**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) R19 was admitted to the facility on [DATE], and has diagnoses that include Dementia, Type 2 Diabetes, mild protein-calorie malnutrition, muscle weakness, physical debility, peripheral vascular disease, neuromuscular bladder dysfunction, history of cerebrovascular accident, and right and left below the knee amputations. R19's quarterly minimum data set (MDS) dated [DATE] indicated R19 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 0 and the facility assessed R19 to require extensive assist with bed mobility, dressing, toileting, and total dependence with transferring using a Hoyer lift, and hygiene. R19 had a suprapubic catheter and was incontinent of stool. R19 had impairment to upper and lower extremities and had a high risk for developing pressure injuries with a Braden score of 9.0 on 8/9/2022. R19's potential for skin issues related to history of pressure injury related to incontinence and decreased mobility care plan initiated on 4/12/2018 had the following interventions in place: - Air mattress- monitor for proper functioning every shift - Notify physician of changes to coccyx and buttocks wound or emerging wounds - Observe wound healing - Provide wound care/preventative skin care per order - Skin checks weekly per facility protocol, document findings - Turn and reposition every two hours to decrease pressure, position on side - Administer treatments as ordered and observe for effectiveness. Initiated 4/16/2018. - Provide incontinence care after each incontinence episode, or per established toileting plan - Assist [R19] to reposition/ turn at frequent intervals to provide pressure relief. Support position with pillows as needed. - Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. - Matrix cushion in wheelchair while up in wheelchair initiated 5/19/2023 - New AP mattress - R19 needs a pressure relieving mattress to protect skin while in bed. Keep air mattress set by weight (range 120-130 pounds). Initiated 5/23/23. - Up for meals and down after meals. - Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Initiated 6/15/2021. - Encourage nutrition and hydration to promote healthier skin - Follow facility protocols for treatment of injury - Observe site for redness, swelling, increasing drainage and pain - Use a draw sheet or lifting device to move [R19] - Complete Braden scale per living center policy. Initiated 8/12/2022. - Conduct weekly skin inspection - Monitor signs and symptoms of infection such as swelling, redness, warmth, discharge, odor- notify physician of significant findings - Nutritional and hydration support - Provide pressure reducing wheelchair cushion - Provide pressure reducing/ relieving mattress - Treatments as ordered - Turn and reposition every two hours - Weekly wound assessments - Provide thorough skin care after incontinent episodes and apply barrier cream. Initiated 9/7/2022. - Provide treatment as ordered. Initiated 9/9/2022. - [R19] needs pressure relieving/reducing mattress, pillows, air mattress to protect the skin while in bed. - [R19] needs pressure relieving/reducing mattress, pillows, air mattress to protect the skin while in chair. - Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Initiated 1/25/2023. - Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable change or observations - Follow facility policy/protocols for prevention/treatment of skin breakdown. Initiated 9/23/2023. - [R19] requires air loss mattress On 9/5/2022, at 12:29 PM, a weekly skin review was completed for R19. Nursing checked the skin tear option and charted a new wound in between buttocks/coccyx. Area was cleaned with normal saline, zinc barrier applied, and covered with bandaged gauze. On 9/5/2022, at 12:31 PM, in the progress notes nursing charted new wound found between buttock/coccyx area. Area cleaned with normal saline, zinc barrier ointment applied, and covered with gauze for protection. Will wait for orders for treatment. Surveyor noted that there were no measurements or a comprehensive assessment performed for R19's newly identified skin concern to R19's coccyx. Surveyor noted there is no indication if nursing contacted R19's physician or let anyone know about R19's new skin concern. On 9/7/2022, at 7:43 PM, a head to toe skin check was documented for R19. Nursing checked the existing other issue option and charted open area to sacrum. On 9/7/2022, at 8:41 PM, in the progress notes Assistant Director of Nursing (ADON)-C charted weekly skin assessment showed open area to coccyx measuring 1.0 cm X (by) 0.5 cm X 0.1 cm (centimeters), moisture associated skin damage (MASD) in appearance. Surveyor notes this is the first assessment of the new skin concern identified on 9/5/22. On 8/1/2023, at 7:26 AM, Surveyor interviewed ADON-C who stated ADON-C did not recall much information regarding R19's wounds. ADON-C did not recall measuring R19's wound on 9/7/2022. Surveyor asked ADON-C what the process was when a new open area is found. ADON-C stated staff would let the wound Registered Nurse (Wound RN)-Q know about it in the morning staff meeting and Wound RN-Q would go assess the wound. On 8/1/2023, at 1:17 PM, Surveyor interviewed Wound RN-Q who stated he does not recall when R19's stage 3 pressure injury started but did recall R19 had MASD before it developed and since the MASD was not healing, the wound Nurse Practitioner (Wound NP-S) and wound RN-Q decided to stage it because it was progressing and then changed the treatments. Surveyor asked wound RN-Q if MASD gets assessed and measured weekly. Wound RN replied that MASD does get assessed and measured weekly on wound rounds with the wound NP-S. Surveyor asked wound RN-Q if an open area is found and wound RN-Q is not in the building, when would the open areas get measured and assessed. Wound RN-Q replied that in the morning staff meeting wound RN-Q is notified and will go and assess the open area. Open areas should be assessed and measured upon identifying the open area. Wound RN-Q works Monday- Thursday about 32 hours a week. Surveyor asked who oversees measuring the open area when wound RN-Q is not in the facility. Wound RN-Q replied wound RN-Q was not sure, all staff can measure the wounds, was not sure why R19's was not measured when found on 9/5/2023. Surveyor asked wound RN-Q how MASD can turn into a stage 3 within a couple weeks. Wound RN-Q replied that was not uncommon, MASD can look like a stage 1 or stage 2 pressure injury and then just opens. Wound RN-Q stated R19 had a lot of contributing factors that increased R19's chances for developing pressure wounds and made it hard for them to heal. Wound RN-Q stated a lot of treatments were tried until the correct combination and now R19's sacrum PI (Pressure Injury) was just about closed. Surveyor asked wound RN-Q who is responsible for initiating and revising the care plan. Wound RN-Q stated wound RN-Q would initiate a care plan for a new treatment and put the orders in but did not go back and revise them. Wound RN-Q stated nursing staff can revise care plans and information is discussed at the morning staff meetings and sometimes care plans got initiated/revised at that time. On 9/8/2022, in the wound notes wound NP-S charted sacrum MASD, partial thickness wound measuring 0.8 cm X 0.4 cm X less than 0.1 cm, 25% fibrous 75% pink tissue. No drainage, no signs, or symptoms of infection. Skin around wound is peeling and fragile. Plan: cleanse with soap and water, apply Zinc Oxide three times a day and as needed. Diligent incontinence cares and offloading. On 9/15/2022, Wound NP-S saw R19 for R19's suprapubic catheter site, but wound NP-S notes do not indicate that wound NP-S assessed R19's MASD on sacrum area. On 10/13/2022, wound NP-S charted R19 had stage three pressure ulcer to sacrum measuring 1.5 cm X 0.5 cm X 0.1 cm, 100% granular tissue. Scant serosanguineous drainage, skin around wound is peeling and fragile. Plan: cleanse with wound cleaner. Apply skin prep to surrounding skin. Apply Hydrofera blue foam and cover with bordered foam dressing. Change three times a week and as needed. Wound NP-S recommended R19 to have limited time up in wheelchair, up in wheelchair only for meals for maximum of two hours at a time. Surveyor noted that R19's care plan was not revised to indicate R19 should only be up in R19's chair for maximum of 2 hours at a time. On 8/1/2023, at 2:50 PM, Surveyor interviewed wound NP-S who stated wound NP-S remembers R19 initially had MASD and then progressed into a stage 3 pressure injury, but wound NP-S has not seen R19 for a while, so not sure of the finer details involving R19's pressure injury. Surveyor asked Wound NP-S if it was common for MASD to progress into a stage 3 pressure injury within a couple weeks. Wound NP-S replied it was very common since MASD is already open skin and R19 had a lot of contributing factors that the pressure injury was unavoidable. Wound NP-S stated wound NP-S recalled wanting R19 on strict bed rest to keep pressure off the sacrum area. Wound NP-S stated R19 enjoyed staying in R19's wheelchair in the TV area and would not want to lay down. On 7/26/2023, at 10:26 AM, Surveyor observed certified nursing assistant (CNA)-P performing cares on R19. Surveyor asked CNA-P how often R19 is up in R19's wheelchair. CNA-P replied R19 gets up for meals and then lays down after meals majority of the time. Surveyor asked CNA-P to clarify majority of the time. CNA-P stated R19 really enjoyed being up in chair to watch R19's shows in the TV room so staff will provide a lot of encouragement and education to R19 as to why R19 should lay down in bed. Surveyor asked CNA-P if R19 was complaint with cares and treatments. CNA-P replied R19 was complaint with cares and treatments but R19 likes to stay in R19's wheelchair for longer period than what it recommended. On 7/27/2023, at 7:37 AM, surveyor interviewed Wound Physician Assistant (Wound PA)-R who stated Wound PA-R has been treating R19 for about 4 months and does not know much about the development of R19's stage 3 pressure injury. Wound PA-R stated R19 has had the sacral wound for a long time and trying to focus on the correct combination of treatment to heal it up. Wound PA-R stated R19 enjoys being up in R19's chair so a lot of encouragement is needed to get R19 to lay back down. Wound PA-R stated R19's