**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, document review and policy review, the facility failed to ensure that fall risks were assessed and that adequate fall interventions were developed, implemented and revised for one of three residents (Resident (R)2) reviewed for falls. R2 was admitted to the facility following a fall at home where R2 sustained a subdural hematoma. The subdural hematoma was still present and in need of monitoring post admission to the facility. Upon admission, R2 was assessed to be at risk for falls with initial safety interventions including a low bed and frequent rounding (frequency not specified). On 4/20/25 the facility placed a sensor alarm to prevent falls. Progress notes indicate R2 frequently setting off the alarms related to impulsivity and frequent self-transfers. On 4/24/25 R2's Nurse Practitioner noted, in their neuro psych initial evaluation of R2: (R2) is oriented times 1(oriented to self), unable to answer questions appropriately. Walking unsteadily in room while self-transfers to bathroom. Poor safety awareness and impulsivity noted. Foley catheter remains intact. Despite assessment documenting R2 is unable to answer questions appropriately, is unsteady, frequently self-transferring and impulsive, these factors were not addressed as risk factors and addressed in R2's care plans to prevent falls. Review of R2's overall care plans include interventions such as 1:1 (one on one) support as indicated without specifying what would be a circumstance to provide 1:1 support. The care plans encourage R2 to be as independent as possible yet R2 is assessed to be at risk for falls and staff are to anticipate needs.On 4/30/25 R2 sustained a fall in their room at approximately 2:15 pm. R2 was found on the floor between the end table and under the television. The motion sensor was not on at the time of the fall. The fall documents indicate prior to staff seeing R2 in their room, R2 was last seen in activities. The fall report does not indicate who assisted R2 back to their room after activities and whether fall interventions were implemented at that time, including activating the sensor alarm. The root cause of the fall was resident was spontaneous with ambulation and forgetting they needed assistance, R2 had motion sensor in place but not on. The intervention post fall was to educate staff on the importance of alarm being on. Staff statements as part of the fall report indicate R2 frequently self-transfers and R2 stood up and fell. The call light was in place but not activated. The fall investigation does not include whether frequent rounding, as a care plan intervention, had been implemented or when R2 was last toileted. The last meal R2 was offered was lunch. There is no indication R2's care plan was revised to address R2's frequent self-transfers or review of R2's routine to assess/implement interventions to prevent falls.R2 was hospitalized [DATE]-[DATE] related to having a change in condition and ultimately having their gallbladder removed. R2 returned to the facility still having a catheter in place with treatment for a urinary tract infection (UTI). The fall risk assessment upon readmission indicated R2 is at risk for falls. There is no notation or assessment post readmission of R2's cognitive status post anesthesia related to R2 having surgery to remove R2's gall bladder. On 5/16/25 R2 had a follow up brain scan where scan results indicated worsening of R2's subdural hematoma since R2's original admission to the facility on 4/17/25. Consultation documentation indicates R2's subdural hematoma increased in size from 9mm to 11mm. On 5/17/25 at approximately 9:00 am R2 was found by a dietary aide on the floor in the dining room. R2 shared they hit their head, and their hip hurt. It was noted in the fall report R2's wheelchair was pushed back, and the brakes were noted to not be on. Statements from staff post fall indicate different timelines of when R2 was last observed or when the breakfast meal took place. The post fall investigation does not include details regarding whether R2 had concluded eating breakfast or if R2 still had a meal in front of them at the time of the fall. R2 had a care plan intervention indicating R2 required supervision and assistance with meals; supervision and assistance is not defined on R2's care plan. There is no indication anyone was supervising R2. R2 was sent to the hospital for evaluation due to noted pain in their head and hip and noted change in mental status. The root cause analysis indicates R2 tried to stand up without a call light because they were in the dining room, the wheelchair was unlocked and R2 requires assistance and is unsteady on their feet. The intervention is to not leave R2 unattended in the dining room. Review of the documentation of R2's initial emergency department visit on 5/17/25 notes the scan results from 5/16/25 and worsening results of the subdural hematoma and indication it may measure a further increase in the bleed than the scan from 5/16/25. Risk management: hospitalization considered but decision made not to admit. Diagnosis includes fall, initial encounter, subdural hematoma, contusion of right hip. R2 was discharged from the hospital at 12:15 pm. Review R2's record post return to the facility on 5/17/25 indicates R2's risk assessment was scored lower than previous fall assessments. No changes were made to R2's care plan regarding worsening subdural hematoma or need for increased monitoring for changes in status beyond the intervention to supervise in the dining room.On 5/17/25 at approximately 3:35 pm R2 was found on the floor in their room with a noted area of discoloration to the left occipital near post temporal line on their head. Statements from staff include different explanations of what R2 was doing at the time of fall including attempting to get something, changing chairs, or adjusting blankets. The fall documentation indicates Certified Nursing Assistant (CNA)1 was in R2's room just prior to R2's fall from the chair. CNA1 did not notice or ensure R2's sensor alarm was in place or activated at the time they were in the room before the fall. CNA1 indicated they were not aware of the safety intervention. R2 was transferred to the emergency department post fall. The emergency department evaluation indicated R2 had a small rebleed on top of the previous intercranial hemorrhage, likely due to recent fall. Transfer to (name of hospital with neurological surgery team) ICU (intensive care unit) for further evaluation and management. Clinical impression: traumatic subdural hematoma with unknown loss of consciousness, initial encounter. The facility's failure to assess R2's risk factors to include frequent self-transferring, impulsivity, and unsteadiness to establish individualized interventions to prevent falls, its failure to develop specific/detailed care plans, and its failure to consistently implement care-planned interventions created a reasonable likelihood for serious harm. R2 sustained 3 avoidable falls in the facility with two fall on 5/17/25 resulting in R2 hitting his head and requiring transfer to the hospital. This created a situation of immediate jeopardy for R2 starting 5/17/25. The Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Corporate Consultant -(CC) were notified of the immediate jeopardy on 7/10/25 at approximately 8:55 pm. The immediate jeopardy was removed on 5/23/25. The deficient practice continues at a scope and severity of an E (potential for harm/pattern) related to the residents at risk for falls in the facility, as the facility continues to implement its action plan. Findings include: The facility's policy titled, Fall Risk Assessment last revised March 2018 revealed, The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for fall and establish a resident-centered falls prevention plan based on relevant assessment information.Upon admission, quarterly, annually, and with significant change, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. Review of the facility's policy titled, Falls-Clinical Protocol last revised March 2018 revealed, Assessment and Recognition:.3. The staff and practitioner will review each resident's risk factors for falling and document in the medical record.5. The staff will evaluate, and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc.Cause Identification.3. The staff and physician will continue to collect and evaluate information until the cause of the falling is identified.Treatment/Management.1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.Monitoring and Follow-Up.4. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. The facility's policy titled, Assessing Falls and Their Causes last revised March 2018 revealed, Purpose: The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall.residents must be assessed upon admission and regularly afterward for potential risk of falls.If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities.Evaluate chains of events or circumstances preceding a recent fall. Review of the facility's policy titled, Falls and Fall Risk Managing last revised March 2018 revealed, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.Resident-Centered Approaches to Managing Falls and Fall Risk.1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.5. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant.8. Position-change alarms will not be used as the primary or sole interventions to prevent falls but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. Review of the undated facility's policy titled, Kardex policy and procedure. revealed, Policy Statement: The facility will maintain an up-do-date Kardex for each resident to provide nursing staff and caregivers with a quick-reference summary of the resident's care needs, routines, and preferences. The Kardex is intended to supplement the comprehensive care plan and ensure continuity and quality of care. Purpose: To provide a concise, accessible reference tool that assists nursing staff in delivering personalized, consistent, and safe care in accordance with the resident's care plan. Scope: Applies to all nursing staff, caregivers, and interdisciplinary team members involved in direct resident care.Kardex: A non-legal, working document summarizing essential care plan components. Care Plan: A legally required document outlining assessed needs and interventions developed by the interdisciplinary team.Each Kardex should include the following sections:.Safety precautions (e.g., fall risk.) .Responsibilities:.CNA [Certified Nursing Assistant]-Use Kardex as a reference for daily care tasks and report changes. According to https://my.clevelandclinic.org/health/diseases/21183-subdural-hematoma, What are the risk factors for subdural hematoma? Anyone can get a subdural hematoma from an accidental head injury. But certain factors can increase your risk, including: Age: People 65 and older and babies are more at risk for getting subdural hematomas. As you age, your brain shrinks inside your skull. The space between your skull and brain widens. This makes the tiny veins in the membranes between your skull and brain stretch. These thinned, stretched veins are more likely to tear, even if you experience a minor head injury. What are the complications of subdural hematoma? Without treatment, large hematomas can lead to coma and death. Other complications include: Brain herniation: Increased pressure from a pool of blood can squeeze and push brain tissue so it moves from its normal position. A brain herniation is often fatal. Repeated bleeding: People older than 65 who are recovering from a hematoma have a higher risk of another hemorrhage due to changes in their brain tissues. Seizures: