sale of my house, and the devil just knocked it out from under me. A review of a Wheelchair training session therapy note dated 11/14/24 found the following, W/C (wheelchair) management: analysis of patient body alignment and functional skills in new or existing w/c and assessment of current seating system for appropriate modifications. Patient in power wheelchair for positioning and safety with on facility van. Patient positioning maintained in wheelchair on van with use of wheelchair seatbelt (lap) which patient is able to release on command 100 percent of the time. Once positioned safely in van power system turned off for safety. Patient able to follow all directions for safe use of power wheelchair on van. Patient demonstrated safe mount and dismount of wheelchair van ramp. Van safety equipment functioned properly with power wheelchair. No issues noted. DON and Administrator present for session. A review of the hospital history and physical from the hospital for the date of 09/19/24 confirmed the resident had bilateral tibia fractures. A review of the facility policy titled Accident/incidents found the following, 1. Response: . 1.1.3 DO NOT move the individual until a physician/advanced practice provider (APP), nurse or emergency medical services has evaluated them for possible injuries. Once evaluated and if the individual has no physical or verbal indication of injury, the patient can be moved to a safe and comfortable place when applicable. When the facility was notified of the immediate jeopardy the NHA asked if this would be past noncompliance. The NHA was advised it would be current noncompliance because the education he provided to the staff failed to address ensuring the policy is followed in regards to moving resident prior to them being assessed by appropriate individuals. b) Facility Plan of Correction The facility submitted the following Plan of Correction (POC) typed as written: F- 689 Resident #8 Resident was evaluated by the licensed nurse upon return to the facility, orders received to obtain x-rays of bilateral lower extremities (BLE) from the physician on 09/17/24. On 09/17/24 the Director of Nursing (DON) interviewed the van driver, the aide assisting with transport and the resident who is alert and orientated to identify if the van was traveling too fast, if driver hit the brakes to hard or negotiated a turn too fast causing residents to slide out of the wheelchair onto floor of the facility van. All staff interviewed indicated No to the above questions. The NHA interviewed the Director of Rehab (DOR) who was present when Resident #8 requested his manual wheelchair for transport to the bank in the facility van. The Director of Rehab, Resident #8 was demanding his manual wheelchair and did not want to wait. (Initials of Resident #8 was secured with the facility van seatbelt and wheelchair was locked into place in the van with securing straps per van protocol. All residents have the potential to be affected. The director of rehab (DOR)/designee initiated an audit on 09/23/24 for all residents in wheelchairs that utilize the facility van to determine safety for transport. Corrective action implemented immediately upon discovery. The Director of Rehab (DOR)/designee will reeducate all interdisciplinary team, medical records/resident appointment scheduling and van driver with a posttest to validate understanding regarding appropriateness of van utilization for transportation, positioning/devices in wheelchairs . The Director of Nursing (DON)/designee will reeducate all Certified Nursing Assistants on removal of lift sling prior to transport in facility van on or before 10/04/24. The Director of Nursing (DON)/designee will reeducate all nursing staff on the post fall process, including any resident that has a fall must be evaluated by a nurse or medical provider prior to moving the resident on 11/19/24 and prior to nursing staff's next scheduled shift. Medical Records/resident appointment scheduling will bring the upcoming week's transportation schedule to IDT on Thursdays for review to ensure the appropriateness of the van for transportation. Any appointments added after the review must be discussed with the IDT team prior to transporting the Resident. Results of monitors will be reported by the NHA/designee monthly to the quality improvement committee for any additional follow up and/or in-servicing until the issue is resolved and randomly thereafter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview and observation, the facility failed to provide services to a resident that are necessary to avoid death, physical harm, pain, mental anguish or emotional distress by not following the Resident's original signed [NAME] Virginia Physician Orders for Scope of Treatment (POST) form. This deficient practice affected Resident #54, who is now deceased . This deficient practice had the potential to also affect one of the fifty-one (51) residents at the facility with POST forms. Resident identifiers: #54. Facility census 51 The facility was notified of the IJ (Immediate Jeopardy) at 1:12 PM on [DATE]. The facility submitted their abatement plan of correction (POC) at 2:13 PM on [DATE] and was forwarded to the State Office for review. The State Office approved the POC at 2:41 PM on [DATE]. After observation, staff interview, review of facility documentation, and record review determining the implementation of the abatement POC, the IJ was abated at 9:20 AM on [DATE]. The IJ started on [DATE] when the POST form was changed and ended on [DATE] at 9:20 AM. The facility's approved abatement POC consisted of the following: Action steps to be completed by the nursing home to remove the allegation of Immediate Jeopardy: (Name of facility) Abatement Plan On [DATE] Center Executive Director and Center Nurse Executive implemented the following plan: 1. The nursing staff immediately verified all POST forms with capacitated residents and all POST forms with MPOA/HCS for all incapacitated residents with findings reported to the Center Nurse Executive for any corrective action immediately upon discovery. 2. All current residents of the facility have the potential to be affected. 