sacral wound is unavoidable and chronic due to R19's contributing factors and diagnoses. Wound PA-R stated since changing R19's current treatment to two times a day, the sacral pressure injury has improved drastically, and the sacral pressure injury is almost closed. Wound PA-R stated the air mattress that R19 has on R19's bed currently is appropriate for R19. On 8/1/2023, at 11:51 AM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of Surveyors concern that R19's skin concern was not assed and measured until 9/7/2023, 2 days after R19's skin concern was first noted and that there was not a root cause analysis completed to determine why R19 developed MASD and no preventative interventions were added to R19's care plan when R19's MASD progressed into a stage 3 pressure injury or when NP-S recommenced R19 should only be up in the wheelchair for meals with a 2 hour maximum. No further information was provided at this time. 4) R24 was admitted to the facility 10/28/16 with a diagnosis of Vascular Dementia. R24 has a BIMS (Brief Interview for Mental Status) score of 6, which indicates significant cognitive impairment for daily decision making. R24 resides on the facility's dementia unit which is not a locked unit. On 7/25/23 at 8:54 AM, Surveyor observed R24 in the unit dining room sitting in their wheelchair. R24 was noted with extensive bruising to their face and was wearing a hard cervical collar. On 7/25/23 at 11:09 AM, Surveyor conducted review of R24's medical record and Surveyor noted: -Wound documentation on 7/6/23 reading DTI (Deep Tissue Injury), right shoulder 1.5 cm (centimeters) x (by) 0.7 cm 100% intact DTI. -Wound documentation on 7/13/23 reading DTI, right shoulder, 1.3 cm x 0.6 cm, 100 % slough. -Wound documentation on 7/20/23 reading, DTI, 2.0 cm x 3.0 cm, 60 % epithelial tissue, 20 % slough tissue, 20 % subcutaneous tissue. Surveyor reviewed R24's pressure injury care plan with a date of 7/6/23. Care plan interventions include monitoring R24's pressure skin integrity to neck every shift, daily treatments and padding of R24's neck brace. Surveyor reviewed R24's TAR (Treatment Administration Record) for July 2023. Surveyor noted an order from 7/6/23 to monitor skin integrity to neck every shift. Surveyor noted nursing staff are signing out this order on a consistent basis. Surveyor notes R24's care plan and TAR were updated with interventions once the facility identified the DTI to the right shoulder. The facility did not update R24's care plan to address the need to monitor R24's skin related to the need for the neck brace until the DTI was identified. On 7/27/23, Surveyor requested to observe R24's wound treatment conducted by Wound Registered Nurse (RN)-Q. Surveyor observed R24's right shoulder. R24's right shoulder is noted with intact skin with a light purple discoloration. Surveyor asked Wound RN-Q how R24 sustained a pressure injury in such an odd location. Wound RN-Q told Surveyor that R24's neck brace ended up causing a pressure injury which has since been padded. On 8/1/23 at 11:15 AM, Surveyor met with Director of Nursing (DON)-B. Surveyor shared concerns related to R24 sustaining a facility acquired pressure injury from their cervical collar due to a fall with fracture that occurred at the facility. The facility did not provide any additional information at this time. Based on observation, interview and record review, the Facility did not ensure that Residents with pressure injuries or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 5 (R15, R406, R19, R24, and R83) of 6 sampled residents reviewed for pressure injuries. *When R15 was identified to have a new open area to the left buttock on 01/05/23, the facility failed to immediately assess R15's new open area and failed to adjust R15's plan of care to prevent the open are from declining to a stage 4 pressure injury on 03/02/23. *R406 returned to the facility on [DATE] after surgery with a new back brace. Facility staff not were not properly trained on how to put the brace on and take it off. Staff statements indicate monitoring back brace every shift, but sometimes R406 would be up all shift and would go long periods without the monitoring of brace. R406 developed a stage 4 pressure injury from the back brace that required surgery. Facility failure to provide care and treatment to prevent the development of stage 4 pressure injuries created a finding of immediate jeopardy that began on 03/02/23. The Nursing Home Administrator (NHA) - A and DON-B were notified of IJ (Immediate Jeopardy) at F686 on 08/01/23 03:33 PM. The jeopardy was removed on 08/07/23, however, the deficient practice continues at a scope/severity of G (harm/isolated) as the facility continues to implement its action plan and as evidenced by the following. *R19 developed a facility acquired stage 3 pressure injury to the coccyx. There was no assessment of wound when it was first observed and no root cause for Moisture Associated Skin Damage (MASD). *R24 Developed a pressure injury due to neck brace. *R83 is at risk of developing pressure injuries and has a care plan intervention to have pressure relieving boots on at all times. Surveyor observations during survey of pressure relieving boots not on while in bed. Observations were made after care observations. Findings include: The Facility Pressure Injury Prevention Guidelines dated 01/05/23 states: Policy: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Policy Explanation and Compliance Guidelines: 1. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g. moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 2. The goal and preferences of the resident and/or authorized representative will be included in the plan of care. 3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. 4. In the absence of prevention orders, the licensed nurse will utilize nursing judgement in accordance with pressure injury prevention guidelines to provide care, and will notify physician to obtain orders. 5. Prevention devices will be utilized in accordance with manufacturer recommendations (e. g., heel flotation devices, cushions, mattresses). 6. Guidelines for prevention may be utilized in obtaining physician orders. The facility may use facility specific guidelines or see Pressure Injury Prevention Guidelines below. a. The guidelines are to be used to assist in treatment decision making. b. Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. c. When physician orders are present, the facility will follow the specific physician orders. 7. Interventions will be documented in the care plan and communicated to all relevant staff. 8. Compliance with interventions will be documented in the medical record. a. For at-risk residents: treatment or medication administration records. b. For residents who have a pressure injury present: treatment or medication administration records; weekly wound summary charting. 9. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include: a. Development of a new pressure injury. b. Lack of progression towards healing or changes in wound characteristics. c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. Under the Facility Skin Integrity - Incontinence Associated Dermatitis (IAD) policy dated 11/22/23 {sic}, it states: Policy: Residents who are incontinent will receive appropriate treatment and services for the prevention and management of incontinence-associated dermatitis (IAD). Definition: Incontinence-associated dermatitis refers to skin damage caused by prolonged or recurrent contact with stool and/or urine. Affected skin areas involve the perineum, and may extend to involve the buttocks, hips, and sacrum. Policy Explanation and Compliance Guidelines: 1. Residents who are incontinent are at risk for developing incontinence-associated dermatitis (IAD). 2. Prolonged or recurrent contact with stool and/or urine may lead to the following: a. Overhydrated or macerated skin. b. Inflamed skin c. Fungal or bacterial skin infections d. Friction damage 3. The facility's approach to the prevention and management of IAD is two-fold: a. Reverse or manage incontinence b. Structured skin care regimen 4. Reverse or Manage Incontinence: a. The facility shall identify causes of incontinence through the comprehensive assessment and implement measures to restore continence as possible. b. A variety of absorbent products may be used to manage incontinence: underpads, pads in clothing, pull-up briefs, and traditional briefs. The product used will be in accordance with the resident's care plan, goals. and preferences. c. Indwelling or external collection devices may be utilized in complicated cases with a physician's order. Indwelling devices will be used in accordance with the facility policy for those devices (i.e. catheter, rectal tube). 5. Structured Skin Care Regimen: a. Cleansing of skin affected by incontinence: i. Cleanse routinely in accordance with plan of care, and promptly as needed upon soiling. ii. Use soft nonabrasive cloths and gentle technique. Do not scrub the skin. iii. Select a cleanser with pH that is neutral or mildly acidic that minimizes potential irritants. A no-rinse pH balanced cleanser is recommended, but mild soap and water may be used. iv. Consider the presence and severity of IAD when determining which cleansing agent or cloth to use. v. Gently dry skin after cleansing with a towel. b, Enhance moisture barrier of the resident's skin by applying moisturizer to affected skin once or twice as daily, as indicated. i. Emollients are designed to prevent dehydration and soften the skin. These are appropriate for routine use. ii. Humectants are designed to pull water into the skin and are intended for use on very dry skin. c. Protect skin from urine and stool by applying a barrier product to affected skin in accordance with plan of care (i. e. twice daily or after each incontinent episode). Examples include: i. Liquid skin sealants containing polymers ii. Dimethicone-based products iii. Petrolatum-based products iv. Combination products d. For residents with candidiasis (fungal skin infection), apply antifungal products as ordered by physician. Examples include: i. Moisture barrier containing an azole agent - this may replace routine moisture barrier product. ii. Antifungal powder - apply to skin prior to applying the routine moisture barrier product. 