Seizures may develop even after you receive treatment for a hematoma. R2's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed R2 was admitted to the facility on [DATE] with diagnosis of traumatic subdural hemorrhage without loss of consciousness due to a fall at home. Additional diagnoses include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. On 4/17/25 at 10:01 pm progress notes indicate: Resident being monitored d/t (due to) being 72hr (hour) new admission to facility post hospitalization d/t fall at home and became increasingly confused was taken to hospital and diagnosed w (with)/Subdural Hematoma and has HX (history) of Dementia; resident also had urinary retention while in hospital and currently has indwelling foley catheter. Resident is alert to name but does not answer simple questions when asked but will make eye contact when being talked too; resident has been non-verbal for nurse this shift and staff to anticipate resident's needs as he is unable to communicate them at this time. Resident has call light within reach but will do 15 min (minute) checks to ensure resident has no needs d/t being unsure if resident is aware of his surroundings. Resident awake/alert this shift did assist w/taking drinks from his sippee (sic) cup when writer giving him meds (medications) tonight.Resident had a fall at home and had AMS (altered mental status) and generalized weakness. He was admitted to the hospital on 4/6 for subdural hematoma. History of dementia, bipolar disorder, PE (pulmonary embolism), HTN (hypertension), AFIB (atrial fibrillation) with long term anticoagulation. VSS (vital signs stable). No s/s (signs/symptoms) of pain. DNR (Do Not Resuscitate). Alert. Nonverbal currently, did not respond to questions. Transferred with assist of 2 with gait belt and [NAME] steady (sic). Surveyor noted R2 was initially placed on 15-minute checks related to not being familiar with the facility. On 4/17/25 a care plan with a problem for agitation related to/manifested by unfamiliar care staff, new living environment, diagnosis of dementia was implemented. Interventions dated 4/17/25 include approach in a calm, non-threatening manner; depression screens PRN (as needed); encourage expression of feelings; encourage resident family to seek out social services with concerns/problems; monitor for changes in mood or behaviors, report to social services & nursing; offer choices; offer quiet setting; psych consult as indicated; re-approach as necessary; speak in a calm soothing voice. Surveyor noted 15 minute checks were not part of R2's initial adjustment/agitation plan of care . On 4/17/25 a care plan for potential for adjustment issues was initiated. Interventions dated 4/17/25 include to allow /encourage to direct care as able; encourage active participation; encourage resident/family to communicate likes/dislikes with staff, share questions/ concerns; encourage to make decisions as able; encourage visits by support system (family, friends, church etc.); provide 1:1 support as needed. The care plan did not specify what would require 1:1 support. On 4/17/25 R2's care plan for alteration in thought process/confusion related to/manifested by traumatic subdural hemorrhage & dementia diagnosis was initiated. Interventions dated 4/17/25 include allow to be as independent as possible; allow time to respond as necessary; attempt to anticipate needs as needed; explain procedures; if appears lost, offer direction; monitor for changes in cognitive behavior and report to social services & nursing; offer choices appropriate with level of ability; offer gentle reminders as needed; offer quiet setting; speak in calm voice. On 4/18/25 a care plan for I am in a new situation with interventions dated 4/18/25 included: accompany to meals, therapy, bathroom, activities as needed; check on resident on how they are adjusting to the facility; describe layout of the facility. Review of R2's admission Minimum Data Set (MDS), located in the MDS tab in the EMR with an Assessment Reference Date (ARD) of 04/22/25, revealed a Brief Interview for Mental Status (BIMS) had no score out of 15, which indicated severe cognitive impairment and R2 was rarely or never understood. According to the MDS, R2 required substantial/maximum assistance from staff for rolling left and right, and dependent with toileting, sit to lying, lying to sitting on the side of the bed, sitting to standing, and chair/bed-to-chair transfers. The resident had a fall in the last month prior to admission/entry or reentry. R2's initial assessment documentation located in the EMR under the Resident Documents tab dated 04/17/25 documented the resident was nonverbal with dementia. Fall preventions identified included gripper socks and grab bars. The resident was assessed to be a fall risk but did not require fall mats or alarms. The care plan for falls was initiated on 04/18/25 and did not include these assessed interventions of gripper socks and grab bars. R2's Care Plan located in the EMR under the Care Plan tab initiated 04/18/25 revealed R2 was at risk for falls as he had a fall at home. Goal documented is Reduction in chance of falls. Interventions included frequent rounding and low bed initiated on 04/18/25. The care plan did not specify what constituted frequent rounding. Review of R2's John Hopkins Fall Risk Assessment Tools located in the EMR under the Observations tab revealed the resident had multiple assessments completed during his stay:Upon admission on [DATE], his score was assessed at 13.0, which indicated moderate fall risk. However, the care plan still identified only the two interventions noted above. Review of R2's Progress Notes located in the EMR under the Progress Notes tab revealed regular and consistent documentation of the resident attempting to self-ambulate and walk, placing himself at risk of falls. However, the resident's care plan failed to identify the resident's history of falling, which included a subdural hematoma from a fall at home. The care plan failed to include a resident-centered approach to R2's confusion and documented frequent attempts to self-ambulate. On 4/18/25 at 1:42 PM documentation includes admit: Resident admitted post hospitalization related to fall at home resulting in a subdural hematoma . Resident 2 assist using gait belt and EZ stand at this time. Resident self-transferred this morning and OT (Occupational Therapist) found him standing beside his dresser. Resident was incontinent of bowel at this time. Resident has a foley catheter and a follow up appointment with urology. Resident has been nonverbal since admission. Resident smiled at writer and will answer yes or no questions by shaking his head. Surveyor noted R2's care plan to address problem of my ability to dress & toilet without assistance includes an intervention dated 4/18/25 to perform self-cares with the assistance of 1 staff member. Surveyor noted there isn't a care plan to address R2's bowel incontinence. On 4/19/25 at 9:46 AM progress notes document . Eats meals in the dining room, needs assist with meals. Transfers with assist of 2 with EZ stand. Resident was leaning to the right in his w/c (wheelchair), pillow placed. On 4 /19/25 at 5:38 PM documentation includes: . Trace edema present to bilateral lower legs, ankles and feet. Resident is using EZ stand for all transfers with 2 staff assistance. Resident needs verbal cues throughout any task and ongoing encouragement. When sitting in wheelchair resident leans to his right side. Staff only used wheelchair for meal this shift as it does not appear safe for resident to sit in chair. He leans forward and will fall out. Goal is for resident to workwith therapy for strengthening. Surveyor noted the use of a pillow to position R2 in the wheelchair was not an added intervention to R2's care plans. Review of R2's Progress Notes located in the EMR under the Progress Notes tab documented on 04/20/25 at 9:49 AM . Eats meals in the dining room, fed self breakfast today. Transfers with assist of 2 with EZ stand. Resident attempting to get out of his w/c several times after breakfast. Resident was then transferred to his recliner. Soft touch call light within reach, uses it at times. R2's Progress Notes located in the EMR under the Progress Notes tab Dietitian (RD) documented on 04/20/25 at 6:49 PM, Motion sensor alarm placed in room as resident tries to get out of his chair on his own without using the call light at times. The intervention to add the motion sensor alarm was initiated on 04/20/25. R2's Care Card information provided by the Administrator on 07/10/25 at 12:32 PM, revealed the resident was identified with interventions for falls on 04/20/25 that included, Motion alarm on when he is in the room by himself for safety. No additional interventions were documented on the Care Card for CNA use. R2's Progress Note located in the EMR under the Progress Notes tab documented on 4/21/25 at 1:08 PM: Resident was observed by another nurse that resident was pushing on the front entrance/exit door while sitting in his w/c. Writer observed resident was restless, attempting to stand up from his w/c. When asked if he had pain he stated yes. PRN (as needed) Tylenol given. Resident was then redirected and assisted to the dining room. Wander guard placed on right wrist. POA (power of attorney) notified. Surveyor noted there is no care plan to address R2's risk for/attempts to exit the facility or a care plan to address R2 wearing a wanderguard. On 4/21/25 at 4:59 PM Medicare charting documents: Medicare. Resident is alert to self and wife only. He does not answer questions appropriately. He is restless and frequently trying to stand unassisted or self-transfer. Motion sensor alarm on while in room alone. He is assisted to common areas as much as possible to be supervised. He is transferring with EZ stand. He does propel self in w/c short distances. He has foley in place draining clear yellow urine. He was incontinent of small BM in brief. He needs assist with eating and drinking. He has occasional facial grimace during transfers and repositioning. Has prn pain medication ordered. He is working with therapy for strengthening, will continue to monitor. Surveyor noted facility nursing staff continue to document about R2's restlessness and frequent attempts to stand or transfer without assistance. This note indicates the need for increased supervision however, increased supervision with specified details is not an intervention on R2's plan of care. On 4/23/25 a SNF Progress Note was completed by Nurse Practitioner (NP1). Under NEURO/PSYCH it is documented - Oriented x1, unable to answer questions appropriately. Walking unsteadily in room while self-transferring to bathroom. Poor safety awareness and impulsivity noted. Foley catheter remains intact draining yellow urine. Under assessment and plan it is documented: G30.1 - Alzheimer's disease with late onset: POA activated. Further decline expected. Longterm (sic) goal to move to Mauston where his son is moving within the next year. Patient continues on memantine for underlying dementia. Due to his underlying dementia, poor safety awareness, and impulsivity, falls are inevitable. Patient is oriented x1 and unable to answer questions appropriately. Surveyor noted R2's care plan for risk for falls does not include R2 receiving memantine (Namenda) which has a side effect of dizziness. Additionally, despite NP1 noting R2's unsteady walking, self-transferring to the bathroom, poor safety awareness, and impulsivity, there are no revisions to R2's care plan to address these risk factors. Surveyor noted it is not documented if the motion sensor was in place and on when NP1 witnessed R2 walking and self-transferring