3. Assistant Director of Nursing (ADON) will immediately initiate re-education with a posttest to validate understanding beginning [DATE] at 2:30 PM to all licensed nursing staff, social services, and Medical Provider prior to his/her next scheduled shift regarding the appropriate and thorough completion of the POST form. Licensed nursing staff, social services and Medical Providers not available during this timeframe will be provided reeducation including posttest prior to the next scheduled shift by the ADON/designee. New Licensed nursing staff, social services and Medical Providers during orientation by the ADON/Designee will receive education and complete a posttest prior to completion of orientation. The CNE (Center Nurse Executive)/Designee will monitor the POST forms on admission and with every change made to the POST Form with any corrective action immediately upon discovery and re-education upon discovery for 30 days and then quarterly. Center Nurse Executive/Designee will review findings with the Center Executive Director/Designee daily. 4. The Center Nurse Executive/designee will present results of audits or monitoring monthly to the Quality Improvement Committee for any additional follow up and/or in servicing until the issue is resolved and randomly thereafter as determined by the Quality Improvement Committee. All corrective actions were completed. All licensed nursing staff working night shift and day shift were in-serviced. This was evidenced by the in-service sing-in sheet produced by the Administrator and surveyor interview of staff at the facility. All POST forms were in the process of being reviewed by the ADON. Once the IJ was abated, the deficient practice remained, and the scope and severity (S/S) was decreased from a J to an E. A deficient practice remained for Residents # 54. Findings Included: a) Resident #54 Resident #54 was admitted on [DATE] to the facility. On [DATE] Resident #54 completed a POST form with the following sections filled out. POST form dated [DATE] was marked under the following sections: Section A is marked Attempt Resuscitation/CPR Section B is marked Limited Additional Interventions Use medical treatment, Iv Fluids and cardiac monitoring as indicated Do Not use intubation or mechanical ventilation. Transfer to hospital if indicated. Avoid intensive care unit. Section C is marked IV fluids for a trial period of no longer than TBS and no Feeding tube Section D is discussed with patient/Resident. Resident did not mark the box to give authorization for anyone else to make decisions if she would lose capacity Post form on [DATE] is signed by Resident and Facility Physician On [DATE] two staff members called Resident # 54's son to obtain a new POST form. Licensed Practical Nurse #26 (LPN) and a Registered Nurse 25 (RN) took a verbal consent for a POST form with the following sections filled out. POST form dated [DATE] was marked under the following sections: section A is marked Do not Attempt Resuscitation/DNR Section B is marked Comfort Measures: Treat with dignity and respect. Keep clean, warm, and dry. Use medications by and route, positioning, wound care and other measures to relieve pain and suffering and promote comfort. Use oxygen, suction and manual treatment of airway obstructions as need for comfort. Do not transfer to hospital for life-sustaining treatment. Section C is marked No IV fluids (provide other measures to assure comfort) and no Feeding tube; Section D is discussed with other -Son. Telephone consent per Son-- LPN #26 / and RN #25 signed Post form on [DATE] is signed by Facility Physician The Resident did not initial the POST form indicating if the resident lost capacity, the POST form could be changed by the medical representative. Therefore, the POST form should not have been changed. A review of the medical record reveals a physician determination of capacity dated [DATE] stating Resident #54 had capacity. Further review of the medical records reveals a nurses note dated [DATE] at 17:18 that reads as follows: Residents daughter (Redacted) called facility asking about residents status, this nurse explained to daughter that resident has not been eating and refused megace today and is unable to participate with therapy. Residents daughter stated that she wanted resident to go have a feeding tube placed and I explained to her that resident signed her POST form when she came to facility and clearly stated that resident did not want a feeding tube. I went to residents room and asked her if she wanted a feeding tube and resident stated that she did not want one. Daughter asked if she could come in for a compassion visit DON approved for this to happen. Notified of (Redacted) Facility Physician the above. A continued review of the medical record reveal a nurses note dated [DATE] at 5:20 AM, that reads as follows: The resident's breathing was labored around midnight, 2L of oxygen was applied via nasal cannula. MD aware. Contacted the Resident's daughter, (Redacted), at 0520 to let her know that the resident was declining and she could come in to the facility to see her. In an interview on [DATE] at 11:30 the Administrator confirmed that Resident did not have a medical power of attorney (MPOA) form on file. The administrator did not know why the new POST form was completed. On [DATE] at 1:23 PM, the surveyor contacted the resident's son by telephone with no answer. A message was left for the son. On [DATE] at 2:23 PM, the Son called back and stated the facility called him to get a POST form signed. He stated he was told there was no paperwork on file and they needed to know if he wanted them to do CPR or not if something should happen to his mother. He could not remember the time but can remember that it was late because he was afraid he would fall asleep if he tried to drive to the facility that night. Further review of the medical records found that Resident #54 expired on [DATE] and did not received CPR per the Resident's wishes. Resident #54 did not receive CPR and in addition was not transferred to the hospital when her condition deteriorated per her wishes. Resident #54 expired at the facility. .