6. Monitoring and Modification of Interventions: a. Monitor response to interventions for managing incontinence and to skin care regimen. b. Notify physician of changes in bowel and bladder habits, including the onset or worsening of incontinence. c. Notify the physician of the presence and severity of IAD. d. Notify the physician of the presence and severity of any skin loss or presence of fungal or bacterial skin infection. e. Modify interventions as needed. Considerations for needed modifications include: i. Changes in medical condition or continence status. ii. New onset or worsening of a pressure injury in area affected by incontinence. iii. Lack of progression towards healing, iv. Resident non-compliance. v. Changes in the resident's goals and preferences. 1.) R15 admitted to facility on 03/05/14 with diagnoses that include Type 2 Diabetes, Peripheral Vascular Disease, Osteomyelitis in the left ankle and foot, and Chronic Kidney Disease Stage 2. R15 was admitted to hospice services on 04/30/22 with weights deferred, indicating the facility would not be conducting routine weighing of the resident. R15's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13, suggesting that R15 as cognitively intact. The MDS further documents that R15 is an extensive assist for bed mobility, totally dependent for transferring, total dependence for toileting, and extensive assist for hygiene. The assessment also documents R15 has having an indwelling catheter, is always incontinent of bowel with no bowel toileting program. R15's weight is documented at 116 pounds. The MDS assessment documents that R15 is at risk for (PI) pressure injury development. R15's Braden Scale assessment, completed 01/05/23, showed a score of 15, which indicated at risk for pressure injury. The care plan documents: Focus: [R15's Name] has actual impairment to skin integrity of RLE (right lower extremity) r/t (related to) peripheral vascular disease, history of chronic vascular wounds, decreased mobility, wheelchair use, and diabetes mellitus Date Initiated: 08/04/2017 Revision on: 03/24/2023 Interventions include Assist resident with repositioning as needed. Resident is able to complete on own. Date Initiated: 02/07/23; Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Date Initiated: 02/07/23; Compression stockings to bilateral lower legs to asset with blood flow return decreasing vascular wound risk. Date Imitated: 02/07/23; Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Date Initiated: 02/07/23; Encourage good nutrition and hydration in order to promote healthier skin. Date Initiated: 02/07/23; Follow Facility protocols for treatment of injury. Date Initiated: 02/07/23; Observe/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. Date Initiated: 02/07/23; Foot cradle on bed. Date Initiated: 06/13/23; Identify/document potential causative factors and eliminate/resolve where possible. Date Initiated: 02/07/23; Keep skin clean and dry. Use lotion on dry skin. House barrier cream to buttocks with peri care. Date Initiated: 02/07/23; Observe/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. Date Initiated: 02/07/23; Provide treatment as ordered. 06/07/23; The resident needs assistance to apply protective garments, Pressure relieving boots. Date Initiated: 02/07/23; The resident needs pressure relieving/reducing mattress, cushion, to protect the skin while up IN CHAIR. Date Initiated: 02/07/23; Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Date Initiated: 02/07/23 Focus: [R15's Name] has potential for pressure ulcers lt (left) and rt (right heels) or potential for pressure ulcer development r/t disease process profound vascular disease of both lower extremities (BLE) Date Initiated: 08/04/2017 Revision on: 03/24/2023 Obtain and observe lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 08/10/2017; Pressure relieving boots at all times as much as [R15's Name] will allow or tolerate. Date initiated: 06/13/2023; Pressure relieving boots at all times as much as [R15's Name] will allow or tolerate. May remove for cares and therapy. Date Initiated: 07/06/2022 Revision: 02/07/2023; The resident needs a pressure reliving mattress to protect the skin while IN BED. Keep air mattress set by weight (Weight range 110-120 pounds) Date Initiated: 12/02/2022 Revision: 02/07/2023; Turn and reposition every 12 [sic] hours in bed and chair and more frequently as needed for comfort. Date Initiated: 01/25/2023 Revision: 07/26/2023; Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Date Initiated: 04/01/2021 Revision: 02/07/2023. Focus: [R15's Name] has potential for pressure ulcers lt and rt heels or potential for pressure ulcer development r/t disease process profound vascular disease of BLE Date Initiated: 08/04/2017 Revision on: 03/24/2023 Administer treatments as ordered and observe for effectiveness. Date Initiated 08/20/2017 Revision on: 02/07/2023; Assist [R15's name] to reposition and/or tu

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility did not ensure 5 (R106, R24, R83, R206 & R103) of 11 residents reviewed were kept free from accidents and hazards. * On [DATE], R106 was provided incontinence care with improper technique by a Certified Nursing Assistant leading to a fall with cervical spine fracture, broken rib and scalp laceration. R106 returned to the facility on [DATE]. On [DATE], R106 expired at the facility. The medical examiner's office ruled R106's cause of death was due to injuries R106 sustained from their fall from bed on [DATE]. *On [DATE] R24, who is severely cognitively impaired and lives on the dementia unit, eloped from the facility and was found by an employee lying in a large pothole in the facility's parking lot with their wheelchair tipped over. R24 was subsequently hospitalized and sustained a cervical spine fracture from the fall in the facility's parking lot on [DATE]. The facility did not conduct a thorough investigation related to R24's elopement, including how R24 was able to leave the dementia unit. The facility's failure to use proper technique when caring for R106 and the failure to ensure that R24 was properly supervised created a finding of immediate jeopardy. The Immediate Jeopardy began on [DATE]. NHA (Nursing Home Administrator)-A was notified of the Immediate Jeopardy on [DATE] at 3:15 PM. The Immediate Jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement its removal plan and as evidenced by the following examples. *R83 was observed throughout the survey without multiple fall interventions in place. R83 sustained multiple falls which the facility did not thoroughly investigate *R206 sustained multiple falls and a thorough investigation was not completed to determine the root cause of the falls and fall prevention interventions to address the root cause were not identified and implemented. *R103 sustained a fall that resulted in a fractured wrist. Post fall, R103 was assessed by an Licensed Practical Nurse (LPN) with no RN assessment. The LPN determined there was no injury. R103 continued to experience wrist pain and was found to have a fractured wrist. Findings include: According to MedlinePlus.gov, The following steps should be followed when turning a patient: If you can, raise the bed to a level that reduces back strain for you. Make the bed flat. Get as close to the person as you can. You may need to put a knee on the bed to get close enough to the patient. Place one of your hands on the patient's shoulder and your other hand on the hip. Standing with one foot ahead of the other, shift your weight to your front foot (or knee if you put your knee on the bed) as you gently pull the patient's shoulder toward you. Then shift your weight to your back foot as you gently pull the person's hip toward you. (Emphasis added.) https://medlineplus.gov/ency/patientinstructions/000426.htm 1.) R106 was admitted to the facility on [DATE] with diagnoses of Pneumonia, Left sided weakness related to Cerebral Vascular Accident, Legal blindness and hearing loss. R106's admission MDS (Minimum Data Set) with ARD (Assessment Reference Date) of [DATE] indicated R106 required extensive assist with of 1 staff member with bed mobility at the time of admission. Surveyor reviewed R106's closed medical record including care, therapy notes and fall investigation. R106's care plan with an initiation date of [DATE] and revision date of [DATE] reads, This resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) recent CVA (Cerebral Vascular Accident) w/ (with) L (left) sided hemiparesis and weakness. Cervical Fracture. Rib Fracture. A care plan intervention initiated on [DATE] includes use of bilateral hearing aids to be worn during cares. On [DATE], at 9:32 AM, Surveyor reviewed R106's physical therapy evaluation dated [DATE] which reads minimal assist with rolling-required 1 person, pelvis, upper body, legs. A physical therapy note dated [DATE] which indicates R106's baseline requires minimal assist for rolling in bed. R106's medical record documents, on [DATE] on NOC (night) shift R106 was in bed without their bilateral hearing aids in. CNA (Certified Nursing Assistant)-NN was assisting resident with incontinence care in bed. R106 was rolled away from the CNA-NN at this time. R106 slid off of their alternating air mattress at this time and fell directly onto the floor on their right side. CNA-NN called LPN (Licensed Practical Nurse)-OO for help at this time. Per statements and facility's fall incident report, a large amount of bleeding was noted from a laceration on R106's head. R106 complained of severe neck pain at this time. No RN assessment was conducted at this time. Director of Nursing (DON)-B was notified of R106's fall from bed and directed facility staff to call 911. The facility determined that R106's inflatable air mattress was the root cause of their fall. R106 returned to the facility on [DATE] with displaced cervical spine fracture, right rib fracture and scalp laceration which required sutures. CNA-NN is no longer employed by the facility and was unavailable for interview. LPN-OO was unavailable for interview. According to a statement obtained on [DATE] by the facility from CNA-NN, As I was providing care, resident asked me if I needed [resident] to rollover more and I told [resident] no, I was doing OK. Patient proceeded to roll over and I noted that [resident] was sliding off the bed. I