in their room. A progress note dated 4/24/25 documents: Constantly trying to pull off brief and pull at catheter and stand at edge of bed on own. Resident re-positioned and toileted many times. Did have one large BM, but after continues to not sleep and self-transfer. CNAs got resident dressed and up in w/c d/t being safety issue. Is currently sitting in nursing station with staff to better monitor for safety. Resident states that he wants to leave and go home. Explained to resident that he is too weak to safely discharge currently and needs rehab for strengthening. Resident nods head in aggreance (sic) but continues to try and stand from w/c or propel towards doorways. Wander guard in place to right wrist at this time. Surveyor also noted staff implementing increased supervision and increased supervision as a safety measure is still not part of R2's fall risk care plan. On 4/24/25 at 11:29 AM progress notes document: Writer obtained verbal consent from APOA/ (name of) for resident to change rooms closer to nurse's station. Resident will be moved to rm (room number documented). Resident status change form completed and put in med recs, nursing notified of consent. A progress note recorded as Late Entry on 04/28/2025 09:52 PM for 4/26/25 at 3:00 AM documents: Resident being monitored d/t having behaviors and wandering t/o (sic) night couple nights ago and also d/t having +UA (positive urinalysis) w/pending culture. Resident has been sleeping this shift w/out any concerns and VSS as noted. On 4/29/25 at 3:45 PM a late entry note for 4/26/25 at 6:40 PM documents: Resident has dementia dx (diagnosis) and has sundown behaviors in the evening, very restless and trying to stand up unassisted. He also tries to get out of bed unassisted all night long, per night nurse report does not sleep much, and motion sensor alarm frequently sounding. He becomes very anxious when his wife is not in the room with him. NP updated and new orders received. Progress notes dated 4/27/25 at 6:50 PM documents new order received to give Melatonin 3mg QHS (at bedtime) for sleep PRN. Surveyor noted R2's care plan was not updated to identify when R2 should receive Melatonin as a PRN and if there is an increased risk for falls with the new medication. On 4/29/25 orders were received for R2 to receive scheduled 5 mg of Melatonin nightly. R2's Progress Note located in the EMR under the Progress Notes tab documented on 04/30/25 at 3:20 PM that R2, .continued to be monitored at this time r/t [related to] unobserved fall in room.found sitting on the floor in between his end table and chair underneath the television by RA [resident aide] .resident stated that he was getting up from his recliner and fell. When asked where he was going, he stated he wasn't sure.Has motion sensor alarm.was not sounding and was turned off. Per orders, motion sensor alarm is to be on at all times when resident is alone in room. Staff re-education to be started on ensure sensor alarm is to be on and frequent rounding. Paper to be signed by staff before starting shift. The fall investigation revealed that the motion sensor was not turned on, according to the fall care plan intervention. Review of staff statements, and the fall investigation details indicate R2 fell at 2:15 PM and was last seen at 1:15 PM in activities and R2's last meal was at 12:00 PM. There isn't detail regarding whether R2 was incontinent/continent of bowel at the time of fall or when R2 was last toileted related to a bowel movement. Certified Nursing Assistant (CNA)7 indicates in their statement R2 was last seen at 2:00 PM but does not specify who saw R2. RN2's statement documented for the question did you ask resident what happened? What was the response? Frequently self-transfers + (and) stood up from recliner + fell. RN2 documents R2 was confused at the time of the fall per baseline. CNA7's statement does not include details of where R2 was seated when observed at 2:00 pm or who made the observation (whether it was CNA7 or other individual). The written statement by CNA7 documents: RA (resident assistant) told staff (referred to as room number) was on (sic) floor. Me (CNA7) and the nurse went and checked on the resident. Checked vitals and then assisted resident up. Resident put feet flat on the floor and stood with minimal assistance. R2's care plan was updated to include: ensure the sensor alarm is turned on prior to leaving the resident in room unsupervised, and call light within reach. Reeducation was provided. The facility root cause analysis completed on 5/1/25 documents Problem statement: was found sitting on floor between table next to recliner under tv. The documented answers to the five why questions include frequently stands up thinking he can walk unassisted; needs assistance; had motion alarm for intervention/not on; call light in reach, call light not on; A+O (alert & oriented) x 2, forgetful. The Root Cause(s): Resident is spontaneous with ambulation forgetting he needs assistance had motion alarm in place was not on. Intervention to re-educate staff on the importance of motion alarms needing to be on. The fall investigation does not include relevant details to help complete a thorough root cause analysis. The investigation does not include a statement from activity staff to determine who assisted R2 back to his room and whether intervention were in place at that time. The intervention to retrain staff on the motion sensor alarm did not address the factors of R2 forgetting he needs assistance and R2 frequently stands up. The Fall Risk Assessment Tool completed on 4/30/25 indicates a score of 20 indicating R2 is at high risk for falls (greater than 13 is considered high risk). Surveyor notes despite R2 having a foley catheter, the risk question for patient care equipment: any equipment that tethers patient (which included a catheter as an example) was not scored as a risk factor. Progress notes on 5/1/25 at 11:12 AM document . Resident continues to attempt to self-transfer. Resident has motion alarm on at all times when resident is in room alone . R2 was transferred to the hospital on 5/1/25 for a change in condition. R2 was admitted and ultimately had gallbladder surgery. R2 readmitted to the facility on [DATE]. The fall assessment completed on 5/9/25 assesses R2 to have a fall risk score of 21 indicating R2 is at high risk for falls. Upon return to the facility there are no revisions to R2's care plans to monitor for any changes related to R2 having received anesthesia during the hospitalization and potential effects that may have on R2 given diagnoses of dementia and subdural hematoma. On 5/10/25 at 1:09 PM progress notes document: Resident readmitted s/p (status post) hospitalization for lap chole (laparoscopic cholecystectomy - gallbladder removal) on 05.06.25. Resident has dementia. He seems more confused than previous. He is attempting multiple times to get up out of wheelchair. He is unable to sit still. Continuous redirection given this shift. Transfers with gait belt, staff and walker. Resident denies any pain, lungs clear throughout, bowel sounds active. On 5/12/25 R2's medical record includes documentation of clarifying orders to re-start Tamsulosin (Flomax) (medication to trea

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 1 of 1 resident (R291) reviewed with a significant change in condition had a comprehensive assessment performed consistent with professional standards of nurse practice (N6, Wisconsin Nurse Practice Act,) the comprehensive person-centered care plan, and the resident's choices. *On [DATE], R291 was having increased difficulty with transfers and eating. The difficulty continued to worsen and on [DATE] at approximately 12:41 a.m., R291 required use of a mechanical lift and had difficulty speaking. The Registered Nurse (RN) on duty did not take vital signs (other than an undocumented pulse oximetry) and did not perform a comprehensive assessment into the change in condition. There was no physician notification of the change in condition. On [DATE] at approximately 7:50 a.m., R291 became unresponsive and was transferred and admitted into the hospital with a diagnosis of severe sepsis. R291 subsequently expired while in the hospital on [DATE]. The facility's failure to perform a comprehensive assessment into a change in condition created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA (Nursing Home Administrator) A of the immediate jeopardy on [DATE] at 3:05 p.m. The immediate jeopardy was removed on [DATE] when the facility began implementing their action plan. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's policy and procedure titled Change of Resident Condition Physician/NP Notification (no date) was reviewed and documents: During hours when the office is not open, the attending physician or physician on call should be notified of any change in condition, change in health status, or incident that includes but is not limited to: Change in basic vital signs, significant change in mental status or other conditions as deemed necessary. According to N6.03(1), Wisconsin Nurse Practice Act, a registered nurse (RN) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. R291 was admitted to the facility on [DATE] with diagnoses that included Transient Ischemic Attack, Vascular Dementia, Chronic Kidney Disease stage 3, Chronic Obstructive Pulmonary Disease, and Diabetes type 2. R291 had an Activated HCPOA (Power of Attorney) for healthcare with advanced directives for a full code, hospitalization, and antibiotics if needed. R291's Initial Minimum Data Set (MDS) dated [DATE] documented R291 needed supervision of one with ambulation and standing/transfers and had a Brief Interview for Mental Status (BIMS) Score of 12, indicating that R291 was moderately cognitively impaired. R291's quarterly MDS dated [DATE] documented her BIMS score remained unchanged at a 12. On [DATE], R291's care plan titled Activities of Daily Living functional status with a start date of [DATE] and current on [DATE] was reviewed and documented: independent with assist of wheeled walker. R291's progress note dated [DATE] at 11:46 AM written by LPN (Licensed Practical Nurse)-E documented: R291 is having difficulty transferring and standing up. She was a max (maximum) assist with cares. She was also a max assist with transferring using a gait belt and w/w (wheeled walker) this morning. She is refusing activities and refusing to eat meals in the dining room today. Continues to c/o (complain of) RUE (right upper extremity) and left flank pain. Scheduled analgesics given as ordered, states that oxycodone doesn't work. R291 moaning throughout the shift. Refusing ice packs to left flank. Will continue to monitor. Nurse Practitioner in facility and updated. R291's progress note dated [DATE] at 1:08 PM written by LPN-E documented: R291 initially refused her lunch stating, I don't know why, but I can't do anything. C/o (complained of) RUE pain at times. When her sister visited, she fed resident her lunch. R291's baseline is set-up for meals and she is able to feed herself. Earlier in the morning R291 was applying make-up and hair spray while sitting in front of the bathroom sink in her w/c (wheelchair). She has been requiring assist of one with transfers, as she states that she cannot stand up on her own. NP (Nurse Practitioner) in facility and updated. R291's progress note dated [DATE] at 12:47 AM written by RN-E documented: R291 was incontinent of urine while sitting in her chair. R291 is unable to use her voice. R291 told CNA that she is unable to walk or use her arms. Used the Sara Steady (mechanical lift) to transfer and R291 was kicking her leg off of the machine and started to shake stated, No, I