started to scream for help and tried to hold onto [resident] but I couldn't and [resident] fell . Note that R106 rolled in the direction that CNA-NN had rolled R106 and that because R106 did not have their hearing aids in, it was more likely that R106 did not hear CNA-NN's response. On [DATE], at 3:40 PM, Surveyor conducted interview with CNA-KK. Surveyor asked CNA-KK whether you should roll a resident away from you or towards you when providing incontinence care. CNA-KK responded that they would check if a resident is a 1 or a 2 assist first for bed mobility. CNA-KK continued that if a resident is a 1 assist with bed mobility, they would make sure to position them properly in bed so they are not next to the opposite edge and roll the resident towards themselves and not away to the opposite side. On [DATE] the facility initiated fall interventions including a low bed, extensive assistance of 2 staff for bed mobility and a bolstered mattress for safety. R106 was readmitted to the facility on [DATE] with a code status of DNR (Do Not Resituate). On [DATE] at approximately 8:30 AM, Staff noted R106 pulseless and not breathing. DON-B was notified and confirmed that resident was pulseless and apneic. The facility contacted the doctor and the resident's representative. The facility's DON notified the medical examiner office of resident's passing. On [DATE], Surveyor requested R106's medical examiner report. R106's report dated [DATE] reads: Immediate Cause of Death: Complications of Cervical Spine Fracture, Due To: Recent stroke; History of pulmonary embolism; Atrial Fibrillation; Hypertension; Congestive Heart Failure, Final Manner of Death: Accident, How Injury Occurred: Rolled out of bed onto floor. On [DATE] at 11:00 AM, Surveyors conducted interview with DON (Director of Nursing)-B. Surveyor asked DON-B of their involvement with R106's fall on [DATE]. DON-B told Surveyor that R106 was sent out 911 per their request due to R106 bleeding from the head. Surveyor inquired as to if there had been any follow up with the medical examiner's office as to R106's cause of death. DON-B said they had not had further contact with the medical examiner's office after reporting R106's death due to their fracture. Surveyors notified DON-B of the serious concerns related R106 being rolled off the bed by CNA-NN during toileting while not wearing hearing aids per care plan, R106 sustaining a cervical spine fracture, right rib fracture, scalp laceration and death at the facility on [DATE] as a result of injuries from the fall at the facility on [DATE]. No further information was provided at this time by the facility. Staff failure to roll R106 towards them rather than away from them, especially on an air mattress, and staff failure to ensure R106 had hearing aids in place during cares to assist with communication during cares created a reasonable likelihood for serious harm. 2.) R24 was admitted to the facility [DATE] with a diagnosis of Vascular Dementia. R24's Quarterly MDS with an ARD of [DATE] indicates R24 requires extensive assistance of 1 staff with transfers and locomotion. R24 is unsteady on their feet and requires staff assistance to maintain their balance. R24 has a BIMS (Brief Interview for Mental Status) score of 6, which indicates significant cognitive impairment for daily decision making. On [DATE], a fall risk assessment indicated resident was a low risk for falls. On [DATE] a quarterly elopement assessment was conducted by the facility indicating that the resident was low risk for elopement. R24 resides on the facility's dementia unit which is not a locked unit. There is a set of heavy doors to the unit, which will alarm if someone with a Wanderguard bracelet attempts to leave the unit. R24 did not have a Wanderguard bracelet because R24 was assessed as being at low risk for elopement. Unless the doors to the unit were propped open, as was observed at times during survey, It would be difficult for residents to leave the unit because the doors are heavy. It would be especially difficult for someone who is smaller and in a wheelchair, like R24, to open the doors by self and leave the unit. On [DATE] at 8:54 AM, Surveyor observed R24 in the unit dining room sitting in their wheelchair. R24 was noted with extensive bruising to their face and was wearing a hard cervical collar. Surveyor requested any self-reports or fall investigations for R24. Surveyor reviewed a fall investigation dated [DATE]. On [DATE] at approximately 6:10 AM, Head of Maintenance-E was outside in the facility parking lot making repairs to a sign on the facility's grounds. Head of Maintenance-E heard a scream and began looking around the facility's parking lot. Head of Maintenance-E found R24 on the ground in the facility parking lot. R24 was subsequently hospitalized after the fall and sustained a cervical spine fracture requiring a neck brace. On [DATE] at 10:00 AM, Surveyor conducted interview with Head of Maintenance-E. Surveyor asked Head of Maintenance-E to tour the facility's parking lot. Head of Maintenance-E showed Surveyor where they had found R24 on [DATE]. A large pothole was noted near the end of the facility's driveway with large crumbling pieces of asphalt. Head of Maintenance-E told Surveyor that they had found R24 lying on the ground with their wheelchair tipped over. Head of Maintenance-E had asked R24 what they were trying to do. R24 told Head of Maintenance-E I want to go home. Head of Maintenance-E told Surveyor that they did not want to leave R24 alone outside because they had already fallen and was afraid that they could get hit by a car in the parking lot. Head of Maintenance-E attempted to call the facility's main number multiple times and there was not any staff picking up the telephone. Head of Maintenance-E told Surveyor that they didn't know what to do next so they proceeded to pick R24 off of the ground and transfer them into their wheelchair. Surveyor asked Head of Maintenance-E if they had ever had training to transfer residents or worked in the capacity of a CNA (certified nursing assistant). Head of Maintenance-E told Surveyor that they had never been trained on how to transfer residents. Head of Maintenance-E added that they probably shouldn't have moved R24 at this time, but they were scared to leave them alone and didn't know what else they could do at the time. Head of Maintenance-E then brought R24 inside the facility to the dementia unit's nursing station. Nursing staff called 911 at this time and R24 was taken to the hospital. Surveyor asked Head of Maintenance-E if they had reported the condition of the facility's parking lot to any other staff members. Head of Maintenance-E told Surveyor that they have been requesting repairs to the parking lot for years and nothing ever seems to happen. Head of Maintenance-E showed Surveyor copies of requisition forms with quotes from [DATE] from an asphalt company at this time. Surveyor asked Head of Maintenance-E if the facility's main entrance is ever locked. Head of Maintenance-E told Surveyor that after hours you would need a code to get into the facility's main entrance but to leave the facility's main entrance, the door will open automatically any time of the day. Head of Maintenance-E told Surveyor the maintenance department had received training not to transfer or move residents sometime after R24's fall but they couldn't remember the exact date. Surveyor notes R24's fall occurred in the facility parking lot near the entrance to the facility grounds from the street. The facility is located on [NAME] Road, which is Business Highway 36, which is a highly trafficked 4 lane highway with a speed limit of 40 miles per hour. On [DATE], at 3:40 PM, Surveyor conducted interview with CNA-KK. CNA-KK worked NOC (night) shift on [DATE] on the facility's dementia unit. Surveyor asked CNA-KK if they recalled assisting R24 on [DATE]. CNA-KK told Surveyor that on [DATE] at approximately 5:30 AM, R24 was toileted, dressed and assisted into their wheelchair by CNA-KK. CNA-KK told Surveyor it was not unusual for R24 to get up at this time of day and that they had last seen R24 at this time in the doorway of R24's room in their wheelchair. CNA-KK told Surveyor they continued with finishing their night shift rounds at this time. Approximately 30 minutes later, CNA-KK was taking dirty linen to the laundry when they were notified by facility's Director of Nursing (DON)-B that R24 had been found outside on the ground. Surveyor asked CNA-KK if R24 was allowed to be outside the facility without staff supervision. CNA-KK told Surveyor that there was no way that R24 should ever be alone outside and that they are still not sure how R24 got all the way to the front of the facility without anyone noticing. On [DATE], at 1:15 PM, Surveyor conducted interview with CNA-LL. Surveyor asked CNA-LL if they recalled assisting R24 on [DATE]. CNA-LL told Surveyor at approximately 5:40 AM they saw R24 self-propelling their wheelchair near the nursing station which neighbors the dementia unit. CNA-LL told Surveyor that R24 was telling CNA-LL about how they had an appointment to go to this morning and that CNA-LL wished the resident a good day. CNA-LL told Surveyor at this time that they had confused R24 with another resident from a different unit at the facility who was alert and oriented. CNA-LL does not frequently work on the facility's dementia unit and did not recognize R24 at this time as they had never seen R24 out of bed. CNA-LL told Surveyor that had they had known the resident they were speaking to was R24 that they would have notified a staff member on the dementia unit that R24 was off of the dementia unit wandering. Surveyor asked CNA-LL if R24 should have been outside of the facility without staff supervision. CNA-LL told Surveyor that they do not believe R24 should have been allowed outside the facility without staff supervision because of their dementia. On [DATE], at 4:12 PM, Surveyor conducted interview with Licensed Practical Nurse (LPN)-MM. Surveyor asked LPN-MM if they recall seeing R24 on [DATE]. LPN-MM told Surveyor that they do not usually have too much interaction with R24 on NOC shift because they do not receive medications on NOC shift. Surveyor asked LPN-MM if it was unusual for R24 to be up that early in the morning. LPN-MM responded that they didn't think it was odd that R24 was out of bed. LPN-MM remembered R24 sitting by the nursing station on [DATE] speaking to CNA-LL but did not recall whether or not R24 was on the dementia unit at this time or outside of the dementia unit's doors. LPN-MM left the nurses station at this time to find the oncoming day shift nurse to conduct shift change reporting. Surveyor asked LPN-MM if R24, a resident with dementia, should have been allowed outside the facility without staff supervision. LPN-MM responded, I don't think it would be a good idea for someone with dementia to be outside alone. On [DATE], at 9:40 AM, Surveyor conducted interview with LPN Unit Manager-M. LPN Unit Manager-M told Surveyor that they were not involved with R24's fall on [DATE] as DON-B is usually the staff person who follows up on major falls and incidents. Surveyor asked if there should be statements from all staff members on duty at the time of a resident's fall. LPN Unit Manager-M responded Ideally, yes. Surveyor asked LPN Unit Manager-M if R24 or any resident with a diagnosis of dementia should be allowed outside the facility without staff supervision. LPN Unit Manager-M responded they were not sure what all the circumstances were but now R24 has a Wanderguard and is not able to get around very easily since their fall with cervical spine fracture. On [DATE], at 11:00 AM, Surveyors conducted interview with DON-B. Surveyor asked how often elopement assessments are conducted. DON-B responded that elopement assessments are conducted quarterly and as needed if staff notice residents being exit seeking. DON-B told surveyor that R24 likes to be outside when the weather is good. DON-B added that R24 was outside around 6:00 AM in the morning on [DATE] and that they were probably hoping to get some sun. DON-B told Surveyor that R24 was never exit seeking and that their intent was never to leave the facility. Surveyor asked DON-B if residents with dementia should be allowed to go outside without staff supervision. No further information was shared at this time. Surveyor reviewed R24's care plan. Surveyor did not note any care plan to address R24 being allowed outside facility independently. Surveyor reviewed facility's investigation of R24's fall with major injury. Surveyor noted a thorough investigation including statements from all working staff including where and when staff had last seen R24 previous to their fall, how R24 had been able to leave the unit, and if the unit's doors had been propped open at the time R24 was observed on another unit was not completed. On [DATE] at 12:30 PM, NHA (Nursing Home Administrator)-A and DON-B were informed of serious concerns related to R24's lack of staff supervision on [DATE] which resulted in R24 leaving the facility where they sustained a fall in the facility's parking lot. R24 was moved without an RN assessment by unlicensed staff and hospitalized with a cervical spine fracture. Surveyor shared concerns of a lack of thorough investigation related to R24's elopement and fall with severe injury including a cervical spine injury, root cause analysis and complete staff statements. No additional information was provided at this time. Staff failure to ensure R24 could not leave the dementia unit unsupervised, staff failure to recognize that a resident from the dementia unit was off the unit, and staff failure to thoroughly investigate the circumstances that allowed R24 to exit the building unnoticed created a reasonable likelihood for serious harm. Surveyor noted CNA-NN received training on [DATE] related to proper bed mobility for residents. Training materials read Repositioning in Bed. Description: this checklist identifies the steps needed to properly position a person in bed. It also provides rationale to explain why these steps are performed. Referenced and adapted from: [NAME]. (2019). [NAME] nursing procedures (8th ed.). Author. [NAME], R. (2018). Safe patient handling, transfer, and positioning. In A. G. [NAME], P. A. [NAME], & W. R. [NAME] (Eds.), Clinical skills & nursing techniques (9th ed.). Elsevier. A check off list was provided for CNA-NN which includes following .Central Placement: Description: position the person in the center of the bed away from the edges. Use the drawsheet when positioning and use at least 2 caregivers who demonstrate proper ergonomics and techniques. Rationale: prevents falling out of bed . Facility completed the checklist with CNA-NN. Surveyor did not see evidence of any further in-services for additional staff related to R106's fall. The immediate jeopardy was removed on [DATE] when the facility implemented the following: *All other residents that have the potential for falls and other safety concerns were assessed and care plans reviewed. *All other residents who have the potential to leave out the doors were assessed. *Wander books were updated. *Staff were educated on: -Residents at Risk to Wander -Communication and Resident Impairment -Kardex and Falls -Root Cause Analysis -Completing Witness Statements *Director of Nursing/designee ensured the safety measures and resident specific interventions were added to care plans and care kardexes. *Quotes obtained to repair outdoor spaces. Repairs to to be completed. *Skills fair completed to ensure staff are competent in performing job duties related to bed mobility, skin and communication. *Facility reviewed the following policies: -Change in Condition -Fall Prevention Program -MD (medical doctor) Notification -RN assessments -Elopement and Wandering Residents -Accidents and Supervision *Witness statements form was revised to include additional details, including root cause analysis. *24 hour condition report was reviewed and revised. Additional information added was changed in condition. *New admission chart review will be conducted within 24 hours. These audits will be completed on new admissions to ensure fall risk assessments are completed. Audits will be reviewed daily by the IDT (Interdisciplinary Team) stand up and stand down meetings. *Outdoor environmental safety sweep will be conducted 3 times per week for one month, weekly for one month and then monthly for 6 months. *All falls will continued to be reviewed at daily stand up/stand down meeting with IDT meeting for proper interventions. *The Facility Assessment was reviewed and updated. *Audits will be brought to QAPI (Quality Assurance and Performance Improvement) for review and advisement of continuation. 5.) R103 was admitted to the facility on [DATE] with Alzheimer's Disease, Repeated Falls, Type 2 Diabetes Mellitus, Fibromyalgia, Chronic Kidney Disease, Obstructive Sleep Apnea, Stage 3, Personality Disorder, Major Depressive Disorder, and Anxiety Disorder. R103 has an activated Health Care Power of Attorney (HCPOA). R103 discharged from the facility on [DATE]. R103's admission Minimum Data Set (MDS) dated [DATE] documents R103 has short and long term memory impairment and demonstrates modified independence for daily decision making. R103's MDS also documents R103 demonstrates inattention and disorganized thinking; demonstrates verbally abusive behaviors, behaviors directed towards others, disrupts cares, disrupts others and their environment, rejection of care, and wandering. R103 required supervision of one staff for transfers and toileting, extensive assistance of 1 for bed mobility and dressing. R103 used a wheelchair for locomotion. R103 had a comprehensive care plan initiated on [DATE] that documented R103 was at risk for falls due to impaired cognitive safety awareness, impulsivity, Alzheimer's, history of falls, and unsteady gait On [DATE], R103's medical record documents R103 was self ambulating and was trying to use the phone. R103 attempted to back up, stumbled, fell, and landed on R103's bottom and laid on R103's back. Staff were unable to get around the desk to R103 fast enough to prevent the fall. The fall investigation does not indicate how R103 was gotten up off the floor. Surveyor notes that a licensed practical nurse (LPN) assessed R103 having range of motion within normal limits, and denied any discomfort. Surveyor notes notification to responsible party and physician was made at 6:35 PM. Surveyor notes that a pain assessment was completed on [DATE] at 8:33 PM which indicated R103's pain level was at a 7. The pain evaluation completed indicates R103 has chronic pain in the right and left knee but a new location of pain is documented of pain in the left wrist. On [DATE], at 9:25 AM, it is documented in R103's electronic medical record (EMR) that the interdisciplinary team met to discuss R103's fall. R103's care plan was reviewed and updated. Putting R103 on 1:1 supervision at night was added as a new fall prevention intervention. On [DATE], at 11:41 AM, Social Services document R103 is being processed for transfer to the hospital. On [DATE], at 12:33 PM, documentation indicates R103 complained of pain in the left wrist in the AM shift. Noted swelling to wrist and fingers, no visible bruising/discoloration present to wrist. On [DATE], at 1:53PM, R103 was transferred to the emergency room for evaluation and treatment. On [DATE], time is unknown, R103 was seen by the physician and documented R103's left wrist is swollen, swelling down to fingers as well. Painful to touch, not red not warm. Concern for fracture, will send [R103] to the hospital. Surveyor notes the hospital evaluation resulted in the identification of a fracture of the left wrist. Surveyor notes there is no documentation a Registered Nurse (RN) completed an assessment of R103 at the time of the fall. On [DATE], at 10:08 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-C in regards to R103's fall. ADON-C is also the unit manager for the unit R103 resided on. ADON-C is not able to confirm what time the fall happened, or how R103 got up off the floor. ADON-C is not sure if there was a RN assessment at the time of R103's fall. On [DATE], at 10:50 AM, Surveyor interviewed Director of Nursing (DON)-B in regards to R103's fall. DON-B stated the certified nursing assistants are instructed to go get a nurse, and then the nurse assess for injuries, if none observed, transferred with a Hoyer lift, if suspect range of motion (ROM) impairment, would call 911. DON-B stated the expectation is that a RN would assess the Resident before being transferred off the floor. If no RN in the building, the nurse is to call the RN on call to be walked through the process and then as soon as possible a RN would document an assessment after physically evaluating the Resident. DON-B will follow up and find out what time R103 fell. DON-B stated that inservicing on fall expectations started in [DATE] and have continued as needed. On [DATE], at 11:22 AM, DON-B stated R103 fell between 6 and 6:30 PM on [DATE], and did not want anyone to touch R103, and R103 got herself up off the floor. On [DATE], at 11:56 AM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and DON-B that there is no documented RN assessment after R103 fell on [DATE]. No further information was provided at this time. On [DATE], at 1:47 PM, Surveyor was provided the following progress note documentation in regards to an RN assessment after R103's fall.