can't do this. R291 was put in a brief and placed in bed. Daughter came to visit with her aunt and daughter was crying uncontrollably, asked to speak with the nurse. When asking her what's wrong, daughter asked, Is my mom dying? Reassurance given. Asked daughter if she would like to have the resident sent to the hospital and she stated No. Offered her hospice services and she declined at this time. There were no vital signs documented and no documentation of a nurse assessment. R291's progress note dated [DATE] at 8:11 AM written by Director of Nurses (DON)-E documented: R291 was found unresponsive by dietary staff, sternal rub applied with no reaction, Blood sugar 149 BP (blood pressure) 153/63 HR (heart rate) 124, RR (respiratory rate) 20 could not get an oxygen level, O2 (oxygen) applied via NC (nasal cannula) at 3 LPM (liters per minute), Lungs course diminished at the base. skin was warm to touch, fingertips were blue. 911 was called at 0750 am and were here and gone by 805 am. Daughter/POA called and updated, resident was sent to hospital per daughter who will meet her there. Surveyor reviewed R291's medical record for vital signs and the last vital signs documented were on [DATE]. No others were documented until R291 was found unresponsive on [DATE]. On [DATE] at 9:56 AM, Surveyor interviewed Director of Nurses (DON)-B who indicated Registered Nurse (RN)-E should have done a full set of vitals with R291's change of condition on [DATE] and did not. On [DATE] at 10:30 AM, Surveyor interviewed R291's activated power of attorney for healthcare (HCPOA)-J who indicated she knew R291 was getting worse on the night of [DATE] but RN-E assured her that R291 was fine and she was overreacting. Due to this conversation, the HCPOA-J told RN-E she didn't want R291 sent to the hospital because she was assured R291 was acting this way because her dementia was progressing. On [DATE] at 12:27 PM, Surveyor interviewed NP (Nurse Practitioner)-I who indicated she was not made aware of changes to R291's transfer status or her difficulty talking. NP-I indicated a full set of vital signs should have been taken with R291's change of condition and stated she (NP-I) would have probably ordered for R291 to be sent to the hospital if she had been notified. On [DATE] at 2:39 PM, Surveyor interviewed RN (Registered Nurse)-E who indicated she did not call R291's physician on [DATE] when R291 had trouble talking and transferring. RN-E indicated she did not know if R291 was faking her condition. RN-E indicated R291 was having trouble transferring and had a hoarse voice. RN-E indicated that she checked R291's O2 level and it was 96% (this was not charted) but did not check her b/p, temperature, or pulse. RN-E indicated she saw R291 several times during the shift and R291 was talking at the time. When asked, RN-E indicated signs of sepsis would include high heart rate, low blood pressure, increased lethargy, decreased appetite, and elevated temp. RN-E indicated R291 was having a decline and she did not take vitals other than her oxygen level and she should have done a thorough assessment with a full set of vitals. On [DATE] at 8:47 AM, Surveyor interviewed LPN-D who indicated R291's pain and confusion was getting worse so she called NP-I on [DATE]. LPN-D indicated it was new for R291 to need help eating and R291 was really shaky. LPN-D indicated she didn't get vitals on R291 but did call NP-I. LPN-D indicated she never knew R291 to need a mechanical lift for transfers and she would call her physician and let therapy know if that happened. On [DATE] at 11:56 AM, Surveyor interviewed Medical Director (MD)-H who is also R291's primary physician. MD-H indicated he would expect to be called with R291's change of condition and he was not. MD-H indicated he would expect the nurse to take a full set of vitals before calling him as irregular vitals would be a main indicator of possible sepsis. On [DATE], Surveyor reviewed R291's hospital medical record which documented: R291 admitted to the emergency room on [DATE] at 8:44 AM. Diagnosed with Severe Sepsis and Acute Metabolic Encephalopathy. Chief complaint of altered mental status. R291 was unable to provide history secondary to acute metabolic encephalopathy and somnolence. Family reported concerns to staff at the skilled nursing facility where she lives but there was no intervention per family. Temperature 104.2, heart rate 100-120s, respiratory rate 30, Oxygen level 95% on room air. Urinalysis positive for infection. [NAME] blood cell 17.10 (normal 4-10.8), Lactic acid 3.3 (normal 0.9-1.7). Sinus tachycardia. Severe sepsis criteria is noted as heart rate above 90, respiratory rate above 20, temperature above 100.4, white blood cell count above 12, and lactate above 2. Hospital social worker notes dated [DATE] at 12:32 PM documented: HCPOA states she has concerns about how the nurse treated R291 last night (at the facility.) She wanted R291 brought to the hospital last night but the night nurse stated R291 was likely faking. Has had issues with this nurse in the past. admitted to the Intensive Care Unit on [DATE] at 3:05 PM. The discharge note from the hospital for R291 dated [DATE] documented: Diagnosis: septic shock, streptococcal bacteremia, aortic valve vegetation embolic strokes, from septic emboli, acute on chronic toxic metabolic encephalopathy, due to sepsis as well as embolic strokes from septic emboli. R291 was admitted to the hospital what initially thought sepsis secondary to the urinary tract infection, but unfortunately further investigation showed septic emboli, with multiple infarcts. Finding were discussed with R291's family who decided on comfort measures. Transitioned to in-house hospice. R291 expired with hospice services on [DATE] at 11:04 AM. Surveyor requested additional information, if available, as to why R291 was not given a thorough assessment including vital signs when she experienced a change in condition and why R291's physician was not consulted, however, none was provided. The facility's failure to complete ongoing, thorough assessments including taking and recording vital signs and the failure to notify the primary physician when a resident was experiencing a significant change in condition resulted in a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. Surveyor notified NHA-A of the immediate jeopardy on [DATE] at 3:05 p.m. The facility removed the immediate jeopardy on [DATE] when they began implementing the following action plan: The Change of Condition policy has been reviewed by DON and modified with the following modifications: - Examples of Change of Condition - Use of Interact tools - include the change of condition pathways and Stop and Watch - VS will be taken immediately or a soon as possible with any change of condition. Once VS and immediate assessment is completed, MD will be notified. VS will be taken a minimum of every 4 hours and more frequently as indicated by the change in condition or MD order. - All changes in condition will be listed on the 24-hour report board Nurse practitioner will provide education to all nurses related to recognition of physiological changes of condition as well as behavioral responses that may indicate a physiological change in condition. Education will include response including interventions, notifications, and documentation. This education will be taped and all nurses not present will be required to view the in-service prior to their next working shift. Nurse involved in incident was part of the NP's education and was also provided one on one education by the DON and ADON on physiological change of condition and behavioral responses that may indicate a change of condition and expectations for response and notification. Interact tools have been implemented and are available electronically within the electronic medical record as well as all Interact tool change of condition pathways have been printed and are located at each nursing station. All licensed staff have been educated on the use of Interact tools as well as their location. All direct care staff will be educated on the Stop and Watch Early Warning tool as well as reporting any resident change of condition to a nurse. Post tests will be given following the education to ensure competency. Medical Director consulted during the development of this corrective action plan. The DON and ADON will review progress notes and 24-hour report board daily for any changes of condition to ensure audits will continue daily for 1 month with ad hoc training provided as necessary for any missed opportunities. Audits will continue 3 x per week for 2 months. All audits and results will be brought to the quality improvement committee for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that 1 (R24) of 2 residents reviewed was provided adequate supervision and assistance devices to prevent accidents. R24 was identified by the facility as a wander/elopement risk due to altered mental status/dementia in June 2023. The facility did place a Wanderguard bracelet, however, at one point they placed it on the resident's wheelchair even when it was known resident was physically capable of standing up from her wheelchair and ambulating without assistance. Resident was able to elope from the facility and was found outside of the facility on two separate occasions, once when it was raining, and once at 1 am. The facility's failure to provide adequate supervision and proper assistance devices to R24 created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 06/27/2024. The immediate jeopardy was removed on 8/15/24, however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. Findings include: The facility's policy, undated and titled: Wander/Elopement Policy & Procedure, documents in part: Elopement definition: When a resident leaves the facility property without the knowledge of the staff. Facility property is defined as: area outside of property lines/plot lines as governed by [NAME] County. Procedure: 3. Residents at risk will have an assessment done on admission, then quarterly, or if a change in condition arises. A resident at risk will have a wander guard placed around their ankle (or different area depending on resident) and placed on the wanderer list. The wanderer list is located in each nurse's station. 4. Wander guards are assessed for proper functioning and placement daily, and the main system checked by the maintenance supervisor on a weekly basis; not only functioning but also response time. 5. The residents care plan will be developed or modified by the intra disciplinary team to indicate the resident is at risk for elopements and specific individual interventions will be developed to encourage alternate behavior from attempting to exit the building. 6. Should an elopement occur: the contributing factors as well as the interventions tried will be documented in the nurse's notes and an incident report will be filled out. Update the administrator and director of nursing immediately. 