[R103's name] on 1:1 cares throughout night with CNA . The progress note provided does not include documentation of a RN assessment. 4.) R206 medical record was reviewed by Surveyor. R206 was a closed record review. On [DATE], R206 was assessed for a Brief Interview for Mental Status (BIMS) and received a score of 14 which indicates R206 is cognitively intact. On [DATE], R206 is assessed for a Risk for Falls and is assessed to be at a moderate risk. On [DATE], R206 is assessed for a Risk for Falls and is assessed to be at a high risk. R206 Progress Notes indicate the following: 1st Fall -On [DATE], at 00:44 AM (12:44 AM) Resident found on back on floor in room by bed on floor. ROM (range of motion) WNL (with normal limits). No pain. No sob (short of breath). Skin w/d (warm and dry). No bleeding or bruises. Said he rolled out of bed to get up and walk. Message left with MD(medical doctor) and family. VSS (vital signs stable). The facility Risk Management Form (fall investigation) indicates: On [DATE] at 1:36 AM found on floor and found 2 inches from bed, Resident was trying to get up and walk. The Action Taken: The mattress was exchanged for a larger bed, booster mattress, and floor mat when in bed. Surveyor notes there is 1 CNA (Certified Nursing Assistant) statement from the 3rd shift. CNA-BB indicates at the beginning of their shift they went to answer a call light. [R206] was on the floor, [R206] indicated they were waiting for help for 2 hours. CNA-BB also indicated there was a floor mat in packaging against the wall and they unwrapped it and placed it next to the bed. DON-B (Director of Nurses) writes below this that there was not a floor mat on the plan of care at the time of this fall because it was a trip hazard. Surveyor notes the fall investigation does not include any information on causative factors contributing to the fall, current preventative measures in place at the time of the fall, and staff statements from the previous shift. CNA-BB statement does not document if the call light was on for 2 hours or if R206's needs were met. CNA-BB was not available for interview. R206 Plan of Care for Falls, initiated [DATE], has the following interventions added: -[DATE] change air mattress to larger size with boosters [sic]. -[DATE] place floor mat next to bed. 2nd Fall - The Progress Note on [DATE], at 8:00 PM, indicates Aide was noted to be walking in hall while resident was calling for help. Aide went into resident room and resident was noted to be slipping down from bed onto floor. Aide immediately called for the nurse. Writer went into room and resident observed sitting on buttock hanging onto wheelchair. Resident was assisted back into bed. Vitals taken and stable. Alert and verbal with confusion per baseline. Neuro check negative, no c/o (complaint of) pain. ROM WNL. No noted skin issues or injury. Will continue with plan of care. On [DATE], at 09:33 AM, R206's medical record documents, IDT (interdisciplinary team) met on this date to discuss resident's most recent fall. CP (care plan) reviewed and updated. New interventions placed for: body pillows and wheelchair out of reach when in bed. IDT will continue to monitor. The facility Risk Management Form (fall investigation), dated [DATE] at 7:25 PM, indicates R206 was observed getting up from bed and trying to get into their wheelchair. There is a statement they were last checked 2 hours prior and were in bed. R206 indicated they were reaching for something and slipped. The root cause of the fall was poor safety awareness. The interventions started was to declutter the room and keep the wheelchair away from the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure 1 (R188) of 1 resident experiencing a change in condition and eventually becoming unresponsive received the necessary RN assessment to prevent further decline. On [DATE] into [DATE] during the night shift, R188 experienced a change in condition. R188 was having vomiting episodes and Certified Nursing Assistant (CNA) L twice notified Registered Nurse (RN) H. RN H did not assess R188. Around 5:00 a.m. R188 was found unresponsive; an assessment still was not completed and R188 died at the facility. The facility's failure to assess R188 immediately after the change in condition and after being found unresponsive created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA) A of the immediate jeopardy on [DATE] at 12:00 p.m. The facility removed the jeopardy on [DATE]. However, the deficient practice continues at a scope/severity of an E (potential for harm/pattern) as the facility continues to implement its action plan. Findings include: Facility policy regarding Changes in Resident Condition with revision date [DATE] indicate: The nursing staff, the resident, the attending physician and the resident's legal representative are notified when changes in the resident's condition occur. Communication with the Interdisciplinary Team and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit. Guidelines: 1. For life-threatening events, call 911 if initial assessment indicates that such action is necessary 4. The SBAR communication form and the progress note are used to a. assess and document changes in condition in an efficient and effective manner; b. Provide assessment information to the physician, and c. Provide clear comprehensive documentation Professional standards of practice for a registered nurse in Wisconsin are delineated in N6, Wisconsin Nurse Practice Act. According to N6, Wisconsin Nurse Practice Act: An R.N. 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 (Licensed Practical Nurse) 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. R188 was admitted to the facility on [DATE] with diagnoses of surgical repair of left femur fracture, Type 2 diabetes, morbid obesity, sleep apnea, atrial fibrillation and hypertension. The admission MDS (minimum data set) dated [DATE] indicates R188 was alert and cognitively intact, needed extensive assistance of two staff for bed mobility and hygiene. It also indicates R188 had a urinary catheter due to urinary retention. The nurses note dated [DATE] 11:41 p.m. indicates UA (urinary analysis) obtained. C and S (culture and sensitivity) pending. Slight bleeding from penis. Has new foley. Is obese. Keeps pulling on tube. Cranberry juice encouraged. Ate 100 percent. No sob (shortness of breath). No n/v (nausea/vomiting). vss (vital signs stable). The nurses note dated [DATE] at 4:15 a.m. indicate observed resting comfortably in bed. UA was sent per lab pick up. no c/o (complaints of ) pain or discomfort. foley intact. monitored for bleeding. call light in reach at all times. This nurses note was written by RN H. On [DATE] at 8:09 AM Surveyor interviewed CNA L. CNA L stated she worked the night shift on [DATE] into [DATE]. CNA L stated sometime earlier in her shift (not sure the time) R188 was vomiting and he had his CPAP (continuous positive airway pressure device) off at the time. CNA L stated R188 asked her to let the nurse know he was vomiting. CNA L stated she told RN H R188 had vomited. CNA L stated RN H just said ok. CNA stated she was doing her rounds and about 2 am R188 had his call light on. CNA L answered R188's call light. R188 had vomited again, and CNA L cleaned the basin. CNA L stated R188 asked again if she told the nurse. CNA L stated she told R188 she did tell the nurse. CNA L stated she told RN H again that R188 had vomited again. CNA L stated she's not sure about the time but about 3 or 4 am CNA L went into R188's room to empty out his catheter. She saw R188 had turned a different color, and CNA L immediately told RN H. CNA L stated RN went to look for ADON K for help. CNA L stated she did not participate in the CPR (cardiopulmonary resuscitation) because she continued doing rounds on the rest of the residents on the unit. RN H completed an SBAR (situation, background, assessment and recommendation) dated [DATE]. The SBAR indicate RN H was called to R188's room per CNA L. RN H observed resident to be unresponsive. 911 called immediately. The SBAR had vital signs dated [DATE]. (There were no vital signs from the current shift.) The SBAR had the following conditions to assess during a change in condition: Mental status changes, Functional status changes, respiratory, GI/abdomen and GU/urinary changes. RN had marked NA for all changes. The SBAR assessment section asks the nurse completing the SBAR for an assessment of what may be the problem with the patient and RN did not complete an assessment and only wrote called 911 immediately. The nurses note dated [DATE] at 5:46 a.m. indicates RN called to room per CNA (certified nursing assistant) during rounding. observed resident unresponsive. 911 called immediately. CPR (cardiopulmonary resuscitation) initiated. (Physician) paged. ADON (assistant director of nursing) updated. (Cross reference F678. Nursing did not immediately call 911 or begin CPR.) On [DATE] at 9:00 a.m. Surveyor interviewed Paramedic I. Paramedic I stated the rescue squad arrived at the facility on [DATE] at 5:11 a.m. and arrived at the resident's bedside at 5:13 a.m. Paramedic I stated R188 remained asystole (state of total cessation of electrical activity from the heart) through the whole call. Paramedic I stated they pronounced R188 dead at the facility with the permission of their medical director. Paramedic I stated R188 had all signs of death. On [DATE] at 10:32 a.m. Surveyor interviewed RN H. RN H stated she remembers that day because it was the worse night of my nursing career. RN H stated when she arrived on her shift [DATE] at 11:00 p.m. she was made aware that she would be working on LTC 1 and Rehab unit. RN H stated both units would total 70 residents for RN H to care for, and she said she couldn't do it. RN H stated she called Former Director of Nursing (DON) J and ADON K that she couldn't do both units and she needed help. RN H stated ADON K came in at 12:00 a.m. to work the rehab unit. Surveyor asked RN H how many residents did she have on LTC 1. RN H stated about 40-50 residents on LTC 1. Surveyor asked RN H when was she made aware R188 was unresponsive. RN H stated about 5:00 a.m. CNA L told her R188 was unresponsive. Surveyor asked RN H what specifically did CNA L tell her about R188 condition. RN H said CNA L told her R188 was unresponsive. RN H stated she immediately went to R188 room and saw he was unresponsive. Surveyor asked RN H what did R188 look like. RN H stated he just looked unresponsive. Surveyor asked if RN H did an assessment, RN H state no she did not because he looked like he needed 911. RN H stated she then ran down the hall to the Rehab unit to get Assistant Director of Nursing (ADON) K. RN H stated ADON K and an agency nurse from another unit went to R188 to perform CPR and RN H called 911. Surveyor asked RN H if at any point during the shift, prior to 5:00 a.m., did CNA L tell her R188 was vomiting. RN H stated I don't remember. Surveyor asked RN H at 5:00 a.m. when she found R188 unresponsive if R188 had on his CPAP. RN H stated she doesn't remember. RN H stated at 2:00 a.m. she went into R188's room to attend to R188's roommate. RN H stated R188's roommate bed was high and his TV was on, so she lowered the bed because R188's roommate was a fall risk and turned off the TV. Surveyor asked if she looked at R188 while she was in the room. RN H stated she saw R188 sleeping. Surveyor asked if R188 had his CPAP on. RN H stated she doesn't remember. Surveyor asked RN H if she was aware R188 was bleeding from his penis on the previous shift. RN H stated she was aware a UA was collected but was not aware of R188 bleeding from his penis. Throughout the interview RN H kept repeating how horrible it was that the facility wanted RN H to work 2 units. At no point during the interview did RN H explain why an assessment was not completed on [DATE]. RN H failed to follow the Nurse Practice Act by failing to assess, plan, and intervene. This prevented nursing from assessing the significance of R188's change in condition. Although vomiting is often symptomatic of an innocuous condition, according to Healthline, Vomiting accompanied by the following symptoms should be treated as a medical emergency: severe chest pain sudden and severe headache shortness of breath blurred vision sudden stomach pain stiff neck and high fever blood in the vomit https://www.healthline.com/health/vomiting-causes-treatment#see-a-doctor On [DATE] at 10:30 a.m. Surveyor spoke with NHA A. Surveyor explained to NHA the concern R188 was experiencing a change in condition, with episodes of vomiting and RN H did not assess R188. Surveyor explained through interviews RN H did not assess R188 when he was found unresponsive. Surveyor explained RN H completed the SBAR dated [DATE] with vital signs from [DATE] and the areas for assessment were not completed. NHA A stated she was not aware R188 was vomiting that night and was not aware RN H did not assess R188 at the time of the change in condition and at the time he was found unresponsive. The failure to follow the Nurse Practice Act by failing to assess R188 after R188 experienced a potentially significant change in condition and after being found unresponsive created a reasonable likelihood for serious harm, thus creating a finding of Immediate Jeopardy. The facility removed the jeopardy on [DATE] when it had implemented the following: ~ The Medical Director contacted by the NHA and advised of deficiency. ~ All licensed nursing staff were educated by the Nurse Manager related to identifying resident change of condition, ensuring completion of a comprehensive assessment, physician/RP notification and ensuring clear comprehensive documentation. ~ Education was provided regarding prompt notification being required when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention: a significant change in the residents attending physical, mental or psychosocial status, including a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications: or need to alter treatment significantly. ~ Current residents with noted change of condition as of 3-28-22 were reviewed for SBAR documentation including comprehensive assessment, physician/RP notification and clear comprehensive documentation. If licensed staff/ RCS (CNA) notices change in condition: If RCS notices a change of condition, they will immediately notify licensed staff as well as fill out the STOP & WATCH form. If licensed staff member notices the change, they would do an assessment/evaluation of the resident, notify physician for further instructions, notify RP and complete SBAR. If resident is unresponsive, they would follow the following steps: - Call for help verbally and pull call light - Chart/PCC (PointClick Care) would be checked for code status - CODE BLUE announced through paging system - 911 called - Physician and RP notified regarding change of condition Based on resident's CPR status, CPR is initiated immediately and continued until 911 arrives. ~ Changes of condition will be communicated shift to shift through change of report as well as the 24-Hour Report. For life threatening events call 911 if initial assessment indicates that such action is necessary. ~ Changes in resident that affect the problem(s)/goal(s) or approach(es) on his/her care plan are documented as revisions and communicated by the IDT (interdisciplinary team) to direct care staff. ~ Director of Nursing (DON) or Nurse Manager will audit 2 resident medical records that have been identified to experience a change of condition, per day x 2 weeks (M-F) to ensure elements of the change of condition procedure have been met. ~ DON or Nurse Manager will review PCC dashboard, 24-hour board, for any noted resident change of condition daily (M-F) for 2 weeks, then 3 times a week for 2 weeks, then weekly thereafter until QA committee deems appropriate. ~ MDS (Minimum Data Set Nurse)/Designee will audit 3 residents care plans from noted resident change of condition for appropriate interventions being care planned 2 times a week for 2 weeks, then weekly thereafter until QA committee deems appropriate. ~ All weekly AT RISK meeting notes will be reviewed and submitted to QAPI monthly to identify trends x 3 months or until QA committee deems appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not have a system to ensure that there was someone working each shift who was certified in CPR (cardiopulmonary resuscitation, which had the potential to affect 93 of 144 residents who are full code. The facility did not immediate basic life support, including Cardio Pulmonary Resuscitation (CPR) to 1(R188) of 2 residents who was unresponsive. On [DATE] during the night shift, R188 was found unresponsive by Certified Nursing Assistant (CNA) L. CNA L told Registered Nurse (RN) H about R188 being unresponsive and RN H did not immediately perform life saving measures. RN H did not assess R188's breathing or pulse. RN H did not use the paging system for assistance, but instead went to a different unit to get Assistant Director of Nursing (ADON) K to assist. Agency Licensed Practical Nurse (LPN) AA was told R188 needed CPR. Agency LPN AA checked R188's breathing and found him to not be breathing and began CPR. The facility's failure to immediately perform basic life support when R188 was found unresponsive and the failure to have a system that ensured each shift had CPR-certified staff created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA) A of the immediate jeopardy on [DATE] at 12:00 p.m. The immediate jeopardy was removed on [DATE] however, the deficient practice continues at a scope/severity of E (potential for harm/pattern) as the facility continues to implement its action plan. Findings include: The facility's policy Medical Emergency Management with revised date of February 2017 indicates: The facility ensures residents receive timely and appropriate interventions in the event of a medical emergency. The staff takes actions to ensure that the resident's airway, breathing, and circulation are maintained until emergency personnel arrive. Staff is aware of each resident's physician's orders and advance directives prior to the administration of cardio-pulmonary resuscitation. Guidelines: 1. Licensed nursing staff in the facility must obtain their CPR certification during their probationary period and keep their certification current during their employment. It is recommended that unlicensed staff that provide direct resident care also maintain a current CPR certification. 4. The facility will maintain an Automated External Defibrillator (AED) if required by state regulation. 5. Once a medical emergency is identified, qualified staff assesses the resident, initiate the appropriate emergency procedure (s) in accordance with physician's orders and/or the resident's advance directive, and calls 911. The staff continues to provide care and monitor the resident until the emergency personnel arrive. 1.) R188 was admitted to the facility on [DATE] with diagnoses of surgical repair of left femur fracture, type 2 diabetes, morbid obesity, sleep apnea, atrial fibrillation and hypertension. The admission MDS (minimum data set) dated [DATE] indicates R188 is alert and cognitively intact, needs extensive assistance of two staff for bed mobility and hygiene. It also indicates R188 had a urinary catheter due to urinary retention. R188 was full-code. The nurses note dated [DATE] at 5:46 a.m. indicates: RN called to room per CNA (certified nursing assistant) during rounding. observed resident unresponsive. 