1.) R24 was readmitted to the facility on [DATE] with diagnoses to include Alzheimer's, Dementia, Anxiety, Obsessive Compulsive Disorder, and Post-Traumatic Stress Disorder. R24's Annual Minimum Data Set (MDS), dated [DATE], documents R24 requires partial/moderate assistance with a helper doing less than half the effort with transitions from sitting to standing. R24's MDS also documents R24 requires partial/moderate assistance to walk 10 feet and requires supervision or touching assistance when wheeling 150 feet in a corridor or similar space. R24's most recent Quarterly MDS dated [DATE], documents R24 has a Brief Interview for Mental Status (BIMS) score of 4, indicating that R24 is severely cognitively impaired. R24's Quarterly MDS also documents that R24 has wandering behavior that occurred 4 to 6 days of the assessment which was less than daily. R24's Wander/Elopement care plan, with a start date of 06/21/2023 and last revised on 07/15/2024, documents that R24 is at risk for wandering/elopement due to an altered mental status related to dementia. R24's physician order dated 7/29/23 documents, Monitor wander guard placement to right ankle every shift. R24's physician order dated 8/10/23 documents, Monitor wander guard placement to left ankle every shift. R24's progress note dated 08/13/2023 at 01:07 PM documents, Resident up and self-propelling around common area this AM. Resident tearful and very upset. Resident anxious and repeatedly asked staff why she is here, what is happening, where should she go, and what she should be doing. Resident very confused and anxious. Resident required 1:1 support from staff due to her emotional state and confusion. R24's physician order dated 8/20/23 documents, Discontinue order to monitor wander guard placement to right ankle every shift. R24's progress note dated 08/20/2023, at 07:39 PM documents, (R24) was up walking in hallway x 2 this shift, very limited safety awareness. She has been repeatedly asking why she is here and where her family is. Will continue to monitor. R24's progress note dated 09/01/2023, at 07:55 PM documents, Resident walking in hall several times without walker or staff assist. Able to re-direct her to sit in w/c (wheelchair) until staff can ambulate with her. R24's progress note dated 10/04/2023 at 08:20 PM documents, Resident has been looking for her daughter since after dinner. Resident began going into the closets and other resident's room. Unable to get her to calm down. Called the daughter so resident could speak to her. Resident was scared that her daughter had ran away. R24's progress note dated 10/28/2023 at 01:47 PM documents, Staff noted resident to be attempting to elope from facility out front door. Resident stated that she was going home. Visitors that were in the facility were leaving at this time and resident thought she should leave as well. Resident was easily redirected away from the front door. No further attempts noted. R24's progress note dated 11/14/2023 at 11:02 AM documents, Continues to self-transfer and walk around independently in spite of reeducation and redirection from staff. Motion alarm activated when she's in room so staff aware when she's moving around independently. Will continue to monitor. R24's physician order dated 11/30/24 documents, Place wander guard to left wrist for safety and due to elopement attempt. R24's progress note dated 11/30/2023 at 05:42 PM documents, Wanderguard replaced to left wrist. R24's progress note dated 01/28/2024 at 05:17 AM documents, This morning resident took sensor alarm and hid it under her pillows and then ambulated herself into the bathroom. Call light was within reach and 15 minute checks being implemented but, resident did not use call light this morning and was asleep during check. Resident assisted from bathroom back to bed and encouraged to use call light and again shown where call light located. R24's progress note dated 02/15/2024 at 04:48 PM documents, Call placed to 911, dnr (do not resuscitate) bracelet on right arm. Wanderguard removed from left wrist. No glasses, dentures or shoes were sent with resident. R24's progress note dated 03/01/2024 at 05:58 PM documents, Resident very distraught this evening. Looking for her mother, husband and children. Thinks she is leaving, refuses to sit in wheelchair, attempting to transfer self with purse and bible out of room into hallway to leave the facility. Not easily redirectable at this time. R24's progress note dated 03/15/2024 at 11:17 AM documents, NP (nurse practitioner) updated: Resident continues to have behaviors/confusion on PM shift. Resident requires 1:1 attention/re-direction after 4 PM which most of the time is not effective. Last evening, resident was confused/crying, and very anxious. We do not have anything to give her PRN. Awaiting response at this time. R24's progress note dated 03/15/2024 at 01:00 PM documents, New order received from Psych NP to increase her sertraline to 150 mg: currently scheduled 100 mg daily. POA and order updated. R24's progress note dated 03/23/2024 at 10:46 AM documents, Behaviors: Resident was found self-ambulating down the hallway without staff or her WC. Resident very anxious and confused. Ativan was given as re-direction and 1:1 support was not effective. PRN was effective. Resident was able to calm down, eat her meal, and then attended the activity. R24's progress note dated 03/27/2024 at 06:30 PM documents, 1830 Writer observed resident self-propelling in her wheelchair towards an exit door with her purse around her shoulder. Resident was looking for her son; he was going to be picking her up. Writer kindly tried to explain to Resident that her son was not in the bldg (building); and that others here were in their rooms winding down for the night. R24's progress note dated 03/31/2024 at 05:45 AM documents, Resident went to bed late last night & did not sleep well night before & has been up since 0300 this morning & asking about going to Chicago and what we are doing & trying to enter other resident's rooms & not being easily redirected as she is looking for her family and unable to redirect her and/or distract her thus, PRN Lorazepam given this morning which was starting to be effective at this time. Will continue to monitor resident. R24's progress note dated 05/15/2024 at 05:56 PM documents, Resident anxious and requesting to go home. Resident reports she lives next door. Resident asked writer to open the door leading outside so she could go home. Writer tried redirecting resident by telling her she needed to wait for family to come. Resident started talking in German and headed toward to exit door. Resident attempted to exit building at that time. Writer and admissions director redirected resident and moved resident away from exit door. Writer administered prn anxiety medication at this time. Admissions director brought her dog to see resident and resident became calm. Wander guard placed on residents wheelchair at this time and POA notified of resident's exit seeking. Resident became calm and went in to dining room for dinner. No further exit seeking attempts. Will continue to monitor. R24's progress note dated 05/20/2024 at 03:38 PM documents, Residents POA called and updated in regard to room change. POA in agreement. Resident will move to 132 5/21/24 once cleaned. On 08/14/24 at 11:12 AM, Surveyor asked NHA (Nursing Home Administrator)-A why R24 had a room change. NHA-A informed Surveyor that a deer came in through another resident's window and exited through R24's window. R24 was relocated due to the window being broken. R24's progress note dated 06/27/2024 at 02:58 PM documents, received from APNP for Ativan PRN (as needed) every 8 hours times 14 days for anxiety. Order entered and initiated. Will continue to monitor. First elopement: R24's progress note dated 06/27/2024 at 03:54 PM, Staff updated writer that resident was found outside by another residents family member in the front of the building standing on her own on the sidewalk. Resident had left her wheelchair in the building and walked out, therefore no alarm sounded d/t her wander guard is attached to her wheelchair. Updated DON and Administrator. R24's physician order dated 06/27/2024 documents, place wander guard to left wrist for safety. R24's Risk for Wandering/Elopement care plan with a start date of 6/27/2024 documents, Monitor for placement of wander guard to LEFT WRIST every shift and check function of wander guard to LEFT WRIST weekly on Monday morning. On 08/13/2024 at 12:20 PM, Surveyor interviewed NHA-A regarding R24 elopement attempt on 6/27/2024 as documented above. NHA-A informed Surveyor there is no investigation for R24's 06/27/2024 elopement. NHA-A stated R24's wander guard was removed from R24's wheelchair and placed on R24's left wrist at that time. On 08/13/2024 at 01:21 PM, Surveyor interviewed MDS coordinator-G regarding R24's wander guard placement on 05/15/2024. MDS coordinator-G informed Surveyor that R24 would not allow staff to put the wander guard on her wrist and it was extremely overwhelming for R24. MDS coordinator-G informed Surveyor that during that time, R24 rarely got out of her chair without assistance. MDS coordinator-G informed Surveyor that she figured that if the wander guard was on the wheelchair, it would still alarm if R24 went to push the door open. MDS coordinator-G informed Surveyor that she brought it up to management as well, and it was agreed to place the wander guard on R24's wheelchair. On 08/13/2024 at 02:56 PM, Surveyor interviewed RN-E and NHA-A regarding R24's elopement on 06/27/2024. RN-E informed Surveyor that a CNA supervisor was informed that someone went out the door and that R24 was by the door. RN-E stated there were a lot of visitors coming in and out, and that R24 had parked her wheelchair and made it about 10 feet out the door, holding the railing, and that a CNA helped R24 back inside. RN-E stated that R24 was maybe outside less than 1 minute. RN-E informed Surveyor that R24's wander guard was on chair because R24 took it off. NHA-A informed Surveyor that R24 would get so angry about having the wander guard on. RN-E informed Surveyor that R24 has eloping behaviors but had not made it outside before. RN-E informed Surveyor she called NHA-A and DON-B and made them aware of R24's elopement on 6/27/2024. NHA-A informed Surveyor that the facility's policy does not consider an elopement to have occurred unless the resident makes it off the facility grounds. NHA-A informed Surveyor that a care conference with R24's son occurred where they discussed placement for R24 at a better fit facility, that is more secure for R24. RN-E informed Surveyor that R24's care conference explained safety and that R24 has not tried to remove the wander guard after putting back on because staff are telling R24 it's a heart monitor and R24 has had no other elopements. On 08/13/24 at 03:35 PM, Surveyor attempted to call the witness who found R24 when R24 eloped on 06/27/2024. The witness did not answer, and Surveyor left a voicemail with contact information for witness to return the call. Second elopement: R24's progress note dated 07/14/2024 at 12:27 AM documents, Front door alarm alerting, writer found pt in parking lot in wheelchair. Pt (patient) stated, I have a brother that doesn't live far from here. Escorted pt back inside, pt in nurse's station with writer. offered pt ice water and snack. R24's progress note dated 07/14/2024 at 08:18 AM documents, NOC (night) shift Nurse reported to writer that resident had an Elopement event at approximately 0130. Nurse stated that she did not hear the alarm from the front door sounding. NOC shift CNA reported that she found resident sitting in her WC in the parking lot. Resident states that she was out looking for Brother. CNA reports that resident was anxious and confused most of NOC shift. PRN medication was given at approximately 0400. Medication effective. Resident sleeping in her bed at this time. Motion sensor in place. Wanderguard in place to left wrist. Resident's Wander documents are posted in both Nurse's stations. Per Elopement Policy & Procedure, Writer initiated 15-minute checks and contacted. On call Nurse, DON (director of nursing), Administrator, MD (medical doctor), and POA (power of attorney) given update. R24's progress note dated 07/14/2024 at 08:36 AM documents, Writer checked proper functioning of Wanderguard System. System functioning properly. Alarm