911 called immediately. CPR (cardiopulmonary resuscitation) initiated. (Physician) paged. ADON (assistant director of nursing) updated. Surveyor reviewed the facility self report dated [DATE] which includes RN H's statement indicating: found patient had a change in status. She called the doctor (paged X 2). Called 911 immediately, as the patient was a full code. (RN) reviewed the chart and found 0 family contacts. While awaiting 911 to come, all necessary documents were printed. DON (Director of Nursing)/NHA were notified. ADON (who was in the building) was notified . RN H completed an SBAR (situation, background, assessment and recommendation) dated [DATE]. The SBAR indicates RN H was called to R188's room per CNA L. RN H observed resident to be unresponsive. 911 called immediately. The SBAR had vital signs dated [DATE]. The SBAR had the following conditions to assess during a change in condition: Mental status changes, Functional status changes, respiratory, GI/abdomen and GU/urinary changes. RN had marked NA for all changes. The SBAR assessment section asks the nurse completing the SBAR for an assessment of what may be the problem with the patient and RN did not complete an assessment and only wrote called 911 immediately. The facility self report does not have any other staff statements. The facility self report does not indicate who began CPR and when R188 was assessed to need CPR. On [DATE] at 9:00 a.m. Surveyor interviewed Paramedic I. Paramedic I stated the rescue squad arrived at the facility on [DATE] at 5:11 a.m. and arrived at the resident's bedside at 5:13 a.m. Paramedic I stated when they arrived at the resident's bedside, the facility staff were performing CPR. Paramedic I stated they let the facility staff continue with CPR until rescue squad got their equipment ready to take over CPR. Paramedic I stated R188 remained asystole (state of total cessation of electrical activity from the heart) through the whole call. Paramedic I stated they pronounced R188 dead at the facility with the permission of their medical director. Paramedic I stated R188 had all signs of death. On [DATE] at 8:09 AM Surveyor interviewed CNA L. CNA L stated she worked the night shift on [DATE] into [DATE]. CNA L stated she's not sure about the time but about 3 or 4 am CNA L went into R188's room to empty out his catheter and saw R188 had turned a different color. CNA L immediately told RN H. CNA L stated RN H went to look for ADON K for help. CNA L stated she did not participate in CPR only doing rounds on the rest of the residents on the unit. On [DATE] at 10:32 a.m. Surveyor interviewed RN H. RN H stated she remembers that day because it was the worse night of my nursing career. Surveyor asked RN H when was she made aware R188 was unresponsive. RN H stated about 5:00 a.m. CNA L told her R188 was unresponsive. Surveyor asked RN H what specifically did CNA L tell her about R188's condition. RN H said CNA L told her R188 was unresponsive. RN H stated she immediately went to R188's room and saw he was unresponsive. Surveyor asked RN H what did R188 look like. RN H stated he just looked unresponsive. Surveyor asked if RN H did an assessment, RN H stated no she did not because he looked like he needed 911. RN H stated she then ran down the hall to the Rehab unit to get ADON K. RN H stated ADON K and an agency nurse from another unit went to R188 to perform CPR and RN H called 911. Surveyor asked RN H at 5:00 a.m. when she found R188 unresponsive, did R188 have his CPAP on. RN H stated she doesn't remember. At no point during the interview did RN H explain why basic life support wasn't started immediately when R188 was found unresponsive. Surveyor asked RN H if she had a current CPR certification card. RN H stated her CPR certification expires in [DATE]. On [DATE] at 9:02 AM Surveyor interviewed ADON K. ADON K stated she was on the rehab unit and R188 was on LTC 1 unit. RN H came from LTC 1 to rehab unit to tell ADON K that R188 was unresponsive. Surveyor asked ADON K approximately how long does it take to go from LTC 1 unit to the Rehab unit where ADON K was located. ADON K indicated it would be at least a minute each way. ADON K stated she went to R188's room and saw R188 wasn't breathing. ADON K stated R188's lips were purple in color and there was foam around his mouth. ADON K stated his CPAP was not on. ADON K stated they started CPR and another nurse called 911. Surveyor asked ADON K if there was a paging system when there is a code situation. ADON K stated (incorrectly) there isn't a paging system which is why RN H had to walk to get help. On [DATE] at 12:50 p.m. Surveyor interviewed Agency LPN AA. Agency LPN AA stated on [DATE] she doesn't remember who told her but she was made aware of R188 needing CPR. Agency LPN AA stated when she arrived to R188's room with a medication tech (doesn't remember the name of the med tech), Agency LPN AA saw R188 laying on his back, his right arm hanging off the side of the bed and his eyes closed. Agency LPN AA listened for R188's breath sounds and didn't hear anything so immediately started CPR with the assistance of the medication tech. Agency LPN AA stated ADON K came into the room shortly and took over for the medication tech. Agency LPN AA stated RN H did not participate in the code situation. Agency LPN AA stated RN H called 911. Agency LPN AA stated R188 did not have his CPAP on and heard that he sometimes was noncompliant with putting it on. Agency LPN AA stated she and RN H continued with CPR until the paramedics arrived. The facility staff did not begin CPR immediately upon finding R188 unresponsive. RN H did not use the paging system but, instead, went to another unit to find a nurse to assist. According to a 2019 Division of Appeals Board (DAB) hearing decision, The driving force behind the American Heart Association guidelines .and regulatory requirements is that CPR must be initiated immediately when a full code resident is found to be nonresponsive. Time is of the essence in initiating CPR. Any delay endangers a nonresponsive individual's safety and his or her life. With CPR, seconds may mean the difference between resuscitation and death. https://www.hhs.gov/about/agencies/dab/decisions/alj-decisions/2019/alj-cr5339/index.html 2.) The total facility census was 144 and total of 93 residents had a full code status at the time of the survey. On [DATE] at 9:52 AM Surveyor asked NHA A for a list of all nursing staff and their CPR certification status. NHA A stated HR (human resources) has not been keeping track of staff's CPR certification status. On [DATE] at 12:16 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B stated every nurse should be CPR certified, but DON-B was not sure if they were or not since the facility has not been tracking that data. DON-B stated it is unknown which staff are or are not certified when they are scheduled to work at this time. DON-B hopes to have CPR training here within the next few days. Subsequently, NHA A gave Surveyor a copy of Agency LPN AA and ADON K CPR certification card. Agency LPN AA's CPR Certification expires [DATE]. ADON K's CPR certification expires [DATE]. The facility was unable to verify the certification status of Registered Nurse (RN) D who successfully provided CPR to R92 on [DATE] when R92 was found unresponsive. Surveyor reviewed RN H personnel file and there wasn't any evidence of a CPR card being obtained at the time of hire. Surveyor reviewed the Facility Assessment which indicates licensed nurses are to annually update their CPR certification. The facility assessment indicates this was reviewed in QAPI (quality assurance performance improvement) on [DATE]. On [DATE] at 10:30 a.m. Surveyor spoke with NHA A. Surveyor explained to NHA A the concern R188 was found unresponsive and an immediate assessment of R188's breathing or pulse was not done. RN H went to a different unit to get another nurse to help. Immediate action was not done when R188 was found unresponsive. Surveyor also explained the concern the facility has no record of their nursing staff CPR certification and no system on keeping track of CPR certification. These failures created a reasonable likelihood that serious harm could occur, thus creating a finding of immediate jeopardy. The facility removed the jeopardy on [DATE], when it had completed the following: ~ The Medical Director was contacted by the NHA A and advised of deficiency on 03-29-22. ~ The Human Resource Director audited licensed nursing staff employee files to determine CPR status. Copy of CPR cards were verified with each licensed nurse and if CPR status is not current employee to be provided with CPR certification class information. ~ An in facility CPR certification class to be held Wednesday, [DATE]. ~ The Human Resource Director will be educated on requirements for mandatory CPR education for licensed nursing staff. Human Resource Director will be responsible for verifying nursing CPR status prior to beginning employment and maintaining current licensed nursing staff CPR status. Copy of CPR cards will be placed in employee files and list expiration dates monitored by Human Resource Director. ~ All licensed nursing staff was educated by the Nurse Manager related to the requirement to maintain an up to date CPR certification at all times while employed at the facility. ~ All licensed nursing staff was educated on the procedure of handling a change of condition and what to do in an emergent situation to avoid delay in treatment. See steps below: If licensed staff/ RCS (CNA) notices change in condition: If RCS (Resident Care Staff/CNA), they would verbally advise licensed staff member of change. If licensed staff member notices the change with the resident, they would follow the following steps: - Call for help verbally and pull call light - CODE BLUE announced through paging system - Chart/PCC would be checked for code status - 911 called - Physician and RP notified regarding change of condition - Based on resident's CPR status, CPR is initiated immediately and continued until 911 arrives. ~ Education was completed. ~ The Scheduler will be provided with a list of current CPR certified licensed nursing staff to ensure at least one CPR certified nurse is working each shift. ~ HRM (Human Resources Manager) or designee audited new licensed nurse employee files weekly to ensure CPR status is verified. ~ DON or designee audited list of CPR certified staff weekly to ensure CPR status is being maintained and review any upcoming expiration dates. ~ DON or designee audited licensed nursing schedules daily (M-F) x 2 weeks to ensure at least one CPR certified licensed nurse is working.