sounded and door locked. Door unlocked after 15 seconds of continuous pressure. R24's risk for Wandering/Elopement care plan documents, 1 hr checks Q shift. x 6 days per policy with a start date of 07/15/2024. No further revisions to care plan interventions documented. On 08/14/2024 at 08:17 AM, Surveyor interviewed LPN (Licensed Practical Nurse)-F regarding LPN-F's progress note documenting R24's elopement on 07/14/2024. LPN-F informed Surveyor that LPN-F arrived to work at 6 AM and there was an agency nurse coming off 3rd shift. LPN-F informed Surveyor that after medication count, LPN-F was going down the board and asked the 3rd shift nurse what happened for R24 to be put on the board. LPN-F informed Surveyor that during early morning hours R24 got out of the building unattended. LPN-F informed Surveyor that LPN-F then began to implement the facility's policy and procedure on elopement. LPN-F informed Surveyor that it was raining that night, and a CNA was coming back in from break and saw R24 in the middle of the driveway, unattended, in front of the building. LPN-F informed Surveyor the CNA was called back in to come do a witness statement. An elopement event was created, notified NHA-A, DON-B and the Medical Director. LPN-F informed Surveyor the CNA was on their 15-minute break and states R24 was outside maybe less than 15 minutes. LPN-F informed Surveyor that another agency CNA was inside at the time but did not hear the alarm. On 08/14/2024 at 08:28 AM, Surveyor asked NHA-A if she was aware of R24's 07/14/2024 elopement. NHA-A stated yes and provided Surveyor with R24's elopement investigation. The facility provided Surveyor with a copy of the wander guard manual. On the manual, DON-B noted that she called the wander guard company, and the wander guard should be placed on arm, wrist, or ankle. Surveyor took pictures of outside the facility. Surveyor captured pictures of the entrance to the facility, from the front door of the facility looking to the road, the posted speed limits, and name of the road in front of the facility. Surveyor noted the speed limit posted looking west on the road is 55 miles per hour (mph) and looking east is 45 mph. Surveyor measured the distance from the front door of the facility to the edge of the road and documented 83 feet 4 inches. On 08/15/2024 at 08:02 AM, Surveyor observed a camera on R24's dresser across from the bed. On 08/15/2024 at 08:05 AM, Surveyor interviewed NHA-A who informed Surveyor R24 is now a one on one (1:1), assigned staff will monitor R24 on camera only while R24 sleeps. The staff member who is assigned to the 1:1 role with R24 has the monitor with them. The 1:1 staff is a resident assistant who is not certified to do care. While R24 is sleeping, the 1:1 can work on other tasks until R24 is awake, and then when R24 is awake, the assigned 1:1 will be tasked only with being with R24. The facility's failure to provide adequate supervision to a resident identified as being at risk for wandering and elopement led to R24 exiting the facility on 2 separate occasions. This created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 06/27/2024. The immediate jeopardy was removed on 8/15/24 when the facility completed the following: - Elopement assessment completed on the identified resident. All residents had an elopement assessment completed as of 8/14/24. Any residents identified as at risk had their care plan reviewed, and interventions modified as needed to ensure safety. - Resident identified in citation is a high risk for elopement. Care plan reviewed and the following interventions were immediately put in place: o Wanderguard was checked for function and for proper placement, checks for placement and function are on the electronic medical record for every shift. o One on one staff supervision for resident implemented. o A comprehensive assessment will be completed using historical data as well as a new interview with residents and their representative to identify any past trauma not already identified and or routines or missed needs. o This resident or any other resident that has exit seeking behaviors or history of elopement will be redirected using individualized interventions for distraction and diversion. Staff will enlist help with other visible staff as needed and maintain a calm presence. The administrator or director of nursing will be notified of any attempts to leave the building. - Elopement policy reviewed, modified and reimplemented by educating all staff to the policy as well as the definition of elopement, interventions to prevent elopement, response to elopement and reporting elopement. Staff have also been educated on the residents currently identified as at risk including the identified resident and interventions developed to prevent elopement and resident safety. - Licensed nurses educated by DON (Director of Nursing) or designee on documentation expectations related to supervision and interventions which is to document on identified resident each shift for effectiveness of interventions. - Medical Director consulted during the development of this corrective action plan. - DON or designee will review progress notes and 24-hour report board daily for 2 weeks and 3 times a week for 4 weeks and then weekly for intervention documentation and effectiveness of same. No additional information was provided as to why the facility did not ensure that R24 was provided adequate supervision and assistance devices to prevent elopement on two separate occasions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that each resident received needed supervision to prevent accidents for 13 of 13 residents reviewed for the use of lifts and 2 of 4 residents reviewed for falls out of total sample of 16 (R1, R2, R3, R6, R8, R9, R10, R11, R12, R13, R14, R15, and R16). R1 was transferred via a Hoyer lift with assist of 2. R1 fell out of the Hoyer lift and struck her head on the floor. The fall caused several facial fractures, a subdural hematoma, neck fractures, and a large laceration to the right side of the head. R1 expired the following day as a result of her injuries. Facility staff had not been educated on the type of sling/harness or size of sling/harness to be used for R1. Facility staff did not ensure that the sling was properly secured on the lift prior to lifting the resident and moving her from one surface to another. R3, R8, R10, R12 and R15 (R15 uses a full body lift PRN (as needed)) all currently reside in the facility and require full body lifts for transfer. Facility staff have not been educated on the use the full-body lift used for each resident or which sling/harness is to be used, including the correct size. The facility has no documentation that any assessments have been completed on residents that require the use of lifts. R15, R6, R14 (or [NAME] steady), R2, R11, and R16 (PRN) currently reside in the facility and require a sit-to-stand lift for transfers. Facility staff have not been educated on the use of the sit-to-stand lifts used for each resident or what sling/harness is to be used, including the correct size. R14 (utilizes an EZ stand), R16, and R13 all currently reside in the facility and require a [NAME] steady lift for transfers. Facility staff have not been educated on the use of the [NAME] steady used for each resident. The facility's failure to ensure each resident is transferred safely created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on [DATE] at 8:31 AM. The immediate jeopardy was removed on [DATE]. However, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. The facility also had deficient practice regarding a fall for R2. R2 had a fall in which she complained of hip pain. The staff moved the resident from the floor to her bed without first having the resident assessed by an RN. This is evidenced by: The Facility's Policy and Procedure entitled Assessing Falls and Their Causes last revised [DATE] documents, in part: .Purpose: The purpose of this procedure are to provide guidance for assessing a resident after a fall and to assist staff in identifying causes of falls. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. General Guidelines: 1. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes. Steps in the Procedure: After the Fall: 3. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. 7. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings . Note: The Assessing Fall and Their Causes policy does not identify for a resident's need to be assessed for injury by a RN (registered nurse). The Facility's Policy and Procedure entitled Low Lift/No Lift Policy and Procedure, dated [DATE], documents the following, in part: .Policy: To ensure the safety of residents and staff, it is the policy of [Facility Name] to minimize/avoid manual lifting of resident during transfers, to provide specific transfer instructions to CNAs/nursing department on each resident, and to facilitate communication between departments and staff. Procedure: c. EZ stand lift. iii. Must have permission form therapy and/or nurse prior to use, if not written on the care plan worksheet. v. All EZ stand lift transfers are 2 assist unless care plan states assist of one. d. Hoyer Lift. ii. Must be 2 assist . The Facility's Policy and Procedure entitled Safe Lifting and Movement of Residents, last revised [DATE], documents the following, in part: .Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation: 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. resident's preferences for assistance; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status; f. Whether the resident is usually cooperative with staff; and g. The resident's goals for rehabilitation, including restoring or maintaining functional abilities. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. 7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding us of equipment and safe lifting techniques. 9. Enough slings, in the sizes required by residents in need, will be available at all times. As an alternative, resident with lifting and movement needs will be provided with single-resident use disposable slings. 10. Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. 11. All equipment design and use will meet or exceed guidelines and regulations concerning resident safety and the use of restraints. 12. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies; c. Provides training on safety, ergonomics and proper use of equipment; and d. Continually evaluates the effectiveness of workplace safety and injury-prevention strategies. The facility currently has approximately 11 different types of lifts by 7 different manufacturers that are used for mechanically transferring residents. The Manufacturer's recommendations and instructions provided by the facility for the lifts observed being used by Surveyors during the survey are as follows, in part . The Manufacturer's User Manual for the Joerns Hoyer Presence, (Full Body Lift) documents the following, in part, on pages 9 and 18: .4. Safety Precautions. Warning: DO NOT lift a patient unless you are trained and competent to do so. ALWAYS carry out DAILY CHECK LIST located towards the end of the manual before using the lift. DO NOT use a sling unless it is recommended for use with the lift. ALWAYS check the sling is suitable for the particular patient and is of the correct size and capability. DO NOT use a sling unless it is recommended for use with the lift. NEVER use a sling, which is frayed or damaged. ALWAYS fit the sling according to the instructions provided (user instructions). HOYER RECOMMENDS THE USE OF GENUINE HOYER PARTS. Hoyer slings and lifters are not designed to be interchangeable with other manufacturer's products. Using other manufacturer's products on Hoyer products is potentially unsafe and could result in serious injury to patient and/or caregiver . The Manufacturer's User Manual for the Joerns Hoyer HPL 600, (Full Body Lift) was not provided to Surveyor by the facility. Surveyor attempted to obtain the User Manual from the manufacturer's website, but this particular model is no longer listed as one of their products. The Manufacturer's User Manual for the Invacare Reliant 450 RHL450-I; Invacare Reliant 450 RPL450-I, and the Invacare Reliant 600 RPL600-I, (Full Body Lift) documents the following, in part, on pages 7 and 9: .2. Safety: General Guidelines: ACCESSORIES WARNING: Invacare products are specifically designed and manufactured for us in conjunction with Invacare accessories. Accessories designed by other manufacturers have not been tested by Invacare and are not recommended for use with Invacare products. 2.2. Operating Information: Invacare slings and patient lift accessories are specifically designed to be used in conjunction with Invacare patient lifts. Slings and accessories designed by other manufacturers are not to be utilized as a component of Invacare's patient lift system. Using the Sling: WARNINGS: Be sure to check the sling attachments each time the sling is removed and replaced, to ensure that it is properly attached before the patient is removed from a stationary object (bed, chair or commode). Lifting the Patient: WARNING: When elevated a few inches off the surface of the stationary object (wheelchair, commode, or bed) and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the hanger bar. If any attachments are not in place, lower the patient back onto the stationary object (wheelchair, commode, or bed) and correct this problem. Invacare slings are made specifically for use with Invacare Patient Lifts. For the safety of the patient, DO NOT intermix slings and patient lifts of different manufacturers. Warranty will be voided. The Manufacturer's User Manual for the Medline, (Sit-to-Stand Lift) documents the following, in part . General Warnings: Never operate the stand assist unless you have been properly trained on all procedures and safe handling methods. Practice using the stand assist prior to performing actual patient lifting so that you are familiar with its operation. Personal Injury Warnings: Use only Medline slings on Medline patient lifts. Use of non-Medline slings could be unsafe and may result in injury to the patient or caregiver. Inspect the slings prior to each use. Do not use a sling that has worn thread or frayed straps. Operating Warnings: Do Not lift a patient unless you are trained and competent to do so. The Manufacturer's User Manual for the EZ Way Smart Stand, (Sit-to-Stand Lift) documents the following, in part . Safety Notes: EZ Way harnesses are made specifically for EZ Way stands. For the safety of the patient and caregiver, only EZ Way harnesses should be used with EZ Way stands. WARNING: For safe operation of the EZ Way Smart Stand, the stand must be used by trained personnel in accordance with the operator's manual, video and training checklist to avoid injury to patient. Example 1 R1 was admitted to the facility on [DATE]. R1 had the following diagnoses, in part: Low back pain, cervicalgia (neck pain), pain in the right and left shoulders, age-related osteoporosis, occlusion and stenosis of unspecified carotid artery, chronic obstructive pulmonary disease, carcinoma in situ of skin (skin cancer), muscle weakness, and unsteadiness on feet. R1's care plan documented the following, in part: Problem: R1 at risk for falling R/T (related to) new to nursing home placement, weakness, impaired mobility. Approach: Transfer status changed to Hoyer lift only, due to inability to use EZ stand r/t shoulder pain and unable to pull self-up for [NAME] steady. Problem: ADL (activities of daily living)/Mobility Deficit related to: Weakness. Approach: Transfer with assist of: 2 staff and Hoyer. R1's CNA care plan documented the following, in part: .Updated [DATE]: Hoyer Sling Color: Blank; Transfers: Hoyer at all times; Total Transfer: 2 assist with Hoyer. Surveyor noted: Hoyer Sling Color is blank on the CNA care plan and does not give staff a way to identify which sling/harness is to be used with R1. R1's Minimum Data Set's (MDS) documented the following, in part: Annual MDS dated [DATE]- .Bed mobility: extensive of one staff. Transfer, Dressing, Toileting, and Hygiene are dependent of two staff. R1 is always incontinent of bowel and bladder . R1's Nurses' Progress Note documented the following: [DATE] at 9:37 AM, At approximately 9:05 AM writer heard CNA yell, 'we need a nurse now!' Writer entered the doorway of room (the number to R1's room). Resident was lying face down on her floor with a large puddle of blood around her head. Writer yelled to staff running towards resident's room to call 911. Admin (Administrator) entered room. Writer grabbed gloves and blanket. Blanket placed under resident's forehead to apply pressure. Resident responded appropriately to writer's questions. Stated that her head and knees hurt. Writer sent CNA for a gown, washcloths, and Hoyer sling. With support to resident's neck and head, resident was turned on her back with the Hoyer sling and placed under her. A gown was placed over resident. Pressure was applied to laceration on right side of forehead. EMS (Emergency Medical Services) arrived. Writer prepared red folder with bed hold notice and transfer paperwork included. DNR (Do Not Resuscitate) bracelet was placed on resident's left wrist. Long Term nurse placed call to resident's Emergency Contact. Resident was lifted by Hoyer sling onto EMS cot. Resident in route at this time to [Hospital Name]. The Facility document titled, Safety Events - Fall report documents the following, in part: .Description: Fall. Event Details: FALL: Location of Fall: Resident Room. Describe exactly what happened; why it happened; what the causes were. If any injury, state part of body injured. If property or equipment damaged, describe damage. Resident fell out of Hoyer lift during transfer. Fall was witnessed by 2 CNAs. Nurse responded. Resident was face down on the floor in the middle of her room. Blood actively draining from laceration on forehead. Resident stated that her forehead and knees hurt. Pain Observation: Does resident exhibit or complaint of pain related to the fall? If so, describe location: Yes (location) - forehead and knees. On a scale of 0-10, how does resident rate intensity of pain if able, or indicate based on observation: 10 - Excruciating Pain - Worst Possible - Interferes with ability to carry on with daily routines, socialization or sleep. Body Observation: Note any injury to the head, extremities, or trunk: Skin tear. Neurological Check: Level of Consciousness: Alert Wakefulness - Perceives the environment clearly and responds appropriately to stimuli. Possible Contributing Factors: None. Interventions: First Aid, Direct Pressure to Wound, Other - EMS called, and Send for CT (Computerized Tomography) of Head. Note: The facility has no documentation that staff were educated prior to the event on the use of the lift or which sling/harness was to be used for R1. CNA's indicated during interviews that the slings/harnesses were universal and that they used slings/harnesses interchangeably between lifts and residents. Note: The manufacturer recommendations for the lifts indicate staff must be trained on the use of the lift prior to completing any transfers, the sling is the appropriate size and capability, never use a sling that is frayed or damaged, complete the daily check list prior to using the lift, Hoyer recommends the use of genuine Hoyer parts, Hoyer slings and lifters are not designed to be interchangeable with other manufacturer's products, and using other manufacturer's products on Hoyer products is potentially unsafe and could result in serious injury to patient and/or caregiver. Note: During the survey, Surveyors inspected sling used at the time of the fall with R1. The sling was noted to have fraying along the upper right side along the seam. The sling contained no markings or labels to indicate the brand, size, or compatibility with the lift it was to be used with. On [DATE] CNA C completed the facility document titled, Employee Statement which states in part . Time incident occurred: 9:05 AM. If any physical evidence of injury occurred, was any part of their body bumped or hit on any object: Yes. If yes, please explain injury type and location: Head injury to R (right) side. Employee statement: Give a full description of all of the facts: Other CNA and I were transferring resident from bed to shower chair using Hoyer. As we were opening legs of Hoyer resident flipped face first on the ground due to left upper sling strap becoming unattached. We grabbed a nurse right away and started applying pressure to head wound until EMS (Emergency Medical Services) arrived. On [DATE] CNA D completed the facility document titled, Employee Statement which states in part . Time incident occurred: 9:05 AM. If any physical evidence of injury occurred, was any part of their body bumped or hit on any object: Yes. If yes, please explain injury type and location: Head, bleeding R (right) side. Employee statement: Give a full description of all of the facts: Me and another CNA were transferring a resident with a Hoyer. We were transferring her to the shower chair. As we were opening up the legs of the Hoyer the top left strap came unattached, and the resident fell landing face first on the ground. We grabbed a nurse right away and started applying pressure to head wound until EMS arrived. Note: Both CNA statements indicate that the top left strap came undone but in the fall investigation and during interviews with both CNA's they indicate it was the left lower strap that came undone. Director of Nursing (DON) B assisted Licensed Practical Nurse (LPN) E in R1's room but no statement was completed by her. On [DATE] Nursing Home Administrator (NHA) A completed the facility document titled, Employee Statement which states in part . Time incident occurred: 9:05 AM. If any physical evidence of injury occurred, was any part of their body bumped or hit on any object: N/A. Employee statement: Give a full description of all of the facts: Writer heard a call out for help and when approaching the living room writer was asked by LPN E to call 911. Writer immediately called 911 and requested emergency assistance. Writer waited at the front door and directed emergency personnel to R1's room. Writer did not see resident or observe event while happening. Emergency Medical Services (EMS) Report titled, Prehospital Care Report, dated [DATE] at 10:02 AM, states in part: .Ambulance dispatched to [Facility Name] for a patient that fell out of a Hoyer lift. Upon arrival we found a 91 y/o (year old) female lying on the floor in care of facility staff. Patient is A/Ox4 (Alert and Oriented). Patients C/C (chief complaint) is a head injury, and neck pain due to a fall from the Hoyer lift. Staff on scene stated they were lifting the patient up with the Hoyer to give her a bath, when one of the straps snapped causing her to fall about 4 feet face first to the ground. Patient denied any LOC (loss of consciousness). However, she was complaining of neck pain along with a 5 inch laceration to her forehead. Bleeding was controlled on scene by EMS with cling wrap and Coban bandages. A soft collar made from a rolled blanket was also used to help support the patients neck. Due to anatomy, the soft collar was used because the rigid collar wouldn't fit properly. Patient was then lifted from the floor and secured to the cot. Once out in the ambulance, all vitals were obtained and noted. A 20G (gauge) IV (intravenous) was established in her left hand. Trauma assessment was performed with no other findings. Patients mental status along with her condition were continually monitored throughout transport to [hospital name]. Upon arrival patient showed no changes in airway, breathing, circulation, or mentation. The Emergency Department Note, dated [DATE] at 10:24 AM, states in part: . 91 y.o. (year old) female presenting after 4 foot fall from Hoyer lift. On initial encounter, patient alert, GCS (Glasgow Coma Scale) 15 (best response), vital signs reassuring. Physical exam significant for right eye proptosis (protrusion of eye socket), posterior midline neck pain, significant right-sided facial blunt trauma, equal grip strength bilaterally. Shortly after arrival right intraocular pressure was checked and was elevated at 50 (normal is 10-21), 23 on the left concern for retro-orbital hematoma (accumulation of blood in the retrobulbar space) with progressively worsening vision changes requiring emergent canthotomy (urgent surgical procedure for orbital compartment syndrome) and canthal lysis (tendon release) which was performed as below. Scans showed significant findings involving multiple right facial fractures with evidence of right or retro-orbital hematoma, small SDH (subdural hematoma), C1 and C2 fractures. I did speak with oculoplastics whom recommended transfer to tertiary center. While in the emergency department patient had acute onset of increased trouble breathing and then had an episode of emesis. This is the second episode of emesis first was prior to arrival. Patient was intubated without difficulty. Around the time of intubation patient had increased blood pressures to over 210 systolic. Hospital CT C-Spine WO (without) Contrast, states in part: . 1. There is horizontally oriented fracture through the body of the dens with mild anterior displacement of the distal fracture fragment (type II dens fracture) (is an upward extension of C2 cervical vertebrae (i.e., axis) up into the C1 cervical vertebrae (i.e., axis)). 2. There is a vertically oriented fracture through the anterior arch of C1. There are also fractures through the bilateral aspects of the posterior arch of C1. 3. There is questionable nondisplaced fracture through the left inferior facet at C4. Hospital CT Facial Bones WO Contrast, states in part: . 1. There are multiple highly comminuted right-sided facial fractures with extensive soft tissue swelling. This includes fractures of the nasal bone, the anterior wall of the right maxillary sinus, the posterior wall of the right maxillary sinus, the lateral right obits and zygoma as well as the right zygomatic arch. 2. There is prominent right retrobulbar fat stranding with an ill-defined gas containing fluid collection along the inferior aspect of the right orbit, consistent with an extraconal retrobulbar hematoma. There is associated right-sided proptosis. R1 was transferred to a Level I trauma center and succumbed to her injuries and expired at 2:00 PM on [DATE]. On [DATE] at 2:00 PM Surveyor interviewed ME N (Medical Examiner). ME N stated R1's death certificate indicated R1's cause of death was blunt force trauma to her head and neck due to fall. On [DATE] at 10:10 AM, Surveyor interviewed EMS staff members H and I. Surveyor asked EMS staff if they could describe what they saw and did upon entering the facility on [DATE] and during transport to the hospital. EMS I stated when we entered the room R1 was lying on the floor on her back. It appeared as if facility staff had already turned her over. R1 had a cloth on forehead and was awake. Staff indicated that the strap broke on the lift during the transfer resulting in the fall. R1 stated that she remembered falling and being on the floor, she also indicated that she was 4 feet in the air at the time of the fall. Surveyor asked EMS staff what type of aide they gave on scene. EMS H stated, We used a blanket the facility provided to make a soft collar, as a rigid color would not fit the resident. We needed to ensure we protected the airway of the resident. Surveyor asked EMS staff if they were able to identify what R1 hit causing the injury. EMS I stated, Based on the extent of the injuries she could have hit the base of the Hoyer, the floor, or both. She had injuries to the mid forehead, bridge of the nose, and over the right eye. The right eye was also swollen with blood pooled behind it. R1 was provided with first aide and pressure to the forehead. On [DATE] at 10:30 AM, Surveyors interviewed CNA C along with DON B. Surveyors asked CNA C to describe what happened during the transfer of R1. CNA C stated, It was just after breakfast. CNA D and I were going to assist R1 to get a bath. R1 liked baths. I informed R1 that I was going to go get the bath ready. When I returned, we transferred R1 from the recliner to the bed with the Hoyer. CNA D placed the shower sling under R1 and hooked her up the Hoyer as I was getting the shower chair and towels. Surveyor asked CNA C where staff were standing when moving the lift. CNA C indicated she was behind the shower chair and CNA D was in front of the Hoyer moving R1. Surveyor asked CNA C if either she or CNA D had their hands on R1 as they were moving the Hoyer. CNA C stated, No we did not. The left side lower (left leg) strap came undone and R1 fell to the ground onto her knees and then fell face forward. I am guessing that the strap was not on all the way. Surveyor asked CNA C if it appeared that R1 had attempted to break her fall. CNA C stated, When she was rolled over, she still had her arms crossed in front of her. DON B brought Surveyors out to common area to show the lift and sling used during the incident. Surveyors noted that the sling is frayed along the right upper strap. Surveyors asked DON B about sling and DON B indicated she was not sure how old the sling was, did not know where it came from, as it did not have an labels or markings to indicate, and she was unsure if it was approved for use with the Hoyer lift. Surveyors asked CNA C how staff determine what lifts and slings to use and how many people are required to use the lifts. CNA C stated, We use the same slings for all brands of lifts. They are interchangeable. DON B stated, We use slings based on the residents height and weight. We use 2 assist for Hoyer lifts and 1 assist with EZ stands or [NAME] steady's unless care plan states otherwise. On [DATE] at 12:30 PM, CNA C came back to Surveyor stating she wanted to correct a statement that was made by DON B during the interview. CNA C stated, We use 2 assist for all full body and sit-to stand lifts and 1 assist for [NAME] steady, unless the care plan indicates otherwise. On [DATE] at 1:29 PM, Surveyor interviewed CNA D. Surveyors asked CNA D if she could tell Surveyors about the events of [DATE] and R1. CNA D stated, CNA C and I were getting R1 ready for a bath. I was assisting R1 in her room with getting undressed. The bath chair was by the closet. I hooked up R1 to the lift and began lifting her off the bed. I began moving the lift towards the shower chair and about to start opening the legs of the lift when R1 fell onto the floor. Surveyor asked CNA D where she and CNA C were in relation to R1. CNA D stated, I was by the bed moving the Hoyer and CNA C was by the shower chair. Surveyor asked CNA D if any staff were guiding or had hands on the resident. CNA D stated, No one had their hands on resident or the sling. Surveyor asked CNA D if staff should have hands on resident when moving them in the lift. CNA D stated, Yes. Surveyor asked CNA D if R1 hit the floor or lift. CNA D stated, I saw the resident fall. When she fell she did not hit the Hoyer. I looked up and saw the sling unattached to the left lower loop by legs. R1 fell right between the legs of the Hoyer onto the floor with head towards the Hoyer and her feet straight out towards the shower chair. R1's knees hit first I think. R1 was awake and did complain of knee pain. Surveyor asked CNA D how she determines what sling to use for residents. CNA D stated, There is a sticker on the top side of the Hoyer beam indicating what size sling to be used. Surveyor asked CNA D if each resident has a specific sling they should be using. CNA D stated, There are no specific slings for residents. Mostly we use the same slings on everyone. I had never gotten R1 into the shower before and had never used this particular sling on her before. Surveyor asked CNA D if any education was completed with her following the fall. CNA D stated, We watched a video on using a lift and had to complete a return demonstration. Surveyor asked CNA D if she learned anything from the video she watched or any of the education she received. CNA D stated, I learned about needing to guide the resident in the sling and having my hands on the resident. On [DATE] at 1:57 PM, Surveyor interviewed LPN E (Licensed Practical Nurse). Surveyor asked LPN E if she could describe the events of the fall for R1. LPN E stated, I was the on the rehab unit that day and had just come over to the long-term area to cover that Nurse's break. At approximately 9:00 AM I head yelling and I couldn't tell where it was coming from so, I yelled Where are you. Staff yelled back R1's room number. I then stepped into the doorway and saw the resident face down in a pool of blood. I yelled for the NHA (Nursing Home Administrator) to call 911. I took bath blanket and put it up to R1's head. The DON and I then supported R1's neck and rolled her onto her back to assess injuries. The DON kept pressure on R1's head. At this time, I could already hear the siren. I put a gown on the resident and then went to get the transfer paperwork ready to send with the resident. On [DATE] at 4:05 PM, Surveyor interviewed CNA L. Surveyor asked CNA L how she decides what lift or lift sling to use on a resident. CNA L stated, Depends on the size of the resident. Blue is large or x-large. Also go off the size chart. Surveyor asked CNA L if she had competency training on the use of the lifts and slings. CNA L stated, We had education last week and prior to that was when I was training in another facility to get my license. Note: The size chart showed to Surveyor by CNA L was a list of slings by cradle type for the full body lift. The cradle type listed on the chart was not a cradle that the facility has. This document was laminated and posted for staff on the CNA desk. On [DATE] at 4:15 PM, Surveyor interviewed CNA M. Surveyor asked CNA M how she decides what lift or lift sling/harness to use on a resident. CNA M stated, Depends on the resident weight. We are able to use all slings on all Hoyer's. Surveyor asked CNA M if she had completed any training for lifts or slings/harnesses. CNA M stated, Yearly refresher training and competencies are done. On [DATE] at 4:30 PM, Surveyor interviewed CNA O. Surveyor asked CNA O how she determines what lift and sling/harness to use with each resident. CNA O stated, I ask if I am unsure. There is a chart at the CNA desk and the resident care sheet says what lift to use for transfers. All Hoyer/full body lift slings/harnesses are all interchangeable. Surveyor asked CNA O if this includes the shower slings. CNA O states, I don't know if those are different sizes. Surveyor asked if CNA O received any education on how to use the lifts in the facility. CNA O stated, I had education during clinicals at another facility. No education prior to January in this facility. Surveyor asked CNA O how many staff are required to use a lift. CNA O stated, You are never to use a lift alone. Note: The facility was unable to provide any competencies [TRUNCATED]